PDL Report January 1, 2015
Self-Funded Customers on the Advantage Prescription Drug List (PDL)
ABOUT THIS PDL REPORT
Your Prescription Drug List (PDL) Report serves as a summary
of updates to your PDL and pharmacy benefit. In this report,
you will find the details of the January 1, 2015 decisions and
how they will affect you and your employees.
SUMMARY OF UPDATES
The January 1, 2015 PDL and pharmacy benefit updates
remove considerable cost and waste out of the healthcare
system while representing only a small percentage of
prescriptions. UnitedHealthcare will send letters notifying any
impacted members of the updates below and provide other
medication options to discuss with their physician.
MORE INFORMATION
For a complete list of lower-cost options and member
communication materials, contact your UnitedHealthcare
representative or go to UHC.com/pharmacy.
PDL DECISION DEFINITION KEY
Down-Tier: Moving to a lower tier for immediate cost savings.
Up-Tier: Moving to a higher tier because they offer less
healthcare value.
New Benefit Coverage: Medications either previously excluded at
launch or new to the market that now have a tier placement.
Exclusion from Coverage: Offer limited value over existing
covered options.
Continued Exclusion: These exclusions will have
limited-to-no member impact since the medication has been
excluded at launch.
Notification: Requires physicians to provide additional
clinical information to verify member benefit coverage.
Supply Limits: Establishes the maximum quantity of drug
that is covered per copayment or in a specified timeframe.
Step Therapy: Requires trial of a lower-cost option before
receiving coverage for the more expensive medication.
Medical Necessity: Evaluates the clinical appropriateness of a
medication in terms of condition being treated, type of
medication, frequency, and duration.
Central Nervous System
Depression medications: Three medications will be excluded from pharmacy benefit coverage. These three medications have Tier 1 options available
that are $150 less costly.
Pain medications: Six medications will be excluded from pharmacy benefit coverage. Three of these medications are brand-only exclusions that have
lower-cost generic options available.
Pain medications: One medication will move to a lower-tier. Members now have access to an additional pain medication in Tier 2.
Sleep medications: One medication will be excluded from pharmacy benefit coverage. Members can move to generic Lunesta, which is in Tier 3, or
another generic option in Tier 1.
Cholesterol
Cholesterol medications: A total of 8 medications (brand and generics) will be excluded from pharmacy benefit coverage. All 8 products work the same
way as the two covered strengths in Tier 2 but are more expensive.
Infections
Fungal Infection medications: Six medications (brand and generics) will be excluded from pharmacy benefit coverage. Tier 1 options and
over-the-counter options (Lamisil AT, Lotrimin, Lotrimin AF) are available for nearly $300 less.
HIV medications: One brand medication will be excluded from pharmacy benefit coverage. Members can move to the generic equivalent in
Tier 2, nevirapine extended-release (generic Viramune XR).
Infection medications: Four medications will be excluded from pharmacy benefit coverage. Three of the impacted medications are brands
that have generic equivalents available in Tier 1 or Tier 2.
Infection medications (up-tiers): Four medications will move to a higher tier. These four medications are high cost generics that average
$400 more than Tier 1 doxycycline monohydrate 50 mg or 100 mg (generic Monodox).
Viral Infection medications: Two medications will be excluded from pharmacy benefit coverage. Members can move to a Tier 1 option,
acyclovir capsule or tablet (generic Zovirax), or over-the-counter Abreva.
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Skin Conditions
Acne medications: Five medications (brand and generics) will be excluded from pharmacy benefit coverage. Three of these medications
have generic equivalent options available in Tier 1.
Acne medications: One medication will move to a higher tier. This is a high cost generic with multiple lower-cost options in Tier 1 that work
the same way.
Acne medications: One medication will be added to pharmacy benefit coverage and will be placed on Tier 3.
Skin Conditions: Ten medications (brand and generic), all with lower-cost options in Tier 1, will be excluded from pharmacy benefit coverage. All have
lower-cost options in Tier 1 that cost, on average, $300 less per Rx.
Skin Conditions: Twelve medications (brand and generics), all with lower-cost options in Tier 1, will move to a higher tier. On average, the Tier 1 options
are $80 less expensive.
Ulcers, Heartburn, and Reflux
Ulcers, Heartburn, and Reflux: Two medications will be excluded from pharmacy benefit coverage. This is a crowded class with multiple lowcost Tier 1 as well as over-the-counter options available. Members can move to Tier 1 options: omeprazole (generic Prilosec), pantoprazole
(generic Protonix).
Ulcers, Heartburn, and Reflux: One medication will be added to pharmacy benefit coverage and will be placed in Tier 3.
Women's Health
Contraceptives: Four medications, all with lower-cost options available, will be excluded from pharmacy benefit coverage. This is a crowded class with
multiple options in Tier 1. These alternatives cost approximately $70 less.
Hormone Replacement: One medication will be excluded from pharmacy benefit coverage. Members can move to Tier 1 option estradiol tablet (generic
Estrace).
Hormone Replacement (up-tiers): Two medications will move to a higher tier. The Hormone Replacement class is crowded and members can move to a
lower-cost option that costs, on average, $80 less per Rx.
Symptoms Associated With Menopause: One medication will be excluded from pharmacy benefit coverage. Members can move to Tier 1 option
paroxetine (generic Paxil).
Miscellaneous
Miscellaneous Exclusions
Blood Pressure medications: Two brand-name blood pressure medications will be excluded from benefit coverage. Members can move to a Tier 1
generic option that costs, on average, about $150 less per Rx.
Cough and Cold medications: One brand medication will be excluded from benefit coverage. Members can move to one of the Tier 1 options that costs
$70 less, or consider trying an over-the-counter medication.
Excessive Secretions medications: One medication will be excluded from benefit coverage. This high cost drug has additional little clinical value
compared to Tier 1 option glycopyrrolate (generic Robinul).
Osteoporosis medications: One brand medication will be excluded from benefit coverage. Members can move to Tier 2 generic equivalent option
raloxifene (generic Evista).
Phosphate Binder medications: One brand medication will be excluded from benefit coverage. Members can move to the Tier 2 generic equivalent
option sevelamer carbonate (generic Renvela).
Transplant medications: One medication will be excluded from benefit coverage. Members can move to Tier 1 option tacrolimus (generic Prograf).
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Miscellaneous Down-Tiers
The following medications will move to a lower tier, allowing members to have a lower-cost option.
One Alzheimer's Disease medication
One Cystinosis medication
Two Diabetes medications
One Hereditary Angioedema medication
Bulk Compounds
Pharmacy compounding is a practice in which a pharmacist combines, mixes, or alters ingredients in response to a prescription to create a
medication tailored to the medical needs of an individual patient. Compound medications are not FDA approved and are priced at a premium by
compounding pharmacies. Implementing bulk chemical exclusions and prior authorization/threshold manages compound cost and use.
To continue ensuring appropriate use of compounds, additional ingredients will be excluded from pharmacy benefit coverage on January 1.
Immunomodulator Medications
Immunomodulator Medications Down-Tiers
Actemra
Cimzia
Simponi (50mg)
Orencia
Xeljanz
Immunomodulator Medications Up-Tiers
Enbrel
Total Number of PDL Updates
3 Tier Benefit Up-Tiers
19
Exclusions
62
New Benefit Coverage
3
Down-Tiers
6
THIS IS THE END OF YOUR REPORT
For more information
Visit UHC.com/pharmacy or contact your UnitedHealthcare representative
Confidential property of UnitedHealth Group.
Do not copy or distribute.
Page 3 of 12
PDL Report January 1, 2 15
Self-Funded Customers on the Advantage Prescription Drug List (PDL)
Individual Medication Details
For more information, contact your UnitedHealthcare Representative.
Class
Exclusions and Up-tiers
Atralin
Lower-Cost Options: tretinoin (generic Retin-A)
Fabior
Lower-Cost Options: tretinoin (generic Retin-A), Tazorac gel
Acne
Neuac 1.2%-5% Kit
Lower-Cost Options: clindamycin solution (generic Cleocin T) plus OTC benzoyl peroxide, clindamycin
1.2%/benzoyl peroxide 5% (generic Duac)
Tretin-X . 375% cream
Lower-Cost Options: tretinoin (generic Retin-A)
Tretin-X . 75% cream
Lower-Cost Options: tretinoin (generic Retin-A)
Tretin-X Kit
Lower-Cost Options: tretinoin (generic Retin-A)
Antara 43mg, 13 mg (brand and generic)
Lower-cost options: fenofibrate 54mg, 16 mg (generic Lofibra)
Antara 3 mg, 9 mg
Lower-cost options: fenofibrate 54mg, 16 mg (generic Lofibra)
Fenoglide
Lower-cost options: fenofibrate 54 mg, 16 mg (generic Lofibra)
Fibricor 35 mg, 1 5 mg (brand and generic)
Lower-cost options: fenofibrate 54 mg, 16 mg (generic Lofibra)
High
Cholesterol
Lipofen (brand and generic)
Lower-cost options: fenofibrate 54 mg, 16 mg (generic Lofibra)
Lofibra 54 mg, 16 mg (Brand only)
Lower-cost options: fenofibrate 54mg, 16 mg (generic Lofibra)
Lofibra 67 mg, 134 mg, 2 mg (brand and generic)
Lower-cost options: fenofibrate 54 mg, 16 mg (generic Lofibra)
Triglide
Lower-cost options: fenofibrate 54 mg, 16 mg (generic Lofibra)
Lovaza (Brand Only)
Lower-cost options: omega-3-acid ethyl esters (generic Lovaza), Vascepa
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Falessa Kit
Lower-cost options: Aubra, Aviane, Delyla, Falmina Lessina, Lutera, Orsythia, Sronyx, (generics Alesse,
Levlite)
Lo Minastrin FE
Lower-cost options: Gildess Fe, Junel Fe, Larin Fe, Microgestin Fe (generics for Loestrin Fe)
Contraceptives
Ortho Evra (Brand Only)
Lower-cost options: norelgestromin/ethinyl estradiol topical patch, Xulane (generic Ortho Evra)
Quartette
Lower-cost options: Introvale, Jolessa, Quasense (generics for Seasonale), Amethia, Camrese, Daysee
(generic for Seasonique); Amethia Lo, Camrese Lo (generic for LoSeasonique)
Cough and Cold
Zutripro (Brand Only)
Lower-cost options: chlorpheniramine/hydrocodone/pseudoephedrine (generic Zutripro)
Desvenlafaxine
Lower-cost options: venlafaxine extended-release capsule (generic Effexor XR), Pristiq
Depression
Khedezla
Lower-cost options: venlafaxine extended-release capsule (generic Effexor XR), Pristiq
Pexeva
Lower-cost options: paroxetine (generic Paxil), paroxetine extended-release (generic Paxil CR)
Excessive
Secretions
Glycate
Lower-cost options: glycopyrrolate (generic Robinul)
Ertaczo
Lower-cost options: ciclopirox (generic Loprox), econazole (generic Spectazole), ketoconazole (generic
Nizoral)
Luzu
Lower-cost options: ciclopirox (generic Loprox), econazole (generic Spectazole), ketoconazole (generic
Nizoral)
Naftin 1%, 2%
Lower-cost options: ciclopirox (generic Loprox), econazole (generic Spectazole), ketoconazole (generic
Nizoral)
Fungal
Infections
Naftin 2% gel
Lower-cost options: ciclopirox (generic Loprox), econazole (generic Spectazole), ketoconazole (generic
Nizoral)
nystatin/triamcinolone (generic Mycolog II) cream & ointment
Lower-cost options: nystatin cream or ointment (generic Mycostatin) + triamcinolone .1% cream or
ointment (generic Kenalog)
Oxistat Lotion
Lower-cost options: ciclopirox (generic Loprox), econazole (generic Spectazole), ketoconazole (generic
Nizoral)
Vusion
Lower-cost options: nystatin cream (generic Mycostatin)
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Micardis (Brand Only)
High Blood
Pressure
HIV
Hormone
Replacement
Lower-cost options: losartan (generic Cozaar), telmisartan (generic Micardis)
Micardis HCT (Brand Only)
Lower-cost options: losartan/hydrochlorothiazide (generic Hyzaar), telmisartan/hydrochlorothiazide
(generic Micardis HCT)
Viramune XR 4 mg (Brand Only)
Lower-cost options: nevirapine extended-release (generic
Viramune XR)
Cenestin
Lower-cost options: estradiol tablet (generic Estrace), Enjuvia, Premarin
Enjuvia
Lower-cost options: estradiol tablet (generic Estrace)
Estrace cream
Lower-cost options: Vagifem, Estring
Avelox tablet (Brand Only)
Lower-cost options: moxifloxacin tablets (generic Avelox)
Cipro suspension (Brand Only)
Lower-cost options: ciprofloxacin oral suspension (generic Cipro Suspension)
Mepron suspension (Brand Only)
Lower-cost options: atovaquone suspension (generic Mepron)
doxycycline 75 mg capsule (generic Monodox)
Lower-cost options: doxycycline monohydrate 5 mg or 1 mg (generic Monodox), doxycycline hyclate
(generic Morgidox, Vibramycin)
Infections
doxycycline hyclate capsule (generic Morgidox)
Lower-cost options: doxycycline monohydrate 5 mg or 1 mg (generic Monodox)
doxycycline hyclate tablet (generic Vibramycin)
Lower-cost options: doxycycline monohydrate 5 mg or 1 mg (generic Monodox)
minocycline tablet (generic Dynacin)
Lower-cost options: doxycycline monohydrate 5 mg or 1 mg (generic Monodox), doxycycline hyclate
(generic Morgidox, Vibramycin), minocycline capsules
tetracycline capsule (generic Sumycin)
Lower-cost options: doxycycline monohydrate 5 mg or 1 mg (generic Monodox), doxycycline hyclate
(generic Morgidox, Vibramycin), minocycline capsules
Osteoporosis
Evista (Brand Only)
Lower-cost options: raloxifene (generic Evista)
Active-Pac with Gabapentin 3
Lower-cost options: gabapentin (generic Neurontin)
Avinza (Brand Only)
Lower-cost options: morphine sulfate extended-release tablet (generic MS Contin), Opana ER, Oxycontin,
morphine sulfate extended-release capsule (generic Avinza), Nucynta ER
Duragesic (Brand Only)
Lower-cost options: fentanyl transdermal patch (generic Duragesic)
fentanyl patch (generic Duragesic)
Pain
Now available in Tier 2 for members
Fioricet with Codeine 5 mg/325 mg/4 mg/3 mg (Brand Only)
Lower-cost options: butalbital/acetaminophen/caffeine/ codeine phosphate 5 mg/325 mg/4 mg/3 mg
(generic Fioricet with Codeine)
Fioricet with Codeine 5 mg/3 mg/4 mg/3 mg (brand and generic)
Lower-cost options: butalbital/acetaminophen/caffeine/ codeine phosphate 5 mg/325 mg/4 mg/3 mg
(generic Fioricet with Codeine)
Zorvolex
Lower-cost options: diclofenac potassium (generic Cataflam), diclofenac sodium (generic Voltaren),
ibuprofen (generic Motrin), naproxen (generic Anaprox, Anaprox DS, Naprosyn)
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Renvela tablets (Brand Only)
Phosphate
Binder
Lower-cost options: sevelamer carbonate (generic Renvela)
Clobex lotion (brand and generic)
Lower-cost options: betamethasone . 5% augmented gel (generic Diprolene), clobetasol propionate . 5%
gel (generic Temovate), clobetasol . 5% solution (generic Temovate)
Clodan Kit
Lower-cost options: clobetasol . 5% gel (generic Temovate), clobetasol . 5% solution (generic Temovate)
Cloderm cream (Brand Only)
Lower-cost options: mometasone furoate cream .1 % (generic Elocon)
Taclonex Ointment (Brand Only)
Lower-cost options: betamethasone/calcipotriene ointment (generic Taclonex)
Neo-Synalar Kit
Lower-cost options: fluocinolone cream (generic Lidex) plus OTC Neosporin
Skin Conditions
Noritate
Lower-cost options: metronidazole .75% cream (generic Metrocream)
Olux (brand and generic)
Lower-cost options: betamethasone . 5% augmented gel (generic Diprolene), clobetasol propionate . 5%
gel (generic Temovate), clobetasol . 5% solution (generic Temovate)
Olux-E (brand and generic)
Lower-cost options: betamethasone . 5% augmented gel (generic Diprolene), clobetasol propionate . 5%
gel (generic Temovate), clobetasol . 5% solution (generic Temovate)
Topicort spray
Lower-cost options: fluocinolone . 5% solution (generic Lidex), desoximetasone . 5% gel (generic
Topicort)
Utopic
Lower-cost options: urea 4 %
Lunesta (Brand Only)
Lower-cost options: zaleplon (generic Sonata), zolpidem (generic Ambien), eszopiclone (generic Lunesta)
Sleep
Brisdelle
Symptoms with
menopause
Lower-cost options: paroxetine (generic Paxil), paroxetine extended-release (generic Paxil CR)
Astagraf XL (Transplant)
Lower-cost options: tacrolimus (generic Prograf)
Transplant
Aciphex Sprinkle
Lower-cost options: omeprazole (generic Prilosec), pantoprazole (generic Protonix), rabeprazole (generic
Aciphex), Dexilant, Nexium Suspension, Prevacid Solu-Tab
Prilosec Suspension
Lower-cost options: omeprazole (generic Prilosec), pantoprazole (generic Protonix), rabeprazole (generic
Aciphex), Dexilant, Nexium Suspension, Prevacid Solu-Tab
Ulcers,
Heartburn, and
Reflux
Protonix Granules for Suspension
Lower-cost options: omeprazole (generic Prilosec), pantoprazole (generic Protonix), rabeprazole (generic
Aciphex), Dexilant, Nexium Suspension, Prevacid Solu-Tab
Denavir
Lower-cost options: acyclovir capsule/tablet (generic Zovirax), famciclovir tablet (generic Famvir),
valacyclovir tablet (generic Valtrex)
Viral Infections
Class
Zovirax cream
Lower-cost options: acyclovir capsule/tablet (generic Zovirax), famciclovir tablet (generic Famvir),
valacyclovir tablet (generic Valtrex)
Up-tiers
clindamycin phosphate 1% (generic Cleocin T)
Acne
Lower-cost options: clindamycin 1% solution (generic Cleocin T), erythromycin 2% gel (generic Emgel,
Erygel), erythromycin 3%/benzoyl peroxide 5% (generic Benzamycin)
amcinonide .1% cream (generic Cyclocort)
Lower-cost options: triamcinolone .5% cream (generic Aristocort)
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amcinonide .1% lotion (generic Cyclocort)
Lower-cost options: betamethasone . 5% lotion (generic Alphatrex)
betamethasone dipropionate . 5% cream (generic Diprosone)
Lower-cost options: triamcinolone .5% cream (generic Aristocort)
betamethasone dipropionate . 5% ointment (generic Diprosone)
Lower-cost options: fluocinonide . 5% ointment (generic Lidex)
bethamethasone dipropionate . 5% augmented lotion (generic Diprolene)
Lower-cost options: betamethasone . 5% augmented gel (generic Alphatrex), clobetasol propionate . 5%
gel (generic Temovate)
bethamethasone dipropionate . 5% augmented ointment (generic Diprolene)
Lower-cost options: clobetasol propionate . 5% emollient ointment (generic Temovate E)
desonide . 5% cream (generic Desowen)
Lower-cost options: alclometasone . 5% cream (generic Aclovate), triamcinolone . 25% cream (generic
Kenalog)
desonide . 5% lotion (generic Desowen)
Lower-cost options: betamethasone valerate .1% lotion (generic Valisone), triamcinolone . 25% lotion
(generic Kenalog)
desonide . 5% ointment (generic Desowen)
Lower-cost options: prednicarbate .1% ointment (generic Dermatop), triamcinolone . 25% ointment
(generic Kenalog)
desoximetasone gel (generic Topicort)
Lower-cost options: fluocinonide . 5% solution (generic Lidex)
desoximetasone ointment (generic Topicort)
Lower-cost options: fluocinonide . 5% ointment (generic Lidex)
fluocinolone . 1% cream (generic Synalar)
Lower-cost options: alclometasone . 5% cream (generic Aclovate), triamcinolone . 25% cream (generic
Kenalog)
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Skin Conditions
fluocinolone . 1% oil (generic Derma-Smoothe/FS)
Lower-cost options: alclometasone . 5% cream (generic Aclovate), betamethasone valerate .1% lotion
(generic Valisone), triamcinolone . 25% cream/lotion (generic Kenalog)
fluocinolone . 1% solution (generic Synalar)
Lower-cost options: betamethasone valerate .1% lotion (generic Valisone), triamcinolone . 25% lotion
(generic Kenalog)
fluocinolone . 25% cream (generic Synalar)
Lower-cost options: betamethasone valerate .1% cream (generic Valisone), prednicarbate .1% cream
(generic Dermatop)
fluocinolone . 25% ointment (generic Synalar)
Lower-cost options: prednicarbate .1% ointment (generic Dermatop), triamcinolone . 25% ointment
(generic Kenalog)
diflorasone diacetate . 5% ointment (generic Apexicon, Florone)
Lower-cost options: clobetasol propionate . 5% emollient ointment (generic Temovate E)
diflorasone diacetate cream . 5% (generic Apexicon E)
Lower-cost options: betamethasone dipropionate . 5% augmented cream (generic Diprolene AF),
fluocinonide . 5% cream (generic Lidex)
fluticasone propionate . 5% lotion (generic Cutivate)
Lower-cost options: triamcinolone acetonide .1% lotion (generic Kenalog)
halobetasol propionate . 5% cream (generic Ultravate)
Lower-cost options: clobetasol propionate . 5% emollient cream (generic Temovate E)
halobetasol propionate . 5% ointment (generic Ultravate)
Lower-cost options: clobetasol propionate . 5% emollient ointment (generic Temovate E)
hydrocortisone valerate .2% cream (generic Westcort)
Lower-cost options: fluticasone propionate . 5% cream (generic Cutivate), prednicarbate .1% cream
(generic Dermatop), triamcinolone . 25% cream (generic Kenalog)
hydrocortisone valerate .2% ointment (generic Westcort)
Lower-cost options: prednicarbate .1% ointment (generic Dermatop), triamcinolone . 25% ointment
(generic Kenalog)
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New Benefit Coverage
Class
Acne
Alzheimer's
Disease
Ulcers,
Heartburn, and
Reflux
clindamycin 1.2%/benzoyl peroxide 5% gel (generic Duac)
Namenda XR
Prevacid Solutab
Down-Tiers
Class
Hereditary
Angioedema
Berinert
Cystinosis
Cystagon
Invokana
Diabetes
Tanzeum
Additional Exclusions
Class
Medication listed below do not have the capability of being covered. See the description next to the the medication for
more information.
clindamycin 1%/benzoyl peroxide 5%
(generic BenzaClin) gel
Acne
In a past PDL change cycle, you chose to exclude brand-name BenzaClin Jar and, due to several
factors including cost, the generic will now follow your decision on the brand and will be
excluded as well.
SelRx
Skin Conditions
When a prescription product becomes available over-the-counter your benefit plan states that
the prescription version will no longer be covered. In the skin condition category, SelRx has overthe-counter options like Selsun Blue.
Nexium capsules
Prevacid capsules
Ulcers,
Heartburn, and
Reflux
When a prescription product becomes available over-the-counter your benefit plan states that
the prescription version will no longer be covered. In the heartburn category, two medications
have become available over-the-counter, Nexium and Prevacid capsules, and will no longer be
covered by the prescription drug plan.
For more information
THIS IS THE END OF YOUR REPORT
Visit UHC.com/pharmacy or contact your UnitedHealthcare representative
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Page 10 of 12
PDL Report January 1, 2015
Self-Funded Customers on the Advantage Prescription Drug List (PDL)
Clinical Program Updates
The medications below will be added to their respective programs on January 1, 2015.
For more information, contact your UnitedHealthcare Representative.
Supply Limit Update
Supply Limits
A supply limit is the largest quantity of medication covered per copayment or in a time period. The following medications will now have a supply
limit.
Anoro Ellipta (Asthma/COPD)
Anoro Ellipta 62.5 mcg/25 mcg Blisters has a new supply limit of 62 blisters per month.
ApexiCon E (Skin Conditions)
ApexiCon E 0.05% cream has a new supply limit of 30 g per copay.
Apriso (Inflammatory Bowel Disease)
Apriso 375 mg capsules has a new supply limit of 124 capsules per month.
Asacol HD (Inflammatory Bowel Disease)
Asacol HD 800 mg tablets has a new supply limit of 62 tablets per month.
Benzamycin (Skin Conditions)
Benzamycin 3%-5% gel (Jar Only) has a new supply limit of 23.3 g per copay.
Cleocin T (Skin Conditions)
Cleocin T 1% Gel has a new supply limit of 30 g per copay.
Cordran (Skin Conditions)
Cordran 0.05% lotion has a new supply limit of 60mL per copay.
Cordran SP (Skin Conditions)
Cordran SP 0.05% cream has a new supply limit of 30 g per copay.
Cutivate (Skin Conditions)
Cutivate 0.05% lotion has a new supply limit of 60mL per copay.
Delzicol (Inflammatory Bowel Disease)
Delzicol 400 mg capsules has a new supply limit of 124 capsules per month.
Derma-Smoothe/FS (Skin Conditions)
Derma-Smoothe/FS 0.01% Body Oil has a new supply limit of 118.28mL per copay.
Desowen (Skin Conditions)
Desowen 0.05% cream and ointment has a new supply limit of 15 g per copay.
Desowen (Skin Conditions)
Desowen 0.05% lotion has a new supply limit of 60mL per copay.
Elidel (Skin Conditions)
Elidel 1% cream has a revised supply limit of 30 g per copay.
Farxiga (Diabetes)
Farxiga 5 mg & 10 mg tablets has a new supply limit of 31 tablets per month.
fluocinolone (Skin Conditions)
fluocinolone 0.01% cream has a new supply limit of 15 g per copay.
Grastek (Allergies)
Grastek has a new supply limit of 31 tablets per month.
Halog (Skin Conditions)
Halog 0.1% cream and ointment has a new supply limit of 30 g per copay.
Jublia (Fungal Infections)
Jublia 10% Topical Solution has a new supply limit of 44 mL per 365 days.
Lialda (Inflammatory Bowel Disease)
Lialda 1.2 g has a new supply limit of 62 tablets per month.
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Lotrisone (Skin Conditions)
Lotrisone 1%-0.05% cream has a new supply limit of 15 g per copay.
Luzu (Skin Conditions)
Luzu 1% cream has a new supply limit of 30 g per copay.
Nuvigil (Narcolepsy)
Nuvigil 200 mg tablets has a new supply limit of 31 tablets per month.
Oralair (Allergies)
Oralair 300 IR has a new supply limit of 31 tablets per copay.
Oxistat (Fungal Infections)
Oxistat 1% cream has a new supply limit of 30 g per copay.
Pentasa (Inflammatory Bowel Disease)
Pentasa 250 mg has a new supply limit of 248 capsules per month.
Pentasa (Inflammatory Bowel Disease)
Pentasa 500 mg has a new supply limit of 124 capsules per month.
Protopic (Skin Conditions)
Protopic 0.03% ointment & 0.1% ointment have a revised supply limit of 30 g per copay.
Ragwitek (Allergies)
Ragwitek 12 Amb a 1-Unit has a new supply limit of 31 tablets per month.
Suboxone (Opiod Dependence)
Suboxone 12 mg/3 mg Films has a new supply limit of 2 films per month.
Synalar (Skin Conditions)
Synalar 0.01% Topical Solution has a new supply limit of 60mL per copay.
Synalar (Skin Conditions)
Synalar 0.025% cream & ointment have a new supply limit of 15 g per copay.
Topicort (Skin Conditions)
Topicort 0.05% (cream, gel, ointment) & 0.25% (cream and ointment) have a new supply limit of 15 g per copay.
Ultravate (Skin Conditions)
Ultravate 0.05% cream & ointment has a new supply limit of 15 g per copay.
Valchlor (Cancer)
Valchlor 0.016% gel has a new supply limit of 120 g per copay.
Veregen (Skin Conditions)
Veregen 15% ointment has a new supply limit of 15 g per copay.
Westcort (Skin Conditions)
Westcort 0.2% cream & ointment have a new supply limit of 15 g per copay.
Zohydro ER (Pain)
Zohydro ER 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg have a new supply limit of 62 tablets per month.
Zontivity (Stroke & Heart Attack Prevention)
Zontivity 2.08 mg tablets has a new supply limit of 31 tablets per month.
Zykadia (Cancer)
Zykadia 150 mg capsules has a new supply limit of 155 capsules per month.
Notification
Notification Updates
Requires physicians to provide additional clinical information to verify member benefit coverage
Syprine (Endocrine)
Sirturo (Tuberculosis)
For more information
THIS IS THE END OF YOUR REPORT
Visit UHC.com/pharmacy or contact your UnitedHealthcare representative
1
Estimated potential member impact is based on March
to June 2014 claims for our standard Traditional and
Advantage PDLs. Estimated member impact for up-tiers is
only based on incented benefit designs.
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