Enhanced Three-Tier PDL Update Summary Updates To Your .

Enhanced Three-Tier PDLUpdate SummaryUpdates to yourprescription benefitsEffective Jan. 1, 2019Within the Prescription Drug List (PDL), medications are groupedby tier. The tier indicates the amount you pay when you fill aprescription. Please reference the chart to the right as you reviewthe following updates to the PDL. Tier 1Tier 2Tier 3Your lowest-costmedicationsYour mid-range costmedicationsYour highest-costmedicationsMedications with new benefit coverageThe following medications were previously not covered under most benefit plans and are now eligible for coverage.Therapeutic UseMedication NameAcneXimino3Bowel PreparationClenpiq3Seebri NeohalerCOPDTrelegyTier Placement3AdmelogAdmelog SolostarFiaspFiasp SteglujanGlaucomaVyzulta3HemophiliaRebinyn3 2018 United HealthCare Services, Inc.Enhanced Three-Tier PDL Update Summary8/18

Therapeutic UseMedication NameTier PlacementNasal PolypsXhance3Nausea and vomitingassociated with pregnancyBonjesta3Neuropathic PainLyrica CR3Opioid Induced ConstipationSymproic2Oral SteroidDecadron tablets (Brand Only)3Skin ConditionsImpoyz3Medications moving to a lower tierThe following medications are moving to a lower tier, making them a lower cost.Therapeutic UseMedication NameTier PlacementSpiriva HandiHalerCOPD3u2Spiriva fiSymfi LoMultiple Sclerosisglatiramer acetate (generic Copaxone)3u1Medications moving to a higher tierThe following medications are moving to a higher tier. Medications may move from a lower tier to a higher tier when they are morecostly and have available lower-cost options.Therapeutic UseDiabetes11Medication NameLevemirLevemir FlextouchTierPlacementLower-Cost Options2u3Basaglar, TresibaHIVAtripla2u3Cimduo, Isentress, Juluca, Symfi, Symfi Lo, Tivicay,TriumeqHormoneReplacementClimara (Brand only)2u3estradiol transdermal patch (generic miflu suspension(Brand only)2u3oseltamivir suspension (generic Tamiflu suspension)Multiple SclerosisCopaxone1u3glatiramer acetate (generic Copaxone)Opioid InducedConstipationMovantik2u3SymproicDiabetic supplies and prescription medications may be subject to different cost-share arrangements for Oxford plans.Please see your Summary of Benefits and Coverage (SBC) for specifics. Medications that require step therapy may require prior authorization(sometimes referred to as precertification) if covered under another benefit. 2018 United HealthCare Services, Inc.Enhanced Three-Tier PDL Update Summary8/18

Enhanced Three-Tier PDLClinical Programs Update SummaryUpdates to yourprescription benefitsEffective Jan. 1, 2019Some medications may have programs or limits that apply. Below are the changes to the current programs and limits that willbe effective Jan. 1, 2019.MNMedical NecessityMedical Necessity is a type of Prior Authorization that evaluates the clinical appropriateness of a medication, such as conditionbeing treated, type of medication, frequency of use, and duration of therapy. The following medications will now requireMedical Necessity for coverage.Therapeutic UseMedication NameOpioid Induced ConstipationMovantikSTStep Therapy2The below medications will be added to the Step Therapy program. You must try one or more other medications before themedication below may be covered.Therapeutic UseMedication NameStep 1 MedicationConstipationAmitizaMust try one of the following dependingon diagnosis: (1) Linzess (2) SymproicCOPDSeebri NeohalerMust try two of the following: (1) SpirivaHandihaler or Respimat (2) IncruseEllipta (3) Tudorza PressairGlyxambiMust try one of the following:(1) Metformin (generic Glucophage,Glucophage XR) (2) Sulfonylurea(e.g. glimepiride) (3) Thiazolidinedione(e.g. pioglitazone)Diabetes1 2018 United HealthCare Services, Inc.Enhanced Three-Tier PDL Update Summary8/18

SLSupply LimitsSupply Limits establish the maximum quantity of a drug that is covered per copay or in a specified time frame. The belowmedications will now be part of the Supply Limits program.Therapeutic UseMedication NameNew or Revised LimitAcneCleocin-T solution30 mL per copaycodeine/phenylephrine/promethazine syrupcodeine/promethazine syrup & solutionFlowTuss solutionHycofenix solutionCough & Coldhydrocodone/homatropine syrupObredon solution120 mL per copay;Maximum of 360 mL permonthTussionex suspensionTuzistra XR suspensionZutripro Oral solutionInflammatory ConditionsSkin ConditionsTaltz 80 mg1 auto injector/syringe permonthdiflorasone diacetate ointment30 grams per copayKenalog (triamcinolone acetonide) aerosol spray63 grams per copay1Diabetic supplies and prescription medications may be subject to different cost-share arrangements for Oxford plans.Please see your Summary of Benefits and Coverage (SBC) for specifics. Medications that require step therapy may require prior authorization(sometimes referred to as precertification) if covered under another benefit.2Referred to as First Start in New Jersey.For additional information:Visit the member website listed on your health plan ID cardto look up the price of drugs covered by your plan, findlower-cost options and more. 2018 United HealthCare Services, Inc.Enhanced Three-Tier PDL Update Summary8/18Call the toll-free phone number on your healthplan ID card to speak with a Customer Servicerepresentative.

Nondiscrimination notice andaccess to communication servicesUnitedHealthcare and its subsidiaries do not discriminate on the basis of race, color, national origin, age, disability or sex in itshealth programs or activities.If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send acomplaint to the Civil Rights Coordinator.Online:Mail:UHC Civil Rights@uhc.comCivil Rights CoordinatorUnitedHealthcare Civil Rights GrievanceP.O. Box 30608Salt Lake City, UT 84130You must send the complaint within 60 days of your experience. A decision will be sent to you within 30 days. If you disagreewith the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, please call the toll-freephone number listed on your ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m., or at the times listed in your healthplan documents.You can also file a complaint with the U.S. Dept. of Health and Human Services.Online: laint forms are available ne:Mail:Toll free 1-800-368-1019, 1-800-537-7697 (TDD)U.S. Dept. of Health and Human Services200 Independence AvenueSW Room 509F, HHH BuildingWashington, D.C. 20201We provide free services to help you communicate with us, including letters in other languages or large print. Or, you can askfor an interpreter. To ask for help, please call the toll-free phone number listed on your ID card, TTY 711, Monday throughFriday, 8 a.m. to 8 p.m., or at the times listed in your health plan documents.

This document applies to commercial group members of UnitedHealthcare and Oxford New York and New Jersey planswith a pharmacy benefit subject to the Enhanced Three-Tier PDL.UnitedHealthcare is a registered trademark owned by UnitedHealth Group, Inc. All branded medications aretrademarks or registered trademarks of their respective owners. Please note not all PDL updates apply to all groupsdepending on state regulation, riders and SPDs.Insurance coverage provided by or through UnitedHealthcare Insurance Company, UnitedHealthcare InsuranceCompany of New York, or Oxford Health Insurance, Inc. Oxford HMO products are underwritten by Oxford Health Plans(NJ), Inc. Administrative services provided by United HealthCare Services, Inc., UnitedHealthcare Service LLC, OxfordHealth Plans LLC, or their affiliates.MT-1153515.2 MS-18-368 2018 United HealthCare Services, Inc. 76637-072018Enhanced Three-Tier PDL Update Summary 8/18

Inflammatory Conditions Taltz 80 mg 1 auto injector/syringe per month Skin Conditions diflorasone diacetate ointment 30 grams per copay Kenalog (triamcinolone acetonide) aerosol spray 63 grams per copay 1 Diabetic supplies and prescription medications may be subje