Prescription Drug List

Transcription

1 Your 205 Prescription List effective January, 205 Please read: This document contains information about commonly prescribed medications. For additional information: Call the toll-free member phone number on the back of your health plan ID card. Visit myuhc.com

2 Your Prescription List This Prescription List (PDL) outlines the most commonly prescribed medications for certain conditions and organizes them into cost levels, also known as tiers. An important part of the PDL is giving you choices so you and your doctor can choose the best course of treatment for you. Go to myuhc.com for complete drug information Since the PDL may change, we encourage you to visit our website, myuhc.com. This website is the best source for up-to-date information about the medications your pharmacy benefit covers, possible lower-cost options, and cost comparisons. 2

3 Table of Contents tiers and cost...5 Programs and Limits....7 s by category...0 Anti-Infectives Antibiotics....0 Antifungals....0 Antivirals...0 Cancer.... Cardiovascular/Heart Disease Coagulation Therapy.... High Blood Pressure.... High Cholesterol Other Central Nervous System Attention Deficit Disorder Depression Migraine Multiple Sclerosis Other Sedatives/Hypnotics Seizure Disorders Dermatology Diabetes/Endocrine Blood Glucose Monitoring Insulin Non-Insulin Endocrine Growth Hormone Other Thyroid Hormone Replacement Eye Conditions Allergies Antibiotics Glaucoma Other....9 Gastrointestinal Acid Suppression....9 Nausea/Vomiting....9 Other....9 HIV/AIDS Infertility Inflammatory Conditions: Rheumatoid Arthritis, Crohn s Disease, Psoriasis, Ulcerative Colitis Men s Health Erectile Dysfunction Prostate Testosterone Therapy Miscellaneous....2 Musculoskeletal Osteoporosis....2 Other....2 Pain Relief Overactive Bladder Respiratory Allergies Asthma/COPD Pulmonary Arterial Hypertension Transplant Vitamins/Electrolytes Women s Health Contraceptives Hormone Replacement Prenatal Vitamins Brand Only Exclusions Index

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5 At UnitedHealthcare, we want to help you better understand your medication options. Your pharmacy benefit offers flexibility and choice in determining the right medication for you. To help you get the most out of your pharmacy benefit, we ve included some of the most commonly asked questions about the Prescription List. What is a Prescription List (PDL)? This document is a list of commonly prescribed medications. s are listed by common categories or class. They are placed into cost levels known as tiers. It includes both brand and generic prescription medications approved by the U.S. Food and Administration (FDA). Please note: Where differences are noted between this PDL and your benefit plan documents, the benefit plan documents will rule. It is not a complete list of medications, and not all medications listed may be covered under your plan. Please look at your benefit plan documents provided by your employer or health plan to see what medications are covered under your plan. You may also log on to myuhc.com or call the toll-free member phone number on the back of your health plan ID card for more information. How do I use my Prescription List? When choosing a medication, you and your doctor should consult the PDL. It will help you and your doctor choose the most cost-effective prescription drugs. This guide tells you if a medication is generic or brand, and if special programs apply. Bring this list with you when you see your doctor. It is organized by common medical conditions. Medications are then listed alphabetically. If your medication is not listed in this document, please visit myuhc.com or call the toll-free member phone number on the back of your health plan ID card. 5

6 What are tiers? s are the different cost levels you pay for a medication. Each tier is assigned a cost, which is determined by your employer or health plan. This is how much you will pay when you fill a prescription. medications are your lowest-cost options. If your medication is placed in 2 or 3, look to see if there is a option available. Discuss these options with your doctor. Check your benefit plan documents to find out your specific pharmacy plan costs. $ Includes Helpful Tips Lowest Cost 2 Mid-range Cost 3 Highest Cost Lower-cost drugs. Some brands and generics are also included. Preferred brand medications. Mostly higher-cost brand as well as select generic drugs. Use drugs for the lowest out-of-pocket costs. Use 2 drugs, instead of 3 to help reduce your out-of-pocket costs. Many 3 drugs have lower-cost options in or 2. Ask your doctor if they could work for you. Please note: Some plans may have two or four tiers, while others may not have any. If you have a high deductible plan, the tier cost levels may apply once you hit your deductible. Refer to your enrollment and plan materials on myuhc.com, or call the toll-free number of the back of your health plan ID card for more information about your benefit plan. When does the Prescription List change? Medications may move to a lower tier at any time. Medications can be up-tiered off cycle when the therapeutically equivalent medication is placed in an equal or lower tier than up-tiered medication. Medications may move to a higher tier on January. Medications may be excluded from coverage on January or July. When a medication changes tiers, you may have to pay a different amount for that medication. For the most up-to-date list, call customer service at the number on the back of your ID card. 6

7 Programs and Limits Some medications are noted with letters next to them. The letters refer to our pharmacy benefit programs. Your benefit plan determines how these medications may be covered for you. DSP E MC N RS SDP SL ST Designated Specialty Program Specialty medications need to be filled at a designated specialty pharmacy for network coverage. Call the number on your ID card or call for more information. May be excluded from coverage or subject to prior authorization and/or trial/ failure of another medication(s). Lower-cost options are available and covered. Multiple Copay More than one month s worth of medication included in package so additional copay applies. Notification or Prior Authorization required* Your doctor is required to provide additional information to us to determine coverage. Refill and Save Program Save money on your copayment when you refill your prescription on time as prescribed. Program eligibility may vary. Select Designated Pharmacy Must use a lower cost medication at retail or transfer the impacted medication to the mail service pharmacy for network coverage. Supply Limit Amount of medication covered per copayment or in a specific time period. Step Therapy Trial of a lower cost medication is required before a higher cost medication is covered. *Depending on your benefit you may have notification or prior authorization requirements for select medications. To learn more about a pharmacy program or to find out if it applies to you, please visit myuhc.com or call the toll-free member phone number on the back of your health plan ID card. 7

8 Why are some medications excluded from coverage? Medications may be excluded from coverage under your pharmacy benefit when it works the same or similar as another prescription medication or an over-the-counter (OTC) medication. There may be other medication options available. Should I talk to my doctor about over-the-counter (OTC) medications? An over-the-counter (OTC) medication may be the right treatment for some conditions. Talk to your doctor about available OTC options. What is the difference between brand-name and generic medications? Generic medications contain the same active ingredients (what makes the medication work) as brandname medications, but they often cost less. Once the patent of a brand-name medication ends, the FDA can approve a generic version with the same active ingredients. These types of medications are known as generic medications. Sometimes, the same company that makes a brand-name medication also makes the generic version. Is it a generic or brand name drug? The drug list shows brand name drugs in bold type (for example, Crestor) and generic drugs in plain type (for example, simvastatin). 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. Visit myuhc.com to make sure. Are you taking a specialty medication? Specialty medications are high cost and may be used to treat rare or complex conditions. Please note, not all specialty medications are listed in the PDL. If you are taking a specialty medication that is on 3, call the toll-free number on the back of your health plan ID card to talk to a representative about finding lower-cost options. OptumRx is the specialty pharmacy that can provide most of your specialty medications along with helpful programs and services. Call OptumRx Specialty Pharmacy at and have your prescriptions delivered right to your home or office. 8

9 What is Mail Service Member Select? Your plan may include a home delivery program called Mail Service Member Select, which encourages you to use the OptumRx Mail Service Pharmacy for medication you take regularly. Choosing home delivery can help you better manage the medication you take on a regular basis, and may save you time and money. You can either confirm enrollment in the OptumRx Mail Service Pharmacy or you can disenroll from mail service and continue to fill your maintenance medications at a retail pharmacy. You can get up to two fills at a retail pharmacy before you have to decide. However, please be aware that you must make a decision about whether or not to enroll in Mail Service Member Select. If you do nothing and continue to fill your medications at a retail pharmacy, you may pay up to 00% of your drug cost until you make a decision and take action. You must confirm your decision every year. To learn more, you may log on to myuhc.com or call the toll-free member phone number on the back of your health plan ID card for more information. How do I get updated information about my pharmacy benefit? Since the PDL may change during your plan year, we encourage you to visit myuhc.com or call the toll-free member phone number on the back of your health plan ID card for more current information. Log on to myuhc.com for the following pharmacy information and tools: Pharmacy benefit and coverage information Possible lower-cost medication options Medication interactions and side effects Participating retail pharmacies by zip code Your prescription history And, if Mail Service is included in your pharmacy benefit, you can also: Refill prescriptions Check the status of your order Set-up reminders for refills Manage your account For more information Call the toll-free member phone number on the back of your health plan ID card. Or, visit myuhc.com Where else can I go for information? HealthCareLane.com includes short videos to help you learn more about UnitedHealthcare benefits and health insurance information. UHCTV.com In certain documents, the Prescription List (PDL) was referred to as the Preferred List (PDL). This change in terms does not affect your benefit coverage. Medications are categorized by common therapeutic conditions in this PDL for ease of reference only. These categories do not determine coverage for the medication for your condition. Your benefit plan determines coverage for these medications. 9

10 Name Anti-Infectives: Antibiotics Adoxa Capsule 3 E Amoxicillin Capsule, Chewable Amoxicillin/Potassium Clavulanate Chewable, Augmentin XR 3 E Azithromycin Cefdinir Capsule Cefuroxime Centany AT 3 E Cephalexin Capsule Ciprofloxacin Clarithromycin Clindamycin Capsule Dificid 3 SL Doryx 3 E Doxycycline Hyclate Capsule, Doxycycline Monohydrate 50, 00 mg Capsule Doxycycline Monohydrate 75 mg Capsule E Levofloxacin Metronidazole Minocycline Capsule, Nitrofurantoin Capsule Nitrofurantoin Macrocrystal Capsule Oracea 3 Name Solodyn 3 Sulfamethoxazole- Trimethoprim Anti-Infectives: Antifungals Ertaczo 3 E Fluconazole Itraconazole Capsule SL Ketoconazole Cream Luzu 3 E, SL Naftin %, 2% Cream, Gel 3 E, SL Nystatin Cream, Ointment Onmel 3 E, SL Oxistat Cream 3 N, SL, ST Oxistat Lotion 3 E Terbinafine SL Anti-Infectives: Antivirals Acyclovir Ointment N, SL, ST Acyclovir Baraclude 2 DSP Denavir Cream 3 E Olysio 2 DSP, N, SL Ribapak DSP, E Ribavirin DSP Tamiflu 3 SL Valacyclovir SL Zovirax Cream 3 E, SL Bold type = Brand name drug [Plain type = Generic drug] DSP = Designated Specialty Program E = May be excluded from coverage MC = Multiple Copay N = Notification or Prior Authorization required RS = May be eligible for the Refill and Save Program SDP = Select Designated Pharmacy SL = Supply Limit ST = Step Therapy 0

11 Name Cancer Bosulif 2 DSP, N, SL, ST Capecitabine DSP, SL Gleevec 2 DSP, N, SL Hydroxyurea Capsule Leucovorin Calcium Mercaptopurine Sutent 2 DSP, N, SL Tasigna 2 DSP, N, SL Xeloda 2 DSP, SL Zytiga 2 DSP, N, SL Cardiovascular/Heart Disease: Coagulation Therapy Clopidogrel Coumadin 2 Effient 3 SL Eliquis 3 SL Enoxaparin Sodium SL Pradaxa 2 SL Warfarin Sodium Xarelto 2 SL Cardiovascular/Heart Disease: High Blood Pressure Amlodipine Amlodipine Besylate-Benazepril SL Amlodipine/Telmisartan E, SL Amturnide 3 E, SL Atenolol Atenolol-Chlorthalidone Azor 3 E, SL Benazepril Benazepril- Hydrochlorothiazide Benicar 2 SL Benicar HCT 2 SL Bidil 2 Bisoprolol Bisoprolol- Hydrochlorothiazide Bystolic 2 Name Cartia XT Carvedilol Chlorthalidone Clonidine Coreg CR 3 E, SL Diltiazem 24 Hour CD Diltiazem Sustained- Release Capsule Diltiazem Sustained- Release Diovan SL Doxazosin Dutoprol 2 SL Edarbi 3 SL Edarbyclor 3 SL Enalapril Enalapril- Hydrochlorothiazide Epaned 3 N Exforge 3 E, SL Exforge HCT 3 E, SL Felodipine Fosinopril Sodium Furosemide Guanfacine Hydralazine Hydrochlorothiazide Indapamide Irbesartan SL Labetalol Lisinopril Lisinopril- Hydrochlorothiazide Losartan Losartan- Hydrochlorothiazide Metoprolol Succinate 50, 00, 200 mg Metoprolol Tartrate Nadolol Nifedipine Extended-Release Propranolol

12 Name Quinapril Ramipril Spironolactone Tekamlo 3 E, SL Telmisartan SL Telmisartan- Hydrochlorothiazide SL Terazosin Torsemide Triamterene- Hydrochlorothiazide Tribenzor 3 E, SL Twynsta 3 E, SL Valsartan SL Valsartan- Hydrochlorothiazide SL Verapamil Verapamil Sustained-Release Cardiovascular/Heart Disease: High Cholesterol Altoprev 3 E, SL Antara 3 E Atorvastatin SL Caduet 3 E, SL Choline Fenofibrate E Crestor 2 SL Fenofibrate 43, 50, 67, 30, 34, 50, 200 mg Capsule Fenofibrate 48, 45 mg Fenofibrate 54, 60 mg Fenofibric Acid 35, 05 mg E E E Name Fenoglide 3 E Gemfibrozil Lipofen 3 E Liptruzet 3 E, SL Livalo 3 SL Lovastatin Niacin Extended- Release Niaspan 3 Omega-3-Acid Ethyl Esters Capsule N Pravastatin Simcor 3 SL Simvastatin Tricor 48, 45 mg 3 E Triglide 3 E Trilipix 3 E Vascepa 3 N Vytorin 3 SL Welchol 2 Zetia 3 SL Cardiovascular/Heart Disease: Other Amiodarone Digoxin Flecainide Isosorbide Mononitrate ER Multaq 2 Nitroglycerin Sublingual Spray SL Nitrolingual Pump Spray 3 E, SL Ranexa 2 Sotalol Bold type = Brand name drug [Plain type = Generic drug] DSP = Designated Specialty Program E = May be excluded from coverage MC = Multiple Copay N = Notification or Prior Authorization required RS = May be eligible for the Refill and Save Program SDP = Select Designated Pharmacy SL = Supply Limit ST = Step Therapy 2

13 Name Release Concerta N, SL Daytrana 3 E, N, SL Dexmethylphenidate Extended-Release Capsule Central Nervous System: Attention Deficit Disorder Adderall XR N, SL Amphetamine Salt Combo N Clonidine Extended- E Dexmethylphenidate Dextroamphetamine Sulfate Dextroamphetamine- Amphetamine Extended-Release E, N, SL N N 3 E, N, SL Dextroamphetamine- Amphetamine N Focalin XR 3 E, N, SL Intuniv 3 E, SL Kapvay 3 E Metadate CD N, SL Methylphenidate N Methylphenidate Extended-Release Capsule Methylphenidate Extended-Release 3 E, N, SL 3 E, N, SL Quillivant XR 3 E, N, SL Ritalin LA 3 E, N, SL Strattera 3 SL Vyvanse 2 N, SL Zenzedi 3 E, N Name Central Nervous System: Depression Amitriptyline Aplenzin 3 E, SL Bupropion Extended- Release Bupropion Sustained- Release Bupropion Citalopram Desvenlafaxine 3 E, SL Doxepin Duloxetine Capsule SL Escitalopram Fluoxetine, Capsule Fluvoxamine Forfivo XL 3 E, SL Imipramine Khedezla 3 E, SL Mirtazapine Nortriptyline Capsule Oleptro 3 E, SL Paroxetine Pexeva 3 E, SL Pristiq ER 3 RS, SL Sertraline Trazodone Venlafaxine Extended- Release Capsule SL Venlafaxine Extended- Release E, SL Venlafaxine Viibryd 3 SL 3

14 Name Name Central Nervous System: Migraine Acetaminophen/ Butalbital/Caffeine SL 325 mg/50 mg/40 mg Acetaminophen/ Butalbital/Caffeine/ Codeine 325 mg/ SL 50 mg/40 mg/30 mg Alsuma 3 E, SL Cambia 3 E, SL Relpax 2 SL Rizatriptan Orally Disintegrating SL Rizatriptan SL Sumatriptan Nasal Spray SL Sumatriptan Succinate, Injection SL Sumavel DosePro 3 SL Treximet 3 E, SL Central Nervous System: Multiple Sclerosis Ampyra 2 DSP, N, SL Aubagio 3 DSP, N, SL, ST Avonex 2 DSP, N, SL Betaseron 2 DSP, N, SL Copaxone 2 DSP, N, SL Extavia 3 DSP, E, N, SL, ST Gilenya 3 DSP, N, SL, ST Rebif 3 DSP, N, SL, ST Tecfidera 2 DSP, N, SL Central Nervous System: Other Abilify 3 SL Alprazolam Extended- Release Alprazolam Aricept 23 mg 3 E Buprenorphine/ Naloxone E, N, SL Buspirone Carbidopa-Levodopa Diazepam Donepezil 5, 0 mg Latuda 3 SL Lithium Capsule Lorazepam Mirapex ER 3 E Modafinil E, N, SL Namenda XR 3 Nuvigil 3 N, SL Olanzapine SL Pramipexole Provigil 3 E, N, SL Quetiapine SL Requip XL 3 E Risperidone Ropinirole Seroquel XR 3 SL Suboxone Film 3 E, N, SL Tasmar 2 Xyrem 3 N, SL Zelapar 3 Ziprasidone Capsule SL Zubsolv N, SL Bold type = Brand name drug [Plain type = Generic drug] DSP = Designated Specialty Program E = May be excluded from coverage MC = Multiple Copay N = Notification or Prior Authorization required RS = May be eligible for the Refill and Save Program SDP = Select Designated Pharmacy SL = Supply Limit ST = Step Therapy 4

15 Name Central Nervous System: Sedatives/Hypnotics Ambien CR 3 E, SL, ST Edluar 3 E, SL, ST Eszopiclone SL, ST Intermezzo 3 E, SL, ST Silenor 3 E, SL Temazepam Capsule Zaleplon Capsule SL Zolpidem Extended- Release E, SL, ST Zolpidem SL Zolpimist 3 SL, ST Central Nervous System: Seizure Disorders Carbamazepine Clonazepam Depakote 3 N, ST Depakote ER 3 N, ST Diazepam Divalproex Delayed- Release Divalproex Extended- Release Gabapentin Capsule, Keppra 3 N, ST Keppra XR 3 N, ST Lamictal 3 N, ST Lamictal XR 3 N, ST Lamotrigine Levetiracetam Extended-Release Levetiracetam Lyrica 3 SDP, SL Neurontin 3 N, ST Oxcarbazepine Oxtellar XR 3 E, N, ST Phenytoin Capsule, Suspension Topamax 3 N, ST Topiramate Name Trileptal 3 N, ST Trokendi XR 3 E, N, ST Zonegran 3 N, ST Zonisamide Capsule Dermatology Absorica 3 E, N Acanya 3 E, SL Aczone 3 SL Adapalene 0.% N, SL Cream, Gel Atralin 3 E, MC, N, SL Azelex 3 SL Benzaclin 3 E, SL Betamethasone Diproionate 0.05% Augmented Lotion, Ointment Betamethasone Dipropionate 0.05% Cream, Ointment Betamethasone Valerate 0.2% Foam E, SL Betamethasone/ Calcipotriene Ointment SL Carac 2 Ciclopirox Cream, Gel, Lotion, Solution Claravis N Clindagel 3 E, SL Clindamycin %/ Benzoyl Peroxide 5% Gel E, SL Clindamycin.2%/ Benzoyl Peroxide 5% Gel SL Clindamycin Gel SL Clindamycin Lotion, Solution, Swabs Clobetasol Propionate Cream, Ointment, Solution Clobetasol Propionate Foam, Lotion, Shampoo E Clocortolone Cream SL, ST 5

16 Name Clotrimazole- Betamethasone Cream SL Clotrimazole- Betamethasone Lotion Condylox Gel 3 Desonide 0.05% Cream, Lotion, Ointment SL Desoximetasone Cream, Gel, Ointment SL Differin 3 N, SL Diflorasone Diacetate 0.05% Cream, Ointment SL Epiduo 3 SL Fabior 3 E, SL Finacea 3 Fluocinonide 0.05% Cream Fluocinonide 0.% Cream E, SL Fluocinolone Cream, Oil, Ointment, Solution SL Hydrocortisone 2.5% Cream, Ointment Hydrocortisone Butyrate Cream E, SL Keralyt Scalp Kit 3 E Locoid Lipocream 3 E, SL Locoid Lotion 3 E, SL Luxiq 3 E, SL Metrogel % 3 E, MC Metronidazole Gel 0.75% Metronidazole Gel % E, MC Mirvaso 3 SL Name Mometasone Furoate Cream, Lotion, Ointment Mupirocin Ointment Noritate 3 E, MC Nystatin-Triamcinolone Acetonide Cream, E Ointment Olux, Olux-E 3 E, SL Oxsoralen-Ul 2 Picato 3 SL Protopic 2 N, SL Retin-A Micro 3 E, N, SL Sodium Sulfacetamide-Sulfur Sorilux 3 E, SL Topicort Spray 3 E, SL Tretin-X 3 E, N, SL Tretinoin N Tretinoin Microspheres E, N, SL Triamcinolone Acetonide Cream, Lotion, Ointment Urea 40% Vanos 3 E, SL Vectical 3 SL Veltin 3 E, SL Verdeso 3 E, SL Virasal 3 E Vusion 3 E, MC Xerese 3 E Ziana 3 E, SL Zyclara 3 E, SL Bold type = Brand name drug [Plain type = Generic drug] DSP = Designated Specialty Program E = May be excluded from coverage MC = Multiple Copay N = Notification or Prior Authorization required RS = May be eligible for the Refill and Save Program SDP = Select Designated Pharmacy SL = Supply Limit ST = Step Therapy 6

17 Name Diabetes: Blood Glucose Monitoring Accu-Chek Active Test Strips SL Accu-Chek Aviva Plus Accu-Chek Aviva Plus Test Strips SL Accu-Chek Comfort Curve Test Strips SL Accu-Chek Compact Test Strips SL Accu-Chek Nano SmartView Accu-Chek Nano SmartView SL Test Strips Contour Test Strips 3 SDP, SL Freestyle Test Strips 3 SDP, SL One Touch Test Strips SL One Touch Ultra Mini One Touch Ultra Test Strips SL One Touch Verio IQ One Touch Verio IQ Test Strips SL One Touch Verio Sync Diabetes: Insulin Humalog KwikPen 2 Humalog Mix KwikPen 2 Humalog Vials Humulin Vials Humulin KwikPen 2 Humulin N KwikPen 2 Humulin N Vials Humulin R Vials Lantus Solostar 3 Name Lantus Vials 3 Levemir Flexpen Levemir Vials Novolog 3 SDP Novolog Flexpen 3 SDP Diabetes: Non-Insulin Bydureon 3 SL Byetta 2 SL Farxiga 3 SL, ST Glimepiride Glipizide Glipizide Extended-Release Glumetza 3 N Glyburide Glyburide-Metformin Invokamet 2 SL Invokana 2 SL, ST Janumet 3 SL, ST Januvia 3 SL, ST Jentadueto 2 SL Kazano 2 SL Kombiglyze XR 2 SL Metformin Metformin Extended- Release Osmotic N Metformin Extended- Release Nesina 2 SL Onglyza 2 SL Oseni 2 SL Pioglitazone SL Pioglitazone-Metformin SL Prandimet 3 Prandin 3 SL Repaglinide SL Tanzeum 2 SL Tradjenta 2 SL Victoza 3 SL 7

18 Name Name Endocrine: Growth Hormone Genotropin 3 DSP, E, N, SL Humatrope 3 DSP, E, N, SL Norditropin 3 DSP, E, N, SL Nutropin AQ NuSpin 2 DSP, N, SL Omnitrope 3 DSP, E, N, SL Saizen 2 DSP, N, SL Tev-Tropin 2 DSP, N, SL Endocrine: Other Calcitriol Capsule Desmopressin Dexamethasone Methylprednisolone Prednisolone Solution, Syrup Prednisone Rayos 3 E Endocrine: Thyroid Hormone Replacement Armour Thyroid 3 Levothyroxine Sodium Levoxyl Liothyronine Sodium Methimazole NP Thyroid Synthroid 2 Tirosint 2 Eye Conditions: Allergies Azelastine 0.05% Ophthalmic Solution SL Bepreve 3 E, SL Elestat 3 E, SL Emadine 3 E Lastacaft 3 SL Pataday 3 E, SL Patanol 3 E, SL Eye Conditions: Antibiotics Erythromycin 0.5% Ophthalmic Ointment Ofloxacin 0.3% Ophthalmic Solution Tobradex ST 3 E, SL Tobramycin/ Dexamethasone 0.3%-0.% Ophthalmic Suspension Eye Conditions: Glaucoma Alphagan P 0.% 2 SL Azopt 2 SL Combigan 2 SL Cosopt PF 3 E, SL Dorzolamide-Timolol 2%-0.5% Ophthalmic Solution Latanoprost 0.005% Ophthalmic Solution Bold type = Brand name drug [Plain type = Generic drug] DSP = Designated Specialty Program E = May be excluded from coverage MC = Multiple Copay N = Notification or Prior Authorization required RS = May be eligible for the Refill and Save Program SDP = Select Designated Pharmacy SL = Supply Limit ST = Step Therapy 8

19 Name Lumigan 2 SL Simbrinza 3 E, SL Timolol Maleate 0.25%, 0.5% Ophthalmic Solution Travatan Z 2 SL Eye Conditions: Other Acuvail 3 E, SL Bromday 3 E, SL Ilevro 3 E Lotemax Gel 3 E, SL Lotemax Solution 3 SL Prolensa 3 E, SL Gastrointestinal: Acid Suppression Aciphex Sprinkle 3 E, SL Dexilant 3 SL Lansoprazole Capsule E, SL Helidac 3 E, SL Nexium Capsule 3 E, SL Nexium Suspension Packet 3 N, SL, ST Omeclamox-Pak 3 SL Omeprazole Capsule Pantoprazole Prevacid Solutab 3 N, SL, ST Prevpac 3 E, SL Prilosec Suspension 3 E, SL Protonix Suspension 3 E, SL Pylera 3 SL Rabeprazole SL Sucralfate Zegerid Capsule 3 E, SL Gastrointestinal: Nausea/Vomiting Ondansetron Ondansetron ODT Sancuso 3 E, SL Zuplenz 3 E, SL Name Gastrointestinal: Other Amitiza 3 N, SL, ST Apriso 2 SL Asacol HD 3 E, SL Canasa 2 Cortifoam 2 Creon 2 Delzicol 3 E, SL Giazo 3 E Golytely 2 Halflytely 3 Hyoscyamine Lialda 2 SL Linzess 2 N, SL Metoclopramide Metozolv ODT 3 E Moviprep 3 Pentasa 3 E, SL Pertzye 3 ST Polyethylene Glycol 3350 Prepopik 3 Procort 3 E Suclear 3 Sulfasalazine Suprep 3 Uceris 3 Ultresa 3 ST Ursodiol Capsule, Viokace 3 ST Zenpep 2 9

20 Name HIV/AIDS Atripla 2 DSP Complera 2 DSP Epzicom 2 DSP Intelence 2 DSP Isentress 2 DSP Kaletra 2 DSP Norvir 2 DSP Prezista 2 DSP Reyataz 2 DSP Stribild 3 DSP, N Sustiva 2 DSP Truvada 2 DSP, N Viread 2 DSP Infertility* Cetrotide 2 DSP Gonal-F 2 DSP Gonal-F RFF 2 DSP Ovidrel 3 DSP *Coverage is determined by the consumer s prescription drug benefit plan. Inflammatory Conditions: Rheumatoid Arthritis, Crohn s Disease, Psoriasis, Ulcerative Colitis Actemra 3 DSP, N, SL, ST Cimzia 2 DSP, N, SL Enbrel 3 DSP, N, SL, ST Humira 2 DSP, N, SL Hydroxychloroquine Sulfate Leflunomide Methotrexate Orencia 3 DSP, N, SL, ST Otezla 3 DSP, N, SL, ST Name Simponi 2 DSP, N, SL Stelara 2 DSP, N, SL Xeljanz 3 DSP, N, SL, ST Men s Health: Erectile Dysfunction Cialis 3 SL Staxyn 3 E, SL Viagra 3 SL Men s Health: Prostate Alfuzosin Avodart 3 N, SDP Doxazosin Finasteride Jalyn 3 E Rapaflo 3 Tamsulosin Capsule Terazosin Capsule, Men s Health: Testosterone Therapy Androderm 2 N, SL Androgel 3 E, N, SL Android 2 Axiron 3 E, N, SL Depo-Testosterone 3 Fortesta 3 E, N, SL Testim 2 N, SL Testosterone Cypionate Injection Testosterone Enanthate Injection Testosterone Topical Gel E, N, SL Testred 2 Bold type = Brand name drug [Plain type = Generic drug] DSP = Designated Specialty Program E = May be excluded from coverage MC = Multiple Copay N = Notification or Prior Authorization required RS = May be eligible for the Refill and Save Program SDP = Select Designated Pharmacy SL = Supply Limit ST = Step Therapy 20

21 Name Miscellaneous Anastrozole Antipyrine/Benzocaine Otic Solution Aranesp 2 DSP, SL Auvi-Q 3 E, SL Benzonatate Capsule Bethkis DSP, N, SL Brisdelle 3 E, SL Bromfed DM 3 Chlorhexidine Gluconate Chlorpheniramine/ Hydrocodone/ Pseudoephedrine SL Solution Ciprodex 2 Epipen 2 SL Epipen-Jr 2 SL Exemestane Fosrenol 2 Hydrocodone/ Chlorpheniramine Suspension SL Hydrocodone/ Homatropine Letrozole Lidocaine Transdermal Patch SL Nuedexta 2 Pegasys 2 DSP, N, SL Procrit 2 DSP, SL Promethazine/Codeine Promethazine/ Dextromethorphan Pulmozyme 2 DSP, N, SL Rectiv 3 N, SL Restasis 3 N, SL Name Rezira 3 Sevelamer Carbonate Soltamox 3 E Tamoxifen Tobi 3 DSP, E, N, SL Tobi Podhaler 3 DSP, N, SL Tobramycin Nebulized Solution DSP, E, N, SL Zonatuss 3 E Musculoskeletal: Osteoporosis Actonel 3 SL Alendronate Sodium SL Atelvia 3 E, SL Binosto 3 E, SL Forteo 2 DSP, N Ibandronate SL Raloxifene Risedronate 50 mg SL Musculoskeletal: Other Allopurinol Amrix 3 E Baclofen Carisoprodol 350 mg Colcrys 2 Cyclobenzaprine Gralise 3 E, SL Horizant 3 E, SL Lorzone 3 E, SL Methocarbamol Soma E Tizanidine Uloric 3 SL 2

22 Name Musculoskeletal: Pain Relief Abstral 3 E, N, SL Acetaminophen/ Codeine SL Celebrex 3 SL Conzip 3 E, SL Diclofenac.5% Topical Solution E Diclofenac Sodium Duexis 3 E, SL Etodolac Capsule Exalgo 3 N, SL Fentanyl Patches SL Fentora 3 E, N, SL Flector 3 E Hydrocodone/ Acetaminophen 5/325 mg, 7.5/325 mg, SL 0/325 mg Hydrocodone/Ibuprofen Hydromorphone Extended-Release N, SL Hydromorphone Ibuprofen Indomethacin Capsule Kadian 3 E, N, SL Ketorolac Lazanda 3 N, SL Meloxicam Methadone Morphine Sulfate Extended-Release 30, 45, 60, 75, 90, 20 mg Capsule N, SL Name Morphine Sulfate Extended-Release Capsule Morphine Sulfate E, N, SL SL Extended-Release Nabumetone Naprelan 3 E Naproxen Nucynta 3 SL Nucynta ER 3 N, SL Onsolis 3 N, SL Opana ER 2 N, SL Oxycodone Oxycodone/ Acetaminophen 5/325 mg, 7.5/325 mg, 0/325 mg SL Oxycontin 2 N, SL Oxymorphone Extended-Release N, SL Rybix ODT 3 E, SL Sprix 3 Subsys 3 N, SL Tramadol Extended- Release E, SL Tramadol Sustained- Release SL Tramadol Vicodin 5/300 mg, 7.5/300 mg, 0/300 mg E, SL Vimovo 3 E, SL Voltaren Gel 2 Zipsor 3 E Zohydro ER 3 N, SL Zolvit 3 E, SL Zorvolex 3 E Bold type = Brand name drug [Plain type = Generic drug] DSP = Designated Specialty Program E = May be excluded from coverage MC = Multiple Copay N = Notification or Prior Authorization required RS = May be eligible for the Refill and Save Program SDP = Select Designated Pharmacy SL = Supply Limit ST = Step Therapy 22

23 Name Overactive Bladder Detrol 3 E Detrol LA 3 E Dicyclomine Enablex 3 E Gelnique 3 E Myrbetriq 3 E Oxybutynin Extended- Release Oxybutynin Oxytrol 3 E Sanctura 3 E Sanctura XR 3 E Tolterodine Extended- Release E Tolterodine E Toviaz 3 Trospium Extended- Release Capsule E Trospium E Vesicare 3 E Respiratory: Allergies Astepro 3 E, SL Azelastine 0.% Nasal Spray SL Azelastine 0.5% Nasal Spray E, SL Beconase AQ 3 E, SL Budesonide Nasal Spray E, SL Clarinex 3 E, SL Clarinex-D 3 E, SL Cyproheptadine Desloratadine Orally Disintegrating, E, SL Dymista 3 E, SL Flunisolide Nasal Spray Fluticasone Nasal Spray SL Name Hydroxyzine Capsule, Levocetirizine SL Nasacort AQ 3 E, SL Nasonex 3 E, SL Omnaris 3 E, SL Promethazine Qnasl 3 E, SL Triamcinolone Nasal Spray E, SL Veramyst 3 E, SL Zetonna 3 SL Respiratory: Asthma/COPD Advair Diskus/HFA 3 RS, SL Aerospan 3 SL Albuterol Sulfate Alvesco SL Asmanex SL Breo Ellipta 3 RS, SL Budesonide Nebs SL Combivent Respimat 3 SL Dulera 3 RS, SL Flovent Diskus/HFA 3 SL Foradil 2 SL Ipratropium Nebs Levalbuterol Nebs E, SL Montelukast SL Perforomist 3 SL Proair HFA 3 SL Proventil HFA 3 SL Pulmicort Flexhaler 3 SDP, SL QVAR SL Spiriva 2 SL Symbicort 3 E, SL Tudorza 2 SL Ventolin HFA SL Xopenex HFA 3 SL Xopenex Nebs 3 E, SL 23

24 Name Respiratory: Pulmonary Arterial Hypertension Adcirca 3 DSP, N, SL Letairis 2 DSP, N, SL Revatio 3 DSP, E, N, SL Sildenafil DSP, N, SL Tracleer 2 DSP, N, SL Tyvaso 2 DSP, N Transplant Astagraf XL 3 DSP, E Azathioprine Cellcept 3 DSP Cyclosporine Modified Capsule DSP Mycophenolate Capsule DSP Mycophenolic Acid DSP Myfortic 3 DSP Neoral 3 DSP Prograf 3 DSP Rapamune 3 DSP Sirolimus DSP Tacrolimus Capsule DSP Vitamins/Electrolytes Fluoride Folic Acid Klor-Con M0 Klor-Con M20 Potassium Chloride Potassium Citrate Name Women s Health: Contraceptives Altavera Amethia MC Apri Aviane Azurette Beyaz 3 E Camrese MC Cryselle Cyclafem Emoquette Enpresse Generess Fe 3 E Gianvi Gildess Fe Jolessa MC Jolivette Junel Junel Fe Kariva Levora-28 Lo Loestrin Fe 3 Lo Minastrin 24 FE 3 E Loryna Low-Ogestrel Lutera Microgestin Microgestin FE Minastrin 24 FE 3 E Mononessa Natazia Bold type = Brand name drug [Plain type = Generic drug] DSP = Designated Specialty Program E = May be excluded from coverage MC = Multiple Copay N = Notification or Prior Authorization required RS = May be eligible for the Refill and Save Program SDP = Select Designated Pharmacy SL = Supply Limit ST = Step Therapy 24

25 Name Necon 0.5/35, /35, /50, 0/ Norgestimate-Ethinyl Estradiol Nortrel 0.5/35 Nuvaring 2 Orsythia Ortho Micronor 3 Ortho Tri-Cyclen 3 Ortho Tri-Cyclen Lo 3 Ortho-Cyclen 3 Ortho-Novum 3 Portia Previfem Quartette 3 E Quasense MC Reclipsen Safyral 3 E Sprintec Syeda Tri-Previfem Tri-Sprintec Trinessa Trivora-28 Viorele Xulane Yasmin 28 3 Yaz 3 Zovia -35E Name Women s Health: Hormone Replacement Cenestin 3 E Climara 2 SL Climara Pro 3 SL Divigel 2 Enjuvia 3 Estrace Cream 3 Estradiol Estradiol/Norethindrone Acetate Estring 2 MC, SL Estrogen/ Methyltestosterone Evamist 2 Medroxyprogesterone Minivelle 3 SL Premarin 3 Prempro 3 Progesterone Micronized Capsule Vagifem 2 Vivelle-Dot 2 SL Women s Health: Prenatal Vitamins Brand Prenatal Vitamins 3 Prenatal Plus 25

26 Common Brand medications excluded from coverage under many benefit plans Aciphex Actiq Actos Adderall Adoxa Ambien Arimidex Astelin Ativan Avelox Avinza Celexa Cipro Suspension Cloderm Cream Cymbalta Diovan HCT Duac Duragesic Effexor XR Entocort EC Evista Femara Fioricet with Codeine 50 mg/325 mg/40 mg/ 30 mg Flomax Geodon Imitrex Injection & s Lexapro Lidoderm Lipitor Lofibra 54, 60 mg Lovaza Lunesta Lower-cost option(s) Omeprazole (generic Prilosec), Pantoprazole (generic Protonix), Rabeprazole (generic Aciphex), Dexilant Fentanyl Lozenge (generic Actiq) Pioglitazone (generic Actos) Amphetamine/Dextroamphetamine Immediate-Release (generic Adderall) Doxycycline Hyclate (generic Vibra-Tab), Doxycycline Monohydrate (generic Adoxa ) Zolpidem (generic Ambien) Anastrozole (generic Arimidex) Azelastine Nasal Spray (generic Astelin) Lorazepam (generic Ativan) Moxifloxacin (generic Avelox) Morphine Sulfate Extended-Release (generic MS Contin), Morphine Sulfate Extended-Release Capsule (generic Avinza) Citalopram (generic Celexa) Ciprofloxacin Oral Suspension (generic Cipro Suspension) Clocortolone 0.% Cream (generic Cloderm), Mometasone Furoate Cream 0. % (generic Elocon) Duloxetine (generic Cymbalta) Valsartan/Hydrochlorothiazide (generic Diovan HCT) Clindamycin Solution (generic Cleocin T) plus OTC Benzoyl Peroxide, Clindamycin.2%/Benzoyl Peroxide 5% (generic Duac) Fentanyl Transdermal Patch (generic Duragesic) Venlafaxine Extended-Release Capsule (generic Effexor XR) Budesonide (generic Entocort EC) Raloxifene (generic Evista) Letrozole (generic Femara) Butalbital/Acetaminophen/Caffeine/Codeine Phosphate 50 mg/325 mg/40 mg/30 mg (generic Fioricet with Codeine) Tamsulosin (generic Flomax) Ziprasidone (generic Geodon) Sumatriptan Injection, (generic Imitrex) Escitalopram (generic Lexapro) Lidocaine Transdermal Patch (generic Lidoderm) Atorvastatin (generic Lipitor) Fenofibrate 54, 60 mg (generic Lofibra) Omega-3-Acid Ethyl Esters (generic Lovaza) Eszopiclone (generic Lunesta), Zaleplon (generic Sonata), Zolpidem (generic Ambien) Bold type = Brand name drug [Plain type = Generic drug] 26

27 Common Brand medications excluded from coverage under many benefit plans Maxalt Maxalt-MLT Mepron Suspension Micardis Micardis HCT Monodox Natroba Optivar Ortho Evra Percocet Plavix Prilosec Protonix Prozac Revatio Risperdal Seroquel Singulair Chewable Singulair Skelaxin Taclonex Ointment Valium Valtrex Viramune XR 400 mg Wellbutrin SR Wellbutrin XL Xanax Xanax XR Zoloft Zutripro Zyprexa Zyprexa Zydis Lower-cost option(s) Rizatriptan (generic Maxalt) Rizatriptan (generic Maxalt), Rizatriptan Orally Disintegrating (generic Maxalt MLT) Atovaquone Suspension (generic Mepron) Losartan (generic Cozaar), Telmisartan (generic Micardis) Losartan/Hydrochlorothiazide (generic Hyzaar), Telmisartan/Hydrochlorothiazide (generic Micardis HCT) Doxycycline Hyclate (generic Vibramycin), Doxycycline Monohydrate (generic Monodox) Malathion (generic Ovide), Permethrin (generic Elimite), Spinosad (generic Natroba) Azelastine (generic Optivar), Lastacaft Norelgestromin/Ethinyl Estradiol Topical Patch, Xulane (generic Ortho Evra) Acetaminophen/Oxycodone (generic Percocet) Clopidogrel (generic Plavix) Omeprazole (generic Prilosec) Pantoprazole (generic Protonix) Fluoxetine (generic Prozac) Sildenafil (generic Revatio) Risperidone (generic Risperdal) Quetiapine (generic Seroquel) Montelukast Chewable (generic Singulair) Montelukast (generic Singulair) Metaxalone (generic Skelaxin) Betamethasone/Calcipotriene Ointment (generic Taclonex) Diazepam (generic Valium) Valacyclovir (generic Valtrex) Nevirapine Extended-Release (generic Viramune XR) Bupropion Extended-Release (generic Wellbutrin SR) Bupropion Extended-Release (generic Wellbutrin XL) Alprazolam (generic Xanax) Alprazolam Extended-Release (generic Xanax XR) Sertraline (generic Zoloft) Chlorpheniramine/Hydrocodone/Pseudoephedrine (generic Zutripro) Olanzapine (generic Zyprexa) Olanzapine (generic Zyprexa), Olanzapine Orally Disintegrating (generic Zyprexa Zydis) Bold type = Brand name drug [Plain type = Generic drug] 27

28 Index A Abilify...4 Absorica...5 Abstral...22 Acanya...5 Accu-Chek Active Test Strips...7 Accu-Chek Aviva Plus...7 Accu-Chek Aviva Plus Test Strips...7 Accu-Chek Comfort Curve Test Strips...7 Accu-Chek Compact Test Strips...7 Accu-Chek Nano SmartView...7 Accu-Chek Nano SmartView Test Strips...7 Acetaminophen/Butalbital/ Caffeine/Codeine 325 mg/ 50 mg/40 mg/30 mg...4 Acetaminophen/Butalbital/Caffeine 325 mg/50 mg/40 mg...4 Acetaminophen/Codeine...22 Acetaminophen/Oxycodone...27 Aciphex... 9, 26 Aciphex Sprinkle...9 Actemra...20 Actiq...26 Actonel...2 Actos...26 Acuvail...9 Acyclovir Ointment...0 Acyclovir...0 Aczone...5 Adapalene 0.% Cream, Gel...5 Adcirca...24 Adderall...3, 26 Adderall XR...3 Adoxa Capsule...0 Adoxa...26 Advair Diskus/HFA...23 Aerospan...23 Albuterol Sulfate...23 Alendronate Sodium...2 Alfuzosin...20 Allopurinol...2 Alphagan P 0.%...8 Alprazolam...4, 27 Alprazolam Extended-Release...4, 27 Alprazolam Extended-Release...4 Alprazolam...4 Alsuma...4 Altavera...24 Altoprev...2 Alvesco...23 Ambien...5, 26 Ambien CR...5 Amethia...24 Amiodarone...2 Amitiza...9 Amitriptyline...3 Amlodipine... Amlodipine/Telmisartan... Amlodipine Besylate-Benazepril... Amoxicillin/Potassium Clavulanate Chewable,...0 Amoxicillin Capsule, Chewable...0 Amphetamine/Dextroamphetamine Immediate-Release...26 Amphetamine Salt Combo...3 Ampyra...4 Amrix...2 Amturnide... Anastrozole...2, 26 Anastrozole...2 Androderm...20 Androgel...20 Android...20 Antara...2 Antipyrine/Benzocaine Otic Solution...2 Aplenzin...3 Apri...24 Apriso...9 Aranesp...2 Aricept 23 mg...4 Arimidex...26 Armour Thyroid...8 Asacol HD...9 Asmanex...23 Astagraf XL...24 Astelin...26 Astepro...23 Atelvia...2 Atenolol... Atenolol-Chlorthalidone... Ativan...26 Atorvastatin...2, 26 Atovaquone Suspension...27 Atralin...5 Atripla...20 Aubagio...4 Augmentin XR...0 Auvi-Q...2 Avelox...26 Avelox...26 Aviane...24 Avinza Avodart...20 Avonex...4 Axiron...20 Azathioprine...24 Azelastine...8, 23, 26, 27 Azelastine 0.05% Ophthalmic Solution...8 Azelastine 0.5% Nasal Spray...23 Azelastine 0.% Nasal Spray...23 Azelastine Nasal Spray...26 Azelex...5 Azithromycin...0 Azopt...8 Azor... Azurette...24 B Baclofen...2 Baraclude...0 Beconase AQ...23 Benazepril... Benazepril-Hydrochlorothiazide... Benicar... Benicar HCT... Benzaclin...5 Benzonatate Capsule...2 Bepreve...8 Betamethasone/Calcipotriene Ointment...5, 27 Betamethasone Diproionate 0.05% Augmented Lotion, Ointment...5 Betamethasone Dipropionate 0.05% Cream, Ointment...5 Betamethasone Valerate 0.2% Foam...5 Betaseron...4 Bethkis...2 Beyaz...24 Bidil... Binosto...2 Bisoprolol... Bisoprolol-Hydrochlorothiazide... Bosulif... Brand Prenatal Vitamins...25 Breo Ellipta...23 Brisdelle...2 Bromday...9 Bromfed DM...2 Budesonide...23, 26 Budesonide Nasal Spray...23 Budesonide Nebs...23 Buprenorphine/Naloxone... 4 Bupropion Extended-Release...3, 27

29 Bupropion Extended-Release...3 Bupropion Sustained-Release...3 Bupropion...3 Buspirone...4 Butalbital/Acetaminophen/ Caffeine/Codeine Phosphate 50 mg/325 mg/40 mg/30 mg...26 Bydureon...7 Byetta...7 Bystolic... C Caduet...2 Calcitriol Capsule...8 Cambia...4 Camrese...24 Canasa...9 Capecitabine... Carac...5 Carbamazepine...5 Carbidopa-Levodopa...4 Carisoprodol 350 mg...2 Cartia XT... Carvedilol... Cefdinir Capsule...0 Cefuroxime...0 Celebrex...22 Celexa...26 Cellcept...24 Cenestin...25 Centany AT...0 Cephalexin Capsule...0 Cetrotide...20 Chlorhexidine Gluconate...2 Chlorpheniramine/Hydrocodone/ Pseudoephedrine...2, 27 Chlorpheniramine/Hydrocodone/ Pseudoephedrine Solution...2 Chlorthalidone... Choline Fenofibrate...2 Cialis...20 Ciclopirox Cream, Gel, Lotion, Solution...5 Cimzia...20 Cipro Suspension...26 Ciprodex...2 Ciprofloxacin Oral Suspension...26 Ciprofloxacin...0 Citalopram...3, 26 Citalopram...3 Claravis...5 Clarinex...23 Clarinex-D...23 Clarithromycin...0 Cleocin T...26 Climara...25 Climara Pro...25 Clindagel...5 Clindamycin %/Benzoyl Peroxide 5% Gel...5 Clindamycin.2%/Benzoyl Peroxide 5%...5, 26 Clindamycin.2%/Benzoyl Peroxide 5% Gel...5 Clindamycin Capsule...0 Clindamycin Gel...5 Clindamycin Lotion, Solution, Swabs...5 Clindamycin Solution...26 Clobetasol Propionate Cream, Ointment, Solution...5 Clobetasol Propionate Foam, Lotion, Shampoo...5 Clocortolone 0.% Cream...26 Clocortolone Cream...5 Cloderm...26 Cloderm Cream...26 Clonazepam...5 Clonidine Extended-Release...3 Clonidine... Clopidogrel..., 27 Clotrimazole-Betamethasone Cream...6 Clotrimazole-Betamethasone Lotion...6 Colcrys...2 Combigan...8 Combivent Respimat...23 Complera...20 Concerta...3 Condylox Gel...6 Contour Test Strips...7 Conzip...22 Copaxone...4 Coreg CR... Cortifoam...9 Cosopt PF...8 Coumadin... Cozaar...27 Creon...9 Crestor...8, 2 Cryselle...24 Cyclafem...24 Cyclobenzaprine...2 Cyclosporine Modified Capsule...24 Cymbalta...26 Cyproheptadine...23 D Daytrana...3 Delzicol Denavir Cream...0 Depakote...5 Depakote ER...5 Depo-Testosterone...20 Desloratadine Orally Disintegrating,...23 Desmopressin...8 Desonide 0.05% Cream, Lotion, Ointment...6 Desoximetasone Cream, Gel, Ointment...6 Desvenlafaxine...3 Detrol...23 Detrol LA...23 Dexamethasone...8 Dexilant... 9, 26 Dexmethylphenidate Extended-Release Capsule...3 Dexmethylphenidate...3 Dextroamphetamine-Amphetamine Extended-Release...3 Dextroamphetamine-Amphetamine...3 Dextroamphetamine Sulfate...3 Diazepam... 4, 5, 27 Diazepam...4, 5 Diclofenac.5% Topical Solution...22 Diclofenac Sodium...22 Dicyclomine...23 Differin...6 Dificid...0 Diflorasone Diacetate 0.05% Cream, Ointment...6 Digoxin...2 Diltiazem 24 Hour CD... Diltiazem Sustained-Release Capsule... Diltiazem Sustained-Release... Diovan..., 26 Diovan HCT...26 Divalproex Delayed-Release...5 Divalproex Extended-Release...5 Divigel...25 Donepezil 5, 0 mg...4 Doryx...0 Dorzolamide-Timolol 2%-0.5% Ophthalmic Solution...8 Doxazosin..., 20 Doxazosin...20 Doxepin...3 Doxycycline Hyclate...0, 26, 27 Doxycycline Hyclate Capsule,...0

30 Doxycycline Monohydrate...0, 26, 27 Doxycycline Monohydrate 50, 00 mg Capsule...0 Doxycycline Monohydrate 75 mg Capsule...0 Doxycycline Monohydrate...26 Duac...26 Duexis...22 Dulera...23 Duloxetine...3, 26 Duloxetine Capsule...3 Duragesic...26 Dutoprol... Dymista...23 E Edarbi... Edarbyclor... Edluar...5 Effexor XR...26 Effient... Elestat...8 Elimite...27 Eliquis... Elocon...26 Emadine...8 Emoquette...24 Enablex...23 Enalapril... Enalapril-Hydrochlorothiazide... Enbrel...20 Enjuvia...25 Enoxaparin Sodium... Enpresse...24 Entocort EC...26 Epaned... Epiduo...6 Epipen...2 Epipen-Jr...2 Epzicom...20 Ertaczo...0 Erythromycin 0.5% Ophthalmic Ointment...8 Escitalopram...3, 26 Escitalopram...3 Estrace Cream...25 Estradiol/Norethindrone Acetate...25 Estradiol...25 Estring...25 Estrogen/Methyltestosterone...25 Eszopiclone...5, 26 Eszopiclone...5 Etodolac Capsule...22 Evamist...25 Evista...26 Exalgo...22 Exemestane...2 Exforge... Exforge HCT... Extavia...4 F Fabior...6 Farxiga...7 Felodipine... Femara...26 Fenofibrate 43, 50, 67, 30, 34, 50, 200 mg Capsule...2 Fenofibrate 48, 45 mg...2 Fenofibrate 54, 60 mg...2, 26 Fenofibrate 54, 60 mg...2 Fenofibric Acid 35, 05 mg...2 Fenoglide...2 Fentanyl Lozenge...26 Fentanyl Patches...22 Fentanyl Transdermal Patch...26 Fentora...22 Finacea...6 Finasteride...20 Fioricet with Codeine...26 Fioricet with Codeine 50 mg/325 mg/40 mg/30 mg...26 Flecainide...2 Flector...22 Flomax...26 Flovent Diskus/HFA...23 Fluconazole...0 Flunisolide Nasal Spray...23 Fluocinolone Cream, Oil, Ointment, Solution...6 Fluocinonide 0.05% Cream...6 Fluocinonide 0.% Cream...6 Fluoride...24 Fluoxetine...3, 27 Fluoxetine, Capsule...3 Fluticasone Nasal Spray...23 Fluvoxamine...3 Focalin XR...3 Folic Acid...24 Foradil...23 Forfivo XL...3 Forteo...2 Fortesta...20 Fosinopril Sodium... Fosrenol...2 Freestyle Test Strips...7 Furosemide... G Gabapentin Capsule,...5 Gelnique Gemfibrozil...2 Generess Fe...24 Genotropin...8 Geodon...26 Gianvi...24 Giazo...9 Gildess Fe...24 Gilenya...4 Gleevec... Glimepiride...7 Glipizide...7 Glipizide Extended-Release...7 Glumetza...7 Glyburide...7 Glyburide-Metformin...7 Golytely...9 Gonal-F...20 Gonal-F RFF...20 Gralise...2 Guanfacine... H Halflytely...9 Helidac...9 Horizant...2 Humalog KwikPen...7 Humalog Mix KwikPen...7 Humalog Vials...7 Humatrope...8 Humira...20 Humulin Vials...7 Humulin KwikPen...7 Humulin N KwikPen...7 Humulin N Vials...7 Humulin R Vials...7 Hydralazine... Hydrochlorothiazide..., 26, 27 Hydrocodone/Acetaminophen 5/325 mg, 7.5/325 mg, 0/325 mg...22 Hydrocodone/Chlorpheniramine Suspension...2 Hydrocodone/Homatropine...2 Hydrocodone/Ibuprofen...22 Hydrocortisone 2.5% Cream, Ointment...6 Hydrocortisone Butyrate Cream...6 Hydromorphone Extended-Release...22 Hydromorphone...22 Hydroxychloroquine Sulfate...20 Hydroxyurea Capsule... Hydroxyzine Capsule,...23 Hyoscyamine...9 Hyzaar...27

31 I Ibandronate...2 Ibuprofen...22 Ilevro...9 Imipramine...3 Imitrex...26 Imitrex Injection & s...26 Indapamide... Indomethacin Capsule...22 Intelence...20 Intermezzo...5 Intuniv...3 Invokamet...7 Invokana...7 Ipratropium Nebs...23 Irbesartan... Isentress...20 Isosorbide Mononitrate ER...2 Itraconazole Capsule...0 J Jalyn...20 Janumet...7 Januvia...7 Jentadueto...7 Jolessa...24 Jolivette...24 Junel...24 Junel Fe...24 K Kadian...22 Kaletra...20 Kapvay...3 Kariva...24 Kazano...7 Keppra...5 Keppra XR...5 Keralyt Scalp Kit...6 Ketoconazole Cream...0 Ketorolac...22 Khedezla...3 Klor-Con M Klor-Con M Kombiglyze XR...7 L Labetalol... Lamictal...5 Lamictal XR...5 Lamotrigine...5 Lansoprazole Capsule...9 Lantus Solostar...7 Lantus Vials...7 Lastacaft...8, 27 Latanoprost 0.005% Ophthalmic Solution...8 Latuda...4 Lazanda...22 Leflunomide...20 Letairis...24 Letrozole...2, 26 Leucovorin Calcium... Levalbuterol Nebs...23 Levemir Flexpen...7 Levemir Vials...7 Levetiracetam Extended-Release...5 Levetiracetam...5 Levocetirizine...23 Levofloxacin...0 Levora Levothyroxine Sodium...8 Levoxyl...8 Lexapro...26 Lialda...9 Lidocaine Transdermal Patch...2, 26 Lidoderm...26 Linzess...9 Liothyronine Sodium...8 Lipitor...26 Lipofen...2 Liptruzet...2 Lisinopril..., 35 Lisinopril-Hydrochlorothiazide... Lithium Capsule...4 Livalo...2 Lo Loestrin Fe...24 Lo Minastrin 24 FE...24 Locoid Lipocream...6 Locoid Lotion...6 Lofibra...26 Lofibra 54, 60 mg...26 Lorazepam...4, 26 Lorazepam...4 Loryna...24 Lorzone...2 Losartan..., 27 Losartan-Hydrochlorothiazide... Losartan/Hydrochlorothiazide...27 Lotemax Gel...9 Lotemax Solution...9 Lovastatin...2 Lovaza...26 Low-Ogestrel...24 Lumigan...9 Lunesta...26 Lutera...24 Luxiq...6 Luzu...0 Lyrica M Malathion...27 Maxalt...27 Maxalt-MLT...27 Maxalt MLT...27 Medroxyprogesterone...25 Meloxicam...22 Mepron...27 Mepron Suspension...27 Mercaptopurine... Metadate CD...3 Metaxalone...27 Metformin...7 Metformin Extended-Release Osmotic...7 Metformin Extended-Release...7 Methadone...22 Methimazole...8 Methocarbamol...2 Methotrexate...20 Methylphenidate...3 Methylphenidate Extended-Release Capsule...3 Methylphenidate Extended-Release...3 Methylprednisolone...8 Metoclopramide...9 Metoprolol Succinate 50, 00, 200 mg... Metoprolol Tartrate... Metozolv ODT...9 Metrogel %...6 Metronidazole Gel 0.75%...6 Metronidazole Gel %...6 Metronidazole...0 Micardis...27 Micardis HCT...27 Microgestin...24 Microgestin FE...24 Minastrin 24 FE...24 Minivelle...25 Minocycline Capsule,...0 Mirapex ER...4 Mirtazapine...3 Mirvaso...6 Modafinil...4 Mometasone Furoate Cream 0. %...26 Mometasone Furoate Cream, Lotion, Ointment...6 Monodox...27 Mononessa...24 Montelukast...23, 27 Montelukast Chewable...27

32 Morphine Sulfate Extended-Release 30, 45, 60, 75, 90, 20 mg Capsule...22 Morphine Sulfate Extended-Release Capsule...22, 26 Morphine Sulfate Extended-Release...22, 26 Moviprep...9 Moxifloxacin...26 MS Contin...26 Multaq...2 Mupirocin Ointment...6 Mycophenolate Capsule...24 Mycophenolic Acid...24 Myfortic...24 Myrbetriq...23 N Nabumetone...22 Nadolol... Naftin %, 2% Cream, Gel...0 Namenda XR...4 Naprelan...22 Naproxen...22 Nasacort AQ...23 Nasonex...23 Natazia...24 Natroba...27 Necon 0.5/35, /35, /50, 0/...25 Neoral...24 Nesina...7 Neurontin...5 Nevirapine Extended-Release...27 Nexium Capsule...9 Nexium Suspension Packet...9 Niacin Extended-Release...2 Niaspan...2 Nifedipine Extended-Release... Nitrofurantoin Capsule...0 Nitrofurantoin Macrocrystal Capsule...0 Nitroglycerin Sublingual Spray...2 Nitrolingual Pump Spray...2 Norditropin...8 Norelgestromin/Ethinyl Estradiol Topical Patch...27 Norgestimate-Ethinyl Estradiol...25 Noritate...6 Nortrel 0.5/ Nortriptyline Capsule...3 Norvir...20 Novolog...7 Novolog Flexpen...7 NP Thyroid...8 Nucynta...22 Nucynta ER...22 Nuedexta...2 Nutropin AQ NuSpin...8 Nuvaring...25 Nuvigil...4 Nystatin-Triamcinolone Acetonide Cream, Ointment...6 Nystatin Cream, Ointment...0 O Ofloxacin 0.3% Ophthalmic Solution...8 Olanzapine...4, 27 Olanzapine Orally Disintegrating...27 Olanzapine...4 Oleptro...3 Olux, Olux-E...6 Olysio...0 Omeclamox-Pak...9 Omega-3-Acid Ethyl Esters...2, 26 Omega-3-Acid Ethyl Esters Capsule...2 Omeprazole... 9, 26, 27 Omeprazole Capsule...9 Omnaris...23 Omnitrope...8 Ondansetron...9 Ondansetron ODT...9 One Touch Test Strips...7 One Touch Ultra Mini...7 One Touch Ultra Test Strips...7 One Touch Verio IQ...7 One Touch Verio IQ Test Strips...7 One Touch Verio Sync...7 Onglyza...7 Onmel...0 Onsolis...22 Opana ER...22 Optivar...27 Oracea...0 Orencia...20 Orsythia...25 Ortho-Cyclen...25 Ortho-Novum...25 Ortho Evra...27 Ortho Micronor...25 Ortho Tri-Cyclen...25 Ortho Tri-Cyclen Lo...25 Oseni...7 OTC Benzoyl Peroxide...26 Otezla...20 Ovide...27 Ovidrel...20 Oxcarbazepine...5 Oxistat Cream...0 Oxistat Lotion...0 Oxsoralen-Ul...6 Oxtellar XR Oxybutynin Extended-Release...23 Oxybutynin...23 Oxycodone/Acetaminophen 5/325 mg, 7.5/325 mg, 0/325 mg...22 Oxycodone...22 Oxycontin...22 Oxymorphone Extended-Release...22 Oxytrol...23 P Pantoprazole... 9, 26, 27 Pantoprazole...9 Paroxetine...3 Pataday...8 Patanol...8 Pegasys...2 Penicillin V Potassium...0 Pentasa...9 Percocet...27 Perforomist...23 Permethrin...27 Pertzye...9 Pexeva...3 Phenytoin Capsule, Suspension...5 Picato...6 Pioglitazone... 7, 26 Pioglitazone-Metformin...7 Plavix...27 Polyethylene Glycol Portia...25 Potassium Chloride...24 Potassium Citrate...24 Pradaxa... Pramipexole...4 Prandimet...7 Prandin...7 Pravastatin...2 Prednisolone Solution, Syrup...8 Prednisone...8 Premarin...25 Prempro...25 Prenatal Plus...25 Prepopik...9 Prevacid Solutab...9 Previfem...25 Prevpac...9 Prezista...20 Prilosec... 9, 26, 27 Prilosec Suspension...9 Pristiq ER...3 Proair HFA...23 Procort...9 Procrit...2 Progesterone Micronized Capsule...25

33 Prograf...24 Prolensa...9 Promethazine/Codeine...2 Promethazine/Dextromethorphan..2 Promethazine...23 Propranolol... Protonix... 9, 26, 27 Protonix Suspension...9 Protopic...6 Proventil HFA...23 Provigil...4 Prozac...27 Pulmicort Flexhaler...23 Pulmozyme...2 Pylera...9 Q Qnasl...23 Quartette...25 Quasense...25 Quetiapine...4, 27 Quetiapine...4 Quillivant XR...3 Quinapril...2 QVAR...23 R Rabeprazole... 9, 26 Rabeprazole...9 Raloxifene...2, 26 Raloxifene...2 Ramipril...2 Ranexa...2 Rapaflo...20 Rapamune...24 Rayos...8 Rebif...4 Reclipsen...25 Rectiv...2 Relpax...4 Repaglinide...7 Requip XL...4 Restasis...2 Retin-A Micro...6 Revatio...24, 27 Reyataz...20 Rezira...2 Ribapak...0 Ribavirin...0 Risedronate 50 mg...2 Risperdal...27 Risperidone...4, 27 Risperidone...4 Ritalin LA...3 Rizatriptan...4, 27 Rizatriptan Orally Disintegrating...4, 27 Rizatriptan...4 Ropinirole...4 Rybix ODT...22 S Safyral...25 Saizen...8 Sanctura...23 Sanctura XR...23 Sancuso...9 Seroquel...4, 27 Seroquel XR...4 Sertraline...3, 27 Sertraline...3 Sevelamer Carbonate...2 Sildenafil...24, 27 Sildenafil...24 Silenor...5 Simbrinza...9 Simcor...2 Simponi...20 Simvastatin...8, 2 Singulair...27 Singulair Chewable...27 Singulair...27 Sirolimus...24 Skelaxin...27 Sodium Sulfacetamide-Sulfur...6 Solodyn...0 Soltamox...2 Soma Sonata...26 Sorilux...6 Sotalol...2 Spinosad...27 Spiriva...23 Spironolactone...2 Sprintec...25 Sprix...22 Staxyn...20 Stelara...20 Strattera...3 Stribild...20 Suboxone Film...4 Subsys...22 Suclear...9 Sucralfate...9 Sulfamethoxazole-Trimethoprim...0 Sulfasalazine...9 Sumatriptan Injection,...26 Sumatriptan Nasal Spray...4 Sumatriptan Succinate, Injection...4 Sumavel DosePro Suprep...9 Sustiva...20 Sutent... Syeda...25 Symbicort...23 Synthroid...8 T Taclonex...27 Taclonex Ointment...27 Tacrolimus Capsule...24 Tamiflu...0 Tamoxifen...2 Tamsulosin...20, 26 Tamsulosin Capsule...20 Tanzeum...7 Tasigna... Tasmar...4 Tecfidera...4 Tekamlo...2 Telmisartan..., 2, 27 Telmisartan-Hydrochlorothiazide...2 Telmisartan/Hydrochlorothiazide...27 Temazepam Capsule...5 Terazosin...2, 20 Terazosin Capsule,...20 Terbinafine...0 Testim...20 Testosterone Cypionate Injection...20 Testosterone Enanthate Injection...20 Testosterone Topical Gel...20 Testred...20 Tev-Tropin...8 Timolol Maleate 0.25%, 0.5% Ophthalmic Solution...9 Tirosint...8 Tizanidine...2 Tobi...2 Tobi Podhaler...2 Tobradex ST...8 Tobramycin/Dexamethasone 0.3%-0.% Ophthalmic Suspension...8 Tobramycin Nebulized Solution...2 Tolterodine Extended-Release...23 Tolterodine...23 Topamax...5 Topicort Spray...6 Topiramate...5 Torsemide...2 Toviaz...23 Tracleer...24 Tradjenta...7 Tramadol Extended-Release...22

34 Tramadol Sustained-Release...22 Tramadol...22 Travatan Z...9 Trazodone...3 Tretin-X...6 Tretinoin...6 Tretinoin Microspheres...6 Treximet...4 Tri-Previfem...25 Tri-Sprintec...25 Triamcinolone Acetonide Cream, Lotion, Ointment...6 Triamcinolone Nasal Spray...23 Triamterene-Hydrochlorothiazide...2 Tribenzor...2 Tricor 48, 45 mg...2 Triglide...2 Trileptal...5 Trilipix...2 Trinessa...25 Trivora Trokendi XR...5 Trospium Extended-Release Capsule...23 Trospium...23 Truvada...20 Tudorza...23 Twynsta...2 Tyvaso...24 U Uceris...9 Uloric...2 Ultresa...9 Urea 40%...6 Ursodiol Capsule,...9 V Vagifem...25 Valacyclovir...0, 27 Valacyclovir...0 Valium...27 Valsartan...2, 26 Valsartan-Hydrochlorothiazide...2 Valsartan/Hydrochlorothiazide...26 Valtrex...27 Vanos...6 Vascepa...2 Vectical...6 Veltin...6 Venlafaxine Extended-Release Capsule...3, 26 Venlafaxine Extended-Release...3 Venlafaxine...3 Ventolin HFA...23 Veramyst...23 Verapamil...2 Verapamil Sustained-Release...2 Verdeso...6 Vesicare...23 Viagra...20 Vibra-Tab...26 Vibramycin...27 Vicodin 5/300 mg, 7.5/300 mg, 0/300 mg...22 Victoza...7 Viibryd...3 Vimovo...22 Viokace...9 Viorele...25 Viramune XR...27 Viramune XR 400 mg...27 Virasal...6 Viread...20 Vivelle-Dot...25 Voltaren Gel...22 Vusion...6 Vytorin...2 Vyvanse...3 W Warfarin Sodium... Welchol...2 Wellbutrin SR...27 Wellbutrin XL...27 X Xanax...27 Xanax XR...27 Xarelto... Xeljanz...20 Xeloda... Xerese...6 Xopenex HFA...23 Xopenex Nebs...23 Xulane...25, 27 Xyrem...4 Y Yasmin Yaz...25 Z Zaleplon...5, 26 Zaleplon Capsule...5 Zegerid Capsule...9 Zelapar...4 Zenpep...9 Zenzedi...3 Zetia...2 Zetonna...23 Ziana...6 Ziprasidone...4, 26 Ziprasidone Capsule...4 Zipsor...22 Zohydro ER...22 Zoloft...27 Zolpidem...5, 26 Zolpidem Extended-Release...5 Zolpidem...5 Zolpimist...5 Zolvit...22 Zonatuss...2 Zonegran...5 Zonisamide Capsule...5 Zorvolex...22 Zovia -35E...25 Zovirax Cream...0 Zubsolv...4 Zuplenz...9 Zutripro...27 Zyclara...6 Zyprexa...27 Zyprexa Zydis...27 Zytiga... 34

35 My Medications worksheet Take this worksheet with you each time you visit a doctor. Each of your doctors should be aware of every drug you take and you should have a list as well. Name of Medicine and Strength I Take This Medicine For Directions Doctor Example: Lisinopril, 20mg High blood pressure One tablet daily Dr. Johnson 35

36 For more information Call the toll-free member phone number on the back of your health plan ID card. Or, visit myuhc.com Where else can I go for information? HealthCareLane.com includes short videos to help you learn more about UnitedHealthcare benefi ts and health insurance information. UHCTV.com health-related topics. All branded medications are trademarks or registered trademarks of their respective owners. 204 United HealthCare Services, Inc. All rights reserved. Created September, Prescription List Traditional Three /5