Your 06 Prescription List Effective January, 06 Please read: This document contains information about the drugs covered under your pharmacy benefit plan. For a complete list of covered drugs or if you have questions: Call the toll-free member phone number on the back of your ID card. Visit optumrx.com Locate a participating retail pharmacy by zip code. Look up possible lower-cost medication alternatives. Compare medication pricing and options. OptumRx optumrx.com
Your Prescription List This Prescription List (PDL) outlines the most commonly prescribed medications from your plan s complete pharmacy benefit coverage list, also known as a formulary. A formulary identifies the drugs available for certain conditions and organizes them into cost levels, also known as tiers. An important part of the PDL is giving you choices so you and your doctor can choose the best course of treatment for you. Go to optumrx.com for complete and up-to-date drug information Since the PDL may change, we encourage you to visit our website, optumrx.com. This website is the best source for up-to-date information about all of the medications your pharmacy benefit covers, possible lower-cost options and cost comparisons. John Smith John Smith JOHN SMITH
Table of Contents tiers and cost.... 5 and limits... 6 s by category... 9 Anti-Infectives Antibiotics... 9 Antifungals... 9 Antivirals.... 9 Cancer... 9 Cardiovascular/Heart Disease Anticoagulants.... 9 High Blood Pressure... 0 High Cholesterol... 0 Other.... Pulmonary Arterial Hypertension... Central Nervous System Attention Deficit Disorder... Depression.... Migraine... Multiple Sclerosis... Other.... Sedatives/Hypnotics... Seizure Disorders... Dermatology... 3 Diabetes/Endocrine Blood Glucose Monitoring... 3 Insulin... 4 Non-Insulin... 5 Endocrine Growth Hormone... 5 Other.... 5 Thyroid Hormone Replacement... 5 Eye Conditions Allergies.... 5 Antibiotics... 5 Glaucoma... 6 Other.... 6 Gastrointestinal Acid Suppression... 6 Nausea/Vomiting... 6 Other.... 6 HIV/AIDS... 6 Infertility... 7 Inflammatory Conditions... 7 Men s Health Erectile Dysfunction... 7 Prostate... 7 Testosterone Therapy... 7 Miscellaneous... 7 Musculoskeletal Osteoporosis... 8 Other.... 8 Pain Relief... 8 Overactive Bladder... 9 Respiratory Asthma/COPD... 9 Nasal Allergies... 9 Oral Allergies... 9 Transplant... 9 Vitamins/Electrolytes... 9 Women s Health Birth Control... 0 Hormone Replacement... 0 Vaginal Anti-Infectives... 0 Index... 3
At OptumRx, we want to help you better understand your medication options. Your pharmacy benefit offers flexibility and choice in determining the right medication for you. To help you get the most out of your pharmacy benefit, we ve included some of the most commonly asked questions about the Prescription List. What is a Prescription List (PDL)? This document is a list of commonly prescribed medications preferred by your plan sponsor for their safety, cost and effectiveness. s are listed by common categories or class. They are placed into cost levels known as tiers. It includes both brand and generic prescription medications approved by the U.S. Food and Administration (FDA). Please note: Where differences are noted between this PDL and your benefit plan documents, the benefit plan documents will rule. It is not intended to be a complete list of medications, and not all medications listed may be covered under your plan. Please look at your benefit plan documents provided by your employer or plan sponsor to see what medications are covered under your plan. You may also log on to optumrx.com or call the toll-free member phone number on the back of your ID card for more information. How do I use my Prescription List? When choosing a medication, you and your doctor should consult the PDL. It will help you and your doctor choose the most cost-effective prescription drugs. This guide tells you if a medication is generic or brand, and if special rules apply. Bring this list with you when you see your doctor. It is organized by common medical conditions. Medications are then listed alphabetically. If your medication is not listed in this document, please visit optumrx.com or call the toll-free member phone number on the back of your ID card. 4
What are tiers? s are the different cost levels you pay for a medication. Each tier is assigned a cost, which is determined by your employer or plan sponsor. This is how much you will pay when you fill a prescription. medications are your lowest-cost options. If your medication is placed in or 3, look to see if there is a option available. Discuss these options with your doctor. names shown in orange are preferred for their cost and effectiveness. If there is a symbol in the column, check your benefit plan documents to find out your specific pharmacy plan costs. $ Includes Helpful Tips $ $ $$ $ $$ $$$ Lowest Cost Mid-range Cost Lower-cost, commonly used generic drugs. Some low-cost brands may be included. Many common brandname drugs, called preferred brands. Use drugs for the lowest out-ofpocket costs. Use drugs, instead of 3, to help reduce your out-of-pocket costs. $$$ $$$ 3 Highest Cost Mostly higher-cost brand drugs, also known as nonpreferred brands. Many 3 drugs have lower-cost options in or. Ask your doctor if they could work for you. Please note: Some plans may have two or four tiers, while others may not have any. If you have a high deductible plan, the tier cost levels will apply once you hit your deductible. Refer to your enrollment and plan materials on optumrx.com, or call the toll-free member phone number of the back of your ID card for more information about your benefit plan. When does the Prescription List change? Medications may move to a lower tier at any time. Medications may move to a higher tier when its generic becomes available. Medications may move to a higher tier or be excluded from coverage on January or July of each year. When a medication changes tiers, you may have to pay a different amount for that medication. For the most up-to-date list, call customer service at the toll-free member phone number on the back of your ID card. 5
Some medications are noted with letters or symbols next to them. The letters and symbols refer to our pharmacy benefit programs and are provided to help you check which medications may have a program or limit. Your benefit plan determines how these medications may be covered for you. PA ST QL Prior Authorization Your doctor is required to provide additional information to determine coverage. Step Therapy Trial of lower cost medication(s) is required before a higher-cost medication is covered. Quantity Limits Amount of medication covered per copayment or in a specific time period. AR Age Restrictions Some restrictions may apply based on patient age. SP GR Specialty Medication Medication is designated as a specialty pharmacy drug. Gender Restrictions Some restrictions may apply based on patient gender. To learn more about a pharmacy program or to find out if it applies to you, please visit optumrx.com or call the toll-free member phone number on the back of your ID card. 6
Why are some medications excluded from coverage? Medications may be excluded from coverage under your pharmacy benefit when it works the same as or similar to another prescription medication or an over-the-counter (OTC) medication. There may be other medication options available. What if I don t agree with a decision about an excluded medication? You (or your authorized representative) and your doctor can ask for an initial coverage decision by calling the toll-free member phone number on the back of your ID card. Should I talk to my doctor about OTC medications? An OTC medication may be the right treatment option for some conditions. Talk to your doctor about available OTC options. Even though these medications may not be covered under your pharmacy benefit, they may cost less than your out-of-pocket expense for prescription medications. What is the difference between brand-name and generic medications? Generic medications contain the same active ingredients (what makes the medication work) as brand-name medications, but they often cost less. Once the patent of a brand-name medication ends, the FDA can approve a generic version with the same active ingredients. These types of medications are known as generic medications. Sometimes the same company that makes a brand-name medication also makes the generic version. Is it a generic or brand-name drug? The drug list shows brand-name drugs in bold type (for example, Lamictal) and generic drugs in plain type (for example, lamotrigine). What if my doctor writes a brand-name prescription? The next time your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lower-cost option is available and if it might be right for you. Generic medications are usually your lowest-cost option, but not always. Visit optumrx.com to make sure. 7
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 -888-70-843 and have your prescriptions delivered right to your home or office. How do I get updated information about my pharmacy benefit? Since the PDL may change during your plan year, we encourage you to visit optumrx.com or call the toll-free member phone number on the back of your ID card for more current information. When you register at optumrx.com and open an account, you can use the website s helpful tools and features to: Look up the price of drugs covered by your plan Find lower-cost options Refill and renew mail service prescriptions View your order status and claims history Sign up for text reminders to take and refill your medicine View your benefits in real time Order medical supplies Shop for health and wellness products More information If you have additional questions please call customer service, 4 hours a day, 7 days a week using the toll-free member phone number on the back of your ID card. Or visit optumrx.com. 8
Name Anti-Infectives: Antibiotics Amoxicillin Amoxicillin/Clavulanate Azithromycin Bethkis SP Cefadroxil Cap Cefdinir Cefuroxime Tab Cephalexin Ciprodex Otic Suspension 3 Ciprofloxacin Tab Clarithromycin Clindamycin Cap Dificid 3 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, Solution Nitrofurantoin Macrocrystalline Nitrofurantoin Monohydrate Macrocrystalline Ofloxacin Otic Solution Oracea 3 QL Penicillin VK Solodyn 3 QL Sulfamethoxazole- Trimethoprim Name Sulfamethoxazole- Trimethoprim DS Anti-Infectives: Antifungals Fluconazole Nystatin Oral Powder Nystatin Suspension Terbinafine Tab Anti-Infectives: Antivirals Acyclovir Cap, Tab, Suspension Baraclude 3 QL, SP Entecavir QL, SP Famciclovir Tab Harvoni PA, QL, SP Pegasys PA, SP Sovaldi PA, QL, ST, SP Tamiflu 3 QL Valacyclovir QL Cancer Anastrozole Tab Capecitabine SP Gleevec PA, QL, SP Letrozole PA Revlimid 3 PA, QL, SP Tamoxifen Tab Tasigna PA, QL, SP Temozolomide PA, SP Zytiga 3 PA, SP Cardiovascular/Heart Disease: Anticoagulants Brilinta QL Clopidogrel QL Effient QL Eliquis 3 QL Enoxaparin QL Pradaxa QL Savaysa 3 QL Warfarin Xarelto QL [Plain type = Generic drug] Call customer service for pricing PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions 9
Name 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 3 QL, ST Diltiazem Tab Diovan 3 QL, ST Doxazosin Dutoprol QL Edarbi 3 QL, ST Edarbyclor 3 QL, ST Enalapril Enalapril/HCTZ Felodipine QL Fosinopril Furosemide Guanfacine Tab (Immediate Release) Hydralazine Hydrochlorothiazide Irbesartan QL Irbesartan/HCTZ QL Labetalol Lisinopril Lisinopril/HCTZ Name 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 Cardiovascular/Heart Disease: High Cholesterol Atorvastatin QL Cholestyramine Crestor QL Fenofibrate 43 mg, 48 mg, 50 mg, 54 mg, 67 mg, 30 mg, 34 mg, QL 45 mg, 50 mg, 60 mg, 00 mg Fenofibrate 0 mg 3 QL, ST Gemfibrozil QL Lipitor 3 QL, ST Livalo 3 QL, ST Lovastatin Lovaza 3 QL Niacin ER Tab QL Omega-3 Acid Cap gm QL Pravastatin Simcor QL [Plain type = Generic drug] Call customer service for pricing PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions 0
Name Simvastatin 5 mg, 0 mg, 0 mg, 40 mg QL Simvastatin 80 mg PA, QL Vascepa QL Vytorin 0-0 mg, 0-0 mg, QL 0-40 mg Vytorin 0-80 mg PA, QL Welchol QL Zetia 3 QL Cardiovascular/Heart Disease: Other Amiodarone Amlodipine/Atorvastatin QL Digoxin Flecainide Isosorbide Mononitrate Nitrostat Ranexa ST Sotalol Cardiovascular/Heart Disease: Pulmonary Arterial Hypertension Adcirca 3 PA, QL, SP Adempas PA, QL, SP Letairis PA, QL, SP Opsumit PA, QL, SP Orenitram 3 PA, SP Sildenafil Tab 0 mg PA, QL, SP Tracleer PA, QL, SP Central Nervous System: Attention Deficit Disorder Adderall XR Cap 3 QL, ST, AR Amphetamine- Dextroamphetamine QL, AR Tab Amphetamine- Dextroamphetamine QL, AR SR 4Hr Cap Dexmethylphenidate ER Cap QL, AR Focalin XR 3 QL, ST, AR Guanfacine ER Tab QL Intuniv 3 QL Name Methylphenidate ER Cap QL, AR Methylphenidate ER Tab QL, AR Methylphenidate SA Osmotic ER Tab QL, AR Methylphenidate Tab QL, AR Strattera QL Vyvanse QL, AR Central Nervous System: Depression Amitriptyline Bupropion Bupropion ER Bupropion SR Bupropion XL QL Citalopram QL Doxepin Duloxetine Cap 0 mg, 30 mg, 60 mg QL 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 3 QL, ST Central Nervous System: Migraine Butalbital- Acetaminophen- Caffeine Cap, Tab QL 50-35-40 mg Migranal 3 QL Relpax 3 QL Rizatriptan Tab, ODT QL [Plain type = Generic drug] Call customer service for pricing PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions
Name Sumatriptan Tab and Spray QL Sumavel Dose 3 QL Zolmitriptan Tab QL Zomig Nasal Spray QL Central Nervous System: Multiple Sclerosis Ampyra PA, QL, SP Avonex Kit PA, QL, SP Avonex Pen Kit PA, QL, SP Avonex Prefill Kit PA, QL, SP Betaseron PA, QL, ST, SP Copaxone PA, QL, SP Gilenya* 3 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 3 QL Alprazolam Tab QL Aripiprazole QL Benztropine Buspirone Carbidopa/Levodopa Tab (Immediate Release) Diazepam Tab Donepezil Tab QL Hydroxyzine HCL Hydroxyzine Pamoate Latuda 3 QL, ST Lithium Carbonate Lorazepam Tab QL Modafinil PA, QL Namenda Tab 3 QL Namenda XR Cap QL Nuvigil 3 PA, QL Olanzapine Tab QL Name Pramipexole Prochlorperazine Quetiapine QL Risperidone Tab QL Ropinirole (Immediate Release) Saphris QL Seroquel XR QL Zelapar 3 Ziprasidone Cap QL Central Nervous System: Sedatives/Hypnotics Eszopiclone Tab QL Silenor 3 QL Temazepam QL Triazolam Tab QL Zolpidem QL Zolpidem ER QL Central Nervous System: Seizure Disorders Carbamazepine Tab Clonazepam QL Divalproex DR Divalproex ER Gabapentin Lamictal Tab, Chew Lamictal ODT 3 Lamictal XR 3 QL Lamotrigine (Immediate Release) Lamotrigine ER QL Levetiracetam Levetiracetam ER QL Lyrica Cap QL Onfi 3 PA, SP Oxcarbazepine Phenytoin Primidone Topiramate Tab Zonisamide * 3 Preferred [Plain type = Generic drug] Call customer service for pricing PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions
Name Dermatology Acanya Gel 3 QL Acyclovir Ointment 5% Aczone Gel 3 Atralin QL, AR Benzaclin 3 QL Betamethasone Dipropionate Cream Ciclopirox Cream Clindamycin Gel, Lotion, Solution Clindamycin/ Benzoyl Peroxide QL Gel -5% Clindamycin/Benzoyl Peroxide Gel QL.-5% Clobetasol Cream, Ointment, Solution Clobex 3 Cloderm 3 Clotrimazole/ Betamethasone Cream, Lotion Desonide Cream, Ointment Desoximetasone Cream, Gel, Ointment Differin 3 QL Econazole Cream Elidel QL, ST, AR Epiduo 3 QL Finacea Fluocinonide Cream, 0.% Fluocinonide Cream, Gel, Ointment, Solution 0.05% Hydrocortisone Cream, Ointment.5% Lidocaine Topical Ointment, Solution Name Lidocaine/Prilocaine Cream Ketoconazole Cream/ Shampoo Metrogel 3 Metronidazole Gel 0.75% Mometasone Mupirocin Ointment Nystatin Cream, Ointment, Powder Nystatin/Triamcinolone Cream, Ointment Oxsoralen-UL PA Permethrin Cream 5% Protopic Ointment 3 QL, AR Retin-A Micro 3 QL, AR Sulfacetamide/Sulfur Emulsion Taclonex 3 QL Tretinoin Cream AR Tretinoin Microsphere Gel QL, AR Triamcinolone Vectical 3 Zovirax Cream Zovirax Ointment 3 Zyclara 3 QL Diabetes/Endocrine Blood: Glucose Monitoring Accu-Chek Active Glucose Control 3 Liquid Accu-Chek Active Test Strips QL Accu-Chek Aviva Plus Control Liquid 3 Accu-Chek Aviva Plus Kit Accu-Chek Aviva Plus Test Strips QL [Plain type = Generic drug] Call customer service for pricing PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions 3
Name Accu-Chek Comfort Curve Control 3 Liquid Accu-Chek Comfort Curve Test Strips QL Accu-Chek Compact Plus Control Liquid 3 Accu-Chek Compact Plus Test Strips QL Accu-Chek Compact Plus Kit 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 3 Accu-Chek SmartView Test Strips QL Accu-Chek Soft Touch Lancets Accu-Chek Softclix Kit Accu-Chek Softclix Lancets Bayer Contour Test Strips 3 PA, QL Dexcom G4 Platinum Kit 3 Dexcom G4 Platinum Sensor Kit 3 Dexcom G4 Platinum Transmitter Kit 3 Freestyle Test Strips 3 PA, QL Glucocard Test Strips 3 PA, QL Insulin Pen Needle Insulin Syringe/ Needle Novofine Pen Needle 3 Name Novofine Autocover Pen Needle 3 Novotwist Pen Needle 3 Onetouch Kit Ultra Smart Onetouch Kit Ultra Onetouch Kit Ultra Onetouch Kit Ultra Mini Onetouch Kit Verio IQ Onetouch Lancets Onetouch Test Strips QL Onetouch Ultra Blue Test Strips QL Onetouch Verio Test Strips QL Precision Test Strips 3 PA, QL Truetest Test Strips 3 PA, QL Truetrack Test Strips 3 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 70/30 Vials Humulin N Vials Humulin N Pen Humulin Pen 70/30 Humulin R U-500 Humulin R Vials Lantus Solostar Lantus Vials Levemir FlexTouch Levemir Vials Novolin 70/30 Vials [Plain type = Generic drug] Call customer service for pricing PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions 4
Name Novolin N Vials Novolin R Vials Novolog Flexpen Novolog Mix Flexpen Novolog Mix 70/30 Vials Novolog Penfill Novolog Vials Diabetes/Endocrine: Non-Insulin Bydureon QL, ST Byetta QL, ST Glimepiride Glipizide Glipizide ER Glipizide XL Glumetza 3 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 Lupron Depot 3.75 mg,.5 mg PA, SP Name Lupron Depot 7.5 mg,.5 mg, PA, SP 30 mg, 45 mg Methylprednisolone Tab Prednisone Prednisolone Solution 5 mg/5 ml Prednisolone Syrup, Solution 5 mg/5 ml Sensipar 3 SP Endocrine: Thyroid Hormone Replacement Armour Thyroid 3 Levothyroxine Liothyronine Methimazole Synthroid 3 Tirosint 3 Eye Conditions: Allergies Azelastine Ophthalmic Solution Pataday Patanol QL Eye Conditions: Antibiotics Ciprofloxacin Ophthalmic Solution QL Erythromycin Ointment Gentamicin Moxeza QL Neomycin/Polymyxin B/Dexamethasone Ointment, Suspension Ofloxacin Ophthalmic Solution QL Polymyxin B/ Trimethoprim Solution Tobramycin Tobramycin/ Dexamethasone Vigamox QL [Plain type = Generic drug] Call customer service for pricing PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions 5
Name 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 3 Lotemax Ophthalmic Gel 3 Ketorolac Ophthalmic Solution QL Prednisolone Ophthalmic Suspension Restasis 3 PA 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 Ranitidine Tab, Cap, Syrup (Rx only) Sucralfate Tab Gastrointestinal: Nausea/Vomiting Meclizine Metoclopramide QL Name Ondansetron Tab QL Transderm-Scop 3 Gastrointestinal: Other Amitiza QL, ST, AR Apriso 3 QL, ST Asacol HD 3 QL, ST Canasa QL Creon Delzicol 3 QL, ST Dicyclomine Diphenoxylate/Atropine Gavilyte Solution QL Hyoscyamine Sublingual Tab Lactulose Lialda QL Linzess QL, ST, AR Movantik QL Moviprep 3 QL Omeclamox Pak QL Pentasa 3 QL Polyethylene Glycol 3350 Powder Protosol HC Prepopik 3 Pylera QL Sulfasalazine Suprep Bowel Prep 3 QL Uceris 3 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 [Plain type = Generic drug] Call customer service for pricing PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions 6
Name 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 3 SP 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 3 QL, AR, GR Stendra QL, AR, GR Viagra 3 QL, AR, GR Men s Health: Prostate Alfuzosin QL Avodart QL Doxazosin Finasteride 5 mg QL Jalyn QL Rapaflo QL Tamsulosin QL Name Terazosin Men s Health: Testosterone Therapy Androderm PA, QL, GR Androgel.6% PA, QL, GR Androgel % 3 PA, QL, GR Testosterone Cypionate IM Injection PA Miscellaneous Allopurinol Antipyrine/Benzocaine Otic Solution 5.4 -.4% Aranesp PA, SP Benzonatate Botox 00, 00 unit Injection PA, SP (non-cosmetic) Bunavail 3 PA, QL Cerdelga 3 PA, QL, SP Chantix 3 QL Cheratussin Chlorhexidine Colcrys QL Cyproheptadine Desmopressin Epipen -Pak QL Euflexxa PA, SP Fosrenol 3 Guaifenesin/Codeine Syrup Homatropine/ Hydrocodone Syrup Hydrocodone/ Chlorpheniramine Liquid Hydrocortisone AC Suppository 5 mg Hydromet Lidocaine Viscous Solution % Makena PA, SP [Plain type = Generic drug] Call customer service for pricing PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions 7
Name Phenazopyridine (Rx only) Phentermine Tab PA Procrit PA, SP Promethazine DM Syrup AR Promethazine/Codeine Syrup AR Pulmozyme SP Rectiv 3 Renvela Tab Rezira 3 Suboxone Film PA, QL Synagis PA, SP Synvisc PA, SP Uloric QL, ST Ursodiol Velphoro 3 Zostavax Injection 3 Zubsolv PA, QL Zutripro 3 Musculoskeletal: Osteoporosis Alendronate Tab Evista 3 QL Forteo PA, SP Ibandronate Tab QL Raloxifene QL Musculoskeletal: Other Baclofen Tab Carisoprodol 350 mg Cyclobenzaprine Tab 5, 0 mg Metaxalone Methocarbamol Tizanidine Cap Tizanidine Tab Musculoskeletal: Pain Relief Acetaminophen w/ Codeine QL Cambia 3 QL Celebrex 3 QL Celecoxib QL Name Diclofenac Tab QL Endocet Tab QL Etodolac QL Fentanyl Patch 5 mcg/hr, 50 mcg/hr, QL 75 mcg/hr, 00 mcg/hr Fentanyl Patch 37.5 mcg/hr, 6.5 mcg/hr, QL 87.5 mcg/hr Gralise 3 QL, ST Hydrocodone w/ Ibuprofen QL Tab 7.5-00 mg Hydrocodone/APAP 5, 7.5, 0/35 mg QL Hydromorphone Tab Ibuprofen Tab 400, 600, 800 mg (Rx only) QL Indomethacin Cap QL Ketorolac Tab QL Lazanda 3 PA, QL Lidocaine Patch 5% QL Meloxicam QL Methadone Tab Morphine Sulfate Tab QL Nabumetone QL Naproxen (Rx only) QL Nucynta 3 QL Nucynta ER 3 PA, QL Opana ER QL Oxycodone Tab 5, 0, 5, 30 mg (Immediate Release) Oxycodone w/ Acetaminophen QL Oxycontin QL Tramadol Tab 50 mg QL Tramadol w/ Acetaminophen QL Vicodin QL Vicodin ES QL [Plain type = Generic drug] Call customer service for pricing PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions 8
Name Voltaren Gel QL Overactive Bladder Enablex 3 QL Gelnique QL Myrbetriq 3 QL, ST Oxybutynin Oxybutynin ER QL Tolterodine QL Toviaz 3 QL Vesicare QL Respiratory: Asthma/COPD Advair Diskus QL Advair HFA QL Aerospan 3 QL Albuterol Nebulizer Solution Breo Ellipta QL Budesonide Inhalation Suspension Combivent Respimat QL Dulera 3 QL, ST Flovent Diskus QL Flovent HFA QL Foradil QL, ST Incruse Ellipta QL Ipratropium/Albuterol Levalbuterol Nebulizer Solution Montelukast QL Perforomist 3 QL Proair HFA, RespiClick QL Proventil HFA 3 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 3 QL, ST Name Respiratory: Nasal Allergies Azelastine Spray QL Dymista Spray 3 QL Fluticasone Spray Ipratropium Spray Nasonex QL Omnaris 3 QL QNasl 3 QL Triamcinolone Spray QL Veramyst QL Zetonna 3 QL Respiratory: Oral Allergies Cetirizine Promethazine Tab AR Desloratadine QL Levocetirizine QL Transplant Azathioprine Tab Cellcept Tab/ Suspension 3 SP Cyclosporine Cap SP Mycophenolate Mofetil 50 mg Cap/ SP 500 mg Tab Mycophenolate Sodium 80 mg, 360 mg SP Tab Prograf Cap 3 SP Rapamune 3 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 [Plain type = Generic drug] Call customer service for pricing PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions 9
Name 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 3 GR Cryselle-8 GR Falmina GR Generess Fe Chewable 3 GR Gianvi GR Gildess Fe GR Jolivette GR Junel GR Kariva GR Levora 8 GR Lo Loestrin 3 GR Lomedia Fe GR Loryna GR Low-Ogestrel GR Lutera GR Medroxyprogesterone Acetate Injection QL Microgestin GR Microgestin Fe GR Minastrin 4 Fe Chewable 3 GR Mono-Linyah GR Mononessa GR Natazia GR Necon GR Nora-Be GR Norgest/Ethi Estradio GR Nortrel GR Nuvaring Ocella GR Orsythia GR Name Ortho Tri-Cyclen Lo 3 GR Previfem GR Reclipsen GR Safyral 3 GR Sprintec 8 GR Tri-Linyah GR Tri-Previfem GR Trinessa GR Tri-Sprintec GR Vestura GR Viorele GR Xulane GR Zarah GR Women s Health: Hormone Replacement Climara Pro QL, GR Divigel 3 GR Duavee QL, GR Estrace Vaginal Cream 3 Estradiol Tab QL, GR Estradiol/Norethindrone Tab QL, GR Medroxyprogesterone Acetate Tab Minivelle 3 QL, GR Osphena 3 Premarin Tab QL, GR Premarin Vaginal Cream Premphase QL, GR Prempro QL, GR Progesterone Cap Vagifem 3 GR Vivelle-Dot 3 QL, GR Women s Health: Vaginal Anti-Infectives Gynazole- Vaginal Cream Metronidazole Vaginal Gel Terconazole Vaginal Cream 3 QL [Plain type = Generic drug] Call customer service for pricing PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions 0
Index of Covered s A Abilify Tab......... Acanya Gel......... 3 Accu-Chek Active Glucose Control Liquid..... 3 Accu-Chek Active Test Strips....... 3 Accu-Chek Aviva Plus Control Liquid..... 3 Accu-Chek Aviva Plus Kit. 3 Accu-Chek Aviva Plus Test Strips....... 3 Accu-Chek Comfort Curve Control Liquid..... 4 Accu-Chek Comfort Curve Test Strips....... 4 Accu-Chek Compact Plus Control Liquid..... 4 Accu-Chek Compact Plus Kit......... 4 Accu-Chek Compact Plus Test Strips....... 4 Accu-Chek FastClix Kit.. 4 Accu-Chek FastClix Lancets 4 Accu-Chek Multiclix Kit.. 4 Accu-Chek Multiclix Lancets4 Accu-Chek Nano Kit.... 4 Accu-Chek SmartView Control Liquid..... 4 Accu-Chek SmartView Test Strips....... 4 Accu-Chek Softclix Kit... 4 Accu-Chek Softclix Lancets 4 Accu-Chek Soft Touch Lancets..... 4 Acetaminophen w/ Codeine 8 Acyclovir Cap, Tab, Suspension 9 Acyclovir Ointment 5%... 3 Aczone Gel......... 3 Adcirca........... Adderall XR Cap...... Adempas.......... Advair Diskus....... 9 Advair HFA........ 9 Aerospan......... 9 Albuterol Nebulizer Solution 9 Alendronate Tab...... 8 Alfuzosin.......... 7 Allopurinol......... 7 Alphagan P........ 6 Alprazolam Tab....... Amiodarone......... Amitiza........... 6 Amitriptyline........ Amlodipine......... 0 Amlodipine/Atorvastatin.. Amlodipine/Benazepril... 0 Amlodipine/Valsartan.... 0 Amlodipine/Valsartan/HCTZ. 0 Amoxicillin.......... 9 Amoxicillin/Clavulanate.... 9 Amphetamine- Dextroamphetamine SR 4Hr Cap........ Amphetamine- Dextroamphetamine Tab Ampyra.......... Anastrozole Tab........9 Androderm........ 7 Androgel %....... 7 Androgel.6%...... 7 Antipyrine/Benzocaine Otic Solution 5.4 -.4%... 7 Apri............. 0 Apriso........... 6 Aranesp.......... 7 Aripiprazole......... Armour Thyroid...... 5 Asacol HD......... 6 Atenolol........... 0 Atenolol/Chlorthalidone... 0 Atorvastatin........ 0 Atralin........... 3 Atripla........... 6 Aviane........... 0 Avodart.......... 7 Avonex Kit......... Avonex Pen Kit...... Avonex Prefill Kit..... Azathioprine Tab...... 9 Azelastine Ophthalmic Solution......... 5 Azelastine Spray....... 9 Azithromycin......... 9 Azopt........... 6 Azor............ 0 Azurette.......... 0 B Baclofen Tab........ 8 Baraclude.......... 9 Bayer Contour Test Strips. 4 Benazepril.......... 0 Benazepril/HCTZ...... 0 Benicar........... 0 Benicar HCT........ 0 Benzaclin.......... 3 Benzonatate........ 7 Benztropine......... Betamethasone Dipropionate 3 Betaseron......... Bethkis............9 Beyaz............ 0 Bisoprolol.......... 0 Bisoprolol/HCTZ....... 0 Botox 00, 00 unit Injection........ 7 Breo Ellipta........ 9 Brilinta............9 Brimonidine......... 6 Budesonide Inhalation Suspension....... 9 Bumetanide......... 0 Bunavail.......... 7 Bupropion.......... Bupropion ER........ Bupropion SR........ Bupropion XL........ Buspirone.......... Butalbital-Acetaminophen- Caffeine Cap, Tab.... Bydureon......... 5 Byetta........... 5 Bystolic........... 0 C Calcitriol Cap........ 5 Cambia........... 8 Canasa........... 6 Capecitabine......... 9 Carafate Suspension... 6 Carbamazepine Tab..... Carbidopa/Levodopa Tab.. Carisoprodol........ 8 Cartia XT.......... 0 Carvedilol.......... 0 [Plain type = Generic drug]
Index of Covered s Cefadroxil Cap........ 9 Cefdinir............9 Cefuroxime Tab........ 9 Celebrex.......... 8 Celecoxib.......... 8 Cellcept Tab/Suspension. 9 Cephalexin.......... 9 Cerdelga.......... 7 Cetirizine.......... 9 Cetrotide.......... 7 Chantix........... 7 Cheratussin......... 7 Chlorhexidine........ 7 Chlorthalidone....... 0 Cholestyramine....... 0 Cialis............ 7 Ciclopirox Cream...... 3 Cimzia Kit......... 7 Ciprodex Otic Suspension. 9 Ciprofloxacin Ophthalmic Solution......... 5 Ciprofloxacin Tab....... 9 Citalopram......... Clarithromycin........ 9 Climara Pro........ 0 Clindamycin/Benzoyl Peroxide 3 Clindamycin........9, 3 Clobetasol Cream, Ointment, Solution......... 3 Clobex........... 3 Cloderm.......... 3 Clonazepam........ Clonidine Patch....... 0 Clonidine Tab........ 0 Clopidogrel.......... 9 Clotrimazole/Betamethasone 3 Colcrys........... 7 Combigan......... 6 Combivent Respimat... 9 Complera......... 6 Copaxone......... Coreg CR.......... 0 Creon............ 6 Crestor........... 0 Cryselle-8......... 0 Cyanocobalamine Injection. 9 Cyclobenzaprine Tab.... 8 Cyclosporine Cap...... 9 Cyproheptadine....... 7 D Delzicol.......... 6 Depen........... 7 Desloratadine........ 9 Desmopressin........ 7 Desonide.......... 3 Desoximetasone..... 3, 5 Dexcom G4 Platinum Kit. 4 Dexcom G4 Platinum Sensor Kit....... 4 Dexcom G4 Platinum Transmitter Kit..... 4 Dexilant.......... 6 Dexmethylphenidate ER... Diazepam Tab........ Diclofenac Tab....... 8 Dicyclomine........ 6 Differin........... 3 Dificid............ 9 Digoxin........... Diltiazem Tab........ 0 Diovan........... 0 Diphenoxylate/Atropine... 6 Divalproex DR........ Divalproex ER........ Divigel........... 0 Donepezil Tab........ Dorzolamide-Timolol Maleate 6 Doxazosin........ 0, 7 Doxepin........... Doxycycline Hyclate...... 9 Doxycycline Monohydrate...9 Duavee........... 0 Dulera........... 9 Duloxetine Cap....... Durezol Ophthalmic Emulsion........ 6 Dutoprol.......... 0 Dymista Spray....... 9 E Econazole Cream...... 3 Edarbi........... 0 Edarbyclor......... 0 Effient............ 9 Elidel............ 3 Eliquis............ 9 Enablex.......... 9 Enalapril........... 0 Enalapril/HCTZ....... 0 Endocet Tab......... 8 Enoxaparin.......... 9 Entecavir........... 9 Epiduo........... 3 Epipen -Pak........ 7 Epzicom.......... 6 Erythromycin......... 9 Erythromycin Ointment... 5 Escitalopram Tab...... Esomeprazole........ 6 Estrace Vaginal Cream.. 0 Estradiol/Norethindrone Tab. 0 Estradiol Tab........ 0 Eszopiclone Tab....... Etodolac.......... 8 Euflexxa.......... 7 Evista............ 8 F Falmina........... 0 Famciclovir Tab........ 9 Famotidine Tab....... 6 Felodipine.......... 0 Fenofibrate......... 0 Fenofibrate........ 0 Fentanyl Patch....... 8 Finacea........... 3 Finasteride......... 7 Flecainide.......... Flovent Diskus....... 9 Flovent HFA........ 9 Fluconazole.......... 9 Fluocinonide........ 3 Fluoxetine Cap....... Fluticasone Spray...... 9 Fluvoxamine Tab...... Focalin XR......... Folic Acid mg....... 9 Follistim AQ........ 7 Foradil........... 9 Forfivo XL......... Forteo........... 8 Fosinopril.......... 0 Fosrenol.......... 7 Freestyle Test Strips.... 4 Furosemide......... 0 [Plain type = Generic drug]
Index of Covered s G Gabapentin......... Gavilyte Solution...... 6 Gelnique.......... 9 Gemfibrozil......... 0 Generess Fe Chewable.. 0 Gentamicin......... 5 Gianvi............ 0 Gildess Fe.......... 0 Gilenya........... Gleevec........... 9 Glimepiride......... 5 Glipizide.......... 5 Glipizide ER......... 5 Glipizide XL......... 5 Glucocard Test Strips... 4 Glumetza......... 5 Glyburide.......... 5 Glyburide/Metformin.... 5 Gonal-f........... 7 Gonal-f RFF........ 7 Gralise........... 8 Guaifenesin/Codeine Syrup. 7 Guanfacine ER Tab..... Guanfacine Tab....... 0 Gynazole- Vaginal Cream 0 H Harvoni........... 9 Homatropine/Hydrocodone Syrup.......... 7 Humalog Kwik Pen 00 unit/ml....... 4 Humalog Mix 50/50 Kwik Pen.... 4 Humalog Mix 50/50 Vials. 4 Humalog Mix 75/5 Kwik Pen.... 4 Humalog Mix 75/5 Vials. 4 Humalog Vials....... 4 Humira Kit......... 7 Humira Pen Kit...... 7 Humira Pen Kit Crohns.. 7 Humira Pen Kit Psoriasis. 7 Humulin 70/30 Vials.... 4 Humulin N Pen...... 4 Humulin N Vials...... 4 Humulin Pen 70/30.... 4 Humulin R U-500..... 4 Humulin R Vials...... 4 Hydralazine......... 0 Hydrochlorothiazide..... 0 Hydrocodone/APAP.... 8 Hydrocodone/Chlorpheniramine Liquid.......... 7 Hydrocodone w/ Ibuprofen. 8 Hydrocortisone AC Suppository....... 7 Hydrocortisone Cream, Ointment.5%..... 3 Hydrocortisone Tab..... 5 Hydromet.......... 7 Hydromorphone Tab.... 8 Hydroxychloroquine..... 7 Hydroxyzine HCL...... Hydroxyzine Pamoate.... Hyoscyamine Sublingual Tab 6 I Ibandronate Tab....... 8 Ibuprofen Tab........ 8 Incruse Ellipta....... 9 Indomethacin Cap..... 8 Insulin Pen Needle.... 4 Insulin Syringe/Needle.. 4 Intelence......... 6 Intuniv........... Invokamet......... 5 Invokana.......... 5 Ipratropium/Albuterol.... 9 Ipratropium Spray...... 9 Irbesartan.......... 0 Irbesartan/HCTZ....... 0 Isentress.......... 6 Isosorbide Mononitrate... J Jalyn............ 7 Janumet.......... 5 Janumet XR........ 5 Januvia........... 5 Jardiance.......... 5 Jolivette........... 0 Junel............ 0 K Kaletra........... 6 Kariva............ 0 Ketoconazole Cream/ Shampoo........ 3 Ketorolac Ophthalmic Solution......... 6 Ketorolac Tab........ 8 Klor-Con 8 and 0 MEQ... 9 Klor-Con M0 and M0... 9 Kombiglyze........ 5 L Labetalol.......... 0 Lactulose.......... 6 Lamictal ODT....... Lamictal Tab, Chew.... Lamictal XR........ Lamotrigine ER....... Lamotrigine......... Lansoprazole........ 6 Lantus Solostar...... 4 Lantus Vials........ 4 Latanoprost......... 6 Latuda........... Lazanda.......... 8 Letairis........... Letrozole........... 9 Levalbuterol Nebulizer Solution.... 9 Levemir FlexTouch..... 4 Levemir Vials....... 4 Levetiracetam........ Levetiracetam ER...... Levitra........... 7 Levocetirizine........ 9 Levofloxacin Tab........9 Levora 8.......... 0 Levothyroxine........ 5 Lialda............ 6 Lidocaine Patch 5%..... 8 Lidocaine/Prilocaine Cream. 3 Lidocaine Topical Ointment, Solution......... 3 Lidocaine Viscous Solution %....... 7 Linzess........... 6 [Plain type = Generic drug] 3
Index of Covered s Liothyronine........ 5 Lipitor........... 0 Lisinopril.......... 0 Lisinopril/HCTZ....... 0 Lithium Carbonate..... Livalo............ 0 Lo Loestrin......... 0 Lomedia Fe......... 0 Lorazepam Tab....... Loryna........... 0 Losartan........... 0 Losartan/HCTZ....... 0 Lotemax Ophthalmic Gel. 6 Lovastatin......... 0 Lovaza........... 0 Low-Ogestrel........ 0 Lumigan.......... 6 Lupron Depot....... 5 Lutera............ 0 Lyrica Cap......... M Makena.......... 7 Meclizine.......... 6 Medroxyprogesterone Acetate0 Meloxicam......... 8 Metaxalone......... 8 Metformin......... 5 Metformin ER........ 5 Methadone Tab....... 8 Methimazole........ 5 Methocarbamol....... 8 Methotrexate Tab...... 7 Methylphenidate ER..... Methylphenidate SA Osmotic ER Tab..... Methylphenidate Tab.... Methylprednisolone Tab... 5 Metoclopramide...... 6 Metoprolol Succinate.... 0 Metoprolol Tartrate..... 0 Metrogel.......... 3 Metronidazole Gel 0.75%.. 3 Metronidazole Tab...... 9 Metronidazole Vaginal Gel. 0 Microgestin......... 0 Microgestin Fe....... 0 Migranal.......... Minastrin 4 Fe Chewable 0 Minivelle.......... 0 Minocycline Cap....... 9 Mirtazapine......... Modafinil.......... Mometasone........ 3 Mono-Linyah........ 0 Mononessa......... 0 Montelukast........ 9 Morphine Sulfate Tab.... 8 Movantik......... 6 Moviprep......... 6 Moxeza.......... 5 Moxifloxacin......... 9 Multi-Vit/Fl Chew...... 9 Mupirocin Ointment.... 3 Mycophenolate Mofetil... 9 Mycophenolate Sodium... 9 Myrbetriq......... 9 N Nabumetone........ 8 Nadolol........... 0 Namenda Tab....... Namenda XR Cap..... Naproxen.......... 8 Nasonex.......... 9 Natazia........... 0 Necon............ 0 Neomycin/Polymyxin B/ Dexamethasone Ointment, Suspension....... 5 Neomycin/Polymyxin/HC Otic Suspension, Solution... 9 Nevirapine......... 6 Nexium........... 6 Niacin ER Tab........ 0 Nifedipine ER........ 0 Nitrofurantoin Macrocrystalline 9 Nitrofurantoin Monohydrate Macrocrystalline......9 Nitrostat.......... Nora-Be........... 0 Norgest/Ethi Estradio.... 0 Nortrel........... 0 Nortriptyline......... Norvir........... 6 Novofine Autocover Pen Needle....... 4 Novofine Pen Needle... 4 Novolin 70/30 Vials.... 4 Novolin N Vials...... 5 Novolin R Vials...... 5 Novolog Flexpen..... 5 Novolog Mix 70/30 Vials. 5 Novolog Mix Flexpen... 5 Novolog Penfill...... 5 Novolog Vials....... 5 Novotwist Pen Needle.. 4 Nucynta.......... 8 Nucynta ER........ 8 Nutropin AQ........ 5 Nuvaring.......... 0 Nuvigil........... Nystatin Cream, Ointment, Powder......... 3 Nystatin Oral Powder..... 9 Nystatin Suspension......9 Nystatin/Triamcinolone Cream, Ointment........ 3 O Ocella............ 0 Ofloxacin Ophthalmic Solution5 Ofloxacin Otic Solution.... 9 Olanzapine Tab....... Omeclamox Pak...... 6 Omega-3 Acid Cap..... 0 Omeprazole......... 6 Omnaris.......... 9 Omnitrope......... 5 Ondansetron Tab...... 6 Onetouch Kit Ultra.... 4 Onetouch Kit Ultra... 4 Onetouch Kit Ultra Mini. 4 Onetouch Kit Ultra Smart. 4 Onetouch Kit Verio IQ... 4 Onetouch Lancets..... 4 Onetouch Test Strips... 4 Onetouch Ultra Blue Test Strips....... 4 Onetouch Verio Test Strips 4 Onfi............ [Plain type = Generic drug] 4
Index of Covered s Onglyza.......... 5 Opana ER......... 8 Opsumit.......... Oracea............ 9 Orencia SC......... 7 Orenitram......... Orsythia........... 0 Ortho Tri-Cyclen Lo.... 0 Osphena.......... 0 Ovidrel........... 7 Oxcarbazepine....... Oxsoralen-UL....... 3 Oxybutynin......... 9 Oxybutynin ER....... 9 Oxycodone Tab....... 8 Oxycodone w/ Acetaminophen... 8 Oxycontin......... 8 P Pantoprazole........ 6 Paroxetine Tab....... Pataday.......... 5 Patanol........... 5 Pegasys........... 9 Penicillin VK..........9 Pentasa.......... 6 Perforomist........ 9 Permethrin Cream 5%... 3 Phenazopyridine...... 8 Phentermine Tab...... 8 Phenytoin.......... Pioglitazone......... 5 Plegridy.......... Polyethylene Glycol 3350 Powder... 6 Polymyxin B/Trimethoprim Solution......... 5 Potassium Chloride ER... 9 Potassium Chloride Micro ER 0 Potassium Citrate...... 0 Pradaxa........... 9 Pramipexole......... Pravastatin......... 0 Precision Test Strips.... 4 Prednisolone Ophthalmic Suspension....... 6 Prednisolone Solution.... 5 Prednisolone Syrup, Solution 5 Prednisone......... 5 Premarin Tab........ 0 Premarin Vaginal Cream. 0 Premphase......... 0 Prempro.......... 0 Prepopik.......... 6 Previfem.......... 0 Prezista.......... 6 Primidone.......... Pristiq........... Proair HFA, RespiClick... 9 Prochlorperazine...... Procrit........... 8 Progesterone Cap...... 0 Prograf Cap........ 9 Promethazine/Codeine Syrup 8 Promethazine DM Syrup.. 8 Promethazine Tab...... 9 Propranolol......... 0 Propranolol ER....... 0 Protopic Ointment.... 3 Protosol HC......... 6 Proventil HFA....... 9 Pulmicort Flexhaler.... 9 Pulmozyme........ 8 Pylera........... 6 Q QNasl............ 9 Quetiapine......... Quinapril.......... 0 Qvar............ 9 R Rabeprazole......... 6 Raloxifene.......... 8 Ramipril........... 0 Ranexa........... Ranitidine.......... 6 Rapaflo........... 7 Rapamune......... 9 Rasuvo........... 7 Rebif............ Rebif Titrtn........ Reclipsen.......... 0 Rectiv........... 8 Relpax........... Renvela Tab........ 8 Restasis.......... 6 Retin-A Micro....... 3 Revlimid........... 9 Reyataz.......... 6 Rezira........... 8 Risperidone Tab....... Rizatriptan Tab, ODT.... Ropinirole.......... S Safyral........... 0 Saizen........... 5 Saphris........... Savaysa........... 9 Sensipar.......... 5 Serevent Diskus...... 9 Seroquel XR........ Sertraline.......... Sildenafil Tab........ Silenor........... Simcor........... 0 Simponi.......... 7 Simvastatin......... Solodyn........... 9 Sotalol........... Sovaldi............9 Spiriva Handihaler.... 9 Spiriva Respimat..... 9 Spironolactone....... 0 Sprintec 8......... 0 Stelara........... 7 Stendra.......... 7 Strattera.......... Stribild........... 6 Suboxone Film....... 8 Sucralfate Tab........ 6 Sulfacetamide/Sulfur Emulsion3 Sulfamethoxazole-Trimethoprim9 Sulfamethoxazole- Trimethoprim DS..... 9 Sulfasalazine........ 6 Sumatriptan Tab and Spray. Sumavel Dose....... [Plain type = Generic drug] 5
Index of Covered s Suprep Bowel Prep.... 6 Sustiva........... 7 Symbicort......... 9 Synagis........... 8 Synthroid......... 5 Synvisc........... 8 T Taclonex.......... 3 Tacrolimus Cap....... 9 Tamiflu............9 Tamoxifen Tab.........9 Tamsulosin......... 7 Tasigna............9 Tecfidera.......... Tekturna.......... 0 Tekturna HCT....... 0 Telmisartan......... 0 Temazepam......... Temozolomide........ 9 Terazosin.......... 0 Terazosin.......... 7 Terbinafine Tab........ 9 Terconazole Vaginal Cream. 0 Testosterone Cypionate IM Injection......... 7 Timolol........... 6 Timoptic Ocudose..... 6 Tirosint........... 5 Tivicay........... 7 Tizanidine.......... 8 Tobramycin......... 5 Tobramycin/Dexamethasone. 5 Tolterodine......... 9 Topiramate Tab....... Torsemide Tab........ 0 Toviaz........... 9 Tracleer.......... Tramadol Tab........ 8 Tramadol w/ Acetaminophen 8 Transderm-Scop...... 6 Travatan Z......... 6 Trazodone.......... Tretinoin Cream....... 3 Tretinoin Microsphere Gel.. 3 Triamcinolone........ 3 Triamcinolone Spray..... 9 Triamterene/HCTZ...... 0 Triazolam Tab........ Tribenzor.......... 0 Tri-Linyah.......... 0 Trinessa........... 0 Tri-Previfem......... 0 Tri-Sprintec......... 0 Triumeq.......... 7 Truetest Test Strips.... 4 Truetrack Test Strips.... 4 Truvada.......... 7 Tudorza Pressair...... 9 U Uceris........... 6 Uloric............ 8 Ursodiol........... 8 V Vagifem.......... 0 Valacyclovir.......... 9 Valsartan.......... 0 Valsartan/HCTZ....... 0 Vascepa.......... Vectical........... 3 Velphoro.......... 8 Venlafaxine ER....... Venlafaxine Tab....... Ventolin HFA....... 9 Veramyst.......... 9 Verapamil ER........ 0 Vesicare.......... 9 Vestura........... 0 Viagra........... 7 Vicodin........... 8 Vicodin ES.......... 8 Victoza........... 5 Vigamox.......... 5 Viibryd........... Viorele........... 0 Viread........... 7 Vitamin D.......... 0 Vivelle-Dot......... 0 Voltaren Gel........ 9 Vytorin........... Vyvanse.......... W Warfarin........... 9 Welchol.......... X Xarelto............9 Xolair............ 9 Xopenex HFA....... 9 Xulane........... 0 Z Zarah............ 0 Zelapar........... Zenpep.......... 6 Zetia............ Zetonna.......... 9 Ziprasidone Cap....... Zolmitriptan Tab....... Zolpidem.......... Zolpidem ER......... Zomacton......... 5 Zomig Nasal Spray.... Zonisamide......... Zostavax Injection..... 8 Zovirax........... 3 Zubsolv.......... 8 Zutripro.......... 8 Zyclara........... 3 Zytiga............ 9 [Plain type = Generic drug] 6
My Medications worksheet Take this worksheet with you each time you visit a doctor. Each of your doctors should be aware of every drug you take and you should have a list as well. Name of Medicine and Strength I Take This Medicine For Directions Doctor Example: Lisinopril, 0 mg High blood pressure One tablet daily Dr. Johnson 7
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