Prescription Drug List

Transcription

1 Your 207 Prescription List Effective July, 207 Student Resources Traditional Three- This Prescription List (PDL) outlines the most commonly prescribed medications for certain conditions and organizes them into cost levels, also known as tiers. For additional information: Visiting and clicking on the Login To My Account link for information to help you better understand and manage your medications. View your current benefits Search for drug prices and lower-cost alternatives Potentially save time and money using home delivery through OptumRx Call the toll-free member phone number on your health plan ID card.

2 Table of Contents tiers and cost... 3 Programs and Limits s by category... 8 Anti-Infectives Antibiotics Antifungals... 8 Antivirals... 8 Cancer Cardiovascular/Heart Disease Coagulation Therapy... 9 High Blood Pressure High Cholesterol....0 Other....0 Central Nervous System Attention Deficit Disorder.... Depression... Migraine.... Multiple Sclerosis Other Sedatives/Hypnotics Seizure Disorders... 2 Dermatology Diabetes/Endocrine Blood Glucose Monitoring Insulin Non-Insulin... 4 Endocrine Growth Hormone Other Thyroid Hormone Replacement Eye Conditions Allergies Antibiotics Dry Eye Disease Glaucoma Gastrointestinal Acid Suppression Nausea/Vomiting Other Gout Hepatitis C HIV/AIDS Infertility Inflammatory Conditions: Rheumatoid Arthritis, Crohn s Disease, Psoriasis, Ulcerative Colitis Men s Health Prostate Testosterone Therapy... 8 Miscellaneous Musculoskeletal Muscle Spasms....9 Osteoporosis....9 Pain Relief....9 Overactive Bladder Respiratory Allergies Asthma/COPD Pulmonary Arterial Hypertension....2 Transplant....2 Vitamins/Electrolytes....2 Women s Health Contraceptives....2 Hormone Replacement Miscellaneous Prenatal Vitamins...23 Index....24

3 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. Medications are listed by common categories or class. They are placed into cost levels known as tiers. It includes both brand and generic prescription medications approved by the Food and 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 university or school to see what medications are covered under your plan. You may also log in to and click on Login To My Account link or call the toll-free member phone number on your health plan ID card for more information. How do I use my PDL? When choosing a medication, you and your doctor should consult the PDL. It will help you and your doctor choose the most cost-effective prescription drugs. This guide tells you if a medication is generic or brand, and if special programs apply. Bring this list with you when you see your doctor. It is organized by common medical conditions. Medications are then listed alphabetically. If your medication is not listed in this document, please visit and click on Login To My Account link or call the toll-free member phone number on your health plan ID card. 3

4 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 university or school. 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. $ tier Includes Helpful tips Your lowest cost 2 Your mid-range cost 3 your highest cost Generics and some brands are also included. Mainly preferred brand drugs. Mostly brand 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 and click on Login To My Account link, or call the toll-free number on your health plan ID card for more information about your benefit plan. When does the PDL change? Medications may move to a lower tier at any time. Medications 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 your ID card. 4

5 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 PA SL 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. Prior authorization required* Your doctor is required to provide additional information to us to determine coverage. Supply limit Amount of medication covered per copayment or in a specific time period. *Depending on your benefit, you may have notification or medical necessity requirements for select medications. To learn more about a pharmacy program or to find out if it applies to you, please visit and click on Login To My Account link or call the toll-free member phone number on your health plan ID card. Why are some medications excluded from coverage? A medication may be excluded from coverage under your pharmacy benefit when it works the same or similar as another prescription medication or an over-the-counter (OTC) medication. Other medication options may be available. Should I talk to my doctor about over-the-counter (OTC) medications? An OTC medication may be the right treatment for some conditions. Talk to your doctor about available options. 5

6 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, Invokana) and generic drugs in plain type (for example, Metformin). What if my doctor writes a brand-name prescription? The next time your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lower-cost option is available and if it might be right for you. Generic medications are usually your lowest-cost option, but not always. For some benefit plans, if a brand-name drug is prescribed and a generic equivalent is available, your cost share may be the copay PLUS the cost difference between the brand-name drug and generic equivalent. Visit and click on Login To My Account link to make sure. Are you taking a specialty medication? Specialty medications are high-cost and are used to treat rare or complex conditions that require additional care and support. For most plans, these medications are managed through the Specialty Pharmacy Program. Take advantage of personalized support designed to help you get the most out of your treatment plan. Visit UHCSpecialtyRx.com or call the toll-free phone number on your health plan ID card to learn more. Please note, not all specialty medications are listed here. If you re taking a specialty medication that is on 3, call the toll-free number on your health plan ID card to talk with a pharmacist about finding lower-cost options or a financial assistance program. 6

7 How do I get updated information about my pharmacy benefit? Since the PDL may change during your plan year, we encourage you to visit and click on Login To My Account link or call the toll-free member phone number on your health plan ID card for more current information. Log in to for the following pharmacy information and tools: Pharmacy benefit and coverage information Possible lower-cost medication options Medication interactions and side effects Participating retail pharmacies by ZIP code Your prescription history And, if home delivery services are included in your pharmacy benefit, you can also: Refill prescriptions Check the status of your order Set up reminders for refills Manage your account For more information Call the toll-free member phone number on your health plan ID card Or, visit and click on Login To My Account link 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. 7

8 Name Anti-Infectives: Antibiotics Amoxicillin Capsule, Chewable Amoxicillin/Potassium Clavulanate Chewable, Azithromycin Cefadroxil Capsule, Cefdinir Capsule Cefixime Suspension Cefprozil Cefuroxime Cephalexin Capsule Ciprodex 2 Ciprofloxacin Clarithromycin Clindamycin Capsule Dificid 3 SL Doxycycline Hyclate 50, 00 mg Capsule, Doxycycline Monohydrate 50, 00 mg Capsule Levofloxacin Metronidazole Minocycline Capsule Minocycline E Moxifloxacin Nitrofurantoin Capsule Nitrofurantoin Macrocrystal Capsule Name Ofloxacin Otic Solution Ofloxacin Oracea 3 Penicillin V Potassium Sulfamethoxazole- Trimethoprim Suprax Capsule, Chewable, Anti-Infectives: Antifungals 3 Cresemba 3 SL Econazole Cream SL Fluconazole Itraconazole Capsule SL Ketoconazole Cream Noxafil, Suspension 2 Nystatin Cream, Ointment Terbinafine SL Anti-Infectives: Antivirals Acyclovir Ointment SL Acyclovir Famciclovir Oseltamivir Capsule SL Valacyclovir SL Valganciclovir 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 PA = Prior authorization required SL = Supply limit 8

9 Name Cancer Bexarotene Capsule 3 DSP, E, PA, SL Bicalutamide Bosulif 2 DSP, PA, SL Cyclophosphamide Capsule 2 Hydroxyurea Capsule Imantinib DSP, PA, SL Imbruvica 2 DSP, PA, SL Leucovorin Calcium Mercaptopurine Revlimid 2 DSP, PA, SL Sutent 2 DSP, PA, SL Targretin Capsule DSP Targretin Gel 3 SL Tasigna 2 DSP, PA, SL Xeloda DSP, SL Zytiga 2 DSP, PA, SL Cardiovascular/Heart Disease: Coagulation Therapy Brilinta 3 SL Clopidogrel Effient 3 SL Eliquis 3 SL Enoxaparin Sodium SL Pradaxa 2 SL Savaysa 3 SL Warfarin Sodium Xarelto 2 SL Cardiovascular/Heart Disease: High Blood Pressure Amlodipine Amlodipine-Benazepril Amlodipine-Valsartan Atenolol Atenolol-Chlorthalidone Benazepril Name Benazepril- Hydrochlorothiazide Benicar 3 E, SL Benicar HCT 3 E, SL Bidil 2 Bisoprolol Bisoprolol- Hydrochlorothiazide Bystolic 2 Cartia XT Carvedilol Chlorthalidone Clonidine Diltiazem 24 Hour CD Diltiazem Sustained- Release Capsule Diltiazem Sustained- Release Doxazosin Dutoprol 2 SL Edarbi 3 SL Edarbyclor 3 SL Enalapril Furosemide Guanfacine Hydralazine Hydrochlorothiazide Irbesartan Labetalol Lisinopril Lisinopril- Hydrochlorothiazide Losartan Losartan- Hydrochlorothiazide Metoprolol Succinate 50, 00, 200 mg Metoprolol Tartrate 25, 50, 00 mg 9

10 Name Nadolol Nifedipine Extended-Release Olmesartan SL Olmesartan- Hydrochlorothiazide SL Propranolol Extended- Release Capsule Propranolol Quinapril Ramipril Spironolactone Telmisartan Telmisartan- Hydrochlorothiazide Terazosin Triamterene- Hydrochlorothiazide Valsartan Valsartan- Hydrochlorothiazide Verapamil Verapamil Sustained-Release Cardiovascular/Heart Disease: High Cholesterol Atorvastatin SL Choline Fenofibrate E Ezetimibe SL Fenofibrate 43, 50, 67, 30, 34, 50, 200 mg Capsule Fenofibrate 40, 48, 20, 45 mg Fenofibrate 54, 60 mg E E Name Fluvastatin Extended- Release SL Gemfibrozil Lipofen 3 E Livalo 3 SL Lovastatin Niacin Extended- Release Niaspan 3 Omega-3-Acid Ethyl Esters Capsule Praluent 2 DSP, PA, SL Pravastatin Repatha 40 mg 3 DSP, PA, SL Rosuvastatin SL Simvastatin Vascepa 3 Vytorin 3 SL Welchol 2 Zetia 3 E, SL Cardiovascular/Heart Disease: Other Amiodarone Corlanor 3 SL Digoxin Entresto 3 SL Flecainide Isosorbide Mononitrate ER Multaq 3 Nitroglycerin Sublingual Ranexa 2 Sotalol Bold type = Brand-name drug [Plain type = Generic drug] DSP = Designated specialty program E = May be excluded from coverage PA = Prior authorization required SL = Supply limit 0

11 Name Central Nervous System: Attention Deficit Disorder Adderall XR SL Amphetamine Salt Combo Concerta SL Daytrana 3 E, SL Dexmethylphenidate Extended-Release Capsule Dexmethylphenidate Immediate-Release Dextroamphetamine- Amphetamine Extended-Release Dextroamphetamine- Amphetamine Immediate-Release Capsule Dextroamphetamine Sulfate Immediate- Release E, SL 3 E, SL Focalin XR 3 E, SL Guanfacine Extended-Release SL Metadate CD 3 E, SL Methylphenidate Chewable Methylphenidate Extended-Release Capsule (generic Metadate CD, Ritalin SR) SL Methylphenidate Extended-Release Capsule (Metadate ER) Methylphenidate Extended-Release (generic Concerta) SL 3 E, SL Methylphenidate Strattera 3 SL Vyvanse 2 SL Name Central Nervous System: Depression Amitriptyline Bupropion Extended- Release Bupropion Sustained- Release Bupropion Citalopram Desvenlafaxine Extended-Release SL (generic Pristiq) Doxepin Duloxetine Capsule SL Escitalopram Fetzima 3 SL Fluoxetine, Capsule Fluvoxamine Mirtazapine Nortriptyline Capsule Paroxetine Sertraline Trazodone Trintellix 3 SL Venlafaxine Extended- Release Capsule Venlafaxine Viibryd 3 SL Central Nervous System: Migraine Acetaminophen/ Butalbital/Caffeine SL 325 mg/50 mg/40 mg Frovatriptan SL Naratriptan SL Relpax 2 SL Rizatriptan ODT, SL Sumatriptan Nasal Spray SL Sumatriptan Succinate, Injection SL

12 Name Central Nervous System: Multiple Sclerosis Ampyra 2 DSP, PA, SL Aubagio 3 DSP, PA, SL Avonex 2 DSP, PA, SL Betaseron 2 DSP, PA, SL Copaxone 20 mg DSP, PA, SL Copaxone 40 mg 2 DSP, PA, SL Gilenya 3 DSP, PA, SL Glatopa 3 DSP, E, PA, SL Plegridy 3 DSP, PA, SL Rebif 3 DSP, PA, SL Tecfidera 2 DSP, PA, SL Zinbryta 3 DSP, PA, SL Central Nervous System: Other Alprazolam Extended- Release Alprazolam Aripiprazole SL Armodafanil E, SL Buprenorphine/ Naloxone E, SL Buspirone Carbidopa-Levodopa Diazepam Donepezil ODT, 5, 0 mg Latuda 3 SL Lithium Capsule Lorazepam Memantine Modafinil SL Naloxone Vial Narcan Nasal Spray 2 SL Olanzapine SL Name Pramipexole Quetiapine Extended- SL Release Quetiapine Risperidone Ropinirole Suboxone Film 3 E, 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 Extended- E, SL Release Zolpidem SL Central Nervous System: Seizure Disorders Carbamazepine Extended-Release Capsule, Carbamazepine Immediate-Release Clonazepam Diazepam Divalproex Delayed- Release Divalproex Extended- Release Bold type = Brand-name drug [Plain type = Generic drug] DSP = Designated specialty program E = May be excluded from coverage PA = Prior authorization required SL = Supply limit 2

13 Name Gabapentin Capsule, Lamotrigine Immediate- Release Levetiracetam Extended-Release Levetiracetam Immediate-Release Lyrica 3 SL Oxcarbazepine Phenytoin Capsule, Suspension Topiramate Immediate- Release Zonisamide Capsule Dermatology Aczone 3 SL Adapalene Cream, Gel, Lotion E, PA, SL Betamethasone Dipropionate 0.05% Augmented Lotion, Ointment Betamethasone Dipropionate 0.05% Cream, Ointment Calcipotriene/ Betamethasone SL Ointment Carac 2 Ciclopirox Cream, Gel, Lotion, Solution Claravis Clindamycin %/ Benzoyl Peroxide 5% Gel E, SL Clindamycin.2%/ Benzoyl Peroxide 5% Gel SL Clindamycin Gel SL Name Clindamycin Lotion, Solution, Swabs Clobetasol Propionate Cream, Ointment, SL Solution Clotrimazole- Betamethasone Cream SL Clotrimazole- Betamethasone Lotion Desonide 0.05% Cream, Lotion, Ointment SL Desoximetasone Cream, Gel, Ointment SL Diflorasone Diacetate 0.05% Cream, Ointment SL Enstilar Foam 3 SL Epiduo/Epiduo Forte 3 E, SL Finacea 3 Fluocinonide 0.05% Cream Fluocinolone Cream, Oil, Ointment, Solution SL Halobetasol Ointment Hydrocortisone 2.5% Cream, Ointment Imiquimod 5% Cream SL Metronidazole 0.75% Topical Gel Minocycline Extended- Release Capsule E Mirvaso 3 SL Mometasone Furoate Cream, Lotion, Ointment Mupirocin Ointment SL Nystatin-Triamcinolone Acetonide Cream, E Ointment Oxsoralen-Ultra 2 Picato 3 SL Regranex 2 SL Solodyn 3 E Taclonex Suspension 3 SL 3

14 Name Tacrolimus Ointment SL Tazorac 3 PA, SL Tretinoin Cream PA, SL Tretinoin Gel E, PA, SL Tretinoin Microspheres E, PA, SL Triamcinolone Acetonide Cream, Lotion, Ointment Vectical 3 SL Diabetes: Blood Glucose Monitoring Accu-Chek Test Strips 3 E, SL Contour Test Strips 3 E, SL Dexcom Continuous Glucose Monitoring 3 SL System Dexcom Sensor 3 SL Dexcom Transmitter 3 SL FreeStyle Test Strips 3 E, SL OneTouch Test Strips SL OneTouch Ultra Mini OneTouch Ultra Test Strips SL OneTouch Verio OneTouch Verio Flex OneTouch Verio IQ OneTouch Verio Sync OneTouch Verio Test Strips SL Diabetes: Insulin Afrezza 3 E, SL Basaglar SL Humalog KwikPens (all formulations) 2 SL Name Humalog Vials (all formulations) SL Humulin KwikPens (all formulations) 2 SL Humulin Vials (all formulations) SL Lantus Solostar 3 E, SL Lantus Vials 3 E, SL Levemir FlexTouch 2 SL Levemir Vials 2 SL Novolin Vials (all formulations) 3 SL Novolog FlexTouch (all formulations) 3 SL Novolog Vials (all formulations) 3 SL Soliqua 2 SL Toujeo SoloStar 3 E, SL Tresiba FlexTouch 3 E, SL Diabetes: Non-Insulin Adlyxin 3 SL Bydureon 2 SL Byetta 2 SL Farxiga 3 SL Glimepiride Glipizide Glipizide Extended-Release Glyburide Glyxambi 3 E, SL Invokamet 2 SL Invokamet XR 2 SL Invokana 2 SL Janumet 3 SL Bold type = Brand-name drug [Plain type = Generic drug] DSP = Designated specialty program E = May be excluded from coverage PA = Prior authorization required SL = Supply limit 4

15 Name Januvia 3 SL Jardiance 2 SL Jentadueto 2 SL Jentadueto XR 2 SL Kazano 2 SL Kombiglyze XR 2 SL Metformin Metformin Extended- Release (generic Glucophage XR) Nesina 2 SL Onglyza 2 SL Oseni 2 SL Pioglitazone SL Synjardy 2 SL Tanzeum 2 SL Tradjenta 2 SL Trulicity 3 SL Victoza 2-Pak 2 SL Victoza 3-Pak 3 SL Xigduo XR 3 E, SL Endocrine: Growth Hormone Nutropin, Nutropin AQ Endocrine: Other Calcitriol Capsule Desmopressin Dexamethasone Methylprednisolone Prenisolone Oral Solution Prednisone 2 DSP, PA, SL Name Endocrine: Thyroid Hormone Replacement Armour Thyroid 3 Levothyroxine Sodium Liothyronine Sodium Methimazole NP Thyroid Synthroid 2 Eye Conditions: Allergies Azelastine 0.05% Ophthalmic Solution SL Lastacaft 3 SL Olopatadine 0.% Ophthalmic Solution SL Pataday 3 E, SL Eye Conditions: Antibiotics Erythromycin 0.5% Ophthalmic Ointment Gentamicin Ophthalmic Ointment, Solution Moxeza 3 Ofloxacin 0.3% Ophthalmic Solution Tobramycin/ Dexamethasone 0.3%-0.% Ophthalmic Suspension Tobramycin Ophthalmic Solution Vigamox 3 5

16 Name Name Eye Conditions: Dry Eye Disease Restasis Single Use Vial 3 SL Xiidra 3 SL Eye Conditions: Glaucoma Alphagan P 0.% 2 SL Azopt 2 SL Combigan 2 SL Latanoprost 0.005% Ophthalmic Solution Lumigan 2 SL Timolol Maleate 0.25%, 0.5% Ophthalmic Solution Travatan Z 2 SL Gastrointestinal: Acid Suppression Dexilant 3 SL Esomeprazole Capsule E, SL Lansoprazole Capsule E, 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 Transderm-Scop 3 Varubi 2 SL Gastrointestinal: Other Amitiza 3 SL Apriso 2 Asacol HD 3 E Canasa 2 Cortifoam 2 Creon 2 Delzicol 3 E Diphenoxylate-Atropine Golytely 2 Hyoscyamine Lialda 2 Linzess 2 SL Metoclopramide Movantik 2 SL Moviprep 3 Polyethylene Glycol 3350 Prepopik 3 Suclear 3 Sulfasalazine Suprep 3 Uceris Foam 2 Uceris 3 Viberzi 3 SL Zenpep 2 Bold type = Brand-name drug [Plain type = Generic drug] DSP = Designated specialty program E = May be excluded from coverage PA = Prior authorization required SL = Supply limit 6

17 Name Gout Allopurinol Colcrys 3 E Mitigare 2 Uloric 3 SL Zurampic 3 SL Hepatitis C Daklinza 2 DSP, PA, SL Epclusa 2 DSP, PA, SL Harvoni 2 DSP, PA, SL Ribavirin DSP Sovaldi 2 DSP, PA, SL Technivie 3 DSP, PA, SL Viekira Pak 3 DSP, PA, SL Zepatier 3 DSP, PA, SL HIV/AIDS Abacavir-Lamivudine DSP Atripla 2 DSP Complera 3 DSP Descovy 3 DSP Epzicom 3 DSP, E Evotaz 2 DSP Genvoya 3 DSP Intelence 2 DSP Isentress 2 DSP Kaletra 2 DSP Lamivudine-Zidovudine DSP Lopinavir-Ritonavir Oral Solution DSP Nevirapine DSP Nevirapine Extended-Release DSP, E Norvir 2 DSP Odefsey 3 DSP Prezcobix 2 DSP Prezista 2 DSP Reyataz 2 DSP Name Selzentry 2 DSP, PA Stribild 3 DSP Sustiva 2 DSP Tivicay 3 DSP Triumeq 2 DSP Truvada 3 DSP, PA Tybost 2 DSP Viread 2 DSP Vitekta 2 DSP Infertility* Cetrotide 2 DSP Clomiphene 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, PA, SL Cimzia 2 DSP, PA, SL Cosentyx 3 DSP, PA, SL Enbrel 3 DSP, PA, SL Humira 2 DSP, PA, SL Hydroxychloroquine Sulfate Leflunomide Methotrexate Orencia 3 DSP, PA, SL Otezla 3 DSP, PA, SL Otrexup 3 E, SL Rasuvo 3 SL Simponi 2 DSP, PA, SL Stelara 2 DSP, PA, SL Taltz 3 DSP, PA, SL Xeljanz 3 DSP, PA, SL Xeljanz XR 3 DSP, PA, SL 7

18 Name Men s Health: Prostate Alfuzosin Cialis 3 SL Doxazosin Dutasteride Capsule Finasteride Rapaflo 3 Tamsulosin Capsule Terazosin Capsule, Men s Health: Testosterone Therapy Androderm 2 SL Androgel 3 E, SL Methyltestosterone Capsule Testim 2 SL Testosterone % Topical Gel E, SL Testosterone Cypionate Injection Miscellaneous Anastrozole Antipyrine/Benzocaine Otic Solution Aranesp 2 DSP, SL Auryxia 3 Auvi-Q 3 E, SL Benzonatate Capsule Bethkis DSP, PA, SL Bromfed DM 3 Cayston 2 PA, SL Cerdelga 2 DSP, PA Chlorhexidine Gluconate Name Chlorpheniramine/ Hydrocodone/ Pseudoephedrine Solution Epinephrine (generic SL 2 SL EpiPen/EpiPen-Jr.) EpiPen/EpiPen Jr. 3 E, SL Fosrenol 3 Hydrocodone/ Chlorpheniramine Suspension SL Hydrocodone/ Homatropine Letrozole Lidocaine Transdermal Patch SL Nuedexta 2 Obredon 3 SL Pegasys 2 DSP, PA, SL Phenazopyridine Procrit 2 DSP, SL Promethazine/Codeine Promethazine/ Dextromethorphan Pulmozyme 2 DSP, PA, SL Rectiv 3 SL Renvela 2 Rezira 3 Tobi Podhaler 3 DSP, PA, SL Tobramycin Nebulized DSP, E, PA, SL Solution Velphoro 2 Veltassa 3 SL Zarxio 2 DSP Bold type = Brand-name drug [Plain type = Generic drug] DSP = Designated specialty program E = May be excluded from coverage PA = Prior authorization required SL = Supply limit 8

19 Name Musculoskeletal: Muscle Spasms Baclofen Carisoprodol 350 mg Cyclobenzaprine Metaxalone Methocarbamol Tizanidine Musculoskeletal: Osteoporosis Alendronate Sodium Forteo 2 DSP, PA Ibandronate SL Raloxifene Risedronate Sodium SL Musculoskeletal: Pain Relief Acetaminophen/ Codeine SL Belbuca 3 SL Butrans 3 E, SL Celecoxib SL Diclofenac Embeda 3 E, SL Etodolac Capsule Fentanyl 2, 25, 50, 75, 00 mcg Patch SL Fentanyl 37.5, 62.5, 87.5 mcg Patch E, SL Fentanyl Citrate Lozenge SL Hydrocodone/ Acetaminophen 5/325, 7.5/325, SL 0/325 mg Hydrocodone/Ibuprofen Name Hydromorphone Hysingla 3 E, SL Ibuprofen Indomethacin Capsule Ketorolac Lazanda 3 SL Meloxicam Methadone, Oral Solution, SL Concentrate Solution Morphine Sulfate Extended-Release SL Morphine Sulfate Oral Solution Nabumetone Naproxen Nucynta 3 SL Nucynta ER 3 SL Opana ER 2 SL Oxycodone/ Acetaminophen 5/325, 7.5/325, 0/325 mg SL Oxycodone Oxycontin 3 E, SL Sprix 3 Subsys 3 E, SL Tramadol- Acetaminophen Tramadol Immediate- Release Tramadol Sustained- Release SL Trezix SL Vicodin 5/300, 7.5/300, 0/300 mg E, SL Voltaren Gel 2 Xtampza ER 3 SL Zohydro ER 3 SL 9

20 Name Overactive Bladder Dicyclomine Oxybutynin Extended- Release Oxybutynin Tolterodine Extended- Release E Tolterodine E Toviaz 3 Vesicare 3 E Respiratory: Allergies Azelastine 0.% Nasal Spray Clarinex 3 E Clarinex-D 3 E Cyproheptadine Fluticasone Nasal Spray SL Hydroxyzine Capsule, Levocetirizine Mometasone Nasal Spray E, SL Promethazine Triamcinolone Nasal Spray E, SL Zetonna 3 SL Respiratory: Asthma/COPD Advair Diskus/HFA 3 SL Aerospan 3 SL Albuterol Nebs Albuterol Sulfate Alvesco SL Anoro Ellipta 3 SL Name Arnuity Ellipta 3 SL Asmanex SL Bevespi Aerosphere 2 SL Breo Ellipta 3 SL Budesonide Nebs SL Combivent Respimat 3 SL Dulera 3 SL Flovent Diskus/HFA 3 SL Incruse Ellipta 2 SL Ipratropium-Albuterol Nebs Ipratropium Nebs Levalbuterol Nebs E, SL Montelukast Perforomist 3 SL ProAir HFA 3 SL ProAir RespiClick 3 SL Proventil HFA 3 SL Pulmicort Flexhaler 3 SL QVAR SL Serevent Diskus 3 SL Spiriva Handihaler 3 SL Spiriva Respimat 3 SL Stiolto Respimat 3 E, SL Striverdi Respimat 2 SL Symbicort 3 SL Tudorza 2 SL Ventolin HFA 2 SL Xopenex HFA 3 SL Xopenex Nebs 3 E, SL Bold type = Brand-name drug [Plain type = Generic drug] DSP = Designated specialty program E = May be excluded from coverage PA = Prior authorization required SL = Supply limit 20

21 Name Respiratory: Pulmonary Arterial Hypertension Adcirca 3 DSP, PA, SL Adempas 2 DSP, PA, SL Letairis 2 DSP, PA, SL Opsumit 2 DSP, PA, SL Orenitram 3 DSP, PA, SL Sildenafil DSP, PA, SL Tracleer 2 DSP, PA, SL Tyvaso 2 DSP, PA Uptravi 3 DSP, PA, SL Transplant Azathioprine Cyclosporine Modified Capsule DSP Mycophenolate Capsule, Suspension DSP Mycophenolic Acid DSP Sirolimus DSP Tacrolimus Capsule DSP Vitamins/Electrolytes Fluoride Folic Acid Klor-Con M0 Klor-Con M20 Potassium Chloride Potassium Citrate Women s Health: Contraceptives Aftera Altavera Alyacen 7/7/7, /35 Amethia Amethia Lo Amethyst Apri Aranelle Name Ashlyna Aubra Aviane Azurette Balziva Bekyree Blisovi Fe Blisovi 24 Fe Briellyn Camila Camrese Camrese Lo Caziant Cesia Chateal Cryselle Cyclafem 7/7/7, /35 Cyred Dasetta 7/7/7, /35 Daysee Deblitane Delyla Desogestrel-Ethinyl Estradiol Drospirenone/Ethinyl Estradiol Drospirenone/Ethinyl Estradiol/Levomefolate Calcium E Econtra EZ Elinest Ella SL Emoquette Enpresse Enskyce Errin Estarylla Fallback Falmina Gianvi 2

22 Name Gildagia Gildess Gildess 24 Fe Gildess Fe Heather Introvale Jencycla Jolessa Jolivette Juleber Junel Junel 24 Fe Junel Fe Kariva Kimidess Kurvelo Kelnor /35 Larin Larin 24 Fe Larin Fe Larissia Leena Lessina Levonest Levonorgestrel.5 mg Levonorgestrel-Ethinyl Estradiol Levora-28 Lo Loestrin Fe 3 LoMedia 24 Fe Loryna Low-Ogestrel Lutera Lyza Marlissa Name Medroxyprogesterone Acetate Microgestin Microgestin Fe Minastrin 24 Fe 3 E Mono-Linyah Mononessa My Way Myzilra Natazia Necon 7/7/7, 0.5/35, /35, /50, 0/ Next Choice Nikki Nora BE Norethindrone 0.35 mg Norethindrone-Ethinyl Estradiol-Ferrous Fumarate Norgestimate-Ethinyl Estradiol Norlyroc Nortrel 7/7/7, 0.5/35, /35 Nuvaring 2 Ocella Ogestrel Opcicon Orsythia Ortho Tri-Cyclen Lo 3 E Philith Pimtrea Pirmella 7/7/7, /35 Plan B One Step Portia Bold type = Brand-name drug [Plain type = Generic drug] DSP = Designated specialty program E = May be excluded from coverage PA = Prior authorization required SL = Supply limit 22

23 Name Previfem Quasense Rajani E Reclipsen Setlakin Sharobel Solia Sprintec Sronyx Syeda Take Action Tarina Fe Taytulla 3 E Tilia Fe Tri-Estarylla Tri-Legest Fe Tri-Linyah Tri-Lo-Estarylla Tri-Lo-Marzia Tri-Lo-Sprintec Tri-Previfem Tri-Sprintec Trinessa Trinessa Lo Trivora-28 Velivet Vestura Vienva Viorele Vyfemla Wera Wymza Fe Xulane Yasmin 28 3 Yaz 3 Zarah Zenchent Zenchent Fe Zovia /35E, /50E Name Women s Health: Hormone Replacement Cenestin 3 E Climara 2 SL Climara Pro 3 SL Divigel 3 Duavee 3 Enjuvia 3 Estrace Cream 3 Estradiol/Norethindrone Acetate Estradiol Estradiol Twice-Weekly Transdermal Patch 3 E, SL Estring 2 SL Estrogen/ Methyltestosterone Evamist 2 Medroxyprogesterone Minivelle 3 SL Premarin 3 Premphase 3 Prempro 3 Progesterone Micronized Capsule Vagifem 3 E Vivelle-Dot SL Yuvafem Women s Health: Miscellaneous Addyi 3 SL Osphena 3 Raloxifene Tamoxifen Women s Health: Prenatal Vitamins Brand Prenatal Vitamins 3 23

24 Index A Abacavir-Lamivudine...7 Accu-Chek Test Strips...4 Acetaminophen/Butalbital/ Caffeine 325 mg/50 mg/ 40 mg... Acetaminophen/Codeine...9 Actemra...7 Acyclovir Ointment... 8 Acyclovir... 8 Aczone... 3 Adapalene Cream, Gel, Lotion... 3 Adcirca...2 Adderall XR... Addyi Adempas...2 Adlyxin...4 Advair Diskus/HFA Aerospan Afrezza...4 Aftera...2 Akynzeo...6 Albuterol Nebs Albuterol Sulfate Alendronate Sodium...9 Alfuzosin...8 Allopurinol...7 Alphagan P 0.%...6 Alprazolam Extended-Release... 2 Alprazolam... 2 Altavera...2 Alvesco Alyacen 7/7/7, / Amethia...2 Amethia Lo...2 Amethyst...2 Amiodarone...0 Amitiza...6 Amitriptyline... Amlodipine... 9 Amlodipine-Benazepril... 9 Amlodipine-Valsartan... 9 Amoxicillin Capsule, Chewable... 8 Amoxicillin/Potassium Clavulanate Chewable,... 8 Amphetamine Salt Combo... Ampyra... 2 Anastrozole...8 Androderm...8 Androgel...8 Anoro Ellipta Antipyrine/Benzocaine Otic Solution...8 Aprepitant Capsule...6 Apri...2 Apriso...6 Aranelle...2 Aranesp...8 Aripiprazole... 2 Armodafanil... 2 Armour Thyroid... 5 Arnuity Ellipta Asacol HD...6 Ashlyna...2 Asmanex Atenolol... 9 Atenolol-Chlorthalidone... 9 Atorvastatin...0 Atripla...7 Aubagio... 2 Aubra Auryxia...8 Auvi-Q...8 Aviane...2 Avonex... 2 Azathioprine...2 Azelastine 0.05% Ophthalmic Solution... 5 Azelastine 0.% Nasal Spray Azithromycin... 8 Azopt...6 Azurette...2 B Baclofen...9 Balziva...2 Basaglar...4 Bekyree...2 Belbuca...9 Benazepril... 9 Benazepril- Hydrochlorothiazide... 9 Benicar... 9 Benicar HCT... 9 Benzonatate Capsule...8 Betamethasone Dipropionate 0.05% Augmented Lotion, Ointment... 3 Betamethasone Dipropionate 0.05% Cream, Ointment... 3 Betaseron... 2 Bethkis...8 Bevespi Aerosphere Bexarotene Capsule... 9 Bicalutamide... 9 Bidil... 9 Bisoprolol... 9 Bisoprolol- Hydrochlorothiazide... 9

25 Blisovi 24 Fe...2 Blisovi Fe...2 Bosulif... 9 Brand Prenatal Vitamins Breo Ellipta Briellyn...2 Brilinta... 9 Bromfed DM...8 Budesonide Nebs Buprenorphine/ Naloxone... 2 Bupropion Extended-Release... Bupropion Sustained-Release... Bupropion... Buspirone... 2 Butrans...9 Bydureon...4 Byetta...4 Bystolic... 9 C Calcipotriene/Betamethasone Ointment... 3 Calcitriol Capsule... 5 Camila...2 Camrese...2 Camrese Lo...2 Canasa...6 Carac... 3 Carbamazepine Extended-Release Capsule,... 2 Carbamazepine Immediate-Release... 2 Carbidopa-Levodopa... 2 Carisoprodol 350 mg...9 Cartia XT... 9 Carvedilol... 9 Cayston...8 Caziant...2 Cefadroxil Capsule,... 8 Cefdinir Capsule... 8 Cefixime Suspension... 8 Cefprozil... 8 Cefuroxime... 8 Celecoxib...9 Cenestin Cephalexin Capsule... 8 Cerdelga...8 Cesia...2 Cetrotide...7 Chateal...2 Chlorhexidine Gluconate...8 Chlorpheniramine/ Hydrocodone/ Pseudoephedrine Solution...8 Chlorthalidone... 9 Choline Fenofibrate...0 Cialis...8 Ciclopirox Cream, Gel, Lotion, Solution... 3 Cimzia...7 Ciprodex... 8 Ciprofloxacin... 8 Citalopram... Claravis... 3 Clarinex Clarinex-D Clarithromycin... 8 Climara Climara Pro Clindamycin %/Benzoyl Peroxide 5% Gel... 3 Clindamycin.2%/Benzoyl Peroxide 5% Gel... 3 Clindamycin Capsule... 8 Clindamycin Gel... 3 Clindamycin Lotion, Solution, Swabs Clobetasol Propionate Cream, Ointment, Solution... 3 Clomiphene...7 Clonazepam... 2 Clonidine... 9 Clopidogrel... 9 Clotrimazole-Betamethasone Cream... 3 Clotrimazole-Betamethasone Lotion... 3 Colcrys...7 Combigan...6 Combivent Respimat Complera...7 Concerta... Contour Test Strips...4 Copaxone 20 mg... 2 Copaxone 40 mg... 2 Corlanor...0 Cortifoam...6 Cosentyx...7 Creon...6 Cresemba... 8 Cryselle...2 Cyclafem 7/7/7, / Cyclobenzaprine...9 Cyclophosphamide Capsule... 9 Cyclosporine Modified Capsule...2 Cyproheptadine Cyred...2 D Daklinza...7 Dasetta 7/7/7, / Daysee...2 Daytrana... Deblitane...2 Delyla...2 Delzicol...6 Descovy...7

26 Desmopressin... 5 Desogestrel-Ethinyl Estradiol...2 Desonide 0.05% Cream, Lotion, Ointment... 3 Desoximetasone Cream, Gel, Ointment... 3 Desvenlafaxine Extended- Release... Dexamethasone... 5 Dexcom Continuous Glucose Monitoring System...4 Dexcom Sensor...4 Dexcom Transmitter...4 Dexilant...6 Dexmethylphenidate Extended-Release Capsule... Dexmethylphenidate Immediate-Release... Dextroamphetamine Sulfate Immediate-Release... Dextroamphetamine- Amphetamine Extended-Release... Dextroamphetamine- Amphetamine Immediate-Release Capsule. Diazepam... 2 Diclofenac...9 Dicyclomine Dificid... 8 Diflorasone Diacetate 0.05% Cream, Ointment... 3 Digoxin...0 Diltiazem 24 Hour CD... 9 Diltiazem Sustained-Release Capsule... 9 Diltiazem Sustained-Release... 9 Diphenoxylate-Atropine...6 Divalproex Delayed-Release... 2 Divalproex Extended-Release... 2 Divigel Donepezil ODT, 5, 0 mg... 2 Doxazosin...9, 8 Doxazosin...8 Doxepin... Doxycycline Hyclate 50, 00 mg Capsule,... 8 Doxycycline Monohydrate 50, 00 mg Capsule... 8 Drospirenone/Ethinyl Estradiol...2 Drospirenone/Ethinyl Estradiol/Levomefolate Calcium...2 Duavee Dulera Duloxetine Capsule... Dutasteride Capsule...8 Dutoprol... 9 E Econazole Cream... 8 Econtra EZ...2 Edarbi... 9 Edarbyclor... 9 Effient... 9 Elinest...2 Eliquis... 9 Ella...2 Embeda...9 Emend Suspension...6 Emoquette...2 Enalapril... 9 Enbrel Enjuvia Enoxaparin Sodium... 9 Enpresse...2 Enskyce...2 Enstilar Foam... 3 Entresto...0 Epclusa...7 Epiduo/Epiduo Forte... 3 Epinephrine...8 EpiPen/EpiPen Jr...8 EpiPen/EpiPen-Jr...8 Epzicom...7 Errin...2 Erythromycin 0.5% Ophthalmic Ointment... 5 Escitalopram... Esomeprazole Capsule...6 Estarylla...2 Estrace Cream Estradiol Estradiol Twice-Weekly Transdermal Patch Estradiol/Norethindrone Acetate Estring Estrogen/Methyltestosterone Eszopiclone... 2 Etodolac Capsule...9 Evamist Evotaz...7 Ezetimibe...0 F Fallback...2 Falmina...2 Famciclovir... 8 Farxiga...4 Fenofibrate 40, 48, 20, 45 mg...0

27 Fenofibrate 43, 50, 67, 30, 34, 50, 200 mg Capsule...0 Fenofibrate 54, 60 mg...0 Fentanyl 2, 25, 50, 75, 00 mcg Patch...9 Fentanyl 37.5, 62.5, 87.5 mcg Patch...9 Fentanyl Citrate Lozenge...9 Fetzima... Finacea... 3 Finasteride...8 Flecainide...0 Flovent Diskus/HFA Fluconazole... 8 Fluocinolone Cream, Oil, Ointment, Solution... 3 Fluocinonide 0.05% Cream... 3 Fluoride...2 Fluoxetine, Capsule... Fluticasone Nasal Spray Fluvastatin Extended-Release...0 Fluvoxamine... Focalin XR... Folic Acid...2 Forteo...9 Fosrenol...8 FreeStyle Test Strips...4 Frovatriptan... Furosemide... 9 G Gabapentin Capsule,... 3 Gemfibrozil...0 Gentamicin Ophthalmic Ointment, Solution... 5 Genvoya...7 Gianvi...2 Gildagia Gildess Gildess 24 Fe Gildess Fe Gilenya... 2 Glatopa... 2 Glimepiride...4 Glipizide...4 Glipizide Extended-Release...4 Glucophage XR... 5 Glyburide...4 Glyxambi...4 Golytely...6 Gonal-F...7 Gonal-F RFF...7 Guanfacine...9, Guanfacine Extended-Release... H Halobetasol Ointment... 3 Harvoni...7 Heather Humalog KwikPens...4 Humalog Vials...4 Humira...7 Humulin KwikPens...4 Humulin Vials...4 Hydralazine... 9 Hydrochlorothiazide... 9 Hydrocodone/Acetaminophen 5/325, 7.5/325, 0/325 mg...9 Hydrocodone/ Chlorpheniramine Suspension...8 Hydrocodone/Homatropine...8 Hydrocodone/Ibuprofen...9 Hydrocortisone 2.5% Cream, Ointment... 3 Hydromorphone...9 Hydroxychloroquine Sulfate Hydroxyurea Capsule... 9 Hydroxyzine Capsule,. 20 Hyoscyamine...6 Hysingla...9 I Ibandronate...9 Ibuprofen...9 Imantinib... 9 Imbruvica... 9 Imiquimod 5% Cream... 3 Incruse Ellipta Indomethacin Capsule...9 Intelence...7 Introvale Invokamet...4 Invokamet XR...4 Invokana...4 Ipratropium Nebs Ipratropium-Albuterol Nebs Irbesartan... 9 Isentress...7 Isosorbide Mononitrate ER...0 Itraconazole Capsule... 8 J Janumet...4 Januvia... 5 Jardiance... 5 Jencycla Jentadueto... 5 Jentadueto XR... 5 Jolessa Jolivette Juleber Junel Junel 24 Fe Junel Fe K Kaletra...7

28 Kariva Kazano... 5 Kelnor / Ketoconazole Cream... 8 Ketorolac...9 Kimidess Klor-Con M0...2 Klor-Con M Kombiglyze XR... 5 Kurvelo L Labetalol... 9 Lamivudine-Zidovudine...7 Lamotrigine Immediate-Release... 3 Lansoprazole Capsule...6 Lantus Solostar...4 Lantus Vials...4 Larin Larin 24 Fe Larin Fe Larissia Lastacaft... 5 Latanoprost 0.005% Ophthalmic Solution...6 Latuda... 2 Lazanda...9 Leena Leflunomide...7 Lessina Letairis...2 Letrozole...8 Leucovorin Calcium... 9 Levalbuterol Nebs Levemir FlexTouch...4 Levemir Vials...4 Levetiracetam Extended-Release... 3 Levetiracetam Immediate-Release... 3 Levocetirizine Levofloxacin... 8 Levonest Levonorgestrel.5 mg Levonorgestrel-Ethinyl Estradiol Levora Levothyroxine Sodium... 5 Lialda...6 Lidocaine Transdermal Patch...8 Linzess...6 Liothyronine Sodium... 5 Lipofen...0 Lisinopril...9, 33 Lisinopril- Hydrochlorothiazide... 9 Lithium Capsule... 2 Livalo...0 Lo Loestrin Fe LoMedia 24 Fe Lopinavir-Ritonavir Oral Solution...7 Lorazepam... 2 Loryna Losartan... 9 Losartan- Hydrochlorothiazide... 9 Lovastatin...0 Low-Ogestrel Lumigan...6 Lutera Lyrica... 3 Lyza M Marlissa Medroxyprogesterone... 22, Medroxyprogesterone Acetate Meloxicam...9 Memantine... 2 Mercaptopurine... 9 Metadate CD... Metadate ER... Metaxalone...9 Metformin... 5 Metformin Extended-Release... 5 Methadone, Oral Solution, Concentrate Solution...9 Methimazole... 5 Methocarbamol...9 Methotrexate...7 Methylphenidate Chewable... Methylphenidate Extended-Release Capsule... Methylphenidate Extended-Release... Methylphenidate... Methylprednisolone... 5 Methyltestosterone Capsule...8 Metoclopramide...6 Metoprolol Succinate 50, 00, 200 mg... 9 Metoprolol Tartrate 25, 50, 00 mg... 9 Metronidazole 0.75% Topical Gel... 3 Metronidazole... 8 Microgestin Microgestin Fe Minastrin 24 Fe Minivelle Minocycline Capsule... 8

29 Minocycline Extended-Release Capsule... 3 Minocycline... 8 Mirtazapine... Mirvaso... 3 Mitigare...7 Modafinil... 2 Mometasone Furoate Cream, Lotion, Ointment... 3 Mometasone Nasal Spray Mono-Linyah Mononessa Montelukast Morphine Sulfate Extended-Release...9 Morphine Sulfate Oral Solution...9 Movantik...6 Moviprep...6 Moxeza... 5 Moxifloxacin... 8 Multaq...0 Mupirocin Ointment... 3 My Way Mycophenolate Capsule, Suspension...2 Mycophenolic Acid...2 Myzilra N Nabumetone...9 Nadolol...0 Naloxone Vial... 2 Naproxen...9 Naratriptan... Narcan Nasal Spray... 2 Natazia Necon 7/7/7, 0.5/35, /35, /50, 0/ Nesina... 5 Nevirapine...7 Nevirapine Extended-Release...7 Next Choice Niacin Extended-Release...0 Niaspan...0 Nifedipine Extended-Release...0 Nikki Nitrofurantoin Capsule... 8 Nitrofurantoin Macrocrystal Capsule... 8 Nitroglycerin Sublingual...0 Nora BE Norethindrone 0.35 mg Norethindrone-Ethinyl Estradiol-Ferrous Fumarate Norgestimate-Ethinyl Estradiol Norlyroc Nortrel 7/7/7, 0.5/35, / Nortriptyline Capsule... Norvir...7 Novolin Vials...4 Novolog FlexTouch...4 Novolog Vials...4 Noxafil, Suspension... 8 NP Thyroid... 5 Nucynta...9 Nucynta ER...9 Nuedexta...8 Nutropin, Nutropin AQ... 5 Nuvaring Nystatin Cream, Ointment... 8 Nystatin-Triamcinolone Acetonide Cream, Ointment O Obredon...8 Ocella Odefsey...7 Ofloxacin 0.3% Ophthalmic Solution... 5 Ofloxacin Otic Solution... 8 Ofloxacin... 8 Ogestrel Olanzapine... 2 Olmesartan...0 Olmesartan- Hydrochlorothiazide...0 Olopatadine 0.% Ophthalmic Solution... 5 Omeclamox-Pak...6 Omega-3-Acid Ethyl Esters Capsule...0 Omeprazole Capsule...6 Ondansetron...6 Ondansetron ODT...6 OneTouch Test Strips...4 OneTouch Ultra Mini...4 OneTouch Ultra Test Strips...4 OneTouch Verio...4 OneTouch Verio Flex...4 OneTouch Verio IQ...4 OneTouch Verio Sync...4 OneTouch Verio Test Strips...4 Onglyza... 5 Opana ER...9 Opcicon Opsumit...2 Oracea... 8 Orencia...7 Orenitram...2 Orsythia Ortho Tri-Cyclen Lo Oseltamivir Capsule... 8 Oseni... 5

30 Osphena Otezla...7 Otrexup...7 Ovidrel...7 Oxcarbazepine... 3 Oxsoralen-Ultra... 3 Oxybutynin Extended-Release Oxybutynin Oxycodone...9 Oxycodone/Acetaminophen 5/325, 7.5/325, 0/325 mg...9 Oxycontin...9 P Pantoprazole...6 Paroxetine... Pataday... 5 Pegasys...8 Penicillin V Potassium... 8 Perforomist Phenazopyridine...8 Phenytoin Capsule, Suspension... 3 Philith Picato... 3 Pimtrea Pioglitazone... 5 Pirmella 7/7/7, / Plan B One Step Plegridy... 2 Polyethylene Glycol Portia Potassium Chloride...2 Potassium Citrate...2 Pradaxa... 9 Praluent...0 Pramipexole... 2 Pravastatin...0 Prednisone... 5 Premarin Premphase Prempro Prenisolone Oral Solution... 5 Prepopik...6 Previfem Prezcobix...7 Prezista...7 Pristiq... ProAir HFA ProAir RespiClick Procrit...8 Progesterone Micronized Capsule Promethazine Promethazine/Codeine...8 Promethazine/ Dextromethorphan...8 Propranolol Extended-Release Capsule...0 Propranolol...0 Proventil HFA Pulmicort Flexhaler Pulmozyme...8 Pylera...6 Q Quasense Quetiapine Extended-Release... 2 Quetiapine... 2 Quinapril...0 QVAR R Rabeprazole...6 Rajani Raloxifene...9, 23 Raloxifene...9 Ramipril...0 Ranexa Ranitadine Syrup...6 Rapaflo...8 Rasuvo...7 Rebif... 2 Reclipsen Rectiv...8 Regranex... 3 Relpax... Renvela...8 Repatha 40 mg...0 Restasis Single Use Vial...6 Revlimid... 9 Reyataz...7 Rezira...8 Ribavirin...7 Risedronate Sodium...9 Risperidone... 2 Ritalin SR... Rizatriptan ODT,... Ropinirole... 2 Rosuvastatin...0 S Savaysa... 9 Selzentry...7 Serevent Diskus Sertraline... Setlakin Sharobel Sildenafil...2 Simponi...7 Simvastatin...0 Sirolimus...2 Solia Soliqua...4 Solodyn... 3 Sotalol...0 Sovaldi...7 Spiriva Handihaler Spiriva Respimat Spironolactone...0

31 Sprintec Sprix...9 Sronyx Stelara...7 Stiolto Respimat Strattera... Stribild...7 Striverdi Respimat Suboxone Film... 2 Subsys...9 Suclear...6 Sucralfate...6 Sulfamethoxazole- Trimethoprim... 8 Sulfasalazine...6 Sumatriptan Nasal Spray... Sumatriptan Succinate, Injection... Suprax Capsule, Chewable,... 8 Suprep...6 Sustiva...7 Sutent... 9 Syeda Symbicort Synjardy... 5 Synthroid... 5 T Taclonex Suspension... 3 Tacrolimus Capsule...2 Tacrolimus Ointment...4 Take Action Taltz...7 Tamoxifen Tamsulosin Capsule...8 Tanzeum... 5 Targretin Capsule... 9 Targretin Gel... 9 Tarina Fe Tasigna... 9 Taytulla Tazorac...4 Tecfidera... 2 Technivie...7 Telmisartan...0 Telmisartan- Hydrochlorothiazide...0 Temazepam Capsule... 2 Terazosin...0, 8 Terazosin Capsule,...8 Terbinafine... 8 Testim...8 Testosterone % Topical Gel...8 Testosterone Cypionate Injection...8 Tilia Fe Timolol Maleate 0.25%, 0.5% Ophthalmic Solution...6 Tivicay...7 Tizanidine...9 Tobi Podhaler...8 Tobramycin Nebulized Solution...8 Tobramycin Ophthalmic Solution... 5 Tobramycin/Dexamethasone 0.3%-0.% Ophthalmic Suspension... 5 Tolcapone... 2 Tolterodine Extended-Release Tolterodine Topiramate Immediate-Release... 3 Toujeo SoloStar...4 Toviaz Tracleer...2 Tradjenta... 5 Tramadol Immediate-Release Tramadol Sustained-Release...9 Tramadol-Acetaminophen...9 Transderm-Scop...6 Travatan Z...6 Trazodone... Tresiba FlexTouch...4 Tretinoin Cream...4 Tretinoin Gel...4 Tretinoin Microspheres...4 Trezix...9 Tri-Estarylla Tri-Legest Fe Tri-Linyah Tri-Lo-Estarylla Tri-Lo-Marzia Tri-Lo-Sprintec Tri-Previfem Tri-Sprintec Triamcinolone Acetonide Cream, Lotion, Ointment...4 Triamcinolone Nasal Spray Triamterene- Hydrochlorothiazide...0 Triazolam... 2 Trinessa Trinessa Lo Trintellix... Triumeq...7 Trivora Trulicity... 5 Truvada...7 Tudorza Tybost...7 Tyvaso...2 U Uceris Foam...6 Uceris...6 Uloric...7 Uptravi...2

32 V Vagifem Valacyclovir... 8 Valganciclovir... 8 Valsartan...0 Valsartan- Hydrochlorothiazide...0 Varubi...6 Vascepa...0 Vectical...4 Velivet Velphoro...8 Veltassa...8 Venlafaxine Extended-Release Capsule... Venlafaxine... Ventolin HFA Verapamil...0 Verapamil Sustained-Release...0 Vesicare Vestura Viberzi...6 Vicodin 5/300, 7.5/300, 0/300 mg...9 Victoza 2-Pak... 5 Victoza 3-Pak... 5 Viekira Pak...7 Vienva Vigamox... 5 Viibryd... Viorele Viread...7 Vitekta...7 Vivelle-Dot Voltaren Gel...9 Vyfemla Vytorin...0 Vyvanse... W Warfarin Sodium... 9 Welchol...0 Wera Wymza Fe X Xarelto... 9 Xeljanz...7 Xeljanz XR...7 Xeloda... 9 Xigduo XR... 5 Xiidra...6 Xopenex HFA Xopenex Nebs Xtampza ER...9 Xulane Xyrem... 2 Y Yasmin Yaz Yuvafem Z Zaleplon Capsule... 2 Zarah Zarxio...8 Zelapar... 2 Zenchent Zenchent Fe Zenpep...6 Zepatier...7 Zetia...0 Zetonna Zinbryta... 2 Ziprasidone Capsule... 2 Zohydro ER...9 Zolpidem Extended-Release... 2 Zolpidem... 2 Zonisamide Capsule... 3 Zovia /35E, /50E Zovirax Cream... 8 Zubsolv... 2 Zurampic...7 Zytiga

33 My medications worksheet Take this worksheet with you each time you visit a doctor. Each of your doctors should be aware of every drug you take and you should have a list as well. Name of medication and strength tier I take this medicine for Directions Doctor Example: Lisinopril, 20 mg High blood pressure One tablet daily Dr. Johnson 33

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36 207 United HealthCare Services, Inc. All rights reserved. Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by UnitedHealthcare Insurance Company, UnitedHealthcare Services, Inc. or their affiliates. Health Plan coverage provided by or through a UnitedHealthcare company. OptumRx is an affiliate of UnitedHealthcare Insurance Company. UnitedHealthcare and the dimensional U logo are registered trademarks owned by UnitedHealth Group Incorporated. All other trademarks are the property of their respective owners. Created March, Prescription List Student Resources Traditional Three- 7/7