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 you pay when you fill a prescription. Please reference the chart to the right as you review the following updates to the PDL. $ $$ $$$ Tier 1 Tier 2 Tier 3 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 Bowel Preparation Clenpiq 3 COPD Seebri Neohaler Trelegy Ellipta 3 Glyxambi 2 Diabetes 1 Ozempic 3 Tresiba 2 Multiple Sclerosis glatiramer acetate (Mylan only generic Copaxone) 1 Opioid Induced Constipation Symproic 2 Medications moving to a lower tier The following medications are moving to a lower tier, making them a lower cost. Therapeutic Use Medication Name Tier Placement COPD HIV Spiriva HandiHaler Spiriva Respimat Cimduo Symfi Symfi Lo 3 u 2 3 u 2
Medications moving to a higher tier The following medications are 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 Diabetes 1 Hormone Replacement Medication Name Levemir Levemir Flextouch Tier Placement Lower-Cost Options 2 u 3 Basaglar, Tresiba Climara (Brand only) 2 2 u 3 estradiol transdermal patch (generic Climara) Infertility Crinone 2 u 3 Endometrin Influenza Tamiflu suspension (Brand only) 2 2 u 3 oseltamivir suspension (generic Tamiflu suspension) 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, 2019, the medications listed below may be excluded from coverage or subject to prior authorization (sometimes referred to as precertification) and/or trial/ failure 3 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 that have programs or limits that apply. Therapeutic Use Medication Name Lower-Cost Options Acne Ximino minocycline immediate-release capsules (generic Minocin) Diabetes 1 Admelog Admelog Solostar Apidra Apidra SoloSTAR Farxiga Fiasp Fiasp FlexTouch Novolin 70/30 Novolin 70/30 Relion Novolin N Novolin N Relion Novolin R Novolin R Relion Novolog Novolog FlexPen Novolog Mix 70/30 Novolog Mix 70/30 Prefilled FlexPen Novolog Penfill Qtern Humalog vial, Humalog KwikPen Invokana, Jardiance Humalog vial, Humalog KwikPen Humulin 70/30 vial, Humulin 70/30 KwikPen Humulin N vial, Humulin N KwikPen Humulin R vial Humalog vial, Humalog KwikPen Humalog 75/25 vial, Humalog 75/25 KwikPen Humalog vial, Humalog KwikPen Glyxambi
Therapeutic Use Medication Name Lower-Cost Options Diabetes 1 Steglatro Invokana, Jardiance Segluromet Invokamet, Invokamet XR, Synjardy, Synjardy XR Steglujan Glyxambi Elevated Phosphate Levels Renvela tablets (Brand Only) sevelamer tablets (generic Renvela) Gaucher Disease Zavesca (Brand Only) miglustat (generic Zavesca) Glaucoma Vyzulta latanoprost (Xalatan), Lumigan, Travatan Z Hemophilia Rebinyn Alprolix, Benefix, Idelvion, Rixubus HIV Atripla Norvir tablets (Brand Only) Cimduo, Isentress, Juluca, Symfi, Symfi Lo, Tivicay, Triumeq ritonavir tablets (generic Norvir) Multiple Sclerosis Copaxone glatiramer acetate (generic Copaxone) Nasal Polyps Xhance fluticasone (generic Flonase) Nausea and vomiting Bonjesta associated with pregnancy Diclegis OTC doxylamine (Unisom) + pyridoxine (Vitamin B6) Neuropathic Pain Lyrica CR gabapentin (generic Neurontin), duloxetine (generic Cymbalta), amitriptyline (generic Elavil), Lyrica Opioid Induced Constipation Movantik Symproic Oral Steroid Decadron tablets (Brand Only) dexamethasone fenoprofen (generic Nalfon) Pain & Inflammation Fenortho Nalfon ibuprofen (generic Motrin), naproxen (generic Aleve, Naprosyn) Seizures Sabril powder pack (Brand Only) vigabatrin powder pack (generic Sabril) Skin Conditions Impoyz betamethasone dipropionate augmented 0.05% cream (generic Diprolene AF), fluocinonide 0.05% cream (generic Lidex cream) Devices excluded from benefit coverage The below devices are not approved by the Food and Drug Administration (FDA) as medications and may be excluded from benefit coverage. Therapeutic Use Device Name Lower-Cost Options Caphosol Saliva Substitutes Neutrasal Discuss with your doctor Salivamax Wound Care Wound care products Discuss with your doctor 1 Diabetic supplies and prescription medications may be subject to different cost-share arrangements for Oxford plans. Please see your Summary of Benefits and Coverage (SBC) for specifics. Medications that require step therapy may require prior authorization (sometimes referred to as precertification) if covered under another benefit. 2 Medication is typically excluded from benefit coverage. 3 Referred to as First Start in New Jersey.
Updates to your prescription benefits Effective Jan. 1, 2019 Traditional Three-Tier PDL Clinical Programs Update Summary Some medications may have programs or limits that apply. Below are the changes to the current programs and limits that will be effective Jan. 1, 2019. MN Medical Necessity Medical Necessity is a type of Prior Authorization that evaluates the clinical appropriateness of a medication, such as condition being treated, type of medication, frequency of use, and duration of therapy. The following medications will now require Medical Necessity for coverage. Therapeutic Use Opioid Induced Constipation Medication Name Movantik ST Step Therapy 3 The below medications will be added to the Step Therapy program. You must try one or more other medications before the medication below may be covered. Therapeutic Use Medication Name Step 1 Medication Constipation COPD Diabetes 1 Amitiza Seebri Neohaler Glyxambi Must try one of the following depending on diagnosis: (1) Linzess (2) Symproic Must try two of the following: (1) Spiriva Handihaler or Respimat (2) Incruse Ellipta (3) Tudorza Pressair Must try one of the following: (1) Metformin (generic Glucophage, Glucophage XR) (2) Sulfonylurea (e.g. glimepiride) (3) Thiazolidinedione (e.g. pioglitazone)
SL Supply Limits Supply Limits establish the maximum quantity of a drug that is covered per copay or in a specified time frame. The below medications will now be part of the Supply Limits program. Therapeutic Use Medication Name New or Revised Limit Acne Cleocin-T solution 30 ml per copay Cough & Cold Inflammatory Conditions Skin Conditions codeine/phenylephrine/promethazine syrup codeine/promethazine syrup & solution FlowTuss solution Hycofenix solution hydrocodone/homatropine syrup Obredon solution Tussionex suspension Tuzistra XR suspension Zutripro Oral solution Taltz 80 mg diflorasone diacetate ointment Kenalog (triamcinolone acetonide) aerosol spray 120 ml per copay; Maximum of 360 ml per month 1 auto injector/syringe per month 30 grams per copay 63 grams per copay 1 Diabetic supplies and prescription medications may be subject to different cost-share arrangements for Oxford plans. Please see your Summary of Benefits and Coverage (SBC) for specifics. Medications that require step therapy may require prior authorization (sometimes referred to as precertification) if covered under another benefit. 2 Medication is typically excluded from benefit coverage. 3 Referred to as First Start in New Jersey. For additional information: 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. Call the toll-free phone number on your health plan ID card to speak with a Customer Service representative.
Nondiscrimination notice and access to communication services UnitedHealthcare and its subsidiaries 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 30608 Salt Lake City, UT 84130 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., or at the times listed in your health plan documents. You can also file a complaint with the U.S. Dept. of Health and Human Services. Online: Phone: Mail: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html Toll free 1-800-368-1019, 1-800-537-7697 (TDD) U.S. Dept. of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, D.C. 20201 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., or at the times listed in your health plan documents.
This document applies to commercial group members of UnitedHealthcare and Oxford New York and New Jersey plans with a pharmacy benefit subject to the Traditional Three-Tier PDL. 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-1152770.2 MS-18-374 76634-072018