Updates to your prescription benefits
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1 Updates to your prescription benefits Effective July 1, 2018 Update Summary 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. Medications with new benefit coverage $ $$ $$$ Tier 1 Tier 2 Tier 3 Your lowest-cost medications Your mid-range cost medications The following medications were previously not covered under most benefit plans and are now eligible for coverage. Your highest-cost medications Tier Placement Acne Aktipak 3 ADHD Cotempla XR-ODT Mydayis 3 Asthma ArmonAir RespiClick 3 Blood Clots Bevyxxa 3 COPD Utibron Neohaler 3 Diabetes* Contour Next Contour Next EZ Contour Next One 2 Diarrhea Motofen 3 Endocrine Disorders Nityr 2 Huntington's Disease Austedo 2 Muscle Spasms Chlorzoxazone 250 mg tablet 3 Oral Steroid Zodex - 12 day pack 3 Pain Parkinson's Disease Acetaminophen 325 mg/caffeine 30 mg/dihydrocodeine 16 mg tablet MorphaBond ER Gocovri Xadago 3 3 Enhanced Three-Tier PDL Update Summary
2 Tier Placement Sexual Dysfunction Intrarosa 3 Skin Conditions tazarotene 0.1% cream (generic Tazorac) 3 Tardive Dyskinesia Ingrezza 3 * For Oxford plans, 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 moving to a lower tier The following medications are moving to a lower tier, making them more affordable. Tier Placement Erectile Dysfunction sildenafil (generic Viagra) 3 u 1 Infertility Endometrin 3 u 2 Brand for Generic Reversal The generic formulation of the below medication is now covered at Tier 1, the lowest member copay. The brand formulation will no longer be covered. Erectile Dysfunction Tier Placement Lower-Cost Options Viagra (Brand only) 1 u 3 sildenafil (generic Viagra) 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, UnitedHealthcare excludes medications that are not approved by the FDA. Skin Conditions Dritho-Crème HP Zithranol Zithranol - RR
3 Visit the member website listed on your health plan ID card to look up the price of drugs covered by your plan, find lower-cost options and more. For more information, call the toll-free number on your health plan ID card to speak with a Customer Service representative. This document applies to commercial group members of UnitedHealthcare and Oxford New York and New Jersey plans. UnitedHealthcare is a registered trademark owned by UnitedHealth Group, Inc. 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 regulation, riders and SPDs. Insurance coverage provided by or through UnitedHealthcare Insurance Company, UnitedHealthcare Insurance Company of New York, or Oxford Health Insurance, Inc. Oxford HMO products are underwritten by Oxford Health Plans (NJ), Inc. Administrative services provided by United HealthCare Services, Inc., UnitedHealthcare Service LLC, Oxford Health Plans LLC, or their affiliates. MS MT United HealthCare Services, Inc Enhanced Three-Tier PDL Update Summary 2/18
4 Updates to your prescription benefits Effective July 1, 2018 Clinical Programs Update Summary MN Medical Necessity Medical Necessity evaluates the clinical appropriateness of a medication in terms of condition being treated, type of medication, frequency of use, and duration of therapy. The following medications will now require Medical Necessity for coverage including use of lower-cost alternatives prior to coverage for certain indications. codeine/phenylephrine/promethazine codeine/promethazine Flowtuss Hycofenix Cough & Cold hydrocodone/homatropine Obredon Tussionex (hydrocodone/chlorpheniramine) Tuzistra XR Zutripro N Notification Notification requires physicians to provide additional clinical information to verify member benefit coverage. Endocrine Huntington s Disease Buphenyl (sodium phenylbutyrate) Xenazine (tetrabenazine) Clinical Programs Update Summary
5 ST Step Therapy + For customers with Step Therapy, these medications will be added to the program. You must try a Step 1 medication before benefit coverage is available. Step 1 Medication Infertility Crinone Must try the following: Secondary Amenorrhea medroxyprogesterone (generic Provera), or progesterone capsules (generic Prometrium). All other Indications: Endometrin + For New Jersey fully-insured members this program is referred to as First Start SL Supply Limits Supply Limits will be applied to new medications when other medications in their therapeutic class already have these clinical programs in place. Supply Limits establish the maximum quantity of a drug that is covered per copay or in a specified time frame. New or Revised Limit Cancer Idhifa 50 mg tablet Idhifa 100 mg tablet 31 tablets per month Fungal Infections ketoconazole 2% cream 30 grams per copay Hormone Replacement Duavee 0.45 mg/20 mg tablet 31 tablets per month Pain acetaminophen 325 mg/caffeine 30 mg/ dihydrocodeine 16 mg tablet 40 tablets per copay Visit the member website listed on your health plan ID card to look up the price of drugs covered by your plan, find lower-cost options and more. For more information, call the toll-free number on your health plan ID card to speak with a Customer Service representative. UnitedHealthcare is a registered trademark owned by UnitedHealth Group, Inc. 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 regulation, riders and SPDs United HealthCare Services, Inc Clinical Programs Update Summary 2/18
6 Nondiscrimination notice and access to communication services UnitedHealthcare and its subsidiaries do not discriminate on the basis of race, color, national origin, age, disability or sex in its health programs or activities. If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to the Civil Rights Coordinator. Online: UHC_Civil_Rights@uhc.com Mail: Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box Salt Lake City, UT You must send the complaint within 60 days of your experience. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, please call the toll-free phone number listed on your ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m., or at the times listed in your health plan documents. You can also file a complaint with the U.S. Dept. of Health and Human Services. Online: Phone: Mail: Complaint forms are available at Toll free , (TDD) U.S. Dept. of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, D.C We provide free services to help you communicate with us, including letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the toll-free phone number listed on your ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m., or at the times listed in your health plan documents.
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Updates to your prescription benefits
Updates to your prescription benefits Effective July 1, 2018 Update Summary Within the Prescription Drug List (PDL), medications are grouped by tier. The tier indicates the amount you pay when you fill
Updates to your prescription benefits
Updates to your prescription benefits Effective July 1, 2018 Update Summary Within the Prescription Drug List (PDL), medications are grouped by tier. The tier indicates the amount you pay when you fill
Updates to your prescription benefits
Updates to your prescription benefits Effective Jan. 1, 2019 Enhanced Three-Tier PDL Update Summary Within the Prescription Drug List (PDL), medications are grouped by tier. The tier indicates the amount
Updates to your prescription benefits
Updates to your prescription benefits Effective July 1, 2019 Traditional 3-Tier PDL Update Summary Within the Prescription Drug List (PDL), prescription drugs are grouped by tier. The tier indicates the
Updates to your prescription benefits
Updates to your prescription benefits Effective Jan. 1, 2018 Update Summary Within the Prescription Drug List (PDL), are grouped by tier. The tier indicates the amount you pay when you fill a prescription.
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Updates to your prescription benefits
Updates to your prescription benefits Effective Jan. 1, 2018 Update Summary Within the Prescription Drug List (PDL), medications are grouped by tier. The tier indicates the amount you pay when you fill
Updates to your prescription benefits
Updates to your prescription benefits Effective Jan. 1, 2018 Update Summary Within the Prescription Drug List (PDL), are grouped by tier. The tier indicates the amount you pay when you fill a prescription.
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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services South Washington County Schools - Deductible Plan Coverage Period: 01/01/2019-12/31/2019 Coverage for: Individual
$0. See the Common Medical Events chart below for your costs for services this plan covers. There is no deductible. There is no deductible. No.
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 12/31/2018 Health Net of CA: HMO E8Q Coverage for: All Covered Members Plan Type:
Summary of Benefits. Allwell Medicare Essentials II (HMO) Maricopa County, Arizona H
2018 Summary of Benefits Allwell Medicare Essentials II (HMO) Maricopa County, Arizona H0351 -- 049-001 Benefits effective January 1, 2018 H0351_18_3205SB_B_ Accepted 10142017 This booklet provides you
Language Assistance Services
Language Assistance Services We 1 provide free language services to help communicate with us. We offer interpreters, letters in other languages, and letters in other formats like large print. To get help,
This health plan meets Minimum Creditable Coverage standards and will satisfy the individual mandate that you have health insurance.
This is a Massachusetts Large Group Plan This health plan meets Minimum Creditable Coverage standards and will satisfy the individual mandate that you have health insurance. Massachusetts Requirement to
Summary of Benefits and Coverage:
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 06/01/2017 05/31/2018 Health Net of CA: SmartCare HMO 40 Standard DCX Coverage for: All Covered