Medicare Formularies

The Upper Peninsula Health Plan (UPHP) covered drugs are selected by the plan with the help of a team of doctors and pharmacists.  The drug list (Formulary) must meet requirements set by Medicare.  Medicare has approved the UPHP formularies.

UPHP covers both brand-name drugs and generic drugs.  Generic drugs have the same active-ingredient formula as a brand-name drugs and are rated by the U.S. Food and Drug Administration to be as safe and effective as the brand-name drugs, while also costing less.

The UPHP Drug List may change throughout the year.  Please see the “Formulary Change History” for your health plan below for further information or contact the plan for the most recent list of drugs.

Information on prior authorization, step therapy, formulary change history, quantity limits, out-of-network coverage, formulary exceptions and coverage determinations, and formulary appeals and grievances is below. (Please note: clicking some of these links will take you away from UPHP’s website).

(Clicking on the links below will take you away from the UPHPs website.)(Last updated 11/01/2019.)

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. Refer to the UPHP Evidence of Coverage for further information on prior authorizations, or call UPHP Customer Service at 1-877-349-9324 (TTY: 711), Monday through Friday from 8 a.m. to 9 p.m. Eastern time, with weekend hours Oct. 1 through March 31.  The call is free. For more information on prior authorization, view the documents below.

Step therapy encourages members 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 members to try Drug A first.  If Drug A does not work, the health plan will then cover Drug B.  This requirement to try a different drug first is called “step therapy.”

Refer to the UPHP Evidence of Coverage for further information on step therapy, or call Magellan Rx Customer Service at 1-844-827-0182 (TTY: 711), seven days per week, 24 hours per day. The call is free. For more information on step therapy, view the documents below.

Review the latest changes to UPHP’s formularies

(Clicking on the links below will take you away from the UPHPs website.)

UPHP Advantage, Choice and MI Health Link have 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.

Emergent and urgently needed out-of-network care are covered.  If members must use an out-of-network pharmacy, they will generally have to pay the full cost (rather than paying their normal share of the cost) when they fill the prescription.  Members can ask UPHP to reimburse them for our share of the cost. Refer to the UPHP Evidence of Coverage for further information on out-of-network coverage and asking the health plan to reimburse members for their share of the cost, or call Magellan Rx’s Customer Service at 1-844-827-0182 (TTY: 711) 24 hours a day, seven days a week.  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 appropriate UPHP Medicare Part D Coverage Determination Request Form below.

Providers 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.

UPHP has a transition policy for members to help them get their medications when they first become a member of our plan.  We will cover a temporary supply of their drug one time only during the first 90 days of their membership in the plan.  This temporary supply will be for a maximum of a month supply (31 days), or less if the prescription is written for fewer days.  The prescription must be filled at a network pharmacy. For assistance on the process, please call the Magellan Rx Prior Authorization Help Desk at 888-274-2031 (TTY: 711), Monday through Friday from 8 a.m. to 6 p.m.

For information on the CMS Best Available Evidence policy, click here.
(Clicking on this link will take you away from UPHP’s website.)


Page Last Updated: 12/3/2019