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Golden rule 3-tier t1000_3

2007 Prescription Drug List Reference Guide IMPORTANT NOTICE – PLEASE READ
This reference guide will help you understand
CAREFULLY
these choices. It will also enable you to ask
your doctor or pharmacist the right questions
Your Prescription Drug List (formerly known
regarding your medication needs. Our goal is
as Preferred Drug List) has changed. Please
to provide information that will help you make
note that prescription medications on this
informed decisions regarding medications for
new list may be in different tiers than those
you and your family.
on your old list, which may impact the
amount you pay for the medication.
Below you will find some common questions We suggest that you print the most current
pharmacy benefit. For additional information, Prescription Drug List from our Customers link
at www.goldenrule.com and bring it with you
to your doctor appointments. Ask your doctor
Services number on the back of your ID card.
to refer to the Prescription Drug List when
prescribing medications. It is a tool that helps
What is a Prescription Drug List?
guide you and your doctor in choosing
A Prescription Drug List (PDL) is a list of Food medications that allow the most effective and
and Drug Administration (FDA)-approved brand- affordable use of your pharmacy benefit.
Your pharmacy benefit offers you flexibility
Your pharmacy benefit is designed to provide and choice in the prescription medications
available to you. Understanding your
selection of prescription medications. This PDL Prescription Drug List will help you make
lists the most commonly prescribed medications more informed decisions about prescription
for certain conditions. You can find the most medications.
current PDL at www.goldenrule.com (click on Customers). You and your doctor may refer to this list to consider prescription medication choices and select the appropriate medication to Keep in mind that your policy/certificate defines coverage for certain medications listed in the What are tier designations and how do
Please note: Some plans have a two-tier
they affect what I actually pay at the
pharmacy benefit, with a copayment for generic pharmacy?
medications and a higher copayment for brand Prescription medications are categorized within medications. The brand copayment applies for three tiers, which determines the amount you medications in Tiers 2 and 3, however using Tier pay when you fill a prescription at a participating 2 medications is a more cost effective option.
retail pharmacy. Your health plan sets the actual benefit amounts for the medications covered Some plans have a three-tier pharmacy benefit.
under your pharmacy benefit. Consult your In your policy/certificate, Tier 1 is referred to as policy/certificate for more specific information “generics;” Tier 2 is referred to as “preferred brands;” and Tier 3 is referred to as “non- deductibles that may apply to your pharmacy Who decides which medications get
Your Lowest-Cost Option
placed in which tier?
Generic Medications
Committee makes tier placement decisions to Tier 1 is your lowest cost option. For the lowest
medications and control health care costs for consider Tier 1 medications if you and your you and your health plan. You and your doctor doctor decide they are appropriate for your decide which medication is appropriate for you.
How often will prescription medications
Midrange-Cost Option
change tiers?
Brand Medications
While medications change tiers infrequently, such changes may occur up to six times per Tier 2 is your middle cost option. Consider Tier 2
calendar year, depending on your benefit.
medications if you and your doctor decide that a Additionally, when a brand-name medication Tier 2 medication is the most appropriate to treat becomes available as a generic, the tier status of corresponding generic will be evaluated. When Your Highest-Cost Option
a medication changes tiers, you may be required Brand Medications
to pay more or less for that medication. These changes may occur without prior notice to you.
Tier 3 is your highest cost option. Sometimes
However, you may visit our Customers link at there are alternatives available in Tier 1 or Tier 2.
If you are currently taking a medication in Tier 3, Services number on the back of your ID card for ask your doctor whether there are Tier 1 or Tier 2 information about a particular medication.
alternatives that may be appropriate for your medications containing one or more ingredients that are prepared “on-site” by a pharmacist, are classified at the Tier 3 level, provided that the individual ingredients used in compounding are 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. You will find these medications become available after the patent on the brand- included in the body of this document within the name medication expires. At that time, other list of medications. UnitedHealthcare has network that is part of our Specialty Pharmacy Before a generic medication can be sold, the includes specialty pharmacies, each selected FDA must be satisfied that the medication based on their clinical expertise for the targeted contains the same active ingredients in the same therapeutic classes, quality of services and cost.
strength as the brand-name equivalent. It must Their pharmacists are trained to help educate also meet the same quality standards. Many members and create personalized plans, if companies that make brand-name medications needed, for these specialty medications, which also produce and market generic medications that are equivalent to the branded products.
Please call our toll-free Specialty Pharmacy prescription for a brand-name medication, ask if representative will answer questions about our a generic equivalent is available and if it might program and then transfer you to a specialty pharmacy based on your particular specialty exceptions, generic medications are usually your lowest cost option. You and your health plan may save money if you and your doctor decide How do I access updated information
the generic medication is right for you.
about my pharmacy benefit?
Since the PDL may change periodically, we
Why are there “notations” next to certain
encourage you to visit our Customers link at medications in the PDL, and what do they
Certain medications in the PDL have a notation, such as N (for “notification”), QL (for “quantity Once there, you can also compare costs of limitations”), QD (for “quantity duration”), and medications to identify cost-saving opportunities DS (for “diabetic supplies”). The specific and contact a registered pharmacist seven days definitions for these notations are listed at the bottom of each page of the PDL. Please call What if I still have questions?
If you have additional questions about your
Services number on the back of your ID card.
Representatives are available to assist you 24 Key points to remember
Your doctor may be able to help you save
money by prescribing medications in Tier 1 and Tier 2 of the PDL. You and your doctor always make the decisions regarding your treatment.
Here are some practical suggestions for getting • Bring the PDL to your doctor appointments and prescribing medications. It is a tool that helps medications that allow the most effective and affordable use of your pharmacy benefit.
• To view the most current version of the PDL and information about your specific benefit plan, please visit our Customer Service Center at • If you have questions about your pharmacy benefit, please call the Member Services phone number on your ID card. Representatives are available to assist you 24 hours a day, except 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.
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 in descriptive terms do not affect your benefit coverage.
2007 Prescription Drug List Reference Guide Bupropion QL
Bupropion Sustained Action QL, N
Acetaminophen with Codeine QL/QD
300mg QL, N
and Butalbital QL/QD
Butorphanol Nasal Spray QL
Estradiol Patch QL
Citalopram QL
Fast Take Test Strips QL, DS
Asmanex QL
Fentanyl Citrate Lollipop QL/QD, N
Fentanyl Transdermal System QL/QD
Fexofenadine QL/QD
Finasteride N
Fluconazole 50, 100, 200mg N
Fluconazole 150mg QL
Fluoxetine QL
Fluticasone Nasal Spray QL
Fluvoxamine QL
Foradil QL
Fortical 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.
E = 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.
2007 Prescription Drug List Reference Guide Freestyle Test Strips QL, DS
Nefazodone QL
Lovastatin QL/QD
Maxalt QL
Maxalt MLT QL
Medroxyprogesterone 150mg/ml QL
Mefloquine QL
Meloxicam QL
Omeprazole QL/QD
Ondansetron QL, N
One Touch Test Strips QL, DS
One Touch Ultra Test Strips QL, DS
Oxybutynin Sustained Release QL
Oxycodone with Acetaminophen QL/QD
Paroxetine QL
Itraconazole QL, N
Mirtazapine QL
Mirtazapine Dispersible Tablet QL
Leflunomide QL
Dosepack, 3 Month QL
Release 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.
E = 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.
2007 Prescription Drug List Reference Guide Pravastatin QL/QD
Precision Q-I-D Test Strips QL, DS
Precision Xtra Test Strips QL, DS
Terconazole Cream QL
Terconazole Suppository QL
Tramadol QL
Tramadol with Acetaminophen QL
Tretinoin N
Pulmicort Flexhaler QL
Pulmicort Turbuhaler QL
Venlafaxine QL
Relpax QL
Ribavirin QL, N
Xopenex HFA QL
Zomig ZMT QL
Sertraline QL
Simvastatin QL/QD
Sodium FluorideSoliaSotalolSpironolactone with Spironolactone
Sprintec
Sucralfate
Sulfacetamide
Sulfacetamide with Sulfur
Sulfamethoxazole with Trimethoprim
Sulfasalazine
Sulfasalazine EC
Sulfatrim
Sulindac
Surestep Test Strips QL, DS
Tamoxifen
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.
E = 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.
2007 Prescription Drug List Reference Guide Copaxone QL
Aciphex QL/QD
Micardis QL/QD
Actonel QL
Micardis HCT QL/QD
Actonel with Calcium QL
Cozaar QL/QD
Actoplus Met QL
Crestor QL/QD
Nasonex QL
Adderall XR QL
Advair Diskus QL
Norditropin QD, N
Advair HFA QL
Differin N
Diovan QL/QD
Diovan HCT QL/QD
Nutropin QD, N
Alphagan P QL
Effexor XR QL
Omnicef QL
Altoprev QL/QD
Enablex QL
Oxycontin QL/QD
Esclim QL
Aricept QL
Estraderm QL
Pegasys QL, N
Aricept ODT QL
Peg-Intron QL, N
Arixtra QL
Estring QL
Prandin QL
Astelin QL
Flovent HFA QL
Avandamet QL
Fosamax QL
Avandaryl QL
Fosamax Plus D QL
Prevacid Solutab QL/QD
Avandia QL
Prevpac QL
Avonex QL
Procrit QD
Azmacort QL
Benicar QL/QD
Humatrope QD, N
Protonix QL/QD
Benicar HCT QL/QD
Hyzaar QL/QD
Protopic N
Imitrex QL
Pulmicort Respules QL
Betaseron QL
Kytril QL, N
Roferon A QL, N
Boniva QL
Lamisil Tablet QL, N
Serevent Diskus QL
Serostim QD, N
Singulair QL
Spiriva QL
Lipitor QL/QD
Climara QL
Lovenox QL
Lumigan QL
Testim 1% 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.
E = 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.
2007 Prescription Drug List Reference Guide Tev-Tropin QD, N
Tilade QL
Toprol XL 50, 100, 200mg
Travatan QL
Travatan Z QL
Tricor Tablet
Triglide
Trileptal
Triphasil
Trusopt
Twinject QL
Urso
Urso Forte
Valtrex QL
Vesicare QL
Vivelle QL
Vivelle-Dot QL
Voltaren Eye Drops
Vytorin QL
Welchol
Yasmin
Zantac Syrup
Zegerid QL/QD
Zomig Nasal Spray QL
Zovirax Ointment, Cream
Zylet
Zyprexa (Zydis = Tier 3)
Zyrtec QL/QD
Zyrtec-D 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.
E = 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.
2007 Prescription Drug List Reference Guide Tier Three
Cymbalta QL
Lyrica QL/QD
Maxair Autohaler QL
Accolate QL
Accu-Chek Test Strips QL, DS
Metadate CD QL
Miacalcin Nasal Spray QL
Detrol LA QL
Allegra-D QL/QD,E
Nasacort QL
Ambien QL/QD
Nasacort AQ QL
Ambien CR QL/QD
Amerge QL
Nexium QL/QD,E
Enbrel QL/QD
Epipen QL
Ascensia Autodisc QL, DS
Epipen Jr. QL
Ascensia Elite QL, DS
Atacand QL/QD
Atacand HCT QL/QD
Famvir QL
Omacor QL
Avalide QL/QD
Ortho Evra QL
Avapro QL/QD
Avinza QL/QD
Focalin QL
Avodart QL, N
Focalin XR QL
Genotropin QD, N
Beconase AQ QL
Glucometer Test Strips QL, DS
Byetta QL
Paxil CR QL
Caduet QL
Penlac QL
Humira QL/QD
Catapres-TTS QL
Intron A QL, N
Celebrex QL/QD
Kadian QL/QD
Kineret QL/QD
Chemstrip BG Test Strips QL, DS
Cialis QD
Lescol QL/QD
Lescol XL QL/QD
Prevacid Capsule QL/QD,E
Clarinex QL/Q,E
Levitra QD
Clarinex-D QL/QD,E
ProAir HFA QL
Climara Pro QL
Lexapro QL
Proventil HFA QL
Provigil QL, N
Prozac Weekly QL
Combipatch QL
Combivent QL
Combunox QL
Relenza QL, N
Concerta QL
Restasis QL, N
Cosopt QL
Lotrel QL
Lotronex QL/QD, N
Retin-A Micro N
Lunesta QL/QD
Rhinocort QL
Rhinocort Aqua 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.
E = 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.
2007 Prescription Drug List Reference Guide Ritalin LA QL
Rosanil
Rozerem QL/QD
Sanctura QL
Sarafem QL
Skelaxin
Sonata QL/QD
Starlix QL
Strattera QL
Symlin QL
Tamiflu QL, N
Tarka
Tazorac N
Tequin
Teveten QL/QD
Theo-24
Tobradex
Topamax
Tracer BG Test Strips QL, DS
Transderm-Scop
Tri-Norinyl
Triaz
Tussionex
Uniphyl
Uniretic
Uroxatral QL
Vagifem
Vantin
Ventolin HFA QL
Verelan PM
Viagra QD
Vigamox
Visicol
Wellbutrin XL QL, N
Xalatan QL
Xopenex Solution
Zelnorm QL/QD, N
Zetia QL/QD
Zmax QL
Zymar
NOTE:
• Compounded prescriptions are

Tier Three
• Pens & cartridges are Tier Three
except for Novolin and Novolog
pens and cartridges which are
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.
E = 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.
2007 Prescription Drug List Reference Guide
Additional Tier Three drugs
with a generic alternative
Effexor QL (Venlafaxine QL)
in Tier One
Actiq QL/QD, N (Fentanyl Citrate Lollipop
Proscar N (Finasteride N)
QL/QD, N)
Prozac QL (Fluoxetine QL)
Rebetol QL, N (Ribavirin QL, N)
Flonase QL (Fluticasone Nasal
Allegra QL/QD (Fexofenadine QL/QD)
Spray QL)
Remeron QL (Mirtazapine QL)
Remeron SolTab QL (Mirtazapine
Dispersible Tablet QL)
Arava QL (Leflunomide QL)
Sporanox QL, N (Itraconazole QL, N)
Terazol QL (Terconazole QL)
Tylenol #3 QL/QD (Acetaminophen with
Codeine QL/QD)
Ultracet QL (Tramadol with
Acetaminophen QL)
Celexa QL (Citalopram QL)
Ultram QL (Tramadol QL)
Copegus QL, N (Ribavirin QL, N)
Darvocet-N QL/QD (Propoxyphene with
Acetaminophen QL/QD)
Vicodin QL/QD, Vicodin ES QL/QD
Depo-Provera QL
Mevacor QL/QD (Lovastatin QL/QD)
150mg/ml QL)
Mobic QL (Meloxicam QL)
Wellbutrin QL (Bupropion QL)
Wellbutrin SR QL, N (Bupropion
Sustained Action QL, N)
Wellbutrin XL 300mg QL, N (Bupropion
Sustained Release 24 Hour QL, N)
Tablet N (Fluconazole N)
Diflucan 150mg QL (Fluconazole QL)
Paxil QL (Paroxetine QL)
Ditropan XL QL (Oxybutynin Sustained
Percocet 5-325, 7.5-500, 10-650 QL/QD
Zocor QL/QD (Simvastatin QL/QD)
Release QL)
Zofran QL, N (Ondansetron QL, N)
Duragesic QL/QD (Fentanyl Transdermal
Zoloft QL (Sertraline QL)
System QL/QD)
Pravachol QL/QD (Pravastatin 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.
E = 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.

Source: http://www.ilhealthagents.com/Prescription%20Drug%20List.pdf

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