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

Updates to your prescription benefits Effective January 1, 2017 for your Traditional Prescription Drug List Please review the following updates. These...
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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.

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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.

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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. Please see your Summary of Benefits and Coverage (SBC) for specifics.

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 April 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. 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

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

BeneFIX, Rixubis

Traditional 3 Tier PDL Update Summary

Therapeutic Use

Medication Name

High Blood Pressure

Prestalia

HIV

Lower-Cost Options

amlodipine (generic Norvasc) plus perindopril (generic Aceon)

2

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. 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.

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-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

Medication Name

Cyclobenzaprine Comfort Pac DermacinRx Ibuprofen Comfort Pac IC 400 Pain

IC 800 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?

If you have any questions, please call us at the toll-free phone number on your health plan ID card or 1-800-444-6222, 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1-800-303-6719, 한국어로 도움이 필요하시면1-888-2014746.

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 Traditional PDL. MT-986895.2 NY, NJ, CT Member MS-16-532 10/16 ©2016 Oxford Health Plans LLC. All rights reserved.

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Traditional 3 Tier PDL Update Summary