Coverage and Drug Information

The University of Michigan prescription drug plan covers outpatient, self-administered medications that require a written prescription.  Within the plan, medications are divided into three tiers with three levels of copays:

  • Tier 1 – Generic Drugs – lowest copay

  • Tier 2 – Preferred Brand Name Drugs – intermediate copay

  • Tier 3 – Non-Preferred Brand Name Drugs – highest copay, plus possible product selection penalty

Prescription  refers to an order written by any licensed physician, or others licensed to prescribe (such as a dentist, physician’s assistant, or nurse practitioner) for a medicinal substance which, under the Federal Food, Drug, and Cosmetic Act, is required to bear on the packaging label the following legend: “Caution: Federal Law prohibits dispensing without a prescription” or “Rx Only.”  

Certain preventive products are covered by the prescription drug plan at $0 copay under the Affordable Care Act.

Drug Tiers

The University of Michigan provides access to approved medications, although there may be higher copays for non-preferred drugs. Appeals for lower copays are not accepted.

Tier 1 – Generic Drugs

Generic drugs cost significantly less on average than comparable brand-name drugs and have different names. Generic drugs are approved by the United States Food and Drug Administration (FDA), contain the same active ingredients and come in the same dosage forms as their brand-name counterparts, and must meet the same safety, production and performance standards.

Tier 2 – Preferred Brand Name Drugs

Brand name drugs are patent-protected and product-trademarked. For each drug class (e.g., cardiovascular, depression), there may be several drugs produced by different manufacturers with different prices that are equal in therapeutic value. Preferred brand name drugs are selected based on clinical efficacy and safety as well as best financial value. Preferred brand name, generic and second tier drugs for the most common drug categories are provided on the U-M Prescription Drug Plan formulary.   

Tier 3 – Non-Preferred Brand Name Drugs

Drugs on the third copay tier are brand-name, FDA-approved drugs that university physicians and pharmacists have not designated as “preferred.”  If a generic equivalent is available, a brand name drug is subject to a higher copay plus a product selection penalty (the cost difference between the generic and brand name medication). These products often are in drug classes that include several similar alternative brand name or generic options.

Search for specific drug information on the formulary, specialty drug list or the MedImpact Drug Price Check.

Coverage

The plan covers:

  • All legend drugs that are approved by the FDA, unless specified otherwise.

  • Drug Efficacy Study Implementation Program (DESI) drugs that lack formal evidence of effectiveness but have been used and accepted for many years without significant safety problems.

  • Emergency allergic reaction kits.

  • Diabetic injectable insulin, needles, and syringes.  Coverage of other diabetic supplies (injection devices, alcohol swabs, testing strips, lancets, and blood glucose testing monitors) is determined by your health plan participation and may be covered at $0 copay when the health plan ID card is used at an authorized provider. Contact your health plan administrator for further instructions on how to obtain diabetic supplies or reimbursement through your health plan.

  • Sterile water for self-administered injection only.

  • Compounded medications are prepared to meet the needs of individual patients and are not FDA approved. They are covered only if they meet ALL of the following criteria (note: compounded medications cannot be filled at NoviXus mail service):

    • The compounded medication must contain at least two covered ingredients,

    • At least one active ingredient must require a prescription by federal law pursuant to an FDA review and approval process,

    • The compounded medication does not require administration by a healthcare professional,

    • The active ingredient(s) must be approved by the FDA for medicinal use in the United States,

    • The compounded medication is not a copy of a commercially available FDA approved product,

    • The safety and effectiveness for the intended use is supported by FDA approval or adequate medical and scientific evidence in the medical literature, and

    • The compounded medication is not intended to replace a drug that has been withdrawn from the market for safety reasons.

Compounds containing bulk chemicals are not covered by the prescription drug plan. Bulk chemicals are not regulated or approved by the FDA, nor is there clinical evidence available to support effectiveness and safety. View the following exceptions per the State of Michigan pediatric compound formulations.

Pediatric Compound Exceptions

​The following compound formulations that contain bulk chemicals are eligible for coverage because they are among the standard pediatric compound formulations developed through a statewide initiative in Michigan. These formulations were developed based on clinical evidence. This list will change as standardized formulations containing bulk chemicals are added, removed, or revised. For the most up-to-date information, please refer to the State-Wide Initiative to Standardize the Compounds of Oral Liquids in Pediatrics.

  • Chloroquine 10 mg/ml oral suspension
  • Chlorpromazine 30 mg/ml oral suspension
  • Ethacrynic acid 1 mg/ml oral suspension
  • Hydrochlorothiazide 10 mg/ml oral syrup
  • Hydroxyurea 100 mg/ml oral solution
  • Methotrexate 0.5 mg/ml oral suspension
  • Metronidazole 50 mg/ml oral suspension
  • Quetiapine 40 mg/ml oral suspension
  • Sodium chloride 4 mEq/ml oral solution
  • Tretinoin 10 mg/ml oral suspension
  • Zinc acetate 10 mg/ml oral syrup

For more information, see Frequently Asked Questions about Pharmacy Compounds.

​Please note: FDA approval of a drug does not guarantee coverage by the plan. New drugs are subject to review by the university and MedImpact before being covered or excluded.  Certain medications and drugs are limited, excluded, or require prior authorization from the plan.

Products Covered at $0 Copay

Certain preventive products are covered by the prescription drug plan at $0 copay under the Affordable Care Act with a written prescription from your health care provider, including for over-the-counter (OTC) products:

  • Aspirin (covered for members age 45 and older)

  • Birth control

    • Self-administered generic hormonal birth control products

    • Self-administered brand hormonal birth control products if no generic equivalent is available

    • Diaphragms and OTC female contraceptives including spermicides, sponges, and female condoms

  • Folic acid (covered for women ages 11 to 49)

  • Fluoride supplements (covered for children up to age 18)

  • Iron supplements (covered for children age 6 to 12 months)

  • Tobacco cessation products (prescription and generic OTC products including gum, lozenges, and patches)

  • Single-entity vitamin D2 and D3 (covered for members age 65 and older)

  • Breast cancer prevention medications tamoxifen and Raloxifene

  • Generic cholesterol medications, known as "statins," to help prevent cardiovascular events in patients who are at risk. Please note that a copay is required for brand name statins.

See HealthCare.gov for a complete list of covered preventive drugs and services.

Exclusions

The plan does not cover:

  • Topical acne medications for individuals age 40 and older.

  • Stimulant-based weight loss products.

  • Blood products.

  • Diagnostic agents.

  • Items approved as devices by the FDA do not go through the same review and approval process as drugs.

  • Cosmetic products or any drug used for cosmetic purposes such as treating facial wrinkles or hair loss.

  • Drugs that lack substantial evidence of safety and efficacy for the proposed use.  These include but are not limited to experimental, investigational, or unproven drugs, or drugs being used for indications that have not been approved by the FDA. Exceptions may be considered using the standard appeal process as allowed under the Affordable Care Act.

  • Injectable medications, except those listed in this website as covered; injections that must be administered by a health care professional are not covered.

  • In general, new drugs and medicines that have not been reviewed by the plan.

  • Prescription products that offer no additional clinical benefit over existing available therapies or existing therapeutically equivalent products in the drug class.

  • Generally, prescription products that are the main active metabolite, the isolated enantiomer, prodrug, or an alteration of an existing product where no added clinical benefits have been shown by published, scientific, peer-reviewed, head-to-head comparative studies.

  • Medical foods.

  • Vitamins, other than prenatal vitamins, injectable B-12, D, K and vitamins specified in the Affordable Care Act.

  • Therapeutic devices, appliances or medical equipment, support garments, or ostomy supplies.

  • Most over-the-counter (OTC) medications, any prescription medication that contains the same active ingredient(s) as an existing OTC medication, or kits that are packaged with an OTC medication.  Select preventive OTC drugs and products are covered at $0 copay under the Affordable Care Act with a written prescription by your physician.

  • Compounded prescription medications that contain bulk chemicals.

Note: Your U-M health plan benefits may cover certain medical equipment and supplies and/or injectables administered by your health care provider.  Questions about items covered or excluded by your health plan should be directed to your health plan company.

Refills

Copays are established for a medication supply for 1-34 days, 35-60 days, and 61-90 days. To have a 90-day supply dispensed, your health care provider must write your prescription for a 90-day quantity.  To maximize cost savings for your maintenance medications, your provider should write a 90-day prescription to be filled either at your local retail pharmacy or through NoviXus mail order service. Mail order should not be used for medications needed immediately, such as antibiotics, or for short-term medications that will be used for less than three months.

Prescriptions cannot be refilled before 75% use (26 days for a 34-day supply or 68 days for a 90-day supply).

One month extra refill of your prescriptions for vacations or travel can be requested by contacting MedImpact at 1-800-681-9578. For longer overseas trips, contact the SSC Contact Center at 734-615-2000. A maximum of two vacation overrides per medication are allowed each year.

Quantity Limits

Some drugs are subject to quantity limits on the amount that you can obtain by plan policy to provide quality and safety.  See the U-M Prescription Drug Plan Formulary for details on specific medications.

If your prescription exceeds the quantity limits, your physician may contact MedImpact to discuss additional supplies by calling 1-800-681-9578.

Step Therapy

Selected drug classes are reviewed and coverage is based on medical evidence. The physician must verify the patient’s trial of a particular drug in the therapeutic class before coverage is allowed for another drug (step drug progression) or provide medical documentation that the patient should be dispensed a drug out of sequence.

Traveling

If you need extra medications for travel, one extra month refill of your prescriptions for vacation can be requested by contacting MedImpact Member Service at 1-800-681-9578.  If you need a supply for more than an extra 34 days, please contact the SSC Contact Center at 734-615-2000 or 866-647-7657 (toll free) at least a week prior to leaving the country.  Before calling, please make sure your pharmacy has a prescription with enough refills for the duration of your trip.

Purchasing Drugs Abroad

Purchasing prescription drugs for personal use in foreign countries and transporting them back into the United States (reimportation) is illegal in the United States. The University of Michigan prescription drug plan does provide for claim reimbursement up to a 34-day supply when drugs are purchased outside the United States on an emergency basis. Regular purchasing of monthly supplies outside the U.S. is discouraged and may result in denial of claims being paid unless pre-approved by the drug plan (i.e., for individuals who live outside the U.S.).