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2008 State Health Benefit Plan (SHBP) Prescription Drug Listfor PPO, PPO Consumer Choice and Indemnity This Prescription Drug List (PDL) contains the most commonly prescribed medications for certainconditions. It represents an abbreviated version of the PDL that is the core of your prescriptiondrug benefit program.
Prescription medications are classified within Tiers based on clinical effectiveness, cost effectivenessand safety. Most generic medications are available at the lowest-cost co-payment, Tier 1. There willbe occasions where generic medications may be classified as Tier 2 or Tier 3 and brand namemedications may be classified as Tier 1. Tier 1 is your lowest co-payment 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 co-payment 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 co-payment 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. Prescription Co-payments for the SHBP PPO, PPO Choice and Indemnity Health Plans’ Pharmacy Benefit Tier 1*. . . . . . . . . . . . . . . . . . . . . . . . . . . . . $10Tier 2*. . . . . . . . . . . . . . . . . . . . . . . . . . . . . $30Tier 3*. . . . . . . . . . . . . . . . . . . . . . . . . . . . $100 *Members are charged the co-payment or the usual and customary price; whichever is less, for • Bring this PDL with you to your doctor appointments and ask your doctor to refer to list when prescribing medications. This tool will help guide you and your doctor in choosing medicationsthat are effective and may save you money.
• To locate a medication not found on the PDL, please visit www.myuhc.com/groups/gdch or call the Customer Care number on the back of your ID card.
• This list is not all-inclusive and does not guarantee coverage.
THIS DOCUMENT LIST IS EFFECTIVE JAN. 1, 2008 THROUGH DEC. 31, 2008. THIS LIST IS SUBJECT TO CHANGE.
2008 State Health Benefit Plan (SHBP) Prescription Drug Listfor PPO, PPO Consumer Choice and Indemnity Albuterol Extended Release Tablet Betamethasone Dipropionate Some medications are noted with N, QD, QL, or DS. The definitions for these symbols are listed QD = Quantity Duration. Some medications have a limited amount that can be covered for a 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 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.
THIS DOCUMENT LIST IS EFFECTIVE JAN. 1, 2008 THROUGH DEC. 31, 2008. THIS LIST IS SUBJECT TO CHANGE.
2008 State Health Benefit Plan (SHBP) Prescription Drug Listfor PPO, PPO Consumer Choice and Indemnity Enalapril with Hydrochlorothiazide Gemfibrozil Some medications are noted with N, QD, QL, or DS. The definitions for these symbols are listed QD = Quantity Duration. Some medications have a limited amount that can be covered for a 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 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.
THIS DOCUMENT LIST IS EFFECTIVE JAN. 1, 2008 THROUGH DEC. 31, 2008. THIS LIST IS SUBJECT TO CHANGE.
2008 State Health Benefit Plan (SHBP) Prescription Drug Listfor PPO, PPO Consumer Choice and Indemnity Some medications are noted with N, QD, QL, or DS. The definitions for these symbols are listed QD = Quantity Duration. Some medications have a limited amount that can be covered for a 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 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.
THIS DOCUMENT LIST IS EFFECTIVE JAN. 1, 2008 THROUGH DEC. 31, 2008. THIS LIST IS SUBJECT TO CHANGE.
2008 State Health Benefit Plan (SHBP) Prescription Drug Listfor PPO, PPO Consumer Choice and Indemnity Some medications are noted with N, QD, QL, or DS. The definitions for these symbols are listed QD = Quantity Duration. Some medications have a limited amount that can be covered for a 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 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.
THIS DOCUMENT LIST IS EFFECTIVE JAN. 1, 2008 THROUGH DEC. 31, 2008. THIS LIST IS SUBJECT TO CHANGE.
2008 State Health Benefit Plan (SHBP) Prescription Drug Listfor PPO, PPO Consumer Choice and Indemnity Some medications are noted with N, QD, QL, or DS. The definitions for these symbols are listed QD = Quantity Duration. Some medications have a limited amount that can be covered for a 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 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.
THIS DOCUMENT LIST IS EFFECTIVE JAN. 1, 2008 THROUGH DEC. 31, 2008. THIS LIST IS SUBJECT TO CHANGE.
2008 State Health Benefit Plan (SHBP) Prescription Drug Listfor PPO, PPO Consumer Choice and Indemnity Some medications are noted with N, QD, QL, or DS. The definitions for these symbols are listed QD = Quantity Duration. Some medications have a limited amount that can be covered for a 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 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.
THIS DOCUMENT LIST IS EFFECTIVE JAN. 1, 2008 THROUGH DEC. 31, 2008. THIS LIST IS SUBJECT TO CHANGE.
2008 State Health Benefit Plan (SHBP) Prescription Drug Listfor PPO, PPO Consumer Choice and Indemnity Some medications are noted with N, QD, QL, or DS. The definitions for these symbols are listed QD = Quantity Duration. Some medications have a limited amount that can be covered for a 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 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.
THIS DOCUMENT LIST IS EFFECTIVE JAN. 1, 2008 THROUGH DEC. 31, 2008. THIS LIST IS SUBJECT TO CHANGE.
2008 State Health Benefit Plan (SHBP) Prescription Drug Listfor PPO, PPO Consumer Choice and Indemnity Additional Tier Three drugs with a generic alternative in Tier One Some medications are noted with N, QD, QL, or DS. The definitions for these symbols are listed QD = Quantity Duration. Some medications have a limited amount that can be covered for a 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 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.
THIS DOCUMENT LIST IS EFFECTIVE JAN. 1, 2008 THROUGH DEC. 31, 2008. THIS LIST IS SUBJECT TO CHANGE.
2008 State Health Benefit Plan (SHBP) Prescription Drug Listfor PPO, PPO Consumer Choice and Indemnity Additional Tier Three drugs with a generic alternative in Tier One Terazol (Terconazole)Toprol XL (Metoprolol Sustained Ultram QL (Tramadol QL)Ultravate Cream, Ointment Univasc (Moexipril)Valium (Diazepam)Vaseretic (Enalapril with Vasotec (Enalapril)Vicodin QL/QD, Vicodin ES QL/QD (Acetaminophen withHydrocodone QL/QD) Voltaren Tablet (Diclofenac)Wellbutrin QL, N Xanax, Xanax XR (Alprazolam)Zantac Syrup (Ranitidine Syrup)Ziac (Bisoprolol with Some medications are noted with N, QD, QL, or DS. The definitions for these symbols are listed QD = Quantity Duration. Some medications have a limited amount that can be covered for a 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 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.
THIS DOCUMENT LIST IS EFFECTIVE JAN. 1, 2008 THROUGH DEC. 31, 2008. THIS LIST IS SUBJECT TO CHANGE.

Source: http://www.clayton.k12.ga.us/administration/humanrsc/benefits/Documents/PPODrugList08.pdf