Your 2014 Prescription Drug List

Transcription

1 Your 204 Prescription List 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 Locate a participating retail pharmacy by zip code. Look up possible lower-cost medication alternatives. Compare medication pricing and options. OptumRx

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 for complete and up-to-date drug information Since the PDL may change, we encourage you to visit our website, 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 2

3 Table of Contents tiers and cost Programs 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... 2 Other Sedatives/Hypnotics... 2 Seizure Disorders... 2 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... 5 Other HIV/AIDS... 6 Infertility... 6 Inflamatory Conditions 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 Contraceptives Hormone Replacement Prenatal Vitamins Vaginal Anti-Infectives Index

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 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 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 2 or 3, 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 2 Mid-range Cost 3 Highest Cost Lower-cost, commonly used generic drugs. Some low-cost brands are also included. Many common brand name drugs, called preferred brands. Mostly higher-cost brand drugs, also known as nonpreferred brands. Use drugs for the lowest out-ofpocket 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 plan, the tier cost levels will apply once you hit your deductible. Refer to your enrollment and plan materials on 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 Programs 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 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. 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 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 or similar as 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. These medications may not be covered under your pharmacy benefit, and 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 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 or call the toll-free member phone number on the back of your ID card for more current information. When you register at 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, 24 hours a day, 7 days a week using the toll-free member phone number on the back of your ID card. Or visit 8

9 Name Name Anti-Infectives: Antibiotics Amoxicillin Amoxicillin/Clavulanate Avelox 2 Azithromycin Cefdinir Cefuroxime Tab Cephalexin Ciprodex Otic Suspension 3 Ciprofloxacin Clarithromycin Clindamycin Cap Dificid 3 PA Doxycycline Hyclate Levofloxacin Metronidazole Tab Minocycline Neomycin/Polymyxin/HC Otic Suspension Nitrofurantoin Macrocrystalline Nitrofurantoin Monohydrate Macrocrystalline Ofloxacin Otic Solution Oracea 3 QL Penicillin VK Solodyn 3 QL Sulfamethoxazole- Trimethoprim Sulfamethoxazole- Trimethoprim DS Anti-Infectives: Antifungals Econazole Fluconazole Ketoconazole Nystatin Terbinafine Anti-Infectives: Antivirals Acyclovir Baraclude 2 QL, SP Incivek 2 PA, QL, SP Pegasys 2 PA, SP Tamiflu 3 QL Valacyclovir Cancer Anastrozole Gleevec 2 PA, QL, SP Letrozole Revlimid 3 PA, QL, ST, SP Tamoxifen Tasigna 2 PA, QL, SP Temodar 2 PA, SP Xeloda 2 SP Cardiovascular/Heart Disease: Anticoagulants Aggrenox 2 QL Brilinta 2 QL Clopidogrel QL Coumadin 3 Effient 2 QL Enoxaparin SP Pradaxa 2 QL Warfarin Xarelto 2 QL [Plain type = Generic drug] 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 2 QL, ST Benazepril Benazepril/HCTZ Benicar 2 QL, ST Benicar HCT 2 QL, ST Bisoprolol Bisoprolol/HCTZ Bystolic 2 QL Carvedilol Chlorthalidone Clonidine Tab Coreg CR 3 QL, ST Diltiazem Diltiazem SR 24HR Diovan 2 QL, ST Diovan HCT 3 QL, ST Doxazosin Dutoprol 2 QL Edarbi 3 QL, ST Edarbyclor 3 QL, ST Enalapril Exforge 2 QL, ST Exforge HCT 2 QL, ST Felodipine QL Fosinopril Furosemide Hydralazine Hydrochlorothiazide Irbesartan QL, ST Labetalol Lisinopril Lisinopril/HCTZ Losartan QL Losartan/HCTZ QL Matzim LA QL Metoprolol Succinate Metoprolol Tartrate Name Micardis 2 QL, ST Micardis HCT 2 QL, ST Nadolol Nifedipine ER Propranolol Propranolol ER Quinapril Ramipril QL Spironolactone Tarka 2 Tekturna 2 QL, ST Tekturna HCT 2 QL, ST Terazosin Triamterene/HCTZ Tribenzor 2 QL, ST Valsartan/HCTZ QL Verapamil ER Verapamil SR Cardiovascular/Heart Disease: High Cholesterol Atorvastatin QL Crestor 2 QL Fenofibrate QL Fenoglide 3 QL, ST Gemfibrozil QL Lipitor 3 QL, ST Lipofen 2 QL Livalo 3 QL, ST Lovastatin Lovaza 2 QL Niaspan ER 3 QL Pravastatin Simcor 2 QL Simvastatin QL Simvastatin 80 mg PA, QL Tricor 3 QL Triglide 3 QL, ST Trilipix 3 QL Vytorin 2 QL Vytorin Tab 0-80 mg 2 PA, QL Welchol 2 QL Zetia 3 QL [Plain type = Generic drug] 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 Digoxin Isosorbide Mononitrate Nitrostat 2 Ranexa 2 ST Sotalol Cardiovascular/Heart Disease: Pulmonary Arterial Hypertension Letairis 2 PA, QL, SP Tracleer 2 PA, QL, SP Central Nervous System: Attention Deficit Disorder Amphetamine- Dextroamphetamine QL, AR Amphetamine- Dextroamphetamine QL, ST, AR Cap SR 24HrR Focalin XR 3 QL, ST, AR Intuniv 2 QL, AR Methylphenidate Cap ER QL, ST, AR Methylphenidate Tab ER QL, AR Methylphenidate HCl Tab Sa Osm ER QL, ST, AR Methylphenidate Tab QL, AR Strattera 2 QL, AR Vyvanse 2 QL, AR Central Nervous System: Depression Amitriptyline Budeprion XL QL Bupropion Bupropion SR Buspirone Citalopram QL Cymbalta 2 Doxepin Escitalopram QL Fluoxetine Lexapro 3 QL Mirtazapine Nortriptyline Paroxetine Pristiq 2 QL Sertraline Trazodone Venlafaxine Venlafaxine ER Cap QL Central Nervous System: Migraine Butalbital- Acetaminophen- QL Caffeine Migranal 3 QL Phrenilin 3 QL Relpax 3 QL Sumatriptan QL Sumavel Dose 3 QL Zomig Nasal Spray 2 QL [Plain type = Generic drug] 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 2 PA, QL, SP Avonex 2 PA, QL, SP Avonex Pen 2 PA, QL, SP Avonex Prefill 2 PA, QL, SP Betaseron 2 PA, QL, SP Copaxone 2 PA, QL, SP Gilenya* 3 PA, QL, ST, SP Rebif 3 PA, QL, ST, SP Rebif Titrtn 3 PA, QL, ST, SP Tecfidera 2 PA, QL, SP Central Nervous System: Other Abilify 2 QL Abilify Disc 2 QL Abilify Solution 2 QL Alprazolam Tab QL Aricept 23 mg 3 QL, ST Azilect 3 Benztropine Carbidopa & Levodopa Diazepam Donepezil QL Hydroxyzine HCl Hydroxyzine Pamoate Lithium Carbonate Lorazepam QL Modafinil PA, QL Namenda 2 QL Olanzapine QL Pramipexole Prochlorperazine Quetiapine QL Risperidone QL Ropinirole Saphris 2 QL Seroquel XR 2 QL Xanax 3 QL Zelapar 3 Name Central Nervous System: Sedatives/Hypnotics Lunesta 3 QL Silenor 3 QL Temazepam QL Zolpidem QL Zolpidem ER QL Central Nervous System: Seizure Disorders Carbamazepine Clonazepam QL Divalproex DR Divalproex ER Gabapentin Lamictal 2 Lamictal ODT 2 Lamictal XR 2 QL Lamotrigine Levetiracetam Levetiracetam ER QL Lyrica 2 QL Oxcarbazepine Phenytoin Topiramate * 3 Preferred [Plain type = Generic drug] PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions 2

13 Name Dermatology Acanya 3 QL Atralin 2 QL, AR Benzaclin 3 QL Carac 2 Clindamycin Clindamycin/Benzoyl Peroxide QL Clobetasol Clobex 3 Cloderm 3 Clotrimazole/ Betamethasone Condylox 3 Desonide Differin 3 QL Elidel 2 QL, ST, AR Epiduo 3 QL Finacea 2 Fluocinonid Hydrocortisone Metrogel 3 Mometasone Mupirocin Nystatin/Triamcinolone Oxsoralen-Ul 2 PA Permethrin Pramosone Cream 3 Pramosone E 3 Pramosone Lotion 2 Protopic 2 QL, ST, AR Retin-A Micro 3 QL, AR Taclonex 3 QL Tretinoin AR Triamcinolone Vectical 3 Zovirax Cream 2 Zovirax Ointment 3 Zyclara 3 QL Name Diabetes/Endocrine Blood: Glucose Monitoring Accu-Chek Act/Gluc 3 Calibration Liquid Accu-Chek Aviva Plus Test Strips Accu-Chek Aviva Test Strips Accu-Chek Comfort 3 Calibration Liquid Accu-Chek Comfort Test Strips Accu-Chek Cpt/Gluc 3 Calibration Liquid Accu-Chek Drum Test Strips Accu-Chek Kit 2 Aviva Plus Accu-Chek Kit 2 Compact Accu-Chek Kit Fastclix 2 Accu-Chek Kit 2 Multiclix Accu-Chek Kit Nano 2 Accu-Chek Kit Softclix 2 Accu-Chek Multiclix 2 Lancets Accu-Chek Smart 3 Calibration Liquid Accu-Chek Smart Test Strips Accu-Chek Sol 3 Calibration Liquid Accu-Chek Sol Comfort 3 Calibration Liquid Fastclix Lancets 2 Insulin Pen Needle 2 Insulin Syringe/ Needle 2 Novofine Auto 3 Novofine 3 Novotwist 3 2 QL 2 QL 2 QL 2 QL 2 QL [Plain type = Generic drug] PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions 3

14 Name Onetouch Kit Ultra Smart 2 Onetouch Kit Ultra 2 Onetouch Kit Ultra 2 2 Onetouch Kit Ultra Mini 2 Onetouch Kit Verio IQ 2 Onetouch Test Strips 2 QL Onetouch Ultra Blue Test Strips 2 QL Onetouch Verio IQ Test Strips 2 QL Onetouch Verio Test Strips 2 QL Soft Touch Lancets 2 Softclix Lan Mis Device 3 Softclix Lancets 2 Surestep Test Strips 2 QL Truetrack Test Strips 3 QL Diabetes/Endocrine: Insulin Humalog Vials 2 Humalog Kwik 2 Humalog Mix 50/50 Kwik Pen 2 Humalog Mix 50/50 Vials 2 Humalog Mix 75/25 Kwik Pen 2 Humalog Mix 75/25 Vials 2 Humulin 70/30 Vials 2 Humulin N Vials 2 Humulin N Pen 2 Humulin Pen 70/30 2 Humulin R Vials 2 Lantus Solostar 2 Lantus Vials 2 Levemir Flexpen 2 Levemir Vials 2 Name Novolin 70/30 Vials 2 Novolin N Vials 2 Novolin R Vials 2 Novolog Flexpen 2 Novolog Mix Flexpen 2 Novolog Mix 70/30 Vials 2 Novolog Penfill 2 Novolog Vials 2 Diabetes/Endocrine: Non-Insulin Actos 3 QL Byetta 2 QL, ST Glimepiride Glipizide Glipizide ER Glipizide XL Glyburide Glyburide/Metformin Janumet 2 QL, ST Janumet XR 2 QL, ST Januvia 2 QL, ST Jentadueto 2 QL, ST Kombiglyze 2 QL, ST Metformin Metformin ER Onglyza 2 QL, ST Pioglitazone QL Prandimet 3 QL, ST Prandin 3 QL, ST Repaglinide QL, ST Tradjenta 2 QL, ST Victoza 3 QL, ST [Plain type = Generic drug] PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions 4

15 Name Name Endocrine: Growth Hormone Nutropin 2 PA, SP Nutropin AQ 2 PA, SP Saizen 2 PA, SP Tev-Tropin 2 PA, SP Endocrine: Other Dexamethasone Lupron Depot 3.75 mg 3 PA, ST, SP.25 mg Lupron Depot 7.5 mg, 22.5 mg, 3 PA, SP 30 mg, 45 mg Methylprednisolone Prednisolone Prednisone Sensipar 3 SP Zemplar 2 SP Endocrine: Thyroid Hormone Replacement Armour Thyroid 3 Levothyroxine Levoxyl Liothyronine Methimazole Synthroid 3 Eye Conditions: Allergies Pataday 2 Patanol 2 QL Eye Conditions: Antibiotics Ciprofloxacin QL Erythromycin Gentamicin Moxeza 2 QL Ofloxacin QL Tobramycin Tobramycin/ Dexamethasone Vigamox 2 QL Eye Conditions: Glaucoma Alphagan P 2 QL Azopt 2 QL Combigan 2 QL Dorzolamide -Timolol Maleate Latanoprost QL Lumigan 2 QL Timolol Timoptic Ocudose 2 Travatan Z 2 QL Eye Conditions: Other Prednisolone Opth Restasis 3 Gastrointestinal: Acid Suppression Aciphex 3 QL, ST Dexilant 2 QL Famotidine Lansoprazole QL Nexium 2 QL Omeprazole QL Pantoprazole QL Ranitidine Sucralfate Gastrointestinal: Nausea/Vomiting Meclizine Metoclopramide QL Ondansetron QL [Plain type = Generic drug] PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions 5

16 Name Name Gastrointestinal: Other Amitiza 2 QL, ST Apriso 2 QL Asacol 3 QL Canasa 2 QL Creon 2 Delzicol 3 QL Dicyclomine Diphenoxylate/Atropine Halflytely Kit 3 QL Lialda 2 QL Moviprep 3 QL Omeclamox Pak 2 Pentasa 3 QL Polyethylene Glycol 3350 Pylera 2 QL Suprep Bowel Prep 3 QL Uceris 3 Zenpep 2 HIV/AIDS Atripla 2 SP Complera 2 SP Epzicom 2 SP Intelence 2 SP Isentress 2 SP Kaletra 2 SP Lamivudine/Zidovudine SP Norvir 2 SP Prezista 2 SP Reyataz 2 SP Sustiva 2 SP Truvada 2 SP Viread 2 SP Infertility Chorionic Gonadotropin PA, ST, SP Follistim AQ 2 PA, SP Gonal-f 2 PA, SP Gonal-f RFF 2 PA, SP Ovidrel 3 SP Inflamatory Conditions Cimzia 3 PA, QL, ST, SP Enbrel 2 PA, QL, ST, SP Enbrel SureClick 2 PA, QL, ST, SP Humira 2 PA, QL, ST, SP Humira Kit 2 PA, QL, ST, SP Humira Pen 2 PA, QL, ST, SP Humira Pen Kit Crohns 2 PA, QL, ST, SP Humira Pen Kit Psoriasis 2 PA, QL, ST, SP Hydroxychloroquine Methotrexate Orencia 3 PA, QL, ST, SP Simponi 3 PA, QL, ST, SP Men s Health: Erectile Dysfunction Cialis 2 QL, AR, GR Levitra 3 QL, AR, GR Viagra 3 QL, AR, GR Men s Health: Prostate Alfuzosin QL Avodart 2 QL Doxazosin Finasteride QL Jalyn 2 QL Rapaflo 2 QL Tamsulosin QL Terazosin [Plain type = Generic drug] PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions 6

17 Name Name Men s Health: Testosterone Therapy Androderm 2 PA, QL, GR Androgel 2 PA, QL, GR Fortesta 3 PA, QL, GR Testim 2 PA, QL, GR Miscellaneous Allopurinol Analpram-HC Cream 3 Analpram-HC Lotion 2 Antipyrine/Benzocaine Solution Otic Aranesp 2 PA, SP Benzonatate Cheratussin Chlorhexidine Colcrys 2 QL Epipen 2-Pak 2 QL Euflexxa 2 PA, ST, SP Fosrenol 3 Hydrocortisone AC Suppository Hydromet Phenazopyridine Phentermine Tab Procrit 2 PA, SP Proctozone Promethazine DM Syrup Promethazine/Codeine Pulmozyme 3 SP Rectiv 3 Renvela 2 Rezira 3 Synvisc 2 PA, ST, SP Uloric 2 QL, ST Zutripro 3 Musculoskeletal: Osteoporosis Actonel 3 QL Alendronate Calcitriol Evista 2 QL Forteo 2 PA, ST, SP Ibandronate QL Musculoskeletal: Other Baclofen Carisoprodol Cyclobenzaprine Metaxalone Methocarbamol Tizanidine [Plain type = Generic drug] PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions 7

18 Name Name Musculoskeletal: Pain Relief Acetaminophen w/ Codeine QL Avinza 2 QL Cambia 3 QL Celebrex 3 QL Diclofenac QL Etodolac QL Fentanyl Patch QL Gralise 3 QL, ST Hydrocodone w/ Ibuprofen QL Hydrocodone w/ Acetaminophen QL Hydromorphone Ibuprofen QL Indomethacin QL Lazanda 3 PA, QL Lidoderm Patch 3 QL Meloxicam QL Methadone Morphine Nabumetone QL Naproxen QL Norco 3 QL Nucynta 3 QL Nucynta ER 2 QL Onsolis 3 PA, QL Oxycodone Oxycodone w/ Acetaminophen QL Oxycontin 2 QL Sprix 3 QL Suboxone 2 PA, QL Subsys 3 PA, QL Tramadol QL Tramadol w/ Acetaminophen QL Vicodin 3 QL Vicodin ES 3 QL Vicodin HP 3 QL Vimovo 2 QL Voltaren Gel 2 QL Overactive Bladder Detrol LA 3 QL, ST Enablex 3 QL Gelnique 2 QL Oxybutynin Oxybutynin ER QL Oxytrol 2 QL Toviaz 3 QL Vesicare 2 QL Respiratory: Asthma/COPD Advair Diskus 2 QL Advair HFA 2 QL Albuterol Nebulizer Solution Asmanex 2 QL Budesonide Combivent 2 QL Flovent Disk 2 QL Flovent HFA 2 QL Foradil 2 ST Ipratropium/Albuterol Levalbuterol Nebulizer Solution Montelukast QL Perforomist 3 QL Proair HFA 2 QL Proventil 3 QL Pulmicort 2 QL Pulmozyme 3 SP Qvar 2 QL Serevent Disk 2 ST Singulair 3 QL Spiriva 2 QL Symbicort 2 QL Ventolin HFA 2 QL Xolair 2 PA, ST, SP Xopenex HFA 3 QL [Plain type = Generic drug] 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 Astepro 2 QL Azelastine QL Fluticasone Nasonex 2 QL Omnaris 3 QL Triamcinolone QL Veramyst 2 QL Zetonna 3 QL Respiratory: Oral Allergies Cetirizine Promethazine Desloratadine QL, ST Levocetirizine QL Loratadine Transplant Azathioprine Cellcept Tab/ Suspension 3 SP Cyclosporine SP Mycophenolate SP Myfortic 3 SP Neoral 3 SP Prograf Cap 3 SP Rapamune 3 SP Tacrolimus SP Vitamins/Electrolytes Ferrous Sulfate Folic Acid Klor-Con Multi-Vit/Fl Chw Omega-3 Fatty Acids Potassium Chloride ER Potassium Chloride Micro ER Tri-Vit-Fl Drops Vitamin D Women s Health: Contraceptives Apri GR Aviane GR Beyaz 2 GR Cryselle-28 GR Gianvi GR Gildess Fe GR Junel Fe GR Kariva GR Lo Loestrin 3 GR Loestrin 24 Fe 3 GR Loryna GR Low-Ogestrel GR Lutera GR Microgestin GR Microgestin Fe GR Natazia 2 GR Necon GR Norgest/Ethi Estradio GR Nortrel GR Nuvaring 2 Ocella GR Ortho Tri-Cyclen Lo 3 GR Portia-28 GR Safyral 2 GR Sprintec 28 GR Syeda GR Trinessa GR Tri-Sprintec GR Vestura GR Zarah GR [Plain type = Generic drug] PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions 9

20 Name Name Women s Health: Hormone Replacement Climara Pro 2 QL, GR Divigel 2 GR Enjuvia 2 QL, GR Estradiol QL, GR Medroxyprogesterone Acetate Premarin 2 QL, GR Premarin Vaginal Cream 2 Premphase 2 QL, GR Prempro 2 QL, GR Progesterone Vagifem 3 GR Vivelle-Dot 2 QL, GR Women s Health: Prenatal Vitamins M-Vit Tab 27- mg Prenafirst Tab Prenaplus Tab Prenatabs Fa Tab Prenatal Prenatal Tab Low Iron Ra Prenatal Tab mg Se-Natal One Tab Sm Prenatal Tab Vitamins Trinatal Rx Tab Trinate Tab Vinate One Tab Women s Health: Vaginal Anti-Infectives Metronidazole Vaginal Gel Terconazole Vaginal Cream QL [Plain type = Generic drug] PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions 20

21 Index of Covered s A Abilify Abilify Disc Abilify Solution Acanya 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 Accu-Chek Kit Aviva Plus 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... 3 Accu-Chek Smart Test Strips Accu-Chek Sol Calibration Liquid... 3 Accu-Chek Sol Comfort Calibration Liquid... 3 Acetaminophen w/ Codeine Aciphex Actonel Actos Acyclovir Advair Diskus Advair HFA Aggrenox Albuterol Nebulizer Solution 8 Alendronate Alfuzosin Allopurinol Alphagan P Alprazolam Tab Amiodarone Amitiza Amitriptyline Amlodipine Amlodipine/Benazepril... 0 Amoxicillin Amoxicillin/Clavulanate Amphetamine- Dextroamphetamine.. Amphetamine- Dextroamphetamine Cap SR 24HrR Ampyra Analpram-HC Cream... 7 Analpram-HC Lotion... 7 Anastrozole Androderm Androgel Antipyrine/Benzocaine Solution Otic Apri Apriso Aranesp Aricept 23 mg Armour Thyroid Asacol Asmanex Astepro Atenolol Atenolol/Chlorthalidone... 0 Atorvastatin Atralin Atripla Avelox Aviane Avinza Avodart Avonex Avonex Pen Avonex Prefill Azathioprine Azelastine Azilect Azithromycin Azopt Azor B Baclofen Baraclude Benazepril Benazepril/HCTZ Benicar Benicar HCT Benzaclin Benzonatate Benztropine Betaseron Beyaz Bisoprolol Bisoprolol/HCTZ Brilinta Budeprion XL Budesonide Bupropion Bupropion SR Buspirone Butalbital-Acetaminophen- Caffeine Byetta Bystolic [Plain type = Generic drug] 2

22 Index of Covered s C Calcitriol Cambia Canasa Carac Carbamazepine Carbidopa & Levodopa... 2 Carisoprodol Carvedilol Cefdinir Cefuroxime Tab Celebrex Cellcept Tab/Suspension. 9 Cephalexin Cetirizine Cheratussin Chlorhexidine Chlorthalidone Chorionic Gonadotropin.. 6 Cialis Cimzia Ciprodex Otic Suspension. 9 Ciprofloxacin Ciprofloxacin Citalopram Clarithromycin Climara Pro Clindamycin Clindamycin/Benzoyl Peroxide 3 Clindamycin Cap Clobetasol Clobex Cloderm Clonazepam Clonidine Tab Clopidogrel Clotrimazole/Betamethasone 3 Colcrys Combigan Combivent Complera Condylox Copaxone Coreg CR Coumadin Creon Crestor Cryselle Cyclobenzaprine Cyclosporine Cymbalta D Delzicol Desloratadine Desonide Detrol LA Dexamethasone Dexilant Diazepam Diclofenac Dicyclomine Differin Dificid Digoxin Diltiazem Diltiazem SR 24HR Diovan Diovan HCT Diphenoxylate/Atropine... 6 Divalproex DR Divalproex ER Divigel Donepezil Dorzolamide -Timolol Maleate Doxazosin Doxazosin Doxepin Doxycycline Hyclate Dutoprol E Econazole Edarbi Edarbyclor Effient Elidel Enablex Enalapril Enbrel Enbrel SureClick Enjuvia Enoxaparin Epiduo Epipen 2-Pak Epzicom Erythromycin Escitalopram Estradiol Etodolac Euflexxa Evista Exforge Exforge HCT F Famotidine Fastclix Lancets Felodipine Fenofibrate Fenoglide Fentanyl Patch Ferrous Sulfate Finacea Finasteride Flovent Disk Flovent HFA Fluconazole Fluocinonide Fluoxetine Fluticasone Focalin XR Folic Acid [Plain type = Generic drug] 22

23 Index of Covered s Follistim AQ Foradil Forteo Fortesta Fosinopril Fosrenol Furosemide G Gabapentin Gelnique Gemfibrozil Gentamicin Gianvi Gildess Fe Gilenya* Gleevec Glimepiride Glipizide Glipizide ER Glipizide XL Glyburide Glyburide/Metformin Gonal-f Gonal-f RFF Gralise H Halflytely Kit Humalog Kwik Humalog Mix 50/50 Kwik Pen Humalog Mix 50/50 Vials. 4 Humalog Mix 75/25 Kwik Pen Humalog Mix 75/25 Vials. 4 Humalog Vials Humira 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 Vials Hydralazine Hydrochlorothiazide Hydrocodone w/ Acetaminophen... 8 Hydrocodone w/ Ibuprofen Hydrocortisone Hydrocortisone AC Suppository Hydromet Hydromorphone Hydroxychloroquine Hydroxyzine HCl Hydroxyzine Pamoate I Ibandronate Ibuprofen Incivek Indomethacin Insulin Pen Needle Insulin Syringe/Needle.. 3 Intelence Intuniv Ipratropium/Albuterol Irbesartan Isentress Isosorbide Mononitrate... J Jalyn Janumet Janumet XR Januvia Jentadueto Junel Fe K Kaletra Kariva Ketoconazole Klor-Con Kombiglyze L Labetalol Lamictal Lamictal ODT Lamictal XR Lamivudine/Zidovudine... 6 Lamotrigine Lansoprazole Lantus Solostar Lantus Vials Latanoprost Lazanda Letairis Letrozole Levalbuterol Nebulizer Solution Levemir Flexpen Levemir Vials Levetiracetam Levetiracetam ER Levitra Levocetirizine Levofloxacin Levothyroxine Levoxyl Lexapro Lialda Lidoderm Patch Liothyronine Lipitor Lipofen Lisinopril Lisinopril/HCTZ Lithium Carbonate Livalo Loestrin 24 Fe [Plain type = Generic drug] 23

24 Index of Covered s Lo Loestrin Loratadine Lorazepam Loryna Losartan Losartan/HCTZ Lovastatin Lovaza Low-Ogestrel Lumigan Lunesta Lupron Depot 3.75 mg,.25 mg... 5 Lupron Depot 7.5 mg, 22.5 mg, 30 mg, 45 mg 5 Lutera Lyrica M Matzim LA Meclizine Medroxyprogesterone Acetate Meloxicam Metaxalone Metformin Metformin ER Methadone Methimazole Methocarbamol Methotrexate Methylphenidate Cap ER.. Methylphenidate HCl Tab Sa Osm ER..... Methylphenidate Tab.... Methylphenidate Tab ER... Methylprednisolone Metoclopramide Metoprolol Succinate Metoprolol Tartrate Metrogel Metronidazole Tab Metronidazole Vaginal Gel. 20 Micardis Micardis HCT Microgestin Microgestin Fe Migranal Minocycline Mirtazapine Modafinil Mometasone Montelukast Morphine Moviprep Moxeza Multi-Vit/Fl Chw Mupirocin M-Vit Tab 27- mg Mycophenolate Myfortic N Nabumetone Nadolol Namenda Naproxen Nasonex Natazia Necon Neomycin/Polymyxin/ HC Otic Suspension Neoral Nexium Niaspan ER Nifedipine ER Nitrofurantoin Macrocrystalline Nitrofurantoin Monohydrate Macrocrystalline Nitrostat Norco 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/Triamcinolone... 3 O Ocella Ofloxacin Ofloxacin Otic Solution Olanzapine Omeclamox Pak Omega-3 Fatty Acids Omeprazole Omnaris Ondansetron Onetouch Kit Ultra Onetouch Kit Ultra Onetouch Kit Ultra Mini. 4 Onetouch Kit Ultra Smart. 4 Onetouch Kit Verio IQ... 4 Onetouch Test Strips... 4 Onetouch Ultra Blue Test Strips Onetouch Verio IQ Test Strips Onetouch Verio Test Strips 4 Onglyza Onsolis Oracea [Plain type = Generic drug] 24

25 Index of Covered s Orencia Ortho Tri-Cyclen Lo Ovidrel Oxcarbazepine Oxsoralen-Ul Oxybutynin Oxybutynin ER Oxycodone Oxycodone w/ Acetaminophen... 8 Oxycontin Oxytrol P Pantoprazole Paroxetine Pataday Patanol Pegasys Penicillin VK Pentasa Perforomist Permethrin Phenazopyridine Phentermine Tab Phenytoin Phrenilin Pioglitazone Polyethylene Glycol Portia Potassium Chloride ER... 9 Potassium Chloride Micro ER 9 Pradaxa Pramipexole Pramosone Cream Pramosone E Pramosone Lotion Prandimet Prandin Pravastatin Prednisolone Prednisolone Opth Prednisone Premarin Premarin Vaginal Cream. 20 Premphase Prempro Prenafirst Tab Prenaplus Tab Prenatabs Fa Tab Prenatal Prenatal Tab Low Iron Prezista Pristiq Proair HFA Prochlorperazine Procrit Proctozone Progesterone Prograf Cap Promethazine Promethazine/Codeine... 7 Promethazine DM Syrup.. 7 Propranolol Propranolol ER Protopic Proventil Pulmicort Pulmozyme Pulmozyme Pylera Q Quetiapine Quinapril Qvar R Ramipril Ranexa Ranitidine Rapaflo Rapamune Ra Prenatal Tab mg. 20 Rebif Rebif Titrtn Rectiv Relpax Renvela Repaglinide Restasis Retin-A Micro Revlimid Reyataz Rezira Risperidone Ropinirole S Safyral Saizen Saphris Se-Natal One Tab Sensipar Serevent Disk Seroquel XR Sertraline Silenor Simcor Simponi Simvastatin Simvastatin 80 mg Singulair Sm Prenatal Tab Vitamins.. 20 Softclix Lancets Softclix Lan Mis Device.. 4 Soft Touch Lancets Solodyn Sotalol Spiriva Spironolactone Sprintec Sprix Strattera Suboxone Subsys Sucralfate Sulfamethoxazole- Trimethoprim [Plain type = Generic drug] 25

26 Index of Covered s Sulfamethoxazole- Trimethoprim DS Sumatriptan Sumavel Dose Suprep Bowel Prep Surestep Test Strips Sustiva Syeda Symbicort Synthroid Synvisc T Taclonex Tacrolimus Tamiflu Tamoxifen Tamsulosin Tarka Tasigna Tecfidera Tekturna Tekturna HCT Temazepam Temodar Terazosin Terazosin Terbinafine Terconazole Vaginal Cream. 20 Testim Tev-Tropin Timolol Timoptic Ocudose Tizanidine Tobramycin Tobramycin/Dexamethasone. 5 Topiramate Toviaz Tracleer Tradjenta Tramadol Tramadol w/ Acetaminophen 8 Travatan Z Trazodone Tretinoin Triamcinolone Triamcinolone Triamterene/HCTZ Tribenzor Tricor Triglide Trilipix Trinatal Rx Tab Trinate Tab Trinessa Tri-Sprintec Tri-Vit-Fl Drops Truetrack Test Strips Truvada U Uceris Uloric V Vagifem Valacyclovir Valsartan/HCTZ Vectical Venlafaxine Venlafaxine ER Cap..... Ventolin HFA Veramyst Verapamil ER Verapamil SR Vesicare Vestura Viagra Vicodin Vicodin ES Vicodin HP Victoza Vigamox Vimovo Vinate One Tab Viread Vitamin D Vivelle-Dot Voltaren Gel Vytorin Vytorin Tab 0-80 mg... 0 Vyvanse W Warfarin Welchol X Xanax Xarelto Xeloda Xolair Xopenex HFA Z Zarah Zelapar Zemplar Zenpep Zetia Zetonna Zolpidem Zolpidem ER Zomig Nasal Spray.... Zovirax Cream Zovirax Ointment Zutripro Zyclara [Plain type = Generic drug] 26

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, 20 mg High blood pressure One tablet daily Dr. Johnson 27

28 OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an Optum TM company a leading provider of integrated health services. Learn more at All Optum TM trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners. ORX6700C_ OptumRx, Inc. Select Standard