UnitedHealthcare SignatureValueTM Offered by UnitedHealthcare of California HMO Pharmacy Schedule of Benefits
Prescription Units or up to a 90-day supply)
This Schedule of Benefits provides specific details about
it may be Medically Necessary for you to receive a
your prescription drug benefit, as well as the exclusions
certain medication without trying an alternative drug first.
and limitations. Together, this document and the
In these instances, your Participating Physicians will
Supplement to the Combined Evidence of Coverage and
need to provide evidence to UnitedHealthcare in the
Disclosure Form as well as the medical Combined
form of documents, lab results, records or clinical trials
Evidence of Coverage and Disclosure Form determine
that establish the use of the requested medications as
the exact terms and conditions of your prescription drug
Medically Necessary. Participating Physicians may call
or fax Preauthorization requests to UnitedHealthcare. Applicable Copayments will be charged for prescriptions
What do I pay when I fill a prescription?
that require Preauthorization if approved.
You will pay only a Copayment when filling a
For a list of the selected medications that require
prescription at a UnitedHealthcare Participating
UnitedHealthcare’s Preauthorization, please contact
Pharmacy. You will pay a Copayment every time a
UnitedHealthcare’s Customer Service department.
prescription is filled. Your Copayments are as shown in the grid above.
There are selected brand-name medications where you
When prescribed by your Participating Physician as
will pay a generic Copayment of just $15. A copy of the
Medically Necessary and filled at a Participating
Selected Brands List is available upon request from
Pharmacy, subject to all the other terms and conditions
UnitedHealthcare’s Customer Service department and
of this outpatient prescription drug benefit, the following
may be found on UnitedHealthcare’s Web site at
Disposable all-in-one prefilled insulin pens, insulin
cartridges and needles for nondisposable pen devices are covered when Medically Necessary, in accordance
Selected generic Formulary, brand-name Formulary and
with UnitedHealthcare’s Preauthorization process.
non-Formulary medications require a Member to go
Federal Legend Drugs: Any medicinal substance
through a Preauthorization process using criteria based
which bears the legend: “Caution: Federal law
upon Food and Drug Administration (FDA)-approved
prohibits dispensing without a prescription.”
indications or medical findings, and the current availability of the medication. UnitedHealthcare reviews
Generic Drugs: Comparable generic drugs may be
requests for these selected medications to ensure that
substituted for brand-name drugs unless they are on
they are Medically Necessary, being prescribed
UnitedHealthcare’s Selected Brands List. A copy of
according to treatment guidelines consistent with
the Selected Brands List is available upon request
standard professional practice and are not otherwise
from UnitedHealthcare’s Customer Service
department or may be found on UnitedHealthcare’s Web site at www.uhcwest.com.
Because UnitedHealthcare offers a comprehensive Formulary, selected non-Formulary medications will not
Miscellaneous Prescription Drug Coverage: For the
be covered until one or more Formulary alternatives, or
purposes of determining coverage, the following items
non-Formulary preferred drugs have been tried.
are considered prescription drug benefits and are
UnitedHealthcare understands that situations arise when
covered when Medically Necessary: glucagons, insulin, insulin syringes, blood glucose test strips,
Questions? Call the Customer Service Department at 1-800-624-8822.
lancets, inhaler extender devices, urine test strips and
Combined Evidence of Coverage and Disclosure
anaphylaxis prevention kits (including, but not limited
to, EpiPen®, Ana-Kits® and Ana-Guard®). See the
Drugs prescribed by a dentist or drugs when
medical Combined Evidence of Coverage and
prescribed for dental treatment are not covered.
Disclosure Form for coverage of other injectable
Drugs when prescribed to shorten the duration of
medications in Section Five under “Your Medical
Enhancement medications when prescribed for the
Oral Contraceptives: Federal Legend oral
following nonmedical conditions are not covered:
contraceptives, prescription diaphragms and oral
weight loss, hair growth, sexual performance, athletic
medications for emergency contraception.
performance, cosmetic purposes, anti-aging for
State Restricted Drugs: Any medicinal substance
cosmetic purposes, and mental performance.
that may be dispensed by prescription only, according
Examples of drugs that are excluded when prescribed
for such conditions include, but are not limited to,
Penlac®, Retin-A®, Renova®, Vaniqa®, Propecia®, Lustra®, Xenical® or Meridia®. This exclusion does not
While the prescription drug benefit covers most
exclude coverage for drugs when Preauthorized as
medications, there are some that are not covered or
Medically Necessary to treat morbid obesity or
limited. These drugs are listed below. Some of the
diagnosed medical conditions affecting memory,
following excluded drugs may be covered under your
including, but not limited to, Alzheimer’s dementia.
medical benefit. Please refer to Section Five of your
Infertility: All forms of prescription medication when
medical Combined Evidence of Coverage and
prescribed for the treatment of infertility are not
Disclosure Form titled “Your Medical Benefits” for more
covered. If your Employer has purchased coverage for
information about medications covered by your medical
infertility treatment, prescription medications for the
treatment of infertility may be covered under that
Administered Drugs: Drugs or medicines delivered or
benefit. Please refer to Section Five of your medical
administered to the Member by the prescriber or the
Combined Evidence of Coverage and Disclosure Form
prescriber’s staff are not covered. Injectable drugs are
titled “Your Medical Benefits” for additional
administered during a Physician’s office visit or self-
Injectable Medications: Except as described under
administered pursuant to training by an appropriate
the section “Medications Covered by Your Benefit,”
health care professional. Refer to Section Five of your
injectable medications, including, but not limited to,
medical Combined Evidence of Coverage and
self-injectables, infusion therapy, allergy serum,
Disclosure Form titled “Your Medical Benefits” for
immunization agents and blood products, are not
more information about medications covered under
covered as an outpatient prescription drug benefit.
However, these medications are covered under your
Compounded Medication: Any medicinal substance
medical benefit as described in and according to the
that has at least one ingredient that is Federal Legend
terms and conditions of your medical Combined
or State Restricted in a therapeutic amount.
Evidence of Coverage and Disclosure Form.
Compounded medications are not covered unless
Outpatient injectable medications administered in the
Physician’s office (except insulin) are covered as a
medical benefit when part of a medical office visit.
Diagnostic Drugs: Drugs used for diagnostic
Injectable medications may be subject to
purposes are not covered. Refer to Section Five of
UnitedHealthcare’s Preauthorization requirements. For
your medical Combined Evidence of Coverage and
additional information, refer to Section Five of your
Disclosure Form for information about medications
medical Combined Evidence of Coverage and
covered for diagnostic tests, services and treatment.
Disclosure Form under “Your Medical Benefits.”
Dietary or nutritional products and food
Inpatient Medications: Medications administered to a
supplements, whether prescription or nonprescription,
Member while an inpatient in a Hospital or while
including vitamins (except prenatal), minerals and
receiving Skilled Nursing Care as an inpatient in a
fluoride supplements, health or beauty aids, herbal
Skilled Nursing Facility are not covered under this
supplements and/or alternative medicine, are not
Pharmacy Schedule of Benefits. Please refer to
covered. Phenylketonura (PKU) testing and treatment
Section Five of your medical Combined Evidence of
is covered under your medical benefit including those
Coverage and Disclosure Form titled “Your Medical
formulas and special food products that are a part of a
Benefits” for information on coverage of prescription
diet prescribed by a Participating Physician provided
medications while hospitalized or in a Skilled Nursing
that the diet is Medically Necessary. For additional
Facility. Outpatient prescription drugs are covered for
information, refer to Section Five of your medical
Members receiving Custodial Care in a rest home,
nursing home, sanitarium, or similar facility if they are
treat the medical condition. (4) The drug has been
obtained from a Participating Pharmacy in accordance
recognized for treatment of a medical condition by one
with all the terms and conditions of coverage set forth
of the following: (a) The American Hospital Formulary
in this Schedule of Benefits and in the Pharmacy
Service Drug Information, (b) One of the following
Supplement to the Combined Evidence of Coverage
compendia, if recognized by the federal Centers for
and Disclosure Form. When a Member is receiving
Medicare and Medicaid Services as part of an
Custodial Care in any facility, relatives, friends or
anticancer chemotherapy regimen: (i) The Elsevier
caregivers may purchase the medication prescribed by
Gold Standard's Clinical Pharmacology; (ii) The
a Participating Physician at a Participating Pharmacy
National Comprehensive Cancer Network Drug and
and pay the applicable Copayment on behalf of the
Biologics Compendium; (iii) The Thompson
Micromedex DRUGDEX, or (c) Two articles from
Investigational or Experimental Drugs: Medication
major peer reviewed medical journals that present
prescribed for experimental or investigational
data supporting the proposed Off-Label Drug Use or
therapies are not covered, unless required by an
uses as generally safe and effective. Nothing in this
external, independent review panel pursuant to
section shall prohibit UnitedHealthcare from use of a
California Health and Safety Code Section 1370.4.
Formulary, Copayment, technology assessment panel,
Further information about Investigational and
or similar mechanism as a means for appropriately
Experimental procedures and external review by an
controlling the utilization of a drug that is prescribed for
independent panel can be found in the medical
a use that is different from the use for which that drug
Combined Evidence of Coverage and Disclosure Form
has been approved for marketing by the FDA. Denial
in Section Five, “Your Medical Benefits” and Section
of a drug as investigational or experimental will allow
Eight, “Overseeing Your Health Care” for appeal
the Member to use the Independent Medical Review
System as defined in the medical Combined Evidence of Coverage and Disclosure Form.
Medications dispensed by a non-Participating
Pharmacy are not covered except for prescriptions
Over-the-Counter Drugs: Medications (except
required as a result of an Emergency or Urgently
insulin) available without a prescription (over-the-
counter) or for which there is a nonprescription chemical and dosage equivalent available, even if
Medications prescribed by non-Participating
ordered by a Physician, are not covered. All
Physicians are not covered except for prescriptions
nonprescription (over-the-counter) contraceptive
required as a result of an Emergency or Urgently
jellies, ointments, foams or devices are not covered.
Prior to Effective Date: Drugs or medicines
New medications that have not been reviewed for
purchased and received prior to the Member’s
safety, efficacy and cost-effectiveness and
effective date or subsequent to the Member’s
approved by UnitedHealthcare are not covered unless
Preauthorized by UnitedHealthcare as Medically Necessary.
Replacement of lost, stolen or destroyed medications
Non-Covered Medical Condition: Prescription
medications for the treatment of a non-covered
Saline and irrigation solutions are not covered.
medical condition are not covered. This exclusion
Saline and irrigation solutions are covered when
does not exclude Medically Necessary medications
Medically Necessary, depending on the purpose for
directly related to non-Covered Services when
which they are prescribed, as part of the home health
complications exceed follow-up care, such as life-
or Durable Medical Equipment benefit. Refer to your
threatening complications of cosmetic surgery.
medical Combined Evidence of Coverage and Disclosure Form Section Five for additional
Off-Label Drug Use. Off Label Drug Use means that
the Provider has prescribed a drug approved by the Food and Drug Administration (FDA) for a use that is
Sexual Dysfunction Medication: All forms of
different than that for which the FDA approved the
medications when prescribed for the treatment of
drug. UnitedHealthcare excludes coverage for Off
sexual dysfunction, which includes, but is not limited
Label Drug Use, including off label self-injectable
to, erectile dysfunction, impotence, anorgasmy or
drugs, except as described in the medical Combined
hyporgasmy, are not covered. An example of such
Evidence of Coverage and Disclosure Form and any
applicable Attachments. If a drug is prescribed for Off-Label Drug Use, the drug and its administration will be covered only if it satisfies the following criteria: (1) The drug is approved by the FDA. (2) The drug is prescribed by a participating licensed health care professional. (3) The drug is Medically Necessary to
Smoking cessation products, including, but not
limited to, nicotine gum, nicotine patches and nicotine nasal spray, are not covered. However, smoking cessation products are covered when the Member is enrolled in a smoking cessation program approved by UnitedHealthcare. For information on UnitedHealthcare’s smoking cessation program, refer to the medical Combined Evidence of Coverage and Disclosure Form in Section Five, “Your Medical Benefits, in the section titled “Outpatient Benefits”, under “Health Education Services” or contact Customer Service or visit our Web site at www.uhcwest.com.
Therapeutic devices or appliances, including, but
not limited to, support garments and other nonmedical substances, insulin pumps and related supplies (these services are provided as Durable Medical Equipment) and hypodermic needles and syringes not related to diabetic needs or cartridges are not covered. Birth control devices and supplies or preparations that do not require a Participating Physician’s prescription by law are also not covered, even if prescribed by a Participating Physician. For further information on certain therapeutic devices and appliances that are covered under your medical benefit, refer to your medical Combined Evidence of Coverage and Disclosure Form in Section Five, titled “Your Medical Benefits” under “Outpatient Benefits” located, for example, in subsections titled “Diabetic Self Management”, “Durable Medical Equipment,” or “Home Health Care and Prosthetics and Corrective Appliances.”
Workers’ Compensation: Medication for which the
cost is recoverable under any workers’ compensation or occupational disease law or any state or government agency, or medication furnished by any other drug or medical service for which no charge is made to the patient is not covered. Further information about workers’ compensation can be found in the medical Combined Evidence of Coverage and Disclosure Form in Section Six under “Payment Responsibility.”
UnitedHealthcare reserves the right to expand the Preauthorization requirement for any drug product.
Questions? Call the HMO Customer Service department at 1-800-624-8822 or TDHI 1-800-442-8833.
2011 United HealthCare Services, Inc.
SOUMYANANDA CHAKRABORTI Department of Signaling Neurobiology and Cancer, Institut Curie Bat 110 - Centre Universitaire, 91405 Orsay Cedex, France Cell: 919432068202, email: [email protected] Date of Birth: 30th October, 1983 Present Position: Postdoctoral researcher at Institut Curie, France (Dept of Signaling, Neurobiology and Cancer). Mentor: Carsten Janke. Research Topi
Non-steroidal anti-inflammatory medications, commonly referred to as NSAID’s are widely used for the treatment of arthritic conditions. These medications have provided significant pain relief, improved function and greater quality of life for millions of patients. These are available in lower doses without prescription and are available in higher doses by prescription. NSAID’s fall into two br