Co.madison.il.us

Updates to your prescription benefits
Effective January 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. 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.
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
Osteoporosis
alendronate (generic Fosamax), ibandronate (generic Boniva) Overactive Bladder
oxybutynin sustained-release (generic Ditropan XL), trospium (generic Sanctura), Sanctura XR, Vesicare Thyroid Hormone
Replacement
Viral Infection
podofilox liquid (generic Condylox liquid) Medication being added to the Select Designated Pharmacy (SDP) Program
Through this program, participants must choose one of three options 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.
Therapeutic Use
Medication Name
Tier Placement
Lower-Cost Options
Depression Diagnosis: citalopram (generic Celexa), fluoxetine (generic Prozac), sertraline (generic Zoloft), Depression
venlafaxine sustained-release (generic Effexor XR), Pristiq Neuropathic Pain Diagnosis: gabapentin (generic Neurontin) 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
sulfacetamide sodium/sulfur (generic Sulfatol) Contraceptive
Gildess FE, Junel FE, Microgestin FE (generics for Loestrin FE) Depression
Erectile Dysfunction
Medications excluded from benefit coverage

Therapeutic Use
Medication Name
Lower-Cost Options
OTC ketotifen (Zaditor), azelastine ophthalmic solution Eye Allergies
bromfenac (generic Xibrom), ketorolac (generic Acular) Hepatitis C
amlodipine (generic Norvasc) plus losartan (generic Cozaar) amlodipine (generic Norvasc) plus Benicar or Micardis amlodipine (generic Norvasc) plus Diovan High Blood
Pressure
amlodipine (generic Norvasc) plus losartan/hydrochlorothiazide amlodipine (generic Norvasc) plus Benicar HCT or Micardis HCT amlodipine (generic Norvasc) plus Diovan HCT High Cholesterol
Inflammation
prednisolone (generic Prelone), Orapred, Pediapred Nasal Allergies
azelastine nasal spray (generic Astelin), Astepro Neuropathic Pain
tramadol extended-release (generic Ultram ER), tramadol immediate-release (generic Ultram) ibuprofen (generic Motrin) plus OTC famotidine (generic Pepcid AC) chlorzoxazone (generic Parafon Forte DSC) chlorzoxazone (generic Parafon Forte DSC), cyclobenzaprine (generic Flexeril), metaxalone (generic Skelaxin), methocarbamol (generic Robaxin) Psoriasis
Restless Legs
Syndrome
metronidazole gel 0.75% (generic Metrogel) metronidazole gel 0.75% (generic Metrogel) Skin Conditions
(Other)
hydrocortisone/pramoxine (generic Analpram E) Toenail Infections
Ulcers, Heartburn &
OTC Zegerid, omeprazole (generic Prilosec), pantoprazole (generic Protonix) For more information
Visit myuhc.com or call the toll-free number on the back of your health plan ID card.
2012 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 Advantage PDL.

Source: http://www.co.madison.il.us/SafetyRisk/PDF/January2013PrescriptionBenefitUpdates.pdf