Prescription Drug List

Transcription

1 Your 206 Four- Prescription List effective July, 206 Please read: This document contains information about commonly prescribed medications. For additional information: Call the toll-free member phone number on 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.... Cardiovascular/Heart Disease Coagulation Therapy... High Blood Pressure.... High Cholesterol Other Central Nervous System Attention Deficit Disorder Depression... 3 Migraine Multiple Sclerosis Other Sedatives/Hypnotics Seizure Disorders... 5 Dermatology Diabetes/Endocrine Blood Glucose Monitoring Insulin Non-Insulin... 7 Endocrine Growth Hormone Other Thyroid Hormone Replacement Eye Conditions Allergies Antibiotics Glaucoma Gastrointestinal Acid Suppression....8 Nausea/Vomiting Other....8 Hepatitis C....9 HIV/AIDS....9 Infertility....9 Inflammatory Conditions: Rheumatoid Arthritis, Crohn s Disease, Psoriasis, Ulcerative Colitis....9 Men s Health Erectile Dysfunction....9 Prostate Testosterone Therapy...20 Miscellaneous Musculoskeletal Osteoporosis....2 Other....2 Pain Relief....2 Overactive Bladder Respiratory Allergies Asthma/COPD Pulmonary Arterial Hypertension Smoking Cessation...23 Transplant Vitamins/Electrolytes Women s Health Contraceptives Hormone Replacement Miscellaneous Prenatal Vitamins...24 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 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 programs 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 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, 3 or 4, 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 and 3 Mid-range Cost 4 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 or 3 drugs instead of 4 to help reduce your out-of-pocket costs. Many 4 drugs have lower cost options in, 2 or 3. Ask your doctor if they could work for you. Please note: Some plans may have two or three tiers, while others may not have any. If you have 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 on 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 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 may be covered for you. DSP E H MC PA RS SDP SL ST 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. May be excluded from coverage or subject to prior authorization and/or trial/ failure of another medication(s). + Lower-cost options are available and covered. Health Care Reform Preventive This medication is part of a Health Care Reform preventive benefit and may be available at no cost to you. Multiple Copay More than one month s worth of medication included in package so additional copay applies. 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. *Depending on your benefit you may have notification or medical necessity requirements for select medications. + For New Jersey fully insured members this program is referred to as First Start. 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 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. 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. For some benefit plans if a brand-name drug is prescribed and a generic equivalent is available, your cost share may be the copay PLUS the cost difference between the brand-name drug and generic equivalent. 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. For most plans, these medications are managed through the Specialty Pharmacy Program. Take advantage of personalized support designed to help you get the most out of your treatment plan. Visit UHCSpecialtyRx.com or call the toll-free phone number on your health plan ID card to learn more. Please note, not all specialty medications are listed here. If you re taking a specialty medication that is on 3 or 4, call the toll-free number on your health plan ID card to talk with a pharmacist about finding lower-cost options or a financial assistance program. 8

9 What is Mail Service Member Select? Your plan may include a home delivery program called Mail Service Member Select, which encourages you to use the OptumRx Mail Service Pharmacy for medication you take regularly. Choosing home delivery can help you better manage the medication you take on a regular basis, and may save you time and money. You can either confirm enrollment in the OptumRx Mail Service Pharmacy or you can disenroll from mail service and continue to fill your maintenance medications at a retail pharmacy. You can get up to two fills at a retail pharmacy before you have to decide. However, please be aware that you must make a decision about whether or not to enroll in Mail Service Member Select. If you do nothing and continue to fill your medications at a retail pharmacy, you may pay more for your medication until you make a decision and take action. You must confirm your decision every year. To learn more, you may log on to myuhc.com or call the toll-free member phone number on your health plan ID card for more information. 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 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 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 Anti-Infectives: Antibiotics Amoxicillin Capsule, Chewable Amoxicillin/Potassium Clavulanate Chewable, Azithromycin Cefadroxil Capsule, Cefdinir Capsule Cefixime Suspension 3 Cefprozil Cefuroxime Cephalexin Capsule Ciprofloxacin Clarithromycin Clindamycin Capsule Dificid 3 SL Doryx 4 E Doxycycline Hyclate 50, 00 mg Capsule, 2 Doxycycline Monohydrate 50, 00 mg Capsule Levofloxacin Metronidazole Minocycline Capsule Minocycline 3 Moxifloxacin 3 Nitrofurantoin Capsule Nitrofurantoin Macrocrystal Capsule Name Ofloxacin s Oracea 4 Penicillin V Potassium Solodyn 4 Sulfamethoxazole- Trimethoprim Suprax Capsule, Chewable, Anti-Infectives: Antifungals 4 Cresemba 3 SL Econazole Cream 3 SL Fluconazole Itraconazole Capsule SL Ketoconazole Cream Noxafil, Suspension 2 Nystatin Cream, Ointment Terbinafine SL Anti-Infectives: Antivirals Acyclovir Ointment 4 PA, SL, ST Acyclovir Famciclovir 2 Tamiflu 3 SL Valacyclovir 2 SL Valaganciclovir SL Zovirax Cream 4 E, SL Bold type = Brand-name drug [Plain type = Generic drug] DSP = Designated Specialty Program E = May be excluded from coverage H = Health Care Reform Preventive MC = Multiple Copay PA = Prior Authorization required RS = May be eligible for the Refill and Save Program SDP = Select Designated Pharmacy SL = Supply Limit ST = Step Therapy 0

11 Name Cancer Bexarotene Capsule 4 DSP, E, PA, SL Bicalutamide Bosulif 2 DSP, PA, SL, ST Cyclophosphamide Capsule 2 Gleevec 2 DSP, PA, SL Hydroxyurea Capsule 3 Imatnib 4 DSP, E, PA, SL Imbruvica 2 DSP, PA, SL Leucovorin Calcium Mercaptopurine Revlimid 2 DSP, PA, SL Sutent 2 DSP, PA, SL Targretin Capsule 2 DSP, PA, SL Targretin Gel 3 PA, SL Tasigna 2 DSP, PA, SL Xeloda DSP, SL Zytiga 2 DSP, PA, SL Cardiovascular/Heart Disease: Coagulation Therapy Clopidogrel Effient 4 SL Eliquis 4 SL Enoxaparin Sodium 2 SL Pradaxa 2 SL Savaysa 4 SL Warfarin Sodium Xarelto 2 SL Cardiovascular/Heart Disease: High Blood Pressure Amlodipine Amlodipine-Benazepril SL Amlodipine-Valsartan 2 SL Atenolol Atenolol-Chlorthalidone Benazepril Benazepril- Hydrochlorothiazide Name Benicar 2 SL Benicar HCT 2 SL Bidil 2 Bisoprolol Bisoprolol- Hydrochlorothiazide Bystolic 2 Cartia XT 2 Carvedilol Chlorthalidone Clonidine Diltiazem 24 Hour CD 2 Diltiazem Sustained- Release Capsule 2 Diltiazem Sustained- Release 2 Doxazosin Dutoprol 2 SL Edarbi 3 SL Edarbyclor 3 SL Enalapril Furosemide Guanfacine Hydralazine Hydrochlorothiazide Irbesartan SL Labetalol Lisinopril Lisinopril- Hydrochlorothiazide Losartan Losartan- Hydrochlorothiazide Metoprolol Succinate 2 50, 00, 200 mg Metoprolol Tartrate Nadolol Nifedipine Extended-Release Propranolol Extended- Release Capsule 2

12 Name Propranolol Quinapril Ramipril Spironolactone Telmisartan 2 SL Telmisartan- Hydrochlorothiazide 2 SL Terazosin Triamterene- Hydrochlorothiazide Valsartan 2 SL Valsartan- Hydrochlorothiazide SL Verapamil Verapamil 3 Sustained-Release Cardiovascular/Heart Disease: High Cholesterol Atorvastatin SL Choline Fenofibrate 4 E Crestor 2 SL Fenofibrate 43, 50, 67, 30, 34, 50, 200 mg Capsule 4 E Fenofibrate 48, 45 mg 4 E Fenofibrate 54, 60 mg 2 Fenoglide 4 E Fluvastatin Extended- Release 3 SL, ST Gemfibrozil Lescol XL 4 E, SL, ST Name Lipitor 4 E, SL Lipofen 4 E Livalo 4 SL, ST Lovastatin Niacin Extended- Release 4 Niaspan 2 Omega-3-Acid Ethyl Esters Capsule 3 PA Praluent 2 DSP, PA, SL, ST Pravastatin Repatha 4 DSP, PA, SL, ST Simcor 4 SL Simvastatin Tricor 48, 45 mg 4 E Vascepa 4 PA Vytorin 4 SL Welchol 2 Zetia 4 SL Cardiovascular/Heart Disease: Other Amiodarone Corlanor 3 PA, SL Digoxin Entresto 4 PA, SL Flecainide Isosorbide Mononitrate ER Nitrostat 2 Ranexa 2 Sotalol Bold type = Brand-name drug [Plain type = Generic drug] DSP = Designated Specialty Program E = May be excluded from coverage H = Health Care Reform Preventive MC = Multiple Copay PA = Prior Authorization required RS = May be eligible for the Refill and Save Program SDP = Select Designated Pharmacy SL = Supply Limit ST = Step Therapy 2

13 Name Central Nervous System: Attention Deficit Disorder Adderall XR 2 PA, SL Amphetamine Salt PA Combo Aptensio XR 4 E, PA, SL Concerta 2 PA, SL Daytrana 4 E, PA, SL Dexmethylphenidate Extended-Release Capsule Dexmethylphenidate Dextroamphetamine- Amphetamine Extended-Release 4 E, PA, SL PA 4 E, PA, SL Dextroamphetamine- Amphetamine PA Dextroamphetamine Sulfate 3 PA Focalin XR 4 E, PA, SL Guanfacine Extended-Release 2 SL Metadate CD 2 PA, SL Methylphenidate Chewable 3 PA Methylphenidate Extended-Release Capsule 4 E, PA, SL Methylphenidate Extended-Release 4 E, PA, SL Methylphenidate PA Strattera 4 SL Vyvanse 2 PA, SL Name Central Nervous System: Depression Amitriptyline Brintellix 4 SL, ST Bupropion Extended- Release Bupropion Sustained- Release Bupropion Citalopram Cymbalta 4 E, SL Doxepin Capsule Duloxetine Capsule 3 SL Escitalopram Fetzima 4 SL, ST Fluoxetine Capsule, Fluvoxamine Lexapro 4 E Mirtazapine Nortriptyline Capsule Paroxetine Pristiq ER 3 RS, SL Sertraline Trazodone Venlafaxine Extended- Release Capsule Venlafaxine Viibryd 4 SL 3

14 Name Central Nervous System: Migraine Acetaminophen/ Butalbital/Caffeine SL 325 mg/50 mg/40 mg Naratriptan SL Relpax 2 SL Rizatriptan ODT, SL Sumatriptan Nasal Spray 2 SL Sumatriptan Succinate, Injection SL Sumavel DosePro 3 SL Central Nervous System: Multiple Sclerosis Ampyra 2 DSP, PA, SL Aubagio 4 DSP, PA, SL, ST Avonex 2 DSP, PA, SL Betaseron 2 DSP, PA, SL Copaxone 2 DSP, PA, SL Gilenya 3 DSP, PA, SL, ST Glatopa 4 DSP, E, PA, SL, ST Rebif 4 DSP, PA, SL, ST Tecfidera 2 DSP, PA, SL Central Nervous System: Other Abilify 4 E, SL Alprazolam Extended- Release Alprazolam Aripiprazole 2 SL Buprenorphine/ Naloxone 4 E, PA, SL Buspirone Name Carbidopa-Levodopa Diazepam Donepezil 5, 0 mg ODT, Latuda 4 SL Lithium Capsule Lorazepam Memantine 2 Modafinil 3 PA, SL Namenda XR 4 E Nuvigil 4 E, PA, SL Olanzapine SL Pramipexole Quetiapine Risperidone Ropinirole Seroquel XR 4 SL Suboxone Film 4 E, PA, SL Tolcapone 2 Xyrem 4 PA, SL Zelapar 3 Ziprasidone Capsule 2 SL Zubsolv 2 PA, SL Central Nervous System: Sedatives/Hypnotics Eszopiclone 2 SL Temazepam Capsule Triazolam Zaleplon Capsule SL Zolpidem Extended- Release 4 E, SL Zolpidem SL Bold type = Brand-name drug [Plain type = Generic drug] DSP = Designated Specialty Program E = May be excluded from coverage H = Health Care Reform Preventive MC = Multiple Copay PA = Prior Authorization required RS = May be eligible for the Refill and Save Program SDP = Select Designated Pharmacy SL = Supply Limit ST = Step Therapy 4

15 Name Central Nervous System: Seizure Disorders Carbamazepine Clonazepam Diazepam Divalproex Delayed- Release Divalproex Extended- Release Gabapentin Capsule, Lamotrigine Levetiracetam Extended-Release 2 Levetiracetam Lyrica 4 SDP, SL, ST Oxcarbazepine Phenytoin Capsule, Suspension Topiramate Zonisamide Capsule Dermatology Absorica 4 E, PA Aczone 4 SL Adapalene 0.% 3 PA, SL Cream, Gel Adapalene 0.3% Gel 3 PA, SL Bethamethasone Dipropionate 0.05% Augmented Lotion, Ointment Betamethasone Dipropionate 0.05% Cream, Ointment Carac 2 Ciclopirox Cream, Gel, Lotion, Solution Claravis 2 PA Clindamycin %/ Benzoyl Peroxide 5% Gel 4 E, SL 3 2 Name Clindamycin.2%/ Benzoyl Peroxide 5% Gel 3 SL Clindamycin Gel 3 SL Clindamycin Lotion 3 Clindamycin Solution, Swabs Clobetasol Propionate Cream, Ointment 2 SL Clobetasol Propionate Solution SL Clotrimazole- Betamethasone Cream SL Clotrimazole- Betamethasone Lotion Condylox Gel 3 Desonide 0.05% Cream, Lotion, Ointment 3 SL Desoximetasone Gel, Ointment 3 SL Differin % Cream, Gel 2 PA, SL Diflorasone Diacetate 0.05% Cream, Ointment 3 SL Epiduo 3 SL Finacea 4 Fluocinonide 0.05% Cream Fluocinolone Cream, Oil, Ointment, Solution 3 SL Halobetasol Ointment 2 Hydrocortisone 2.5% Cream, Ointment Imiquimod 5% Cream 2 SL Metronidazole 0.75% Topical Gel Mirvaso 4 SL Mometasone Furoate Cream, Lotion, Ointment Mupirocin Ointment Nystatin-Triamcinolone Acetonide Cream, Ointment 4 E 5

16 Name Oxsoralen-Ul 2 Picato 3 SL Regranex 2 PA, SL Tacrolimus Ointment 2 PA, SL Tazorac 4 PA, SL Tretinoin PA, SL Tretinoin Microspheres 4 E, PA, SL Triamcinolone Acetonide Cream, Lotion, Ointment Vectical 3 SL Diabetes: Blood Glucose Monitoring Accu-Chek Test Strips 4 E, SL Contour Test Strips 4 E, SL Dexcom Continuous Glucose Monitoring 3 PA, SL System Dexcom Sensor 3 PA, SL Dexcom Transmitter 3 PA, SL FreeStyle Test Strips 4 E, SL OneTouch Test Strips SL OneTouch Ultra Meter OneTouch Ultra Mini OneTouch Ultra Test Strips SL OneTouch Verio OneTouch Verio IQ OneTouch Verio Sync OneTouch Verio Test Strips SL Name Diabetes: Insulin Afrezza 4 E, PA, SL, ST Humalog KwikPen 2 SL Humalog Mix KwikPen 2 SL Humalog Mix KwikPen 2 SL Humalog Vials SL Humulin KwikPen 2 SL Humulin Vials SL Humulin N KwikPen 2 SL Humulin N Vials SL Humulin R Vials SL Lantus Solostar 3 SL Lantus Vials 3 SL Levemir FlexTouch SL Levemir Vials SL Novolin Vials 3 SDP, SL, ST Novolin N Vials 3 SDP, SL, ST Novolin R Vials 3 SDP, SL, ST Novolog FlexTouch 4 SDP, SL, ST Novolog Mix 70/30 FlexTouch 4 SDP, SL, ST Novolog Mix 70/30 Vials 4 SDP, SL, ST Novolog Vials 4 SDP, SL, ST Toujeo SoloStar 4 E, SL Bold type = Brand-name drug [Plain type = Generic drug] DSP = Designated Specialty Program E = May be excluded from coverage H = Health Care Reform Preventive MC = Multiple Copay PA = Prior Authorization required RS = May be eligible for the Refill and Save Program SDP = Select Designated Pharmacy SL = Supply Limit ST = Step Therapy 6

17 Name Name Diabetes: Non-Insulin Bydureon 2 SL Byetta 2 SL Farxiga 4 SL, ST Glimepiride Glipizide Glipizide Extended-Release Glyburide Glyxambi 4 E, SL, ST Invokamet 2 SL Invokana 2 SL, ST Janumet 4 SL, ST Januvia 4 SL, ST Jardiance 2 SL, ST Jentadueto 2 SL Kazano 2 SL Kombiglyze XR 2 SL Metformin Metformin Extended- Release (generic Glucophage XR) Nesina 2 SL Onglyza 2 SL Oseni 2 SL Pioglitazone SL Tanzeum 2 SL Tradjenta 2 SL Trulicity 4 SL, ST Victoza 2-Pak 2 SL Victoza 3-Pak 3 SL Xigduo XR 4 E, SL, ST Endocrine: Growth Hormone Nutropin, Nutropin AQ 2 DSP, PA, SL Endocrine: Other Calcitriol Capsule Desmopressin Dexamethasone Methylprednisolone Prenisolone Oral Solution Prednisone Endocrine: Thyroid Hormone Replacement Armour Thyroid 3 Levothyroxine Sodium Liothyronine Sodium 2 Methimazole NP Thyroid Synthroid 2 Tirosint 4 E Eye Conditions: Allergies Azelastine 0.05% Ophthalmic Solution SL Lastacaft 3 SL Olopatadine 0.% Ophthalmic Solution 3 SL Pataday 4 E, SL Eye Conditions: Antibiotics Erythromycin 0.5% Ophthalmic Ointment Gentamicin Ophthalmic Ointment, Solution Moxeza 4 Ofloxacin 0.3% Ophthalmic Solution 7

18 Name Tobramycin/ Dexamethasone 0.3%-0.% Ophthalmic 2 Suspension Tobramycin Ophthalmic Solution Vigamox 4 Eye Conditions: Glaucoma Alphagan P 0.% 2 SL Azopt 2 SL Combigan 2 SL Latanoprost 0.005% Ophthalmic Solution Lumigan 2 SL Timolol Maleate 0.25%, 0.5% Ophthalmic Solution Travatan Z 2 SL Gastrointestinal: Acid Suppression Dexilant 3 SL Esomeprazole Capsule 4 E, SL Lansoprazole Capsules 3 E, SL Nexium Capsule 4 E, SL Omeclamox-Pak 3 SL Omeprazole Capsule Pantoprazole Pylera 3 SL Rabeprazole 3 SL Ranitadine Syrup Sucralfate Name Gastrointestinal: Nausea/Vomiting Akynzeo 4 SL Emend 2 SL Ondansetron Ondansetron ODT Transderm-Scop 3 Gastrointestinal: Other Amitiza 4 PA, SL, ST Apriso 2 Asacol HD 4 E Canasa 2 Cortifoam 2 Creon 2 Delzicol 4 E Diphenoxylate-Atropine Golytely 2 Hyoscyamine Lialda 2 Linzess 2 PA, SL Metoclopramide Movantik 2 PA, SL Moviprep 3 Polyethylene Glycol Prepopik 3 Suclear 3 Sulfasalazine Suprep 3 Uceris 3 Zenpep 2 Bold type = Brand-name drug [Plain type = Generic drug] DSP = Designated Specialty Program E = May be excluded from coverage H = Health Care Reform Preventive MC = Multiple Copay PA = Prior Authorization required RS = May be eligible for the Refill and Save Program SDP = Select Designated Pharmacy SL = Supply Limit ST = Step Therapy 8

19 Name Name Hepatitis C Daklinza 2 DSP, PA, SL, ST Harvoni 2 DSP, PA, SL Ribapak 3 DSP, E Ribavirin DSP Sovaldi 2 DSP, PA, SL, ST Technivie 4 DSP, PA, SL Viekira Pak 4 DSP, PA, SL, ST HIV/AIDS Atripla 2 DSP Complera 2 DSP Epzicom 2 DSP Evotaz 2 DSP Intelence 2 DSP Isentress 2 DSP Kaletra 2 DSP Lamivudine-Zidovudine DSP Nevirapine DSP Nevirapine Extended-Release 2 DSP Norvir 2 DSP Prezcobix 2 DSP Prezista 2 DSP Reyataz 2 DSP Stribild 3 DSP, ST Sustiva 2 DSP Tivicay 3 DSP Triumeq 2 DSP Truvada 2 DSP Tybost 2 DSP Viread 2 DSP Vitekta 2 DSP Infertility* Cetrotide 2 DSP Clomiphene DSP Gonal-F 2 DSP Gonal-F RFF 2 DSP Ovidrel 3 DSP *Coverage is determined by the consumer s prescription drug benefit plan. Inflammatory Conditions: Rheumatoid Arthritis, Crohn s Disease, Psoriasis, Ulcerative Colitis Actemra 4 DSP, PA, SL, ST Cimzia 2 DSP, PA, SL Cosentyx 4 DSP, PA, SL, ST Enbrel 4 DSP, PA, SL, ST Humira 2 DSP, PA, SL Hydroxychloroquine Sulfate Leflunomide Methotrexate Orencia 4 DSP, PA, SL, ST Otezla 4 DSP, PA, SL, ST Otrexup 4 E, SL, ST Rasuvo 4 SL, ST Simponi 2 DSP, PA, SL Stelara 2 DSP, PA, SL Xeljanz 4 DSP, PA, SL, ST Men s Health: Erectile Dysfunction Cialis 4 SL Levitra 4 SL Stendra 4 SL Viagra 4 SL 9

20 Name Men s Health: Prostate Alfuzosin Cialis 4 SL, ST Doxazosin Dutasteride Capsule 3 SDP Finasteride Rapaflo 4 Tamsulosin Capsule Terazosin Capsule, Men s Health: Testosterone Therapy Androderm 2 PA, SL Androgel 4 E, PA, SL Methyltestosterone Capsule 2 Testim 2 PA, SL Testosterone % Topical Gel 4 E, PA, SL Testosterone Cypionate Injection Miscellaneous Anastrozole Antipyrine/Benzocaine Otic Solution Aranesp 2 DSP, SL Auryxia 3 Benzonatate Capsule Bethkis 2 DSP, PA, SL Bromfed DM 3 Cayston 2 PA, SL Cerdelga 2 DSP, PA Name Chlorpheniramine/ Hydrocodone/ Pseudoephedrine Solution 2 SL Ciprodex 2 Epipen 2 SL Epipen-Jr 2 SL Fosrenol 3 Hydrocodone/ Chlorpheniramine Suspension 3 SL Hydrocodone/ Homatropine Letrozole Lidocaine Transdermal Patch 2 SL Nuedexta 2 Obredon 4 SL, ST Pegasys 2 DSP, PA, SL Phenazopyridine Procrit 2 DSP, SL Promethazine/Codeine Promethazine/ Dextromethorphan Pulmozyme 2 DSP, PA, SL Rectiv 3 PA, SL Renvela 2 Restasis 4 PA, SL Rezira 3 Tobi Podhaler 3 DSP, PA, SL Tobramycin Nebulized Solution 4 DSP, E, PA, SL Velphoro 2 Bold type = Brand-name drug [Plain type = Generic drug] DSP = Designated Specialty Program E = May be excluded from coverage H = Health Care Reform Preventive MC = Multiple Copay PA = Prior Authorization required RS = May be eligible for the Refill and Save Program SDP = Select Designated Pharmacy SL = Supply Limit ST = Step Therapy 20

21 Name Musculoskeletal: Osteoporosis Alendronate Sodium SL Forteo 2 DSP, PA Ibandronate 2 SL Raloxifene 2 Risedronate Sodium 3 SL Musculoskeletal: Other Allopurinol Baclofen Carisoprodol 350 mg Colcrys 4 E Cyclobenzaprine Metaxalone 3 Methocarbamol Mitigare 2 Tizanidine Uloric 4 SL, ST Musculoskeletal: Pain Relief Acetaminophen/ Codeine SL Celecoxib 2 SL Diclofenac Embeda 4 E, PA, SL, ST Etodolac Capsule Fentanyl 2, 25, 50, 75, 00 mcg Patch 2 SL Fentanyl 37.5, 62.5, 87.5 mcg Patch 4 E, SL Fentanyl Citrate Lozenge 2 PA, SL Hydrocodone/ Acetaminophen 5/325, 7.5/325, 0/325 mg SL Name Hydrocodone/Ibuprofen Hydromorphone Hysingla 4 E, PA, SL, ST Ibuprofen Indomethacin Capsule Ketorolac Lazanda 4 PA, SL Meloxicam Methadone, Oral Solution, SL Concentrate Solution Morphine Sulfate Extended-Release SL Morphine Sulfate Oral Solution Nabumetone Naproxen Nucynta 4 SL Nucynta ER 3 PA, SL Opana ER 2 PA, SL Oxycodone/ Acetaminophen 5/325, 7.5/325, 0/325 mg SL Oxycodone Oxycontin 4 PA, SL, ST Sprix 3 Subsys 4 E, PA, SL Tramadol- SL Acetaminophen Tramadol Sustained- Release 2 SL Tramadol Trezix 4 SL Vicodin 5/300, 7.5/300, 4 E, SL 0/300 mg Voltaren Gel 2 Zohydro ER 4 PA, SL, ST 2

22 Name Overactive Bladder Dicyclomine Oxybutynin Extended- Release 2 Oxybutynin Tolterodine Extended- Release 4 E Tolterodine 4 E Toviaz 3 Vesicare 4 E Respiratory: Allergies Azelastine 0.% Nasal Spray 3 SL Clarinex 4 E, SL Clarinex-D 3 E, SL Cyproheptadine Fluticasone Nasal Spray 2 SL Hydroxyzine Capsule, Levocetirizine SL Nasonex 4 E, SL Promethazine Qnasl 4 E, SL Triamcinolone Nasal Spray 4 E, SL Zetonna 3 SL Respiratory: Asthma/COPD Advair Diskus/HFA 3 RS, SL Aerospan 3 SL Albuterol Nebs Albuterol Sulfate Alvesco SL Name Anoro Ellipta 3 SL Arnuity Ellipta 3 SL Asmanex SL Breo Ellipta 3 RS, SL Budesonide Nebs 2 SL Combivent Respimat 3 SL Dulera 4 SL, ST Flovent Diskus/HFA 3 SL Foradil 3 SL Incruse Ellipta 2 SL Ipratropium-Albuterol Nebs Ipratropium Nebs Levalbuterol Nebs 4 E, SL Montelukast Chewable, SL Montelukast Granules 2 SL Perforomist 3 SL ProAir HFA 3 SL ProAir Respiclick 3 SL Proventil HFA 3 SL Pulmicort Flexhaler 4 SDP, SL QVAR SL Seebri Neohaler 2 SL Serevent Diskus 3 SL Spiriva Handihaler 4 SL Spiriva Respimat 4 SL Stiolto Respimat 4 E, SL Striverdi Respimat 2 SL Symbicort 3 RS, SL Tudorza 2 SL Utibron Neohaler 2 SL Ventolin HFA 2 SL Xopenex HFA 3 SL Xopenex Nebs 4 E, SL Bold type = Brand-name drug [Plain type = Generic drug] DSP = Designated Specialty Program E = May be excluded from coverage H = Health Care Reform Preventive MC = Multiple Copay PA = Prior Authorization required RS = May be eligible for the Refill and Save Program SDP = Select Designated Pharmacy SL = Supply Limit ST = Step Therapy 22

23 Name Respiratory: Pulmonary Arterial Hypertension Adcirca 4 DSP, PA, SL Adempas 2 DSP, PA, SL Letairis 2 DSP, PA, SL Opsumit 2 DSP, PA, SL Orenitram 4 DSP, PA, SL Sildenafil DSP, PA, SL Tracleer 2 DSP, PA, SL Tyvaso 2 DSP, PA Smoking Cessation Bupropion Sustained- Release H, PA Chantix 4 H, PA Nicoderm CQ 3 H, PA Nicorette Gum 3 H, PA Nicorette Lozenge 3 H, PA Nicorette Mini-Lozenge 3 H, PA Nicotine Gum H, PA Nicotine Lozenge H, PA Nicotine Patch H, PA Nicotrol Inhaler 3 H, PA Nicotrol Nasal Spray 3 H, PA Thrive Gum H, PA Transplant Azathioprine Cyclosporine Modified Capsule DSP Mycophenolate Capsule, Suspension DSP Mycophenolic Acid 2 DSP Sirolimus DSP Tacrolimus Capsule DSP Name Vitamins/Electrolytes Fluoride Folic Acid Klor-Con M0 Klor-Con M20 Potassium Chloride Potassium Citrate Women s Health: Contraceptives Apri H Aviane H Azurette 2 Cryselle H Cyclafem H Ella H Enskyce H Gildess 2 Gildess Fe H Introvale 2 H Jolessa 2 H Junel 2 Junel Fe H Levora-28 H Lo Loestrin Fe 3 Loryna 3 Low-Ogestrel H Lutera H Microgestin 2 Microgestin FE H Minastrin 24 FE 4 E Mononessa 3 Natazia H Necon 0.5/35, /35, /50, 0/ H Next Choice H 23

24 Name Norgestimate-Ethinyl Estradiol 3 Nortrel 0.5/35 H Nuvaring 2 H Orsythia H Ortho-Cyclen H Ortho Micronor H Ortho-Novum 3 Ortho-Novum 7/7/7 H Ortho Tri-Cyclen H Plan B One Step H Quasense 2 H Reclipsen H Sprintec 3 Sronyx H Tri-Lo-Estarylla 3 Tri-Lo-Marzia 3 Tri-Lo-Sprintec 3 Tri-Previfem 3 Tri-Sprintec 3 Trinessa 3 Trinessa Lo 3 Vestura 3 Viorele 2 Xulane 3 H Yasmin 28 H Yaz 2 Women s Health: Hormone Replacement Cenestin 4 E Climara 2 SL Climara Pro 3 SL Divigel 3 Duavee 3 Name Enjuvia 3 Estrace Cream 3 Estradiol/Norethindrone Acetate 2 Estradiol Estradiol Twice-Weekly Transdermal Patch 4 E, SL Estring 2 MC, SL Estrogen/ Methyltestosterone Evamist 2 Medroxyprogesterone Minivelle 3 SL Premarin 3 Premphase 3 Prempro 3 Progesterone Micronized Capsule Vagifem 2 Vivelle-Dot 2 SL Women s Health: Miscellaneous Osphena 3 Raloxifene 2 H, PA Tamoxifen H, PA Women s Health: Prenatal Vitamins Brand Prenatal Vitamins 2 3 Bold type = Brand-name drug [Plain type = Generic drug] DSP = Designated Specialty Program E = May be excluded from coverage H = Health Care Reform Preventive MC = Multiple Copay PA = Prior Authorization required RS = May be eligible for the Refill and Save Program SDP = Select Designated Pharmacy SL = Supply Limit ST = Step Therapy 24

25 Index A Abilify...4 Absorica... 5 Accu-Chek Test Strips...6 Acetaminophen/Butalbital/ Caffeine 325 mg/50 mg/ 40 mg...4 Acetaminophen/Codeine...2 Actemra...9 Acyclovir Ointment...0 Acyclovir...0 Aczone... 5 Adapalene 0.% Cream, Gel.. 5 Adapalene 0.3% Gel... 5 Adcirca Adderall XR... 3 Adempas Advair Diskus/HFA Aerospan Afrezza...6 Akynzeo...8 Albuterol Nebs Albuterol Sulfate Alendronate Sodium...2 Alfuzosin Allopurinol...2 Alphagan P 0.%...8 Alprazolam Extended-Release...4 Alprazolam...4 Alvesco Amiodarone... 2 Amitiza...8 Amitriptyline... 3 Amlodipine... Amlodipine-Benazepril... Amlodipine-Valsartan... Amoxicillin/Potassium Clavulanate Chewable,...0 Amoxicillin Capsule, Chewable...0 Amphetamine Salt Combo... 3 Ampyra...4 Anastrozole Androderm Androgel Anoro Ellipta Antipyrine/Benzocaine Otic Solution Apri Apriso...8 Aptensio XR... 3 Aranesp Aripiprazole...4 Armour Thyroid...7 Arnuity Ellipta Asacol HD...8 Asmanex Atenolol... Atenolol-Chlorthalidone... Atorvastatin... 2 Atripla...9 Aubagio...4 Auryxia Aviane Avonex...4 Azathioprine Azelastine 0.05% Ophthalmic Solution...7 Azelastine 0.% Nasal Spray Azithromycin...0 Azopt...8 Azurette B Baclofen...2 Benazepril... Benazepril- Hydrochlorothiazide... Benicar... Benicar HCT... Benzonatate Capsule Betamethasone Dipropionate 0.05% Cream, Ointment... 5 Betaseron...4 Bethamethasone Dipropionate 0.05% Augmented Lotion, Ointment... 5 Bethkis Bexarotene Capsule... Bicalutamide... Bidil... Bisoprolol... Bisoprolol- Hydrochlorothiazide... Bosulif... Brand Prenatal Vitamins Breo Ellipta Brintellix... 3 Bromfed DM Budesonide Nebs Buprenorphine/Naloxone...4 Bupropion Extended-Release... 3 Bupropion Sustained-Release...3, 23 Bupropion... 3 Buspirone...4 Bydureon...7 Byetta...7 Bystolic...

26 C Calcitriol Capsule...7 Canasa...8 Carac... 5 Carbamazepine... 5 Carbidopa-Levodopa...4 Carisoprodol 350 mg...2 Cartia XT... Carvedilol... Cayston Cefadroxil Capsule,...0 Cefdinir Capsule...0 Cefixime Suspension...0 Cefprozil...0 Cefuroxime...0 Celecoxib...2 Cenestin Cephalexin Capsule...0 Cerdelga Cetrotide...9 Chantix Chlorpheniramine/ Hydrocodone/ Pseudoephedrine Solution Chlorthalidone... Choline Fenofibrate... 2 Cialis...9, 20 Ciclopirox Cream, Gel, Lotion, Solution... 5 Cimzia...9 Ciprodex Ciprofloxacin...0 Citalopram... 3 Claravis... 5 Clarinex Clarinex-D Clarithromycin...0 Climara Climara Pro Clindamycin %/Benzoyl Peroxide 5% Gel... 5 Clindamycin.2%/Benzoyl Peroxide 5% Gel... 5 Clindamycin Capsule...0 Clindamycin Gel... 5 Clindamycin Lotion... 5 Clindamycin Solution, Swabs... 5 Clobetasol Propionate Cream, Ointment... 5 Clobetasol Propionate Solution... 5 Clomiphene...9 Clonazepam... 5 Clonidine... Clopidogrel... Clotrimazole-Betamethasone Cream... 5 Clotrimazole-Betamethasone Lotion... 5 Colcrys...2 Combigan...8 Combivent Respimat Complera...9 Concerta... 3 Condylox Gel... 5 Contour Test Strips...6 Copaxone...4 Corlanor... 2 Cortifoam...8 Cosentyx...9 Creon...8 Cresemba...0 Crestor... 2 Cryselle Cyclafem Cyclobenzaprine...2 Cyclophosphamide Capsule Cyclosporine Modified Capsule Cymbalta... 3 Cyproheptadine D Daklinza...9 Daytrana... 3 Delzicol...8 Desmopressin...7 Desonide 0.05% Cream, Lotion, Ointment... 5 Desoximetasone Gel, Ointment... 5 Dexamethasone...7 Dexcom Continuous Glucose Monitoring System...6 Dexcom Sensor...6 Dexcom Transmitter...6 Dexilant...8 Dexmethylphenidate Extended-Release Capsule... 3 Dexmethylphenidate... 3 Dextroamphetamine- Amphetamine Extended-Release... 3 Dextroamphetamine- Amphetamine... 3 Dextroamphetamine Sulfate... 3 Diazepam...4, 5 Diclofenac...2 Dicyclomine Differin % Cream, Gel... 5 Dificid...0 Diflorasone Diacetate 0.05% Cream, Ointment... 5 Digoxin... 2 Diltiazem 24 Hour CD...

27 Diltiazem Sustained-Release Capsule... Diltiazem Sustained-Release... Diphenoxylate-Atropine...8 Divalproex Delayed-Release... 5 Divalproex Extended-Release... 5 Divigel Donepezil 5, 0 mg ODT,...4 Doryx...0 Doxazosin..., 20 Doxazosin Doxepin Capsule... 3 Doxycycline Hyclate 50, 00 mg Capsule,...0 Doxycycline Monohydrate 50, 00 mg Capsule...0 Duavee Dulera Duloxetine Capsule... 3 Dutasteride Capsule Dutoprol... E Econazole Cream...0 Edarbi... Edarbyclor... Effient... Eliquis... Ella Embeda...2 Emend...8 Enalapril... Enbrel...9 Enjuvia Enoxaparin Sodium... Enskyce Entresto... 2 Epiduo... 5 Epipen Epipen-Jr Epzicom...9 Erythromycin 0.5% Ophthalmic Ointment...7 Escitalopram... 3 Esomeprazole Capsule...8 Estrace Cream Estradiol/Norethindrone Acetate Estradiol Estradiol Twice-Weekly Transdermal Patch Estring Estrogen/Methyltestosterone Eszopiclone...4 Etodolac Capsule...2 Evamist Evotaz...9 F Famciclovir...0 Farxiga...7 Fenofibrate 43, 50, 67, 30, 34, 50, 200 mg Capsule... 2 Fenofibrate 48, 45 mg... 2 Fenofibrate 54, 60 mg... 2 Fenoglide... 2 Fentanyl 2, 25, 50, 75, 00 mcg Patch...2 Fentanyl 37.5, 62.5, 87.5 mcg Patch...2 Fentanyl Citrate Lozenge...2 Fetzima... 3 Finacea Finasteride Flecainide... 2 Flovent Diskus/HFA Fluconazole...0 Fluocinolone Cream, Oil, Ointment, Solution... 5 Fluocinonide 0.05% Cream... 5 Fluoride Fluoxetine Capsule,... 3 Fluticasone Nasal Spray Fluvastatin Extended-Release... 2 Fluvoxamine... 3 Focalin XR... 3 Folic Acid Foradil Forteo...2 Fosrenol FreeStyle Test Strips...6 Furosemide... G Gabapentin Capsule,... 5 Gemfibrozil... 2 Gentamicin Ophthalmic Ointment, Solution...7 Gildess Gildess Fe Gilenya...4 Glatopa...4 Gleevec... Glimepiride...7 Glipizide...7 Glipizide Extended-Release...7 Glyburide...7 Glyxambi...7 Golytely...8 Gonal-F...9 Gonal-F RFF...9 Guanfacine..., 3

28 Guanfacine Extended-Release... 3 H Halobetasol Ointment... 5 Harvoni...9 Humalog KwikPen...6 Humalog Mix KwikPen...6 Humalog Mix KwikPen...6 Humalog Vials...6 Humira...9 Humulin KwikPen...6 Humulin Vials...6 Humulin N KwikPen...6 Humulin N Vials...6 Humulin R Vials...6 Hydralazine... Hydrochlorothiazide... Hydrocodone/Acetaminophen 5/325, 7.5/325, 0/325 mg...2 Hydrocodone/ Chlorpheniramine Suspension Hydrocodone/Homatropine Hydrocodone/Ibuprofen...2 Hydrocortisone 2.5% Cream, Ointment... 5 Hydromorphone...2 Hydroxychloroquine Sulfate...9 Hydroxyurea Capsule... Hydroxyzine Capsule,. 22 Hyoscyamine...8 Hysingla...2 I Ibandronate...2 Ibuprofen...2 Imatnib... Imbruvica... Imiquimod 5% Cream... 5 Incruse Ellipta Indomethacin Capsule...2 Intelence...9 Introvale Invokamet...7 Invokana...7 Ipratropium-Albuterol Nebs Ipratropium Nebs Irbesartan... Isentress...9 Isosorbide Mononitrate ER... 2 Itraconazole Capsule...0 J Janumet...7 Januvia...7 Jardiance...7 Jentadueto...7 Jolessa Junel Junel Fe K Kaletra...9 Kazano...7 Ketoconazole Cream...0 Ketorolac...2 Klor-Con M Klor-Con M Kombiglyze XR...7 L Labetalol... Lamivudine-Zidovudine...9 Lamotrigine... 5 Lansoprazole Capsules...8 Lantus Solostar Lantus Vials...6 Lastacaft...7 Latanoprost 0.005% Ophthalmic Solution...8 Latuda...4 Lazanda...2 Leflunomide...9 Lescol XL... 2 Letairis Letrozole Leucovorin Calcium... Levalbuterol Nebs Levemir FlexTouch...6 Levemir Vials...6 Levetiracetam Extended-Release... 5 Levetiracetam... 5 Levitra...9 Levocetirizine Levofloxacin...0 Levora Levothyroxine Sodium...7 Lexapro... 3 Lialda...8 Lidocaine Transdermal Patch Linzess...8 Liothyronine Sodium...7 Lipitor... 2 Lipofen... 2 Lisinopril..., 34 Lisinopril- Hydrochlorothiazide... Lithium Capsule...4 Livalo... 2 Lo Loestrin Fe Lorazepam...4 Loryna Losartan...

29 Losartan- Hydrochlorothiazide... Lovastatin... 2 Low-Ogestrel Lumigan...8 Lutera Lyrica... 5 M Medroxyprogesterone Meloxicam...2 Memantine...4 Mercaptopurine... Metadate CD... 3 Metaxalone...2 Metformin...7 Metformin Extended-Release (generic Glucophage XR)...7 Methadone, Oral Solution, Concentrate Solution...2 Methimazole...7 Methocarbamol...2 Methotrexate...9 Methylphenidate Chewable... 3 Methylphenidate Extended-Release Capsule... 3 Methylphenidate Extended-Release... 3 Methylphenidate... 3 Methylprednisolone...7 Methyltestosterone Capsule Metoclopramide...8 Metoprolol Succinate 50, 00, 200 mg... Metoprolol Tartrate... Metronidazole 0.75% Topical Gel... 5 Metronidazole...0 Microgestin Microgestin FE Minastrin 24 FE Minivelle Minocycline Capsule...0 Minocycline...0 Mirtazapine... 3 Mirvaso... 5 Mitigare...2 Modafinil...4 Mometasone Furoate Cream, Lotion, Ointment... 5 Mononessa Montelukast Chewable, Montelukast Granules Morphine Sulfate Extended-Release...2 Morphine Sulfate Oral Solution...2 Movantik...8 Moviprep...8 Moxeza...7 Moxifloxacin...0 Mupirocin Ointment... 5 Mycophenolate Capsule, Suspension Mycophenolic Acid N Nabumetone...2 Nadolol... Namenda XR...4 Naproxen...2 Naratriptan...4 Nasonex Natazia Necon 0.5/35, /35, /50, 0/ Nesina...7 Nevirapine...9 Nevirapine Extended-Release...9 Nexium Capsule...8 Next Choice Niacin Extended-Release... 2 Niaspan... 2 Nicoderm CQ Nicorette Gum Nicorette Lozenge Nicorette Mini-Lozenge Nicotine Gum Nicotine Lozenge Nicotine Patch Nicotrol Inhaler Nicotrol Nasal Spray Nifedipine Extended-Release... Nitrofurantoin Capsule...0 Nitrofurantoin Macrocrystal Capsule...0 Nitrostat... 2 Norgestimate-Ethinyl Estradiol Nortrel 0.5/ Nortriptyline Capsule... 3 Norvir...9 Novolin Vials...6 Novolin N Vials...6 Novolin R Vials...6 Novolog FlexTouch...6 Novolog Mix 70/30 FlexTouch...6 Novolog Mix 70/30 Vials...6 Novolog Vials...6 Noxafil, Suspension...0

30 NP Thyroid...7 Nucynta...2 Nucynta ER...2 Nuedexta Nutropin, Nutropin AQ...7 Nuvaring Nuvigil...4 Nystatin-Triamcinolone Acetonide Cream, Ointment... 5 Nystatin Cream, Ointment...0 O Obredon Ofloxacin 0.3% Ophthalmic Solution...7 Ofloxacin s...0 Olanzapine...4 Olopatadine 0.% Ophthalmic Solution...7 Omeclamox-Pak...8 Omega-3-Acid Ethyl Esters Capsule... 2 Omeprazole Capsule...8 Ondansetron...8 Ondansetron ODT...8 OneTouch Test Strips...6 OneTouch Ultra Meter...6 OneTouch Ultra Mini...6 OneTouch Ultra Test Strips...6 OneTouch Verio...6 OneTouch Verio IQ...6 OneTouch Verio Sync...6 OneTouch Verio Test Strips...6 Onglyza...7 Opana ER...2 Opsumit Oracea...0 Orencia...9 Orenitram Orsythia Ortho-Cyclen Ortho-Novum Ortho-Novum 7/7/ Ortho Micronor Ortho Tri-Cyclen Oseni...7 Osphena Otezla...9 Otrexup...9 Ovidrel...9 Oxcarbazepine... 5 Oxsoralen-Ul... 5 Oxybutynin Extended-Release Oxybutynin Oxycodone/Acetaminophen 5/325, 7.5/325, 0/325 mg...2 Oxycodone...2 Oxycontin...2 P Pantoprazole...8 Paroxetine... 3 Pataday...7 Pegasys Penicillin V Potassium...0 Perforomist Phenazopyridine Phenytoin Capsule, Suspension... 5 Picato...6 Pioglitazone...7 Plan B One Step Polyethylene Glycol Potassium Chloride Potassium Citrate Pradaxa... Praluent... 2 Pramipexole Pravastatin... 2 Prednisone...7 Premarin Premphase Prempro Prenisolone Oral Solution...7 Prepopik...8 Prezcobix...9 Prezista...9 Pristiq ER... 3 ProAir HFA ProAir Respiclick Procrit Progesterone Micronized Capsule Promethazine/Codeine Promethazine/ Dextromethorphan Promethazine Propranolol Extended-Release Capsule... Propranolol... 2 Proventil HFA Pulmicort Flexhaler Pulmozyme Pylera...8 Q Qnasl Quasense Quetiapine...4 Quinapril... 2 QVAR R Rabeprazole...8 Raloxifene...2, 24 Raloxifene...2 Ramipril... 2 Ranexa... 2 Ranitadine Syrup...8

31 Rapaflo Rasuvo...9 Rebif...4 Reclipsen Rectiv Regranex...6 Relpax...4 Renvela Repatha... 2 Restasis Revlimid... Reyataz...9 Rezira Ribapak...9 Ribavirin...9 Risedronate Sodium...2 Risperidone...4 Rizatriptan ODT,...4 Ropinirole...4 S Savaysa... Seebri Neohaler Serevent Diskus Seroquel XR...4 Sertraline... 3 Sildenafil Simcor... 2 Simponi...9 Simvastatin... 2 Sirolimus Solodyn...0 Sotalol... 2 Sovaldi...9 Spiriva Handihaler Spiriva Respimat Spironolactone... 2 Sprintec Sprix...2 Sronyx Stelara...9 Stendra...9 Stiolto Respimat Strattera... 3 Stribild...9 Striverdi Respimat Suboxone Film...4 Subsys...2 Suclear...8 Sucralfate...8 Sulfamethoxazole- Trimethoprim...0 Sulfasalazine...8 Sumatriptan Nasal Spray...4 Sumatriptan Succinate, Injection...4 Sumavel DosePro...4 Suprax Capsule, Chewable,...0 Suprep...8 Sustiva...9 Sutent... Symbicort Synthroid...7 T Tacrolimus Capsule Tacrolimus Ointment...6 Tamiflu...0 Tamoxifen Tamsulosin Capsule Tanzeum...7 Targretin Capsule... Targretin Gel... Tasigna... Tazorac...6 Tecfidera...4 Technivie...9 Telmisartan... 2 Telmisartan- Hydrochlorothiazide... 2 Temazepam Capsule Terazosin... 2, 20 Terazosin Capsule, Terbinafine...0 Testim Testosterone % Topical Gel Testosterone Cypionate Injection Thrive Gum Timolol Maleate 0.25%, 0.5% Ophthalmic Solution...8 Tirosint...7 Tivicay...9 Tizanidine...2 Tobi Podhaler Tobramycin/Dexamethasone 0.3%-0.% Ophthalmic Suspension...8 Tobramycin Nebulized Solution Tobramycin Ophthalmic Solution...8 Tolcapone...4 Tolterodine Extended-Release Tolterodine Topiramate... 5 Toujeo SoloStar...6 Toviaz Tracleer Tradjenta...7 Tramadol-Acetaminophen...2 Tramadol Sustained-Release...2 Tramadol...2 Transderm-Scop...8 Travatan Z...8 Trazodone... 3 Tretinoin...6 Tretinoin Microspheres...6

32 Trezix...2 Tri-Lo-Estarylla Tri-Lo-Marzia Tri-Lo-Sprintec Tri-Previfem Tri-Sprintec Triamcinolone Acetonide Cream, Lotion, Ointment...6 Triamcinolone Nasal Spray Triamterene- Hydrochlorothiazide... 2 Triazolam...4 Tricor 48, 45 mg... 2 Trinessa Trinessa Lo Triumeq...9 Trulicity...7 Truvada...9 Tudorza Tybost...9 Tyvaso U Uceris...8 Uloric...2 Utibron Neohaler V Vagifem Valacyclovir...0 Valaganciclovir...0 Valsartan... 2 Valsartan- Hydrochlorothiazide... 2 Vascepa... 2 Vectical...6 Velphoro Venlafaxine Extended-Release Capsule... 3 Venlafaxine... 3 Ventolin HFA Verapamil... 2 Verapamil Sustained-Release.. 2 Vesicare Vestura Viagra...9 Vicodin 5/300, 7.5/300, 0/300 mg...2 Victoza 2-Pak...7 Victoza 3-Pak...7 Viekira Pak...9 Vigamox...8 Viibryd... 3 Viorele Viread...9 Vitekta...9 Vivelle-Dot Voltaren Gel...2 Vytorin... 2 Vyvanse... 3 W Warfarin Sodium... Welchol... 2 X Xarelto... Xeljanz...9 Xeloda... Xigduo XR...7 Xopenex HFA Xopenex Nebs Xulane Xyrem...4 Y Yasmin Yaz Z Zaleplon Capsule...4 Zelapar...4 Zenpep...8 Zetia... 2 Zetonna Ziprasidone Capsule...4 Zohydro ER...2 Zolpidem Extended-Release...4 Zolpidem...4 Zonisamide Capsule... 5 Zovirax Cream...0 Zubsolv...4 Zytiga... 32

33 Notes 33

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 I Take This Medicine For Directions Doctor Example: Lisinopril, 20 mg High blood pressure One tablet daily Dr. Johnson 34

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36 For more information Call the toll-free member phone number on 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. 206 United HealthCare Services, Inc. All rights reserved. Created February, Prescription List Advantage Four /6