Your 2018 Prescription Drug List

Transcription

1 Your 208 Prescription List Traditional Three- This Prescription List (PDL) is accurate as of July 208 and is subject to change after this date. The next anticipated update will be January 209. This PDL applies to members of our UnitedHealthcare, River Valley and Oxford medical plans with a pharmacy benefit subject to the Traditional Three- PDL. Your estimated coverage and copayment/coinsurance may vary based on the benefit plan you choose and the effective date of the plan. Effective July, 208

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3 Table of Contents tiers....4 Restrictions on which medications are covered...6 s by category....8 Anti-Infectives Antibiotics...8 Antifungals...8 Antivirals...8 Cancer...8 Cardiovascular/Heart Disease Coagulation Therapy...9 High Blood Pressure...9 High Cholesterol...0 Other...0 Central Nervous System Attention Deficit Disorder...0 Depression...0 Migraine... Multiple Sclerosis... Other... Sedatives/Hypnotics... Seizure Disorders...2 Dermatology...2 Diabetes Blood Glucose Monitoring...3 Insulin...3 Non-Insulin...3 Endocrine Growth Hormone...4 Other...4 Thyroid Hormone Replacement...4 Eye Conditions Allergies...4 Antibiotics...4 Dry Eye Disease...4 Glaucoma...5 Gastrointestinal Acid Suppression...5 Nausea/Vomiting...5 Other...5 Gout...5 Hepatitis C...5 HIV/AIDS...6 Infertility...6 Inflammatory Conditions: Rheumatoid Arthritis, Crohn s Disease, Psoriasis, Ulcerative Colitis...6 Medications for Sexual Dysfuntion...7 Men s Health Prostate...7 Testosterone Therapy...7 Miscellaneous...7 Musculoskeletal Muscle Spasms...7 Osteoporosis...8 Pain Relief...8 Overactive Bladder...8 Respiratory Allergies...8 Asthma/COPD...9 Pulmonary Arterial Hypertension...9 Smoking Cessation...9 Transplant Vitamins/Electrolytes...20 Women s Health Contraceptives...20 Hormone Replacement...22 Miscellaneous...22 Prenatal Vitamins...22 Index...23

4 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 (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. Bring this list with you when you see your doctor. It makes it easier for you and your doctor to make informed decisions about your medications and may help you save money. Please note: Where differences are noted between this PDL and your benefit plan documents, the benefit plan documents will rule. This PDL is not a complete list of medications, and not all medications listed may be covered under your plan. Please look at your benefit plan documents provided by your employer or health plan to see which medications are covered under your plan. What is a tier? s indicate the amount you pay for your prescription, which is determined by your employer or benefit plan. medications provide the highest overall value with the lowest out-of-pocket costs. Choosing medications in lower tiers may save you money. Ask your doctor if a or 2 option could work for you. Your Cost What s Covered Helpful Hints $ Lowest $$ Mid-range $$$ Higher 2 3 Medications that provide the highest overall value. Mostly generic drugs. Some brand-name drugs may also be included. Medications that provide good overall value. A mix of brand-name and generic drugs. Medications that provide the lowest overall value. Mostly brand-name drugs, as well as some generics. 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. Some plans may have different tiers. If you have a high deductible plan, the tier cost levels may apply once you hit your deductible. Who decides 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. 4

5 How is the overall value of a medication determined? Many sources and factors are considered, including: Clinical Value: How safe and effective a medication is compared to other medications used to treat the same or similar medical conditions. Cost: How much a medication costs compared to other medications used to treat similar medical conditions. Outcomes Data: Studies that show how a medication may affect total health care costs. Why are certain medications excluded? We review medications based on their total value, including effectiveness and safety, how much they cost, and the availability of alternative medications to treat the same or similar medical conditions. Certain medications may be excluded from coverage or subject to prior authorization (sometimes referred to as precertification) 2 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 3 ). There are also some instances where the same product can be made by two or more manufacturers, but greatly vary in cost. In these instances, only the lower-cost product may be covered. You should review your benefit plan documents to confirm if any medications are excluded from your plan. You can log in to the member website listed on your health plan ID card at any time to check your medication coverage. Talk to your doctor to see if there are lower-cost options or over-the-counter medications available. 2 Depending on your benefit, you may have notification or medical necessity requirements for select medications. 3 This is not applicable for plans written in New Jersey. For New York plans, a prescription drug product that is therapeutically equivalent to an over-the-counter drug may be covered if it is determined to be medically necessary. What is the difference between brand-name and generic medications? Generic medications contain the same active ingredients (what makes the medication work) as brand-name medications, but they often cost less. Once the patent of a brand-name medication ends, the FDA can approve a generic version with the same active ingredients. These types of medications are known as generic medications. Sometimes, the same company that makes a brand-name medication also makes the generic version. What if my doctor writes a brand-name prescription? The next time your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lower-cost option is available and if it might be right for you. Generic medications are usually your lowest-cost option, but not always. For some benefit plans, if a brand-name drug is prescribed and a generic equivalent is available, your cost-share may be the copayment PLUS the cost difference between the brand-name drug and the generic equivalent. How often are PDLs updated? PDL changes typically occur twice per year. However, changes that have a positive impact for you such as new medications or cost savings may occur at any time. You can log in to the member website listed on your health plan ID card at any time to check your medication coverage and lower-cost options. 5

6 Can a medication change tiers? Yes. changes may generally occur two times per year. When a medication changes tiers, you may pay more or less for that medication, depending on the tier change. If one of your medications changes tiers, speak with your doctor to determine if a lower-cost option may be available for you. Are there other restrictions on which medications are covered? Yes. Some medications may have additional requirements or limits depending on your benefit plan. You should review your benefit plan documents to confirm if any of these programs apply to your plan. The medications that have programs that apply are noted with letters next to them. Examples include: May be excluded from coverage or subject to prior authorization and/or trial/failure of another medication(s). Referred to as First Start in New Jersey. (E) Lower-cost options are available and covered. Health Care Reform Preventive (H) This medication is part of a health care reform preventive benefit and may be available at no additional cost to you. Health Care Reform Preventive with prior authorization (H-PA) May be part of health care reform preventive and available at no additional cost to you if prior authorization criteria is met. Prior Authorization (sometimes referred to as precertification) 4 (PA) Requires your doctor to provide information about why you are taking a medication to determine how it may be covered by your plan. Refill and Save Program 5 (RS) Save money on your copayment when you refill your prescription on time as prescribed. Program eligibility may vary. Specialty Medication (SP) Specialty medications treat complex or rare conditions and may require special storage and handling. You may be required to obtain these medications from a specialty pharmacy. Step Therapy (referred to as First Start in New Jersey) (ST) Requires you to try one or more other medications before the medication you are requesting may be covered. Supply Limits (SL) Specifies the largest quantity of medication covered per copayment or in a defined period of time. 4 Depending on your benefit, you may have notification or medical necessity requirements for select medications. 5 Not applicable to Oxford plans. 6

7 I m taking a specialty medication. Who can I contact for more information? Specialty medications are high-cost and are used to treat rare or complex conditions that require additional care and support. For most plans, these medications are managed through the specialty pharmacy program. Take advantage of personalized support designed to help you get the most out of your treatment plan. Visit 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 health plan ID card to talk with a pharmacist about finding lower-cost options or a financial assistance program. Who can I contact if I have questions about my PDL? Online Log in to the member website listed on your health plan ID card. Once online, you ll have access to the following information and tools: Pharmacy benefit and coverage information Possible lower-cost medication options Medication interactions and side effects Participating retail pharmacies by ZIP code Your prescription history And, if home delivery services are included in your pharmacy benefit, you can also: Refill prescriptions Check the status of your order Set up reminders for refills Manage your account Check your PDL often for updates. By phone Call the toll-free phone number on your health plan ID card to speak with a customer service representative. We can answer any questions you have about your pharmacy benefit plan, including lower-cost options. 7

8 Name Anti-Infectives: Antibiotics Amoxicillin Capsule, Chewable Tablet Amoxicillin/Potassium Clavulanate Chewable Tablet, Tablet Azithromycin Tablet Cefadroxil Capsule, Tablet Cefdinir Capsule Cefixime Suspension Cefprozil Tablet Cefuroxime Tablet Cephalexin Capsule Ciprodex 3 Ciprofloxacin Tablet Clarithromycin Tablet Clindamycin Capsule Dificid 3 SL Doxycycline Hyclate 50, 00 mg Capsule, Tablet Doxycycline Monohydrate 50, 00 mg Capsule Levofloxacin Tablet Metronidazole Tablet Minocycline Capsule Minocycline Tablet E Moxifloxacin Tablet Nitrofurantoin Capsule Nitrofurantoin Macrocrystal Capsule Ofloxacin Otic Solution Ofloxacin Tablet Penicillin V Potassium Tablet Sulfamethoxazole-Trimethoprim Tablet Suprax Capsule, Chewable Tablet, Tablet 3 Name Anti-Infectives: Antifungals Cresemba 3 SL Econazole Cream SL Fluconazole Tablet Itraconazole Capsule SL Ketoconazole Cream SL Noxafil Tablet, Suspension 2 Nystatin Cream, Ointment Terbinafine Tablet SL Anti-Infectives: Antivirals Acyclovir Ointment PA, SL, ST Acyclovir Tablet Famciclovir Tablet Oseltamivir Capsule, Suspension SL Valacyclovir Tablet SL Valganciclovir SL Zovirax Cream 3 E, SL Cancer Alunbrig 2 PA, SL, SP Bexarotene Capsule 3 E, PA, SL, SP Bicalutamide Bosulif 2 PA, SL, SP, ST Cyclophosphamide Capsule 2 Hydroxyurea Capsule Idhifa 2 PA, SL, SP Imantinib Tablet PA, SL, SP Imbruvica 2 PA, SL, SP Leucovorin Calcium Tablet Mercaptopurine Tablet Revlimid 2 PA, SL, SP Rydapt 2 PA, SL, SP Sutent 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 8 PA = Prior authorization required RS = May be eligible for the refill and save program SL = Supply limit SP = Specialty medication ST = Step therapy

9 Name Targretin Capsule SP Targretin Gel 3 SL Tasigna 2 PA, SL, SP, ST Xeloda SL, SP Zykadia 2 PA, SL, SP Zytiga 2 PA, SL, SP Cardiovascular/Heart Disease: Coagulation Therapy Bevyxxa 3 SL Brilinta 3 SL Clopidogrel Eliquis 3 SL Enoxaparin Sodium SL Pradaxa 2 SL Prasugrel SL Savaysa 3 SL Warfarin Sodium Xarelto 2 SL Cardiovascular/Heart Disease: High Blood Pressure Amlodipine Amlodipine-Benazepril Amlodipine-Valsartan Atenolol Atenolol-Chlorthalidone Benazepril Benazepril-Hydrochlorothiazide Bidil 2 Bisoprolol Bisoprolol-Hydrochlorothiazide Bystolic 2 Byvalson 2 SL Cartia XT Carvedilol Immediate-Release Tablet Chlorthalidone Clonidine Tablet Diltiazem 24 Hour CD Diltiazem Sustained-Release Capsule Name Diltiazem Sustained-Release Tablet Doxazosin Edarbi 3 SL Edarbyclor 3 SL Enalapril Furosemide Guanfacine Hydralazine Hydrochlorothiazide Irbesartan Labetalol Lisinopril Lisinopril-Hydrochlorothiazide Losartan Losartan-Hydrochlorothiazide Metoprolol Succinate Extended- Release 50, 00, 200 mg Metoprolol Tartrate 25, 50, 00 mg Nadolol Nifedipine Extended-Release Olmesartan SL Olmesartan-Hydrochlorothiazide SL Propranolol Extended-Release Capsule Propranolol Tablet Quinapril Ramipril Spironolactone Telmisartan Telmisartan-Hydrochlorothiazide Terazosin Triamterene-Hydrochlorothiazide Valsartan Valsartan-Hydrochlorothiazide Verapamil Verapamil Sustained-Release 9

10 Name Cardiovascular/Heart Disease: High Cholesterol Atorvastatin H-PA, SL Choline Fenofibrate E Ezetimibe Tablet SL Ezetimibe/Simvastatin SL Fenofibrate 54, 60 mg Tablet Fluvastatin Extended-Release Tablet SL, ST Gemfibrozil Livalo 3 E, SL, ST Lovastatin H Niacin Extended-Release Tablet Niaspan 3 Omega-3-Acid Ethyl Esters Capsule PA Praluent 2 PA, SL, SP, ST Pravastatin Repatha 3 PA, SL, SP, ST Rosuvastatin SL Simvastatin H-PA Vascepa 3 PA Welchol 2 Cardiovascular/Heart Disease: Other Amiodarone Corlanor 3 PA, SL Digoxin Entresto 3 PA, SL Flecainide Isosorbide Mononitrate ER Multaq 3 PA Nitroglycerin Sublingual Tablet Ranexa 2 Sotalol Name Central Nervous System: Attention Deficit Disorder Adderall XR PA, SL Amphetamine Salt Combo PA Atomoxetine SL Concerta PA, SL Dexmethylphenidate Immediate- Release Tablet PA Dextroamphetamine-Amphetamine Immediate-Release Tablet PA Dextroamphetamine Sulfate Immediate-Release Tablet PA Guanfacine Extended-Release SL Methylphenidate Chewable Tablet PA Methylphenidate Extended-Release Capsule (generic Metadate CD, PA, SL Ritalin LA) Methylphenidate Extended-Release Capsule (Metadate ER, generic PA, SL Ritalin SR) Methylphenidate Extended-Release Tablet (generic Concerta) 3 E, PA, SL Methylphenidate Immediate-Release Tablet PA Vyvanse 2 PA, SL Central Nervous System: Depression Amitriptyline Tablet Bupropion Extended-Release Tablet Bupropion Sustained-Release Tablet Bupropion Tablet Citalopram Tablet Desvenlafaxine Extended-Release Tablet (generic Pristiq) SL Doxepin Duloxetine Capsule SL Escitalopram Tablet Fetzima 3 SL, ST Fluoxetine Capsule (generic Prozac) 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 0 PA = Prior authorization required RS = May be eligible for the refill and save program SL = Supply limit SP = Specialty medication ST = Step therapy

11 Name Fluvoxamine Tablet Mirtazapine Tablet Nortriptyline Capsule Paroxetine Tablet Sertraline Tablet Trazodone Tablet Trintellix 3 SL, ST Venlafaxine Extended-Release Capsule Venlafaxine Tablet Viibryd 3 SL Central Nervous System: Migraine Acetaminophen/Butalbital/Caffeine 325 mg/50 mg/40 mg SL Eletriptan SL Frovatriptan SL Naratriptan SL Rizatriptan ODT, Tablet SL Sumatriptan Nasal Spray SL Sumatriptan Succinate Tablet, Injection SL 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 Copaxone PA, SL, SP Gilenya 3 PA, SL, SP Glatiramer (generic Copaxone) 3 E, PA, SL, SP, ST Plegridy 3 PA, SL, SP Rebif 3 PA, SL, SP, ST Tecfidera 2 PA, SL, SP Zinbryta 3 PA, SL, SP Central Nervous System: Other Alprazolam Extended-Release Tablet Alprazolam Tablet Aripiprazole Tablet SL Name Armodafinil PA, SL Austedo 2 PA, SL, SP Buspirone Tablet Carbidopa-Levodopa Diazepam Tablet Donepezil ODT, 5, 0 mg Tablet Ingrezza 3 PA, SL, SP Latuda 3 SL Lithium Capsule Lorazepam Tablet Memantine Immediate-Release Modafinil Tablet PA, SL Naloxone Vial Narcan Nasal Spray 2 SL Olanzapine Tablet SL Pramipexole Tablet Quetiapine Extended-Release Tablet SL Quetiapine Immediate-Release Tablet Risperidone Tablet Ropinirole Tablet Suboxone Film 3 E, PA, SL Tolcapone Xyrem 3 PA, SL Zelapar 3 Ziprasidone Capsule SL Zubsolv SL Central Nervous System: Sedatives/Hypnotics Eszopiclone Tablet SL Temazepam Capsule Triazolam Tablet Zaleplon Capsule SL Zolpidem Extended-Release Tablet E, SL Zolpidem Immediate-Release Tablet SL

12 Name Central Nervous System: Seizure Disorders Carbamazepine Extended-Release Capsule, Tablet Carbamazepine Immediate-Release Tablet Clonazepam Tablet Diazepam Tablet Divalproex Delayed-Release Tablet Divalproex Extended-Release Tablet Gabapentin Capsule, Tablet Lamotrigine Immediate-Release Tablet Levetiracetam Extended-Release Tablet Levetiracetam Immediate-Release Tablet Lyrica 3 SL, ST Oxcarbazepine Tablet Phenytoin Capsule, Suspension Topiramate Immediate-Release Tablet Zonisamide Capsule Dermatology Aczone SL Adapalene 0.%/Benzoyl Peroxide 2.5% Gel E, SL Adapalene Cream, Gel, Lotion E, PA, SL Betamethasone Dipropionate 0.05% Augmented Lotion, Ointment Betamethasone Dipropionate 0.05% Cream, Ointment Calcipotriene/Betamethasone Ointment SL Carac 2 Ciclopirox Cream, Gel, Lotion, Solution Claravis PA Clindamycin.2%/Benzoyl Peroxide 5% Gel SL Name Clindamycin Gel SL Clindamycin Lotion, Solution, Swabs Clobetasol Propionate Cream, Ointment, Solution SL Clotrimazole-Betamethasone Cream SL Clotrimazole-Betamethasone Lotion Dapsone 5% Gel 3 E, SL Desonide 0.05% Cream, Lotion, Ointment SL Desoximetasone Cream, Gel, Ointment SL Diflorasone Diacetate 0.05% Cream SL Diflorasone Diacetate 0.05% Ointment Dupixent 3 PA, SL, SP, ST Elidel 3 SL, ST Enstilar Foam 3 SL Eucrisa 3 SL, ST Finacea 3 Fluocinonide 0.05% Cream Fluocinolone Cream, Oil, Ointment, Solution SL Fluorouracil 0.5% Cream 3 SL Halobetasol Ointment SL Hydrocortisone 2.5% Cream, Ointment Imiquimod 5% Cream SL Metronidazole 0.75% Topical Gel Minocycline Extended-Release E, PA Mirvaso 3 SL Mometasone Furoate Cream, Lotion, Ointment Mupirocin Ointment SL Oracea 3 Oxsoralen-Ultra 2 Picato 3 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 2 PA = Prior authorization required RS = May be eligible for the refill and save program SL = Supply limit SP = Specialty medication ST = Step therapy

13 Name Regranex 2 PA, SL Rhofade 3 PA, SL Solodyn 3 E, PA Taclonex Suspension 3 SL Tacrolimus Ointment SL, ST Tazarotene 0.% Cream (generic Tazorac) 3 E, PA, SL Tazorac 0.% Cream PA, SL Tazorac Gel, 0.05% Cream 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 6 Accu-Chek Test Strips 3 E, SL Contour Next 2 Contour Next EZ 2 Contour Next One 2 Contour Next Test Strips 2 SL Contour Test Strips 3 E, 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 6 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. Name Diabetes: Insulin 6 Afrezza 3 E, PA, SL Basaglar SL Humalog KwikPens (all formulations) 2 SL Humalog Vials (all formulations) SL Humulin KwikPens (all formulations) 2 SL Humulin Vials (all formulations) SL Lantus Solostar 3 E, SL Lantus Vials 3 E, SL Levemir FlexTouch 2 SL Levemir Vials 2 SL Novolin Vials (all formulations) 3 SL, ST Novolog FlexPen (all formulations) 3 SL, ST Novolog Vials (all formulations) 3 SL, ST Toujeo SoloStar 3 E, SL Tresiba FlexTouch 3 E, SL 6 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 6 Adlyxin 3 SL Bydureon 2 SL Byetta 2 SL Farxiga 3 SL, ST Glimepiride Glipizide Glipizide Extended-Release Glyburide Glyxambi 3 E, SL, ST Invokamet 2 SL Invokamet XR 2 SL Invokana 2 SL, ST Janumet 3 SL, ST 3

14 Name Januvia 3 SL, ST Jardiance 2 SL, ST Jentadueto 2 SL Jentadueto XR 2 SL Kazano 2 SL Kombiglyze XR 2 SL Metformin Metformin Extended-Release Tablet (generic Glucophage XR) Nesina 2 SL Onglyza 2 SL Oseni 2 SL Pioglitazone SL Soliqua 2 PA, SL Synjardy 2 SL 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 Xultophy 3 E, SL 6 Diabetic supplies and prescription medications may be subject to different cost-share arrangements for Oxford plans. Please see your Summary of Benefits and Coverage (SBC) for specifics. Medications that require step therapy may require prior authorization (sometimes referred to as precertification) if covered under another benefit. Endocrine: Growth Hormone 7 Nutropin, Nutropin AQ 2 PA, SL, SP 7 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. Name Endocrine: Other Calcitriol Capsule Desmopressin Tablet Dexamethasone Tablet Methylprednisolone Tablet Prenisolone Oral Solution Prednisone Tablet Endocrine: Thyroid Hormone Replacement Armour Thyroid 3 Levothyroxine Sodium Tablet Liothyronine Sodium Tablet Methimazole Tablet NP Thyroid Tablet Synthroid 2 Eye Conditions: Allergies Azelastine 0.05% Ophthalmic Solution Lastacaft 3 SL Olopatadine 0.% Ophthalmic Solution SL Eye Conditions: Antibiotics Erythromycin 0.5% Ophthalmic Ointment Gentamicin Ophthalmic Ointment, Solution Moxeza 3 Moxifloxacin Ophthalmic Solution Ofloxacin 0.3% Ophthalmic Solution Tobramycin/Dexamethasone 0.3%- 0.% Ophthalmic Suspension Tobramycin Ophthalmic Solution Eye Conditions: Dry Eye Disease Restasis Single Use Vial 3 PA, SL Xiidra 3 PA, SL 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 4 PA = Prior authorization required RS = May be eligible for the refill and save program SL = Supply limit SP = Specialty medication ST = Step therapy

15 Name Eye Conditions: Glaucoma Alphagan P 0.% 2 SL Azopt 2 SL Combigan 2 SL Latanoprost 0.005% Ophthalmic Solution Lumigan 2 SL Timolol 0.25%, 0.5% Ophthalmic Solution Travatan Z 2 SL Gastrointestinal: Acid Suppression Dexilant 3 SL Omeclamox-Pak 3 SL Omeprazole Capsule Pantoprazole Tablet Pylera 3 SL Rabeprazole Tablet SL Ranitadine Syrup Sucralfate Tablet Gastrointestinal: Nausea/Vomiting Akynzeo 3 SL Aprepitant Capsule SL Emend Suspension 2 SL Ondansetron Ondansetron ODT Scopolamine Transdermal Patch Varubi 2 SL Gastrointestinal: Other Amitiza 3 PA, SL, ST Apriso 2 Canasa 2 Cortifoam 2 Creon 2 Diphenoxylate-Atropine Tablet Golytely 2 Hyoscyamine Tablet Name Lialda Linzess 2 PA, SL Mesalmine Delayed-Release Tablet (generic Lialda) 3 E Metoclopramide Tablet Movantik 2 PA, SL Moviprep 3 Polyethylene Glycol 3350 Prepopik 3 Sulfasalazine Tablet Suprep 3 Uceris Foam 2 Uceris Tablet 3 Viberzi 3 PA, SL Zenpep 2 Gout Allopurinol Tablet Mitigare 2 Uloric 3 SL, ST Zurampic 3 PA, SL Hepatitis C Daklinza 3 PA, SL, SP, ST Epclusa 2 PA, SL, SP Harvoni 2 PA, SL, SP Mavyret 2 PA, SL, SP Ribavirin Tablet 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 5

16 Name HIV/AIDS Abacavir-Lamivudine SP Atazanavir Capsule SP Atripla 2 SP Complera 3 SP Descovy 3 SP Efavirenz SP Epzicom 3 E, SP Evotaz 2 SP Genvoya 3 SP, ST Intelence 2 SP Isentress 2 SP Kaletra Tablet 2 SP Lamivudine-Zidovudine SP Lopinavir-Ritonavir Oral Solution SP Nevirapine SP Nevirapine Extended-Release E, SP Norvir 2 SP Odefsey 3 SP Prezcobix 2 SP Prezista 2 SP Selzentry 2 PA, SP Stribild 3 SP, ST Tenofovir Tablet SP Tivicay 3 SP Triumeq 2 SP Truvada 3 SP Tybost 2 SP Vitekta 2 SP Name Infertility 7 Cetrotide 2 SP Clomiphene SP Crinone 2 PA, ST Endometrin 2 PA Gonal-F 2 SP Gonal-F RFF 2 SP Ovidrel 3 SP 7 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 Tablet Orencia 3 PA, SL, SP, ST Otezla 2 PA, SL, SP Otrexup 3 E, SL, ST Rasuvo 3 SL, ST 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 3 PA, SL, SP, ST Xeljanz XR 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 6 PA = Prior authorization required RS = May be eligible for the refill and save program SL = Supply limit SP = Specialty medication ST = Step therapy

17 Name Medications for Sexual Dysfunction 7 Addyi 3 PA, SL Cialis 3 SL Intrarosa 3 SL Levitra 3 SL Osphena 3 SL Sildenafil Tablet (generic Viagra) SL Stendra 3 PA, SL 7 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 Tablet Doxazosin Tablet Dutasteride Capsule Finasteride Tablet Rapaflo 3 Tamsulosin Capsule Terazosin Capsule, Tablet Men s Health: Testosterone Therapy Androderm 2 PA, SL Androgel 3 E, PA, SL Methyltestosterone Capsule Testim PA, SL Testosterone % Topical Gel E, PA, SL Testosterone Cypionate Injection Miscellaneous Anastrozole Tablet Aranesp 2 SL, SP Auryxia 3 Bethkis PA, SL, SP Cayston 2 PA, SL Cerdelga 2 PA, SP Chlorhexidine Gluconate Name Chlorpheniramine/Hydrocodone/ Pseudoephedrine Solution PA, SL Epinephrine (generic EpiPen/ EpiPen-Jr.) 2 SL EpiPen/EpiPen Jr. 3 E, SL Hydrocodone/Chlorpheniramine Suspension PA, SL Lanthanum Chewable Tablet Letrozole Lidocaine Transdermal Patch (generic Lidoderm) PA, SL Nityr 2 PA, SP Nuedexta 2 PA Obredon 3 PA, SL, ST Pegasys 2 PA, SL, SP Phenazopyridine Procrit 2 SL, SP Promethazine/Codeine PA Promethazine/Dextromethorphan Pulmozyme 2 PA, SL, SP Rectiv 3 SL Rezira 3 Sevelamer Syprine 3 PA, SP Tobi Podhaler 3 PA, SL, SP Velphoro 2 Veltassa 3 PA, SL Zarxio 2 SP Musculoskeletal: Muscle Spasms Baclofen Tablet Carisoprodol 350 mg Tablet Cyclobenzaprine Metaxalone Tablet Methocarbamol Tablet Tizanidine Tablet 7

18 Name Musculoskeletal: Osteoporosis Alendronate Sodium Tablet Forteo 3 PA, SP Ibandronate Tablet SL Raloxifene Tablet Risedronate Sodium Tablet SL Tymlos 3 PA, SP Musculoskeletal: Pain Relief Acetaminophen/Codeine Tablet SL Belbuca 3 PA, SL Celecoxib SL Diclofenac Tablet Etodolac Capsule Fentanyl 2, 25, 50, 75, 00 mcg Patch PA, SL Fentanyl Citrate Lozenge PA, SL Hydrocodone/Acetaminophen 5/325, 7.5/325, 0/325 mg Tablet SL Hydrocodone/Ibuprofen Tablet Hydromorphone Immediate-Release Tablet Ibuprofen Tablet Indomethacin Capsule Ketorolac Tablet Lazanda 3 PA, SL Meloxicam Tablet Methadone Tablet, Oral Solution, Concentrate Solution PA, SL Morphine Sulfate Extended-Release Tablet PA, SL Morphine Sulfate Oral Solution Nabumetone Tablet Naproxen Tablet Nucynta 3 SL Name Nucynta ER 3 PA, SL Oxycodone/Acetaminophen 5/325, 7.5/325, 0/325 mg Tablet SL Oxycodone Tablet Oxycontin 3 E, PA, SL, ST Sprix 3 Tramadol-Acetaminophen Tramadol Immediate-Release Tablet Tramadol Sustained-Release Tablet SL Trezix SL Vicodin 5/300, 7.5/300, 0/300 mg Tablet E, SL Voltaren Gel 2 Xtampza ER 2 PA, SL Zohydro ER 3 PA, SL, ST Overactive Bladder Dicyclomine Tablet Oxybutynin Extended-Release Tablet Oxybutynin Tablet Toviaz 3 Respiratory: Allergies Azelastine 0.% Nasal Spray Cyproheptadine Tablet Fluticasone Nasal Spray SL Hydroxyzine Capsule, Tablet Levocetirizine Tablet Promethazine Tablet Zetonna 3 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 8 PA = Prior authorization required RS = May be eligible for the refill and save program SL = Supply limit SP = Specialty medication ST = Step therapy

19 Name Respiratory: Asthma/COPD Advair Diskus/HFA 3 RS, SL Albuterol Nebs Alvesco SL Anoro Ellipta 3 SL Arnuity Ellipta 3 SL Asmanex TwistHaler, HFA SL Bevespi Aerosphere 2 SL Breo Ellipta 3 RS, SL Budesonide Nebs SL Combivent Respimat 3 SL Dulera 3 E, SL, ST Flovent Diskus/HFA 3 SL Fluticasone/Salmeterol RespiClick (generic AirDuo RespiClick) SL Incruse Ellipta 2 SL Ipratropium-Albuterol Nebs Ipratropium Nebs Levalbuterol Nebs E, SL Montelukast Perforomist 3 SL ProAir HFA/RespiClick 3 SL Proventil HFA 3 SL Pulmicort Flexhaler 3 SL, ST QVAR Redihaler SL Serevent Diskus 3 SL Spiriva Handihaler/Respimat 3 SL Striverdi Respimat 2 SL Symbicort 3 RS, SL Tudorza 2 SL Ventolin HFA 2 SL Xopenex HFA 3 SL Name Respiratory: Pulmonary Arterial Hypertension Adcirca 3 PA, SL, SP Adempas 2 PA, SL, SP Letairis 2 PA, SL, SP Opsumit 2 PA, SL, SP Orenitram 3 PA, SL, SP Sildenafil Tablet (generic Revatio) SL, SP Tracleer 2 PA, SL, SP Tyvaso 2 PA, SP Uptravi 3 PA, SL, SP Smoking Cessation Bupropion Sustained-Release Tablet H-PA Chantix Tablet 3 H-PA Nicoderm CQ 3 H-PA Nicorette Gum 3 H-PA Nicorette Lozenge 2 H-PA Nicorette Mini-Lozenge 2 H-PA Nicotine Gum H-PA Nicotine Lozenge H-PA Nicotine Patch H-PA Nicotrol Inhaler 3 H-PA Nicotrol Nasal Spray 3 H-PA Thrive Gum H-PA Transplant Azathioprine Tablet Cyclosporine Modified Capsule SP Mycophenolate Capsule, Suspension SP Mycophenolic Acid Tablet SP Sirolimus Tablet SP Tacrolimus Capsule SP 9

20 Name Vitamins/Electrolytes Fluoride Folic Acid Klor-Con M0 Klor-Con M20 Potassium Chloride Potassium Citrate Women s Health: Contraceptives Aftera H Altavera H Alyacen 7/7/7, /35 H Amethia H Amethia Lo H Amethyst H Apri H Aranelle H Ashlyna H Aubra H Aviane H Azurette H Balziva H Bekyree H Blisovi Fe H Blisovi 24 Fe H Briellyn H Camila H Camrese H Camrese Lo H Caziant H Cesia H Chateal H Cryselle H Name 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 Drospirenone/Ethinyl Estradiol/ Levomefolate Calcium E Econtra EZ H Elinest H Ella H, SL Emoquette H Enpresse H Enskyce H Errin H Estarylla H Fallback H Falmina H Fayosim E Gianvi H Gildagia H Gildess H Gildess 24 Fe H Gildess Fe H Heather H Introvale H Jencycla H Jolessa H Jolivette H Juleber 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 20 PA = Prior authorization required RS = May be eligible for the refill and save program SL = Supply limit SP = Specialty medication ST = Step therapy

21 Name Junel H Junel 24 Fe H Junel Fe H Kariva H Kimidess H Kurvelo H Kelnor /35 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 Lo Loestrin Fe 3 LoMedia 24 Fe H Loryna H Low-Ogestrel H Lutera H Lyza H Marlissa H Medroxyprogesterone Acetate H Mibelas 24 Fe Chewable Tablet E Microgestin H Microgestin Fe H Mono-Linyah H Mononessa H My Way H Myzilra H Natazia 2 Necon 7/7/7, 0.5/35, /35, /50, 0/ H Next Choice H Name Nikki H Nora BE H Norethindrone 0.35 mg H Norethindrone-Ethinyl Estradiol- Ferrous Fumarate H Norgestimate-Ethinyl Estradiol H Norlyroc H Nortrel 7/7/7, 0.5/35, /35 H Nuvaring 2 H Ocella H Ogestrel H Opcicon H Orsythia H Philith H Pimtrea H Pirmella 7/7/7, /35 H Plan B One Step H Portia H Previfem H Quasense H Rajani E Reclipsen H Rivelsa E Setlakin H Sharobel H Solia H Sprintec H Sronyx H Syeda H Take Action H Tarina Fe H Tilia Fe H Tri-Estarylla H Tri-Legest Fe H Tri-Linyah H Tri-Lo-Estarylla H 2

22 Name Tri-Lo-Marzia H Tri-Lo-Sprintec H Tri-Previfem H Tri-Sprintec H Trinessa H Trinessa Lo H Trivora-28 H Velivet H Vestura H Vienva H Viorele H Vyfemla H Wera H Wymza Fe H Xulane H Yasmin 28 3 Yaz 3 Zarah H Zenchent H Zenchent Fe H Zovia /35E, /50E H Women s Health: Hormone Replacement Climara Pro 3 SL Divigel 3 Duavee 3 SL Estrace Cream Estradiol Cream (generic Estrace) 3 E Estradiol/Norethindrone Acetate Tablet Name Estradiol Tablet Estradiol Twice-Weekly Transdermal Patch (generic Vivelle-Dot) Estradiol Weekly Transdermal Patch (generic Climara) 3 E, SL SL Estring 2 SL Estrogen/Methyltestosterone Tablet Evamist 2 Medroxyprogesterone Minivelle 3 SL Premarin 3 Premphase 3 Prempro 3 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 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 22 PA = Prior authorization required RS = May be eligible for the refill and save program SL = Supply limit SP = Specialty medication ST = Step therapy

23 Index A Abacavir-Lamivudine... 6 Accu-Chek Test Strips... 3 Acetaminophen/Butalbital/Caffeine 325 mg/50 mg/40 mg... Acetaminophen/Codeine Tablet... 8 Actemra... 6 Acyclovir Ointment... 8 Acyclovir Tablet... 8 Aczone... 2 Adapalene 0.%/Benzoyl Peroxide 2.5% Gel... 2 Adapalene Cream, Gel, Lotion... 2 Adcirca... 9 Adderall XR... 0 Addyi... 7 Adempas... 9 Adlyxin... 3 Advair Diskus/HFA... 9 Afrezza... 3 Aftera...20 AirDuo RespiClick... 9 Akynzeo... 5 Albuterol Nebs... 9 Alendronate Sodium Tablet... 8 Alfuzosin Tablet... 7 Allopurinol Tablet... 5 Alphagan P 0.%... 5 Alprazolam Extended-Release Tablet... Alprazolam Tablet... Altavera...20 Alunbrig... 8 Alvesco... 9 Alyacen 7/7/7, / Amethia...20 Amethia Lo...20 Amethyst...20 Amiodarone... 0 Amitiza... 5 Amitriptyline Tablet... 0 Amlodipine... 9 Amlodipine-Benazepril... 9 Amlodipine-Valsartan... 9 Amoxicillin Capsule, Chewable Tablet... 8 Amoxicillin/Potassium Clavulanate Chewable Tablet, Tablet... 8 Amphetamine Salt Combo... 0 Ampyra... Anastrozole Tablet... 7 Androderm... 7 Androgel... 7 Anoro Ellipta... 9 Aprepitant Capsule... 5 Apri...20 Apriso... 5 Aranelle...20 Aranesp... 7 Aripiprazole Tablet... Armodafinil... Armour Thyroid... 4 Arnuity Ellipta... 9 Ashlyna...20 Asmanex TwistHaler, HFA... 9 Atazanavir Capsule... 6 Atenolol... 9 Atenolol-Chlorthalidone... 9 Atomoxetine... 0 Atorvastatin... 0 Atripla... 6 Aubagio... Aubra...20 Auryxia... 7 Austedo... Aviane...20 Avonex... Azathioprine Tablet... 9 Azelastine 0.05% Ophthalmic Solution... 4 Azelastine 0.% Nasal Spray... 8 Azithromycin Tablet... 8 Azopt... 5 Azurette...20 B Baclofen Tablet... 7 Balziva...20 Basaglar... 3 Bekyree...20 Belbuca... 8 Benazepril... 9 Benazepril-Hydrochlorothiazide... 9 Betamethasone Dipropionate 0.05% Augmented Lotion, Ointment... 2 Betamethasone Dipropionate 0.05% Cream, Ointment... 2 Betaseron... Bethkis... 7 Bevespi Aerosphere... 9 Bevyxxa... 9 Bexarotene Capsule... 8 Bicalutamide... 8 Bidil... 9 Bisoprolol... 9 Bisoprolol-Hydrochlorothiazide... 9 Blisovi 24 Fe...20 Blisovi Fe...20 Bosulif... 8 Brand Prenatal Vitamins...22 Breo Ellipta... 9 Briellyn...20 Brilinta... 9 Budesonide Nebs... 9 Bupropion Extended-Release Tablet... 0 Bupropion Sustained-Release Tablet... 0, 9 Bupropion Tablet... 0 Buspirone Tablet... Bydureon... 3 Byetta... 3 Bystolic... 9 Byvalson... 9 C Calcipotriene/Betamethasone Ointment... 2 Calcitriol Capsule... 4 Camila...20 Camrese...20 Camrese Lo...20 Canasa... 5 Carac... 2 Carbamazepine Extended-Release Capsule, Tablet... 2 Carbamazepine Immediate-Release Tablet... 2 Carbidopa-Levodopa... Carisoprodol 350 mg Tablet... 7 Cartia XT... 9 Carvedilol Immediate-Release Tablet

24 Cayston... 7 Caziant...20 Cefadroxil Capsule, Tablet... 8 Cefdinir Capsule... 8 Cefixime Suspension... 8 Cefprozil Tablet... 8 Cefuroxime Tablet... 8 Celecoxib... 8 Cephalexin Capsule... 8 Cerdelga... 7 Cesia...20 Cetrotide... 6 Chantix Tablet... 9 Chateal...20 Chlorhexidine Gluconate... 7 Chlorpheniramine/Hydrocodone/ Pseudoephedrine Solution... 7 Chlorthalidone... 9 Choline Fenofibrate... 0 Cialis... 7 Ciclopirox Cream, Gel, Lotion, Solution... 2 Cimzia... 6 Ciprodex... 8 Ciprofloxacin Tablet... 8 Citalopram Tablet... 0 Claravis... 2 Clarithromycin Tablet... 8 Climara...22 Climara Pro...22 Clindamycin.2%/Benzoyl Peroxide 5% Gel... 2 Clindamycin Capsule... 8 Clindamycin Gel... 2 Clindamycin Lotion, Solution, Swabs... 2 Clobetasol Propionate Cream, Ointment, Solution... 2 Clomiphene... 6 Clonazepam Tablet... 2 Clonidine Tablet... 9 Clopidogrel... 9 Clotrimazole-Betamethasone Cream... 2 Clotrimazole-Betamethasone Lotion... 2 Combigan... 5 Combivent Respimat... 9 Complera... 6 Concerta... 0 Contour Next... 3 Contour Next EZ... 3 Contour Next One... 3 Contour Next Test Strips... 3 Contour Test Strips... 3 Copaxone... Corlanor... 0 Cortifoam... 5 Cosentyx... 6 Creon... 5 Cresemba... 8 Crinone... 6 Cryselle...20 Cyclafem 7/7/7, / Cyclobenzaprine... 7 Cyclophosphamide Capsule... 8 Cyclosporine Modified Capsule... 9 Cyproheptadine Tablet... 8 Cyred...20 D Daklinza... 5 Dapsone 5% Gel... 2 Dasetta 7/7/7, / Daysee...20 Deblitane...20 Delyla...20 Descovy... 6 Desmopressin Tablet... 4 Desogestrel-Ethinyl Estradiol...20 Desonide 0.05% Cream, Lotion, Ointment... 2 Desoximetasone Cream, Gel, Ointment... 2 Desvenlafaxine Extended-Release Tablet... 0 Dexamethasone Tablet... 4 Dexilant... 5 Dexmethylphenidate Immediate-Release Tablet... 0 Dextroamphetamine Sulfate Immediate-Release Tablet... 0 Dextroamphetamine-Amphetamine Immediate-Release Tablet... 0 Diazepam Tablet..., 2 Diclofenac Tablet... 8 Dicyclomine Tablet... 8 Dificid... 8 Diflorasone Diacetate 0.05% Cream... 2 Diflorasone Diacetate 0.05% Ointment... 2 Digoxin... 0 Diltiazem 24 Hour CD... 9 Diltiazem Sustained-Release Capsule... 9 Diltiazem Sustained-Release Tablet... 9 Diphenoxylate-Atropine Tablet... 5 Divalproex Delayed-Release Tablet... 2 Divalproex Extended-Release Tablet... 2 Divigel...22 Donepezil ODT, 5, 0 mg Tablet... Doxazosin...9, 7 Doxazosin Tablet... 7 Doxepin... 0 Doxycycline Hyclate 50, 00 mg Capsule, Tablet... 8 Doxycycline Monohydrate 50, 00 mg Capsule... 8 Drospirenone/Ethinyl Estradiol...20 Drospirenone/Ethinyl Estradiol/ Levomefolate Calcium...20 Duavee...22 Dulera... 9 Duloxetine Capsule... 0 Dupixent... 2 Dutasteride Capsule... 7 E Econazole Cream... 8 Econtra EZ...20 Edarbi... 9 Edarbyclor... 9 Efavirenz... 6 Eletriptan... Elidel... 2 Elinest...20 Eliquis... 9 Ella...20 Emend Suspension... 5 Emoquette...20 Enalapril... 9 Enbrel... 6 Endometrin... 6 Enoxaparin Sodium... 9 Enpresse...20 Enskyce...20 Enstilar Foam... 2 Entresto

25 Epclusa... 5 Epinephrine... 7 EpiPen/EpiPen Jr... 7 EpiPen/EpiPen-Jr... 7 Epzicom... 6 Errin...20 Erythromycin 0.5% Ophthalmic Ointment... 4 Escitalopram Tablet... 0 Estarylla...20 Estrace...22 Estrace Cream...22 Estradiol Cream...22 Estradiol Tablet...22 Estradiol Twice-Weekly Transdermal Patch...22 Estradiol Weekly Transdermal Patch...22 Estradiol/Norethindrone Acetate Tablet...22 Estring...22 Estrogen/Methyltestosterone Tablet..22 Eszopiclone Tablet... Etodolac Capsule... 8 Eucrisa... 2 Evamist...22 Evotaz... 6 Ezetimibe Tablet... 0 Ezetimibe/Simvastatin... 0 F Fallback...20 Falmina...20 Famciclovir Tablet... 8 Farxiga... 3 Fayosim...20 Fenofibrate 54, 60 mg Tablet... 0 Fentanyl 2, 25, 50, 75, 00 mcg Patch... 8 Fentanyl Citrate Lozenge... 8 Fetzima... 0 Finacea... 2 Finasteride Tablet... 7 Flecainide... 0 Flovent Diskus/HFA... 9 Fluconazole Tablet... 8 Fluocinolone Cream, Oil, Ointment, Solution... 2 Fluocinonide 0.05% Cream... 2 Fluoride...20 Fluorouracil 0.5% Cream... 2 Fluoxetine Capsule... 0 Fluticasone Nasal Spray... 8 Fluticasone/Salmeterol RespiClick... 9 Fluvastatin Extended-Release Tablet... 0 Fluvoxamine Tablet... Folic Acid...20 Forteo... 8 FreeStyle Test Strips... 3 Frovatriptan... Furosemide... 9 G Gabapentin Capsule, Tablet... 2 Gemfibrozil... 0 Gentamicin Ophthalmic Ointment, Solution... 4 Genvoya... 6 Gianvi...20 Gildagia...20 Gildess...20 Gildess 24 Fe...20 Gildess Fe...20 Gilenya... Glatiramer... Glimepiride... 3 Glipizide... 3 Glipizide Extended-Release... 3 Glucophage XR... 4 Glyburide... 3 Glyxambi... 3 Golytely... 5 Gonal-F... 6 Gonal-F RFF... 6 Guanfacine...9, 0 Guanfacine Extended-Release... 0 H Halobetasol Ointment... 2 Harvoni... 5 Heather...20 Humalog KwikPens... 3 Humalog Vials... 3 Humira... 6 Humulin KwikPens... 3 Humulin Vials... 3 Hydralazine... 9 Hydrochlorothiazide... 9 Hydrocodone/Acetaminophen 5/325, 7.5/325, 0/325 mg Tablet... 8 Hydrocodone/Chlorpheniramine Suspension... 7 Hydrocodone/Ibuprofen Tablet... 8 Hydrocortisone 2.5% Cream, Ointment... 2 Hydromorphone Immediate-Release Tablet... 8 Hydroxychloroquine Sulfate... 6 Hydroxyurea Capsule... 8 Hydroxyzine Capsule, Tablet... 8 Hyoscyamine Tablet... 5 Ibandronate Tablet... 8 Ibuprofen Tablet... 8 Idhifa... 8 Imantinib Tablet... 8 Imbruvica... 8 Imiquimod 5% Cream... 2 Incruse Ellipta... 9 Indomethacin Capsule... 8 Ingrezza... Intelence... 6 Intrarosa... 7 Introvale...20 Invokamet... 3 Invokamet XR... 3 Invokana... 3 Ipratropium Nebs... 9 Ipratropium-Albuterol Nebs... 9 Irbesartan... 9 Isentress... 6 Isosorbide Mononitrate ER... 0 Itraconazole Capsule... 8 I J Janumet... 3 Januvia... 4 Jardiance... 4 Jencycla...20 Jentadueto... 4 Jentadueto XR... 4 Jolessa...20 Jolivette...20 Juleber...20 Junel...2 Junel 24 Fe...2 Junel Fe...2 K Kaletra Tablet

26 Kariva...2 Kazano... 4 Kelnor / Ketoconazole Cream... 8 Ketorolac Tablet... 8 Kevzara... 6 Kimidess...2 Klor-Con M Klor-Con M Kombiglyze XR... 4 Kurvelo...2 L Labetalol... 9 Lamivudine-Zidovudine... 6 Lamotrigine Immediate-Release Tablet... 2 Lanthanum Chewable Tablet... 7 Lantus Solostar... 3 Lantus Vials... 3 Larin... 2 Larin 24 Fe...2 Larin Fe... 2 Larissia...2 Lastacaft... 4 Latanoprost 0.005% Ophthalmic Solution... 5 Latuda... Lazanda... 8 Leena... 2 Leflunomide... 6 Lessina...2 Letairis... 9 Letrozole... 7 Leucovorin Calcium Tablet... 8 Levalbuterol Nebs... 9 Levemir FlexTouch... 3 Levemir Vials... 3 Levetiracetam Extended-Release Tablet... 2 Levetiracetam Immediate-Release Tablet... 2 Levitra... 7 Levocetirizine Tablet... 8 Levofloxacin Tablet... 8 Levonest...2 Levonorgestrel.5 mg...2 Levonorgestrel-Ethinyl Estradiol... 2 Levora Levothyroxine Sodium Tablet... 4 Lialda... 5 Lidocaine Transdermal Patch... 7 Lidoderm... 7 Linzess... 5 Liothyronine Sodium Tablet... 4 Lisinopril... 9 Lisinopril-Hydrochlorothiazide... 9 Lithium Capsule... Livalo... 0 Lo Loestrin Fe...2 LoMedia 24 Fe...2 Lopinavir-Ritonavir Oral Solution... 6 Lorazepam Tablet... Loryna...2 Losartan... 9 Losartan-Hydrochlorothiazide... 9 Lovastatin... 0 Low-Ogestrel...2 Lumigan... 5 Lutera...2 Lyrica... 2 Lyza...2 M Marlissa...2 Mavyret... 5 Medroxyprogesterone... 2, 22 Medroxyprogesterone Acetate...2 Meloxicam Tablet... 8 Memantine Immediate-Release... Mercaptopurine Tablet... 8 Mesalmine Delayed-Release Tablet... 5 Metadate CD... 0 Metadate ER... 0 Metaxalone Tablet... 7 Metformin... 4 Metformin Extended-Release Tablet... 4 Methadone Tablet, Oral Solution, Concentrate Solution... 8 Methimazole Tablet... 4 Methocarbamol Tablet... 7 Methotrexate Tablet... 6 Methylphenidate Chewable Tablet... 0 Methylphenidate Extended-Release Capsule... 0 Methylphenidate Extended-Release Tablet... 0 Methylphenidate Immediate-Release Tablet... 0 Methylprednisolone Tablet... 4 Methyltestosterone Capsule... 7 Metoclopramide Tablet... 5 Metoprolol Succinate Extended-Release 50, 00, 200 mg... 9 Metoprolol Tartrate 25, 50, 00 mg... 9 Metronidazole 0.75% Topical Gel... 2 Metronidazole Tablet... 8 Mibelas 24 Fe Chewable Tablet...2 Microgestin...2 Microgestin Fe...2 Minivelle...22 Minocycline Capsule... 8 Minocycline Extended-Release... 2 Minocycline Tablet... 8 Mirtazapine Tablet... Mirvaso... 2 Mitigare... 5 Modafinil Tablet... Mometasone Furoate Cream, Lotion, Ointment... 2 Mono-Linyah...2 Mononessa...2 Montelukast... 9 Morphine Sulfate Extended-Release Tablet... 8 Morphine Sulfate Oral Solution... 8 Movantik... 5 Moviprep... 5 Moxeza... 4 Moxifloxacin Ophthalmic Solution... 4 Moxifloxacin Tablet... 8 Multaq... 0 Mupirocin Ointment... 2 My Way...2 Mycophenolate Capsule, Suspension... 9 Mycophenolic Acid Tablet... 9 Myzilra...2 N Nabumetone Tablet... 8 Nadolol... 9 Naloxone Vial... Naproxen Tablet... 8 Naratriptan... Narcan Nasal Spray... Natazia

27 Necon 7/7/7, 0.5/35, /35, /50, 0/...2 Nesina... 4 Nevirapine... 6 Nevirapine Extended-Release... 6 Next Choice...2 Niacin Extended-Release Tablet... 0 Niaspan... 0 Nicoderm CQ... 9 Nicorette Gum... 9 Nicorette Lozenge... 9 Nicorette Mini-Lozenge... 9 Nicotine Gum... 9 Nicotine Lozenge... 9 Nicotine Patch... 9 Nicotrol Inhaler... 9 Nicotrol Nasal Spray... 9 Nifedipine Extended-Release... 9 Nikki...2 Nitrofurantoin Capsule... 8 Nitrofurantoin Macrocrystal Capsule... 8 Nitroglycerin Sublingual Tablet... 0 Nityr... 7 Nora BE...2 Norethindrone 0.35 mg... 2 Norethindrone-Ethinyl Estradiol-Ferrous Fumarate... 2 Norgestimate-Ethinyl Estradiol... 2 Norlyroc... 2 Nortrel 7/7/7, 0.5/35, / Nortriptyline Capsule... Norvir... 6 Novolin Vials... 3 Novolog FlexPen... 3 Novolog Vials... 3 Noxafil Tablet, Suspension... 8 NP Thyroid Tablet... 4 Nucynta... 8 Nucynta ER... 8 Nuedexta... 7 Nutropin, Nutropin AQ... 4 Nuvaring...2 Nystatin Cream, Ointment... 8 O Obredon... 7 Ocella...2 Odefsey... 6 Ofloxacin 0.3% Ophthalmic Solution.. 4 Ofloxacin Otic Solution... 8 Ofloxacin Tablet... 8 Ogestrel...2 Olanzapine Tablet... Olmesartan... 9 Olmesartan-Hydrochlorothiazide... 9 Olopatadine 0.% Ophthalmic Solution... 4 Omeclamox-Pak... 5 Omega-3-Acid Ethyl Esters Capsule.. 0 Omeprazole Capsule... 5 Ondansetron... 5 Ondansetron ODT... 5 OneTouch Test Strips... 3 OneTouch Ultra Mini... 3 OneTouch Ultra Test Strips... 3 OneTouch Verio... 3 OneTouch Verio Flex... 3 OneTouch Verio IQ... 3 OneTouch Verio Sync... 3 OneTouch Verio Test Strips... 3 Onglyza... 4 Opcicon...2 Opsumit... 9 Oracea... 2 Orencia... 6 Orenitram... 9 Orsythia...2 Oseltamivir Capsule, Suspension... 8 Oseni... 4 Osphena... 7 Otezla... 6 Otrexup... 6 Ovidrel... 6 Oxcarbazepine Tablet... 2 Oxsoralen-Ultra... 2 Oxybutynin Extended-Release Tablet... 8 Oxybutynin Tablet... 8 Oxycodone Tablet... 8 Oxycodone/Acetaminophen 5/325, 7.5/325, 0/325 mg Tablet... 8 Oxycontin... 8 P Pantoprazole Tablet... 5 Paroxetine Tablet... Pegasys... 7 Penicillin V Potassium Tablet... 8 Perforomist... 9 Phenazopyridine... 7 Phenytoin Capsule, Suspension... 2 Philith...2 Picato... 2 Pimtrea...2 Pioglitazone... 4 Pirmella 7/7/7, / Plan B One Step...2 Plegridy... Polyethylene Glycol Portia...2 Potassium Chloride...20 Potassium Citrate...20 Pradaxa... 9 Praluent... 0 Pramipexole Tablet... Prasugrel... 9 Pravastatin... 0 Prednisone Tablet... 4 Premarin...22 Premphase...22 Prempro...22 Prenisolone Oral Solution... 4 Prepopik... 5 Previfem...2 Prezcobix... 6 Prezista... 6 Pristiq... 0 ProAir HFA/RespiClick... 9 Procrit... 7 Progesterone Micronized Capsule...22 Promethazine Tablet... 8 Promethazine/Codeine... 7 Promethazine/Dextromethorphan... 7 Propranolol Extended-Release Capsule... 9 Propranolol Tablet... 9 Proventil HFA... 9 Prozac... 0 Pulmicort Flexhaler... 9 Pulmozyme... 7 Pylera... 5 Q Quasense...2 Quetiapine Extended-Release Tablet. Quetiapine Immediate-Release Tablet. Quinapril... 9 QVAR Redihaler... 9 R Rabeprazole Tablet

28 Rajani...2 Raloxifene...8, 22 Raloxifene Tablet... 8 Ramipril... 9 Ranexa... 0 Ranitadine Syrup... 5 Rapaflo... 7 Rasuvo... 6 Rebif... Reclipsen...2 Rectiv... 7 Regranex... 3 Repatha... 0 Restasis Single Use Vial... 4 Revatio... 9 Revlimid... 8 Rezira... 7 Rhofade... 3 Ribavirin Tablet... 5 Risedronate Sodium Tablet... 8 Risperidone Tablet... Ritalin LA... 0 Ritalin SR... 0 Rivelsa...2 Rizatriptan ODT, Tablet... Ropinirole Tablet... Rosuvastatin... 0 Rydapt... 8 S Savaysa... 9 Scopolamine Transdermal Patch... 5 Selzentry... 6 Serevent Diskus... 9 Sertraline Tablet... Setlakin...2 Sevelamer... 7 Sharobel... 2 Sildenafil Tablet...7, 9 Siliq... 6 Simponi... 6 Simvastatin... 0 Sirolimus Tablet... 9 Solia... 2 Soliqua... 4 Solodyn... 3 Sotalol... 0 Sovaldi... 5 Spiriva Handihaler/Respimat... 9 Spironolactone... 9 Sprintec...2 Sprix... 8 Sronyx...2 Stelara... 6 Stendra... 7 Stribild... 6 Striverdi Respimat... 9 Suboxone Film... Sucralfate Tablet... 5 Sulfamethoxazole-Trimethoprim Tablet... 8 Sulfasalazine Tablet... 5 Sumatriptan Nasal Spray... Sumatriptan Succinate Tablet, Injection... Suprax Capsule, Chewable Tablet, Tablet... 8 Suprep... 5 Sutent... 8 Syeda...2 Symbicort... 9 Synjardy... 4 Synjardy XR... 4 Synthroid... 4 Syprine... 7 T Taclonex Suspension... 3 Tacrolimus Capsule... 9 Tacrolimus Ointment... 3 Take Action...2 Taltz... 6 Tamoxifen...22 Tamsulosin Capsule... 7 Targretin Capsule... 9 Targretin Gel... 9 Tarina Fe...2 Tasigna... 9 Tazarotene 0.% Cream... 3 Tazorac... 3 Tazorac 0.% Cream... 3 Tazorac Gel, 0.05% Cream... 3 Tecfidera... Technivie... 5 Telmisartan... 9 Telmisartan-Hydrochlorothiazide... 9 Temazepam Capsule... Tenofovir Tablet... 6 Terazosin...9, 7 Terazosin Capsule, Tablet... 7 Terbinafine Tablet... 8 Testim... 7 Testosterone % Topical Gel... 7 Testosterone Cypionate Injection... 7 Thrive Gum... 9 Tilia Fe...2 Timolol 0.25%, 0.5% Ophthalmic Solution... 5 Tivicay... 6 Tizanidine Tablet... 7 Tobi Podhaler... 7 Tobramycin Ophthalmic Solution... 4 Tobramycin/Dexamethasone 0.3%-0.% Ophthalmic Suspension... 4 Tolcapone... Topiramate Immediate-Release Tablet... 2 Toujeo SoloStar... 3 Toviaz... 8 Tracleer... 9 Tradjenta... 4 Tramadol Immediate-Release Tablet... 8 Tramadol Sustained-Release Tablet... 8 Tramadol-Acetaminophen... 8 Travatan Z... 5 Trazodone Tablet... Tremfya... 6 Tresiba FlexTouch... 3 Tretinoin Cream... 3 Tretinoin Gel... 3 Tretinoin Microspheres... 3 Trezix... 8 Tri-Estarylla...2 Tri-Legest Fe...2 Tri-Linyah...2 Tri-Lo-Estarylla...2 Tri-Lo-Marzia...22 Tri-Lo-Sprintec...22 Tri-Previfem...22 Tri-Sprintec...22 Triamcinolone Acetonide Cream, Lotion, Ointment... 3 Triamterene-Hydrochlorothiazide... 9 Triazolam Tablet... Trinessa...22 Trinessa Lo...22 Trintellix... Triumeq

29 Trivora Trulicity... 4 Truvada... 6 Tudorza... 9 Tybost... 6 Tymlos... 8 Tyvaso... 9 U Uceris Foam... 5 Uceris Tablet... 5 Uloric... 5 Uptravi... 9 V Valacyclovir Tablet... 8 Valganciclovir... 8 Valsartan... 9 Valsartan-Hydrochlorothiazide... 9 Varubi... 5 Vascepa... 0 Vectical... 3 Velivet...22 Velphoro... 7 Veltassa... 7 Venlafaxine Extended-Release Capsule... Venlafaxine Tablet... Ventolin HFA... 9 Verapamil... 9 Verapamil Sustained-Release... 9 Vestura...22 Viagra... 7 Viberzi... 5 Vicodin 5/300, 7.5/300, 0/300 mg Tablet... 8 Victoza 2-Pak... 4 Victoza 3-Pak... 4 Viekira Pak... 5 Viekira XR... 5 Vienva...22 Viibryd... Viorele...22 Vitekta... 6 Vivelle-Dot...22 Voltaren Gel... 8 Vosevi... 5 Vyfemla...22 Vyvanse... 0 W Warfarin Sodium... 9 Welchol... 0 Wera...22 Wymza Fe...22 X Xarelto... 9 Xeljanz... 6 Xeljanz XR... 6 Xeloda... 9 Xigduo XR... 4 Xiidra... 4 Xopenex HFA... 9 Xtampza ER... 8 Xulane...22 Xultophy... 4 Xyrem... Y Yasmin Yaz...22 Yuvafem...22 Z Zaleplon Capsule... Zarah...22 Zarxio... 7 Zelapar... Zenchent...22 Zenchent Fe...22 Zenpep... 5 Zepatier... 5 Zetonna... 8 Zinbryta... Ziprasidone Capsule... Zohydro ER... 8 Zolpidem Extended-Release Tablet... Zolpidem Immediate-Release Tablet.. Zonisamide Capsule... 2 Zovia /35E, /50E...22 Zovirax Cream... 8 Zubsolv... Zurampic... 5 Zykadia... 9 Zytiga

30 Nondiscrimination notice and access to communication services UnitedHealthcare and its subsidiaries do not discriminate on the basis of race, color, national origin, age, disability or sex in its health programs or activities. If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to the Civil Rights Coordinator. Online: UHC_Civil_Rights@uhc.com Mail: Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box Salt Lake City, UT 8430 You must send the complaint within 60 days of your experience. A decision will be sent to you within 30 days. If you disagree with the decision, you have 5 days to ask us to look at it again. If you need help with your complaint, please call the toll-free phone number listed on your ID card, TTY 7, Monday through Friday, 8 a.m. to 8 p.m., or at the times listed in your health plan documents. You can also file a complaint with the U.S. Dept. of Health and Human Services. Online: Phone: Mail: Complaint forms are available at Toll free , (TDD) U.S. Dept. of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, D.C We provide free services to help you communicate with us, including letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the toll-free phone number listed on your ID card, TTY 7, Monday through Friday, 8 a.m. to 8 p.m., or at the times listed in your health plan documents. 30

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