drug coverage criteria â new and therapeutic equivalent medications
drug coverage criteria â new and therapeutic equivalent medications
drug coverage criteria â new and therapeutic equivalent medications
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Medication/DrugFormulary Alternative(s)hydrochlorothiazideTricor 48mg <strong>and</strong> 145mgFenofibrate, Antara, Fenoglide, Lipofen, TriglideTrilipixFenofibrate, Antara, Fenoglide, Lipofen, TriglideTwynstaMicardis + amlodipineUcerisBudesonide (generic Entocort EC)Ultravate X Combination Package Halobetasol (generic Ultravate) plus ammonium lactate (Lac-Hydrin)UltresaCreon, Zenpep, PancreazeUmecta emulsion, foam, suspension Urea 40%Umecta Kit (nail film pen/ filmsuspension)Urea 40% emulsion (Umecta) + hyaluronate gel 0.2%(Hylira)Umecta PD Urea 40%Uramaxin GT 45%Urea 40% emulsionUramaxin GT Kit Urea 40%Valturna 150-160mg, 300-320mg Tablet Diovan + TekturnaVeltinClindamycin gel + tretinoin gelVenlafaxine EREffexor XRViokaceCreon, Zenpep, PancreazeVimovoNaproxen sodium plus proton pump inhibitorXereseZovirax 5% cream + OTC hydrocortisone 1% creamXopenex NebulesAlbuterol nebulized solutionZetonna (ciclesonide)OmnarisZianaClindamycin gel + tretinoin gelZipsor 25mgDiclofenac potassium or diclofenac sodiumZolvitacetaminophen with hydrocodone solutionZonatussBenzonatateZuplenzondansetron tablet (generic for Zofran) , ondansetron ODT(generic for Zofran ODT)ZyclaraImiquimod 5% creamDEFINITIONSFor all of the definitions below, copayment/cost share will vary based on the members pl<strong>and</strong>esign. Refer to the Member's specific certificate of <strong>coverage</strong>, contract <strong>and</strong>/or prescription <strong>drug</strong>rider as applicable.Mail Order Pharmacy: A network pharmacy contracted to provide up to a 90-day supply ofcertain prescription <strong>medications</strong> (<strong>new</strong> or refill) by mail.Specialty Pharmacy: A network pharmacy contracted to provide <strong>coverage</strong> for specialty<strong>medications</strong> at an in network benefit level for members enrolled on NY <strong>and</strong> NJ LOBs.Retail Pharmacy: A network non-mail order pharmacy contracted to provide prescription<strong>medications</strong> (<strong>new</strong> or refill). NOTE: For members enrolled on NY LOBs <strong>new</strong> <strong>and</strong> re<strong>new</strong>ing on orafter 01/12/12, if a retail pharmacy has contracted with the PBM, in advance, for the same rates<strong>and</strong> terms <strong>and</strong> conditions as the mail order or specialty pharmacy, covered prescriptions will beavailable at the same co-payment or other reimbursement level that would apply to the mail-orderor non-retail specialty pharmacies (should any of these pharmacies be available in the servicearea).REFERENCESThe foregoing Oxford policy has been adapted from an existing UnitedHealthcare PharmacyClinical Pharmacy Program that was researched, developed <strong>and</strong> approved by the UnitedHealthGroup National Pharmacy & Therapeutics CommitteeDrug Coverage Criteria - New <strong>and</strong> Therapeutic Equivalent Medications: Clinical Policy (Effective 04/01/2013)©1996-2013, Oxford Health Plans, LLC6
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