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2008 Four-Tier Prescription Drug List Reference Guide Your UnitedHealthcare pharmacy benefit
Understanding Tiers
offers flexibility and choice in finding the right
Prescription medications are categorized within medication for you.
four tiers. Each tier is assigned a copayment, the amount you pay when you fill a prescription, which is determined by your employer or health plan. Consult your benefit plan documents to find out the specific copayments, coinsurance choices and make informed decisions.
and deductibles that are part of your plan. You 2. Help you understand which questions to and your doctor decide which medication is What is a Prescription Drug List (PDL)?
Tier 1 – Your Lowest-Cost Option
A PDL is a list of Food and Drug Administration This is your lowest copayment option. For the always consider Tier 1 medications if you and your doctor decide they are right for your selection of prescription medications. Below you Tier 2 and Tier 3 – Your Midrange-Cost
medications for certain conditions. You and your Consider Tier 2 medications if you and your doctor may refer to this list to select the right doctor decide that a Tier 2 medication is right The benefit plan documents provided by your If you are currently taking a medication in Tier 3, employer or health plan include a Summary ask your doctor whether there are Tier 1 or Tier 2 Plan Description (SPD) or a Certificate of alternatives that may be right for your treatment.
Sometimes there are alternatives available in documents to determine which medications are Tier 1 or Tier 2 that may be appropriate to treat Tier 4 – Your Highest-Cost Option
This is your highest copayment option.
Sometimes there are alternatives available in Tier 1, Tier 2, or Tier 3 that may be appropriate to treat your condition. If you are currently taking a medication in Tier 4, ask your doctor whether there are Tier 1, Tier 2, or Tier 3 alternatives that may be right for your treatment.
If you have pharmacy benefit coverage with UnitedHealthcare, you may learn more about your benefit by visiting www.myuhc.com or by calling the Customer Care telephone
number printed on your ID card. If you are not currently enrolled with UnitedHealthcare for pharmacy benefit coverage, you may access www.myuhc.com for additional information
during your open enrollment period or you may contact your employer or health plan for additional information.
Compounded medications, medications with
What factors does the PDL Management
one or more ingredients that are prepared “on- Committee look at to make tier placement
site” by a pharmacist, are classified at the Tier 3 decisions?
level. However, if any one of the ingredients in the compound is classified as being on Tier 4 tier placement of a particular prescription medication based upon clinical information from Please note: Some plans have a two-tier
Therapeutics (P&T) Committee and economic and financial considerations. The Committee pharmacy benefit. Generally, a two-tier closed looks at the overall health care value of a particular medication in order to balance the medications classified in Tier 3 and Tier 4 of this need for flexibility and choice for our members PDL. A two-tier open pharmacy benefit plan covers one tier at the lower copayment and covers a second tier at a higher copayment. How often will prescription medications
In addition, some plans have a three-tier change tiers?
prescription plan. Refer to your enrollment Medications may move to a higher tier up to materials, check the Drug Pricing / Coverage three times per calendar year, depending on information on www.myuhc.com, or call the
your benefit. Additionally, when a brand name Customer Care number on your ID card for more medication becomes available as a generic, the information about your benefit plan.
tier status of the brand name medication and its corresponding generic will be evaluated. When Who decides which medications get
a medication changes tiers, you may be required placed in which tier?
to pay more or less for that medication. These changes may occur without prior notice to you.
Committee makes tier placement decisions to pharmacy coverage, please call the Customer medications and control health care costs for you and your employer or health plan. The PDL www.myuhc.com.
Management Committee is comprised of senior level physicians and business leaders. You and If you have pharmacy benefit coverage with UnitedHealthcare, you may learn more about your benefit by visiting www.myuhc.com or by calling the Customer Care telephone
number printed on your ID card. If you are not currently enrolled with UnitedHealthcare for pharmacy benefit coverage, you may access www.myuhc.com for additional information
during your open enrollment period or you may contact your employer or health plan for additional information.
What is the difference between brand
When should I consider discussing
name and generic medications?
over-the-counter or non-prescription
Generic medications contain the same active medications with my doctor?
ingredients as brand name medications, but they often cost less. Generic medications appropriate treatment for many conditions.
become available after the patent on the brand Consult your doctor about over-the-counter name medication expires. At that time, other alternatives to treat your condition. These companies are permitted to manufacture an pharmacy benefit, but they may cost less than medication. Many companies that make brand your out-of-pocket expense for prescription Why are there notations next to certain
medications in the PDL, and what do
prescription for a brand name medication, ask if they mean?
a generic equivalent is available and if it might The specific definitions for these notations (QLL, QD, N, etc.) are listed at the bottom of each page exceptions, generic medications are usually your of the PDL and refer to our pharmacy programs.
lowest cost option. Please note that some generic medications may be in Tier 2, Tier 3, or Tier 4 and will not have the lowest copayment • Confirm coverage based on your benefit plan available under your pharmacy benefit plan. Go • Alert pharmacists and doctors of potentially to myuhc.com to determine the copayment for • Notify your pharmacist and doctor of duplication Why is the medication that I am currently
taking no longer covered?
Medications may be excluded from coverage
Please call Customer Care if you need additional under your pharmacy benefit. For example, a prescription medication may be excluded from coverage when it is therapeutically equivalent to What should I do if I use a self-
an over-the-counter medication. Medications on administered injectable medication?
the PDL and other over-the-counter medications You may have coverage for self-administered injectable medications through your pharmacy benefit plan. UnitedHealthcare has developed a medications. Please call our toll-free Specialty Pharmacy Referral Line at 1-866-429-8177 where a representative will answer questions about our program and then transfer you to a specialty pharmacy based on your particular specialty If you have pharmacy benefit coverage with UnitedHealthcare, you may learn more about your benefit by visiting www.myuhc.com or by calling the Customer Care telephone
number printed on your ID card. If you are not currently enrolled with UnitedHealthcare for pharmacy benefit coverage, you may access www.myuhc.com for additional information
during your open enrollment period or you may contact your employer or health plan for additional information.
How do I access updated information
What if I still have questions?
about my pharmacy benefit?
Please call the Customer Care number on your Since the PDL may change periodically, we ID card. Representatives are available to assist encourage you to visit www.myuhc.com or call
you 24 hours a day, except Thanksgiving and the Customer Care number on your ID card for • Pharmacy benefit and coverage information • Specific copayment amounts for prescription • Possible lower-cost medication alternatives • A list of medications based on a specific • Medication interactions and side effects, etc. • Locate a participating retail pharmacy by zip And, if mail order is included in your pharmacy If you have pharmacy benefit coverage with UnitedHealthcare, you may learn more about your benefit by visiting www.myuhc.com or by calling the Customer Care telephone
number printed on your ID card. If you are not currently enrolled with UnitedHealthcare for pharmacy benefit coverage, you may access www.myuhc.com for additional information
during your open enrollment period or you may contact your employer or health plan for additional information.
In certain documents, the Prescription Drug List (PDL) was referred to as the “Preferred Drug List (PDL).” This change in descriptive terms does not affect your benefit coverage.
Where differences are noted between this PDL reference guide and your benefit plan documents, the benefit plan documents will govern.
2008 Four-Tier Prescription Drug List Reference Guide Bupropion QL
Bupropion Sustained Action QL, N
Acetaminophen with Codeine QL/QD
and Butalbital QL/QD
Citalopram QL
Estradiol Patch QL
Fast Take Test Strips QL, DS
Fluconazole 50, 100, 200mg N
Asmanex QL
Fluconazole 150mg QL
Flunisolide Nasal Spray QL
Fluoxetine QL
Fluticasone Nasal Spray QL
Fluvoxamine QL
Foradil QL
Freestyle Lite Test Strips QL, DS
Freestyle Test Strips QL, DS
Some medications are noted with N, QD, QL, or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
N = Notification. There are a few medications that your doctor must notify us of to make sure their use is covered within your benefit.
QD = Quantity Duration. Some medications have a limited amount that can be covered for a specific period of time.
QL = Quantity Level. Some medications have a limited amount that can be covered at one time.
DS = Diabetic Supplies. Diabetic supplies may be covered by your benefit plan.
2008 Four-Tier Prescription Drug List Reference Guide Meloxicam QL
One Touch Test Strips QL, DS
One Touch Ultra Test Strips QL, DS
Oxycodone with Acetaminophen QL/QD
Mirtazapine QL
Mirtazapine Dispersible Tablet QL
Itraconazole QL, N
Precision Q-I-D Test Strips QL, DS
Precision Xtra Test Strips QL, DS
Leflunomide QL
Nefazodone QL
Lovastatin QL/QD
Maxalt QL
Maxalt MLT QL
Pulmicort Flexhaler QL
Pulmicort Turbuhaler QL
Medroxyprogesterone 150mg/ml QL
Mefloquine QL
Relpax QL
Some medications are noted with N, QD, QL, or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
N = Notification. There are a few medications that your doctor must notify us of to make sure their use is covered within your benefit.
QD = Quantity Duration. Some medications have a limited amount that can be covered for a specific period of time.
QL = Quantity Level. Some medications have a limited amount that can be covered at one time.
DS = Diabetic Supplies. Diabetic supplies may be covered by your benefit plan.
2008 Four-Tier Prescription Drug List Reference Guide Ribavirin QL, N
Zomig ZMT QL
Sertraline QL
Silver Sulfadiazine
Simvastatin QL/QD
Sodium Fluoride
Sotalol
Spironolactone with
Spironolactone
Sprintec
Sucralfate
Sulfacetamide
Sulfacetamide with Sulfur
Sulfamethoxazole with Trimethoprim
Sulfasalazine
Sulfasalazine EC
Sulfatrim
Sulindac
Surestep Test Strips QL, DS
Tamoxifen
Temazepam
Terazosin
Terbutaline
Terconazole Suppository QL
Tetracycline
Theophylline
Thyroid
Timolol Drops
Tizanidine
Tobramycin
Torsemide
Tramadol QL
Tramadol with
Acetaminophen QL
Trazodone
Tretinoin N
Tri-Sprintec
Triamcinolone
Triamterene with Hydrochlorothiazide
Triazolam
Trimethobenzamide
Trimethobenzamide with Benzocaine
Trimethoprim
Trimipramine Maleate
Trinessa
Trivora
Ursodiol
Venlafaxine QL
Verapamil
Warfarin
Xopenex HFA QL
Zomig QL
Some medications are noted with N, QD, QL, or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
N = Notification. There are a few medications that your doctor must notify us of to make sure their use is covered within your benefit.
QD = Quantity Duration. Some medications have a limited amount that can be covered for a specific period of time.
QL = Quantity Level. Some medications have a limited amount that can be covered at one time.
DS = Diabetic Supplies. Diabetic supplies may be covered by your benefit plan.
2008 Four-Tier Prescription Drug List Reference Guide Climara QL
Kytril QL, N
Aciphex QL/QD
Copaxone QL
Actonel 5, 35mg QL
Actonel with Calcium QL
Actoplus Met QL
Cozaar QL/QD
Lidoderm QL/QD
Crestor QL/QD
Adderall XR QL
Lipitor QL/QD
Lovenox QL
Lumigan QL
Alphagan P QL
Altoprev QL/QD
Diovan QL/QD
Androgel QL
Diovan HCT QL/QD
Duetact QL
Aricept QL
Effexor XR QL
Micardis QL/QD
Aricept ODT QL
Micardis HCT QL/QD
Emend QL, N
Arixtra QL
Enablex QL
Astelin QL
Esclim QL
Nasonex QL
Avandamet QL
Estraderm QL
Avandaryl QL
Avandia QL
Avonex QL
Estring QL
Norditropin QD, N
Fentanyl Citrate Lollipop QL/QD, N
Nutropin QD, N
Benicar QL/QD
Fentanyl Transdermal System QL/QD
Benicar HCT QL/QD
Fexofenadine QL/QD
Omeprazole QL/QD
Fortical QL
Ondansetron QL, N
Betaseron QL/QD
Fosamax QL
Fosamax Plus D QL
Boniva QL
Butorphanol Nasal Spray QL
Byetta QL
Oxycontin QL/QD
Paroxetine QL
Pegasys QL, N
Peg-Intron QL, N
Humatrope QD, N
Cefdinir QL
Hyzaar QL/QD
Prandin QL
Imitrex Injection QL
Pravastatin QL/QD
Janumet QL
Januvia QL
Some medications are noted with N, QD, QL, or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
N = Notification. There are a few medications that your doctor must notify us of to make sure their use is covered within your benefit.
QD = Quantity Duration. Some medications have a limited amount that can be covered for a specific period of time.
QL = Quantity Level. Some medications have a limited amount that can be covered at one time.
DS = Diabetic Supplies. Diabetic supplies may be covered by your benefit plan.
2008 Four-Tier Prescription Drug List Reference Guide Prevacid Solutab QL/QD
Prevpac QL
Zyrtec QL/QD
Procrit QD
Zyrtec-D QL/QD
Proctofoam-HC
Prograf
Prometrium
Protonix QL/QD
Protopic N
Pulmicort Respules QL
Quinapril
Quinapril with Hydrochlorothiazide
Ranexa QL
Renagel
Requip
Retin-A Micro QL, N
Risperdal (M-Tab = Tier 3)
Roferon A QL, N
Seroquel
Serostim QD, N
Singulair QL
Soriatane
Spiriva QL
Sular
Symbyax
Synthroid
Tazorac QL, N
Tegretol
Tegretol XR
Terbinafine Tablet QL, N
Testim 1% QL
Tev-Tropin QD, N
Tilade QL
Tolmetin
Travatan QL
Travatan Z QL
Tricor Tablet
Triglide
Triphasil
Trusopt
Twinject QL
Urso
Urso Forte
Valtrex QL
Vesicare QL
Vivelle QL
Vivelle-Dot QL
Voltaren Eye Drops
Vytorin QL
Welchol
Yasmin
Yaz
Zegerid QL/QD
Zolpidem QL/QD
Zomig Nasal Spray QL
Zovirax Ointment, Cream
Zylet
Some medications are noted with N, QD, QL, or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
N = Notification. There are a few medications that your doctor must notify us of to make sure their use is covered within your benefit.
QD = Quantity Duration. Some medications have a limited amount that can be covered for a specific period of time.
QL = Quantity Level. Some medications have a limited amount that can be covered at one time.
DS = Diabetic Supplies. Diabetic supplies may be covered by your benefit plan.
2008 Four-Tier Prescription Drug List Reference Guide Tier Three
Humira QL/QD
Accolate QL
Imitrex Nasal Spray QL
Accu-Chek Test Strips QL, DS
Clarinex QL/QD, Excluded
Imitrex Tablet QL
Clarinex-D QL/QD, Excluded
Climara Pro QL
Kadian QL/QD
Actiq QL/QD, N
Kineret QL/QD
Actonel 75mg QL
Combipatch QL
Combivent QL
Advair Diskus QL
Combunox QL
Lamisil Tablet QL, N
Advair HFA QL
Concerta QL
Cosopt QL
Lescol QL/QD
Allegra QL/QD
Lescol XL QL/QD
Allegra-D QL/QD, Excluded
Levitra QD
Cymbalta QL
Ambien QL/QD
Dosepack, 3 Month QL
Amerge QL
Daytrana QL
Amlodipine and Benazepril QL
Lexapro QL
Detrol LA QL
Differin QL, N
Ascensia Autodisc QL, DS
Ascensia Elite QL, DS
Ditropan XL QL
Atacand QL/QD
Atacand HCT QL/QD
Lotrel QL
Lovaza QL
Avalide QL/QD
Duragesic QL/QD
Avapro QL/QD
Lunesta QL/QD
Avinza QL/QD
Enbrel QL/QD
Lyrica QL/QD
Avodart QL, N
Epipen QL
Epipen Jr. QL
Maxair Autohaler QL
Azmacort QL
Beconase AQ QL
Metadate CD QL
Famciclovir QL
Famvir QL
Miacalcin Nasal Spray QL
24 Hour 300mg QL, N
Byetta QL
Finasteride N
Caduet QL
Flovent HFA QL
Focalin QL
Nasacort QL
Catapres-TTS QL
Focalin XR QL
Nasacort AQ QL
Glucometer Test Strips QL, DS
Celebrex QL/QD
Nexium QL/QD, Excluded
Chemstrip BG Test Strips QL, DS
Cialis QD
Ciclopirox Solution, Topical QL
Some medications are noted with N, QD, QL, or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
N = Notification. There are a few medications that your doctor must notify us of to make sure their use is covered within your benefit.
QD = Quantity Duration. Some medications have a limited amount that can be covered for a specific period of time.
QL = Quantity Level. Some medications have a limited amount that can be covered at one time.
DS = Diabetic Supplies. Diabetic supplies may be covered by your benefit plan.
Excluded = Many benefit plans exclude coverage of medications that are classified by the Pharmacy and Therapeutics Committee as therapeutically equivalent to over-the-counter
medications. Check your benefit plan documents for coverage information or call the Customer Care number on your ID card for more information.
2008 Four-Tier Prescription Drug List Reference Guide Starlix QL
Omnicef QL
Strattera QL
Symlin QL
Ortho Evra QL
Tamiflu QL, N
Terazol QL
Terconazole Cream QL
Teveten QL/QD
Oxybutynin Sustained Release QL
Tracer BG Test Strips QL, DS
Paxil CR QL
Penlac QL
Pravachol QL/QD
Uroxatral QL
Ventolin HFA QL
Prevacid Capsule QL/QD, Excluded
ProAir HFA QL
Viagra QD
Proscar N
Proventil HFA QL
Provigil QL, N
Wellbutrin XL QL, N
Prozac Weekly QL
Xalatan QL
Xyzal QL/QD
Zelnorm QL/QD, N
Relenza QL, N
Zetia QL/QD
Restasis QL, N
Rhinocort QL
Zofran QL, N
Rhinocort Aqua QL
Ritalin LA QL
Robinul Forte
Rosanil
Rozerem QL/QD
Sanctura QL
• Compounded prescriptions are
Sarafem QL
Tier Three
Seasonale QL
Serevent Diskus QL
• Pens & cartridges are Tier Three
except for Novolin and Novolog
pens and cartridges which are
Sonata QL/QD
Tier Two.
Some medications are noted with N, QD, QL, or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
N = Notification. There are a few medications that your doctor must notify us of to make sure their use is covered within your benefit.
QD = Quantity Duration. Some medications have a limited amount that can be covered for a specific period of time.
QL = Quantity Level. Some medications have a limited amount that can be covered at one time.
DS = Diabetic Supplies. Diabetic supplies may be covered by your benefit plan.
Excluded = Many benefit plans exclude coverage of medications that are classified by the Pharmacy and Therapeutics Committee as therapeutically equivalent to over-the-counter
medications. Check your benefit plan documents for coverage information or call the Customer Care number on your ID card for more information.
2008 Four-Tier Prescription Drug List Reference Guide Tier Four
Accutane
Ambien CR QL/QD
Bravelle
Follistim
Follistim AQ
Genotropin QD, N
Geref QD, N
Infergen QL, N
Intron A QL, N
Menopur
Rebif QL
Repronex
Saizen QD, N
Sotret 30mg Capsule
Some medications are noted with N, QD, QL, or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
N = Notification. There are a few medications that your doctor must notify us of to make sure their use is covered within your benefit.
QD = Quantity Duration. Some medications have a limited amount that can be covered for a specific period of time.
QL = Quantity Level. Some medications have a limited amount that can be covered at one time.
DS = Diabetic Supplies. Diabetic supplies may be covered by your benefit plan.
Excluded = Many benefit plans exclude coverage of medications that are classified by the Pharmacy and Therapeutics Committee as therapeutically equivalent to over-the-counter
medications. Check your benefit plan documents for coverage information or call the Customer Care number on your ID card for more information.
2008 Four-Tier Prescription Drug List Reference Guide Additional Tier Three drugs
with a generic alternative
Flonase QL (Fluticasone Nasal
Spray QL)
Sporanox QL, N (Itraconazole QL, N)
in Tier One
Tylenol #3 QL/QD (Acetaminophen with
Arava QL (Leflunomide QL)
Codeine QL/QD)
Ultracet QL (Tramadol with
Acetaminophen QL)
Ultram QL (Tramadol QL)
Vicodin QL/QD, Vicodin ES QL/QD
Celexa QL (Citalopram QL)
Mevacor QL/QD (Lovastatin QL/QD)
Mobic QL (Meloxicam QL)
Wellbutrin QL (Bupropion QL)
Wellbutrin SR QL, N (Bupropion
Sustained Action QL, N)
Copegus QL, N (Ribavirin QL, N)
Darvocet-N QL/QD (Propoxyphene with
Acetaminophen QL/QD)
Nasarel QL, Nasalide QL (Flunisolide
Depo-Provera QL
Nasal Spray QL)
Zocor QL/QD (Simvastatin QL/QD)
Zoloft QL (Sertraline QL)
Acetate 150mg/ml QL)
Percocet 5-325, 7.5-500, 10-650 QL/QD
Tablet N (Fluconazole N)
Diflucan 150mg QL (Fluconazole QL)
Prozac QL (Fluoxetine QL)
Effexor QL (Venlafaxine QL)
Rebetol QL, N (Ribavirin QL, N)
Remeron QL (Mirtazapine QL)
Remeron SolTab QL (Mirtazapine
Dispersible Tablet QL)
Some medications are noted with N, QD, QL, or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
N = Notification. There are a few medications that your doctor must notify us of to make sure their use is covered within your benefit.
QD = Quantity Duration. Some medications have a limited amount that can be covered for a specific period of time.
QL = Quantity Level. Some medications have a limited amount that can be covered at one time.
DS = Diabetic Supplies. Diabetic supplies may be covered by your benefit plan.

Source: http://www.walker-insurance.com/nss-folder/medicalinsurance/United%20Healthcare%20Prescription%20Drug%20List%202008.pdf

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