Your Sutter Health Plus 2015 Prescription Drug List* Prepared by OptumRx for Sutter Health Plus Members

Transcription

1 Your Sutter Health Plus 05 Prescription List* Prepared by OptumRx for Sutter Health Plus Members Please read: This document contains information about your Sutter Health Plus pharmacy benefit. * This is not a complete list of medications covered under your Sutter Health Plus (SHP) pharmacy benefit. For a complete list of covered drugs or if you have questions about the information contained in this Prescription List: Please call OptumRx at: You may also visit optumrx.com to: View the complete Sutter Health Plus formulary. Locate a participating retail pharmacy by ZIP code. Look up possible lower-cost medication alternatives. Compare medication pricing and options. OptumRx optumrx.com

2 Your Prescription List This Prescription List (PDL) outlines the most commonly prescribed medications from Sutter Health Plus complete pharmacy benefit coverage list, also known as a formulary. A formulary identifies the drugs available for certain conditions and organizes them into cost levels, or tiers. An important purpose of this PDL is to help you understand your choices so you and your doctor can discuss and agree on the best course of treatment for you. Log in to optumrx.com for complete and up-to-date drug information. This PDL may change, and we encourage you to visit the OptumRx website at optumrx.com to view the updated PDL. The website is the best source for up-to-date information about all of the medications your pharmacy benefit covers, including valuable information to help you: Look up possible lower-cost options. Review medication copayment tiers. Compare medication pricing and options. Learn more about which medications require prior authorization, have quantity limits or are considered specialty medications. John Smith John Smith John Smith

3 Table of Contents tiers and cost Preventive Care Medications... 5 Processes and limitations... 8 s by category... 0 Anti-Infectives Antibiotics... 0 Antifungals... 0 Antivirals Cancer... 0 Cardiovascular/Heart Disease Anticoagulants High Blood Pressure... High Cholesterol... Other.... Pulmonary Arterial Hypertension... Central Nervous System Attention Deficit Disorder... Depression.... Migraine... Multiple Sclerosis... 3 Other Sedatives/Hypnotics... 3 Seizure Disorders... 3 Dermatology... 4 Diabetes/Endocrine Blood Glucose Monitoring-Devices Blood Glucose Monitoring-Lancets and Needles4 Blood Glucose Monitoring-Solutions... 4 Blood Glucose Monitoring-Test Strips Insulin... 5 Non-Insulin... 5 Diabetic Meters... 6 Diabetes Solutions & Aids... 6 Endocrine Other Thyroid Hormone Replacement... 6 Eye Conditions Allergies Antibiotics... 6 Glaucoma... 6 Other Gastrointestinal Acid Suppression... 7 Nausea/Vomiting... 7 Other HIV/AIDS... 7 Inflammatory Conditions... 7 Men s Health Erectile Dysfunction... 8 Prostate... 8 Testosterone Therapy... 8 Miscellaneous... 8 Musculoskeletal Osteoporosis... 8 Other Pain Relief... 9 Overactive Bladder... 9 Respiratory Asthma/COPD... 9 Nasal Allergies... 0 Oral Allergies... 0 Smoking Cessation... 0 Transplant... 0 Vitamins/Electrolytes... 0 Women s Health Contraceptives Hormone Replacement... Prenatal Vitamins... Vaginal Anti-Infectives... Index... My Medications Worksheet

4 At OptumRx and Sutter Health Plus, 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 provide in this section the answers to 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 selected from the Sutter Health Plus complete formulary for their safety, cost and effectiveness. The formulary and this PDL include both brand and generic prescription medications approved by the U.S. Food and Administration (FDA). The formulary and this PDL are available on line through an interactive search tool that enables you to search by specific drug name, or to browse by generic name, brand name, therapeutic classification or cost tier. Please note: If there are differences between this PDL and your Evidence of Coverage (EOC), the EOC is the controlling description of your pharmacy coverage, and the limitations and exclusions that apply to your pharmacy coverage. This PDL is not a complete list of medications. You may log in to optumrx.com or call OptumRx at for a complete list of all medications covered. There may be times when the PDL and OptumRx online formulary tool vary. In such cases, the online drug formulary takes precedence. How do I use my Prescription List? We encourage you to bring this PDL with you when you see your provider. It will help you and your provider discuss and choose the most cost-effective prescription drugs. This guide tells you if a medication is generic or brand, which affects costs. It also indicates whether you must first follow any special processes or rules to receive a particular medication. This printed version of the PDL is organized by common medical conditions. Within each condition category, medications are then listed alphabetically. If your medication is not listed in this PDL, it will still be covered if it is in the Sutter Health Plus formulary, which you can find at optumrx.com. You may also call toll-free to OptumRx at or Sutter Health Plus Member Services at if you have questions regarding your pharmacy benefit. 4

5 What are tiers? s are the different cost levels you pay for a medication. Each tier is assigned a member cost share. This is how much you will pay when you fill a prescription. medications are generics, and are your lowest-cost options. medications are preferred brand name drugs and have the second lowest cost share. If your medication is in or 3, look to see if there is a option available. Discuss these options with your provider. If your medication is a specialty medication, used to treat rare or complex medical disorders, a percent-of-cost coinsurance applies. All preventive care medication categories have products that are covered with $0 copay. Preventive Care Medications SHP covers the following at zero cost share when prescribed by a participating Provider and obtained at a network pharmacy: Prenatal vitamins for pregnant members Vitamin D for members age 60 and older Vitamins in conjunction with fluoride Folic acid for women considering pregnancy Iron supplementation for infants between ages 6 to months Aspirin for members age 45 and older Select birth control products, FDA-approved contraceptive drugs and devices Select smoking cessation products Breast cancer medications raloxifene or tamoxifen for women age 35 and older and at increased risk for the first occurrence of breast cancer, after risk assessment and counseling Influenza (flu) vaccine 5

6 Understanding the PDL The list of prescription medications starts on page 9. names shown in orange are preferred options in this category for their cost and effectiveness. A symbol in the column indicates a specialty medication. Please call OptumRx at to find out the cost of the drug for purposes of calculating your specific cost share. Important note: costs change frequently. If you are subject to a percent-of-cost coinsurance or deductible, confirm your cost share by calling your pharmacy or OptumRx before you pick up your prescription. $ Includes Helpful Tips $ $ Lowest Cost Generic medications Use drugs for the lowest out-ofpocket costs. $$ $$$ Mid-range Cost Preferred brand-name medications Use drugs, instead of 3 to help reduce your out-of-pocket costs. $$$$ $$$ $$$$$ 3 Highest Cost 4 Specialty Medications Non-preferred brand-name medications High-cost medications that may require special handling. Includes both injectable and oral medications. Many 3 drugs have lower-cost and equally effective alternatives in or. Ask your provider if they could work for you. Specialty medications are limited to a 30-day supply, so make sure to get your refill on time to continue your medication. Please read your Benefit Summary Chart and your EOC carefully to understand the cost share exceptions to the four tiers described above. Examples include erectile dysfunction and infertility drugs, which are subject to 50 percent coinsurance. Maintenance Medications Maintenance medications are drugs that are usually prescribed for long-term use and which do not require frequent dosage adjustments, such as birth control. They include medications prescribed for a chronic condition like diabetes or high blood pressure. These drugs are usually taken longer than 60 days. 6

7 OptumRx Mail Service Pharmacy OptumRx Mail Service Pharmacy is an optional service for your convenience and cost savings. If you use this service for your maintenance medications, you can get a three-month supply for the same cost share amount as two months supply at a retail pharmacy. It s convenient since your prescription is delivered right to your home or office. Please note that specialty medications are dispensed in a maximum 30-day supply at a time. So these are not eligible for the cost share reductions. OptumRx Specialty Pharmacy OptumRx 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. Please note that use of OptumRx Specialty Pharmacy services is not mandatory, but is available for your convenience. Deductibles If your plan has a deductible, you must first satisfy the applicable deductible (pay the full cost of the drug) before the tier cost levels become effective, unless an exception applies. Please see your Health Plan Benefits and Coverage Matrix in your EOC for specific information about your cost share for pharmacy benefits, and any applicable cost share exceptions. You may also call Sutter Health Plus Member Services toll free at for more information about your benefit plan. When does the Sutter Health Plus formulary and this Prescription List change? The OptumRx National Pharmacy and Therapeutics Committee and the Sutter Health Plus Pharmacy and Therapeutics Committee evaluate new drugs on a regular basis (at least four times per year), to determine if any changes should be made to the Sutter Health Plus formulary, to ensure rational and cost-effective use of pharmaceutical agents. Physicians may request that the Sutter Health Plus committees consider modifications to guidelines, process requirements or limitations imposed on a certain drug. The OptumRx and Sutter Health Plus committees review all medications for efficacy, quality, safety, and alternatives. They also review the cost of a drug in determining its placement in a, and the processes and limitations that will be imposed on the drug. Please note: 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 on January or July of each year. 7

8 Your pharmacy benefits, including tiers and restrictions, are based on plan year. During your plan year, any changes to the PDL that benefit you, such as moving a medication to a lower tier for lower cost share, take effect right away. Most PDL changes that increase cost share or impose new limits or processes on a medication you take do not affect you until the start of your next plan year. Note, however, that when a generic version of a brand name medication becomes available, the generic is at a lower tier. If you choose to continue taking the brand name product instead of the generic, you are responsible for the increased cost sharing. For the most up-to-date formulary and PDL, call OptumRx toll-free at Processes and Limitations Some medications are subject to process requirements and limitations, which are identified by the letters and symbols explained in the chart below. Your EOC explains the details of those process requirements and limitations, and how you can request exceptions to the process requirements or limitations. PA ST QL AR SP GR Prior Authorization Your provider is required to provide additional information to determine coverage. Step Therapy Trial of a lower cost or more clinically-appropriate medication is required before a higher-cost medication is covered. Discuss with your provider some exceptions are allowed when medically necessary or when indicated to meet continuity of care requirements. Quantity Limits Amount of medication covered per copayment or in a specific time period. Age Restrictions Some restrictions may apply based on patient age. Specialty Medication Medication is designated as a specialty pharmacy drug. Members receiving specialty medications are encouraged to participate in OptumRx Specialty Pharmacy Programs. Gender Restrictions Review may be required because this medication is specifically designed for female or male use. To learn more about a pharmacy benefit process requirement or limitation, or to find out if it applies to you, please visit optumrx.com or call toll-free to OptumRx at or SHP Member Services at

9 What is the difference between brand name and generic medications? Generic medications contain the same active ingredients (what makes the medication work) as brand name medications, but they often cost less. Once the patent of a brand name medication ends, the FDA can approve a generic version with the same active ingredients. These types of medications are known as generic medications. Sometimes, the same company that makes a brand name medication also makes the generic version. Is it a generic or brand name drug? The drug list shows brand name drugs in bold type (for example, Coumadin) and generic drugs in plain type (for example, Warfarin). Are you taking a specialty medication? 4 is for specialty medications that treat rare or complex conditions and are typically higher-cost medications. Please note, not all specialty medications are listed in the PDL. You may also log in to optumrx.com or call OptumRx toll-free at for a complete list of all medications covered. OptumRx 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. How do I get updated information about my pharmacy benefit? Since the PDL may change during your plan year, we encourage you to visit optumrx.com or call OptumRx toll-free at for more current information. When you register at optumrx.com and open an account, you can use the website s helpful tools and features to: Look up the price of drugs covered by your plan Find lower-cost options Refill and renew mail service prescriptions View your order status and claims history Sign up for text reminders to take and refill your medicine View your benefits in real time Order medical supplies Shop for health and wellness products More Information If you have additional questions please call OptumRx or Sutter Health Plus Member Services, 4/7 at or visit optumrx.com. 9

10 Name Name Anti-Infectives: Antibiotics Amoxicillin Amoxicillin/Clavulanate Azithromycin Bethkis SP Cefdinir Cefuroxime Tab Cephalexin Ciprodex Otic Suspension 3 Ciprofloxacin Tab Clarithromycin Clindamycin Cap Dificid 3 PA Doxycycline Hyclate Cap Doxycycline Hyclate Tab (immediate release) Doxycycline QL Monohydrate Cap Levofloxacin Tab Metronidazole Tab Minocycline Cap Neomycin/Polymyxin/ HC Otic Suspension, Solution Nitrofurantoin Macrocrystalline Nitrofurantoin Monohydrate Macrocrystalline Ofloxacin Otic Solution Oracea 3 QL Penicillin VK Solodyn 3 QL Sulfamethoxazole- Trimethoprim Sulfamethoxazole- Trimethoprim DS Anti-Infectives: Antifungals Fluconazole Nystatin Suspension Terbinafine Tab Anti-Infectives: Antivirals Acyclovir Tab, Cap, Suspension Baraclude QL, SP Famciclovir Tab Olysio PA, QL, SP Pegasys PA, SP Sovaldi PA, QL, SP Tamiflu 3 QL Valacyclovir Cancer Anastrozole Gleevec PA, QL, SP Letrozole PA Revlimid PA, QL, SP Tamoxifen Tab PC; may be PC if meets PA criteria Tasigna PA, QL, SP Zytiga PA, SP Cardiovascular/Heart Disease: Anticoagulants Aggrenox QL Aspirin (RX only) PC Brilinta QL Clopidogrel QL Coumadin 3 Effient QL Enoxaparin Pradaxa QL Warfarin Xarelto QL [Plain type = Generic drug] Call customer service for pricing AR Age Restrictions GR Gender Restrictions PA Prior Authorization PC Preventive Care QL Quantity Limits SP Specialty Medication ST Step Therapy 0

11 Name Cardiovascular/Heart Disease: High Blood Pressure Amlodipine QL Amlodipine/Benazepril QL Atenolol Atenolol/Chlorthalidone Azor QL, ST Benazepril Benazepril/HCTZ Benicar QL, ST Benicar HCT QL, ST Bisoprolol Bisoprolol/HCTZ Bumetanide Bystolic QL Cartia XT QL Carvedilol Chlorthalidone Clonidine Tab Coreg CR 3 QL, ST Diovan 3 QL, ST Doxazosin Dutoprol QL Edarbi 3 QL, ST Edarbyclor 3 QL, ST Enalapril Exforge QL, ST Exforge HCT QL, ST Felodipine QL Fosinopril Furosemide Guanfacine Tab Hydralazine Hydrochlorothiazide Irbesartan QL Irbesartan/HCTZ QL Labetalol Lisinopril Lisinopril/HCTZ Losartan QL Losartan/HCTZ QL Metoprolol Succinate Metoprolol Tartrate Name Micardis HCT QL, ST Nadolol Nifedipine ER Propranolol Propranolol ER Quinapril Ramipril QL Spironolactone Tarka Tekturna QL, ST Tekturna HCT QL, ST Telmisartan QL Terazosin Torsemide Tab Triamterene/HCTZ Tribenzor QL, ST Valsartan QL Valsartan/HCTZ QL Verapamil ER Cardiovascular/Heart Disease: High Cholesterol Atorvastatin QL Crestor QL Fenofibrate QL Gemfibrozil QL Lipitor 3 QL, ST Lipofen 3 QL Livalo 3 QL, ST Lovastatin Lovaza 3 QL Niacin ER Tab QL Omega-3 Acid Cap gm QL Pravastatin Simcor QL Simvastatin QL Simvastatin 80 mg PA, QL Vascepa QL Vytorin QL Vytorin Tab 0-80 mg PA, QL Welchol QL Zetia 3 QL [Plain type = Generic drug] Call customer service for pricing AR Age Restrictions GR Gender Restrictions PA Prior Authorization PC Preventive Care QL Quantity Limits SP Specialty Medication ST Step Therapy

12 Name Name Cardiovascular/Heart Disease: Other Amiodarone Amlodipine/Atorvastatin QL Digoxin Flecainide Isosorbide Mononitrate Nitrostat Ranexa ST Sotalol Cardiovascular/Heart Disease: Pulmonary Arterial Hypertension Adcirca PA, QL, SP Letairis PA, QL, SP Opsumit PA, QL, SP Sildenafil Tab 0 mg PA, QL, SP Tracleer PA, QL, SP Central Nervous System: Attention Deficit Disorder Amphetamine- Dextroamphetamine QL, AR Amphetamine- Dextroamphetamine QL, AR Cap SR 4HR Dexmethylphenidate ER 3 QL, AR Focalin XR 3 QL, ST, AR Intuniv QL, AR Methylphenidate Cap ER QL, AR Methylphenidate Tab ER QL, AR Methylphenidate HCL Tab Sa Osm ER QL, AR Methylphenidate Tab QL, AR Strattera QL, AR Vyvanse QL, AR Central Nervous System: Depression Amitriptyline Budeprion XL QL Bupropion SR Citalopram QL Cymbalta 3 QL Doxepin Duloxetine Cap QL Escitalopram Tab QL Fluoxetine Cap (Not PMDD) Forfivo XL QL Mirtazapine Nortriptyline Paroxetine Pristiq QL Sertraline Trazodone Venlafaxine Venlafaxine ER Cap QL Viibryd 3 QL, ST Central Nervous System: Migraine Butalbital- Acetaminophen- QL Caffeine Tab Migranal 3 QL Phrenilin 3 QL Relpax 3 QL Rizatriptan Tab, ODT QL Sumatriptan Tab and Spray QL Sumavel Dose 3 QL Zomig Nasal Spray QL [Plain type = Generic drug] Call customer service for pricing AR Age Restrictions GR Gender Restrictions PA Prior Authorization PC Preventive Care QL Quantity Limits SP Specialty Medication ST Step Therapy

13 Name Central Nervous System: Multiple Sclerosis Ampyra PA, QL, SP Avonex Kit PA, QL, SP Avonex Pen Kit PA, QL, SP Avonex Prefill Kit PA, QL, SP Betaseron PA, QL, SP Copaxone PA, QL, SP Gilenya* PA, QL, ST, SP Rebif PA, QL, ST, SP Rebif Titrtn PA, QL, ST, SP Tecfidera PA, QL, SP Central Nervous System: Other Abilify QL Abilify Disc QL Abilify Solution QL Alprazolam Tab QL Benztropine Buspirone Carbidopa/Levodopa Tab Diazepam Tab Donepezil Tab QL Hydroxyzine HCl Hydroxyzine Pamoate Lithium Carbonate Lorazepam Tab QL Modafinil PA, QL Namenda Tab QL Namenda XR QL Olanzapine Tab QL Pramipexole Prochlorperazine Quetiapine QL Risperidone Tab QL Ropinirole Saphris QL Seroquel XR QL Zelapar 3 Ziprasidone Cap QL Name Central Nervous System: Sedatives/Hypnotics Ezopiclone Tab QL Lunesta 3 QL Silenor 3 QL Temazepam QL Triazolam Tab QL Zolpidem QL Zolpidem ER QL Central Nervous System: Seizure Disorders Carbamazepine Tab Clonazepam QL Divalproex DR Divalproex ER Gabapentin Lamictal Lamictal ODT Lamictal XR 3 QL Lamotrigine Lamotrigine ER QL Levetiracetam Levetiracetam ER QL Lyrica Cap QL Onfi PA, SP Oxcarbazepine Phenytoin Topiramate Tab * 3 Preferred (over other 3 agents) AR Age Restrictions [Plain type = Generic drug] GR Gender Restrictions Call customer service for pricing PA Prior Authorization PC Preventive Care QL Quantity Limits SP Specialty Medication ST Step Therapy 3

14 Name Dermatology Acanya Gel 3 QL Acyclovir Ointment 5% Aczone Gel 3 Atralin QL, AR Benzaclin 3 QL Carac Clindamycin Gel, Lotion, Solution Clindamycin/Benzoyl Peroxide Gel -5% QL Clobetasol Cream, Gel, Ointment Clobex 3 Cloderm 3 Clotrimazole/ Betamethasone Cream, Lotion Condylox 3 Desonide Differin 3 QL Econazole Cream Elidel QL, ST, AR Epiduo 3 QL Finacea Fluocinonide Cream, Gel, Ointment 0.05% Hydrocortisone Cream.5% Ketoconazole Cream/ Shampoo Metrogel 3 Metronidazole Gel 0.75% Mometasone Mupirocin QL Nystatin Cream, Ointment, Powder Nystatin/Triamcinolone Cream, Ointment Name Oxsoralen-Ul PA Permethrin Cream 5% Protopic Ointment QL, ST, AR Retin-A Micro 3 QL, AR Silver Sulfadiazine Cream % Taclonex 3 QL Tretinoin Microsphere Gel QL, AR Triamcinolone Vectical 3 Zovirax Cream Zovirax Ointment 3 Zyclara 3 QL Diabetes/Endocrine: Blood Glucose Monitoring-Devices Accu-Chek Kit Aviva Plus Novofine 3 Novofine Auto 3 Novotwist 3 Softclix Lan Mis Device 3 Diabetes/Endocrine: Blood Glucose Monitoring-Lancets and Needles Accu-Chek Multiclix Lancets Fastclix Lancets Insulin Pen Needle Insulin Syringe/ Needle Soft Touch Lancets Softclix Lancets Diabetes/Endocrine: Blood Glucose Monitoring-Solutions Accu-Chek Act/Gluc Calibration Liquid 3 Accu-Chek Cpt/Gluc Calibration Liquid 3 Accu-Chek Smart Calibration Liquid 3 [Plain type = Generic drug] Call customer service for pricing AR Age Restrictions GR Gender Restrictions PA Prior Authorization PC Preventive Care QL Quantity Limits SP Specialty Medication ST Step Therapy 4

15 Name Accu-Chek Sol Calibration Liquid 3 Accu-Chek Sol Comfort 3 Calibration Liquid Diabetes/Endocrine: Blood Glucose Monitoring-Test Strips Accu-Chek Aviva Plus Test Strips QL Accu-Chek Aviva Test Strips QL Accu-Chek Comfort Test Strips QL Accu-Chek Drum Test Strips QL Accu-Chek Kit Compact Accu-Chek Kit Fastclix Accu-Chek Kit Multiclix Accu-Chek Kit Nano Accu-Chek Kit Softclix Accu-Chek Smart Test Strips QL Glucocard Test Strips Onetouch Kit Ultra Onetouch Kit Ultra Onetouch Kit Ultra Mini Onetouch Kit Ultra Smart Onetouch Kit Verio IQ Onetouch Test Strips QL Onetouch Ultra Blue Test Strips QL Onetouch Verio Test Strips QL Onetouch Verio IQ Test Strips QL Surestep Test Strips QL Truetrack Test Strips 3 QL Name Diabetes/Endocrine: Insulin Humalog Vials Humalog Kwik Humalog Mix 50/50 Kwik Pen Humalog Mix 50/50 Vials Humalog Mix 75/5 Kwik Pen Humalog Mix 75/5 Vials Humulin 70/30 Vials Humulin N Vials Humulin N Pen Humulin Pen 70/30 Humulin R U-500 Humulin R Vials Lantus Solostar Lantus Vials Levemir Flexpen Levemir Vials Novolin 70/30 Vials Novolin N Vials Novolin R Vials Novolog Flexpen Novolog Mix Flexpen Novolog Mix 70/30 Vials Novolog Penfill Novolog Vials Diabetes/Endocrine: Non-Insulin Byetta QL, ST Glimepiride Glipizide Glipizide ER Glipizide XL Glyburide Glyburide/Metformin Invokamet QL, ST Invokana QL, ST [Plain type = Generic drug] Call customer service for pricing AR Age Restrictions GR Gender Restrictions PA Prior Authorization PC Preventive Care QL Quantity Limits SP Specialty Medication ST Step Therapy 5

16 Name Janumet QL, ST Janumet XR QL, ST Januvia QL, ST Jentadueto QL, ST Kombiglyze QL, ST Metformin Metformin ER Onglyza QL, ST Pioglitazone QL Prandimet 3 QL, ST Prandin 3 QL, ST Repaglinide QL Tradjenta QL, ST Victoza 3 QL, ST Diabetic Meters Accu-Chek Diabetic Meters Glucocard Diabetic Meters One Touch Diabetic Meters Diabetes Solutions & Aids Magni-guide Device Endocrine: Growth Hormone Nutropin PA, SP Nutropin AQ PA, SP Saizen PA, SP Tev-Tropin PA, SP Endocrine: Other Calcitriol Dexamethasone Tab Lupron Depot 3.75 mg,.5 mg Lupron Depot 7.5 mg,.5 mg, 30 mg, 45 mg Methylprednisolone PA, SP PA, SP Name Prednisolone Solution (5 mg/5 ml and 5 mg/5 ml) Prednisone Sensipar SP Endocrine: Thyroid Hormone Replacement Armour Thyroid 3 Levothyroxine Liothyronine Methimazole Synthroid 3 Eye Conditions: Allergies Azelastine Pataday Patanol QL Eye Conditions: Antibiotics Ciprofloxacin QL Erythromycin Ointment Gentamicin Moxeza QL Ofloxacin QL Polymixin B/ Trimethoprim Solution Tobramycin Tobramycin/ Dexamethasone Vigamox QL Eye Conditions: Glaucoma Alphagan P QL Azopt QL Brimonidine QL Combigan QL Dorzolamide -Timolol Maleate Latanoprost QL Lumigan QL [Plain type = Generic drug] Call customer service for pricing AR Age Restrictions GR Gender Restrictions PA Prior Authorization PC Preventive Care QL Quantity Limits SP Specialty Medication ST Step Therapy 6

17 Name Timolol Timoptic Ocudose Travatan Z QL Eye Conditions: Other Ketorolac Ophthalmic Solution Prednisolone Opth Restasis 3 PA Gastrointestinal: Acid Suppression Carafate Suspension Dexilant QL Famotidine 0 mg and 40 mg (RX only) Lansoprazole (RX Only) QL Nexium (RX only) QL Omeprazole (RX Only) QL Pantoprazole QL Rabeprazole QL Ranitidine Tab, Cap, Syrup (RX Only) Sucralfate Tab Gastrointestinal: Nausea/Vomiting Meclizine Metoclopramide QL Ondansetron Tab QL Transderm-Scop 3 Gastrointestinal: Other Amitiza QL, ST, AR Apriso QL Asacol HD 3 QL Canasa QL Creon Delzicol 3 QL Dicyclomine Diphenoxylate/Atropine Halflytely Kit 3 QL Moviprep 3 QL Omeclamox Pak QL Pentasa 3 QL Name Polyethylene Glycol 3350 Pylera QL Suclear Bowel Prep 3 QL Suprep Bowel Prep 3 QL Uceris 3 Zenpep (Not 5,000 units) HIV/AIDS Atripla SP Complera SP Epzicom SP Intelence SP Isentress SP Kaletra SP Norvir SP Prezista SP Reyataz SP Stribild SP Truvada PA, SP Viread SP Inflammatory Conditions Cimzia PA, QL, SP Enbrel PA, QL, ST, SP Enbrel SureClick PA, QL, ST, SP Humira Kit PA, QL, SP Humira Pen Kit PA, QL, SP Humira Pen Kit Crohns PA, QL, SP Humira Pen Kit Psoriasis PA, QL, SP Hydroxychloroquine Methotrexate Tab Orencia SC PA, QL, ST, SP Simponi PA, QL, SP Stelara PA, QL, SP [Plain type = Generic drug] Call customer service for pricing AR Age Restrictions GR Gender Restrictions PA Prior Authorization PC Preventive Care QL Quantity Limits SP Specialty Medication ST Step Therapy 7

18 Name Men s Health: Erectile Dysfunction Cialis PA, QL, AR, GR Levitra PA, QL, AR, GR Viagra PA, QL, AR, GR Men s Health: Prostate Alfuzosin QL Avodart QL Doxazosin Finasteride 5 mg QL Jalyn QL Rapaflo QL Tamsulosin QL Terazosin Men s Health: Testosterone Therapy Androderm PA, QL, GR Androgel PA, QL, GR Fortesta 3 PA, QL, GR Testim PA, QL, GR Testosterone Cypionate IM Injection PA Miscellaneous Allopurinol Antipyrine/Benzocaine Solution Otic % Aranesp PA, SP Benzonatate Botox 00, 00 unit Injection PA, SP Cheratussin Chlorhexidine Colcrys QL Epipen -Pak QL Euflexxa PA, SP Fosrenol 3 Name Hydrocortisone AC Suppository 5 mg Hydromet Lidocaine Viscous Solution % Makena PA, SP Phenazopyridine Tab (RX Only) Phentermine Tab Procrit PA, SP Promethazine DM Syrup AR Promethazine/Codeine Syrup AR Pulmozyme SP Rectiv 3 Renvela Rezira 3 Suboxone Film PA, QL Synagis PA, SP Synvisc PA, SP Uloric QL, ST Zubsolv PA, QL Zutripro 3 Musculoskeletal: Osteoporosis Actonel 3 QL Alendronate Tab Evista 3 QL Forteo PA, SP Ibandronate Tab QL Raloxifene QL Musculoskeletal: Other Baclofen Tab Carisoprodol Cyclobenzaprine Tab 5, 0 mg Metaxalone Methocarbamol Tizanidine [Plain type = Generic drug] Call customer service for pricing AR Age Restrictions GR Gender Restrictions PA Prior Authorization PC Preventive Care QL Quantity Limits SP Specialty Medication ST Step Therapy 8

19 Name Musculoskeletal: Pain Relief Acetaminophen w/ Codeine QL Cambia 3 QL Celebrex 3 QL Diclofenac Tab QL Endocet Tab QL Etodolac QL Fentanyl Patch QL Gralise 3 QL, ST Hydrocodone w/ Ibuprofen Tab QL mg Hydrocodone/APAP 5, 7.5, 0/35 mg QL Hydromorphone Tab Ibuprofen Tab 400, 600, 800 mg (RX Only) QL Indomethacin Cap QL Lazanda 3 PA, QL Lidocaine Patch 5% QL Lidoderm Patch 3 QL Meloxicam QL Methadone Tab Morphine Sulfate ER Tab QL Nabumetone QL Naproxen (RX Only) QL Nucynta 3 QL Nucynta ER QL Oxycodone Tab 5,5, 30 mg Oxycodone w/ Acetaminophen QL Oxycontin QL Sprix 3 QL Subsys 3 PA, QL Tramadol 50 mg QL Tramadol w/ Acetaminophen QL Vicodin 3 QL Name Vicodin ES 3 QL Voltaren Gel QL Overactive Bladder Enablex 3 QL Gelnique QL Oxybutynin Oxybutynin ER QL Tolterodine ER QL Toviaz 3 QL Vesicare QL Respiratory: Asthma/COPD Advair Diskus QL Advair HFA QL Aerospan 3 QL Albuterol Nebulizer Solution Asmanex QL Breo Ellipta QL Budesonide Combivent Respimat QL Dulera 3 QL, ST Flovent Diskus QL Flovent HFA QL Foradil QL, ST Ipratropium/Albuterol QL Levalbuterol Nebulizer Solution Montelukast QL Perforomist 3 QL Proair HFA QL Proventil 3 QL Pulmicort QL Qvar QL Serevent Diskus QL, ST Spiriva QL Symbicort QL Tudorza Pressair QL Ventolin HFA QL Xolair PA, SP Xopenex HFA 3 QL [Plain type = Generic drug] Call customer service for pricing AR Age Restrictions GR Gender Restrictions PA Prior Authorization PC Preventive Care QL Quantity Limits SP Specialty Medication ST Step Therapy 9

20 Name Respiratory: Nasal Allergies Azelastine Spray QL Dymista Spray 3 QL Fluticasone Spray Ipratropium Spray Nasonex QL Omnaris 3 QL Triamcinolone Spray QL Veramyst QL Zetonna 3 QL Respiratory: Oral Allergies Cetirizine Desloratadine QL Levocetirizine QL Loratadine Promethazine Tab AR Smoking Cessation Products Bupropion PC AR, QL Chantix PC AR, QL Nicotrol Inh 3 AR, QL Nicotrol NS 3 AR, QL Transplant Azathioprine Cellcept Tab/ Suspension SP Cyclosporine Cap SP Mycophenolate 50 mg Cap/500 mg Tab SP Prograf Cap SP Rapamune SP Tacrolimus Cap SP Vitamins/Electrolytes Cyanocobalamin Injection Ferrous Sulfate (Rx only) PC AR Klor-Con M0, M0 Multi-Vit/Fl Chew PC Name Potassium Chloride ER Potassium Chloride Micro ER Tab, Cap Vitamin D 50,000 units (RX Only) PC Women s Health: Contraceptives AR Apri PC GR Aviane PC GR Beyaz GR Cryselle-8 PC GR Generess Fe Chewable 3 GR Gianvi PC GR Gildess Fe PC GR Jolivette PC GR Junel Fe PC GR Kariva PC GR Lo Loestrin 3 GR Loryna PC GR Low-Ogestrel PC GR Lutera PC GR Medroxyprogesterone Acetate Injection 3 QL Microgestin PC GR Microgestin Fe PC GR Minastrin 4 Fe Chewable 3 GR Mononessa PC GR Natazia GR Necon PC GR Norgest/Ethi Estradio PC GR Nortrel PC GR Nuvaring Ocella PC GR Orsythia PC GR Ortho Tri-Cyclen Lo 3 GR Previfem PC GR Reclipsen PC GR Safyral GR Sprintec 8 PC GR Trinessa PC GR [Plain type = Generic drug] Call customer service for pricing AR Age Restrictions GR Gender Restrictions PA Prior Authorization PC Preventive Care QL Quantity Limits SP Specialty Medication ST Step Therapy 0

21 Name Tri-Sprintec PC GR Vestura PC GR Viorele PC GR Women s Health: Hormone Replacement Climara Pro QL, GR Divigel GR Enjuvia QL, GR Estrace Vaginal Cream 3 Estradiol Tab QL, GR Estradiol/ Norethindrone Tab QL, GR Medroxyprogesterone Acetate Tab Premarin Tab QL, GR Premarin Vaginal Cream Premphase QL, GR Prempro QL, GR Progesterone Cap Vagifem 3 GR Vivelle-Dot QL, GR Name Women s Health: Prenatal Vitamins Folic Acid mg (RX Only) Prenaplus Tab Prenatal Tab Low Iron Ra Prenatal Tab mg Se-Natal One Tab Sm Prenatal Tab Vitamins Trinatal Rx Tab Trinate Tab PC PC PC PC PC PC PC PC Women s Health: Vaginal Anti-Infectives Metronidazole Vaginal Gel Terconazole Vaginal Cream QL [Plain type = Generic drug] Call customer service for pricing AR Age Restrictions GR Gender Restrictions PA Prior Authorization PC Preventive Care QL Quantity Limits SP Specialty Medication ST Step Therapy

22 Index of Covered s A Abilify Abilify Disc Abilify Solution Acanya Gel Accu-Chek Act/Gluc Calibration Liquid... 4 Accu-Chek Aviva Plus Test Strips Accu-Chek Aviva Test Strips 5 Accu-Chek Comfort Test Strips Accu-Chek Cpt/Gluc Calibration Liquid... 4 Accu-Chek Diabetic Meters 6 Accu-Chek Drum Test Strips 5 Accu-Chek Kit Aviva Plus. 4 Accu-Chek Kit Compact.. 5 Accu-Chek Kit Fastclix... 5 Accu-Chek Kit Multiclix.. 5 Accu-Chek Kit Nano Accu-Chek Kit Softclix... 5 Accu-Chek Multiclix Lancets4 Accu-Chek Smart Calibration Liquid Accu-Chek Smart Test Strips5 Accu-Chek Sol Calibration Liquid Accu-Chek Sol Comfort Calibration Liquid... 5 Acetaminophen w/ Codeine 9 Actonel Acyclovir Ointment 5%... 4 Acyclovir Tab, Cap, Suspension Aczone Gel Adcirca Advair Diskus Advair HFA Aerospan Aggrenox Albuterol Nebulizer Solution 9 Alendronate Tab Alfuzosin Allopurinol Alphagan P Alprazolam Tab Amiodarone Amitiza Amitriptyline Amlodipine Amlodipine/Atorvastatin.. Amlodipine/Benazepril... Amoxicillin Amoxicillin/Clavulanate... 0 Amphetamine- Dextroamphetamine.. Amphetamine- Dextroamphetamine Cap SR 4HR Ampyra Anastrozole Androderm Androgel Antipyrine/Benzocaine Solution Otic % Apri Apriso Aranesp Armour Thyroid Asacol HD Asmanex Aspirin Atenolol Atenolol/Chlorthalidone... Atorvastatin Atralin Atripla Aviane Avodart Avonex Kit Avonex Pen Kit Avonex Prefill Kit Azathioprine Azelastine Azelastine Spray Azithromycin Azopt Azor B Baclofen Tab Baraclude Benazepril Benazepril/HCTZ Benicar Benicar HCT Benzaclin Benzonatate Benztropine Betaseron Bethkis Beyaz Bisoprolol Bisoprolol/HCTZ Botox 00, 00 unit Injection Breo Ellipta Brilinta Brimonidine Budeprion XL Budesonide Bumetanide Bupropion Bupropion SR Buspirone Butalbital-Acetaminophen- Caffeine Tab Byetta Bystolic [Plain type = Generic drug]

23 Index of Covered s C Calcitriol Cambia Canasa Carac Carafate Suspension... 7 Carbamazepine Tab Carbidopa/Levodopa Tab.. 3 Carisoprodol Cartia XT Carvedilol Cefdinir Cefuroxime Tab Celebrex Cellcept Tab/Suspension. 0 Cephalexin Cetirizine Chantix Cheratussin Chlorhexidine Chlorthalidone Cialis Cimzia Ciprodex Otic Suspension 0 Ciprofloxacin Ciprofloxacin Tab Citalopram Clarithromycin Climara Pro Clindamycin/Benzoyl Peroxide Gel -5% Clindamycin Cap Clindamycin Gel, Lotion, Solution Clobetasol Cream, Gel, Ointment Clobex Cloderm Clonazepam Clonidine Tab Clopidogrel Clotrimazole/Betamethasone Cream, Lotion Colcrys Combigan Combivent Respimat... 9 Complera Condylox Copaxone Coreg CR Coumadin Creon Crestor Cryselle Cyanocobalamin Injection.. 0 Cyclobenzaprine Tab Cyclosporine Cap Cymbalta d Delzicol Desloratadine Desonide Dexamethasone Tab Dexilant Dexmethylphenidate ER... Diazepam Tab Diclofenac Tab Dicyclomine Differin Dificid Digoxin Diovan Diphenoxylate/Atropine... 7 Divalproex DR Divalproex ER Divigel Donepezil Tab Dorzolamide -Timolol Maleate Doxazosin Doxazosin Doxepin Doxycycline Hyclate Cap.. 0 Doxycycline Hyclate Tab... 0 Doxycycline Monohydrate Cap0 Dulera Duloxetine Cap Dutoprol Dymista Spray e Econazole Cream Edarbi Edarbyclor Effient Elidel Enablex Enalapril Enbrel Enbrel SureClick Endocet Tab Enjuvia Enoxaparin Epiduo Epipen -Pak Epzicom Erythromycin Ointment... 6 Escitalopram Tab Estrace Vaginal Cream.. Estradiol/ Norethindrone Tab Estradiol Tab Etodolac Euflexxa Evista Exforge Exforge HCT Ezopiclone Tab [Plain type = Generic drug] 3

24 Index of Covered s f Famciclovir Tab Famotidine Fastclix Lancets Felodipine Fenofibrate Fentanyl Patch Ferrous Sulfate Finacea Finasteride Flecainide Flovent Diskus Flovent HFA Fluconazole Fluocinonide Cream, Gel, Ointment 0.05% Fluoxetine Cap Fluticasone Spray Focalin XR Folic Acid mg Foradil Forfivo XL Forteo Fortesta Fosinopril Fosrenol Furosemide g Gabapentin Gelnique Gemfibrozil Generess Fe Chewable.. 0 Gentamicin Gianvi Gildess Fe Gilenya Gleevec Glimepiride Glipizide Glipizide ER Glipizide XL Glucocard Diabetic Meters 6 Glucocard Test Strips... 5 Glyburide Glyburide/Metformin Gralise Guanfacine Tab h Halflytely Kit Humalog Kwik Humalog Mix 50/50 Kwik Pen Humalog Mix 50/50 Vials. 5 Humalog Mix 75/5 Kwik Pen Humalog Mix 75/5 Vials. 5 Humalog Vials Humira Kit Humira Pen Kit Humira Pen Kit Crohns.. 7 Humira Pen Kit Psoriasis. 7 Humulin 70/30 Vials Humulin N Pen Humulin N Vials Humulin Pen 70/ Humulin R U Humulin R Vials Hydralazine Hydrochlorothiazide..... Hydrocodone/APAP Hydrocodone w/ Ibuprofen Tab Hydrocortisone AC Suppository Hydrocortisone Cream.5% 4 Hydromet Hydromorphone Tab Hydroxychloroquine Hydroxyzine HCl Hydroxyzine Pamoate i Ibandronate Tab Ibuprofen Tab Indomethacin Cap Insulin Pen Needle Insulin Syringe/Needle.. 4 Intelence Intuniv Invokamet Invokana Ipratropium/Albuterol Ipratropium Spray Irbesartan Irbesartan/HCTZ Isentress Isosorbide Mononitrate... j Jalyn Janumet Janumet XR Januvia Jentadueto Jolivette Junel Fe k Kaletra Kariva Ketoconazole Cream/ Shampoo Ketorolac Ophthalmic Solution Klor-Con M0, M Kombiglyze [Plain type = Generic drug] 4

25 Index of Covered s l Labetalol Lamictal Lamictal ODT Lamictal XR Lamotrigine Lamotrigine ER Lansoprazole Lantus Solostar Lantus Vials Latanoprost Lazanda Letairis Letrozole Levalbuterol Nebulizer Solution Levemir Flexpen Levemir Vials Levetiracetam Levetiracetam ER Levitra Levocetirizine Levofloxacin Tab Levothyroxine Lidocaine Patch 5% Lidocaine Viscous Solution % Lidoderm Patch Liothyronine Lipitor Lipofen Lisinopril Lisinopril/HCTZ Lithium Carbonate Livalo Lo Loestrin Loratadine Lorazepam Tab Loryna Losartan Losartan/HCTZ Lovastatin Lovaza Low-Ogestrel Lumigan Lunesta Lupron Depot Lutera Lyrica Cap m Magni-guide Device Makena Meclizine Medroxyprogesterone Acetate Injection Medroxyprogesterone Acetate Tab Meloxicam Metaxalone Metformin Metformin ER Methadone Tab Methimazole Methocarbamol Methotrexate Tab Methylphenidate Cap ER.. Methylphenidate HCL Tab Sa Osm ER Methylphenidate Tab.... Methylphenidate Tab ER... Methylprednisolone Metoclopramide Metoprolol Succinate.... Metoprolol Tartrate..... Metrogel Metronidazole Gel 0.75%.. 4 Metronidazole Tab Metronidazole Vaginal Gel. Micardis HCT Microgestin Microgestin Fe Migranal Minastrin 4 Fe Chewable 0 Minocycline Cap Mirtazapine Modafinil Mometasone Mononessa Montelukast Morphine Sulfate ER Tab.. 9 Moviprep Moxeza Multi-Vit/Fl Chew Mupirocin Mycophenolate 50 mg Cap/500 mg Tab n Nabumetone Nadolol Namenda Tab Namenda XR Naproxen Nasonex Natazia Necon Neomycin/Polymyxin/HC Otic Suspension, Solution.. 0 Nexium Niacin ER Tab Nicotrol Inh Nicotrol NS Nifedipine ER Nitrofurantoin Macrocrystalline Nitrofurantoin Monohydrate Macrocrystalline Nitrostat Norgest/Ethi Estradio Nortrel [Plain type = Generic drug] 5

26 Index of Covered s Nortriptyline Norvir Novofine Novofine Auto Novolin 70/30 Vials Novolin N Vials Novolin R Vials Novolog Flexpen Novolog Mix 70/30 Vials. 5 Novolog Mix Flexpen... 5 Novolog Penfill Novolog Vials Novotwist Nucynta Nucynta ER Nutropin Nutropin AQ Nuvaring Nystatin Cream, Ointment, Powder Nystatin Suspension Nystatin/Triamcinolone Cream, Ointment o Ocella Ofloxacin Ofloxacin Otic Solution... 0 Olanzapine Tab Olysio Omeclamox Pak Omega-3 Acid Cap..... Omeprazole Omnaris Ondansetron Tab One Touch Diabetic Meters 6 Onetouch Kit Ultra Onetouch Kit Ultra... 5 Onetouch Kit Ultra Mini. 5 Onetouch Kit Ultra Smart. 5 Onetouch Kit Verio IQ... 5 Onetouch Test Strips... 5 Onetouch Ultra Blue Test Strips Onetouch Verio IQ Test Strips Onetouch Verio Test Strips 5 Onfi Onglyza Opsumit Oracea Orencia SC Orsythia Ortho Tri-Cyclen Lo Oxcarbazepine Oxsoralen-Ul Oxybutynin Oxybutynin ER Oxycodone Tab Oxycodone w/ Acetaminophen... 9 Oxycontin p Pantoprazole Paroxetine Pataday Patanol Pegasys Penicillin VK Pentasa Perforomist Permethrin Cream 5%... 4 Phenazopyridine Tab Phentermine Tab Phenytoin Phrenilin Pioglitazone Polyethylene Glycol Polymixin B/Trimethoprim Solution Potassium Chloride ER... 0 Potassium Chloride Micro ER Tab, Cap Pradaxa Pramipexole Prandimet Prandin Pravastatin Prednisolone Opth Prednisolone Solution Prednisone Premarin Tab Premarin Vaginal Cream. Premphase Prempro Prenaplus Tab Prenatal Tab Low Iron.... Previfem Prezista Pristiq Proair HFA Prochlorperazine Procrit Progesterone Cap Prograf Cap Promethazine/Codeine Syrup 8 Promethazine DM Syrup.. 8 Promethazine Tab Propranolol Propranolol ER Protopic Ointment Proventil Pulmicort Pulmozyme Pylera q Quetiapine [Plain type = Generic drug] 6

27 Index of Covered s Quinapril Qvar r Rabeprazole Raloxifene Ramipril Ranexa Ranitidine Tab, Cap, Syrup. 7 Rapaflo Rapamune Ra Prenatal Tab Rebif Rebif Titrtn Reclipsen Rectiv Relpax Renvela Repaglinide Restasis Retin-A Micro Revlimid Reyataz Rezira Risperidone Tab Rizatriptan Tab, ODT.... Ropinirole s Safyral Saizen Saphris Se-Natal One Tab Sensipar Serevent Diskus Seroquel XR Sertraline Sildenafil Tab Silenor Silver Sulfadiazine Cream % 4 Simcor Simponi Simvastatin Sm Prenatal Tab Vitamins.. Softclix Lancets Softclix Lan Mis Device.. 4 Soft Touch Lancets Solodyn Sotalol Sovaldi Spiriva Spironolactone Sprintec Sprix Stelara Strattera Stribild Suboxone Film Subsys Suclear Bowel Prep Sucralfate Tab Sulfamethoxazole- Trimethoprim Sulfamethoxazole- Trimethoprim DS Sumatriptan Tab and Spray. Sumavel Dose Suprep Bowel Prep Surestep Test Strips Symbicort Synagis Synthroid Synvisc t Taclonex Tacrolimus Cap Tamiflu Tamoxifen Tab Tamsulosin Tarka Tasigna Tecfidera Tekturna Tekturna HCT Telmisartan Temazepam Terazosin , 8 Terbinafine Tab Terconazole Vaginal Cream. Testim Testosterone Cypionate IM Injection Tev-Tropin Timolol Timoptic Ocudose Tizanidine Tobramycin Tobramycin/Dexamethasone. 6 Tolterodine ER Topiramate Tab Torsemide Tab Toviaz Tracleer Tradjenta Tramadol Tramadol w/ Acetaminophen 9 Transderm-Scop Travatan Z Trazodone Tretinoin Microsphere Gel.. 4 Triamcinolone Triamcinolone Spray Triamterene/HCTZ..... Triazolam Tab Tribenzor Trinatal Rx Tab Trinate Tab Trinessa [Plain type = Generic drug] 7

28 Index of Covered s Tri-Sprintec Truetrack Test Strips Truvada Tudorza Pressair u Uceris Uloric v Vagifem Valacyclovir Valsartan Valsartan/HCTZ Vascepa Vectical Venlafaxine Venlafaxine ER Cap..... Ventolin HFA Veramyst Verapamil ER Vesicare Vestura Viagra Vicodin Vicodin ES Victoza Vigamox Viibryd Viorele Viread Vitamin D 50,000 units... 0 Vivelle-Dot Voltaren Gel Vytorin Vytorin Tab Vyvanse w Warfarin Welchol x Xarelto Xolair Xopenex HFA z Zelapar Zenpep Zetia Zetonna Ziprasidone Cap Zolpidem Zolpidem ER Zomig Nasal Spray.... Zovirax Cream Zovirax Ointment Zubsolv Zutripro Zyclara Zytiga [Plain type = Generic drug] 8

29 My Medications worksheet Take this worksheet with you each time you visit a provider. Each of your providers 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 Provider Example: Lisinopril, 0 mg High blood pressure One tablet daily Dr. Johnson 9

30 optumrx.com OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an Optum TM company a leading provider of integrated health services. Learn more at optum.com. All Optum TM trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners. 05 OptumRx, Inc. ORX640 ORX6700D-SHP_500 Sutter Health Plus