Formulary

Pills
The List of Covered Drugs (Formulary) is a list of drugs that members can get in Upper Peninsula Health Plan (UPHP) MI Health Link (Medicare-Medicaid Plan).

  • UPHP MI Health Link is a health plan that contracts with both Medicare and Michigan Medicaid to provide benefits of both programs to enrollees.
  • Generic drugs are made up of the same active ingredients as brand name drugs.  They usually cost less than the brand name drug and usually don’t have well-known names.  Generic drugs are approved by the Food and Drug Administration (FDA).  UPHP MI Health Link covers both brand name drugs and generic drugs.
  • The drugs on the List of Covered Drugs are the drugs covered by UPHP MI Health Link.  These drugs are available at pharmacies within our network.  A pharmacy is in our network if we have an agreement with them to work with us and provide you services.  We refer to these pharmacies as “network pharmacies.”
  • You can always check UPHP MI Health Link’s up-to-date List of Covered Drugs.

View the comprehensive formulary, which is a complete list of covered drugs, for the appropriate calendar year below. You can also search for a specific drug by keying in the first few letters of the drug name:

To search alphabetically, go to the Alphabetical Listing section.  The section provides an alphabetical list of all of the drugs included in this document.  Both brand name drugs and generic drugs are listed in the Index.  Look in the Index and find your drug.  Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

To search by medical condition, find the section labeled “List of Drugs by Medical Condition”. Then find your medical condition. For example, if you have a heart condition, you should look in that category; that is where you will find drugs that treat heart conditions.

UPHP MI Health Link has a transition policy to help you get your medications when you first become a member of our plan. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of UPHP MI Health Link. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception.

We will cover a 30-day supply of your drug if:

  • you are taking a drug that is not on our Drug List; or
  • health plan rules do not let you get the amount ordered by your prescriber; or
  • the drug requires prior approval by UPHP MI Health Link; or
  • you are taking a drug that is part of a step therapy restriction.

If you live in a nursing home or other long-term care facility, you may refill your prescription for as long as 98 days. You may refill the drug multiple times during the 90 days. This gives your prescriber time to change your drugs to ones on the Drug List or ask for an exception. Exceptions are available in situations where you experience a change in the level of care you are receiving that also requires you to transition from one facility or treatment center to another. In such circumstances, you would be eligible for a temporary, one-time fill exception even if you are outside of the first 90 days as a member of the plan. For more information regarding the transition policy, see the UPHP MI Health Link Member Handbook.

For the most recent list of drugs, call Magellan Rx Customer Service at 1-855-380-0275 (TTY: 711), seven days a week, 24 hours per day.  Calls to these numbers are free.

For more information, read the  UPHP Prescription Drug Transition Policy for the applicable plan year below:

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. 

Step therapy encourages you to try a safer or more effective drug before the plan covers another drug.  For example, if Drug A and Drug B treat the same medical condition, UPHP may require you to try Drug A first.  If Drug A does not work for you, the health plan will then cover Drug B.  This requirement to try a different drug first is called “step therapy.”

Review the latest changes to UPHP’s formulary.  (Clicking on this link will take you away from the UPHPs website.)

UPHP MI Health Link has quantity limits.  This is when there is a limit on the amount that a drug is covered per prescription, or within a specific time frame.

  • Quantity Limits (Clicking on this link will take you away from the UPHPs website.)

You must use network pharmacies except in emergency or urgent care situations.  If you go to an out-of-network pharmacy for prescriptions when it is not an emergency, you will have to pay out of pocket for the service. Read the UPHP MI Health Link Member Handbook for more information.

Refer to the UPHP MI Health Link Member Handbook for further information on out-of-network coverage and asking the health plan to reimburse you for their share of the cost, or call Magellan Rx’s Customer Service at 1-855-380-0275 (TTY 711), 7 days per week, 24 hours a day.  The call is free.

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 both the Centers for Medicare and Medicaid Services (CMS) Coverage Determination Request Form and UPHP Medicare Part D Coverage Determination Request Form below.

The doctor’s office may submit either form via fax to Magellan Rx at 1-248-341-8133 or via mail to:

Magellan Rx Management
PO Box 2187 
Maryland Heights, MO 63043

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

CMS Best Available Evidence Policy (Clicking on this link will take you away from the UPHPs website.)

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Page Last Updated: 05/2/2019