Your 2017 Formulary - Steward Health Care System

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

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

Visit your plan’s member website listed on your ID card.• 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 2017 Formulary

OptumRx 1

Effective January 1, 2017

Premium Select Standard

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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 your plan’s member website for complete and up-to-date drug information

Since the Formulary may change, we encourage you to visit your plan’s member website, which should be listed on your ID card. 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.

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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. . . . . . . . . . . . . . . . . . . . . . . . 10High Blood Pressure . . . . . . . . . . . . . . . . . . . . 10High Cholesterol . . . . . . . . . . . . . . . . . . . . . . 10Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Pulmonary Arterial Hypertension . . . . . . . . . . 11

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

Dermatology . . . . . . . . . . . . . . . . . . . . . . . . 13

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

EndocrineGrowth Hormone . . . . . . . . . . . . . . . . . . . . . 15Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Thyroid Hormone Replacement . . . . . . . . . . . 16

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

GastrointestinalAcid Suppression . . . . . . . . . . . . . . . . . . . . . . 16Nausea/Vomiting . . . . . . . . . . . . . . . . . . . . . . 17Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

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

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

Men’s HealthErectile Dysfunction . . . . . . . . . . . . . . . . . . . . 18Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Testosterone Therapy . . . . . . . . . . . . . . . . . . . 18

Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . 18

MusculoskeletalOsteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . 19 Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Pain Relief . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Overactive Bladder . . . . . . . . . . . . . . . . . . . 20

RespiratoryAsthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . 20Nasal Allergies . . . . . . . . . . . . . . . . . . . . . . . . 20Oral Allergies . . . . . . . . . . . . . . . . . . . . . . . . . 20

Transplant . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Vitamins/Electrolytes . . . . . . . . . . . . . . . . . 21

Women’s HealthBirth Control . . . . . . . . . . . . . . . . . . . . . . . . . 21Hormone Replacement . . . . . . . . . . . . . . . . . 21Vaginal Anti-Infectives . . . . . . . . . . . . . . . . . . 22

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

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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 your plan’s member website or call the toll-free member phone number on 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 your plan’s member website or call the toll-free member phone number on 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.

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 your plan’s member website or call the toll-free member phone number on 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 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.

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

EExcluded – May be excluded from coverage or subject to prior authorization. Lower-cost options are available and covered.

To learn more about a pharmacy program or to find out if it applies to you, please visit your plan’s member website or call the toll-free member phone number on 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, Clobex) and generic drugs in plain type (for example, clobetasol).

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 your plan’s member website 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.

BriovaRx, the OptumRx specialty pharmacy, can provide most of your specialty medications along with helpful programs and services. Call BriovaRx 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 your plan’s member website or call the toll-free member phone number on the back of your ID card for more current information.

When you register on our website 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 home delivery prescriptions

• View your order status and claims history

• View your benefits in real time

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 your ID card. Or visit your plan’s member website.

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Bold type = Brand-name drug [Plain type = Generic drug]E Excluded

PA Prior Authorization ST Step Therapy

QL Quantity LimitsSP Specialty Program

Drug NameDrug Tier

Programs and Limits

Anti-Infectives: Antibiotics

Amoxicillin 1Amoxicillin/Clavulanate 1Azasite 3Azithromycin 1Bethkis 2 SPCefadroxil Cap 1Cefdinir 1Cefuroxime Tab 1Cephalexin 1Ciprodex Otic

Suspension2

Ciprofloxacin Tab 1Clarithromycin 1Clindamycin Cap 1Doryx MPC 3 STDoxycycline Hyclate Cap 1Doxycycline Hyclate Tab

(Immediate Release)1

Doxycycline Monohydrate Cap

1

Doxycycline Monohydrate Oral Suspension, Tab

1

Erythromycin 1Kitabis E ST, SPLevofloxacin Tab 1Metronidazole Tab 1Minocycline Cap 1Moxifloxacin 1Neomycin/Polymyxin/

HC Otic Suspension, Solution

1

Nitrofurantoin Macrocrystalline

1

Nitrofurantoin Monohydrate Macrocrystalline

1

Ofloxacin Otic Solution 1Oracea 3Penicillin VK 1Solodyn 3

Drug NameDrug Tier

Programs and Limits

Sulfamethoxazole-Trimethoprim

1

Sulfamethoxazole-Trimethoprim DS

1

TOBI Nebulizer E ST, SPTOBI Podhaler E ST, SP

Anti-Infectives: Antifungals

Fluconazole 1Jublia Solution 3 PAKerydin Solution 3 PANystatin Suspension 1Terbinafine Tab 1 QL

Anti-Infectives: Antivirals

Acyclovir Cap, Tab, Suspension

1

Daklinza 3 PA, QL, SPEntecavir 1 QL, SPEpclusa* 2 PA, QL, SPFamciclovir Tab 1Harvoni* 2 PA, QL, SPSovaldi* 2 PA, QL, ST, SPTamiflu 3 QLValacyclovir 1 QLZepatier* 2 PA, QL, SP

Cancer

Akynzeo 3 QLAnastrozole Tab 1Capecitabine 1 PA, SPLetrozole 1Revlimid 3 PA, SPSprycel 2 PA, SPTamoxifen Tab 1Tasigna 3 PA, SPTemozolomide 1 PA, SPZytiga 3 PA, SP

* PA Required

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QL Quantity Limits SP Specialty Program

Drug NameDrug Tier

Programs and Limits

Cardiovascular/Heart Disease: AnticoagulantsBrilinta 2Clopidogrel 1Effient 2Eliquis 3 QLEnoxaparin 1 QL, SPPradaxa 2 QLSavaysa 3 QLWarfarin 1Xarelto 2 QLCardiovascular/Heart Disease: High Blood PressureAmlodipine 1Amlodipine/Benazepril 1Amlodipine/Valsartan 1Amlodipine/Valsartan/

HCTZ1

Atenolol 1Atenolol/Chlorthalidone 1Azor 2 STBenazepril 1Benazepril/HCTZ 1Benicar 2 STBenicar HCT 2 STBisoprolol 1Bisoprolol/HCTZ 1Bumetanide 1Bystolic 2Cartia XT 1Carvedilol 1Chlorthalidone 1Clonidine Patch 1Clonidine Tab 1Diltiazem Tab 1Doxazosin 1Edarbi 3 STEdarbyclor 3 STEnalapril 1Enalapril/HCTZ 1Felodipine 1Fosinopril 1Furosemide 1

Drug NameDrug Tier

Programs and Limits

Guanfacine Tab (Immediate Release)

1

Hydralazine 1Hydrochlorothiazide 1Irbesartan 1Irbesartan/HCTZ 1Labetalol 1Lisinopril 1Lisinopril/HCTZ 1Losartan 1Losartan/HCTZ 1Metoprolol Succinate 1Metoprolol Tartrate 1Nadolol 1Nifedipine ER 1Propranolol 1Propranolol ER 1Quinapril 1Ramipril 1Spironolactone 1Tekturna 2 STTekturna HCT 2 STTelmisartan 1Terazosin 1Torsemide Tab 1Triamterene/HCTZ 1Tribenzor 2 STValsartan 1Valsartan/HCTZ 1Verapamil ER 1Cardiovascular/Heart Disease: High CholesterolAtorvastatin 1Cholestyramine 1Crestor 3Fenofibrate 40 mg,

43 mg, 48 mg, 50 mg, 54 mg, 67 mg, 120 mg, 130 mg, 134 mg, 145 mg, 150 mg, 160 mg, 200 mg

1

Gemfibrozil 1

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Drug NameDrug Tier

Programs and Limits

Lipitor 3 STLivalo 3 STLovastatin 1Lovaza 3Niacin ER Tab 1Omega-3 Acid Cap

1 gm1

Praluent* 2 PA, QL, SPPravastatin 1Rosuvastatin 1Simvastatin 5 mg, 10

mg, 20 mg, 40 mg1

Simvastatin 80 mg 1 PAVascepa 2Vytorin 10-10 mg,

10-20 mg, 10-40 mg

2

Vytorin 10-80 mg 2 PAWelchol 2Zetia 3

Cardiovascular/Heart Disease: Other

Amiodarone 1Amlodipine/Atorvastatin 1Corlanor 3 PA, QLDigoxin 1Flecainide 1Isosorbide Mononitrate 1Nitrostat 3Ranexa 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, SP

Drug NameDrug Tier

Programs and Limits

Central Nervous System: Attention Deficit DisorderAdderall XR Cap 3 PA, QL, STAmphetamine-

Dextroamphetamine Tab

1 PA, QL

Amphetamine-Dextroamphetamine SR 24Hr Cap

1 PA, QL

Dexmethylphenidate ER Cap

1 PA, QL

Evekeo 3 PA, QL, STGuanfacine ER Tab 1 QLMethylphenidate

ER Cap1 PA, QL

Methylphenidate ER Tab 1 PA, QLMethylphenidate SA

Osmotic ER Tab1 PA, QL

Methylphenidate Tab 1 PA, QLStrattera 2 QLVyvanse 2 PA, QL

Central Nervous System: Depression

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

30 mg, 60 mg1 QL

Escitalopram Tab 1Fluoxetine Cap

(not PMDD)1

Fluvoxamine Tab 1Forfivo XL 2 QLMirtazapine 1Nortriptyline 1Paroxetine Tab 1Pristiq 2 QLRisperidone Tab 1 QLSertraline 1

* PA Required

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Drug NameDrug Tier

Programs and Limits

Trazodone 1Venlafaxine Tab 1Venlafaxine ER Cap 1Venlafaxine ER Tab 1Viibryd 3 QL, ST

Central Nervous System: Migraine

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

1

Migranal 3 QLRelpax 3 QLRizatriptan Tab, ODT 1 QLSumatriptan Tab

and Spray1 QL

Sumavel Dose 3 QLZolmitriptan Tab 1 QLCentral Nervous System: Multiple SclerosisAmpyra 2 PA, QL, SPAubagio 3 PA, QL, ST, SPAvonex Kit* 2 PA, QL, SPAvonex Pen Kit* 2 PA, QL, SPAvonex Prefill Kit* 2 PA, QL, SPBetaseron* 2 PA, QL, SPCopaxone 20 mg/mL

& 40 mg/mL*2 PA, QL, SP

Extavia E PA, QL, SPGilenya*+ 3 PA, QL, ST, SPPlegridy E PA, QL, SPRebif E PA, QL, ST, SPRebif Titrtn E PA, QL, ST, SPTecfidera* 2 PA, QL, SP

Central Nervous System: Other

Abilify Tab 3 QLAlprazolam Tab 1 QLAripiprazole 1 QLBenztropine 1Buspirone 1

Drug NameDrug Tier

Programs and Limits

Carbidopa/Levodopa Tab (Immediate Release)

1

Diazepam Tab 1Donepezil Tab 1Hydroxyzine HCL 1Hydroxyzine Pamoate 1Latuda 3 QL, STLithium Carbonate 1Lorazepam Tab 1 QLModafinil 1 PA, QLNamenda XR 2 QLNamzaric 2 QLNuvigil 3 PA, QLOlanzapine Tab 1 QLProchlorperazine 1Quetiapine 1 QLRexulti 3 QLRisperidone Tab 1 QLRopinirole


Saphris 2 QLSeroquel XR 2 QLZiprasidone 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 1Lamotrigine


Lamotrigine ER 1Levetiracetam 1Levetiracetam ER 1+ Tier 3 Preferred* PA Required

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Drug NameDrug Tier

Programs and Limits

Lyrica Cap 2 QLOnfi 3 PAOxcarbazepine 1Phenytoin 1Primidone 1Topiramate Tab 1Vimpat 3Zonisamide 1

Dermatology

Acanya Gel E STAcyclovir Ointment 5% 1Aczone Gel 3Atralin 3 PABenzaclin E STBenzamycin E STBetamethasone

Dipropionate Cream1

Ciclopirox Cream 1Clindamycin Gel,

Lotion, Solution1

Clindamycin/ Benzoyl Peroxide Gel 1-5%

1

Clindamycin/Benzoyl Peroxide Gel 1.2-5%

1

Clobetasol Cream, Ointment, Solution

1

Clobex 3Clotrimazole/

Betamethasone Cream, Lotion

1

Cortifoam 3Desonide Cream,

Ointment1

Desoximetasone Cream, Gel, Ointment

1

Differin 3 PADuac E STEconazole Cream 1Elidel 2 STEpiduo & Epiduo

Forte3

Drug NameDrug Tier

Programs and Limits

Finacea 3 STFluocinonide 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

Mirvaso Gel 2Mupirocin Ointment 1Nystatin Cream,

Ointment, Powder1

Nystatin/Triamcinolone Cream, Ointment

1

Onexton 3Oxsoralen-UL 2Permethrin Cream 5% 1Proctofoam HC 2Retin-A Micro 3 PASoolantra 2Sulfacetamide/Sulfur

Emulsion1

Taclonex 3 QLTazorac 3 QL, ARTretinoin Cream 1 PATretinoin Microsphere

Gel1 PA

Triamcinolone 1Vectical 3Veltin E STZiana Gel E STZovirax Cream 2Zovirax Ointment 3Zyclara 3

14




Drug NameDrug Tier

Programs and Limits

Diabetes/Endocrine Blood: Glucose MonitoringAccu-Chek Active

Glucose Control Liquid

E

Accu-Chek Active Test Strips

E QL

Accu-Chek Aviva Connect Kit

E

Accu-Chek Aviva Plus Control Liquid

E

Accu-Chek Aviva Plus Kit

E

Accu-Chek Aviva Plus Test Strips

E QL

Accu-Chek Compact Plus Control Liquid

E

Accu-Chek Compact Plus Test Strips

E QL

Accu-Chek Compact Plus Kit

E

Accu-Chek FastClix Kit

E

Accu-Chek FastClix Lancets

E

Accu-Chek Multiclix Kit

E

Accu-Chek Multiclix Lancets

E

Accu-Chek Nano SmartView Kit

E

Accu-Chek SmartView Control Liquid

E

Accu-Chek SmartView Test Strips

E QL

Accu-Chek Soft Touch Lancets

E

Accu-Chek Softclix Kit EAccu-Chek Softclix

LancetsE

Bayer Contour Test Strips

E QL, ST

Drug NameDrug Tier

Programs and Limits

Dexcom G4 Platinum Kit

3

Dexcom G4 Platinum Sensor Kit

3

Dexcom G4 Platinum Transmitter Kit

3

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

Needle 2

Novofine Pen Needle 3Novofine Autocover

Pen Needle3

Novotwist Pen Needle

3

Onetouch Kit Ultra Smart

2

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

Mini2

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

Test Strips2 QL

Onetouch Verio Test Strips

2 QL

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

Diabetes/Endocrine: Insulin

Apidra E STHumalog Mix 50/50

Vial and KwikPen2

Humalog Mix 75-25 Vial and KwikPen

2

Humalog U-100 Vial and KwikPen

2

Humalog U-200 KwikPen

2

Humulin 70-30 Vial and KwikPen

2

15




Drug NameDrug Tier

Programs and Limits

Humulin N Vial and KwikPen

2

Humulin R U-500 Vial and KwikPen

2

Humulin R Vial 2Lantus SoloStar 2Lantus Vial 2Levemir FlexTouch ELevemir Vial ENovolin 70/30 Vial ENovolin N Vial ENovolin R Vial ENovolog Flexpen ENovolog Mix 70/30

Vial and FlexpenE

Novolog Penfill ENovolog Vial EToujeo SoloStar 2Tresiba E

Diabetes/Endocrine: Non-Insulin

alogliptin Ealogliptin/metformin Ealogliptin/

pioglitazoneE

Bydureon 2 QL, STByetta 2 QL, STFarxiga E STGlimepiride 1Glipizide 1Glipizide ER 1Glipizide XL 1Glumetza 3 PAGlyburide 1Glyburide/Metformin 1Invokamet 2 STInvokamet XR 2 STInvokana 2 STJanumet 2 STJanumet XR 2 STJanuvia 2 STJardiance 2 STJentadueto 2 STJentadueto XR 2 ST

Drug NameDrug Tier

Programs and Limits

Kazano E STKombiglyze E STMetformin 1Metformin ER 1Nesina E STOnglyza E STOseni E STPioglitazone 1Synjardy 2 STTanzeum E QL, STTradjenta 2 STTrulicity 2 QL, STVictoza 2 QL, STXigduo XR E ST

Endocrine: Growth Hormone

Genotropin E PA, SPHumatrope E PA, SPNorditropin 2 PA, SPNutropin AQ 2 PA, SPOmnitrope E PA, SPSaizen 2 PA, SPZomacton E PA, SP

Endocrine: Other

Calcitriol Cap 1Dexamethasone Tab 1H.P. Acthar 2 PA, SPHydrocortisone Tab 1Lupron Depot

3.75 mg, 11.25 mg3 PA, SP

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

2 PA, SP

Methylprednisolone Tab 1Prednisone 1Prednisolone Solution

25 mg/5 ml1

Prednisolone Syrup, Solution 15 mg/5 ml

1

Sensipar 3 PA

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Drug NameDrug Tier

Programs and Limits

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

Eye Conditions: Allergies

Azelastine Ophthalmic Solution

1

Bepreve 3 STLastacaft 3 STPataday 2Pazeo 2

Eye Conditions: Antibiotics

Besivance 3Ciprofloxacin

Ophthalmic Solution1

Erythromycin Ointment 1Gentamicin 1Moxeza 2 Neomycin/Polymyxin

B/Dexamethasone Ointment, Suspension

1

Ofloxacin Ophthalmic Solution

1

Polymyxin B/Trim-ethoprim Solution

1

Tobramycin 1Tobramycin/

Dexamethasone1

Vigamox 2

Drug NameDrug Tier

Programs and Limits

Eye Conditions: Glaucoma

Alphagan P 2Azopt 2Betimol 3Brimonidine 1Combigan 2Cosopt PF 3Dorzolamide-Timolol

Maleate1

Latanoprost 1 QLLumigan 2 QLRescula E QLSimbrinza 2Timolol 1Timoptic Ocudose 2Travatan Z 2 QLZioptan E QL

Eye Conditions: Other

Durezol Ophthalmic Emulsion

3

Lotemax Ophthalmic Gel

3 QL

Ketorolac Ophthalmic Solution

1

Prednisolone Ophthalmic Suspension

1

Restasis 3 PA

Gastrointestinal: Acid Suppression

Dexilant 2 QLDuexis E QL, STEsomeprazole (Rx only) 1 QLFamotidine Tab 20 mg

and 40 mg (Rx only)1

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

Syrup (Rx only)1

Sucralfate Tab 1Vimovo E PA, QL

17




Drug NameDrug Tier

Programs and Limits

Gastrointestinal: Nausea/Vomiting

Meclizine 1Metoclopramide 1Ondansetron Tab, ODT 1 QLTransderm-Scop 3Varubi 3 QL

Gastrointestinal: Other

Amitiza 2 QL, STApriso 2Asacol HD E STCanasa 2Creon 2Delzicol E STDipentum 3Gavilyte Solution 1Hyoscyamine Sublingual

Tab1

Lactulose 1Lialda 2Linzess 2 QL, STmesalamine DR E STMoviprep 3Omeclamox Pak 2Pancreaze E STPentasa 3Pertzye E STPolyethylene

Glycol 3350 Powder1

Prepopik 3Protosol HC 1Pylera 2Sulfasalazine 1Suprep Bowel Prep 3Uceris Foam 3Ultresa E STViokace E STZenpep 2

Drug NameDrug Tier

Programs and Limits

HIV/AIDS

Atripla 2 SP Complera 2 SPEpzicom 2 SPGenvoya 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

Infertility

Bravelle E PA, SPCetrotide 2 SPFollistim AQ E PA, SPGonal-f 2 PA, SPGonal-f RFF 2 PA, SPOvidrel 3 SP

Inflammatory Conditions

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

Crohns*2 PA, SP

Humira Pen Kit Psoriasis*

2 PA, SP

Hydroxychloroquine 1Methotrexate Tab 1Orencia SC 3 PA, ST, SPOtezla 3 PA, ST, SPOtrexup 3 PA, QL

* PA Required

18




Drug NameDrug Tier

Programs and Limits

Rasuvo 2 PA, QLSimponi* 2 PA, SPStelara* 2 PA, SPXeljanz 3 PA, ST, SP

Men’s Health: Erectile Dysfunction

Cialis 2 QLLevitra E QLStaxyn E QLStendra E QLViagra 2 QL

Men’s Health: Prostate

Alfuzosin 1Cialis 2.5 mg & 5 mg 2 QLDoxazosin 1Finasteride 5 mg 1Rapaflo 2Tamsulosin 1Terazosin 1

Men’s Health: Testosterone Therapy

Androderm 2 PAAndrogel 1.62% 2 PAAndrogel 1% E PA, STAxiron E PAFortesta E PATestim E PATestosterone Cypionate

IM Injection1 PA

Vogelxo E PA

Miscellaneous

Adrenaclick E STAllopurinol 1Antipyrine/Benzocaine

Otic Solution 5.4 - 1.4%

1

Aranesp E PA, SPAuryxia 3Auvi-Q E STBenzonatate 1

Drug NameDrug Tier

Programs and Limits

Botox 100, 200 unit Injection (non-cosmetic)

2 PA, SP

Bunavail 3 PA, QLCerdelga 3 PA, SPChantix 3 QLCheratussin 1Chlorhexidine 1Colcrys 2Cyproheptadine 1Desmopressin 1EpiPen & EpiPen Jr 2Epogen E PA, SPEuflexxa 2 PA, SPFosrenol 3Granix 2 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 2 PA, SPNeupogen 2 PA, SPPhenazopyridine

(Rx only)1

Phentermine Tab 1 PAProcrit 2 PA, SPPromethazine DM Syrup 1Promethazine/Codeine

Syrup1 AR

Pulmozyme 2 PA, SPRenvela Tab, Pack 2Rezira 3Suboxone Film 2 PA, QL

* PA Required

19




Drug NameDrug Tier

Programs and Limits

Synagis 2 PA, SPSynvisc 2 PA, SPSynvisc One 2 PA, SPUloric 2 STUrsodiol 1Velphoro 3Zarxio 2 PA, SPZostavax Injection 3Zubsolv 2 PA, QLZutripro 3

Musculoskeletal: Osteoporosis

Alendronate Tab 35 mg & 70 mg

1 QL

Binosto 3 QLEvista 3Forteo 2 PA, SPIbandronate Tab 1Raloxifene 1

Musculoskeletal: Other

Baclofen Tab 1Carisoprodol 350 mg 1Cyclobenzaprine Tab

5, 10 mg1

Lorzone 3Metaxalone 1Methocarbamol 1Tizanidine Cap 1Tizanidine Tab 1

Musculoskeletal: Pain Relief

Abstral E PA, QLAcetaminophen

w/ Codeine 1

Cambia E STCelebrex 3Celecoxib 1Diclofenac Tab 1Embeda 2 QLEndocet Tab 1Etodolac 1

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

Fentora E PA, QLGralise 3 QL, STHydrocodone/APAP

5, 7.5, 10/325 mg 1

Hydromorphone Tab 1Hysingla ER E QL, STIbuprofen Tab 400, 600,

800 mg (Rx only)1

Indomethacin Cap 1Kadian E QL, STKetorolac Tab 1 QLLazanda E PA, QLLidocaine Patch 5% 1Meloxicam 1Methadone Tab 1Morphine Sulfate Tab 1 QLNabumetone 1Naproxen (Rx only) 1Nucynta ER E QL, STOpana ER E QLOxycodone Tab 5,

10, 15, 30 mg (Immediate Release)

1

Oxycodone w/ Acetaminophen

1

Oxycontin 2 QLSubsys E PA, QLTivorbex 3 STTramadol Tab 50 mg 1Tramadol

w/ Acetaminophen 1

Vicodin 1Vicodin ES 1

20




Drug NameDrug Tier

Programs and Limits

Voltaren Gel 3 QL Zohydro ER E QL, STZorvolex E

Overactive Bladder

Myrbetriq E STOxybutynin 1Oxybutynin ER 1Tolterodine 1Toviaz 3Vesicare 2

Respiratory: Asthma/COPD

Advair Diskus 2 QLAdvair HFA 2 QLAerospan 3 QLAlbuterol

Nebulizer Solution1 QL

Alvesco E QL, STAnoro Ellipta 2 QLArnuity Ellipta 2 QLAsmanex E QL, STBreo Ellipta 2 QLBudesonide Inhalation

Suspension1 QL

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

Nebulizer Solution1 QL

Levalbuterol Nebulizer Solution

1 QL

Montelukast 1Perforomist 3 QLProair HFA, RespiClick 2 QLProventil HFA E QL, STPulmicort Flexhaler 2 QL

Drug NameDrug Tier

Programs and Limits

Qvar E QLSeebri 3 QLSerevent Diskus 2 QLSpiriva Handihaler 2 QLSpiriva Respimat 2 QLStiolto 2 QLSymbicort 2 QLTudorza E QL, STVentolin HFA 2 QLXolair 2 PA, SPXopenex HFA E QL, ST

Respiratory: Nasal Allergies

Astepro 3 QLAzelastine Spray 1 QLDymista Spray 2 QLFluticasone Spray 1Ipratropium Spray 1 QLMometasone 1 QLNasonex 2 QLOmnaris 3 QLQNasl 3 QLTriamcinolone Spray 1 QLZetonna 3 QL

Respiratory: Oral Allergies

Cetirizine 1Promethazine Tab 1Desloratadine 1Levocetirizine 1

Transplant

Azathioprine Tab 1Cellcept Tab/

Suspension3 SP

Cyclosporine Cap 1 SPMycophenolate Mofetil

250 mg Cap/ 500 mg Tab

1 SP

21




Drug NameDrug Tier

Programs and Limits

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 1Multi-Vit/Fl Chew 1Potassium Chloride ER

Tab, Cap1

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 1Aviane 1Azurette 1Cryselle-28 1Falmina 1Generess Fe

Chewable3

Gianvi 1Gildess 1Jolivette 1Junel 1Kariva 1Levora 28 1Lo Loestrin 3Lomedia Fe 1Loryna 1

Drug NameDrug Tier

Programs and Limits

Low-Ogestrel 1Lutera 1Medroxyprogesterone

Acetate Injection1 QL

Microgestin 1Microgestin Fe 1Minastrin 24 Fe

Chewable3

Mono-Linyah 1Mononessa 1Natazia 2Necon 1Nora-Be 1Norgest/Ethi Estradio 1Nortrel 1Nuvaring 2Ocella 1Orsythia 1Ortho Tri-Cyclen Lo 3Previfem 1Reclipsen 1Sprintec 28 1Tri-Linyah 1Tri-Previfem 1Trinessa 1Tri-Sprintec 1Vestura 1Viorele 1Xulane 1Zarah 1

Women’s Health: Hormone Replacement

Climara Pro 2Divigel 3Duavee 2Elestrin Gel 3Estrace Vaginal Cream 3Estradiol Tab 1Estradiol/Norethindrone

Tab1

Medroxyprogesterone Acetate Tab

1

22




Drug NameDrug Tier

Programs and Limits

Minivelle 3Osphena 3Premarin Tab 2Premarin Vaginal

Cream2

Premphase 2Prempro 2Progesterone Cap 1Vagifem 3

Women’s Health: Vaginal Anti-Infectives

Gynazole-1 Vaginal Cream

3

Metronidazole Vaginal Gel

1

Terconazole Vaginal Cream

1

Bold type = Brand-name drug [Plain type = Generic drug] 23

Index of Drugs

A

Abilify Tab . . . . . . . . . 12Abstral . . . . . . . . . . . 19Acanya Gel. . . . . . . . . 13Accu-Chek Active Glucose

Control Liquid . . . . . 14Accu-Chek Active

Test Strips . . . . . . . 14Accu-Chek Aviva

Connect Kit . . . . . . 14Accu-Chek Aviva Plus

Control Liquid . . . . . 14Accu-Chek Aviva Plus Kit . 14Accu-Chek Aviva Plus Test

Strips . . . . . . . . . . 14Accu-Chek Compact Plus

Control Liquid . . . . . 14Accu-Chek Compact

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

Test Strips . . . . . . . 14Accu-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 19Acyclovir Cap, Tab, Suspension 9Acyclovir Ointment 5% . . . 13Aczone Gel. . . . . . . . . 13Adcirca . . . . . . . . . . . 11Adderall XR Cap . . . . . . 11

Adempas. . . . . . . . . . 11Adrenaclick . . . . . . . . 18Advair Diskus . . . . . . . 20Advair HFA . . . . . . . . 20Aerospan . . . . . . . . . 20Akynzeo . . . . . . . . . . . 9Albuterol Nebulizer Solution 20Alendronate Tab . . . . . . 19Alfuzosin . . . . . . . . . . 18Allopurinol . . . . . . . . . 18alogliptin . . . . . . . . . 15alogliptin/metformin . . . 15alogliptin/pioglitazone . . 15Alphagan P . . . . . . . . 16Alprazolam Tab . . . . . . . 12Alvesco. . . . . . . . . . . 20Amiodarone. . . . . . . . . 11Amitiza. . . . . . . . . . . 17Amitriptyline . . . . . . . . 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 . . . . . . . . 18Androgel 1% . . . . . . . 18Androgel 1.62% . . . . . . 18Anoro Ellipta . . . . . . . 20Antipyrine/Benzocaine Otic

Solution 5.4 - 1.4% . . . 18Apidra . . . . . . . . . . . 14Apri . . . . . . . . . . . . . 21Apriso . . . . . . . . . . . 17Aranesp . . . . . . . . . . 18

Aripiprazole . . . . . . . . . 12Armour Thyroid . . . . . . 16Arnuity Ellipta . . . . . . . 20Asacol HD . . . . . . . . . 17Asmanex. . . . . . . . . . 20Astepro . . . . . . . . . . 20Atenolol. . . . . . . . . . . 10Atenolol/Chlorthalidone. . . 10Atorvastatin . . . . . . . . 10Atralin . . . . . . . . . . . 13Atripla . . . . . . . . . . . 17Aubagio . . . . . . . . . . 12Auryxia . . . . . . . . . . 18Auvi-Q . . . . . . . . . . . 18Aviane . . . . . . . . . . . 21Avonex Kit. . . . . . . . . 12Avonex Pen Kit . . . . . . 12Avonex Prefill Kit . . . . . 12Axiron . . . . . . . . . . . 18Azasite . . . . . . . . . . . . 9Azathioprine Tab . . . . . . 20Azelastine Ophthalmic

Solution . . . . . . . . . 16Azelastine Spray. . . . . . . 20Azithromycin . . . . . . . . . 9Azopt . . . . . . . . . . . 16Azor . . . . . . . . . . . . 10Azurette . . . . . . . . . . 21

B

Baclofen Tab . . . . . . . . 19Bayer Contour Test Strips . 14Benazepril. . . . . . . . . . 10Benazepril/HCTZ . . . . . . 10Benicar . . . . . . . . . . . 10Benicar HCT . . . . . . . . 10Benzaclin. . . . . . . . . . 13Benzamycin . . . . . . . . 13Benzonatate . . . . . . . . 18Benztropine . . . . . . . . . 12Bepreve . . . . . . . . . . 16


Index of Drugs

Besivance . . . . . . . . . 16Betamethasone Dipropionate

Cream. . . . . . . . . . 13Betaseron . . . . . . . . . 12Bethkis . . . . . . . . . . . . 9Betimol. . . . . . . . . . . 16Binosto. . . . . . . . . . . 19Bisoprolol . . . . . . . . . . 10Bisoprolol/HCTZ . . . . . . . 10Botox 100, 200 unit

Injection . . . . . . . . 18Bravelle . . . . . . . . . . 17Breo Ellipta . . . . . . . . 20Brilinta . . . . . . . . . . . 10Brimonidine . . . . . . . . . 16Budesonide Inhalation

Suspension . . . . . . . 20Bumetanide . . . . . . . . . 10Bunavail . . . . . . . . . . 18Bupropion. . . . . . . . . . 11Bupropion ER . . . . . . . . 11Bupropion SR . . . . . . . . 11Bupropion XL . . . . . . . . 11Buspirone . . . . . . . . . . 12Butalbital-Acetaminophen-

Caffeine Cap, Tab . . . . 12Bydureon . . . . . . . . . 15Byetta . . . . . . . . . . . 15Bystolic. . . . . . . . . . . 10

C

Calcitriol Cap . . . . . . . . 15Cambia. . . . . . . . . . . 19Canasa . . . . . . . . . . . 17Capecitabine . . . . . . . . . 9Carbamazepine Tab . . . . . 12Carbidopa/Levodopa Tab . . 12Carisoprodol . . . . . . . . 19Cartia XT . . . . . . . . . . 10Carvedilol . . . . . . . . . . 10Cefadroxil Cap . . . . . . . . 9

Cefdinir . . . . . . . . . . . . 9Cefuroxime Tab . . . . . . . . 9Celebrex . . . . . . . . . . 19Celecoxib . . . . . . . . . . 19Cellcept Tab/Suspension . 20Cephalexin . . . . . . . . . . 9Cerdelga . . . . . . . . . . 18Cetirizine . . . . . . . . . . 20Cetrotide. . . . . . . . . . 17Chantix. . . . . . . . . . . 18Cheratussin . . . . . . . . . 18Chlorhexidine . . . . . . . . 18Chlorthalidone . . . . . . . 10Cholestyramine . . . . . . . 10Cialis . . . . . . . . . . . . 18Ciclopirox Cream . . . . . . 13Cimzia Kit . . . . . . . . . 17Ciprodex Otic Suspension . 9Ciprofloxacin Ophthalmic

Solution . . . . . . . . . 16Ciprofloxacin Tab . . . . . . . 9Clarithromycin . . . . . . . . 9Climara Pro . . . . . . . . 21Clindamycin/Benzoyl Peroxide

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

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

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

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

Cream, Lotion . . . . . . 13Colcrys . . . . . . . . . . . 18Combigan . . . . . . . . . 16Combivent Respimat . . . 20

Complera . . . . . . . . . 17Copaxone . . . . . . . . . 12Corlanor . . . . . . . . . . 11Cortifoam . . . . . . . . . 13Cosopt PF . . . . . . . . . 16Creon. . . . . . . . . . . . 17Crestor . . . . . . . . . . . 10Cryselle-28 . . . . . . . . . 21Cyanocobalamine Injection . 21Cyclobenzaprine Tab . . . . 19Cyclosporine Cap . . . . . . 20Cyproheptadine . . . . . . . 18

D

Daklinza . . . . . . . . . . . 9Delzicol . . . . . . . . . . 17Depen . . . . . . . . . . . 17Desloratadine . . . . . . . . 20Desmopressin . . . . . . . . 18Desonide Cream, Ointment . 13Desoximetasone Cream, Gel,

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

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

Transmitter Kit. . . . . 14Dexilant . . . . . . . . . . 16Dexmethylphenidate ER Cap 11Diazepam Tab . . . . . . . . 12Diclofenac Tab . . . . . . . 19Differin. . . . . . . . . . . 13Digoxin . . . . . . . . . . . 11Diltiazem Tab . . . . . . . . 10Dipentum . . . . . . . . . 17Divalproex DR . . . . . . . . 12Divalproex ER . . . . . . . . 12Divigel . . . . . . . . . . . 21Donepezil Tab . . . . . . . . 12Doryx MPC. . . . . . . . . . 9


Index of Drugs

Dorzolamide-Timolol Maleate 16Doxazosin . . . . . . . . 10, 18Doxepin . . . . . . . . . . . 11Doxycycline Hyclate Cap . . . 9Doxycycline Hyclate Tab . . . . 9Doxycycline Monohydrate Cap 9Doxycycline Monohydrate Oral

Suspension, Tab . . . . . . 9Duac . . . . . . . . . . . . 13Duavee. . . . . . . . . . . 21Duexis . . . . . . . . . . . 16Dulera . . . . . . . . . . . 20Duloxetine Cap . . . . . . . 11Durezol Ophthalmic

Emulsion . . . . . . . . 16Dymista Spray . . . . . . . 20

E

Econazole Cream . . . . . . 13Edarbi . . . . . . . . . . . 10Edarbyclor . . . . . . . . . 10Effient . . . . . . . . . . . 10Elestrin Gel . . . . . . . . 21Elidel . . . . . . . . . . . . 13Eliquis . . . . . . . . . . . 10Embeda . . . . . . . . . . 19Enalapril. . . . . . . . . . . 10Enalapril/HCTZ . . . . . . . 10Endocet Tab. . . . . . . . . 19Enoxaparin . . . . . . . . . 10Entecavir . . . . . . . . . . . 9Epclusa. . . . . . . . . . . . 9Epiduo & Epiduo Forte . . 13EpiPen & EpiPen Jr . . . . 18Epogen. . . . . . . . . . . 18Epzicom . . . . . . . . . . 17Erythromycin . . . . . . . . . 9Erythromycin Ointment . . . 16Escitalopram Tab . . . . . . 11Esomeprazole . . . . . . . . 16Estrace Vaginal Cream . . 21

Estradiol/Norethindrone Tab . 21Estradiol Tab . . . . . . . . 21Eszopiclone Tab . . . . . . . 12Etodolac . . . . . . . . . . 19Euflexxa . . . . . . . . . . 18Evekeo . . . . . . . . . . . 11Evista. . . . . . . . . . . . 19Extavia . . . . . . . . . . . 12

F

Falmina . . . . . . . . . . . 21Famciclovir Tab . . . . . . . . 9Famotidine Tab . . . . . . . 16Farxiga . . . . . . . . . . . 15Felodipine . . . . . . . . . . 10Fenofibrate . . . . . . . . . 10Fentanyl Patch . . . . . . . 19Fentora. . . . . . . . . . . 19Finacea. . . . . . . . . . . 13Finasteride . . . . . . . . . 18Flecainide . . . . . . . . . . 11Flovent Diskus. . . . . . . 20Flovent HFA . . . . . . . . 20Fluconazole . . . . . . . . . . 9Fluocinonide Cream, 0.1% . 13Fluocinonide Cream, Gel,

Ointment, Solution 0.05% 13Fluoxetine Cap . . . . . . . 11Fluticasone Spray . . . . . . 20Fluvoxamine Tab . . . . . . 11Folic Acid 1 mg . . . . . . . 21Follistim AQ . . . . . . . . 17Foradil . . . . . . . . . . . 20Forfivo XL . . . . . . . . . 11Forteo . . . . . . . . . . . 19Fortesta . . . . . . . . . . 18Fosinopril . . . . . . . . . . 10Fosrenol . . . . . . . . . . 18Freestyle Test Strips . . . . 14Furosemide . . . . . . . . . 10

G

Gabapentin . . . . . . . . . 12Gavilyte Solution . . . . . . 17Gemfibrozil . . . . . . . . . 10Generess Fe Chewable . . 21Genotropin . . . . . . . . 15Gentamicin . . . . . . . . . 16Genvoya . . . . . . . . . . 17Gianvi . . . . . . . . . . . . 21Gildess . . . . . . . . . . . 21Gilenya. . . . . . . . . . . 12Glimepiride . . . . . . . . . 15Glipizide . . . . . . . . . . 15Glipizide ER . . . . . . . . . 15Glipizide XL . . . . . . . . . 15Glumetza . . . . . . . . . 15Glyburide . . . . . . . . . . 15Glyburide/Metformin . . . . 15Gonal-f . . . . . . . . . . . 17Gonal-f RFF . . . . . . . . 17Gralise . . . . . . . . . . . 19Granix . . . . . . . . . . . 18Guaifenesin/Codeine Syrup . 18Guanfacine ER Tab . . . . . 11Guanfacine Tab . . . . . . . 10Gynazole-1 Vaginal Cream 22

H

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

Syrup . . . . . . . . . . 18H.P. Acthar . . . . . . . . . 15Humalog Mix 50/50 Vial and

KwikPen . . . . . . . . 14Humalog Mix 75-25 Vial and

KwikPen . . . . . . . . 14Humalog U-100 Vial and

KwikPen . . . . . . . . 14Humalog U-200 KwikPen . 14Humatrope . . . . . . . . 15Humira Kit . . . . . . . . . 17


Index of Drugs

Humira Pen Kit . . . . . . 17Humira Pen Kit Crohns . . 17Humira Pen Kit Psoriasis . 17Humulin 70-30 Vial and

KwikPen . . . . . . . . 14Humulin N Vial and

KwikPen . . . . . . . . 15Humulin R U-500 Vial and

KwikPen . . . . . . . . 15Humulin R Vial. . . . . . . 15Hydralazine . . . . . . . . . 10Hydrochlorothiazide. . . . . 10Hydrocodone/APAP . . . . . 19Hydrocodone/Chlorpheniramine

Liquid . . . . . . . . . . 18Hydrocortisone AC

Suppository . . . . . . . 18Hydrocortisone Cream,

Ointment 2.5% . . . . . 13Hydrocortisone Tab . . . . . 15Hydromet . . . . . . . . . . 18Hydromorphone Tab . . . . 19Hydroxychloroquine . . . . . 17Hydroxyzine HCL . . . . . . 12Hydroxyzine Pamoate . . . . 12Hyoscyamine Sublingual Tab 17Hysingla ER . . . . . . . . 19

I

Ibandronate Tab. . . . . . . 19Ibuprofen Tab . . . . . . . . 19Incruse Ellipta . . . . . . . 20Indomethacin Cap . . . . . 19Insulin Pen Needle . . . . 14Insulin Syringe/Needle . . 14Intelence . . . . . . . . . 17Invokamet . . . . . . . . . 15Invokamet XR . . . . . . . 15Invokana. . . . . . . . . . 15Ipratropium/Albuterol Nebulizer

Solution . . . . . . . . . 20

Ipratropium Spray . . . . . . 20Irbesartan . . . . . . . . . . 10Irbesartan/HCTZ. . . . . . . 10Isentress . . . . . . . . . . 17Isosorbide Mononitrate . . . 11

J

Janumet . . . . . . . . . . 15Janumet XR . . . . . . . . 15Januvia. . . . . . . . . . . 15Jardiance. . . . . . . . . . 15Jentadueto. . . . . . . . . 15Jentadueto XR. . . . . . . 15Jolivette . . . . . . . . . . . 21Jublia Solution. . . . . . . . 9Junel . . . . . . . . . . . . 21

K

Kadian . . . . . . . . . . . 19Kaletra . . . . . . . . . . . 17Kariva . . . . . . . . . . . . 21Kazano. . . . . . . . . . . 15Kerydin Solution . . . . . . 9Ketoconazole Cream/

Shampoo . . . . . . . . 13Ketorolac Ophthalmic

Solution . . . . . . . . . 16Ketorolac Tab . . . . . . . . 19Kitabis . . . . . . . . . . . . 9Klor-Con 8 and 10 MEQ. . . 21Klor-Con M10 and M20. . . 21Kombiglyze . . . . . . . . 15

L

Labetalol . . . . . . . . . . 10Lactulose . . . . . . . . . . 17Lamotrigine ER . . . . . . . 12Lamotrigine . . . . . . . . 12Lansoprazole . . . . . . . . 16Lantus SoloStar . . . . . . 15

Lantus Vial . . . . . . . . . 15Lastacaft . . . . . . . . . . 16Latanoprost . . . . . . . . . 16Latuda . . . . . . . . . . . 12Lazanda . . . . . . . . . . 19Letairis . . . . . . . . . . . 11Letrozole . . . . . . . . . . . 9Levalbuterol

Nebulizer Solution. . . . 20Levemir FlexTouch. . . . . 15Levemir Vial . . . . . . . . 15Levetiracetam . . . . . . . . 12Levetiracetam ER . . . . . . 12Levitra . . . . . . . . . . . 18Levocetirizine . . . . . . . . 20Levofloxacin Tab. . . . . . . . 9Levora 28 . . . . . . . . . . 21Levothyroxine . . . . . . . . 16Lialda. . . . . . . . . . . . 17Lidocaine Patch 5% . . . . . 19Lidocaine/Prilocaine Cream . 13Lidocaine Topical Ointment,

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

Solution 2%. . . . . . . 18Linzess . . . . . . . . . . . 17Liothyronine . . . . . . . . 16Lipitor . . . . . . . . . . . 11Lisinopril . . . . . . . . . . 10Lisinopril/HCTZ . . . . . . . 10Lithium Carbonate . . . . . 12Livalo. . . . . . . . . . . . 11Lo Loestrin . . . . . . . . . 21Lomedia Fe . . . . . . . . . 21Lorazepam Tab . . . . . . . 12Loryna . . . . . . . . . . . 21Lorzone . . . . . . . . . . 19Losartan. . . . . . . . . . . 10Losartan/HCTZ . . . . . . . 10Lotemax Ophthalmic Gel . 16Lovastatin . . . . . . . . . 11Lovaza . . . . . . . . . . . 11


Index of Drugs

Low-Ogestrel . . . . . . . . 21Lumigan . . . . . . . . . . 16Lupron Depot . . . . . . . 15Lutera . . . . . . . . . . . . 21Lyrica Cap . . . . . . . . . 13

M

Makena . . . . . . . . . . 18Meclizine . . . . . . . . . . 17Medroxyprogesterone Acetate

Injection. . . . . . . . . 21Medroxyprogesterone Acetate

Tab . . . . . . . . . . . 21Meloxicam . . . . . . . . . 19mesalamine DR . . . . . . 17Metaxalone . . . . . . . . . 19Metformin . . . . . . . . . 15Metformin ER . . . . . . . . 15Methadone Tab . . . . . . . 19Methimazole . . . . . . . . 16Methocarbamol . . . . . . . 19Methotrexate Tab . . . . . . 17Methylphenidate ER Cap . . 11Methylphenidate ER Tab. . . 11Methylphenidate SA Osmotic

ER Tab. . . . . . . . . . 11Methylphenidate Tab . . . . 11Methylprednisolone Tab . . . 15Metoclopramide . . . . . . 17Metoprolol Succinate . . . . 10Metoprolol Tartrate . . . . . 10Metrogel . . . . . . . . . . 13Metronidazole Gel 0.75%. . 13Metronidazole Tab . . . . . . 9Metronidazole Vaginal Gel . 22Microgestin . . . . . . . . . 21Microgestin Fe . . . . . . . 21Migranal . . . . . . . . . . 12Minastrin 24 Fe Chewable 21Minivelle . . . . . . . . . . 22Minocycline Cap . . . . . . . 9

Mirtazapine . . . . . . . . . 11Mirvaso Gel . . . . . . . . 13Modafinil . . . . . . . . . . 12Mometasone . . . . . . . . 20Mono-Linyah . . . . . . . . 21Mononessa . . . . . . . . . 21Montelukast . . . . . . . . 20Morphine Sulfate Tab . . . . 19Moviprep . . . . . . . . . 17Moxeza . . . . . . . . . . 16Moxifloxacin . . . . . . . . . 9Multi-Vit/Fl Chew . . . . . . 21Mupirocin Ointment . . . . 13Mycophenolate Mofetil . . . 20Mycophenolate Sodium . . . 21Myrbetriq . . . . . . . . . 20

N

Nabumetone . . . . . . . . 19Nadolol . . . . . . . . . . . 10Namenda XR. . . . . . . . 12Namzaric . . . . . . . . . . 12Naproxen . . . . . . . . . . 19Nasonex . . . . . . . . . . 20Natazia. . . . . . . . . . . 21Necon. . . . . . . . . . . . 21Neomycin/Polymyxin B/

Dexamethasone Ointment, Suspension . . . . . . . 16

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

Nesina . . . . . . . . . . . 15Neupogen . . . . . . . . . 18Nevirapine . . . . . . . . . 17Niacin ER Tab . . . . . . . . 11Nifedipine ER . . . . . . . . 10Nitrofurantoin Macrocrystalline 9Nitrofurantoin Monohydrate

Macrocrystalline . . . . . . 9Nitrostat . . . . . . . . . . 11Nora-Be . . . . . . . . . . . 21

Norditropin . . . . . . . . 15Norgest/Ethi Estradio . . . . 21Nortrel . . . . . . . . . . . 21Nortriptyline. . . . . . . . . 11Norvir . . . . . . . . . . . 17Novofine Autocover Pen

Needle . . . . . . . . . 14Novofine Pen Needle . . . 14Novolin 70/30 Vial. . . . . 15Novolin N Vial . . . . . . . 15Novolin R Vial . . . . . . . 15Novolog Flexpen . . . . . 15Novolog Mix 70/30 Vial and

Flexpen. . . . . . . . . 15Novolog Penfill . . . . . . 15Novolog Vial. . . . . . . . 15Novotwist Pen Needle . . 14Nucynta ER . . . . . . . . 19Nutropin AQ. . . . . . . . 15Nuvaring. . . . . . . . . . 21Nuvigil . . . . . . . . . . . 12Nystatin Cream, Ointment,

Powder . . . . . . . . . 13Nystatin Suspension. . . . . . 9Nystatin/Triamcinolone Cream,

Ointment . . . . . . . . 13

O

Ocella . . . . . . . . . . . . 21Ofloxacin Ophthalmic Solution 16Ofloxacin Otic Solution . . . . 9Olanzapine Tab . . . . . . . 12Omeclamox Pak . . . . . . 17Omega-3 Acid Cap . . . . . 11Omeprazole . . . . . . . . . 16Omnaris . . . . . . . . . . 20Omnitrope . . . . . . . . . 15Ondansetron Tab, ODT . . . 17Onetouch Kit Ultra . . . . 14Onetouch Kit Ultra 2 . . . 14Onetouch Kit Ultra Mini . 14


Index of Drugs

Onetouch Kit Ultra Smart. 14Onetouch Kit Verio IQ. . . 14Onetouch Test Strips . . . 14Onetouch Ultra Blue Test

Strips . . . . . . . . . . 14Onetouch Verio Test Strips 14Onexton . . . . . . . . . . 13Onfi . . . . . . . . . . . . 13Onglyza . . . . . . . . . . 15Opana ER . . . . . . . . . 19Opsumit . . . . . . . . . . 11Oracea . . . . . . . . . . . . 9Orencia SC . . . . . . . . . 17Orenitram . . . . . . . . . 11Orsythia . . . . . . . . . . . 21Ortho Tri-Cyclen Lo . . . . 21Oseni . . . . . . . . . . . . 15Osphena . . . . . . . . . . 22Otezla . . . . . . . . . . . 17Otrexup . . . . . . . . . . 17Ovidrel . . . . . . . . . . . 17Oxcarbazepine . . . . . . . 13Oxsoralen-UL . . . . . . . 13Oxybutynin . . . . . . . . . 20Oxybutynin ER . . . . . . . 20Oxycodone Tab . . . . . . . 19Oxycodone

w/ Acetaminophen . . . 19Oxycontin . . . . . . . . . 19

P

Pancreaze . . . . . . . . . 17Pantoprazole . . . . . . . . 16Paroxetine Tab . . . . . . . 11Pataday . . . . . . . . . . 16Pazeo. . . . . . . . . . . . 16Penicillin VK. . . . . . . . . . 9Pentasa . . . . . . . . . . 17Perforomist . . . . . . . . 20Permethrin Cream 5% . . . 13Pertzye. . . . . . . . . . . 17

Phenazopyridine . . . . . . 18Phentermine Tab . . . . . . 18Phenytoin . . . . . . . . . . 13Pioglitazone. . . . . . . . . 15Plegridy . . . . . . . . . . 12Polyethylene

Glycol 3350 Powder. . . 17Polymyxin B/Trim-ethoprim

Solution . . . . . . . . . 16Potassium Chloride ER

Tab, Cap. . . . . . . . . 21Potassium Chloride Micro

ER Tab. . . . . . . . . . 21Potassium Citrate . . . . . . 21Pradaxa . . . . . . . . . . 10Praluent . . . . . . . . . . 11Pravastatin . . . . . . . . . 11Precision Test Strips . . . . 14Prednisolone Ophthalmic

Suspension . . . . . . . 16Prednisolone Solution . . . . 15Prednisolone Syrup, Solution 15Prednisone . . . . . . . . . 15Premarin Tab. . . . . . . . 22Premarin Vaginal Cream . 22Premphase . . . . . . . . . 22Prempro . . . . . . . . . . 22Prepopik . . . . . . . . . . 17Previfem . . . . . . . . . . 21Prezcobix . . . . . . . . . 17Prezista . . . . . . . . . . 17Primidone . . . . . . . . . . 13Pristiq . . . . . . . . . . . 11Proair HFA, RespiClick. . . 20Prochlorperazine . . . . . . 12Procrit . . . . . . . . . . . 18Proctofoam HC . . . . . . 13Progesterone Cap . . . . . . 22Prograf Cap . . . . . . . . 21Promethazine/Codeine Syrup 18Promethazine DM Syrup . . 18Promethazine Tab . . . . . . 20

Propranolol . . . . . . . . . 10Propranolol ER . . . . . . . 10Protosol HC . . . . . . . . . 17Proventil HFA . . . . . . . 20Pulmicort Flexhaler . . . . 20Pulmozyme . . . . . . . . 18Pylera . . . . . . . . . . . 17

Q

QNasl. . . . . . . . . . . . 20Quetiapine . . . . . . . . . 12Quinapril . . . . . . . . . . 10Qvar . . . . . . . . . . . . 20

R

Raloxifene. . . . . . . . . . 19Ramipril . . . . . . . . . . . 10Ranexa . . . . . . . . . . . 11Ranitidine Tab, Cap, Syrup . 16Rapaflo. . . . . . . . . . . 18Rapamune . . . . . . . . . 21Rasuvo . . . . . . . . . . . 18Rebif . . . . . . . . . . . . 12Rebif Titrtn . . . . . . . . 12Reclipsen . . . . . . . . . . 21Relpax . . . . . . . . . . . 12Renvela Tab, Pack . . . . . 18Rescula. . . . . . . . . . . 16Restasis . . . . . . . . . . 16Retin-A Micro . . . . . . . 13Revlimid . . . . . . . . . . . 9Rexulti . . . . . . . . . . . 12Reyataz . . . . . . . . . . 17Rezira . . . . . . . . . . . 18Risperidone Tab . . . . . 11, 12Rizatriptan Tab, ODT . . . . 12Ropinirole . . . . . . . . . 12Rosuvastatin . . . . . . . . 11


Index of Drugs

S

Saizen . . . . . . . . . . . 15Saphris . . . . . . . . . . . 12Savaysa . . . . . . . . . . 10Seebri . . . . . . . . . . . 20Sensipar . . . . . . . . . . 15Serevent Diskus . . . . . . 20Seroquel XR . . . . . . . . 12Sertraline . . . . . . . . . . 11Sildenafil Tab . . . . . . . . 11Silenor . . . . . . . . . . . 12Simbrinza . . . . . . . . . 16Simponi . . . . . . . . . . 18Simvastatin . . . . . . . . . 11Solodyn . . . . . . . . . . . 9Soolantra . . . . . . . . . 13Sotalol . . . . . . . . . . . 11Sovaldi . . . . . . . . . . . . 9Spiriva Handihaler . . . . 20Spiriva Respimat . . . . . 20Spironolactone . . . . . . . 10Sprintec 28 . . . . . . . . . 21Sprycel . . . . . . . . . . . . 9Staxyn . . . . . . . . . . . 18Stelara . . . . . . . . . . . 18Stendra . . . . . . . . . . 18Stiolto . . . . . . . . . . . 20Strattera . . . . . . . . . . 11Stribild . . . . . . . . . . . 17Suboxone Film. . . . . . . 18Subsys . . . . . . . . . . . 19Sucralfate Tab . . . . . . . . 16Sulfacetamide/Sulfur Emulsion 13Sulfamethoxazole-Trimethoprim 9Sulfamethoxazole-

Trimethoprim DS . . . . . 9Sulfasalazine . . . . . . . . 17Sumatriptan Tab and Spray . 12Sumavel Dose . . . . . . . 12Suprep Bowel Prep . . . . 17Sustiva . . . . . . . . . . . 17

Symbicort . . . . . . . . . 20Synagis. . . . . . . . . . . 19Synjardy . . . . . . . . . . 15Synthroid . . . . . . . . . 16Synvisc . . . . . . . . . . . 19Synvisc One . . . . . . . . 19

T

Taclonex . . . . . . . . . . 13Tacrolimus Cap . . . . . . . 21Tamiflu . . . . . . . . . . . . 9Tamoxifen Tab. . . . . . . . . 9Tamsulosin . . . . . . . . . 18Tanzeum . . . . . . . . . . 15Tasigna. . . . . . . . . . . . 9Tazorac. . . . . . . . . . . 13Tecfidera . . . . . . . . . . 12Tekturna . . . . . . . . . . 10Tekturna HCT . . . . . . . 10Telmisartan . . . . . . . . . 10Temazepam . . . . . . . . . 12Temozolomide . . . . . . . . 9Terazosin . . . . . . . . . . 10Terazosin . . . . . . . . . . 18Terbinafine Tab . . . . . . . . 9Terconazole Vaginal Cream . 22Testim . . . . . . . . . . . 18Testosterone Cypionate IM

Injection. . . . . . . . . 18Timolol . . . . . . . . . . . 16Timoptic Ocudose . . . . . 16Tirosint. . . . . . . . . . . 16Tivicay . . . . . . . . . . . 17Tivorbex . . . . . . . . . . 19Tizanidine Cap . . . . . . . 19Tizanidine Tab. . . . . . . . 19TOBI Nebulizer . . . . . . . 9TOBI Podhaler . . . . . . . . 9Tobramycin . . . . . . . . . 16Tobramycin/Dexamethasone. 16Tolterodine . . . . . . . . . 20

Topiramate Tab . . . . . . . 13Torsemide Tab. . . . . . . . 10Toujeo SoloStar . . . . . . 15Toviaz . . . . . . . . . . . 20Tracleer . . . . . . . . . . 11Tradjenta. . . . . . . . . . 15Tramadol Tab . . . . . . . . 19Tramadol w/ Acetaminophen 19Transderm-Scop . . . . . . 17Travatan Z . . . . . . . . . 16Trazodone. . . . . . . . . . 12Tresiba . . . . . . . . . . . 15Tretinoin Cream . . . . . . . 13Tretinoin Microsphere Gel . . 13Triamcinolone . . . . . . . . 13Triamcinolone Spray. . . . . 20Triamterene/HCTZ . . . . . . 10Triazolam Tab . . . . . . . . 12Tribenzor. . . . . . . . . . 10Tri-Linyah . . . . . . . . . . 21Trinessa . . . . . . . . . . . 21Tri-Previfem . . . . . . . . . 21Tri-Sprintec . . . . . . . . . 21Triumeq . . . . . . . . . . 17Truetest Test Strips . . . . 14Truetrack Test Strips. . . . 14Trulicity . . . . . . . . . . 15Truvada . . . . . . . . . . 17Tudorza . . . . . . . . . . 20Uceris Foam . . . . . . . . 17

U

Uloric. . . . . . . . . . . . 19Ultresa . . . . . . . . . . . 17Ursodiol . . . . . . . . . . . 19

V

Vagifem . . . . . . . . . . 22Valacyclovir . . . . . . . . . . 9Valsartan . . . . . . . . . . 10Valsartan/HCTZ . . . . . . . 10


Index of Drugs

Varubi . . . . . . . . . . . 17Vascepa . . . . . . . . . . 11Vectical. . . . . . . . . . . 13Velphoro . . . . . . . . . . 19Veltin. . . . . . . . . . . . 13Venlafaxine ER Cap . . . . . 12Venlafaxine ER Tab . . . . . 12Venlafaxine Tab . . . . . . . 12Ventolin HFA . . . . . . . 20Verapamil ER . . . . . . . . 10Vesicare . . . . . . . . . . 20Vestura . . . . . . . . . . . 21Viagra . . . . . . . . . . . 18Vicodin . . . . . . . . . . . 19Vicodin ES. . . . . . . . . . 19Victoza . . . . . . . . . . . 15Vigamox . . . . . . . . . . 16Viibryd . . . . . . . . . . . 12Vimovo . . . . . . . . . . 16Vimpat . . . . . . . . . . . 13Viokace . . . . . . . . . . 17Viorele . . . . . . . . . . . 21Viread . . . . . . . . . . . 17Vitamin D . . . . . . . . . . 21Vogelxo . . . . . . . . . . 18Voltaren Gel . . . . . . . . 20Vytorin . . . . . . . . . . . 11Vyvanse . . . . . . . . . . 11

W

Warfarin . . . . . . . . . . 10Welchol . . . . . . . . . . 11

X

Xarelto . . . . . . . . . . . 10Xeljanz . . . . . . . . . . . 18Xigduo XR . . . . . . . . . 15Xolair. . . . . . . . . . . . 20Xopenex HFA . . . . . . . 20Xulane . . . . . . . . . . . 21

Z

Zarah . . . . . . . . . . . . 21Zarxio . . . . . . . . . . . 19Zenpep . . . . . . . . . . 17Zepatier . . . . . . . . . . . 9Zetia . . . . . . . . . . . . 11Zetonna . . . . . . . . . . 20Ziana Gel. . . . . . . . . . 13Zioptan. . . . . . . . . . . 16Ziprasidone Cap. . . . . . . 12Zohydro ER . . . . . . . . 20Zolmitriptan Tab. . . . . . . 12Zolpidem . . . . . . . . . . 12Zolpidem ER. . . . . . . . . 12Zomacton . . . . . . . . . 15Zonisamide . . . . . . . . . 13Zorvolex . . . . . . . . . . 20Zostavax Injection. . . . . 19Zovirax Cream . . . . . . . 13Zovirax Ointment . . . . . 13Zubsolv . . . . . . . . . . 19Zutripro . . . . . . . . . . 19Zyclara . . . . . . . . . . . 13Zytiga . . . . . . . . . . . . 9

31

“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

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