Your 2019 Prescription Drug List Enhanced Three-Tier

Transcription

1 Your 209 Prescription List Enhanced Three- Effective January Jan.,, This Prescription List (PDL) is accurate as of Jan., 209 and is subject to change after this date. The next anticipated update will be July, 209. This PDL applies to members of our UnitedHealthcare and Oxford medical plans with a pharmacy benefit subject to the Enhanced Three- PDL. Your estimated coverage and copayment/coinsurance may vary based on the benefit plan you choose and the effective date of the plan.

2 Table of Contents Understanding your Prescription List... 3 Medication tips... 5 Reading your PDL... 6 Questions... 8 s by category... 9 Anti-Infectives Antibiotics... 9 Antifungals... 9 Antivirals Cancer... 9 Cardiovascular/Heart Disease Coagulation Therapy... 0 High Blood Pressure... 0 High Cholesterol... Other... Central Nervous System Attention Deficit Disorder... Depression... 2 Migraine... 2 Multiple Sclerosis... 2 Other... 2 Sedatives/Hypnotics... 3 Seizure Disorders... 3 Dermatology... 3 Diabetes Blood Glucose Monitoring... 4 Insulin... 4 Non-Insulin... 5 Endocrine Growth Hormone... 5 Other... 6 Thyroid Hormone Replacement... 6 Eye Conditions Allergies... 6 Antibiotics... 6 Dry Eye Disease... 6 Glaucoma Gastrointestinal Acid Suppression... 6 Nausea/Vomiting... 6 Other... 6 Gout... 7 Hepatitis C... 7 HIV/AIDS... 7 Infertility... 8 Inflammatory Conditions: Rheumatoid Arthritis, Crohn s Disease, Psoriasis, Ulcerative Colitis... 8 Medications for Sexual Dysfunction... 8 Men s Health Prostate... 8 Testosterone Therapy... 8 Miscellaneous... 9 Musculoskeletal Muscle Spasms... 9 Osteoporosis... 9 Pain Relief... 9 Overactive Bladder Respiratory Allergies Asthma/COPD Pulmonary Arterial Hypertension Smoking Cessation... 2 Transplant... 2 Vitamins/Electrolytes... 2 Women s Health Contraceptives... 2 Hormone Replacement Miscellaneous Prenatal Vitamins Index... 25

3 Understanding your Prescription 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 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. How do I use my PDL? You and your doctor can consult the PDL to help you select the most cost-effective prescription medications. This guide tells you if a medication is generic or a brand-name, and if there are coverage requirements or limits. Bring this list with you when you see your doctor. If your medication is not listed here, please visit your plan s member website or call the toll-free member phone number on your health plan ID card. About this PDL Where differences exist between this PDL and your benefit plan documents, the benefit plan documents rule. This PDL is not a complete list of medications, and not all medications listed may be covered by your plan. Please look at the benefit plan documents provided by your employer or health plan to see which medications are covered under your plan. What are tiers? s are the different cost levels you pay for a medication. Each tier is assigned a cost, determined by your employer or benefit plan. This is how much you will pay when you fill a prescription. See page 6 for additional information. When does the PDL change? PDL changes typically occur twice per year. However, changes that have a positive impact for you such as coverage for 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. 3

4 Understanding your Prescription List (continued) Why are some medications excluded from coverage? 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 2 ). 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 overthe-counter medications available. Who decides which 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.. Depending on your benefit, you may have notification or medical necessity requirements for select medications. 2. For New York and New Jersey 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. 4

5 Medication tips 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 for 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? If your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lower-cost option is available and could 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. Over-the-counter (OTC) medications An OTC medication may be the right treatment option for some conditions. Talk to your doctor about available OTC options. Even though these medications may not be covered by your pharmacy benefit, they may cost less than a prescription medication. What if I am taking a specialty medication? Specialty medications are high-cost and are used to treat rare or complex conditions that require additional care and support. For most plans, these medications are managed through the specialty pharmacy program. Take advantage of personalized support designed to help you get the most out of your treatment plan. Visit the member website listed on your health plan ID card or call the toll-free phone number on your 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 ID card to talk with a pharmacist about finding lower-cost options or a financial assistance program. 5

6 Reading your PDL The PDL gives you choices so you and your doctor can determine your best course of treatment. In this PDL, brand-name medications are shown in bold type and generic medications in plain type. information. Using lower-tier medications can help you pay your lowest out-of-pocket cost. Your plan may have multiple or no tiers. Please note: If you have a high deductible plan, the tier cost levels may apply once you hit your deductible. Includes Helpful Tips $ Lower-cost Medications that provide the highest overall value. Mostly generic drugs. Some brand-name drugs may also be included. 2 $$ Mid-range cost Medications that provide good overall value. Mainly preferred brand-name drugs. 3 $$$ Highest-cost Medications that provide the lowest overall value. Use drugs for the lowest out-of-pocket costs. Use 2 drugs, instead of 3, to help reduce your out-of-pocket costs. Ask your doctor if a or 2 option could work for you. 6

7 Reading your PDL (continued) list information. In this drug list, some medications are noted with letters next to them to help you see which ones may have coverage requirements or limits. Your benefit plan determines how these medications may be covered for you. H H-PA Health Care Reform Preventive 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 May be part of health care reform preventive and available at no additional cost to you if prior authorization criteria is met. PA Prior Authorization (sometimes referred to as Precertification) 3 Requires your doctor to provide information about why you are taking a medication to determine how it may be covered by your plan. RS Refill and Save Program 4 Save money on your copayment when you refill your prescription on time as prescribed. Program eligibility may vary. SP ST SL Specialty Medication 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) Requires you to try one or more other medications before the medication you are requesting may be covered. Supply Limits Specifies the largest quantity of medication covered per copayment or in a defined period of time. 3. Depending on your benefit, you may have notification or medical necessity requirements for select medications. 4. Not applicable to Oxford plans. 7

8 Questions For the most current list of covered medications or if you have questions: Call the toll-free member phone number on your health plan ID card. Visit your plan s member website listed on your health plan ID card to: View your pharmacy benefit and coverage information, including prescription history View medication interactions and side effects Locate a participating retail pharmacy by ZIP code Look up possible lower-cost medication alternatives 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 Compare medication pricing and options 8

9 Name Anti-Infectives: Antibiotics Amoxicillin Capsule, Chewable Amoxicillin/Potassium Clavulanate Chewable, Azithromycin Cefadroxil Capsule, Cefdinir Capsule Cefixime Suspension Cefprozil Cefuroxime Cephalexin Capsule Ciprodex 3 Ciprofloxacin Clarithromycin Clindamycin Capsule Name Anti-Infectives: Antifungals Cresemba 3 SL Econazole Cream SL Fluconazole Itraconazole Capsule SL Ketoconazole Cream SL Noxafil, Suspension 2 Nystatin Cream, Ointment Terbinafine SL Anti-Infectives: Antivirals Acyclovir Ointment PA, SL, ST Acyclovir Famciclovir Oseltamivir Capsule, Suspension SL Valacyclovir SL Dificid 3 SL Doxycycline Capsule, Levofloxacin Minocycline Capsule Moxifloxacin Nitrofurantoin Capsule Nitrofurantoin Macrocrystal Capsule Ofloxacin Otic Solution Ofloxacin Penicillin V Potassium Sulfamethoxazole-Trimethoprim Suprax Capsule, Chewable, 3 Valganciclovir SL Cancer Alunbrig 2 PA, SL, SP Bexarotene Capsule 3 SP Bicalutamide Bosulif 2 PA, SL, SP, ST Braftovi 3 PA, SL, SP Calquence 2 PA, SL, SP Cyclophosphamide Capsule Erleada 3 PA, SL, SP Calquence 2 PA, SL, SP Ibrance 2 PA, SL, SP Idhifa 2 PA, SL, SP Imantinib PA, SL, SP Imbruvica 2 PA, SL, SP Bold type = Brand-name drug [Plain type = Generic drug] H = May be part of health care reform preventive H-PA = May be part of health care reform preventive with prior authorization PA = Prior authorization required 9 RS = May be eligible for the refill and save program SL = Supply limit SP = Specialty medication ST = Step therapy

10 Name Name Leucovorin Calcium Bystolic 2 Mektovi 3 PA, SL, SP Mercaptopurine Nerlynx 2 PA, SL, SP Revlimid 2 PA, SL, SP Rydapt 2 PA, SL, SP Sutent 2 PA, SL, SP Targretin Capsule SP Targretin Gel 3 SL Tasigna 2 PA, SL, SP, ST Verzenio 2 PA, SL, SP Xeloda SL, SP Zykadia 2 PA, SL, SP Zytiga 2 PA, SL, SP Cardiovascular/Heart Disease: Coagulation Therapy Bevyxxa 3 SL Brilinta 3 SL Clopidogrel Eliquis 3 SL Enoxaparin Sodium SL Pradaxa 2 SL Prasugrel SL Savaysa 3 SL Warfarin Sodium Xarelto 2 SL Cardiovascular/Heart Disease: High Blood Pressure Amlodipine Amlodipine-Benazepril Amlodipine-Valsartan Atenolol Atenolol-Chlorthalidone Benazepril Benazepril-Hydrochlorothiazide Bidil 2 Bisoprolol Bisoprolol-Hydrochlorothiazide Byvalson 2 SL Cartia XT Carvedilol Immediate-Release Chlorthalidone Clonidine Diltiazem 24 Hour CD Diltiazem Sustained-Release Capsule Diltiazem Sustained-Release Doxazosin Edarbi 3 SL Edarbyclor 3 SL Enalapril Furosemide Guanfacine Hydralazine Hydrochlorothiazide Irbesartan Labetalol Lisinopril Lisinopril-Hydrochlorothiazide Losartan Losartan-Hydrochlorothiazide Metoprolol Succinate Extended- Release Metoprolol Tartrate 25, 50, 00 mg Nadolol Nifedipine Extended-Release Olmesartan SL Olmesartan-Hydrochlorothiazide SL Propranolol Extended-Release Capsule Propranolol Quinapril Ramipril 0

11 Name Name Spironolactone Cardiovascular/Heart Disease: Other Telmisartan Amiodarone Telmisartan-Hydrochlorothiazide Terazosin Triamterene-Hydrochlorothiazide Valsartan Valsartan-Hydrochlorothiazide Verapamil Verapamil Sustained-Release Cardiovascular/Heart Disease: High Cholesterol Atorvastatin H-PA, SL Colesevelam Packet for Suspension, 3 (generic Welchol) Ezetimibe SL Ezetimibe/Simvastatin SL Fenofibrate 54, 60 mg Fluvastatin Extended-Release SL, ST Gemfibrozil Lovastatin H Niacin Extended-Release Niaspan 3 Omega-3-Acid Ethyl Esters Capsule PA Praluent 2 PA, SL, SP, ST Pravastatin Repatha 3 PA, SL, SP, ST Rosuvastatin SL Simvastatin H-PA Vascepa 3 PA Welchol Packet for Suspension, Corlanor 3 PA, SL Digoxin Entresto 3 PA, SL Flecainide Isosorbide Mononitrate ER Multaq 3 PA Nitroglycerin Sublingual Ranexa 2 Sotalol Central Nervous System: Attention Deficit Disorder Adderall XR PA, SL Amphetamine Salt Combo PA Atomoxetine SL Concerta PA, SL Dexmethylphenidate Immediate- Release PA Dextroamphetamine- Amphetamine Immediate-Release PA Dextroamphetamine Sulfate Immediate-Release PA Guanfacine Extended-Release SL Methylphenidate Chewable PA Methylphenidate Extended- Release Capsule (generic PA, SL Metadate CD, Ritalin LA) Methylphenidate Extended- Release Capsule (Metadate ER, PA, SL generic Ritalin SR) Methylphenidate Extended- Release (generic 3 PA, SL Concerta) Methylphenidate Immediate- Release PA Vyvanse 2 PA, SL Bold type = Brand-name drug [Plain type = Generic drug] H = May be part of health care reform preventive H-PA = May be part of health care reform preventive with prior authorization PA = Prior authorization required RS = May be eligible for the refill and save program SL = Supply limit SP = Specialty medication ST = Step therapy

12 Name Central Nervous System: Depression Name Central Nervous System: Multiple Sclerosis Amitriptyline Bupropion Extended-Release Bupropion Sustained-Release Bupropion Citalopram Desvenlafaxine Extended- Release (generic Pristiq) SL Doxepin Duloxetine Capsule SL Escitalopram Fetzima 3 SL, ST Fluoxetine Capsule (generic Prozac) Fluvoxamine Mirtazapine Nortriptyline Capsule Paroxetine Sertraline Trazodone Trintellix 3 SL, ST Venlafaxine Extended-Release Capsule Venlafaxine Viibryd 3 SL Central Nervous System: Migraine Acetaminophen/Butalbital/ Caffeine 325 mg/50 mg/40 mg SL Eletriptan SL Frovatriptan SL Naratriptan SL Rizatriptan ODT, SL Sumatriptan Nasal Spray SL Sumatriptan Succinate, Injection SL Ampyra 2 PA, SL, SP Aubagio 3 PA, SL, SP Avonex 2 PA, SL, SP Betaseron 2 PA, SL, SP Gilenya 3 PA, SL, SP Glatiramer (generic Copaxone) [Mylan version only] PA, SL, SP Plegridy 3 PA, SL, SP Rebif 3 PA, SL, SP, ST Tecfidera 2 PA, SL, SP Central Nervous System: Other Alprazolam Extended-Release Alprazolam Aripiprazole SL Armodafinil PA, SL Austedo 2 PA, SL, SP Buprenorphine Sublingual Buspirone Carbidopa-Levodopa Diazepam Donepezil ODT, 5, 0 mg Latuda 3 SL Lithium Capsule Lorazepam Memantine Immediate-Release Modafinil PA, SL Naloxone Vial Narcan Nasal Spray 2 SL Olanzapine SL Pramipexole Quetiapine Extended-Release SL 2

13 Name Quetiapine Immediate-Release Risperidone Ropinirole Suboxone Film 3 PA, SL Tolcapone Xyrem 3 PA, SL Zelapar 3 Ziprasidone Capsule SL Zubsolv SL Central Nervous System: Sedatives/Hypnotics Eszopiclone SL Temazepam Capsule Triazolam Zaleplon Capsule SL Zolpidem Immediate-Release SL Central Nervous System: Seizure Disorders Carbamazepine Extended- Release Capsule, Carbamazepine Immediate- Release Clonazepam Diazepam Divalproex Delayed-Release Divalproex Extended-Release Gabapentin Capsule, Lamotrigine Immediate-Release Levetiracetam Extended-Release Levetiracetam Immediate-Release Lyrica 3 SL, ST Name Lyrica CR 3 SL, ST Oxcarbazepine Phenytoin Capsule, Suspension Topiramate Immediate-Release Zonisamide Capsule Dermatology Aczone SL Betamethasone Dipropionate 0.05% Augmented Lotion, Ointment Betamethasone Dipropionate 0.05% Cream, Ointment Calcipotriene/Betamethasone Ointment SL Carac 2 Ciclopirox Cream, Gel, Lotion, Solution Claravis PA Clindamycin.2%/Benzoyl Peroxide 5% Gel SL Clindamycin Gel SL Clindamycin Lotion, Swabs Clindamycin Solution SL Clobetasol Propionate Cream, Ointment, Solution SL Clotrimazole-Betamethasone Cream SL Clotrimazole-Betamethasone Lotion Dapsone 5% Gel 3 SL Desonide 0.05% Cream, Lotion, Ointment SL Desoximetasone Cream, Gel, Ointment SL Diflorasone Diacetate 0.05% Cream, Ointment SL Dupixent 3 PA, SL, SP, ST Bold type = Brand-name drug [Plain type = Generic drug] H = May be part of health care reform preventive H-PA = May be part of health care reform preventive with prior authorization PA = Prior authorization required 3 RS = May be eligible for the refill and save program SL = Supply limit SP = Specialty medication ST = Step therapy

14 Name Elidel 3 SL, ST Enstilar Foam 3 SL Eucrisa 3 SL, ST Finacea 3 Fluocinonide 0.05% Cream Fluocinolone Cream, Oil, Ointment, Solution SL Fluorouracil 0.5% Cream 3 SL Halobetasol Ointment SL Hydrocortisone 2.5% Cream, Ointment Imiquimod 5% Cream SL Metronidazole 0.75% Topical Gel Minocycline Extended-Release (generic Solodyn) PA Mirvaso 3 SL Mometasone Furoate Cream, Lotion, Ointment Mupirocin Ointment SL Oracea 3 Oxsoralen-Ultra 2 Picato 3 SL Regranex 2 PA, SL Rhofade 3 PA, SL Taclonex Suspension 3 SL Tacrolimus Ointment SL, ST Tazarotene 0.% Cream (generic Tazorac) 3 PA, SL Tazorac 0.% Cream PA, SL Tazorac Gel, 0.05% Cream 3 PA, SL Tretinoin Cream PA, SL Triamcinolone Acetonide Cream, Lotion, Ointment Vectical 3 SL Name Diabetes: Blood Glucose Monitoring 5 Accu-Chek Test Strips 3 SL Contour Next EZ Meter 2 Contour Next Meter 2 Contour Next One Meter 2 Contour Next Test Strips 2 SL Contour Test Strips 3 SL FreeStyle Test Strips 3 SL OneTouch Ultra 2 Meter OneTouch Ultra Test Strips SL OneTouch UltraMini Meter OneTouch Verio Flex Meter OneTouch Verio IQ Meter OneTouch Verio Meter OneTouch Verio Sync Meter OneTouch Verio Test Strips SL 5 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. Diabetes: Insulin 5 Admelog SoloStar, Vials 3 SL Apidra SoloStar, Vials 3 SL Basaglar SL Fiasp FlexTouch, Vials 3 SL Humalog KwikPens (all formulations) 2 SL Humalog Vials (all formulations) SL Humulin KwikPens (all formulations) 2 SL Humulin Vials (all formulations) SL Lantus SoloStar 3 SL Lantus Vials 3 SL 4

15 Name Levemir FlexTouch, Vials 3 SL Novolin Vials (all formulations) 3 SL Novolog FlexPen, Vials 3 SL (all formulations) Tresiba FlexTouch 2 SL 5 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. Diabetes: Non-Insulin 5 Adlyxin 3 SL Bydureon, Bydureon Bcise 2 SL Byetta 2 SL Farxiga 3 SL, ST Glimepiride Glipizide Glipizide Extended-Release Glyburide Glyxambi 2 SL, ST Invokamet, Invokamet XR 2 SL Invokana 2 SL, ST Janumet 3 SL, ST Januvia 3 SL, ST Jardiance 2 SL, ST Jentadueto, Jentadueto XR 2 SL Kazano 2 SL Kombiglyze XR 2 SL Metformin Metformin Extended-Release (generic Glucophage XR) Name Nesina 2 SL Onglyza 2 SL Oseni 2 SL Ozempic 3 SL Pioglitazone SL Qtern 3 SL, ST Segluromet 3 SL, ST Soliqua 2 PA, SL Steglatro 3 SL, ST Steglujan 3 SL, ST Synjardy, Synjardy XR 2 SL Tradjenta 2 SL Trulicity 3 SL Victoza 2-Pak 2 SL Victoza 3-Pak 3 SL Xigduo XR 3 SL, ST 5 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. Endocrine: Growth Hormone 6 Nutropin, Nutropin AQ 2 PA, SL, SP 6 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. Bold type = Brand-name drug [Plain type = Generic drug] H = May be part of health care reform preventive H-PA = May be part of health care reform preventive with prior authorization PA = Prior authorization required 5 RS = May be eligible for the refill and save program SL = Supply limit SP = Specialty medication ST = Step therapy

16 Name Name Endocrine: Other Eye Conditions: Glaucoma Calcitriol Capsule Desmopressin Dexamethasone Methylprednisolone Prenisolone Oral Solution Prednisone Endocrine: Thyroid Hormone Replacement Armour Thyroid 3 Levothyroxine Sodium Liothyronine Sodium Methimazole NP Thyroid Synthroid 2 Eye Conditions: Allergies Azelastine 0.05% Ophthalmic Solution Lastacaft 3 SL Olopatadine 0.% Ophthalmic Solution SL Eye Conditions: Antibiotics Erythromycin 0.5% Ophthalmic Ointment Gentamicin Ophthalmic Ointment, Solution Moxeza 3 Moxifloxacin Ophthalmic Solution Ofloxacin 0.3% Ophthalmic Solution Tobramycin/Dexamethasone 0.3%-0.% Ophthalmic Suspension Tobramycin Ophthalmic Solution Eye Conditions: Dry Eye Disease Restasis Single Use Vial 3 PA, SL Xiidra 3 PA, SL Alphagan P 0.% 2 SL Azopt 2 SL Combigan 2 SL Latanoprost 0.005% Ophthalmic Solution Lumigan 2 SL Timolol 0.25%, 0.5% Ophthalmic Solution Travatan Z 2 SL Gastrointestinal: Acid Suppression Dexilant 3 SL Omeclamox-Pak 3 SL Omeprazole Capsule Pantoprazole Pylera 3 SL Rabeprazole SL Ranitadine Syrup Sucralfate Gastrointestinal: Nausea/Vomiting Akynzeo 3 SL Aprepitant Capsule SL Emend Suspension 2 SL Ondansetron Ondansetron ODT Scopolamine Transdermal Patch Varubi 2 SL Gastrointestinal: Other Amitiza 3 PA, SL, ST Apriso 2 Budesonide Extended-Release (generic Uceris) 3 Canasa 2 Clenpiq 3 Cortifoam 2 Creon 2 6

17 Name Diphenoxylate-Atropine Golytely 2 Hyoscyamine Lialda Linzess 2 PA, SL Mesalmine Delayed-Release (generic Lialda) 3 Metoclopramide Movantik 3 PA, SL Moviprep 3 Polyethylene Glycol 3350 Prepopik 3 Sulfasalazine Suprep 3 Symproic 2 PA, SL Uceris Foam 2 Uceris Viberzi 3 PA, SL Zenpep 2 Gout Allopurinol Duzallo 3 PA, SL Mitigare 2 Uloric 3 SL, ST Zurampic 3 PA, SL Hepatitis C Daklinza 3 PA, SL, SP, ST Epclusa 2 PA, SL, SP Harvoni 2 PA, SL, SP Mavyret 2 PA, SL, SP Ribavirin SP Name Sovaldi 3 PA, SL, SP, ST Technivie 3 PA, SL, SP, ST Viekira Pak 3 PA, SL, SP, ST Viekira XR 3 PA, SL, SP, ST Vosevi 2 PA, SL, SP Zepatier 3 PA, SL, SP, ST HIV/AIDS Abacavir-Lamivudine SP Atazanavir Capsule SP Atripla 3 SP Cimduo 2 SP Complera 3 SP Descovy 3 SP Efavirenz SP Evotaz 2 SP Genvoya 3 SP Intelence 2 SP Isentress 2 SP Juluca 2 SP Kaletra 2 SP Lamivudine-Zidovudine SP Lopinavir-Ritonavir Oral Solution SP Nevirapine SP Nevirapine Extended-Release SP Odefsey 3 SP Prezcobix 2 SP Prezista 2 SP Ritonavir SP Selzentry 2 PA, SP Stribild 3 SP Bold type = Brand-name drug [Plain type = Generic drug] H = May be part of health care reform preventive H-PA = May be part of health care reform preventive with prior authorization PA = Prior authorization required 7 RS = May be eligible for the refill and save program SL = Supply limit SP = Specialty medication ST = Step therapy

18 Name Symfi 2 SP Symfi Lo 2 SP Tenofovir SP Tivicay 3 SP Triumeq 2 SP Truvada 3 SP Tybost 2 SP Vitekta 2 SP Infertility 6 Cetrotide 2 PA, SP Clomiphene PA Endometrin 2 PA Gonal-F 2 PA, SP Gonal-F RFF 2 PA, SP Ovidrel 3 PA, SP 6 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. Inflammatory Conditions: Rheumatoid Arthritis, Crohn s Disease, Psoriasis, Ulcerative Colitis Actemra 3 PA, SL, SP, ST Cimzia 2 PA, SL, SP Cosentyx 3 PA, SL, SP, ST Enbrel 3 PA, SL, SP, ST Humira 2 PA, SL, SP Hydroxychloroquine Sulfate Kevzara 3 PA, SL, SP, ST Leflunomide Methotrexate Orencia 3 PA, SL, SP, ST Otezla 2 PA, SL, SP Rasuvo 3 SL, ST Siliq 3 PA, SL, SP, ST Name Simponi 2 PA, SL, SP Stelara 2 PA, SL, SP Taltz 3 PA, SL, SP, ST Tremfya 2 PA, SL, SP Xeljanz, Xeljanz XR 3 PA, SL, SP, ST Medications for Sexual Dysfunction 6 Addyi 3 PA, SL Cialis 3 SL Intrarosa 3 SL Levitra 3 SL Osphena 3 SL Sildenafil (generic Viagra) SL Stendra 3 PA, SL 6 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. Men s Health: Prostate Alfuzosin Doxazosin Dutasteride Capsule Finasteride Rapaflo 3 Tamsulosin Capsule Terazosin Capsule, Men s Health: Testosterone Therapy Androderm 2 PA, SL Androgel 3 PA, SL Methyltestosterone Capsule Testim PA, SL Testosterone % Topical Gel PA, SL Testosterone Cypionate Injection 8

19 Name Name Miscellaneous Tobi Podhaler 3 PA, SL, SP Anastrozole Aranesp 2 SL, SP Auryxia 3 Bethkis PA, SL, SP Cayston 2 PA, SL, SP Cerdelga 2 PA, SP Chlorhexidine Gluconate Chlorpheniramine/Hydrocodone/ Pseudoephedrine Solution PA, SL Epinephrine (generic EpiPen/ EpiPen-Jr.) 2 SL EpiPen/EpiPen Jr. 3 SL Hydrocodone/Chlorpheniramine Suspension PA, SL Lanthanum Chewable Letrozole Lidocaine Transdermal Patch (generic Lidoderm) PA, SL Nityr 2 PA, SP Nuedexta 2 PA Obredon 3 PA, SL, ST Pegasys 2 PA, SL, SP Phenazopyridine Procrit 2 SL, SP Promethazine/Codeine PA, SL Promethazine/Dextromethorphan Pulmozyme 2 PA, SL, SP Rectiv 3 SL Rezira 3 Sevelamer Syprine PA, SP Trientine (generic Syprine) 3 PA, SP Velphoro 2 Veltassa 3 PA, SL Zarxio 2 SP Musculoskeletal: Muscle Spasms Baclofen Carisoprodol 350 mg Cyclobenzaprine Metaxalone Methocarbamol Tizanidine Musculoskeletal: Osteoporosis Alendronate Sodium Forteo 3 PA, SP Ibandronate SL Raloxifene Risedronate Sodium SL Tymlos 3 PA, SP Musculoskeletal: Pain Relief Acetaminophen/Codeine SL Belbuca 3 PA, SL Celecoxib SL Diclofenac Etodolac Capsule Fentanyl 2, 25, 50, 75, 00 mcg Patch PA, SL, ST Fentanyl Citrate Lozenge PA, SL Hydrocodone/Acetaminophen 5/325, 7.5/325, 0/325 mg SL Hydrocodone/Ibuprofen Bold type = Brand-name drug [Plain type = Generic drug] H = May be part of health care reform preventive H-PA = May be part of health care reform preventive with prior authorization PA = Prior authorization required 9 RS = May be eligible for the refill and save program SL = Supply limit SP = Specialty medication ST = Step therapy

20 Name Hydromorphone Immediate- Release Ibuprofen Indomethacin Capsule Ketorolac Lazanda 3 PA, SL Meloxicam Methadone, Oral Solution, Concentrate Solution PA, SL Morphine Sulfate Extended- Release PA, SL Morphine Sulfate Oral Solution Nabumetone Naproxen Nucynta 3 SL Nucynta ER 3 PA, SL Oxycodone/Acetaminophen 5/325, 7.5/325, 0/325 mg SL Oxycodone Oxycontin 3 PA, SL, ST Sprix 3 Tramadol-Acetaminophen SL Tramadol Immediate-Release Tramadol Sustained-Release SL Trezix SL Vicodin 5/300, 7.5/300, 0/300 mg SL Voltaren Gel 2 Xtampza ER 2 PA, SL Zohydro ER 3 PA, SL, ST Overactive Bladder Dicyclomine Oxybutynin Extended-Release Oxybutynin Toviaz 3 Name Respiratory: Allergies Azelastine 0.% Nasal Spray Fluticasone Nasal Spray SL Zetonna 3 SL Respiratory: Asthma/COPD Advair Diskus/HFA 3 RS, SL Albuterol Nebs Alvesco SL Anoro Ellipta 3 SL Arnuity Ellipta 3 SL Asmanex TwistHaler, HFA SL Bevespi Aerosphere 2 SL Breo Ellipta 3 RS, SL Budesonide Nebs SL Combivent Respimat 3 SL Flovent Diskus/HFA 3 SL Fluticasone/Salmeterol RespiClick (generic AirDuo RespiClick) SL Incruse Ellipta 2 SL Ipratropium-Albuterol Nebs Ipratropium Nebs Montelukast Perforomist 3 SL ProAir HFA/RespiClick 3 SL Proventil HFA 3 SL Pulmicort Flexhaler 3 SL, ST QVAR Redihaler SL Seebri Neohaler 3 SL, ST Serevent Diskus 3 SL Spiriva Handihaler/Respimat 2 SL Striverdi Respimat 2 SL Symbicort 3 RS, SL Trelegy Ellipta 3 RS, SL Tudorza 2 SL Ventolin HFA 2 SL Xopenex HFA 3 SL 20

21 Name Respiratory: Pulmonary Arterial Hypertension Adempas 2 PA, SL, SP Letairis 2 PA, SL, SP Opsumit 2 PA, SL, SP Orenitram 3 PA, SL, SP Sildenafil (generic Revatio) PA, SL, SP Tadalafil (generic Adcirca) PA, SL, SP Tracleer 2 PA, SL, SP Tyvaso 2 PA, SP Uptravi 3 PA, SL, SP Smoking Cessation Bupropion Sustained-Release H-PA Chantix 3 H-PA Nicoderm CQ 3 H-PA Nicorette Gum 3 H-PA Nicorette Lozenge 2 H-PA Nicorette Mini-Lozenge 2 H-PA Nicotine Gum H-PA Nicotine Lozenge H-PA Nicotine Patch H-PA Nicotrol Inhaler 3 H-PA Nicotrol Nasal Spray 3 H-PA Transplant Azathioprine Cyclosporine Modified Capsule SP Mycophenolate Capsule, Suspension SP Mycophenolic Acid SP Sirolimus SP Tacrolimus Capsule SP Name Vitamins/Electrolytes Fluoride Folic Acid Klor-Con M0 Klor-Con M20 Potassium Chloride Potassium Citrate Women s Health: Contraceptives Aftera H Altavera H Alyacen 7/7/7, /35 H Amethia H Amethia Lo H Amethyst H Apri H Aranelle H Ashlyna H Aubra H Aviane H Azurette H Balziva H Bekyree H Blisovi Fe H Blisovi 24 Fe H Briellyn H Camila H Camrese H Camrese Lo H Caziant H Chateal H Bold type = Brand-name drug [Plain type = Generic drug] H = May be part of health care reform preventive H-PA = May be part of health care reform preventive with prior authorization PA = Prior authorization required 2 RS = May be eligible for the refill and save program SL = Supply limit SP = Specialty medication ST = Step therapy

22 Name Cryselle H Cyclafem 7/7/7, /35 H Cyred H Dasetta 7/7/7, /35 H Daysee H Deblitane H Delyla H Desogestrel-Ethinyl Estradiol H Drospirenone-Ethinyl Estradiol H Econtra EZ H Elinest H Ella H, SL Emoquette H Enpresse H Enskyce H Errin H Estarylla H Fallback H Falmina H Gianvi H Gildagia H Heather H Introvale H Isibloom H Jencycla H Jolessa H Jolivette H Juleber H Junel H Junel 24 Fe H Junel Fe H Kariva H Kelnor /35 H Kimidess H Name Kurvelo H Larin H Larin 24 Fe H Larin Fe H Larissia H Leena H Lessina H Levonest H Levonorgestrel.5 mg H Levonorgestrel-Ethinyl Estradiol H Levora-28 H Lillow H Lo Loestrin Fe 3 LoMedia 24 Fe H Loryna H Low-Ogestrel H Lutera H Lyza H Marlissa H Medroxyprogesterone Acetate H Microgestin H Microgestin Fe H Mono-Linyah H Mononessa H My Choice H My Way H Myzilra H Natazia 2 Necon 7/7/7, 0.5/35, /35, /50, 0/ H Next Choice One Dose H Nikki H Nora BE H Norethindrone 0.35 mg H 22

23 Name Norethindrone-Ethinyl Estradiol- Ferrous Fumarate H Norgestimate-Ethinyl Estradiol H Norlyda H Norlyroc H Nortrel 7/7/7, 0.5/35, /35 H Nuvaring 2 H Ocella H Ogestrel H Opcicon One Step H Option 2 H Orsythia H Philith H Pimtrea H Pirmella 7/7/7, /35 H Plan B One Step H Portia H Previfem H Quasense H Reclipsen H Setlakin H Sharobel H Solia H Sprintec H Sronyx H Syeda H Take Action H Tarina Fe H Tilia Fe H Tri Femynor H Tri-Estarylla H Name Tri-Legest Fe H Tri-Linyah H Tri-Lo-Estarylla H Tri-Lo-Marzia H Tri-Lo-Sprintec H Tri-Previfem H Tri-Sprintec H Tri-Vylibra H Trinessa H Trinessa Lo H Trivora-28 H Velivet H Vestura H Vienva H Viorele H Vyfemla H Vylibra H Wera H Wymza Fe H Xulane H Yasmin 28 3 Yaz 3 Zarah H Zenchent H Zenchent Fe H Zovia /35E, /50E H Bold type = Brand-name drug [Plain type = Generic drug] H = May be part of health care reform preventive H-PA = May be part of health care reform preventive with prior authorization PA = Prior authorization required 23 RS = May be eligible for the refill and save program SL = Supply limit SP = Specialty medication ST = Step therapy

24 Name Women s Health: Hormone Replacement Climara Pro 3 SL Divigel 3 Duavee 3 SL Estrace Cream Estradiol Cream (generic Estrace) 3 Estradiol/Norethindrone Acetate Estradiol Estradiol Twice-Weekly Transdermal Patch (generic 3 SL Vivelle-Dot) Estradiol Weekly Transdermal Patch (generic Climara) SL Estring 2 SL Estrogen/Methyltestosterone Evamist 2 Medroxyprogesterone Minivelle 3 SL Premarin 3 Premphase 3 Prempro 3 Progesterone Micronized Capsule Vivelle-Dot SL Yuvafem Name Women s Health: Miscellaneous Raloxifene H-PA Tamoxifen H-PA Women s Health: Prenatal Vitamins Brand Prenatal Vitamins 3 24

25 Index A Abacavir-Lamivudine... 7 Accu-Chek Test Strips... 4 Acetaminophen/Butalbital/Caffeine 325 mg/50 mg/40 mg... 2 Acetaminophen/Codeine... 9 Actemra... 8 Acyclovir Ointment... 9 Acyclovir... 9 Aczone... 3 Adcirca... 2 Adderall XR... Addyi... 8 Adempas... 2 Adlyxin... 5 Admelog SoloStar, Vials... 4 Advair Diskus/HFA Aftera... 2 AirDuo RespiClick Akynzeo... 6 Albuterol Nebs Alendronate Sodium... 9 Alfuzosin... 8 Allopurinol... 7 Alphagan P 0.%... 6 Alprazolam Extended-Release... 2 Alprazolam... 2 Altavera... 2 Alunbrig... 9 Alvesco Alyacen 7/7/7, / Amethia... 2 Amethia Lo... 2 Amethyst... 2 Amiodarone... Amitiza... 6 Amitriptyline... 2 Amlodipine... 0 Amlodipine-Benazepril... 0 Amlodipine-Valsartan... 0 Amoxicillin Capsule, Chewable... 9 Amoxicillin/Potassium Clavulanate Chewable,... 9 Amphetamine Salt Combo... Ampyra... 2 Anastrozole... 9 Androderm... 8 Androgel... 8 Anoro Ellipta Apidra SoloStar, Vials... 4 Aprepitant Capsule... 6 Apri... 2 Apriso... 6 Aranelle... 2 Aranesp... 9 Aripiprazole... 2 Armodafinil... 2 Armour Thyroid... 6 Arnuity Ellipta Ashlyna... 2 Asmanex TwistHaler, HFA Atazanavir Capsule... 7 Atenolol... 0 Atenolol-Chlorthalidone... 0 Atomoxetine... Atorvastatin... Atripla... 7 Aubagio... 2 Aubra... 2 Auryxia... 9 Austedo... 2 Aviane... 2 Avonex... 2 Azathioprine... 2 Azelastine 0.05% Ophthalmic Solution... 6 Azelastine 0.% Nasal Spray Azithromycin... 9 Azopt... 6 Azurette... 2 B Baclofen... 9 Balziva... 2 Basaglar... 4 Bekyree... 2 Belbuca... 9 Benazepril... 0 Benazepril-Hydrochlorothiazide... 0 Betamethasone Dipropionate 0.05% Augmented Lotion, Ointment... 3 Betamethasone Dipropionate 0.05% Cream, Ointment... 3 Betaseron... 2 Bethkis... 9 Bevespi Aerosphere Bevyxxa... 0 Bexarotene Capsule... 9 Bicalutamide... 9 Bidil... 0 Bisoprolol... 0 Bisoprolol-Hydrochlorothiazide... 0 Blisovi 24 Fe... 2 Blisovi Fe... 2 Bosulif... 9 Braftovi... 9 Brand Prenatal Vitamins Breo Ellipta Briellyn... 2 Brilinta... 0 Budesonide Extended-Release... 6 Budesonide Nebs Buprenorphine Sublingual... 2 Bupropion Extended-Release... 2 Bupropion Sustained-Release...2, 2 Bupropion... 2 Buspirone... 2 Bydureon, Bydureon Bcise... 5 Byetta... 5 Bystolic... 0 Byvalson... 0 C Calcipotriene/Betamethasone Ointment

26 Calcitriol Capsule... 6 Calquence... 9 Camila... 2 Camrese... 2 Camrese Lo... 2 Canasa... 6 Carac... 3 Carbamazepine Extended-Release Capsule,... 3 Carbamazepine Immediate-Release... 3 Carbidopa-Levodopa... 2 Carisoprodol 350 mg... 9 Cartia XT... 0 Carvedilol Immediate-Release... 0 Cayston... 9 Caziant... 2 Cefadroxil Capsule,... 9 Cefdinir Capsule... 9 Cefixime Suspension... 9 Cefprozil... 9 Cefuroxime... 9 Celecoxib... 9 Cephalexin Capsule... 9 Cerdelga... 9 Cetrotide... 8 Chantix... 2 Chateal... 2 Chlorhexidine Gluconate... 9 Chlorpheniramine/Hydrocodone/ Pseudoephedrine Solution... 9 Chlorthalidone... 0 Cialis... 8 Ciclopirox Cream, Gel, Lotion, Solution... 3 Cimduo... 7 Cimzia... 8 Ciprodex... 9 Ciprofloxacin... 9 Citalopram... 2 Claravis... 3 Clarithromycin... 9 Clenpiq... 6 Climara Climara Pro Clindamycin.2%/Benzoyl Peroxide 5% Gel... 3 Clindamycin Capsule... 9 Clindamycin Gel... 3 Clindamycin Lotion, Swabs... 3 Clindamycin Solution... 3 Clobetasol Propionate Cream, Ointment, Solution... 3 Clomiphene... 8 Clonazepam... 3 Clonidine... 0 Clopidogrel... 0 Clotrimazole-Betamethasone Cream... 3 Clotrimazole-Betamethasone Lotion... 3 Colesevelam Packet for Suspension,... Combigan... 6 Combivent Respimat Complera... 7 Concerta... Contour Next EZ Meter... 4 Contour Next Meter... 4 Contour Next One Meter... 4 Contour Next Test Strips... 4 Contour Test Strips... 4 Copaxone... 2 Corlanor... Cortifoam... 6 Cosentyx... 8 Creon... 6 Cresemba... 9 Cryselle Cyclafem 7/7/7, / Cyclobenzaprine... 9 Cyclophosphamide Capsule... 9 Cyclosporine Modified Capsule... 2 Cyred D Daklinza... 7 Dapsone 5% Gel... 3 Dasetta 7/7/7, / Daysee Deblitane Delyla Descovy... 7 Desmopressin... 6 Desogestrel-Ethinyl Estradiol Desonide 0.05% Cream, Lotion, Ointment... 3 Desoximetasone Cream, Gel, Ointment... 3 Desvenlafaxine Extended-Release... 2 Dexamethasone... 6 Dexilant... 6 Dexmethylphenidate Immediate- Release... Dextroamphetamine Sulfate Immediate-Release... Dextroamphetamine-Amphetamine Immediate-Release... Diazepam...2, 3 Diclofenac... 9 Dicyclomine Dificid... 9 Diflorasone Diacetate 0.05% Cream, Ointment... 3 Digoxin... Diltiazem 24 Hour CD... 0 Diltiazem Sustained-Release Capsule... 0 Diltiazem Sustained-Release... 0 Diphenoxylate-Atropine... 7 Divalproex Delayed-Release... 3 Divalproex Extended-Release... 3 Divigel Donepezil ODT, 5, 0 mg... 2 Doxazosin...0, 8 Doxazosin... 8 Doxepin... 2 Doxycycline Capsule,... 9 Drospirenone-Ethinyl Estradiol Duavee Duloxetine Capsule... 2 Dupixent... 3 Dutasteride Capsule... 8 Duzallo... 7

27 E Econazole Cream... 9 Econtra EZ Edarbi... 0 Edarbyclor... 0 Efavirenz... 7 Eletriptan... 2 Elidel... 4 Elinest Eliquis... 0 Ella Emend Suspension... 6 Emoquette Enalapril... 0 Enbrel... 8 Endometrin... 8 Enoxaparin Sodium... 0 Enpresse Enskyce Enstilar Foam... 4 Entresto... Epclusa... 7 Epinephrine... 9 EpiPen/EpiPen Jr... 9 EpiPen/EpiPen-Jr... 9 Erleada... 9 Errin Erythromycin 0.5% Ophthalmic Ointment... 6 Escitalopram... 2 Estarylla Estrace Estrace Cream Estradiol Cream Estradiol Estradiol Twice-Weekly Transdermal Patch Estradiol Weekly Transdermal Patch Estradiol/Norethindrone Acetate Estring Estrogen/Methyltestosterone Eszopiclone... 3 Etodolac Capsule... 9 Eucrisa... 4 Evamist Evotaz... 7 Ezetimibe... Ezetimibe/Simvastatin... F Fallback Falmina Famciclovir... 9 Farxiga... 5 Fenofibrate 54, 60 mg... Fentanyl 2, 25, 50, 75, 00 mcg Patch... 9 Fentanyl Citrate Lozenge... 9 Fetzima... 2 Fiasp FlexTouch, Vials... 4 Finacea... 4 Finasteride... 8 Flecainide... Flovent Diskus/HFA Fluconazole... 9 Fluocinolone Cream, Oil, Ointment, Solution... 4 Fluocinonide 0.05% Cream... 4 Fluoride... 2 Fluorouracil 0.5% Cream... 4 Fluoxetine Capsule... 2 Fluticasone Nasal Spray Fluticasone/Salmeterol RespiClick Fluvastatin Extended-Release... Fluvoxamine... 2 Folic Acid... 2 Forteo... 9 FreeStyle Test Strips... 4 Frovatriptan... 2 Furosemide... 0 G Gabapentin Capsule,... 3 Gemfibrozil... Gentamicin Ophthalmic Ointment, Solution... 6 Genvoya... 7 Gianvi Gildagia Gilenya... 2 Glatiramer... 2 Glimepiride... 5 Glipizide... 5 Glipizide Extended-Release... 5 Glucophage XR... 5 Glyburide... 5 Glyxambi... 5 Golytely... 7 Gonal-F... 8 Gonal-F RFF... 8 Guanfacine...0, Guanfacine Extended-Release... H Halobetasol Ointment... 4 Harvoni... 7 Heather Humalog KwikPens... 4 Humalog Vials... 4 Humira... 8 Humulin KwikPens... 4 Humulin Vials... 4 Hydralazine... 0 Hydrochlorothiazide... 0 Hydrocodone/Acetaminophen 5/325, 7.5/325, 0/325 mg... 9 Hydrocodone/Chlorpheniramine Suspension... 9 Hydrocodone/Ibuprofen... 9 Hydrocortisone 2.5% Cream, Ointment... 4 Hydromorphone Immediate-Release Hydroxychloroquine Sulfate... 8 Hyoscyamine... 7 I Ibandronate... 9 Ibrance... 9 Ibuprofen... 9, 20 Idhifa... 9 Imantinib... 9 Imbruvica... 9

28 Imiquimod 5% Cream... 4 Incruse Ellipta Indomethacin Capsule Intelence... 7 Intrarosa... 8 Introvale Invokamet, Invokamet XR... 5 Invokana... 5 Ipratropium Nebs Ipratropium-Albuterol Nebs Irbesartan... 0 Isentress... 7 Isibloom Isosorbide Mononitrate ER... Itraconazole Capsule... 9 J Janumet... 5 Januvia... 5 Jardiance... 5 Jencycla Jentadueto, Jentadueto XR... 5 Jolessa Jolivette Juleber Juluca... 7 Junel Junel 24 Fe Junel Fe K Kaletra... 7 Kariva Kazano... 5 Kelnor / Ketoconazole Cream... 9 Ketorolac Kevzara... 8 Kimidess Klor-Con M Klor-Con M Kombiglyze XR... 5 Kurvelo L Labetalol... 0 Lamivudine-Zidovudine... 7 Lamotrigine Immediate-Release... 3 Lanthanum Chewable... 9 Lantus SoloStar... 4 Lantus Vials... 4 Larin Larin 24 Fe Larin Fe Larissia Lastacaft... 6 Latanoprost 0.005% Ophthalmic Solution... 6 Latuda... 2 Lazanda Leena Leflunomide... 8 Lessina Letairis... 2 Letrozole... 9 Leucovorin Calcium... 0 Levemir FlexTouch, Vials... 5 Levetiracetam Extended-Release... 3 Levetiracetam Immediate-Release... 3 Levitra... 8 Levofloxacin... 9 Levonest Levonorgestrel.5 mg Levonorgestrel-Ethinyl Estradiol Levora Levothyroxine Sodium... 6 Lialda... 7 Lidocaine Transdermal Patch... 9 Lidoderm... 9 Lillow Linzess... 7 Liothyronine Sodium... 6 Lisinopril... 0 Lisinopril-Hydrochlorothiazide... 0 Lithium Capsule... 2 Lo Loestrin Fe LoMedia 24 Fe Lopinavir-Ritonavir Oral Solution... 7 Lorazepam... 2 Loryna Losartan... 0 Losartan-Hydrochlorothiazide... 0 Lovastatin... Low-Ogestrel Lumigan... 6 Lutera Lyrica... 3 Lyrica CR... 3 Lyza M Marlissa Mavyret... 7 Medroxyprogesterone... 22, 24 Medroxyprogesterone Acetate Mektovi... 0 Meloxicam Memantine Immediate-Release... 2 Mercaptopurine... 0 Mesalmine Delayed-Release... 7 Metadate CD... Metadate ER... Metaxalone... 9 Metformin... 5 Metformin Extended-Release... 5 Methadone, Oral Solution, Concentrate Solution Methimazole... 6 Methocarbamol... 9 Methotrexate... 8 Methylphenidate Chewable.. Methylphenidate Extended-Release Capsule... Methylphenidate Extended-Release... Methylphenidate Immediate-Release... Methylprednisolone... 6 Methyltestosterone Capsule... 8 Metoclopramide... 7 Metoprolol Succinate Extended- Release... 0 Metoprolol Tartrate 25, 50, 00 mg... 0

29 Metronidazole 0.75% Topical Gel... 4 Microgestin Microgestin Fe Minivelle Minocycline Capsule... 9 Minocycline Extended-Release... 4 Mirtazapine... 2 Mirvaso... 4 Mitigare... 7 Modafinil... 2 Mometasone Furoate Cream, Lotion, Ointment... 4 Mono-Linyah Mononessa Montelukast Morphine Sulfate Extended-Release Morphine Sulfate Oral Solution Movantik... 7 Moviprep... 7 Moxeza... 6 Moxifloxacin Ophthalmic Solution.. 6 Moxifloxacin... 9 Multaq... Mupirocin Ointment... 4 My Choice My Way Mycophenolate Capsule, Suspension... 2 Mycophenolic Acid... 2 Myzilra N Nabumetone Nadolol... 0 Naloxone Vial... 2 Naproxen Naratriptan... 2 Narcan Nasal Spray... 2 Natazia Necon 7/7/7, 0.5/35, /35, /50, 0/ Nerlynx... 0 Nesina... 5 Nevirapine... 7 Nevirapine Extended-Release... 7 Next Choice One Dose Niacin Extended-Release... Niaspan... Nicoderm CQ... 2 Nicorette Gum... 2 Nicorette Lozenge... 2 Nicorette Mini-Lozenge... 2 Nicotine Gum... 2 Nicotine Lozenge... 2 Nicotine Patch... 2 Nicotrol Inhaler... 2 Nicotrol Nasal Spray... 2 Nifedipine Extended-Release... 0 Nikki Nitrofurantoin Capsule... 9 Nitrofurantoin Macrocrystal Capsule... 9 Nitroglycerin Sublingual... Nityr... 9 Nora BE Norethindrone 0.35 mg Norethindrone-Ethinyl Estradiol- Ferrous Fumarate Norgestimate-Ethinyl Estradiol Norlyda Norlyroc Nortrel 7/7/7, 0.5/35, / Nortriptyline Capsule... 2 Novolin Vials... 5 Novolog FlexPen, Vials... 5 Noxafil, Suspension... 9 NP Thyroid... 6 Nucynta Nucynta ER Nuedexta... 9 Nutropin, Nutropin AQ... 5 Nuvaring Nystatin Cream, Ointment... 9 O Obredon... 9 Ocella Odefsey... 7 Ofloxacin 0.3% Ophthalmic Solution... 6 Ofloxacin Otic Solution... 9 Ofloxacin... 9 Ogestrel Olanzapine... 2 Olmesartan... 0 Olmesartan-Hydrochlorothiazide... 0 Olopatadine 0.% Ophthalmic Solution... 6 Omeclamox-Pak... 6 Omega-3-Acid Ethyl Esters Capsule... Omeprazole Capsule... 6 Ondansetron... 6 Ondansetron ODT... 6 OneTouch Ultra 2 Meter... 4 OneTouch Ultra Test Strips... 4 OneTouch UltraMini Meter... 4 OneTouch Verio Flex Meter... 4 OneTouch Verio IQ Meter... 4 OneTouch Verio Meter... 4 OneTouch Verio Sync Meter... 4 OneTouch Verio Test Strips... 4 Onglyza... 5 Opcicon One Step Opsumit... 2 Option Oracea... 4 Orencia... 8 Orenitram... 2 Orsythia Oseltamivir Capsule, Suspension... 9 Oseni... 5 Osphena... 8 Otezla... 8 Ovidrel... 8 Oxcarbazepine... 3 Oxsoralen-Ultra... 4 Oxybutynin Extended-Release Oxybutynin Oxycodone Oxycodone/Acetaminophen 5/325, 7.5/325, 0/325 mg Oxycontin Ozempic... 5 P Pantoprazole... 6 Paroxetine... 2 Pegasys... 9

30 Penicillin V Potassium... 9 Perforomist Phenazopyridine... 9 Phenytoin Capsule, Suspension... 3 Philith Picato... 4 Pimtrea Pioglitazone... 5 Pirmella 7/7/7, / Plan B One Step Plegridy... 2 Polyethylene Glycol Portia Potassium Chloride... 2 Potassium Citrate... 2 Pradaxa... 0 Praluent... Pramipexole... 2 Prasugrel... 0 Pravastatin... Prednisone... 6 Premarin Premphase Prempro Prenisolone Oral Solution... 6 Prepopik... 7 Previfem Prezcobix... 7 Prezista... 7 Pristiq... 2 ProAir HFA/RespiClick Procrit... 9 Progesterone Micronized Capsule Promethazine/Codeine... 9 Promethazine/Dextromethorphan.. 9 Propranolol Extended-Release Capsule... 0 Propranolol... 0 Proventil HFA Prozac... 2 Pulmicort Flexhaler Pulmozyme... 9 Pylera... 6 Q Qtern... 5 Quasense Quetiapine Extended-Release... 2 Quetiapine Immediate-Release... 3 Quinapril... 0 QVAR Redihaler R Rabeprazole... 6 Raloxifene... 9, 24 Raloxifene... 9 Ramipril... 0 Ranexa... Ranitadine Syrup... 6 Rapaflo... 8 Rasuvo... 8 Rebif... 2 Reclipsen Rectiv... 9 Regranex... 4 Repatha... Restasis Single Use Vial... 6 Revatio... 2 Revlimid... 0 Rezira... 9 Rhofade... 4 Ribavirin... 7 Risedronate Sodium... 9 Risperidone... 3 Ritalin LA... Ritalin SR... Ritonavir... 7 Rizatriptan ODT,... 2 Ropinirole... 3 Rosuvastatin... Rydapt... 0 S Savaysa... 0 Scopolamine Transdermal Patch... 6 Seebri Neohaler Segluromet... 5 Selzentry... 7 Serevent Diskus Sertraline Setlakin Sevelamer... 9 Sharobel Sildenafil... 8, 2 Siliq... 8 Simponi... 8 Simvastatin... Sirolimus... 2 Solia Soliqua... 5 Solodyn... 4 Sotalol... Sovaldi... 7 Spiriva Handihaler/Respimat Spironolactone... Sprintec Sprix Sronyx Steglatro... 5 Steglujan... 5 Stelara... 8 Stendra... 8 Stribild... 7 Striverdi Respimat Suboxone Film... 3 Sucralfate... 6 Sulfamethoxazole-Trimethoprim... 9 Sulfasalazine... 7 Sumatriptan Nasal Spray... 2 Sumatriptan Succinate, Injection... 2 Suprax Capsule, Chewable,... 9 Suprep... 7 Sutent... 0 Syeda Symbicort Symfi... 8 Symfi Lo... 8 Symproic... 7 Synjardy, Synjardy XR... 5 Synthroid... 6 Syprine... 9 T Taclonex Suspension... 4

31 Tacrolimus Capsule... 2 Tacrolimus Ointment... 4 Tadalafil... 2 Take Action Taltz... 8 Tamoxifen Tamsulosin Capsule... 8 Targretin Capsule... 0 Targretin Gel... 0 Tarina Fe Tasigna... 0 Tazarotene 0.% Cream... 4 Tazorac... 4 Tazorac 0.% Cream... 4 Tazorac Gel, 0.05% Cream... 4 Tecfidera... 2 Technivie... 7 Telmisartan... Telmisartan-Hydrochlorothiazide... Temazepam Capsule... 3 Tenofovir... 8 Terazosin..., 8 Terazosin Capsule,... 8 Terbinafine... 9 Testim... 8 Testosterone % Topical Gel... 8 Testosterone Cypionate Injection... 8 Tilia Fe Timolol 0.25%, 0.5% Ophthalmic Solution... 6 Tivicay... 8 Tizanidine... 9 Tobi Podhaler... 9 Tobramycin Ophthalmic Solution... 6 Tobramycin/Dexamethasone 0.3%- 0.% Ophthalmic Suspension... 6 Tolcapone... 3 Topiramate Immediate-Release... 3 Toviaz Tracleer... 2 Tradjenta... 5 Tramadol Immediate-Release Tramadol Sustained-Release Tramadol-Acetaminophen Travatan Z... 6 Trazodone... 2 Trelegy Ellipta Tremfya... 8 Tresiba FlexTouch... 5 Tretinoin Cream... 4 Trezix Tri Femynor Tri-Estarylla Tri-Legest Fe Tri-Linyah Tri-Lo-Estarylla Tri-Lo-Marzia Tri-Lo-Sprintec Tri-Previfem Tri-Sprintec Tri-Vylibra Triamcinolone Acetonide Cream, Lotion, Ointment... 4 Triamterene-Hydrochlorothiazide... Triazolam... 3 Trientine... 9 Trinessa Trinessa Lo Trintellix... 2 Triumeq... 8 Trivora Trulicity... 5 Truvada... 8 Tudorza Tybost... 8 Tymlos... 9 Tyvaso... 2 U Uceris...6, 7 Uceris Foam... 7 Uceris... 7 Uloric... 7 Uptravi... 2 V Valacyclovir... 9 Valganciclovir... 9 Valsartan... Valsartan-Hydrochlorothiazide... Varubi... 6 Vascepa... Vectical... 4 Velivet Velphoro... 9 Veltassa... 9 Venlafaxine Extended-Release Capsule... 2 Venlafaxine... 2 Ventolin HFA Verapamil... Verapamil Sustained-Release... Verzenio... 0 Vestura Viagra... 8 Viberzi... 7 Vicodin 5/300, 7.5/300, 0/300 mg Victoza 2-Pak... 5 Victoza 3-Pak... 5 Viekira Pak... 7 Viekira XR... 7 Vienva Viibryd... 2 Viorele Vitekta... 8 Vivelle-Dot Voltaren Gel Vosevi... 7 Vyfemla Vylibra Vyvanse... W Warfarin Sodium... 0 Welchol... Welchol Packet for Suspension,... Wera Wymza Fe X Xarelto... 0 Xeljanz, Xeljanz XR... 8 Xeloda