Prescription Drug Lists

Check your PDL to stay updated on your pharmacy coverage

A Prescription Drug List (PDL) – also called a formulary – is a list of commonly used medications, organized into cost levels, called tiers. These costs are decided by your employer or health plan. View your PDL to learn what’s covered by your plan.

Sign in to view the PDL (or formulary) for your plan

Sign in to your member account

Try the UnitedHealthcare app for members

Use your mobile device to get instant access to see your prescription drug coverage and benefits.

Learn more about the app for members

Use your mobile device to get instant access to see your prescription drug coverage and benefits.

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Health Insurance Marketplace and Small and Large Group plans

Learn about PDLs for health plans available through the Health Insurance Marketplace (also called State Exchange plans), Small Business Health Options Program (SHOP) and Small Group and Large Group plans. 

Individual and SHOP Marketplace Drug Lists (On-Exchange)

Small Group and Large Group Drug Lists (Off-Exchange)

Looking for information about Health Care Reform?

Find information about Affordable Care Act (ACA) plans.

View General Prescription Drug Lists (PDLs)

View the lists below to find general pharmacy benefits information for UnitedHealthcare plans, including certain PDLs. Remember, this is only general information. Sign in to your member account or call the number on your health plan ID card to see your PDL and get specific information about your pharmacy benefits.

Advantage

Access

Traditional

Essential

The following Prescription Drug Lists for California may be refreshed on a monthly basis. If you need an exclusion exception, view our process as described in Your Right to Request an Exclusion Exception.

Small Group - Standard plans

Large Group - Advantage

Large Group - Access

Large Group - Essential

Small Group - Advantage

Small Group - Essential

Small Group - Specialty medication cost share (SMCS)

Small Group - Medical

Public Options Plans – benefits for diabetic supplies

Benefits for diabetic supplies provided under the outpatient prescription drug benefit

Certain diabetic supplies will be covered at zero-dollar cost share not subject to any deductible:

  • Standard insulin syringes with needles
  • Blood-testing strips – glucose
  • Urine-testing strips – glucose
  • Ketone-testing strips and tablets
  • Lancets and lancet devices
  • Glucose meters
  • Continuous Glucose Monitors including Dexcom and Freestyle Libre Continuous Glucose Monitors
Diabetic Durable Medical Equipment coverage under the medical certificate of coverage

Diabetic equipment for diabetes includes but is not limited to:

  • Insulin infusion pumps
  • Insulin pump supplies (infusion sets, needles and/or soft cannulas, reservoirs, glass cartridges and insertion sets)
  • Syringes with needles for external pumps

Diabetic equipment must be ordered by and under the direction of a physician.

Durable Medical Equipment limitation:

  • Diabetic equipment including insulin pumps are considered an Essential Health Benefit and not subject to the annual dollar limit on the UnitedHealthcare fully insured certificates of coverage.

UnitedHealthcare Connecticut Plans

Advantage
Traditional
Access

Oxford Connecticut Plans

Advantage
Traditional
Access

Small Group Standard Plans – benefits for mental health drugs

Benefits for mental health drugs provided under the outpatient prescription drug benefit

Certain mental health drugs will be available for $5 copayment for members 18 years of age and younger, if covered on the health plan:

Medication Class/Group $5 Cost Share Medications 2024 COC Benefits - Small Group Standard Plans with the $5 Mental Health cost-share
SSRIs
  • citalopram hydrobromide tablet
  • fluoxetine hcl capsule
  • sertraline hcl tablet
  • paroxetine hcl tablet
  • escitalopram oxalate tablet

$9150 / $18300 OOP; $9150 / $18300 OOP Network Only

$8850 / $17700 OOP; $8850 / $17700 OOP Network Only

$5800 / $11600 OOP; $5800 / $11600 OOP Network Only

$2000 / $4000 OOP; $2000 / $4000 OOP Network Only

$6350 / $12700 Ded. $7200/ $14400 OOP; $6350 / $12700 Ded. $7200 / $14400 OOP Network Only
SNRIs
  • duloxetine hcl enteric coated pellets capsule (20mg, 30mg, 60mg)
  • venlafaxine hcl tablet
  • venlafaxine hcl capsule ER 24 hour
Atypical antidepressants
  • trazodone hcl tablet
  • bupropion hcl tablet
  • bupropion hcl tablet ER 24 hour (150mg and 300mg)
  • bupropion hcl tablet er 12 hour
Anti-hypertensives
  • prazosin hcl capsule
Atypical anxiolytics
  • lorazepam tablet
  • clonazepam tablet
  • alprazolam tablet
Alpha Agonists
  • clonidine hcl tablet
  • clonidine hcl tablet ER
  • guanfacine hcl tablet
  • guanfacine hcl tablet ER 24 hour
Beta blockers
  • propranolol hcl tablet
Anti-manic agents
  • risperidone tablet
  • lithium carbonate tablet ER
  • lithium carbonate capsule
  • olanzapine tablet
Stimulants
  • dexmethylphenidate hcl tablet
  • methylphenidate hcl tablet
  • amphetamine-dextroamphetamine tablet
Anti-psychotics
  • quetiapine fumarate tablet
  • aripiprazole tablet
  • Rexulti (brexpiprazole) tablet
  • lurasidone hcl tablet
GnRH analogs
  • leuprolide acetate injection kit 5 mg/ml
Sex hormones
  • estradiol tablet
  • testosterone cypionate
Nonsteroidal anti-androgens
  • bicalutamide tablet
5-alpha reductase inhibitors
  • finasteride tablet 5 mg

Small Group Standard Plans – benefits for cardiovascular drugs

Benefits for cardiovascular drugs provided under the outpatient prescription drug benefit

Certain generic drugs related to prevention and treatment of cardiovascular disease will be available for $0 cost-sharing, if covered on the health plan:

Condition Medication Classes/Groups at Zero Cost-Sharing $0 Cost Share Medications

Hypercholesterolemia

Cholesterol absorption inhibitors
  • ezetimibe tablets

Statins
  • atorvastatin calcium tablets
  • fluvastatin sodium capsules
  • fluvastatin sodium ER tablets
  • lovastatin tablets
  • pitavastatin calcium tablets
  • pravastatin sodium tablets
  • rosuvastatin calcium tablets
  • simvastatin tablets

Hypertension

Angiotensin-converting enzyme (ACE) inhibitors
  • benazepril hcl tablets
  • captopril tablets
  • enalapril maleate oral solution and tablets
  • fosinopril sodium tablets
  • lisinopril tablets
  • moexipril hcl tablets
  • perindopril erbumine tablets
  • quinapril hcl tablets
  • ramipril capsules
  • trandolapril tablets

Angiotensin receptor blockers
  • candesartan cilexetil tablets
  • irbesartan tablets
  • losartan potassium tablets
  • olmesartan medoxomil tablets
  • telmisartan tablets
  • valsartan tablets

Beta blockers
  • acebutolol hcl capsules
  • atenolol tablets
  • betaxolol hcl tablets
  • bisoprolol fumarate tablets
  • carvedilol phosphate ER capsules
  • carvedilol tablets
  • labetalol hcl tablets
  • metoprolol succinate ER tablets
  • metoprolol tartrate tablets
  • nadolol tablets
  • nebivolol hcl tablets
  • pindolol tablets
  • propranolol hcl ER capsules
  • propranolol hcl oral solution and tablets
  • sotalol hcl tablets
  • timolol maleate tablets

Calcium channel blockers
  • amlodipine besylate tablets
  • cartia XT capsules
  • diltiazem hcl ER capsules
  • diltiazem hcl ER tablets
  • diltiazem hcr tablets
  • dilt-XR capsules
  • felodipine ER tablets
  • isradipine capsules
  • matzim LA tablets
  • nicardipine hcl capsules
  • nifedipine capsules
  • nifedipine ER tablets
  • nimodipine capsules
  • nisoldipine ER tablets
  • taztia XT capsules
  • tiadylt capsules
  • verapamil hcl ER tablets
  • verapamil hcl tablets

Thiazide diuretics
  • chlorthalidone tablets
  • hydrochlorothiazide tablets and capsules
  • indapamide tablets
  • metolazone tablets

Post-event care

Anticoagulants
  • dabigatran etexilate mesylate capsules
  • jantoven tablets
  • warfarin sodium tablets

Aspirin (NSAIDs)
  • aspirin 81mg

Beta blockers
  • acebutolol hcl capsules
  • atenolol tablets
  • betaxolol hcl tablets
  • bisoprolol fumarate tablets
  • carvedilol phosphate ER capsules
  • carvedilol tablets
  • labetalol hcl tablets
  • metoprolol succinate ER tablets
  • metoprolol tartrate tablets
  • nadolol tablets
  • nebivolol hcl tablets
  • pindolol tablets
  • propranolol hcl ER capsules
  • propranolol hcl oral solution and tablets
  • sotalol hcl tablets
  • timolol maleate tablets

Platelet inhibitors (Plavix)
  • clopidogrel bisulfate tablets

Tobacco use

Antidepressants (only Bupropion)
  • bupropion SR tablet

Nicotine receptor partial agonist (Varenicline)
  • varenicline tartrate tablets

Nicotine replacement therapies
  • nicotine gum, patch and lozenge

Access

Advantage

Traditional

Essential

Advantage

Essential

Advantage

Essential

Monthly Prescription Drug List Update

Large Group - Advantage

Large Group - Access

Large Group - Essential

Small Group - Essential

Advantage

Traditional

Access

Traditional Non-Erisa ASO

This drug list shows which drugs can be dispensed in quantities up to a 90-day or 100-day supply.

UnitedHealthcare Services Company of the River Valley, Inc.

Prescription Drug Lists for River Valley are found under "Standard drug lists" above.

Advantage

Advantage

Essential

Zero-cost preventive care medications

As part of Health Care Reform, health plans must cover certain Preventive Care Medications at no cost to you. Stay up to date on any changes in the law and get updates about Health Care Reform at healthcare.gov.

These lists are for general information only. Lists may change over time and some medications listed may not be covered by your specific plan.

To find the most updated information:

  • Review your benefit documents.
  • View current lists on myuhc.com.
  • Call the phone number on your health plan ID card.

Advantage and Essential

Traditional, Access and Enhanced

California Preventive Care Medication Lists

Advantage and Essential HMO and PPO
Traditional, Access, and Enhanced HMO and PPO

Advantage and Essential

Traditional, Access and Enhanced

For non-contraceptive preventive care prescription drug lists, refer to the Standard Zero-cost preventive care medications (PPACA) dropdown.

Advantage and Essential

Traditional, Access and Enhanced

The health reform law (Affordable Care Act) requires most health plans to pay for birth control (contraceptives and sterilization) for women at no cost to you. Some organizations can choose not to cover birth control (contraceptives) as part of their group health plan for religious reasons. If you are a member of one of these groups (Eligible Organizations), UnitedHealthcare is required to cover certain birth control products and services at no cost to you.

You can use your Contraceptive Services Only ID card to get the birth control services, products and drugs on the Contraceptive Services Only drug list for $0 cost-share if they are:

  • Prescribed by a health care professional such as your doctor
  • For services performed by a network health care professional
  • For products and drugs filled at a network pharmacy

Most Commonly Used Contraceptive Services Only drug lists:

If your benefit plan is based in California and fully insured:

If your benefit plan is based in Connecticut, District of Columbia, Delaware, Illinois, Massachusetts, Maryland, Oregon, or Washington, and fully insured:

Preventive Medication List (optional add-on)

The below lists contain preventive medications that may be covered under your plan. If your plan has one of these lists, your insurance benefit may be applied before you meet your deductible for the listed preventive medications. Some medications may have other requirements or limits depending on your benefit plan.

These lists are for general information only. Lists may change over time and some medications listed may not be covered by your specific plan.

To find the most updated information:

  • Review your benefit documents
  • View current lists on your member account
  • Call the phone number on your health plan ID card

Vital Medication Program

This list includes certain classes of preferred drugs offered at no out-of-pocket cost to you. They include certain vital use drugs such as preferred insulins.

This list is for general information only. The drug list may change over time and may not be covered by your specific plan.

To find the most up-to-date information:

  • Review your benefit documents
  • View current lists on your member account
  • Call the phone number on your member ID card