LDI 2016 PRESCRIPTION DRUG LIST

Transcription

1 LDI 06 PRESCRIPTION DRUG LIST PRESCRIPTION DRUG LIST FEATURES Quick-reference guide to the Formulary listing by specific drug class or major therapeutic use Reference for drugs available as generics Reference for Non-Preferred Brand Alternatives FORMULARY & BENEFIT QUESTIONS, PRIOR AUTHORIZATION Phone: or toll free AUTOMATED REFILLS ONLY Phone: or toll free YOUR PRESCRIPTION DRUG 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, 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. Effective January, 06 Health s Made Personal.

2 At LDI, 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. 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. 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.

3 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, 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 Mid-range Cost Highest Cost Lower-cost drugs. Some low-cost brands are also included. Mix of brands and generics. Use drugs for the lowest out-of-pocket costs. Use drugs, instead of to help reduce your out-of-pocket costs. Mostly higher-cost Many drugs have brand as well as lower-cost options in select generic drugs. 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. PROGRAMS AND LIMITS 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 AR SP Prior Authorization Your doctor is required to provide additional information to determine coverage. Step Therapy Trial of a lower cost medication is required before a higher-cost medication is covered. Quantity Limits Amount of medication covered per copayment or in a specific time period. Age Restrictions Some restrictions may apply based on patient age. Specialty Medication- Medication is designated as a specialty pharmacy drug. GR Gender Restrictions Some restrictions may apply based on patient gender.

4 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. INDEX Anti-Infectives... 5 Infertility... Cancer... 5 Inflammatory Conditions... Cardiovascular/Heart Disease.. 5, 6, 7 Men s Health... Central Nervous System... 7, 8, 9 Miscellaneous..., 4 Dermatology... 9, 0 Musculoskeletal... 4, 5 Diabetes... 9, 0, Overactive Bladder... 5 Endocrine... Respiratory... 5, 6 Eye Conditions..., Transplant... 6 Gastrointestinal..., Vitamins/Electrolytes... 6 HIV/AIDS... Women s Health

5 Name Anti-Infectives: Antibiotics Amoxicillin Amoxicillin/ Clavulanate Azithromycin Bethkis SP Cefadroxil Cap Cefdinir Cefuroxime Tab Cephalexin Ciprodex Otic Suspension Ciprofloxacin Tab Clarithromycin Clindamycin Cap Dificid PA Doxycycline Hyclate Cap Doxycycline Hyclate Tab (Immediate Release) Doxycycline Monohydrate Cap Doxycycline Monohydrate Oral Suspension, Tab Erythromycin Levofloxacin Tab Metronidazole Tab Minocycline Cap Moxifloxacin Neomycin/ Polymyxin/ HC Otic Suspension, Nitrofurantoin Macrocrystalline Name Nitrofurantoin Monohydrate Macrocrystalline Ofloxacin Otic Oracea QL Penicillin VK Solodyn QL Sulfamethoxazole- Trimethoprim Sulfamethoxazole- Trimethoprim DS Anti-Infectives: Antifungals Fluconazole Nystatin Oral Powder Nystatin Suspension Terbinafine Tab Anti-Infectives: Antivirals Acyclovir Cap, Tab, Suspension Baraclude QL, SP Entecavir QL, SP Famciclovir Tab Harvoni PA, QL, SP Pegasys PA, SP Sovaldi PA, QL, ST, SP Tamiflu QL Valacyclovir QL Cancer Anastrozole Tab Capecitabine SP Gleevec PA, QL, SP Letrozole PA Revlimid PA, QL, SP Tamoxifen Tab Tasigna PA, QL, SP 5

6 Name Temozolomide PA, SP Zytiga PA, SP Cardiovascular/Heart Disease: Anticoagulants Brilinta QL Clopidogrel QL Effient QL Eliquis QL Enoxaparin QL Pradaxa QL Savaysa QL Warfarin Xarelto QL Cardiovascular/Heart Disease: High Blood Pressure Amlodipine QL Amlodipine/ Benazepril QL Amlodipine/ Valsartan QL Amlodipine/ Valsartan/ HCTZ 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 Patch QL Clonidine Tab Coreg CR QL, ST Diltiazem Tab Diovan QL, ST Name Doxazosin Dutoprol QL Edarbi QL, ST Edarbyclor QL, ST Enalapril Enalapril/HCTZ Felodipine QL Fosinopril Furosemide Guanfacine Tab (Immediate Release) Hydralazine Hydrochlorothiazide Irbesartan QL Irbesartan/HCTZ QL Labetalol Lisinopril Lisinopril/HCTZ Losartan QL Losartan/HCTZ QL Metoprolol Succinate Metoprolol Tartrate Nadolol Nifedipine ER Propranolol Propranolol ER Quinapril Ramipril QL Spironolactone Tekturna QL, ST Tekturna HCT QL, ST Telmisartan QL Terazosin Torsemide Tab Triamterene/HCTZ Tribenzor QL, ST Valsartan QL Valsartan/HCTZ QL Verapamil ER 6

7 Name Cardiovascular/Heart Disease: High Cholesterol Atorvastatin QL Cholestyramine Crestor QL Fenofibrate 4 mg, 48mg, 50mg, 54mg, 67mg, 0mg, 4mg, QL 45mg, 50mg, 60mg, 00mg Fenofibrate 0 mg QL, ST Gemfibrozil QL Lipitor QL, ST Livalo QL, ST Lovastatin Lovaza QL Niacin ER Tab QL Omega- Acid Cap gm QL Pravastatin Simcor QL Simvastatin 5 mg, 0mg, 0 mg, QL 40 mg Simvastatin 80 mg PA, QL Vascepa QL Vytorin 0-0mg, 0-0mg, QL 0-40mg Vytorin PA, QL Welchol QL Zetia QL Cardiovascular/Heart Disease: Other Amiodarone Amlodipine/ Atorvastatin QL, ST Digoxin Flecainide Isosorbide Mononitrate Name Nitrostat Ranexa ST Sotalol Cardiovascular/Heart Disease: Pulmonary Arterial Hypertension Adcirca PA, QL, SP Adempas PA, QL, SP Letairis PA, QL, SP Opsumit PA, QL, SP Orenitram PA, SP Sildenafil Tab 0 mg PA, QL, SP Tracleer PA, QL, SP Central Nervous System: Attention Deficit Disorder Adderall XR Cap QL, ST, AR Amphetamine- Dextroamphetamine Tab Amphetamine- Dextroamphetamine SR 4Hr Cap QL, AR QL, ST, AR Dexmethylphenidate ER Cap QL, ST, AR Focalin XR QL, ST, AR Guanfacine ER Tab QL Intuniv QL Methylphenidate ER Cap QL, ST, AR Methylphenidate ER Tab QL, AR Methylphenidate SA Osmotic ER Tab QL, ST, AR Methylphenidate Tab QL, AR Strattera QL Vyvanse QL, AR Central Nervous System: Depression Amitriptyline Bupropion 7

8 Name Bupropion ER Bupropion SR Bupropion XL QL Citalopram QL Doxepin Duloxetine Cap 0 mg, 0 mg, QL 60 mg Escitalopram Tab QL Fluoxetine Cap (not PMDD) Fluvoxamine Tab Forfivo XL QL Mirtazapine Nortriptyline Paroxetine Tab Pristiq QL Sertraline Trazodone Venlafaxine Tab Venlafaxine ER Cap QL Venlafaxine ER Tab QL Viibryd QL, ST Central Nervous System: Migraine Butalbital- Acetaminophen- Caffeine Cap, Tab QL mg Migranal QL Relpax QL Rizatriptan Tab, ODT QL Sumatriptan Tab and Spray QL Sumavel Dose QL Zolmitriptan Tab QL Zomig Nasal Spray QL * Preferred 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 Copaxone PA, QL, SP Gilenya* PA, QL, ST, SP Plegridy PA, QL, SP Rebif PA, QL, ST, SP Rebif Titrtn PA, QL, ST, SP Tecfidera PA, QL, SP Central Nervous System: Other Abilify Tab QL Alprazolam Tab QL Aripiprazole QL Benztropine Buspirone Carbidopa/ Levodopa Tab (Immediate Release) Diazepam Tab Donepezil Tab QL Hydroxyzine HCL Hydroxyzine Pamoate Latuda QL, ST Lithium Carbonate Lorazepam Tab QL Modafinil PA, QL Namenda Tab QL Namenda XR Cap QL Nuvigil PA, QL Olanzapine Tab QL Pramipexole Prochlorperazine 8

9 Name Quetiapine QL Risperidone Tab QL Ropinirole (Immediate Release) Saphris QL Seroquel XR QL Zelapar Ziprasidone Cap QL, ST Central Nervous System: Sedatives/ Hypnotics Eszopiclone Tab QL Silenor 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 Tab, Chew Lamictal ODT Lamictal XR QL Lamotrigine (Immediate Release) Lamotrigine ER QL Levetiracetam Levetiracetam ER QL Lyrica Cap QL Onfi PA, SP Oxcarbazepine Phenytoin Primidone Topiramate Tab Zonisamide Dermatology Acanya Gel QL Name Acyclovir Ointment 5% Aczone Gel Atralin QL, AR Benzaclin QL Betamethasone Dipropionate Cream Ciclopirox Cream Clindamycin Gel, Lotion, Clindamycin/ Benzoyl Peroxide QL Gel -5% Clindamycin/ Benzoyl Peroxide QL Gel.-5% Clobetasol Cream, Ointment, Clobex Cloderm Clotrimazole/ Betamethasone Cream, Lotion Desonide Cream, Ointment Desoximetasone Cream, Gel, Ointment Differin QL Econazole Cream Elidel QL, ST, AR Epiduo QL Finacea Fluocinonide Cream, 0.% Fluocinonide Cream, Gel, Ointment, 0.05% 9

10 Name Hydrocortisone Cream, Ointment.5% Lidocaine Topical Ointment, Lidocaine/Prilocaine Cream Ketoconazole Cream/ Shampoo Metrogel Metronidazole Gel 0.75% Mometasone Mupirocin Ointment Nystatin Cream, Ointment, Powder Nystatin/ Triamcinolone Cream, Ointment Oxsoralen-UL PA Permethrin Cream 5% Protopic Ointment QL, AR Retin-A Micro QL, AR Sulfacetamide/ Sulfur Emulsion Taclonex QL Tretinoin Cream AR Tretinoin Microsphere Gel QL, AR Triamcinolone Vectical Zovirax Cream Zovirax Ointment Zyclara QL Name Diabetes/Endocrine Blood: Glucose Monitoring Accu-Chek Active Glucose Control Liquid Accu-Chek Active Test Strips QL Accu-Chek Aviva Plus Control Liquid Accu-Chek Aviva Plus Kit Accu-Chek Aviva Plus Test Strips QL Accu-Chek Comfort Curve Control Liquid Accu-Chek Comfort Curve Test Strips QL Accu-Chek Compact Plus Control Liquid Accu-Chek Compact Plus Kit Accu-Chek Compact Plus Test Strips QL Accu-Chek FastClix Kit Accu-Chek FastClix Lancets Accu-Chek Multiclix Kit Accu-Chek Multiclix Lancets Accu-Chek Nano Kit Accu-Chek SmartView Control Liquid Accu-Chek SmartView Test Strips QL 0

11 Name Accu-Chek Softclix Kit Accu-Chek Softclix Lancets Accu-Chek Soft Touch Lancets Bayer Contour Test Strips PA, QL Dexcom G4 Platinum Kit Dexcom G4 Platinum Sensor Kit Dexcom G4 Platinum Transmitter Kit Freestyle Test Strips PA, QL Glucocard Test Strips PA, QL Insulin Pen Needle Insulin Syringe/ Needle Novofine Pen Needle Novofine Autocover Pen Needle Novotwist Pen Needle Onetouch Kit Ultra Smart Onetouch Kit Ultra Onetouch Kit Ultra Onetouch Kit Ultra Mini Onetouch Kit Verio IQ Onetouch Lancets Name Onetouch Test Strips QL Onetouch Ultra Blue Test Strips QL Onetouch Verio Test Strips QL Precision Test Strips PA, QL Truetest Test Strips PA, QL Truetrack Test Strips PA, QL Diabetes/Endocrine: Insulin Humalog Vials Humalog Kwik Pen 00 unit/ml Humalog Mix 50/50 Kwik Pen Humalog Mix 50/50 Vials Humalog Mix 75/5 Kwik Pen Humalog Mix 75/5 Vials Humulin 70/0 Vials Humulin N Vials Humulin N Pen Humulin Pen 70/0 Humulin R U-500 Humulin R Vials Lantus Solostar Lantus Vials Levemir FlexTouch Levemir Vials Novolin 70/0 Vials Novolin N Vials Novolin R Vials Novolog Flexpen

12 Name Novolog Mix Flexpen Novolog Mix 70/0 Vials Novolog Penfill Novolog Vials Diabetes/Endocrine: Non-Insulin Bydureon QL, ST Byetta QL, ST Glimepiride Glipizide Glipizide ER Glipizide XL Glumetza PA Glyburide Glyburide/ Metformin Invokamet QL, ST Invokana QL, ST Janumet QL, ST Janumet XR QL, ST Januvia QL, ST Jardiance QL, ST Kombiglyze QL, ST Metformin Metformin ER Onglyza QL, ST Pioglitazone QL Victoza QL, ST Endocrine: Growth Hormone Nutropin AQ PA, SP Omnitrope PA, ST, SP Saizen PA, SP Zomacton PA, ST, SP Endocrine: Other Calcitriol Cap Dexamethasone Tab Hydrocortisone Tab Name Lupron Depot.75 mg,.5 mg PA, SP Lupron Depot 7.5 mg,.5 mg, PA, SP 0 mg, 45 mg Methylprednisolone Tab Prednisone Prednisolone 5 mg/5 ml Prednisolone Syrup, 5 mg/5 ml Sensipar SP Endocrine: Thyroid Hormone Replacement Armour Thyroid Levothyroxine Liothyronine Methimazole Synthroid Tirosint Eye Conditions: Allergies Azelastine Ophthalmic Pataday Patanol QL Eye Conditions: Antibiotics Ciprofloxacin Ophthalmic QL Erythromycin Ointment Gentamicin Moxeza QL

13 Name Neomycin/ Polymyxin B/ Dexamethasone Ointment, Suspension Ofloxacin Ophthalmic QL Polymyxin B/ Trimethoprim Tobramycin Tobramycin/ Dexamethasone Vigamox QL Eye Conditions: Glaucoma Alphagan P QL Azopt QL Brimonidine Combigan QL Dorzolamide-Timolol Maleate Latanoprost QL Lumigan QL Timolol Timoptic Ocudose Travatan Z QL Eye Conditions: Other Durezol Ophthalmic Emulsion Lotemax Ophthalmic Gel Ketorolac Ophthalmic QL Prednisolone Ophthalmic Suspension Restasis PA Name Gastrointestinal: Acid Suppression Carafate Suspension Dexilant QL Esomeprazole (Rx only) 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, ST Ranitidine Tab, Cap, Syrup (Rx only) Sucralfate Tab Gastrointestinal: Nausea/Vomiting Meclizine Metoclopramide QL Ondansetron Tab QL Transderm-Scop Gastrointestinal: Other Amitiza QL, ST, AR Apriso QL, ST Asacol HD QL, ST Canasa QL Creon Delzicol QL, ST Dicyclomine Diphenoxylate/ Atropine Gavilyte QL Hyoscyamine Sublingual Tab Lactulose Lialda QL

14 Name Linzess QL, ST, AR Movantik QL Moviprep QL Omeclamox Pak QL Pentasa QL Polyethylene Glycol 50 Powder Prepopik Protosol HC Pylera QL Sulfasalazine Suprep Bowel Prep QL Uceris Zenpep HIV/AIDS Atripla SP Complera SP Epzicom SP Intelence SP Isentress SP Kaletra SP Nevirapine SP Norvir SP Prezista SP Reyataz SP Stribild SP Sustiva SP Tivicay SP Triumeq SP Truvada SP Viread SP Infertility Cetrotide SP Follistim AQ PA, SP Gonal-f PA, SP Gonal-f RFF PA, SP Ovidrel SP Name Inflammatory Conditions Cimzia Kit PA, QL, SP Depen Humira Kit PA, QL, SP Humira Pen Kit PA, QL, SP Humira Pen Kit Crohns PA, QL, SP Humira Pen Kit Psoriasis PA, QL, SP Hydroxychloroquine Methotrexate Tab Orencia SC PA, QL, ST, SP Rasuvo PA, QL, ST, SP Simponi PA, QL, SP Stelara PA, QL, SP Men s Health: Erectile Dysfunction Cialis QL, AR, GR Levitra QL, AR, GR Stendra QL, AR, GR Viagra QL, AR, GR Men s Health: Prostate Alfuzosin QL Avodart QL Doxazosin Finasteride 5 mg QL Jalyn QL Rapaflo QL Tamsulosin QL Terazosin Men s Health: Testosterone Therapy Androderm PA, QL, GR Androgel.6% PA, QL, GR Androgel % PA, QL, GR 4

15 Name Testosterone Cypionate IM Injection Miscellaneous PA Allopurinol Antipyrine/ Benzocaine Otic % Aranesp PA, SP Benzonatate Botox 00, 00 unit Injection (non PA, SP cosmetic) Bunavail PA, QL Cerdelga PA, QL, SP Chantix QL Cheratussin Chlorhexidine Colcrys QL Cyproheptadine Desmopressin Epipen -Pak QL Euflexxa PA, SP Fosrenol Guaifenesin/Codeine Syrup Homatropine/ Hydrocodone Syrup Hydrocodone/ Chlorpheniramine Liquid Hydrocortisone AC Suppository 5 mg Hydromet Lidocaine Viscous % Makena PA, SP Name Phenazopyridine (Rx only) Phentermine Tab PA Procrit PA, SP Promethazine DM Syrup AR Promethazine/ Codeine Syrup AR Pulmozyme SP Rectiv Renvela Tab Rezira Suboxone Film PA, QL Synagis PA, SP Synvisc PA, SP Uloric QL, ST Ursodiol Velphoro Zostavax Injection Zubsolv PA, QL Zutripro Musculoskeletal: Osteoporosis Alendronate Tab Evista QL Forteo PA, SP Ibandronate Tab QL Raloxifene QL Musculoskeletal: Other Baclofen Tab Carisoprodol 50 mg Cyclobenzaprine Tab 5, 0 mg Metaxalone Methocarbamol Tizanidine Cap Tizanidine Tab 5

16 Name Musculoskeletal: Pain Relief Acetaminophen w/ Codeine QL Cambia QL Celebrex QL Celecoxib QL Diclofenac Tab QL Endocet Tab QL Etodolac QL Fentanyl Patch 5 mcg/hr, 50 mcg/hr, 75 mcg/ QL hr, 00 mcg/hr Fentanyl Patch 7.5 mcg/hr, 6.5 mcg/hr, QL 87.5 mcg/hr Gralise QL, ST Hydrocodone w/ Ibuprofen Tab QL mg Hydrocodone/APAP 5, 7.5, 0/5 mg QL Hydromorphone Tab Ibuprofen Tab 400, 600, 800 mg (Rx QL only) Indomethacin Cap QL Ketorolac Tab QL Lazanda PA, QL Lidocaine Patch 5% QL Meloxicam QL Methadone Tab Morphine Sulfate Tab QL Nabumetone QL Naproxen (Rx only) QL Nucynta QL Nucynta ER PA, QL Opana ER QL Name Oxycodone Tab 5, 0, 5, 0 mg (Immediate Release) Oxycodone w/ Acetaminophen QL Oxycontin QL Tramadol Tab 50 mg QL Tramadol w/acetaminophen QL Vicodin QL Vicodin ES QL Voltaren Gel QL Overactive Bladder Enablex QL Gelnique QL Myrbetriq QL, ST Oxybutynin Oxybutynin ER QL Tolterodine QL, ST Toviaz QL Vesicare QL Respiratory: Asthma/COPD Advair Diskus QL Advair HFA QL Aerospan QL Albuterol Nebulizer Breo Ellipta QL Budesonide Inhalation Suspension Combivent Respimat QL Dulera QL, ST Flovent Diskus QL Flovent HFA QL Foradil QL, ST Incruse Ellipta QL 6

17 Name Ipratropium/ Albuterol Levalbuterol Nebulizer Montelukast QL Perforomist QL Proair HFA, RespiClick QL Proventil HFA QL, ST Pulmicort Flexhaler QL QVAR QL Serevent Diskus QL, ST Spiriva Handihaler QL Spiriva Respimat QL Symbicort QL Tudorza Pressair QL Ventolin HFA QL Xolair PA, SP Xopenex HFA QL, ST Respiratory: Nasal Allergies Azelastine Spray QL Dymista Spray QL Fluticasone Spray Ipratropium Spray Nasonex QL Omnaris QL QNasl QL Triamcinolone Spray QL Veramyst QL Zetonna QL Respiratory: Oral Allergies Cetirizine Promethazine Tab AR Desloratadine QL Levocetirizine QL Transplant Azathioprine Tab Name Cellcept Tab/ Suspension SP Cyclosporine Cap SP Mycophenolate Mofetil 50 mg SP Cap/ 500 mg Tab Mycophenolate Sodium 80 mg, SP 60 mg Tab Prograf Cap SP Rapamune SP Tacrolimus Cap SP Vitamins/Electrolytes Cyanocobalamine Injection Folic Acid mg (Rx only) Klor-Con 8 and 0 MEQ Klor-Con M0 and M0 Multi-Vit/Fl Chew Potassium Chloride ER Tab, Cap Potassium Chloride Micro ER Tab Potassium Citrate 540 mg, 080 mg Tab Vitamin D 50,000 units (Rx only) Women s Health: Birth Control Apri GR Aviane GR Azurette GR Beyaz GR Cryselle-8 GR Falmina GR Generess Fe Chewable GR 7

18 Name Gianvi GR Gildess Fe GR Jolivette GR Junel GR Kariva GR Levora 8 GR Lo Loestrin GR Lomedia Fe GR Loryna GR Low-Ogestrel GR Lutera GR Medroxyprogesterone Acetate Injection QL Microgestin GR Microgestin Fe GR Minastrin 4 Fe Chewable GR Mono-Linyah GR Mononessa GR Natazia GR Necon GR Nora-Be GR Norgest/Ethi Estradio GR Nortrel GR Nuvaring Ocella GR Orsythia GR Ortho Tri-Cyclen Lo GR Previfem GR Reclipsen GR Safyral GR Sprintec 8 GR Tri-Linyah GR Tri-Previfem GR Trinessa GR Tri-Sprintec GR Vestura GR Viorele GR Xulane GR Zarah GR Name Women s Health: Hormone Replacement Climara Pro QL, GR Divigel GR Duavee QL, GR Estrace Vaginal Cream Estradiol Tab QL, GR Estradiol/Norethindrone Tab Medroxyprogesterone Acetate Tab QL, GR Minivelle QL, GR Osphena Premarin Tab QL, GR Premarin Vaginal Cream Premphase QL, GR Prempro QL, GR Progesterone Cap Vagifem GR Vivelle-Dot QL, GR Women s Health: Vaginal Anti- Infectives Gynazole- Vaginal Cream Metronidazole Vaginal Gel Terconazole Vaginal Cream QL 8

19 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 9