Medicare Formularies

2026 UPHP MI Coordinated Health

• Formulary (List of Covered Drugs) (Last updated 12/30/2025.)
• Formulary (List of Covered Drugs) – Large Print (Last updated 12/30/2025.)
• Part D Drug Prior Authorization Criteria
• Part D Step Therapy Criteria
• Part D Formulary Exception Criteria
• Medicaid Benefit Drug Prior Authorization Criteria
• Formulary Change History
• Machine Readable Formulary (JSON)

2025 UPHP MI Health Link Formulary (List of Covered Drugs) 
(Clicking on this link will take you away from UPHP’s website.)(Last updated 12/01/2025.)

2024 UPHP MI Health Link Formulary (List of Covered Drugs) 
(Clicking on this link will take you away from UPHP’s website.)(Last updated 12/01/2024.)

The Pharmacy Benefit Portal allows members to review their pharmacy claims history, find a network pharmacy, look up a covered drug and the cost, and more. Click the link for your Medicare Plan below to sign in or register as a new user. 

MI Coordinated Health Member Portal

Certain drugs may need to get approval from UPHP before we can cover them. This is called a prior authorization, coverage decision, or coverage determination. It is an initial decision we make about your drug coverage or about the amount we pay for your drugs.  Sometimes plan approval is required so that we can be sure the drug is covered by Medicare rules.  To be covered, the drug must be used for a medically accepted indication. That means the drug is approved by the Food and Drug Administration (FDA) or supported by certain medical references.

Here are examples of coverage decisions you ask us to make about your Medicare Part D drugs:

• You ask us to make an exception*, including asking us to:
  • cover a Medicare Part D drug that isn’t on our plan’s Drug List or
  • set aside a restriction on our coverage for a drug (such as limits on the amount you can get)

*If you ask for an exception, give us a “supporting statement.” The supporting statement includes your doctor or other prescriber’s medical reasons for the exception request.

• You ask us if a drug is covered for you (such as when your drug is on our plan’s Drug List but we must approve it for you before we cover it)
• You ask us to pay for a drug you already bought. This is asking for a coverage decision about payment. Refer to Chapter 7 of the UPHP Member Handbook.

NOTE: If your pharmacy tells you that your prescription can’t be filled as written, the pharmacy gives you a written notice explaining how to contact us to ask for a coverage decision.

You can also ask us to make a coverage decision about the drugs covered under your Medicaid Benefit.

How to ask for a coverage decision depends on your UPHP Medicare plan:

• UPHP MI Health Link
  • In writing using the form below:
    • UPHP MI Health Link Medicare Drug Coverage Determination Request Form
    • Mail your request to:

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

• • • Fax your request to:

1-866-391-6730

• • By Phone:

1-855-380-0275

• UPHP MI Coordinated Health
  •  Online at Express Scripts
    • Clicking on this link will take you away from UPHP’s website
  • In writing using the form below:
    • UPHP MI Coordinated Health Medicare Coverage Determination Request Form
    • Mail your request to:

Express Scripts
Attn: Medicare Reviews
PO Box 66571
St. Louis, MO 63166-6571

• • • Fax your request to:

1-877-251-5896

• • By Phone:
    • 1-800-935-6103
    • TTY: 1-800-716-3231

 If you disagree with a coverage decision we made, you can appeal our decision. See the ‘Drug Appeals and Grievances’ Section of this page for more information.

In general, we want you to try lower-cost drugs that are as effective before we cover drugs that cost more. For example, if Drug A and Drug B treat the same medical condition, and Drug A costs less than Drug B, we may require you to try Drug A first. If Drug A doesn’t work for you, then we cover Drug B. This is called step therapy. If you or your provider do not feel it is safe or appropriate for you to try Drug A, you can ask for an exception.

For some drugs, we limit the amount of the drug you can have. This is called a quantity limit. For example, if it’s normally considered safe to take only one pill per day for a certain drug, we might limit how much of a drug you can get each time you fill your prescription. If you or your provider feel you need more than the amount we limit, you can ask for an exception.

If we make an initial coverage decision about your drug and you aren’t satisfied with this decision, you can “appeal” the decision. This is also called a redetermination. An appeal is a formal way of asking us to review and change a coverage decision we made.

How to ask for an Appeal

• • In writing using the appropriate form below:

MI Health Link Request for Redetermination of Medicare Prescription Drug Denial Form

MI Coordinated Health Request for Redetermination of Medicare Prescription Drug Denial Form

• • • Mail your request to:

Express Scripts
Attn: Medicare Clinical Appeals
PO Box 66588
St. Louis, MO 63166-6588

• • • Fax your request to:

1-877-852-4070

• • By Phone:
    • 1-800-935-6103 (1-800-716-3231 TTY)

The complaint process is used for certain types of problems only, such as problems about quality of care, waiting times, coordination of care, and customer service.

There are different kinds of complaints. You can make an internal complaint and/or an external complaint.

• An internal complaint is filed with and reviewed by our plan. To make an internal complaint, call your care coordinator or UPHP Customer Service at 1-877-349-9324 (TTY: 711). You can make the complaint at any time unless it’s about a Medicare Part D drug. If the complaint is about a Medicare Part D drug, you must make it within 60 calendar days after you had the problem you want to complain about.

You can mail or fax written grievances to:

Upper Peninsula Health Plan
Attn: Customer Service
853 W. Washington St.
Marquette, MI 49855

Fax: 1-906-225-7690

• An external complaint is filed with and reviewed by an organization not affiliated with our plan. If you need help making an internal and/or external complaint, you can call the MI Coordinated Health Ombudsman at 1-888-746-6456. See Chapter 9 of the Member Handbook to find out how to file an external complaint.

Generally, we pay for drugs filled at an out-of-network pharmacy only when you aren’t able to use a network pharmacy. We have network pharmacies outside of our service area where you can get prescriptions filled as a member of our plan. In these cases, check with your care coordinator or UPHP Customer Service first to find out if there’s a network pharmacy nearby. You can also use our Provider and Pharmacy Directory to find network pharmacies in our network nearest to you. 

We pay for prescriptions filled at an out-of-network pharmacy in the following cases:

• You traveled outside the plan’s service area and ran out of (or lost) your drug(s); or you became ill and could not access a network pharmacy.
• You were unable to get your drug in a timely manner within the plan’s service area. For example, there was no network pharmacy within a reasonable driving distance that provides 24/7 service and you needed the drug right away.
• Your medication is not stocked regularly at an accessible network or mail-order pharmacy.
• While you were a patient in an emergency department, provider-based clinic, outpatient surgery or other outpatient facility, your drug was dispensed from an out-of-network pharmacy located in one of these institutions, and you could not get the drug filled at a network pharmacy.
• You were evacuated or displaced from where you live due to a State or Federally declared disaster or health emergency.

Before using an out-of-network pharmacy, call UPHP customer service to see if there is an in-network pharmacy in the area. We have many in-network pharmacies located outside of our service area, including other states.

In most cases, we will only cover up to a 30-day supply of a drug filled at an out-of-network pharmacy. If you are traveling and need more than a 30-day supply, contact UPHP Customer Service to see if an exception can be made for you.

If you must use an out-of-network pharmacy, you must generally pay the full cost instead of a copay when you get your prescription. You can ask us to pay you back for our share of the cost. You may be required to pay the difference between what you pay for the drug at the out-of-network pharmacy and the cost we would cover at an in-network pharmacy. We may not be able to pay you back for Medicaid-covered drugs or products filled at an out-of-network pharmacy. For more information on how to ask UPHP to pay you back, see Core Benefits & Cost Sharing – Bills.

UPHP has a transition policy for members to help them get their medications when they first become a member of our plan.  In some cases, we can give you a temporary supply of a drug when the drug isn’t on our Drug List or is limited in some way. This gives you time to talk with your provider about getting a different drug or to ask us to cover the drug.

You must be in one of these situations:

• You’re new to our plan.
  • We cover a temporary supply of your drug during the first 90 days of your membership in our plan.
  • This temporary supply is for up to 30 days.
  • If your prescription is written for fewer days, we allow multiple refills to provide up to a maximum of 30 days of medication. You must fill the prescription at a network pharmacy.
  • Long-term care pharmacies may provide your drug in small amounts at a time to prevent waste.

• You’ve been in our plan for more than 90 days, live in a long-term care facility, and need a supply right away.
  • We cover one 31-day supply, or less if your prescription is written for fewer days. This is in addition to the temporary supply above.
  • If you have a level of care change, we will cover a temporary supply upon admission to, or discharge from, a long-term care facility in the following cases:
  • If you need an early refill on your drug due to entering or leaving a long-term facility and have not been able to bring your drugs with you.
  • If you have been prescribed a drug with limits because of a level of care change.
  • If you have been prescribed a drug not on our Drug List because of a level of care change.

You can ask us to pay for a temporary supply by calling UPHP Customer Service or your care coordinator. For more information, see Chapter 5 of the Member Handbook.

UPHP 2025 Prescription Drug Transition Policy

UPHP 2026 Prescription Drug Transition Policy

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