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M.stglive.myharvardpilgrim.org

Updates to your prescription benefits
Effective January 1, 2014

Within the Prescription Drug List (PDL), medications are grouped by tier. The tier indicates the amount you pay when you fill a prescription. Please reference this chart as you review the following updates. Most options listed are available in Tier 1, your lowest cost option.
If your medication is listed below, you may continue taking it, but you may pay a higher cost. We encourage you to
discuss the listed lower-cost option(s) that may also treat your condition with your doctor. Most options listed are available
in Tier 1, your lowest-cost tier.

Medications moving to a lower-tier
The following medications are moving to a lower-tier, making them more affordable.
Therapeutic Use
Medication Name
Placement
Diabetes
Multiple Sclerosis
Medications moving to a higher tier
Medications may move from a lower tier to a higher tier when they are more costly and have available lower-cost options.

Therapeutic Use
Medication Name
Tier Placement
Lower-Cost Options
tretinoin (generic Retin-A), adapalene (generic Differin) Allergies
Based on your diagnosis, talk to your doctor about options Excess Growth
Excessive
methylphenidate (generic Ritalin), methylphenidate extended- Sleepiness
release (generic Concerta), Adderall XR, Vyvanse Growth Hormone
Low Platelet Levels
naratriptan (generic Amerge), rizatriptan (generic Maxalt), Migraine
rizatriptan orally disintegrating tablet (Maxalt MLT), sumatriptan Multiple Sclerosis
Pulmonary Arterial
Hypertension
OTC Nicotine Patch, bupropion sustained-release Smoking Cessation
Transplant
Ulcers due to H.
metronidazole (generic Flagyl) plus tetracycline plus OTC
*Excluded for the majority of benefit plans.

Medications with New Benefit Coverage
The following medications were previously not covered under most benefit plans and are now eligible for coverage.
Therapeutic Use
Medication Name
Tier Placement
Inflammatory Bowel Disease
Sleep Disorders
Ulcers due to H. pylori
Medications excluded from benefit coverage
We evaluate medications based on their total value, including how a medication works and how much it costs. When
several medications work in the same way, we may choose to exclude the higher-cost option. The medications listed
below will no longer be covered under many of our pharmacy benefit plans.
Therapeutic Use
Medication Name
Lower-Cost Options
Amnesteem, Claravis, Myorisan, Sotret, Zenatane (branded generics for clindamycin 1%/benzoyl peroxide 5% gel (generic Benzaclin) clindamycin 1%/benzoyl peroxide 5% gel (generic Benzaclin) clindamycin 1%/benzoyl peroxide 5% gel (generic Benzaclin) adapalene (generic Differin), tretinoin (generic Retin-A) amphetamine/dextroamphetamine immediate-release (generic Adderall) methylphenidate (generic Ritalin), methylphenidate extended-release (generic Concerta), Adderall XR, Vyvanse methylphenidate (generic Ritalin), methylphenidate extended-release (generic Metadate CD), Adderall XR, Vyvanse Allergic Reactions
Allergies
fluticasone (generic Flonase), Omnaris, Zetonna, Qnasl, Nasonex 2013 United HealthCare Services, Inc. Confidential Information. All branded medications are trademarks or registered trademarks of their respective UnitedHealthcare® and the dimensional U logo are registered marks owned by owners. Please note not all PDL updates apply to all groups depending on state Unitedhealth Group, Inc. Applies to Traditional PDL. alprazolam extended-release (generic Xanax XR) Cancer Pain
fentanyl citrate (generic Actiq), Lazanda, Onsolis, Subsys Depression
venlafaxine extended-release capsule (generic Effexor XR), Pristiq bupropion extended-release (generic Wellbutrin XL) Dermatitis
hydrocortisone butyrate (generic Locoid) Diabetes
Fungal Infections
Inflammation
balsalazide (generic Colazal), sulfasalazine (generic Azulfidine), Apriso, Inflammatory Bowel
balsalazide (generic Colazal), sulfasalazine (generic Azulfidine), Apriso, Mental Health
olanzapine (generic Zyprexa), olanzapine orally disintegrating tablet sumatriptan injection and tablets (generic Imitrex) Migraines
rizatriptan (generic Maxalt), rizatriptan orally disintegrating tablet Detrol (tolterodine) (brand and generic) Enablex oxybutynin (generic Ditropan), oxybutynin extended-release Overactive Bladder
(generic Ditropan XL), Oxytrol OTC, Toviaz Sanctura (trospium) (brand and generic) Sanctura XR (trospium extended-release) (brand and generic) Pancreatic Enzyme
Replacement
Psoriasis
calcipotriene solution (generic Dovonex) 2013 United HealthCare Services, Inc. Confidential Information. All branded medications are trademarks or registered trademarks of their respective UnitedHealthcare® and the dimensional U logo are registered marks owned by owners. Please note not all PDL updates apply to all groups depending on state Unitedhealth Group, Inc. Applies to Traditional PDL. Pulmonary Arterial
Hypertension
Topical Viral

Infections
Ulcers due to H.
Pylori

For more information
Visit myuhc.com or call the toll-free number on the back of your health plan ID card.
2013 United HealthCare Services, Inc. Confidential Information. All branded medications are trademarks or registered trademarks of their respective UnitedHealthcare® and the dimensional U logo are registered marks owned by owners. Please note not all PDL updates apply to all groups depending on state Unitedhealth Group, Inc. Applies to Traditional PDL.

Source: http://m.stglive.myharvardpilgrim.org/live/uhc_com/Assets/Documents/pharmTradMember.pdf

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