Prescription Drug List

Transcription

1 Your 204 Prescription List effective July, 204 Optum360 Advantage Three- Please 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 Locate a participating retail pharmacy by ZIP code. Look up possible lower-cost medication alternatives. Compare medication pricing and options.

2 Your Prescription List This Prescription 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 information Since 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 benefit covers, possible lower-cost options, and cost comparisons. 2

3 Table of Contents tiers and cost Programs and Limits s by category....0 Anti-Infectives Antibiotics....0 Antifungals...0 Antivirals....0 Cancer....0 Cardiovascular/Heart Disease Coagulation Therapy...0 High Blood Pressure.... High Cholesterol Other Central Nervous System Attention Deficit Disorder Depression... 2 Migraine Multiple Sclerosis Other Sedatives/Hypnotics Seizure Disorders... 4 Dermatology Diabetes/Endocrine Blood Glucose Monitoring Insulin Non-Insulin... 6 Endocrine Growth Hormone Other Thyroid Hormone Replacement Eye Conditions Allergies Antibiotics Glaucoma Other Gastrointestinal Acid Suppression Nausea/Vomiting Other HIV/AIDS Infertility Men s Health Erectile Dysfunction Prostate Testosterone Therapy... 8 Miscellaneous....9 Musculoskeletal Osteoporosis....9 Other....9 Pain Relief....9 Rheumatoid Arthritis Overactive Bladder Respiratory Allergies Asthma/COPD....2 Pulmonary Arterial Hypertension....2 Transplant....2 Vitamins/Electrolytes....2 Women s Health Contraceptives Hormone Replacement Prenatal Vitamins...23 Index

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5 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 List. What is a Prescription List (PDL)? This document is a list of commonly prescribed medications. s 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 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 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. 5

6 What are tiers? s 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. medications are your lowest-cost options. If your medication is placed in 2 or 3, look to see if there is a option available. Discuss these options with your doctor. Check your benefit plan documents to find out your specific pharmacy plan costs. $ Includes Helpful Tips Lowest Cost 2 Mid-range Cost 3 Highest Cost Lower-cost drugs. Some brands and generics are also included. Mix of brands and generics. Mostly higher-cost brand as well as select generic drugs. Use drugs for the lowest out of-pocket costs. Use 2 drugs, instead of 3 to help reduce your out-of-pocket costs. Many 3 drugs have lower cost options in or 2. Ask your doctor 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 List change? Medications may move to a lower tier at any time. Medications may move to a higher tier when a generic becomes available. Medications may move to a higher tier or be excluded from coverage most often on January or July. 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. 6

7 Programs and Limits Some medications are noted with letters next to them. The letters refer to our pharmacy benefit programs. Your benefit plan determines how these medications are covered and may differ than what is noted in the PDL. Call the number for Member Services listed on the back of your ID card if you have any questions about your prescription drug coverage. DSP MC N RS SDP SL ST /2T Designated 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 for more information. Multiple Copay More than one month s worth of medication included in package so additional copay applies. Notification or Prior Authorization required* Your doctor is required to provide additional information to us to determine coverage. Refill and Save Program Save money on your copayment when you refill your prescription on time as prescribed. Program eligibility may vary. Select Designated Pharmacy Must use a lower cost medication at retail or transfer the impacted medication to the mail service pharmacy for network coverage. Supply Limit Amount of medication covered per copayment or in a specific time period. Step Therapy Trial of a lower cost medication is required before a higher cost medication is covered. 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. 7

8 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 brandname 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 are high cost and may be used to treat rare or complex conditions. Please note, not all specialty medications are listed in the PDL. If you are taking a specialty medication that is on 3, 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 and have your prescriptions delivered right to your home or office. 8

9 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: Pharmacy benefit and coverage information Possible lower-cost medication options Medication interactions and side effects Participating retail pharmacies by zip code Your prescription history And, if Mail Service is included in your pharmacy benefit, you can also: Refill prescriptions Check the status of your order Set-up reminders for refills Manage your account For more information Call the toll-free member phone number on the back of your health plan ID card. Or, visit myuhc.com Where else can I go for information? HealthCareLane.com includes short videos to help you learn more about UnitedHealthcare benefits and health insurance information. UHCTV.com is a fun and easy way to learn about health terms and other health-related topics. In certain documents, the Prescription List (PDL) was referred to as the Preferred 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. 9

10 Name Name Anti-Infectives: Antibiotics Amoxicillin Amoxicillin/Potassium Clavulanate Azithromycin Cefdinir 2 Cefuroxime Cephalexin Ciprofloxacin Tablet Clarithromycin Tablet Clindamycin Dificid 3 SL Doxycycline Capsule, Tablet Doxycycline Hyclate Capsule, Tablet Levofloxacin Metronidazole Minocycline Capsule, Tablet Nitrofurantoin Nitrofurantoin Macrocrystal Oracea 3 Penicillin V Potassium Solodyn 3 Sulfamethoxazole- Trimethoprim Anti-Infectives: Antifungals Fluconazole Itraconazole SL Ketoconazole Nystatin Terbinafine SL Anti-Infectives: Antivirals Acyclovir Ointment 3 SL Acyclovir Tablet Baraclude 2 DSP Incivek 2 DSP, N, SL Olysio 2 DSP, N, SL Ribavirin DSP Tamiflu 3 SL Valacyclovir 2 SL Zovirax Cream 3 SL Cancer Bosulif 2 DSP, N, SL, ST Gleevec 2 DSP, N, SL Hydroxyurea Leucovorin Calcium Mercaptopurine Sutent 2 DSP, N, SL Tasigna 2 DSP, N, SL Xeloda 2 DSP, SL Zytiga 2 DSP, N, SL Cardiovascular/Heart Disease: Coagulation Therapy Clopidogrel Coumadin 2 Effient 3 SL Eliquis 3 SL Enoxaparin Sodium 2 SL Pradaxa 2 SL Warfarin Sodium Xarelto 2 SL Bold type = Brand name drug [Plain type = Generic drug] DSP = Designated Specialty Program MC = Multiple Copay N = Notification or Prior Authorization required RS = May be eligible for the Refill and Save Program SDP = Select Designated Pharmacy SL = Supply Limit ST = Step Therapy /2T = May be eligible for Half Tablet 0

11 Name Cardiovascular/Heart Disease: High Blood Pressure Amlodipine Amlodipine Besylate-Benazepril 2 SL Atenolol Atenolol-Chlorthalidone Benazepril Benazepril- Hydrochlorothiazide Benicar 2 SL, /2T Benicar HCT 2 SL Bidil 2 Bisoprolol Bisoprolol- Hydrochlorothiazide Bystolic 2 Cartia XT 2 Carvedilol Chlorthalidone Clonidine Tablet Diltiazem 24 Hour CD 2 Diltiazem Sustained- Release Capsule 2 Diltiazem Sustained- Release Tablet 2 Diovan 3 SL, /2T Doxazosin Dutoprol 2 SL Edarbi 3 SL Edarbyclor 3 SL Enalapril Enalapril- Hydrochlorothiazide Felodipine Fosinopril Sodium Name Furosemide Guanfacine Hydralazine Hydrochlorothiazide Indapamide Irbesartan 2 SL, /2T Labetalol Lisinopril Lisinopril- Hydrochlorothiazide Losartan /2T Losartan- Hydrochlorothiazide Metoprolol Succinate 50, 00, 200 mg 2 Metoprolol Tartrate Micardis HCT 2 SL Nadolol Nifedipine Extended-Release Propranolol Quinapril Ramipril Spironolactone Telmisartan 2 SL Terazosin Torsemide Triamterene- Hydrochlorothiazide Valsartan- Hydrochlorothiazide 2 SL Verapamil Verapamil Sustained-Release 3

12 Name Name Cardiovascular/Heart Disease: High Cholesterol Atorvastatin SL, /2T Crestor 2 SDP, SL, /2T Fenofibrate 54, 60 mg 2 Fenofibrate Micronized 43, 30 mg 2 Fenoglide 3 Gemfibrozil Lipofen 2 Livalo 3 SL Lovastatin Lovaza 3 N Niacin Extended- Release Tablet 3 Niaspan 2 Pravastatin /2T Simcor 3 SL Simvastatin /2T Vascepa 3 N Vytorin 3 SL Welchol 2 Zetia 3 SL Cardiovascular/Heart Disease: Other Amiodarone Digoxin Flecainide Isosorbide Mononitrate ER Multaq 2 Nitroglycerin Sublingual Spray 3 SL Ranexa 2 Sotalol Central Nervous System: Attention Deficit Disorder Adderall XR 2 SL Amphetamine Salt Combo Concerta 2 SL Daytrana 3 Dexmethylphenidate Dextroamphetamine Sulfate 3 Dextroamphetamine- Amphetamine Focalin XR 3 Intuniv 3 Metadate CD 2 SL Methylphenidate Methylphenidate Extended-Release Capsule Methylphenidate Extended-Release Tablet Strattera 3 SL Vyvanse 2 SL Central Nervous System: Depression Amitriptyline Bupropion Bupropion Extended-Release Bupropion Sustained-Release Citalopram Doxepin Duloxetine 3 SL 3 3 Bold type = Brand name drug [Plain type = Generic drug] DSP = Designated Specialty Program MC = Multiple Copay N = Notification or Prior Authorization required RS = May be eligible for the Refill and Save Program SDP = Select Designated Pharmacy SL = Supply Limit ST = Step Therapy /2T = May be eligible for Half Tablet 2

13 Name Escitalopram /2T Fluoxetine Fluvoxamine Imipramine Mirtazapine Nortriptyline Paroxetine Pristiq ER 3 RS, SL Sertraline /2T Trazodone Venlafaxine Venlafaxine Extended- Release Capsule SL Viibryd 3 SDP, SL Central Nervous System: Migraine Acetaminophen/ Butalbital/Caffeine SL Relpax 2 SL Rizatriptan Orally Disintegrating Tablet 3 SL Rizatriptan Tablet 2 SL Sumatriptan Nasal Spray 2 SL Sumatriptan Succinate Tablet, SL Injection Sumavel DosePro 3 SL Central Nervous System: Multiple Sclerosis Ampyra 2 DSP, N, SL Aubagio 3 DSP, N, SL, ST Avonex 2 DSP, N, SL Betaseron 2 DSP, N, SL Copaxone 20 mg 2 DSP, N, SL Gilenya 3 DSP, N, SL, ST Rebif 3 DSP, N, SL, ST Tecfidera 2 DSP, N, SL Name Central Nervous System: Other Abilify 3 N, SL, /2T Alprazolam Alprazolam Extended-Release Buspirone Carbidopa-Levodopa Diazepam Donepezil 5, 0 mg Latuda 3 SL Lithium Lorazepam Nuvigil 3 N, SL Olanzapine N, SL Pramipexole Quetiapine 2 SL Risperidone Ropinirole Seroquel XR 3 N, SL Tasmar 2 Xyrem 3 N, SL Zelapar 3 Ziprasidone 2 SL Zubsolv 2 N, SL Central Nervous System: Sedatives/Hypnotics Lunesta 3 SL, ST Temazepam Zaleplon SL Zolpidem SL Zolpimist 3 SL, ST 3

14 Name Central Nervous System: Seizure Disorders Carbamazepine Clonazepam Depakote 3 N, ST Depakote ER 3 N, ST Diazepam Divalproex Divalproex Extended-Release Gabapentin Keppra 3 N, ST Keppra XR 3 N, ST Lamictal 3 N, ST Lamictal XR 3 N, ST Lamotrigine Levetiracetam Levetiracetam Extended-Release 2 Lyrica 3 SDP, SL Neurontin 3 N, ST Oxcarbazepine Phenytoin Topamax 3 N, ST Topiramate Trileptal 3 N, ST Zonegran 3 N, ST Zonisamide Name Dermatology Aczone 3 SL Adapalene 3 N, SL Azelex 3 SL Betamethasone Dipropionate Cream, Lotion, Ointment Carac 2 Ciclopirox Cream, Gel, Lotion, Solution Claravis 2 N Clindamycin %/ Benzoyl Peroxide 5% Jar 3 SL Clindamycin Gel, Lotion, Solution, Swabs Clobetasol Propionate Cream, Lotion, Ointment, Solution Cloderm 3 SL Clotrimazole- Betamethasone Cream, Lotion Condylox Gel 3 Desonide Cream, Lotion, Ointment Differin % 2 N, SL Differin 3% 3 N, SL Epiduo 3 SL Finacea 3 Fluocinonide 0.05% Cream, Ointment, Solution Bold type = Brand name drug [Plain type = Generic drug] DSP = Designated Specialty Program MC = Multiple Copay N = Notification or Prior Authorization required RS = May be eligible for the Refill and Save Program SDP = Select Designated Pharmacy SL = Supply Limit ST = Step Therapy /2T = May be eligible for Half Tablet 4

15 Name Hydrocortisone Cream, Ointment Metronidazole Gel 0.75% Mometasone Furoate Cream, Lotion, Ointment Mupirocin Ointment Nystatin-Triamcinolone Acetonide Cream, Ointment Oxsoralen-Ul 2 Picato 3 SL Protopic 2 N, SL Sodium Sulfacetamide-Sulfur Stelara 2 DSP, N, SL Taclonex 3 SL Tretinoin N Triamcinolone Acetonide Cream, Lotion, Ointment Vectical 3 SL Diabetes: Blood Glucose Monitoring Accu-Chek Active Test Strips Accu-Chek Aviva Plus Accu-Chek Aviva Plus Test Strips Accu-Chek Comfort Curve Test Strips Accu-Chek Compact Test Strips Accu-Chek Nano SmartView SL SL SL SL Name Accu-Chek Nano SmartView SL Test Strips Contour Test Strips 3 SDP, SL Freestyle Test Strips 3 SDP, SL One Touch Test Strips SL One Touch Ultra Meter One Touch Ultra Mini One Touch Ultra Test Strips SL One Touch Verio IQ One Touch Verio IQ Test Strips SL Diabetes: Insulin Humalog KwikPen 2 Humalog Mix KwikPen 2 Humalog Vials Humulin Vials Humulin KwikPen 2 Humulin N KwikPen 2 Humulin N Vials Humulin R Vials Lantus Solostar 3 Lantus Vials 3 Levemir Flexpen Levemir Vials Novolog 3 SDP Novolog Flexpen 3 SDP 5

16 Name Name Diabetes: Non-Insulin Bydureon 3 SL Byetta 2 SL Glimepiride Glipizide Glipizide Extended-Release Glumetza 3 Glyburide Glyburide-Metformin Janumet 3 SDP, SL Januvia 3 SDP, SL Jentadueto 2 SL Kazano 2 SL Kombiglyze XR 2 SL Metformin Metformin Extended-Release Nesina 2 SL Onglyza 2 SL Oseni 2 SL Pioglitazone 2 SL Pioglitazone-Metformin 2 SL Prandimet 3 Prandin 3 SL Repaglinide 2 SL Tradjenta 2 SL Victoza 3 SL Endocrine: Growth Hormone Nutropin AQ NuSpin 2 DSP, N, SL Saizen 2 DSP, N, SL Tev-Tropin 2 DSP, N, SL Endocrine: Other Calcitriol Desmopressin Dexamethasone Methylprednisolone Prednisolone Prednisone Endocrine: Thyroid Hormone Replacement Armour Thyroid 3 Levothyroxine Sodium Levoxyl 2 Liothyronine Sodium 2 Methimazole NP Thyroid Synthroid 2 Tirosint 2 Eye Conditions: Allergies Azelastine 3 SL Lastacaft 3 SL Eye Conditions: Antibiotics Erythromycin Ofloxacin Polymyxin B Sulfate/ Trimethoprim Tobramycin/ Dexamethasone 2 Bold type = Brand name drug [Plain type = Generic drug] DSP = Designated Specialty Program MC = Multiple Copay N = Notification or Prior Authorization required RS = May be eligible for the Refill and Save Program SDP = Select Designated Pharmacy SL = Supply Limit ST = Step Therapy /2T = May be eligible for Half Tablet 6

17 Name Name Eye Conditions: Glaucoma Alphagan P 0.% 2 SL Azopt 2 SL Combigan 2 SL Dorzolamide-Timolol 2 Latanoprost Lumigan 2 SL Timolol Maleate Travatan Z 2 SL Eye Conditions: Other Lotemax Solution 3 SL Gastrointestinal: Acid Suppression Dexilant 3 N, SL Omeclamox-Pak 3 N, SL Omeprazole N Pantoprazole N Pylera 3 SL Rabeprazole 3 SL Sucralfate Tablet Gastrointestinal: Nausea/Vomiting Ondansetron Ondansetron ODT Gastrointestinal: Other Amitiza 3 N, SL, ST Apriso 2 Canasa 2 Cortifoam 2 Creon 2 Golytely 2 Halflytely 3 Hyoscyamine Lialda 2 Linzess 2 N, SL Metoclopramide Moviprep 3 Polyethylene Glycol Prepopik 3 Suclear 3 Sulfasalazine Suprep 3 Uceris 3 Ursodiol Zenpep 2 7

18 Name Name HIV/AIDS Atripla 2 DSP Complera 2 DSP Epzicom 2 DSP Intelence 2 DSP Isentress 2 DSP Kaletra 2 DSP Norvir 2 DSP Prezista 2 DSP Reyataz 2 DSP Stribild 3 DSP, N Sustiva 2 DSP Truvada 2 DSP, N Viread 2 DSP Infertility* Cetrotide 2 DSP Gonal-F 2 DSP Gonal-F RFF 2 DSP Ovidrel 3 DSP *Coverage is determined by the consumer s prescription drug benefit plan. Men s Health: Prostate Alfuzosin Avodart 3 N, SDP Doxazosin Finasteride Rapaflo 3 Tamsulosin Terazosin Men s Health: Testosterone Therapy Androderm 2 N, SL Android 2 Depo-Testosterone 3 Testim 2 N, SL Testosterone Cypionate Testosterone Enanthate Testred 2 Men s Health: Erectile Dysfunction Cialis 3 SL Viagra 3 SL Bold type = Brand name drug [Plain type = Generic drug] DSP = Designated Specialty Program MC = Multiple Copay N = Notification or Prior Authorization required RS = May be eligible for the Refill and Save Program SDP = Select Designated Pharmacy SL = Supply Limit ST = Step Therapy /2T = May be eligible for Half Tablet 8

19 Name Name Miscellaneous Anastrozole Antipyrine/Benzocaine Aranesp 2 DSP, SL Benzonatate Bethkis 2 DSP, N, SL Bromfed DM 3 Chlorhexidine Gluconate Ciprodex 2 Epipen 2 SL Epipen-Jr 2 SL Exemestane 2 Fosrenol 2 Hydrocodone/ Chlorpheniramine 3 SL Hydrocodone/ Homatropine Letrozole Lidocaine Transdermal Patch 2 SL Nuedexta 2 Pegasys 2 DSP, N, SL Procrit 2 DSP, SL Promethazine/Codeine Promethazine/ Dextromethorphan Pulmozyme 2 DSP, N, SL Rectiv 3 N, SL Renvela 2 Restasis 3 N, SL Rezira 3 Tamoxifen Tobi Podhaler 3 DSP, N, SL Zutripro 3 SL Musculoskeletal: Osteoporosis Actonel 3 SL Alendronate Sodium SL Evista 2 Forteo 2 DSP, N Ibandronate 2 SL Musculoskeletal: Other Allopurinol Baclofen Carisoprodol 350 mg Colcrys 2 Cyclobenzaprine Methocarbamol Tizanidine Tablet Uloric 3 SL Musculoskeletal: Pain Relief Acetaminophen/ Codeine SL Avinza 3 N, SL Celebrex 3 SL Diclofenac Sodium Duragesic SL Etodolac Exalgo 3 N, SL Fentanyl Patches 3 SL Hydrocodone/ Acetaminophen SL Hydrocodone/Ibuprofen Hydromorphone Ibuprofen Indomethacin 9

20 Name Ketorolac Lazanda 3 N, SL Meloxicam Methadone Morphine Sulfate Extended-Release Tablet SL Nabumetone Naproxen Nucynta 3 SL Nucynta ER 3 N, SL Onsolis 3 N, SL Opana ER 2 N, SL Oxycodone Oxycodone/ Acetaminophen SL Oxycontin 2 N, SL Oxymorphone Extended-Release 3 N, SL Sprix 3 Subsys 3 N, SL Tramadol Tramadol Sustained-Release 2 SL Voltaren Gel 2 Name Musculoskeletal: Rheumatoid Arthritis Cimzia 2 DSP, N, SL Enbrel 2 DSP, N, SL Humira 3 DSP, N, SL, ST Hydroxychloroquine Sulfate Leflunomide Methotrexate Orencia 3 DSP, N, SL Simponi 2 DSP, N, SL Overactive Bladder Dicyclomine Oxybutynin Oxybutynin Extended-Release 2 Toviaz 3 Respiratory: Allergies Azelastine 3 SL Cyproheptadine Flunisolide Spray 3 Fluticasone Propionate 2 SL Hydroxyzine Levocetirizine Tablet SL Promethazine Zetonna 3 SL Bold type = Brand name drug [Plain type = Generic drug] DSP = Designated Specialty Program MC = Multiple Copay N = Notification or Prior Authorization required RS = May be eligible for the Refill and Save Program SDP = Select Designated Pharmacy SL = Supply Limit ST = Step Therapy /2T = May be eligible for Half Tablet 20

21 Name Name Respiratory: Asthma/COPD Advair Diskus/HFA 3 RS, SL Albuterol Sulfate Alvesco SL Asmanex SL Breo Ellipta 3 RS, SL Budesonide Nebs 2 SL Combivent Respimat 3 SL Dulera 3 RS, SL Flovent HFA 3 SDP, SL Foradil 2 SL Ipratropium Montelukast SL Perforomist 3 SL Proair HFA 3 SL Proventil HFA 3 SL Pulmicort Flexhaler 3 SDP, SL QVAR SL Spiriva 2 SL Tudorza 2 SL Ventolin HFA SL Xopenex HFA 3 SL Respiratory: Pulmonary Arterial Hypertension Adcirca 3 DSP, N, SL Letairis 2 DSP, N, SL Sildenafil DSP, N, SL Tracleer 2 DSP, N, SL Tyvaso 2 DSP, N Transplant Azathioprine Cellcept 3 DSP Cyclosporine Modified DSP Mycophenolate DSP Mycophenolic Acid 2 DSP Myfortic 3 DSP Neoral 3 DSP Prograf 3 DSP Rapamune 3 DSP Sirolimus 2 DSP Tacrolimus DSP Vitamins/Electrolytes Fluoride Folic Acid Klor-Con M0 Klor-Con M20 Potassium Chloride Potassium Citrate 2

22 Name Women s Health: Contraceptives Altavera Amethia 3 MC Apri Aviane Azurette 2 Camrese 3 MC Cryselle Cyclafem Emoquette Enpresse Gianvi 3 Gildess Fe Jolessa 2 MC Jolivette 3 Junel 2 Junel Fe Kariva 2 Levora-28 Lo Loestrin Fe 3 Loryna 3 Low-Ogestrel Lutera Microgestin 2 Microgestin FE Mononessa 3 Natazia Name Necon 0.5/35, /35, /50, 0/ Norgestimate-Ethinyl Estradiol 3 Nortrel 0.5/35 Nuvaring 2 Orsythia Ortho Evra 3 Ortho Micronor Ortho Tri-Cyclen Ortho Tri-Cyclen Lo 3 Ortho-Cyclen Ortho-Novum 3 Ortho-Novum 7/7/7 Portia Previfem 3 Quasense 2 MC Reclipsen Sprintec 3 Syeda 3 Trinessa 3 Tri-Previfem 3 Tri-Sprintec 3 Trivora-28 Viorele 2 Yasmin 28 Yaz 2 Zovia -35E Bold type = Brand name drug [Plain type = Generic drug] DSP = Designated Specialty Program MC = Multiple Copay N = Notification or Prior Authorization required RS = May be eligible for the Refill and Save Program SDP = Select Designated Pharmacy SL = Supply Limit ST = Step Therapy /2T = May be eligible for Half Tablet 22

23 Name Name Women s Health: Hormone Replacement Cenestin 2 Climara 2 SL Climara Pro 3 SL Divigel 2 Enjuvia 2 Estrace Cream 2 Estradiol Estradiol/Norethindrone Acetate 2 Estring 2 MC, SL Estrogen/ Methyltestosterone Evamist 2 Medroxyprogesterone Minivelle 3 SL Premarin 3 Prempro 3 Progesterone Micronized Capsule 2 Vagifem 2 Vivelle-Dot 2 SL Women s Health: Prenatal Vitamins Brand Prenatal Vitamins 3 Prenatal Plus 23

24 Index A Abilify...3 Accu-Chek Active Test Strips...5 Accu-Chek Aviva Plus...5 Accu-Chek Aviva Plus Test Strips...5 Accu-Chek Comfort Curve Test Strips...5 Accu-Chek Compact Test Strips...5 Accu-Chek Nano SmartView...5 Accu-Chek Nano SmartView Test Strips...5 Acetaminophen/Butalbital/ Caffeine...3 Acetaminophen/Codeine...9 Actonel...9 Acyclovir Ointment...0 Acyclovir Tablet...0 Aczone...4 Adapalene...4 Adcirca...2 Adderall XR...2 Advair Diskus/HFA...2 Albuterol Sulfate...2 Alendronate Sodium...9 Alfuzosin...8 Allopurinol...9 Alphagan P 0.%...7 Alprazolam...3 Alprazolam Extended-Release...3 Altavera...22 Alvesco...2 Amethia...22 Amiodarone...2 Amitiza...7 Amitriptyline...2 Amlodipine... Amlodipine Besylate-Benazepril... Amoxicillin...0 Amoxicillin/Potassium Clavulanate...0 Amphetamine Salt Combo...2 Ampyra...3 Anastrozole...9 Androderm...8 Android...8 Antipyrine/Benzocaine...9 Apri...22 Apriso...7 Aranesp...9 Armour Thyroid...6 Asmanex...2 Atenolol... Atenolol-Chlorthalidone... Atorvastatin...2 Atripla...8 Aubagio...3 Aviane...22 Avinza...9 Avodart...8 Avonex...3 Azathioprine...2 Azelastine...6, 20 Azelex...4 Azithromycin...0 Azopt...7 Azurette...22 B Baclofen...9 Baraclude...0 Benazepril... Benazepril- Hydrochlorothiazide... Benicar... Benicar HCT... Benzonatate Betamethasone Dipropionate Cream, Lotion, Ointment...4 Betaseron...3 Bethkis...9 Bidil... Bisoprolol... Bisoprolol- Hydrochlorothiazide... Bosulif...0 Brand Prenatal Vitamins...23 Breo Ellipta...2 Bromfed DM...9 Budesonide Nebs...2 Bupropion...2 Bupropion Extended-Release...2 Bupropion Sustained-Release...2 Buspirone...3 Bydureon...6 Byetta...6 Bystolic... C Calcitriol...6 Camrese...22 Canasa...7 Carac...4 Carbamazepine...4 Carbidopa-Levodopa...3 Carisoprodol 350 mg...9 Cartia XT... Carvedilol... Cefdinir...0 Cefuroxime...0 Celebrex...9 Cellcept...2 Cenestin...23 Cephalexin...0 Cetrotide...8 Chlorhexidine Gluconate...9 Chlorthalidone...

25 Cialis...8 Ciclopirox Cream, Gel, Lotion, Solution...4 Cimzia...20 Ciprodex...9 Ciprofloxacin Tablet...0 Citalopram...2 Claravis...4 Clarithromycin Tablet...0 Climara...23 Climara Pro...23 Clindamycin... 0, 4 Clindamycin %/Benzoyl Peroxide 5% Jar...4 Clindamycin Gel, Lotion, Solution, Swabs...4 Clobetasol Propionate Cream, Lotion, Ointment, Solution...4 Cloderm...4 Clonazepam...4 Clonidine Tablet... Clopidogrel...0 Clotrimazole-Betamethasone Cream, Lotion...4 Colcrys...9 Combigan...7 Combivent Respimat...2 Complera...8 Concerta...2 Condylox Gel...4 Contour Test Strips...5 Copaxone 20 mg...3 Cortifoam...7 Coumadin...0 Creon...7 Crestor...8, 2 Cryselle...22 Cyclafem...22 Cyclobenzaprine...9 Cyclosporine Modified...2 Cyproheptadine...20 D Daytrana...2 Depakote...4 Depakote ER...4 Depo-Testosterone...8 Desmopressin...6 Desonide Cream, Lotion, Ointment...4 Dexamethasone...6 Dexilant...7 Dexmethylphenidate...2 Dextroamphetamine- Amphetamine...2 Dextroamphetamine Sulfate...2 Diazepam... 3, 4 Diclofenac Sodium...9 Dicyclomine...20 Differin %...4 Differin 3%...4 Dificid...0 Digoxin...2 Diltiazem 24 Hour CD... Diltiazem Sustained-Release Capsule... Diltiazem Sustained-Release Tablet... Diovan... Divalproex...4 Divalproex Extended-Release...4 Divigel...23 Donepezil 5, 0 mg...3 Dorzolamide-Timolol...7 Doxazosin..., 8 Doxepin...2 Doxycycline Capsule, Tablet...0 Doxycycline Hyclate Capsule, Tablet...0 Dulera...2 Duloxetine...2 Duragesic...9 Dutoprol E Edarbi... Edarbyclor... Effient...0 Eliquis...0 Emoquette...22 Enalapril... Enalapril- Hydrochlorothiazide... Enbrel...20 Enjuvia...23 Enoxaparin Sodium...0 Enpresse...22 Epiduo...4 Epipen...9 Epipen-Jr...9 Epzicom...8 Erythromycin...6 Escitalopram...3 Estrace Cream...23 Estradiol...22, 23 Estradiol/Norethindrone Acetate...23 Estring...23 Estrogen/ Methyltestosterone...23 Etodolac...9 Evamist...23 Evista...9 Exalgo...9 Exemestane...9 F Felodipine... Fenofibrate 54, 60 mg...2 Fenofibrate Micronized 43, 30 mg...2 Fenoglide...2 Fentanyl Patches...9 Finacea...4 Finasteride...8 Flecainide...2 Flovent HFA...2 Fluconazole...0

26 Flunisolide Spray...20 Fluocinonide 0.05% Cream, Ointment, Solution...4 Fluoride...2 Fluoxetine...3 Fluticasone Propionate...20 Fluvoxamine...3 Focalin XR...2 Folic Acid...2 Foradil...2 Forteo...9 Fosinopril Sodium... Fosrenol...9 Freestyle Test Strips...5 Furosemide... G Gabapentin...4 Gemfibrozil...2 Gianvi...22 Gildess Fe...22 Gilenya...3 Gleevec...0 Glimepiride...6 Glipizide...6 Glipizide Extended-Release...6 Glumetza...6 Glyburide...6 Glyburide-Metformin...6 Golytely...7 Gonal-F...8 Gonal-F RFF...8 Guanfacine... H Halflytely...7 Humalog KwikPen...5 Humalog Mix KwikPen...5 Humalog Vials...5 Humira...20 Humulin Vials...5 Humulin KwikPen...5 Humulin N KwikPen...5 Humulin N Vials...5 Humulin R Vials...5 Hydralazine... Hydrochlorothiazide... Hydrocodone/ Acetaminophen...9 Hydrocodone/ Chlorpheniramine...9 Hydrocodone/Homatropine... 9 Hydrocodone/Ibuprofen...9 Hydrocortisone Cream, Ointment...5 Hydromorphone...9 Hydroxychloroquine Sulfate...20 Hydroxyurea...0 Hydroxyzine...20 Hyoscyamine...7 I Ibandronate...9 Ibuprofen...9 Imipramine...3 Incivek...0 Indapamide... Indomethacin...9 Intelence...8 Intuniv...2 Ipratropium...2 Irbesartan... Isentress...8 Isosorbide Mononitrate ER...2 Itraconazole...0 J Janumet...6 Januvia...6 Jentadueto...6 Jolessa...22 Jolivette...22 Junel...22 Junel Fe...22 K Kaletra...8 Kariva Kazano...6 Keppra...4 Keppra XR...4 Ketoconazole...0 Ketorolac...20 Klor-Con M0...2 Klor-Con M Kombiglyze XR...6 L Labetalol... Lamictal...4 Lamictal XR...4 Lamotrigine...4 Lantus Solostar...5 Lantus Vials...5 Lastacaft...6 Latanoprost...7 Latuda...3 Lazanda...20 Leflunomide...20 Letairis...2 Letrozole...9 Leucovorin Calcium...0 Levemir Flexpen...5 Levemir Vials...5 Levetiracetam...4 Levetiracetam Extended-Release...4 Levocetirizine Tablet...20 Levofloxacin...0 Levora Levothyroxine Sodium...6 Levoxyl...6 Lialda...7 Lidocaine Transdermal Patch...9 Linzess...7 Liothyronine Sodium...6 Lipofen...2 Lisinopril..., 34 Lisinopril- Hydrochlorothiazide... Lithium...3

27 Livalo...2 Lo Loestrin Fe...22 Lorazepam...3 Loryna...22 Losartan... Losartan- Hydrochlorothiazide... Lotemax Solution...7 Lovastatin...2 Lovaza...2 Low-Ogestrel...22 Lumigan...7 Lunesta...3 Lutera...22 Lyrica...4 M Medroxyprogesterone...23 Meloxicam...20 Mercaptopurine...0 Metadate CD...2 Metformin...6 Metformin Extended-Release...6 Methadone...20 Methimazole...6 Methocarbamol...9 Methotrexate...20 Methylphenidate...2 Methylphenidate Extended-Release Capsule..2 Methylphenidate Extended-Release Tablet...2 Methylprednisolone...6 Metoclopramide...7 Metoprolol Succinate 50, 00, 200 mg... Metoprolol Tartrate... Metronidazole...0, 5 Metronidazole Gel 0.75%...5 Micardis HCT... Microgestin...22 Microgestin FE...22 Minivelle...23 Minocycline Capsule, Tablet...0 Mirtazapine...3 Mometasone Furoate Cream, Lotion, Ointment...5 Mononessa...22 Montelukast...2 Morphine Sulfate Extended-Release Tablet...20 Moviprep...7 Multaq...2 Mupirocin Ointment...5 Mycophenolate...2 Mycophenolic Acid...2 Myfortic...2 N Nabumetone...20 Nadolol... Naproxen...20 Natazia...22 Necon 0.5/35, /35, /50, 0/...22 Neoral...2 Nesina...6 Neurontin...4 Niacin Extended-Release Tablet...2 Niaspan...2 Nifedipine Extended-Release. Nitrofurantoin...0 Nitrofurantoin Macrocrystal...0 Nitroglycerin Sublingual Spray...2 Norgestimate-Ethinyl Estradiol...22 Nortrel 0.5/ Nortriptyline...3 Norvir...8 Novolog...5 Novolog Flexpen...5 NP Thyroid...6 Nucynta Nucynta ER...20 Nuedexta...9 Nutropin AQ NuSpin...6 Nuvaring...22 Nuvigil...3 Nystatin...0 Nystatin-Triamcinolone Acetonide Cream, Ointment...5 O Ofloxacin...6 Olanzapine...3 Olysio...0 Omeclamox-Pak...7 Omeprazole...7 Ondansetron...7 Ondansetron ODT...7 One Touch Test Strips...5 One Touch Ultra Meter...5 One Touch Ultra Mini...5 One Touch Ultra Test Strips..5 One Touch Verio IQ...5 One Touch Verio IQ Test Strips...5 Onglyza...6 Onsolis...20 Opana ER...20 Oracea...0 Orencia...20 Orsythia...22 Ortho-Cyclen...22 Ortho-Novum...22 Ortho-Novum 7/7/ Ortho Evra...22 Ortho Micronor...22 Ortho Tri-Cyclen...22 Ortho Tri-Cyclen Lo...22 Oseni...6 Ovidrel...8 Oxcarbazepine...4 Oxsoralen-Ul...5 Oxybutynin...20

28 Oxybutynin Extended-Release...20 Oxycodone...20 Oxycodone/Acetaminophen...20 Oxycontin...20 Oxymorphone Extended-Release...20 P Pantoprazole...7 Paroxetine...3 Pegasys...9 Penicillin V Potassium...0 Perforomist...2 Phenytoin...4 Picato...5 Pioglitazone...6 Pioglitazone-Metformin...6 Polyethylene Glycol Polymyxin B Sulfate/ Trimethoprim...6 Portia...22 Potassium Chloride...2 Potassium Citrate...2 Pradaxa...0 Pramipexole...3 Prandimet...6 Prandin...6 Pravastatin...2 Prednisolone...6 Prednisone...6 Premarin...23 Prempro...23 Prenatal Plus...23 Prepopik...7 Previfem...22 Prezista...8 Pristiq ER...3 Proair HFA...2 Procrit...9 Progesterone Micronized Capsule...23 Prograf...2 Promethazine... 9, 20 Promethazine/Codeine...9 Promethazine/ Dextromethorphan...9 Propranolol... Protopic...5 Proventil HFA...2 Pulmicort Flexhaler...2 Pulmozyme...9 Pylera...7 Q Quasense...22 Quetiapine...3 Quinapril... QVAR...2 R Rabeprazole...7 Ramipril... Ranexa...2 Rapaflo...8 Rapamune...2 Rebif...3 Reclipsen...22 Rectiv...9 Relpax...3 Renvela...9 Repaglinide...6 Restasis...9 Reyataz...8 Rezira...9 Ribavirin...0 Risperidone...3 Rizatriptan Orally Disintegrating Tablet...3 Rizatriptan Tablet...3 Ropinirole...3 S Saizen...6 Seroquel XR...3 Sertraline...3 Sildenafil...2 Simcor...2 Simponi Simvastatin...8, 2 Sirolimus...2 Sodium Sulfacetamide-Sulfur...5 Solodyn...0 Sotalol...2 Spiriva...2 Spironolactone... Sprintec...22 Sprix...20 Stelara...5 Strattera...2 Stribild...8 Subsys...20 Suclear...7 Sucralfate Tablet...7 Sulfamethoxazole- Trimethoprim...0 Sulfasalazine...7 Sumatriptan Nasal Spray...3 Sumatriptan Succinate Tablet, Injection...3 Sumavel DosePro...3 Suprep...7 Sustiva...8 Sutent...0 Syeda...22 Synthroid...6 T Taclonex...5 Tacrolimus...2 Tamiflu...0 Tamoxifen...9 Tamsulosin...8 Tasigna...0 Tasmar...3 Tecfidera...3 Telmisartan... Temazepam...3 Terazosin..., 8 Terbinafine...0 Testim...8 Testosterone Cypionate...8

29 Testosterone Enanthate...8 Testred...8 Tev-Tropin...6 Timolol Maleate...7 Tirosint...6 Tizanidine Tablet...9 Tobi Podhaler...9 Tobramycin/Dexamethasone..6 Topamax...4 Topiramate...4 Torsemide... Toviaz...20 Tracleer...2 Tradjenta...6 Tramadol...20 Tramadol Sustained-Release...20 Travatan Z...7 Trazodone...3 Tretinoin...5 Tri-Previfem...22 Tri-Sprintec...22 Triamcinolone Acetonide Cream, Lotion, Ointment...5 Triamterene- Hydrochlorothiazide... Trileptal...4 Trinessa...22 Trivora Truvada...8 Tudorza...2 Tyvaso...2 U Uceris...7 Uloric...9 Ursodiol...7 V Vagifem...23 Valacyclovir...0 Valsartan- Hydrochlorothiazide... Vascepa...2 Vectical...5 Venlafaxine...3 Venlafaxine Extended-Release Capsule...3 Ventolin HFA...2 Verapamil... Verapamil Sustained-Release.. Viagra...8 Victoza...6 Viibryd...3 Viorele...22 Viread...8 Vivelle-Dot...23 Voltaren Gel...20 Vytorin...2 Vyvanse...2 W Warfarin Sodium...0 Welchol...2 X Xarelto...0 Xeloda...0 Xopenex HFA...2 Xyrem...3 Y Yasmin Yaz...22 Z Zaleplon...3 Zelapar...3 Zenpep...7 Zetia...2 Zetonna...20 Ziprasidone...3 Zolpidem...3 Zolpimist...3 Zonegran...4 Zonisamide...4 Zovia -35E...22 Zovirax Cream...0 Zubsolv...3 Zutripro...9 Zytiga

30 Notes 30

31 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 I Take This Medicine For Directions Doctor Example: Lisinopril, 20mg High blood pressure One tablet daily Dr. Johnson 3

32 For more information Call the toll-free member phone number on the back of your health plan ID card. Or, visit myuhc.com Where else can I go for information? HealthCareLane.com includes short videos to help you learn more about UnitedHealthcare benefi ts and health insurance information. UHCTV.com is a fun and easy way to learn about health terms and other health-related topics. All branded medications are trademarks or registered trademarks of their respective owners. 204 United HealthCare Services, Inc. All rights reserved. Created June, Prescription List Optum360 Advantage Three- 7/4