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2006 Three-Tier Prescription Drug List Reference Guide Your pharmacy benefit offers you flexibility and choice in the prescription medications available toyou. Understanding your Prescription Drug List will help you make more informed decisionsabout prescription medications.
This booklet will help you understand these choices for our health plans -- MD-Individual PracticeAssociation, Inc. (M.D. IPA), Optimum Choice, Inc. (OCI), and MAMSI Life and Health InsuranceCompany (MLH).1 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 people have asked regarding our pharmacybenefit. If you currently have pharmacy benefit coverage with one of our health plans, please visitus at www.mamsiUnitedHealthcare.com or call the Customer Care telephone number on yourhealth plan identification (ID) card for additional information. If you are not currently enrolled withus for pharmacy benefit coverage, you may access www.mamsiUnitedHealthcare.com for additionalinformation during your open enrollment period or you may contact your employer or health planfor additional information.
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). Your pharmacy benefit is designed to provide you with a comprehensive selection of prescriptionmedications. This booklet lists the most commonly prescribed medications for certain conditions. Ifyou currently have pharmacy benefit coverage with one of our health plans, you can find ourcomplete PDL at www.mamsiUnitedHealthcare.com. You and your doctor may refer to this list toconsider prescription medication choices and select the appropriate medication to meet yourneeds. 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 PDL foundin this booklet. These benefit plan documents may include a Summary Plan Description or aCertificate of Coverage, and a Pharmacy Rider. If you do not have the benefit plan documents,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? Typically, prescription medications are categorized within three tiers. Each tier is assigned acopayment, which is an amount you pay when you fill a prescription at a participating retailpharmacy or refill your ongoing prescription through our mail-order pharmacy service. Youremployer or health plan sets the actual copayment amounts for the medications covered underyour pharmacy benefit. Consult the benefit plan documents provided by your employer or healthplan for more specific information about the copayments, coinsurance, and deductibles that mayapply to your pharmacy benefit coverage. 1The corporate headquarters for M.D. IPA, OCI, and MLH is 4 Taft Court, Rockville, MD 20850. M.D. IPA is not available in Delaware 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.
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. 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. A two-tier open pharmacy benefit plan covers one tier at the lower copayment and coversa second tier at a higher copayment. And, some plans may use different terminology for the tiers.
Refer to your enrollment materials or call the Customer Care telephone number on your health planID 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 to help ensure access to a widerange of medications and control health care costs for you and your employer or health plan. Youand your doctor decide which medication is appropriate for you.
How often will prescription medications change tiers? While medications change tiers infrequently, such changes may occur up to four times per calendaryear, depending on your benefit. Additionally, when a brand-name medication becomes availableas a generic, that brand-name medication may move to a higher tier. When a medication changestiers, you may be required to pay more or less for that medication. These changes may occurwithout prior notice to you. However, if you currently have pharmacy benefit coverage with one ofour health plans, you may visit our Web site, www.mamsiUnitedHealthcare.com, or call theCustomer Care telephone number on your ID card for copayment information about a particularmedication. What is the difference between brand-name and generic medications? Generic medications contain the same active ingredients as brand-name medications, but theyoften cost less. Generic medications become available after the patent on the brand-namemedication expires. At that time, other companies are permitted to manufacture a chemicallyequivalent medication. Many companies that make brand-name medications also produce andmarket 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.
“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. If a therapeutic alternative isavailable and appropriate for you to use, it may cost you less than the medication your doctor mayprescribe. Some therapeutic alternatives may also be available without a prescription (“over-the-counter”). If you are interested in pursuing therapeutic alternatives, please talk to your doctor tosee if a therapeutic alternative may be right for you.
Why is the medication that I am currently taking no longer covered? Medications may be excluded from coverage under your pharmacy benefit. For example, aprescription medication may be excluded from coverage when the FDA approves an over-the-counter (non-prescription) equivalent to the prescription medication. 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 discussing “over-the-counter” or non-prescription medications with mydoctor? An over-the-counter medication can be an appropriate treatment for many conditions. Consult yourdoctor about over-the-counter alternatives to treat your condition. These medications are notcovered under your pharmacy benefit, but they may cost less than your out-of-pocket expense forprescription medications.
Why are there “notations” next to certain medications in the PDL, and what do they mean? Certain medications in this booklet have a notation, such as N (for “notification”), QL (for “quantitylimitations”), QD (for “quantity duration”), and DS (for “diabetic supplies”). These notations identifymedications that have special criteria for coverage attached to them. Some may require yourdoctor to notify us to make sure that their use is covered within your benefit. Others have amaximum quantity allowed for each copayment. Still others have additional programs that apply.
The specific definitions for these notations are listed at the bottom of each page of the PDL. Some of our plans include other special criteria for coverage, such as prior authorization. Themedications requiring prior authorization under these plans are listed on our Web site,www.mamsiUnitedHealthcare.com.
Be sure you read your plan documents carefully to be sure you understand the special criteria forcoverage applicable to you.
How do I access updated information about my pharmacy benefit? Since the PDL may change periodically, we encourage you to visitwww.mamsiUnitedHealthcare.com for the most current information. If you are not currently enrolled with us for pharmacy benefit coverage, you may accesswww.mamsiUnitedHealthcare.com during your open enrollment period for the most currentinformation. In addition to information about your pharmacy benefit, www.mamsiUnitedHealthcare.com is youronline resource for a variety of health and wellness topics. The site is designed to help you makethe best health care decisions for you and your family.
With www.mamsiUnitedHealthcare.com, you can view your prescription claims history and comparecosts of medications to identify cost-saving opportunities.
How do I find information about my pharmacy benefit on www.mamsiUnitedHealthcare.com? Simply log on to our Web site, select “Members” then “Prescription Drug List” and follow theinstructions.
If you currently have pharmacy benefit coverage with one of our health plans and you haveadditional questions about your pharmacy benefit, please call the Customer Care telephone numberon your ID card. If you are not currently enrolled with us for pharmacy benefit coverage, you mayaccess www.mamsiUnitedHealthcare.com during your open enrollment period for the most currentinformation.
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.mamsiUnitedHealthcare.com. Once you have logged in, click on“Members” then “Prescription Drug List.” • If you currently have pharmacy benefit coverage with one of our health plans and you have additional questions about your pharmacy benefit, please call the Customer Care telephonenumber on your ID card. In certain benefit plans, the Prescription Drug List (PDL) is referred to as the “Preferred Drug List;” Tier 1 is referred to as “generics;”Tier 2 is referred to as “formulary brand name drugs;” and Tier 3 is referred to as “non-formulary brand name drugs.” These changesin descriptive terms do not affect your benefit coverage. Always refer to your benefit coverage to determine your coverage formedications and copayment. Some medications listed on the Prescription Drug List may not be covered under your specific benefit.
Where differences are noted between this PDL reference guide and your benefit plan documents, the benefit plan documents willgovern.
2006 Three-Tier Prescription Drug List 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.
2006 Three-Tier Prescription Drug List Reference Guide Enalapril with Hydrochlorothiazide Hydroxychloroquine 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.
2006 Three-Tier Prescription Drug List 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.
2006 Three-Tier Prescription Drug List Reference Guide Bactroban Cream, Nasal Ointment Effexor 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.
2006 Three-Tier Prescription Drug List 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.
2006 Three-Tier Prescription Drug List 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.
2006 Three-Tier Prescription Drug List Reference Guide Relenza QL, NRestasis QLRetin-A Micro NRhinocort QLRhinocort Aqua QLRitalin LA QLRobinul ForteRosanilSanctura QLSarafem QLSkelaxinSonata QL/QDStarlix QLStrattera QLTamiflu QL, NTarkaTazoracTequinTeveten QL/QDTheo-24Tracer BG Test Strips QL, DSTransderm-ScopTri-NorinylTussionexUniphylUnireticUnivascUroxatral QLVagifemVantin NOTE:• Compounded prescriptions are Tier Three • Pens & cartridges are Tier Three except for Novolin and Novolog pens and cartridgesthat are Tier Two.
Vicodin ESVigamoxVisicolXalatan QLXanax XRXopenexZegerid QL/QDZelnorm QL/QD, NZymar 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.
2006 Three-Tier Prescription Drug List 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: http://www.bsi-va.com/MyBenefitsNavigator/images_basic/Standard_PDL.pdf