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UnitedHealthcare Pharmacy - July 1 PDL Report
Fully Insured Customers on the Traditional PDLThe July 1, 2011 Prescription Drug List (PDL) and pharmacy benefit updates represent a small percentage of all prescriptions – no medications in the top 100 – but create significant value for our customers. These decisions are designed to drive the greatest total health care value, while preserving affordable choice for members, with the least amount of disruption. Please see the "Decision Definitions Key" tab for symbol and program descriptions. For a general list of all impacted medications and member communication materials or for more detailed rationale, please visit EmployereServices.com or contact your UnitedHealthcare representative.
Decisions
Assessment
Effective Date
Therapeutic Class Overviews (for drug-specific details, see the individual decisions section below)
Eye Allergies / Infections
Eye medication class continues to expand despite being mostly single use products with the presence of OTC options.
} Elestat is priced at a premium - over seven times more expensive than Zaditor OTC. } Emadine is a low-utilized product offering little health care value compared to lower-cost options.
} Pataday and Patanol are the market leaders in this class yet are also the most expensive options. With a 34% price increase over the last two Pataday and Patanol
years, Pataday and Patanol are over eight times more expensive than Zaditor OTC. } Zymaxid, excluded at launch, is a direct follow-on product to Tier 3 Zymar and is over five times more expensive than its Tier 1 generic options. Hormone Replacement Therapy
Aggressive marketing around using testosterone for lifestyle symptoms drives utilization of hormone replacement drugs, creating unnecessary costs.
} Androgel is therapeutically equivalent to Testim - same dosage form and strength yet is twice as expensive, making it a lower overall value. In Androgel
the top 20 for spend, we will be removing it from benefit coverage.
Testim is less than half the price of Androgel, making it a better overall value and sufficient for a Tier 2 placement.
Tirosint
} Tirosint, indicated for Thyroid Replacement, offers sufficient value to be placed with other alternatives in Tier 2.
Pain
The pain class continues to expand with the release of expensive, follow-on products despite the large number of Tier 1 generic options available.
} Cambia, indicated to treat migraine headaches, contains the same active ingredient that is available as a Tier 1 generic, diclofenac sodium, yet is over nine and half times more expensive. Sumatriptan (generic Imitrex) is also available in Tier 1.
} Orbivan, excluded at launch, is over four times more expensive than Tier 1 generic Fioricet - only difference is 25mg of acetaminophen.
} Pennsaid, excluded at launch, requires 40 drops on the affected knee four times per day and is over three times more expensive than Voltaren Pennsaid
gel, an easier to use product available in Tier 2. Rybix ODT
} Rybix ODT, excluded at launch, is over 11 times more expensive than Tier 1 generic tramadol.
} Vimovo, excluded at launch, is for patients with high risk of developing an ulcer from naproxen and is a combination of naproxen (also available OTC as Aleve) and Nexium yet is over three times more expensive than generic options available. Any ulcer medication can be used to prevent an ulcer, many OTC options exist.
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Decisions
Assessment
Effective Date
Individual Decisions Note: Individual decisions below also include all class decisions listed above.
Down-Tiers
Colcrys (gout)
Multaq (heart rhythm disorders)
Samsca (low sodium)
Decisions will be implemented prior to July 1, 2011 so members can take advantage of the cost savings.
Stelara (psoriasis)
Tyvaso (pulmonary arterial
Differin lotion (acne)
Solodyn 55mg, 80mg, 105mg
These medications were evaluated and will now be covered under the pharmacy benefit on Tier 2 and Tier 3 since they offer sufficient value compared to alternatives in their therapeutic class.
Testim (testosterone replacement)
Tirosint (thyroid replacement)
Androgel (testosterone
Androgel is therapeutically equivalent to Testim - same dosage form and strength yet is twice as expensive, making it a lower overall
value. In the top 20 for spend, we will be removing it from benefit coverage.
Aricept 23mg (Alzheimer's
Aricept 23mg, excluded at launch, is priced at a premium to its currently available 5mg and 10mg generic strengths in Tier 2. Cambia (pain - migraine
Cambia, excluded at launch, is priced over nine times more than Tier 1 generic options.
Elestat (eye allergies)
Elestat is priced at a premium - over seven times more expensive than Zaditor OTC.
Emadine (eye allergies)
Emadine is a low-utilized product offering little health care value compared to other lower-cost options.
Mirapex ER (Parkinson's
Mirapex ER, excluded at launch, may be commonly used off-label for Restless Leg Syndrome (RLS) and is over 15 times more expensive
than Tier 1 generic Requip and generic Mirapex.
Pataday and Patanol (eye
Pataday and Patanol are the market leaders in this class yet are also the most expensive options. With a 34% price increase over the last two
years, they are over eight times more expensive than Zaditor OTC.
Pennsaid (pain - knee
Pennsaid, excluded at launch, requires 40 drops on the affected knee four times per day yet is over three times more expensive than
Voltaren gel, an easier to use product available in Tier 2. Orbivan (pain - tension
Orbivan, excluded at launch, is over four times more expensive than Tier 1 generic Fioricet - only difference is an additional 25mg of
Rybix ODT (pain)
Rybix ODT, excluded at launch, is an oral-disintegrating version yet is over 11 times more expensive than Tier 1 generic tramadol options.
Vimovo, excluded at launch, is a combination product that reduces ulcers associated with using pain medications yet is three times more
Vimovo (pain)
expensive than its individual components.
Zonatuss (cough)
Zonatuss, excluded at launch, is almost three times more expensive than Tier 1 generic benzonatate.
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Decisions
Assessment
Effective Date
Individual Decisions (continued) Note: Individual decisions below also include all class decisions listed above.
Exclusions1 (continued)
Zyclara, excluded at launch, is priced at a premium to generic imiquimod 5% in Tier 2 and contains a lower dosage strength of 3.75% without a Zyclara (skin lesions)
Zymaxid (eye allergies)
Zymaxid, excluded at launch, is a direct follow-on product to Tier 3 Zymar and is over five times more expensive than its Tier 1 generic options. ProgressionRx requires members to try a lower-cost option (known as Step 1) before progressing to a more expensive option (known as Step Pulmonary Arterial
2) for benefit coverage. New Letairis users will be directed to first try Tracleer. Current users will be grandfathered and therefore, will not be Hypertension (PAH): Letairis
The Refill and Save Program will be expanded to include Dulera, a medication within the asthma class. Members will receive a $20 retail Asthma: Dulera
discount on Dulera when they adhere to their treatment regimen and make timely prescription refills. Multiple sclerosis medications have increased in price by 19.5% every year since 2008. Products being included in the Notification program • Avonex
are used to treat relapsing forms of MS while aiming to reduce future clinical relapses. Existing users will be grandfathered.
• Betaseron
• Copaxone
• Extavia
• Gilenya
• Rebif
Victoza is available in a 2-pk and 3-pk with injection pens that can be set to three different dosages – 0.6mg, 1.2mg, or 1.8mg. While label indication recommends trying the 1.2mg dose (2-pk) before the 1.8mg (3-pk), majority of utilization is in the more expensive 3-pk – our analysis Victoza (diabetes)
indicates most did not try the 2-pk first. The supply limit will redirect members to first try the less expensive 2-pk before benefit coverage is available for the 3-pk.
1 For customers that implemented the Exclude at Launch Program, the green buttons indicate which medications were excluded at launch and will have minimal to no member impact. For customers that did not, medications are in Tier 3.
Please note: For customers not on the 2007 Pharmacy Rider, exclusions based on the 2007 Rider, ProgressionRx, and Refill & Save Program will be not implemented until customer’s renewal of the new pharmacy rider and as allowed by
state regulation.
For more information about these pharmacy benefit updates, please visit
EmployereServices.com or contact your UnitedHealthcare representative.
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Decision Definitions Key
Decision
Definition
Down-tiers refer to medications that move to a lower tier, which can occur at any time throughout the year to provide members with Down-tiers
immediate cost savings.
Up-tiers refer to medications that move to a higher tier because they offer less health care value (either clinically and/or financially) than Up-tiers
similar medications in their therapeutic classes.
New tier placements occur for medications that have been previously excluded at launch, but now offer sufficient health care value to New Tier Placements
have a tier placement.
We do not make the decision to exclude medications from benefit coverage lightly. A medication is only excluded from benefit coverage Exclusions
when it offers no clinical value over other options in its class and its exclusion can be leveraged to achieve significant savings for our customers and preserve affordable choices for members.
Continued Exclusions
These exclusions will have little to no member impact since the medication has been excluded at launch.
This program encourages members to comply with their treatment regimen by rewarding them with a discount on their copayment for Refill and Save
timely prescription refills.
ProgressionRx directs members to try a lower-cost medication (known as Step 1) before progressing to a higher-cost alternative (known ProgressionRx
Notification requires physicians provide additional clinical information to verify member benefit coverage and ensure appropriate use based Notification
Supply Limits
Supply Limits establish the maximum quantity of drug that is covered per copay or in a specified timeframe.
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.
Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group. M49070-C 3/11 2011 United HealthCare Services, Inc.
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