Microsoft word - ms-12-903_jan 2013 adv. pdl updates member flier_final
Updates to your prescription benefits
Effective Jan. 1, 2013 for your Advantage PDL
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. Most options listed are available in Tier 1, your lowest-cost option.
If your medication is listed below,
you may continue taking it, but you may pay a higher cost. We encourage you to
discuss the listed lower-cost option(s) that may also treat your condition with your doctor.
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.
alendronate (generic Fosamax), ibandronate (generic Boniva)
oxybutynin (generic Ditropan), oxybutynin sustained-release
(generic Ditropan XL), trospium (generic Sanctura), Sanctura XR, Vesicare
podofilox liquid (generic Condylox liquid)
Medication being added to the Select Designated Pharmacy (SDP) Program
Through this program, you must choose one of three options to continue to receive network benefits. Call the Pharmacy
Customer Service member telephone number on the back of your health plan ID card to determine if this program applies
to your benefit plan. This program currently applies to New York small and large group fully insured groups only.
Depression Diagnosis: citalopram (generic Celexa), fluoxetine (generic Prozac), sertraline (generic Zoloft), venlafaxine
sustained-release (generic Effexor XR), Pristiq Neuropathic Pain Diagnosis: gabapentin (generic Neurontin)
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 prescription drug products that are comprised of
components available in over-the-counter form or equivalent. The medications listed below are not covered under the
pharmacy benefit plan.
OTC Zegerid, omeprazole (generic Prilosec), pantoprazole (generic Protonix)
Medications that require precertification (Connecticut and New York only)
The medications listed below require your physician to provide additional prescribing information to determine if coverage
sulfacetamide sodium/sulfur (generic Sulfatol)
Gildess FE, Junel FE, Microgestin FE (generics for Loestrin FE)
OTC ketotifen (Zaditor), azelastine ophthalmic solution (generic Optivar),
bromfenac (generic Xibrom), ketorolac (generic Acular)
amlodipine (generic Norvasc) plus losartan (generic Cozaar)
amlodipine (generic Norvasc) plus Benicar or Micardis
amlodipine (generic Norvasc) plus Diovan
amlodipine (generic Norvasc) plus losartan/hydrochlorothiazide
amlodipine (generic Norvasc) plus Benicar HCT or Micardis HCT
amlodipine (generic Norvasc) plus Diovan HCT
prednisolone (generic Prelone), Orapred, Pediapred
azelastine nasal spray (generic Astelin), Astepro
tramadol extended-release (generic Ultram ER), tramadol immediate-release
ibuprofen (generic Motrin) plus OTC famotidine (generic Pepcid AC)
chlorzoxazone (generic Parafon Forte DSC)
chlorzoxazone (generic Parafon Forte DSC), cyclobenzaprine (generic Flexeril),
metaxalone (generic Skelaxin), methocarbamol (generic Robaxin)
metronidazole gel 0.75% (generic Metrogel)
metronidazole gel 0.75% (generic Metrogel)
hydrocortisone/pramoxine (generic Analpram E)
1. For impacted plans, these medications may also move to the highest tier based on the benefit plan (Tier 4). Please refer to Rider language to determine exclusion status. For Connecticut and New York, medications may be excluded unless medically necessary. 2. These medications were excluded at launch in Connecticut and New York (unless medically necessary) - precertification may already be in place. They are covered in New Jersey.
For more information
For questions about your pharmacy benefit, please visit oxfordhealth.com or call the Pharmacy
Customer Service member telephone number on the back of your health plan ID card. If you are hearing impaired and require assistance, please call our TTY/TDD line at 1-800-201-4875. Please call 1-800-303-6719 for assistance in Chinese, 1-800-544-4249 for assistance in Korean, or the telephone number on your health plan ID card for assistance in English and other languages.
2012 Oxford Health Plans LLC. All rights reserved. Confidential Information. Do not reproduce or redistribute without the express permission of UnitedHealth Group. This does not apply to UnitedHealthcare WEST business administered by Prescription Solutions by OptumRx. UnitedHealthcare® and the dimensional U logo are registered marks owned by UnitedHealth Group Incorporated. 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 regulations, Riders and Summary Plan Descriptions (SPDs). For Internal Use Only. 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.
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