Microsoft word - ms-11-937_oxford adv pdl changes summary_final_082311.doc

Oxford Advantage PDL and Benefit Plan Updates Summary
Effective January 1, 2012
There will be member mailings for all up-tiers, exclusions, precertifications and medications included in the Select Designated Pharmacy Program.
Down-Tiers
Therapeutic Use
Medication Name
Tier Placement
Effective Date
Enzyme Deficiency
Menstrual Bleeding
Pulmonary Arterial Hypertension
Up-Tiers
Therapeutic Use
Medication Name
Tier Placement
Alternatives
tretinoin cream or gel (generic Retin-A)  amlodipine (generic Norvasc) + lisinopril (generic Prinivil, Zestril) High Blood Pressure
lovastatin (generic Mevacor), pravastatin High Cholesterol
(generic Pravachol), simvastatin (generic Zocor) lovastatin (generic Mevacor), pravastatin (generic Pravachol), simvastatin (generic Zocor) Rheumatoid Arthritis / Crohn’s Disease /
Psoriasis
Viral Infections
Copyright 2011 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 Pacificare 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. New Tier Placements
Therapeutic Use
Medication Name
Effective Date
Placement
Oral Contraceptive
Generic Launch – Lipitor
New Generic Tier
Brand Tier
Therapeutic Use
Medication Name
Effective Date
Placement
Placement
High Cholesterol
November 30, 20111
1. This change is dependent on the launch of the generic, which is anticipated to be November 30, 2011. If there is a delay in the launch date, the decision will be re-evaluated. Oxford Exclusions
New Benefit
Therapeutic Use
Medication Name
Alternatives
Coverage
Pacnex LP
omeprazole / sodium bicarbonate
omeprazole (generic Prilosec), pantoprazole (generic Ulcers, Heartburn & Reflux
2. Prescription Drug Products that are comprised of components that are available in Over-the-Counter form or equivalent are not covered under the pharmacy benefit plans. Exclusions3 – Precertification necessary (CT and NY only)
New Benefit
Therapeutic Use
Medication Name
Coverage
Alternatives
sodium sulfacetamide / sulfur (generic Sulfatol) clindamycin gel (generic Cleocin) + tretinoin gel (generic Retin A) Benign Prostatic
tamsulosin (generic Flomax) + finasteride (generic Proscar) Hyperplasia
Chest Pain
Eye Infections
tobramycin / dexamethasone suspension (generic Tobradex)  amlodipine (generic Norvasc) + hydrochlorothiazide (generic Hydrodiuril) + lisinopril (generic Prinivil, Zestril)  amlodipine + hydrochlorothiazide + ramipril (generic Altace) amlodipine + losartan / hydrochlorothiazide (generic Hyzaar) amlodipine (generic Norvasc) + lisinopril (generic Prinivil, Zestril) High Blood Pressure
amlodipine (generic Norasc) + hydrochlorothiazide (generic Hydrodiuril) + lisinopril (generic Prinivil, Zestril) amlodipine + hydrochlorothiazide + ramipril (generic Altace) amlodipine + losartan / hydrochlorothiazide (generic Hyzaar) High Cholesterol
3. 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 CT and NY, medications may 4. These medications were excluded at launch in CT & NY (unless medically necessary) - precertification may already be in place. They are covered in NJ. Exclusions3 – Precertification necessary (CT and NY only) (continued)
Migraines
sumatriptan injection (generic Imitrex), Sumavel Dosepro ondansetron ODT (generic Zofran ODT), ondansetron tablet Oral Contraceptive
acetaminophen / codeine (generic Tylenol #3) Psoriasis / Other Skin
Conditions
Sleep Aid
doxepin (generic Sinequan), zaleplon (generic Sonata), zolpidem (generic Ambien) Viral Infections
3. 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 CT and NY, medications may 4. These medications were excluded at launch in CT & NY (unless medically necessary) - precertification may already be in place. They are covered in NJ. Multiple Product Packaging Exclusions3 – Precertification necessary (CT and NY only)
New Benefit
Therapeutic Use
Medication Name
Coverage
Alternatives
doxycycline (generic Monodox, Vibramycin) hydrocortisone / pramoxine cream (generic Analpram E) Dermatitis
desonide cream or ointment (generic Desowen) triamcinolone cream (generic Aristocort) Diaper Rash
ciclopirox 8% topical solution (generic Penlac) Fungal Infections
Infections
Muscle Relaxant
clobetasol cream or ointment (generic Temovate) Psoriasis
salicylic acid shampoo (generic Salex), salicylic acid gel (generic Stridex) 3. 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 CT and NY, medications may 4. These medications were excluded at launch in CT & NY (unless medically necessary) - precertification may already be in place. They are covered in NJ. Select Designated Pharmacy Program (NY Small Group Fully Insured only)5
Therapeutic Use
Medication Name
Tier as of January 1, 2012
Alternatives
lisinopril (generic Prinivil, Zestril), losartan (generic Cozaar), ramipril Iisinopril (generic Prinivil, Zestril) + hydrochlorothiazide (generic High Blood Pressure
ramipril (generic Altace) + hydrochlorothiazide 5. NY Large Group Fully Insured is scheduled to implement on 1-1-12; if implemented NY Large Group will be impacted as well. ProgressionRx (Step Therapy) – (CT and NY only)
Current Tier
Therapeutic Use
Medication
Step 1 Medication
Grandfathering
Program Information
Placement
Multiple Sclerosis
Rheumatoid Arthritis /
Crohn’s Disease
Sleep Aid
Notification – Called Precertification
Therapeutic Use
Medication Name
Current Tier
Grandfathering
Immune Modulator
New Supply Limits
New Supply
Therapeutic Use
Medication Name
Current Supply Limit
Mailings
Overrides
Attention Deficit
Hyperactivity Disorder
Chest Pain
Diabetes6
Skin Lesions
Testosterone Replacement
Viral Infections
6. Diabetic supplies and prescription medications may be subject to different cost share arrangements. Confirm these state mandates with your Oxford Account Manager. Modified Supply Limits
Current Supply
Therapeutic Use
Medication Name
New Supply Limit
Mailings
Overrides
mg/3mL, 0.63mg/3ml, 1.25mg/3mL Metadate CD 20mg, 30mg Attention Deficit Hyperactivity
Disorder (ADHD)
Diabetes6
0.8mg,1mg,1.8mg,2mg Genotropin Miniquick Growth Hormones
Psychosis
6. Diabetic supplies and prescription medications may be subject to different cost share arrangements. Confirm these state mandates with your Oxford Account Manager.

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