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2005 Prescription Drug List Consumer Reference Guide You have choices in the prescription medications you and your doctor select to treat you.
Understanding them will help you make more informed health care decisions.
Your pharmacy benefit provides you with many choices. This booklet will help you understandthose choices. It will also enable you to ask your doctor or pharmacist the right questionsregarding your medication needs. Our goal is to provide information that will help you makeinformed decisions regarding medications for you and your family.
Below you will find some common questions many plan members have asked regardingUnitedHealthcare’s pharmacy benefit. If you have additional questions, please visit us atwww.365wellst.com or call the Customer Service number on your ID card.
A Prescription Drug List (PDL) is a list of prescription medications. The PDL includes brand nameand generic medications that have been approved by the United States Food and DrugAdministration (FDA) as safe and effective. The UnitedHealthcare pharmacy benefit is designed to provide you with a comprehensive selectionof prescription medications. This booklet lists the most commonly prescribed medications forcertain conditions. You can find our complete PDL at www.365wellst.com. You and your doctormay refer to this list to consider prescription medication choices and select the appropriatemedication to meet your needs. Keep in mind that the benefit plan documents provided by your employer or health plan defineyour pharmacy coverage and may exclude coverage for certain medications listed in the condensedPDL found in this booklet. Examples of benefit plan documents may include a Summary PlanDescription or a Certificate of Coverage, and a Pharmacy Rider. If you do not have the benefit plandocuments, please contact your employer or health plan for this information. What are tier designations and how do they affect what I actually pay at the pharmacy? Prescription medications are categorized within three tiers. Each Tier is assigned a copayment,which is an amount you pay when you visit the pharmacy or order your medications through ourmail order service. Your employer or health plan sets the actual copayment amounts for themedications covered under your pharmacy benefit. Consult the benefit plan documents providedby your employer or health plan for more information about specific copayments, coinsurance, anddeductibles. Tier 1 is your lowest copayment option. For the lowest out-of-pocket expense, you should alwaysconsider Tier 1 medications if you and your doctor decide they are appropriate for your treatment. Midrange Cost Option Tier 2 is your middle copayment option. Consider Tier 2 medications if you and your doctordecide that a Tier 2 medication is the most appropriate to treat your condition. To learn more about your pharmacy benefit and to review potential Tier 1 and Tier 2 alternative medications that are covered by yourbenefit, simply visit www.365wellst.com. You may also call the Customer Service telephone number printed on your ID card forinformation about your pharmacy benefit.
Tier 3 is your highest copayment option. Sometimes there are alternatives available in Tier 1 orTier 2. If you are currently taking a medication in Tier 3, ask your doctor whether there are Tier 1 orTier 2 alternatives that may be appropriate for your treatment. Compounded medications, thosemedications containing one or more ingredients that are prepared “on-site” by a pharmacist, areclassified at the Tier 3 level, provided that the individual ingredients used in compounding arecovered under the pharmacy benefit. Please note: Some plans have a two-tier pharmacy benefit rather than a three-tier pharmacybenefit. Generally, a two-tier closed pharmacy benefit plan does not cover medications classified inTier 3 of this PDL. A two-tier open pharmacy benefit plan covers one tier at the lower copaymentand covers a second tier at a higher copayment. In addition, some plans have a four-tier prescription plan. Refer to your enrollment materials, checkthe Price A Medication section on www.365wellst.com, or call the Customer Service number onyour ID card for more information about your benefit plan.
Who decides which medications get placed in which tier? Our PDL Management Committee makes tier placement decisions.
This approach helps to ensure access to a wide range of medications and controls health care costsfor you and your employer or health plan. You and your doctor decide which medication isappropriate for you.
How often will prescription medications change tiers? The tier placement of a medication on the PDL may change. While medications change tiersinfrequently, such changes may occur up to four times per calendar year, depending on yourbenefit. Additionally, when a brand name medication becomes available as a generic, that brandname medication may move to a higher tier. When a medication changes tiers, you may berequired to pay more or less for that medication. These changes may occur without prior notice toyou. However, you may visit our Web site, www.365wellst.com, or call the Customer Servicenumber on your ID card for copayment information about a particular medication.
What is the difference between brand name and generic medications? Generic medications are medications that contain the same active ingredients as brand namemedications, but they often cost less. Generic medications become available after the patent onthe brand name medication expires. At that time, other companies are permitted to manufacture achemically equivalent medication. Many companies that make brand name medications alsoproduce and market generic medications that are equivalent to the branded products. Before a generic medication can be sold, the FDA must be satisfied that the medication containsthe same active ingredients in the same strength as the brand name equivalent. It must also meetthe same quality standards.
The next time your doctor gives you a prescription for a brand name medication, ask if a genericequivalent is available and if it might be appropriate for you. You and your employer or health planmay save money if you and your doctor decide the generic medication is right for you.
To learn more about your pharmacy benefit and to review potential Tier 1 and Tier 2 alternative medications that are covered by yourbenefit, simply visit www.365wellst.com. You may also call the Customer Service telephone number printed on your ID card forinformation about your pharmacy benefit.
“Therapeutic alternative” is a term that we use to describe two or more chemically differentmedications that may be used to treat the same medical condition. A therapeutic alternative maycost you less than the medication your doctor may prescribe. Some therapeutic alternatives mayalso be available without a prescription, i.e., “over-the-counter.” If you are interested in pursuingtherapeutic alternatives, please talk to your doctor to see if a therapeutic alternative may be rightfor you.
Why might the medication that I am used to taking no longer be covered? Periodically, medications may be excluded from coverage under your pharmacy benefit. Forexample, a prescription medication may be excluded from coverage when the FDA approves anover-the-counter (non-prescription) equivalent to the prescription medication. The prescriptionversion of the medication is excluded from coverage under your pharmacy benefit and removedfrom the PDL because your pharmacy benefit excludes coverage for over-the-counter medications. Your doctor can recommend either over-the-counter or prescription medications for your treatment.
You can purchase an over-the-counter medication at your local pharmacy without a prescription.
When should I consider “over-the-counter” or non-prescription medications? An over-the-counter medication can be an appropriate treatment for many conditions. Consultwith your doctor about over-the-counter alternatives to treat your condition. These medications arenot covered under your pharmacy benefit, but they can cost less than your out-of-pocket expensefor prescription medications.
Why are there “notations” next to certain medications in the PDL, and what do they mean? Certain medications have a notation, such as N (for “notification”), QL (for “quantity limitations”),QD (for “quantity duration”), and DS (for “diabetic supplies”), in this booklet. These notationsidentify medications that have special programs attached to them. Some may require your doctorto notify us before they are dispensed, to make sure that their use is covered within your benefit.
Others have a maximum quantity allowed for each copayment. Still others have additionalprograms that apply. The specific definitions for these notations are listed at the bottom of eachpage of the PDL. How do I access updated information about my pharmacy benefit? Since the PDL may change periodically, we encourage you to visit www.365wellst.com for the mostcurrent information. In addition to information about your pharmacy benefit, www.365wellst.com isyour online resource for a variety of health and wellness topics. The site is designed to help youmake the best health care decisions for you and your family.
With www.365wellst.com, you can view your prescription claims history, compare costs ofmedications to identify cost-saving opportunities, fill prescriptions online for mail order ofmedications you take regularly, check the status of your mail order and contact a registeredpharmacist seven days a week.
To learn more about your pharmacy benefit and to review potential Tier 1 and Tier 2 alternative medications that are covered by yourbenefit, simply visit www.365wellst.com. You may also call the Customer Service telephone number printed on your ID card forinformation about your pharmacy benefit.
How do I find information about my pharmacy benefit on www.365wellst.com? To learn more about your pharmacy benefit coverage, please visit www.365wellst.com. Registering iseasy. From there, you just need to click on Price A Medication and you will have access tocopayment, pricing, and coverage information on most prescription medications. You will also haveaccess to the following information.
• Pharmacy benefit and coverage information• Member-specific copayment amounts for prescription medications• Lower-cost medication alternatives• A list of medications based on a specific medical condition• Medication interactions, side effects, etc.
At www.365wellst.com, you will also be able to:• Locate a participating retail pharmacy by zip code• Order ongoing prescriptions by mail• Review your prescription history• Set up e-mail reminders for prescription refills If you have additional questions about your pharmacy benefit, please call the Customer Servicenumber on your ID card. Representatives are available to assist you 24 hours a day, exceptThanksgiving and Christmas.
To learn more about your pharmacy benefit and to review potential Tier 1 and Tier 2 alternative medications that are covered by yourbenefit, simply visit www.365wellst.com. You may also call the Customer Service telephone number printed on your ID card forinformation about your pharmacy benefit.
Your doctor may be able to help you save money by prescribing medications in Tier 1 and Tier 2 ofthe PDL. You and your doctor always make the decisions regarding your treatment. Here are somepractical suggestions for getting the most out of your pharmacy benefit:• Bring this PDL booklet to your doctor appointments and ask your doctor to refer to the PDL when prescribing medications. It is a tool that helps guide you and your doctor in choosing medicationsthat allow the most effective and affordable use of your pharmacy benefit.
• If you would like to view a more complete version of the PDL and information about your specific benefit plan, please visit www.365wellst.com. Once you have logged in, click on Price A Medication.
• Inquire about the availability of a cost-saving Tier 1 alternative. Some Tier 1 medications may be used to treat the same medical condition as medications classified in Tiers 2 and 3, but are lessexpensive. As a result, Tier 1 medications are available to you for the lowest out-of-pocketexpense.
• Ask your doctor or pharmacist if there is an over-the-counter medication available to treat your • Always refer to your benefit plan materials to determine your coverage for medications and copayment, coinsurance, and deductibles. Examples of benefit plan documents may include aSummary Plan Description or a Certificate of Coverage, and a Pharmacy Rider. If you do not havethe benefit plan documents, please contact your employer or health plan for this information.
Some medications listed on the PDL may not be covered under your specific benefit plan.
• If you still have questions about your pharmacy benefit, please call the Customer Service number on your ID card. Representatives are available to assist you 24 hours a day, except Thanksgivingand Christmas.
In certain documents the Prescription Drug List (PDL) was referred to as the “Preferred Drug List (PDL).” This change in descriptiveterms does not affect your benefit coverage.
Where differences are noted, the benefit plan documents will govern.
In certain documents Tier 1 was referred to as “generics;” Tier 2 was referred to as “preferred brands” or “brand name on the PDL;”and Tier 3 was referred to as “non-preferred brands,” “not on the PDL,” or “brand name not on the PDL.” These changes indescriptive terms do not affect your benefit coverage.
To learn more about your pharmacy benefit and to review potential Tier 1 and Tier 2 alternative medications that are covered by yourbenefit, simply visit www.365wellst.com. You may also call the Customer Service telephone number printed on your ID card forinformation about your pharmacy benefit.
2005 Prescription Drug List Consumer Reference Guide Albuterol Extended Release Tablet Betamethsone with Clotrimazole Some drugs are noted with N, QD, QL, or DS. The definitions for these symbols are listed below.
QD = Quantity Duration. Some drugs have a limited amount that can be covered for a specific Your benefit plan determines how these drugs may be covered for you.
N = Notification. There are a few drugs that your physician must notify us of to make sure their QL = Quantity Level. Some drugs have a limited amount that can be covered at one time.
DS = Diabetic Supplies. Diabetic supplies may be covered by your benefit plan.
2005 Prescription Drug List Consumer Reference Guide Enalapril with Hydrochlorothiazide Guaifenex PSE Some drugs are noted with N, QD, QL, or DS. The definitions for these symbols are listed below.
QD = Quantity Duration. Some drugs have a limited amount that can be covered for a specific Your benefit plan determines how these drugs may be covered for you.
N = Notification. There are a few drugs that your physician must notify us of to make sure their QL = Quantity Level. Some drugs have a limited amount that can be covered at one time.
DS = Diabetic Supplies. Diabetic supplies may be covered by your benefit plan.
2005 Prescription Drug List Consumer Reference Guide Some drugs are noted with N, QD, QL, or DS. The definitions for these symbols are listed below.
QD = Quantity Duration. Some drugs have a limited amount that can be covered for a specific Your benefit plan determines how these drugs may be covered for you.
N = Notification. There are a few drugs that your physician must notify us of to make sure their QL = Quantity Level. Some drugs have a limited amount that can be covered at one time.
DS = Diabetic Supplies. Diabetic supplies may be covered by your benefit plan.
2005 Prescription Drug List Consumer Reference Guide Bactroban Cream, Nasal Ointment Ditropan XL QL Some drugs are noted with N, QD, QL, or DS. The definitions for these symbols are listed below.
QD = Quantity Duration. Some drugs have a limited amount that can be covered for a specific Your benefit plan determines how these drugs may be covered for you.
N = Notification. There are a few drugs that your physician must notify us of to make sure their QL = Quantity Level. Some drugs have a limited amount that can be covered at one time.
DS = Diabetic Supplies. Diabetic supplies may be covered by your benefit plan.
2005 Prescription Drug List Consumer Reference Guide Some drugs are noted with N, QD, QL, or DS. The definitions for these symbols are listed below.
QD = Quantity Duration. Some drugs have a limited amount that can be covered for a specific Your benefit plan determines how these drugs may be covered for you.
N = Notification. There are a few drugs that your physician must notify us of to make sure their QL = Quantity Level. Some drugs have a limited amount that can be covered at one time.
DS = Diabetic Supplies. Diabetic supplies may be covered by your benefit plan.
2005 Prescription Drug List Consumer Reference Guide Some drugs are noted with N, QD, QL, or DS. The definitions for these symbols are listed below.
QD = Quantity Duration. Some drugs have a limited amount that can be covered for a specific Your benefit plan determines how these drugs may be covered for you.
N = Notification. There are a few drugs that your physician must notify us of to make sure their QL = Quantity Level. Some drugs have a limited amount that can be covered at one time.
DS = Diabetic Supplies. Diabetic supplies may be covered by your benefit plan.
2005 Prescription Drug List Consumer Reference Guide • Compounded prescriptions are Tier Three Some drugs are noted with N, QD, QL, or DS. The definitions for these symbols are listed below.
QD = Quantity Duration. Some drugs have a limited amount that can be covered for a specific Your benefit plan determines how these drugs may be covered for you.
N = Notification. There are a few drugs that your physician must notify us of to make sure their QL = Quantity Level. Some drugs have a limited amount that can be covered at one time.
DS = Diabetic Supplies. Diabetic supplies may be covered by your benefit plan.
2005 Prescription Drug List Consumer Reference Guide Some drugs are noted with N, QD, QL, or DS. The definitions for these symbols are listed below.
QD = Quantity Duration. Some drugs have a limited amount that can be covered for a specific Your benefit plan determines how these drugs may be covered for you.
N = Notification. There are a few drugs that your physician must notify us of to make sure their QL = Quantity Level. Some drugs have a limited amount that can be covered at one time.
DS = Diabetic Supplies. Diabetic supplies may be covered by your benefit plan.

Source: https://phpmm.org/Portals/79/WebFiles/uhc_formu2005.pdf