January 2024 4T Advantage Member Summary

Therapeutic use Medication name Tier placement

ADHD amphetamine/dextroamphetamine extended-release (generic Tier 2

Adderall XR)

ADHD methylphenidate hydrochloride extended-release (generic Tier 2

Concerta)

Asthma QVAR RediHaler Tier 1

Asthma/COPD fluticasone/salmeterol Diskus [Wixela Inhub (generic Advair Tier 3

Diskus)]

Cancer bexarotene capsules (generic Targretin) Tier 2

Cancer bexarotene gel (generic Targretin) Tier 3

continued

Pharmacy | Advantage PDL

Updates to your prescription benefits

Effective January 1, 2024

Advantage 4-Tier PDL update summary

Within the Prescription Drug List (PDL), prescription drugs are grouped by tier. The tier indicates the amount you pay

when you fill a prescription. Please reference the chart to the right as you review the following updates to the PDL.

Tier 1

Lowest-cost medications

Tier 2 and 3

Mid-range cost

$$$

Tier 4

Highest-cost

Prescription drugs with new benefit coverage

The following drugs were previously not covered under most benefit plans and are now eligible for coverage.

Therapeutic use Medication name Tier placement

Diabetes Insulin Lispro Junior KwikPen (unbranded Humalog Junior Tier 2

KwikPen)

Diabetes Insulin Lispro KwikPen (unbranded Humalog KwikPen) Tier 2

Diabetes Insulin Lispro Protamine/Insulin Lispro KwikPen Mix 75/25 Tier 2

(unbranded Humalog Mix 75/25 KwikPen)

Diabetes Insulin Lispro vial (unbranded Humalog) Tier 1

Inflammatory bowel disease mesalamine delayed-release (generic Delzicol) Tier 2

Inflammatory bowel disease mesalamine delayed-release (generic Lialda) Tier 2

Mental health asenapine maleate sublingual tablet (generic Saphris) Tier 3

Neutropenia Udenyca Tier 2

Therapeutic use Medication name Tier placement

Inflammatory bowel disease Apriso (brand only) Tier 2 to Tier 1

Neutropenia Neulasta Tier 3 to Tier 2

Medication name

Fluticasone propionate

salmeterol Respiclick

(Airduo Respiclick

authorized brand alternative

Brukinsa

Mekinist

Tafinlar

Prescription drugs moving to a lower tier

The following drugs are moving to a lower tier, making them a lower cost.

Prescription drugs moving to a higher tier

The following medications are 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 Tier placement Alternative treatment option(s)

Asthma/COPD / Tier 2 to Tier 3 Arnuity Ellipta, QVAR RediHaler

)

Cancer Tier 2 to Tier 3 Discuss alternative treatment

options with your provider

Cancer Tier 3 to Tier 4 Discuss alternative treatment

options with your provider

Cancer Tier 3 to Tier 4 Discuss alternative treatment

options with your provider

Advantage 4-Tier PDL update summary

Prescription drugs excluded from benefit coverage

2,3

We evaluate prescription drugs based on their total value, including how a drug works and how much it costs. When several

drugs work in the same way, we may choose to exclude the higher-cost option. Effective January 1, 2024, the drugs listed below

may be excluded from coverage or you may need to get a prior authorization. Sign into your online account to check which

drugs your plan covers and if there are any actions you need to take.

Therapeutic use Medication name Alternative treatment option(s)

Acne Finacea gel (brand only) azelaic acid gel (generic Finacea)

ADHD Adderall XR (brand only) amphetamine/dextroamphetamine extended-release

24 hr (generic Adderall XR)

ADHD Concerta (brand only) methylphenidate extended-release osmotic release

(generic Concerta)

ADHD Vyvanse (brand only) lisdexamfetamine dimesylate (generic Vyvanse)

Asthma Flovent Diskus Arnuity Ellipta, QVAR RediHaler

Asthma Flovent HFA Arnuity Ellipta, QVAR RediHaler

Asthma Fluticasone propionate

HFA (Flovent HFA

authorized brand

alternative)

Arnuity Ellipta, QVAR RediHaler

Asthma Pulmicort Flexhaler Arnuity Ellipta, QVAR RediHaler

Asthma/COPD Advair Diskus (brand only) fluticasone propionate/salmeterol (generic Advair Diskus)

Asthma/COPD Fluticasone/salmeterol

aerosol HFA (Advair

HFA authorized brand

alternative)

fluticasone propionate/salmeterol (generic Advair

Diskus), Advair HFA, Breo Ellipta, Symbicort

Asthma/COPD Fluticasone/Vilanterol

Ellipta (Breo Ellipta

authorized brand

alternative)

fluticasone propionate/salmeterol (generic Advair

Diskus), Advair HFA, Breo Ellipta, Symbicort

Cancer Targretin capsule (brand

only)

bexarotene capsule (generic Targretin)

Cancer Targretin gel (brand only) bexarotene gel (generic Targretin)

Chest pain BiDil (brand only) isosorbide dinitrate/hydralazine (generic BiDil)

Cholesterol/lipid lowering Ezetimibe/Atorvastatin

simvastatin/ezetimibe (generic Vytorin), ezetimibe

(generic Zetia) plus atorvastatin (generic Lipitor)

Diabetes Humalog Tempo Pen

Humalog KwikPen, Insulin Lispro KwikPen (unbranded

Humalog), Lyumjev KwikPen

Diabetes Humalog vial Insulin Lispro vial (unbranded Humalog)

Diabetes Kombiglyze XR (brand

only)

saxagliptin/metformin extended-release (generic

Kombiglyze XR)

Diabetes Lyumjev Tempo Pen

Humalog KwikPen, Insulin Lispro KwikPen (unbranded

Humalog), Lyumjev KwikPen

Diabetes Onglyza (brand only) saxagliptin (generic Onglyza)

Diabetes Rezvoglar Kwikpen

Lantus, Toujeo

Advantage 4-Tier PDL update summary

disease

Therapeutic use Medication name Alternative treatment option(s)

High blood pressure Edarbi candesartan (generic Atacand), irbesartan (generic

Avapro), losartan (generic Cozaar), olmesartan (generic

Benicar), telmisartan (generic Micardis), valsartan

(generic Diovan)

High blood pressure Edarbyclor candesartan HCT (generic Atacand HCT), irbesartan

HCT (generic Avalide), losartan HCT (generic Hyzaar),

olmesartan HCT (Benicar HCT), valsartan HCT (generic

Diovan HCT)

HIV Prezista (brand only) darunavir (generic Prezista)

Infections Ciprodex (brand only) ciprofloxacin/dexamethasone otic suspension (generic

Ciprodex)

Inflammatory bowel Lialda (brand only) mesalamine delayed-release (generic Delzicol),

mesalamine delayed-release (generic Lialda), Apriso

Inflammatory bowel Uceris rectal foam (brand

only)

budesonide rectal foam (generic Uceris)

Inflammatory conditions Abrilada

1,4

Adalimumab-adaz (unbranded Hyrimoz)

, Amjevita

Cyltezo

, Hadlima

, Humira

Inflammatory conditions Adalimumab-fkjp

1,4

Adalimumab-adaz (unbranded Hyrimoz)

, Amjevita

Cyltezo

, Hadlima

, Humira

Inflammatory conditions Hulio

1,4

Adalimumab-adaz (unbranded Hyrimoz)

, Amjevita

Cyltezo

, Hadlima

, Humira

Inflammatory conditions Hyrimoz

1,4

Adalimumab-adaz (unbranded Hyrimoz)

, Amjevita

Cyltezo

, Hadlima

, Humira

Inflammatory conditions Idacio

1,4

Adalimumab-adaz (unbranded Hyrimoz)

, Amjevita

Cyltezo

, Hadlima

, Humira

Inflammatory conditions Yuflyma

1,4

Adalimumab-adaz (unbranded Hyrimoz)

, Amjevita

Cyltezo

, Hadlima

, Humira

Inflammatory conditions Yusimry

1,4

Adalimumab-adaz (unbranded Hyrimoz)

, Amjevita

Cyltezo

, Hadlima

, Humira

Mental health Latuda (brand only) lurasidone (generic Latuda)

Mental health Saphris (brand only) asenapine maleate sublingual tablet (generic Saphris)

Multiple sclerosis Aubagio (brand only)

teriflunomide (generic Aubagio)

Narcolepsy Xyrem brand

armodafinil (generic Nuvigil), modafinil (generic Provigil),

Sodium Oxybate [Xyrem authorized generic (Hikma)]

Sunosi

, Wakix

, Xywav

Neutropenia Ziextenzo Neulasta, Udenyca

Oral steroid Cortisone

hydrocortisone (generic Cortef)

Overactive bladder Oxybutynin 5 mg/5 ml oral

solution

oxybutynin oral syrup (generic Ditropan)

Ulcers, heartburn & reflux Konvomep

lansoprazole orally disintegrating tablet (generic Prevacid

Solu-tab)

, Nexium Suspension

, OTC - Nexium, Prevacid,

Prilosec, Zegerid

Step Therapy or Prior Authorization may be required prior to coverage.

Exclusion includes brand, generic and authorized generic products unless otherwise noted.

For benefits that do not exclude, Step Therapy or Prior Authorization may be required.

Newly released medication which was excluded from coverage at the time of launch and will continue to be excluded from our pharmacy benefit.

Advantage 4-Tier PDL update summary

Therapeutic use Medication name Step 1 Medication

Cancer Mekinist plus Tafinlar Where both combinations have similar indications

members new to therapy must try: Zelboraf plus

Cotellic

Advantage 4-Tier PDL clinical programs update summary

Some prescription drugs may have programs or limits that apply. Below are the changes that will be effective January 1, 2024

Step Therapy

5,6

The medications below have a new or revised Step Therapy program. You must try one or more other medications before the

medications below may be covered.

Supply Limits

Supply Limits establish the maximum quantity of a drug that is covered per copay or in a specified time frame. The drugs below

will now be part of the Supply Limits program.

Therapeutic use Medication name New Supply Limit

Blood disorders Promacta 12.5 mg 62 packets/month

Blood disorders Promacta 25 mg 186 packets/month

Referred to as First Start in New Jersey.

Applies to new utilizers only. Current utilizers on these medications will have continuation of therapy.

Advantage 4-Tier PDL clinical programs update summary

Nondiscrimination notice and

access to communication services

UnitedHealthcare® and its subsidiaries do not discriminate on the basis of race, color, national origin, age, disability or sex in

their health programs or activities.

If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a

complaint to the Civil Rights Coordinator.

Online: [email protected]

Mail: Civil Rights Coordinator

UnitedHealthcare Civil Rights Grievance

P.O. Box 30608

Salt Lake City, UT 84130

You must send the complaint within 60 days of your experience. A decision will be sent to you within 30 days. If you disagree

with 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-free

phone number listed on your member ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m., or at the times listed in your

health plan documents.

You can also file a complaint with the U.S. Dept. of Health and Human Services.

Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

Phone: Toll free 1-800-368-1019, 1-800-537-7697 (TDD)

Mail: U.S. Dept. of Health and Human Services

200 Independence Avenue SW

Room 509F, HHH Building

Washington, D.C. 20201

We provide free services to help you communicate with us, including letters in other languages or large print. Or, you can ask

for an interpreter. To ask for help, please call the toll-free phone number listed on your member ID card, TTY 711, Monday

through Friday, 8 a.m. to 8 p.m., or at the times listed in your health plan documents.

Nondiscrimination notice and access to communication services

Learn more

Call the toll-free phone

number on your member ID

card to speak with a Customer

Service representative.

Visit the member website listed on

your member ID card to look up the

price of drugs covered by your plan,

find lower-cost options and more.

This document applies to commercial group members of UnitedHealthcare and Oxford New York and New Jersey plans with a pharmacy benefit subject to the Advantage 4-Tier PDL.

UnitedHealthcare® is a registered trademark owned by UnitedHealth Group, Inc. All branded medications are trademarks or registered trademarks of their respective owners. Please note not all PDL updates apply

to all groups depending on state regulation, riders and SPDs.

Insurance coverage provided by or through UnitedHealthcare Insurance Company, UnitedHealthcare Insurance Company 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, Oxford Health Plans LLC, or their affiliates.