Your 2015 Prescription Drug List - UMR Portal · of Tier 3, to help reduce your out-of-pocket...

For a complete list of covered drugs or if you have questions:

Call the toll-free member phone number on the back of your ID card.

Visit optumrx.com• Locate a participating retail pharmacy by zip code.• Look up possible lower-cost medication alternatives.• Compare medication pricing and options.

Please read: This document contains information about the drugs covered under your pharmacy benefit plan.

Your 2015 Prescription Drug List

OptumRx | optumrx.com 1

Effective January 1, 2015

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Your Prescription Drug List

This Prescription Drug List (PDL) outlines the most commonly prescribed medications from your plan’s complete pharmacy benefit coverage list, also known as a formulary. A formulary identifies the drugs available 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 optumrx.com for complete and up-to-date drug information

Since the PDL may change, we encourage you to visit our website, optumrx.com. This website is the best source for up-to-date information about all of the medications your pharmacy benefit covers, possible lower-cost options, and cost comparisons.

John Smith

John Smith

John Smith

3

Table of Contents

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

Programs and limits . . . . . . . . . . . . . . . . . . . 6

Drugs by category . . . . . . . . . . . . . . . . . . . . 9

Anti-InfectivesAntibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

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

Cardiovascular/Heart DiseaseAnticoagulants. . . . . . . . . . . . . . . . . . . . . . . . . 9High Blood Pressure . . . . . . . . . . . . . . . . . . . . 10High Cholesterol . . . . . . . . . . . . . . . . . . . . . . 10Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Pulmonary Arterial Hypertension . . . . . . . . . . 11

Central Nervous SystemAttention Deficit Disorder . . . . . . . . . . . . . . . 11Depression. . . . . . . . . . . . . . . . . . . . . . . . . . . 11Migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . 12Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Sedatives/Hypnotics . . . . . . . . . . . . . . . . . . . . 12Seizure Disorders . . . . . . . . . . . . . . . . . . . . . . 12

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

Diabetes/EndocrineBlood Glucose Monitoring . . . . . . . . . . . . . . . 13Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Non-Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . 14

EndocrineGrowth Hormone . . . . . . . . . . . . . . . . . . . . . 15Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Thyroid Hormone Replacement . . . . . . . . . . . 15

Eye ConditionsAllergies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

GastrointestinalAcid Suppression . . . . . . . . . . . . . . . . . . . . . . 15Nausea/Vomiting . . . . . . . . . . . . . . . . . . . . . . 16Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Inflammatory Conditions . . . . . . . . . . . . . . 16

Men’s HealthErectile Dysfunction . . . . . . . . . . . . . . . . . . . . 16Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Testosterone Therapy . . . . . . . . . . . . . . . . . . . 17

Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . 17

MusculoskeletalOsteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . 17 Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Pain Relief . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Overactive Bladder . . . . . . . . . . . . . . . . . . . 18

RespiratoryAsthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . 18Nasal Allergies . . . . . . . . . . . . . . . . . . . . . . . . 19Oral Allergies . . . . . . . . . . . . . . . . . . . . . . . . . 19

Transplant . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Vitamins/Electrolytes . . . . . . . . . . . . . . . . . 19

Women’s HealthBirth Control . . . . . . . . . . . . . . . . . . . . . . . . . 19Hormone Replacement . . . . . . . . . . . . . . . . . 20Vaginal Anti-Infectives . . . . . . . . . . . . . . . . . . 20

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

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

What is a Prescription Drug List (PDL)?

This document is a list of commonly prescribed medications preferred by your plan sponsor for their safety, cost and effectiveness. Drugs are listed by common categories or class. They are placed into cost levels known as tiers. It includes both brand and generic prescription medications approved by the U.S. Food and Drug Administration (FDA).

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

How do I use my 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 rules apply. Bring this list with you when you see your doctor. It is organized by common medical conditions. Medications are then listed alphabetically.

If your medication is not listed in this document, please visit optumrx.com or call the toll-free member phone number on the back of your ID card.

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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 plan sponsor. This is how much you will pay when you fill a prescription. Tier 1 medications are your lowest-cost options. If your medication is placed in Tier 2 or 3, look to see if there is a Tier 1 option available. Discuss these options with your doctor.

Drug names shown in orange are preferred for their cost and effectiveness. If there is a symbol in the Drug Tier column, check your benefit plan documents to find out your specific pharmacy plan costs.

$ Drug Tier Includes Helpful Tips

Tier 1 Lowest Cost

Lower-cost, commonly used generic drugs. Some low-cost brands may be included.

Use Tier 1 drugs for the lowest out-of- pocket costs.

Tier 2 Mid-range Cost

Many common brand-name drugs, called preferred brands.

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

Tier 3 Highest Cost

Mostly higher-cost brand drugs, also known as non-preferred brands.

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

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

When does the Prescription Drug List change?

• Medications may move to a lower tier at any time. • Medications may move to a higher tier when its generic becomes available.• Medications may move to a higher tier or be excluded from coverage on

January 1 or July 1 of each year.

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

For the most up-to-date list, call customer service at the toll-free member phone number on the back of your ID card.

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Programs and Limits

Some medications are noted with letters or symbols next to them. The letters and symbols refer to our pharmacy benefit programs and are provided to help you check which medications may have a program or limit. Your benefit plan determines how these medications may be covered for you.

PA Prior Authorization – Your doctor is required to provide additional information to determine coverage.

ST Step Therapy – Trial of lower cost medication(s) is required before a higher-cost medication is covered.

QL Quantity Limits – Amount of medication covered per copayment or in a specific time period.

AR Age Restrictions – Some restrictions may apply based on patient age.

SPSpecialty Medication – Medication is designated as a specialty pharmacy drug.

GR Gender Restrictions – Some restrictions may apply based on gender.

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

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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 as or similar to another prescription medication or an over-the-counter (OTC) medication. There may be other medication options available.

What if I don’t agree with a decision about an excluded medication?

You (or your authorized representative) and your doctor can ask for an initial coverage decision by calling the toll-free member phone number on the back of your ID card.

Should I talk to my doctor about OTC medications?

An OTC medication may be the right treatment option for some conditions. Talk to your doctor about available OTC options. Even though these medications may not be covered under your pharmacy benefit, they may cost less than your out-of-pocket expense for prescription medications.

What is the difference between brand-name and generic medications?

Generic medications contain the same active ingredients (what makes the medication work) as brand-name medications, but they often cost less. Once the patent of a brand-name medication ends, the FDA can approve a generic version with the same active ingredients. These types of medications are known as generic medications. Sometimes the same company that makes a brand-name medication also makes the generic version.

Is it a generic or brand-name drug?

The drug list shows brand-name drugs in bold type (for example, Coumadin) and generic drugs in plain type (for example, Warfarin).

What if my doctor writes a brand-name prescription?

The next time your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lower-cost option is available and if it might be right for you. Generic medications are usually your lowest-cost option, but not always. Visit optumrx.com to make sure.

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Are you taking a specialty medication?

Specialty medications treat rare or complex conditions and are typically higher cost medications. Please note, not all specialty medications are listed in the PDL.

OptumRx is the specialty pharmacy that can provide most of your specialty medications along with helpful programs and services. Call OptumRx® Specialty Pharmacy at 1-888-702-8423 and have your prescriptions delivered right to your home or office.

How do I get updated information about my pharmacy benefit?

Since the PDL may change during your plan year, we encourage you to visit optumrx.com or call the toll-free member phone number on the back of your ID card for more current information.

When you register at optumrx.com and open an account, you can use the website’s helpful tools and features to:

• Look up the price of drugs covered by your plan

• Find lower-cost options

• Refill and renew mail service prescriptions

• View your order status and claims history

• Sign up for text reminders to take and refill your medicine

• View your benefits in real time

• Order medical supplies

• Shop for health and wellness products

More informationIf you have additional questions please call customer service, 24 hours a day, 7 days a week using the toll-free member phone number on the back of your ID card. Or visit optumrx.com.

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Bold type = Brand-name drug [Plain type = Generic drug] Call customer service for pricing

PA Prior Authorization ST Step TherapyQL Quantity Limits

AR Age RestrictionsSP Specialty ProgramGR Gender Restrictions

Drug NameDrug Tier

Programs and Limits

Anti-Infectives: Antibiotics

Amoxicillin 1Amoxicillin/Clavulanate 1Avelox 2Azithromycin 1Bethkis SPCefdinir 1Cefuroxime Tab 1Cephalexin Tab 1Ciprodex Otic

Suspension3

Ciprofloxacin Tab 1Clarithromycin 1Clindamycin Cap 1Dificid 3 PADoxycycline Hyclate Cap 1Doxycycline Hyclate Tab

(immediate Release)1

Doxycycline Monohydrate Cap

1 QL

Levofloxacin Tab 1Metronidazole Tab 1Minocycline Cap 1Neomycin/Polymyxin/

HC Otic Suspension, Solution

1

Nitrofurantoin Macrocrystalline

1

Nitrofurantoin Monohydrate Macrocrystalline

1

Ofloxacin Otic Solution 1Oracea 3 QLPenicillin VK 1Solodyn 3 QLSulfamethoxazole-

Trimethoprim1

Sulfamethoxazole-Trimethoprim DS

1

Drug NameDrug Tier

Programs and Limits

Anti-Infectives: Antifungals

Fluconazole 1 QLKetoconazole 1 PA (tab only)Nystatin 1Terbinafine Tab 1

Anti-Infectives: Antivirals

Acyclovir Tab, Cap, Suspension

1

Baraclude 3 QL, SPFamciclovir Tab 1Olysio 2 PA, QL, SPPegasys PA, SPSovaldi 2 PA, QL, SPTamiflu 3 QLValacyclovir 1

Cancer

Anastrozole Tab 1Gleevec 2 PA, QL, SPLetrozole 1 PARevlimid 3 PA, QL, SPTamoxifen 1Tasigna 2 PA, QL, SPZytiga 3 PA, SPCardiovascular/Heart Disease: AnticoagulantsAggrenox 2 QLBrilinta 2 QLClopidogrel 1 QLCoumadin 3Effient 2 QLEliquis 3 QLEnoxaparin 1Pradaxa 2 QLWarfarin 1Xarelto 2 QL

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Drug NameDrug Tier

Programs and Limits

Cardiovascular/Heart Disease: High Blood PressureAmlodipine 1 QLAmlodipine/Benazepril 1 QLAtenolol 1Atenolol/Chlorthalidone 1Azor 2 QL, STBenazepril 1Benazepril/HCTZ 1Benicar 2 QL, STBenicar HCT 2 QL, STBisoprolol 1Bisoprolol/HCTZ 1Bumetanide 1Bystolic 2 QLCartia XT 1 QLCarvedilol 1Chlorthalidone 1Clonidine Tab 1Coreg CR 3 QL, STDiovan 3 QL, STDoxazosin 1 QLDutoprol 2 QLEdarbi 3 QL, STEdarbyclor 3 QL, STEnalapril 1Exforge 2 QL, STExforge HCT 2 QL, STFelodipine 1 QLFosinopril 1Furosemide 1Guanfacine Tab 1Hydralazine 1Hydrochlorothiazide 1Irbesartan 1 QLIrbesartan/HCTZ 1 QLLabetalol 1Lisinopril 1Lisinopril/HCTZ 1Losartan 1 QLLosartan/HCTZ 1 QLMetoprolol Succinate 1Metoprolol Tartrate 1

Drug NameDrug Tier

Programs and Limits

Nadolol 1Nifedipine ER 1Propranolol 1Propranolol ER 1Quinapril 1Ramipril 1 QLSpironolactone 1Tarka 2Tekturna 2 QL, STTekturna HCT 2 QL, STTelmisartan 1 QLTerazosin 1Torsemide 1Triamterene/HCTZ 1Tribenzor 2 QL, STValsartan 1 QLValsartan/HCTZ 1 QLVerapamil ER 1Cardiovascular/Heart Disease: High CholesterolAtorvastatin 1 QLCrestor 2 QLFenofibrate 1 QLGemfibrozil 1 QLLipitor 3 QL, STLivalo 3 QL, STLovastatin 1Lovaza 3 QLNiacin ER Tab (Rx only) 1 QLOmega-3-Acid Cap

1 gm (Rx only)1 QL

Pravastatin 1 QLSimcor 2 QLSimvastatin 1 QLSimvastatin 80 mg 1 PA, QLVascepa 2 QLVytorin 2 QLVytorin Tab 10-80 mg 2 PA, QLWelchol 2 QLZetia 3 QL

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Drug NameDrug Tier

Programs and Limits

Cardiovascular/Heart Disease: Other

Amiodarone 1Amlodipine/Atorvastatin 1 QLDigoxin 1Flecainide 1Isosorbide Mononitrate 1Nitrostat 2Ranexa 2 STSotalol 1Cardiovascular/Heart Disease: Pulmonary Arterial HypertensionAdcirca 3 PA, QL, SPLetairis 2 PA, QL, SPOpsumit 2 PA, QL, SPSildenafil Tab 20 mg 1 PA, QL, SPTracleer 2 PA, QL, SPCentral Nervous System: Attention Deficit DisorderAmphetamine-

Dextroamphetamine 1 QL

Amphetamine-Dextroamphetamine SR Cap 24Hr

1 QL

Dexmethylphenidate 1 QLFocalin XR 3 QL, STIntuniv 2 QLMethylphenidate ER

Cap1 QL

Methylphenidate ER Tab 1 QLMethylphenidate HCL

Sa Osm ER Tab1 QL

Methylphenidate Tab 1 QLStrattera 2 QLVyvanse 2 QL

Drug NameDrug Tier

Programs and Limits

Central Nervous System: Depression

Amitriptyline 1Budeprion XL 1 QLBupropion 1 QLBupropion SR 1 QLCitalopram 1 QLCymbalta 3 QLDoxepin 1 QLDuloxetine 1 QLEscitalopram Tab 1 QLFluoxetine (not PMDD) 1Forfivo XL 2 QLMirtazapine 1Nortriptyline 1Paroxetine 1 QLPristiq 2 QLSertraline 1 QLTrazodone 1Venlafaxine 1Venlafaxine ER Cap 1 QLViibryd 3 QL, ST

Central Nervous System: Migraine

Butalbital-Acetaminophen-Caffeine Tab

1 QL

Migranal 3 QLPhrenilin 3 QLRelpax 3 QLRizatriptan Tab, ODT 1 QLSumatriptan Tab and

Spray 1 QL

Sumavel Dose 3 QLZomig Nasal Spray 2 QL

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Drug NameDrug Tier

Programs and Limits

Central Nervous System: Multiple SclerosisAmpyra 2 PA, QL, SPAvonex Kit PA, QL, SPAvonex Pen Kit PA, QL, SPAvonex Prefill Kit PA, QL, SPBetaseron PA, QL, SPCopaxone PA, QL, SPGilenya* 3 PA, QL, ST, SPRebif PA, QL, ST, SPRebif Titrtn PA, QL, ST, SPTecfidera 2 PA, QL, SP

Central Nervous System: Other

Abilify 2 QLAbilify Disc 2 QLAbilify Solution 2 QLAlprazolam Tab 1 QLBenztropine 1Buspirone 1Carbidopa/Levodopa

Tab 1

Diazepam 1Hydroxyzine HCL 1Hydroxyzine Pamoate 1Lithium Carbonate 1Lorazepam Tab 1 QLModafinil 1 PA, QLNamenda Tab 2 QLNamenda XR 2 QLOlanzapine Tab 1 QLPramipexole 1Prochlorperazine 1Quetiapine 1 QLRisperidone Tab 1 QLRopinirole 1Saphris 2 QLSeroquel XR 2 QLZelapar 3Ziprasidone Cap 1 QL

Drug NameDrug Tier

Programs and Limits

Central Nervous System: Sedatives/HypnoticsEszoplicone Tab 1 QLLunesta 3 QLSilenor 3 QLTemazepam 1 QLTriazolam Tab 1 QLZolpidem 1 QLZolpidem ER 1 QLCentral Nervous System: Seizure DisordersCarbamazepine Tab 1Clonazepam 1 QLDivalproex DR 1Divalproex ER 1Gabapentin 1Lamictal 2Lamictal ODT 2Lamictal XR 3 QLLamotrigine 1Lamotrigine ER 1 QLLevetiracetam 1Levetiracetam ER 1 QLLyrica Cap 2 QLOnfi 3 PA, QLOxcarbazepine 1Phenytoin 1Topiramate 1

* Tier 3 Preferred

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Drug NameDrug Tier

Programs and Limits

Dermatology

Acanya Gel 3 QLAcyclovir Ointment 5% 1Aczone Gel 3Atralin 2 QL, ARBenzaclin 3 QLCarac 2Clindamycin Gel,

Lotion, Solution 1

Clindamycin/ Benzoyl Peroxide Gel 1-5%

1 QL

Clobetasol Cream, Gel, Ointment

1

Clobex 3Cloderm 3Clotrimazole/

Betamethasone1

Condylox 3Desonide 1Differin 3 QLEconazole Cream 1Elidel 2 QL, ST, AREpiduo 3 QL, ARFinacea 2Fluocinonide Cream,

Gel, Ointment 0.05%

1

Hydrocortisone 2.5% 1Metrogel 3Metronidazole Gel

0.75%1

Mometasone 1Mupirocin 1 QLNystatin Cream,

Ointment, Powder1

Nystatin/Triamcinolone 1Oxsoralen-Ul 2 PAPermethrin Cream 5% 1Protopic 2 QL, ST, ARRetin-A Micro 3 QL, AR

Drug NameDrug Tier

Programs and Limits

Silver Sulfadiazine Cream 1%

1

Taclonex 3 QLTretinoin Microsphere

Gel1 QL, AR

Triamcinolone 1Vectical 3Zovirax Cream 2Zovirax Ointment 3Zyclara 3 QLDiabetes/Endocrine Blood: Glucose MonitoringAccu-Chek Act/Gluc

Calibration Liquid2

Accu-Chek Aviva Plus Test Strips

2 QL

Accu-Chek Aviva Test Strips

2 QL

Accu-Chek Comfort Calibration Liquid

2

Accu-Chek Comfort Test Strips

2 QL

Accu-Chek Cpt/Gluc Calibration Liquid

2

Accu-Chek Drum Test Strips

2 QL

Accu-Chek Kit Aviva Plus

2

Accu-Chek Kit Compact

2

Accu-Chek Kit Fastclix 2Accu-Chek Kit

Multiclix2

Accu-Chek Kit Nano 2Accu-Chek Kit Softclix 2Accu-Chek

Multiclix Lancets2

Accu-Chek Smart Calibration Liquid

2

Accu-Chek Smart Test Strips

2 QL

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Drug NameDrug Tier

Programs and Limits

Accu-Chek Sol Calibration Liquid

2

Accu-Chek Sol Comfort Calibration Liquid

2

Fastclix Lancets 2Glucocard Test Strips 1Insulin Pen Needle 2Insulin Syringe/

Needle 2

Novofine 2Novofine Auto 2Novotwist 2Onetouch Kit Ultra

Smart2

Onetouch Kit Ultra 2Onetouch Kit Ultra 2 2Onetouch Kit Ultra

Mini2

Onetouch Kit Verio IQ 2Onetouch Test Strips 2 QLOnetouch Ultra Blue

Test Strips2 QL

Onetouch Verio IQ Test Strips

2 QL

Onetouch Verio Test Strips

2 QL

Soft Touch Lancets 2Softclix Lan Mis

Device2

Softclix Lancets 2Surestep Test Strips 2 QLTruetrack Test Strips 3 QL

Diabetes/Endocrine: Insulin

Humalog Vials 2Humalog Kwik 2Humalog Mix

50/50 Kwik Pen2

Humalog Mix 50/50 Vials

2

Humalog Mix 75/25 Kwik Pen

2

Drug NameDrug Tier

Programs and Limits

Humalog Mix 75/25 Vials

2

Humulin 70/30 Vials 2Humulin N Vials 2Humulin N Pen 2Humulin Pen 70/30 2Humulin R U-500 2Humulin R Vials 2Lantus Solostar 2Lantus Vials 2Levemir Flexpen 2Levemir Vials 2Novolin 70/30 Vials 2Novolin N Vials 2Novolin R Vials 2Novolog Flexpen 2Novolog Mix Flexpen 2Novolog Mix

70/30 Vials2

Novolog Penfill 2Novolog Vials 2

Diabetes/Endocrine: Non-Insulin

Byetta 2 QL, STGlimepiride 1Glipizide 1Glipizide ER 1Glipizide XL 1Glyburide 1Glyburide/Metformin 1Invokamet 2 QL, STInvokana 2 QL, STJanumet 2 QL, STJanumet XR 2 QL, STJanuvia 2 QL, STJentadueto 2 QL, STKombiglyze 2 QL, STMetformin 1Metformin ER 1Onglyza 2 QL, STPioglitazone 1 QLTradjenta 2 QL, STVictoza 3 QL, ST

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Drug NameDrug Tier

Programs and Limits

Endocrine: Growth Hormone

Nutropin PA, SPNutropin AQ PA, SPSaizen PA, SPTev-Tropin PA, SP

Endocrine: Other

Dexamethasone Tab 1Lupron Depot

3.75 mg, 11.25 mg PA, SP

Lupron Depot 7.5 mg, 22.5 mg, 30 mg, 45 mg

PA, SP

Methylprednisolone Tab 1Prednisolone 1Prednisone 1Sensipar 3 SPEndocrine: Thyroid Hormone Replacement Armour Thyroid 3Levothyroxine 1Levoxyl 1Liothyronine 1Methimazole 1Synthroid 3

Eye Conditions: Allergies

Azelastine Solution 1Pataday 2Patanol 2 QL

Eye Conditions: Antibiotics

Ciprofloxacin 1 QLErythromycin 1Gentamicin 1Moxeza 2 QL

Drug NameDrug Tier

Programs and Limits

Ofloxacin 1 QLPolymyxin B/

Trimethoprim Solution

1

Tobramycin 1Tobramycin/

Dexamethasone1

Vigamox 2 QL

Eye Conditions: Glaucoma

Alphagan P 2 QLAzopt 2 QLBrimonidine 1 QLCombigan 2 QLDorzolamide-Timolol

Maleate 1

Latanoprost 1 QLLumigan 2 QLTimolol 1Timoptic Ocudose 2Travatan Z 2 QL

Eye Conditions: Other

Ketorolac Ophthalmic Solution

1 QL

Prednisolone Opth 1Restasis 3 PA

Gastrointestinal: Acid Suppression

Dexilant 2 QLFamotidine Tab 20 mg

and 40 mg (Rx only)1

Lansoprazole (Rx only) 1 QLNexium (Rx only) 2 QLOmeprazole (Rx only) 1 QLPantoprazole 1 QLRabeprazole 1 QLRanitidine (Rx only) 1Sucralfate 1

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Drug NameDrug Tier

Programs and Limits

Gastrointestinal: Nausea/Vomiting

Metoclopramide 1 QLOndansetron Tab 1 QLTransderm-Scop 3

Gastrointestinal: Other

Amitiza 2 QL, ST, ARApriso 2 QLAsacol HD 3 QLCanasa 2 QLCreon 2Delzicol 3 QLDicyclomine 1Diphenoxylate/Atropine 1Halflytely Kit 3 QLMoviprep 3 QLOmeclamox Pak 2 QLPentasa 3 QLPylera 2 QLSuclear Bowel Prep 3 QLSuprep Bowel Prep 3 QLUceris 3Zenpep

(not 5,000 units)2

HIV/AIDS

Atripla 2 SP Complera 2 SPEpzicom 2 SPIntelence 2 SPIsentress 2 QL, SPKaletra 2 SPNorvir 2 SPPrezista 2 SPReyataz 2 SPStribild 2 SPTruvada 2 PA, SPViread 2 SP

Drug NameDrug Tier

Programs and Limits

Infertility

Follistim AQ PA, SPGonal-f PA, SPGonal-f RFF PA, SPOvidrel PA, SP

Inflammatory Conditions

Cimzia PA, QL, SPEnbrel PA, QL, ST, SPEnbrel SureClick PA, QL, ST, SPHumira Kit PA, QL, SPHumira Pen PA, QL, SPHumira Pen Kit

Crohns PA, QL, SP

Humira Pen Kit Psoriasis

PA, QL, SP

Hydroxychloroquine 1Methotrexate Tab 1Orencia SC PA, QL, ST, SPSimponi PA, QL, SPStelara PA, QL, SP

Men’s Health: Erectile Dysfunction

Cialis 2 QL, AR, GRLevitra 3 QL, AR, GRViagra 3 QL, AR, GR

Men’s Health: Prostate

Alfuzosin 1 QLAvodart 2 QLDoxazosin 1 QLFinasteride 5 mg 1 QLJalyn 2 QLRapaflo 2 QLTamsulosin 1 QLTerazosin 1

17




Drug NameDrug Tier

Programs and Limits

Men’s Health: Testosterone Therapy

Androderm 2 PA, QL, GRAndrogel 2 PA, QL, GRFortesta 3 PA, QL, GRTestim 2 PA, QL, GR

Miscellaneous

Allopurinol 1Antipyrine/Benzocaine

Otic Solution 5.4 - 1.4%

1

Aranesp PA, SPBenzonatate 1Botox 100, 200 unit

Injection PA, SP

Cheratussin 1Chlorhexidine 1Colcrys 2 QLEpipen 2-Pak 2 QLEuflexxa PA, SPFosrenol 3Hydrocortisone AC

Suppository 1

Hydromet 1Lidocaine Viscous

Solution1

Makena PA, SPPhenazopyridine

(Rx only)1

Phentermine Tab 1Procrit PA, SPPromethazine DM Syrup 1 ARPromethazine/Codeine 1 ARPulmozyme 2 SPRectiv 3

Drug NameDrug Tier

Programs and Limits

Renvela 3Rezira 3Suboxone Film 2 PA, QLSynagis PA, SPSynvisc PA, SPUloric 2 QL, STZubsolv 2 PA, QLZutripro 3

Musculoskeletal: Osteoporosis

Actonel 3 QLAlendronate Tab 1 QLCalcitriol 1Evista 3 QLForteo PA, QL, SPIbandronate Tab 1 QLRaloxifene 1

Musculoskeletal: Other

Baclofen Tab 1Carisoprodol 1Cyclobenzaprine Tab

5, 10 mg1

Metaxalone 1Methocarbamol 1Tizanidine 1

18




Drug NameDrug Tier

Programs and Limits

Musculoskeletal: Pain Relief

Acetaminophen w/ Codeine

1 QL

Cambia 3 QLCelebrex 3 QLDiclofenac 1 QLEndocet Tab 1 QLEtodolac 1 QLFentanyl Patch 1 QLGralise 3 QL, STHydrocodone

w/ Ibuprofen Tab 7.5-200 mg

1 QL

Hydrocodone/APAP 5, 7.5, 10/325 mg

1 QL

Hydromorphone 1Ibuprofen (Rx only) 1 QLIndomethacin 1 QLLazanda 3 PA, QLLidocaine Patch 5% 1 QLMeloxicam 1 QLMethadone Tab 1Morphine Sulfate Tab 1Nabumetone 1 QLNaproxen (Rx only) 1 QLNucynta 3 QLNucynta ER 2 QLOxycodone Tab

5, 15, 30 mg1

Oxycodone w/ Acetaminophen

1 QL

Oxycontin 2 QLSprix 3 QLSubsys 3 PA, QLTramadol Tab 50 mg 1 QLTramadol

w/ Acetaminophen 1 QL

Vicodin 1 QLVicodin ES 1 QLVoltaren Gel 2 QL

Drug NameDrug Tier

Programs and Limits

Overactive Bladder

Detrol LA 3 QL, STEnablex 3 QLGelnique 2 QLOxybutynin 1Oxybutynin ER 1 QLTolterodine ER 1 QLToviaz 3 QLVesicare 2 QL

Respiratory: Asthma/COPD

Advair Diskus 2 QLAdvair HFA 2 QLAerospan 3Albuterol Nebulizer

Solution1

Asmanex 2 QLBreo Ellipta 2 QLBudesonide 1Combivent Respimat 2 QLDulera 3 QL, STFlovent Diskus 2 QLFlovent HFA 2 QLForadil 2 QL, STIpratropium/Albuterol 1Levalbuterol Nebulizer

Solution1

Montelukast 1 QLPerforomist 3 QLProair HFA 2 QLProventil 3 QLPulmicort 2 QLQvar 2 QLSerevent Diskus 2 QL, STSpiriva 2 QLSymbicort 2 QLTudorza Pressair 2 QLVentolin HFA 2 QLXolair PA, SPXopenex HFA 3 QL

19




Drug NameDrug Tier

Programs and Limits

Respiratory: Nasal Allergies

Azelastine Spray 1 QLDymista Spray 3 QLFluticasone Spray 1Ipratropium Spray 1Nasonex 2 QLOmnaris 3 QLTriamcinolone Spray 1 QLVeramyst 2 QLZetonna 3 QL

Respiratory: Oral Allergies

Promethazine Tab 1 ARDesloratadine 1 QLLevocetirizine 1 QL

Transplant

Azathioprine 1Cellcept 3 SP Cyclosporine Cap 1 SPMycophenolate 250 mg

Cap/500 mg Tab1 SP

Prograf 3 SPRapamune 3 SPTacrolimus Cap 1 SP

Vitamins/Electrolytes

Folic Acid 1 mg (Rx only)

1

Klor-Con 1Multi-Vit/Fl Chew 1Potassium Chloride ER 1Potassium Chloride

Micro ER1

Tri-Vit-Fl Drops 1Vitamin D (Rx only) 1

Drug NameDrug Tier

Programs and Limits

Women’s Health: Birth Control

Apri 1 GRAviane 1 GRBeyaz 2 GRCryselle-28 1 GRGeneress Fe

Chewable3 GR

Gianvi 1 GRGildess Fe 1 GRJolivette 1 GRJunel Fe 1 GRKariva 1 GRLevora 28 1 GRLo Loestrin 3 GRLoryna 1 GRLow-Ogestrel 1 GRLutera 1 GRMedroxyprogesterone

Acetate Injection1 QL

Microgestin 1 GRMicrogestin Fe 1 GRMinastrin 24 Fe

Chewable3 GR

Mononessa 1 GRNatazia 2 GRNecon 1 GRNorgest/Ethi Estradio 1 GRNortrel 1 GRNuvaring 2Ocella 1 GROrsythia 1 GROrtho Tri-Cyclen Lo 3 GRPrevifem 1 GRReclipsen 1 GRSafyral 2 GRSprintec 28 1 GRTrinessa 1 GRTri-Sprintec 1 GRVestura 1 GRViorele 1 GR

20




Drug NameDrug Tier

Programs and Limits

Women’s Health: Hormone Replacement

Climara Pro 2 QL, GRDivigel 2 GREnjuvia 2 QL, GREstrace Vaginal Cream 3Estradiol 1 QL, GREstradiol/Norethindrone

Tab1 QL, GR

Medroxyprogesterone Acetate Tab

1

Premarin 2 QL, GRPremarin Vaginal

Cream2

Drug NameDrug Tier

Programs and Limits

Premphase 2 QL, GRPrempro 2 QL, GRProgesterone Capsule 1Vagifem 3 GRVivelle-Dot 2 QL, GR

Women’s Health: Vaginal Anti-Infectives

Metronidazole Vaginal Gel

1

Terconazole Vaginal Cream

1 QL

Bold type = Brand-name drug [Plain type = Generic drug] 21

Index of Covered Drugs

A

Abilify . . . . . . . . . . 12Abilify Disc. . . . . . . . . 12Abilify Solution . . . . . . 12Acanya Gel. . . . . . . . . 13Accu-Chek Act/Gluc

Calibration Liquid . . . 13Accu-Chek Aviva Plus Test

Strips . . . . . . . . . . 13Accu-Chek Aviva

Test Strips . . . . . . . 13Accu-Chek Comfort

Calibration Liquid . . . 13Accu-Chek Comfort

Test Strips . . . . . . . 13Accu-Chek Cpt/Gluc

Calibration Liquid . . . 13Accu-Chek Drum Test Strips 13Accu-Chek Kit Aviva Plus . 13Accu-Chek Kit Compact . . 13Accu-Chek Kit Fastclix. . . 13Accu-Chek Kit Multiclix . . 13Accu-Chek Kit Nano . . . . 13Accu-Chek Kit Softclix. . . 13Accu-Chek Multiclix Lancets 13Accu-Chek Smart Calibration

Liquid. . . . . . . . . . 13Accu-Chek Smart Test Strips 13Accu-Chek Sol Calibration

Liquid. . . . . . . . . . 14Accu-Chek Sol Comfort

Calibration Liquid . . . 14Acetaminophen w/ Codeine 18Actonel. . . . . . . . . . . 17Acyclovir Ointment 5% . . . 13Acyclovir Tab, Cap, Suspension 9Aczone Gel. . . . . . . . . 13Adcirca . . . . . . . . . . . 11Advair Diskus . . . . . . . 18Advair HFA . . . . . . . . 18Aerospan . . . . . . . . . 18Aggrenox . . . . . . . . . . 9

Albuterol Nebulizer Solution 18Alendronate Tab . . . . . . 17Alfuzosin . . . . . . . . . . 16Allopurinol . . . . . . . . . 17Alphagan P . . . . . . . . 15Alprazolam Tab . . . . . . . 12Amiodarone. . . . . . . . . 11Amitiza. . . . . . . . . . . 16Amitriptyline . . . . . . . . 11Amlodipine . . . . . . . . . 10Amlodipine/Atorvastatin . . 11Amlodipine/Benazepril . . . 10Amoxicillin . . . . . . . . . . 9Amoxicillin/Clavulanate . . . . 9Amphetamine-

Dextroamphetamine . . 11Amphetamine-

Dextroamphetamine SR Cap 24Hr . . . . . . 11

Ampyra . . . . . . . . . . 12Anastrozole Tab . . . . . . . . 9Androderm . . . . . . . . 17Androgel. . . . . . . . . . 17Antipyrine/Benzocaine Otic

Solution 5.4 - 1.4% . . . 17Apri . . . . . . . . . . . . . 19Apriso . . . . . . . . . . . 16Aranesp . . . . . . . . . . 17Armour Thyroid . . . . . . 15Asacol HD . . . . . . . . . 16Asmanex. . . . . . . . . . 18Atenolol . . . . . . . . . . 10Atenolol/Chlorthalidone. . . 10Atorvastatin . . . . . . . . 10Atralin . . . . . . . . . . . 13Atripla . . . . . . . . . . . 16Avelox . . . . . . . . . . . . 9Aviane . . . . . . . . . . . 19Avodart . . . . . . . . . . 16Avonex Kit. . . . . . . . . 12Avonex Pen Kit . . . . . . 12Avonex Prefill Kit . . . . . 12Azathioprine . . . . . . . . 19

Azelastine Solution . . . . . 15Azelastine Spray. . . . . . . 19Azithromycin . . . . . . . . . 9Azopt . . . . . . . . . . . 15Azor . . . . . . . . . . . . 10

B

Baclofen Tab . . . . . . . . 17Baraclude . . . . . . . . . . 9Benazepril . . . . . . . . . 10Benazepril/HCTZ . . . . . . 10Benicar . . . . . . . . . . . 10Benicar HCT . . . . . . . . 10Benzaclin. . . . . . . . . . 13Benzonatate . . . . . . . . 17Benztropine . . . . . . . . . 12Betaseron . . . . . . . . . 12Bethkis . . . . . . . . . . . . 9Beyaz. . . . . . . . . . . . 19Bisoprolol . . . . . . . . . . 10Bisoprolol/HCTZ . . . . . . 10Botox 100, 200

unit Injection. . . . . . 17Breo Ellipta . . . . . . . . 18Brilinta . . . . . . . . . . . . 9Brimonidine . . . . . . . . . 15Budeprion XL . . . . . . . . 11Budesonide . . . . . . . . . 18Bumetanide . . . . . . . . . 10Bupropion. . . . . . . . . . 11Bupropion SR . . . . . . . . 11Buspirone . . . . . . . . . . 12Butalbital-Acetaminophen-

Caffeine Tab. . . . . . . 11Byetta . . . . . . . . . . . 14Bystolic. . . . . . . . . . . 10

C

Calcitriol . . . . . . . . . . 17Cambia. . . . . . . . . . . 18Canasa . . . . . . . . . . . 16Carac . . . . . . . . . . . . 13



Carbamazepine Tab . . . . . 12Carbidopa/Levodopa Tab . . 12Carisoprodol . . . . . . . . 17Cartia XT . . . . . . . . . . 10Carvedilol . . . . . . . . . 10Cefdinir . . . . . . . . . . . . 9Cefuroxime Tab . . . . . . . . 9Celebrex . . . . . . . . . . 18Cellcept . . . . . . . . . . 19Cephalexin Tab . . . . . . . . 9Cheratussin . . . . . . . . . 17Chlorhexidine . . . . . . . 17Chlorthalidone . . . . . . . 10Cialis . . . . . . . . . . . . 16Cimzia . . . . . . . . . . . 16Ciprodex Otic Suspension . 9Ciprofloxacin . . . . . . . . 15Ciprofloxacin Tab . . . . . . . 9Citalopram . . . . . . . . . 11Clarithromycin . . . . . . . . 9Climara Pro . . . . . . . . 20Clindamycin/Benzoyl Peroxide

Gel 1-5% . . . . . . . . 13Clindamycin Cap . . . . . . . 9Clindamycin Gel, Lotion,

Solution . . . . . . . . 13Clobetasol Cream, Gel,

Ointment . . . . . . . . 13Clobex . . . . . . . . . . . 13Cloderm . . . . . . . . . . 13Clonazepam . . . . . . . . 12Clonidine Tab . . . . . . . . 10Clopidogrel . . . . . . . . . . 9Clotrimazole/Betamethasone 13Colcrys . . . . . . . . . . . 17Combigan . . . . . . . . 15Combivent Respimat . . . 18Complera . . . . . . . . . 16Condylox. . . . . . . . . . 13Copaxone . . . . . . . . . 12Coreg CR . . . . . . . . . . 10Coumadin . . . . . . . . . . 9Creon. . . . . . . . . . . . 16

Crestor . . . . . . . . . . . 10Cryselle-28 . . . . . . . . . 19Cyclobenzaprine Tab . . . . 17Cyclosporine Cap . . . . . . 19Cymbalta. . . . . . . . . . 11

D

Delzicol . . . . . . . . . . 16Desloratadine . . . . . . . . 19Desonide . . . . . . . . . . 13Detrol LA. . . . . . . . . . 18Dexamethasone Tab. . . . . 15Dexilant . . . . . . . . . . 15Dexmethylphenidate . . . . 11Diazepam . . . . . . . . . 12Diclofenac. . . . . . . . . . 18Dicyclomine . . . . . . . . 16Differin. . . . . . . . . . . 13Dificid . . . . . . . . . . . . 9Digoxin . . . . . . . . . . . 11Diovan . . . . . . . . . . . 10Diphenoxylate/Atropine . . . 16Divalproex DR . . . . . . . . 12Divalproex ER . . . . . . . . 12Divigel . . . . . . . . . . . 20Dorzolamide-Timolol Maleate 15Doxazosin . . . . . . . . . . 10Doxazosin . . . . . . . . . . 16Doxepin . . . . . . . . . . 11Doxycycline Hyclate Cap . . . 9Doxycycline Hyclate Tab . . . . 9Doxycycline Monohydrate Cap 9Dulera . . . . . . . . . . . 18Duloxetine . . . . . . . . . 11Dutoprol . . . . . . . . . . 10Dymista Spray . . . . . . . 19

E

Econazole Cream . . . . . . 13Edarbi . . . . . . . . . . . 10Edarbyclor . . . . . . . . . 10Effient . . . . . . . . . . . . 9

Elidel . . . . . . . . . . . . 13Eliquis . . . . . . . . . . . . 9Enablex . . . . . . . . . . 18Enalapril. . . . . . . . . . . 10Enbrel . . . . . . . . . . . 16Enbrel SureClick . . . . . 16Endocet Tab. . . . . . . . . 18Enjuvia . . . . . . . . . . . 20Enoxaparin . . . . . . . . . . 9Epiduo . . . . . . . . . . . 13Epipen 2-Pak. . . . . . . . 17Epzicom . . . . . . . . . . 16Erythromycin . . . . . . . . 15Escitalopram Tab . . . . . . 11Estrace Vaginal Cream . . 20Estradiol. . . . . . . . . . . 20Estradiol/Norethindrone Tab . 20Eszoplicone Tab . . . . . . . 12Etodolac . . . . . . . . . . 18Euflexxa . . . . . . . . . . 17Evista. . . . . . . . . . . . 17Exforge . . . . . . . . . . 10Exforge HCT . . . . . . . . 10

F

Famciclovir Tab . . . . . . . . 9Famotidine Tab . . . . . . . 15Fastclix Lancets . . . . . . 14Felodipine . . . . . . . . . . 10Fenofibrate . . . . . . . . . 10Fentanyl Patch . . . . . . . 18Finacea. . . . . . . . . . . 13Finasteride . . . . . . . . . 16Flecainide . . . . . . . . . . 11Flovent Diskus . . . . . . 18Flovent HFA . . . . . . . . 18Fluconazole . . . . . . . . . . 9Fluocinonide Cream, Gel,

Ointment 0.05% . . . . 13Fluoxetine (not PMDD) . . . 11Fluticasone Spray . . . . . . 19Focalin XR . . . . . . . . . 11



Folic Acid 1 mg . . . . . . . 19Follistim AQ . . . . . . . . 16Foradil . . . . . . . . . . . 18Forfivo XL . . . . . . . . . 11Forteo . . . . . . . . . . . 17Fortesta . . . . . . . . . . 17Fosinopril . . . . . . . . . . 10Fosrenol . . . . . . . . . . 17Furosemide . . . . . . . . . 10

G

Gabapentin . . . . . . . . . 12Gelnique . . . . . . . . . . 18Gemfibrozil . . . . . . . . . 10Generess Fe Chewable . . 19Gentamicin . . . . . . . . . 15Gianvi . . . . . . . . . . . . 19Gildess Fe . . . . . . . . . . 19Gilenya. . . . . . . . . . . 12Gleevec . . . . . . . . . . . 9Glimepiride . . . . . . . . . 14Glipizide . . . . . . . . . . 14Glipizide ER . . . . . . . . . 14Glipizide XL . . . . . . . . . 14Glucocard Test Strips . . . 14Glyburide . . . . . . . . . 14Glyburide/Metformin . . . . 14Gonal-f . . . . . . . . . . . 16Gonal-f RFF . . . . . . . . 16Gralise . . . . . . . . . . . 18Guanfacine Tab . . . . . . . 10

H

Halflytely Kit . . . . . . . 16Humalog Kwik . . . . . . 14Humalog Mix

50/50 Kwik Pen . . . . 14Humalog Mix 50/50 Vials . 14Humalog Mix

75/25 Kwik Pen . . . . 14Humalog Mix 75/25 Vials . 14Humalog Vials . . . . . . . 14

Humira Kit . . . . . . . . . 16Humira Pen . . . . . . . . 16Humira Pen Kit Crohns . . 16Humira Pen Kit Psoriasis . 16Humulin 70/30 Vials. . . . 14Humulin N Pen . . . . . . 14Humulin N Vials . . . . . . 14Humulin Pen 70/30 . . . . 14Humulin R U-500 . . . . . 14Humulin R Vials . . . . . . 14Hydralazine . . . . . . . . . 10Hydrochlorothiazide. . . . . 10Hydrocodone/APAP . . . . 18Hydrocodone w/

Ibuprofen Tab . . . . . . 18Hydrocortisone 2.5% . . . . 13Hydrocortisone AC

Suppository . . . . . . . 17Hydromet . . . . . . . . . . 17Hydromorphone . . . . . . 18Hydroxychloroquine . . . . 16Hydroxyzine HCL . . . . . . 12Hydroxyzine Pamoate . . . . 12

I

Ibandronate Tab. . . . . . . 17Ibuprofen . . . . . . . . . . 18Indomethacin . . . . . . . . 18Insulin Pen Needle . . . . 14Insulin Syringe/Needle . . 14Intelence . . . . . . . . . 16Intuniv . . . . . . . . . . . 11Invokamet . . . . . . . . . 14Invokana. . . . . . . . . . 14Ipratropium/Albuterol . . . . 18Ipratropium Spray . . . . . . 19Irbesartan . . . . . . . . . . 10Irbesartan/HCTZ. . . . . . . 10Isentress . . . . . . . . . . 16Isosorbide Mononitrate . . . 11

J

Jalyn . . . . . . . . . . . . 16Janumet . . . . . . . . . . 14Janumet XR . . . . . . . . 14Januvia. . . . . . . . . . . 14Jentadueto. . . . . . . . . 14Jolivette . . . . . . . . . . . 19Junel Fe . . . . . . . . . . . 19

K

Kaletra . . . . . . . . . . . 16Kariva . . . . . . . . . . . . 19Ketoconazole . . . . . . . . . 9Ketorolac Ophthalmic

Solution . . . . . . . . . 15Klor-Con . . . . . . . . . . 19Kombiglyze . . . . . . . 14

L

Labetalol . . . . . . . . . . 10Lamictal . . . . . . . . . . 12Lamictal ODT . . . . . . . 12Lamictal XR . . . . . . . . 12Lamotrigine . . . . . . . . 12Lamotrigine ER . . . . . . . 12Lansoprazole . . . . . . . . 15Lantus Solostar . . . . . . 14Lantus Vials . . . . . . . . 14Latanoprost . . . . . . . . 15Lazanda . . . . . . . . . . 18Letairis . . . . . . . . . . . 11Letrozole . . . . . . . . . . . 9Levalbuterol Nebulizer

Solution . . . . . . . . . 18Levemir Flexpen. . . . . . 14Levemir Vials . . . . . . . 14Levetiracetam . . . . . . . . 12Levetiracetam ER . . . . . . 12Levitra . . . . . . . . . . . 16Levocetirizine . . . . . . . . 19Levofloxacin Tab. . . . . . . . 9Levora 28 . . . . . . . . . . 19



Levothyroxine . . . . . . . . 15Levoxyl . . . . . . . . . . . 15Lidocaine Patch 5% . . . . . 18Lidocaine Viscous Solution . 17Liothyronine . . . . . . . . 15Lipitor . . . . . . . . . . . 10Lisinopril . . . . . . . . . . 10Lisinopril/HCTZ . . . . . . . 10Lithium Carbonate . . . . . 12Livalo. . . . . . . . . . . . 10Lo Loestrin . . . . . . . . 19Lorazepam Tab . . . . . . . 12Loryna . . . . . . . . . . . 19Losartan . . . . . . . . . . 10Losartan/HCTZ . . . . . . . 10Lovastatin . . . . . . . . . 10Lovaza . . . . . . . . . . 10Low-Ogestrel . . . . . . . . 19Lumigan . . . . . . . . . . 15Lunesta . . . . . . . . . . 12Lupron Depot . . . . . . . 15Lutera . . . . . . . . . . . . 19Lyrica Cap . . . . . . . . . 12

M

Makena . . . . . . . . . . 17Medroxyprogesterone

Acetate Injection . . . . 19Medroxyprogesterone

Acetate Tab . . . . . . . 20Meloxicam . . . . . . . . . 18Metaxalone . . . . . . . . . 17Metformin . . . . . . . . . 14Metformin ER . . . . . . . . 14Methadone Tab . . . . . . . 18Methimazole . . . . . . . . 15Methocarbamol . . . . . . 17Methotrexate Tab . . . . . . 16Methylphenidate ER Cap . . 11Methylphenidate ER Tab. . . 11Methylphenidate HCL Sa

Osm ER Tab . . . . . . . 11Methylphenidate Tab . . . . 11

Methylprednisolone Tab . . . 15Metoclopramide . . . . . . 16Metoprolol Succinate . . . . 10Metoprolol Tartrate . . . . . 10Metrogel . . . . . . . . . . 13Metronidazole Gel 0.75%. . 13Metronidazole Tab . . . . . . 9Metronidazole Vaginal Gel . 20Microgestin . . . . . . . . . 19Microgestin Fe . . . . . . . 19Migranal . . . . . . . . . . 11Minastrin 24 Fe Chewable 19Minocycline Cap . . . . . . . 9Mirtazapine . . . . . . . . 11Modafinil . . . . . . . . . 12Mometasone . . . . . . . 13Mononessa . . . . . . . . . 19Montelukast . . . . . . . . 18Morphine Sulfate Tab . . . . 18Moviprep . . . . . . . . . 16Moxeza . . . . . . . . . . 15Multi-Vit/Fl Chew . . . . . . 19Mupirocin . . . . . . . . . . 13Mycophenolate . . . . . . . 19

N

Nabumetone . . . . . . . . 18Nadolol . . . . . . . . . . . 10Namenda Tab . . . . . . . 12Namenda XR. . . . . . . . 12Naproxen . . . . . . . . . . 18Nasonex . . . . . . . . . . 19Natazia. . . . . . . . . . . 19Necon. . . . . . . . . . . . 19Neomycin/Polymyxin/HC Otic

Suspension, Solution . . . 9Nexium (Rx only) . . . . . 15Niacin ER Tab . . . . . . . . 10Nifedipine ER . . . . . . . . 10Nitrofurantoin Macrocrystalline 9Nitrofurantoin Monohydrate

Macrocrystalline . . . . . . 9Nitrostat . . . . . . . . . . 11

Norgest/Ethi Estradio . . . . 19Nortrel . . . . . . . . . . . 19Nortriptyline. . . . . . . . . 11Norvir . . . . . . . . . . . 16Novofine. . . . . . . . . . 14Novofine Auto. . . . . . . 14Novolin 70/30 Vials . . . . 14Novolin N Vials . . . . . . 14Novolin R Vials . . . . . . 14Novolog Flexpen . . . . . 14Novolog Mix 70/30 Vials . 14Novolog Mix Flexpen . . . 14Novolog Penfill . . . . . . 14Novolog Vials . . . . . . . 14Novotwist . . . . . . . . . 14Nucynta . . . . . . . . . . 18Nucynta ER . . . . . . . . 18Nutropin . . . . . . . . . . 15Nutropin AQ. . . . . . . . 15Nuvaring. . . . . . . . . . 19Nystatin . . . . . . . . . . . . 9Nystatin Cream, Ointment,

Powder . . . . . . . . . 13Nystatin/Triamcinolone . . . 13

O

Ocella . . . . . . . . . . . . 19Ofloxacin . . . . . . . . . 15Ofloxacin Otic Solution . . . . 9Olanzapine Tab . . . . . . . 12Olysio . . . . . . . . . . . . 9Omeclamox Pak . . . . . . 16Omega-3-Acid Cap . . . . . 10Omeprazole . . . . . . . . . 15Omnaris . . . . . . . . . . 19Ondansetron Tab . . . . . . 16Onetouch Kit Ultra . . . . 14Onetouch Kit Ultra 2 . . . 14Onetouch Kit Ultra Mini . 14Onetouch Kit Ultra Smart. 14Onetouch Kit Verio IQ. . . 14Onetouch Test Strips . . . 14



Onetouch Ultra Blue Test Strips . . . . . . . . . . 14

Onetouch Verio IQ Test Strips . . . . . . . 14

Onetouch Verio Test Strips 14Onfi . . . . . . . . . . . . 12Onglyza . . . . . . . . . . 14Opsumit . . . . . . . . . . 11Oracea . . . . . . . . . . . . 9Orencia SC . . . . . . . . . 16Orsythia . . . . . . . . . . . 19Ortho Tri-Cyclen Lo . . . . 19Ovidrel . . . . . . . . . . . 16Oxcarbazepine . . . . . . . 12Oxsoralen-Ul . . . . . . . 13Oxybutynin . . . . . . . . . 18Oxybutynin ER . . . . . . . 18Oxycodone Tab . . . . . . . 18Oxycodone

w/ Acetaminophen . . . 18Oxycontin . . . . . . . . . 18

P

Pantoprazole . . . . . . . . 15Paroxetine . . . . . . . . . 11Pataday . . . . . . . . . . 15Patanol. . . . . . . . . . . 15Pegasys . . . . . . . . . . . 9Penicillin VK. . . . . . . . . . 9Pentasa . . . . . . . . . . 16Perforomist . . . . . . . . 18Permethrin Cream 5% . . . 13Phenazopyridine . . . . . . 17Phentermine Tab . . . . . . 17Phenytoin . . . . . . . . . 12Phrenilin . . . . . . . . . . 11Pioglitazone . . . . . . . . 14Polymyxin B/Trimethoprim

Solution . . . . . . . . . 15Potassium Chloride ER . . . 19Potassium Chloride Micro ER 19Pradaxa . . . . . . . . . . . 9Pramipexole . . . . . . . . 12

Pravastatin . . . . . . . . . 10Prednisolone . . . . . . . . 15Prednisolone Opth . . . . . 15Prednisone . . . . . . . . . 15Premarin . . . . . . . . . . 20Premarin Vaginal Cream . 20Premphase . . . . . . . . . 20Prempro . . . . . . . . . . 20Previfem . . . . . . . . . . 19Prezista . . . . . . . . . . 16Pristiq . . . . . . . . . . . 11Proair HFA . . . . . . . . . 18Prochlorperazine . . . . . . 12Procrit . . . . . . . . . . . 17Progesterone Capsule . . . . 20Prograf . . . . . . . . . . . 19Promethazine/Codeine . . . 17Promethazine DM Syrup . . 17Promethazine Tab . . . . . . 19Propranolol . . . . . . . . . 10Propranolol ER . . . . . . . 10Protopic . . . . . . . . . . 13Proventil . . . . . . . . . . 18Pulmicort. . . . . . . . . . 18Pulmozyme . . . . . . . . 17Pylera . . . . . . . . . . . 16

Q

Quetiapine . . . . . . . . . 12Quinapril . . . . . . . . . . 10Qvar . . . . . . . . . . . . 18

R

Rabeprazole. . . . . . . . . 15Raloxifene. . . . . . . . . . 17Ramipril . . . . . . . . . . . 10Ranexa . . . . . . . . . . . 11Ranitidine . . . . . . . . . . 15Rapaflo. . . . . . . . . . . 16Rapamune . . . . . . . . 19Rebif . . . . . . . . . . . . 12Rebif Titrtn . . . . . . . . 12

Reclipsen . . . . . . . . . . 19Rectiv . . . . . . . . . . . 17Relpax . . . . . . . . . . . 11Renvela . . . . . . . . . . 17Restasis . . . . . . . . . . 15Retin-A Micro . . . . . . . 13Revlimid . . . . . . . . . . . 9Reyataz . . . . . . . . . . 16Rezira . . . . . . . . . . . 17Risperidone Tab . . . . . . . 12Rizatriptan Tab, ODT . . . . 11Ropinirole . . . . . . . . . 12

S

Safyral . . . . . . . . . . . 19Saizen . . . . . . . . . . . 15Saphris . . . . . . . . . . . 12Sensipar . . . . . . . . . . 15Serevent Diskus . . . . . . 18Seroquel XR . . . . . . . . 12Sertraline . . . . . . . . . . 11Sildenafil Tab . . . . . . . . 11Silenor . . . . . . . . . . . 12Silver Sulfadiazine Cream 1% 13Simcor . . . . . . . . . . . 10Simponi . . . . . . . . . . 16Simvastatin . . . . . . . . 10Softclix Lancets . . . . . . 14Softclix Lan Mis Device . . 14Soft Touch Lancets . . . . 14Solodyn . . . . . . . . . . . 9Sotalol . . . . . . . . . . . 11Sovaldi . . . . . . . . . . . . 9Spiriva . . . . . . . . . . . 18Spironolactone . . . . . . . 10Sprintec 28 . . . . . . . . . 19Sprix . . . . . . . . . . . . 18Stelara . . . . . . . . . . . 16Strattera . . . . . . . . . . 11Stribild . . . . . . . . . . . 16Suboxone Film. . . . . . . 17Subsys . . . . . . . . . . . 18Suclear Bowel Prep . . . . 16



Sucralfate . . . . . . . . . . 15Sulfamethoxazole-Trimethoprim 9Sulfamethoxazole-

Trimethoprim DS . . . . . 9Sumatriptan Tab and Spray . 11Sumavel Dose . . . . . . . 11Suprep Bowel Prep . . . . 16Surestep Test Strips . . . . 14Symbicort . . . . . . . . . 18Synagis. . . . . . . . . . . 17Synthroid . . . . . . . . 15Synvisc . . . . . . . . . . . 17

T

Taclonex . . . . . . . . . . 13Tacrolimus Cap . . . . . . . 19Tamiflu . . . . . . . . . . . . 9Tamoxifen. . . . . . . . . . . 9Tamsulosin . . . . . . . . . 16Tarka . . . . . . . . . . . . 10Tasigna. . . . . . . . . . . . 9Tecfidera . . . . . . . . . . 12Tekturna . . . . . . . . . . 10Tekturna HCT . . . . . . . 10Telmisartan . . . . . . . . . 10Temazepam . . . . . . . . . 12Terazosin . . . . . . . . . . 10Terazosin . . . . . . . . . . 16Terbinafine Tab . . . . . . . . 9Terconazole Vaginal Cream . 20Testim . . . . . . . . . . . 17Tev-Tropin . . . . . . . . . 15Timolol . . . . . . . . . . . 15Timoptic Ocudose . . . . . 15Tizanidine . . . . . . . . . 17Tobramycin . . . . . . . . . 15Tobramycin/Dexamethasone. 15Tolterodine ER. . . . . . . . 18Topiramate . . . . . . . . . 12Torsemide . . . . . . . . . . 10Toviaz . . . . . . . . . . . 18

Tracleer . . . . . . . . . . 11Tradjenta. . . . . . . . . . 14Tramadol Tab . . . . . . . . 18Tramadol w/ Acetaminophen 18Transderm-Scop . . . . . . 16Travatan Z . . . . . . . . . 15Trazodone . . . . . . . . . 11Tretinoin Microsphere Gel . . 13Triamcinolone . . . . . . . . 13Triamcinolone Spray. . . . . 19Triamterene/HCTZ . . . . . 10Triazolam Tab . . . . . . . . 12Tribenzor. . . . . . . . . . 10Trinessa . . . . . . . . . . . 19Tri-Sprintec . . . . . . . . . 19Tri-Vit-Fl Drops . . . . . . . 19Truetrack Test Strips. . . . 14Truvada . . . . . . . . . . 16Tudorza Pressair . . . . . . 18

U

Uceris . . . . . . . . . . . 16Uloric. . . . . . . . . . . . 17Vagifem . . . . . . . . . . 20

V

Valacyclovir . . . . . . . . . . 9Valsartan . . . . . . . . . . 10Valsartan/HCTZ . . . . . . . 10Vascepa . . . . . . . . . . 10Vectical. . . . . . . . . . . 13Venlafaxine . . . . . . . . . 11Venlafaxine ER Cap . . . . . 11Ventolin HFA . . . . . . . 18Veramyst. . . . . . . . . . 19Verapamil ER . . . . . . . . 10Vesicare . . . . . . . . . . 18Vestura . . . . . . . . . . . 19Viagra . . . . . . . . . . . 16Vicodin. . . . . . . . . . . 18Vicodin ES . . . . . . . . . 18

Victoza . . . . . . . . . . . 14Vigamox . . . . . . . . . . 15Viibryd . . . . . . . . . . . 11Viorele . . . . . . . . . . . 19Viread . . . . . . . . . . . 16Vitamin D . . . . . . . . . . 19Vivelle-Dot. . . . . . . . . 20Voltaren Gel . . . . . . . . 18Vytorin . . . . . . . . . . 10Vyvanse . . . . . . . . . . 11

W

Warfarin . . . . . . . . . . . 9Welchol . . . . . . . . . . 10

X

Xarelto . . . . . . . . . . . . 9Xolair. . . . . . . . . . . . 18Xopenex HFA . . . . . . . 18

Z

Zelapar. . . . . . . . . . . 12Zenpep. . . . . . . . . . . 16Zetia . . . . . . . . . . . . 10Zetonna . . . . . . . . . . 19Ziprasidone Cap. . . . . . . 12Zolpidem . . . . . . . . . . 12Zolpidem ER. . . . . . . . . 12Zomig Nasal Spray . . . . 11Zovirax Cream . . . . . . . 13Zovirax Ointment . . . . . 13Zubsolv . . . . . . . . . . 17Zutripro . . . . . . . . . . 17Zyclara . . . . . . . . . . . 13Zytiga . . . . . . . . . . . . 9

27

“My Medications” worksheet

Take this worksheet with you each time you visit a doctor. Each of your doctors should be aware of every drug you take and you should have a list as well.

Name of Medicine and Strength

Drug Tier

I Take This Medicine For

Directions Doctor

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

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