Preferred Drug List (PDL) - UHCprovider.com

1 Preferred Drug List (PDL)UnitedHealthcare Community Plan of Nebraska Heritage HealthEffective Date: 12/1/2022 2022 United HealthCare Services, Inc. All Rights Community Plan does not treat members differently because of sex, age, race, color, disability, religion or national you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to: Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance Box 30608 Salt Lake City, UTAH 84130 can send a complaint at any time. We will acknowledge your complaint in writing within ten (10) calendar days of receipt.

2 A decision will be sent to you no later than 90 calendar days from receipt of your can also file a complaint with the Dept. of Health and Human Services. Online: Complaint forms are available at Phone: Toll-free 1-800-368-1019, 1-800-537-7697 (TDD) Mail: Dept. of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, 20201If you need help with your complaint, please call Member Services at 1-800-641-1902, TTY 711, Monday Friday, 7:00 7:00 CT (6:00 6:00 MT).We provide free services to help you communicate with us.

3 Such as, letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call Member Services at 1-800-641-1902, TTY 711, Monday Friday, 7:00 7:00 CT (6:00 6:00 MT).CSNE15MC4035987_002 UnitedHealthcare Community Plan no da un tratamiento diferente a sus miembros en base a su sexo, edad, raza, color, discapacidad, religi n o usted piensa que ha sido tratado injustamente por razones como su sexo, edad, raza, color, discapacidad o nacionalidad, puede enviar una queja a: Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance Box 30608 Salt Lake City, UTAH 84130 enviar una queja en cualquier momento.

4 Reconoceremos su queja por escrito dentro de los diez (10) d as calendario despu s de recibirla. Se le enviar a usted una decisi n a m s tardar 90 d as calendario a partir de la recepci n de su queja. Usted tambi n puede presentar una queja con el Departamento de Salud y Servicios Humanos de los Estados Unidos. Internet: Formas para las quejas se encuentran disponibles en: Tel fono: Llamada gratuita, 1-800-368-1019, 1-800-537-7697 (TDD) Correo: Department of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, 20201Si necesita ayuda para presentar su queja, por favor llame a Servicios para Miembros al 1-800-641-1902, TTY 711, de lunes a viernes, 7:00 7:00 CT (6:00 6:00 MT).

5 Ofrecemos servicios gratuitos para ayudarle a comunicarse con nosotros. Tales como, cartas en otros idiomas o en letra grande. O bien, puede solicitar un int rprete. Para pedir ayuda, por favor llame a Servicios para Miembros al 1-800-641-1902, TTY 711, de lunes a viernes, 7:00 7:00 CT (6:00 6:00 MT).iINTRODUCTION This Preferred Drug List (PDL) Reference Guide gives you information that explains how covered medications are selected; exclusions and limitations; and steps to take when a medication is not included on the PDL. It also gives you at-a-glance specifics on the medications and the coverage level for each to assist you when prescribing for your patients with UnitedHealthcare Community Plan pharmacy benefits.

6 The drugs on our PDL are reviewed and approved for inclusion by our Pharmacy and Therapeutics (P&T) Committee to provide the most clinically appropriate and cost-effective medications for UnitedHealthcare Community Plan patients. The Committee is comprised of UnitedHealthcare Community Plan medical directors and pharmacists, as well as physicians and pharmacists who are not employees or agents of UnitedHealthcare Community Plan or our affiliates. The P&T Committee meets quarterly to discuss pharmaceutical selection and pharmacy program management. Decisions are posted at and communicated quarterly by newsletter to all participating physicians who receive the PDL.

7 This edition incorporates drugs added to the PDL since the last edition, as well as revisions to the prescribing information based on changes in pharmacotherapy. iiOVERVIEW Our PDL is organized into sections. Each section includes therapeutic groupings identified by either a drug class or disease category. Products with lower case text indicate the generic formulation. product entries with all capital letters indicate a brand name formulation of the product . Unless exceptions are noted, all applicable dosage forms and strengths are included in the PDL. PDL product DESCRIPTIONS Please see the following examples of how medication strengths and dosage forms that we provide coverage for are described in the PDL.

8 Any strength and dosage exceptions that do not follow these examples are noted in the PDL. STRENGTH Products covered include all strengths associated with the dosage form of the cited product . Example: carvedilol ( generic COREG) All strengths of Coreg would be covered by this listing. EXTENDED RELEASE AND DELAYED RELEASE Extended-release and delayed-release products require their own entry. Example: diltiazem ER ( generic CARDIZEM CD) DOSAGE FORMS Dosage forms covered will be consistent with the category and use where listed. Example: ciprofloxacin neomycin/polymyxin/ hydrocortisone ( generic CORTISPORIN) As listed in the Otic section, the previous example is limited to the otic solution and suspension.

9 In this example, the ophthalmic solution, ointment and topical cream cannot be assumed to be on the list unless there are entries for these products in the Ophthalmic and Dermatology sections of the PDL. When a strength or dosage form is specified, only the specified strength and dosage form is on the PDL. Other strengths/dosage forms of the referenced product are not included. Example: citalopram 40 mg tabs Celexa tabs product SELECTION CRITERIA The P&T Committee considers clinical information on new-to-market drugs that are typically included in an outpatient pharmacy benefit.

10 The evaluation includes all or some of the following: Safety Efficacy Comparison studies Approved indications Adverse effects Contraindications/warnings/precautions Pharmacokinetics Patient administration/compliance considerations Medical outcome and pharmaco-economicstudiesWhen a new drug is considered for PDL inclusion, it is reviewed relative to similar drugs currently included in the PDL. This review process may result in deletion of a drug from a particular therapeutic class in an effort to continually promote prescription of the most clinically useful and cost-effective drugs.