DC Government Employees Traditional Three-Tier myuhc

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Your 2014Prescription Drug Listeffective July 1, 2014

DC Government Employees Traditional Three-Tier

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

For additional information:

Call 1-800-603-3923.

Visit myuhc.com®

•LocateaparticipatingretailpharmacybyZIPcode.

•Lookuppossiblelower-costmedicationalternatives.

•Comparemedicationpricingandoptions.

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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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

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

Eye ConditionsAllergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

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

HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

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

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

Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

MusculoskeletalOsteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Pain Relief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Rheumatoid Arthritis . . . . . . . . . . . . . . . . . . . . . . . . 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 1-800-603-3923.

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 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 myuhc.com or call 1-800-603-3923.

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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

Preferred brand medications .

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 .

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 on January 1.

• Medications may be excluded from coverage 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 1-800-603-3923.

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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 may be covered for you.

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

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

1/2T Half Tablet Program – Save up-to 50% when you split your tablet (double the strength) in half . Program eligibility may vary .

*Depending on your benefit you may have notification or prior authorization requirements for select medications .

To learn more about a pharmacy program or to find out if it applies to you, please visit myuhc.com or call 1-800-603-3923.

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. These medications are not covered under your pharmacy benefit, but they may cost less than your out-of-pocket expense for prescription medications.

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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.

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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 1-800-603-3923.

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

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 1-800-603-3923.

Or, visit myuhc.com®

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

N = Notification or Prior Authorization requiredSL = Supply Limit1/2T = May be eligible for Half Tablet

Drug Name Drug Tier

Requirements & Limits

Anti-Infectives: Antibiotics

Adoxa Capsule 3Amoxicillin 1Amoxicillin/Potassium Clavulanate

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Augmentin XR 3Azithromycin 1Cefdinir 1Cefuroxime 1Centany AT 3Cephalexin 1Ciprofloxacin Tablet 1Clarithromycin Tablet 1Clindamycin 1Dificid 3 SLDoryx 3Doxycycline Capsule, Tablet

1

Doxycycline Hyclate Capsule, Tablet

1

Levofloxacin 1Metronidazole 1Minocycline Capsule, Tablet

1

Nitrofurantoin 1Nitrofurantoin Macrocrystal

1

Oracea 3PenicillinVPotassium 1Solodyn 3Sulfamethoxazole-Trimethoprim

1

Drug Name Drug Tier


Anti-Infectives: Antifungals

Fluconazole 1Itraconazole 1 SLKetoconazole 1Nystatin 1Onmel 3 SLTerbinafine 1 SL

Anti-Infectives: Antivirals

Acyclovir Ointment 1 SLAcyclovir Tablet 1Baraclude 2Incivek 2 N, SLOlysio 2 N, SLRibapak 1Ribavirin 1Tamiflu 3 SLValacyclovir 1 SLZovirax Cream 3 SL

Cancer

Bosulif 2 N, SLGleevec 2 N, SLHydroxyurea 1Leucovorin Calcium 1Mercaptopurine 1Sutent 2 N, SLTasigna 2 N, SLXeloda 2 SLZytiga 2 N, SL

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Drug Name Drug Tier


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

1 SL

Amlodipine/Telmisartan 1 SLAmturnide 3 SLAtenolol 1Atenolol-Chlorthalidone 1Azor 3 SLBenazepril 1Benazepril-Hydrochlorothiazide

1

Benicar 2 SL, 1/2TBenicar HCT 2 SLBidil 2Bisoprolol 1Bisoprolol-Hydrochlorothiazide

1

Bystolic 2Cartia XT 1Carvedilol 1Chlorthalidone 1Clonidine Tablet 1Coreg CR 3 SLDiltiazem 24 Hour CD 1Diltiazem Sustained-Release Capsule

1

Diltiazem Sustained-Release Tablet

1

Diovan 3 SL, 1/2TDoxazosin 1

Drug Name Drug Tier


Dutoprol 2 SLEdarbi 3 SLEdarbyclor 3 SLEnalapril 1Enalapril-Hydrochlorothiazide

1

Exforge 3 SLExforge HCT 3 SLFelodipine 1Fosinopril Sodium 1Furosemide 1Guanfacine 1Hydralazine 1Hydrochlorothiazide 1Indapamide 1Irbesartan 1 SL, 1/2TLabetalol 1Lisinopril 1Lisinopril-Hydrochlorothiazide

1

Losartan 1 1/2TLosartan-Hydrochlorothiazide

1

Metoprolol Succinate 50, 100, 200 mg

1

Metoprolol Tartrate 1Micardis HCT 2 SLNadolol 1Nexiclon XR 3Nifedipine Extended-Release

1

Propranolol 1Quinapril 1Ramipril 1Spironolactone 1Tekamlo 3 SLTelmisartan 1 SLTerazosin 1Torsemide 1Triamterene-Hydrochlorothiazide

1

Tribenzor 3 SL

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Drug Name Drug Tier


Twynsta 3 SLValsartan-Hydrochlorothiazide

1 SL

Verapamil 1Verapamil Sustained-Release

1

Cardiovascular/Heart Disease: High CholesterolAltoprev 3 SLAtorvastatin 1 SL, 1/2TCaduet 3 SLCholine Fenofibrate 1Crestor 2 SL, 1/2TFenofibrate 48, 145 mg 1Fenofibrate 54, 160 mg 1Fenofibrate Micronized 43, 130 mg

1

Fenoglide 3Gemfibrozil 1Lipofen 2Liptruzet 3 SLLivalo 3 SLLovastatin 1Lovaza 3 NNiacin Extended-Release Tablet

1

Niaspan 3Pravastatin 1 1/2TSimcor 3 SLSimvastatin 1 1/2TTricor 48 mg, 145 mg 3Trilipix 3Vascepa 3 NVytorin 3 SLWelchol 2Zetia 3 SL

Drug Name Drug Tier


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

1

Multaq 2Nitroglycerin Sublingual Spray

1 SL

Nitrolingual Pump Spray 3 SL

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

1 N

Clonidine Extended-Release Tablet

1

Concerta 1 N, SLDaytrana 3 N, SLDexmethylphenidate 1 NDexmethylphenidate Extended-Release Capsule

1 N, SL

Dextroamphetamine Sulfate

1 N

Dextroamphetamine-Amphetamine

1 N

Dextroamphetamine-Amphetamine Extended-Release

3 N, SL

Focalin XR 3 N, SLIntuniv 2 SLKapvay 3

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Drug Name Drug Tier


Metadate CD 1 N, SLMethylphenidate 1 NMethylphenidate Extended-Release Capsule

3 N, SL

Methylphenidate Extended-Release Tablet

3 N, SL

Quillivant XR 3 N, SLRitalin LA 3 N, SLStrattera 3 SLVyvanse 2 N, SLZenzedi 3 N

Central Nervous System: Depression

Amitriptyline 1Aplenzin 3 SLBupropion 1Bupropion Extended-Release

1

Bupropion Sustained-Release

1

Citalopram 1Desvenlafaxine 3 SLDoxepin 1Duloxetine 1 SLEscitalopram 1 1/2TFluoxetine 1Fluvoxamine 1Forfivo XL 3 SLImipramine 1Mirtazapine 1Nortriptyline 1Oleptro 3 SLParoxetine 1Pristiq ER 3 SL

Drug Name Drug Tier


Sertraline 1 1/2TTrazodone 1Venlafaxine 1Venlafaxine Extended-Release Capsule

1 SL

Venlafaxine Extended-Release Tablet

1 SL

Viibryd 3 SL

Central Nervous System: Migraine

Acetaminophen/Butalbital/Caffeine

1 SL

Alsuma 3 SLCambia 3 SLRelpax 2 SLRizatriptan Orally Disintegrating Tablet

1 SL

Rizatriptan Tablet 1 SLSumatriptan Nasal Spray

1 SL

Sumatriptan Succinate Tablet, Injection

1 SL

Sumavel DosePro 3 SLTreximet 3 SLCentral Nervous System: Multiple SclerosisAmpyra 2 N, SLAubagio 3 N, SLAvonex 2 N, SLBetaseron 2 N, SLCopaxone 20 mg 2 N, SLExtavia 3 N, SLGilenya 3 N, SLRebif 3 N, SLTecfidera 2 N, SL

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Drug Name Drug Tier


Central Nervous System: Other

Abilify 3 SL, 1/2TAlprazolam 1Alprazolam Extended-Release

1

Aricept 23 mg 3Buprenorphine/Naloxone Tablet

1 N, SL

Buspirone 1Carbidopa-Levodopa 1Diazepam 1Donepezil 5, 10 mg 1Latuda 3 SLLithium 1Lorazepam 1Mirapex ER 3Modafinil 1 N, SLNuvigil 3 N, SLOlanzapine 1 SLPramipexole 1Provigil 3 N, SLQuetiapine 1 SLRequip XL 3Risperidone 1Ropinirole 1Seroquel XR 3 SLSuboxone Film 2 N, SLTasmar 2Xyrem 3 N, SLZelapar 3Ziprasidone 1 SLZubsolv 1 N, SL

Drug Name Drug Tier


Central Nervous System: Sedatives/HypnoticsAmbien CR 3 SLEdluar 3 SLIntermezzo 3 SLLunesta 3 SLSilenor 3 SLTemazepam 1Zaleplon 1 SLZolpidem 1 SLZolpidem Extended-Release

1 SL

Zolpimist 3 SLCentral Nervous System: Seizure DisordersCarbamazepine 1Clonazepam 1Depakote 3 NDepakote ER 3 NDiazepam 1Divalproex 1Divalproex Extended-Release

1

Gabapentin 1Keppra 3 NKeppra XR 3 NLamictal 3 NLamictal XR 3 NLamotrigine 1Levetiracetam 1Levetiracetam Extended-Release

1

Lyrica 3 SLNeurontin 3 NOxcarbazepine 1

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Drug Name Drug Tier


Oxtellar XR 3 NPhenytoin 1Topamax 3 NTopiramate 1Trileptal 3 NTrokendi XR 3 NZonegran 3 NZonisamide 1

Dermatology

Absorica 3 NAcanya 3 SLAczone 3 SLAdapalene 1 N, SLAzelex 3 SLBenzaclin 3 SLBetamethasone Dipropionate Cream, Lotion, Ointment

1

Betamethasone Valerate Foam

1 SL

Carac 2Ciclopirox Cream, Gel, Lotion, Solution

1

Claravis 1 NClindagel 3 SLClindamycin 1%/Benzoyl Peroxide 5% Jar

1 SL

Clindamycin 1 .2%/Benzoyl Peroxide 5%

1 SL

Clindamycin Gel, Lotion, Solution, Swabs

1

Clobetasol Propionate Cream, Lotion, Ointment, Solution

1

Clobex Shampoo 3 SLCloderm 3 SLClotrimazole-Betamethasone Cream, Lotion

1

Condylox Gel 3Desonide Cream, Lotion, Ointment

1

Differin 3 N, SL

Drug Name Drug Tier


Duac 3 SLEpiduo 3 SLFinacea 3Fluocinonide 0 .05% Cream, Ointment, Solution

1

Fluocinonide 0 .1% Cream

1 SL

Hydrocortisone Butyrate Cream

1 SL

Hydrocortisone Cream, Ointment

1

Keralyt Scalp Kit 3Locoid Lipocream 3 SLLocoid Lotion 3 SLLuxiq 3 SLMetrogel 1% 3Metronidazole Gel 0 .75% 1Metronidazole Gel 1% 1Mometasone Furoate Cream, Lotion, Ointment

1

Mupirocin Ointment 1Nystatin-Triamcinolone Acetonide Cream, Ointment

1

Oxsoralen-Ul 2Picato 3 SLProtopic 2 N, SLRetin-A Micro 3 N, SLSodium Sulfacetamide-Sulfur

1

Sorilux 3 SLStelara 2 N, SLSumadan 3Sumaxin CP 3Sumaxin TS 3Taclonex 3 SLTretinoin 1 NTretinoin Microspheres 1 N, SLTriamcinolone Acetonide Cream, Lotion, Ointment

1

Trianex 1 SLUmecta 3

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Drug Name Drug Tier


Umecta PD 3Uramaxin GT 3Vanos 3 SLVectical 3 SLVeltin 3 SLVerdeso 3 SLVirasal 3Xerese 3Ziana 3 SLZyclara 3 SL

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 SLFreestyle Test Strips 3 SLOne Touch Test Strips 1 SL

One Touch Ultra Mini 1One Touch Ultra Test Strips 1 SL

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

Drug Name Drug Tier


Diabetes: Insulin

Humalog KwikPen 2Humalog Mix 75-25 KwikPen 2

Humalog Vials 1Humulin 70-30 Vials 1Humulin KwikPen 2Humulin N KwikPen 2Humulin N Vials 1Humulin R Vials 1Lantus Solostar 3Lantus Vials 2Levemir Flexpen 1Levemir Vials 1Novolog 3Novolog Flexpen 3

Diabetes: Non-Insulin

Bydureon 3 SLByetta 2 SLGlimepiride 1Glipizide 1Glipizide Extended-Release

1

Glumetza 3Glyburide 1Glyburide-Metformin 1Janumet 3 SLJanuvia 3 SLJentadueto 2 SLKazano 2 SLKombiglyze XR 2 SLMetformin 1Metformin Extended-Release

1

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Drug Name Drug Tier


Nesina 2 SLOnglyza 2 SLOseni 2 SLPioglitazone 1 SLPioglitazone-Metformin 1 SLPrandimet 3Prandin 3 SLRepaglinide 1 SLTradjenta 2 SLVictoza 3 SL

Endocrine: Growth Hormone

Genotropin 3 N, SLHumatrope 3 N, SLNorditropin 3 N, SLNutropin AQ NuSpin 2 N, SLOmnitrope 3 N, SLSaizen 2 N, SLTev-Tropin 2 N, SL

Endocrine: Other

Calcitriol 1Desmopressin 1Dexamethasone 1Methylprednisolone 1Prednisolone 1Prednisone 1Rayos 3Endocrine: Thyroid Hormone ReplacementArmour Thyroid 3Levothyroxine Sodium 1Levoxyl 1Liothyronine Sodium 1Methimazole 1NP Thyroid 1Synthroid 2Tirosint 2

Drug Name Drug Tier


Eye Conditions: Allergies

Azelastine 1 SLBepreve 3 SLElestat 3 SLEmadine 3Lastacaft 3 SLPataday 3 SLPatanol 3 SL

Eye Conditions: Antibiotics

Erythromycin 1Ofloxacin 1Polymyxin B Sulfate/Trimethoprim

1

Tobradex ST 3 SLTobramycin/Dexamethasone

1

Eye Conditions: Glaucoma

Alphagan P 0.1% 2 SLAzopt 2 SLCombigan 2 SLCosopt PF 3 SLDorzolamide-Timolol 1Latanoprost 1Lumigan 2 SLSimbrinza 3 SLTimolol Maleate 1Travatan Z 2 SL

Eye Conditions: Other

Acuvail 3 SLBromday 3 SLIlevro 3Lotemax Gel 3 SLLotemax Solution 3 SLProlensa 3 SL

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Drug Name Drug Tier


Gastrointestinal: Acid Suppression

Dexilant 3 SLHelidac 3 SLNexium 3 SLOmeclamox-Pak 3 SLOmeprazole 1Pantoprazole 1Prevacid Capsules 3 SLPrevacid Solutab 3 SLPrevpac 3 SLPylera 3 SLRabeprazole 1 SLSucralfate Tablet 1Zegerid Capsule 3 SL

Gastrointestinal: Nausea/Vomiting

Ondansetron 1Ondansetron ODT 1Sancuso 3 SLZuplenz 3 SL

Gastrointestinal: Other

Amitiza 3 N, SLApriso 2Asacol HD Tablet 3Canasa 2Cortifoam 2Creon 2Delzicol 3Giazo 3Golytely 2Halflytely 3Hyoscyamine 1

Drug Name Drug Tier


Lialda 2Linzess 2 N, SLMetoclopramide 1Metozolv ODT 3Moviprep 3Pentasa 3Pertzye 3Polyethylene Glycol 3350

1

Prepopik 3Procort 3Suclear 3Sulfasalazine 1Suprep 3Uceris 3Ultresa 3Ursodiol 1Viokace 3Zenpep 2

HIV/AIDS

Atripla 2Complera 2Epzicom 2Intelence 2Isentress 2Kaletra 2Norvir 2Prezista 2Reyataz 2Stribild 3 NSustiva 2Truvada 2 NViread 2

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Drug Name Drug Tier


Infertility*

Cetrotide 2Gonal-F 2Gonal-F RFF 2Ovidrel 3*Coverage is determined by the consumer’s prescription drug benefit plan .

Men’s Health: Erectile Dysfunction

Cialis 3 SLStaxyn 3 SLViagra 3 SL

Men’s Health: Prostate

Alfuzosin 1Avodart 3 NDoxazosin 1Finasteride 1Jalyn 3Rapaflo 3Tamsulosin 1Terazosin 1

Men’s Health: Testosterone Therapy

Androderm 2 N, SLAndrogel 3 N, SLAndroid 2Axiron 3 N, SLDepo-Testosterone 3Fortesta 3 N, SLTestim 2 N, SLTestosterone Cypionate 1Testosterone Enanthate 1Testred 2

Drug Name Drug Tier


Miscellaneous

Anastrozole 1Antipyrine/Benzocaine 1Aranesp 2 SLAuvi-Q 3 SLBenzonatate 1Bethkis 1 N, SLBromfed DM 3Chlorhexidine Gluconate 1Ciprodex 2Epipen 2 SLEpipen-Jr 2 SLExemestane 1Fosrenol 2Hydrocodone/Chlorpheniramine

1 SL

Hydrocodone/Homatropine

1

Letrozole 1Lidocaine Transdermal Patch

1 SL

Nuedexta 2Pegasys 2 N, SLProcrit 2 SLPromethazine/Codeine 1Promethazine/Dextromethorphan

1

Pulmozyme 2 N, SLRectiv 3 N, SLRenvela 2Restasis 3 N, SLRezira 3Soltamox 3

20



Drug Name Drug Tier


Tamoxifen 1Tobi 3 N, SLTobi Podhaler 3 N, SLTobramycin Nebulized Solution

1 N, SL

Zonatuss 3Zutripro 3 SL

Musculoskeletal: Osteoporosis

Actonel 3 SLAlendronate Sodium 1 SLAtelvia 3 SLBinosto 3 SLEvista 2Forteo 2 NIbandronate 1 SL

Musculoskeletal: Other

Allopurinol 1Amrix 3Baclofen 1Carisoprodol 350 mg 1Colcrys 2Cyclobenzaprine 1Gralise 3 SLHorizant 3 SLLorzone 3 SLMethocarbamol 1Soma 250 3Tizanidine Tablet 1Uloric 3 SL

Drug Name Drug Tier


Musculoskeletal: Pain Relief

Abstral 3 N, SLAcetaminophen/Codeine

1 SL

Avinza 3 N, SLCelebrex 3 SLConzip 3 SLDiclofenac Sodium 1Duexis 3 SLDuragesic 3 SLEtodolac 1Exalgo 3 N, SLFentanyl Patches 1 SLFentora 3 N, SLFlector 3Hydrocodone/Acetaminophen

1 SL

Hydrocodone/Acetaminophen 5/300 mg, 7 .5/300 mg, 10/300 mg

1 SL

Hydrocodone/Ibuprofen 1Hydromorphone 1Ibuprofen 1Indomethacin 1Kadian 3 N, SLKetorolac 1Lazanda 3 N, SLMeloxicam 1Methadone 1

21

Drug Name Drug Tier


Morphine Sulfate Extended-Release Capsule

1 N, SL

Morphine Sulfate Extended-Release Tablet

1 SL

Nabumetone 1Naprelan 3Naproxen 1Nucynta 3 SLNucynta ER 3 N, SLOnsolis 3 N, SLOpana ER 2 N, SLOxycodone 1Oxycodone/Acetaminophen

1 SL

Oxycontin 2 N, SLOxymorphone Extended-Release

1 N, SL

Pennsaid 3Rybix ODT 3 SLSprix 3Subsys 3 N, SLTramadol 1Tramadol Extended-Release

1 SL

Tramadol Sustained-Release

1 SL

Vimovo 3 SLVoltaren Gel 2Zipsor 3Zolvit 3 SL

Drug Name Drug Tier


Musculoskeletal: Rheumatoid Arthritis

Cimzia 2 N, SLEnbrel 2 N, SLHumira 3 N, SLHydroxychloroquine Sulfate

1

Leflunomide 1Methotrexate 1Orencia 3 N, SLSimponi 2 N, SL

Overactive Bladder

Detrol 3Detrol LA 3Dicyclomine 1Enablex 3Gelnique 3Myrbetriq 3Oxybutynin 1Oxybutynin Extended-Release

1

Oxytrol 3Sanctura 3Sanctura XR 3Tolterodine 1Tolterodine Extended-Release

1

Toviaz 3Trospium 1Trospium Extended-Release

1

Vesicare 3

22



Drug Name Drug Tier


Respiratory: Allergies

Astepro 3 SLAzelastine 1 SLBeconase AQ 3 SLClarinex 3 SLClarinex-D 3 SLCyproheptadine 1Desloratadine 1 SLDymista 3 SLFlunisolide Spray 1Fluticasone Propionate 1 SLHydroxyzine 1Levocetirizine Tablet 1 SLNasacort AQ 3 SLNasonex 3 SLOmnaris 2 SLPromethazine 1Qnasl 3 SLRhinocort Aqua 3 SLTriamcinolone Spray 1 SLVeramyst 3 SLZetonna 2 SL

Respiratory: Asthma/COPD

Advair Diskus/HFA 3 SLAlbuterol Sulfate 1Alvesco 1 SLAsmanex 1 SLBreo Ellipta 3 SLBudesonide Nebs 1 SLCombivent Respimat 3 SL

Drug Name Drug Tier


Dulera 3 SLFlovent HFA 3 SLForadil 2 SLIpratropium 1Levalbuterol Nebs 1 SLMontelukast 1 SLPerforomist 3 SLProair HFA 3 SLProventil HFA 3 SLPulmicort Flexhaler 3 SLQVAR 1 SLSpiriva 2 SLSymbicort 3 SLTudorza 2 SLVentolin HFA 1 SLXopenex HFA 3 SLXopenex Nebs 3 SLRespiratory: Pulmonary Arterial HypertensionAdcirca 3 N, SLLetairis 2 N, SLRevatio 3 N, SLSildenafil 1 N, SLTracleer 2 N, SLTyvaso 2 N

23

Drug Name Drug Tier


Transplant

Azathioprine 1Cellcept 3Cyclosporine Modified 1Mycophenolate 1Mycophenolic Acid 1Myfortic 3Neoral 3Prograf 3Rapamune 3Sirolimus 1Tacrolimus 1

Vitamins/Electrolytes

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

Women’s Health: Contraceptives

Altavera 1Amethia 1Apri 1Aviane 1Azurette 1Beyaz 3Camrese 1Cryselle 1Cyclafem 1Emoquette 1Enpresse 1Generess Fe 3Gianvi 1Gildess Fe 1Jolessa 1Jolivette 1Junel 1Junel Fe 1

Drug Name Drug Tier


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

1

Norgestimate-Ethinyl Estradiol

1

Nortrel 0 .5/35 1Nuvaring 2Orsythia 1Ortho Evra 3Ortho Micronor 3Ortho Tri-Cyclen 3Ortho Tri-Cyclen Lo 3Ortho-Cyclen 3Ortho-Novum 3Portia 1Previfem 1Quasense 1Reclipsen 1Safyral 3Sprintec 1Syeda 1Trinessa 1Tri-Previfem 1Tri-Sprintec 1Trivora-28 1Viorele 1Yasmin 28 3Yaz 3Zovia 1-35E 1

24



Drug Name Drug Tier


Women’s Health: Hormone Replacement

Cenestin 2Climara 2 SLClimara Pro 3 SLDivigel 2Enjuvia 2Estrace Cream 2Estradiol 1Estradiol/Norethindrone Acetate

1

Estring 2 SLEstrogen/Methyltestosterone

1

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

1

Vagifem 2Vivelle-Dot 2 SL

Drug Name Drug Tier


Women’s Health: Prenatal Vitamins

Brand Prenatal Vitamins 3

Prenatal Plus 1

25

Index

A

Abilify ....................................14Absorica ................................. 15Abstral ................................... 20Acanya ................................... 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 .............................. 13Acetaminophen/Codeine ....... 20Actonel .................................. 20Acuvail ...................................17Acyclovir Ointment ................10Acyclovir Tablet .....................10Aczone ................................... 15Adapalene .............................. 15Adcirca .................................. 22Adderall XR .......................... 12Adoxa Capsule ........................10Advair Diskus/HFA .............. 22Albuterol Sulfate ................... 22Alendronate Sodium ............. 20Alfuzosin ................................19Allopurinol ............................ 20Alphagan P 0.1% ....................17Alprazolam .............................14Alprazolam

Extended-Release ................14Alsuma .................................. 13Altavera ................................. 23

Altoprev ................................. 12Alvesco .................................. 22Ambien CR ............................14Amethia................................. 23Amiodarone ........................... 12Amitiza...................................18Amitriptyline ......................... 13Amlodipine ............................11Amlodipine/Telmisartan ........11Amlodipine

Besylate-Benazepril .............11Amoxicillin .............................10Amoxicillin/Potassium

Clavulanate ..........................10Amphetamine Salt Combo .... 12Ampyra.................................. 13Amrix .................................... 20Amturnide ..............................11Anastrozole ............................19Androderm .............................19Androgel.................................19Android ..................................19Antipyrine/Benzocaine ..........19Aplenzin ................................ 13Apri ....................................... 23Apriso .....................................18Aranesp ..................................19Aricept 23 mg .........................14Armour Thyroid .....................17Asacol HD Tablet ..................18Asmanex ................................ 22Astepro .................................. 22Atelvia ................................... 20Atenolol ..................................11Atenolol-Chlorthalidone ........11Atorvastatin ........................... 12Atripla ....................................18Aubagio ................................. 13Augmentin XR .......................10Auvi-Q ...................................19Aviane ................................... 23Avinza ................................... 20

Avodart ...................................19Avonex ................................... 13Axiron ....................................19Azathioprine .......................... 23Azelastine ......................... 17, 22Azelex .................................... 15Azithromycin .........................10Azopt ......................................17Azor .......................................11Azurette ................................ 23

B

Baclofen ................................. 20Baraclude ................................10Beconase AQ ......................... 22Benazepril...............................11Benazepril-

Hydrochlorothiazide ............11Benicar ...................................11Benicar HCT .........................11Benzaclin ............................... 15Benzonatate ............................19Bepreve ...................................17Betamethasone Dipropionate

Cream, Lotion, Ointment .. 15Betamethasone

Valerate Foam ..................... 15Betaseron ............................... 13Bethkis ...................................19Beyaz ..................................... 23Bidil ........................................11Binosto .................................. 20Bisoprolol ................................11Bisoprolol-

Hydrochlorothiazide ............11Bosulif ....................................10Brand Prenatal Vitamins ....... 24Breo Ellipta ........................... 22Bromday .................................17Bromfed DM ..........................19Budesonide Nebs ................... 22

26

Buprenorphine/Naloxone Tablet ...................................14

Bupropion .............................. 13Bupropion

Extended-Release ............... 13Bupropion

Sustained-Release ............... 13Buspirone ................................14Bydureon ................................16Byetta .....................................16Bystolic ...................................11

C

Caduet ................................... 12Calcitriol .................................17Cambia .................................. 13Camrese ................................. 23Canasa ....................................18Carac ..................................... 15Carbamazepine .......................14Carbidopa-Levodopa ..............14Carisoprodol 350 mg ............. 20Cartia XT ...............................11Carvedilol ...............................11Cefdinir ..................................10Cefuroxime .............................10Celebrex ................................. 20Cellcept ................................. 23Cenestin ................................ 24Centany AT ............................10Cephalexin .............................10Cetrotide ................................19Chlorhexidine Gluconate ........19Chlorthalidone .......................11Choline Fenofibrate ............... 12Cialis ......................................19Ciclopirox Cream, Gel,

Lotion, Solution ................. 15Cimzia ....................................21Ciprodex .................................19Ciprofloxacin Tablet ...............10Citalopram ............................. 13Claravis .................................. 15Clarinex ................................. 22

Clarinex-D ............................ 22Clarithromycin Tablet ............10Climara.................................. 24Climara Pro ........................... 24Clindagel ............................... 15Clindamycin .....................10, 15Clindamycin 1%/Benzoyl

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

Peroxide 5% ........................ 15Clindamycin Gel, Lotion,

Solution, Swabs .................. 15Clobetasol Propionate Cream,

Lotion, Ointment, Solution 15Clobex Shampoo ................... 15Cloderm ................................ 15Clonazepam ............................14Clonidine Extended-Release

Tablet .................................. 12Clonidine Tablet .....................11Clopidogrel .............................11Clotrimazole-Betamethasone

Cream, Lotion .................... 15Colcrys .................................. 20Combigan ...............................17Combivent Respimat ............. 22Complera ................................18Concerta ................................ 12Condylox Gel ........................ 15Contour Test Strips ................16Conzip ................................... 20Copaxone 20 mg ................... 13Coreg CR ...............................11Cortifoam ...............................18Cosopt PF ..............................17Coumadin...............................11Creon ......................................18Crestor ............................... 8, 12Cryselle .................................. 23Cyclafem ............................... 23Cyclobenzaprine .................... 20Cyclosporine Modified .......... 23Cyproheptadine ..................... 22

D

Daytrana ................................ 12Delzicol ..................................18Depakote ................................14Depakote ER ..........................14Depo-Testosterone ..................19Desloratadine......................... 22Desmopressin .........................17Desonide Cream, Lotion,

Ointment ............................ 15Desvenlafaxine ...................... 13Detrol .....................................21Detrol LA...............................21Dexamethasone ......................17Dexilant ..................................18Dexmethylphenidate .............. 12Dexmethylphenidate

Extended-Release Capsule . 12Dextroamphetamine-

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

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

Dextroamphetamine Sulfate .. 12Diazepam ...............................14Diclofenac Sodium ................ 20Dicyclomine ...........................21Differin .................................. 15Dificid ....................................10Digoxin ................................. 12Diltiazem 24 Hour CD ..........11Diltiazem Sustained-Release

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

Tablet ...................................11Diovan ....................................11Divalproex ..............................14Divalproex Extended-Release .14Divigel ................................... 24Donepezil 5, 10 mg ................14Doryx .....................................10Dorzolamide-Timolol .............17Doxazosin .........................11, 19Doxepin ................................. 13

27

Doxycycline Capsule, Tablet ..10Doxycycline Hyclate

Capsule, Tablet ....................10Duac ...................................... 15Duexis ................................... 20Dulera .................................... 22Duloxetine ............................. 13Duragesic ............................... 20Dutoprol .................................11Dymista ................................. 22

E

Edarbi .....................................11Edarbyclor ..............................11Edluar .....................................14Effient ....................................11Elestat .....................................17Eliquis ....................................11Emadine .................................17Emoquette ............................. 23Enablex ...................................21Enalapril .................................11Enalapril-

Hydrochlorothiazide ............11Enbrel .....................................21Enjuvia .................................. 24Enoxaparin Sodium ................11Enpresse ................................ 23Epiduo ................................... 15Epipen ....................................19Epipen-Jr ................................19Epzicom .................................18Erythromycin .........................17Escitalopram .......................... 13Estrace Cream ....................... 24Estradiol .......................... 23, 24Estradiol/Norethindrone

Acetate ................................ 24Estring ................................... 24Estrogen/

Methyltestosterone ............. 24Etodolac ................................ 20Evamist .................................. 24Evista ..................................... 20

Exalgo ................................... 20Exemestane.............................19Exforge ...................................11Exforge HCT .........................11Extavia................................... 13

F

Felodipine ...............................11Fenofibrate 48, 145 mg .......... 12Fenofibrate 54, 160 mg .......... 12Fenofibrate Micronized

43, 130 mg .......................... 12Fenoglide ............................... 12Fentanyl Patches .................... 20Fentora ................................... 20Finacea .................................. 15Finasteride ..............................19Flecainide .............................. 12Flector ................................... 20Flovent HFA ......................... 22Fluconazole.............................10Flunisolide Spray ................... 22Fluocinonide 0.05% Cream,

Ointment, Solution ............. 15Fluocinonide 0.1% Cream ..... 15Fluoride ................................. 23Fluoxetine .............................. 13Fluticasone Propionate .......... 22Fluvoxamine .......................... 13Focalin XR ............................ 12Folic Acid .............................. 23Foradil ................................... 22Forfivo XL ............................. 13Forteo .................................... 20Fortesta ...................................19Fosinopril Sodium ..................11Fosrenol ..................................19Freestyle Test Strips................16Furosemide .............................11

G

Gabapentin .............................14Gelnique .................................21Gemfibrozil ........................... 12

Generess Fe ........................... 23Genotropin .............................17Gianvi .................................... 23Giazo ......................................18Gildess Fe .............................. 23Gilenya .................................. 13Gleevec ...................................10Glimepiride ............................16Glipizide .................................16Glipizide Extended-Release ...16Glumetza ................................16Glyburide................................16Glyburide-Metformin ............16Golytely ..................................18Gonal-F ..................................19Gonal-F RFF .........................19Gralise ................................... 20Guanfacine .............................11

H

Halflytely ................................18Helidac ...................................18Horizant ................................ 20Humalog KwikPen .................16Humalog Mix 75-25

KwikPen ..............................16Humalog Vials .......................16Humatrope .............................17Humira ...................................21Humulin 70-30 Vials .............16Humulin KwikPen .................16Humulin N KwikPen .............16Humulin N Vials ....................16Humulin R Vials ....................16Hydralazine ............................11Hydrochlorothiazide ...............11Hydrocodone/

Acetaminophen .................. 20Hydrocodone/Acetaminophen

5/300 mg, 7.5/300 mg, 10/300 mg .......................... 20

Hydrocodone/Chlorpheniramine ...............19

Hydrocodone/Homatropine ...19

28

Hydrocodone/Ibuprofen ........ 20Hydrocortisone Butyrate

Cream ................................. 15Hydrocortisone Cream,

Ointment ............................ 15Hydromorphone .................... 20Hydroxychloroquine Sulfate ...21Hydroxyurea ...........................10Hydroxyzine .......................... 22Hyoscyamine ..........................18

I

Ibandronate ........................... 20Ibuprofen ............................... 20Ilevro ......................................17Imipramine ............................ 13Incivek ....................................10Indapamide .............................11Indomethacin ........................ 20Intelence .................................18Intermezzo .............................14Intuniv ................................... 12Ipratropium............................ 22Irbesartan ...............................11Isentress ..................................18Isosorbide Mononitrate ER ... 12Itraconazole ............................10

J

Jalyn ........................................19Janumet ..................................16Januvia ....................................16Jentadueto ...............................16Jolessa .................................... 23Jolivette .................................. 23Junel ....................................... 23Junel Fe .................................. 23

K

Kadian ................................... 20Kaletra ....................................18Kapvay ................................... 12Kariva .................................... 23Kazano ...................................16Keppra ....................................14

Keppra XR .............................14Keralyt Scalp Kit ................... 15Ketoconazole ..........................10Ketorolac ............................... 20Klor-Con M10 ...................... 23Klor-Con M20 ...................... 23Kombiglyze XR ......................16

L

Labetalol .................................11Lamictal .................................14Lamictal XR ...........................14Lamotrigine ............................14Lantus Solostar .......................16Lantus Vials ...........................16Lastacaft .................................17Latanoprost ............................17Latuda ....................................14Lazanda ................................. 20Leflunomide ...........................21Letairis .................................. 22Letrozole ................................19Leucovorin Calcium ...............10Levalbuterol Nebs .................. 22Levemir Flexpen ....................16Levemir Vials .........................16Levetiracetam .........................14Levetiracetam

Extended-Release ................14Levocetirizine Tablet ............. 22Levofloxacin ...........................10Levora-28 .............................. 23Levothyroxine Sodium ...........17Levoxyl ...................................17Lialda .....................................18Lidocaine Transdermal

Patch ....................................19Linzess ...................................18Liothyronine Sodium .............17Lipofen .................................. 12Liptruzet ............................... 12Lisinopril ..........................11, 34Lisinopril-

Hydrochlorothiazide ............11

Lithium ..................................14Livalo .................................... 12Lo Loestrin Fe ...................... 23Locoid Lipocream ................. 15Locoid Lotion ....................... 15Lorazepam..............................14Loryna ................................... 23Lorzone ................................. 20Losartan .................................11Losartan-

Hydrochlorothiazide ............11Lotemax Gel ..........................17Lotemax Solution ...................17Lovastatin .............................. 12Lovaza ................................... 12Low-Ogestrel ........................ 23Lumigan .................................17Lunesta ...................................14Lutera .................................... 23Luxiq ..................................... 15Lyrica .....................................14

M

Medroxyprogesterone ............ 24Meloxicam ............................. 20Mercaptopurine ......................10Metadate CD ........................ 13Metformin ..............................16Metformin

Extended-Release ................16Methadone ............................ 20Methimazole ..........................17Methocarbamol ..................... 20Methotrexate ..........................21Methylphenidate .................... 13Methylphenidate

Extended-Release Capsule . 13Methylphenidate

Extended-Release Tablet .... 13Methylprednisolone ................17Metoclopramide .....................18Metoprolol Succinate

50, 100, 200 mg ...................11Metoprolol Tartrate ................11

29

Metozolv ODT ......................18Metrogel 1% .......................... 15Metronidazole ..................10, 15Metronidazole Gel 0.75% ...... 15Metronidazole Gel 1% ........... 15Micardis HCT .......................11Microgestin ........................... 23Microgestin FE ..................... 23Minastrin 24 FE ................... 23Minivelle ............................... 24Minocycline Capsule, Tablet ..10Mirapex ER ............................14Mirtazapine ........................... 13Modafinil ...............................14Mometasone Furoate Cream,

Lotion, Ointment ............... 15Mononessa ............................. 23Montelukast ........................... 22Morphine Sulfate

Extended-Release Capsule ..21Morphine Sulfate

Extended-Release Tablet .....21Moviprep ................................18Multaq ................................... 12Mupirocin Ointment ............. 15Mycophenolate ...................... 23Mycophenolic Acid ................ 23Myfortic ................................ 23Myrbetriq ...............................21

N

Nabumetone ...........................21Nadolol ...................................11Naprelan .................................21Naproxen ................................21Nasacort AQ .......................... 22Nasonex ................................. 22Natazia .................................. 23Necon 0.5/35, 1/35,

1/50, 10/11 .......................... 23Neoral .................................... 23Nesina .....................................17Neurontin ...............................14Nexiclon XR ...........................11

Nexium ...................................18Niacin Extended-Release

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

Spray ................................... 12Nitrolingual Pump Spray ...... 12Norditropin.............................17Norgestimate-Ethinyl

Estradiol ............................. 23Nortrel 0.5/35 ........................ 23Nortriptyline ......................... 13Norvir .....................................18Novolog ..................................16Novolog Flexpen ....................16NP Thyroid ............................17Nucynta ..................................21Nucynta ER ............................21Nuedexta ................................19Nutropin AQ NuSpin .............17Nuvaring................................ 23Nuvigil....................................14Nystatin ..................................10Nystatin-Triamcinolone

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

O

Ofloxacin ................................17Olanzapine .............................14Oleptro .................................. 13Olysio .....................................10Omeclamox-Pak .....................18Omeprazole ............................18Omnaris ................................ 22Omnitrope ..............................17Ondansetron ...........................18Ondansetron ODT .................18One Touch Test Strips ............16One Touch Ultra Mini ...........16One Touch Ultra Test Strips ..16

One Touch Verio IQ ...............16One Touch Verio IQ

Test Strips ............................16Onglyza ..................................17Onmel ....................................10Onsolis ...................................21Opana ER ..............................21Oracea ....................................10Orencia ...................................21Orsythia ................................ 23Ortho-Cyclen ........................ 23Ortho-Novum ....................... 23Ortho Evra ............................ 23Ortho Micronor .................... 23Ortho Tri-Cyclen .................. 23Ortho Tri-Cyclen Lo............. 23Oseni ......................................17Ovidrel ...................................19Oxcarbazepine ........................14Oxsoralen-Ul ......................... 15Oxtellar XR ........................... 15Oxybutynin ............................21Oxybutynin

Extended-Release ................21Oxycodone .............................21Oxycodone/Acetaminophen ...21Oxycontin ...............................21Oxymorphone Extended-

Release .................................21Oxytrol ...................................21

P

Pantoprazole ...........................18Paroxetine .............................. 13Pataday ...................................17Patanol ....................................17Pegasys ...................................19Penicillin V Potassium ............10Pennsaid .................................21Pentasa ....................................18Perforomist ............................ 22Pertzye ....................................18Phenytoin .............................. 15Picato ..................................... 15

30

Pioglitazone ............................17Pioglitazone-Metformin .........17Polyethylene Glycol 3350 ........18Polymyxin B Sulfate/

Trimethoprim ......................17Portia ..................................... 23Potassium Chloride ............... 23Potassium Citrate .................. 23Pradaxa ...................................11Pramipexole ............................14Prandimet ...............................17Prandin ...................................17Pravastatin ............................. 12Prednisolone ...........................17Prednisone ..............................17Premarin ................................ 24Prempro ................................. 24Prenatal Plus .......................... 24Prepopik .................................18Prevacid Capsules ...................18Prevacid Solutab .....................18Previfem ................................ 23Prevpac ...................................18Prezista ...................................18Pristiq ER .............................. 13Proair HFA ........................... 22Procort ....................................18Procrit .....................................19Progesterone Micronized

Capsule ............................... 24Prograf ................................... 23Prolensa ..................................17Promethazine....................19, 22Promethazine/Codeine ...........19Promethazine/

Dextromethorphan ..............19Propranolol .............................11Protopic ................................. 15Proventil HFA ....................... 22Provigil ...................................14Pulmicort Flexhaler ............... 22Pulmozyme ............................19Pylera ......................................18

Q

Qnasl ..................................... 22Quasense ............................... 23Quetiapine ..............................14Quillivant XR ........................ 13Quinapril ................................11QVAR ................................... 22

R

Rabeprazole ............................18Ramipril .................................11Ranexa ................................... 12Rapaflo ...................................19Rapamune ............................. 23Rayos ......................................17Rebif ...................................... 13Reclipsen ............................... 23Rectiv .....................................19Relpax .................................... 13Renvela ...................................19Repaglinide ............................17Requip XL ..............................14Restasis ...................................19Retin-A Micro ....................... 15Revatio .................................. 22Reyataz ...................................18Rezira .....................................19Rhinocort Aqua ..................... 22Ribapak ..................................10Ribavirin .................................10Risperidone ............................14Ritalin LA ............................. 13Rizatriptan Orally

Disintegrating Tablet .......... 13Rizatriptan Tablet.................. 13Ropinirole ...............................14Rybix ODT ............................21

S

Safyral ................................... 23Saizen .....................................17Sanctura .................................21Sanctura XR ...........................21Sancuso ...................................18

Seroquel XR ...........................14Sertraline ............................... 13Sildenafil................................ 22Silenor ....................................14Simbrinza ...............................17Simcor ................................... 12Simponi ..................................21Simvastatin ........................ 8, 12Sirolimus ............................... 23Sodium

Sulfacetamide-Sulfur .......... 15Solodyn ...................................10Soltamox .................................19Soma 250 ............................... 20Sorilux ................................... 15Sotalol.................................... 12Spiriva ................................... 22Spironolactone ........................11Sprintec ................................. 23Sprix .......................................21Staxyn.....................................19Stelara .................................... 15Strattera ................................. 13Stribild ....................................18Suboxone Film .......................14Subsys .....................................21Suclear ....................................18Sucralfate Tablet .....................18Sulfamethoxazole-

Trimethoprim ......................10Sulfasalazine ...........................18Sumadan ................................ 15Sumatriptan Nasal Spray ....... 13Sumatriptan Succinate

Tablet, Injection .................. 13Sumavel DosePro .................. 13Sumaxin CP .......................... 15Sumaxin TS .......................... 15Suprep ....................................18Sustiva ....................................18Sutent .....................................10Syeda ..................................... 23Symbicort .............................. 22Synthroid ................................17

31

T

Taclonex ................................ 15Tacrolimus ............................. 23Tamiflu ...................................10Tamoxifen.............................. 20Tamsulosin .............................19Tasigna ...................................10Tasmar ....................................14Tecfidera ................................ 13Tekamlo ..................................11Telmisartan.............................11Temazepam ............................14Terazosin ..........................11, 19Terbinafine .............................10Testim .....................................19Testosterone Cypionate ...........19Testosterone Enanthate ..........19Testred ....................................19Tev-Tropin ..............................17Timolol Maleate .....................17Tirosint ...................................17Tizanidine Tablet .................. 20Tobi ....................................... 20Tobi Podhaler ........................ 20Tobradex ST ...........................17Tobramycin/Dexamethasone ..17Tobramycin Nebulized

Solution .............................. 20Tolterodine .............................21Tolterodine

Extended-Release ................21Topamax ................................ 15Topiramate ............................ 15Torsemide ...............................11Toviaz .....................................21Tracleer .................................. 22Tradjenta.................................17Tramadol ................................21Tramadol Extended-Release ...21Tramadol Sustained-Release ...21Travatan Z ..............................17Trazodone .............................. 13Tretinoin ................................ 15Tretinoin Microspheres ......... 15

Treximet ................................ 13Tri-Previfem .......................... 23Tri-Sprintec ........................... 23Triamcinolone Acetonide

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

Hydrochlorothiazide ............11Trianex .................................. 15Tribenzor ................................11Tricor 48 mg, 145 mg ............ 12Trileptal ................................. 15Trilipix ................................... 12Trinessa ................................. 23Trivora-28 .............................. 23Trokendi XR ......................... 15Trospium ................................21Trospium Extended-Release ...21Truvada ..................................18Tudorza ................................. 22Twynsta ................................. 12Tyvaso ................................... 22

U

Uceris ......................................18Uloric ..................................... 20Ultresa ....................................18Umecta .............................15, 16Umecta PD .............................16Uramaxin GT .........................16Ursodiol ..................................18

V

Vagifem ................................. 24Valacyclovir ............................10Valsartan-

Hydrochlorothiazide ........... 12Vanos ......................................16Vascepa .................................. 12Vectical ...................................16Veltin ......................................16Venlafaxine ............................ 13Venlafaxine Extended-Release

Capsule ............................... 13

Venlafaxine Extended-Release Tablet .................................. 13

Ventolin HFA ........................ 22Veramyst ................................ 22Verapamil .............................. 12Verapamil

Sustained-Release ............... 12Verdeso ...................................16Vesicare ...................................21Viagra .....................................19Victoza ...................................17Viibryd .................................. 13Vimovo ...................................21Viokace ...................................18Viorele ................................... 23Virasal ....................................16Viread .....................................18Vivelle-Dot ............................ 24Voltaren Gel ...........................21Vytorin .................................. 12Vyvanse ................................. 13

W

Warfarin Sodium ...................11Welchol ................................. 12

X

Xarelto ....................................11Xeloda ....................................10Xerese .....................................16Xopenex HFA ....................... 22Xopenex Nebs ........................ 22Xyrem .....................................14

Y

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

Z

Zaleplon .................................14Zegerid Capsule .....................18Zelapar ...................................14Zenpep ...................................18Zenzedi ................................. 13Zetia ...................................... 12

32

Zetonna ................................. 22Ziana ......................................16Ziprasidone .............................14Zipsor .....................................21Zolpidem ................................14Zolpidem Extended-Release ...14Zolpimist ................................14

Zolvit ......................................21Zonatuss ................................ 20Zonegran ............................... 15Zonisamide ............................ 15Zovia 1-35E ........................... 23Zovirax Cream .......................10Zubsolv ...................................14

Zuplenz ..................................18Zutripro ................................. 20Zyclara ....................................16Zytiga .....................................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

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

© 2014 United HealthCare Services, Inc . All rights reserved . Created April, 2014 . 2014 Prescription Drug List – DC Government Employees Traditional Three-Tier 7/14

For more information

Call 1-800-603-3923.

Or, visit myuhc.com®

Documents

DC Government Employees Traditional Three-Tier myuhc