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.
2006 ROK CUP INTERNATIONAL FINAL Following up the big success of the past editions we are glad to inform you that Vortex is going to organize the 2006 Rok Cup International Final scheduled for the weekend 13/15 October 2006 on the South Garda Karting Circuit (Lonato –Italy). After 3 consecutive years we could have chosen a different Circuit for the 2006 event, but considering the ma
CENTRAL RETINAL VEIN OCCLUSION AFTER SILDENAFIL CITRATE (VIAGRA) USE Bassam Nawaiseh, MD*, Ahmed Shobaki MD*, Ahmad Hassouneh, MD*, Issam Bataineh, MD*, Mohamed Al-Jaar, MD* This is a report of a 31-year old male patient who presented with poor vision of his left eye of one-week duration after the use of two tablets of Sildenafil citrate (Viagra) approximately 24 hours before a
Oxford Advantage PDL and Benefit Plan Updates Summary