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.
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)
- Individual Health Insurance Marketplace (if selecting a plan on your own)
- SHOP Marketplace (If selecting a plan through your job)
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
- Advantage Tier 3 Prescription Drug List for UnitedHealthcare, Neighborhood Health Plan, River Valley, All Savers, and Oxford medical plans (1/1/2025)
- Advantage Tier 3 Prescription Drug List for UnitedHealthcare, Neighborhood Health Plan, River Valley, All Savers, and Oxford medical plans (9/1/2024)
- Advantage Tier 4 Prescription Drug List for UnitedHealthcare, Golden Rule, UnitedHealthOne, Oxford, All Savers, Neighborhood Health Plan and River Valley medical plans (1/1/2025)
- Advantage Tier 4 Prescription Drug List for UnitedHealthcare, Golden Rule, UnitedHealthOne, Oxford, All Savers, Neighborhood Health Plan and River Valley medical plans (9/1/2024)
Access
- Access Tier 3 Prescription Drug List for UnitedHealthcare, Neighborhood Health Plan, River Valley and Oxford medical plans (1/1/2025)
- Access Tier 3 Prescription Drug List for UnitedHealthcare, Neighborhood Health Plan, River Valley and Oxford medical plans (9/1/2024)
- Access Tier 4 Prescription Drug List for UnitedHealthcare, Neighborhood Health Plan, River Valley and Oxford medical plans (1/1/2025)
- Access Tier 4 Prescription Drug List for UnitedHealthcare, Neighborhood Health Plan, River Valley and Oxford medical plans (9/1/2024)
Traditional
- Traditional Tier 3 Prescription Drug List for UnitedHealthcare, River Valley, Oxford and Student Resources medical plans (1/1/2025)
- Traditional Tier 3 Prescription Drug List for UnitedHealthcare, River Valley, Oxford and Student Resources medical plans (9/1/2024)
- Traditional Tier 4 Prescription Drug List for UnitedHealthcare and Student Resources medical plans (1/1/2025)
- Traditional Tier 4 Prescription Drug List for UnitedHealthcare and Student Resources medical plans (9/1/2024)
Essential
- Essential Tier 4 Prescription Drug List for UnitedHealthcare, All Savers, Golden Rule, Neighborhood Health Plan and River Valley medical plans (1/1/2025)
- Essential Tier 4 Prescription Drug List for UnitedHealthcare, All Savers, Golden Rule, Neighborhood Health Plan and River Valley medical plans (9/1/2024)
UHC Premium
- Premium Prescription Drug List (1/1/2024)
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
- Standard Tier 4 PPO Prescription Drug List CDI Version (1/1/2025 Cycle)
- Standard Tier 4 PPO Prescription Drug List CDI Version (12/1/2024)
- Standard Tier 4 HMO and PPO Prescription Drug List DMHC Version (1/1/2025 Cycle)
- Standard Tier 4 HMO and PPO Prescription Drug List DMHC Version (12/1/2024)
Large Group - Advantage
- Large Group Tier 3 PPO Prescription Drug List CDI Version (1/1/2025 Cycle)
- Large Group Tier 3 PPO Prescription Drug List CDI Version (12/1/2024)
- Large Group Tier 3 HMO and PPO Prescription Drug List DMHC Version (1/1/2025 Cycle)
- Large Group Tier 3 HMO and PPO Prescription Drug List DMHC Version (12/1/2024)
- Large Group Tier 4 PPO Prescription Drug List CDI Version (1/1/2025 Cycle)
- Large Group Tier 4 PPO Prescription Drug List CDI Version (12/1/2024)
- Large Group Tier 4 HMO and PPO Prescription Drug List DMHC Version (1/1/2025 Cycle)
- Large Group Tier 4 HMO and PPO Prescription Drug List DMHC Version (12/1/2024)
Large Group - Access
- Access Tier 3 PPO Prescription Drug List CDI Version (1/1/2025 Cycle)
- Access Tier 3 PPO Prescription Drug List CDI Version (12/1/2024)
- Access Tier 3 HMO and PPO Prescription Drug List DMHC Version (1/1/2025 Cycle)
- Access Tier 3 HMO and PPO Prescription Drug List DMHC Version (12/1/2024)
- Access Tier 4 PPO Prescription Drug List CDI Version (1/1/2025 Cycle)
- Access Tier 4 PPO Prescription Drug List CDI Version (12/1/2024)
- Access Tier 4 HMO and PPO Prescription Drug List DMHC Version (1/1/2025 Cycle)
- Access Tier 4 HMO and PPO Prescription Drug List DMHC Version (12/1/2024)
Large Group - Essential
- Essential Tier 4 Prescription drug List DMHC Version (1/1/2025 Cycle)
- Essential Tier 4 Prescription drug List DMHC Version (12/1/2024)
Small Group - Advantage
- UHC Advantage Tier 4 Prescription Drug List (1/1/2024)
Small Group - Essential
- UHC Essential Tier 4 Prescription Drug List (1/1/2024)
Small Group - Specialty medication cost share (SMCS)
- SMCS Drug List (1/1/2024)
Small Group - Medical
- Medical Drug List (1/1/2024)
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
- UHC Advantage Tier 3 Prescription Drug List (1/1/2025)
- UHC Advantage Tier 3 Prescription Drug List (9/1/2024)
- UHC Advantage Tier 3 Prescription Drug List (5/1/2024)
- UHC Advantage Tier 4 Prescription Drug List (1/1/2025)
- UHC Advantage Tier 4 Prescription Drug List (9/1/2024)
- UHC Advantage Tier 4 Prescription Drug List (5/1/2024)
Traditional
- UHC Traditional Tier 3 Prescription Drug List (1/1/2025)
- UHC Traditional Tier 3 Prescription Drug List (9/1/2024)
- UHC Traditional Tier 3 Prescription Drug List (5/1/2024)
Access
- UHC Access Tier 3 Prescription Drug List (1/1/2025)
- UHC Access Tier 3 Prescription Drug List (9/1/2024)
- UHC Access Tier 3 Prescription Drug List (5/1/2024)
Oxford Connecticut Plans
Advantage
- Oxford Advantage Tier 3 Prescription Drug List (1/1/2025)
- Oxford Advantage Tier 3 Prescription Drug List (9/1/2024)
- Oxford Advantage Tier 3 Prescription Drug List (5/1/2024)
- Oxford Advantage Tier 4 Prescription Drug List (1/1/2025)
- Oxford Advantage Tier 4 Prescription Drug List (9/1/2024)
- Oxford Advantage Tier 4 Prescription Drug List (5/1/2024)
Traditional
- Oxford Traditional Tier 3 Prescription Drug List (1/1/2025)
- Oxford Traditional Tier 3 Prescription Drug List (9/1/2024)
- Oxford Traditional Tier 3 Prescription Drug List (5/1/2024)
Access
- Oxford Access Tier 3 Prescription Drug List (1/1/2025)
- Oxford Access Tier 3 Prescription Drug List (9/1/2024)
- Oxford Access Tier 3 Prescription Drug List (5/1/2024)
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 |
|
$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 |
|
|
| Atypical antidepressants |
|
|
| Anti-hypertensives |
|
|
| Atypical anxiolytics |
|
|
| Alpha Agonists |
|
|
| Beta blockers |
|
|
| Anti-manic agents |
|
|
| Stimulants |
|
|
| Anti-psychotics |
|
|
| GnRH analogs |
|
|
| Sex hormones |
|
|
| Nonsteroidal anti-androgens |
|
|
| 5-alpha reductase inhibitors |
|
Access
- Access Tier 3 Prescription Drug List (1/1/2025)
- Access Tier 3 Prescription Drug List (9/1/2024)
- Access Tier 3 Prescription Drug List (5/1/2024)
- Access Tier 4 Prescription Drug List (1/1/2025)
- Access Tier 4 Prescription Drug List (9/1/2024)
- Access Tier 4 Prescription Drug List (5/1/2024)
Advantage
- Advantage Tier 3 Prescription Drug List (1/1/2025)
- Advantage Tier 3 Prescription Drug List (9/1/2024)
- Advantage Tier 3 Prescription Drug List (5/1/2024)
- Advantage Tier 4 Prescription Drug List (1/1/2025)
- Advantage Tier 4 Prescription Drug List (9/1/2024)
- Advantage Tier 4 Prescription Drug List (5/1/2024)
Traditional
- Traditional Tier 3 Prescription Drug List (1/1/2025)
- Traditional Tier 3 Prescription Drug List (9/1/2024)
- Traditional Tier 3 Prescription Drug List (5/1/2024)
- Traditional Tier 4 Prescription Drug List (1/1/2025)
- Traditional Tier 4 Prescription Drug List (9/1/2024)
- Traditional Tier 4 Prescription Drug List (5/1/2024)
Essential
- Essential Tier 4 Prescription Drug List (1/1/2025)
- Essential Tier 4 Prescription Drug List (9/1/2024)
- Essential Tier 4 Prescription Drug List (5/1/2024)
Advantage
- Advantage Tier 3 Prescription Drug List (1/1/2025)
- Advantage Tier 3 Prescription Drug List (9/1/2024)
Essential
- Essential Tier 4 Prescription Drug List (1/1/2025)
- Essential Tier 4 Prescription Drug List (9/1/2024)
Advantage
- Advantage Tier 3 Prescription Drug List (9/1/2024)
- Advantage Tier 3 Prescription Drug List (5/1/2024)
- Advantage Tier 3 Prescription Drug List (1/1/2024)
- Advantage Tier 4 Prescription Drug List (9/1/2024)
- Advantage Tier 4 Prescription Drug List (5/1/2024)
- Advantage Tier 4 Prescription Drug List (1/1/2024)
Essential
- Essential Tier 4 Prescription Drug List (9/1/2024)
- Essential Tier 4 Prescription Drug List (5/1/2024)
- Essential Tier 4 Prescription Drug List (1/1/2024)
Monthly Prescription Drug List Update
Large Group - Advantage
- Large Group Advantage 1-3 Tier Prescription Drug List (3 Tier plan) (1/1/2025)
- Large Group Advantage 1-3 Tier Prescription Drug List (3 Tier plan) (9/1/2024)
- Large Group Advantage 1-4 Tier Prescription Drug List (4 Tier plan) (1/1/2025)
- Large Group Advantage 1-4 Tier Prescription Drug List (4 Tier plan) (9/1/2024)
Large Group - Access
- Large Group Access 1-3 Tier Prescription Drug List (3 Tier plan) (1/1/2025)
- Large Group Access 1-3 Tier Prescription Drug List (3 Tier plan) (9/1/2024)
- Large Group Access 1-4 Tier Prescription Drug List (4 Tier plan) (1/1/2025)
- Large Group Access 1-4 Tier Prescription Drug List (4 Tier plan) (9/1/2024)
Large Group - Essential
- Large Group Essential 1-4 Tier Prescription Drug List (4 Tier plan) (1/1/2025)
- Large Group Essential 1-4 Tier Prescription Drug List (4 Tier plan) (9/1/2024)
Small Group - Essential
Advantage
- Advantage Prescription Drug List update summary March 2025
- Advantage Prescription Drug List update summary Feb 2025
- Advantage Prescription Drug List update summary Jan 2025
Traditional
- Traditional Prescription Drug List update summary March 2025
- Traditional Prescription Drug List update summary Feb 2025
- Traditional Prescription Drug List update summary Jan 2025
Access
- Access Prescription Drug List update summary March 2025
- Access Prescription Drug List update summary Feb 2025
- Access Prescription Drug List update summary Jan 2025
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
- Advantage Tier 3 Prescription Drug List (1/1/2025)
- Advantage Tier 3 Prescription Drug List (9/1/2024)
Essential
- Essential Tier 4 Prescription Drug List (1/1/2025)
- Essential Tier 4 Prescription Drug List (9/1/2024)
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
- Advantage and Essential Zero Cost Share Preventive Medications (1/1/2025)
- Advantage and Essential Zero Cost Share Preventive Medications (9/1/2024)
Traditional, Access and Enhanced
California Preventive Care Medication Lists
Advantage and Essential HMO and PPO
- Advantage and Essential HMO and PPO Zero Cost Share Preventive Medications (1/1/2025)
- Advantage and Essential HMO and PPO Zero Cost Share Preventive Medications (9/1/2024)
Traditional, Access, and Enhanced HMO and PPO
Advantage and Essential
- Advantage and Essential Zero Cost Share Preventive Medications (1/1/2025)
- Advantage and Essential Zero Cost Share Preventive Medications (9/1/2024)
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
- Advantage and Essential Zero Cost Share Preventive Medications (1/1/2025)
- Advantage and Essential Zero Cost Share Preventive Medications (9/1/2024)
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:
- Contraceptive Services Only drug list (all states other than those below), effective January 1, 2025
- Contraceptive Services Only drug list (all states other than those below), effective September 1, 2024
- Emergency Contraceptive Services Only drug list (all states), effective January 1, 2025
- Emergency Contraceptive Services Only drug list (all states), effective September 1, 2024
If your benefit plan is based in California and fully insured:
- CA Contraceptive Services Only drug list, effective January 1, 2025
- CA Contraceptive Services Only drug list, effective September 1, 2024
If your benefit plan is based in Connecticut, District of Columbia, Delaware, Illinois, Massachusetts, Maryland, Oregon, or Washington, and fully insured:
- CT/DC/DE/IL/MA/MD/OR/WA Contraceptive Services Only drug list, effective January 1, 2025
- CT/DC/DE/IL/MA/MD/OR/WA Contraceptive Services Only drug list, effective September 1, 2024
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
- Preventive Medication List: Core (1/1/2025)
- Preventive Medication List: Core (9/1/2024)
- Preventive Medication List: Core Plus (1/1/2025)
- Preventive Medication List: Core Plus (9/1/2024)
- Preventive Medication List: Expanded (1/1/2025)
- Preventive Medication List: Expanded (9/1/2024)
- Preventive Medication List: Federal Guided (1/1/2025)
- Preventive Medication List: Federal Guided (9/1/2024)
- Preventive Medication List: Universal (1/1/2025)
- Preventive Medication List: Universal (9/1/2024)
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