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2010 Formularies
2010 Preferred Part D Formulary
2010 Non-Preferred Part D Formulary

2009 Formularies
Medicare Preferred Drug Formulary
Medicare Non-Preferred Drug Formulary

This section describes your prescription drug coverage as a member of our Plan. We will explain what a formulary is and how to use it, our drug management programs, how much you will pay when you fill a prescription for a covered drug, and what an Explanation of Benefits is and how to get copies.

What is the UPREHS Prime Medicare Part D Plan Formulary?
UPREHS saves you money and stretches your benefits. Depot Drug Mail Pharmacy charges less money for your drugs than retail pharmacies. Less money charged to your benefit gives you more prescriptions before you need to pay out of pocket. You must fill all maintenance prescriptions from the preferred Depot Drug Mail Pharmacy. Maintenance prescriptions are those you intend to take longer than 30 days.

Follow prescription-ordering instructions in your Prime Medicare Part D Plan Benefit Guide. You can order refills through the UPREHS toll-free telephone lines from 4 AM to 11 PM, Mountain Time at 1- 800-547-0421, or the UPREHS website at www.uphealth.com. Your doctor can fax your new prescription to us at 801-595-4440 or you may mail it to us at:

Depot Drug Mail Pharmacy
PO Box 165090
Salt Lake City, UT 84116-5090

A formulary is a list of covered drugs selected by UPREHS in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. UPREHS will generally cover the drugs listed in our formulary as long as the drug is medically necessary, is filled at a network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review detailed instructions in your UPREHS Prime Medicare Part D Plan Benefit Guide for 2010.

This document is a partial formulary list and includes only some of the drugs UPREHS covers. For a list of nonpreferred formulary Tier 3 drugs, or a complete listing of all prescription drugs covered, please visit our website at www.uphealth.com or call Customer Services at 1-800-547-0421, Monday through Friday, from 7:30 AM to 3:30 PM, Mountain Time. TTY/TDD users call the national number 711.

2010 30-Day Copayment Amounts for Part D Drugs

PHARMACY TYPE	Tier 1 30-Day	Tier 2 30-Day	Tier 3 30-Day	Tier 4 30-Day
UPREHS Mail Order Pharmacy (DEPOT DRUG MAIL) - Preferred Pharmacy $$$ Your Best Money Saver 30, 60, or 90-Day Supplies Available	$5	$10	Higher of $40 or 33% of drug cost	Higher of $50 or 33% of drug cost
Ascend Specialty Drug Mail Order Pharmacy - Preferred Pharmacy for self-injectable medications, and those for oncology (cancer) or transplant (not insulin) $$$ Your Best Money Saver 30-Day Supply Available	$5	$10	Higher of $40 or 33% of drug cost	Higher of $50 or 33% of drug cost
UPREHS Depot Drug Walk-In Pharmacies - Preferred Pharmacies $$$ Your Best Money Saver 30, 60, or 90-Day Supplies Available	$7	$15	Higher of $40 or 33% of drug cost	Higher of $100 or 33% of drug cost
National Retail Pharmacy Network Non-Preferred Pharmacies 30-day or less Supply Only	$15	$30	Higher of $50 or 33% of drug cost	Higher of $100 or 33% of drug cost
Out-of-Network Pharmacy - Emergency Only We pay you the UPREHS cost for the Part D drug minus your tier copay amount. You pay any charges above UPREHS cost. Non-Part D drugs are not covered.	$15	$30	Higher of $50 or 33% of drug cost	Higher of $100 or 33% of drug cost

What is a formulary?
We have a formulary that lists all drugs that we cover. For 2010, we have included ALL covered Medicare Part D drugs in our formulary. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary; the prescription is filled through our preferred Depot Drug Pharmacies or at a nonpreferred network retail pharmacy (30-day supply only), it is a covered Medicare Part D drug, and other coverage rules are followed. For certain prescription drugs, we have additional requirements for coverage or limits on certain drugs. These requirements and limits are described in Section 4.

Medicare and our Plan, with the help of a team of health care providers select the drugs on the formulary. We select the prescription therapies believed to be a necessary part of a quality treatment program and both brand name drugs and generic drugs are included on the formulary. A generic drug has the same active ingredient formula as the brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and as effective as brand name drugs.

We have included all Medicare Part D covered drugs on our formulary. In some cases, the law prohibits coverage of certain types of drugs. See Drug Exclusions, later in this section, for more information about the types of drugs that cannot be covered under a Medicare Prescription Drug Plan.

In certain situations, prescriptions filled at an out of network pharmacy may also be covered. See Section 1 for more information about filling prescription at out of network pharmacies.

The UPREHS Prime Medicare Plan includes some prescription drugs on our formulary that are not a Medicare Part D benefit. Our Formulary Book identifies those drugs for you. Those drugs must be obtained through the Depot Drug Mail Pharmacy. If you need your prescription filled urgently, you may have a one-time-only fill at a nonpreferred network retail pharmacy. Any additional refills must go through the Depot Drug Mail Pharmacy with the exception of certain specialty drugs obtained through the Ascend Specialty Drug Pharmacy. Ask your physician to write 2 prescriptions for you: a one-month supply to be filled at a nonpreferred network retail pharmacy and a long-term prescription to send to the Depot Drug Mail Pharmacy.

We offer some prescription drugs not covered by Medicare Part D. The copayment you pay when you fill a prescription for these drugs does not count towards the deductible that UPREHS pays for you, the Medicare portion of your initial coverage limit, or your total out of pocket costs (that is, the amount you pay does not help you with your $4,550 out of pocket costs or to qualify for catastrophic coverage). The portion of drug costs we pay for these drugs is applied to the extra benefit that we give you to enhance your initial coverage limit. Once that amount is used by you for either Medicare Part D covered drugs, or the additional drugs we offer to you, 100% of the cost for those drugs will be paid out of pocket by you.

How to use the UPREHS Prime Medicare Part D Plan Formulary Book
The formulary provides coverage information about the drugs covered by UPREHS. If you have trouble finding your drug in the Therapeutic Category List, turn to the Alphabetical Listing. Generic drugs are listed in lower-case italics (e.g., amitriptyline) within the formulary lists. Brand name drugs are capitalized in the formulary lists (e.g., LEVAQUIN).

How do you find out what drugs are on our formulary?
You have been sent a 2010 UPREHS Prime Medicare Plan Preferred Drug Formulary Book with all tier
1, 2 and 4 preferred formulary drugs listed. If the Part D drug is not in those tiers, it is in tier 3,
nonpreferred formulary drugs. All covered Medicare Part D drugs are on your formulary including some
drugs not covered by Medicare. Since a formulary can change at any time, if there is any question about
drug coverage, you must call Customer Services for clarification at 1-800-547-0421. You can also get
updated information about the drugs covered by us by visiting our Website at www.uphealth.com.

What are drug tiers?
Drugs on our formulary are organized into different drug tiers, or groups of different drug types. Your copayment depends on which drug tier your drug is in. The table below shows the copayment amount you pay for each tier when you are in your initial coverage period and when you obtain your prescription from the DEPOT DRUG MAIL, DEPOT DRUG Walk-In Pharmacies, Ascend Specialty Drug Pharmacy, or a nonpreferred network retail pharmacy. As you can see, your benefits are stretched through lower copayments and lower drug prices when you obtain your prescriptions from the DEPOT DRUG MAIL Pharmacy. We are able to pass our quantity discounts back to you in the form of expanded benefits, lower copayments, and lower charges for your drugs.

Use the preferred Ascend Specialty Pharmacy
Ascend Specialty Pharmacy provides self-injectable medications that treat conditions such as Rheumatoid Arthritis, Multiple Sclerosis, Hepatitis-C, Cancer, Transplant and other conditions requiring self-injectable medications (excluding insulin). These medications often require special mail handling because of spoilage possibilities. UPREHS believes that you should have specialized care provided by Ascend including educational materials and pharmacy counseling to help you understand your medication therapy.

UPREHS saves you money and stretches your benefits by using the UPREHS preferred Ascend Specialty Pharmacy. We even provide you with the same low Tier copayment amounts through Ascend as you get when you use the Depot Drug Mail Pharmacy. Specialty Pharmacy medications are very expensive so UPREHS has contracted with Ascend for very low costs for you. Less money charged to your benefit gives you more prescriptions before you need to pay out of pocket. You have the option to enroll in this additional benefit at no cost and have specialty medications delivered directly to you by Ascend Specialty Pharmacy. You will always be advised when to expect your shipment and most medications are shipped overnight via priority mail. In addition, you will be provided with unlimited access to skilled specialty pharmacy consultation. You may contact them at 1-800-850-9122 toll-free.

ALPHABETICAL DRUG LIST (ALPHABETICAL DRUG INDEX)
Drugs are listed alphabetically by name with the page where the drug is under the Therapeutic Category Listing. You can turn to that page in the Therapeutic Category to see the coverage information for that drug.

THERAPEUTIC DRUG LIST (MEDICAL CONDITION)
Drugs in this listing are grouped depending on the type of Therapeutic Category that they are used to treat. Physicians most often used this list to identify your formulary drugs. The Therapeutic Category drugs are listed alphabetically in their Drug Class and the drugs within the class are listed alphabetically by name. A Therapeutic Category Drug Class can have numerous sub-classes. For example, drugs used to treat pain are listed under the Drug Class category, Analgesics and then under the sub-class Opioid Analgesics; then alphabetically aspirin/codeine by name. Another example are drugs used to treat a heart condition are listed under the Drug Class, Cardiovascular Agents and then alphabetically by sub-class Platelet Aggregation Inhibitors and then alphabetically by name PLAVIX. If you know what your drug is used for, look for the Therapeutic Category. Then look under the Drug Name for your drug.

Last Updated: 04/11/2010

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