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How prescription drug coverage works with the PPO Plans
The PPO plans pay benefits at different levels for Tier-1, Tier-2 and Tier-3 prescription drugs. All prescription drugs covered by the plan are categorized into these three tiers on the prescription drug list (PDL). The tier status of a prescription drug can change periodically based on the Prescription Drug List Management Committee's periodic tiering decisions. When that occurs, you may pay more or less for a prescription drug, depending on its tier assignment. Since the PDL may change periodically, you can visit or call UnitedHealthcare at 800 387 7508 for the most current information.
Each tier is assigned a copay, which is the amount you pay when you visit the pharmacy or order your medications through mail order. Your copay will also depend on whether or not you visit the pharmacy or use the mail order service.
Here's how the tier system works:
  • Tier-1 is your lowest copay option. For the lowest out-of-pocket expense, you should consider Tier-1 drugs if you and your provider decide they are appropriate for your treatment.
  • Tier-2 is your middle copay option. Consider a Tier-2 drug if no Tier-1 drug is available to treat your condition.
  • Tier-3 is your highest copay option. The drugs in Tier-3 are usually more costly. Sometimes there are alternatives available in Tier-1 or Tier-2.
For prescription drug products at a retail in-network pharmacy, you are responsible for paying the lowest of the following:
  • The applicable copayment and/or coinsurance.
  • The network pharmacy's usual and customary charge for the prescription drug product.
  • The prescription drug charge for that prescription drug product.
Your prescription drug benefits – PPO Plans
The following table shows your prescription drug copays and the benefits available to you when you enroll in the PPO.
UnitedHealthcare network pharmacy or home delivery service
Non-network pharmacy
  • At a pharmacy, you pay:
    • $10 copay for a Tier 1 drug
    • $25 copay for a Tier 2 drug
    • $50 copay for a Tier 3 drug
  • Through home delivery, you pay (for up to a 90-day supply; refills by phone or online):
    • $25 copay for a Tier 1 drug
    • $62.50 copay for a Tier 2 drug
    • $125 copay for a Tier 3 drug
  • No claim forms
  • Up to a 31-day supply
  • You pay full cost of covered prescription at time of purchase
  • Your reimbursement is equal to the amount you paid less the applicable copay (as shown in column on left) within 45 days of the purchase.
  • If the reimbursement is submitted 46 days or later, your reimbursement will be equal to UnitedHealthcare's discounted drug costs, minus the appropriate copay.
  • Claim forms required
  • Up to a 31-day supply
Note: Copays apply to the in-network out-of-pocket maximum only.