Your 2017 Formulary
Effective January 1, 2017
Please read: This document contains information about the drugs
covered under your pharmacy benefit plan.
For a complete list of covered drugs or if you have questions:
Call the toll-free member phone number
on the back of your ID card.
Visit optumrx.com
• Locate a participating retail pharmacy by zip code.
• Look up possible lower-cost medication alternatives.
• Compare medication pricing and options.
OptumRx | optumrx.com
Select Standard 1
Your Formulary
This Formulary outlines the most commonly prescribed medications from your plan’s
complete pharmacy benefit coverage list, also known as a Prescription Drug List (PDL).
A formulary identifies the drugs available for certain conditions and organizes them
into cost levels, also known as tiers. An important part of the Formulary is giving you
choices so you and your doctor can choose the best course of treatment for you.
Go to optumrx.com for complete and up-to-date drug information
Since the Formulary may change, we encourage you to visit our website, optumrx.com.
This website is the best source for up-to-date information about all of the medications
your pharmacy benefit covers, possible lower-cost options and cost comparisons.
John Smith
John Smith
JOHN SMITH
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 . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Men’s Health
Erectile Dysfunction . . . . . . . . . . . . . . . . . . . . 17
Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Testosterone Therapy . . . . . . . . . . . . . . . . . . . 17
Cardiovascular/Heart Disease
Anticoagulants. . . . . . . . . . . . . . . . . . . . . . . . . 9
High Blood Pressure . . . . . . . . . . . . . . . . . . . . 10
High Cholesterol . . . . . . . . . . . . . . . . . . . . . . 10
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Pulmonary Arterial Hypertension . . . . . . . . . . 11
Central Nervous System
Attention Deficit Disorder . . . . . . . . . . . . . . .
Depression. . . . . . . . . . . . . . . . . . . . . . . . . . .
Migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . .
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Sedatives/Hypnotics . . . . . . . . . . . . . . . . . . . .
Seizure Disorders . . . . . . . . . . . . . . . . . . . . . .
11
11
11
12
12
12
12
Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Inflammatory Conditions . . . . . . . . . . . . . . 17
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . 17
Musculoskeletal
Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . 18
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Pain Relief . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Overactive Bladder . . . . . . . . . . . . . . . . . . . 19
Respiratory
Asthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . 19
Nasal Allergies . . . . . . . . . . . . . . . . . . . . . . . . 19
Oral Allergies . . . . . . . . . . . . . . . . . . . . . . . . . 19
Dermatology . . . . . . . . . . . . . . . . . . . . . . . . 12
Transplant . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Diabetes/Endocrine
Blood Glucose Monitoring . . . . . . . . . . . . . . . 13
Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Non-Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Vitamins/Electrolytes . . . . . . . . . . . . . . . . . 19
Endocrine
Growth Hormone . . . . . . . . . . . . . . . . . . . . . 15
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Thyroid Hormone Replacement . . . . . . . . . . . 15
Eye Conditions
Allergies. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . .
Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
15
15
15
16
Women’s Health
Birth Control . . . . . . . . . . . . . . . . . . . . . . . . . 20
Hormone Replacement . . . . . . . . . . . . . . . . . 20
Vaginal Anti-Infectives . . . . . . . . . . . . . . . . . . 20
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
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 preferred by your plan
sponsor for their safety, cost and effectiveness. Drugs are listed by common categories or
class. They are placed into cost levels known as tiers. It includes both brand and generic
prescription medications approved by the U.S. Food and Drug Administration (FDA).
Please note: Where differences are noted between this Formulary and your benefit
plan documents, the benefit plan documents will rule. It is not intended to be a
complete list of medications, and not all medications listed may be covered under your
plan. Please look at your benefit plan documents provided by your employer or plan
sponsor to see what medications are covered under your plan. You may also log on to
optumrx.com or call the toll-free member phone number on the back of your
ID card for more information.
How do I use my Formulary?
When choosing a medication, you and your doctor should consult the Formulary. It
will help you and your doctor choose the most cost-effective prescription drugs. This
guide tells you if a medication is generic or brand, and if special rules apply. Bring this
list with you when you see your doctor. It is organized by common medical conditions.
Medications are then listed alphabetically.
If your medication is not listed in this document, please visit optumrx.com
or call the toll-free member phone number on the back of your ID card.
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 employer or plan sponsor. This is how much you will pay
when you fill a prescription. Tier 1 medications are your lowest-cost options. If your
medication is placed in Tier 2 or 3, look to see if there is a Tier 1 option available.
Discuss these options with your doctor.
Check your benefit plan documents to find out your specific pharmacy plan costs.
$
$
$$
$$$
Drug Tier
Includes
Helpful Tips
Tier 1
Lowest Cost
Lower-cost, commonly
used generic drugs.
Some low-cost brands
may be included.
Use Tier 1 drugs for
the lowest out-ofpocket costs.
Tier 2
Mid-range
Cost
Many common brandname 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 nonpreferred brands.
Many Tier 3 drugs have
lower-cost options in Tier
1 or 2. Ask your doctor if
they could work for you.
Please note: Some plans may have two or four tiers, while others may not have any.
If you have a high deductible plan, the tier cost levels will apply once you hit your
deductible. Refer to your enrollment and plan materials on optumrx.com,
or call the toll-free member phone number of the back of your ID card for more
information about your benefit plan.
When does the Formulary change?
• Medications may move to a lower tier at any time.
• Medications may move to a higher tier when its generic becomes available.
• Medications may move to a higher tier or be excluded from coverage
on January 1 or July 1 of each year.
When a medication changes tiers, you may have to pay a different amount
for that medication.
For the most up-to-date list, call customer service at the toll-free member
phone number on the back of your ID card.
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.
PA
Prior Authorization – Your doctor is required to provide additional
information to determine coverage.
ST
Step Therapy – Trial of lower cost medication(s) is required before
a higher-cost medication is covered.
QL
Quantity Limits – Amount of medication covered per copayment
or in a specific time period.
AR
Age Restrictions – Some restrictions may apply based on patient age.
SP
Specialty Medication – Medication is designated as a specialty
pharmacy drug.
To learn more about a pharmacy program or to find out if it applies to you, please
visit optumrx.com or call the toll-free member phone number on the back
of your ID card.
6
Why are some medications excluded from coverage?
Medications may be excluded from coverage under your pharmacy benefit when it
works the same as or similar to another prescription medication or an over-the-counter
(OTC) medication. There may be other medication options available.
What if I don’t agree with a decision about an excluded medication?
You (or your authorized representative) and your doctor can ask for an initial coverage
decision by calling the toll-free member phone number on the back of your ID card.
Should I talk to my doctor about OTC medications?
An OTC medication may be the right treatment option for some conditions. Talk to
your doctor about available OTC options. Even though these medications may not
be covered under your pharmacy benefit, they may cost less than your out-of-pocket
expense for prescription medications.
What is the difference between brand-name and generic medications?
Generic medications contain the same active ingredients (what makes the medication
work) as brand-name medications, but they often cost less. Once the patent of a
brand-name medication ends, the FDA can approve a generic version with the same
active ingredients. These types of medications are known as generic medications.
Sometimes the same company that makes a brand-name medication also makes the
generic version.
Is it a generic or brand-name drug?
The drug list shows brand-name drugs in bold type (for example, Clobex)
and generic drugs in plain type (for example, clobetasol).
What if my doctor writes a brand-name prescription?
The next time your doctor gives you a prescription for a brand-name medication,
ask if a generic equivalent or lower-cost option is available and if it might be right
for you. Generic medications are usually your lowest-cost option, but not always.
Visit optumrx.com to make sure.
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.
OptumRx is the specialty pharmacy that can provide most of your specialty medications
along with helpful programs and services. Call OptumRx® Specialty Pharmacy at
1-888-702-8423 and have your prescriptions delivered right to your home or office.
How do I get updated information about my pharmacy benefit?
Since the Formulary may change during your plan year, we encourage you to visit
optumrx.com or call the toll-free member phone number on the back of
your ID card for more current information.
When you register at optumrx.com and open an account, you can use the website’s
helpful tools and features to:
• Look up the price of drugs covered by your plan
• Find lower-cost options
• Refill and renew mail service prescriptions
• View your order status and claims history
• Sign up for text reminders to take and refill your medicine
• View your benefits in real time
• Order medical supplies
• Shop for health and wellness products
More information
If you have additional questions please call customer service, 24 hours
a day, 7 days a week using the toll-free member phone number on the
back of your ID card. Or visit optumrx.com.
8
Drug Name
Drug
Tier
Programs
and Limits
SulfamethoxazoleTrimethoprim DS
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
Levofloxacin Tab
Metronidazole Tab
Minocycline Cap
Moxifloxacin
Neomycin/Polymyxin/
HC Otic Suspension,
Solution
Nitrofurantoin
Macrocrystalline
Nitrofurantoin
Monohydrate
Macrocrystalline
Ofloxacin Otic Solution
Oracea
Penicillin VK
Solodyn
SulfamethoxazoleTrimethoprim
1
1
3
1
2
1
1
1
1
1
1
Programs
and Limits
1
Anti-Infectives: Antifungals
SP
Fluconazole
Jublia Solution
Kerydin Solution
Nystatin Suspension
Terbinafine Tab
1
3
3
1
1
PA
PA
QL
Anti-Infectives: Antivirals
2
1
1
1
3
1
Drug
Tier
Drug Name
ST
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
1
1
1
1
1
1
1
1
1
1
3
1
3
1
Bold type = Brand-name drug
[Plain type = Generic drug]
Akynzeo
Anastrozole Tab
Capecitabine
Letrozole
Revlimid
Sprycel
Tamoxifen Tab
Tasigna
Temozolomide
Zytiga
3
1
1
1
3
2
1
3
1
3
QL
SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
Cardiovascular/Heart Disease:
Anticoagulants
Brilinta
Clopidogrel
Effient
Eliquis
Enoxaparin
Pradaxa
Savaysa
Warfarin
Xarelto
PA Prior Authorization
ST Step Therapy
QL Quantity Limits
2
1
2
3
1
2
3
1
2
QL
QL, SP
QL
QL
QL
AR Age Restrictions
SP Specialty Program
9
Drug Programs
Tier
and Limits
Cardiovascular/Heart Disease:
High Blood Pressure
Drug Name
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
Guanfacine Tab
(Immediate Release)
Hydralazine
Hydrochlorothiazide
Irbesartan
Irbesartan/HCTZ
Labetalol
Lisinopril
Lisinopril/HCTZ
Losartan
Losartan/HCTZ
Metoprolol Succinate
1
1
1
1
1
1
2
1
1
2
2
1
1
1
2
1
1
1
1
1
1
1
3
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Bold type = Brand-name
Brand name drug
[Plain type = Generic drug]
ST
ST
ST
Drug Name
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
Drug
Tier
Programs
and Limits
1
1
1
1
1
1
1
1
2
2
1
1
1
1
2
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
Gemfibrozil
Lipitor
Livalo
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
PA Prior Authorization
ST Step Therapy
QL Quantity Limits
1
1
3
1
1
3
3
1
3
1
ST
ST
1
2
1
1
PA, QL, SP
1
1
AR Age Restrictions
SP Specialty Program
GR Gender Restriction
PA
10
Drug Name
Vascepa
Vytorin 10-10 mg,
10-20 mg,
10-40 mg
Vytorin 10-80 mg
Welchol
Zetia
Drug
Tier
Programs
and Limits
2
2
2
2
3
PA
1
1
3
1
1
1
3
2
1
PA, QL
ST
Cardiovascular/Heart Disease:
Pulmonary Arterial Hypertension
Adcirca
Adempas
Letairis
Opsumit
Orenitram
Sildenafil Tab 20 mg
Tracleer
3
2
2
2
3
1
2
PA, QL, SP
PA, QL, SP
PA, QL, SP
PA, QL, SP
PA, SP
PA, QL, SP
PA, QL, SP
Central Nervous System:
Attention Deficit Disorder
Adderall XR Cap
AmphetamineDextroamphetamine
Tab
AmphetamineDextroamphetamine
SR 24Hr Cap
Dexmethylphenidate ER
Cap
Evekeo
Guanfacine ER Tab
Methylphenidate
ER Cap
Methylphenidate ER Tab
3
1
PA, QL, ST
PA, QL
1
PA, QL
1
PA, QL
3
1
PA, QL, ST
QL
1
PA, QL
1
PA, QL
Brand name drug
Bold type = Brand-name
[Plain type = Generic drug]
Methylphenidate SA
Osmotic ER Tab
Methylphenidate Tab
Strattera
Vyvanse
Drug
Tier
Programs
and Limits
1
PA, QL
1
2
2
PA, QL
QL
PA, QL
Central Nervous System: Depression
Cardiovascular/Heart Disease: Other
Amiodarone
Amlodipine/Atorvastatin
Corlanor
Digoxin
Flecainide
Isosorbide Mononitrate
Nitrostat
Ranexa
Sotalol
Drug Name
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
Risperidone Tab
Sertraline
Trazodone
Venlafaxine Tab
Venlafaxine ER Cap
Venlafaxine ER Tab
Viibryd
1
1
1
1
1
1
QL
1
QL
1
1
1
2
1
1
1
2
1
1
1
1
1
1
3
QL
QL
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
PA Prior Authorization
ST Step Therapy
QL Quantity Limits
1
3
3
1
QL
QL
QL
1
QL
3
1
QL
QL
AR Age Restrictions
SP Specialty Program
GR Gender Restriction
11
Drug
Tier
Central Nervous System:
Multiple Sclerosis
Drug Name
Ampyra
Aubagio
Avonex Kit
Avonex Pen Kit
Avonex Prefill Kit
Betaseron
Copaxone 20 mg/mL
& 40 mg/mL
Gilenya*
Rebif
Rebif Titrtn
Tecfidera
Programs
and Limits
Seroquel XR
Ziprasidone Cap
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
3
3
3
2
PA, QL, ST, SP
PA, QL, ST, SP
PA, QL, ST, SP
PA, QL, SP
Central Nervous System: Other
Abilify Tab
Alprazolam Tab
Aripiprazole
Benztropine
Buspirone
Carbidopa/Levodopa
Tab (Immediate
Release)
Diazepam Tab
Donepezil Tab
Hydroxyzine HCL
Hydroxyzine Pamoate
Latuda
Lithium Carbonate
Lorazepam Tab
Modafinil
Namenda XR
Namzaric
Nuvigil
Olanzapine Tab
Prochlorperazine
Quetiapine
Rexulti
Risperidone Tab
Ropinirole
(Immediate Release)
Saphris
3
1
1
1
1
QL
QL
QL
1
1
1
1
1
3
1
1
1
2
2
3
1
1
1
3
1
QL, ST
QL
PA, QL
QL
QL
PA, QL
QL
QL
QL
QL
1
2
Drug Name
Drug
Tier
Programs
and Limits
2
1
QL
QL
Central Nervous System:
Sedatives/Hypnotics
Eszopiclone Tab
Silenor
Temazepam
Triazolam Tab
Zolpidem
Zolpidem ER
1
3
1
1
1
1
QL
QL
QL
QL
QL
QL
Central Nervous System:
Seizure Disorders
Carbamazepine Tab
Clonazepam
Divalproex DR
Divalproex ER
Gabapentin
Lamotrigine
(Immediate Release)
Lamotrigine ER
Levetiracetam
Levetiracetam ER
Lyrica Cap
Onfi
Oxcarbazepine
Phenytoin
Primidone
Topiramate Tab
Vimpat
Zonisamide
1
1
1
1
1
QL
1
1
1
1
2
3
1
1
1
1
3
1
QL
PA
Dermatology
Acanya Gel
Acyclovir Ointment 5%
Aczone Gel
Atralin
Benzaclin
Betamethasone
Dipropionate Cream
Ciclopirox Cream
Clindamycin Gel,
Lotion, Solution
3
1
3
3
3
ST
PA
ST
1
1
1
QL
* Tier 3 Preferred
Bold type = Brand-name drug
[Plain type = Generic drug]
PA Prior Authorization
ST Step Therapy
QL Quantity Limits
AR Age Restrictions
SP Specialty Program
12
Drug Name
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
Desoximetasone Cream,
Gel, Ointment
Differin
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
Drug
Tier
Programs
and Limits
1
1
1
3
1
3
1
1
3
1
2
PA
ST
3
3
1
1
1
1
1
1
3
1
2
1
1
Bold type = Brand-name drug
[Plain type = Generic drug]
ST
Drug
Tier
Drug Name
Nystatin/Triamcinolone
Cream, Ointment
Onexton
Oxsoralen-UL
Permethrin Cream 5%
Proctofoam HC
Retin-A Micro
Soolantra
Sulfacetamide/Sulfur
Emulsion
Taclonex
Tazorac
Tretinoin Cream
Tretinoin Microsphere
Gel
Triamcinolone
Vectical
Zovirax Cream
Zovirax Ointment
Zyclara
Programs
and Limits
1
3
2
1
2
3
2
PA
1
3
3
1
QL
QL, AR
PA
1
PA
1
3
2
3
3
Diabetes/Endocrine Blood:
Glucose Monitoring
Accu-Chek Active
Glucose Control
Liquid
Accu-Chek Active Test
Strips
Accu-Chek Aviva
Connect Kit
Accu-Chek Aviva Plus
Control Liquid
Accu-Chek Aviva Plus
Kit
Accu-Chek Aviva Plus
Test Strips
Accu-Chek Compact
Plus Control Liquid
Accu-Chek Compact
Plus Test Strips
Accu-Chek Compact
Plus Kit
Accu-Chek FastClix
Kit
PA Prior Authorization
ST Step Therapy
QL Quantity Limits
3
2
QL
2
3
2
2
QL
3
2
QL
2
2
AR Age Restrictions
SP Specialty Program
13
Drug Name
Accu-Chek FastClix
Lancets
Accu-Chek Multiclix
Kit
Accu-Chek Multiclix
Lancets
Accu-Chek Nano
SmartView Kit
Accu-Chek SmartView
Control Liquid
Accu-Chek SmartView
Test Strips
Accu-Chek Soft Touch
Lancets
Accu-Chek Softclix Kit
Accu-Chek Softclix
Lancets
Bayer Contour Test
Strips
Dexcom G4 Platinum
Kit
Dexcom G4 Platinum
Sensor Kit
Dexcom G4 Platinum
Transmitter Kit
Freestyle Test Strips
Insulin Pen Needle
Insulin Syringe/
Needle
Novofine Pen Needle
Novofine Autocover
Pen Needle
Novotwist Pen
Needle
Onetouch Kit Ultra
Smart
Onetouch Kit Ultra
Onetouch Kit Ultra 2
Onetouch Kit Ultra
Mini
Onetouch Kit Verio IQ
Onetouch Test Strips
Drug
Tier
Programs
and Limits
Drug Name
Onetouch Ultra Blue
Test Strips
Onetouch Verio
Test Strips
Precision Test Strips
2
2
2
Drug
Tier
Programs
and Limits
2
QL
2
QL
3
QL, ST
Diabetes/Endocrine: Insulin
2
3
2
QL
2
2
2
3
QL, ST
3
3
3
3
2
QL, ST
2
3
3
3
2
2
2
Bold type = Brand-name drug
[Plain type = Generic drug]
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
Diabetes/Endocrine: Non-Insulin
2
2
2
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
QL
Bydureon
Byetta
Farxiga
Glimepiride
Glipizide
Glipizide ER
PA Prior Authorization
ST Step Therapy
QL Quantity Limits
2
2
3
1
1
1
QL, ST
QL, ST
ST
AR Age Restrictions
SP Specialty Program
14
Drug Name
Glipizide XL
Glumetza
Glyburide
Glyburide/Metformin
Invokamet
Invokamet XR
Invokana
Janumet
Janumet XR
Januvia
Jardiance
Jentadueto
Jentadueto XR
Kombiglyze
Metformin
Metformin ER
Onglyza
Pioglitazone
Synjardy
Tradjenta
Trulicity
Victoza
Drug
Tier
1
3
1
1
2
2
2
2
2
2
2
2
2
3
1
1
3
1
2
2
2
2
Programs
and Limits
Sensipar
PA
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
QL, ST
QL, ST
Endocrine: Growth Hormone
Norditropin
Nutropin AQ
Saizen
2
2
2
PA, SP
PA, SP
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
1
1
2
1
3
2
1
1
1
1
Bold type = Brand-name drug
[Plain type = Generic drug]
Drug Name
PA, SP
PA, SP
PA, SP
Drug
Tier
Programs
and Limits
3
PA
Endocrine:
Thyroid Hormone Replacement
Armour Thyroid
Levothyroxine
Liothyronine
Methimazole
Synthroid
Tirosint
3
1
1
1
3
3
Eye Conditions: Allergies
Azelastine Ophthalmic
Solution
Bepreve
Lastacaft
Pataday
Pazeo
1
3
3
2
2
ST
ST
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
PA Prior Authorization
ST Step Therapy
QL Quantity Limits
2
2
3
AR Age Restrictions
SP Specialty Program
15
Drug Name
Drug
Tier
Brimonidine
Combigan
Cosopt PF
Dorzolamide-Timolol
Maleate
Latanoprost
Lumigan
Simbrinza
Timolol
Timoptic Ocudose
Travatan Z
Programs
and Limits
1
2
3
QL
QL
QL
Eye Conditions: Other
Durezol Ophthalmic
Emulsion
Lotemax Ophthalmic
Gel
Ketorolac Ophthalmic
Solution
Prednisolone
Ophthalmic
Suspension
Restasis
3
3
QL
1
1
3
PA
Gastrointestinal: Acid Suppression
Dexilant
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
2
1
QL
QL
1
1
1
1
QL
QL
QL
1
1
Gastrointestinal: Nausea/Vomiting
Meclizine
Metoclopramide
Ondansetron Tab, ODT
Transderm-Scop
Varubi
1
1
1
3
3
Bold type = Brand-name drug
[Plain type = Generic drug]
Programs
and Limits
Gastrointestinal: Other
1
1
2
2
1
2
2
Drug
Tier
Drug Name
QL
QL
Amitiza
Apriso
Canasa
Creon
Delzicol
Dipentum
Gavilyte Solution
Hyoscyamine Sublingual
Tab
Lactulose
Lialda
Linzess
Moviprep
Omeclamox Pak
Pentasa
Polyethylene
Glycol 3350 Powder
Prepopik
Protosol HC
Pylera
Sulfasalazine
Suprep Bowel Prep
Uceris Foam
Zenpep
2
2
2
2
3
3
1
QL, ST
ST
1
1
2
2
3
2
3
QL, ST
1
3
1
2
1
3
3
2
HIV/AIDS
Atripla
Complera
Epzicom
Intelence
Isentress
Kaletra
Nevirapine
Norvir
Prezcobix
Prezista
Reyataz
Stribild
Sustiva
Tivicay
Triumeq
Truvada
Viread
PA Prior Authorization
ST Step Therapy
QL Quantity Limits
2
2
2
2
2
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
AR Age Restrictions
SP Specialty Program
16
Drug Name
Drug
Tier
Programs
and Limits
Infertility
Cetrotide
Gonal-f
Gonal-f RFF
Ovidrel
2
2
2
3
SP
PA, SP
PA, SP
SP
Inflammatory Conditions
Cimzia Kit
Depen
Genvoya
Humira Kit
Humira Pen Kit
Humira Pen Kit
Crohns
Humira Pen Kit
Psoriasis
Hydroxychloroquine
Methotrexate Tab
Orencia SC
Otezla
Otrexup
Rasuvo
Simponi
Stelara
Xeljanz
2
2
2
2
2
PA, SP
2
PA, SP
2
PA, SP
1
1
3
3
3
2
2
2
3
PA, ST, SP
PA, ST, SP
PA, QL
PA, QL
PA, SP
PA, SP
PA, ST, SP
SP
PA, SP
PA, SP
Men’s Health: Erectile Dysfunction
Cialis
Levitra
Stendra
Viagra
2
3
3
2
QL
QL
QL
QL
Men’s Health: Prostate
Alfuzosin
Cialis 2.5 mg & 5 mg
Doxazosin
Finasteride 5 mg
Rapaflo
Tamsulosin
Terazosin
1
2
1
1
2
1
1
QL
Men’s Health: Testosterone Therapy
Androderm
Androgel 1.62%
2
2
Bold type = Brand-name drug
[Plain type = Generic drug]
PA
PA
Drug Name
Androgel 1%
Testosterone Cypionate
IM Injection
Drug
Tier
Programs
and Limits
3
PA, ST
1
PA
Miscellaneous
Allopurinol
Antipyrine/Benzocaine
Otic Solution
5.4 - 1.4%
Aranesp
Auryxia
Benzonatate
Botox 100, 200 unit
Injection
(non-cosmetic)
Bunavail
Cerdelga
Chantix
Cheratussin
Chlorhexidine
Colcrys
Cyproheptadine
Desmopressin
EpiPen & EpiPen Jr
Euflexxa
Fosrenol
Granix
Guaifenesin/Codeine
Syrup
Homatropine/
Hydrocodone Syrup
Hydrocodone/
Chlorpheniramine
Liquid
Hydrocortisone AC
Suppository 25 mg
Hydromet
Lidocaine Viscous
Solution 2%
Makena
Neupogen
Phenazopyridine
(Rx only)
Phentermine Tab
PA Prior Authorization
ST Step Therapy
QL Quantity Limits
1
1
2
3
1
PA, SP
2
PA, SP
3
3
3
1
1
2
1
1
2
2
3
2
PA, QL
PA, SP
QL
PA, SP
PA, SP
1
1
1
1
1
1
2
2
PA, SP
PA, SP
1
1
PA
AR Age Restrictions
SP Specialty Program
17
Drug Name
Drug
Tier
Programs
and Limits
2
1
PA, SP
1
AR
2
2
3
2
2
2
2
2
1
3
2
3
2
3
PA, SP
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
PA, QL
PA, SP
PA, SP
PA, SP
ST
PA, SP
PA, QL
Musculoskeletal: Osteoporosis
Alendronate Tab 35 mg
& 70 mg
Binosto
Evista
Forteo
Ibandronate Tab
Raloxifene
1
QL
3
3
2
1
1
QL
Musculoskeletal: Other
Baclofen Tab
Carisoprodol 350 mg
Cyclobenzaprine Tab
5, 10 mg
Lorzone
Metaxalone
Methocarbamol
Tizanidine Cap
Tizanidine Tab
1
1
1
3
1
1
1
1
Musculoskeletal: Pain Relief
Acetaminophen
w/ Codeine
Celebrex
Celecoxib
1
3
1
Bold type = Brand-name drug
[Plain type = Generic drug]
PA, SP
Drug
Tier
Drug Name
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
Gralise
Hydrocodone/APAP
5, 7.5, 10/325 mg
Hydromorphone Tab
Ibuprofen Tab 400, 600,
800 mg (Rx only)
Indomethacin Cap
Ketorolac Tab
Lazanda
Lidocaine Patch 5%
Meloxicam
Methadone Tab
Morphine Sulfate Tab
Nabumetone
Naproxen (Rx only)
Opana ER
Oxycodone Tab 5,
10, 15, 30 mg
(Immediate Release)
Oxycodone
w/ Acetaminophen
Oxycontin
Tivorbex
Tramadol Tab 50 mg
Tramadol
w/ Acetaminophen
Vicodin
Vicodin ES
Voltaren Gel
Zohydro ER
Zorvolex
PA Prior Authorization
ST Step Therapy
QL Quantity Limits
Programs
and Limits
1
2
1
1
QL
1
QL
1
QL
3
QL, ST
1
1
1
1
1
3
1
1
1
1
1
1
2
QL
PA, QL
QL
QL
1
1
2
3
1
QL
ST
1
1
1
3
3
3
QL
QL, ST
AR Age Restrictions
SP Specialty Program
18
Drug Name
Drug
Tier
Programs
and Limits
Overactive Bladder
Myrbetriq
Oxybutynin
Oxybutynin ER
Tolterodine
Toviaz
Vesicare
3
1
1
1
3
2
ST
Respiratory: Asthma/COPD
Advair Diskus
Advair HFA
Aerospan
Albuterol
Nebulizer Solution
Anoro Ellipta
Arnuity Ellipta
Breo Ellipta
Budesonide Inhalation
Suspension
Combivent Respimat
Dulera
Flovent Diskus
Flovent HFA
Foradil
Incruse Ellipta
Ipratropium/Albuterol
Nebulizer Solution
Levalbuterol
Nebulizer Solution
Montelukast
Perforomist
Proair HFA, RespiClick
Proventil HFA
Pulmicort Flexhaler
Qvar
Seebri
Serevent Diskus
Spiriva Handihaler
Spiriva Respimat
Stiolto
Symbicort
Ventolin HFA
2
2
3
QL
QL
QL
1
QL
2
2
2
QL
QL
QL
1
QL
2
3
2
2
2
2
QL
QL, ST
QL
QL
QL
QL
1
QL
1
QL
1
3
2
3
2
2
3
2
2
2
2
2
2
QL
QL
QL, ST
QL
QL
QL
QL
QL
QL
QL
QL
QL
Bold type = Brand-name drug
[Plain type = Generic drug]
Drug Name
Drug
Tier
Programs
and Limits
Xolair
Xopenex HFA
2
3
PA, SP
QL, ST
Respiratory: Nasal Allergies
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
Vitamins/Electrolytes
Cyanocobalamine
Injection
Folic Acid 1 mg
(Rx only)
Klor-Con 8 and 10 MEQ
Klor-Con M10 and M20
PA Prior Authorization
ST Step Therapy
QL Quantity Limits
1
1
1
1
AR Age Restrictions
SP Specialty Program
19
Drug Name
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)
Drug
Tier
Programs
and Limits
1
Ocella
Orsythia
Ortho Tri-Cyclen Lo
Previfem
Reclipsen
Sprintec 28
Tri-Linyah
Tri-Previfem
Trinessa
Tri-Sprintec
Vestura
Viorele
Xulane
Zarah
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
Lo Loestrin
Lomedia Fe
Loryna
Low-Ogestrel
Lutera
Medroxyprogesterone
Acetate Injection
Microgestin
Microgestin Fe
Minastrin 24 Fe
Chewable
Mono-Linyah
Mononessa
Natazia
Necon
Nora-Be
Norgest/Ethi Estradio
Nortrel
Nuvaring
1
1
1
1
1
1
1
1
1
1
1
3
1
1
1
1
1
1
Programs
and Limits
1
1
3
1
1
1
1
1
1
1
1
1
1
1
Women’s Health: Hormone Replacement
3
1
Drug
Tier
Drug Name
QL
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
3
Women’s Health: Vaginal Anti-Infectives
1
1
2
1
1
1
1
2
Gynazole-1 Vaginal
Cream
Metronidazole
Vaginal Gel
Terconazole
Vaginal Cream
Bold type = Brand-name drug
[Plain type = Generic drug]
PA Prior Authorization
ST Step Therapy
QL Quantity Limits
3
1
1
AR Age Restrictions
SP Specialty Program
20
Index of Covered Drugs
A
Abilify Tab . . . . . . . . . 12
Acanya Gel. . . . . . . . . 12
Accu-Chek Active Glucose
Control Liquid . . . . . 13
Accu-Chek Active
Test Strips . . . . . . . 13
Accu-Chek Aviva
Connect Kit . . . . . . 13
Accu-Chek Aviva Plus Control
Liquid. . . . . . . . . . 13
Accu-Chek Aviva Plus Kit . 13
Accu-Chek Aviva Plus Test
Strips . . . . . . . . . . 13
Accu-Chek Compact Plus
Control Liquid . . . . . 13
Accu-Chek Compact
Plus Kit . . . . . . . . . 13
Accu-Chek Compact Plus
Test Strips . . . . . . . 13
Accu-Chek FastClix Kit . . 13
Accu-Chek FastClix Lancets 14
Accu-Chek Multiclix Kit . . 14
Accu-Chek Multiclix Lancets14
Accu-Chek Nano SmartView
Kit . . . . . . . . . . . 14
Accu-Chek SmartView
Control Liquid . . . . . 14
Accu-Chek SmartView
Test Strips . . . . . . . 14
Accu-Chek Softclix Kit. . . 14
Accu-Chek Softclix Lancets 14
Accu-Chek Soft Touch
Lancets . . . . . . . . . 14
Acetaminophen w/ Codeine 18
Acyclovir Cap, Tab, Suspension 9
Acyclovir Ointment 5% . . . 12
Aczone Gel. . . . . . . . . 12
Adcirca . . . . . . . . . . . 11
Adderall XR Cap . . . . . . 11
Adempas. . . . . . . . . . 11
Advair Diskus . . . . . . . 19
Advair HFA . . . . . . . . 19
Aerospan . . . . . . . . . 19
Akynzeo . . . . . . . . . . . 9
Albuterol Nebulizer Solution 19
Alendronate Tab . . . . . . 18
Alfuzosin . . . . . . . . . . 17
Allopurinol . . . . . . . . . 17
Bold type = Brand-name drug
[Plain type = Generic drug]
Alphagan P . . . . . . . .
Alprazolam Tab . . . . . . .
Amiodarone. . . . . . . . .
Amitiza. . . . . . . . . . .
Amitriptyline . . . . . . . .
Amlodipine . . . . . . . . .
Amlodipine/Atorvastatin . .
Amlodipine/Benazepril . . .
Amlodipine/Valsartan . . . .
Amlodipine/Valsartan/HCTZ .
Amoxicillin . . . . . . . . .
Amoxicillin/Clavulanate . . .
Amphetamine-Dextroamphetamine SR 24Hr Cap . .
AmphetamineDextroamphetamine Tab
Ampyra . . . . . . . . . .
Anastrozole Tab . . . . . . .
Androderm . . . . . . . .
Androgel 1% . . . . . . .
Androgel 1.62% . . . . . .
Anoro Ellipta . . . . . . .
Antipyrine/Benzocaine Otic
Solution 5.4 - 1.4% . . .
Apri . . . . . . . . . . . . .
Apriso . . . . . . . . . . .
Aranesp . . . . . . . . . .
Aripiprazole . . . . . . . . .
Armour Thyroid . . . . . .
Arnuity Ellipta . . . . . . .
Astepro . . . . . . . . . .
Atenolol. . . . . . . . . . .
Atenolol/Chlorthalidone. . .
Atorvastatin . . . . . . . .
Atralin . . . . . . . . . . .
Atripla . . . . . . . . . . .
Aubagio . . . . . . . . . .
Auryxia . . . . . . . . . .
Aviane . . . . . . . . . . .
Avonex Kit. . . . . . . . .
Avonex Pen Kit . . . . . .
Avonex Prefill Kit . . . . .
Azasite . . . . . . . . . . .
Azathioprine Tab . . . . . .
Azelastine Ophthalmic
Solution . . . . . . . . .
Azelastine Spray. . . . . . .
Azithromycin . . . . . . . .
Azopt . . . . . . . . . . .
Azor . . . . . . . . . . . .
15
12
11
16
11
10
11
10
10
10
.9
.9
11
11
12
.9
17
17
17
19
17
20
16
17
12
15
19
19
10
10
10
12
16
12
17
20
12
12
12
.9
19
15
19
.9
15
10
Azurette . . . . . . . . . . 20
B
Baclofen Tab . . . . . . . .
Bayer Contour Test Strips .
Benazepril. . . . . . . . . .
Benazepril/HCTZ . . . . . .
Benicar . . . . . . . . . . .
Benicar HCT . . . . . . . .
Benzaclin. . . . . . . . . .
Benzonatate . . . . . . . .
Benztropine . . . . . . . . .
Bepreve . . . . . . . . . .
Besivance . . . . . . . . .
Betamethasone Dipropionate
Cream. . . . . . . . . .
Betaseron . . . . . . . . .
Bethkis . . . . . . . . . . .
Betimol. . . . . . . . . . .
Binosto. . . . . . . . . . .
Bisoprolol . . . . . . . . . .
Bisoprolol/HCTZ . . . . . . .
Botox 100, 200 unit
Injection . . . . . . . .
Breo Ellipta . . . . . . . .
Brilinta . . . . . . . . . . .
Brimonidine . . . . . . . . .
Budesonide Inhalation
Suspension . . . . . . .
Bumetanide . . . . . . . . .
Bunavail . . . . . . . . . .
Bupropion. . . . . . . . . .
Bupropion ER . . . . . . . .
Bupropion SR . . . . . . . .
Bupropion XL . . . . . . . .
Buspirone . . . . . . . . . .
Butalbital-AcetaminophenCaffeine Cap, Tab . . . .
Bydureon . . . . . . . . .
Byetta . . . . . . . . . . .
Bystolic. . . . . . . . . . .
18
14
10
10
10
10
12
17
12
15
15
12
12
.9
15
18
10
10
17
19
.9
16
19
10
17
11
11
11
11
12
11
14
14
10
C
Calcitriol Cap . . . .
Canasa . . . . . . .
Capecitabine . . . .
Carbamazepine Tab .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
15
16
.9
12
21
Index of Covered Drugs
Carbidopa/Levodopa Tab . . 12
Carisoprodol . . . . . . . . 18
Cartia XT . . . . . . . . . . 10
Carvedilol . . . . . . . . . . 10
Cefadroxil Cap . . . . . . . . 9
Cefdinir . . . . . . . . . . . . 9
Cefuroxime Tab . . . . . . . . 9
Celebrex . . . . . . . . . . 18
Celecoxib . . . . . . . . . . 18
Cellcept Tab/Suspension . 19
Cephalexin . . . . . . . . . . 9
Cerdelga . . . . . . . . . . 17
Cetirizine . . . . . . . . . . 19
Cetrotide. . . . . . . . . . 17
Chantix. . . . . . . . . . . 17
Cheratussin . . . . . . . . . 17
Chlorhexidine . . . . . . . . 17
Chlorthalidone . . . . . . . 10
Cholestyramine . . . . . . . 10
Cialis . . . . . . . . . . . . 17
Ciclopirox Cream . . . . . . 12
Cimzia Kit . . . . . . . . . 17
Ciprodex Otic Suspension . 9
Ciprofloxacin Ophthalmic
Solution . . . . . . . . . 15
Ciprofloxacin Tab . . . . . . . 9
Clarithromycin . . . . . . . . 9
Climara Pro . . . . . . . . 20
Clindamycin/Benzoyl Peroxide
Gel 1.2-5% . . . . . . . 13
Clindamycin/Benzoyl Peroxide
Gel 1-5% . . . . . . . . 13
Clindamycin Cap . . . . . . . 9
Clindamycin Gel, Lotion,
Solution . . . . . . . . . 12
Clobetasol Cream, Ointment,
Solution . . . . . . . . . 13
Clobex . . . . . . . . . . . 13
Clonazepam . . . . . . . . 12
Clonidine Patch . . . . . . . 10
Clonidine Tab . . . . . . . . 10
Clopidogrel . . . . . . . . . . 9
Clotrimazole/Betamethasone
Cream, Lotion . . . . . . 13
Colcrys . . . . . . . . . . . 17
Combigan . . . . . . . . . 16
Combivent Respimat . . . 19
Complera . . . . . . . . . 16
Copaxone . . . . . . . . . 12
Corlanor . . . . . . . . . . 11
Bold type = Brand-name drug
[Plain type = Generic drug]
Cortifoam . . . . . . . .
Cosopt PF . . . . . . . .
Creon. . . . . . . . . . .
Crestor . . . . . . . . . .
Cryselle-28 . . . . . . . .
Cyanocobalamine Injection
Cyclobenzaprine Tab . . .
Cyclosporine Cap . . . . .
Cyproheptadine . . . . . .
.
.
.
.
.
.
.
.
.
13
16
16
10
20
19
18
19
17
D
Daklinza . . . . . . . . . . . 9
Delzicol . . . . . . . . . . 16
Depen . . . . . . . . . . . 17
Desloratadine . . . . . . . . 19
Desmopressin . . . . . . . . 17
Desonide Cream, Ointment . 13
Desoximetasone Cream, Gel,
Ointment . . . . . . . . 13
Dexamethasone Tab . . . . 15
Dexcom G4 Platinum Kit . 14
Dexcom G4 Platinum
Sensor Kit . . . . . . . 14
Dexcom G4 Platinum
Transmitter Kit. . . . . 14
Dexilant . . . . . . . . . . 16
Dexmethylphenidate ER Cap 11
Diazepam Tab . . . . . . . . 12
Diclofenac Tab . . . . . . . 18
Differin. . . . . . . . . . . 13
Digoxin . . . . . . . . . . . 11
Diltiazem Tab . . . . . . . . 10
Dipentum . . . . . . . . . 16
Divalproex DR . . . . . . . . 12
Divalproex ER . . . . . . . . 12
Divigel . . . . . . . . . . . 20
Donepezil Tab . . . . . . . . 12
Doryx MPC. . . . . . . . . . 9
Dorzolamide-Timolol Maleate 16
Doxazosin . . . . . . . . 10, 17
Doxepin . . . . . . . . . . . 11
Doxycycline Hyclate Cap . . . 9
Doxycycline Hyclate Tab . . . . 9
Doxycycline Monohydrate Cap 9
Doxycycline Monohydrate Oral
Suspension, Tab . . . . . . 9
Duavee. . . . . . . . . . . 20
Dulera . . . . . . . . . . . 19
Duloxetine Cap . . . . . . . 11
Durezol Ophthalmic
Emulsion . . . . . . . . 16
Dymista Spray . . . . . . . 19
E
Econazole Cream . . . . . .
Edarbi . . . . . . . . . . .
Edarbyclor . . . . . . . . .
Effient . . . . . . . . . . .
Elestrin Gel . . . . . . . .
Elidel . . . . . . . . . . . .
Eliquis . . . . . . . . . . .
Embeda . . . . . . . . . .
Enalapril. . . . . . . . . . .
Enalapril/HCTZ . . . . . . .
Endocet Tab . . . . . . . . .
Enoxaparin . . . . . . . . .
Entecavir . . . . . . . . . .
Epclusa . . . . . . . . . . .
Epiduo & Epiduo Forte . .
EpiPen & EpiPen Jr . . . .
Epzicom . . . . . . . . . .
Erythromycin . . . . . . . .
Erythromycin Ointment . . .
Escitalopram Tab . . . . . .
Esomeprazole . . . . . . . .
Estrace Vaginal Cream . .
Estradiol/Norethindrone Tab .
Estradiol Tab . . . . . . . .
Eszopiclone Tab . . . . . . .
Etodolac . . . . . . . . . .
Euflexxa . . . . . . . . . .
Evekeo . . . . . . . . . . .
Evista. . . . . . . . . . . .
13
10
10
.9
20
13
.9
18
10
10
18
.9
.9
.9
13
17
16
.9
15
11
16
20
20
20
12
18
17
11
18
F
Falmina . . . . .
Famciclovir Tab .
Famotidine Tab .
Farxiga . . . . .
Felodipine . . . .
Fenofibrate . . .
Fentanyl Patch .
Finacea . . . . .
Finasteride . . .
Flecainide . . . .
Flovent Diskus .
Flovent HFA . .
.
.
.
.
.
.
.
.
.
.
.
.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
.
.
.
.
.
.
20
.9
16
14
10
10
18
13
17
11
19
19
22
Index of Covered Drugs
Fluconazole . . . . . . . . . . 9
Fluocinonide Cream, 0.1% 13
Fluocinonide Cream, Gel,
Ointment, Solution 0.05%13
Fluoxetine Cap . . . . . . . 11
Fluticasone Spray . . . . . . 19
Fluvoxamine Tab . . . . . . 11
Folic Acid 1 mg . . . . . . . 19
Foradil . . . . . . . . . . . 19
Forfivo XL . . . . . . . . . 11
Forteo . . . . . . . . . . . 18
Fosinopril . . . . . . . . . . 10
Fosrenol . . . . . . . . . . 17
Freestyle Test Strips . . . . 14
Furosemide . . . . . . . . . 10
G
Gabapentin . . . . . . . . .
Gavilyte Solution . . . . . .
Gemfibrozil . . . . . . . . .
Generess Fe Chewable . .
Gentamicin . . . . . . . . .
Genvoya . . . . . . . . . .
Gianvi . . . . . . . . . . . .
Gildess . . . . . . . . . . .
Gilenya. . . . . . . . . . .
Glimepiride . . . . . . . . .
Glipizide . . . . . . . . . .
Glipizide ER . . . . . . . . .
Glipizide XL . . . . . . . . .
Glumetza . . . . . . . . .
Glyburide . . . . . . . . . .
Glyburide/Metformin . . . .
Gonal-f . . . . . . . . . . .
Gonal-f RFF . . . . . . . .
Gralise . . . . . . . . . . .
Granix . . . . . . . . . . .
Guaifenesin/Codeine Syrup .
Guanfacine ER Tab . . . . .
Guanfacine Tab . . . . . . .
Gynazole-1 Vaginal Cream
12
16
10
20
15
17
20
20
12
14
14
14
15
15
15
15
17
17
18
17
17
11
10
20
H
Harvoni . . . . . . . . . . . 9
Homatropine/Hydrocodone
Syrup . . . . . . . . . . 17
H.P. Acthar . . . . . . . . . 15
Bold type = Brand-name drug
[Plain type = Generic drug]
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
Humira Kit . . . . . . . . . 17
Humira Pen Kit . . . . . . 17
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 . . . . . 18
Hydrocodone/Chlorpheniramine
Liquid . . . . . . . . . . 17
Hydrocortisone AC
Suppository . . . . . . . 17
Hydrocortisone Cream,
Ointment 2.5% . . . . . 13
Hydrocortisone Tab . . . . . 15
Hydromet . . . . . . . . . . 17
Hydromorphone Tab . . . . 18
Hydroxychloroquine . . . . . 17
Hydroxyzine HCL . . . . . . 12
Hydroxyzine Pamoate . . . . 12
Hyoscyamine Sublingual Tab 16
I
Ibandronate Tab. . . . . . . 18
Ibuprofen Tab . . . . . . . . 18
Incruse Ellipta . . . . . . . 19
Indomethacin Cap . . . . . 18
Insulin Pen Needle . . . . 14
Insulin Syringe/Needle . . 14
Intelence . . . . . . . . . 16
Invokamet . . . . . . . . . 15
Invokamet XR . . . . . . . 15
Invokana . . . . . . . . . . 15
Ipratropium/Albuterol Nebulizer
Solution . . . . . . . . . 19
Ipratropium Spray . . . . . . 19
Irbesartan . . . . . . .
Irbesartan/HCTZ . . . .
Isentress . . . . . . .
Isosorbide Mononitrate
.
.
.
.
.
.
.
.
.
.
.
.
10
10
16
11
.
.
.
.
.
.
.
.
.
.
.
.
.
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.
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.
.
.
.
.
.
.
.
.
.
.
15
15
15
15
15
15
20
.9
20
J
Janumet . . . .
Janumet XR . .
Januvia. . . . .
Jardiance. . . .
Jentadueto. . .
Jentadueto XR .
Jolivette . . . . .
Jublia Solution.
Junel . . . . . .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
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.
.
.
.
.
.
.
.
.
.
.
K
Kaletra . . . . . . . . .
Kariva . . . . . . . . . .
Kerydin Solution . . .
Ketoconazole Cream/
Shampoo . . . . . .
Ketorolac Ophthalmic
Solution . . . . . . .
Ketorolac Tab . . . . . .
Klor-Con 8 and 10 MEQ.
Klor-Con M10 and M20.
Kombiglyze . . . . . .
. . 16
. . 20
. . .9
. . 13
.
.
.
.
.
.
.
.
.
.
16
18
19
19
15
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
10
16
12
12
16
14
14
15
16
12
18
11
.9
L
Labetalol . . . . . . .
Lactulose . . . . . . .
Lamotrigine ER . . . .
Lamotrigine . . . . . .
Lansoprazole . . . . .
Lantus SoloStar . . .
Lantus Vial . . . . . .
Lastacaft . . . . . . .
Latanoprost . . . . . .
Latuda . . . . . . . .
Lazanda . . . . . . .
Letairis . . . . . . . .
Letrozole . . . . . . .
Levalbuterol
Nebulizer Solution .
Levemir FlexTouch. .
Levemir Vial . . . . .
.
.
.
.
.
.
.
.
.
.
.
.
.
. . . 19
. . . 14
. . . 14
23
Index of Covered Drugs
Levetiracetam . . . . . . . .
Levetiracetam ER . . . . . .
Levitra . . . . . . . . . . .
Levocetirizine . . . . . . . .
Levofloxacin Tab. . . . . . .
Levora 28 . . . . . . . . . .
Levothyroxine . . . . . . . .
Lialda. . . . . . . . . . . .
Lidocaine Patch 5% . . . . .
Lidocaine/Prilocaine Cream .
Lidocaine Topical Ointment,
Solution . . . . . . . . .
Lidocaine Viscous Solution
2% . . . . . . . . . . .
Linzess . . . . . . . . . . .
Liothyronine . . . . . . . .
Lipitor . . . . . . . . . . .
Lisinopril . . . . . . . . . .
Lisinopril/HCTZ . . . . . . .
Lithium Carbonate . . . . .
Livalo. . . . . . . . . . . .
Lo Loestrin . . . . . . . . .
Lomedia Fe . . . . . . . . .
Lorazepam Tab . . . . . . .
Loryna . . . . . . . . . . .
Lorzone . . . . . . . . . .
Losartan. . . . . . . . . . .
Losartan/HCTZ . . . . . . .
Lotemax Ophthalmic Gel .
Lovastatin . . . . . . . . .
Lovaza . . . . . . . . . . .
Low-Ogestrel . . . . . . . .
Lumigan . . . . . . . . . .
Lupron Depot . . . . . . .
Lutera . . . . . . . . . . . .
Lyrica Cap . . . . . . . . .
12
12
17
19
.9
20
15
16
18
13
13
17
16
15
10
10
10
12
10
20
20
12
20
18
10
10
16
10
10
20
16
15
20
12
M
Makena . . . . . . . . . . 17
Meclizine . . . . . . . . . . 16
Medroxyprogesterone Acetate
Injection . . . . . . . . . 20
Medroxyprogesterone Acetate
Tab . . . . . . . . . . . 20
Meloxicam . . . . . . . . . 18
Metaxalone . . . . . . . . . 18
Metformin . . . . . . . . . 15
Metformin ER . . . . . . . . 15
Methadone Tab . . . . . . . 18
Bold type = Brand-name drug
[Plain type = Generic drug]
Methimazole . . . . . . . .
Methocarbamol . . . . . . .
Methotrexate Tab . . . . . .
Methylphenidate ER Cap . .
Methylphenidate ER Tab. . .
Methylphenidate SA
Osmotic ER Tab . . . . .
Methylphenidate Tab . . . .
Methylprednisolone Tab . . .
Metoclopramide . . . . . .
Metoprolol Succinate . . . .
Metoprolol Tartrate . . . . .
Metrogel . . . . . . . . . .
Metronidazole Gel 0.75%. .
Metronidazole Tab . . . . .
Metronidazole Vaginal Gel .
Microgestin . . . . . . . . .
Microgestin Fe . . . . . . .
Migranal . . . . . . . . . .
Minastrin 24 Fe Chewable
Minivelle . . . . . . . . . .
Minocycline Cap . . . . . .
Mirtazapine . . . . . . . . .
Mirvaso Gel . . . . . . . .
Modafinil . . . . . . . . . .
Mometasone . . . . . . . .
Mono-Linyah . . . . . . . .
Mononessa . . . . . . . . .
Montelukast . . . . . . . .
Morphine Sulfate Tab . . . .
Moviprep . . . . . . . . .
Moxeza . . . . . . . . . .
Moxifloxacin . . . . . . . .
Multi-Vit/Fl Chew . . . . . .
Mupirocin Ointment . . . .
Mycophenolate Mofetil . . .
Mycophenolate Sodium . . .
Myrbetriq . . . . . . . . .
15
18
17
11
11
11
11
15
16
10
10
13
13
.9
20
20
20
11
20
20
.9
11
13
12
19
20
20
19
18
16
15
.9
20
13
19
19
19
Neomycin/Polymyxin B/
Dexamethasone Ointment,
Suspension . . . . . . . 15
Neomycin/Polymyxin/HC Otic
Suspension, Solution . . . 9
Neupogen . . . . . . . . . 17
Nevirapine . . . . . . . . . 16
Niacin ER Tab . . . . . . . . 10
Nifedipine ER . . . . . . . . 10
Nitrofurantoin Macrocrystalline 9
Nitrofurantoin Monohydrate
Macrocrystalline . . . . . . 9
Nitrostat . . . . . . . . . . 11
Nora-Be . . . . . . . . . . . 20
Norditropin . . . . . . . . 15
Norgest/Ethi Estradio . . . . 20
Nortrel . . . . . . . . . . . 20
Nortriptyline. . . . . . . . . 11
Norvir . . . . . . . . . . . 16
Novofine Autocover Pen
Needle . . . . . . . . . 14
Novofine Pen Needle . . . 14
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
Novotwist Pen Needle . . 14
Nutropin AQ . . . . . . . . 15
Nuvaring . . . . . . . . . . 20
Nuvigil . . . . . . . . . . . 12
Nystatin Cream, Ointment,
Powder . . . . . . . . . 13
Nystatin Suspension . . . . . . 9
Nystatin/Triamcinolone Cream,
Ointment . . . . . . . . 13
N
Nabumetone .
Nadolol . . . .
Namenda XR.
Namzaric . . .
Naproxen . . .
Nasonex . . .
Natazia. . . .
Necon. . . . .
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.
.
.
.
18
10
12
12
18
19
20
20
O
Ocella . . . . . . . . . . . . 20
Ofloxacin Ophthalmic Solution15
Ofloxacin Otic Solution . . . . 9
Olanzapine Tab . . . . . . . 12
Omeclamox Pak . . . . . . 16
Omega-3 Acid Cap . . . . . 10
Omeprazole . . . . . . . . . 16
Omnaris . . . . . . . . . . 19
24
Index of Covered Drugs
Ondansetron Tab, ODT . . .
Onetouch Kit Ultra . . . .
Onetouch Kit Ultra 2 . . .
Onetouch Kit Ultra Mini .
Onetouch Kit Ultra Smart.
Onetouch Kit Verio IQ. . .
Onetouch Test Strips . . .
Onetouch Ultra Blue Test
Strips . . . . . . . . . .
Onetouch Verio Test Strips
Onexton . . . . . . . . . .
Onfi . . . . . . . . . . . .
Onglyza . . . . . . . . . .
Opana ER . . . . . . . . .
Opsumit . . . . . . . . . .
Oracea . . . . . . . . . . .
Orencia SC . . . . . . . . .
Orenitram . . . . . . . . .
Orsythia . . . . . . . . . . .
Ortho Tri-Cyclen Lo . . . .
Osphena . . . . . . . . . .
Otezla . . . . . . . . . . .
Otrexup . . . . . . . . . .
Ovidrel . . . . . . . . . . .
Oxcarbazepine . . . . . . .
Oxsoralen-UL . . . . . . .
Oxybutynin . . . . . . . . .
Oxybutynin ER . . . . . . .
Oxycodone Tab . . . . . . .
Oxycodone
w/ Acetaminophen . . .
Oxycontin . . . . . . . . .
16
14
14
14
14
14
14
14
14
13
12
15
18
11
.9
17
11
20
20
20
17
17
17
12
13
19
19
18
18
18
P
Pantoprazole . . . . .
Paroxetine Tab . . . .
Pataday . . . . . . .
Pazeo. . . . . . . . .
Penicillin VK . . . . . .
Pentasa . . . . . . .
Perforomist . . . . .
Permethrin Cream 5%
Phenazopyridine . . .
Phentermine Tab . . .
Phenytoin . . . . . . .
Pioglitazone . . . . . .
Polyethylene Glycol
3350 Powder . . .
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.
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.
16
11
15
15
.9
16
19
13
17
17
12
15
. . . 16
Bold type = Brand-name drug
[Plain type = Generic drug]
Polymyxin B/Trimethoprim
Solution . . . . . . . . .
Potassium Chloride ER
Tab, Cap. . . . . . . . .
Potassium Chloride Micro
ER Tab . . . . . . . . . .
Potassium Citrate . . . . . .
Pradaxa . . . . . . . . . .
Praluent . . . . . . . . . .
Pravastatin . . . . . . . . .
Precision Test Strips . . . .
Prednisolone Ophthalmic
Suspension . . . . . . .
Prednisolone Solution . . . .
Prednisolone Syrup, Solution
Prednisone . . . . . . . . .
Premarin Tab. . . . . . . .
Premarin Vaginal Cream .
Premphase . . . . . . . . .
Prempro . . . . . . . . . .
Prepopik . . . . . . . . . .
Previfem . . . . . . . . . .
Prezcobix . . . . . . . . .
Prezista . . . . . . . . . .
Primidone . . . . . . . . . .
Pristiq . . . . . . . . . . .
Proair HFA, RespiClick . . .
Prochlorperazine . . . . . .
Procrit . . . . . . . . . . .
Proctofoam HC . . . . . .
Progesterone Cap . . . . . .
Prograf Cap . . . . . . . .
Promethazine/Codeine Syrup
Promethazine DM Syrup . .
Promethazine Tab . . . . . .
Propranolol . . . . . . . . .
Propranolol ER . . . . . . .
Protosol HC . . . . . . . . .
Proventil HFA . . . . . . .
Pulmicort Flexhaler . . . .
Pulmozyme . . . . . . . .
Pylera . . . . . . . . . . .
R
15
20
20
20
.9
10
10
14
16
15
15
15
20
20
20
20
16
20
16
16
12
11
19
12
18
13
20
19
18
18
19
10
10
16
19
19
18
16
Q
QNasl. . .
Quetiapine
Quinapril .
Qvar . . .
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19
12
10
19
Raloxifene. . . . . . . . . . 18
Ramipril . . . . . . . . . . . 10
Ranexa . . . . . . . . . . . 11
Ranitidine Tab, Cap, Syrup . 16
Rapaflo. . . . . . . . . . . 17
Rapamune . . . . . . . . . 19
Rasuvo . . . . . . . . . . . 17
Rebif . . . . . . . . . . . . 12
Rebif Titrtn . . . . . . . . 12
Reclipsen . . . . . . . . . . 20
Relpax . . . . . . . . . . . 11
Renvela Tab, Pack . . . . . 18
Restasis . . . . . . . . . . 16
Retin-A Micro . . . . . . . 13
Revlimid . . . . . . . . . . . 9
Rexulti . . . . . . . . . . . 12
Reyataz . . . . . . . . . . 16
Rezira . . . . . . . . . . . 18
Risperidone Tab . . . . . 11, 12
Rizatriptan Tab, ODT . . . . 11
Ropinirole . . . . . . . . . . 12
Rosuvastatin . . . . . . . . 10
S
Saizen . . . . . . .
Saphris . . . . . . .
Savaysa . . . . . .
Seebri . . . . . . .
Sensipar . . . . . .
Serevent Diskus . .
Seroquel XR . . . .
Sertraline . . . . . .
Sildenafil Tab . . . .
Silenor . . . . . . .
Simbrinza . . . . .
Simponi . . . . . .
Simvastatin . . . . .
Solodyn . . . . . .
Soolantra . . . . .
Sotalol . . . . . . .
Sovaldi . . . . . . .
Spiriva Handihaler
Spiriva Respimat .
Spironolactone . . .
Sprintec 28 . . . . .
Sprycel . . . . . . .
Stelara . . . . . . .
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15
12
.9
19
15
19
12
11
11
12
16
17
10
.9
13
11
.9
19
19
10
20
.9
17
25
Index of Covered Drugs
Stendra . . . . . . . . . . 17
Stiolto . . . . . . . . . . . 19
Strattera . . . . . . . . . . 11
Stribild . . . . . . . . . . . 16
Suboxone Film. . . . . . . 18
Sucralfate Tab . . . . . . . . 16
Sulfacetamide/Sulfur Emulsion13
Sulfamethoxazole-Trimethoprim9
SulfamethoxazoleTrimethoprim DS . . . . . 9
Sulfasalazine . . . . . . . . 16
Sumatriptan Tab and Spray . 11
Sumavel Dose . . . . . . . 11
Suprep Bowel Prep . . . . 16
Sustiva . . . . . . . . . . . 16
Symbicort . . . . . . . . . 19
Synagis. . . . . . . . . . . 18
Synjardy . . . . . . . . . . 15
Synthroid . . . . . . . . . 15
Synvisc . . . . . . . . . . . 18
Synvisc One . . . . . . . . 18
T
Taclonex . . . . . . . . . . 13
Tacrolimus Cap . . . . . . . 19
Tamiflu . . . . . . . . . . . . 9
Tamoxifen Tab. . . . . . . . . 9
Tamsulosin . . . . . . . . . 17
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 . 20
Testosterone Cypionate IM
Injection . . . . . . . . . 17
Timolol . . . . . . . . . . . 16
Timoptic Ocudose . . . . . 16
Tirosint. . . . . . . . . . . 15
Tivicay . . . . . . . . . . . 16
Tivorbex . . . . . . . . . . 18
Tizanidine . . . . . . . . . . 18
Tobramycin . . . . . . . . . 15
Tobramycin/Dexamethasone. 15
Bold type = Brand-name drug
[Plain type = Generic drug]
Tolterodine . . . . . . . . .
Topiramate Tab . . . . . . .
Torsemide Tab . . . . . . . .
Toujeo SoloStar . . . . . .
Toviaz . . . . . . . . . . .
Tracleer . . . . . . . . . .
Tradjenta. . . . . . . . . .
Tramadol Tab . . . . . . . .
Tramadol w/ Acetaminophen
Transderm-Scop . . . . . .
Travatan Z . . . . . . . . .
Trazodone. . . . . . . . . .
Tresiba . . . . . . . . . . .
Tretinoin Cream . . . . . . .
Tretinoin Microsphere Gel . .
Triamcinolone . . . . . . . .
Triamcinolone Spray. . . . .
Triamterene/HCTZ . . . . . .
Triazolam Tab . . . . . . . .
Tribenzor. . . . . . . . . .
Tri-Linyah . . . . . . . . . .
Trinessa . . . . . . . . . . .
Tri-Previfem . . . . . . . . .
Tri-Sprintec . . . . . . . . .
Triumeq . . . . . . . . . .
Trulicity . . . . . . . . . .
Truvada . . . . . . . . . .
19
12
10
14
19
11
15
18
18
16
16
11
14
13
13
13
19
10
12
10
20
20
20
20
16
15
16
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20
17
18
18
15
15
11
12
20
16
20
18
11
11
W
Warfarin . . . . . . . . . . . 9
Welchol . . . . . . . . . . 11
X
Xarelto . . . .
Xeljanz . . . .
Xolair. . . . .
Xopenex HFA
Xulane . . . .
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.9
17
19
19
20
Zarah . . . . . . . .
Zarxio . . . . . . .
Zenpep . . . . . .
Zepatier . . . . . .
Zetia . . . . . . . .
Zetonna . . . . . .
Ziprasidone Cap. . .
Zohydro ER . . . .
Zolmitriptan Tab. . .
Zolpidem . . . . . .
Zolpidem ER. . . . .
Zonisamide . . . . .
Zorvolex . . . . . .
Zostavax Injection.
Zovirax Cream . . .
Zovirax Ointment .
Zubsolv . . . . . .
Zutripro . . . . . .
Zyclara . . . . . . .
Zytiga . . . . . . .
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20
18
16
.9
11
19
12
18
11
12
12
12
18
18
13
13
18
18
13
.9
Z
U
Uceris Foam . . . . . . . . 16
Uloric. . . . . . . . . . . . 18
Ursodiol . . . . . . . . . . . 18
V
Vagifem . . . . .
Valacyclovir . . . .
Valsartan . . . . .
Valsartan/HCTZ . .
Varubi . . . . . .
Vascepa . . . . .
Vectical. . . . . .
Velphoro . . . . .
Venlafaxine ER Cap
Venlafaxine ER Tab
Venlafaxine Tab . .
Ventolin HFA . .
Verapamil ER . . .
Vesicare . . . . .
Vestura . . . .
Viagra . . . .
Vicodin . . . .
Vicodin ES. . .
Victoza . . . .
Vigamox . . .
Viibryd . . . .
Vimpat . . . .
Viorele . . . .
Viread . . . .
Vitamin D . . .
Voltaren Gel .
Vytorin . . . .
Vyvanse . . .
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20
.9
10
10
16
11
13
18
11
11
11
19
10
19
26
“My Medications” worksheet
Take this worksheet with you each time you visit a doctor. Each of your doctors should be aware of
every drug you take and you should have a list as well.
Name of Medicine
and Strength
Drug
Tier
I Take This
Medicine For
Directions
Doctor
Example: Lisinopril, 20 mg
Tier 1
High blood pressure
One tablet daily
Dr. Johnson
27
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