Your 2017
Prescription Drug List
Effective July 1, 2017
Student Resources Traditional Three-Tier
This Prescription Drug List (PDL) outlines the most commonly prescribed medications
for certain conditions and organizes them into cost levels, also known as tiers.
For additional information:
Visiting www.uhcsr.com and clicking on the “Login To My Account”

link for information to help you better understand and manage your medications.
• View your current benefits
• Search for drug prices and lower-cost alternatives
• Potential y save time and money using home delivery through OptumRx®
Call the tol -free member phone number on your health plan ID card.
1

Table of Contents
Drug tiers and cost . . . . . . . . . . . . . . . . . . . . . . .3
Gastrointestinal
Programs and Limits . . . . . . . . . . . . . . . . . . . . . .5
Acid Suppression . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Drugs by category . . . . . . . . . . . . . . . . . . . . . . . .8
Nausea/Vomiting . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Anti-Infectives
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Gout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Hepatitis C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Cardiovascular/Heart Disease
Coagulation Therapy . . . . . . . . . . . . . . . . . . . . . . . . .9
Inflammatory Conditions: Rheumatoid
High Blood Pressure . . . . . . . . . . . . . . . . . . . . . . . . .9
Arthritis, Crohn’s Disease, Psoriasis,
Ulcerative Colitis . . . . . . . . . . . . . . . . . . . . . . . . 17
High Cholesterol . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Men’s Health
Central Nervous System
Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Attention Deficit Disorder . . . . . . . . . . . . . . . . . . . .11
Testosterone Therapy . . . . . . . . . . . . . . . . . . . . . . 18
Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
Musculoskeletal
Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Muscle Spasms . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Sedatives/Hypnotics . . . . . . . . . . . . . . . . . . . . . . . 12
Pain Relief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Seizure Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Overactive Bladder . . . . . . . . . . . . . . . . . . . . . . 20
Diabetes/Endocrine
Respiratory
Blood Glucose Monitoring . . . . . . . . . . . . . . . . . . 14
Allergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Asthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Non-Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Pulmonary Arterial Hypertension . . . . . . . . . . . . 21
Endocrine
Transplant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Growth Hormone . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Vitamins/Electrolytes . . . . . . . . . . . . . . . . . . . 21
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Women’s Health
Thyroid Hormone Replacement . . . . . . . . . . . . . 15
Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Eye Conditions
Hormone Replacement . . . . . . . . . . . . . . . . . . . . . 23
Allergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Miscel aneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Dry Eye Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Prenatal Vitamins . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
2

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. Medications 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 Food and Drug Administration (FDA).
Please note: Where differences are noted between this PDL and your benefit plan documents, the
benefit plan documents will rule. It is not a complete list of medications, and not all medications listed
may be covered under your plan. Please look at your benefit plan documents provided by your university
or school to see what medications are covered under your plan. You may also log in to www.uhcsr.com and
click on “Login To My Account” link or call the toll-free member phone number on your health plan ID
card for more information.
How do I use my PDL?
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 programs apply. Bring this list with you when you see your doctor. It is organized
by common medical conditions. Medications are then listed alphabetically.
If your medication is not listed in this document, please visit www.uhcsr.com and click on “Login To My
Account” link or call the toll-free member phone number on your health plan ID card.
3

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 university or school. 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
Generics and some
Use Tier 1 drugs for the lowest
Your lowest cost
brands are also included .
out-of-pocket costs .
Tier 2
Mainly preferred
Use Tier 2 drugs instead of
Your mid-range
brand drugs .
Tier 3 to help reduce your
cost
out-of-pocket costs .
Tier 3
Mostly brand drugs .
Many Tier 3 drugs have
your highest
lower-cost options in Tier 1 or 2 .
cost
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 may apply once you hit your deductible. Refer to your enrollment and
plan materials on www.uhcsr.com and click on “Login To My Account” link, or call the toll-free number
on your health plan ID card for more information about your benefit plan.
When does the PDL change?
• Medications may move to a lower tier at any time.
• Medications can be up-tiered off cycle when the therapeutically equivalent medication is
placed in an equal or lower tier than up-tiered medication.
• Medications may move to a higher tier on January 1.
• Medications may be excluded from coverage on January 1 or July 1.
When a medication changes tiers, you may have to pay a different amount for that medication.
For the most up-to-date list, call customer service at the number on your ID card.
4

Programs and limits
Some medications are noted with letters next to them. The letters refer to our pharmacy benefit
programs. Your benefit plan determines how these medications may be covered for you.
Designated specialty program – Specialty medications need to be fil ed
DSP
at a designated specialty pharmacy for network coverage . Call the number on your
ID card or call 1-888-739-5820 for more information .
May be excluded from coverage or subject to prior authorization and/or trial/
E
failure of another medication(s) . Lower-cost options are available and covered .
Prior authorization required
PA
* – Your doctor is required to provide additional
information to us to determine coverage .
Supply limit
SL
– Amount of medication covered per copayment or in a specific
time period .
*Depending on your benefit, you may have notification or medical necessity requirements for select medications .
To learn more about a pharmacy program or to find out if it applies to you, please visit www.uhcsr.com
and click on “Login To My Account” link or call the toll-free member phone number on your health plan
ID card.
Why are some medications excluded from coverage?
A medication may be excluded from coverage under your pharmacy benefit when it works the same or
similar as another prescription medication or an over-the-counter (OTC) medication. Other medication
options may be available.
Should I talk to my doctor about over-the-counter (OTC)
medications?
An OTC medication may be the right treatment for some conditions. Talk to your doctor about
available options.
5

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, Invokana) and generic drugs in plain
type (for example, Metformin).
What if my doctor writes a brand-name prescription?
The next time your doctor gives you a prescription for a brand-name medication, ask if a generic
equivalent or lower-cost option is available and if it might be right for you. Generic medications
are usually your lowest-cost option, but not always. For some benefit plans, if a brand-name drug
is prescribed and a generic equivalent is available, your cost share may be the copay PLUS the cost
difference between the brand-name drug and generic equivalent. Visit www.uhcsr.com and click on
“Login To My Account” link to make sure.
Are you taking a specialty medication?
Specialty medications are high-cost and are used to treat rare or complex conditions that require
additional care and support. For most plans, these medications are managed through the Specialty
Pharmacy Program. Take advantage of personalized support designed to help you get the most out of
your treatment plan. Visit UHCSpecialtyRx.com or call the toll-free phone number on your health plan
ID card to learn more.
Please note, not all specialty medications are listed here. If you’re taking a specialty medication that is
on Tier 3, call the toll-free number on your health plan ID card to talk with a pharmacist about finding
lower-cost options or a financial assistance program.
6

How do I get updated information about my pharmacy benefit?
Since the PDL may change during your plan year, we encourage you to visit www.uhcsr.com and click
on “Login To My Account” link or call the toll-free member phone number on your health plan ID card
for more current information.
Log in to www.uhcsr.com for the following pharmacy information and tools:
• Pharmacy benefit and coverage information
• Possible lower-cost medication options
• Medication interactions and side effects
• Participating retail pharmacies by ZIP code
• Your prescription history
And, if home delivery services are included in your pharmacy benefit, you can also:
• Refill prescriptions
• Check the status of your order
• Set up reminders for refills
• Manage your account
For more information
Call the tol -free member phone number on your health plan ID card
Or, visit www.uhcsr.com and click on “Login To My Account” link
In certain documents, the Prescription Drug List (PDL) was referred to as the “Preferred Drug List (PDL) .” This change in terms does not affect your benefit coverage .
Medications are categorized by common therapeutic conditions in this PDL for ease of reference only . These categories do not determine coverage for the medication for your condition .
Your benefit plan determines coverage for these medications .
7

Drug Requirements
Drug Name
Drug Requirements
Tier  & Limits
Drug Name
Tier  & Limits
Anti-Infectives: Antibiotics
Ofloxacin Otic Solution
1
Ofloxacin Tablet
1
Amoxicillin Capsule,
Oracea
1
3
Chewable Tablet
Penicil in V Potassium
Amoxicillin/Potassium
Tablet
1
Clavulanate Chewable
1
Sulfamethoxazole-
Tablet, Tablet
1
Trimethoprim Tablet
Azithromycin Tablet
1
Suprax Capsule,
Cefadroxil Capsule,
Chewable Tablet,
1
3
Tablet
Tablet
Cefdinir Capsule
1
Anti-Infectives: Antifungals
Cefixime Suspension
1
Cefprozil Tablet
1
Cresemba
3
SL
Cefuroxime Tablet
1
Econazole Cream
1
SL
Cephalexin Capsule
1
Fluconazole Tablet
1
Ciprodex
2
Itraconazole Capsule
1
SL
Ciprofloxacin Tablet
1
Ketoconazole Cream
1
Clarithromycin Tablet
1
Noxafil Tablet,
Clindamycin Capsule
1
Suspension
2
Dificid
3
SL
Nystatin Cream,
1
Doxycycline Hyclate
Ointment
50, 100 mg Capsule,
1
Terbinafine Tablet
1
SL
Tablet
Anti-Infectives: Antivirals
Doxycycline Monohydrate
1
50, 100 mg Capsule
Acyclovir Ointment
1
SL
Levofloxacin Tablet
1
Acyclovir Tablet
1
Metronidazole Tablet
1
Famciclovir Tablet
1
Minocycline Capsule
1
Oseltamivir Capsule
1
SL
Minocycline Tablet
1
E
Valacyclovir Tablet
1
SL
Moxifloxacin Tablet
1
Valganciclovir
1
SL
Nitrofurantoin Capsule
1
Zovirax Cream
3
E, SL
Nitrofurantoin
1
Macrocrystal Capsule
Bold type = Brand-name drug
[Plain type = Generic drug]
DSP = Designated specialty program
PA = Prior authorization required
E = May be excluded from coverage
SL = Supply limit
8

Drug Requirements
Drug Requirements
Drug Name
Drug Name
Tier  & Limits
Tier  & Limits
Cancer
Benazepril-
1
Hydrochlorothiazide
Bexarotene Capsule
3
DSP, E, PA, SL
Benicar
3
E, SL
Bicalutamide
1
Benicar HCT
3
E, SL
Bosulif
2
DSP, PA, SL
Bidil
2
Cyclophosphamide
Bisoprolol
1
Capsule
2
Bisoprolol-
1
Hydroxyurea Capsule
1
Hydrochlorothiazide
Imantinib Tablet
1
DSP, PA, SL
Bystolic
2
Imbruvica
2
DSP, PA, SL
Cartia XT
1
Leucovorin Calcium
Carvedilol
1
1
Tablet
Chlorthalidone
1
Mercaptopurine Tablet
1
Clonidine Tablet
1
Revlimid
2
DSP, PA, SL
Diltiazem 24 Hour CD
1
Sutent
2
DSP, PA, SL
Diltiazem Sustained-
1
Targretin Capsule
1
DSP
Release Capsule
Targretin Gel
3
SL
Diltiazem Sustained-
1
Tasigna
2
DSP, PA, SL
Release Tablet
Xeloda
1
DSP, SL
Doxazosin
1
Zytiga
2
DSP, PA, SL
Dutoprol
2
SL
Cardiovascular/Heart Disease:
Edarbi
3
SL
Coagulation Therapy
Edarbyclor
3
SL
Brilinta
3
SL
Enalapril
1
Clopidogrel
1
Furosemide
1
Effient
3
SL
Guanfacine
1
Eliquis
3
SL
Hydralazine
1
Enoxaparin Sodium
1
SL
Hydrochlorothiazide
1
Pradaxa
2
SL
Irbesartan
1
Savaysa
3
SL
Labetalol
1
Warfarin Sodium
1
Lisinopril
1
Xarelto
2
SL
Lisinopril-
1
Cardiovascular/Heart Disease:
Hydrochlorothiazide
High Blood Pressure
Losartan
1
Amlodipine
1
Losartan-
1
Amlodipine-Benazepril
1
Hydrochlorothiazide
Amlodipine-Valsartan
1
Metoprolol Succinate
1
Atenolol
1
50, 100, 200 mg
Atenolol-Chlorthalidone
1
Metoprolol Tartrate
1
Benazepril
1
25, 50, 100 mg
9

Drug Requirements
Drug Requirements
Drug Name
Drug Name
Tier  & Limits
Tier  & Limits
Nadolol
1
Fluvastatin Extended-
1
SL
Nifedipine
Release Tablet
1
Extended-Release
Gemfibrozil
1
Olmesartan
1
SL
Lipofen
3
E
Olmesartan-
Livalo
3
SL
1
SL
Hydrochlorothiazide
Lovastatin
1
Propranolol Extended-
1
Niacin Extended-
Release Capsule
1
Release Tablet
Propranolol Tablet
1
Niaspan
3
Quinapril
1
Omega-3-Acid Ethyl
1
Ramipril
1
Esters Capsule
Spironolactone
1
Praluent
2
DSP, PA, SL
Telmisartan
1
Pravastatin
1
Telmisartan-
Repatha 140 mg
3
DSP, PA, SL
1
Hydrochlorothiazide
Rosuvastatin
1
SL
Terazosin
1
Simvastatin
1
Triamterene-
1
Vascepa
3
Hydrochlorothiazide
Vytorin
3
SL
Valsartan
1
Welchol
2
Valsartan-
1
Zetia
3
E, SL
Hydrochlorothiazide
Verapamil
1
Cardiovascular/Heart Disease: Other
Verapamil
1
Amiodarone
1
Sustained-Release
Corlanor
3
SL
Cardiovascular/Heart Disease:
Digoxin
1
High Cholesterol
Entresto
3
SL
Atorvastatin
1
SL
Flecainide
1
Choline Fenofibrate
1
E
Isosorbide
Ezetimibe Tablet
1
SL
1
Mononitrate ER
Fenofibrate 43, 50, 67,
Multaq
3
130, 134, 150, 200 mg
1
E
Nitroglycerin Sublingual
Capsule
1
Tablet
Fenofibrate 40, 48, 120,
1
E
Ranexa
2
145 mg Tablet
Sotalol
1
Fenofibrate 54, 160 mg
1
Tablet
Bold type = Brand-name drug
[Plain type = Generic drug]
DSP = Designated specialty program
PA = Prior authorization required
E = May be excluded from coverage
SL = Supply limit
10

Drug Requirements
Drug Requirements
Drug Name
Drug Name
Tier  & Limits
Tier  & Limits
Central Nervous System:
Central Nervous System: Depression
Attention Deficit Disorder
Adderall XR
1
SL
Amitriptyline Tablet
1
Amphetamine Salt
Bupropion Extended-
1
1
Combo
Release Tablet
Concerta
1
SL
Bupropion Sustained-
1
Daytrana
3
E, SL
Release Tablet
Dexmethylphenidate
Bupropion Tablet
1
Extended-Release
1
E, SL
Citalopram Tablet
1
Capsule
Desvenlafaxine
Dexmethylphenidate
Extended-Release
1
SL
Immediate-Release
1
Tablet (generic Pristiq)
Tablet
Doxepin
1
Dextroamphetamine-
Duloxetine Capsule
1
SL
Amphetamine
3
E, SL
Escitalopram Tablet
1
Extended-Release
Fetzima
3
SL
Dextroamphetamine-
Fluoxetine Tablet,
Amphetamine
1
1
Capsule
Immediate-Release
Fluvoxamine Tablet
1
Capsule
Mirtazapine Tablet
1
Dextroamphetamine
Nortriptyline Capsule
1
Sulfate Immediate-
1
Paroxetine Tablet
1
Release Tablet
Sertraline Tablet
1
Focalin XR
3
E, SL
Trazodone Tablet
1
Guanfacine
1
SL
Trintellix
3
SL
Extended-Release
Venlafaxine Extended-
Metadate CD
3
E, SL
1
Release Capsule
Methylphenidate
1
Venlafaxine Tablet
1
Chewable Tablet
Viibryd
3
SL
Methylphenidate
Extended-Release
Central Nervous System: Migraine
Capsule (generic
1
SL
Acetaminophen/
Metadate CD,
Butalbital/Caffeine
1
SL
Ritalin SR)
325 mg/50 mg/40 mg
Methylphenidate
Frovatriptan
1
SL
Extended-Release
1
SL
Naratriptan
1
SL
Capsule (Metadate ER)
Relpax
2
SL
Methylphenidate
Rizatriptan ODT, Tablet
1
SL
Extended-Release Tablet 3
E, SL
Sumatriptan Nasal
(generic Concerta)
1
SL
Spray
Methylphenidate Tablet
1
Sumatriptan Succinate
Strattera
3
SL
1
SL
Tablet, Injection
Vyvanse
2
SL
11

Drug Requirements
Drug Requirements
Drug Name
Drug Name
Tier  & Limits
Tier  & Limits
Central Nervous System:
Pramipexole Tablet
1
Multiple Sclerosis
Quetiapine Extended-
1
SL
Ampyra
2
DSP, PA, SL
Release Tablet
Aubagio
3
DSP, PA, SL
Quetiapine Tablet
1
Avonex
2
DSP, PA, SL
Risperidone Tablet
1
Betaseron
2
DSP, PA, SL
Ropinirole Tablet
1
Copaxone 20 mg
1
DSP, PA, SL
Suboxone Film
3
E, SL
Copaxone 40 mg
2
DSP, PA, SL
Tolcapone
1
Gilenya
3
DSP, PA, SL
Xyrem
3
PA, SL
Glatopa
3
DSP, E, PA, SL
Zelapar
3
Plegridy
3
DSP, PA, SL
Ziprasidone Capsule
1
SL
Rebif
3
DSP, PA, SL
Zubsolv
1
SL
Tecfidera
2
DSP, PA, SL
Central Nervous System:
Zinbryta
3
DSP, PA, SL
Sedatives/Hypnotics
Eszopiclone Tablet
1
SL
Central Nervous System: Other
Temazepam Capsule
1
Alprazolam Extended-
Triazolam Tablet
1
1
Release Tablet
Zaleplon Capsule
1
SL
Alprazolam Tablet
1
Zolpidem Extended-
1
E, SL
Aripiprazole Tablet
1
SL
Release Tablet
Armodafanil
1
E, SL
Zolpidem Tablet
1
SL
Buprenorphine/
Central Nervous System:
1
E, SL
Naloxone Tablet
Seizure Disorders
Buspirone Tablet
1
Carbamazepine
Carbidopa-Levodopa
1
Extended-Release
1
Diazepam Tablet
1
Capsule, Tablet
Donepezil ODT,
Carbamazepine
1
5, 10 mg Tablet
Immediate-Release
1
Latuda
3
SL
Tablet
Lithium Capsule
1
Clonazepam Tablet
1
Lorazepam Tablet
1
Diazepam Tablet
1
Memantine
1
Divalproex Delayed-
1
Modafinil Tablet
1
SL
Release Tablet
Naloxone Vial
1
Divalproex Extended-
1
Narcan Nasal Spray
2
SL
Release Tablet
Olanzapine Tablet
1
SL
Bold type = Brand-name drug
[Plain type = Generic drug]
DSP = Designated specialty program
PA = Prior authorization required
E = May be excluded from coverage
SL = Supply limit
12

Drug Requirements
Drug Requirements
Drug Name
Drug Name
Tier  & Limits
Tier  & Limits
Gabapentin Capsule,
Clindamycin Lotion,
1
1
Tablet
Solution, Swabs
Lamotrigine Immediate-
Clobetasol Propionate
1
Release Tablet
Cream, Ointment,
1
SL
Levetiracetam
Solution
Extended-Release
1
Clotrimazole-
1
SL
Tablet
Betamethasone Cream
Levetiracetam
Clotrimazole-
1
Immediate-Release
1
Betamethasone Lotion
Tablet
Desonide 0 .05% Cream,
Lyrica
1
SL
3
SL
Lotion, Ointment
Oxcarbazepine Tablet
1
Desoximetasone Cream,
1
SL
Phenytoin Capsule,
Gel, Ointment
1
Suspension
Diflorasone Diacetate
1
SL
Topiramate Immediate-
0 .05% Cream, Ointment
1
Release Tablet
Enstilar Foam
3
SL
Zonisamide Capsule
1
Epiduo/Epiduo Forte
3
E, SL
Finacea
Dermatology
3
Fluocinonide 0 .05%
1
Aczone
3
SL
Cream
Adapalene Cream, Gel,
Fluocinolone Cream, Oil,
1
E, PA, SL
1
SL
Lotion
Ointment, Solution
Betamethasone
Halobetasol Ointment
1
Dipropionate 0 .05%
Hydrocortisone 2 .5%
1
1
Augmented Lotion,
Cream, Ointment
Ointment
Imiquimod 5% Cream
1
SL
Betamethasone
Metronidazole 0 .75%
Dipropionate 0 .05%
1
1
Topical Gel
Cream, Ointment
Minocycline Extended-
Calcipotriene/
1
E
Release Capsule
Betamethasone
1
SL
Mirvaso
3
SL
Ointment
Mometasone Furoate
Carac
2
1
Cream, Lotion, Ointment
Ciclopirox Cream, Gel,
1
Mupirocin Ointment
1
SL
Lotion, Solution
Nystatin-Triamcinolone
Claravis
1
Acetonide Cream,
1
E
Clindamycin 1%/
1
E, SL
Ointment
Benzoyl Peroxide 5% Gel
Oxsoralen-Ultra
2
Clindamycin 1 .2%/
1
SL
Picato
3
SL
Benzoyl Peroxide 5% Gel
Regranex
2
SL
Clindamycin Gel
1
SL
Solodyn
3
E
Taclonex Suspension
3
SL
13

Drug Requirements
Drug Requirements
Drug Name
Drug Name
Tier  & Limits
Tier  & Limits
Tacrolimus Ointment
1
SL
Humalog Vials
1
SL
Tazorac
3
PA, SL
(al formulations)
Tretinoin Cream
1
PA, SL
Humulin KwikPens
2
SL
Tretinoin Gel
1
E, PA, SL
(al formulations)
Tretinoin Microspheres
1
E, PA, SL
Humulin Vials
1
SL
Triamcinolone Acetonide
(al formulations)
1
Cream, Lotion, Ointment
Lantus Solostar
3
E, SL
Vectical
3
SL
Lantus Vials
3
E, SL
Levemir FlexTouch
2
SL
Diabetes: Blood Glucose Monitoring
Levemir Vials
2
SL
Accu-Chek
Novolin Vials
3
SL
Test Strips
3
E, SL
(al formulations)
Contour Test Strips
3
E, SL
Novolog FlexTouch
3
SL
Dexcom Continuous
(al formulations)
Glucose Monitoring
3
SL
Novolog Vials
3
SL
System
(al formulations)
Dexcom Sensor
3
SL
Soliqua
2
SL
Dexcom Transmitter
3
SL
Toujeo SoloStar
3
E, SL
FreeStyle Test Strips
3
E, SL
Tresiba FlexTouch
3
E, SL
OneTouch Test Strips
1
SL
Diabetes: Non-Insulin
OneTouch Ultra Mini
1
OneTouch Ultra
Adlyxin
3
SL
Test Strips
1
SL
Bydureon
2
SL
OneTouch Verio
1
Byetta
2
SL
OneTouch Verio Flex
1
Farxiga
3
SL
OneTouch Verio IQ
1
Glimepiride
1
OneTouch Verio Sync
1
Glipizide
1
OneTouch Verio
Glipizide
1
Test Strips
1
SL
Extended-Release
Glyburide
1
Diabetes: Insulin
Glyxambi
3
E, SL
Afrezza
3
E, SL
Invokamet
2
SL
Basaglar
1
SL
Invokamet XR
2
SL
Humalog KwikPens
Invokana
2
SL
2
SL
(al formulations)
Janumet
3
SL
Bold type = Brand-name drug
[Plain type = Generic drug]
DSP = Designated specialty program
PA = Prior authorization required
E = May be excluded from coverage
SL = Supply limit
14

Drug Requirements
Drug Requirements
Drug Name
Drug Name
Tier  & Limits
Tier  & Limits
Januvia
3
SL
Endocrine: Thyroid Hormone
Jardiance
2
SL
Replacement
Jentadueto
2
SL
Armour Thyroid
3
Jentadueto XR
2
SL
Levothyroxine Sodium
1
Kazano
2
SL
Tablet
Kombiglyze XR
2
SL
Liothyronine Sodium
1
Metformin
1
Tablet
Metformin Extended-
Methimazole Tablet
1
Release Tablet (generic
1
NP Thyroid Tablet
1
Glucophage XR)
Synthroid
2
Nesina
2
SL
Eye Conditions: Allergies
Onglyza
2
SL
Oseni
2
SL
Azelastine 0 .05%
1
SL
Pioglitazone
1
SL
Ophthalmic Solution
Synjardy
2
SL
Lastacaft
3
SL
Tanzeum
2
SL
Olopatadine 0 .1%
1
SL
Tradjenta
2
SL
Ophthalmic Solution
Trulicity
3
SL
Pataday
3
E, SL
Victoza 2-Pak
2
SL
Eye Conditions: Antibiotics
Victoza 3-Pak
3
SL
Xigduo XR
3
E, SL
Erythromycin 0 .5%
1
Ophthalmic Ointment
Endocrine: Growth Hormone
Gentamicin Ophthalmic
1
Nutropin,
Ointment, Solution
Nutropin AQ
2
DSP, PA, SL
Moxeza
3
Ofloxacin 0 .3%
Endocrine: Other
1
Ophthalmic Solution
Calcitriol Capsule
1
Tobramycin/
Desmopressin Tablet
1
Dexamethasone
1
Dexamethasone Tablet
1
0 .3%-0 .1% Ophthalmic
Methylprednisolone
Suspension
1
Tablet
Tobramycin Ophthalmic
1
Prenisolone Oral
Solution
1
Solution
Vigamox
3
Prednisone Tablet
1
15

Drug Requirements
Drug Requirements
Drug Name
Drug Name
Tier  & Limits
Tier  & Limits
Eye Conditions: Dry Eye Disease
Gastrointestinal: Nausea/Vomiting
Restasis Single Use
Akynzeo
3
SL
Vial
3
SL
Aprepitant Capsule
1
SL
Xiidra
3
SL
Emend Suspension
2
SL
Eye Conditions: Glaucoma
Ondansetron
1
Ondansetron ODT
1
Alphagan P 0.1%
2
SL
Transderm-Scop
3
Azopt
2
SL
Varubi
2
SL
Combigan
2
SL
Gastrointestinal: Other
Latanoprost 0 .005%
1
Ophthalmic Solution
Amitiza
3
SL
Lumigan
2
SL
Apriso
2
Timolol Maleate
Asacol HD Tablet
3
E
0 .25%, 0 .5%
1
Canasa
2
Ophthalmic Solution
Cortifoam
2
Travatan Z
2
SL
Creon
2
Gastrointestinal: Acid Suppression
Delzicol
3
E
Diphenoxylate-Atropine
Dexilant
3
SL
1
Tablet
Esomeprazole Capsule
1
E, SL
Golytely
2
Lansoprazole Capsule
1
E, SL
Hyoscyamine Tablet
1
Omeclamox-Pak
3
SL
Lialda
2
Omeprazole Capsule
1
Linzess
2
SL
Pantoprazole Tablet
1
Metoclopramide Tablet
1
Pylera
3
SL
Movantik
2
SL
Rabeprazole Tablet
1
SL
Moviprep
3
Ranitadine Syrup
1
Polyethylene
Sucralfate Tablet
1
1
Glycol 3350
Prepopik
3
Suclear
3
Sulfasalazine Tablet
1
Suprep
3
Uceris Foam
2
Uceris Tablet
3
Viberzi
3
SL
Zenpep
2
Bold type = Brand-name drug
[Plain type = Generic drug]
DSP = Designated specialty program
PA = Prior authorization required
E = May be excluded from coverage
SL = Supply limit
16

Drug Requirements
Drug Requirements
Drug Name
Drug Name
Tier  & Limits
Tier  & Limits
Selzentry
Gout
2
DSP, PA
Stribild
3
DSP
Allopurinol Tablet
1
Sustiva
2
DSP
Colcrys
3
E
Tivicay
3
DSP
Mitigare
2
Triumeq
2
DSP
Uloric
3
SL
Truvada
3
DSP, PA
Zurampic
3
SL
Tybost
2
DSP
Viread
Hepatitis C
2
DSP
Vitekta
2
DSP
Daklinza
2
DSP, PA, SL
Infertility*
Epclusa
2
DSP, PA, SL
Harvoni
2
DSP, PA, SL
Cetrotide
2
DSP
Ribavirin Tablet
1
DSP
Clomiphene
1
DSP
Sovaldi
2
DSP, PA, SL
Gonal-F
2
DSP
Technivie
3
DSP, PA, SL
Gonal-F RFF
2
DSP
Viekira Pak
3
DSP, PA, SL
Ovidrel
3
DSP
Zepatier
3
DSP, PA, SL
*Coverage is determined by the consumer’s prescription drug benefit plan .
Inflammatory Conditions: Rheumatoid
HIV/AIDS
Arthritis, Crohn’s Disease, Psoriasis,
Abacavir-Lamivudine
1
DSP
Ulcerative Colitis
Atripla
2
DSP
Actemra
3
DSP, PA, SL
Complera
3
DSP
Cimzia
2
DSP, PA, SL
Descovy
3
DSP
Cosentyx
3
DSP, PA, SL
Epzicom
3
DSP, E
Enbrel
3
DSP, PA, SL
Evotaz
2
DSP
Humira
2
DSP, PA, SL
Genvoya
3
DSP
Hydroxychloroquine
1
Intelence
2
DSP
Sulfate
Isentress
2
DSP
Leflunomide
1
Kaletra Tablet
2
DSP
Methotrexate Tablet
1
Lamivudine-Zidovudine
1
DSP
Orencia
3
DSP, PA, SL
Lopinavir-Ritonavir Oral
Otezla
3
DSP, PA, SL
1
DSP
Solution
Otrexup
3
E, SL
Nevirapine
1
DSP
Rasuvo
3
SL
Nevirapine
1
DSP, E
Simponi
2
DSP, PA, SL
Extended-Release
Stelara
2
DSP, PA, SL
Norvir
2
DSP
Taltz
3
DSP, PA, SL
Odefsey
3
DSP
Xeljanz
3
DSP, PA, SL
Prezcobix
2
DSP
Xeljanz XR
3
DSP, PA, SL
Prezista
2
DSP
Reyataz
2
DSP
17

Drug Requirements
Drug Requirements
Drug Name
Drug Name
Tier  & Limits
Tier  & Limits
Men’s Health: Prostate
Chlorpheniramine/
Hydrocodone/
1
SL
Alfuzosin Tablet
1
Pseudoephedrine
Cialis
3
SL
Solution
Doxazosin Tablet
1
Epinephrine (generic
2
SL
Dutasteride Capsule
1
EpiPen/EpiPen-Jr.)
Finasteride Tablet
1
EpiPen/EpiPen Jr.
3
E, SL
Rapaflo
3
Fosrenol
3
Tamsulosin Capsule
1
Hydrocodone/
Terazosin Capsule, Tablet
1
Chlorpheniramine
1
SL
Suspension
Men’s Health: Testosterone Therapy
Hydrocodone/
Homatropine
1
Androderm
2
SL
Letrozole
1
Androgel
3
E, SL
Lidocaine Transdermal
Methyltestosterone
1
Patch
1
SL
Capsule
Nuedexta
2
Testim
2
SL
Obredon
3
SL
Testosterone 1%
1
E, SL
Pegasys
2
DSP, PA, SL
Topical Gel
Phenazopyridine
1
Testosterone Cypionate
1
Procrit
2
DSP, SL
Injection
Promethazine/Codeine
1
Miscellaneous
Promethazine/
1
Dextromethorphan
Anastrozole Tablet
1
Pulmozyme
2
DSP, PA, SL
Antipyrine/Benzocaine
1
Rectiv
3
SL
Otic Solution
Renvela
2
Aranesp
2
DSP, SL
Rezira
3
Auryxia
3
Tobi Podhaler
3
DSP, PA, SL
Auvi-Q
3
E, SL
Tobramycin Nebulized
Benzonatate Capsule
1
1
DSP, E, PA, SL
Solution
Bethkis
1
DSP, PA, SL
Velphoro
2
Bromfed DM
3
Veltassa
3
SL
Cayston
2
PA, SL
Zarxio
2
DSP
Cerdelga
2
DSP, PA
Chlorhexidine Gluconate
1
Bold type = Brand-name drug
[Plain type = Generic drug]
DSP = Designated specialty program
PA = Prior authorization required
E = May be excluded from coverage
SL = Supply limit
18

Drug Requirements
Drug Requirements
Drug Name
Drug Name
Tier  & Limits
Tier  & Limits
Musculoskeletal: Muscle Spasms
Hydromorphone Tablet
1
Hysingla
3
E, SL
Baclofen Tablet
1
Ibuprofen Tablet
1
Carisoprodol 350 mg
Indomethacin Capsule
1
1
Tablet
Ketorolac Tablet
1
Cyclobenzaprine
1
Lazanda
3
SL
Metaxalone Tablet
1
Meloxicam Tablet
1
Methocarbamol Tablet
1
Methadone Tablet,
Tizanidine Tablet
1
Oral Solution,
1
SL
Concentrate Solution
Musculoskeletal: Osteoporosis
Morphine Sulfate
Alendronate Sodium
Extended-Release Tablet
1
SL
1
Tablet
Morphine Sulfate Oral
Forteo
2
DSP, PA
Solution
1
Ibandronate Tablet
1
SL
Nabumetone Tablet
1
Raloxifene Tablet
1
Naproxen Tablet
1
Risedronate Sodium
Nucynta
3
SL
1
SL
Tablet
Nucynta ER
3
SL
Opana ER
2
SL
Musculoskeletal: Pain Relief
Oxycodone/
Acetaminophen/
Acetaminophen
1
SL
1
SL
Codeine Tablet
5/325, 7 .5/325,
10/325 mg Tablet
Belbuca
3
SL
Oxycodone Tablet
1
Butrans
3
E, SL
Oxycontin
3
E, SL
Celecoxib
1
SL
Sprix
3
Diclofenac Tablet
1
Subsys
3
E, SL
Embeda
3
E, SL
Tramadol-
Etodolac Capsule
1
1
Acetaminophen
Fentanyl 12, 25, 50,
1
SL
Tramadol Immediate-
75, 100 mcg Patch
1
Release Tablet
Fentanyl 37 .5, 62 .5,
1
E, SL
Tramadol Sustained-
87 .5 mcg Patch
1
SL
Release Tablet
Fentanyl Citrate
1
SL
Trezix
1
SL
Lozenge
Vicodin 5/300, 7 .5/300,
Hydrocodone/
1
E, SL
10/300 mg Tablet
Acetaminophen
1
SL
Voltaren Gel
2
5/325, 7 .5/325,
Xtampza ER
3
SL
10/325 mg Tablet
Zohydro ER
3
SL
Hydrocodone/Ibuprofen
1
Tablet
19

Drug Requirements
Drug Requirements
Drug Name
Drug Name
Tier  & Limits
Tier  & Limits
Arnuity Ellipta
Overactive Bladder
3
SL
Asmanex
1
SL
Dicyclomine Tablet
1
Bevespi Aerosphere
2
SL
Oxybutynin Extended-
Breo Ellipta
3
SL
1
Release Tablet
Budesonide Nebs
1
SL
Oxybutynin Tablet
1
Combivent Respimat
3
SL
Tolterodine Extended-
1
E
Dulera
3
SL
Release Tablet
Flovent Diskus/HFA
3
SL
Tolterodine Tablet
1
E
Incruse Ellipta
2
SL
Toviaz
3
Ipratropium-Albuterol
Vesicare
3
E
1
Nebs
Respiratory: Allergies
Ipratropium Nebs
1
Levalbuterol Nebs
1
E, SL
Azelastine 0 .1%
1
Montelukast
1
Nasal Spray
Perforomist
3
SL
Clarinex
3
E
ProAir HFA
3
SL
Clarinex-D
3
E
ProAir RespiClick
3
SL
Cyproheptadine Tablet
1
Proventil HFA
3
SL
Fluticasone Nasal Spray
1
SL
Pulmicort Flexhaler
3
SL
Hydroxyzine Capsule,
1
QVAR
1
SL
Tablet
Serevent Diskus
3
SL
Levocetirizine Tablet
1
Spiriva Handihaler
3
SL
Mometasone
1
E, SL
Spiriva Respimat
3
SL
Nasal Spray
Stiolto Respimat
3
E, SL
Promethazine Tablet
1
Striverdi Respimat
2
SL
Triamcinolone
1
E, SL
Symbicort
3
SL
Nasal Spray
Tudorza
2
SL
Zetonna
3
SL
Ventolin HFA
2
SL
Respiratory: Asthma/COPD
Xopenex HFA
3
SL
Xopenex Nebs
3
E, SL
Advair Diskus/HFA
3
SL
Aerospan
3
SL
Albuterol Nebs
1
Albuterol Sulfate Tablet
1
Alvesco
1
SL
Anoro Ellipta
3
SL
Bold type = Brand-name drug
[Plain type = Generic drug]
DSP = Designated specialty program
PA = Prior authorization required
E = May be excluded from coverage
SL = Supply limit
20

Drug Requirements
Drug Requirements
Drug Name
Drug Name
Tier  & Limits
Tier  & Limits
Respiratory: Pulmonary Arterial
Ashlyna
1
Hypertension
Aubra
1
Adcirca
3
DSP, PA, SL
Aviane
1
Adempas
2
DSP, PA, SL
Azurette
1
Letairis
2
DSP, PA, SL
Balziva
1
Opsumit
2
DSP, PA, SL
Bekyree
1
Orenitram
3
DSP, PA, SL
Blisovi Fe
1
Sildenafil Tablet
1
DSP, PA, SL
Blisovi 24 Fe
1
Tracleer
2
DSP, PA, SL
Briel yn
1
Tyvaso
2
DSP, PA
Camila
1
Uptravi
3
DSP, PA, SL
Camrese
1
Transplant
Camrese Lo
1
Caziant
1
Azathioprine Tablet
1
Cesia
1
Cyclosporine Modified
Chateal
1
1
DSP
Capsule
Crysel e
1
Mycophenolate Capsule,
1
DSP
Cyclafem 7/7/7, 1/35
1
Suspension
Cyred
1
Mycophenolic Acid
1
DSP
Dasetta 7/7/7, 1/35
1
Tablet
Daysee
1
Sirolimus Tablet
1
DSP
Deblitane
1
Tacrolimus Capsule
1
DSP
Delyla
1
Vitamins/Electrolytes
Desogestrel-Ethinyl
1
Estradiol
Fluoride
1
Drospirenone/Ethinyl
Folic Acid
1
1
Estradiol
Klor-Con M10
1
Drospirenone/Ethinyl
Klor-Con M20
1
Estradiol/Levomefolate
1
E
Potassium Chloride
1
Calcium
Potassium Citrate
1
Econtra EZ
1
Elinest
1
Women’s Health: Contraceptives
Ella
1
SL
Aftera
1
Emoquette
1
Altavera
1
Enpresse
1
Alyacen 7/7/7, 1/35
1
Enskyce
1
Amethia
1
Errin
1
Amethia Lo
1
Estarylla
1
Amethyst
1
Fallback
1
Apri
1
Falmina
1
Aranelle
1
Gianvi
1
21

Drug Requirements
Drug Requirements
Drug Name
Drug Name
Tier  & Limits
Tier  & Limits
Gildagia
1
Medroxyprogesterone
1
Gildess
1
Acetate
Gildess 24 Fe
1
Microgestin
1
Gildess Fe
1
Microgestin Fe
1
Heather
1
Minastrin 24 Fe
3
E
Introvale
1
Mono-Linyah
1
Jencycla
1
Mononessa
1
Jolessa
1
My Way
1
Jolivette
1
Myzilra
1
Juleber
1
Natazia
1
Junel
1
Necon 7/7/7, 0 .5/35,
1
Junel 24 Fe
1
1/35, 1/50, 10/11
Junel Fe
1
Next Choice
1
Kariva
1
Nikki
1
Kimidess
1
Nora BE
1
Kurvelo
1
Norethindrone 0 .35 mg
1
Kelnor 1/35
1
Norethindrone-Ethinyl
Larin
1
Estradiol-Ferrous
1
Larin 24 Fe
1
Fumarate
Larin Fe
1
Norgestimate-Ethinyl
1
Larissia
1
Estradiol
Leena
1
Norlyroc
1
Lessina
1
Nortrel 7/7/7, 0 .5/35,
1
Levonest
1
1/35
Levonorgestrel 1 .5 mg
1
Nuvaring
2
Levonorgestrel-Ethinyl
Ocella
1
1
Estradiol
Ogestrel
1
Levora-28
1
Opcicon
1
Lo Loestrin Fe
3
Orsythia
1
LoMedia 24 Fe
1
Ortho Tri-Cyclen Lo
3
E
Loryna
1
Philith
1
Low-Ogestrel
1
Pimtrea
1
Lutera
1
Pirmel a 7/7/7, 1/35
1
Lyza
1
Plan B One Step
1
Marlissa
1
Portia
1
Bold type = Brand-name drug
[Plain type = Generic drug]
DSP = Designated specialty program
PA = Prior authorization required
E = May be excluded from coverage
SL = Supply limit
22

Drug Requirements
Drug Requirements
Drug Name
Drug Name
Tier  & Limits
Tier  & Limits
Previfem
1
Women’s Health: Hormone Replacement
Quasense
1
Rajani
1
E
Cenestin
3
E
Reclipsen
1
Climara
2
SL
Setlakin
1
Climara Pro
3
SL
Sharobel
1
Divigel
3
Solia
1
Duavee
3
Sprintec
1
Enjuvia
3
Sronyx
1
Estrace Cream
3
Syeda
1
Estradiol/Norethindrone
1
Take Action
1
Acetate Tablet
Tarina Fe
1
Estradiol Tablet
1
Taytulla
3
E
Estradiol Twice-Weekly
3
E, SL
Tilia Fe
1
Transdermal Patch
Tri-Estarylla
1
Estring
2
SL
Tri-Legest Fe
1
Estrogen/
Tri-Linyah
1
Methyltestosterone
1
Tri-Lo-Estarylla
1
Tablet
Tri-Lo-Marzia
1
Evamist
2
Tri-Lo-Sprintec
1
Medroxyprogesterone
1
Tri-Previfem
1
Minivelle
3
SL
Tri-Sprintec
1
Premarin
3
Trinessa
1
Premphase
3
Trinessa Lo
1
Prempro
3
Trivora-28
1
Progesterone
1
Velivet
1
Micronized Capsule
Vestura
1
Vagifem
3
E
Vienva
1
Vivelle-Dot
1
SL
Viorele
1
Yuvafem
1
Vyfemla
1
Women’s Health: Miscellaneous
Wera
1
Wymza Fe
1
Addyi
3
SL
Xulane
1
Osphena
3
Yasmin 28
3
Raloxifene
1
Yaz
3
Tamoxifen
1
Zarah
1
Women’s Health: Prenatal Vitamins
Zenchent
1
Zenchent Fe
1
Brand Prenatal
Zovia 1/35E, 1/50E
1
Vitamins
3
23

Index
A
Amethyst ................................21
Auryxia ...................................18
Abacavir-Lamivudine .............17
Amiodarone ............................10
Auvi-Q ...................................18
Accu-Chek Test Strips ...........14
Amitiza...................................16
Aviane ....................................21
Acetaminophen/Butalbital/
Amitriptyline Tablet ...............11
Avonex ................................... 12
Caffeine 325 mg/50 mg/
Amlodipine ............................. 9
Azathioprine Tablet ................21
40 mg ..................................11
Amlodipine-Benazepril ........... 9
Azelastine 0.05% Ophthalmic
Acetaminophen/Codeine
Amlodipine-Valsartan ............. 9
Solution .............................. 15
Tablet ...................................19
Amoxicillin Capsule,
Azelastine 0.1%
Actemra ..................................17
Chewable Tablet ................... 8
Nasal Spray ......................... 20
Acyclovir Ointment ................. 8
Amoxicillin/Potassium
Azithromycin Tablet ................ 8
Acyclovir Tablet ...................... 8
Clavulanate Chewable
Azopt ......................................16
Aczone ................................... 13
Tablet, Tablet ........................ 8
Azurette .................................21
Adapalene Cream, Gel,
Amphetamine Salt Combo .....11
B
Lotion ................................. 13
Ampyra.................................. 12
Baclofen Tablet .......................19
Adcirca ...................................21
Anastrozole Tablet .................18
Balziva ....................................21
Adderall XR ...........................11
Androderm .............................18
Basaglar ..................................14
Addyi ..................................... 23
Androgel.................................18
Bekyree ...................................21
Adempas .................................21
Anoro Ellipta......................... 20
Belbuca ...................................19
Adlyxin ...................................14
Antipyrine/Benzocaine
Benazepril................................ 9
Advair Diskus/HFA .............. 20
Otic Solution .......................18
Benazepril-
Aerospan ............................... 20
Aprepitant Capsule .................16
Hydrochlorothiazide ............. 9
Afrezza ...................................14
Apri ........................................21
Benicar .................................... 9
Aftera .....................................21
Apriso .....................................16
Benicar HCT .......................... 9
Akynzeo .................................16
Aranelle ..................................21
Benzonatate Capsule ..............18
Albuterol Nebs ...................... 20
Aranesp ..................................18
Betamethasone Dipropionate
Albuterol Sulfate Tablet ......... 20
Aripiprazole Tablet ................ 12
0.05% Augmented Lotion,
Alendronate Sodium Tablet....19
Armodafanil .......................... 12
Ointment ............................ 13
Alfuzosin Tablet .....................18
Armour Thyroid .................... 15
Betamethasone Dipropionate
Allopurinol Tablet ..................17
Arnuity Ellipta ...................... 20
0.05% Cream, Ointment .... 13
Alphagan P 0.1% ....................16
Asacol HD Tablet ..................16
Betaseron ............................... 12
Alprazolam Extended-Release
Ashlyna ..................................21
Bethkis ...................................18
Tablet .................................. 12
Asmanex ................................ 20
Bevespi Aerosphere ............... 20
Alprazolam Tablet ................. 12
Atenolol ................................... 9
Bexarotene Capsule ................. 9
Altavera ..................................21
Atenolol-Chlorthalidone ......... 9
Bicalutamide ............................ 9
Alvesco .................................. 20
Atorvastatin ............................10
Bidil ......................................... 9
Alyacen 7/7/7, 1/35 .................21
Atripla ....................................17
Bisoprolol ................................. 9
Amethia..................................21
Aubagio ................................. 12
Bisoprolol-
Amethia Lo ............................21
Aubra ......................................21
Hydrochlorothiazide ............. 9
24

Blisovi 24 Fe ...........................21
Caziant ...................................21
Clobetasol Propionate Cream,
Blisovi Fe ................................21
Cefadroxil Capsule, Tablet ...... 8
Ointment, Solution ............. 13
Bosulif ..................................... 9
Cefdinir Capsule ..................... 8
Clomiphene ............................17
Brand Prenatal Vitamins ....... 23
Cefixime Suspension ............... 8
Clonazepam Tablet ................ 12
Breo Ellipta ........................... 20
Cefprozil Tablet ....................... 8
Clonidine Tablet ...................... 9
Briellyn ...................................21
Cefuroxime Tablet ................... 8
Clopidogrel .............................. 9
Brilinta .................................... 9
Celecoxib ................................19
Clotrimazole-Betamethasone
Bromfed DM ..........................18
Cenestin ................................ 23
Cream ................................. 13
Budesonide Nebs ................... 20
Cephalexin Capsule ................. 8
Clotrimazole-Betamethasone
Buprenorphine/
Cerdelga .................................18
Lotion ................................. 13
Naloxone Tablet .................. 12
Cesia .......................................21
Colcrys ...................................17
Bupropion Extended-Release
Cetrotide ................................17
Combigan ...............................16
Tablet ...................................11
Chateal ...................................21
Combivent Respimat ............. 20
Bupropion Sustained-Release
Chlorhexidine Gluconate ........18
Complera ................................17
Tablet ...................................11
Chlorpheniramine/
Concerta .................................11
Bupropion Tablet ....................11
Hydrocodone/
Contour Test Strips ................14
Buspirone Tablet .................... 12
Pseudoephedrine Solution ...18
Copaxone 20 mg ................... 12
Butrans ...................................19
Chlorthalidone ........................ 9
Copaxone 40 mg ................... 12
Bydureon ................................14
Choline Fenofibrate ................10
Corlanor .................................10
Byetta .....................................14
Cialis ......................................18
Cortifoam ...............................16
Bystolic .................................... 9
Ciclopirox Cream, Gel,
Cosentyx.................................17
C
Lotion, Solution ................. 13
Creon ......................................16
Cresemba ................................. 8
Calcipotriene/Betamethasone
Cimzia ....................................17
Cryselle ...................................21
Ointment ............................ 13
Ciprodex .................................. 8
Cyclafem 7/7/7, 1/35...............21
Calcitriol Capsule .................. 15
Ciprofloxacin Tablet ................ 8
Cyclobenzaprine .....................19
Camila ....................................21
Citalopram Tablet ...................11
Cyclophosphamide Capsule ..... 9
Camrese ..................................21
Claravis .................................. 13
Cyclosporine Modified
Camrese Lo ............................21
Clarinex ................................. 20
Capsule ................................21
Canasa ....................................16
Clarinex-D ............................ 20
Cyproheptadine Tablet .......... 20
Carac ..................................... 13
Clarithromycin Tablet ............. 8
Cyred ......................................21
Carbamazepine
Climara.................................. 23
Extended-Release Capsule,
Climara Pro ........................... 23
D
Tablet .................................. 12
Clindamycin 1%/Benzoyl
Daklinza .................................17
Carbamazepine
Peroxide 5% Gel ................. 13
Dasetta 7/7/7, 1/35 .................21
Immediate-Release Tablet .. 12
Clindamycin 1.2%/Benzoyl
Daysee ....................................21
Carbidopa-Levodopa ............. 12
Peroxide 5% Gel ................. 13
Daytrana .................................11
Carisoprodol 350 mg Tablet ...19
Clindamycin Capsule .............. 8
Deblitane ................................21
Cartia XT ................................ 9
Clindamycin Gel ................... 13
Delyla .....................................21
Carvedilol ................................ 9
Clindamycin Lotion,
Delzicol ..................................16
Cayston ...................................18
Solution, Swabs .................. 13
Descovy ..................................17
25

Desmopressin Tablet ............. 15
Diphenoxylate-Atropine
Enjuvia .................................. 23
Desogestrel-Ethinyl
Tablet ...................................16
Enoxaparin Sodium ................. 9
Estradiol ..............................21
Divalproex Delayed-Release
Enpresse .................................21
Desonide 0.05% Cream,
Tablet .................................. 12
Enskyce ..................................21
Lotion, Ointment ............... 13
Divalproex Extended-Release
Enstilar Foam ........................ 13
Desoximetasone Cream, Gel,
Tablet .................................. 12
Entresto ..................................10
Ointment ............................ 13
Divigel ................................... 23
Epclusa ...................................17
Desvenlafaxine Extended-
Donepezil ODT, 5, 10 mg
Epiduo/Epiduo Forte ............. 13
Release Tablet ......................11
Tablet .................................. 12
Epinephrine ............................18
Dexamethasone Tablet .......... 15
Doxazosin ...........................9, 18
EpiPen/EpiPen Jr. ..................18
Doxazosin Tablet ....................18
Dexcom Continuous Glucose
EpiPen/EpiPen-Jr. ..................18
Doxepin ..................................11
Monitoring System ..............14
Epzicom .................................17
Doxycycline Hyclate
Dexcom Sensor .......................14
Errin .......................................21
50, 100 mg Capsule, Tablet .. 8
Dexcom Transmitter ..............14
Erythromycin 0.5%
Doxycycline Monohydrate
Dexilant ..................................16
Ophthalmic Ointment ........ 15
50, 100 mg Capsule .............. 8
Dexmethylphenidate
Escitalopram Tablet ................11
Drospirenone/Ethinyl
Extended-Release Capsule ..11
Esomeprazole Capsule ............16
Estradiol ..............................21
Dexmethylphenidate
Estarylla .................................21
Drospirenone/Ethinyl
Immediate-Release Tablet ...11
Estrace Cream ....................... 23
Estradiol/Levomefolate
Dextroamphetamine Sulfate
Estradiol Tablet ..................... 23
Calcium ...............................21
Immediate-Release Tablet ...11
Estradiol Twice-Weekly
Duavee ................................... 23
Dextroamphetamine-
Transdermal Patch .............. 23
Dulera .................................... 20
Amphetamine
Estradiol/Norethindrone
Duloxetine Capsule ................11
Extended-Release ................11
Dutasteride Capsule ...............18
Acetate Tablet ..................... 23
Estring ................................... 23
Dextroamphetamine-
Dutoprol .................................. 9
Estrogen/Methyltestosterone
Amphetamine
E
Tablet .................................. 23
Immediate-Release Capsule 11
Econazole Cream .................... 8
Eszopiclone Tablet ................. 12
Diazepam Tablet ................... 12
Econtra EZ ............................21
Etodolac Capsule ....................19
Diclofenac Tablet ....................19
Edarbi ...................................... 9
Evamist .................................. 23
Dicyclomine Tablet ............... 20
Edarbyclor ............................... 9
Evotaz .....................................17
Dificid ..................................... 8
Effient ..................................... 9
Ezetimibe Tablet ....................10
Diflorasone Diacetate 0.05%
Elinest ....................................21
Cream, Ointment ............... 13
F
Eliquis ..................................... 9
Digoxin ..................................10
Ella .........................................21
Fallback ..................................21
Diltiazem 24 Hour CD ........... 9
Embeda ..................................19
Falmina ..................................21
Diltiazem Sustained-Release
Emend Suspension .................16
Famciclovir Tablet ................... 8
Capsule ................................. 9
Emoquette ..............................21
Farxiga ....................................14
Diltiazem Sustained-Release
Enalapril .................................. 9
Fenofibrate 40, 48, 120,
Tablet .................................... 9
Enbrel .....................................17
145 mg Tablet ......................10
26

Fenofibrate 43, 50, 67, 130,
Gildess 24 Fe ......................... 22
Hydroxyurea Capsule .............. 9
134, 150, 200 mg Capsule ...10
Gildess Fe .............................. 22
Hydroxyzine Capsule, Tablet 20
Fenofibrate 54, 160 mg
Gilenya .................................. 12
Hyoscyamine Tablet ...............16
Tablet ...................................10
Glatopa .................................. 12
Hysingla .................................19
Fentanyl 12, 25, 50, 75,
Glimepiride ............................14
I
100 mcg Patch .....................19
Glipizide .................................14
Fentanyl 37.5, 62.5, 87.5 mcg
Glipizide Extended-Release ...14
Ibandronate Tablet .................19
Patch ....................................19
Glucophage XR ..................... 15
Ibuprofen Tablet .....................19
Fentanyl Citrate Lozenge .......19
Glyburide................................14
Imantinib Tablet ...................... 9
Fetzima ...................................11
Glyxambi ................................14
Imbruvica ................................ 9
Finacea .................................. 13
Golytely ..................................16
Imiquimod 5% Cream ........... 13
Finasteride Tablet ...................18
Gonal-F ..................................17
Incruse Ellipta ....................... 20
Flecainide ...............................10
Gonal-F RFF .........................17
Indomethacin Capsule ............19
Flovent Diskus/HFA ............. 20
Guanfacine .........................9, 11
Intelence .................................17
Fluconazole Tablet ................... 8
Guanfacine
Introvale ................................ 22
Fluocinolone Cream, Oil,
Extended-Release ................11
Invokamet ...............................14
Ointment, Solution ............. 13
H
Invokamet XR ........................14
Fluocinonide 0.05% Cream ... 13
Invokana .................................14
Fluoride ..................................21
Halobetasol Ointment ........... 13
Ipratropium Nebs .................. 20
Fluoxetine Tablet, Capsule .....11
Harvoni ..................................17
Ipratropium-Albuterol Nebs .. 20
Fluticasone Nasal Spray ......... 20
Heather .................................. 22
Irbesartan ................................ 9
Fluvastatin Extended-Release
Humalog KwikPens ...............14
Isentress ..................................17
Tablet ...................................10
Humalog Vials .......................14
Isosorbide Mononitrate ER ....10
Fluvoxamine Tablet ................11
Humira ...................................17
Itraconazole Capsule ................ 8
Focalin XR .............................11
Humulin KwikPens ................14
J
Folic Acid ...............................21
Humulin Vials ........................14
Forteo .....................................19
Hydralazine ............................. 9
Janumet ..................................14
Fosrenol ..................................18
Hydrochlorothiazide ................ 9
Januvia ................................... 15
FreeStyle Test Strips ...............14
Hydrocodone/Acetaminophen
Jardiance ................................ 15
Frovatriptan ............................11
5/325, 7.5/325, 10/325 mg
Jencycla .................................. 22
Furosemide .............................. 9
Tablet ...................................19
Jentadueto .............................. 15
Hydrocodone/
Jentadueto XR ....................... 15
G
Chlorpheniramine
Jolessa .................................... 22
Gabapentin Capsule, Tablet .. 13
Suspension ...........................18
Jolivette .................................. 22
Gemfibrozil ............................10
Hydrocodone/Homatropine ...18
Juleber .................................... 22
Gentamicin Ophthalmic
Hydrocodone/Ibuprofen
Junel ....................................... 22
Ointment, Solution ............. 15
Tablet ...................................19
Junel 24 Fe ............................. 22
Genvoya ..................................17
Hydrocortisone 2.5% Cream,
Junel Fe .................................. 22
Gianvi .....................................21
Ointment ............................ 13
Gildagia ................................. 22
Hydromorphone Tablet ..........19
K
Gildess ................................... 22
Hydroxychloroquine Sulfate ...17
Kaletra Tablet .........................17
27

Kariva .................................... 22
Levocetirizine Tablet ............. 20
Medroxyprogesterone
Kazano .................................. 15
Levofloxacin Tablet ................. 8
Acetate ................................ 22
Kelnor 1/35 ............................ 22
Levonest ................................ 22
Meloxicam Tablet ...................19
Ketoconazole Cream ............... 8
Levonorgestrel 1.5 mg ........... 22
Memantine ............................ 12
Ketorolac Tablet ......................19
Levonorgestrel-Ethinyl
Mercaptopurine Tablet ............ 9
Kimidess ................................ 22
Estradiol ............................. 22
Metadate CD .........................11
Klor-Con M10 .......................21
Levora-28 .............................. 22
Metadate ER ..........................11
Klor-Con M20 .......................21
Levothyroxine Sodium
Metaxalone Tablet ..................19
Kombiglyze XR ..................... 15
Tablet .................................. 15
Metformin ............................. 15
Kurvelo .................................. 22
Lialda .....................................16
Metformin Extended-Release
L
Lidocaine Transdermal
Tablet .................................. 15
Labetalol .................................. 9
Patch ....................................18
Methadone Tablet, Oral
Lamivudine-Zidovudine ........17
Linzess ...................................16
Solution, Concentrate
Lamotrigine
Liothyronine Sodium
Solution ...............................19
Immediate-Release Tablet .. 13
Tablet .................................. 15
Methimazole Tablet .............. 15
Lansoprazole Capsule .............16
Lipofen ...................................10
Methocarbamol Tablet ...........19
Lantus Solostar .......................14
Lisinopril ............................9, 33
Methotrexate Tablet ...............17
Lantus Vials ...........................14
Lisinopril-
Methylphenidate Chewable
Larin ...................................... 22
Hydrochlorothiazide ............. 9
Tablet ...................................11
Larin 24 Fe ............................ 22
Lithium Capsule .................... 12
Methylphenidate
Larin Fe ................................. 22
Livalo .....................................10
Extended-Release Capsule ..11
Larissia .................................. 22
Lo Loestrin Fe ...................... 22
Methylphenidate
Lastacaft ................................ 15
LoMedia 24 Fe ...................... 22
Extended-Release Tablet .....11
Latanoprost 0.005%
Lopinavir-Ritonavir Oral
Methylphenidate Tablet ..........11
Ophthalmic Solution ...........16
Solution ...............................17
Methylprednisolone Tablet .... 15
Latuda ................................... 12
Lorazepam Tablet .................. 12
Methyltestosterone Capsule ....18
Lazanda ..................................19
Loryna ................................... 22
Metoclopramide Tablet ..........16
Leena ..................................... 22
Losartan .................................. 9
Metoprolol Succinate
Leflunomide ...........................17
Losartan-
50, 100, 200 mg .................... 9
Lessina ................................... 22
Hydrochlorothiazide ............. 9
Letairis ...................................21
Metoprolol Tartrate
Lovastatin ...............................10
Letrozole ................................18
25, 50, 100 mg ...................... 9
Low-Ogestrel ........................ 22
Leucovorin Calcium Tablet ..... 9
Metronidazole 0.75% Topical
Lumigan .................................16
Levalbuterol Nebs .................. 20
Gel ...................................... 13
Lutera .................................... 22
Levemir FlexTouch ................14
Lyrica .................................... 13
Metronidazole Tablet .............. 8
Levemir Vials .........................14
Lyza ....................................... 22
Microgestin ........................... 22
Levetiracetam
Microgestin Fe ...................... 22
Extended-Release Tablet .... 13
M
Minastrin 24 Fe ..................... 22
Levetiracetam
Marlissa ................................. 22
Minivelle ............................... 23
Immediate-Release Tablet .. 13
Medroxyprogesterone ...... 22, 23
Minocycline Capsule ............... 8
28

Minocycline
Nevirapine ..............................17
O
Extended-Release
Nevirapine
Obredon .................................18
Capsule ............................... 13
Extended-Release ................17
Ocella .................................... 22
Minocycline Tablet .................. 8
Next Choice........................... 22
Odefsey ...................................17
Mirtazapine Tablet .................11
Niacin Extended-Release
Ofloxacin 0.3% Ophthalmic
Mirvaso ................................. 13
Tablet ...................................10
Solution .............................. 15
Mitigare ..................................17
Niaspan ..................................10
Ofloxacin Otic Solution ........... 8
Modafinil Tablet .................... 12
Nifedipine
Ofloxacin Tablet ...................... 8
Mometasone Furoate Cream,
Extended-Release ................10
Ogestrel ................................. 22
Lotion, Ointment ............... 13
Nikki ..................................... 22
Olanzapine Tablet ................. 12
Mometasone Nasal Spray ...... 20
Nitrofurantoin Capsule ............ 8
Olmesartan .............................10
Mono-Linyah ........................ 22
Nitrofurantoin Macrocrystal
Olmesartan-
Mononessa ............................. 22
Capsule ................................. 8
Hydrochlorothiazide ............10
Montelukast ........................... 20
Nitroglycerin Sublingual
Olopatadine 0.1% Ophthalmic
Morphine Sulfate
Tablet ...................................10
Solution .............................. 15
Extended-Release Tablet .....19
Nora BE ................................ 22
Omeclamox-Pak .....................16
Morphine Sulfate
Norethindrone 0.35 mg ......... 22
Omega-3-Acid Ethyl Esters
Oral Solution .......................19
Norethindrone-Ethinyl
Capsule ................................10
Movantik ................................16
Estradiol-Ferrous
Omeprazole Capsule ..............16
Moviprep ................................16
Fumarate ............................ 22
Ondansetron ...........................16
Moxeza .................................. 15
Norgestimate-Ethinyl
Ondansetron ODT .................16
Moxifloxacin Tablet ................. 8
Estradiol ............................. 22
OneTouch Test Strips .............14
Multaq ....................................10
Norlyroc ................................. 22
OneTouch Ultra Mini ............14
Mupirocin Ointment ............. 13
Nortrel 7/7/7, 0.5/35, 1/35 ..... 22
OneTouch Ultra Test Strips ....14
My Way ................................. 22
Nortriptyline Capsule .............11
OneTouch Verio .....................14
Mycophenolate Capsule,
Norvir .....................................17
OneTouch Verio Flex ..............14
Suspension ...........................21
Novolin Vials ..........................14
OneTouch Verio IQ ................14
Mycophenolic Acid Tablet ......21
Novolog FlexTouch ................14
OneTouch Verio Sync .............14
Myzilra .................................. 22
Novolog Vials .........................14
OneTouch Verio Test Strips ....14
N
Noxafil Tablet, Suspension ...... 8
Onglyza ................................. 15
Nabumetone Tablet ................19
NP Thyroid Tablet ................ 15
Opana ER ..............................19
Nadolol ...................................10
Nucynta ..................................19
Opcicon ................................. 22
Naloxone Vial ........................ 12
Nucynta ER ............................19
Opsumit .................................21
Naproxen Tablet .....................19
Nuedexta ................................18
Oracea ..................................... 8
Naratriptan .............................11
Nutropin, Nutropin AQ ........ 15
Orencia ...................................17
Narcan Nasal Spray ............... 12
Nuvaring................................ 22
Orenitram ...............................21
Natazia .................................. 22
Nystatin Cream, Ointment...... 8
Orsythia ................................ 22
Necon 7/7/7, 0.5/35, 1/35,
Nystatin-Triamcinolone
Ortho Tri-Cyclen Lo............. 22
1/50, 10/11 .......................... 22
Acetonide Cream,
Oseltamivir Capsule ................ 8
Nesina .................................... 15
Ointment ............................ 13
Oseni ..................................... 15
29

Osphena ................................ 23
Premarin ................................ 23
Ranitadine Syrup ....................16
Otezla .....................................17
Premphase ............................. 23
Rapaflo ...................................18
Otrexup ..................................17
Prempro ................................. 23
Rasuvo ....................................17
Ovidrel ...................................17
Prenisolone Oral Solution...... 15
Rebif ...................................... 12
Oxcarbazepine Tablet ............ 13
Prepopik .................................16
Reclipsen ............................... 23
Oxsoralen-Ultra ..................... 13
Previfem ................................ 23
Rectiv .....................................18
Oxybutynin Extended-Release
Prezcobix ................................17
Regranex ................................ 13
Tablet .................................. 20
Prezista ...................................17
Relpax .....................................11
Oxybutynin Tablet ................ 20
Pristiq .....................................11
Renvela ...................................18
Oxycodone Tablet ...................19
ProAir HFA .......................... 20
Repatha 140 mg......................10
Oxycodone/Acetaminophen
ProAir RespiClick ................. 20
Restasis Single Use Vial .........16
5/325, 7.5/325, 10/325 mg
Procrit .....................................18
Revlimid .................................. 9
Tablet ...................................19
Progesterone Micronized
Reyataz ...................................17
Oxycontin ...............................19
Capsule ............................... 23
Rezira .....................................18
P
Promethazine Tablet .............. 20
Ribavirin Tablet ......................17
Promethazine/Codeine ...........18
Risedronate Sodium Tablet ....19
Pantoprazole Tablet ................16
Promethazine/
Risperidone Tablet ................. 12
Paroxetine Tablet ....................11
Dextromethorphan ..............18
Ritalin SR ...............................11
Pataday .................................. 15
Propranolol Extended-Release
Rizatriptan ODT, Tablet ........11
Pegasys ...................................18
Capsule ................................10
Ropinirole Tablet ................... 12
Penicillin V Potassium Tablet .. 8
Propranolol Tablet ..................10
Rosuvastatin ...........................10
Perforomist ............................ 20
Proventil HFA ....................... 20
Phenazopyridine .....................18
S
Pulmicort Flexhaler ............... 20
Phenytoin Capsule,
Savaysa .................................... 9
Pulmozyme ............................18
Suspension .......................... 13
Selzentry .................................17
Pylera ......................................16
Philith ................................... 22
Serevent Diskus ..................... 20
Picato ..................................... 13
Q
Sertraline Tablet .....................11
Pimtrea .................................. 22
Quasense ............................... 23
Setlakin ................................. 23
Pioglitazone ........................... 15
Quetiapine Extended-Release
Sharobel ................................. 23
Pirmella 7/7/7, 1/35 ............... 22
Tablet .................................. 12
Sildenafil Tablet ......................21
Plan B One Step .................... 22
Quetiapine Tablet .................. 12
Simponi ..................................17
Plegridy ................................. 12
Quinapril ................................10
Simvastatin .............................10
Polyethylene Glycol 3350 ........16
QVAR ................................... 20
Sirolimus Tablet ......................21
Portia ..................................... 22
Solia ....................................... 23
Potassium Chloride ................21
R
Soliqua ....................................14
Potassium Citrate ...................21
Rabeprazole Tablet .................16
Solodyn .................................. 13
Pradaxa .................................... 9
Rajani .................................... 23
Sotalol.....................................10
Praluent ..................................10
Raloxifene .........................19, 23
Sovaldi ....................................17
Pramipexole Tablet ................ 12
Raloxifene Tablet ....................19
Spiriva Handihaler ................ 20
Pravastatin ..............................10
Ramipril .................................10
Spiriva Respimat.................... 20
Prednisone Tablet .................. 15
Ranexa ....................................10
Spironolactone ........................10
30

Sprintec ................................. 23
Taytulla ................................. 23
Tramadol Sustained-Release
Sprix .......................................19
Tazorac ...................................14
Tablet ...................................19
Sronyx.................................... 23
Tecfidera ................................ 12
Tramadol-Acetaminophen ......19
Stelara .....................................17
Technivie ................................17
Transderm-Scop .....................16
Stiolto Respimat .................... 20
Telmisartan.............................10
Travatan Z ..............................16
Strattera ..................................11
Telmisartan-
Trazodone Tablet ....................11
Stribild ....................................17
Hydrochlorothiazide ............10
Tresiba FlexTouch ..................14
Striverdi Respimat ................. 20
Temazepam Capsule .............. 12
Tretinoin Cream .....................14
Suboxone Film ...................... 12
Terazosin ..........................10, 18
Tretinoin Gel ..........................14
Subsys .....................................19
Terazosin Capsule, Tablet .......18
Tretinoin Microspheres ..........14
Suclear ....................................16
Terbinafine Tablet ................... 8
Trezix .....................................19
Sucralfate Tablet .....................16
Testim .....................................18
Tri-Estarylla .......................... 23
Sulfamethoxazole-
Testosterone 1% Topical Gel ..18
Tri-Legest Fe ......................... 23
Trimethoprim Tablet ............ 8
Testosterone Cypionate
Tri-Linyah ............................. 23
Sulfasalazine Tablet ................16
Injection ...............................18
Tri-Lo-Estarylla .................... 23
Sumatriptan Nasal Spray ........11
Tilia Fe .................................. 23
Tri-Lo-Marzia ....................... 23
Sumatriptan Succinate
Timolol Maleate 0.25%, 0.5%
Tri-Lo-Sprintec ..................... 23
Tablet, Injection ...................11
Ophthalmic Solution ...........16
Tri-Previfem .......................... 23
Suprax Capsule, Chewable
Tivicay ....................................17
Tri-Sprintec ........................... 23
Tablet, Tablet ........................ 8
Tizanidine Tablet ...................19
Triamcinolone Acetonide
Suprep ....................................16
Tobi Podhaler .........................18
Cream, Lotion, Ointment ...14
Sustiva ....................................17
Tobramycin Nebulized
Triamcinolone Nasal Spray .... 20
Sutent ...................................... 9
Solution ...............................18
Triamterene-
Syeda ..................................... 23
Tobramycin Ophthalmic
Hydrochlorothiazide ............10
Symbicort .............................. 20
Solution .............................. 15
Triazolam Tablet ................... 12
Synjardy ................................. 15
Trinessa ................................. 23
Tobramycin/Dexamethasone
Synthroid ............................... 15
Trinessa Lo ............................ 23
0.3%-0.1% Ophthalmic
T
Trintellix .................................11
Suspension .......................... 15
Triumeq ..................................17
Taclonex Suspension .............. 13
Tolcapone .............................. 12
Trivora-28 .............................. 23
Tacrolimus Capsule ................21
Tolterodine Extended-Release
Trulicity ................................. 15
Tacrolimus Ointment .............14
Tablet .................................. 20
Truvada ..................................17
Take Action ........................... 23
Tolterodine Tablet ................. 20
Tudorza ................................. 20
Taltz .......................................17
Topiramate
Tybost .....................................17
Tamoxifen.............................. 23
Immediate-Release Tablet .. 13
Tyvaso ....................................21
Tamsulosin Capsule ................18
Toujeo SoloStar ......................14
Tanzeum ................................ 15
Toviaz .................................... 20
U
Targretin Capsule .................... 9
Tracleer ...................................21
Uceris Foam ............................16
Targretin Gel ........................... 9
Tradjenta................................ 15
Uceris Tablet ...........................16
Tarina Fe ............................... 23
Tramadol Immediate-Release
Uloric ......................................17
Tasigna .................................... 9
Tablet ...................................19
Uptravi....................................21
31

V
Viread .....................................17
Z
Vagifem ................................. 23
Vitekta ....................................17
Zaleplon Capsule ................... 12
Valacyclovir Tablet .................. 8
Vivelle-Dot ............................ 23
Zarah ..................................... 23
Valganciclovir .......................... 8
Voltaren Gel ...........................19
Zarxio .....................................18
Valsartan .................................10
Vyfemla ................................. 23
Zelapar .................................. 12
Valsartan-
Vytorin ...................................10
Zenchent ............................... 23
Hydrochlorothiazide ............10
Vyvanse ..................................11
Zenchent Fe .......................... 23
Varubi .....................................16
W
Zenpep ...................................16
Vascepa ...................................10
Warfarin Sodium .................... 9
Zepatier ..................................17
Vectical ...................................14
Welchol ..................................10
Zetia .......................................10
Velivet .................................... 23
Wera ...................................... 23
Zetonna ................................. 20
Velphoro .................................18
Wymza Fe ............................. 23
Zinbryta ................................ 12
Veltassa ...................................18
Ziprasidone Capsule .............. 12
Venlafaxine Extended-Release
X
Zohydro ER ...........................19
Capsule ................................11
Xarelto ..................................... 9
Zolpidem Extended-Release
Venlafaxine Tablet ..................11
Xeljanz ....................................17
Tablet .................................. 12
Ventolin HFA ........................ 20
Xeljanz XR .............................17
Zolpidem Tablet .................... 12
Verapamil ...............................10
Xeloda ..................................... 9
Zonisamide Capsule .............. 13
Verapamil Sustained-Release ..10
Xigduo XR ............................ 15
Zovia 1/35E, 1/50E .............. 23
Vesicare .................................. 20
Xiidra .....................................16
Zovirax Cream ........................ 8
Vestura ................................... 23
Xopenex HFA ....................... 20
Zubsolv .................................. 12
Viberzi ....................................16
Xopenex Nebs ........................ 20
Zurampic ................................17
Vicodin 5/300, 7.5/300,
Xtampza ER ...........................19
Zytiga ...................................... 9
10/300 mg Tablet ................19
Xulane ................................... 23
Victoza 2-Pak ........................ 15
Xyrem .................................... 12
Victoza 3-Pak ........................ 15
Y
Viekira Pak .............................17
Vienva .................................... 23
Yasmin 28 .............................. 23
Vigamox ................................ 15
Yaz ......................................... 23
Viibryd ...................................11
Yuvafem ................................. 23
Viorele ................................... 23
32

“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 medication
Drug
I take this
Directions
Doctor
and strength
tier
medicine for
Example: Lisinopril, 20 mg
Tier 1
High blood pressure
One tablet daily
Dr . Johnson
33

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Mail:
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UnitedHealthcare Civil Rights Grievance


P.O. Box 30608


Salt Lake City, Utah 84130
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You can also file a complaint with the U.S. Dept. of Health and Human Services.

Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf


Complaint forms are available at
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Washington, D.C. 20201
We provide free services to help you communicate with us, including letters in other languages or
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listed on your ID card TTY 711, Monday through Friday, 8 a.m. to 8 p.m.
34

35

© 2017 United HealthCare Services, Inc . All rights reserved . Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates .
Administrative services provided by UnitedHealthcare Insurance Company, UnitedHealthcare Services, Inc . or their affiliates .
Health Plan coverage provided by or through a UnitedHealthcare company . OptumRx is an affiliate of UnitedHealthcare Insurance Company .
UnitedHealthcare® and the dimensional U logo are registered trademarks owned by UnitedHealth Group Incorporated .
All other trademarks are the property of their respective owners .
Created March, 2017 . 2017 Prescription Drug List – Student Resources Traditional Three-Tier
7/17