Your 2017 Prescription Drug List - OptumRx · 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

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 2017 Prescription Drug List

OptumRx | optumrx.com 1

Effective January 1, 2017

2

Your Prescription Drug List

This Prescription Drug List (PDL) outlines the most commonly prescribed medications from your plan’s complete pharmacy benefit coverage list, also known as a formulary. A formulary identifies the drugs available for certain conditions and organizes them into cost levels, also known as tiers. An important part of the PDL is giving you choices so you and your doctor can choose the best course of treatment for you.

Go to optumrx.com for complete and up-to-date drug information

Since the PDL 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 . . . . . . . . . . . . . . . . . . . . . . . . . . 14

EndocrineGrowth Hormone . . . . . . . . . . . . . . . . . . . . . 14Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Thyroid Hormone Replacement . . . . . . . . . . . 15

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

GastrointestinalAcid Suppression . . . . . . . . . . . . . . . . . . . . . . 15Nausea/Vomiting . . . . . . . . . . . . . . . . . . . . . . 16Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

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

Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Inflammatory Conditions . . . . . . . . . . . . . . 16

Men’s HealthProstate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Testosterone Therapy . . . . . . . . . . . . . . . . . . . 17

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

MusculoskeletalOsteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . 17 Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Pain Relief . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Overactive Bladder . . . . . . . . . . . . . . . . . . . 18

RespiratoryAsthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . 18Nasal Allergies . . . . . . . . . . . . . . . . . . . . . . . . 18Oral Allergies . . . . . . . . . . . . . . . . . . . . . . . . . 19

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

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

Women’s HealthBirth Control . . . . . . . . . . . . . . . . . . . . . . . . . 19Hormone Replacement . . . . . . . . . . . . . . . . . 20Vaginal Anti-Infectives . . . . . . . . . . . . . . . . . . 20

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

4

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 Prescription Drug List.

What is a Prescription Drug List (PDL)?

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 PDL 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 Prescription Drug List?

When choosing a medication, you and your doctor should consult the PDL. It will help you and your doctor choose the most cost-effective prescription drugs. This guide tells you if a medication is generic or brand, and if special rules apply. Bring this list with you when you see your doctor. It is organized by common medical conditions. Medications are then listed alphabetically.

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

5

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

Tier 1 Preferrred Generics

Lower-cost generic drugs.

Tier 2 Non-preferred generics

Higher-cost generic drugs.

Tier 3 Preferred Brands

Lower-cost brand drugs.

Tier 4 Non-Preferred Brands

Higher-cost brand drugs.

Tier 5 Specialty

Specialty drugs.

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.

$

$$

$$$

$$$$

$$$$$

$

$$

$$$

$$$$

$$$$$

$

$$

$$$

$$$$

$$$$$

$

$$

$$$

$$$$

$$$$$

$

$$

$$$

$$$$

$$$$$

6

When does the Prescription Drug List change?

• Medications may move to a lower tier at any time. • Medications may move to a higher tier when 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.

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.

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.

7

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, Coumadin) and generic drugs in plain type (for example, Warfarin).

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.

8

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 PDL.

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 PDL 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.

9

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

PA Prior Authorization ST Step Therapy

QL Quantity Limits SP Specialty Program

Drug NameDrug Tier

Programs and Limits

Anti-Infectives: Antibiotics

Amoxicillin 1Amoxicillin/Clavulanate 1Azasite 5Azithromycin 1Bethkis 5 SPCefadroxil Cap 1Cefdinir 1Cefuroxime Tab 1Cephalexin 1Ciprodex Otic

Suspension4

Ciprofloxacin Tab 1Clarithromycin 1Clindamycin Cap 1Doryx MPC 4 STDoxycycline Hyclate Cap 1Doxycycline Hyclate Tab

(immediate Release)1

Doxycycline Monohydrate Cap

1 QL

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

HC Otic Suspension, Solution

1

Nitrofurantoin Macrocrystalline

1

Nitrofurantoin Monohydrate Macrocrystalline

1

Ofloxacin Otic Solution 1Oracea 4 QLPenicillin VK 1Solodyn 4 QLSulfamethoxazole-

Trimethoprim1

Sulfamethoxazole-Trimethoprim DS

1

Drug NameDrug Tier

Programs and Limits

Anti-Infectives: Antifungals

Fluconazole 1Jublia Solution 4 PAKerydin Solution 4 PANystatin Suspension 1Terbinafine Tab 1

Anti-Infectives: Antivirals

Acyclovir Tab, Cap, Suspension

1

Daklinza 5 PA, QL, SPEntecavir 5 QL, SPEpclusa 5 PA, QL, SPFamciclovir Tab 1Harvoni 5 PA, QL, SPSovaldi 5 PA, QL, SPTamiflu 4 QLValacyclovir 1Zepatier 5 PA, QL, SP

Cancer

Akynzeo 4 QLAnastrozole Tab 1Capecitabine 5 PA, SPGleevec 5 PA, QL, SPLetrozole 1 PARevlimid 5 PA, QL, SPSprycel 5 PA, SPTamoxifen Tab 1Tasigna 5 PA, QL, SPTemozolmide 5 PA, SPZytiga 5 PA, SPCardiovascular/Heart Disease: AnticoagulantsBrilinta 3 QLClopidogrel 1 QLEffient 3 QLEliquis 4 QLEnoxaparin 1Pradaxa 3 QLSavaysa 4 QLWarfarin 1Xarelto 3 QL

10




Drug NameDrug Tier

Programs and Limits

Cardiovascular/Heart Disease: High Blood PressureAmlodipine 1 QLAmlodipine/Benazepril 1 QLAtenolol 1Atenolol/Chlorthalidone 1Azor 3 QL, STBenazepril 1Benazepril/HCTZ 1Benicar 3 QL, STBenicar HCT 3 QL, STBisoprolol 1Bisoprolol/HCTZ 1Bumetanide 1Bystolic 3 QLCartia XT 1 QLCarvedilol 1Chlorthalidone 1Clonidine Patch 1Clonidine Tab 1Coreg CR 4 QL, STDiltiazem tab 1Diovan 4 QL, STDoxazosin 1Edarbi 4 QL, STEdarbyclor 4 QL, STEnalapril 1Enalapril/HCTZ 1Felodipine 1 QLFosinopril 1Furosemide 1Guanfacine Tab

Immediate Release1

Hydralazine 1Hydrochlorothiazide 1Irbesartan 1 QLIrbesartan/HCTZ 1 QLLabetalol 1Lisinopril 1Lisinopril/HCTZ 1Losartan 1 QLLosartan/HCTZ 1 QLMetoprolol Succinate 1Metoprolol Tartrate 1

Drug NameDrug Tier

Programs and Limits

Nadolol 1Nifedipine ER 1Propranolol 1Propranolol ER 1Quinapril 1Ramipril 1 QLSpironolactone 1Tekturna 3 QL, STTekturna HCT 3 QL, STTelmisartan 1 QLTerazosin 1Torsemide Tab 1Triamterene/HCTZ 1Tribenzor 3 QL, STValsartan 1 QLValsartan/HCTZ 1 QLVerapamil ER 1Cardiovascular/Heart Disease: High CholesterolAtorvastatin 1 QLCrestor 3 QLFenofibrate 1Gemfibrozil 1 QLLipitor 4 QL, STLipofen 4 QLLivalo 4 QL, STLovastatin 1Lovaza 4 QLNiacin ER Tab 1 QLOmega-3 Acid Cap

1 gm1 QL

Praluent 5 PA, QL, SPPravastatin 1Rosuvastatin 1Simvastatin 1Simvastatin 80 mg 1 PA, QLVascepa 3Vytorin 3Vytorin Tab 10-80 mg 3 PAWelchol 3Zetia 4

11




Drug NameDrug Tier

Programs and Limits

Cardiovascular/Heart Disease: Other

Amiodarone 1Amlodipine/Atorvastatin 2 QL, STCorlanor 4 PA, QLDigoxin 1Flecainide 1Isosorbide Mononitrate 1Nitrostat 3Ranexa 3 STSotalol 1Cardiovascular/Heart Disease: Pulmonary Arterial HypertensionAdcirca 5 PA, QL, SPAdempas 5 PA, QL, SPLetairis 5 PA, QL, SPOpsumit 5 PA, QL, SPOrenitram 5 PA, SPSildenafil Tab 20 mg 5 PA, QL, SPTracleer 5 PA, QL, SPCentral Nervous System: Attention Deficit DisorderAdderall XR Cap 4 PA, QL, STAmphetamine-

Dextroamphetamine 1 QL, AR

Amphetamine- Dextroamphetamine SR 24Hr Cap

2 QL, ST, AR

Dexmethylphenidate ER 2 QL, ST, AREvekeo 4 PA, QL, STGuanfacine ER Tab 1 QLMethylphenidate

ER Cap2 QL, ST, AR

Methylphenidate ER Tab 1 QL, ARMethylphenidate Sa Osm

ER Tab2 QL, ST, AR

Methylphenidate Tab 1 QL, ARStrattera 3 QLVyvanse 3 QL, AR

Drug NameDrug Tier

Programs and Limits

Central Nervous System: Depression

Amitriptyline 1Budeprion XL 1 QLBupropion 1Bupropion ER 1Bupropion SR 1Doxepin 1Duloxetine Cap 1 QLEscitalopram Tab 1 QLFluoxetine Cap

(not PMDD)1

Fluvoxamine Tab 1Forfivo XL 3 QLMirtazapine 1Nortriptyline 1Paroxetine 1Pristiq 3 QLRisperidone Tab 1 QLSertraline 1Trazodone 1Venlafaxine 1Venlafaxine ER Cap 1Venlafaxine ER Tab 1Viibryd 4 QL, ST

Central Nervous System: Migraine

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

1

Migranal 4 QLRelpax 4 QLRizatriptan Tab, ODT 1 QLSumatriptan Tab

and Spray1 QL

Sumavel Dose 4 QLZolmitriptan Tab 1 QL

12




Drug NameDrug Tier

Programs and Limits

Central Nervous System: Multiple SclerosisAmpyra 5 PA, QL, SPAubagio 5 PA, QL, ST, SPAvonex Kit 5 PA, QL, SPAvonex Pen Kit 5 PA, QL, SPAvonex Prefill Kit 5 PA, QL, SPBetaseron 5 PA, QL, SPCopaxone 5 PA, QL, SPGilenya 5 PA, QL, ST, SPRebif 5 PA, QL, ST, SPRebif Titrtn 5 PA, QL, ST, SPTecfidera 5 PA, QL, SP

Central Nervous System: Other

Abilify Tab 3 QLAlprazolam Tab 1 QLBenztropine 1Buspirone 1Carbidopa/Levodopa Tab 1Diazepam Tab 1Donepezil Tab 1Hydroxyzine HCL 1Hydroxyzine Pamoate 1Latuda 4 QL, STLithium Carbonate 1Lorazepam Tab 1 QLModafinil 2 PA, QLNamenda XR 3 QLNamzaric 3 QLNuvigi 4 PA, QLOlanzapine Tab 1 QLProchlorperazine 1Quetiapine 1 QLRisperidone Tab 1 QLRopinirole 1Saphris 3 QLSeroquel XR 3 QLZiprasidone Cap 2 QL

Drug NameDrug Tier

Programs and Limits

Central Nervous System: Sedatives/HypnoticsEszopiclone Tab 1 QLLunesta 4 QLSilenor 4 QLTemazepam 1 QLTriazolam Tab 1 QLZolpidem 1 QLZolpidem ER 1 QLCentral Nervous System: Seizure DisordersCarbamazepine Tab 1Clonazepam 1 QLDivalproex DR 1Divalproex ER 1Gabapentin 1Lamotrigine 1Lamotrigine ER 1Levetiracetam 1Levetiracetam ER 1 QLLyrica Cap 3 QLOnfi 5 PAOxcarbazepine 1Phenytoin 1Primidone 1Topiramate Tab 1Vimpat 4Zonisamide 1

Dermatology

Acanya Gel 4 STAcyclovir Ointment 5% 1Aczone Gel 3Atralin 3 PABenzaclin 4 QLBetamethasone

Dipropionate Cream1

Ciclopirox Cream 1Clindamycin Gel, Lotion,

Solution1

Clindamycin/ Benzoyl Peroxide Gel 1-5%

1

13




Drug NameDrug Tier

Programs and Limits

Clindamycin/Benzoyl Peroxide Gel 1.2-5%

1

Clobetasol Cream, Gel, Ointment

1

Clobex 4Clotrimazole/

Betamethasone Cream, Lotion

1

Cortifoam 4Desonide Cream 1Desonide cream, ointment 1Desoximetasone Cream,

Gel, Ointment1

Differin 4 PAEconazole Cream 1Elidel 3 STEpiduo & Epiduo Forte 4Finacea 3 STFluocinonide Cream,

0.1%1

Fluocinonide Cream, Gel, Ointment 0.05%

1

Hydrocortisone Cream, Ointment 2.5%

1

Ketoconazole Cream/Shampoo

1

Metrogel 4Metronidazole Gel 0.75% 1Mirvaso Gel 3Mupirocin Ointment 1Nystatin Cream,

Ointment, Powder1

Nystatin/Triamcinolone Cream, Ointment

1

Onexton 4Oxsoralen-Ul 3 PAPermethrin Cream 5% 1Proctofoam HC 3Retin-A Micro 4Soolantra 3Sulfacetamide/Sulfur

Emulsion1

Taclonex 4 QLTazorac 4 QL, AR

Drug NameDrug Tier

Programs and Limits

Tretinoin Microsphere Gel 1 QL, ARTriamcinolone 1Vectical 4Zovirax Cream 3Zovirax Ointment 4Zyclara 4Diabetes/Endocrine Blood: Glucose MonitoringAccu-Chek Act/Gluc

Calibration Liquid4

Accu-Check Aviva Connect Kit

3

Accu-Chek Aviva Test Strips

3 QL

Accu-Chek Comfort Test Strips

3

Accu-Chek Cpt/Gluc Calibration Liquid

4

Accu-Chek Kit Aviva Plus

3

Accu-Chek Kit Compact 3Accu-Chek Kit Fastclix 3Accu-Chek Kit Mlticlix 3Accu-Chek Kit Nano 3Accu-Chek Kit Softclix 3Accu-Chek Mlticlix

Lancets3

Accu-Chek Smart Calibration Liquid

4

Accu-Chek Smart Test Strips

3

Accu-Chek Sol Calibration Liquid

4

Accu-Chek Sol Comfort Calibration Liquid

4

Bayer Contour Test Strips

4 QL, ST

Dexcom G4 Platinum 4Dexcom G4 Platinum

Sensor Kit4

Dexcom G4 Platinum Transmitter Kit

4

Fastclix Lancets 3

14




Drug NameDrug Tier

Programs and Limits

Freestyle Test Strips 4 QL, STGlucocard Test Strips 1Insulin Pen Needle 3Insulin Syringe/Needle 3Novofine Pen Needle 4Novofine Auto 4Novotwist 4Onetouch Kit Ultra

Smart3

Onetouch Kit Ultra 3Onetouch Kit Ultra 2 3Onetouch Kit Ultra Mini 3Onetouch Kit Verio IQ 3Onetouch Test Strips 3 QLOnetouch Ultra Blue

Test Strips3 QL

Onetouch Verio IQ Test Strips

3 QL

Onetouch Verio Test Strips

3 QL

Precision Test Strips 4 QL, ST

Diabetes/Endocrine: Insulin

Humalog Mix 50/50 Kwik Pen Vials

3

Humalog Mix 75/25 Kwik Pen Vial

3

Humalog Mix 75/25 Vials

3

Humalog U-100 Vial and KwikPen

3

Humalog U-200 Kwik Pen

3

Humulin 70/30 Vials 3Humulin N Vials 3Humulin N Pen 3Humulin Pen 70/30 3Humulin R U-500 3Humulin R Vials 3Lantus Solostar 3Lantus Vials 3Levemir Flexpen 3Levemir Vials 3

Drug NameDrug Tier

Programs and Limits

Novolin 70/30 Vials 3Novolin N Vials 3Novolin R Vials 3Novolog Flexpen 3Novolog Flexpen 3Novolog Mix

70/30 Vials3

Novolog Penfill 3Novolog Vials 3Toujeo SoloStar 3Tresiba 4

Diabetes/Endocrine: Non-Insulin

Bydureon 3 QL, STByetta 3 QL, STFarxiga 4 STGlimepiride 1Glipizide 1Glipizide ER 1Glipizide XL 1Glumetza 4 PAGlyburide 1Glyburide/Metformin 1Invokamet 3 QSTInvokana 3 STJanumet 3 STJanumet XR 3 STJanuvia 3 STJentadueto 3 STKombiglyze 3 STMetformin 1Metformin ER 1Onglyza 3 STPioglitazone 1 QLSynjardy 3Tradjenta 3 QL, STTrulicity 3 QL, STVictoza 4 QL, ST

Endocrine: Growth Hormone

Nutropin 5 PA, SPNutropin AQ 5 PA, SPSaizen 5 PA, SP

15




Drug NameDrug Tier

Programs and Limits

Endocrine: Other

Calcitriol Cap 1Dexamethasone Tab 1H.P. Acthar 5 PA, SPHydrocortisone Tab 1Lupron Depot

3.75 mg, 11.25 mg5 PA, SP

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

5 PA, SP

Methylprednisolone Tab 1Prednisolone Solution

(5 mg/5 mL and 15 mg/5 mL)

1

Prednisolone Syrup Solution 15mg/5 ml

1

Prednisone 1Sensipar 5 PAEndocrine: Thyroid Hormone Replacement Armour Thyroid 4Levothyroxine 1Liothyronine 1Methimazole 1Synthroid 4Tirosint 4

Eye Conditions: Allergies

Azelastine Solution 1Bepreve 4 STLastacaft 4 STPataday 3Pazeo 3

Eye Conditions: Antibiotics

Besivance 4Ciprofloxacin Opthalmic

Solution1 QL

Erythromycin Ointment 1Gentamicin 1

Drug NameDrug Tier

Programs and Limits

Neomycin/Polymyxin B/Dexamethasone Ointment, Suspension

1

Moxeza 3 QLOfloxacin 1Polymyxin B/Trimethoprim

Solution1

Tobramycin 1Tobramycin/

Dexamethasone1

Vigamox 3

Eye Conditions: Glaucoma

Alphagan P 3Azopt 3Betimol 4Brimonidine 1Combigan 3Cosopt PF 4Dorzolamide-Timolol

Maleate1

Latanoprost 1 QLLumigan 3 QLSimbrinza 3Timolol 1Timoptic Ocudose 3Travatan Z 3 QL

Eye Conditions: Other

Durezol Opthalmic Emulsion

4

Lotemax Opthalmic Gel 4 QLKetorolac Opthalmic

Solution1 QL

Prednisolone Opth 1Restasis 3 PA

Gastrointestinal: Acid Suppression

Dexilant 3 QLEsomeprazole (Rx Only) 1 QLFamotidine Tab 20 mg

and 40 mg (Rx only)1

Lansoprazole (Rx only) 1 QLOmeprazole (Rx only) 1 QL

16




Drug NameDrug Tier

Programs and Limits

Pantoprazole 1 QLRanitidine Tab, Cap, Syrup

(Rx only)1

Sucralfate Tab 1

Gastrointestinal: Nausea/Vomiting

Meclizine 2Metoclopramide 1 QLOndansetron Tab 1 QLTransderm-Scop 4Varubi 4 QL

Gastrointestinal: Other

Amitiza 3 QL, STApriso 3Canasa 3Creon 3Delzicol 4Gavilyte Solution 1Hyoscaymine Sublingual

Tab1

Lactulose 1Lialda 3Linzess 3 QL, STMoviprep 4Omeclamox Pak 3Pentasa 4Polyethylene

Glycol 33502

Preopopik 4Protosol HC 1Pylera 3 QLSuprep Bowel Prep 4Uceris 4Zenpep

(Not 5,000 units)3

HIV/AIDS

Atripla 5 SP Complera 5 SPEpzicom 5 SPGenvoya 5 SPIntelence 5 SPIsentress 5 SP

Drug NameDrug Tier

Programs and Limits

Kaletra 5 SPNevirapine 5Norvir 5 SPPrezista 5 SPReyataz 5 SPStribild 5 SPSustiva 5 SPTivacay 5 SPTriumeq 5 SPTruvada 5 SPViread 5 SP

Infertility

Cetrotide 5 SPGonal-f 5 PA, SPGonal-f RFF 5 PA, SPOvidrel 5 SP

Inflammatory Conditions

Cimzia 5 PA, SPDepen 5Enbrel SureClick 5 PA, ST, SPHumira Kit 5 PA, SPHumira Pen Kit 5 PA, SPHumira Pen Kit Crohns 5 PA, SPHumira Pen Kit Psoriasis 5 PA, SPHydroxychloroquine 1Methotrexate Tab 1Orencia SC 5 PA, QL, ST, SPOtezla 5 PA, ST, SPOtrexup 4 PA, QLRasuvo 3 PA, QLSimponi 5 PA, QL, SPStelara 5 PA, QL, SP Xeljanz 5 PA, ST, SP

Men’s Health: Prostate

Alfuzosin 1 QLCialis 2.5mg & 5mg 3 QLDoxazosin 1Finasteride 5 mg 1 QLRapaflo 3Tamsulosin 1Terazosin 1

17




Drug NameDrug Tier

Programs and Limits

Men’s Health: Testosterone Therapy

Androderm 4 PAAndrogel 4 PATestosterone Cypionate IM

Injection2 PA

Miscellaneous

Allopurinol 1Antipyrine/Benzocaine

Otic Solution 5.4 - 1.4%

1

Aranesp 5 PA, SPAuryxia 4Benzonatate 1Botox 100, 200 unit

Injection5 PA, SP

Bunavail 4 PA, QLCerdelga 5 PA, SPChantix 4 QLCheratussin 1Chlorhexidine 1Colcrys 3 QLEpipen 2-Pak 3 QLEuflexxa 5 PA, SPFosrenol 4Granix 5 PA, SPGuaifenesin/Codeine

Syrup1

Hydrocortisone AC Suppository 25 mg

1

Hydromet 1Lidocaine Viscous Solution

2%1

Makena 5 PA, SPNeupogen 5 PA, SPPhenazopyridine

(Rx only)1

Phentermine Tab 2 PAProcrit 5 PA, SPPromethazine DM Syrup 1Promethazine/Codeine

Syrup1

Pulmozyme 5 SP

Drug NameDrug Tier

Programs and Limits

Renvela 3Rezira 4Suboxone Film 3 PA, QLSynagis 5 PA, SPSynvisc 5 PA, SPSynvisc One 5 PA, SPUloric 3 QL, STUrsodiol 1Velphoro 4Zarxio 5 PA, SPZostavax Injection 1Zubsolv 3 PA, QLZutripro 4

Musculoskeletal: Osteoporosis

Alendronate Tab 1Binosto 4 QLEvista 4 QLForteo 5 PA, SPIbandronate Tab 1Raloxifene 1

Musculoskeletal: Other

Baclofen Tab 1Carisoprodol 350 mg 1Cyclobenzaprine Tab

5, 10 mg1

Lorzone 4Metaxalone 2Methocarbamol 1Tizanidine Tab 1

Musculoskeletal: Pain Relief

Acetaminophen w/ Codeine

1 QL

Celebrex 4 QLCelecoxib 1Diclofenac Tab 1 QLEmbeda 3Endocet Tab 1 QLEtodolac 1 QLFentanyl Patch 1 QLGralise 4 QL, ST

18




Drug NameDrug Tier

Programs and Limits

Hydrocodone 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 QLKetolorac Tab 1Lazanda 4 PA, QLLidocaine Patch 5% 1Meloxicam 1Methadone Tab 1Morphine Sulfate ER Tab 1Nabumetone 1Naproxen (Rx only) 1Opana ER 4 QLOxycodone Tab 5, 15, 30

mg 1

Oxycodone w/ Acetaminophen

1 QL

Oxycontin 3 QLTivorbex 4 STTramadol Tab 50 mg 1 QLTramadol

w/ Acetaminophen 1 QL

Vicodin 2 QLVicodin ES 2 QLVoltaren Gel 3 QL Zohydro ER 4 QL, STZorvolex 4

Overactive Bladder

Myrbetriq 4 STOxybutynin 1Oxybutynin ER 1Tolterodine ER 2Toviaz 4Vesicare 3

Drug NameDrug Tier

Programs and Limits

Respiratory: Asthma/COPD

Advair Diskus 3 QLAdvair HFA 3 QLAerospan 4 QLAlbuterol

Nebulizer Solution1 QL

Anoro Ellipta 3 QLArnuity Ellipta 3 QLBreo Ellipta 3 QLBudesonide 2Combivent Respimat 3 QLDulera 4 QL, STFlovent Diskus 3 QLFlovent HFA 3 QLForadil 3 QL, STIncruse Ellipta 3 QLIpratropium/Albuterol 2Levalbuterol

Nebulizer Solution2

Montelukast 1 QLPerforomist 4 QLProair HFA 3 QLProventil 4 QLPulmicort Flexhaler 3 QLQvar 3 QLSerevent Diskus 3 QL, STSpiriva 3 QLSymbicort 3 QLTudorza Pressair 3 QLVentolin HFA 3 QLXolair 5 PA, SPXopenex HFA 4 QL, ST

Respiratory: Nasal Allergies

Astepro 4 QLAzelastine Spray 1 QLDymista Spray 3 QLFluticasone Spray 1Ipratropium Spray 1 QLNasonex 3 QL

19




Drug NameDrug Tier

Programs and Limits

Omnaris 4 QLQNasl 4 QLTriamcinolone Spray 2 QLZetonna 4 QL

Respiratory: Oral Allergies

Cetirizine 2Promethazine Tab 1Desloratadine 2Levocetirizine 1

Transplant

Azathioprine Tab 1Cellcept Tab/Suspension 5 SPCyclosporine Cap 5 SPMycophenolate 250 mg

Cap/500 mg Tab5 SP

Prograf Cap 5 SPRapamune 5 SPTacrolimus Cap 5 SP

Vitamins/Electrolytes

Cyanocobalamine Injection

2

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

1

Potassium Citrate 540mg, 1080mg tab

1

Vitamin D 50,000 units (Rx only)

1

Drug NameDrug Tier

Programs and Limits

Women’s Health: Birth Control

Apri 1Aviane 1Azurette 1Cryselle-28 1Falmina 1Generess Fe Chewable 4Gianvi 1Gildess Fe 1Jolivette 1Junel Fe 1Kariva 1Levora 28 1Lo Loestrin 4Lomedia FE 1Loryna 1Low-Ogestrel 1Lutera 1Medroxyprogesterone

Acetate Injection2 QL

Microgestin 1Microgestin Fe 1Minastrin 24 Fe

Chewable4

Mono-Linyah 1Mononessa 1Natazia 3Necon 1Norgest/Ethi Estradio 1Nortrel 1Nuvaring 3Ocella 1Orsythia 1Ortho Tri-Cyclen Lo 4Previfem 1Reclipsen 1Sprintec 28 1Trinessa 1Tri-Linyah 1Tri-Previfem 1Tri-Sprintec 1

20




Drug NameDrug Tier

Programs and Limits

Vestura 1Viorele 1Xulane 1Zarah 1

Women’s Health: Hormone Replacement

Climara Pro 3Divigel 3Duavee 3Elestrin Gel 4Estrace Vaginal Cream 4Estradiol Tab 1Estradiol/Norethindrone

Tab2

Medroxyprogesterone Acetate Tab

1

Minivelle 4Osphena 4Premarin Tab 3

Drug NameDrug Tier

Programs and Limits

Premarin Vaginal Cream 3Premphase 3Prempro 3Progesterone Cap 2Vagifem 4

Women’s Health: Vaginal Anti-Infectives

Gynazole- 1 Vaginal Cream

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-Check Aviva

Connect Kit . . . . . . 13Accu-Chek Act/Gluc

Calibration Liquid . . . 13Accu-Chek Aviva

Test Strips . . . . . . . 13Accu-Chek Comfort

Test Strips . . . . . . . 13Accu-Chek Cpt/Gluc

Calibration Liquid . . . 13Accu-Chek Kit Aviva Plus . 13Accu-Chek Kit Compact . . 13Accu-Chek Kit Fastclix. . . 13Accu-Chek Kit Mlticlix. . . 13Accu-Chek Kit Nano . . . . 13Accu-Chek Kit Softclix. . . 13Accu-Chek Mlticlix Lancets 13Accu-Chek Smart

Calibration Liquid . . . 13Accu-Chek Smart Test Strips 13Accu-Chek Sol Calibration

Liquid. . . . . . . . . . 13Accu-Chek Sol Comfort

Calibration Liquid . . . 13Acetaminophen w/ Codeine 17Acyclovir Ointment 5% . . . 12Acyclovir Tab, Cap, Suspension 9Aczone Gel. . . . . . . . . 12Adcirca . . . . . . . . . . . 11Adderall XR Cap . . . . . . 11Adempas. . . . . . . . . . 11Advair Diskus . . . . . . . 18Advair HFA . . . . . . . . 18Aerospan . . . . . . . . . 18Akynzeo . . . . . . . . . . . 9Albuterol Nebulizer Solution 18Alendronate Tab . . . . . . 17Alfuzosin . . . . . . . . . . 16Allopurinol . . . . . . . . . 17Alphagan P . . . . . . . . 15Alprazolam Tab . . . . . . . 12Amiodarone. . . . . . . . . 11Amitiza. . . . . . . . . . . 16Amitriptyline . . . . . . . . 11Amlodipine . . . . . . . . . 10

Amlodipine/Atorvastatin . . 11Amlodipine/Benazepril . . . 10Amoxicillin . . . . . . . . . . 9Amoxicillin/Clavulanate . . . . 9Amphetamine-

Dextroamphetamine . . 11Amphetamine-Dextroamph-

etamine SR 24Hr Cap . . 11Ampyra . . . . . . . . . . 12Anastrozole Tab . . . . . . . . 9Androderm . . . . . . . . 17Androgel. . . . . . . . . . 17Anoro Ellipta . . . . . . . 18Antipyrine/Benzocaine Otic

Solution 5.4 - 1.4% . . . 17Apri . . . . . . . . . . . . . 19Apriso . . . . . . . . . . . 16Aranesp . . . . . . . . . . 17Armour Thyroid . . . . . . 15Arnuity Ellipta . . . . . . . 18Astepro . . . . . . . . . . 18Atenolol. . . . . . . . . . . 10Atenolol/Chlorthalidone. . . 10Atorvastatin . . . . . . . . 10Atralin . . . . . . . . . . . 12Atripla . . . . . . . . . . . 16Aubagio . . . . . . . . . . 12Auryxia . . . . . . . . . . 17Aviane . . . . . . . . . . . 19Avonex Kit. . . . . . . . . 12Avonex Pen Kit . . . . . . 12Avonex Prefill Kit . . . . . 12Azasite . . . . . . . . . . . . 9Azathioprine Tab . . . . . . 19Azelastine Solution . . . . . 15Azelastine Spray. . . . . . . 18Azithromycin . . . . . . . . . 9Azopt . . . . . . . . . . . 15Azor . . . . . . . . . . . . 10Azurette . . . . . . . . . . 19

B

Baclofen Tab . . . . . . . . 17Bayer Contour Test Strips . 13Benazepril. . . . . . . . . . 10Benazepril/HCTZ . . . . . . 10Benicar . . . . . . . . . . . 10Benicar HCT . . . . . . . . 10

Benzaclin. . . . . . . . . . 12Benzonatate . . . . . . . . 17Benztropine . . . . . . . . . 12Bepreve . . . . . . . . . . 15Besivance . . . . . . . . . 15Betamethasone Dipropionate

Cream. . . . . . . . . . 12Betaseron . . . . . . . . . 12Bethkis . . . . . . . . . . . . 9Betimol. . . . . . . . . . . 15Binosto. . . . . . . . . . . 17Bisoprolol . . . . . . . . . . 10Bisoprolol/HCTZ . . . . . . . 10Botox 100, 200 unit

Injection . . . . . . . . 17Breo Ellipta . . . . . . . . 18Brilinta . . . . . . . . . . . . 9Brimonidine . . . . . . . . . 15Budeprion XL . . . . . . . . 11Budesonide . . . . . . . . . 18Bumetanide . . . . . . . . . 10Bunavail . . . . . . . . . . 17Bupropion. . . . . . . . . . 11Bupropion ER . . . . . . . . 11Bupropion SR . . . . . . . . 11Buspirone . . . . . . . . . . 12Butalbital-Acetaminophen-

Caffeine Cap . . . . . . 11Bydureon . . . . . . . . . 14Byetta . . . . . . . . . . . 14Bystolic. . . . . . . . . . . 10

C

Calcitriol Cap . . . . . . . . 15Canasa . . . . . . . . . . . 16Capecitabine . . . . . . . . . 9Carbamazepine Tab . . . . . 12Carbidopa/Levodopa Tab . . 12Carisoprodol . . . . . . . . 17Cartia XT . . . . . . . . . . 10Carvedilol . . . . . . . . . . 10Cefadroxil Cap . . . . . . . . 9Cefdinir . . . . . . . . . . . . 9Cefuroxime Tab . . . . . . . . 9Celebrex . . . . . . . . . . 17Celecoxib . . . . . . . . . . 17Cellcept Tab/Suspension . 19Cephalexin . . . . . . . . . . 9



Cerdelga . . . . . . . . . . 17Cetirizine . . . . . . . . . . 19Cetrotide . . . . . . . . . 16Chantix. . . . . . . . . . . 17Cheratussin . . . . . . . . . 17Chlorhexidine . . . . . . . . 17Chlorthalidone . . . . . . . 10Cialis . . . . . . . . . . . . 16Ciclopirox Cream . . . . . . 12Cimzia . . . . . . . . . . . 16Ciprodex Otic Suspension . 9Ciprofloxacin Opthalmic

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

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

Gel 1-5% . . . . . . . . 12Clindamycin Cap . . . . . . . 9Clindamycin Gel, Lotion,

Solution . . . . . . . . . 12Clobetasol Cream, Gel,

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

Cream, Lotion . . . . . . 13Colcrys . . . . . . . . . . . 17Combigan . . . . . . . . . 15Combivent Respimat . . . 18Complera . . . . . . . . . 16Copaxone . . . . . . . . . 12Coreg CR . . . . . . . . . . 10Corlanor . . . . . . . . . . 11Cortifoam . . . . . . . . . 13Cosopt PF . . . . . . . . . 15Creon. . . . . . . . . . . . 16Crestor . . . . . . . . . . . 10Cryselle-28 . . . . . . . . . 19Cyanocobalamine Injection . 19Cyclobenzaprine Tab . . . . 17Cyclosporine Cap . . . . . . 19

D

Daklinza . . . . . . . . . . . 9Delzicol . . . . . . . . . . 16Depen . . . . . . . . . . . 16Desloratadine . . . . . . . . 19Desonide Cream . . . . . . 13Desonide cream, ointment . 13Desoximetasone Cream, Gel,

Ointment . . . . . . . . 13Dexamethasone Tab . . . . 15Dexcom G4 Platinum . . . 13Dexcom G4 Platinum Sensor

Kit . . . . . . . . . . . 13Dexcom G4 Platinum

Transmitter Kit. . . . . 13Dexilant . . . . . . . . . . 15Dexmethylphenidate ER . . . 11Diazepam Tab . . . . . . . . 12Diclofenac Tab . . . . . . . 17Differin. . . . . . . . . . . 13Digoxin . . . . . . . . . . . 11Diltiazem tab . . . . . . . . 10Diovan . . . . . . . . . . . 10Divalproex DR . . . . . . . . 12Divalproex ER . . . . . . . . 12Divigel . . . . . . . . . . . 20Donepezil Tab . . . . . . . . 12Doryx MPC. . . . . . . . . . 9Dorzolamide-Timolol Maleate 15Doxazosin . . . . . . . . . . 10Doxazosin . . . . . . . . . . 16Doxepin . . . . . . . . . . . 11Doxycycline Hyclate . . . . . . 9Doxycycline Monohydrate Cap 9Duavee. . . . . . . . . . . 20Dulera . . . . . . . . . . . 18Duloxetine Cap . . . . . . . 11Durezol Opthalmic

Emulsion . . . . . . . . 15Dymista Spray . . . . . . . 18

E

Econazole Cream . . . . . . 13Edarbi . . . . . . . . . . . 10Edarbyclor . . . . . . . . . 10Effient . . . . . . . . . . . . 9Elestrin Gel . . . . . . . . 20

Elidel . . . . . . . . . . . . 13Eliquis . . . . . . . . . . . . 9Embeda . . . . . . . . . . 17Enalapril. . . . . . . . . . . 10Enalapril/HCTZ . . . . . . . 10Enbrel SureClick . . . . . . 16Endocet Tab. . . . . . . . . 17Enoxaparin . . . . . . . . . . 9Entecavir . . . . . . . . . . . 9Epclusa. . . . . . . . . . . . 9Epiduo & Epiduo Forte . . 13Epipen 2-Pak. . . . . . . . 17Epzicom . . . . . . . . . . 16Erythromycin . . . . . . . . . 9Erythromycin Ointment . . . 15Escitalopram Tab . . . . . . 11Esomeprazole . . . . . . . . 15Estrace Vaginal Cream . . 20Estradiol/Norethindrone Tab . 20Estradiol Tab . . . . . . . . 20Eszopiclone Tab . . . . . . . 12Etodolac . . . . . . . . . . 17Euflexxa . . . . . . . . . . 17Evekeo . . . . . . . . . . . 11Evista. . . . . . . . . . . . 17

F

Falmina . . . . . . . . . . . 19Famciclovir Tab . . . . . . . . 9Famotidine Tab . . . . . . . 15Farxiga . . . . . . . . . . . 14Fastclix Lancets . . . . . . 13Felodipine . . . . . . . . . . 10Fenofibrate . . . . . . . . . 10Fentanyl Patch . . . . . . . 17Finacea. . . . . . . . . . . 13Finasteride . . . . . . . . . 16Flecainide . . . . . . . . . . 11Flovent Diskus. . . . . . . 18Flovent HFA . . . . . . . . 18Fluconazole . . . . . . . . . . 9Fluocinonide Cream, 0.1% . 13Fluocinonide Cream, Gel,

Ointment 0.05% . . . . 13Fluoxetine Cap . . . . . . . 11Fluticasone Spray . . . . . . 18Fluvoxamine Tab . . . . . . 11Folic Acid 1 mg . . . . . . . 19



Foradil . . . . . . . . . . . 18Forfivo XL . . . . . . . . . 11Forteo . . . . . . . . . . . 17Fosinopril . . . . . . . . . . 10Fosrenol . . . . . . . . . . 17Freestyle Test Strips . . . . 14Furosemide . . . . . . . . . 10

G

Gabapentin . . . . . . . . . 12Gavilyte Solution . . . . . . 16Gemfibrozil . . . . . . . . . 10Generess Fe Chewable . . 19Gentamicin . . . . . . . . . 15Genvoya . . . . . . . . . . 16Gianvi . . . . . . . . . . . . 19Gildess Fe . . . . . . . . . . 19Gilenya. . . . . . . . . . . 12Gleevec . . . . . . . . . . . 9Glimepiride . . . . . . . . . 14Glipizide . . . . . . . . . . 14Glipizide ER . . . . . . . . . 14Glipizide XL . . . . . . . . . 14Glucocard Test Strips . . . 14Glumetza . . . . . . . . . 14Glyburide . . . . . . . . . . 14Glyburide/Metformin . . . . 14Gonal-f . . . . . . . . . . . 16Gonal-f RFF . . . . . . . . 16Gralise . . . . . . . . . . . 17Granix . . . . . . . . . . . 17Guaifenesin/Codeine Syrup . 17Guanfacine ER Tab . . . . . 11Guanfacine Tab Immediate

Release . . . . . . . . . 10Gynazole- 1 Vaginal Cream 20

H

Harvoni . . . . . . . . . . . 9H.P. Acthar . . . . . . . . . 15Humalog Mix

50/50 Kwik Pen Vials . 14Humalog Mix

75/25 Kwik Pen Vial . . 14Humalog Mix

75/25 Vials . . . . . . . 14

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

Humalog U-200 Kwik Pen. 14Humira Kit . . . . . . . . . 16Humira Pen Kit . . . . . . 16Humira Pen Kit Crohns . . 16Humira Pen Kit Psoriasis . 16Humulin 70/30 Vials. . . . 14Humulin N Pen . . . . . . 14Humulin N Vials . . . . . . 14Humulin Pen 70/30 . . . . 14Humulin R U-500 . . . . . 14Humulin R Vials . . . . . . 14Hydralazine . . . . . . . . . 10Hydrochlorothiazide. . . . . 10Hydrocodone/APAP

5, 7.5, 10/325 mg . . . 18Hydrocodone w/ Ibuprofen

Tab 7.5-200 mg . . . . . 18Hydrocortisone AC Suppository

25 mg. . . . . . . . . . 17Hydrocortisone Cream,

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

I

Ibandronate Tab. . . . . . . 17Ibuprofen Tab . . . . . . . . 18Incruse Ellipta . . . . . . . 18Indomethacin Cap . . . . . 18Insulin Pen Needle . . . . 14Insulin Syringe/Needle . . 14Intelence . . . . . . . . . 16Invokamet . . . . . . . . . 14Invokana. . . . . . . . . . 14Ipratropium/Albuterol . . . . 18Ipratropium Spray . . . . . . 18Irbesartan . . . . . . . . . . 10Irbesartan/HCTZ. . . . . . . 10Isentress . . . . . . . . . . 16Isosorbide Mononitrate . . . 11

J

Janumet . . . . . . . . . . 14Janumet XR . . . . . . . . 14Januvia. . . . . . . . . . . 14Jentadueto. . . . . . . . . 14Jolivette . . . . . . . . . . . 19Jublia Solution. . . . . . . . 9Junel Fe . . . . . . . . . . . 19

K

Kaletra . . . . . . . . . . . 16Kariva . . . . . . . . . . . . 19Kerydin Solution . . . . . . 9Ketoconazole Cream/

Shampoo . . . . . . . . 13Ketolorac Tab . . . . . . . . 18Ketorolac Opthalmic Solution 15 Klor-Con 8 and 10 MEQ . . 19Klor-Con M10 and M20. . . 19Kombiglyze . . . . . . . . 14

L

Labetalol . . . . . . . . . . 10Lactulose . . . . . . . . . . 16Lamotrigine . . . . . . . . 12Lamotrigine ER . . . . . . . 12Lansoprazole . . . . . . . . 15Lantus Solostar . . . . . . 14Lantus Vials . . . . . . . . 14Lastacaft . . . . . . . . . . 15Latanoprost . . . . . . . . . 15Latuda . . . . . . . . . . . 12Lazanda . . . . . . . . . . 18Letairis . . . . . . . . . . . 11Letrozole . . . . . . . . . . . 9Levalbuterol

Nebulizer Solution. . . . 18Levemir Flexpen. . . . . . 14Levemir Vials . . . . . . . 14Levetiracetam . . . . . . . . 12Levetiracetam ER . . . . . . 12Levocetirizine . . . . . . . . 19Levofloxacin Tab. . . . . . . . 9Levora 28 . . . . . . . . . . 19Levothyroxine . . . . . . . . 15Lialda. . . . . . . . . . . . 16



Lidocaine Patch 5% . . . . . 18Lidocaine Viscous

Solution 2%. . . . . . . 17Linzess . . . . . . . . . . . 16Liothyronine . . . . . . . . 15Lipitor . . . . . . . . . . . 10Lipofen. . . . . . . . . . . 10Lisinopril . . . . . . . . . . 10Lisinopril/HCTZ . . . . . . . 10Lithium Carbonate . . . . . 12Livalo. . . . . . . . . . . . 10Lo Loestrin . . . . . . . . . 19Lomedia FE . . . . . . . . . 19Lorazepam Tab . . . . . . . 12Loryna . . . . . . . . . . . 19Lorzone . . . . . . . . . . 17Losartan. . . . . . . . . . . 10Losartan/HCTZ . . . . . . . 10Lotemax Opthalmic Gel . . 15Lovastatin . . . . . . . . . 10Lovaza . . . . . . . . . . . 10Low-Ogestrel . . . . . . . . 19Lumigan . . . . . . . . . . 15Lunesta . . . . . . . . . . 12Lupron Depot . . . . . . . 15Lutera . . . . . . . . . . . . 19Lyrica Cap . . . . . . . . . 12

M

Makena . . . . . . . . . . 17Meclizine . . . . . . . . . . 16Medroxyprogesterone

Acetate Injection . . . . 19Medroxyprogesterone

Acetate Tab . . . . . . . 20Meloxicam . . . . . . . . . 18Metaxalone . . . . . . . . . 17Metformin . . . . . . . . . 14Metformin ER . . . . . . . . 14Methadone Tab . . . . . . . 18Methimazole . . . . . . . . 15Methocarbamol . . . . . . . 17Methotrexate Tab . . . . . . 16Methylphenidate ER Cap . . 11Methylphenidate ER Tab. . . 11Methylphenidate Sa Osm

ER Tab. . . . . . . . . . 11Methylphenidate Tab . . . . 11

Methylprednisolone Tab . . . 15Metoclopramide . . . . . . 16Metoprolol Succinate . . . . 10Metoprolol Tartrate . . . . . 10Metrogel . . . . . . . . . . 13Metronidazole Gel 0.75%. . 13Metronidazole Tab . . . . . . 9Metronidazole Vaginal Gel . 20Microgestin . . . . . . . . . 19Microgestin Fe . . . . . . . 19Migranal . . . . . . . . . . 11Minastrin 24 Fe Chewable 19Minivelle . . . . . . . . . . 20Minocycline Cap . . . . . . . 9Mirtazapine . . . . . . . . . 11Mirvaso Gel . . . . . . . . 13Modafinil . . . . . . . . . . 12Mono-Linyah . . . . . . . . 19Mononessa . . . . . . . . . 19Montelukast . . . . . . . . 18Morphine Sulfate ER Tab . . 18Moviprep . . . . . . . . . 16Moxeza . . . . . . . . . . 15Multi-Vit/Fl Chew . . . . . . 19Mupirocin Ointment . . . . 13Mycophenolate 250 mg Cap/500

mg Tab . . . . . . . . . 19Myrbetriq . . . . . . . . . 18

N

Nabumetone . . . . . . . . 18Nadolol . . . . . . . . . . . 10Namenda XR. . . . . . . . 12Namzaric . . . . . . . . . . 12Naproxen . . . . . . . . . . 18Nasonex . . . . . . . . . . 18Natazia. . . . . . . . . . . 19Necon. . . . . . . . . . . . 19Neomycin/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 . . . . . . . . . . 11Norgest/Ethi Estradio . . . . 19Nortrel . . . . . . . . . . . 19Nortriptyline. . . . . . . . . 11Norvir . . . . . . . . . . . 16Novofine Auto. . . . . . . 14Novofine Pen Needle . . . 14Novolin 70/30 Vials . . . . 14Novolin N Vials . . . . . . 14Novolin R Vials . . . . . . 14Novolog Flexpen . . . . . 14Novolog Flexpen . . . . . 14Novolog Mix 70/30 Vials . 14Novolog Penfill . . . . . . 14Novolog Vials . . . . . . . 14Novotwist . . . . . . . . . 14Nutropin . . . . . . . . . . 14Nutropin AQ. . . . . . . . 14Nuvaring. . . . . . . . . . 19Nuvigi . . . . . . . . . . . 12Nystatin Cream,

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

Ointment . . . . . . . . 13

O

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

Strips . . . . . . . . . . 14Onetouch Verio IQ

Test Strips . . . . . . . 14



Onetouch Verio Test Strips 14Onexton . . . . . . . . . . 13Onfi . . . . . . . . . . . . 12Onglyza . . . . . . . . . . 14Opana ER . . . . . . . . . 18Opsumit . . . . . . . . . . 11Oracea . . . . . . . . . . . . 9Orencia SC . . . . . . . . . 16Orenitram. . . . . . . . . . 11Orsythia . . . . . . . . . . . 19Ortho Tri-Cyclen Lo . . . . 19Osphena . . . . . . . . . . 20Otezla . . . . . . . . . . . 16Otrexup . . . . . . . . . . 16Ovidrel . . . . . . . . . . . 16Oxcarbazepine . . . . . . . 12Oxsoralen-Ul. . . . . . . . 13Oxybutynin . . . . . . . . . 18Oxybutynin ER . . . . . . . 18Oxycodone Tab . . . . . . . 18Oxycodone

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

P

Pantoprazole . . . . . . . . 16Paroxetine. . . . . . . . . . 11Pataday . . . . . . . . . . 15Pazeo. . . . . . . . . . . . 15Penicillin VK. . . . . . . . . . 9Pentasa . . . . . . . . . . 16Perforomist . . . . . . . . 18Permethrin Cream 5% . . . 13Phenazopyridine . . . . . . 17Phentermine Tab . . . . . . 17Phenytoin . . . . . . . . . . 12Pioglitazone. . . . . . . . . 14Polyethylene Glycol 3350 . . 16Polymyxin B/Trimethoprim

Solution . . . . . . . . . 15Potassium Chloride ER Tab,

Cap . . . . . . . . . . . 19Potassium Chloride Micro ER 19Potassium Citrate . . . . . . 19Pradaxa . . . . . . . . . . . 9Praluent . . . . . . . . . . 10Pravastatin . . . . . . . . . 10Precision Test Strips . . . . 14

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

Q

QNasl. . . . . . . . . . . . 19Quetiapine . . . . . . . . . 12Quinapril . . . . . . . . . . 10Qvar . . . . . . . . . . . . 18

R

Raloxifene. . . . . . . . . . 17Ramipril . . . . . . . . . . . 10Ranexa . . . . . . . . . . . 11Ranitidine Tab, Cap, Syrup . 16Rapaflo. . . . . . . . . . . 16Rapamune . . . . . . . . . 19Rasuvo . . . . . . . . . . . 16Rebif . . . . . . . . . . . . 12Rebif Titrtn . . . . . . . . 12Reclipsen . . . . . . . . . . 19

Relpax . . . . . . . . . . . 11Renvela . . . . . . . . . . 17Restasis . . . . . . . . . . 15Retin-A Micro . . . . . . . 13Revlimid . . . . . . . . . . . 9Reyataz . . . . . . . . . . 16Rezira . . . . . . . . . . . 17Risperidone Tab . . . . . 11, 12Rizatriptan Tab, ODT . . . . 11Ropinirole . . . . . . . . . . 12Rosuvastatin . . . . . . . . 10

S

Saizen . . . . . . . . . . . 14Saphris . . . . . . . . . . . 12Savaysa . . . . . . . . . . . . 9Sensipar . . . . . . . . . . 15Serevent Diskus . . . . . . 18Seroquel XR . . . . . . . . 12Sertraline . . . . . . . . . . 11Sildenafil Tab . . . . . . . . 11Silenor . . . . . . . . . . . 12Simbrinza . . . . . . . . . 15Simponi . . . . . . . . . . 16Simvastatin . . . . . . . . . 10Solodyn . . . . . . . . . . . 9Soolantra . . . . . . . . . . 13Sotalol . . . . . . . . . . . 11Sovaldi . . . . . . . . . . . . 9Spiriva . . . . . . . . . . . 18Spironolactone . . . . . . . 10Sprintec 28 . . . . . . . . . 19Sprycel . . . . . . . . . . . . 9Stelara . . . . . . . . . . . 16Strattera . . . . . . . . . . 11Stribild . . . . . . . . . . . 16Suboxone Film. . . . . . . 17Sucralfate Tab . . . . . . . . 16Sulfacetamide/Sulfur Emulsion 13Sulfamethoxazole-Trimethoprim 9Sulfamethoxazole-

Trimethoprim DS . . . . . 9Sumatriptan Tab and Spray . 11Sumavel Dose . . . . . . . 11Suprep Bowel Prep . . . . 16Sustiva . . . . . . . . . . . 16Symbicort . . . . . . . . . 18



Synagis. . . . . . . . . . . 17Synjardy . . . . . . . . . . 14Synthroid . . . . . . . . . 15Synvisc . . . . . . . . . . . 17Synvisc One . . . . . . . . 17

T

Taclonex . . . . . . . . . . 13Tacrolimus Cap . . . . . . . 19Tamiflu . . . . . . . . . . . . 9Tamoxifen Tab. . . . . . . . . 9Tamsulosin . . . . . . . . . 16Tasigna. . . . . . . . . . . . 9Tazorac. . . . . . . . . . . 13Tecfidera . . . . . . . . . . 12Tekturna . . . . . . . . . . 10Tekturna HCT . . . . . . . 10Telmisartan . . . . . . . . . 10Temazepam . . . . . . . . . 12Temozolmide . . . . . . . . 9Terazosin . . . . . . . . 10, 16Terbinafine Tab . . . . . . . . 9Terconazole Vaginal Cream . 20Testosterone Cypionate IM

Injection. . . . . . . . . 17Timolol . . . . . . . . . . . 15Timoptic Ocudose . . . . . 15Tirosint. . . . . . . . . . . 15Tivacay. . . . . . . . . . . 16Tivorbex . . . . . . . . . . 18Tizanidine Tab. . . . . . . . 17Tobramycin . . . . . . . . . 15Tobramycin/Dexamethasone. 15Tolterodine ER. . . . . . . . 18Topiramate Tab . . . . . . . 12Torsemide Tab. . . . . . . . 10Toujeo SoloStar . . . . . . 14Toviaz . . . . . . . . . . . 18Tracleer . . . . . . . . . . 11Tradjenta. . . . . . . . . . 14Tramadol Tab . . . . . . . . 18Tramadol w/ Acetaminophen 18Transderm-Scop . . . . . . 16Travatan Z . . . . . . . . . 15Trazodone. . . . . . . . . . 11Tresiba . . . . . . . . . . . 14Tretinoin Microsphere Gel . . 13

Triamcinolone . . . . . . . . 13Triamcinolone Spray. . . . . 19Triamterene/HCTZ . . . . . . 10Triazolam Tab . . . . . . . . 12Tribenzor. . . . . . . . . . 10Tri-Linyah . . . . . . . . . . 19Trinessa . . . . . . . . . . . 19Tri-Previfem . . . . . . . . . 19Tri-Sprintec . . . . . . . . . 19Triumeq . . . . . . . . . . 16Trulicity . . . . . . . . . . 14Truvada . . . . . . . . . . 16Tudorza Pressair . . . . . . 18

U

Uceris . . . . . . . . . . . 16Uloric. . . . . . . . . . . . 17Ursodiol . . . . . . . . . . . 17

V

Vagifem . . . . . . . . . . 20Valacyclovir . . . . . . . . . . 9Valsartan . . . . . . . . . . 10Valsartan/HCTZ . . . . . . . 10Varubi . . . . . . . . . . . 16Vascepa . . . . . . . . . . 10Vectical. . . . . . . . . . . 13Velphoro . . . . . . . . . . 17Venlafaxine . . . . . . . . . 11Venlafaxine ER . . . . . . . 11Ventolin HFA . . . . . . . 18Verapamil ER . . . . . . . . 10Vesicare . . . . . . . . . . 18Vestura . . . . . . . . . . . 20Vicodin. . . . . . . . . . . 18Vicodin ES . . . . . . . . . 18Victoza . . . . . . . . . . . 14Vigamox . . . . . . . . . . 15Viibryd . . . . . . . . . . . 11Vimpat . . . . . . . . . . . 12Viorele . . . . . . . . . . . 20Viread . . . . . . . . . . . 16Vitamin D 50,000 units . . . 19Voltaren Gel . . . . . . . . 18Vytorin . . . . . . . . . . . 10Vyvanse . . . . . . . . . . 11

W

Warfarin . . . . . . . . . . . 9Welchol . . . . . . . . . . 10

X

Xarelto . . . . . . . . . . . . 9Xeljanz . . . . . . . . . . . 16Xolair. . . . . . . . . . . . 18Xopenex HFA . . . . . . . 18Xulane . . . . . . . . . . . 20

Z

Zarah . . . . . . . . . . . . 20Zarxio . . . . . . . . . . . 17Zenpep. . . . . . . . . . . 16Zepatier . . . . . . . . . . . 9Zetia . . . . . . . . . . . . 10Zetonna . . . . . . . . . . 19Ziprasidone Cap. . . . . . . 12Zohydro ER . . . . . . . . 18Zolmitriptan Tab. . . . . . 11Zolpidem . . . . . . . . . . 12Zolpidem ER. . . . . . . . . 12Zonisamide . . . . . . . . . 12Zorvolex . . . . . . . . . . 18Zostavax Injection. . . . . 17Zovirax Cream . . . . . . . 13Zovirax Ointment . . . . . 13Zubsolv . . . . . . . . . . 17Zutripro . . . . . . . . . . 17Zyclara . . . . . . . . . . . 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.

All Optum trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners.

©2017 OptumRx, Inc. ORX6700A-COK_170101

optumrx.com

Core Standard

Documents

Your 2017 Prescription Drug List - OptumRx · 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