Your 2016 Four-Tier Prescription Drug List

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Your 2016 Four-TierPrescription Drug Listeffective July 1, 2016

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

For additional information:

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

Visit myuhc.com®

• 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 myuhc.com® for complete drug informationSince the PDL may change, we encourage you to visit our website, myuhc.com. 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

Gastrointestinal

Acid Suppression . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Nausea/Vomiting . . . . . . . . . . . . . . . . . . . . . . . . . . 18Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Hepatitis C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

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

Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

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

Men’s Health

Erectile Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . 19Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Testosterone Therapy . . . . . . . . . . . . . . . . . . . . . . 20

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

Musculoskeletal

Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Pain Relief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Overactive Bladder . . . . . . . . . . . . . . . . . . . . . . 22

Respiratory

Allergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Asthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Pulmonary Arterial Hypertension . . . . . . . . . . . . 23

Smoking Cessation . . . . . . . . . . . . . . . . . . . . . 23

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

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

Women’s Health

Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Hormone Replacement . . . . . . . . . . . . . . . . . . . . . 24Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Prenatal Vitamins . . . . . . . . . . . . . . . . . . . . . . . . . . 24

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

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

MCMultiple Copay – More than one month’s worth of medication included in package so additional copay applies .

PAPrior Authorization required* – Your doctor is required to provide additional information to us to determine coverage .

RSRefill and Save Program – Save money on your copayment when you refill your prescription on time as prescribed . Program eligibility may vary .

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 .

*Depending on your benefit you may have notification or medical necessity requirements for select medications .+For New Jersey fully insured members this program is referred to as First Start .

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

Log on to myuhc.com for the following pharmacy information and tools: • Pharmacy benefit and coverage information• Possible lower-cost medication options• Medication interactions and side effects• Participating retail pharmacies by zip code• Your prescription history

And, if Mail Service is included in your pharmacy benefit, you can also:• Refill prescriptions• Check the status of your order• Set-up e-mail reminders for refills• Manage your account

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

Or, visit myuhc.com®

Where else can I go for information? HealthCareLane.com includes short videos to help you learn more about UnitedHealthcare benefits and health insurance information.

UHCTV.com is a fun and easy way to learn about health terms and other health-related topics.

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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 PreventiveMC = Multiple Copay

PA = Prior Authorization requiredRS = May be eligible for the Refill and Save ProgramSDP = 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 1Cefixime Suspension 3Cefprozil Tablet 1Cefuroxime Tablet 1Cephalexin Capsule 1Ciprofloxacin Tablet 1Clarithromycin Tablet 1Clindamycin Capsule 1Dificid 3 SLDoryx 4 EDoxycycline Hyclate 50, 100 mg 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

Anti-Infectives: Antifungals

Cresemba 3 SLEconazole Cream 3 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 PA, SL, STAcyclovir Tablet 1Famciclovir 2Tamiflu 3 SLValacyclovir Tablet 2 SLValaganciclovir 1 SLZovirax Cream 4 E, SL

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Drug NameDrug Tier


Cancer

Bexarotene Capsule 4 DSP, E, PA, SLBicalutamide 1Bosulif 2 DSP, PA, SL, STCyclophosphamide Capsule

2

Gleevec 2 DSP, PA, SLHydroxyurea Capsule 3Imatnib Tablet 4 DSP, E, PA, SLImbruvica 2 DSP, PA, SLLeucovorin Calcium Tablet

1

Mercaptopurine Tablet 1Revlimid 2 DSP, PA, SLSutent 2 DSP, PA, SLTargretin Capsule 2 DSP, PA, SLTargretin Gel 3 PA, SLTasigna 2 DSP, PA, SLXeloda 1 DSP, SLZytiga 2 DSP, PA, 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-Benazepril 1 SLAmlodipine-Valsartan 2 SLAtenolol 1Atenolol-Chlorthalidone 1Benazepril 1Benazepril-Hydrochlorothiazide

1

Drug NameDrug Tier


Benicar 2 SLBenicar HCT 2 SLBidil 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

Doxazosin 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 EFluvastatin Extended-Release Tablet

3 SL, ST

Gemfibrozil 1Lescol XL 4 E, SL, ST

Drug NameDrug Tier


Lipitor 4 E, SLLipofen 4 ELivalo 4 SL, STLovastatin 1Niacin Extended-Release Tablet

4

Niaspan 2Omega-3-Acid Ethyl Esters Capsule

3 PA

Praluent 2 DSP, PA, SL, STPravastatin 1Repatha 4 DSP, PA, SL, STSimcor 4 SLSimvastatin 1Tricor 48, 145 mg 4 EVascepa 4 PAVytorin 4 SLWelchol 2Zetia 4 SL

Cardiovascular/Heart Disease: Other

Amiodarone 1Corlanor 3 PA, SLDigoxin 1Entresto 4 PA, SLFlecainide 1Isosorbide Mononitrate ER

1

Nitrostat 2Ranexa 2Sotalol 1

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Drug NameDrug Tier


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

1 PA

Aptensio XR 4 E, PA, SLConcerta 2 PA, SLDaytrana 4 E, PA, SLDexmethylphenidate Extended-Release Capsule

4 E, PA, SL

Dexmethylphenidate Tablet

1 PA

Dextroamphetamine-Amphetamine Extended-Release

4 E, PA, SL

Dextroamphetamine-Amphetamine Tablet

1 PA

Dextroamphetamine Sulfate Tablet

3 PA

Focalin XR 4 E, PA, SLGuanfacine Extended-Release

2 SL

Metadate CD 2 PA, SLMethylphenidate Chewable Tablet

3 PA

Methylphenidate Extended-Release Capsule

4 E, PA, SL

Methylphenidate Extended-Release Tablet

4 E, PA, SL

Methylphenidate Tablet 1 PAStrattera 4 SLVyvanse 2 PA, 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 RS, SLSertraline Tablet 1Trazodone Tablet 1Venlafaxine Extended-Release Capsule

1

Venlafaxine Tablet 1Viibryd 4 SL

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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, PA, SLAubagio 4 DSP, PA, SL, STAvonex 2 DSP, PA, SLBetaseron 2 DSP, PA, SLCopaxone 2 DSP, PA, SLGilenya 3 DSP, PA, SL, ST

Glatopa 4DSP, E, PA,

SL, STRebif 4 DSP, PA, SL, STTecfidera 2 DSP, PA, SL

Central Nervous System: Other

Abilify Tablet 4 E, SLAlprazolam Extended-Release Tablet

1

Alprazolam Tablet 1Aripiprazole Tablet 2 SLBuprenorphine/Naloxone Tablet

4 E, PA, 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 Tablet 2Modafinil Tablet 3 PA, SLNamenda XR 4 ENuvigil 4 E, PA, SLOlanzapine Tablet 1 SLPramipexole Tablet 1Quetiapine Tablet 1Risperidone Tablet 1Ropinirole Tablet 1Seroquel XR 4 SLSuboxone Film 4 E, PA, SLTolcapone 2Xyrem 4 PA, SLZelapar 3Ziprasidone Capsule 2 SLZubsolv 2 PA, 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, PAAczone 4 SLAdapalene 0 .1% Cream, Gel

3 PA, SL

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

3

Betamethasone Dipropionate 0 .05% Cream, Ointment

2

Carac 2Ciclopirox Cream, Gel, Lotion, Solution

1

Claravis 2 PAClindamycin 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

2 SL

Clobetasol Propionate 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 PA, SL

Diflorasone Diacetate 0 .05% Cream, Ointment

3 SL

Epiduo 3 SLFinacea 4Fluocinonide 0 .05% Cream

1

Fluocinolone Cream, Oil, Ointment, Solution

3 SL

Halobetasol Ointment 2Hydrocortisone 2 .5% Cream, Ointment

1

Imiquimod 5% Cream 2 SLMetronidazole 0 .75% Topical Gel

1

Mirvaso 4 SLMometasone Furoate Cream, Lotion, Ointment

1

Mupirocin Ointment 1Nystatin-Triamcinolone Acetonide Cream, Ointment

4 E

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Drug NameDrug Tier


Oxsoralen-Ul 2Picato 3 SLRegranex 2 PA, SLTacrolimus Ointment 2 PA, SLTazorac 4 PA, SLTretinoin 1 PA, SLTretinoin Microspheres 4 E, PA, 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 Continuous Glucose Monitoring System

3 PA, SL

Dexcom Sensor 3 PA, SLDexcom Transmitter 3 PA, 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, PA, 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 FlexTouch 4 SDP, SL, STNovolog Mix 70/30 FlexTouch

4 SDP, SL, ST

Novolog Mix 70/30 Vials

4 SDP, SL, ST

Novolog Vials 4 SDP, SL, STToujeo SoloStar 4 E, SL

17

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, PA, SL

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 SLOlopatadine 0 .1% Ophthalmic Solution

3 SL

Pataday 4 E, SL

Eye Conditions: Antibiotics

Erythromycin 0 .5% Ophthalmic Ointment

1

Gentamicin Ophthalmic Ointment, Solution

1

Moxeza 4Ofloxacin 0 .3% Ophthalmic Solution

1

18




Drug NameDrug Tier


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

2

Tobramycin Ophthalmic Solution

1

Vigamox 4

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

Drug NameDrug Tier


Gastrointestinal: Nausea/Vomiting

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

Gastrointestinal: Other

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

1

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

2

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

19

Drug NameDrug Tier


Hepatitis C

Daklinza 2 DSP, PA, SL, STHarvoni 2 DSP, PA, SLRibapak 3 DSP, ERibavirin Tablet 1 DSPSovaldi 2 DSP, PA, SL, STTechnivie 4 DSP, PA, SLViekira Pak 4 DSP, PA, SL, ST

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 DSP

Drug NameDrug Tier


Infertility*

Cetrotide 2 DSPClomiphene 1 DSPGonal-F 2 DSPGonal-F RFF 2 DSPOvidrel 3 DSP*Coverage is determined by the consumer’s prescription drug benefit plan .

Inflammatory Conditions: Rheumatoid Arthritis, Crohn’s Disease, Psoriasis, Ulcerative ColitisActemra 4 DSP, PA, SL, STCimzia 2 DSP, PA, SLCosentyx 4 DSP, PA, SL, STEnbrel 4 DSP, PA, SL, STHumira 2 DSP, PA, SLHydroxychloroquine Sulfate Tablet

1

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

Men’s Health: Erectile Dysfunction

Cialis 4 SLLevitra 4 SLStendra 4 SLViagra 4 SL

20




Drug NameDrug Tier


Men’s Health: Prostate

Alfuzosin Tablet 1Cialis 4 SL, STDoxazosin Tablet 1Dutasteride Capsule 3 SDPFinasteride Tablet 1Rapaflo 4Tamsulosin Capsule 1Terazosin Capsule, Tablet 1

Men’s Health: Testosterone Therapy

Androderm 2 PA, SLAndrogel 4 E, PA, SLMethyltestosterone Capsule

2

Testim 2 PA, SLTestosterone 1% Topical Gel

4 E, PA, SL

Testosterone Cypionate Injection

1

Miscellaneous

Anastrozole Tablet 1Antipyrine/Benzocaine Otic Solution

1

Aranesp 2 DSP, SLAuryxia 3Benzonatate Capsule 1Bethkis 2 DSP, PA, SLBromfed DM 3Cayston 2 PA, SLCerdelga 2 DSP, PA

Drug NameDrug Tier


Chlorpheniramine/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 2Obredon 4 SL, STPegasys 2 DSP, PA, SLPhenazopyridine 1Procrit 2 DSP, SLPromethazine/Codeine 1Promethazine/Dextromethorphan

1

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

4 DSP, E, PA, SL

Velphoro 2

21

Drug NameDrug Tier


Musculoskeletal: Osteoporosis

Alendronate Sodium Tablet

1 SL

Forteo 2 DSP, PAIbandronate 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

Musculoskeletal: Pain Relief

Acetaminophen/Codeine Tablet

1 SL

Celecoxib 2 SLDiclofenac Tablet 1Embeda 4 E, PA, SL, STEtodolac Capsule 1Fentanyl 12, 25, 50, 75, 100 mcg Patch

2 SL

Fentanyl 37 .5, 62 .5, 87 .5 mcg Patch

4 E, SL

Fentanyl Citrate Lozenge

2 PA, SL

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

1 SL

Drug NameDrug Tier


Hydrocodone/Ibuprofen Tablet

1

Hydromorphone Tablet 1Hysingla 4 E, PA, SL, STIbuprofen Tablet 1Indomethacin Capsule 1Ketorolac Tablet 1Lazanda 4 PA, 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 PA, SLOpana ER 2 PA, SLOxycodone/Acetaminophen 5/325, 7 .5/325, 10/325 mg Tablet

1 SL

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

1 SL

Tramadol Sustained-Release Tablet

2 SL

Tramadol Tablet 1Trezix 4 SLVicodin 5/300, 7 .5/300, 10/300 mg Tablet

4 E, SL

Voltaren Gel 2Zohydro ER 4 PA, SL, ST

22




Drug NameDrug Tier


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

Respiratory: Asthma/COPD

Advair Diskus/HFA 3 RS, SLAerospan 3 SLAlbuterol Nebs 1Albuterol Sulfate Tablet 1Alvesco 1 SL

Drug NameDrug Tier


Anoro Ellipta 3 SLArnuity Ellipta 3 SLAsmanex 1 SLBreo Ellipta 3 RS, SLBudesonide Nebs 2 SLCombivent Respimat 3 SLDulera 4 SL, STFlovent 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 SLProAir Respiclick 3 SLProventil HFA 3 SLPulmicort Flexhaler 4 SDP, SLQVAR 1 SLSeebri Neohaler 2 SLSerevent Diskus 3 SLSpiriva Handihaler 4 SLSpiriva Respimat 4 SLStiolto Respimat 4 E, SLStriverdi Respimat 2 SLSymbicort 3 RS, SLTudorza 2 SLUtibron Neohaler 2 SLVentolin HFA 2 SLXopenex HFA 3 SLXopenex Nebs 4 E, SL

23

Drug NameDrug Tier


Respiratory: Pulmonary Arterial HypertensionAdcirca 4 DSP, PA, SLAdempas 2 DSP, PA, SLLetairis 2 DSP, PA, SLOpsumit 2 DSP, PA, SLOrenitram 4 DSP, PA, SLSildenafil Tablet 1 DSP, PA, SLTracleer 2 DSP, PA, SLTyvaso 2 DSP, PA

Smoking Cessation

Bupropion Sustained-Release Tablet

1 H, PA

Chantix Tablet 4 H, PANicoderm CQ 3 H, PANicorette Gum 3 H, PANicorette Lozenge 3 H, PANicorette Mini-Lozenge

3 H, PA

Nicotine Gum 1 H, PANicotine Lozenge 1 H, PANicotine Patch 1 H, PANicotrol Inhaler 3 H, PANicotrol Nasal Spray 3 H, PAThrive Gum 1 H, PA

Transplant

Azathioprine Tablet 1Cyclosporine Modified Capsule

1 DSP

Mycophenolate Capsule, Suspension

1 DSP

Mycophenolic Acid Tablet

2 DSP

Sirolimus Tablet 1 DSPTacrolimus Capsule 1 DSP

Drug NameDrug Tier


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 HLevora-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 H

24




Drug NameDrug Tier


Norgestimate-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 HPlan B One Step 1 HQuasense 2 HReclipsen 1 HSprintec 3Sronyx 1 HTri-Lo-Estarylla 3Tri-Lo-Marzia 3Tri-Lo-Sprintec 3Tri-Previfem 3Tri-Sprintec 3Trinessa 3Trinessa Lo 3Vestura 3Viorele 2Xulane 3 HYasmin 28 1 HYaz 2

Women’s Health: Hormone Replacement

Cenestin 4 EClimara 2 SLClimara Pro 3 SLDivigel 3Duavee 3

Drug NameDrug Tier


Enjuvia 3Estrace Cream 3Estradiol/Norethindrone Acetate Tablet

2

Estradiol Tablet 1Estradiol Twice-Weekly Transdermal Patch

4 E, SL

Estring 2 MC, SLEstrogen/Methyltestosterone Tablet

1

Evamist 2Medroxyprogesterone Tablet

1

Minivelle 3 SLPremarin 3Premphase 3Prempro 3Progesterone Micronized Capsule

2

Vagifem 2Vivelle-Dot 2 SL

Women’s Health: Miscellaneous

Osphena 3Raloxifene 2 H, PATamoxifen 1 H, PA

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 .................................. 23Adderall XR .......................... 13Adempas ................................ 23Advair Diskus/HFA .............. 22Aerospan ............................... 22Afrezza ...................................16Akynzeo .................................18Albuterol Nebs ...................... 22Albuterol Sulfate Tablet ......... 22Alendronate Sodium Tablet....21Alfuzosin Tablet .................... 20Allopurinol Tablet ..................21Alphagan P 0.1% ....................18Alprazolam Extended-Release

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

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

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

Amphetamine Salt Combo .... 13Ampyra...................................14Anastrozole Tablet ................ 20Androderm ............................ 20Androgel................................ 20Anoro Ellipta......................... 22Antipyrine/Benzocaine

Otic Solution ...................... 20Apri ....................................... 23Apriso .....................................18Aptensio XR .......................... 13Aranesp ................................. 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 ......................... 22Azithromycin Tablet ...............10Azopt ......................................18Azurette ................................ 23

B

Baclofen Tablet .......................21Benazepril...............................11Benazepril-

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

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

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

Bethkis .................................. 20Bexarotene Capsule ................11Bicalutamide ...........................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, 23Bupropion Tablet ................... 13Buspirone Tablet .....................14Bydureon ................................17Byetta .....................................17Bystolic ...................................11

26

C

Calcitriol Capsule ...................17Canasa ....................................18Carac ..................................... 15Carbamazepine Tablet ........... 15Carbidopa-Levodopa ..............14Carisoprodol 350 mg Tablet ...21Cartia XT ...............................11Carvedilol ...............................11Cayston .................................. 20Cefadroxil Capsule, Tablet .....10Cefdinir Capsule ....................10Cefixime Suspension ..............10Cefprozil Tablet ......................10Cefuroxime Tablet ..................10Celecoxib ................................21Cenestin ................................ 24Cephalexin Capsule ................10Cerdelga ................................ 20Cetrotide ................................19Chantix Tablet ....................... 23Chlorpheniramine/

Hydrocodone/Pseudoephedrine Solution .. 20

Chlorthalidone .......................11Choline Fenofibrate ............... 12Cialis ................................19, 20Ciclopirox Cream, Gel, Lotion,

Solution .............................. 15Cimzia ....................................19Ciprodex ................................ 20Ciprofloxacin Tablet ...............10Citalopram Tablet .................. 13Claravis .................................. 15Clarinex ................................. 22Clarinex-D ............................ 22Clarithromycin 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 ............................ 15Clobetasol Propionate

Solution .............................. 15Clomiphene ............................19Clonazepam Tablet ................ 15Clonidine Tablet .....................11Clopidogrel .............................11Clotrimazole-Betamethasone

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

Lotion ................................. 15Colcrys ...................................21Combigan ...............................18Combivent Respimat ............. 22Complera ................................19Concerta ................................ 13Condylox Gel ........................ 15Contour Test Strips ................16Copaxone................................14Corlanor ................................ 12Cortifoam ...............................18Cosentyx.................................19Creon ......................................18Cresemba ................................10Crestor ................................... 12Cryselle .................................. 23Cyclafem ............................... 23Cyclobenzaprine Tablet ..........21Cyclophosphamide Capsule ....11

Cyclosporine Modified Capsule ............................... 23

Cymbalta ............................... 13Cyproheptadine Tablet .......... 22

D

Daklinza .................................19Daytrana ................................ 13Delzicol ..................................18Desmopressin Tablet ..............17Desonide 0.05% Cream,

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

Ointment ............................ 15Dexamethasone Tablet ...........17Dexcom Continuous Glucose

Monitoring System ..............16Dexcom 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 ............... 22Differin 1% Cream, Gel ........ 15Dificid ....................................10Diflorasone Diacetate 0.05%

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

27

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

Diltiazem Sustained-Release Tablet ...................................11

Diphenoxylate-Atropine Tablet ...................................18

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

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

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

Tablet ...................................14Doryx .....................................10Doxazosin .........................11, 20Doxazosin Tablet ................... 20Doxepin Capsule ................... 13Doxycycline Hyclate

50, 100 mg Capsule, Tablet ...................................10

Doxycycline Monohydrate 50, 100 mg Capsule .............10

Duavee ................................... 24Dulera .................................... 22Duloxetine Capsule ............... 13Dutasteride Capsule .............. 20Dutoprol .................................11

E

Econazole Cream ...................10Edarbi .....................................11Edarbyclor ..............................11Effient ....................................11Eliquis ....................................11Ella ........................................ 23Embeda ..................................21Emend ....................................18Enalapril .................................11Enbrel .....................................19Enjuvia .................................. 24Enoxaparin Sodium ................11

Enskyce ................................. 23Entresto ................................. 12Epiduo ................................... 15Epipen ................................... 20Epipen-Jr ............................... 20Epzicom .................................19Erythromycin 0.5%

Ophthalmic Ointment .........17Escitalopram Tablet ............... 13Esomeprazole Capsule ............18Estrace 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, 25, 50, 75,

100 mcg Patch .....................21Fentanyl 37.5, 62.5, 87.5 mcg

Patch ....................................21Fentanyl Citrate Lozenge .......21Fetzima .................................. 13Finacea .................................. 15

Finasteride Tablet .................. 20Flecainide .............................. 12Flovent Diskus/HFA ............. 22Fluconazole Tablet ..................10Fluocinolone Cream, Oil,

Ointment, Solution ............. 15Fluocinonide 0.05% Cream ... 15Fluoride ................................. 23Fluoxetine Capsule, Tablet .... 13Fluticasone Nasal Spray ......... 22Fluvastatin Extended-Release

Tablet .................................. 12Fluvoxamine Tablet ............... 13Focalin XR ............................ 13Folic Acid .............................. 23Foradil ................................... 22Forteo .....................................21Fosrenol ................................. 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 ..................................18Gonal-F ..................................19Gonal-F RFF .........................19Guanfacine .......................11, 13

28

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

H

Halobetasol Ointment ........... 15Harvoni ..................................19Humalog 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 ....................16Humulin 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 22Hyoscyamine Tablet ...............18Hysingla .................................21

I

Ibandronate Tablet .................21

Ibuprofen Tablet .....................21Imatnib Tablet ........................11Imbruvica ...............................11Imiquimod 5% Cream ........... 15Incruse Ellipta ....................... 22Indomethacin Capsule ............21Intelence .................................19Introvale ................................ 23Invokamet ...............................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 .......................16

Lantus Vials ...........................16Lastacaft .................................17Latanoprost 0.005%

Ophthalmic Solution ...........18Latuda ....................................14Lazanda ..................................21Leflunomide Tablet ................19Lescol XL .............................. 12Letairis .................................. 23Letrozole Tablet .................... 20Leucovorin Calcium Tablet ....11Levalbuterol Nebs .................. 22Levemir FlexTouch ................16Levemir Vials .........................16Levetiracetam

Extended-Release Tablet .... 15Levetiracetam Tablet ............. 15Levitra ....................................19Levocetirizine Tablet ............. 22Levofloxacin 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 .................................11

29

Losartan- Hydrochlorothiazide ............11

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

M

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

Meloxicam Tablet ...................21Memantine Tablet ..................14Mercaptopurine Tablet ...........11Metadate CD ........................ 13Metaxalone Tablet ..................21Metformin ..............................17Metformin Extended-Release

Tablet (generic Glucophage XR) ......................................17

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

Methimazole Tablet ...............17Methocarbamol Tablet ...........21Methotrexate Tablet ...............19Methylphenidate Chewable

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

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

Methylphenidate Extended-Release Tablet .... 13

Methylphenidate Tablet ......... 13Methylprednisolone Tablet .....17Methyltestosterone Capsule ... 20Metoclopramide Tablet ..........18Metoprolol Succinate

50, 100, 200 mg ...................11Metoprolol Tartrate ................11

Metronidazole 0.75% Topical Gel ......................... 15

Metronidazole Tablet .............10Microgestin ........................... 23Microgestin FE ..................... 23Minastrin 24 FE ................... 23Minivelle ............................... 24Minocycline Capsule ..............10Minocycline Tablet .................10Mirtazapine Tablet ................ 13Mirvaso ................................. 15Mitigare ..................................21Modafinil Tablet .....................14Mometasone Furoate Cream,

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

Tablet .................................. 22Montelukast Granules ........... 22Morphine Sulfate

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

Oral Solution .......................21Movantik ................................18Moviprep ................................18Moxeza ...................................17Moxifloxacin Tablet ................10Mupirocin Ointment ............. 15Mycophenolate Capsule,

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

N

Nabumetone Tablet ................21Nadolol ...................................11Namenda XR ..........................14Naproxen Tablet .....................21Naratriptan .............................14Nasonex ................................. 22Natazia .................................. 23

Necon 0.5/35, 1/35, 1/50, 10/11 .......................... 23

Nesina .....................................17Nevirapine ..............................19Nevirapine

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

Tablet .................................. 12Niaspan ................................. 12Nicoderm CQ........................ 23Nicorette Gum ...................... 23Nicorette Lozenge ................. 23Nicorette Mini-Lozenge ....... 23Nicotine Gum ....................... 23Nicotine Lozenge .................. 23Nicotine Patch ....................... 23Nicotrol Inhaler ..................... 23Nicotrol Nasal Spray .............. 23Nifedipine

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

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

Estradiol ............................. 24Nortrel 0.5/35 ........................ 24Nortriptyline Capsule ............ 13Norvir .....................................19Novolin 70-30 Vials ...............16Novolin N Vials .....................16Novolin R Vials ......................16Novolog FlexTouch ................16Novolog Mix 70/30

FlexTouch ............................16Novolog Mix 70/30 Vials .......16Novolog Vials .........................16Noxafil Tablet, Suspension .....10

30

NP Thyroid Tablet .................17Nucynta ..................................21Nucynta ER ............................21Nuedexta ............................... 20Nutropin, Nutropin AQ .........17Nuvaring................................ 24Nuvigil....................................14Nystatin-Triamcinolone

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

Nystatin Cream, Ointment.....10

O

Obredon ................................ 20Ofloxacin 0.3% Ophthalmic

Solution ...............................17Ofloxacin Tablets ....................10Olanzapine Tablet ..................14Olopatadine 0.1% Ophthalmic

Solution ...............................17Omeclamox-Pak .....................18Omega-3-Acid Ethyl Esters

Capsule ............................... 12Omeprazole 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 ................................ 23Oracea ....................................10Orencia ...................................19Orenitram .............................. 23Orsythia ................................ 24

Ortho-Cyclen ........................ 24Ortho-Novum ....................... 24Ortho-Novum 7/7/7 .............. 24Ortho Micronor .................... 24Ortho Tri-Cyclen .................. 24Oseni ......................................17Osphena ................................ 24Otezla .....................................19Otrexup ..................................19Ovidrel ...................................19Oxcarbazepine Tablet ............ 15Oxsoralen-Ul ......................... 15Oxybutynin Extended-Release

Tablet .................................. 22Oxybutynin Tablet ................ 22Oxycodone/Acetaminophen

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

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

P

Pantoprazole Tablet ................18Paroxetine Tablet ................... 13Pataday ...................................17Pegasys .................................. 20Penicillin V Potassium

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

Suspension .......................... 15Picato ......................................16Pioglitazone ............................17Plan B One Step .................... 24Polyethylene Glycol 3350 ........18Potassium Chloride ............... 23Potassium Citrate .................. 23Pradaxa ...................................11Praluent ................................. 12Pramipexole Tablet .................14

Pravastatin ............................. 12Prednisone Tablet ...................17Premarin ................................ 24Premphase ............................. 24Prempro ................................. 24Prenisolone Oral Solution.......17Prepopik .................................18Prezcobix ................................19Prezista ...................................19Pristiq ER .............................. 13ProAir HFA .......................... 22ProAir Respiclick .................. 22Procrit .................................... 20Progesterone Micronized

Capsule ............................... 24Promethazine/Codeine .......... 20Promethazine/

Dextromethorphan ............. 20Promethazine Tablet .............. 22Propranolol Extended-Release

Capsule ................................11Propranolol Tablet ................. 12Proventil HFA ....................... 22Pulmicort Flexhaler ............... 22Pulmozyme ........................... 20Pylera ......................................18

Q

Qnasl ..................................... 22Quasense ............................... 24Quetiapine Tablet ...................14Quinapril ............................... 12QVAR ................................... 22

R

Rabeprazole Tablet .................18Raloxifene .........................21, 24Raloxifene Tablet ....................21Ramipril ................................ 12Ranexa ................................... 12Ranitadine Syrup ....................18

31

Rapaflo .................................. 20Rasuvo ....................................19Rebif .......................................14Reclipsen ............................... 24Rectiv .................................... 20Regranex .................................16Relpax .....................................14Renvela .................................. 20Repatha ................................. 12Restasis .................................. 20Revlimid .................................11Reyataz ...................................19Rezira .................................... 20Ribapak ..................................19Ribavirin Tablet ......................19Risedronate Sodium Tablet ....21Risperidone Tablet ..................14Rizatriptan ODT, Tablet ........14Ropinirole Tablet ....................14

S

Savaysa ...................................11Seebri Neohaler ..................... 22Serevent Diskus ..................... 22Seroquel XR ...........................14Sertraline Tablet .................... 13Sildenafil Tablet ..................... 23Simcor ................................... 12Simponi ..................................19Simvastatin ............................ 12Sirolimus Tablet ..................... 23Solodyn ...................................10Sotalol.................................... 12Sovaldi ....................................19Spiriva Handihaler ................ 22Spiriva Respimat.................... 22Spironolactone ....................... 12Sprintec ................................. 24Sprix .......................................21Sronyx.................................... 24Stelara .....................................19

Stendra ...................................19Stiolto Respimat .................... 22Strattera ................................. 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 ............... 20Tanzeum .................................17Targretin Capsule ...................11Targretin Gel ..........................11Tasigna ...................................11Tazorac ...................................16Tecfidera .................................14Technivie ................................19Telmisartan............................ 12Telmisartan-

Hydrochlorothiazide ........... 12Temazepam Capsule ...............14

Terazosin ......................... 12, 20Terazosin Capsule, Tablet ...... 20Terbinafine Tablet ..................10Testim .................................... 20Testosterone 1% Topical

Gel ...................................... 20Testosterone Cypionate

Injection .............................. 20Thrive Gum .......................... 23Timolol Maleate 0.25%, 0.5%

Ophthalmic Solution ...........18Tirosint ...................................17Tivicay ....................................19Tizanidine Tablet ...................21Tobi Podhaler ........................ 20Tobramycin/Dexamethasone

0.3%-0.1% Ophthalmic Suspension ...........................18

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

Tobramycin Ophthalmic Solution ...............................18

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

Tablet .................................. 22Tolterodine Tablet ................. 22Topiramate Tablet .................. 15Toujeo SoloStar ......................16Toviaz .................................... 22Tracleer .................................. 23Tradjenta.................................17Tramadol-Acetaminophen ......21Tramadol Sustained-Release

Tablet ...................................21Tramadol Tablet .....................21Transderm-Scop .....................18Travatan Z ..............................18Trazodone Tablet ................... 13Tretinoin .................................16Tretinoin Microspheres ..........16

32

Trezix .....................................21Tri-Lo-Estarylla .................... 24Tri-Lo-Marzia ....................... 24Tri-Lo-Sprintec ..................... 24Tri-Previfem .......................... 24Tri-Sprintec ........................... 24Triamcinolone Acetonide

Cream, Lotion, Ointment ...16Triamcinolone Nasal Spray .... 22Triamterene-

Hydrochlorothiazide ........... 12Triazolam Tablet ....................14Tricor 48, 145 mg .................. 12Trinessa ................................. 24Trinessa Lo ............................ 24Triumeq ..................................19Trulicity ..................................17Truvada ..................................19Tudorza ................................. 22Tybost .....................................19Tyvaso ................................... 23

U

Uceris ......................................18Uloric ......................................21Utibron Neohaler ................... 22

V

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

Valsartan- Hydrochlorothiazide ........... 12

Vascepa .................................. 12Vectical ...................................16Velphoro ................................ 20Venlafaxine Extended-Release

Capsule ............................... 13Venlafaxine Tablet ................. 13Ventolin HFA ........................ 22Verapamil .............................. 12Verapamil Sustained-Release . 12Vesicare .................................. 22Vestura ................................... 24Viagra .....................................19Vicodin 5/300, 7.5/300,

10/300 mg Tablet ................21Victoza 2-Pak .........................17Victoza 3-Pak .........................17Viekira Pak .............................19Vigamox .................................18Viibryd .................................. 13Viorele ................................... 24Viread .....................................19Vitekta ....................................19Vivelle-Dot ............................ 24Voltaren Gel ...........................21Vytorin .................................. 12Vyvanse ................................. 13

W

Warfarin Sodium ...................11Welchol ................................. 12

X

Xarelto ....................................11Xeljanz ....................................19Xeloda ....................................11Xigduo XR .............................17Xopenex HFA ....................... 22Xopenex Nebs ........................ 22Xulane ................................... 24Xyrem .....................................14

Y

Yasmin 28 .............................. 24Yaz ......................................... 24

Z

Zaleplon Capsule ....................14Zelapar ...................................14Zenpep ...................................18Zetia ...................................... 12Zetonna ................................. 22Ziprasidone Capsule ...............14Zohydro ER ...........................21Zolpidem Extended-Release

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

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

For more information

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

Or, visit myuhc.com®

Where else can I go for information? HealthCareLane.com includes short videos to help you learn more about UnitedHealthcare benefi ts and health insurance information.

UHCTV.com is a fun and easy way to learn about health terms and other health-related topics.

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

© 2016 United HealthCare Services, Inc . All rights reserved . Created February, 2016 . 2016 Prescription Drug List – Advantage Four-Tier 100-16911 7/16

Date post:	01-Jan-2017
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Your 2016 Four-Tier Prescription Drug List

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