Updates to your prescription benefits Effective July 1, 2016 for your Traditional Prescription Drug List
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1 Updates to your prescription benefits Effective July 1, 2016 for your Traditional Prescription Drug List Please review the following updates. These will affect your Prescription Drug List (PDL) as of July 1, $ $$ $$$ Within the PDL, medications are grouped by tiers. The tier indicates the amount your covered employees pay when they have a prescription filled. 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 highestcost medications Medications moving to a lower tier The following medications are moving to a lower tier, making them more affordable. Down-tiers occur throughout the year, helping members take immediate advantage of the cost savings. Therapeutic Use Medication Name Tier Placement Cancer Targretin Capsules Medications with new benefit coverage The following medications were not covered before under most benefit plans and are now eligible for coverage. Therapeutic Use Medication Name Tier Placement Symbicort Asthma/COPD Seebri NeoHaler Utibron NeoHaler Cough/Cold Narcolepsy Pain Obredon modafanil (generic Provigil) Trezix Applies to Traditional PDL
2 Medications that require precertification The medications listed below require your covered employees physician(s) 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 New Benefit Coverage Lower-Cost Options ADHD Aptensio XR Precertification 2 Concerta, Metadate CD Evekeo Precertification 2 release (generic Adderall), dextroamphetamine amphetamine/dextroamphetamine immediate- immediate-release (generic Dexedrine) Allergies Pazeo Precertification 2 Optivar), olopatadine ophthalmic solution (generic OTC ketotifen (Zaditor), azelastine (generic Patanol), Lastacaft Alzheimer's Disease Cancer Exelon Patch (Brand rivastigmine transdermal patch (generic Exelon), rivastigmine oral capsules (generic Exelon) Namenda XR memantine immediate-relase (generic Namenda) 2 donepezil (generic Aricept) plus memantine Namzaric Precertification (generic Namenda) bexarotene caps (generic for Targretin) Targretin capsules COPD Stiolto Respimat Precertification 2 Anoro Ellipta, Utibron NeoHaler Cough/Cold FlowTuss Precertification 2 guaifenesin/codeine solution (Cheratussin AC) Hycofenix Precertification 2 2 hydrocodone polistirex/chlorpheniramine polistirex Tuzistra XR Precertification (generic Tussionex Pennkinetic), Z-Tuss AC Diabetes* Toujeo Solostar Precertification 2 Lantus, Levemir Heart Rhythm Betapace (Brand sotalol (generic Betapace) Hemophilia Novoeight Precertification 2 Advate, Helixate FS, Kogenate FS, Recombinate Hemorrhoids High Blood Pressure Anusol HC Supp (Brand Cardizem (Brand Cardizem CD (Brand Cardizem LA (Brand Dibenzyline (Brand Tenoretic (Brand Tenormin (Brand Vaseretic (Brand Vasotec (Brand hydrocortisone cream (generic Anusol-HC), hydrocortisone suppository (generic Anusol-HC) diltiazem (generic Cardizem) diltiazem extended-release (generic Cardizem CD) diltiazem extended-release (generic Cardizem LA) phenoxybenzamine (generic Dibenzyline) atenolol/chlorthalidone (generic Tenoretic) atenolol (generic Tenormin) enalapril/hydrochlorothiazide (generic Vaseretic) enalapril (generic Vasotec)
3 Therapeutic Use Medication Name New Benefit Coverage Lower-Cost Options Hormone Replacement Huntington's Disease Infections Irritable Bowel Syndrome Lipid/Cholesterol Lowering Mental Health Migraine Zestoretic (Brand Zestril (Brand estradiol transdermal patches (generic for Vivelle-Dot) Xenazine (Brand Augmentin (Brand Augmentin ES- 600 (Brand E.E.S. 400 (Brand Metrogel 0.75% Vaginal (Brand Precertification 2 lisinopril/hydrochlorothiazide (generic Zestoretic) lisinopril (generic Zestril) Vivelle-Dot tetrabenazine (generic Xenazine) amoxicillin/clavulanic acid (generic Augmentin) erythromycin ethylsuccinate (generic E.E.S. 400) Nuvessa Precertification 2 Valcyte (Brand Zyvox (Brand Librax (Brand Lotronex (Brand Lescol XL (Brand Anafranil (Brand Invega (Brand metronidazole 0.75% vaginal gel (generic Metrogel-Vaginal) valganciclovir (generic Valcyte) linezolid (generic Zyvox) chlordiazepoxide/clidinium (generic Librax) alosetron (generic Lotronex) fluvastatin extended-release (generic Lescol XL) clomipramine (generic Anafranil) paliperidone (generic Invega) 2 duloxetine (generic Cymbalta), venlafaxine Irenka Precertification extended-release (generic Effexor XR) Wellbutrin (Brand Axert (Brand D.H.E. 45 (Brand Migranal (Brand bupropion (generic Wellbutrin) almotriptan (generic Axert) dihydroergotamine (generic D.H.E. 45) dihydroergotamine nasal spray (generic Migranal) Narcolepsy Nuvigil modafinil (generic Provigil) Pain Disalcid (Brand only) Precertification 2 salsalate (generic Disalcid) Embeda Precertification 2 mcg/hr only) (generic Duragesic), morphine sulfate extended-release (generic MS Contin), fentanyl transdermal patch (12, 25, 50, 75, 100 Opana ER, Nucynta ER
4 Therapeutic Use Medication Name New Benefit Coverage Lower-Cost Options Parkinson's Disease Prostate Benign Prostatic Hypertrophy Rosacea Skin Conditions Supportive Care for Cystic Fibrosis Ulcerative Colitis Ulcers, Heatburn, & Reflux fentanyl transdermal patch 37.5, 62.5, 87.5 mcg/hr only (Select strengths only) 2 fentanyl transdermal patch (12, 25, 50, 75, 100 Precertification mcg/hr only) (generic Duragesic) Tivorbex Precertification 2 Motrin), indomethacin capsule (generic Indocin), meloxicam (generic Mobic), naproxen (generic diclofenac (generic Voltaren), ibuprofen (generic Naprosyn) Lodosyn (Brand carbidopa (generic Lodosyn) Rytary Precertification 2 (generic Sinemet CR), carbidopa/levodopa carbidopa/levodopa extended-release tablet (generic Sinemet) Tasmar (Brand Avodart (Brand doxycycline delayed-release capsule (Oracea authorized generic) Clarifoam EF (Brand Kenalog Spray (Brand Loprox Shampoo (Brand Penlac Nail Lacquer (Brand Proctocort (Brand Synalar 0.01% solution (Brand Synalar 0.025% cream, ointment (Brand Precertification 2 Kitabis Pak Precertification 2 Bethkis Colazal (Brand Zegerid packet tolcapone (generic Tasmar) dutasteride (generic Avodart), finasteride (generic Proscar) minocycline (generic Minoicin), doxycycline hyclate (generic Morgidox, Vibramycin), doxycycline monohydrate 50 mg and 100 mg (generic Monodox), Oracea sulfacetamide sodium/sulfur 10-5% (generic Clarifoam EF) triamcinolone spray (generic Kenalog) ciclopirox shampoo (generic Loprox Shampoo) ciclopirox 8% solution (generic Penlac Nail Lacquer) hydrocortisone 1% cream (generic Proctocort), hydrocortisone 30 mg suppository (generic Proctocort) fluocinolone 0.01% solution (generic Synalar) fluocinolone 0.025% cream, ointment (generic Synalar) balsalazide (generic Colazal) omeprazole (generic Prilosec), pantoprazole (generic Protonix), rabeprazole (generic Aciphex), Dexilant, Prevacid Solu-Tab, Nexium Suspension, OTC Nexium, OTC Prevacid 24; OTC Prilosec, OTC Zegerid * Diabetic supplies and prescription medications may be subject to different cost-share arrangements due to state mandates.
5 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. 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 Pain Duexis ibuprofen (generic Motrin) plus OTC famotidine (generic Pepcid AC) Ulcers, Heartburn, & Vimovo OTC naproxen plus OTC omeprazole (generic Prilosec) Reflux * 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 marketed prescription medications 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 Irritable Bowel Syndrome Neuropathy Skin Conditions Medication Name Donnatal Donnatal Extentabs Active Pac/Gabapentin Kit Salex Kit Salex Shampoo Need more information? Please contact your Oxford representative for more information, or visit oxfordhealth.com.
6 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 NY, NJ, CT Employer MS B 04/ Oxford Health Plans LLC. All rights reserved. 7/16 C
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