UPMC
for Life
UPMC Health Plan Medicare Program
October 31,2016
7.10.2230 AT 0.274 92765DII.p06 179622743
'11'1"'1111'11"1'1'1111111111"111111111"11" •• 11111 •• 11111111
Address Deleted
Dear Mr. AUSTIN:
As health care costs continue to rise, UPMC for Life strives to improve
the value and
affordability of the health care benefits we offer our members. One of the ways we do this is to make changes to the list of covered prescription drugs our members use. The list of covered prescription drugs is called a formulary. Our goal is to give you the most value possible for your money. In order to do this, we must sometimes change the drugs that are covered by our plan. Medications may be added or removed from the formulary. How a medication is covered may also be changed. All changes to the formulary are made with the help of our local doctors and pharmacists.
affordability of the health care benefits we offer our members. One of the ways we do this is to make changes to the list of covered prescription drugs our members use. The list of covered prescription drugs is called a formulary. Our goal is to give you the most value possible for your money. In order to do this, we must sometimes change the drugs that are covered by our plan. Medications may be added or removed from the formulary. How a medication is covered may also be changed. All changes to the formulary are made with the help of our local doctors and pharmacists.
Effective January 1, 2017,
UPMC for Life's coverage of dextroamphetamine/amphetamine
ER will move from a Tier 1 copayment to a Tier
3 copayment. Our records show that you
have used dextroamphetamine/amphetamine ER as prescribed by your doctor. Amphetamine/dextroamphetamine immediate tablet, dexmethylphenidate immediate release, dextroamphetamine immediate release, and methylphenidate immediate release
work similarly to
dextroamphetamine/amphetamine ER and are available at a lower copayment. You can continue to get dextroamphetamine/amphetamine ER in
2017 at a Tier 3 copayment. Or you can share this letter with your doctor and discuss trying a lower tier formulary medication.
To request an exception, contact Member Services at 1-877-539-3080, or ask your
doctor to contact Pharmacy Services at 1-800-979-8762. You or your doctor can also fax your request for an exception to
412-454-7722. For
more information about filing an exception, please see Chapter 9, Section 6
of your Evidence of Coverage CEOC).
You have the right to file a grievance if you disagree with our decision to
change the tier of your medication. To file a grievance,
please call UPMC/or Life Member Services at 1-877-539-3080. For more information about filing a grievance, please see Chapter 9, Section 10 of your EOC.
If you have any questions, contact UPMC for
Life toll-free at 1-877-539-3080. TTY users should
call 1-800-361-2629. Our hours of operation change throughout the year. We are available to
take your call October 1 through February 14 from 8 a.m. to 8 p.m. seven days a week and
February 15 through September 30 from 8 a.m. to 8 p.m. Monday through Friday and from 8
a.m. to 3 p.m. on Saturday.
call 1-800-361-2629. Our hours of operation change throughout the year. We are available to
take your call October 1 through February 14 from 8 a.m. to 8 p.m. seven days a week and
February 15 through September 30 from 8 a.m. to 8 p.m. Monday through Friday and from 8
a.m. to 3 p.m. on Saturday.
Sincerely,
UPMC for Life Pharmacy Services
The UPMC for Life HMO and PPO plans, the UPMC for Life Dual (HMO SNP) plan, and the
UPMC for Life Options (HMO SNP) plan have contracts with Medicare. UPMC for Life Dual
also has a contract with the Pennsylvania Medical Assistance (Medicaid) program. Enrollment in
UPMC for Life depends on contract renewal. UPMC for Life and UPMC for Life Options are
products of and operated by UPMC Health Plan Inc., UPMC Health Network Inc., and UPMC
Health Benefits Inc. UPMC for Life Dual is a product of and operated by UPMC for You Inc.
UPMC for Life Options (HMO SNP) plan have contracts with Medicare. UPMC for Life Dual
also has a contract with the Pennsylvania Medical Assistance (Medicaid) program. Enrollment in
UPMC for Life depends on contract renewal. UPMC for Life and UPMC for Life Options are
products of and operated by UPMC Health Plan Inc., UPMC Health Network Inc., and UPMC
Health Benefits Inc. UPMC for Life Dual is a product of and operated by UPMC for You Inc.
The formulary may change at any time. You will receive notice when necessary. This
information is not a complete description of benefits. Contact the plan for more information.
Limitations, copayments, and restrictions may apply. Benefits and copayments may change on
January 1 of each year.
information is not a complete description of benefits. Contact the plan for more information.
Limitations, copayments, and restrictions may apply. Benefits and copayments may change on
January 1 of each year.
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