Your 2016 Formulary - myuhc.com · 1 Your 2016 Formulary SignatureValue Three-Tier effective July...
Transcript of Your 2016 Formulary - myuhc.com · 1 Your 2016 Formulary SignatureValue Three-Tier effective July...
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Your 2016 FormularySignatureValue Three-Tiereffective July 1, 2016
Please read: This document contains information about commonly prescribed medications.
For additional information:
Call the toll-free member phone number on your health plan ID card.
Visit myuhc.com® or optumrx.com®
• Locate a participating retail pharmacy by ZIP code.
• Look up possible lower-cost medication alternatives.
• Compare medication pricing and options.
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Your FormularyThis Formulary outlines the most commonly prescribed medications for certain conditions and organizes them into coverage levels. An important part of the Formulary is giving you choices so you and your doctor can choose the best course of treatment for you.
Go to myuhc.com for complete drug informationSince the Formulary may change, we encourage you to visit our website, myuhc.com or optumrx.com. This website is the best source for up-to-date information about the medications your pharmacy benefi t covers, possible lower-cost options, and cost comparisons. The complete formulary is also publicly available here on optumrx.com and is updated on a monthly basis.
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Table of Contents
Drug coverage levels and cost . . . . . . . . . . .5
Programs and Limits . . . . . . . . . . . . . . . . . . . . . .7
Drugs by category . . . . . . . . . . . . . . . . . . . . . . 10
Anti-InfectivesAntibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
Cardiovascular/Heart DiseaseCoagulation Therapy . . . . . . . . . . . . . . . . . . . . . . . .11High Blood Pressure . . . . . . . . . . . . . . . . . . . . . . . .11High Cholesterol . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Central Nervous SystemAttention Deficit Disorder . . . . . . . . . . . . . . . . . . . 14Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Sedatives/Hypnotics . . . . . . . . . . . . . . . . . . . . . . . 16Seizure Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Diabetes/EndocrineBlood Glucose Monitoring . . . . . . . . . . . . . . . . . . 18Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Non-Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
EndocrineGrowth Hormone . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Thyroid Hormone Replacement . . . . . . . . . . . . . 19
Eye ConditionsAllergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
GastrointestinalAcid Suppression . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Nausea/Vomiting . . . . . . . . . . . . . . . . . . . . . . . . . . 20Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Inflammatory Conditions: Rheumatoid Arthritis, Crohn’s Disease, Psoriasis, Ulcerative Colitis . . . . . . . . . . . . . . . . . . . . . . . . 22
Men’s HealthErectile Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . 22Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Testosterone Therapy . . . . . . . . . . . . . . . . . . . . . . 22
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
MusculoskeletalOsteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Pain Relief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Overactive Bladder . . . . . . . . . . . . . . . . . . . . . . 25
RespiratoryAsthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Nasal Allergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Oral Allergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Pulmonary Arterial Hypertension . . . . . . . . . . . . 26
Transplant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Vitamins/Electrolytes . . . . . . . . . . . . . . . . . . . 26
Women’s HealthContraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Hormone Replacement . . . . . . . . . . . . . . . . . . . . . 28Prenatal Vitamins . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
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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 Formulary.
What is a Formulary? This document is a list of commonly prescribed medications. Drugs are listed by common categories or class. It includes both brand and generic prescription medications approved by the U.S. Food and Drug Administration (FDA).
Please note: Where differences are noted between this Formulary and your benefit plan documents, the benefit plan documents will rule. It is not a complete list of medications, and not all medications listed may be covered under your plan. Please look at your benefit plan documents provided by your employer or health plan to see what medications are covered under your plan. You may also log on to myuhc.com or optumrx.com or call the toll-free member phone number on your health plan ID card for more information.
How do I use my Formulary List? When choosing a medication, you and your doctor should consult the Formulary. It will help you and your doctor choose the most cost-effective prescription drugs. This guide tells you if a medication is generic or brand, and if special 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 optumrx.com or call the toll-free member phone number on your health plan ID card.
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What are Coverage Levels? Coverage Levels are the different cost levels you pay for a medication. Each level 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. Formulary Generic medications are your lowest-cost options. If your medication is placed in Formulary Brand or Non-Formulary levels, look to see if there is a Formulary Generic option available. Discuss these options with your doctor.
Check your benefit plan documents to find out your specific pharmacy plan costs.
$ Coverage Level Includes Helpful Tips
Formulary Generic Lowest Cost
Lower-cost drugs . Some low-cost brands are also included .
Use Formulary Generic drugs for the lowest out-of-pocket costs .
Formulary Brand Mid-range Cost
Cost effective brand drugs .
Use Formulary Brand drugs, instead of Non-Formulary to help reduce your out-of-pocket costs .
Non-Formulary Highest Cost
Mostly higher-cost brand as well as select generic drugs .
Many Non-Formulary drugs have lower-cost options in Formulary Generic or Brand levels . Ask your doctor if they could work for you .
Please note: Some plans may have two or four coverage levels, while others may not have any. If you have a high deductible plan, the coverage cost levels may apply once you hit your deductible. Refer to your enrollment and plan materials on myuhc.com or optumrx.com, or call the toll-free number on your health plan ID card for more information about your benefit plan.
When does the Formulary List change?• Medications may move to a lower level at any time.
• Medications may move to a higher level when its generic becomes available.
• Medications may move to a higher level most often on January 1 or July 1.
When a medication changes levels, you may have to pay a different amount for that medication.
For the most up-to-date list, call customer service at the number on your ID card.
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Programs and LimitsSome medications are noted with letters next to them. The letters refer to our pharmacy benefit programs. Your benefit plan determines how these medications may be covered for you.
AEAge Edit – This medication applies to a specific age group . Members outside of this age group need to meet specific criteria for approval .
EExceptions required for select markets in California and Oklahoma. Your doctor is required to provide additional information to UnitedHealthcare to verify medical necessity of certain medications .
FB Formulary Brand
FG Formulary Generic
GEGender Edit – This medication is covered only for specific gender based on FDA approved indications .
HHealth Care Reform Preventive – This medication is part of a Health Care Reform preventive benefit and may be available at no cost to you .
M Medical – The medication may be covered under medical with Prior Authorization .
NFNon-Formulary – Non-formulary drugs are available on your highest Cost Tier (Tier 3) .
PAPrior Authorization required – Your doctor is required to provide additional information to UnitedHealthcare to determine coverage .
QLQuantity Limit – Amount of medication covered per copayment or in a specific time period .
STStep Therapy – Trial of a lower cost medication is required before a higher cost medication is covered .
To learn more about a pharmacy program or to find out if it applies to you, please visit myuhc.com or optumrx.com or call the toll-free member phone number on your health plan ID card.
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Why are some medications excluded from coverage? Medications may be excluded from coverage under your pharmacy benefit as defined by your Pharmacy Schedule of Benefits. There may be other medication options available.
Should I talk to my doctor about over-the-counter (OTC) medications? An over-the-counter (OTC) medication may be the right treatment for some conditions. Talk to your doctor about available OTC options.
What is the difference between brand-name and generic medications? Generic medications contain the same active ingredients (what makes the medication work) as brand-name medications, but they often cost less. Once the patent of a brand-name medication ends, the FDA can approve a generic version with the same active ingredients. These types of medications are known as generic medications. Sometimes, the same company that makes a brand-name medication also makes the generic version.
Is it a generic or brand-name drug?The drug list shows brand-name drugs in bold type (for example, Crestor) and generic drugs in plain type (for example, Simvastatin).
What if my doctor writes a brand-name prescription? The next time your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lower-cost option is available and if it might be right for you. Generic medications are usually your lowest-cost option, but not always. For some benefit plans if a brand-name drug is prescribed and a generic equivalent is available, your cost share may be the copay PLUS the cost difference between the brand-name drug and generic equivalent. Visit myuhc.com or optumrx.com to make sure.
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How do I get updated information about my pharmacy benefit? Since the Formulary may change during your plan year, we encourage you to visit myuhc.com or optumrx.com or call the toll-free member phone number on your health plan ID card for more current information.
Log on to optumrx.com for the following pharmacy information and tools:
• Pharmacy benefit and coverage information
• Possible lower-cost medication options
• A list of medications based on a specific medical condition
• Medication interactions and side effects
• Participating retail pharmacies by zip code
• Your prescription history
And, if Mail Service is included in your pharmacy benefit, you can also:
• Refill prescriptions
• Check the status of your order
• Set-up e-mail reminders for refills
• Manage your account
Medications are categorized by common therapeutic conditions in this Formulary 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 or optumrx.com
Where else can I go for information? HealthCareLane.com includes short videos to help you learn more about UnitedHealthcare benefits and health insurance information.
UHCTV.com is a fun and easy way to learn about health terms and other health-related topics.
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Bold type = Brand-name drug[Plain type = Generic drug]
AE = Age EditE = Exceptions requiredFB = Formulary Brand
FG = Formulary Generic GE = Gender EditH = Health Care Reform PreventiveM = Medical
NF = Non-FormularyPA = Prior Authorization requiredQL = Quantity LimitST = Step Therapy
Drug NameCoverage Level
Requirements& Limits
Anti-Infectives: Antibiotics
Amoxicillin FGAmoxicillin/Potassium Clavulanate
FG
Antipyrine/Benzocaine Otic
FG
Azithromycin FGBethkis FBCefaclor Suspension FBCefaclor Tablet FGCefadroxil FG QLCefdinir FGCefpodoxime FGCefprozil FGCefuroxime FGCephalexin FGChloroxylenol/Hydrocortisone/Pramoxine Otic
FG
Ciprofloxacin FGClarithromycin IR/ER FGCleocin Vaginal Suppository
FB
Clindamycin FGClindesse NFDapsone FBDemeclocycline FGDicloxacillin FGDoxycycline Hyclate FGDoxycycline Monohydrate Tablet
FG QL
Erythromycin FGErythromycin/Sulfisoxazole
FG
Ethambutol FGIsoniazid FGLevofloxacin FG
Drug NameCoverage Level
Requirements& Limits
Linezolid Tablet FG QLMethenamine FGMetronidazole Tablet FGMinocycline FGMycobutin FBNebuPent Nebs FB QLNeomycin FGNeomycin/Polymixin/Hydrocortisone Otic
FG
Nitrofurantoin FGNitrofurantoin Macrocrystal
FG
Ofloxacin Otic FGOracea NF QLParomomycin FGPenicillin VK FGPramoxine-HC Otic FGPyrazinamide FGRifampin FGSolodyn NF QLSulfadiazine FGSulfamethoxazole/Trimethoprim, Sulfamethoxazole/Trimethoprim DS
FG
Tetracycline FGTobi NF QL, STTrimethoprim FGZmax FB
Anti-Infectives: Antifungals
Clotrimazole Troche FGCresemba NFFluconazole FGGriseofulvin FGItraconazole FG PAKetoconazole Cream, Shampoo
FG
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Drug NameCoverage Level
Requirements& Limits
Metronidazole Vaginal Gel
FG
Nystatin FGTerbinafine FG QLTerconazole FG QLVandazole Gel FG
Anti-Infectives: Antivirals
Acyclovir FGAdefovir FGAmantadine Capsule, Syrup
FG
Baraclude NF E, QLDaklinza FB PA, QLEntecavir FG QLEpivir HBV Solution FBFamciclovir FGHarvoni FB PA, QLLamivudine FGOlysio NF PA, QLPegasys MRibavirin Tablet FG PARimantidine FGSovaldi FB PA, QLValacyclovir FG QLValcyte Solution FBValganciclovir Tablet FG QLViekira Pak NF PA, QLZovirax Cream FB EZovirax Ointment NF E
Cancer
Alkeran FBBexarotene FG PABicalutamide FGCapecitabine FGCaprelsa FB PA, QLCyclophosphamide FGEmcyt FBEtoposide FGErivedge FB PA, QLExemestane FGFareston FBFlutamide FGHexalen FB
Drug NameCoverage Level
Requirements& Limits
Hydroxyurea FGImatinib FG PA, QLLetrozole FG PALeucovorin Calcium FGLeukeran FBLomustine FGLysodren FBMatulane FBMercaptopurine FGMyleran FBNilandrone FBTabloid FBTasigna FB PA, QLTemozolomide FG PATretinoin Capsule FGTykerb FB PAXeloda NF EZytiga NF PACardiovascular/Heart Disease: Coagulation TherapyAggrenox NFBrilinta FB QLClopidogrel FG QLDisopyramide FGEffient FB QLEliquis NF QLJantoven FGPradaxa FB QLSavaysa NF QLTiclopidine FG QLWarfarin FGXarelto FB QLCardiovascular/Heart Disease: High Blood PressureAcebutolol FGAcetazolamide FGAcetazolamide ER FGAfeditab CR FGAldactazide 25/25 mg FBAmiloride FGAmiloride/ Hydrochlorothiazide
FG
Amlodipine FG QLAmlodipine/Benazepril FG QLAtenolol FG
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Bold type = Brand-name drug[Plain type = Generic drug]
AE = Age EditE = Exceptions requiredFB = Formulary Brand
FG = Formulary Generic GE = Gender EditH = Health Care Reform PreventiveM = Medical
NF = Non-FormularyPA = Prior Authorization requiredQL = Quantity LimitST = Step Therapy
Drug NameCoverage Level
Requirements& Limits
Atenolol/Chlorthalidone
FG
Azor FB QL, STBenazepril FGBenazepril/Hydrochlorothiazide
FG
Benicar FB QL, STBenicar HCT FB QL, STBetaxolol FGBisoprolol FGBisoprolol/Hydrochlorothiazide
FG
Bumetanide FGBystolic FB QLCaptopril FGCaptopril/ Hydrochlorothiazide
FG
Cartia XT FGCarvedilol FGChlorothiazide FGChlorthalidone FGClonidine Tablet FGClorpres NFDilatrate SR FBDiltiazem Sustained-Release Capsule
FG
Diltiazem Tablet FGDiovan NF E, QL, STDoxazosin FGDutoprol FB QLEdarbi NF E, QL, STEdarbyclor NF QL, STEnalapril FGEnalapril/Hydrochlorothiazide
FG
Eprosartan FG QLExforge NF E, QL, STExforge HCT NF E, QL, ST
Drug NameCoverage Level
Requirements& Limits
Ezide FGFelodipine FG QLFosinopril FGFosinopril/Hydrochlorothiazide
FG
Furosemide FGGuanfacine FGHydralazine FGHydrochlorothiazide FGIndapamide FGIrbesartan FG QLIrbesartan/Hydrochlorothiazide
FG QL
Isradipine FGLabetalol FGLisinopril FGLisinopril/Hydrochlorothiazide
FG
Losartan FG QLLosartan/Hydrochlorothiazide
FG QL
Methazolamide FGMethyclothia FGMethyldopa FGMethyldopa/Hydrochlorothiazide
FG
Metolazone FGMetoprolol Succinate ER
FG
Metoprolol Tartrate FGMicardis HCT FB E, QL, STMinoxidil FGMoexipril FGMoexipril/Hydrochlorothiazide
FG
Nadolol FGNicardipine FGNifediac CC FG
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Drug NameCoverage Level
Requirements& Limits
Nifedical XL FGNifedipine IR/ER FGPerindopril FGPhenoxybenzamine FGPindolol FGPrazosin FGPropranolol/Hydrochlorothiazide
FG
Propranolol IR/ER FGQuinapril FGRamipril FG QLReserpine FGSotalol FGSotalol AF FGSpironolactone FGSpironolactone/Hydrochlorothiazide
FG
Taztia XT FGTekturna FB QL, STTekturna HCT FB QL, STTelmisartan FB QLTerazosin FG QLTimolol FGTorsemide FGTrandolapril/ Verapamil CR
FG
Triamterene/Hydrochlorothiazide
FG
Tribenzor FB QL, STValsartan FG QLValsartan/Hydrochlorothiazide
FG QL
Valturna FB QLVerapamil Sustained-Release Capsule
FG QL
Verapamil Sustained-Release Tablet
FG
Verapamil Tablet FGCardiovascular/Heart Disease: High CholesterolAntara NF QLAtorvastatin FG QLCholestyramine FGCholine Fenofibrate Capsule
FG E, QL
Drug NameCoverage Level
Requirements& Limits
Colestipol FGCrestor FB QLFenofibrate 48, 145 mg Tablet
FG E, QL
Fenofibrate 54, 160 mg Tablet
FG QL
Fenofibrate Capsule FG QLFenofibrate Micronized FG QLFenoglide NF QL, STGemfibrozil FG QLLipofen FB QLLivalo NF QL, STLovastatin FGLovaza FB E, QLNiacin ER FG QLNiaspan NF QLOmega-3-Acid Ethyl Esters Capsule
FG PA, QL
Praluent M QLPravastatin FGPrevalite FGSimcor FB QLSimvastatin 5, 10, 20, 40 mg
FG QL
Simvastatin 80 mg FG PA, QLVascepa FB QLVytorin FB PA, QLWelchol FB
Cardiovascular/Heart Disease: Other
Amiodarone FGAnagrelide FGCilostazol FGCorlanor NF PA, QLDigoxin FGDilatrate SR FBDisopyramide FGFlecainide FGIsochron FGIsoditrate ER FGIsordil FBIsosorbide Dinitrate IR/ER
FG
Isosorbide Mononitrate IR/ER
FG
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Bold type = Brand-name drug[Plain type = Generic drug]
AE = Age EditE = Exceptions requiredFB = Formulary Brand
FG = Formulary Generic GE = Gender EditH = Health Care Reform PreventiveM = Medical
NF = Non-FormularyPA = Prior Authorization requiredQL = Quantity LimitST = Step Therapy
Drug NameCoverage Level
Requirements& Limits
Isoxsuprine FGMexiletine FGMidodrine FGNitroBid FBNitroDur Patch FBNitroglycerin ER FGNitrolingual Pump Spray
FG
Nitrostat FBNitroTime FGNorpace CR FBPacerone NFPentoxifylline FGPropafenone FGQuinidine IR/ER FGRanexa FB QL, STSotalol FGCentral Nervous System: Attention Deficit DisorderAdderall XR FB AE, QLDextroamphetamine/Amphetamine
FG AE, QL
Dextroamphetamine/Amphetamine Extended-Release
NF AE, E, QL
Dextroamphetamine Sulfate Extended-Release
FG AE, PA, QL
Dextroamphetamine Sulfate Tablet
FG AE, PA, QL
Guanfacine ER FG AE, QLIntuniv NF AE, E, QLMetadate ER FG AE, PA, QLMethylphenidate Controlled-Release Tablet
FG AE, QL
Methylphenidate Tablet FG AE, PA, QLStrattera FB QL
Drug NameCoverage Level
Requirements& Limits
Vyvanse FB AE, QL
Central Nervous System: Depression
Amitriptyline FGAmoxapine FGBupropion FGBupropion SR FG HBupropion XL FG QLCitalopram FG QLClomipramine FGCymbalta NF E, QLDesipramine FGDoxepin FGDuloxetine 20, 30, 60 mg
FG QL
Escitalopram FG QLFluoxetine FGFluvoxamine FGForfivo XL FB QLImipramine FGMaprotiline FGMirtazapine, Mirtazapine ODT
FG
Nefazodone FGNortriptyline FGParoxetine FGParoxetine ER FG QLPaxil Suspension FBPhenelzine FGPristiq FB QLProtriptyline FGSertraline FGTranylcypromine FGTrazodone FGVenlafaxine FGVenlafaxine Extended-Release Capsule
FG QL
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Drug NameCoverage Level
Requirements& Limits
Venlafaxine Extended-Release Tablet
FG QL
Viibryd NF QL, ST
Central Nervous System: Migraine
Acetaminophen/Butalbital/Caffeine
FG QL
Cambia NF E, QLIsometheptene/Acetaminophen/Dichloralphenazone
FG
Migragesic FGMigranal NF QLNodolor FGPhrenilin Forte NF QLRizatriptan FG QLSumatriptan Nasal Spray, Tablet
FG QL
Sumavel DosePro MZecuity NF E, QL, STZolmitriptan FG QLZomig Spray FB E, QLCentral Nervous System: Multiple SclerosisAmpyra FB PA, QLAvonex M QLBetaseron M QLCopaxone M QLExtavia M QLGilenya NF PA, QLPlegridy M QLRebif, Rebif Rebidose M QLTecfidera FB PA, QL
Central Nervous System: Other
Alprazolam IR/ER FG QLAricept 5, 10 mg Tablet, ODT
NF QL
Aricept 23 mg NF QL, STAripiprazole ODT FG QLAripiprazole Solution, Tablet
FG QL
Azilect NF QLBenztropine FGBromocriptine FG
Drug NameCoverage Level
Requirements& Limits
Buspirone FGCarbidopa/Levodopa IR/ER
FG
Chlordiazepoxide FG QLChlordiazepoxide/Amitriptyline
FG
Chlorpromazine FGClorazepate FG QLClozapine FG QLCompro Suppository FGDiazepam FGDonepezil, Donepezil ODT
FG QL
Entaone FGErgoloid Mesylate FGFluphenazine FGGalantamine IR/ER FGHaloperidol FGHydroxyzine FGLatuda NF QL, STLithium IR/ER FGLorazepam FG QLLoxapine FGMeprobamate FGNamenda XR FB QLNamzaric NF QL, STNuvigil NF PA, QLOlanzapine, Olanzapine ODT
FG QL
Oxazepam FG QLPerphenazine/Amitriptyline
FG
Pramipexole FGProchlorperazine FGQuetiapine FG QLRisperidone, Risperidone ODT
FG QL
Rivastigmine FG QLRopinirole FGSaphris FB PA, QLSeroquel XR FB QLSuboxone Film FB PA, QLSuboxone Tablet NF PA, QLThioridazine FGThiothixene FG
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Bold type = Brand-name drug[Plain type = Generic drug]
AE = Age EditE = Exceptions requiredFB = Formulary Brand
FG = Formulary Generic GE = Gender EditH = Health Care Reform PreventiveM = Medical
NF = Non-FormularyPA = Prior Authorization requiredQL = Quantity LimitST = Step Therapy
Drug NameCoverage Level
Requirements& Limits
Trifluoperazine FGTrihexyphenidyl FGXyrem NF PA, QLZelapar NF QLZiprasidone FG QLZubsolv FB PA, QLCentral Nervous System: Sedatives/HypnoticsEszopiclone FG QLFlurazepam FG PA, QLSilenor NF QLTemazepam FG QLTriazolam FG QLZaleplon FG QLZolpidem FG QLCentral Nervous System: Seizure DisordersCarbamazepine IR/ER
FG
Clonazepam, Clonazepam ODT
FG QL
Diazepam Gel FG QLDivalproex FGDivalproex Extended-Release
FG
Epitol FGEthosuximide FGGabapentin FGLamictal Chewable, Tablet
FB E
Lamictal Starter Kit FB QLLamictal XR NF E, PA, QLLamotrigine Chewable, Tablet
FG
Lamotrigine ER FG QLLamotrigine ODT NFLevetiracetam ER NF QL, STLevetiracetam IR FG
Drug NameCoverage Level
Requirements& Limits
Lyrica Capsule FB QLLyrica Solution NF QLOxcarbazepine FGPhenobarbital FGPhenytoin FGTopiragen FGTopiramate FGValproic Acid FGZonisamide FG
Dermatology
Acanya NF E, QLActicin FGAcyclovir FGAczone Gel NFAdapalene FG AE, QLAla Quin FGAlclometasone FGAlphatrex FGAmmonium Lactate FGAmnesteem FG PA, QLAtralin FB AE, QLAvita FG AE, QLBenzaclin NF E, QLBenzamycin Pack FBBetamethasone FGCalcipotriene-Betamethasone
FB QL
Calcipotriene Ointment FG QLCalcitriol Ointment FGCerovel FGCiclodan FGCiclopirox Cream, Gel, Lotion, Solution
FG
Claravis FG E, PAClindamax Lotion FGClindamycin Gel, Lotion, Solution, Swabs
FG
17
Drug NameCoverage Level
Requirements& Limits
Clindareach Kit FGClobetasol, Clobetasol E
FG
Clobex Lotion, Shampoo
NF E
Clobex Spray NF E, QLCloderm NFCloderm Pump NFCormax FGDermazene FGDesonide FGDesoximetasone FGDifferin Cream, Lotion
NF AE, QL
Differin Gel NF E, QLDrithoCreme HP FBDrithoScalp FBEconazole FGElidel FB AE, QL, STEpiduo, Epiduo Forte
NF AE, QL
Ery Pad FGErythromycin FGErythromycin/Benzoyl Peroxide
FG
Ethyl Chloride FGEurax FBExoderm FGFinacea FBFinacea Plus FBFluocinolone FGFluocinonide, Fluocinonide E
FG
Fluorouracil 0 .5% Cream
FB
Fluorouracil Solution, 5% Cream
FG
Fluticasone FGGentamicin FGHydrocortisone FGHypercare FGImiquimod FG QLLaclotion FGLidocaine FGLidocaine/Prilocaine FG
Drug NameCoverage Level
Requirements& Limits
Lindane FGLokara FGMetrogel 1% NF EMetronidazole 0 .75% Cream, Lotion
FG
Mirvaso NF PA, QLMometasone Furoate FGMupirocin Calcium Cream
FG QL
Mupirocin Ointment FGMyorisan FG PANystatin FGNystop FGPermethrin FGPicato NF STPodofilox FGPramcort FGPramosone Cream, Ointment
NF
Pramosone E Cream
NF
Pramosone Lotion NFProtopic NF AE, PA, QLRetin-A Micro Gel, Pump
FB AE, QL
Rosadan Cream FGSelenium Sulfide FGSilver Nitrate FGSilver Sulfadiazine FGSulfacetamide Sodium FGSulfacetamide Sodium-Sulfur
FG
Taclonex Ointment NF E, QLTaclonex Scalp NF QLTacrolimus Ointment FG AE, QLTazorac NF AE, QLTretin-X FB AE, QLTretinoin FG AE, ETriamcinolone Acetonide
FG
Trianex FBTriderm FGUrea 40% Lotion FGVectical NF EVitazol FG
18
Bold type = Brand-name drug[Plain type = Generic drug]
AE = Age EditE = Exceptions requiredFB = Formulary Brand
FG = Formulary Generic GE = Gender EditH = Health Care Reform PreventiveM = Medical
NF = Non-FormularyPA = Prior Authorization requiredQL = Quantity LimitST = Step Therapy
Drug NameCoverage Level
Requirements& Limits
Voltaren Gel FB QLZenatane FG E, PAZyclara Cream, Pump
NF QL
Diabetes/Endocrine: Blood Glucose MonitoringAccu-Chek Test Strips
NF PA, QL
Bayer Breeze2 Test Strips
NF PA, QL
Bayer Contour Test Strips
NF PA, QL
FastClix Lancets FB QLFreestyle Test Strips
NF PA, QL
Glucocard Test Strips
NF PA, QL
Novofine Autocover Pen Needles
NF
Novofine Pen Needles
NF
Novofine Plus Pen Needles
FB
Novotwist Pen Needles
NF
OneTouch Test Strips
FB QL
OneTouch Ultra Blue Test Strips
FB QL
OneTouch Verio IQ Test Strips
FB QL
Relion Test Strips NF PA, QLSoft Touch Lancets FB QLSoftClix Lancets FB QL
Diabetes/Endocrine: Insulin
Apidra Solostar NF STApidra Vial NF ST
Drug NameCoverage Level
Requirements& Limits
Humalog KwikPen 100u/ml
FB
Humalog Mix 75-25 KwikPen
FB
Humalog Vial FBHumulin 70-30 Vial FBHumulin KwikPen FBHumulin N KwikPen FBHumulin N Vial FBHumulin R U-500 Vial
FB
Lantus Solostar FBLantus Vial FBLevemir Flexpen FBLevemir Vial FBNovolin N Vial FB ENovolin R Vial FB ENovolin Vial FB ENovolog Flexpen FB ENovolog Mix FB ENovolog Vial FB E
Diabetes/Endocrine: Non-Insulin
Acarbose FGBydureon FB QL, STByetta FB QL, STChlorpropamide FG AEGlimepiride FGGlipizide IR/XL FGGlipizide/Metformin FGGlucagen FBGlucagon FB QLGlumetza NF PAGlyburide FGGlyburide/Metformin FGGlyxambi NF QL, STInvokamet FB QL, STInvokana FB QL, ST
19
Drug NameCoverage Level
Requirements& Limits
Janumet FB QL, STJanumet XR FB QL, STJanuvia FB QL, STJardiance FB QL, STJentadueto NF QL, STJuvisync FB QL, STKombiglyze XR FB QL, STMetformin FGMetformin Extended-Release
FG PA
Nateglinide FG QLOnglyza FB QL, STPioglitazone FG QL, STPioglitazone/Glimepiride FG QL, STPioglitazone/Metformin FG QL, STRepaglinide FG QL, STSymlin NF PASynjardy FB QL, STTolazamide FG STTolbutamide FG STTradjenta NF QL, STTrulicity FB QL, STVictoza FB QL, ST
Endocrine: Growth Hormone
Lupron Depot MNorditropin MNutropin Aq NuSpin MSaizen MTev-Tropin M
Endocrine: Other
Asmalpred, Asmalpred Plus
FB
Calcitriol FGCortisone FGDesmopressin FGDexamethasone FGFludrocortisone FGHydrocortisone Tablet FGMedrol 2 mg FBMethylergonovine FGMethylprednisolone FGMillipred Tablet FGParicalcitol FG
Drug NameCoverage Level
Requirements& Limits
Prednisolone Solution, Tablet
FG
Prednisone FGZemplar FBEndocrine: Thyroid Hormone ReplacementLevothyroxine Sodium FGLevoxyl FGLiothyronine Sodium FGMethimazole FGPropylthiouracil FGTirosint NFUnithroid FG
Eye Conditions: Allergies
Azelastine 0 .05% Solution
FG
Cromolyn FGEpinastine FG ELastacaft NF QLNaphazoline 0 .1% FGPataday NF EPhenylephrine FG
Eye Conditions: Antibiotics
Bacitracin FGBacitracin/Polymyxin FGCiprofloxacin FG QLErythromycin FGGentamicin FGIlotycin FGMoxeza FB QLNatacyn FBNeomycin/Bacitracin/Polymyxin
FG
Neomycin/Polymixin/Gramicidin
FG
Ofloxacin FG QLPolymyxin B/Trimethoprim
FG
Sulfacetamide Sodium FGTobradex Ointment NFTobramycin/Dexamethasone
FG
20
Bold type = Brand-name drug[Plain type = Generic drug]
AE = Age EditE = Exceptions requiredFB = Formulary Brand
FG = Formulary Generic GE = Gender EditH = Health Care Reform PreventiveM = Medical
NF = Non-FormularyPA = Prior Authorization requiredQL = Quantity LimitST = Step Therapy
Drug NameCoverage Level
Requirements& Limits
Tobramycin Ophth Solution
FG E
Tobrex NF ETrifluridine FGVigamox FB QL
Eye Conditions: Glaucoma
Alphagan P FB QLAzopt FB QLBetaxolol FGBetimol NF QLBetoptic-S FBCarteolol FGCombigan FB QLDorzolamide FG QLDorzolamide/Timolol FGIstalol FBLatanoprost FG QLLevobunolol FGLumigan FB QLMetipranolol FGTimolol Maleate FGTimoptic Ocudose FBTravatan Z FB QL
Eye Conditions: Other
Atropine FGBlephamide SOP NFBrimonidine FGCyclogyl FBCyclopentolate FGDexamethasone FGDiclofenac FG QLFluorometholone FGFlurbiprofen FGFML Forte FBHomatropine FGIso Carbachol FB
Drug NameCoverage Level
Requirements& Limits
Iso Homatropine FBKetorolac FG QLNeomycin/Bacitracin/Polymyxin/Hydrocortisone
FG
Neomycin/Polymixin/Dexamethasone
FG
Phospholine FBPred Mild FBPrednisolone Solution, Tablet
FG
Proparacaine FGRestasis NF PASulfacetamide Sodium/Prednisolone
FG
Tetracaine FGTropicamide FG
Gastrointestinal: Acid Suppression
Carafate FBCimetidine FGDexilant FB QLLansoprazole FG QLMisoprostol FGNizatidine FGOmeclamox-Pak FB QLOmeprazole FG QLPantoprazole FG QLPylera FB QLRanitidine FGSucralfate Tablet FGZegerid NF QL, ST
Gastrointestinal: Nausea/Vomiting
Antivert 50 mg FBDronabinol FG PAOndansetron FG QLOndansetron ODT FG
21
Drug NameCoverage Level
Requirements& Limits
Promethazine FG AETrimethobenzamide FG
Gastrointestinal: Other
Amitiza FB QL, STAnalpram Advanced NFAnalpram-HC Cream
NF
Analpram-HC Lotion
NF
Analpram-HC Shingles
NF
Apriso NF QL, STAuryxia NFB-donna FGBelladonna Alkaloids/Phenobarbital
FG
Budesonide FGCalcium Acetate FGCanasa FB QLChlordiazepoxide/Clidinium
FG
Creon FBDelzicol NF E, QL, STDicyclomine FGDificid NFDigex NF FBDipentum NFDiphenoxylate/Atropine FGGavilyte FG QLHalflytely NF QLHyoscyamine FGLactulose FGLialda FB QLLinzess FB AE, QL, STMesalamine Enema FGMetoclopramide Solution, Tablet
FG QL
Movantik FB QLPancrelipase FGParegoric Tincture FGPentasa NF E, QLPolyethylene Glycol 3350
FG QL
Prepopik NF
Drug NameCoverage Level
Requirements& Limits
Propantheline FGRenvela Packet NFRenvela Tablet FBRowasa Enema NFSevelamer FGSulfasalazine FGSuprep NF QLTrilyte FG QLUceris NFUrsodiol FGZenpep FB
HIV/AIDS
Abacavir FGAbacavir/Lamivudine FGAptivus FBAtripla FBComplera FBCrixivan FBDidanosine FGEdurant FBEmtriva FBEpivir Solution FBEpzicom FBEvotaz FBFuzeon FB QLGenvoya FBIntelence FBInvirase FBIsentress FBKaletra FBLamivudine FGLamivudine/Zidovudine FGLexiva FBNevirapine FGNorvir FBPrezcobix FBPrezista FBRescriptor FBRetrovir FBReyataz FBSelzentry FB PAStavudine FGStribild FB PASustiva FB
22
Bold type = Brand-name drug[Plain type = Generic drug]
AE = Age EditE = Exceptions requiredFB = Formulary Brand
FG = Formulary Generic GE = Gender EditH = Health Care Reform PreventiveM = Medical
NF = Non-FormularyPA = Prior Authorization requiredQL = Quantity LimitST = Step Therapy
Drug NameCoverage Level
Requirements& Limits
Tivicay FBTriumeq FBTrizivir NFTruvada FBVidex Solution FBViracept FBViread FBVitekta FBZiagen FBZidovudine FG
Infertility*
Cetrotide MClomiphene FG GEFollistim AQ MGonal-F MGonal-F Rff MOvidrel M*Coverage is determined by the consumer’s prescription drug benefit plan .
Inflammatory Conditions: RheumatoidArthritis, Crohn’s Disease, Psoriasis, Ulcerative ColitisCimzia M QLCuprimine NF PADepen FBHumira MHydroxychloroquine Sulfate
FG
Leflunomide FG QLMethotrexate FGOrencia M QLRemicade MRheumatrex NFSimponi M QLStelara M QLTrexall NF
Drug NameCoverage Level
Requirements& Limits
Men’s Health: Erectile Dysfunction*
Cialis FBAE, GE, PA, QL
Stendra FBAE, GE, PA, QL
*Coverage is determined by the consumer’s prescription drug benefit plan .
Men’s Health: Prostate
Alfuzosin FG QLDoxazosin FGDutasteride FG QLDutasteride-Tamsulosin FG QLFinasteride FGRapaflo FB QLTamsulosin FG QLTerazosin FG
Men’s Health: Testosterone Therapy
Androderm FB GE, PA, QLAndrogel 1% NF GE, PA, QLAndrogel 1.62% FB GE, PA, QLAndroxy FG PAAxiron NF GE, PA, QLFortesta NF GE, PA, QLTestim NF GE, PA, QLTestosterone Gel 1% FG GE, PA, QLTestred NF PA
Miscellaneous
Acetic Acid Otic FGAcetylcysteine FGAerochamber FB QLAlinia FB QLAnastrozole FGAntipyrine/Benzocaine FGAnucort-HC FG
23
Drug NameCoverage Level
Requirements& Limits
Aranesp MBenzocaine Otic FGBenzonatate FGBiltricide FBBunavail NF PA, QLCerdelga NF PA, QLChloroquine FGCitric Acid/Sodium Citrate
FG
Condylox NFDanazol FGDaraprim NF PADeconsal-II FBDifil-G Forte Liquid FGDisulfiram FGEasivent FB QLElmiron FBEpipen 2-Pak FB QLEpipen-Jr FB QLErgocalciferol 50,000 Unit Capsule
FG
Euflexxa MExemestane FGEZ Spacer FB QLFosrenol NFGranix MGuaifenesin/Codeine FGGuanidine FBHumibid DM FBHydrocodone/Homatropine
FG
Hydrocortisone/Acetic Acid Otic
FG
Hydrocortisone Pramoxine
FG
Hydrocortisone Suppository
FG
Hypersal Nebs FBInspirease FBKuvan FB PA, QLLetrozole FGLidocaine Patch FG QLLidocaine Viscous FGLidoderm Patch NF E, QLMebendazole FG
Drug NameCoverage Level
Requirements& Limits
Mefloquine FGMegestrol AC FGMephyton FBMestinon Syrup FBMultigen Folic FBMultigen Plus FBNaltrexone FGNessi Spacer FB QLNeupogen MOptihaler FB QLPhenazopyridine FGPilocarpine FGPrimaquine FGProcrit MProctocream HC FGProctofoam HC FBProctosol HC FGProctozone HC FGProglycem FBPromethazine/Codeine FG AEPromethazine/Dextromethorphan
FG AE
Promethazine VC/Codeine
FG AE
Pyridostigmine FGRectiv NF PARenvela NFRezira NFSodium Polystyrene Sulfonate Powder
FG
Soriatane NF QLSSKI FBSynarel FBSynvisc MSynvisc One MTamoxifen FG HTriamcinolone/Orabase FGVelphoro NFVitamin D 50,000 Unit FGVortex FB QLWatchHaler FB QLYodoxin FBZemplar FBZutripro NF
24
Bold type = Brand-name drug[Plain type = Generic drug]
AE = Age EditE = Exceptions requiredFB = Formulary Brand
FG = Formulary Generic GE = Gender EditH = Health Care Reform PreventiveM = Medical
NF = Non-FormularyPA = Prior Authorization requiredQL = Quantity LimitST = Step Therapy
Drug NameCoverage Level
Requirements& Limits
Musculoskeletal: Osteoporosis
Actonel NF E, QLAlendronate Oral Solution FG QL
Alendronate Tablet FG QLCalcitonin Spray FG QLForteo MFortical NF QLIbandronate FG QLRaloxifene FG H, QL
Musculoskeletal: Other
Allopurinol FGBaclofen FGCarisoprodol FGColcrys FB QLCyclobenzaprine FGDantrolene FGMethocarbamol FGOrphenadrine/Aspirin/Caffeine FG
Orphenadrine ER FGProbenecid FGTizanidine Tablet FGUloric FB QL, ST
Musculoskeletal: Pain Relief
Acetaminophen/Codeine
FG QL
Acetaminophen/Oxycodone
FG QL
Ascomp/Codeine FG QLAvinza NF PA, QLBupap 50/650 mg FB QLButalbital/Acetaminophen FG QL
Drug NameCoverage Level
Requirements& Limits
Butalbital/Acetaminophen/Caffeine
FG QL
Butalbital/Acetaminophen/Caffeine/Codeine
FG QL
Butalbital/Aspirin/Caffeine
FG QL
Butalbital/Aspirin/Caffeine/Codeine
FG QL
Celecoxib NF QLCholine Magnesium Trisalicylate
FG QL
Codeine FGDiclofenac Sodium FG QLDiflunisal FG QLDuraxin FGEmbeda FB QLEsgic Plus FB QLEtodolac IR/ER FG QLFenoprofen FG QLFentanyl Patch 12, 25, 50, 75, 100 mcg
FG QL
Flector Patch NF E, QLFlurbiprofen FG QLFortigan FGGralise NF QL, STHydrocodone/Acetaminophen
FG QL
Hydrocodone/Ibuprofen
FG QL
Hydromorphone IR/ER FG QLIbuprofen FG QLIndocin Suppository FB QLIndomethacin IR/ER FG QLKetoprofen IR/ER FG QLKetorolac FG QLLazanda NF PA, QL
25
Drug NameCoverage Level
Requirements& Limits
Levorphanol FG QLMeclofenamate FG QLMeloxicam FG QLMeperidine FGMethadone FG QLMorphine Sulfate Beads Sustained-Release
FG QL
Morphine Sulfate Controlled-Release Tablet
FG QL
Morphine Sulfate Immediate-Release Tablet, Solution
FG
Morphine Sulfate Sustained-Release Capsule
FG E, QL
Nabumetone FG QLNalfon 200 mg Capsule
FB QL
Naproxen FG QLNucynta NF QLNucynta ER NF QL, STOpana ER FB QLOrbivan FB QLOxaprozin FGOxycodone IR FGOxycodone/Acetaminophen
FG QL
Oxycontin FB QLOxymorphone FG QLPentazocine/Acetaminophen
FG QL
Pentazocine/Naloxone FG QLPhenyltoloxamine/Acetaminophen
FG
Piroxicam FG QLSalsalate FGSedapap FB QLSulindac FG QLTivorbex NF E, QL, STTolmetin FG QLTramadol FGVimovo NF QL, STVoltaren Gel FB QL
Drug NameCoverage Level
Requirements& Limits
Zohydro ER NF QL, STZorvolex NF E, QL
Overactive Bladder
Bethanechol FGEnablex NF E, QLGelnique 10% FB QLMyrbetriq NF QL, STOxybutynin FGOxybutynin Extended-Release
FG QL
Oxytrol NF E, QLToviaz NF QLVesicare FB QL
Respiratory: Asthma/COPD
Advair Diskus FB QLAdvair HFA FB QLAerospan NF QLAlbuterol Sulfate FGAminophylline FGAnoro Ellipta FB QLArnuity Ellipta FB QLAsmanex NF QL, STAtrovent HFA NF QLBreo Ellipta FB QLBudesonide Nebs FG QLCombivent Respimat
FB QL
Cromolyn Nebs FGFlovent Diskus FB QLFlovent HFA FB QLForadil FB QLIncruse Ellipta FB QLIpratropium FGIpratropium/Albuterol Nebs
FG
Montelukast FG QLPerforomist NF QLProair HFA FB QLProair Respiclick FB QLPulmicort Flexhaler FB QLPulmicort Respules NF QLQVAR FB QL
26
Bold type = Brand-name drug[Plain type = Generic drug]
AE = Age EditE = Exceptions requiredFB = Formulary Brand
FG = Formulary Generic GE = Gender EditH = Health Care Reform PreventiveM = Medical
NF = Non-FormularyPA = Prior Authorization requiredQL = Quantity LimitST = Step Therapy
Drug NameCoverage Level
Requirements& Limits
Serevent FB QLSpiriva HandiHaler, Respimat
FB QL
Stiolto Respimat FB QLStriverdi Respimat NF QL, STSymbicort FB QLTerbutaline FGTheophylline SR FGTudorza FB QLVentolin HFA FB QLXopenex HFA NF QL, ST
Respiratory: Nasal Allergies
Azelastine 0 .1% Solution
FG QL
Dymista Spray FB E, QLFlunisolide FG QLFluticasone Propionate FG QLIpratropium FGNasonex FB E, QLOmnaris NF E, QLQNasl NF QLVeramyst NF E, QLZetonna NF E, QL
Respiratory: Oral Allergies
Carbinoxamine FGClemastine FGCyproheptadine FGDexchlorpheniramine FGHydroxyzine FGPromethazine FG AERespiratory: Pulmonary Arterial HypertensionAdcirca NF PA, QLAdempas FB PA, QLLetairis FB PA, QLOpsumit FB PA, QL
Drug NameCoverage Level
Requirements& Limits
Orenitram NF PASildenafil Tablet 20 mg FG PA, QLTracleer FB PA, QL
Transplant
Azathioprine FGCyclosporine, Cyclosporine Modified
FG
Gengraf FGTacrolimus FG
Vitamins/Electrolytes
Fluoride Chewable Tablet, Drops
FG H
Folic Acid 1 mg FGKlor-Con 10 FGKlor-Con M10 FGKlor-Con M20 FGPotassium Chloride FGPotassium Citrate FG
Women’s Health: Contraceptives
Altavera FG HAlyacen FG HApri FG HAranelle FG HAubra FG HAviane FG HAzurette FG HBalziva FG HBeyaz NF HBriellyn FG HCamila FG HCaziant FG HCesia FG HChateal FG HCryselle FG HCyclafem FG H
27
Drug NameCoverage Level
Requirements& Limits
Dasetta FG HDrospirenone/Ethinyl Estradiol
FG H
Elinest FG HElla FG H, QLEmoquette FG HEnpresse FG HEnskyce FG HErrin FG HEstarylla FG HFalmina FG HGianvi FG HGildagia FG HGildess, Gildess Fe FG HHeather FG HImplanon FG HIntrovale FG HJencycla FG HJolessa FG HJolivette FG HJunel FG HJunel Fe FG HKariva FG HKelnor FG HKurvelo FG HLarin, Larin FE FG HLeena FG HLessina FG HLevonest FG HLevonorgestrel FG AE, H, QLLevonorgestrel/Ethinyl Estradiol
FG H
Levora-28 FG HLo Loestrin NF HLoestrin FBLoryna FG HLow-Ogestrel FG HLutera FG HLyza FG HMarlissa FG HMedroxyprogesterone Acetate Injection
FG H, PA
Microgestin FG HMicrogestin FE FG HMono-Linyah FG H
Drug NameCoverage Level
Requirements& Limits
Mononessa FG HMyzilra FG HNatazia FB HNecon 0 .5/35, 1/35, 1/50, 10/11
FG H
Nikki FG HNora-BE FG HNorethindrone FG HNorgestimate-Ethinyl Estradiol
FG H
Norgestrel/Ethinyl Estradiol
FG H
Nortrel FG HNuvaring FB HOcella FG HOgestrel FG HOrsythia FG HOrtho Coil FG HOrtho Flat FG HOrtho Flex FG HPhilith FG HPimtrea FG HPortia FG HPrevifem FG HPrimella FG HQuasense FG HReclipsen FG HSafyral NF HSharobel FG HSolia FG HSprintec FG HSronyx FG HSyeda FG HTarina FE FG HTri-Estarylla FG HTri-Linyah FG HTri-Previfem FG HTri-Sprintec FG HTrinessa FG HTrinessa Lo NF HTrivora-28 FG HVelivet FG HVestura FG HVyfemla FG HViorele FG H
28
Bold type = Brand-name drug[Plain type = Generic drug]
AE = Age EditE = Exceptions requiredFB = Formulary Brand
FG = Formulary Generic GE = Gender EditH = Health Care Reform PreventiveM = Medical
NF = Non-FormularyPA = Prior Authorization requiredQL = Quantity LimitST = Step Therapy
Drug NameCoverage Level
Requirements& Limits
Wera FG HWide-Seal FG HXulane FG HYasmin 28 NF E, HYaz NF E, HZarah FG HZenchent FG HZovia FG H
Women’s Health: Hormone Replacement
Alora FB GE, QLCenestin NF GE, QLClimara Pro FB GE, QLCovaryx, Covaryx HS FG GE, PA, QLDivigel NFDuavee FB GE, QLElestrin NF GEEnjuvia NF GE, QLEstradiol Tablet FG GE, QLEstradiol Twice Weekly Patch
NF GE, QL
Estradiol Weekly Patch, Tablet
FG GE, QL
Estrogen/Methyltestosterone, Estrogen/Methyltestosterone HS
FG GE, QL
Estropipate FG GE, QL
Drug NameCoverage Level
Requirements& Limits
Evamist NF GE, QLJinteli FG QLMakena MMedroxyprogesterone FG GEMenest FG GE, QLMimvey FG GE, QLMinivelle NF QLNorethindrone FG GENorethindrone/Ethinyl Estradiol
FG GE, QL
OrthoEst FG GE, QLOsphena NFPremarin FB GE, QLPremarin Vaginal Cream
FB
Premphase FB GE, QLPrempro FB GE, QLVagifem FB GEVivelle-Dot NF E, GE, QL
Women’s Health: Prenatal Vitamins
Brand Prenatal Vitamins/Folic Acid 1 mg
FB
Generic Prenatal Vitamins/Folic Acid 1 mg
FG
29
Index of covered drugs
A
Abacavir .................................. 21Abacavir/Lamivudine ............. 21Acanya ..................................... 16Acarbose .................................. 18Accu-Chek Test Strips ............ 18Acebutolol ............................... 11Acetaminophen/Butalbital/
Caffeine ................................ 15Acetaminophen/Codeine ........24Acetaminophen/Oxycodone ....24Acetazolamide ......................... 11Acetazolamide ER................... 11Acetic Acid Otic ................22, 23Acetylcysteine .......................... 22Acticin ..................................... 16Actonel ....................................24Acyclovir ........................... 11, 16Aczone Gel .............................. 16Adapalene ................................ 16Adcirca ....................................26Adderall XR ............................ 14Adefovir ................................... 11Adempas ..................................26Advair Diskus .......................... 25Advair HFA ............................ 25Aerochamber ........................... 22Aerospan ................................. 25Afeditab CR ............................ 11Aggrenox ................................. 11Ala Quin ................................. 16Albuterol Sulfate ..................... 25Alclometasone ......................... 16Aldactazide 25/25 mg ............. 11Alendronate Oral Solution ......24Alendronate Tablet ..................24Alfuzosin ................................. 22Alinia ...................................... 22Alkeran .................................... 11Allopurinol ..............................24Alora........................................28Alphagan P..............................20Alphatrex ................................. 16Alprazolam IR/ER ................. 15
Altavera ...................................26Alyacen ....................................26Amantadine Capsule, Syrup .... 11Amiloride ................................ 11Amiloride/
Hydrochlorothiazide ............ 11Aminophylline ........................ 25Amiodarone............................. 13Amitiza ................................... 21Amitriptyline ..................... 14, 15Amlodipine ............................. 11Amlodipine/Benazepril ........... 11Ammonium Lactate ................ 16Amnesteem ............................. 16Amoxapine .............................. 14Amoxicillin ............................. 10Amoxicillin/Potassium
Clavulanate .......................... 10Ampyra ................................... 15Anagrelide ............................... 13Analpram-HC Cream ............. 21Analpram-HC Lotion ............. 21Analpram-HC Shingles .......... 21Analpram Advanced................ 21Anastrozole ............................. 22Androderm .............................. 22Androgel 1% ............................ 22Androgel 1.62% ....................... 22Androxy .................................. 22Anoro Ellipta .......................... 25Antara ..................................... 13Antipyrine/Benzocaine ..... 10, 22Antipyrine/Benzocaine Otic ... 10Antivert 50 mg ........................20Anucort-HC ............................ 22Apidra Solostar ........................ 18Apidra Vial .............................. 18Apri .........................................26Apriso ...................................... 21Aptivus .................................... 21Aranelle ...................................26Aranesp ................................... 23Aricept 23 mg.......................... 15
Aricept 5, 10 mg Tablet, ODT .................................... 15
Aripiprazole ODT................... 15Aripiprazole Solution, Tablet .. 15Arnuity Ellipta ........................ 25Ascomp/Codeine .....................24Asmalpred, Asmalpred Plus .... 19Asmanex .................................. 25Atenolol ............................. 11, 12Atenolol/Chlorthalidone .........12Atorvastatin ............................. 13Atralin ..................................... 16Atripla ..................................... 21Atropine ............................ 20, 21Atrovent HFA ......................... 25Aubra .......................................26Auryxia .................................... 21Aviane .....................................26Avinza .....................................24Avita ........................................ 16Avonex ..................................... 15Axiron ..................................... 22Azathioprine ...........................26Azelastine 0.05% Solution ....... 19Azelastine 0.1% Solution ......... 26Azilect ..................................... 15Azithromycin .......................... 10Azopt .......................................20Azor ........................................12Azurette ..................................26
B
B-donna................................... 21Bacitracin .......................... 19, 20Bacitracin/Polymyxin ........ 19, 20Baclofen ...................................24Balziva .....................................26Baraclude ................................. 11Bayer Breeze2 Test Strips ........ 18Bayer Contour Test Strips ....... 18Belladonna Alkaloids/
Phenobarbital ....................... 21Benazepril ......................... 11, 12
30
Benazepril/ Hydrochlorothiazide ............12
Benicar ....................................12Benicar HCT ..........................12Benzaclin ................................. 16Benzamycin Pack .................... 16Benzocaine Otic ................ 10, 23Benzonatate ............................. 23Benztropine ............................. 15Betamethasone ........................ 16Betaseron ................................. 15Betaxolol ............................12, 20Bethanechol ............................. 25Bethkis .................................... 10Betimol ....................................20Betoptic-S ................................20Bexarotene ............................... 11Beyaz .......................................26Bicalutamide ............................ 11Biltricide .................................. 23Bisoprolol .................................12Bisoprolol/
Hydrochlorothiazide ............12Blephamide SOP .....................20Brand Prenatal Vitamins/
Folic Acid 1 mg .................... 28Breo Ellipta ............................. 25Briellyn ....................................26Brilinta .................................... 11Brimonidine ............................20Bromocriptine ......................... 15Budesonide ........................ 21, 25Budesonide Nebs ..................... 25Bumetanide .............................12Bunavail ................................... 23Bupap 50/650 mg ....................24Bupropion ................................ 14Bupropion SR .......................... 14Bupropion XL ......................... 14Buspirone................................. 15Butalbital/Acetaminophen ......24Butalbital/Acetaminophen/
Caffeine ................................24Butalbital/Acetaminophen/
Caffeine/Codeine .................24Butalbital/Aspirin/Caffeine .....24
Butalbital/Aspirin/Caffeine/Codeine ................................24
Bydureon ................................. 18Byetta ...................................... 18Bystolic ....................................12
C
Calcipotriene-Betamethasone .. 16Calcipotriene Ointment .......... 16Calcitonin Spray ......................24Calcitriol ............................ 16, 19Calcitriol Ointment ................. 16Calcium Acetate ...................... 21Cambia .................................... 15Camila .....................................26Canasa ..................................... 21Capecitabine ............................ 11Caprelsa ................................... 11Captopril .................................12Captopril/
Hydrochlorothiazide ............12Carafate ...................................20Carbamazepine IR/ER ........... 16Carbidopa/Levodopa IR/ER .. 15Carbinoxamine ........................26Carisoprodol ............................24Carteolol ..................................20Cartia XT ................................12Carvedilol ................................12Caziant ....................................26Cefaclor Suspension ................ 10Cefaclor Tablet ........................ 10Cefadroxil ................................ 10Cefdinir ................................... 10Cefpodoxime ........................... 10Cefprozil ................................. 10Cefuroxime .............................. 10Celecoxib .................................24Cenestin ..................................28Cephalexin .............................. 10Cerdelga .................................. 23Cerovel .................................... 16Cesia ........................................26Cetrotide ................................. 22Chateal ....................................26Chlordiazepoxide .............. 15, 21
Chlordiazepoxide/ Amitriptyline ....................... 15
Chlordiazepoxide/ Clidinium ............................. 21
Chloroquine ............................ 23Chlorothiazide .........................12Chloroxylenol/Hydrocortisone/
Pramoxine Otic .................... 10Chlorpromazine ...................... 15Chlorpropamide ...................... 18Chlorthalidone ........................12Cholestyramine ....................... 13Choline Fenofibrate Capsule ... 13Choline Magnesium
Trisalicylate ..........................24Cialis ....................................... 22Ciclodan .................................. 16Ciclopirox Cream, Gel,
Lotion, Solution ................... 16Cilostazol................................. 13Cimetidine...............................20Cimzia ..................................... 22Ciprofloxacin ..................... 10, 19Citalopram .............................. 14Citric Acid/Sodium Citrate ..... 23Claravis .................................... 16Clarithromycin IR/ER ............ 10Clemastine ...............................26Cleocin Vaginal
Suppository ........................... 10Climara Pro .............................28Clindamax Lotion ................... 16Clindamycin ...................... 10, 16Clindamycin Gel, Lotion,
Solution, Swabs .................... 16Clindareach Kit ....................... 17Clindesse ................................. 10Clobetasol, Clobetasol E ......... 17Clobex Lotion, Shampoo ........ 17Clobex Spray ........................... 17Cloderm .................................. 17Cloderm Pump ........................ 17Clomiphene ............................. 22Clomipramine ......................... 14Clonazepam,
Clonazepam ODT ............... 16Clonidine Tablet ......................12
31
Clopidogrel .............................. 11Clorazepate .............................. 15Clorpres ...................................12Clotrimazole Troche ............... 10Clozapine ................................ 15Codeine ............................. 23, 24Colcrys ....................................24Colestipol ................................ 13Combigan ................................20Combivent Respimat ............... 25Complera ................................. 21Compro Suppository ............... 15Condylox ................................. 23Copaxone ................................ 15Corlanor .................................. 13Cormax.................................... 17Cortisone ................................. 19Covaryx, Covaryx HS .............28Creon ....................................... 21Cresemba ................................. 10Crestor ..................................... 13Crixivan ................................... 21Cromolyn .......................... 19, 25Cromolyn Nebs ....................... 25Cryselle....................................26Cuprimine ............................... 22Cyclafem .................................26Cyclobenzaprine ......................24Cyclogyl ...................................20Cyclopentolate .........................20Cyclophosphamide .................. 11Cyclosporine, Cyclosporine
Modified ...............................26Cymbalta ................................. 14Cyproheptadine .......................26
D
Daklinza .................................. 11Danazol ................................... 23Dantrolene ...............................24Dapsone ................................... 10Daraprim ................................. 23Dasetta .................................... 27Deconsal-II ............................. 23Delzicol ................................... 21Demeclocycline ....................... 10Depen ...................................... 22
Dermazene .............................. 17Desipramine ............................ 14Desmopressin .......................... 19Desonide ................................. 17Desoximetasone ....................... 17Dexamethasone ................. 19, 20Dexchlorpheniramine ..............26Dexilant ...................................20Dextroamphetamine/
Amphetamine ....................... 14Dextroamphetamine/
Amphetamine Extended-Release ................. 14
Dextroamphetamine Sulfate Extended-Release ................. 14
Dextroamphetamine Sulfate Tablet.................................... 14
Diazepam .......................... 15, 16Diazepam Gel ......................... 16Diclofenac..........................20, 24Diclofenac Sodium ..................24Dicloxacillin ............................ 10Dicyclomine ............................ 21Didanosine .............................. 21Differin Cream, Lotion ........... 17Differin Gel ............................. 17Dificid ..................................... 21Difil-G Forte Liquid ............... 23Diflunisal .................................24Digex NF ................................ 21Digoxin ................................... 13Dilatrate SR ...................... 12, 13Diltiazem Sustained-Release
Capsule .................................12Diltiazem Tablet ......................12Diovan .....................................12Dipentum ................................ 21Diphenoxylate/Atropine .......... 21Disopyramide .................... 11, 13Disulfiram ............................... 23Divalproex ............................... 16Divalproex
Extended-Release ................. 16Divigel ..................................... 28Donepezil, Donepezil ODT ... 15Dorzolamide ............................20Dorzolamide/Timolol .............20
Doxazosin ..........................12, 22Doxepin ................................... 14Doxycycline Hyclate ................ 10Doxycycline Monohydrate
Tablet.................................... 10DrithoCreme HP .................... 17DrithoScalp ............................. 17Dronabinol ..............................20Drospirenone/
Ethinyl Estradiol .................. 27Duavee.....................................28Duloxetine 20, 30, 60 mg ........ 14Duraxin ...................................24Dutasteride .............................. 22Dutasteride-Tamsulosin........... 22Dutoprol ..................................12Dymista Spray .........................26
E
Easivent ................................... 23Econazole ................................ 17Edarbi ......................................12Edarbyclor ...............................12Edurant ................................... 21Effient ..................................... 11Elestrin ....................................28Elidel ....................................... 17Elinest ..................................... 27Eliquis ..................................... 11Ella .......................................... 27Elmiron ................................... 23Embeda ...................................24Emcyt ...................................... 11Emoquette ............................... 27Emtriva .................................... 21Enablex .................................... 25Enalapril ..................................12Enalapril/
Hydrochlorothiazide ............12Enjuvia ....................................28Enpresse .................................. 27Enskyce ................................... 27Entaone ................................... 15Entecavir ................................. 11Epiduo, Epiduo Forte .............. 17Epinastine ............................... 19Epipen-Jr ................................. 23
32
Epipen 2-Pak ........................... 23Epitol ....................................... 16Epivir HBV Solution ............... 11Epivir Solution ........................ 21Eprosartan ...............................12Epzicom .................................. 21Ergocalciferol 50,000 Unit
Capsule ................................. 23Ergoloid Mesylate ................... 15Erivedge .................................. 11Errin ........................................ 27Ery Pad .................................... 17Erythromycin ...............10, 17, 19Erythromycin/
Benzoyl Peroxide .................. 17Erythromycin/Sulfisoxazole .... 10Escitalopram ............................ 14Esgic Plus ................................24Estarylla .................................. 27Estradiol Tablet .......................28Estradiol Twice
Weekly Patch ....................... 28Estradiol Weekly Patch,
Tablet....................................28Estrogen/Methyltestosterone,
Estrogen/Methyltestosterone HS ........................................ 28
Estropipate .............................. 28Eszopiclone ............................. 16Ethambutol .............................. 10Ethosuximide .......................... 16Ethyl Chloride ......................... 17Etodolac IR/ER ......................24Etoposide ................................. 11Euflexxa ................................... 23Eurax ....................................... 17Evamist....................................28Evotaz ...................................... 21Exemestane ....................... 11, 23Exforge ....................................12Exforge HCT ..........................12Exoderm .................................. 17Extavia .................................... 15EZ Spacer ................................ 23Ezide .......................................12
F
Falmina ................................... 27Famciclovir .............................. 11Fareston ................................... 11FastClix Lancets ...................... 18Felodipine ................................12Fenofibrate 48, 145 mg Tablet .. 13Fenofibrate 54, 160 mg Tablet .. 13Fenofibrate Capsule ................. 13Fenofibrate Micronized ........... 13Fenoglide ................................. 13Fenoprofen ...............................24Fentanyl Patch 12, 25,
50, 75, 100 mcg ....................24Finacea .................................... 17Finacea Plus............................. 17Finasteride ............................... 22Flecainide ................................ 13Flector Patch ...........................24Flovent Diskus ........................ 25Flovent HFA ........................... 25Fluconazole ............................. 10Fludrocortisone ....................... 19Flunisolide ...............................26Fluocinolone ............................ 17Fluocinonide,
Fluocinonide E ..................... 17Fluoride Chewable Tablet,
Drops ....................................26Fluorometholone .....................20Fluorouracil 0.5% Cream ........ 17Fluorouracil Solution,
5% Cream ............................. 17Fluoxetine ................................ 14Fluphenazine ........................... 15Flurazepam .............................. 16Flurbiprofen .......................20, 24Flutamide ................................ 11Fluticasone .........................17, 26Fluticasone Propionate ............26Fluvoxamine ............................ 14FML Forte ..............................20Folic Acid 1 mg .................26, 28Follistim AQ ........................... 22Foradil ..................................... 25Forfivo XL ............................... 14
Forteo ......................................24Fortesta .................................... 22Fortical ....................................24Fortigan ...................................24Fosinopril ................................12Fosinopril/
Hydrochlorothiazide ............12Fosrenol ................................... 23Freestyle Test Strips ................ 18Furosemide ..............................12Fuzeon ..................................... 21
G
Gabapentin .............................. 16Galantamine IR/ER ............... 15Gavilyte ................................... 21Gelnique 10% .......................... 25Gemfibrozil ............................. 13Generic Prenatal Vitamins/
Folic Acid 1 mg .................... 28Gengraf ...................................26Gentamicin .........................17, 19Genvoya................................... 21Gianvi ...................................... 27Gildagia ................................... 27Gildess, Gildess Fe .................. 27Gilenya .................................... 15Glimepiride ....................... 18, 19Glipizide/Metformin............... 18Glipizide IR/XL ..................... 18Glucagen ................................. 18Glucagon ................................. 18Glucocard Test Strips .............. 18Glumetza ................................. 18Glyburide ................................ 18Glyburide/Metformin ............. 18Glyxambi ................................. 18Gonal-F ................................... 22Gonal-F Rff ............................ 22Gralise .....................................24Granix ..................................... 23Griseofulvin ............................ 10Guaifenesin/Codeine .............. 23Guanfacine ........................ 12, 14Guanfacine ER ........................ 14Guanidine ............................... 23
33
H
Halflytely ................................. 21Haloperidol ............................. 15Harvoni ................................... 11Heather ................................... 27Hexalen ................................... 11Homatropine .....................20, 23Humalog KwikPen 100u/ml ... 18Humalog Mix 75-25
KwikPen ............................... 18Humalog Vial .......................... 18Humibid DM .......................... 23Humira .................................... 22Humulin 70-30 Vial ................ 18Humulin KwikPen .................. 18Humulin N KwikPen .............. 18Humulin N Vial ...................... 18Humulin R U-500 Vial ........... 18Hydralazine .............................12Hydrochlorothiazide .......... 11-13Hydrocodone/
Acetaminophen ....................24Hydrocodone/Homatropine .... 23Hydrocodone/Ibuprofen ..........24Hydrocortisone ..10, 17, 19, 20, 23Hydrocortisone/
Acetic Acid Otic .................. 23Hydrocortisone
Pramoxine ...................... 10, 23Hydrocortisone Suppository .... 23Hydrocortisone Tablet ............. 19Hydromorphone IR/ER ..........24Hydroxychloroquine Sulfate .... 22Hydroxyurea ............................ 11Hydroxyzine ...................... 15, 26Hyoscyamine ........................... 21Hypercare ................................ 17Hypersal Nebs ......................... 23
I
Ibandronate .............................24Ibuprofen .................................24Ilotycin .................................... 19Imatinib ................................... 11Imipramine .............................. 14Imiquimod ............................... 17
Implanon ................................. 27Incruse Ellipta ......................... 25Indapamide ..............................12Indocin Suppository ................24Indomethacin IR/ER ..............24Inspirease ................................. 23Intelence .................................. 21Introvale .................................. 27Intuniv ..................................... 14Invirase .................................... 21Invokamet ................................ 18Invokana .................................. 18Ipratropium ....................... 25, 26Ipratropium/Albuterol Nebs .... 25Irbesartan ................................12Irbesartan/
Hydrochlorothiazide ............12Isentress ................................... 21Iso Carbachol ..........................20Iso Homatropine .....................20Isochron ................................... 13Isoditrate ER ........................... 13Isometheptene/Acetaminophen/
Dichloralphenazone ............. 15Isoniazid .................................. 10Isordil ...................................... 13Isosorbide Dinitrate IR/ER .... 13Isosorbide Mononitrate
IR/ER .................................. 13Isoxsuprine .............................. 14Isradipine .................................12Istalol .......................................20Itraconazole ............................. 10
J
Jantoven ................................... 11Janumet ................................... 19Janumet XR ............................. 19Januvia ..................................... 19Jardiance .................................. 19Jencycla .................................... 27Jentadueto ................................ 19Jinteli ....................................... 28Jolessa ...................................... 27Jolivette .................................... 27Junel......................................... 27Junel Fe .................................... 27
Juvisync ................................... 19
K
Kaletra ..................................... 21Kariva ...................................... 27Kelnor ...................................... 27Ketoconazole Cream,
Shampoo .............................. 10Ketoprofen IR/ER ..................24Ketorolac ...........................20, 24Klor-Con 10 ............................26Klor-Con M10 ........................26Klor-Con M20 ........................26Kombiglyze XR ....................... 19Kurvelo .................................... 27Kuvan ...................................... 23
L
Labetalol ..................................12Laclotion ................................. 17Lactulose ................................. 21Lamictal Chewable, Tablet ...... 16Lamictal Starter Kit ................ 16Lamictal XR ............................ 16Lamivudine ....................... 11, 21Lamivudine/Zidovudine ......... 21Lamotrigine Chewable,
Tablet.................................... 16Lamotrigine ER ...................... 16Lamotrigine ODT .................. 16Lansoprazole ...........................20Lantus Solostar ........................ 18Lantus Vial .............................. 18Larin, Larin FE ...................... 27Lastacaft .................................. 19Latanoprost .............................20Latuda ..................................... 15Lazanda ...................................24Leena ....................................... 27Leflunomide ............................ 22Lessina..................................... 27Letairis ....................................26Letrozole ........................... 11, 23Leucovorin Calcium ................ 11Leukeran ................................. 11Levemir Flexpen ..................... 18Levemir Vial ........................... 18
34
Levetiracetam ER ................... 16Levetiracetam IR ..................... 16Levobunolol .............................20Levofloxacin ............................ 10Levonest .................................. 27Levonorgestrel ......................... 27Levonorgestrel/Ethinyl
Estradiol ............................... 27Levora-28 ................................ 27Levorphanol ............................ 25Levothyroxine Sodium ............ 19Levoxyl .................................... 19Lexiva ...................................... 21Lialda ...................................... 21Lidocaine ............................17, 23Lidocaine/Prilocaine ............... 17Lidocaine Patch ....................... 23Lidocaine Viscous ................... 23Lidoderm Patch ....................... 23Lindane ................................... 17Linezolid Tablet ...................... 10Linzess .................................... 21Liothyronine Sodium .............. 19Lipofen .................................... 13Lisinopril ........................... 12, 39Lisinopril/
Hydrochlorothiazide ............12Lithium IR/ER ....................... 15Livalo ...................................... 13Lo Loestrin ............................. 27Loestrin ................................... 27Lokara ..................................... 17Lomustine ............................... 11Lorazepam .............................. 15Loryna ..................................... 27Losartan ..................................12Losartan/
Hydrochlorothiazide ............12Lovastatin ................................ 13Lovaza ..................................... 13Low-Ogestrel .......................... 27Loxapine .................................. 15Lumigan ..................................20Lupron Depot .......................... 19Lutera ...................................... 27Lyrica Capsule ......................... 16Lyrica Solution ........................ 16
Lysodren .................................. 11Lyza ......................................... 27
M
Makena ...................................28Maprotiline ............................. 14Marlissa ................................... 27Matulane ................................. 11Mebendazole ........................... 23Meclofenamate ........................ 25Medrol 2 mg ............................ 19Medroxyprogesterone ........ 27, 28Medroxyprogesterone
Acetate Injection .................. 27Mefloquine .............................. 23Megestrol AC .......................... 23Meloxicam ............................... 25Menest ..................................... 28Meperidine .............................. 25Mephyton ................................ 23Meprobamate .......................... 15Mercaptopurine ....................... 11Mesalamine Enema ................. 21Mestinon Syrup ....................... 23Metadate ER ........................... 14Metformin ......................... 18, 19Metformin Extended-Release .. 19Methadone .............................. 25Methazolamide .......................12Methenamine .......................... 10Methimazole ........................... 19Methocarbamol .......................24Methotrexate ........................... 22Methyclothia ...........................12Methyldopa .............................12Methyldopa/
Hydrochlorothiazide ............12Methylergonovine .................... 19Methylphenidate Controlled-
Release Tablet ....................... 14Methylphenidate Tablet ........... 14Methylprednisolone ................. 19Metipranolol ............................20Metoclopramide Solution,
Tablet.................................... 21Metolazone ..............................12Metoprolol Succinate ER ........12
Metoprolol Tartrate .................12Metrogel 1% ............................ 17Metronidazole 0.75% Cream,
Lotion ................................... 17Metronidazole Tablet .............. 10Metronidazole Vaginal Gel ..... 11Mexiletine ............................... 14Micardis HCT ........................12Microgestin ............................. 27Microgestin FE ....................... 27Midodrine ............................... 14Migragesic ............................... 15Migranal .................................. 15Millipred Tablet ...................... 19Mimvey ...................................28Minivelle ................................. 28Minocycline............................. 10Minoxidil ................................12Mirtazapine,
Mirtazapine ODT ................ 14Mirvaso ................................... 17Misoprostol .............................20Moexipril .................................12Moexipril/
Hydrochlorothiazide ............12Mometasone Furoate ............... 17Mono-Linyah .......................... 27Mononessa ............................... 27Montelukast ............................ 25Morphine Sulfate Beads
Sustained-Release ................. 25Morphine Sulfate
Controlled-Release Tablet .... 25Morphine Sulfate Immediate-
Release Tablet, Solution ....... 25Morphine Sulfate
Sustained-Release Capsule ... 25Movantik ................................. 21Moxeza .................................... 19Multigen Folic ......................... 23Multigen Plus .......................... 23Mupirocin Calcium Cream ..... 17Mupirocin Ointment ............... 17Mycobutin ............................... 10Myleran ................................... 11Myorisan ................................. 17Myrbetriq ................................ 25
35
Myzilra .................................... 27
N
Nabumetone ............................ 25Nadolol ....................................12Nalfon 200 mg Capsule........... 25Naltrexone ............................... 23Namenda XR........................... 15Namzaric ................................. 15Naphazoline 0.1% .................... 19Naproxen ................................. 25Nasonex ...................................26Natacyn ................................... 19Natazia .................................... 27Nateglinide .............................. 19NebuPent Nebs ....................... 10Necon 0.5/35, 1/35,
1/50, 10/11 ........................... 27Nefazodone ............................. 14Neomycin .....................10, 19, 20Neomycin/Bacitracin/
Polymyxin ...................... 19, 20Neomycin/Bacitracin/
Polymyxin/Hydrocortisone ..20Neomycin/Polymixin/
Dexamethasone ....................20Neomycin/Polymixin/
Gramicidin ........................... 19Neomycin/Polymixin/
Hydrocortisone Otic ............ 10Nessi Spacer ............................ 23Neupogen ................................ 23Nevirapine ............................... 21Niacin ER ............................... 13Niaspan ................................... 13Nicardipine ..............................12Nifediac CC ............................12Nifedical XL ........................... 13Nifedipine IR/ER ................... 13Nikki ....................................... 27Nilandrone .............................. 11NitroBid .................................. 14NitroDur Patch ....................... 14Nitrofurantoin ......................... 10Nitrofurantoin
Macrocrystal ......................... 10Nitroglycerin ER ..................... 14
Nitrolingual Pump Spray ........ 14Nitrostat .................................. 14NitroTime ................................ 14Nizatidine ................................20Nodolor ................................... 15Nora-BE .................................. 27Norditropin ............................. 19Norethindrone ................... 27, 28Norethindrone/
Ethinyl Estradiol ..................28Norgestimate-Ethinyl
Estradiol ............................... 27Norgestrel/Ethinyl
Estradiol ............................... 27Norpace CR............................. 14Nortrel ..................................... 27Nortriptyline ........................... 14Norvir ...................................... 21Novofine Autocover
Pen Needles .......................... 18Novofine Pen Needles ............. 18Novofine Plus Pen Needles ..... 18Novolin N Vial ........................ 18Novolin R Vial ........................ 18Novolin Vial ............................ 18Novolog Flexpen ..................... 18Novolog Mix ........................... 18Novolog Vial ........................... 18Novotwist Pen Needles ........... 18Nucynta ................................... 25Nucynta ER ............................. 25Nutropin Aq NuSpin .............. 19Nuvaring ................................. 27Nuvigil .................................... 15Nystatin ..............................11, 17Nystop ..................................... 17
O
Ocella ...................................... 27Ofloxacin ........................... 10, 19Ofloxacin Otic ......................... 10Ogestrel ................................... 27Olanzapine,
Olanzapine ODT ................. 15Olysio ...................................... 11Omeclamox-Pak ......................20
Omega-3-Acid Ethyl Esters Capsule ................................. 13
Omeprazole .............................20Omnaris ..................................26Ondansetron ............................20Ondansetron ODT .................20OneTouch Test Strips .............. 18OneTouch Ultra Blue
Test Strips ............................ 18OneTouch Verio IQ
Test Strips ............................ 18Onglyza ................................... 19Opana ER ............................... 25Opsumit ..................................26Optihaler ................................. 23Oracea ..................................... 10Orbivan ................................... 25Orencia .................................... 22Orenitram ................................26Orphenadrine/Aspirin/
Caffeine ................................24Orphenadrine ER ....................24Orsythia .................................. 27Ortho Coil .............................. 27Ortho Flat ............................... 27Ortho Flex ............................... 27OrthoEst ................................. 28Osphena .................................. 28Ovidrel .................................... 22Oxaprozin ................................ 25Oxazepam ............................... 15Oxcarbazepine ......................... 16Oxybutynin ............................. 25Oxybutynin
Extended-Release ................. 25Oxycodone/Acetaminophen .... 25Oxycodone IR ......................... 25Oxycontin ................................ 25Oxymorphone ......................... 25Oxytrol .................................... 25
P
Pacerone .................................. 14Pancrelipase ............................. 21Pantoprazole ............................20Paregoric Tincture ................... 21Paricalcitol ............................... 19
36
Paromomycin ........................... 10Paroxetine ................................ 14Paroxetine ER ......................... 14Pataday .................................... 19Paxil Suspension ...................... 14Pegasys .................................... 11Penicillin VK ........................... 10Pentasa ..................................... 21Pentazocine/Acetaminophen ... 25Pentazocine/Naloxone ............. 25Pentoxifylline .......................... 14Perforomist .............................. 25Perindopril ............................... 13Permethrin .............................. 17Perphenazine/Amitriptyline .... 15Phenazopyridine ...................... 23Phenelzine ............................... 14Phenobarbital .................... 16, 21Phenoxybenzamine ................. 13Phenylephrine .......................... 19Phenyltoloxamine/
Acetaminophen .................... 25Phenytoin ................................ 16Philith ..................................... 27Phospholine .............................20Phrenilin Forte ........................ 15Picato ....................................... 17Pilocarpine .............................. 23Pimtrea .................................... 27Pindolol ................................... 13Pioglitazone ............................. 19Pioglitazone/Glimepiride ........ 19Pioglitazone/Metformin .......... 19Piroxicam ................................ 25Plegridy ................................... 15Podofilox ................................. 17Polyethylene Glycol 3350 ........ 21Polymyxin B/Trimethoprim .... 19Portia ....................................... 27Potassium Chloride .................26Potassium Citrate ....................26Pradaxa .................................... 11Praluent ................................... 13Pramcort .................................. 17Pramipexole ............................. 15Pramosone Cream, Ointment . 17Pramosone E Cream ............... 17
Pramosone Lotion ................... 17Pramoxine-HC Otic ............... 10Pravastatin ............................... 13Prazosin ................................... 13Pred Mild ................................20Prednisolone Solution,
Tablet.............................. 19, 20Prednisone ............................... 19Premarin ..................................28Premarin Vaginal Cream .........28Premphase ...............................28Prempro ...................................28Prepopik .................................. 21Prevalite ................................... 13Previfem .................................. 27Prezcobix ................................. 21Prezista .................................... 21Primaquine .............................. 23Primella ................................... 27Pristiq ...................................... 14Proair HFA ............................. 25Proair Respiclick ..................... 25Probenecid ...............................24Prochlorperazine ..................... 15Procrit ...................................... 23Proctocream HC ..................... 23Proctofoam HC ....................... 23Proctosol HC........................... 23Proctozone HC ....................... 23Proglycem ................................ 23Promethazine .............. 21, 23, 26Promethazine/Codeine ............ 23Promethazine/
Dextromethorphan ............... 23Promethazine VC/Codeine ..... 23Propafenone ............................. 14Propantheline .......................... 21Proparacaine ............................20Propranolol/
Hydrochlorothiazide ............ 13Propranolol IR/ER .................. 13Propylthiouracil ....................... 19Protopic ................................... 17Protriptyline ............................ 14Pulmicort Flexhaler ................. 25Pulmicort Respules ................. 25Pylera .......................................20
Pyrazinamide........................... 10Pyridostigmine ........................ 23
Q
QNasl ......................................26Quasense ................................. 27Quetiapine ............................... 15Quinapril ................................. 13Quinidine IR/ER .................... 14QVAR ..................................... 25
R
Raloxifene................................24Ramipril .................................. 13Ranexa ..................................... 14Ranitidine ................................20Rapaflo .................................... 22Rebif, Rebif Rebidose .............. 15Reclipsen ................................. 27Rectiv ...................................... 23Relion Test Strips .................... 18Remicade ................................. 22Renvela .............................. 21, 23Renvela Packet ........................ 21Renvela Tablet ......................... 21Repaglinide ............................. 19Rescriptor ................................ 21Reserpine ................................. 13Restasis ....................................20Retin-A Micro Gel, Pump ...... 17Retrovir ................................... 21Reyataz .................................... 21Rezira ...................................... 23Rheumatrex ............................. 22Ribavirin Tablet ....................... 11Rifampin ................................. 10Rimantidine ............................ 11Risperidone,
Risperidone ODT ................ 15Rivastigmine ........................... 15Rizatriptan .............................. 15Ropinirole ................................ 15Rosadan Cream ....................... 17Rowasa Enema ........................ 21
S
Safyral ..................................... 27
37
Saizen ...................................... 19Salsalate ................................... 25Saphris ..................................... 15Savaysa .................................... 11Sedapap ................................... 25Selenium Sulfide ..................... 17Selzentry .................................. 21Serevent ...................................26Seroquel XR ............................ 15Sertraline ................................. 14Sevelamer ................................ 21Sharobel ................................... 27Sildenafil Tablet 20 mg ...........26Silenor ..................................... 16Silver Nitrate ........................... 17Silver Sulfadiazine ................... 17Simcor ..................................... 13Simponi ................................... 22Simvastatin 5, 10, 20, 40 mg .... 13Simvastatin 80 mg ................... 13Sodium Polystyrene Sulfonate
Powder .................................. 23Soft Touch Lancets ................. 18SoftClix Lancets...................... 18Solia ......................................... 27Solodyn.................................... 10Soriatane .................................. 23Sotalol ............................... 13, 14Sotalol AF ............................... 13Sovaldi ..................................... 11Spiriva HandiHaler,
Respimat ..............................26Spironolactone ......................... 13Spironolactone/
Hydrochlorothiazide ............ 13Sprintec ................................... 27Sronyx ..................................... 27SSKI ........................................ 23Stavudine ................................. 21Stelara ...................................... 22Stendra .................................... 22Stiolto Respimat ......................26Strattera ................................... 14Stribild ..................................... 21Striverdi Respimat ................... 26Suboxone Film ........................ 15Suboxone Tablet ...................... 15
Sucralfate Tablet ......................20Sulfacetamide Sodium ..17, 19, 20Sulfacetamide
Sodium-Sulfur ..................... 17Sulfacetamide Sodium/
Prednisolone .........................20Sulfadiazine ....................... 10, 17Sulfamethoxazole/Trimethoprim,
Sulfamethoxazole/Trimethoprim DS ................ 10
Sulfasalazine ............................ 21Sulindac ................................... 25Sumatriptan Nasal Spray,
Tablet.................................... 15Sumavel DosePro .................... 15Suprep ..................................... 21Sustiva ..................................... 21Syeda ....................................... 27Symbicort ................................26Symlin ..................................... 19Synarel ..................................... 23Synjardy ................................... 19Synvisc ..................................... 23Synvisc One ............................. 23
T
Tabloid ..................................... 11Taclonex Ointment .................. 17Taclonex Scalp ......................... 17Tacrolimus ..........................17, 26Tacrolimus Ointment .............. 17Tamoxifen ............................... 23Tamsulosin .............................. 22Tarina FE ................................ 27Tasigna .................................... 11Tazorac .................................... 17Taztia XT ................................ 13Tecfidera .................................. 15Tekturna .................................. 13Tekturna HCT ........................ 13Telmisartan ............................. 13Temazepam ............................. 16Temozolomide ......................... 11Terazosin ........................... 13, 22Terbinafine .............................. 11Terbutaline ..............................26Terconazole.............................. 11
Testim...................................... 22Testosterone Gel 1% ................ 22Testred ..................................... 22Tetracaine ................................20Tetracycline ............................. 10Tev-Tropin ............................... 19Theophylline SR .....................26Thioridazine ............................ 15Thiothixene ............................. 15Ticlopidine .............................. 11Timolol .............................. 13, 20Timolol Maleate ......................20Timoptic Ocudose ...................20Tirosint .................................... 19Tivicay ..................................... 22Tivorbex .................................. 25Tizanidine Tablet ....................24Tobi ......................................... 10Tobradex Ointment ................. 19Tobramycin/
Dexamethasone .................... 19Tobramycin Ophth Solution....20Tobrex......................................20Tolazamide .............................. 19Tolbutamide ............................ 19Tolmetin .................................. 25Topiragen ................................ 16Topiramate .............................. 16Torsemide ................................ 13Toviaz ...................................... 25Tracleer ....................................26Tradjenta ................................. 19Tramadol ................................. 25Trandolapril/Verapamil CR .... 13Tranylcypromine ..................... 14Travatan Z ...............................20Trazodone ................................ 14Tretin-X ................................... 17Tretinoin .............................11, 17Tretinoin Capsule .................... 11Trexall ..................................... 22Tri-Estarylla ............................ 27Tri-Linyah ............................... 27Tri-Previfem ............................ 27Tri-Sprintec ............................. 27Triamcinolone/Orabase ........... 23Triamcinolone Acetonide ........ 17
38
Triamterene/ Hydrochlorothiazide ............ 13
Trianex .................................... 17Triazolam ................................ 16Tribenzor ................................. 13Triderm ................................... 17Trifluoperazine ........................ 16Trifluridine ..............................20Trihexyphenidyl ...................... 16Trilyte ...................................... 21Trimethobenzamide ................ 21Trimethoprim .................... 10, 19Trinessa ................................... 27Trinessa Lo .............................. 27Triumeq ................................... 22Trivora-28 ................................ 27Trizivir..................................... 22Tropicamide.............................20Trulicity ................................... 19Truvada ................................... 22Tudorza ...................................26Tykerb...................................... 11
U
Uceris....................................... 21Uloric .......................................24Unithroid ................................. 19Urea 40% Lotion ..................... 17Ursodiol ................................... 21
V
Vagifem ................................... 28Valacyclovir ............................. 11Valcyte Solution....................... 11Valganciclovir Tablet ............... 11Valproic Acid ........................... 16Valsartan .................................. 13Valsartan/
Hydrochlorothiazide ............ 13Valturna ................................... 13Vandazole Gel ......................... 11Vascepa .................................... 13Vectical .................................... 17Velivet ...................................... 27Velphoro .................................. 23Venlafaxine ........................ 14, 15
Venlafaxine Extended-Release Capsule ................................. 14
Venlafaxine Extended-Release Tablet.................................... 15
Ventolin HFA ..........................26Veramyst ..................................26Verapamil Sustained-Release
Capsule ................................. 13Verapamil Sustained-Release
Tablet.................................... 13Verapamil Tablet ..................... 13Vesicare .................................... 25Vestura..................................... 27Victoza .................................... 19Videx Solution ......................... 22Viekira Pak .............................. 11Vigamox ..................................20Viibryd .................................... 15Vimovo .................................... 25Viorele ..................................... 27Viracept ................................... 22Viread ...................................... 22Vitamin D 50,000 Unit ........... 23Vitazol ..................................... 17Vitekta ..................................... 22Vivelle-Dot .............................. 28Voltaren Gel ...................... 18, 25Vortex ...................................... 23Vyfemla ................................... 27Vytorin .................................... 13Vyvanse ................................... 14
W
Warfarin .................................. 11WatchHaler ............................. 23Welchol ................................... 13Wera ........................................28Wide-Seal ...............................28
X
Xarelto ..................................... 11Xeloda ..................................... 11Xopenex HFA ......................... 26Xulane .....................................28Xyrem ...................................... 16
Y
Yasmin 28 ................................28Yaz ...........................................28Yodoxin ................................... 23
Z
Zaleplon .................................. 16Zarah ....................................... 28Zecuity .................................... 15Zegerid ....................................20Zelapar .................................... 16Zemplar ............................. 19, 23Zenatane .................................. 18Zenchent .................................28Zenpep .................................... 21Zetonna ...................................26Ziagen ..................................... 22Zidovudine ........................ 21, 22Ziprasidone .............................. 16Zmax ....................................... 10Zohydro ER ............................ 25Zolmitriptan ............................ 15Zolpidem ................................. 16Zomig Spray ............................ 15Zonisamide.............................. 16Zorvolex .................................. 25Zovia .......................................28Zovirax Cream ........................ 11Zovirax Ointment ................... 11Zubsolv .................................... 16Zutripro ................................... 23Zyclara Cream, Pump ............. 18Zytiga ...................................... 11
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“My Medications” worksheetTake this worksheet with you each time you visit a doctor. Each of your doctors should be aware of every drug you take and you should have a list as well.
Name of Medicineand Strength
CoverageLevel
I Take ThisMedicine For
Directions Doctor
Example: Lisinopril, 20 mgFormulary Generic
High blood pressure One tablet daily Dr . Johnson
For more information
Call the toll-free member phone number on your health plan ID card.
Or, visit myuhc.com or optumrx.com
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© 2016 United HealthCare Services, Inc . All rights reserved . Created February, 2016 . 2016 Formulary SignatureValue Three-Tier104-0102 7/16