100-8107 4tr f1000_108 dg_3
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
Imitrex Nasal Spray
QL
Accolate
QL
Clarinex
QL/QD, Excluded
Imitrex Tablet
QL
Accu-Chek Test Strips
QL, DS
Clarinex-D
QL/QD, Excluded
Climara Pro
QL
Kadian
QL/QD
Kineret
QL/QD
Actiq
QL/QD, N
Combipatch
QL
Actonel 75mg
QL
Combivent
QL
Combunox
QL
Lamisil Tablet
QL, N
Advair Diskus
QL
Concerta
QL
Advair HFA
QL
Cosopt
QL
Lescol
QL/QD
Lescol XL
QL/QD
Allegra
QL/QD
Allegra-D
QL/QD, Excluded
Levitra
QD
Cymbalta
QL
Dosepack, 3 Month
QL
Ambien
QL/QD
Daytrana
QL
Amerge
QL
Lexapro
QL
Amlodipine and Benazepril
QL
Detrol LA
QL
Differin
QL, N
Ascensia Autodisc
QL, DS
Ditropan XL
QL
Ascensia Elite
QL, DS
Atacand
QL/QD
Lotrel
QL
Atacand HCT
QL/QD
Lovaza
QL
Duragesic
QL/QD
Avalide
QL/QD
Lunesta
QL/QD
Avapro
QL/QD
Enbrel
QL/QD
Lyrica
QL/QD
Avinza
QL/QD
Epipen
QL
Avodart
QL, N
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
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
Humira
QL/QD
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
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
Sarafem
QL
• Compounded prescriptions are
Seasonale
QL
Tier Three
Serevent Diskus
QL
Skelaxin
• Pens & cartridges are Tier Three
except for Novolin and Novolog
Sonata
QL/QD
pens and cartridges which are
Starlix
QL
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://parkavenueinsurance.com/pdf/20084tierPDL.pdf
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O NASCIMENTO DO CIDADÃO DIFERENTE: PROGNÓSTICO OU JULGAMENTO Universidade de Santo Amaro - INTRODUÇÃO E OBJETIVOS O nascimento de bebês em condições que exigem a intervenção de profissionais da saúde são bastante comuns. No entanto, quando a condição, como no caso das anomalias congênitas, indica o desenvolvimento de deficiência, impedimento ou desvantage