2018 Prescription Drug List

Your 2018 Prescription Drug List
Advantage Three-Tier
This PDL is accurate as of January 2018 and is subject to change after this date. The next anticipated update will
be July 2018. This PDL applies to members of our UnitedHealthcare, Neighborhood Health Plan, River Valley and
Oxford medical plans with a pharmacy benefit. Your estimated coverage and copayment/coinsurance may vary
based on the benefit plan you choose and the effective date of the plan.
Effective Jan. 1, 2018

Table of Contents
Drug tiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Gastrointestinal
Restrictions on what medications Acid Suppression. . . . . . . . . . . . . . . . . . . . . . . . 15
are covered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Nausea/Vomiting. . . . . . . . . . . . . . . . . . . . . . . . 15
Drugs by category . . . . . . . . . . . . . . . . . . . . . . . 8 Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Anti-Infectives Gout. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Hepatitis C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Antifungals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 HIV/AIDS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Infertility. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Inflammatory Conditions: Rheumatoid
Cardiovascular/Heart Disease Arthritis, Crohn’s Disease, Psoriasis,
Coagulation Therapy . . . . . . . . . . . . . . . . . . . . . . 9 Ulcerative Colitis. . . . . . . . . . . . . . . . . . . . . . . . 17
High Blood Pressure . . . . . . . . . . . . . . . . . . . . . . 9
Medications for Sexual Dysfuntion . . . . . . . 17
High Cholesterol. . . . . . . . . . . . . . . . . . . . . . . . . 10
Men’s Health
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Central Nervous System
Testosterone Therapy. . . . . . . . . . . . . . . . . . . . . 17
Attention Deficit Disorder. . . . . . . . . . . . . . . . . . 10
Depression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Miscellaneous. . . . . . . . . . . . . . . . . . . . . . . . . . 17
Migraine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Musculoskeletal
Multiple Sclerosis. . . . . . . . . . . . . . . . . . . . . . . . 11 Muscle Spasms. . . . . . . . . . . . . . . . . . . . . . . . . . 18
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Osteoporosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Sedatives/Hypnotics . . . . . . . . . . . . . . . . . . . . . 12 Pain Relief. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Seizure Disorders. . . . . . . . . . . . . . . . . . . . . . . . 12 Overactive Bladder. . . . . . . . . . . . . . . . . . . . . . 19
Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Respiratory
Diabetes Allergies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Blood Glucose Monitoring. . . . . . . . . . . . . . . . . 13 Asthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Insulin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Pulmonary Arterial Hypertension. . . . . . . . . . . 19
Non-Insulin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Smoking Cessation. . . . . . . . . . . . . . . . . . . . . 20
Endocrine
Transplant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Growth Hormone. . . . . . . . . . . . . . . . . . . . . . . . 14
Vitamins/Electrolytes. . . . . . . . . . . . . . . . . . . 20
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Thyroid Hormone Replacement. . . . . . . . . . . . 14 Women’s Health
Eye Conditions Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Allergies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Hormone Replacement. . . . . . . . . . . . . . . . . . . 22
Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Miscellaneous. . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Dry Eye Disease. . . . . . . . . . . . . . . . . . . . . . . . . 15 Prenatal Vitamins . . . . . . . . . . . . . . . . . . . . . . . . 22
Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
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, we’ve included some of the most commonly asked questions about the
Prescription Drug List (PDL).
What is a PDL?
This document is a list of the most commonly prescribed medications. It includes both brand-name and generic
prescription medications approved by the Food and Drug Administration (FDA). Medications are listed by
common categories or classes and placed in tiers that represent the cost you pay out-of-pocket. They are then
listed in alphabetical order. Bring this list with you when you see your doctor. It makes it easier for you and your
doctor to make informed decisions about your medications and may help you save money.
Please note: Where differences are noted between this PDL and your benefit plan documents, the benefit
plan documents will rule. This PDL 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 which medications are covered under your plan.
What is a tier?
Tiers indicate the amount you pay for your prescription, which is determined by your employer or benefit plan.
Tier 1 medications provide the highest overall value with the lowest out-of-pocket costs. Choosing medications
in lower tiers may save you money. Ask your doctor if a Tier 1 or Tier 2 option could work for you.
Your Cost Drug Tier* What’s Covered Helpful Hints

Medications that provide the highest overall
$ Use Tier 1 drugs for the lowest
1 value. Mostly generic drugs. Some brand-name
Lowest out-of-pocket costs.
drugs may also be included.
$$ Medications that provide good overall value. Use Tier 2 drugs, instead of Tier 3, to
2
Mid-range A mix of brand-name and generic drugs. help reduce your out-of-pocket costs.
Medications that provide the lowest overall
$$$ Ask your doctor if a Tier 1 or Tier 2
3 value. Mostly brand-name drugs, as well as
Higher option could work for you.
some generics.
* Some plans may have different tiers. If you have a high deductible plan, the tier cost levels may apply once you hit your
deductible.
Who decides what medications are covered?

Thousands of medications are already available and more come to the market regularly. Often, several
medications are available to treat the same condition.
The UnitedHealthcare® Pharmacy and Therapeutics Committee, which includes both internal and external
physicians and pharmacists, meets regularly to provide clinical reviews of all medications. Using this
information, the PDL Management Committee, which includes senior UnitedHealth Group® physicians and
business leaders, meets to evaluate overall health care value. They also determine coverage and tier status for
all medications.
4
How is the overall value of a medication determined?
Many sources and factors are considered, including:
• Clinical Value: How safe and effective a medication is compared to other medications used to treat the same
or similar medical conditions.
• Cost: How much a medication costs compared to other medications used to treat similar medical conditions.
• Outcomes Data: Studies that show how a medication may affect total health care costs.
Why are certain medications excluded?

We review medications based on their total value, including effectiveness and safety, how much they cost, and
the availability of alternative medications to treat the same or similar medical conditions. Certain medications
may be excluded from coverage or subject to prior authorization (sometimes referred to as precertification)+ if
similar alternatives are available at a lower cost.
Examples include medications that work the same way, but one is much more expensive than the other, or
options that are available without a prescription (also referred to as over-the-counter medications**). There are
also some instances where the same product can be made by two or more manufacturers, but greatly vary
in cost. In these instances, only the lower-cost product may be covered. You should review your benefit plan
documents to confirm if any medications are excluded from your plan. You can log in to the member website
listed on your health plan ID card at any time to check your medication coverage. Talk to your doctor to see if
there are lower-cost options or over-the-counter medications available.
+
Depending on your benefit, you may have notification or medical necessity requirements for select medications.
** This is not applicable for plans written in New Jersey. For New York plans, a prescription drug product that is therapeutically
equivalent to an over-the-counter drug may be covered if it is determined to be medically necessary.
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.
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 copayment PLUS the cost difference between the brand-name drug and
the generic equivalent.
How often are PDLs updated?

PDL changes typically occur twice per year. However, changes that have a positive impact for you — such as
new medications or cost savings — may occur at any time. You can log in to the member website listed on your
health plan ID card at any time to check your medication coverage and lower-cost options.
5
Can a medication change tiers?
Yes. Tier changes may generally occur two times per year. When a medication changes tiers, you may pay more
or less for that medication, depending on the tier change. If one of your medications changes tiers, speak with
your doctor to determine if a lower-cost option may be available for you.
Are there other restrictions on what medications are covered?

Yes. Some medications may have additional requirements or limits depending on your benefit plan. You should
review your benefit plan documents to confirm if any of these programs apply to your plan. The medications that
have programs that apply are noted with letters next to them. Examples include:
May be excluded from coverage or subject to prior authorization and/or trial/failure of another
medication(s). Referred to as First Start in New Jersey. (E)
Lower-cost options are available and covered.
Health Care Reform Preventive (H)
This medication is part of a health care reform preventive benefit and may be available at no additional cost
to you.
Health Care Reform Preventive with prior authorization (H-PA)
May be part of health care reform preventive and at no additional cost to you if prior authorization criteria is met.
Prior Authorization (sometimes referred to as precertification)1 (PA)
Requires your doctor to provide information about why you are taking a medication to determine how it may
be covered by your plan.
Refill and Save Program2 (RS)
Save money on your copayment when you refill your prescription on time as prescribed. Program eligibility
may vary.
Specialty Medication (SP)
Specialty medications treat complex or rare conditions and may require special storage and handling. You may
be required to obtain these medications from a specialty pharmacy.
Step Therapy (referred to as First Start in New Jersey) (ST)
Requires you to try one or more other medications before the medication you are requesting may be covered.
Supply Limits (SL)
Specifies the largest quantity of medication covered per copayment or in a defined period of time.
Depending on your benefit, you may have notification or medical necessity requirements for select medications.
1
Not applicable to Neighborhood Health Plan and Oxford plans.

2
6
I’m taking a specialty medication. Who can I contact for
more information?
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 you’re taking a specialty medication that is
on a higher tier, call the toll-free phone number on your health plan ID card to talk with a pharmacist
about finding lower-cost options or a financial assistance program.
Who can I contact if I have questions about my PDL?

Online
Log in to the member website listed on your health plan ID card. Once online, you’ll have access to the
following 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
Check your PDL often for updates.
By phone
Call the toll-free phone number on your health plan ID card to speak with a customer service
representative. We can answer any questions you have about your pharmacy benefit plan, including
lower-cost options.
7
Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Anti-Infectives: Antibiotics Anti-Infectives: Antifungals
Amoxicillin Capsule, Chewable Cresemba 3 SL
1
Tablet
Econazole Cream 3 SL
Amoxicillin/Potassium Clavulanate
1
Chewable Tablet, Tablet Fluconazole Tablet 1
Azithromycin Tablet 1 Itraconazole Capsule 1 SL
Cefadroxil Capsule, Tablet 1 Ketoconazole Cream 1
Cefdinir Capsule 1 Noxafil Tablet, Suspension 2
Cefixime Suspension 3 Nystatin Cream, Ointment 1
Cefprozil Tablet 1 Terbinafine Tablet 1 SL
Cefuroxime Tablet 1 Anti-Infectives: Antivirals
Cephalexin Capsule 1 Acyclovir Ointment 3 PA, SL, ST
Ciprodex 3 Acyclovir Tablet 1
Ciprofloxacin Tablet 1 Famciclovir Tablet 2
Clarithromycin Tablet 1 Oseltamivir Capsule 2 SL
Clindamycin Capsule 1 Valacyclovir Tablet 1 SL
Dificid 3 SL Valganciclovir 1 SL
Doxycycline Hyclate 50, 100 mg Zovirax Cream 3 E, SL
2
Capsule, Tablet
Doxycycline Monohydrate Cancer
1
50, 100 mg Capsule Bexarotene Capsule 3 E, PA, SL, SP
Levofloxacin Tablet 1 Bicalutamide 1
Metronidazole Tablet 1 Bosulif 2 PA, SL, SP, ST
Minocycline Capsule 1 Cyclophosphamide Capsule 2
Minocycline Tablet 3 E Hydroxyurea Capsule 1
Moxifloxacin Tablet 3 Imatinib Tablet 1 PA, SL, SP
Nitrofurantoin Capsule 1 Imbruvica 2 PA, SL, SP
Nitrofurantoin Macrocrystal Capsule 1 Leucovorin Calcium Tablet 1
Ofloxacin Otic Solution 2 Mercaptopurine Tablet 1
Ofloxacin Tablet 1 Revlimid 2 PA, SL, SP
Oracea 3 Sutent 2 PA, SL, SP
Penicillin V Potassium Tablet 1 Targretin Capsule 2 SP
Sulfamethoxazole-Trimethoprim
1
Tablet
Suprax Capsule, Chewable Tablet,
3
Tablet
Bold type = Brand-name drug PA = Prior authorization required

[Plain type = Generic drug] RS = May be eligible for the refill and save program
E = May be excluded from coverage SL = Supply limit
H = May be part of health care reform preventive SP = Specialty medication
H-PA = May be part of health care reform preventive with prior authorization ST = Step therapy
8
Drug Name Drug Name
Targretin Gel 3 SL Dutoprol 3 E, SL
Tasigna 2 PA, SL, SP, ST Edarbi 3 SL
Xeloda 1 SL, SP Edarbyclor 3 SL
Zytiga 2 PA, SL, SP Enalapril 1
Cardiovascular/Heart Disease: Coagulation Therapy Furosemide 1
Brilinta 3 SL Guanfacine 1
Clopidogrel 1 Hydralazine 1
Effient 3 SL Hydrochlorothiazide 1
Eliquis 3 SL Irbesartan 1
Enoxaparin Sodium 2 SL Labetalol 1
Pradaxa 2 SL Lisinopril 1
Savaysa 3 SL Lisinopril-Hydrochlorothiazide 1
Warfarin Sodium 1 Losartan 1
Xarelto 2 SL Losartan-Hydrochlorothiazide 1
Cardiovascular/Heart Disease: High Blood Pressure Metoprolol Succinate Extended-
2
Release 50, 100, 200 mg
Amlodipine 1
Metoprolol Tartrate 25, 50, 100 mg 1
Amlodipine-Benazepril 1
Nadolol 1
Amlodipine-Valsartan 2
Nifedipine Extended-Release 1
Atenolol 1
Olmesartan 2 SL
Atenolol-Chlorthalidone 1
Olmesartan-Hydrochlorothiazide 2 SL
Benazepril 1
Propranolol Extended-Release
2
Benazepril-Hydrochlorothiazide 1 Capsule
Bidil 2 Propranolol Tablet 1
Bisoprolol 1 Quinapril 1
Bisoprolol-Hydrochlorothiazide 1 Ramipril 1
Bystolic 2 Spironolactone 1
Byvalson 2 SL Telmisartan 2
Cartia XT 2 Telmisartan-Hydrochlorothiazide 2
Carvedilol 1 Terazosin 1
Chlorthalidone 1 Triamterene-Hydrochlorothiazide 1
Clonidine Tablet 1 Valsartan 2
Diltiazem 24 Hour CD 2 Valsartan-Hydrochlorothiazide 1

Diltiazem Sustained-Release Verapamil 1
2
Capsule
Verapamil Sustained-Release 3
Diltiazem Sustained-Release Tablet 2
Doxazosin 1
9
Drug Name Drug Name
Cardiovascular/Heart Disease: High Cholesterol Isosorbide Mononitrate ER 1
Atorvastatin 1 H-PA, SL Multaq 3 PA
Choline Fenofibrate 3 E Nitroglycerin Sublingual Tablet 1
Ezetimibe Tablet 3 SL Ranexa 2
Ezetimibe/Simvastatin 3 SL Sotalol 1
Fenofibrate 43, 50, 67, 130, 134, Central Nervous System: Attention Deficit Disorder
3 E
150, 200 mg Capsule
Adderall XR 2 PA, SL
Fenofibrate 40, 48, 120, 145 mg
3 E
Tablet Amphetamine Salt Combo 1 PA
Fenofibrate 54, 160 mg Tablet 2 Atomoxetine 3 SL
Fluvastatin Extended-Release Tablet 3 SL, ST Concerta 2 PA, SL
Gemfibrozil 1 Daytrana 3 E, PA, SL
Lipofen 3 E Dexmethylphenidate Extended-
3 E, PA, SL
Release Capsule
Livalo 3 E, SL, ST
Dexmethylphenidate Immediate-
Lovastatin 1 H 1 PA
Release Tablet
Niacin Extended-Release Tablet 3 Dextroamphetamine-Amphetamine
3 E, PA, SL
Extended-Release Capsule
Niaspan 2
Dextroamphetamine-Amphetamine
1 PA
Omega-3-Acid Ethyl Esters Capsule 3 PA Immediate-Release Tablet
Praluent 2 PA, SL, SP, ST Dextroamphetamine Sulfate
3 PA
Immediate-Release Tablet
Pravastatin 1
Focalin XR 3 E, PA, SL
Repatha 140 mg 3 PA, SL, SP, ST
Guanfacine Extended-Release 2 SL
Rosuvastatin 2 SL Methylphenidate Chewable Tablet 3 PA
Simvastatin 1 H-PA Methylphenidate Extended-Release
Vascepa 3 PA Capsule (generic Metadate CD, 2 PA, SL
Ritalin LA)
Welchol 2 Methylphenidate Extended-Release
3 E, PA, SL
Cardiovascular/Heart Disease: Other Tablet (generic Concerta)
Methylphenidate Extended-Release
Amiodarone 1
Tablet (Metadate ER, generic 3 PA, SL
Corlanor 3 PA, SL Ritalin SR)
Methylphenidate Immediate-Release
Digoxin 1 1 PA
Tablet
Entresto 3 PA, SL Vyvanse 2 PA, SL
Flecainide 1

10
Drug Name Drug Name
Central Nervous System: Depression Central Nervous System: Multiple Sclerosis
Amitriptyline Tablet 1 Ampyra 2 PA, SL, SP
Bupropion Extended-Release Tablet 1 Aubagio 3 PA, SL, SP
Bupropion Sustained-Release Tablet 1 Avonex 2 PA, SL, SP
Bupropion Tablet 1 Betaseron 2 PA, SL, SP
Citalopram Tablet 1 Copaxone 2 PA, SL, SP
Desvenlafaxine Extended-Release Gilenya 3 PA, SL, SP
3 SL
Tablet (generic Pristiq)
E, PA, SL,
Doxepin 1 Glatopa 3
SP, ST
Duloxetine Capsule 3 SL Plegridy 3 PA, SL, SP
Escitalopram Tablet 1 Rebif 3 PA, SL, SP, ST
Fetzima 3 SL, ST Tecfidera 2 PA, SL, SP
Fluoxetine Capsule (generic Prozac) 1 Zinbryta 3 PA, SL, SP
Fluvoxamine Tablet 1 Central Nervous System: Other
Mirtazapine Tablet 1 Alprazolam Extended-Release
1
Tablet
Nortriptyline Capsule 1
Alprazolam Tablet 1
Paroxetine Tablet 1
Aripiprazole Tablet 2 SL
Sertraline Tablet 1
Armodafinil 3 PA, SL
Trazodone Tablet 1
Buprenorphine/Naloxone Tablet
3 E, PA, SL
Trintellix 3 E, SL, ST (generic Suboxone)
Venlafaxine Extended-Release Buspirone Tablet 1
1
Capsule
Carbidopa-Levodopa 1
Venlafaxine Tablet 1
Diazepam Tablet 1
Viibryd 3 SL
Donepezil 5, 10 mg ODT, Tablet 1
Central Nervous System: Migraine
Latuda 3 SL
Acetaminophen/Butalbital/Caffeine
1 SL Lithium Capsule 1
325 mg/50 mg/40 mg
Eletriptan 2 SL Lorazepam Tablet 1
Frovatriptan 3 SL Memantine Tablet 2
Naratriptan 1 SL Modafinil Tablet 3 PA, SL
Rizatriptan ODT, Tablet 1 SL Naloxone Vials 1
Sumatriptan Nasal Spray 2 SL Narcan Nasal Spray 2 SL
Sumatriptan Succinate Tablet, Olanzapine Tablet 1 SL
1 SL
Injection
Pramipexole Tablet 1
Quetiapine Extended-Release Tablet 3 SL
11
Drug Name Drug Name
Quetiapine Immediate-Release Oxcarbazepine Tablet 1
1
Tablet
Phenytoin Capsule, Suspension 1
Risperidone Tablet 1
Topiramate Immediate-Release
Ropinirole Tablet 1 1
Tablet
Suboxone Film 3 E, PA, SL Zonisamide Capsule 1
Tolcapone 2 Dermatology
Xyrem 3 PA, SL Aczone 3 SL
Zelapar 3 Adapalene 0.1%/Benzoyl Peroxide
3 E, SL
2.5% Gel
Ziprasidone Capsule 2 SL
Adapalene Cream, Gel, Lotion 3 E, PA, SL
Zubsolv 2 SL
Betamethasone Dipropionate 0.05%
3
Central Nervous System: Sedatives/Hypnotics Augmented Lotion, Ointment
Eszopiclone Tablet 2 SL Betamethasone Dipropionate 0.05%
2
Cream, Ointment
Temazepam Capsule 1 Calcipotriene/Betamethasone
3 SL
Triazolam Tablet 1 Ointment
Zaleplon Capsule 1 SL Carac 2

Ciclopirox Cream, Gel, Lotion,
Zolpidem Extended-Release Tablet 3 E, SL 1
Solution
Zolpidem Immediate-Release Tablet 1 SL Claravis 2 PA
Central Nervous System: Seizure Disorders Clindamycin 1%/Benzoyl Peroxide
3 E, SL
Carbamazepine Extended-Release 5% Gel
2
Capsule Clindamycin 1.2%/Benzoyl Peroxide
3 SL
Carbamazepine Extended-Release 5% Gel
3
Tablet Clindamycin Gel 3 SL
Carbamazepine Immediate-Release
1 Clindamycin Lotion 3
Tablet
Clonazepam Tablet 1 Clindamycin Solution, Swabs 1
Clobetasol Propionate Cream,
Diazepam Tablet 1 2 SL
Ointment
Divalproex Delayed-Release Tablet 1 Clobetasol Propionate Solution 1 SL
Divalproex Extended-Release Tablet 2 Clotrimazole-Betamethasone Cream 1 SL
Gabapentin Capsule, Tablet 1 Clotrimazole-Betamethasone Lotion 1
Lamotrigine Immediate-Release Desonide 0.05% Cream, Lotion,
1 3 SL
Tablet Ointment
Levetiracetam Extended-Release
2 Desoximetasone Gel, Ointment 3 SL
Tablet
Levetiracetam Immediate-Release Diflorasone Diacetate 0.05% Cream,
1 3 SL
Tablet Ointment
Lyrica 3 SL, ST Dupixent 3 PA, SL, SP, ST

12
Drug Name Drug Name
Elidel 3 SL, ST Diabetes: Blood Glucose Monitoring*
Enstilar Foam 3 SL Accu-Chek Test Strips 3 E, SL
Epiduo Forte 3 E, SL Contour Test Strips 3 E, SL
Eucrisa 3 SL, ST Dexcom Continuous Glucose
3 PA, SL
Monitoring System
Finacea 3
Dexcom Sensor 3 PA, SL
Fluocinolone Cream, Oil, Solution 3 SL
Dexcom Transmitter 3 PA, SL
Fluocinolone Ointment 2 SL
FreeStyle Test Strips 3 E, SL
Fluocinonide 0.05% Cream 1
OneTouch Test Strips 1 SL
Halobetasol Ointment 2
OneTouch Ultra Meter 1
Hydrocortisone 2.5% Cream,
1 OneTouch Ultra Mini 1
Ointment
Imiquimod 5% Cream 1 SL OneTouch Ultra Test Strips 1 SL
Metronidazole 0.75% Topical Gel 1 OneTouch Verio 1
Minocycline Extended-Release OneTouch Verio Flex 1
3 E
Capsule
OneTouch Verio IQ 1
Mirvaso 3 SL
OneTouch Verio Sync 1
Mometasone Furoate Cream, Lotion,
1
Ointment OneTouch Verio Test Strips 1 SL
Mupirocin Ointment 1 SL Diabetes: Insulin*
Nystatin-Triamcinolone Acetonide Afrezza 3 E, PA, SL
3 E
Cream, Ointment
Basaglar 1 SL
Oxsoralen-Ultra 2
Humalog KwikPens (all formulations) 2 SL
Picato 3 SL
Humalog Vials (all formulations) 1 SL
Regranex 2 PA, SL
Humulin KwikPens (all formulations) 2 SL
Rhofade 3 PA, SL
Humulin Vials (all formulations) 1 SL
Solodyn 3 E, PA
Lantus Solostar 3 E, SL
Taclonex Suspension 3 SL
Lantus Vials 3 E, SL
Tacrolimus Ointment 2 SL, ST
Tazarotene 0.1% Cream (generic Levemir FlexTouch 2 SL
3 E, PA, SL
Tazorac) Levemir Vials 2 SL
Tazorac 3 PA, SL Novolin Vials (all formulations) 3 SL, ST
Tretinoin Cream 3 PA, SL Novolog FlexPen (all formulations) 3 SL, ST
Tretinoin Gel 3 E, PA, SL Novolog Vials (all formulations) 3 SL, ST
Tretinoin Microspheres 3 E, PA, SL Toujeo SoloStar 3 E, SL
Triamcinolone Acetonide Cream,
1 Tresiba FlexTouch 3 E, SL
Lotion, Ointment
Vectical 3 SL
* Diabetic supplies and prescription medications may be subject to different cost-share arrangements for Oxford plans. Please
see your Summary of Benefits and Coverage (SBC) for specifics. Medications that require step therapy may require prior
authorization (sometimes referred to as precertification) if covered under another benefit.
13
Drug Name Drug Name
Diabetes: Non-Insulin* Synjardy XR 2 SL
Adlyxin 3 SL Tanzeum 2 SL
Bydureon 2 SL Tradjenta 2 SL
Byetta 2 SL Trulicity 3 SL
Farxiga 3 SL, ST Victoza 2-Pak 2 SL
Glimepiride 1 Victoza 3-Pak 3 SL
Glipizide 1 Xigduo XR 3 E, SL, ST
Glipizide Extended-Release 1 Xultophy 3 E, SL
Glyburide 1 Endocrine: Growth Hormone**
Glyxambi 3 E, SL, ST Nutropin, Nutropin AQ 2 PA, SL, SP
Invokamet 2 SL Endocrine: Other
Invokamet XR 2 SL Calcitriol Capsule 1
Invokana 2 SL, ST Desmopressin Tablet 1
Janumet 3 SL, ST Dexamethasone Tablet 1
Januvia 3 SL, ST Methylprednisolone Tablet 1
Jardiance 2 SL, ST Prenisolone Oral Solution 1
Jentadueto 2 SL Prednisone Tablet 1
Jentadueto XR 2 SL Rayaldee 3 E
Kazano 2 SL Endocrine: Thyroid Hormone Replacement
Kombiglyze XR 2 SL Armour Thyroid 3
Metformin 1 Levothyroxine Sodium Tablet 1
Metformin Extended-Release Tablet Liothyronine Sodium Tablet 2
1
(generic Glucophage XR)
Methimazole Tablet 1
Nesina 2 SL
NP Thyroid Tablet 1
Onglyza 2 SL
Synthroid 2
Oseni 2 SL
Eye Conditions: Allergies
Pioglitazone 1 SL
Azelastine 0.05% Ophthalmic
Soliqua 2 PA, SL 1
Solution
Synjardy 2 SL Lastacaft 3 SL
* Diabetic supplies and prescription medications may be subject to different cost-share arrangements for Oxford plans. Please
see your Summary of Benefits and Coverage (SBC) for specifics. Medications that require step therapy may require prior
authorization (sometimes referred to as precertification) if covered under another benefit.
**.Coverage is determined by the consumer’s prescription drug benefit plan. Please consult plan documents regarding benefit
coverage and cost-share. Prior authorization (sometimes referred to as precertification) may be required for Oxford plans.

14
Drug Name Drug Name
Olopatadine 0.1% Ophthalmic Gastrointestinal: Nausea/Vomiting
3 SL
Solution
Akynzeo 3 SL
Olopatadine 0.2% Ophthalmic
3 E, SL
Solution Aprepitant Capsule 2 SL
Eye Conditions: Antibiotics Emend Suspension 2 SL
Erythromycin 0.5% Ophthalmic Ondansetron 1
1
Ointment
Gentamicin Ophthalmic Ointment, Ondansetron ODT 1
1
Solution Scopolamine Transdermal Patch 3
Moxeza 3 Varubi 2 SL
Moxifloxacin Ophthalmic Solution 3 Gastrointestinal: Other
Ofloxacin 0.3% Ophthalmic Solution 1 Amitiza 3 PA, SL, ST
Tobramycin/Dexamethasone 0.3%-
2 Apriso 2
0.1% Ophthalmic Suspension
Tobramycin Ophthalmic Solution 1 Asacol HD Tablet 3 E
Eye Conditions: Dry Eye Disease Canasa 2
Restasis MultiDose 3 E, PA, SL Cortifoam 2
Restasis Single Use Vials 3 PA, SL Creon 2
Xiidra 3 PA, SL Delzicol 3 E
Eye Conditions: Glaucoma Diphenoxylate-Atropine Tablet 1
Alphagan P 0.1% 2 SL Golytely 2
Azopt 2 SL Hyoscyamine Tablet 1
Combigan 2 SL Lialda 2
Latanoprost 0.005% Ophthalmic Linzess 2 PA, SL
1
Solution Mesalmine Delayed-Release Tablet
3 E
Lumigan 2 SL (generic Lialda)
Timolol Maleate 0.25%, 0.5% Metoclopramide Tablet 1
1
Ophthalmic Solution Movantik 2 PA, SL
Travatan Z 2 SL
Moviprep 3
Gastrointestinal: Acid Suppression
Polyethylene Glycol 3350 2
Dexilant 3 SL
Prepopik 3
Esomeprazole Capsule 3 E, SL
Suclear 3
Lansoprazole Capsule 3 E, SL
Sulfasalazine Tablet 1
Omeclamox-Pak 3 SL
Suprep 3
Omeprazole Capsule 1
Uceris Foam 2
Pantoprazole Tablet 1
Uceris Tablet 3
Pylera 3 SL
Viberzi 3 PA, SL
Ranitadine Syrup 1
Zenpep 2
Rabeprazole Tablet 3 SL
Sucralfate Tablet 1
15
Drug Name Drug Name
Gout Lamivudine-Zidovudine 1 SP
Allopurinol Tablet 1 Lopinavir-Ritonavir Oral Solution 2 SP
Colcrys 3 E Nevirapine 1 SP
Mitigare 2 Nevirapine Extended-Release 3 E, SP
Uloric 3 SL, ST Norvir 2 SP
Zurampic 3 PA, SL Odefsey 3 SP
Hepatitis C Prezcobix 2 SP
Daklinza 3 PA, SL, SP, ST Prezista 2 SP
Epclusa 2 PA, SL, SP Reyataz 2 SP
Harvoni 2 PA, SL, SP Selzentry 2 PA, SP
Mavyret 2 PA, SL, SP Stribild 3 SP, ST
Ribavirin Tablet 1 SP Sustiva 2 SP
Sovaldi 3 PA, SL, SP, ST Tivicay 3 SP
Technivie 3 PA, SL, SP, ST Triumeq 2 SP
Viekira Pak 3 PA, SL, SP, ST Truvada 3 SP
Viekira XR 3 PA, SL, SP, ST Tybost 2 SP
Vosevi 2 PA, SL, SP Viread 2 SP
Zepatier 3 PA, SL, SP, ST Vitekta 2 SP
HIV/AIDS Infertility**
Abacavir-Lamivudine 2 SP Cetrotide 2 SP
Atripla 2 SP Clomiphene 1 SP
Complera 3 SP Gonal-F 2 SP
Descovy 3 SP Gonal-F RFF 2 SP
Epzicom 3 E, SP Ovidrel 3 SP
Evotaz 2 SP
Genvoya 3 SP, ST
Intelence 2 SP
Isentress 2 SP
Kaletra Tablet 2 SP

16
Drug Name Drug Name
Inflammatory Conditions: Rheumatoid Arthritis, Crohn’s Men’s Health: Testosterone Therapy
Disease, Psoriasis, Ulcerative Colitis
Androderm 2 PA, SL
Actemra 3 PA, SL, SP, ST
Androgel 3 E, PA, SL
Cimzia 2 PA, SL, SP
Methyltestosterone Capsule 2
Cosentyx 3 PA, SL, SP, ST
Testim 2 PA, SL
Enbrel 3 PA, SL, SP, ST
Testosterone 1% Topical Gel 3 E, PA, SL
Humira 2 PA, SP, SL
Testosterone Cypionate Injection 1
Hydroxychloroquine Sulfate 1
Miscellaneous
Leflunomide 1
Anastrozole Tablet 1
Methotrexate Tablet 1
Aranesp 2 SL, SP
Orencia 3 PA, SL, SP, ST
Auryxia 3
Otezla 2 PA, SL, SP
Auvi-Q 3 E, SL
Otrexup 3 E, SL, ST
Benzonatate Capsule 1
Rasuvo 3 SL, ST
Bethkis 2 PA, SL, SP
Simponi 2 PA, SL, SP
Cayston 2 PA, SL
Stelara 2 PA, SL, SP
Cerdelga 2 PA, SP
Taltz 3 PA, SL, SP, ST
Chlorhexidine Gluconate 1
Xeljanz 3 PA, SL, SP, ST
Chlorpheniramine/Hydrocodone/
Xeljanz XR 3 PA, SL, SP, ST 2 SL
Pseudoephedrine Solution
Medications for Sexual Dysfunction** Epinephrine (generic EpiPen/
2 SL
EpiPen-Jr.)
Addyi 3 PA, SL
EpiPen/EpiPen-Jr. 3 E, SL
Cialis 3 SL
Fosrenol 3
Levitra 3 SL
Hydrocodone/Chlorpheniramine
3 SL
Osphena 3 Suspension
Stendra 3 PA, SL Letrozole Tablet 1
Viagra 3 SL Lidocaine Transdermal Patch
3 PA, SL
(generic Lidoderm)
Men’s Health: Prostate
Nuedexta 2
Alfuzosin Tablet 1
Obredon 3 SL, ST
Doxazosin Tablet 1
Pegasys 2 PA, SP, SL
Dutasteride Capsule 3
Phenazopyridine 1
Finasteride Tablet 1
Procrit 2 SL, SP
Rapaflo 3
Promethazine/Codeine 1
Tamsulosin Capsule 1
Promethazine/Dextromethorphan 1
Terazosin Capsule, Tablet 1
17
Drug Name Drug Name
Pulmozyme 2 PA, SL, SP Etodolac Capsule 1
Rectiv 3 SL Fentanyl 12, 25, 50, 75, 100 mcg
2 SL
Patch
Rezira 3
Fentanyl Citrate Lozenge 2 PA, SL
Sevelamer 2
Hydrocodone/Acetaminophen
1 SL
Tobi Podhaler 3 PA, SL, SP 5/325, 7.5/325, 10/325 mg Tablet
Tobramycin Nebulized Solution 3 E, PA, SL, SP Hydrocodone/Ibuprofen Tablet 1
Velphoro 2 Hydromorphone Immediate-Release

1
Tablet
Veltassa 3 PA, SL
Hysingla 3 E, PA, SL, ST
Zarxio 2 SP
Ibuprofen Tablet 1
Musculoskeletal: Muscle Spasms
Indomethacin Capsule 1
Baclofen Tablet 1
Ketorolac Tablet 1
Carisoprodol 350 mg Tablet 1
Lazanda 3 PA, SL
Cyclobenzaprine 1
Meloxicam Tablet 1
Metaxalone Tablet 3 Methadone Tablet, Oral Solution,
1 SL
Methocarbamol Tablet 1 Concentrate Solution
Morphine Sulfate Extended-Release
Tizanidine Tablet 1 1 SL
Tablet
Musculoskeletal: Osteoporosis Morphine Sulfate Oral Solution 1
Alendronate Sodium Tablet 1 Nabumetone Tablet 1
Forteo 3 PA, SP Naproxen Tablet 1
Ibandronate Tablet 2 SL Nucynta 3 SL
Raloxifene Tablet 2 Nucynta ER 3 PA, SL
Risedronate Sodium Tablet 3 SL Opana ER 3 E, PA, SL
Tymlos 3 PA, SP Oxycodone Tablet 1
Musculoskeletal: Pain Relief Oxycodone/Acetaminophen 5/325,
1 SL
Acetaminophen/Codeine Tablet 1 SL 7.5/325, 10/325 mg Tablet
Oxycontin 3 E, PA, SL, ST
Arymo ER 3 E, PA, SL, ST
Sprix 3
Belbuca 3 PA, SL, ST
Subsys 3 E, PA, SL
Butrans 3 E, PA, SL, ST
Tramadol-Acetaminophen 1
Celecoxib 2 SL
Tramadol Immediate-Release Tablet 1
Diclofenac Tablet 1
Tramadol Sustained-Release Tablet 2 SL
Embeda 3 E, PA, SL, ST
Trezix 3 SL

18
Drug Name Drug Name
Vicodin 5/300, 7.5/300, 10/300 mg Combivent Respimat 3 SL
3 E, SL
Tablet
Dulera 3 E, SL, ST
Voltaren Gel 2
Flovent Diskus/HFA 3 SL
Xtampza ER 2 PA, SL
Fluticasone/Salmeterol RespiClick
Zohydro ER 3 PA, SL, ST 2 SL
(generic AirDuo RespiClick)
Overactive Bladder Incruse Ellipta 2 SL
Dicyclomine Tablet 1 Ipratropium-Albuterol Nebs 1
Oxybutynin Extended-Release Ipratropium Nebs 1
2
Tablet
Levalbuterol Nebs 3 E, SL
Oxybutynin Tablet 1
Montelukast Chewable Tablet, Tablet 1
Tolterodine Extended-Release Tablet 3 E
Montelukast Granules 2
Tolterodine Tablet 3 E
Perforomist 3 SL
Toviaz 3
ProAir HFA/RespiClick 3 SL
Vesicare 3 E
Proventil HFA 3 SL
Respiratory: Allergies
Pulmicort Flexhaler 3 SL, ST
Azelastine 0.1% Nasal Spray 3
QVAR MDI 1 SL
Clarinex 3 E
Serevent Diskus 3 SL
Clarinex-D 3 E
Spiriva Handihaler/Respimat 3 SL
Cyproheptadine Tablet 1
Stiolto Respimat 3 E, SL
Fluticasone Nasal Spray 2 SL
Striverdi Respimat 2 SL
Hydroxyzine Capsule, Tablet 1
Symbicort 3 RS, SL
Levocetirizine Tablet 1
Tudorza 2 SL
Promethazine Tablet 1
Ventolin HFA 2 SL
Zetonna 3 SL
Xopenex HFA 3 SL
Respiratory: Asthma/COPD
Respiratory: Pulmonary Arterial Hypertension
Advair Diskus/HFA 3 RS, SL
Adcirca 3 PA, SL, SP
Aerospan 3 SL
Adempas 2 PA, SL, SP
AirDuo RespiClick 3 E, SL
Letairis 2 PA, SL, SP
Albuterol Nebs 1
Opsumit 2 PA, SL, SP
Alvesco 1 SL
Orenitram 3 PA, SL, SP
Anoro Ellipta 3 SL
Sildenafil Tablet 1 PA, SL, SP
Arnuity Ellipta 3 SL
Tracleer 2 PA, SL, SP
Asmanex TwistHaler, HFA 1 SL
Tyvaso 2 PA, SP
Bevespi Aerosphere 2 SL
Uptravi 3 PA, SL, SP
Breo Ellipta 3 RS, SL
Budesonide Nebs 2 SL
19
Drug Name Drug Name
Smoking Cessation Apri 1 H
Bupropion Sustained-Release Tablet 1 H-PA 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 Mini-Lozenge 3 H-PA Camila 1 H
Nicotine Gum 1 H-PA Caziant 1 H
Nicotine Lozenge 1 H-PA Cesia 1 H
Nicotine Patch 1 H-PA Chateal 1 H
Nicotrol Inhaler 3 H-PA Cryselle 1 H
Nicotrol Nasal Spray 3 H-PA Cyclafem 7/7/7, 1/35 1 H
Thrive Gum 1 H-PA Cyred 1 H
Transplant Dasetta 7/7/7, 1/35 1 H
Azathioprine Tablet 1 Deblitane 1 H
Cyclosporine Modified Capsule 1 SP Delyla 1 H
Mycophenolate Capsule, Desogestrel-Ethinyl Estradiol
1 SP 1 H
Suspension (generic Ortho-Cept)
Mycophenolic Acid Tablet 2 SP Drospirenone-Ethinyl Estradiol-
3 E
Levomefolate Calcium
Sirolimus Tablet 1 SP
Econtra EZ 1 H
Tacrolimus Capsule 1 SP
Elinest 1 H
Vitamins/Electrolytes
Ella 1 H, SL
Fluoride 1
Emoquette 1 H
Folic Acid 1
Enpresse 1 H
Klor-Con M10 1
Enskyce 1 H
Klor-Con M20 1
Errin 1 H
Potassium Chloride 1
Estarylla 1 H
Potassium Citrate 1
Fallback 1 H
Women’s Health: Contraceptives
Falmina 1 H
Aftera 1 H
Fayosim 3 E
Altavera 1 H
Gildess 2
Alyacen 7/7/7, 1/35 1 H

20
Drug Name Drug Name
Gildess Fe 1 H Myzilra 1 H
Heather 1 H Natazia 2
Introvale 2 H Necon 7/7/7, 0.5/35, 1/35, 1/50,
1 H
10/11
Jencycla 1 H
Next Choice 1 H
Jolessa 2 H
Nora BE 1 H
Jolivette 1 H
Norethindrone 0.35 mg 1 H
Juleber 1 H
Norethindrone-Ethinyl Estradiol-
1 H
Junel 2 Ferrous Fumarate
Junel Fe 1 H Norgestimate-Ethinyl Estradiol
(generic Ortho-Cyclen, Ortho 1 H
Kurvelo 1 H Tri-Cyclen)
Kelnor 1/35 1 H Norgestimate-Ethinyl Estradiol Lo
2
(generic Ortho Tri-Cyclen Lo)
Larin Fe 1 H
Norlyroc 1 H
Larissia 1 H
Nortrel 7/7/7, 0.5/35, 1/35 1 H
Leena 1 H
Nuvaring 2 H
Lessina 1 H
Opcicon 1 H
Levonest 1 H
Orsythia 1 H
Levonorgestrel 1.5 mg 1 H
Ortho Tri-Cyclen Lo 3 E
Levonorgestrel-Ethinyl Estradiol
(generic Alesse, Nordette, 1 H Pirmella 7/7/7, 1/35 1 H
Triphasil) Plan B One Step 1 H
Levonorgestrel-Ethinyl Estradiol
2 H Portia 1 H
(generic Seasonale)
Levora-28 1 H Previfem 1 H
Lo Loestrin Fe 3 Quasense 2 H
Loryna 3 Rajani 3 E
Low-Ogestrel 1 H React 1 H
Lutera 1 H Reclipsen 1 H
Lyza 1 H Rivelsa 3 E
Marlissa 1 H Setlakin 2 H
Medroxyprogesterone Acetate 1 H Sharobel 1 H
Mibelas 24 Fe Chewable Tablet 3 E Solia 1 H
Microgestin 2 Sprintec 1 H
Microgestin Fe 1 H Sronyx 1 H
Mono-Linyah 1 H Take Action 1 H
MonoNessa 1 H Tarina Fe 1 H
My Way 1 H Taytulla 3 E
21
Drug Name Drug Name
Tri-Estarylla 1 H Estradiol Twice-Weekly Transdermal
3 E, SL
Patch
Tri-Linyah 1 H
Estring 2 SL
Tri-Lo-Estarylla 2
Estrogen/Methyltestosterone Tablet 1
Tri-Lo-Marzia 2
Evamist 2
Tri-Lo-Sprintec 2
Medroxyprogesterone 1
Tri-Previfem 1 H
Minivelle 3 SL
Tri-Sprintec 1 H
Premarin 3
Trinessa 1 H
Premphase 3
Trinessa Lo 2
Prempro 3
Trivora-28 1 H
Progesterone Micronized Capsule 2
Velivet 1 H
Vivelle-Dot 2 SL
Vestura 3
Yuvafem 2
Vienva 1 H
Women’s Health: Miscellaneous
Viorele 2
Raloxifene 2 H-PA
Wera 1 H
Tamoxifen 1 H-PA
Xulane 3 H
Women’s Health: Prenatal Vitamins
Yasmin 28 2
Brand Prenatal Vitamins 3
Yaz 2
Zovia 1/35E, 1/50E 1 H
Women’s Health: Hormone Replacement
Climara 2 SL
Climara Pro 3 SL
Divigel 3
Duavee 3
Estrace Cream 3
Estradiol/Norethindrone Acetate
2
Tablet
Estradiol Tablet 1

22
Index
A Anastrozole Tablet................................... 17 Bevespi Aerosphere............................... 19
Abacavir-Lamivudine.............................. 16 Androderm................................................ 17 Bexarotene Capsule................................. 8
Accu-Chek Test Strips............................ 13 Androgel.................................................... 17 Bicalutamide............................................... 8
Acetaminophen/Butalbital/Caffeine Anoro Ellipta.............................................. 19 Bidil............................................................... 9
325 mg/50 mg/40 mg....................... 11 Aprepitant Capsule................................. 15 Bisoprolol..................................................... 9
Acetaminophen/Codeine Tablet......... 18 Apri..............................................................20 Bisoprolol-Hydrochlorothiazide............. 9
Actemra...................................................... 17 Apriso......................................................... 15 Blisovi Fe....................................................20
Acyclovir Ointment.................................... 8 Aranelle......................................................20 Bosulif........................................................... 8
Acyclovir Tablet.......................................... 8 Aranesp...................................................... 17 Brand Prenatal Vitamins........................22
Aczone....................................................... 12 Aripiprazole Tablet.................................. 11 Breo Ellipta................................................ 19
Adapalene 0.1%/Benzoyl Armodafinil................................................ 11 Brilinta.......................................................... 9
Peroxide 2.5% Gel............................... 12 Armour Thyroid........................................ 14 Budesonide Nebs.................................... 19
Adapalene Cream, Gel, Lotion............. 12 Arnuity Ellipta............................................ 19 Buprenorphine/Naloxone Tablet......... 11
Adcirca....................................................... 19 Arymo ER.................................................. 18 Bupropion Extended-Release
Adderall XR............................................... 10 Asacol HD Tablet..................................... 15 Tablet...................................................... 11
Addyi........................................................... 17 Asmanex TwistHaler, HFA..................... 19 Bupropion Sustained-Release
Adempas................................................... 19 Atenolol........................................................ 9 Tablet............................................... 11, 20
Adlyxin........................................................ 14 Atenolol-Chlorthalidone........................... 9 Bupropion Tablet..................................... 11
Advair Diskus/HFA.................................. 19 Atomoxetine.............................................. 10 Buspirone Tablet...................................... 11
Aerospan................................................... 19 Atorvastatin............................................... 10 Butrans....................................................... 18
Afrezza....................................................... 13 Atripla......................................................... 16 Bydureon................................................... 14
Aftera..........................................................20 Aubagio...................................................... 11 Byetta......................................................... 14
AirDuo RespiClick................................... 19 Aubra..........................................................20 Bystolic......................................................... 9
Akynzeo..................................................... 15 Auryxia....................................................... 17 Byvalson...................................................... 9
Albuterol Nebs......................................... 19 Auvi-Q......................................................... 17
C
Alendronate Sodium Tablet.................. 18 Aviane.........................................................20
Avonex........................................................ 11 Calcipotriene/Betamethasone
Alesse......................................................... 21
Azathioprine Tablet.................................20 Ointment................................................ 12
Alfuzosin Tablet........................................ 17
Azelastine 0.05% Ophthalmic Calcitriol Capsule.................................... 14
Allopurinol Tablet..................................... 16
Solution.................................................. 14 Camila........................................................20
Alphagan P 0.1%...................................... 15
Azelastine 0.1% Nasal Spray................. 19 Canasa....................................................... 15
Alprazolam Extended-Release
Azithromycin Tablet.................................. 8 Carac.......................................................... 12
Tablet...................................................... 11
Azopt.......................................................... 15 Carbamazepine Extended-Release
Alprazolam Tablet.................................... 11
Azurette......................................................20 Capsule.................................................. 12
Altavera......................................................20
Carbamazepine Extended-Release
Alvesco....................................................... 19 B Tablet...................................................... 12
Alyacen 7/7/7, 1/35.................................20
Baclofen Tablet........................................ 18 Carbamazepine Immediate-Release
Amiodarone.............................................. 10
Basaglar..................................................... 13 Tablet...................................................... 12
Amitiza........................................................ 15
Belbuca...................................................... 18 Carbidopa-Levodopa............................. 11
Amitriptyline Tablet.................................. 11
Benazepril................................................... 9 Carisoprodol 350 mg Tablet................. 18
Amlodipine.................................................. 9
Benazepril-Hydrochlorothiazide............ 9 Cartia XT...................................................... 9
Amlodipine-Benazepril............................. 9
Benzonatate Capsule............................. 17 Carvedilol..................................................... 9
Amlodipine-Valsartan............................... 9
Betamethasone Dipropionate 0.05% Cayston...................................................... 17
Amoxicillin Capsule, Chewable
Augmented Lotion, Ointment........... 12 Caziant.......................................................20
Tablet........................................................ 8
Betamethasone Dipropionate 0.05% Cefadroxil Capsule, Tablet...................... 8
Amoxicillin/Potassium Clavulanate
Cream, Ointment................................. 12 Cefdinir Capsule........................................ 8
Chewable Tablet, Tablet...................... 8
Betaseron.................................................. 11 Cefixime Suspension................................ 8
Amphetamine Salt Combo................... 10
Bethkis....................................................... 17 Cefprozil Tablet.......................................... 8
Ampyra....................................................... 11
23
Cefuroxime Tablet..................................... 8 Contour Test Strips................................. 13 Diflorasone Diacetate 0.05% Cream,
Celecoxib................................................... 18 Copaxone.................................................. 11 Ointment................................................ 12
Cephalexin Capsule.................................. 8 Corlanor..................................................... 10 Digoxin....................................................... 10
Cerdelga.................................................... 17 Cortifoam................................................... 15 Diltiazem 24 Hour CD............................... 9
Cesia...........................................................20 Cosentyx.................................................... 17 Diltiazem Sustained-Release
Cetrotide.................................................... 16 Creon.......................................................... 15 Capsule.................................................... 9
Chantix Tablet...........................................20 Cresemba.................................................... 8 Diltiazem Sustained-Release Tablet..... 9
Chateal.......................................................20 Cryselle......................................................20 Diphenoxylate-Atropine Tablet............. 15
Chlorhexidine Gluconate....................... 17 Cyclafem 7/7/7, 1/35..............................20 Divalproex Delayed-Release Tablet.... 12
Chlorpheniramine/Hydrocodone/ Cyclobenzaprine...................................... 18 Divalproex Extended-Release
Pseudoephedrine Solution............... 17 Cyclophosphamide Capsule.................. 8 Tablet...................................................... 12
Chlorthalidone............................................ 9 Cyclosporine Modified Capsule..........20 Divigel.........................................................22
Choline Fenofibrate................................. 10 Cyproheptadine Tablet........................... 19 Donepezil 5, 10 mg ODT, Tablet.......... 11
Cialis........................................................... 17 Cyred..........................................................20 Doxazosin..............................................9, 17
Ciclopirox Cream, Gel, Lotion, Doxazosin Tablet..................................... 17
D
Solution.................................................. 12 Doxepin...................................................... 11
Cimzia......................................................... 17 Daklinza..................................................... 16 Doxycycline Hyclate 50, 100 mg
Ciprodex...................................................... 8 Dasetta 7/7/7, 1/35.................................20 Capsule, Tablet...................................... 8
Ciprofloxacin Tablet.................................. 8 Daytrana..................................................... 10 Doxycycline Monohydrate
Citalopram Tablet.................................... 11 Deblitane....................................................20 50, 100 mg Capsule............................. 8
Claravis....................................................... 12 Delyla..........................................................20 Drospirenone-Ethinyl Estradiol-
Clarinex...................................................... 19 Delzicol....................................................... 15 Levomefolate Calcium........................20
Clarinex-D.................................................. 19 Descovy..................................................... 16 Duavee.......................................................22
Clarithromycin Tablet................................ 8 Desmopressin Tablet.............................. 14 Dulera......................................................... 19
Climara.......................................................22 Desogestrel-Ethinyl Estradiol................20 Duloxetine Capsule................................. 11
Climara Pro...............................................22 Desonide 0.05% Cream, Lotion, Dupixent..................................................... 12
Clindamycin 1%/Benzoyl Peroxide Ointment................................................ 12 Dutasteride Capsule............................... 17
5% Gel.................................................... 12 Desoximetasone Gel, Ointment........... 12 Dutoprol....................................................... 9
Clindamycin 1.2%/Benzoyl Peroxide Desvenlafaxine Extended-Release
Tablet...................................................... 11 E
5% Gel.................................................... 12
Clindamycin Capsule................................ 8 Dexamethasone Tablet.......................... 14 Econazole Cream...................................... 8
Clindamycin Gel....................................... 12 Dexcom Continuous Glucose Econtra EZ................................................20
Clindamycin Lotion................................. 12 Monitoring System.............................. 13 Edarbi........................................................... 9
Clindamycin Solution, Swabs............... 12 Dexcom Sensor....................................... 13 Edarbyclor................................................... 9
Clobetasol Propionate Cream, Dexcom Transmitter................................ 13 Effient............................................................ 9
Ointment................................................ 12 Dexilant...................................................... 15 Eletriptan.................................................... 11
Clobetasol Propionate Solution........... 12 Dexmethylphenidate Elidel........................................................... 13
Clomiphene............................................... 16 Extended-Release Capsule.............. 10 Elinest.........................................................20
Clonazepam Tablet................................. 12 Dexmethylphenidate Eliquis........................................................... 9
Clonidine Tablet......................................... 9 Immediate-Release Tablet................. 10 Ella...............................................................20
Clopidogrel.................................................. 9 Dextroamphetamine Sulfate Embeda...................................................... 18
Clotrimazole-Betamethasone Immediate-Release Tablet................. 10 Emend Suspension................................. 15
Cream..................................................... 12 Dextroamphetamine-Amphetamine Emoquette.................................................20
Clotrimazole-Betamethasone Extended-Release Capsule.............. 10 Enalapril....................................................... 9
Lotion...................................................... 12 Dextroamphetamine-Amphetamine Enbrel......................................................... 17
Colcrys....................................................... 16 Immediate-Release Tablet................. 10 Enoxaparin Sodium................................... 9
Combigan.................................................. 15 Diazepam Tablet................................11, 12 Enpresse....................................................20
Combivent Respimat.............................. 19 Diclofenac Tablet..................................... 18 Enskyce.....................................................20
Complera................................................... 16 Dicyclomine Tablet.................................. 19 Enstilar Foam............................................ 13
Concerta.................................................... 10 Dificid............................................................ 8 Entresto...................................................... 10
24
Epclusa...................................................... 16 Fluocinonide 0.05% Cream.................. 13 Hydrocodone/Acetaminophen
Epiduo Forte............................................. 13 Fluoride......................................................20 5/325, 7.5/325, 10/325 mg
Epinephrine............................................... 17 Fluoxetine Capsule.................................. 11 Tablet...................................................... 18
EpiPen/EpiPen-Jr.................................... 17 Fluticasone Nasal Spray........................ 19 Hydrocodone/Chlorpheniramine
Epzicom..................................................... 16 Fluticasone/Salmeterol RespiClick..... 19 Suspension........................................... 17
Errin.............................................................20 Fluvastatin Extended-Release Hydrocodone/Ibuprofen Tablet........... 18
Erythromycin 0.5% Ophthalmic Tablet...................................................... 10 Hydrocortisone 2.5% Cream,
Ointment................................................ 15 Fluvoxamine Tablet................................. 11 Ointment................................................ 13
Escitalopram Tablet................................ 11 Focalin XR................................................. 10 Hydromorphone Immediate-Release
Esomeprazole Capsule.......................... 15 Folic Acid...................................................20 Tablet...................................................... 18
Estarylla......................................................20 Forteo......................................................... 18 Hydroxychloroquine Sulfate.................. 17
Estrace Cream..........................................22 Fosrenol..................................................... 17 Hydroxyurea Capsule............................... 8
Estradiol Tablet.........................................22 FreeStyle Test Strips............................... 13 Hydroxyzine Capsule, Tablet................ 19
Estradiol Twice-Weekly Transdermal Frovatriptan............................................... 11 Hyoscyamine Tablet................................ 15
Patch.......................................................22 Furosemide................................................. 9 Hysingla..................................................... 18
Estradiol/Norethindrone Acetate
G I
Tablet......................................................22
Estring........................................................22 Gabapentin Capsule, Tablet................. 12 Ibandronate Tablet.................................. 18
Estrogen/Methyltestosterone Gemfibrozil................................................ 10 Ibuprofen Tablet....................................... 18
Tablet......................................................22 Gentamicin Ophthalmic Ointment, Imatinib Tablet............................................ 8
Eszopiclone Tablet.................................. 12 Solution.................................................. 15 Imbruvica..................................................... 8
Etodolac Capsule.................................... 18 Genvoya..................................................... 16 Imiquimod 5% Cream............................. 13
Eucrisa........................................................ 13 Gildess................................................20, 21 Incruse Ellipta........................................... 19
Evamist.......................................................22 Gildess Fe.................................................. 21 Indomethacin Capsule........................... 18
Evotaz......................................................... 16 Gilenya........................................................ 11 Intelence.................................................... 16
Ezetimibe Tablet...................................... 10 Glatopa....................................................... 11 Introvale...................................................... 21
Ezetimibe/Simvastatin............................ 10 Glimepiride................................................ 14 Invokamet.................................................. 14
Glipizide..................................................... 14 Invokamet XR........................................... 14
F Glipizide Extended-Release................. 14 Invokana..................................................... 14
Fallback......................................................20 Glucophage XR........................................ 14 Ipratropium Nebs..................................... 19
Falmina.......................................................20 Glyburide................................................... 14 Ipratropium-Albuterol Nebs.................. 19
Famciclovir Tablet...................................... 8 Glyxambi.................................................... 14 Irbesartan.................................................... 9
Farxiga........................................................ 14 Golytely...................................................... 15 Isentress..................................................... 16
Fayosim......................................................20 Gonal-F....................................................... 16 Isosorbide Mononitrate ER................... 10
Fenofibrate 40, 48, 120, 145 mg Gonal-F RFF.............................................. 16 Itraconazole Capsule................................ 8
Tablet...................................................... 10 Guanfacine............................................9, 10
J
Fenofibrate 43, 50, 67, 130, 134, Guanfacine Extended-Release............ 10
150, 200 mg Capsule........................ 10 Janumet..................................................... 14
H Januvia....................................................... 14
Fenofibrate 54, 160 mg Tablet............. 10
Fentanyl 12, 25, 50, 75, 100 mcg Halobetasol Ointment............................ 13 Jardiance................................................... 14
Patch....................................................... 18 Harvoni....................................................... 16 Jencycla..................................................... 21
Fentanyl Citrate Lozenge....................... 18 Heather...................................................... 21 Jentadueto................................................ 14
Fetzima....................................................... 11 Humalog KwikPens................................. 13 Jentadueto XR.......................................... 14
Finacea....................................................... 13 Humalog Vials.......................................... 13 Jolessa....................................................... 21
Finasteride Tablet.................................... 17 Humira........................................................ 17 Jolivette...................................................... 21
Flecainide.................................................. 10 Humulin KwikPens.................................. 13 Juleber........................................................ 21
Flovent Diskus/HFA................................ 19 Humulin Vials............................................ 13 Junel........................................................... 21
Fluconazole Tablet.................................... 8 Hydralazine................................................. 9 Junel Fe...................................................... 21
Fluocinolone Cream, Oil, Solution....... 13 Hydrochlorothiazide.................................. 9
K
Fluocinolone Ointment........................... 13
Kaletra Tablet............................................ 16
25
Kazano....................................................... 14 Lipofen....................................................... 10 Metoprolol Succinate
Kelnor 1/35............................................... 21 Lisinopril....................................................... 9 Extended-Release
Ketoconazole Cream................................ 8 Lisinopril-Hydrochlorothiazide............... 9 50, 100, 200 mg.................................... 9
Ketorolac Tablet....................................... 18 Lithium Capsule....................................... 11 Metoprolol Tartrate 25, 50, 100 mg...... 9
Klor-Con M10...........................................20 Livalo........................................................... 10 Metronidazole 0.75% Topical Gel........ 13
Klor-Con M20...........................................20 Lo Loestrin Fe........................................... 21 Metronidazole Tablet................................ 8
Kombiglyze XR......................................... 14 Lopinavir-Ritonavir Oral Solution......... 16 Mibelas 24 Fe Chewable Tablet.......... 21
Kurvelo....................................................... 21 Lorazepam Tablet.................................... 11 Microgestin............................................... 21
Loryna........................................................ 21 Microgestin Fe.......................................... 21
L
Losartan....................................................... 9 Minivelle.....................................................22
Labetalol...................................................... 9 Losartan-Hydrochlorothiazide................ 9 Minocycline Capsule................................ 8
Lamivudine-Zidovudine......................... 16 Lovastatin.................................................. 10 Minocycline Extended-Release
Lamotrigine Immediate-Release Low-Ogestrel............................................ 21 Capsule.................................................. 13
Tablet...................................................... 12 Lumigan..................................................... 15 Minocycline Tablet..................................... 8
Lansoprazole Capsule........................... 15 Lutera.......................................................... 21 Mirtazapine Tablet................................... 11
Lantus Solostar........................................ 13 Lyrica.......................................................... 12 Mirvaso....................................................... 13
Lantus Vials............................................... 13 Lyza............................................................. 21 Mitigare...................................................... 16
Larin Fe...................................................... 21 Modafinil Tablet........................................ 11
Larissia....................................................... 21 M
Mometasone Furoate Cream, Lotion,
Lastacaft.................................................... 14 Marlissa...................................................... 21 Ointment................................................ 13
Latanoprost 0.005% Ophthalmic Mavyret....................................................... 16 Mono-Linyah............................................. 21
Solution.................................................. 15 Medroxyprogesterone..................... 21, 22 MonoNessa............................................... 21
Latuda........................................................ 11 Medroxyprogesterone Acetate............ 21 Montelukast Chewable Tablet,
Lazanda..................................................... 18 Meloxicam Tablet.................................... 18 Tablet...................................................... 19
Leena.......................................................... 21 Memantine Tablet.................................... 11 Montelukast Granules............................ 19
Leflunomide.............................................. 17 Mercaptopurine Tablet............................. 8 Morphine Sulfate Extended-Release
Lessina....................................................... 21 Mesalmine Delayed-Release Tablet.... 15 Tablet...................................................... 18
Letairis........................................................ 19 Metadate CD............................................. 10 Morphine Sulfate Oral Solution............ 18
Letrozole Tablet........................................ 17 Metadate ER............................................. 10 Movantik.................................................... 15
Leucovorin Calcium Tablet..................... 8 Metaxalone Tablet................................... 18 Moviprep.................................................... 15
Levalbuterol Nebs................................... 19 Metformin.................................................. 14 Moxeza....................................................... 15
Levemir FlexTouch................................... 13 Metformin Extended-Release Moxifloxacin Ophthalmic Solution....... 15
Levemir Vials............................................. 13 Tablet...................................................... 14 Moxifloxacin Tablet.................................... 8
Levetiracetam Extended-Release Methadone Tablet, Oral Solution, Multaq........................................................ 10
Tablet...................................................... 12 Concentrate Solution.......................... 18 Mupirocin Ointment................................ 13
Levetiracetam Immediate-Release Methimazole Tablet................................. 14 My Way....................................................... 21
Tablet...................................................... 12 Methocarbamol Tablet........................... 18 Mycophenolate Capsule,
Levitra......................................................... 17 Methotrexate Tablet................................ 17 Suspension...........................................20
Levocetirizine Tablet............................... 19 Methylphenidate Chewable Tablet...... 10 Mycophenolic Acid Tablet.....................20
Levofloxacin Tablet.................................... 8 Methylphenidate Extended-Release Myzilra........................................................ 21
Levonest.................................................... 21 Capsule.................................................. 10
Levonorgestrel 1.5 mg........................... 21 Methylphenidate Extended-Release N
Levonorgestrel-Ethinyl Estradiol.......... 21 Tablet...................................................... 10 Nabumetone Tablet................................ 18
Levora-28................................................... 21 Methylphenidate Immediate-Release Nadolol......................................................... 9
Levothyroxine Sodium Tablet............... 14 Tablet...................................................... 10 Naloxone Vials.......................................... 11
Lialda.......................................................... 15 Methylprednisolone Tablet.................... 14 Naproxen Tablet....................................... 18
Lidocaine Transdermal Patch.............. 17 Methyltestosterone Capsule................. 17 Naratriptan................................................ 11
Lidoderm................................................... 17 Metoclopramide Tablet.......................... 15 Narcan Nasal Spray................................ 11
Linzess....................................................... 15 Natazia....................................................... 21
Liothyronine Sodium Tablet.................. 14
26
Necon 7/7/7, 0.5/35, 1/35, Ofloxacin Otic Solution............................ 8 P
1/50, 10/11............................................ 21 Ofloxacin Tablet......................................... 8 Pantoprazole Tablet................................ 15
Nesina........................................................ 14 Olanzapine Tablet.................................... 11 Paroxetine Tablet..................................... 11
Nevirapine................................................. 16 Olmesartan................................................. 9 Pegasys...................................................... 17
Nevirapine Extended-Release.............. 16 Olmesartan-Hydrochlorothiazide.......... 9 Penicillin V Potassium Tablet.................. 8
Next Choice.............................................. 21 Olopatadine 0.1% Ophthalmic Perforomist................................................ 19
Niacin Extended-Release Tablet......... 10 Solution.................................................. 15 Phenazopyridine...................................... 17
Niaspan...................................................... 10 Olopatadine 0.2% Ophthalmic Phenytoin Capsule, Suspension.......... 12
Nicoderm CQ...........................................20 Solution.................................................. 15 Picato.......................................................... 13
Nicorette Gum..........................................20 Omeclamox-Pak...................................... 15 Pioglitazone.............................................. 14
Nicorette Lozenge...................................20 Omega-3-Acid Ethyl Esters Capsule.. 10 Pirmella 7/7/7, 1/35................................ 21
Nicorette Mini-Lozenge..........................20 Omeprazole Capsule.............................. 15 Plan B One Step...................................... 21
Nicotine Gum............................................20 Ondansetron............................................. 15 Plegridy...................................................... 11
Nicotine Lozenge.....................................20 Ondansetron ODT................................... 15 Polyethylene Glycol 3350..................... 15
Nicotine Patch..........................................20 OneTouch Test Strips............................. 13 Portia.......................................................... 21
Nicotrol Inhaler.........................................20 OneTouch Ultra Meter............................ 13 Potassium Chloride.................................20
Nicotrol Nasal Spray...............................20 OneTouch Ultra Mini............................... 13 Potassium Citrate....................................20
Nifedipine Extended-Release................. 9 OneTouch Ultra Test Strips................... 13 Pradaxa........................................................ 9
Nitrofurantoin Capsule............................. 8 OneTouch Verio....................................... 13 Praluent...................................................... 10
Nitrofurantoin Macrocrystal Capsule.... 8 OneTouch Verio Flex............................... 13 Pramipexole Tablet.................................. 11
Nitroglycerin Sublingual Tablet............ 10 OneTouch Verio IQ.................................. 13 Pravastatin................................................. 10
Nora BE...................................................... 21 OneTouch Verio Sync............................. 13 Prednisone Tablet................................... 14
Nordette..................................................... 21 OneTouch Verio Test Strips................... 13 Premarin....................................................22
Norethindrone 0.35 mg......................... 21 Onglyza...................................................... 14 Premphase................................................22
Norethindrone-Ethinyl Opana ER.................................................. 18 Prempro.....................................................22
Estradiol-Ferrous Fumarate.............. 21 Opcicon..................................................... 21 Prenisolone Oral Solution...................... 14
Norgestimate-Ethinyl Estradiol............. 21 Opsumit..................................................... 19 Prepopik.................................................... 15
Norgestimate-Ethinyl Estradiol Lo....... 21 Oracea.......................................................... 8 Previfem..................................................... 21
Norlyroc..................................................... 21 Orencia....................................................... 17 Prezcobix................................................... 16
Nortrel 7/7/7, 0.5/35, 1/35.................... 21 Orenitram................................................... 19 Prezista....................................................... 16
Nortriptyline Capsule.............................. 11 Orsythia...................................................... 21 Pristiq.......................................................... 11
Norvir.......................................................... 16 Ortho Tri-Cyclen....................................... 21 ProAir HFA/RespiClick........................... 19
Novolin Vials............................................. 13 Ortho Tri-Cyclen Lo................................. 21 Procrit......................................................... 17
Novolog FlexPen...................................... 13 Ortho-Cept................................................20 Progesterone Micronized Capsule......22
Novolog Vials............................................ 13 Ortho-Cyclen............................................ 21 Promethazine Tablet............................... 19
Noxafil Tablet, Suspension...................... 8 Oseltamivir Capsule.................................. 8 Promethazine/Codeine.......................... 17
NP Thyroid Tablet.................................... 14 Oseni........................................................... 14 Promethazine/Dextromethorphan...... 17
Nucynta...................................................... 18 Osphena.................................................... 17 Propranolol Extended-Release
Nucynta ER............................................... 18 Otezla.......................................................... 17 Capsule.................................................... 9
Nuedexta................................................... 17 Otrexup...................................................... 17 Propranolol Tablet..................................... 9
Nutropin, Nutropin AQ............................ 14 Ovidrel........................................................ 16 Proventil HFA............................................ 19
Nuvaring..................................................... 21 Oxcarbazepine Tablet............................ 12 Prozac........................................................ 11
Nystatin Cream, Ointment....................... 8 Oxsoralen-Ultra........................................ 13 Pulmicort Flexhaler................................. 19
Nystatin-Triamcinolone Acetonide Oxybutynin Extended-Release Pulmozyme............................................... 18
Cream, Ointment................................. 13 Tablet...................................................... 19 Pylera.......................................................... 15
Oxybutynin Tablet................................... 19
O Q
Oxycodone Tablet................................... 18
Obredon..................................................... 17 Oxycodone/Acetaminophen 5/325, Quasense.................................................. 21
Odefsey...................................................... 16 7.5/325, 10/325 mg Tablet............... 18 Quetiapine Extended-Release
Ofloxacin 0.3% Ophthalmic Solution.. 15 Oxycontin.................................................. 18 Tablet...................................................... 11
27
Quetiapine Immediate-Release Sirolimus Tablet........................................20 Taytulla....................................................... 21
Tablet...................................................... 12 Solia............................................................ 21 Tazarotene 0.1% Cream......................... 13
Quinapril...................................................... 9 Soliqua....................................................... 14 Tazorac....................................................... 13
QVAR MDI................................................. 19 Solodyn...................................................... 13 Tecfidera.................................................... 11
Sotalol......................................................... 10 Technivie.................................................... 16
R
Sovaldi........................................................ 16 Telmisartan.................................................. 9
Rabeprazole Tablet................................. 15 Spiriva Handihaler/Respimat................ 19 Telmisartan-Hydrochlorothiazide.......... 9
Rajani.......................................................... 21 Spironolactone........................................... 9 Temazepam Capsule.............................. 12
Raloxifene...........................................18, 22 Sprintec...................................................... 21 Terazosin...............................................9, 17
Raloxifene Tablet..................................... 18 Sprix............................................................ 18 Terazosin Capsule, Tablet..................... 17
Ramipril........................................................ 9 Sronyx........................................................ 21 Terbinafine Tablet...................................... 8
Ranexa....................................................... 10 Stelara........................................................ 17 Testim......................................................... 17
Ranitadine Syrup..................................... 15 Stendra....................................................... 17 Testosterone 1% Topical Gel................ 17
Rapaflo....................................................... 17 Stiolto Respimat....................................... 19 Testosterone Cypionate Injection........ 17
Rasuvo....................................................... 17 Stribild........................................................ 16 Thrive Gum................................................20
Rayaldee.................................................... 14 Striverdi Respimat................................... 19 Timolol Maleate 0.25%, 0.5%
React.......................................................... 21 Suboxone............................................11, 12 Ophthalmic Solution........................... 15
Rebif............................................................ 11 Suboxone Film......................................... 12 Tivicay......................................................... 16
Reclipsen................................................... 21 Subsys........................................................ 18 Tizanidine Tablet...................................... 18
Rectiv.......................................................... 18 Suclear....................................................... 15 Tobi Podhaler........................................... 18
Regranex................................................... 13 Sucralfate Tablet...................................... 15 Tobramycin Nebulized Solution........... 18
Repatha 140 mg...................................... 10 Sulfamethoxazole-Trimethoprim Tobramycin Ophthalmic Solution........ 15
Restasis MultiDose................................. 15 Tablet........................................................ 8 Tobramycin/Dexamethasone
Restasis Single Use Vials...................... 15 Sulfasalazine Tablet................................ 15 0.3%-0.1% Ophthalmic Suspension.15
Revlimid....................................................... 8 Sumatriptan Nasal Spray....................... 11 Tolcapone.................................................. 12
Reyataz...................................................... 16 Sumatriptan Succinate Tablet, Tolterodine Extended-Release
Rezira.......................................................... 18 Injection.................................................. 11 Tablet...................................................... 19
Rhofade..................................................... 13 Suprax Capsule, Chewable Tablet, Tolterodine Tablet.................................... 19
Ribavirin Tablet......................................... 16 Tablet........................................................ 8 Topiramate Immediate-Release
Risedronate Sodium Tablet.................. 18 Suprep........................................................ 15 Tablet...................................................... 12
Risperidone Tablet.................................. 12 Sustiva........................................................ 16 Toujeo SoloStar........................................ 13
Ritalin LA................................................... 10 Sutent........................................................... 8 Toviaz.......................................................... 19
Ritalin SR................................................... 10 Symbicort.................................................. 19 Tracleer...................................................... 19
Rivelsa........................................................ 21 Synjardy..................................................... 14 Tradjenta.................................................... 14
Rizatriptan ODT, Tablet.......................... 11 Synjardy XR............................................... 14 Tramadol Immediate-Release
Ropinirole Tablet...................................... 12 Synthroid.................................................... 14 Tablet...................................................... 18
Rosuvastatin............................................. 10 Tramadol Sustained-Release
T
S Tablet...................................................... 18
Taclonex Suspension............................. 13 Tramadol-Acetaminophen..................... 18
Savaysa........................................................ 9 Tacrolimus Capsule................................20 Travatan Z.................................................. 15
Scopolamine Transdermal Patch........ 15 Tacrolimus Ointment............................... 13 Trazodone Tablet..................................... 11
Seasonale.................................................. 21 Take Action............................................... 21 Tresiba FlexTouch.................................... 13
Selzentry.................................................... 16 Taltz............................................................. 17 Tretinoin Cream........................................ 13
Serevent Diskus....................................... 19 Tamoxifen..................................................22 Tretinoin Gel.............................................. 13
Sertraline Tablet....................................... 11 Tamsulosin Capsule................................ 17 Tretinoin Microspheres........................... 13
Setlakin....................................................... 21 Tanzeum.................................................... 14 Trezix........................................................... 18
Sevelamer.................................................. 18 Targretin Capsule...................................... 8 Tri-Estarylla................................................22
Sharobel..................................................... 21 Targretin Gel............................................... 9 Tri-Linyah...................................................22
Sildenafil Tablet........................................ 19 Tarina Fe.................................................... 21 Tri-Lo-Estarylla..........................................22
Simponi...................................................... 17 Tasigna......................................................... 9 Tri-Lo-Marzia.............................................22
Simvastatin................................................ 10
28
Tri-Lo-Sprintec..........................................22 Viekira XR.................................................. 16
Tri-Previfem...............................................22 Vienva.........................................................22
Tri-Sprintec................................................22 Viibryd........................................................ 11
Triamcinolone Acetonide Cream, Lotion, Viorele.........................................................22
Ointment................................................ 13 Viread......................................................... 16
Triamterene-Hydrochlorothiazide.......... 9 Vitekta........................................................ 16
Triazolam Tablet....................................... 12 Vivelle-Dot.................................................22
Trinessa......................................................22 Voltaren Gel.............................................. 19
Trinessa Lo................................................22 Vosevi......................................................... 16
Trintellix...................................................... 11 Vyvanse...................................................... 10
Triphasil...................................................... 21
W
Triumeq...................................................... 16
Trivora-28...................................................22 Warfarin Sodium........................................ 9
Trulicity....................................................... 14 Welchol...................................................... 10
Truvada...................................................... 16 Wera............................................................22
Tudorza...................................................... 19 X
Tybost......................................................... 16
Tymlos........................................................ 18 Xarelto.......................................................... 9
Tyvaso........................................................ 19 Xeljanz........................................................ 17
Xeljanz XR.................................................. 17
U Xeloda........................................................... 9
Uceris Foam.............................................. 15 Xigduo XR................................................. 14
Uceris Tablet............................................. 15 Xiidra........................................................... 15
Uloric........................................................... 16 Xopenex HFA............................................ 19
Uptravi........................................................ 19 Xtampza ER.............................................. 19
Xulane.........................................................22
V Xultophy..................................................... 14
Valacyclovir Tablet..................................... 8 Xyrem.......................................................... 12
Valganciclovir.............................................. 8
Y
Valsartan...................................................... 9
Valsartan-Hydrochlorothiazide............... 9 Yasmin 28..................................................22
Varubi......................................................... 15 Yaz...............................................................22
Vascepa..................................................... 10 Yuvafem.....................................................22
Vectical....................................................... 13 Z
Velivet.........................................................22
Velphoro..................................................... 18 Zaleplon Capsule.................................... 12
Veltassa...................................................... 18 Zarxio.......................................................... 18
Venlafaxine Extended-Release Zelapar....................................................... 12
Capsule.................................................. 11 Zenpep....................................................... 15
Venlafaxine Tablet................................... 11 Zepatier...................................................... 16
Ventolin HFA............................................. 19 Zetonna...................................................... 19
Verapamil..................................................... 9 Zinbryta...................................................... 11
Ziprasidone Capsule.............................. 12
Verapamil Sustained-Release................ 9
Zohydro ER............................................... 19
Vesicare..................................................... 19
Zolpidem Extended-Release Tablet... 12
Vestura.......................................................22
Zolpidem Immediate-Release Tablet.. 12
Viagra......................................................... 17
Viberzi......................................................... 15 Zonisamide Capsule............................... 12
Vicodin 5/300, 7.5/300, 10/300 mg Zovia 1/35E, 1/50E.................................22
Tablet...................................................... 19 Zovirax Cream............................................ 8
Victoza 2-Pak............................................ 14 Zubsolv....................................................... 12
Victoza 3-Pak............................................ 14 Zurampic.................................................... 16
Viekira Pak................................................ 16 Zytiga............................................................ 9
29
Nondiscrimination notice and
access to communication services
UnitedHealthcare® and its subsidiaries do not discriminate on the basis of race, color, national origin, age, disability or sex in its
health programs or activities.
If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a
complaint to the Civil Rights Coordinator.
Online: UHC_Civil_Rights@uhc.com
Mail: Civil Rights Coordinator

UnitedHealthcare Civil Rights Grievance
P.O. Box 30608
Salt Lake City, UT 84130
You must send the complaint within 60 days of your experience. A decision will be sent to you within 30 days. If you disagree
with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, please call the toll-free
phone number listed on your ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m., or at the times listed in your health
plan documents.
You can also file a complaint with the U.S. Dept. of Health and Human Services.
Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
Complaint forms are available at
http://www.hhs.gov/ocr/office/file/index.html
Phone: Toll free 1-800-368-1019, 1-800-537-7697 (TDD)
Mail: U.S. Dept. of Health and Human Services

200 Independence Avenue
SW Room 509F, HHH Building
Washington, D.C. 20201
We provide free services to help you communicate with us, including letters in other languages or large print. Or, you can ask
for an interpreter. To ask for help, please call the toll-free phone number listed on your ID card, TTY 711, Monday through
Friday, 8 a.m. to 8 p.m., or at the times listed in your health plan documents.
30
31
This document applies to commercial group members of UnitedHealthcare and Oxford New York and New Jersey plans.
Insurance coverage provided by or through UnitedHealthcare Insurance Company, UnitedHealthcare Insurance Company of New York, or
Oxford Health Insurance, Inc. Oxford HMO products are underwritten by Oxford Health Plans (NJ), Inc. Administrative services provided by
United HealthCare Services, Inc., UnitedHealthcare Service LLC, Oxford Health Plans LLC, or their affiliates.
UnitedHealthcare® is a registered trademark owned by UnitedHealth Group Incorporated. All other trademarks are the property of their
respective owners.
M56950 MT-1153336.0 MS-17-511 ©2017 United HealthCare Services, Inc. 67816-082017

100-17902 2018 Prescription Drug List — Advantage Three-Tier 8/17

2018 Prescription Drug List

Diunggah oleh

Informasi Dokumen

Judul Asli

Hak Cipta

Format Tersedia

Bagikan dokumen Ini

Bagikan atau Tanam Dokumen

Opsi Berbagi

Apakah menurut Anda dokumen ini bermanfaat?

Apakah konten ini tidak pantas?

Hak Cipta:

Format Tersedia

2018 Prescription Drug List

Diunggah oleh

Hak Cipta:

Format Tersedia

Your 2018 Prescription Drug List

Effective Jan. 1, 2018

Your Cost Drug Tier* What’s Covered Helpful Hints

Who decides what medications are covered?

Why are certain medications excluded?

What is the difference between brand-name and generic

What if my doctor writes a brand-name prescription?

How often are PDLs updated?

Are there other restrictions on what medications are covered?

Not applicable to Neighborhood Health Plan and Oxford plans.

Who can I contact if I have questions about my PDL?

Bold type = Brand-name drug PA = Prior authorization required

Clonidine Tablet 1 Valsartan 2

Diltiazem 24 Hour CD 2 Valsartan-Hydrochlorothiazide 1

Bold type = Brand-name drug PA = Prior authorization required

Zaleplon Capsule 1 SL Carac 2

Lyrica 3 SL, ST Dupixent 3 PA, SL, SP, ST

Bold type = Brand-name drug PA = Prior authorization required

Bold type = Brand-name drug PA = Prior authorization required

Eye Conditions: Dry Eye Disease Canasa 2

Restasis MultiDose 3 E, PA, SL Cortifoam 2

Restasis Single Use Vials 3 PA, SL Creon 2

Xiidra 3 PA, SL Delzicol 3 E

Eye Conditions: Glaucoma Diphenoxylate-Atropine Tablet 1

Alphagan P 0.1% 2 SL Golytely 2

Azopt 2 SL Hyoscyamine Tablet 1

Bold type = Brand-name drug PA = Prior authorization required

Velphoro 2 Hydromorphone Immediate-Release

Bold type = Brand-name drug PA = Prior authorization required

Bold type = Brand-name drug PA = Prior authorization required

Medroxyprogesterone Acetate 1 H Sharobel 1 H

Mibelas 24 Fe Chewable Tablet 3 E Solia 1 H

Mono-Linyah 1 H Take Action 1 H

Bold type = Brand-name drug PA = Prior authorization required

Mail: Civil Rights Coordinator

Phone: Toll free 1-800-368-1019, 1-800-537-7697 (TDD)

Mail: U.S. Dept. of Health and Human Services

M56950 MT-1153336.0 MS-17-511 ©2017 United HealthCare Services, Inc. 67816-082017

Anda mungkin juga menyukai