What are Prescription Drugs Lists (PDLs)
When your doctor prescribes a medication, it’s important to know if it is covered. To do that, you’ll want to know how to access your plan’s Prescription Drug List (PDL), sometimes called a formulary. The PDL is a list of the most commonly prescribed medications. It includes both brand-name and generic prescription medications approved by the U.S. Food and Drug Administration (FDA). Medications are listed by common categories or classes and placed in tiers that represent the cost you pay out-of-pocket.
What is a drug tier? How does it work?
Prescription Drug Lists often have tiers, or groups of drugs categorized by cost. Your cost-share or copayment is based on which tier your drug is in. There are typically three or four tiers:
- Tier 1: Least expensive drug options, often generic drugs
- Tier 2: Higher price generic and lower-price brand-name drugs
- Tier 3: Mainly higher price brand-name drugs
- Tier 4: Highest cost prescription drugs
What’s the difference between brand and generic drugs?
A brand-name drug is the name given to the medication by the company that makes the drug.
Brand-name drug companies:
- Invested in research and development
- Adhered to stringent clinical testing for safety and efficacy1
A generic drug is chemically identical — a copy of the brand-name drug. The two are considered bioequivalent and expected to do the same thing for you.
One example of a bioequivalent prescription drug is the brand-name Lipitor® versus its generic counterpart of atorvastatin. The generic name of a drug is the name of the active ingredient in both the brand-name and generic versions of the drug. Both brand-name and generic drugs are approved by the U.S. Food and Drug Administration (FDA).
Generic drugs can be:
- As effective as brand-name drugs2
- Often less expensive than brand-name drugs2
- Different than brand-name drugs mainly based on inactive ingredients, the ingredients that change the consistency, color or taste — but not the chemical activity — of the drug3
Does health insurance cover all prescription drugs?
Medications under different names may provide similar clinical benefits yet look different and have different price points. Sometimes only certain types or brands of prescriptions are covered under your plan. Know your pharmacy benefits and if your prescription is covered before you head to the pharmacy counter.
How do I know if a plan covers my prescriptions?
Sign in to your health plan account to view your Prescription Drug list (PDL) or call the number on your member ID card.
Prescription drugs are evaluated on the following:
- How well they work
- How they compare to others in the same class
- Total cost
Medicare Part B covers some outpatient prescription drugs. If a drug is not covered under Part B, it may be covered under Part D. See examples of Part B drugs commonly covered. Most Medicare Part D drug plans have their own Prescription Drug List, also known as a formulary, with drugs placed into tiers.
Most Medicaid plans cover some prescription drugs, but the Prescription Drug List and plan benefits can vary from state to state.
If you are enrolled in a UnitedHealthcare Community Plan, sign in to your health plan account to confirm your pharmacy benefits.
How can I understand my prescription drug label?
The label on your prescription medication container is there to help you take your medication correctly and safely, as well as be aware of possible side effects. In order to help you make sense of your prescription drug label, look for the following:
Your name (if you don’t see your name, ask to talk to the pharmacist)
Name of the medication
Dosage instructions/how to take the medication — take ONLY as directed on the label. If there are questions as to what “twice a day means,” ask if that means 12 hours apart.
Expiration date/discard after date
Number of refills allowed
Prescription number (Rx #, often printed in the upper left hand corner)
Pharmacy phone number
Name and location of pharmacy
Name of the doctor who prescribed the medication
Warning label, often printed on the back. (Not all prescription drug labels include a warning.)
If any of this information is hard to read, ask your pharmacist to print it in larger type.
Other questions to ask your pharmacist
- How should I store the medication?
- Is there anything I shouldn’t eat or drink while taking the prescription? Any vitamins or supplements to avoid? What about alcohol?
- Is it safe to take with any other prescription or over-the-counter drugs?
- When can I stop taking the medication?
Before making health care decisions, seek the advice of a medical health care professional.
What is prior authorization?
Prior authorization (PA) is also known as precertification, prior notification, or prior approval. No matter what it is called, PA is basically a way to verify the medication is covered by your plan. PA also helps control costs for everyone.4
A drug might require prior authorization if it is:5
- A brand-name drug that has a generic equivalent
- More costly than other drugs within the same category/class
- Used for cosmetic reasons only
To help the prior authorization process go smoothly, it might be helpful to:
- Check the policy documents or Prescription Drug List (PDL) to see if you need prior authorization
- Work with your doctor to submit a prior authorization
- Keep careful records of your prior authorization to know when it expires
- Begin the process of getting a new prior authorization at least one month in advance
To find out if a drug needs prior authorization, call the number on your member ID card or sign in to your health plan account.
What if my plan doesn’t cover the drug prescribed by my doctor?
Sometimes a drug prescribed by your doctor isn’t covered under your plan because there are more cost-effective options out there. Talk to your doctor about similar drugs or treatment options that may work just as well.