HM Medical Clinic

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For our clients
Preventive Care Medications
Traditional Prescription Drug List (PDL)1,2,3,4
$0 Cost-share Medications & Products
U.S. Preventive Services Task Force A & B Recommendation
Medications and Supplements
These medications and supplements will be covered at $0 cost-share when:
 Prescribed by a health care professional  Age and/or gender appropriate  Filled at a network pharmacy Most medications are available over-the-counter (OTC) except for prescription fluoride. All brands are covered by the pharmacy benefit.  Prevent preeclampsia during Aspirin – 81 mg Women Childbearing age Aspirin – 81, 162 & Prevent cardiovascular disease Folic acid 400 & Women Childbearing age Prevent birth defects Prevent anemia due to Iron liquid supplement Children age 0-1 year iron deficiency Vitamin D - 400 & Fall risk prevention Fluoride tablets, solution Children age 0-6 Prevent dental cavities if water (not toothpaste, rinses) source is deficient in fluoride Over-the-Counter (OTC) Contraceptives for Women
These contraceptives are available over-the-counter (OTC) and will be covered at $0 cost-share when:
 Prescribed by a health care professional  Filled at a network pharmacy Contraceptive films Contraceptive foams Contraceptive gels Contraceptive spongesEmergency contraceptives (generic for Plan B, generic for Plan B One-Step)Female condoms Male contraceptives are not covered under the Patient Protection and Affordable Care Act (PPACA).
1. Please note this list is subject to change.
2. Always refer to your benefit plan materials to determine your coverage for medications and cost-share. Some medications listed on the PDL may not be covered under your specific benefit. Where differences are noted, the benefit plan documents will govern.
3. Groups that qualify for a religious exemption will receive the U.S. Preventive Services Task Force A & B Recommendation medications listed on the Preventive Care Medications list without cost-share. They will not receive either the OTC or PDL Tier 1 contraceptives without cost-share. However, UnitedHealthcare will provide or arrange for contraceptive coverage for members of Eligible Organizations as required by PPACA.
4. All branded medications are trademarks or registered trademarks of their respective owners.
Prescription Hormonal Contraceptives
Brand Hormonal Contraceptives

Natazia NuvaRing Available July 1, 2015 Generic Hormonal Contraceptives
Altavera, Chateal, Kurvelo, Levonorgestrel/Ethinyl Estradiol, Levora-28, Marlissa, Portia (generic Nordette) Alyacen 1/35, Cyclafem 1/35, Dasetta 1/35, Necon 1/35, Nortrel 1/35, Pirmella (generic Ortho-Novum 1/35) Alyacen 7/7/7, Cyclafem 7/7/7, Dasetta 7/7/7, Necon 7/7/7, Nortrel 7/7/7, Pirmella 7/7/7 (generic Ortho-Novum 7/7/7) Amethia, Ashlyna, Camrese, Daysee (generic Seasonique) Amethia Lo, Camrese Lo, Levonorgestrel/Ethinyl Estradiol 0.1 mg/20 mcg/10 mcg (generic LoSeasonique) Amethyst, Levonorgestrel/Ethinyl Estradiol 0.09 mg/20 mcg (generic Lybrel) Apri, Emoquette, Enskyce, Desogestrel/Ethinyl Estradiol, Reclipsen, Solia (generic Desogen, Ortho-Cept) Aranelle, Leena (generic Tri-Norinyl) Aubra, Aviane, Delyla, Falmina, Lessina, Levonorgestrel/Ethinyl Estradiol 0.1 mg/20 mcg, Lutera, Orsythia, Sronyx (generic Alesse) Azurette, Desogestrel/Ethinyl Estradiol, Kariva, Pimtrea, Viorele (generic Mircette) Balziva, Briellyn, Gildagia, Philith, Vyfemla, Zenchent (generic Ovcon-35) Camila, Deblitane, Errin, Heather, Jencycla, Jolivette, Lyza, Nora-BE, Norethindrone 35 mcg, Norlyroc, Sharobel (generic Micronor, Nor-Q-D) Caziant, Velivet, Cesia (generic Cyclessa) Cryselle, Elinest, Low-Ogestrel, Norgestrel/Ethinyl Estradiol 0.3 mg/30 mcg, Ogestrel (generic Lo/Ovral, Ovral) Drospirenone/Ethinyl Estradiol 3 mg/30 mcg, Ocella, Syeda, Zarah (generic Yasmin) Enpresse, Levonest, Myzilra, Trivora-28 (generic Triphasil) Estarylla, MonoNessa, Mono-Linyah, Norgestimate/Ethinyl Estradiol, Previfem, Sprintec (generic Ortho-Cyclen) Gianvi, Loryna, Nikki, Vestura (generic Yaz) Gildess FE, Junel FE, Larin FE, Microgestin FE, Tarina FE (generic Loestrin FE) Gildess, Junel, Larin, Microgestin (generic Loestrin) Introvale, Jolessa, Levonorgestrel/Ethinyl Estradiol 0.15 mg/30 mcg, Quasense (generic Seasonale) Kelnor 1/35, Zovia 1/35E (generic Demulen 1/35) LoMedia 24 FE, Gildess 24 FE, Larin 24 FE (generic Loestrin 24 FE) Medroxyprogesterone Acetate (generic Depo-Provera) Necon 1/50 (generic Norinyl 1/50) Necon 0.5/35, Nortrel 0.5/35, Wera 0.5/35 (generic Brevicon, Modicon) Necon 10/11 (generic Ortho-Novum 10/11) Norgestimate/Ethinyl Estradiol, Tri-Estarylla, Tri-Linyah, Trinessa, Tri-Previfem, Tri-Sprintec (generic Ortho Tri-Cyclen) Wymzya FE, Zenchent FE (generic Femcon FE) Tilia FE, Tri-Legest FE (generic Estrostep FE) Xulane (generic Ortho Evra) Zovia 1/50E (generic Demulen 1/50) Prescription Emergency Contraceptives
Brand Emergency Contraceptives
ella
Plan B One-Step
Generic Emergency Contraceptives
Levonorestrel 0.75 mg, Next Choice (generic Plan B)
EContra EZ, Fallback Solo, Levonorgestrel 1.5 mg, My Way, Next Choice One Dose, Opcicon One-Step
(generic Plan B One-Step)
Oral Contraceptive Contraceptive Vaginal Ring Injectable Contraceptive Contraceptive Transdermal Patch Prescription Cervical Caps and Diaphragms
Tobacco Cessation Medications
If you need help to quit smoking or using tobacco products, these preventive medications will be available at $0 cost-share
starting on your health plan's next renewal date on or after January 1, 2015. To qualify, you need to:  Be age 18 or older  Ask your doctor to obtain notification/prior authorization. Your doctor will need to let us know you are also getting counseling to help you stop using tobacco products.
 Get a prescription for these products from your doctor, even if the products are sold over-the-counter (OTC)  Fill the prescription at a network pharmacyUp to two 90-day treatment courses are covered at no cost each year. Prior authorization is required for each 90-day drug supply.
Over-the-counter • Nicotine Replacement Gum
Medications
• Nicotine Replacement Lozenge Requires Prior • Nicotine Replacement Patch • Bupropion sustained-release (generic Zyban) Tablet • Nicotrol Inhaler These three prescription medications are covered with Prior Authorization after members have tried:
• Nicotrol Nasal Spray 1) One over-the-counter nicotine product and
• Chantix Tablet 2) Bupropion sustained-release (generic Zyban) separately Breast Cancer Preventive Medications
For women who are at increased risk for breast cancer but have not had breast cancer, these preventive medications are available
at $0 cost-share. To qualify, a woman must:  Be age 35 or older  At increased risk for the first occurrence of breast cancer – after risk assessment and counseling  Obtain Prior AuthorizationMost plans cover these medications at normal cost-share for the treatment of breast cancer, to prevent breast cancer recurrence and for other indications. They are available at $0 cost-share to prevent the first occurrence of breast cancer if a Prior Authorization is obtained. If a woman qualifies, she can receive these drugs at $0 cost-share for up to five years, minus any time she has been taking them for prevention.
Health Care Reform Pharmacy Benefit Preventive Care Medication Coverage
Frequently Asked Questions We know that many of our clients have questions about the pharmacy benefit Preventive Care Medication coverage required by the Patient Protection and Affordable Care Act (PPACA), or "health reform law" effective August 1, 2012 and continuing to be clarified by the U.S. Departments of Labor, Health & Human Services and the Treasury. In response, we have prepared the following FAQ to address your questions, and steps UnitedHealthcare is taking to help manage the added costs represented by this coverage requirement. If you need more information, please contact your UnitedHealthcare representative or, visit UnitedHealthcare's United for Reform Resource Center.
What medications are covered?
How does this affect our pharmacy coverage?
The health reform law requires coverage of U.S. Preventive To satisfy PPACA requirements, we maintain a list of Services Task Force A & B Recommendation medications Preventive Care Medications on the Traditional PDL, when age-, gender- and/or condition-appropriate, and listed on pages 1-3 of this document. These medications are FDA-approved prescription and over-the-counter (OTC) available at no cost to members on both standard and high- contraceptive methods for women at 100%, without deductible or consumer-driven health (CDH) plans.
charging a co-payment, co-insurance or deductible, when prescribed by a health care professional and filled at a How will the May 11, 2015 FAQ issued by the
Departments of Labor, Health & Human Services &

network pharmacy. the Treasury affect our contraceptive coverage?
 Select prescription contraceptives have been covered at The May 11, 2015 FAQ newly requires coverage of 18 $0 cost-share by most plans since 2012. methods of FDA-approved contraception8.  U.S. Preventive Services Task Force A & B Our Preventive Care Medication list already covers 12 of the Recommendation medications and OTC contraceptives 13 FDA-approved methods available under your pharmacy
became available at network retail pharmacies at $0 cost- benefit. The remaining method will become available July 1,
share beginning November 1, 2013. 5 2015 under your pharmacy benefit, and includes:  Breast cancer preventive medications became available at  Vaginal rings (NuvaRing) $0 cost-share on September 24, 2014 for eligible women. The other five forms of FDA-approved contraception are  Tobacco cessation products will become available at $0 provided under your medical benefit.
cost-share for eligible members on your plan's next renewal date on or after January 1, 2015. As a response to the May 11, 2015 FAQ, we have also made the exception process easier to understand for members and  Due to a May 11, 2015 FAQ released by the U.S. providers – if members need a method of pharmacy benefit Departments of Labor, Health & Human Services and the contraception that is not on this list for medical reasons. Treasury, one new method of contraception, vaginal rings, Medical reasons can include severity of side effects, whether will become available on July 1, 2015.
the contraception is permanent or reversible, and whether the  Low-dose aspirin (81 mg) will become available at $0 cost- member is able to adhere to instructions for use. share on September 1, 2015 for pregnant women at risk for preeclampsia.
5. The cost for U.S. Preventive Services Task Force A & B Recommendation medications and OTC contraceptives on this list could be reimbursed back to Feb. 20, 2013 when the U.S. Dept. of Labor FAQ guidance was issued. However, they became available at network retail pharmacies at $0 cost-share on November 1, 2013.
6. When informed by a member's health care provider, UnitedHealthcare will accommodate a coverage exception request for any member when one of the zero cost contraceptives listed on the Preventive Care Medications list may be medically inappropriate as determined by the health care provider for that member and UnitedHealthcare will waive the otherwise applicable cost-sharing for a contraceptive not represented on the Preventive Care Medications list.
7. U.S. Dept. of Health and Human Services, National Heart, Lung and Blood Institute, http://www.nhlbi.nih.gov/health/resources/heart/hbp-pregnancy.
8. The contraceptive methods for women currently identified by the FDA include: (1) sterilization surgery for women; (2) surgical sterilization implant for women; (3) implantable rod; (4) IUD copper; (5) IUD with progestin; (6) shot/injection; (7) oral contraceptives (combined pill); (8) oral contraceptives (progestin only); (9) oral contraceptives extended/continuous use; (10) patch; (11) vaginal contraceptive ring; (12) diaphragm; (13) sponge; (14) cervical cap; (15) female condom; (16) spermicide; (17) emergency contraception (Plan B/Plan B One Step/Next Choice); and (18) emergency contraception (Ella). Frequently Asked Questions continued How will aspirin to prevent preeclampsia during
How will the breast cancer preventive medications
pregnancy be covered?
be covered?
Effective Sept. 1, 2015, UnitedHealthcare will cover low- Effective Sept. 24, 2014, UnitedHealthcare began covering dose or baby aspirin (81 mg) for pregnant women who are at risk-reducing breast cancer medications as a preventive benefit risk for preeclampsia. This low-dose aspirin will be covered at for women:  Age 35 and older  Prescribed by a health care provider  At increased risk for the first occurrence of breast cancer -  Filled at a network pharmacy after risk assessment and counseling Preeclampsia affects about 6-8% of pregnant women,  Who obtain Prior Authorization according to the U.S. Dept. of Health and Human Services and the National Heart, Lung and Blood Institute.7 For this population, UnitedHealthcare covers raloxifene or tamoxifen without cost-share for up to five years for eligible
How will the tobacco cessation products
women, minus any time members have already been
be covered?
taking these drugs for prevention. In addition to this ACA
Effective on your plan's next renewal date on or after January preventive coverage, UnitedHealthcare currently covers these 1, 2015, UnitedHealthcare will cover select OTC and drugs when prescribed for breast cancer treatment, to prevent prescription tobacco cessation products at $0 cost-share for breast cancer recurrence and for other indications, although eligible members.
cost-sharing may apply.
To qualify, members must be: What is UnitedHealthcare doing to manage the
 Age 18 or older cost of this coverage?
 Ask their doctor to obtain Prior Authorization/ The health reform law specifically permits health insurance Notification to confirm they are also getting counseling
plans to use reasonable medical management techniques such to help them stop using tobacco products as tiering to manage these preventive services.
 Get a prescription for the products from their physician,  For prescription contraceptive coverage – Specifically,
even if the products are sold OTC UnitedHealthcare has determined that contraceptives  Fill the prescription at a network pharmacy with the same progestin are equivalent to each other. Products available will include nicotine replacement gum, Therefore, each unique progestin contraceptive medication lozenges, patches and generic Zyban, or sustained-release is represented in PDL Tier 1 at no cost-share, making sure bupropion. Brand Zyban will be excluded since the generic women have access to a variety of contraceptives.6 is covered. Nicotrol® and Chantix® will be covered without
One additional method of pharmacy benefit contraception cost share when the above criteria are met and after failure/ will become available starting July 1, 2015 due to the May contraindication to a course of OTC nicotine replacement 11, 2015 FAQs issued by the government. The new method therapy and a separate course of bupropion.
covered will be vaginal rings. We will continue to monitor Some self-funded customers will receive the new tobacco the market for new generics to help control costs. We may cessation benefit without Prior Authorization if their also institute clinical programs such as Prior Authorization Summary Plan Description (SPD) does not contain Prior or Step Therapy in future plan years. Authorization or Notification language, or if they currently Additional contraceptives are covered in higher-cost tiers at cover tobacco cessation products without Prior Authorization.
the applicable plan cost-share.
For breast cancer preventive medications – The Prior
Authorization program will be used to manage the cost of these medications. Approximately five percent of the women currently taking these medications will qualify to receive them without cost-share.
9. Centers for Disease Control, NCHS Data Brief, No. 136, December 2013, http://www.cdc.gov/nchs/data/databriefs/db136.pdf.
For tobacco cessation products – The Prior Authorization
What if we have a high-deductible or consumer-
and Step Therapy programs will be used to manage the cost driven health (CDH) plan?
of these products. Brand Zyban will be excluded since the The same no-cost option Preventive Care Medications are generic formulation, bupropion sustained-release, will be available for your members. However, if a member fills a covered. Nicotrol® and Chantix® will be covered without prescription for covered products not on your plan's no- cost share after failure/contraindication to a course of OTC cost drug list, they will need to pay the full cost, until your nicotine replacement therapy and a course of bupropion. pharmacy plan deductible is reached.  For low-dose aspirin prescribed for preeclampsia
Pregnant women at risk for preeclampsia must get a How can our enrolled members learn about
prescription from their doctor to receive low-dose aspirin Preventive Care Medications?
at no cost. Low-dose aspirin is also inexpensive. The Standard Preventive Care Medication Lists and FAQs are cost of this program is expected to be negligible because available from your UnitedHealth representative. In addition, the average number of pregnant women in the U.S. is information is available to members on myuhc.com, or by
approximately 10% of women ages 15-44,8 and only 6-8% calling the number on their health plan ID card.
of these women are at risk for this condition.7 As a result, approximately 0.8% of women ages 15-44 in the U.S. may What if the health care reform law requirements for
develop preeclampsia. Preventive Care Medication
coverage change?

Are there exceptions for customers who do not
If the law requiring plans to provide Preventive Care want to implement this reform provision?
Medications at no cost changes, we will keep you informed Yes, there are some exceptions. If your plan is grandfathered, of how our plans will comply with these changes through our or has a religious exemption as either a Religiously Exempt standard client communications.
Employer or an Eligible Organization, your plan may be exempt. For plan years that began on or after January 1, 2014, non-profit religious organizations could self-certify themselves as Eligible Organizations and exclude coverage of contraceptives if they have religious objections to covering contraceptives. However, customers must provide the correct certifications prior to their renewal date, in order to qualify. If you believe that your firm qualifies for an exemption, please notify your broker, consultant, or UnitedHealthcare representative. Groups that qualify for a religious exemption will receive the U.S. Preventive Services Task Force A & B Recommendation medications listed on the Preventive Care Medications list when prescribed without cost-share; they will not receive either the prescribed OTC or PDL Tier 1 contraceptives without cost-share. However, UnitedHealthcare will provide or arrange for contraceptive coverage for members of Eligible Organizations as required by PPACA. M51372-NN 6/15 2015 United HealthCare Services, Inc.

Source: https://www.uhc.com/content/dam/uhcdotcom/en/HealthReform/PDF/Provisions/ClientFAQtrad.pdf

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