Your 2015 Prescription Drug List

Transcription

1 Your 05 Prescription List Effective January, 05 Please read: This document contains information about the drugs covered under your pharmacy benefit plan. For a complete list of covered drugs or if you have questions: Call the toll-free member phone number on the back of your ID card. Visit optumrx.com 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 your plan s 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, 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 optumrx.com for complete and up-to-date drug information Since the PDL may change, we encourage you to visit our website, optumrx.com. This website is the best source for up-to-date information about all of the medications your pharmacy benefit covers, possible lower-cost options, and cost comparisons. John Smith John Smith John Smith

3 Table of Contents tiers and cost and limits... 6 s by category... 9 Anti-Infectives Antibiotics... 9 Antifungals... 9 Antivirals Cancer... 9 Cardiovascular/Heart Disease Anticoagulants High Blood Pressure... 0 High Cholesterol... 0 Other.... Pulmonary Arterial Hypertension... Central Nervous System Attention Deficit Disorder... Depression.... Migraine... Multiple Sclerosis... Other.... Sedatives/Hypnotics... Seizure Disorders... Dermatology... 3 Diabetes/Endocrine Blood Glucose Monitoring... 3 Insulin... 4 Non-Insulin... 4 Endocrine Growth Hormone... 5 Other Thyroid Hormone Replacement... 5 Eye Conditions Allergies Antibiotics... 5 Glaucoma... 5 Other Gastrointestinal Acid Suppression... 5 Nausea/Vomiting... 6 Other HIV/AIDS... 6 Infertility... 6 Inflammatory Conditions... 6 Men s Health Erectile Dysfunction... 6 Prostate... 6 Testosterone Therapy... 7 Miscellaneous... 7 Musculoskeletal Osteoporosis... 7 Other Pain Relief... 8 Overactive Bladder... 8 Respiratory Asthma/COPD... 8 Nasal Allergies... 9 Oral Allergies... 9 Transplant... 9 Vitamins/Electrolytes... 9 Women s Health Birth Control... 9 Hormone Replacement... 0 Vaginal Anti-Infectives... 0 Index... 3

4 At OptumRx, 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 preferred by your plan sponsor for their safety, cost and effectiveness. 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 intended to be 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 plan sponsor to see what medications are covered under your plan. You may also log on to optumrx.com or call the toll-free member phone number on the back of your ID card for more information. How do I use my Prescription List? When choosing a medication, you and your doctor should consult the PDL. It will help you and your doctor choose the most cost-effective prescription drugs. This guide tells you if a medication is generic or brand, and if special rules apply. Bring this list with you when you see your doctor. It is organized by common medical conditions. Medications are then listed alphabetically. If your medication is not listed in this document, please visit optumrx.com or call the toll-free member phone number on the back of your ID card. 4

5 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 plan sponsor. This is how much you will pay when you fill a prescription. medications are your lowest-cost options. If your medication is placed in or 3, look to see if there is a option available. Discuss these options with your doctor. names shown in orange are preferred for their cost and effectiveness. If there is a symbol in the column, check your benefit plan documents to find out your specific pharmacy plan costs. $ Includes Helpful Tips $ $$ $ $ $$ $$$ $$$ $$$ Lowest Cost Mid-range Cost 3 Highest Cost Lower-cost, commonly used generic drugs. Some low-cost brands may be included. Many common brandname drugs, called preferred brands. Mostly higher-cost brand drugs, also known as nonpreferred brands. Use drugs for the lowest out-ofpocket costs. Use drugs, instead of 3, to help reduce your out-of-pocket costs. Many 3 drugs have lower-cost options in or. Ask your doctor if they could work for you. Please note: Some plans may have two or four tiers, while others may not have any. If you have a high deductible plan, the tier cost levels will apply once you hit your deductible. Refer to your enrollment and plan materials on optumrx.com, or call the toll-free member phone number of the back of your 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 its generic becomes available. Medications may move to a higher tier or be excluded from coverage on January or July of each year. When a medication changes tiers, you may have to pay a different amount for that medication. For the most up-to-date list, call customer service at the toll-free member phone number on the back of your ID card. 5

6 Some medications are noted with letters or symbols next to them. The letters and symbols refer to our pharmacy benefit programs and are provided to help you check which medications may have a program or limit. Your benefit plan determines how these medications may be covered for you. PA ST QL Prior Authorization Your doctor is required to provide additional information to determine coverage. Step Therapy Trial of lower cost medication(s) is required before a higher-cost medication is covered. Quantity Limits Amount of medication covered per copayment or in a specific time period. AR Age Restrictions Some restrictions may apply based on patient age. SP Specialty Medication Medication is designated as a specialty pharmacy drug. GR Gender Restrictions Some restrictions may apply based on gender. To learn more about a pharmacy program or to find out if it applies to you, please visit optumrx.com or call the toll-free member phone number on the back of your ID card. 6

7 Why are some medications excluded from coverage? Medications may be excluded from coverage under your pharmacy benefit when it works the same as or similar to another prescription medication or an over-the-counter (OTC) medication. There may be other medication options available. What if I don t agree with a decision about an excluded medication? You (or your authorized representative) and your doctor can ask for an initial coverage decision by calling the toll-free member phone number on the back of your ID card. Should I talk to my doctor about OTC medications? An OTC medication may be the right treatment option for some conditions. Talk to your doctor about available OTC options. Even though these medications may not be covered under your pharmacy benefit, they may cost less than your out-of-pocket expense for prescription medications. What is the difference between brand-name and generic medications? Generic medications contain the same active ingredients (what makes the medication work) as 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). What if my doctor writes a brand-name prescription? The next time your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lower-cost option is available and if it might be right for you. Generic medications are usually your lowest-cost option, but not always. Visit optumrx.com to make sure. 7

8 Are you taking a specialty medication? Specialty medications treat rare or complex conditions and are typically higher cost medications. Please note, not all specialty medications are listed in the PDL. OptumRx is the specialty pharmacy that can provide most of your specialty medications along with helpful programs and services. Call OptumRx Specialty Pharmacy at and have your prescriptions delivered right to your home or office. 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 the toll-free member phone number on the back of your ID card 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 customer service, 4 hours a day, 7 days a week using the toll-free member phone number on the back of your ID card. Or visit optumrx.com. 8

9 Name Name Anti-Infectives: Antibiotics Amoxicillin Amoxicillin/Clavulanate Avelox Azithromycin Bethkis SP Cefdinir Cefuroxime Tab Cephalexin Tab 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 QL Ketoconazole PA (tab only) Nystatin Terbinafine Tab Anti-Infectives: Antivirals Acyclovir Tab, Cap, Suspension Baraclude 3 QL, SP Famciclovir Tab Olysio PA, QL, SP Pegasys PA, SP Sovaldi PA, QL, SP Tamiflu 3 QL Valacyclovir Cancer Anastrozole Tab Gleevec PA, QL, SP Letrozole PA Revlimid 3 PA, QL, SP Tamoxifen Tasigna PA, QL, SP Zytiga 3 PA, SP Cardiovascular/Heart Disease: Anticoagulants Aggrenox QL Brilinta QL Clopidogrel QL Coumadin 3 Effient QL Eliquis 3 QL Enoxaparin Pradaxa QL Warfarin Xarelto QL [Plain type = Generic drug] Call customer service for pricing PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions 9

10 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 QL 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 Nadolol Nifedipine ER Propranolol Propranolol ER Quinapril Ramipril QL Spironolactone Tarka Tekturna QL, ST Tekturna HCT QL, ST Telmisartan QL Terazosin Torsemide 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 Livalo 3 QL, ST Lovastatin Lovaza 3 QL Niacin ER Tab (Rx only) QL Omega-3-Acid Cap gm (Rx only) QL Pravastatin QL 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 PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions 0

11 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 3 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 Amphetamine- Dextroamphetamine QL SR Cap 4Hr Dexmethylphenidate QL Focalin XR 3 QL, ST Intuniv QL Methylphenidate ER Cap QL Methylphenidate ER Tab QL Methylphenidate HCL Sa Osm ER Tab QL Methylphenidate Tab QL Strattera QL Vyvanse QL Central Nervous System: Depression Amitriptyline Budeprion XL QL Bupropion QL Bupropion SR QL Citalopram QL Cymbalta 3 QL Doxepin QL Duloxetine QL Escitalopram Tab QL Fluoxetine (not PMDD) Forfivo XL QL Mirtazapine Nortriptyline Paroxetine QL Pristiq QL Sertraline QL 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 PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions

12 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* 3 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 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 Eszoplicone 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 3 PA, QL Oxcarbazepine Phenytoin Topiramate * 3 Preferred [Plain type = Generic drug] Call customer service for pricing PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions

13 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 QL Gel -5% Clobetasol Cream, Gel, Ointment Clobex 3 Cloderm 3 Clotrimazole/ Betamethasone Condylox 3 Desonide Differin 3 QL Econazole Cream Elidel QL, ST, AR Epiduo 3 QL, AR Finacea Fluocinonide Cream, Gel, Ointment 0.05% Hydrocortisone.5% Metrogel 3 Metronidazole Gel 0.75% Mometasone Mupirocin QL Nystatin Cream, Ointment, Powder Nystatin/Triamcinolone Oxsoralen-Ul PA Permethrin Cream 5% Protopic QL, ST, AR Retin-A Micro 3 QL, AR Name 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 Accu-Chek Act/Gluc Calibration Liquid Accu-Chek Aviva Plus Test Strips QL Accu-Chek Aviva Test Strips QL Accu-Chek Comfort Calibration Liquid Accu-Chek Comfort Test Strips QL Accu-Chek Cpt/Gluc Calibration Liquid Accu-Chek Drum Test Strips QL Accu-Chek Kit Aviva Plus Accu-Chek Kit Compact Accu-Chek Kit Fastclix Accu-Chek Kit Multiclix Accu-Chek Kit Nano Accu-Chek Kit Softclix Accu-Chek Multiclix Lancets Accu-Chek Smart Calibration Liquid Accu-Chek Smart Test Strips QL [Plain type = Generic drug] Call customer service for pricing PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions 3

14 Name Accu-Chek Sol Calibration Liquid Accu-Chek Sol Comfort Calibration Liquid Fastclix Lancets Glucocard Test Strips Insulin Pen Needle Insulin Syringe/ Needle Novofine Novofine Auto Novotwist Onetouch Kit Ultra Smart Onetouch Kit Ultra Onetouch Kit Ultra Onetouch Kit Ultra Mini Onetouch Kit Verio IQ Onetouch Test Strips QL Onetouch Ultra Blue Test Strips QL Onetouch Verio IQ Test Strips QL Onetouch Verio Test Strips QL Soft Touch Lancets Softclix Lan Mis Device Softclix Lancets Surestep Test Strips QL Truetrack Test Strips 3 QL Diabetes/Endocrine: Insulin Humalog Vials Humalog Kwik Humalog Mix 50/50 Kwik Pen Humalog Mix 50/50 Vials Humalog Mix 75/5 Kwik Pen Name 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 Janumet QL, ST Janumet XR QL, ST Januvia QL, ST Jentadueto QL, ST Kombiglyze QL, ST Metformin Metformin ER Onglyza QL, ST Pioglitazone QL Tradjenta QL, ST Victoza 3 QL, ST [Plain type = Generic drug] Call customer service for pricing PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions 4

15 Name Endocrine: Growth Hormone Nutropin PA, SP Nutropin AQ PA, SP Saizen PA, SP Tev-Tropin PA, SP Endocrine: Other Dexamethasone Tab Lupron Depot 3.75 mg,.5 mg PA, SP Lupron Depot 7.5 mg,.5 mg, PA, SP 30 mg, 45 mg Methylprednisolone Tab Prednisolone Prednisone Sensipar 3 SP Endocrine: Thyroid Hormone Replacement Armour Thyroid 3 Levothyroxine Levoxyl Liothyronine Methimazole Synthroid 3 Eye Conditions: Allergies Azelastine Solution Pataday Patanol QL Eye Conditions: Antibiotics Ciprofloxacin QL Erythromycin Gentamicin Moxeza QL Name Ofloxacin QL Polymyxin 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 Timolol Timoptic Ocudose Travatan Z QL Eye Conditions: Other Ketorolac Ophthalmic Solution QL Prednisolone Opth Restasis 3 PA Gastrointestinal: Acid Suppression Dexilant QL Famotidine Tab 0 mg and 40 mg (Rx only) Lansoprazole (Rx only) QL Nexium (Rx only) QL Omeprazole (Rx only) QL Pantoprazole QL Rabeprazole QL Ranitidine (Rx only) Sucralfate [Plain type = Generic drug] Call customer service for pricing PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions 5

16 Name Name Gastrointestinal: Nausea/Vomiting 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 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 QL, SP Kaletra SP Norvir SP Prezista SP Reyataz SP Stribild SP Truvada PA, SP Viread SP Infertility Follistim AQ PA, SP Gonal-f PA, SP Gonal-f RFF PA, SP Ovidrel PA, 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 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 Men s Health: Erectile Dysfunction Cialis QL, AR, GR Levitra 3 QL, AR, GR Viagra 3 QL, AR, GR Men s Health: Prostate Alfuzosin QL Avodart QL Doxazosin QL Finasteride 5 mg QL Jalyn QL Rapaflo QL Tamsulosin QL Terazosin [Plain type = Generic drug] Call customer service for pricing PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions 6

17 Name Men s Health: Testosterone Therapy Androderm PA, QL, GR Androgel PA, QL, GR Fortesta 3 PA, QL, GR Testim PA, QL, GR Miscellaneous Allopurinol Antipyrine/Benzocaine Otic Solution % Aranesp PA, SP Benzonatate Botox 00, 00 unit Injection PA, SP Cheratussin Chlorhexidine Colcrys QL Epipen -Pak QL Euflexxa PA, SP Fosrenol 3 Hydrocortisone AC Suppository Hydromet Lidocaine Viscous Solution Makena PA, SP Phenazopyridine (Rx only) Phentermine Tab Procrit PA, SP Promethazine DM Syrup AR Promethazine/Codeine AR Pulmozyme SP Rectiv 3 Name Renvela 3 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 QL Calcitriol Evista 3 QL Forteo PA, QL, SP Ibandronate Tab QL Raloxifene Musculoskeletal: Other Baclofen Tab Carisoprodol Cyclobenzaprine Tab 5, 0 mg Metaxalone Methocarbamol Tizanidine [Plain type = Generic drug] Call customer service for pricing PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions 7

18 Name Musculoskeletal: Pain Relief Acetaminophen w/ Codeine QL Cambia 3 QL Celebrex 3 QL Diclofenac 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 Ibuprofen (Rx only) QL Indomethacin QL Lazanda 3 PA, QL Lidocaine Patch 5% QL Meloxicam QL Methadone Tab Morphine Sulfate Tab 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 Tab 50 mg QL Tramadol w/ Acetaminophen QL Vicodin QL Vicodin ES QL Voltaren Gel QL Name Overactive Bladder Detrol LA 3 QL, ST 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 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 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 PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions 8

19 Name 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 Promethazine Tab AR Desloratadine QL Levocetirizine QL Transplant Azathioprine Cellcept 3 SP Cyclosporine Cap SP Mycophenolate 50 mg Cap/500 mg Tab SP Prograf 3 SP Rapamune 3 SP Tacrolimus Cap SP Vitamins/Electrolytes Folic Acid mg (Rx only) Klor-Con Multi-Vit/Fl Chew Potassium Chloride ER Potassium Chloride Micro ER Tri-Vit-Fl Drops Vitamin D (Rx only) Women s Health: Birth Control Apri GR Aviane GR Beyaz GR Cryselle-8 GR Generess Fe Chewable 3 GR Gianvi GR Gildess Fe GR Jolivette GR Junel Fe GR Kariva GR Levora 8 GR Lo Loestrin 3 GR Loryna GR Low-Ogestrel GR Lutera GR Medroxyprogesterone Acetate Injection QL Microgestin GR Microgestin Fe GR Minastrin 4 Fe Chewable 3 GR Mononessa GR Natazia GR Necon GR Norgest/Ethi Estradio GR Nortrel GR Nuvaring Ocella GR Orsythia GR Ortho Tri-Cyclen Lo 3 GR Previfem GR Reclipsen GR Safyral GR Sprintec 8 GR Trinessa GR Tri-Sprintec GR Vestura GR Viorele GR [Plain type = Generic drug] Call customer service for pricing PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions 9

20 Name Women s Health: Hormone Replacement Climara Pro QL, GR Divigel GR Enjuvia QL, GR Estrace Vaginal Cream 3 Estradiol QL, GR Estradiol/Norethindrone Tab QL, GR Medroxyprogesterone Acetate Tab Premarin QL, GR Premarin Vaginal Cream Name Premphase QL, GR Prempro QL, GR Progesterone Capsule Vagifem 3 GR Vivelle-Dot QL, GR Women s Health: Vaginal Anti-Infectives Metronidazole Vaginal Gel Terconazole Vaginal Cream QL [Plain type = Generic drug] Call customer service for pricing PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions 0

21 Index of Covered s a Abilify Abilify Disc Abilify Solution Acanya Gel Accu-Chek Act/Gluc Calibration Liquid... 3 Accu-Chek Aviva Plus Test Strips Accu-Chek Aviva Test Strips Accu-Chek Comfort Calibration Liquid... 3 Accu-Chek Comfort Test Strips Accu-Chek Cpt/Gluc Calibration Liquid... 3 Accu-Chek Drum Test Strips 3 Accu-Chek Kit Aviva Plus. 3 Accu-Chek Kit Compact.. 3 Accu-Chek Kit Fastclix... 3 Accu-Chek Kit Multiclix.. 3 Accu-Chek Kit Nano Accu-Chek Kit Softclix... 3 Accu-Chek Multiclix Lancets3 Accu-Chek Smart Calibration Liquid Accu-Chek Smart Test Strips3 Accu-Chek Sol Calibration Liquid Accu-Chek Sol Comfort Calibration Liquid... 4 Acetaminophen w/ Codeine 8 Actonel Acyclovir Ointment 5%... 3 Acyclovir Tab, Cap, Suspension 9 Aczone Gel Adcirca Advair Diskus Advair HFA Aerospan Aggrenox Albuterol Nebulizer Solution 8 Alendronate Tab Alfuzosin Allopurinol Alphagan P Alprazolam Tab Amiodarone Amitiza Amitriptyline Amlodipine Amlodipine/Atorvastatin.. Amlodipine/Benazepril... 0 Amoxicillin Amoxicillin/Clavulanate Amphetamine- Dextroamphetamine.. Amphetamine- Dextroamphetamine SR Cap 4Hr Ampyra Anastrozole Tab Androderm Androgel Antipyrine/Benzocaine Otic Solution %... 7 Apri Apriso Aranesp Armour Thyroid Asacol HD Asmanex Atenolol Atenolol/Chlorthalidone... 0 Atorvastatin Atralin Atripla Avelox Aviane Avodart Avonex Kit Avonex Pen Kit Avonex Prefill Kit..... Azathioprine Azelastine Solution 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 c Calcitriol Cambia Canasa Carac [Plain type = Generic drug]

22 Index of Covered s Carbamazepine Tab..... Carbidopa/Levodopa Tab.. Carisoprodol Cartia XT Carvedilol Cefdinir Cefuroxime Tab Celebrex Cellcept Cephalexin Tab Cheratussin Chlorhexidine Chlorthalidone Cialis Cimzia Ciprodex Otic Suspension. 9 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 3 Colcrys Combigan Combivent Respimat... 8 Complera Condylox Copaxone Coreg CR Coumadin Creon Crestor Cryselle Cyclobenzaprine Tab Cyclosporine Cap Cymbalta d Delzicol Desloratadine Desonide Detrol LA Dexamethasone Tab Dexilant Dexmethylphenidate.... Diazepam Diclofenac Dicyclomine Differin Dificid Digoxin Diovan Diphenoxylate/Atropine... 6 Divalproex DR Divalproex ER Divigel Dorzolamide-Timolol Maleate 5 Doxazosin Doxazosin Doxepin Doxycycline Hyclate Cap... 9 Doxycycline Hyclate Tab....9 Doxycycline Monohydrate Cap 9 Dulera Duloxetine Dutoprol Dymista Spray e Econazole Cream Edarbi Edarbyclor Effient Elidel Eliquis Enablex Enalapril Enbrel Enbrel SureClick Endocet Tab Enjuvia Enoxaparin Epiduo Epipen -Pak Epzicom Erythromycin Escitalopram Tab Estrace Vaginal Cream.. 0 Estradiol Estradiol/Norethindrone Tab. 0 Eszoplicone Tab Etodolac Euflexxa Evista Exforge Exforge HCT f Famciclovir Tab Famotidine Tab Fastclix Lancets Felodipine Fenofibrate Fentanyl Patch Finacea Finasteride Flecainide Flovent Diskus Flovent HFA Fluconazole Fluocinonide Cream, Gel, Ointment 0.05% Fluoxetine (not PMDD)... Fluticasone Spray Focalin XR [Plain type = Generic drug]

23 Index of Covered s Folic Acid mg Follistim AQ Foradil Forfivo XL Forteo Fortesta Fosinopril Fosrenol Furosemide g Gabapentin Gelnique Gemfibrozil Generess Fe Chewable.. 9 Gentamicin Gianvi Gildess Fe Gilenya Gleevec Glimepiride Glipizide Glipizide ER Glipizide XL Glucocard Test Strips... 4 Glyburide Glyburide/Metformin Gonal-f Gonal-f RFF Gralise Guanfacine Tab h Halflytely Kit Humalog Kwik Humalog Mix 50/50 Kwik Pen Humalog Mix 50/50 Vials. 4 Humalog Mix 75/5 Kwik Pen Humalog Mix 75/5 Vials. 4 Humalog Vials Humira Kit Humira Pen Humira Pen Kit Crohns.. 6 Humira Pen Kit Psoriasis. 6 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.5% Hydrocortisone AC Suppository Hydromet Hydromorphone Hydroxychloroquine Hydroxyzine HCL Hydroxyzine Pamoate.... i Ibandronate Tab Ibuprofen Indomethacin Insulin Pen Needle Insulin Syringe/Needle.. 4 Intelence Intuniv Invokamet Invokana Ipratropium/Albuterol Ipratropium Spray Irbesartan Irbesartan/HCTZ Isentress Isosorbide Mononitrate... [Plain type = Generic drug] 3 j Jalyn Janumet Janumet XR Januvia Jentadueto Jolivette Junel Fe k Kaletra Kariva Ketoconazole Ketorolac Ophthalmic Solution Klor-Con Kombiglyze 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 Levora

24 Index of Covered s Levothyroxine Levoxyl Lidocaine Patch 5% Lidocaine Viscous Solution. 7 Liothyronine Lipitor Lisinopril Lisinopril/HCTZ Lithium Carbonate..... Livalo Lo Loestrin Lorazepam Tab Loryna Losartan Losartan/HCTZ Lovastatin Lovaza Low-Ogestrel Lumigan Lunesta Lupron Depot Lutera Lyrica Cap m Makena Medroxyprogesterone Acetate Injection Medroxyprogesterone Acetate Tab Meloxicam Metaxalone Metformin Metformin ER Methadone Tab Methimazole Methocarbamol Methotrexate Tab Methylphenidate ER Cap.. Methylphenidate ER Tab... Methylphenidate HCL Sa Osm ER Tab Methylphenidate Tab.... Methylprednisolone Tab... 5 Metoclopramide Metoprolol Succinate Metoprolol Tartrate Metrogel Metronidazole Gel 0.75%.. 3 Metronidazole Tab Metronidazole Vaginal Gel. 0 Microgestin Microgestin Fe Migranal Minastrin 4 Fe Chewable 9 Minocycline Cap Mirtazapine Modafinil Mometasone Mononessa Montelukast Morphine Sulfate Tab Moviprep Moxeza Multi-Vit/Fl Chew Mupirocin Mycophenolate n Nabumetone Nadolol Namenda Tab Namenda XR Naproxen Nasonex Natazia Necon Neomycin/Polymyxin/HC Otic Suspension, Solution... 9 Nexium (Rx only) Niacin ER Tab Nifedipine ER Nitrofurantoin Macrocrystalline 9 Nitrofurantoin Monohydrate Macrocrystalline Nitrostat Norgest/Ethi Estradio Nortrel Nortriptyline Norvir Novofine Novofine Auto Novolin 70/30 Vials Novolin N Vials Novolin R Vials Novolog Flexpen Novolog Mix 70/30 Vials. 4 Novolog Mix Flexpen... 4 Novolog Penfill Novolog Vials Novotwist Nucynta Nucynta ER Nutropin Nutropin AQ Nuvaring Nystatin Nystatin Cream, Ointment, Powder Nystatin/Triamcinolone... 3 [Plain type = Generic drug] 4 o Ocella Ofloxacin Ofloxacin Otic Solution Olanzapine Tab Olysio Omeclamox Pak Omega-3-Acid Cap Omeprazole Omnaris Ondansetron Tab Onetouch Kit Ultra Onetouch Kit Ultra... 4 Onetouch Kit Ultra Mini. 4 Onetouch Kit Ultra Smart. 4 Onetouch Kit Verio IQ... 4 Onetouch Test Strips... 4

25 Index of Covered s Onetouch Ultra Blue Test Strips Onetouch Verio IQ Test Strips Onetouch Verio Test Strips 4 Onfi Onglyza Opsumit Oracea Orencia SC Orsythia Ortho Tri-Cyclen Lo Ovidrel Oxcarbazepine Oxsoralen-Ul Oxybutynin Oxybutynin ER Oxycodone Tab Oxycodone w/ Acetaminophen... 8 Oxycontin p Pantoprazole Paroxetine Pataday Patanol Pegasys Penicillin VK Pentasa Perforomist Permethrin Cream 5%... 3 Phenazopyridine Phentermine Tab Phenytoin Phrenilin Pioglitazone Polymyxin B/Trimethoprim Solution Potassium Chloride ER... 9 Potassium Chloride Micro ER 9 Pradaxa Pramipexole Pravastatin Prednisolone Prednisolone Opth Prednisone Premarin Premarin Vaginal Cream. 0 Premphase Prempro Previfem Prezista Pristiq Proair HFA Prochlorperazine Procrit Progesterone Capsule Prograf Promethazine/Codeine... 7 Promethazine DM Syrup.. 7 Promethazine Tab Propranolol Propranolol ER Protopic Proventil Pulmicort Pulmozyme Pylera q Quetiapine Quinapril Qvar r Rabeprazole Raloxifene Ramipril Ranexa Ranitidine Rapaflo Rapamune Rebif Rebif Titrtn Reclipsen Rectiv Relpax Renvela Restasis Retin-A Micro Revlimid Reyataz Rezira Risperidone Tab Rizatriptan Tab, ODT.... Ropinirole s Safyral Saizen Saphris Sensipar Serevent Diskus Seroquel XR Sertraline Sildenafil Tab Silenor Silver Sulfadiazine Cream % 3 Simcor Simponi Simvastatin 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 [Plain type = Generic drug] 5

26 Index of Covered s Sucralfate Sulfamethoxazole-Trimethoprim9 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 Tamsulosin Tarka Tasigna Tecfidera Tekturna Tekturna HCT Telmisartan Temazepam Terazosin Terazosin Terbinafine Tab Terconazole Vaginal Cream. 0 Testim Tev-Tropin Timolol Timoptic Ocudose Tizanidine Tobramycin Tobramycin/Dexamethasone. 5 Tolterodine ER Topiramate Torsemide Toviaz Tracleer Tradjenta Tramadol Tab Tramadol w/ Acetaminophen 8 Transderm-Scop Travatan Z Trazodone Tretinoin Microsphere Gel.. 3 Triamcinolone Triamcinolone Spray Triamterene/HCTZ Triazolam Tab Tribenzor Trinessa Tri-Sprintec Tri-Vit-Fl Drops Truetrack Test Strips Truvada Tudorza Pressair u Uceris Uloric Vagifem v 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 Vivelle-Dot Voltaren Gel Vytorin 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] 6

27 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 7

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