Connecticut Advantage 3 Tier Prescription Drug List, effective Jan. 1, 2017

135 Pages·2016·1.36 MB·English

Your 2017 Three-Tier
Prescription Drug List
effective January 1, 2017
Connecticut Advantage Three-Tier
Please read: This document contains information about commonly prescribed
medications. This Prescription Drug List (PDL) is accurate as of January 1, 2017 and is
subject to change after this date. The next anticipated update will be in July 2017. Your
estimated coverage and copay/co-insurance may vary based on the benefit plan you
choose and the effective date of the plan.
For additional information:

Call the toll-free member phone number on your health plan ID card.
Visit myuhc.com®
• Locate a participating retail pharmacy by ZIP code.
• Look up possible lower-cost medication alternatives.
• Compare medication pricing and options.
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Your Prescription Drug List
This Prescription Drug List (PDL) outlines covered medications for certain conditions and organizes
them into cost levels, also known as tiers. An important part of the PDL is giving you choices so you
and your doctor can choose the best course of treatment for you.
Go to myuhc.com® for complete drug information
Since the PDL may change, we encourage you to visit our website, myuhc.com. This website is the
best source for up-to-date information about the medications your pharmacy benefit covers, possible
lower-cost options, and cost comparisons. To view PDL information without logging on to the member
portal, visit myuhc.com and select “Pharmacy Information” under “Links and Tools.”
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At UnitedHealthcare, we want to help you better
understand your medication options.
Your pharmacy benefit offers flexibility and choice in determining the right medication
for you. To help you get the most out of your pharmacy benefit, we’ve included some of
the most commonly asked questions about the Prescription Drug List.
What is a Prescription Drug List (PDL)?
This document is a list of covered medications. Drugs are listed by common categories class. They
are placed into cost levels known as tiers. It includes both brand and generic prescription medications
approved by the U.S. Food and Drug Administration (FDA).
Please note: Where differences are noted between this PDL and your benefit plan documents, the
benefit plan documents will rule. Please look at your benefit plan documents provided by your employer
or health plan to see what medications are covered under your plan. You may also log on to myuhc.com or
call the toll-free member phone number on your health plan ID card for more information.
How do I use my Prescription Drug List?
Bring your PDL with you when you see your doctor. When choosing a medication, you and your doctor
should consult this guide. It will help you and your doctor choose the most cost-effective prescription
drugs. This guide will also help you know if a medication has special programs that apply to it.
When a Prescription Drug Product is excluded from coverage, you or your representative may request
an exception to gain access to the excluded Prescription Drug Product. To make a request, contact us in
writing or call the toll-free number on your ID card. We will notify you of our determination within
72 hours.
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What are tiers?
Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, which is
determined by your employer or health plan. This is how much you will pay when you fill a prescription.
Tier 1 medications are your lowest-cost options. If your medication is placed in Tier 2 or 3, look to see if
there is a Tier 1 option available. Discuss these options with your doctor.
Check your benefit plan documents to find out your specific pharmacy plan costs.
$ Drug Tier Includes Helpful Tips
Tier 1 Lower-cost drugs. Use Tier 1 drugs for the lowest
Lowest Cost Some brands and generics out-of-pocket costs.
are also included.
Tier 2 Preferred brands. Use Tier 2 drugs, instead of
Mid-range Cost Tier 3 to help reduce your
out-of-pocket costs.
Tier 3 Higher cost brands and Many Tier 3 drugs have
Highest Cost generics. lower-cost options in Tier 1 or 2.
Ask your doctor if they could
work for you.
Please note: Some plans may not have any tiers. If you have a high deductible plan, the tier cost levels
may apply once you hit your deductible. Refer to your enrollment and plan materials on myuhc.com, or
call the toll-free number on your health plan ID card for more information about your benefit plan.
When does the Prescription Drug List change?
• Medications may move to a lower tier at any time.
• Medications may move to a higher tier when a generic becomes available.
• Medications may move to a higher tier or be excluded from coverage most often on
January 1 or July 1.
When a medication changes tiers, you may have to pay a different amount for that medication.
For the most up-to-date list, call customer service at the number on your ID card.
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Programs and Limits
Your benefit plan determines how these medications are covered and may differ than what is noted in
the PDL. Call the number for Member Services listed on your ID card if you have any questions about
your prescription drug coverage.
Health Care Reform (HCR) Preventive – This medication is part of a Health Care Reform
preventive benefit and may be available at no cost to you.
Prior Authorization required* – Your doctor is required to provide additional information to us to
determine coverage.
Supply Limit – Amount of medication covered per copayment or in a specific time period.
Step Therapy – Trial of a lower cost medication is required before a higher cost medication is
covered.
*Depending on your benefit you may have notification or medical necessity requirements for select medications.
To learn more about a pharmacy program or to find out if it applies to you, please visit myuhc.com or
call the toll-free member phone number on your health plan ID card.
Why are some medications excluded from coverage?
Medications may be excluded from coverage under your pharmacy benefit when it works the same or
similar as another prescription medication or an over-the-counter (OTC) medication. There may be
other medication options available.
Should I talk to my doctor about over-the-counter (OTC)
medications?
An over-the-counter (OTC) medication may be the right treatment for some conditions. Talk to your
doctor about available OTC options.
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What is the difference between brand-name and generic
medications?
Generic medications contain the same active ingredients (what makes the medication work) as brand-
name medications, but they often cost less. Once the patent of a brand-name medication ends, the FDA
can approve a generic version with the same active ingredients. These types of medications are known
as generic medications. Sometimes, the same company that makes a brand-name medication also makes
the generic version.
What if my doctor writes a brand-name prescription?
The next time your doctor gives you a prescription for a brand-name medication, ask if a generic
equivalent or lower-cost option is available and if it might be right for you. Generic medications
are usually your lowest-cost option, but not always. For some benefit plans if a brand-name drug
is prescribed and a generic equivalent is available, your cost share may be the copay PLUS the cost
difference between the brand-name drug and generic equivalent. Visit myuhc.com to make sure.
Are you taking a specialty medication?
Specialty medications are high-cost and may be used to treat rare or complex conditions. For most
plans, these medications are managed through the Specialty Pharmacy Program. Take advantage
of personalized support designed to help you get the most out of your treatment plan. Visit
UHCSpecialtyRx.com or call the toll-free phone number on your health plan ID card to learn more.
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How do I get updated information about my pharmacy benefit?
Since the PDL may change during your plan year, we encourage you to visit myuhc.com or call the
toll-free member phone number on your health plan ID card for more current information.
Log on to myuhc.com for the following pharmacy information and tools:
• Pharmacy benefit and coverage information
• Possible lower-cost medication options
• Medication interactions and side effects
• Participating retail pharmacies by zip code
• Your prescription history
And, if Mail Service is included in your pharmacy benefit, you can also:
• Refill prescriptions
• Check the status of your order
• Set-up e-mail reminders for refills
• Manage your account
For more information

Call the toll-free member phone number on your health plan ID card.
Or, visit myuhc.com®
Where else can I go for information?
HealthCareLane.com includes short videos to help you learn more about UnitedHealthcare
benefits and health insurance information.
UHCTV.com is a fun and easy way to learn about health terms and other health-related topics.
In certain documents, the Prescription Drug List (PDL) was referred to as the “Preferred Drug List (PDL).” This change in terms does not affect your benefit coverage.
Medications are categorized by common therapeutic conditions in this PDL for ease of reference only. These categories do not determine coverage for the medication for your condition.
Your benefit plan determines coverage for these medications.
All branded medications are trademarks or registered trademarks of their respective owners.
© 2016 United HealthCare Services, Inc. All rights reserved. Created January, 2017. 2017 Prescription Drug List – Connecticut Advantage Three-Tier
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Benefit Prior Supply Step
Product Name Specialty
Tier Authorization Limit Therapy
1ST BASE CRE Tier 3 X
2-DEOXY-D POW -GLUCOSE Tier 3
5-METHYLTETR POW Tier 3 X
5-METHYLTETR POW CALCIUM Tier 3 X
8-MOP CAP 10MG Tier 2
A-LIPOIC POW ACID Tier 3 X
A.A.G.C KIT CRE TERODERM Tier 3 X
A/G PRO TAB Tier 3
ABACA/LAMIVU TAB 600-300 Tier 1 X
ABACAV/LAMIV TAB /ZIDOVUD Tier 1 X
ABACAVIR TAB 300MG Tier 1 X
ABILIFY TAB 10MG Tier 3 X X
ABILIFY TAB 15MG Tier 3 X X
ABILIFY TAB 20MG Tier 3 X X
ABILIFY TAB 2MG Tier 3 X X
ABILIFY TAB 30MG Tier 3 X X
ABILIFY TAB 5MG Tier 3 X X
ABILIFY DISC TAB 10MG Tier 3 X
ABSORICA CAP 10MG Tier 3 X X
ABSORICA CAP 20MG Tier 3 X X
ABSORICA CAP 25MG Tier 3 X X
ABSORICA CAP 30MG Tier 3 X X
ABSORICA CAP 35MG Tier 3 X X
ABSORICA CAP 40MG Tier 3 X X
ABSTRAL SUB 100MCG Tier 3 X X X
ABSTRAL SUB 200MCG Tier 3 X X X
ABSTRAL SUB 300MCG Tier 3 X X X
ABSTRAL SUB 400MCG Tier 3 X X X
ABSTRAL SUB 600MCG Tier 3 X X X
ABSTRAL SUB 800MCG Tier 3 X X X
ACAMPRO CAL TAB 333MG Tier 1
ACANYA GEL 1.2-2.5% Tier 3 X X
ACARBOSE TAB 100MG Tier 1
ACARBOSE TAB 25MG Tier 1
ACARBOSE TAB 50MG Tier 1
ACCOLATE TAB 10MG Tier 3 X
ACCOLATE TAB 20MG Tier 3 X
ACCU-CHEK KIT AVA CONN Tier 1 X
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Benefit Prior Supply Step
Product Name Specialty
Tier Authorization Limit Therapy
ACCU-CHEK KIT AVIVA PL Tier 1 X
ACCU-CHEK KIT COMPACT Tier 1 X
ACCU-CHEK KIT FASTCLIX Tier 1
ACCU-CHEK KIT MLTICLIX Tier 1
ACCU-CHEK KIT NANO Tier 1 X
ACCU-CHEK KIT SOFTCLIX Tier 1
ACCU-CHEK LIQ ACT/GLUC Tier 1
ACCU-CHEK LIQ SMART Tier 1
ACCU-CHEK MIS ADAPTER Tier 3
ACCU-CHEK MIS AVIVA Tier 3 X
ACCU-CHEK MIS BATTERY Tier 3
ACCU-CHEK MIS CLIP Tier 3
ACCU-CHEK MIS MLTICLIX Tier 1
ACCU-CHEK MIS SPRT COM Tier 3
ACCU-CHEK SOL Tier 1
ACCU-CHEK SOL COMPACT Tier 1
ACCU-CHEK TES ACTIVE Tier 3 X X
ACCU-CHEK TES AVIVA Tier 3 X X
ACCU-CHEK TES AVIVA PL Tier 3 X X
ACCU-CHEK TES COMPACT Tier 3 X X
ACCU-CHEK TES DRUM Tier 3 X X
ACCU-CHEK TES SMART Tier 3 X X
ACCU-CK COMF TES CURVE Tier 3 X X
ACCUPRIL TAB 10MG Tier 3
ACCUPRIL TAB 20MG Tier 3
ACCUPRIL TAB 40MG Tier 3
ACCUPRIL TAB 5MG Tier 3
ACCURETIC TAB 10-12.5 Tier 3
ACCURETIC TAB 20-12.5 Tier 3
ACCURETIC TAB 20-25MG Tier 3
ACCUTREND SOL GLUCOSE Tier 1
ACCUTREND TES GLUCOSE Tier 3 X X
ACE ACD/ALUM SOL 2% OTIC Tier 1
ACEBUTOLOL CAP 200MG Tier 1
ACEBUTOLOL CAP 400MG Tier 1
ACEON TAB 4MG Tier 3
ACEON TAB 8MG Tier 3
ACETASOL HC SOL OTIC Tier 2
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Benefit Prior Supply Step
Product Name Specialty
Tier Authorization Limit Therapy
ACETAZOLAMID CAP 500MG ER Tier 1
ACETAZOLAMID TAB 125MG Tier 1
ACETAZOLAMID TAB 250MG Tier 1
ACETIC ACID SOL 2% OTIC Tier 1
ACETYLCYST SOL 10% Tier 1
ACETYLCYST SOL 20% Tier 1
ACIDO LACTOB POW 10BU/GM Tier 3 X
ACIDO LACTOB POW 1BU/GM Tier 3 X
ACIDOPHILUS POW LACTOBAC Tier 3 X
ACIPHEX TAB 20MG Tier 3 X X
ACIPHEX SPR CAP 10MG Tier 3 X X
ACIPHEX SPR CAP 5MG Tier 3 X X
ACITRETIN CAP 10MG Tier 1
ACITRETIN CAP 17.5MG Tier 1
ACITRETIN CAP 25MG Tier 1
ACLOVATE CRE 0.05% Tier 3
ACTEMRA INJ 162/0.9 Tier 3 X X X X
ACTICLATE TAB 150MG Tier 3 X
ACTICLATE TAB 75MG Tier 3 X
ACTIGALL CAP 300MG Tier 3
ACTIMMUNE INJ 2MU/0.5 Tier 2 X X X
ACTIQ LOZ 1200MCG Tier 3 X X X
ACTIQ LOZ 1600MCG Tier 3 X X X
ACTIQ LOZ 200MCG Tier 3 X X X
ACTIQ LOZ 400MCG Tier 3 X X X
ACTIQ LOZ 600MCG Tier 3 X X X
ACTIQ LOZ 800MCG Tier 3 X X X
ACTIVE MEDIC KIT SPECIMEN Tier 1
ACTIVE OB CAP Tier 3
ACTIVE-PREP CRE KIT I Tier 3 X
ACTIVE-PREP CRE KIT II Tier 3 X
ACTIVE-PREP CRE KIT III Tier 3 X
ACTIVE-PREP CRE KIT IV Tier 3 X
ACTIVE-PREP CRE KIT V Tier 3 X
ACTIVELLA TAB 0.5-0.1 Tier 3
ACTIVELLA TAB 1-0.5MG Tier 3
ACTONEL TAB 150MG Tier 3 X
ACTONEL TAB 30MG Tier 3
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