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List of Covered Select Part B Drugs and Supplies The chart below lists select Part B drugs and supplies that are covered by UPMC for Life. We generally cover the drugs and supplies listed as long as they are medically necessary. You must fill these drugs at a network pharmacy or supply provider and follow other plan rules as listed in the Evidence of Coverage for your plan. This document only includes covered Part B drugs and supplies. For a listing of Part D prescription drugs covered by UPMC for Life HMO and PPO plans, please click here. For a listing of Part D prescription drugs covered by UPMC for Life Dual, please click here. For a listing of Part D prescription drugs covered by UPMC for Life Options, please click here. If you have questions or need help finding a covered drug or supply, please call Member Services. You can call us at 1-877-539-3080 seven days a week from 8 a.m. to 8 p.m. * TTY users should call 1-800-361-2629. Select Part B Drugs and Supplies Covered by Your Plan Drug or Supply Name Generic Requirements/Limits Euflexxa sodium hyaluronate PA Lifescan blood glucose meters various Lifescan diabetic test strips various The above chart does not include all of the Part B drugs or supplies we cover. * Our hours of operation change twice a year. You can call us October 1 through February 14, seven days a week from 8 a.m. to 8 p.m. From February 15 through September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m., and Saturday from 8 a.m. to 3 p.m. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits may change on January 1 of each year. The formulary and/or pharmacy network may change at any time. You will receive notice when necessary. Y0069_16_1230 Accepted

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Page 1: List of Covered Select Part B Drugs and Supplies ·  · 2016-05-16List of Covered Select Part B Drugs and Supplies ... Lifescan diabetic test strips various ... Microsoft Word -

List of Covered Select Part B Drugs and Supplies The chart below lists select Part B drugs and supplies that are covered by UPMC for Life. We generally cover the drugs and supplies listed as long as they are medically necessary. You must fill these drugs at a network pharmacy or supply provider and follow other plan rules as listed in the Evidence of Coverage for your plan. This document only includes covered Part B drugs and supplies. For a listing of Part D prescription drugs covered by UPMC for Life HMO and PPO plans, please click here. For a listing of Part D prescription drugs covered by UPMC for Life Dual, please click here. For a listing of Part D prescription drugs covered by UPMC for Life Options, please click here. If you have questions or need help finding a covered drug or supply, please call Member Services. You can call us at 1-877-539-3080 seven days a week from 8 a.m. to 8 p.m.* TTY users should call 1-800-361-2629.

Select Part B Drugs and Supplies Covered by Your Plan

Drug or Supply Name Generic Requirements/Limits Euflexxa sodium hyaluronate PA Lifescan blood glucose meters various

Lifescan diabetic test strips various

The above chart does not include all of the Part B drugs or supplies we cover. *Our hours of operation change twice a year. You can call us October 1 through February 14, seven days a week from 8 a.m. to 8 p.m. From February 15 through September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m., and Saturday from 8 a.m. to 3 p.m.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits may change on January 1 of each year. The formulary and/or pharmacy network may change at any time. You will receive notice when necessary. Y0069_16_1230 Accepted

https://www.upmchealthplan.com/docs/medicare/2016/2016_Formulary.pdf
https://p.widencdn.net/csqbhq
https://p.widencdn.net/7fdef9
Page 2: List of Covered Select Part B Drugs and Supplies ·  · 2016-05-16List of Covered Select Part B Drugs and Supplies ... Lifescan diabetic test strips various ... Microsoft Word -

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.

Copyright 2016 UPMC Health Plan Inc. All rights reserved. 2016_PRTBLST_16SNP0049 (RT) 5/11/16 WEB


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