your 2015 prescription drug list · 2015-06-10 · 2 your prescription drug list this prescription...

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Your 2015Prescription Drug Listeffective July 1, 2015

Please read: This document contains information about commonly prescribed medications.

For additional information:

Call the toll-free member phone number on your health plan ID card.

Visit myuhc.com®

• Locate a participating retail pharmacy by ZIP code.

• Look up possible lower-cost medication alternatives.

• Compare medication pricing and options.

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Your Prescription Drug List This Prescription Drug 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 myuhc.com® for complete drug informationSince the PDL may change, we encourage you to visit our website, myuhc.com. This website is the best source for up-to-date information about the medications your pharmacy benefi t covers, possible lower-cost options, and cost comparisons.

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Table of Contents

Drug tiers and cost . . . . . . . . . . . . . . . . . . . . . . .5

Programs and Limits . . . . . . . . . . . . . . . . . . . . . .7

Drugs by category . . . . . . . . . . . . . . . . . . . . . . 10

Anti-InfectivesAntibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Cardiovascular/Heart DiseaseCoagulation Therapy . . . . . . . . . . . . . . . . . . . . . . . .11High Blood Pressure . . . . . . . . . . . . . . . . . . . . . . . .11High Cholesterol . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Central Nervous SystemAttention Deficit Disorder . . . . . . . . . . . . . . . . . . . 12Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Sedatives/Hypnotics . . . . . . . . . . . . . . . . . . . . . . . 14Seizure Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Diabetes/EndocrineBlood Glucose Monitoring . . . . . . . . . . . . . . . . . . 16Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Non-Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

EndocrineGrowth Hormone . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Thyroid Hormone Replacement . . . . . . . . . . . . . 17

Eye ConditionsAllergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

GastrointestinalAcid Suppression . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Nausea/Vomiting . . . . . . . . . . . . . . . . . . . . . . . . . . 18Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Hepatitis C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Inflammatory Conditions: Rheumatoid Arthritis, Crohn’s Disease, Psoriasis, Ulcerative Colitis . . . . . . . . . . . . . . . . . . . . . . . . 19

Men’s HealthErectile Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . 19Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Testosterone Therapy . . . . . . . . . . . . . . . . . . . . . . 20

Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

MusculoskeletalOsteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Pain Relief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Overactive Bladder . . . . . . . . . . . . . . . . . . . . . . 21

RespiratoryAllergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Asthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Pulmonary Arterial Hypertension . . . . . . . . . . . . 22

Transplant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Vitamins/Electrolytes . . . . . . . . . . . . . . . . . . . 23

Women’s HealthContraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Hormone Replacement . . . . . . . . . . . . . . . . . . . . . 24Prenatal Vitamins . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

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At UnitedHealthcare, 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 Drug List.

What is a Prescription Drug List (PDL)? This document is a list of commonly prescribed medications. Drugs 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 Drug 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 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 health plan to see what medications are covered under your plan. You may also log on to myuhc.com or call the toll-free member phone number on your health plan ID card for more information.

How do I use my Prescription Drug 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 myuhc.com or call the toll-free member phone number on your health plan ID card.

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What are tiers? Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, which is determined by your employer or health plan. This is how much you will pay when you fill a prescription. Tier 1 medications are your lowest-cost options. If your medication is placed in Tier 2 or 3, look to see if there is a Tier 1 option available. Discuss these options with your doctor.

Check your benefit plan documents to find out your specific pharmacy plan costs.

$ Drug Tier Includes Helpful Tips

Tier 1Lowest Cost

Lower-cost drugs . Some brands and generics are also included .

Use Tier 1 drugs for the lowestout-of-pocket costs .

Tier 2Mid-range Cost

Mix of brands and generics .

Use Tier 2 drugs, instead ofTier 3 to help reduce yourout-of-pocket costs .

Tier 3Highest Cost

Mostly higher-cost brand as well as select generic drugs .

Many Tier 3 drugs have lower-cost options in Tier 1 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 may apply once you hit your deductible. Refer to your enrollment and plan materials on myuhc.com, or call the toll-free number on your health plan ID card for more information about your benefit plan.

When does the Prescription Drug 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 1 or July 1.

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 number on your ID card.

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Programs and LimitsSome medications are noted with letters next to them. The letters refer to our pharmacy benefit programs. Your benefit plan determines how these medications are covered and may differ than what is noted in the PDL. Call the number for Member Services listed on your ID card if you have any questions about your prescription drug coverage.

DSPDesignated Specialty Program – Specialty medications need to be filled at a designated specialty pharmacy for network coverage . Call the number on your ID card or call 1-888-739-5820 for more information .

EMay be excluded from coverage or subject to prior authorization and/or trial/failure of another medication(s) .+ Lower-cost options are available and covered .

MCMultiple Copay – More than one month’s worth of medication included in package so additional copay applies .

NNotification or Prior Authorization required* – Your doctor is required to provide additional information to us to determine coverage .

RSRefill and Save Program – Save money on your copayment when you refill your prescription on time as prescribed . Program eligibility may vary .

SDPSelect Designated Pharmacy – Must use a lower cost medication at retail or transfer the impacted medication to the mail service pharmacy for network coverage .

SLSupply Limit – Amount of medication covered per copayment or in a specific time period .

STStep Therapy+ – Trial of a lower cost medication is required before a higher cost medication is covered .

*Depending on your benefit you may have notification or prior authorization requirements for select medications .+For New Jersey fully insured members this program is referred to as First Start .

To learn more about a pharmacy program or to find out if it applies to you, please visit myuhc.com or call the toll-free member phone number on your health plan ID card.

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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 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, 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. Visit myuhc.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 phone 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 Tier 3, call the toll-free number on your health plan ID card to talk with a pharmacist about finding lower-cost options or a financial assistance program.

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What is Mail Service Member Select? Your plan may include a home delivery program called Mail Service Member Select, which encourages you to use the OptumRx® Mail Service Pharmacy for medication you take regularly. Choosing home delivery can help you better manage the medication you take on a regular basis, and may save you time and money.

You can either confirm enrollment in the OptumRx Mail Service Pharmacy or you can disenroll from mail service and continue to fill your maintenance medications at a retail pharmacy. You can get up to two fills at a retail pharmacy before you have to decide. However, please be aware that you must make a decision about whether or not to enroll in Mail Service Member Select.

If you do nothing and continue to fill your medications at a retail pharmacy, you may pay up to 100% of your drug cost until you make a decision and take action. You must confirm your decision every year. To learn more, you may log on to myuhc.com or call the toll-free member phone number on your health plan ID card for more information.

How do I get updated information about my pharmacy benefit?Since the PDL may change during your plan year, we encourage you to visit myuhc.com or call the toll-free member phone number on your health plan ID card for more current information.

Log on to myuhc.com for the following pharmacy information and tools: • Pharmacy benefit and coverage information• Possible lower-cost medication options• Medication interactions and side effects• Participating retail pharmacies by zip code• Your prescription history

And, if Mail Service is included in your pharmacy benefit, you can also:• Refill prescriptions• Check the status of your order• Set-up e-mail reminders for refills• Manage your account

In certain documents, the Prescription Drug List (PDL) was referred to as the “Preferred Drug 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 benefit plan determines coverage for these medications .

For more information Call the toll-free member phone number on your health plan ID card.

Or, visit myuhc.com®

Where else can I go for information? HealthCareLane.com includes short videos to help you learn more about UnitedHealthcare benefits and health insurance information.

UHCTV.com is a fun and easy way to learn about health terms and other health-related topics.

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Bold type = Brand name drug[Plain type = Generic drug]

DSP = Designated Specialty ProgramE = May be excluded from coverageMC = Multiple Copay

N = Notification or Prior Authorization requiredRS = May be eligible for the Refill and Save ProgramSDP = Select Designated PharmacySL = Supply LimitST = Step Therapy

Drug NameDrug Tier

Requirements & Limits

Anti-Infectives: Antibiotics

Amoxicillin Capsule, Chewable Tablet

1

Amoxicillin/Potassium Clavulanate Chewable Tablet, Tablet

1

Azithromycin Tablet 1Cefadroxil Capsule, Tablet

1

Cefdinir Capsule 2Cefprozil Tablet 1Cefuroxime Tablet 1Cephalexin Capsule 1Ciprofloxacin Tablet 1Clarithromycin Tablet 1Clindamycin Capsule 1Dificid 3 SLDoryx 3 EDoxycycline Hyclate Capsule, Tablet

2

Doxycycline Monohydrate 50, 100 mg Capsule

1

Levofloxacin Tablet 1Metronidazole Tablet 1Minocycline Capsule 1Minocycline Tablet 3Moxifloxacin Tablet 3Nitrofurantoin Capsule 1Nitrofurantoin Macrocrystal Capsule

1

Ofloxacin Tablet 1Oracea 3Penicillin V Potassium Tablet 1

Solodyn 3

Drug NameDrug Tier


Sulfamethoxazole-Trimethoprim Tablet

1

Suprax Capsule, Suspension, Tablet

3

Anti-Infectives: Antifungals

Econazole Cream 1Fluconazole Tablet 1Itraconazole Capsule 1 SLKetoconazole Cream 1Nystatin Cream, Ointment

1

Terbinafine Tablet 1 SL

Anti-Infectives: Antivirals

Acyclovir Ointment 3 N, SL, STAcyclovir Tablet 1Famciclovir Tablet 1Tamiflu 3 SLValacyclovir Tablet 2 SLZovirax Cream 3 E, SL

Cancer

Bicalutamide 1Bosulif 2 DSP, N, SL, STCapecitabine Tablet 1 DSP, SLCyclophosphamide Capsule

3

Gleevec 2 DSP, N, SLHydroxyurea Capsule 1Imbruvica 2 DSP, N, SLLeucovorin Calcium Tablet

1

Mercaptopurine Tablet 1Revlimid 2 DSP, N, SLSutent 2 DSP, N, SLTasigna 2 DSP, N, SLZytiga 2 DSP, N, SL

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Drug NameDrug Tier


Cardiovascular/Heart Disease: Coagulation TherapyClopidogrel 1Effient 3 SLEliquis 3 SLEnoxaparin Sodium 2 SLPradaxa 2 SLWarfarin Sodium 1Xarelto 2 SLCardiovascular/Heart Disease: High Blood PressureAmlodipine 1Amlodipine Besylate-Benazepril

2 SL

Amlodipine-Valsartan 3 E, SLAtenolol 1Atenolol-Chlorthalidone 1Azor 3 E, SLBenazepril 1Benazepril-Hydrochlorothiazide

1

Benicar 2 SLBenicar HCT 2 SLBidil 2Bisoprolol 1Bisoprolol-Hydrochlorothiazide

1

Bystolic 2Cartia XT 2Carvedilol 1Chlorthalidone 1Clonidine Tablet 1Diltiazem 24 Hour CD 2Diltiazem Sustained-Release Capsule

2

Diltiazem Sustained-Release Tablet

2

Diovan 3 E, SLDoxazosin 1Dutoprol 2 SL

Drug NameDrug Tier


Edarbi 3 SLEdarbyclor 3 SLEnalapril 1Furosemide 1Guanfacine 1Hydralazine 1Hydrochlorothiazide 1Irbesartan 1 SLLabetalol 1Lisinopril 1Lisinopril-Hydrochlorothiazide

1

Losartan 1Losartan-Hydrochlorothiazide

1

Metoprolol Succinate 50, 100, 200 mg

2

Metoprolol Tartrate 1Nadolol 1Nifedipine Extended-Release

1

Propranolol Extended-Release Capsule

2

Propranolol Tablet 1Quinapril 1Ramipril 1Spironolactone 1Telmisartan 2 SLTelmisartan-Hydrochlorothiazide

2 SL

Terazosin 1Triamterene-Hydrochlorothiazide

1

Valsartan 2 SLValsartan-Hydrochlorothiazide

1 SL

Verapamil 1Verapamil Sustained-Release

3

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Drug NameDrug Tier


Cardiovascular/Heart Disease: High CholesterolAtorvastatin 1 SLCholine Fenofibrate 3 ECrestor 2 SLFenofibrate 43, 50 , 67, 130, 134, 150, 200 mg Capsule

3 E

Fenofibrate 48, 145 mg Tablet

3 E

Fenofibrate 54, 160 mg Tablet

2

Fenoglide 3 EGemfibrozil 1Lipitor 3 E, SLLipofen 3 ELivalo 3 SLLovastatin 1Niacin Extended-Release Tablet

3

Niaspan 2Omega-3-Acid Ethyl Esters Capsule

3 N

Pravastatin 1Simcor 3 SLSimvastatin 1Tricor 48, 145 mg 3 ETrilipix 3 EVascepa 3 NVytorin 3 SLWelchol 2Zetia 3 SL

Drug NameDrug Tier


Cardiovascular/Heart Disease: OtherAmiodarone 1Digoxin 1Flecainide 1Isosorbide Mononitrate ER

1

Nitrostat 2Ranexa 2Sotalol 1Central Nervous System: Attention Deficit DisorderAdderall XR 2 N, SLAmphetamine Salt Combo

1 N

Concerta 2 N, SLDaytrana 3 E, N, SLDexmethylphenidate Extended-Release Capsule

3 E, N, SL

Dexmethylphenidate Tablet

1 N

Dextroamphetamine-Amphetamine Extended-Release

3 E, N, SL

Dextroamphetamine-Amphetamine Tablet

1 N

Dextroamphetamine Sulfate Tablet

3 N

Focalin XR 3 E, N, SLGuanfacine Extended-Release

3 E, SL

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Drug NameDrug Tier


Intuniv 3 E, SLMetadate CD 2 N, SLMethylphenidate 1 NMethylphenidate Extended-Release Capsule

3 E, N, SL

Methylphenidate Extended-Release Tablet

3 E, N, SL

Strattera 3 SLVyvanse 2 N, SL

Central Nervous System: Depression

Amitriptyline Tablet 1Brintellix 3 SL, STBupropion Extended-Release Tablet

1

Bupropion Sustained-Release Tablet

1

Bupropion Tablet 1Citalopram Tablet 1Cymbalta 3 E, SLDoxepin 1Duloxetine Capsule 3 SLEscitalopram Tablet 1Fetzima 3 SL, STFluoxetine Tablet, Capsule

1

Fluvoxamine Tablet 1Lexapro 3 EMirtazapine Tablet 1Nortriptyline Capsule 1Paroxetine Tablet 1Pristiq ER 3 RS, SL

Drug NameDrug Tier


Sertraline Tablet 1Trazodone Tablet 1Venlafaxine Extended-Release Capsule

1

Venlafaxine Tablet 1Viibryd 3 SLWellbutrin XL 3 E

Central Nervous System: Migraine

Acetaminophen/Butalbital/Caffeine 325 mg/50 mg/40mg

1 SL

Naratriptan 1 SLRelpax 2 SLRizatriptan Tablet 2 SLSumatriptan Nasal Spray 2 SLSumatriptan Succinate Tablet, Injection

1 SL

Sumavel DosePro 3 SLCentral Nervous System: Multiple SclerosisAmpyra 2 DSP, N, SLAubagio 3 DSP, N, SL, STAvonex 2 DSP, N, SLBetaseron 2 DSP, N, SLCopaxone 2 DSP, N, SL

Extavia 3DSP, E, N,

SL, STGilenya 3 DSP, N, SL, STRebif 3 DSP, N, SL, STTecfidera 2 DSP, N, SL

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Drug NameDrug Tier


Central Nervous System: Other

Abilify 3 SLAlprazolam Extended-Release Tablet

1

Alprazolam Tablet 1Buprenorphine/Naloxone Tablet

3 E, N, SL

Buspirone Tablet 1Carbidopa-Levodopa 1Diazepam Tablet 1Donepezil 5, 10 mg ODT, Tablet

1

Latuda 3 SLLithium Capsule 1Lorazepam Tablet 1Modafinil Tablet 3 E, N, SLNamenda XR 3Nuvigil 3 N, SLOlanzapine Tablet 1 SLPramipexole Tablet 1Quetiapine Tablet 1 SLRisperidone Tablet 1Ropinirole Tablet 1Seroquel XR 3 SLSuboxone Film 3 E, N, SLTasmar 2Xyrem 3 N, SLZelapar 3Ziprasidone Capsule 2 SLZubsolv 2 N, SL

Drug NameDrug Tier


Central Nervous System: Sedatives/HypnoticsEszopiclone Tablet 3 SLLunesta 3 E, SLTemazepam Capsule 1Triazolam Tablet 1Zaleplon Capsule 1 SLZolpidem Extended-Release Tablet

3 E, SL

Zolpidem Tablet 1 SLCentral Nervous System: Seizure DisordersCarbamazepine Tablet 1Clonazepam Tablet 1Diazepam Tablet 1Divalproex Delayed-Release Tablet

1

Divalproex Extended-Release Tablet

1

Gabapentin Capsule, Tablet

1

Lamotrigine Tablet 1Levetiracetam Extended-Release Tablet

2

Levetiracetam Tablet 1Lyrica 3 SDP, SL, STOxcarbazepine Tablet 1Phenytoin Capsule, Suspension

1

Topiramate Tablet 1Zonisamide Capsule 1

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Drug NameDrug Tier


Dermatology

Absorica 3 E, NAczone 3 SLAdapalene 0 .1% Cream, Gel

3 N, SL

Adapalene 0 .3% Gel 3 N, SLBetamethasone Diproionate 0 .05% Augmented Lotion, Ointment

3

Betamethasone Dipropionate 0 .05% Cream, Ointment

2

Carac 2Ciclopirox Cream, Gel, Lotion, Solution

1

Claravis 2 NClindamycin 1%/Benzoyl Peroxide 5% Gel

3 E, SL

Clindamycin 1 .2%/Benzoyl Peroxide 5% Gel

3 SL

Clindamycin Gel 3 SLClindamycin Lotion 3Clindamycin Solution, Swabs

1

Clobetasol Propionate Cream, Ointment, Solution

1

Clotrimazole-Betamethasone Cream

1 SL

Clotrimazole-Betamethasone Lotion

1

Condylox Gel 3Desonide 0 .05% Cream, Lotion, Ointment

3 SL

Drug NameDrug Tier


Desoximetasone Gel, Ointment

3 SL

Differin 1% 2 N, SLDiflorasone Diacetate 0 .05% Cream, Ointment

3 SL

Epiduo 3 SLFinacea 3Fluocinolone Cream, Oil, Ointment, Solution

3 SL

Fluocinonide 0 .05% Cream

1

Hydrocortisone 2 .5% Cream, Ointment

1

Imiquimod 5% Cream 2 SLMetronidazole Gel 0 .75% 1Mirvaso 3 SLMometasone Furoate Cream, Lotion, Ointment

1

Mupirocin Ointment 1Nystatin-Triamcinolone Acetonide Cream, Ointment

3 E

Oxsoralen-Ul 2Picato 3 SLRegranex 2 N, SLSodium Sulfacetamide-Sulfur

1

Tacrolimus Ointment 2 N, SLTazorac 3 SLTretinoin 1 N, SLTretinoin Microspheres 3 E, N, SLTriamcinolone Acetonide Cream, Lotion, Ointment

1

Vectical 3 SL

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Drug NameDrug Tier


Diabetes: Blood Glucose Monitoring

Accu-Chek Active Test Strips

1 SL

Accu-Chek Aviva Plus

1

Accu-Chek Aviva Plus Test Strips

1 SL

Accu-Chek Comfort Curve Test Strips

1 SL

Accu-Chek Compact Test Strips

1 SL

Accu-Chek Nano SmartView

1

Accu-Chek Nano SmartView Test Strips

1 SL

Contour Test Strips 3 SDP, SLFreestyle Test Strips 3 SDP, SLOne Touch Test Strips

1 SL

One Touch Ultra Meter

1

One Touch Ultra Mini 1One Touch Ultra Test Strips

1 SL

One Touch Verio 1One Touch Verio IQ 1One Touch Verio IQ Test Strips

1 SL

One Touch Verio Sync

1

Drug NameDrug Tier


Diabetes: Insulin

Humalog KwikPen 2 SLHumalog Mix 50-50 KwikPen

2 SL

Humalog Mix 75-25 KwikPen

2 SL

Humalog Vials 1 SLHumulin 70-30 KwikPen

2 SL

Humulin 70-30 Vials 1 SLHumulin N KwikPen 2 SLHumulin N Vials 1 SLHumulin R Vials 1 SLLantus Solostar 3 SLLantus Vials 3 SLLevemir FlexTouch 1 SLLevemir Vials 1 SLNovolin 70-30 Vials 3 SDP, SL, STNovolin N Vials 3 SDP, SL, STNovolin R Vials 3 SDP, SL, STNovolog Flexpen 3 SDP, SL, STNovolog Mix 70/30 Flexpen

3 SDP, SL, ST

Novolog Mix 70/30 Vials

3 SDP, SL, ST

Novolog Vials 3 SDP, SL, ST

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Drug NameDrug Tier


Diabetes: Non-Insulin

Bydureon 2 SLByetta 2 SLFarxiga 3 SL, STGlimepiride 1Glipizide 1Glipizide Extended-Release

1

Glyburide 1Invokamet 2 SLInvokana 2 SL, STJanumet 3 SL, STJanuvia 3 SL, STJardiance 2 SL, STJentadueto 2 SLKazano 2 SLKombiglyze XR 2 SLMetformin 1Metformin Extended-Release Tablet

1

Nesina 2 SLOnglyza 2 SLOseni 2 SLPioglitazone 1 SLTanzeum 2 SLTradjenta 2 SLTrulicity 3 SL, STVictoza 2-Pak 2 SLVictoza 3-Pak 3 SL

Endocrine: Growth Hormone

Genotropin 3 DSP, E, N, SLHumatrope 3 DSP, E, N, SLNorditropin 3 DSP, E, N, SLNutropin, Nutropin AQ

2 DSP, N, SL

Omnitrope 3 DSP, E, N, SLSaizen 3 DSP, E, N, SLTev-Tropin 3 DSP, E, N, SL

Drug NameDrug Tier


Endocrine: Other

Calcitriol Capsule 1Desmopressin Tablet 1Dexamethasone Tablet 1Methylprednisolone Tablet

1

Prenisolone Oral Solution

1

Prednisone Tablet 1Endocrine: Thyroid Hormone ReplacementArmour Thyroid 3Levothyroxine Sodium Tablet

1

Liothyronine Sodium Tablet

2

Methimazole Tablet 1NP Thyroid Tablet 1Synthroid 2Tirosint 2

Eye Conditions: Allergies

Azelastine 0 .05% Ophthalmic Solution

2 SL

Lastacaft 3 SLPatanol 3 E, SL

Eye Conditions: Antibiotics

Erythromycin 0 .5% Ophthalmic Ointment

1

Gentamicin Ophthalmic Ointment, Solution

1

Moxeza 3Ofloxacin 0 .3% Ophthalmic Solution

1

Tobramycin/Dexamethasone 0 .3%-0 .1% Ophthalmic Suspension

2

Tobramycin Ophthalmic Solution

1

Vigamox 3

18




Drug NameDrug Tier


Eye Conditions: Glaucoma

Alphagan P 0.1% 2 SLAzopt 2 SLCombigan 2 SLLatanoprost 0 .005% Ophthalmic Solution

1

Lumigan 2 SLTimolol Maleate 0 .25%, 0 .5% Ophthalmic Solution

1

Travatan Z 2 SL

Gastrointestinal: Acid Suppression

Dexilant 3 SLEsomeprazole Capsule 3 E, SLLansoprazole Capsules 3 E, SLNexium Capsule 3 E, SLOmeclamox-Pak 3 SLOmeprazole Capsule 1Pantoprazole Tablet 1Pylera 3 SLRanitadine Syrup 1Rabeprazole Tablet 3 SLSucralfate Tablet 1

Gastrointestinal: Nausea/Vomiting

Ondansetron 1Ondansetron ODT 1Transderm-Scop 3

Drug NameDrug Tier


Gastrointestinal: Other

Amitiza 3 N, SL, STApriso 2Asacol HD Tablet 3 ECanasa 2Cortifoam 2Creon 2Delzicol 3 EDiphenoxylate-Atropine Tablet

1

Golytely 2Hyoscyamine Tablet 1Lialda 2Linzess 2 N, SLMetoclopramide Tablet 1Moviprep 3Polyethylene Glycol 3350

2

Prepopik 3Suclear 3Sulfasalazine Tablet 1Suprep 3Uceris 3Zenpep 2

Hepatitis C

Harvoni 2 DSP, N, SLOlysio 3 DSP, N, SL, STRibapak 3 DSP, ERibavirin Tablet 1 DSPSovaldi 2 DSP, N, SL, STViekira Pak 3 DSP, N, SL, ST

19

Drug NameDrug Tier


HIV/AIDS

Atripla 2 DSPComplera 2 DSPEpzicom 2 DSPIntelence 2 DSPIsentress 2 DSPKaletra 2 DSPLamivudine-Zidovudine 1 DSPNevirapine 1 DSPNevirapine Extended-Release

1 DSP

Norvir 2 DSPPrezista 2 DSPReyataz 2 DSPStribild 3 DSP, STSustiva 2 DSPTivicay 3 DSPTriumeq 2 DSPTruvada 2 DSPViread 2 DSP

Infertility*

Cetrotide 2 DSPClomiphene 1 DSPGonal-F 2 DSPGonal-F RFF 2 DSPOvidrel 3 DSP*Coverage is determined by the consumer’s prescription drug benefit plan .

Drug NameDrug Tier


Inflammatory Conditions: Rheumatoid Arthritis, Crohn’s Disease, Psoriasis, Ulcerative ColitisActemra 3 DSP, N, SL, STCimzia 2 DSP, N, SLEnbrel 3 DSP, N, SL, STHumira 2 DSP, N, SLHydroxychloroquine Sulfate

1

Leflunomide 1Methotrexate Tablet 1Orencia 3 DSP, N, SL, STOtezla 3 DSP, N, SL, STOtrexup 3 E, SL, STRasuvo 3 SL, STSimponi 2 DSP, N, SLStelara 2 DSP, N, SLXeljanz 3 DSP, N, SL, ST

Men’s Health: Erectile Dysfunction

Cialis 3 SLLevitra 3 SLStendra 3 SLViagra 3 SL

Men’s Health: Prostate

Alfuzosin Tablet 1Doxazosin Tablet 1Finasteride Tablet 1Rapaflo 3Tamsulosin Capsule 1Terazosin Capsule, Tablet 1

20




Drug NameDrug Tier


Men’s Health: Testosterone Therapy

Androderm 2 N, SLAndrogel 3 E, N, SLAndroid 2Testim 2 N, SLTestosterone Cypionate Injection

1

Miscellaneous

Anastrozole Tablet 1Antipyrine/Benzocaine Otic Solution

1

Aranesp 2 DSP, SLBenzonatate Capsule 1Bethkis 2 DSP, N, SLBromfed DM 3Cayston 2 N, SLCerdelga 2 DSP, NChlorhexidine Gluconate 1Chlorpheniramine/Hydrocodone/Pseudoephedrine Solution

2 SL

Ciprodex 2Epipen 2 SLEpipen-Jr 2 SLFosrenol 2Hydrocodone/Chlorpheniramine Suspension

3 SL

Drug NameDrug Tier


Hydrocodone/Homatropine

1

Letrozole Tablet 1Lidocaine Transdermal Patch

2 SL

Nuedexta 2Pegasys 2 DSP, N, SLPhenazopyridine 1Procrit 2 DSP, SLPromethazine/Codeine 1Promethazine/Dextromethorphan

1

Pulmozyme 2 DSP, N, SLRectiv 3 N, SLRenvela 2Restasis 3 N, SLRezira 3Tamoxifen Tablet 1Tobi Podhaler 3 DSP, N, SLTobramycin Nebulized Solution

3 DSP, E, N, SL

Velphoro 2

Musculoskeletal: Osteoporosis

Actonel 3 SLAlendronate Sodium Tablet

1 SL

Forteo 2 DSP, NIbandronate Tablet 2 SLRaloxifene Tablet 2

21

Drug NameDrug Tier


Musculoskeletal: Other

Allopurinol Tablet 1Baclofen Tablet 1Carisoprodol 350 mg Tablet

1

Colcrys 2Cyclobenzaprine 1Metaxalone Tablet 3Methocarbamol Tablet 1Tizanidine Tablet 1Uloric 3 SL

Musculoskeletal: Pain Relief

Acetaminophen/Codeine Tablet

1 SL

Celecoxib 3 SLDiclofenac Tablet 1Etodolac Capsule 1Fentanyl Patches 2 SLHydrocodone/Acetaminophen 5/325 mg, 7 .5/325 mg, 10/325 mg Tablet

1 SL

Hydrocodone/Ibuprofen Tablet

1

Hydromorphone Tablet 1Ibuprofen Tablet 1Indomethacin Capsule 1Ketorolac Tablet 1Lazanda 3 N, SLMeloxicam Tablet 1Methadone Tablet 1Morphine Sulfate Extended-Release Tablet

1 SL

Drug NameDrug Tier


Morphine Sulfate Oral Solution

1

Nabumetone Tablet 1Naproxen Tablet 1Nucynta 3 SLNucynta ER 3 N, SLOpana ER 2 N, SLOxycodone Tablet 1Oxycodone/Acetaminophen 5/325 mg, 7 .5/325 mg, 10/325 mg Tablet

1 SL

Oxycontin 3 N, SL, STSprix 3Subsys 3 N, SLTramadol-Acetaminophen

1 SL

Tramadol Sustained-Release Tablet

2 SL

Tramadol Tablet 1Vicodin 5/300 mg, 7 .5/300 mg, 10/300 mg Tablet

3 E, SL

Voltaren Gel 2Zohydro ER 3 N, SL, ST

Overactive Bladder

Dicyclomine Tablet 1Oxybutynin Extended-Release Tablet

2

Oxybutynin Tablet 1Tolterodine Extended-Release Tablet

3 E

Tolterodine Tablet 3 EToviaz 3Vesicare 3 E

22




Drug NameDrug Tier


Respiratory: Allergies

Azelastine 0 .1% Nasal Spray

3 SL

Clarinex 3 E, SLClarinex-D 3 E, SLCyproheptadine Tablet 1Dymista 3 E, SLFluticasone Nasal Spray 2 SLHydroxyzine Capsule, Tablet

1

Levocetirizine Tablet 1 SLNasonex 3 E, SLPromethazine Tablet 1Qnasl 3 E, SLTriamcinolone Nasal Spray

3 E, SL

Zetonna 3 SL

Respiratory: Asthma/COPD

Advair Diskus/HFA 3 RS, SLAerospan 3 SLAlbuterol Nebs 1Albuterol Sulfate Tablet 1Alvesco 1 SLAsmanex 1 SLBreo Ellipta 3 RS, SLBudesonide Nebs 2 SLCombivent Respimat 3 SLDulera 3 RS, SLFlovent Diskus/HFA 3 SLForadil 2 SL

Drug NameDrug Tier


Incruse Ellipta 2 SLIpratropium-Albuterol Nebs

1

Ipratropium Nebs 1Levalbuterol Nebs 3 E, SLMontelukast Chewable Tablet, Tablet

1 SL

Montelukast Granules 2 SLPerforomist 3 SLProair HFA 3 SLProventil HFA 3 SLPulmicort Flexhaler 3 SDP, SLQVAR 1 SLSpiriva Handihaler 3 SLSpiriva Respimat 3 SLSymbicort 3 E, SLTudorza 2 SLVentolin HFA 1 SLXopenex HFA 3 SLXopenex Nebs 3 E, SLRespiratory: Pulmonary Arterial HypertensionAdcirca 3 DSP, N, SLAdempas 2 DSP, N, SLLetairis 2 DSP, N, SLOpsumit 2 DSP, N, SLSildenafil Tablet 1 DSP, N, SLTracleer 2 DSP, N, SLTyvaso 2 DSP, N

23

Drug NameDrug Tier


Transplant

Azathioprine Tablet 1Cellcept 3 DSPCyclosporine Modified Capsule

1 DSP

Mycophenolate Capsule, Suspension

1 DSP

Mycophenolic Acid Tablet

2 DSP

Myfortic 3 DSPNeoral 3 DSPPrograf 3 DSPRapamune 3 DSPSirolimus Tablet 1 DSPTacrolimus Capsule 1 DSP

Vitamins/Electrolytes

Fluoride 1Folic Acid 1Klor-Con M10 1Klor-Con M20 1Potassium Chloride 1Potassium Citrate 1

Women’s Health: Contraceptives

Apri 1Aviane 1Azurette 2Cryselle 1Cyclafem 1Enskyce 1Gildess 2Gildess Fe 1Junel 2

Drug NameDrug Tier


Junel Fe 1Levora-28 1Lo Loestrin Fe 3Loryna 3Low-Ogestrel 1Lutera 1Microgestin 2Microgestin FE 1Minastrin 24 FE 3 EMononessa 3Natazia 1Necon 0 .5/35, 1/35, 1/50, 10/11

1

Norgestimate-Ethinyl Estradiol

3

Nortrel 0 .5/35 1Nuvaring 2Orsythia 1Ortho-Cyclen 1Ortho Micronor 1Ortho-Novum 3Ortho-Novum 7/7/7 1Ortho Tri-Cyclen 1Ortho Tri-Cyclen Lo 3Reclipsen 1Sprintec 3Sronyx 1Tri-Previfem 3Tri-Sprintec 3Trinessa 3Vestura 3Viorele 2Xulane 3Yasmin 28 1Yaz 2

24




Drug NameDrug Tier


Women’s Health: Hormone Replacement

Cenestin 3 EClimara 2 SLClimara Pro 3 SLDivigel 2Duavee 3Enjuvia 3Estrace Cream 3Estradiol/Norethindrone Acetate Tablet

2

Estradiol Tablet 1Estradiol Twice-Weekly Transdermal Patch

3 E, SL

Estring 2 MC, SLEstrogen/Methyltestosterone Tablet

1

Evamist 2Medroxyprogesterone 1Minivelle 3 SLPremarin 3Premphase 3Prempro 3Progesterone Micronized Capsule

2

Vagifem 2Vivelle-Dot 2 SL

Drug NameDrug Tier


Women’s Health: Prenatal Vitamins

Brand Prenatal Vitamins

3

Prenatal Plus 1

25

IndexA

Abilify ................................... 14Absorica .................................15Accu-Chek Active

Test Strips ...........................16Accu-Chek Aviva Plus ...........16Accu-Chek Aviva Plus

Test Strips ...........................16Accu-Chek Comfort Curve

Test Strips ...........................16Accu-Chek Compact

Test Strips ...........................16Accu-Chek Nano

SmartView ..........................16Accu-Chek Nano

SmartView Test Strips ........16Acetaminophen/Butalbital/

Caffeine 325 mg/ 50 mg/40mg .......................13

Acetaminophen/Codeine Tablet ..................................21

Actemra .................................19Actonel ..................................20Acyclovir Ointment ...............10Acyclovir Tablet ....................10Aczone ...................................15Adapalene 0.1% Cream, Gel..15Adapalene 0.3% Gel ..............15Adcirca ..................................22Adderall XR ..........................12Adempas ................................22Advair Diskus/HFA ..............22Aerospan ...............................22Albuterol Nebs ......................22Albuterol Sulfate Tablet .........22Alendronate Sodium Tablet...20Alfuzosin Tablet ....................19Allopurinol Tablet .................21Alphagan P 0.1% ...................18

Alprazolam Extended-Release Tablet .................................. 14

Alprazolam Tablet ................. 14Alvesco ..................................22Amiodarone ...........................12Amitiza..................................18Amitriptyline Tablet ..............13Amlodipine ...........................11Amlodipine-Valsartan ...........11Amlodipine Besylate-

Benazepril ...........................11Amoxicillin/Potassium

Clavulanate Chewable Tablet, Tablet ......................10

Amoxicillin Capsule, Chewable Tablet .................10

Amphetamine Salt Combo ....12Ampyra..................................13Anastrozole Tablet ................20Androderm ............................20Androgel................................20Android .................................20Antipyrine/Benzocaine

Otic Solution ......................20Apri .......................................23Apriso ....................................18Aranesp .................................20Armour Thyroid .................... 17Asacol HD Tablet .................18Asmanex ................................22Atenolol .................................11Atenolol-Chlorthalidone .......11Atorvastatin ...........................12Atripla ...................................19Aubagio .................................13Aviane ...................................23Avonex ...................................13Azathioprine Tablet ...............23

Azelastine 0.05% Ophthalmic Solution .......... 17

Azelastine 0.1% Nasal Spray .........................22

Azithromycin Tablet ..............10Azopt .....................................18Azor ......................................11Azurette ................................23

B

Baclofen Tablet ......................21Benazepril..............................11Benazepril-

Hydrochlorothiazide ...........11Benicar ..................................11Benicar HCT ........................11Benzonatate Capsule .............20Betamethasone Diproionate

0.05% Augmented Lotion, Ointment ............................15

Betamethasone Dipropionate 0.05% Cream, Ointment ....15

Betaseron ...............................13Bethkis ..................................20Bicalutamide ..........................10Bidil .......................................11Bisoprolol ...............................11Bisoprolol-

Hydrochlorothiazide ...........11Bosulif ...................................10Brand Prenatal Vitamins .......24Breo Ellipta ...........................22Brintellix................................13Bromfed DM .........................20Budesonide Nebs ...................22Buprenorphine/Naloxone

Tablet .................................. 14Bupropion Extended-Release

Tablet ..................................13

26

Bupropion Sustained-Release Tablet ..................................13

Bupropion Tablet ...................13Buspirone Tablet .................... 14Bydureon ............................... 17Byetta .................................... 17Bystolic ..................................11

C

Calcitriol Capsule .................. 17Canasa ...................................18Capecitabine Tablet ...............10Carac .....................................15Carbamazepine Tablet ........... 14Carbidopa-Levodopa ............. 14Carisoprodol 350 mg Tablet ..21Cartia XT ..............................11Carvedilol ..............................11Cayston ..................................20Cefadroxil Capsule, Tablet ....10Cefdinir Capsule ...................10Cefprozil Tablet .....................10Cefuroxime Tablet .................10Celecoxib ...............................21Cellcept .................................23Cenestin ................................24Cephalexin Capsule ...............10Cerdelga ................................20Cetrotide ...............................19Chlorhexidine Gluconate .......20Chlorpheniramine/

Hydrocodone/Pseudoephedrine Solution ..20

Chlorthalidone ......................11Choline Fenofibrate ...............12Cialis .....................................19Ciclopirox Cream, Gel, Lotion,

Solution ..............................15Cimzia ...................................19Ciprodex ................................20Ciprofloxacin Tablet ..............10

Citalopram Tablet ..................13Claravis ..................................15Clarinex .................................22Clarinex-D ............................22Clarithromycin Tablet ...........10Climara..................................24Climara Pro ...........................24Clindamycin 1%/Benzoyl

Peroxide 5% Gel .................15Clindamycin 1.2%/Benzoyl

Peroxide 5% Gel .................15Clindamycin Capsule ............10Clindamycin Gel ...................15Clindamycin Lotion ..............15Clindamycin Solution, Swabs 15Clobetasol Propionate Cream,

Ointment, Solution .............15Clomiphene ...........................19Clonazepam Tablet ................ 14Clonidine Tablet ....................11Clopidogrel ............................11Clotrimazole-Betamethasone

Cream .................................15Clotrimazole-Betamethasone

Lotion .................................15Colcrys ..................................21Combigan ..............................18Combivent Respimat .............22Complera ...............................19Concerta ................................12Condylox Gel ........................15Contour Test Strips ...............16Copaxone...............................13Cortifoam ..............................18Creon .....................................18Crestor ...................................12Cryselle ..................................23Cyclafem ...............................23Cyclobenzaprine ....................21Cyclophosphamide Capsule ...10

Cyclosporine Modified Capsule ...............................23

Cymbalta ...............................13Cyproheptadine Tablet ..........22

D

Daytrana ................................12Delzicol .................................18Desmopressin Tablet ............. 17Desonide 0.05% Cream,

Lotion, Ointment ...............15Desoximetasone Gel,

Ointment ............................15Dexamethasone Tablet .......... 17Dexilant .................................18Dexmethylphenidate

Extended-Release Capsule ...............................12

Dexmethylphenidate Tablet ...12Dextroamphetamine-

Amphetamine Extended-Release ...............12

Dextroamphetamine-Amphetamine Tablet ..........12

Dextroamphetamine Sulfate Tablet ..................................12

Diazepam Tablet ................... 14Diclofenac Tablet ...................21Dicyclomine Tablet ...............21Differin 1% ............................15Dificid ...................................10Diflorasone Diacetate 0.05%

Cream, Ointment ...............15Digoxin .................................12Diltiazem 24 Hour CD .........11Diltiazem Sustained-Release

Capsule ...............................11Diltiazem Sustained-Release

Tablet ..................................11Diovan ...................................11

27

Diphenoxylate-Atropine Tablet ..................................18

Divalproex Delayed-Release Tablet .................................. 14

Divalproex Extended-Release Tablet .................................. 14

Divigel ...................................24Donepezil 5, 10 mg ODT,

Tablet .................................. 14Doryx ....................................10Doxazosin ........................ 11, 19Doxazosin Tablet ...................19Doxepin .................................13Doxycycline Hyclate Capsule,

Tablet ..................................10Doxycycline Monohydrate

50, 100 mg Capsule ............10Duavee ...................................24Dulera ....................................22Duloxetine Capsule ...............13Dutoprol ................................11Dymista .................................22

E

Econazole Cream ..................10Edarbi ....................................11Edarbyclor .............................11Effient ...................................11Eliquis ...................................11Enalapril ................................11Enbrel ....................................19Enjuvia ..................................24Enoxaparin Sodium ...............11Enskyce .................................23Epiduo ...................................15Epipen ...................................20Epipen-Jr ...............................20Epzicom ................................19Erythromycin 0.5%

Ophthalmic Ointment ........ 17Escitalopram Tablet ...............13

Esomeprazole Capsule ...........18Estrace Cream .......................24Estradiol/Norethindrone

Acetate Tablet .....................24Estradiol Tablet .....................24Estradiol Twice-Weekly

Transdermal Patch ..............24Estring ...................................24Estrogen/Methyltestosterone

Tablet ..................................24Eszopiclone Tablet ................. 14Etodolac Capsule ...................21Evamist ..................................24Extavia...................................13

F

Famciclovir Tablet .................10Farxiga ................................... 17Fenofibrate 43, 50 , 67, 130,

134, 150, 200 mg Capsule ..12Fenofibrate 48, 145 mg

Tablet ..................................12Fenofibrate 54, 160 mg

Tablet ..................................12Fenoglide ...............................12Fentanyl Patches ....................21Fetzima ..................................13Finacea ..................................15Finasteride Tablet ..................19Flecainide ..............................12Flovent Diskus/HFA .............22Fluconazole Tablet .................10Fluocinolone Cream, Oil,

Ointment, Solution .............15Fluocinonide 0.05% Cream ...15Fluoride .................................23Fluoxetine Tablet, Capsule ....13Fluticasone Nasal Spray .........22Fluvoxamine Tablet ...............13Focalin XR ............................12Folic Acid ..............................23

Foradil ...................................22Forteo ....................................20Fosrenol .................................20Freestyle Test Strips...............16Furosemide ............................11

G

Gabapentin Capsule, Tablet .. 14Gemfibrozil ...........................12Genotropin ............................ 17Gentamicin Ophthalmic

Ointment, Solution ............. 17Gildess ...................................23Gildess Fe ..............................23Gilenya ..................................13Gleevec ..................................10Glimepiride ........................... 17Glipizide ................................ 17Glipizide Extended-Release .. 17Glyburide............................... 17Golytely .................................18Gonal-F .................................19Gonal-F RFF ........................19Guanfacine ...................... 11, 12Guanfacine

Extended-Release ...............12

H

Harvoni .................................18Humalog KwikPen ................16Humalog Mix 50-50

KwikPen .............................16Humalog Mix 75-25

KwikPen .............................16Humalog Vials ......................16Humatrope ............................ 17Humira ..................................19Humulin 70-30 KwikPen ......16Humulin 70-30 Vials ............16Humulin N KwikPen ............16Humulin N Vials ...................16Humulin R Vials ...................16

28

Hydralazine ...........................11Hydrochlorothiazide ..............11Hydrocodone/Acetaminophen

5/325 mg, 7.5/325 mg, 10/325 mg Tablet ................21

Hydrocodone/ Chlorpheniramine Suspension ..........................20

Hydrocodone/Homatropine ..20Hydrocodone/Ibuprofen

Tablet ..................................21Hydrocortisone 2.5% Cream,

Ointment ............................15Hydromorphone Tablet .........21Hydroxychloroquine Sulfate ..19Hydroxyurea Capsule ............10Hydroxyzine Capsule,

Tablet ..................................22Hyoscyamine Tablet ..............18

I

Ibandronate Tablet ................20Ibuprofen Tablet ....................21Imbruvica ..............................10Imiquimod 5% Cream ...........15Incruse Ellipta .......................22Indomethacin Capsule ...........21Intelence ................................19Intuniv ...................................13Invokamet .............................. 17Invokana ................................ 17Ipratropium-Albuterol Nebs ..22Ipratropium Nebs ..................22Irbesartan ..............................11Isentress .................................19Isosorbide Mononitrate ER ...12Itraconazole Capsule ..............10

J

Janumet ................................. 17Januvia ................................... 17Jardiance ................................ 17

Jentadueto .............................. 17Junel .......................................23Junel Fe ..................................23

K

Kaletra ...................................19Kazano .................................. 17Ketoconazole Cream .............10Ketorolac Tablet .....................21Klor-Con M10 ......................23Klor-Con M20 ......................23Kombiglyze XR ..................... 17

L

Labetalol ................................11Lamivudine-Zidovudine .......19Lamotrigine Tablet ................ 14Lansoprazole Capsules ..........18Lantus Solostar ......................16Lantus Vials ..........................16Lastacaft ................................ 17Latanoprost 0.005%

Ophthalmic Solution ..........18Latuda ................................... 14Lazanda .................................21Leflunomide ..........................19Letairis ..................................22Letrozole Tablet ....................20Leucovorin Calcium Tablet ...10Levalbuterol Nebs ..................22Levemir FlexTouch ...............16Levemir Vials ........................16Levetiracetam

Extended-Release Tablet .... 14Levetiracetam Tablet ............. 14Levitra ...................................19Levocetirizine Tablet .............22Levofloxacin Tablet ...............10Levora-28 ..............................23Levothyroxine Sodium

Tablet .................................. 17Lexapro..................................13

Lialda ....................................18Lidocaine Transdermal

Patch ...................................20Linzess ..................................18Liothyronine Sodium

Tablet .................................. 17Lipitor ....................................12Lipofen ..................................12Lisinopril ......................... 11, 33Lisinopril-

Hydrochlorothiazide ...........11Lithium Capsule .................... 14Livalo ....................................12Lo Loestrin Fe ......................23Lorazepam Tablet .................. 14Loryna ...................................23Losartan ................................11Losartan-

Hydrochlorothiazide ...........11Lovastatin ..............................12Low-Ogestrel ........................23Lumigan ................................18Lunesta .................................. 14Lutera ....................................23Lyrica .................................... 14

M

Medroxyprogesterone ............24Meloxicam Tablet ..................21Mercaptopurine Tablet ..........10Metadate CD ........................13Metaxalone Tablet .................21Metformin ............................. 17Metformin Extended-Release

Tablet .................................. 17Methadone Tablet .................21Methimazole Tablet .............. 17Methocarbamol Tablet ..........21Methotrexate Tablet ..............19Methylphenidate ....................13

29

Methylphenidate Extended-Release Capsule ...............................13

Methylphenidate Extended-Release Tablet ....13

Methylprednisolone Tablet .... 17Metoclopramide Tablet .........18Metoprolol Succinate 50, 100,

200 mg ...............................11Metoprolol Tartrate ...............11Metronidazole Gel 0.75% ......15Metronidazole Tablet ............10Microgestin ...........................23Microgestin FE .....................23Minastrin 24 FE ...................23Minivelle ...............................24Minocycline Capsule .............10Minocycline Tablet ................10Mirtazapine Tablet ................13Mirvaso .................................15Modafinil Tablet .................... 14Mometasone Furoate Cream,

Lotion, Ointment ...............15Mononessa .............................23Montelukast Chewable Tablet,

Tablet ..................................22Montelukast Granules ...........22Morphine Sulfate

Extended-Release Tablet ....21Morphine Sulfate Oral

Solution ..............................21Moviprep ...............................18Moxeza .................................. 17Moxifloxacin Tablet ...............10Mupirocin Ointment .............15Mycophenolate Capsule,

Suspension ..........................23Mycophenolic Acid Tablet .....23Myfortic ................................23

N

Nabumetone Tablet ...............21Nadolol ..................................11Namenda XR ......................... 14Naproxen Tablet ....................21Naratriptan ............................13Nasonex .................................22Natazia ..................................23Necon 0.5/35, 1/35, 1/50,

10/11 ...................................23Neoral ....................................23Nesina .................................... 17Nevirapine .............................19Nevirapine

Extended-Release ...............19Nexium Capsule ....................18Niacin Extended-Release

Tablet ..................................12Niaspan .................................12Nifedipine Extended-Release 11Nitrofurantoin Capsule ..........10Nitrofurantoin Macrocrystal

Capsule ...............................10Nitrostat ................................12Norditropin............................ 17Norgestimate-Ethinyl

Estradiol .............................23Nortrel 0.5/35 ........................23Nortriptyline Capsule ............13Norvir ....................................19Novolin 70-30 Vials ..............16Novolin N Vials ....................16Novolin R Vials .....................16Novolog Flexpen ...................16Novolog Mix 70/30

Flexpen ...............................16Novolog Mix 70/30 Vials ......16Novolog Vials ........................16NP Thyroid Tablet ................ 17Nucynta .................................21Nucynta ER ...........................21

Nuedexta ...............................20Nutropin, Nutropin AQ ........ 17Nuvaring................................23Nuvigil................................... 14Nystatin-Triamcinolone

Acetonide Cream, Ointment ............................15

Nystatin Cream, Ointment....10

O

Ofloxacin 0.3% Ophthalmic Solution .............................. 17

Ofloxacin Tablet ....................10Olanzapine Tablet ................. 14Olysio ....................................18Omeclamox-Pak ....................18Omega-3-Acid Ethyl Esters

Capsule ...............................12Omeprazole Capsule .............18Omnitrope ............................. 17Ondansetron ..........................18Ondansetron ODT ................18One Touch Test Strips ...........16One Touch Ultra Meter .........16One Touch Ultra Mini ..........16One Touch Ultra Test Strips .16One Touch Verio ...................16One Touch Verio IQ ..............16One Touch Verio IQ

Test Strips ...........................16One Touch Verio Sync ...........16Onglyza ................................. 17Opana ER .............................21Opsumit ................................22Oracea ...................................10Orencia ..................................19Orsythia ................................23Ortho-Cyclen ........................23Ortho-Novum .......................23Ortho-Novum 7/7/7 ..............23Ortho Micronor ....................23

30

Ortho Tri-Cyclen ..................23Ortho Tri-Cyclen Lo.............23Oseni ..................................... 17Otezla ....................................19Otrexup .................................19Ovidrel ..................................19Oxcarbazepine Tablet ............ 14Oxsoralen-Ul .........................15Oxybutynin Extended-Release

Tablet ..................................21Oxybutynin Tablet ................21Oxycodone/Acetaminophen

5/325 mg, 7.5/325 mg, 10/325 mg Tablet ................21

Oxycodone Tablet ..................21Oxycontin ..............................21

P

Pantoprazole Tablet ...............18Paroxetine Tablet ...................13Patanol ................................... 17Pegasys ..................................20Penicillin V Potassium

Tablet ..................................10Perforomist ............................22Phenazopyridine ....................20Phenytoin Capsule,

Suspension .......................... 14Picato .....................................15Pioglitazone ........................... 17Polyethylene Glycol 3350 .......18Potassium Chloride ...............23Potassium Citrate ..................23Pradaxa ..................................11Pramipexole Tablet ................ 14Pravastatin .............................12Prednisone Tablet .................. 17Premarin ................................24Premphase .............................24Prempro .................................24Prenatal Plus ..........................24

Prenisolone Oral Solution...... 17Prepopik ................................18Prezista ..................................19Pristiq ER ..............................13Proair HFA ...........................22Procrit ....................................20Progesterone Micronized

Capsule ...............................24Prograf ...................................23Promethazine/Codeine ..........20Promethazine/

Dextromethorphan .............20Promethazine Tablet ..............22Propranolol Extended-Release

Capsule ...............................11Propranolol Tablet .................11Proventil HFA .......................22Pulmicort Flexhaler ...............22Pulmozyme ...........................20Pylera .....................................18

Q

Qnasl .....................................22Quetiapine Tablet .................. 14Quinapril ...............................11QVAR ...................................22

R

Rabeprazole Tablet ................18Raloxifene Tablet ...................20Ramipril ................................11Ranexa ...................................12Ranitadine Syrup ...................18Rapaflo ..................................19Rapamune .............................23Rasuvo ...................................19Rebif ......................................13Reclipsen ...............................23Rectiv ....................................20Regranex ................................15Relpax ....................................13Renvela ..................................20

Restasis ..................................20Revlimid ................................10Reyataz ..................................19Rezira ....................................20Ribapak .................................18Ribavirin Tablet .....................18Risperidone Tablet ................. 14Rizatriptan Tablet..................13Ropinirole Tablet ................... 14

S

Saizen .................................... 17Seroquel XR .......................... 14Sertraline Tablet ....................13Sildenafil Tablet .....................22Simcor ...................................12Simponi .................................19Simvastatin ............................12Sirolimus Tablet .....................23Sodium Sulfacetamide-Sulfur 15Solodyn ..................................10Sotalol....................................12Sovaldi ...................................18Spiriva Handihaler ................22Spiriva Respimat....................22Spironolactone .......................11Sprintec .................................23Sprix ......................................21Sronyx....................................23Stelara ....................................19Stendra ..................................19Strattera .................................13Stribild ...................................19Suboxone Film ...................... 14Subsys ....................................21Suclear ...................................18Sucralfate Tablet ....................18Sulfamethoxazole-

Trimethoprim Tablet ..........10Sulfasalazine Tablet ...............18Sumatriptan Nasal Spray .......13

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Sumatriptan Succinate Tablet, Injection ..............................13

Sumavel DosePro ..................13Suprax Capsule, Suspension,

Tablet ..................................10Suprep ...................................18Sustiva ...................................19Sutent ....................................10Symbicort ..............................22Synthroid ............................... 17

T

Tacrolimus Capsule ...............23Tacrolimus Ointment ............15Tamiflu ..................................10Tamoxifen Tablet ...................20Tamsulosin Capsule ...............19Tanzeum ................................ 17Tasigna ..................................10Tasmar ................................... 14Tazorac ..................................15Tecfidera ................................13Telmisartan............................11Telmisartan-

Hydrochlorothiazide ...........11Temazepam Capsule .............. 14Terazosin ......................... 11, 19Terazosin Capsule, Tablet ......19Terbinafine Tablet .................10Testim ....................................20Testosterone Cypionate

Injection ..............................20Tev-Tropin ............................. 17Timolol Maleate 0.25%, 0.5%

Ophthalmic Solution ..........18Tirosint .................................. 17Tivicay ...................................19Tizanidine Tablet ..................21Tobi Podhaler ........................20

Tobramycin/Dexamethasone 0.3%-0.1% Ophthalmic Suspension .......................... 17

Tobramycin Nebulized Solution ..............................20

Tobramycin Ophthalmic Solution .............................. 17

Tolterodine Extended-Release Tablet ..................................21

Tolterodine Tablet .................21Topiramate Tablet .................. 14Toviaz ....................................21Tracleer ..................................22Tradjenta................................ 17Tramadol-Acetaminophen .....21Tramadol Sustained-Release

Tablet ..................................21Tramadol Tablet ....................21Transderm-Scop ....................18Travatan Z .............................18Trazodone Tablet ...................13Tretinoin ................................15Tretinoin Microspheres .........15Tri-Previfem ..........................23Tri-Sprintec ...........................23Triamcinolone Acetonide

Cream, Lotion, Ointment ..15Triamcinolone Nasal Spray ....22Triamterene-

Hydrochlorothiazide ...........11Triazolam Tablet ................... 14Tricor 48, 145 mg ..................12Trilipix ...................................12Trinessa .................................23Triumeq .................................19Trulicity ................................. 17Truvada .................................19Tudorza .................................22Tyvaso ...................................22

U

Uceris .....................................18Uloric .....................................21

V

Vagifem .................................24Valacyclovir Tablet ................10Valsartan ................................11Valsartan-

Hydrochlorothiazide ...........11Vascepa ..................................12Vectical ..................................15Velphoro ................................20Venlafaxine Extended-Release

Capsule ...............................13Venlafaxine Tablet .................13Ventolin HFA ........................22Verapamil ..............................11Verapamil Sustained-Release .11Vesicare ..................................21Vestura ...................................23Viagra ....................................19Vicodin 5/300 mg,

7.5/300 mg, 10/300 mg Tablet ..................................21

Victoza 2-Pak ........................ 17Victoza 3-Pak ........................ 17Viekira Pak ............................18Vigamox ................................ 17Viibryd ..................................13Viorele ...................................23Viread ....................................19Vivelle-Dot ............................24Voltaren Gel ..........................21Vytorin ..................................12Vyvanse .................................13

W

Warfarin Sodium ..................11Welchol .................................12Wellbutrin XL .......................13

32

X

Xarelto ...................................11Xeljanz ...................................19Xopenex HFA .......................22Xopenex Nebs ........................22Xulane ...................................23Xyrem .................................... 14

Y

Yasmin 28 ..............................23Yaz .........................................23

Z

Zaleplon Capsule ................... 14Zelapar .................................. 14Zenpep ..................................18Zetia ......................................12Zetonna .................................22Ziprasidone Capsule .............. 14Zohydro ER ..........................21Zolpidem Extended-Release

Tablet .................................. 14Zolpidem Tablet .................... 14Zonisamide Capsule .............. 14Zovirax Cream ......................10Zubsolv .................................. 14Zytiga ....................................10

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“My Medications” worksheetTake 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 Medicineand Strength

DrugTier

I Take ThisMedicine For

Directions Doctor

Example: Lisinopril, 20mg Tier 1 High blood pressure One tablet daily Dr . Johnson

34

Notes

All branded medications are trademarks or registered trademarks of their respective owners .

© 2015 United HealthCare Services, Inc . All rights reserved . Created February, 2015 . 2015 Prescription Drug List – Advantage Three-Tier 100-16334 7/15

For more information

Call the toll-free member phone number on your health plan ID card.

Or, visit myuhc.com®

Where else can I go for information? HealthCareLane.com includes short videos to help you learn more about UnitedHealthcare benefi ts and health insurance information.

UHCTV.com is a fun and easy way to learn about health terms and other health-related topics.

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