Updates to your prescription benefits Effective January 1, 2017 for your Traditional Prescription Drug List Please review the following updates. These will affect your Prescription Drug List (PDL) as of January 1, 2017. Within the PDL, medications are grouped by tiers. The tier indicates the amount your employees pay when they fill a prescription. Please reference this chart as you review the updates below. Most options listed are available in Tier 1, your lowest-cost option.
$
$$$
$$
Tier 1
Tier 2
Tier 3
Your lowest-cost medications
Your mid-range cost medications
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 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
Cancer
imatinib (generic Gleevec)
Diabetes*
Basaglar
Tier Placement
until 3/31/2017 beginning 4/1/2017
Kovaltry Hemophilia
Novoeight Nuwiq
Inflammatory Bowel Disease
Uceris Foam
Inflammatory Conditions
Taltz
Multiple Sclerosis
Plegridy
Neutropenia
Zarxio Belbuca
Pain Xtampza ER * Diabetic supplies and prescription medications may be subject to different cost-share arrangements due to state mandates.
Traditional 3 Tier PDL Update Summary
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
Asthma
Ventolin HFA
Diabetes*
Levemir
Tier Placement
Lower-Cost Options
N/A
beginning 4/1/2017
Basaglar
Advate Recombinate
Hemophilia
Kogenate FS, Kovaltry, Novoeight, Nuwiq
Xyntha, Xyntha SoloFuse Complera HIV
See PDL for lower cost options Truvada
Opioid Induced Constipation
Relistor
Movantik
Skin Conditions
Fluoroplex 1%
Carac
* Diabetic supplies and prescription medications may be subject to different cost-share arrangements due to state mandates.
Medications that require precertification For the medications listed below, your covered employees’ physician(s) 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
Cancer
Gleevec (Brand only)
Contraceptives
Ortho Tri-Cyclen Lo (Brand Only)
2
tretinoin (generic Retin-A) 1
imatinib (generic Gleevec) 1
norgestimate/ethinyl estradiol, Tri-Lo-Estarylla, Tri-LoMarzia, Tri-Lo-Sprintec, Trinesa (generic for Ortho TriCyclen Lo)
1
Diabetes*
Lantus, Lantus Solostar (Excluded beginning 4/1/2017)
Basaglar, Levemir, Levemir FlexTouch
2
Tresiba FlexTouch Glaucoma
bimatoprost 0.03% (generic Lumigan) 2
latanoprost (generic Xalatan), Lumigan 0.01%, Travatan Z
2
Adynovate
Kogenate FS, Kovaltry, Novoeight, Nuwiq Hemophilia
1
Helixate FS 2
Ixinity High Blood Pressure
BeneFIX, Rixubis 2
Prestalia
amlodipine (generic Norvasc) plus perindopril (generic Aceon)
Traditional 3 Tier PDL Update Summary
HIV
nevirapine extended-release (generic 1 Viramune XR) Viramune (Brand Only) 2
Onzetra Xsail
sumatriptan nasal spray (generic Imitrex) 1
Sumavel DosePro
sumatriptan injection (generic Imitrex)
Migraines
sumatriptan injection, nasal spray, tablets (generic Imitrex)
2
Zecuity
2
Zembrace SymTouch Granix
nevirapine (generic Viramune)
1
sumatriptan injection (generic Imitrex)
2
Neutropenia
Zarxio 1
Neupogen 1
morphine extended-release tablet (generic MS Contin), tramadol extended-release (generic Ultram ER), Belbuca
Oxaydo
2
oxycodone immediate-release (generic Oxy IR)
oxycodone extended-release 1 (OxyContin Authorized Generic)
fentanyl transdermal patch 12, 25, 50, 75, 100 mcg/hr (generic Duragesic), morphine sulfate extended-release tablet (generic MS Contin), Nucynta ER, Opana ER, Xtampza ER
Butrans
Pain
1
OxyContin Vivlodex
2
meloxicam (generic Mobic)
Prescription Emollients/Moisturizers Skin Conditions Neo-Synalar cream Transplant
Envarsus XR
2
2
1
OTC Aquaphor, OTC Eucerin, OTC Lubriderm, OTC White Petroleum OTC Triple Antibiotic Ointment plus fluocinolone 0.025% cream (generic Synalar) tacrolimus (generic Prograf)
* Diabetic supplies and prescription medications may be subject to different cost-share arrangements due to state mandates. 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. 1
Traditional 3 Tier PDL Update Summary
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-thecounter 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
Medication Name
Cyclobenzaprine Comfort Pac DermacinRx Ibuprofen Comfort Pac IC 400 IC 800 Pain Leva Set Lidocaine/Prilocaine LP Lite Pak Meloxicam Comfort Pac Relador Pak Beau RX Celacyn Lactic Acid (Brand and Generic) Skin Conditions
Lactic Acid Racemic Recedo Restizan Regenecare
Traditional 3 Tier PDL Update Summary
Need more information?
Please contact your Oxford representative for more information, or visit oxfordhealth.com. 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.
MT1017308.1 NY, NJ, CT Employer (Internal Use Only) MS-16-534 10/16 ©2016 Oxford Health Plans LLC. All rights reserved.
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Traditional 3 Tier PDL Update Summary