Pharmacies and Claims

The Prime Therapeutics network for University of Michigan prescription drug plan members covers over 95% of the pharmacies in Michigan, including most major pharmacy chains. You can also save money on prescriptions when you fill eligible medications through a mail order service.

Find a Retail Pharmacy

To find a pharmacy that accepts your Prime Therapeutics card anywhere in the U.S.:

File a Claim

If you have your prescription filled at a pharmacy that does not participate in the Prime Therapeutics network, or if you do not present your Prime Therapeutics drug plan ID card when you fill a prescription at a participating network pharmacy, call the Shared Services Center - HR Customer Care at 734-615-2000 locally or 1-866-647-7657 toll-free for off-campus long-distance calls within the U.S., to speak with a representative Monday - Friday, 8 a.m. - 1 p.m. and 2-5 p.m. Ask for the Prescription Drug Team to see if you can be reimbursed at the pharmacy. If you do not receive reimbursement at the pharmacy, you will need to:

  1. Pay the full cost of the drug.

  2. File a claim with Prime Therapeutics for reimbursement within 90 days of the fill date.

Reimbursement claims are limited to a 34-day supply based on the contracted price that a participating pharmacy would charge for the same drug, minus your copay amount. The plan will not reimburse member costs above the contracted price.

Mail your reimbursement claim form as instructed on the form.

Coordination of Benefits and Secondary Claims

You may be covered by more than one health plan that includes prescription drug coverage. When your plans are coordinated with one another, they work together to give you maximum benefits.

All prescription drug claims must be processed within 90 days of the date of service to receive payment, consistent with Medicare Part D requirements. The University of Michigan drug plan will not adjudicate claims over 90 days old.

For those not Medicare eligible, your primary prescription drug plan is the coverage you select through your own employer, while coverage under your spouse’s employer is generally your secondary carrier. When your U-M health plan is your primary prescription drug plan, it pays for all covered prescription drugs, less copays and deductibles, if applicable. Your secondary health plan may pay for drugs not covered by the U-M Prescription Drug Plan, and possibly part of the copays required under the U-M plan.

When a non-U-M prescription drug plan is primary, but does not cover the drugs you received, U-M Prescription Drug Plan pays for drugs which are covered under the U-M plan, less copays and deductibles.

If you are insured under more than one plan with drug coverage, it is your responsibility to notify the pharmacy you use at the time of purchase for coordination of your benefits. Failure to bill the University of Michigan prescription drug plan and other drug plan(s) appropriately could result in additional out-of-pocket expenses for you.

When a member has prescription drug coverage through another plan that does not contain a coordination of benefits provision, the benefits of that other plan shall, to the extent not prohibited by applicable law, be payable before U-M Prescription Drug Plan determines the extent, if any, to which any drugs provided to the member constitute covered drugs. Unless a Medicare Part D plan is primary, any benefits payable under the other plan shall not exceed the amount U-M Prescription Drug Plan would have paid if there was no other plan. If a person has a Medicare Advantage Plan that includes prescription drug coverage, the U-M plan will not pay any prescription drug benefits (nor medical benefits).

For members with coverage under another prescription drug plan with applicable coordination of benefits clauses, all benefits will be coordinated in accordance with applicable law and the terms and conditions of the U-M Prescription Drug Plan. When coverage under U-M Prescription Drug Plan and coverage under another plan applies, the order in which the various plans will pay drug benefits will be determined as follows using the first rule that applies:

  1. A plan that covers a person other than as a dependent will be deemed to pay its benefits before a plan that covers the person as a dependent; except that if the person is also enrolled as a Medicare beneficiary Medicare is: (i) secondary to the plan covering the person as a dependent; and (ii) primary to the plan covering the person as other than a dependent. In this case, the benefits of a plan that covers the person as a dependent will be determined before the benefits of a plan that covers the person as other than a dependent and is secondary to Medicare.

  2. The plan that covers the person as a dependent child of a person whose birthday comes first in a calendar year will be primary to the plan that covers the person as a dependent child of a person whose birthday comes later in that calendar year. If both parents have the same birthday, the benefits of a plan that covered one parent longer are determined before those of a plan that covered the other parent for a shorter period of time.

  3. Claims for dependent minor children of separated or divorced spouses or children whose custody or guardianship is determined by a court will be processed in accordance with the following rules:

    1. Benefits for a minor child of divorced or separated parents will be determined first by the court decree and second by the plan covering the child as a dependent of the parent with legal custody prior to the plan of the parent without legal custody.

    2. Benefits of the plan covering the minor child of a remarried parent with legal custody will be determined first by the plan of the parent with legal custody; second, by the plan of the spouse of the parent with legal custody; and finally, by the plan of the parent without legal custody.

    3. In the event of joint legal custody, benefits for a minor dependent child of divorced or separated parents will be determined as provided in section “b” above.

    4. If, however, a court decree otherwise establishes financial responsibility for medical, dental or other health care expenses for minor children, subsections (i) through (iii) will not apply. Benefits of the plan covering the minor child as a dependent of the parent with such responsibility will be determined prior to any other plan that covers the minor child as a dependent.

  4. If subsections “a”, “b”, and “c” above do not establish an order of payment, the plan under which the person has been covered for the longest will pay its benefits first, subject to the following: The plan that covers the person as a laid off or retired employee or his/her dependent shall be determined after the benefits of any other plan that covers the person as an employee who is not laid-off or retired or his/her dependent. If the other plan is lawfully issued in another state and does not have a provision regarding laid-off or retired employees; and, as a result, each plan determines its benefits after the other, then this paragraph will not apply.

  5. The benefits of a plan that covers the person on whose expenses a claim is based under a right of continuation pursuant to federal or state law shall be determined after the benefits of any other plan that covers the person other than under such right of continuation. If the other plan does not have a provision regarding the right of continuation pursuant to applicable law; and, as a result, each plan determines its benefits after the other, then this paragraph will not apply.

Disclaimer

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 Prime Therapeutics pricing tool. The pricing tool will not provide cost estimates for the product selection penalty or medications that require prior authorization.