5/1/06 pdl decisions

Oxford Advantage PDL and Benefit Plan Updates Summary
Effective July 1, 2011

Down-Tiers
Therapeutic Use
Medication Name
Tier Placement
Effective Date
Heart Rhythm Disorders
Low Sodium
Psoriasis
Pulmonary Arterial Hypertension (PAH)
New Tier Placements
Therapeutic Use
Medication Name
Current Benefit Coverage
Effective Date
Placement
Excluded at launch in CT & NY (unless medically Excluded at launch in CT & NY (unless medically Testosterone Replacement
Precertification (CT & NY); covered in NJ Excluded at launch in CT & NY (unless medically Thyroid Replacement

2011 United HealthCare Services, Inc. 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. 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. 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. MS-11-116
Up-Tiers
Therapeutic Use
Medication Name
Tier Placement
Alternatives
clindamycin / benzoyl peroxide (generic Benzaclin) minocycline extended-release (generic Solodyn) lovastatin (generic Mevacor) plus Niaspan Cholesterol Lowering
Antara, fenofibrate (generic Tricor), Lipofen, Tricor fentanyl transdermal patch (generic Duragesic) epinephrine (generic Adrenaclick), EpiPen, EpiPen Severe Allergic Reactions
Diabetic Medication Up-Tiers– (NJ only)1
Therapeutic Use
Medication Name
Tier Placement
Effective Date
Diabetes
1. Diabetic supplies and prescription medications in NY and CT are subject to the lowest medical copayment. Please contact your Oxford Account Manager for further details. Exclusions 2 – Precertification necessary (CT and NY only)
Therapeutic Use
Medication Name
New Benefit Coverage
Alternatives
Alzheimer’s Disease
Precertification3 donepezil
Precertification3
covered if medically necessary Excluded; however will be Zaditor OTC (ketotifen OTC – various brands), azelastine (generic Eye Allergies
covered if medically necessary Excluded; however will be ciprofloxacin ophthalmic (generic Ciloxan), Eye Infections
Precertification3
ofloxacin ophthalmic (generic Ocuflox), Zymar diclofenac potassium (generic Cataflam), Cambia Precertification3
Orbivan Precertification3
butalbital / acetaminophen / caffeine (generic Fioricet) Pennsaid Precertification3
Precertification3
naproxen plus Aciphex, Dexilant, omeprazole (generic Prilosec), or Vimovo Precertification3
Parkinson’s Disease
Precertification3
Skin Lesions
Zyclara Precertification3
Testosterone Replacement
2. 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 be excluded unless medically necessary. 3. 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) 
Therapeutic Use
Medication Name
Tier as of July 1, 2011
Alternatives
Refill and Save Program – (CT and NY only)
Therapeutic Use
Medication Name
Current Tier Placement
Effective Date
ProgressionRx (Step Therapy) - (CT and NY only)
Therapeutic Use
Medication
Current Tier Placement
Step 1 Medication
Grandfathering
Pulmonary Arterial Hypertension (PAH)
Notification – Called Precertification
Therapeutic Use
Medication Name
Current Tier / Benefit Coverage
Grandfathering
Mailings
Multiple Sclerosis
Progesterone Replacement
4. Currently precertification applies for Oxford business in CT and NY, but NOT in NJ. Supply Limits
Current Supply
Therapeutic Use
Medication Name
New Supply Limit
Mailings
Overrides
clindamycin / benzoyl peroxide 5% gel (generic Antifungal
Cholesterol Lowering
Diabetes
High Blood Pressure
Glucose-Elevating
Growth Hormones
Genotropin miniquick 0.8/1/1.2/1.4/1.6/1.8/2mg Lovenox 30mg/0.3ml, 40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml, Low Molecular Weight
Heparins
Topical Immunosuppressant

Source: http://mysite.pratt.edu/~smcdani6/Oxford%20ADVANTAGE%20PDL%20and%20Ben%20Plan%20Updates%20Summary%20for%2007%2001%2011_FINAL.pdf