Medicare AdvantageCoverageMedium impact
Important updates on influenza prevention and treatment
UPMC Health Plan·Family Medicine, Internal Medicine, Geriatrics +3 more·Provider Notice
Effective date
Feb 1, 2025
We identified it
Aug 7, 2026
Summary
UPMC Health Plan now covers oseltamivir (generic Tamiflu) at $0 cost share for seniors (age 65+) and certain high-risk members with Medicare Part D benefits, effective February 1, 2025. This is a coverage expansion for antiviral flu treatment. The policy reinforces clinical recommendations for antiviral therapy, masking, and flu vaccination but does not introduce new billing requirements.
Action Required
By February 1, 2025: Billing team should verify member eligibility for $0 cost-share oseltamivir through UPMC Health Plan systems before processing pharmacy claims. Confirm that prescriptions route to preferred, in-network pharmacies to ensure the $0 cost-share applies. Providers should document medical necessity (suspected or confirmed influenza with high-risk status) on prescriptions to support coverage. No changes to billing codes or prior authorization workflows are required, but claims processing staff should be aware that cost-sharing for this medication has changed for specified UPMC for Life and UPMC for Life Complete Care (HMO D-SNP) members. Communicate this change to prescribing providers so they understand the benefit for eligible patients.