· Several popular brand-name medications have been approved for OTC sales in recent years. Prescription strength formulas are available without a prescription for conditions such

UnitedHealth Pharmaceutical SolutionsSM Half Tablet Program

Prescription medication costs continue to increase and represent nearly

16% of total health care costs. Programs such as consumer-driven health

plans, high deductible benefit designs, and increased copayments, have

employees searching for information and ways to maximize their benefit.

An Evidence-Based Program

The UnitedHealth Pharmaceutical Solutions (UHPS) Half Tablet Program

is a simple way to help your employees save money on prescription

medications. The UHPS program targets only those medications deemed

appropriate for pill-splitting. We selected the following medications based

on established clinical criteria.

*Half Tablet Program also applies to the generic equivalents to these brands.

Therapeutic Category Medications1

ACE inhibitors Aceon, Mavik*, Univasc*

Angiotensin Receptor Blockers (ARBs) Atacand, Avapro, Benicar, Cozaar, Diovan

Anti-depressants Lexapro, Pexeva, Zoloft*

Lipid-lowering medications (statins) Crestor, Lipitor, Pravachol*, Zocor*

1 List of medications subject to changewithout notice.

Members who have been

prescribed one of the eligible

medications will receive a

letter describing the program

and instructions on how to

request a pill splitter. The

program is completely

voluntary, and members are

instructed to talk to their

physicians about whether they

are good candidates for the

Half Tablet Program.

UnitedHealthcare

Half TabletProgram

Significant Savings

The Half Tablet Program can save significant dollars for your employees and

help UHPS maximize its pharmacy benefit. The program requires that the

member's physician write a new prescription for half the quantity of tablets at a

double strength dosage, with instructions to take half of a tablet. When the

member submits the prescription at a participating pharmacy, the claim will

process according to the physician's instructions, and the member will pay up

to half of the regular copayment or coinsurance.

Members Make the Decision

The UHPS Half Tablet Program puts the member in control. The program is

completely voluntary, so members decide whether or not they participate.

Member communications reinforce that the program is voluntary and

encourage discussion with their physicians.

We provide members with the information they need to make an educated

decision about the program. In addition to information contained in the initial

member letter, they may also visit myuhc.com® for information on

prescription claim history, drug interactions and drug cost information.

For More Information

The UHPS Half Tablet Program helps make prescription medications more

affordable in a simple way. For more information on the UHPS Half Tablet

Program, contact your UnitedHealthcare representative.

The Half Tablet Program

can save significant dollars

for your employees.

100-7108 6/07 employer ©2007 United HealthCare Services, Inc.

Spend less on prescription medications. More on life.

As consumers, we often price shop to get the best value for our dollar. But you may not realize that you can also compare prices for prescription medications. There are often many medications that treat a particular illness. The medications may be equally effective, but their costs can vary greatly. Here are some tips on how to save money on prescription medications by choosing medications that offer better health value and cost less.

Know Your Pharmacy Benefit

Each prescription medication has a copay, which is the amount that you pay for that medication under your pharmacy benefit. The copay amount depends on which “tier” the medication is in on your Prescription Drug List (PDL). Medications in Tier 1 have the lowest copay, and they are your most affordable options. Medications in Tier 3 have the highest copay. Knowing which medications are in Tier 1 and Tier 2 will help you understand where you can save money.

• Go to myuhc.com® and click on “Pharmacies and Prescriptions” to price medications and make note of your lowest cost options. Ask your doctor if they are appropriate for your treatment.

• Ask your doctor or pharmacist if a less expensive alternative is available.

• Call the customer service number on your ID card and ask the representative to check for lower cost options.

Consider Pharmacies That Offer Discounts on Generics

Some retail pharmacies offer very low prices on select generic drugs—often less than your usual copay—and include commonly prescribed generic medications for several conditions such as asthma, anxiety, high blood pressure and infection (antibiotics).

• Ask your doctor if there is a generic alternative that is appropriate for your treatment.

• Refer to the list on the back to see generic medications that are often included in retail generic discount programs.

• Check with your local pharmacy to see if it offers a discount on generic medications.

• Be sure to give the pharmacist your ID card so the claim can be processed under your pharmacy benefit. You should only have to pay the pharmacy’s discounted cost.

Ask About Over-the-Counter (OTC) Alternatives

Several popular brand-name medications have been approved for OTC sales in recent years. Prescription strength formulas are available without a prescription for conditions such as allergies, heartburn and acid reflux.

• Ask your doctor or pharmacist if there is an OTC alternative available that is right for you.

• Use your Flexible Spending Account dollars on eligible products.

• Check product and manufacturer Web sites for money saving coupons.

Be sure to tell your doctor and pharmacist that saving money is important to you. They can help you identify your low cost options and help you save money.

Check with your local pharmacy to see if it offers discounts on generic medications. Not all generics are included in discount programs and medications and discount amounts may vary by pharmacy.

Listed below are some commonly prescribed generic medications that are often included in retail generic discount programs.

Retail Pharmacy Generic Discount Programs

Allergies & Cold And Flu

Benzonatate 100mg Dec-Chlorphen Promethazine DM syrup

AntibiotiC treAtments

Amoxicillin Cephalexin Ciprofloxacin Doxycycline Erythrocin Erythromycin EC Metronidazole Penicillin VK Sulfamethoxazole-Trimethoprim Tetracycline

Arthritis & PAin

Allopurinol Colchicine Cyclobenzaprine Dexamethasone Diclofenac DR Ibuprofen Meloxicam Naproxen Piroxicam 20mg

AsthmA Albuterol syrup Albuterol nebulizer solution

Cholesterol

Lovastatin Pravastatin

diAbetes Glimepiride Glipizide Glyburide Metformin Metformin ER

FungAl inFeCtions

Fluconazole Nystatin/Triamcin Nystatin

gAstrointestinAl heAlth

Dicyclomine Hyoscyamine Hyoscyamine ER 0.375 Metoclopramide Promethazine Ranitidine

heArt heAlth &

blood Pressure

Atenolol-Chlorthalidone Atenolol Benazepril Bisoprolol-HCTZ Carvedilol Clonidine Digitek Doxazosin Enalapril Furosemide Hydrochlorothiazide (HCTZ) Isosorbide Mononitrate ER Lisinopril-HCTZ Lisinopril Metoprolol Tartrate Propranolol Spironolactone Triamterene-HCTZ Verapamil Warfarin

mentAl heAlth

Amitriptyline Buspirone Citalopram Doxepin HCL Fluoxetine Paroxetine Trazodone

skin Conditions

Hydrocortisone Triamcinolone

thyroid Conditions

Levothyroxine

Viruses

Acyclovir

VitAmins &

nutritionAl heAlth

Folic Acid Klor-Con Potassium Chloride

Women’s heAlth

Estradiol Medroxyprogesterone Acetate

other mediCAl

Conditions

Prednisone

100-8637 4/08© 2008 United HealthCare Services, Inc.

Prescription Drug List 2008 Consumer Reference Guide

creo

1

2008 Four-Tier Prescription Drug List Reference Guide

Your UnitedHealthcare pharmacy benefi t offers fl exibility

and choice in fi nding the right medication for you.

This guide will:

1. Help you understand your medication choices and make informed decisions.

2. Help you understand which questions to ask your doctor or pharmacist.

What is a Prescription Drug List (PDL)?

A PDL is a list of Food and Drug Administration (FDA)-approved brand name and generic medications.

Your UnitedHealthcare pharmacy benefi t provides coverage for a comprehensive selection of prescription medications. Below you will fi nd some commonly prescribed medications for certain conditions. You and your doctor may refer to this list to select the right medication to meet your needs.

The benefi t plan documents provided by your employer or health plan include a Summary Plan Description (SPD) or a Certifi cate of Coverage (COC). Please refer to these documents to determine which medications are covered under your individual plan.

If you have pharmacy benefi t coverage with UnitedHealthcare, you may learn more about your benefi t 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 benefi t 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.

2

Understanding Tiers

Prescription medications are categorized within four tiers. Each tier is assigned a copayment, the amount you pay when you fi ll a prescription, which is determined by your employer or health plan. Consult your benefi t plan documents to fi nd out the specifi c copayments, coinsurance and deductibles that are part of your plan. You and your doctor decide which medication is appropriate for you.

Tier 1 – Your Lowest-Cost Option

This is your lowest copayment option. For the lowest out-of-pocket expense, you should always consider Tier 1 medications if you and your doctor decide they are right for your treatment.

Tier 2 and Tier 3 – Your Midrange-Cost Options

Consider Tier 2 medications if you and your doctor decide that a Tier 2 medication is right for you.

If you are currently taking a medication in Tier 3, ask your doctor whether there are Tier 1 or Tier 2 alternatives that may be right for your treatment. Sometimes there are alternatives available in Tier 1 or Tier 2 that may be appropriate to treat your condition.

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.

Compounded medications, medications with one or more ingredients that are prepared “on-site” by a pharmacist, are classifi ed at the Tier 3 level. However, if any one of the ingredients in the compound is classifi ed as being on Tier 4 then a Tier 4 copayment will apply.Please note: Some plans have a two-tier pharmacy benefi t rather than a four-tier pharmacy benefi t. Generally, a two-tier closed pharmacy benefi t plan does not cover medications classifi ed in Tier 3 and Tier 4 of this PDL. A two-tier open pharmacy benefi t plan covers one tier at the lower copayment and covers a second tier at a higher copayment.

In addition, some plans have a three-tier prescription plan. Refer to your enrollment materials, check the Drug Pricing / Coverage information on www.myuhc.com, or call the Customer Care number on your ID card for more information about your benefi t plan.


3

Who decides which medications get placed in which tier?

The UnitedHealthcare PDL Management Committee makes tier placement decisions to help ensure access to a wide range of medications and control health care costs for you and your employer or health plan. The PDL Management Committee is comprised of senior level physicians and business leaders. You and your doctor decide which medication is appropriate for you.

What factors does the PDL Management Committee look

at to make tier placement decisions?

The PDL Management Committee decides the tier placement of a particular prescription medication based upon clinical information from the UnitedHealthcare Pharmacy and Therapeutics (P&T) Committee and economic and fi nancial considerations. The Committee looks at the overall health care value of a particular medication in order to balance the need for fl exibility and choice for our members and an affordable pharmacy benefi t for employer groups and health plans.

How often will prescription medications change tiers?

Medications may move to a higher tier up to three times per calendar year, depending on your benefi t. Additionally, when a brand name medication becomes available as a generic, the tier status of the brand name medication and its corresponding generic will be evaluated. When a medication changes tiers, you may be required to pay more or less for that medication. These changes may occur without prior notice to you. For the most current information on your pharmacy coverage, please call the Customer Care number on your ID card or visit www.myuhc.com.


4

What is the difference between brand name and generic

medications?

Generic medications contain the same active ingredients as brand name medications, but they often cost less. Generic medications become available after the patent on the brand name medication expires. At that time, other companies are permitted to manufacture an FDA-approved, chemically equivalent medication. Many companies that make brand name medications also produce and market generic medications.

The next time your doctor gives you a prescription for a brand name medication, ask if a generic equivalent is available and if it might be appropriate for you. While there are exceptions, generic medications are usually your 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 available under your pharmacy benefi t plan. Go to myuhc.com to determine the copayment for your generic medication.

Why is the medication that I am currently taking no

longer covered?

Medications may be excluded from coverage under your pharmacy benefi t. For example, a prescription medication may be excluded from coverage when it is therapeutically equivalent to an over-the-counter medication. Medications on the PDL and other over-the-counter medications may be available.


5

When should I consider discussing over-the-counter or

non-prescription medications with my doctor?

An over-the-counter medication can be an appropriate treatment for many conditions. Consult your doctor about over-the-counter alternatives to treat your condition. These medications are not covered under your pharmacy benefi t, but they may cost less than your out-of-pocket expense for prescription medications.

Why are there notations next to certain medications in

the PDL, and what do they mean?

The specifi c defi nitions for these notations (QLL, QD, N, etc.) are listed at the bottom of each page of the PDL and refer to our pharmacy programs. These programs can help:

• Confi rm coverage based on your benefi t plan

• Alert pharmacists and doctors of potentially harmful medication interactions

• Notify your pharmacist and doctor of duplication in treatments

Please call Customer Care if you need additional information about these notations.


6

What should I do if I use a self-administered injectable

medication?

You may have coverage for self-administered injectable medications through your pharmacy benefi t plan. UnitedHealthcare has developed a specialty pharmacy network for these 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 medication prescription.

How do I access updated information about my

pharmacy benefi t?

Since the PDL may change periodically, we encourage you to visit www.myuhc.com or call the Customer Care number on your ID card for more current information.

Log on to myuhc.com for the following pharmacy resources and tools:

• Pharmacy benefi t and coverage information

• Specifi c copayment amounts for prescription medications

• Possible lower-cost medication alternatives

• A list of medications based on a specifi c medical condition

• Medication interactions and side effects, etc.

• Locate a participating retail pharmacy by zip code

• Review your prescription history

And, if mail order is included in your pharmacy benefi t, you can also:

• Refi ll prescriptions

• Check the status of your order

• Set up e-mail reminders for refi lls

• Manage your account


7

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 benefi t coverage with UnitedHealthcare, you may learn more about your benefi t 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 benefi t 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 benefi t coverage.Where differences are noted between this PDL reference guide and your benefi t plan documents, the benefi t plan docu-ments will govern.

8

Tier 1

Prescription Drug List - 2008 Consumer Reference Guide

Acetaminophen with Codeine QL/QD

Acetaminophen with Hydrocodone QL/QD

Acyclovir Tablet, Capsule, SuspensionAllopurinolAlprazolamAlprazolam Extended ReleaseAmitriptylineAmlodipine BesylateAmoxicillinAmoxicillin with Potassium ClavulanateAmphetamine with Dextroamphetamine

Salt CombinationAmpicillinAsmanex QL

AtenololAtenolol with ChlorthalidoneAzithromycinBisoprolol with HydrochlorothiazideBupropion QL

Bupropion Sustained Action QL, N

BuspironeButalbital with Acetaminophen & CaffeineCaptoprilCarbamazepineCarisoprodolCarvedilolCefaclorCefadroxilCefuroximeCephalexinChlorhexidine CilostazolCiprofl oxacinCitalopram QL

Clarithromycin TabletClindamycin CapsuleClindamycin Gel, Solution, Lotion, SwabsClindamycin Vaginal CreamClobetasol ClonazepamClonidineClotrimazole with BetamethasoneColestipolCromolynCyclessaCyclobenzaprine

Desmopressin DesogenDiazepam Diclofenac DicyclomineDigoxinDiltiazem Controlled Release CapsuleDiltiazem Sustained Release 12 Hour

CapsuleDiltiazem TabletDoxazosinDoxepinDoxycycline EnalaprilEnalapril with HydrochlorothiazideErythromycinEstradiol Patch QL

Estropipate Etidronate DisodiumEtodolacFelodipineFenofi brateFluconazole 50, 100, 200mg N Fluconazole 150mg QL Flunisolide Nasal Spray QL

FluocinonideFluoxetine QL

FlurazepamFluticasone Nasal Spray QL

Folic AcidForadil QL

FosinoprilFrova QL

FurosemideGabapentin Capsule, TabletGemfi brozilGentamicin GlimepirideGlipizideGlipizide Extended ReleaseGlyburideHydrochlorothiazideHydroxychloroquineHydroxyzineIbuprofen - Prescription strengths onlyIbuprofen with HydrocodoneImipramine

Tier 1

Some medications are noted with N, QD, QL, or DS. The defi nitions for these symbols are listed below. Your benefi t plan determines how these medications may be covered for you. N = Notifi cation. There are a few medications that your doctor must notify us of to make sure their use is covered within your benefi t.QD = Quantity Duration. Some medications have a limited amount that can be covered for a specifi c 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 benefi t plan.

9

Tier 1


IndapamideIndomethacinIsosorbide IsradipineKetoconazoleLefl unomide QL

LevothyroxineLevoxylLisinoprilLisinopril with HydrochlorothiazideLithium Carbonate Lo/OvralLorazepamLovastatin QL/QD

Maxalt QL

Maxalt MLT QL

Medroxyprogesterone 150mg/ml QL

Medroxyprogesterone TabletMeloxicam QL

MetforminMetformin Extended ReleaseMethocarbamolMethotrexateMethylphenidateMethylphenidate Extended ReleaseMethylprednisoloneMetoclopramideMetoprololMetoprolol Succinate Sustained Release

25mgMetronidazole Metronidazole CreamMirtazapine QL

Mirtazapine Dispersible Tablet QL

NadololNaproxen - Prescription strengths onlyNeomycin/Polymyxin/HydrocortisoneNifedipineNifedipine Controlled Release TabletNifedipine Extended ReleaseNortriptylineNovolin VialsNovolog VialsNystatinNystatin with TriamcinoloneOfl oxacin Eye DropsOfl oxacin Otic Drops

Orapred Oral SolutionOxybutyninOxycodone with Acetaminophen QL/QD

Penicillin V PotassiumPhenytoinPiroxicamPolymyxin B with TrimethoprimPotassium ChloridePotassium CitratePrazosinPrednisonePrimidonePromethazinePromethazine with CodeinePropoxyphene with Acetaminophen QL/QD

Propranolol TabletPulmicort Flexhaler QL

Pulmicort Turbuhaler QL

QVAR QL

Ranitidine SyrupRelpax QL

Sertraline QL

Simvastatin QL/QD

SpironolactoneSulfamethoxazole with TrimethoprimSulindacTamoxifenTemazepamTerazosinTerconazole Suppository QL

TetracyclineTheophyllineTramadol QL

Tramadol with Acetaminophen QL

TrazodoneTriamcinolone Triamterene with HydrochlorothiazideTriazolamTrimipramine MaleateVenlafaxine QL

VerapamilWarfarinXopenex HFA QL

Zomig QL

Zomig ZMT QL

Zonisamide

Tier 1 continued


10

Tier 2


AceonAciphex QL/QD

ActivellaActonel 5, 35mg QL

Actonel with Calcium QL

Actoplus Met QL

Actos QL

Adderall XR QL

AdvicorAlesseAlphagan P QL

AltaceAltoprev QL/QD

AntaraAsacolAstelin QL

Avandamet QL

Avandaryl QL

Avandia QL

Axid Oral SolutionBenicar QL/QD

Benicar HCT QL/QD

Biaxin XLBiDilBoniva QL

Butorphanol Nasal Spray QL

Byetta QL

CabergolineCardizem LACefdinir QL

CefprozilCenestinClarithromycin SuspensionClimara QL

ClindesseCoregCoumadinCozaar QL/QD

Crestor QL/QD

DepakoteDepakote ERDilantinDiltiazem Sustained Action CapsuleDiltiazem Sustained Release 24 Hour

CapsuleDiovan QL/QD

Diovan HCT QL/QD

Duetact QL

Effexor XR QL

Emend QL, N

Enablex QL

EnjuviaEsclim QL

Estraderm QL

EstratestEstratest H.S.Estring QL

EvistaFentanyl Citrate Lollipop QL/QD, N

Fentanyl Transdermal System QL/QD

Fexofenadine QL/QD

Fortical QL

Fosamax QL

Fosamax Plus D QL

Fosinopril with HydrochlorothiazideGeodonGlipizide with MetforminGlyburide with MetforminGlycopyrrolateHyzaar QL/QD

Imitrex Injection QL

IsotretinoinJanumet QL

Januvia QL

Kytril QL, N

Lamisil Tablet QL, N

LanoxinLantus VialsLeuprolideLevaquinLevemir VialsLidoderm QL/QD

Lipitor QL/QD

Lofi bra TabletLumigan QL

Mesalamine EnemaMetoprolol Succinate Sustained Release

50, 100, 200mgMetronidazole Vaginal GelMicardis QL/QD

Micardis HCT QL/QD

MinocyclineMoexiprilNabumetone

Tier 2


creo

11

Tier 2


Nasonex QL

NiaspanOmeprazole QL/QD

Ondansetron QL, N

OrphenadrineOrphenadrine CompoundOrtho-PrefestOxandroloneOxcarbazepineOxycontin QL/QD

OxytrolParoxetine QL

PlavixPravastatin QL/QD

PrecarePremarinPremphasePremproPrevacid Solutab QL/QD

PrometriumProtonix QL/QD

Protopic NPulmicort Respules QL

QuinaprilQuinapril with HydrochlorothiazideRanexa QL

Risperdal (M-Tab = Tier 3)SeroquelSingulair QL

Spiriva QL

SularSymbyaxSynthroidTegretolTegretol XRTerbinafi ne Tablet QL, N

Tilade QL

TolmetinTravatan QL

Travatan Z QL

Tricor TabletTriglideTriphasilTwinject QL

Valtrex QL

Vesicare QL

Vivelle QL

Vivelle Dot QL

Vytorin QL

YasminYazZantac SyrupZegerid QL/QD

Zolpidem QL/QD

Zomig Nasal Spray QL

ZyletZyprexa (Zydis = Tier 3)Zyrtec QL/QD

Zyrtec-D QL/QD

Tier 2 continued


creo

12

Tier 3

Tier 3


AbilifyAccolate QL

AccuprilAccureticActiq QL/QD, N

Actonel 75mg QL

Advair Diskus QL

Advair HFA QL

Allegra QL/QD Allegra-D QL/QD, Excluded

Ambien QL/QD

Ambien CR QL/QD

Amerge QL

Amlodipine and Benazepril QL

ApriArmour ThyroidAtacand QL/QD

Augmentin XRAvapro QL/QD

AveloxAxert QL

Azmacort QL

Beconase AQ QL

Biaxin SuspensionBupropion Sustained Release 24 Hour

300mg QL, N

Catapres-TTS QL

CefzilCelebrex QL/QD

CesiaCialis QD

Ciclopirox Solution, Topical QL

Cipro XRCiprofl oxacin Tablet, Sustained Release,

24 HourClarinex QL/QD, Excluded

Clarinex-D QL/QD, Excluded

Climara Pro QL

Combipatch QL

Combivent QL

Concerta QL

Cosopt QL

CryselleCymbalta QL

Daytrana QL

Detrol LA QL

Differin QL, N

Ditropan XL QL

Duragesic QL/QD

Elidel NEpipen QL

Epipen Jr. QL

Estrostep FEFactiveFamciclovir QL

Famvir QL

FemHRTFinasteride NFlomaxFlovent HFA QL

Focalin QL

Focalin XR QL

GlucovanceGlumetzaHumalog Humulin Imitrex Nasal Spray QL

Imitrex Tablet QL

Inderal LAKetekLamictalLamisil Tablet QL, N

Lantus SoloStarLescol QL/QD

Levemir PenLevitra QD

Levonorgestrel-Ethinyl Estradiol Tablet, Dosepack, 3 Month QL

LevothroidLexapro QL

LialdaLoestrinLoestrin FELotensinLotrel QL

Lovaza QL

Low-OgestrelLunesta QL/QD

Lyrica QL/QD

Metadate CD QL

Some medications are noted with N, QD, QL, or DS. The defi nitions for these symbols are listed below. Your benefi t plan determines how these medications may be covered for you. N = Notifi cation. There are a few medications that your doctor must notify us of to make sure their use is covered within your benefi t.QD = Quantity Duration. Some medications have a limited amount that can be covered for a specifi c 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 benefi t plan.Excluded = Many benefi t plans exclude coverage of medications that are classifi ed by the Pharmacy and Therapeutics Committee as therapeutically equivalent to over-the-counter medications. Check your benefi t plan documents for coverage information or call the Customer Care number on your ID card for more information.

13

Tier 3

Tier 3 continued


MetaglipMircetteModiconMonopril HCTNasacort AQ QL

Nexium QL/QD, Excluded

NordetteOmnicef QL

Orapred ODTOrtho Evra QL

Ortho Tri-CyclenOrtho Tri-Cyclen LoOrtho-CeptOrtho-CyclenOrtho-NovumOscionOxybutynin Sustained Release QL

Paxil QL

Paxil CR QL

Pravachol QL/QD

Prevacid Capsule QL/QD, Excluded

ProAir HFA QL

Propranolol Sustained Action CapsuleProventil HFA QL

ReclipsenRelafenRestoril 7.5, 22.5mgRhinocort AQ QL

Ritalin LA QL

Rozerem QL/QD

Sanctura QL

Serevent Diskus QL

SkelaxinSoliaSonata QL/QD

Strattera QL

Symlin QL

TequinTerazol QL

Terconazole Cream QL

Teveten QL/QD

TobradexTopamaxToprol XL 50, 100, 200mgTrandolapril

TriazTrileptalUnivascUroxatral QL

VantinVelivetVentolin HFA QL

Verapamil Capsule, 24 Hour Sustained Release Pellets

Verelan PMViagra QD

Wellbutrin XL QL, N

Xalatan QL

Xopenex SolutionXyzal QL/QD

Zetia QL/QD

Zmax QL

Zofran QL, N

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 defi nitions for these symbols are listed below. Your benefi t plan determines how these medications may be covered for you. N = Notifi cation. There are a few medications that your doctor must notify us of to make sure their use is covered within your benefi t.QD = Quantity Duration. Some medications have a limited amount that can be covered for a specifi c 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 benefi t plan.Excluded = Many benefi t plans exclude coverage of medications that are classifi ed by the Pharmacy and Therapeutics Committee as therapeutically equivalent to over-the-counter medications. Check your benefi t plan documents for coverage information or call the Customer Care number on your ID card for more information.

creo

14

Tier 3

Adderall (Amphetamine with Dextroamphetamine Salt Combination)

Aldactone (Spironolactone)Amaryl (Glimepiride)Anaprox (Naproxen)Ativan (Lorazepam)Augmentin ES (Amoxicillin with Potassium

Clavulanate)Biaxin Tablet (Clarithromycin Tablet)Buspar (Buspirone)Calan, Calan SR (Verapamil)Capoten (Captopril)Cardizem CD except for 360mg strength

(Diltiazem Sustained Release 24 Hour Capsule)

Cardura (Doxazosin)Ceftin (Cefuroxime)Celexa QL (Citalopram QL)Ciloxan Eye Drops (Ciprofl oxacin)Cipro (Ciprofl oxacin)Cleocin T (Clindamycin Gel, Lotion,

Solution, Swabs)Colestid (Colestipol)Coreg (Carvedilol)Darvocet-N QL/QD (Propoxyphene with

Acetaminophen QL/QD)DDAVP (Desmopressin)Depo-Provera QL (Medroxyprogesterone

Acetate 150mg/ml QL)DiaBeta, Micronase, Glynase (Glyburide)Didronel (Etidronate Disodium)Difl ucan 50, 100, 200mg Tablet N

(Fluconazole N) Difl ucan 150mg QL (Fluconazole QL) Duricef (Cefadroxil)Dyazide (Triamterene with

Hydrochlorothiazide)Dynacirc (Isradipine)Effexor QL (Venlafaxine QL)Eskalith CR (Lithium Carbonate

Controlled Release)Fioricet (Butalbital with Acetaminophen

and Caffeine)Flonase QL (Fluticasone Nasal Spray QL)Floxin Otic (Ofl oxacin Otic Drops)Glucophage, XR (Metformin)Glucotrol, XL (Glipizide)

Hytrin (Terazosin)Inderal (Propranolol)Kefl ex (Cephalexin)Klonopin (Clonazepam)Lasix (Furosemide)Lopid (Gemfi brozil)Lopressor (Metoprolol)Medrol Dosepak (Methylprednisolone)Mevacor QL/QD (Lovastatin QL/QD)

Mobic QL (Meloxicam QL)Monopril (Fosinopril)Motrin (Ibuprofen) - Prescription strengths

onlyNaprosyn (Naproxen) - Prescription

strengths onlyNasarel QL, Nasalide QL (Flunisolide

Nasal Spray QL)Neurontin Capsule, Tablet (Gabapentin)Norvasc (Amlodipine Besylate)Ocufl ox Eye Drops (Ofl oxacin)Percocet 5-325, 7.5-500, 10-650

QL/QD (Oxycodone with Acetaminophen QL/QD)

Plendil (Felodipine)Pletal (Cilostazol)Prinivil, Zestril (Lisinopril)Prinzide, Zestoretic (Lisinopril with

Hydrochlorothiazide)Procardia XL (Nifedipine Extended

Release)Provera (Medroxyprogesterone)Prozac QL (Fluoxetine QL)Remeron QL (Mirtazapine QL)Remeron SolTab QL (Mirtazapine

Dispersible Tablet QL)Restoril 15, 30mg (Temazepam)Ritalin (Methylphenidate)Ritalin SR (Methylphenidate Extended

Release)Surmontil (Trimipramine Maleate)Tenormin (Atenolol)Tenoretic (Atenolol with Chlorthalidone)Tiazac (Diltiazem)Toprol XL 25mg (Metoprolol Succinate

Sustained Release)Tylenol #3 QL/QD (Acetaminophen with

Codeine QL/QD)


Additional Tier Three drugs with a generic alternative in Tier One


creo

15

Additional Tier Three drugs with a generic alternative in Tier One

Tier 3


Ultracet QL (Tramadol with Acetaminophen QL)

Ultram QL (Tramadol QL)Valium (Diazepam)Vaseretic (Enalapril with

Hydrochlorothiazide)Vasotec (Enalapril)Vicodin QL/QD, Vicodin ES QL/QD

(Acetaminophen with Hydrocodone QL/QD)

Vicoprofen (Ibuprofen with Hydrocodone)Voltaren Tablet (Diclofenac)Wellbutrin QL (Bupropion QL)Wellbutrin SR QL, N (Bupropion

Sustained Action QL, N)Xanax, Xanax XR (Alprazolam)Zantac Syrup (Ranitidine Syrup)Ziac (Bisoprolol with Hydrochlorothiazide)Zithromax (Azithromycin)Zocor QL/QD (Simvastatin QL/QD)Zoloft QL (Sertraline QL)Zonegran (Zonisamide)Zovirax Capsule, Tablet, Suspension

(Acyclovir)


16

Tier 4


Tier Four

AccutaneAmbien CR ql/qdBravelleFollistimFollistim AQGenotropin qD, NGeref qD, NInfergen ql, NIntron A QL, NMenopurRebif qlRepronexSaizen qD, NSotret 30mg Capsule

myuhc.com®

Medication Costs and Comparisons

creo

© 2008 Medco Health Solutions, Inc. / UnitedHealthCare Services, Inc. All rights reserved. 100-8107 DL922616 1/08Advantage Consumer PDL F300

www.myuhc.com

Documents

· Several popular brand-name medications have been approved for OTC sales in recent years. Prescription strength formulas are available without a prescription for conditions such