Microsoft word - 070113_oxford_advcustomermemberflyer_030413

Important information about your
prescription benefits
Effective July 1, 2013
Within the Prescription Drug List (PDL), medications are grouped by tier. The tier indicates the amount you pay when you fill a prescription. Your lower-cost options are found in Tier 1. Medications moving to a lower tier
Medications may move from a higher tier to a lower tier, which can occur at any time throughout the year to provide
members with immediate cost savings.

Condition
Medication Name
Utilization
Effective Date
Placement
Allergies
New benefit coverage
The following medications, previously not covered under most of our benefit plans, will now be eligible for coverage under
many plans. Tier placement for these medications is shown below.
Condition
Medication Name
Utilization
Effective Date
Placement
Cancer Pain
Nasal Allergies
1. Pre-certification is already required to verify diagnosis. Medications moving to a higher tier
We evaluate medications based on their total value, including how a medication works. When two or more medications
work the same way, other factors, including cost, may play a role in their tier placement on the PDL. Medications may
move to a higher tier because they offer less health care value than similar medications in their therapeutic classes.
If your medication is listed below, you may continue taking it, but you may pay a higher cost. We encourage you to talk
with your doctor about the lower-cost option(s) listed below that also may treat your condition.
Condition
Medication Name
Utilization
Lower-Cost Options
Placement
Excess Growth
Sleepiness
(generic Ritalin LA), Adderall XR, Vyvanse HIV-related
Complication
Low Platelet
Migraine
sumatriptan succinate (generic Imitrex) fluticasone (generic Flonase), Nasal Allergies
Overactive
Medications moving to a higher tier (continued)
Condition
Medication Name
Utilization
Lower-Cost Options
Placement
Pulmonary
Arterial
Hypertension
Transplant
Medications being added to the Select Designated Pharmacy Program2
Through this program, members must either fill their prescription by mail or switch to a lower-cost option, or do both in
order to continue to receive network benefits. Call the number on the back of your health plan ID card to determine if this
program applies to your benefit plan and for additional details about the program.
Medication
Condition
Tier Placement
Utilization
Lower-Cost Options
fluoxetine (generic Prozac), paroxetine (generic Paxil), Depression
sertraline (generic Zoloft), citalopram (generic Celexa), escitalopram (generic Lexapro) Overactive
oxybutynin (generic Ditropan), oxybutynin extended- release (generic Ditropan XL), trospium (Sanctura) 2. New York Small and Large Group Fully Insured groups only Medications no longer covered under most of our benefit plans
When several medications work in the same way, we may choose to not cover the higher-cost option. The medications
listed below will no longer be covered under many of our pharmacy benefit plans.
Medication
New Benefit
Condition
Utilization
Lower-Cost Options
Coverage
Over-the-counter (OTC) salicylic acid products 3. 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 Medications that require pre-certification (Connecticut and New York only)
The medications listed below require your physician to provide additional prescribing information to determine if coverage
is available.
New Benefit
Condition
Medication Name
Utilization
Lower-Cost Options
Coverage
Allergies/Asthma
Breast Cancer
2013 Oxford Health Plans LLC. All rights reserved. Please note not all PDL updates apply to all groups depending on state regulations, UnitedHealthcare® and the dimensional U logo are registered marks owned by Riders and Summary Plan Descriptions (SPDs). Oxford HMO products are Unitedhealth Group, Inc. Applies to Advantage PDL. All branded medications are underwritten by Oxford Health Plans (NY), Inc., Oxford Health Plans (NJ), Inc.and trademarks or registered trademarks of their respective owners. Oxford Health Plans (CT), Inc. Oxford insurance products are underwritten by Medications that require pre-certification (Connecticut and New York only) - continued
New Benefit
Condition
Medication Name
Utilization
Lower-Cost Options
Coverage
Cancer Pain
Depression
Wellbutrin SR) bupropion extended-release (generic Dermatitis
Glaucoma
High Blood
Pressure
Diovan HCT) doxycycline hyclate (generic Vibramycin), Monodox (brand only) Pre-certification4 0.28 Infections
Inflammatory
Bowel Disease
(generic Elimite), spinosad (generic Natroba) Nasal Allergies
fluticasone (generic Flonase), azelastine Osteoporosis
extended-release (generic Ambien CR) zaleplon (generic Sonata), zolpidem Stroke and Heart
Attack
Prevention
Ketodan Combination Package Pre-certification5 Topical Fungal
Infections
Ciclodan Combination Package Pre-certification5 2013 Oxford Health Plans LLC. All rights reserved. Please note not all PDL updates apply to all groups depending on state regulations, UnitedHealthcare® and the dimensional U logo are registered marks owned by Riders and Summary Plan Descriptions (SPDs). Oxford HMO products are Unitedhealth Group, Inc. Applies to Advantage PDL. All branded medications are underwritten by Oxford Health Plans (NY), Inc., Oxford Health Plans (NJ), Inc.and trademarks or registered trademarks of their respective owners. Oxford Health Plans (CT), Inc. Oxford insurance products are underwritten by Medications that require pre-certification (Connecticut and New York only) - continued
New Benefit
Condition
Medication Name
Utilization
Lower-Cost Options
Coverage
(Biaxin) + amoxicillin (Amoxil), PrevPac Ulcers,
Heartburn &
Protonix (brand only) Pre-certification4 4. 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 Connecticut and New York, medications may be excluded unless medically necessary. 5. These medications were excluded at launch in Connecticut and New York (unless medically necessary) – pre-certification may already be in place. They are covered in New Jersey. For more information
For questions about your pharmacy benefit, please visit oxfordhealth.com or call the Pharmacy
Customer Service member telephone number on the back of your health plan ID card. If you are hearing impaired and require assistance, please call our TTY/TDD line at 1-800-201-4875. Please call 1-800-303-6719 for assistance in Chinese, 1-888-201-4746 for assistance in Korean, or the telephone number on your health plan ID card for assistance in English and other languages. 2013 Oxford Health Plans LLC. All rights reserved. Please note not all PDL updates apply to all groups depending on state regulations, UnitedHealthcare® and the dimensional U logo are registered marks owned by Riders and Summary Plan Descriptions (SPDs). Oxford HMO products are Unitedhealth Group, Inc. Applies to Advantage PDL. All branded medications are underwritten by Oxford Health Plans (NY), Inc., Oxford Health Plans (NJ), Inc.and trademarks or registered trademarks of their respective owners. Oxford Health Plans (CT), Inc. Oxford insurance products are underwritten by

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