Your 2016 Formulary - myuhc.com · 1 Your 2016 Formulary SignatureValue Three-Tier effective July 1, 2016 Please read: This document contains information about commonly prescribed

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Your 2016 FormularySignatureValue Three-Tiereffective July 1, 2016

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® or optumrx.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 FormularyThis Formulary outlines the most commonly prescribed medications for certain conditions and organizes them into coverage levels. An important part of the Formulary 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 Formulary may change, we encourage you to visit our website, myuhc.com or optumrx.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. The complete formulary is also publicly available here on optumrx.com and is updated on a monthly basis.

https://www.optumrx.com/ClientFormulary/formulary.asp?var=PHSCA&infoid=PHSCA

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Table of Contents

Drug coverage levels and cost . . . . . . . . . . .5

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

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

Anti-InfectivesAntibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Cardiovascular/Heart DiseaseCoagulation Therapy . . . . . . . . . . . . . . . . . . . . . . . .11High Blood Pressure . . . . . . . . . . . . . . . . . . . . . . . .11High Cholesterol . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Central Nervous SystemAttention Deficit Disorder . . . . . . . . . . . . . . . . . . . 14Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Sedatives/Hypnotics . . . . . . . . . . . . . . . . . . . . . . . 16Seizure Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Diabetes/EndocrineBlood Glucose Monitoring . . . . . . . . . . . . . . . . . . 18Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Non-Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

EndocrineGrowth Hormone . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Thyroid Hormone Replacement . . . . . . . . . . . . . 19

Eye ConditionsAllergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

GastrointestinalAcid Suppression . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Nausea/Vomiting . . . . . . . . . . . . . . . . . . . . . . . . . . 20Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Inflammatory Conditions: Rheumatoid Arthritis, Crohn’s Disease, Psoriasis, Ulcerative Colitis . . . . . . . . . . . . . . . . . . . . . . . . 22

Men’s HealthErectile Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . 22Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Testosterone Therapy . . . . . . . . . . . . . . . . . . . . . . 22

Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

MusculoskeletalOsteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Pain Relief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Overactive Bladder . . . . . . . . . . . . . . . . . . . . . . 25

RespiratoryAsthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Nasal Allergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Oral Allergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Pulmonary Arterial Hypertension . . . . . . . . . . . . 26

Transplant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Vitamins/Electrolytes . . . . . . . . . . . . . . . . . . . 26

Women’s HealthContraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Hormone Replacement . . . . . . . . . . . . . . . . . . . . . 28Prenatal Vitamins . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

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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 Formulary.

What is a Formulary? This document is a list of commonly prescribed medications. Drugs are listed by common categories or class. 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 Formulary 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 optumrx.com or call the toll-free member phone number on your health plan ID card for more information.

How do I use my Formulary List? When choosing a medication, you and your doctor should consult the Formulary. 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 optumrx.com or call the toll-free member phone number on your health plan ID card.

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What are Coverage Levels? Coverage Levels are the different cost levels you pay for a medication. Each level 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. Formulary Generic medications are your lowest-cost options. If your medication is placed in Formulary Brand or Non-Formulary levels, look to see if there is a Formulary Generic option available. Discuss these options with your doctor.

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

$ Coverage Level Includes Helpful Tips

Formulary Generic Lowest Cost

Lower-cost drugs . Some low-cost brands are also included .

Use Formulary Generic drugs for the lowest out-of-pocket costs .

Formulary Brand Mid-range Cost

Cost effective brand drugs .

Use Formulary Brand drugs, instead of Non-Formulary to help reduce your out-of-pocket costs .

Non-Formulary Highest Cost

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

Many Non-Formulary drugs have lower-cost options in Formulary Generic or Brand levels . Ask your doctor if they could work for you .

Please note: Some plans may have two or four coverage levels, while others may not have any. If you have a high deductible plan, the coverage cost levels may apply once you hit your deductible. Refer to your enrollment and plan materials on myuhc.com or optumrx.com, or call the toll-free number on your health plan ID card for more information about your benefit plan.

When does the Formulary List change?• Medications may move to a lower level at any time.

• Medications may move to a higher level when its generic becomes available.

• Medications may move to a higher level most often on January 1 or July 1.

When a medication changes levels, 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 may be covered for you.

AEAge Edit – This medication applies to a specific age group . Members outside of this age group need to meet specific criteria for approval .

EExceptions required for select markets in California and Oklahoma. Your doctor is required to provide additional information to UnitedHealthcare to verify medical necessity of certain medications .

FB Formulary Brand

FG Formulary Generic

GEGender Edit – This medication is covered only for specific gender based on FDA approved indications .

HHealth Care Reform Preventive – This medication is part of a Health Care Reform preventive benefit and may be available at no cost to you .

M Medical – The medication may be covered under medical with Prior Authorization .

NFNon-Formulary – Non-formulary drugs are available on your highest Cost Tier (Tier 3) .

PAPrior Authorization required – Your doctor is required to provide additional information to UnitedHealthcare to determine coverage .

QLQuantity 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 .

To learn more about a pharmacy program or to find out if it applies to you, please visit myuhc.com or optumrx.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 as defined by your Pharmacy Schedule of Benefits. 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. For some benefit plans if a brand-name drug is prescribed and a generic equivalent is available, your cost share may be the copay PLUS the cost difference between the brand-name drug and generic equivalent. Visit myuhc.com or optumrx.com to make sure.

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

Log on to optumrx.com for the following pharmacy information and tools:

• Pharmacy benefit and coverage information

• Possible lower-cost medication options

• A list of medications based on a specific medical condition

• 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

Medications are categorized by common therapeutic conditions in this Formulary 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


Or, visit myuhc.com or optumrx.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]

AE = Age EditE = Exceptions requiredFB = Formulary Brand

FG = Formulary Generic GE = Gender EditH = Health Care Reform PreventiveM = Medical

NF = Non-FormularyPA = Prior Authorization requiredQL = Quantity LimitST = Step Therapy

Drug NameCoverage Level

Requirements& Limits

Anti-Infectives: Antibiotics

Amoxicillin FGAmoxicillin/Potassium Clavulanate

FG

Antipyrine/Benzocaine Otic

FG

Azithromycin FGBethkis FBCefaclor Suspension FBCefaclor Tablet FGCefadroxil FG QLCefdinir FGCefpodoxime FGCefprozil FGCefuroxime FGCephalexin FGChloroxylenol/Hydrocortisone/Pramoxine Otic

FG

Ciprofloxacin FGClarithromycin IR/ER FGCleocin Vaginal Suppository

FB

Clindamycin FGClindesse NFDapsone FBDemeclocycline FGDicloxacillin FGDoxycycline Hyclate FGDoxycycline Monohydrate Tablet

FG QL

Erythromycin FGErythromycin/Sulfisoxazole

FG

Ethambutol FGIsoniazid FGLevofloxacin FG



Linezolid Tablet FG QLMethenamine FGMetronidazole Tablet FGMinocycline FGMycobutin FBNebuPent Nebs FB QLNeomycin FGNeomycin/Polymixin/Hydrocortisone Otic

FG

Nitrofurantoin FGNitrofurantoin Macrocrystal

FG

Ofloxacin Otic FGOracea NF QLParomomycin FGPenicillin VK FGPramoxine-HC Otic FGPyrazinamide FGRifampin FGSolodyn NF QLSulfadiazine FGSulfamethoxazole/Trimethoprim, Sulfamethoxazole/Trimethoprim DS

FG

Tetracycline FGTobi NF QL, STTrimethoprim FGZmax FB

Anti-Infectives: Antifungals

Clotrimazole Troche FGCresemba NFFluconazole FGGriseofulvin FGItraconazole FG PAKetoconazole Cream, Shampoo

FG

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Metronidazole Vaginal Gel

FG

Nystatin FGTerbinafine FG QLTerconazole FG QLVandazole Gel FG

Anti-Infectives: Antivirals

Acyclovir FGAdefovir FGAmantadine Capsule, Syrup

FG

Baraclude NF E, QLDaklinza FB PA, QLEntecavir FG QLEpivir HBV Solution FBFamciclovir FGHarvoni FB PA, QLLamivudine FGOlysio NF PA, QLPegasys MRibavirin Tablet FG PARimantidine FGSovaldi FB PA, QLValacyclovir FG QLValcyte Solution FBValganciclovir Tablet FG QLViekira Pak NF PA, QLZovirax Cream FB EZovirax Ointment NF E

Cancer

Alkeran FBBexarotene FG PABicalutamide FGCapecitabine FGCaprelsa FB PA, QLCyclophosphamide FGEmcyt FBEtoposide FGErivedge FB PA, QLExemestane FGFareston FBFlutamide FGHexalen FB



Hydroxyurea FGImatinib FG PA, QLLetrozole FG PALeucovorin Calcium FGLeukeran FBLomustine FGLysodren FBMatulane FBMercaptopurine FGMyleran FBNilandrone FBTabloid FBTasigna FB PA, QLTemozolomide FG PATretinoin Capsule FGTykerb FB PAXeloda NF EZytiga NF PACardiovascular/Heart Disease: Coagulation TherapyAggrenox NFBrilinta FB QLClopidogrel FG QLDisopyramide FGEffient FB QLEliquis NF QLJantoven FGPradaxa FB QLSavaysa NF QLTiclopidine FG QLWarfarin FGXarelto FB QLCardiovascular/Heart Disease: High Blood PressureAcebutolol FGAcetazolamide FGAcetazolamide ER FGAfeditab CR FGAldactazide 25/25 mg FBAmiloride FGAmiloride/ Hydrochlorothiazide

FG

Amlodipine FG QLAmlodipine/Benazepril FG QLAtenolol FG

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Atenolol/Chlorthalidone

FG

Azor FB QL, STBenazepril FGBenazepril/Hydrochlorothiazide

FG

Benicar FB QL, STBenicar HCT FB QL, STBetaxolol FGBisoprolol FGBisoprolol/Hydrochlorothiazide

FG

Bumetanide FGBystolic FB QLCaptopril FGCaptopril/ Hydrochlorothiazide

FG

Cartia XT FGCarvedilol FGChlorothiazide FGChlorthalidone FGClonidine Tablet FGClorpres NFDilatrate SR FBDiltiazem Sustained-Release Capsule

FG

Diltiazem Tablet FGDiovan NF E, QL, STDoxazosin FGDutoprol FB QLEdarbi NF E, QL, STEdarbyclor NF QL, STEnalapril FGEnalapril/Hydrochlorothiazide

FG

Eprosartan FG QLExforge NF E, QL, STExforge HCT NF E, QL, ST



Ezide FGFelodipine FG QLFosinopril FGFosinopril/Hydrochlorothiazide

FG

Furosemide FGGuanfacine FGHydralazine FGHydrochlorothiazide FGIndapamide FGIrbesartan FG QLIrbesartan/Hydrochlorothiazide

FG QL

Isradipine FGLabetalol FGLisinopril FGLisinopril/Hydrochlorothiazide

FG

Losartan FG QLLosartan/Hydrochlorothiazide

FG QL

Methazolamide FGMethyclothia FGMethyldopa FGMethyldopa/Hydrochlorothiazide

FG

Metolazone FGMetoprolol Succinate ER

FG

Metoprolol Tartrate FGMicardis HCT FB E, QL, STMinoxidil FGMoexipril FGMoexipril/Hydrochlorothiazide

FG

Nadolol FGNicardipine FGNifediac CC FG

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Nifedical XL FGNifedipine IR/ER FGPerindopril FGPhenoxybenzamine FGPindolol FGPrazosin FGPropranolol/Hydrochlorothiazide

FG

Propranolol IR/ER FGQuinapril FGRamipril FG QLReserpine FGSotalol FGSotalol AF FGSpironolactone FGSpironolactone/Hydrochlorothiazide

FG

Taztia XT FGTekturna FB QL, STTekturna HCT FB QL, STTelmisartan FB QLTerazosin FG QLTimolol FGTorsemide FGTrandolapril/ Verapamil CR

FG

Triamterene/Hydrochlorothiazide

FG

Tribenzor FB QL, STValsartan FG QLValsartan/Hydrochlorothiazide

FG QL

Valturna FB QLVerapamil Sustained-Release Capsule

FG QL

Verapamil Sustained-Release Tablet

FG

Verapamil Tablet FGCardiovascular/Heart Disease: High CholesterolAntara NF QLAtorvastatin FG QLCholestyramine FGCholine Fenofibrate Capsule

FG E, QL



Colestipol FGCrestor FB QLFenofibrate 48, 145 mg Tablet

FG E, QL

Fenofibrate 54, 160 mg Tablet

FG QL

Fenofibrate Capsule FG QLFenofibrate Micronized FG QLFenoglide NF QL, STGemfibrozil FG QLLipofen FB QLLivalo NF QL, STLovastatin FGLovaza FB E, QLNiacin ER FG QLNiaspan NF QLOmega-3-Acid Ethyl Esters Capsule

FG PA, QL

Praluent M QLPravastatin FGPrevalite FGSimcor FB QLSimvastatin 5, 10, 20, 40 mg

FG QL

Simvastatin 80 mg FG PA, QLVascepa FB QLVytorin FB PA, QLWelchol FB

Cardiovascular/Heart Disease: Other

Amiodarone FGAnagrelide FGCilostazol FGCorlanor NF PA, QLDigoxin FGDilatrate SR FBDisopyramide FGFlecainide FGIsochron FGIsoditrate ER FGIsordil FBIsosorbide Dinitrate IR/ER

FG

Isosorbide Mononitrate IR/ER

FG

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Isoxsuprine FGMexiletine FGMidodrine FGNitroBid FBNitroDur Patch FBNitroglycerin ER FGNitrolingual Pump Spray

FG

Nitrostat FBNitroTime FGNorpace CR FBPacerone NFPentoxifylline FGPropafenone FGQuinidine IR/ER FGRanexa FB QL, STSotalol FGCentral Nervous System: Attention Deficit DisorderAdderall XR FB AE, QLDextroamphetamine/Amphetamine

FG AE, QL

Dextroamphetamine/Amphetamine Extended-Release

NF AE, E, QL

Dextroamphetamine Sulfate Extended-Release

FG AE, PA, QL

Dextroamphetamine Sulfate Tablet

FG AE, PA, QL

Guanfacine ER FG AE, QLIntuniv NF AE, E, QLMetadate ER FG AE, PA, QLMethylphenidate Controlled-Release Tablet

FG AE, QL

Methylphenidate Tablet FG AE, PA, QLStrattera FB QL



Vyvanse FB AE, QL

Central Nervous System: Depression

Amitriptyline FGAmoxapine FGBupropion FGBupropion SR FG HBupropion XL FG QLCitalopram FG QLClomipramine FGCymbalta NF E, QLDesipramine FGDoxepin FGDuloxetine 20, 30, 60 mg

FG QL

Escitalopram FG QLFluoxetine FGFluvoxamine FGForfivo XL FB QLImipramine FGMaprotiline FGMirtazapine, Mirtazapine ODT

FG

Nefazodone FGNortriptyline FGParoxetine FGParoxetine ER FG QLPaxil Suspension FBPhenelzine FGPristiq FB QLProtriptyline FGSertraline FGTranylcypromine FGTrazodone FGVenlafaxine FGVenlafaxine Extended-Release Capsule

FG QL

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Venlafaxine Extended-Release Tablet

FG QL

Viibryd NF QL, ST

Central Nervous System: Migraine

Acetaminophen/Butalbital/Caffeine

FG QL

Cambia NF E, QLIsometheptene/Acetaminophen/Dichloralphenazone

FG

Migragesic FGMigranal NF QLNodolor FGPhrenilin Forte NF QLRizatriptan FG QLSumatriptan Nasal Spray, Tablet

FG QL

Sumavel DosePro MZecuity NF E, QL, STZolmitriptan FG QLZomig Spray FB E, QLCentral Nervous System: Multiple SclerosisAmpyra FB PA, QLAvonex M QLBetaseron M QLCopaxone M QLExtavia M QLGilenya NF PA, QLPlegridy M QLRebif, Rebif Rebidose M QLTecfidera FB PA, QL

Central Nervous System: Other

Alprazolam IR/ER FG QLAricept 5, 10 mg Tablet, ODT

NF QL

Aricept 23 mg NF QL, STAripiprazole ODT FG QLAripiprazole Solution, Tablet

FG QL

Azilect NF QLBenztropine FGBromocriptine FG



Buspirone FGCarbidopa/Levodopa IR/ER

FG

Chlordiazepoxide FG QLChlordiazepoxide/Amitriptyline

FG

Chlorpromazine FGClorazepate FG QLClozapine FG QLCompro Suppository FGDiazepam FGDonepezil, Donepezil ODT

FG QL

Entaone FGErgoloid Mesylate FGFluphenazine FGGalantamine IR/ER FGHaloperidol FGHydroxyzine FGLatuda NF QL, STLithium IR/ER FGLorazepam FG QLLoxapine FGMeprobamate FGNamenda XR FB QLNamzaric NF QL, STNuvigil NF PA, QLOlanzapine, Olanzapine ODT

FG QL

Oxazepam FG QLPerphenazine/Amitriptyline

FG

Pramipexole FGProchlorperazine FGQuetiapine FG QLRisperidone, Risperidone ODT

FG QL

Rivastigmine FG QLRopinirole FGSaphris FB PA, QLSeroquel XR FB QLSuboxone Film FB PA, QLSuboxone Tablet NF PA, QLThioridazine FGThiothixene FG

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Trifluoperazine FGTrihexyphenidyl FGXyrem NF PA, QLZelapar NF QLZiprasidone FG QLZubsolv FB PA, QLCentral Nervous System: Sedatives/HypnoticsEszopiclone FG QLFlurazepam FG PA, QLSilenor NF QLTemazepam FG QLTriazolam FG QLZaleplon FG QLZolpidem FG QLCentral Nervous System: Seizure DisordersCarbamazepine IR/ER

FG

Clonazepam, Clonazepam ODT

FG QL

Diazepam Gel FG QLDivalproex FGDivalproex Extended-Release

FG

Epitol FGEthosuximide FGGabapentin FGLamictal Chewable, Tablet

FB E

Lamictal Starter Kit FB QLLamictal XR NF E, PA, QLLamotrigine Chewable, Tablet

FG

Lamotrigine ER FG QLLamotrigine ODT NFLevetiracetam ER NF QL, STLevetiracetam IR FG



Lyrica Capsule FB QLLyrica Solution NF QLOxcarbazepine FGPhenobarbital FGPhenytoin FGTopiragen FGTopiramate FGValproic Acid FGZonisamide FG

Dermatology

Acanya NF E, QLActicin FGAcyclovir FGAczone Gel NFAdapalene FG AE, QLAla Quin FGAlclometasone FGAlphatrex FGAmmonium Lactate FGAmnesteem FG PA, QLAtralin FB AE, QLAvita FG AE, QLBenzaclin NF E, QLBenzamycin Pack FBBetamethasone FGCalcipotriene-Betamethasone

FB QL

Calcipotriene Ointment FG QLCalcitriol Ointment FGCerovel FGCiclodan FGCiclopirox Cream, Gel, Lotion, Solution

FG

Claravis FG E, PAClindamax Lotion FGClindamycin Gel, Lotion, Solution, Swabs

FG

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Clindareach Kit FGClobetasol, Clobetasol E

FG

Clobex Lotion, Shampoo

NF E

Clobex Spray NF E, QLCloderm NFCloderm Pump NFCormax FGDermazene FGDesonide FGDesoximetasone FGDifferin Cream, Lotion

NF AE, QL

Differin Gel NF E, QLDrithoCreme HP FBDrithoScalp FBEconazole FGElidel FB AE, QL, STEpiduo, Epiduo Forte

NF AE, QL

Ery Pad FGErythromycin FGErythromycin/Benzoyl Peroxide

FG

Ethyl Chloride FGEurax FBExoderm FGFinacea FBFinacea Plus FBFluocinolone FGFluocinonide, Fluocinonide E

FG

Fluorouracil 0 .5% Cream

FB

Fluorouracil Solution, 5% Cream

FG

Fluticasone FGGentamicin FGHydrocortisone FGHypercare FGImiquimod FG QLLaclotion FGLidocaine FGLidocaine/Prilocaine FG



Lindane FGLokara FGMetrogel 1% NF EMetronidazole 0 .75% Cream, Lotion

FG

Mirvaso NF PA, QLMometasone Furoate FGMupirocin Calcium Cream

FG QL

Mupirocin Ointment FGMyorisan FG PANystatin FGNystop FGPermethrin FGPicato NF STPodofilox FGPramcort FGPramosone Cream, Ointment

NF

Pramosone E Cream

NF

Pramosone Lotion NFProtopic NF AE, PA, QLRetin-A Micro Gel, Pump

FB AE, QL

Rosadan Cream FGSelenium Sulfide FGSilver Nitrate FGSilver Sulfadiazine FGSulfacetamide Sodium FGSulfacetamide Sodium-Sulfur

FG

Taclonex Ointment NF E, QLTaclonex Scalp NF QLTacrolimus Ointment FG AE, QLTazorac NF AE, QLTretin-X FB AE, QLTretinoin FG AE, ETriamcinolone Acetonide

FG

Trianex FBTriderm FGUrea 40% Lotion FGVectical NF EVitazol FG

18







Voltaren Gel FB QLZenatane FG E, PAZyclara Cream, Pump

NF QL

Diabetes/Endocrine: Blood Glucose MonitoringAccu-Chek Test Strips

NF PA, QL

Bayer Breeze2 Test Strips

NF PA, QL

Bayer Contour Test Strips

NF PA, QL

FastClix Lancets FB QLFreestyle Test Strips

NF PA, QL

Glucocard Test Strips

NF PA, QL

Novofine Autocover Pen Needles

NF

Novofine Pen Needles

NF

Novofine Plus Pen Needles

FB

Novotwist Pen Needles

NF

OneTouch Test Strips

FB QL

OneTouch Ultra Blue Test Strips

FB QL

OneTouch Verio IQ Test Strips

FB QL

Relion Test Strips NF PA, QLSoft Touch Lancets FB QLSoftClix Lancets FB QL

Diabetes/Endocrine: Insulin

Apidra Solostar NF STApidra Vial NF ST



Humalog KwikPen 100u/ml

FB

Humalog Mix 75-25 KwikPen

FB

Humalog Vial FBHumulin 70-30 Vial FBHumulin KwikPen FBHumulin N KwikPen FBHumulin N Vial FBHumulin R U-500 Vial

FB

Lantus Solostar FBLantus Vial FBLevemir Flexpen FBLevemir Vial FBNovolin N Vial FB ENovolin R Vial FB ENovolin Vial FB ENovolog Flexpen FB ENovolog Mix FB ENovolog Vial FB E

Diabetes/Endocrine: Non-Insulin

Acarbose FGBydureon FB QL, STByetta FB QL, STChlorpropamide FG AEGlimepiride FGGlipizide IR/XL FGGlipizide/Metformin FGGlucagen FBGlucagon FB QLGlumetza NF PAGlyburide FGGlyburide/Metformin FGGlyxambi NF QL, STInvokamet FB QL, STInvokana FB QL, ST

19



Janumet FB QL, STJanumet XR FB QL, STJanuvia FB QL, STJardiance FB QL, STJentadueto NF QL, STJuvisync FB QL, STKombiglyze XR FB QL, STMetformin FGMetformin Extended-Release

FG PA

Nateglinide FG QLOnglyza FB QL, STPioglitazone FG QL, STPioglitazone/Glimepiride FG QL, STPioglitazone/Metformin FG QL, STRepaglinide FG QL, STSymlin NF PASynjardy FB QL, STTolazamide FG STTolbutamide FG STTradjenta NF QL, STTrulicity FB QL, STVictoza FB QL, ST

Endocrine: Growth Hormone

Lupron Depot MNorditropin MNutropin Aq NuSpin MSaizen MTev-Tropin M

Endocrine: Other

Asmalpred, Asmalpred Plus

FB

Calcitriol FGCortisone FGDesmopressin FGDexamethasone FGFludrocortisone FGHydrocortisone Tablet FGMedrol 2 mg FBMethylergonovine FGMethylprednisolone FGMillipred Tablet FGParicalcitol FG



Prednisolone Solution, Tablet

FG

Prednisone FGZemplar FBEndocrine: Thyroid Hormone ReplacementLevothyroxine Sodium FGLevoxyl FGLiothyronine Sodium FGMethimazole FGPropylthiouracil FGTirosint NFUnithroid FG

Eye Conditions: Allergies

Azelastine 0 .05% Solution

FG

Cromolyn FGEpinastine FG ELastacaft NF QLNaphazoline 0 .1% FGPataday NF EPhenylephrine FG

Eye Conditions: Antibiotics

Bacitracin FGBacitracin/Polymyxin FGCiprofloxacin FG QLErythromycin FGGentamicin FGIlotycin FGMoxeza FB QLNatacyn FBNeomycin/Bacitracin/Polymyxin

FG

Neomycin/Polymixin/Gramicidin

FG

Ofloxacin FG QLPolymyxin B/Trimethoprim

FG

Sulfacetamide Sodium FGTobradex Ointment NFTobramycin/Dexamethasone

FG

20







Tobramycin Ophth Solution

FG E

Tobrex NF ETrifluridine FGVigamox FB QL

Eye Conditions: Glaucoma

Alphagan P FB QLAzopt FB QLBetaxolol FGBetimol NF QLBetoptic-S FBCarteolol FGCombigan FB QLDorzolamide FG QLDorzolamide/Timolol FGIstalol FBLatanoprost FG QLLevobunolol FGLumigan FB QLMetipranolol FGTimolol Maleate FGTimoptic Ocudose FBTravatan Z FB QL

Eye Conditions: Other

Atropine FGBlephamide SOP NFBrimonidine FGCyclogyl FBCyclopentolate FGDexamethasone FGDiclofenac FG QLFluorometholone FGFlurbiprofen FGFML Forte FBHomatropine FGIso Carbachol FB



Iso Homatropine FBKetorolac FG QLNeomycin/Bacitracin/Polymyxin/Hydrocortisone

FG

Neomycin/Polymixin/Dexamethasone

FG

Phospholine FBPred Mild FBPrednisolone Solution, Tablet

FG

Proparacaine FGRestasis NF PASulfacetamide Sodium/Prednisolone

FG

Tetracaine FGTropicamide FG

Gastrointestinal: Acid Suppression

Carafate FBCimetidine FGDexilant FB QLLansoprazole FG QLMisoprostol FGNizatidine FGOmeclamox-Pak FB QLOmeprazole FG QLPantoprazole FG QLPylera FB QLRanitidine FGSucralfate Tablet FGZegerid NF QL, ST

Gastrointestinal: Nausea/Vomiting

Antivert 50 mg FBDronabinol FG PAOndansetron FG QLOndansetron ODT FG

21



Promethazine FG AETrimethobenzamide FG

Gastrointestinal: Other

Amitiza FB QL, STAnalpram Advanced NFAnalpram-HC Cream

NF

Analpram-HC Lotion

NF

Analpram-HC Shingles

NF

Apriso NF QL, STAuryxia NFB-donna FGBelladonna Alkaloids/Phenobarbital

FG

Budesonide FGCalcium Acetate FGCanasa FB QLChlordiazepoxide/Clidinium

FG

Creon FBDelzicol NF E, QL, STDicyclomine FGDificid NFDigex NF FBDipentum NFDiphenoxylate/Atropine FGGavilyte FG QLHalflytely NF QLHyoscyamine FGLactulose FGLialda FB QLLinzess FB AE, QL, STMesalamine Enema FGMetoclopramide Solution, Tablet

FG QL

Movantik FB QLPancrelipase FGParegoric Tincture FGPentasa NF E, QLPolyethylene Glycol 3350

FG QL

Prepopik NF



Propantheline FGRenvela Packet NFRenvela Tablet FBRowasa Enema NFSevelamer FGSulfasalazine FGSuprep NF QLTrilyte FG QLUceris NFUrsodiol FGZenpep FB

HIV/AIDS

Abacavir FGAbacavir/Lamivudine FGAptivus FBAtripla FBComplera FBCrixivan FBDidanosine FGEdurant FBEmtriva FBEpivir Solution FBEpzicom FBEvotaz FBFuzeon FB QLGenvoya FBIntelence FBInvirase FBIsentress FBKaletra FBLamivudine FGLamivudine/Zidovudine FGLexiva FBNevirapine FGNorvir FBPrezcobix FBPrezista FBRescriptor FBRetrovir FBReyataz FBSelzentry FB PAStavudine FGStribild FB PASustiva FB

22







Tivicay FBTriumeq FBTrizivir NFTruvada FBVidex Solution FBViracept FBViread FBVitekta FBZiagen FBZidovudine FG

Infertility*

Cetrotide MClomiphene FG GEFollistim AQ MGonal-F MGonal-F Rff MOvidrel M*Coverage is determined by the consumer’s prescription drug benefit plan .

Inflammatory Conditions: RheumatoidArthritis, Crohn’s Disease, Psoriasis, Ulcerative ColitisCimzia M QLCuprimine NF PADepen FBHumira MHydroxychloroquine Sulfate

FG

Leflunomide FG QLMethotrexate FGOrencia M QLRemicade MRheumatrex NFSimponi M QLStelara M QLTrexall NF



Men’s Health: Erectile Dysfunction*

Cialis FBAE, GE, PA, QL

Stendra FBAE, GE, PA, QL

*Coverage is determined by the consumer’s prescription drug benefit plan .

Men’s Health: Prostate

Alfuzosin FG QLDoxazosin FGDutasteride FG QLDutasteride-Tamsulosin FG QLFinasteride FGRapaflo FB QLTamsulosin FG QLTerazosin FG

Men’s Health: Testosterone Therapy

Androderm FB GE, PA, QLAndrogel 1% NF GE, PA, QLAndrogel 1.62% FB GE, PA, QLAndroxy FG PAAxiron NF GE, PA, QLFortesta NF GE, PA, QLTestim NF GE, PA, QLTestosterone Gel 1% FG GE, PA, QLTestred NF PA

Miscellaneous

Acetic Acid Otic FGAcetylcysteine FGAerochamber FB QLAlinia FB QLAnastrozole FGAntipyrine/Benzocaine FGAnucort-HC FG

23



Aranesp MBenzocaine Otic FGBenzonatate FGBiltricide FBBunavail NF PA, QLCerdelga NF PA, QLChloroquine FGCitric Acid/Sodium Citrate

FG

Condylox NFDanazol FGDaraprim NF PADeconsal-II FBDifil-G Forte Liquid FGDisulfiram FGEasivent FB QLElmiron FBEpipen 2-Pak FB QLEpipen-Jr FB QLErgocalciferol 50,000 Unit Capsule

FG

Euflexxa MExemestane FGEZ Spacer FB QLFosrenol NFGranix MGuaifenesin/Codeine FGGuanidine FBHumibid DM FBHydrocodone/Homatropine

FG

Hydrocortisone/Acetic Acid Otic

FG

Hydrocortisone Pramoxine

FG

Hydrocortisone Suppository

FG

Hypersal Nebs FBInspirease FBKuvan FB PA, QLLetrozole FGLidocaine Patch FG QLLidocaine Viscous FGLidoderm Patch NF E, QLMebendazole FG



Mefloquine FGMegestrol AC FGMephyton FBMestinon Syrup FBMultigen Folic FBMultigen Plus FBNaltrexone FGNessi Spacer FB QLNeupogen MOptihaler FB QLPhenazopyridine FGPilocarpine FGPrimaquine FGProcrit MProctocream HC FGProctofoam HC FBProctosol HC FGProctozone HC FGProglycem FBPromethazine/Codeine FG AEPromethazine/Dextromethorphan

FG AE

Promethazine VC/Codeine

FG AE

Pyridostigmine FGRectiv NF PARenvela NFRezira NFSodium Polystyrene Sulfonate Powder

FG

Soriatane NF QLSSKI FBSynarel FBSynvisc MSynvisc One MTamoxifen FG HTriamcinolone/Orabase FGVelphoro NFVitamin D 50,000 Unit FGVortex FB QLWatchHaler FB QLYodoxin FBZemplar FBZutripro NF

24







Musculoskeletal: Osteoporosis

Actonel NF E, QLAlendronate Oral Solution FG QL

Alendronate Tablet FG QLCalcitonin Spray FG QLForteo MFortical NF QLIbandronate FG QLRaloxifene FG H, QL

Musculoskeletal: Other

Allopurinol FGBaclofen FGCarisoprodol FGColcrys FB QLCyclobenzaprine FGDantrolene FGMethocarbamol FGOrphenadrine/Aspirin/Caffeine FG

Orphenadrine ER FGProbenecid FGTizanidine Tablet FGUloric FB QL, ST

Musculoskeletal: Pain Relief

Acetaminophen/Codeine

FG QL

Acetaminophen/Oxycodone

FG QL

Ascomp/Codeine FG QLAvinza NF PA, QLBupap 50/650 mg FB QLButalbital/Acetaminophen FG QL



Butalbital/Acetaminophen/Caffeine

FG QL

Butalbital/Acetaminophen/Caffeine/Codeine

FG QL

Butalbital/Aspirin/Caffeine

FG QL

Butalbital/Aspirin/Caffeine/Codeine

FG QL

Celecoxib NF QLCholine Magnesium Trisalicylate

FG QL

Codeine FGDiclofenac Sodium FG QLDiflunisal FG QLDuraxin FGEmbeda FB QLEsgic Plus FB QLEtodolac IR/ER FG QLFenoprofen FG QLFentanyl Patch 12, 25, 50, 75, 100 mcg

FG QL

Flector Patch NF E, QLFlurbiprofen FG QLFortigan FGGralise NF QL, STHydrocodone/Acetaminophen

FG QL

Hydrocodone/Ibuprofen

FG QL

Hydromorphone IR/ER FG QLIbuprofen FG QLIndocin Suppository FB QLIndomethacin IR/ER FG QLKetoprofen IR/ER FG QLKetorolac FG QLLazanda NF PA, QL

25



Levorphanol FG QLMeclofenamate FG QLMeloxicam FG QLMeperidine FGMethadone FG QLMorphine Sulfate Beads Sustained-Release

FG QL

Morphine Sulfate Controlled-Release Tablet

FG QL

Morphine Sulfate Immediate-Release Tablet, Solution

FG

Morphine Sulfate Sustained-Release Capsule

FG E, QL

Nabumetone FG QLNalfon 200 mg Capsule

FB QL

Naproxen FG QLNucynta NF QLNucynta ER NF QL, STOpana ER FB QLOrbivan FB QLOxaprozin FGOxycodone IR FGOxycodone/Acetaminophen

FG QL

Oxycontin FB QLOxymorphone FG QLPentazocine/Acetaminophen

FG QL

Pentazocine/Naloxone FG QLPhenyltoloxamine/Acetaminophen

FG

Piroxicam FG QLSalsalate FGSedapap FB QLSulindac FG QLTivorbex NF E, QL, STTolmetin FG QLTramadol FGVimovo NF QL, STVoltaren Gel FB QL



Zohydro ER NF QL, STZorvolex NF E, QL

Overactive Bladder

Bethanechol FGEnablex NF E, QLGelnique 10% FB QLMyrbetriq NF QL, STOxybutynin FGOxybutynin Extended-Release

FG QL

Oxytrol NF E, QLToviaz NF QLVesicare FB QL

Respiratory: Asthma/COPD

Advair Diskus FB QLAdvair HFA FB QLAerospan NF QLAlbuterol Sulfate FGAminophylline FGAnoro Ellipta FB QLArnuity Ellipta FB QLAsmanex NF QL, STAtrovent HFA NF QLBreo Ellipta FB QLBudesonide Nebs FG QLCombivent Respimat

FB QL

Cromolyn Nebs FGFlovent Diskus FB QLFlovent HFA FB QLForadil FB QLIncruse Ellipta FB QLIpratropium FGIpratropium/Albuterol Nebs

FG

Montelukast FG QLPerforomist NF QLProair HFA FB QLProair Respiclick FB QLPulmicort Flexhaler FB QLPulmicort Respules NF QLQVAR FB QL

26







Serevent FB QLSpiriva HandiHaler, Respimat

FB QL

Stiolto Respimat FB QLStriverdi Respimat NF QL, STSymbicort FB QLTerbutaline FGTheophylline SR FGTudorza FB QLVentolin HFA FB QLXopenex HFA NF QL, ST

Respiratory: Nasal Allergies

Azelastine 0 .1% Solution

FG QL

Dymista Spray FB E, QLFlunisolide FG QLFluticasone Propionate FG QLIpratropium FGNasonex FB E, QLOmnaris NF E, QLQNasl NF QLVeramyst NF E, QLZetonna NF E, QL

Respiratory: Oral Allergies

Carbinoxamine FGClemastine FGCyproheptadine FGDexchlorpheniramine FGHydroxyzine FGPromethazine FG AERespiratory: Pulmonary Arterial HypertensionAdcirca NF PA, QLAdempas FB PA, QLLetairis FB PA, QLOpsumit FB PA, QL



Orenitram NF PASildenafil Tablet 20 mg FG PA, QLTracleer FB PA, QL

Transplant

Azathioprine FGCyclosporine, Cyclosporine Modified

FG

Gengraf FGTacrolimus FG

Vitamins/Electrolytes

Fluoride Chewable Tablet, Drops

FG H

Folic Acid 1 mg FGKlor-Con 10 FGKlor-Con M10 FGKlor-Con M20 FGPotassium Chloride FGPotassium Citrate FG

Women’s Health: Contraceptives

Altavera FG HAlyacen FG HApri FG HAranelle FG HAubra FG HAviane FG HAzurette FG HBalziva FG HBeyaz NF HBriellyn FG HCamila FG HCaziant FG HCesia FG HChateal FG HCryselle FG HCyclafem FG H

27



Dasetta FG HDrospirenone/Ethinyl Estradiol

FG H

Elinest FG HElla FG H, QLEmoquette FG HEnpresse FG HEnskyce FG HErrin FG HEstarylla FG HFalmina FG HGianvi FG HGildagia FG HGildess, Gildess Fe FG HHeather FG HImplanon FG HIntrovale FG HJencycla FG HJolessa FG HJolivette FG HJunel FG HJunel Fe FG HKariva FG HKelnor FG HKurvelo FG HLarin, Larin FE FG HLeena FG HLessina FG HLevonest FG HLevonorgestrel FG AE, H, QLLevonorgestrel/Ethinyl Estradiol

FG H

Levora-28 FG HLo Loestrin NF HLoestrin FBLoryna FG HLow-Ogestrel FG HLutera FG HLyza FG HMarlissa FG HMedroxyprogesterone Acetate Injection

FG H, PA

Microgestin FG HMicrogestin FE FG HMono-Linyah FG H



Mononessa FG HMyzilra FG HNatazia FB HNecon 0 .5/35, 1/35, 1/50, 10/11

FG H

Nikki FG HNora-BE FG HNorethindrone FG HNorgestimate-Ethinyl Estradiol

FG H

Norgestrel/Ethinyl Estradiol

FG H

Nortrel FG HNuvaring FB HOcella FG HOgestrel FG HOrsythia FG HOrtho Coil FG HOrtho Flat FG HOrtho Flex FG HPhilith FG HPimtrea FG HPortia FG HPrevifem FG HPrimella FG HQuasense FG HReclipsen FG HSafyral NF HSharobel FG HSolia FG HSprintec FG HSronyx FG HSyeda FG HTarina FE FG HTri-Estarylla FG HTri-Linyah FG HTri-Previfem FG HTri-Sprintec FG HTrinessa FG HTrinessa Lo NF HTrivora-28 FG HVelivet FG HVestura FG HVyfemla FG HViorele FG H

28







Wera FG HWide-Seal FG HXulane FG HYasmin 28 NF E, HYaz NF E, HZarah FG HZenchent FG HZovia FG H

Women’s Health: Hormone Replacement

Alora FB GE, QLCenestin NF GE, QLClimara Pro FB GE, QLCovaryx, Covaryx HS FG GE, PA, QLDivigel NFDuavee FB GE, QLElestrin NF GEEnjuvia NF GE, QLEstradiol Tablet FG GE, QLEstradiol Twice Weekly Patch

NF GE, QL

Estradiol Weekly Patch, Tablet

FG GE, QL

Estrogen/Methyltestosterone, Estrogen/Methyltestosterone HS

FG GE, QL

Estropipate FG GE, QL



Evamist NF GE, QLJinteli FG QLMakena MMedroxyprogesterone FG GEMenest FG GE, QLMimvey FG GE, QLMinivelle NF QLNorethindrone FG GENorethindrone/Ethinyl Estradiol

FG GE, QL

OrthoEst FG GE, QLOsphena NFPremarin FB GE, QLPremarin Vaginal Cream

FB

Premphase FB GE, QLPrempro FB GE, QLVagifem FB GEVivelle-Dot NF E, GE, QL

Women’s Health: Prenatal Vitamins

Brand Prenatal Vitamins/Folic Acid 1 mg

FB

Generic Prenatal Vitamins/Folic Acid 1 mg

FG

29

Index of covered drugs

A

Abacavir .................................. 21Abacavir/Lamivudine ............. 21Acanya ..................................... 16Acarbose .................................. 18Accu-Chek Test Strips ............ 18Acebutolol ............................... 11Acetaminophen/Butalbital/

Caffeine ................................ 15Acetaminophen/Codeine ........24Acetaminophen/Oxycodone ....24Acetazolamide ......................... 11Acetazolamide ER................... 11Acetic Acid Otic ................22, 23Acetylcysteine .......................... 22Acticin ..................................... 16Actonel ....................................24Acyclovir ........................... 11, 16Aczone Gel .............................. 16Adapalene ................................ 16Adcirca ....................................26Adderall XR ............................ 14Adefovir ................................... 11Adempas ..................................26Advair Diskus .......................... 25Advair HFA ............................ 25Aerochamber ........................... 22Aerospan ................................. 25Afeditab CR ............................ 11Aggrenox ................................. 11Ala Quin ................................. 16Albuterol Sulfate ..................... 25Alclometasone ......................... 16Aldactazide 25/25 mg ............. 11Alendronate Oral Solution ......24Alendronate Tablet ..................24Alfuzosin ................................. 22Alinia ...................................... 22Alkeran .................................... 11Allopurinol ..............................24Alora........................................28Alphagan P..............................20Alphatrex ................................. 16Alprazolam IR/ER ................. 15

Altavera ...................................26Alyacen ....................................26Amantadine Capsule, Syrup .... 11Amiloride ................................ 11Amiloride/

Hydrochlorothiazide ............ 11Aminophylline ........................ 25Amiodarone............................. 13Amitiza ................................... 21Amitriptyline ..................... 14, 15Amlodipine ............................. 11Amlodipine/Benazepril ........... 11Ammonium Lactate ................ 16Amnesteem ............................. 16Amoxapine .............................. 14Amoxicillin ............................. 10Amoxicillin/Potassium

Clavulanate .......................... 10Ampyra ................................... 15Anagrelide ............................... 13Analpram-HC Cream ............. 21Analpram-HC Lotion ............. 21Analpram-HC Shingles .......... 21Analpram Advanced................ 21Anastrozole ............................. 22Androderm .............................. 22Androgel 1% ............................ 22Androgel 1.62% ....................... 22Androxy .................................. 22Anoro Ellipta .......................... 25Antara ..................................... 13Antipyrine/Benzocaine ..... 10, 22Antipyrine/Benzocaine Otic ... 10Antivert 50 mg ........................20Anucort-HC ............................ 22Apidra Solostar ........................ 18Apidra Vial .............................. 18Apri .........................................26Apriso ...................................... 21Aptivus .................................... 21Aranelle ...................................26Aranesp ................................... 23Aricept 23 mg.......................... 15

Aricept 5, 10 mg Tablet, ODT .................................... 15

Aripiprazole ODT................... 15Aripiprazole Solution, Tablet .. 15Arnuity Ellipta ........................ 25Ascomp/Codeine .....................24Asmalpred, Asmalpred Plus .... 19Asmanex .................................. 25Atenolol ............................. 11, 12Atenolol/Chlorthalidone .........12Atorvastatin ............................. 13Atralin ..................................... 16Atripla ..................................... 21Atropine ............................ 20, 21Atrovent HFA ......................... 25Aubra .......................................26Auryxia .................................... 21Aviane .....................................26Avinza .....................................24Avita ........................................ 16Avonex ..................................... 15Axiron ..................................... 22Azathioprine ...........................26Azelastine 0.05% Solution ....... 19Azelastine 0.1% Solution ......... 26Azilect ..................................... 15Azithromycin .......................... 10Azopt .......................................20Azor ........................................12Azurette ..................................26

B

B-donna................................... 21Bacitracin .......................... 19, 20Bacitracin/Polymyxin ........ 19, 20Baclofen ...................................24Balziva .....................................26Baraclude ................................. 11Bayer Breeze2 Test Strips ........ 18Bayer Contour Test Strips ....... 18Belladonna Alkaloids/

Phenobarbital ....................... 21Benazepril ......................... 11, 12

30

Benazepril/ Hydrochlorothiazide ............12

Benicar ....................................12Benicar HCT ..........................12Benzaclin ................................. 16Benzamycin Pack .................... 16Benzocaine Otic ................ 10, 23Benzonatate ............................. 23Benztropine ............................. 15Betamethasone ........................ 16Betaseron ................................. 15Betaxolol ............................12, 20Bethanechol ............................. 25Bethkis .................................... 10Betimol ....................................20Betoptic-S ................................20Bexarotene ............................... 11Beyaz .......................................26Bicalutamide ............................ 11Biltricide .................................. 23Bisoprolol .................................12Bisoprolol/

Hydrochlorothiazide ............12Blephamide SOP .....................20Brand Prenatal Vitamins/

Folic Acid 1 mg .................... 28Breo Ellipta ............................. 25Briellyn ....................................26Brilinta .................................... 11Brimonidine ............................20Bromocriptine ......................... 15Budesonide ........................ 21, 25Budesonide Nebs ..................... 25Bumetanide .............................12Bunavail ................................... 23Bupap 50/650 mg ....................24Bupropion ................................ 14Bupropion SR .......................... 14Bupropion XL ......................... 14Buspirone................................. 15Butalbital/Acetaminophen ......24Butalbital/Acetaminophen/

Caffeine ................................24Butalbital/Acetaminophen/

Caffeine/Codeine .................24Butalbital/Aspirin/Caffeine .....24

Butalbital/Aspirin/Caffeine/Codeine ................................24

Bydureon ................................. 18Byetta ...................................... 18Bystolic ....................................12

C

Calcipotriene-Betamethasone .. 16Calcipotriene Ointment .......... 16Calcitonin Spray ......................24Calcitriol ............................ 16, 19Calcitriol Ointment ................. 16Calcium Acetate ...................... 21Cambia .................................... 15Camila .....................................26Canasa ..................................... 21Capecitabine ............................ 11Caprelsa ................................... 11Captopril .................................12Captopril/

Hydrochlorothiazide ............12Carafate ...................................20Carbamazepine IR/ER ........... 16Carbidopa/Levodopa IR/ER .. 15Carbinoxamine ........................26Carisoprodol ............................24Carteolol ..................................20Cartia XT ................................12Carvedilol ................................12Caziant ....................................26Cefaclor Suspension ................ 10Cefaclor Tablet ........................ 10Cefadroxil ................................ 10Cefdinir ................................... 10Cefpodoxime ........................... 10Cefprozil ................................. 10Cefuroxime .............................. 10Celecoxib .................................24Cenestin ..................................28Cephalexin .............................. 10Cerdelga .................................. 23Cerovel .................................... 16Cesia ........................................26Cetrotide ................................. 22Chateal ....................................26Chlordiazepoxide .............. 15, 21

Chlordiazepoxide/ Amitriptyline ....................... 15

Chlordiazepoxide/ Clidinium ............................. 21

Chloroquine ............................ 23Chlorothiazide .........................12Chloroxylenol/Hydrocortisone/

Pramoxine Otic .................... 10Chlorpromazine ...................... 15Chlorpropamide ...................... 18Chlorthalidone ........................12Cholestyramine ....................... 13Choline Fenofibrate Capsule ... 13Choline Magnesium

Trisalicylate ..........................24Cialis ....................................... 22Ciclodan .................................. 16Ciclopirox Cream, Gel,

Lotion, Solution ................... 16Cilostazol................................. 13Cimetidine...............................20Cimzia ..................................... 22Ciprofloxacin ..................... 10, 19Citalopram .............................. 14Citric Acid/Sodium Citrate ..... 23Claravis .................................... 16Clarithromycin IR/ER ............ 10Clemastine ...............................26Cleocin Vaginal

Suppository ........................... 10Climara Pro .............................28Clindamax Lotion ................... 16Clindamycin ...................... 10, 16Clindamycin Gel, Lotion,

Solution, Swabs .................... 16Clindareach Kit ....................... 17Clindesse ................................. 10Clobetasol, Clobetasol E ......... 17Clobex Lotion, Shampoo ........ 17Clobex Spray ........................... 17Cloderm .................................. 17Cloderm Pump ........................ 17Clomiphene ............................. 22Clomipramine ......................... 14Clonazepam,

Clonazepam ODT ............... 16Clonidine Tablet ......................12

31

Clopidogrel .............................. 11Clorazepate .............................. 15Clorpres ...................................12Clotrimazole Troche ............... 10Clozapine ................................ 15Codeine ............................. 23, 24Colcrys ....................................24Colestipol ................................ 13Combigan ................................20Combivent Respimat ............... 25Complera ................................. 21Compro Suppository ............... 15Condylox ................................. 23Copaxone ................................ 15Corlanor .................................. 13Cormax.................................... 17Cortisone ................................. 19Covaryx, Covaryx HS .............28Creon ....................................... 21Cresemba ................................. 10Crestor ..................................... 13Crixivan ................................... 21Cromolyn .......................... 19, 25Cromolyn Nebs ....................... 25Cryselle....................................26Cuprimine ............................... 22Cyclafem .................................26Cyclobenzaprine ......................24Cyclogyl ...................................20Cyclopentolate .........................20Cyclophosphamide .................. 11Cyclosporine, Cyclosporine

Modified ...............................26Cymbalta ................................. 14Cyproheptadine .......................26

D

Daklinza .................................. 11Danazol ................................... 23Dantrolene ...............................24Dapsone ................................... 10Daraprim ................................. 23Dasetta .................................... 27Deconsal-II ............................. 23Delzicol ................................... 21Demeclocycline ....................... 10Depen ...................................... 22

Dermazene .............................. 17Desipramine ............................ 14Desmopressin .......................... 19Desonide ................................. 17Desoximetasone ....................... 17Dexamethasone ................. 19, 20Dexchlorpheniramine ..............26Dexilant ...................................20Dextroamphetamine/

Amphetamine ....................... 14Dextroamphetamine/

Amphetamine Extended-Release ................. 14

Dextroamphetamine Sulfate Extended-Release ................. 14

Dextroamphetamine Sulfate Tablet.................................... 14

Diazepam .......................... 15, 16Diazepam Gel ......................... 16Diclofenac..........................20, 24Diclofenac Sodium ..................24Dicloxacillin ............................ 10Dicyclomine ............................ 21Didanosine .............................. 21Differin Cream, Lotion ........... 17Differin Gel ............................. 17Dificid ..................................... 21Difil-G Forte Liquid ............... 23Diflunisal .................................24Digex NF ................................ 21Digoxin ................................... 13Dilatrate SR ...................... 12, 13Diltiazem Sustained-Release

Capsule .................................12Diltiazem Tablet ......................12Diovan .....................................12Dipentum ................................ 21Diphenoxylate/Atropine .......... 21Disopyramide .................... 11, 13Disulfiram ............................... 23Divalproex ............................... 16Divalproex

Extended-Release ................. 16Divigel ..................................... 28Donepezil, Donepezil ODT ... 15Dorzolamide ............................20Dorzolamide/Timolol .............20

Doxazosin ..........................12, 22Doxepin ................................... 14Doxycycline Hyclate ................ 10Doxycycline Monohydrate

Tablet.................................... 10DrithoCreme HP .................... 17DrithoScalp ............................. 17Dronabinol ..............................20Drospirenone/

Ethinyl Estradiol .................. 27Duavee.....................................28Duloxetine 20, 30, 60 mg ........ 14Duraxin ...................................24Dutasteride .............................. 22Dutasteride-Tamsulosin........... 22Dutoprol ..................................12Dymista Spray .........................26

E

Easivent ................................... 23Econazole ................................ 17Edarbi ......................................12Edarbyclor ...............................12Edurant ................................... 21Effient ..................................... 11Elestrin ....................................28Elidel ....................................... 17Elinest ..................................... 27Eliquis ..................................... 11Ella .......................................... 27Elmiron ................................... 23Embeda ...................................24Emcyt ...................................... 11Emoquette ............................... 27Emtriva .................................... 21Enablex .................................... 25Enalapril ..................................12Enalapril/

Hydrochlorothiazide ............12Enjuvia ....................................28Enpresse .................................. 27Enskyce ................................... 27Entaone ................................... 15Entecavir ................................. 11Epiduo, Epiduo Forte .............. 17Epinastine ............................... 19Epipen-Jr ................................. 23

32

Epipen 2-Pak ........................... 23Epitol ....................................... 16Epivir HBV Solution ............... 11Epivir Solution ........................ 21Eprosartan ...............................12Epzicom .................................. 21Ergocalciferol 50,000 Unit

Capsule ................................. 23Ergoloid Mesylate ................... 15Erivedge .................................. 11Errin ........................................ 27Ery Pad .................................... 17Erythromycin ...............10, 17, 19Erythromycin/

Benzoyl Peroxide .................. 17Erythromycin/Sulfisoxazole .... 10Escitalopram ............................ 14Esgic Plus ................................24Estarylla .................................. 27Estradiol Tablet .......................28Estradiol Twice

Weekly Patch ....................... 28Estradiol Weekly Patch,

Tablet....................................28Estrogen/Methyltestosterone,

Estrogen/Methyltestosterone HS ........................................ 28

Estropipate .............................. 28Eszopiclone ............................. 16Ethambutol .............................. 10Ethosuximide .......................... 16Ethyl Chloride ......................... 17Etodolac IR/ER ......................24Etoposide ................................. 11Euflexxa ................................... 23Eurax ....................................... 17Evamist....................................28Evotaz ...................................... 21Exemestane ....................... 11, 23Exforge ....................................12Exforge HCT ..........................12Exoderm .................................. 17Extavia .................................... 15EZ Spacer ................................ 23Ezide .......................................12

F

Falmina ................................... 27Famciclovir .............................. 11Fareston ................................... 11FastClix Lancets ...................... 18Felodipine ................................12Fenofibrate 48, 145 mg Tablet .. 13Fenofibrate 54, 160 mg Tablet .. 13Fenofibrate Capsule ................. 13Fenofibrate Micronized ........... 13Fenoglide ................................. 13Fenoprofen ...............................24Fentanyl Patch 12, 25,

50, 75, 100 mcg ....................24Finacea .................................... 17Finacea Plus............................. 17Finasteride ............................... 22Flecainide ................................ 13Flector Patch ...........................24Flovent Diskus ........................ 25Flovent HFA ........................... 25Fluconazole ............................. 10Fludrocortisone ....................... 19Flunisolide ...............................26Fluocinolone ............................ 17Fluocinonide,

Fluocinonide E ..................... 17Fluoride Chewable Tablet,

Drops ....................................26Fluorometholone .....................20Fluorouracil 0.5% Cream ........ 17Fluorouracil Solution,

5% Cream ............................. 17Fluoxetine ................................ 14Fluphenazine ........................... 15Flurazepam .............................. 16Flurbiprofen .......................20, 24Flutamide ................................ 11Fluticasone .........................17, 26Fluticasone Propionate ............26Fluvoxamine ............................ 14FML Forte ..............................20Folic Acid 1 mg .................26, 28Follistim AQ ........................... 22Foradil ..................................... 25Forfivo XL ............................... 14

Forteo ......................................24Fortesta .................................... 22Fortical ....................................24Fortigan ...................................24Fosinopril ................................12Fosinopril/

Hydrochlorothiazide ............12Fosrenol ................................... 23Freestyle Test Strips ................ 18Furosemide ..............................12Fuzeon ..................................... 21

G

Gabapentin .............................. 16Galantamine IR/ER ............... 15Gavilyte ................................... 21Gelnique 10% .......................... 25Gemfibrozil ............................. 13Generic Prenatal Vitamins/

Folic Acid 1 mg .................... 28Gengraf ...................................26Gentamicin .........................17, 19Genvoya................................... 21Gianvi ...................................... 27Gildagia ................................... 27Gildess, Gildess Fe .................. 27Gilenya .................................... 15Glimepiride ....................... 18, 19Glipizide/Metformin............... 18Glipizide IR/XL ..................... 18Glucagen ................................. 18Glucagon ................................. 18Glucocard Test Strips .............. 18Glumetza ................................. 18Glyburide ................................ 18Glyburide/Metformin ............. 18Glyxambi ................................. 18Gonal-F ................................... 22Gonal-F Rff ............................ 22Gralise .....................................24Granix ..................................... 23Griseofulvin ............................ 10Guaifenesin/Codeine .............. 23Guanfacine ........................ 12, 14Guanfacine ER ........................ 14Guanidine ............................... 23

33

H

Halflytely ................................. 21Haloperidol ............................. 15Harvoni ................................... 11Heather ................................... 27Hexalen ................................... 11Homatropine .....................20, 23Humalog KwikPen 100u/ml ... 18Humalog Mix 75-25

KwikPen ............................... 18Humalog Vial .......................... 18Humibid DM .......................... 23Humira .................................... 22Humulin 70-30 Vial ................ 18Humulin KwikPen .................. 18Humulin N KwikPen .............. 18Humulin N Vial ...................... 18Humulin R U-500 Vial ........... 18Hydralazine .............................12Hydrochlorothiazide .......... 11-13Hydrocodone/

Acetaminophen ....................24Hydrocodone/Homatropine .... 23Hydrocodone/Ibuprofen ..........24Hydrocortisone ..10, 17, 19, 20, 23Hydrocortisone/

Acetic Acid Otic .................. 23Hydrocortisone

Pramoxine ...................... 10, 23Hydrocortisone Suppository .... 23Hydrocortisone Tablet ............. 19Hydromorphone IR/ER ..........24Hydroxychloroquine Sulfate .... 22Hydroxyurea ............................ 11Hydroxyzine ...................... 15, 26Hyoscyamine ........................... 21Hypercare ................................ 17Hypersal Nebs ......................... 23

I

Ibandronate .............................24Ibuprofen .................................24Ilotycin .................................... 19Imatinib ................................... 11Imipramine .............................. 14Imiquimod ............................... 17

Implanon ................................. 27Incruse Ellipta ......................... 25Indapamide ..............................12Indocin Suppository ................24Indomethacin IR/ER ..............24Inspirease ................................. 23Intelence .................................. 21Introvale .................................. 27Intuniv ..................................... 14Invirase .................................... 21Invokamet ................................ 18Invokana .................................. 18Ipratropium ....................... 25, 26Ipratropium/Albuterol Nebs .... 25Irbesartan ................................12Irbesartan/

Hydrochlorothiazide ............12Isentress ................................... 21Iso Carbachol ..........................20Iso Homatropine .....................20Isochron ................................... 13Isoditrate ER ........................... 13Isometheptene/Acetaminophen/

Dichloralphenazone ............. 15Isoniazid .................................. 10Isordil ...................................... 13Isosorbide Dinitrate IR/ER .... 13Isosorbide Mononitrate

IR/ER .................................. 13Isoxsuprine .............................. 14Isradipine .................................12Istalol .......................................20Itraconazole ............................. 10

J

Jantoven ................................... 11Janumet ................................... 19Janumet XR ............................. 19Januvia ..................................... 19Jardiance .................................. 19Jencycla .................................... 27Jentadueto ................................ 19Jinteli ....................................... 28Jolessa ...................................... 27Jolivette .................................... 27Junel......................................... 27Junel Fe .................................... 27

Juvisync ................................... 19

K

Kaletra ..................................... 21Kariva ...................................... 27Kelnor ...................................... 27Ketoconazole Cream,

Shampoo .............................. 10Ketoprofen IR/ER ..................24Ketorolac ...........................20, 24Klor-Con 10 ............................26Klor-Con M10 ........................26Klor-Con M20 ........................26Kombiglyze XR ....................... 19Kurvelo .................................... 27Kuvan ...................................... 23

L

Labetalol ..................................12Laclotion ................................. 17Lactulose ................................. 21Lamictal Chewable, Tablet ...... 16Lamictal Starter Kit ................ 16Lamictal XR ............................ 16Lamivudine ....................... 11, 21Lamivudine/Zidovudine ......... 21Lamotrigine Chewable,

Tablet.................................... 16Lamotrigine ER ...................... 16Lamotrigine ODT .................. 16Lansoprazole ...........................20Lantus Solostar ........................ 18Lantus Vial .............................. 18Larin, Larin FE ...................... 27Lastacaft .................................. 19Latanoprost .............................20Latuda ..................................... 15Lazanda ...................................24Leena ....................................... 27Leflunomide ............................ 22Lessina..................................... 27Letairis ....................................26Letrozole ........................... 11, 23Leucovorin Calcium ................ 11Leukeran ................................. 11Levemir Flexpen ..................... 18Levemir Vial ........................... 18

34

Levetiracetam ER ................... 16Levetiracetam IR ..................... 16Levobunolol .............................20Levofloxacin ............................ 10Levonest .................................. 27Levonorgestrel ......................... 27Levonorgestrel/Ethinyl

Estradiol ............................... 27Levora-28 ................................ 27Levorphanol ............................ 25Levothyroxine Sodium ............ 19Levoxyl .................................... 19Lexiva ...................................... 21Lialda ...................................... 21Lidocaine ............................17, 23Lidocaine/Prilocaine ............... 17Lidocaine Patch ....................... 23Lidocaine Viscous ................... 23Lidoderm Patch ....................... 23Lindane ................................... 17Linezolid Tablet ...................... 10Linzess .................................... 21Liothyronine Sodium .............. 19Lipofen .................................... 13Lisinopril ........................... 12, 39Lisinopril/

Hydrochlorothiazide ............12Lithium IR/ER ....................... 15Livalo ...................................... 13Lo Loestrin ............................. 27Loestrin ................................... 27Lokara ..................................... 17Lomustine ............................... 11Lorazepam .............................. 15Loryna ..................................... 27Losartan ..................................12Losartan/

Hydrochlorothiazide ............12Lovastatin ................................ 13Lovaza ..................................... 13Low-Ogestrel .......................... 27Loxapine .................................. 15Lumigan ..................................20Lupron Depot .......................... 19Lutera ...................................... 27Lyrica Capsule ......................... 16Lyrica Solution ........................ 16

Lysodren .................................. 11Lyza ......................................... 27

M

Makena ...................................28Maprotiline ............................. 14Marlissa ................................... 27Matulane ................................. 11Mebendazole ........................... 23Meclofenamate ........................ 25Medrol 2 mg ............................ 19Medroxyprogesterone ........ 27, 28Medroxyprogesterone

Acetate Injection .................. 27Mefloquine .............................. 23Megestrol AC .......................... 23Meloxicam ............................... 25Menest ..................................... 28Meperidine .............................. 25Mephyton ................................ 23Meprobamate .......................... 15Mercaptopurine ....................... 11Mesalamine Enema ................. 21Mestinon Syrup ....................... 23Metadate ER ........................... 14Metformin ......................... 18, 19Metformin Extended-Release .. 19Methadone .............................. 25Methazolamide .......................12Methenamine .......................... 10Methimazole ........................... 19Methocarbamol .......................24Methotrexate ........................... 22Methyclothia ...........................12Methyldopa .............................12Methyldopa/

Hydrochlorothiazide ............12Methylergonovine .................... 19Methylphenidate Controlled-

Release Tablet ....................... 14Methylphenidate Tablet ........... 14Methylprednisolone ................. 19Metipranolol ............................20Metoclopramide Solution,

Tablet.................................... 21Metolazone ..............................12Metoprolol Succinate ER ........12

Metoprolol Tartrate .................12Metrogel 1% ............................ 17Metronidazole 0.75% Cream,

Lotion ................................... 17Metronidazole Tablet .............. 10Metronidazole Vaginal Gel ..... 11Mexiletine ............................... 14Micardis HCT ........................12Microgestin ............................. 27Microgestin FE ....................... 27Midodrine ............................... 14Migragesic ............................... 15Migranal .................................. 15Millipred Tablet ...................... 19Mimvey ...................................28Minivelle ................................. 28Minocycline............................. 10Minoxidil ................................12Mirtazapine,

Mirtazapine ODT ................ 14Mirvaso ................................... 17Misoprostol .............................20Moexipril .................................12Moexipril/

Hydrochlorothiazide ............12Mometasone Furoate ............... 17Mono-Linyah .......................... 27Mononessa ............................... 27Montelukast ............................ 25Morphine Sulfate Beads

Sustained-Release ................. 25Morphine Sulfate

Controlled-Release Tablet .... 25Morphine Sulfate Immediate-

Release Tablet, Solution ....... 25Morphine Sulfate

Sustained-Release Capsule ... 25Movantik ................................. 21Moxeza .................................... 19Multigen Folic ......................... 23Multigen Plus .......................... 23Mupirocin Calcium Cream ..... 17Mupirocin Ointment ............... 17Mycobutin ............................... 10Myleran ................................... 11Myorisan ................................. 17Myrbetriq ................................ 25

35

Myzilra .................................... 27

N

Nabumetone ............................ 25Nadolol ....................................12Nalfon 200 mg Capsule........... 25Naltrexone ............................... 23Namenda XR........................... 15Namzaric ................................. 15Naphazoline 0.1% .................... 19Naproxen ................................. 25Nasonex ...................................26Natacyn ................................... 19Natazia .................................... 27Nateglinide .............................. 19NebuPent Nebs ....................... 10Necon 0.5/35, 1/35,

1/50, 10/11 ........................... 27Nefazodone ............................. 14Neomycin .....................10, 19, 20Neomycin/Bacitracin/

Polymyxin ...................... 19, 20Neomycin/Bacitracin/

Polymyxin/Hydrocortisone ..20Neomycin/Polymixin/

Dexamethasone ....................20Neomycin/Polymixin/

Gramicidin ........................... 19Neomycin/Polymixin/

Hydrocortisone Otic ............ 10Nessi Spacer ............................ 23Neupogen ................................ 23Nevirapine ............................... 21Niacin ER ............................... 13Niaspan ................................... 13Nicardipine ..............................12Nifediac CC ............................12Nifedical XL ........................... 13Nifedipine IR/ER ................... 13Nikki ....................................... 27Nilandrone .............................. 11NitroBid .................................. 14NitroDur Patch ....................... 14Nitrofurantoin ......................... 10Nitrofurantoin

Macrocrystal ......................... 10Nitroglycerin ER ..................... 14

Nitrolingual Pump Spray ........ 14Nitrostat .................................. 14NitroTime ................................ 14Nizatidine ................................20Nodolor ................................... 15Nora-BE .................................. 27Norditropin ............................. 19Norethindrone ................... 27, 28Norethindrone/

Ethinyl Estradiol ..................28Norgestimate-Ethinyl

Estradiol ............................... 27Norgestrel/Ethinyl

Estradiol ............................... 27Norpace CR............................. 14Nortrel ..................................... 27Nortriptyline ........................... 14Norvir ...................................... 21Novofine Autocover

Pen Needles .......................... 18Novofine Pen Needles ............. 18Novofine Plus Pen Needles ..... 18Novolin N Vial ........................ 18Novolin R Vial ........................ 18Novolin Vial ............................ 18Novolog Flexpen ..................... 18Novolog Mix ........................... 18Novolog Vial ........................... 18Novotwist Pen Needles ........... 18Nucynta ................................... 25Nucynta ER ............................. 25Nutropin Aq NuSpin .............. 19Nuvaring ................................. 27Nuvigil .................................... 15Nystatin ..............................11, 17Nystop ..................................... 17

O

Ocella ...................................... 27Ofloxacin ........................... 10, 19Ofloxacin Otic ......................... 10Ogestrel ................................... 27Olanzapine,

Olanzapine ODT ................. 15Olysio ...................................... 11Omeclamox-Pak ......................20

Omega-3-Acid Ethyl Esters Capsule ................................. 13

Omeprazole .............................20Omnaris ..................................26Ondansetron ............................20Ondansetron ODT .................20OneTouch Test Strips .............. 18OneTouch Ultra Blue

Test Strips ............................ 18OneTouch Verio IQ

Test Strips ............................ 18Onglyza ................................... 19Opana ER ............................... 25Opsumit ..................................26Optihaler ................................. 23Oracea ..................................... 10Orbivan ................................... 25Orencia .................................... 22Orenitram ................................26Orphenadrine/Aspirin/

Caffeine ................................24Orphenadrine ER ....................24Orsythia .................................. 27Ortho Coil .............................. 27Ortho Flat ............................... 27Ortho Flex ............................... 27OrthoEst ................................. 28Osphena .................................. 28Ovidrel .................................... 22Oxaprozin ................................ 25Oxazepam ............................... 15Oxcarbazepine ......................... 16Oxybutynin ............................. 25Oxybutynin

Extended-Release ................. 25Oxycodone/Acetaminophen .... 25Oxycodone IR ......................... 25Oxycontin ................................ 25Oxymorphone ......................... 25Oxytrol .................................... 25

P

Pacerone .................................. 14Pancrelipase ............................. 21Pantoprazole ............................20Paregoric Tincture ................... 21Paricalcitol ............................... 19

36

Paromomycin ........................... 10Paroxetine ................................ 14Paroxetine ER ......................... 14Pataday .................................... 19Paxil Suspension ...................... 14Pegasys .................................... 11Penicillin VK ........................... 10Pentasa ..................................... 21Pentazocine/Acetaminophen ... 25Pentazocine/Naloxone ............. 25Pentoxifylline .......................... 14Perforomist .............................. 25Perindopril ............................... 13Permethrin .............................. 17Perphenazine/Amitriptyline .... 15Phenazopyridine ...................... 23Phenelzine ............................... 14Phenobarbital .................... 16, 21Phenoxybenzamine ................. 13Phenylephrine .......................... 19Phenyltoloxamine/

Acetaminophen .................... 25Phenytoin ................................ 16Philith ..................................... 27Phospholine .............................20Phrenilin Forte ........................ 15Picato ....................................... 17Pilocarpine .............................. 23Pimtrea .................................... 27Pindolol ................................... 13Pioglitazone ............................. 19Pioglitazone/Glimepiride ........ 19Pioglitazone/Metformin .......... 19Piroxicam ................................ 25Plegridy ................................... 15Podofilox ................................. 17Polyethylene Glycol 3350 ........ 21Polymyxin B/Trimethoprim .... 19Portia ....................................... 27Potassium Chloride .................26Potassium Citrate ....................26Pradaxa .................................... 11Praluent ................................... 13Pramcort .................................. 17Pramipexole ............................. 15Pramosone Cream, Ointment . 17Pramosone E Cream ............... 17

Pramosone Lotion ................... 17Pramoxine-HC Otic ............... 10Pravastatin ............................... 13Prazosin ................................... 13Pred Mild ................................20Prednisolone Solution,

Tablet.............................. 19, 20Prednisone ............................... 19Premarin ..................................28Premarin Vaginal Cream .........28Premphase ...............................28Prempro ...................................28Prepopik .................................. 21Prevalite ................................... 13Previfem .................................. 27Prezcobix ................................. 21Prezista .................................... 21Primaquine .............................. 23Primella ................................... 27Pristiq ...................................... 14Proair HFA ............................. 25Proair Respiclick ..................... 25Probenecid ...............................24Prochlorperazine ..................... 15Procrit ...................................... 23Proctocream HC ..................... 23Proctofoam HC ....................... 23Proctosol HC........................... 23Proctozone HC ....................... 23Proglycem ................................ 23Promethazine .............. 21, 23, 26Promethazine/Codeine ............ 23Promethazine/

Dextromethorphan ............... 23Promethazine VC/Codeine ..... 23Propafenone ............................. 14Propantheline .......................... 21Proparacaine ............................20Propranolol/

Hydrochlorothiazide ............ 13Propranolol IR/ER .................. 13Propylthiouracil ....................... 19Protopic ................................... 17Protriptyline ............................ 14Pulmicort Flexhaler ................. 25Pulmicort Respules ................. 25Pylera .......................................20

Pyrazinamide........................... 10Pyridostigmine ........................ 23

Q

QNasl ......................................26Quasense ................................. 27Quetiapine ............................... 15Quinapril ................................. 13Quinidine IR/ER .................... 14QVAR ..................................... 25

R

Raloxifene................................24Ramipril .................................. 13Ranexa ..................................... 14Ranitidine ................................20Rapaflo .................................... 22Rebif, Rebif Rebidose .............. 15Reclipsen ................................. 27Rectiv ...................................... 23Relion Test Strips .................... 18Remicade ................................. 22Renvela .............................. 21, 23Renvela Packet ........................ 21Renvela Tablet ......................... 21Repaglinide ............................. 19Rescriptor ................................ 21Reserpine ................................. 13Restasis ....................................20Retin-A Micro Gel, Pump ...... 17Retrovir ................................... 21Reyataz .................................... 21Rezira ...................................... 23Rheumatrex ............................. 22Ribavirin Tablet ....................... 11Rifampin ................................. 10Rimantidine ............................ 11Risperidone,

Risperidone ODT ................ 15Rivastigmine ........................... 15Rizatriptan .............................. 15Ropinirole ................................ 15Rosadan Cream ....................... 17Rowasa Enema ........................ 21

S

Safyral ..................................... 27

37

Saizen ...................................... 19Salsalate ................................... 25Saphris ..................................... 15Savaysa .................................... 11Sedapap ................................... 25Selenium Sulfide ..................... 17Selzentry .................................. 21Serevent ...................................26Seroquel XR ............................ 15Sertraline ................................. 14Sevelamer ................................ 21Sharobel ................................... 27Sildenafil Tablet 20 mg ...........26Silenor ..................................... 16Silver Nitrate ........................... 17Silver Sulfadiazine ................... 17Simcor ..................................... 13Simponi ................................... 22Simvastatin 5, 10, 20, 40 mg .... 13Simvastatin 80 mg ................... 13Sodium Polystyrene Sulfonate

Powder .................................. 23Soft Touch Lancets ................. 18SoftClix Lancets...................... 18Solia ......................................... 27Solodyn.................................... 10Soriatane .................................. 23Sotalol ............................... 13, 14Sotalol AF ............................... 13Sovaldi ..................................... 11Spiriva HandiHaler,

Respimat ..............................26Spironolactone ......................... 13Spironolactone/

Hydrochlorothiazide ............ 13Sprintec ................................... 27Sronyx ..................................... 27SSKI ........................................ 23Stavudine ................................. 21Stelara ...................................... 22Stendra .................................... 22Stiolto Respimat ......................26Strattera ................................... 14Stribild ..................................... 21Striverdi Respimat ................... 26Suboxone Film ........................ 15Suboxone Tablet ...................... 15

Sucralfate Tablet ......................20Sulfacetamide Sodium ..17, 19, 20Sulfacetamide

Sodium-Sulfur ..................... 17Sulfacetamide Sodium/

Prednisolone .........................20Sulfadiazine ....................... 10, 17Sulfamethoxazole/Trimethoprim,

Sulfamethoxazole/Trimethoprim DS ................ 10

Sulfasalazine ............................ 21Sulindac ................................... 25Sumatriptan Nasal Spray,

Tablet.................................... 15Sumavel DosePro .................... 15Suprep ..................................... 21Sustiva ..................................... 21Syeda ....................................... 27Symbicort ................................26Symlin ..................................... 19Synarel ..................................... 23Synjardy ................................... 19Synvisc ..................................... 23Synvisc One ............................. 23

T

Tabloid ..................................... 11Taclonex Ointment .................. 17Taclonex Scalp ......................... 17Tacrolimus ..........................17, 26Tacrolimus Ointment .............. 17Tamoxifen ............................... 23Tamsulosin .............................. 22Tarina FE ................................ 27Tasigna .................................... 11Tazorac .................................... 17Taztia XT ................................ 13Tecfidera .................................. 15Tekturna .................................. 13Tekturna HCT ........................ 13Telmisartan ............................. 13Temazepam ............................. 16Temozolomide ......................... 11Terazosin ........................... 13, 22Terbinafine .............................. 11Terbutaline ..............................26Terconazole.............................. 11

Testim...................................... 22Testosterone Gel 1% ................ 22Testred ..................................... 22Tetracaine ................................20Tetracycline ............................. 10Tev-Tropin ............................... 19Theophylline SR .....................26Thioridazine ............................ 15Thiothixene ............................. 15Ticlopidine .............................. 11Timolol .............................. 13, 20Timolol Maleate ......................20Timoptic Ocudose ...................20Tirosint .................................... 19Tivicay ..................................... 22Tivorbex .................................. 25Tizanidine Tablet ....................24Tobi ......................................... 10Tobradex Ointment ................. 19Tobramycin/

Dexamethasone .................... 19Tobramycin Ophth Solution....20Tobrex......................................20Tolazamide .............................. 19Tolbutamide ............................ 19Tolmetin .................................. 25Topiragen ................................ 16Topiramate .............................. 16Torsemide ................................ 13Toviaz ...................................... 25Tracleer ....................................26Tradjenta ................................. 19Tramadol ................................. 25Trandolapril/Verapamil CR .... 13Tranylcypromine ..................... 14Travatan Z ...............................20Trazodone ................................ 14Tretin-X ................................... 17Tretinoin .............................11, 17Tretinoin Capsule .................... 11Trexall ..................................... 22Tri-Estarylla ............................ 27Tri-Linyah ............................... 27Tri-Previfem ............................ 27Tri-Sprintec ............................. 27Triamcinolone/Orabase ........... 23Triamcinolone Acetonide ........ 17

38

Triamterene/ Hydrochlorothiazide ............ 13

Trianex .................................... 17Triazolam ................................ 16Tribenzor ................................. 13Triderm ................................... 17Trifluoperazine ........................ 16Trifluridine ..............................20Trihexyphenidyl ...................... 16Trilyte ...................................... 21Trimethobenzamide ................ 21Trimethoprim .................... 10, 19Trinessa ................................... 27Trinessa Lo .............................. 27Triumeq ................................... 22Trivora-28 ................................ 27Trizivir..................................... 22Tropicamide.............................20Trulicity ................................... 19Truvada ................................... 22Tudorza ...................................26Tykerb...................................... 11

U

Uceris....................................... 21Uloric .......................................24Unithroid ................................. 19Urea 40% Lotion ..................... 17Ursodiol ................................... 21

V

Vagifem ................................... 28Valacyclovir ............................. 11Valcyte Solution....................... 11Valganciclovir Tablet ............... 11Valproic Acid ........................... 16Valsartan .................................. 13Valsartan/

Hydrochlorothiazide ............ 13Valturna ................................... 13Vandazole Gel ......................... 11Vascepa .................................... 13Vectical .................................... 17Velivet ...................................... 27Velphoro .................................. 23Venlafaxine ........................ 14, 15

Venlafaxine Extended-Release Capsule ................................. 14

Venlafaxine Extended-Release Tablet.................................... 15

Ventolin HFA ..........................26Veramyst ..................................26Verapamil Sustained-Release

Capsule ................................. 13Verapamil Sustained-Release

Tablet.................................... 13Verapamil Tablet ..................... 13Vesicare .................................... 25Vestura..................................... 27Victoza .................................... 19Videx Solution ......................... 22Viekira Pak .............................. 11Vigamox ..................................20Viibryd .................................... 15Vimovo .................................... 25Viorele ..................................... 27Viracept ................................... 22Viread ...................................... 22Vitamin D 50,000 Unit ........... 23Vitazol ..................................... 17Vitekta ..................................... 22Vivelle-Dot .............................. 28Voltaren Gel ...................... 18, 25Vortex ...................................... 23Vyfemla ................................... 27Vytorin .................................... 13Vyvanse ................................... 14

W

Warfarin .................................. 11WatchHaler ............................. 23Welchol ................................... 13Wera ........................................28Wide-Seal ...............................28

X

Xarelto ..................................... 11Xeloda ..................................... 11Xopenex HFA ......................... 26Xulane .....................................28Xyrem ...................................... 16

Y

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

Z

Zaleplon .................................. 16Zarah ....................................... 28Zecuity .................................... 15Zegerid ....................................20Zelapar .................................... 16Zemplar ............................. 19, 23Zenatane .................................. 18Zenchent .................................28Zenpep .................................... 21Zetonna ...................................26Ziagen ..................................... 22Zidovudine ........................ 21, 22Ziprasidone .............................. 16Zmax ....................................... 10Zohydro ER ............................ 25Zolmitriptan ............................ 15Zolpidem ................................. 16Zomig Spray ............................ 15Zonisamide.............................. 16Zorvolex .................................. 25Zovia .......................................28Zovirax Cream ........................ 11Zovirax Ointment ................... 11Zubsolv .................................... 16Zutripro ................................... 23Zyclara Cream, Pump ............. 18Zytiga ...................................... 11

39

“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

CoverageLevel

I Take ThisMedicine For

Directions Doctor

Example: Lisinopril, 20 mgFormulary Generic

High blood pressure One tablet daily Dr . Johnson

For more information


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© 2016 United HealthCare Services, Inc . All rights reserved . Created February, 2016 . 2016 Formulary SignatureValue Three-Tier104-0102 7/16

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Your 2016 Formulary - myuhc.com · 1 Your 2016 Formulary SignatureValue Three-Tier effective July 1, 2016 Please read: This document contains information about commonly prescribed