your prescription drug list/formulary · 1/1/2020 · tiers. it includes both brand and generic...

1

2020

Your Prescription Drug List/Formulary

Effective January 1, 2020

For a complete list of covered drugs or if you have questions:

• Call a customer care representative toll-free at (855) 828-9834 (TTY 711).

• Visit www.HealthSelectRx.com

— Locate an OptumRx in-network pharmacy

— Look up possible lower-cost medication alternatives

— Compare medication pricing and options

Please read: This document contains information about the drugs covered under your pharmacy benefit plan.

HealthSelectSM of Texas

2

Your Prescription Drug List / Formulary

This formulary outlines the most commonly prescribed medications covered under your plan’s prescription drug benefits. The formulary is also known as the Prescription Drug List (PDL). A formulary identifies the drugs available for certain conditions and organizes them into cost levels, also known as tiers. An important part of the formulary is giving you choices so you and your doctor can choose the best course of treatment for you.

Go to www.HealthSelectRx.com for complete and up-to-date drug information

Since the formulary may change, we encourage you to visit our website, www.HealthSelectRx.com and click on Prescription Drug List. This website is the best source for up-to-date information about all of the medications your pharmacy benefit covers, possible lower-cost options and cost comparisons.

3

Understanding your Prescription Drug List/formularyWhat is a formulary?

This document is a list of prescription medications covered by your plan for their safety, cost and effectiveness. Medications are listed by categories or class and 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).

Where differences exist between this formulary and your benefit plan documents, the benefit plan documents will rule. This may not be a complete list of medications, and not all medications listed may be covered under your plan. Please look at the Master Benefit Plan Document (MBPD) provided by your plan for full details.

How do I use my formulary?

You and your doctor can consult the formulary to help you select the most cost-effective prescription medications. 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 on this document, it may not be covered by the HealthSelect Prescription Drug Program or Consumer Directed HealthSelect Prescription Drug Program. Please visit www.HealthSelectRx.com and click on Prescription Drug List for the most up to date list of medications covered under your plan. If you have any questions, call a customer care representative toll-free at (855) 828-9834 (TTY 711).

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 plan. This is how much you will pay when you fill a prescription. The HealthSelect of Texas Prescription Drug Program has different copays assigned depending on which tier a drug is. The Consumer Directed HealthSelect Prescription Drug Program has coinsurance assigned for each drug tier that applies once the annual combined medical and pharmacy deductible is met. 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.

4

When does the formulary change?

• Medications may move to a lower tier at any time.

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

• Medications may move to a higher tier or be excluded from coverage on January 1 or July 1 of each year.

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

For the most up-to-date list, call a customer care representative, 24 hours a day, 7 days a week toll-free at (855) 828-9834 (TTY 711).

Why are some medications excluded from coverage?

A medication may be excluded from coverage under your prescription drug plan when it works the same as or similar to another prescription medication or an over-the-counter (OTC) medication that is more cost-effective.

What if I don’t agree with a decision about an excluded medication?

You (or your authorized representative) and your doctor can ask for an appeal to cover an excluded medication by calling a customer care representative toll-free at (855) 828-9834 (TTY 711).

5

Medication Tips What is the difference between brand-name and generic medications?

Generic medications contain the same active ingredients (what makes the medication work) as brand-name medications, but they often cost less. Once the patent of a brand-name medication ends, the FDA can approve a generic version with the same active ingredients.

What if my doctor writes a brand-name prescription?

If your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lower-cost option is available and if it might be right for you. Generic medications are usually your lowest-cost option, but not always.

An OTC medication may be the right treatment option for some conditions. Talk to your doctor about available OTC options. Even though these medications may not be covered under your pharmacy benefit, they may cost less than prescription medications covered under your prescription drug plan.

What if I am taking a specialty medication?

Specialty medications treat rare or complex conditions and are typically higher cost medications. Please note, not all specialty medications are listed in the Formulary. BriovaRx®, the OptumRx specialty pharmacy, can provide most of your specialty medications along with helpful programs and services. Call BriovaRx at (855) 427-4682 and have your prescriptions delivered right to your home or doctor’s office.

6

Reading your formularyThe formulary give your choices so you and your doctor can determine your best course of treatment. In this formulary, brand-name medications are shown in UPPERCASE (for example, CLOBEX) and generic medications in lowercase (for example, clobetasol).

Tier information

Using lower tier or preferred medications can help you pay your lowest out-of-pocket cost. Your prescription drug plan has multiple tiers. Please note: If you have a high deductible plan, the tier cost levels will apply once you hit your deductible.

Drug Tier Includes Helpful Tips

Tier 1 Lowest Cost

Lower-cost, commonly used generic drugs. Some low-cost brands may be included.

Use Tier 1 drugs for the lowest out-of-pocket costs.

Tier 2 Mid-range Cost

Many common brand-name drugs, called preferred brands.

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

Tier 3 Highest Cost

Mostly higher-cost brand drugs, also known as non-preferred brands.

Many Tier 3 drugs have lower-cost options in Tier 1 or 2. Ask your doctor if they could work for you.

Tier E Excluded May be excluded from coverage or subject to prior authorization. Lower-cost options are available and covered.

Drug list information

In this drug list, some medications are noted with letters next to them to help you see which ones may have coverage requirements or limits. Your benefit plan determines how these medications may be covered for you.

PA Prior Authorization – Your doctor is required to provide additional information before the drug will be covered by your prescription drug plan.

ST Step Therapy – Requires you to first try a cost-effective medication before the more expensive medication will be covered.

QL Quantity Limit – Limits the amount of a medication that will be covered under your prescription drug plan.

SP Specialty Medication – Drugs that are used in the treatment of rare or complex conditions and are typically injected or infused, are high cost, have special delivery and storage requirements, or require close monitoring or care coordination with your doctor.

E Excluded – Drugs that are not covered by your health plan. Lower-cost options are available and covered.

Table of Contents

Analgesics - Drugs for Pain.................................................................................................................................9Analgesics - Drugs for Pain and Inflammation.................................................................................................... 9Anesthetics..........................................................................................................................................................9Anti-Addiction / Substance Abuse Treatment Agents....................................................................................... 10Antibacterials.....................................................................................................................................................10Anticoagulants...................................................................................................................................................11Anticonvulsants - Drugs for Seizures................................................................................................................ 11Antidementia Agents - Drugs for Alzheimer's Disease and Dementia.............................................................. 11Antidepressants.................................................................................................................................................11Antiemetics - Drugs for Nausea and Vomiting.................................................................................................. 12Antifungals.........................................................................................................................................................12Antigout Agents................................................................................................................................................. 12Antimigraine Agents.......................................................................................................................................... 12Antineoplastics - Drugs for Cancer....................................................................................................................12Antiparasitics..................................................................................................................................................... 12Antiparkinson Agents........................................................................................................................................ 13Antiplatelets.......................................................................................................................................................13Antipsychotics - Drugs for Mood Disorders....................................................................................................... 13Antivirals............................................................................................................................................................13Anxiolytics - Drugs for Anxiety...........................................................................................................................14Bipolar Agents - Drugs for Mood Disorders.......................................................................................................14Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders..............................................14Cardiovascular Agents - Drugs for Heart and Circulation Conditions............................................................... 14Central Nervous System Agents - Drugs for Attention Deficit Disorder........................................................... 16Central Nervous System Agents - Drugs for Multiple Sclerosis........................................................................ 16Central Nervous System Agents - Miscellaneous............................................................................................. 17Dental and Oral Agents - Drugs for Mouth and Throat Conditions....................................................................17Dermatological Agents - Drugs for Skin Conditions.......................................................................................... 17Diabetes - Antidiabetic Agents.......................................................................................................................... 18Diabetes - Glycemic Agents.............................................................................................................................. 18Diabetes - Insulins.............................................................................................................................................18Electrolytes / Minerals / Metals / Vitamins.........................................................................................................19Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer................................................................................20Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions.................................................20Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment............................................. 20Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions.......................................................20Genitourinary Agents - Drugs for Prostate Conditions...................................................................................... 21Hormonal Agents - Adrenal............................................................................................................................... 21Hormonal Agents - Men's Health.......................................................................................................................21Hormonal Agents - Osteoporosis...................................................................................................................... 21Hormonal Agents - Pituitary.............................................................................................................................. 21Hormonal Agents - Sex Hormones and Birth Control........................................................................................22Hormonal Agents - Thyroid............................................................................................................................... 23Immunological Agents - Drugs for Immune System Stimulation or Suppression.............................................. 23Inflammatory Bowel Disease Agents.................................................................................................................24Metabolic Bone Disease Agents - Drugs for Osteoporosis............................................................................... 25Metabolic Bone Disease Agents - Other........................................................................................................... 25Miscellaneous Therapeutic Agents................................................................................................................... 25Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation...........................................................25Ophthalmic Agents - Drugs for Glaucoma.........................................................................................................25Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions......................................................................... 26

7

Otic Agents - Drugs for Ear Conditions............................................................................................................. 26Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold........................................................26Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions................................... 27Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis.................................................................... 28Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension.................................................... 28Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm...................................................................... 28Sleep Disorder Agents...................................................................................................................................... 28

8

Drug Name Drug Tier Notes

Analgesics - Drugs for Pain

acetaminophen-codeine #2

1 QL


1 QL


1 QL

acetaminophen-codeine oral tablet 300-15 mg, 300-60 mg

1 QL

apap-caff-dihydrocodeine oral capsule

1 QL

BELBUCA 2 PA; QL

butalbital-apap-caffeine oral capsule

1

butalbital-apap-caffeine oral tablet 50-325-40 mg

1

fentanyl 1 PA; QL

hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg

1 QL

hydromorphone hcl oral tablet

1 QL

HYSINGLA ER 2 PA; QL

morphine sulfate er oral tablet extended release

1 PA; QL

NUCYNTA E

oxycodone hcl oral tablet

1 QL

oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

1 QL

OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT

2 PA; QL


tramadol hcl ir 1 QL

trezix oral capsule 320.5-30-16 mg

1 QL

Analgesics - Drugs for Pain and Inflammation

celecoxib oral 1 QL

diclofenac sodium oral 1

diclofenac sodium transdermal gel 1 %

1 QL

etodolac oral tablet 1

ibu oral tablet 600 mg, 800 mg

1

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

1

indomethacin oral 1 ST

ketorolac tromethamine oral

1 QL

meloxicam oral tablet 1

nabumetone oral 1

NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR 375 MG, 500 MG

3

NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR 750 MG

E

naproxen oral tablet 1

naproxen sodium oral tablet 275 mg, 550 mg

1

Anesthetics

lidocaine external patch 5 %

1

lidocaine ointment 5 % external

1


1 QL


E

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet.

9


lidocaine-prilocaine external cream

1

Anti-Addiction / Substance Abuse Treatment Agents

BUNAVAIL 3 QL

buprenorphine hcl sublingual

1 QL

buprenorphine hcl-naloxone hcl sublingual tablet sublingual

1 QL

CHANTIX CONTINUING MONTH PAK

$0 QL

CHANTIX STARTING MONTH PAK

$0 QL

naltrexone hcl oral 1

NARCAN 2

SUBOXONE SUBLINGUAL FILM

2 QL

ZUBSOLV 2 QL

Antibacterials

amoxicillin oral capsule 1

amoxicillin oral suspension reconstituted

1

amoxicillin oral tablet 1

amoxicillin-potassium clavulanate oral suspension reconstituted

1

amoxicillin-potassium clavulanate oral tablet

1

azithromycin oral suspension reconstituted

1

azithromycin oral tablet 250 mg, 500 mg, 600 mg

1

cefdinir 1

cefuroxime axetil oral tablet

1


cephalexin oral capsule 1

cephalexin oral suspension reconstituted

1

ciprofloxacin hcl oral tablet 250 mg, 500 mg

1

clarithromycin oral tablet

1

clindamycin hcl oral 1

CLINDESSE 3

DIFICID 3

doxycycline hyclate oral capsule

1

doxycycline hyclate oral tablet 100 mg, 50 mg

1

doxycycline hyclate oral tablet 150 mg, 75 mg

1 ST

doxycycline hyclate oral tablet 20 mg

E

doxycycline monohydrate oral capsule 100 mg, 150 mg, 75 mg

1 ST

doxycycline monohydrate oral capsule 50 mg

1

doxycycline monohydrate oral tablet

1 ST

levofloxacin oral tablet 1

metronidazole oral tablet

1

metronidazole vaginal 1

minocycline hcl oral capsule

1

mupirocin external 1

nitrofurantoin macrocrystal oral

1

nitrofurantoin monohydrate macrocrystals

1

NUZYRA ORAL TABLET 150 MG

3


10


penicillin v potassium oral tablet

1

SEYSARA 3 ST

sulfamethoxazole-trimethoprim oral tablet

1

XEPI 3

XIMINO 3

Anticoagulants

BEVYXXA 3 QL

ELIQUIS 2 QL

ELIQUIS STARTER PACK

2 QL

enoxaparin sodium 1 SP; QL

PRADAXA 2 QL

SAVAYSA 3 QL

warfarin sodium oral 1

XARELTO 2 QL

XARELTO STARTER PACK

2 QL

Anticonvulsants - Drugs for Seizures

carbamazepine oral tablet

1

divalproex sodium er oral tablet extended release 24 hour

1

divalproex sodium oral tablet delayed release

1

EPIDIOLEX 3 PA; SP

gabapentin oral capsule

1

gabapentin oral tablet 1

lamotrigine oral tablet 1

levetiracetam oral tablet

1

oxcarbazepine oral tablet

1

SYMPAZAN 3 PA

topiramate oral tablet 1


VIMPAT INTRAVENOUS

E

VIMPAT ORAL 3

zonisamide oral 1

Antidementia Agents - Drugs for Alzheimer's Disease and Dementia

donepezil hcl oral tablet 1

memantine hcl oral tablet 10 mg, 5 mg

1

NAMZARIC 2 QL

Antidepressants

amitriptyline hcl oral 1

bupropion hcl er (sr) 1 QL

bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg

1 QL

BUPROPION HCL ER (XL) ORAL TABLET EXTENDED RELEASE 24 HOUR 450 MG

2 QL

bupropion hcl oral 1

citalopram hydrobromide oral tablet

1

desvenlafaxine succinate er

1 QL

doxepin hcl oral capsule

1

duloxetine hcl oral 1 QL

escitalopram oxalate oral tablet

1

fluoxetine hcl oral capsule

1

fluoxetine hcl oral tablet 1

fluvoxamine maleate 1

FORFIVO XL 3 QL

mirtazapine oral tablet 1


11


nortriptyline hcl oral capsule

1

paroxetine hcl oral tablet

1

sertraline hcl oral tablet 1

trazodone hcl oral 1

TRINTELLIX 3 ST; QL

venlafaxine hcl 1

venlafaxine hcl er 1

VIIBRYD ORAL TABLET

3 QL

VIIBRYD STARTER PACK

3 QL

Antiemetics - Drugs for Nausea and Vomiting

meclizine hcl oral tablet 1

metoclopramide hcl oral tablet 10 mg

1

ondansetron hcl oral tablet 24 mg

1 QL

ondansetron hcl oral tablet 4 mg, 8 mg

1

ondansetron odt 1

prochlorperazine maleate oral

1

TRANSDERM-SCOP (1.5 MG)

3

VARUBI ORAL 3 QL

Antifungals

CRESEMBA ORAL 3

fluconazole oral tablet 1

GYNAZOLE-1 3

KERYDIN 3 PA

ketoconazole external cream

1

ketoconazole external shampoo 2 %

1

nystatin external cream 1

nystatin mouth/throat 1


terbinafine hcl oral 1 QL

terconazole vaginal cream

1

Antigout Agents

allopurinol oral 1

colchicine tablet 0.6 mg oral

1

colchicine tablet 0.6 mg oral

E

COLCRYS 2

ULORIC 3 ST

Antimigraine Agents

AIMOVIG 2 PA; QL

eletriptan hydrobromide 1 QL

EMGALITY 2 PA; QL

rizatriptan benzoate 1 QL

sumatriptan succinate oral

1 QL

Antineoplastics - Drugs for Cancer

anastrozole oral 1

CABOMETYX 2 PA; SP

capecitabine 1 PA; SP

IBRANCE 3 PA; SP

IDHIFA 3 PA; SP; QL

letrozole oral 1

mercaptopurine oral 1

REVLIMID 2 PA; SP

SPRYCEL 2 PA; SP

tamoxifen citrate oral 1

XTANDI 3 PA; SP

YONSA 3 PA; SP

Antiparasitics

ARAKODA 3

EMVERM 2

hydroxychloroquine sulfate oral

1

SOLOSEC 3


12


Antiparkinson Agents

carbidopa-levodopa oral tablet

1

INBRIJA 3 PA; SP

pramipexole dihydrochloride

1

ropinirole hcl 1

RYTARY 3 ST

Antiplatelets

BRILINTA 2

clopidogrel bisulfate oral

1

ZONTIVITY 3

Antipsychotics - Drugs for Mood Disorders

ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE

3

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER

3

aripiprazole oral tablet 1 QL

ARISTADA E

ARISTADA INITIO E

INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

3

INVEGA TRINZA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

3

LATUDA 3 QL

olanzapine oral tablet 1 QL

PERSERIS E

quetiapine fumarate 1 QL

REXULTI 3 QL

risperidone oral tablet 1 QL

SAPHRIS 2 QL


VRAYLAR 3 ST; QL

ziprasidone hcl 1 QL

Antivirals

acyclovir oral tablet 1

ATRIPLA E

BIKTARVY 3

CIMDUO 2

DESCOVY 3 PA

DOVATO 2

entecavir 1 SP; QL

EPCLUSA 2 PA; SP; QL

GENVOYA 3

HARVONI ORAL TABLET 90-400 MG

2 PA; SP; QL

ISENTRESS ORAL TABLET

2

JULUCA 2

MAVYRET 2 PA; SP; QL

ODEFSEY 3

oseltamivir phosphate oral

1 QL

PREZCOBIX 2

PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG

2

ritonavir 1

STRIBILD 3

SYMFI 2

SYMFI LO 2

TAMIFLU ORAL CAPSULE 75 MG

E

tenofovir disoproxil fumarate

1

TIVICAY 2

TRIUMEQ 2

TRUVADA 2

valacyclovir hcl oral 1 QL

VEMLIDY 3 SP

VOSEVI 2 PA; SP; QL


13


XOFLUZA 3 QL

Anxiolytics - Drugs for Anxiety

alprazolam oral tablet 1 QL

buspirone hcl oral 1

clonazepam oral tablet 1 QL

diazepam oral tablet 1

hydroxyzine hcl oral tablet

1

hydroxyzine pamoate oral

1

lorazepam oral tablet 1 QL

triazolam 1 QL

Bipolar Agents - Drugs for Mood Disorders

lithium carbonate er 1

lithium carbonate oral capsule

1

Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders

ADYNOVATE 3 SP

AFSTYLA 3 SP

ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML

2 PA; SP

ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE

2 PA; SP

ELOCTATE 3 SP

JIVI 3 SP

KOGENATE FS 3 SP

KOVALTRY 3 SP

MULPLETA 2 PA; SP


NEULASTA ONPRO 3 PA; SP

NEULASTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA; SP

NIVESTYM 2 PA; SP

NOVOEIGHT 3 SP

NUWIQ 3 SP

RETACRIT 2 PA; SP

UDENYCA 3 PA; SP

ULTOMIRIS 2 PA; SP

ZARXIO 2 PA; SP

Cardiovascular Agents - Drugs for Heart and Circulation Conditions

amiodarone hcl oral 1

amlodipine besylate oral

1

amlodipine besylate-benazepril hcl

1

amlodipine besylate-valsartan

1

amlodipine-olmesartan 1

atenolol oral 1

atenolol-chlorthalidone 1

atorvastatin calcium oral

1

benazepril hcl oral 1

benazepril-hydrochlorothiazide

1

bisoprolol fumarate 1

bisoprolol-hydrochlorothiazide

1

bumetanide oral 1

BYSTOLIC 2

cartia xt 1

carvedilol 1

chlorthalidone oral tablet 25 mg, 50 mg

1


14


choline fenofibrate 1

clonidine hcl oral 1

CORLANOR ORAL TABLET

3 PA; QL

digoxin oral tablet 1

diltiazem hcl er beads 1

diltiazem hcl er coated beads oral capsule extended release 24 hour

1

dilt-xr 1

doxazosin mesylate oral

1

EDARBI 3 ST

EDARBYCLOR 3 ST

enalapril maleate oral 1

ENTRESTO 2 QL

ezetimibe 1

ezetimibe-simvastatin 1

fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg

1 ST

fenofibrate oral tablet 120 mg, 40 mg

E


1


1 ST

fenofibric acid oral capsule delayed release

1

flecainide acetate 1

furosemide oral tablet 1

gemfibrozil oral 1

guanfacine hcl oral 1

HEMANGEOL 3

hydralazine hcl oral 1

hydrochlorothiazide oral

1

irbesartan 1


irbesartan-hydrochlorothiazide

1

isosorbide mononitrate er

1

labetalol hcl oral 1

lisinopril oral 1

lisinopril-hydrochlorothiazide

1

LIVALO 3 ST

losartan potassium 1

losartan potassium-hctz 1

lovastatin 1

metoprolol succinate er 1

metoprolol tartrate oral 1

MULTAQ 3

nadolol oral tablet 20 mg, 40 mg, 80 mg

1

nifedipine er 1

nifedipine er osmotic release

1

nitroglycerin sublingual 1

olmesartan medoxomil oral

1

olmesartan medoxomil-hctz

1

omega-3-acid ethyl esters

1 PA

PRALUENT SUBCUTANEOUS SOLUTION PEN-INJECTOR

E

pravastatin sodium 1

prazosin hcl oral capsule 1 mg, 5 mg

1

propranolol hcl er 1

propranolol hcl oral tablet

1

ramipril 1

REPATHA E


15


REPATHA PUSHTRONEX SYSTEM

E

REPATHA SURECLICK

E

rosuvastatin calcium 1

simvastatin oral 1

sotalol hcl oral 1

spironolactone oral 1

TEKTURNA 2 ST

TEKTURNA HCT 2 ST

telmisartan 1

telmisartan-hctz 1

torsemide oral 1

triamterene-hctz oral capsule 37.5-25 mg

1

triamterene-hctz oral tablet

1

valsartan 1

valsartan-hydrochlorothiazide

1

VASCEPA 2 PA

verapamil hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 360 mg

1

verapamil hcl er oral tablet extended release 120 mg, 180 mg, 240 mg

1

Central Nervous System Agents - Drugs for Attention Deficit Disorder

ADDERALL XR E

ADZENYS ER 3 PA; ST; QL

amphetamine-dextroamphetamine

1 PA; QL

amphetamine-dextroamphetamine er

1 PA; QL


atomoxetine hcl 1 QL

dexmethylphenidate hcl 1 PA; QL

dexmethylphenidate hcl er

1 PA; ST; QL

guanfacine hcl er 1

methylphenidate hcl er oral tablet extended release

1 PA; ST; QL

methylphenidate hcl er oral tablet extended release 24 hour

1 PA; QL

methylphenidate hcl oral tablet

1 PA; QL

VYVANSE 2 PA; QL

Central Nervous System Agents - Drugs for Multiple Sclerosis

AMPYRA 3 PA; SP; QL

AUBAGIO 3 PA; SP; QL

AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT

2 PA; SP; QL

AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT

2 PA; SP; QL

BETASERON SUBCUTANEOUS KIT

2 PA; SP; QL

COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

2 PA; SP; QL

GILENYA 3 PA; SP; QL

REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR

3 PA; SP; QL

REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR

3 PA; SP; QL


16


REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA; SP; QL

REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA; SP; QL

TECFIDERA 2 PA; SP; QL

Central Nervous System Agents - Miscellaneous

ADDYI 3 PA; QL

AUSTEDO 3 PA; SP; QL

CONTRAVE E

GRALISE 3 ST; QL

GRALISE STARTER 3 ST; QL

HORIZANT ORAL TABLET EXTENDED RELEASE

3 PA; QL

LYRICA ORAL CAPSULE

2 QL

phentermine hcl oral capsule 30 mg

E

phentermine hcl oral tablet

E

SAXENDA E

TIGLUTIK 3 PA; SP; QL

Dental and Oral Agents - Drugs for Mouth and Throat Conditions

chlorhexidine gluconate mouth/throat

E

lidocaine viscous 1

Dermatological Agents - Drugs for Skin Conditions

ABSORICA E

ACZONE EXTERNAL GEL 7.5 %

2


betamethasone dipropionate external cream

1

BRYHALI E

claravis 1 PA

clindamycin phosphate-benzoyl peroxide external gel 1-5 %

1 ST

clindamycin phosphate external lotion

1

clindamycin phosphate external solution

1

clindamycin phosphate external swab

1

CLINDAMYCIN PHOSPHATE GEL 1 % EXTERNAL

E

clindamycin phosphate gel 1 % external

1

clobetasol propionate external cream

1

clobetasol propionate external ointment

1

clobetasol propionate external solution

1

clotrimazole-betamethasone external cream

1

DUPIXENT 2 PA; SP; QL

ENSTILAR E

EPIDUO FORTE 3

EUCRISA 2 ST

fluocinonide cream 0.1 % external

E

fluocinonide external cream 0.05 %

1

FLUOROPLEX 3

FLUOROURACIL EXTERNAL CREAM 0.5 %

2

fluorouracil external cream 5 %

1


17


hydrocortisone external cream 1 %, 2.5 %

1

hydrocortisone external ointment 1 %, 2.5 %

1

metronidazole external cream

1

metronidazole external gel

1

MIRVASO 2

mometasone furoate external cream

1

myorisan 1 PA

ONEXTON 3

QBREXZA 3 QL

RETIN-A MICRO PUMP EXTERNAL GEL 0.06 %, 0.08 %

2 PA

SERNIVO 3

SOOLANTRA 2

TACLONEX EXTERNAL OINTMENT

E

TACLONEX EXTERNAL SUSPENSION

3 QL

TOLAK 3 ST

tretinoin external cream 1 PA

triamcinolone acetonide external cream

1

triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 %

1

Diabetes - Antidiabetic Agents

BYDUREON BCISE AUTOINJECTOR

2 ST; QL

BYDUREON PEN 2 ST; QL

BYETTA 10 MCG PEN 2 ST; QL

BYETTA 5 MCG PEN 2 ST; QL

FARXIGA E

glimepiride 1


glipizide er 1

glipizide ir 1

glyburide oral 1

GLYXAMBI 2 ST

INVOKAMET 2 ST

INVOKAMET XR 2 ST

INVOKANA 2 ST

JANUMET 2 ST

JANUMET XR 2 ST

JANUVIA 2 ST

JARDIANCE 2 ST

JENTADUETO 2 ST

JENTADUETO XR 2 ST

metformin hcl er 1

metformin hcl er (mod) E

metformin hcl er (osm) oral tablet extended release 24 hour 1000 mg, 500 mg

E

metformin hcl oral tablet

1

OZEMPIC 2 ST; QL

pioglitazone hcl 1

SOLIQUA 2 ST; QL

SYNJARDY 2 ST

SYNJARDY XR 2 ST

TRADJENTA 2 ST

TRULICITY 2 ST; QL

VICTOZA 2 ST; QL

Diabetes - Glycemic Agents

GLUCAGON EMERGENCY

2

Diabetes - Insulins

HUMALOG 2

HUMALOG U-100 AND U-200 KWIKPEN

2

HUMALOG MIX 50/50 KWIKPEN

2


18


HUMALOG MIX 50/50 VIAL

2

HUMALOG MIX 75/25 KWIKPEN

2

HUMALOG MIX 75/25 VIAL

2

HUMALOG U-100 JUNIOR KWIKPEN

2

HUMULIN 70/30 KWIKPEN

2

HUMULIN 70/30 VIAL 2

HUMULIN N KWIKPEN 2

HUMULIN N VIAL 2

HUMULIN R U-500 KWIKPEN

2

HUMULIN R U-500 VIAL (CONCENTRATED)

2

HUMULIN R VIAL 2

LANTUS U-100 SOLOSTAR

2

LANTUS U-100 VIAL 2

LEVEMIR U-100 FLEXTOUCH

E

LEVEMIR U-100 VIAL E

NOVOFINE AUTOCOVER PEN NEEDLE

$0

NOVOFINE PEN NEEDLE 32G X 6 MM

$0

NOVOFINE PLUS PEN NEEDLE

$0

NOVOLIN 70/30 FLEXPEN

E

NOVOLIN 70/30 VIAL E

NOVOLIN N VIAL E

NOVOLIN R VIAL E

NOVOLOG U-100 FLEXPEN

E

NOVOLOG MIX 70/30 FLEXPEN

E


NOVOLOG MIX 70/30 VIAL

E

NOVOLOG U-100 PENFILL

E

NOVOLOG U-100 VIAL E

NOVOTWIST PEN NEEDLE 32G X 5 MM

$0

TOUJEO MAX SOLOSTAR

2

TOUJEO SOLOSTAR 2

TRESIBA E

TRESIBA FLEXTOUCH

E

Electrolytes / Minerals / Metals / Vitamins

CYANOCOBALAMIN INJECTION SOLUTION 2000 MCG/ML

3

ergocalciferol oral capsule

1

folic acid oral tablet 1 mg

1

klor-con m20 1

LOKELMA 3

multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg

1

potassium chloride crys er

1

potassium chloride er 1

potassium citrate er 1

sodium fluoride oral tablet chewable

$0

VELTASSA 3

vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut)

1


19


Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer

DEXILANT 2 QL

esomeprazole magnesium oral capsule delayed release

E

famotidine oral tablet 20 mg, 40 mg

1

lansoprazole oral capsule delayed release

1 ST; QL

omeprazole oral capsule delayed release

1 ST; QL

pantoprazole sodium oral

1 ST; QL

rabeprazole sodium oral tablet delayed release

1 ST; QL

ranitidine hcl oral capsule

1

ranitidine hcl oral syrup 1

ranitidine hcl oral tablet 150 mg, 300 mg

1

sucralfate oral tablet 1

Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions

CLENPIQ 3

dicyclomine hcl oral capsule

1

dicyclomine hcl oral tablet

1

diphenoxylate-atropine oral tablet

1

LINZESS 2 ST; QL

MOTEGRITY 3 ST; QL

MOVANTIK E

OMECLAMOX-PAK 2


PLENVU 3

PREPOPIK 3

PYLERA 2

SUPREP BOWEL PREP KIT

3

SYMPROIC 2 ST; QL

VIBERZI 3 PA; QL

Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment

CERDELGA 3 PA; SP

CREON 2

NITYR 3 PA; SP

STRENSIQ 2 PA; SP

ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 15000-47000 UNIT, 20000-63000 UNIT, 25000-79000 UNIT, 3000-14000 UNIT, 40000-126000 UNIT, 5000-24000 UNIT

2

Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions

AURYXIA 3

CIALIS 3 QL

DEPEN TITRATABS 2 SP

INTRAROSA 3

MYRBETRIQ 2

oxybutynin chloride er 1

oxybutynin chloride oral tablet

1

phenazopyridine hcl oral tablet 100 mg, 200 mg

1


20


sildenafil citrate oral tablet 100 mg, 25 mg, 50 mg

1 QL

STENDRA E

tadalafil oral 1 QL

tolterodine tartrate er 1

TOVIAZ 3

VELPHORO 3

VESICARE 3

Genitourinary Agents - Drugs for Prostate Conditions

alfuzosin hcl er 1

dutasteride oral 1

finasteride oral tablet 5 mg

1

tamsulosin hcl 1

terazosin hcl oral capsule 1 mg, 10 mg, 5 mg

1

Hormonal Agents - Adrenal

dexamethasone oral tablet

1

hydrocortisone oral 1

methylprednisolone oral tablet therapy pack

1

prednisolone oral solution

1

prednisolone sodium phosphate oral solution 10 mg/5ml, 15 mg/5ml, 20 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml

1

prednisone oral tablet 1

prednisone oral tablet therapy pack

1

TAPERDEX 12-DAY E

TAPERDEX 6-DAY E


TAPERDEX 7-DAY ORAL TABLET THERAPY PACK 1.5 MG (27)

E

Hormonal Agents - Men's Health

ANDRODERM TRANSDERMAL PATCH 24 HOUR

2 PA

TESTOSTERONE CYPIONATE INJECTION SOLUTION 200 MG/ML

E

testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml

1 PA

testosterone transdermal gel 10 mg/act (2%), 12.5 mg/act (1%), 20.25 mg/1.25gm (1.62%), 20.25 mg/act (1.62%), 25 mg/2.5gm (1%), 40.5 mg/2.5gm (1.62%), 50 mg/5gm (1%)

1 PA

XYOSTED 3 PA

Hormonal Agents - Osteoporosis

OSPHENA 3

raloxifene hcl 1

Hormonal Agents - Pituitary

ACTHAR 2 PA; SP

FOLLISTIM AQ SUBCUTANEOUS

2 PA; SP

ganirelix acetate solution prefilled syringe 250 mcg/0.5ml subcutaneous

1 PA; SP


21


ganirelix acetate solution prefilled syringe 250 mcg/0.5ml subcutaneous

1PA; Made by Organon/Merck; SP

LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 7.5 MG

2 PA; SP

LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 22.5 MG

2 PA; SP

LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG

2 PA; SP

LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG

2 PA; SP

NOCDURNA 3

NORDITROPIN FLEXPRO

2 PA; SP

NUTROPIN AQ NUSPIN 10

2 PA; SP


2 PA; SP


2 PA; SP

OMNITROPE 2 PA; SP

ORILISSA 2 PA; QL

Hormonal Agents - Sex Hormones and Birth Control

apri $0 QL

aviane $0 QL

BIJUVA 3

blisovi 24 fe $0 QL

blisovi fe 1.5/30 $0 QL

CLIMARA PRO 2

cryselle-28 $0 QL

DIVIGEL 3


drospirenone-ethinyl estradiol

$0 QL

DUAVEE 2

ELESTRIN 3

ENDOMETRIN 2 PA

enskyce oral tablet 0.15-30 mg-mcg

$0 QL

estarylla $0 QL

estradiol oral 1

estradiol transdermal 1

estradiol vaginal cream 1

gianvi $0 QL

IMVEXXY MAINTENANCE PACK

3

IMVEXXY STARTER PACK

3

isibloom $0 QL

junel 1/20 $0 QL

junel fe 1.5/30 $0 QL

junel fe 1/20 $0 QL

junel fe 24 $0 QL

kariva $0 QL

larissia $0 QL

lessina $0 QL

levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg

$0 QL

LO LOESTRIN FE $0 QL

loryna $0 QL

low-ogestrel $0 QL

MAKENA 2 PA; SP

medroxyprogesterone acetate intramuscular

$0 QL

medroxyprogesterone acetate oral

1

MINIVELLE 3

MIRENA (52 MG) E

mono-linyah $0 QL


22


NATAZIA $0 QL

norethindrone acetate oral

1

norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg

$0 QL

norethindrone oral $0 QL

norgestimate-ethinyl estradiol triphasic

$0 QL

nortrel 1/35 (21) $0 QL

nortrel 1/35 (28) $0 QL

NUVARING $0 QL

PREMARIN ORAL 2

PREMARIN VAGINAL 2

PREMPHASE 2

PREMPRO 2

progesterone micronized oral

1

sprintec 28 $0 QL

syeda $0 QL

TAYTULLA $0 QL

tri femynor $0 QL

tri-linyah $0 QL

tri-lo-marzia $0 QL

tri-lo-sprintec $0 QL

tri-sprintec $0 QL

vienva $0 QL

xulane $0 QL

yuvafem 1

Hormonal Agents - Thyroid

ARMOUR THYROID 3 ST

levothyroxine sodium oral

1

liothyronine sodium oral 1

methimazole oral 1

NATURE-THROID 3 ST

SYNTHROID 3 ST

TIROSINT 3


TIROSINT-SOL 3

Immunological Agents - Drugs for Immune System Stimulation or Suppression

ACTEMRA ACTPEN 3 PA; SP

ACTEMRA SUBCUTANEOUS

3 PA; SP

azathioprine oral 1

CIMZIA PREFILLED KIT

2 PA; SP

CIMZIA STARTER KIT 2 PA; SP

CIMZIA VIAL KIT 2 PA; SP

COSENTYX SENSOREADY (300 MG)

E SP

COSENTYX SENSOREADY PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML

E SP

cyclosporine modified oral capsule

1 SP

ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA; SP

ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR

3 PA; SP

FIRAZYR 3 PA; SP

HAEGARDA 3 PA; SP

HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML, 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML

2 PA; SP


23


HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT

2 PA; SP

HUMIRA PEN-CD/UC/HS STARTER

2 PA; SP

HUMIRA PEN-PS/UV/ADOL HS START

2 PA; SP

HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT

2 PA; SP

INFLECTRA 2 PA; SP

leflunomide oral 1

methotrexate oral 1

methotrexate sodium oral

1

mycophenolate mofetil oral capsule

1 SP

mycophenolate mofetil oral tablet

1 SP

mycophenolate sodium 1 SP

ORENCIA CLICKJECT 3 PA; SP

ORENCIA INTRAVENOUS

3 PA; SP

ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA; SP

OTEZLA ORAL TABLET

2 PA; SP

OTEZLA ORAL TABLET THERAPY PACK

2 PA; SP


RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 MG/0.2ML, 12.5 MG/0.25ML, 15 MG/0.3ML, 17.5 MG/0.35ML, 20 MG/0.4ML, 22.5 MG/0.45ML, 25 MG/0.5ML, 30 MG/0.6ML, 7.5 MG/0.15ML

2 PA; QL

RENFLEXIS 2 PA; SP

RINVOQ 2 PA; SP

RUCONEST 3 PA; SP

SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR

2 PA; SP

SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

2 PA; SP

SKYRIZI (150 MG DOSE)

2 PA; SP

STELARA INTRAVENOUS

2 PA; SP

STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

2 PA; SP; QL

tacrolimus oral 1 SP

TALTZ 3 PA; SP

TREMFYA 2 PA; SP

XELJANZ 2 PA; SP

XELJANZ XR 2 PA; SP

Inflammatory Bowel Disease Agents

APRISO 2

DIPENTUM E

LIALDA E


24


mesalamine oral tablet delayed release 1.2 gm

1

mesalamine oral tablet delayed release 800 mg

1 ST

PENTASA 3

PROCTOFOAM HC 2

UCERIS RECTAL 3

Metabolic Bone Disease Agents - Drugs for Osteoporosis

alendronate sodium oral tablet 10 mg, 5 mg

1

alendronate sodium oral tablet 35 mg, 70 mg

1 QL

BINOSTO 3 QL

FORTEO SUBCUTANEOUS SOLUTION 600 MCG/2.4ML

2 PA; SP

ibandronate sodium oral

1 QL

RAYALDEE 3

TYMLOS 2 PA; SP

Metabolic Bone Disease Agents - Other

calcitriol oral capsule 1

Miscellaneous Therapeutic Agents

BOTOX 2PA; Non-Cosmetic; SP

DUROLANE INTRA-ARTICULAR

2 PA; SP

EUFLEXXA INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE

2 PA; SP

GELSYN-3 2 PA; SP

TAKHZYRO 3 PA; SP


Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation

AZASITE 3

BESIVANCE 3

erythromycin ophthalmic

1

gentamicin sulfate ophthalmic solution

1

INVELTYS 3

ketorolac tromethamine ophthalmic

1

LOTEMAX OPHTHALMIC GEL

E

LOTEMAX OPHTHALMIC OINTMENT

E

LOTEMAX SM 3

MOXEZA 2

moxifloxacin hcl ophthalmic

1

ofloxacin ophthalmic 1

olopatadine hcl ophthalmic

1

PAZEO E

prednisolone acetate ophthalmic

1

PROLENSA 2 QL

tobramycin ophthalmic 1

Ophthalmic Agents - Drugs for Glaucoma

ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %

2

ALPHAGAN P OPHTHALMIC SOLUTION 0.15 %

E

AZOPT 2

BETIMOL 3


25


brimonidine tartrate ophthalmic

1

COMBIGAN 2

dorzolamide hcl-timolol mal

1

latanoprost ophthalmic 1

LUMIGAN OPHTHALMIC SOLUTION 0.01 %

2 QL

RHOPRESSA 2

ROCKLATAN 2 QL

SIMBRINZA 2

timolol maleate ophthalmic solution

1

TRAVATAN Z 2 QL

ZIOPTAN E

Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions

LASTACAFT 3 ST

neomycin-polymyxin-dexameth ophthalmic ointment

1

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1

1

polymyxin b-trimethoprim

1

RESTASIS 2 PA

RESTASIS MULTIDOSE OPHTHALMIC EMULSION 0.05 %

2 PA

tobramycin-dexamethasone

1

XIIDRA 2 PA

Otic Agents - Drugs for Ear Conditions

CIPRODEX 2


neomycin-polymyxin-hc otic suspension

1

ofloxacin otic 1

OTOVEL E

Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold

ASTEPRO NASAL SOLUTION 0.15 %

3 QL

azelastine hcl nasal solution 0.1 %, 137 mcg/spray

1 QL

benzonatate 1

desloratadine oral tablet

1

DYMISTA 2 QL

fluticasone propionate nasal

1

hydrocodone polst-cpm polst er oral suspension extended release

1 PA; QL

ipratropium bromide nasal

1

levocetirizine dihydrochloride oral tablet

1

mometasone furoate nasal

1 QL

OMNARIS 3 QL

promethazine hcl oral tablet

1

promethazine-codeine 1 PA; QL

promethazine-dm oral syrup

1

pseudoephedrine-bromphen-dm oral syrup 30-2-10 mg/5ml

1

QNASL 3 QL

QNASL CHILDRENS 3 QL


26


XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED

2 PA; SP

ZETONNA 3 QL

Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions

ADVAIR DISKUS 1 QL

ADVAIR HFA 2 QL

ALBUTEROL SULFATE HFA AEROSOL SOLUTION 108 (90 BASE) MCG/ACT INHALATION

E Made by Par


EMade by Prasco


E Made by Teva

albuterol sulfate inhalation

1 QL

ANORO ELLIPTA 2 QL

ARNUITY ELLIPTA 2 QL

ATROVENT HFA 3 QL

BREO ELLIPTA 2 QL

budesonide inhalation 1 QL

COMBIVENT RESPIMAT

2 QL

epinephrine injection solution 0.3 mg/0.3ml

1 ST

epinephrine injection solution auto-injector 0.15 mg/0.15ml

1 ST


epinephrine solution auto-injector 0.15 mg/0.3ml injection

1 Made by Mylan


1


1 Made by Mylan


1

EPIPEN 2-PAK INJECTION SOLUTION AUTO-INJECTOR

3 ST

EPIPEN JR 2-PAK INJECTION SOLUTION AUTO-INJECTOR

E

FLOVENT DISKUS 2 QL

FLOVENT HFA 2 QL

INCRUSE ELLIPTA 2 QL

ipratropium-albuterol 1 QL

LONHALA MAGNAIR REFILL KIT

3 QL

LONHALA MAGNAIR STARTER KIT

3 QL

montelukast sodium oral tablet

1

montelukast sodium oral tablet chewable

1

PROAIR HFA 2 QL

PROAIR RESPICLICK 2 QL

PROVENTIL HFA E

PULMICORT FLEXHALER

2 QL

QVAR REDIHALER E

SEREVENT DISKUS 2 QL

SPIRIVA HANDIHALER

2 QL


27


SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT

2 QL

STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 2.5-2.5 MCG/ACT

2 QL

SYMBICORT 2 QL

SYMJEPI 3

TRELEGY ELLIPTA 2 ST; QL

VENTOLIN HFA 2 QL

Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis

BETHKIS 2 SP

TOBI PODHALER E SP

Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension

ADEMPAS 2 PA; SP; QL

OPSUMIT 2 PA; SP; QL

ORENITRAM 3 PA; SP

sildenafil citrate oral tablet 20 mg

1 PA; SP; QL

TRACLEER 62.5 MG, 125 MG

3 PA; SP; QL

TRACLEER 32 MG 2 PA; SP; QL

Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm

baclofen oral 1

carisoprodol oral 1

cyclobenzaprine hcl oral tablet 5 mg, 7.5 mg

1

cyclobenzaprine hcl tablet 10 mg oral

1


cyclobenzaprine hcl tablet 10 mg oral

E

LORZONE E

metaxalone 1

methocarbamol oral 1

tizanidine hcl oral 1

Sleep Disorder Agents

eszopiclone 1 QL

modafinil 1 PA; QL

SILENOR 3 QL

temazepam 1 QL

XYREM 3 PA; SP; QL

zolpidem tartrate er 1 QL

zolpidem tartrate oral 1 QL


28

Index of Drugs

ABILIFY MAINTENA................. 13ABSORICA............................... 17acetaminophen-codeine..............9acetaminophen-codeine #2.........9acetaminophen-codeine #3.........9acetaminophen-codeine #4.........9ACTEMRA................................ 23ACTEMRA ACTPEN.................23ACTHAR................................... 21acyclovir.................................... 13ACZONE................................... 17ADDERALL XR......................... 16ADDYI....................................... 17ADEMPAS................................ 28ADVAIR DISKUS...................... 27ADVAIR HFA............................ 27ADYNOVATE............................14ADZENYS ER........................... 16AFSTYLA.................................. 14AIMOVIG...................................12albuterol sulfate.........................27ALBUTEROL SULFATE HFA... 27alendronate sodium.................. 25alfuzosin hcl er.......................... 21allopurinol..................................12ALPHAGAN P........................... 25alprazolam................................ 14amiodarone hcl......................... 14amitriptyline hcl......................... 11amlodipine besylate.................. 14amlodipine besylate-benazepril hcl............................................. 14amlodipine besylate-valsartan.. 14amlodipine-olmesartan..............14amoxicillin................................. 10amoxicillin-potassium clavulanate................................10amphetamine-dextroamphetamine.................. 16amphetamine-dextroamphetamine er.............. 16AMPYRA...................................16anastrozole............................... 12ANDRODERM.......................... 21ANORO ELLIPTA..................... 27apap-caff-dihydrocodeine........... 9apri............................................ 22APRISO.................................... 24ARAKODA................................ 12ARANESP (ALBUMIN FREE)...14aripiprazole............................... 13ARISTADA................................ 13ARISTADA INITIO.................... 13

ARMOUR THYROID.................23ARNUITY ELLIPTA...................27ASTEPRO.................................26atenolol..................................... 14atenolol-chlorthalidone..............14atomoxetine hcl.........................16atorvastatin calcium.................. 14ATRIPLA................................... 13ATROVENT HFA...................... 27AUBAGIO..................................16AURYXIA.................................. 20AUSTEDO.................................17aviane....................................... 22AVONEX PEN...........................16AVONEX PREFILLED.............. 16AZASITE................................... 25azathioprine.............................. 23azelastine hcl............................ 26azithromycin..............................10AZOPT...................................... 25baclofen.................................... 28BELBUCA................................... 9benazepril hcl............................14benazepril-hydrochlorothiazide. 14benzonatate.............................. 26BESIVANCE............................. 25betamethasone dipropionate.... 17BETASERON............................16BETHKIS...................................28BETIMOL.................................. 25BEVYXXA................................. 11BIJUVA..................................... 22BIKTARVY................................ 13BINOSTO..................................25bisoprolol fumarate................... 14bisoprolol-hydrochlorothiazide.. 14blisovi 24 fe............................... 22blisovi fe 1.5/30......................... 22BOTOX..................................... 25BREO ELLIPTA........................ 27BRILINTA..................................13brimonidine tartrate................... 26BRYHALI...................................17budesonide............................... 27bumetanide............................... 14BUNAVAIL................................ 10buprenorphine hcl..................... 10buprenorphine hcl-naloxone hcl............................................. 10bupropion hcl............................ 11bupropion hcl er (sr)..................11bupropion hcl er (xl).................. 11BUPROPION HCL ER (XL)...... 11

buspirone hcl.............................14butalbital-apap-caffeine...............9BYDUREON..............................18BYDUREON BCISE AUTOINJECTOR...................... 18BYETTA 10 MCG PEN............. 18BYETTA 5 MCG PEN............... 18BYSTOLIC................................ 14CABOMETYX........................... 12calcitriol..................................... 25capecitabine..............................12carbamazepine......................... 11carbidopa-levodopa.................. 13carisoprodol.............................. 28cartia xt..................................... 14carvedilol...................................14cefdinir...................................... 10cefuroxime axetil ....................... 10celecoxib..................................... 9cephalexin.................................10CERDELGA.............................. 20CHANTIX CONTINUING MONTH PAK.............................10CHANTIX STARTING MONTH PAK...........................................10chlorhexidine gluconate............ 17chlorthalidone............................14choline fenofibrate.....................15CIALIS.......................................20CIMDUO................................... 13CIMZIA......................................23CIMZIA PREFILLED KIT...........23CIMZIA STARTER KIT............. 23CIPRODEX............................... 26ciprofloxacin hcl........................ 10citalopram hydrobromide.......... 11claravis......................................17clarithromycin............................10CLENPIQ.................................. 20CLIMARA PRO......................... 22clindamycin hcl..........................10clindamycin phosphate............. 17CLINDAMYCIN PHOSPHATE.. 17clindamycin phosphate-benzoyl peroxide.......................17CLINDESSE..............................10clobetasol propionate................17clonazepam...............................14clonidine hcl.............................. 15clopidogrel bisulfate.................. 13clotrimazole-betamethasone.....17colchicine.................................. 12COLCRYS.................................12

29

COMBIGAN.............................. 26COMBIVENT RESPIMAT......... 27CONTRAVE.............................. 17COPAXONE..............................16CORLANOR..............................15COSENTYX SENSOREADY (300 MG)...................................23COSENTYX SENSOREADY PEN...........................................23CREON..................................... 20CRESEMBA..............................12cryselle-28.................................22CYANOCOBALAMIN................ 19cyclobenzaprine hcl.................. 28cyclosporine modified............... 23DEPEN TITRATABS.................20DESCOVY................................ 13desloratadine............................ 26desvenlafaxine succinate er......11dexamethasone........................ 21DEXILANT................................ 20dexmethylphenidate hcl............ 16dexmethylphenidate hcl er........ 16diazepam.................................. 14diclofenac sodium....................... 9dicyclomine hcl..........................20DIFICID..................................... 10digoxin.......................................15diltiazem hcl er beads............... 15diltiazem hcl er coated beads... 15dilt-xr......................................... 15DIPENTUM............................... 24diphenoxylate-atropine..............20divalproex sodium..................... 11divalproex sodium er.................11DIVIGEL....................................22donepezil hcl............................. 11dorzolamide hcl-timolol mal...... 26DOVATO...................................13doxazosin mesylate.................. 15doxepin hcl................................11doxycycline hyclate................... 10doxycycline monohydrate......... 10drospirenone-ethinyl estradiol...22DUAVEE................................... 22duloxetine hcl............................ 11DUPIXENT................................17DUROLANE.............................. 25dutasteride................................ 21DYMISTA.................................. 26EDARBI.....................................15EDARBYCLOR......................... 15ELESTRIN................................ 22

eletriptan hydrobromide............ 12ELIQUIS....................................11ELIQUIS STARTER PACK....... 11ELOCTATE............................... 14EMGALITY................................12EMVERM.................................. 12enalapril maleate.......................15ENBREL....................................23ENBREL SURECLICK.............. 23ENDOMETRIN..........................22enoxaparin sodium....................11enskyce.....................................22ENSTILAR................................ 17entecavir................................... 13ENTRESTO.............................. 15EPCLUSA................................. 13EPIDIOLEX............................... 11EPIDUO FORTE....................... 17epinephrine............................... 27EPIPEN 2-PAK......................... 27EPIPEN JR 2-PAK.................... 27ergocalciferol.............................19erythromycin............................. 25escitalopram oxalate................. 11esomeprazole magnesium........20estarylla.....................................22estradiol.................................... 22eszopiclone............................... 28etodolac...................................... 9EUCRISA.................................. 17EUFLEXXA............................... 25ezetimibe...................................15ezetimibe-simvastatin............... 15famotidine................................. 20FARXIGA.................................. 18fenofibrate................................. 15fenofibrate micronized...............15fenofibric acid............................15fentanyl....................................... 9finasteride................................. 21FIRAZYR...................................23flecainide acetate...................... 15FLOVENT DISKUS................... 27FLOVENT HFA......................... 27fluconazole................................12fluocinonide...............................17FLUOROPLEX..........................17FLUOROURACIL......................17fluorouracil ................................ 17fluoxetine hcl............................. 11fluticasone propionate...............26fluvoxamine maleate................. 11folic acid.................................... 19

FOLLISTIM AQ......................... 21FORFIVO XL.............................11FORTEO................................... 25furosemide................................ 15gabapentin................................ 11ganirelix acetate..................21, 22GELSYN-3................................ 25gemfibrozil .................................15gentamicin sulfate..................... 25GENVOYA................................ 13gianvi.........................................22GILENYA.................................. 16glimepiride.................................18glipizide er.................................18glipizide ir.................................. 18GLUCAGON EMERGENCY..... 18glyburide................................... 18GLYXAMBI................................18GRALISE.................................. 17GRALISE STARTER.................17guanfacine hcl...........................15guanfacine hcl er.......................16GYNAZOLE-1........................... 12HAEGARDA..............................23HARVONI..................................13HEMANGEOL........................... 15HORIZANT................................17HUMALOG................................18HUMALOG KWIKPEN.............. 18HUMALOG MIX 50/50 KWIKPEN................................. 18HUMALOG MIX 50/50 VIAL......19HUMALOG MIX 75/25 KWIKPEN................................. 19HUMALOG MIX 75/25 VIAL......19HUMALOG U-100 JUNIOR KWIKPEN................................. 19HUMIRA....................................24HUMIRA PEDIATRIC CROHNS START......................23HUMIRA PEN........................... 24HUMIRA PEN-CD/UC/HS STARTER................................. 24HUMIRA PEN-PS/UV/ADOL HS START................................ 24HUMULIN 70/30 KWIKPEN...... 19HUMULIN 70/30 VIAL...............19HUMULIN N KWIKPEN............ 19HUMULIN N VIAL..................... 19HUMULIN R U-500 KWIKPEN..19HUMULIN R U-500 VIAL (CONCENTRATED)..................19HUMULIN R VIAL..................... 19

30

hydralazine hcl.......................... 15hydrochlorothiazide...................15hydrocodone polst-cpm polst er...............................................26hydrocodone-acetaminophen..... 9hydrocortisone.................... 18, 21hydromorphone hcl..................... 9hydroxychloroquine sulfate....... 12hydroxyzine hcl......................... 14hydroxyzine pamoate................14HYSINGLA ER............................9ibandronate sodium.................. 25IBRANCE.................................. 12ibu............................................... 9ibuprofen..................................... 9IDHIFA...................................... 12IMVEXXY MAINTENANCE PACK........................................ 22IMVEXXY STARTER PACK..... 22INBRIJA.................................... 13INCRUSE ELLIPTA.................. 27indomethacin...............................9INFLECTRA.............................. 24INTRAROSA............................. 20INVEGA SUSTENNA................13INVEGA TRINZA...................... 13INVELTYS.................................25INVOKAMET.............................18INVOKAMET XR.......................18INVOKANA............................... 18ipratropium bromide.................. 26ipratropium-albuterol................. 27irbesartan.................................. 15irbesartan-hydrochlorothiazide..15ISENTRESS..............................13isibloom.....................................22isosorbide mononitrate er......... 15JANUMET................................. 18JANUMET XR........................... 18JANUVIA...................................18JARDIANCE..............................18JENTADUETO.......................... 18JENTADUETO XR.................... 18JIVI............................................14JULUCA.................................... 13junel 1/20.................................. 22junel fe 1.5/30........................... 22junel fe 1/20.............................. 22junel fe 24................................. 22kariva........................................ 22KERYDIN.................................. 12ketoconazole.............................12ketorolac tromethamine........ 9, 25

klor-con m20............................. 19KOGENATE FS........................ 14KOVALTRY...............................14labetalol hcl............................... 15lamotrigine................................ 11lansoprazole..............................20LANTUS SOLOSTAR............... 19LANTUS U-100 VIAL................ 19larissia.......................................22LASTACAFT............................. 26latanoprost................................ 26LATUDA....................................13leflunomide................................24lessina.......................................22letrozole.................................... 12LEVEMIR U-100 FLEXTOUCH.19LEVEMIR U-100 VIAL...............19levetiracetam.............................11levocetirizine dihydrochloride....26levofloxacin............................... 10levonorgestrel-ethinyl estrad.....22levothyroxine sodium................ 23LIALDA......................................24lidocaine......................................9lidocaine viscous.......................17lidocaine-prilocaine................... 10LINZESS................................... 20liothyronine sodium................... 23lisinopril ..................................... 15lisinopril-hydrochlorothiazide.....15lithium carbonate.......................14lithium carbonate er.................. 14LIVALO..................................... 15LO LOESTRIN FE.....................22LOKELMA................................. 19LONHALA MAGNAIR REFILL KIT............................................ 27LONHALA MAGNAIR STARTER KIT...........................27lorazepam................................. 14loryna........................................ 22LORZONE.................................28losartan potassium....................15losartan potassium-hctz............ 15LOTEMAX.................................25LOTEMAX SM.......................... 25lovastatin...................................15low-ogestrel...............................22LUMIGAN..................................26LUPRON DEPOT (1-MONTH)..22LUPRON DEPOT (3-MONTH)..22LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG..22

LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG..22LYRICA..................................... 17MAKENA...................................22MAVYRET.................................13meclizine hcl............................. 12medroxyprogesterone acetate.. 22meloxicam...................................9memantine hcl...........................11mercaptopurine......................... 12mesalamine...............................25metaxalone............................... 28metformin hcl er........................ 18metformin hcl er (mod)..............18metformin hcl er (osm).............. 18metformin hcl ir ......................... 18methimazole..............................23methocarbamol......................... 28methotrexate............................. 24methotrexate sodium................ 24methylphenidate hcl.................. 16methylphenidate hcl er..............16methylprednisolone...................21metoclopramide hcl...................12metoprolol succinate er.............15metoprolol tartrate.....................15metronidazole..................... 10, 18MINIVELLE............................... 22minocycline hcl..........................10MIRENA (52 MG)......................22mirtazapine............................... 11MIRVASO................................. 18modafinil ....................................28mometasone furoate........... 18, 26mono-linyah.............................. 22montelukast sodium.................. 27morphine sulfate er..................... 9MOTEGRITY.............................20MOVANTIK............................... 20MOXEZA...................................25moxifloxacin hcl.........................25MULPLETA............................... 14MULTAQ................................... 15multivitamin/fluoride.................. 19mupirocin.................................. 10mycophenolate mofetil .............. 24mycophenolate sodium............. 24myorisan................................... 18MYRBETRIQ.............................20nabumetone................................ 9nadolol...................................... 15naltrexone hcl............................10NAMZARIC............................... 11

31

NAPRELAN.................................9naproxen..................................... 9naproxen sodium........................ 9NARCAN...................................10NATAZIA...................................23NATURE-THROID.................... 23neomycin-polymyxin-dexameth 26neomycin-polymyxin-hc............ 26NEULASTA............................... 14NEULASTA ONPRO.................14nifedipine er.............................. 15nifedipine er osmotic release.... 15nitrofurantoin macrocrystal........10nitrofurantoin monohydrate macrocrystals............................10nitroglycerin...............................15NITYR....................................... 20NIVESTYM................................14NOCDURNA............................. 22NORDITROPIN FLEXPRO....... 22norethindrone............................23norethindrone acetate............... 23norethindrone acet-ethinyl est...23norgestimate-ethinyl estradiol triphasic.....................................23nortrel 1/35 (21)........................ 23nortrel 1/35 (28)........................ 23nortriptyline hcl..........................12NOVOEIGHT............................ 14NOVOFINE AUTOCOVER PEN NEEDLE........................... 19NOVOFINE PEN NEEDLE....... 19NOVOFINE PLUS PEN NEEDLE....................................19NOVOLIN 70/30 FLEXPEN...... 19NOVOLIN 70/30 VIAL............... 19NOVOLIN N VIAL..................... 19NOVOLIN R VIAL..................... 19NOVOLOG FLEXPEN.............. 19NOVOLOG MIX 70/30 FLEXPEN..................................19NOVOLOG MIX 70/30 VIAL......19NOVOLOG PENFILL................ 19NOVOLOG U-100 VIAL............ 19NOVOTWIST PEN NEEDLE.... 19NUCYNTA...................................9NUTROPIN AQ NUSPIN 10..... 22NUTROPIN AQ NUSPIN 20..... 22NUTROPIN AQ NUSPIN 5....... 22NUVARING............................... 23NUWIQ......................................14NUZYRA................................... 10nystatin......................................12

ODEFSEY.................................13ofloxacin..............................25, 26olanzapine.................................13olmesartan medoxomil..............15olmesartan medoxomil-hctz...... 15olopatadine hcl..........................25OMECLAMOX-PAK.................. 20omega-3-acid ethyl esters.........15omeprazole............................... 20OMNARIS................................. 26OMNITROPE............................ 22ondansetron hcl........................ 12ondansetron odt........................ 12ONEXTON................................ 18OPSUMIT..................................28ORENCIA..................................24ORENCIA CLICKJECT............. 24ORENITRAM............................ 28ORILISSA................................. 22oseltamivir phosphate............... 13OSPHENA................................ 21OTEZLA.................................... 24OTOVEL................................... 26oxcarbazepine...........................11oxybutynin chloride................... 20oxybutynin chloride er............... 20oxycodone hcl............................. 9oxycodone-acetaminophen.........9OXYCONTIN...............................9OZEMPIC..................................18pantoprazole sodium.................20paroxetine hcl............................12PAZEO......................................25penicillin v potassium................ 11PENTASA................................. 25PERSERIS................................13phenazopyridine hcl.................. 20phentermine hcl........................ 17pioglitazone hcl......................... 18PLENVU....................................20polymyxin b-trimethoprim..........26potassium chloride crys er........ 19potassium chloride er................19potassium citrate er...................19PRADAXA.................................11PRALUENT...............................15pramipexole dihydrochloride..... 13pravastatin sodium....................15prazosin hcl...............................15prednisolone............................. 21prednisolone acetate.................25prednisolone sodium phosphate................................. 21

prednisone................................ 21PREMARIN............................... 23PREMPHASE........................... 23PREMPRO................................23PREPOPIK................................20PREZCOBIX............................. 13PREZISTA................................ 13PROAIR HFA............................ 27PROAIR RESPICLICK..............27prochlorperazine maleate......... 12PROCTOFOAM HC.................. 25progesterone micronized.......... 23PROLENSA.............................. 25promethazine hcl.......................26promethazine-codeine.............. 26promethazine-dm...................... 26propranolol hcl.......................... 15propranolol hcl er...................... 15PROVENTIL HFA..................... 27pseudoephedrine-bromphen-dm............................................. 26PULMICORT FLEXHALER.......27PYLERA....................................20QBREXZA.................................18QNASL......................................26QNASL CHILDRENS................ 26quetiapine fumarate.................. 13QVAR REDIHALER.................. 27rabeprazole sodium.................. 20raloxifene hcl.............................21ramipril ...................................... 15ranitidine hcl..............................20RASUVO...................................24RAYALDEE...............................25REBIF....................................... 17REBIF REBIDOSE....................16REBIF REBIDOSE TITRATION PACK.................... 16REBIF TITRATION PACK.........17RENFLEXIS.............................. 24REPATHA................................. 15REPATHA PUSHTRONEX SYSTEM................................... 16REPATHA SURECLICK........... 16RESTASIS................................ 26RESTASIS MULTIDOSE.......... 26RETACRIT................................ 14RETIN-A MICRO PUMP........... 18REVLIMID................................. 12REXULTI...................................13RHOPRESSA........................... 26RINVOQ....................................24risperidone................................ 13

32

ritonavir..................................... 13rizatriptan benzoate.................. 12ROCKLATAN............................ 26ropinirole hcl..............................13rosuvastatin calcium................. 16RUCONEST..............................24RYTARY................................... 13SAPHRIS.................................. 13SAVAYSA................................. 11SAXENDA.................................17SEREVENT DISKUS................ 27SERNIVO..................................18sertraline hcl..............................12SEYSARA................................. 11sildenafil citrate................... 21, 28SILENOR.................................. 28SIMBRINZA.............................. 26SIMPONI...................................24simvastatin................................ 16SKYRIZI (150 MG DOSE).........24sodium fluoride..........................19SOLIQUA.................................. 18SOLOSEC.................................12SOOLANTRA............................18sotalol hcl.................................. 16SPIRIVA HANDIHALER............27SPIRIVA RESPIMAT................ 28spironolactone...........................16sprintec 28................................ 23SPRYCEL................................. 12STELARA..................................24STENDRA.................................21STIOLTO RESPIMAT............... 28STRENSIQ................................20STRIBILD..................................13SUBOXONE..............................10sucralfate.................................. 20sulfamethoxazole-trimethoprim.11sumatriptan succinate............... 12SUPREP BOWEL PREP KIT....20syeda........................................ 23SYMBICORT.............................28SYMFI....................................... 13SYMFI LO................................. 13SYMJEPI...................................28SYMPAZAN.............................. 11SYMPROIC...............................20SYNJARDY...............................18SYNJARDY XR.........................18SYNTHROID.............................23TACLONEX...............................18tacrolimus..................................24tadalafil ......................................21

TAKHZYRO.............................. 25TALTZ....................................... 24TAMIFLU...................................13tamoxifen citrate........................12tamsulosin hcl........................... 21TAPERDEX 12-DAY................. 21TAPERDEX 6-DAY................... 21TAPERDEX 7-DAY................... 21TAYTULLA................................23TECFIDERA..............................17TEKTURNA...............................16TEKTURNA HCT...................... 16telmisartan................................ 16telmisartan-hctz.........................16temazepam............................... 28tenofovir disoproxil fumarate.....13terazosin hcl..............................21terbinafine hcl............................12terconazole............................... 12testosterone.............................. 21TESTOSTERONE CYPIONATE............................. 21testosterone cypionate..............21TIGLUTIK..................................17timolol maleate..........................26TIROSINT................................. 23TIROSINT-SOL.........................23TIVICAY.................................... 13tizanidine hcl............................. 28TOBI PODHALER.....................28tobramycin................................ 25tobramycin-dexamethasone......26TOLAK...................................... 18tolterodine tartrate er.................21topiramate................................. 11torsemide.................................. 16TOUJEO MAX SOLOSTAR...... 19TOUJEO SOLOSTAR...............19TOVIAZ..................................... 21TRACLEER...............................28TRADJENTA.............................18tramadol hcl ir ............................. 9TRANSDERM-SCOP (1.5 MG).12TRAVATAN Z............................26trazodone hcl............................ 12TRELEGY ELLIPTA..................28TREMFYA.................................24TRESIBA...................................19TRESIBA FLEXTOUCH............19tretinoin..................................... 18trezix........................................... 9tri femynor................................. 23triamcinolone acetonide............ 18

triamterene-hctz........................ 16triazolam................................... 14tri-linyah.................................... 23tri-lo-marzia............................... 23tri-lo-sprintec............................. 23TRINTELLIX..............................12tri-sprintec................................. 23TRIUMEQ................................. 13TRULICITY............................... 18TRUVADA.................................13TYMLOS................................... 25UCERIS.................................... 25UDENYCA................................ 14ULORIC.................................... 12ULTOMIRIS.............................. 14valacyclovir hcl..........................13valsartan................................... 16valsartan-hydrochlorothiazide... 16VARUBI.....................................12VASCEPA................................. 16VELPHORO.............................. 21VELTASSA............................... 19VEMLIDY.................................. 13venlafaxine hcl.......................... 12venlafaxine hcl er...................... 12VENTOLIN HFA........................28verapamil hcl er.........................16VESICARE................................21VIBERZI.................................... 20VICTOZA.................................. 18vienva........................................23VIIBRYD....................................12VIIBRYD STARTER PACK....... 12VIMPAT.....................................11vitamin d (ergocalciferol)...........19VOSEVI.....................................13VRAYLAR................................. 13VYVANSE................................. 16warfarin sodium.........................11XARELTO................................. 11XARELTO STARTER PACK.....11XELJANZ.................................. 24XELJANZ XR............................ 24XEPI..........................................11XIIDRA...................................... 26XIMINO..................................... 11XOFLUZA................................. 14XOLAIR.....................................27XTANDI.....................................12xulane....................................... 23XYOSTED.................................21XYREM..................................... 28YONSA..................................... 12

33

yuvafem.................................... 23ZARXIO.....................................14ZENPEP....................................20ZETONNA.................................27ZIOPTAN.................................. 26ziprasidone hcl.......................... 13zolpidem tartrate....................... 28zolpidem tartrate er................... 28zonisamide................................11ZONTIVITY............................... 13ZUBSOLV................................. 10

34

“My Medications” worksheet

Take 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 Medicine and Strength

Drug Tier

I Take This Medicine For

Directions Doctor

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

-Continued on back-

Notice of Nondiscrimination

Optum companies (together, “Optum”) provide services to health plans and other health programs or activities. Optum on behalf of itself and its affiliated companies

your prescription drug list/formulary · 1/1/2020 · tiers. it includes both brand and generic...

Documents