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Your 2017

Prescription Drug List


Effective July 1, 2017

This Prescription Drug List (PDL) outlines the most commonly prescribed medications
for certain conditions and organizes them into cost levels, also known as tiers.

For additional information:

Visit myuhc.com for information to help you better understand and


manage your medications.
View your current benefits
Search for drug prices and lower-cost alternatives
Potentially save time and money using home delivery through OptumRx

Call the toll-free member phone number on your health plan ID card.

1
Table of Contents
Drug tiers and cost . . . . . . . . . . . . . . . . . . . . . . . 3 Gastrointestinal
Programs and Limits . . . . . . . . . . . . . . . . . . . . . . 5 Acid Suppression. . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Drugs by category . . . . . . . . . . . . . . . . . . . . . . . . 8 Nausea/Vomiting. . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Anti-Infectives
Antibiotics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Gout. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Hepatitis C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 HIV/AIDS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Cardiovascular/Heart Disease Inflammatory Conditions: Rheumatoid
Coagulation Therapy . . . . . . . . . . . . . . . . . . . . . . . . . 9 Arthritis, Crohns Disease, Psoriasis,
High Blood Pressure. . . . . . . . . . . . . . . . . . . . . . . . . 9 Ulcerative Colitis. . . . . . . . . . . . . . . . . . . . . . . . . 17
High Cholesterol. . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Mens Health
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Erectile Dysfunction. . . . . . . . . . . . . . . . . . . . . . . . . 18
Central Nervous System Prostate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Attention Deficit Disorder. . . . . . . . . . . . . . . . . . . . 11 Testosterone Therapy . . . . . . . . . . . . . . . . . . . . . . . 18
Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Miscellaneous. . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Migraine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Musculoskeletal
Multiple Sclerosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Muscle Spasms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Osteoporosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Sedatives/Hypnotics. . . . . . . . . . . . . . . . . . . . . . . . 12 Pain Relief. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Seizure Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Overactive Bladder. . . . . . . . . . . . . . . . . . . . . . . 20
Dermatology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Respiratory
Diabetes/Endocrine
Allergies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Blood Glucose Monitoring. . . . . . . . . . . . . . . . . . . 14
Asthma/COPD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Pulmonary Arterial Hypertension. . . . . . . . . . . . . 21
Non-Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Smoking Cessation . . . . . . . . . . . . . . . . . . . . . . 21
Endocrine
Transplant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Growth Hormone. . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Vitamins/Electrolytes. . . . . . . . . . . . . . . . . . . . 21
Thyroid Hormone Replacement. . . . . . . . . . . . . . 15 Womens Health
Eye Conditions Contraceptives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Allergies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Hormone Replacement. . . . . . . . . . . . . . . . . . . . . . 23
Antibiotics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Miscellaneous. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Dry Eye Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Prenatal Vitamins . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Glaucoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
2
At UnitedHealthcare, we want to help you better
understand your medication options.
Your pharmacy benefit offers flexibility and choice in determining the right medication
for you. To help you get the most out of your pharmacy benefit, weve included some of
the most commonly asked questions about the Prescription Drug List.

What is a Prescription Drug List (PDL)?


This document is a list of commonly prescribed medications. Medications are listed by common
categories or class. They are placed into cost levels known as tiers. It includes both brand and generic
prescription medications approved by the Food and Drug Administration (FDA).
Please note: Where differences are noted between this PDL and your benefit plan documents, the
benefit plan documents will rule. It is not a complete list of medications, and not all medications listed
may be covered under your plan. Please look at your benefit plan documents provided by your employer
or health plan to see what medications are covered under your plan. You may also log in to myuhc.com or
call the toll-free member phone number on your health plan ID card for more information.

How do I use my PDL?


When choosing a medication, you and your doctor should consult the PDL. It will help you and your
doctor choose the most cost-effective prescription drugs. This guide tells you if a medication is generic
or brand, and if special programs apply. Bring this list with you when you see your doctor. It is organized
by common medical conditions. Medications are then listed alphabetically.
If your medication is not listed in this document, please visit myuhc.com or call the toll-free member
phone number on your health plan ID card.

3
What are tiers?
Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, which is
determined by your employer or health plan. This is how much you will pay when you fill a prescription.
Tier 1 medications are your lowest-cost options. If your medication is placed in Tier 2 or 3, look to see if
there is a Tier 1 option available. Discuss these options with your doctor.
Check your benefit plan documents to find out your specific pharmacy plan costs.

$ Drug tier Includes Helpful tips


Tier 1 Some brands and generics Use Tier 1 drugs for the lowest
Your lowest are also included. outof-pocket costs.
cost

Tier 2 Mix of brands and Use Tier 2 drugs instead of


Your mid-range generics. Tier 3 to help reduce your
cost out-of-pocket costs.

Tier 3 Mostly brand as well as Many Tier 3 drugs have


Your highest select generic drugs. lowercost options in Tier 1 or 2.
cost Ask your doctor if they could
work for you.

Please note: Some plans may have two or four tiers, while others may not have any. If you have a high
deductible plan, the tier cost levels may apply once you hit your deductible. Refer to your enrollment
and plan materials on myuhc.com, or call the toll-free number on your health plan ID card for more
information about your benefit plan.

When does the PDL change?


Medications may move to a lower tier at any time.
Medications may move to a higher tier when a generic becomes available.
Medications may move to a higher tier or be excluded from coverage most often on
January 1 or July 1.
When a medication changes tiers, you may have to pay a different amount for that medication.
For the most up-to-date list, call customer service at the number on your ID card.

4
Programs and limits
Some medications are noted with letters next to them. The letters refer to our pharmacy benefit
programs. Your benefit plan determines how these medications are covered and may differ than what
is noted in the PDL. Call the number for Member Services listed on your ID card if you have any
questions about your prescription drug coverage.

Designated specialty program Specialty medications need to be filled


DSP at a designated specialty pharmacy for network coverage. Call the number on your
ID card or call 1-888-739-5820 for more information.

May be excluded from coverage or subject to prior authorization and/or trial/


E
failure of another medication(s).+ Lower-cost options are available and covered.

Health care reform preventive This medication is part of a health care reform
H
preventive benefit and may be available at no cost to you.

Multiple copay More than one months worth of medication included in package so
MC
additional copay applies.

Prior authorization required* Your doctor is required to provide additional


PA
information to us to determine coverage.

Refill and save program Save money on your copayment when you refill your
RS
prescription on time as prescribed. Program eligibility may vary.

Supply limit Amount of medication covered per copayment or in a specific


SL
time period.
+
Step therapy Trial of a different medication is required before another medication
ST
may be covered.

*Depending on your benefit, you may have notification or medical necessity requirements for select medications.
+
For New Jersey fully insured members, this program is referred to as First Start.

To learn more about a pharmacy program or to find out if it applies to you, please visit myuhc.com or
call the toll-free member phone number on your health plan ID card.

5
Why are some medications excluded from coverage?
A medication may be excluded from coverage under your pharmacy benefit when it works the same or
similar as another prescription medication or an over-the-counter (OTC) medication. Other medication
options may be available.

Should I talk to my doctor about over-the-counter (OTC)


medications?
An OTC medication may be the right treatment for some conditions. Talk to your doctor about
available options.

What is the difference between brand-name and generic


medications?
Generic medications contain the same active ingredients (what makes the medication work) as brand-
name medications, but they often cost less. Once the patent of a brand-name medication ends, the FDA
can approve a generic version with the same active ingredients. These types of medications are known
as generic medications. Sometimes, the same company that makes a brand-name medication also makes
the generic version.

Is it a generic or brand-name drug?


The drug list shows brand-name drugs in bold type (for example, Invokana) and generic drugs in plain
type (for example, Metformin).

What if my doctor writes a brand-name prescription?


The next time your doctor gives you a prescription for a brand-name medication, ask if a generic
equivalent or lower-cost option is available and if it might be right for you. Generic medications
are usually your lowest-cost option, but not always. For some benefit plans, if a brand-name drug
is prescribed and a generic equivalent is available, your cost share may be the copay PLUS the cost
difference between the brand-name drug and generic equivalent. Visit myuhc.com to make sure.

Are you taking a specialty medication?


Specialty medications are high-cost and are used to treat rare or complex conditions that require
additional care and support. For most plans, these medications are managed through the Specialty
Pharmacy Program. Take advantage of personalized support designed to help you get the most out of
your treatment plan. Visit UHCSpecialtyRx.com or call the toll-free phone number on your health plan
ID card to learn more.
Please note, not all specialty medications are listed here. If youre taking a specialty medication that is
on Tier 3, call the toll-free number on your health plan ID card to talk with a pharmacist about finding
lower-cost options or a financial assistance program.

6
What is OptumRx Mail Service Member Select?
Your plan may include a home delivery program called Mail Service Member Select. The program
encourages you to use the home delivery through OptumRx for maintenance medications, which are
medications you take regularly. Home delivery can help you better manage the medication you take on a
regular basis, and may save you time and money.
Once the program starts, you have a limited number of fills at your retail pharmacy. If you do not
confirm your home delivery enrollment, you may pay more for your medication until you do. You can also
choose to disenroll from the program to continue filling at your retail pharmacy for your standard copay or
cost share.

How do I get updated information about my pharmacy


benefit?
Since the PDL may change during your plan year, we encourage you to visit myuhc.com or call the
toll-free member phone number on your health plan ID card for more current information.
Log in to myuhc.com for the following pharmacy information and tools:
Pharmacy benefit and coverage information
Possible lower-cost medication options
Medication interactions and side effects
Participating retail pharmacies by ZIP code
Your prescription history
And, if home delivery services are included in your pharmacy benefit, you can also:
Refill prescriptions
Check the status of your order
Set up reminders for refills
Manage your account

For more information


Call the toll-free member phone number on your health plan ID card
Or, visit myuhc.com

In certain documents, the Prescription Drug List (PDL) was referred to as the Preferred Drug List (PDL). This change in terms does not affect your benet coverage.
Medications are categorized by common therapeutic conditions in this PDL for ease of reference only. These categories do not determine coverage for the medication for your condition.
Your benet plan determines coverage for these medications.

7
Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Ofloxacin Tablet 1
Anti-Infectives: Antibiotics
Oracea 3
Amoxicillin Capsule, Penicillin V Potassium
1 1
Chewable Tablet Tablet
Amoxicillin/Potassium Sulfamethoxazole-
1
Clavulanate Chewable 1 Trimethoprim Tablet
Tablet, Tablet Suprax Capsule,
Azithromycin Tablet 1 Chewable Tablet, 3
Cefadroxil Capsule, Tablet
1
Tablet
Anti-Infectives: Antifungals
Cefdinir Capsule 1
Cefixime Suspension 3 Cresemba 3 SL
Cefprozil Tablet 1 Econazole Cream 3 SL
Cefuroxime Tablet 1 Fluconazole Tablet 1
Cephalexin Capsule 1 Itraconazole Capsule 1 SL
Ciprodex 3 Ketoconazole Cream 1
Ciprofloxacin Tablet 1 Noxafil Tablet,
2
Clarithromycin Tablet 1 Suspension
Clindamycin Capsule 1 Nystatin Cream,
1
Dificid 3 SL Ointment
Doxycycline Hyclate Terbinafine Tablet 1 SL
50, 100 mg Capsule, 2
Anti-Infectives: Antivirals
Tablet
Doxycycline Monohydrate Acyclovir Ointment 3 PA, SL, ST
1
50, 100 mg Capsule Acyclovir Tablet 1
Levofloxacin Tablet 1 Famciclovir Tablet 2
Metronidazole Tablet 1 Oseltamivir Capsule 2 SL
Minocycline Capsule 1 Valacyclovir Tablet 1 SL
Minocycline Tablet 3 E Valganciclovir 1 SL
Moxifloxacin Tablet 3 Zovirax Cream 3 E, SL
Nitrofurantoin Capsule 1
Nitrofurantoin
1
Macrocrystal Capsule
Ofloxacin Otic Solution 2

Bold type = Brand-name drug MC = Multiple copay


[Plain type = Generic drug] PA = Prior authorization required
DSP = Designated specialty program RS = May be eligible for the refill and save program
E = May be excluded from coverage SL = Supply limit
H = Health care reform preventive ST = Step therapy
8
Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Benazepril-
Cancer 1
Hydrochlorothiazide
Bexarotene Capsule 3 DSP, E, PA, SL Benicar 3 E, SL
Bicalutamide 1 Benicar HCT 3 E, SL
Bosulif 2 DSP, PA, SL, ST Bidil 2
Cyclophosphamide Bisoprolol 1
2
Capsule Bisoprolol-
1
Hydroxyurea Capsule 1 Hydrochlorothiazide
Imatinib Tablet 1 DSP, PA, SL Bystolic 2
Imbruvica 2 DSP, PA, SL Cartia XT 2
Leucovorin Calcium Carvedilol 1
1
Tablet Chlorthalidone 1
Mercaptopurine Tablet 1 Clonidine Tablet 1
Revlimid 2 DSP, PA, SL Diltiazem 24 Hour CD 2
Sutent 2 DSP, PA, SL Diltiazem Sustained-
2
Targretin Capsule 2 DSP Release Capsule
Targretin Gel 3 SL Diltiazem Sustained-
2
Tasigna 2 DSP, PA, SL, ST Release Tablet
Xeloda 1 DSP, SL Doxazosin 1
Zytiga 2 DSP, PA, SL Dutoprol 2 SL
Cardiovascular/Heart Disease: Edarbi 3 SL
Coagulation Therapy Edarbyclor 3 SL
Brilinta 3 SL Enalapril 1
Clopidogrel 1 Furosemide 1
Effient 3 SL Guanfacine 1
Eliquis 3 SL Hydralazine 1
Enoxaparin Sodium 2 SL Hydrochlorothiazide 1
Pradaxa 2 SL Irbesartan 1
Savaysa 3 SL Labetalol 1
Warfarin Sodium 1 Lisinopril 1
Xarelto 2 SL Lisinopril-
1
Cardiovascular/Heart Disease: Hydrochlorothiazide
High Blood Pressure Losartan 1
Amlodipine 1 Losartan-
1
Amlodipine-Benazepril 1 Hydrochlorothiazide
Amlodipine-Valsartan 2 Metoprolol Succinate
2
Atenolol 1 50, 100, 200 mg
Atenolol-Chlorthalidone 1 Metoprolol Tartrate
1
Benazepril 1 25, 50, 100 mg

9
Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Nadolol 1 Fluvastatin Extended-
3 SL, ST
Nifedipine Release Tablet
1
Extended-Release Gemfibrozil 1
Olmesartan 2 SL Lipofen 3 E
Olmesartan- Livalo 3 SL, ST
2 SL
Hydrochlorothiazide Lovastatin 1
Propranolol Extended- Niacin Extended-
2 3
Release Capsule Release Tablet
Propranolol Tablet 1 Niaspan 2
Quinapril 1 Omega-3-Acid Ethyl
3 PA
Ramipril 1 Esters Capsule
Spironolactone 1 Praluent 2 DSP, PA, SL, ST
Telmisartan 2 Pravastatin 1
Telmisartan- Repatha 140 mg 3 DSP, PA, SL, ST
2
Hydrochlorothiazide Rosuvastatin 2 SL
Terazosin 1 Simvastatin 1
Triamterene- Vascepa 3 PA
1
Hydrochlorothiazide Vytorin 3 SL
Valsartan 2 Welchol 2
Valsartan- Zetia 3 E, SL
1
Hydrochlorothiazide
Cardiovascular/Heart Disease: Other
Verapamil 1
Verapamil Amiodarone 1
3
Sustained-Release Corlanor 3 PA, SL
Cardiovascular/Heart Disease: Digoxin 1
High Cholesterol Entresto 3 PA, SL
Atorvastatin 1 SL Flecainide 1
Choline Fenofibrate 3 E Isosorbide
Ezetimibe Tablet 3 SL 1
Mononitrate ER
Fenofibrate 43, 50, 67, Multaq 3 PA
130, 134, 150, 200 mg 3 E Nitroglycerin Sublingual
Capsule 1
Tablet
Fenofibrate 40, 48, 120, Ranexa 2
3 E
145 mg Tablet Sotalol 1
Fenofibrate
2
54, 160 mg Tablet

Bold type = Brand-name drug MC = Multiple copay


[Plain type = Generic drug] PA = Prior authorization required
DSP = Designated specialty program RS = May be eligible for the refill and save program
E = May be excluded from coverage SL = Supply limit
H = Health care reform preventive ST = Step therapy
10
Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Central Nervous System:
Central Nervous System: Depression
Attention Deficit Disorder
Adderall XR 2 PA, SL Amitriptyline Tablet 1
Amphetamine Salt Bupropion Extended-
1 PA 1
Combo Release Tablet
Concerta 2 PA, SL Bupropion Sustained-
1
Daytrana 3 E, PA, SL Release Tablet
Dexmethylphenidate Bupropion Tablet 1
Extended-Release 3 E, PA, SL Citalopram Tablet 1
Capsule Desvenlafaxine
Dexmethylphenidate Extended-Release 3 RS, SL
Immediate-Release 1 PA Tablet (generic Pristiq)
Tablet Doxepin 1
Dextroamphetamine- Duloxetine Capsule 3 SL
Amphetamine 3 E, PA, SL Escitalopram Tablet 1
Extended-Release Fetzima 3 SL, ST
Dextroamphetamine- Fluoxetine Tablet,
Amphetamine Capsule (generic 1
1 PA
Immediate-Release Prozac)
Capsule Fluvoxamine Tablet 1
Dextroamphetamine Mirtazapine Tablet 1
Sulfate Immediate- 3 PA Nortriptyline Capsule 1
Release Tablet Paroxetine Tablet 1
Focalin XR 3 E, PA, SL Sertraline Tablet 1
Guanfacine Trazodone Tablet 1
2 SL
Extended-Release Trintellix 3 SL, ST
Metadate CD 3 E, PA, SL Venlafaxine Extended-
Methylphenidate 1
3 PA Release Capsule
Chewable Tablet Venlafaxine Tablet 1
Methylphenidate Viibryd 3 SL
Extended-Release
Capsule (generic 2 PA, SL Central Nervous System: Migraine
Metadate CD, Acetaminophen/
Ritalin LA) Butalbital/Caffeine 1 SL
Methylphenidate 325 mg/50 mg/40 mg
Extended-Release Tablet 3 E, PA, SL Frovatriptan 3 SL
(generic Concerta) Naratriptan 1 SL
Methylphenidate Relpax 2 SL
Extended-Release 3 PA, SL Rizatriptan ODT, Tablet 1 SL
Tablet (Metadate ER) Sumatriptan Nasal Spray 2 SL
Methylphenidate Tablet 1 PA
Strattera 3 SL
Vyvanse 2 PA, SL

11
Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Sumatriptan Naloxone Vials 1
Succinate Tablet, 1 SL Narcan Nasal Spray 2 SL
Injection Olanzapine Tablet 1 SL
Central Nervous System: Pramipexole Tablet 1
Multiple Sclerosis Quetiapine Extended-
3 SL
Ampyra 2 DSP, PA, SL Release Tablet
Aubagio 3 DSP, PA, SL Quetiapine Tablet 1
Avonex 2 DSP, PA, SL Risperidone Tablet 1
Betaseron 2 DSP, PA, SL Ropinirole Tablet 1
Copaxone 2 DSP, PA, SL Suboxone Film 3 E, PA, SL
Gilenya 3 DSP, PA, SL Tolcapone 2
DSP, E, PA, Xyrem 3 PA, SL
Glatopa 3
SL, ST Zelapar 3
Plegridy 3 DSP, PA, SL Ziprasidone Capsule 2 SL
Rebif 3 DSP, PA, SL, ST Zubsolv 2 SL
Tecfidera 2 DSP, PA, SL Central Nervous System:
Zinbryta 3 DSP, PA, SL Sedatives/Hypnotics
Eszopiclone Tablet 2 SL
Central Nervous System: Other
Temazepam Capsule 1
Alprazolam Extended- Triazolam Tablet 1
1
Release Tablet Zaleplon Capsule 1 SL
Alprazolam Tablet 1 Zolpidem Extended-
3 E, SL
Aripiprazole Tablet 2 SL Release Tablet
Armodafanil 3 E, PA, SL Zolpidem Tablet 1 SL
Buprenorphine/ Central Nervous System:
3 E, PA, SL
Naloxone Tablet Seizure Disorders
Buspirone Tablet 1 Carbamazepine
Carbidopa-Levodopa 1 Extended-Release 2
Diazepam Tablet 1 Capsule
Donepezil 5, 10 mg Carbamazepine
1
ODT, Tablet Extended-Release 3
Latuda 3 SL Tablet
Lithium Capsule 1 Carbamazepine
Lorazepam Tablet 1 Immediate-Release 1
Memantine Tablet 2 Tablet
Modafinil Tablet 3 PA, SL Clonazepam Tablet 1

Bold type = Brand-name drug MC = Multiple copay


[Plain type = Generic drug] PA = Prior authorization required
DSP = Designated specialty program RS = May be eligible for the refill and save program
E = May be excluded from coverage SL = Supply limit
H = Health care reform preventive ST = Step therapy
12
Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Diazepam Tablet 1 Claravis 2 PA
Divalproex Delayed- Clindamycin 1%/
1 3 E, SL
Release Tablet Benzoyl Peroxide 5% Gel
Divalproex Extended- Clindamycin 1.2%/
2 3 SL
Release Tablet Benzoyl Peroxide 5% Gel
Gabapentin Capsule, Clindamycin Gel 3 SL
1
Tablet Clindamycin Lotion 3
Lamotrigine Immediate- Clindamycin Solution,
1 1
Release Tablet Swabs
Levetiracetam Clobetasol Propionate
2 SL
Extended-Release 2 Cream, Ointment
Tablet Clobetasol Propionate
1 SL
Levetiracetam Solution
Immediate-Release 1 Clotrimazole-
1 SL
Tablet Betamethasone Cream
Lyrica 3 SL, ST Clotrimazole-
1
Oxcarbazepine Tablet 1 Betamethasone Lotion
Phenytoin Capsule, Desonide 0.05% Cream,
1 3 SL
Suspension Lotion, Ointment
Topiramate Immediate- Desoximetasone Gel,
1 3 SL
Release Tablet Ointment
Zonisamide Capsule 1 Differin 0.1% Cream,
3 E, PA, SL
Gel, Lotion
Dermatology
Diflorasone Diacetate
3 SL
Aczone 3 SL 0.05% Cream, Ointment
Adapalene 0.1% Enstilar Foam 3 SL
3 E, PA, SL
Cream, Gel, Lotion Epiduo/Epiduo Forte 3 E, SL
Adapalene 0.3% Gel 3 E, PA, SL Finacea 3
Betamethasone Fluocinolone Cream,
3 SL
Dipropionate 0.05% Oil, Solution
3
Augmented Lotion, Fluocinolone Ointment 2 SL
Ointment Fluocinonide 0.05%
1
Betamethasone Cream
Dipropionate 0.05% 2 Halobetasol Ointment 2
Cream, Ointment Hydrocortisone 2.5%
1
Calcipotriene/ Cream, Ointment
Betamethasone 3 SL Imiquimod 5% Cream 1 SL
Ointment Metronidazole 0.75%
Carac 2 1
Topical Gel
Ciclopirox Cream, Gel, Minocycline Extended-
1 3 E
Lotion, Solution Release Capsule

13
Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Mirvaso 3 SL OneTouch Ultra Mini 1
Mometasone Furoate OneTouch Ultra
1 1 SL
Cream, Lotion, Ointment Test Strips
Mupirocin Ointment 1 SL OneTouch Verio 1
Nystatin-Triamcinolone OneTouch Verio Flex 1
Acetonide Cream, 3 E OneTouch Verio IQ 1
Ointment OneTouch Verio Sync 1
Oxsoralen-Ultra 2 OneTouch Verio
1 SL
Picato 3 SL Test Strips
Regranex 2 PA, SL
Diabetes: Insulin
Solodyn 3 E, PA
Taclonex Suspension 3 SL Afrezza 3 E, PA, SL, ST
Tacrolimus Ointment 2 PA, SL Basaglar 1 SL
Tazorac 3 PA, SL Humalog KwikPens
2 SL
Tretinoin Cream 3 PA, SL (all formulations)
Tretinoin Gel 3 E, PA, SL Humalog Vials
1 SL
Tretinoin Microspheres 3 E, PA, SL (all formulations)
Triamcinolone Acetonide Humulin KwikPens
1 2 SL
Cream, Lotion, Ointment (all formulations)
Vectical 3 SL Humulin Vials
1 SL
(all formulations)
Diabetes: Blood Glucose Monitoring
Lantus Solostar 3 E, SL
Accu-Chek Lantus Vials 3 E, SL
3 E, SL
Test Strips Levemir FlexTouch 2 SL
Contour Test Strips 3 E, SL Levemir Vials 2 SL
Dexcom Continuous Novolin Vials
3 SL, ST
Glucose Monitoring 3 PA, SL (all formulations)
System Novolog FlexTouch
3 SL, ST
Dexcom Sensor 3 PA, SL (all formulations)
Dexcom Transmitter 3 PA, SL Novolog Vials
3 SL, ST
FreeStyle Test Strips 3 E, SL (all formulations)
OneTouch Soliqua 2 PA, SL
1 SL
Test Strips Toujeo SoloStar 3 E, SL
OneTouch Ultra Tresiba FlexTouch 3 E, SL
1
Meter

Bold type = Brand-name drug MC = Multiple copay


[Plain type = Generic drug] PA = Prior authorization required
DSP = Designated specialty program RS = May be eligible for the refill and save program
E = May be excluded from coverage SL = Supply limit
H = Health care reform preventive ST = Step therapy
14
Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits

Diabetes: Non-Insulin Endocrine: Other


Adlyxin 3 SL Calcitriol Capsule 1
Bydureon 2 SL Desmopressin Tablet 1
Byetta 2 SL Dexamethasone Tablet 1
Farxiga 3 SL, ST Methylprednisolone
1
Glimepiride 1 Tablet
Glipizide 1 Prenisolone Oral
1
Glipizide Solution
1
Extended-Release Prednisone Tablet 1
Glyburide 1 Endocrine: Thyroid Hormone
Glyxambi 3 E, SL, ST Replacement
Invokamet 2 SL Armour Thyroid 3
Invokamet XR 2 SL Levothyroxine Sodium
1
Invokana 2 SL, ST Tablet
Janumet 3 SL, ST Liothyronine Sodium
2
Januvia 3 SL, ST Tablet
Jardiance 2 SL, ST Methimazole Tablet 1
Jentadueto 2 SL NP Thyroid Tablet 1
Jentadueto XR 2 SL Synthroid 2
Kazano 2 SL
Eye Conditions: Allergies
Kombiglyze XR 2 SL
Metformin 1 Azelastine 0.05%
1 SL
Metformin Extended- Ophthalmic Solution
Release Tablet (generic 1 Lastacaft 3 SL
Glucophage XR) Olopatadine 0.1%
3 SL
Nesina 2 SL Ophthalmic Solution
Onglyza 2 SL Pataday 3 E, SL
Oseni 2 SL
Eye Conditions: Antibiotics
Pioglitazone 1 SL
Synjardy 2 SL Erythromycin 0.5%
1
Tanzeum 2 SL Ophthalmic Ointment
Tradjenta 2 SL Gentamicin Ophthalmic
1
Trulicity 3 SL Ointment, Solution
Victoza 2-Pak 2 SL Moxeza 3
Victoza 3-Pak 3 SL Ofloxacin 0.3%
1
Xigduo XR 3 E, SL, ST Ophthalmic Solution
Tobramycin/
Endocrine: Growth Hormone Dexamethasone
2
Nutropin, 0.3%-0.1% Ophthalmic
2 DSP, PA, SL Suspension
Nutropin AQ

15
Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Tobramycin Ophthalmic
1 Gastrointestinal: Nausea/Vomiting
Solution
Vigamox 3 Akynzeo 3 SL
Aprepitant Capsule 2 SL
Eye Conditions: Dry Eye Disease
Emend Suspension 2 SL
Restasis Single Use Ondansetron 1
3 PA, SL
Vials Ondansetron ODT 1
Xiidra 3 PA, SL Transderm-Scop 3
Varubi 2 SL
Eye Conditions: Glaucoma
Gastrointestinal: Other
Alphagan P 0.1% 2 SL
Azopt 2 SL Amitiza 3 PA, SL, ST
Combigan 2 SL Apriso 2
Latanoprost 0.005% Asacol HD Tablet 3 E
1
Ophthalmic Solution Canasa 2
Lumigan 2 SL Cortifoam 2
Timolol Maleate 0.25%, Creon 2
0.5% Ophthalmic 1 Delzicol 3 E
Solution Diphenoxylate-Atropine
Travatan Z 2 SL 1
Tablet
Gastrointestinal: Acid Suppression Golytely 2
Hyoscyamine Tablet 1
Dexilant 3 SL Lialda 2
Esomeprazole Capsule 3 E, SL Linzess 2 PA, SL
Lansoprazole Capsule 3 E, SL Metoclopramide Tablet 1
Omeclamox-Pak 3 SL Movantik 2 PA, SL
Omeprazole Capsule 1 Moviprep 3
Pantoprazole Tablet 1 Polyethylene
Pylera 3 SL 2
Glycol 3350
Ranitadine Syrup 1 Prepopik 3
Rabeprazole Tablet 3 SL Suclear 3
Sucralfate Tablet 1 Sulfasalazine Tablet 1
Suprep 3
Uceris Foam 2
Uceris Tablet 3
Viberzi 3 PA, SL
Zenpep 2

Bold type = Brand-name drug MC = Multiple copay


[Plain type = Generic drug] PA = Prior authorization required
DSP = Designated specialty program RS = May be eligible for the refill and save program
E = May be excluded from coverage SL = Supply limit
H = Health care reform preventive ST = Step therapy
16
Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Selzentry 2 DSP, PA
Gout
Stribild 3 DSP, ST
Allopurinol Tablet 1 Sustiva 2 DSP
Colcrys 3 E Tivicay 3 DSP
Mitigare 2 Triumeq 2 DSP
Uloric 3 SL, ST Truvada 3 DSP
Zurampic 3 PA, SL Tybost 2 DSP
Viread 2 DSP
Hepatitis C
Vitekta 2 DSP
Daklinza 3 DSP, PA, SL, ST
Infertility*
Epclusa 2 DSP, PA, SL
Harvoni 2 DSP, PA, SL Cetrotide 2 DSP
Ribavirin Tablet 1 DSP Clomiphene 1 DSP
Sovaldi 2 DSP, PA, SL, ST Gonal-F 2 DSP
Technivie 3 DSP, PA, SL, ST Gonal-F RFF 2 DSP
Viekira Pak 3 DSP, PA, SL, ST Ovidrel 3 DSP
Zepatier 3 DSP, PA, SL, ST *Coverage is determined by the consumers prescription drug benefit plan.
Inflammatory Conditions: Rheumatoid
HIV/AIDS
Arthritis, Crohns Disease, Psoriasis,
Abacavir-Lamivudine 2 DSP Ulcerative Colitis
Atripla 2 DSP Actemra 3 DSP, PA, SL, ST
Complera 3 DSP Cimzia 2 DSP, PA, SL
Descovy 3 DSP Cosentyx 3 DSP, PA, SL, ST
Epzicom 3 DSP, E Enbrel 3 DSP, PA, SL, ST
Evotaz 2 DSP Humira 2 DSP, PA, SL
Genvoya 3 DSP, ST Hydroxychloroquine
1
Intelence 2 DSP Sulfate
Isentress 2 DSP Leflunomide 1
Kaletra Tablet 2 DSP Methotrexate Tablet 1
Lamivudine-Zidovudine 1 DSP Orencia 3 DSP, PA, SL, ST
Lopinavir-Ritonavir Otezla 3 DSP, PA, SL, ST
2 DSP
Oral Solution Otrexup 3 E, SL, ST
Nevirapine 1 DSP Rasuvo 3 SL, ST
Nevirapine Simponi 2 DSP, PA, SL
3 DSP, E
Extended-Release Stelara 2 DSP, PA, SL
Norvir 2 DSP Taltz 3 DSP, PA, SL, ST
Odefsey 3 DSP Xeljanz 3 DSP, PA, SL, ST
Prezcobix 2 DSP Xeljanz XR 3 DSP, PA, SL, ST
Prezista 2 DSP
Reyataz 2 DSP

17
Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Bethkis 2 DSP, PA, SL
Mens Health: Erectile Dysfunction
Bromfed DM 3
Cialis 3 SL Cayston 2 PA, SL
Levitra 3 SL Cerdelga 2 DSP, PA
Stendra 3 PA, SL Chlorhexidine Gluconate 1
Viagra 3 SL Chlorpheniramine/
Hydrocodone/
Mens Health: Prostate 2 SL
Pseudoephedrine
Alfuzosin Tablet 1 Solution
Cialis 3 SL, ST Epinephrine (generic
2 SL
Doxazosin Tablet 1 EpiPen/EpiPen-Jr.)
Dutasteride Capsule 3 PA EpiPen/EpiPen-Jr. 3 E, SL
Finasteride Tablet 1 Fosrenol 3
Rapaflo 3 Hydrocodone/
Tamsulosin Capsule 1 Chlorpheniramine 3 SL
Terazosin Capsule, Tablet 1 Suspension
Hydrocodone/
Mens Health: Testosterone Therapy 1
Homatropine
Androderm 2 PA, SL Letrozole Tablet 1
Androgel 3 E, PA, SL Lidocaine Transdermal
3 PA, SL
Patch
Methyltestosterone
2 Nuedexta 2
Capsule
Testim 2 PA, SL Obredon 3 SL, ST
Testosterone 1% Pegasys 2 DSP, PA, SL
3 E, PA, SL Phenazopyridine 1
Topical Gel
Testosterone Cypionate Procrit 2 DSP, SL
1 Promethazine/Codeine 1
Injection
Promethazine/
Miscellaneous 1
Dextromethorphan
Anastrozole Tablet 1 Pulmozyme 2 DSP, PA, SL
Antipyrine/Benzocaine Rectiv 3 SL
1 Renvela 2
Otic Solution
Aranesp 2 DSP, SL Rezira 3
Auryxia 3 Tobi Podhaler 3 DSP, PA, SL
Auvi-Q 3 E, SL Tobramycin Nebulized
3 DSP, E, PA, SL
Benzonatate Capsule 1 Solution

Bold type = Brand-name drug MC = Multiple copay


[Plain type = Generic drug] PA = Prior authorization required
DSP = Designated specialty program RS = May be eligible for the refill and save program
E = May be excluded from coverage SL = Supply limit
H = Health care reform preventive ST = Step therapy
18
Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Velphoro 2 Hydromorphone Tablet 1
Veltassa 3 PA, SL Hysingla 3 E, PA, SL, ST
Zarxio 2 DSP Ibuprofen Tablet 1
Indomethacin Capsule 1
Musculoskeletal: Muscle Spasms
Ketorolac Tablet 1
Baclofen Tablet 1 Lazanda 3 PA, SL
Carisoprodol 350 mg Meloxicam Tablet 1
1
Tablet Methadone Tablet,
Cyclobenzaprine 1 Oral Solution, 1 SL
Metaxalone Tablet 3 Concentrate Solution
Methocarbamol Tablet 1 Morphine Sulfate
1 SL
Tizanidine Tablet 1 Extended-Release Tablet
Morphine Sulfate Oral
Musculoskeletal: Osteoporosis 1
Solution
Alendronate Sodium Nabumetone Tablet 1
1
Tablet Naproxen Tablet 1
Forteo 2 DSP, PA Nucynta 3 SL
Ibandronate Tablet 2 SL Nucynta ER 3 PA, SL
Raloxifene Tablet 2 Opana ER 2 PA, SL
Risedronate Sodium Oxycodone Tablet 1
3 SL
Tablet Oxycodone/
Acetaminophen
Musculoskeletal: Pain Relief 1 SL
5/325, 7.5/325,
Acetaminophen/ 10/325 mg Tablet
1 SL Oxycontin 3 E, PA, SL, ST
Codeine Tablet
Belbuca 3 PA, SL, ST Sprix 3
Butrans 3 E, PA, SL, ST Subsys 3 E, PA, SL
Celecoxib 2 SL Tramadol-
1
Diclofenac Tablet 1 Acetaminophen
Embeda 3 E, PA, SL, ST Tramadol Immediate-
1
Etodolac Capsule 1 Release Tablet
Fentanyl 12, 25, 50, Tramadol Sustained-
2 SL 2 SL
75, 100 mcg Patch Release Tablet
Fentanyl 37.5, 62.5, Trezix 3 SL
3 E, SL Vicodin
87.5 mcg Patch
Fentanyl Citrate 5/300, 7.5/300, 3 E, SL
2 PA, SL 10/300 mg Tablet
Lozenge
Hydrocodone/ Voltaren Gel 2
Acetaminophen Xtampza ER 3 PA, SL
1 SL Zohydro ER 3 PA, SL, ST
5/325, 7.5/325,
10/325 mg Tablet
Hydrocodone/Ibuprofen
1
Tablet

19
Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Alvesco 1 SL
Overactive Bladder
Anoro Ellipta 3 SL
Dicyclomine Tablet 1 Arnuity Ellipta 3 SL
Oxybutynin Extended- Asmanex 1 SL
2
Release Tablet Bevespi Aerosphere 2 SL
Oxybutynin Tablet 1 Breo Ellipta 3 RS, SL
Tolterodine Extended- Budesonide Nebs 2 SL
3 E
Release Tablet Combivent Respimat 3 SL
Tolterodine Tablet 3 E Dulera 3 SL, ST
Toviaz 3 Flovent Diskus/HFA 3 SL
Vesicare 3 E Incruse Ellipta 2 SL
Ipratropium-Albuterol
Respiratory: Allergies 1
Nebs
Azelastine 0.1% Ipratropium Nebs 1
3
Nasal Spray Levalbuterol Nebs 3 E, SL
Clarinex 3 E Montelukast Chewable
1
Clarinex-D 3 E Tablet, Tablet
Cyproheptadine Tablet 1 Montelukast Granules 2
Fluticasone Nasal Spray 2 SL Perforomist 3 SL
Hydroxyzine Capsule, ProAir HFA 3 SL
1
Tablet ProAir RespiClick 3 SL
Levocetirizine Tablet 1 Proventil HFA 3 SL
Mometasone Pulmicort Flexhaler 3 SL, ST
3 E, SL
Nasal Spray QVAR 1 SL
Promethazine Tablet 1 Serevent Diskus 3 SL
Triamcinolone Spiriva Handihaler 3 SL
3 E, SL
Nasal Spray Spiriva Respimat 3 SL
Zetonna 3 SL Stiolto Respimat 3 E, SL
Respiratory: Asthma/COPD Striverdi Respimat 2 SL
Symbicort 3 RS, SL
Advair Diskus/HFA 3 RS, SL Tudorza 2 SL
Aerospan 3 SL Ventolin HFA 2 SL
Albuterol Nebs 1 Xopenex HFA 3 SL
Albuterol Sulfate Tablet 1 Xopenex Nebs 3 E, SL

Bold type = Brand-name drug MC = Multiple copay


[Plain type = Generic drug] PA = Prior authorization required
DSP = Designated specialty program RS = May be eligible for the refill and save program
E = May be excluded from coverage SL = Supply limit
H = Health care reform preventive ST = Step therapy
20
Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Respiratory: Pulmonary Arterial
Vitamins/Electrolytes
Hypertension
Adcirca 3 DSP, PA, SL Fluoride 1
Adempas 2 DSP, PA, SL Folic Acid 1
Letairis 2 DSP, PA, SL Klor-Con M10 1
Opsumit 2 DSP, PA, SL Klor-Con M20 1
Orenitram 3 DSP, PA, SL Potassium Chloride 1
Sildenafil Tablet 1 DSP, PA, SL Potassium Citrate 1
Tracleer 2 DSP, PA, SL
Womens Health: Contraceptives
Tyvaso 2 DSP, PA
Uptravi 3 DSP, PA, SL Aftera 1 H
Altavera 1 H
Smoking Cessation
Alyacen 7/7/7, 1/35 1 H
Bupropion Sustained- Apri 1 H
1 H, PA
Release Tablet Aranelle 1 H
Chantix Tablet 3 H, PA Aubra 1 H
Nicoderm CQ 3 H, PA Aviane 1 H
Nicorette Gum 3 H, PA Azurette 2
Nicorette Lozenge 3 H, PA Blisovi Fe 1 H
Nicorette Camila 1 H
3 H, PA
Mini-Lozenge Caziant 1 H
Nicotine Gum 1 H, PA Cesia 1 H
Nicotine Lozenge 1 H, PA Chateal 1 H
Nicotine Patch 1 H, PA Cryselle 1 H
Nicotrol Inhaler 3 H, PA Cyclafem 7/7/7, 1/35 1 H
Nicotrol Nasal Spray 3 H, PA Cyred 1 H
Thrive Gum 1 H, PA Dasetta 7/7/7, 1/35 1 H
Deblitane 1 H
Transplant
Delyla 1 H
Azathioprine Tablet 1 Desogestrel-Ethinyl
Cyclosporine Modified Estradiol (generic 1 H
1 DSP
Capsule Ortho-Cept)
Mycophenolate Capsule, Drospirenone-Ethinyl
1 DSP
Suspension Estradiol-Levomefolate 3 E
Mycophenolic Acid Calcium
2 DSP
Tablet Econtra EZ 1 H
Sirolimus Tablet 1 DSP Elinest 1 H
Tacrolimus Capsule 1 DSP Ella 1 H, SL
Emoquette 1 H
Enpresse 1 H

21
Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Enskyce 1 H Lyza 1 H
Errin 1 H Marlissa 1 H
Estarylla 1 H Medroxyprogesterone
1 H
Fallback 1 H Acetate
Falmina 1 H Microgestin 2
Gildess 2 Microgestin Fe 1 H
Gildess Fe 1 H Minastrin 24 Fe 3 E
Heather 1 H Mono-Linyah 1 H
Introvale 2 H MonoNessa 1 H
Jencycla 1 H My Way 1 H
Jolessa 2 H Myzilra 1 H
Jolivette 1 H Natazia 2
Juleber 1 H Necon 7/7/7, 0.5/35,
1 H
Junel 2 1/35, 1/50, 10/11
Junel Fe 1 H Next Choice 1 H
Kurvelo 1 H Nora BE 1 H
Kelnor 1/35 1 H Norethindrone 0.35 mg 1 H
Larin Fe 1 H Norethindrone-Ethinyl
Larissia 1 H Estradiol-Ferrous 1 H
Leena 1 H Fumarate
Lessina 1 H Norgestimate-Ethinyl
Levonest 1 H Estradiol (generic
1 H
Levonorgestrel 1.5 mg 1 H Ortho-Cyclen, Ortho
Levonorgestrel-Ethinyl Tri-Cyclen)
Estradiol (generic Norgestimate-Ethinyl
1 H Estradiol Lo (generic 3
Alesse, Nordette,
Triphasil) Ortho Tri-Cyclen Lo)
Levonorgestrel-Ethinyl Norlyroc 1 H
Estradiol (generic 2 H Nortrel 7/7/7, 0.5/35,
1 H
Seasonale) 1/35
Levora-28 1 H Nuvaring 2 H
Lo Loestrin Fe 3 Opcicon 1 H
Loryna 3 Orsythia 1 H
Low-Ogestrel 1 H Ortho Tri-Cyclen Lo 3 E
Lutera 1 H Pirmella 7/7/7, 1/35 1 H

Bold type = Brand-name drug MC = Multiple copay


[Plain type = Generic drug] PA = Prior authorization required
DSP = Designated specialty program RS = May be eligible for the refill and save program
E = May be excluded from coverage SL = Supply limit
H = Health care reform preventive ST = Step therapy
22
Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Plan B One Step 1 H
Womens Health: Hormone Replacement
Portia 1 H
Previfem 1 H Cenestin 3 E
Quasense 2 H Climara 2 SL
Rajani 3 E Climara Pro 3 SL
React 1 H Divigel 3
Reclipsen 1 H Duavee 3
Setlakin 2 H Enjuvia 3
Sharobel 1 H Estrace Cream 3
Solia 1 H Estradiol/Norethindrone
2
Sprintec 1 H Acetate Tablet
Sronyx 1 H Estradiol Tablet 1
Take Action 1 H Estradiol Twice-Weekly
3 E, SL
Tarina Fe 1 H Transdermal Patch
Taytulla 3 E Estring 2 MC, SL
Tri-Estarylla 1 H Estrogen/
Tri-Linyah 1 H Methyltestosterone 1
Tri-Lo-Estarylla 3 Tablet
Tri-Lo-Marzia 3 Evamist 2
Tri-Lo-Sprintec 3 Medroxyprogesterone 1
Tri-Previfem 1 H Minivelle 3 SL
Tri-Sprintec 1 H Premarin 3
Trinessa 1 H Premphase 3
Trinessa Lo 3 Prempro 3
Trivora-28 1 H Progesterone
2
Velivet 1 H Micronized Capsule
Vestura 3 Vagifem 3 E
Vienva 1 H Vivelle-Dot 2 SL
Viorele 2 Yuvafem 2
Wera 1 H Womens Health: Miscellaneous
Xulane 3 H
Yasmin 28 2 Addyi 3 PA, SL
Yaz 2 Osphena 3
Zovia 1/35E, 1/50E 1 H Raloxifene 2 H, PA
Tamoxifen 1 H, PA
Womens Health: Prenatal Vitamins
Brand Prenatal
3
Vitamins

23
Index
A Amitiza.................................. 16 Azathioprine Tablet................21
Abacavir-Lamivudine............. 17 Amitriptyline Tablet............... 11 Azelastine 0.05% Ophthalmic
Accu-Chek Test Strips........... 14 Amlodipine..............................9 Solution...............................15
Acetaminophen/Butalbital/ Amlodipine-Benazepril............9 Azelastine 0.1%
Caffeine 325 mg/50 mg/ Amlodipine-Valsartan..............9 Nasal Spray..........................20
40 mg.................................. 11 Amoxicillin Capsule, Azithromycin Tablet.................8
Chewable Tablet....................8 Azopt...................................... 16
Acetaminophen/
Amoxicillin/Potassium Azurette.................................21
Codeine Tablet.................... 19
Actemra.................................. 17 Clavulanate Chewable B
Acyclovir Ointment..................8 Tablet, Tablet........................8
Baclofen Tablet....................... 19
Acyclovir Tablet.......................8 Amphetamine Salt Combo..... 11
Basaglar.................................. 14
Aczone....................................13 Ampyra..................................12
Belbuca................................... 19
Adapalene 0.1% Cream, Gel, Anastrozole Tablet.................18
Benazepril................................9
Lotion..................................13 Androderm.............................18
Benazepril-
Adapalene 0.3% Gel...............13 Androgel................................18
Hydrochlorothiazide..............9
Adcirca...................................21 Anoro Ellipta.........................20
Benicar.....................................9
Adderall XR........................... 11 Antipyrine/Benzocaine
Benicar HCT...........................9
Addyi......................................23 Otic Solution.......................18
Benzonatate Capsule.............. 18
Adempas.................................21 Aprepitant Capsule................. 16
Betamethasone Dipropionate
Adlyxin...................................15 Apri........................................21 0.05% Augmented Lotion,
Advair Diskus/HFA...............20 Apriso..................................... 16 Ointment.............................13
Aerospan................................20 Aranelle..................................21 Betamethasone Dipropionate
Afrezza................................... 14 Aranesp..................................18 0.05% Cream, Ointment.....13
Aftera.....................................21 Aripiprazole Tablet.................12 Betaseron................................12
Akynzeo................................. 16 Armodafanil...........................12 Bethkis...................................18
Albuterol Nebs.......................20 Armour Thyroid.....................15 Bevespi Aerosphere................20
Albuterol Sulfate Tablet..........20 Arnuity Ellipta.......................20 Bexarotene Capsule..................9
Alendronate Sodium Tablet... 19 Asacol HD Tablet.................. 16 Bicalutamide.............................9
Alesse.....................................22 Asmanex.................................20 Bidil..........................................9
Alfuzosin Tablet.....................18 Atenolol....................................9 Bisoprolol..................................9
Allopurinol Tablet.................. 17 Atenolol-Chlorthalidone..........9 Bisoprolol-
Alphagan P 0.1%.................... 16 Atorvastatin............................10 Hydrochlorothiazide..............9
Alprazolam Extended-Release Atripla.................................... 17 Blisovi Fe................................21
Tablet...................................12 Aubagio..................................12 Bosulif......................................9
Alprazolam Tablet..................12 Aubra......................................21 Brand Prenatal Vitamins........23
Altavera..................................21 Auryxia...................................18 Breo Ellipta............................20
Alvesco...................................20 Auvi-Q...................................18 Brilinta.....................................9
Alyacen 7/7/7, 1/35.................21 Aviane....................................21 Bromfed DM..........................18
Amiodarone............................10 Avonex....................................12 Budesonide Nebs....................20
24
Buprenorphine/ Cesia.......................................21 Clotrimazole-Betamethasone
Naloxone Tablet...................12 Cetrotide................................ 17 Cream..................................13
Bupropion Extended-Release Chantix Tablet........................21 Clotrimazole-Betamethasone
Tablet................................... 11 Chateal...................................21 Lotion..................................13
Bupropion Sustained-Release Chlorhexidine Gluconate........18 Colcrys................................... 17
Tablet............................. 11, 21 Chlorpheniramine/ Combigan............................... 16
Bupropion Tablet.................... 11 Hydrocodone/ Combivent Respimat..............20
Buspirone Tablet.....................12 Pseudoephedrine Solution... 18 Complera................................ 17
Butrans................................... 19 Chlorthalidone.........................9 Concerta................................. 11
Bydureon................................15 Choline Fenofibrate................10 Contour Test Strips................ 14
Byetta.....................................15 Cialis......................................18 Copaxone...............................12
Bystolic.....................................9 Ciclopirox Cream, Gel, Corlanor.................................10
C Lotion, Solution..................13 Cortifoam............................... 16
Cimzia.................................... 17 Cosentyx................................ 17
Calcipotriene/Betamethasone
Ciprodex...................................8 Creon...................................... 16
Ointment.............................13
Ciprofloxacin Tablet.................8 Cresemba..................................8
Calcitriol Capsule...................15
Citalopram Tablet................... 11 Cryselle...................................21
Camila....................................21
Claravis...................................13 Cyclafem 7/7/7, 1/35..............21
Canasa.................................... 16
Clarinex..................................20 Cyclobenzaprine..................... 19
Carac......................................13
Clarinex-D.............................20 Cyclophosphamide Capsule......9
Carbamazepine Extended-
Release Capsule...................12 Clarithromycin Tablet..............8 Cyclosporine Modified
Carbamazepine Extended- Climara..................................23 Capsule................................21
Release Tablet......................12 Climara Pro............................23 Cyproheptadine Tablet...........20
Carbamazepine Immediate- Clindamycin 1%/Benzoyl Cyred......................................21
Release Tablet......................12 Peroxide 5% Gel..................13
Clindamycin 1.2%/Benzoyl
D
Carbidopa-Levodopa..............12
Carisoprodol 350 mg Tablet... 19 Peroxide 5% Gel..................13 Daklinza................................. 17
Cartia XT.................................9 Clindamycin Capsule...............8 Dasetta 7/7/7, 1/35.................21
Carvedilol.................................9 Clindamycin Gel....................13 Daytrana................................. 11
Cayston...................................18 Clindamycin Lotion...............13 Deblitane................................21
Caziant...................................21 Clindamycin Solution, Delyla.....................................21
Cefadroxil Capsule, Tablet.......8 Swabs...................................13 Delzicol.................................. 16
Cefdinir Capsule......................8 Clobetasol Propionate Descovy.................................. 17
Cefixime Suspension................8 Cream, Ointment................13 Desmopressin Tablet..............15
Cefprozil Tablet........................8 Clobetasol Propionate Desogestrel-Ethinyl
Cefuroxime Tablet....................8 Solution...............................13 Estradiol..............................21
Celecoxib................................ 19 Clomiphene............................ 17 Desonide 0.05% Cream,
Cenestin.................................23 Clonazepam Tablet.................12 Lotion, Ointment................13
Cephalexin Capsule..................8 Clonidine Tablet.......................9 Desoximetasone Gel,
Cerdelga.................................18 Clopidogrel...............................9 Ointment.............................13
25
Desvenlafaxine Extended- Divigel....................................23 Epinephrine............................18
Release Tablet...................... 11 Donepezil 5, 10 mg ODT, EpiPen/EpiPen-Jr...................18
Dexamethasone Tablet...........15 Tablet...................................12 Epzicom................................. 17
Dexcom Continuous Glucose Doxazosin........................... 9, 18 Errin.......................................22
Monitoring System.............. 14 Doxazosin Tablet....................18 Erythromycin 0.5%
Dexcom Sensor....................... 14 Doxepin.................................. 11 Ophthalmic Ointment.........15
Dexcom Transmitter.............. 14 Doxycycline Hyclate Escitalopram Tablet................ 11
Dexilant.................................. 16 50, 100 mg Capsule, Tablet...8 Esomeprazole Capsule............ 16
Dexmethylphenidate Doxycycline Monohydrate Estarylla.................................22
Extended-Release Capsule.. 11 50, 100 mg Capsule...............8 Estrace Cream........................23
Dexmethylphenidate Drospirenone-Ethinyl Estradiol Tablet......................23
Immediate-Release Estradiol-Levomefolate Estradiol Twice-Weekly
Tablet................................... 11 Calcium...............................21 Transdermal Patch...............23
Dextroamphetamine Sulfate Duavee....................................23 Estradiol/Norethindrone
Immediate-Release Tablet... 11 Dulera.....................................20 Acetate Tablet......................23
Dextroamphetamine- Duloxetine Capsule................ 11 Estring....................................23
Amphetamine Dutasteride Capsule...............18 Estrogen/Methyltestosterone
Extended-Release................ 11 Dutoprol...................................9 Tablet...................................23
Dextroamphetamine- Eszopiclone Tablet..................12
E
Amphetamine Immediate- Etodolac Capsule.................... 19
Release Capsule................... 11 Econazole Cream.....................8 Evamist...................................23
Diazepam Tablet..............12, 13 Econtra EZ............................21 Evotaz..................................... 17
Diclofenac Tablet.................... 19 Edarbi.......................................9 Ezetimibe Tablet.................... 10
Dicyclomine Tablet................20 Edarbyclor................................9
Effient......................................9 F
Differin 0.1% Cream, Gel,
Lotion..................................13 Elinest....................................21 Fallback..................................22
Dificid......................................8 Eliquis......................................9 Falmina..................................22
Diflorasone Diacetate 0.05% Ella.........................................21 Famciclovir Tablet....................8
Cream, Ointment................13 Embeda.................................. 19 Farxiga....................................15
Digoxin..................................10 Emend Suspension................. 16 Fenofibrate 40, 48, 120,
Diltiazem 24 Hour CD............9 Emoquette..............................21 145 mg Tablet......................10
Diltiazem Sustained-Release Enalapril...................................9 Fenofibrate 43, 50 , 67, 130,
Capsule..................................9 Enbrel..................................... 17 134, 150, 200 mg Capsule... 10
Diltiazem Sustained-Release Enjuvia...................................23 Fenofibrate 54, 160 mg
Tablet.....................................9 Enoxaparin Sodium..................9 Tablet...................................10
Diphenoxylate-Atropine Enpresse.................................21 Fentanyl 12, 25, 50,
Tablet................................... 16 Enskyce..................................22 75, 100 mcg Patch............... 19
Divalproex Delayed-Release Enstilar Foam.........................13 Fentanyl 37.5, 62.5, 87.5 mcg
Tablet...................................13 Entresto..................................10 Patch.................................... 19
Divalproex Extended-Release Epclusa................................... 17 Fentanyl Citrate Lozenge....... 19
Tablet...................................13 Epiduo/Epiduo Forte..............13 Fetzima................................... 11
26
Finacea...................................13 Gonal-F RFF......................... 17 Intelence................................. 17
Finasteride Tablet...................18 Guanfacine......................... 9, 11 Introvale.................................22
Flecainide...............................10 Guanfacine Invokamet...............................15
Flovent Diskus/HFA..............20 Extended-Release................ 11 Invokamet XR........................15
Fluconazole Tablet....................8 Invokana.................................15
H
Fluocinolone Cream, Oil, Ipratropium Nebs...................20
Halobetasol Ointment............13 Ipratropium-Albuterol Nebs...20
Solution...............................13
Harvoni.................................. 17 Irbesartan.................................9
Fluocinolone Ointment..........13
Heather...................................22 Isentress.................................. 17
Fluocinonide 0.05% Cream....13
Humalog KwikPens............... 14 Isosorbide Mononitrate ER....10
Fluoride..................................21
Humalog Vials....................... 14 Itraconazole Capsule.................8
Fluoxetine Tablet, Capsule..... 11
Humira................................... 17
Fluticasone Nasal Spray..........20 J
Humulin KwikPens................ 14
Fluvastatin Extended-Release
Humulin Vials........................ 14 Janumet..................................15
Tablet...................................10
Hydralazine..............................9 Januvia....................................15
Fluvoxamine Tablet................ 11
Hydrochlorothiazide.................9 Jardiance.................................15
Focalin XR............................. 11
Hydrocodone/Acetaminophen Jencycla...................................22
Folic Acid...............................21
5/325, 7.5/325, 10/325 mg Jentadueto...............................15
Forteo..................................... 19
Tablet................................... 19 Jentadueto XR........................15
Fosrenol..................................18
Hydrocodone/ Jolessa.....................................22
FreeStyle Test Strips............... 14
Chlorpheniramine Jolivette...................................22
Frovatriptan............................ 11 Suspension...........................18 Juleber.....................................22
Furosemide...............................9 Hydrocodone/Homatropine...18 Junel........................................22
G Hydrocodone/ Junel Fe...................................22
Ibuprofen Tablet.................. 19
Gabapentin Capsule, Tablet...13 K
Hydrocortisone 2.5% Cream,
Gemfibrozil............................10
Ointment.............................13 Kaletra Tablet......................... 17
Gentamicin Ophthalmic
Hydromorphone Tablet.......... 19 Kazano...................................15
Ointment, Solution..............15
Hydroxychloroquine Sulfate... 17 Kelnor 1/35.............................22
Genvoya.................................. 17
Hydroxyurea Capsule...............9 Ketoconazole Cream................8
Gildess....................................22
Hydroxyzine Capsule, Tablet.20 Ketorolac Tablet...................... 19
Gildess Fe...............................22
Hyoscyamine Tablet............... 16 Klor-Con M10.......................21
Gilenya...................................12
Hysingla................................. 19 Klor-Con M20.......................21
Glatopa...................................12
Kombiglyze XR......................15
Glimepiride............................15 I
Kurvelo...................................22
Glipizide.................................15 Ibandronate Tablet................. 19
Glipizide Extended-Release...15 Ibuprofen Tablet..................... 19 L
Glucophage XR......................15 Imatinib Tablet.........................9 Labetalol...................................9
Glyburide...............................15 Imbruvica.................................9 Lamivudine-Zidovudine........ 17
Glyxambi................................15 Imiquimod 5% Cream............13 Lamotrigine
Golytely.................................. 16 Incruse Ellipta........................20 Immediate-Release Tablet...13
Gonal-F.................................. 17 Indomethacin Capsule............ 19 Lansoprazole Capsule............. 16
27
Lantus Solostar....................... 14 Lisinopril- Methylphenidate Extended-
Lantus Vials........................... 14 Hydrochlorothiazide..............9 Release Capsule................... 11
Larin Fe..................................22 Lithium Capsule.....................12 Methylphenidate Extended-
Larissia...................................22 Livalo.....................................10 Release Tablet...................... 11
Lastacaft.................................15 Lo Loestrin Fe.......................22 Methylphenidate Tablet.......... 11
Latanoprost 0.005% Lopinavir-Ritonavir Methylprednisolone Tablet.....15
Ophthalmic Solution........... 16 Oral Solution....................... 17 Methyltestosterone Capsule....18
Latuda....................................12 Lorazepam Tablet...................12 Metoclopramide Tablet.......... 16
Lazanda.................................. 19 Loryna....................................22 Metoprolol Succinate
Leena......................................22 Losartan...................................9 50, 100, 200 mg.....................9
Leflunomide........................... 17 Losartan- Metoprolol Tartrate
Lessina....................................22 Hydrochlorothiazide..............9 25, 50, 100 mg.......................9
Letairis...................................21 Lovastatin...............................10 Metronidazole 0.75%
Letrozole Tablet.....................18 Low-Ogestrel.........................22 Topical Gel..........................13
Lumigan................................. 16 Metronidazole Tablet...............8
Leucovorin Calcium Tablet......9
Lutera.....................................22 Microgestin............................22
Levalbuterol Nebs...................20
Lyrica.....................................13 Microgestin Fe.......................22
Levemir FlexTouch................ 14
Lyza........................................22 Minastrin 24 Fe......................22
Levemir Vials......................... 14
Minivelle................................23
Levetiracetam M
Minocycline Capsule................8
Extended-Release Tablet.....13
Marlissa..................................22 Minocycline
Levetiracetam Immediate- Medroxyprogesterone.......22, 23 Extended-Release Capsule..13
Release Tablet......................13 Medroxyprogesterone Minocycline Tablet...................8
Levitra....................................18 Acetate.................................22 Mirtazapine Tablet................. 11
Levocetirizine Tablet..............20 Meloxicam Tablet................... 19 Mirvaso.................................. 14
Levofloxacin Tablet..................8 Memantine Tablet..................12 Mitigare.................................. 17
Levonest.................................22 Mercaptopurine Tablet.............9 Modafinil Tablet.....................12
Levonorgestrel 1.5 mg............22 Metadate CD......................... 11 Mometasone Furoate Cream,
Levonorgestrel-Ethinyl Metadate ER.......................... 11 Lotion, Ointment................ 14
Estradiol..............................22 Metaxalone Tablet.................. 19 Mometasone Nasal Spray.......20
Levora-28...............................22 Metformin..............................15 Mono-Linyah.........................22
Levothyroxine Sodium Metformin Extended-Release MonoNessa.............................22
Tablet...................................15 Tablet...................................15 Montelukast Chewable Tablet,
Lialda..................................... 16 Methadone Tablet, Tablet...................................20
Lidocaine Transdermal Oral Solution, Concentrate Montelukast Granules............20
Patch....................................18 Solution............................... 19 Morphine Sulfate
Linzess................................... 16 Methimazole Tablet...............15 Extended-Release Tablet..... 19
Liothyronine Sodium Methocarbamol Tablet........... 19 Morphine Sulfate
Tablet...................................15 Methotrexate Tablet............... 17 Oral Solution....................... 19
Lipofen...................................10 Methylphenidate Chewable Movantik................................ 16
Lisinopril............................ 9, 32 Tablet................................... 11 Moviprep................................ 16
28
Moxeza...................................15 Nitrofurantoin Macrocrystal Olmesartan.............................10
Moxifloxacin Tablet..................8 Capsule..................................8 Olmesartan-
Multaq....................................10 Nitroglycerin Sublingual Hydrochlorothiazide............10
Mupirocin Ointment.............. 14 Tablet...................................10 Olopatadine 0.1%
My Way..................................22 Nora BE.................................22 Ophthalmic Solution...........15
Mycophenolate Capsule, Nordette.................................22 Omeclamox-Pak..................... 16
Suspension...........................21 Norethindrone 0.35 mg..........22 Omega-3-Acid Ethyl Esters
Mycophenolic Acid Tablet......21 Norethindrone-Ethinyl Capsule................................ 10
Myzilra...................................22 Estradiol-Ferrous Omeprazole Capsule.............. 16
Fumarate.............................22 Ondansetron........................... 16
N Norgestimate-Ethinyl Ondansetron ODT................. 16
Nabumetone Tablet................ 19 Estradiol..............................22 OneTouch Test Strips............. 14
Nadolol...................................10 Norgestimate-Ethinyl OneTouch Ultra Meter........... 14
Naloxone Vials.......................12 Estradiol Lo........................22 OneTouch Ultra Mini............ 14
Naproxen Tablet..................... 19 Norlyroc..................................22 OneTouch Ultra Test Strips.... 14
Naratriptan............................. 11 Nortrel 7/7/7, 0.5/35, 1/35......22 OneTouch Verio..................... 14
Narcan Nasal Spray................12 Nortriptyline Capsule............. 11 OneTouch Verio Flex.............. 14
Natazia...................................22 Norvir..................................... 17 OneTouch Verio IQ................ 14
Necon 7/7/7, 0.5/35, 1/35, Novolin Vials.......................... 14 OneTouch Verio Sync............. 14
1/50, 10/11...........................22 Novolog FlexTouch................ 14 OneTouch Verio Test Strips.... 14
Nesina.....................................15 Novolog Vials......................... 14
Onglyza..................................15
Nevirapine.............................. 17 Noxafil Tablet, Suspension.......8
Opana ER.............................. 19
Nevirapine NP Thyroid Tablet.................15
Opcicon..................................22
Extended-Release................ 17 Nucynta.................................. 19
Opsumit.................................21
Next Choice...........................22 Nucynta ER............................ 19
Oracea......................................8
Niacin Extended-Release Nuedexta................................18
Orencia................................... 17
Nutropin, Nutropin AQ.........15
Tablet...................................10 Orenitram...............................21
Nuvaring................................22
Niaspan.................................. 10 Orsythia.................................22
Nystatin Cream, Ointment......8
Nicoderm CQ........................21 Ortho Tri-Cyclen...................22
Nystatin-Triamcinolone
Nicorette Gum.......................21 Ortho Tri-Cyclen Lo.............22
Acetonide Cream,
Nicorette Lozenge..................21 Ortho-Cept............................21
Ointment............................. 14
Nicorette Mini-Lozenge........21 Ortho-Cyclen.........................22
Nicotine Gum........................21 O Oseltamivir Capsule.................8
Nicotine Lozenge...................21 Obredon.................................18 Oseni......................................15
Nicotine Patch........................21 Odefsey................................... 17 Osphena.................................23
Nicotrol Inhaler......................21 Ofloxacin 0.3% Ophthalmic Otezla..................................... 17
Nicotrol Nasal Spray...............21 Solution...............................15 Otrexup.................................. 17
Nifedipine Ofloxacin Otic Solution............8 Ovidrel................................... 17
Extended-Release................10 Ofloxacin Tablet.......................8 Oxcarbazepine Tablet.............13
Nitrofurantoin Capsule.............8 Olanzapine Tablet..................12 Oxsoralen-Ultra...................... 14
29
Oxybutynin Extended-Release Pristiq..................................... 11 Relpax..................................... 11
Tablet...................................20 ProAir HFA...........................20 Renvela................................... 18
Oxybutynin Tablet.................20 ProAir RespiClick..................20 Repatha 140 mg..................... 10
Oxycodone Tablet................... 19 Procrit.....................................18 Restasis Single Use Vials........ 16
Oxycodone/Acetaminophen Progesterone Micronized Revlimid...................................9
5/325, 7.5/325, 10/325 mg Capsule................................23 Reyataz................................... 17
Tablet................................... 19 Promethazine Tablet...............20 Rezira.....................................18
Oxycontin............................... 19 Promethazine/Codeine...........18 Ribavirin Tablet...................... 17
Promethazine/ Risedronate Sodium Tablet.... 19
P
Dextromethorphan..............18 Risperidone Tablet..................12
Pantoprazole Tablet................ 16 Propranolol Extended-Release Ritalin LA.............................. 11
Paroxetine Tablet.................... 11 Capsule................................10 Rizatriptan ODT, Tablet........ 11
Pataday...................................15 Propranolol Tablet..................10 Ropinirole Tablet....................12
Pegasys...................................18 Proventil HFA........................20 Rosuvastatin...........................10
Penicillin V Potassium Tablet...8 Prozac..................................... 11
Perforomist.............................20 Pulmicort Flexhaler................20 S
Phenazopyridine.....................18 Pulmozyme............................ 18 Savaysa.....................................9
Phenytoin Capsule, Pylera...................................... 16 Seasonale................................22
Suspension...........................13 Selzentry................................. 17
Q
Picato...................................... 14 Serevent Diskus......................20
Pioglitazone............................15 Quasense................................23 Sertraline Tablet..................... 11
Quetiapine Extended-Release
Pirmella 7/7/7, 1/35................22 Setlakin..................................23
Tablet...................................12
Plan B One Step.....................23 Sharobel..................................23
Quetiapine Tablet...................12
Plegridy..................................12 Sildenafil Tablet......................21
Quinapril................................10
Polyethylene Glycol 3350........ 16 Simponi.................................. 17
QVAR....................................20
Portia......................................23 Simvastatin.............................10
Potassium Chloride................21 R Sirolimus Tablet......................21
Potassium Citrate...................21 Rabeprazole Tablet................. 16 Solia........................................23
Pradaxa.....................................9 Rajani.....................................23 Soliqua.................................... 14
Praluent..................................10 Raloxifene......................... 19, 23 Solodyn................................... 14
Pramipexole Tablet.................12 Raloxifene Tablet.................... 19 Sotalol....................................10
Pravastatin.............................. 10 Ramipril.................................10 Sovaldi.................................... 17
Prednisone Tablet...................15 Ranexa.................................... 10 Spiriva Handihaler.................20
Premarin.................................23 Ranitadine Syrup.................... 16 Spiriva Respimat....................20
Premphase..............................23 Rapaflo...................................18 Spironolactone........................ 10
Prempro..................................23 Rasuvo.................................... 17 Sprintec..................................23
Prenisolone Oral Solution......15 React......................................23 Sprix....................................... 19
Prepopik................................. 16 Rebif.......................................12 Sronyx....................................23
Previfem.................................23 Reclipsen................................23 Stelara..................................... 17
Prezcobix................................ 17 Rectiv..................................... 18 Stendra...................................18
Prezista................................... 17 Regranex................................. 14 Stiolto Respimat.....................20
30
Strattera.................................. 11 Telmisartan- Trazodone Tablet.................... 11
Stribild.................................... 17 Hydrochlorothiazide............10 Tresiba FlexTouch.................. 14
Striverdi Respimat..................20 Temazepam Capsule...............12 Tretinoin Cream..................... 14
Suboxone Film.......................12 Terazosin.......................... 10, 18 Tretinoin Gel.......................... 14
Subsys..................................... 19 Terazosin Capsule, Tablet....... 18 Tretinoin Microspheres.......... 14
Suclear.................................... 16 Terbinafine Tablet....................8 Trezix..................................... 19
Sucralfate Tablet..................... 16 Testim.....................................18 Tri-Estarylla...........................23
Sulfamethoxazole- Testosterone 1% Tri-Linyah..............................23
Topical Gel.......................... 18 Tri-Lo-Estarylla.....................23
Trimethoprim Tablet.............8
Testosterone Cypionate Tri-Lo-Marzia........................23
Sulfasalazine Tablet................ 16
Injection...............................18 Tri-Lo-Sprintec......................23
Sumatriptan Nasal Spray........ 11
Thrive Gum...........................21 Tri-Previfem...........................23
Sumatriptan Succinate Tablet,
Timolol Maleate 0.25%, 0.5% Tri-Sprintec............................23
Injection...............................12
Ophthalmic Solution........... 16 Triamcinolone Acetonide
Suprax Capsule, Chewable
Tivicay.................................... 17 Cream, Lotion, Ointment... 14
Tablet, Tablet.........................8
Tizanidine Tablet................... 19 Triamcinolone Nasal Spray.....20
Suprep.................................... 16 Triamterene-
Tobi Podhaler......................... 18
Sustiva.................................... 17 Hydrochlorothiazide............10
Tobramycin Nebulized
Sutent.......................................9 Triazolam Tablet....................12
Solution...............................18
Symbicort...............................20 Trinessa..................................23
Tobramycin Ophthalmic
Synjardy..................................15 Trinessa Lo.............................23
Solution............................... 16
Synthroid................................15 Tobramycin/Dexamethasone Trintellix................................. 11
0.3%-0.1% Ophthalmic Triphasil.................................22
T
Suspension...........................15 Triumeq.................................. 17
Taclonex Suspension............... 14 Trivora-28...............................23
Tolcapone...............................12
Tacrolimus Capsule................21 Trulicity..................................15
Tolterodine Extended-Release
Tacrolimus Ointment............. 14 Truvada.................................. 17
Tablet...................................20
Take Action............................23 Tudorza..................................20
Tolterodine Tablet..................20
Taltz....................................... 17 Tybost..................................... 17
Topiramate Immediate-Release
Tamoxifen..............................23 Tyvaso....................................21
Tablet...................................13
Tamsulosin Capsule................18 Toujeo SoloStar...................... 14 U
Tanzeum.................................15 Toviaz.....................................20
Targretin Capsule.....................9 Uceris Foam............................ 16
Tracleer...................................21
Uceris Tablet........................... 16
Targretin Gel............................9 Tradjenta................................15 Uloric...................................... 17
Tarina Fe................................23 Tramadol Immediate-Release Uptravi...................................21
Tasigna.....................................9 Tablet................................... 19
Taytulla..................................23 Tramadol Sustained-Release V
Tazorac................................... 14 Tablet................................... 19 Vagifem..................................23
Tecfidera.................................12 Tramadol-Acetaminophen...... 19 Valacyclovir Tablet...................8
Technivie................................ 17 Transderm-Scop..................... 16 Valganciclovir...........................8
Telmisartan............................10 Travatan Z.............................. 16 Valsartan.................................10
31
Valsartan- Viorele....................................23 Y
Hydrochlorothiazide............10 Viread..................................... 17 Yasmin 28...............................23
Varubi..................................... 16 Vitekta.................................... 17 Yaz..........................................23
Vascepa...................................10 Vivelle-Dot.............................23 Yuvafem..................................23
Vectical................................... 14 Voltaren Gel........................... 19
Velivet.....................................23 Vytorin...................................10 Z
Velphoro................................. 19 Vyvanse.................................. 11 Zaleplon Capsule....................12
Veltassa................................... 19 Zarxio..................................... 19
W
Venlafaxine Extended-Release Zelapar...................................12
Capsule................................ 11 Warfarin Sodium.....................9 Zenpep................................... 16
Venlafaxine Tablet.................. 11 Welchol..................................10 Zepatier.................................. 17
Ventolin HFA.........................20 Wera.......................................23 Zetia.......................................10
Verapamil...............................10 X Zetonna..................................20
Verapamil Sustained-Release.. 10 Zinbryta.................................12
Xarelto......................................9
Vesicare...................................20 Ziprasidone Capsule...............12
Xeljanz.................................... 17
Vestura....................................23 Zohydro ER........................... 19
Xeljanz XR............................. 17
Viagra.....................................18 Zolpidem Extended-Release
Xeloda......................................9
Viberzi.................................... 16 Tablet...................................12
Xigduo XR.............................15
Vicodin 5/300, 7.5/300, Zolpidem Tablet.....................12
Xiidra..................................... 16
10/300 mg Tablet................ 19 Zonisamide Capsule...............13
Xopenex HFA........................20
Victoza 2-Pak.........................15 Zovia 1/35E, 1/50E...............23
Xopenex Nebs.........................20
Victoza 3-Pak.........................15 Zovirax Cream.........................8
Xtampza ER........................... 19
Viekira Pak............................. 17 Zubsolv...................................12
Xulane....................................23
Vienva.....................................23 Zurampic................................ 17
Xyrem.....................................12
Vigamox................................. 16 Zytiga.......................................9
Viibryd................................... 11

32
My medications worksheet
Take this worksheet with you each time you visit a doctor. Each of your doctors should be aware of every
drug you take and you should have a list as well.

Name of medication Drug I take this


Directions Doctor
and strength tier medicine for

Example: Lisinopril, 20 mg Tier 1 High blood pressure One tablet daily Dr. Johnson

33
Nondiscrimination notice and access to
communication services
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Mail: Civil Rights Coordinator


UnitedHealthcare Civil Rights Grievance
P.O. Box 30608
Salt Lake City, Utah 84130
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If you need help with your complaint, please call the toll-free phone number listed on your
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You can also file a complaint with the U.S. Dept. of Health and Human Services.

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Complaint forms are available at
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We provide free services to help you communicate with us, including letters in other languages or
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listed on your ID card TTY 711, Monday through Friday, 8 a.m. to 8 p.m.

34
35
2017 United HealthCare Services, Inc. All rights reserved. Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates.
Administrative services provided by UnitedHealthcare Insurance Company, UnitedHealthcare Services, Inc. or their affiliates.
Health Plan coverage provided by or through a UnitedHealthcare company. OptumRx is an affiliate of UnitedHealthcare Insurance Company.
UnitedHealthcare and the dimensional U logo are registered trademarks owned by UnitedHealth Group Incorporated.
All other trademarks are the property of their respective owners.
Created February, 2017. 2017 Prescription Drug List Advantage Three-Tier
100-17540 7/17