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 tiers with different copay levels:

  • Tier 0 – Preferred Insulins and Affordable Care Act Preventative Products – zero copay

  • 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 0 – Preferred Insulins and Affordable Care Act Preventive Products

Preferred insulins and 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. 

Tier 0, preferred brand name drugs will automatically move to Tier 3 non-preferred status when an FDA-approved generic enters the market.

Products Covered at $0 Copay with a Written Prescription

  • Aspirin (covered for members age 45 and older)

  • Birth control

    • Self-administered generic hormonal birth control products

    • 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)

  • Insulin:

    • Self-administered generic biosimilar or follow-on insulin products (e.g., insulin lispro (Admelog), insulin glargine (Basaglar), insulin aspart)

    • Self-administered brand insulin products, if no biosimilar or follow-on is available  (e.g., Humulin, Novolin)

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

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

  • Breast cancer prevention medications tamoxifen and raloxifene

  • Generic cholesterol medications, known as "statins," to help prevent cardiovascular events in patients who are at risk.

  • Vaccines: select preventive immunizations are covered when administered at immunizing pharmacy

  • Generic medications approved for the prevention of Human Immunodeficiency Virus (HIV)

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

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. Tier 2, preferred brand name drugs will automatically move to Tier 3 non-preferred status upon generic market entry of an FDA approved generic.

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 or Magellan Rx.


Drug formulary coverage is evaluated on several criteria including efficacy, safety, clinical appropriateness, place in therapy, treatment guidelines, clinical expert opinion, therapeutic alternatives, cost, and utilization. Financial considerations may be included in determining the best value for formulary coverage. See News and Updates for the information on drug coverage changes.

New drug entities are excluded from coverage until the plan has had the opportunity to review the product for formulary consideration.

Opioid Coverage

As of July 1, 2018, consistent with Michigan’s Public Act 251 of 2017, opioid prescriptions for acute pain are limited to a 7-day supply.

For a summary of all new opioid laws in Michigan, please refer to the Department of Licensing and Regulatory Affairs (LARA) and the Michigan Department of Health and Human Services (DHHS)’s Frequently Asked Questions document.


The plan does not cover:

  • Blood products.

  • Diagnostic agents.

  • Therapeutic devices, appliances or medical equipment, support garments, or ostomy supplies (diabetic syringes are covered under the prescription plan; for durable medical equipment (diabetic testing supplies, ostomy supplies, etc.) coverage information, contact your medical benefit provider).

  • 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 select prescription prenatal vitamins, vitamin D, K, injectable B-12 and those specified in the Affordable Care Act.

  • 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.


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 Birdi 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.

One month extra refill of your prescriptions for vacations or travel can be requested by contacting Magellan Rx at (888) 272-1346. 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 Magellan Rx to discuss additional supplies by calling (888) 272-1346.

In an effort to provide greater patient support and avoid medication waste, the plan has a Split-Fill Program for select medications. The Split-Fill Program requires a trial of a medication for a shorter time, confirming effectiveness and tolerance, before filling a larger supply. Products with a split-fill requirement are limited to a 14- or 15-day supply for the first three months of fills (i.e., six split-fills), after which a month’s supply is generally permitted. Split-fills will process at the pharmacy, with a copay corresponding to the supply received (e.g., a half-copay for a 15-day supply). Medications with a split-fill requirement are denoted with an “SF” on the Magellan formulary tool.

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.


If you need extra medications for travel, one extra month refill of your prescriptions for vacation can be requested by contacting Magellan Rx at (888) 272-1346.  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 other 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. Download the University of Michigan Prescription Drug Claim Form. 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.).


Please be advised that the University of Michigan Prescription Drug Plan formulary is updated periodically and changes may appear prior to their effective date to allow for client notification. The University of Michigan does not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. The medical provider should consult the drug manufacturer's product literature or standard references for more detailed information. Every effort is made to ensure complete and accurate information; however, the most accurate source of medication coverage and member cost is the Magellan Rx pricing tool. The pricing tool will not provide cost estimates for the product selection penalty or medications that require prior authorization.