your 2014 prescription drug list - oci homepage · your prescription drug list this prescription...

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Your 2014Prescription Drug ListPlease read: This document contains information about commonly prescribed medications.

For additional information:

Call the toll-free member phone number on the back of your health plan ID card.

Visit myuhc.com®

•LocateaparticipatingretailpharmacybyZIPcode.

•Lookuppossiblelower-costmedicationalternatives.

•Comparemedicationpricingandoptions.

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

Go to myuhc.com® for complete drug informationSince the PDL may change, we encourage you to visit our website, myuhc.com. This website is the best source for up-to-date information about the medications your pharmacy benefi t 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-InfectivesAntibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Cardiovascular/Heart DiseaseCoagulation Therapy . . . . . . . . . . . . . . . . . . . . . . . .11High Blood Pressure . . . . . . . . . . . . . . . . . . . . . . . .11High Cholesterol . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Central Nervous SystemAttention Deficit Disorder . . . . . . . . . . . . . . . . . . . 12Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Sedatives/Hypnotics . . . . . . . . . . . . . . . . . . . . . . . 14Seizure Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . 14

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

Diabetes/EndocrineBlood Glucose Monitoring . . . . . . . . . . . . . . . . . . 16Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Non-Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

EndocrineGrowth Hormone . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Thyroid Hormone Replacement . . . . . . . . . . . . . 17

Eye ConditionsAllergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

GastrointestinalAcid Suppression . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Nausea/Vomiting . . . . . . . . . . . . . . . . . . . . . . . . . . 18Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

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

Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Men’s HealthErectile Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . 19Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Testosterone Therapy . . . . . . . . . . . . . . . . . . . . . . 19

Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

MusculoskeletalOsteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Pain Relief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Rheumatoid Arthritis . . . . . . . . . . . . . . . . . . . . . . . . 21

Overactive Bladder . . . . . . . . . . . . . . . . . . . . . . 21

RespiratoryAsthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Nasal Allergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Oral Allergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Pulmonary Arterial Hypertension . . . . . . . . . . . . 22

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

Vitamins/Electrolytes . . . . . . . . . . . . . . . . . . . 23

Women’s HealthContraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Hormone Replacement . . . . . . . . . . . . . . . . . . . . . 24Prenatal Vitamins . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

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At UnitedHealthcare, we want to help you better understand your medication options. Your pharmacy benefit offers flexibility and choice in determining the right medication for you. To help you get the most out of your pharmacy benefit, we’ve included some of the most commonly asked questions about the Prescription Drug List.

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

Please note: Where differences are noted between this PDL and your benefit plan documents, the benefit plan documents will rule. It is not a complete list of medications, and not all medications listed may be covered under your plan. Please look at your benefit plan documents provided by your employer or health plan to see what medications are covered under your plan. You may also log on to myuhc.com or call the toll-free member phone number on the back of 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 your doctor choose the most cost-effective prescription drugs. This guide tells you if a medication is generic or brand, and if special rules apply. Bring this list with you when you see your doctor. It is organized by common medical conditions. Medications are then listed alphabetically.

If your medication is not listed in this document, please visit myuhc.com or call the toll-free member phone number on the back of your health plan ID card.

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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 is determined by your employer or health plan. This is how much you will pay when you fill a prescription. Tier 1 medications are your lowest-cost options. If your medication is placed in Tier 2 or 3, look to see if there is a Tier 1 option available. Discuss these options with your doctor.

Check your benefit plan documents to find out your specific pharmacy plan costs.

$ Drug Tier Includes Helpful Tips

Tier 1Lowest Cost

Lower-cost drugs . Some low-cost brands are also included .

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

Tier 2 and 3Mid-range Cost

Mix of brands and generics .

Use Tier 2 or Tier 3 drugs instead of Tier 4 to help reduce your out-of-pocket costs .

Tier 4Highest Cost

Mostly higher-cost brand as well as select generic drugs .

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 four tiers, while others may not have any. If you have a high deductible plan, the tier cost levels may apply once you hit your deductible. Refer to your enrollment and plan materials on myuhc.com, or call the toll-free number of the back of your health plan ID card for more information about your benefit plan.

When does the Prescription Drug List change?• Medicationsmaymovetoalowertieratanytime.

• Medicationsmaymovetoahighertierwhenitsgenericbecomesavailable.

• Medicationsmaymovetoahighertierorbeexcludedfromcoveragemostoftenon 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, call customer service at the number on the back of your ID card.

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Programs and LimitsSome medications are noted with letters next to them. The letters refer to our pharmacy benefit programs. Your benefit plan determines how these medications may be covered for you.

DSPDesignated Specialty Program – Specialty medications need to be filled at a designated specialty pharmacy for network coverage . Call the number on your ID card or call 1-888-739-5820 for more information .

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

MC Multiple Copay – More than one month’s worth of medication included in package so additional copay applies .

N Notification or Prior Authorization required* – Your doctor is required to provide additional information to UnitedHealthcare to determine coverage .

RS Refill and Save Program – Save money on your copayment when you refill your prescription on time as prescribed . Program eligibility may vary .

SDP Select Designated Pharmacy – Must use a lower cost medication at retail or transfer the designated medication to the mail service pharmacy for network coverage .

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

ST Step Therapy – Trial of a lower cost medication is required before a higher cost medication is covered .

1/2T Half Tablet Program – Save up-to 50% when you split your tablet (double the strength) in half . Program eligibility may vary .

*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 myuhc.com or call the toll-free member phone number on the back of your health plan ID card.

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

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 your doctor about available OTC options. These medications are not covered under your pharmacy benefit, but they may cost less than your out-of-pocket expense for prescription medications.

What is the difference between brand-name and generic medications? Generic medications contain the same active ingredients (what makes the medication work) as brand-name medications, but they often cost less. Once the patent of a brand-name medication ends, the FDA can approve a generic version with the same active ingredients. These types of medications are known as generic medications. Sometimes, the same company that makes a brand-name medication also makes the generic version.

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 plain type (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 generic equivalent or lower-cost option is available and if it might be right for you. Generic medications are usually your lowest-cost option, but not always. Visit myuhc.com to make sure.

Are you taking a specialty medication? Specialty medications treat rare and complex conditions and are typically higher cost medications. Please note, not all specialty medications are listed in the PDL.

If you are taking a specialty medication that is on Tier 2, Tier 3 or Tier 4, call the toll-free number on the back of your health plan ID card to talk to a representative about finding lower-cost options.

OptumRx is the specialty pharmacy that can provide most of your specialty medications along with helpful programs and services. Call OptumRx Specialty Pharmacy at 1-888-702-8423 and have your prescriptions delivered right to your home or office.

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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 myuhc.com or call the toll-free member phone number on the back of your health plan ID card for more current information.

Log on to myuhc.com for the following pharmacy information and tools:

• Pharmacybenefitandcoverageinformation

• Possiblelower-costmedicationoptions

• Alistofmedicationsbasedonaspecificmedicalcondition

• Medicationinteractionsandsideeffects

• Participatingretailpharmaciesbyzipcode

• Yourprescriptionhistory

And, if Mail Service is included in your pharmacy benefit, you can also:

• Refillprescriptions

• Checkthestatusofyourorder

• Set-upe-mailremindersforrefills

• Manageyouraccount

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


Or,visitmyuhc.com®

Where else can I go for information? HealthCareLane.com includesshortvideostohelpyoulearnmoreabout UnitedHealthcare benefits and health insurance information.

UHCTV.comisafunandeasywaytolearnabouthealthtermsandother health-related topics.

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

DSP = Designated Specialty ProgramE = May be excluded from coverageMC = Multiple Copay

N = Notification or Prior Authorization requiredRS = May be eligible for the Refill and Save ProgramSDP = Select Designated PharmacySL = Supply LimitST = Step Therapy1/2T = May be eligible for Half Tablet

Drug Name Drug Tier

Requirements & Limits

Anti-Infectives: Antibiotics

Adoxa Capsule 4 EAdoxa Tablet 4 EAmoxicillin 1Amoxicillin/Potassium Clavulanate

1

Augmentin XR 4 EAzithromycin 1Cefdinir 2Cefuroxime 1Centany AT 4 ECephalexin 1Ciprofloxacin Tablet 1Clarithromycin Tablet 1Clindamycin 1Dificid 3 SLDoryx 4 EDoxycycline Hyclate 1Doxycycline Monohydrate

1

Levofloxacin 1Metronidazole 1Minocycline 1Monodox 4 ENitrofurantoin 1Nitrofurantoin Macrocrystal

1

Oracea 4PenicillinVPotassium 1Solodyn 45, 90, 135 mg 4

Solodyn 55, 65, 80, 105, 115 mg 4

Sulfamethoxazole-Trimethoprim

1

Drug Name Drug Tier


Anti-Infectives: Antifungals

Fluconazole 1Itraconazole 1Ketoconazole 1Nystatin 1Onmel 4 E, SLTerbinafine 1 SL

Anti-Infectives: Antivirals

Acyclovir Ointment 3 SLAcyclovir Tablet 1Baraclude 2 DSPIncivek 2 DSP, N, SLRibapak 4 DSP, ERibavirin 1 DSPTamiflu 3 SLValacyclovir 2 SLValtrex 4 E, SLZovirax Cream 3 SLZovirax Ointment 4 E, SL

Cancer

Bosulif 2 DSP, N, SLGleevec 2 DSP, N, SLHydroxyurea 3Leucovorin Calcium 1Mercaptopurine 1Xeloda 2 DSP, SLZytiga 2 DSP, N, SL

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Drug Name Drug Tier


Cardiovascular/Heart Disease: Coagulation TherapyClopidogrel 1Coumadin 2Effient 4 SLEnoxaparin Sodium 2 SLPlavix 4 EPradaxa 4 SLWarfarin Sodium 1Xarelto 2 SLCardiovascular/Heart Disease: High Blood PressureAmlodipine 1Amlodipine Besylate-Benazepril

2 SL

Amturnide 4 E, SLAtenolol 1Atenolol-Chlorthalidone 1Azor 4 E, SLBenazepril 1Benazepril-Hydrochlorothiazide

1

Benicar 2 SL, 1/2TBenicar HCT 2 SLBidil 2Bisoprolol 1Bisoprolol-Hydrochlorothiazide

1

Bystolic 2Cartia XT 2Carvedilol 1Chlorthalidone 1Clonidine Tablet 1Coreg CR 4 E, SLDiltiazem 24 Hour CD 2Diltiazem Sustained-Release Capsule

2

Diltiazem Sustained-Release Tablet

2

Diovan 3 SL, 1/2TDiovan HCT 4 E, SL

Drug Name Drug Tier


Doxazosin 1Edarbi 3 SLEdarbyclor 3 SLEnalapril 1Enalapril-Hydrochlorothiazide

1

Exforge 4 E, SLExforge HCT 4 E, SLFelodipine 1Fosinopril Sodium 1Furosemide 1Guanfacine 1Hydralazine 1Hydrochlorothiazide 1Indapamide 1Irbesartan 2 SL, 1/2TLabetalol 1Lisinopril 1Lisinopril-Hydrochlorothiazide

1

Losartan 1 1/2TLosartan-Hydrochlorothiazide

1

Metoprolol Succinate 50, 100, 200 mg

2

Metoprolol Tartrate 1Micardis 2 SLMicardis HCT 2 SLNadolol 1Nexiclon XR 4 ENifedical XL 1Nifedipine Extended-Release

1

Propranolol 1Quinapril 1Ramipril 1Spironolactone 1Tekamlo 4 E, SLTerazosin 1Toprol XL 4Torsemide 1

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Drug Name Drug Tier


Triamterene-Hydrochlorothiazide

1

Tribenzor 4 E, SLTwynsta 4 E, SLValsartan-Hydrochlorothiazide

2 SL

Verapamil 1Verapamil Sustained-Release

3

Cardiovascular/Heart Disease: High CholesterolAltoprev 4 E, SLAtorvastatin 1 SL, 1/2TCaduet 4 E, SLCholine Fenofibrate 4 ECrestor 2 SL, 1/2TFenofibrate 48, 145 mg 4 EFenofibrate 54, 160 mg 2Fenofibrate Micronized 43, 130 mg

2

Fenoglide 3Gemfibrozil 1Lipitor 4 E, SL, 1/2TLipofen 2Livalo 4 SLLovastatin 1Lovaza 4 NNiaspan 4Pravastatin 1 1/2TSimcor 4 SLSimvastatin 1 1/2TTricor 48 mg, 145 mg 4 ETrilipix 4 EVytorin 4 SLWelchol 2Zetia 4 SL

Drug Name Drug Tier


Cardiovascular/Heart Disease: OtherAmiodarone 1Digoxin 1Flecainide 1Isosorbide Mononitrate ER

1

Multaq 2Nitroglycerin Sublingual Spray

3 SL

Nitrolingual Pump Spray 4 E, SL

Ranexa 2Sotalol 1Central Nervous System: Attention Deficit DisorderAdderall 4 E, NAdderall XR 2 N, SLAmphetamine Salt Combo

1 N

Concerta 4 E, N, SLDexmethylphenidate 1 NDextroamphetamine Sulfate

1 N

Dextroamphetamine-Amphetamine

1 N

Dextroamphetamine-Amphetamine Extended-Release

4 E, N, SL

Focalin XR 4 N, SLIntuniv 2 SLKapvay 4 EMetadate CD 4 E, N, SLMethylphenidate 1 NMethylphenidate Extended-Release Capsule

4 N, SL

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Drug Name Drug Tier


Methylphenidate Extended-Release Tablet

4 N, SL

Strattera 4 SLVyvanse 2 N, SL

Central Nervous System: Depression

Amitriptyline 1Aplenzin 4 E, SLBupropion 1Bupropion Extended-Release

1

Bupropion Sustained-Release

1

Celexa 4 ECitalopram 1Cymbalta 3 SDP, SLDesvenlafaxine 4 E, SLDoxepin 1Effexor XR 4 E, SLEscitalopram 1 SL, 1/2TFluoxetine 1Fluvoxamine 1Forfivo XL 4 E, SLImipramine 1Lexapro 4 E, SL, 1/2TMirtazapine 1Nortriptyline 1Oleptro 4 E, SLParoxetine 1Pristiq ER 3 RS, SLProzac 4 ESertraline 1 1/2TTrazodone 1Venlafaxine 1Venlafaxine Extended-Release Capsule

1 SL

Venlafaxine Extended-Release Tablet

3 E, SL

Viibryd 4 SDP, SLWellbutrin SR 4 EWellbutrin XL 4 EZoloft 4 E, 1/2T

Drug Name Drug Tier


Central Nervous System: Migraine

Acetaminophen/Butalbital/Caffeine

1 SL

Alsuma 4 E, SLCambia 4 E, SLImitrex 4 E, SLMaxalt 4 E, SLMaxalt MLT 4 E, SLRelpax 2 SLRizatriptan Orally Disintegrating Tablet

3 SL

Rizatriptan Tablet 2 SLSumatriptan Nasal Spray 2 SLSumatriptan Succinate Tablet, Injection

1 SL

Sumavel DosePro 3 SLTreximet 4 E, SLCentral Nervous System: Multiple SclerosisAmpyra 2 DSP, N, SLAubagio 4 DSP, N, SL, STAvonex 2 DSP, N, SLBetaseron 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

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Drug Name Drug Tier


Central Nervous System: Other

Abilify 4 SL, 1/2TAlprazolam 1Alprazolam Extended-Release

1

Aricept 23 mg 4 EAtivan 4 EBuspirone 1Carbidopa-Levodopa 1Diazepam 1Donepezil 5, 10 mg 1Geodon 4 E, SLLatuda 4 SLLithium 1Lorazepam 1Modafinil 4 E, N, SLMirapex ER 4 ENuvigil 4 N, SLOlanzapine 1 SLPramipexole 1Provigil 4 E, N, SLQuetiapine 2 SLRequip XL 4 ERisperdal 4 ERisperidone 1Ropinirole 1Ropinirole Extended-Release

4 E

Seroquel 4 E, SLSeroquel XR 4 SLSuboxone Film 2 N, SLTasmar 2Valium 4 EXanax 4 EXanax XR 4 E

Drug Name Drug Tier


Xyrem 4 N, SLZelapar 3Ziprasidone 2 SLZyprexa 4 E, SLZyprexa Zydis 4 E, SLCentral Nervous System: Sedatives/HypnoticsAmbien 4 E, SL, STAmbien CR 4 E, SL, STEdluar 4 E, SL, STIntermezzo 4 E, SL, STLunesta 4 SL, STSilenor 4 E, SLTemazepam 1Zaleplon 1 SLZolpidem 1 SLZolpidem Extended-Release

4 SL, ST

Zolpimist 3 SL, STCentral Nervous System: Seizure DisordersCarbamazepine 1Clonazepam 1Depakote 4 N, STDepakote ER 4 N, STDiazepam 1Divalproex 1Divalproex Extended-Release

1

Gabapentin 1Keppra 4 N, STKeppra XR 4 N, STLamictal 4 N, STLamictal XR 4 N, STLamotrigine 1Levetiracetam 1

15

Drug Name Drug Tier


Levetiracetam Extended-Release

2

Lyrica 4 SDP, SLNeurontin 4 NOxcarbazepine 1Phenytoin 1Topamax 4 N, STTopiramate 1Trileptal 4 N, STZonegran 4 NZonisamide 1

Dermatology

Absorica 4 E, NAcanya 4 E, SLAczone 4 SLAdapalene 3 N, SLAzelex 3 SLBenzaclin 4 E, SLBetamethasone Dipropionate

1

Carac 2Ciclopirox Cream, Gel, Lotion, Solution

1

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

3 SL

Clindamycin 1 .2%/Benzoyl Peroxide 5%

4 E, SL

Clindamycin Gel, Lotion, Solution, Swabs

1

Clobetasol Propionate 1Clobex Shampoo 4 E, SLCloderm 3 SLClotrimazole-Betamethasone

1

Condylox Gel 3Desonide 1Differin 1% 2 N, SLDifferin 3% 3 N, SL

Drug Name Drug Tier


Duac 4 E, SLEpiduo 3 SLFinacea 4Fluocinonide 1Hydrocortisone 1Keralyt Scalp Kit 4 ELocoid Lipocream 4 E, SLLocoid Lotion 4 E, SLMetrogel 1% 4 E, MCMetronidazole Gel 0 .75% 2 SLMetronidazole Gel 1% 4 E, MC, SLMometasone Furoate 1Mupirocin Ointment 1Nystatin-Triamcinolone Acetonide

1

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

1

Sorilux 4 E, SLStelara 2 DSP, N, SLSumadan 4 ESumaxin CP 4 ESumaxin TS 4 ETaclonex 4 SLTretinoin 1 NTretinoin Microspheres 4 E, N, SLTriamcinolone Acetonide 1Trianex 4 E, SLUmecta 4 EUmecta PD 4 EUramaxin GT 4 EVeltin 4 E, SLVirasal 4 EXerese 4 EZiana 4 E, SLZyclara 4 E, SL

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Drug Name Drug Tier


Diabetes: Blood Glucose Monitoring

Accu-Chek Active Test Strips 1 SL

Accu-Chek Aviva Plus 1

Accu-Chek Aviva Plus Test Strips 1 SL

Accu-Chek Comfort Curve Test Strips 1 SL

Accu-Chek Compact Test Strips 1 SL

Accu-Chek Nano SmartView 1

Accu-Chek Nano SmartView Test Strips

1 SL

Contour Test Strips 4 SDP, SLFreestyle Test Strips 4 SDP, SLOne Touch Test Strips 1 SL

One Touch Ultra Mini 1One Touch Ultra Test Strips 1 SL

One Touch Verio IQ 1One Touch Verio IQ Test Strips 1 SL

Drug Name Drug Tier


Diabetes: Insulin

Humalog KwikPen 2Humalog Mix 75-25 KwikPen 2

Humalog Vials 1Humulin 70-30 Vials 1Humulin KwikPen 2Humulin N KwikPen 2Humulin N Vials 1Humulin R Vial 1Lantus Solostar 4Lantus Vials 2Levemir Flexpen 4Levemir Vials 2Novolog 4 SDPNovolog Flexpen 4 SDP

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Drug Name Drug Tier


Diabetes: Non-Insulin

Actos 4 E, SL, 1/2TBydureon 3 SLByetta 2 SLGlimepiride 1Glipizide 1Glipizide Extended-Release

1

Glumetza 4Glyburide 1Glyburide-Metformin 1Janumet 4 SDP, SLJanuvia 4 SDP, SLJentadueto 2 SLKazano 2 SLKombiglyze XR 2 SLMetformin 1Metformin Extended-Release

1

Nesina 2 SLOnglyza 2 SLOseni 2 SLPioglitazone 2 SLPioglitazone-Metformin 2 SLPrandimet 3Prandin 4 SLRepaglinide 2 SLTradjenta 2 SLVictoza 3 SL

Endocrine: Growth Hormone

Genotropin 4 DSP, E, N, SLHumatrope 4 DSP, E, N, SLNorditropin 4 DSP, E, N, SLNutropin AQ NuSpin 2 DSP, N, SLOmnitrope 4 DSP, E, N, SLSaizen 2 DSP, N, SLTev-Tropin 2 DSP, N, SL

Drug Name Drug Tier


Endocrine: Other

Calcitriol 1Desmopressin 1Dexamethasone 1Methylprednisolone 1Prednisolone 1Prednisone 1Rayos 4 EEndocrine: Thyroid Hormone ReplacementArmour Thyroid 3Levothyroxine Sodium 1Levoxyl 2Liothyronine Sodium 2Methimazole 1NP Thyroid 1Synthroid 2Tirosint 2

Eye Conditions: Allergies

Azelastine 3 SLBepreve 4 E, SLElestat 4 E, SLEmadine 4 ELastacaft 3 SLOptivar 4 E, SLPataday 4 E, SLPatanol 4 E, SL

Eye Conditions: Antibiotics

Ciprodex 2Erythromycin 1Ofloxacin 1Polymyxin B Sulfate/Trimethoprim

1

Tobradex ST 4 E, SLTobramycin/Dexamethasone

2

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Drug Name Drug Tier


Eye Conditions: Glaucoma

Alphagan P 0.1% 2 SLAzopt 2 SLCombigan 2 SLCosopt PF 4 E, SLDorzolamide-Timolol 2Latanoprost 1 SLLumigan 2 SLTimolol Maleate 1Travatan Z 2 SL

Eye Conditions: Other

Acuvail 4 E, SLBromday 4 E, SL

Gastrointestinal: Acid Suppression

Aciphex 3 SLDexilant 3 SLHelidac 4 E, SLNexium 3 E, SLOmeclamox-Pak 3 SLOmeprazole 1Pantoprazole 1Prevacid Capsules 3 E, SLPrevacid Solutab 4 E, SLPrevpac 4 E, SLPrilosec Capsules 3 EProtonix Tablets 4 EPylera 3 SLSucralfate Tablet 1Zegerid Capsule 4 E, SL

Drug Name Drug Tier


Gastrointestinal: Nausea/Vomiting

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

Gastrointestinal: Other

Apriso 2Asacol HD Tablet 4 E, SDPCanasa 2Cortifoam 2Creon 2Delzicol 4 EEntocort EC 4 EGolytely 2Halflytely 3Hyoscyamine 1Lialda 2Metoclopramide 1Metozolv ODT 4 EPentasa 4 EPertzye 4 EPolyethylene Glycol 3350

1

Procort 4 ESulfasalazine 1Suprep 3Ultresa 4 EUceris 3Ursodiol 1Viokace 4 EZenpep 2

19

Drug Name Drug Tier


HIV/AIDS

Atripla 2 DSPComplera 2 DSPEpzicom 2 DSPIntelence 2 DSPIsentress 2 DSPKaletra 2 DSPNorvir 2 DSPPrezista 2 DSPReyataz 2 DSPSustiva 2 DSPTruvada 2 DSP, NViread 2 DSP

Infertility*

Cetrotide 2 DSPGonal-F 2 DSPGonal-F RFF 2 DSPOvidrel 3 DSP*Coverage is determined by the consumer’s prescription drug benefit plan .

Men’s Health: Erectile Dysfunction

Cialis 4 SLStaxyn 4 E, SLViagra 4 SL

Drug Name Drug Tier


Men’s Health: Prostate

Alfuzosin 1Avodart 4 N, SDPDoxazosin 1Finasteride 1Flomax 4 EJalyn 4 ERapaflo 4Tamsulosin 1Terazosin 1

Men’s Health: Testosterone Therapy

Androderm 2 SLAndrogel 4 E, SLAndroid 2Axiron 4 E, SLDepo-Testosterone 4Fortesta 4 E, SLTestim 2 SLTestosterone Cypionate 1Testosterone Enanthate 1Testred 2

20




Drug Name Drug Tier


Miscellaneous

Anastrozole 1Antipyrine/Benzocaine 1Aranesp 2 DSP, SLArimidex 4 EAuvi-Q 4 E, SLBenzonatate 1Bromfed DM 3Chlorhexidine Gluconate 1Epipen 2 SLEpipen-Jr 2 SLExemestane 2Femara 4 EFosrenol 2Hydrocodone/Chlorpheniramine

3 SL

Hydrocodone/Homatropine

1

Letrozole 1Lidoderm Patch 2 SLNatroba 4 ENuedexta 2Pegasys 2 DSP, N, SLProcrit 2 DSP, SLPromethazine/Codeine 1Promethazine/Dextromethorphan

1

Pulmozyme 2 DSP, SLRectiv 3 N, SLRenvela 2Restasis 4 N, SLRezira 3Soltamox 4 E

Drug Name Drug Tier


Tamoxifen 1Zemplar 2 DSPZonatuss 4 EZutripro 3 SL

Musculoskeletal: Osteoporosis

Actonel 3 SLAlendronate Sodium 1 SLAtelvia 4 E, SLBinosto 4 E, SLEvista 2Forteo 2 DSP, NIbandronate 2 SL

Musculoskeletal: Other

Allopurinol 1Amrix 4 EBaclofen 1Carisoprodol 350 mg 1Colcrys 2Cyclobenzaprine 1Gralise 4 E, SLHorizant 4 E, SLLorzone 4 E, SLMethocarbamol 1Skelaxin 4 ESoma 250 4 ETizanidine Tablet 1Uloric 3 SL

21

Drug Name Drug Tier


Musculoskeletal: Pain Relief

Abstral 4 E, N, SLAcetaminophen/Codeine

1 SL

Actiq 4 E, N, SLAvinza 4 SLCelebrex 4 SLConzip 4 E, SLDiclofenac Sodium 1Duexis 4 E, SLDuragesic 1 SLEtodolac 1Exalgo 4 SLFentanyl Patches 3 SLFentora 4 E, N, SLFlector 4 EHydrocodone/Acetaminophen

1 SL

Hydrocodone/Ibuprofen 1Hydromorphone 1Ibuprofen 1Indomethacin 1Kadian 4 E, SLKetorolac 1Lazanda 4 N, SLMeloxicam 1Methadone 1Morphine Sulfate Extended-Release Capsule

4 E, SL

Morphine Sulfate Extended-Release Tablet

1 SL

Nabumetone 1Naprelan 4 ENaproxen 1Nucynta 4 SLNucynta ER 4 SLOpana ER 2 SLOxycodone 1

Drug Name Drug Tier


Oxycodone/Acetaminophen

1 SL

Oxycontin 2 SLPennsaid 4 EPercocet 4 E, SLRybix ODT 4 E, SLSprix 3 SLSubsys 3 N, SLTramadol 1Tramadol Extended-Release

4 E, SL

Tramadol Sustained-Release

2 SL

Vimovo 4 E, SLVoltaren Gel 2Zipsor 4 EZolvit 4 E, SL

Musculoskeletal: Rheumatoid Arthritis

Cimzia 2 DSP, N, SLEnbrel 2 DSP, N, SLHumira 4 DSP, N, SL, STHydroxychloroquine Sulfate

1

Leflunomide 1Methotrexate 1Orencia 3 DSP, N, SLSimponi 2 DSP, N, SL

22




Drug Name Drug Tier


Overactive Bladder

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

2

Oxytrol 4 ESanctura 4 ESanctura XR 4 ETolterodine 4 EToviaz 3Trospium 4 ETrospium Extended-Release

4 E

Vesicare 4 E

Respiratory: Asthma/COPD

Advair Diskus 3 RS, SLAdvair HFA 3 RS, SLAlbuterol Sulfate 1Alvesco 1 SLAsmanex 1 SLBudesonide Nebs 2 SLCombivent Respimat 3 SLDulera 3 RS, SLFlovent HFA 4 SDP, SLForadil 2 SLIpratropium 1Levalbuterol Nebs 4 E, SLMontelukast 1 SLPerforomist 3 SLProair HFA 3 SL

Drug Name Drug Tier


Proventil HFA 3 SLPulmicort Flexhaler 4 SDP, SLQVAR 1 SLSingulair 4 E, SLSpiriva 2 SLSymbicort 4 SDP, SLTudorza 2 SLVentolin HFA 1 SLXopenex HFA 3 SLXopenex Nebs 4 E, SL

Respiratory: Nasal Allergies

Astelin 4 E, SLAstepro 4 E, SLAzelastine 3 SLBeconase AQ 4 E, SLDymista 4 E, SLFluticasone Propionate 1 SLNasonex 3 SLOmnaris 2 SLQnasl 3 SLVeramyst 4 E, SLZetonna 2 SL

Respiratory: Oral Allergies

Clarinex 4 E, SLClarinex-D 3 E, SLCyproheptadine 1Desloratadine 3 E, SLHydroxyzine 1Levocetirizine Tablet 1 SLPromethazine 1

23

Drug Name Drug Tier


Respiratory: Pulmonary Arterial HypertensionAdcirca 4 DSP, N, SLLetairis 2 DSP, NRevatio 4 DSP, E, N, SLSildenafil 1 DSP, N, SLTracleer 2 DSP, NTyvaso 2 DSP, N

Transplant

Azathioprine 1Cellcept 4 DSPCyclosporine Modified 1 DSPMycophenolate 1 DSPMyfortic 4 DSPNeoral 4 DSPPrograf 4 DSPRapamune 2 DSPTacrolimus 1 DSP

Vitamins/Electrolytes

Fluoride 1Folic Acid 1Klor-Con M10 1Klor-Con M20 1Potassium Chloride 1Potassium Citrate 1

Women’s Health: Contraceptives

Altavera 1Amethia 3 MCApri 1Aviane 1Azurette 2Beyaz 4 ECamrese 3 MCCryselle 1Cyclafem 1Ella 1 SLEmoquette 1Enpresse 1Generess Fe 4 EGianvi 3Gildess Fe 1

Drug Name Drug Tier


Jolessa 2 MCJolivette 3Junel 2Junel Fe 1Kariva 2Levora-28 1Lo Loestrin Fe 3Loestrin 24 Fe 3Loryna 3Low-Ogestrel 1Lutera 1Microgestin 2Microgestin FE 1Mononessa 3Natazia 1Necon 0 .5/35, 1/35, 1/50, 10/11

1

Norgestimate-Ethinyl Estradiol

3

Nortrel 0 .5/35 1Nuvaring 2Orsythia 1Ortho Evra 3Ortho Micronor 1Ortho Tri-Cyclen 1Ortho Tri-Cyclen Lo 3Ortho-Cyclen 1Ortho-Novum 3Portia 1Previfem 3Quasense 2 MCReclipsen 1Safyral 4 ESprintec 3Syeda 3Trinessa 3Tri-Previfem 3Tri-Sprintec 3Trivora-28 1Viorele 2Yasmin 28 1Yaz 2Zovia 1-35E 1

24




Drug Name Drug Tier


Women’s Health: Hormone Replacement

Cenestin 2Climara 2 SLClimara Pro 3 SLDivigel 2Enjuvia 2Estrace Cream 2Estradiol 1Estradiol/Norethindrone Acetate

2

Estring 2 MC, SLEstrogen/Methyltestosterone

1

Evamist 2Medroxyprogesterone 1Premarin 3Prempro 3Progesterone Micronized Capsule

2

Vagifem 2Vivelle-Dot 2 SL

Drug Name Drug Tier


Women’s Health: Prenatal Vitamins

Brand Prenatal Vitamins 3

Prenatal Plus 1

25

Index of covered drugs

A

Abilify ....................................14Absorica ................................. 15Abstral ....................................21Acanya ................................... 15Accu-Chek Active

Test Strips ............................16Accu-Chek Aviva Plus ............16Accu-Chek Aviva Plus

Test Strips ............................16Accu-Chek Comfort Curve Test

Strips ...................................16Accu-Chek Compact

Test Strips ............................16Accu-Chek Nano

SmartView ...........................16Accu-Chek Nano

SmartView Test Strips .........16Acetaminophen/Butalbital/

Caffeine .............................. 13Acetaminophen/Codeine ........21Aciphex ..................................18Actiq .......................................21Actonel .................................. 20Actos ......................................17Acuvail ...................................18Acyclovir Ointment ................10Acyclovir Tablet .....................10Aczone ................................... 15Adapalene .............................. 15Adcirca .................................. 23Adderall ................................. 12Adderall XR .......................... 12Adoxa Capsule ........................10Adoxa Tablet ..........................10Advair Diskus ........................ 22Advair HFA .......................... 22Albuterol Sulfate ................... 22Alendronate Sodium ............. 20Alfuzosin ................................19

Allopurinol ............................ 20Alphagan P 0.1% ....................18Alprazolam .............................14Alprazolam

Extended-Release ................14Alsuma .................................. 13Altavera ................................. 23Altoprev ................................. 12Alvesco .................................. 22Ambien ...................................14Ambien CR ............................14Amethia................................. 23Amiodarone ........................... 12Amitriptyline ......................... 13Amlodipine ............................11Amlodipine

Besylate-Benazepril .............11Amoxicillin .............................10Amoxicillin/Potassium

Clavulanate ..........................10Amphetamine Salt Combo .... 12Ampyra.................................. 13Amrix .................................... 20Amturnide ..............................11Anastrozole ........................... 20Androderm .............................19Androgel.................................19Android ..................................19Antipyrine/Benzocaine ......... 20Aplenzin ................................ 13Apri ....................................... 23Apriso .....................................18Aranesp ................................. 20Aricept 23 mg .........................14Arimidex ............................... 20Armour Thyroid .....................17Asacol HD Tablet ..................18Asmanex ................................ 22Astelin ................................... 22Astepro .................................. 22

Atelvia ................................... 20Atenolol ..................................11Atenolol-Chlorthalidone ........11Ativan .....................................14Atorvastatin ........................... 12Atripla ....................................19Aubagio ................................. 13Augmentin XR .......................10Auvi-Q .................................. 20Aviane ................................... 23Avinza ....................................21Avodart ...................................19Avonex ................................... 13Axiron ....................................19Azathioprine .......................... 23Azelastine ......................... 17, 22Azelastine ......................... 17, 22Azelex .................................... 15Azithromycin .........................10Azopt ......................................18Azor .......................................11Azurette ................................ 23

B

Baclofen ................................. 20Baraclude ................................10Beconase AQ ......................... 22Benazepril...............................11Benazepril-

Hydrochlorothiazide ............11Benicar ...................................11Benicar HCT .........................11Benzaclin ............................... 15Benzonatate ........................... 20Bepreve ...................................17Betamethasone

Dipropionate ....................... 15Betaseron ............................... 13Beyaz ..................................... 23Bidil ........................................11Binosto .................................. 20

26

Bisoprolol ................................11Bisoprolol-

Hydrochlorothiazide ............11Bosulif ....................................10Brand Prenatal Vitamins ....... 24Bromday .................................18Bromfed DM ......................... 20Budesonide Nebs ................... 22Bupropion .............................. 13Bupropion

Extended-Release ............... 13Bupropion

Sustained-Release ............... 13Buspirone ................................14Bydureon ................................17Byetta .....................................17Bystolic ...................................11

C

Caduet ................................... 12Calcitriol .................................17Cambia .................................. 13Camrese ................................. 23Canasa ....................................18Carac ..................................... 15Carbamazepine .......................14Carbidopa-Levodopa ..............14Carisoprodol 350 mg ............. 20Cartia XT ...............................11Carvedilol ...............................11Cefdinir ..................................10Cefuroxime .............................10Celebrex ..................................21Celexa .................................... 13Cellcept ................................. 23Cenestin ................................ 24Centany AT ............................10Cephalexin .............................10Cetrotide ................................19Chlorhexidine Gluconate ....... 20Chlorthalidone .......................11Choline Fenofibrate ............... 12Cialis ......................................19

Ciclopirox Cream, Gel, Lotion, Solution ................. 15

Cimzia ....................................21Ciprodex .................................17Ciprofloxacin Tablet ...............10Citalopram ............................. 13Claravis .................................. 15Clarinex ................................. 22Clarinex-D ............................ 22Clarithromycin Tablet ............10Climara.................................. 24Climara Pro ........................... 24Clindagel ............................... 15Clindamycin .....................10, 15Clindamycin 1%/Benzoyl

Peroxide 5% Jar ................... 15Clindamycin 1.2%/Benzoyl

Peroxide 5% ........................ 15Clindamycin Gel, Lotion,

Solution, Swabs .................. 15Clobetasol Propionate ............ 15Clobex Shampoo ................... 15Cloderm ................................ 15Clonazepam ............................14Clonidine Tablet .....................11Clopidogrel .............................11Clotrimazole-Betamethasone 15Colcrys .................................. 20Combigan ...............................18Combivent Respimat ............. 22Complera ................................19Concerta ................................ 12Condylox Gel ........................ 15Contour Test Strips ................16Conzip ....................................21Copaxone............................... 13Coreg CR ...............................11Cortifoam ...............................18Cosopt PF ..............................18Coumadin...............................11Creon ......................................18Crestor ............................... 8, 12Cryselle .................................. 23

Cyclafem ............................... 23Cyclobenzaprine .................... 20Cyclosporine Modified .......... 23Cymbalta ............................... 13Cyproheptadine ..................... 22

D

Delzicol ..................................18Depakote ................................14Depakote ER ..........................14Depo-Testosterone ..................19Desloratadine......................... 22Desmopressin .........................17Desonide ............................... 15Desvenlafaxine ...................... 13Detrol .................................... 22Detrol LA.............................. 22Dexamethasone ......................17Dexilant ..................................18Dexmethylphenidate .............. 12Dextroamphetamine-

Amphetamine ..................... 12Dextroamphetamine-

Amphetamine Extended-Release ............... 12

Dextroamphetamine Sulfate .. 12Diazepam ...............................14Diazepam ...............................14Diclofenac Sodium .................21Dicyclomine .......................... 22Differin 1% ............................ 15Differin 3% ............................ 15Dificid ....................................10Digoxin ................................. 12Diltiazem 24 Hour CD ..........11Diltiazem Sustained-Release

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

Tablet ...................................11Diovan ....................................11Diovan HCT ..........................11Divalproex ..............................14

27

Divalproex Extended-Release ................14

Divigel ................................... 24Donepezil 5, 10 mg ................14Doryx .....................................10Dorzolamide-Timolol .............18Doxazosin .........................11, 19Doxazosin .........................11, 19Doxepin ................................. 13Doxycycline Hyclate ...............10Doxycycline Monohydrate......10Duac ...................................... 15Duexis ....................................21Dulera .................................... 22Duragesic ................................21Dymista ................................. 22

E

Edarbi .....................................11Edarbyclor ..............................11Edluar .....................................14Effexor XR ............................ 13Effient ....................................11Elestat .....................................17Ella ........................................ 23Emadine .................................17Emoquette ............................. 23Enablex .................................. 22Enalapril .................................11Enalapril-

Hydrochlorothiazide ............11Enbrel .....................................21Enjuvia .................................. 24Enoxaparin Sodium ................11Enpresse ................................ 23Entocort EC ...........................18Epiduo ................................... 15Epipen ................................... 20Epipen-Jr ............................... 20Epzicom .................................19Erythromycin .........................17Escitalopram .......................... 13Estrace Cream ....................... 24

Estradiol .......................... 23, 24Estradiol/Norethindrone

Acetate ................................ 24Estring ................................... 24Estrogen/Methyltestosterone 24Etodolac .................................21Evamist .................................. 24Evista ..................................... 20Exalgo ....................................21Exemestane............................ 20Exforge ...................................11Exforge HCT .........................11Extavia................................... 13

F

Felodipine ...............................11Femara ................................... 20Fenofibrate 48, 145 mg .......... 12Fenofibrate 54, 160 mg .......... 12Fenofibrate Micronized

43, 130 mg .......................... 12Fenoglide ............................... 12Fentanyl Patches .....................21Fentora ....................................21Finacea .................................. 15Finasteride ..............................19Flecainide .............................. 12Flector ....................................21Flomax ...................................19Flovent HFA ......................... 22Fluconazole.............................10Fluocinonide .......................... 15Fluoride ................................. 23Fluoxetine .............................. 13Fluticasone Propionate .......... 22Fluvoxamine .......................... 13Focalin XR ............................ 12Folic Acid .............................. 23Foradil ................................... 22Forfivo XL ............................. 13Forteo .................................... 20Fortesta ...................................19Fosinopril Sodium ..................11

Fosrenol ................................. 20Freestyle Test Strips................16Furosemide .............................11

G

Gabapentin .............................14Gelnique ................................ 22Gemfibrozil ........................... 12Generess Fe ........................... 23Genotropin .............................17Geodon ...................................14Gianvi .................................... 23Gildess Fe .............................. 23Gilenya .................................. 13Gleevec ...................................10Glimepiride ............................17Glipizide .................................17Glipizide Extended-Release ...17Glumetza ................................17Glyburide................................17Glyburide-Metformin ............17Golytely ..................................18Gonal-F ..................................19Gonal-F RFF .........................19Gralise ................................... 20Guanfacine .............................11

H

Halflytely ................................18Helidac ...................................18Horizant ................................ 20Humalog KwikPen .................16Humalog Mix 75-25

KwikPen ..............................16Humalog Vials .......................16Humatrope .............................17Humira ...................................21Humulin 70-30 Vials .............16Humulin KwikPen .................16Humulin N KwikPen .............16Humulin N Vials ....................16Humulin R Vial .....................16Hydralazine ............................11

28

Hydrochlorothiazide ...............11Hydrocodone/

Acetaminophen ...................21Hydrocodone/

Chlorpheniramine .............. 20Hydrocodone/Homatropine .. 20Hydrocodone/Ibuprofen .........21Hydrocortisone ...................... 15Hydromorphone .....................21Hydroxychloroquine Sulfate ...21Hydroxyurea ...........................10Hydroxyzine .......................... 22Hyoscyamine ..........................18

I

Ibandronate ........................... 20Ibuprofen ................................21Imipramine ............................ 13Imitrex ................................... 13Incivek ....................................10Indapamide .............................11Indomethacin .........................21Intelence .................................19Intermezzo .............................14Intuniv ................................... 12Ipratropium............................ 22Irbesartan ...............................11Isentress ..................................19Isosorbide Mononitrate ER ... 12

J

Jalyn ........................................19Janumet ..................................17Januvia ....................................17Jentadueto ...............................17Jolessa .................................... 23Jolivette .................................. 23Junel ....................................... 23Junel Fe .................................. 23

K

Kadian ....................................21Kaletra ....................................19

Kapvay ................................... 12Kariva .................................... 23Kazano ...................................17Keppra ....................................14Keppra XR .............................14Keralyt Scalp Kit ................... 15Ketoconazole ..........................10Ketorolac ................................21Klor-Con M10 ...................... 23Klor-Con M20 ...................... 23Kombiglyze XR ......................17

L

Labetalol .................................11Lamictal .................................14Lamictal XR ...........................14Lamotrigine ............................14Lantus Solostar .......................16Lantus Vials ...........................16Lastacaft .................................17Latanoprost ............................18Latuda ....................................14Lazanda ..................................21Leflunomide ...........................21Letairis .................................. 23Letrozole ............................... 20Leucovorin Calcium ...............10Levalbuterol Nebs .................. 22Levemir Flexpen ....................16Levemir Vials .........................16Levetiracetam ...................14, 15Levetiracetam

Extended-Release ............... 15Levocetirizine Tablet ............. 22Levofloxacin ...........................10Levora-28 .............................. 23Levothyroxine Sodium ...........17Levoxyl ...................................17Lexapro.................................. 13Lialda .....................................18Lidoderm Patch ..................... 20Liothyronine Sodium .............17Lipitor .................................... 12

Lipofen .................................. 12Lisinopril ..........................11, 28Lisinopril-

Hydrochlorothiazide ............11Lithium ..................................14Livalo .................................... 12Lo Loestrin Fe ...................... 23Locoid Lipocream ................. 15Locoid Lotion ....................... 15Loestrin 24 Fe ....................... 23Lorazepam..............................14Loryna ................................... 23Lorzone ................................. 20Losartan .................................11Losartan-

Hydrochlorothiazide ............11Lovastatin .............................. 12Lovaza ................................... 12Low-Ogestrel ........................ 23Lumigan .................................18Lunesta ...................................14Lutera .................................... 23Lyrica .................................... 15

M

Maxalt ................................... 13Maxalt MLT ......................... 13Medroxyprogesterone ............ 24Meloxicam ..............................21Mercaptopurine ......................10Metadate CD ........................ 12Metformin ..............................17Metformin

Extended-Release ................17Methadone .............................21Methimazole ..........................17Methocarbamol ..................... 20Methotrexate ..........................21Methylphenidate .............. 12, 13Methylphenidate

Extended-Release Capsule . 12Methylphenidate

Extended-Release Tablet .... 13

29

Methylprednisolone ................17Metoclopramide .....................18Metoprolol Succinate

50, 100, 200 mg ...................11Metoprolol Tartrate ................11Metozolv ODT ......................18Metrogel 1% .......................... 15Metronidazole ..................10, 15Metronidazole Gel 0.75% ...... 15Metronidazole Gel 1% ........... 15Micardis .................................11Micardis HCT .......................11Microgestin ........................... 23Microgestin FE ..................... 23Minocycline ............................10Mirapex ER ............................14Mirtazapine ........................... 13Modafinil ...............................14Mometasone Furoate ............. 15Monodox ................................10Mononessa ............................. 23Montelukast ........................... 22Morphine Sulfate

Extended-Release Capsule ..21Morphine Sulfate

Extended-Release Tablet .....21Multaq ................................... 12Mupirocin Ointment ............. 15Mycophenolate ...................... 23Myfortic ................................ 23Myrbetriq .............................. 22

N

Nabumetone ...........................21Nadolol ...................................11Naprelan .................................21Naproxen ................................21Nasonex ................................. 22Natazia .................................. 23Natroba .................................. 20Necon 0.5/35, 1/35, 1/50,

10/11 ................................... 23Neoral .................................... 23

Nesina .....................................17Neurontin .............................. 15Nexiclon XR ...........................11Nexium ...................................18Niaspan ................................. 12Nifedical XL ..........................11Nifedipine

Extended-Release ................11Nitrofurantoin ........................10Nitrofurantoin Macrocrystal ..10Nitroglycerin Sublingual

Spray ................................... 12Nitrolingual Pump Spray ...... 12Norditropin.............................17Norgestimate-Ethinyl

Estradiol ............................. 23Nortrel 0.5/35 ........................ 23Nortriptyline ......................... 13Norvir .....................................19Novolog ..................................16Novolog Flexpen ....................16NP Thyroid ............................17Nucynta ..................................21Nucynta ER ............................21Nuedexta ............................... 20Nutropin AQ NuSpin .............17Nuvaring................................ 23Nuvigil....................................14Nystatin ..................................10Nystatin-Triamcinolone

Acetonide ........................... 15

O

Ofloxacin ................................17Olanzapine .............................14Oleptro .................................. 13Omeclamox-Pak .....................18Omeprazole ............................18Omnaris ................................ 22Omnitrope ..............................17Ondansetron ...........................18Ondansetron ODT .................18One Touch Test Strips ............16

One Touch Ultra Mini ...........16One Touch Ultra Test Strips ..16One Touch Verio IQ ...............16One Touch Verio IQ

Test Strips ............................16Onglyza ..................................17Onmel ....................................10Opana ER ..............................21Optivar ...................................17Oracea ....................................10Orencia ...................................21Orsythia ................................ 23Ortho-Cyclen ........................ 23Ortho-Novum ....................... 23Ortho Evra ............................ 23Ortho Micronor .................... 23Ortho Tri-Cyclen .................. 23Ortho Tri-Cyclen Lo............. 23Oseni ......................................17Ovidrel ...................................19Oxcarbazepine ....................... 15Oxsoralen-Ul ......................... 15Oxybutynin ........................... 22Oxybutynin

Extended-Release ............... 22Oxycodone .............................21Oxycodone/Acetaminophen ...21Oxycontin ...............................21Oxytrol .................................. 22

P

Pantoprazole ...........................18Paroxetine .............................. 13Pataday ...................................17Patanol ....................................17Pegasys .................................. 20Penicillin V Potassium ............10Pennsaid .................................21Pentasa ....................................18Percocet ..................................21Perforomist ............................ 22Pertzye ....................................18Phenytoin .............................. 15

30

Picato ..................................... 15Pioglitazone ............................17Pioglitazone-Metformin .........17Plavix ......................................11Polyethylene Glycol 3350 ........18Polymyxin B Sulfate/

Trimethoprim ......................17Portia ..................................... 23Potassium Chloride ............... 23Potassium Citrate .................. 23Pradaxa ...................................11Pramipexole ............................14Prandimet ...............................17Prandin ...................................17Pravastatin ............................. 12Prednisolone ...........................17Prednisone ..............................17Premarin ................................ 24Prempro ................................. 24Prenatal Plus .......................... 24Prevacid Capsules ...................18Prevacid Solutab .....................18Previfem ................................ 23Prevpac ...................................18Prezista ...................................19Prilosec Capsules ....................18Pristiq ER .............................. 13Proair HFA ........................... 22Procort ....................................18Procrit .................................... 20Progesterone Micronized

Capsule ............................... 24Prograf ................................... 23Promethazine................... 20, 22Promethazine/Codeine .......... 20Promethazine/

Dextromethorphan ............. 20Propranolol .............................11Protonix Tablets......................18Protopic ................................. 15Proventil HFA ....................... 22Provigil ...................................14Prozac .................................... 13

Pulmicort Flexhaler ............... 22Pulmozyme ........................... 20Pylera ......................................18

Q

Qnasl ..................................... 22Quasense ............................... 23Quetiapine ..............................14Quinapril ................................11QVAR ................................... 22

R

Ramipril .................................11Ranexa ................................... 12Rapaflo ...................................19Rapamune ............................. 23Rayos ......................................17Rebif ...................................... 13Reclipsen ............................... 23Rectiv .................................... 20Relpax .................................... 13Renvela .................................. 20Repaglinide ............................17Requip XL ..............................14Restasis .................................. 20Retin-A Micro ....................... 15Revatio .................................. 23Reyataz ...................................19Rezira .................................... 20Ribapak ..................................10Ribavirin .................................10Risperdal ................................14Risperidone ............................14Rizatriptan Orally

Disintegrating Tablet .......... 13Rizatriptan Tablet.................. 13Ropinirole ...............................14Ropinirole Extended-Release .14Rybix ODT ............................21

S

Safyral ................................... 23Saizen .....................................17

Sanctura ................................ 22Sanctura XR .......................... 22Sancuso ...................................18Seroquel ..................................14Seroquel XR ...........................14Sertraline ............................... 13Sildenafil................................ 23Silenor ....................................14Simcor ................................... 12Simponi ..................................21Simvastatin ........................ 8, 12Singulair ................................ 22Skelaxin ................................. 20Sodium

Sulfacetamide-Sulfur .......... 15Solodyn 45, 90, 135 mg ..........10Solodyn 55, 65, 80, 105,

115 mg .................................10Soltamox ................................ 20Soma 250 ............................... 20Sorilux ................................... 15Sotalol.................................... 12Spiriva ................................... 22Spironolactone ........................11Sprintec ................................. 23Sprix .......................................21Staxyn.....................................19Stelara .................................... 15Strattera ................................. 13Suboxone Film .......................14Subsys .....................................21Sucralfate Tablet .....................18Sulfamethoxazole-

Trimethoprim ......................10Sulfasalazine ...........................18Sumadan ................................ 15Sumatriptan Nasal Spray ....... 13Sumatriptan Succinate

Tablet, Injection .................. 13Sumavel DosePro .................. 13Sumaxin CP .......................... 15Sumaxin TS .......................... 15Suprep ....................................18

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Sustiva ....................................19Syeda ..................................... 23Symbicort .............................. 22Synthroid ................................17

T

Taclonex ................................ 15Tacrolimus ............................. 23Tamiflu ...................................10Tamoxifen.............................. 20Tamsulosin .............................19Tasmar ....................................14Tecfidera ................................ 13Tekamlo ..................................11Temazepam ............................14Terazosin ..........................11, 19Terazosin ..........................11, 19Terbinafine .............................10Testim .....................................19Testosterone Cypionate ...........19Testosterone Enanthate ..........19Testred ....................................19Tev-Tropin ..............................17Timolol Maleate .....................18Tirosint ...................................17Tizanidine Tablet .................. 20Tobradex ST ...........................17Tobramycin/Dexamethasone ..17Tolterodine ............................ 22Topamax ................................ 15Topiramate ............................ 15Toprol XL ...............................11Torsemide ...............................11Toviaz .................................... 22Tracleer .................................. 23Tradjenta.................................17Tramadol ................................21Tramadol Extended-Release ...21Tramadol Sustained-Release ...21Travatan Z ..............................18Trazodone .............................. 13Tretinoin ................................ 15Tretinoin Microspheres ......... 15

Treximet ................................ 13Tri-Previfem .......................... 23Tri-Sprintec ........................... 23Triamcinolone Acetonide ...... 15Triamterene-

Hydrochlorothiazide ........... 12Trianex .................................. 15Tribenzor ............................... 12Tricor 48 mg, 145 mg ............ 12Trileptal ................................. 15Trilipix ................................... 12Trinessa ................................. 23Trivora-28 .............................. 23Trospium ............................... 22Trospium Extended-Release .. 22Truvada ..................................19Tudorza ................................. 22Twynsta ................................. 12Tyvaso ................................... 23

U

Uceris ......................................18Uloric ..................................... 20Ultresa ....................................18Umecta .................................. 15Umecta PD ............................ 15Uramaxin GT ........................ 15Ursodiol ..................................18

V

Vagifem ................................. 24Valacyclovir ............................10Valium ....................................14Valsartan-

Hydrochlorothiazide ........... 12Valtrex ....................................10Veltin ..................................... 15Venlafaxine ............................ 13Venlafaxine Extended-Release

Capsule ............................... 13Venlafaxine Extended-Release

Tablet .................................. 13Ventolin HFA ........................ 22

Veramyst ................................ 22Verapamil .............................. 12Verapamil Sustained-Release . 12Vesicare .................................. 22Viagra .....................................19Victoza ...................................17Viibryd .................................. 13Vimovo ...................................21Viokace ...................................18Viorele ................................... 23Virasal ................................... 15Viread .....................................19Vivelle-Dot ............................ 24Voltaren Gel ...........................21Vytorin .................................. 12Vyvanse ................................. 13

W

Warfarin Sodium ...................11Welchol ................................. 12Wellbutrin SR ....................... 13Wellbutrin XL ....................... 13

X

Xanax .....................................14Xanax XR ...............................14Xarelto ....................................11Xeloda ....................................10Xerese .................................... 15Xopenex HFA ....................... 22Xopenex Nebs ........................ 22Xyrem .....................................14

Y

Yasmin 28 .............................. 23Yaz ......................................... 23

Z

Zaleplon .................................14Zegerid Capsule .....................18Zelapar ...................................14Zemplar ................................. 20Zenpep ...................................18Zetia ...................................... 12

32

Zetonna ................................. 22Ziana ..................................... 15Ziprasidone .............................14Zipsor .....................................21Zoloft .................................... 13Zolpidem ................................14Zolpidem Extended-Release ...14Zolpimist ................................14Zolvit ......................................21Zonatuss ................................ 20Zonegran ............................... 15Zonisamide ............................ 15Zovia 1-35E ........................... 23Zovirax Cream .......................10Zovirax Ointment ..................10Zuplenz ..................................18Zutripro ................................. 20Zyclara ................................... 15Zyprexa ...................................14Zyprexa Zydis .........................14Zytiga .....................................10

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

Name of Medicineand Strength

DrugTier

I Take ThisMedicine For

Directions Doctor

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

For more information


Or,visitmyuhc.com®

Where else can I go for information? HealthCareLane.com includesshortvideostohelpyoulearnmoreabout UnitedHealthcare benefi ts and health insurance information.

UHCTV.comisafunandeasywaytolearnabouthealthtermsandother health-related topics.

All branded medications are trademarks or registered trademarks of their respective owners .

© 2013 United HealthCare Services, Inc . All rights reserved . Created August, 2013 . 2014 Prescription Drug List – Advantage Four-Tier 100-12731 1/14

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