Pharmacy Services

The prescription drug list (PDL) includes a list of preferred medications, along with the edits listed below that will determine if an authorization for medical necessity/exception process needs to be followed. If an authorization is required, please follow the steps below to complete a medication authorization form, and send the completed form to UM Health Plan for review:

• Members will have the lowest cost share with a Tier 1 medication, so consider prescribing a generic, Tier 1 medication when appropriate.
• When a brand-name medication becomes available as a generic, that brand-name product may have a higher cost share for the member.
• The pharmacist may substitute the name brand for a lower cost generic equivalent unless the physician specifies that the medication must be dispensed as written (DAW).

1. UM Health Plan may call or fax the office indicating that criteria was not met for the requested medication, however the member would meet criteria for a different medication(s) with similar therapeutic objectives.
2. UM Health Plan would ask the provider if they would be willing to switch to the preferred medication.
3. If the provider agrees, UM Health Plan will withdraw the original case with a note stating that the provider is willing to switch to a preferred medication.
4. For preferred medication that requires authorization, a new case will be started for the preferred medication.
5. An approval letter for the preferred medication that the provider agreed to change will be sent to the member and the provider.

All drugs with a step therapy are labeled with ST in the prescription drug list. All requirements related to a step therapy for a certain drug are included in the step therapy document listed below.

‍Step Therapy Criteria

Certain drugs on the formulary require prior authorization. These drugs will not be approved for payment until the conditions for approval of the drug are met and the authorization processed by PHP. Please access prior authorization criteria.

Please note: Medications requiring prior authorization, as well as criteria for use, are subject to change. For the most up-to-date information on coverage and cost of a medication, call Customer Service at 800-832-9186. Coverage is based on the member's benefit plan.

Medication Prior Authorization Form‍

Requests will be reviewed within 24 hours of receipt. Applicable chart notes can be attached to facilitate review. Notification will go out within 7 days from the date of request based upon the type and urgency of the request.

Medications that are not listed in the prescription drug list (PDL) are excluded from coverage, or medications that are excluded based upon the members' benefit design must be reviewed with the exception process.

Providers may initiate the exception process using the link below:

Online Medication Exception Process Form

‍Online requests will be reviewed within 24 hours of receipt. Applicable chart notes can be attached to facilitate review. Notification will go out within 7 days from the date of request based upon the type and urgency of the request..

Prescription Drug Formularies

‍This link will take you to the Forms page. Once on the Forms page you will need to scrolling down to the section called Pharmacy Forms and Prescription Drug Lists to view the Prescription Drug Formularies.

Medication Notification Table

Medication Authorization Form

CVS Specialty Pharmacy Medication List

• CVS/Caremark Mail-Order Form
• CVS/Caremark Specialty Pharmacy - Medication Order Form
• Coram (CVS) Home Infusion Referral Form
• Soleo Home Infusion Referral Form
• KabaFusion Infusion Referral Form
• Metro Infectious Disease Consultants Infusion Referral Form
• Infusion Associates

Preventive Medication Flyer

• FDA Drug Recalls
• CVS Drug Recalls

Medical and Drug Policies