2017
Your Prescription
Drug List/Formulary
Effective July 1, 2017
Please read:
For a complete list of covered drugs
or if you have questions:
This document contains
information about the drugs
covered under your pharmacy
benefit plan.
•Call a customer care representative
toll-free at (866) 336-9371 (TTY 711)*.
Our representatives can answer
both medical and prescription
drug questions.
•Visit www.HealthSelectRx.com
— Locate an OptumRx
in-network pharmacy
*HealthSelect Prescription Drug Program will have
a new phone number for your prescription drug
questions. This new number will be on the new
prescription ID card that you will receive from
OptumRx in August. You can begin using the new
prescription drug program ID card on September 1.
HealthSelect
— Look up possible lower-cost
medication alternatives.
— Compare medication pricing
and options.
of Texas
SM
1
Your Prescription Drug List / Formulary
This formulary outlines the most commonly prescribed medications covered under your plan’s
prescription drug benefits. The formulary is also known as the Prescription Drug List (PDL). A
formulary identifies the drugs available for certain conditions and organizes them into cost levels,
also known as tiers. An important part of the formulary is giving you choices so you and your
doctor can choose the best course of treatment for you.
Go to www.HealthSelectRx.com for complete and up-to-date drug information
Since the formulary may change, we encourage you to visit our website, www.HealthSelectRx.com
and click on Prescription Drug List. This website is the best source for up-to-date information
about all of the medications your pharmacy benefit covers, possible lower-cost options and
cost comparisons.
2
Table of Contents
Drug tiers and cost . . . . . . . . . . . . . . . . . . . 5
Programs and limits . . . . . . . . . . . . . . . . . . 6
Drugs by category . . . . . . . . . . . . . . . . . . . 9
Gastrointestinal
Acid Suppression . . . . . . . . . . . . . . . . . . . . 16
Nausea/Vomiting . . . . . . . . . . . . . . . . . . . . . 16
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Anti-Infectives
Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Men’s Health
Erectile Dysfunction . . . . . . . . . . . . . . . . . . . 17
Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Testosterone Therapy . . . . . . . . . . . . . . . . . 18
Cardiovascular/Heart Disease
Anticoagulants . . . . . . . . . . . . . . . . . . . . . . .
High Blood Pressure . . . . . . . . . . . . . . . . . .
High Cholesterol . . . . . . . . . . . . . . . . . . . . .
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pulmonary Arterial Hypertension . . . . . . . . .
10
10
10
11
11
Central Nervous System
Attention Deficit Disorder . . . . . . . . . . . . . .
Depression . . . . . . . . . . . . . . . . . . . . . . . . .
Migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Multiple Sclerosis . . . . . . . . . . . . . . . . . . . .
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Sedatives/Hypnotics . . . . . . . . . . . . . . . . . .
Seizure Disorders . . . . . . . . . . . . . . . . . . . .
11
11
12
12
12
12
12
Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Inflammatory Conditions . . . . . . . . . . . . . 17
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . 18
Musculoskeletal
Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . 19
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Pain Relief . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Overactive Bladder . . . . . . . . . . . . . . . . . . 20
Respiratory
Asthma/COPD . . . . . . . . . . . . . . . . . . . . . . . 20
Nasal Allergies . . . . . . . . . . . . . . . . . . . . . . . 20
Oral Allergies . . . . . . . . . . . . . . . . . . . . . . . . 20
Dermatology . . . . . . . . . . . . . . . . . . . . . . . 13
Transplant . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Diabetes/Endocrine
Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Non-Insulin . . . . . . . . . . . . . . . . . . . . . . . . . 14
Vitamins/Electrolytes . . . . . . . . . . . . . . . . 21
Endocrine
Growth Hormone . . . . . . . . . . . . . . . . . . . . . 14
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Thyroid Hormone Replacement . . . . . . . . . 15
Eye Conditions
Allergies . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . .
Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . .
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Women’s Health
Birth Control . . . . . . . . . . . . . . . . . . . . . . . . 21
Hormone Replacement . . . . . . . . . . . . . . . . 22
Vaginal Anti-Infectives . . . . . . . . . . . . . . . . . 22
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
15
15
15
16
3
At OptumRx, we want
to help you better understand
your medication options.
Your pharmacy benefit offers flexibility and choice in determining the right medication for you.
To help you get the most out of your pharmacy benefit, we’ve included some of the most
commonly asked questions about the formulary.
What is a formulary?
This document is a list of commonly prescribed medications covered by your prescription drug
program for their safety, cost and effectiveness. Drugs are listed by common categories or class.
They are placed into cost levels known as tiers. It includes both brand and generic prescription
medications approved by the U.S. Food and Drug Administration (FDA).
Please note: Where differences are noted between this formulary and your benefit plan documents,
the benefit plan documents will rule. This document is not intended to be a complete list of
medications, and not all medications listed may be covered under your plan. Please look at the
Master Benefit Plan Document (MBPD) provided by your plan to see what medications are covered
under your plan. You may also visit www.HealthSelectRx.com and click on Prescription Drug List
or call a customer care representative toll free at (866) 336-9371 (TTY 711)*.
How do I use my formulary?
When choosing a medication, you and your doctor should consult the formulary. It will help
you and your doctor choose the most cost-effective prescription drugs. This guide tells you if
a medication is generic or brand, and if special rules apply. Bring this list with you when you
see your doctor. It is organized by common medical conditions. Medications are also listed
alphabetically by name at the end of the formulary.
If your medication is not listed on this document, it may not be covered by the HealthSelect
Prescription Drug Program or Consumer Directed HealthSelect Prescription Drug Program.
Please visit www.HealthSelectRx.com and click on Prescription Drug Tool for the most up to
date list of medications covered under your plan. If you have any questions, call a customer care
representative toll-free at (866) 336-9371 (TTY 711)*.
4
What are tiers?
Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, which is
determined by your plan. This is how much you will pay when you fill a prescription. The HealthSelect
of Texas Prescription Drug Program has different copays assigned depending on which tier a drug
is. The Consumer Directed HealthSelect Prescription Drug Program has coinsurance assigned for
each drug tier that applies once the annual combined medical and pharmacy deductible is met. Tier
1 medications are your lowest-cost options. If your medication is placed in Tier 2 or 3, look to see if
there is a Tier 1 option available. Discuss these options with your doctor.
Drug names shown in green are preferred for their cost and effectiveness. If there is a  symbol
in the Drug Tier column, check your benefit plan documents to find out your specific pharmacy
plan costs.
$
Drug Tier
Includes
Helpful Tips
$
Tier 1
Lowest Cost
Lower-cost, commonly
used generic drugs. Some
low-cost brands may
be included.
Use Tier 1 drugs for the
lowest out-of-pocket costs.
Tier 2
Mid-range Cost
Many common brand-name
drugs, called
preferred brands.
Use Tier 2 drugs, instead of
Tier 3, to help reduce your
out-of-pocket costs.
Tier 3
Highest Cost
Mostly higher-cost brand
drugs, also known as
non-preferred brands.
Many Tier 3 drugs have
lower-cost options in Tier 1
or 2. Ask your doctor if they
could work for you.
$$
$$$
When does the formulary change?
• Medications may move to a lower tier at any time.
• Medications may move to a higher tier when its generic becomes available.
• Medications may move to a higher tier or be excluded from coverage on
January 1 or July 1 of each year.
When a medication changes tiers, you may have to pay a different amount for that medication.
For the most up-to-date list, call a customer care representative, 24 hours a day, seven days
a week toll-free at (866) 336-9371 (TTY 711)*.
*HealthSelect Prescription Drug Program will have a new phone number for your prescription drug questions. This new
number will be on the new prescription ID card that you will receive from OptumRx in August. You can begin using the new
prescription drug program ID card on September 1.
5
Programs and Limits
Some medications are noted with letters or symbols next to them. The letters and symbols refer to
our pharmacy benefit programs and are provided to help you check which medications may have
a program or limit. Your benefit plan determines how these medications may be covered for you.
Programs and Limits
PA
Prior Authorization — Your doctor is required to provide additional information before
the drug will be covered by your prescription drug plan.
ST
Step Therapy — Requires you to first try a cost-effective medication before the
more expensive medication will be covered.
QL
Quantity Limits — L
imits the amount of a medication that will be covered under
your prescription drug plan.
SP
Specialty Medication — D
rugs that are used in the treatment of rare or complex
conditions and are typically injected or infused, are high
cost, have special delivery and storage requirements,
or require close monitoring or care coordination with
your doctor.
E
Excluded — D
rugs that are not covered by your health plan. Lower-cost options
are available and covered.
To learn more about a pharmacy program or to find out if it applies to you, please visit
www.HealthSelectRx.com and click on Prescription Drug List or call a customer care
representative toll-free at (866) 336-9371 (TTY 711)*.
6
Why are some medications excluded from coverage?
Medications may be excluded from coverage under your prescription drug plan when it works the
same as or similar to another prescription medication or an over-the-counter (OTC) medication that
is more cost-effective. There may be other medication options available to treat your condition.
What if I don’t agree with a decision about an excluded medication?
You (or your authorized representative) and your doctor can ask for an appeal to cover
an excluded medication by calling a customer care representative toll-free
at (866) 336-9371 (TTY 711)*.
Should I talk to my doctor about OTC medications?
An OTC medication may be the right treatment option for some conditions. Talk to your doctor
about available OTC options. Even though these medications may not be covered under your
pharmacy benefit, they may cost less than prescription medications covered under your
prescription drug plan.
What is the difference between brand-name and generic medications?
Generic medications contain the same active ingredients (what makes the medication work) as
brand-name medications, but they often cost less. Once the patent of a brand-name medication
ends, the FDA can approve a generic version with the same active ingredients. These types of
medications are known as generic medications. Sometimes the same company that makes a
brand-name medication also makes the generic version.
How can I tell a generic drug from a brand-name drug on this formulary?
This formulary shows brand-name drugs in bold type (for example, Lamictal) and generic drugs
in plain type (for example, lamotrigine).
What if my doctor writes a brand-name prescription?
The next time your doctor gives you a prescription for a brand-name medication, ask if a generic
equivalent or lower-cost option is available and if it might be right for you. Generic medications
are usually your lowest-cost option, but not always. Visit www.HealthSelectRx.com and click on
Drug Pricing Tool to find out an estimated cost for your medications and if there are lower cost
alternatives available.
*HealthSelect Prescription Drug Program will have a new phone number for your prescription drug questions. This new
number will be on the new prescription ID card that you will receive from OptumRx in August. You can begin using the new
prescription drug program ID card on September 1.
7
Are you taking a specialty medication?
Specialty medications treat rare or complex conditions and are typically higher cost medications.
Please note, not all specialty medications are listed in the Formulary.
BriovaRx®, the OptumRx specialty pharmacy, can provide most of your specialty medications
along with helpful programs and services. Call BriovaRx® at (855) 427-4682 and have your
prescriptions delivered right to your home or office.
How do I get updated information about my pharmacy benefit?
Since the Formulary may change during your plan year, we encourage you to visit
www.HealthSelectRx.com and click on Prescription Drug List or call a customer care
representative at (866) 336-9371 (TTY 711)* for the most current drug coverage information.
You can register and create an account at www.Optumrx.com/HealthSelectrx. You can use the
website’s helpful tools and features to:
• Refill and renew mail service prescriptions
• View your order status and claims history
• Sign up for text reminders to take and refill your medicine
• View your benefits in real time
• Look up the price of drugs covered by your plan
• Find lower-cost options
More information
*HealthSelect Prescription Drug Program will have
a new phone number for your prescription drug
questions. This new number will be on the new
prescription ID card that you will receive from
OptumRx in August. You can begin using the new
prescription drug program ID card on September 1.
Call a customer care representative
toll-free at (866) 336-9371 (TTY 711)*.
Or visit www.HealthSelectRx.com.
8
Drug Name
Drug
Tier Programs
and Limits
Anti-Infectives: Antibiotics
Amoxicillin
Amoxicillin/
Clavulanate
Azasite
Azithromycin
Bethkis
Cefadroxil Cap
Cefdinir
Cefuroxime Tab
Cephalexin
Ciprodex Otic
Suspension
Ciprofloxacin Tab
Clarithromycin
Clindamycin Cap
Doryx MPC
Doxycycline Hyclate
Cap
Doxycycline Hyclate
Tab (Immediate
Release)
Doxycycline
Monohydrate Cap
Doxycycline
Monohydrate Oral
Suspension, Tab
Erythromycin
Kitabis
Levofloxacin Tab
Metronidazole Tab
Minocycline Cap
Moxifloxacin
Neomycin/
Polymyxin/HC
Otic Suspension,
Solution
Nitrofurantoin
Macrocrystalline
Nitrofurantoin
Monohydrate
Macrocrystalline
1
1
3
1
2
1
1
1
1
SP
Drug
Tier Drug Name
Ofloxacin Otic
Solution
Oracea
Penicillin VK
Solodyn
SulfamethoxazoleTrimethoprim
SulfamethoxazoleTrimethoprim DS
TOBI Nebulizer
TOBI Podhaler
Tobramycin Neb
1
3
1
3
1
1
E
E
E
2
Anti-Infectives: Antifungals
1
1
1
3
Fluconazole
Jublia Solution
Kerydin Solution
Nystatin Suspension
Terbinafine Tab
1
Programs
and Limits
1
3
3
1
1
PA
PA
QL
Anti-Infectives: Antivirals
1
1
1
1
E
1
1
1
1
1
1
1
Bold type = Brand-name drug
[Plain type = Generic drug]
E Excluded
Acyclovir Cap, Tab,
Suspension
Daklinza
Entecavir
Epclusa
Famciclovir Tab
Harvoni
Sovaldi
Tamiflu
Valacyclovir
Zepatier
1
3
1
2
1
2
2
3
1
2
PA, QL, SP
QL, SP
PA, QL, SP
PA, QL, SP
PA, QL, ST, SP
QL
QL
PA, QL, SP
Cancer
Akynzeo
Anastrozole Tab
Capecitabine
Letrozole
Revlimid
Sprycel
Tamoxifen Tab
Tasigna
Temozolomide
Zytiga
PA Prior Authorization
ST Step Therapy
3
1
1
1
3
2
1
3
1
3
QL
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
QL Quantity Limits
SP Specialty Program
9
Drug Programs
Tier and Limits
Cardiovascular/Heart Disease:
Anticoagulants
Drug Name
Brilinta
Clopidogrel
Effient
Eliquis
Enoxaparin
Pradaxa
Savaysa
Warfarin
Xarelto
2
1
2
3
1
2
3
1
2
Amlodipine
Amlodipine/Benazepril
Amlodipine/Valsartan
Amlodipine/Valsartan/
HCTZ
Atenolol
Atenolol/
Chlorthalidone
Azor
Benazepril
Benazepril/HCTZ
Benicar
Benicar HCT
Bisoprolol
Bisoprolol/HCTZ
Bumetanide
Bystolic
Cartia XT
Carvedilol
Chlorthalidone
Clonidine Patch
Clonidine Tab
Diltiazem Tab
Doxazosin
Edarbi
Edarbyclor
Enalapril
Enalapril/HCTZ
Felodipine
Fosinopril
Furosemide
1
1
1
Cardiovascular/Heart Disease:
High Blood Pressure
QL
QL
QL
QL
QL
1
1
1
3
1
1
3
3
1
1
1
2
1
1
1
1
1
1
1
3
3
1
1
1
1
1
Bold type = Brand-name drug
[Plain type = Generic drug]
E Excluded
ST
ST
ST
Drug
Tier Drug Name
Guanfacine Tab
(Immediate
Release)
Hydralazine
Hydrochlorothiazide
Irbesartan
Irbesartan/HCTZ
Labetalol
Lisinopril
Lisinopril/HCTZ
Losartan
Losartan/HCTZ
Metoprolol Succinate
Metoprolol Tartrate
Nadolol
Nifedipine ER
Propranolol
Propranolol ER
Quinapril
Ramipril
Spironolactone
Tekturna
Tekturna HCT
Telmisartan
Terazosin
Torsemide Tab
Triamterene/HCTZ
Tribenzor
Valsartan
Valsartan/HCTZ
Verapamil ER
Programs
and Limits
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
1
1
1
1
3
1
1
1
ST
ST
ST
Cardiovascular/Heart Disease:
High Cholesterol
ST
ST
Atorvastatin
Cholestyramine
Crestor
Fenofibrate 40 mg,
43 mg, 48 mg,
50 mg, 54 mg,
67 mg, 120 mg,
130 mg, 134 mg,
145 mg, 150 mg,
160 mg, 200 mg
PA Prior Authorization
ST Step Therapy
1
1
3
1
QL Quantity Limits
SP Specialty Program
10
Drug Name
Gemfibrozil
Lipitor
Lovastatin
Lovaza
Niacin ER Tab
Omega-3 Acid Cap
1 gm
Praluent
Pravastatin
Rosuvastatin
Simvastatin 5 mg, 10
mg, 20 mg, 40 mg
Simvastatin 80 mg
Vascepa
Vytorin 10-10 mg,
10-20 mg,
10-40 mg
Vytorin 10-80 mg
Welchol
Zetia
Drug
Tier 1
3
1
3
1
Programs
and Limits
ST
1
2
1
1
PA, QL, SP
1
1
2
PA
2
2
2
3
PA
Cardiovascular/Heart Disease: Other
Amiodarone
Amlodipine/
Atorvastatin
Corlanor
Digoxin
Flecainide
Isosorbide
Mononitrate
Multaq
Nitrostat
Ranexa
Sotalol
1
1
3
1
1
PA, QL
1
3
3
2
1
ST
Cardiovascular/Heart Disease:
Pulmonary Arterial Hypertension
Adcirca
Adempas
Letairis
Opsumit
Orenitram
Sildenafil Tab 20 mg
Tracleer
3
2
2
2
3
1
2
Bold type = Brand-name drug
[Plain type = Generic drug]
E Excluded
PA, QL, SP
PA, QL, SP
PA, QL, SP
PA, QL, SP
PA, SP
PA, QL
PA, QL, SP
Drug
Tier Central Nervous System:
Attention Deficit Disorder
Drug Name
Adderall XR Cap
AmphetamineDextroamphetamine Tab
AmphetamineDextroamphetamine SR
24Hr Cap
Dexmethylphenidate
ER Cap
Evekeo
Guanfacine ER Tab
Methylphenidate
ER Cap
Methylphenidate ER
Tab
Methylphenidate SA
Osmotic ER Tab
Methylphenidate Tab
Strattera
Vyvanse
Programs
and Limits
3
PA, QL, ST
1
PA, QL
1
PA, QL
1
PA, QL
3
1
PA, QL, ST
QL
1
PA, QL
1
PA, QL
1
PA, QL
1
2
2
PA, QL
QL
PA, QL
Central Nervous System: Depression
Amitriptyline
Bupropion
Bupropion ER
Bupropion SR
Bupropion XL
Doxepin
Duloxetine Cap 20
mg, 30 mg, 60 mg
Escitalopram Tab
Fluoxetine Cap
(not PMDD)
Fluvoxamine Tab
Forfivo XL
Mirtazapine
Nortriptyline
Paroxetine Tab
Pristiq
PA Prior Authorization
ST Step Therapy
1
1
1
1
1
1
1
QL
QL
1
1
1
2
1
1
1
3
QL
QL
QL Quantity Limits
SP Specialty Program
11
Drug Name
Risperidone Tab
Sertraline
Trazodone
Venlafaxine Tab
Venlafaxine ER Cap
Venlafaxine ER Tab
Viibryd
Drug
Tier Programs
and Limits
1
1
1
1
1
1
3
QL
QL, ST
Central Nervous System: Migraine
ButalbitalAcetaminophenCaffeine Cap, Tab
50-325-40 mg
Migranal
Relpax
Rizatriptan Tab, ODT
Sumatriptan Tab
and Spray
Sumavel Dose
Zolmitriptan Tab
1
3
3
1
QL
QL
QL
1
QL
3
1
QL
QL
Central Nervous System:
Multiple Sclerosis
Ampyra
Aubagio
Avonex Kit
Avonex Pen Kit
Avonex Prefill Kit
Betaseron
Copaxone 20 mg/mL
& 40 mg/mL
Extavia
Gilenya
Plegridy
Rebif
Rebif Titrtn
Tecfidera
2
3
2
2
2
2
PA, QL, SP
PA, QL, ST, SP
PA, QL, SP
PA, QL, SP
PA, QL, SP
PA, QL, SP
2
PA, QL, SP
E
3
E
E
E
2
PA, QL, ST, SP
PA, QL, SP
Central Nervous System: Other
Alprazolam Tab
Aripiprazole
Benztropine
Buspirone
1
1
1
1
Bold type = Brand-name drug
[Plain type = Generic drug]
E Excluded
QL
QL
Drug
Tier Drug Name
Carbidopa/Levodopa
Tab (Immediate
Release)
Diazepam Tab
Donepezil Tab
Hydroxyzine HCL
Hydroxyzine Pamoate
Latuda
Invega Sustenna
Invega Trinza
Lithium Carbonate
Lorazepam Tab
Modafinil
Namenda XR
Namzaric
Olanzapine Tab
Prochlorperazine
Quetiapine
Rexulti
Risperidone Tab
Ropinirole
(Immediate
Release)
Saphris
Seroquel XR
Ziprasidone Cap
Programs
and Limits
1
1
1
1
1
3
3
3
1
1
1
2
2
1
1
1
3
1
QL, ST
QL
PA, QL
QL
QL
QL
QL
QL
QL
1
2
3
1
QL
QL
QL
Eszopiclone Tab
Silenor
Temazepam
Triazolam Tab
Zolpidem
Zolpidem ER
1
3
1
1
1
1
QL
QL
QL
QL
QL
QL
Carbamazepine Tab
Clonazepam
Divalproex DR
Divalproex ER
Gabapentin
Lamotrigine
(Immediate
Release)
1
1
1
1
1
Central Nervous System:
Sedatives/Hypnotics
Central Nervous System:
Seizure Disorders
PA Prior Authorization
ST Step Therapy
QL
1
QL Quantity Limits
SP Specialty Program
12
Drug Name
Lamotrigine ER
Levetiracetam
Levetiracetam ER
Lyrica Cap
Onfi
Oxcarbazepine
Phenytoin
Primidone
Topiramate Tab
Vimpat
Zonisamide
Drug
Tier 1
1
1
2
3
1
1
1
1
3
1
Programs
and Limits
QL
PA
Dermatology
Absorica
Acanya Gel
Acyclovir Ointment
5%
Aczone Gel
Atralin
Benzaclin
Benzamycin
Betamethasone
Dipropionate
Cream
Ciclopirox Cream
Clindamycin Gel,
Lotion, Solution
Clindamycin/
Benzoyl Peroxide
Gel 1-5%
Clindamycin/Benzoyl
Peroxide Gel
1.2-5%
Clobetasol Cream,
Ointment, Solution
Clobex
Clotrimazole/
Betamethasone
Cream, Lotion
Cortifoam
Desonide Cream,
Ointment
3
E
PA
1
3
3
E
E
1
1
1
1
1
1
3
1
3
1
Bold type = Brand-name drug
[Plain type = Generic drug]
E Excluded
PA
Drug
Tier Drug Name
Desoximetasone
Cream, Gel,
Ointment
Differin
Duac
Econazole Cream
Elidel
Epiduo & Epiduo
Forte
Finacea
Fluocinonide Cream,
0.1%
Fluocinonide Cream,
Gel, Ointment,
Solution 0.05%
Hydrocortisone
Cream, Ointment
2.5%
Lidocaine Topical
Ointment, Solution
Lidocaine/Prilocaine
Cream
Ketoconazole Cream/
Shampoo
Metrogel
Metronidazole Gel
0.75%
Mirvaso Gel
Mupirocin Ointment
Nystatin Cream,
Ointment, Powder
Nystatin/Triamcinolone
Cream, Ointment
Onexton
Oxsoralen-UL
Permethrin Cream 5%
Proctofoam HC
Retin-A Micro
Soolantra
Sulfacetamide/Sulfur
Emulsion
Taclonex
Tazorac
PA Prior Authorization
ST Step Therapy
Programs
and Limits
1
3
E
1
2
PA
ST
3
3
ST
1
1
1
1
1
1
3
1
2
1
1
1
3
2
1
2
3
2
PA
1
3
3
QL
QL Quantity Limits
SP Specialty Program
13
Drug Name
Tretinoin Cream
Tretinoin Microsphere
Gel
Triamcinolone
Vectical
Veltin
Ziana Gel
Zovirax Cream
Zovirax Ointment
Zyclara
Drug
Tier Programs
and Limits
1
PA
1
PA
1
3
E
E
2
3
3
Diabetes/Endocrine: Insulin
Apidra
Humalog Mix 50/50
Vial and KwikPen
Humalog Mix 75-25
Vial and KwikPen
Humalog U-100 Vial
and KwikPen
Humalog U-200
KwikPen
Humulin 70-30 Vial
and KwikPen
Humulin N Vial and
KwikPen
Humulin R U-500 Vial
and KwikPen
Humulin R Vial
Lantus SoloStar
Lantus Vial
Levemir FlexTouch
Levemir Vial
Novolin 70/30 Vial
Novolin N Vial
Novolin R Vial
Novolog Flexpen
Novolog Mix 70/30
Vial and Flexpen
Novolog Penfill
Novolog Vial
Toujeo SoloStar
Tresiba
E
2
2
2
2
2
2
2
2
2
2
E
E
E
E
E
E
E
E
E
2
E
Bold type = Brand-name drug
[Plain type = Generic drug]
E Excluded
Drug
Tier Drug Name
Programs
and Limits
Diabetes/Endocrine: Non-Insulin
alogliptin
alogliptin/metformin
alogliptin/
pioglitazone
Bydureon
Byetta
Farxiga
Glimepiride
Glipizide
Glipizide ER
Glipizide XL
Glumetza
Glyburide
Glyburide/Metformin
Invokamet
Invokamet XR
Invokana
Janumet
Janumet XR
Januvia
Jardiance
Jentadueto
Jentadueto XR
Kazano
Kombiglyze
Metformin
Metformin ER
Nesina
Onglyza
Oseni
Pioglitazone
Synjardy
Tanzeum
Tradjenta
Trulicity
Victoza
Xigduo XR
E
E
E
2
2
E
1
1
1
1
3
1
1
2
2
2
2
2
2
2
2
2
E
E
1
1
E
E
E
1
2
E
2
2
2
E
QL, ST
QL, ST
PA
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
QL, ST
QL, ST
Endocrine: Growth Hormone
Genotropin
Humatrope
Norditropin
PA Prior Authorization
ST Step Therapy
E
E
2
PA, SP
QL Quantity Limits
SP Specialty Program
14
Drug Name
Drug
Tier Programs
and Limits
Nutropin AQ
Omnitrope
Saizen
Zomacton
2
E
E
E
PA, SP
Endocrine: Other
Calcitriol Cap
Dexamethasone Tab
H.P. Acthar
Hydrocortisone Tab
Lupron Depot
3.75 mg, 11.25 mg
Lupron Depot
7.5 mg, 22.5 mg,
30 mg, 45 mg
Methylprednisolone
Tab
Prednisone
Prednisolone Solution
25 mg/5 ml
Prednisolone Syrup,
Solution 15 mg/5
ml
Sensipar
1
1
2
1
3
2
PA, SP
PA, SP
PA, SP
1
1
1
1
3
Endocrine:
Thyroid Hormone Replacement
Armour Thyroid
Levothyroxine
Liothyronine
Methimazole
Synthroid
Tirosint
PA
3
1
1
1
3
3
Eye Conditions: Allergies
Azelastine Ophthalmic
Solution
Bepreve
Lastacaft
Pataday
Pazeo
1
3
3
2
2
Bold type = Brand-name drug
[Plain type = Generic drug]
E Excluded
ST
ST
Drug
Tier Drug Name
Programs
and Limits
Eye Conditions: Antibiotics
Besivance
Ciprofloxacin
Ophthalmic
Solution
Erythromycin
Ointment
Gentamicin
Moxeza
Neomycin/Polymyxin
B/Dexamethasone
Ointment,
Suspension
Ofloxacin Ophthalmic
Solution
Polymyxin B/Trimethoprim Solution
Tobramycin
Tobramycin/
Dexamethasone
Vigamox
3
1
1
1
2
1
1
1
1
1
2
Eye Conditions: Glaucoma
Alphagan P
Azopt
Betimol
Brimonidine
Combigan
Cosopt PF
Dorzolamide-Timolol
Maleate
Latanoprost
Lumigan
Rescula
Simbrinza
Timolol
Timoptic Ocudose
Travatan Z
Zioptan
PA Prior Authorization
ST Step Therapy
2
2
3
1
2
3
1
1
2
E
2
1
2
2
E
QL
QL
QL
QL Quantity Limits
SP Specialty Program
15
Drug Name
Drug
Tier Programs
and Limits
3
3
QL
1
1
3
PA
Gastrointestinal: Acid Suppression
Dexilant
Duexis
Esomeprazole (Rx
only)
Famotidine Tab 20 mg
and 40 mg (Rx
only)
Lansoprazole (Rx only)
Omeprazole (Rx only)
Pantoprazole
Ranitidine Tab, Cap,
Syrup (Rx only)
Sucralfate Tab
Vimovo
2
E
QL
1
QL
1
1
1
1
QL
QL
QL
1
1
E
Gastrointestinal: Nausea/Vomiting
Meclizine
Metoclopramide
Ondansetron Tab,
ODT
Transderm-Scop
Varubi
Programs
and Limits
Gastrointestinal: Other
Eye Conditions: Other
Durezol Ophthalmic
Emulsion
Lotemax Ophthalmic
Gel
Ketorolac Ophthalmic
Solution
Prednisolone
Ophthalmic
Suspension
Restasis
Drug
Tier Drug Name
1
1
1
QL
3
3
QL
Bold type = Brand-name drug
[Plain type = Generic drug]
E Excluded
Amitiza
Apriso
Asacol HD
Canasa
Creon
Delzicol
Dipentum
Gavilyte Solution
Hyoscyamine
Sublingual Tab
Lactulose
Lialda
Linzess
mesalamine DR
Moviprep
Omeclamox Pak
Pancreaze
Pentasa
Pertzye
Polyethylene
Glycol 3350
Powder
Prepopik
Protosol HC
Pylera
Sulfasalazine
Suprep Bowel Prep
Uceris Foam
Ultresa
Viokace
Zenpep
PA Prior Authorization
ST Step Therapy
2
2
E
2
2
E
3
1
QL, ST
1
1
2
2
E
3
2
E
3
E
QL, ST
1
3
1
2
1
3
3
E
E
2
QL Quantity Limits
SP Specialty Program
16
Drug Name
Drug
Tier Programs
and Limits
HIV/AIDS
Atripla
Complera
Epzicom
Genvoya
Intelence
Isentress
Kaletra Solution
Kaletra Tab
Nevirapine
Norvir
Prezcobix
Prezista
Reyataz
Stribild
Sustiva
Tivicay
Triumeq
Truvada
Viread
Programs
and Limits
Inflammatory Conditions
2
2
2
2
2
2
3
2
1
2
2
2
2
2
2
2
2
2
2
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
Infertility
Bravelle
Cetrotide
Follistim AQ
Gonal-f
Gonal-f RFF
Ovidrel
Drug
Tier Drug Name
E
2
E
2
2
3
SP
PA, SP
PA, SP
SP
Cimzia Kit
Cosentyx
Depen
Enbrel
Humira Kit
Humira Pen Kit
Humira Pen Kit
Crohns
Humira Pen Kit
Psoriasis
Hydroxychloroquine
Inflectra
Methotrexate Tab
Orencia SC
Otezla
Otrexup
Rasuvo
Simponi
Stelara
Taltz
Xeljanz
2
E
2
3
2
2
PA, SP
2
PA, SP
2
PA, SP
1
E
1
3
3
3
2
2
2
3
3
PA, ST, SP
PA, ST, SP
PA, QL
PA, QL
PA, SP
PA, SP
PA, ST, SP
PA, ST, SP
PA, SP
PA, SP
PA, SP
Men’s Health: Erectile Dysfunction
Cialis
Levitra
Staxyn
Stendra
Viagra
2
E
E
E
2
QL
QL
Men’s Health: Prostate
Alfuzosin
Cialis 2.5 mg & 5 mg
Doxazosin
Finasteride 5 mg
Rapaflo
Tamsulosin
Terazosin
Bold type = Brand-name drug
[Plain type = Generic drug]
E Excluded
PA Prior Authorization
ST Step Therapy
1
2
1
1
2
1
1
QL
QL Quantity Limits
SP Specialty Program
17
Drug Name
Drug
Tier Programs
and Limits
Men’s Health: Testosterone Therapy
Androderm
Androgel 1.62%
Androgel 1%
Axiron
Fortesta
Testim
Testosterone
Cypionate IM
Injection
Vogelxo
2
2
E
E
E
E
PA
PA
1
PA
E
Miscellaneous
Adrenaclick
Allopurinol
Antipyrine/Benzocaine
Otic Solution
5.4 - 1.4%
Aranesp
Auryxia
Auvi-Q
Benzonatate
Bunavail
Cerdelga
Chantix
Cheratussin
Chlorhexidine
Colcrys
Cyproheptadine
Desmopressin
Epinephrine
Auto-Injector
(Authorized
Generic for EpiPen
made by Mylan)
Epinephrine
Auto- Injector
(made by Impax)
EpiPen & EpiPen Jr
Epogen
Fosrenol
Granix
E
1
1
E
3
E
1
3
3
3
1
1
2
1
1
PA, QL
PA, SP
QL
2
E
E
E
3
2
Bold type = Brand-name drug
[Plain type = Generic drug]
E Excluded
Drug
Tier Drug Name
Guaifenesin/Codeine
Syrup
Homatropine/
Hydrocodone
Syrup
Hydrocodone/
Chlorpheniramine
Liquid
Hydrocortisone AC
Suppository 25 mg
Hydromet
Lidocaine Viscous
Solution 2%
Makena
Narcan
Neupogen
Phenazopyridine
(Rx only)
Phentermine Tab
Procrit
Promethazine DM
Syrup
Promethazine/Codeine
Syrup
Pulmozyme
Renvela Tab, Pack
Rezira
Suboxone Film
Synagis
Synvisc
Synvisc One
Uloric
Ursodiol
Velphoro
Zarxio
Zostavax Injection
Zubsolv
Zutripro
Programs
and Limits
1
1
1
1
1
1
2
2
2
PA, SP
PA, SP
1
1
2
PA
PA, SP
1
1
2
2
3
2
2
2
2
2
1
3
2
3
2
3
PA, SP, QL
PA, QL
PA, SP
PA, SP
PA, SP
ST
PA, SP
PA, QL
PA, SP
PA Prior Authorization
ST Step Therapy
QL Quantity Limits
SP Specialty Program
18
Drug Name
Drug
Tier Programs
and Limits
Musculoskeletal: Osteoporosis
Alendronate Tab 35
mg & 70 mg
Binosto
Evista
Forteo
Ibandronate Tab
Raloxifene
1
QL
3
3
2
1
1
QL
PA, SP
QL
Musculoskeletal: Other
Baclofen Tab
Carisoprodol 350 mg
Cyclobenzaprine Tab
5, 10 mg
Metaxalone
Methocarbamol
Tizanidine Cap
Tizanidine Tab
1
1
1
1
1
1
1
Musculoskeletal: Pain Relief
Abstral
Acetaminophen
w/ Codeine
Cambia
Celebrex
Celecoxib
Diclofenac Tab
Embeda
Endocet Tab
Etodolac
Fentanyl Patch
25 mcg/hr,
50 mcg/hr,
75 mcg/hr,
100 mcg/hr
Fentanyl Patch
37.5 mcg/hr,
62.5 mcg/hr,
87.5 mcg/hr
Fentora
Flector patch
Gralise
E
1
E
3
1
1
2
1
1
QL
QL
QL
QL
QL
1
QL
1
QL
E
3
3
QL
QL, ST
Bold type = Brand-name drug
[Plain type = Generic drug]
E Excluded
Drug Name
Hydrocodone/APAP
5, 7.5, 10/325 mg
Hydromorphone Tab
Hysingla ER
Ibuprofen Tab 400,
600, 800 mg (Rx
only)
Indomethacin Cap
Kadian
Ketorolac Tab
Lazanda
Lidocaine Patch 5%
Meloxicam
Methadone Tab
Morphine Sulfate Tab
Nabumetone
Naproxen (Rx only)
Nucynta ER
Opana ER
Oxycodone Tab
5, 10, 15, 30
mg (Immediate
Release)
Oxycodone
w/ Acetaminophen
Oxycontin
Subsys
Tramadol Tab 50 mg
Tramadol
w/ Acetaminophen
Vicodin
Vicodin ES
Voltaren Gel
Xtampza ER
Zohydro ER
Zorvolex
PA Prior Authorization
ST Step Therapy
Drug
Tier Programs
and Limits
1
QL
1
E
QL
1
1
E
1
E
1
1
1
1
1
1
E
E
QL
QL
1
QL
1
QL
2
E
1
QL
1
1
1
3
E
E
E
QL
QL
QL
QL Quantity Limits
SP Specialty Program
19
Drug Name
Drug
Tier Programs
and Limits
Overactive Bladder
Myrbetriq
Oxybutynin
Oxybutynin ER
Tolterodine
Toviaz
Vesicare
2
1
1
1
3
2
2
2
3
QL
QL
QL
1
QL
E
2
2
E
2
QL
QL
QL
1
QL
2
E
2
2
2
2
QL
1
QL
QL
QL
QL
QL
E
1
QL
1
3
QL
2
QL
E
2
E
3
2
2
2
Bold type = Brand-name drug
[Plain type = Generic drug]
E Excluded
Drug
Tier Programs
and Limits
Stiolto
Symbicort
Tudorza
Ventolin HFA
Xopenex HFA
2
2
E
2
E
QL
QL
QL
Respiratory: Nasal Allergies
Respiratory: Asthma/COPD
Advair Diskus
Advair HFA
Aerospan
Albuterol
Nebulizer Solution
Alvesco
Anoro Ellipta
Arnuity Ellipta
Asmanex
Breo Ellipta
Budesonide Inhalation
Suspension
Combivent Respimat
Dulera
Flovent Diskus
Flovent HFA
Foradil
Incruse Ellipta
Ipratropium/Albuterol
Nebulizer Solution
Levalbuterol Inhaler
Levalbuterol
Nebulizer Solution
Montelukast
Perforomist
Proair HFA,
RespiClick
Proventil HFA
Pulmicort Flexhaler
Qvar
Seebri
Serevent Diskus
Spiriva Handihaler
Spiriva Respimat
Drug Name
QL
Astepro
Azelastine Spray
Dymista Spray
Fluticasone Spray
Ipratropium Spray
Mometasone
Nasonex
Omnaris
QNasl
Triamcinolone Spray
Zetonna
3
1
2
1
1
1
2
3
3
1
3
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
Respiratory: Oral Allergies
Cetirizine
Promethazine Tab
Desloratadine
Levocetirizine
1
1
1
1
Transplant
Azathioprine Tab
Cellcept Tab/
Suspension
Cyclosporine Cap
Mycophenolate Mofetil
250 mg Cap/
500 mg Tab
Mycophenolate
Sodium 180 mg,
360 mg Tab
Prograf Cap
Rapamune
Tacrolimus Cap
1
3
SP
1
SP
1
SP
1
SP
3
3
1
SP
SP
SP
QL
QL
QL
QL
PA Prior Authorization
ST Step Therapy
QL Quantity Limits
SP Specialty Program
20
Drug Name
Drug
Tier Programs
and Limits
Vitamins/Electrolytes
Folic Acid 1 mg
(Rx only)
Klor-Con 8 and 10
MEQ
Klor-Con M10 and
M20
Multi-Vit/Fl Chew
Potassium Chloride
ER Tab, Cap
Potassium Chloride
Micro ER Tab
Potassium Citrate
540 mg, 1080 mg
Tab
Vitamin D 50,000 units
(Rx only)
1
1
1
1
1
1
1
1
Women’s Health: Birth Control
Apri
Aviane
Azurette
Cryselle-28
Falmina
Generess Fe
Chewable
Gianvi
Gildess
Jolivette
Junel
Kariva
Levora 28
1
1
1
1
1
3
1
1
1
1
1
1
Bold type = Brand-name drug
[Plain type = Generic drug]
E Excluded
Drug
Tier Drug Name
Lomedia Fe
Loryna
Low-Ogestrel
Lutera
Medroxyprogesterone
Acetate Injection
Microgestin
Microgestin Fe
Minastrin 24 Fe
Chewable
Mono-Linyah
Mononessa
Necon
Nora-Be
Norgest/Ethi Estradio
Nortrel
Nuvaring
Ocella
Orsythia
Ortho Tri-Cyclen Lo
Previfem
Reclipsen
Sprintec 28
Tri-Linyah
Tri-Previfem
Trinessa
Tri-Sprintec
Vestura
Viorele
Xulane
Zarah
PA Prior Authorization
ST Step Therapy
Programs
and Limits
1
1
1
1
1
QL
1
1
3
1
1
1
1
1
1
2
1
1
3
1
1
1
1
1
1
1
1
1
1
1
QL Quantity Limits
SP Specialty Program
21
Drug Name
Drug
Tier Programs
and Limits
Women’s Health: Hormone Replacement
Climara Pro
Divigel
Duavee
Elestrin Gel
Estrace Vaginal
Cream
Estradiol Tab
Estradiol/
Norethindrone Tab
Medroxyprogesterone
Acetate Tab
Minivelle
Osphena
Premarin Tab
Premarin Vaginal
Cream
Premphase
Prempro
Progesterone Cap
Vagifem
2
3
2
3
3
1
1
1
3
3
2
2
2
2
1
3
Women’s Health: Vaginal Anti-Infectives
Gynazole-1 Vaginal
Cream
Metronidazole
Vaginal Gel
Terconazole
Vaginal Cream
3
1
1
Bold type = Brand-name drug
[Plain type = Generic drug]
E Excluded
PA Prior Authorization
ST Step Therapy
QL Quantity Limits
SP Specialty Program
22
Index of Drugs
A
Absorica . . . . . . . . . . 13
Abstral . . . . . . . . . . . 19
Acanya Gel . . . . . . . . .13
Acetaminophen w/ Codeine 19
Acyclovir Cap, Tab,
Suspension . . . . . . . . 9
Acyclovir Ointment 5% . . .13
Aczone Gel . . . . . . . . .13
Adcirca . . . . . . . . . . .11
Adderall XR Cap . . . . . .11
Adempas . . . . . . . . . .11
Adrenaclick . . . . . . . . .18
Advair Diskus . . . . . . . .20
Advair HFA . . . . . . . . . 20
Aerospan . . . . . . . . . .20
Akynzeo . . . . . . . . . . . 9
Albuterol Nebulizer Solution 20
Alendronate Tab . . . . . . .19
Alfuzosin . . . . . . . . . . .17
Allopurinol . . . . . . . . . .18
alogliptin . . . . . . . . . . 14
alogliptin/metformin . . . .14
alogliptin/pioglitazone . . . 14
Alphagan P . . . . . . . . .15
Alprazolam Tab . . . . . . . 12
Alvesco . . . . . . . . . . .20
Amiodarone . . . . . . . . .11
Amitiza . . . . . . . . . . . 16
Amitriptyline . . . . . . . . .11
Amlodipine . . . . . . . . . 10
Amlodipine/Atorvastatin . . . 11
Amlodipine/Benazepril . . . 10
Amlodipine/Valsartan . . . . 10
Amlodipine/Valsartan/HCTZ . 10
Amoxicillin . . . . . . . . . . 9
Amoxicillin/Clavulanate . . . 9
Bold type = Brand-name drug
[Plain type = Generic drug]
Amphetamine-Dextroamphetamine SR
24Hr Cap . . . . . . . . 11
Amphetamine-Dextroamphetamine Tab . . . . 11
Ampyra . . . . . . . . . . .12
Anastrozole Tab . . . . . . . 9
Androderm . . . . . . . . .18
Androgel 1% . . . . . . . .18
Androgel 1.62% . . . . . . 18
Anoro Ellipta . . . . . . . . 20
Antipyrine/Benzocaine Otic
Solution 5.4 - 1.4% . . . 18
Apidra . . . . . . . . . . . .14
Apri . . . . . . . . . . . . . 21
Apriso . . . . . . . . . . . .16
Aranesp . . . . . . . . . . .18
Aripiprazole . . . . . . . . .12
Armour Thyroid . . . . . . .15
Arnuity Ellipta . . . . . . . .20
Asacol HD . . . . . . . . . .16
Asmanex . . . . . . . . . . 20
Astepro . . . . . . . . . . .20
Atenolol . . . . . . . . . . .10
Atenolol/Chlorthalidone . . .10
Atorvastatin . . . . . . . . .10
Atralin . . . . . . . . . . . .13
Atripla . . . . . . . . . . . .17
Aubagio . . . . . . . . . . .12
Auryxia . . . . . . . . . . . 18
Auvi-Q . . . . . . . . . . . .18
Aviane . . . . . . . . . . . .21
Avonex Kit . . . . . . . . . 12
Avonex Pen Kit . . . . . . .12
Avonex Prefill Kit . . . . . .12
Axiron . . . . . . . . . . . .18
Azasite . . . . . . . . . . . . 9
Azathioprine Tab . . . . . . .20
Azelastine Ophthalmic
Solution . . . . . . . . . 15
Azelastine Spray . . . . . . .20
Azithromycin . . . . . . . . . 9
Azopt . . . . . . . . . . . . 15
Azor . . . . . . . . . . . . .10
Azurette . . . . . . . . . . .21
B
Baclofen Tab . . . . . . . . .19
Benazepril . . . . . . . . . .10
Benazepril/HCTZ . . . . . .10
Benicar . . . . . . . . . . .10
Benicar HCT . . . . . . . . 10
Benzaclin . . . . . . . . . .13
Benzamycin . . . . . . . . .13
Benzonatate . . . . . . . . .18
Benztropine . . . . . . . . .12
Bepreve . . . . . . . . . . .15
Besivance . . . . . . . . . .15
Betamethasone D
ipropionate Cream . . . . 13
Betaseron . . . . . . . . . .12
Bethkis . . . . . . . . . . . . 9
Betimol . . . . . . . . . . .15
Binosto . . . . . . . . . . .19
Bisoprolol . . . . . . . . . .10
Bisoprolol/HCTZ . . . . . . .10
Bravelle . . . . . . . . . . .17
Breo Ellipta . . . . . . . . .20
Brilinta . . . . . . . . . . . 10
Brimonidine . . . . . . . . .15
Budesonide Inhalation
Suspension . . . . . . . 20
Bumetanide . . . . . . . . .10
Bunavail . . . . . . . . . . .18
Bupropion . . . . . . . . . .11
Bupropion ER . . . . . . . .11
23
Index of Drugs
Bupropion SR . . . . . . . .11
Bupropion XL . . . . . . . . 11
Buspirone . . . . . . . . . .12
Butalbital-AcetaminophenCaffeine Cap, Tab . . . .12
Bydureon . . . . . . . . . .14
Byetta . . . . . . . . . . . .14
Bystolic . . . . . . . . . . .10
C
Calcitriol Cap . . . . . . . . 15
Cambia . . . . . . . . . . .19
Canasa . . . . . . . . . . . 16
Capecitabine . . . . . . . . . 9
Carbamazepine Tab . . . . .12
Carbidopa/Levodopa Tab
(Immediate Release) . . . 12
Carisoprodol . . . . . . . . .19
Cartia XT . . . . . . . . . . .10
Carvedilol . . . . . . . . . .10
Cefadroxil Cap . . . . . . . . 9
Cefdinir . . . . . . . . . . . . 9
Cefuroxime Tab . . . . . . . 9
Celebrex . . . . . . . . . . 19
Celecoxib . . . . . . . . . .19
Cellcept Tab/Suspension . 20
Cephalexin . . . . . . . . . . 9
Cerdelga . . . . . . . . . . 18
Cetirizine . . . . . . . . . . .20
Cetrotide . . . . . . . . . . 17
Chantix . . . . . . . . . . .18
Cheratussin . . . . . . . . .18
Chlorhexidine . . . . . . . .18
Chlorthalidone . . . . . . . .10
Cholestyramine . . . . . . .10
Cialis . . . . . . . . . . . . 17
Ciclopirox Cream . . . . . . 13
Cimzia Kit . . . . . . . . . .17
Bold type = Brand-name drug
[Plain type = Generic drug]
Ciprodex Otic Suspension . 9
Ciprofloxacin Ophthalmic
Solution . . . . . . . . . 15
Ciprofloxacin Tab . . . . . . . 9
Clarithromycin . . . . . . . . 9
Climara Pro . . . . . . . . .22
Clindamycin/Benzoyl
Peroxide Gel 1.2-5% . . 13
Clindamycin/
Benzoyl Peroxide
Gel 1-5% . . . . . . . . 13
Clindamycin Cap . . . . . . . 9
Clindamycin Gel, Lotion,
Solution . . . . . . . . . 13
Clobetasol Cream,
Ointment, Solution . . . . 13
Clobex . . . . . . . . . . . .13
Clonazepam . . . . . . . . .12
Clonidine Patch . . . . . . .10
Clonidine Tab . . . . . . . . 10
Clopidogrel . . . . . . . . . 10
Clotrimazole/Betamethasone
Cream, Lotion . . . . . .13
Colcrys . . . . . . . . . . .18
Combigan . . . . . . . . . .15
Combivent Respimat . . . .20
Complera . . . . . . . . . .17
Copaxone . . . . . . . . . .12
Corlanor . . . . . . . . . . .11
Cortifoam . . . . . . . . . .13
Cosentyx . . . . . . . . . . 17
Cosopt PF . . . . . . . . . .15
Creon . . . . . . . . . . . .16
Crestor . . . . . . . . . . . 10
Cryselle-28 . . . . . . . . . 21
Cyclobenzaprine Tab . . . . 19
Cyclosporine Cap . . . . . .20
Cyproheptadine . . . . . . .18
D
Daklinza . . . . . . . . . . . 9
Delzicol . . . . . . . . . . .16
Depen . . . . . . . . . . . .17
Desloratadine . . . . . . . .20
Desmopressin . . . . . . . .18
Desonide Cream, Ointment . 13
Desoximetasone Cream,
Gel, Ointment . . . . . . 13
Dexamethasone Tab . . . . 15
Dexilant . . . . . . . . . . .16
Dexmethylphenidate ER Cap11
Diazepam Tab . . . . . . . .12
Diclofenac Tab . . . . . . . .19
Differin . . . . . . . . . . . 13
Digoxin . . . . . . . . . . . 11
Diltiazem Tab . . . . . . . . 10
Dipentum . . . . . . . . . .16
Divalproex DR . . . . . . . .12
Divalproex ER . . . . . . . .12
Divigel . . . . . . . . . . . .22
Donepezil Tab . . . . . . . .12
Doryx MPC . . . . . . . . . 9
Dorzolamide-Timolol
Maleate . . . . . . . . . 15
Doxazosin . . . . . . . .10, 17
Doxepin . . . . . . . . . . .11
Doxycycline Hyclate Cap . . 9
Doxycycline Hyclate Tab
(Immediate Release) . . . 9
Doxycycline Monohydrate
Cap . . . . . . . . . . . . 9
Doxycycline Monohydrate Oral
Suspension, Tab . . . . . 9
Duac . . . . . . . . . . . . .13
Duavee . . . . . . . . . . . 22
Duexis . . . . . . . . . . . .16
Dulera . . . . . . . . . . . .20
24
Index of Drugs
Duloxetine Cap . . . . . . . 11
Durezol Ophthalmic
Emulsion . . . . . . . . 16
Dymista Spray . . . . . . . 20
E
Econazole Cream . . . . . .13
Edarbi . . . . . . . . . . . .10
Edarbyclor . . . . . . . . . 10
Effient . . . . . . . . . . . .10
Elestrin Gel . . . . . . . . .22
Elidel . . . . . . . . . . . . 13
Eliquis . . . . . . . . . . . .10
Embeda . . . . . . . . . . .19
Enalapril . . . . . . . . . . .10
Enalapril/HCTZ . . . . . . . 10
Enbrel . . . . . . . . . . . .17
Endocet Tab . . . . . . . . .19
Enoxaparin . . . . . . . . . 10
Entecavir . . . . . . . . . . . 9
Epclusa . . . . . . . . . . . 9
Epiduo & Epiduo Forte . . . 13
Epinephrine Auto-Injector . 18
EpiPen & EpiPen Jr . . . . .18
Epogen . . . . . . . . . . .18
Epzicom . . . . . . . . . . .17
Erythromycin . . . . . . . . . 9
Erythromycin Ointment . . . 15
Escitalopram Tab . . . . . . 11
Esomeprazole (Rx only) . . .16
Estrace Vaginal Cream . . . 22
Estradiol/Norethindrone Tab . 22
Estradiol Tab . . . . . . . . .22
Eszopiclone Tab . . . . . . .12
Etodolac . . . . . . . . . . .19
Evekeo . . . . . . . . . . . 11
Evista . . . . . . . . . . . .19
Extavia . . . . . . . . . . . 12
Bold type = Brand-name drug
[Plain type = Generic drug]
F
Falmina . . . . . . . . . . . 21
Famciclovir Tab . . . . . . . 9
Famotidine Tab (Rx only) . . 16
Farxiga . . . . . . . . . . . 14
Felodipine . . . . . . . . . .10
Fenofibrate . . . . . . . . . 10
Fentanyl Patch . . . . . . . .19
Fentora . . . . . . . . . . .19
Finacea . . . . . . . . . . .13
Finasteride . . . . . . . . . .17
Flecainide . . . . . . . . . .11
Flector patch . . . . . . . .19
Flovent Diskus . . . . . . .20
Flovent HFA . . . . . . . . .20
Fluconazole . . . . . . . . . 9
Fluocinonide Cream, 0.1% . 13
Fluocinonide Cream,
Gel, Ointment,
Solution 0.05% . . . . . 13
Fluoxetine Cap (not PMDD) . 11
Fluticasone Spray . . . . . .20
Fluvoxamine Tab . . . . . . 11
Folic Acid (Rx only) . . . . .21
Follistim AQ . . . . . . . . .17
Foradil . . . . . . . . . . . .20
Forfivo XL . . . . . . . . . .11
Forteo . . . . . . . . . . . .19
Fortesta . . . . . . . . . . .18
Fosinopril . . . . . . . . . . 10
Fosrenol . . . . . . . . . . .18
Furosemide . . . . . . . . . 10
G
Gabapentin . . . . . . . .
Gavilyte Solution . . . . .
Gemfibrozil . . . . . . . .
Generess Fe Chewable .
.
.
.
.
12
16
11
21
Genotropin . . . . . . . . .14
Gentamicin . . . . . . . . . 15
Genvoya . . . . . . . . . . .17
Gianvi . . . . . . . . . . . .21
Gildess . . . . . . . . . . . .21
Gilenya . . . . . . . . . . . 12
Glimepiride . . . . . . . . . 14
Glipizide . . . . . . . . . . .14
Glipizide ER . . . . . . . . .14
Glipizide XL . . . . . . . . .14
Glumetza . . . . . . . . . .14
Glyburide . . . . . . . . . . 14
Glyburide/Metformin . . . . 14
Gonal-f . . . . . . . . . . . 17
Gonal-f RFF . . . . . . . . .17
Gralise . . . . . . . . . . . 19
Granix . . . . . . . . . . . .18
Guaifenesin/Codeine Syrup . 18
Guanfacine ER Tab . . . . . 11
Guanfacine Tab
(Immediate Release) . . . 10
Gynazole-1 Vaginal Cream 22
H
Harvoni . . . . . . . . . . . 9
Homatropine/Hydrocodone
Syrup . . . . . . . . . . 18
H.P. Acthar . . . . . . . . . 15
Humalog Mix 50/50 Vial and
KwikPen . . . . . . . . . 14
Humalog Mix 75-25 Vial and
KwikPen . . . . . . . . . 14
Humalog U-100 Vial and
KwikPen . . . . . . . . . 14
Humalog U-200 KwikPen . 14
Humatrope . . . . . . . . .14
Humira Kit . . . . . . . . . 17
Humira Pen Kit . . . . . . .17
25
Index of Drugs
Humira Pen Kit Crohns . . 17
Humira Pen Kit Psoriasis . 17
Humulin 70-30 Vial and
KwikPen . . . . . . . . . 14
Humulin N Vial and
KwikPen . . . . . . . . . 14
Humulin R U-500 Vial and
KwikPen . . . . . . . . . 14
Humulin R Vial . . . . . . . 14
Hydralazine . . . . . . . . . 10
Hydrochlorothiazide . . . . .10
Hydrocodone/APAP . . . .19
Hydrocodone/
Chlorpheniramine Liquid . 18
Hydrocortisone AC
Suppository . . . . . . .18
Hydrocortisone Cream,
Ointment 2.5% . . . . . 13
Hydrocortisone Tab . . . . .15
Hydromet . . . . . . . . . . 18
Hydromorphone Tab . . . . .19
Hydroxychloroquine . . . . .17
Hydroxyzine HCL . . . . . .12
Hydroxyzine Pamoate . . . .12
Hyoscyamine Sublingual Tab 16
Hysingla ER . . . . . . . . .19
I
Ibandronate Tab . . . . . . .19
Ibuprofen Tab (Rx only) . . . 19
Incruse Ellipta . . . . . . . 20
Indomethacin Cap . . . . . .19
Inflectra . . . . . . . . . . .17
Intelence . . . . . . . . . .17
Invega Sustenna . . . . . .12
Invega Trinza . . . . . . . .12
Invokamet . . . . . . . . . .14
Invokamet XR . . . . . . . .14
Bold type = Brand-name drug
[Plain type = Generic drug]
Invokana . . . . . . . . . . 14
Ipratropium/Albuterol
Nebulizer Solution . . . .20
Ipratropium Spray . . . . . .20
Irbesartan . . . . . . . . . .10
Irbesartan/HCTZ . . . . . . .10
Isentress . . . . . . . . . . 17
Isosorbide Mononitrate . . .11
J
Janumet . . . . . . . . . . .14
Janumet XR . . . . . . . . .14
Januvia . . . . . . . . . . .14
Jardiance . . . . . . . . . .14
Jentadueto . . . . . . . . .14
Jentadueto XR . . . . . . .14
Jolivette . . . . . . . . . . .21
Jublia Solution . . . . . . . 9
Junel . . . . . . . . . . . . .21
K
Kadian . . . . . . . . . . . .19
Kaletra Solution . . . . . . 17
Kaletra Tab . . . . . . . . .17
Kariva . . . . . . . . . . . .21
Kazano . . . . . . . . . . . 14
Kerydin Solution . . . . . . 9
Ketoconazole Cream/
Shampoo . . . . . . . . 13
Ketorolac Ophthalmic
Solution . . . . . . . . . 16
Ketorolac Tab . . . . . . . .19
Kitabis . . . . . . . . . . . . 9
Klor-Con 8 and 10 MEQ . . . 21
Klor-Con M10 and M20 . . .21
Kombiglyze . . . . . . . . .14
L
Labetalol . . . . . . . . . . .10
Lactulose . . . . . . . . . . 16
Lamotrigine ER . . . . . . . 13
Lamotrigine
(Immediate Release) . . . 12
Lansoprazole (Rx only) . . . 16
Lantus SoloStar . . . . . . 14
Lantus Vial . . . . . . . . . 14
Lastacaft . . . . . . . . . .15
Latanoprost . . . . . . . . .15
Latuda . . . . . . . . . . . .12
Lazanda . . . . . . . . . . .19
Letairis . . . . . . . . . . . 11
Letrozole . . . . . . . . . . . 9
Levalbuterol Inhaler . . . . 20
Levalbuterol
Nebulizer Solution . . . .20
Levemir FlexTouch . . . . .14
Levemir Vial . . . . . . . . .14
Levetiracetam . . . . . . . .13
Levetiracetam ER . . . . . .13
Levitra . . . . . . . . . . . .17
Levocetirizine . . . . . . . .20
Levofloxacin Tab . . . . . . . 9
Levora 28 . . . . . . . . . . 21
Levothyroxine . . . . . . . .15
Lialda . . . . . . . . . . . .16
Lidocaine Patch 5% . . . . .19
Lidocaine/Prilocaine Cream . 13
Lidocaine Topical Ointment,
Solution . . . . . . . . . 13
Lidocaine Viscous
Solution 2% . . . . . . .18
Linzess . . . . . . . . . . . 16
Liothyronine . . . . . . . . .15
Lipitor . . . . . . . . . . . .11
Lisinopril . . . . . . . . . . .10
26
Index of Drugs
Lisinopril/HCTZ . . . . . . .10
Lithium Carbonate . . . . . .12
Lomedia Fe . . . . . . . . . 21
Lorazepam Tab . . . . . . . 12
Loryna . . . . . . . . . . . .21
Losartan . . . . . . . . . . .10
Losartan/HCTZ . . . . . . . 10
Lotemax Ophthalmic Gel . 16
Lovastatin . . . . . . . . . .11
Lovaza . . . . . . . . . . . 11
Low-Ogestrel . . . . . . . . 21
Lumigan . . . . . . . . . . .15
Lupron Depot . . . . . . . .15
Lutera . . . . . . . . . . . .21
Lyrica Cap . . . . . . . . . 13
M
Makena . . . . . . . . . . .18
Meclizine . . . . . . . . . . 16
Medroxyprogesterone
Acetate Injection . . . . . 21
Medroxyprogesterone
Acetate Tab . . . . . . . 22
Meloxicam . . . . . . . . . .19
mesalamine DR . . . . . . .16
Metaxalone . . . . . . . . . 19
Metformin . . . . . . . . . .14
Metformin ER . . . . . . . .14
Methadone Tab . . . . . . . 19
Methimazole . . . . . . . . .15
Methocarbamol . . . . . . .19
Methotrexate Tab . . . . . .17
Methylphenidate ER Cap . . 11
Methylphenidate ER Tab . . 11
Methylphenidate SA
Osmotic ER Tab . . . . .11
Methylphenidate Tab . . . . 11
Methylprednisolone Tab . . . 15
Bold type = Brand-name drug
[Plain type = Generic drug]
Metoclopramide . . . . . . .16
Metoprolol Succinate . . . .10
Metoprolol Tartrate . . . . . 10
Metrogel . . . . . . . . . . 13
Metronidazole Gel 0.75% . .13
Metronidazole Tab . . . . . . 9
Metronidazole
Vaginal Gel . . . . . . . . 22
Microgestin . . . . . . . . . 21
Microgestin Fe . . . . . . . .21
Migranal . . . . . . . . . . .12
Minastrin 24 Fe Chewable . 21
Minivelle . . . . . . . . . . 22
Minocycline Cap . . . . . . . 9
Mirtazapine . . . . . . . . . 11
Mirvaso Gel . . . . . . . . .13
Modafinil . . . . . . . . . . .12
Mometasone . . . . . . . . 20
Mono-Linyah . . . . . . . . 21
Mononessa . . . . . . . . . 21
Montelukast . . . . . . . . .20
Morphine Sulfate Tab . . . .19
Moviprep . . . . . . . . . .16
Moxeza . . . . . . . . . . .15
Moxifloxacin . . . . . . . . . 9
Multaq . . . . . . . . . . . .11
Multi-Vit/Fl Chew . . . . . . 21
Mupirocin Ointment . . . . .13
Mycophenolate Mofetil 250 mg
Cap/
500 mg Tab . . . . . . . 20
Mycophenolate Sodium 180
mg, 360 mg Tab . . . . .20
Myrbetriq . . . . . . . . . .20
N
Nabumetone . . . . . . . . .19
Nadolol . . . . . . . . . . . 10
Namenda XR . . . . . . . .12
Namzaric . . . . . . . . . .12
Naproxen (Rx only) . . . . . 19
Narcan . . . . . . . . . . . 18
Nasonex . . . . . . . . . . .20
Necon . . . . . . . . . . . .21
Neomycin/Polymyxin B/
Dexamethasone
Ointment, Suspension . . 15
Neomycin/Polymyxin/HC Otic
Suspension, Solution . . . 9
Nesina . . . . . . . . . . . .14
Neupogen . . . . . . . . . .18
Nevirapine . . . . . . . . . .17
Niacin ER Tab . . . . . . . .11
Nifedipine ER . . . . . . . . 10
Nitrofurantoin
Macrocrystalline . . . . . 9
Nitrofurantoin Monohydrate
Macrocrystalline . . . . . 9
Nitrostat . . . . . . . . . . .11
Nora-Be . . . . . . . . . . .21
Norditropin . . . . . . . . .14
Norgest/Ethi Estradio . . . .21
Nortrel . . . . . . . . . . . .21
Nortriptyline . . . . . . . . .11
Norvir . . . . . . . . . . . .17
Novolin 70/30 Vial . . . . . 14
Novolin N Vial . . . . . . . .14
Novolin R Vial . . . . . . . .14
Novolog Flexpen . . . . . .14
Novolog Mix 70/30 Vial
and Flexpen . . . . . . . 14
Novolog Penfill . . . . . . .14
Novolog Vial . . . . . . . . 14
27
Index of Drugs
Nucynta ER . . . . . . . . .19
Nutropin AQ . . . . . . . . 15
Nuvaring . . . . . . . . . . 21
Nystatin Cream, Ointment,
Powder . . . . . . . . . 13
Nystatin Suspension . . . . . 9
Nystatin/Triamcinolone
Cream, Ointment . . . . 13
O
Ocella . . . . . . . . . . . .21
Ofloxacin Ophthalmic
Solution . . . . . . . . . 15
Ofloxacin Otic Solution . . . . 9
Olanzapine Tab . . . . . . . 12
Omeclamox Pak . . . . . .16
Omega-3 Acid Cap . . . . . 11
Omeprazole (Rx only) . . . .16
Omnaris . . . . . . . . . . .20
Omnitrope . . . . . . . . . 15
Ondansetron Tab, ODT . . . 16
Onexton . . . . . . . . . . .13
Onfi . . . . . . . . . . . . .13
Onglyza . . . . . . . . . . .14
Opana ER . . . . . . . . . .19
Opsumit . . . . . . . . . . .11
Oracea . . . . . . . . . . . . 9
Orencia SC . . . . . . . . .17
Orenitram . . . . . . . . . .11
Orsythia . . . . . . . . . . .21
Ortho Tri-Cyclen Lo . . . . 21
Oseni . . . . . . . . . . . . 14
Osphena . . . . . . . . . . 22
Otezla . . . . . . . . . . . .17
Otrexup . . . . . . . . . . .17
Ovidrel . . . . . . . . . . . 17
Oxcarbazepine . . . . . . . 13
Oxsoralen-UL . . . . . . . .13
Bold type = Brand-name drug
[Plain type = Generic drug]
Oxybutynin . . . . . . . . .20
Oxybutynin ER . . . . . . . .20
Oxycodone Tab
(Immediate Release) . . . 19
Oxycodone
w/ Acetaminophen . . . 19
Oxycontin . . . . . . . . . .19
P
Pancreaze . . . . . . . . . 16
Pantoprazole . . . . . . . . 16
Paroxetine Tab . . . . . . . .11
Pataday . . . . . . . . . . .15
Pazeo . . . . . . . . . . . .15
Penicillin VK . . . . . . . . . 9
Pentasa . . . . . . . . . . .16
Perforomist . . . . . . . . .20
Permethrin Cream 5% . . . .13
Pertzye . . . . . . . . . . . 16
Phenazopyridine (Rx only) . . 18
Phentermine Tab . . . . . . 18
Phenytoin . . . . . . . . . .13
Pioglitazone . . . . . . . . .14
Plegridy . . . . . . . . . . .12
Polyethylene
Glycol 3350 Powder . . . 16
Polymyxin B/Trim-ethoprim
Solution . . . . . . . . . 15
Potassium Chloride ER
Tab, Cap . . . . . . . . .21
Potassium Chloride Micro
ER Tab . . . . . . . . . .21
Potassium Citrate Tab . . . .21
Pradaxa . . . . . . . . . . .10
Praluent . . . . . . . . . . .11
Pravastatin . . . . . . . . . .11
Prednisolone Ophthalmic
Suspension . . . . . . . 16
Prednisolone Solution . . . .15
Prednisolone Syrup,
Solution . . . . . . . . . 15
Prednisone . . . . . . . . . 15
Premarin Tab . . . . . . . .22
Premarin Vaginal Cream . . 22
Premphase . . . . . . . . .22
Prempro . . . . . . . . . . .22
Prepopik . . . . . . . . . . 16
Previfem . . . . . . . . . . .21
Prezcobix . . . . . . . . . .17
Prezista . . . . . . . . . . .17
Primidone . . . . . . . . . .13
Pristiq . . . . . . . . . . . .11
Proair HFA, RespiClick . . . 20
Prochlorperazine . . . . . . 12
Procrit . . . . . . . . . . . .18
Proctofoam HC . . . . . . .13
Progesterone Cap . . . . . .22
Prograf Cap . . . . . . . . .20
Promethazine/Codeine
Syrup . . . . . . . . . . 18
Promethazine DM Syrup . . 18
Promethazine Tab . . . . . .20
Propranolol . . . . . . . . . 10
Propranolol ER . . . . . . . 10
Protosol HC . . . . . . . . .16
Proventil HFA . . . . . . . .20
Pulmicort Flexhaler . . . . 20
Pulmozyme . . . . . . . . .18
Pylera . . . . . . . . . . . .16
Q
QNasl . . . . . . . . . . . .20
Quetiapine . . . . . . . . . .12
Quinapril . . . . . . . . . . .10
Qvar . . . . . . . . . . . . .20
28
Index of Drugs
R
Raloxifene . . . . . . . . . .19
Ramipril . . . . . . . . . . .10
Ranexa . . . . . . . . . . . 11
Ranitidine Tab, Cap,
Syrup (Rx only) . . . . . . 16
Rapaflo . . . . . . . . . . .17
Rapamune . . . . . . . . . 20
Rasuvo . . . . . . . . . . . 17
Rebif . . . . . . . . . . . . .12
Rebif Titrtn . . . . . . . . .12
Reclipsen . . . . . . . . . . 21
Relpax . . . . . . . . . . . .12
Renvela Tab, Pack . . . . .18
Rescula . . . . . . . . . . .15
Restasis . . . . . . . . . . .16
Retin-A Micro . . . . . . . .13
Revlimid . . . . . . . . . . . 9
Rexulti . . . . . . . . . . . .12
Reyataz . . . . . . . . . . .17
Rezira . . . . . . . . . . . .18
Risperidone Tab . . . . . . .12
Risperidone Tab . . . . . . .12
Rizatriptan Tab, ODT . . . . 12
Ropinirole
(Immediate Release) . . . 12
Rosuvastatin . . . . . . . . .11
S
Saizen . . . . . . . . . . . .15
Saphris . . . . . . . . . . . 12
Savaysa . . . . . . . . . . .10
Seebri . . . . . . . . . . . .20
Sensipar . . . . . . . . . . 15
Serevent Diskus . . . . . . 20
Seroquel XR . . . . . . . . 12
Sertraline . . . . . . . . . . 12
Bold type = Brand-name drug
[Plain type = Generic drug]
Sildenafil Tab . . . . . . . . 11
Silenor . . . . . . . . . . . .12
Simbrinza . . . . . . . . . .15
Simponi . . . . . . . . . . .17
Simvastatin . . . . . . . . . 11
Solodyn . . . . . . . . . . . 9
Soolantra . . . . . . . . . .13
Sotalol . . . . . . . . . . . .11
Sovaldi . . . . . . . . . . . . 9
Spiriva Handihaler . . . . .20
Spiriva Respimat . . . . . .20
Spironolactone . . . . . . . 10
Sprintec 28 . . . . . . . . . 21
Sprycel . . . . . . . . . . . . 9
Staxyn . . . . . . . . . . . .17
Stelara . . . . . . . . . . . 17
Stendra . . . . . . . . . . .17
Stiolto . . . . . . . . . . . .20
Strattera . . . . . . . . . . 11
Stribild . . . . . . . . . . . 17
Suboxone Film . . . . . . .18
Subsys . . . . . . . . . . . 19
Sucralfate Tab . . . . . . . .16
Sulfacetamide/Sulfur
Emulsion . . . . . . . . . 13
SulfamethoxazoleTrimethoprim . . . . . . . 9
SulfamethoxazoleTrimethoprim DS . . . . . 9
Sulfasalazine . . . . . . . . 16
Sumatriptan Tab and Spray . 12
Sumavel Dose . . . . . . . 12
Suprep Bowel Prep . . . . .16
Sustiva . . . . . . . . . . . 17
Symbicort . . . . . . . . . .20
Synagis . . . . . . . . . . .18
Synjardy . . . . . . . . . . .14
Synthroid . . . . . . . . . .15
Synvisc . . . . . . . . . . .18
Synvisc One . . . . . . . . 18
T
Taclonex . . . . . . . . . . 13
Tacrolimus Cap . . . . . . . 20
Taltz . . . . . . . . . . . . .17
Tamiflu . . . . . . . . . . . . 9
Tamoxifen Tab . . . . . . . . 9
Tamsulosin . . . . . . . . . .17
Tanzeum . . . . . . . . . . 14
Tasigna . . . . . . . . . . . 9
Tazorac . . . . . . . . . . .13
Tecfidera . . . . . . . . . . 12
Tekturna . . . . . . . . . . .10
Tekturna HCT . . . . . . . .10
Telmisartan . . . . . . . . . 10
Temazepam . . . . . . . . .12
Temozolomide . . . . . . . . 9
Terazosin . . . . . . . . 10, 17
Terbinafine Tab . . . . . . . . 9
Terconazole Vaginal Cream . 22
Testim . . . . . . . . . . . .18
Testosterone Cypionate IM
Injection . . . . . . . . .18
Timolol . . . . . . . . . . . .15
Timoptic Ocudose . . . . .15
Tirosint . . . . . . . . . . . 15
Tivicay . . . . . . . . . . . .17
Tizanidine Cap . . . . . . . .19
Tizanidine Tab . . . . . . . .19
TOBI Nebulizer . . . . . . . 9
TOBI Podhaler . . . . . . . 9
Tobramycin . . . . . . . . . 15
Tobramycin/
Dexamethasone . . . . .15
29
Index of Drugs
Tobramycin Neb . . . . . . . 9
Tolterodine . . . . . . . . . .20
Topiramate Tab . . . . . . . 13
Torsemide Tab . . . . . . . .10
Toujeo SoloStar . . . . . . 14
Toviaz . . . . . . . . . . . .20
Tracleer . . . . . . . . . . .11
Tradjenta . . . . . . . . . .14
Tramadol Tab . . . . . . . . 19
Tramadol
w/ Acetaminophen . . . 19
Transderm-Scop . . . . . .16
Travatan Z . . . . . . . . . 15
Trazodone . . . . . . . . . .12
Tresiba . . . . . . . . . . . 14
Tretinoin Cream . . . . . . .14
Tretinoin Microsphere Gel . . 14
Triamcinolone . . . . . . . .14
Triamcinolone Spray . . . . .20
Triamterene/HCTZ . . . . . .10
Triazolam Tab . . . . . . . . 12
Tribenzor . . . . . . . . . .10
Tri-Linyah . . . . . . . . . . 21
Trinessa . . . . . . . . . . .21
Tri-Previfem . . . . . . . . .21
Tri-Sprintec . . . . . . . . . 21
Triumeq . . . . . . . . . . .17
Trulicity . . . . . . . . . . .14
Truvada . . . . . . . . . . .17
Tudorza . . . . . . . . . . .20
U
Uceris Foam . . . . . . . . 16
Uloric . . . . . . . . . . . .18
Ultresa . . . . . . . . . . . 16
Ursodiol . . . . . . . . . . .18
Bold type = Brand-name drug
[Plain type = Generic drug]
V
Vagifem . . . . . . . . . . .22
Valacyclovir . . . . . . . . . . 9
Valsartan . . . . . . . . . . .10
Valsartan/HCTZ . . . . . . .10
Varubi . . . . . . . . . . . .16
Vascepa . . . . . . . . . . .11
Vectical . . . . . . . . . . .14
Velphoro . . . . . . . . . . 18
Veltin . . . . . . . . . . . . 14
Venlafaxine ER Cap . . . . .12
Venlafaxine ER Tab . . . . . 12
Venlafaxine Tab . . . . . . . 12
Ventolin HFA . . . . . . . . 20
Verapamil ER . . . . . . . . 10
Vesicare . . . . . . . . . . .20
Vestura . . . . . . . . . . . .21
Viagra . . . . . . . . . . . .17
Vicodin . . . . . . . . . . . .19
Vicodin ES . . . . . . . . . .19
Victoza . . . . . . . . . . . 14
Vigamox . . . . . . . . . . .15
Viibryd . . . . . . . . . . . .12
Vimovo . . . . . . . . . . .16
Vimpat . . . . . . . . . . . .13
Viokace . . . . . . . . . . .16
Viorele . . . . . . . . . . . .21
Viread . . . . . . . . . . . .17
Vitamin D (Rx only) . . . . . 21
Vogelxo . . . . . . . . . . .18
Voltaren Gel . . . . . . . . 19
Vytorin . . . . . . . . . . . .11
Vyvanse . . . . . . . . . . .11
X
Xarelto . . . . . . . . . . . 10
Xeljanz . . . . . . . . . . . 17
Xigduo XR . . . . . . . . . 14
Xopenex HFA . . . . . . . .20
Xtampza ER . . . . . . . . 19
Xulane . . . . . . . . . . . .21
Z
Zarah . . . . . . . . . . . . 21
Zarxio . . . . . . . . . . . .18
Zenpep . . . . . . . . . . .16
Zepatier . . . . . . . . . . . 9
Zetia . . . . . . . . . . . . .11
Zetonna . . . . . . . . . . .20
Ziana Gel . . . . . . . . . .14
Zioptan . . . . . . . . . . .15
Ziprasidone Cap . . . . . . .12
Zohydro ER . . . . . . . . .19
Zolmitriptan Tab . . . . . . .12
Zolpidem . . . . . . . . . . 12
Zolpidem ER . . . . . . . . .12
Zomacton . . . . . . . . . 15
Zonisamide . . . . . . . . . 13
Zorvolex . . . . . . . . . . .19
Zostavax Injection . . . . .18
Zovirax Cream . . . . . . .14
Zovirax Ointment . . . . . .14
Zubsolv . . . . . . . . . . .18
Zutripro . . . . . . . . . . .18
Zyclara . . . . . . . . . . . 14
Zytiga . . . . . . . . . . . . 9
W
Warfarin . . . . . . . . . . .10
Welchol . . . . . . . . . . .11
30
“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.
“My Medications” worksheet
Name of Medicine
and Strength
Drug
Tier
I Take This
Medicine For
Directions
Doctor
Example: Lisinopril, 20 mg
Tier 1
High blood pressure
One tablet daily
Dr. Johnson
31
*HealthSelect Prescription Drug Program will have a new phone number for your prescription drug questions. This new
number will be on the new prescription ID card that you will receive from OptumRx in August. You can begin using the new
prescription drug program ID card on September 1.
HealthSelect
of Texas
SM
ORX6700-ERS_170512
Premium standard 32