your 2017 formulary · 2017-07-03 · used generic drugs. some low-cost brands may be included. use...

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

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

Visit your plan’s member website listed on your ID card.• Locate a participating retail pharmacy by zip code.• Look up possible lower-cost medication alternatives.• Compare medication pricing and options.

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

Your 2017 Formulary

OptumRx 1

Effective July 1, 2017

Select Standard

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Your Formulary

This Formulary outlines the most commonly prescribed medications from your plan’s complete pharmacy benefit coverage list, also known as a Prescription Drug List (PDL). A formulary identifies the drugs available for certain conditions and organizes them into cost levels, also known as tiers. 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 your plan’s member website for complete and up-to-date drug information

Since the Formulary may change, we encourage you to visit our website, your plan’s member website, which should be listed on your ID card. This website is the best source for up-to-date information about all of the medications your pharmacy benefit covers, possible lower-cost options and cost comparisons.

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Table of Contents

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

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

Anti-InfectivesAntibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Cardiovascular/Heart DiseaseAnticoagulants. . . . . . . . . . . . . . . . . . . . . . . . . 8High Blood Pressure . . . . . . . . . . . . . . . . . . . . . 8High Cholesterol . . . . . . . . . . . . . . . . . . . . . . . 9Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Pulmonary Arterial Hypertension . . . . . . . . . . 10

Central Nervous SystemAttention Deficit Disorder . . . . . . . . . . . . . . . 10Depression. . . . . . . . . . . . . . . . . . . . . . . . . . . 10Migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . 10Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Sedatives/Hypnotics . . . . . . . . . . . . . . . . . . . . 11Seizure Disorders . . . . . . . . . . . . . . . . . . . . . . 11

Dermatology . . . . . . . . . . . . . . . . . . . . . . . . 11

Diabetes/EndocrineBlood Glucose Monitoring . . . . . . . . . . . . . . . 12Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Non-Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . 13

EndocrineGrowth Hormone . . . . . . . . . . . . . . . . . . . . . 13Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Thyroid Hormone Replacement . . . . . . . . . . . 13

Eye ConditionsAllergies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

GastrointestinalAcid Suppression . . . . . . . . . . . . . . . . . . . . . . 14Nausea/Vomiting . . . . . . . . . . . . . . . . . . . . . . 14Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Inflammatory Conditions . . . . . . . . . . . . . . 15

Men’s HealthErectile Dysfunction . . . . . . . . . . . . . . . . . . . . 15Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Testosterone Therapy . . . . . . . . . . . . . . . . . . . 15

Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . 15

MusculoskeletalOsteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . 16 Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Pain Relief . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Overactive Bladder . . . . . . . . . . . . . . . . . . . 16

RespiratoryAsthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . 17Nasal Allergies . . . . . . . . . . . . . . . . . . . . . . . . 17Oral Allergies . . . . . . . . . . . . . . . . . . . . . . . . . 17

Transplant . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Vitamins/Electrolytes . . . . . . . . . . . . . . . . . 17

Women’s HealthBirth Control . . . . . . . . . . . . . . . . . . . . . . . . . 17Hormone Replacement . . . . . . . . . . . . . . . . . 18Vaginal Anti-Infectives . . . . . . . . . . . . . . . . . . 18

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

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

What is a Formulary?

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

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

How do I use my Formulary?

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

If your medication is not listed in this document, please visit your plan’s member website or call the toll-free member phone number on your ID card.

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What are tiers?

Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, which is determined by your employer or plan sponsor. This is how much you will pay when you fill a prescription. Tier 1 medications are your lowest-cost options. If your medication is placed in Tier 2 or 3, look to see if there is a Tier 1 option available. Discuss these options with your doctor.

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

$ Drug Tier Includes Helpful Tips

Tier 1 Lowest Cost

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

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

Tier 2 Mid-range Cost

Many common brand-name drugs, called preferred brands.

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

Tier 3 Highest Cost

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

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

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

When does the Formulary change?

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

on January 1 or July 1 of each year.

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

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

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Why are some medications excluded from coverage?

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

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

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

Should I talk to my doctor about OTC medications?

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

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

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

Is it a generic or brand-name drug?

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

What if my doctor writes a brand-name prescription?

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

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Are you taking a specialty medication?

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

BriovaRx, the OptumRx specialty pharmacy, can provide most of your specialty medications along with helpful programs and services. Call BriovaRx and have your prescriptions delivered right to your home or office.

How do I get updated information about my pharmacy benefit?

Since the Formulary may change during your plan year, we encourage you to visit your plan’s member website or call the toll-free member phone number on your ID card for more current information.

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

• Look up the price of drugs covered by your plan

• Find lower-cost options

• Refill and renew home delivery prescriptions

• View your order status and claims history

• View your benefits in real time

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

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

Drug NameDrug Tier

Anti-Infectives: Antibiotics

Amoxicillin 1Amoxicillin/Clavulanate 1Azasite 3Azithromycin 1Bethkis 2Cefadroxil Cap 1Cefdinir 1Cefuroxime Tab 1Cephalexin 1Ciprodex Otic Suspension 2Ciprofloxacin Tab 1Clarithromycin 1Clindamycin Cap 1Doryx MPC 3Doxycycline Hyclate Cap 1Doxycycline Hyclate Tab (Immediate

Release)1

Doxycycline Monohydrate Cap 1Doxycycline Monohydrate Oral

Suspension, Tab1

Erythromycin 1Levofloxacin Tab 1Metronidazole Tab 1Minocycline Cap 1Moxifloxacin 1Neomycin/Polymyxin/HC Otic

Suspension, Solution1

Nitrofurantoin Macrocrystalline 1Nitrofurantoin Monohydrate

Macrocrystalline1

Ofloxacin Otic Solution 1Oracea 3Penicillin VK 1Solodyn 3Sulfamethoxazole-Trimethoprim 1Sulfamethoxazole-Trimethoprim DS 1

Anti-Infectives: Antifungals

Fluconazole 1Jublia Solution 3Kerydin Solution 3

Drug NameDrug Tier

Nystatin Suspension 1Terbinafine Tab 1

Anti-Infectives: Antivirals

Acyclovir Cap, Tab, Suspension 1Daklinza 3Entecavir 1Epclusa 2Famciclovir Tab 1Harvoni 2Sovaldi 2Tamiflu 3Valacyclovir 1Zepatier 2

CancerAkynzeo 3Anastrozole Tab 1Capecitabine 1Letrozole 1Revlimid 3Sprycel 2Tamoxifen Tab 1Tasigna 3Temozolomide 1Zytiga 3Cardiovascular/Heart Disease: AnticoagulantsBrilinta 2Clopidogrel 1Effient 2Eliquis 3Enoxaparin 1Pradaxa 2Savaysa 3Warfarin 1Xarelto 2Cardiovascular/Heart Disease: High Blood PressureAmlodipine 1Amlodipine/Benazepril 1Amlodipine/Valsartan 1Amlodipine/Valsartan/HCTZ 1Atenolol 1Atenolol/Chlorthalidone 1

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Drug NameDrug Tier

Azor 3Benazepril 1Benazepril/HCTZ 1Benicar 3Benicar HCT 3Bisoprolol 1Bisoprolol/HCTZ 1Bumetanide 1Bystolic 2Cartia XT 1Carvedilol 1Chlorthalidone 1Clonidine Patch 1Clonidine Tab 1Diltiazem Tab 1Doxazosin 1Edarbi 3Edarbyclor 3Enalapril 1Enalapril/HCTZ 1Felodipine 1Fosinopril 1Furosemide 1Guanfacine Tab (Immediate Release) 1Hydralazine 1Hydrochlorothiazide 1Irbesartan 1Irbesartan/HCTZ 1Labetalol 1Lisinopril 1Lisinopril/HCTZ 1Losartan 1Losartan/HCTZ 1Metoprolol Succinate 1Metoprolol Tartrate 1Nadolol 1Nifedipine ER 1Propranolol 1Propranolol ER 1Quinapril 1Ramipril 1Spironolactone 1Tekturna 2Tekturna HCT 2

Drug NameDrug Tier

Telmisartan 1Terazosin 1Torsemide Tab 1Triamterene/HCTZ 1Tribenzor 3Valsartan 1Valsartan/HCTZ 1Verapamil ER 1Cardiovascular/Heart Disease: High CholesterolAtorvastatin 1Cholestyramine 1Crestor 3Fenofibrate 40 mg, 43 mg, 48 mg,

50 mg, 54 mg, 67 mg, 120 mg, 130 mg, 134 mg, 145 mg, 150 mg, 160 mg, 200 mg

1

Gemfibrozil 1Lipitor 3Lovastatin 1Lovaza 3Niacin ER Tab 1Omega-3 Acid Cap 1 gm 1Praluent 2Pravastatin 1Rosuvastatin 1Simvastatin 5 mg, 10 mg, 20 mg,

40 mg1

Simvastatin 80 mg 1Vascepa 2Vytorin 10-10 mg, 10-20 mg,

10-40 mg2

Vytorin 10-80 mg 2Welchol 2Zetia 3

Cardiovascular/Heart Disease: Other

Amiodarone 1Amlodipine/Atorvastatin 1Corlanor 3Digoxin 1Flecainide 1Isosorbide Mononitrate 1Multaq 3

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Drug NameDrug Tier

Nitrostat 3Ranexa 2Sotalol 1Cardiovascular/Heart Disease: Pulmonary Arterial HypertensionAdcirca 3Adempas 2Letairis 2Opsumit 2Orenitram 3Sildenafil Tab 20 mg 1Tracleer 2Central Nervous System: Attention Deficit DisorderAdderall XR Cap 3Amphetamine-

Dextroamphetamine Tab 1

Amphetamine-Dextroamphetamine SR 24Hr Cap

1

Dexmethylphenidate ER Cap 1Evekeo 3Guanfacine ER Tab 1Methylphenidate ER Cap 1Methylphenidate ER Tab 1Methylphenidate SA Osmotic ER Tab 1Methylphenidate Tab 1Strattera 2Vyvanse 2

Central Nervous System: Depression

Amitriptyline 1Bupropion 1Bupropion ER 1Bupropion SR 1Bupropion XL 1Doxepin 1Duloxetine Cap 20 mg, 30 mg,

60 mg1

Escitalopram Tab 1Fluoxetine Cap

(not PMDD)1

Fluvoxamine Tab 1Forfivo XL 2Mirtazapine 1

Drug NameDrug Tier

Nortriptyline 1Paroxetine Tab 1Pristiq 3Risperidone Tab 1Sertraline 1Trazodone 1Venlafaxine Tab 1Venlafaxine ER Cap 1Venlafaxine ER Tab 1Viibryd 3

Central Nervous System: Migraine

Butalbital-Acetaminophen-Caffeine Cap, Tab 50-325-40 mg

1

Migranal 3Relpax 3Rizatriptan Tab, ODT 1Sumatriptan Tab and Spray 1Sumavel Dose 3Zolmitriptan Tab 1Central Nervous System: Multiple SclerosisAmpyra 2Aubagio 3Avonex Kit 2Avonex Pen Kit 2Avonex Prefill Kit 2Betaseron 2Copaxone 20 mg/mL & 40 mg/mL 2Gilenya* 3Rebif 3Rebif Titrtn 3Tecfidera 2

Central Nervous System: Other

Alprazolam Tab 1Aripiprazole 1Benztropine 1Buspirone 1Carbidopa/Levodopa Tab

(Immediate Release)1

Diazepam Tab 1

* Tier 3 Preferred

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Drug NameDrug Tier

Donepezil Tab 1Hydroxyzine HCL 1Hydroxyzine Pamoate 1Invega Sustenna 3Invega Trinza 3Latuda 3Lithium Carbonate 1Lorazepam Tab 1Modafinil 1Namenda XR 2Namzaric 2Olanzapine Tab 1Prochlorperazine 1Quetiapine 1Rexulti 3Risperidone Tab 1Ropinirole (Immediate Release) 1Saphris 2Seroquel XR 3Ziprasidone Cap 1Central Nervous System: Sedatives/HypnoticsEszopiclone Tab 1Silenor 3Temazepam 1Triazolam Tab 1Zolpidem 1Zolpidem ER 1Central Nervous System: Seizure DisordersCarbamazepine Tab 1Clonazepam 1Divalproex DR 1Divalproex ER 1Gabapentin 1Lamotrigine (Immediate Release) 1Lamotrigine ER 1Levetiracetam 1Levetiracetam ER 1Lyrica Cap 2Onfi 3Oxcarbazepine 1Phenytoin 1Primidone 1

Drug NameDrug Tier

Topiramate Tab 1Vimpat 3Zonisamide 1

Dermatology

Absorica 3Acanya Gel 3Acyclovir Ointment 5% 1Aczone Gel 3Atralin 3Benzaclin 3Betamethasone Dipropionate Cream 1Ciclopirox Cream 1Clindamycin Gel, Lotion, Solution 1Clindamycin/

Benzoyl Peroxide Gel 1-5%1

Clindamycin/Benzoyl Peroxide Gel 1.2-5%

1

Clobetasol Cream, Ointment, Solution

1

Clobex 3Clotrimazole/Betamethasone Cream,

Lotion1

Cortifoam 3Desonide Cream, Ointment 1Desoximetasone Cream, Gel,

Ointment1

Differin 3Econazole Cream 1Elidel 2Epiduo & Epiduo Forte 3Finacea 3Fluocinonide Cream, 0.1% 1Fluocinonide Cream, Gel, Ointment,

Solution 0.05%1

Hydrocortisone Cream, Ointment 2.5%

1

Lidocaine Topical Ointment, Solution 1Lidocaine/Prilocaine Cream 1Ketoconazole Cream/Shampoo 1Metrogel 3Metronidazole Gel 0.75% 1Mirvaso Gel 2Mupirocin Ointment 1

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Drug NameDrug Tier

Nystatin Cream, Ointment, Powder 1Nystatin/Triamcinolone Cream,

Ointment1

Onexton 3Oxsoralen-UL 2Permethrin Cream 5% 1Proctofoam HC 2Retin-A Micro gel 0.1%, 0.04% 3Soolantra 2Sulfacetamide/Sulfur Emulsion 1Taclonex 3Tazorac 3Tretinoin Cream 1Tretinoin Microsphere Gel 1Triamcinolone 1Vectical 3Zovirax Cream 2Zovirax Ointment 3Zyclara 3Diabetes/Endocrine Blood: Glucose MonitoringAccu-Chek Active Glucose

Control Liquid3

Accu-Chek Active Test Strips 2Accu-Chek Aviva Connect Kit 2Accu-Chek Aviva Plus

Control Liquid3

Accu-Chek Aviva Plus Kit 2Accu-Chek Aviva Plus Test Strips 2Accu-Chek Compact Plus Control

Liquid3

Accu-Chek Compact Plus Test Strips

2

Accu-Chek Compact Plus Kit 2Accu-Chek FastClix Kit 2Accu-Chek FastClix Lancets 2Accu-Chek Guide Control Liquid 3Accu-Chek Guide Kit 2Accu-Chek Guide Test Strips 2Accu-Chek Multiclix Kit 2Accu-Chek Multiclix Lancets 2Accu-Chek Nano SmartView Kit 2Accu-Chek SmartView

Control Liquid3

Drug NameDrug Tier

Accu-Chek SmartView Test Strips

2

Accu-Chek Soft Touch Lancets 2Accu-Chek Softclix Kit 2Accu-Chek Softclix Lancets 2Bayer Contour Test Strips 3Dexcom G4 Platinum Kit 3Dexcom G4 Platinum Sensor Kit 3Dexcom G4 Platinum

Transmitter Kit3

Freestyle Test Strips 3Dexcom G5 Kit 3Dexcom G5 Sensor Kit 3Dexcom G5 Transmitter Kit 3Insulin Pen Needle 2Insulin Syringe/Needle 2Novofine Pen Needle 3Novofine Autocover Pen Needle 3Novotwist Pen Needle 3Onetouch Kit Ultra Smart 2Onetouch Kit Ultra 2Onetouch Kit Ultra 2 2Onetouch Kit Ultra Mini 2Onetouch Kit Verio IQ 2Onetouch Test Strips 2Onetouch Ultra Blue Test Strips 2Onetouch Verio Test Strips 2Precision Test Strips 3

Diabetes/Endocrine: Insulin

Basaglar 3Humalog Mix 50/50 Vial

and KwikPen2

Humalog Mix 75-25 Vial and KwikPen

2

Humalog U-100 Vial and KwikPen 2Humalog U-200 KwikPen 2Humulin 70-30 Vial and KwikPen 2Humulin N Vial and KwikPen 2Humulin R U-500 Vial

and KwikPen2

Humulin R Vial 2Lantus SoloStar 2Lantus Vial 2

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Drug NameDrug Tier

Levemir FlexTouch 2Levemir Vial 2Novolin 70/30 Vial 2Novolin N Vial 2Novolin R Vial 2Novolog Flexpen 2Novolog Mix 70/30 Vial

and Flexpen2

Novolog Penfill 2Novolog Vial 2Toujeo SoloStar 2Tresiba 3

Diabetes/Endocrine: Non-Insulin

Bydureon 2Byetta 2Farxiga 3Glimepiride 1Glipizide 1Glipizide ER 1Glipizide XL 1Glumetza 3Glyburide 1Glyburide/Metformin 1Invokamet 2Invokamet XR 2Invokana 2Janumet 2Janumet XR 2Januvia 2Jardiance 2Jentadueto 2Jentadueto XR 2Kombiglyze 3Metformin 1Metformin ER 1Onglyza 3Pioglitazone 1Synjardy 2Tradjenta 2Trulicity 2Victoza 2

Drug NameDrug Tier

Endocrine: Growth Hormone

Norditropin 2Nutropin AQ 2

Endocrine: Other

Calcitriol Cap 1Dexamethasone Tab 1H.P. Acthar 2Hydrocortisone Tab 1Lupron Depot 3.75 mg, 11.25 mg 3Lupron Depot 7.5 mg, 22.5 mg,

30 mg, 45 mg2

Methylprednisolone Tab 1Prednisone 1Prednisolone Solution 25 mg/5 ml 1Prednisolone Syrup, Solution

15 mg/5 ml1

Sensipar 3Endocrine: Thyroid Hormone Replacement Armour Thyroid 3Levothyroxine 1Liothyronine 1Methimazole 1Synthroid 3Tirosint 3

Eye Conditions: Allergies

Azelastine Ophthalmic Solution 1Bepreve 3Lastacaft 3Pataday 2Pazeo 2

Eye Conditions: Antibiotics

Besivance 3Ciprofloxacin Ophthalmic Solution 1Erythromycin Ointment 1Gentamicin 1Moxeza 2 Neomycin/Polymyxin B/

Dexamethasone Ointment, Suspension

1

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Drug NameDrug Tier

Ofloxacin Ophthalmic Solution 1Polymyxin B/Trimethoprim Solution 1Tobramycin 1Tobramycin/Dexamethasone 1Vigamox 2

Eye Conditions: Glaucoma

Alphagan P 2Azopt 2Betimol 3Brimonidine 1Combigan 2Cosopt PF 3Dorzolamide-Timolol Maleate 1Latanoprost 1Lumigan 2Simbrinza 2Timolol 1Timoptic Ocudose 2Travatan Z 2

Eye Conditions: Other

Durezol Ophthalmic Emulsion 3Lotemax Ophthalmic Gel 3Ketorolac Ophthalmic Solution 1Prednisolone Ophthalmic Suspension 1Restasis 2Xiidra 2

Gastrointestinal: Acid Suppression

Dexilant 2Esomeprazole Magnesium (Rx only) 1Famotidine Tab 20 mg

and 40 mg (Rx only)1

Lansoprazole (Rx only) 1Omeprazole (Rx only) 1Pantoprazole 1Ranitidine Tab, Cap, Syrup (Rx only) 1Sucralfate Tab 1

Gastrointestinal: Nausea/Vomiting

Meclizine 1Metoclopramide 1Ondansetron Tab, ODT 1

Drug NameDrug Tier

Transderm-Scop 3Varubi 3

Gastrointestinal: OtherAmitiza 2Apriso 2Canasa 2Creon 2Delzicol 3Dipentum 3Gavilyte Solution 1Hyoscyamine Sublingual Tab 1Lactulose 1Lialda 2Linzess 2Moviprep 3Omeclamox Pak 2Pentasa 3Polyethylene Glycol 3350 Powder 1Prepopik 3Protosol HC 1Pylera 2Sulfasalazine 1Suprep Bowel Prep 3Uceris Foam 3Zenpep 2HIV/AIDSAtripla 2Complera 2Epzicom 3Genvoya 2Intelence 2Isentress 2Kaletra Solution 2Kaletra Tablet 3Nevirapine 1Norvir 2Prezcobix 2Prezista 2Reyataz 2Stribild 2Sustiva 2Tivicay 2Triumeq 2

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Drug NameDrug Tier

Truvada 2Viread 2

Infertility

Cetrotide 2Gonal-f 2Gonal-f RFF 2Ovidrel 3

Inflammatory Conditions

Cimzia Kit 2Depen 2Enbrel 3Humira Kit 2Humira Pen Kit 2Humira Pen Kit Crohns 2Humira Pen Kit Psoriasis 2Hydroxychloroquine 1Methotrexate Tab 1Orencia SC 3Otezla 3Otrexup 3Rasuvo 2Remicade 2Simponi 2Simponi Aria 2Stelara 2Taltz* 3Xeljanz 3

Men’s Health: Erectile Dysfunction

Cialis 2Levitra 3Stendra 3Viagra 2

Men’s Health: Prostate

Alfuzosin 1Cialis 2.5 mg & 5 mg 2Doxazosin 1Finasteride 5 mg 1Rapaflo 2

Drug NameDrug Tier

Tamsulosin 1Terazosin 1

Men’s Health: Testosterone Therapy

Androderm 2Androgel 1.62% 2Androgel 1% 3Testosterone Cypionate IM Injection 1

Miscellaneous

Allopurinol 1Antipyrine/Benzocaine Otic Solution

5.4 - 1.4%1

Aranesp 2Auryxia 3Benzonatate 1Botox 100, 200 unit Injection

(non-cosmetic)2

Bunavail 3Cerdelga 3Chantix 3Cheratussin 1Chlorhexidine 1Colcrys 2Cyproheptadine 1Desmopressin 1Epinephrine Auto-Injector

(Authorized Generic of EpiPen made by Mylan)

2

EpiPen & EpiPen Jr 3Euflexxa 2Fosrenol 3Granix 2Guaifenesin/Codeine Syrup 1Homatropine/Hydrocodone Syrup 1Hydrocodone/Chlorpheniramine

Liquid1

Hydrocortisone AC Suppository 25 mg

1

Hydromet 1Lidocaine Viscous Solution 2% 1Makena 2Narcan 2Neupogen 2Phenazopyridine (Rx only) 1* Tier 3 Preferred

16


Drug NameDrug Tier

Phentermine Tab 1Procrit 2Promethazine DM Syrup 1Promethazine/Codeine Syrup 1Pulmozyme 2Renvela Tab, Pack 2Rezira 3Suboxone Film 2Synagis 2Synvisc 2Synvisc One 2Uloric 2Ursodiol 1Velphoro 3Zarxio 2Zostavax Injection 3Zubsolv 2Zutripro 3

Musculoskeletal: Osteoporosis

Alendronate Tab 35 mg & 70 mg 1Binosto 3Evista 3Forteo 2Ibandronate Tab 1Raloxifene 1

Musculoskeletal: Other

Baclofen Tab 1Carisoprodol 350 mg 1Cyclobenzaprine Tab 5, 10 mg 1Lorzone 3Metaxalone 1Methocarbamol 1Tizanidine Cap 1Tizanidine Tab 1

Musculoskeletal: Pain Relief

Acetaminophen w/ Codeine 1Celebrex 3Celecoxib 1Diclofenac Tab 1Embeda 2Endocet Tab 1

Drug NameDrug Tier

Etodolac 1Flector patch 3Fentanyl Patch 25 mcg/hr,

50 mcg/hr, 75 mcg/hr, 100 mcg/hr

1

Fentanyl Patch 37.5 mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr

1

Gralise 3Hydrocodone/APAP

5, 7.5, 10/325 mg 1

Hydromorphone Tab 1Ibuprofen Tab 400, 600, 800 mg

(Rx only)1

Indomethacin Cap 1Ketorolac Tab 1Lidocaine Patch 5% 1Meloxicam 1Methadone Tab 1Morphine Sulfate Tab 1Nabumetone 1Naproxen (Rx only) 1Opana ER 2Oxycodone Tab 5, 10, 15, 30 mg

(Immediate Release)1

Oxycodone w/ Acetaminophen 1Oxycontin 2Tivorbex 3Tramadol Tab 50 mg 1Tramadol w/ Acetaminophen 1Vicodin 1Vicodin ES 1Voltaren Gel 3Zohydro ER 3Zorvolex 3

Overactive Bladder

Myrbetriq 3Oxybutynin 1Oxybutynin ER 1Tolterodine 1Toviaz 3Vesicare 2

17


Drug NameDrug Tier

Respiratory: Asthma/COPD

Advair Diskus 2Advair HFA 2Aerospan 3Albuterol Nebulizer Solution 1Anoro Ellipta 2Arnuity Ellipta 2Breo Ellipta 2Budesonide Inhalation Suspension 1Combivent Respimat 2Dulera 3Flovent Diskus 2Flovent HFA 2Foradil 2Incruse Ellipta 2Ipratropium/Albuterol Nebulizer

Solution1

Levalbuterol Nebulizer Solution 1Montelukast 1Perforomist 3Proair HFA, RespiClick 2Proventil HFA 3Pulmicort Flexhaler 2Qvar 2Seebri 3Serevent Diskus 2Spiriva Handihaler 2Spiriva Respimat 2Stiolto 2Symbicort 2Ventolin HFA 2Xolair 2Xopenex HFA 3

Respiratory: Nasal Allergies

Astepro 3Azelastine Spray 1Dymista Spray 2Fluticasone Spray 1Ipratropium Spray 1Mometasone 1Nasonex 2Omnaris 3

Drug NameDrug Tier

QNasl 3Triamcinolone Spray 1Zetonna 3

Respiratory: Oral Allergies

Cetirizine 1Promethazine Tab 1Desloratadine 1Levocetirizine 1

Transplant

Azathioprine Tab 1Cellcept Tab/Suspension 3Cyclosporine Cap 1Mycophenolate Mofetil

250 mg Cap/500 mg Tab1

Mycophenolate Sodium 180 mg, 360 mg Tab

1

Prograf Cap 3Rapamune 3Tacrolimus Cap 1

Vitamins/Electrolytes

Cyanocobalamine Injection 1Folic Acid 1 mg (Rx only) 1Klor-Con 8 and 10 MEQ 1Klor-Con M10 and M20 1Multi-Vit/Fl Chew 1Potassium Chloride ER Tab, Cap 1Potassium Chloride Micro ER Tab 1Potassium Citrate

540 mg, 1080 mg Tab1

Vitamin D 50,000 units (Rx only) 1

Women’s Health: Birth Control

Apri 1Aviane 1Azurette 1Cryselle-28 1Falmina 1Generess Fe Chewable 3Gianvi 1Gildess 1Jolivette 1

18


Drug NameDrug Tier

Junel 1Kariva 1Levora 28 1Lo Loestrin 3Lomedia Fe 1Loryna 1Low-Ogestrel 1Lutera 1Medroxyprogesterone Acetate

Injection1

Microgestin 1Microgestin Fe 1Minastrin 24 Fe Chewable 3Mono-Linyah 1Mononessa 1Natazia 2Necon 1Nora-Be 1Norgest/Ethi Estradio 1Nortrel 1Nuvaring 2Ocella 1Orsythia 1Ortho Tri-Cyclen Lo 3Previfem 1Reclipsen 1Sprintec 28 1Tri-Linyah 1Tri-Previfem 1Trinessa 1Tri-Sprintec 1Vestura 1Viorele 1Xulane 1Zarah 1

Drug NameDrug Tier

Women’s Health: Hormone Replacement

Climara Pro 2Divigel 3Duavee 2Elestrin Gel 3Estrace Vaginal Cream 3Estradiol Tab 1Estradiol/Norethindrone Tab 1Medroxyprogesterone Acetate Tab 1Minivelle 3Osphena 3Premarin Tab 2Premarin Vaginal Cream 2Premphase 2Prempro 2Progesterone Cap 1Vagifem 3

Women’s Health: Vaginal Anti-Infectives

Gynazole-1 Vaginal Cream 3Metronidazole Vaginal Gel 1Terconazole Vaginal Cream 1

Bold type = Brand-name drug [Plain type = Generic drug] 19

Index of Covered Drugs

A

Absorica . . . . . . . . . . 11Acanya Gel. . . . . . . . . 11Accu-Chek Active Glucose

Control Liquid . . . . . 12Accu-Chek Active

Test Strips . . . . . . . 12Accu-Chek Aviva Connect

Kit . . . . . . . . . . . 12Accu-Chek Aviva Plus

Control Liquid . . . . . 12Accu-Chek Aviva Plus Kit . 12Accu-Chek Aviva Plus

Test Strips . . . . . . . 12Accu-Chek Compact Plus

Control Liquid . . . . . 12Accu-Chek Compact Plus

Kit . . . . . . . . . . . 12Accu-Chek Compact Plus

Test Strips . . . . . . . 12Accu-Chek FastClix Kit . . 12Accu-Chek FastClix Lancets 12Accu-Chek Guide Control

Liquid. . . . . . . . . . 12Accu-Chek Guide Kit . . . 12Accu-Chek Guide Test Strips 12Accu-Chek Multiclix Kit . . 12Accu-Chek Multiclix Lancets 12Accu-Chek Nano

SmartView Kit . . . . . 12Accu-Chek SmartView

Control Liquid . . . . . 12Accu-Chek SmartView

Test Strips . . . . . . . 12Accu-Chek Softclix Kit. . . 12Accu-Chek Softclix Lancets 12Accu-Chek Soft Touch

Lancets . . . . . . . . . 12Acetaminophen w/ Codeine 16Acyclovir Cap, Tab, Suspension 8Acyclovir Ointment 5% . . . 11Aczone Gel. . . . . . . . . 11Adcirca . . . . . . . . . . . 10Adderall XR Cap . . . . . . 10Adempas. . . . . . . . . . 10Advair Diskus . . . . . . . 17Advair HFA . . . . . . . . 17Aerospan . . . . . . . . . 17Akynzeo . . . . . . . . . . . 8Albuterol Nebulizer Solution 17

Alendronate Tab . . . . . . 16Alfuzosin . . . . . . . . . . 15Allopurinol . . . . . . . . . 15Alphagan P . . . . . . . . 14Alprazolam Tab . . . . . . . 10Amiodarone. . . . . . . . . . 9Amitiza. . . . . . . . . . . 14Amitriptyline . . . . . . . . 10Amlodipine . . . . . . . . . . 8Amlodipine/Atorvastatin . . . 9Amlodipine/Benazepril . . . . 8Amlodipine/Valsartan . . . . . 8Amlodipine/Valsartan/HCTZ . . 8Amoxicillin . . . . . . . . . . 8Amoxicillin/Clavulanate . . . . 8Amphetamine-Dextroamph-

etamine SR 24Hr Cap . . 10Amphetamine-

Dextroamphetamine Tab 10Ampyra . . . . . . . . . . 10Anastrozole Tab . . . . . . . . 8Androderm . . . . . . . . 15Androgel 1% . . . . . . . 15Androgel 1.62% . . . . . . 15Anoro Ellipta . . . . . . . 17Antipyrine/Benzocaine Otic

Solution 5.4 - 1.4% . . . 15Apri . . . . . . . . . . . . . 17Apriso . . . . . . . . . . . 14Aranesp . . . . . . . . . . 15Aripiprazole . . . . . . . . . 10Armour Thyroid . . . . . . 13Arnuity Ellipta . . . . . . . 17Astepro . . . . . . . . . . 17Atenolol. . . . . . . . . . . . 8Atenolol/Chlorthalidone. . . . 8Atorvastatin . . . . . . . . . 9Atralin . . . . . . . . . . . 11Atripla . . . . . . . . . . . 14Aubagio . . . . . . . . . . 10Auryxia . . . . . . . . . . 15Aviane . . . . . . . . . . . 17Avonex Kit. . . . . . . . . 10Avonex Pen Kit . . . . . . 10Avonex Prefill Kit . . . . . 10Azasite . . . . . . . . . . . . 8Azathioprine Tab . . . . . . 17Azelastine Ophthalmic

Solution . . . . . . . . . 13Azelastine Spray. . . . . . . 17Azithromycin . . . . . . . . . 8

Azopt . . . . . . . . . . . 14Azor . . . . . . . . . . . . . 9Azurette . . . . . . . . . . 17

B

Baclofen Tab . . . . . . . . 16Basaglar . . . . . . . . . . 12Bayer Contour Test Strips . 12Benazepril. . . . . . . . . . . 9Benazepril/HCTZ . . . . . . . 9Benicar . . . . . . . . . . . . 9Benicar HCT . . . . . . . . . 9Benzaclin. . . . . . . . . . 11Benzonatate . . . . . . . . 15Benztropine . . . . . . . . . 10Bepreve . . . . . . . . . . 13Besivance . . . . . . . . . 13Betamethasone Dipropionate

Cream. . . . . . . . . . 11Betaseron . . . . . . . . . 10Bethkis . . . . . . . . . . . . 8Betimol. . . . . . . . . . . 14Binosto. . . . . . . . . . . 16Bisoprolol . . . . . . . . . . . 9Bisoprolol/HCTZ . . . . . . . . 9Botox 100, 200 unit

Injection . . . . . . . . 15Breo Ellipta . . . . . . . . 17Brilinta . . . . . . . . . . . . 8Brimonidine . . . . . . . . . 14Budesonide Inhalation

Suspension . . . . . . . 17Bumetanide . . . . . . . . . . 9Bunavail . . . . . . . . . . 15Bupropion. . . . . . . . . . 10Bupropion ER . . . . . . . . 10Bupropion SR . . . . . . . . 10Bupropion XL . . . . . . . . 10Buspirone . . . . . . . . . . 10Butalbital-Acetaminophen-

Caffeine . . . . . . . . . 10Bydureon . . . . . . . . . 13Byetta . . . . . . . . . . . 13Bystolic. . . . . . . . . . . . 9

C

Calcitriol Cap . . . . . . . . 13Canasa . . . . . . . . . . . 14Capecitabine . . . . . . . . . 8



Carbamazepine Tab . . . . . 11Carbidopa/Levodopa Tab . . 10Carisoprodol . . . . . . . . 16Cartia XT . . . . . . . . . . . 9Carvedilol . . . . . . . . . . . 9Cefadroxil Cap . . . . . . . . 8Cefdinir . . . . . . . . . . . . 8Cefuroxime Tab . . . . . . . . 8Celebrex . . . . . . . . . . 16Celecoxib . . . . . . . . . . 16Cellcept Tab/Suspension . 17Cephalexin . . . . . . . . . . 8Cerdelga . . . . . . . . . . 15Cetirizine . . . . . . . . . . 17Cetrotide. . . . . . . . . . 15Chantix. . . . . . . . . . . 15Cheratussin . . . . . . . . . 15Chlorhexidine . . . . . . . . 15Chlorthalidone . . . . . . . . 9Cholestyramine . . . . . . . . 9Cialis . . . . . . . . . . . . 15Ciclopirox Cream . . . . . . 11Cimzia Kit . . . . . . . . . 15Ciprodex Otic Suspension . 8Ciprofloxacin Ophthalmic

Solution . . . . . . . . . 13Ciprofloxacin Tab . . . . . . . 8Clarithromycin . . . . . . . . 8Climara Pro . . . . . . . . 18Clindamycin/Benzoyl Peroxide

Gel 1.2-5% . . . . . . . 11Clindamycin/Benzoyl Peroxide

Gel 1-5% . . . . . . . . 11Clindamycin Cap . . . . . . . 8Clindamycin Gel, Lotion,

Solution . . . . . . . . . 11Clobetasol Cream, Ointment,

Solution . . . . . . . . . 11Clobex . . . . . . . . . . . 11Clonazepam . . . . . . . . 11Clonidine Patch . . . . . . . . 9Clonidine Tab . . . . . . . . . 9Clopidogrel . . . . . . . . . . 8Clotrimazole/Betamethasone

Cream, Lotion . . . . . . 11Colcrys . . . . . . . . . . . 15Combigan . . . . . . . . . 14Combivent Respimat . . . 17Complera . . . . . . . . . 14Copaxone . . . . . . . . . 10

Corlanor . . . . . . . . . . . 9Cortifoam . . . . . . . . . 11Cosopt PF . . . . . . . . . 14Creon. . . . . . . . . . . . 14Crestor . . . . . . . . . . . . 9Cryselle-28 . . . . . . . . . 17Cyanocobalamine Injection . 17Cyclobenzaprine . . . . . . 16Cyclosporine Cap . . . . . . 17Cyproheptadine . . . . . . . 15

D

Daklinza . . . . . . . . . . . 8Delzicol . . . . . . . . . . 14Depen . . . . . . . . . . . 15Desloratadine . . . . . . . . 17Desmopressin . . . . . . . . 15Desonide Cream, Ointment . 11Desoximetasone Cream, Gel,

Ointment . . . . . . . . 11Dexamethasone Tab . . . . 13Dexcom G4 Platinum Kit . 12Dexcom G4 Platinum

Sensor Kit . . . . . . . 12Dexcom G4 Platinum

Transmitter Kit. . . . . 12Dexcom G5 Kit. . . . . . . 12Dexcom G5 Sensor Kit . . 12Dexcom G5 Transmitter Kit 12Dexilant . . . . . . . . . . 14Dexmethylphenidate ER Cap 10Diazepam Tab . . . . . . . . 10Diclofenac Tab . . . . . . . 16Differin. . . . . . . . . . . 11Digoxin . . . . . . . . . . . . 9Diltiazem Tab . . . . . . . . . 9Dipentum . . . . . . . . . 14Divalproex DR . . . . . . . . 11Divalproex ER . . . . . . . . 11Divigel . . . . . . . . . . . 18Donepezil Tab . . . . . . . . 11Doryx MPC. . . . . . . . . . 8Dorzolamide-Timolol Maleate 14Doxazosin . . . . . . . . . 9, 15Doxepin . . . . . . . . . . . 10Doxycycline Hyclate . . . . . . 8Doxycycline Monohydrate Cap 8Doxycycline Monohydrate Oral

Suspension, Tab . . . . . . 8Duavee. . . . . . . . . . . 18

Dulera . . . . . . . . . . . 17Duloxetine Cap . . . . . . . 10Durezol Ophthalmic

Emulsion . . . . . . . . 14Dymista Spray . . . . . . . 17

E

Econazole Cream . . . . . . 11Edarbi . . . . . . . . . . . . 9Edarbyclor . . . . . . . . . . 9Effient . . . . . . . . . . . . 8Elestrin Gel . . . . . . . . 18Elidel . . . . . . . . . . . . 11Eliquis . . . . . . . . . . . . 8Embeda . . . . . . . . . . 16Enalapril. . . . . . . . . . . . 9Enalapril/HCTZ . . . . . . . . 9Enbrel . . . . . . . . . . . 15Endocet Tab. . . . . . . . . 16Enoxaparin . . . . . . . . . . 8Entecavir . . . . . . . . . . . 8Epclusa. . . . . . . . . . . . 8Epiduo & Epiduo Forte . . 11Epinephrine Auto-Injector 15EpiPen & EpiPen Jr . . . . 15Epzicom . . . . . . . . . . 14Erythromycin . . . . . . . . . 8Erythromycin Ointment . . . 13Escitalopram Tab . . . . . . 10Esomeprazole Magnesium . 14Estrace Vaginal Cream . . 18Estradiol/Norethindrone Tab . 18Estradiol Tab . . . . . . . . 18Eszopiclone Tab . . . . . . . 11Etodolac . . . . . . . . . . 16Euflexxa . . . . . . . . . . 15Evekeo . . . . . . . . . . . 10Evista. . . . . . . . . . . . 16

F

Falmina . . . . . . . . . . . 17Famciclovir Tab . . . . . . . . 8Famotidine Tab . . . . . . . 14Farxiga . . . . . . . . . . . 13Felodipine . . . . . . . . . . . 9Fenofibrate . . . . . . . . . . 9Fentanyl Patch . . . . . . . 16Finacea. . . . . . . . . . . 11Finasteride . . . . . . . . . 15



Flecainide . . . . . . . . . . . 9Flector patch. . . . . . . . 16Flovent Diskus. . . . . . . 17Flovent HFA . . . . . . . . 17Fluconazole . . . . . . . . . . 8Fluocinonide Cream, 0.1% 11Fluocinonide Cream, Gel,

Ointment, Solution 0.05% 11Fluoxetine Cap . . . . . . . 10Fluticasone Spray . . . . . . 17Fluvoxamine Tab . . . . . . 10Folic Acid . . . . . . . . . . 17Foradil . . . . . . . . . . . 17Forfivo XL . . . . . . . . . 10Forteo . . . . . . . . . . . 16Fosinopril . . . . . . . . . . . 9Fosrenol . . . . . . . . . . 15Freestyle Test Strips . . . . 12Furosemide . . . . . . . . . . 9

G

Gabapentin . . . . . . . . . 11Gavilyte Solution . . . . . . 14Gemfibrozil . . . . . . . . . . 9Generess Fe Chewable . . 17Gentamicin . . . . . . . . . 13Genvoya . . . . . . . . . . 14Gianvi . . . . . . . . . . . . 17Gildess . . . . . . . . . . . 17Gilenya. . . . . . . . . . . 10Glimepiride . . . . . . . . . 13Glipizide . . . . . . . . . . 13Glipizide ER . . . . . . . . . 13Glipizide XL . . . . . . . . . 13Glumetza . . . . . . . . . 13Glyburide . . . . . . . . . . 13Glyburide/Metformin . . . . 13Gonal-f . . . . . . . . . . . 15Gonal-f RFF . . . . . . . . 15Gralise . . . . . . . . . . . 16Granix . . . . . . . . . . . 15Guaifenesin/Codeine Syrup . 15Guanfacine ER Tab . . . . . 10Guanfacine Tab . . . . . . . . 9Gynazole-1 Vaginal Cream 18

H

Harvoni . . . . . . . . . . . 8

Homatropine/Hydrocodone Syrup . . . . . . . . . . 15

H.P. Acthar . . . . . . . . . 13Humalog Mix 50/50 Vial

and KwikPen. . . . . . 12Humalog Mix 75-25 Vial

and KwikPen. . . . . . 12Humalog U-100 Vial and

KwikPen . . . . . . . . 12Humalog U-200 KwikPen . 12Humira Kit . . . . . . . . . 15Humira Pen Kit . . . . . . 15Humira Pen Kit Crohns . . 15Humira Pen Kit Psoriasis . 15Humulin 70-30 Vial and

KwikPen . . . . . . . . 12Humulin N Vial and

KwikPen . . . . . . . . 12Humulin R U-500 Vial

and KwikPen. . . . . . 12Humulin R Vial. . . . . . . 12Hydralazine . . . . . . . . . . 9Hydrochlorothiazide. . . . . . 9Hydrocodone/APAP . . . . . 16Hydrocodone/

Chlorpheniramine Liquid 15Hydrocortisone AC

Suppository . . . . . . . 15Hydrocortisone Cream,

Ointment 2.5% . . . . . 11Hydrocortisone Tab . . . . . 13Hydromet . . . . . . . . . . 15Hydromorphone Tab . . . . 16Hydroxychloroquine . . . . . 15Hydroxyzine HCL . . . . . . 11Hydroxyzine Pamoate . . . . 11Hyoscyamine Sublingual Tab 14

I

Ibandronate Tab. . . . . . . 16Ibuprofen Tab . . . . . . . . 16Incruse Ellipta . . . . . . . 17Indomethacin Cap . . . . . 16Insulin Pen Needle . . . . 12Insulin Syringe/Needle . . 12Intelence . . . . . . . . . 14Invega Sustenna. . . . . . 11Invega Trinza . . . . . . . 11Invokamet . . . . . . . . . 13Invokamet XR . . . . . . . 13

Invokana. . . . . . . . . . 13Ipratropium/Albuterol Nebulizer

Solution . . . . . . . . . 17Ipratropium Spray . . . . . . 17Irbesartan . . . . . . . . . . . 9Irbesartan/HCTZ. . . . . . . . 9Isentress . . . . . . . . . . 14Isosorbide Mononitrate . . . . 9

J

Janumet . . . . . . . . . . 13Janumet XR . . . . . . . . 13Januvia. . . . . . . . . . . 13Jardiance. . . . . . . . . . 13Jentadueto. . . . . . . . . 13Jentadueto XR. . . . . . . 13Jolivette . . . . . . . . . . . 17Jublia Solution. . . . . . . . 8Junel . . . . . . . . . . . . 18

K

Kaletra Solution . . . . . . 14Kaletra Tablet . . . . . . . 14Kariva . . . . . . . . . . . . 18Kerydin Solution . . . . . . 8Ketoconazole Cream/

Shampoo . . . . . . . . 11Ketorolac Ophthalmic

Solution . . . . . . . . . 14Ketorolac Tab . . . . . . . . 16Klor-Con 8 and 10 MEQ. . . 17Klor-Con M10 and M20. . . 17Kombiglyze . . . . . . . . 13

L

Labetalol . . . . . . . . . . . 9Lactulose . . . . . . . . . . 14Lamotrigine ER . . . . . . . 11Lamotrigine . . . . . . . . . 11Lansoprazole . . . . . . . . 14Lantus SoloStar . . . . . . 12Lantus Vial . . . . . . . . . 12Lastacaft . . . . . . . . . . 13Latanoprost . . . . . . . . . 14Latuda . . . . . . . . . . . 11Letairis . . . . . . . . . . . 10Letrozole . . . . . . . . . . . 8



Levalbuterol Nebulizer Solution . . . . . . . . . 17

Levemir FlexTouch. . . . . 13Levemir Vial . . . . . . . . 13Levetiracetam . . . . . . . . 11Levetiracetam ER . . . . . . 11Levitra . . . . . . . . . . . 15Levocetirizine . . . . . . . . 17Levofloxacin Tab. . . . . . . . 8Levora 28 . . . . . . . . . . 18Levothyroxine . . . . . . . . 13Lialda. . . . . . . . . . . . 14Lidocaine Patch 5% . . . . . 16Lidocaine/Prilocaine Cream . 11Lidocaine Topical Ointment,

Solution . . . . . . . . . 11Lidocaine Viscous Solution

2% . . . . . . . . . . . 15Linzess . . . . . . . . . . . 14Liothyronine . . . . . . . . 13Lipitor . . . . . . . . . . . . 9Lisinopril . . . . . . . . . . . 9Lisinopril/HCTZ . . . . . . . . 9Lithium Carbonate . . . . . 11Lo Loestrin . . . . . . . . . 18Lomedia Fe . . . . . . . . . 18Lorazepam Tab . . . . . . . 11Loryna . . . . . . . . . . . 18Lorzone . . . . . . . . . . 16Losartan. . . . . . . . . . . . 9Losartan/HCTZ . . . . . . . . 9Lotemax Ophthalmic Gel . 14Lovastatin . . . . . . . . . . 9Lovaza . . . . . . . . . . . . 9Low-Ogestrel . . . . . . . . 18Lumigan . . . . . . . . . . 14Lupron Depot . . . . . . . 13Lutera . . . . . . . . . . . . 18Lyrica Cap . . . . . . . . . 11

M

Makena . . . . . . . . . . 15Meclizine . . . . . . . . . . 14Medroxyprogesterone Acetate

Injection. . . . . . . . . 18Medroxyprogesterone Acetate

Tab . . . . . . . . . . . 18Meloxicam . . . . . . . . . 16Metaxalone . . . . . . . . . 16Metformin . . . . . . . . . 13

Metformin ER . . . . . . . . 13Methadone Tab . . . . . . . 16Methimazole . . . . . . . . 13Methocarbamol . . . . . . . 16Methotrexate Tab . . . . . . 15Methylphenidate ER. . . . . 10Methylphenidate SA

Osmotic ER . . . . . . . 10Methylphenidate Tab . . . . 10Methylprednisolone Tab . . . 13Metoclopramide . . . . . . 14Metoprolol Succinate . . . . . 9Metoprolol Tartrate . . . . . . 9Metrogel . . . . . . . . . . 11Metronidazole Gel 0.75%. . 11Metronidazole Tab . . . . . . 8Metronidazole Vaginal Gel . 18Microgestin . . . . . . . . . 18Microgestin Fe . . . . . . . 18Migranal . . . . . . . . . . 10Minastrin 24 Fe Chewable 18Minivelle . . . . . . . . . . 18Minocycline Cap . . . . . . . 8Mirtazapine . . . . . . . . . 10Mirvaso Gel . . . . . . . . 11Modafinil . . . . . . . . . . 11Mometasone . . . . . . . . 17Mono-Linyah . . . . . . . . 18Mononessa . . . . . . . . . 18Montelukast . . . . . . . . 17Morphine Sulfate Tab . . . . 16Moviprep . . . . . . . . . 14Moxeza . . . . . . . . . . 13Moxifloxacin . . . . . . . . . 8Multaq . . . . . . . . . . . . 9Multi-Vit/Fl Chew . . . . . . 17Mupirocin Ointment . . . . 11Mycophenolate Mofetil . . . 17Mycophenolate Sodium . . . 17Myrbetriq . . . . . . . . . 16

N

Nabumetone . . . . . . . . 16Nadolol . . . . . . . . . . . . 9Namenda XR. . . . . . . . 11Namzaric . . . . . . . . . . 11Naproxen . . . . . . . . . . 16Narcan . . . . . . . . . . . 15Nasonex . . . . . . . . . . 17

Natazia. . . . . . . . . . . 18Necon. . . . . . . . . . . . 18 Neomycin/Polymyxin B/

Dexamethasone Ointment, Suspension . . . . . . . 13

Neomycin/Polymyxin/HC Otic Suspension, Solution . . . 8

Neupogen . . . . . . . . . 15Nevirapine . . . . . . . . . 14Niacin ER Tab . . . . . . . . . 9Nifedipine ER . . . . . . . . . 9Nitrofurantoin Macrocrystalline 8Nitrofurantoin Monohydrate

Macrocrystalline . . . . . . 8Nitrostat . . . . . . . . . . 10Nora-Be . . . . . . . . . . . 18Norditropin . . . . . . . . 13Norgest/Ethi Estradio . . . . 18Nortrel . . . . . . . . . . . 18Nortriptyline. . . . . . . . . 10Norvir . . . . . . . . . . . 14Novofine Autocover Pen

Needle . . . . . . . . . 12Novofine Pen Needle . . . 12Novolin 70/30 Vial. . . . . 13Novolin N Vial . . . . . . . 13Novolin R Vial . . . . . . . 13Novolog Flexpen . . . . . 13Novolog Mix 70/30 Vial

and Flexpen . . . . . . 13Novolog Penfill . . . . . . 13Novolog Vial. . . . . . . . 13Novotwist Pen Needle . . 12Nutropin AQ. . . . . . . . 13Nuvaring. . . . . . . . . . 18Nystatin Cream, Ointment,

Powder . . . . . . . . . 12Nystatin Suspension. . . . . . 8Nystatin/Triamcinolone Cream,

Ointment . . . . . . . . 12

O

Ocella . . . . . . . . . . . . 18Ofloxacin Ophthalmic Solution 14Ofloxacin Otic Solution . . . . 8Olanzapine Tab . . . . . . . 11Omeclamox Pak . . . . . . 14Omega-3 Acid Cap . . . . . . 9Omeprazole . . . . . . . . . 14Omnaris . . . . . . . . . . 17



Ondansetron Tab, ODT . . . 14Onetouch Kit Ultra . . . . 12Onetouch Kit Ultra 2 . . . 12Onetouch Kit Ultra Mini . 12Onetouch Kit Ultra Smart. 12Onetouch Kit Verio IQ. . . 12Onetouch Test Strips . . . 12Onetouch Ultra Blue Test

Strips . . . . . . . . . . 12Onetouch Verio Test Strips 12Onexton . . . . . . . . . . 12Onfi . . . . . . . . . . . . 11Onglyza . . . . . . . . . . 13Opana ER . . . . . . . . . 16Opsumit . . . . . . . . . . 10Oracea . . . . . . . . . . . . 8Orencia SC . . . . . . . . . 15Orenitram . . . . . . . . . 10Orsythia . . . . . . . . . . . 18Ortho Tri-Cyclen Lo . . . . 18Osphena . . . . . . . . . . 18Otezla . . . . . . . . . . . 15Otrexup . . . . . . . . . . 15Ovidrel . . . . . . . . . . . 15Oxcarbazepine . . . . . . . 11Oxsoralen-UL . . . . . . . 12Oxybutynin . . . . . . . . . 16Oxybutynin ER . . . . . . . 16Oxycodone Tab . . . . . . . 16Oxycodone w/

Acetaminophen . . . . . 16Oxycontin . . . . . . . . . 16

P

Pantoprazole . . . . . . . . 14Paroxetine Tab . . . . . . . 10Pataday . . . . . . . . . . 13Pazeo. . . . . . . . . . . . 13Penicillin VK. . . . . . . . . . 8Pentasa . . . . . . . . . . 14Perforomist . . . . . . . . 17Permethrin Cream 5% . . . 12Phenazopyridine . . . . . . 15Phentermine Tab . . . . . . 16Phenytoin . . . . . . . . . . 11Pioglitazone. . . . . . . . . 13Polyethylene Glycol 3350

Powder . . . . . . . . . 14Polymyxin B/Trimethoprim

Solution . . . . . . . . . 14

Potassium Chloride ER . . . 17Potassium Chloride Micro ER 17Potassium Citrate . . . . . . 17Pradaxa . . . . . . . . . . . 8Praluent . . . . . . . . . . . 9Pravastatin . . . . . . . . . . 9Precision Test Strips . . . . 12Prednisolone Ophthalmic

Suspension . . . . . . . 14Prednisolone Solution . . . . 13Prednisolone Syrup, Solution 13Prednisone . . . . . . . . . 13Premarin Tab. . . . . . . . 18Premarin Vaginal Cream . 18Premphase . . . . . . . . . 18Prempro . . . . . . . . . . 18Prepopik . . . . . . . . . . 14Previfem . . . . . . . . . . 18Prezcobix . . . . . . . . . 14Prezista . . . . . . . . . . 14Primidone . . . . . . . . . . 11Pristiq . . . . . . . . . . . 10Proair HFA, RespiClick. . . 17Prochlorperazine . . . . . . 11Procrit . . . . . . . . . . . 16Proctofoam HC . . . . . . 12Progesterone Cap . . . . . . 18Prograf Cap . . . . . . . . 17Promethazine/Codeine Syrup 16Promethazine DM Syrup . . 16Promethazine Tab . . . . . . 17Propranolol . . . . . . . . . . 9Propranolol ER . . . . . . . . 9Protosol HC . . . . . . . . . 14Proventil HFA . . . . . . . 17Pulmicort Flexhaler . . . . 17Pulmozyme . . . . . . . . 16Pylera . . . . . . . . . . . 14

Q

QNasl. . . . . . . . . . . . 17Quetiapine . . . . . . . . . 11Quinapril . . . . . . . . . . . 9Qvar . . . . . . . . . . . . 17

R

Raloxifene. . . . . . . . . . 16Ramipril . . . . . . . . . . . . 9Ranexa . . . . . . . . . . . 10

Ranitidine Tab, Cap, Syrup . 14Rapaflo. . . . . . . . . . . 15Rapamune . . . . . . . . . 17Rasuvo . . . . . . . . . . . 15Rebif . . . . . . . . . . . . 10Rebif Titrtn . . . . . . . . 10Reclipsen . . . . . . . . . . 18Relpax . . . . . . . . . . . 10Remicade . . . . . . . . . 15Renvela Tab, Pack . . . . . 16Restasis . . . . . . . . . . 14Retin-A Micro gel 0.1%,

0.04% . . . . . . . . . 12Revlimid . . . . . . . . . . . 8Rexulti . . . . . . . . . . . 11Reyataz . . . . . . . . . . 14Rezira . . . . . . . . . . . 16Risperidone . . . . . . . 10, 11Rizatriptan Tab, ODT . . . . 10Ropinirole . . . . . . . . . . 11Rosuvastatin . . . . . . . . . 9

S

Saphris . . . . . . . . . . . 11Savaysa . . . . . . . . . . . 8Seebri . . . . . . . . . . . 17Sensipar . . . . . . . . . . 13Serevent Diskus . . . . . . 17Seroquel XR . . . . . . . . 11Sertraline . . . . . . . . . . 10Sildenafil Tab . . . . . . . . 10Silenor . . . . . . . . . . . 11Simbrinza . . . . . . . . . 14Simponi . . . . . . . . . . 15Simponi Aria. . . . . . . . 15Simvastatin . . . . . . . . . . 9Solodyn . . . . . . . . . . . 8Soolantra . . . . . . . . . 12Sotalol . . . . . . . . . . . 10Sovaldi . . . . . . . . . . . . 8Spiriva Handihaler . . . . 17Spiriva Respimat . . . . . 17Spironolactone . . . . . . . . 9Sprintec 28 . . . . . . . . . 18Sprycel . . . . . . . . . . . . 8Stelara . . . . . . . . . . . 15Stendra . . . . . . . . . . 15Stiolto . . . . . . . . . . . 17Strattera . . . . . . . . . . 10Stribild . . . . . . . . . . . 14



Suboxone Film. . . . . . . 16Sucralfate Tab . . . . . . . . 14Sulfacetamide/Sulfur Emulsion 12Sulfamethoxazole-Trimethoprim 8Sulfamethoxazole-

Trimethoprim DS . . . . . 8Sulfasalazine . . . . . . . . 14Sumatriptan Tab and Spray . 10Sumavel Dose . . . . . . . 10Suprep Bowel Prep . . . . 14Sustiva . . . . . . . . . . . 14Symbicort . . . . . . . . . 17Synagis. . . . . . . . . . . 16Synjardy . . . . . . . . . . 13Synthroid . . . . . . . . . 13Synvisc . . . . . . . . . . . 16Synvisc One . . . . . . . . 16

T

Taclonex . . . . . . . . . . 12Tacrolimus Cap . . . . . . . 17Taltz . . . . . . . . . . . . 15Tamiflu . . . . . . . . . . . . 8Tamoxifen Tab. . . . . . . . . 8Tamsulosin . . . . . . . . . 15Tasigna. . . . . . . . . . . . 8Tazorac. . . . . . . . . . . 12Tecfidera . . . . . . . . . . 10Tekturna . . . . . . . . . . . 9Tekturna HCT . . . . . . . . 9Telmisartan . . . . . . . . . . 9Temazepam . . . . . . . . . 11Temozolomide . . . . . . . . 8Terazosin . . . . . . . . . 9, 15Terbinafine Tab . . . . . . . . 8Terconazole Vaginal Cream . 18Testosterone Cypionate IM

Injection. . . . . . . . . 15Timolol . . . . . . . . . . . 14Timoptic Ocudose . . . . . 14Tirosint. . . . . . . . . . . 13Tivicay . . . . . . . . . . . 14Tivorbex . . . . . . . . . . 16Tizanidine . . . . . . . . . . 16Tobramycin . . . . . . . . . 14Tobramycin/Dexamethasone. 14Tolterodine . . . . . . . . . 16Topiramate Tab . . . . . . . 11Torsemide Tab. . . . . . . . . 9Toujeo SoloStar . . . . . . 13

Toviaz . . . . . . . . . . . 16Tracleer . . . . . . . . . . 10Tradjenta. . . . . . . . . . 13Tramadol Tab . . . . . . . . 16Tramadol w/ Acetaminophen 16Transderm-Scop . . . . . . 14Travatan Z . . . . . . . . . 14Trazodone. . . . . . . . . . 10Tresiba . . . . . . . . . . . 13Tretinoin Cream . . . . . . . 12Tretinoin Microsphere Gel . . 12Triamcinolone . . . . . . . . 12Triamcinolone Spray. . . . . 17Triamterene/HCTZ . . . . . . . 9Triazolam Tab . . . . . . . . 11Tribenzor. . . . . . . . . . . 9Tri-Linyah . . . . . . . . . . 18Trinessa . . . . . . . . . . . 18Tri-Previfem . . . . . . . . . 18Tri-Sprintec . . . . . . . . . 18Triumeq . . . . . . . . . . 14Trulicity . . . . . . . . . . 13Truvada . . . . . . . . . . 15

U

Uceris Foam . . . . . . . . 14Uloric. . . . . . . . . . . . 16Ursodiol . . . . . . . . . . . 16

V

Vagifem . . . . . . . . . . 18Valacyclovir . . . . . . . . . . 8Valsartan . . . . . . . . . . . 9Valsartan/HCTZ . . . . . . . . 9Varubi . . . . . . . . . . . 14Vascepa . . . . . . . . . . . 9Vectical. . . . . . . . . . . 12Velphoro . . . . . . . . . . 16Venlafaxine ER . . . . . . . 10Venlafaxine . . . . . . . . . 10Ventolin HFA . . . . . . . 17Verapamil ER . . . . . . . . . 9Vesicare . . . . . . . . . . 16Vestura . . . . . . . . . . . 18Viagra . . . . . . . . . . . 15Vicodin . . . . . . . . . . . 16Vicodin ES. . . . . . . . . . 16Victoza . . . . . . . . . . . 13Vigamox . . . . . . . . . . 14

Viibryd . . . . . . . . . . . 10Vimpat . . . . . . . . . . . 11Viorele . . . . . . . . . . . 18Viread . . . . . . . . . . . 15Vitamin D . . . . . . . . . . 17Voltaren Gel . . . . . . . . 16Vytorin . . . . . . . . . . . . 9Vyvanse . . . . . . . . . . 10

W

Warfarin . . . . . . . . . . . 8Welchol . . . . . . . . . . . 9

X

Xarelto . . . . . . . . . . . . 8Xeljanz . . . . . . . . . . . 15Xiidra. . . . . . . . . . . . 14Xolair. . . . . . . . . . . . 17Xopenex HFA . . . . . . . 17Xulane . . . . . . . . . . . 18

Z

Zarah . . . . . . . . . . . . 18Zarxio . . . . . . . . . . . 16Zenpep . . . . . . . . . . 14Zepatier . . . . . . . . . . . 8Zetia . . . . . . . . . . . . . 9Zetonna . . . . . . . . . . 17Ziprasidone Cap. . . . . . . 11Zohydro ER . . . . . . . . 16Zolmitriptan Tab. . . . . . . 10Zolpidem . . . . . . . . . . 11Zolpidem ER. . . . . . . . . 11Zonisamide . . . . . . . . . 11Zorvolex . . . . . . . . . . 16Zostavax Injection. . . . . 16Zovirax Cream . . . . . . . 12Zovirax Ointment . . . . . 12Zubsolv . . . . . . . . . . 16Zutripro . . . . . . . . . . 16Zyclara . . . . . . . . . . . 12Zytiga . . . . . . . . . . . . 8

25

“My Medications” worksheet

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

Name of Medicine and Strength

Drug Tier

I Take This Medicine For

Directions Doctor

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

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All Optum trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners.

©2017 OptumRx, Inc. ORX6700CC_170701 64018-032017 Select Standard

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All Optum® trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners. © 2016 Optum, Inc. All rights reserved. ORX284511_161212

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We provide assistance free of charge to people with disabilities or whose primary language is not English. To request a document in another format such as large print or to get language assistance such as a qualified interpreter, please call the number located on the back of your prescription ID card, TTY 711. Representatives are available 24 hours a day, seven days a week. If you believe that we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can send a complaint to:

OptumRx Civil Rights Coordinator 11000 Optum Circle Eden Prairie, MN 55344 Phone: 1-800-562-6223, TTY 711 Fax: 855-351-5495 Email: [email protected]

If you need help filing a complaint, please call the number located on the back of your prescription ID card, TTY 711. Representatives are available 24 hours a day, seven days a week. You can also file a complaint directly with the U.S. Dept. of Health and Human services online, by phone, or by mail: Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html Phone: Toll-free 1-800-368-1019, 800-537-7697 (TDD) Mail: U.S. Dept. of Health and Human Services. 200 Independence Avenue,

SW Room 509F, HHH Building Washington, D.C. 20201 This information is available in other formats like large print. To ask for another format, please call the telephone number listed on your health plan ID card.

Multi-language interpreter servicesATTENTION: If you speak English, language assistance services, free of charge, are available to you. Please call the toll-free phone number listed on your identification card.

ATENCIÓN: Si habla español (Spanish), hay servicios de asistencia de idiomas, sin cargo, a su

disposición. Llame al número de teléfono gratuito que aparece en su tarjeta de identificación.

請注意：如果您說中文 (Chinese)，我們免費為您提供語言協助服務。請撥打會員卡所列的免付費會員電話號碼。

XIN LƯU Ý: Nếu quý vị nói tiếng Việt (Vietnamese), quý vị sẽ được cung cấp dịch vụ trợ giúp về ngôn ngữ miễn phí. Vui lòng gọi số điện thoại miễn phí ở mặt sau thẻ hội viên của quý vị.

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ВНИМАНИЕ: бесплатные услуги перевода доступны для людей, чей родной язык является русском (Russian). Позвоните по бесплатному номеру телефона, указанному на вашей идентификаци-онной карте.

مقر ىلع لاصتالا ءاجرلا .كل ةحاتم ةيناجملا ةيوغللا ةدعاسملا تامدخ نإف ،(Arabic) ةيبرعلا ثدحتت تنك اذإ :هيبنت.ةيوضعلا فّرعم ىلع دوجوملا يناجملا فتاهلا

ATANSYON: Si w pale Kreyòl ayisyen (Haitian Creole), ou kapab benefisye sèvis ki gratis pou ede w nan lang pa w. Tanpri rele nimewo gratis ki sou kat idantifikasyon w.

ATTENTION : Si vous parlez français (French), des services d’aide linguistique vous sont proposés gratuitement. Veuillez appeler le numéro de téléphone gratuit figurant sur votre carte d’identification.

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ATTENZIONE: in caso la lingua parlata sia l’italiano (Italian), sono disponibili servizi di assistenza linguistica gratuiti. Per favore chiamate il numero di telefono verde indicato sulla vostra tessera identificativa.

ACHTUNG: Falls Sie Deutsch (German) sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Bitte rufen Sie die gebührenfreie Rufnummer auf der Rückseite Ihres Mitgliedsausweises an.

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نفلت هرامش اب افطل .دشاب یم امش رایتخا رد ناگیار روط هب ینابز دادما تامدخ ،تسا (Farsi) یسراف امش نابز رگا :هجوت.ديريگب سامت هدش دیق امش یياسانش تراک یور هک یناگیار

ध्यान दें: यदि आप हिंदी (Hindi) बोलत ेह,ै आपको भाषा सहायता सेबाए,ं नि:शुल्क उपलब्ध हैं। कृपया अपन ेपहचान पत्र पर सूचीबद्ध टोल-फ्री फोन नंबर पर कॉल करें।

CEEB TOOM: Yog koj hais Lus Hmoob (Hmong), muaj kev pab txhais lus pub dawb rau koj. Thov hu rau tus xov tooj hu deb dawb uas teev muaj nyob rau ntawm koj daim yuaj cim qhia tus kheej.

ចំណាប់អារម្មណ៍ៈ បើសិនអ្នកនិយាយភាសាខ្មែរ(Khmer)សេវាជំនួយភាសាដោយឥតគិតថ្លៃ គឺមានសំរាប់អ្នក។ សូមទូរស័ព្ទទៅលេខឥតគិតថ្លៃ ដែលមាននៅលើអត្ដសញ្ញាណប័ណ្ណរបស់អ្នក។

PAKDAAR: Nu saritaem ti Ilocano (Ilocano), ti serbisyo para ti baddang ti lengguahe nga awanan bayadna, ket sidadaan para kenyam. Maidawat nga awagan iti toll-free a numero ti telepono nga nakalista ayan iti identification card mo.

DÍÍ BAA’ÁKONÍNÍZIN: Diné (Navajo) bizaad bee yániłti’go, saad bee áka›anída›awo›ígíí, t’áá jíík’eh, bee ná’ahóót’i’. T’áá shǫǫdí ninaaltsoos nitł’izí bee nééhozinígíí bine’dę́ę́› t’áá jíík’ehgo béésh bee hane’í biká’ígíí bee hodíilnih.

OGOW: Haddii aad ku hadasho Soomaali (Somali), adeegyada taageerada luqadda, oo bilaash ah, ayaad heli kartaa. Fadlan wac lambarka telefonka khadka bilaashka ee ku yaalla kaarkaaga aqoonsiga.

your 2017 formulary · 2017-07-03 · used generic drugs. some low-cost brands may be included. use...

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