Prescription Drug List

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1 Your 07 Four- Prescription List effective January, 07 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.

3 Table of Contents tiers and cost... 5 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... 4 Dermatology Diabetes/Endocrine Blood Glucose Monitoring Insulin Non-Insulin... 6 Endocrine Growth Hormone Other Thyroid Hormone Replacement Eye Conditions Allergies Antibiotics Glaucoma Gastrointestinal Acid Suppression Nausea/Vomiting Other....8 Gout....8 Hepatitis C HIV/AIDS Infertility....9 Inflammatory Conditions: Rheumatoid Arthritis, Crohn s Disease, Psoriasis, Ulcerative Colitis....9 Men s Health Erectile Dysfunction....9 Prostate....9 Testosterone Therapy...9 Miscellaneous....9 Musculoskeletal Muscle Spasms....0 Osteoporosis....0 Pain Relief....0 Overactive Bladder.... Respiratory Allergies.... Asthma/COPD.... Pulmonary Arterial Hypertension.... Smoking Cessation... Transplant.... Vitamins/Electrolytes.... Women s Health Contraceptives....3 Hormone Replacement....4 Miscellaneous....4 Prenatal Vitamins...4 Index....5

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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, 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 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 or 3 drugs instead of 4 to help reduce your out-of-pocket costs. Many 4 drugs have lower cost options in, 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 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. 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, Invokana) and generic drugs in plain type (for example, Metformin). 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 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 Doxycycline Hyclate 50, 00 mg Capsule, Doxycycline Hyclate Delayed-Release 4 E Doxycycline Monohydrate 50, 00 mg Capsule Levofloxacin Metronidazole Minocycline Capsule Minocycline 3 Moxifloxacin 3 Nitrofurantoin Capsule Name Nitrofurantoin Macrocrystal Capsule Ofloxacin s Oracea 4 Penicillin V Potassium Solodyn 4 Sulfamethoxazole- Trimethoprim Suprax Capsule, Chewable, 4 Anti-Infectives: Antifungals Cresemba 3 SL Econazole Cream 3 SL Fluconazole Itraconazole Capsule SL Ketoconazole Cream Noxafil, Suspension Nystatin Cream, Ointment Terbinafine SL Anti-Infectives: Antivirals Acyclovir Ointment 4 PA, SL, ST Acyclovir Famciclovir Tamiflu 3 SL Valacyclovir 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 SL = Supply Limit ST = Step Therapy 0

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

12 Name Telmisartan SL Telmisartan- Hydrochlorothiazide SL Terazosin Triamterene- Hydrochlorothiazide Valsartan SL Valsartan- Hydrochlorothiazide SL Verapamil Verapamil Sustained-Release 3 Cardiovascular/Heart Disease: High Cholesterol Atorvastatin SL Choline Fenofibrate 4 E Crestor 4 E, SL Fenofibrate 43, 50, 67, 30, 34, 50, 00 mg 4 E Capsule Fenofibrate 40, 48, 0, 45 mg 4 E Fenofibrate 54, 60 mg Fluvastatin Extended- Release 3 SL, ST Gemfibrozil Lipofen 4 E Livalo 4 SL, ST Lovastatin Niacin Extended- Release 4 Niaspan Omega-3-Acid Ethyl Esters Capsule 3 PA Praluent DSP, PA, SL, ST Pravastatin Name Repatha 4 DSP, PA, SL, ST Rosuvastatin SL Simvastatin Vascepa 4 PA Vytorin 4 SL Welchol Zetia 4 SL Cardiovascular/Heart Disease: Other Amiodarone Corlanor 3 PA, SL Digoxin Entresto 4 PA, SL Flecainide Isosorbide Mononitrate ER Multaq 4 PA Nitrostat Ranexa Sotalol Central Nervous System: Attention Deficit Disorder Adderall XR PA, SL Amphetamine Salt PA Combo Aptensio XR 4 E, PA, SL Concerta 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 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 SL = Supply Limit ST = Step Therapy

13 Name Dextroamphetamine- Amphetamine PA Dextroamphetamine Sulfate 3 PA Focalin XR 4 E, PA, SL Guanfacine Extended-Release SL Metadate CD PA, SL Methylphenidate Chewable 3 PA Methylphenidate Extended-Release 4 E, PA, SL Capsule Methylphenidate Extended-Release 4 E, PA, SL Methylphenidate PA Strattera 4 SL Vyvanse PA, SL Central Nervous System: Depression Amitriptyline Bupropion Extended- Release Bupropion Sustained- Release Bupropion Citalopram Doxepin Capsule Duloxetine Capsule 3 SL Escitalopram Fetzima 4 SL, ST Fluoxetine Capsule, Fluvoxamine Mirtazapine Nortriptyline Capsule Paroxetine Pristiq ER 3 RS, SL Sertraline Trazodone Trintellix 4 SL, ST Name Venlafaxine Extended- Release Capsule Venlafaxine Viibryd 4 SL Central Nervous System: Migraine Acetaminophen/ Butalbital/Caffeine SL 35 mg/50 mg/40 mg Frovatriptan 3 SL Naratriptan SL Relpax SL Rizatriptan ODT, SL Sumatriptan Nasal Spray SL Sumatriptan Succinate, Injection SL Sumavel DosePro 4 E, SL Central Nervous System: Multiple Sclerosis Ampyra DSP, PA, SL Aubagio 3 DSP, PA, SL Avonex DSP, PA, SL Betaseron DSP, PA, SL Copaxone DSP, PA, SL Gilenya 3 DSP, PA, SL Glatopa 4 DSP, E, PA, SL, ST Plegridy 3 DSP, PA, SL Rebif 4 DSP, PA, SL, ST Tecfidera DSP, PA, SL Central Nervous System: Other Alprazolam Extended- Release Alprazolam Aripiprazole SL Armodafanil 4 E, PA, SL Buprenorphine/ Naloxone 4 E, PA, SL Buspirone Carbidopa-Levodopa Diazepam 3

14 Name Donepezil 5, 0 mg ODT, Latuda 4 SL Lithium Capsule Lorazepam Memantine Modafinil 3 PA, SL Olanzapine SL Pramipexole Quetiapine Risperidone Ropinirole Seroquel XR 4 SL Suboxone Film 4 E, PA, SL Tolcapone Xyrem 4 PA, SL Zelapar 3 Ziprasidone Capsule SL Zubsolv PA, SL Central Nervous System: Sedatives/Hypnotics Eszopiclone SL Temazepam Capsule Triazolam Zaleplon Capsule SL Zolpidem Extended- Release 4 E, SL Zolpidem SL Central Nervous System: Seizure Disorders Carbamazepine Extended-Release Capsule Carbamazepine Extended-Release 3 Name Carbamazepine Clonazepam Diazepam Divalproex Delayed- Release Divalproex Extended- Release Gabapentin Capsule, Lamotrigine Levetiracetam Extended-Release Levetiracetam Lyrica 4 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 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 SL = Supply Limit ST = Step Therapy 4

15 Name Ciclopirox Cream, Gel, Lotion, Solution Claravis PA Clindamycin %/ Benzoyl Peroxide 5% Gel 4 E, SL Clindamycin.%/ Benzoyl Peroxide 5% Gel 3 SL Clindamycin Gel 3 SL Clindamycin Lotion 3 Clindamycin Solution, Swabs Clobetasol Propionate Cream, Ointment 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 PA, SL Diflorasone Diacetate 0.05% Cream, Ointment 3 SL Epiduo 3 SL Epiduo Forte 4 E, SL Finacea 4 Fluocinonide 0.05% Cream Fluocinolone Cream, Oil, Solution 3 SL Fluocinolone Ointment SL Halobetasol Ointment Hydrocortisone.5% Cream, Ointment Imiquimod 5% Cream SL Metronidazole 0.75% Topical Gel Name Mirvaso 4 SL Mometasone Furoate Cream, Lotion, Ointment Mupirocin Ointment SL Nystatin-Triamcinolone Acetonide Cream, 4 E Ointment Oxsoralen-Ul Picato 3 SL Regranex PA, SL Tacrolimus Ointment 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 Flex OneTouch Verio IQ OneTouch Verio Sync OneTouch Verio Test Strips SL 5

16 Name Name Diabetes: Insulin Afrezza 4 E, PA, SL, ST Basaglar 3 until 3/3/7 3 SL beginning 4//7 Humalog KwikPens (all formulations) SL Humalog Vials (all formulations) SL Humulin KwikPens (all formulations) SL Humulin Vials SL (all formulations) Lantus Solostar 3 until 3/3/7 4 and Excluded beginning 4//7 Lantus Vials 3 until 3/3/7 4 and Excluded beginning 4//7 Levemir FlexTouch until 3/3/7 beginning 4//7 Levemir Vials until 3/3/7 beginning 4// SL E SL E SL SL Novolin Vials (all formulations) 3 SL, ST Novolog FlexTouch (all formulations) 4 SL, ST Novolog Vials (all formulations) 4 SL, ST Toujeo SoloStar 4 E, SL Tresiba FlexTouch 4 E, SL Diabetes: Non-Insulin Bydureon SL Byetta SL Farxiga 4 SL, ST Glimepiride Glipizide Glipizide Extended-Release Glyburide Glyxambi 4 E, SL, ST Invokamet SL Invokana SL, ST Janumet 4 SL, ST Januvia 4 SL, ST Jardiance SL, ST Jentadueto SL Kazano SL Kombiglyze XR SL Metformin Metformin Extended- Release (generic Glucophage XR) Nesina SL Onglyza SL Oseni SL Pioglitazone SL Synjardy SL Tanzeum SL Tradjenta SL Trulicity 4 SL, ST Victoza -Pak SL Victoza 3-Pak 3 SL Xigduo XR 4 E, SL, ST 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 SL = Supply Limit ST = Step Therapy 6

17 Name Endocrine: Growth Hormone Nutropin, Nutropin AQ Endocrine: Other Calcitriol Capsule Desmopressin Dexamethasone Methylprednisolone Prenisolone Oral Solution Prednisone Endocrine: Thyroid Hormone Replacement Armour Thyroid 3 Levothyroxine Sodium Liothyronine Sodium Methimazole NP Thyroid Synthroid Eye Conditions: Allergies DSP, PA, SL 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 Name Tobramycin/ Dexamethasone 0.3%-0.% Ophthalmic Suspension Tobramycin Ophthalmic Solution Vigamox 4 Eye Conditions: Glaucoma Alphagan P 0.% SL Azopt SL Combigan SL Latanoprost 0.005% Ophthalmic Solution Lumigan SL Timolol Maleate 0.5%, 0.5% Ophthalmic Solution Travatan Z SL Gastrointestinal: Acid Suppression Dexilant 3 SL Esomeprazole Capsule 4 E, SL Lansoprazole Capsules 3 E, SL Omeclamox-Pak 3 SL Omeprazole Capsule Pantoprazole Pylera 3 SL Rabeprazole 3 SL Ranitadine Syrup Sucralfate Gastrointestinal: Nausea/Vomiting Akynzeo 4 SL Emend Capsule SL Ondansetron Ondansetron ODT Transderm-Scop 3 Varubi SL 7

18 Name Name Gastrointestinal: Other Amitiza 4 PA, SL, ST Apriso Asacol HD 4 E Canasa Cortifoam Creon Delzicol 4 E Diphenoxylate-Atropine Golytely Hyoscyamine Lialda Linzess PA, SL Metoclopramide Movantik PA, SL Moviprep 3 Polyethylene Glycol 3350 Prepopik 3 Suclear 3 Sulfasalazine Suprep 3 Uceris Foam Uceris 3 Viberzi 4 PA, SL Zenpep Gout Allopurinol Colcrys 4 E Mitigare Uloric 4 SL, ST Hepatitis C Daklinza DSP, PA, SL, ST Harvoni DSP, PA, SL Ribapak 3 DSP, E Ribavirin DSP Sovaldi DSP, PA, SL, ST Technivie 4 DSP, PA, SL Viekira Pak 4 DSP, PA, SL, ST Zepatier 4 DSP, PA, SL, ST HIV/AIDS Atripla DSP Complera 4 DSP Descovy 4 DSP Epzicom DSP Evotaz DSP Genvoya 4 DSP, ST Intelence DSP Isentress DSP Kaletra DSP Lamivudine-Zidovudine DSP Nevirapine DSP Nevirapine Extended-Release 4 DSP, E Norvir DSP Odefsey 4 DSP Prezcobix DSP Prezista DSP Reyataz DSP Stribild 3 DSP, ST Sustiva DSP Tivicay 3 DSP Triumeq DSP 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 SL = Supply Limit ST = Step Therapy 8

19 Name Truvada 4 DSP Tybost DSP Viread DSP Vitekta DSP Infertility* Cetrotide DSP Clomiphene DSP Gonal-F DSP Gonal-F RFF 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 DSP, PA, SL Cosentyx 3 DSP, PA, SL, ST Enbrel 4 DSP, PA, SL, ST Humira 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 DSP, PA, SL Stelara DSP, PA, SL Taltz 4 DSP, PA, SL, ST Xeljanz 4 DSP, PA, SL, ST Men s Health: Erectile Dysfunction Cialis 4 SL Levitra 4 SL Stendra 4 SL Viagra 4 SL Name Men s Health: Prostate Alfuzosin Cialis 4 SL, ST Doxazosin Dutasteride Capsule 3 PA Finasteride Rapaflo 4 Tamsulosin Capsule Terazosin Capsule, Men s Health: Testosterone Therapy Androderm PA, SL Androgel 4 E, PA, SL Methyltestosterone Capsule Testim PA, SL Testosterone % Topical Gel 4 E, PA, SL Testosterone Cypionate Injection Miscellaneous Anastrozole Antipyrine/Benzocaine Otic Solution Aranesp DSP, SL Auryxia 3 Benzonatate Capsule Bethkis DSP, PA, SL Bromfed DM 3 Cayston PA, SL Cerdelga DSP, PA Chlorpheniramine/ Hydrocodone/ Pseudoephedrine SL Solution Ciprodex Epipen SL Epipen-Jr SL Fosrenol 3 9

20 Name Hydrocodone/ Chlorpheniramine 3 SL Suspension Hydrocodone/ Homatropine Letrozole Lidocaine Transdermal Patch SL Nuedexta Obredon 4 SL, ST Pegasys DSP, PA, SL Phenazopyridine Procrit DSP, SL Promethazine/Codeine Promethazine/ Dextromethorphan Pulmozyme DSP, PA, SL Rectiv 3 PA, SL Renvela Restasis 4 PA, SL Rezira 3 Tobi Podhaler 3 DSP, PA, SL Tobramycin Nebulized Solution 4 DSP, E, PA, SL Veltassa 3 PA, SL Velphoro Zarxio DSP Musculoskeletal: Muscle Spasms Baclofen Carisoprodol 350 mg Cyclobenzaprine Metaxalone 3 Methocarbamol Tizanidine Name Musculoskeletal: Osteoporosis Alendronate Sodium SL Forteo DSP, PA Ibandronate SL Raloxifene Risedronate Sodium 3 SL Musculoskeletal: Pain Relief Acetaminophen/ Codeine SL Belbuca 3 PA, SL, ST Butrans 4 E, PA, SL, ST Celecoxib SL Diclofenac Embeda 4 E, PA, SL, ST Etodolac Capsule Fentanyl, 5, 50, 75, 00 mcg Patch SL Fentanyl 37.5, 6.5, 87.5 mcg Patch 4 E, SL Fentanyl Citrate Lozenge PA, SL Hydrocodone/ Acetaminophen 5/35, 7.5/35, 0/35 mg SL Hydrocodone/Ibuprofen Hydromorphone Hysingla 4 E, PA, SL, ST Ibuprofen Indomethacin Capsule Ketorolac 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 SL = Supply Limit ST = Step Therapy 0

21 Name 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 PA, SL Oxycodone/ Acetaminophen 5/35, 7.5/35, 0/35 mg SL Oxycodone Oxycontin 4 E, PA, SL, ST Sprix 3 Subsys 4 E, PA, SL Tramadol- SL Acetaminophen Tramadol Sustained- Release SL Tramadol Trezix 4 SL Vicodin 5/300, 7.5/300, 4 E, SL 0/300 mg Voltaren Gel Xtampza ER 3 PA, SL Zohydro ER 4 PA, SL, ST Overactive Bladder Dicyclomine Oxybutynin Extended- Release Oxybutynin Tolterodine Extended- Release 4 E Name 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 SL Hydroxyzine Capsule, Levocetirizine SL Mometasone Nasal Spray 4 E, SL Promethazine 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 Anoro Ellipta 3 SL Arnuity Ellipta 3 SL Asmanex SL Breo Ellipta 3 RS, SL Budesonide Nebs SL Combivent Respimat 3 SL Dulera 4 SL, ST Flovent Diskus/HFA 3 SL Incruse Ellipta SL Ipratropium-Albuterol Nebs Ipratropium Nebs Levalbuterol Nebs 4 E, SL

22 Name Montelukast Chewable, Montelukast Granules Perforomist 3 SL ProAir HFA 3 SL ProAir Respiclick 3 SL Proventil HFA 3 SL Pulmicort Flexhaler 4 SL QVAR SL Seebri Neohaler SL Serevent Diskus 3 SL Spiriva Handihaler 4 SL Spiriva Respimat 4 SL Stiolto Respimat 4 E, SL Striverdi Respimat SL Symbicort 3 RS, SL Tudorza SL Utibron Neohaler SL Ventolin HFA SL Xopenex HFA 3 SL Xopenex Nebs 4 E, SL Respiratory: Pulmonary Arterial Hypertension Adcirca 4 DSP, PA, SL Adempas DSP, PA, SL Letairis DSP, PA, SL Opsumit DSP, PA, SL Orenitram 4 DSP, PA, SL Sildenafil DSP, PA, SL Tracleer DSP, PA, SL Tyvaso DSP, PA Uptravi 4 DSP, PA, SL Name 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 DSP Sirolimus DSP Tacrolimus Capsule DSP Vitamins/Electrolytes Fluoride Folic Acid Klor-Con M0 Klor-Con M0 Potassium Chloride Potassium Citrate 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 SL = Supply Limit ST = Step Therapy

23 Name Women s Health: Contraceptives Alyacen 7/7/7 H Apri H Aviane H Azurette Camila H Cryselle H Cyclafem H Cyclafem 7/7/7 H Dasetta 7/7/7 H Deblitane H Ella H Enskyce H Errin H Estarylla H Gildess Gildess Fe H Heather H Introvale H Jencycla H Jolessa H Jolivette H Junel Junel Fe H Levora-8 H Lo Loestrin Fe 3 Loryna 3 Low-Ogestrel H Lutera H Lyza H Microgestin Microgestin FE H Minastrin 4 FE 4 E Mono-Linyah H MonoNessa H Natazia H Necon 7/7/7, 0.5/35, /35, /50, 0/ H Next Choice H Nora BE H Name Norethindrone 0.35 mg H Norgestimate-Ethinyl Estradiol 3 Norgestimate-Ethinyl Estradiol Lo Norlyroc H Nortrel 7/7/7, 0.5/35 H Nuvaring H Orsythia H Ortho-Cyclen 4 Ortho Micronor 4 Ortho-Novum 4 Ortho-Novum 7/7/7 4 Ortho Tri-Cyclen 4 Ortho Tri-Cyclen Lo 4 E Pirmella 7/7/7 H Plan B One Step H Previfem H Quasense H Reclipsen H Sharobel H Sprintec H Sronyx H Tri-Estarylla H Tri-Linyah H Tri-Lo-Estarylla 3 Tri-Lo-Marzia 3 Tri-Lo-Sprintec 3 Tri-Previfem H Tri-Sprintec H Trinessa H Trinessa Lo 3 Vestura 3 Viorele Xulane 3 H Yasmin 8 H Yaz 3

24 Name Name Women s Health: Hormone Replacement Cenestin 4 E Climara SL Climara Pro 3 SL Divigel 3 Duavee 3 Enjuvia 3 Estrace Cream 3 Estradiol/Norethindrone Acetate Estradiol Estradiol Twice-Weekly Transdermal Patch 4 E, SL Estring MC, SL Estrogen/ Methyltestosterone Evamist Medroxyprogesterone Minivelle 3 SL Premarin 3 Premphase 3 Prempro 3 Progesterone Micronized Capsule Vagifem Vivelle-Dot SL Women s Health: Miscellaneous Addyi 4 PA, SL Osphena 3 Raloxifene H, PA Tamoxifen H, PA Women s Health: Prenatal Vitamins Brand Prenatal Vitamins 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 SL = Supply Limit ST = Step Therapy 4

25 Index A Absorica...4 Accu-Chek Test Strips... 5 Acetaminophen/Butalbital/ Caffeine 35 mg/50 mg/ 40 mg... 3 Acetaminophen/ Codeine... 0 Actemra...9 Acyclovir Ointment...0 Acyclovir...0 Aczone...4 Adapalene 0.% Cream, Gel...4 Adapalene 0.3% Gel...4 Adcirca... Adderall XR... Addyi... 4 Adempas... Advair Diskus/HFA... Aerospan... Afrezza...6 Akynzeo...7 Albuterol Nebs... Albuterol Sulfate... Alendronate Sodium... 0 Alfuzosin...9 Allopurinol...8 Alphagan P 0.%...7 Alprazolam Extended-Release... 3 Alprazolam... 3 Alvesco... Alyacen 7/7/ Amiodarone... Amitiza...8 Amitriptyline... 3 Amlodipine... Amlodipine-Benazepril... Amlodipine-Valsartan... Amoxicillin/Potassium Clavulanate Chewable,...0 Amoxicillin Capsule, Chewable...0 Amphetamine Salt Combo... Ampyra... 3 Anastrozole...9 Androderm...9 Androgel...9 Anoro Ellipta... Antipyrine/Benzocaine Otic Solution...9 Apri... 3 Apriso...8 Aptensio XR... Aranesp...9 Aripiprazole... 3 Armodafanil... 3 Armour Thyroid...7 Arnuity Ellipta... Asacol HD...8 Asmanex... Atenolol... Atenolol-Chlorthalidone... Atorvastatin... Atripla...8 Aubagio... 3 Auryxia...9 Aviane... 3 Avonex... 3 Azathioprine... Azelastine 0.05% Ophthalmic Solution...7 Azelastine 0.% Nasal Spray... Azithromycin...0 Azopt Azurette... 3 B Baclofen... 0 Basaglar...6 Belbuca... 0 Benazepril... Benazepril- Hydrochlorothiazide... Benicar... Benicar HCT... Benzonatate Capsule...9 Betamethasone Dipropionate 0.05% Cream, Ointment...4 Betaseron... 3 Bethamethasone Dipropionate 0.05% Augmented Lotion, Ointment...4 Bethkis...9 Bexarotene Capsule... Bicalutamide... Bidil... Bisoprolol... Bisoprolol- Hydrochlorothiazide... Bosulif... Brand Prenatal Vitamins... 4 Breo Ellipta... Bromfed DM...9 Budesonide Nebs... Buprenorphine/ Naloxone... 3 Bupropion Extended-Release... 3 Bupropion Sustained-Release...3, Bupropion... 3 Buspirone... 3 Butrans... 0

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

27 Diclofenac... 0 Dicyclomine... Differin % Cream, Gel... 5 Dificid...0 Diflorasone Diacetate 0.05% Cream, Ointment... 5 Digoxin... Diltiazem 4 Hour CD... Diltiazem Sustained-Release Capsule... Diltiazem Sustained-Release... Diphenoxylate-Atropine...8 Divalproex Delayed-Release...4 Divalproex Extended-Release...4 Divigel... 4 Donepezil 5, 0 mg ODT,...4 Doxazosin..., 9 Doxazosin...9 Doxepin Capsule... 3 Doxycycline Hyclate 50, 00 mg Capsule,...0 Doxycycline Hyclate Delayed-Release...0 Doxycycline Monohydrate 50, 00 mg Capsule...0 Duavee... 4 Dulera... Duloxetine Capsule... 3 Dutasteride Capsule...9 Dutoprol... E Econazole Cream...0 Edarbi... Edarbyclor... Effient... Eliquis... Ella... 3 Embeda... 0 Emend Capsule...7 Enalapril... Enbrel...9 Enjuvia... 4 Enoxaparin Sodium... Enskyce... 3 Entresto... Epiduo... 5 Epiduo Forte... 5 Epipen...9 Epipen-Jr...9 Epzicom...8 Errin... 3 Erythromycin 0.5% Ophthalmic Ointment...7 Escitalopram... 3 Esomeprazole Capsule...7 Estarylla... 3 Estrace Cream... 4 Estradiol/Norethindrone Acetate... 4 Estradiol... 4 Estradiol Twice-Weekly Transdermal Patch... 4 Estring... 4 Estrogen/Methyltestosterone... 4 Eszopiclone...4 Etodolac Capsule... 0 Evamist... 4 Evotaz...8 F Famciclovir...0 Farxiga...6 Fenofibrate 40, 48, 0, 45 mg... 7 Fenofibrate 43, 50, 67, 30, 34, 50, 00 mg Capsule... Fenofibrate 54, 60 mg... Fentanyl, 5, 50, 75, 00 mcg Patch... 0 Fentanyl 37.5, 6.5, 87.5 mcg Patch... 0 Fentanyl Citrate Lozenge... 0 Fetzima... 3 Finacea... 5 Finasteride...9 Flecainide... Flovent Diskus/HFA... Fluconazole...0 Fluocinolone Cream, Oil, Solution... 5 Fluocinolone Ointment... 5 Fluocinonide 0.05% Cream... 5 Fluoride... Fluoxetine Capsule,... 3 Fluticasone Nasal Spray... Fluvastatin Extended-Release... Fluvoxamine... 3 Focalin XR... 3 Folic Acid... Forteo... 0 Fosrenol...9 FreeStyle Test Strips... 5 Frovatriptan... 3 Furosemide... G Gabapentin Capsule,...4 Gemfibrozil... Gentamicin Ophthalmic Ointment, Solution...7 Genvoya...8 Gildess... 3 Gildess Fe... 3

28 Gilenya... 3 Glatopa... 3 Glimepiride...6 Glipizide...6 Glipizide Extended-Release...6 Glyburide...6 Glyxambi...6 Golytely...8 Gonal-F...9 Gonal-F RFF...9 Guanfacine..., 3 Guanfacine Extended-Release... 3 H Halobetasol Ointment... 5 Harvoni...8 Heather... 3 Humalog KwikPens...6 Humalog Vials...6 Humira...9 Humulin KwikPens...6 Humulin Vials...6 Hydralazine... Hydrochlorothiazide... Hydrocodone/Acetaminophen 5/35, 7.5/35, 0/35 mg... 0 Hydrocodone/ Chlorpheniramine Suspension... 0 Hydrocodone/Homatropine... 0 Hydrocodone/ Ibuprofen... 0 Hydrocortisone.5% Cream, Ointment... 5 Hydromorphone... 0 Hydroxychloroquine Sulfate...9 Hydroxyurea Capsule... Hydroxyzine Capsule,... Hyoscyamine...8 Hysingla... 0 I Ibandronate... 0 Ibuprofen... 0 Imatinib... Imbruvica... Imiquimod 5% Cream... 5 Incruse Ellipta... Indomethacin Capsule... 0 Intelence...8 Introvale... 3 Invokamet...6 Invokana...6 Ipratropium-Albuterol Nebs... Ipratropium Nebs... Irbesartan... Isentress...8 Isosorbide Mononitrate ER... Itraconazole Capsule...0 J Janumet...6 Januvia...6 Jardiance...6 Jencycla... 3 Jentadueto...6 Jolessa... 3 Jolivette... 3 Junel... 3 Junel Fe... 3 K Kaletra...8 Kazano...6 Ketoconazole Cream...0 Ketorolac... 0 Klor-Con M Klor-Con M0... Kombiglyze XR...6 L Labetalol... Lamivudine-Zidovudine...8 Lamotrigine...4 Lansoprazole Capsules...7 Lantus Solostar...6 Lantus Vials...6 Lastacaft...7 Latanoprost 0.005% Ophthalmic Solution...7 Latuda...4 Lazanda... Leflunomide...9 Letairis... Letrozole... 0 Leucovorin Calcium... Levalbuterol Nebs... Levemir FlexTouch...6 Levemir Vials...6 Levetiracetam Extended-Release...4 Levetiracetam...4 Levitra...9 Levocetirizine... Levofloxacin...0 Levora Levothyroxine Sodium...7 Lialda...8 Lidocaine Transdermal Patch... 0 Linzess...8 Liothyronine Sodium...7 Lipofen... Lisinopril..., 34 Lisinopril- Hydrochlorothiazide... Lithium Capsule...4

29 Livalo... Lo Loestrin Fe... 3 Lorazepam...4 Loryna... 3 Losartan... Losartan- Hydrochlorothiazide... Lovastatin... Low-Ogestrel... 3 Lumigan...7 Lutera... 3 Lyrica...4 Lyza... 3 M Medroxyprogesterone... 4 Meloxicam... Memantine...4 Mercaptopurine... Metadate CD... 3 Metaxalone... 0 Metformin...6 Metformin Extended-Release (generic Glucophage XR)...6 Methadone, Oral Solution, Concentrate Solution... Methimazole...7 Methocarbamol... 0 Methotrexate...9 Methylphenidate Chewable... 3 Methylphenidate Extended-Release Capsule... 3 Methylphenidate Extended-Release... 3 Methylphenidate... 3 Methylprednisolone...7 Methyltestosterone Capsule...9 Metoclopramide...8 Metoprolol Succinate 50, 00, 00 mg... Metoprolol Tartrate 50, 00 mg... Metronidazole 0.75% Topical Gel... 5 Metronidazole...0 Microgestin... 3 Microgestin FE... 3 Minastrin 4 FE... 3 Minivelle... 4 Minocycline Capsule...0 Minocycline...0 Mirtazapine... 3 Mirvaso... 5 Mitigare...8 Modafinil...4 Mometasone Furoate Cream, Lotion, Ointment... 5 Mometasone Nasal Spray... Mono-Linyah... 3 MonoNessa... 3 Montelukast Chewable,... Montelukast Granules... Morphine Sulfate Extended-Release... Morphine Sulfate Oral Solution... Movantik...8 Moviprep...8 Moxeza...7 Moxifloxacin...0 Multaq... Mupirocin Ointment... 5 Mycophenolate Capsule, Suspension... Mycophenolic Acid... 9 N Nabumetone... Nadolol... Naproxen... Naratriptan... 3 Natazia... 3 Necon 7/7/7, 0.5/35, /35, /50, 0/... 3 Nesina...6 Nevirapine...8 Nevirapine Extended-Release...8 Next Choice... 3 Niacin Extended-Release... Niaspan... 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... Nora BE... 3 Norethindrone 0.35 mg... 3 Norgestimate-Ethinyl Estradiol... 3 Norgestimate-Ethinyl Estradiol Lo... 3 Norlyroc... 3 Nortrel 7/7/7, 0.5/ Nortriptyline Capsule... 3

30 Norvir...8 Novolin Vials...6 Novolog FlexTouch...6 Novolog Vials...6 Noxafil, Suspension...0 NP Thyroid...7 Nucynta... Nucynta ER... Nuedexta... 0 Nutropin, Nutropin AQ...7 Nuvaring... 3 Nystatin-Triamcinolone Acetonide Cream, Ointment... 5 Nystatin Cream, Ointment...0 O Obredon... 0 Odefsey...8 Ofloxacin 0.3% Ophthalmic Solution...7 Ofloxacin s...0 Olanzapine...4 Olopatadine 0.% Ophthalmic Solution...7 Omeclamox-Pak...7 Omega-3-Acid Ethyl Esters Capsule... Omeprazole Capsule...7 Ondansetron...7 Ondansetron ODT...7 OneTouch Test Strips... 5 OneTouch Ultra Meter... 5 OneTouch Ultra Mini... 5 OneTouch Ultra Test Strips... 5 OneTouch Verio... 5 OneTouch Verio Flex... 5 OneTouch Verio IQ... 5 OneTouch Verio Sync... 5 OneTouch Verio Test Strips... 5 Onglyza...6 Opana ER... Opsumit... Oracea...0 Orencia...9 Orenitram... Orsythia... 3 Ortho-Cyclen... 3 Ortho-Novum... 3 Ortho-Novum 7/7/ Ortho Micronor... 3 Ortho Tri-Cyclen... 3 Ortho Tri-Cyclen Lo... 3 Oseni...6 Osphena... 4 Otezla...9 Otrexup...9 Ovidrel...9 Oxcarbazepine...4 Oxsoralen-Ul... 5 Oxybutynin Extended-Release... Oxybutynin... Oxycodone/Acetaminophen 5/35, 7.5/35, 0/35 mg... Oxycodone... Oxycontin... P Pantoprazole...7 Paroxetine... 3 Pataday...7 Pegasys... 0 Penicillin V Potassium...0 Perforomist... Phenazopyridine... 0 Phenytoin Capsule, Suspension...4 Picato... 5 Pioglitazone Pirmella 7/7/ Plan B One Step... 3 Plegridy... 3 Polyethylene Glycol Potassium Chloride... Potassium Citrate... Pradaxa... Praluent... Pramipexole...4 Pravastatin... Prednisone...7 Premarin... 4 Premphase... 4 Prempro... 4 Prenisolone Oral Solution...7 Prepopik...8 Previfem... 3 Prezcobix...8 Prezista...8 Pristiq ER... 3 ProAir HFA... ProAir Respiclick... Procrit... 0 Progesterone Micronized Capsule... 4 Promethazine/Codeine... 0 Promethazine/ Dextromethorphan... 0 Promethazine... Propranolol Extended-Release Capsule... Propranolol... Proventil HFA... Pulmicort Flexhaler... Pulmozyme... 0 Pylera...7 Q Quasense... 3 Quetiapine...4 Quinapril...

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

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

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, 0 mg High blood pressure One tablet daily Dr. Johnson 34

35

36 For more information Call the toll-free member phone number on your health plan ID card. Or, visit myuhc.com All branded medications are trademarks or registered trademarks of their respective owners. 06 United HealthCare Services, Inc. All rights reserved. Created August, Prescription List Advantage Four /7

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