Your 2019 Prescription Drug List Flex Standard Three-Tier

Transcription

1 Your 209 Prescription List Flex Standard 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 Flex Standard 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... 6 Other... 6 Thyroid Hormone Replacement... 6 Eye Conditions Allergies... 6 Antibiotics... 6 Dry Eye Disease... 6 Glaucoma Gastrointestinal Acid Suppression... 6 Nausea/Vomiting... 7 Other... 7 Gout... 7 Hepatitis C... 7 HIV/AIDS... 8 Infertility... 8 Inflammatory Conditions: Rheumatoid Arthritis, Crohn s Disease, Psoriasis, Ulcerative Colitis... 8 Medications for Sexual Dysfunction... 9 Men s Health Prostate... 9 Testosterone Therapy... 9 Miscellaneous... 9 Musculoskeletal Muscle Spasms Osteoporosis Pain Relief Overactive Bladder Respiratory Allergies Asthma/COPD... 2 Pulmonary Arterial Hypertension Smoking Cessation... 2 Transplant Vitamins/Electrolytes Women s Health Contraceptives 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. E H H-PA May be excluded from coverage or subject to prior authorization and/or trial/ failure of another medication(s). (Referred to as First Start in New Jersey) Lower-cost options are available and covered. 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 Fluconazole Itraconazole Capsule SL Ketoconazole Cream Noxafil, Suspension 2 Nystatin Cream, Ointment Terbinafine SL Anti-Infectives: Antivirals Acyclovir Ointment Acyclovir Famciclovir Oseltamivir Capsule, Suspension SL Valacyclovir Dificid 3 SL Doxycycline Capsule, Levofloxacin Minocycline Capsule Minocycline 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 E, SP Bicalutamide Bosulif 2 PA, SL, SP, ST Braftovi 3 PA, SP Calquence 2 PA, SL, SP Cyclophosphamide Capsule Erleada 3 PA, SL, SP Hydroxyurea Capsule Ibrance 2 PA, SP Idhifa 2 PA, SL, SP Imantinib PA, SL, SP Imbruvica 2 PA, SL, SP Bold type = Brand-name drug [Plain type = Generic drug] E = May be excluded from coverage H = May be part of health care reform preventive H-PA = May be part of health care reform preventive with prior authorization 9 PA = Prior authorization required RS = May be eligible for the refill and save program SL = Supply limit SP = Specialty medication ST = Step therapy

10 Name Name Leucovorin Calcium Bidil 2 Mektovi 3 PA, SP Mercaptopurine Nerlynx 2 PA, SL, SP Revlimid 2 PA, SP Rydapt 2 PA, SP Sutent 2 PA, SL, SP Targretin Capsule SP Targretin Gel 3 Tasigna 2 PA, SL, SP, ST Verzenio 2 PA, SL, SP Xeloda SP Zykadia 2 PA, SP Zytiga 2 PA, SL, SP Cardiovascular/Heart Disease: Coagulation Therapy Bevyxxa 3 SL Brilinta 2 SL Clopidogrel Eliquis 3 SL Enoxaparin Sodium 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 Bisoprolol Bisoprolol-Hydrochlorothiazide Bystolic 2 Byvalson 2 SL Cartia XT Carvedilol Chlorthalidone Clonidine Diltiazem 24 Hour CD Diltiazem Sustained-Release Capsule Diltiazem Sustained-Release Doxazosin Edarbi 2 SL Edarbyclor 2 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 0

11 Name Propranolol Extended-Release Capsule Propranolol Quinapril Ramipril Spironolactone Telmisartan Telmisartan-Hydrochlorothiazide Terazosin Triamterene-Hydrochlorothiazide Valsartan Valsartan-Hydrochlorothiazide Verapamil Verapamil Sustained-Release Name Rosuvastatin SL Simvastatin H-PA Vascepa 2 PA Welchol Packet for Suspension, Cardiovascular/Heart Disease: Other Amiodarone Corlanor 3 PA, SL Digoxin Entresto 3 PA, SL Flecainide Isosorbide Mononitrate ER Multaq 3 PA Nitroglycerin Sublingual Cardiovascular/Heart Disease: High Cholesterol Atorvastatin H-PA, SL Colesevelam Packet for Suspension, (generic 3 E Welchol) Ezetimibe SL Ezetimibe-Simvastatin SL Fenofibrate 54, 60 mg Fluvastatin Extended-Release SL 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 Ranexa 2 Sotalol Central Nervous System: Attention Deficit Disorder Adderall XR SL Amphetamine Salt Combo Atomoxetine SL Concerta SL Daytrana 3 SL Dexmethylphenidate Immediate- Release Dextroamphetamine- Amphetamine Immediate-Release Dextroamphetamine Sulfate Immediate-Release Guanfacine Extended-Release SL Methylphenidate Chewable Methylphenidate Extended- Release Capsule (generic Metadate CD, Ritalin LA) SL Bold type = Brand-name drug [Plain type = Generic drug] E = May be excluded from coverage 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 Methylphenidate Extended- Release (Metadate ER, generic SL Ritalin SR) Methylphenidate Extended- Release (generic 3 E, SL Concerta) Methylphenidate Immediate- Release Mydayis 2 SL Vyvanse 2 SL Central Nervous System: Depression 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 Fluvoxamine Mirtazapine Nortriptyline Capsule Paroxetine Sertraline Trazodone Trintellix 3 SL, ST Venlafaxine Extended-Release Capsule Venlafaxine Viibryd 2 SL Name Central Nervous System: Migraine Acetaminophen/Butalbital/ Caffeine 325 mg/50 mg/40 mg Eletriptan Frovatriptan Naratriptan Rizatriptan ODT, SL Sumatriptan Nasal Spray Sumatriptan Succinate, Injection Central Nervous System: Multiple Sclerosis 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 2 SL 2

13 Name Lithium Capsule Lorazepam Memantine Immediate-Release Modafinil PA, SL Naloxone Vial Narcan Nasal Spray 2 Olanzapine SL Pramipexole Quetiapine Extended-Release SL Quetiapine Risperidone Ropinirole Suboxone Film 3 E, 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 SL Central Nervous System: Seizure Disorders Carbamazepine Extended- Release Capsule, Carbamazepine Immediate- Release Clonazepam Diazepam Name Divalproex Delayed-Release Divalproex Extended-Release Gabapentin Capsule, Lamotrigine Immediate-Release Levetiracetam Extended-Release Levetiracetam Immediate-Release Lyrica 3 SL Lyrica CR 2 SL Oxcarbazepine Phenytoin Capsule, Suspension Topiramate Immediate-Release Zonisamide Capsule Dermatology Aczone Betamethasone Dipropionate 0.05% Augmented Lotion, Ointment Betamethasone Dipropionate 0.05% Cream, Ointment Calcipotriene/Betamethasone Ointment Carac 2 Ciclopirox Cream, Gel, Lotion, Solution Claravis PA Clindamycin.2%/Benzoyl Peroxide 5% Gel Clindamycin Gel Clindamycin Lotion, Solution, Swabs Clobetasol Propionate Cream, Ointment, Solution Bold type = Brand-name drug [Plain type = Generic drug] E = May be excluded from coverage H = May be part of health care reform preventive H-PA = May be part of health care reform preventive with prior authorization 3 PA = Prior authorization required RS = May be eligible for the refill and save program SL = Supply limit SP = Specialty medication ST = Step therapy

14 Name Clotrimazole-Betamethasone Cream Clotrimazole-Betamethasone Lotion Dapsone 5% Gel 3 E Desonide 0.05% Cream, Lotion, Ointment Desoximetasone Cream, Gel, Ointment Diflorasone Diacetate 0.05% Cream, Ointment Dupixent 3 PA, SL, SP, ST Elidel 3 Enstilar Foam 3 Eucrisa 3 ST Finacea 2 Fluocinonide 0.05% Cream Fluocinolone Cream, Oil, Ointment, Solution Fluorouracil 0.5% Cream 3 Halobetasol Ointment Hydrocortisone 2.5% Cream, Ointment Imiquimod 5% Cream Impoyz 3 Metronidazole 0.75% Topical Gel Minocycline Extended-Release (generic Solodyn) Mirvaso 3 Mometasone Furoate Cream, Lotion, Ointment Mupirocin Ointment Oracea 3 Oxsoralen-Ultra 2 Picato 3 Regranex 2 PA Rhofade 3 Taclonex Suspension 3 Tacrolimus Ointment ST Name Tazarotene 0.% Cream (generic Tazorac) 3 E, PA Tazorac 0.% Cream PA Tazorac Gel, 0.05% Cream 2 PA Tretinoin Cream PA Triamcinolone Acetonide Cream, Lotion, Ointment Vectical 3 Ximino 3 Diabetes: Blood Glucose Monitoring 5 Accu-Chek Test Strips 3 E, 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 E, SL FreeStyle Test Strips 3 E, 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 E Apidra SoloStar, Vials 3 E Basaglar Fiasp FlexTouch, Vials 3 E Humalog KwikPens (all formulations) 2 4

15 Name Humalog Vials (all formulations) Humulin KwikPens (all formulations) 2 Humulin Vials (all formulations) Lantus SoloStar 3 E Lantus Vials 3 E Levemir FlexTouch, Vials 3 Novolin Vials (all formulations) 3 E Novolog FlexPen, Vials (all formulations) 3 E Toujeo SoloStar 3 E Tresiba FlexTouch 2 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 E, 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 Name Jentadueto, 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 Ozempic 3 SL Pioglitazone SL Qtern 3 E, SL, ST Segluromet 3 E, SL, ST Soliqua 2 PA, SL Steglatro 3 E, SL, ST Steglujan 3 E, 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 E, 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. Bold type = Brand-name drug [Plain type = Generic drug] E = May be excluded from coverage H = May be part of health care reform preventive H-PA = May be part of health care reform preventive with prior authorization 5 PA = Prior authorization required RS = May be eligible for the refill and save program SL = Supply limit SP = Specialty medication ST = Step therapy

16 Name 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. Endocrine: Other Calcitriol Capsule Desmopressin Dexamethasone Methylprednisolone Prenisolone Oral Solution Prednisone Endocrine: Thyroid Hormone Replacement Armour Thyroid 2 Levothyroxine Sodium Liothyronine Sodium Methimazole NP Thyroid Synthroid 2 Eye Conditions: Allergies Azelastine 0.05% Ophthalmic Solution Lastacaft 3 Olopatadine Ophthalmic Solution Eye Conditions: Antibiotics Erythromycin 0.5% Ophthalmic Ointment Gentamicin Ophthalmic Ointment, Solution Moxeza 3 Name Tobramycin/Dexamethasone 0.3%-0.% Ophthalmic Suspension Tobramycin Ophthalmic Solution Eye Conditions: Dry Eye Disease Restasis MultiDose 3 PA, SL Restasis Single Use Vials 2 PA, SL Xiidra 2 SL Eye Conditions: Glaucoma Alphagan P 0.% 2 Azopt 2 Combigan 2 Latanoprost 0.005% Ophthalmic Solution Lumigan 2 Timolol 0.25%, 0.5% Ophthalmic Solution Travatan Z 2 Vyzulta 3 Gastrointestinal: Acid Suppression Dexilant 2 SL Omeclamox-Pak 3 SL Omeprazole Capsule Pantoprazole Pylera 3 SL Rabeprazole SL Ranitadine Syrup Sucralfate Moxifloxacin Ophthalmic Solution Ofloxacin 0.3% Ophthalmic Solution 6

17 Name Gastrointestinal: Nausea/Vomiting Akynzeo 3 Aprepitant Capsule Bonjesta 2 PA Diclegis 2 Emend Suspension 2 Ondansetron Ondansetron ODT Scopolamine Transdermal Patch Varubi 2 Gastrointestinal: Other Amitiza 3 PA, SL, ST Apriso 2 Asacol HD 3 E Budesonide Extended-Release (generic Uceris) 3 E Canasa 2 Clenpiq 2 Cortifoam 2 Creon 2 Diphenoxylate-Atropine Golytely 2 Hyoscyamine Lialda Linzess 2 PA, SL Mesalamine Delayed-Release (generic Lialda) 3 E Metoclopramide Movantik 3 E, PA, SL Moviprep 2 Name Polyethylene Glycol 3350 Prepopik 2 Sulfasalazine Suprep 2 Symproic 2 PA, SL Uceris Foam 2 Uceris Viberzi 3 SL Zenpep 2 Gout Allopurinol Colcrys 3 E Duzallo 3 PA, SL Mitigare 2 Uloric 3 SL 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 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 Bold type = Brand-name drug [Plain type = Generic drug] E = May be excluded from coverage H = May be part of health care reform preventive H-PA = May be part of health care reform preventive with prior authorization 7 PA = Prior authorization required RS = May be eligible for the refill and save program SL = Supply limit SP = Specialty medication ST = Step therapy

18 Name HIV/AIDS Abacavir-Lamivudine SP Atazanavir Capsule SP Atripla 3 E, 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 Symfi 2 SP Symfi Lo 2 SP Tenofovir SP Tivicay 3 SP Triumeq 2 SP Truvada 3 SP Tybost 2 SP Vitekta 2 SP Name Infertility 6 Cetrotide 2 SP Clomiphene SP Endometrin 2 PA Gonal-F 2 SP Gonal-F RFF 2 SP Ovidrel 3 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 Siliq 3 PA, SL, SP, ST 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 8

19 Name Medications for Sexual Dysfunction 6 Name Cayston 2 PA, SL, SP Addyi 3 SL Cialis 2 SL Intrarosa 2 SL Levitra 2 SL Osphena 2 SL Sildenafil (generic Viagra) SL Stendra 2 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 2 Tamsulosin Capsule Terazosin Capsule, Men s Health: Testosterone Therapy Androderm 2 SL Androgel 3 E, SL Methyltestosterone Capsule Testim SL Testosterone % Topical Gel E, SL Testosterone Cypionate Injection Miscellaneous Anastrozole Aranesp 2 SL, SP Cerdelga 2 PA, SP Chlorhexidine Gluconate Chlorpheniramine/Hydrocodone/ Pseudoephedrine Solution PA Epinephrine (generic EpiPen/ EpiPen-Jr.) 2 EpiPen/EpiPen Jr. 3 E Hydrocodone/Chlorpheniramine Suspension PA Lanthanum Chewable Letrozole Lidocaine Transdermal Patch (generic Lidoderm) PA, SL Nityr 2 PA, SP Nuedexta 2 PA Obredon 3 PA Pegasys 2 PA, SL, SP Phenazopyridine Procrit 2 SL, SP Promethazine/Codeine PA Promethazine/Dextromethorphan Pulmozyme 2 PA, SL, SP Rectiv 3 SL Rezira 3 Sevelamer Syprine PA, SP Tobi Podhaler 3 PA, SL, SP Velphoro 2 Veltassa 3 SL Zarxio 2 SP Auryxia 3 Bethkis PA, SL, SP Bold type = Brand-name drug [Plain type = Generic drug] E = May be excluded from coverage H = May be part of health care reform preventive H-PA = May be part of health care reform preventive with prior authorization 9 PA = Prior authorization required RS = May be eligible for the refill and save program SL = Supply limit SP = Specialty medication ST = Step therapy

20 Name Musculoskeletal: Muscle Spasms Baclofen Carisoprodol 350 mg Cyclobenzaprine Metaxalone Methocarbamol Tizanidine Musculoskeletal: Osteoporosis Name Methadone, Oral Solution, Concentrate Solution PA, SL Morphine Sulfate Extended- Release PA, SL Morphine Sulfate Oral Solution Nabumetone Naproxen Nucynta 2 SL Nucynta ER 3 PA, SL Alendronate Sodium Forteo 3 PA, SP Ibandronate SL Raloxifene Risedronate Sodium SL Tymlos 3 PA, SP Musculoskeletal: Pain Relief Acetaminophen/Codeine SL Arymo ER 3 E, PA, SL, ST Belbuca 3 PA, SL Celecoxib SL Diclofenac Embeda 3 E, PA, SL, ST Etodolac Capsule Fentanyl Citrate Lozenge PA, SL Fentanyl Patch PA, SL Hydrocodone/Acetaminophen 5/325, 7.5/325, 0/325 mg SL Hydrocodone/Ibuprofen Hydromorphone Immediate- Release Hysingla 3 E, PA, SL Ibuprofen Indomethacin Capsule Ketorolac Lazanda 3 PA, SL Opana ER 3 E, PA, SL Oxycodone/Acetaminophen 5/325, 7.5/325, 0/325 mg SL Oxycodone Oxycontin 3 E, PA, SL Sprix 3 Tramadol-Acetaminophen 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 2 Respiratory: Allergies Azelastine 0.% Nasal Spray Fluticasone Nasal Spray Zetonna 3 Meloxicam 20

21 Name Respiratory: Asthma/COPD Advair Diskus/HFA 2 RS, SL AirDuo RespiClick 3 E, SL Albuterol Nebs Alvesco SL Anoro Ellipta 3 SL Arnuity Ellipta 3 SL Asmanex TwistHaler/HFA SL Bevespi Aerosphere 2 SL Breo Ellipta 2 RS, SL Budesonide Nebs SL Combivent Respimat 2 SL Dulera 3 SL, ST Flovent Diskus/HFA 2 SL Fluticasone/Salmeterol ResipClick (generic AirDuo RespiClick) SL Incruse Ellipta 2 SL Ipratropium-Albuterol Nebs Ipratropium Nebs Montelukast Perforomist 3 SL ProAir HFA/RespiClick 3 Proventil HFA 3 Pulmicort Flexhaler 3 SL, ST QVAR Redihaler SL Seebri Neohaler 3 SL, ST Serevent Diskus 3 SL Spiriva Handihaler/ Respimat 2 SL Stiolto Respimat 3 E, SL Striverdi Respimat 2 SL Symbicort 2 RS, SL Name Trelegy Ellipta 3 RS, SL Tudorza 2 SL Ventolin HFA 2 Xopenex HFA 3 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 2 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 Thrive Gum H-PA Bold type = Brand-name drug [Plain type = Generic drug] E = May be excluded from coverage H = May be part of health care reform preventive H-PA = May be part of health care reform preventive with prior authorization 2 PA = Prior authorization required RS = May be eligible for the refill and save program SL = Supply limit SP = Specialty medication ST = Step therapy

22 Name Transplant Azathioprine Cyclosporine Modified Capsule SP Mycophenolate Capsule, Suspension SP Mycophenolic Acid SP Sirolimus SP Tacrolimus Capsule SP 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 Name Caziant H Chateal H 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 22

23 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 2 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 Name Nora BE H Norethindrone 0.35 mg H 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 Sharobel H Solia H Sprintec H Sronyx H Syeda H Take Action H Tarina Fe H Tilia Fe H Tri Femynor H Bold type = Brand-name drug [Plain type = Generic drug] E = May be excluded from coverage H = May be part of health care reform preventive H-PA = May be part of health care reform preventive with prior authorization 23 PA = Prior authorization required RS = May be eligible for the refill and save program SL = Supply limit SP = Specialty medication ST = Step therapy

24 Name Tri-Estarylla H 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 Name Women s Health: Hormone Replacement Climara Pro 2 SL Divigel 2 Duavee 3 SL Estrace Cream Estradiol Cream (generic Estrace) 3 E Estradiol/Norethindrone Acetate Estradiol Estradiol Twice-Weekly Transdermal Patch (generic 3 E, SL Vivelle-Dot) Estradiol Weekly Transdermal Patch (generic Climara) SL Estring 2 SL Estrogen/Methyltestosterone Evamist 2 Medroxyprogesterone Minivelle 2 SL Premarin 2 Premphase 3 Prempro 2 Progesterone Micronized Capsule Vivelle-Dot SL Yuvafem 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... 8 Accu-Chek Test Strips... 4 Acetaminophen/Butalbital/Caffeine 325 mg/50 mg/40 mg... 2 Acetaminophen/Codeine Actemra... 8 Acyclovir Ointment... 9 Acyclovir... 9 Aczone... 3 Adcirca... 2 Adderall XR... Addyi... 9 Adempas... 2 Adlyxin... 5 Admelog SoloStar, Vials... 4 Advair Diskus/HFA... 2 Aftera AirDuo RespiClick... 2 Akynzeo... 7 Albuterol Nebs... 2 Alendronate Sodium Alfuzosin... 9 Allopurinol... 7 Alphagan P 0.%... 6 Alprazolam Extended-Release... 2 Alprazolam... 2 Altavera Alunbrig... 9 Alvesco... 2 Alyacen 7/7/7, / Amethia Amethia Lo Amethyst Amiodarone... Amitiza... 7 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... 9 Androgel... 9 Anoro Ellipta... 2 Apidra SoloStar, Vials... 4 Aprepitant Capsule... 7 Apri Apriso... 7 Aranelle Aranesp... 9 Aripiprazole... 2 Armodafinil... 2 Armour Thyroid... 6 Arnuity Ellipta... 2 Arymo ER Asacol HD... 7 Ashlyna Asmanex TwistHaler/HFA... 2 Atazanavir Capsule... 8 Atenolol... 0 Atenolol-Chlorthalidone... 0 Atomoxetine... Atorvastatin... Atripla... 8 Aubagio... 2 Aubra Auryxia... 9 Austedo... 2 Aviane Avonex... 2 Azathioprine Azelastine 0.05% Ophthalmic Solution... 6 Azelastine 0.% Nasal Spray Azithromycin... 9 Azopt... 6 Azurette B Baclofen Balziva Basaglar... 4 Bekyree Belbuca 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... 2 Bevyxxa... 0 Bexarotene Capsule... 9 Bicalutamide... 9 Bidil... 0 Bisoprolol... 0 Bisoprolol-Hydrochlorothiazide... 0 Blisovi 24 Fe Blisovi Fe Bonjesta... 7 Bosulif... 9 Braftovi... 9 Brand Prenatal Vitamins Breo Ellipta... 2 Briellyn Brilinta... 0 Budesonide Extended-Release... 7 Budesonide Nebs... 2 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

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

27 Duloxetine Capsule... 2 Dupixent... 4 Dutasteride Capsule... 9 Duzallo... 7 E Econazole Cream... 9 Econtra EZ Edarbi... 0 Edarbyclor... 0 Efavirenz... 8 Eletriptan... 2 Elidel... 4 Elinest Eliquis... 0 Ella Embeda Emend Suspension... 7 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 Eucrisa... 4 Evamist Evotaz... 8 Ezetimibe... Ezetimibe-Simvastatin... F Fallback Falmina Famciclovir... 9 Farxiga... 5 Fenofibrate 54, 60 mg... Fentanyl Citrate Lozenge Fentanyl Patch Fetzima... 2 Fiasp FlexTouch, Vials... 4 Finacea... 4 Finasteride... 9 Flecainide... Flovent Diskus/HFA... 2 Fluconazole... 9 Fluocinolone Cream, Oil, Ointment, Solution... 4 Fluocinonide 0.05% Cream... 4 Fluoride Fluorouracil 0.5% Cream... 4 Fluoxetine Capsule... 2 Fluticasone Nasal Spray Fluticasone/Salmeterol ResipClick... 2 Fluvastatin Extended-Release... Fluvoxamine... 2 Folic Acid Forteo FreeStyle Test Strips... 4 Frovatriptan... 2 Furosemide... 0 G Gabapentin Capsule, Gemfibrozil... Gentamicin Ophthalmic Ointment, Solution... 6 Genvoya... 8 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... 5 Humira... 8 Humulin KwikPens... 5 Humulin Vials... 5 Hydralazine... 0 Hydrochlorothiazide... 0 Hydrocodone/Acetaminophen 5/325, 7.5/325, 0/325 mg Hydrocodone/Chlorpheniramine Suspension... 9 Hydrocodone/Ibuprofen Hydrocortisone 2.5% Cream, Ointment... 4 Hydromorphone Immediate-Release Hydroxychloroquine Sulfate... 8 Hydroxyurea Capsule... 9 Hyoscyamine... 7 Hysingla... 20

28 I Ibandronate Ibrance... 9 Ibuprofen Idhifa... 9 Imantinib... 9 Imbruvica... 9 Imiquimod 5% Cream... 4 Impoyz... 4 Incruse Ellipta... 2 Indomethacin Capsule Intelence... 8 Intrarosa... 9 Introvale Invokamet, Invokamet XR... 5 Invokana... 5 Ipratropium Nebs... 2 Ipratropium-Albuterol Nebs... 2 Irbesartan... 0 Isentress... 8 Isibloom Isosorbide Mononitrate ER... Itraconazole Capsule... 9 J Janumet... 5 Januvia... 5 Jardiance... 5 Jencycla Jentadueto, Jentadueto XR... 5 Jolessa Jolivette Juleber Juluca... 8 Junel Junel 24 Fe Junel Fe K Kaletra... 8 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... 8 Lamotrigine Immediate-Release... 3 Lanthanum Chewable... 9 Lantus SoloStar... 5 Lantus Vials... 5 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... 9 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 Lisinopril... 0 Lisinopril-Hydrochlorothiazide... 0 Lithium Capsule... 3 Lo Loestrin Fe LoMedia 24 Fe Lopinavir-Ritonavir Oral Solution... 8 Lorazepam... 3 Loryna Losartan... 0 Losartan-Hydrochlorothiazide... 0 Lovastatin... Low-Ogestrel Lumigan... 6 Lutera Lyrica... 3 Lyrica CR... 3 Lyza M Marlissa Mavyret... 7 Medroxyprogesterone... 23, 24 Medroxyprogesterone Acetate Mektovi... 0 Meloxicam Memantine Immediate-Release... 3 Mercaptopurine... 0 Mesalamine Delayed-Release... 7 Metadate CD... Metadate ER... 2 Metaxalone Metformin... 5 Metformin Extended-Release... 5 Methadone, Oral Solution, Concentrate Solution Methimazole... 6 Methocarbamol Methotrexate... 8 Methylphenidate Chewable... Methylphenidate Extended-Release Capsule... Methylphenidate Extended-Release... 2

29 Methylphenidate Immediate-Release... 2 Methylprednisolone... 6 Methyltestosterone Capsule... 9 Metoclopramide... 7 Metoprolol Succinate Extended- Release... 0 Metoprolol Tartrate 25, 50, 00 mg... 0 Metronidazole 0.75% Topical Gel... 4 Microgestin Microgestin Fe Minivelle Minocycline Capsule... 9 Minocycline Extended-Release... 4 Minocycline... 9 Mirtazapine... 2 Mirvaso... 4 Mitigare... 7 Modafinil... 3 Mometasone Furoate Cream, Lotion, Ointment... 4 Mono-Linyah Mononessa Montelukast... 2 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 Mycophenolic Acid Mydayis... 2 Myzilra N Nabumetone Nadolol... 0 Naloxone Vial... 3 Naproxen Naratriptan... 2 Narcan Nasal Spray... 3 Natazia Necon 7/7/7, 0.5/35, /35, /50, 0/ Nerlynx... 0 Nesina... 5 Nevirapine... 8 Nevirapine Extended-Release... 8 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... 6 Nuvaring Nystatin Cream, Ointment... 9 O Obredon... 9 Ocella Odefsey... 8 Ofloxacin 0.3% Ophthalmic Solution... 6 Ofloxacin Otic Solution... 9 Ofloxacin... 9 Ogestrel Olanzapine... 3 Olmesartan... 0 Olmesartan-Hydrochlorothiazide... 0 Olopatadine Ophthalmic Solution... 6 Omeclamox-Pak... 6 Omega-3-Acid Ethyl Esters Capsule... Omeprazole Capsule... 6 Ondansetron... 7 Ondansetron ODT... 7 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 Opana ER Opcicon One Step Opsumit... 2 Option Oracea... 4 Orencia... 8 Orenitram... 2 Orsythia Oseltamivir Capsule, Suspension... 9 Oseni... 5 Osphena... 9 Otezla... 8 Ovidrel... 8 Oxcarbazepine... 3 Oxsoralen-Ultra... 4 Oxybutynin Extended-Release... 20

30 Oxybutynin Oxycodone Oxycodone/Acetaminophen 5/325, 7.5/325, 0/325 mg Oxycontin Ozempic... 5 P Pantoprazole... 6 Paroxetine... 2 Pegasys... 9 Penicillin V Potassium... 9 Perforomist... 2 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 Potassium Citrate Pradaxa... 0 Praluent... Pramipexole... 3 Prasugrel... 0 Pravastatin... Prednisone... 6 Premarin Premphase Prempro Prenisolone Oral Solution... 6 Prepopik... 7 Previfem Prezcobix... 8 Prezista... 8 Pristiq... 2 ProAir HFA/RespiClick... 2 Procrit... 9 Progesterone Micronized Capsule Promethazine/Codeine... 9 Promethazine/Dextromethorphan.. 9 Propranolol Extended-Release Capsule... Propranolol... Proventil HFA... 2 Pulmicort Flexhaler... 2 Pulmozyme... 9 Pylera... 6 Q Qtern... 5 Quasense Quetiapine Extended-Release... 3 Quetiapine... 3 Quinapril... QVAR Redihaler... 2 R Rabeprazole... 6 Raloxifene... 20, 24 Raloxifene Ramipril... Ranexa... Ranitadine Syrup... 6 Rapaflo... 9 Rasuvo... 8 Rebif... 2 Reclipsen Rectiv... 9 Regranex... 4 Repatha... Restasis MultiDose... 6 Restasis Single Use Vials... 6 Revatio... 2 Revlimid... 0 Rezira... 9 Rhofade... 4 Ribavirin... 7 Risedronate Sodium Risperidone... 3 Ritalin LA... Ritalin SR... 2 Ritonavir... 8 Rizatriptan ODT,... 2 Ropinirole... 3 Rosuvastatin Rydapt... 0 S Savaysa... 0 Scopolamine Transdermal Patch... 7 Seebri Neohaler... 2 Segluromet... 5 Selzentry... 8 Serevent Diskus... 2 Sertraline... 2 Setlakin Sevelamer... 9 Sharobel Sildenafil...9, 2 Siliq... 8 Simponi... 8 Simvastatin... Sirolimus Solia Soliqua... 5 Solodyn... 4 Sotalol... Sovaldi... 7 Spiriva Handihaler/ Respimat... 2 Spironolactone... Sprintec Sprix Sronyx Steglatro... 5 Steglujan... 5 Stelara... 8 Stendra... 9 Stiolto Respimat... 2 Stribild... 8 Striverdi Respimat... 2 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

31 Syeda Symbicort... 2 Symfi... 8 Symfi Lo... 8 Symproic... 7 Synjardy, Synjardy XR... 5 Synthroid... 6 Syprine... 9 T Taclonex Suspension... 4 Tacrolimus Capsule Tacrolimus Ointment... 4 Tadalafil... 2 Take Action Taltz... 8 Tamoxifen Tamsulosin Capsule... 9 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..., 9 Terazosin Capsule,... 9 Terbinafine... 9 Testim... 9 Testosterone % Topical Gel... 9 Testosterone Cypionate Injection... 9 Thrive Gum... 2 Tilia Fe Timolol 0.25%, 0.5% Ophthalmic Solution... 6 Tivicay... 8 Tizanidine Tobi Podhaler... 9 Tobramycin Ophthalmic Solution... 6 Tobramycin/Dexamethasone 0.3%-0.% Ophthalmic Suspension... 6 Tolcapone... 3 Topiramate Immediate-Release... 3 Toujeo SoloStar... 5 Toviaz Tracleer... 2 Tradjenta... 5 Tramadol Immediate-Release Tramadol Sustained-Release Tramadol-Acetaminophen Travatan Z... 6 Trazodone... 2 Trelegy Ellipta... 2 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 Trinessa Trinessa Lo Trintellix... 2 Triumeq... 8 Trivora Trulicity... 5 Truvada... 8 Tudorza... 2 Tybost... 8 Tymlos Tyvaso... 2 U Uceris... 7 Uceris Foam... 7 Uceris... 7 Uloric... 7 Uptravi... 2 V Valacyclovir... 9 Valganciclovir... 9 Valsartan... Valsartan-Hydrochlorothiazide... Varubi... 7 Vascepa... Vectical... 4 Velivet Velphoro... 9 Veltassa... 9 Venlafaxine Extended-Release Capsule... 2 Venlafaxine... 2 Ventolin HFA... 2 Verapamil... Verapamil Sustained-Release... Verzenio... 0 Vestura Viagra... 9 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