Your 2017 Prescription Drug List -...

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Your 2017Prescription Drug ListEffective July 1, 2017

This Prescription Drug List (PDL) outlines the most commonly prescribed medications for certain conditions and organizes them into cost levels, also known as tiers.

For additional information:

Visit myuhc.com® for information to help you better understand and manage your medications.

• View your current benefits

• Search for drug prices and lower-cost alternatives

• Potentially save time and money using home delivery through OptumRx®

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

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Table of Contents

Drug tiers and cost . . . . . . . . . . . . . . . . . . . . . . .3

Programs and Limits . . . . . . . . . . . . . . . . . . . . . .5

Drugs by category . . . . . . . . . . . . . . . . . . . . . . . .8

Anti-Infectives

Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Cardiovascular/Heart Disease

Coagulation Therapy . . . . . . . . . . . . . . . . . . . . . . . . .9

High Blood Pressure . . . . . . . . . . . . . . . . . . . . . . . . .9

High Cholesterol . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Central Nervous System

Attention Deficit Disorder . . . . . . . . . . . . . . . . . . . .11

Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Sedatives/Hypnotics . . . . . . . . . . . . . . . . . . . . . . . 12

Seizure Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Diabetes/Endocrine

Blood Glucose Monitoring . . . . . . . . . . . . . . . . . . 14

Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Non-Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Endocrine

Growth Hormone . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Thyroid Hormone Replacement . . . . . . . . . . . . . 15

Eye Conditions

Allergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Dry Eye Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Gastrointestinal

Acid Suppression . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Nausea/Vomiting . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Gout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Hepatitis C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Inflammatory Conditions: RheumatoidArthritis, Crohn’s Disease, Psoriasis,Ulcerative Colitis . . . . . . . . . . . . . . . . . . . . . . . . 17

Men’s Health

Erectile Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . 18

Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Testosterone Therapy . . . . . . . . . . . . . . . . . . . . . . 18

Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Musculoskeletal

Muscle Spasms . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Pain Relief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Overactive Bladder . . . . . . . . . . . . . . . . . . . . . . 20

Respiratory

Allergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Asthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Pulmonary Arterial Hypertension . . . . . . . . . . . . 21

Smoking Cessation . . . . . . . . . . . . . . . . . . . . . 21

Transplant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Vitamins/Electrolytes . . . . . . . . . . . . . . . . . . . 21

Women’s Health

Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Hormone Replacement . . . . . . . . . . . . . . . . . . . . . 23

Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Prenatal Vitamins . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

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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. Medications 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 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 in 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 PDL? 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 or 3, look to see if there is a Tier 1 option available. Discuss these options with your doctor.

Check your benefit plan documents to find out your specific pharmacy plan costs.

$ Drug tier Includes Helpful tips

Tier 1Your lowest cost

Some brands and generics are also included .

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

Tier 2Your mid-range cost

Mix of brands and generics .

Use Tier 2 drugs instead ofTier 3 to help reduce yourout-of-pocket costs .

Tier 3Your highest cost

Mostly brand as well as select generic drugs .

Many Tier 3 drugs have lower-cost options in Tier 1 or 2 . Ask your doctor if they could work for you .

Please note: Some plans may have two or four tiers, while others may not have any. If you have a high deductible plan, the tier cost levels 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 PDL 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 are covered and may differ than what is noted in the PDL. Call the number for Member Services listed on your ID card if you have any questions about your prescription drug coverage.

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 .

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

STStep therapy+ – Trial of a different medication is required before another medication may be 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? A medication 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. Other medication options may be available.

Should I talk to my doctor about over-the-counter (OTC) medications? An OTC medication may be the right treatment for some conditions. Talk to your doctor about available 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, Invokana) and generic drugs in plain type (for example, Metformin).

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 are used to treat rare or complex conditions that require additional care and support. 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, 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 OptumRx Mail Service Member Select? Your plan may include a home delivery program called Mail Service Member Select. The program encourages you to use the home delivery through OptumRx® for maintenance medications, which are medications you take regularly. Home delivery can help you better manage the medication you take on a regular basis, and may save you time and money.

Once the program starts, you have a limited number of fills at your retail pharmacy. If you do not confirm your home delivery enrollment, you may pay more for your medication until you do. You can also choose to disenroll from the program to continue filling at your retail pharmacy for your standard copay or cost share.

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 in 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 home delivery services are included in your pharmacy benefit, you can also:

• Refill prescriptions• Check the status of your order• Set up 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®

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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

MC = Multiple copay PA = Prior authorization requiredRS = May be eligible for the refill and save programSL = 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 1Ciprodex 3Ciprofloxacin Tablet 1Clarithromycin Tablet 1Clindamycin Capsule 1Dificid 3 SLDoxycycline Hyclate 50, 100 mg Capsule, Tablet

2

Doxycycline Monohydrate 50, 100 mg Capsule

1

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

1

Ofloxacin Otic Solution 2

Drug NameDrug Tier


Ofloxacin Tablet 1Oracea 3Penicillin V Potassium Tablet 1

Sulfamethoxazole-Trimethoprim Tablet

1

Suprax Capsule, Chewable Tablet, Tablet

3

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 3 PA, SL, STAcyclovir Tablet 1Famciclovir Tablet 2Oseltamivir Capsule 2 SLValacyclovir Tablet 1 SLValganciclovir 1 SLZovirax Cream 3 E, SL

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Drug NameDrug Tier


Cancer

Bexarotene Capsule 3 DSP, E, PA, SLBicalutamide 1Bosulif 2 DSP, PA, SL, STCyclophosphamide Capsule

2

Hydroxyurea Capsule 1Imatinib Tablet 1 DSP, PA, SLImbruvica 2 DSP, PA, SLLeucovorin Calcium Tablet

1

Mercaptopurine Tablet 1Revlimid 2 DSP, PA, SLSutent 2 DSP, PA, SLTargretin Capsule 2 DSPTargretin Gel 3 SLTasigna 2 DSP, PA, SL, STXeloda 1 DSP, SLZytiga 2 DSP, PA, SLCardiovascular/Heart Disease: Coagulation TherapyBrilinta 3 SLClopidogrel 1Effient 3 SLEliquis 3 SLEnoxaparin Sodium 2 SLPradaxa 2 SLSavaysa 3 SLWarfarin Sodium 1Xarelto 2 SLCardiovascular/Heart Disease: High Blood PressureAmlodipine 1Amlodipine-Benazepril 1Amlodipine-Valsartan 2Atenolol 1Atenolol-Chlorthalidone 1Benazepril 1

Drug NameDrug Tier


Benazepril-Hydrochlorothiazide

1

Benicar 3 E, SLBenicar HCT 3 E, 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 1Labetalol 1Lisinopril 1Lisinopril-Hydrochlorothiazide

1

Losartan 1Losartan-Hydrochlorothiazide

1

Metoprolol Succinate 50, 100, 200 mg

2

Metoprolol Tartrate 25, 50, 100 mg

1

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Drug NameDrug Tier


Nadolol 1Nifedipine Extended-Release

1

Olmesartan 2 SLOlmesartan-Hydrochlorothiazide

2 SL

Propranolol Extended-Release Capsule

2

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

2

Terazosin 1Triamterene-Hydrochlorothiazide

1

Valsartan 2Valsartan-Hydrochlorothiazide

1

Verapamil 1Verapamil Sustained-Release

3

Cardiovascular/Heart Disease: High CholesterolAtorvastatin 1 SLCholine Fenofibrate 3 EEzetimibe Tablet 3 SLFenofibrate 43, 50 , 67, 130, 134, 150, 200 mg Capsule

3 E

Fenofibrate 40, 48, 120, 145 mg Tablet

3 E

Fenofibrate 54, 160 mg Tablet

2

Drug NameDrug Tier


Fluvastatin Extended-Release Tablet

3 SL, ST

Gemfibrozil 1Lipofen 3 ELivalo 3 SL, STLovastatin 1Niacin Extended-Release Tablet

3

Niaspan 2Omega-3-Acid Ethyl Esters Capsule

3 PA

Praluent 2 DSP, PA, SL, STPravastatin 1Repatha 140 mg 3 DSP, PA, SL, STRosuvastatin 2 SLSimvastatin 1Vascepa 3 PAVytorin 3 SLWelchol 2Zetia 3 E, SL

Cardiovascular/Heart Disease: Other

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

1

Multaq 3 PANitroglycerin Sublingual Tablet

1

Ranexa 2Sotalol 1

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Drug NameDrug Tier


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

1 PA

Concerta 2 PA, SLDaytrana 3 E, PA, SLDexmethylphenidate Extended-Release Capsule

3 E, PA, SL

Dexmethylphenidate Immediate-Release Tablet

1 PA

Dextroamphetamine-Amphetamine Extended-Release

3 E, PA, SL

Dextroamphetamine-Amphetamine Immediate-Release Capsule

1 PA

Dextroamphetamine Sulfate Immediate-Release Tablet

3 PA

Focalin XR 3 E, PA, SLGuanfacine Extended-Release

2 SL

Metadate CD 3 E, PA, SLMethylphenidate Chewable Tablet

3 PA

Methylphenidate Extended-Release Capsule (generic Metadate CD, Ritalin LA)

2 PA, SL

Methylphenidate Extended-Release Tablet (generic Concerta)

3 E, PA, SL

Methylphenidate Extended-Release Tablet (Metadate ER)

3 PA, SL

Methylphenidate Tablet 1 PAStrattera 3 SLVyvanse 2 PA, SL

Drug NameDrug Tier


Central Nervous System: Depression

Amitriptyline Tablet 1Bupropion Extended-Release Tablet

1

Bupropion Sustained-Release Tablet

1

Bupropion Tablet 1Citalopram Tablet 1Desvenlafaxine Extended-Release Tablet (generic Pristiq)

3 RS, SL

Doxepin 1Duloxetine Capsule 3 SLEscitalopram Tablet 1Fetzima 3 SL, STFluoxetine Tablet, Capsule (generic Prozac)

1

Fluvoxamine Tablet 1Mirtazapine Tablet 1Nortriptyline Capsule 1Paroxetine Tablet 1Sertraline Tablet 1Trazodone Tablet 1Trintellix 3 SL, STVenlafaxine Extended-Release Capsule

1

Venlafaxine Tablet 1Viibryd 3 SL

Central Nervous System: Migraine

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

1 SL

Frovatriptan 3 SLNaratriptan 1 SLRelpax 2 SLRizatriptan ODT, Tablet 1 SLSumatriptan Nasal Spray 2 SL

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Drug NameDrug Tier


Sumatriptan Succinate Tablet, Injection

1 SL

Central Nervous System: Multiple SclerosisAmpyra 2 DSP, PA, SLAubagio 3 DSP, PA, SLAvonex 2 DSP, PA, SLBetaseron 2 DSP, PA, SLCopaxone 2 DSP, PA, SLGilenya 3 DSP, PA, SL

Glatopa 3DSP, E, PA,

SL, STPlegridy 3 DSP, PA, SLRebif 3 DSP, PA, SL, STTecfidera 2 DSP, PA, SLZinbryta 3 DSP, PA, SL

Central Nervous System: Other

Alprazolam Extended-Release Tablet

1

Alprazolam Tablet 1Aripiprazole Tablet 2 SLArmodafanil 3 E, PA, SLBuprenorphine/Naloxone Tablet

3 E, PA, SL

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

1

Latuda 3 SLLithium Capsule 1Lorazepam Tablet 1Memantine Tablet 2Modafinil Tablet 3 PA, SL

Drug NameDrug Tier


Naloxone Vials 1Narcan Nasal Spray 2 SLOlanzapine Tablet 1 SLPramipexole Tablet 1Quetiapine Extended-Release Tablet

3 SL

Quetiapine Tablet 1Risperidone Tablet 1Ropinirole Tablet 1Suboxone Film 3 E, PA, SLTolcapone 2Xyrem 3 PA, SLZelapar 3Ziprasidone Capsule 2 SLZubsolv 2 SLCentral Nervous System: Sedatives/HypnoticsEszopiclone Tablet 2 SLTemazepam Capsule 1Triazolam Tablet 1Zaleplon Capsule 1 SLZolpidem Extended-Release Tablet

3 E, SL

Zolpidem Tablet 1 SLCentral Nervous System: Seizure DisordersCarbamazepine Extended-Release Capsule

2

Carbamazepine Extended-Release Tablet

3

Carbamazepine Immediate-Release Tablet

1

Clonazepam Tablet 1

13

Drug NameDrug Tier


Diazepam Tablet 1Divalproex Delayed-Release Tablet

1

Divalproex Extended-Release Tablet

2

Gabapentin Capsule, Tablet

1

Lamotrigine Immediate-Release Tablet

1

Levetiracetam Extended-Release Tablet

2

Levetiracetam Immediate-Release Tablet

1

Lyrica 3 SL, STOxcarbazepine Tablet 1Phenytoin Capsule, Suspension

1

Topiramate Immediate-Release Tablet

1

Zonisamide Capsule 1

Dermatology

Aczone 3 SLAdapalene 0 .1% Cream, Gel, Lotion

3 E, PA, SL

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

3

Betamethasone Dipropionate 0 .05% Cream, Ointment

2

Calcipotriene/Betamethasone Ointment

3 SL

Carac 2Ciclopirox Cream, Gel, Lotion, Solution

1

Drug NameDrug Tier


Claravis 2 PAClindamycin 1%/Benzoyl Peroxide 5% Gel

3 E, SL

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

Desonide 0 .05% Cream, Lotion, Ointment

3 SL

Desoximetasone Gel, Ointment

3 SL

Differin 0.1% Cream, Gel, Lotion

3 E, PA, SL

Diflorasone Diacetate 0 .05% Cream, Ointment

3 SL

Enstilar Foam 3 SLEpiduo/Epiduo Forte 3 E, SLFinacea 3Fluocinolone Cream, Oil, Solution

3 SL

Fluocinolone Ointment 2 SLFluocinonide 0 .05% Cream

1

Halobetasol Ointment 2Hydrocortisone 2 .5% Cream, Ointment

1

Imiquimod 5% Cream 1 SLMetronidazole 0 .75% Topical Gel

1

Minocycline Extended-Release Capsule

3 E

14




Drug NameDrug Tier


Mirvaso 3 SLMometasone Furoate Cream, Lotion, Ointment

1

Mupirocin Ointment 1 SLNystatin-Triamcinolone Acetonide Cream, Ointment

3 E

Oxsoralen-Ultra 2Picato 3 SLRegranex 2 PA, SLSolodyn 3 E, PATaclonex Suspension 3 SLTacrolimus Ointment 2 PA, SLTazorac 3 PA, SLTretinoin Cream 3 PA, SLTretinoin Gel 3 E, PA, SLTretinoin Microspheres 3 E, PA, SLTriamcinolone Acetonide Cream, Lotion, Ointment

1

Vectical 3 SL

Diabetes: Blood Glucose Monitoring

Accu-Chek Test Strips

3 E, SL

Contour Test Strips 3 E, SLDexcom Continuous Glucose Monitoring System

3 PA, SL

Dexcom Sensor 3 PA, SLDexcom Transmitter 3 PA, SLFreeStyle Test Strips 3 E, SLOneTouch Test Strips

1 SL

OneTouch Ultra Meter

1

Drug NameDrug Tier


OneTouch Ultra Mini 1OneTouch Ultra Test Strips

1 SL

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

1 SL

Diabetes: Insulin

Afrezza 3 E, PA, SL, STBasaglar 1 SLHumalog KwikPens (all formulations)

2 SL

Humalog Vials (all formulations)

1 SL

Humulin KwikPens (all formulations)

2 SL

Humulin Vials (all formulations)

1 SL

Lantus Solostar 3 E, SLLantus Vials 3 E, SLLevemir FlexTouch 2 SLLevemir Vials 2 SLNovolin Vials (all formulations)

3 SL, ST

Novolog FlexTouch (all formulations)

3 SL, ST

Novolog Vials (all formulations)

3 SL, ST

Soliqua 2 PA, SLToujeo SoloStar 3 E, SLTresiba FlexTouch 3 E, SL

15

Drug NameDrug Tier


Diabetes: Non-Insulin

Adlyxin 3 SLBydureon 2 SLByetta 2 SLFarxiga 3 SL, STGlimepiride 1Glipizide 1Glipizide Extended-Release

1

Glyburide 1Glyxambi 3 E, SL, STInvokamet 2 SLInvokamet XR 2 SLInvokana 2 SL, STJanumet 3 SL, STJanuvia 3 SL, STJardiance 2 SL, STJentadueto 2 SLJentadueto XR 2 SLKazano 2 SLKombiglyze XR 2 SLMetformin 1Metformin Extended-Release Tablet (generic Glucophage XR)

1

Nesina 2 SLOnglyza 2 SLOseni 2 SLPioglitazone 1 SLSynjardy 2 SLTanzeum 2 SLTradjenta 2 SLTrulicity 3 SLVictoza 2-Pak 2 SLVictoza 3-Pak 3 SLXigduo XR 3 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 2

Eye Conditions: Allergies

Azelastine 0 .05% Ophthalmic Solution

1 SL

Lastacaft 3 SLOlopatadine 0 .1% Ophthalmic Solution

3 SL

Pataday 3 E, SL

Eye Conditions: Antibiotics

Erythromycin 0 .5% Ophthalmic Ointment

1

Gentamicin Ophthalmic Ointment, Solution

1

Moxeza 3Ofloxacin 0 .3% Ophthalmic Solution

1

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

2

16




Drug NameDrug Tier


Tobramycin Ophthalmic Solution

1

Vigamox 3

Eye Conditions: Dry Eye Disease

Restasis Single Use Vials

3 PA, SL

Xiidra 3 PA, SL

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 3 E, SLLansoprazole Capsule 3 E, SLOmeclamox-Pak 3 SLOmeprazole Capsule 1Pantoprazole Tablet 1Pylera 3 SLRanitadine Syrup 1Rabeprazole Tablet 3 SLSucralfate Tablet 1

Drug NameDrug Tier


Gastrointestinal: Nausea/Vomiting

Akynzeo 3 SLAprepitant Capsule 2 SLEmend Suspension 2 SLOndansetron 1Ondansetron ODT 1Transderm-Scop 3Varubi 2 SL

Gastrointestinal: Other

Amitiza 3 PA, SL, STApriso 2Asacol HD Tablet 3 ECanasa 2Cortifoam 2Creon 2Delzicol 3 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 Foam 2Uceris Tablet 3Viberzi 3 PA, SLZenpep 2

17

Drug NameDrug Tier


Gout

Allopurinol Tablet 1Colcrys 3 EMitigare 2Uloric 3 SL, STZurampic 3 PA, SL

Hepatitis C

Daklinza 3 DSP, PA, SL, STEpclusa 2 DSP, PA, SLHarvoni 2 DSP, PA, SLRibavirin Tablet 1 DSPSovaldi 2 DSP, PA, SL, STTechnivie 3 DSP, PA, SL, STViekira Pak 3 DSP, PA, SL, STZepatier 3 DSP, PA, SL, ST

HIV/AIDS

Abacavir-Lamivudine 2 DSPAtripla 2 DSPComplera 3 DSPDescovy 3 DSPEpzicom 3 DSP, EEvotaz 2 DSPGenvoya 3 DSP, STIntelence 2 DSPIsentress 2 DSPKaletra Tablet 2 DSPLamivudine-Zidovudine 1 DSPLopinavir-Ritonavir Oral Solution

2 DSP

Nevirapine 1 DSPNevirapine Extended-Release

3 DSP, E

Norvir 2 DSPOdefsey 3 DSPPrezcobix 2 DSPPrezista 2 DSPReyataz 2 DSP

Drug NameDrug Tier


Selzentry 2 DSP, PAStribild 3 DSP, STSustiva 2 DSPTivicay 3 DSPTriumeq 2 DSPTruvada 3 DSP, PATybost 2 DSPViread 2 DSPVitekta 2 DSP

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 3 DSP, PA, SL, STCimzia 2 DSP, PA, SLCosentyx 3 DSP, PA, SL, STEnbrel 3 DSP, PA, SL, STHumira 2 DSP, PA, SLHydroxychloroquine Sulfate

1

Leflunomide 1Methotrexate Tablet 1Orencia 3 DSP, PA, SL, STOtezla 3 DSP, PA, SL, STOtrexup 3 E, SL, STRasuvo 3 SL, STSimponi 2 DSP, PA, SLStelara 2 DSP, PA, SLTaltz 3 DSP, PA, SL, STXeljanz 3 DSP, PA, SL, STXeljanz XR 3 DSP, PA, SL, ST

18




Drug NameDrug Tier


Men’s Health: Erectile Dysfunction

Cialis 3 SLLevitra 3 SLStendra 3 PA, SLViagra 3 SL

Men’s Health: Prostate

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

Men’s Health: Testosterone Therapy

Androderm 2 PA, SLAndrogel 3 E, PA, SLMethyltestosterone Capsule

2

Testim 2 PA, SLTestosterone 1% Topical Gel

3 E, PA, SL

Testosterone Cypionate Injection

1

Miscellaneous

Anastrozole Tablet 1Antipyrine/Benzocaine Otic Solution

1

Aranesp 2 DSP, SLAuryxia 3Auvi-Q 3 E, SLBenzonatate Capsule 1

Drug NameDrug Tier


Bethkis 2 DSP, PA, SLBromfed DM 3Cayston 2 PA, SLCerdelga 2 DSP, PAChlorhexidine Gluconate 1Chlorpheniramine/Hydrocodone/Pseudoephedrine Solution

2 SL

Epinephrine (generic EpiPen/EpiPen-Jr.)

2 SL

EpiPen/EpiPen-Jr. 3 E, SLFosrenol 3Hydrocodone/Chlorpheniramine Suspension

3 SL

Hydrocodone/Homatropine

1

Letrozole Tablet 1Lidocaine Transdermal Patch

3 PA, SL

Nuedexta 2Obredon 3 SL, STPegasys 2 DSP, PA, SLPhenazopyridine 1Procrit 2 DSP, SLPromethazine/Codeine 1Promethazine/Dextromethorphan

1

Pulmozyme 2 DSP, PA, SLRectiv 3 SLRenvela 2Rezira 3Tobi Podhaler 3 DSP, PA, SLTobramycin Nebulized Solution

3 DSP, E, PA, SL

19

Drug NameDrug Tier


Velphoro 2Veltassa 3 PA, SLZarxio 2 DSP

Musculoskeletal: Muscle Spasms

Baclofen Tablet 1Carisoprodol 350 mg Tablet

1

Cyclobenzaprine 1Metaxalone Tablet 3Methocarbamol Tablet 1Tizanidine Tablet 1

Musculoskeletal: Osteoporosis

Alendronate Sodium Tablet

1

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

3 SL

Musculoskeletal: Pain Relief

Acetaminophen/Codeine Tablet

1 SL

Belbuca 3 PA, SL, STButrans 3 E, PA, SL, STCelecoxib 2 SLDiclofenac Tablet 1Embeda 3 E, PA, SL, STEtodolac Capsule 1Fentanyl 12, 25, 50, 75, 100 mcg Patch

2 SL

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

3 E, SL

Fentanyl Citrate Lozenge

2 PA, SL

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

1 SL

Hydrocodone/Ibuprofen Tablet

1

Drug NameDrug Tier


Hydromorphone Tablet 1Hysingla 3 E, PA, SL, STIbuprofen Tablet 1Indomethacin Capsule 1Ketorolac Tablet 1Lazanda 3 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 3 SLNucynta ER 3 PA, SLOpana ER 2 PA, SLOxycodone Tablet 1Oxycodone/Acetaminophen 5/325, 7 .5/325, 10/325 mg Tablet

1 SL

Oxycontin 3 E, PA, SL, STSprix 3Subsys 3 E, PA, SLTramadol-Acetaminophen

1

Tramadol Immediate-Release Tablet

1

Tramadol Sustained-Release Tablet

2 SL

Trezix 3 SLVicodin 5/300, 7 .5/300, 10/300 mg Tablet

3 E, SL

Voltaren Gel 2Xtampza ER 3 PA, SLZohydro ER 3 PA, SL, ST

20




Drug NameDrug Tier


Overactive Bladder

Dicyclomine Tablet 1Oxybutynin Extended-Release Tablet

2

Oxybutynin Tablet 1Tolterodine Extended-Release Tablet

3 E

Tolterodine Tablet 3 EToviaz 3Vesicare 3 E

Respiratory: Allergies

Azelastine 0 .1% Nasal Spray

3

Clarinex 3 EClarinex-D 3 ECyproheptadine Tablet 1Fluticasone Nasal Spray 2 SLHydroxyzine Capsule, Tablet

1

Levocetirizine Tablet 1Mometasone Nasal Spray

3 E, SL

Promethazine Tablet 1Triamcinolone Nasal Spray

3 E, SL

Zetonna 3 SL

Respiratory: Asthma/COPD

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

Drug NameDrug Tier


Alvesco 1 SLAnoro Ellipta 3 SLArnuity Ellipta 3 SLAsmanex 1 SLBevespi Aerosphere 2 SLBreo Ellipta 3 RS, SLBudesonide Nebs 2 SLCombivent Respimat 3 SLDulera 3 SL, STFlovent Diskus/HFA 3 SLIncruse Ellipta 2 SLIpratropium-Albuterol Nebs

1

Ipratropium Nebs 1Levalbuterol Nebs 3 E, SLMontelukast Chewable Tablet, Tablet

1

Montelukast Granules 2Perforomist 3 SLProAir HFA 3 SLProAir RespiClick 3 SLProventil HFA 3 SLPulmicort Flexhaler 3 SL, STQVAR 1 SLSerevent Diskus 3 SLSpiriva Handihaler 3 SLSpiriva Respimat 3 SLStiolto Respimat 3 E, SLStriverdi Respimat 2 SLSymbicort 3 RS, SLTudorza 2 SLVentolin HFA 2 SLXopenex HFA 3 SLXopenex Nebs 3 E, SL

21

Drug NameDrug Tier


Respiratory: Pulmonary Arterial HypertensionAdcirca 3 DSP, PA, SLAdempas 2 DSP, PA, SLLetairis 2 DSP, PA, SLOpsumit 2 DSP, PA, SLOrenitram 3 DSP, PA, SLSildenafil Tablet 1 DSP, PA, SLTracleer 2 DSP, PA, SLTyvaso 2 DSP, PAUptravi 3 DSP, PA, SL

Smoking Cessation

Bupropion Sustained-Release Tablet

1 H, PA

Chantix Tablet 3 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

Aftera 1 HAltavera 1 HAlyacen 7/7/7, 1/35 1 HApri 1 HAranelle 1 HAubra 1 HAviane 1 HAzurette 2Blisovi Fe 1 HCamila 1 HCaziant 1 HCesia 1 HChateal 1 HCryselle 1 HCyclafem 7/7/7, 1/35 1 HCyred 1 HDasetta 7/7/7, 1/35 1 HDeblitane 1 HDelyla 1 HDesogestrel-Ethinyl Estradiol (generic Ortho-Cept)

1 H

Drospirenone-Ethinyl Estradiol-Levomefolate Calcium

3 E

Econtra EZ 1 HElinest 1 HElla 1 H, SLEmoquette 1 HEnpresse 1 H

22




Drug NameDrug Tier


Enskyce 1 HErrin 1 HEstarylla 1 HFallback 1 HFalmina 1 HGildess 2Gildess Fe 1 HHeather 1 HIntrovale 2 HJencycla 1 HJolessa 2 HJolivette 1 HJuleber 1 HJunel 2Junel Fe 1 HKurvelo 1 HKelnor 1/35 1 HLarin Fe 1 HLarissia 1 HLeena 1 HLessina 1 HLevonest 1 HLevonorgestrel 1 .5 mg 1 HLevonorgestrel-Ethinyl Estradiol (generic Alesse, Nordette, Triphasil)

1 H

Levonorgestrel-Ethinyl Estradiol (generic Seasonale)

2 H

Levora-28 1 HLo Loestrin Fe 3Loryna 3Low-Ogestrel 1 HLutera 1 H

Drug NameDrug Tier


Lyza 1 HMarlissa 1 HMedroxyprogesterone Acetate

1 H

Microgestin 2Microgestin Fe 1 HMinastrin 24 Fe 3 EMono-Linyah 1 HMonoNessa 1 HMy Way 1 HMyzilra 1 HNatazia 2Necon 7/7/7, 0 .5/35, 1/35, 1/50, 10/11

1 H

Next Choice 1 HNora BE 1 HNorethindrone 0 .35 mg 1 HNorethindrone-Ethinyl Estradiol-Ferrous Fumarate

1 H

Norgestimate-Ethinyl Estradiol (generic Ortho-Cyclen, Ortho Tri-Cyclen)

1 H

Norgestimate-Ethinyl Estradiol Lo (generic Ortho Tri-Cyclen Lo)

3

Norlyroc 1 HNortrel 7/7/7, 0 .5/35, 1/35

1 H

Nuvaring 2 HOpcicon 1 HOrsythia 1 HOrtho Tri-Cyclen Lo 3 EPirmella 7/7/7, 1/35 1 H

23

Drug NameDrug Tier


Plan B One Step 1 HPortia 1 HPrevifem 1 HQuasense 2 HRajani 3 EReact 1 HReclipsen 1 HSetlakin 2 HSharobel 1 HSolia 1 HSprintec 1 HSronyx 1 HTake Action 1 HTarina Fe 1 HTaytulla 3 ETri-Estarylla 1 HTri-Linyah 1 HTri-Lo-Estarylla 3Tri-Lo-Marzia 3Tri-Lo-Sprintec 3Tri-Previfem 1 HTri-Sprintec 1 HTrinessa 1 HTrinessa Lo 3Trivora-28 1 HVelivet 1 HVestura 3Vienva 1 HViorele 2Wera 1 HXulane 3 HYasmin 28 2Yaz 2Zovia 1/35E, 1/50E 1 H

Drug NameDrug Tier


Women’s Health: Hormone Replacement

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

2

Estradiol Tablet 1Estradiol Twice-Weekly Transdermal Patch

3 E, SL

Estring 2 MC, SLEstrogen/Methyltestosterone Tablet

1

Evamist 2Medroxyprogesterone 1Minivelle 3 SLPremarin 3Premphase 3Prempro 3Progesterone Micronized Capsule

2

Vagifem 3 EVivelle-Dot 2 SLYuvafem 2

Women’s Health: Miscellaneous

Addyi 3 PA, SLOsphena 3Raloxifene 2 H, PATamoxifen 1 H, PA

Women’s Health: Prenatal Vitamins

Brand Prenatal Vitamins

3

24

IndexA

Abacavir-Lamivudine ............ 17Accu-Chek Test Strips .......... 14Acetaminophen/Butalbital/

Caffeine 325 mg/50 mg/ 40 mg .................................11

Acetaminophen/ Codeine Tablet ...................19

Actemra ................................. 17Acyclovir Ointment .................8Acyclovir Tablet ......................8Aczone ...................................13Adapalene 0.1% Cream, Gel,

Lotion .................................13Adapalene 0.3% Gel ..............13Adcirca ..................................21Adderall XR ..........................11Addyi .....................................23Adempas ................................21Adlyxin ..................................15Advair Diskus/HFA ..............20Aerospan ...............................20Afrezza .................................. 14Aftera ....................................21Akynzeo ................................16Albuterol Nebs ......................20Albuterol Sulfate Tablet .........20Alendronate Sodium Tablet...19Alesse ....................................22Alfuzosin Tablet ....................18Allopurinol Tablet ................. 17Alphagan P 0.1% ...................16Alprazolam Extended-Release

Tablet ..................................12Alprazolam Tablet .................12Altavera .................................21Alvesco ..................................20Alyacen 7/7/7, 1/35 ................21Amiodarone ...........................10

Amitiza..................................16Amitriptyline Tablet ..............11Amlodipine .............................9Amlodipine-Benazepril ...........9Amlodipine-Valsartan .............9Amoxicillin Capsule,

Chewable Tablet ...................8Amoxicillin/Potassium

Clavulanate Chewable Tablet, Tablet .......................8

Amphetamine Salt Combo ....11Ampyra..................................12Anastrozole Tablet ................18Androderm ............................18Androgel................................18Anoro Ellipta.........................20Antipyrine/Benzocaine

Otic Solution ......................18Aprepitant Capsule ................16Apri .......................................21Apriso ....................................16Aranelle .................................21Aranesp .................................18Aripiprazole Tablet ................12Armodafanil ..........................12Armour Thyroid ....................15Arnuity Ellipta ......................20Asacol HD Tablet .................16Asmanex ................................20Atenolol ...................................9Atenolol-Chlorthalidone .........9Atorvastatin ...........................10Atripla ................................... 17Aubagio .................................12Aubra .....................................21Auryxia ..................................18Auvi-Q ..................................18Aviane ...................................21Avonex ...................................12

Azathioprine Tablet ...............21Azelastine 0.05% Ophthalmic

Solution ..............................15Azelastine 0.1%

Nasal Spray .........................20Azithromycin Tablet ................8Azopt .....................................16Azurette ................................21

B

Baclofen Tablet ......................19Basaglar ................................. 14Belbuca ..................................19Benazepril................................9Benazepril-

Hydrochlorothiazide .............9Benicar ....................................9Benicar HCT ..........................9Benzonatate Capsule .............18Betamethasone Dipropionate

0.05% Augmented Lotion, Ointment ............................13

Betamethasone Dipropionate 0.05% Cream, Ointment ....13

Betaseron ...............................12Bethkis ..................................18Bevespi Aerosphere ...............20Bexarotene Capsule .................9Bicalutamide ............................9Bidil .........................................9Bisoprolol .................................9Bisoprolol-

Hydrochlorothiazide .............9Blisovi Fe ...............................21Bosulif .....................................9Brand Prenatal Vitamins .......23Breo Ellipta ...........................20Brilinta ....................................9Bromfed DM .........................18Budesonide Nebs ...................20

25

Buprenorphine/ Naloxone Tablet ..................12

Bupropion Extended-Release Tablet ..................................11

Bupropion Sustained-Release Tablet ............................ 11, 21

Bupropion Tablet ...................11Buspirone Tablet ....................12Butrans ..................................19Bydureon ...............................15Byetta ....................................15Bystolic ....................................9

C

Calcipotriene/Betamethasone Ointment ............................13

Calcitriol Capsule ..................15Camila ...................................21Canasa ...................................16Carac .....................................13Carbamazepine Extended-

Release Capsule ..................12Carbamazepine Extended-

Release Tablet .....................12Carbamazepine Immediate-

Release Tablet .....................12Carbidopa-Levodopa .............12Carisoprodol 350 mg Tablet ..19Cartia XT ................................9Carvedilol ................................9Cayston ..................................18Caziant ..................................21Cefadroxil Capsule, Tablet ......8Cefdinir Capsule .....................8Cefixime Suspension ...............8Cefprozil Tablet .......................8Cefuroxime Tablet ...................8Celecoxib ...............................19Cenestin ................................23Cephalexin Capsule .................8Cerdelga ................................18

Cesia ......................................21Cetrotide ............................... 17Chantix Tablet .......................21Chateal ..................................21Chlorhexidine Gluconate .......18Chlorpheniramine/

Hydrocodone/Pseudoephedrine Solution ..18

Chlorthalidone ........................9Choline Fenofibrate ...............10Cialis .....................................18Ciclopirox Cream, Gel,

Lotion, Solution .................13Cimzia ................................... 17Ciprodex ..................................8Ciprofloxacin Tablet ................8Citalopram Tablet ..................11Claravis ..................................13Clarinex .................................20Clarinex-D ............................20Clarithromycin Tablet .............8Climara..................................23Climara Pro ...........................23Clindamycin 1%/Benzoyl

Peroxide 5% Gel .................13Clindamycin 1.2%/Benzoyl

Peroxide 5% Gel .................13Clindamycin Capsule ..............8Clindamycin Gel ...................13Clindamycin Lotion ..............13Clindamycin Solution,

Swabs ..................................13Clobetasol Propionate

Cream, Ointment ...............13Clobetasol Propionate

Solution ..............................13Clomiphene ........................... 17Clonazepam Tablet ................12Clonidine Tablet ......................9Clopidogrel ..............................9

Clotrimazole-Betamethasone Cream .................................13

Clotrimazole-Betamethasone Lotion .................................13

Colcrys .................................. 17Combigan ..............................16Combivent Respimat .............20Complera ............................... 17Concerta ................................11Contour Test Strips ............... 14Copaxone...............................12Corlanor ................................10Cortifoam ..............................16Cosentyx................................ 17Creon .....................................16Cresemba .................................8Cryselle ..................................21Cyclafem 7/7/7, 1/35..............21Cyclobenzaprine ....................19Cyclophosphamide Capsule .....9Cyclosporine Modified

Capsule ...............................21Cyproheptadine Tablet ..........20Cyred .....................................21

D

Daklinza ................................ 17Dasetta 7/7/7, 1/35 ................21Daytrana ................................11Deblitane ...............................21Delyla ....................................21Delzicol .................................16Descovy ................................. 17Desmopressin Tablet .............15Desogestrel-Ethinyl

Estradiol .............................21Desonide 0.05% Cream,

Lotion, Ointment ...............13Desoximetasone Gel,

Ointment ............................13

26

Desvenlafaxine Extended-Release Tablet .....................11

Dexamethasone Tablet ..........15Dexcom Continuous Glucose

Monitoring System ............. 14Dexcom Sensor ...................... 14Dexcom Transmitter ............. 14Dexilant .................................16Dexmethylphenidate

Extended-Release Capsule .11Dexmethylphenidate

Immediate-Release Tablet ..................................11

Dextroamphetamine Sulfate Immediate-Release Tablet ..11

Dextroamphetamine-Amphetamine Extended-Release ...............11

Dextroamphetamine-Amphetamine Immediate-Release Capsule ..................11

Diazepam Tablet .............12, 13Diclofenac Tablet ...................19Dicyclomine Tablet ...............20Differin 0.1% Cream, Gel,

Lotion .................................13Dificid .....................................8Diflorasone Diacetate 0.05%

Cream, Ointment ...............13Digoxin .................................10Diltiazem 24 Hour CD ...........9Diltiazem Sustained-Release

Capsule .................................9Diltiazem Sustained-Release

Tablet ....................................9Diphenoxylate-Atropine

Tablet ..................................16Divalproex Delayed-Release

Tablet ..................................13Divalproex Extended-Release

Tablet ..................................13

Divigel ...................................23Donepezil 5, 10 mg ODT,

Tablet ..................................12Doxazosin .......................... 9, 18Doxazosin Tablet ...................18Doxepin .................................11Doxycycline Hyclate

50, 100 mg Capsule, Tablet ..8Doxycycline Monohydrate

50, 100 mg Capsule ..............8Drospirenone-Ethinyl

Estradiol-Levomefolate Calcium ..............................21

Duavee ...................................23Dulera ....................................20Duloxetine Capsule ...............11Dutasteride Capsule ..............18Dutoprol ..................................9

E

Econazole Cream ....................8Econtra EZ ...........................21Edarbi ......................................9Edarbyclor ...............................9Effient .....................................9Elinest ...................................21Eliquis .....................................9Ella ........................................21Embeda .................................19Emend Suspension ................16Emoquette .............................21Enalapril ..................................9Enbrel .................................... 17Enjuvia ..................................23Enoxaparin Sodium .................9Enpresse ................................21Enskyce .................................22Enstilar Foam ........................13Entresto .................................10Epclusa .................................. 17Epiduo/Epiduo Forte .............13

Epinephrine ...........................18EpiPen/EpiPen-Jr. .................18Epzicom ................................ 17Errin ......................................22Erythromycin 0.5%

Ophthalmic Ointment ........15Escitalopram Tablet ...............11Esomeprazole Capsule ...........16Estarylla ................................22Estrace Cream .......................23Estradiol Tablet .....................23Estradiol Twice-Weekly

Transdermal Patch ..............23Estradiol/Norethindrone

Acetate Tablet .....................23Estring ...................................23Estrogen/Methyltestosterone

Tablet ..................................23Eszopiclone Tablet .................12Etodolac Capsule ...................19Evamist ..................................23Evotaz .................................... 17Ezetimibe Tablet ...................10

F

Fallback .................................22Falmina .................................22Famciclovir Tablet ...................8Farxiga ...................................15Fenofibrate 40, 48, 120,

145 mg Tablet .....................10Fenofibrate 43, 50 , 67, 130,

134, 150, 200 mg Capsule ..10Fenofibrate 54, 160 mg

Tablet ..................................10Fentanyl 12, 25, 50,

75, 100 mcg Patch ..............19Fentanyl 37.5, 62.5, 87.5 mcg

Patch ...................................19Fentanyl Citrate Lozenge ......19Fetzima ..................................11

27

Finacea ..................................13Finasteride Tablet ..................18Flecainide ..............................10Flovent Diskus/HFA .............20Fluconazole Tablet ...................8Fluocinolone Cream, Oil,

Solution ..............................13Fluocinolone Ointment .........13Fluocinonide 0.05% Cream ...13Fluoride .................................21Fluoxetine Tablet, Capsule ....11Fluticasone Nasal Spray .........20Fluvastatin Extended-Release

Tablet ..................................10Fluvoxamine Tablet ...............11Focalin XR ............................11Folic Acid ..............................21Forteo ....................................19Fosrenol .................................18FreeStyle Test Strips .............. 14Frovatriptan ...........................11Furosemide ..............................9

G

Gabapentin Capsule, Tablet ..13Gemfibrozil ...........................10Gentamicin Ophthalmic

Ointment, Solution .............15Genvoya ................................. 17Gildess ...................................22Gildess Fe ..............................22Gilenya ..................................12Glatopa ..................................12Glimepiride ...........................15Glipizide ................................15Glipizide Extended-Release ..15Glucophage XR .....................15Glyburide...............................15Glyxambi ...............................15Golytely .................................16Gonal-F ................................. 17

Gonal-F RFF ........................ 17Guanfacine ........................ 9, 11Guanfacine

Extended-Release ...............11

H

Halobetasol Ointment ...........13Harvoni ................................. 17Heather ..................................22Humalog KwikPens .............. 14Humalog Vials ...................... 14Humira .................................. 17Humulin KwikPens ............... 14Humulin Vials ....................... 14Hydralazine .............................9Hydrochlorothiazide ................9Hydrocodone/Acetaminophen

5/325, 7.5/325, 10/325 mg Tablet ..................................19

Hydrocodone/ Chlorpheniramine Suspension ..........................18

Hydrocodone/Homatropine ..18Hydrocodone/

Ibuprofen Tablet .................19Hydrocortisone 2.5% Cream,

Ointment ............................13Hydromorphone Tablet .........19Hydroxychloroquine Sulfate .. 17Hydroxyurea Capsule ..............9Hydroxyzine Capsule, Tablet 20Hyoscyamine Tablet ..............16Hysingla ................................19

I

Ibandronate Tablet ................19Ibuprofen Tablet ....................19Imatinib Tablet ........................9Imbruvica ................................9Imiquimod 5% Cream ...........13Incruse Ellipta .......................20Indomethacin Capsule ...........19

Intelence ................................ 17Introvale ................................22Invokamet ..............................15Invokamet XR .......................15Invokana ................................15Ipratropium Nebs ..................20Ipratropium-Albuterol Nebs ..20Irbesartan ................................9Isentress ................................. 17Isosorbide Mononitrate ER ...10Itraconazole Capsule ................8

J

Janumet .................................15Januvia ...................................15Jardiance ................................15Jencycla ..................................22Jentadueto ..............................15Jentadueto XR .......................15Jolessa ....................................22Jolivette ..................................22Juleber ....................................22Junel .......................................22Junel Fe ..................................22

K

Kaletra Tablet ........................ 17Kazano ..................................15Kelnor 1/35 ............................22Ketoconazole Cream ...............8Ketorolac Tablet .....................19Klor-Con M10 ......................21Klor-Con M20 ......................21Kombiglyze XR .....................15Kurvelo ..................................22

L

Labetalol ..................................9Lamivudine-Zidovudine ....... 17Lamotrigine

Immediate-Release Tablet ..13Lansoprazole Capsule ............16

28

Lantus Solostar ...................... 14Lantus Vials .......................... 14Larin Fe .................................22Larissia ..................................22Lastacaft ................................15Latanoprost 0.005%

Ophthalmic Solution ..........16Latuda ...................................12Lazanda .................................19Leena .....................................22Leflunomide .......................... 17Lessina ...................................22Letairis ..................................21Letrozole Tablet ....................18Leucovorin Calcium Tablet .....9Levalbuterol Nebs ..................20Levemir FlexTouch ............... 14Levemir Vials ........................ 14Levetiracetam

Extended-Release Tablet ....13Levetiracetam Immediate-

Release Tablet .....................13Levitra ...................................18Levocetirizine Tablet .............20Levofloxacin Tablet .................8Levonest ................................22Levonorgestrel 1.5 mg ...........22Levonorgestrel-Ethinyl

Estradiol .............................22Levora-28 ..............................22Levothyroxine Sodium

Tablet ..................................15Lialda ....................................16Lidocaine Transdermal

Patch ...................................18Linzess ..................................16Liothyronine Sodium

Tablet ..................................15Lipofen ..................................10Lisinopril ........................... 9, 32

Lisinopril- Hydrochlorothiazide .............9

Lithium Capsule ....................12Livalo ....................................10Lo Loestrin Fe ......................22Lopinavir-Ritonavir

Oral Solution ...................... 17Lorazepam Tablet ..................12Loryna ...................................22Losartan ..................................9Losartan-

Hydrochlorothiazide .............9Lovastatin ..............................10Low-Ogestrel ........................22Lumigan ................................16Lutera ....................................22Lyrica ....................................13Lyza .......................................22

M

Marlissa .................................22Medroxyprogesterone ......22, 23Medroxyprogesterone

Acetate ................................22Meloxicam Tablet ..................19Memantine Tablet .................12Mercaptopurine Tablet ............9Metadate CD ........................11Metadate ER .........................11Metaxalone Tablet .................19Metformin .............................15Metformin Extended-Release

Tablet ..................................15Methadone Tablet,

Oral Solution, Concentrate Solution ..............................19

Methimazole Tablet ..............15Methocarbamol Tablet ..........19Methotrexate Tablet .............. 17Methylphenidate Chewable

Tablet ..................................11

Methylphenidate Extended-Release Capsule ..................11

Methylphenidate Extended-Release Tablet .....................11

Methylphenidate Tablet .........11Methylprednisolone Tablet ....15Methyltestosterone Capsule ...18Metoclopramide Tablet .........16Metoprolol Succinate

50, 100, 200 mg ....................9Metoprolol Tartrate

25, 50, 100 mg ......................9Metronidazole 0.75%

Topical Gel .........................13Metronidazole Tablet ..............8Microgestin ...........................22Microgestin Fe ......................22Minastrin 24 Fe .....................22Minivelle ...............................23Minocycline Capsule ...............8Minocycline

Extended-Release Capsule .13Minocycline Tablet ..................8Mirtazapine Tablet ................11Mirvaso ................................. 14Mitigare ................................. 17Modafinil Tablet ....................12Mometasone Furoate Cream,

Lotion, Ointment ............... 14Mometasone Nasal Spray ......20Mono-Linyah ........................22MonoNessa ............................22Montelukast Chewable Tablet,

Tablet ..................................20Montelukast Granules ...........20Morphine Sulfate

Extended-Release Tablet ....19Morphine Sulfate

Oral Solution ......................19Movantik ...............................16Moviprep ...............................16

29

Moxeza ..................................15Moxifloxacin Tablet .................8Multaq ...................................10Mupirocin Ointment ............. 14My Way .................................22Mycophenolate Capsule,

Suspension ..........................21Mycophenolic Acid Tablet .....21Myzilra ..................................22

N

Nabumetone Tablet ...............19Nadolol ..................................10Naloxone Vials ......................12Naproxen Tablet ....................19Naratriptan ............................11Narcan Nasal Spray ...............12Natazia ..................................22Necon 7/7/7, 0.5/35, 1/35,

1/50, 10/11 ..........................22Nesina ....................................15Nevirapine ............................. 17Nevirapine

Extended-Release ............... 17Next Choice...........................22Niacin Extended-Release

Tablet ..................................10Niaspan .................................10Nicoderm CQ........................21Nicorette Gum ......................21Nicorette Lozenge .................21Nicorette Mini-Lozenge .......21Nicotine Gum .......................21Nicotine Lozenge ..................21Nicotine Patch .......................21Nicotrol Inhaler .....................21Nicotrol Nasal Spray ..............21Nifedipine

Extended-Release ...............10Nitrofurantoin Capsule ............8

Nitrofurantoin Macrocrystal Capsule .................................8

Nitroglycerin Sublingual Tablet ..................................10

Nora BE ................................22Nordette ................................22Norethindrone 0.35 mg .........22Norethindrone-Ethinyl

Estradiol-Ferrous Fumarate ............................22

Norgestimate-Ethinyl Estradiol .............................22

Norgestimate-Ethinyl Estradiol Lo .......................22

Norlyroc .................................22Nortrel 7/7/7, 0.5/35, 1/35 .....22Nortriptyline Capsule ............11Norvir .................................... 17Novolin Vials ......................... 14Novolog FlexTouch ............... 14Novolog Vials ........................ 14Noxafil Tablet, Suspension ......8NP Thyroid Tablet ................15Nucynta .................................19Nucynta ER ...........................19Nuedexta ...............................18Nutropin, Nutropin AQ ........15Nuvaring................................22Nystatin Cream, Ointment......8Nystatin-Triamcinolone

Acetonide Cream, Ointment ............................ 14

O

Obredon ................................18Odefsey .................................. 17Ofloxacin 0.3% Ophthalmic

Solution ..............................15Ofloxacin Otic Solution ...........8Ofloxacin Tablet ......................8Olanzapine Tablet .................12

Olmesartan ............................10Olmesartan-

Hydrochlorothiazide ...........10Olopatadine 0.1%

Ophthalmic Solution ..........15Omeclamox-Pak ....................16Omega-3-Acid Ethyl Esters

Capsule ...............................10Omeprazole Capsule .............16Ondansetron ..........................16Ondansetron ODT ................16OneTouch Test Strips ............ 14OneTouch Ultra Meter .......... 14OneTouch Ultra Mini ........... 14OneTouch Ultra Test Strips ... 14OneTouch Verio .................... 14OneTouch Verio Flex ............. 14OneTouch Verio IQ ............... 14OneTouch Verio Sync ............ 14OneTouch Verio Test Strips ... 14Onglyza .................................15Opana ER .............................19Opcicon .................................22Opsumit ................................21Oracea .....................................8Orencia .................................. 17Orenitram ..............................21Orsythia ................................22Ortho Tri-Cyclen ..................22Ortho Tri-Cyclen Lo.............22Ortho-Cept ...........................21Ortho-Cyclen ........................22Oseltamivir Capsule ................8Oseni .....................................15Osphena ................................23Otezla .................................... 17Otrexup ................................. 17Ovidrel .................................. 17Oxcarbazepine Tablet ............13Oxsoralen-Ultra ..................... 14

30

Oxybutynin Extended-Release Tablet ..................................20

Oxybutynin Tablet ................20Oxycodone Tablet ..................19Oxycodone/Acetaminophen

5/325, 7.5/325, 10/325 mg Tablet ..................................19

Oxycontin ..............................19

P

Pantoprazole Tablet ...............16Paroxetine Tablet ...................11Pataday ..................................15Pegasys ..................................18Penicillin V Potassium Tablet ..8Perforomist ............................20Phenazopyridine ....................18Phenytoin Capsule,

Suspension ..........................13Picato ..................................... 14Pioglitazone ...........................15Pirmella 7/7/7, 1/35 ...............22Plan B One Step ....................23Plegridy .................................12Polyethylene Glycol 3350 .......16Portia .....................................23Potassium Chloride ...............21Potassium Citrate ..................21Pradaxa ....................................9Praluent .................................10Pramipexole Tablet ................12Pravastatin .............................10Prednisone Tablet ..................15Premarin ................................23Premphase .............................23Prempro .................................23Prenisolone Oral Solution......15Prepopik ................................16Previfem ................................23Prezcobix ............................... 17Prezista .................................. 17

Pristiq ....................................11ProAir HFA ..........................20ProAir RespiClick .................20Procrit ....................................18Progesterone Micronized

Capsule ...............................23Promethazine Tablet ..............20Promethazine/Codeine ..........18Promethazine/

Dextromethorphan .............18Propranolol Extended-Release

Capsule ...............................10Propranolol Tablet .................10Proventil HFA .......................20Prozac ....................................11Pulmicort Flexhaler ...............20Pulmozyme ...........................18Pylera .....................................16

Q

Quasense ...............................23Quetiapine Extended-Release

Tablet ..................................12Quetiapine Tablet ..................12Quinapril ...............................10QVAR ...................................20

R

Rabeprazole Tablet ................16Rajani ....................................23Raloxifene ........................ 19, 23Raloxifene Tablet ...................19Ramipril ................................10Ranexa ...................................10Ranitadine Syrup ...................16Rapaflo ..................................18Rasuvo ................................... 17React......................................23Rebif ......................................12Reclipsen ...............................23Rectiv ....................................18Regranex ................................ 14

Relpax ....................................11Renvela ..................................18Repatha 140 mg.....................10Restasis Single Use Vials .......16Revlimid ..................................9Reyataz .................................. 17Rezira ....................................18Ribavirin Tablet ..................... 17Risedronate Sodium Tablet ...19Risperidone Tablet .................12Ritalin LA .............................11Rizatriptan ODT, Tablet .......11Ropinirole Tablet ...................12Rosuvastatin ..........................10

S

Savaysa ....................................9Seasonale ...............................22Selzentry ................................ 17Serevent Diskus .....................20Sertraline Tablet ....................11Setlakin .................................23Sharobel .................................23Sildenafil Tablet .....................21Simponi ................................. 17Simvastatin ............................10Sirolimus Tablet .....................21Solia .......................................23Soliqua ................................... 14Solodyn .................................. 14Sotalol....................................10Sovaldi ................................... 17Spiriva Handihaler ................20Spiriva Respimat....................20Spironolactone .......................10Sprintec .................................23Sprix ......................................19Sronyx....................................23Stelara .................................... 17Stendra ..................................18Stiolto Respimat ....................20

31

Strattera .................................11Stribild ................................... 17Striverdi Respimat .................20Suboxone Film ......................12Subsys ....................................19Suclear ...................................16Sucralfate Tablet ....................16Sulfamethoxazole-

Trimethoprim Tablet ............8Sulfasalazine Tablet ...............16Sumatriptan Nasal Spray .......11Sumatriptan Succinate Tablet,

Injection ..............................12Suprax Capsule, Chewable

Tablet, Tablet ........................8Suprep ...................................16Sustiva ................................... 17Sutent ......................................9Symbicort ..............................20Synjardy .................................15Synthroid ...............................15

T

Taclonex Suspension .............. 14Tacrolimus Capsule ...............21Tacrolimus Ointment ............ 14Take Action ...........................23Taltz ...................................... 17Tamoxifen..............................23Tamsulosin Capsule ...............18Tanzeum ................................15Targretin Capsule ....................9Targretin Gel ...........................9Tarina Fe ...............................23Tasigna ....................................9Taytulla .................................23Tazorac .................................. 14Tecfidera ................................12Technivie ............................... 17Telmisartan............................10

Telmisartan-Hydrochlorothiazide ...........10

Temazepam Capsule ..............12Terazosin ......................... 10, 18Terazosin Capsule, Tablet ......18Terbinafine Tablet ...................8Testim ....................................18Testosterone 1%

Topical Gel .........................18Testosterone Cypionate

Injection ..............................18Thrive Gum ..........................21Timolol Maleate 0.25%, 0.5%

Ophthalmic Solution ..........16Tivicay ................................... 17Tizanidine Tablet ..................19Tobi Podhaler ........................18Tobramycin Nebulized

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

Solution ..............................16Tobramycin/Dexamethasone

0.3%-0.1% Ophthalmic Suspension ..........................15

Tolcapone ..............................12Tolterodine Extended-Release

Tablet ..................................20Tolterodine Tablet .................20Topiramate Immediate-Release

Tablet ..................................13Toujeo SoloStar ..................... 14Toviaz ....................................20Tracleer ..................................21Tradjenta................................15Tramadol Immediate-Release

Tablet ..................................19Tramadol Sustained-Release

Tablet ..................................19Tramadol-Acetaminophen .....19Transderm-Scop ....................16Travatan Z .............................16

Trazodone Tablet ...................11Tresiba FlexTouch ................. 14Tretinoin Cream .................... 14Tretinoin Gel ......................... 14Tretinoin Microspheres ......... 14Trezix ....................................19Tri-Estarylla ..........................23Tri-Linyah .............................23Tri-Lo-Estarylla ....................23Tri-Lo-Marzia .......................23Tri-Lo-Sprintec .....................23Tri-Previfem ..........................23Tri-Sprintec ...........................23Triamcinolone Acetonide

Cream, Lotion, Ointment .. 14Triamcinolone Nasal Spray ....20Triamterene-

Hydrochlorothiazide ...........10Triazolam Tablet ...................12Trinessa .................................23Trinessa Lo ............................23Trintellix ................................11Triphasil ................................22Triumeq ................................. 17Trivora-28 ..............................23Trulicity .................................15Truvada ................................. 17Tudorza .................................20Tybost .................................... 17Tyvaso ...................................21

U

Uceris Foam ...........................16Uceris Tablet ..........................16Uloric ..................................... 17Uptravi...................................21

V

Vagifem .................................23Valacyclovir Tablet ..................8Valganciclovir ..........................8Valsartan ................................10

32

Valsartan- Hydrochlorothiazide ...........10

Varubi ....................................16Vascepa ..................................10Vectical .................................. 14Velivet ....................................23Velphoro ................................19Veltassa ..................................19Venlafaxine Extended-Release

Capsule ...............................11Venlafaxine Tablet .................11Ventolin HFA ........................20Verapamil ..............................10Verapamil Sustained-Release .10Vesicare ..................................20Vestura ...................................23Viagra ....................................18Viberzi ...................................16Vicodin 5/300, 7.5/300,

10/300 mg Tablet ...............19Victoza 2-Pak ........................15Victoza 3-Pak ........................15Viekira Pak ............................ 17Vienva ....................................23Vigamox ................................16Viibryd ..................................11

Viorele ...................................23Viread .................................... 17Vitekta ................................... 17Vivelle-Dot ............................23Voltaren Gel ..........................19Vytorin ..................................10Vyvanse .................................11

W

Warfarin Sodium ....................9Welchol .................................10Wera ......................................23

X

Xarelto .....................................9Xeljanz ................................... 17Xeljanz XR ............................ 17Xeloda .....................................9Xigduo XR ............................15Xiidra ....................................16Xopenex HFA .......................20Xopenex Nebs ........................20Xtampza ER ..........................19Xulane ...................................23Xyrem ....................................12

Y

Yasmin 28 ..............................23Yaz .........................................23Yuvafem .................................23

Z

Zaleplon Capsule ...................12Zarxio ....................................19Zelapar ..................................12Zenpep ..................................16Zepatier ................................. 17Zetia ......................................10Zetonna .................................20Zinbryta ................................12Ziprasidone Capsule ..............12Zohydro ER ..........................19Zolpidem Extended-Release

Tablet ..................................12Zolpidem Tablet ....................12Zonisamide Capsule ..............13Zovia 1/35E, 1/50E ..............23Zovirax Cream ........................8Zubsolv ..................................12Zurampic ............................... 17Zytiga ......................................9

33

“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 medication and strength

Drugtier

I take this medicine for

Directions Doctor

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

34

Nondiscrimination notice and access to communication servicesUnitedHealthcare® does not discriminate on the basis of race, color, national origin, age, disability, or sex in its health programs or activities.

If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to the Civil Rights Coordinator.

Online: [email protected]

Mail: Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box 30608 Salt Lake City, Utah 84130

You must send the complaint within 60 days of your experience. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, please call the toll-free phone number listed on your ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m.

You can also file a complaint with the U.S. Dept. of Health and Human Services.

Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

Phone: Toll free 1-800-368-1019, 1-800-537-7697 (TDD)

Mail: U.S. Dept. of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, D.C. 20201

We provide free services to help you communicate with us, including letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the toll-free phone number listed on your ID card TTY 711, Monday through Friday, 8 a.m. to 8 p.m.

35

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Health Plan coverage provided by or through a UnitedHealthcare company . OptumRx is an affiliate of UnitedHealthcare Insurance Company .UnitedHealthcare® and the dimensional U logo are registered trademarks owned by UnitedHealth Group Incorporated .

All other trademarks are the property of their respective owners . Created February, 2017 . 2017 Prescription Drug List – Advantage Three-Tier

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