Your 206 Prescription List effective January, 206 Golden Rule Advantage Four- Please read: This document contains information about commonly prescribed medications. For additional information: Call the toll-free Member Services number on your health plan ID card. Visiting www.uhone.com, clicking on the Customer Center link at the top of the page and then selecting the Prescription (Rx) Coverage tab on the left hand side of the page provides you access to: Locate a participating retail pharmacy by ZIP code. Look up possible lower-cost medication alternatives. Compare medication pricing and options. Note: Benefits may not be available for all drugs on this list. A drug on this list is covered under your insurance plan only if the condition for which it is prescribed is also covered under your insurance plan. For example, if treatment of mental disorders is excluded from your coverage, drugs prescribed in connection with that treatment also may be excluded from your coverage.
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 the Customer Center link at www.uhone.com for complete drug information Since the PDL may change, we encourage you to visit our website, www.uhone.com. Click on the Customer Center link at the top of the page and then select the Prescription (Rx) Coverage tab on the left hand side of the page. This website is the best source for up-to-date information about the medications your pharmacy benefit covers, possible lower-cost options, and cost comparisons. 2
Table of Contents tiers and cost... 5 Programs and Limits.... 7 s by category...0 Anti-Infectives Antibiotics....0 Antifungals...0 Antivirals...0 Cancer.... Cardiovascular/Heart Disease Coagulation Therapy... High Blood Pressure.... High Cholesterol.... 2 Other.... 2 Central Nervous System Attention Deficit Disorder.... 3 Depression... 3 Migraine.... 4 Multiple Sclerosis.... 4 Other.... 4 Sedatives/Hypnotics.... 4 Seizure Disorders... 5 Dermatology.... 5 Diabetes/Endocrine Blood Glucose Monitoring.... 6 Insulin.... 6 Non-Insulin... 7 Endocrine Other.... 7 Thyroid Hormone Replacement.... 7 Eye Conditions Allergies.... 7 Antibiotics.... 8 Glaucoma.... 8 Gastrointestinal Acid Suppression....8 Nausea/Vomiting.... 8 Other....8 Hepatitis C....9 HIV/AIDS....9 Inflammatory Conditions: Rheumatoid Arthritis, Crohn s Disease, Psoriasis, Ulcerative Colitis....9 Men s Health Erectile Dysfunction....9 Prostate....9 Testosterone Therapy...9 Miscellaneous....20 Musculoskeletal Osteoporosis....2 Other....2 Pain Relief....2 Overactive Bladder....22 Respiratory Allergies....22 Asthma/COPD....22 Pulmonary Arterial Hypertension....23 Smoking Cessation...23 Transplant....23 Vitamins/Electrolytes....23 Women s Health Contraceptives....23 Hormone Replacement....24 Miscellaneous....24 Prenatal Vitamins...24 Index....25 3
4
We want to help you better understand your medication options. Your pharmacy benefit offers flexibility and choice in determining the right medication for you. To help you get the most out of your pharmacy benefit, we ve included some of the most commonly asked questions about the Prescription List. What is a Prescription List (PDL)? This document is a list of commonly prescribed medications. s are listed by common categories or class. They are placed into cost levels known as tiers. It includes both brand and generic prescription medications approved by the U.S. Food and Administration (FDA). Please note: Where differences are noted between this PDL and your policy/certificate, the policy/ certificate will rule. It is not a complete list of medications, and not all medications listed may be covered under your plan. Please look at your policy/certificate to see what medications are covered under your plan. You may also log on to www.uhone.com or call the toll-free Member Services number on your health plan ID card for more information. How do I use my Prescription List? When choosing a medication, you and your doctor should consult the PDL. It will help you and your doctor choose the most cost-effective prescription drugs. This guide tells you if a medication is generic or brand, and if special programs apply. Bring this list with you when you see your doctor. It is organized by common medical conditions. Medications are then listed alphabetically. If your medication is not listed in this document, please visit www.uhone.com or call the toll-free Member Services number on your health plan ID card. Policy/certificates include a Summary Plan Description (SPD) or a Certificate of Coverage (COC). 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 policy/certificate. 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, 3 or 4, look to see if there is a option available. Discuss these options with your doctor. Check your policy/certificate to find out your specific pharmacy plan costs. $ Includes Helpful Tips Lowest Cost 2 and 3 Mid-range Cost 4 Highest Cost Lower-cost drugs. Some brands and generics are also included. Mix of brands and generics. Mostly higher-cost brand as well as select generic drugs. Use drugs for the lowest out of-pocket costs. Use 2 or 3 drugs instead of 4 to help reduce your out-of-pocket costs. Many 4 drugs have lower cost options in, 2 or 3. Ask your doctor if they could work for you. Please note: Some plans may have two or three tiers, while others may not have any. If you have a high deductible plan, the tier cost levels may apply once you hit your deductible. Refer to your policy/certificate, or call the toll-free Member Services number on your health plan ID card for more information about your policy/certificate. When does the Prescription List change? Medications may move to a lower tier at any time. Medications may move to a higher tier when a generic becomes available. Medications may move to a higher tier or be excluded from coverage most often on January or July. When a medication changes tiers, you may have to pay a different amount for that medication. For the most up-to-date list, please visit www.uhone.com. 6
Programs and Limits Some medications are noted with letters next to them. The letters refer to our pharmacy benefit programs. Your policy/certificate determines how these medications may be covered for you. H SL Health Care Reform Preventive This medication is part of a Health Care Reform preventive benefit and may be available at no cost to you. Supply Limit Amount of medication covered per copayment or in a specific time period. To learn more about a pharmacy program or to find out if it applies to you, please visit www.uhone.com or call the toll-free Member Services number on your health plan ID card. Why are some medications excluded from coverage? Medications may be excluded from coverage under your pharmacy benefit when it works the same or similar as another prescription medication or an over-the-counter (OTC) medication. There may be other medication options available. Should I talk to my doctor about over-the-counter (OTC) medications? An over-the-counter (OTC) medication may be the right treatment for some conditions. Talk to your doctor about available OTC options. What is the difference between brand-name and generic medications? Generic medications contain the same active ingredients (what makes the medication work) as brandname medications, but they often cost less. Once the patent of a brand-name medication ends, the FDA can approve a generic version with the same active ingredients. These types of medications are known as generic medications. Sometimes, the same company that makes a brand-name medication also makes the generic version. 7
Is it a generic or brand-name drug? The drug list shows brand-name drugs in bold type (for example, Crestor) and generic drugs in plain type (for example, Simvastatin). What if my doctor writes a brand-name prescription? The next time your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lower-cost option is available and if it might be right for you. Generic medications are usually your lowest-cost option, but not always. For some benefit plans if a brand-name drug is prescribed and a generic equivalent is available, your cost share may be the copay PLUS the cost difference between the brand-name drug and generic equivalent. Visit www.uhone.com to make sure. Are you taking a specialty medication? Specialty medications are high-cost and may be used to treat rare or complex conditions. For most plans, these medications are managed through the Specialty Pharmacy Program. Take advantage of personalized support designed to help you get the most out of your treatment plan. Visit UHCSpecialtyRx.com or call the toll-free Member Services number on your health plan ID card to learn more. Please note, not all specialty medications are listed here. If you re taking a specialty medication that is on 3 or 4, call the toll-free Member Services number on your health plan ID card to talk with a pharmacist about finding lower-cost options or a financial assistance program. 8
How do I get updated information about my pharmacy benefit? Since the PDL may change during your plan year, we encourage you to visit www.uhone.com or call the toll-free Member Services number on your health plan ID card for more current information. For more information Call the toll-free Member Services number on your health plan ID card. Or, visit www.uhone.com In certain documents, the Prescription List (PDL) was referred to as the Preferred List (PDL). This change in terms does not affect your benefit coverage. Medications are categorized by common therapeutic conditions in this PDL for ease of reference only. These categories do not determine coverage for the medication for your condition. Your policy/certificate determines coverage for these medications. 9
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 4 Doxycycline Hyclate Capsule, 2 Doxycycline Monohydrate 50, 00 mg Capsule Levofloxacin Metronidazole Minocycline Capsule Minocycline 3 Moxifloxacin 3 Nitrofurantoin Capsule Nitrofurantoin Macrocrystal Capsule Name Ofloxacin s Oracea 4 Penicillin V Potassium Solodyn 4 Sulfamethoxazole- Trimethoprim Suprax Capsule, Chewable, Anti-Infectives: Antifungals 4 Econazole Cream SL Fluconazole Itraconazole Capsule SL Ketoconazole Cream Noxafil, Suspension 2 Nystatin Cream, Ointment Terbinafine SL Anti-Infectives: Antivirals Acyclovir Ointment 4 SL Acyclovir Famciclovir Tamiflu 3 SL Valacyclovir 2 SL Valaganciclovir SL Zovirax Cream 4 SL Bold type = Brand-name drug [Plain type = Generic drug] H = Health Care Reform Preventive SL = Supply Limit 0
Name Cancer Bicalutamide Bosulif 2 SL Cyclophosphamide Capsule 2 Gleevec 2 SL Hydroxyurea Capsule 3 Imbruvica 2 SL Leucovorin Calcium Mercaptopurine Revlimid 2 SL Sutent 2 SL Tasigna 2 SL Xeloda SL Zytiga 2 SL Cardiovascular/Heart Disease: Coagulation Therapy Clopidogrel Effient 4 SL Eliquis 4 SL Enoxaparin Sodium 2 SL Pradaxa 2 SL Savaysa 4 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 Name Bidil 2 Bisoprolol Bisoprolol- Hydrochlorothiazide Bystolic 2 Cartia XT 2 Carvedilol Chlorthalidone Clonidine Diltiazem 24 Hour CD 2 Diltiazem Sustained- 2 Release Capsule Diltiazem Sustained- Release 2 Diovan 4 SL 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
Name Propranolol Quinapril Ramipril Spironolactone Telmisartan 2 SL Telmisartan- Hydrochlorothiazide 2 SL Terazosin Triamterene- Hydrochlorothiazide Valsartan 2 SL Valsartan- Hydrochlorothiazide SL Verapamil Verapamil 3 Sustained-Release Cardiovascular/Heart Disease: High Cholesterol Atorvastatin SL Choline Fenofibrate 4 Crestor 2 SL Fenofibrate 43, 50, 67, 30, 34, 50, 200 mg Capsule Fenofibrate 48, 45 mg 4 Fenofibrate 54, 60 mg 2 Fenoglide 4 Gemfibrozil Lescol XL 4 SL Lipitor 4 SL 4 Name Lipofen 4 Livalo 4 SL Lovastatin Niacin Extended- Release 4 Niaspan 2 Omega-3-Acid Ethyl Esters Capsule 3 Pravastatin Simcor 4 SL Simvastatin Tricor 48, 45 mg 4 Vascepa 4 Vytorin 4 SL Welchol 2 Zetia 4 SL Cardiovascular/Heart Disease: Other Amiodarone Digoxin Flecainide Isosorbide Mononitrate ER Nitrostat 2 Ranexa 2 Sotalol Bold type = Brand-name drug [Plain type = Generic drug] H = Health Care Reform Preventive SL = Supply Limit 2
Name Central Nervous System: Attention Deficit Disorder Adderall XR 2 SL Amphetamine Salt Combo Concerta 2 SL Daytrana 4 SL Dexmethylphenidate Extended-Release Capsule Dexmethylphenidate Dextroamphetamine- Amphetamine Extended-Release 4 SL 4 SL Dextroamphetamine- Amphetamine Dextroamphetamine Sulfate 3 Focalin XR 4 SL Guanfacine Extended-Release 4 SL Intuniv 4 SL Metadate CD 2 SL Methylphenidate Chewable Methylphenidate Extended-Release Capsule Methylphenidate Extended-Release 3 4 SL 4 SL Methylphenidate Strattera 4 SL Vyvanse 2 SL Name Central Nervous System: Depression Amitriptyline Brintellix 4 SL Bupropion Extended- Release Bupropion Sustained- Release Bupropion Citalopram Cymbalta 4 SL Doxepin Capsule Duloxetine Capsule 3 SL Escitalopram Fetzima 4 SL Fluoxetine Capsule, Fluvoxamine Lexapro 4 Mirtazapine Nortriptyline Capsule Paroxetine Pristiq ER 3 SL Sertraline Trazodone Venlafaxine Extended- Release Capsule Venlafaxine Viibryd 4 SL Wellbutrin XL 4 3
Name Central Nervous System: Migraine Acetaminophen/ Butalbital/Caffeine SL 325 mg/50 mg/40 mg 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 SL Aubagio 4 SL Avonex 2 SL Betaseron 2 SL Copaxone 2 SL Gilenya 3 SL Glatopa 4 SL Rebif 4 SL Tecfidera 2 SL Central Nervous System: Other Abilify 4 SL Alprazolam Extended- Release Alprazolam Aripiprazole 2 SL Buprenorphine/ Naloxone 4 SL Buspirone Name Carbidopa-Levodopa Diazepam Donepezil 5, 0 mg ODT, Latuda 4 SL Lithium Capsule Lorazepam Memantine 3 Modafinil 4 SL Namenda XR 4 Nuvigil 4 SL Olanzapine SL Pramipexole Quetiapine SL Risperidone Ropinirole Seroquel XR 4 SL Suboxone Film 4 SL Tolcapone 2 Xyrem 4 SL Zelapar 3 Ziprasidone Capsule 2 SL Zubsolv 2 SL Central Nervous System: Sedatives/Hypnotics Eszopiclone 2 SL Temazepam Capsule Triazolam Zaleplon Capsule SL Zolpidem Extended- Release 4 SL Zolpidem SL Bold type = Brand-name drug [Plain type = Generic drug] H = Health Care Reform Preventive SL = Supply Limit 4
Name Central Nervous System: Seizure Disorders Carbamazepine Clonazepam Diazepam Divalproex Delayed- Release Divalproex Extended- Release Gabapentin Capsule, Lamotrigine Levetiracetam Extended-Release 2 Levetiracetam Lyrica 4 SL Oxcarbazepine Phenytoin Capsule, Suspension Topiramate Zonisamide Capsule Dermatology Absorica 4 Aczone 4 SL Adapalene 0.% 3 SL Cream, Gel Adapalene 0.3% Gel 3 SL Bethamethasone Dipropionate 0.05% Augmented Lotion, Ointment Betamethasone Dipropionate 0.05% Cream, Ointment Carac 2 Ciclopirox Cream, Gel, Lotion, Solution Claravis 2 Clindamycin %/ Benzoyl Peroxide 5% Gel 3 2 4 SL Name Clindamycin.2%/ Benzoyl Peroxide 5% Gel 3 SL Clindamycin Gel 3 SL Clindamycin Lotion 3 Clindamycin Solution, Swabs Clobetasol Propionate Cream, Ointment, SL Solution Clotrimazole- Betamethasone Cream SL Clotrimazole- Betamethasone Lotion Condylox Gel 3 Desonide 0.05% Cream, Lotion, Ointment 3 SL Desoximetasone Gel, Ointment 3 SL Differin % Cream, Gel 2 SL Diflorasone Diacetate 0.05% Cream, Ointment 3 SL Epiduo 3 SL Finacea 4 Fluocinonide 0.05% Cream Fluocinolone Cream, Oil, Ointment, Solution 3 SL Hydrocortisone 2.5% Cream, Ointment Imiquimod 5% Cream 2 SL Metronidazole Gel 0.75% Mirvaso 4 SL Mometasone Furoate Cream, Lotion, Ointment Mupirocin Ointment Nystatin-Triamcinolone Acetonide Cream, 4 Ointment Oxsoralen-Ul 2 Picato 3 SL 5
Name Regranex 2 SL Tacrolimus Ointment 2 SL Tazorac 4 SL Tretinoin SL Tretinoin Microspheres 4 SL Triamcinolone Acetonide Cream, Lotion, Ointment Vectical 3 SL Diabetes: Blood Glucose Monitoring Accu-Chek Test Strips 4 SL Contour Test Strips 4 SL Dexcom G4 Platinum Continuous Glucose 3 SL Monitoring System Dexcom Sensor 3 SL Dexcom Transmitter 3 SL FreeStyle Test Strips 4 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 Name Diabetes: Insulin Afrezza 4 SL Humalog KwikPen 2 SL Humalog Mix 50-50 KwikPen 2 SL Humalog Mix 75-25 KwikPen 2 SL Humalog Vials SL Humulin 70-30 KwikPen 2 SL Humulin 70-30 Vials SL Humulin N KwikPen 2 SL Humulin N Vials SL Humulin R Vials SL Lantus Solostar 3 SL Lantus Vials 3 SL Levemir FlexTouch SL Levemir Vials SL Novolin 70-30 Vials 3 SL Novolin N Vials 3 SL Novolin R Vials 3 SL Novolog Flexpen 4 SL Novolog Mix 70/30 Flexpen 4 SL Novolog Mix 70/30 Vials 4 SL Novolog Vials 4 SL Bold type = Brand-name drug [Plain type = Generic drug] H = Health Care Reform Preventive SL = Supply Limit 6
Name Name Diabetes: Non-Insulin Bydureon 2 SL Byetta 2 SL Farxiga 4 SL Glimepiride Glipizide Glipizide Extended-Release Glyburide Glyxambi 4 SL Invokamet 2 SL Invokana 2 SL Janumet 4 SL Januvia 4 SL Jardiance 2 SL Jentadueto 2 SL Kazano 2 SL Kombiglyze XR 2 SL Metformin Metformin Extended- Release (generic Glucophage XR) Nesina 2 SL Onglyza 2 SL Oseni 2 SL Pioglitazone SL Tanzeum 2 SL Tradjenta 2 SL Trulicity 4 SL Victoza 2-Pak 2 SL Victoza 3-Pak 3 SL Xigduo XR 4 SL Endocrine: Other 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 4 Eye Conditions: Allergies Azelastine 0.05% Ophthalmic Solution SL Lastacaft 3 SL Pataday 4 SL Patanol 4 SL 7
Name Name Eye Conditions: Antibiotics Erythromycin 0.5% Ophthalmic Ointment Gentamicin Ophthalmic Ointment, Solution Moxeza 4 Ofloxacin 0.3% Ophthalmic Solution Tobramycin/ Dexamethasone 0.3%-0.% Ophthalmic 2 Suspension Tobramycin Ophthalmic Solution Vigamox 4 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 Gastrointestinal: Acid Suppression Dexilant 3 SL Esomeprazole Capsule 4 SL Lansoprazole Capsules 3 SL Nexium Capsule 4 SL Omeclamox-Pak 3 SL Omeprazole Capsule Pantoprazole Pylera 3 SL Rabeprazole 3 SL Ranitadine Syrup Sucralfate Gastrointestinal: Nausea/Vomiting Akynzeo 4 SL Emend 2 SL Ondansetron Ondansetron ODT Transderm-Scop 3 Gastrointestinal: Other Amitiza 4 SL Apriso 2 Asacol HD 4 Canasa 2 Cortifoam 2 Creon 2 Delzicol 4 Bold type = Brand-name drug [Plain type = Generic drug] H = Health Care Reform Preventive SL = Supply Limit 8
Name Diphenoxylate-Atropine Golytely 2 Hyoscyamine Lialda 2 Linzess 2 SL Metoclopramide Movantik 2 SL Moviprep 3 Polyethylene Glycol 3350 2 Prepopik 3 Suclear 3 Sulfasalazine Suprep 3 Uceris 3 Zenpep 2 Hepatitis C Harvoni 2 SL Ribapak 4 Ribavirin Sovaldi 2 SL Viekira Pak 4 SL HIV/AIDS Atripla 2 Complera 2 Epzicom 2 Evotaz 2 Intelence 2 Isentress 2 Kaletra 2 Lamivudine-Zidovudine Nevirapine Name Nevirapine Extended-Release 2 Norvir 2 Prezcobix 2 Prezista 2 Reyataz 2 Stribild 3 Sustiva 2 Tivicay 3 Triumeq 2 Truvada 2 Tybost 2 Viread 2 Vitekta 2 Inflammatory Conditions: Rheumatoid Arthritis, Crohn s Disease, Psoriasis, Ulcerative Colitis Actemra 4 SL Cimzia 2 SL Cosentyx 4 SL Enbrel 4 SL Humira 2 SL Hydroxychloroquine Sulfate Leflunomide Methotrexate Orencia 4 SL Otezla 4 SL Otrexup 4 SL Rasuvo 4 SL Simponi 2 SL Stelara 2 SL Xeljanz 4 SL 9
Name Men s Health: Erectile Dysfunction Cialis 4 SL Levitra 4 SL Stendra 4 SL Viagra 4 SL Men s Health: Prostate Alfuzosin Cialis 4 SL Doxazosin Finasteride Rapaflo 4 Tamsulosin Capsule Terazosin Capsule, Men s Health: Testosterone Therapy Androderm 2 SL Androgel 4 SL Android 2 Testim 2 SL Testosterone Cypionate Injection Miscellaneous Anastrozole Antipyrine/Benzocaine Otic Solution Aranesp 2 SL Auryxia 3 Benzonatate Capsule Bethkis 2 SL Bromfed DM 3 Cayston 2 SL Name Cerdelga 2 Chlorpheniramine/ Hydrocodone/ Pseudoephedrine 2 SL Solution 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 SL Phenazopyridine Procrit 2 SL Promethazine/Codeine Promethazine/ Dextromethorphan Pulmozyme 2 SL Rectiv 3 SL Renvela 2 Restasis 4 SL Rezira 3 Tobi Podhaler 3 SL Tobramycin Nebulized Solution 4 SL Velphoro 2 Bold type = Brand-name drug [Plain type = Generic drug] H = Health Care Reform Preventive SL = Supply Limit 20
Name Musculoskeletal: Osteoporosis Alendronate Sodium SL Forteo 2 Ibandronate 2 SL Raloxifene 2 Risedronate Sodium 3 SL Musculoskeletal: Other Allopurinol Baclofen Carisoprodol 350 mg Colcrys 4 Cyclobenzaprine Metaxalone 3 Methocarbamol Mitigare 2 Tizanidine Uloric 4 SL Musculoskeletal: Pain Relief Acetaminophen/ Codeine SL Celecoxib 3 SL Diclofenac Etodolac Capsule Fentanyl 2 mcg, 25 mcg, 50 mcg, 2 SL 75 mcg, 00 mcg Patch Fentanyl Citrate Lozenge 2 SL Hydrocodone/ Acetaminophen 5/325, 7.5/325, 0/325 mg SL Name Hydrocodone/Ibuprofen Hydromorphone Hysingla 4 SL Ibuprofen Indomethacin Capsule Ketorolac Lazanda 3 SL Meloxicam Methadone, Oral Solution, SL Concentrate Solution Morphine Sulfate Extended-Release SL Morphine Sulfate Oral Solution Nabumetone Naproxen Nucynta 4 SL Nucynta ER 3 SL Opana ER 2 SL Oxycodone/ Acetaminophen 5/325, 7.5/325, 0/325 mg SL Oxycodone Oxycontin 4 SL Sprix 3 Subsys 4 SL Tramadol- Acetaminophen SL Tramadol Sustained- Release 2 SL Tramadol Vicodin 5/300, 7.5/300, 0/300 mg 4 SL Voltaren Gel 2 Zohydro ER 4 SL 2
Name Overactive Bladder Dicyclomine Oxybutynin Extended- Release 2 Oxybutynin Tolterodine Extended- Release 4 Tolterodine 4 Toviaz 3 Vesicare 4 Respiratory: Allergies Azelastine 0.% Nasal Spray 3 SL Clarinex 4 SL Clarinex-D 3 SL Cyproheptadine Fluticasone Nasal Spray 2 SL Hydroxyzine Capsule, Levocetirizine SL Nasonex 4 SL Promethazine Qnasl 4 SL Triamcinolone Nasal Spray 4 SL Zetonna 3 SL Respiratory: Asthma/COPD Advair Diskus/HFA 3 SL Aerospan 3 SL Albuterol Nebs Albuterol Sulfate Alvesco SL Name Arnuity Ellipta 3 SL Asmanex SL Breo Ellipta 3 SL Budesonide Nebs 2 SL Combivent Respimat 3 SL Dulera 3 SL Flovent Diskus/HFA 3 SL Foradil 3 SL Incruse Ellipta 2 SL Ipratropium-Albuterol Nebs Ipratropium Nebs Levalbuterol Nebs 4 SL Montelukast Chewable, SL Montelukast Granules 2 SL Perforomist 3 SL Proair HFA 3 SL Proventil HFA 3 SL Pulmicort Flexhaler 4 SL QVAR SL Serevent Diskus 3 SL Spiriva Handihaler 4 SL Spiriva Respimat 4 SL Striverdi Respimat 2 SL Symbicort 4 SL Tudorza 2 SL Ventolin HFA SL Xopenex HFA 3 SL Xopenex Nebs 4 SL Bold type = Brand-name drug [Plain type = Generic drug] H = Health Care Reform Preventive SL = Supply Limit 22
Name Respiratory: Pulmonary Arterial Hypertension Adcirca 4 SL Adempas 2 SL Letairis 2 SL Opsumit 2 SL Orenitram 4 SL Sildenafil SL Tracleer 2 SL Tyvaso 2 Smoking Cessation Bupropion Sustained- Release H Chantix 3 H 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 Nicotrol Nasal Spray 3 H Thrive Gum H Transplant Azathioprine Cellcept 4 Cyclosporine Modified Capsule Mycophenolate Capsule, Suspension Mycophenolic Acid 2 Myfortic 4 Neoral 4 Name Prograf 4 Rapamune 4 Sirolimus Tacrolimus Capsule 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 H Cryselle H Cyclafem H Ella H Enskyce H Gildess 2 H Gildess Fe H Introvale 2 H Jolessa 2 H Junel 2 H Junel Fe H Levora-28 H Lo Loestrin Fe 3 H Loryna 3 H Low-Ogestrel H Lutera H Microgestin 2 H Microgestin FE H Minastrin 24 FE 4 H Mononessa 3 H Natazia H 23
Name Necon 0.5/35, /35, /50, 0/ H Next Choice H Norgestimate-Ethinyl Estradiol 3 H Nortrel 0.5/35 H Nuvaring 2 H Orsythia H Ortho-Cyclen H Ortho Micronor H Ortho-Novum 3 H Ortho-Novum 7/7/7 H Ortho Tri-Cyclen H Ortho Tri-Cyclen Lo 3 H Plan B One Step H Quasense 2 H Reclipsen H Sprintec 3 H Sronyx H Tri-Previfem 3 H Tri-Sprintec 3 H Trinessa 3 H Vestura 3 H Viorele 2 H Xulane 3 H Yasmin 28 H Yaz 2 H Women s Health: Hormone Replacement Cenestin 4 Climara 2 SL Climara Pro 3 SL Divigel 3 Duavee 3 Enjuvia 3 Name Estrace Cream 3 Estradiol/Norethindrone Acetate 2 Estradiol Estradiol Twice-Weekly Transdermal Patch 4 SL Estring 2 SL Estrogen/ Methyltestosterone Evamist 2 Medroxyprogesterone Minivelle 3 SL Premarin 3 Premphase 3 Prempro 3 Progesterone Micronized Capsule Vagifem 2 Vivelle-Dot 2 SL Women s Health: Miscellaneous Osphena 3 Raloxifene 2 H Tamoxifen H Women s Health: Prenatal Vitamins Brand Prenatal Vitamins 2 3 Bold type = Brand-name drug [Plain type = Generic drug] H = Health Care Reform Preventive SL = Supply Limit 24
Index A Abilify...4 Absorica... 5 Accu-Chek Test Strips...6 Acetaminophen/Butalbital/ Caffeine 325 mg/ 50 mg/40 mg...4 Acetaminophen/Codeine...2 Actemra...9 Acyclovir Ointment...0 Acyclovir...0 Aczone... 5 Adapalene 0.% Cream, Gel.. 5 Adapalene 0.3% Gel... 5 Adcirca... 23 Adderall XR... 3 Adempas... 23 Advair Diskus/HFA... 22 Aerospan... 22 Afrezza...6 Akynzeo...8 Albuterol Nebs... 22 Albuterol Sulfate... 22 Alendronate Sodium...2 Alfuzosin... 20 Allopurinol...2 Alphagan P 0.%...8 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... 3 Ampyra...4 Anastrozole... 20 Androderm... 20 Androgel... 20 Android... 20 Antipyrine/Benzocaine Otic Solution... 20 Apri... 23 Apriso...8 Aranesp... 20 Aripiprazole...4 Armour Thyroid...7 Arnuity Ellipta... 22 Asacol HD...8 Asmanex... 22 Atenolol... Atenolol-Chlorthalidone... Atorvastatin... 2 Atripla...9 Aubagio...4 Auryxia... 20 Aviane... 23 Avonex...4 Azathioprine... 23 Azelastine 0.05% Ophthalmic Solution...7 Azelastine 0.% Nasal Spray... 22 Azithromycin...0 Azopt...8 25 Azurette... 23 B Baclofen...2 Benazepril... Benazepril- Hydrochlorothiazide... Benicar... Benicar HCT... Benzonatate Capsule... 20 Betamethasone Dipropionate 0.05% Cream, Ointment... 5 Betaseron...4 Bethamethasone Dipropionate 0.05% Augmented Lotion, Ointment... 5 Bethkis... 20 Bicalutamide... Bidil... Bisoprolol... Bisoprolol- Hydrochlorothiazide... Bosulif... Brand Prenatal Vitamins... 24 Breo Ellipta... 22 Brintellix... 3 Bromfed DM... 20 Budesonide Nebs... 22 Buprenorphine/Naloxone...4 Bupropion Extended-Release... 3 Bupropion Sustained-Release...3, 23 Bupropion... 3 Buspirone...4 Bydureon...7 Byetta...7 Bystolic...
C Calcitriol Capsule...7 Canasa...8 Carac... 5 Carbamazepine... 5 Carbidopa-Levodopa...4 Carisoprodol 350 mg...2 Cartia XT... Carvedilol... Cayston... 20 Cefadroxil Capsule,...0 Cefdinir Capsule...0 Cefixime Suspension...0 Cefprozil...0 Cefuroxime...0 Celecoxib...2 Cellcept... 23 Cenestin... 24 Cephalexin Capsule...0 Cerdelga... 20 Chantix... 23 Chlorpheniramine/ Hydrocodone/ Pseudoephedrine Solution... 20 Chlorthalidone... Choline Fenofibrate... 2 Cialis... 20 Ciclopirox Cream, Gel, Lotion, Solution... 5 Cimzia...9 Ciprodex... 20 Ciprofloxacin...0 Citalopram... 3 Claravis... 5 Clarinex... 22 Clarinex-D... 22 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 Clonazepam... 5 Clonidine... Clopidogrel... Clotrimazole-Betamethasone Cream... 5 Clotrimazole-Betamethasone Lotion... 5 Colcrys...2 Combigan...8 Combivent Respimat... 22 Complera...9 Concerta... 3 Condylox Gel... 5 Contour Test Strips...6 Copaxone...4 Cortifoam...8 Cosentyx...9 Creon...8 Crestor... 2 Cryselle... 23 Cyclafem... 23 Cyclobenzaprine...2 Cyclophosphamide Capsule... Cyclosporine Modified Capsule... 23 Cymbalta... 3 Cyproheptadine... 22 D Daytrana... 3 Delzicol...8 26 Desmopressin...7 Desonide 0.05% Cream, Lotion, Ointment... 5 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... 3 Dexmethylphenidate... 3 Dextroamphetamine- Amphetamine Extended-Release... 3 Dextroamphetamine- Amphetamine... 3 Dextroamphetamine Sulfate... 3 Diazepam...4, 5 Diclofenac...2 Dicyclomine... 22 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...9
Divalproex Delayed-Release... 5 Divalproex Extended-Release... 5 Divigel... 24 Donepezil 5, 0 mg ODT,...4 Doryx...0 Doxazosin..., 20 Doxazosin... 20 Doxepin Capsule... 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...9 Erythromycin 0.5% Ophthalmic Ointment...8 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...2 Evamist... 24 Evotaz...9 F Famciclovir...0 Farxiga...7 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...2 Fentanyl Citrate Lozenge...2 Fetzima... 3 Finacea... 5 Finasteride... 20 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... 22 27 Fluvoxamine... 3 Focalin XR... 3 Folic Acid... 23 Foradil... 22 Forteo...2 Fosrenol... 20 FreeStyle Test Strips...6 Furosemide... G Gabapentin Capsule,... 5 Gemfibrozil... 2 Gentamicin Ophthalmic Ointment, Solution...8 Gildess... 23 Gildess Fe... 23 Gilenya...4 Glatopa...4 Gleevec... Glimepiride...7 Glipizide...7 Glipizide Extended-Release...7 Glyburide...7 Glyxambi...7 Golytely...9 Guanfacine..., 3 Guanfacine Extended-Release... 3 H Harvoni...9 Humalog KwikPen...6 Humalog Mix 50-50 KwikPen...6 Humalog Mix 75-25 KwikPen...6 Humalog Vials...6 Humira...9 Humulin 70-30 KwikPen...6 Humulin 70-30 Vials...6 Humulin N KwikPen...6
Humulin N Vials...6 Humulin R Vials...6 Hydralazine... Hydrochlorothiazide... Hydrocodone/Acetaminophen 5/325, 7.5/325, 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... Hydroxyzine Capsule,... 22 Hyoscyamine...9 Hysingla...2 I Ibandronate...2 Ibuprofen...2 Imbruvica... Imiquimod 5% Cream... 5 Incruse Ellipta... 22 Indomethacin Capsule...2 Intelence...9 Introvale... 23 Intuniv... 3 Invokamet...7 Invokana...7 Ipratropium-Albuterol Nebs... 22 Ipratropium Nebs... 22 Irbesartan... Isentress...9 Isosorbide Mononitrate ER... 2 Itraconazole Capsule...0 J Janumet...7 Januvia...7 Jardiance...7 Jentadueto...7 Jolessa... 23 Junel... 23 Junel Fe... 23 K Kaletra...9 Kazano...7 Ketoconazole Cream...0 Ketorolac...2 Klor-Con M0... 23 Klor-Con M20... 23 Kombiglyze XR...7 L Labetalol... Lamivudine-Zidovudine...9 Lamotrigine... 5 Lansoprazole Capsules...8 Lantus Solostar...6 Lantus Vials...6 Lastacaft...7 Latanoprost 0.005% Ophthalmic Solution...8 Latuda...4 Lazanda...2 Leflunomide...9 Lescol XL... 2 Letairis... 23 Letrozole... 20 Leucovorin Calcium... Levalbuterol Nebs... 22 Levemir FlexTouch...6 Levemir Vials...6 28 Levetiracetam Extended-Release... 5 Levetiracetam... 5 Levitra... 20 Levocetirizine... 22 Levofloxacin...0 Levora-28... 23 Levothyroxine Sodium...7 Lexapro... 3 Lialda...9 Lidocaine Transdermal Patch... 20 Linzess...9 Liothyronine Sodium...7 Lipitor... 2 Lipofen... 2 Lisinopril..., 34 Lisinopril- Hydrochlorothiazide... Lithium Capsule...4 Livalo... 2 Lo Loestrin Fe... 23 Lorazepam...4 Loryna... 23 Losartan... Losartan- Hydrochlorothiazide... Lovastatin... 2 Low-Ogestrel... 23 Lumigan...8 Lutera... 23 Lyrica... 5 M Medroxyprogesterone... 24 Meloxicam...2 Memantine...4 Mercaptopurine... Metadate CD... 3
Metaxalone...2 Metformin...7 Metformin Extended-Release (generic Glucophage XR)...7 Methadone, Oral Solution, Concentrate Solution...2 Methimazole...7 Methocarbamol...2 Methotrexate...9 Methylphenidate Chewable... 3 Methylphenidate Extended-Release Capsule... 3 Methylphenidate Extended-Release... 3 Methylphenidate... 3 Methylprednisolone...7 Metoclopramide...9 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...2 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...9 Moviprep...9 Moxeza...8 Moxifloxacin...0 Mupirocin Ointment... 5 Mycophenolate Capsule, Suspension... 23 Mycophenolic Acid... 23 Myfortic... 23 N Nabumetone...2 Nadolol... Namenda XR...4 Naproxen...2 Naratriptan...4 Nasonex... 22 Natazia... 23 Necon 0.5/35, /35, /50, 0/... 24 Neoral... 23 Nesina...7 Nevirapine...9 Nevirapine Extended-Release...9 Nexium Capsule...8 Next Choice... 24 Niacin Extended-Release... 2 Niaspan... 2 Nicoderm CQ... 23 Nicorette Gum... 23 Nicorette Lozenge... 23 Nicorette Mini-Lozenge... 23 29 Nicotine Gum... 23 Nicotine Lozenge... 23 Nicotine Patch... 23 Nicotrol Inhaler... 23 Nicotrol Nasal Spray... 23 Nifedipine Extended-Release... Nitrofurantoin Capsule...0 Nitrofurantoin Macrocrystal Capsule...0 Nitrostat... 2 Norgestimate-Ethinyl Estradiol... 24 Nortrel 0.5/35... 24 Nortriptyline Capsule... 3 Norvir...9 Novolin 70-30 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 Nuvaring... 24 Nuvigil...4 Nystatin-Triamcinolone Acetonide Cream, Ointment... 5 Nystatin Cream, Ointment...0 O Ofloxacin 0.3% Ophthalmic Solution...8 Ofloxacin s...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 OneTouch Verio IQ...6 OneTouch Verio Sync...6 OneTouch Verio Test Strips...6 Onglyza...7 Opana ER...2 Opsumit... 23 Oracea...0 Orencia...9 Orenitram... 23 Orsythia... 24 Ortho-Cyclen... 24 Ortho-Novum... 24 Ortho-Novum 7/7/7... 24 Ortho Micronor... 24 Ortho Tri-Cyclen... 24 Ortho Tri-Cyclen Lo... 24 Oseni...7 Osphena... 24 Otezla...9 Otrexup...9 Oxcarbazepine... 5 Oxsoralen-Ul... 5 Oxybutynin Extended-Release... 22 Oxybutynin... 22 Oxycodone/Acetaminophen 5/325, 7.5/325, 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... 5 Picato... 5 Pioglitazone...7 Plan B One Step... 24 Polyethylene Glycol 3350...9 Potassium Chloride... 23 Potassium Citrate... 23 Pradaxa... Pramipexole...4 Pravastatin... 2 Prednisone...7 Premarin... 24 Premphase... 24 Prempro... 24 Prenisolone Oral Solution...7 Prepopik...9 Prezcobix...9 Prezista...9 Pristiq ER... 3 Proair HFA... 22 Procrit... 20 Progesterone Micronized Capsule... 24 Prograf... 23 Promethazine/Codeine... 20 Promethazine/ Dextromethorphan... 20 Promethazine... 22 30 Propranolol Extended-Release Capsule... Propranolol... 2 Proventil HFA... 22 Pulmicort Flexhaler... 22 Pulmozyme... 20 Pylera...8 Q Qnasl... 22 Quasense... 24 Quetiapine...4 Quinapril... 2 QVAR... 22 R Rabeprazole...8 Raloxifene...2, 24 Raloxifene...2 Ramipril... 2 Ranexa... 2 Ranitadine Syrup...8 Rapaflo... 20 Rapamune... 23 Rasuvo...9 Rebif...4 Reclipsen... 24 Rectiv... 20 Regranex...6 Relpax...4 Renvela... 20 Restasis... 20 Revlimid... Reyataz...9 Rezira... 20 Ribapak...9 Ribavirin...9 Risedronate Sodium...2 Risperidone...4 Rizatriptan ODT,...4 Ropinirole...4
S Savaysa... Serevent Diskus... 22 Seroquel XR...4 Sertraline... 3 Sildenafil... 23 Simcor... 2 Simponi...9 Simvastatin... 2 Sirolimus... 23 Solodyn...0 Sotalol... 2 Sovaldi...9 Spiriva Handihaler... 22 Spiriva Respimat... 22 Spironolactone... 2 Sprintec... 24 Sprix...2 Sronyx... 24 Stelara...9 Stendra... 20 Strattera... 3 Stribild...9 Striverdi Respimat... 22 Suboxone Film...4 Subsys...2 Suclear...9 Sucralfate...8 Sulfamethoxazole- Trimethoprim...0 Sulfasalazine...9 Sumatriptan Nasal Spray...4 Sumatriptan Succinate, Injection...4 Sumavel DosePro...4 Suprax Capsule, Chewable,...0 Suprep...9 Sustiva...9 Sutent... Symbicort... 22 Synthroid...7 T Tacrolimus Capsule... 23 Tacrolimus Ointment...6 Tamiflu...0 Tamoxifen... 24 Tamsulosin Capsule... 20 Tanzeum...7 Tasigna... Tazorac...6 Tecfidera...4 Telmisartan... 2 Telmisartan- Hydrochlorothiazide... 2 Temazepam Capsule...4 Terazosin... 2, 20 Terazosin Capsule,... 20 Terbinafine...0 Testim... 20 Testosterone Cypionate Injection... 20 Thrive Gum... 23 Timolol Maleate 0.25%, 0.5% Ophthalmic Solution...8 Tirosint...7 Tivicay...9 Tizanidine...2 Tobi Podhaler... 20 Tobramycin/Dexamethasone 0.3%-0.% Ophthalmic Suspension...8 Tobramycin Nebulized Solution... 20 Tobramycin Ophthalmic Solution...8 Tolcapone...4 Tolterodine Extended-Release... 22 Tolterodine... 22 3 Topiramate... 5 Toviaz... 22 Tracleer... 23 Tradjenta...7 Tramadol-Acetaminophen...2 Tramadol Sustained-Release...2 Tramadol...2 Transderm-Scop...8 Travatan Z...8 Trazodone... 3 Tretinoin...6 Tretinoin Microspheres...6 Tri-Previfem... 24 Tri-Sprintec... 24 Triamcinolone Acetonide Cream, Lotion, Ointment...6 Triamcinolone Nasal Spray... 22 Triamterene- Hydrochlorothiazide... 2 Triazolam...4 Tricor 48, 45 mg... 2 Trinessa... 24 Triumeq...9 Trulicity...7 Truvada...9 Tudorza... 22 Tybost...9 Tyvaso... 23 U Uceris...9 Uloric...2 V Vagifem... 24 Valacyclovir...0 Valaganciclovir...0 Valsartan... 2 Valsartan- Hydrochlorothiazide... 2
Vascepa... 2 Vectical...6 Velphoro... 20 Venlafaxine Extended-Release Capsule... 3 Venlafaxine... 3 Ventolin HFA... 22 Verapamil... 2 Verapamil Sustained-Release... 2 Vesicare... 22 Vestura... 24 Viagra... 20 Vicodin 5/300, 7.5/300, 0/300 mg...2 Victoza 2-Pak...7 Victoza 3-Pak...7 Viekira Pak...9 Vigamox...8 Viibryd... 3 Viorele... 24 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... 24 Xyrem...4 Y Yasmin 28... 24 Yaz... 24 Z Zaleplon Capsule...4 Zelapar...4 Zenpep...9 Zetia... 2 Zetonna... 22 Ziprasidone Capsule...4 Zohydro ER...2 Zolpidem Extended-Release...4 Zolpidem...4 Zonisamide Capsule... 5 Zovirax Cream...0 Zubsolv...4 Zytiga... 32
Notes 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, 20 mg High blood pressure One tablet daily Dr. Johnson 34
For more information Call the toll-free Member Services number on your health plan ID card. Or, visit www.uhone.com All branded medications are trademarks or registered trademarks of their respective owners. 205 United HealthCare Services, Inc. All rights reserved. Created September, 205. 206 Prescription List Golden Rule Advantage Four- /6