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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
(SL, N, etc.) are listed at the bottom of each page
the Customer Care number on your ID card for of the PDL and refer to our pharmacy programs.
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 Bupropion N
Bupropion Sustained Action N
Acetaminophen with Codeine SL
Calcipotriene Solution, Topical SL
and Butalbital SL
Acetaminophen with Hydrocodone SL
Alendronate SL
Dorzolamide Eye Drops SL
Estradiol Patch SL
Asmanex SL
Fast Take Test Strips SL, DS
Flunisolide Nasal Spray SL
Fluticasone Nasal Spray SL
Foradil SL
Some medications are noted with N, P, SL, DS, or 1/2T. 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.
P
= Progression Rx.
SL = Supply Limit. Some medications have a limited amount that can be covered per copayment or period of 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 SL, DS
Freestyle Test Strips SL, DS
Maxalt SL
Maxalt MLT SL
Medroxyprogesterone 150mg/ml SL
Ondansetron SL
One Touch Test Strips SL, DS
One Touch Ultra Test Strips SL, DS
Oxycodone with Acetaminophen SL
Oxycodone with Ibuprofen SL
Itraconazole SL
Mirtazapine Dispersible Tablet SL
Morphine Sulfate Controlled Release SL
Pravastatin 1/2T
Precision Q-I-D Test Strips SL, DS
Precision Xtra Test Strips SL, DS
Some medications are noted with N, P, SL, DS, or 1/2T. 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.
P
= Progression Rx.
SL = Supply Limit. Some medications have a limited amount that can be covered per copayment or period of 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 Propoxyphene with Acetaminophen SL
Acetaminophen SL
Tretinoin SL, N
Pulmicort Flexhaler SL
Pulmicort Turbuhaler SL
Relpax SL
Ribavirin SL, N
Risperidone SL
Venlafaxine SL
Ventolin HFA SL
Sertraline 1/2T
Simvastatin 1/2T
Zolpidem SL
Zomig ZMT SL
Spironolactone
Sprintec
Sucralfate
Sulfacetamide
Sulfacetamide with Sulfur
Sulfamethoxazole with Trimethoprim
Sulfasalazine
Sulfasalazine EC
Sulfatrim
Sulindac
Sumatriptan Succinate Injection SL
Surestep Test Strips SL, DS
Tamoxifen
Temazepam
Terazosin
Terbinafine Tablet SL
Some medications are noted with N, P, SL, DS, or 1/2T. 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.
P
= Progression Rx.
SL = Supply Limit. Some medications have a limited amount that can be covered per copayment or period of 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 Granisetron Tablet SL
Hyzaar SL
Aciphex SL
Actonel SL
Climara SL
Janumet SL
Actonel with Calcium SL
Januvia SL
Actoplus Met SL
Combigan SL
Copaxone SL
Adderall XR SL
Cozaar SL, 1/2T
Crestor SL, 1/2T
Alphagan P SL
Lidoderm SL
Altoprev SL
Diclofenac Sodium Drops SL
Lindane SL
Androgel SL
Lipitor SL, 1/2T
Aranesp SL
Lovenox SL
Lumigan SL
Divigel SL
Arixtra SL
Dorzolamide/Timolol Eye Drops SL
Dovonex Cream, Ointment SL
Astelin SL
Duetact SL
Atrovent Inhaler SL
Effexor XR SL
Avandamet SL
Elestat SL
Avandaryl SL
Avandia SL
Micardis SL
Avonex SL
Micardis HCT SL
Moexipril 1/2T
Epogen SL
Esclim SL
Benicar SL, 1/
Estraderm SL
Nasonex SL
Benicar HCT SL
Betimol SL
Boniva SL
Estring SL
Evamist SL
Nutropin SL, N
Butorphanol Nasal Spray SL
Byetta SL
Fentanyl Citrate Lollipop SL, N
Omeprazole 40mg SL
Fentanyl Transdermal System SL
Optivar SL
Finasteride N
Oxycontin SL
Geodon SL
Pegasys SL, N
Cefdinir SL
Glucagon Emergency Kit SL
Peg-Intron SL, N
Some medications are noted with N, P, SL, DS, or 1/2T. 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.
P
= Progression Rx.
SL = Supply Limit. Some medications have a limited amount that can be covered per copayment or period of 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 Prandin SL
Zyprexa (Zydis = Tier 3) SL
Prevpac SL
Procrit SL
Proctofoam-HC
Prograf
Prometrium
Protonix SL
Protopic SL, N
Pulmicort Respules SL
Pylera
Quinapril with Hydrochlorothiazide
Ranexa
Rapamune
Rebif SL
Renagel
Renvela
Retin-A Micro SL, N
Roferon A SL, N
Saizen SL, N
Sanctura XR
Seroquel SL
Serostim SL, N
Simcor SL
Singulair SL
Soriatane
Spiriva SL
Sular 8.5, 10, 17, 25.5, 34mg
Symbyax SL
Synthroid
Tazorac SL, N
Tegretol
Tev-Tropin SL, N
Tilade SL
Tobramycin/Dexamethasone Eye Drops
Tolmetin
Travatan SL
Travatan Z SL
Tricor 48, 145mg
Triglide
Twinject SL
Vagifem
Valtrex SL
Vesicare
Vivelle SL
Vivelle-Dot SL
Voltaren Gel
Vytorin SL
Vyvanse SL
Welchol
Yasmin
Yaz
Zaleplon SL
Zegerid SL
Zomig Nasal Spray SL
Some medications are noted with N, P, SL, DS, or 1/2T. 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.
P
= Progression Rx.
SL = Supply Limit. Some medications have a limited amount that can be covered per copayment or period of 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
Brevoxyl Excluded
Elidel SL, N
Abilify SL
Accolate SL
Caduet SL, Excluded
Enbrel SL, N
Accu-Chek Test Strips SL, DS
Epipen SL
Epipen Jr. SL
Catapres-TTS SL
Actiq SL, N
Acular SL
Celebrex SL
Exforge SL
Adoxa Excluded
Advair Diskus SL
Cesamet SL, P
Advair HFA SL
Chemstrip BG Test Strips SL, DS
Famciclovir SL
Cialis SL
Famvir SL
Fentora SL, N
Allegra ODT SL, Excluded
Allegra Suspension SL, Excluded
Clarinex SL, Excluded
Flovent HFA SL
Allegra-D SL, Excluded
Clarinex-D SL, Excluded
Focalin SL
Climara Pro SL
Focalin XR SL
Clindagel SL
Fosamax Plus D SL
Alvesco SL
Clobetasol Propionate Foam SL
Genotropin SL, N, Excluded
Ambien CR SL
Glucometer Test Strips SL, DS
Amerge SL
Amlodipine and Benazepril SL
Combipatch SL
Combivent SL
Concerta SL
Release 24 Hour SL
Coreg CR SL, Excluded
Humatrope SL, N, Excluded
Cosopt SL
Anzemet SL
Humira SL, N
Cymbalta SL
Imitrex Nasal Spray SL
Ascensia Autodisc SL, DS
Imitrex Tablet SL
Ascensia Elite SL, DS
Daytrana SL
Atacand SL, 1/
Atacand HCT SL
Intron A SL, N
Invega SL
Avalide SL
Kadian SL
Avapro SL, 1/
Keppra XR Excluded
Avinza SL
Kineret SL, N
Avodart SL, N
Differin SL, N
Kytril Tablet SL
Diovan SL, 1/2T
Azmacort SL
Diovan HCT SL
Lescol SL
Bactroban SL
Lescol XL SL
Beconase AQ SL
Doryx Excluded
Levitra SL
Betaseron SL, P
Dosepack, 3 Month SL
Duragesic SL
Lexapro SL, 1/2T
Some medications are noted with N, P, SL, DS, or 1/2T. 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.
P
= Progression Rx.
SL = Supply Limit. Some medications have a limited amount that can be covered per copayment or period of 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
and prescription 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 24 Hour SL
Serevent Diskus SL
Pataday SL
Seroquel XR SL
Patanol SL
Paxil CR SL
Soma 250mg Excluded
Sonata SL, P
Lotrel SL
Starlix SL
Perforomist SL
Stavzor Excluded
Lunesta SL, P
Strattera SL
Pexeva SL, 1/2T
Sumatriptan Succinate Nasal Spray SL
Lyrica SL
Sumatriptan Succinate Tablet SL
Mavik 1/2T
Symlin SL
Maxair Autohaler SL
Tamiflu SL
Tekturna SL
Metadate CD SL
Testim SL, Excluded
Prevacid Capsule SL, Excluded
Teveten SL
Prevacid Solutab SL, Excluded
Prilosec Rx 10, 20mg Excluded
Prilosec Rx 40mg SL, Excluded
Tracer BG Test Strips SL, DS
Pristiq SL
ProAir HFA SL
Nexium Capsule SL, Excluded
Treximet SL, Excluded
Nexium Suspension SL
Proscar N
Proventil HFA SL
Triaz Excluded
Provigil SL, N
Norditropin SL, N, Excluded
Prozac Weekly SL
Relenza SL
Omnicef SL
Univasc 1/2T
Omnitrope SL, N, Excluded
Requip XL Excluded
Uroxatral SL
Opana ER SL
Restasis SL, N
Ortho Evra SL
Rhinocort SL
Venlafaxine Extended Release SL,
Rhinocort Aqua SL
Excluded
Risperdal M-Tab SL
Veramyst SL, Excluded
Ritalin LA SL
Rozerem SL, P
Viagra SL
Sancuso SL, Excluded
Seasonale SL
Wellbutrin XL SL, N
Pantoprazole SL
Xalatan SL
Some medications are noted with N, P, SL, DS, or 1/2T. 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.
P
= Progression Rx.
SL = Supply Limit. Some medications have a limited amount that can be covered per copayment or period of 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
and prescription 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
Xopenex HFA SL
Xopenex Solution
Xyzal SL
Zelnorm SL, N
Zetia SL
Ziana SL
Zmax SL
Zyflo
Zyflo CR SL
Zylet
Zymar
NOTE:
• 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, P, SL, DS, or 1/2T. 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.
P
= Progression Rx.
SL = Supply Limit. Some medications have a limited amount that can be covered per copayment or period of 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
and prescription 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
Effexor SL (Venlafaxine SL)
Percocet 5-325, 7.5-500, 10-650 SL
(Oxycodone with Acetaminophen SL)
in Tier One
Pravachol 1/2T (Pravastatin 1/2T)
Flonase SL (Fluticasone Nasal Spray SL)
Ambien SL, P (Zolpidem SL)
Fosamax SL (Alendronate SL)
Rebetol SL, N (Ribavirin SL, N)
Imitrex Injection SL (Sumatriptan
Succinate Injection SL)
Remeron SolTab SL (Mirtazapine
Dispersible Tablet SL)
Risperdal SL (Risperidone SL)
Lamisil Tablet SL (Terbinafine Tablet SL)
Sporanox SL (Itraconazole SL)
Combunox SL (Oxycodone with
Ibuprofen SL)
Trusopt SL (Dorzolamide Eye Drops SL)
Copegus SL, N (Ribavirin SL, N)
Tylenol #3 SL (Acetaminophen with
Codeine SL)
Darvocet-N SL (Propoxyphene with
Ultracet SL (Tramadol with
Acetaminophen SL)
Acetaminophen SL)
Depo-Provera SL
Acetate 150mg/ml SL)
Vicodin SL, Vicodin ES SL
Nasarel, Nasalide SL (Flunisolide Nasal
Spray SL)
Dovenex Solution SL (Calcipotriene
Solution, Topical SL)
Wellbutrin N (Bupropion N)
Some medications are noted with N, P, SL, DS, or 1/2T. 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.
P
= Progression Rx.
SL = Supply Limit. Some medications have a limited amount that can be covered per copayment or period of 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 Wellbutrin SR N (Bupropion Sustained
Action N)
Xanax, Xanax XR (Alprazolam)Zantac Syrup (Ranitidine Syrup)Ziac (Bisoprolol with Zithromax (Azithromycin)
Zocor 1/2T (Simvastatin 1/2T)
Zofran SL (Ondansetron SL)
Zoloft 1/2T (Sertraline 1/2T)
Zonegran (Zonisamide)
Zovirax Tablet, Capsule, Suspension
Some medications are noted with N, P, SL, DS, or 1/2T. 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.
P
= Progression Rx.
SL = Supply Limit. Some medications have a limited amount that can be covered per copayment or period of time.
DS = Diabetic Supplies. Diabetic supplies may be covered by your benefit plan.
1/2T = Eligible for Half Tablet Program.

Source: http://www.corpsyn.net/carrier/images/carrier_080609_3tier_Rx_guide.pdf

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