Your 2016 Formulary - UMR

For a complete list of covered drugs or if you have questions:

Call the toll-free member phone number on the back of your ID card.

Visit optumrx.com• Locate a participating retail pharmacy by zip code.• Look up possible lower-cost medication alternatives.• Compare medication pricing and options.

Please read: This document contains information about the drugs covered under your pharmacy benefit plan.

Your 2016 Formulary

OptumRx | optumrx.com 1

Effective July 1, 2016

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Your Formulary

This Formulary outlines the most commonly prescribed medications from your plan’s complete pharmacy benefit coverage list, also known as a Prescription Drug List (PDL). A formulary identifies the drugs available for certain conditions and organizes them into cost levels, also known as tiers. 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 optumrx.com for complete and up-to-date drug information

Since the Formulary may change, we encourage you to visit our website, optumrx.com. This website is the best source for up-to-date information about all of the medications your pharmacy benefit covers, possible lower-cost options and cost comparisons.

John Smith

John Smith

JOHN SMITH

3

Table of Contents

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

Programs and limits . . . . . . . . . . . . . . . . . . . 6

Drugs by category . . . . . . . . . . . . . . . . . . . . 9

Anti-InfectivesAntibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Cardiovascular/Heart DiseaseAnticoagulants. . . . . . . . . . . . . . . . . . . . . . . . . 9High Blood Pressure . . . . . . . . . . . . . . . . . . . . 10High Cholesterol . . . . . . . . . . . . . . . . . . . . . . 10Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Pulmonary Arterial Hypertension . . . . . . . . . . 11

Central Nervous SystemAttention Deficit Disorder . . . . . . . . . . . . . . . 11Depression. . . . . . . . . . . . . . . . . . . . . . . . . . . 11Migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . 12Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Sedatives/Hypnotics . . . . . . . . . . . . . . . . . . . . 12Seizure Disorders . . . . . . . . . . . . . . . . . . . . . . 12

Dermatology . . . . . . . . . . . . . . . . . . . . . . . . 12

Diabetes/EndocrineBlood Glucose Monitoring . . . . . . . . . . . . . . . 13Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Non-Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . 15

EndocrineGrowth Hormone . . . . . . . . . . . . . . . . . . . . . 15Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Thyroid Hormone Replacement . . . . . . . . . . . 15

Eye ConditionsAllergies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

GastrointestinalAcid Suppression . . . . . . . . . . . . . . . . . . . . . . 16Nausea/Vomiting . . . . . . . . . . . . . . . . . . . . . . 16Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Inflammatory Conditions . . . . . . . . . . . . . . 17

Men’s HealthErectile Dysfunction . . . . . . . . . . . . . . . . . . . . 17Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Testosterone Therapy . . . . . . . . . . . . . . . . . . . 17

Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . 17

MusculoskeletalOsteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Pain Relief . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Overactive Bladder . . . . . . . . . . . . . . . . . . . 19

RespiratoryAsthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . 19Nasal Allergies . . . . . . . . . . . . . . . . . . . . . . . . 19Oral Allergies . . . . . . . . . . . . . . . . . . . . . . . . . 19

Transplant . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Vitamins/Electrolytes . . . . . . . . . . . . . . . . . 19

Women’s HealthBirth Control . . . . . . . . . . . . . . . . . . . . . . . . . 20Hormone Replacement . . . . . . . . . . . . . . . . . 20Vaginal Anti-Infectives . . . . . . . . . . . . . . . . . . 20

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

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At OptumRx, we want to help you better understand your medication options. Your pharmacy benefit offers flexibility and choice in determining the right medication for you. To help you get the most out of your pharmacy benefit, we’ve included some of the most commonly asked questions about the Formulary.

What is a Formulary?

This document is a list of commonly prescribed medications preferred by your plan sponsor for their safety, cost and effectiveness. Drugs are listed by common categories or class. They are placed into cost levels known as tiers. It includes both brand and generic prescription medications approved by the U.S. Food and Drug Administration (FDA).

Please note: Where differences are noted between this Formulary and your benefit plan documents, the benefit plan documents will rule. It is not intended to be a complete list of medications, and not all medications listed may be covered under your plan. Please look at your benefit plan documents provided by your employer or plan sponsor to see what medications are covered under your plan. You may also log on to optumrx.com or call the toll-free member phone number on the back of your ID card for more information.

How do I use my Formulary?

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 rules apply. Bring this list with you when you see your doctor. It is organized by common medical conditions. Medications are then listed alphabetically.

If your medication is not listed in this document, please visit optumrx.com or call the toll-free member phone number on the back of your ID card.

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What are tiers?

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

Drug names shown in orange are preferred for their cost and effectiveness. If there is a symbol in the Drug Tier column, check your benefit plan documents to find out your specific pharmacy plan costs.

$ Drug Tier Includes Helpful Tips

Tier 1 Lowest Cost

Lower-cost, commonly used generic drugs. Some low-cost brands may be included.

Use Tier 1 drugs for the lowest out-of- pocket costs.

Tier 2 Mid-range Cost

Many common brand-name drugs, called preferred brands.

Use Tier 2 drugs, instead of Tier 3, to help reduce your out-of-pocket costs.

Tier 3 Highest Cost

Mostly higher-cost brand drugs, also known as non-preferred brands.

Many Tier 3 drugs have lower-cost options in Tier 1 or 2. Ask your doctor if they could work for you.

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

When does the Formulary change?

• Medications may move to a lower tier at any time. • Medications may move to a higher tier when its generic becomes available.• Medications may move to a higher tier or be excluded from coverage

on January 1 or July 1 of each year.

When a medication changes tiers, you may have to pay a different amount for that medication.

For the most up-to-date list, call customer service at the toll-free member phone number on the back of your ID card.

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Programs and Limits

Some medications are noted with letters or symbols next to them. The letters and symbols refer to our pharmacy benefit programs and are provided to help you check which medications may have a program or limit. Your benefit plan determines how these medications may be covered for you.

PA Prior Authorization – Your doctor is required to provide additional information to determine coverage.

ST Step Therapy – Trial of lower cost medication(s) is required before a higher-cost medication is covered.

QL Quantity Limits – Amount of medication covered per copayment or in a specific time period.

AR Age Restrictions – Some restrictions may apply based on patient age.

SPSpecialty Medication – Medication is designated as a specialty pharmacy drug.

GRGender Restrictions – Some restrictions may apply based on patient gender.

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

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Why are some medications excluded from coverage?

Medications may be excluded from coverage under your pharmacy benefit when it works the same as or similar to another prescription medication or an over-the-counter (OTC) medication. There may be other medication options available.

What if I don’t agree with a decision about an excluded medication?

You (or your authorized representative) and your doctor can ask for an initial coverage decision by calling the toll-free member phone number on the back of your ID card.

Should I talk to my doctor about OTC medications?

An OTC medication may be the right treatment option for some conditions. Talk to your doctor about available OTC options. Even though these medications may not be covered under your pharmacy benefit, they may cost less than your out-of-pocket expense for prescription medications.

What is the difference between brand-name and generic medications?

Generic medications contain the same active ingredients (what makes the medication work) as brand-name medications, but they often cost less. Once the patent of a brand-name medication ends, the FDA can approve a generic version with the same active ingredients. These types of medications are known as generic medications. Sometimes the same company that makes a brand-name medication also makes the generic version.

Is it a generic or brand-name drug?

The drug list shows brand-name drugs in bold type (for example, Lamictal) and generic drugs in plain type (for example, lamotrigine).

What if my doctor writes a brand-name prescription?

The next time your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lower-cost option is available and if it might be right for you. Generic medications are usually your lowest-cost option, but not always. Visit optumrx.com to make sure.

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Are you taking a specialty medication?

Specialty medications treat rare or complex conditions and are typically higher cost medications. Please note, not all specialty medications are listed in the Formulary.

OptumRx is the specialty pharmacy that can provide most of your specialty medications along with helpful programs and services. Call OptumRx® Specialty Pharmacy at 1-888-702-8423 and have your prescriptions delivered right to your home or office.

How do I get updated information about my pharmacy benefit?

Since the Formulary may change during your plan year, we encourage you to visit optumrx.com or call the toll-free member phone number on the back of your ID card for more current information.

When you register at optumrx.com and open an account, you can use the website’s helpful tools and features to:

• Look up the price of drugs covered by your plan

• Find lower-cost options

• Refill and renew mail service prescriptions

• View your order status and claims history

• Sign up for text reminders to take and refill your medicine

• View your benefits in real time

• Order medical supplies

• Shop for health and wellness products

More informationIf you have additional questions please call customer service, 24 hours a day, 7 days a week using the toll-free member phone number on the back of your ID card. Or visit optumrx.com.

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Bold type = Brand-name drug [Plain type = Generic drug] Call customer service for pricing

PA Prior Authorization ST Step TherapyQL Quantity Limits

AR Age RestrictionsSP Specialty ProgramGR Gender Restrictions

Drug NameDrug Tier

Programs and Limits

Anti-Infectives: Antibiotics

Amoxicillin 1Amoxicillin/Clavulanate 1Azithromycin 1Bethkis 2 SPCefadroxil Cap 1Cefdinir 1Cefuroxime Tab 1Cephalexin 1Ciprodex Otic

Suspension3

Ciprofloxacin Tab 1Clarithromycin 1Clindamycin Cap 1Dificid 3Doxycycline Hyclate Cap 1Doxycycline Hyclate Tab

(Immediate Release)1

Doxycycline Monohydrate Cap

1

Doxycycline Monohydrate Oral Suspension, Tab

1

Erythromycin 1Levofloxacin Tab 1Metronidazole Tab 1Minocycline Cap 1Moxifloxacin 1Neomycin/Polymyxin/

HC Otic Suspension, Solution

1

Nitrofurantoin Macrocrystalline

1

Nitrofurantoin Monohydrate Macrocrystalline

1

Ofloxacin Otic Solution 1Oracea 3 QLPenicillin VK 1Solodyn 3 QL

Drug NameDrug Tier

Programs and Limits

Sulfamethoxazole-Trimethoprim

1

Sulfamethoxazole-Trimethoprim DS

1

Anti-Infectives: Antifungals

Fluconazole 1Nystatin Suspension 1Terbinafine Tab 1 QL

Anti-Infectives: Antivirals

Acyclovir Cap, Tab, Suspension

1

Baraclude 3 QL, SPDaklinza 2 PA, QL, SPEntecavir 1 QL, SPFamciclovir Tab 1Harvoni 2 PA, QL, SPSovaldi 2 PA, QL, ST, SPTamiflu 3 QLValacyclovir 1 QL

Cancer

Anastrozole Tab 1Capecitabine 1 SPLetrozole 1Revlimid 2 PA, QL, SPTamoxifen Tab 1Tasigna 2 PA, QL, SPTemozolomide 1 PA, SPZytiga 3 PA, SPCardiovascular/Heart Disease: AnticoagulantsBrilinta 2 QLClopidogrel 1 QLEffient 2 QLEliquis 3 QLEnoxaparin QL, SPPradaxa 2 QLSavaysa 3 QLWarfarin 1Xarelto 2 QL

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Drug NameDrug Tier

Programs and Limits

Cardiovascular/Heart Disease: High Blood PressureAmlodipine 1 QLAmlodipine/Benazepril 1 QLAmlodipine/Valsartan 1 QLAmlodipine/Valsartan/

HCTZ1 QL

Atenolol 1Atenolol/Chlorthalidone 1Azor 2 QL, STBenazepril 1Benazepril/HCTZ 1Benicar 2 QL, STBenicar HCT 2 QL, STBisoprolol 1Bisoprolol/HCTZ 1Bumetanide 1Bystolic 2 QLCartia XT 1 QLCarvedilol 1Chlorthalidone 1Clonidine Patch 1 QLClonidine Tab 1Coreg CR 3 QL, STDiltiazem Tab 1Diovan 3 QLDoxazosin 1Edarbi 3 QL, STEdarbyclor 3 QL, STEnalapril 1Enalapril/HCTZ 1Felodipine 1 QLFosinopril 1Furosemide 1Guanfacine Tab


Hydralazine 1Hydrochlorothiazide 1Irbesartan 1 QLIrbesartan/HCTZ 1 QLLabetalol 1Lisinopril 1Lisinopril/HCTZ 1Losartan 1 QL

Drug NameDrug Tier

Programs and Limits

Losartan/HCTZ 1 QLMetoprolol Succinate 1Metoprolol Tartrate 1Nadolol 1Nifedipine ER 1Propranolol 1Propranolol ER 1Quinapril 1Ramipril 1 QLSpironolactone 1Tekturna 2 QL, STTekturna HCT 2 QL, STTelmisartan 1 QLTerazosin 1Torsemide Tab 1Triamterene/HCTZ 1Tribenzor 2 QL, STValsartan 1 QLValsartan/HCTZ 1 QLVerapamil ER 1Cardiovascular/Heart Disease: High CholesterolAtorvastatin 1 QLCholestyramine 1Crestor 2 QLFenofibrate 43 mg,

48 mg, 50 mg, 54 mg, 67 mg, 130 mg, 134 mg, 145 mg, 150 mg, 160 mg, 200 mg

1 QL

Fenofibrate 40 mg, 120 mg

3 QL, ST

Gemfibrozil 1 QLLipitor 3 QL, STLivalo 3 QL, STLovastatin 1Lovaza 3 QLNiacin ER Tab 1 QLOmega-3 Acid Cap

1 gm1 QL

Praluent PA, QL, SPPravastatin 1

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Drug NameDrug Tier

Programs and Limits

Simvastatin 5 mg, 10 mg, 20 mg, 40 mg

1 QL

Simvastatin 80 mg 1 PA, QLVascepa 2 QLVytorin 10-10 mg,

10-20 mg, 10-40 mg

2 QL

Vytorin 10-80 mg 2 PA, QLWelchol 2 QLZetia 3 QL

Cardiovascular/Heart Disease: Other

Amiodarone 1Amlodipine/Atorvastatin 1 QLCorlanor 3 PA, QLDigoxin 1Flecainide 1Isosorbide Mononitrate 1Nitrostat 2Ranexa 2 STSotalol 1Cardiovascular/Heart Disease: Pulmonary Arterial HypertensionAdcirca 3 PA, QL, SPAdempas 2 PA, QL, SPLetairis 2 PA, QL, SPOpsumit 2 PA, QL, SPOrenitram 3 PA, SPSildenafil Tab 20 mg 1 PA, QL, SPTracleer 2 PA, QL, SPCentral Nervous System: Attention Deficit DisorderAdderall XR Cap 3 QL, STAmphetamine-

Dextroamphetamine Tab

1 QL

Amphetamine-Dextroamphetamine SR 24Hr Cap

1 QL

Dexmethylphenidate ER Cap

1 QL

Focalin XR 3 QL, STGuanfacine ER Tab 1 QL

Drug NameDrug Tier

Programs and Limits

Methylphenidate ER Cap

1 QL

Methylphenidate ER Tab 1 QLMethylphenidate SA

Osmotic ER Tab1 QL

Methylphenidate Tab 1 QLStrattera 2 QLVyvanse 2 QL

Central Nervous System: Depression

Amitriptyline 1Bupropion 1Bupropion ER 1Bupropion SR 1Bupropion XL 1 QLCitalopram 1 QLDoxepin 1Duloxetine Cap 20 mg,

30 mg, 60 mg1 QL

Escitalopram Tab 1 QLFluoxetine Cap

(not PMDD)1

Fluvoxamine Tab 1Forfivo XL 2 QLMirtazapine 1Nortriptyline 1Paroxetine Tab 1Pristiq 2 QLSertraline 1Trazodone 1Venlafaxine Tab 1Venlafaxine ER Cap 1 QLVenlafaxine ER Tab 1 QLViibryd 3 QL, ST

Central Nervous System: Migraine

Butalbital-Acetaminophen-Caffeine Cap, Tab 50-325-40 mg

1 QL

Migranal 3 QLRelpax 3 QLRizatriptan Tab, ODT 1 QL

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Drug NameDrug Tier

Programs and Limits

Sumatriptan Tab and Spray

1 QL

Sumavel Dose 3 QLZolmitriptan Tab 1 QLZomig Nasal Spray 2 QLCentral Nervous System: Multiple SclerosisAmpyra 2 PA, QL, SPAvonex Kit PA, QL, SPAvonex Pen Kit PA, QL, SPAvonex Prefill Kit PA, QL, SPCopaxone PA, QL, SPGilenya* 3 PA, QL, ST, SPPlegridy PA, QL, SPRebif PA, QL, ST, SPRebif Titrtn PA, QL, ST, SPTecfidera 2 PA, QL, SP

Central Nervous System: Other

Abilify Tab 3 QLAlprazolam Tab 1 QLAripiprazole 1 QLBenztropine 1Buspirone 1Carbidopa/Levodopa

Tab (Immediate Release)

1

Diazepam Tab 1Donepezil Tab 1 QLHydroxyzine HCL 1Hydroxyzine Pamoate 1Latuda 3 QL, STLithium Carbonate 1Lorazepam Tab 1 QLModafinil 1 PA, QLNamenda XR 2 QLNuvigil 3 PA, QLOlanzapine Tab 1 QLPramipexole 1Prochlorperazine 1Quetiapine 1 QLRisperidone Tab 1 QL

Drug NameDrug Tier

Programs and Limits

Ropinirole (Immediate Release)

1

Saphris 2 QLSeroquel XR 2 QLZelapar 3Ziprasidone Cap 1 QLCentral Nervous System: Sedatives/HypnoticsEszopiclone Tab 1 QLSilenor 3 QLTemazepam 1 QLTriazolam Tab 1 QLZolpidem 1 QLZolpidem ER 1 QLCentral Nervous System: Seizure DisordersCarbamazepine Tab 1Clonazepam 1 QLDivalproex DR 1Divalproex ER 1Gabapentin 1Lamictal Starter Kit 2 QLLamictal XR 3 QLLamotrigine


Lamotrigine ER 1 QLLevetiracetam 1Levetiracetam ER 1 QLLyrica Cap 2 QLOnfi 3 PAOxcarbazepine 1Phenytoin 1Primidone 1Topiramate Tab 1Zonisamide 1

Dermatology

Acanya Gel 3 QLAcyclovir Ointment 5% 1Aczone Gel 3Atralin 3 QL , ARBenzaclin 3 QLBetamethasone

Dipropionate Cream1

* Tier 3 Preferred

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Drug NameDrug Tier

Programs and Limits

Ciclopirox Cream 1Clindamycin Gel,

Lotion, Solution1

Clindamycin/ Benzoyl Peroxide Gel 1-5%

1 QL

Clindamycin/Benzoyl Peroxide Gel 1.2-5%

1 QL

Clobetasol Cream, Ointment, Solution

1

Clobex 3Cloderm 3Clotrimazole/

Betamethasone Cream, Lotion

1

Desonide Cream, Ointment

1

Desoximetasone Cream, Gel, Ointment

1

Differin 3 QL, AR Econazole Cream 1Elidel 2 QL , ST, AREpiduo 3 QL, ARFinacea 2Fluocinonide Cream,

0.1%1

Fluocinonide Cream, Gel, Ointment, Solution 0.05%

1

Hydrocortisone Cream, Ointment 2.5%

1

Lidocaine Topical Ointment, Solution

1

Lidocaine/Prilocaine Cream

1

Ketoconazole Cream/Shampoo

1

Metrogel 3Metronidazole Gel

0.75%1

Mometasone 1Mupirocin Ointment 1

Drug NameDrug Tier

Programs and Limits

Nystatin Cream, Ointment, Powder

1

Nystatin/Triamcinolone Cream, Ointment

1

Oxsoralen-UL 2 PAPermethrin Cream 5% 1Proctofoam HC 2Retin-A Micro 3 QL, ARSulfacetamide/Sulfur

Emulsion1

Taclonex 3 QLTazorac 3 ARTretinoin Cream 1 ARTretinoin Microsphere

Gel1 QL, AR

Triamcinolone 1Vectical 3Zovirax Cream 2Zovirax Ointment 3Zyclara 3 QLDiabetes/Endocrine Blood: Glucose MonitoringAccu-Chek Active

Glucose Control Liquid

2

Accu-Chek Active Test Strips

2 QL

Accu-Chek Aviva Plus Control Liquid

2

Accu-Chek Aviva Plus Kit

2

Accu-Chek Aviva Plus Test Strips

2 QL

Accu-Chek Comfort Curve Control Liquid

2

Accu-Chek Comfort Curve Test Strips

2 QL

Accu-Chek Compact Plus Control Liquid

2

Accu-Chek Compact Plus Test Strips

2 QL

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Drug NameDrug Tier

Programs and Limits

Accu-Chek Compact Plus Kit

2

Accu-Chek FastClix Kit

2

Accu-Chek FastClix Lancets

2

Accu-Chek Multiclix Kit

2

Accu-Chek Multiclix Lancets

2

Accu-Chek Nano SmartView Kit

2

Accu-Chek SmartView Control Liquid

2

Accu-Chek SmartView Test Strips

2 QL

Accu-Chek Soft Touch Lancets

2

Accu-Chek Softclix Kit 2Accu-Chek Softclix

Lancets2

Bayer Contour Test Strips

3 QL, ST

Dexcom G4 Platinum Kit

3

Dexcom G4 Platinum Sensor Kit

3

Dexcom G4 Platinum Transmitter Kit

3

Freestyle Test Strips 3 QL, STInsulin Pen Needle 2Insulin Syringe/

Needle 2

Novofine Pen Needle 2Novofine Autocover

Pen Needle2

Novotwist Pen Needle 2

Onetouch Kit Ultra Smart

2

Onetouch Kit Ultra 2Onetouch Kit Ultra 2 2Onetouch Kit Ultra

Mini2

Drug NameDrug Tier

Programs and Limits

Onetouch Kit Verio IQ 2Onetouch Lancets 2Onetouch Test Strips 2 QLOnetouch Ultra Blue

Test Strips2 QL

Onetouch Verio Test Strips

2 QL

Precision Test Strips 3 QL, STTruetest Test Strips 3 QL, STTruetrack Test Strips 3 QL, ST

Diabetes/Endocrine: Insulin

Humalog Vials 2Humalog Kwik Pen

100 unit/ml2

Humalog Mix 50/50 Kwik Pen

2

Humalog Mix 50/50 Vials

2

Humalog Mix 75/25 Kwik Pen

2

Humalog Mix 75/25 Vials

2

Humulin 70/30 Vials 2Humulin N Vials 2Humulin N Pen 2Humulin Pen 70/30 2Humulin R U-500 2Humulin R Vials 2Lantus Solostar 2Lantus Vials 2Levemir FlexTouch 2Levemir Vials 2Novolin 70/30 Vials 2Novolin N Vials 2Novolin R Vials 2Novolog Flexpen 2Novolog Mix Flexpen 2Novolog Mix

70/30 Vials2

Novolog Penfill 2Novolog Vials 2

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Drug NameDrug Tier

Programs and Limits

Diabetes/Endocrine: Non-Insulin

Bydureon 2 QL, STByetta 2 QL, STGlimepiride 1Glipizide 1Glipizide ER 1Glipizide XL 1Glumetza 3 PAGlyburide 1Glyburide/Metformin 1Invokamet 2 QL, STInvokana 2 QL, STJanumet 2 QL, STJanumet XR 2 QL, STJanuvia 2 QL, STJardiance 2 QL, STKombiglyze 2 QL, STMetformin 1Metformin ER 1Onglyza 2 QL, STPioglitazone 1 QLSynjardy 2 QL, STTrulicity 2 QL, STVictoza 2 QL, ST

Endocrine: Growth Hormone

Norditropin PA, SPNutropin AQ PA, SPOmnitrope PA, ST, SPSaizen PA, SPZomacton PA, ST, SP

Endocrine: Other

Calcitriol Cap 1Dexamethasone Tab 1Hydrocortisone Tab 1Lupron Depot

3.75 mg, 11.25 mg PA, SP

Lupron Depot 7.5 mg, 22.5 mg, 30 mg, 45 mg

PA, SP

Methylprednisolone Tab 1Prednisone 1

Drug NameDrug Tier

Programs and Limits

Prednisolone Solution 25 mg/5 ml

1

Prednisolone Syrup, Solution 15 mg/5 ml

1

Sensipar 3Endocrine: Thyroid Hormone Replacement Armour Thyroid 3Levothyroxine 1Liothyronine 1Methimazole 1Synthroid 3Tirosint 3

Eye Conditions: Allergies

Azelastine Ophthalmic Solution

1

Pataday 2Patanol 3 QL

Eye Conditions: Antibiotics

Ciprofloxacin Ophthalmic Solution

1 QL

Erythromycin Ointment 1Gentamicin 1Moxeza 2 QL Neomycin/Polymyxin

B/Dexamethasone Ointment, Suspension

1

Ofloxacin Ophthalmic Solution

1 QL

Polymyxin B/Trimethoprim Solution

1

Tobramycin 1Tobramycin/

Dexamethasone1

Vigamox 2 QL

Eye Conditions: Glaucoma

Alphagan P 2 QLAzopt 2 QLBrimonidine 1

16




Drug NameDrug Tier

Programs and Limits

Combigan 2 QLDorzolamide-Timolol

Maleate1

Latanoprost 1 QLLumigan 2 QLTimolol 1Timoptic Ocudose 2Travatan Z 2 QL

Eye Conditions: Other

Durezol Ophthalmic Emulsion

3

Lotemax Ophthalmic Gel

3 QL

Ketorolac Ophthalmic Solution

1 QL

Prednisolone Ophthalmic Suspension

1

Restasis 3 PA

Gastrointestinal: Acid Suppression

Carafate Suspension 2Dexilant 2 QLEsomeprazole (Rx only) 1 QLFamotidine Tab 20 mg

and 40 mg (Rx only)1

Lansoprazole (Rx only) 1 QLOmeprazole (Rx only) 1 QLPantoprazole 1 QLRabeprazole 1 QLRanitidine Tab, Cap,

Syrup (Rx only)1

Sucralfate Tab 1

Gastrointestinal: Nausea/Vomiting

Metoclopramide 1 QLOndansetron Tab 1 QLTransderm-Scop 3

Gastrointestinal: Other

Amitiza 2 QL, ST, ARAsacol HD 3 QL, STCanasa 2 QL

Drug NameDrug Tier

Programs and Limits

Creon 2Delzicol 3 QL, STDicyclomine 1Diphenoxylate/Atropine 1Gavilyte Solution 1 QLHyoscyamine Sublingual

Tab1

Lactulose 1Lialda 2 QLLinzess 2 QL, ST, ARMovantik 2 QLMoviprep 3 QLOmeclamox Pak 2 QLPentasa 3 QLPolyethylene

Glycol 3350 Powder1

Protosol HC 1Prepopik 3Pylera 2 QLSulfasalazine 1Suprep Bowel Prep 3 QLUceris 3Zenpep 2

HIV/AIDS

Atripla 2 SP Complera 2 SPEpzicom 2 SPIntelence 2 SPIsentress 2 SPKaletra 2 SPNevirapine 1 SPNorvir 2 SPPrezcobix 2 SPPrezista 2 SPReyataz 2 SPStribild 2 SPSustiva 2 SPTivicay 2 SPTriumeq 2 SPTruvada 2 SPViread 2 SP

17




Drug NameDrug Tier

Programs and Limits

Infertility

Cetrotide PA, SPFollistim AQ PA, SPGonal-f PA, SPGonal-f RFF PA, SPOvidrel PA, SP

Inflammatory Conditions

Cimzia Kit PA, QL, SPDepen 2Humira Kit PA, QL, SPHumira Pen Kit PA, QL, SPHumira Pen Kit

Crohns PA, QL, SP

Humira Pen Kit Psoriasis

PA, QL, SP

Hydroxychloroquine 1Methotrexate Tab 1Orencia SC PA, QL, ST, SPRasuvo 2 PA, QLSimponi PA, QL, SPStelara PA, QL, SP

Men’s Health: Erectile Dysfunction

Cialis 2 QL, AR, GRLevitra 3 QL, AR, GRStendra 2 QL, AR, GRViagra 3 QL, AR, GR

Men’s Health: Prostate

Alfuzosin 1 QLAvodart 3 QLDoxazosin 1Finasteride 5 mg 1 QLRapaflo 2 QLTamsulosin 1 QLTerazosin 1

Men’s Health: Testosterone Therapy

Androderm 2 PA, QL, GRAndrogel 1.62% 2 PA, QL, GRAndrogel 1% 3 PA, QL, ST, GR

Drug NameDrug Tier

Programs and Limits

Testosterone Cypionate IM Injection

1 PA

Miscellaneous

Allopurinol 1Antipyrine/Benzocaine

Otic Solution 5.4 - 1.4%

1

Aranesp PA, SPBenzonatate 1Botox 100, 200 unit

Injection (non-cosmetic)

2 PA, SP

Bunavail 3 PA, QLCerdelga 3 PA, QL, SPChantix 3 QLCheratussin 1Chlorhexidine 1Colcrys 2 QLCyproheptadine 1Desmopressin 1Epipen 2-Pak 2 QLEuflexxa PA, SPFosrenol 3Granix PA, SPGuaifenesin/Codeine

Syrup1

Homatropine/Hydrocodone Syrup

1

Hydrocodone/Chlorpheniramine Liquid

1

Hydrocortisone AC Suppository 25 mg

1

Hydromet 1Lidocaine Viscous

Solution 2%1

Makena PA, SPNeupogen PA, SPPhenazopyridine

(Rx only)1

Phentermine Tab 1 PAProcrit PA, SP

18




Drug NameDrug Tier

Programs and Limits

Promethazine DM Syrup 1 ARPromethazine/Codeine

Syrup1 AR

Pulmozyme 2 SPRectiv 3Renvela Tab 2Rezira 3Suboxone Film 2 PA, QLSynagis PA, SPSynvisc PA, SPUloric 2 QL, STUrsodiol 1Velphoro 3Zubsolv 2 PA, QLZutripro 3

Musculoskeletal: Osteoporosis

Alendronate Tab 1 QLEvista 3 QLForteo QL, PA, SPIbandronate Tab 1 QLRaloxifene 1 QL

Musculoskeletal: Other

Baclofen Tab 1Carisoprodol 350 mg 1Cyclobenzaprine Tab

5, 10 mg1

Metaxalone 1Methocarbamol 1Tizanidine Cap 1Tizanidine Tab 1

Musculoskeletal: Pain Relief

Acetaminophen w/ Codeine

1 QL

Cambia 3 QLCelebrex 3 QLCelecoxib 1 QLDiclofenac Tab 1 QLEmbeda 2 QLEndocet Tab 1 QLEtodolac 1 QL

Drug NameDrug Tier

Programs and Limits

Fentanyl Patch 25 mcg/hr, 50 mcg/hr, 75 mcg/hr, 100 mcg/hr

1 QL

Fentanyl Patch 37.5 mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr

1 QL

Gralise 3 QL, STHydrocodone

w/ Ibuprofen Tab 7.5-200 mg

1 QL

Hydrocodone/APAP 5, 7.5, 10/325 mg

1 QL

Hydromorphone Tab 1Ibuprofen Tab 400, 600,

800 mg (Rx only)1 QL

Indomethacin Cap 1 QLKetorolac Tab 1 QLLazanda 3 PA, QLLidocaine Patch 5% 1 QLMeloxicam 1 QLMethadone Tab 1Morphine Sulfate Tab 1 QLNabumetone 1 QLNaproxen (Rx only) 1 QLOpana ER 2 QLOxycodone Tab 5,

10, 15, 30 mg (Immediate Release)

1

Oxycodone w/ Acetaminophen

1 QL

Oxycontin 2 QLSubsys 3 PA, QLTivorbex 3 QL, STTramadol Tab 50 mg 1 QLTramadol

w/ Acetaminophen 1 QL

Vicodin 1 QLVicodin ES 1 QLVoltaren Gel 2 QL Zohydro ER 3 QL, STZorvolex 3 QL

19




Drug NameDrug Tier

Programs and Limits

Overactive Bladder

Enablex 3 QLGelnique 2 QLMyrbetriq 3 QL, STOxybutynin 1Oxybutynin ER 1 QLTolterodine 1 QLToviaz 3 QLVesicare 2 QL

Respiratory: Asthma/COPD

Advair Diskus 2 QLAdvair HFA 2 QLAerospan 3 QLAlbuterol

Nebulizer Solution1 QL

Anoro Ellipta 2 QLArnuity Ellipta 2 QLBreo Ellipta 2 QLBudesonide Inhalation

Suspension1 QL

Combivent Respimat 2 QLDulera 3 QL, STFlovent Diskus 2 QLFlovent HFA 2 QLForadil 2 QLIncruse Ellipta 2 QLIpratropium/Albuterol

Nebulizer Solution1 QL

Levalbuterol Nebulizer Solution

1 QL

Montelukast 1 QLPerforomist 3 QLProair HFA, RespiClick 2 QLProventil HFA 3 QL, STPulmicort Flexhaler 2 QLQvar 2 QLSerevent Diskus 2 QLSpiriva Handihaler 2 QLSpiriva Respimat 2 QLStiolto 2 QLSymbicort 2 QLTudorza Pressair 2 QL

Drug NameDrug Tier

Programs and Limits

Ventolin HFA 2 QLXolair PA, SPXopenex HFA 3 QL, ST

Respiratory: Nasal Allergies

Astepro 3 QLAzelastine Spray 1 QLDymista Spray 2 QLFluticasone Spray 1Ipratropium Spray 1Nasonex 2 QLOmnaris 3 QLQNasl 3 QLTriamcinolone Spray 1Zetonna 3 QL

Respiratory: Oral Allergies

Promethazine Tab 1 ARDesloratadine 1 QLLevocetirizine 1 QL

Transplant

Azathioprine Tab 1Cellcept Tab/

Suspension3 SP

Cyclosporine Cap 1 SPMycophenolate Mofetil

250 mg Cap/ 500 mg Tab

1 SP

Mycophenolate Sodium 180 mg, 360 mg Tab

1 SP

Prograf Cap 3 SPRapamune 3 SPTacrolimus Cap 1 SP

Vitamins/Electrolytes

Cyanocobalamine Injection

1

Folic Acid 1 mg (Rx only)

1

Klor-Con 8 and 10 MEQ 1Klor-Con M10 and M20 1

20




Drug NameDrug Tier

Programs and Limits

Potassium Chloride ER Tab, Cap

1

Potassium Chloride Micro ER Tab

1

Potassium Citrate 540 mg, 1080 mg Tab

1

Vitamin D 50,000 units (Rx only)

1

Women’s Health: Birth Control

Apri 1 GRAviane 1 GRAzurette 1 GRCryselle-28 1 GRFalmina 1 GRGeneress Fe

Chewable3 GR

Gianvi 1 GRGildess 1 GRJolivette 1 GRJunel 1 GRKariva 1 GRLevora 28 1 GRLo Loestrin 3 GRLomedia Fe 1 GRLoryna 1 GRLow-Ogestrel 1 GRLutera 1 GRMedroxyprogesterone

Acetate Injection1 QL

Microgestin 1 GRMicrogestin Fe 1 GRMinastrin 24 Fe

Chewable3 GR

Mono-Linyah 1 GRMononessa 1 GRNatazia 2 GRNecon 1 GRNora-Be 1 GRNorgest/Ethi Estradio 1 GRNortrel 1 GRNuvaring 2Ocella 1 GR

Drug NameDrug Tier

Programs and Limits

Orsythia 1 GROrtho Tri-Cyclen Lo 3 GRPrevifem 1 GRReclipsen 1 GRSprintec 28 1 GRTri-Linyah 1 GRTri-Previfem 1 GRTrinessa 1 GRTri-Sprintec 1 GRVestura 1 GRViorele 1 GRXulane 1 GRZarah 1 GR

Women’s Health: Hormone Replacement

Climara Pro 2 QL, GRDivigel 3 GRDuavee 2 QL, GRElestrin Gel 3 GREstrace Vaginal Cream 3Estradiol Tab 1 QL, GREstradiol/Norethindrone

Tab1 QL, GR

Medroxyprogesterone Acetate Tab

1

Minivelle 3 QL, GROsphena 3Premarin Tab 2 QL, GRPremarin Vaginal

Cream2

Premphase 2 QL, GRPrempro 2 QL, GRProgesterone Cap 1Vagifem 3 GR

Women’s Health: Vaginal Anti-Infectives

Gynazole-1 Vaginal Cream

3

Metronidazole Vaginal Gel

1

Terconazole Vaginal Cream

1 QL

Bold type = Brand-name drug [Plain type = Generic drug] 21

Index of Covered Drugs

A

Abilify Tab . . . . . . . . . 12Acanya Gel. . . . . . . . . 12Accu-Chek Active Glucose

Control Liquid . . . . . 13Accu-Chek Active

Test Strips . . . . . . . 13Accu-Chek Aviva Plus

Control Liquid . . . . . 13Accu-Chek Aviva Plus Kit . 13Accu-Chek Aviva Plus Test

Strips . . . . . . . . . . 13Accu-Chek Comfort Curve

Control Liquid . . . . . 13Accu-Chek Comfort Curve

Test Strips . . . . . . . 13Accu-Chek Compact Plus

Control Liquid . . . . . 13Accu-Chek Compact

Plus Kit . . . . . . . . . 14Accu-Chek Compact Plus

Test Strips . . . . . . . 13Accu-Chek FastClix Kit . . 14Accu-Chek FastClix Lancets 14Accu-Chek Multiclix Kit . . 14Accu-Chek Multiclix Lancets 14Accu-Chek Nano

SmartView Kit . . . . . 14Accu-Chek SmartView

Control Liquid . . . . . 14Accu-Chek SmartView

Test Strips . . . . . . . 14Accu-Chek Softclix Kit. . . 14Accu-Chek Softclix Lancets 14Accu-Chek Soft

Touch Lancets . . . . . 14Acetaminophen w/ Codeine 18Acyclovir Cap, Tab, Suspension 9Acyclovir Ointment 5% . . . 12Aczone Gel. . . . . . . . . 12Adcirca . . . . . . . . . . . 11Adderall XR Cap . . . . . . 11Adempas. . . . . . . . . . 11Advair Diskus . . . . . . . 19Advair HFA . . . . . . . . 19Aerospan . . . . . . . . . 19Albuterol Nebulizer Solution 19Alendronate Tab . . . . . . 18Alfuzosin . . . . . . . . . . 17

Allopurinol . . . . . . . . . 17Alphagan P . . . . . . . . 15Alprazolam Tab . . . . . . . 12Amiodarone. . . . . . . . . 11Amitiza. . . . . . . . . . . 16Amitriptyline . . . . . . . . 11Amlodipine . . . . . . . . . 10Amlodipine/Atorvastatin . . 11Amlodipine/Benazepril . . . 10Amlodipine/Valsartan . . . . 10Amlodipine/Valsartan/HCTZ . 10Amoxicillin . . . . . . . . . . 9Amoxicillin/Clavulanate . . . . 9Amphetamine-Dextroamph-

etamine SR 24Hr Cap . . 11Amphetamine-

Dextroamphetamine Tab 11Ampyra . . . . . . . . . . 12Anastrozole Tab . . . . . . . . 9Androderm . . . . . . . . 17Androgel 1% . . . . . . . 17Androgel 1.62% . . . . . . 17Anoro Ellipta . . . . . . . 19Antipyrine/Benzocaine Otic

Solution 5.4 - 1.4% . . . 17Apri . . . . . . . . . . . . . 20Aranesp . . . . . . . . . . 17Aripiprazole . . . . . . . . . 12Armour Thyroid . . . . . . 15Arnuity Ellipta . . . . . . . 19Asacol HD . . . . . . . . . 16Astepro . . . . . . . . . . 19Atenolol. . . . . . . . . . . 10Atenolol/Chlorthalidone. . . 10Atorvastatin . . . . . . . . 10Atralin . . . . . . . . . . . 12Atripla . . . . . . . . . . . 16Aviane . . . . . . . . . . . 20Avodart . . . . . . . . . . 17Avonex Kit. . . . . . . . . 12Avonex Pen Kit . . . . . . 12Avonex Prefill Kit . . . . . 12Azathioprine Tab . . . . . . 19Azelastine Ophthalmic

Solution . . . . . . . . . 15Azelastine Spray. . . . . . . 19Azithromycin . . . . . . . . . 9Azopt . . . . . . . . . . . 15Azor . . . . . . . . . . . . 10Azurette . . . . . . . . . . 20

B

Baclofen Tab . . . . . . . . 18Baraclude . . . . . . . . . . 9Bayer Contour Test Strips . 14Benazepril. . . . . . . . . . 10Benazepril/HCTZ . . . . . . 10Benicar . . . . . . . . . . . 10Benicar HCT . . . . . . . . 10Benzaclin. . . . . . . . . . 12Benzonatate . . . . . . . . 17Benztropine . . . . . . . . . 12Betamethasone Dipropionate 12Bethkis . . . . . . . . . . . . 9Bisoprolol . . . . . . . . . . 10Bisoprolol/HCTZ . . . . . . . 10Botox 100, 200 unit

Injection . . . . . . . . 17Breo Ellipta . . . . . . . . 19Brilinta . . . . . . . . . . . . 9Brimonidine . . . . . . . . . 15Budesonide Inhalation

Suspension . . . . . . . 19Bumetanide . . . . . . . . . 10Bunavail . . . . . . . . . . 17Bupropion. . . . . . . . . . 11Bupropion ER . . . . . . . . 11Bupropion SR . . . . . . . . 11Bupropion XL . . . . . . . . 11Buspirone . . . . . . . . . . 12Butalbital-Acetaminophen-

Caffeine Cap, Tab . . . . 11Bydureon . . . . . . . . . 15Byetta . . . . . . . . . . . 15Bystolic. . . . . . . . . . . 10

C

Calcitriol Cap . . . . . . . . 15Cambia. . . . . . . . . . . 18Canasa . . . . . . . . . . . 16Capecitabine . . . . . . . . . 9Carafate Suspension . . . 16Carbamazepine Tab . . . . . 12Carbidopa/Levodopa Tab . . 12Carisoprodol . . . . . . . . 18Cartia XT . . . . . . . . . . 10Carvedilol . . . . . . . . . . 10Cefadroxil Cap . . . . . . . . 9Cefdinir . . . . . . . . . . . . 9



Cefuroxime Tab . . . . . . . . 9Celebrex . . . . . . . . . . 18Celecoxib . . . . . . . . . . 18Cellcept Tab/Suspension . 19Cephalexin . . . . . . . . . . 9Cerdelga . . . . . . . . . . 17Cetrotide. . . . . . . . . . 17Chantix. . . . . . . . . . . 17Cheratussin . . . . . . . . . 17Chlorhexidine . . . . . . . . 17Chlorthalidone . . . . . . . 10Cholestyramine . . . . . . . 10Cialis . . . . . . . . . . . . 17Ciclopirox Cream . . . . . . 13Cimzia Kit . . . . . . . . . 17Ciprodex Otic Suspension . 9Ciprofloxacin Ophthalmic

Solution . . . . . . . . . 15Ciprofloxacin Tab . . . . . . . 9Citalopram . . . . . . . . . 11Clarithromycin . . . . . . . . 9Climara Pro . . . . . . . . 20Clindamycin/Benzoyl Peroxide

Gel 1.2-5% . . . . . . . 13Clindamycin/Benzoyl Peroxide

Gel 1-5% . . . . . . . . 13Clindamycin Cap . . . . . . . 9Clindamycin Gel, Lotion,

Solution . . . . . . . . . 13Clobetasol Cream, Ointment,

Solution . . . . . . . . . 13Clobex . . . . . . . . . . . 13Cloderm . . . . . . . . . . 13Clonazepam . . . . . . . . 12Clonidine Patch . . . . . . . 10Clonidine Tab . . . . . . . . 10Clopidogrel . . . . . . . . . . 9Clotrimazole/Betamethasone

Cream, Lotion . . . . . . 13Colcrys . . . . . . . . . . . 17Combigan . . . . . . . . . 16Combivent Respimat . . . 19Complera . . . . . . . . . 16Copaxone . . . . . . . . . 12Coreg CR . . . . . . . . . . 10Corlanor . . . . . . . . . . 11Creon. . . . . . . . . . . . 16Crestor . . . . . . . . . . . 10Cryselle-28 . . . . . . . . . 20Cyanocobalamine Injection . 19

Cyclobenzaprine Tab . . . . 18Cyclosporine Cap . . . . . . 19Cyproheptadine . . . . . . . 17

D

Daklinza . . . . . . . . . . . 9Delzicol . . . . . . . . . . 16Depen . . . . . . . . . . . 17Desloratadine . . . . . . . . 19Desmopressin . . . . . . . . 17Desonide Cream, Ointment . 13Desoximetasone Cream, Gel,

Ointment . . . . . . . . 13Dexamethasone Tab . . . . 15Dexcom G4 Platinum Kit . 14Dexcom G4 Platinum

Sensor Kit . . . . . . . 14 Dexcom G4 Platinum

Transmitter Kit. . . . . 14Dexilant . . . . . . . . . . 16Dexmethylphenidate ER Cap 11Diazepam Tab . . . . . . . . 12Diclofenac Tab . . . . . . . 18Dicyclomine . . . . . . . . 16Differin. . . . . . . . . . . 13Dificid . . . . . . . . . . . . 9Digoxin . . . . . . . . . . . 11Diltiazem Tab . . . . . . . . 10Diovan . . . . . . . . . . . 10Diphenoxylate/Atropine . . . 16Divalproex DR . . . . . . . . 12Divalproex ER . . . . . . . . 12Divigel . . . . . . . . . . . 20Donepezil Tab . . . . . . . . 12Dorzolamide-Timolol Maleate 16Doxazosin . . . . . . . . 10, 17Doxepin . . . . . . . . . . . 11Doxycycline Hyclate . . . . . . 9Doxycycline Monohydrate . . . 9Duavee. . . . . . . . . . . 20Dulera . . . . . . . . . . . 19Duloxetine Cap . . . . . . . 11Durezol Ophthalmic

Emulsion . . . . . . . . 16Dymista Spray . . . . . . . 19

E

Econazole Cream . . . . . . 13Edarbi . . . . . . . . . . . 10Edarbyclor . . . . . . . . . 10Effient . . . . . . . . . . . . 9Elestrin Gel . . . . . . . . 20Elidel . . . . . . . . . . . . 13Eliquis . . . . . . . . . . . . 9Embeda . . . . . . . . . . 18Enablex . . . . . . . . . . 19Enalapril. . . . . . . . . . . 10Enalapril/HCTZ . . . . . . . 10Endocet Tab. . . . . . . . . 18Enoxaparin . . . . . . . . . . 9Entecavir . . . . . . . . . . . 9Epiduo . . . . . . . . . . . 13Epipen 2-Pak. . . . . . . . 17Epzicom . . . . . . . . . . 16Erythromycin . . . . . . . 9, 15Escitalopram Tab . . . . . . 11Esomeprazole . . . . . . . . 16Estrace Vaginal Cream . . 20Estradiol/Norethindrone Tab . 20Estradiol Tab . . . . . . . . 20Eszopiclone Tab . . . . . . . 12Etodolac . . . . . . . . . . 18Euflexxa . . . . . . . . . . 17Evista. . . . . . . . . . . . 18

F

Falmina . . . . . . . . . . . 20Famciclovir Tab . . . . . . . . 9Famotidine Tab . . . . . . . 16Felodipine . . . . . . . . . . 10Fenofibrate . . . . . . . . 10Fenofibrate . . . . . . . . . 10Fentanyl Patch . . . . . . . 18Finacea. . . . . . . . . . . 13Finasteride . . . . . . . . . 17Flecainide . . . . . . . . . . 11Flovent Diskus. . . . . . . 19Flovent HFA . . . . . . . . 19Fluconazole . . . . . . . . . . 9Fluocinonide Cream, 0.1% 13Fluocinonide Cream, Gel,

Ointment, Solution 0.05% 13Fluoxetine Cap . . . . . . . 11Fluticasone Spray . . . . . . 19



Fluvoxamine Tab . . . . . . 11Focalin XR . . . . . . . . . 11Folic Acid . . . . . . . . . . 19Follistim AQ . . . . . . . . 17Foradil . . . . . . . . . . . 19Forfivo XL . . . . . . . . . 11Forteo . . . . . . . . . . . 18Fosinopril . . . . . . . . . . 10Fosrenol . . . . . . . . . . 17Freestyle Test Strips . . . . 14Furosemide . . . . . . . . . 10

G

Gabapentin . . . . . . . . . 12Gavilyte Solution . . . . . . 16Gelnique . . . . . . . . . . 19Gemfibrozil . . . . . . . . . 10Generess Fe Chewable . . 20Gentamicin . . . . . . . . . 15Gianvi . . . . . . . . . . . . 20Gildess . . . . . . . . . . . 20Gilenya. . . . . . . . . . . 12Glimepiride . . . . . . . . . 15Glipizide . . . . . . . . . . 15Glipizide ER . . . . . . . . . 15Glipizide XL . . . . . . . . . 15Glumetza . . . . . . . . . 15Glyburide . . . . . . . . . . 15Glyburide/Metformin . . . . 15Gonal-f . . . . . . . . . . . 17Gonal-f RFF . . . . . . . . 17Gralise . . . . . . . . . . . 18Granix . . . . . . . . . . . 17Guaifenesin/Codeine Syrup . 17Guanfacine ER Tab . . . . . 11Guanfacine Tab . . . . . . . 10Gynazole-1 Vaginal Cream 20

H

Harvoni . . . . . . . . . . . 9Homatropine/Hydrocodone

Syrup . . . . . . . . . . 17Humalog Kwik Pen

100 unit/ml. . . . . . . 14Humalog Mix

50/50 Kwik Pen . . . . 14Humalog Mix 50/50 Vials . 14

Humalog Mix 75/25 Kwik Pen . . . . 14

Humalog Mix 75/25 Vials . 14Humalog Vials . . . . . . . 14Humira Kit . . . . . . . . . 17Humira Pen Kit . . . . . . 17Humira Pen Kit Crohns . . 17Humira Pen Kit Psoriasis . 17Humulin 70/30 Vials. . . . 14Humulin N Pen . . . . . . 14Humulin N Vials . . . . . . 14Humulin Pen 70/30 . . . . 14Humulin R U-500 . . . . . 14Humulin R Vials . . . . . . 14Hydralazine . . . . . . . . . 10Hydrochlorothiazide. . . . . 10Hydrocodone/APAP . . . . 18Hydrocodone/

Chlorpheniramine Liquid 17Hydrocodone w/ Ibuprofen . 18Hydrocortisone AC

Suppository . . . . . . . 17Hydrocortisone Cream,

Ointment 2.5% . . . . . 13Hydrocortisone Tab . . . . . 15Hydromet . . . . . . . . . . 17Hydromorphone Tab . . . . 18Hydroxychloroquine . . . . . 17Hydroxyzine HCL . . . . . . 12Hydroxyzine Pamoate . . . . 12Hyoscyamine Sublingual Tab 16

I

Ibandronate Tab. . . . . . . 18Ibuprofen Tab 4 . . . . . . . 18Incruse Ellipta . . . . . . . 19Indomethacin Cap . . . . . 18Insulin Pen Needle . . . . 14Insulin Syringe/Needle . . 14Intelence . . . . . . . . . 16Invokamet . . . . . . . . . 15Invokana. . . . . . . . . . 15Ipratropium/Albuterol

Nebulizer Solution. . . . 19Ipratropium Spray . . . . . . 19Irbesartan . . . . . . . . . . 10Irbesartan/HCTZ. . . . . . . 10Isentress . . . . . . . . . . 16

Isosorbide Mononitrate . . . 11

J

Janumet . . . . . . . . . . 15Janumet XR . . . . . . . . 15Januvia. . . . . . . . . . . 15Jardiance. . . . . . . . . . 15Jolivette . . . . . . . . . . . 20Junel . . . . . . . . . . . . 20

K

Kaletra . . . . . . . . . . . 16Kariva . . . . . . . . . . . . 20Ketoconazole

Cream/Shampoo . . . . 13Ketorolac Ophthalmic

Solution . . . . . . . . . 16Ketorolac Tab . . . . . . . . 18Klor-Con 8 and 10 MEQ. . . 19Klor-Con M10 and M20. . . 19Kombiglyze . . . . . . . . 15

L

Labetalol . . . . . . . . . . 10Lactulose . . . . . . . . . . 16Lamictal Starter Kit . . . . 12Lamictal XR . . . . . . . . 12Lamotrigine ER . . . . . . . 12Lamotrigine . . . . . . . . . 12Lansoprazole . . . . . . . . 16Lantus Solostar . . . . . . 14Lantus Vials . . . . . . . . 14Latanoprost . . . . . . . . . 16Latuda . . . . . . . . . . . 12Lazanda . . . . . . . . . . 18Letairis . . . . . . . . . . . 11Letrozole . . . . . . . . . . . 9Levalbuterol

Nebulizer Solution. . . . 19Levemir FlexTouch. . . . . 14Levemir Vials . . . . . . . 14Levetiracetam . . . . . . . . 12Levetiracetam ER . . . . . . 12Levitra . . . . . . . . . . . 17Levocetirizine . . . . . . . . 19Levofloxacin Tab. . . . . . . . 9



Levora 28 . . . . . . . . . . 20Levothyroxine . . . . . . . . 15Lialda. . . . . . . . . . . . 16Lidocaine Patch 5% . . . . . 18Lidocaine/Prilocaine Cream . 13Lidocaine Topical Ointment,

Solution . . . . . . . . . 13Lidocaine Viscous

Solution 2%. . . . . . . 17Linzess . . . . . . . . . . . 16Liothyronine . . . . . . . . 15Lipitor . . . . . . . . . . . 10Lisinopril . . . . . . . . . . 10Lisinopril/HCTZ . . . . . . . 10Lithium Carbonate . . . . . 12Livalo. . . . . . . . . . . . 10Lo Loestrin . . . . . . . . . 20Lomedia Fe . . . . . . . . . 20Lorazepam Tab . . . . . . . 12Loryna . . . . . . . . . . . 20Losartan. . . . . . . . . . . 10Losartan/HCTZ . . . . . . . 10Lotemax Ophthalmic Gel . 16Lovastatin . . . . . . . . . 10Lovaza . . . . . . . . . . . 10Low-Ogestrel . . . . . . . . 20Lumigan . . . . . . . . . . 16Lupron Depot . . . . . . . 15Lutera . . . . . . . . . . . . 20Lyrica Cap . . . . . . . . . 12

M

Makena . . . . . . . . . . 17Medroxyprogesterone Acetate 20Meloxicam . . . . . . . . . 18Metaxalone . . . . . . . . . 18Metformin . . . . . . . . . 15Metformin ER . . . . . . . . 15Methadone Tab . . . . . . . 18Methimazole . . . . . . . . 15Methocarbamol . . . . . . . 18Methotrexate Tab . . . . . . 17Methylphenidate ER. . . . . 11Methylphenidate SA

Osmotic ER Tab . . . . . 11Methylphenidate Tab . . . . 11Methylprednisolone Tab . . . 15

Metoclopramide . . . . . . 16Metoprolol Succinate . . . . 10Metoprolol Tartrate . . . . . 10Metrogel . . . . . . . . . . 13Metronidazole Gel 0.75%. . 13Metronidazole Tab . . . . . . 9Metronidazole Vaginal Gel . 20Microgestin . . . . . . . . . 20Microgestin Fe . . . . . . . 20Migranal . . . . . . . . . . 11Minastrin 24 Fe Chewable 20Minivelle . . . . . . . . . . 20Minocycline Cap . . . . . . . 9Mirtazapine . . . . . . . . . 11Modafinil . . . . . . . . . . 12Mometasone . . . . . . . . 13Mono-Linyah . . . . . . . . 20Mononessa . . . . . . . . . 20Montelukast . . . . . . . . 19Morphine Sulfate Tab . . . . 18Movantik . . . . . . . . . 16Moviprep . . . . . . . . . 16Moxeza . . . . . . . . . . 15Moxifloxacin . . . . . . . . . 9Mupirocin Ointment . . . . 13Mycophenolate Mofetil . . . 19Mycophenolate Sodium . . . 19Myrbetriq . . . . . . . . . 19

N

Nabumetone . . . . . . . . 18Nadolol . . . . . . . . . . . 10Namenda XR. . . . . . . . 12Naproxen . . . . . . . . . . 18Nasonex . . . . . . . . . . 19Natazia. . . . . . . . . . . 20Necon. . . . . . . . . . . . 20Neomycin/Polymyxin B/

Dexamethasone Ointment, Suspension . . . . . . . 15

Neomycin/Polymyxin/HC Otic Suspension, Solution . . . 9

Neupogen . . . . . . . . . 17Nevirapine . . . . . . . . . 16Niacin ER Tab . . . . . . . . 10Nifedipine ER . . . . . . . . 10Nitrofurantoin Macrocrystalline 9

Nitrofurantoin Monohydrate Macrocrystalline . . . . . . 9

Nitrostat . . . . . . . . . . 11Nora-Be . . . . . . . . . . . 20Norditropin . . . . . . . . 15Norgest/Ethi Estradio . . . . 20Nortrel . . . . . . . . . . . 20Nortriptyline. . . . . . . . . 11Norvir . . . . . . . . . . . 16Novofine Autocover

Pen Needle. . . . . . . 14Novofine Pen Needle . . . 14Novolin 70/30 Vials . . . . 14Novolin N Vials . . . . . . 14Novolin R Vials . . . . . . 14Novolog Flexpen . . . . . 14Novolog Mix 70/30 Vials . 14Novolog Mix Flexpen . . . 14Novolog Penfill . . . . . . 14Novolog Vials . . . . . . . 14Novotwist Pen Needle . . 14Nutropin AQ. . . . . . . . 15Nuvaring. . . . . . . . . . 20Nuvigil . . . . . . . . . . . 12Nystatin . . . . . . . . . . . 13Nystatin Suspension. . . . . . 9Nystatin/Triamcinolone Cream,

Ointment . . . . . . . . 13

O

Ocella . . . . . . . . . . . . 20Ofloxacin Ophthalmic Solution 15Ofloxacin Otic Solution . . . . 9Olanzapine Tab . . . . . . . 12Omeclamox Pak . . . . . . 16Omega-3 Acid Cap . . . . . 10Omeprazole . . . . . . . . . 16Omnaris . . . . . . . . . . 19Omnitrope . . . . . . . . . 15Ondansetron Tab . . . . . . 16Onetouch Kit Ultra . . . . 14Onetouch Kit Ultra 2 . . . 14Onetouch Kit Ultra Mini . 14Onetouch Kit Ultra Smart. 14Onetouch Kit Verio IQ. . . 14Onetouch Lancets . . . . . 14Onetouch Test Strips . . . 14



Onetouch Ultra Blue Test Strips . . . . . . . 14

Onetouch Verio Test Strips 14Onfi . . . . . . . . . . . . 12Onglyza . . . . . . . . . . 15Opana ER . . . . . . . . . 18Opsumit . . . . . . . . . . 11Oracea . . . . . . . . . . . . 9Orencia SC . . . . . . . . . 17Orenitram . . . . . . . . . 11Orsythia . . . . . . . . . . . 20Ortho Tri-Cyclen Lo . . . . 20Osphena . . . . . . . . . . 20Ovidrel . . . . . . . . . . . 17Oxcarbazepine . . . . . . . 12Oxsoralen-UL . . . . . . . 13Oxybutynin . . . . . . . . . 19Oxybutynin ER . . . . . . . 19Oxycodone Tab . . . . . . . 18Oxycodone

w/ Acetaminophen . . . 18Oxycontin . . . . . . . . . 18

P

Pantoprazole . . . . . . . . 16Paroxetine Tab . . . . . . . 11Pataday . . . . . . . . . . 15Patanol. . . . . . . . . . . 15Penicillin VK. . . . . . . . . . 9Pentasa . . . . . . . . . . 16Perforomist . . . . . . . . 19Permethrin Cream 5% . . . 13Phenazopyridine . . . . . . 17Phentermine Tab . . . . . . 17Phenytoin . . . . . . . . . . 12Pioglitazone. . . . . . . . . 15Plegridy . . . . . . . . . . 12Polyethylene Glycol

3350 Powder . . . . . . 16Polymyxin B/Trimethoprim

Solution . . . . . . . . . 15Potassium Chloride ER . . . 20Potassium Chloride Micro ER 20Potassium Citrate . . . . . . 20Pradaxa . . . . . . . . . . . 9Praluent . . . . . . . . . . 10Pramipexole . . . . . . . . . 12

Pravastatin . . . . . . . . . 10Precision Test Strips . . . . 14Prednisolone Ophthalmic

Suspension . . . . . . . 16Prednisolone . . . . . . . . 15Prednisone . . . . . . . . . 15Premarin Tab. . . . . . . . 20Premarin Vaginal Cream . 20Premphase . . . . . . . . . 20Prempro . . . . . . . . . . 20Prepopik . . . . . . . . . . 16Previfem . . . . . . . . . . 20Prezcobix . . . . . . . . . 16Prezista . . . . . . . . . . 16Primidone . . . . . . . . . . 12Pristiq . . . . . . . . . . . 11Proair HFA, RespiClick. . . 19Prochlorperazine . . . . . . 12Procrit . . . . . . . . . . . 17Proctofoam HC . . . . . . 13Progesterone Cap . . . . . . 20Prograf Cap . . . . . . . . 19Promethazine/Codeine Syrup 18Promethazine DM Syrup . . 18Promethazine Tab . . . . . . 19Propranolol . . . . . . . . . 10Propranolol ER . . . . . . . 10Protosol HC . . . . . . . . . 16Proventil HFA . . . . . . . 19Pulmicort Flexhaler . . . . 19Pulmozyme . . . . . . . . 18Pylera . . . . . . . . . . . 16

Q

QNasl. . . . . . . . . . . . 19Quetiapine . . . . . . . . . 12Quinapril . . . . . . . . . . 10Qvar . . . . . . . . . . . . 19

R

Rabeprazole. . . . . . . . . 16Raloxifene. . . . . . . . . . 18Ramipril . . . . . . . . . . . 10Ranexa . . . . . . . . . . . 11Ranitidine . . . . . . . . . . 16Rapaflo. . . . . . . . . . . 17Rapamune . . . . . . . . . 19

Rasuvo . . . . . . . . . . . 17Rebif . . . . . . . . . . . . 12Rebif Titrtn . . . . . . . . 12Reclipsen . . . . . . . . . . 20Rectiv . . . . . . . . . . . 18Relpax . . . . . . . . . . . 11Renvela Tab . . . . . . . . 18Restasis . . . . . . . . . . 16Retin-A Micro . . . . . . . 13Revlimid . . . . . . . . . . . 9Reyataz . . . . . . . . . . 16Rezira . . . . . . . . . . . 18Risperidone Tab . . . . . . . 12Rizatriptan Tab, ODT . . . . 11Ropinirole . . . . . . . . . . 12

S

Saizen . . . . . . . . . . . 15Saphris . . . . . . . . . . . 12Savaysa . . . . . . . . . . . 9Sensipar . . . . . . . . . . 15Serevent Diskus . . . . . . 19Seroquel XR . . . . . . . . 12Sertraline . . . . . . . . . . 11Sildenafil Tab . . . . . . . . 11Silenor . . . . . . . . . . . 12Simponi . . . . . . . . . . 17Simvastatin . . . . . . . . . 11Solodyn . . . . . . . . . . . 9Sotalol . . . . . . . . . . . 11Sovaldi . . . . . . . . . . . . 9Spiriva Handihaler . . . . 19Spiriva Respimat . . . . . 19Spironolactone . . . . . . . 10Sprintec 28 . . . . . . . . . 20Stelara . . . . . . . . . . . 17Stendra . . . . . . . . . . 17Stiolto . . . . . . . . . . . 19Strattera . . . . . . . . . . 11Stribild . . . . . . . . . . . 16Suboxone Film. . . . . . . 18Subsys . . . . . . . . . . . 18Sucralfate Tab . . . . . . . . 16Sulfacetamide/Sulfur Emulsion 13Sulfamethoxazole-Trimethoprim 9Sulfamethoxazole-

Trimethoprim DS . . . . . 9



Sulfasalazine . . . . . . . . 16Sumatriptan Tab and Spray . 12Sumavel Dose . . . . . . . 12Suprep Bowel Prep . . . . 16Sustiva . . . . . . . . . . . 16Symbicort . . . . . . . . . 19Synagis. . . . . . . . . . . 18Synjardy . . . . . . . . . . 15Synthroid . . . . . . . . . 15Synvisc . . . . . . . . . . . 18

T

Taclonex . . . . . . . . . . 13Tacrolimus Cap . . . . . . . 19Tamiflu . . . . . . . . . . . . 9Tamoxifen Tab. . . . . . . . . 9Tamsulosin . . . . . . . . . 17Tasigna. . . . . . . . . . . . 9Tazorac. . . . . . . . . . . 13Tecfidera . . . . . . . . . . 12Tekturna . . . . . . . . . . 10Tekturna HCT . . . . . . . 10Telmisartan . . . . . . . . . 10Temazepam . . . . . . . . . 12Temozolomide . . . . . . . . 9Terazosin . . . . . . . . 10, 17Terbinafine Tab . . . . . . . . 9Terconazole Vaginal Cream . 20Testosterone Cypionate IM

Injection. . . . . . . . . 17Timolol . . . . . . . . . . . 16Timoptic Ocudose . . . . . 16Tirosint. . . . . . . . . . . 15Tivicay . . . . . . . . . . . 16Tivorbex . . . . . . . . . . 18Tizanidine . . . . . . . . . . 18Tobramycin . . . . . . . . . 15Tobramycin/Dexamethasone. 15Tolterodine . . . . . . . . . 19Topiramate Tab . . . . . . . 12Torsemide Tab. . . . . . . . 10Toviaz . . . . . . . . . . . 19Tracleer . . . . . . . . . . 11Tramadol Tab . . . . . . . . 18

Tramadol w/ Acetaminophen 18Transderm-Scop . . . . . . 16Travatan Z . . . . . . . . . 16Trazodone. . . . . . . . . . 11Tretinoin Cream . . . . . . . 13Tretinoin Microsphere Gel . . 13Triamcinolone . . . . . . . . 13Triamcinolone Spray. . . . . 19Triamterene/HCTZ . . . . . . 10Triazolam Tab . . . . . . . . 12Tribenzor. . . . . . . . . . 10Tri-Linyah . . . . . . . . . . 20Trinessa . . . . . . . . . . . 20Tri-Previfem . . . . . . . . . 20Tri-Sprintec . . . . . . . . . 20Triumeq . . . . . . . . . . 16Truetest Test Strips . . . . 14Truetrack Test Strips. . . . 14Trulicity . . . . . . . . . . 15Truvada . . . . . . . . . . 16Tudorza Pressair . . . . . . 19

U

Uceris . . . . . . . . . . . 16Uloric. . . . . . . . . . . . 18Ursodiol . . . . . . . . . . . 18

V

Vagifem . . . . . . . . . . 20Valacyclovir . . . . . . . . . . 9Valsartan . . . . . . . . . . 10Valsartan/HCTZ . . . . . . . 10Vascepa . . . . . . . . . . 11Vectical. . . . . . . . . . . 13Velphoro . . . . . . . . . . 18Venlafaxine ER . . . . . . . 11Venlafaxine Tab . . . . . . . 11Ventolin HFA . . . . . . . 19Verapamil ER . . . . . . . . 10Vesicare . . . . . . . . . . 19Vestura . . . . . . . . . . . 20Viagra . . . . . . . . . . . 17Vicodin . . . . . . . . . . . 18

Vicodin ES. . . . . . . . . . 18Victoza . . . . . . . . . . . 15Vigamox . . . . . . . . . . 15Viibryd . . . . . . . . . . . 11Viorele . . . . . . . . . . . 20Viread . . . . . . . . . . . 16Vitamin D . . . . . . . . . . 20Voltaren Gel . . . . . . . . 18Vytorin . . . . . . . . . . . 11Vyvanse . . . . . . . . . . 11

W

Warfarin . . . . . . . . . . . 9Welchol . . . . . . . . . . 11

X

Xarelto . . . . . . . . . . . . 9Xolair. . . . . . . . . . . . 19Xopenex HFA . . . . . . . 19Xulane . . . . . . . . . . . 20

Z

Zarah . . . . . . . . . . . . 20Zelapar. . . . . . . . . . . 12Zenpep . . . . . . . . . . 16Zetia . . . . . . . . . . . . 11Zetonna . . . . . . . . . . 19Ziprasidone Cap. . . . . . . 12Zohydro ER . . . . . . . . 18Zolmitriptan Tab. . . . . . . 12Zolpidem . . . . . . . . . . 12Zolpidem ER. . . . . . . . . 12Zomacton . . . . . . . . . 15Zomig Nasal Spray . . . . 12Zonisamide . . . . . . . . . 12Zorvolex . . . . . . . . . . 18Zovirax. . . . . . . . . . . 13Zubsolv . . . . . . . . . . 18Zutripro . . . . . . . . . . 18Zyclara . . . . . . . . . . . 13Zytiga . . . . . . . . . . . . 9

27

“My Medications” worksheet

Take this worksheet with you each time you visit a doctor. Each of your doctors should be aware of every drug you take and you should have a list as well.

Name of Medicine and Strength

Drug Tier

I Take This Medicine For

Directions Doctor

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

OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an Optum® company — a leading provider of integrated health services. Learn more at optum.com.

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