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 www.optumrx.com Locate a participating retail pharmacy by zip code. Look up possible lower-cost medication alternatives. Compare medication pricing and options. OptumRx www.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 www.optumrx.com for complete and up-to-date drug information Since the PDL may change, we encourage you to visit our website, www.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 2
Table of Contents tiers and cost.... 5 Programs 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... 2 Other.... 2 Sedatives/Hypnotics... 2 Seizure Disorders... 2 Dermatology... 3 Diabetes/Endocrine Blood Glucose Monitoring... 3 Insulin... 4 Non-Insulin... 4 Endocrine Growth Hormone... 5 Other.... 5 Thyroid Hormone Replacement... 5 Eye Conditions Allergies.... 5 Antibiotics... 5 Glaucoma... 5 Other.... 5 Gastrointestinal Acid Suppression... 5 Nausea/Vomiting... 5 Other.... 6 HIV/AIDS... 6 Infertility... 6 Inflamatory Conditions.... 6 Men s Health Erectile Dysfunction... 6 Prostate... 6 Testosterone Therapy... 7 Miscellaneous... 7 Musculoskeletal Osteoporosis... 7 Other.... 7 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.... 9 Hormone Replacement... 20 Prenatal Vitamins... 20 Vaginal Anti-Infectives... 20 Index... 2 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 www.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 www.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 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 www.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
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 www.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 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 www.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 -888-702-8423 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 www.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 www.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, 24 hours a day, 7 days a week using the toll-free member phone number on the back of your ID card. Or visit www.optumrx.com. 8
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
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
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
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
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
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
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
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
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
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
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
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 28-0.8 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
Index of Covered s A Abilify........... 2 Abilify Disc......... 2 Abilify Solution...... 2 Acanya........... 3 Accu-Chek Act/Gluc Calibration Liquid... 3 Accu-Chek Aviva Plus Test Strips..... 3 Accu-Chek Aviva Test Strips....... 3 Accu-Chek Comfort Calibration Liquid... 3 Accu-Chek Comfort Test Strips....... 3 Accu-Chek Cpt/Gluc Calibration Liquid... 3 Accu-Chek Drum Test Strips....... 3 Accu-Chek Kit Aviva Plus....... 3 Accu-Chek Kit Compact.. 3 Accu-Chek Kit Fastclix... 3 Accu-Chek Kit Multiclix.. 3 Accu-Chek Kit Nano.... 3 Accu-Chek Kit Softclix... 3 Accu-Chek Multiclix Lancets3 Accu-Chek Smart Calibration Liquid... 3 Accu-Chek Smart Test Strips....... 3 Accu-Chek Sol Calibration Liquid... 3 Accu-Chek Sol Comfort Calibration Liquid... 3 Acetaminophen w/ Codeine....... 8 Aciphex.......... 5 Actonel........... 7 Actos............ 4 Acyclovir........... 9 Advair Diskus....... 8 Advair HFA........ 8 Aggrenox.......... 9 Albuterol Nebulizer Solution 8 Alendronate......... 7 Alfuzosin.......... 6 Allopurinol......... 7 Alphagan P........ 5 Alprazolam Tab....... 2 Amiodarone......... Amitiza........... 6 Amitriptyline........ Amlodipine......... 0 Amlodipine/Benazepril... 0 Amoxicillin.......... 9 Amoxicillin/Clavulanate.... 9 Amphetamine- Dextroamphetamine.. Amphetamine- Dextroamphetamine Cap SR 24HrR...... Ampyra.......... 2 Analpram-HC Cream... 7 Analpram-HC Lotion... 7 Anastrozole..........9 Androderm......... 7 Androgel.......... 7 Antipyrine/Benzocaine Solution Otic...... 7 Apri............. 9 Apriso........... 6 Aranesp.......... 7 Aricept 23 mg....... 2 Armour Thyroid...... 5 Asacol........... 6 Asmanex......... 8 Astepro.......... 9 Atenolol........... 0 Atenolol/Chlorthalidone... 0 Atorvastatin........ 0 Atralin........... 3 Atripla.......... 6 Avelox............ 9 Aviane........... 9 Avinza........... 8 Avodart.......... 6 Avonex........... 2 Avonex Pen........ 2 Avonex Prefill....... 2 Azathioprine........ 9 Azelastine.......... 9 Azilect........... 2 Azithromycin......... 9 Azopt........... 5 Azor............ 0 B Baclofen.......... 7 Baraclude.......... 9 Benazepril.......... 0 Benazepril/HCTZ...... 0 Benicar........... 0 Benicar HCT........ 0 Benzaclin.......... 3 Benzonatate........ 7 Benztropine......... 2 Betaseron......... 2 Beyaz............ 9 Bisoprolol.......... 0 Bisoprolol/HCTZ....... 0 Brilinta............9 Budeprion XL........ Budesonide......... 8 Bupropion.......... Bupropion SR........ Buspirone.......... Butalbital-Acetaminophen- Caffeine........ Byetta........... 4 Bystolic........... 0 [Plain type = Generic drug] 2
Index of Covered s C Calcitriol.......... 7 Cambia........... 8 Canasa........... 6 Carac............ 3 Carbamazepine....... 2 Carbidopa & Levodopa... 2 Carisoprodol........ 7 Carvedilol.......... 0 Cefdinir............9 Cefuroxime Tab........ 9 Celebrex.......... 8 Cellcept Tab/Suspension. 9 Cephalexin.......... 9 Cetirizine.......... 9 Cheratussin......... 7 Chlorhexidine........ 7 Chlorthalidone....... 0 Chorionic Gonadotropin.. 6 Cialis............ 6 Cimzia........... 6 Ciprodex Otic Suspension. 9 Ciprofloxacin......... 9 Ciprofloxacin........ 5 Citalopram......... Clarithromycin........ 9 Climara Pro........ 20 Clindamycin......... 3 Clindamycin/Benzoyl Peroxide 3 Clindamycin Cap....... 9 Clobetasol......... 3 Clobex........... 3 Cloderm.......... 3 Clonazepam........ 2 Clonidine Tab........ 0 Clopidogrel.......... 9 Clotrimazole/Betamethasone 3 Colcrys........... 7 Combigan......... 5 Combivent......... 8 Complera......... 6 Condylox.......... 3 Copaxone......... 2 Coreg CR.......... 0 Coumadin.......... 9 Creon............ 6 Crestor........... 0 Cryselle-28......... 9 Cyclobenzaprine...... 7 Cyclosporine........ 9 Cymbalta.......... D Delzicol.......... 6 Desloratadine........ 9 Desonide.......... 3 Detrol LA.......... 8 Dexamethasone....... 5 Dexilant.......... 5 Diazepam.......... 2 Diclofenac.......... 8 Dicyclomine......... 6 Differin........... 3 Dificid............ 9 Digoxin........... Diltiazem.......... 0 Diltiazem SR 24HR..... 0 Diovan........... 0 Diovan HCT........ 0 Diphenoxylate/Atropine... 6 Divalproex DR........ 2 Divalproex ER........ 2 Divigel........... 20 Donepezil......... 2 Dorzolamide -Timolol Maleate......... 5 Doxazosin......... 0 Doxazosin.......... 6 Doxepin.......... Doxycycline Hyclate...... 9 Dutoprol.......... 0 E Econazole...........9 Edarbi........... 0 Edarbyclor......... 0 Effient............ 9 Elidel............ 3 Enablex.......... 8 Enalapril........... 0 Enbrel........... 6 Enbrel SureClick...... 6 Enjuvia........... 20 Enoxaparin.......... 9 Epiduo........... 3 Epipen 2-Pak........ 7 Epzicom.......... 6 Erythromycin........ 5 Escitalopram........ Estradiol........... 20 Etodolac.......... 8 Euflexxa.......... 7 Evista............ 7 Exforge.......... 0 Exforge HCT........ 0 F Famotidine......... 5 Fastclix Lancets...... 3 Felodipine.......... 0 Fenofibrate......... 0 Fenoglide......... 0 Fentanyl Patch....... 8 Ferrous Sulfate....... 9 Finacea........... 3 Finasteride......... 6 Flovent Disk........ 8 Flovent HFA........ 8 Fluconazole.......... 9 Fluocinonide........ 3 Fluoxetine.......... Fluticasone......... 9 Focalin XR......... Folic Acid.......... 9 [Plain type = Generic drug] 22
Index of Covered s Follistim AQ........ 6 Foradil........... 8 Forteo........... 7 Fortesta........... 7 Fosinopril.......... 0 Fosrenol.......... 7 Furosemide......... 0 G Gabapentin......... 2 Gelnique.......... 8 Gemfibrozil......... 0 Gentamicin......... 5 Gianvi............ 9 Gildess Fe.......... 9 Gilenya*.......... 2 Gleevec........... 9 Glimepiride......... 4 Glipizide.......... 4 Glipizide ER......... 4 Glipizide XL......... 4 Glyburide.......... 4 Glyburide/Metformin.... 4 Gonal-f........... 6 Gonal-f RFF........ 6 Gralise........... 8 H Halflytely Kit....... 6 Humalog Kwik...... 4 Humalog Mix 50/50 Kwik Pen.... 4 Humalog Mix 50/50 Vials. 4 Humalog Mix 75/25 Kwik Pen.... 4 Humalog Mix 75/25 Vials. 4 Humalog Vials....... 4 Humira........... 6 Humira Kit......... 6 Humira Pen........ 6 Humira Pen Kit Crohns.. 6 Humira Pen Kit Psoriasis. 6 Humulin 70/30 Vials.... 4 Humulin N Pen...... 4 Humulin N Vials...... 4 Humulin Pen 70/30.... 4 Humulin R Vials...... 4 Hydralazine......... 0 Hydrochlorothiazide..... 0 Hydrocodone w/ Acetaminophen... 8 Hydrocodone w/ Ibuprofen...... 8 Hydrocortisone....... 3 Hydrocortisone AC Suppository....... 7 Hydromet.......... 7 Hydromorphone...... 8 Hydroxychloroquine.... 6 Hydroxyzine HCl...... 2 Hydroxyzine Pamoate.... 2 I Ibandronate......... 7 Ibuprofen.......... 8 Incivek............ 9 Indomethacin........ 8 Insulin Pen Needle.... 3 Insulin Syringe/Needle.. 3 Intelence.......... 6 Intuniv........... Ipratropium/Albuterol.... 8 Irbesartan.......... 0 Isentress.......... 6 Isosorbide Mononitrate... J Jalyn............ 6 Janumet.......... 4 Janumet XR........ 4 Januvia........... 4 Jentadueto......... 4 Junel Fe........... 9 K Kaletra........... 6 Kariva........... 9 Ketoconazole.........9 Klor-Con.......... 9 Kombiglyze....... 4 L Labetalol.......... 0 Lamictal.......... 2 Lamictal ODT....... 2 Lamictal XR........ 2 Lamivudine/Zidovudine... 6 Lamotrigine........ 2 Lansoprazole........ 5 Lantus Solostar...... 4 Lantus Vials........ 4 Latanoprost........ 5 Lazanda.......... 8 Letairis........... Letrozole........... 9 Levalbuterol Nebulizer Solution........ 8 Levemir Flexpen...... 4 Levemir Vials....... 4 Levetiracetam........ 2 Levetiracetam ER...... 2 Levitra........... 6 Levocetirizine........ 9 Levofloxacin..........9 Levothyroxine........ 5 Levoxyl........... 5 Lexapro.......... Lialda............ 6 Lidoderm Patch...... 8 Liothyronine........ 5 Lipitor........... 0 Lipofen........... 0 Lisinopril.......... 0 Lisinopril/HCTZ....... 0 Lithium Carbonate..... 2 Livalo............ 0 Loestrin 24 Fe....... 9 [Plain type = Generic drug] 23
Index of Covered s Lo Loestrin......... 9 Loratadine......... 9 Lorazepam......... 2 Loryna........... 9 Losartan........... 0 Losartan/HCTZ....... 0 Lovastatin.......... 0 Lovaza........... 0 Low-Ogestrel........ 9 Lumigan.......... 5 Lunesta.......... 2 Lupron Depot 3.75 mg,.25 mg... 5 Lupron Depot 7.5 mg, 22.5 mg, 30 mg, 45 mg 5 Lutera............ 9 Lyrica............ 2 M Matzim LA......... 0 Meclizine.......... 5 Medroxyprogesterone Acetate......... 20 Meloxicam......... 8 Metaxalone......... 7 Metformin......... 4 Metformin ER........ 4 Methadone......... 8 Methimazole........ 5 Methocarbamol....... 7 Methotrexate........ 6 Methylphenidate Cap ER.. Methylphenidate HCl Tab Sa Osm ER..... Methylphenidate Tab.... Methylphenidate Tab ER... Methylprednisolone.... 5 Metoclopramide...... 5 Metoprolol Succinate.... 0 Metoprolol Tartrate..... 0 Metrogel.......... 3 Metronidazole Tab...... 9 Metronidazole Vaginal Gel. 20 Micardis.......... 0 Micardis HCT........ 0 Microgestin......... 9 Microgestin Fe....... 9 Migranal.......... Minocycline..........9 Mirtazapine......... Modafinil.......... 2 Mometasone........ 3 Montelukast........ 8 Morphine.......... 8 Moviprep......... 6 Moxeza.......... 5 Multi-Vit/Fl Chw...... 9 Mupirocin.......... 3 M-Vit Tab 27- mg..... 20 Mycophenolate....... 9 Myfortic.......... 9 N Nabumetone........ 8 Nadolol........... 0 Namenda......... 2 Naproxen.......... 8 Nasonex.......... 9 Natazia........... 9 Necon............ 9 Neomycin/Polymyxin/ HC Otic Suspension.... 9 Neoral........... 9 Nexium........... 5 Niaspan ER......... 0 Nifedipine ER........ 0 Nitrofurantoin Macrocrystalline......9 Nitrofurantoin Monohydrate Macrocrystalline......9 Nitrostat.......... Norco............ 8 Norgest/Ethi Estradio.... 9 Nortrel........... 9 Nortriptyline......... Norvir........... 6 Novofine.......... 3 Novofine Auto....... 3 Novolin 70/30 Vials.... 4 Novolin N Vials...... 4 Novolin R Vials...... 4 Novolog Flexpen..... 4 Novolog Mix 70/30 Vials. 4 Novolog Mix Flexpen... 4 Novolog Penfill...... 4 Novolog Vials....... 4 Novotwist......... 3 Nucynta.......... 8 Nucynta ER........ 8 Nutropin.......... 5 Nutropin AQ........ 5 Nuvaring.......... 9 Nystatin............9 Nystatin/Triamcinolone... 3 O Ocella............ 9 Ofloxacin.......... 5 Ofloxacin Otic Solution.... 9 Olanzapine......... 2 Omeclamox Pak...... 6 Omega-3 Fatty Acids.... 9 Omeprazole......... 5 Omnaris.......... 9 Ondansetron........ 5 Onetouch Kit Ultra.... 4 Onetouch Kit Ultra 2... 4 Onetouch Kit Ultra Mini. 4 Onetouch Kit Ultra Smart. 4 Onetouch Kit Verio IQ... 4 Onetouch Test Strips... 4 Onetouch Ultra Blue Test Strips....... 4 Onetouch Verio IQ Test Strips....... 4 Onetouch Verio Test Strips 4 Onglyza......... 4 Onsolis........... 8 Oracea............ 9 [Plain type = Generic drug] 24
Index of Covered s Orencia........... 6 Ortho Tri-Cyclen Lo.... 9 Ovidrel........... 6 Oxcarbazepine....... 2 Oxsoralen-Ul....... 3 Oxybutynin......... 8 Oxybutynin ER....... 8 Oxycodone......... 8 Oxycodone w/ Acetaminophen... 8 Oxycontin......... 8 Oxytrol........... 8 P Pantoprazole........ 5 Paroxetine.......... Pataday.......... 5 Patanol........... 5 Pegasys........... 9 Penicillin VK..........9 Pentasa.......... 6 Perforomist........ 8 Permethrin......... 3 Phenazopyridine...... 7 Phentermine Tab...... 7 Phenytoin.......... 2 Phrenilin.......... Pioglitazone......... 4 Polyethylene Glycol 3350.. 6 Portia-28.......... 9 Potassium Chloride ER... 9 Potassium Chloride Micro ER 9 Pradaxa........... 9 Pramipexole......... 2 Pramosone Cream..... 3 Pramosone E........ 3 Pramosone Lotion..... 3 Prandimet......... 4 Prandin........... 4 Pravastatin......... 0 Prednisolone........ 5 Prednisolone Opth..... 5 Prednisone......... 5 Premarin.......... 20 Premarin Vaginal Cream. 20 Premphase......... 20 Prempro......... 20 Prenafirst Tab........ 20 Prenaplus Tab........ 20 Prenatabs Fa Tab...... 20 Prenatal........... 20 Prenatal Tab Low Iron.... 20 Prezista.......... 6 Pristiq........... Proair HFA......... 8 Prochlorperazine...... 2 Procrit........... 7 Proctozone........ 7 Progesterone........ 20 Prograf Cap........ 9 Promethazine........ 9 Promethazine/Codeine... 7 Promethazine DM Syrup.. 7 Propranolol......... 0 Propranolol ER....... 0 Protopic.......... 3 Proventil.......... 8 Pulmicort.......... 8 Pulmozyme........ 7 Pulmozyme........ 8 Pylera........... 6 Q Quetiapine......... 2 Quinapril.......... 0 Qvar............ 8 R Ramipril........... 0 Ranexa........... Ranitidine.......... 5 Rapaflo........... 6 Rapamune......... 9 Ra Prenatal Tab 28-0.8 mg. 20 Rebif............ 2 Rebif Titrtn........ 2 Rectiv........... 7 Relpax........... Renvela.......... 7 Repaglinide......... 4 Restasis.......... 5 Retin-A Micro....... 3 Revlimid........... 9 Reyataz.......... 6 Rezira........... 7 Risperidone......... 2 Ropinirole......... 2 S Safyral......... 9 Saizen........... 5 Saphris........... 2 Se-Natal One Tab...... 20 Sensipar.......... 5 Serevent Disk....... 8 Seroquel XR........ 2 Sertraline.......... Silenor........... 2 Simcor........... 0 Simponi.......... 6 Simvastatin........ 0 Simvastatin 80 mg..... 0 Singulair......... 8 Sm Prenatal Tab Vitamins.. 20 Softclix Lancets...... 4 Softclix Lan Mis Device.. 4 Soft Touch Lancets.... 4 Solodyn........... 9 Sotalol........... Spiriva........... 8 Spironolactone....... 0 Sprintec 28......... 9 Sprix............ 8 Strattera.......... Suboxone......... 8 Subsys........... 8 Sucralfate.......... 5 Sulfamethoxazole- Trimethoprim....... 9 [Plain type = Generic drug] 25
Index of Covered s Sulfamethoxazole- Trimethoprim DS..... 9 Sumatriptan........ Sumavel Dose....... Suprep Bowel Prep.... 6 Surestep Test Strips.... 4 Sustiva........... 6 Syeda............ 9 Symbicort......... 8 Synthroid......... 5 Synvisc........... 7 T Taclonex.......... 3 Tacrolimus.......... 9 Tamiflu............9 Tamoxifen...........9 Tamsulosin......... 6 Tarka............ 0 Tasigna............9 Tecfidera.......... 2 Tekturna.......... 0 Tekturna HCT....... 0 Temazepam......... 2 Temodar........... 9 Terazosin.......... 0 Terazosin.......... 6 Terbinafine.......... 9 Terconazole Vaginal Cream. 20 Testim............ 7 Tev-Tropin......... 5 Timolol........... 5 Timoptic Ocudose..... 5 Tizanidine.......... 7 Tobramycin......... 5 Tobramycin/Dexamethasone. 5 Topiramate......... 2 Toviaz........... 8 Tracleer.......... Tradjenta.......... 4 Tramadol.......... 8 Tramadol w/ Acetaminophen 8 Travatan Z......... 5 Trazodone.......... Tretinoin.......... 3 Triamcinolone........ 3 Triamcinolone........ 9 Triamterene/HCTZ..... 0 Tribenzor.......... 0 Tricor............ 0 Triglide........... 0 Trilipix........... 0 Trinatal Rx Tab....... 20 Trinate Tab......... 20 Trinessa........... 9 Tri-Sprintec......... 9 Tri-Vit-Fl Drops....... 9 Truetrack Test Strips.... 4 Truvada.......... 6 U Uceris........... 6 Uloric............ 7 V Vagifem.......... 20 Valacyclovir.......... 9 Valsartan/HCTZ....... 0 Vectical........... 3 Venlafaxine......... Venlafaxine ER Cap..... Ventolin HFA....... 8 Veramyst.......... 9 Verapamil ER........ 0 Verapamil SR........ 0 Vesicare.......... 8 Vestura........... 9 Viagra........... 6 Vicodin........... 8 Vicodin ES......... 8 Vicodin HP......... 8 Victoza........... 4 Vigamox.......... 5 Vimovo........... 8 Vinate One Tab....... 20 Viread........... 6 Vitamin D.......... 9 Vivelle-Dot......... 20 Voltaren Gel........ 8 Vytorin........... 0 Vytorin Tab 0-80 mg... 0 Vyvanse.......... W Warfarin........... 9 Welchol.......... 0 X Xanax........... 2 Xarelto............9 Xeloda............ 9 Xolair............ 8 Xopenex HFA....... 8 Z Zarah............ 9 Zelapar........... 2 Zemplar.......... 5 Zenpep........... 6 Zetia............ 0 Zetonna.......... 9 Zolpidem.......... 2 Zolpidem ER......... 2 Zomig Nasal Spray.... Zovirax Cream....... 3 Zovirax Ointment..... 3 Zutripro.......... 7 Zyclara........... 3 [Plain type = Generic drug] 26
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
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