Announcing Enhanced Prescription Drug Benefit

Please see below some of the upcoming changes to the Pharmacy Program available through your United Healthcare Plan. We are excited to announce these changes will be implemented by May 20, 2016 retroactive to Jan. 1, 2016.

Enhanced Prescription Drug List (PDL)  

We understand many members were impacted adversely by the pharmacy program changes.  Based on this feedback, Human Resources and Brown and Brown have been negotiating with the UHC reps to implement solutions.  We are now able to move to the Enhanced PDL, a program not previously offered, at no cost to you or the plan.  Please see details at our 2016 Rx Information webpage.  We feel confident the Enhanced Prescription Drug List will address many of the concerns that were shared.  Below are some highlights of the changes:

  • Generics in Tier 1 vs. Generics in all tiers currently
    • Generics are primarily placed in Tier 1. In unique situations where the generic is placed in a higher tier, its brand counterpart will be in Tier 1, helping ensure there is always a lowest cost option available for members.
  • Brands in any tier including Tier 1 (no change)
    • In cases where generics are not available, certain brand name medications are placed in Tier 1 when they offer the best overall healthcare value.
  • Up-tiers once a year vs. twice a year
    • Medications may move from a lower tier to a higher tier once a year as part of our regularly scheduled January 1 pharmacy benefit updates.
  • Down-tiers throughout the year (same)
    • Medications may be moved to a lower tier at any time as we respond to market trends, price changes and new clinical information.
  • Immediate evaluation of new drugs (same)
    • We conduct regular drug evaluations when a new generic launches. In these cases, its brand counterpart may move to a higher tier at that time.
  • Limited medication exclusions (less exclusions please see exclusions list)
    • The Enhanced PDL limits the number of exclusions. However, there are some instances when medications may be permanently excluded:
      • Over the counter alternatives
      • Newly launched drugs may not be covered while we evaluate the drug to ensure they are supported by appropriate clinical programs.
  • Clinical and Utilization Management Programs (same)
    • To help manage costs and ensure safe and appropriate use, we may apply utilization management programs to otherwise excluded medications including prior authorization, quantity limits and step therapy.

Once the new PDL is implemented, United Healthcare will run an impact report going back to January 1, 2016.  Any claims incurred since the plan’s inception in which members paid a higher price for a medication that was previously excluded or will now be in a lower cost tier, will be reprocessed.  This may be a lengthy process (anticipated 30-60 days); however, we are pleased with the ability to offer a solution to those affected.  Members who paid out of pocket for their medication, rather than filing a claim, will need to submit a claim form which will be available soon.  Any questions or issues may be submitted through the escalation mailbox provided below.

  • Removal of Mail Service Member Select (MSMS) Program
    • The automatic opt-in mail service feature for certain maintenance medications will be removed from the plan. Members will now have the option whether to fill their maintenance medication at a retail pharmacy or through mail order.  There will no longer be the need to opt out.
  • Prescription Issues Escalation Mailbox
    • We have created an Escalated Pharmacy Issues Mailbox for Stetson members to utilize for the following concerns:
      • Assistance with clinical programs such as: prior authorization, step therapy and supply limits after a provider has reached out to OptumRx.
      • Assistance with OptumRx reviewing pertinent clinical information or submitting an appeal.
      • Submitting a claim form for reimbursement of out of pocket costs previously incurred and now covered by Enhanced PDL.
      • Please note: the mailbox should not be used to inquire about pricing or alternative medications as this information can be located at myuhc.com in the Manage My Prescription/Price a Medication sections.  Issues navigating these tools can be addressed by contacting the member services number listed in the back of the ID card.
      • Mailbox address is Stetson_escalations@uhc.com
  • More to come on … 90 day supply at retail (filed with the state currently pending review)
    • We understand a major change in the program was the lack of availability of 90 day refills at retail pharmacies. United Healthcare has made an exception and confirmed its ability to administer the program in the same way; however, it requires filing of the plan change with the state of Florida.  At this time, we do not have an estimated time for the change to be completed as we wait for state approval.  Once the date is confirmed, an announcement will be made.  Please stay tuned.

Please stay tuned for a schedule of information sessions from UHC!