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.

Therapeutic Use
Medication Name
Tier Placement
Lower-Cost Options
alendronate (generic Fosamax), ibandronate (generic Boniva) oxybutynin (generic Ditropan), oxybutynin sustained-release Overactive Bladder
(generic Ditropan XL), trospium (generic Sanctura), Sanctura XR, Vesicare Thyroid Hormone
Viral Infection
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.
Therapeutic Use
Medication Name
Tier Placement
Lower-Cost Options
Depression Diagnosis: citalopram (generic Celexa), fluoxetine (generic Prozac), sertraline (generic Zoloft), venlafaxine Depression
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.
Therapeutic Use
Medication Name
Lower-Cost Options
Ulcers, Heartburn
OTC Zegerid, omeprazole (generic Prilosec), pantoprazole (generic Protonix) and Reflux
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
is available.
Therapeutic Use
Medication Name
Lower-Cost Options
sulfacetamide sodium/sulfur (generic Sulfatol) Contraceptive
Gildess FE, Junel FE, Microgestin FE (generics for Loestrin FE) Depression
Erectile Dysfunction
OTC ketotifen (Zaditor), azelastine ophthalmic solution (generic Optivar), Eye Allergies
bromfenac (generic Xibrom), ketorolac (generic Acular) Hepatitis C
amlodipine (generic Norvasc) plus losartan (generic Cozaar) amlodipine (generic Norvasc) plus Benicar or Micardis amlodipine (generic Norvasc) plus Diovan High Blood
amlodipine (generic Norvasc) plus losartan/hydrochlorothiazide amlodipine (generic Norvasc) plus Benicar HCT or Micardis HCT amlodipine (generic Norvasc) plus Diovan HCT High Cholesterol
prednisolone (generic Prelone), Orapred, Pediapred Nasal Allergies
azelastine nasal spray (generic Astelin), Astepro Neuropathic Pain
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) Psoriasis
Restless Legs
metronidazole gel 0.75% (generic Metrogel) metronidazole gel 0.75% (generic Metrogel) Skin Conditions

hydrocortisone/pramoxine (generic Analpram E) Toenail Infections
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 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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