Your 2016 Formulary

Transcription

Your 2016 Formulary

Your 2016 Formulary
SignatureValue Three-Tier
effective July 1, 2016
Please read: This document contains information about commonly prescribed
medications.
For additional information:
Call the toll-free member phone number on your health plan ID card.
Visit myuhc.com® or optumrx.com®
• Locate a participating retail pharmacy by ZIP code.
• Look up possible lower-cost medication alternatives.
• Compare medication pricing and options.
1
Your Formulary
This Formulary outlines the most commonly prescribed medications for certain conditions and organizes
them into coverage levels. An important part of the Formulary is giving you choices so you and your
doctor can choose the best course of treatment for you.
Go to myuhc.com for complete drug information
Since the Formulary may change, we encourage you to visit our website, myuhc.com or optumrx.com.
This website is the best source for up-to-date information about the medications your pharmacy benefit
covers, possible lower-cost options, and cost comparisons. The complete formulary is also publicly
available here on optumrx.com and is updated on a monthly basis.
2
Table of Contents
Drug coverage levels and cost . . . . . . . . . . . 5
Gastrointestinal
Acid Suppression. . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Nausea/Vomiting. . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Programs and Limits . . . . . . . . . . . . . . . . . . . . . . 7
Drugs by category . . . . . . . . . . . . . . . . . . . . . . . 10
Anti-Infectives
Antibiotics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
HIV/AIDS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Inflammatory Conditions: Rheumatoid
Arthritis, Crohn’s Disease, Psoriasis,
Ulcerative Colitis. . . . . . . . . . . . . . . . . . . . . . . . . 22
Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Cardiovascular/Heart Disease
Coagulation Therapy . . . . . . . . . . . . . . . . . . . . . . . .
High Blood Pressure. . . . . . . . . . . . . . . . . . . . . . . .
High Cholesterol. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Central Nervous System
Attention Deficit Disorder. . . . . . . . . . . . . . . . . . . .
Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Migraine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Multiple Sclerosis. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Sedatives/Hypnotics. . . . . . . . . . . . . . . . . . . . . . . .
Seizure Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . .
Men’s Health
Erectile Dysfunction. . . . . . . . . . . . . . . . . . . . . . . . . 22
Prostate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Testosterone Therapy . . . . . . . . . . . . . . . . . . . . . . . 22
11
11
13
13
Miscellaneous. . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Musculoskeletal
Osteoporosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Pain Relief. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
14
14
15
15
15
16
16
Overactive Bladder. . . . . . . . . . . . . . . . . . . . . . . 25
Respiratory
Asthma/COPD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Nasal Allergies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Oral Allergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pulmonary Arterial Hypertension. . . . . . . . . . . . .
Dermatology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Diabetes/Endocrine
Blood Glucose Monitoring. . . . . . . . . . . . . . . . . . . 18
Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Non-Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Transplant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Vitamins/Electrolytes. . . . . . . . . . . . . . . . . . . . 26
Endocrine
Growth Hormone. . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Thyroid Hormone Replacement. . . . . . . . . . . . . . 19
Eye Conditions
Allergies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Antibiotics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Glaucoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
25
26
26
26
Women’s Health
Contraceptives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Hormone Replacement. . . . . . . . . . . . . . . . . . . . . . 28
Prenatal Vitamins . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
19
19
20
20
3
4
At UnitedHealthcare, we want to help you better
understand your medication options.
Your pharmacy benefit offers flexibility and choice in determining the right medication
for you. To help you get the most out of your pharmacy benefit, we’ve included some of
the most commonly asked questions about the Formulary.
What is a Formulary?
This document is a list of commonly prescribed medications. Drugs are listed by common categories or
class. It includes both brand and generic prescription medications approved by the U.S. Food and Drug
Administration (FDA).
Please note: Where differences are noted between this Formulary and your benefit plan documents,
the benefit plan documents will rule. It is not a complete list of medications, and not all medications
listed may be covered under your plan. Please look at your benefit plan documents provided by your
employer or health plan to see what medications are covered under your plan. You may also log on to
myuhc.com or optumrx.com or call the toll-free member phone number on your health plan ID card
for more information.
How do I use my Formulary List?
When choosing a medication, you and your doctor should consult the Formulary. It will help you and
your doctor choose the most cost-effective prescription drugs. This guide tells you if a medication is
generic or brand, and if special programs apply. Bring this list with you when you see your doctor. It is
organized by common medical conditions. Medications are then listed alphabetically.
If your medication is not listed in this document, please visit myuhc.com or optumrx.com or call the
toll-free member phone number on your health plan ID card.
5
What are Coverage Levels?
Coverage Levels are the different cost levels you pay for a medication. Each level is assigned a cost,
which is determined by your employer or health plan. This is how much you will pay when you fill a
prescription. Formulary Generic medications are your lowest-cost options. If your medication is placed in
Formulary Brand or Non-Formulary levels, look to see if there is a Formulary Generic option available.
Discuss these options with your doctor.
Check your benefit plan documents to find out your specific pharmacy plan costs.
$
Coverage Level
Includes
Helpful Tips
Formulary Generic
Lowest Cost
Lower-cost drugs.
Some low-cost brands
are also included.
Use Formulary Generic drugs for
the lowest out‑of-pocket costs.
Formulary Brand
Mid-range Cost
Cost effective
brand drugs.
Use Formulary Brand drugs,
instead of Non-Formulary to help
reduce your out-of-pocket costs.
Non-Formulary
Highest Cost
Mostly higher-cost
brand as well as select
generic drugs.
Many Non-Formulary drugs have
lower‑cost options in Formulary
Generic or Brand levels. Ask your
doctor if they could work for you.
Please note: Some plans may have two or four coverage levels, while others may not have any. If you
have a high deductible plan, the coverage cost levels may apply once you hit your deductible. Refer to
your enrollment and plan materials on myuhc.com or optumrx.com, or call the toll-free number on
your health plan ID card for more information about your benefit plan.
When does the Formulary List change?
• Medications may move to a lower level at any time.
• Medications may move to a higher level when its generic becomes available.
• Medications may move to a higher level most often on January 1 or July 1.
When a medication changes levels, you may have to pay a different amount for that medication.
For the most up-to-date list, call customer service at the number on your ID card.
6
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.
AE
Age Edit – This medication applies to a specific age group. Members outside of this
age group need to meet specific criteria for approval.
E
Exceptions required for select markets in California and Oklahoma.
Your doctor is required to provide additional information to UnitedHealthcare to verify
medical necessity of certain medications.
FB
Formulary Brand
FG
Formulary Generic
GE
Gender Edit – This medication is covered only for specific gender based on FDA
approved indications.
H
Health Care Reform Preventive – This medication is part of a Health Care Reform
preventive benefit and may be available at no cost to you.
M
Medical – The medication may be covered under medical with Prior Authorization.
NF
Non-Formulary – Non-formulary drugs are available on your highest Cost Tier
(Tier 3).
PA
Prior Authorization required – Your doctor is required to provide additional
information to UnitedHealthcare to determine coverage.
QL
Quantity Limit – Amount of medication covered per copayment or in a specific
time period.
ST
Step Therapy – Trial of a lower cost medication is required before a higher cost
medication is covered.
To learn more about a pharmacy program or to find out if it applies to you, please visit myuhc.com or
optumrx.com or call the toll-free member phone number on your health plan ID card.
7
Why are some medications excluded from coverage?
Medications may be excluded from coverage under your pharmacy benefit as defined by your Pharmacy
Schedule of Benefits. There may be other medication options available.
Should I talk to my doctor about over-the-counter (OTC)
medications?
An over-the-counter (OTC) medication may be the right treatment for some conditions. Talk to your
doctor about available OTC options.
What is the difference between brand-name and generic
medications?
Generic medications contain the same active ingredients (what makes the medication work) as brandname medications, but they often cost less. Once the patent of a brand-name medication ends, the FDA
can approve a generic version with the same active ingredients. These types of medications are known
as generic medications. Sometimes, the same company that makes a brand-name medication also makes
the generic version.
Is it a generic or brand-name drug?
The drug list shows brand-name drugs in bold type (for example, Crestor) and generic drugs in plain
type (for example, Simvastatin).
What if my doctor writes a brand-name prescription?
The next time your doctor gives you a prescription for a brand-name medication, ask if a generic
equivalent or lower-cost option is available and if it might be right for you. Generic medications
are usually your lowest-cost option, but not always. For some benefit plans if a brand-name drug
is prescribed and a generic equivalent is available, your cost share may be the copay PLUS the cost
difference between the brand-name drug and generic equivalent. Visit myuhc.com or optumrx.com
to make sure.
8
How do I get updated information about my pharmacy
benefit?
Since the Formulary may change during your plan year, we encourage you to visit myuhc.com or
optumrx.com or call the toll-free member phone number on your health plan ID card for more current
information.
Log on to optumrx.com for the following pharmacy information and tools:
• Pharmacy benefit and coverage information
• Possible lower-cost medication options
• A list of medications based on a specific medical condition
• Medication interactions and side effects
• Participating retail pharmacies by zip code
• Your prescription history
And, if Mail Service is included in your pharmacy benefit, you can also:
• Refill prescriptions
• Check the status of your order
• Set-up e-mail reminders for refills
• Manage your account
For more information
Or, visit myuhc.com or optumrx.com
Where else can I go for information?
HealthCareLane.com includes short videos to help you learn more about
UnitedHealthcare benefits and health insurance information.
UHCTV.com is a fun and easy way to learn about health terms and other
health-related topics.
Medications are categorized by common therapeutic conditions in this Formulary for ease of reference only. These categories do not determine coverage for the medication for your
condition. Your beneﬁt plan determines coverage for these medications.
9
Drug Name
Coverage Requirements
Level
& Limits
Anti-Infectives: Antibiotics
Amoxicillin
Amoxicillin/Potassium
Clavulanate
Antipyrine/Benzocaine
Otic
Azithromycin
Bethkis
Cefaclor Suspension
Cefaclor Tablet
Cefadroxil
Cefdinir
Cefpodoxime
Cefprozil
Cefuroxime
Cephalexin
Chloroxylenol/
Hydrocortisone/
Pramoxine Otic
Ciprofloxacin
Clarithromycin IR/ER
Cleocin Vaginal
Suppository
Clindamycin
Clindesse
Dapsone
Demeclocycline
Dicloxacillin
Doxycycline Hyclate
Doxycycline
Monohydrate Tablet
Erythromycin
Erythromycin/
Sulfisoxazole
Ethambutol
Isoniazid
Levofloxacin
FG
FG
FG
FG
FB
FB
FG
FG
FG
FG
FG
FG
FG
QL
FG
FG
FG
FB
FG
NF
FB
FG
FG
FG
FG
FG
FG
FG
FG
FG
Level
& Limits
Drug Name
Linezolid Tablet
Methenamine
Metronidazole Tablet
Minocycline
Mycobutin
NebuPent Nebs
Neomycin
Neomycin/Polymixin/
Hydrocortisone Otic
Nitrofurantoin
Nitrofurantoin
Macrocrystal
Ofloxacin Otic
Oracea
Paromomycin
Penicillin VK
Pramoxine-HC Otic
Pyrazinamide
Rifampin
Solodyn
Sulfadiazine
Sulfamethoxazole/
Trimethoprim,
Sulfamethoxazole/
Trimethoprim DS
Tetracycline
Tobi
Trimethoprim
Zmax
FG
FG
FG
FG
FB
FB
FG
QL
QL
FG
FG
FG
FG
NF
FG
FG
FG
FG
FG
NF
FG
QL
QL
FG
FG
NF
FG
FB
QL, ST
Anti-Infectives: Antifungals
QL
Clotrimazole Troche
Cresemba
Fluconazole
Griseofulvin
Itraconazole
Ketoconazole Cream,
Shampoo
Bold type = Brand-name drug
[Plain type = Generic drug]
FG = Formulary Generic
AE = Age Edit
GE = Gender Edit
E = Exceptions required
H = Health Care Reform Preventive
FB = Formulary Brand
M = Medical
10
FG
NF
FG
FG
FG
PA
FG
NF = Non-Formulary
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
Drug Name
Metronidazole Vaginal
Gel
Nystatin
Terbinafine
Terconazole
Vandazole Gel
Level
& Limits
Drug Name
Hydroxyurea
FG
Imatinib
FG
Letrozole
FG
Leucovorin Calcium
FG
Leukeran
FB
Lomustine
FG
Lysodren
FB
Matulane
FB
Mercaptopurine
FG
Myleran
FB
Nilandrone
FB
Tabloid
FB
Tasigna
FB
Temozolomide
FG
Tretinoin Capsule
FG
Tykerb
FB
Xeloda
NF
Zytiga
NF
Cardiovascular/Heart Disease:
Coagulation Therapy
Aggrenox
NF
Brilinta
FB
Clopidogrel
FG
Disopyramide
FG
Effient
FB
Eliquis
NF
Jantoven
FG
Pradaxa
FB
Savaysa
NF
Ticlopidine
FG
Warfarin
FG
Xarelto
FB
High Blood Pressure
Acebutolol
FG
Acetazolamide
FG
Acetazolamide ER
FG
Afeditab CR
FG
Aldactazide 25/25 mg
FB
Amiloride
FG
Amiloride/
FG
Hydrochlorothiazide
Amlodipine
FG
Amlodipine/Benazepril
FG
Atenolol
FG
FG
FG
FG
FG
FG
QL
QL
Anti-Infectives: Antivirals
Acyclovir
Adefovir
Amantadine Capsule,
Syrup
Baraclude
Daklinza
Entecavir
Epivir HBV Solution
Famciclovir
Harvoni
Lamivudine
Olysio
Pegasys
Ribavirin Tablet
Rimantidine
Sovaldi
Valacyclovir
Valcyte Solution
Valganciclovir Tablet
Viekira Pak
Zovirax Cream
Zovirax Ointment
FG
FG
FG
NF
FB
FG
FB
FG
FB
FG
NF
M
FG
FG
FB
FG
FB
FG
NF
FB
NF
E, QL
PA, QL
QL
PA, QL
PA, QL
PA
PA, QL
QL
QL
PA, QL
E
E
Cancer
Alkeran
Bexarotene
Bicalutamide
Capecitabine
Caprelsa
Cyclophosphamide
Emcyt
Etoposide
Erivedge
Exemestane
Fareston
Flutamide
Hexalen
FB
FG
FG
FG
FB
FG
FB
FG
FB
FG
FB
FG
FB
Level
& Limits
PA
PA, QL
PA, QL
11
PA, QL
PA
PA, QL
PA
PA
E
PA
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
Drug Name
Atenolol/
Chlorthalidone
Azor
Benazepril
Benazepril/
Hydrochlorothiazide
Benicar
Benicar HCT
Betaxolol
Bisoprolol
Bisoprolol/
Hydrochlorothiazide
Bumetanide
Bystolic
Captopril
Captopril/
Hydrochlorothiazide
Cartia XT
Carvedilol
Chlorothiazide
Chlorthalidone
Clonidine Tablet
Clorpres
Dilatrate SR
Diltiazem SustainedRelease Capsule
Diltiazem Tablet
Diovan
Doxazosin
Dutoprol
Edarbi
Edarbyclor
Enalapril
Enalapril/
Hydrochlorothiazide
Eprosartan
Exforge
Exforge HCT
Level
& Limits
FG
FB
FG
QL, ST
FG
FB
FB
FG
FG
QL, ST
QL, ST
FG
FG
FB
FG
QL
FG
FG
FG
FG
FG
FG
NF
FB
FG
FG
NF
FG
FB
NF
NF
FG
E, QL, ST
QL
E, QL, ST
QL, ST
FG
FG
NF
NF
QL
E, QL, ST
E, QL, ST
Level
& Limits
Drug Name
Ezide
Felodipine
Fosinopril
Fosinopril/
Hydrochlorothiazide
Furosemide
Guanfacine
Hydralazine
Hydrochlorothiazide
Indapamide
Irbesartan
Irbesartan/
Hydrochlorothiazide
Isradipine
Labetalol
Lisinopril
Lisinopril/
Hydrochlorothiazide
Losartan
Losartan/
Hydrochlorothiazide
Methazolamide
Methyclothia
Methyldopa
Methyldopa/
Hydrochlorothiazide
Metolazone
Metoprolol
Succinate ER
Metoprolol Tartrate
Micardis HCT
Minoxidil
Moexipril
Moexipril/
Hydrochlorothiazide
Nadolol
Nicardipine
Nifediac CC
AE = Age Edit
GE = Gender Edit
M = Medical
12
FG
FG
FG
QL
FG
FG
FG
FG
FG
FG
FG
QL
FG
QL
FG
FG
FG
FG
FG
QL
FG
QL
FG
FG
FG
FG
FG
FG
FG
FB
FG
FG
E, QL, ST
FG
FG
FG
FG
NF = Non-Formulary
QL = Quantity Limit
ST = Step Therapy
Drug Name
Level
& Limits
Nifedical XL
FG
Nifedipine IR/ER
FG
Perindopril
FG
Phenoxybenzamine
FG
Pindolol
FG
Prazosin
FG
Propranolol/
FG
Hydrochlorothiazide
Propranolol IR/ER
FG
Quinapril
FG
Ramipril
FG
Reserpine
FG
Sotalol
FG
Sotalol AF
FG
Spironolactone
FG
Spironolactone/
FG
Hydrochlorothiazide
Taztia XT
FG
Tekturna
FB
Tekturna HCT
FB
Telmisartan
FB
Terazosin
FG
Timolol
FG
Torsemide
FG
Trandolapril/
FG
Verapamil CR
Triamterene/
FG
Hydrochlorothiazide
Tribenzor
FB
Valsartan
FG
Valsartan/
FG
Hydrochlorothiazide
Valturna
FB
Verapamil SustainedFG
Release Capsule
Verapamil SustainedFG
Release Tablet
Verapamil Tablet
FG
High Cholesterol
Antara
NF
Atorvastatin
FG
Cholestyramine
FG
Choline Fenofibrate
FG
Capsule
Drug Name
Colestipol
Crestor
Fenofibrate
48, 145 mg Tablet
Fenofibrate
54, 160 mg Tablet
Fenofibrate Capsule
Fenofibrate Micronized
Fenoglide
Gemfibrozil
Lipofen
Livalo
Lovastatin
Lovaza
Niacin ER
Niaspan
Omega-3-Acid Ethyl
Esters Capsule
Praluent
Pravastatin
Prevalite
Simcor
Simvastatin 5, 10,
20, 40 mg
Simvastatin 80 mg
Vascepa
Vytorin
Welchol
QL
QL, ST
QL, ST
QL
QL
QL, ST
QL
Level
& Limits
FG
FB
QL
FG
E, QL
FG
QL
FG
FG
NF
FG
FB
NF
FG
FB
FG
NF
QL
QL
QL, ST
QL
QL
QL, ST
FG
PA, QL
M
FG
FG
FB
QL
FG
QL
FG
FB
FB
FB
PA, QL
QL
PA, QL
E, QL
QL
QL
QL
Cardiovascular/Heart Disease: Other
Amiodarone
Anagrelide
Cilostazol
Corlanor
Digoxin
Dilatrate SR
Disopyramide
Flecainide
Isochron
Isoditrate ER
Isordil
Isosorbide Dinitrate
IR/ER
Isosorbide Mononitrate
IR/ER
QL
QL
QL
QL
QL
E, QL
13
FG
FG
FG
NF
FG
FB
FG
FG
FG
FG
FB
FG
FG
PA, QL
Drug Name
Level
& Limits
Isoxsuprine
FG
Mexiletine
FG
Midodrine
FG
NitroBid
FB
NitroDur Patch
FB
Nitroglycerin ER
FG
Nitrolingual Pump
FG
Spray
Nitrostat
FB
NitroTime
FG
Norpace CR
FB
Pacerone
NF
Pentoxifylline
FG
Propafenone
FG
Quinidine IR/ER
FG
Ranexa
FB
Sotalol
FG
Central Nervous System:
Attention Deficit Disorder
Adderall XR
FB
Dextroamphetamine/
FG
Amphetamine
Dextroamphetamine/
Amphetamine
NF
Extended-Release
Dextroamphetamine
Sulfate ExtendedFG
Release
Dextroamphetamine
FG
Sulfate Tablet
Guanfacine ER
FG
Intuniv
NF
Metadate ER
FG
Methylphenidate
Controlled-Release
FG
Tablet
Methylphenidate Tablet
FG
Strattera
FB
Level
& Limits
Drug Name
Vyvanse
FB
AE, QL
Central Nervous System: Depression
QL, ST
AE, QL
AE, QL
AE, E, QL
AE, PA, QL
AE, PA, QL
AE, QL
AE, E, QL
AE, PA, QL
AE, QL
AE, PA, QL
QL
Amitriptyline
Amoxapine
Bupropion
Bupropion SR
Bupropion XL
Citalopram
Clomipramine
Cymbalta
Desipramine
Doxepin
Duloxetine 20, 30,
60 mg
Escitalopram
Fluoxetine
Fluvoxamine
Forfivo XL
Imipramine
Maprotiline
Mirtazapine,
Mirtazapine ODT
Nefazodone
Nortriptyline
Paroxetine
Paroxetine ER
Paxil Suspension
Phenelzine
Pristiq
Protriptyline
Sertraline
Tranylcypromine
Trazodone
Venlafaxine
Venlafaxine ExtendedRelease Capsule
AE = Age Edit
GE = Gender Edit
M = Medical
14
FG
FG
FG
FG
FG
FG
FG
NF
FG
FG
H
QL
QL
E, QL
FG
QL
FG
FG
FG
FB
FG
FG
QL
QL
FG
FG
FG
FG
FG
FB
FG
FB
FG
FG
FG
FG
FG
FG
QL
QL
QL
NF = Non-Formulary
QL = Quantity Limit
ST = Step Therapy
Drug Name
Venlafaxine ExtendedRelease Tablet
Viibryd
Level
& Limits
FG
QL
NF
QL, ST
Drug Name
Buspirone
Carbidopa/Levodopa
IR/ER
Chlordiazepoxide
Chlordiazepoxide/
Amitriptyline
Chlorpromazine
Clorazepate
Clozapine
Compro Suppository
Diazepam
Donepezil,
Donepezil ODT
Entaone
Ergoloid Mesylate
Fluphenazine
Galantamine IR/ER
Haloperidol
Hydroxyzine
Latuda
Lithium IR/ER
Lorazepam
Loxapine
Meprobamate
Namenda XR
Namzaric
Nuvigil
Olanzapine,
Olanzapine ODT
Oxazepam
Perphenazine/
Amitriptyline
Pramipexole
Prochlorperazine
Quetiapine
Risperidone,
Risperidone ODT
Rivastigmine
Ropinirole
Saphris
Seroquel XR
Suboxone Film
Suboxone Tablet
Thioridazine
Thiothixene
Central Nervous System: Migraine
Acetaminophen/
FG
Butalbital/Caffeine
Cambia
NF
Isometheptene/
Acetaminophen/
FG
Dichloralphenazone
Migragesic
FG
Migranal
NF
Nodolor
FG
Phrenilin Forte
NF
Rizatriptan
FG
Sumatriptan Nasal
FG
Spray, Tablet
Sumavel DosePro
M
Zecuity
NF
Zolmitriptan
FG
Zomig Spray
FB
Multiple Sclerosis
Ampyra
FB
Avonex
M
Betaseron
M
Copaxone
M
Extavia
M
Gilenya
NF
Plegridy
M
Rebif, Rebif Rebidose
M
Tecfidera
FB
QL
E, QL
QL
QL
QL
QL
E, QL, ST
QL
E, QL
PA, QL
QL
QL
QL
QL
PA, QL
QL
QL
PA, QL
Central Nervous System: Other
Alprazolam IR/ER
Aricept 5, 10 mg
Tablet, ODT
Aricept 23 mg
Aripiprazole ODT
Aripiprazole Solution,
Tablet
Azilect
Benztropine
Bromocriptine
FG
QL
NF
QL
NF
FG
QL, ST
QL
FG
QL
NF
FG
FG
QL
15
Level
& Limits
FG
FG
FG
QL
FG
FG
FG
FG
FG
FG
FG
QL
QL
QL
FG
FG
FG
FG
FG
FG
NF
FG
FG
FG
FG
FB
NF
NF
QL
QL, ST
PA, QL
FG
QL
FG
QL
QL, ST
QL
FG
FG
FG
FG
QL
FG
QL
FG
FG
FB
FB
FB
NF
FG
FG
QL
PA, QL
QL
PA, QL
PA, QL
Drug Name
Level
& Limits
Trifluoperazine
FG
Trihexyphenidyl
FG
Xyrem
NF
Zelapar
NF
Ziprasidone
FG
Zubsolv
FB
Sedatives/Hypnotics
Eszopiclone
FG
Flurazepam
FG
Silenor
NF
Temazepam
FG
Triazolam
FG
Zaleplon
FG
Zolpidem
FG
Seizure Disorders
Carbamazepine
FG
IR/ER
Clonazepam,
FG
Clonazepam ODT
Diazepam Gel
FG
Divalproex
FG
Divalproex
FG
Extended-Release
Epitol
FG
Ethosuximide
FG
Gabapentin
FG
Lamictal Chewable,
FB
Tablet
Lamictal Starter Kit
FB
Lamictal XR
NF
Lamotrigine Chewable,
FG
Tablet
Lamotrigine ER
FG
Lamotrigine ODT
NF
Levetiracetam ER
NF
Levetiracetam IR
FG
PA, QL
QL
QL
PA, QL
QL
PA, QL
QL
QL
QL
QL
QL
QL
QL
E
QL
E, PA, QL
QL
QL, ST
Level
& Limits
Drug Name
Lyrica Capsule
Lyrica Solution
Oxcarbazepine
Phenobarbital
Phenytoin
Topiragen
Topiramate
Valproic Acid
Zonisamide
FB
NF
FG
FG
FG
FG
FG
FG
FG
QL
QL
NF
FG
FG
NF
FG
FG
FG
FG
FG
FG
FB
FG
NF
FB
FG
E, QL
Dermatology
Acanya
Acticin
Acyclovir
Aczone Gel
Adapalene
Ala Quin
Alclometasone
Alphatrex
Ammonium Lactate
Amnesteem
Atralin
Avita
Benzaclin
Benzamycin Pack
Betamethasone
CalcipotrieneBetamethasone
Calcipotriene Ointment
Calcitriol Ointment
Cerovel
Ciclodan
Ciclopirox Cream, Gel,
Lotion, Solution
Claravis
Clindamax Lotion
Clindamycin Gel,
Lotion, Solution, Swabs
AE = Age Edit
GE = Gender Edit
M = Medical
16
AE, QL
PA, QL
AE, QL
AE, QL
E, QL
FB
QL
FG
FG
FG
FG
QL
FG
FG
FG
E, PA
FG
NF = Non-Formulary
QL = Quantity Limit
ST = Step Therapy
Drug Name
Clindareach Kit
Clobetasol,
Clobetasol E
Clobex Lotion,
Shampoo
Clobex Spray
Cloderm
Cloderm Pump
Cormax
Dermazene
Desonide
Desoximetasone
Differin Cream,
Lotion
Differin Gel
DrithoCreme HP
DrithoScalp
Econazole
Elidel
Epiduo,
Epiduo Forte
Ery Pad
Erythromycin
Erythromycin/Benzoyl
Peroxide
Ethyl Chloride
Eurax
Exoderm
Finacea
Finacea Plus
Fluocinolone
Fluocinonide,
Fluocinonide E
Fluorouracil 0.5%
Cream
Fluorouracil Solution,
5% Cream
Fluticasone
Gentamicin
Hydrocortisone
Hypercare
Imiquimod
Laclotion
Lidocaine
Lidocaine/Prilocaine
Level
& Limits
Drug Name
FG
Lindane
Lokara
Metrogel 1%
Metronidazole 0.75%
Cream, Lotion
Mirvaso
Mometasone Furoate
Mupirocin Calcium
Cream
Mupirocin Ointment
Myorisan
Nystatin
Nystop
Permethrin
Picato
Podofilox
Pramcort
Pramosone Cream,
Ointment
Pramosone E
Cream
Pramosone Lotion
Protopic
Retin-A Micro
Gel, Pump
Rosadan Cream
Selenium Sulfide
Silver Nitrate
Silver Sulfadiazine
Sulfacetamide Sodium
Sulfacetamide
Sodium-Sulfur
Taclonex Ointment
Taclonex Scalp
Tacrolimus Ointment
Tazorac
Tretin-X
Tretinoin
Triamcinolone
Acetonide
Trianex
Triderm
Urea 40% Lotion
Vectical
Vitazol
FG
NF
E
NF
NF
NF
FG
FG
FG
FG
E, QL
NF
AE, QL
NF
FB
FB
FG
FB
E, QL
AE, QL, ST
NF
AE, QL
FG
FG
FG
FG
FB
FG
FB
FB
FG
FG
FB
FG
FG
FG
FG
FG
FG
FG
FG
FG
QL
17
Level
& Limits
FG
FG
NF
E
FG
NF
FG
PA, QL
FG
QL
FG
FG
FG
FG
FG
NF
FG
FG
PA
ST
NF
NF
NF
NF
AE, PA, QL
FB
AE, QL
FG
FG
FG
FG
FG
FG
NF
NF
FG
NF
FB
FG
E, QL
QL
AE, QL
AE, QL
AE, QL
AE, E
FG
FB
FG
FG
NF
FG
E
Drug Name
Level
& Limits
Voltaren Gel
FB
Zenatane
FG
Zyclara Cream,
NF
Pump
Diabetes/Endocrine:
Blood Glucose Monitoring
Accu-Chek
NF
Test Strips
Bayer Breeze2
NF
Test Strips
Bayer Contour
NF
Test Strips
FastClix Lancets
FB
Freestyle
NF
Test Strips
Glucocard
NF
Test Strips
Novofine Autocover
NF
Pen Needles
Novofine Pen
NF
Needles
Novofine Plus Pen
FB
Needles
Novotwist Pen
NF
Needles
OneTouch
FB
Test Strips
OneTouch Ultra
FB
Blue Test Strips
OneTouch Verio IQ
FB
Test Strips
Relion Test Strips
NF
Soft Touch Lancets
FB
SoftClix Lancets
FB
QL
E, PA
QL
PA, QL
PA, QL
PA, QL
QL
PA, QL
PA, QL
NF
NF
Humalog KwikPen
100u/ml
Humalog Mix 75-25
KwikPen
Humalog Vial
Humulin 70-30 Vial
Humulin KwikPen
Humulin N KwikPen
Humulin N Vial
Humulin R
U-500 Vial
Lantus Solostar
Lantus Vial
Levemir Flexpen
Levemir Vial
Novolin N Vial
Novolin R Vial
Novolin Vial
Novolog Flexpen
Novolog Mix
Novolog Vial
FB
FB
FB
FB
FB
FB
FB
FB
FB
FB
FB
FB
FB
FB
FB
FB
FB
FB
E
E
E
E
E
E
Diabetes/Endocrine: Non-Insulin
QL
QL
QL
PA, QL
QL
QL
Diabetes/Endocrine: Insulin
Apidra Solostar
Apidra Vial
Level
& Limits
Drug Name
ST
ST
Acarbose
Bydureon
Byetta
Chlorpropamide
Glimepiride
Glipizide IR/XL
Glipizide/Metformin
Glucagen
Glucagon
Glumetza
Glyburide
Glyburide/Metformin
Glyxambi
Invokamet
Invokana
AE = Age Edit
GE = Gender Edit
M = Medical
18
FG
FB
FB
FG
FG
FG
FG
FB
FB
NF
FG
FG
NF
FB
FB
QL, ST
QL, ST
AE
QL
PA
QL, ST
QL, ST
QL, ST
NF = Non-Formulary
QL = Quantity Limit
ST = Step Therapy
Drug Name
Janumet
Janumet XR
Januvia
Jardiance
Jentadueto
Juvisync
Kombiglyze XR
Metformin
Metformin
Extended-Release
Nateglinide
Onglyza
Pioglitazone
Pioglitazone/Glimepiride
Pioglitazone/Metformin
Repaglinide
Symlin
Synjardy
Tolazamide
Tolbutamide
Tradjenta
Trulicity
Victoza
Level
& Limits
FB
FB
FB
FB
NF
FB
FB
FG
QL, ST
QL, ST
QL, ST
QL, ST
QL, ST
QL, ST
QL, ST
FG
PA
FG
FB
FG
FG
FG
FG
NF
FB
FG
FG
NF
FB
FB
QL
QL, ST
QL, ST
QL, ST
QL, ST
QL, ST
PA
QL, ST
ST
ST
QL, ST
QL, ST
QL, ST
Drug Name
Level
& Limits
Prednisolone Solution,
FG
Tablet
Prednisone
FG
Zemplar
FB
Endocrine:
Thyroid Hormone Replacement
Levothyroxine Sodium
FG
Levoxyl
FG
Liothyronine Sodium
FG
Methimazole
FG
Propylthiouracil
FG
Tirosint
NF
Unithroid
FG
Eye Conditions: Allergies
Azelastine 0.05%
Solution
Cromolyn
Epinastine
Lastacaft
Naphazoline 0.1%
Pataday
Phenylephrine
FG
FG
FG
NF
FG
NF
FG
Endocrine: Growth Hormone
Eye Conditions: Antibiotics
Lupron Depot
Norditropin
Nutropin Aq NuSpin
Saizen
Tev-Tropin
Bacitracin
Bacitracin/Polymyxin
Ciprofloxacin
Erythromycin
Gentamicin
Ilotycin
Moxeza
Natacyn
Neomycin/Bacitracin/
Polymyxin
Neomycin/Polymixin/
Gramicidin
Ofloxacin
Polymyxin B/
Trimethoprim
Sulfacetamide Sodium
Tobradex Ointment
Tobramycin/
Dexamethasone
M
M
M
M
M
Endocrine: Other
Asmalpred,
Asmalpred Plus
Calcitriol
Cortisone
Desmopressin
Dexamethasone
Fludrocortisone
Hydrocortisone Tablet
Medrol 2 mg
Methylergonovine
Methylprednisolone
Millipred Tablet
Paricalcitol
FB
FG
FG
FG
FG
FG
FG
FB
FG
FG
FG
FG
19
FG
FG
FG
FG
FG
FG
FB
FB
E
QL
E
QL
QL
FG
FG
FG
FG
FG
NF
FG
QL
Drug Name
Level
& Limits
Tobramycin Ophth
Solution
Tobrex
Trifluridine
Vigamox
FG
E
NF
FG
FB
E
QL
Eye Conditions: Glaucoma
Alphagan P
Azopt
Betaxolol
Betimol
Betoptic-S
Carteolol
Combigan
Dorzolamide
Dorzolamide/Timolol
Istalol
Latanoprost
Levobunolol
Lumigan
Metipranolol
Timolol Maleate
Timoptic Ocudose
Travatan Z
FB
FB
FG
NF
FB
FG
FB
FG
FG
FB
FG
FG
FB
FG
FG
FB
FB
QL
QL
QL
QL
QL
FG
NF
FG
FB
FG
FG
FG
FG
FG
FB
FG
FB
Iso Homatropine
Ketorolac
Polymyxin/
Hydrocortisone
Neomycin/Polymixin/
Dexamethasone
Phospholine
Pred Mild
Tablet
Proparacaine
Restasis
Sulfacetamide
Sodium/Prednisolone
Tetracaine
Tropicamide
FB
FG
QL
FG
FG
FB
FB
FG
FG
NF
PA
FG
FG
FG
QL
Gastrointestinal: Acid Suppression
QL
Carafate
Cimetidine
Dexilant
Lansoprazole
Misoprostol
Nizatidine
Omeclamox-Pak
Omeprazole
Pantoprazole
Pylera
Ranitidine
Sucralfate Tablet
Zegerid
QL
Eye Conditions: Other
Atropine
Blephamide SOP
Brimonidine
Cyclogyl
Cyclopentolate
Dexamethasone
Diclofenac
Fluorometholone
Flurbiprofen
FML Forte
Homatropine
Iso Carbachol
Level
& Limits
Drug Name
QL
FB
FG
FB
FG
FG
FG
FB
FG
FG
FB
FG
FG
NF
QL
QL
QL
QL
QL
QL
QL, ST
Gastrointestinal: Nausea/Vomiting
Antivert 50 mg
Dronabinol
Ondansetron
Ondansetron ODT
AE = Age Edit
GE = Gender Edit
M = Medical
20
FB
FG
FG
FG
PA
QL
NF = Non-Formulary
QL = Quantity Limit
ST = Step Therapy
Drug Name
Level
& Limits
Promethazine
Trimethobenzamide
FG
FG
AE
FB
NF
QL, ST
Drug Name
Propantheline
Renvela Packet
Renvela Tablet
Rowasa Enema
Sevelamer
Sulfasalazine
Suprep
Trilyte
Uceris
Ursodiol
Zenpep
Gastrointestinal: Other
Amitiza
Analpram Advanced
Analpram-HC
Cream
Analpram-HC
Lotion
Analpram-HC
Shingles
Apriso
Auryxia
B-donna
Belladonna Alkaloids/
Phenobarbital
Budesonide
Calcium Acetate
Canasa
Chlordiazepoxide/
Clidinium
Creon
Delzicol
Dicyclomine
Dificid
Digex NF
Dipentum
Diphenoxylate/Atropine
Gavilyte
Halflytely
Hyoscyamine
Lactulose
Lialda
Linzess
Mesalamine Enema
Metoclopramide
Solution, Tablet
Movantik
Pancrelipase
Paregoric Tincture
Pentasa
Polyethylene Glycol
3350
Prepopik
NF
NF
NF
NF
NF
FG
Abacavir
Abacavir/Lamivudine
Aptivus
Atripla
Complera
Crixivan
Didanosine
Edurant
Emtriva
Epivir Solution
Epzicom
Evotaz
Fuzeon
Genvoya
Intelence
Invirase
Isentress
Kaletra
Lamivudine
Lamivudine/Zidovudine
Lexiva
Nevirapine
Norvir
Prezcobix
Prezista
Rescriptor
Retrovir
Reyataz
Selzentry
Stavudine
Stribild
Sustiva
QL
FG
FB
NF
FG
NF
FB
NF
FG
FG
NF
FG
FG
FB
FB
FG
E, QL, ST
QL
QL
QL
AE, QL, ST
FG
QL
FB
FG
FG
NF
QL
E, QL
FG
QL
FG
NF
FB
NF
FG
FG
NF
FG
NF
FG
FB
QL
QL
HIV/AIDS
QL, ST
FG
FG
FG
FB
Level
& Limits
NF
21
FG
FG
FB
FB
FB
FB
FG
FB
FB
FB
FB
FB
FB
FB
FB
FB
FB
FB
FG
FG
FB
FG
FB
FB
FB
FB
FB
FB
FB
FG
FB
FB
QL
PA
PA
Drug Name
Tivicay
Triumeq
Trizivir
Truvada
Videx Solution
Viracept
Viread
Vitekta
Ziagen
Zidovudine
Level
& Limits
FB
FB
NF
FB
FB
FB
FB
FB
FB
FG
Men’s Health: Erectile Dysfunction*
M
FG
M
M
M
M
Cialis
FB
Stendra
FB
AE, GE,
PA, QL
AE, GE,
PA, QL
*Coverage is determined by the consumer’s prescription drug benefit plan.
Men’s Health: Prostate
Infertility*
Cetrotide
Clomiphene
Follistim AQ
Gonal-F
Gonal-F Rff
Ovidrel
Level
& Limits
Drug Name
GE
*Coverage is determined by the consumer’s prescription drug benefit plan.
Inflammatory Conditions: Rheumatoid
Arthritis, Crohn’s Disease, Psoriasis,
Ulcerative Colitis
Cimzia
M
QL
Cuprimine
NF
PA
Depen
FB
Humira
M
Hydroxychloroquine
FG
Sulfate
Leflunomide
FG
QL
Methotrexate
FG
Orencia
M
QL
Remicade
M
Rheumatrex
NF
Simponi
M
QL
Stelara
M
QL
Trexall
NF
Alfuzosin
Doxazosin
Dutasteride
Dutasteride-Tamsulosin
Finasteride
Rapaflo
Tamsulosin
Terazosin
FG
FG
FG
FG
FG
FB
FG
FG
QL
QL
QL
QL
QL
Men’s Health: Testosterone Therapy
Androderm
Androgel 1%
Androgel 1.62%
Androxy
Axiron
Fortesta
Testim
Testosterone Gel 1%
Testred
FB
NF
FB
FG
NF
NF
NF
FG
NF
GE, PA, QL
GE, PA, QL
GE, PA, QL
PA
GE, PA, QL
GE, PA, QL
GE, PA, QL
GE, PA, QL
PA
Miscellaneous
Acetic Acid Otic
Acetylcysteine
Aerochamber
Alinia
Anastrozole
Antipyrine/Benzocaine
Anucort-HC
AE = Age Edit
GE = Gender Edit
M = Medical
22
FG
FG
FB
FB
FG
FG
FG
QL
QL
NF = Non-Formulary
QL = Quantity Limit
ST = Step Therapy
Drug Name
Aranesp
Benzocaine Otic
Benzonatate
Biltricide
Bunavail
Cerdelga
Chloroquine
Citric Acid/Sodium
Citrate
Condylox
Danazol
Daraprim
Deconsal-II
Difil-G Forte Liquid
Disulfiram
Easivent
Elmiron
Epipen 2-Pak
Epipen-Jr
Ergocalciferol 50,000
Unit Capsule
Euflexxa
Exemestane
EZ Spacer
Fosrenol
Granix
Guaifenesin/Codeine
Guanidine
Humibid DM
Hydrocodone/
Homatropine
Hydrocortisone/Acetic
Acid Otic
Hydrocortisone
Pramoxine
Hydrocortisone
Suppository
Hypersal Nebs
Inspirease
Kuvan
Letrozole
Lidocaine Patch
Lidocaine Viscous
Lidoderm Patch
Mebendazole
Level
& Limits
M
FG
FG
FB
NF
NF
FG
Drug Name
Mefloquine
Megestrol AC
Mephyton
Mestinon Syrup
Multigen Folic
Multigen Plus
Naltrexone
Nessi Spacer
Neupogen
Optihaler
Phenazopyridine
Pilocarpine
Primaquine
Procrit
Proctocream HC
Proctofoam HC
Proctosol HC
Proctozone HC
Proglycem
Promethazine/Codeine
Promethazine/
Dextromethorphan
Promethazine VC/
Codeine
Pyridostigmine
Rectiv
Renvela
Rezira
Sodium Polystyrene
Sulfonate Powder
Soriatane
SSKI
Synarel
Synvisc
Synvisc One
Tamoxifen
Triamcinolone/Orabase
Velphoro
Vitamin D 50,000 Unit
Vortex
WatchHaler
Yodoxin
Zemplar
Zutripro
PA, QL
PA, QL
FG
NF
FG
NF
FB
FG
FG
FB
FB
FB
FB
PA
QL
QL
QL
FG
M
FG
FB
NF
M
FG
FB
FB
QL
FG
FG
FG
FG
FB
FB
FB
FG
FG
FG
NF
FG
PA, QL
QL
E, QL
23
Level
& Limits
FG
FG
FB
FB
FB
FB
FG
FB
M
FB
FG
FG
FG
M
FG
FB
FG
FG
FB
FG
QL
QL
AE
FG
AE
FG
AE
FG
NF
NF
NF
PA
FG
NF
FB
FB
M
M
FG
FG
NF
FG
FB
FB
FB
FB
NF
QL
H
QL
QL
Drug Name
Level
& Limits
Musculoskeletal: Osteoporosis
Actonel
Alendronate Oral
Solution
Alendronate Tablet
Calcitonin Spray
Forteo
Fortical
Ibandronate
Raloxifene
NF
E, QL
FG
QL
FG
FG
M
NF
FG
FG
QL
QL
QL
QL
H, QL
Musculoskeletal: Other
Allopurinol
Baclofen
Carisoprodol
Colcrys
Cyclobenzaprine
Dantrolene
Methocarbamol
Orphenadrine/Aspirin/
Caffeine
Orphenadrine ER
Probenecid
Tizanidine Tablet
Uloric
FG
FG
FG
FB
FG
FG
FG
QL
FG
FG
FG
FG
FB
QL, ST
Musculoskeletal: Pain Relief
Acetaminophen/
Codeine
Acetaminophen/
Oxycodone
Ascomp/Codeine
Avinza
Bupap 50/650 mg
Butalbital/
Acetaminophen
FG
QL
FG
QL
FG
NF
FB
QL
PA, QL
QL
FG
QL
Level
& Limits
Drug Name
Butalbital/
Acetaminophen/
Caffeine
Butalbital/
Acetaminophen/
Caffeine/Codeine
Butalbital/Aspirin/
Caffeine
Butalbital/Aspirin/
Caffeine/Codeine
Celecoxib
Choline Magnesium
Trisalicylate
Codeine
Diclofenac Sodium
Diflunisal
Duraxin
Embeda
Esgic Plus
Etodolac IR/ER
Fenoprofen
Fentanyl Patch 12, 25,
50, 75, 100 mcg
Flector Patch
Flurbiprofen
Fortigan
Gralise
Hydrocodone/
Acetaminophen
Hydrocodone/
Ibuprofen
Hydromorphone IR/ER
Ibuprofen
Indocin Suppository
Indomethacin IR/ER
Ketoprofen IR/ER
Ketorolac
Lazanda
AE = Age Edit
GE = Gender Edit
M = Medical
24
FG
QL
FG
QL
FG
QL
FG
QL
NF
QL
FG
QL
FG
FG
FG
FG
FB
FB
FG
FG
QL
QL
QL
QL
FG
QL
NF
FG
FG
NF
E, QL
QL
QL, ST
FG
QL
FG
QL
FG
FG
FB
FG
FG
FG
NF
QL
QL
QL
QL
QL
QL
PA, QL
QL
QL
NF = Non-Formulary
QL = Quantity Limit
ST = Step Therapy
Drug Name
Levorphanol
Meclofenamate
Meloxicam
Meperidine
Methadone
Morphine Sulfate Beads
Sustained-Release
Morphine Sulfate
Controlled-Release
Tablet
Morphine Sulfate
Immediate-Release
Tablet, Solution
Morphine Sulfate
Sustained-Release
Capsule
Nabumetone
Nalfon 200 mg
Capsule
Naproxen
Nucynta
Nucynta ER
Opana ER
Orbivan
Oxaprozin
Oxycodone IR
Oxycodone/
Acetaminophen
Oxycontin
Oxymorphone
Pentazocine/
Acetaminophen
Pentazocine/Naloxone
Phenyltoloxamine/
Acetaminophen
Piroxicam
Salsalate
Sedapap
Sulindac
Tivorbex
Tolmetin
Tramadol
Vimovo
Voltaren Gel
Level
& Limits
FG
FG
FG
FG
FG
QL
FG
QL
FG
QL
Drug Name
Zohydro ER
Zorvolex
QL
QL
QL
E, QL
FG
QL
FB
QL
FG
NF
NF
FB
FB
FG
FG
QL
QL
QL, ST
QL
QL
FG
QL
FB
FG
QL
QL
FG
QL
FG
QL
Bethanechol
Enablex
Gelnique 10%
Myrbetriq
Oxybutynin
Oxybutynin
Extended-Release
Oxytrol
Toviaz
Vesicare
QL, ST
E, QL
FG
NF
FB
NF
FG
E, QL
QL
QL, ST
FG
QL
NF
NF
FB
E, QL
QL
QL
Respiratory: Asthma/COPD
Advair Diskus
Advair HFA
Aerospan
Albuterol Sulfate
Aminophylline
Anoro Ellipta
Arnuity Ellipta
Asmanex
Atrovent HFA
Breo Ellipta
Budesonide Nebs
Combivent
Respimat
Cromolyn Nebs
Flovent Diskus
Flovent HFA
Foradil
Incruse Ellipta
Ipratropium
Ipratropium/Albuterol
Nebs
Montelukast
Perforomist
Proair HFA
Proair Respiclick
Pulmicort Flexhaler
Pulmicort Respules
QVAR
FG
FG
FG
FB
FG
NF
FG
FG
NF
FB
NF
NF
Overactive Bladder
FG
FG
Level
& Limits
QL
QL
QL
E, QL, ST
QL
QL, ST
QL
25
FB
FB
NF
FG
FG
FB
FB
NF
NF
FB
FG
QL
QL
QL
QL
QL
QL, ST
QL
QL
QL
FB
QL
FG
FB
FB
FB
FB
FG
QL
QL
QL
QL
FG
FG
NF
FB
FB
FB
NF
FB
QL
QL
QL
QL
QL
QL
QL
Drug Name
Serevent
Spiriva HandiHaler,
Respimat
Stiolto Respimat
Striverdi Respimat
Symbicort
Terbutaline
Theophylline SR
Tudorza
Ventolin HFA
Xopenex HFA
Level
& Limits
FB
QL
FB
QL
FB
NF
FB
FG
FG
FB
FB
NF
QL
QL, ST
QL
QL
QL
QL, ST
Respiratory: Nasal Allergies
Azelastine 0.1%
Solution
Dymista Spray
Flunisolide
Fluticasone Propionate
Ipratropium
Nasonex
Omnaris
QNasl
Veramyst
Zetonna
FG
QL
FB
FG
FG
FG
FB
NF
NF
NF
NF
E, QL
QL
QL
E, QL
E, QL
QL
E, QL
E, QL
Respiratory: Oral Allergies
Carbinoxamine
FG
Clemastine
FG
Cyproheptadine
FG
Dexchlorpheniramine
FG
Hydroxyzine
FG
Promethazine
FG
AE
Respiratory:
Pulmonary Arterial Hypertension
Adcirca
NF
PA, QL
Adempas
FB
PA, QL
Letairis
FB
PA, QL
Opsumit
FB
PA, QL
Level
& Limits
Drug Name
Orenitram
Sildenafil Tablet 20 mg
Tracleer
NF
FG
FB
PA
PA, QL
PA, QL
Transplant
Azathioprine
Cyclosporine,
Cyclosporine Modified
Gengraf
Tacrolimus
FG
FG
FG
FG
Vitamins/Electrolytes
Fluoride Chewable
Tablet, Drops
Folic Acid 1 mg
Klor-Con 10
Klor-Con M10
Klor-Con M20
Potassium Chloride
Potassium Citrate
FG
H
FG
FG
FG
FG
FG
FG
Women’s Health: Contraceptives
Altavera
Alyacen
Apri
Aranelle
Aubra
Aviane
Azurette
Balziva
Beyaz
Briellyn
Camila
Caziant
Cesia
Chateal
Cryselle
Cyclafem
AE = Age Edit
GE = Gender Edit
M = Medical
26
FG
FG
FG
FG
FG
FG
FG
FG
NF
FG
FG
FG
FG
FG
FG
FG
H
H
H
H
H
H
H
H
H
H
H
H
H
H
H
H
NF = Non-Formulary
QL = Quantity Limit
ST = Step Therapy
Drug Name
Dasetta
Drospirenone/Ethinyl
Estradiol
Elinest
Ella
Emoquette
Enpresse
Enskyce
Errin
Estarylla
Falmina
Gianvi
Gildagia
Gildess, Gildess Fe
Heather
Implanon
Introvale
Jencycla
Jolessa
Jolivette
Junel
Junel Fe
Kariva
Kelnor
Kurvelo
Larin, Larin FE
Leena
Lessina
Levonest
Levonorgestrel
Levonorgestrel/Ethinyl
Estradiol
Levora-28
Lo Loestrin
Loestrin
Loryna
Low-Ogestrel
Lutera
Lyza
Marlissa
Medroxyprogesterone
Acetate Injection
Microgestin
Microgestin FE
Mono-Linyah
Level
& Limits
FG
H
FG
H
FG
FG
FG
FG
FG
FG
FG
FG
FG
FG
FG
FG
FG
FG
FG
FG
FG
FG
FG
FG
FG
FG
FG
FG
FG
FG
FG
H
H, QL
H
H
H
H
H
H
H
H
H
H
H
H
H
H
H
H
H
H
H
H
H
H
H
H
AE, H, QL
FG
H
FG
NF
FB
FG
FG
FG
FG
FG
H
H
FG
H, PA
FG
FG
FG
H
H
H
Drug Name
Mononessa
Myzilra
Natazia
Necon 0.5/35, 1/35,
1/50, 10/11
Nikki
Nora-BE
Norethindrone
Norgestimate-Ethinyl
Estradiol
Norgestrel/Ethinyl
Estradiol
Nortrel
Nuvaring
Ocella
Ogestrel
Orsythia
Ortho Coil
Ortho Flat
Ortho Flex
Philith
Pimtrea
Portia
Previfem
Primella
Quasense
Reclipsen
Safyral
Sharobel
Solia
Sprintec
Sronyx
Syeda
Tarina FE
Tri-Estarylla
Tri-Linyah
Tri-Previfem
Tri-Sprintec
Trinessa
Trinessa Lo
Trivora-28
Velivet
Vestura
Vyfemla
Viorele
H
H
H
H
H
27
Level
& Limits
FG
FG
FB
H
H
H
FG
H
FG
FG
FG
H
H
H
FG
H
FG
H
FG
FB
FG
FG
FG
FG
FG
FG
FG
FG
FG
FG
FG
FG
FG
NF
FG
FG
FG
FG
FG
FG
FG
FG
FG
FG
FG
NF
FG
FG
FG
FG
FG
H
H
H
H
H
H
H
H
H
H
H
H
H
H
H
H
H
H
H
H
H
H
H
H
H
H
H
H
H
H
H
H
H
Drug Name
Wera
Wide-Seal
Xulane
Yasmin 28
Yaz
Zarah
Zenchent
Zovia
Level
& Limits
FG
FG
FG
NF
NF
FG
FG
FG
H
H
H
E, H
E, H
H
H
H
FB
NF
FB
FG
NF
FB
NF
NF
FG
GE, QL
GE, QL
GE, QL
GE, PA, QL
GE, QL
GE
GE, QL
GE, QL
Evamist
Jinteli
Makena
Medroxyprogesterone
Menest
Mimvey
Minivelle
Norethindrone
Norethindrone/Ethinyl
Estradiol
OrthoEst
Osphena
Premarin
Premarin Vaginal
Cream
Premphase
Prempro
Vagifem
Vivelle-Dot
NF
GE, QL
Women’s Health: Prenatal Vitamins
FG
GE, QL
FG
GE, QL
FG
GE, QL
Women’s Health: Hormone Replacement
Alora
Cenestin
Climara Pro
Covaryx, Covaryx HS
Divigel
Duavee
Elestrin
Enjuvia
Estradiol Tablet
Estradiol Twice Weekly
Patch
Estradiol Weekly Patch,
Tablet
Estrogen/
Methyltestosterone,
Estrogen/
Methyltestosterone HS
Estropipate
Level
& Limits
Drug Name
Brand Prenatal
Vitamins/Folic Acid
1 mg
Generic Prenatal
Vitamins/Folic Acid
1 mg
AE = Age Edit
GE = Gender Edit
M = Medical
28
NF
FG
M
FG
FG
FG
NF
FG
GE, QL
QL
FG
GE, QL
FG
NF
FB
GE, QL
GE
GE, QL
GE, QL
QL
GE
GE, QL
FB
FB
FB
FB
NF
GE, QL
GE, QL
GE
E, GE, QL
FB
FG
NF = Non-Formulary
QL = Quantity Limit
ST = Step Therapy
Index of covered drugs
A
Abacavir................................... 21
Abacavir/Lamivudine.............. 21
Acanya...................................... 16
Acarbose................................... 18
Accu-Chek Test Strips............. 18
Acebutolol................................ 11
Acetaminophen/Butalbital/
Caffeine................................. 15
Acetaminophen/Codeine......... 24
Acetaminophen/Oxycodone..... 24
Acetazolamide.......................... 11
Acetazolamide ER................... 11
Acetic Acid Otic................. 22, 23
Acetylcysteine........................... 22
Acticin...................................... 16
Actonel..................................... 24
Acyclovir............................ 11, 16
Aczone Gel............................... 16
Adapalene................................. 16
Adcirca..................................... 26
Adderall XR............................. 14
Adefovir.................................... 11
Adempas................................... 26
Advair Diskus........................... 25
Advair HFA............................. 25
Aerochamber............................ 22
Aerospan.................................. 25
Afeditab CR............................. 11
Aggrenox.................................. 11
Ala Quin.................................. 16
Albuterol Sulfate...................... 25
Alclometasone.......................... 16
Aldactazide 25/25 mg.............. 11
Alendronate Oral Solution....... 24
Alendronate Tablet................... 24
Alfuzosin.................................. 22
Alinia....................................... 22
Alkeran..................................... 11
Allopurinol............................... 24
Alora........................................ 28
Alphagan P.............................. 20
Alphatrex.................................. 16
Alprazolam IR/ER.................. 15
Altavera.................................... 26
Alyacen..................................... 26
Amantadine Capsule, Syrup..... 11
Amiloride................................. 11
Amiloride/
Hydrochlorothiazide............. 11
Aminophylline......................... 25
Amiodarone............................. 13
Amitiza.................................... 21
Amitriptyline...................... 14, 15
Amlodipine.............................. 11
Amlodipine/Benazepril............ 11
Ammonium Lactate................. 16
Amnesteem.............................. 16
Amoxapine............................... 14
Amoxicillin.............................. 10
Amoxicillin/Potassium
Clavulanate........................... 10
Ampyra.................................... 15
Anagrelide................................ 13
Analpram-HC Cream.............. 21
Analpram-HC Lotion.............. 21
Analpram-HC Shingles........... 21
Analpram Advanced................ 21
Anastrozole.............................. 22
Androderm............................... 22
Androgel 1%............................. 22
Androgel 1.62%........................ 22
Androxy................................... 22
Anoro Ellipta........................... 25
Antara...................................... 13
Antipyrine/Benzocaine...... 10, 22
Antipyrine/Benzocaine Otic.... 10
Antivert 50 mg......................... 20
Anucort-HC............................. 22
Apidra Solostar......................... 18
Apidra Vial............................... 18
Apri.......................................... 26
Apriso....................................... 21
Aptivus..................................... 21
Aranelle.................................... 26
Aranesp.................................... 23
Aricept 23 mg.......................... 15
29
Aricept 5, 10 mg Tablet,
ODT..................................... 15
Aripiprazole ODT................... 15
Aripiprazole Solution, Tablet... 15
Arnuity Ellipta......................... 25
Ascomp/Codeine...................... 24
Asmalpred, Asmalpred Plus..... 19
Asmanex................................... 25
Atenolol.............................. 11, 12
Atenolol/Chlorthalidone.......... 12
Atorvastatin.............................. 13
Atralin...................................... 16
Atripla...................................... 21
Atropine............................. 20, 21
Atrovent HFA.......................... 25
Aubra........................................ 26
Auryxia..................................... 21
Aviane...................................... 26
Avinza...................................... 24
Avita......................................... 16
Avonex...................................... 15
Axiron...................................... 22
Azathioprine............................ 26
Azelastine 0.05% Solution........ 19
Azelastine 0.1% Solution.......... 26
Azilect...................................... 15
Azithromycin........................... 10
Azopt........................................ 20
Azor......................................... 12
Azurette................................... 26
B
B-donna................................... 21
Bacitracin........................... 19, 20
Bacitracin/Polymyxin......... 19, 20
Baclofen.................................... 24
Balziva...................................... 26
Baraclude.................................. 11
Bayer Breeze2 Test Strips......... 18
Bayer Contour Test Strips........ 18
Belladonna Alkaloids/
Phenobarbital........................ 21
Benazepril.......................... 11, 12
Benazepril/
Benicar..................................... 12
Benicar HCT........................... 12
Benzaclin.................................. 16
Benzamycin Pack..................... 16
Benzocaine Otic................. 10, 23
Benzonatate.............................. 23
Benztropine.............................. 15
Betamethasone......................... 16
Betaseron.................................. 15
Betaxolol.............................12, 20
Bethanechol.............................. 25
Bethkis..................................... 10
Betimol..................................... 20
Betoptic-S................................. 20
Bexarotene................................ 11
Beyaz........................................ 26
Bicalutamide............................. 11
Biltricide................................... 23
Bisoprolol.................................. 12
Bisoprolol/
Blephamide SOP...................... 20
Brand Prenatal Vitamins/
Folic Acid 1 mg..................... 28
Breo Ellipta.............................. 25
Briellyn..................................... 26
Brilinta..................................... 11
Brimonidine............................. 20
Bromocriptine.......................... 15
Budesonide......................... 21, 25
Budesonide Nebs...................... 25
Bumetanide.............................. 12
Bunavail.................................... 23
Bupap 50/650 mg..................... 24
Bupropion................................. 14
Bupropion SR........................... 14
Bupropion XL.......................... 14
Buspirone................................. 15
Butalbital/Acetaminophen....... 24
Butalbital/Acetaminophen/
Caffeine................................. 24
Butalbital/Acetaminophen/
Caffeine/Codeine.................. 24
Butalbital/Aspirin/Caffeine...... 24
Butalbital/Aspirin/Caffeine/
Codeine................................. 24
Bydureon.................................. 18
Byetta....................................... 18
Bystolic..................................... 12
C
Calcipotriene-Betamethasone... 16
Calcipotriene Ointment........... 16
Calcitonin Spray....................... 24
Calcitriol............................. 16, 19
Calcitriol Ointment.................. 16
Calcium Acetate....................... 21
Cambia..................................... 15
Camila...................................... 26
Canasa...................................... 21
Capecitabine............................. 11
Caprelsa.................................... 11
Captopril.................................. 12
Captopril/
Carafate.................................... 20
Carbamazepine IR/ER............ 16
Carbidopa/Levodopa IR/ER... 15
Carbinoxamine......................... 26
Carisoprodol............................. 24
Carteolol................................... 20
Cartia XT................................. 12
Carvedilol................................. 12
Caziant..................................... 26
Cefaclor Suspension................. 10
Cefaclor Tablet......................... 10
Cefadroxil................................. 10
Cefdinir.................................... 10
Cefpodoxime............................ 10
Cefprozil.................................. 10
Cefuroxime............................... 10
Celecoxib.................................. 24
Cenestin................................... 28
Cephalexin............................... 10
Cerdelga................................... 23
Cerovel..................................... 16
Cesia......................................... 26
Cetrotide.................................. 22
Chateal..................................... 26
Chlordiazepoxide............... 15, 21
30
Chlordiazepoxide/
Amitriptyline........................ 15
Chlordiazepoxide/
Clidinium.............................. 21
Chloroquine............................. 23
Chlorothiazide.......................... 12
Chloroxylenol/Hydrocortisone/
Pramoxine Otic..................... 10
Chlorpromazine....................... 15
Chlorpropamide....................... 18
Chlorthalidone......................... 12
Cholestyramine........................ 13
Choline Fenofibrate Capsule.... 13
Choline Magnesium
Trisalicylate........................... 24
Cialis........................................ 22
Ciclodan................................... 16
Ciclopirox Cream, Gel,
Lotion, Solution.................... 16
Cilostazol................................. 13
Cimetidine............................... 20
Cimzia...................................... 22
Ciprofloxacin...................... 10, 19
Citalopram............................... 14
Citric Acid/Sodium Citrate...... 23
Claravis..................................... 16
Clarithromycin IR/ER............. 10
Clemastine................................ 26
Cleocin Vaginal
Suppository............................ 10
Climara Pro.............................. 28
Clindamax Lotion.................... 16
Clindamycin....................... 10, 16
Clindamycin Gel, Lotion,
Solution, Swabs..................... 16
Clindareach Kit........................ 17
Clindesse.................................. 10
Clobetasol, Clobetasol E.......... 17
Clobex Lotion, Shampoo......... 17
Clobex Spray............................ 17
Cloderm................................... 17
Cloderm Pump......................... 17
Clomiphene.............................. 22
Clomipramine.......................... 14
Clonazepam,
Clonazepam ODT................ 16
Clonidine Tablet....................... 12
Clopidogrel............................... 11
Clorazepate............................... 15
Clorpres.................................... 12
Clotrimazole Troche................ 10
Clozapine................................. 15
Codeine.............................. 23, 24
Colcrys..................................... 24
Colestipol................................. 13
Combigan................................. 20
Combivent Respimat................ 25
Complera.................................. 21
Compro Suppository................ 15
Condylox.................................. 23
Copaxone................................. 15
Corlanor................................... 13
Cormax.................................... 17
Cortisone.................................. 19
Covaryx, Covaryx HS.............. 28
Creon........................................ 21
Cresemba.................................. 10
Crestor...................................... 13
Crixivan.................................... 21
Cromolyn........................... 19, 25
Cromolyn Nebs........................ 25
Cryselle.................................... 26
Cuprimine................................ 22
Cyclafem.................................. 26
Cyclobenzaprine....................... 24
Cyclogyl.................................... 20
Cyclopentolate.......................... 20
Cyclophosphamide................... 11
Cyclosporine, Cyclosporine
Modified................................ 26
Cymbalta.................................. 14
Cyproheptadine........................ 26
D
Daklinza................................... 11
Danazol.................................... 23
Dantrolene................................ 24
Dapsone.................................... 10
Daraprim.................................. 23
Dasetta..................................... 27
Deconsal-II.............................. 23
Delzicol.................................... 21
Demeclocycline........................ 10
Depen....................................... 22
Dermazene............................... 17
Desipramine............................. 14
Desmopressin........................... 19
Desonide.................................. 17
Desoximetasone........................ 17
Dexamethasone.................. 19, 20
Dexchlorpheniramine............... 26
Dexilant.................................... 20
Dextroamphetamine/
Amphetamine........................ 14
Dextroamphetamine/
Amphetamine
Extended-Release.................. 14
Dextroamphetamine Sulfate
Dextroamphetamine Sulfate
Tablet.................................... 14
Diazepam........................... 15, 16
Diazepam Gel.......................... 16
Diclofenac.......................... 20, 24
Diclofenac Sodium................... 24
Dicloxacillin............................. 10
Dicyclomine............................. 21
Didanosine............................... 21
Differin Cream, Lotion............ 17
Differin Gel.............................. 17
Dificid...................................... 21
Difil-G Forte Liquid................ 23
Diflunisal.................................. 24
Digex NF................................. 21
Digoxin.................................... 13
Dilatrate SR....................... 12, 13
Diltiazem Sustained-Release
Capsule.................................. 12
Diltiazem Tablet....................... 12
Diovan...................................... 12
Dipentum................................. 21
Diphenoxylate/Atropine........... 21
Disopyramide..................... 11, 13
Disulfiram................................ 23
Divalproex................................ 16
Divalproex
Divigel...................................... 28
Donepezil, Donepezil ODT.... 15
Dorzolamide............................. 20
Dorzolamide/Timolol.............. 20
31
Doxazosin........................... 12, 22
Doxepin.................................... 14
Doxycycline Hyclate................. 10
Doxycycline Monohydrate
Tablet.................................... 10
DrithoCreme HP..................... 17
DrithoScalp.............................. 17
Dronabinol............................... 20
Drospirenone/
Ethinyl Estradiol................... 27
Duavee..................................... 28
Duloxetine 20, 30, 60 mg......... 14
Duraxin.................................... 24
Dutasteride............................... 22
Dutasteride-Tamsulosin........... 22
Dutoprol................................... 12
Dymista Spray.......................... 26
E
Easivent.................................... 23
Econazole................................. 17
Edarbi....................................... 12
Edarbyclor................................ 12
Edurant.................................... 21
Effient...................................... 11
Elestrin..................................... 28
Elidel........................................ 17
Elinest...................................... 27
Eliquis...................................... 11
Ella........................................... 27
Elmiron.................................... 23
Embeda.................................... 24
Emcyt....................................... 11
Emoquette................................ 27
Emtriva..................................... 21
Enablex..................................... 25
Enalapril................................... 12
Enalapril/
Enjuvia..................................... 28
Enpresse................................... 27
Enskyce.................................... 27
Entaone.................................... 15
Entecavir.................................. 11
Epiduo, Epiduo Forte............... 17
Epinastine................................ 19
Epipen-Jr.................................. 23
Epipen 2-Pak............................ 23
Epitol........................................ 16
Epivir HBV Solution................ 11
Epivir Solution......................... 21
Eprosartan................................ 12
Epzicom................................... 21
Ergocalciferol 50,000 Unit
Capsule.................................. 23
Ergoloid Mesylate.................... 15
Erivedge................................... 11
Errin......................................... 27
Ery Pad..................................... 17
Erythromycin................ 10, 17, 19
Erythromycin/
Benzoyl Peroxide................... 17
Erythromycin/Sulfisoxazole..... 10
Escitalopram............................. 14
Esgic Plus................................. 24
Estarylla................................... 27
Estradiol Tablet........................ 28
Estradiol Twice
Weekly Patch........................ 28
Estradiol Weekly Patch,
Tablet.................................... 28
Estrogen/Methyltestosterone,
Estrogen/Methyltestosterone
HS......................................... 28
Estropipate............................... 28
Eszopiclone.............................. 16
Ethambutol............................... 10
Ethosuximide........................... 16
Ethyl Chloride.......................... 17
Etodolac IR/ER....................... 24
Etoposide.................................. 11
Euflexxa.................................... 23
Eurax........................................ 17
Evamist.................................... 28
Evotaz....................................... 21
Exemestane........................ 11, 23
Exforge..................................... 12
Exforge HCT........................... 12
Exoderm................................... 17
Extavia..................................... 15
EZ Spacer................................. 23
Ezide........................................ 12
F
Falmina.................................... 27
Famciclovir............................... 11
Fareston.................................... 11
FastClix Lancets....................... 18
Felodipine................................. 12
Fenofibrate 48, 145 mg Tablet... 13
Fenofibrate 54, 160 mg Tablet... 13
Fenofibrate Capsule.................. 13
Fenofibrate Micronized............ 13
Fenoglide.................................. 13
Fenoprofen................................ 24
Fentanyl Patch 12, 25,
50, 75, 100 mcg..................... 24
Finacea..................................... 17
Finacea Plus............................. 17
Finasteride................................ 22
Flecainide................................. 13
Flector Patch............................ 24
Flovent Diskus......................... 25
Flovent HFA............................ 25
Fluconazole.............................. 10
Fludrocortisone........................ 19
Flunisolide................................ 26
Fluocinolone............................. 17
Fluocinonide,
Fluocinonide E...................... 17
Fluoride Chewable Tablet,
Drops..................................... 26
Fluorometholone...................... 20
Fluorouracil 0.5% Cream......... 17
Fluorouracil Solution,
5% Cream.............................. 17
Fluoxetine................................. 14
Fluphenazine............................ 15
Flurazepam............................... 16
Flurbiprofen........................ 20, 24
Flutamide................................. 11
Fluticasone..........................17, 26
Fluticasone Propionate............. 26
Fluvoxamine............................. 14
FML Forte............................... 20
Folic Acid 1 mg.................. 26, 28
Follistim AQ............................ 22
Foradil...................................... 25
Forfivo XL................................ 14
32
Forteo....................................... 24
Fortesta..................................... 22
Fortical..................................... 24
Fortigan.................................... 24
Fosinopril................................. 12
Fosinopril/
Fosrenol.................................... 23
Freestyle Test Strips................. 18
Furosemide............................... 12
Fuzeon...................................... 21
G
Gabapentin............................... 16
Galantamine IR/ER................ 15
Gavilyte.................................... 21
Gelnique 10%........................... 25
Gemfibrozil.............................. 13
Generic Prenatal Vitamins/
Folic Acid 1 mg..................... 28
Gengraf.................................... 26
Gentamicin..........................17, 19
Genvoya................................... 21
Gianvi....................................... 27
Gildagia.................................... 27
Gildess, Gildess Fe................... 27
Gilenya..................................... 15
Glimepiride........................ 18, 19
Glipizide/Metformin............... 18
Glipizide IR/XL...................... 18
Glucagen.................................. 18
Glucagon.................................. 18
Glucocard Test Strips............... 18
Glumetza.................................. 18
Glyburide................................. 18
Glyburide/Metformin.............. 18
Glyxambi.................................. 18
Gonal-F.................................... 22
Gonal-F Rff............................. 22
Gralise...................................... 24
Granix...................................... 23
Griseofulvin............................. 10
Guaifenesin/Codeine............... 23
Guanfacine......................... 12, 14
Guanfacine ER......................... 14
Guanidine................................ 23
H
Halflytely.................................. 21
Haloperidol.............................. 15
Harvoni.................................... 11
Heather.................................... 27
Hexalen.................................... 11
Homatropine...................... 20, 23
Humalog KwikPen 100u/ml.... 18
Humalog Mix 75-25
KwikPen................................ 18
Humalog Vial........................... 18
Humibid DM........................... 23
Humira..................................... 22
Humulin 70-30 Vial................. 18
Humulin KwikPen................... 18
Humulin N KwikPen............... 18
Humulin N Vial....................... 18
Humulin R U-500 Vial............ 18
Hydralazine.............................. 12
Hydrochlorothiazide........... 11-13
Hydrocodone/
Acetaminophen..................... 24
Hydrocodone/Homatropine..... 23
Hydrocodone/Ibuprofen........... 24
Hydrocortisone...10, 17, 19, 20, 23
Hydrocortisone/
Acetic Acid Otic................... 23
Hydrocortisone
Pramoxine....................... 10, 23
Hydrocortisone Suppository..... 23
Hydrocortisone Tablet.............. 19
Hydromorphone IR/ER........... 24
Hydroxychloroquine Sulfate..... 22
Hydroxyurea............................. 11
Hydroxyzine....................... 15, 26
Hyoscyamine............................ 21
Hypercare................................. 17
Hypersal Nebs.......................... 23
I
Ibandronate.............................. 24
Ibuprofen.................................. 24
Ilotycin..................................... 19
Imatinib.................................... 11
Imipramine............................... 14
Imiquimod................................ 17
Implanon.................................. 27
Incruse Ellipta.......................... 25
Indapamide............................... 12
Indocin Suppository................. 24
Indomethacin IR/ER............... 24
Inspirease.................................. 23
Intelence................................... 21
Introvale................................... 27
Intuniv...................................... 14
Invirase..................................... 21
Invokamet................................. 18
Invokana................................... 18
Ipratropium........................ 25, 26
Ipratropium/Albuterol Nebs..... 25
Irbesartan................................. 12
Irbesartan/
Isentress.................................... 21
Iso Carbachol........................... 20
Iso Homatropine...................... 20
Isochron.................................... 13
Isoditrate ER............................ 13
Isometheptene/Acetaminophen/
Dichloralphenazone.............. 15
Isoniazid................................... 10
Isordil....................................... 13
Isosorbide Dinitrate IR/ER..... 13
Isosorbide Mononitrate
IR/ER................................... 13
Isoxsuprine............................... 14
Isradipine.................................. 12
Istalol........................................ 20
Itraconazole.............................. 10
J
Jantoven.................................... 11
Janumet.................................... 19
Janumet XR.............................. 19
Januvia...................................... 19
Jardiance................................... 19
Jencycla..................................... 27
Jentadueto................................. 19
Jinteli........................................ 28
Jolessa....................................... 27
Jolivette..................................... 27
Junel......................................... 27
Junel Fe..................................... 27
33
Juvisync.................................... 19
K
Kaletra...................................... 21
Kariva....................................... 27
Kelnor....................................... 27
Ketoconazole Cream,
Shampoo............................... 10
Ketoprofen IR/ER................... 24
Ketorolac............................ 20, 24
Klor-Con 10............................. 26
Klor-Con M10......................... 26
Klor-Con M20......................... 26
Kombiglyze XR........................ 19
Kurvelo..................................... 27
Kuvan....................................... 23
L
Labetalol................................... 12
Laclotion.................................. 17
Lactulose.................................. 21
Lamictal Chewable, Tablet....... 16
Lamictal Starter Kit................. 16
Lamictal XR............................. 16
Lamivudine........................ 11, 21
Lamivudine/Zidovudine.......... 21
Lamotrigine Chewable,
Tablet.................................... 16
Lamotrigine ER....................... 16
Lamotrigine ODT................... 16
Lansoprazole............................ 20
Lantus Solostar......................... 18
Lantus Vial............................... 18
Larin, Larin FE....................... 27
Lastacaft................................... 19
Latanoprost.............................. 20
Latuda...................................... 15
Lazanda.................................... 24
Leena........................................ 27
Leflunomide............................. 22
Lessina..................................... 27
Letairis..................................... 26
Letrozole............................ 11, 23
Leucovorin Calcium................. 11
Leukeran.................................. 11
Levemir Flexpen...................... 18
Levemir Vial............................ 18
Levetiracetam ER.................... 16
Levetiracetam IR...................... 16
Levobunolol.............................. 20
Levofloxacin............................. 10
Levonest................................... 27
Levonorgestrel.......................... 27
Levonorgestrel/Ethinyl
Estradiol................................ 27
Levora-28................................. 27
Levorphanol............................. 25
Levothyroxine Sodium............. 19
Levoxyl..................................... 19
Lexiva....................................... 21
Lialda....................................... 21
Lidocaine.............................17, 23
Lidocaine/Prilocaine................ 17
Lidocaine Patch........................ 23
Lidocaine Viscous.................... 23
Lidoderm Patch........................ 23
Lindane.................................... 17
Linezolid Tablet....................... 10
Linzess..................................... 21
Liothyronine Sodium............... 19
Lipofen..................................... 13
Lisinopril............................ 12, 39
Lisinopril/
Lithium IR/ER........................ 15
Livalo....................................... 13
Lo Loestrin.............................. 27
Loestrin.................................... 27
Lokara...................................... 17
Lomustine................................ 11
Lorazepam............................... 15
Loryna...................................... 27
Losartan................................... 12
Losartan/
Lovastatin................................. 13
Lovaza...................................... 13
Low-Ogestrel........................... 27
Loxapine................................... 15
Lumigan................................... 20
Lupron Depot........................... 19
Lutera....................................... 27
Lyrica Capsule.......................... 16
Lyrica Solution......................... 16
Lysodren................................... 11
Lyza.......................................... 27
M
Makena.................................... 28
Maprotiline.............................. 14
Marlissa.................................... 27
Matulane.................................. 11
Mebendazole............................ 23
Meclofenamate......................... 25
Medrol 2 mg............................. 19
Medroxyprogesterone......... 27, 28
Medroxyprogesterone
Acetate Injection................... 27
Mefloquine............................... 23
Megestrol AC........................... 23
Meloxicam................................ 25
Menest...................................... 28
Meperidine............................... 25
Mephyton................................. 23
Meprobamate........................... 15
Mercaptopurine........................ 11
Mesalamine Enema.................. 21
Mestinon Syrup........................ 23
Metadate ER............................ 14
Metformin.......................... 18, 19
Metformin Extended-Release... 19
Methadone............................... 25
Methazolamide........................ 12
Methenamine........................... 10
Methimazole............................ 19
Methocarbamol........................ 24
Methotrexate............................ 22
Methyclothia............................ 12
Methyldopa.............................. 12
Methyldopa/
Methylergonovine..................... 19
Methylphenidate ControlledRelease Tablet........................ 14
Methylphenidate Tablet............ 14
Methylprednisolone.................. 19
Metipranolol............................. 20
Metoclopramide Solution,
Tablet.................................... 21
Metolazone............................... 12
Metoprolol Succinate ER......... 12
34
Metoprolol Tartrate.................. 12
Metrogel 1%............................. 17
Metronidazole 0.75% Cream,
Lotion.................................... 17
Metronidazole Tablet............... 10
Metronidazole Vaginal Gel...... 11
Mexiletine................................ 14
Micardis HCT......................... 12
Microgestin.............................. 27
Microgestin FE........................ 27
Midodrine................................ 14
Migragesic................................ 15
Migranal................................... 15
Millipred Tablet....................... 19
Mimvey.................................... 28
Minivelle.................................. 28
Minocycline............................. 10
Minoxidil................................. 12
Mirtazapine,
Mirtazapine ODT................. 14
Mirvaso.................................... 17
Misoprostol.............................. 20
Moexipril.................................. 12
Moexipril/
Mometasone Furoate................ 17
Mono-Linyah........................... 27
Mononessa................................ 27
Montelukast............................. 25
Morphine Sulfate Beads
Sustained-Release.................. 25
Morphine Sulfate
Controlled-Release Tablet..... 25
Morphine Sulfate ImmediateRelease Tablet, Solution........ 25
Morphine Sulfate
Sustained-Release Capsule.... 25
Movantik.................................. 21
Moxeza..................................... 19
Multigen Folic.......................... 23
Multigen Plus........................... 23
Mupirocin Calcium Cream...... 17
Mupirocin Ointment................ 17
Mycobutin................................ 10
Myleran.................................... 11
Myorisan.................................. 17
Myrbetriq................................. 25
Myzilra..................................... 27
N
Nabumetone............................. 25
Nadolol..................................... 12
Nalfon 200 mg Capsule........... 25
Naltrexone................................ 23
Namenda XR........................... 15
Namzaric.................................. 15
Naphazoline 0.1%..................... 19
Naproxen.................................. 25
Nasonex.................................... 26
Natacyn.................................... 19
Natazia..................................... 27
Nateglinide............................... 19
NebuPent Nebs........................ 10
Necon 0.5/35, 1/35,
1/50, 10/11............................ 27
Nefazodone.............................. 14
Neomycin......................10, 19, 20
Polymyxin....................... 19, 20
Polymyxin/Hydrocortisone... 20
Neomycin/Polymixin/
Dexamethasone..................... 20
Neomycin/Polymixin/
Gramicidin............................ 19
Neomycin/Polymixin/
Hydrocortisone Otic............. 10
Nessi Spacer............................. 23
Neupogen................................. 23
Nevirapine................................ 21
Niacin ER................................ 13
Niaspan.................................... 13
Nicardipine............................... 12
Nifediac CC............................. 12
Nifedical XL............................ 13
Nifedipine IR/ER.................... 13
Nikki........................................ 27
Nilandrone............................... 11
NitroBid................................... 14
NitroDur Patch........................ 14
Nitrofurantoin.......................... 10
Nitrofurantoin
Macrocrystal.......................... 10
Nitroglycerin ER...................... 14
Nitrolingual Pump Spray......... 14
Nitrostat................................... 14
NitroTime................................. 14
Nizatidine................................. 20
Nodolor.................................... 15
Nora-BE................................... 27
Norditropin.............................. 19
Norethindrone.................... 27, 28
Norethindrone/
Ethinyl Estradiol................... 28
Norgestimate-Ethinyl
Estradiol................................ 27
Norgestrel/Ethinyl
Estradiol................................ 27
Norpace CR............................. 14
Nortrel...................................... 27
Nortriptyline............................ 14
Norvir....................................... 21
Novofine Autocover
Pen Needles........................... 18
Novofine Pen Needles.............. 18
Novofine Plus Pen Needles...... 18
Novolin N Vial......................... 18
Novolin R Vial......................... 18
Novolin Vial............................. 18
Novolog Flexpen...................... 18
Novolog Mix............................ 18
Novolog Vial............................ 18
Novotwist Pen Needles............ 18
Nucynta.................................... 25
Nucynta ER.............................. 25
Nutropin Aq NuSpin............... 19
Nuvaring.................................. 27
Nuvigil..................................... 15
Nystatin...............................11, 17
Nystop...................................... 17
O
Ocella....................................... 27
Ofloxacin............................ 10, 19
Ofloxacin Otic.......................... 10
Ogestrel.................................... 27
Olanzapine,
Olanzapine ODT.................. 15
Olysio....................................... 11
Omeclamox-Pak....................... 20
35
Omega-3-Acid Ethyl Esters
Capsule.................................. 13
Omeprazole.............................. 20
Omnaris................................... 26
Ondansetron............................. 20
Ondansetron ODT.................. 20
OneTouch Test Strips............... 18
OneTouch Ultra Blue
Test Strips............................. 18
OneTouch Verio IQ
Test Strips............................. 18
Onglyza.................................... 19
Opana ER................................ 25
Opsumit................................... 26
Optihaler.................................. 23
Oracea...................................... 10
Orbivan.................................... 25
Orencia..................................... 22
Orenitram................................. 26
Orphenadrine/Aspirin/
Caffeine................................. 24
Orphenadrine ER..................... 24
Orsythia................................... 27
Ortho Coil............................... 27
Ortho Flat................................ 27
Ortho Flex................................ 27
OrthoEst.................................. 28
Osphena................................... 28
Ovidrel..................................... 22
Oxaprozin................................. 25
Oxazepam................................ 15
Oxcarbazepine.......................... 16
Oxybutynin.............................. 25
Oxybutynin
Oxycodone/Acetaminophen..... 25
Oxycodone IR.......................... 25
Oxycontin................................. 25
Oxymorphone.......................... 25
Oxytrol..................................... 25
P
Pacerone................................... 14
Pancrelipase.............................. 21
Pantoprazole............................. 20
Paregoric Tincture.................... 21
Paricalcitol................................ 19
Paromomycin............................ 10
Paroxetine................................. 14
Paroxetine ER.......................... 14
Pataday..................................... 19
Paxil Suspension....................... 14
Pegasys..................................... 11
Penicillin VK............................ 10
Pentasa...................................... 21
Pentazocine/Acetaminophen.... 25
Pentazocine/Naloxone.............. 25
Pentoxifylline........................... 14
Perforomist............................... 25
Perindopril................................ 13
Permethrin............................... 17
Perphenazine/Amitriptyline..... 15
Phenazopyridine....................... 23
Phenelzine................................ 14
Phenobarbital..................... 16, 21
Phenoxybenzamine.................. 13
Phenylephrine........................... 19
Phenyltoloxamine/
Acetaminophen..................... 25
Phenytoin................................. 16
Philith...................................... 27
Phospholine.............................. 20
Phrenilin Forte......................... 15
Picato........................................ 17
Pilocarpine............................... 23
Pimtrea..................................... 27
Pindolol.................................... 13
Pioglitazone.............................. 19
Pioglitazone/Glimepiride......... 19
Pioglitazone/Metformin........... 19
Piroxicam................................. 25
Plegridy.................................... 15
Podofilox.................................. 17
Polyethylene Glycol 3350......... 21
Polymyxin B/Trimethoprim..... 19
Portia........................................ 27
Potassium Chloride.................. 26
Potassium Citrate..................... 26
Pradaxa..................................... 11
Praluent.................................... 13
Pramcort................................... 17
Pramipexole.............................. 15
Pramosone Cream, Ointment.. 17
Pramosone E Cream................ 17
Pramosone Lotion.................... 17
Pramoxine-HC Otic................ 10
Pravastatin................................ 13
Prazosin.................................... 13
Pred Mild................................. 20
Tablet.............................. 19, 20
Prednisone................................ 19
Premarin................................... 28
Premarin Vaginal Cream.......... 28
Premphase................................ 28
Prempro.................................... 28
Prepopik................................... 21
Prevalite.................................... 13
Previfem................................... 27
Prezcobix.................................. 21
Prezista..................................... 21
Primaquine............................... 23
Primella.................................... 27
Pristiq....................................... 14
Proair HFA.............................. 25
Proair Respiclick...................... 25
Probenecid................................ 24
Prochlorperazine...................... 15
Procrit....................................... 23
Proctocream HC...................... 23
Proctofoam HC........................ 23
Proctosol HC........................... 23
Proctozone HC........................ 23
Proglycem................................. 23
Promethazine............... 21, 23, 26
Promethazine/Codeine............. 23
Promethazine/
Dextromethorphan................ 23
Promethazine VC/Codeine...... 23
Propafenone.............................. 14
Propantheline........................... 21
Proparacaine............................. 20
Propranolol/
Propranolol IR/ER................... 13
Propylthiouracil........................ 19
Protopic.................................... 17
Protriptyline............................. 14
Pulmicort Flexhaler.................. 25
Pulmicort Respules.................. 25
Pylera........................................ 20
36
Pyrazinamide........................... 10
Pyridostigmine......................... 23
Q
QNasl....................................... 26
Quasense.................................. 27
Quetiapine................................ 15
Quinapril.................................. 13
Quinidine IR/ER..................... 14
QVAR...................................... 25
R
Raloxifene................................ 24
Ramipril................................... 13
Ranexa...................................... 14
Ranitidine................................. 20
Rapaflo..................................... 22
Rebif, Rebif Rebidose............... 15
Reclipsen.................................. 27
Rectiv....................................... 23
Relion Test Strips..................... 18
Remicade.................................. 22
Renvela............................... 21, 23
Renvela Packet......................... 21
Renvela Tablet.......................... 21
Repaglinide.............................. 19
Rescriptor................................. 21
Reserpine.................................. 13
Restasis..................................... 20
Retin-A Micro Gel, Pump....... 17
Retrovir.................................... 21
Reyataz..................................... 21
Rezira....................................... 23
Rheumatrex.............................. 22
Ribavirin Tablet........................ 11
Rifampin.................................. 10
Rimantidine............................. 11
Risperidone,
Risperidone ODT................. 15
Rivastigmine............................ 15
Rizatriptan............................... 15
Ropinirole................................. 15
Rosadan Cream........................ 17
Rowasa Enema......................... 21
S
Safyral...................................... 27
Saizen....................................... 19
Salsalate.................................... 25
Saphris...................................... 15
Savaysa..................................... 11
Sedapap.................................... 25
Selenium Sulfide...................... 17
Selzentry................................... 21
Serevent.................................... 26
Seroquel XR............................. 15
Sertraline.................................. 14
Sevelamer................................. 21
Sharobel.................................... 27
Sildenafil Tablet 20 mg............ 26
Silenor...................................... 16
Silver Nitrate............................ 17
Silver Sulfadiazine.................... 17
Simcor...................................... 13
Simponi.................................... 22
Simvastatin 5, 10, 20, 40 mg..... 13
Simvastatin 80 mg.................... 13
Sodium Polystyrene Sulfonate
Powder................................... 23
Soft Touch Lancets.................. 18
SoftClix Lancets...................... 18
Solia.......................................... 27
Solodyn.................................... 10
Soriatane................................... 23
Sotalol................................ 13, 14
Sotalol AF................................ 13
Sovaldi...................................... 11
Spiriva HandiHaler,
Respimat............................... 26
Spironolactone.......................... 13
Spironolactone/
Sprintec.................................... 27
Sronyx...................................... 27
SSKI......................................... 23
Stavudine.................................. 21
Stelara....................................... 22
Stendra..................................... 22
Stiolto Respimat....................... 26
Strattera.................................... 14
Stribild...................................... 21
Striverdi Respimat.................... 26
Suboxone Film......................... 15
Suboxone Tablet....................... 15
Sucralfate Tablet....................... 20
Sulfacetamide Sodium... 17, 19, 20
Sulfacetamide
Sodium-Sulfur...................... 17
Sulfacetamide Sodium/
Prednisolone.......................... 20
Sulfadiazine........................ 10, 17
Sulfamethoxazole/Trimethoprim,
Sulfamethoxazole/
Trimethoprim DS................. 10
Sulfasalazine............................. 21
Sulindac.................................... 25
Sumatriptan Nasal Spray,
Tablet.................................... 15
Sumavel DosePro..................... 15
Suprep...................................... 21
Sustiva...................................... 21
Syeda........................................ 27
Symbicort................................. 26
Symlin...................................... 19
Synarel...................................... 23
Synjardy.................................... 19
Synvisc...................................... 23
Synvisc One.............................. 23
T
Tabloid...................................... 11
Taclonex Ointment................... 17
Taclonex Scalp.......................... 17
Tacrolimus...........................17, 26
Tacrolimus Ointment............... 17
Tamoxifen................................ 23
Tamsulosin............................... 22
Tarina FE................................. 27
Tasigna..................................... 11
Tazorac..................................... 17
Taztia XT................................. 13
Tecfidera................................... 15
Tekturna................................... 13
Tekturna HCT......................... 13
Telmisartan.............................. 13
Temazepam.............................. 16
Temozolomide.......................... 11
Terazosin............................ 13, 22
Terbinafine............................... 11
Terbutaline............................... 26
Terconazole.............................. 11
37
Testim...................................... 22
Testosterone Gel 1%................. 22
Testred...................................... 22
Tetracaine................................. 20
Tetracycline.............................. 10
Tev-Tropin................................ 19
Theophylline SR...................... 26
Thioridazine............................. 15
Thiothixene.............................. 15
Ticlopidine............................... 11
Timolol............................... 13, 20
Timolol Maleate....................... 20
Timoptic Ocudose.................... 20
Tirosint..................................... 19
Tivicay...................................... 22
Tivorbex................................... 25
Tizanidine Tablet..................... 24
Tobi.......................................... 10
Tobradex Ointment.................. 19
Tobramycin/
Dexamethasone..................... 19
Tobramycin Ophth Solution.... 20
Tobrex...................................... 20
Tolazamide............................... 19
Tolbutamide............................. 19
Tolmetin................................... 25
Topiragen................................. 16
Topiramate............................... 16
Torsemide................................. 13
Toviaz....................................... 25
Tracleer..................................... 26
Tradjenta.................................. 19
Tramadol.................................. 25
Trandolapril/Verapamil CR..... 13
Tranylcypromine...................... 14
Travatan Z................................ 20
Trazodone................................. 14
Tretin-X.................................... 17
Tretinoin..............................11, 17
Tretinoin Capsule..................... 11
Trexall...................................... 22
Tri-Estarylla............................. 27
Tri-Linyah................................ 27
Tri-Previfem............................. 27
Tri-Sprintec.............................. 27
Triamcinolone/Orabase............ 23
Triamcinolone Acetonide......... 17
Triamterene/
Trianex..................................... 17
Triazolam................................. 16
Tribenzor.................................. 13
Triderm.................................... 17
Trifluoperazine......................... 16
Trifluridine............................... 20
Trihexyphenidyl....................... 16
Trilyte....................................... 21
Trimethobenzamide................. 21
Trimethoprim..................... 10, 19
Trinessa.................................... 27
Trinessa Lo............................... 27
Triumeq.................................... 22
Trivora-28................................. 27
Trizivir..................................... 22
Tropicamide............................. 20
Trulicity.................................... 19
Truvada.................................... 22
Tudorza.................................... 26
Tykerb...................................... 11
U
Uceris....................................... 21
Uloric........................................ 24
Unithroid.................................. 19
Urea 40% Lotion...................... 17
Ursodiol.................................... 21
V
Vagifem.................................... 28
Valacyclovir.............................. 11
Valcyte Solution....................... 11
Valganciclovir Tablet................ 11
Valproic Acid............................ 16
Valsartan................................... 13
Valsartan/
Valturna.................................... 13
Vandazole Gel.......................... 11
Vascepa..................................... 13
Vectical..................................... 17
Velivet....................................... 27
Velphoro................................... 23
Venlafaxine......................... 14, 15
Venlafaxine Extended-Release
Capsule.................................. 14
Venlafaxine Extended-Release
Tablet.................................... 15
Ventolin HFA........................... 26
Veramyst................................... 26
Verapamil Sustained-Release
Capsule.................................. 13
Verapamil Sustained-Release
Tablet.................................... 13
Verapamil Tablet...................... 13
Vesicare..................................... 25
Vestura..................................... 27
Victoza..................................... 19
Videx Solution.......................... 22
Viekira Pak............................... 11
Vigamox................................... 20
Viibryd..................................... 15
Vimovo..................................... 25
Viorele...................................... 27
Viracept.................................... 22
Viread....................................... 22
Vitamin D 50,000 Unit............ 23
Vitazol...................................... 17
Vitekta...................................... 22
Vivelle-Dot............................... 28
Voltaren Gel....................... 18, 25
Vortex....................................... 23
Vyfemla.................................... 27
Vytorin..................................... 13
Vyvanse.................................... 14
W
Warfarin................................... 11
WatchHaler.............................. 23
Welchol.................................... 13
Wera......................................... 28
Wide-Seal................................ 28
X
Xarelto...................................... 11
Xeloda...................................... 11
Xopenex HFA.......................... 26
Xulane...................................... 28
Xyrem....................................... 16
38
Y
Yasmin 28................................. 28
Yaz............................................ 28
Yodoxin.................................... 23
Z
Zaleplon................................... 16
Zarah........................................ 28
Zecuity..................................... 15
Zegerid..................................... 20
Zelapar..................................... 16
Zemplar.............................. 19, 23
Zenatane................................... 18
Zenchent.................................. 28
Zenpep..................................... 21
Zetonna.................................... 26
Ziagen...................................... 22
Zidovudine......................... 21, 22
Ziprasidone............................... 16
Zmax........................................ 10
Zohydro ER............................. 25
Zolmitriptan............................. 15
Zolpidem.................................. 16
Zomig Spray............................. 15
Zonisamide.............................. 16
Zorvolex................................... 25
Zovia........................................ 28
Zovirax Cream......................... 11
Zovirax Ointment.................... 11
Zubsolv..................................... 16
Zutripro.................................... 23
Zyclara Cream, Pump.............. 18
Zytiga....................................... 11
“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
Coverage
Level
I Take This
Medicine For
Directions
Doctor
Example: Lisinopril, 20 mg
Formulary
Generic
High blood pressure
One tablet daily
Dr. Johnson
39
For more information
Or, visit myuhc.com or optumrx.com
Where else can I go for information?
HealthCareLane.com includes short videos to help you learn more about
UnitedHealthcare benefits and health insurance information.
UHCTV.com is a fun and easy way to learn about health terms and other
health-related topics.
All branded medications are trademarks or registered trademarks of their respective owners .
© 2016 United HealthCare Services, Inc . All rights reserved . Created February, 2016 . 2016 Formulary SignatureValue Three-Tier
104-0102 7/16

Your 2016 Formulary

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