Updates to your prescription benefits Effective January 1, 2017 for your Advantage Prescription Drug List

Transcription

1 Updates to your prescription benefits Effective January 1, 2017 for your Advantage Prescription Drug List Please review the following updates. These will affect your Prescription Drug List (PDL) as of January 1, $ $$ $$$ Within the PDL, medications are grouped by tiers. The tier indicates the amount you pay when you fill a prescription. Please reference the chart to the right as you review the updates below. Most options listed are available in Tier 1, your lowest-cost option. Tier 1 Your lowest-cost medications Tier 2 Your mid-range cost medications Tier 3 Your highest-cost medications Please note that some Connecticut plans have a fourth tier that includes higher cost brand-name and generic medications, as well as non-preferred brand-name and specialty medications. 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 norethindrone/ethinyl estradiol / /1-35 mg-mcg (Alyacen 7/7/7, Cyclafem 7/7/7, Dasetta 7/7/7, Necon 7/7/7, Nortrel 7/7/7, Pirmella 7/7/7 (generics for Ortho-Novum 7/7/7)) Oral Contraceptives norgestimate/ethinyl estradiol / / mg-mcg (Tri-Estarylla, Tri-Linyah Tri-Previfem, Tri-Sprintec, Trinessa (generics for Ortho Tri-Cyclen)) norgestimate/ethinyl estradiol 0.25 mg-35 mcg (Estarylla, Mono-Linyah, MonoNessa, Previfem, Sprintec (generics for Ortho-Cyclen)) norethindrone 0.35 mg (Camila, Deblitane, Errin, Heather, Jencycla, Jolivette, Lyza, Nora BE, Norlyroc, Sharobel (generics for Ortho Micronor, Nor-QD))

2 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 Cancer Diabetes* Hemophilia Inflammatory Bowel Disease Inflammatory Conditions Multiple Sclerosis Neutropenia Pain imatinib (generic Gleevec) Basaglar Kovaltry Novoeight Nuwiq Uceris Foam Taltz Plegridy Zarxio Belbuca Xtampza ER until 3/31/2017 beginning 4/1/2017 * Diabetic supplies and prescription medications may be subject to different cost-share arrangements. Please see your Summary of Benefits and Coverage (SBC) for specifics. 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 Medication Name Tier Placement Lower-Cost Options Diabetes* Levemir beginning 4/1/2017 Basaglar Advate Hemophilia Recombinate Kogenate FS, Kovaltry, Novoeight, Nuwiq Xyntha, Xyntha SoloFuse HIV Complera Truvada See PDL for lower cost options

3 Oral Contraceptives Seizures Nor-QD Ortho Cyclen Ortho Micronor Ortho-Novum 7/7/7 Ortho Tri-Cyclen carbamazepine extendedrelease tablet (generic Tegretol XR) divalproex extended-release (generic Depakote ER) norethindrone 0.35 mg (Camila, Deblitane, Errin, Heather, Jencycla, Jolivette, Lyza, Nora BE, Norlyroc, Sharobel (generics for Ortho Micronor, Nor-QD)) norgestimate/ethinyl estradiol 0.25 mg-35 mcg (Estarylla, Mono-Linyah, MonoNessa, Previfem, Sprintec (generics for Ortho-Cyclen)) norethindrone 0.35 mg (Camila, Deblitane, Errin, Heather, Jencycla, Jolivette, Lyza, Nora BE, Norlyroc, Sharobel (generics for Ortho Micronor, Nor-QD)) norethindrone/ethinyl estradiol / /1-35 mg-mcg (Alyacen 7/7/7, Cyclafem 7/7/7, Dasetta 7/7/7, Necon 7/7/7, Nortrel 7/7/7, Pirmella 7/7/7 (generics for Ortho-Novum 7/7/7)) norgestimate/ethinyl estradiol / / mg-mcg (Tri- Estarylla, Tri-Linyah Tri-Previfem, Tri- Sprintec, Trinessa (generics for Ortho Tri- Cyclen)) carbamazepine extended-release capsule (generic Carbatrol) divalproex (generic Depakote) Skin Conditions Fluoroplex 1% Carac * Diabetic supplies and prescription medications may be subject to different cost-share arrangements. Please see your Summary of Benefits and Coverage (SBC) for specifics. Medications that require precertification For the medications listed below, your physician will need to give us more prescribing information to determine if coverage is available. Sometimes this may mean that another medication will need to be tried first before a medication will be covered under your benefit. Therapeutic Use Medication Name Lower-Cost Options Acne Epiduo Forte 2 tretinoin (generic Retin-A) Cancer Gleevec (Brand only) 1 imatinib (generic Gleevec) Contraceptives Ortho Tri-Cyclen Lo (Brand Only) 1 Tri-Lo-Marzia, Tri-Lo-Sprintec, Trinesa (generic norgestimate/ethinyl estradiol, Tri-Lo-Estarylla, for Ortho Tri-Cyclen Lo) Diabetes* Lantus, Lantus Solostar (Excluded beginning 4/1/2017) 1 Tresiba FlexTouch 2 Basaglar, Levemir, Levemir FlexTouch Glaucoma bimatoprost 0.03% (generic Lumigan) 2 latanoprost (generic Xalatan), Lumigan 0.01%, Travatan Z

4 Therapeutic Use Medication Name Lower-Cost Options Hemophilia Adynovate 2 Helixate FS 1 Kogenate FS, Kovaltry, Novoeight, Nuwiq Ixinity 2 BeneFIX, Rixubis 2 amlodipine (generic Norvasc) plus perindopril High Blood Pressure Prestalia (generic Aceon) HIV nevirapine extended-release (generic Viramune XR) 1 Viramune (Brand Only) 1 nevirapine (generic Viramune) Migraines Onzetra Xsail 2 Sumavel DosePro 1 Zecuity 2 Zembrace SymTouch 2 sumatriptan nasal spray (generic Imitrex) sumatriptan injection (generic Imitrex) sumatriptan injection, nasal spray, tablets (generic Imitrex) sumatriptan injection (generic Imitrex) Neutropenia Pain Granix 2 Neupogen 1 Butrans 1 Oxaydo 2 Zarxio morphine extended-release tablet (generic MS Contin), tramadol extended-release (generic Ultram ER), Belbuca oxycodone immediate-release (generic Oxy IR) oxycodone extended-release (OxyContin Authorized Generic) 2 fentanyl transdermal patch 12, 25, 50, 75, 100 mcg/hr (generic Duragesic), morphine sulfate OxyContin 1 extended-release tablet (generic MS Contin), Nucynta ER, Opana ER, Xtampza ER Vivlodex 2 meloxicam (generic Mobic) Skin Conditions Prescription Emollients/Moisturizers 1 Neo-Synalar cream 2 OTC Aquaphor, OTC Eucerin, OTC Lubriderm, OTC White Petroleum OTC Triple Antibiotic Ointment plus fluocinolone 0.025% cream (generic Synalar) Transplant Envarsus XR 2 tacrolimus (generic Prograf) * Diabetic supplies and prescription medications may be subject to different cost-share arrangements. Please see your Summary of Benefits and Coverage (SBC) for specifics. 1 For impacted plans, these medications may also move to the highest tier (Tier 3). Please refer to additional coverage language to determine exclusion status. For New York, medications may be excluded unless medically necessary. 2 These medications were excluded at launch in New York (unless medically necessary) precertification may already be in place.

5 Legend 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 Overactive Bladder Oxytrol oxybutynin (generic Ditropan), oxybutynin extended-release (generic Ditropan XL), Toviaz, Oxytrol OTC Stroke & Heart Attack Prevention Durlaza OTC aspirin * In New Jersey, prescription drug products that include components available in over-the-counter form or equivalent are not covered under the pharmacy benefit plans; in New York, this includes non-fda approved legend drugs, non-legend drugs and drugs available over-the-counter that do not require a prescription order refill by federal or state law before being dispensed. Any prescription drug product that is therapeutically equivalent to an over-the-counter drug is not covered unless it is determined to be medically necessary. Non-FDA approved medications excluded from coverage There are several prescription medications marketed that are not approved by the U.S. Food & Drug Administration (FDA). In order to ensure coverage is provided for FDA-approved medications, we exclude medications that are not approved by the FDA. Therapeutic Use Pain Skin Conditions Medication Name Cyclobenzaprine Comfort Pac DermacinRx Ibuprofen Comfort Pac IC 400 IC 800 Leva Set Lidocaine/Prilocaine LP Lite Pak Meloxicam Comfort Pac Relador Pak Beau RX Celacyn Lactic Acid (Brand and Generic) Lactic Acid Racemic Recedo Restizan Regenecare

6 Need more information? If you have any questions, please call us at the toll-free phone number on your health plan ID card or , Monday through Friday, 8 a.m. to 6 p.m. ET. TTY users can dial 711. Si usted necesita ayuda en español llame al número de teléfono en su tarjeta de identificación, 若需中文協助, 請致電 , 한국어로도움이필요하시면 , or the phone number on your ID card for help in English and other languages. The company does not discriminate on the basis of race, color, national origin, sex, age, or disability in health programs and activities. We provide free services to help you communicate with us. Such as letters in other languages or large print. You can also ask for an interpreter. To ask for help, please call the toll-free phone number listed on your health plan ID card Monday through Friday, 8 a.m. to 6 p.m. TTY users can dial 711. Please note that not all PDL updates apply to all groups depending on state regulations, additional coverage and Summary Plan Descriptions (SPDs). Oxford HMO products are underwritten by Oxford Health Plans (NY), Inc., Oxford Health Plans (NJ), Inc. and Oxford Health Plans (CT), Inc. Oxford insurance products are underwritten by Oxford Health Insurance, Inc. Administrative services provided by Oxford Health Plans LLC. UnitedHealthcare and the dimensional U logo are registered marks owned by UnitedHealth Group, Inc. All branded medications are trademarks or registered trademarks of their respective owners. Applies to Advantage PDL. MT NY, NJ, CT Member MS / Oxford Health Plans LLC. All rights reserved. 1/17 C