EFTA00525166.pdf

UnitedHealthcare 01/30/2019 KARYNA SHULIAK 6100 RED HOOK QTRS SUITE B-3 ST. THOMAS, VI 00802 Dear KARYNA SHULIAK: RE: Coverage Approval Patient: KARYNA SHULIAK Physician: ELLEN MARMUR File ID: PA-53100240 Date of Request: 01/30/2019 Date of Decision: 01/30/2019 We are pleased to inform you that your prescription for CLARAVIS has been approved for coverage up to the plan's supply limit for this medication. This medication is approved for coverage until 07/30/2019, or until coverage for the medication is no longer available under the benefit plan or the medication becomes subject to a pharmacy benefit coverage requirement, such as supply limits or notification, whichever occurs first. You will be responsible for paying your copayment and any additional amount, as required by the provisions of your pharmacy benefit. Your UnitedHealthcare Insurance Company prescription drug program is administered by OptumRx. For certain drugs, more information is needed to determine coverage eligibility. In these cases, your physician must supply the additional information needed to determine if the coverage conditions have been met. The information your physician provided was reviewed and the coverage was approved. A letter was sent to your physician informing him or her of the decision. UnitedHealthcare encourages members to take an active role in their health care. If you have questions about this coverage decision, please call a representative at 1-800-711-4555. Representatives are available to help you 5 a.m. — 10 p.m. PT, Monday-Friday and 6 a.m. — 3 p.m. PT, Saturday. Thank you for choosing UnitedHealthcare. Sincerely, OptumRx EFTA00525166