unitedhealthcare - platinum copay select medications list

7/18/2019 UnitedHealthcare - Platinum Copay Select Medications List

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Your 2015 Four-TierPrescription Drug Listeffective January 1, 2015

UnitedHealthOne Advantage Four-Tier

Please read: This document contains information about commonly prescribed

medications.

For additional information:

Call the toll-free Member Services number on the back of your health

plan ID card.

Visiting www.uhone.com, clicking on the “Customer Center” link at

the top of the page and then selecting the “Prescription (Rx) Drug Coverage”

tab on the left hand side of the page provides you access to:

• Locate a participating retail pharmacy by ZIP code.

• Look up possible lower-cost medication alternatives.

• Compare medication pricing and options.

Note: Benefits may not be available for all drugs on this list. A drug on this list is covered under your insurance plan only i f the condition for

which it is prescribed is also covered under your insurance plan. For example, if treatment of mental disorders is excluded from your coverage,

drugs prescribed in connection with that treatment also may be excluded from your coverage.



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Your Prescription Drug List This Prescription Drug List (PDL) outlines the most commonly prescribed medications for certainconditions and organizes them into cost levels, also known as tiers. An important part of the PDL isgiving you choices so you and your doctor can choose the best course of treatment for you.

Go to the “Customer Center” link at www.uhone.com forcomplete drug informationSince the PDL may change, we encourage you to visit our website, ww w.uhone.com. Click on the“Customer Center” link at the top of the page and then select the “Prescription (Rx) Drug Coverage”tab on the left hand side of the page. This website is the best source for up-to-date information about themedications your pharmacy benefit covers, possible lower-cost options, and cost comparisons.



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Table of Contents

Drug tiers and cost . . . . . . . . . . . . . . . . . . . . . . . . 5

Programs and Limits . . . . . . . . . . . . . . . . . . . . . . 7

Drugs by category . . . . . . . . . . . . . . . . . . . . . . . 10

Anti-Infectives

Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Cardiovascular/Heart Disease

Coagulation Therapy . . . . . . . . . . . . . . . . . . . . . . . .11

High Blood Pressure . . . . . . . . . . . . . . . . . . . . . . . .11

High Cholesterol . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Central Nervous System

Attention Deficit Disorder . . . . . . . . . . . . . . . . . . . 13

Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Multiple Sclerosis. . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Sedatives/Hypnotics . . . . . . . . . . . . . . . . . . . . . . . 15Seizure Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Diabetes/Endocrine

Blood Glucose Monitoring . . . . . . . . . . . . . . . . . . 17

Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Non-Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Endocrine

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Thyroid Hormone Replacement . . . . . . . . . . . . . 18

Eye Conditions

Allergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Gastrointestinal

Acid Suppression . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Nausea/Vomiting . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Inflammatory Conditions: Rheumatoid

Arthritis, Crohn’s Disease, Psoriasis,

Ulcerative Colitis . . . . . . . . . . . . . . . . . . . . . . . . 20

Men’s Health

Erectile Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . 20

Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Testosterone Therapy . . . . . . . . . . . . . . . . . . . . . . 20

Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Musculoskeletal

Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Pain Relief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Overactive Bladder . . . . . . . . . . . . . . . . . . . . . . 22

Respiratory

Allergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Asthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Pulmonary Arterial Hypertension . . . . . . . . . . . . 23

Transplant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Vitamins/Electrolytes . . . . . . . . . . . . . . . . . . . 24

Women’s Health

Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Hormone Replacement . . . . . . . . . . . . . . . . . . . . . 25

Prenatal Vitamins . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Brand Only Exclusions . . . . . . . . . . . . . . . . . . 26

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28



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We want to help you better understand your medicationoptions.

Your pharmacy benefit offers flexibility and choice in determining the right medicationfor you. To help you get the most out of your pharmacy benefit, we’ve included some ofthe most commonly asked questions about the Prescription Drug List.

What is a Prescription Drug List (PDL)? This document is a list of commonly prescribed medications. Drugs are listed by common categoriesor class. They are placed into cost levels known as tiers. It includes both brand and generic prescriptionmedications approved by the U.S. Food and Drug Administration (FDA).

Please note: Where differences are noted between this PDL and your policy/certificate1, the policy/certificate will rule. It is not a complete list of medications, and not all medications listed may be coveredunder your plan. Please look at your policy/certificate to see what medications are covered under your

plan. You may also log on to www.uhone.com or call the toll-free Member Services number on the backof your health plan ID card for more information.

How do I use my Prescription Drug List? When choosing a medication, you and your doctor should consult the PDL. It will help you and yourdoctor choose the most cost-effective prescription drugs. This guide tells you if a medication is genericor brand, and if special programs apply. Bring this list with you when you see your doctor. It is organizedby common medical conditions. Medications are then listed alphabetically.

If your medication is not listed in this document, please visit ww w.uhone.com or call the toll-free

Member Services number on the back of your health plan ID card.

1Policy/certificates include a Summary Plan Description (SPD) or a Cer tificate of Coverage (COC).



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What are tiers? Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, which isdetermined by your policy/certificate. This is how much you will pay when you fill a prescription. Tier1 medications are your lowest-cost options. If your medication is placed in Tier 2, 3 or 4, look to see ifthere is a Tier 1 option available. Discuss these options with your doctor.

Check your policy/certificate to find out your specific pharmacy plan costs.

$ Drug Tier Includes Helpful Tips

Tier 1Lowest Cost

Lower-cost drugs.Some brands and genericsare also included.

Use Tier 1 drugs for the lowestout-of-pocket costs.

Tier 2 and 3Mid-range Cost

Mix of brands andgenerics.

Use Tier 2 or Tier 3 drugs insteadof Tier 4 to help reduce yourout-of-pocket costs.

Tier 4Highest Cost

Mostly higher-cost brandas well as select genericdrugs.

Many Tier 4 drugs have lower-costoptions in Tier 1, 2 or 3. Ask yourdoctor if they could work for you.

Please note: Some plans may have two or three tiers, while others may not have any. If you have ahigh deductible plan, the tier cost levels may apply once you hit your deductible. Refer to your policy/certificate, or call the toll-free Member Services number on the back of your health plan ID card formore information about your policy/certificate.

When does the Prescription Drug List change?• Medications may move to a lower tier at any time.

• Medications may move to a higher tier when a generic becomes available.

• Medications may move to a higher tier or be excluded from coverage most often on January 1 or July 1.

When a medication changes tiers, you may have to pay a different amount for that medication.

For the most up-to-date list, please visit ww w.uhone.com.



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Programs and LimitsSome medications are noted with letters next to them. The letters refer to our pharmacy benefitprograms. Your policy/certificate determines how these medications may be covered for you.

DSPDesignated Specialty Program – Specialty medications need to be filledat a designated specialty pharmacy for network coverage. Call the number on your

ID card or call 1-888-739-5820 for more information.

EMay be excluded from coverage or subject to prior authorization and/or trial/failure of another medication(s). Lower-cost options are available and covered.

NNotification or Prior Authorization required* – Your doctor is required to provideadditional information to us to determine coverage.

SDPSelect Designated Pharmacy – Must use a lower cost medication at retail ortransfer the impacted medication to the mail service pharmacy for network coverage.

SL Supply Limit – Amount of medication covered per copayment or in a specifictime period.

STStep Therapy – Trial of a lower cost medication is required before a higher costmedication is covered.

*Depending on your benefit you may have notification or prior authorization requirements for select medications.

To learn more about a pharmacy program or to find out if it applies to you, please visit ww w.uhone.com or call the toll-free Member Services number on the back of your health plan ID card.

Why are some medications excluded from coverage?Medications may be excluded from coverage under your pharmacy benefit when it works the same orsimilar as another prescription medication or an over-the-counter (OTC) medication. There may beother medication options available.



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Should I talk to my doctor about over-the-counter (OTC)medications? An over-the-counter (OTC) medication may be the right treatment for some conditions. Talk to yourdoctor about available OTC options.

What is the difference between brand-name and genericmedications?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 FDAcan approve a generic version with the same active ingredients. These types of medications are knownas generic medications. Sometimes, the same company that makes a brand-name medication also makesthe generic version.

Is it a generic or brand name drug?

The drug list shows brand name drugs in bold type (for example, Crestor ) and generic drugs in plaintype (for example, simvastatin).

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 genericequivalent or lower-cost option is available and if it might be right for you. Generic medications areusually your lowest-cost option, but not always. Visit ww w.uhone.com to make sure.

Are you taking a specialty medication?Specialty medications are high-cost and may be used to treat rare or complex conditions. For mostplans, these medications are managed through the Specialty Pharmacy Program. Take advantageof personalized support designed to help you get the most out of your treatment plan. VisitUHCSpecialtyRx.com or call the toll-free Member Services number on the back of your health plan IDcard to learn more.

Please note, not all specialty medications are listed here. If you’re taking a specialty medication that is on Tier 3 or Tier 4, call the toll-free Member Services number on the back of your health plan ID card totalk with a pharmacist about finding lower-cost options or a financial assistance program.



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How do I get updated information about my pharmacy benefit?Since the PDL may change during your plan year, we encourage you to visit www.uhone.com or call thetoll-free Member Services number on the back of your health plan ID card for more current information.

In certain documents, the Prescription Drug List (PDL) was referred to as the “Preferred Drug List (PDL).” This change in terms does not affect your benefit coverage.

Medications are categorized by common therapeutic conditions in this PDL for ease of reference only. These categories do not determine coverage for the medication for your condition.Your benefit plan determines coverage for these medications.

For more information

Call the toll-free Member Services number on the back of your health plan ID card.

Or, visit www.uhone.com



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Bold type = Brand name drug

[Plain type = Generic drug]

DSP = Designated Specialty Program

E = May be excluded from coverage

N = Notification or Prior Authorization required

SDP = Select Designated Pharmacy

SL = Supply Limit

ST = Step Therapy

Drug NameDrug

Tier

Requirements

& Limits

Anti-Infectives: Antibiotics

Adoxa Capsule 4 EAmoxicillin Capsule,

Chewable Tablet 1Amoxicillin/PotassiumClavulanate ChewableTablet, Tablet

1

Augmentin XR 4 EAzithromycin Tablet 1Cefdinir Capsule 2Cefuroxime Tablet 1Centany AT 4 ECephalexin Capsule 1Ciprofloxacin Tablet 1Clarithromycin Tablet 1Clindamycin Capsule 1Dificid 3 SLDoryx 4 EDoxycycline HyclateCapsule, Tablet

2

DoxycyclineMonohydrate50, 100 mg Capsule

1

Doxycycline

Monohydrate 75 mgCapsule 4 E

Levofloxacin Tablet 1Metronidazole Tablet 1Minocycline Capsule 1Minocycline Tablet 3Nitrofurantoin Capsule 1NitrofurantoinMacrocrystal Capsule

1

Oracea 4

Drug NameDrug

Tier

Requirements

& Limits

Penicillin V PotassiumTablet

1

Solodyn 4Sulfamethoxazole-

Trimethoprim Tablet 1

Anti-Infectives: Antifungals

Ertaczo 4 EFluconazole Tablet 1Itraconazole Capsule 1 SLKetoconazole Cream 1Luzu 4 E, SLNaftin 1%, 2%Cream, Gel

4 E, SL

Nystatin Cream,Ointment 1Onmel 4 E, SLOxistat Cream 4 N, SL, STOxistat Lotion 4 ETerbinafine Tablet 1 SL

Anti-Infectives: Antivirals

Acyclovir Ointment 4 N, SL, STAcyclovir Tablet 1Baraclude 2 DSP

Denavir Cream 4 EOlysio 2 DSP, N, SLRibapak 4 DSP, ERibavirin Tablet 1 DSPTamiflu 3 SLValacyclovir Tablet 2 SLZovirax Cream 4 E, SL



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Drug NameDrug

Tier

Requirements

& Limits

Cancer

Bosulif 2 DSP, N, SL, STCapecitabine Tablet 1 DSP, SL

Gleevec 2 DSP, N, SLHydroxyurea Capsule 3Leucovorin CalciumTablet

1

Mercaptopurine Tablet 1Sutent 2 DSP, N, SLTasigna 2 DSP, N, SLZytiga 2 DSP, N, SLCardiovascular/Heart Disease:Coagulation Therapy

Clopidogrel 1Coumadin 2Effient 4 SLEliquis 4 SLEnoxaparin Sodium 2 SLPradaxa 2 SLWarfarin Sodium 1Xarelto 2 SLCardiovascular/Heart Disease:High Blood PressureAmlodipine 1

AmlodipineBesylate-Benazepril

2 SL

Amlodipine/Telmisartan 4 E, SL Amturnide 4 E, SLAtenolol 1Atenolol-Chlorthalidone 1

Azor 4 E, SLBenazepril 1Benazepril-Hydrochlorothiazide

1

Benicar 2 SL

Benicar HCT 2 SLBidil 2Bisoprolol 1Bisoprolol-Hydrochlorothiazide

1

Bystolic 2Cartia XT 2

Drug NameDrug

Tier

Requirements

& Limits

Carvedilol 1Chlorthalidone 1Clonidine Tablet 1Coreg CR 4 E, SL

Diltiazem 24 Hour CD 2Diltiazem Sustained-Release Capsule

2

Diltiazem Sustained-Release Tablet

2

Diovan 3 SLDoxazosin 1Dutoprol 2 SLEdarbi 3 SLEdarbyclor 3 SLEnalapril 1Enalapril-Hydrochlorothiazide

1

Epaned 3 NExforge 4 E, SLExforge HCT 4 E, SLFelodipine 1Fosinopril Sodium 1Furosemide 1Guanfacine 1Hydralazine 1

Hydrochlorothiazide 1Indapamide 1Irbesartan 2 SLLabetalol 1Lisinopril 1Lisinopril-Hydrochlorothiazide

1

Losartan 1Losartan-Hydrochlorothiazide

1

Metoprolol Succinate

50, 100, 200 mg 2Metoprolol Tartrate 1Nadolol 1NifedipineExtended-Release

1

Propranolol Tablet 1Quinapril 1



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SL = Supply Limit

ST = Step Therapy

Drug NameDrug

Tier

Requirements

& Limits

Ramipril 1Spironolactone 1Tekamlo 4 E, SLTelmisartan 2 SL

Telmisartan/Hydrochlorothiazide

2 SL

Terazosin 1Torsemide 1Triamterene-Hydrochlorothiazide

1

Tribenzor 4 E, SLTwynsta 4 E, SLValsartan 3 SLValsartan-Hydrochlorothiazide

2 SL

Verapamil 1VerapamilSustained-Release

3

Cardiovascular/Heart Disease:High Cholesterol

Altoprev 4 E, SL Antara 4 EAtorvastatin 1 SLCaduet 4 E, SLCholine Fenofibrate 4 E

Crestor 2 SLFenofibrate 43, 50 , 67,130, 134, 150, 200 mgCapsule

4 E

Fenofibrate 48, 145 mgTablet

4 E

Fenofibrate 54, 160 mgTablet

2

Fenofibric Acid 4 EFenoglide 4 E

Drug NameDrug

Tier

Requirements

& Limits

Gemfibrozil 1Lipofen 4 ELiptruzet 4 E, SLLivalo 4 SL

Lovastatin 1Niacin Extended-Release Tablet

4

Niaspan 2Omega-3-Acid EthylEsters Capsule

3 N

Pravastatin 1Simcor 4 SLSimvastatin 1Tricor 48, 145 mg 4 ETriglide 4 E Vascepa 4 N Vytorin 4 SLWelchol 2Zetia 4 SLCardiovascular/Heart Disease:OtherAmiodarone 1Digoxin 1Flecainide 1Isosorbide

Mononitrate ER1

Multaq 2NitroglycerinSublingual Spray

3 SL

NitrolingualPump Spray

4 E, SL

Ranexa 2Sotalol 1



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Drug NameDrug

Tier

Requirements

& Limits

Central Nervous System: Attention Deficit Disorder Adderall XR 2 N, SLAmphetamine Salt

Combo 1 NClonidine Extended-Release Tablet

4 E

Concerta 2 N, SLDaytrana 4 E, N, SLDexmethylphenidateExtended-ReleaseCapsule

4 E, N, SL

DexmethylphenidateTablet

1 N

DextroamphetamineSulfate Tablet 3 NDextroamphetamine-AmphetamineExtended-Release

4 E, N, SL

Dextroamphetamine-Amphetamine Tablet

1 N

Focalin XR 4 E, N, SLIntuniv 4 E, SLKapvay 4 EMetadate CD 2 N, SL

Methylphenidate 1 NMethylphenidateExtended-ReleaseCapsule

4 E, N, SL

MethylphenidateExtended-ReleaseTablet

4 E, N, SL

Quillivant XR 4 E, N, SLRitalin LA 4 E, N, SLStrattera 4 SL

Vyvanse 2 N, SL

Zenzedi 4 E, N

Drug NameDrug

Tier

Requirements

& Limits

Central Nervous System: Depression

Amitriptyline Tablet 1 Aplenzin 4 E, SL

Bupropion Extended-Release Tablet

1

Bupropion Sustained-Release Tablet

1

Bupropion Tablet 1Citalopram Tablet 1Desvenlafaxine 4 E, SLDoxepin Capsule 1Duloxetine Capsule 3 SLEscitalopram Tablet 1Fluoxetine Capsule,Tablet 1Fluvoxamine Tablet 1Forfivo XL 4 E, SLImipramine Tablet 1Khedezla 4 EMirtazapine Tablet 1Nortriptyline Capsule 1Oleptro 4 E, SLParoxetine Tablet 1Pexeva 4 E, SL

Pristiq ER 3 SLSertraline Tablet 1Trazodone Tablet 1Venlafaxine Extended-Release Capsule

1 SL

Venlafaxine Extended-Release Tablet

3 E, SL

Venlafaxine Tablet 1 Viibryd 4 SL



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SL = Supply Limit

ST = Step Therapy

Drug NameDrug

Tier

Requirements

& Limits

Central Nervous System: Migraine

Acetaminophen/Butalbital/Caffeine

325 mg/50 mg/40 mg

1 SL

Acetaminophen/Butalbital/Caffeine/Codeine 325 mg/50 mg/40 mg/30 mg

1 SL

Alsuma 4 E, SLCambia 4 E, SLRelpax 2 SLRizatriptan OrallyDisintegrating Tablet

3 SL

Rizatriptan Tablet 2 SLSumatriptan Nasal Spray 2 SLSumatriptan SuccinateTablet, Injection

1 SL

Sumavel DosePro 3 SLTreximet 4 E, SLCentral Nervous System:Multiple Sclerosis

Ampyra 2 DSP, N, SL Aubagio 4 DSP, N, SL, ST Avonex 2 DSP, N, SL

Betaseron 2 DSP, N, SLCopaxone 2 DSP, N, SL

Extavia 4DSP, E, N,

SL, STGilenya 3 DSP, N, SL, STRebif 4 DSP, N, SL, STTecfidera 2 DSP, N, SL

Drug NameDrug

Tier

Requirements

& Limits

Central Nervous System: Other

Abilify 4 SLAlprazolam Extended-

Release Tablet 1Alprazolam Tablet 1

Aricept 23 mg 4 EBuprenorphine/Naloxone Tablet

4 E, N, SL

Buspirone Tablet 1Carbidopa-Levodopa 1Diazepam Tablet 1Donepezil 5, 10 mgTablet

1

Latuda 4 SLLithium Capsule 1Lorazepam Tablet 1Modafinil Tablet 4 E, N, SLMirapex ER 4 ENamenda XR 4Nuvigil 4 N, SLOlanzapine Tablet 1 SLPramipexole Tablet 1Provigil 4 E, N, SLQuetiapine Tablet 2 SL

Requip XL 4 ERisperidone Tablet 1Ropinirole Tablet 1Seroquel XR 4 SLSuboxone Film 4 E, N, SLTasmar 2Xyrem 4 N, SLZelapar 3Ziprasidone Capsule 2 SLZubsolv 2 N, SL



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Drug NameDrug

Tier

Requirements

& Limits

Central Nervous System:Sedatives/Hypnotics

Ambien CR 4 E, SL, STEdluar 4 E, SL, ST

Eszopiclone Tablet 3 SL, STIntermezzo 4 E, SL, STSilenor 4 E, SLTemazepam Capsule 1Zaleplon Capsule 1 SLZolpidem Extended-Release Tablet

4 E, SL, ST

Zolpidem Tablet 1 SLZolpimist 3 SL, STCentral Nervous System:Seizure DisordersCarbamazepine Tablet 1Clonazepam Tablet 1Depakote 4 N, STDepakote ER 4 N, STDiazepam Tablet 1Divalproex Delayed-Release Tablet

1

Divalproex Extended-Release Tablet

1

Gabapentin Capsule,

Tablet1

Keppra 4 N, STKeppra XR 4 N, STLamictal 4 N, STLamictal XR 4 N, STLamotrigine Tablet 1LevetiracetamExtended-ReleaseTablet

2

Levetiracetam Tablet 1Lyrica 4 SDP, SL

Neurontin 4 N, STOxcarbazepine Tablet 1Oxtellar XR 4 E, N, STPhenytoin Capsule,Suspension

1

Topamax 4 N, STTopiramate Tablet 1Trileptal 4 N, ST

Drug NameDrug

Tier

Requirements

& Limits

Trokendi XR 4 E, N, STZonegran 4 N, STZonisamide Capsule 1

Dermatology Absorica 4 E, N Acanya 4 E, SL Aczone 4 SLAdapalene 0.1%Cream, Gel

3 N, SL

Adapalene 0.3% Gel 3 N, SL Atralin 4 E, N, SL Azelex 3 SLBenzaclin 4 E, SL

BethamethasoneDipropionate 0.05%Augmented Lotion,Ointment

3

BetamethasoneDipropionate 0.05%Cream, Ointment

2

BetamethasoneValerate 0.12% Foam

4 E, SL

Betamethasone/Calcipotriene Ointment

3 SL

Carac 2Ciclopirox Cream, Gel,Lotion, Solution

1

Claravis 2 NClindagel 4 E, SLClindamycin 1%/Benzoyl Peroxide 5% Gel

4 E, SL

Clindamycin 1.2%/Benzoyl Peroxide 5% Gel

3 SL

Clindamycin Gel 3 SLClindamycin Lotion 3

Clindamycin Solution,Swabs

1

Clobetasol PropionateCream, Ointment,Solution

1

Clobetasol PropionateFoam, Lotion, Shampoo

4 E

Clocortolone Cream 3 SL, ST



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SL = Supply Limit

ST = Step Therapy

Drug NameDrug

Tier

Requirements

& Limits

Clotrimazole-Betamethasone Cream

1 SL

Clotrimazole-Betamethasone Lotion

1

Condylox Gel 3Desonide 0.05% Cream,Lotion, Ointment

3 SL

Desoximetasone Gel,Ointment

3 SL

Differin 1% 2 N, SLDiflorasone Diacetate0.05% Cream, Ointment

3 SL

Epiduo 3 SLFabior 4 E, SLFinacea 4Fluocinonide 0.05%Cream

1

Fluocinonide 0.1%Cream

4 E, SL

Fluocinolone Cream, Oil,Ointment, Solution

3 SL

Hydrocortisone 2.5%Cream, Ointment

1

Hydrocortisone ButyrateCream

4 E, SL

Keralyt Scalp Kit 4 ELocoid Lipocream 4 E, SLLocoid Lotion 4 E, SLLuxiq 4 E, SLMetrogel 1% 4 EMetronidazole Gel 0.75% 1Metronidazole Gel 1% 4 EMirvaso 4 SL

Drug NameDrug

Tier

Requirements

& Limits

Mometasone FuroateCream, Lotion, Ointment

1

Mupirocin Ointment 1Noritate 4 E

Nystatin-TriamcinoloneAcetonide Cream,Ointment

4 E

Oxsoralen-Ul 2Picato 3 SLProtopic 2 N, SLRetin-A Micro 4 E, N, SLSodiumSulfacetamide-Sulfur

1

Sorilux 4 E, SLTopicort Spray 4 E, SLTretin-X 4 E, N, SLTretinoin 1 NTretinoin Microspheres 4 E, N, SLTriamcinolone AcetonideCream, Lotion, Ointment

1

Urea 40% 1 Vanos 4 E, SL Vectical 3 SL Veltin 4 E, SL Verdeso 4 E, SL

Virasal 4 E Vusion 4 EXerese 4 EZiana 4 E, SLZyclara 4 E, SL



17

Drug NameDrug

Tier

Requirements

& Limits

Diabetes: Blood Glucose Monitoring

Accu-Chek ActiveTest Strips

1 SL

Accu-Chek AvivaPlus

1

Accu-Chek AvivaPlus Test Strips

1 SL

Accu-Chek ComfortCurve Test Strips

1 SL

Accu-Chek CompactTest Strips

1 SL

Accu-Chek NanoSmartView

1

Accu-Chek NanoSmartViewTest Strips

1 SL

Contour Test Strips 4 SDP, SLFreestyle Test Strips 4 SDP, SLOne TouchTest Strips

1 SL

One Touch UltraMeter

1

One Touch Ultra Mini 1One Touch Ultra

Test Strips

1 SL

One Touch Verio IQ 1One Touch Verio IQTest Strips

1 SL

One Touch VerioSync

1

Diabetes: Insulin

Humalog KwikPen 2Humalog Mix 75-25KwikPen

2

Humalog Vials 1Humulin 70-30 Vials 1Humulin KwikPen 2Humulin N KwikPen 2Humulin N Vials 1Humulin R Vials 1

Drug NameDrug

Tier

Requirements

& Limits

Lantus Solostar 3Lantus Vials 3Levemir Flexpen 1Levemir Vials 1

Novolog 4 SDPNovolog Flexpen 4 SDP

Diabetes: Non-Insulin

Bydureon 3 SLByetta 2 SLFarxiga 4 SL, STGlimepiride 1Glipizide 1Glipizide

Extended-Release

1

Glumetza 4 NGlyburide 1Glyburide-Metformin 1Invokamet 2 SLInvokana 2 SL, STJanumet 4 SL, STJanuvia 4 SL, STJentadueto 2 SLKazano 2 SLKombiglyze XR 2 SL

Metformin 1Metformin Extended-Release Osmotic Tablet

3 N

Metformin Extended-Release Tablet

1

Nesina 2 SLOnglyza 2 SLOseni 2 SLPioglitazone 2 SLPioglitazone-Metformin 2 SLPrandimet 3

Prandin 4 SLRepaglinide 2 SLTanzeum 2 SLTradjenta 2 SL

Victoza 3 SL



18







SL = Supply Limit

ST = Step Therapy

Drug NameDrug

Tier

Requirements

& Limits

Endocrine: Other

Calcitriol Capsule 1Desmopressin Tablet 1

Dexamethasone Tablet 1MethylprednisoloneTablet

1

Prednisolone Solution,Syrup

1

Prednisone Tablet 1Rayos 4 EEndocrine:Thyroid Hormone Replacement

Armour Thyroid 3Levothyroxine SodiumTablet 1Levoxyl 2Liothyronine SodiumTablet

2

Methimazole Tablet 1NP Thyroid Tablet 1Synthroid 2Tirosint 2

Eye Conditions: Allergies

Azelastine 0.05%Ophthalmic Solution 3 SL

Bepreve 4 E, SLElestat 4 E, SLEmadine 4 ELastacaft 3 SLPataday 4 E, SLPatanol 4 E, SL

Drug NameDrug

Tier

Requirements

& Limits

Eye Conditions: Antibiotics

Erythromycin 0.5%Ophthalmic Ointment

1

Ofloxacin 0.3%Ophthalmic Solution

1

Tobradex ST 4 E, SLTobramycin/Dexamethasone0.3%-0.1% OphthalmicSuspension

2

Eye Conditions: Glaucoma

Alphagan P 0.1% 2 SL Azopt 2 SLCombigan 2 SLCosopt PF 4 E, SLDorzolamide-Timolol2%-0.5% OphthalmicSolution

2

Latanoprost 0.005%Ophthalmic Solution

1

Lumigan 2 SLSimbrinza 4 E, SLTimolol Maleate 0.25%,

0.5% OphthalmicSolution 1

Travatan Z 2 SL



19

Drug NameDrug

Tier

Requirements

& Limits

Eye Conditions: Other

Acuvail 4 E, SLBromday 4 E, SL

Ilevro 4 ELotemax Gel 4 E, SLLotemax Solution 4 SLProlensa 4 E, SL

Gastrointestinal: Acid Suppression

Aciphex Sprinkle 4 E, SLDexilant 3 SLHelidac 4 E, SLLansoprazole Capsules 3 E, SLNexium Capsule

4 E, SLNexium SuspensionPacket

3 N, SL, ST

Omeclamox-Pak 3 SLOmeprazole Capsule 1Pantoprazole Tablet 1Prevacid Solutab 3 N, SL, STPrevpac 4 E, SLPrilosec Suspension 4 E, SLProtonix Suspension 4 E, SLPylera 3 SL

Rabeprazole Tablet 3 SLSucralfate Tablet 1Zegerid Capsule 4 E, SL

Gastrointestinal: Nausea/Vomiting

Ondansetron 1Ondansetron ODT 1Sancuso 4 E, SLZuplenz 4 E, SL

Gastrointestinal: Other

Amitiza 4 N, SL, ST Apriso 2 SL Asacol HD Tablet 4 E, SLCanasa 2Cortifoam 2

Drug NameDrug

Tier

Requirements

& Limits

Creon 2Delzicol 4 E, SLGiazo 4 EGolytely 2

Halflytely 3Hyoscyamine Tablet 1Lialda 2 SLLinzess 2 N, SLMetoclopramide Tablet 1Metozolv ODT 4 EMoviprep 3Pentasa 4 E, SLPertzye 4 STPolyethylene

Glycol 3350

2

Prepopik 3Procort 4 ESuclear 3Sulfasalazine Tablet 1Suprep 3Uceris 3Ultresa 4 STUrsodiol Capsule, Tablet 1

Viokace 4 STZenpep 2

HIV/AIDS

Atripla 2 DSPComplera 2 DSPEpzicom 2 DSPIntelence 2 DSPIsentress 2 DSPKaletra 2 DSPNorvir 2 DSPPrezista 2 DSPReyataz 2 DSPStribild 3 DSP, NSustiva 2 DSPTruvada 2 DSP, N

Viread 2 DSP



20







SL = Supply Limit

ST = Step Therapy

Drug NameDrug

Tier

Requirements

& Limits

Inflammatory Conditions: Rheumatoid Arthritis, Crohn’s Disease, Psoriasis,Ulcerative Colitis

Actemra 4 DSP, N, SL, ST

Cimzia 2 DSP, N, SLEnbrel 4 DSP, N, SL, STHumira 2 DSP, N, SLHydroxychloroquineSulfate Tablet

1

Leflunomide Tablet 1Methotrexate Tablet 1Orencia 4 DSP, N, SL, STOtezla 4 DSP, N, SL, STSimponi 2 DSP, N, SLStelara

2 DSP, N, SLXeljanz 4 DSP, N, SL, ST

Men’s Health: Erectile Dysfunction

Cialis 4 SLStaxyn 4 E, SL

Viagra 4 SL

Men’s Health: Prostate

Alfuzosin Tablet 1 Avodart 4 N, SDP

Doxazosin Tablet 1Finasteride Tablet 1Jalyn 4 ERapaflo 4Tamsulosin Capsule 1Terazosin Capsule, Tablet 1

Drug NameDrug

Tier

Requirements

& Limits

Men’s Health: Testosterone Therapy

Androderm 2 N, SL Androgel 4 E, N, SL

Android 2 Axiron 4 E, N, SLDepo-Testosterone 4Fortesta 4 E, N, SLTestim 2 N, SLTestosterone CypionateInjection

1

Testosterone EnanthateInjection

1

Testosterone Topical Gel 4 E, N, SLTestred 2

Miscellaneous

Anastrozole Tablet 1Antipyrine/BenzocaineOtic Solution

1

Aranesp 2 DSP, SL Auvi-Q 4 E, SLBenzonatate Capsule 1Bethkis 2 DSP, N, SLBrisdelle 4 E, SL

Bromfed DM 3Chlorpheniramine/Hydrocodone/PseudoephedrineSolution

3 SL

Ciprodex 2



21

Drug NameDrug

Tier

Requirements

& Limits

Epipen 2 SLEpipen-Jr 2 SLExemestane Tablet 2Fosrenol 2

Hydrocodone/ChlorpheniramineSuspension

3 SL

Hydrocodone/Homatropine

1

Letrozole Tablet 1Lidocaine TransdermalPatch

2 SL

Nuedexta 2Pegasys 2 DSP, N, SLProcrit 2 DSP, SLPromethazine/Codeine 1Promethazine/Dextromethorphan

1

Pulmozyme 2 DSP, N, SLRectiv 3 N, SLRestasis 4 N, SLRezira 3Sevelamer Carbonate 2Soltamox 4 ETamoxifen Tablet 1

Tobi 4 DSP, E, N, SLTobi Podhaler 3 DSP, N, SLTobramycinNebulized Solution

4 DSP, E, N, SL

Zonatuss 4 E

Musculoskeletal: Osteoporosis

Actonel 3 SLAlendronate SodiumTablet

1 SL

Atelvia 4 E, SL

Binosto 4 E, SLForteo 2 DSP, NIbandronate Tablet 2 SLRaloxifene Tablet 2Risedronate 150 mgTablet

3 SL

Drug NameDrug

Tier

Requirements

& Limits

Musculoskeletal: Other

Allopurinol Tablet 1

Amrix 4 EBaclofen Tablet 1Carisoprodol 350 mgTablet

1

Colcrys 2Cyclobenzaprine Tablet 1Gralise 4 E, SLHorizant 4 E, SLLorzone 4 E, SLMethocarbamol Tablet 1Soma 250 4 E

Tizanidine Tablet 1Uloric 4 SL

Musculoskeletal: Pain Relief

Abstral 4 E, N, SLAcetaminophen/Codeine Tablet

1 SL

Celebrex 4 SLConzip 4 E, SLDiclofenac 1.5% TopicalSolution

4 E

Diclofenac SodiumTablet

1

Duexis 4 E, SLEtodolac Capsule 1Fentanyl Patches 2 SLFentora 4 E, N, SLFlector 4 EHydrocodone/Acetaminophen 5/325,7.5/325, 10/325 mg

Tablet

1 SL

Hydrocodone/IbuprofenTablet

1

HydromorphoneExtended-Release Tablet

3 N, SL

Hydromorphone Tablet 1Ibuprofen Tablet 1



22







SL = Supply Limit

ST = Step Therapy

Drug NameDrug

Tier

Requirements

& Limits

Indomethacin Capsule 1Kadian 4 E, N, SLKetorolac Tablet 1Lazanda 3 N, SL

Meloxicam Tablet 1Methadone Tablet 1Morphine SulfateExtended-Release10, 20, 30, 50, 60, 80,100, 200 mg Capsule

3 E, N, SL

Morphine SulfateExtended-Release30, 45, 60, 75, 90,120 mg Capsule

3 N, SL

Morphine SulfateExtended-Release Tablet 1 SLNabumetone Tablet 1Naprelan 4 ENaproxen Tablet 1Nucynta 4 SLNucynta ER 4 N, SLOnsolis 3 N, SLOpana ER 2 N, SLOxycodone Tablet 1Oxycodone/

Acetaminophen5/325, 7.5/325,10/325 mg Tablet

1 SL

Oxycontin 2 N, SLOxymorphoneExtended-ReleaseTablet

3 N, SL

Rybix ODT 4 E, SLSprix 3Subsys 3 N, SL

Drug NameDrug

Tier

Requirements

& Limits

Tramadol Extended-Release Tablet

4 E, SL

Tramadol Sustained-Release Tablet

2 SL

Tramadol Tablet 1Vicodin 5/300, 7.5/300,10/300 mg Tablet

4 E, SL

Vimovo 4 E, SL Voltaren Gel 2Zipsor 4 EZohydro ER 4 N, SLZolvit 4 E, SLZorvolex 4 E

Overactive Bladder

Detrol 4 EDetrol LA 4 EDicyclomine Tablet 1Enablex 4 EGelnique 4 EMyrbetriq 4 EOxybutynin Extended-Release Tablet

2

Oxybutynin Tablet 1Oxytrol 4 E

Sanctura 4 ESanctura XR 4 ETolterodine Extended-Release Tablet

4 E

Tolterodine Tablet 4 EToviaz 3Trospium Extended-Release Capsule

4 E

Trospium Tablet 4 E Vesicare 4 E



23

Drug NameDrug

Tier

Requirements

& Limits

Respiratory: Allergies

Azelastine 0.1%Nasal Spray

3 SL

Azelastine 0.15%Nasal Spray

3 E, SL

Beconase AQ 4 E, SLBudesonideNasal Spray

4 E, SL

Clarinex 4 E, SLClarinex-D 3 E, SLCyproheptadine Tablet 1Desloratadine OrallyDisintegrating Tablet,Tablet

3 E, SL

Dymista 4 E, SLFlunisolide Nasal Spray 3Fluticasone Nasal Spray 2 SLHydroxyzine Capsule,Tablet

1

Levocetirizine Tablet 1 SLNasacort AQ 4 E, SLNasonex 4 E, SLOmnaris 4 E, SLPromethazine Tablet 1

Qnasl 4 E, SLTriamcinoloneNasal Spray

4 E, SL

Veramyst 4 E, SLZetonna 3 SL

Respiratory: Asthma/COPD

Advair Diskus/HFA 3 SL Aerospan 3 SLAlbuterol Sulfate Tablet 1

Alvesco 1 SL

Asmanex 1 SLBreo Ellipta 3 SLBudesonide Nebs 2 SLCombivent Respimat 3 SLDulera 3 SLFlovent Diskus/HFA 3 SLForadil 2 SL

Drug NameDrug

Tier

Requirements

& Limits

Ipratropium Nebs 1Levalbuterol Nebs 4 E, SLMontelukast ChewableTablet, Tablet

1 SL

Montelukast Granules 2 SLPerforomist 3 SLProair HFA 3 SLProventil HFA 3 SLPulmicort Flexhaler 4 SDP, SLQVAR 1 SLSpiriva 2 SLSymbicort 4 E, SLTudorza 2 SL

Ventolin HFA 1 SLXopenex HFA

3 SLXopenex Nebs 4 E, SLRespiratory:Pulmonary Arterial Hypertension

Adcirca 4 DSP, N, SLLetairis 2 DSP, N, SLRevatio 4 DSP, E, N, SLSildenafil Tablet 1 DSP, N, SLTracleer 2 DSP, N, SLTyvaso 2 DSP, N

Transplant

Astagraf XL 4 DSP, EAzathioprine Tablet 1Cellcept 4 DSPCyclosporine ModifiedCapsule

1 DSP

Mycophenolate Capsule 1 DSPMycophenolic AcidTablet

2 DSP

Myfortic 4 DSPNeoral 4 DSP

Prograf 4 DSPRapamune 4 DSPSirolimus Tablet 2 DSPTacrolimus Capsule 1 DSP



24







SL = Supply Limit

ST = Step Therapy

Drug NameDrug

Tier

Requirements

& Limits

Vitamins/Electrolytes

Fluoride 1Folic Acid 1

Klor-Con M10 1Klor-Con M20 1Potassium Chloride 1Potassium Citrate 1

Women’s Health: Contraceptives

Altavera 1Amethia 3Apri 1Aviane 1

Azurette 2Beyaz 4 ECamrese 3Cryselle 1Cyclafem 1Emoquette 1Enpresse 1Generess Fe 4 EGianvi 3Gildess Fe 1Jolessa 2

Jolivette 3Junel 2Junel Fe 1Kariva 2Levora-28 1Lo Loestrin Fe 3Lo Minastrin 24 FE 4 ELoMedia 24 FE 3Loryna 3Low-Ogestrel 1Lutera 1

Drug NameDrug

Tier

Requirements

& Limits

Microgestin 2Microgestin FE 1Minastrin 24 FE 4 EMononessa 3

Natazia 1Necon 0.5/35, 1/35,1/50, 10/11

1

Norgestimate-EthinylEstradiol

3

Nortrel 0.5/35 1Nuvaring 2Orsythia 1Ortho Micronor 1Ortho Tri-Cyclen 1Ortho Tri-Cyclen Lo 3Ortho-Cyclen 1Ortho-Novum 3Ortho-Novum 7/7/7 1Portia 1Previfem 3Quartette 4 EQuasense 2Reclipsen 1Safyral 4 ESprintec 3

Syeda 3Tri-Previfem 3Tri-Sprintec 3Trinessa 3Trivora-28 1Viorele 2Xulane 3Yasmin 28 1Yaz 2Zovia 1-35E 1



25

Drug NameDrug

Tier

Requirements

& Limits

Women’s Health: Hormone Replacement

Cenestin 4 EClimara 2 SL

Climara Pro 3 SLDivigel 2Enjuvia 3Estrace Cream 3Estradiol Tablet 1Estradiol/NorethindroneAcetate Tablet

2

Estring 2 SLEstrogen/MethyltestosteroneTablet

1

Evamist 2MedroxyprogesteroneTablet

1

Minivelle 3 SLPremarin 3Prempro 3ProgesteroneMicronized Capsule

2

Vagifem 2 Vivelle-Dot 2 SL

Drug NameDrug

Tier

Requirements

& Limits

Women’s Health: Prenatal Vitamins

Brand Prenatal Vitamins

3

Prenatal Plus 1



26

Bold type = Brand name drug [Plain type = Generic drug]

Common Brand medicationsexcluded from coverage undermany benefit plans

Lower-cost option(s)

AciphexOmeprazole (generic Prilosec), Pantoprazole (generic Protonix),Rabeprazole (generic Aciphex), Dexilant

Actiq Fentanyl Lozenge (generic Actiq)

Actos Pioglitazone (generic Actos) Adderall

Amphetamine/Dextroamphetamine Immediate-Release(generic Adderall)

Adoxa TabletDoxycycline Hyclate (generic Vibra-Tab), Doxycycline MonohydrateTablet (generic Adoxa Tablet)

Ambien Zolpidem (generic Ambien) Arimidex Anastrozole (generic Arimidex) Astelin Azelastine Nasal Spray (generic Astelin) Ativan Lorazepam (generic Ativan) Avelox Tablet Moxifloxacin Tablet (generic Avelox)

AvinzaMorphine Sulfate Extended-Release Tablet (generic MS Contin),

Morphine Sulfate Extended-Release Capsule (generic Avinza)Celexa Citalopram (generic Celexa)Cipro Suspension Ciprofloxacin Oral Suspension (generic Cipro Suspension)

Cloderm CreamClocortolone 0.1% Cream (generic Cloderm),Mometasone Furoate Cream 0.1 % (generic Elocon)

Cymbalta Duloxetine (generic Cymbalta)Diovan HCT Valsartan/Hydrochlorothiazide (generic Diovan HCT)

Duac Clindamycin Solution (generic Cleocin T) plus OTC BenzoylPeroxide, Clindamycin 1.2%/Benzoyl Peroxide 5% (generic Duac)

Duragesic Fentanyl Transdermal Patch (generic Duragesic)Effexor XR Venlafaxine Extended-Release Capsule (generic Effexor XR)

Entocort EC Budesonide (generic Entocort EC)Evista Raloxifene (generic Evista)Femara Letrozole (generic Femara)Fioricet with Codeine50 mg/325 mg/40 mg/30 mg

Butalbital/Acetaminophen/Caffeine/Codeine Phosphate50 mg/325 mg/40 mg/30 mg (generic Fioricet with Codeine)

Flomax Tamsulosin (generic Flomax)Geodon Ziprasidone (generic Geodon)Imitrex Injection &Tablets

Sumatriptan Injection, Tablet (generic Imitrex)

LexaproEscitalopram (generic Lexapro)Lidoderm Lidocaine Transdermal Patch (generic Lidoderm)

Lipitor Atorvastatin (generic Lipitor)Lofibra 54, 160 mg Fenofibrate 54, 160 mg (generic Lofibra)Lovaza Omega-3-Acid Ethyl Esters (generic Lovaza)

LunestaEszopiclone (generic Lunesta), Zaleplon (generic Sonata),Zolpidem (generic Ambien)



27

Bold type = Brand name drug [Plain type = Generic drug]

Common Brand medicationsexcluded from coverage undermany benefit plans

Lower-cost option(s)

Maxalt Rizatriptan (generic Maxalt)

Maxalt-MLTRizatriptan (generic Maxalt), Rizatriptan Orally Disintegrating Tablet(generic Maxalt MLT)

Mepron Suspension Atovaquone Suspension (generic Mepron)Micardis Losartan (generic Cozaar), Telmisartan (generic Micardis)

Micardis HCTLosartan/Hydrochlorothiazide (generic Hyzaar),Telmisartan/Hydrochlorothiazide (generic Micardis HCT)

MonodoxDoxycycline Hyclate (generic Vibramycin), DoxycyclineMonohydrate (generic Monodox)

NatrobaMalathion (generic Ovide), Permethrin (generic Elimite),Spinosad (generic Natroba)

Optivar Azelastine (generic Optivar), Lastacaft

Ortho EvraNorelgestromin/Ethinyl Estradiol Topical Patch,Xulane (generic Ortho Evra)

Percocet Acetaminophen/Oxycodone (generic Percocet)Plavix Clopidogrel (generic Plavix)Prilosec Omeprazole (generic Prilosec)Protonix Pantoprazole (generic Protonix)Prozac Fluoxetine (generic Prozac)Revatio Sildenafil (generic Revatio)Risperdal Risperidone (generic Risperdal)Seroquel Quetiapine (generic Seroquel)Singulair ChewableTablet

Montelukast Chewable Tablet (generic Singulair)

Singulair Tablet Montelukast (generic Singulair)

Skelaxin Metaxalone (generic Skelaxin)Taclonex Ointment Betamethasone/Calcipotriene Ointment (generic Taclonex)

Valium Diazepam (generic Valium) Valtrex Valacyclovir (generic Valtrex) Viramune XR 400 mg Nevirapine Extended-Release (generic Viramune XR)Wellbutrin SR Bupropion Extended-Release (generic Wellbutrin SR)Wellbutrin XL Bupropion Extended-Release (generic Wellbutrin XL)Xanax Alprazolam (generic Xanax)Xanax XR Alprazolam Extended-Release (generic Xanax XR)Zoloft Sertraline (generic Zoloft)

Zutripro Chlorpheniramine/Hydrocodone/Pseudoephedrine(generic Zutripro)Zyprexa Olanzapine (generic Zyprexa)

Zyprexa ZydisOlanzapine (generic Zyprexa), Olanzapine Orally DisintegratingTablet (generic Zyprexa Zydis)



28

Index A

Abilify ..............................................14 Absorica ...........................................15 Abstral ..............................................21 Acanya ..............................................15

Accu-Chek Active Test Strips .........17 Accu-Chek Aviva Plus .....................17 Accu-Chek Aviva Plus Test Strips ...17 Accu-Chek Comfort Curve

Test Strips .....................................17 Accu-Chek Compact Test Strips .....17 Accu-Chek Nano SmartView ..........17 Accu-Chek Nano SmartView

Test Strips .....................................17 Acetaminophen/Butalbital /

Caffeine/Codeine 325 mg/50 mg/40 mg/30 mg .....................14

Acetaminophen/Butalbital /Caffeine

325 mg/50 mg/40 mg ...................14 Acetaminophen/Codeine Tablet ......21 Acetaminophen/Oxycodone ............27 Aciphex ...................................... 19, 26 Aciphex Sprinkle ..............................19 Actemra ............................................20 Actiq.................................................26 Actonel .............................................21 Actos ................................................26 Acuvail .............................................19 Acyclovir Ointment .........................10 Acyclovir Tablet ...............................10

Aczone .............................................15 Adapalene 0.1% Cream, Gel ............15 Adapalene 0.3% Gel ........................15 Adcirca .............................................23 Adderal l .....................................13, 26 Adderal l XR .....................................13 Adoxa Capsule .................................10 Adoxa Tablet ....................................26 Advair Diskus/HFA ........................23 Aerospan ..........................................23 Albuterol Sulfate Tablet ...................23 Alendronate Sodium Tablet .............21 Alfuzosin Tablet ..............................20

Allopurinol Tablet ............................21 Alphagan P 0.1% ..............................18 Alprazolam.................................14, 27 Alprazolam Extended-Release ...14, 27 Alprazolam Extended-Release

Tablet ............................................14 Alprazolam Tablet ...........................14 Alsuma ............................................. 14 Altavera ............................................24 Altoprev ...........................................12 Alvesco .............................................23

Ambien.......................................15, 26 Ambien CR ......................................15 Amethia ...........................................24 Amiodarone .....................................12 Amitiza ............................................19 Amitriptyline Tablet ........................13

Amlodipine ......................................11 Amlodipine/Telmisartan .................11 Amlodipine Besylate-Benazepril .....11 Amoxicil lin/Potassium Clavulanate

Chewable Tablet, Tablet ...............10 Amoxicil lin Capsule, Chewable

Tablet ............................................10 Amphetamine/Dextroamphetamine

Immediate-Release .......................26 Amphetamine Salt Combo ..............13 Ampyra ............................................14 Amrix ...............................................21

Amturnide........................................11 Anastrozole ................................20, 26 Anastrozole Tablet ...........................20 Androderm .......................................20 Androgel ..........................................20 Android ............................................20 Antara ..............................................12 Antipyrine/Benzocaine

Otic Solution ................................20 Aplenzin ...........................................13 Apri ..................................................24 Apriso ...............................................19 Aranesp ............................................20

Aricept 23 mg ..................................14 Arimidex ..........................................26 Armour Thyroid ..............................18 Asacol HD Tablet ............................19 Asmanex ...........................................23 Astagraf XL .....................................23 Astelin ..............................................26 Atelvia ..............................................21 Atenolol ............................................11 Atenolol-Chlorthalidone .................11 Ativan ...............................................26 Atorvastatin ...............................12, 26 Atovaquone Suspension ...................27

Atralin ..............................................15 Atripla ..............................................19 Aubagio ............................................14 Augmentin XR.................................10 Auvi-Q .............................................20 Avelox ...............................................26 Avelox Tablet....................................26 Aviane ..............................................24 Avinza ..............................................26 Avodart ............................................20 Avonex..............................................14

Axiron ..............................................20 Azathioprine Tablet .........................23 Azelastine.......................18, 23, 26, 27 Azelastine 0.05% Ophthalmic

Solution.........................................18 Azelastine 0.15% Nasal Spray ..........23

Azelastine 0.1% Nasal Spray ............23 Azelastine Nasal Spray.....................26 Azelex ..............................................15 Azithromycin Tablet ........................10 Azopt ...............................................18 Azor .................................................11 Azurette ...........................................24

B

Baclofen Tablet.................................21Baraclude ..........................................10Beconase AQ ....................................23

Benazepril ........................................11Benazepril-Hydrochlorothiazide .....11Benicar .............................................11Benicar HCT ...................................11Benzaclin..........................................15Benzonatate Capsule ........................20Bepreve .............................................18Betamethasone/Calcipotriene

Ointment ................................15, 27Betamethasone Dipropionate

0.05% Cream, Ointment ..............15Betamethasone Valerate 0.12%

Foam .............................................15Betaseron ..........................................14Bethamethasone Dipropionate

0.05% Augmented Lotion,Ointment ......................................15

Bethkis .............................................20Beyaz ................................................24Bidil ..................................................11Binosto .............................................21Bisoprolol .........................................11Bisoprolol-Hydrochlorothiazide ......11Bosulif ..............................................11Brand Prenatal Vitamins..................25

Breo Ellipta ......................................23Brisdelle ...........................................20Bromday ...........................................19Bromfed DM ...................................20Budesonide .................................23, 26Budesonide Nasal Spray ...................23Budesonide Nebs ..............................23Buprenorphine/Naloxone Tablet .....14Bupropion Extended-Release .....13, 27Bupropion Extended-Release

Tablet ............................................13



29

Bupropion Sustained-Release Tablet ............................................13

Bupropion Tablet ..............................13Buspirone Tablet ..............................14Butalbital/Acetaminophen/

Caffeine/Codeine Phosphate50 mg/325 mg/40 mg/30 mg ........26

Bydureon ..........................................17Byetta ...............................................17Bystolic .............................................11

C

Caduet ..............................................12Calcitriol Capsule.............................18Cambia .............................................14Camrese ...........................................24Canasa ..............................................19Capecitabine Tablet ..........................11Carac ................................................15Carbamazepine Tablet .....................15

Carbidopa-Levodopa .......................14Carisoprodol 350 mg Tablet .............21Cartia XT .........................................11Carvedilol .........................................11Cefdinir Capsule ..............................10Cefuroxime Tablet ...........................10Celebrex ...........................................21Celexa ...............................................26Cellcept ............................................23Cenestin ...........................................25Centany AT .....................................10Cephalexin Capsule .........................10

Chlorpheniramine/Hydrocodone/Pseudoephedrine.....................20, 27Chlorpheniramine/Hydrocodone/

Pseudoephedrine Solution ............20Chlorthalidone .................................11Choline Fenofibrate ..........................12Cialis ................................................20Ciclopirox Cream, Gel, Lotion,

Solution.........................................15Cimzia ..............................................20Cipro Suspension .............................26Ciprodex ...........................................20Ciprofloxacin Oral Suspension ........26

Ciprofloxacin Tablet .........................10Citalopram .................................13, 26Citalopram Tablet ............................13Claravis ............................................15Clarinex ............................................23Clarinex-D .......................................23Clarithromycin Tablet ......................10Cleocin T .........................................26Climara ............................................25Climara Pro ......................................25Clindagel ..........................................15

Clindamycin 1%/BenzoylPeroxide 5% Gel ...........................15

Clindamycin 1.2%/BenzoylPeroxide 5% ............................15, 26

Clindamycin 1.2%/BenzoylPeroxide 5% Gel ...........................15

Clindamycin Capsule .......................10Clindamycin Gel ..............................15

Clindamycin Lotion .........................15Clindamycin Solution ................15, 26Clindamycin Solution, Swabs ..........15Clobetasol Propionate Cream,

Ointment, Solution .......................15Clobetasol Propionate Foam,

Lotion, Shampoo ..........................15Clocortolone 0.1% Cream ................26Clocortolone Cream .........................15Cloderm ...........................................26Cloderm Cream ...............................26Clonazepam Tablet ..........................15Clonidine Extended-Release

Tablet ............................................13Clonidine Tablet ..............................11Clopidogrel.................................11, 27Clotrimazole-Betamethasone

Cream ...........................................16Clotrimazole-Betamethasone

Lotion ...........................................16Colcrys .............................................21Combigan .........................................18Combivent Respimat........................23Complera ..........................................19Concerta ...........................................13

Condylox Gel ...................................16Contour Test Strips ..........................17Conzip ..............................................21Copaxone .........................................14Coreg CR .........................................11Cortifoam .........................................19Cosopt PF ........................................18Coumadin ........................................11Cozaar ..............................................27Creon................................................19Crestor ..........................................8, 12Cryselle ............................................24Cyclafem ..........................................24

Cyclobenzaprine Tablet....................21Cyclosporine Modified Capsule.......23Cymbalta ..........................................26Cyproheptadine Tablet.....................23

D

Daytrana ..........................................13Delzicol ............................................19Denavir Cream .................................10Depakote ..........................................15Depakote ER ...................................15

Depo-Testosterone ...........................20Desloratadine Orally Disintegrating

Tablet, Tablet ................................23Desmopressin Tablet ........................18Desonide 0.05% Cream, Lotion,

Ointment ......................................16Desoximetasone Gel, Ointment ......16Desvenlafaxine .................................13Detrol ...............................................22Detrol LA ........................................22Dexamethasone Tablet .....................18Dexilant .....................................19, 26Dexmethylphenidate

Extended-Release Capsule ...........13Dexmethylphenidate Tablet .............13Dextroamphetamine-Amphetamine

Extended-Release .........................13Dextroamphetamine-Amphetamine

Tablet ............................................13Dextroamphetamine Sulfate

Tablet ............................................13Diazepam .............................14, 15, 27Diazepam Tablet ........................14, 15Diclofenac 1.5% Topical Solution ....21Diclofenac Sodium Tablet ................21Dicyclomine Tablet ..........................22Differin 1%.......................................16Dificid ..............................................10Diflorasone Diacetate 0.05%

Cream, Ointment .........................16Digoxin ............................................12Diltiazem 24 Hour CD....................11Diltiazem Sustained-Release

Capsule .........................................11Diltiazem Sustained-Release

Tablet ............................................11Diovan ........................................11, 26Diovan HCT ....................................26Divalproex Delayed-Release

Tablet ............................................15Divalproex Extended-Release

Tablet ............................................15Divigel ..............................................25Donepezil 5, 10 mg Tablet ...............14Doryx ...............................................10

Dorzolamide-Timolol 2%-0.5%Ophthalmic Solution ....................18

Doxazosin ..................................11, 20Doxazosin Tablet .............................20Doxepin Capsule ..............................13Doxycycline Hyclate ............10, 26, 27Doxycycline Hyclate Capsule,

Tablet ............................................10Doxycycline Monohydrate ...10, 26, 27Doxycycline Monohydrate

50, 100 mg Capsule ......................10



30

Doxycycline Monohydrate75 mg Capsule ..............................10

Doxycycline Monohydrate Tablet ....26Duac .................................................26Duexis ..............................................21Dulera ..............................................23Duloxetine ..................................13, 26Duloxetine Capsule ..........................13

Duragesic .........................................26Dutoprol ...........................................11Dymista ............................................23

E

Edarbi ..............................................11Edarbyclor ........................................11Edluar ..............................................15Effexor XR .......................................26Effient ..............................................11Elestat ..............................................18Elimite .............................................27

Eliquis ..............................................11Elocon ..............................................26Emadine ...........................................18Emoquette ........................................24Enablex.............................................22Enalapril...........................................11Enalapril-Hydrochlorothiazide ........11Enbrel ...............................................20Enjuvia .............................................25Enoxaparin Sodium .........................11Enpresse ...........................................24Entocort EC .....................................26Epaned .............................................11

Epiduo ..............................................16Epipen ..............................................21Epipen-Jr ..........................................21Epzicom ...........................................19Ertaczo .............................................10Erythromycin 0.5% Ophthalmic

Ointment ......................................18Escitalopram ..............................13, 26Escitalopram Tablet .........................13Estrace Cream ..................................25Estradiol/Norethindrone Acetate

Tablet ............................................25Estradiol Tablet ................................25

Estring .............................................25Estrogen/Methyltestosterone

Tablet ............................................25Eszopiclone ................................15, 26Eszopiclone Tablet ...........................15Etodolac Capsule .............................21Evamist ............................................25Evista ................................................26Exemestane Tablet ...........................21Exforge .............................................11Exforge HCT ...................................11

Extavia .............................................14

F

Fabior ...............................................16Farxiga .............................................17Felodipine .........................................11Femara ..............................................26Fenofibrate 43, 50 , 67, 130,

134, 150, 200 mg Capsule ............12Fenofibrate 48, 145 mg Tablet ..........12Fenofibrate 54, 160 mg...............12, 26Fenofibrate 54, 160 mg Tablet .........12Fenofibric Acid .................................12Fenoglide ..........................................12Fentanyl Lozenge .............................26Fentanyl Patches ...............................21Fentanyl Transdermal Patch ............26Fentora .............................................21Finacea .............................................16Finasteride Tablet.............................20

Fioricet with Codeine ......................26Fioricet with Codeine 50 mg/

325 mg/40 mg/30 mg ...................26Flecainide .........................................12Flector ..............................................21Flomax .............................................26Flovent Diskus/HFA .......................23Fluconazole Tablet ...........................10Flunisolide Nasal Spray ...................23Fluocinolone Cream, Oil,

Ointment, Solution .......................16Fluocinonide 0.05% Cream..............16Fluocinonide 0.1% Cream ................16Fluoride ............................................24Fluoxetine...................................13, 27Fluoxetine Capsule, Tablet...............13Fluticasone Nasal Spray ...................23Fluvoxamine Tablet ..........................13Focalin XR .......................................13Folic Acid .........................................24Foradil ..............................................23Forfivo XL........................................13Forteo ...............................................21Fortesta.............................................20Fosinopril Sodium ............................11

Fosrenol ............................................21Freestyle Test Strips .........................17Furosemide .......................................11

G

Gabapentin Capsule, Tablet .............15Gelnique...........................................22Gemfibrozil ......................................12Generess Fe ......................................24Geodon ............................................26Gianvi...............................................24

Giazo ................................................19Gildess Fe .........................................24Gilenya .............................................14Gleevec .............................................11Glimepiride ......................................17Glipizide ...........................................17Glipizide Extended-Release .............17Glumetza ..........................................17

Glyburide .........................................17Glyburide-Metformin ......................17Golytely ............................................19Gralise ..............................................21Guanfacine .......................................11

H

Halflytely .........................................19Helidac .............................................19Horizant ...........................................21Humalog KwikPen ..........................17Humalog Mix 75-25 KwikPen ........17

Humalog Vials .................................17Humira .............................................20Humulin 70-30 Vials .......................17Humulin KwikPen ...........................17Humulin N KwikPen .......................17Humulin N Vials .............................17Humulin R Vials ..............................17Hydralazine ......................................11Hydrochlorothiazide ......11, 12, 26, 27Hydrocodone/Acetaminophen

5/325, 7.5/325, 10/325 mg Tablet ............................................21

Hydrocodone/ChlorpheniramineSuspension ....................................21

Hydrocodone/Homatropine ............21Hydrocodone/Ibuprofen Tablet .......21Hydrocortisone 2.5% Cream,

Ointment ......................................16Hydrocortisone Butyrate Cream ......16Hydromorphone Extended-Release

Tablet ............................................21Hydromorphone Tablet ....................21Hydroxychloroquine Sulfate Tablet .20Hydroxyurea Capsule .......................11Hydroxyzine Capsule, Tablet ...........23

Hyoscyamine Tablet .........................19Hyzaar ..............................................27

I

Ibandronate Tablet ...........................21Ibuprofen Tablet ...............................21Ilevro ................................................19Imipramine Tablet ...........................13Imitrex ..............................................26Imitrex Injection & Tablets ..............26Indapamide ......................................11



31

Indomethacin Capsule .....................22Intelence ...........................................19Intermezzo .......................................15Intuniv ..............................................13Invokamet ........................................17Invokana ...........................................17Ipratropium Nebs .............................23Irbesartan .........................................11

Isentress ............................................19Isosorbide Mononitrate ER..............12Itraconazole Capsule ........................10

J

Jalyn .................................................20 Janumet ............................................17 Januvia ..............................................17 Jentadueto .........................................17 Jolessa ...............................................24 Jolivette ............................................24 Junel .................................................24

Junel Fe.............................................24

K

Kadian ..............................................22Kaletra ..............................................19Kapvay ..............................................13Kariva ...............................................24Kazano .............................................17Keppra ..............................................15Keppra XR .......................................15Keralyt Scalp Kit ..............................16Ketoconazole Cream ........................10

Ketorolac Tablet ...............................22Khedezla ..........................................13Klor-Con M10 .................................24Klor-Con M20 .................................24Kombiglyze XR ................................17

L

Labetalol ..........................................11Lamictal ...........................................15Lamictal XR ....................................15Lamotrigine Tablet ..........................15Lansoprazole Capsules .....................19Lantus Solostar ................................17

Lantus Vials .....................................17Lastacaft .....................................18, 27Latanoprost 0.005% Ophthalmic

Solution.........................................18Latuda ..............................................14Lazanda ............................................22Leflunomide Tablet ..........................20Letair is .............................................23Letrozole ....................................21, 26Letrozole Tablet ...............................21Leucovorin Calcium Tablet..............11

Levalbuterol Nebs ............................23Levemir Flexpen ..............................17Levemir Vials ...................................17Levetiracetam Extended-Release

Tablet ............................................15Levetiracetam Tablet .......................15Levocetirizine Tablet .......................23Levofloxacin Tablet ..........................10

Levora-28 .........................................24Levothyroxine Sodium Tablet .........18Levoxyl .............................................18Lexapro ............................................26Lialda ...............................................19Lidocaine Transdermal Patch ....21, 26Lidoderm .........................................26Linzess .............................................19Liothyronine Sodium Tablet ............18Lipitor ..............................................26Lipofen .............................................12Liptruzet ..........................................12Lisinopril ....................................11, 35Lisinopril-Hydrochlorothiazide .......11Lithium Capsule ..............................14Livalo ...............................................12Lo Loestrin Fe .................................24Lo Minastrin 24 FE ........................24Locoid Lipocream ............................16Locoid Lotion ..................................16Lofibra ..............................................26Lofibra 54, 160 mg ...........................26LoMedia 24 FE ...............................24Lorazepam .................................14, 26Lorazepam Tablet ............................14

Loryna ..............................................24Lorzone ............................................21Losartan .....................................11, 27Losartan-Hydrochlorothiazide ........11Losartan/Hydrochlorothiazide ........27Lotemax Gel ....................................19Lotemax Solution .............................19Lovastatin ........................................12Lovaza ..............................................26Low-Ogestrel ...................................24Lumigan ...........................................18Lunesta .............................................26Lutera ...............................................24

Luxiq ................................................16Luzu .................................................10Lyrica ...............................................15

M

Malathion.........................................27Maxalt ..............................................27Maxalt-MLT ....................................27Maxalt MLT ....................................27Medroxyprogesterone Tablet ...........25Meloxicam Tablet.............................22

Mepron .............................................27Mepron Suspension ..........................27Mercaptopurine Tablet .....................11Metadate CD ...................................13Metaxalone .......................................27Metformin ........................................17Metformin Extended-Release

Osmotic Tablet .............................17Metformin Extended-Release

Tablet ............................................17Methadone Tablet ............................22Methimazole Tablet .........................18Methocarbamol Tablet .....................21Methotrexate Tablet .........................20Methylphenidate ..............................13Methylphenidate Extended-Release

Capsule .........................................13Methylphenidate Extended-Release

Tablet ............................................13Methylprednisolone Tablet ..............18

Metoclopramide Tablet ....................19Metoprolol Succinate

50, 100, 200 mg ............................11Metoprolol Tartrate ..........................11Metozolv ODT ................................19Metrogel 1% .....................................16Metronidazole Gel 0.75% ................16Metronidazole Gel 1% .....................16Metronidazole Tablet .......................10Micardis ...........................................27Micardis HCT .................................27Microgestin ......................................24

Microgestin FE ................................24Minastrin 24 FE ..............................24Minivel le ..........................................25Minocycline Capsule .......................10Minocycline Tablet ..........................10Mirapex ER ..................................... 14Mirtazapine Tablet ...........................13Mirvaso ............................................16Modafinil Tablet ..............................14Mometasone Furoate

Cream 0.1 % .................................26Mometasone Furoate Cream,

Lotion, Ointment .........................16Monodox ..........................................27Mononessa .......................................24Montelukast ...............................23, 27Montelukast Chewable Tablet ...23, 27Montelukast Chewable Tablet,

Tablet ............................................23Montelukast Granules......................23Morphine Sulfate Extended-Release

10, 20, 30, 50, 60, 80, 100, 200 mgCapsule .........................................22



32

Morphine Sulfate Extended-Release30, 45, 60, 75, 90, 120 mgCapsule .........................................22

Morphine Sulfate Extended-ReleaseCapsule .........................................26

Morphine Sulfate Extended-Release Tablet ......................................22, 26

Moviprep ..........................................19

Moxifloxacin Tablet .........................26MS Contin .......................................26Multaq ..............................................12Mupirocin Ointment........................16Mycophenolate Capsule ...................23Mycophenolic Acid Tablet ...............23Myfortic ...........................................23Myrbetriq .........................................22

N

Nabumetone Tablet ..........................22Nadolol .............................................11

Naftin 1%, 2% Cream, Gel ..............10Namenda XR ...................................14Naprelan ...........................................22Naproxen Tablet ...............................22Nasacort AQ ....................................23Nasonex ............................................23Natazia .............................................24Natroba ............................................27Necon 0.5/35, 1/35, 1/50, 10/11 ......24Neoral...............................................23Nesina ..............................................17Neurontin .........................................15Nevirapine Extended-Release ..........27

Nexium Capsule ...............................19Nexium Suspension Packet ..............19Niacin Extended-Release Tablet ......12Niaspan ............................................12Nifedipine Extended-Release ..........11Nitrofurantoin Capsule ....................10Nitrofurantoin Macrocrystal

Capsule .........................................10Nitroglycerin Sublingual Spray ........12Nitrolingual Pump Spray .................12Norelgestromin/Ethinyl Estradiol

Topical Patch ................................27Norgestimate-Ethinyl Estradiol ......24

Noritate ............................................16Nortrel 0.5/35 ..................................24Nortriptyline Capsule ......................13Norvir ...............................................19Novolog ............................................17Novolog Flexpen ..............................17NP Thyroid Tablet ...........................18Nucynta ............................................22Nucynta ER .....................................22Nuedexta ..........................................21Nuvaring ..........................................24

Nuvigil .............................................14Nystatin-Triamcinolone Acetonide

Cream, Ointment .........................16Nystatin Cream, Ointment ..............10

O

Ofloxacin 0.3% OphthalmicSolution.........................................18

Olanzapine .................................14, 27Olanzapine Orally Disintegrating

Tablet ............................................27Olanzapine Tablet ............................14Oleptro .............................................13Olysio ...............................................10Omeclamox-Pak ...............................19Omega-3-Acid Ethyl Esters.......12, 26Omega-3-Acid Ethyl Esters

Capsule .........................................12Omeprazole .......................... 19, 26, 27Omeprazole Capsule ........................19

Omnaris ...........................................23Ondansetron ....................................19Ondansetron ODT ..........................19One Touch Test Strips .....................17One Touch Ultra Meter ...................17One Touch Ultra Mini .....................17One Touch Ultra Test Strips ............17One Touch Verio IQ ........................17One Touch Verio IQ Test Strips ......17One Touch Verio Sync .....................17Onglyza ............................................17Onmel ..............................................10Onsolis .............................................22

Opana ER ........................................22Optivar .............................................27Oracea ..............................................10Orencia .............................................20Orsythia ...........................................24Ortho-Cyclen ...................................24Ortho-Novum ..................................24Ortho-Novum 7/7/7 ........................24Ortho Evra .......................................27Ortho Micronor ...............................24Ortho Tri-Cyclen .............................24Ortho Tri-Cyclen Lo .......................24Oseni ................................................17

OTC Benzoyl Peroxide ....................26Otezla ...............................................20Ovide ................................................27Oxcarbazepine Tablet ......................15Oxistat Cream ..................................10Oxistat Lotion ..................................10Oxsoralen-Ul....................................16Oxtellar XR .....................................15Oxybutynin Extended-Release

Tablet ............................................22Oxybutynin Tablet ...........................22

Oxycodone/Acetaminophen 5/325,7.5/325, 10/325 mg Tablet ............22

Oxycodone Tablet ............................22Oxycontin ........................................22Oxymorphone Extended-Release

Tablet ............................................22Oxytrol .............................................22

PPantoprazole ......................... 19, 26, 27Pantoprazole Tablet ..........................19Paroxetine Tablet .............................13Pataday .............................................18Patanol..............................................18Pegasys .............................................21Penicill in V Potassium Tablet ..........10Pentasa .............................................19Percocet ............................................27Perforomist .......................................23Permethrin .......................................27

Pertzye..............................................19Pexeva ...............................................13Phenytoin Capsule, Suspension .......15Picato ................................................16Pioglitazone ................................ 17, 26Pioglitazone-Metformin ..................17Plavix ................................................27Polyethylene Glycol 3350 .................19Portia ................................................24Potassium Chloride ..........................24Potassium Citrate .............................24Pradaxa .............................................11Pramipexole Tablet...........................14

Prandimet.........................................17Prandin .............................................17Pravastatin ........................................12Prednisolone Solution, Syrup ...........18Prednisone Tablet.............................18Premarin...........................................25Prempro ............................................25Prenatal Plus ....................................25Prepopik ...........................................19Prevacid Solutab ...............................19Previfem ...........................................24Prevpac .............................................19Prezista .............................................19

Prilosec ................................. 19, 26, 27Prilosec Suspension ..........................19Pristiq ER ........................................13Proair HFA ......................................23Procort..............................................19Procrit ..............................................21Progesterone Micronized Capsule ...25Prograf .............................................23Prolensa ............................................19Promethazine/Codeine ....................21Promethazine/Dextromethorphan ..21



33

Promethazine Tablet ........................23Propranolol Tablet ............................11Protonix ................................19, 26, 27Protonix Suspension .........................19Protopic ............................................16Proventil HFA .................................23Provigil .............................................14Prozac ...............................................27

Pulmicort Flexhaler .........................23Pulmozyme ......................................21Pylera................................................19

Q

Qnasl ................................................23Quartette ..........................................24Quasense ..........................................24Quetiapine ..................................14, 27Quetiapine Tablet.............................14Quillivant XR ..................................13Quinapril ..........................................11

QVAR ..............................................23

R

Rabeprazole ................................19, 26Rabeprazole Tablet ...........................19Raloxifene ..................................21, 26Raloxifene Tablet .............................21Ramipril ...........................................12Ranexa ..............................................12Rapaflo .............................................20Rapamune ........................................23Rayos ................................................18

Rebif .................................................14Reclipsen ..........................................24Rectiv ...............................................21Relpax ..............................................14Repaglinide ......................................17Requip XL .......................................14Restasis .............................................21Retin-A Micro .................................16Revatio .......................................23, 27Reyataz .............................................19Rezira ...............................................21Ribapak ............................................10Ribavirin Tablet ...............................10

Risedronate 150 mg Tablet ..............21Risperdal ..........................................27Risperidone ................................14, 27Risperidone Tablet ...........................14Ritalin LA........................................13Rizatriptan .................................14, 27Rizatriptan Orally Disintegrating

Tablet ......................................14, 27Rizatriptan Tablet ............................14Ropinirole Tablet .............................14Rybix ODT ......................................22

S

Safyral ..............................................24Sanctura ...........................................22Sanctura XR .....................................22Sancuso ............................................19Seroquel ......................................14, 27Seroquel XR .....................................14

Sertraline ....................................13, 27Sertraline Tablet ...............................13Sevelamer Carbonate .......................21Sildenafil ....................................23, 27Sildenafil Tablet ...............................23Silenor ..............................................15Simbrinza .........................................18Simcor ..............................................12Simponi ............................................20Simvastatin ...................................8, 12Singulair ...........................................27Singulair Chewable Tablet ...............27Singulair Tablet ................................27

Sirolimus Tablet ...............................23Skelax in ............................................27Sodium Sulfacetamide-Sulfur .........16Solodyn ............................................10Soltamox...........................................21Soma 250..........................................21Sonata ...............................................26Sorilux ..............................................16Sotalol ..............................................12Spinosad ...........................................27Spiriva ..............................................23Spironolactone ..................................12

Sprintec ............................................24Sprix .................................................22Staxyn ..............................................20Stelara...............................................20Strattera ............................................13Stribild .............................................19Suboxone Film .................................14Subsys ...............................................22Suclear ..............................................19Sucralfate Tablet ..............................19Sulfamethoxazole-Trimethoprim

Tablet ............................................10Sulfasalazine Tablet .........................19

Sumatriptan Injection, Tablet ..........26Sumatriptan Nasal Spray .................14Sumatriptan Succinate Tablet,

Injection ........................................14Sumavel DosePro .............................14Suprep ..............................................19Sustiva ..............................................19Sutent ...............................................11Syeda ................................................24Symbicort .........................................23Synthroid ..........................................18

T

Taclonex ...........................................27 Taclonex Ointment ..........................27 Tacrolimus Capsule ..........................23 Tamiflu .............................................10 Tamoxifen Tablet .............................21 Tamsulosin .................................20, 26

Tamsulosin Capsule .........................20 Tanzeum ..........................................17 Tasigna .............................................11 Tasmar ..............................................14 Tecfidera ...........................................14 Tekamlo ...........................................12 Telmisartan ..........................11, 12, 27 Telmisartan/

Hydrochlorothiazide ..............12, 27 Temazepam Capsule ........................15 Terazosin ....................................12, 20 Terazosin Capsule, Tablet ................20 Terbinafine Tablet ............................10

Testim ..............................................20 Testosterone Cypionate Injection .....20 Testosterone Enanthate Injection ....20 Testosterone Topical Gel..................20 Testred..............................................20 Timolol Maleate 0.25%, 0.5%

Ophthalmic Solution ....................18 Tirosint ............................................18 Tizanidine Tablet .............................21 Tobi ..................................................21 Tobi Podhaler ...................................21 Tobradex ST .....................................18

Tobramycin/Dexamethasone0.3%-0.1% OphthalmicSuspension ....................................18

Tobramycin Nebulized Solution ......21 Tolterodine Extended-Release

Tablet ............................................22 Tolterodine Tablet ............................22 Topamax ...........................................15 Topicort Spray ..................................16 Topiramate Tablet ............................15 Torsemide .........................................12 Toviaz ...............................................22 Tracleer ............................................23

Tradjenta ..........................................17 Tramadol Extended-Release

Tablet ............................................22 Tramadol Sustained-Release

Tablet ............................................22 Tramadol Tablet ...............................22 Travatan Z ........................................18 Trazodone Tablet .............................13 Tretin-X ...........................................16 Tretinoin ..........................................16 Tretinoin Microspheres ....................16



34

Treximet ........................................... 14 Tri-Previfem .....................................24 Tri-Sprintec ......................................24 Triamcinolone Acetonide Cream,

Lotion, Ointment .........................16 Triamcinolone Nasal Spray ..............23 Triamterene-Hydrochlorothiazide ...12 Tribenzor ..........................................12

Tricor 48, 145 mg .............................12 Triglide .............................................12 Trileptal ............................................15 Trinessa ............................................24 Trivora-28.........................................24 Trokendi XR ....................................15 Trospium Extended-Release

Capsule .........................................22 Trospium Tablet ...............................22 Truvada ............................................19 Tudorza ............................................23 Twynsta ............................................12 Tyvaso ..............................................23

U

Uceris ...............................................19Uloric ...............................................21Ultresa ..............................................19Urea 40% ..........................................16Ursodiol Capsule, Tablet ..................19

V

Vagifem ............................................25Valacyclovir ................................10, 27Valacyclovir Tablet ...........................10

Valium ..............................................27Valsartan ....................................12, 26Valsartan-Hydrochlorothiazide .......12Valsartan/Hydrochlorothiazide .......26Valtrex ..............................................27Vanos ................................................16Vascepa .............................................12Vectical .............................................16Veltin ................................................16Venlafaxine Extended-Release

Capsule ...................................13, 26Venlafaxine Extended-Release

Tablet ............................................13

Venlafaxine Tablet ...........................13Ventolin HFA ..................................23Veramyst ...........................................23Verapamil .........................................12Verapamil Sustained-Release ...........12Verdeso .............................................16Vesicare ............................................22Viagra ...............................................20

Vibra-Tab .........................................26Vibramycin .......................................27Vicodin 5/300, 7.5/300,

10/300 mg Tablet..........................22Victoza .............................................17Viibryd .............................................13Vimovo .............................................22Viokace .............................................19Viorele ..............................................24Viramune XR ...................................27Viramune XR 400 mg......................27Virasa l ..............................................16Viread ...............................................19Vivelle-Dot ......................................25Voltaren Gel .....................................22Vusion ..............................................16Vytorin .............................................12Vyvanse ............................................13

W

Warfarin Sodium .............................11 Welchol ............................................12 Wellbutrin SR ..................................27 Wellbutrin XL .................................27

X Xanax ...............................................27 Xanax XR .........................................27 Xarelto ..............................................11 Xeljanz..............................................20 Xerese ...............................................16 Xopenex HFA ..................................23 Xopenex Nebs ..................................23 Xulane ........................................24, 27 Xyrem ...............................................14

Y

Yasmin 28 .........................................24 Yaz ....................................................24

Z

Zaleplon .....................................15, 26Zaleplon Capsule .............................15

Zegerid Capsule ...............................19Zelapar .............................................14Zenpep .............................................19Zenzedi ............................................13Zetia .................................................12Zetonna ............................................23Ziana ................................................16Ziprasidone ................................14, 26Ziprasidone Capsule .........................14Zipsor ...............................................22Zohydro ER .....................................22Zoloft ...............................................27Zolpidem ....................................15, 26

Zolpidem Extended-Release Tablet .15Zolpidem Tablet ...............................15Zolpimist ..........................................15Zolvit ................................................22Zonatuss ...........................................21Zonegran ..........................................15Zonisamide Capsule ........................15Zorvolex ...........................................22Zovia 1-35E .....................................24Zovirax Cream .................................10Zubsolv .............................................14Zuplenz ............................................19Zutripro ............................................27Zyclara .............................................16Zyprexa ............................................27Zyprexa Zydis ..................................27Zytiga ...............................................11



35

“My Medications” worksheet Take this worksheet with you each time you visit a doctor. Each of your doctors should be aware of everydrug you take and you should have a list as well.

Name of Medicine

and Strength

Drug

Tier

I Take This

Medicine ForDirections Doctor

Example: Lisinopril, 20 mg Tier 1 High blood pressure One tablet daily Dr. Johnson



For more information

Call the toll-free Member Services number on the back of your health plan ID card.

Or, visit www.uhone.com

unitedhealthcare - platinum copay select medications list

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