Updates to your prescription benefits
Effective January 1, 2015
Within the Prescription Drug List (PDL), medications
are grouped by tier. The tier indicates the amount you
pay when you fill a prescription. Please reference this
chart as you review the following updates. Most options
listed are available in Tier 1, your lowest cost option.
If your medication is listed below, you may continue taking it, but you may pay a higher cost. We encourage you to
discuss the listed lower-cost option(s) that may also treat your condition with your doctor. Most options listed are available
in Tier 1, your lowest-cost tier.
Medications moving to a lower-tier
The following medications are moving to a lower-tier, making them more affordable.
Therapeutic Use
Medication Name
Cystinosis
Cystagon
Tier
Placement
Invokana
Diabetes
Tanzeum
Hereditary Angioedema
Berinert
Pain
fentanyl patch (generic Duragesic)
Medications moving to a higher tier
Medications may move from a lower tier to a higher tier when they are more costly and have available lower-cost options.
Tier
Placement
Therapeutic Use
Medication Name
Acne
clindamycin
phosphate 1%
(generic Cleocin T)
gel, lotion
clindamycin 1% solution (generic Cleocin T), erythromycin 2%
gel (generic Emgel, Erygel)
Enjuvia
estradiol tablet (generic Estrace)
Estrace cream
Vagifem, Estring
Hormone
Replacement
doxycycline hyclate
capsule (generic
Morgidox)
doxycycline hyclate
tablet (generic
Vibramycin)
Infections
Lower-Cost Options
doxycycline monohydrate 50 mg or 100 mg (generic Monodox)
doxycycline monohydrate 50 mg or 100 mg (generic Monodox)
minocycline tablet
(generic Dynacin)
doxycycline monohydrate 50 mg or 100 mg (generic Monodox),
doxycycline hyclate (generic Morgidox, Vibramycin), minocycline
capsule (generic Minocin)
tetracycline capsule
(generic Sumycin)
doxycycline monohydrate 50 mg or 100 mg (generic Monodox),
doxycycline hyclate (generic Morgidox, Vibramycin), minocycline
capsule (generic Minocin)
© 2014 United HealthCare Services, Inc. Confidential Information.
UnitedHealthcare® and the dimensional U logo are registered marks owned by
Unitedhealth Group, Inc. Applies to Advantage PDL.
100-13289 8/14 C1516-01
All branded medications are trademarks or registered trademarks of their respective
owners. Please note not all PDL updates apply to all groups depending on state
regulation, riders and SPDs.
Skin Conditions
amcinonide 0.1%
cream (generic
Cyclocort)
amcinonide 0.1%
lotion (generic
Cyclocort)
betamethasone
dipropionate 0.05%
cream (generic
Diprosone)
betamethasone
dipropionate 0.05%
ointment (generic
Diprosone)
bethamethasone
dipropionate 0.05%
augmented lotion
(generic Diprolene)
bethamethasone
dipropionate 0.05%
augmented ointment
(generic Diprolene)
desonide 0.05%
cream (generic
Desowen)
desonide 0.05%
lotion (generic
Desowen)
desonide 0.05%
ointment (generic
Desowen)
desoximetasone gel
(generic Topicort)
desoximetasone
ointment (generic
Topicort)
diflorasone diacetate
0.05% ointment
(generic Apexicon,
Florone)
diflorasone diacetate
cream 0.05% (generic
Apexicon E)
fluocinolone 0.01%
cream (generic
Synalar)
fluocinolone 0.01% oil
(generic DermaSmoothe/FS)
fluocinolone 0.01%
solution (generic
Synalar)
fluocinolone 0.025%
cream (generic
Synalar)
fluocinolone 0.025%
ointment (generic
Synalar)
fluticasone propionate
0.05% lotion (generic
Cutivate)
halobetasol
propionate 0.05%
cream (generic
Ultravate)
© 2014 United HealthCare Services, Inc. Confidential Information.
UnitedHealthcare® and the dimensional U logo are registered marks owned by
Unitedhealth Group, Inc. Applies to Advantage PDL.
100-13289 2/14 C1516-01
triamcinolone 0.5% cream (generic Aristocort)
betamethasone 0.05% lotion (generic Alphatrex)
triamcinolone 0.5% cream (generic Aristocort)
fluocinonide 0.05% ointment (generic Lidex)
betamethasone 0.05% augmented gel (generic Alphatrex),
clobetasol propionate 0.05% gel (generic Temovate)
clobetasol propionate 0.05% emollient ointment (generic
Temovate E)
alclometasone 0.05% cream (generic Aclovate), triamcinolone
0.025% cream (generic Kenalog)
betamethasone valerate 0.1% lotion (generic Valisone),
triamcinolone 0.025% lotion (generic Kenalog)
prednicarbate 0.1% ointment (generic Dermatop), triamcinolone
0.025% ointment (generic Kenalog)
fluocinonide 0.05% solution (generic Lidex)
fluocinonide 0.05% ointment (generic Lidex)
clobetasol propionate 0.05% emollient ointment (generic
Temovate E)
betamethasone dipropionate 0.05% augmented cream (generic
Diprolene AF), fluocinonide 0.05% cream (generic Lidex)
alclometasone 0.05% cream (generic Aclovate), triamcinolone
0.025% cream (generic Kenalog)
alclometasone 0.05% cream (generic Aclovate), betamethasone
valerate 0.1% lotion (generic Valisone), triamcinolone 0.025%
cream/lotion (generic Kenalog)
betamethasone valerate 0.1% lotion (generic Valisone),
triamcinolone 0.025% lotion (generic Kenalog)
betamethasone valerate 0.1% cream (generic Valisone),
prednicarbate 0.1% cream (generic Dermatop)
prednicarbate 0.1% ointment (generic Dermatop), triamcinolone
0.025% ointment (generic Kenalog)
triamcinolone acetonide 0.1% lotion (generic Kenalog)
clobetasol propionate 0.05% emollient cream
(generic Temovate E)
All branded medications are trademarks or registered trademarks of their respective
owners. Please note not all PDL updates apply to all groups depending on state
regulation, riders and SPDs.
halobetasol
propionate 0.05%
ointment (generic
Ultravate)
hydrocortisone
valerate 0.2% cream
(generic Westcort)
hydrocortisone
valerate 0.2%
ointment (generic
Westcort)
clobetasol propionate 0.05% emollient ointment (generic
Temovate E)
fluticasone propionate 0.05% cream (generic Cutivate),
prednicarbate 0.1% cream (generic Dermatop)
prednicarbate 0.1% ointment (generic Dermatop), triamcinolone
0.025% ointment (generic Kenalog)
Medications with New Benefit Coverage
The following medications were previously not covered under most benefit plans and are now eligible for coverage.
Therapeutic Use
Medication Name
Acne
clindamycin 1.2%/benzoyl peroxide
5% gel (generic Duac)
Alzheimer's Disease
Namenda XR
Ulcers, Heartburn, and Reflux
Prevacid Solutab*
Tier Placement
*Covered for children under the age of 6 and prior authorization is required for members over the age of 6.
Medications excluded from benefit coverage
We evaluate medications based on their total value, including how a medication works and how much it costs. When
several medications work in the same way, we may choose to exclude the higher-cost option. The medications listed
below will no longer be covered under many of our pharmacy benefit plans.
Therapeutic Use
Medication Name
Lower-Cost Options
Acne
Atralin
clindamycin 1%/benzoyl peroxide 5%
(generic BenzaClin) gel
Fabior
tretinoin (generic Retin-A)
clindamycin solution (generic Cleocin T) plus OTC benzoyl
peroxide, clindamycin 1.2%/benzoyl peroxide 5% (generic Duac)
tretinoin (generic Retin-A), Tazorac gel
clindamycin solution (generic Cleocin T) plus OTC benzoyl
peroxide, clindamycin 1.2%/benzoyl peroxide 5% (generic Duac)
tretinoin (generic Retin-A)
Aubra, Aviane, Delyla, Falmina Lessina, Lutera, Orsythia, Sronyx,
(generics Alesse, Levlite)
Gildess Fe, Junel Fe, Larin Fe, Microgestin Fe (branded generics
for Loestrin Fe)
norelgestromin/ethinyl estradiol topical patch, Xulane (generic
Ortho Evra)
Introvale, Jolessa, Quasense (generics for Seasonale), Amethia,
Camrese, Daysee (generic for Seasonique); Amethia Lo, Camrese
Lo (generic for LoSeasonique)
Neuac 1.2%-5% Kit
Tretin-X cream, kit
Falessa Kit
Lo Minastrin FE
Contraceptive
Ortho Evra (Brand Only)
Quartette
Cough and Cold
Depression
Excessive
Secretions
Zutripro (Brand Only)
chlorpheniramine/hydrocodone/pseudoephedrine (generic Zutripro)
Desvenlafaxine (fumarate)
venlafaxine extended-release capsule (generic Effexor XR), Pristiq
Khedezla
venlafaxine extended-release capsule (generic Effexor XR), Pristiq
Pexeva
paroxetine (generic Paxil), paroxetine extended-release
(generic Paxil CR)
Glycate
glycopyrrolate (generic Robinul)
Ertaczo
ciclopirox (generic Loprox), econazole (generic Spectazole),
ketoconazole (generic Nizoral), OTC Lamisil AT, Lotrimin,
Lotrimin AF
Fungal Infections
Luzu
© 2014 United HealthCare Services, Inc. Confidential Information.
UnitedHealthcare® and the dimensional U logo are registered marks owned by
Unitedhealth Group, Inc. Applies to Advantage PDL.
100-13289 2/14 C1516-01
All branded medications are trademarks or registered trademarks of their respective
owners. Please note not all PDL updates apply to all groups depending on state
regulation, riders and SPDs.
Naftin 1%, 2%cream and gel
nystatin/triamcinolone (generic Mycolog
II) cream, ointment
Oxistat Lotion
High Blood
Pressure
Vusion
nystatin Cream (generic Mycostatin), OTC miconazole cream
Micardis (Brand Only)
losartan (generic Cozaar), telmisartan (generic Micardis)
Micardis HCT (Brand Only)
losartan/hydrochlorothiazide (generic Hyzaar),
telmisartan/hydrochlorothiazide (generic Micardis HCT)
Antara 30 mg, 43 mg, 90 mg, 130 mg
(brand and generic)
Fenoglide
Fibricor 35 mg, 105 mg (brand and
generic)
Lipofen (brand and generic)
High Cholesterol
HIV
Hormone
Replacement
Infections
Osteoporosis
Pain
Phosphate
Binder
Skin Conditions
nystatin cream (generic Mycostatin) + triamcinolone 0.1% cream or
ointment (generic Kenalog)
ciclopirox (generic Loprox), econazole (generic Spectazole),
ketoconazole (generic Nizoral), OTC Lamisil AT, Lotrimin,
Lotrimin AF
fenofibrate 54 mg, 160 mg (generic Lofibra)
Lofibra 67 mg, 134 mg, 200 mg (brand
and generic)
Lofibra 54 mg, 160 mg
(Brand only)
Lovaza (Brand Only)
omega-3-acid ethyl esters (generic Lovaza), Vascepa
Triglide
Viramune XR 400 mg
(Brand Only)
fenofibrate 54 mg, 160 mg (generic Lofibra)
Cenestin
estradiol tablet (generic Estrace), Enjuvia, Premarin
Avelox tablet (Brand Only)
moxifloxacin tablets (generic Avelox)
Cipro suspension (Brand Only)
ciprofloxacin oral suspension (generic Cipro Suspension)
doxycycline 75 mg capsule (generic
Monodox)
doxycycline monohydrate 50 mg or 100 mg (generic Monodox),
doxycycline hyclate (generic Morgidox, Vibramycin)
Mepron suspension (Brand Only)
atovaquone suspension (generic Mepron)
Evista (Brand Only)
raloxifene (generic Evista)
Active-Pac with Gabapentin 300
gabapentin (generic Neurontin)
Avinza (Brand Only)
morphine sulfate extended-release tablet (generic MS Contin),
morphine sulfate extended-release capsule (generic Avinza),
Nucynta ER, Opana ER, Oxycontin
Duragesic (Brand Only)
fentanyl transdermal patch (generic Duragesic)
Fioricet with Codeine 50 mg/325 mg/40
mg/30 mg (Brand Only)
Fioricet with Codeine 50 mg/300 mg/40
mg/30 mg (brand and generic)
butalbital/acetaminophen/caffeine/codeine phosphate 50 mg/325
mg/40 mg/30 mg (generic Fioricet with Codeine)
Zorvolex
diclofenac potassium (generic Cataflam), diclofenac sodium
(generic Voltaren), ibuprofen (generic Motrin), naproxen (generic
Anaprox, Anaprox DS, Naprosyn)
Renvela tablets (Brand Only)
sevelamer carbonate (generic Renvela)
Clobex lotion (brand and generic)
betamethasone 0.05% augmented gel (generic Diprolene),
clobetasol 0.05% gel (generic Temovate), clobetasol 0.05%
solution (generic Temovate)
Clodan Kit
Cloderm cream (Brand Only)
© 2014 United HealthCare Services, Inc. Confidential Information.
UnitedHealthcare® and the dimensional U logo are registered marks owned by
Unitedhealth Group, Inc. Applies to Advantage PDL.
100-13289 2/14 C1516-01
nevirapine extended-release (generic Viramune XR)
clobetasol 0.05% gel (generic Temovate), clobetasol 0.05%
solution (generic Temovate)
clocortolone 0.1% cream (generic Cloderm), mometasone furoate
cream 0.1 % (generic Elocon)
All branded medications are trademarks or registered trademarks of their respective
owners. Please note not all PDL updates apply to all groups depending on state
regulation, riders and SPDs.
Neo-Synalar Kit
fluocinolone cream (generic Lidex) plus OTC Neosporin
Noritate 1%
metronidazole 0.75% cream (generic Metrocream)
Olux foam (brand and generic)
Olux-E foam (brand and generic)
betamethasone 0.05% augmented gel (generic Diprolene),
clobetasol propionate 0.05% gel (generic Temovate), clobetasol
0.05% solution (generic Temovate)
SelRx
selenium sulfide shampoo
Taclonex ointment (Brand Only)
betamethasone/calcipotriene ointment (generic Taclonex)
Topicort spray
desoximetasone 0.05% gel (generic Topicort), fluocinolone 0.05%
solution (generic Lidex),
Utopic
urea 40%
Sleep
Lunesta (Brand Only)
eszopiclone (generic Lunesta), zaleplon (generic Sonata),
zolpidem (generic Ambien)
Symptoms
associated with
menopause
Brisdelle
paroxetine (generic Paxil), paroxetine extended-release
(generic Paxil CR)
Transplant
Astagraf XL
tacrolimus (generic Prograf)
Aciphex Sprinkle
Ulcers,
Heartburn, and
Reflux
Nexium capsules
Prilosec Suspension
omeprazole (generic Prilosec), pantoprazole (generic Protonix),
rabeprazole (generic Aciphex), Dexilant, Nexium Suspension*,
Prevacid SoluTab*
Protonix Granules for Suspension
Denavir
Viral Infections
Zovirax cream
acyclovir capsule or tablet (generic Zovirax), famciclovir tablet
(generic Famvir), valacyclovir tablet (generic Valtrex)
For more information
Visit myuhc.com or call the toll-free number on the back of your health plan ID card.
*Covered for children under the age of 6 and prior authorization is required for members over the age of 6.
© 2014 United HealthCare Services, Inc. Confidential Information.
UnitedHealthcare® and the dimensional U logo are registered marks owned by
Unitedhealth Group, Inc. Applies to Advantage PDL.
100-13289 2/14 C1516-01
All branded medications are trademarks or registered trademarks of their respective
owners. Please note not all PDL updates apply to all groups depending on state
regulation, riders and SPDs.