Welcome to your UnitedHealthcare Pharmacy Benefit
Effective July 1, 2009, your pharmacy benefits, associated with your medical plan, will also be changing to UnitedHealthcare. As a result, the list of medications covered under your pharmacy benefit may change. Your Prescription Drug List (PDL) will consist of three tiers – Tier 1 is the lowest copayment tier and Tier 3 is the highest copayment or coinsurance tier. Although the copayments or coinsurance amounts for each benefit level that you have today will not be changing, the tier that the medication is on may be different. We encourage you to review the PDL Guide that is included in your enrollment kit. This guide will help you understand your medication choices, explain how PDL decisions are made and alert you to any requirements or limitations such as prior authorization, step therapy or quantity limits. Frequently Asked Questions Where can I get additional information or questions answered regarding my pharmacy coverage? You should first refer to the benefit information contained in your enrollment kit and the copy of the PDL Guide. If your question cannot be answered, please contact your Human Resources department for further assistance. Will I pay more for my medications? The same copayments or coinsurance benefit structure that you have in place today will also apply to your new benefit. However, a given medication may be on a lower or higher tier resulting in a change to your out-of-pocket costs. Refer to the PDL for specific drug tier placement. Will I be able to continue taking the same drugs as I do today? Review the PDL for the drugs you are taking. There may be some medications that are excluded from coverage under your new plan. Examples of these drugs are listed below. Excluded Drug(s) Alternative(s)
Prevacid Omeprazole, Nexium, Protonix Allegra, Allegra-D, Clarinex, Clarinex-D
Cimetidine, Famotidine, Ranitidine Available
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What are the drug restrictions or limitations that I should be aware of? Some medications may require prior authorization approval from Prescription Solutions, UnitedHealthcare’s Pharmacy Benefit Manager, before your pharmacy can dispense the medication. These medications are denoted with a ‘PA” in the PDL Guide. Effective July 1, 2009, if your physician determines that you should continue taking a medication that requires prior authorization, he/she can call Prescription Solutions Prior Authorization Department to make a request. Some medications may require step therapy, a process that requires a trial of a different drug with the same therapeutic effect prior to allowing the requested medication. In this instance, our pharmacy system will review your prescription claims history and, if you have tried the first line drugs or are already taking the requested drug, the pharmacy will dispense the requested medication for the appropriate copay or coinsurance. If not found, a prior authorization approval through Prescription Solutions is required for your prescribed medication before it can be dispensed. These medications are denoted with a ‘ST” in the PDL Guide and include examples such as: Avapro, Atacand, Benicar, Cozaar, Detrol / Detrol LA, Diovan, Janumet, Januvia, Micardis, Sanctura and Tekturna. Some medications may have quantity limitations for clinical safety and cost effectiveness. These medications are denoted with a ‘QL” in the PDL Guide. Examples of quantity limitations include:
¾ Drugs to treat migraine such as Frova, Maxalt, Replax, Zomig and sumatriptan
(generic Imitrex). These medications are limited to four tablets per prescription. All the drugs listed here are covered on tier 1. Our data analysis indicates that most people utilizing these drugs do not require more than four tablets per 30 days. If you do require more than four per 30 days, you can fill an additional prescription for the applicable tier 1 copayment.
¾ Drugs to treat impotence such as Cialis, Levitra and Viagra. These medications are
limited to five tablets per 30 days at retail pharmacies and 15 tablets per 90 days at mail service.
What should I do if I use a self-administered injectable medication? You will continue to have coverage for self-administered injectable medications through your pharmacy benefit plan. To manage costs for you and the District, UnitedHealthcare has developed a specialty pharmacy network for these medications. Please call our toll-free Specialty Pharmacy Referral Line at 1-866-429-8177 where a representative will answer questions about our program and transfer you to a specialty pharmacy based on your particular specialty medication prescription.
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Will I be able to utilize the same pharmacy as I do today? UnitedHealthcare offers an extensive pharmacy network with over 60,000 pharmacies nationwide. A list of national pharmacy chains that participate in our network is included in your enrollment kit. You may continue to request a 90-day supply of medication at a retail pharmacy or take advantage of the convenience of mail order service. Mail order medications are delivered directly to your home or office without incurring a shipping charge. Due to the high-cost and special handling required of some medications, UnitedHealthcare has developed a Specialty Pharmacy Network for your use. This Network includes self- administered injectables, some oral medications for the treatment of Hepatitis B, HIV or AIDS as well as transplant rejection medications. Please call our toll-free Specialty Pharmacy Referral Line at 1-866-429-8177 where a representative will answer questions about our program and transfer you to a specialty pharmacy based on your particular specialty medication prescription.
New Refill Rules – Under your new plan, you may request refills every 23 days for a 30-day
prescription and every 63 days for a 90-day prescription. Refill requests anytime sooner will result in a refill to soon rejection.
– Specialty Pharmacy medications, including self-administered injectables, are
allowed 2 fills at a retail pharmacy after which must be filled through Prescription Solutions Specialty Pharmacy. As a reminder, we will notify you of this requirement after your first retail fill.
If I’m currently using mail service, will my prescriptions be transferred? Yes. If you have open refills through Walgreens mail service, these prescriptions will be transferred to Prescription Solutions, UnitedHealthcare’s mail service pharmacy. Effective July 1, 2009, you will be able to order mail service prescriptions by calling Prescription Solutions at 1-800-562-6223.
Administrative services provided by UnitedHealthcare Insurance Company, UnitedHealthcare Services, Inc. or their affiliates.
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Welcome to your UnitedHealthcare Pharmacy Benefit
Effective July 1, 2009, your pharmacy benefits, associated with your medical plan, will also 
