Prescription Drug List

Transcription

1 Your 206 Prescription List Effective January, 206 Oxford New York and New Jersey Advantage Three- Please read: This document contains information about commonly prescribed medications. For additional information: Call us at the toll-free phone number on your health plan ID card. TTY users can dial 7. Si usted necesita ayuda en español llame al número de teléfono en su tarjeta de identificación, , , or the phone number on your ID card for help in English and other languages. Visit oxfordhealth.com, click the Pharmacies & Prescriptions tab and then Online Pharmacy to log in to the OptumRx website and: Locate a participating retail pharmacy by ZIP code. Look up possible lower-cost medication alternatives. Compare medication pricing and options. OptumRx Pharmacy is the administrator of your Oxford pharmacy benefit plan.

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 oxfordhealth.com for drug information. Since the PDL may change, we encourage you to visit our website, oxfordhealth.com. This website is the best source for accessing up-to-date information about the medications your pharmacy benefit covers, possible lower-cost options, and cost comparisons. 2

3 Table of Contents tiers and cost Programs and Limits s by category....0 Anti-Infectives Antibiotics....0 Antifungals...0 Antivirals....0 Cancer....0 Cardiovascular/Heart Disease Coagulation Therapy... 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....8 Nausea/Vomiting Other....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 Osteoporosis Other Pain Relief Overactive Bladder....2 Respiratory Allergies....2 Asthma/COPD Pulmonary Arterial Hypertension Smoking Cessation...22 Transplant Vitamins/Electrolytes Women s Health Contraceptives Hormone Replacement Miscellaneous Prenatal Vitamins...24 Index

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5 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 (PDL). 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 health plan documents, the health plan documents will rule. The PDL is not a complete list of medications, and not all medications listed may be covered under your plan. Please look at your health plan documents provided by your employer or health plan to see what medications are covered under your plan. You may also log on to oxfordhealth.com or call us at the toll-free phone number on your health plan ID card for more information. How do I use my PDL? 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 a generic or brand name and if special programs apply. Bring this guide 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 guide, please visit oxfordhealth.com or call us at the toll-free phone number on your health plan ID card. TTY users can dial 7. Si usted necesita ayuda en español llame al número de teléfono en su tarjeta de identificación, , , or the phone number on your ID card for help in English and other languages. 5

6 What are tiers? s are the different cost levels you pay for a medication. Each tier is assigned a cost, which is determined by your employer or health plan. This is how much you will pay when you fill a prescription. medications are your lowest-cost options. If your medication is placed in 2 or 3, look to see if there is a option available. Discuss these options with your doctor. Check your health plan documents for your specific pharmacy plan costs. $ Includes Helpful Tips Lowest Cost 2 Mid-range Cost 3 Highest Cost Lower-cost drugs. Some brand names and generics are also included. Mix of brand name and generics. Mostly higher-cost brand names as well as select generic drugs. Use drugs for the lowest out of-pocket costs. Use 2 drugs, instead of 3, to help reduce your out-of-pocket costs. Many 3 drugs have lower cost options in or 2. Ask your doctor if they could work for you. Please note: Some plans may have two or four tiers, while others may not have any. If you have a high deductible health plan, the tier cost levels may apply once you hit your deductible. Refer to your enrollment and plan materials on oxfordhealth.com, or call us at the toll-free phone number on your health plan ID card for more information about your health plan. When does the PDL 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 us at the toll-free phone number on your health plan 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 health plan determines how these medications are covered and may differ from what is noted in the PDL. Call us at the toll-free phone number on your health plan ID card if you have any questions about your prescription drug coverage. DSP E H MC N RS SDP SL ST Designated Specialty Program Specialty medications need to be filled at a designated specialty pharmacy for in-network coverage. Call us at the toll-free phone number on your health plan 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 Copayment More than one month s worth of medication included in package so additional copayment applies. Notification or Precertification (sometimes referred to as preauthorization) required 2 Your doctor is required to provide additional information to us to determine coverage. Refill and Save Program Save money on your copayment when you refill your prescription on time as prescribed. Program eligibility may vary. Select Designated Pharmacy Must use a lower-cost medication at retail or transfer the impacted medication to the mail service pharmacy for in-network coverage. Supply Limit Amount of medication covered per copayment or in a specific time period. Step Therapy 3 Trial of a lower-cost medication is required before a higher-cost medication is covered. 2 Depending on your benefit, you may have notification or precertification requirements for select medications. 3 For New Jersey 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 oxfordhealth.com or call us at the toll-free phone number on your health plan ID card. TTY users can dial 7. Si usted necesita ayuda en español llame al número de teléfono en su tarjeta de identificación, , , or the phone number on your ID card for help in English and other languages. 7

8 Why are some medications excluded from coverage? A medication 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. 4 There may be other medication options available. Should I talk to my doctor about over-the-counter (OTC) medications? An over-the-counter (OTC) medication may be the right treatment for some conditions. Talk to your doctor about available OTC options. These medications are not covered under your pharmacy benefit, but they may cost less than your out-of-pocket expense for prescription medications. What is the difference between brand-name and generic medications? Generic medications contain the same active ingredients (what makes the medication work) as brandname medications, but they often cost less. Once the patent of a brand-name medication ends, the FDA can approve a generic version with the same active ingredients. These types of medications are known as generic medications. Sometimes, the same company that makes a brand-name medication also makes the generic version. Is it a generic or brand-name medication? The PDL shows brand-name medications in bold type (for example, Crestor) and generic medications in plain type (for example, Simvastatin). What if my doctor writes a prescription for a brand-name medication? 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 health plans, if a brand-name medication is prescribed and a generic equivalent is available, your share of the cost may be the copayment PLUS the cost difference between the brand-name medication and its generic equivalent. Visit oxfordhealth.com to make sure. 4 This is not applicable for plans written in New Jersey. For New York plans, a prescription drug product that is therapeutically equivalent to an over-the counter drug may be covered if it is determined to be medically necessary. 8

9 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. 5 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, call us at the toll-free phone number on your health plan ID card to talk with a pharmacist about finding lower-cost options or a financial assistance program. 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 oxfordhealth.com or call us at the toll-free 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 oxfordhealth.com or call us at the toll-free phone number on your health plan ID card for more current information. For more information Call us at the toll-free phone number on your health plan ID card. TTY users can dial 7. Si usted necesita ayuda en español llame al número de teléfono en su tarjeta de identificación, , , or the phone number on your ID card for help in English and other languages. Or, visit oxfordhealth.com. 5 Not all plans require use of the specialty network. Please refer to your Prescription List Rider to determine if the specialty network is required as part of your plan. 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 health plan determines coverage for these medications. 9

10 Name Anti-Infectives: Antibiotics Amoxicillin Capsule, Chewable Amoxicillin/Potassium Clavulanate Chewable, Azithromycin Cefadroxil Capsule, Cefdinir Capsule 2 Cefixime Suspension 3 Cefprozil Cefuroxime Cephalexin Capsule Ciprofloxacin Clarithromycin Clindamycin Capsule Dificid 3 SL Doryx 3 E Doxycycline Hyclate Capsule, 2 Doxycycline Monohydrate 50, 00 mg Capsule Levofloxacin Metronidazole Minocycline Capsule Minocycline 3 Moxifloxacin 3 Nitrofurantoin Capsule Nitrofurantoin Macrocrystal Capsule Ofloxacin Oracea 3 Penicillin V Potassium Solodyn 3 Name Sulfamethoxazole- Trimethoprim Suprax Capsule, Chewable, Anti-Infectives: Antifungals 3 Econazole Cream SL Fluconazole Itraconazole Capsule SL Ketoconazole Cream Noxafil, Suspension 2 Nystatin Cream, Ointment Terbinafine SL Anti-Infectives: Antivirals Acyclovir Ointment 3 N, SL, ST Acyclovir Famciclovir Tamiflu 3 SL Valacyclovir 2 SL Valaganciclovir SL Zovirax Cream 3 E, SL Cancer Bicalutamide Bosulif 2 DSP, N, SL, ST Cyclophosphamide Capsule 2 Gleevec 2 DSP, N, SL Hydroxyurea Capsule Imbruvica 2 DSP, N, SL Leucovorin Calcium Mercaptopurine Revlimid 2 DSP, N, SL Bold type = Brand-name medication [Plain type = Generic medication] DSP = Designated Specialty Program E = May be excluded from coverage MC = Multiple Copayment N = Notification or precertification (sometimes referred to as preauthorization) required RS = May be eligible for the Refill and Save Program SDP = Select Designated Pharmacy SL = Supply Limit ST = Step Therapy 0

11 Name Sutent 2 DSP, N, SL Tasigna 2 DSP, N, SL Xeloda DSP, SL Zytiga 2 DSP, N, SL Cardiovascular/Heart Disease: Coagulation Therapy Clopidogrel Effient 3 SL Eliquis 3 SL Enoxaparin Sodium 2 SL Pradaxa 2 SL Savaysa 3 SL Warfarin Sodium Xarelto 2 SL Cardiovascular/Heart Disease: High Blood Pressure Amlodipine Amlodipine Besylate-Benazepril 2 SL Amlodipine-Valsartan 3 SL Atenolol Atenolol-Chlorthalidone Benazepril Benazepril- Hydrochlorothiazide Benicar 2 SL Benicar HCT 2 SL Bidil 2 Bisoprolol Bisoprolol- Hydrochlorothiazide Bystolic 2 Cartia XT 2 Carvedilol Chlorthalidone Clonidine Diltiazem 24 Hour CD 2 Diltiazem Sustained- Release Capsule 2 Diltiazem Sustained- Release 2 Diovan 3 E, SL Name Doxazosin Dutoprol 2 SL Edarbi 3 SL Edarbyclor 3 SL Enalapril Furosemide Guanfacine Hydralazine Hydrochlorothiazide Irbesartan SL Labetalol Lisinopril Lisinopril- Hydrochlorothiazide Losartan Losartan- Hydrochlorothiazide Metoprolol Succinate 50, 00, 200 mg 2 Metoprolol Tartrate Nadolol Nifedipine Extended-Release Propranolol Extended- Release Capsule 2 Propranolol Quinapril Ramipril Spironolactone Telmisartan 2 SL Telmisartan- Hydrochlorothiazide 2 SL Terazosin Triamterene- Hydrochlorothiazide Valsartan 2 SL Valsartan- Hydrochlorothiazide SL Verapamil Verapamil Sustained-Release 3

12 Name Name Cardiovascular/Heart Disease: Other Amiodarone Digoxin Flecainide Isosorbide Mononitrate ER Nitrostat 2 Ranexa 2 Sotalol Central Nervous System: Attention Deficit Disorder Adderall XR 2 N, SL Amphetamine Salt N Combo Concerta 2 N, SL Daytrana 3 E, N, SL Dexmethylphenidate Extended-Release Capsule Cardiovascular/Heart Disease: High Cholesterol Atorvastatin SL Choline Fenofibrate 3 E Crestor 2 SL Fenofibrate 43, 50, 67, 30, 34, 50, 200 mg 3 E Capsule Fenofibrate 48, 45 mg 3 E Fenofibrate 54, 60 mg 2 Fenoglide 3 E Gemfibrozil Lescol XL 3 SL, ST Lipitor 3 E, SL Lipofen 3 E Livalo 3 SL, ST Lovastatin Niacin Extended- Release 3 Niaspan 2 Omega-3-Acid Ethyl Esters Capsule 3 N Pravastatin Simcor 3 SL Simvastatin Tricor 48, 45 mg 3 E Trilipix 3 E Vascepa 3 N Vytorin 3 SL Welchol 2 Zetia 3 SL Dexmethylphenidate Dextroamphetamine- Amphetamine Extended-Release 3 E, N, SL N 3 E, N, SL Dextroamphetamine- Amphetamine N Dextroamphetamine Sulfate 3 N Focalin XR 3 E, N, SL Guanfacine Extended-Release 3 SL, ST Bold type = Brand-name medication [Plain type = Generic medication] DSP = Designated Specialty Program E = May be excluded from coverage MC = Multiple Copayment N = Notification or precertification (sometimes referred to as preauthorization) required RS = May be eligible for the Refill and Save Program SDP = Select Designated Pharmacy SL = Supply Limit ST = Step Therapy 2

13 Name Intuniv 3 E, SL, ST Metadate CD 2 N, SL Methylphenidate Chewable 3 N Methylphenidate Extended-Release 3 E, N, SL Capsule Methylphenidate Extended-Release 3 E, N, SL Methylphenidate N Strattera 3 SL Vyvanse 2 N, SL Central Nervous System: Depression Amitriptyline Brintellix 3 SL, ST Bupropion Extended- Release Bupropion Sustained- Release Bupropion Citalopram Cymbalta 3 E, SL Doxepin Duloxetine Capsule 3 SL Escitalopram Fetzima 3 SL, ST Fluoxetine, Capsule Fluvoxamine Lexapro 3 E Mirtazapine Nortriptyline Capsule Paroxetine Name Pristiq ER 3 RS, SL Sertraline Trazodone Venlafaxine Extended- Release Capsule Venlafaxine Viibryd 3 SL Wellbutrin XL 3 E Central Nervous System: Migraine Acetaminophen/ Butalbital/Caffeine 325 mg/50 mg/40mg SL Naratriptan SL Relpax 2 SL Rizatriptan ODT, SL Sumatriptan Nasal Spray 2 SL Sumatriptan Succinate, Injection SL Sumavel DosePro 3 SL Central Nervous System: Multiple Sclerosis Ampyra 2 DSP, N, SL Aubagio 3 DSP, N, SL, ST Avonex 2 DSP, N, SL Betaseron 2 DSP, N, SL Copaxone 2 DSP, N, SL Gilenya 3 DSP, N, SL, ST Glatopa 3 DSP, E, N, SL, ST Rebif 3 DSP, N, SL, ST Tecfidera 2 DSP, N, SL 3

14 Name Central Nervous System: Other Abilify 3 E, SL Alprazolam Extended- Release Alprazolam Aripiprazole 2 SL Buprenorphine/ Naloxone 3 E, N, SL Buspirone Carbidopa-Levodopa Diazepam Donepezil 5, 0 mg ODT, Latuda 3 SL Lithium Capsule Lorazepam Memantine 3 Modafinil 3 E, N, SL Namenda XR 3 Nuvigil 3 N, SL Olanzapine SL Pramipexole Quetiapine SL Risperidone Ropinirole Seroquel XR 3 SL Suboxone Film 3 E, N, SL Tolcapone 2 Xyrem 3 N, SL Zelapar 3 Ziprasidone Capsule 2 SL Zubsolv 2 N, SL Name Central Nervous System: Sedatives/Hypnotics Eszopiclone 2 SL Temazepam Capsule Triazolam Zaleplon Capsule SL Zolpidem Extended- Release 3 E, SL Zolpidem SL Central Nervous System: Seizure Disorders Carbamazepine Clonazepam Diazepam Divalproex Delayed- Release Divalproex Extended- Release Gabapentin Capsule, Lamotrigine Levetiracetam Extended-Release 2 Levetiracetam Lyrica 3 SDP, SL, ST Oxcarbazepine Phenytoin Capsule, Suspension Topiramate Zonisamide Capsule Bold type = Brand-name medication [Plain type = Generic medication] DSP = Designated Specialty Program E = May be excluded from coverage MC = Multiple Copayment N = Notification or precertification (sometimes referred to as preauthorization) required RS = May be eligible for the Refill and Save Program SDP = Select Designated Pharmacy SL = Supply Limit ST = Step Therapy 4

15 Name Dermatology Absorica 3 E, N Aczone 3 SL Adapalene 0.% 3 N, SL Cream, Gel Adapalene 0.3% Gel 3 N, SL Betamethasone Diproionate 0.05% Augmented Lotion, Ointment Betamethasone Dipropionate 0.05% Cream, Ointment Carac 2 Ciclopirox Cream, Gel, Lotion, Solution Claravis 2 N Clindamycin %/ Benzoyl Peroxide 5% Gel 3 E, SL Clindamycin.2%/ Benzoyl Peroxide 5% Gel 3 SL Clindamycin Gel 3 SL Clindamycin Lotion 3 Clindamycin Solution, Swabs Clobetasol Propionate Cream, Ointment, Solution 3 2 SL Clotrimazole- Betamethasone Cream SL Clotrimazole- Betamethasone Lotion Condylox Gel 3 Desonide 0.05% Cream, Lotion, Ointment 3 SL Name Desoximetasone Gel, Ointment 3 SL Differin % Cream, Gel 2 N, SL Diflorasone Diacetate 0.05% Cream, Ointment 3 SL Epiduo 3 SL Finacea 3 Fluocinolone Cream, Oil, Ointment, Solution 3 SL Fluocinonide 0.05% Cream Hydrocortisone 2.5% Cream, Ointment Imiquimod 5% Cream 2 SL Metronidazole Gel 0.75% Mirvaso 3 SL Mometasone Furoate Cream, Lotion, Ointment Mupirocin Ointment Nystatin-Triamcinolone Acetonide Cream, 3 E Ointment Oxsoralen-Ul 2 Picato 3 SL Regranex 2 N, SL Tacrolimus Ointment 2 N, SL Tazorac 3 N, SL Tretinoin N, SL Tretinoin Microspheres 3 E, N, SL Triamcinolone Acetonide Cream, Lotion, Ointment Vectical 3 SL 5

16 Name Diabetes: Blood Glucose Monitoring* Accu-Chek Test Strips 3 E, SL Contour Test Strips 3 E, SL Dexcom G4 Platinum Continuous Glucose 3 N, SL Monitoring System Dexcom Sensor 3 N, SL Dexcom Transmitter 3 N, SL FreeStyle Test Strips 3 E, SL OneTouch Test Strips SL OneTouch Ultra Meter OneTouch Ultra Mini OneTouch Ultra Test Strips SL OneTouch Verio OneTouch Verio IQ OneTouch Verio Sync OneTouch Verio Test Strips SL *Note: Diabetic supplies and prescription medications may be subject to different cost share arrangements. Please see your Summary of Benefits and Coverage (SBC) for specifics. Diabetes: Insulin* Afrezza 3 E, SL, ST Humalog KwikPen 2 SL Humalog Mix KwikPen 2 SL Humalog Mix KwikPen 2 SL Humalog Vials SL Humulin KwikPen 2 SL Humulin Vials SL Humulin N KwikPen 2 SL Humulin N Vials SL Name Humulin R Vials SL Lantus Solostar 3 SL Lantus Vials 3 SL Levemir FlexTouch SL Levemir Vials SL Novolin Vials 3 N, SL, ST Novolin N Vials 3 N, SL, ST Novolin R Vials 3 N, SL, ST Novolog Flexpen 3 N, SL, ST Novolog Mix 70/30 Flexpen 3 N, SL, ST Novolog Mix 70/30 Vials 3 N, SL, ST Novolog Vials 3 N, SL, ST *Note: Diabetic supplies and prescription medications may be subject to different cost share arrangements. Please see your Summary of Benefits and Coverage (SBC) for specifics. Diabetes: Non-Insulin* Bydureon 2 SL Byetta 2 SL Farxiga 3 N, SL, ST Glimepiride Glipizide Glipizide Extended-Release Glyburide Glyxambi 3 E, SL, ST Invokamet 2 SL Invokana 2 N, SL, ST Janumet 3 N, SL, ST Januvia 3 N, SL, ST Jardiance 2 N, SL, ST Jentadueto 2 SL Kazano 2 SL Kombiglyze XR 2 SL Metformin Bold type = Brand-name medication [Plain type = Generic medication] DSP = Designated Specialty Program E = May be excluded from coverage MC = Multiple Copayment N = Notification or precertification (sometimes referred to as preauthorization) required RS = May be eligible for the Refill and Save Program SDP = Select Designated Pharmacy SL = Supply Limit ST = Step Therapy 6

17 Name Metformin Extended- Release (generic Glucophage XR) Nesina 2 SL Onglyza 2 SL Oseni 2 SL Pioglitazone SL Tanzeum 2 SL Tradjenta 2 SL Trulicity 3 N, SL, ST Victoza 2-Pak 2 SL Victoza 3-Pak 3 SL Xigduo XR 3 E, SL, ST *Note: Diabetic supplies and prescription medications may be subject to different cost share arrangements. Please see your Summary of Benefits and Coverage (SBC) for specifics. Endocrine: Growth Hormone Nutropin, Nutropin AQ Endocrine: Other 2 DSP, N, SL Calcitriol Capsule Desmopressin Dexamethasone Methylprednisolone Prenisolone Oral Solution Prednisone Endocrine: Thyroid Hormone Replacement Armour Thyroid 3 Levothyroxine Sodium Liothyronine Sodium 2 Methimazole NP Thyroid Synthroid 2 Tirosint 3 E Name Eye Conditions: Allergies Azelastine 0.05% Ophthalmic Solution SL Lastacaft 3 SL Pataday 3 E, SL Patanol 3 E, SL Eye Conditions: Antibiotics Erythromycin 0.5% Ophthalmic Ointment Gentamicin Ophthalmic Ointment, Solution Moxeza 3 Ofloxacin 0.3% Ophthalmic Solution Tobramycin/ Dexamethasone 0.3%-0.% Ophthalmic 2 Suspension Tobramycin Ophthalmic Solution Vigamox 3 Eye Conditions: Glaucoma Alphagan P 0.% 2 SL Azopt 2 SL Combigan 2 SL Latanoprost 0.005% Ophthalmic Solution Lumigan 2 SL Timolol Maleate 0.25%, 0.5% Ophthalmic Solution Travatan Z 2 SL 7

18 Name Gastrointestinal: Acid Suppression Dexilant 3 SL Esomeprazole Capsule 3 E, SL Lansoprazole Capsules 3 E, SL Nexium Capsule 3 E, SL Omeclamox-Pak 3 SL Omeprazole Capsule Pantoprazole Pylera 3 SL Ranitadine Syrup Rabeprazole 3 SL Sucralfate Gastrointestinal: Nausea/Vomiting Akynzeo 3 SL Emend 2 SL Ondansetron Ondansetron ODT Transderm-Scop 3 Gastrointestinal: Other Amitiza 3 N, SL, ST Apriso 2 Asacol HD 3 E Canasa 2 Cortifoam 2 Creon 2 Delzicol 3 E Diphenoxylate-Atropine Golytely 2 Hyoscyamine Lialda 2 Name Linzess 2 N, SL Metoclopramide Movantik 2 N, SL Moviprep 3 Polyethylene Glycol Prepopik 3 Suclear 3 Sulfasalazine Suprep 3 Uceris 3 Zenpep 2 Hepatitis C Harvoni 2 DSP, N, SL Ribapak 3 DSP, N Ribavirin DSP Sovaldi 2 DSP, N, SL, ST Viekira Pak 3 DSP, N, SL, ST HIV/AIDS Atripla 2 DSP Complera 2 DSP Epzicom 2 DSP Evotaz 2 DSP Intelence 2 DSP Isentress 2 DSP Kaletra 2 DSP Lamivudine-Zidovudine DSP Nevirapine DSP Nevirapine Extended-Release 2 DSP Norvir 2 DSP Prezcobix 2 DSP Bold type = Brand-name medication [Plain type = Generic medication] DSP = Designated Specialty Program E = May be excluded from coverage MC = Multiple Copayment N = Notification or precertification (sometimes referred to as preauthorization) required RS = May be eligible for the Refill and Save Program SDP = Select Designated Pharmacy SL = Supply Limit ST = Step Therapy 8

19 Name Prezista 2 DSP Reyataz 2 DSP Stribild 3 DSP, ST Sustiva 2 DSP Tivicay 3 DSP Triumeq 2 DSP Truvada 2 DSP Tybost 2 DSP Viread 2 DSP Vitekta 2 DSP Infertility* Cetrotide 2 DSP, N Clomiphene DSP, N Gonal-F 2 DSP, N Gonal-F RFF 2 DSP, N Ovidrel 3 DSP, N *Coverage is determined by your prescription drug benefit plan. Inflammatory Conditions: Rheumatoid Arthritis, Crohn s Disease, Psoriasis, Ulcerative Colitis Actemra 3 DSP, N, SL, ST Cimzia 2 DSP, N, SL Cosentyx 3 DSP, N, SL, ST Enbrel 3 DSP, N, SL, ST Humira 2 DSP, N, SL Hydroxychloroquine Sulfate Leflunomide Methotrexate Orencia 3 DSP, N, SL, ST Otezla 3 DSP, N, SL, ST Otrexup 3 E, SL, ST Rasuvo 3 SL, ST Simponi 2 DSP, N, SL Stelara 2 DSP, N, SL Xeljanz 3 DSP, N, SL, ST Name Men s Health: Erectile Dysfunction Cialis 3 N, SL Levitra 3 N, SL Stendra 3 N, SL Viagra 3 N, SL Men s Health: Prostate Alfuzosin Cialis 3 N, SL, ST Doxazosin Finasteride Rapaflo 3 Tamsulosin Capsule Terazosin Capsule, Men s Health: Testosterone Therapy Androderm 2 N, SL Androgel 3 E, N, SL Android 2 Testim 2 N, SL Testosterone Cypionate Injection Miscellaneous Anastrozole Antipyrine/Benzocaine Otic Solution Aranesp 2 DSP, SL Auryxia 3 Benzonatate Capsule Bethkis 2 DSP, N, SL Bromfed DM 3 Cayston 2 N, SL Cerdelga 2 DSP, N Chlorhexidine Gluconate 9

20 Name Chlorpheniramine/ Hydrocodone/ Pseudoephedrine Solution 2 SL Ciprodex 2 Epipen 2 SL Epipen-Jr 2 SL Fosrenol 3 Hydrocodone/ Chlorpheniramine Suspension 3 SL Hydrocodone/ Homatropine Letrozole Lidocaine Transdermal Patch 2 SL Nuedexta 2 Pegasys 2 DSP, N, SL Phenazopyridine Procrit 2 DSP, SL Promethazine/Codeine Promethazine/ Dextromethorphan Pulmozyme 2 DSP, N, SL Rectiv 3 N, SL Renvela 2 Restasis 3 N, SL Rezira 3 Tobi Podhaler 3 DSP, N, SL Tobramycin Nebulized Solution 3 DSP, E, N, SL Velphoro 2 Name Musculoskeletal: Osteoporosis Alendronate Sodium SL Forteo 2 DSP, N Ibandronate 2 SL Raloxifene 2 Risedronate Sodium 3 SL Musculoskeletal: Other Allopurinol Baclofen Carisoprodol 350 mg Colcrys 3 E Cyclobenzaprine Metaxalone 3 Methocarbamol Mitigare 2 Tizanidine Uloric 3 SL, ST Musculoskeletal: Pain Relief Acetaminophen/ Codeine SL Celecoxib 3 SL Diclofenac Etodolac Capsule Fentanyl 2 mcg, 25 mcg, 50 mcg, 75 mcg, 00 mcg Patch 2 SL Bold type = Brand-name medication [Plain type = Generic medication] DSP = Designated Specialty Program E = May be excluded from coverage MC = Multiple Copayment N = Notification or precertification (sometimes referred to as preauthorization) required RS = May be eligible for the Refill and Save Program SDP = Select Designated Pharmacy SL = Supply Limit ST = Step Therapy 20

21 Name Fentanyl Citrate Lozenge 2 N, SL Hydrocodone/ Acetaminophen 5/325 mg, 7.5/325 mg, SL 0/325 mg Hydrocodone/Ibuprofen Hydromorphone Hysingla 3 E, N, SL, ST Ibuprofen Indomethacin Capsule Ketorolac Lazanda 3 N, SL Meloxicam Methadone, Oral Solution, SL Concentrate Solution Morphine Sulfate Extended-Release SL Morphine Sulfate Oral Solution Nabumetone Naproxen Nucynta 3 SL Nucynta ER 3 N, SL Opana ER 2 N, SL Oxycodone Oxycodone/ Acetaminophen 5/325 mg, 7.5/325 mg, 0/325 mg SL Oxycontin 3 N, SL, ST Sprix 3 Subsys 3 E, N, SL Tramadol- Acetaminophen SL Name Tramadol Sustained- Release 2 SL Tramadol Vicodin 5/300 mg, 7.5/300 mg, 3 E, SL 0/300 mg Voltaren Gel 2 Zohydro ER 3 N, SL, ST Overactive Bladder Dicyclomine Oxybutynin Extended- Release 2 Oxybutynin Tolterodine Extended- Release 3 E Tolterodine 3 E Toviaz 3 Vesicare 3 E Respiratory: Allergies Azelastine 0.% Nasal Spray 3 SL Clarinex 3 E, SL Clarinex-D 3 E, SL Cyproheptadine Fluticasone Nasal Spray 2 SL Hydroxyzine Capsule, Levocetirizine SL Nasonex 3 E, SL Promethazine Qnasl 3 E, SL Triamcinolone Nasal Spray 3 E, SL Zetonna 3 SL 2

22 Name Respiratory: Asthma/COPD Advair Diskus/HFA 3 RS, SL Aerospan 3 SL Albuterol Nebs Albuterol Sulfate Alvesco SL Arnuity Ellipta 3 SL Asmanex SL Breo Ellipta 3 RS, SL Budesonide Nebs 2 SL Combivent Respimat 3 SL Dulera 3 RS, SL Flovent Diskus/HFA 3 SL Foradil 3 SL Incruse Ellipta 2 SL Ipratropium-Albuterol Nebs Ipratropium Nebs Levalbuterol Nebs 3 E, SL Montelukast Chewable, SL Montelukast Granules 2 SL Perforomist 3 SL Proair HFA 3 SL Proventil HFA 3 SL Pulmicort Flexhaler 3 SDP, SL QVAR SL Serevent Diskus 3 SL Spiriva Handihaler 3 SL Spiriva Respimat 3 SL Striverdi Respimat 2 SL Symbicort 3 E, SL Name Tudorza 2 SL Ventolin HFA SL Xopenex HFA 3 SL Xopenex Nebs 3 E, SL Respiratory: Pulmonary Arterial Hypertension Adcirca 3 DSP, N, SL Adempas 2 DSP, N, SL Letairis 2 DSP, N, SL Opsumit 2 DSP, N, SL Orenitram 3 DSP, N, SL Sildenafil DSP, N, SL Tracleer 2 DSP, N, SL Tyvaso 2 DSP, N Smoking Cessation Bupropion Sustained- Release H Chantix 3 H, N Nicoderm CQ 3 H Nicorette Gum 3 H Nicorette Lozenge 3 H Nicorette Mini-Lozenge 3 H Nicotine Gum H Nicotine Lozenge H Nicotine Patch H Nicotrol Inhaler 3 H, N Nicotrol Nasal Spray 3 H, N Thrive Gum H Bold type = Brand-name medication [Plain type = Generic medication] DSP = Designated Specialty Program E = May be excluded from coverage MC = Multiple Copayment N = Notification or precertification (sometimes referred to as preauthorization) required RS = May be eligible for the Refill and Save Program SDP = Select Designated Pharmacy SL = Supply Limit ST = Step Therapy 22

23 Name Transplant Azathioprine Cellcept 3 DSP Cyclosporine Modified Capsule DSP Mycophenolate Capsule, Suspension DSP Mycophenolic Acid 2 DSP Myfortic 3 DSP Neoral 3 DSP Prograf 3 DSP Rapamune 3 DSP Sirolimus DSP Tacrolimus Capsule DSP Vitamins/Electrolytes Fluoride Folic Acid Klor-Con M0 Klor-Con M20 Potassium Chloride Potassium Citrate Women s Health: Contraceptives Apri H Aviane H Azurette 2 Cryselle H Cyclafem H Ella H Enskyce H Gildess 2 Gildess Fe H Introvale 2 H Jolessa 2 H Junel 2 Name Junel Fe H Levora-28 H Lo Loestrin Fe 3 Loryna 3 Low-Ogestrel H Lutera H Microgestin 2 Microgestin FE H Minastrin 24 FE 3 E Mononessa 3 Natazia H Necon 0.5/35, /35, /50, 0/ H Next Choice H Norgestimate-Ethinyl Estradiol 3 Nortrel 0.5/35 H Nuvaring 2 H Orsythia H Ortho-Cyclen H Ortho Micronor H Ortho-Novum 3 Ortho-Novum 7/7/7 H Ortho Tri-Cyclen H Ortho Tri-Cyclen Lo 3 Plan B One Step H Quasense 2 H Reclipsen H Sprintec 3 Sronyx H Tri-Previfem 3 Tri-Sprintec 3 Trinessa 3 Vestura 3 Viorele 2 Xulane 3 H Yasmin 28 H Yaz 2 23

24 Name Name Women s Health: Hormone Replacement Cenestin 3 E Climara 2 SL Climara Pro 3 SL Divigel 3 Duavee 3 Enjuvia 3 Estrace Cream 3 Estradiol/Norethindrone Acetate 2 Estradiol Estradiol Twice-Weekly Transdermal Patch 3 E, SL Estring 2 MC, SL Estrogen/ Methyltestosterone Evamist 2 Medroxyprogesterone Minivelle 3 SL Premarin 3 Premphase 3 Prempro 3 Progesterone Micronized Capsule 2 Vagifem 2 Vivelle-Dot 2 SL Women s Health: Miscellaneous Osphena 3 Raloxifene 2 H, N Tamoxifen H, N Women s Health: Prenatal Vitamins Brand Prenatal Vitamins 3 Bold type = Brand-name medication [Plain type = Generic medication] DSP = Designated Specialty Program E = May be excluded from coverage MC = Multiple Copayment N = Notification or precertification (sometimes referred to as preauthorization) required RS = May be eligible for the Refill and Save Program SDP = Select Designated Pharmacy SL = Supply Limit ST = Step Therapy 24

25 Index A Abilify...4 Absorica...5 Accu-Chek Test Strips...6 Acetaminophen/Butalbital/ Caffeine 325 mg/50 mg/ 40mg...3 Acetaminophen/Codeine...20 Actemra...9 Acyclovir Ointment...0 Acyclovir...0 Aczone...5 Adapalene 0.% Cream, Gel..5 Adapalene 0.3% Gel...5 Adcirca...22 Adderall XR...2 Adempas...22 Advair Diskus/HFA...22 Aerospan...22 Afrezza...6 Akynzeo...8 Albuterol Nebs...22 Albuterol Sulfate...22 Alendronate Sodium...20 Alfuzosin...9 Allopurinol...20 Alphagan P 0.%...7 Alprazolam Extended-Release...4 Alprazolam...4 Alvesco...22 Amiodarone...2 Amitiza...8 Amitriptyline...3 Amlodipine... Amlodipine-Valsartan... Amlodipine Besylate-Benazepril... Amoxicillin/Potassium Clavulanate Chewable,...0 Amoxicillin Capsule, Chewable...0 Amphetamine Salt Combo...2 Ampyra...3 Anastrozole...9 Androderm...9 Androgel...9 Android...9 Antipyrine/Benzocaine Otic Solution...9 Apri...23 Apriso...8 Aranesp...9 Aripiprazole...4 Armour Thyroid...7 Arnuity Ellipta...22 Asacol HD...8 Asmanex...22 Atenolol... Atenolol-Chlorthalidone... Atorvastatin...2 Atripla...8 Aubagio...3 Auryxia...9 Aviane...23 Avonex...3 Azathioprine...23 Azelastine 0.05% Ophthalmic Solution...7 Azelastine 0.% Nasal Spray..2 Azithromycin...0 Azopt...7 Azurette...23 B Baclofen...20 Benazepril Benazepril- Hydrochlorothiazide... Benicar... Benicar HCT... Benzonatate Capsule...9 Betamethasone Diproionate 0.05% Augmented Lotion, Ointment...5 Betamethasone Dipropionate 0.05% Cream, Ointment...5 Betaseron...3 Bethkis...9 Bicalutamide...0 Bidil... Bisoprolol... Bisoprolol- Hydrochlorothiazide... Bosulif...0 Brand Prenatal Vitamins...24 Breo Ellipta...22 Brintellix...3 Bromfed DM...9 Budesonide Nebs...22 Buprenorphine/Naloxone...4 Bupropion Extended-Release...3 Bupropion Sustained-Release...3, 22 Bupropion...3 Buspirone...4 Bydureon...6 Byetta...6 Bystolic... C Calcitriol Capsule...7 Canasa...8 Carac...5 Carbamazepine...4

26 Carbidopa-Levodopa...4 Carisoprodol 350 mg...20 Cartia XT... Carvedilol... Cayston...9 Cefadroxil Capsule,...0 Cefdinir Capsule...0 Cefixime Suspension...0 Cefprozil...0 Cefuroxime...0 Celecoxib...20 Cellcept...23 Cenestin...24 Cephalexin Capsule...0 Cerdelga...9 Cetrotide...9 Chantix...22 Chlorhexidine Gluconate...9 Chlorpheniramine/ Hydrocodone/ Pseudoephedrine Solution...20 Chlorthalidone... Choline Fenofibrate...2 Cialis...9 Ciclopirox Cream, Gel, Lotion, Solution...5 Cimzia...9 Ciprodex...20 Ciprofloxacin...0 Citalopram...3 Claravis...5 Clarinex...2 Clarinex-D...2 Clarithromycin...0 Climara...24 Climara Pro...24 Clindamycin %/Benzoyl Peroxide 5% Gel...5 Clindamycin.2%/Benzoyl Peroxide 5% Gel...5 Clindamycin Capsule...0 Clindamycin Gel...5 Clindamycin Lotion...5 Clindamycin Solution, Swabs...5 Clobetasol Propionate Cream, Ointment, Solution...5 Clomiphene...9 Clonazepam...4 Clonidine... Clopidogrel... Clotrimazole-Betamethasone Cream...5 Clotrimazole-Betamethasone Lotion...5 Colcrys...20 Combigan...7 Combivent Respimat...22 Complera...8 Concerta...2 Condylox Gel...5 Contour Test Strips...6 Copaxone...3 Cortifoam...8 Cosentyx...9 Creon...8 Crestor...2 Cryselle...23 Cyclafem...23 Cyclobenzaprine...20 Cyclophosphamide Capsule...0 Cyclosporine Modified Capsule...23 Cymbalta...3 Cyproheptadine...2 D Daytrana...2 Delzicol...8 Desmopressin...7 Desonide 0.05% Cream, Lotion, Ointment Desoximetasone Gel, Ointment...5 Dexamethasone...7 Dexcom G4 Platinum Continuous Glucose Monitoring System...6 Dexcom Sensor...6 Dexcom Transmitter...6 Dexilant...8 Dexmethylphenidate Extended-Release Capsule..2 Dexmethylphenidate...2 Dextroamphetamine- Amphetamine Extended-Release...2 Dextroamphetamine- Amphetamine...2 Dextroamphetamine Sulfate...2 Diazepam...4 Diclofenac...20 Dicyclomine...2 Differin % Cream, Gel...5 Dificid...0 Diflorasone Diacetate 0.05% Cream, Ointment...5 Digoxin...2 Diltiazem 24 Hour CD... Diltiazem Sustained-Release Capsule... Diltiazem Sustained-Release... Diovan... Diphenoxylate-Atropine...8 Divalproex Delayed-Release...4 Divalproex Extended-Release...4 Divigel...24

27 Donepezil 5, 0 mg ODT,...4 Doryx...0 Doxazosin..., 9 Doxazosin...9 Doxepin...3 Doxycycline Hyclate Capsule,...0 Doxycycline Monohydrate 50, 00 mg Capsule...0 Duavee...24 Dulera...22 Duloxetine Capsule...3 Dutoprol... E Econazole Cream...0 Edarbi... Edarbyclor... Effient... Eliquis... Ella...23 Emend...8 Enalapril... Enbrel...9 Enjuvia...24 Enoxaparin Sodium... Enskyce...23 Epiduo...5 Epipen...20 Epipen-Jr...20 Epzicom...8 Erythromycin 0.5% Ophthalmic Ointment...7 Escitalopram...3 Esomeprazole Capsule...8 Estrace Cream...24 Estradiol/Norethindrone Acetate...24 Estradiol...24 Estradiol Twice-Weekly Transdermal Patch...24 Estring...24 Estrogen/Methyltestosterone...24 Eszopiclone...4 Etodolac Capsule...20 Evamist...24 Evotaz...8 F Famciclovir...0 Farxiga...6 Fenofibrate 43, 50, 67, 30, 34, 50, 200 mg Capsule...2 Fenofibrate 48, 45 mg...2 Fenofibrate 54, 60 mg...2 Fenoglide...2 Fentanyl 2 mcg, 25 mcg, 50 mcg, 75 mcg, 00 mcg Patch...20 Fentanyl Citrate Lozenge...2 Fetzima...3 Finacea...5 Finasteride...9 Flecainide...2 Flovent Diskus/HFA...22 Fluconazole...0 Fluocinolone Cream, Oil, Ointment, Solution...5 Fluocinonide 0.05% Cream...5 Fluoride...23 Fluoxetine, Capsule...3 Fluticasone Nasal Spray...2 Fluvoxamine...3 Focalin XR...2 Folic Acid...23 Foradil...22 Forteo Fosrenol...20 FreeStyle Test Strips...6 Furosemide... G Gabapentin Capsule,...4 Gemfibrozil...2 Gentamicin Ophthalmic Ointment, Solution...7 Gildess...23 Gildess Fe...23 Gilenya...3 Glatopa...3 Gleevec...0 Glimepiride...6 Glipizide...6 Glipizide Extended-Release...6 Glyburide...6 Glyxambi...6 Golytely...8 Gonal-F...9 Gonal-F RFF...9 Guanfacine..., 2 Guanfacine Extended-Release...2 H Harvoni...8 Humalog KwikPen...6 Humalog Mix KwikPen...6 Humalog Mix KwikPen...6 Humalog Vials...6 Humira...9 Humulin KwikPen...6 Humulin Vials...6 Humulin N KwikPen...6 Humulin N Vials...6 Humulin R Vials...6 Hydralazine... Hydrochlorothiazide...

28 Hydrocodone/Acetaminophen 5/325 mg, 7.5/325 mg, 0/325 mg...2 Hydrocodone/ Chlorpheniramine Suspension...20 Hydrocodone/Homatropine...20 Hydrocodone/Ibuprofen...2 Hydrocortisone 2.5% Cream, Ointment...5 Hydromorphone...2 Hydroxychloroquine Sulfate...9 Hydroxyurea Capsule...0 Hydroxyzine Capsule,...2 Hyoscyamine...8 Hysingla...2 I Ibandronate...20 Ibuprofen...2 Imbruvica...0 Imiquimod 5% Cream...5 Incruse Ellipta...22 Indomethacin Capsule...2 Intelence...8 Introvale...23 Intuniv...3 Invokamet...6 Invokana...6 Ipratropium-Albuterol Nebs...22 Ipratropium Nebs...22 Irbesartan... Isentress...8 Isosorbide Mononitrate ER...2 Itraconazole Capsule...0 J Janumet...6 Januvia...6 Jardiance...6 Jentadueto...6 Jolessa...23 Junel...23 Junel Fe...23 K Kaletra...8 Kazano...6 Ketoconazole Cream...0 Ketorolac...2 Klor-Con M Klor-Con M Kombiglyze XR...6 L Labetalol... Lamivudine-Zidovudine...8 Lamotrigine...4 Lansoprazole Capsules...8 Lantus Solostar...6 Lantus Vials...6 Lastacaft...7 Latanoprost 0.005% Ophthalmic Solution...7 Latuda...4 Lazanda...2 Leflunomide...9 Lescol XL...2 Letairis...22 Letrozole...20 Leucovorin Calcium...0 Levalbuterol Nebs...22 Levemir FlexTouch...6 Levemir Vials...6 Levetiracetam Extended-Release...4 Levetiracetam...4 Levitra...9 Levocetirizine...2 Levofloxacin...0 Levora Levothyroxine Sodium...7 Lexapro...3 Lialda...8 Lidocaine Transdermal Patch...20 Linzess...8 Liothyronine Sodium..7 Lipitor...2 Lipofen...2 Lisinopril..., 33 Lisinopril- Hydrochlorothiazide... Lithium Capsule...4 Livalo...2 Lo Loestrin Fe...23 Lorazepam...4 Loryna...23 Losartan... Losartan- Hydrochlorothiazide... Lovastatin...2 Low-Ogestrel...23 Lumigan...7 Lutera...23 Lyrica...4 M Medroxyprogesterone...24 Meloxicam...2 Memantine...4 Mercaptopurine...0 Metadate CD...3 Metaxalone...20 Metformin... 6, 7 Metformin Extended-Release (generic Glucophage XR)...7 Methadone, Oral Solution, Concentrate Solution...2

29 Methimazole...7 Methocarbamol...20 Methotrexate...9 Methylphenidate Chewable...3 Methylphenidate Extended- Release Capsule...3 Methylphenidate Extended- Release...3 Methylphenidate...3 Methylprednisolone...7 Metoclopramide...8 Metoprolol Succinate 50, 00, 200 mg... Metoprolol Tartrate... Metronidazole Gel 0.75%...5 Metronidazole...0 Microgestin...23 Microgestin FE...23 Minastrin 24 FE...23 Minivelle...24 Minocycline Capsule...0 Minocycline...0 Mirtazapine...3 Mirvaso...5 Mitigare...20 Modafinil...4 Mometasone Furoate Cream, Lotion, Ointment...5 Mononessa...23 Montelukast Chewable,...22 Montelukast Granules...22 Morphine Sulfate Extended-Release...2 Morphine Sulfate Oral Solution...2 Movantik...8 Moviprep...8 Moxeza...7 Moxifloxacin...0 Mupirocin Ointment...5 Mycophenolate Capsule, Suspension...23 Mycophenolic Acid...23 Myfortic...23 N Nabumetone...2 Nadolol... Namenda XR...4 Naproxen...2 Naratriptan...3 Nasonex...2 Natazia...23 Necon 0.5/35, /35, /50, 0/...23 Neoral...23 Nesina...7 Nevirapine...8 Nevirapine Extended-Release.8 Nexium Capsule...8 Next Choice...23 Niacin Extended-Release...2 Niaspan...2 Nicoderm CQ...22 Nicorette Gum...22 Nicorette Lozenge...22 Nicorette Mini-Lozenge...22 Nicotine Gum...22 Nicotine Lozenge...22 Nicotine Patch...22 Nicotrol Inhaler...22 Nicotrol Nasal Spray...22 Nifedipine Extended-Release... Nitrofurantoin Capsule...0 Nitrofurantoin Macrocrystal Capsule...0 Nitrostat Norgestimate-Ethinyl Estradiol...23 Nortrel 0.5/ Nortriptyline Capsule...3 Norvir...8 Novolin Vials...6 Novolin N Vials...6 Novolin R Vials...6 Novolog Flexpen...6 Novolog Mix 70/30 Flexpen..6 Novolog Mix 70/30 Vials...6 Novolog Vials...6 Noxafil, Suspension...0 NP Thyroid...7 Nucynta...2 Nucynta ER...2 Nuedexta...20 Nutropin, Nutropin AQ...7 Nuvaring...23 Nuvigil...4 Nystatin-Triamcinolone Acetonide Cream, Ointment...5 Nystatin Cream, Ointment...0 O Ofloxacin 0.3% Ophthalmic Solution...7 Ofloxacin...0 Olanzapine...4 Omeclamox-Pak...8 Omega-3-Acid Ethyl Esters Capsule...2 Omeprazole Capsule...8 Ondansetron...8 Ondansetron ODT...8 OneTouch Test Strips...6 OneTouch Ultra Meter...6 OneTouch Ultra Mini...6 OneTouch Ultra Test Strips...6 OneTouch Verio...6

30 OneTouch Verio IQ...6 OneTouch Verio Sync...6 OneTouch Verio Test Strips...6 Onglyza...7 Opana ER...2 Opsumit...22 Oracea...0 Orencia...9 Orenitram...22 Orsythia...23 Ortho-Cyclen...23 Ortho-Novum...23 Ortho-Novum 7/7/ Ortho Micronor...23 Ortho Tri-Cyclen...23 Ortho Tri-Cyclen Lo...23 Oseni...7 Osphena...24 Otezla...9 Otrexup...9 Ovidrel...9 Oxcarbazepine...4 Oxsoralen-Ul...5 Oxybutynin Extended-Release...2 Oxybutynin...2 Oxycodone/Acetaminophen 5/325 mg, 7.5/325 mg, 0/325 mg...2 Oxycodone...2 Oxycontin...2 P Pantoprazole...8 Paroxetine...3 Pataday...7 Patanol...7 Pegasys...20 Penicillin V Potassium...0 Perforomist...22 Phenazopyridine...20 Phenytoin Capsule, Suspension...4 Picato...5 Pioglitazone...7 Plan B One Step...23 Polyethylene Glycol Potassium Chloride...23 Potassium Citrate...23 Pradaxa... Pramipexole...4 Pravastatin...2 Prednisone...7 Premarin...24 Premphase...24 Prempro...24 Prenisolone Oral Solution...7 Prepopik...8 Prezcobix...8 Prezista...9 Pristiq ER...3 Proair HFA...22 Procrit...20 Progesterone Micronized Capsule...24 Prograf...23 Promethazine/Codeine...20 Promethazine/ Dextromethorphan...20 Promethazine...2 Propranolol Extended-Release Capsule... Propranolol... Proventil HFA...22 Pulmicort Flexhaler...22 Pulmozyme...20 Pylera...8 Q Qnasl...2 Quasense Quetiapine...4 Quinapril... QVAR...22 R Rabeprazole...8 Raloxifene...20, 24 Raloxifene...20 Ramipril... Ranexa...2 Ranitadine Syrup...8 Rapaflo...9 Rapamune...23 Rasuvo...9 Rebif...3 Reclipsen...23 Rectiv...20 Regranex...5 Relpax...3 Renvela...20 Restasis...20 Revlimid...0 Reyataz...9 Rezira...20 Ribapak...8 Ribavirin...8 Risedronate Sodium...20 Risperidone...4 Rizatriptan ODT,...3 Ropinirole...4 S Savaysa... Serevent Diskus...22 Seroquel XR...4 Sertraline...3 Sildenafil...22 Simcor...2 Simponi...9 Simvastatin...2 Sirolimus...23 Solodyn...0

31 Sotalol...2 Sovaldi...8 Spiriva Handihaler...22 Spiriva Respimat...22 Spironolactone... Sprintec...23 Sprix...2 Sronyx...23 Stelara...9 Stendra...9 Strattera...3 Stribild...9 Striverdi Respimat...22 Suboxone Film...4 Subsys...2 Suclear...8 Sucralfate...8 Sulfamethoxazole- Trimethoprim...0 Sulfasalazine...8 Sumatriptan Nasal Spray...3 Sumatriptan Succinate, Injection...3 Sumavel DosePro...3 Suprax Capsule, Chewable,...0 Suprep...8 Sustiva...9 Sutent... Symbicort...22 Synthroid...7 T Tacrolimus Capsule...23 Tacrolimus Ointment...5 Tamiflu...0 Tamoxifen...24 Tamsulosin Capsule...9 Tanzeum...7 Tasigna... Tazorac...5 Tecfidera...3 Telmisartan... Telmisartan- Hydrochlorothiazide... Temazepam Capsule...4 Terazosin..., 9 Terazosin Capsule,...9 Terbinafine...0 Testim...9 Testosterone Cypionate Injection...9 Thrive Gum...22 Timolol Maleate 0.25%, 0.5% Ophthalmic Solution...7 Tirosint...7 Tivicay...9 Tizanidine...20 Tobi Podhaler...20 Tobramycin/Dexamethasone 0.3%-0.% Ophthalmic Suspension...7 Tobramycin Nebulized Solution...20 Tobramycin Ophthalmic Solution...7 Tolcapone...4 Tolterodine Extended-Release...2 Tolterodine...2 Topiramate...4 Toviaz...2 Tracleer...22 Tradjenta...7 Tramadol-Acetaminophen...2 Tramadol Sustained-Release...2 Tramadol...2 Transderm-Scop...8 Travatan Z...7 Trazodone...3 Tretinoin Tretinoin Microspheres...5 Tri-Previfem...23 Tri-Sprintec...23 Triamcinolone Acetonide Cream, Lotion, Ointment...5 Triamcinolone Nasal Spray...2 Triamterene- Hydrochlorothiazide... Triazolam...4 Tricor 48, 45 mg...2 Trilipix...2 Trinessa...23 Triumeq...9 Trulicity...7 Truvada...9 Tudorza...22 Tybost...9 Tyvaso...22 U Uceris...8 Uloric...20 V Vagifem...24 Valacyclovir...0 Valaganciclovir...0 Valsartan... Valsartan- Hydrochlorothiazide... Vascepa...2 Vectical...5 Velphoro...20 Venlafaxine Extended-Release Capsule...3 Venlafaxine...3 Ventolin HFA...22 Verapamil... Verapamil Sustained-Release... Vesicare...2 Vestura...23

32 Viagra...9 Vicodin 5/300 mg, 7.5/300 mg, 0/300 mg...2 Victoza 2-Pak...7 Victoza 3-Pak...7 Viekira Pak...8 Vigamox...7 Viibryd...3 Viorele...23 Viread...9 Vitekta...9 Vivelle-Dot...24 Voltaren Gel...2 Vytorin...2 Vyvanse...3 W Warfarin Sodium... Welchol...2 Wellbutrin XL...3 X Xarelto... Xeljanz...9 Xeloda... Xigduo XR...7 Xopenex HFA...22 Xopenex Nebs...22 Xulane...23 Xyrem...4 Y Yasmin Yaz...23 Z Zaleplon Capsule...4 Zelapar...4 Zenpep...8 Zetia...2 Zetonna...2 Ziprasidone Capsule...4 Zohydro ER...2 Zolpidem Extended-Release...4 Zolpidem...4 Zonisamide Capsule...4 Zovirax Cream...0 Zubsolv...4 Zytiga... 32

33 My Medications worksheet Take this worksheet with you each time you visit a doctor. Each of your doctors should be aware of every drug you take and you should have a list as well. Name of Medicine and Strength I Take This Medicine For Directions Doctor Example: Lisinopril, 20mg High blood pressure One tablet daily Dr. Johnson 33

34 Notes 34

35

36 For more information Call us at the toll-free phone number on your health plan ID card. TTY users can dial 7. Si usted necesita ayuda en español llame al número de teléfono en su tarjeta de identifi cación, , , or the phone number on your ID card for help in English and other languages. Or, visit oxfordhealth.com. All branded medications are trademarks or registered trademarks of their respective owners. Oxford HMO products provided by or through Oxford Health Plans (NY), Inc. and Oxford Health Plans (NJ), Inc. Oxford insurance products provided by or through Oxford Health Insurance, Inc. 205 Oxford Health Plans LLC. All rights reserved. Created September, Prescription List Oxford New York and New Jersey Advantage Three- 97 Rev 7 MS MT: /6