Your 2018 Prescription Drug List

Transcription

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

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3 Table of Contents tiers....4 Restrictions on what 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... Migraine... Multiple Sclerosis... Other... Sedatives/Hypnotics...2 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...5 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, 2 or 3 option could work for you. Your Cost * What s Covered Helpful Hints $ Lowest $$ Mid-range $$$ Higher 2 and 3 4 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 or 3 drugs, instead of 4, to help reduce your out-of-pocket costs. Ask your doctor if a, 2 or 3 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 what 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) + 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**). 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. + Depending on your benefit, you may have notification or medical necessity requirements for select medications. ** 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 what 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 at no cost to you if prior authorization criteria is met. Prior Authorization (sometimes referred to as precertification) (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 2 (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. Depending on your benefit, you may have notification or medical necessity requirements for select medications. 2 Not applicable to Neighborhood Health Plan and 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 UHCSpecialtyRx.com or call the toll-free phone number on your health plan ID card to learn more. Please note, not all specialty medications are listed here. If you re taking a specialty medication that is on 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 Amoxicillin/Potassium Clavulanate Chewable, Azithromycin Cefadroxil Capsule, Cefdinir Capsule Cefixime Suspension Cefprozil Cefuroxime Cephalexin Capsule Ciprodex 3 Ciprofloxacin Clarithromycin Clindamycin Capsule Dificid 3 SL Doxycycline Hyclate Capsule, Doxycycline Monohydrate 50, 00 mg Capsule Levofloxacin Metronidazole Minocycline Capsule Minocycline Moxifloxacin Nitrofurantoin Capsule Nitrofurantoin Macrocrystal Capsule Ofloxacin Otic Solution Ofloxacin Oracea 4 Penicillin V Potassium Sulfamethoxazole-Trimethoprim Suprax Capsule, Chewable, 4 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 SL Valacyclovir Valganciclovir SL Zovirax Cream 4 Cancer Bexarotene Capsule 4 E, PA, SL, SP Bicalutamide Bosulif 2 PA, SL, SP, ST Cyclophosphamide Capsule 2 Hydroxyurea Capsule Imantinib PA, SL, SP Imbruvica 2 PA, SL, SP Leucovorin Calcium Mercaptopurine Revlimid 2 PA, SP Sutent 2 PA, SL, SP Targretin Capsule SP Targretin Gel 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 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 Tasigna 2 PA, SL, SP, ST Xeloda SP Zytiga 2 PA, SL, SP Cardiovascular/Heart Disease: Coagulation Therapy Brilinta 2 SL Clopidogrel Effient 2 SL Eliquis 4 SL Enoxaparin Sodium Pradaxa 2 SL Savaysa 4 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 Chlorthalidone Clonidine Diltiazem 24 Hour CD Diltiazem Sustained-Release Capsule Diltiazem Sustained-Release Doxazosin Dutoprol 4 E, SL Name 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 Propranolol Extended-Release Capsule Propranolol 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 Ezetimibe SL Ezetimibe-Simvastatin SL Fenofibrate 43, 50, 67, 30, 34, 50, 200 mg Capsule Fenofibrate 40, 48, 20, 45 mg Fenofibrate 54, 60 mg Fluvastatin Extended-Release SL Gemfibrozil Lipofen 4 Livalo 4 SL Lovastatin H Niacin Extended-Release Niaspan 3 Omega-3-Acid Ethyl Esters Capsule PA Praluent 2 PA, SL, SP, ST Pravastatin Repatha 40 mg 4 PA, SL, SP, ST Rosuvastatin SL Simvastatin H-PA Vascepa 2 PA Welchol 2 Cardiovascular/Heart Disease: Other Amiodarone Corlanor 3 PA, SL Digoxin Entresto 4 PA, SL Flecainide Isosorbide Mononitrate ER Name Multaq 4 PA Nitroglycerin Sublingual Ranexa 2 Sotalol Central Nervous System: Attention Deficit Disorder Adderall XR PA, SL Amphetamine Salt Combo PA Atomoxetine SL Concerta PA, SL Daytrana 4 PA, SL Dexmethylphenidate Extended- Release Capsule PA, SL Dexmethylphenidate Immediate- Release PA Dextroamphetamine-Amphetamine Extended-Release Capsule 4 E, PA, SL Dextroamphetamine-Amphetamine Immediate-Release PA Dextroamphetamine Sulfate Immediate-Release PA Focalin XR 4 PA, SL Guanfacine Extended-Release SL Methylphenidate Chewable PA Methylphenidate Extended-Release Capsule (generic Metadate CD, PA, SL Ritalin LA) Methylphenidate Extended-Release (Metadate ER, generic PA, SL Ritalin SR) Methylphenidate Extended-Release (generic Concerta) 4 E, PA, SL Methylphenidate Immediate-Release PA Vyvanse 2 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 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 Central Nervous System: Depression Amitriptyline Bupropion Extended-Release Bupropion Sustained-Release Bupropion Citalopram Desvenlafaxine Extended-Release (generic Pristiq) Doxepin SL Duloxetine Capsule SL Escitalopram Fetzima 4 SL, ST Fluoxetine Capsule Fluvoxamine Mirtazapine Nortriptyline Capsule Paroxetine Sertraline Trazodone Trintellix 4 SL, ST Venlafaxine Extended-Release Capsule Venlafaxine Viibryd 2 SL Central Nervous System: Migraine Acetaminophen/Butalbital/Caffeine 325 mg/50 mg/40 mg SL Eletriptan Frovatriptan Naratriptan Rizatriptan ODT, Sumatriptan Nasal Spray Sumatriptan Succinate, Injection Name 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 20 mg PA, SL, SP Copaxone 40 mg 2 PA, SL, SP Gilenya 3 PA, SL, SP Glatopa 4 E, PA, SL, SP, ST Plegridy 3 PA, SL, SP Rebif 4 PA, SL, SP, ST Tecfidera 2 PA, SL, SP Zinbryta 4 PA, SL, SP Central Nervous System: Other Alprazolam Extended-Release Alprazolam Aripiprazole SL Armodafinil PA, SL Buprenorphine/Naloxone E, PA, SL Buspirone Carbidopa-Levodopa Diazepam Donepezil ODT, 5, 0 mg Latuda 2 SL Lithium Capsule Lorazepam Memantine Modafinil PA, SL Naloxone Vial Narcan Nasal Spray 2 Olanzapine SL Pramipexole Quetiapine Extended-Release SL Quetiapine

12 Name Risperidone Ropinirole Suboxone Film 4 E, PA, SL Tolcapone Xyrem 4 PA, SL Zelapar 3 Ziprasidone Capsule SL Zubsolv SL Central Nervous System: Sedatives/Hypnotics Eszopiclone SL Temazepam Capsule Triazolam Zaleplon Capsule SL Zolpidem Extended-Release SL Zolpidem SL Central Nervous System: Seizure Disorders Carbamazepine Extended-Release Capsule, Carbamazepine Immediate-Release Clonazepam Diazepam Divalproex Delayed-Release Divalproex Extended-Release Gabapentin Capsule, Lamotrigine Immediate-Release Levetiracetam Extended-Release Levetiracetam Immediate-Release Lyrica 4 SL Oxcarbazepine Phenytoin Capsule, Suspension Topiramate Immediate-Release Zonisamide Capsule Name Dermatology Aczone 2 Adapalene Cream, Gel, Lotion E, PA Adapalene 0.%/Benzoyl Peroxide 2.5% Gel 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 %/Benzoyl Peroxide 5% Gel Clindamycin.2%/Benzoyl Peroxide 5% Gel Clindamycin Gel Clindamycin Lotion, Solution, Swabs Clobetasol Propionate Cream, Ointment, Solution Clotrimazole-Betamethasone Cream Clotrimazole-Betamethasone Lotion Desonide 0.05% Cream, Lotion, Ointment Desoximetasone Cream, Gel, Ointment Diflorasone Diacetate 0.05% Cream, Ointment Dupixent 4 SL, SP, ST Elidel 3 Enstilar Foam 4 Epiduo Forte 2 Eucrisa 3 ST Finacea 2 Fluocinonide 0.05% Cream 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 Fluocinolone Cream, Oil, Ointment, Solution Halobetasol Ointment Hydrocortisone 2.5% Cream, Ointment Imiquimod 5% Cream Metronidazole 0.75% Topical Gel Minocycline Extended-Release Mirvaso 4 Mometasone Furoate Cream, Lotion, Ointment Mupirocin Ointment Nystatin-Triamcinolone Acetonide Cream, Ointment Oxsoralen-Ultra 2 Picato 3 Regranex 2 PA Rhofade 4 Solodyn 4 Taclonex Suspension 4 Tacrolimus Ointment ST Tazarotene 0.% Cream 4 E, PA Tazorac 0.% Cream PA Tazorac Gel, 0.05% Cream 2 PA Tretinoin Cream PA Tretinoin Gel PA Tretinoin Microspheres PA Triamcinolone Acetonide Cream, Lotion, Ointment Vectical 3 Diabetes: Blood Glucose Monitoring* Accu-Chek Test Strips 4 E, SL Contour Test Strips 4 E, SL Dexcom Continuous Glucose Monitoring System 3 PA, SL Dexcom Sensor 3 PA, SL Dexcom Transmitter 3 PA, SL FreeStyle Test Strips 4 E, SL Name OneTouch Test Strips SL OneTouch Ultra Mini OneTouch Ultra Test Strips SL OneTouch Verio OneTouch Verio Flex OneTouch Verio IQ OneTouch Verio Sync OneTouch Verio Test Strips SL Diabetes: Insulin* Afrezza 4 Basaglar Humalog KwikPens (all formulations) 2 Humalog Vials (all formulations) Humulin KwikPens (all formulations) 2 Humulin Vials (all formulations) Lantus Solostar 4 E Lantus Vials 4 E Levemir FlexTouch 2 Levemir Vials 2 Novolin Vials (all formulations) 4 ST Novolog FlexPen (all formulations) 4 ST Novolog Vials (all formulations) 4 ST Toujeo SoloStar 4 E Tresiba FlexTouch 4 E Diabetes: Non-Insulin* Adlyxin 4 SL Bydureon 2 SL Byetta 2 SL Farxiga 4 SL, ST Glimepiride Glipizide Glipizide Extended-Release Glyburide * 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. 3

14 Name Glyxambi 4 SL, ST Invokamet 2 SL Invokamet XR 2 SL Invokana 2 SL, ST Janumet 4 SL, ST Januvia 4 SL, ST Jardiance 2 SL, ST Jentadueto 2 SL Jentadueto XR 2 SL Kazano 2 SL Kombiglyze XR 2 SL Metformin Metformin Extended-Release (generic Glucophage XR) Nesina 2 SL Onglyza 2 SL Oseni 2 SL Pioglitazone SL Soliqua 2 PA, SL Synjardy 2 SL Synjardy XR 2 SL Tanzeum 2 SL Tradjenta 2 SL Trulicity 3 SL Victoza 2-Pak 2 SL Victoza 3-Pak 2 SL Xigduo XR 4 SL, ST Xultophy 4 E, SL Endocrine: Growth Hormone** Nutropin, Nutropin AQ 2 PA, SL, SP Name Endocrine: Other Calcitriol Capsule Desmopressin Dexamethasone Methylprednisolone Prenisolone Oral Solution Prednisone Rayaldee 4 E 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 4 Moxifloxacin Ophthalmic Solution Ofloxacin 0.3% Ophthalmic Solution Tobramycin/Dexamethasone 0.3%- 0.% Ophthalmic Suspension Tobramycin Ophthalmic Solution * 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. **.Coverage is determined by the consumer s prescription drug benefit plan. Please consult plan documents regarding benefit coverage and cost-share. Prior authorization (sometimes referred to as precertification) may be required for Oxford plans. Bold type = Brand-name drug [Plain type = Generic drug] 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: Dry Eye Disease Restasis MultiDose 4 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 Maleate 0.25%, 0.5% Ophthalmic Solution Travatan Z 2 Gastrointestinal: Acid Suppression Dexilant 2 SL Esomeprazole Capsule E, SL Lansoprazole Capsule E, SL Omeclamox-Pak 3 SL Omeprazole Capsule Pantoprazole Pylera 3 SL Rabeprazole SL Ranitadine Syrup Sucralfate Gastrointestinal: Nausea/Vomiting Akynzeo 4 Aprepitant Capsule Emend Suspension 2 Ondansetron Ondansetron ODT Scopolamine Transdermal Patch Varubi 2 Gastrointestinal: Other Amitiza 4 SL, ST Apriso 2 Asacol HD 4 E Name Canasa 2 Cortifoam 2 Creon 2 Delzicol 4 E Diphenoxylate-Atropine Golytely 2 Hyoscyamine Lialda Linzess 2 PA, SL Mesalamine Delayed-Release (generic Lialda) 4 E Metoclopramide Movantik 2 PA, SL Moviprep 2 Polyethylene Glycol 3350 Prepopik 2 Suclear 3 Sulfasalazine Suprep 2 Uceris Foam 2 Uceris 4 Viberzi 4 SL Zenpep 2 Gout Allopurinol Colcrys 4 E Mitigare 2 Uloric 4 SL Zurampic 4 PA, SL Hepatitis C Daklinza 4 PA, SL, SP, ST Epclusa 2 PA, SL, SP Harvoni 2 PA, SL, SP Mavyret 2 PA, SL, SP Ribavirin SP Sovaldi 4 PA, SL, SP, ST 5

16 Name Technivie 4 PA, SL, SP, ST Viekira Pak 4 PA, SL, SP, ST Viekira XR 4 PA, SL, SP, ST Vosevi 2 PA, SL, SP Zepatier 4 PA, SL, SP, ST HIV/AIDS Abacavir-Lamivudine SP Atripla 2 SP Complera 4 SP Descovy 4 SP Epzicom 4 E, SP Evotaz 2 SP Genvoya 4 SP, ST Intelence 2 SP Isentress 2 SP Kaletra 2 SP Lamivudine-Zidovudine SP Lopinavir-Ritonavir Oral Solution SP Nevirapine SP Nevirapine Extended-Release SP Norvir 2 SP Odefsey 4 SP Prezcobix 2 SP Prezista 2 SP Reyataz 2 SP Selzentry 2 PA, SP Stribild 3 SP, ST Sustiva 2 SP Tivicay 3 SP Triumeq 2 SP Truvada 4 SP Name Tybost 2 SP Viread 2 SP Vitekta 2 SP Infertility** Cetrotide 2 SP Clomiphene SP Gonal-F 2 SP Gonal-F RFF 2 SP Ovidrel 3 SP Inflammatory Conditions: Rheumatoid Arthritis, Crohn s Disease, Psoriasis, Ulcerative Colitis Actemra 4 PA, SL, SP, ST Cimzia 2 PA, SL, SP Cosentyx 3 PA, SL, SP, ST Enbrel 4 PA, SL, SP, ST Humira 2 PA, SL, SP Hydroxychloroquine Sulfate Leflunomide Methotrexate Orencia 4 PA, SL, SP, ST Otezla 2 PA, SL, SP Otrexup 4 SL Rasuvo 4 SL Simponi 2 PA, SL, SP Stelara 2 PA, SL, SP Taltz 4 PA, SL, SP, ST Xeljanz 4 PA, SL, SP, ST Xeljanz XR 4 PA, SL, SP, ST **.Coverage is determined by the consumer s prescription drug benefit plan. Please consult plan documents regarding benefit coverage and cost-share. Prior authorization (sometimes referred to as precertification) may be required for Oxford plans. Bold type = Brand-name drug [Plain type = Generic drug] 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** Addyi 4 PA, SL Cialis 2 SL Levitra 2 SL Osphena 2 Stendra 2 SL Viagra 2 SL Men s Health: Prostate Alfuzosin Doxazosin Dutasteride Capsule Finasteride Rapaflo 2 Tamsulosin Capsule Terazosin Capsule, Men s Health: Testosterone Therapy Androderm 2 SL Androgel 4 E, SL Methyltestosterone Capsule Testim 2 SL Testosterone % Topical Gel E, SL Testosterone Cypionate Injection Miscellaneous Anastrozole Aranesp 2 SL, SP Auryxia 3 Auvi-Q 4 E, SL Benzonatate Capsule Bethkis PA, SL, SP Cayston 2 PA, SL Cerdelga 2 PA, SP Chlorhexidine Gluconate Chlorpheniramine/Hydrocodone/ Pseudoephedrine Solution Name Epinephrine (generic EpiPen/ EpiPen-Jr.) 2 EpiPen/EpiPen Jr. 4 E Fosrenol 3 Hydrocodone/Chlorpheniramine Suspension SL Letrozole Lidocaine Transdermal Patch (generic Lidoderm) PA, SL Nuedexta 2 Obredon 4 ST Pegasys 2 PA, SL, SP Phenazopyridine Procrit 2 SL, SP Promethazine/Codeine Promethazine/Dextromethorphan Pulmozyme 2 PA, SL, SP Rectiv 3 SL Rezira 3 Sevelamer Tobi Podhaler 3 PA, S, SP Tobramycin Nebulized Solution E, PA, SL, SP Velphoro 2 Veltassa 3 SL Zarxio 2 SP Musculoskeletal: Muscle Spasms Baclofen Carisoprodol 350 mg Cyclobenzaprine Metaxalone Methocarbamol Tizanidine **.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. 7

18 Name Musculoskeletal: Osteoporosis Alendronate Sodium Forteo 3 PA, SP Ibandronate SL Raloxifene Risedronate Sodium SL Tymlos 3 PA, SP Musculoskeletal: Pain Relief Acetaminophen/Codeine SL Arymo ER 4 E, PA, SL, ST Belbuca 4 PA, SL Butrans 4 E, PA, SL Celecoxib SL Diclofenac Embeda 4 E, PA, SL, ST Etodolac Capsule Fentanyl Citrate Lozenge PA, SL Fentanyl Patch SL Hydrocodone/Acetaminophen 5/325, 7.5/325, 0/325 mg SL Hydrocodone/Ibuprofen Hydromorphone Immediate-Release Hysingla 4 E, PA, SL Ibuprofen Indomethacin Capsule Ketorolac Lazanda 4 PA, SL Meloxicam Methadone, Oral Solution, Concentrate Solution SL Morphine Sulfate Extended-Release SL Morphine Sulfate Oral Solution Nabumetone Name Naproxen Nucynta 2 SL Nucynta ER 3 PA, SL Opana ER 4 E, PA, SL Oxycodone/Acetaminophen 5/325, 7.5/325, 0/325 mg SL Oxycodone Oxycontin 4 E, PA, SL Sprix 3 Subsys 4 E, PA, SL 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 4 PA, SL, ST Overactive Bladder Dicyclomine Oxybutynin Extended-Release Oxybutynin Tolterodine Extended-Release Tolterodine Toviaz 2 Vesicare 4 Respiratory: Allergies Azelastine 0.% Nasal Spray Clarinex 4 Clarinex-D 3 Cyproheptadine Fluticasone Nasal Spray 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 Hydroxyzine Capsule, Levocetirizine Promethazine Zetonna 3 Respiratory: Asthma/COPD Advair Diskus/HFA 2 RS, SL Aerospan 3 SL AirDuo RespiClick 4 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 4 SL, ST Flovent Diskus/HFA 2 SL Fluticasone/Salmeterol ResipClick (generic AirDuo RespiClick) SL Incruse Ellipta 2 SL Ipratropium-Albuterol Nebs Ipratropium Nebs Levalbuterol Nebs SL Montelukast Perforomist 3 SL ProAir HFA 3 Proventil HFA/RespiClick 3 Pulmicort Flexhaler 4 SL, ST QVAR MDI SL Serevent Diskus 3 SL Spiriva Handihaler 2 SL Spiriva Respimat 4 SL Stiolto Respimat 4 E, SL Striverdi Respimat 2 SL Name Symbicort 2 RS, SL Tudorza 2 SL Ventolin HFA 2 Xopenex HFA 3 Respiratory: Pulmonary Arterial Hypertension Adcirca 4 PA, SL, SP Adempas 2 PA, SL, SP Letairis 2 PA, SL, SP Opsumit 2 PA, SL, SP Orenitram 4 PA, SL, SP Sildenafil PA, SL, SP Tracleer 2 PA, SL, SP Tyvaso 2 PA, SP Uptravi 4 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 3 H-PA Nicorette Mini-Lozenge 3 H-PA Nicotine Gum H-PA Nicotine Lozenge H-PA Nicotine Patch H-PA Nicotrol Inhaler 4 H-PA Nicotrol Nasal Spray 4 H-PA Thrive Gum H-PA Transplant Azathioprine Cyclosporine Modified Capsule SP Mycophenolate Capsule, Suspension SP Mycophenolic Acid SP Sirolimus 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 Econtra EZ H Elinest H Ella H, SL Emoquette H Enpresse H Enskyce H Errin H Estarylla H Fallback H Falmina H Fayosim 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 Junel 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 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 2 LoMedia 24 Fe H Loryna H Low-Ogestrel H Lutera H Lyza H Marlissa H Medroxyprogesterone Acetate H Mibelas 24 Fe Chewable 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 Nikki H Nora BE H Name 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 Ortho Tri-Cyclen Lo 4 E Philith H Pimtrea H Pirmella 7/7/7, /35 H Plan B One Step H Portia H Previfem H Quasense H Rajani Reclipsen H Rivelsa Setlakin Sharobel H Solia H Sprintec H Sronyx H Syeda H Take Action H Tarina Fe H Taytulla 4 Tilia Fe H Tri-Estarylla H Tri-Legest Fe H Tri-Linyah H Tri-Lo-Estarylla H Tri-Lo-Marzia H 2

22 Name 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 2 SL Climara Pro 2 SL Divigel 2 Duavee 3 Estrace Cream 2 Estradiol/Norethindrone Acetate Estradiol Name Estradiol Twice-Weekly Transdermal Patch 4 E, 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 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... 8 Actemra... 6 Acyclovir Ointment... 8 Acyclovir... 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 Aerospan... 9 Afrezza... 3 Aftera...20 AirDuo RespiClick... 9 Akynzeo... 5 Albuterol Nebs... 9 Alendronate Sodium... 8 Alfuzosin... 7 Allopurinol... 5 Alphagan P 0.%... 5 Alprazolam Extended-Release... Alprazolam... Altavera...20 Alvesco... 9 Alyacen 7/7/7, / Amethia...20 Amethia Lo...20 Amethyst...20 Amiodarone... 0 Amitiza... 5 Amitriptyline... Amlodipine... 9 Amlodipine-Benazepril... 9 Amlodipine-Valsartan... 9 Amoxicillin Capsule, Chewable... 8 Amoxicillin/Potassium Clavulanate Chewable,... 8 Amphetamine Salt Combo... 0 Ampyra... Anastrozole... 7 Androderm... 7 Androgel... 7 Anoro Ellipta... 9 Aprepitant Capsule... 5 Apri...20 Apriso... 5 Aranelle...20 Aranesp... 7 Aripiprazole... Armodafinil... Armour Thyroid... 4 Arnuity Ellipta... 9 Arymo ER... 8 Asacol HD... 5 Ashlyna...20 Asmanex TwistHaler/HFA... 9 Atenolol... 9 Atenolol-Chlorthalidone... 9 Atomoxetine... 0 Atorvastatin... 0 Atripla... 6 Aubagio... Aubra...20 Auryxia... 7 Auvi-Q... 7 Aviane...20 Avonex... Azathioprine... 9 Azelastine 0.05% Ophthalmic Solution... 4 Azelastine 0.% Nasal Spray... 8 Azithromycin... 8 Azopt... 5 Azurette...20 B Baclofen... 7 Balziva...20 Basaglar... 3 Bekyree...20 Belbuca... 8 Benazepril... 9 Benazepril-Hydrochlorothiazide... 9 Benzonatate Capsule... 7 Betamethasone Dipropionate 0.05% Augmented Lotion, Ointment... 2 Betamethasone Dipropionate 0.05% Cream, Ointment... 2 Betaseron... Bethkis... 7 Bevespi Aerosphere... 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 Buprenorphine/Naloxone... Bupropion Extended-Release... Bupropion Sustained-Release..., 9 Bupropion... Buspirone... Butrans... 8 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,... 2 Carbamazepine Immediate-Release... 2 Carbidopa-Levodopa... Carisoprodol 350 mg

24 Cartia XT... 9 Carvedilol... 9 Cayston... 7 Caziant...20 Cefadroxil Capsule,... 8 Cefdinir Capsule... 8 Cefixime Suspension... 8 Cefprozil... 8 Cefuroxime... 8 Celecoxib... 8 Cephalexin Capsule... 8 Cerdelga... 7 Cesia...20 Cetrotide... 6 Chantix... 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... 8 Citalopram... Claravis... 2 Clarinex... 8 Clarinex-D... 8 Clarithromycin... 8 Climara...22 Climara Pro...22 Clindamycin %/Benzoyl Peroxide 5% Gel... 2 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... 2 Clonidine... 9 Clopidogrel... 9 Clotrimazole-Betamethasone Cream... 2 Clotrimazole-Betamethasone Lotion... 2 Colcrys... 5 Combigan... 5 Combivent Respimat... 9 Complera... 6 Concerta... 0 Contour Test Strips... 3 Copaxone 20 mg... Copaxone 40 mg... Corlanor... 0 Cortifoam... 5 Cosentyx... 6 Creon... 5 Cresemba... 8 Cryselle...20 Cyclafem 7/7/7, / Cyclobenzaprine... 7 Cyclophosphamide Capsule... 8 Cyclosporine Modified Capsule... 9 Cyproheptadine... 8 Cyred...20 D Daklinza... 5 Dasetta 7/7/7, / Daysee...20 Daytrana... 0 Deblitane...20 Delyla...20 Delzicol... 5 Descovy... 6 Desmopressin... 4 Desogestrel-Ethinyl Estradiol...20 Desonide 0.05% Cream, Lotion, Ointment... 2 Desoximetasone Cream, Gel, Ointment... 2 Desvenlafaxine Extended-Release... Dexamethasone... 4 Dexcom Continuous Glucose Monitoring System... 3 Dexcom Sensor... 3 Dexcom Transmitter... 3 Dexilant... 5 Dexmethylphenidate Extended-Release Capsule... 0 Dexmethylphenidate Immediate-Release... 0 Dextroamphetamine Sulfate Immediate-Release... 0 Dextroamphetamine-Amphetamine Extended-Release Capsule... 0 Dextroamphetamine-Amphetamine Immediate-Release... 0 Diazepam..., 2 Diclofenac... 8 Dicyclomine... 8 Dificid... 8 Diflorasone Diacetate 0.05% Cream, Ointment... 2 Digoxin... 0 Diltiazem 24 Hour CD... 9 Diltiazem Sustained-Release Capsule... 9 Diltiazem Sustained-Release... 9 Diphenoxylate-Atropine... 5 Divalproex Delayed-Release... 2 Divalproex Extended-Release... 2 Divigel...22 Donepezil ODT, 5, 0 mg... Doxazosin...9, 7 Doxazosin... 7 Doxepin... Doxycycline Hyclate Capsule,... 8 Doxycycline Monohydrate 50, 00 mg Capsule... 8 Drospirenone/Ethinyl Estradiol...20 Drospirenone/Ethinyl Estradiol/ Levomefolate Calcium...20 DSP... 8 Duavee...22 Dulera... 9 Duloxetine Capsule... Dupixent... 2 Dutasteride Capsule... 7 Dutoprol... 9 E Econazole Cream... 8 Econtra EZ...20 Edarbi... 9 Edarbyclor... 9 Effient... 9 Eletriptan... Elidel... 2 Elinest...20 Eliquis

25 Ella...20 Embeda... 8 Emend Suspension... 5 Emoquette...20 Enalapril... 9 Enbrel... 6 Enoxaparin Sodium... 9 Enpresse...20 Enskyce...20 Enstilar Foam... 2 Entresto... 0 Epclusa... 5 Epiduo Forte... 2 Epinephrine... 7 EpiPen/EpiPen Jr... 7 EpiPen/EpiPen-Jr... 7 Epzicom... 6 Errin...20 Erythromycin 0.5% Ophthalmic Ointment... 4 Escitalopram... Esomeprazole Capsule... 5 Estarylla...20 Estrace Cream...22 Estradiol...22 Estradiol Twice-Weekly Transdermal Patch...22 Estradiol/Norethindrone Acetate...22 Estring...22 Estrogen/Methyltestosterone..22 Eszopiclone... 2 Etodolac Capsule... 8 Eucrisa... 2 Evamist...22 Evotaz... 6 Ezetimibe... 0 Ezetimibe-Simvastatin... 0 F Fallback...20 Falmina...20 Famciclovir... 8 Farxiga... 3 Fayosim...20 Fenofibrate 40, 48, 20, 45 mg... 0 Fenofibrate 43, 50, 67, 30, 34, 50, 200 mg Capsule... 0 Fenofibrate 54, 60 mg... 0 Fentanyl Citrate Lozenge... 8 Fentanyl Patch... 8 Fetzima... Finacea... 2 Finasteride... 7 Flecainide... 0 Flovent Diskus/HFA... 9 Fluconazole... 8 Fluocinolone Cream, Oil, Ointment, Solution... 3 Fluocinonide 0.05% Cream... 2 Fluoride...20 Fluoxetine Capsule... Fluticasone Nasal Spray... 8 Fluticasone/Salmeterol ResipClick... 9 Fluvastatin Extended-Release... 0 Fluvoxamine... Focalin XR... 0 Folic Acid...20 Forteo... 8 Fosrenol... 7 FreeStyle Test Strips... 3 Frovatriptan... Furosemide... 9 G Gabapentin Capsule,... 2 Gemfibrozil... 0 Gentamicin Ophthalmic Ointment, Solution... 4 Genvoya... 6 Gianvi...20 Gildagia...20 Gildess...20 Gildess 24 Fe...20 Gildess Fe...20 Gilenya... Glatopa... Glimepiride... 3 Glipizide... 3 Glipizide Extended-Release... 3 Glucophage XR... 4 Glyburide... 3 Glyxambi... 4 Golytely... 5 Gonal-F... 6 Gonal-F RFF... 6 Guanfacine...9, 0 Guanfacine Extended-Release... 0 H Halobetasol Ointment... 3 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... 8 Hydrocodone/Chlorpheniramine Suspension... 7 Hydrocodone/Ibuprofen... 8 Hydrocortisone 2.5% Cream, Ointment... 3 Hydromorphone Immediate-Release... 8 Hydroxychloroquine Sulfate... 6 Hydroxyurea Capsule... 8 Hydroxyzine Capsule,... 9 Hyoscyamine... 5 Hysingla... 8 Ibandronate... 8 Ibuprofen... 8 Imantinib... 8 Imbruvica... 8 Imiquimod 5% Cream... 3 Incruse Ellipta... 9 Indomethacin Capsule... 8 Intelence... 6 Introvale...20 Invokamet... 4 Invokamet XR... 4 Invokana... 4 Ipratropium Nebs... 9 Ipratropium-Albuterol Nebs... 9 Irbesartan... 9 Isentress... 6 Isosorbide Mononitrate ER... 0 Itraconazole Capsule... 8 I J Janumet... 4 Januvia

26 Jardiance... 4 Jencycla...20 Jentadueto... 4 Jentadueto XR... 4 Jolessa...20 Jolivette...20 Juleber...20 Junel...20, 2 Junel 24 Fe...2 Junel Fe... 2 K Kaletra... 6 Kariva...2 Kazano... 4 Kelnor / Ketoconazole Cream... 8 Ketorolac... 8 Kimidess...2 Klor-Con M Klor-Con M Kombiglyze XR... 4 Kurvelo...2 L Labetalol... 9 Lamivudine-Zidovudine... 6 Lamotrigine Immediate-Release... 2 Lansoprazole Capsule... 5 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... 8 Levalbuterol Nebs... 9 Levemir FlexTouch... 3 Levemir Vials... 3 Levetiracetam Extended-Release... 2 Levetiracetam Immediate-Release... 2 Levitra... 7 Levocetirizine... 9 Levofloxacin... 8 Levonest...2 Levonorgestrel.5 mg...2 Levonorgestrel-Ethinyl Estradiol...2 Levora Levothyroxine Sodium... 4 Lialda... 5 Lidocaine Transdermal Patch... 7 Lidoderm... 7 Linzess... 5 Liothyronine Sodium... 4 Lipofen... 0 Lisinopril... 9 Lisinopril-Hydrochlorothiazide... 9 Lithium Capsule... Livalo... 0 Lo Loestrin Fe...2 LoMedia 24 Fe...2 Lopinavir-Ritonavir Oral Solution... 6 Lorazepam... 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... 8 Memantine... Mercaptopurine... 8 Mesalamine Delayed-Release... 5 Metadate CD... 0 Metadate ER... 0 Metaxalone... 7 Metformin... 4 Metformin Extended-Release... 4 Methadone, Oral Solution, Concentrate Solution... 8 Methimazole... 4 Methocarbamol... 7 Methotrexate... 6 Methylphenidate Chewable... 0 Methylphenidate Extended-Release Capsule... 0 Methylphenidate Extended-Release... 0 Methylphenidate Immediate-Release... 0 Methylprednisolone... 4 Methyltestosterone Capsule... 7 Metoclopramide... 5 Metoprolol Succinate Extended-Release... 9 Metoprolol Tartrate 25, 50, 00 mg... 9 Metronidazole 0.75% Topical Gel... 3 Metronidazole... 8 Mibelas 24 Fe Chewable...2 Microgestin...2 Microgestin Fe...2 Minivelle...22 Minocycline Capsule... 8 Minocycline Extended-Release... 3 Minocycline... 8 Mirtazapine... Mirvaso... 3 Mitigare... 5 Modafinil... Mometasone Furoate Cream, Lotion, Ointment... 3 Mono-Linyah...2 Mononessa...2 Montelukast... 9 Morphine Sulfate Extended-Release... 8 Morphine Sulfate Oral Solution... 8 Movantik... 5 Moviprep... 5 Moxeza... 4 Moxifloxacin Ophthalmic Solution... 4 Moxifloxacin... 8 Multaq... 0 Mupirocin Ointment... 3 My Way

27 Mycophenolate Capsule, Suspension.9 Mycophenolic Acid... 9 Myzilra...2 N Nabumetone... 8 Nadolol... 9 Naloxone Vial... Naproxen... 8 Naratriptan... Narcan Nasal Spray... Natazia...2 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... 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... 0 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, Suspension... 8 NP Thyroid... 4 Nucynta... 8 Nucynta ER... 8 Nuedexta... 7 Nutropin, Nutropin AQ... 4 Nuvaring...2 Nystatin Cream, Ointment... 8 Nystatin-Triamcinolone Acetonide Cream, Ointment... 3 O Obredon... 7 Ocella...2 Odefsey... 6 Ofloxacin 0.3% Ophthalmic Solution... 4 Ofloxacin Otic Solution... 8 Ofloxacin... 8 Ogestrel...2 Olanzapine... Olmesartan... 9 Olmesartan-Hydrochlorothiazide... 9 Olopatadine 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 Opana ER... 8 Opcicon...2 Opsumit... 9 Oracea... 8 Orencia... 6 Orenitram... 9 Orsythia...2 Ortho Tri-Cyclen Lo...2 Oseltamivir Capsule... 8 Oseni... 4 Osphena... 7 Otezla... 6 Otrexup... 6 Ovidrel... 6 Oxcarbazepine... 2 Oxsoralen-Ultra... 3 Oxybutynin Extended-Release... 8 Oxybutynin... 8 Oxycodone... 8 Oxycodone/Acetaminophen 5/325, 7.5/325, 0/325 mg... 8 Oxycontin... 8 P Pantoprazole... 5 Paroxetine... Pegasys... 7 Penicillin V Potassium... 8 Perforomist... 9 Phenazopyridine... 7 Phenytoin Capsule, Suspension... 2 Philith...2 Picato... 3 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... Pravastatin... 0 Prednisone... 4 Premarin...22 Premphase...22 Prempro...22 Prenisolone Oral Solution... 4 Prepopik... 5 Previfem...2 Prezcobix... 6 Prezista... 6 Pristiq... ProAir HFA... 9 Procrit... 7 Progesterone Micronized Capsule...22 Promethazine... 9 Promethazine/Codeine... 7 Promethazine/Dextromethorphan... 7 Propranolol Extended-Release Capsule

28 Propranolol... 9 Proventil HFA/RespiClick... 9 Pulmicort Flexhaler... 9 Pulmozyme... 7 Pylera... 5 Q Quasense... 2 Quetiapine Extended-Release. Quetiapine... Quinapril... 9 QVAR MDI... 9 R Rabeprazole... 5 Rajani...2 Raloxifene...8, 22 Raloxifene... 8 Ramipril... 9 Ranexa... 0 Ranitadine Syrup... 5 Rapaflo... 7 Rasuvo... 6 Rayaldee... 4 Rebif... Reclipsen...2 Rectiv... 7 Regranex... 3 Repatha 40 mg... 0 Restasis MultiDose... 5 Restasis Single Use Vials... 5 Revlimid... 8 Reyataz... 6 Rezira... 7 Rhofade... 3 Ribavirin... 5 Risedronate Sodium... 8 Risperidone... 2 Ritalin LA... 0 Ritalin SR... 0 Rivelsa...2 Rizatriptan ODT,... Ropinirole... 2 Rosuvastatin... 0 S Savaysa... 9 Scopolamine Transdermal Patch... 5 Selzentry... 6 Serevent Diskus... 9 Sertraline... Setlakin...2 Sevelamer... 7 Sharobel...2 Sildenafil... 9 Simponi... 6 Simvastatin... 0 Sirolimus... 9 Solia...2 Soliqua... 4 Solodyn... 3 Sotalol... 0 Sovaldi... 5 Spiriva Handihaler... 9 Spiriva Respimat... 9 Spironolactone... 9 Sprintec...2 Sprix... 8 Sronyx...2 Stelara... 6 Stendra... 7 Stiolto Respimat... 9 Stribild... 6 Striverdi Respimat... 9 Suboxone Film... 2 Subsys... 8 Suclear... 5 Sucralfate... 5 Sulfamethoxazole-Trimethoprim... 8 Sulfasalazine... 5 Sumatriptan Nasal Spray... Sumatriptan Succinate, Injection... Suprax Capsule, Chewable,... 8 Suprep... 5 Sustiva... 6 Sutent... 8 Syeda...2 Symbicort... 9 Synjardy... 4 Synjardy XR... 4 Synthroid... 4 T Taclonex Suspension... 3 Tacrolimus Capsule... 9 Tacrolimus Ointment... 3 Take Action...2 Taltz... 6 Tamoxifen...22 Tamsulosin Capsule... 7 Tanzeum... 4 Targretin Capsule... 8 Targretin Gel... 8 Tarina Fe...2 Tasigna... 9 Taytulla...2 Tazarotene 0.% Cream... 3 Tazorac 0.% Cream... 3 Tazorac Gel, 0.05% Cream... 3 Tecfidera... Technivie... 6 Telmisartan... 9 Telmisartan-Hydrochlorothiazide... 9 Temazepam Capsule... 2 Terazosin...9, 7 Terazosin Capsule,... 7 Terbinafine... 8 Testim... 7 Testosterone % Topical Gel... 7 Testosterone Cypionate Injection... 7 Thrive Gum... 9 Tilia Fe...2 Timolol Maleate 0.25%, 0.5% Ophthalmic Solution... 5 Tivicay... 6 Tizanidine... 7 Tobi Podhaler... 7 Tobramycin Nebulized Solution... 7 Tobramycin Ophthalmic Solution... 4 Tobramycin/Dexamethasone 0.3%-0.% Ophthalmic Suspension... 4 Tolcapone... 2 Tolterodine Extended-Release... 8 Tolterodine... 8 Topiramate Immediate-Release... 2 Toujeo SoloStar... 3 Toviaz... 8 Tracleer... 9 Tradjenta... 4 Tramadol Immediate-Release... 8 Tramadol Sustained-Release... 8 Tramadol-Acetaminophen... 8 Travatan Z... 5 Trazodone... 28

29 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... 2 Tri-Lo-Sprintec...22 Tri-Previfem...22 Tri-Sprintec...22 Triamcinolone Acetonide Cream, Lotion, Ointment... 3 Triamterene-Hydrochlorothiazide... 9 Triazolam... 2 Trinessa...22 Trinessa Lo...22 Trintellix... Triumeq... 6 Trivora Trulicity... 4 Truvada... 6 Tudorza... 9 Tybost... 6 Tymlos... 8 Tyvaso... 9 U Uceris Foam... 5 Uceris... 5 Uloric... 5 Uptravi... 9 V Valacyclovir... 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... Ventolin HFA... 9 Verapamil... 9 Verapamil Sustained-Release... 9 Vesicare... 8 Vestura...22 Viagra... 7 Viberzi... 5 Vicodin 5/300, 7.5/300, 0/300 mg... 8 Victoza 2-Pak... 4 Victoza 3-Pak... 4 Viekira Pak... 6 Viekira XR... 6 Vienva...22 Viibryd... Viorele...22 Viread... 6 Vitekta... 6 Vivelle-Dot...22 Voltaren Gel... 8 Vosevi... 6 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... 5 Xopenex HFA... 9 Xtampza ER... 8 Xulane...22 Xultophy... 4 Xyrem... 2 Y Yasmin Yaz...22 Yuvafem...22 Z Zaleplon Capsule... 2 Zarah...22 Zarxio... 7 Zelapar... 2 Zenchent...22 Zenchent Fe Zenpep... 5 Zepatier... 6 Zetonna... 9 Zinbryta... Ziprasidone Capsule... 2 Zohydro ER... 8 Zolpidem Extended-Release... 2 Zolpidem... 2 Zonisamide Capsule... 2 Zovia /35E, /50E...22 Zovirax Cream... 8 Zubsolv... 2 Zurampic... 5 Zytiga... 9

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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