Updates to your prescription benefits
|
|
- Lindsey Park
- 5 years ago
- Views:
Transcription
1 Updates to your prescription benefits Effective Jan. 1, 2018 Update Summary Within the Prescription Drug List (PDL), medications are grouped by tier. The tier indicates the amount you pay when you fill a prescription. Please reference this chart as you review the following updates. $ $$ $$$ Tier 1 Tiers 2 and 3 Tier 4 Your lowest-cost medications Your mid-range cost medications Your highest-cost medications Medications with new benefit coverage. The following medications were previously not covered under most benefit plans and are now eligible for coverage. Therapeutic Use Medication Name Tier Placement Allergies RyVent 4 Chest Pain GoNitro 4 Constipation Trulance 4 Dry Eye Disease Restasis MultiDose 4 Eye Pain/Inflammation BromSite 4 Hepatitis C Infections Mavyret Vosevi Daxbia Otovel 2 4 Migraines Ergomar 4 Oral Steroid LoCort ZonaCort 4 Osteoporosis Tymlos 3 Skin Conditions Micort-HC 2.5% cream Rhofade 4 Access Four-Tier Member Update Summary
2 Medications moving to a lower tier. The following medications are moving to a lower tier, making them more affordable. Therapeutic Use Medication Name Tier Placement Inflammatory Conditions Otezla 4 u 2 Pain Xtampza ER 3 u 2 Medications moving to a higher tier. Medications may move from a lower tier to a higher tier when they are more costly and have available lower-cost options. Therapeutic Use Acne Allergic Reactions Cancer Medication Name Differin 0.1% cream, gel, lotion* EpiPen (Brand Only)* EpiPen Jr (Brand Only)* Mekinist Tafinlar Tier Placement Lower-Cost Options 3 u 4 OTC Differin gel 2 u 4 epinephrine auto-injector (generic EpiPen) epinephrine auto-injector (generic EpiPen Jr) 2 u 3 Discuss with your doctor Contraceptive Natazia $0 u 2 $0 cost-share contraceptives Hepatitis C Daklinza Sovaldi 2 u 4 Discuss with your doctor Infections Albenza 2 u 4 OTC pyrantel pamoate Ciprodex otic 2 u 3 ofloxacin 0.3 % solution (generic Floxin Otic, Ocuflox) Osteoporosis Forteo 2 u 3 Discuss with your doctor Medications excluded from benefit coverage. We evaluate medications based on their total value, including how a medication works and how much it costs. When several medications work in the same way, we may choose to exclude the higher-cost option. Effective Jan. 1, 2018, the medications listed below may be excluded from coverage or subject to prior authorization (sometimes referred to as precertification) and/or trial/failure** of another medication(s). You should review your benefit plan documents and pharmacy benefit coverage for a full list of medications that are excluded or have programs or limits that apply. Therapeutic Use Medication Name Lower-Cost Options ADHD Strattera (Brand Only) atomoxetine (generic Strattera) Asthma/COPD AirDuo Respiclick (Brand Only) fluticasone/salmeterol powder for inhalation (generic AirDuo Respiclick), Advair Diskus/HFA, Breo Ellipta, Symbicort Cholesterol/Lipid Lowering Vytorin (Brand Only) simvastatin/ezetimibe (generic Vytorin) Diabetes*** Xultophy Soliqua * Medication is typically excluded from benefit coverage. ** Referred to as First Start in New Jersey. *** For Oxford plans, diabetic supplies and prescription medications may be subject to different cost-share arrangements. Please see your Summary of Benefits and Coverage (SBC) for specifics.
3 Therapeutic Use Medication Name Lower-Cost Options Duchenne Muscular Dystrophy Elevated Parathyroid Hormone Endocrine Disorders Emflaza Rayaldee Sandostatin (Brand Only) prednisone calcitriol (generic Rocaltrol), doxercalciferol (generic Hectorol), paricalcitol (generic Zemplar) octreotide (generic Sandostatin) Hepatitis B Baraclude tablets (Brand Only) entecavir tablet (generic Baraclude) Dutoprol metoprolol (generic Toprol-XL) plus hydrochlorothiazide High Blood Pressure Inderal LA (Brand Only) metoprolol extended-release/ propranolol extended-release capsule (generic Inderal LA) hydrochlorothiazide (Dutoprol metoprolol (generic Toprol-XL) plus hydrochlorothiazide Authorized Generic) Infections Vigamox (Brand Only) moxifloxacin ophthalmic solution (generic Viagamox) Influenza Tamiflu capsules (Brand Only) oseltamivir capsules (generic Tamiflu) Mental Health Opioid Induced Constipation Pain Parkinson's Disease Skin Conditions Pristiq (Brand Only) Prozac Weekly (Brand Only) Seroquel XR (Brand Only) Relistor tablet Arymo ER Opana ER Azilect (Brand Only) Cordran cream (Brand Only) Cordran lotion (Brand Only) desvenlafaxine extended-release tablet (generic Pristiq) fluoxetine capsules (generic Prozac) quetiapine extended-release (generic Seroquel XR) Movantik morphine sulfate extended-release tablet (generic MS Contin), Nucynta ER, Xtampza ER rasagiline (generic Azilect) flurandrenolide 0.05% cream (generic Cordran cream), hydrocortisone valerate 0.2% cream (generic Westcort cream), prednicarbate 0.1% cream (generic Dermatop cream) flurandrenolide 0.05% lotion (generic Cordran), triamcinolone acetonide 0.1% lotion (generic Kenalog lotion)
4 Prescription medications with over-the-counter equivalents.**** Prescription medications containing the same active ingredient available in an over-the-counter product may be excluded from coverage. Therapeutic Use Medication Name Lower-Cost Options Stroke & Heart Attack Prevention Yosprala OTC aspirin plus omeprazole (Prilosec), pantoprazole (Protonix) **** This is not applicable for plans written in New Jersey. For New York plans, a prescription drug product that is therapeutically equivalent to an over-the counter drug may be covered if it is determined to be medically necessary. Visit the member website listed on your health plan ID card to look up the price of drugs covered by your plan, find lower-cost options and more. For more information, call the toll-free phone number on the back of your health plan ID card to speak with a Customer Service respresentive. This document applies to commercial group members of UnitedHealthcare and Oxford New York and New Jersey plans. UnitedHealthcare is a registered trademark owned by UnitedHealth Group, Inc. All branded medications are trademarks or registered trademarks of their respective owners. Please note not all PDL updates apply to all groups depending on state regulation, riders and SPDs. Insurance coverage provided by or through UnitedHealthcare Insurance Company, UnitedHealthcare Insurance Company of New York, or Oxford Health Insurance, Inc. Oxford HMO products are underwritten by Oxford Health Plans (NJ), Inc. Administrative services provided by United HealthCare Services, Inc., UnitedHealthcare Service LLC, Oxford Health Plans LLC, or their affiliates. MT MS / United HealthCare Services, Inc. Access Four-Tier PDL Update Summary
5 Nondiscrimination notice and access to communication services UnitedHealthcare and Oxford do not discriminate on the basis of race, color, national origin, age, disability or sex in its health programs or activities. If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to the Civil Rights Coordinator. Online: UHC_Civil_Rights@uhc.com Mail: Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box Salt Lake City, UT You must send the complaint within 60 days of your experience. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, please call the toll-free phone number listed on your ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m. if you are a UnitedHealthcare member, or Monday through Friday, 8 a.m. to 6 p.m. if you are a member of an Oxford plan. You can also file a complaint with the U.S. Dept. of Health and Human Services. Online: Complaint forms are available at Phone: Toll free , (TDD) Mail: U.S. Dept. of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, D.C We provide free services to help you communicate with us, including letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the toll-free phone number listed on your ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m. if you are a UnitedHealthcare member, or Monday through Friday, 8 a.m. to 6 p.m. if you are a member of an Oxford plan.
6
Updates to your prescription benefits
Updates to your prescription benefits Effective Jan. 1, 2018 Update Summary Within the Prescription Drug List (PDL), medications are grouped by tier. The tier indicates the amount you pay when you fill
More informationUpdates to your prescription benefits
Updates to your prescription benefits Effective January 1, 2018 Update Summary Within the Prescription Drug List (PDL), medications are grouped by tier. The tier indicates the amount you pay when you fill
More informationUpdates to your prescription benefits
Updates to your prescription benefits Effective Jan. 1, 2018 Update Summary Within the Prescription Drug List (PDL), medications are grouped by tier. The tier indicates the amount you pay when you fill
More informationSubject: HPN/SHL COMMERCIAL PDL UPDATES EFFECTIVE JANUARY 1, 2018
Date: November 7, 2017 To: From: HPN/SHL Contracted Pharmacies and Providers Ryan Bitton, PharmD, MBA Senior Director, Pharmacy Subject: HPN/SHL COMMERCIAL PDL UPDATES EFFECTIVE JANUARY 1, 2018 Effective
More informationPharmacy Benefit Coverage Updates Jan. 1, 2018
Pharmacy Benefit Coverage Updates Jan. 1, 2018 UnitedHealthcare routinely evaluates prescription benefit coverage to help ensure we offer members affordable and effective medication options. Medications
More informationUpdates to your prescription benefits
Updates to your prescription benefits Effective July 1, 2018 Update Summary Within the Prescription Drug List (PDL), medications are grouped by tier. The tier indicates the amount you pay when you fill
More informationUpdates to your prescription benefits
Updates to your prescription benefits Effective July 1, 2018 Update Summary Within the Prescription Drug List (PDL), medications are grouped by tier. The tier indicates the amount you pay when you fill
More information$250 (Deductible does not apply to Tier 1 and Tier 2) $500 (Deductible does not apply to Tier 1 and Tier 2)
Benefit Summary Outpatient Prescription Drug Illinois 5/50/100/250 Plan 455 Your Co-payment and/or Co-insurance is determined by the tier to which the Prescription Drug List (PDL) Management Committee
More informationUpdates to your prescription benefits
Updates to your prescription benefits Effective Jan. 1, 2019 Traditional Three-Tier PDL Update Summary Within the Prescription Drug List (PDL), medications are grouped by tier. The tier indicates the amount
More informationUpdates to your prescription benefits
Updates to your prescription benefits Effective January 1, 2019 Update Summary Within the Prescription Drug List (PDL), medications are grouped by tier. The tier indicates the amount you pay when you fill
More informationHealth TALK. Heart smart. Plan to quit. Know your cholesterol numbers.
Health TALK FALL 2018 VOLTEE PARA ESPAÑOL! Plan to quit. Every November, the Great American Smokeout asks everyone to quit smoking. You can quit for just that one day, or it could be the fi rst day of
More informationHealth TALK. Mammograms save lives. Plan to quit.
Health TALK FALL 2018 VOLTEE PARA ESPAÑOL! Plan to quit. Every November, the Great American Smokeout asks everyone to quit smoking. You can quit for just that one day. Or it could be the fi rst day of
More informationSanta Clara Family Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan) 2017 Drug List
Upcoming Changes to Santa Clara Family Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan) 2017 Drug List Updated 8/1/2017 Santa Clara Family Health Plan (SCFHP) Cal MediConnect Plan (Medicare-Medicaid
More informationHealth TALK. Toothache? Did you know?
Health TALK SUMMER 2018 Did you know? About 618 people in the United States are killed by extreme heat every year. Heat-related illnesses happen when the body is not able to properly cool itself. Older
More informationHealth TALK. Toothache? KidsHealth
Health TALK SUMMER 2018 KidsHealth UnitedHealthcare and KidsHealth have teamed up to provide advice you need, when you want it. Parents can get doctor-approved advice. Kids can fi nd fun health games and
More informationHealth TALK. Toothache? Keep your coverage.
Health TALK SUMMER 2018 VOLTEE PARA ESPAÑOL! Keep your coverage. You may have received a letter from the Mississippi Division of Medicaid. A special open enrollment process will begin July 1 through August
More informationHealth TALK. Toothache? KidsHealth
Health TALK SUMMER 2018 KidsHealth UnitedHealthcare and KidsHealth have teamed up to provide advice you need, when you want it. Parents can get doctor-approved advice. Kids can fi nd fun health games and
More information2018 Preventive Schedule
2018 Preventive Schedule Medicare-Covered Services PLAN YOUR CARE: KNOW WHAT YOU NEED AND WHEN TO GET IT Preventive or routine care helps us stay well or finds problems early, when they are easier to treat.
More informationTusculum College. Benefit Summary. $25 Copay. $25 Copay. after Deductible. 20% after Deductible 20% after Deductible
Benefit Plan Features: Annual Deductible Benefit Summary Your Cost In-Network Individual/Family $750/$1500 Annual Out-of-Pocket Maximum Individual/Family $3500/$7000 4th Quarter Carry-over Covered Services
More information2017 Preventive Schedule
2017 Preventive Schedule PLAN YOUR CARE: KNOW WHAT YOU NEED AND WHEN TO GET IT Preventive or routine care helps us stay well or finds problems early, when they are easier to treat. The preventive guidelines
More informationHealth TALK. The right care. Register online!
Health TALK SPRING 2019 VOLTEE PARA ESPAÑOL! Register online! You can get important information about your health plan anytime at myuhc.com/communityplan. At this secure site, you can view your ID card,
More informationDRUG TESTING IN PAIN MANAGEMENT AND SUBSTANCE USE DISORDER(S) TREATMENT
TREATMENT Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent
More informationLARTRUVO (olaratumab)
LARTRUVO (olaratumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationHealth TALK. Take charge. Health4Me TM. Prepare to see your provider.
Health TALK SPRING 2018 Health4Me TM Do you have the UnitedHealthcare Health4Me mobile app? Health4Me has many of the same features as your secure member website, myuhc.com/communityplan. You can view
More informationPediatric Dental and Vision
Individual & Family Plans (IFP) and Small Business Group (SBG) Health Net of California, Inc. (Health Net) Pediatric Dental and Vision Andre Hamil Health Net When you purchase a Health Net PureCare HSP
More informationRELISTOR (methylnaltrexone bromide) INJECTION FOR SUBCUTANEOUS USE
RELISTOR (methylnaltrexone bromide) INJECTION FOR SUBCUTANEOUS USE Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for
More informationDepartment of Origin: Integrated Healthcare Services. Approved by: Chief Medical Officer Department(s) Affected: Date approved: 01/10/17
Reference #: MP/D005 Page: 1 of 3 PRODUCT APPLICATION: PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc. (PAS) Non-ERISA PreferredOne Community Health Plan
More informationCalendar Year Deductible Annual Benefit Maximum. ADA Code Covered Services Member pays. n/a Office visit $5 per visit
Blue Shield of California Dental HMO Plan Dental HMO Basic Benefit summary Effective January 1, 2018 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE
More informationTYMLOS (abaloparatide)
TYMLOS (abaloparatide) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationHealth TALK. Toothache? KidsHealth
Health TALK SUMMER 2018 KidsHealth UnitedHealthcare and KidsHealth have teamed up to provide advice you need, when you want it. Parents can get doctor-approved advice. Kids can fi nd fun health games and
More informationQuarterly pharmacy formulary change notice
Quarterly pharmacy formulary change notice The formulary changes listed in the table below were reviewed and approved at our second quarter 2018 Pharmacy and Therapeutics Committee meeting. Effective October
More informationPANCREATIC ISLET TRANSPLANT
PANCREATIC ISLET TRANSPLANT Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationORAL IMPLANT PROCEDURES
ORAL IMPLANT PROCEDURES Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and
More informationPharmacy benefit guide
FlexRx SM 5-Tier Pharmacy benefit guide 1 Welcome to FlexRx The NHP FlexRx SM program is built for choice, savings, and convenience with benefits including: Low-cost drug tier for many common medications
More informationMEDICAL COVERAGE GUIDELINES ORIGINAL EFFECTIVE DATE: 10/04/17 SECTION: DRUGS LAST REVIEW DATE: LAST CRITERIA REVISION DATE: ARCHIVE DATE:
BAVENCIO (avelumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationDental Options 2018 BALTIMORE CITY PUBLIC SCHOOLS
Dental Options 2018 BALTIMORE CITY PUBLIC SCHOOLS Contents Important Information for 2018... 1 Dental HMO (DHMO) Dental Plan... 2 Preferred Dental PPO (DPPO) Dental Plan... 3 Summary of Dental PPO Benefits...
More informationSmile SM Value 50/1500/No Ortho/MAC
Blue Shield of California Dental PPO Plan Smile SM Value 50/1500/No Ortho/MAC Benefit summary Effective January 1, 2018 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A
More informationQuarterly pharmacy formulary change notice
Provider Bulletin October 2018 Quarterly pharmacy formulary change notice The formulary changes listed in the table below apply to all Anthem HealthKeepers Plus patients. The changes listed in the table
More informationGENETIC TESTING FOR PREDICTING RISK OF NONFAMILIAL BREAST CANCER
Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent upon
More informationGENETIC TESTING FOR TAMOXIFEN TREATMENT
GENETIC TESTING FOR TAMOXIFEN TREATMENT Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical
More information01/10/17. Replaces Effective Policy Dated: Amino Acid Based Elemental Formula (AABF) 09/28/15 Reference #: MP/A003 Page: 1 of 3
Reference #: MP/A003 Page: 1 of 3 PRODUCT APPLICATION: PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc. (PAS) Non-ERISA PreferredOne Community Health Plan
More informationENDOBRONCHIAL ULTRASOUND FOR DIAGNOSIS AND STAGING OF LUNG CANCER
CANCER Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent
More informationHigh-Cost Drug Exclusions
PHARMACY SERVICES High-Cost Exclusions The high cost medications listed below are excluded from coverage because lower cost similar alternatives are available. To help you get the best health benefit at
More informationALPHA1-PROTEINASE INHIBITORS
ALPHA1-PROTEINASE INHIBITORS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationSmile SM Deluxe Gold 50/1500/Ortho/U85
Blue Shield of California Dental PPO Plan Smile SM Deluxe Gold 50/1500/Ortho/U85 Benefit summary Effective January 1, 2017 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS
More informationCalendar Year Deductible Annual Benefit Maximum. ADA Code Covered Services Member pays
An independent member of the Blue Shield Association A50861-SG (1/19) Dental HMO Plan Dental HMO Standard Benefit summary Effective January 1, 2019 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE
More informationIMMUNE CELL FUNCTION ASSAY
IMMUNE CELL FUNCTION ASSAY Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and
More informationNon-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document.
HYDROXYPROGESTERONE THERAPY Makena (hydroxyprogesterone caproate injection) Hydroxyprogesterone caproate compound Hydroxyprogesterone caproate injection with benzyl benzoate and the preservative benzyl
More informationQuarterly pharmacy formulary change notice
MEDICAID PROVIDER BULLETIN October 2018 The formulary changes listed in the table below were reviewed and approved at the second-quarter 2018 Pharmacy and Therapeutics Committee meeting. Effective October
More informationFYI ONLY Generic Name. Generics available. zoledronic acid N/A
Criteria Document: Reference #: PC/A011 Page 1 of 5 PRODUCT APPLICATION: PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc. (PAS) Non-ERISA PreferredOne Community
More informationTusculum College. Benefit Summary Option/Quote: 2. 30% after Deductible. $35 Copay. 30% after Deductible
Benefit Plan Features: Annual Deductible Effective Date: 4/1/2018 Network: S Benefit Summary Option/Quote: 2 Your Cost In-Network Individual/Family $1250/$2500 Annual Out-of-Pocket Maximum Tusculum College
More information2019 Formulary Update
MEDICARE ADVANTAGE BlueShield of Northeastern New York Formulary Update BlueShield of Northeastern New York has updated its formulary (drug list) since its original publication in January. This document
More informationHealth TALK. Heart smart. Plan to quit. Know your cholesterol numbers.
Health TALK FALL 2018 VOLTEE PARA ESPAÑOL! Plan to quit. Every November, the Great American Smokeout asks everyone to quit smoking. You can quit for just that one day. Or it could be the fi rst day of
More informationHEMATOPOIETIC CELL TRANSPLANTATION FOR EPITHELIAL OVARIAN CARCINOMA
CARCINOMA Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent
More informationREQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax:
REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax: Address: Fax Number: Anthem Blue Cross Cal MediConnect Plan 1-844-493-9213 Medicare Prior Authorization
More informationMOLECULAR TESTING IN THE MANAGEMENT OF PULMONARY NODULES
MOLECULAR TESTING IN THE MANAGEMENT OF PULMONARY NODULES Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services,
More informationRADIOFREQUENCY ABLATION OF PRIMARY OR METASTATIC LIVER TUMORS
Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent upon
More informationSmile SM Plus 50/1500/Ortho/MAC
Dental PPO Plan Smile SM Plus 50/1500/Ortho/MAC Benefit summary Effective January 1, 2019 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF
More informationMEMBER GRIEVANCES AND APPEALS PROCEDURES
MEMBER GRIEVANCES AND APPEALS PROCEDURES We value our members. We want you to let us know right away if you are not happy with our health plan. This includes if you have any questions, complaints or problems
More informationFlexRx 6-Tier. SM Pharmacy Benefit Guide
FlexRx 6-Tier SM Pharmacy Benefit Guide Welcome to FlexRx The AllWays Health Partners FlexRx SM program is built for choice, savings, and convenience with benefits including: Low-cost drug tier for many
More informationPARSABIV (etelcalcetide)
PARSABIV (etelcalcetide) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and
More informationINTRAVITREAL IMPLANTS
INTRAVITREAL IMPLANTS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationGENETIC TESTING FOR KRAS, NRAS AND BRAF VARIANT ANALYSIS IN METASTATIC COLORECTAL CANCER
METASTATIC COLORECTAL CANCER Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationBLINCYTO (blinatumomab)
BLINCYTO (blinatumomab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and
More informationMEDICAL COVERAGE GUIDELINES ORIGINAL EFFECTIVE DATE: 12/19/17 SECTION: MEDICINE LAST REVIEW DATE: LAST CRITERIA REVISION DATE: ARCHIVE DATE:
MEDICAL FOODS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are
More informationSOMATULINE DEPOT (lanreotide acetate)
SOMATULINE DEPOT (lanreotide acetate) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical
More informationENTYVIO (vedolizumab)
ENTYVIO (vedolizumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationNon-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document.
XOLAIR (omalizumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationDental Plus of Idaho THE POLICY PROVIDES DENTAL BENEFITS ONLY.
Dental Plus of Idaho THE POLICY PROVIDES DENTAL BENEFITS ONLY. Form No. 005DPID(1/18) The Dental Plus of Idaho plan is a managed care dental policy and is underwritten by: Willamette Dental of Idaho, Inc.
More informationAPOKYN (apomorphine hydrochloride)
APOKYN (apomorphine hydrochloride) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More information2019 PHARMACY DIRECTORY
2019 PHARMACY DIRECTORY This is a brief explanation and overview of the pharmacies members can use to get their prescription drugs. In a continued effort to offer our members value, pharmacies may be added
More informationEXAMPLE ONLY. RxBIN Issuer (80840) ID NAME Drew Zehnder. Houston Methodist 6565 Fannin Street, GB164 Houston, TX 77030
Houston Methodist 6565 Fannin Street, GB164 Houston, TX 77030 00001 RxBIN 004336 RxPCN ADV RxGRP RX3151 Issuer (80840) 9151014609 ID NAME 111111111 Drew Zehnder Present this Prescription Card to fill your
More information2017 Preventive Schedule
2017 Preventive Schedule PLAN YOUR CARE: KNOW WHAT YOU NEED AND WHEN TO GET IT Preventive or routine care helps us stay well or finds problems early, when they are easier to treat. The preventive guidelines
More informationHealth New England (HNE) is making some changes to your Plan, most of which become effective July 1, 2015.
April 17, 2015 FULLY FUNDED PLANS ONLY RE: Semi-Annual Notice of Changes Dear HNE Member: Health New England (HNE) is making some changes to your Plan, most of which become effective July 1, 2015. I have
More informationPart D Pharmacy. An Independent Licensee of the Blue Cross Blue Shield Association ( )
Part D Pharmacy 1 An Independent Licensee of the Blue Cross Blue Shield Association 044507 (12-21-2017) New MA pharmacy partner We ve selected CVS Caremark to manage our part D pharmacy benefits Providence
More informationDrug List exclusions for Blue Cross commercial plans
Drug List exclusions for Blue Cross commercial plans The drugs shown below aren t covered on the commercial Blue Cross Blue Shield of Michigan drug lists. In most cases, if you fill a prescription for
More informationPROTEOMIC TESTING FOR SYSTEMIC THERAPY IN NON-SMALL-CELL LUNG CANCER
CANCER Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent
More informationStep Therapy Criteria
Tier 5 Formulary Step Therapy 2016 Updated: 05/24/2016 Effective: 06/01/2016 What is Step Therapy? Some prescription drugs require step therapy (ST). In some cases, the plan requires you to first try certain
More informationCIMZIA (certolizumab pegol)
CIMZIA (certolizumab pegol) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationNon-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document.
NUCALA (mepolizumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationDrug Formulary Update, April 2017 Commercial and State Programs
Drug Formulary Update, April 2017 Commercial and State Programs Updates to the HealthPartners Commercial and State Program Drug Formularies are listed below. Updates apply to all Commercial groups (PreferredRx,
More informationFECAL ANALYSIS IN THE DIAGNOSIS OF INTESTINAL DYSBIOSIS
FECAL ANALYSIS IN THE DIAGNOSIS OF INTESTINAL DYSBIOSIS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services,
More informationGenerics. Lead with. P r e s c r i p t i o n S t e p T h e r a p y P r o g r a m
Lead with Generics P r e s c r i p t i o n S t e p T h e r a p y P r o g r a m WWW.BCBSLA.COM 04HQ3972 5/09 Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity
More informationSTELARA (ustekinumab)
STELARA (ustekinumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationDrug Formulary Update, January 2017 Commercial and State Programs
Drug Formulary Update, January 2017 Commercial and State Programs Updates to the HealthPartners Commercial and State Program Drug Formularies are listed below. Updates apply to all Commercial groups (PreferredRx,
More information01/26/17. Replaces Effective Policy Dated: Autism Spectrum Disorders in Children: Assessment 01/19/16 and Evaluation Reference #: MP/A005 Page 1 of 4
Reference #: MP/A005 Page 1 of 4 PRODUCT APPLICATION: PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc. (PAS) Non-ERISA PreferredOne Community Health Plan
More information2019 Drug List Negative Changes
2019 Drug List Negative Changes Updated 03/26/2019 If you are taking a drug that is removed from the formulary (also known as the Drug List), we will tell you. We will also tell you if we add any restrictions
More informationMYLOTARG (gemtuzumab ozogamicin)
MYLOTARG (gemtuzumab ozogamicin) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationMULTIMARKER SERUM TESTING RELATED TO OVARIAN CANCER
MULTIMARKER SERUM TESTING RELATED TO OVARIAN CANCER Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures,
More informationINTRAPERITONEAL CHEMOTHERAPY, CYTOREDUCTION
INTRAPERITONEAL CHEMOTHERAPY, CYTOREDUCTION Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures,
More informationAmitriptyline Hydrochloride Heart Health & BP Amlodipine Besylate 5mg Norvasc Antibiotics Amoxicillin 500 mg Amoxil
Antiviral Acyclovir 400mg Zovirax Asthma Advair Diskus Diskus 250/50 Fluticasone/Salmeterol Asthma Albuterol Sulfate 2.5 mg/3 ml Proventil Arthritis and Pain Allendronate Sodium 70 mg Fosamax Arthritis
More informationAmitriptyline Hydrochloride Heart Health & BP Amlodipine Besylate 5mg Norvasc Antibiotics Amoxicillin 500 mg Amoxil
School Corp Formulary Antiviral Acyclovir 400mg Zovirax Asthma Advair Diskus Diskus 250/50 Fluticasone/Salmeterol Asthma Albuterol Sulfate 2.5 mg/3 ml Proventil Arthritis and Pain Allendronate Sodium 70
More information2018 Preventive Schedule Effective 1/1/2018
2018 Preventive Schedule Effective 1/1/2018 PLAN YOUR CARE: KNOW WHAT YOU NEED AND WHEN TO GET IT Preventive or routine care helps us stay well or finds problems early, when they are easier to treat. The
More informationPURPOSE: The intent of this policy is to provide guidelines for coverage of dental procedures under the medical benefit.
Integrated Reference #: MP/D009 Page 1 of 4 PRODUCT APPLICATION: PreferredOne Community Health Plan (PCHP) PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc.
More informationPharmacy Program Updates: Quarterly Pharmacy Changes Effective July 1, 2017
Pharmacy Program Updates: Quarterly Pharmacy Changes Effective July 1, 2017 DRUG LIST CHANGES Based on the availability of new prescription medications and Prime s National Pharmacy and Therapeutics Committee
More information03/13/18. A. Symptoms lasting for greater than or equal to 12 months that have resulted to significant impairment in activities of daily living; and
Reference #: MC/I008 Page: 1 of 5 PRODUCT APPLICATION: PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc. (PAS) Non-ERISA PreferredOne Community Health Plan
More information