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
10 Do’s and Dont’s in Zeiten der neuen Grippe vulgo „Schweinegrippe“ (Martin Sprenger, Allgemeinmediziner, Master of Public Health. Graz, 04.11.2009) 1. Niemals von einem Einzelfall auf das Risiko einer Bevölkerung schließen So tragisch Einzelfälle sind, sie sind nicht repräsentativ für die Allgemeinheit. Der 100-jährige Raucher ist kein Beweis für die Unschädlichkeit des R
Lecture: Plants Of The Palomar College Arboretum W. P. Armstrong & Tony Rangel, April 2011 If You Get Lost In Wayne's Word Pages, Find This Page Again At The Top Of Brief Summary Of The Palomar College Arboretum By 1970, campus horticulturist Bob Kelly had already begun planting trees in an undeveloped area east of campus (near the Perimeter Road). ASG President Brian Hawthorne be