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2009 Three-Tier Prescription Drug List Reference Guide Your UnitedHealthcare pharmacy benefit
Tier 1 – Your Lowest-Cost Option
offers flexibility and choice in finding the right
This is your lowest copayment option. For the medication for you.
always consider Tier 1 medications if you andyour doctor decide they are right for your choices and make informed decisions.
Tier 2 – Your Midrange-Cost Option
2. Help you understand which questions to This is your middle copayment option. Consider Tier 2 medications if you and your doctor decidethat a Tier 2 medication is right for your What is a Prescription Drug List (PDL)?
A PDL is a list of Food and Drug Administration(FDA)-approved brand name and generic Tier 3 – Your Highest-Cost Option
This is your highest copayment option.
Sometimes there are alternatives available in Tier 1 or Tier 2 that may be appropriate to treat selection of prescription medications. Below you your condition. If you are currently taking a medication in Tier 3, ask your doctor whether medications for certain conditions. You and your there are Tier 1 or Tier 2 alternatives that may be doctor may refer to this list to select the right Compounded medications, medications with
The benefit plan documents provided by your one or more ingredients that are prepared employer or health plan include a Summary “on-site” by a pharmacist, are classified at the Plan Description (SPD) or a Certificate of Please note: Some plans have a two-tier
documents to determine which medications are pharmacy benefit rather than a three-tier pharmacy benefit. Generally, a two-tier closed Understanding Tiers
Prescription medications are categorized within medications classified in Tier 3 of this PDL. A three tiers. Each tier is assigned a copayment, two-tier open pharmacy benefit plan covers one the amount you pay when you fill a prescription, tier at the lower copayment and covers a second which is determined by your employer or health plan. Consult your benefit plan documents to find out the specific copayments, coinsurance prescription plan. Refer to your enrollment and deductibles that are part of your plan. materials, check the Drug Pricing / Coverage Some plans may require you to pay the entire
information on www.myuhc.com, or call the
cost of the medication until the plan deductible
Customer Care number on your ID card for more has been met, or may require you to meet a
information about your benefit plan.
deductible before copayments or coinsurance
applies.

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.
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 employer or health plan. The PDL name medication expires. At that time, other Management Committee is comprised of senior companies are permitted to manufacture an business leaders. You and your doctor decide medication. Many companies that make brand which medication is appropriate for you.
name medications also produce and marketgeneric medications.
What factors does the PDL Management
Committee look at to make tier placement

decisions?
prescription for a brand name medication, ask if a generic equivalent is available and if it might tier placement of a particular prescription medication based upon clinical information from exceptions, generic medications are usually your lowest cost option. Please note that some Therapeutics (P&T) Committee and economic generic medications may be in Tier 2 or Tier 3 and financial considerations. The Committee looks at the overall health care value of a available under your pharmacy benefit plan. particular medication in order to balance the Go to myuhc.com to determine the copayment
need for flexibility and choice for our members Why is the medication that I am currently
taking no longer covered?
How often will prescription medications
Medications may be excluded from coverage change tiers?
under your pharmacy benefit. For example, a Medications may move to a higher tier up to six prescription medication may be excluded from times per calendar year, depending on your coverage when it is therapeutically equivalent to an over-the-counter or prescription medication.
medication becomes available as a generic, the Alternatives on the PDL and other over-the- tier status of the brand name medication and its corresponding generic will be evaluated. When When should I consider discussing
a medication changes tiers, you may be required over-the-counter or non-prescription
to pay more or less for that medication. These medications with my doctor?
changes may occur without prior notice to you.
For the most current information on your pharmacy coverage, please call the Customer appropriate treatment for many conditions.
Consult your doctor about over-the-counter www.myuhc.com.
alternatives to treat your condition. Thesemedications are not covered under yourpharmacy benefit, but they may cost less thanyour out-of-pocket expense for prescriptionmedications.
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.
Why are there notations next to certain
How do I access updated information
medications in the PDL, and what do
about my pharmacy benefit?
they mean?
Since the PDL may change periodically, we The specific definitions for these notations encourage you to visit www.myuhc.com or call
(QLL, QD, N, etc.) are listed at the bottom of
the Customer Care number on your ID card for each page of the PDL and refer to our pharmacy Log on to myuhc.com for the following
• Confirm coverage based on your benefit plan • Alert pharmacists and doctors of potentially • Pharmacy benefit and coverage information • Specific copayment amounts for prescription • Notify your pharmacist and doctor of duplication • Possible lower-cost medication alternatives Please call Customer Care if you need additional • A list of medications based on a specific What should I do if I use a self-
• Medication interactions and side effects, etc. administered injectable medication?
You may have coverage for self-administered
• Locate a participating retail pharmacy by zip injectable medications through your pharmacy benefit plan. UnitedHealthcare has developed aspecialty pharmacy network for these medications. Please call our toll-free SpecialtyPharmacy Referral Line at 1-866-429-8177 where And, if mail order is included in your pharmacy a representative will answer questions about our program and then transfer you to a specialty pharmacy based on your particular specialtymedication prescription.
What if I still have questions?
Please call the Customer Care number on your
ID card. Representatives are available to assist
you 24 hours a day, except Thanksgiving and
Christmas.
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.
2009 Three-Tier Prescription Drug List Reference Guide Acetaminophen with Codeine QLL/QD
Bupropion Sustained Action N
and Butalbital QLL/QD
Calcipotriene Solution, Topical QLL
Alendronate QLL
Estradiol Patch QLL
Fast Take Test Strips QLL, DS
Asmanex QLL
Fluconazole 50, 100, 200mg N
Fluticasone Nasal Spray QLL
Foradil QLL
Some medications are noted with N, QD, QLL, or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
= Notification. There are a few medications that your doctor must notify us of to make sure their use is covered within your benefit.
= Progression Rx.
QD = Quantity Duration. Some medications have a limited amount that can be covered for a specific period of time.
QLL = Quantity Level Limit. 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.
1/2T = Eligible for Half Tablet Program.
2009 Three-Tier Prescription Drug List Reference Guide Freestyle Lite Test Strips QLL, DS
Freestyle Test Strips QLL, DS
Frova QLL
Maxalt QLL
Maxalt MLT QLL
Medroxyprogesterone 150mg/ml QLL
Ondansetron QLL
One Touch Test Strips QLL, DS
One Touch Ultra Test Strips QLL, DS
Oxycodone with Ibuprofen QLL
Itraconazole QD, N
Mirtazapine Dispersible Tablet QLL
Pravastatin 1/2T
Precision Q-I-D Test Strips QLL, DS
Precision Xtra Test Strips QLL, DS
Some medications are noted with N, QD, QLL, or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
= Notification. There are a few medications that your doctor must notify us of to make sure their use is covered within your benefit.
= Progression Rx.
QD = Quantity Duration. Some medications have a limited amount that can be covered for a specific period of time.
QLL = Quantity Level Limit. 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.
1/2T = Eligible for Half Tablet Program.
2009 Three-Tier Prescription Drug List Reference Guide Acetaminophen QLL
Tretinoin N
Pulmicort Flexhaler QLL
Pulmicort Turbuhaler QLL
Relpax QLL
Ribavirin QLL, N
Venlafaxine QLL
Risperidone QLL
Xopenex HFA QLL
Zolpidem QLL/QD
Sertraline 1/2T
Zomig QLL
Zomig ZMT QLL
Simvastatin 1/2T
Spironolactone
Sprintec
Sucralfate
Sulfacetamide
Sulfacetamide with Sulfur
Sulfamethoxazole with Trimethoprim
Sulfasalazine
Sulfasalazine EC
Sulfatrim
Sulindac
Surestep Test Strips QLL, DS
Tamoxifen
Temazepam
Terazosin
Terbutaline
Terconazole Suppository
Tetracycline
Theophylline
Theophylline Anhydrous Tablet,
Some medications are noted with N, QD, QLL, or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
= Notification. There are a few medications that your doctor must notify us of to make sure their use is covered within your benefit.
= Progression Rx.
QD = Quantity Duration. Some medications have a limited amount that can be covered for a specific period of time.
QLL = Quantity Level Limit. 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.
1/2T = Eligible for Half Tablet Program.
2009 Three-Tier Prescription Drug List Reference Guide Climara QLL
Janumet QLL
Combigan QLL
Januvia QLL
Aciphex QLL/QD
Copaxone QLL
Actonel QLL
Cozaar QLL/QD, 1/2T
Actonel with Calcium QLL
Crestor QLL/QD, 1/2T
Actoplus Met QLL
Actos QLL
Adderall XR QLL
Lidoderm QLL/QD
Alphagan P QLL
Lipitor QLL/QD, 1/2T
Altoprev QLL/QD
Lovenox QLL
Androgel QLL
Lumigan QLL
Dovonex Cream, Ointment QLL
Duetact QLL
Aranesp QLL/QD
Effexor XR QLL
Emend QLL
Arixtra QLL
Astelin QLL
Micardis QLL/QD
Epogen QLL/QD
Micardis HCT QLL/QD
Avandamet QLL
Esclim QLL
Avandaryl QLL
Estraderm QLL
Moexipril 1/2T
Avandia QLL
Avonex QLL
Nasonex QLL
Azor QLL/QD
Estring QLL
Benicar QLL/QD, 1/
Benicar HCT QLL/QD
Betaseron QLL/QD
Nutropin QLL/QD, N
Fentanyl Citrate Lollipop QLL/QD, N
Boniva QLL
Fentanyl Transdermal System QLL/QD
Butorphanol Nasal Spray QLL
Omeprazole 40mg QLL/QD
Byetta QLL
Geodon QLL
Oxycontin QLL/QD
Cefdinir QLL
Pegasys QLL, N
Granisetron Tablet QLL
Peg-Intron QLL, N
Hyzaar QLL/QD
Prandin QLL
Imitrex Injection QLL
Intal QLL
Some medications are noted with N, QD, QLL, or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
= Notification. There are a few medications that your doctor must notify us of to make sure their use is covered within your benefit.
= Progression Rx.
QD = Quantity Duration. Some medications have a limited amount that can be covered for a specific period of time.
QLL = Quantity Level Limit. 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.
1/2T = Eligible for Half Tablet Program.
2009 Three-Tier Prescription Drug List Reference Guide Prevpac QLL
Procrit QLL/QD
Zyprexa (Zydis = Tier 3) QLL
Proctofoam-HC
Prograf
Prometrium
Protonix QLL/QD
Protopic QLL, N
Pulmicort Respules QLL
Pylera
Quinapril
Quinapril with Hydrochlorothiazide
Ramipril Capsule
Ranexa
Rapamune
Renagel
Renvela
Retin-A Micro QLL, N
Roferon A QLL, N
Saizen QLL/QD, N
Seroquel QLL
Serostim QLL/QD, N
Simcor QLL/QD
Singulair QLL
Soriatane
Spiriva QLL
Sular 8.5, 10, 17, 25.5, 34mg
Symbyax
Synthroid
Tazorac QLL, N
Tegretol
Tegretol XR
Terbinafine Tablet N
Tev-Tropin QLL/QD, N
Tilade QLL
Tolmetin
Travatan QLL
Travatan Z QLL
Tricor 48, 145mg
Triglide
Trusopt
Twinject QLL
Urso
Urso Forte
Vagifem
Valtrex QLL
Vesicare
Vivelle QLL
Vivelle-Dot QLL
Vytorin QLL
Vyvanse QLL
Welchol
Yaz
Zegerid QLL/QD
Zomig Nasal Spray QLL
Zovirax Ointment, Cream
Some medications are noted with N, QD, QLL, or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
= Notification. There are a few medications that your doctor must notify us of to make sure their use is covered within your benefit.
= Progression Rx.
QD = Quantity Duration. Some medications have a limited amount that can be covered for a specific period of time.
QLL = Quantity Level Limit. 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.
1/2T = Eligible for Half Tablet Program.
2009 Three-Tier Prescription Drug List Reference Guide Tier Three
Catapres-TTS QLL
Abilify QLL
Accolate QLL
Famciclovir QLL
Accu-Chek Test Strips QLL, DS
Celebrex QLL/QD
Famvir QLL
Cesamet QLL, P
Fentora QLL/QD, N
Chemstrip BG Test Strips QLL, DS
Actiq QLL/QD, N
Cialis QD
Finasteride N
Acular QLL
Adoxa Excluded
Flovent HFA QLL
Advair Diskus QLL
Focalin QLL
Advair HFA QLL
Focalin XR QLL
Clarinex QLL/QD, Excluded
Fosamax Plus D QLL
Clarinex-D QLL/QD, Excluded
Genotropin QLL/QD, N, Excluded
Climara Pro QLL
Glucometer Test Strips QLL, DS
Clindagel QD
Clobetasol Propionate Foam QLL
Allegra ODT QLL/QD, Excluded
Allegra Suspension QLL/QD, Excluded
Allegra-D QLL/QD, Excluded
Combipatch QLL
Combivent QLL
Humatrope QLL/QD, N, Excluded
Concerta QLL
Ambien CR QLL/QD
Coreg CR QLL, Excluded
Amerge QLL
Cosopt QLL
Humira QLL/QD
Amlodipine and Benazepril QLL
Imitrex Nasal Spray QLL
Anzemet QLL
Imitrex Tablet QLL
Cymbalta QLL/QD
Ascensia Autodisc QLL, DS
Daytrana QLL
Intron A QLL, N
Ascensia Elite QLL, DS
Invega QLL
Atacand QLL/QD, 1/
Kadian QLL/QD
Atacand HCT QLL/QD
Kineret QLL/QD
Avalide QLL/QD
Kytril Tablet QLL
Avapro QLL/QD, 1/
Differin QLL, N
Lamisil Tablet QD, N
Avinza QLL/QD
Diovan QLL/QD, 1/2T
Avodart QLL, N
Diovan HCT QLL/QD
Lescol QLL/QD
Axert QLL
Lescol XL QLL/QD
Azmacort QLL
Bactroban QLL
Doryx Excluded
Levitra QD
Beconase AQ QLL
Dosepack, 3 Month QLL
Duragesic QLL/QD
Lexapro QLL, 1/2T
Elidel QLL, N
Enbrel QLL/QD
24 Hour QLL, N
Epipen QLL
Caduet QLL, Excluded
Epipen Jr. QLL
Exforge QLL/QD
Some medications are noted with N, QD, QLL, or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
= Notification. There are a few medications that your doctor must notify us of to make sure their use is covered within your benefit.
= Progression Rx.
QD = Quantity Duration. Some medications have a limited amount that can be covered for a specific period of time.
QLL = Quantity Level Limit. 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.
1/2T = Eligible for Half Tablet Program.
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.
2009 Three-Tier Prescription Drug List Reference Guide Lotrel QLL
Tekturna QLL/QD
Pexeva QLL, 1/2T
Lunesta QLL/QD, P
Testim QLL, Excluded
Lyrica QLL/QD
Teveten QLL/QD
Mavik 1/2T
Maxair Autohaler QLL
Tracer BG Test Strips QLL, DS
Metadate CD QLL
Prevacid Capsule QLL/QD, Excluded
Treximet QLL, Excluded
Prevacid Solutab QLL/QD, Excluded
Prilosec Rx 10, 20mg Excluded
Triaz Excluded
Prilosec Rx 40mg QLL/QD, Excluded
Pristiq QLL
ProAir HFA QLL
Univasc 1/2T
Proscar N
Uroxatral QLL
Nexium Capsule QLL/QD, Excluded
Proventil HFA QLL
Nexium Suspension QLL/QD
Provigil QLL, N
Prozac Weekly QLL
Ventolin HFA QLL
Veramyst QLL, Excluded
Norditropin QLL/QD, N, Excluded
Rebif QLL/QD
Relenza QLL, N
Viagra QD
Omnicef QLL
Restasis QLL, N
Omnitrope QLL/QD, N, Excluded
Opana ER QLL/QD
Rhinocort QLL
Rhinocort Aqua QLL
Wellbutrin XL QLL, N
Ortho Evra QLL
Risperdal M-Tab QLL
Xalatan QLL
Ritalin LA QLL
Xyzal QLL/QD
Rozerem QLL/QD, P
Zaleplon QLL/QD
Zelnorm QLL/QD, N
Zetia QLL/QD
Seasonale QLL
Ziana QLL
Serevent Diskus QLL
Zyflo CR QLL
Pantoprazole QLL/QD
Seroquel XR QLL
24 Hour QLL
Sonata QLL/QD
• Compounded prescriptions are
Starlix QLL
Tier Three
Strattera QLL
Paxil CR QLL
• Insulin pens & cartridges are Tier
Symlin QLL
Three except for Novolin and
Novolog pens and cartridges
which are Tier Two.
Perforomist QLL
Some medications are noted with N, QD, QLL, or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
= Notification. There are a few medications that your doctor must notify us of to make sure their use is covered within your benefit.
= Progression Rx.
QD = Quantity Duration. Some medications have a limited amount that can be covered for a specific period of time.
QLL = Quantity Level Limit. 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.
1/2T = Eligible for Half Tablet Program.
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.
2009 Three-Tier Prescription Drug List Reference Guide
Additional Tier Three drugs
with a generic equivalent
in Tier One
Flonase QLL (Fluticasone Nasal
Rebetol QLL, N (Ribavirin QLL, N)
Ambien QLL/QD (Zolpidem QLL/QD)
Spray QLL)
Remeron SolTab QLL (Mirtazapine
Fosamax QLL (Alendronate QLL)
Dispersible Tablet QLL)
Risperdal QLL (Risperidone QLL)
Sporanox QD, N (Itraconazole QD, N)
Tylenol #3 QLL/QD (Acetaminophen with
Codeine QLL/QD)
Ultracet QLL (Tramadol with
Acetaminophen QLL)
Combunox QLL (Oxycodone with
Ibuprofen QLL)
Copegus QLL, N (Ribavirin QLL, N)
Darvocet-N QLL/QD (Propoxyphene with
Acetaminophen QLL/QD)
Vicodin QLL/QD, Vicodin ES QLL/QD
Depo-Provera QLL
Acetate 150mg/ml QLL)
Wellbutrin SR N (Bupropion Sustained
Action N)
Tablet N (Fluconazole N)
Percocet 5-325, 7.5-500, 10-650 QLL/QD
Dovenex Solution QLL (Calcipotriene
Zocor 1/2T (Simvastatin 1/2T)
Solution, Topical QLL)
Zofran QLL (Ondansetron QLL)
Zoloft 1/2T (Sertraline 1/2T)
Pravachol 1/2T (Pravastatin 1/2T)
Effexor QLL (Venlafaxine QLL)
Some medications are noted with N, QD, QLL, or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
= Notification. There are a few medications that your doctor must notify us of to make sure their use is covered within your benefit.
= Progression Rx.
QD = Quantity Duration. Some medications have a limited amount that can be covered for a specific period of time.
QLL = Quantity Level Limit. 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.
1/2T = Eligible for Half Tablet Program.

Source: http://www.dlretiree.info/pdf/2009%20PDL%203%20tier_DPMP_FD%20ver%20012009.pdf

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