Your 2016 Four-Tier Prescription Drug List - myNHP.com · Your 2016 Four-Tier Prescription Drug...

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Your 2016 Four-TierPrescription Drug Listeffective January 1, 2016NHP Advantage Four-Tier

Please read: This document contains information about commonly prescribed medications.

For additional information:

Call the toll-free member phone number on your health plan ID card.

Visiting www.mynhp.com, clicking on the “Members” link and then selecting the “Pharmacy” tab on the left hand side of the page provides you access to:

• Locate a participating retail pharmacy by ZIP code.

• Look up possible lower-cost medication alternatives.

• Compare medication pricing and options.

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Your Prescription Drug List This Prescription Drug List (PDL) outlines the most commonly prescribed medications for certain conditions and organizes them into cost levels, also known as tiers. An important part of the PDL is giving you choices so you and your doctor can choose the best course of treatment for you.

Go to www.mynhp.com for complete drug informationSince the PDL may change, we encourage you to visit our website, www.mynhp.com. Click on the “Members” link and then select the “Pharmacy” tab on the left hand side of the page. This website is the best source for up-to-date information about the medications your pharmacy benefi t covers, possible lower-cost options, and cost comparisons.

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Table of Contents

Drug tiers and cost . . . . . . . . . . . . . . . . . . . . . . .5

Programs and Limits . . . . . . . . . . . . . . . . . . . . . .7

Drugs by category . . . . . . . . . . . . . . . . . . . . . . 10

Anti-InfectivesAntibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Cardiovascular/Heart DiseaseCoagulation Therapy . . . . . . . . . . . . . . . . . . . . . . . .11High Blood Pressure . . . . . . . . . . . . . . . . . . . . . . . .11High Cholesterol . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Central Nervous SystemAttention Deficit Disorder . . . . . . . . . . . . . . . . . . . 13Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Sedatives/Hypnotics . . . . . . . . . . . . . . . . . . . . . . . 14Seizure Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Diabetes/EndocrineBlood Glucose Monitoring . . . . . . . . . . . . . . . . . . 16Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Non-Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

EndocrineGrowth Hormone . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Thyroid Hormone Replacement . . . . . . . . . . . . . 17

Eye ConditionsAllergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

GastrointestinalAcid Suppression . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Nausea/Vomiting . . . . . . . . . . . . . . . . . . . . . . . . . . 18Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Hepatitis C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Inflammatory Conditions: Rheumatoid Arthritis, Crohn’s Disease, Psoriasis, Ulcerative Colitis . . . . . . . . . . . . . . . . . . . . . . . . 19

Men’s HealthProstate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Testosterone Therapy . . . . . . . . . . . . . . . . . . . . . . 19

Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

MusculoskeletalOsteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Pain Relief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Overactive Bladder . . . . . . . . . . . . . . . . . . . . . . 21

RespiratoryAllergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Asthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Pulmonary Arterial Hypertension . . . . . . . . . . . . 22

Smoking Cessation . . . . . . . . . . . . . . . . . . . . . 22

Transplant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Vitamins/Electrolytes . . . . . . . . . . . . . . . . . . . 23

Women’s HealthContraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Hormone Replacement . . . . . . . . . . . . . . . . . . . . . 24Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Prenatal Vitamins . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

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We want to help you better understand your medication options. Your pharmacy benefit offers flexibility and choice in determining the right medication for you. To help you get the most out of your pharmacy benefit, we’ve included some of the most commonly asked questions about the Prescription Drug List.

What is a Prescription Drug List (PDL)? This document is a list of commonly prescribed medications. Drugs are listed by common categories or class. They are placed into cost levels known as tiers. It includes both brand and generic prescription medications approved by the U.S. Food and Drug Administration (FDA).

Please note: Where differences are noted between this PDL and your benefit plan documents, the benefit plan documents will rule. It is not a complete list of medications, and not all medications listed may be covered under your plan. Please look at your benefit plan documents provided by your employer or health plan to see what medications are covered under your plan. You may also log on to www.mynhp.com or call the toll-free member phone number on your health plan ID card for more information.

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

If your medication is not listed in this document, please visit www.mynhp.com or call the toll-free member phone number on your health plan ID card.

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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 health plan. 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, 3 or 4, 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 1Lowest Cost

Lower-cost drugs . Some brands and generics are also included .

Use Tier 1 drugs for the lowestout-of-pocket costs .

Tier 2 and 3Mid-range Cost

Mix of brands and generics .

Use Tier 2 or Tier 3 drugs instead of Tier 4 to help reduce your out-of-pocket costs .

Tier 4Highest Cost

Mostly higher-cost brand as well as select generic drugs .

Many Tier 4 drugs have lower-costoptions in Tier 1, 2 or 3 . Ask yourdoctor if they could work for you .

Please note: Some plans may have two or three tiers, while others may not have any. If you have a high deductible plan, the tier cost levels may apply once you hit your deductible. Refer to your enrollment and plan materials on www.mynhp.com, or call the toll-free number on your health plan ID card for more information about your benefit plan.

When does the Prescription Drug List change?• Medications may move to a lower tier at any time.

• Medications may move to a higher tier when a generic becomes available.

• Medications may move to a higher tier or be excluded from coverage most often on January 1 or July 1.

When a medication changes tiers, you may have to pay a different amount for that medication.

For the most up-to-date list, call customer service at the number on your ID card.

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Programs and LimitsSome medications are noted with letters next to them. The letters refer to our pharmacy benefit programs. Your benefit plan determines how these medications may be covered for you.

DSPDesignated Specialty Program* – Specialty medications need to be filled at a designated specialty pharmacy for network coverage . Call the number on your ID card or call 1-888-739-5820 for more information .

EMay be excluded from coverage or subject to prior authorization and/or trial/failure of another medication(s) .** Lower-cost options are available and covered .

HHealth Care Reform Preventive – This medication is part of a Health Care Reform preventive benefit and may be available at no cost to you .

NNotification or Prior Authorization required*** – Your doctor is required to provide additional information to us to determine coverage .

SDPSelect Designated Pharmacy – Must use a lower cost medication at retail or transfer the impacted medication to the mail service pharmacy for network coverage .

SLSupply Limit – Amount of medication covered per copayment or in a specific time period .

STStep Therapy – Trial of a lower cost medication is required before a higher cost medication is covered .

* Specialty medications may have a different cost share, please consult your benefit documents .

** Some medications may require tried/failed criteria instead of being excluded from coverage .

*** Depending on your benefit you may have notification or prior authorization requirements for select medications .

To learn more about a pharmacy program or to find out if it applies to you, please visit www.mynhp.com or call the toll-free member phone number on your health plan ID card.

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Why are some medications excluded from coverage? Medications may be excluded from coverage under your pharmacy benefit when it works the same or similar as another prescription medication or an over-the-counter (OTC) medication. There may be other medication options available.

Should I talk to my doctor about over-the-counter (OTC) medications? An over-the-counter (OTC) medication may be the right treatment for some conditions. Talk to your doctor about available OTC options.

What is the difference between brand-name and generic medications? Generic medications contain the same active ingredients (what makes the medication work) as 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, Crestor) and generic drugs in plain type (for example, Simvastatin).

What if my doctor writes a brand-name prescription? The next time your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lower-cost option is available and if it might be right for you. Generic medications are usually your lowest-cost option, but not always. For some benefit plans if a brand-name drug is prescribed and a generic equivalent is available, your cost share may be the copay PLUS the cost difference between the brand-name drug and generic equivalent. Visit www.mynhp.com to make sure.

Are you taking a specialty medication? Specialty medications are high-cost and may be used to treat rare or complex conditions. For most plans, these medications are managed through the Specialty Pharmacy Program. Take advantage of personalized support designed to help you get the most out of your treatment plan. Visit UHCSpecialtyRx.com or call the toll-free phone number on your health plan ID card to learn more.

Please note, not all specialty medications are listed here. If you’re taking a specialty medication that is on Tier 3 or Tier 4, call the toll-free number on your health plan ID card to talk with a pharmacist about finding lower-cost options or a financial assistance program.

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What is Mail Service Member Select? Your plan may include a home delivery program called Mail Service Member Select, which encourages you to use the OptumRx® Mail Service Pharmacy for medication you take regularly. Choosing home delivery can help you better manage the medication you take on a regular basis, and may save you time and money.

You can either confirm enrollment in the OptumRx Mail Service Pharmacy or you can disenroll from mail service and continue to fill your maintenance medications at a retail pharmacy. You can get up to two fills at a retail pharmacy before you have to decide. However, please be aware that you must make a decision about whether or not to enroll in Mail Service Member Select.

If you do nothing and continue to fill your medications at a retail pharmacy, you may pay more for your medication until you make a decision and take action. You must confirm your decision every year. To learn more, you may log on to www.mynhp.com or call the toll-free member phone number on your health plan ID card for more information.

How do I get updated information about my pharmacy benefit?Since the PDL may change during your plan year, we encourage you to visit www.mynhp.com or call the toll-free member phone number on your health plan ID card for more current information.

Si usted esta interesado en conocer mas sobre su beneficio de farmacia o si necesita asistencia leyendo esta información, por favor llame al numero de telefono en la parte de atras de su tarjeta de identificacion.

In certain documents, the Prescription Drug List (PDL) was referred to as the “Preferred Drug List (PDL) .” This change in terms does not affect your benefit coverage .

Medications are categorized by common therapeutic conditions in this PDL for ease of reference only . These categories do not determine coverage for the medication for your condition . Your benefit plan determines coverage for these medications .

For more information


Or, visit www.mynhp.com

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

DSP = Designated Specialty ProgramE = May be excluded from coverageH = Health Care Reform Preventive

N = Notification or Prior Authorization requiredSDP = Select Designated PharmacySL = Supply LimitST = Step Therapy

Drug NameDrug Tier

Requirements & Limits

Anti-Infectives: Antibiotics

Amoxicillin Capsule, Chewable Tablet

1

Amoxicillin/Potassium Clavulanate Chewable Tablet, Tablet

1

Azithromycin Tablet 1Cefadroxil Capsule, Tablet

1

Cefdinir Capsule 2Cefixime Suspension 3Cefprozil Tablet 1Cefuroxime Tablet 1Cephalexin Capsule 1Ciprofloxacin Tablet 1Clarithromycin Tablet 1Clindamycin Capsule 1Dificid 3 SLDoryx 4 EDoxycycline Hyclate Capsule, Tablet

2

Doxycycline Monohydrate 50, 100 mg Capsule

1

Levofloxacin Tablet 1Metronidazole Tablet 1Minocycline Capsule 1Minocycline Tablet 3Moxifloxacin Tablet 3Nitrofurantoin Capsule 1Nitrofurantoin Macrocrystal Capsule

1

Drug NameDrug Tier


Ofloxacin Tablets 1Oracea 4Penicillin V Potassium Tablet 1

Solodyn 4Sulfamethoxazole-Trimethoprim Tablet

1

Suprax Capsule, Chewable Tablet, Tablet

4

Zyvox 2 N, SL

Anti-Infectives: Antifungals

Econazole Cream 1 SLFluconazole Tablet 1Itraconazole Capsule 1 SLKetoconazole Cream 1Noxafil Tablet, Suspension

2

Nystatin Cream, Ointment

1

Terbinafine Tablet 1 SL

Anti-Infectives: Antivirals

Acyclovir Ointment 4 N, SL, STAcyclovir Tablet 1Famciclovir 1Tamiflu 3 SLValacyclovir Tablet 2 SLValaganciclovir 1 SLZovirax Cream 4 E, SL

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Drug NameDrug Tier


Cancer

Bicalutamide 1Bosulif 2 DSP, N, SL, STCyclophosphamide Capsule

2

Gleevec 2 DSP, N, SLHydroxyurea Capsule 3Imbruvica 2 DSP, N, SLLeucovorin Calcium Tablet

1

Mercaptopurine Tablet 1Revlimid 2 DSP, N, SLSutent 2 DSP, N, SLTasigna 2 DSP, N, SLXeloda 1 DSP, SLZytiga 2 DSP, N, SLCardiovascular/Heart Disease: Coagulation TherapyClopidogrel 1Effient 4 SLEliquis 4 SLEnoxaparin Sodium 2 SLPradaxa 2 SLSavaysa 4 SLWarfarin Sodium 1Xarelto 2 SLCardiovascular/Heart Disease: High Blood PressureAmlodipine 1Amlodipine Besylate-Benazepril

2 SL

Amlodipine-Valsartan 3 SLAtenolol 1Atenolol-Chlorthalidone 1Benazepril 1Benazepril-Hydrochlorothiazide

1

Benicar 2 SLBenicar HCT 2 SL

Drug NameDrug Tier


Bidil 2Bisoprolol 1Bisoprolol-Hydrochlorothiazide

1

Bystolic 2Cartia XT 2Carvedilol 1Chlorthalidone 1Clonidine Tablet 1Diltiazem 24 Hour CD 2Diltiazem Sustained-Release Capsule

2

Diltiazem Sustained-Release Tablet

2

Diovan 4 E, SLDoxazosin 1Dutoprol 2 SLEdarbi 3 SLEdarbyclor 3 SLEnalapril 1Furosemide 1Guanfacine 1Hydralazine 1Hydrochlorothiazide 1Irbesartan 1 SLLabetalol 1Lisinopril 1Lisinopril-Hydrochlorothiazide

1

Losartan 1Losartan-Hydrochlorothiazide

1

Metoprolol Succinate 50, 100, 200 mg

2

Metoprolol Tartrate 1Nadolol 1Nifedipine Extended-Release

1

Propranolol Extended-Release Capsule

2

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Drug NameDrug Tier


Propranolol Tablet 1Quinapril 1Ramipril 1Spironolactone 1Telmisartan 2 SLTelmisartan-Hydrochlorothiazide

2 SL

Terazosin 1Triamterene-Hydrochlorothiazide

1

Valsartan 2 SLValsartan-Hydrochlorothiazide

1 SL

Verapamil 1Verapamil Sustained-Release

3

Cardiovascular/Heart Disease: High CholesterolAtorvastatin 1 SLCholine Fenofibrate 4 ECrestor 2 SLFenofibrate 43, 50 , 67, 130, 134, 150, 200 mg Capsule

4 E

Fenofibrate 48, 145 mg Tablet

4 E

Fenofibrate 54, 160 mg Tablet

2

Fenoglide 4 EGemfibrozil 1Lescol XL 4 SL, STLipitor 4 E, SL

Drug NameDrug Tier


Lipofen 4 ELivalo 4 SL, STLovastatin 1Niacin Extended-Release Tablet

4

Niaspan 2Omega-3-Acid Ethyl Esters Capsule

3 N

Pravastatin 1Simcor 4 SLSimvastatin 1Tricor 48, 145 mg 4 EVascepa 4 NVytorin 4 SLWelchol 2Zetia 4 SLCardiovascular/Heart Disease: OtherAmiodarone 1Digoxin 1Flecainide 1Isosorbide Mononitrate ER

1

Nitrostat 2Ranexa 2Sotalol 1

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Drug NameDrug Tier


Central Nervous System: Attention Deficit DisorderAdderall XR 2 N, SLAmphetamine Salt Combo

1 N

Concerta 2 N, SLDaytrana 4 E, N, SLDexmethylphenidate Extended-Release Capsule

4 E, N, SL

Dexmethylphenidate Tablet

1 N

Dextroamphetamine-Amphetamine Extended-Release

4 E, N, SL

Dextroamphetamine-Amphetamine Tablet

1 N

Dextroamphetamine Sulfate Tablet

3 N

Focalin XR 4 E, N, SLGuanfacine Extended-Release

4 SL, ST

Intuniv 4 E, SL, STMetadate CD 2 N, SLMethylphenidate Chewable Tablet

3 N

Methylphenidate Extended-Release Capsule

4 E, N, SL

Methylphenidate Extended-Release Tablet

4 E, N, SL

Methylphenidate Tablet 1 NStrattera 4 SLVyvanse 2 N, SL

Drug NameDrug Tier


Central Nervous System: Depression

Amitriptyline Tablet 1Brintellix 4 SL, STBupropion Extended-Release Tablet

1

Bupropion Sustained-Release Tablet

1

Bupropion Tablet 1Citalopram Tablet 1Cymbalta 4 E, SLDoxepin Capsule 1Duloxetine Capsule 3 SLEscitalopram Tablet 1Fetzima 4 SL, STFluoxetine Capsule, Tablet

1

Fluvoxamine Tablet 1Lexapro 4 EMirtazapine Tablet 1Nortriptyline Capsule 1Paroxetine Tablet 1Pristiq ER 3 SLSertraline Tablet 1Trazodone Tablet 1Venlafaxine Extended-Release Capsule

1

Venlafaxine Tablet 1Viibryd 4 SLWellbutrin XL 4 E

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Drug NameDrug Tier


Central Nervous System: Migraine

Acetaminophen/Butalbital/Caffeine 325 mg/50 mg/40 mg

1 SL

Naratriptan 1 SLRelpax 2 SLRizatriptan ODT, Tablet 1 SLSumatriptan Nasal Spray 2 SLSumatriptan Succinate Tablet, Injection

1 SL

Sumavel DosePro 3 SLCentral Nervous System: Multiple SclerosisAmpyra 2 DSP, N, SLAubagio 4 DSP, N, SL, STAvonex 2 DSP, N, SLBetaseron 2 DSP, N, SLCopaxone 2 DSP, N, SLGilenya 3 DSP, N, SL, ST

Glatopa 4DSP, E, N,

SL, STRebif 4 DSP, N, SL, STTecfidera 2 DSP, N, SL

Central Nervous System: Other

Abilify Tablet 4 E, SLAlprazolam Extended-Release Tablet

1

Alprazolam Tablet 1Aripiprazole Tablet 2 SLBuprenorphine/Naloxone Tablet

4 E, N, SL

Buspirone Tablet 1

Drug NameDrug Tier


Carbidopa-Levodopa 1Diazepam Tablet 1Donepezil 5, 10 mg ODT, Tablet

1

Latuda 4 SLLithium Capsule 1Lorazepam Tablet 1Memantine 3Modafinil Tablet 4 E, N, SLNamenda XR 4Nuvigil 4 N, SLOlanzapine Tablet 1 SLPramipexole Tablet 1Quetiapine Tablet 1 SLRisperidone Tablet 1Ropinirole Tablet 1Seroquel XR 4 SLSuboxone Film 4 E, N, SLTolcapone 2Xyrem 4 N, SLZelapar 3Ziprasidone Capsule 2 SLZubsolv 2 N, SLCentral Nervous System: Sedatives/HypnoticsEszopiclone Tablet 2 SLTemazepam Capsule 1Triazolam Tablet 1Zaleplon Capsule 1 SLZolpidem Extended-Release Tablet

4 E, SL

Zolpidem Tablet 1 SL

15

Drug NameDrug Tier


Central Nervous System: Seizure DisordersCarbamazepine Tablet 1Clonazepam Tablet 1Diazepam Tablet 1Divalproex Delayed-Release Tablet

1

Divalproex Extended-Release Tablet

1

Gabapentin Capsule, Tablet

1

Lamotrigine Tablet 1Levetiracetam Extended-Release Tablet

2

Levetiracetam Tablet 1Lyrica 4 SDP, SL, STOxcarbazepine Tablet 1Phenytoin Capsule, Suspension

1

Topiramate Tablet 1Zonisamide Capsule 1

Dermatology

Absorica 4 E, NAczone 4 SLAdapalene 0 .1% Cream, Gel

3 N, SL

Adapalene 0 .3% Gel 3 N, SLBethamethasone Dipropionate 0 .05% Augmented Lotion, Ointment

3

Betamethasone Dipropionate 0 .05% Cream, Ointment

2

Carac 2Ciclopirox Cream, Gel, Lotion, Solution

1

Claravis 2 NClindamycin 1%/Benzoyl Peroxide 5% Gel

4 E, SL

Drug NameDrug Tier


Clindamycin 1 .2%/Benzoyl Peroxide 5% Gel

3 SL

Clindamycin Gel 3 SLClindamycin Lotion 3Clindamycin Solution, Swabs

1

Clobetasol Propionate Cream, Ointment, Solution

1 SL

Clotrimazole-Betamethasone Cream

1 SL

Clotrimazole-Betamethasone Lotion

1

Condylox Gel 3Desonide 0 .05% Cream, Lotion, Ointment

3 SL

Desoximetasone Gel, Ointment

3 SL

Differin 1% Cream, Gel

2 N, SL

Diflorasone Diacetate 0 .05% Cream, Ointment

3 SL

Epiduo 3 SLFinacea 4Fluocinonide 0 .05% Cream

1

Fluocinolone Cream, Oil, Ointment, Solution

3 SL

Hydrocortisone 2 .5% Cream, Ointment

1

Imiquimod 5% Cream 2 SLMetronidazole Gel 0 .75% 1Mirvaso 4 SLMometasone Furoate Cream, Lotion, Ointment

1

Mupirocin Ointment 1Nystatin-Triamcinolone Acetonide Cream, Ointment

4 E

Oxsoralen-Ul 2Picato 3 SL

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Drug NameDrug Tier


Regranex 2 N, SLTacrolimus Ointment 2 N, SLTazorac 4 N, SLTretinoin 1 N, SLTretinoin Microspheres 4 E, N, SLTriamcinolone Acetonide Cream, Lotion, Ointment

1

Vectical 3 SL

Diabetes: Blood Glucose Monitoring

Accu-Chek Test Strips

4 E, SL

Contour Test Strips 4 E, SLDexcom G4 Platinum Continuous Glucose Monitoring System

3 N, SL

Dexcom Sensor 3 N, SLDexcom Transmitter 3 N, SLFreeStyle Test Strips 4 E, SLOneTouch Test Strips

1 SL

OneTouch Ultra Meter

1

OneTouch Ultra Mini 1OneTouch Ultra Test Strips

1 SL

OneTouch Verio 1OneTouch Verio IQ 1OneTouch Verio Sync 1OneTouch Verio Test Strips

1 SL

Drug NameDrug Tier


Diabetes: Insulin

Afrezza 4 E, N, SL, STHumalog KwikPen 2 SLHumalog Mix 50-50 KwikPen

2 SL

Humalog Mix 75-25 KwikPen

2 SL

Humalog Vials 1 SLHumulin 70-30 KwikPen

2 SL

Humulin 70-30 Vials 1 SLHumulin N KwikPen 2 SLHumulin N Vials 1 SLHumulin R Vials 1 SLLantus Solostar 3 SLLantus Vials 3 SLLevemir FlexTouch 1 SLLevemir Vials 1 SLNovolin 70-30 Vials 3 SDP, SL, STNovolin N Vials 3 SDP, SL, STNovolin R Vials 3 SDP, SL, STNovolog Flexpen 4 SDP, SL, STNovolog Mix 70/30 Flexpen

4 SDP, SL, ST

Novolog Mix 70/30 Vials

4 SDP, SL, ST

Novolog Vials 4 SDP, SL, ST

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Drug NameDrug Tier


Diabetes: Non-Insulin

Bydureon 2 SLByetta 2 SLFarxiga 4 SL, STGlimepiride 1Glipizide 1Glipizide Extended-Release

1

Glyburide 1Glyxambi 4 E, SL, STInvokamet 2 SLInvokana 2 SL, STJanumet 4 SL, STJanuvia 4 SL, STJardiance 2 SL, STJentadueto 2 SLKazano 2 SLKombiglyze XR 2 SLMetformin 1Metformin Extended-Release Tablet (generic Glucophage XR)

1

Nesina 2 SLOnglyza 2 SLOseni 2 SLPioglitazone 1 SLTanzeum 2 SLTradjenta 2 SLTrulicity 4 SL, STVictoza 2-Pak 2 SLVictoza 3-Pak 3 SLXigduo XR 4 E, SL, ST

Endocrine: Growth Hormone*

Nutropin, Nutropin AQ

2 DSP, N, SL

* Benefit coverage and your cost share for growth hormone drugs is determined by your prescription drug benefit plan . Please consult your plan documents .

Drug NameDrug Tier


Endocrine: Other

Calcitriol Capsule 1Desmopressin Tablet 1Dexamethasone Tablet 1Methylprednisolone Tablet

1

Prenisolone Oral Solution

1

Prednisone Tablet 1Endocrine: Thyroid Hormone ReplacementArmour Thyroid 3Levothyroxine Sodium Tablet

1

Liothyronine Sodium Tablet

2

Methimazole Tablet 1NP Thyroid Tablet 1Synthroid 2Tirosint 4 E

Eye Conditions: Allergies

Azelastine 0 .05% Ophthalmic Solution

1 SL

Lastacaft 3 SLPataday 4 E, SLPatanol 4 E, SL

Eye Conditions: Antibiotics

Erythromycin 0 .5% Ophthalmic Ointment

1

Gentamicin Ophthalmic Ointment, Solution

1

Moxeza 4Ofloxacin 0 .3% Ophthalmic Solution

1

Tobramycin/Dexamethasone 0 .3%-0 .1% Ophthalmic Suspension

2

Tobramycin Ophthalmic Solution

1

Vigamox 4

18




Drug NameDrug Tier


Eye Conditions: Glaucoma

Alphagan P 0.1% 2 SLAzopt 2 SLCombigan 2 SLLatanoprost 0 .005% Ophthalmic Solution

1

Lumigan 2 SLTimolol Maleate 0 .25%, 0 .5% Ophthalmic Solution

1

Travatan Z 2 SL

Gastrointestinal: Acid Suppression

Dexilant 3 SLEsomeprazole Capsule 4 E, SLLansoprazole Capsules 3 E, SLNexium Capsule 4 E, SLOmeclamox-Pak 3 SLOmeprazole Capsule 1Pantoprazole Tablet 1Pylera 3 SLRabeprazole Tablet 3 SLRanitadine Syrup 1Sucralfate Tablet 1

Gastrointestinal: Nausea/Vomiting

Akynzeo 4 SLEmend 2 SLOndansetron 1Ondansetron ODT 1Transderm-Scop 3

Drug NameDrug Tier


Gastrointestinal: Other

Amitiza 4 N, SL, STApriso 2Asacol HD Tablet 4 ECanasa 2Cortifoam 2Creon 2Delzicol 4 EDiphenoxylate-Atropine Tablet

1

Golytely 2Hyoscyamine Tablet 1Lialda 2Linzess 2 N, SLMetoclopramide Tablet 1Movantik 2 N, SLMoviprep 3Polyethylene Glycol 3350

2

Prepopik 3Suclear 3Sulfasalazine Tablet 1Suprep 3Uceris 3Zenpep 2

Hepatitis C

Harvoni 2 DSP, N, SLRibapak 4 DSP, ERibavirin Tablet 1 DSPSovaldi 2 DSP, N, SL, STViekira Pak 4 DSP, N, SL, ST

19

Drug NameDrug Tier


HIV/AIDS

Atripla 2 DSPComplera 2 DSPEpzicom 2 DSPEvotaz 2 DSPIntelence 2 DSPIsentress 2 DSPKaletra 2 DSPLamivudine-Zidovudine 1 DSPNevirapine 1 DSPNevirapine Extended-Release

2 DSP

Norvir 2 DSPPrezcobix 2 DSPPrezista 2 DSPReyataz 2 DSPStribild 3 DSP, STSustiva 2 DSPTivicay 3 DSPTriumeq 2 DSPTruvada 2 DSPTybost 2 DSPViread 2 DSPVitekta 2 DSPInflammatory Conditions: Rheumatoid Arthritis, Crohn’s Disease, Psoriasis, Ulcerative ColitisActemra 4 DSP, N, SL, STCimzia 2 DSP, N, SLCosentyx 4 DSP, N, SL, STEnbrel 4 DSP, N, SL, STHumira 2 DSP, N, SL

Drug NameDrug Tier


Hydroxychloroquine Sulfate Tablet

1

Leflunomide Tablet 1Methotrexate Tablet 1Orencia 4 DSP, N, SL, STOtezla 4 DSP, N, SL, STOtrexup 4 E, SL, STRasuvo 4 SL, STSimponi 2 DSP, N, SLStelara 2 DSP, N, SLXeljanz 4 DSP, N, SL, ST

Men’s Health: Prostate

Alfuzosin Tablet 1Cialis 4 SL, STDoxazosin Tablet 1Finasteride Tablet 1Rapaflo 4Tamsulosin Capsule 1Terazosin Capsule, Tablet 1

Men’s Health: Testosterone Therapy

Androderm 2 N, SLAndrogel 4 E, N, SLAndroid 2Testim 2 N, SLTestosterone Cypionate Injection

1

20




Drug NameDrug Tier


Miscellaneous

Anastrozole Tablet 1Antipyrine/Benzocaine Otic Solution

1

Aranesp 2 DSP, SLAuryxia 3Benzonatate Capsule 1Bethkis 2 DSP, N, SLBromfed DM 3Cayston 2 N, SLCerdelga 2 DSP, NChlorpheniramine/Hydrocodone/Pseudoephedrine Solution

2 SL

Ciprodex 2Epipen 2 SLEpipen-Jr 2 SLFosrenol 3Hydrocodone/Chlorpheniramine Suspension

3 SL

Hydrocodone/Homatropine

1

Letrozole Tablet 1Lidocaine Transdermal Patch

2 SL

Nuedexta 2Pegasys 2 DSP, N, SLPhenazopyridine 1Procrit 2 DSP, SLPromethazine/Codeine 1Promethazine/Dextromethorphan

1

Drug NameDrug Tier


Pulmozyme 2 DSP, N, SLRectiv 3 N, SLRenvela 2Restasis 4 N, SLRezira 3Tobi Podhaler 3 DSP, N, SLTobramycin Nebulized Solution

4 DSP, E, N, SL

Velphoro 2

Musculoskeletal: Osteoporosis

Alendronate Sodium Tablet

1 SL

Forteo 2 DSP, NIbandronate Tablet 2 SLRaloxifene Tablet 2Risedronate Sodium Tablet

3 SL

Musculoskeletal: Other

Allopurinol Tablet 1Baclofen Tablet 1Carisoprodol 350 mg Tablet

1

Colcrys 4 ECyclobenzaprine Tablet 1Metaxalone Tablet 3Methocarbamol Tablet 1Mitigare 2Tizanidine Tablet 1Uloric 4 SL, ST

21

Drug NameDrug Tier


Musculoskeletal: Pain Relief

Acetaminophen/Codeine Tablet

1 SL

Celecoxib 3 SL, STDiclofenac Tablet 1Etodolac Capsule 1Fentanyl 12 mcg, 25 mcg, 50 mcg, 75 mcg, 100 mcg Patch

2 SL

Fentanyl Citrate Lozenge

2 N, SL

Hydrocodone/Acetaminophen 5/325, 7 .5/325, 10/325 mg Tablet

1 SL

Hydrocodone/Ibuprofen Tablet

1

Hydromorphone Tablet 1Hysingla 4 E, N, SL, STIbuprofen Tablet 1Indomethacin Capsule 1Ketorolac Tablet 1Lazanda 3 N, SLMeloxicam Tablet 1Methadone Tablet, Oral Solution, Concentrate Solution

1 SL

Morphine Sulfate Extended-Release Tablet

1 SL

Morphine Sulfate Oral Solution

1

Nabumetone Tablet 1Naproxen Tablet 1Nucynta 4 SLNucynta ER 3 N, SLOpana ER 2 N, SLOxycodone/Acetaminophen 5/325, 7 .5/325, 10/325 mg Tablet

1 SL

Drug NameDrug Tier


Oxycodone Tablet 1Oxycontin 4 N, SL, STSprix 3Subsys 4 E, N, SLTramadol-Acetaminophen

1 SL

Tramadol Sustained-Release Tablet

2 SL

Tramadol Tablet 1Vicodin 5/300, 7 .5/300, 10/300 mg Tablet

4 E, SL

Voltaren Gel 2Zohydro ER 4 N, SL, ST

Overactive Bladder

Dicyclomine Tablet 1Oxybutynin Extended-Release Tablet

2

Oxybutynin Tablet 1Tolterodine Extended-Release Tablet

4 E

Tolterodine Tablet 4 EToviaz 3Vesicare 4 E

Respiratory: Allergies

Azelastine 0 .1% Nasal Spray

3 SL

Clarinex 4 E, SLClarinex-D 3 E, SLCyproheptadine Tablet 1Fluticasone Nasal Spray 2 SLHydroxyzine Capsule, Tablet

1

Levocetirizine Tablet 1 SLNasonex 4 E, SLPromethazine Tablet 1Qnasl 4 E, SLTriamcinolone Nasal Spray

4 E, SL

Zetonna 3 SL

22




Drug NameDrug Tier


Respiratory: Asthma/COPD

Advair Diskus/HFA 3 SLAerospan 3 SLAlbuterol Nebs 1Albuterol Sulfate Tablet 1Alvesco 1 SLArnuity Ellipta 3 SLAsmanex 1 SLBreo Ellipta 3 SLBudesonide Nebs 2 SLCombivent Respimat 3 SLDulera 3 SLFlovent Diskus/HFA 3 SLForadil 3 SLIncruse Ellipta 2 SLIpratropium-Albuterol Nebs

1

Ipratropium Nebs 1Levalbuterol Nebs 4 E, SLMontelukast Chewable Tablet, Tablet

1 SL

Montelukast Granules 2 SLPerforomist 3 SLProair HFA 3 SLProventil HFA 3 SLPulmicort Flexhaler 4 SDP, SLQVAR 1 SLSerevent Diskus 3 SLSpiriva Handihaler 4 SLSpiriva Respimat 4 SLStriverdi Respimat 2 SLSymbicort 4 E, SL

Drug NameDrug Tier


Tudorza 2 SLVentolin HFA 1 SLXopenex HFA 3 SLXopenex Nebs 4 E, SLRespiratory: Pulmonary Arterial HypertensionAdcirca 4 DSP, N, SLAdempas 2 DSP, N, SLLetairis 2 DSP, N, SLOpsumit 2 DSP, N, SLOrenitram 4 DSP, N, SLSildenafil Tablet 1 DSP, N, SLTracleer 2 DSP, N, SLTyvaso 2 DSP, N

Smoking Cessation

Bupropion Sustained-Release Tablet

1 H

Chantix Tablet 3 H, NNicoderm CQ 3 HNicorette Gum 3 HNicorette Lozenge 3 HNicorette Mini-Lozenge

3 H

Nicotine Gum 1 HNicotine Lozenge 1 HNicotine Patch 1 HNicotrol Inhaler 3 H, NNicotrol Nasal Spray 3 H, NThrive Gum 1 H

23

Drug NameDrug Tier


Transplant

Azathioprine Tablet 1Cellcept 4 DSPCyclosporine Modified Capsule

1 DSP

Mycophenolate Capsule, Suspension

1 DSP

Mycophenolic Acid Tablet

2 DSP

Myfortic 4 DSPNeoral 4 DSPPrograf 4 DSPRapamune 4 DSPSirolimus Tablet 1 DSPTacrolimus Capsule 1 DSP

Vitamins/Electrolytes

Fluoride 1Folic Acid 1Klor-Con M10 1Klor-Con M20 1Potassium Chloride 1Potassium Citrate 1

Women’s Health: Contraceptives

Apri 1 HAviane 1 HAzurette 2Cryselle 1 HCyclafem 1 HElla 1 HEnskyce 1 HGildess 2Gildess Fe 1 HIntrovale 2 HJolessa 2 HJunel 2Junel Fe 1 H

Drug NameDrug Tier


Levora-28 1 HLo Loestrin Fe 3Loryna 3Low-Ogestrel 1 HLutera 1 HMicrogestin 2Microgestin FE 1 HMinastrin 24 FE 4 EMononessa 3Natazia 1 HNecon 0 .5/35, 1/35, 1/50, 10/11

1 H

Next Choice 1 HNorgestimate-Ethinyl Estradiol

3

Nortrel 0 .5/35 1 HNuvaring 2 HOrsythia 1 HOrtho-Cyclen 1 HOrtho Micronor 1 HOrtho-Novum 3Ortho-Novum 7/7/7 1 HOrtho Tri-Cyclen 1 HOrtho Tri-Cyclen Lo 3Plan B One Step 1 HQuasense 2 HReclipsen 1 HSprintec 3Sronyx 1 HTri-Previfem 3Tri-Sprintec 3Trinessa 3Vestura 3Viorele 2Xulane 3 HYasmin 28 1 HYaz 2

24




Drug NameDrug Tier


Women’s Health: Hormone Replacement

Cenestin 4 EClimara 2 SLClimara Pro 3 SLDivigel 3Duavee 3Enjuvia 3Estrace Cream 3Estradiol/Norethindrone Acetate Tablet

2

Estradiol Tablet 1Estradiol Twice-Weekly Transdermal Patch

4 E, SL

Estring 2 SLEstrogen/Methyltestosterone Tablet

1

Evamist 2Medroxyprogesterone Tablet

1

Minivelle 3 SLPremarin 3Premphase 3Prempro 3Progesterone Micronized Capsule

2

Vagifem 2Vivelle-Dot 2 SL

Drug NameDrug Tier


Women’s Health: Miscellaneous

Osphena 3Raloxifene 2 H, NTamoxifen 1 H, N

Women’s Health: Prenatal Vitamins

Brand Prenatal Vitamins

3

25

IndexA

Abilify Tablet .........................14Absorica ................................. 15Accu-Chek Test Strips ...........16Acetaminophen/Butalbital/

Caffeine 325 mg/50 mg/ 40 mg ..................................14

Acetaminophen/Codeine Tablet ...................................21

Actemra ..................................19Acyclovir Ointment ................10Acyclovir Tablet .....................10Aczone ................................... 15Adapalene 0.1% Cream, Gel.. 15Adapalene 0.3% Gel .............. 15Adcirca .................................. 22Adderall XR .......................... 13Adempas ................................ 22Advair Diskus/HFA .............. 22Aerospan ............................... 22Afrezza ...................................16Akynzeo .................................18Albuterol Nebs ...................... 22Albuterol Sulfate Tablet ......... 22Alendronate Sodium Tablet... 20Alfuzosin Tablet .....................19Allopurinol Tablet ................. 20Alphagan P 0.1% ....................18Alprazolam Extended-Release

Tablet ...................................14Alprazolam Tablet ..................14Alvesco .................................. 22Amiodarone ........................... 12Amitiza...................................18Amitriptyline Tablet .............. 13Amlodipine ............................11Amlodipine-Valsartan ............11

Amlodipine Besylate-Benazepril .............11

Amoxicillin/Potassium Clavulanate Chewable Tablet, Tablet .......................10

Amoxicillin Capsule, Chewable Tablet ..................10

Amphetamine Salt Combo .... 13Ampyra...................................14Anastrozole Tablet ................ 20Androderm .............................19Androgel.................................19Android ..................................19Antipyrine/Benzocaine

Otic Solution ...................... 20Apri ....................................... 23Apriso .....................................18Aranesp ................................. 20Aripiprazole Tablet .................14Armour Thyroid .....................17Arnuity Ellipta ...................... 22Asacol HD Tablet ..................18Asmanex ................................ 22Atenolol ..................................11Atenolol-Chlorthalidone ........11Atorvastatin ........................... 12Atripla ....................................19Aubagio ..................................14Auryxia .................................. 20Aviane ................................... 23Avonex ....................................14Azathioprine Tablet ............... 23Azelastine 0.05%

Ophthalmic Solution ...........17Azelastine 0.1% Nasal Spray ..21Azithromycin Tablet ...............10Azopt ......................................18Azurette ................................ 23

B

Baclofen Tablet ...................... 20Benazepril...............................11Benazepril-

Hydrochlorothiazide ............11Benicar ...................................11Benicar HCT .........................11Benzonatate Capsule ............. 20Betamethasone Dipropionate

0.05% Cream, Ointment .... 15Betaseron ................................14Bethamethasone Dipropionate

0.05% Augmented Lotion, Ointment ............................ 15

Bethkis .................................. 20Bicalutamide ...........................11Bidil ........................................11Bisoprolol ................................11Bisoprolol-

Hydrochlorothiazide ............11Bosulif ....................................11Brand Prenatal Vitamins ....... 24Breo Ellipta ........................... 22Brintellix................................ 13Bromfed DM ......................... 20Budesonide Nebs ................... 22Buprenorphine/Naloxone

Tablet ...................................14Bupropion Extended-Release

Tablet .................................. 13Bupropion Sustained-Release

Tablet .............................13, 22Bupropion Tablet ................... 13Buspirone Tablet .....................14Bydureon ................................17Byetta .....................................17Bystolic ...................................11

26

C

Calcitriol Capsule ...................17Canasa ....................................18Carac ..................................... 15Carbamazepine Tablet ........... 15Carbidopa-Levodopa ..............14Carisoprodol 350 mg Tablet .. 20Cartia XT ...............................11Carvedilol ...............................11Cayston .................................. 20Cefadroxil Capsule, Tablet .....10Cefdinir Capsule ....................10Cefixime Suspension ..............10Cefprozil Tablet ......................10Cefuroxime Tablet ..................10Celecoxib ................................21Cellcept ................................. 23Cenestin ................................ 24Cephalexin Capsule ................10Cerdelga ................................ 20Chantix Tablet ....................... 22Chlorpheniramine/

Hydrocodone/Pseudoephedrine Solution .. 20

Chlorthalidone .......................11Choline Fenofibrate ............... 12Cialis ......................................19Ciclopirox Cream, Gel,

Lotion, Solution ................. 15Cimzia ....................................19Ciprodex ................................ 20Ciprofloxacin Tablet ...............10Citalopram Tablet .................. 13Claravis .................................. 15Clarinex ..................................21Clarinex-D .............................21Clarithromycin Tablet ............10Climara.................................. 24Climara Pro ........................... 24

Clindamycin 1%/Benzoyl Peroxide 5% Gel ................. 15

Clindamycin 1.2%/Benzoyl Peroxide 5% Gel ................. 15

Clindamycin Capsule .............10Clindamycin Gel ................... 15Clindamycin Lotion .............. 15Clindamycin Solution,

Swabs .................................. 15Clobetasol Propionate Cream,

Ointment, Solution ............. 15Clonazepam Tablet ................ 15Clonidine Tablet .....................11Clopidogrel .............................11Clotrimazole-Betamethasone

Cream ................................. 15Clotrimazole-Betamethasone

Lotion ................................. 15Colcrys .................................. 20Combigan ...............................18Combivent Respimat ............. 22Complera ................................19Concerta ................................ 13Condylox Gel ........................ 15Contour Test Strips ................16Copaxone................................14Cortifoam ...............................18Cosentyx.................................19Creon ......................................18Crestor .................................. 12Cryselle .................................. 23Cyclafem ............................... 23Cyclobenzaprine Tablet ......... 20Cyclophosphamide Capsule ....11Cyclosporine Modified

Capsule ............................... 23Cymbalta ............................... 13Cyproheptadine Tablet ...........21

D

Daytrana ................................ 13

Delzicol ..................................18Desmopressin Tablet ..............17Desonide 0.05% Cream,

Lotion, Ointment ............... 15Desoximetasone Gel,

Ointment ............................ 15Dexamethasone Tablet ...........17Dexcom G4 Platinum

Continuous Glucose Monitoring System ..............16

Dexcom Sensor .......................16Dexcom Transmitter ..............16Dexilant ..................................18Dexmethylphenidate

Extended-Release Capsule ............................... 13

Dexmethylphenidate Tablet ... 13Dextroamphetamine-

Amphetamine Extended-Release ............... 13

Dextroamphetamine-Amphetamine Tablet .......... 13

Dextroamphetamine Sulfate Tablet .................................. 13

Diazepam Tablet ..............14, 15Diclofenac Tablet ....................21Dicyclomine Tablet ................21Differin 1% Cream, Gel ........ 15Dificid ....................................10Diflorasone Diacetate 0.05%

Cream, Ointment ............... 15Digoxin ................................. 12Diltiazem 24 Hour CD ..........11Diltiazem Sustained-Release

Capsule ................................11Diltiazem Sustained-Release

Tablet ...................................11Diovan ....................................11Diphenoxylate-Atropine

Tablet ...................................18

27

Divalproex Delayed-Release Tablet .................................. 15

Divalproex Extended-Release Tablet .................................. 15

Divigel ................................... 24Donepezil 5, 10 mg ODT,

Tablet ...................................14Doryx .....................................10Doxazosin .........................11, 19Doxazosin Tablet ....................19Doxepin Capsule ................... 13Doxycycline Hyclate Capsule,

Tablet ...................................10Doxycycline Monohydrate

50, 100 mg Capsule .............10Duavee ................................... 24Dulera .................................... 22Duloxetine Capsule ............... 13Dutoprol .................................11

E

Econazole Cream ...................10Edarbi .....................................11Edarbyclor ..............................11Effient ....................................11Eliquis ....................................11Ella ........................................ 23Emend ....................................18Enalapril .................................11Enbrel .....................................19Enjuvia .................................. 24Enoxaparin Sodium ................11Enskyce ................................. 23Epiduo ................................... 15Epipen ................................... 20Epipen-Jr ............................... 20Epzicom .................................19Erythromycin 0.5%

Ophthalmic Ointment .........17Escitalopram Tablet ............... 13Esomeprazole Capsule ............18

Estrace Cream ....................... 24Estradiol/Norethindrone

Acetate Tablet ..................... 24Estradiol Tablet ..................... 24Estradiol Twice-Weekly

Transdermal Patch .............. 24Estring ................................... 24Estrogen/Methyltestosterone

Tablet .................................. 24Eszopiclone Tablet ..................14Etodolac Capsule ....................21Evamist .................................. 24Evotaz .....................................19

F

Famciclovir .............................10Farxiga ....................................17Fenofibrate 43, 50 , 67, 130,

134, 150, 200 mg Capsule .. 12Fenofibrate 48, 145 mg

Tablet .................................. 12Fenofibrate 54, 160 mg

Tablet .................................. 12Fenoglide ............................... 12Fentanyl 12 mcg, 25 mcg,

50 mcg, 75 mcg, 100 mcg Patch ....................................21

Fentanyl Citrate Lozenge .......21Fetzima .................................. 13Finacea .................................. 15Finasteride Tablet ...................19Flecainide .............................. 12Flovent Diskus/HFA ............. 22Fluconazole Tablet ..................10Fluocinolone Cream, Oil,

Ointment, Solution ............. 15Fluocinonide 0.05% Cream ... 15Fluoride ................................. 23Fluoxetine Capsule, Tablet .... 13Fluticasone Nasal Spray ..........21Fluvoxamine Tablet ............... 13

Focalin XR ............................ 13Folic Acid .............................. 23Foradil ................................... 22Forteo .................................... 20Fosrenol ................................. 20FreeStyle Test Strips ...............16Furosemide .............................11

G

Gabapentin Capsule, Tablet .. 15Gemfibrozil ........................... 12Gentamicin Ophthalmic

Ointment, Solution ..............17Gildess ................................... 23Gildess Fe .............................. 23Gilenya ...................................14Glatopa ...................................14Gleevec ...................................11Glimepiride ............................17Glipizide .................................17Glipizide Extended-Release ...17Glyburide................................17Glyxambi ................................17Golytely ..................................18Guanfacine .......................11, 13Guanfacine

Extended-Release ............... 13

H

Harvoni ..................................18Humalog KwikPen .................16Humalog Mix 50-50

KwikPen ..............................16Humalog Mix 75-25

KwikPen ..............................16Humalog Vials .......................16Humira ...................................19Humulin 70-30 KwikPen .......16Humulin 70-30 Vials .............16Humulin N KwikPen .............16Humulin N Vials ....................16

28

Humulin R Vials ....................16Hydralazine ............................11Hydrochlorothiazide ...............11Hydrocodone/Acetaminophen

5/325, 7.5/325, 10/325 mg Tablet ...................................21

Hydrocodone/ Chlorpheniramine Suspension .......................... 20

Hydrocodone/Homatropine .. 20Hydrocodone/Ibuprofen

Tablet ...................................21Hydrocortisone 2.5% Cream,

Ointment ............................ 15Hydromorphone Tablet ..........21Hydroxychloroquine Sulfate

Tablet ...................................19Hydroxyurea Capsule .............11Hydroxyzine Capsule,

Tablet ...................................21Hyoscyamine Tablet ...............18Hysingla .................................21

I

Ibandronate Tablet ................ 20Ibuprofen Tablet .....................21Imbruvica ...............................11Imiquimod 5% Cream ........... 15Incruse Ellipta ....................... 22Indomethacin Capsule ............21Intelence .................................19Introvale ................................ 23Intuniv ................................... 13Invokamet ...............................17Invokana .................................17Ipratropium-Albuterol Nebs .. 22Ipratropium Nebs .................. 22Irbesartan ...............................11Isentress ..................................19Isosorbide Mononitrate ER ... 12Itraconazole Capsule ...............10

J

Janumet ..................................17Januvia ....................................17Jardiance .................................17Jentadueto ...............................17Jolessa .................................... 23Junel ....................................... 23Junel Fe .................................. 23

K

Kaletra ....................................19Kazano ...................................17Ketoconazole Cream ..............10Ketorolac Tablet ......................21Klor-Con M10 ...................... 23Klor-Con M20 ...................... 23Kombiglyze XR ......................17

L

Labetalol .................................11Lamivudine-Zidovudine ........19Lamotrigine Tablet ................ 15Lansoprazole Capsules ...........18Lantus Solostar .......................16Lantus Vials ...........................16Lastacaft .................................17Latanoprost 0.005%

Ophthalmic Solution ...........18Latuda ....................................14Lazanda ..................................21Leflunomide Tablet ................19Lescol XL .............................. 12Letairis .................................. 22Letrozole Tablet .................... 20Leucovorin Calcium Tablet ....11Levalbuterol Nebs .................. 22Levemir FlexTouch ................16Levemir Vials .........................16Levetiracetam

Extended-Release Tablet .... 15Levetiracetam Tablet ............. 15

Levocetirizine Tablet ..............21Levofloxacin Tablet ................10Levora-28 .............................. 23Levothyroxine Sodium

Tablet ...................................17Lexapro.................................. 13Lialda .....................................18Lidocaine Transdermal

Patch ................................... 20Linzess ...................................18Liothyronine Sodium Tablet ..17Lipitor .................................... 12Lipofen .................................. 12Lisinopril ..........................11, 34Lisinopril-

Hydrochlorothiazide ............11Lithium Capsule .....................14Livalo .................................... 12Lo Loestrin Fe ...................... 23Lorazepam Tablet ...................14Loryna ................................... 23Losartan .................................11Losartan-

Hydrochlorothiazide ............11Lovastatin .............................. 12Low-Ogestrel ........................ 23Lumigan .................................18Lutera .................................... 23Lyrica .................................... 15

M

Medroxyprogesterone Tablet .................................. 24

Meloxicam Tablet ...................21Memantine .............................14Mercaptopurine Tablet ...........11Metadate CD ........................ 13Metaxalone Tablet ................. 20Metformin ..............................17

29

Metformin Extended-Release Tablet (generic Glucophage XR) ..................17

Methadone Tablet, Oral Solution, Concentrate Solution ...............................21

Methimazole Tablet ...............17Methocarbamol Tablet .......... 20Methotrexate Tablet ...............19Methylphenidate Chewable

Tablet .................................. 13Methylphenidate

Extended-Release Capsule ............................... 13

Methylphenidate Extended-Release Tablet .... 13

Methylphenidate Tablet ......... 13Methylprednisolone Tablet .....17Metoclopramide Tablet ..........18Metoprolol Succinate

50, 100, 200 mg ...................11Metoprolol Tartrate ................11Metronidazole Gel 0.75% ...... 15Metronidazole Tablet .............10Microgestin ........................... 23Microgestin FE ..................... 23Minastrin 24 FE ................... 23Minivelle ............................... 24Minocycline Capsule ..............10Minocycline Tablet .................10Mirtazapine Tablet ................ 13Mirvaso ................................. 15Mitigare ................................. 20Modafinil Tablet .....................14Mometasone Furoate Cream,

Lotion, Ointment ............... 15Mononessa ............................. 23Montelukast Chewable Tablet,

Tablet .................................. 22Montelukast Granules ........... 22

Morphine Sulfate Extended-Release Tablet .....21

Morphine Sulfate Oral Solution .......................21

Movantik ................................18Moviprep ................................18Moxeza ...................................17Moxifloxacin Tablet ................10Mupirocin Ointment ............. 15Mycophenolate Capsule,

Suspension .......................... 23Mycophenolic Acid Tablet ..... 23Myfortic ................................ 23

N

Nabumetone Tablet ................21Nadolol ...................................11Namenda XR ..........................14Naproxen Tablet .....................21Naratriptan .............................14Nasonex ..................................21Natazia .................................. 23Necon 0.5/35, 1/35,

1/50, 10/11 .......................... 23Neoral .................................... 23Nesina .....................................17Nevirapine ..............................19Nevirapine

Extended-Release ................19Nexium Capsule .....................18Next Choice........................... 23Niacin Extended-Release

Tablet .................................. 12Niaspan ................................. 12Nicoderm CQ........................ 22Nicorette Gum ...................... 22Nicorette Lozenge ................. 22Nicorette Mini-Lozenge ....... 22Nicotine Gum ....................... 22Nicotine Lozenge .................. 22Nicotine Patch ....................... 22

Nicotrol Inhaler ..................... 22Nicotrol Nasal Spray .............. 22Nifedipine

Extended-Release ................11Nitrofurantoin Capsule ...........10Nitrofurantoin Macrocrystal

Capsule ................................10Nitrostat ................................ 12Norgestimate-Ethinyl

Estradiol ............................. 23Nortrel 0.5/35 ........................ 23Nortriptyline Capsule ............ 13Norvir .....................................19Novolin 70-30 Vials ...............16Novolin N Vials .....................16Novolin R Vials ......................16Novolog Flexpen ....................16Novolog Mix 70/30 Flexpen ..16Novolog Mix 70/30 Vials .......16Novolog Vials .........................16Noxafil Tablet, Suspension .....10NP Thyroid Tablet .................17Nucynta ..................................21Nucynta ER ............................21Nuedexta ............................... 20Nutropin, Nutropin AQ .........17Nuvaring................................ 23Nuvigil....................................14Nystatin-Triamcinolone

Acetonide Cream, Ointment ............................ 15

Nystatin Cream, Ointment.....10

O

Ofloxacin 0.3% Ophthalmic Solution ...............................17

Ofloxacin Tablets ....................10Olanzapine Tablet ..................14Omeclamox-Pak .....................18Omega-3-Acid Ethyl Esters

Capsule ............................... 12

30

Omeprazole Capsule ..............18Ondansetron ...........................18Ondansetron ODT .................18OneTouch Test Strips .............16OneTouch Ultra Meter ...........16OneTouch Ultra Mini ............16OneTouch Ultra Test Strips ....16OneTouch Verio .....................16OneTouch Verio IQ ................16OneTouch Verio Sync .............16OneTouch Verio Test Strips ....16Onglyza ..................................17Opana ER ..............................21Opsumit ................................ 22Oracea ....................................10Orencia ...................................19Orenitram .............................. 22Orsythia ................................ 23Ortho-Cyclen ........................ 23Ortho-Novum ....................... 23Ortho-Novum 7/7/7 .............. 23Ortho Micronor .................... 23Ortho Tri-Cyclen .................. 23Ortho Tri-Cyclen Lo............. 23Oseni ......................................17Osphena ................................ 24Otezla .....................................19Otrexup ..................................19Oxcarbazepine Tablet ............ 15Oxsoralen-Ul ......................... 15Oxybutynin Extended-Release

Tablet ...................................21Oxybutynin Tablet .................21Oxycodone/Acetaminophen

5/325, 7.5/325, 10/325 mg Tablet ...................................21

Oxycodone Tablet ...................21Oxycontin ...............................21

P

Pantoprazole Tablet ................18

Paroxetine Tablet ................... 13Pataday ...................................17Patanol ....................................17Pegasys .................................. 20Penicillin V Potassium

Tablet ...................................10Perforomist ............................ 22Phenazopyridine .................... 20Phenytoin Capsule,

Suspension .......................... 15Picato ..................................... 15Pioglitazone ............................17Plan B One Step .................... 23Polyethylene Glycol 3350 ........18Potassium Chloride ............... 23Potassium Citrate .................. 23Pradaxa ...................................11Pramipexole Tablet .................14Pravastatin ............................. 12Prednisone Tablet ...................17Premarin ................................ 24Premphase ............................. 24Prempro ................................. 24Prenisolone Oral Solution.......17Prepopik .................................18Prezcobix ................................19Prezista ...................................19Pristiq ER .............................. 13Proair HFA ........................... 22Procrit .................................... 20Progesterone Micronized

Capsule ............................... 24Prograf ................................... 23Promethazine/Codeine .......... 20Promethazine/

Dextromethorphan ............. 20Promethazine Tablet ...............21Propranolol Extended-Release

Capsule ................................11Propranolol Tablet ................. 12

Proventil HFA ....................... 22Pulmicort Flexhaler ............... 22Pulmozyme ........................... 20Pylera ......................................18

Q

Qnasl ......................................21Quasense ............................... 23Quetiapine Tablet ...................14Quinapril ............................... 12QVAR ................................... 22

R

Rabeprazole Tablet .................18Raloxifene ........................ 20, 24Raloxifene Tablet ................... 20Ramipril ................................ 12Ranexa ................................... 12Ranitadine Syrup ....................18Rapaflo ...................................19Rapamune ............................. 23Rasuvo ....................................19Rebif .......................................14Reclipsen ............................... 23Rectiv .................................... 20Regranex .................................16Relpax .....................................14Renvela .................................. 20Restasis .................................. 20Revlimid .................................11Reyataz ...................................19Rezira .................................... 20Ribapak ..................................18Ribavirin Tablet ......................18Risedronate Sodium Tablet ... 20Risperidone Tablet ..................14Rizatriptan ODT, Tablet ........14Ropinirole Tablet ....................14

S

Savaysa ...................................11

31

Serevent Diskus ..................... 22Seroquel XR ...........................14Sertraline Tablet .................... 13Sildenafil Tablet ..................... 22Simcor ................................... 12Simponi ..................................19Simvastatin ............................ 12Sirolimus Tablet ..................... 23Solodyn ...................................10Sotalol.................................... 12Sovaldi ....................................18Spiriva Handihaler ................ 22Spiriva Respimat.................... 22Spironolactone ....................... 12Sprintec ................................. 23Sprix .......................................21Sronyx.................................... 23Stelara .....................................19Strattera ................................. 13Stribild ....................................19Striverdi Respimat ................. 22Suboxone Film .......................14Subsys .....................................21Suclear ....................................18Sucralfate Tablet .....................18Sulfamethoxazole-

Trimethoprim Tablet ...........10Sulfasalazine Tablet ................18Sumatriptan Nasal Spray ........14Sumatriptan Succinate Tablet,

Injection ...............................14Sumavel DosePro ...................14Suprax Capsule, Chewable

Tablet, Tablet .......................10Suprep ....................................18Sustiva ....................................19Sutent .....................................11Symbicort .............................. 22Synthroid ................................17

T

Tacrolimus Capsule ............... 23Tacrolimus Ointment .............16Tamiflu ...................................10Tamoxifen.............................. 24Tamsulosin Capsule ................19Tanzeum .................................17Tasigna ...................................11Tazorac ...................................16Tecfidera .................................14Telmisartan............................ 12Telmisartan-

Hydrochlorothiazide ........... 12Temazepam Capsule ...............14Terazosin ..........................12, 19Terazosin Capsule, Tablet .......19Terbinafine Tablet ..................10Testim .....................................19Testosterone Cypionate

Injection ...............................19Thrive Gum .......................... 22Timolol Maleate 0.25%, 0.5%

Ophthalmic Solution ...........18Tirosint ...................................17Tivicay ....................................19Tizanidine Tablet .................. 20Tobi Podhaler ........................ 20Tobramycin/Dexamethasone

0.3%-0.1% Ophthalmic Suspension ...........................17

Tobramycin Nebulized Solution .............................. 20

Tobramycin Ophthalmic Solution ...............................17

Tolcapone ...............................14Tolterodine Extended-Release

Tablet ...................................21Tolterodine Tablet ..................21Topiramate Tablet .................. 15Toviaz .....................................21

Tracleer .................................. 22Tradjenta.................................17Tramadol-Acetaminophen ......21Tramadol Sustained-Release

Tablet ...................................21Tramadol Tablet .....................21Transderm-Scop .....................18Travatan Z ..............................18Trazodone Tablet ................... 13Tretinoin .................................16Tretinoin Microspheres ..........16Tri-Previfem .......................... 23Tri-Sprintec ........................... 23Triamcinolone Acetonide

Cream, Lotion, Ointment ...16Triamcinolone Nasal Spray .....21Triamterene-

Hydrochlorothiazide ........... 12Triazolam Tablet ....................14Tricor 48, 145 mg .................. 12Trinessa ................................. 23Triumeq ..................................19Trulicity ..................................17Truvada ..................................19Tudorza ................................. 22Tybost .....................................19Tyvaso ................................... 22

U

Uceris ......................................18Uloric ..................................... 20

V

Vagifem ................................. 24Valacyclovir Tablet .................10Valaganciclovir .......................10Valsartan ................................ 12Valsartan-

Hydrochlorothiazide ........... 12Vascepa .................................. 12Vectical ...................................16

32

Velphoro ................................ 20Venlafaxine Extended-Release

Capsule ............................... 13Venlafaxine Tablet ................. 13Ventolin HFA ........................ 22Verapamil .............................. 12Verapamil Sustained-Release . 12Vesicare ...................................21Vestura ................................... 23Vicodin 5/300, 7.5/300,

10/300 mg Tablet ................21Victoza 2-Pak .........................17Victoza 3-Pak .........................17Viekira Pak .............................18Vigamox .................................17Viibryd .................................. 13Viorele ................................... 23Viread .....................................19Vitekta ....................................19Vivelle-Dot ............................ 24

Voltaren Gel ...........................21Vytorin .................................. 12Vyvanse ................................. 13

W

Warfarin Sodium ...................11Welchol ................................. 12Wellbutrin XL ....................... 13

X

Xarelto ....................................11Xeljanz ....................................19Xeloda ....................................11Xigduo XR .............................17Xopenex HFA ....................... 22Xopenex Nebs ........................ 22Xulane ................................... 23Xyrem .....................................14

Y

Yasmin 28 .............................. 23

Yaz ......................................... 23

Z

Zaleplon Capsule ....................14Zelapar ...................................14Zenpep ...................................18Zetia ...................................... 12Zetonna ..................................21Ziprasidone Capsule ...............14Zohydro ER ...........................21Zolpidem Extended-Release

Tablet ...................................14Zolpidem Tablet .....................14Zonisamide Capsule .............. 15Zovirax Cream .......................10Zubsolv ...................................14Zytiga .....................................11Zyvox ......................................10

33

Notes

34

“My Medications” worksheetTake 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 Medicineand Strength

DrugTier

I Take ThisMedicine For

Directions Doctor

Example: Lisinopril, 20 mg Tier 1 High blood pressure One tablet daily Dr . Johnson

All branded medications are trademarks or registered trademarks of their respective owners .

© 2015 United HealthCare Services, Inc . All rights reserved . Created September, 2015 . 2016 Prescription Drug List – NHP Advantage Four-Tier 213-8835 1/16

For more information


Or, visit www.mynhp.com

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