Formulary

Certain drugs may need to get approval from UPHP before we will agree to cover the drug for a member.  This is called “prior authorization.”  Sometimes plan approval is required so that we can be sure the drug is covered by Medicare rules.  Sometimes the requirement for getting approval in advance helps guide appropriate use of certain drugs.  If the prior authorization does not get approved, the drug might not be covered by the health plan. 

• Prior Authorization Criteria (Clicking on this link will take you away from UPHPs website.)

If a drug is not covered in the way you would like it to be covered, you can ask the plan to make an “exception” by submitting a formulary exception form.  An exception is a type of coverage decision.  Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.

Download and print the UPHP Medicare Part D Coverage Determination Request Form below to start the coverage determination process.

• UPHP MI Health Link Part D Coverage Determination Request Form

The doctor’s office may submit the form via fax to Prime Therapeutics at 1-866-391-6730 or via mail to:

UPHP MI Health Link
ATTN: MPD — 1000UR
P.O. Box 64806
St. Paul, MN 55164-0811

Read more about the Medicare Prescription Drug Coverage Determination and Exceptions process.