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2009 Four-Tier Prescription Drug List Reference Guide IMPORTANT NOTICE – PLEASE READ
Your pharmacy benefit offers flexibility and
CAREFULLY
choice in finding the right medication for you.
Your Prescription Drug List (formerly known as
Preferred Drug List) has changed. Please note
that prescription medications on this new list
may be in different tiers than those on your old
choices and make informed decisions.
list, which may impact the amount you pay for
2. Help you understand which questions to the medication.
We suggest that you print the most current
What is a Prescription Drug List (PDL)?
Prescription Drug List from our Customers link
A PDL is a list of Food and Drug Administration at www.goldenrule.com and bring it with you
to your doctor appointments. Ask your doctor
to refer to the Prescription Drug List when
prescribing medications. It is a tool that helps
Your pharmacy benefit provides coverage for a guide you and your doctor in choosing
medications that allow the most effective and
affordable use of your pharmacy benefit.
commonly prescribed medications for certain conditions. You and your doctor may refer to this list to select the right medication to meet Please refer to your policy / certificate to determine which medications are covered under Understanding Tiers
Prescription medications are categorized within
four tiers. The tier determines the amount you pay when you fill a prescription. The amount is determined by your health plan. Consult your policy / certificate to find out the specific copayments, coinsurance, and deductibles that are part of your plan. You and your doctor decide which medication is appropriate for you. 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.
Your Lowest-Cost Option
Who decides which medications get
Tier 1 – The medications in Tier 1 are your
placed in which tier?
lowest cost option. For the lowest out-of-pocket expense, you should always consider Tier 1 Committee makes tier placement decisions to medications if you and your doctor decide they medications and control health care costs for you and your health plan. Guidance is based on Your Midrange-Cost Options
similarities and differences compared with other Tier 2 – Consider Tier 2 medications if you and
medications that treat the same disease or your doctor decide that a Tier 2 medication is condition. The PDL Management Committee is Tier 3 – If you are currently taking a medication
business leaders. You and your doctor decide in Tier 3, ask your doctor whether there are Tier which medication is appropriate for you.
1 or Tier 2 alternatives that may be right for your What factors does the PDL Management
treatment. Sometimes there are alternatives Committee look at to make tier placement
available in Tier 1 or Tier 2 that may be decisions?
appropriate to treat your condition.
Your Highest-Cost Option
tier placement of a particular prescription Tier 4 – The medications in Tier 4 are your
medication based upon clinical information from highest cost options. Sometimes there are the UnitedHealthcare National Pharmacy and alternatives available in Tier 1, Tier 2, or Tier 3 Therapeutics (P&T) Committee and economic that may be appropriate to treat your condition.
and financial considerations. The Committee If you are currently taking a medication in Tier 4, looks at the overall health care value of a ask your doctor whether there are Tier 1, Tier 2, particular medication in order to balance the or Tier 3 alternatives that may be right for your need for flexibility and choice for our members and an affordable pharmacy benefit for the Compounded medications, medications with
one or more ingredients that are prepared “on- How often will prescription medications
site” by a pharmacist, are classified at the Tier 3 change tiers?
level. However, if any one of the ingredients in Medications may move to a higher tier up to the compound is classified as being on Tier 4 three times per calendar year, depending on your benefit. Additionally, when a brand name medication becomes available as a generic, the Over-the-Counter Medications
tier status of the brand name medication and its For many conditions, an over-the-counter (OTC) corresponding generic will be evaluated. When a medication changes tiers, you may be required treatment. OTC medications are defined as to pay more or less for that medication. These medications that do not require a prescription changes may occur without prior notice to you.
by federal or state law to be dispensed.
pharmacy coverage, please call the Member Therapeutic equivalents and OTC medications Services number on the back of your ID card or may not be covered under your pharmacy or medical benefit, but they may cost less than www.goldenrule.com.
your out-of-pocket expense for prescription 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.
What is the difference between brand
What should I do if I use a self-
name and generic medications?
administered injectable medication?
Generic medications contain the same active You may have coverage for self-administered ingredients as brand name medications, but injectable medications through your pharmacy they often cost less. Generic medications benefit plan. UnitedHealthcare has developed a become available after the patent on the brand name medication expires. At that time, other medications. Please call our toll-free Specialty companies are permitted to manufacture an Pharmacy Referral Line at 1-866-429-8177 where a representative will answer questions about our medication. Many companies that make brand program and then transfer you to a specialty pharmacy based on your particular specialty How do I access updated information
prescription for a brand name medication, ask if about my pharmacy benefit?
a generic equivalent is available and if it might Since the PDL may change periodically, we encourage you to visit our Customers link at www.goldenrule.com for the most current
While there are exceptions, generic medications are generally included on the PDL in Tier 1. If a generic medication does not offer significant Once there, you can also compare costs of financial savings over the brand, it may be medications to identify cost-saving opportunities placed in the same tier as the brand or in a and contact a registered pharmacist seven days Go to the Customers link at www.goldenrule.com
What if I still have questions?
Please call the Member Services number on the back of your ID card. Representatives are available to assist you 24 hours a day, except Why are there “notations” next to certain
medications in the PDL, and what do they
mean?
The specific definitions for these notations
(SL, DS) are listed at the bottom of each page of the PDL and refer to our pharmacy programs.
• Confirm coverage based on your benefit plan • Alert pharmacists and doctors of potentially • Notify your pharmacist and doctor of duplication additional information about these notations. 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 Four-Tier Prescription Drug List Reference Guide Your Lowest-Cost Option
(Tier One)
Acetaminophen with Codeine SL
Calcipotriene Solution, Topical SL
and Butalbital SL
Acetaminophen with Hydrocodone SL
Alendronate SL
Estradiol Patch SL
Fast Take Test Strips SL, DS
Asmanex SL
Fluticasone Nasal Spray SL
Some medications are noted with SL or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
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.
2009 Four-Tier Prescription Drug List Reference Guide Foradil SL
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
Precision Q-I-D Test Strips SL, DS
Precision Xtra Test Strips SL, DS
Some medications are noted with SL or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
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.
2009 Four-Tier Prescription Drug List Reference Guide Tramadol with Acetaminophen SL
Propoxyphene with Acetaminophen SL
Pulmicort Flexhaler SL
Pulmicort Turbuhaler SL
Relpax SL
Ribavirin SL
Venlafaxine SL
Risperidone SL
Xopenex HFA SL
Zolpidem SL
Zomig ZMT SL
Spironolactone
Sprintec
Sucralfate
Sulfacetamide
Sulfacetamide with Sulfur
Sulfamethoxazole with Trimethoprim
Sulfasalazine
Sulfasalazine EC
Sulfatrim
Sulindac
Surestep Test Strips SL, DS
Tamoxifen
Temazepam
Terazosin
Terbutaline
Terconazole Suppository
Tetracycline
Theophylline
Some medications are noted with SL or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
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.
2009 Four-Tier Prescription Drug List Reference Guide Your Midrange-Cost Option
(Tier Two)
Climara SL
Janumet SL
Combigan SL
Januvia SL
Copaxone SL
Aciphex SL
Cozaar SL
Actonel SL
Crestor SL
Actonel with Calcium SL
Actoplus Met SL
Adderall XR SL
Lidoderm SL
Lipitor SL
Alphagan P SL
Altoprev SL
Lovenox SL
Lumigan SL
Androgel SL
Dovonex Cream, Ointment SL
Duetact SL
Effexor XR SL
Aranesp SL
Arixtra SL
Micardis SL
Micardis HCT SL
Astelin SL
Epogen SL
Esclim SL
Avandamet SL
Estraderm SL
Avandaryl SL
Avandia SL
Nasonex SL
Avonex SL
Estring SL
Benicar SL
Benicar HCT SL
Nutropin SL
Betaseron SL
Fentanyl Citrate Lollipop SL
Fentanyl Transdermal System SL
Omeprazole 40mg SL
Boniva SL
Butorphanol Nasal Spray SL
Byetta SL
Geodon SL
Oxycontin SL
Pegasys SL
Cefdinir SL
Peg-Intron SL
Granisetron Tablet SL
Prandin SL
Hyzaar SL
Imitrex Injection SL
Some medications are noted with SL or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
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.
2009 Four-Tier Prescription Drug List Reference Guide Prevpac SL
Procrit SL
Proctofoam-HC
Prograf
Prometrium
Protonix SL
Protopic SL
Pulmicort Respules SL
Pylera
Quinapril
Quinapril with Hydrochlorothiazide
Ramipril Capsule
Ranexa
Rapamune
Renagel
Renvela
Retin-A Micro SL
Roferon A SL
Saizen SL
Seroquel SL
Serostim SL
Simcor SL
Singulair SL
Soriatane
Spiriva SL
Sular 8.5, 10, 17, 25.5, 34mg
Symbyax
Synthroid
Tazorac SL
Tegretol
Tegretol XR
Terbinafine Tablet
Tev-Tropin SL
Tilade SL
Tolmetin
Travatan SL
Travatan Z SL
Tricor 48, 145mg
Triglide
Trusopt
Twinject SL
Urso
Urso Forte
Vagifem
Valtrex SL
Vesicare
Vivelle SL
Vivelle-Dot SL
Vytorin SL
Vyvanse SL
Welchol
Yaz
Zegerid SL
Zomig Nasal Spray SL
Zovirax Ointment, Cream
Zyprexa (Zydis = Tier 3) SL
Some medications are noted with SL or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
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.
2009 Four-Tier Prescription Drug List Reference Guide Your Higher-Cost Option
Famvir SL
(Tier Three)
Celebrex SL
Fentora SL
Abilify SL
Accolate SL
Cesamet SL
Accu-Chek Test Strips SL, DS
Chemstrip BG Test Strips SL, DS
Cialis SL
Flovent HFA SL
Focalin SL
Focalin XR SL
Fosamax Plus D SL
Acular SL
Glucometer Test Strips SL, DS
Advair Diskus SL
Clarinex SL
Advair HFA SL
Clarinex-D SL
Climara Pro SL
Clindagel SL
Clobetasol Propionate Foam SL
Allegra ODT SL
Combipatch SL
Humira SL
Allegra Suspension SL
Combivent SL
Allegra-D SL
Concerta SL
Imitrex Nasal Spray SL
Cosopt SL
Imitrex Tablet SL
Ambien CR SL
Amerge SL
Invega SL
Amlodipine and Benazepril SL
Cymbalta SL
Kadian SL
Anzemet SL
Daytrana SL
Kineret SL
Kytril Tablet SL
Ascensia Autodisc SL, DS
Lamisil Tablet SL
Ascensia Elite SL, DS
Atacand SL
Lescol SL
Atacand HCT SL
Lescol XL SL
Differin SL
Avalide SL
Diovan SL
Levitra SL
Avapro SL
Diovan HCT SL
Dosepack, 3 Month SL
Avinza SL
Avodart SL
Lexapro SL
Azmacort SL
Bactroban SL
Duragesic SL
Beconase AQ SL
Elidel SL
Enbrel SL
Epipen SL
Epipen Jr. SL
Lotrel SL
Exforge SL
Lunesta SL
Famciclovir SL
Lyrica SL
Some medications are noted with SL or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
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.
2009 Four-Tier Prescription Drug List Reference Guide Maxair Autohaler SL
Tracer BG Test Strips SL, DS
Metadate CD SL
Prevacid Capsule SL
Prilosec Rx 40mg SL
Pristiq SL
Uroxatral SL
ProAir HFA SL
Ventolin HFA SL
Proventil HFA SL
Provigil SL
Prozac Weekly SL
Nexium Capsule SL
Viagra SL
Nexium Suspension SL
Relenza SL
Restasis SL
Wellbutrin XL SL
Xalatan SL
Rhinocort SL
Omnicef SL
Rhinocort Aqua SL
Opana ER SL
Risperdal M-Tab SL
Ritalin LA SL
Zaleplon SL
Ortho Evra SL
Zelnorm SL
Rozerem SL
Seasonale SL
Zyflo CR SL
Serevent Diskus SL
Seroquel XR SL
Pantoprazole SL
Sonata SL
Starlix SL
24 Hour SL
Strattera SL
Symlin SL
Paxil CR SL
Tamiflu SL
Tekturna SL
• Compounded prescriptions are
Perforomist SL
Tier Three
Pexeva SL
• Insulin pens & cartridges are Tier
Teveten SL
Three except for Novolin and
Novolog pens and cartridges
which are Tier Two.
Some medications are noted with SL or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
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.
2009 Four-Tier Prescription Drug List Reference Guide Your Highest-Cost Option
(Tier Four)
Accutane
Adoxa
Bravelle
Caduet SL
Coreg CR SL
Doryx
Follistim
Follistim AQ
Genotropin SL
Humatrope SL
Infergen SL
Intron A SL
Menopur
Norditropin SL
Omnitrope SL
Prevacid Solutab SL
Rebif SL
Repronex
Testim SL
Treximet SL
Veramyst SL
Some medications are noted with SL or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
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.
2009 Four-Tier Prescription Drug List Reference Guide
Additional Tier Three drugs
with a generic equivalent
in Tier One
Rebetol SL (Ribavirin SL)
Flonase SL (Fluticasone Nasal Spray SL)
Remeron SolTab SL (Mirtazapine
Ambien SL (Zolpidem SL)
Dispersible Tablet SL)
Fosamax SL (Alendronate SL)
Risperdal SL (Risperidone SL)
Sporanox SL (Itraconazole SL)
Tylenol #3 SL (Acetaminophen with
Codeine SL)
Ultracet SL (Tramadol with
Acetaminophen SL)
Combunox SL (Oxycodone with
Ibuprofen SL)
Copegus SL (Ribavirin SL)
Darvocet-N SL (Propoxyphene with
Vicodin SL, Vicodin ES SL
Acetaminophen SL)
Depo-Provera SL
Acetate 150mg/ml SL)
Percocet 5-325, 7.5-500, 10-650 SL
(Oxycodone with Acetaminophen SL)
Zofran SL (Ondansetron SL)
Dovenex Solution SL (Calcipotriene
Solution, Topical SL)
Effexor SL (Venlafaxine SL)
Some medications are noted with SL or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
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.

Source: http://www.ehealthcard.com/ehealthinsurance/benefits/ifp/GoldenRule/GoldenRule-Gen23-RX123878.pdf

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