Advantage Three-Tier PDL Update Summary Updates To Your .

Advantage 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 NameBowel PreparationClenpiqCOPDTier Placement3Seebri NeohalerTrelegy Ellipta3Glyxambi2Ozempic3Tresiba2Multiple Sclerosisglatiramer acetate (Mylan only generic Copaxone)2Opioid Induced ConstipationSymproic2Diabetes1Medications moving to a lower tierThe following medications are moving to a lower tier, making them a lower cost.Therapeutic UseCOPDMedication NameSpiriva HandiHalerSpiriva RespimatTier Placement3u2CimduoHIV3u2SymfiSymfi Lo 2018 United HealthCare Services, Inc.100-18281 Advantage Three-Tier PDL Update Summary8/18

Medications 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 UseDiabetes1Pain & InflammationMedication NameTierPlacementLevemirLevemir Flextouchketoprofen extendedrelease (generic Oruvail)Lower-Cost Options2u3Basaglar, Tresiba1u3ibuprofen (generic Motrin), ketoprofen (generic Orudis),naproxen (generic Aleve, Naprosyn)Medications excluded from benefit coverageWe evaluate medications based on their total value, including how a medication works and how much it costs. When severalmedications work in the same way, we may choose to exclude the higher-cost option. Effective Jan. 1, 2019, the medications listedbelow may be excluded from coverage or subject to prior authorization (sometimes referred to as precertification) and/or trial/failure2 of another medication(s). You should review your benefit plan documents and pharmacy benefit coverage for a full list ofmedications that are excluded or that have programs or limits that apply.Therapeutic UseMedication NameLower-Cost OptionsAcneXiminominocycline immediate-release capsules (generic Minocin)AdmelogAdmelog SolostarHumalog vial, Humalog KwikPenApidraApidra SoloSTARFarxigaInvokana, JardianceFiaspHumalog vial, Humalog KwikPenFiasp FlexTouchNovolin 70/30Humulin 70/30 vial, Humulin 70/30 KwikPenNovolin 70/30 RelionNovolin NDiabetes1Humulin N vial, Humulin N KwikPenNovolin N RelionNovolin RHumulin R vialNovolin R RelionNovologHumalog vial, Humalog KwikPenNovolog FlexPenNovolog Mix 70/30Novolog Mix 70/30 Prefilled FlexPenHumalog 75/25 vial, Humalog 75/25 KwikPenNovolog PenfillHumalog vial, Humalog KwikPenQternGlyxambiSeglurometInvokamet, Invokamet XR, Synjardy, Synjardy XRSteglatroInvokana, JardianceSteglujanGlyxambi 2018 United HealthCare Services, Inc.100-18281 Advantage Three-Tier PDL Update Summary8/18

Therapeutic UseMedication NameLower-Cost OptionsElevated PhosphateLevelsRenvela tablets (Brand Only)sevelamer tablets (generic Renvela)Gaucher DiseaseZavesca (Brand Only)miglustat (generic Zavesca)GlaucomaVyzultalatanoprost (Xalatan), Lumigan, Travatan ZHemophiliaRebinynAlprolix, Benefix, Idelvion, RixubusAtriplaCimduo, Isentress, Juluca, Symfi, Symfi Lo, Tivicay, TriumeqNorvir tablets (Brand Only)ritonavir tablets (generic Norvir)Multiple SclerosisCopaxoneglatiramer acetate (generic Copaxone)Nasal PolypsXhancefluticasone (generic Flonase)Nausea and vomitingassociated withpregnancyBonjestaNeuropathic PainLyrica CRgabapentin (generic Neurontin), duloxetine (genericCymbalta), amitriptyline (generic Elavil), LyricaOpioid InducedConstipationMovantikSymproicOral SteroidDecadron tablets (Brand Only)dexamethasoneHIVOTC doxylamine (Unisom) pyridoxine (Vitamin B6)Diclegisfenoprofen (generic Nalfon)Pain & Inflammationibuprofen (generic Motrin), naproxen (generic Aleve,Naprosyn)FenorthoNalfonSeizuresSabril powder pack (Brand Only)vigabatrin powder pack (generic Sabril)Skin ConditionsImpoyzbetamethasone dipropionate augmented 0.05% cream(generic Diprolene AF), fluocinonide 0.05% cream (genericLidex cream)Devices excluded from benefit coverageThe below devices are not approved by the Food and Drug Administration (FDA) as medications and may be excluded frombenefit coverage.Therapeutic UseDevice NameLower-Cost OptionsCaphosolSaliva SubstitutesNeutrasalDiscuss with your doctorSalivamaxWound CareWound care productsDiscuss with your doctorDiabetic 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 priorauthorization (sometimes referred to as precertification) if covered under another benefit.2Referred to as First Start in New Jersey.1 2018 United HealthCare Services, Inc.100-18281 Advantage Three-Tier PDL Update Summary8/18

Advantage 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.100-18281 Advantage 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.100-18281 Advantage Three-Tier PDL Update SummaryCall the toll-free phone number on your healthplan ID card to speak with a Customer Servicerepresentative.8/18

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 Advantage 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-1152765.2 MS-18-366 2018 United HealthCare Services, Inc. 76633-072018100-18281 Advantage Three-Tier PDL Update Summary8/18

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