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2008 Prescription Drug List Reference Guide The UnitedHealthcare pharmacy benefit offers
What is a Prescription Drug List?
you flexibility and choice in the prescription
A Prescription Drug List (PDL) is a list of Food medications available to you. Understanding
and Drug Administration (FDA)-approved brand- your Prescription Drug List will help you make
more informed decisions about prescription
medications.
designed to provide you with coverage for a This guide will help you understand these choices. It will also enable you to ask your commonly prescribed medications for certain regarding your medication needs. Our goal is to conditions. You and your doctor may refer to provide information that will help you make this list to consider prescription medication informed decisions regarding medications for choices and select the appropriate medication to Below you will find some common questions Keep in mind that the benefit plan documents people have asked regarding UnitedHealthcare’s provided by your health plan may include a pharmacy benefit. If you have pharmacy benefit Summary Plan Description or a Certificate of coverage with UnitedHealthcare, please visit us at www.uhcsr.com or call the Customer Service
documents define your pharmacy coverage and may exclude coverage for certain medications information. If you are not currently enrolled listed in the PDL found in this guide. If you do with UnitedHealthcare for pharmacy benefit not have the benefit plan documents, please coverage, you may access www.uhcsr.com for
contact your health plan for this information. enrollment period or you may contact your health plan for additional information.
If you have pharmacy benefit coverage with UnitedHealthcare, you may learn more about your benefit by visiting www.uhcsr.com or by calling the Customer Service telephone
number printed on your ID card. If you are not currently enrolled with UnitedHealthcare for pharmacy benefit coverage, you may access www.uhcsr.com for additional information
during your open enrollment period or you may contact your health plan for additional information.
What are tier designations and how do
Your Highest-Cost Option
they affect what I actually pay at the
Tier 3 is your highest copayment option.
pharmacy?
Sometimes there are alternatives available in Prescription medications are categorized within Tier 1 or Tier 2. If you are currently taking a three tiers. Each tier is assigned a copayment, medication in Tier 3, ask your doctor whether which is an amount you pay when you fill a there are Tier 1 or Tier 2 alternatives that may be prescription at a participating retail pharmacy or appropriate for your treatment. Compounded refill your ongoing prescription through the medications, those medications containing one network mail-order pharmacy service. Your or more ingredients that are prepared “on-site” health plan sets the actual copayment amounts by a pharmacist, are classified at the Tier 3 level, provided that the individual ingredients used in pharmacy benefit. Consult the benefit plan compounding are covered under the pharmacy documents provided by your health plan for copayments, coinsurance, and deductibles that Please note: Some plans have a two-tier
may apply to your pharmacy benefit coverage. pharmacy benefit rather than a three-tierpharmacy benefit. Generally, a two-tier closed Your Lowest-Cost Option
Tier 1 is your lowest copayment option. For the
medications classified in Tier 3 of this PDL. A two-tier open pharmacy benefit plan covers one always consider Tier 1 medications if you and tier at the lower copayment and covers a second your doctor decide they are appropriate for your Midrange-Cost Option
prescription plan. Refer to your enrollment Tier 2 is your middle copayment option.
materials, check the Drug Pricing / Coverage Consider Tier 2 medications if you and your information on www.uhcsr.com, or call the
doctor decide that a Tier 2 medication is the Customer Service number on your ID card for most appropriate to treat your condition. more information about your benefit plan.
If you have pharmacy benefit coverage with UnitedHealthcare, you may learn more about your benefit by visiting www.uhcsr.com or by calling the Customer Service telephone
number printed on your ID card. If you are not currently enrolled with UnitedHealthcare for pharmacy benefit coverage, you may access www.uhcsr.com for additional information
during your open enrollment period or you may contact your health plan for additional information.
Who decides which medications get
What is the difference between brand-
placed in which tier?
name and generic medications?
Generic medications contain the same active Committee makes tier placement decisions to ingredients as brand-name medications, but they often cost less. Generic medications medications and control health care costs for become available after the patent on the brand- you and your health plan. You and your doctor name medication expires. At that time, other decide which medication is appropriate for you.
How often will prescription medications
change tiers?
Before a generic medication can be sold, the While medications change tiers infrequently, FDA must be satisfied that the medication such changes may occur up to six times per contains the same active ingredients in the same calendar year, depending on your benefit.
strength as the brand-name equivalent. It must Additionally, when a brand-name medication also meet the same quality standards. Many becomes available as a generic, the tier status of companies that make brand-name medications also produce and market generic medications corresponding generic will be evaluated. When that are equivalent to the branded products.
a medication changes tiers, you may be required to pay more or less for that medication. These changes may occur without prior notice to you.
prescription for a brand-name medication, ask if a generic equivalent is available and if it might coverage with UnitedHealthcare, you may visit our Web site, www.uhcsr.com, or call the
exceptions, generic medications are usually your Customer Service number on your ID card for lowest cost option. You and your health plan may save money if you and your doctor decide the generic medication is right for you.
Why is the medication that I am currently
taking no longer covered?
Medications may be excluded from coverage
Your doctor can recommend either an over-the- counter medication or a prescription medication for your treatment. You can purchase an over- the-counter medication at your local pharmacy If you have pharmacy benefit coverage with UnitedHealthcare, you may learn more about your benefit by visiting www.uhcsr.com or by calling the Customer Service telephone
number printed on your ID card. If you are not currently enrolled with UnitedHealthcare for pharmacy benefit coverage, you may access www.uhcsr.com for additional information
during your open enrollment period or you may contact your health plan for additional information.
When should I consider discussing “over-
How do I access updated information
the-counter” or non-prescription
about my pharmacy benefit?
medications with my doctor?
Since the PDL may change periodically, we encourage you to visit www.uhcsr.com or call
appropriate treatment for many conditions.
the Customer Service number on your ID card Consult your doctor about over-the-counter for the most current information. In addition to alternatives to treat your condition. These www.uhcsr.com is your online resource for a
pharmacy benefit, but they may cost less than variety of health and wellness topics. The site is your out-of-pocket expense for prescription designed to help you make informed health care Why are there “notations” next to certain
With www.uhcsr.com, you can view your
medications in the PDL, and what do they
prescription claims history, compare costs of notation, N (for “notification”). The specific definition for this notation is listed at the bottom of each page of the PDL. Please call Customer Service if you need additional information about If you have pharmacy benefit coverage with UnitedHealthcare, you may learn more about your benefit by visiting www.uhcsr.com or by calling the Customer Service telephone
number printed on your ID card. If you are not currently enrolled with UnitedHealthcare for pharmacy benefit coverage, you may access www.uhcsr.com for additional information
during your open enrollment period or you may contact your health plan for additional information.
How do I find information about my
What if I still have questions?
pharmacy benefit on www.uhcsr.com?
If you have pharmacy benefit coverage with If you have pharmacy benefit coverage with UnitedHealthcare, you may learn more about questions about your pharmacy benefit, please your coverage by visiting www.uhcsr.com. After
call the Customer Service number on your ID logging in to “My Account”, click on the card. Representatives are available to assist you “Pharmacy” link, and follow the instructions for from 7 a.m. to 6 p.m. CST, except Thanksgiving initial registration. Once registered, you can log and Christmas. If you are not currently enrolled in and click on the Prescriptions tab, then on with UnitedHealthcare for pharmacy benefit Drug Pricing / Coverage, and you will have coverage, please contact your health plan for access to copayment, pricing, and coverage information on most prescription medications.
You will also have access to the following Key points to remember
Your doctor may be able to help you save
• Pharmacy benefit and coverage information money by prescribing medications in Tier 1 and • Specific copayment amounts for prescription Tier 2 of the PDL. You and your doctor always make the decisions regarding your treatment.
Here are some practical suggestions for getting • Possible lower-cost medication alternatives • A list of medications based on a specific • Medication interactions, side effects, etc. appointments and ask your doctor to refer to the PDL when prescribing medications. It is a tool At www.uhcsr.com, you will also be able to:
that helps guide you and your doctor in choosing • Locate a participating retail pharmacy by medications that allow the most effective and affordable use of your pharmacy benefit.
• If you would like information about your specific If mail order is included in your pharmacy benefit plan, please visit www.uhcsr.com.
• Access www.uhcsr.com to refill prescriptions
• If you have pharmacy benefit coverage with questions about your pharmacy benefit, please call the Customer Service number on your ID card. Representatives are available to assist you from 7 a.m. to 6 p.m. CST, except Thanksgiving If you have pharmacy benefit coverage with UnitedHealthcare, you may learn more about your benefit by visiting www.uhcsr.com or by calling the Customer Service telephone
number printed on your ID card. If you are not currently enrolled with UnitedHealthcare for pharmacy benefit coverage, you may access www.uhcsr.com for additional information
during your open enrollment period or you may contact your health plan for additional information.
2008 Prescription Drug List Reference Guide Some medications are noted with N. 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.
2008 Prescription Drug List Reference Guide Oxycodone with Acetaminophen Oxycodone with Ibuprofen Pantoprazole Paroxetine Penicillin V PotassiumPhenytoinPiroxicamPolymyxin B with TrimethoprimPotassium ChloridePotassium CitratePravastatin PrazosinPrednisonePrimidonePromethazinePromethazine with CodeinePropoxyphene with Acetaminophen Propranolol Sustained Action CapsulePropranolol TabletPulmicort Flexhaler Pulmicort Turbuhaler Quinapril Quinapril with HydrochlorothiazideQVAR Ramipril CapsuleRanitidine SyrupRelpax Sertraline Simvastatin SpironolactoneSulfamethoxazole with TrimethoprimSulindacTamoxifenTemazepamTerazosinTerbinafine Tablet Terconazole Cream Terconazole Suppository TetracyclineTheophyllineTolmetinTramadol Tramadol with Acetaminophen TrandolaprilTrazodoneTriamcinolone Triamterene with HydrochlorothiazideTrimipramine Maleate Some medications are noted with N. 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.
2008 Prescription Drug List Reference Guide Some medications are noted with N. 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.
2008 Prescription Drug List Reference Guide Tier Three
Levitra N
Allegra Suspension Excluded
Allegra-D Excluded
Nexium Excluded
Clarinex Excluded
Clarinex-D Excluded
Prevacid Capsule Excluded
Differin N
Triaz Excluded
• Compounded prescriptions are
Tier Three
• Insulin pens & cartridges are Tier
Three except for Novolin and
Novolog pens and cartridges
which are Tier Two.
Some medications are noted with N. 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.
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 Prescription Drug List Reference Guide Additional Tier Three drugs
with a generic equivalent
in Tier One
Some medications are noted with N. 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.

Source: https://www.wwu.edu/chw/student_health/forms/United%20Healthcare%20RX%20formulary%202008.pdf