your 2018 formulary - brown university · many common brand-name drugs, called preferred brands....

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 2018 Formulary

OptumRx 1

Effective January 1, 2018

Premium 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

Programs and limits . . . . . . . . . . . . . . . . . . . 7

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

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

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

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

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

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

Diabetes/EndocrineBlood Glucose Monitoring . . . . . . . . . . . . . . . 13Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Non-Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . 15

EndocrineGrowth Hormone . . . . . . . . . . . . . . . . . . . . . 15Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Thyroid Hormone Replacement . . . . . . . . . . . 16

Eye ConditionsAllergies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

GastrointestinalAcid Suppression . . . . . . . . . . . . . . . . . . . . . . 16Nausea/Vomiting . . . . . . . . . . . . . . . . . . . . . . 17Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

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

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

Inflammatory Conditions . . . . . . . . . . . . . . 17

Men’s HealthErectile Dysfunction . . . . . . . . . . . . . . . . . . . . 18Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Testosterone Therapy . . . . . . . . . . . . . . . . . . . 18

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

MusculoskeletalOsteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . 19 Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Pain Relief . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

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

RespiratoryAsthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . 20Nasal Allergies . . . . . . . . . . . . . . . . . . . . . . . . 21Oral Allergies . . . . . . . . . . . . . . . . . . . . . . . . . 21

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

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

Women’s HealthBirth Control . . . . . . . . . . . . . . . . . . . . . . . . . 21Hormone Replacement . . . . . . . . . . . . . . . . . 22Vaginal Anti-Infectives . . . . . . . . . . . . . . . . . . 22

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

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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.

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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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.

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.

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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.

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.

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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

Programs and Limits

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

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

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

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

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

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

EExcluded – May be excluded from coverage or subject to prior authorization. Lower-cost options are available and covered.

To learn more about a pharmacy program or to find out if it applies to you, please visit your plan’s member website or call the toll-free member phone number on your ID card.

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Excluded brand-name medications with generic equivalents for 2018*

The brand-name medications below are excluded on the formulary. These brand-name medications have been identified to have available generic equivalents covered at Tier 1 on the formulary. Speak with your pharmacist to have your excluded brand-name medication substituted with its generic equivalent.

A generic medication contains the same active ingredient(s) as a brand-name medication. An active ingredient is what makes the medication work. For example, Liptor® and its generic both contain atorvastatin, which reduces the amount of bad cholesterol in the blood. Brand-name medications are often protected by a patent. When the patent ends, drug companies can apply to the U.S. Food and Drug Administration (FDA) to begin making generic versions of the medication.

Aciphex

Acticlate

Adderall XR

Alphagan P

Ambien

Ambien CR

Androgel 1%

Azor

Benicar

Benicar HCT

Benzamycin

Benzaclin

Beyaz

Carafate

Celebrex

Concerta

Crestor

Cymbalta

Cytomel

Depo — Testost Inj

Dilantin

Dilantin Chewable

Dilantin Suspension

Diovan

Diovan HCT

Duac

Duragesic

Effexor XR

Glumetza

Kadian

Lexapro

Lidoderm

Lipitor

Lovaza

Lunesta

Minastrin

Nasonex

Nexium

Nitrostat

Norco

Norvasc

Nuvigil

Ortho Tri Cyclen

Ortho Tri Cyclen Lo

Percocet

Prevacid

Pristiq

Prozac

Pulmicort Inh Suspension

Retin-A Micro Gel

Singulair

Taclonex

Tamiflu

Tobi Nebulizer

Tobradex

Toprol XL

Tribenzor

Vagifem

Valium

Vitafol

Vivelle-Dot

Voltaren

Vytorin

Wellbutrin

Wellbutrin SR

Wellbutrin XL

Xanax

Xanax XR

Yaz

Zegerid

Zetia

Ziana

Zoloft

Zomig

Zomig ZMT

Zovirax

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.

* These brand-name medications have been identified to have available generic equivalents. Not all brand-name medications have generic equivalents. Brand-name medications without generic equivalents are included in the following medication list.

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

AR Age RestrictionsPA Prior Authorization ST Step Therapy

QL Quantity Limits SP Specialty Program

Drug NameDrug Tier

Programs and Limits

Anti-Infectives: Antibiotics

Amoxicillin 1Amoxicillin/Clavulanate 1Azasite 3Azithromycin 1Bethkis 2 SPCefdinir 1Cefuroxime Tab 1Cephalexin 1Ciprodex Otic

Suspension2

Ciprofloxacin Tab 1Clarithromycin 1Clindamycin Cap 1Doryx MPC 3Doxycycline Hyclate Cap 1Doxycycline Hyclate Tab

(Immediate Release)1

Doxycycline Monohydrate Cap

1

Doxycycline Monohydrate Oral Suspension, Tab

1

Erythromycin 1Kitabis E SPLevofloxacin Tab 1Metronidazole Tab 1Minocycline Cap 1Nitrofurantoin

Macrocrystalline1

Nitrofurantoin Monohydrate Macrocrystalline

1

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

Trimethoprim1

Drug NameDrug Tier

Programs and Limits

Sulfamethoxazole-Trimethoprim DS

1

TOBI podhaler E ST, SPTobramycin (M) E ST, SP

Anti-Infectives: Antifungals

Fluconazole 1Jublia Solution 3 PAKerydin Solution 3 PANystatin Suspension 1Terbinafine Tab 1 QL

Anti-Infectives: Antivirals

Acyclovir Cap, Tab, Suspension

1

Descovy 2 SPEntecavir 1 QL, SPEpclusa 2 PA, QL, SPFamciclovir Tab 1Harvoni 2 PA, QL, SPMavyret 2 PA, QL, SPOdefsey 2 SPOseltamivir 1 QLValacyclovir 1 QLZepatier 3 PA, QL, SP

CancerAkynzeo 3 QLAnastrozole Tab 1Cabometyx 2 PA, SPCapecitabine 1 PA, SPLetrozole 1Mercaptopurine 1 SPRevlimid 3 PA, SPSprycel 2 PA, SPTamoxifen Tab 1Zytiga 3 PA, SP

(M) Co-Branded Product

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Drug NameDrug Tier

Programs and Limits

Cardiovascular/Heart Disease: AnticoagulantsBrilinta 2Clopidogrel 1Effient 2Eliquis 3 QLEnoxaparin 1 QL, SPPradaxa 2 QLSavaysa 3 QLWarfarin 1Xarelto 2 QLZontivity 3Cardiovascular/Heart Disease: High Blood PressureAmlodipine 1Amlodipine/Benazepril 1Amlodipine/Valsartan 1Atenolol 1Atenolol/Chlorthalidone 1Benazepril 1Benazepril/HCTZ 1Bisoprolol 1Bisoprolol/HCTZ 1Bumetanide 1Bystolic 2Byvalson 2Cartia XT 1Carvedilol 1Chlorthalidone 1Clonidine Tab 1Diltiazem ER 1Doxazosin 1Edarbi 3 STEdarbyclor 3 STEnalapril 1Furosemide 1Guanfacine Tab


Hydralazine 1Hydrochlorothiazide 1Irbesartan 1

Drug NameDrug Tier

Programs and Limits

Labetalol 1Lisinopril 1Lisinopril/HCTZ 1Losartan 1Losartan/HCTZ 1Metoprolol Succinate 1Metoprolol Tartrate 1Nadolol 1Nifedipine ER 1Olmesartan 1Olmesartan HCT 1Prazosin 1Propranolol 1Propranolol ER 1Quinapril 1Ramipril 1Spironolactone 1Tekturna 2 STTekturna HCT 2 STTelmisartan 1Terazosin 1Torsemide Tab 1Triamterene/HCTZ 1Valsartan 1Valsartan/HCTZ 1Verapamil ER 1Cardiovascular/Heart Disease: High CholesterolAtorvastatin 1Choline Fenofibrate ER 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 1Livalo 3 STLovastatin 1Niacin ER Tab 1

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Drug NameDrug Tier

Programs and Limits

Omega-3 Acid Cap 1 gm

1

Praluent 2 PA, QL, SPPravastatin 1Rosuvastatin 1Simvastatin 5 mg, 10

mg, 20 mg, 40 mg1

Simvastatin 80 mg 1 PAVascepa 2Welchol 2

Cardiovascular/Heart Disease: Other

Corlanor 3 PA, QLDigoxin 1Flecainide 1Isosorbide Mononitrate

ER1

Multaq 3Nitroglycerin SL Tab 1Ranexa 2 STSotalol 1Cardiovascular/Heart Disease: Pulmonary Arterial HypertensionAdcirca 3 PA, QL, SPAdempas 2 PA, QL, SPLetairis 2 PA, QL, SPOpsumit 2 PA, QL, SPOrenitram 3 PA, SPSildenafil Tab 20 mg 1 PA, QL, SPTracleer 2 PA, QL, SP

Drug NameDrug Tier

Programs and Limits

Central Nervous System: Attention Deficit DisorderAmphetamine-

Dextroamphetamine Tab

1 PA, QL

Amphetamine-Dextroamphetamine SR 24Hr Cap

1 PA, QL

Dexmethylphenidate ER Cap

1 PA, QL

Guanfacine ER Tab 1Methylphenidate

ER Cap1 PA, QL

Methylphenidate ER Tab 1 PA, QLMethylphenidate SA

Osmotic ER Tab1 PA, QL

Methylphenidate Tab 1 PA, QLStrattera 3 QLVyvanse 2 QL, PA

Central Nervous System: Depression

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

30 mg, 60 mg1 QL

Escitalopram Tab 1Fluoxetine Cap

(not PMDD)1

Forfivo XL 2 QLMirtazapine 1Nortriptyline 1Paroxetine Tab 1Rexulti 3 QLRisperidone Tab 1 QLSertraline 1

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Drug NameDrug Tier

Programs and Limits

Trazodone 1Trintellix 3 QL, STVenlafaxine Tab 1Venlafaxine ER Cap 1Venlafaxine ER Tab 1Viibryd 3 QL

Central Nervous System: Migraine

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

1

Migranal 3 QLRelpax 3 QLRizatriptan Tab, ODT 1 QLSumatriptan Tab

and Spray1 QL

Sumavel Dose 3 QLCentral Nervous System: Multiple SclerosisAmpyra 2 PA, QL, SPAubagio 3 PA, QL, ST, SPAvonex Kit 2 PA, QL, SPAvonex Pen Kit 2 PA, QL, SPAvonex Prefill Kit 2 PA, QL, SPBetaseron 2 PA, QL, SPCopaxone 20 mg/mL

& 40 mg/mL2 PA, QL, SP

Extavia E PA, QL, ST, SPGilenya+ 3 PA, QL, ST, SPPlegridy E PA, QL, ST, SPRebif E PA, QL, ST, SPRebif Titrtn E PA, QL, ST, SPTecfidera 2 PA, QL, SP

Central Nervous System: Other

Alprazolam Tab 1 QLAripiprazole 1 QLAristada 3Buspirone 1Diazepam Tab 1Hydroxyzine HCL 1

Drug NameDrug Tier

Programs and Limits

Hydroxyzine Pamoate 1Invega Sustenna 3Invega Trinza 3Latuda 3 QL, STLorazepam Tab 1 QLModafinil 1 PA, QLNamenda XR 2 QLNamzaric 2 QLOlanzapine Tab 1 QLPramipexole 1Quetiapine 1 QLRisperidone Tab 1 QLRopinirole


Saphris 2 QLXyrem 3 PA, QL, SPCentral Nervous System: Sedatives/HypnoticsEszopiclone Tab 1 QLSilenor 3 QLTemazepam 1 QLTriazolam Tab 1 QLZaleplon 1 QLZolpidem 1 QLZolpidem ER 1 QLCentral Nervous System: Seizure DisordersClonazepam 1 QLDivalproex DR 1Divalproex ER 1Gabapentin 1Lamotrigine


Levetiracetam 1Levetiracetam ER 1Lyrica Cap 2 QLOxcarbazepine 1Primidone 1Topiramate Tab 1Trokendi XR E STVimpat 3Zonisamide 1

+ Tier 3 Preferred

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Drug NameDrug Tier

Programs and Limits

Dermatology

Absorica 3 PAAcanya Gel E STAczone Gel 3Aktipak E STAtralin 3 PAClaravis 1 PAClindamycin Gel,

Lotion, Solution1

Clindamycin/ Benzoyl Peroxide Gel 1-5%

1

Clindamycin/Benzoyl Peroxide Gel 1.2-5%

1

Clobetasol Cream, Ointment, Solution

1

Clobex 3Clotrimazole/

Betamethasone Cream, Lotion

1

Dupixent 2 PA, QL, SPElidel 2 STEpiduo & Epiduo

Forte3

Eucrisa 2 STFluocinonide Cream,

0.1%1

Fluocinonide Cream, Gel, Ointment, Solution 0.05%

1

Hydrocortisone Cream, Ointment 2.5%

1

Ketoconazole Cream/Shampoo

1

Lidocaine Topical Ointment, Solution

1

Metrogel 3Metronidazole Gel

0.75%1

Drug NameDrug Tier

Programs and Limits

Mirvaso Gel 2Mupirocin Ointment 1Myorisan 1 PANystatin Cream,

Ointment, Powder1

Onexton 3Oxsoralen-UL 2Pennsaid Solution E PAPermethrin Cream 5% 1Proctofoam HC 2Soolantra 2Tazorac 3Tretinoin Cream 1 PATretinoin Microsphere

Gel1 PA

Triamcinolone 1Vectical 3Veltin E STZovirax Cream 2Zyclara 3Diabetes/Endocrine Blood: Glucose MonitoringAccu-Chek Active

Glucose Control Liquid

E

Accu-Chek Active Test Strips

E QL

Accu-Chek Aviva Connect Kit

E

Accu-Chek Aviva Plus Control Liquid

E

Accu-Chek Aviva Plus Kit

E

Accu-Chek Aviva Plus Test Strips

E QL

Accu-Chek Compact Plus Control Liquid

E

Accu-Chek Compact Plus Test Strips

E QL

Accu-Chek Compact Plus Kit

E

Accu-Chek FastClix Kit

2

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Drug NameDrug Tier

Programs and Limits

Accu-Chek FastClix Lancets

2

Accu-Chek Guide Control Liquid

E

Accu-Chek Guide Kit EAccu-Chek Guide Test

StripsE QL

Accu-Chek Multiclix Kit

2

Accu-Chek Multiclix Lancets

2

Accu-Chek Nano SmartView Kit

E

Accu-Chek SmartView Control Liquid

E

Accu-Chek SmartView Test Strips

E QL

Accu-Chek Soft Touch Lancets

2

Accu-Chek Softclix Kit 2Accu-Chek Softclix

Lancets2

Bayer Contour Test Strips

E QL, ST

Dexcom G4 Platinum Kit

3

Dexcom G4 Platinum Sensor Kit

3

Dexcom G4 Platinum Transmitter Kit

3

Dexcom G5 Kit 3Dexcom G5 Sensor

Kit3

Dexcom G5 Transmitter Kit

3

Freestyle Test Strips E QL, STInsulin Pen Needle 2Insulin Syringe/

Needle 2

Novofine Pen Needle 3

Drug NameDrug Tier

Programs and Limits

Novofine Autocover Pen Needle

3

Novotwist Pen Needle

3

OneTouch Ultra 2 System

2

OneTouch UltraMini System Kit

2

OneTouch Verio IQ System Kit

2

OneTouch Verio Sync System Kit

2

OneTouch Verio System Kit

2

OneTouch Verio Flex System Kit

2

OneTouch Ultra Test Strips

2 QL

OneTouch Verio Test Strips

2 QL

Precision Test Strips E QL, ST

Diabetes/Endocrine: Insulin

Apidra E STBasaglar E STHumalog Mix 50/50

Vial and KwikPen2

Humalog Mix 75-25 Vial and KwikPen

2

Humalog U-100 Vial and KwikPen

2

Humalog U-200 KwikPen

2

Humulin 70-30 Vial and KwikPen

2

Humulin N Vial and KwikPen

2

Humulin R U-500 Vial and KwikPen

2

Humulin R Vial 2Lantus SoloStar 2Lantus Vial 2

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Drug NameDrug Tier

Programs and Limits

Levemir FlexTouch ELevemir Vial ENovolin 70/30 Vial ENovolin N Vial ENovolin R Vial ENovolog Flexpen ENovolog Mix 70/30

Vial and FlexpenE

Novolog Penfill ENovolog Vial EToujeo SoloStar 2Tresiba E

Diabetes/Endocrine: Non-Insulin

Adlyxin E QL, STAlogliptin (M) E STAlogliptin/

metformin (M)E ST

Alogliptin/pioglitazone (M)

E ST

Bydureon 2 QL, STByetta 2 QL, STFarxiga E STGlimepiride 1Glipizide 1Glipizide ER 1Glipizide XL 1Glumetza 3 PAGlyburide 1Invokamet 2 STInvokamet XR 2 STInvokana 2 STJanumet 2 STJanumet XR 2 STJanuvia 2 STJardiance 2 STJentadueto 2 STJentadueto XR 2 STKazano E STKombiglyze E ST

Drug NameDrug Tier

Programs and Limits

Metformin 1Metformin ER 1Nesina E STOnglyza E STOseni E STPioglitazone 1Soliqua 2 QL, STSynjardy 2 STSynjardy XR 2 STTanzeum E QL, STTradjenta 2 STTrulicity 2 QL, STVictoza 2 QL, STXigduo XR E ST

Endocrine: Growth Hormone

Genotropin E PA, SPHumatrope E PA, SPNorditropin 2 PA, SPNutropin AQ 2 PA, SPOmnitrope 2 PA, SPSaizen E PA, SPZomacton E PA, SP

Endocrine: Other

Calcitriol Cap 1Clomiphene 1Dexamethasone Tab 1H.P. Acthar 2 PA, SP


16




Drug NameDrug Tier

Programs and Limits

Hydrocortisone Tab 1Lupron Depot

3.75 mg, 11.25 mg3 PA, SP

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

2 PA, SP

Methylprednisolone Tab 1Prednisone 1Prednisolone Solution

25 mg/5 ml1

Prednisolone Syrup, Solution 15 mg/5 ml

1

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

Eye Conditions: Allergies

Azelastine Ophthalmic Solution

1

Pataday 3Pazeo 2

Eye Conditions: Antibiotics

Besivance 3Ciprofloxacin

Ophthalmic Solution1

Erythromycin Ointment 1Moxeza 2Ofloxacin Ophthalmic

Solution1

Polymyxin B/Trimethoprim Solution

1

Tobramycin 1Tobramycin/

Dexamethasone1

Vigamox 3

Drug NameDrug Tier

Programs and Limits

Eye Conditions: Glaucoma

Azopt 2Betimol 3Combigan 2Cosopt PF 3Latanoprost 1 QLLumigan 2 QLRescula E QLSimbrinza 2Travatan Z 2 QLZioptan E QL

Eye Conditions: Other

Ketorolac Ophthalmic Solution

1

Prednisolone Ophthalmic Suspension

1

Restasis 2 PARestasis Multidose 2 PAXiidra 2 PA

Gastrointestinal: Acid Suppression

Dexilant 2 QLDuexis E QL, STEsomeprazole

Magnesium (Rx only)

1 QL

Famotidine Tab 20 mg and 40 mg (Rx only)

1

Lansoprazole (Rx only) 1 QLOmeprazole (Rx only) 1 QLPantoprazole 1 QLRanitidine Tab, Cap,

Syrup (Rx only)1

Sucralfate Tab 1Vimovo E PA, QL

17




Drug NameDrug Tier

Programs and Limits

Gastrointestinal: Nausea/Vomiting

Meclizine 1Metoclopramide 1Ondansetron ODT 1 QLOndansetron Tab 1Varubi 3 QL

Gastrointestinal: OtherAmitiza 2 QL, STApriso 2Asacol HD E STCanasa 2Creon 2Delzicol E STDicyclomine 1Dipentum 3Diphenoxylate/Atropine 1Gavilyte Solution 1Lialda E STLinzess 2 QL, STMesalamine DR (M) E STMisoprostol 1Pancreaze E STPentasa 3Pertzye E STPolyethylene

Glycol 3350 Powder1

Prepopik 3Pylera 2Rabeprazole 1 QLSuprep Bowel Prep 3Uceris Foam 3Ultresa E STViokace E STZenpep 2

Drug NameDrug Tier

Programs and Limits

HIV/AIDS

Atripla 2 SP Complera 2 SPGenvoya 2 SPIsentress 2 SPNorvir 2 SPPrezcobix 2 SPPrezista 2 SPReyataz 2 SPStribild 2 SPTivicay 2 SPTriumeq 2 SPTruvada 2 SPViread 2 SP

Infertility

Bravelle E PA, SPCetrotide 2 PA, SPFollistim AQ E PA, SPGonal-f 2 PA, SPGonal-f RFF 2 PA, SPOvidrel 3 SP

Inflammatory Conditions

Cimzia Kit 2 PA, SPCosentyx+ 3 PA, SPDepen 2 SPEnbrel 3 PA, ST, SPHumira Kit 2 PA, SPHumira Pen Kit 2 PA, SPHumira Pen Kit

Crohns2 PA, SP

Humira Pen Kit Psoriasis

2 PA, SP

Hydroxychloroquine 1Inflectra E PA, SPLeflunomide 1Methotrexate Tab 1

+ Tier 3 Preferred (M) Co-Branded Product

18




Drug NameDrug Tier

Programs and Limits

Orencia SC 3 PA, ST, SPOtezla 2 PA, SPRasuvo 2 PA, QLRemicade 2 PA, SPSimponi 2 PA, SPSimponi Aria 2 PA, SPStelara 2 PA, SPTaltz E PA, ST, SPXeljanz 3 PA, ST, SP

Men’s Health: Erectile Dysfunction

Cialis 2 QLLevitra E QLStaxyn E QLStendra E QLViagra 2 QL

Men’s Health: Prostate

Cialis 2.5 mg & 5 mg 2 QLDoxazosin 1Dutasteride 1Finasteride 5 mg 1Rapaflo 2Tamsulosin 1Terazosin

Men’s Health: Testosterone Therapy

Androderm 2 PAAndrogel 1.62% 2 PAAxiron E PAFortesta E PATestim E PATestosterone Cypionate

IM Injection1 PA

Vogelxo E PA

Drug NameDrug Tier

Programs and Limits

Miscellaneous

Adrenaclick E STAllopurinol 1Aranesp E PA, SPArmodafinil 1 PA, QLAuryxia 3Auvi-Q E STBenzonatate 1Botox 100, 200 unit

Injection (non-cosmetic)

2 PA, SP

Bunavail 3 QLCerdelga 3 PA, SPCheratussin 1Chlorhexidine 1Colcrys 2Contrave 2 PAEpinephrine

Auto-Injector (Authorized Generic for EpiPen made by Mylan)

2

Epinephrine Auto-Injector (M) (made by Impax)

E ST

EpiPen & EpiPen Jr E STEpogen E PA, SPEuflexxa 2 PA, SPFosrenol 3Granix 2 PA, SPGuaifenesin/Codeine

Syrup1

Hydrocodone/Chlorpheniramine Liquid

1


19




Drug NameDrug Tier

Programs and Limits

Hydrocodone Polistirex/Chlorpheniramine ER Suspension

1

Lidocaine Viscous Solution 2%

1

Makena 2 PA, SPNarcan 2Neupogen 2 PA, SPPhenazopyridine

(Rx only)1

Phentermine Tab 1 PAProcrit 2 PA, SPPromethazine DM Syrup 1Promethazine/Codeine

Syrup1

Renvela Tab 2Rezira 3Suboxone Film 2 QLSynvisc 2 PA, SPSynvisc One 2 PA, SPUloric 2 STVelphoro 3Zarxio 2 PA, SPZubsolv 2 QLZurampic 3Zutripro 3

Musculoskeletal: Osteoporosis

Alendronate Tab 35 mg & 70 mg

1 QL

Binosto 3 QLForteo 2 PA, SPTymlos 2 PA, SP

Musculoskeletal: Other

Amrix EBaclofen Tab 1Carisoprodol 350 mg 1

Drug NameDrug Tier

Programs and Limits

Cyclobenzaprine Tab 5, 10 mg

1

Lorzone 3Metaxalone 1Methocarbamol 1Tizanidine Cap 1Tizanidine Tab 1

Musculoskeletal: Pain Relief

Abstral E PA, QLAcetaminophen

w/ Codeine 1 QL

Arymo ER E PA, QLCambia E STCelecoxib 1 QLDiclofenac Gel 1 QLDiclofenac Tab 1Embeda 2 PA, QLEtodolac 1Fentanyl Patch

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

1 PA, QL

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

1 PA, QL

Fentora E PA, QLFlector patch 3 QLGralise 3 QL, STHydrocodone/

Acetaminophen 5, 7.5, 10/325 mg

1 QL

Hydromorphone Tab 1 QLHysingla ER 2 PA, QLIbuprofen Tab 400, 600,

800 mg (Rx only)1

20




Drug NameDrug Tier

Programs and Limits

Indomethacin Cap 1Ketorolac Tab 1 QLLazanda E PA, QLLidocaine Patch 5% 1Meloxicam 1Methadone Tab 1 PAMorphine Sulfate ER 1 PA, QLNabumetone 1Naproxen (Rx only) 1Nucynta ER E PA, QLOxycodone Tab 5,

10, 15, 30 mg (Immediate Release)

1 QL

Oxycodone w/ Acetaminophen

1 QL

Oxycontin 2 PA, QLSubsys E PA, QLTramadol Tab 50 mg 1Tramadol

w/ Acetaminophen 1

Xtampza ER E PA, QLZohydro ER E PA, QLZorvolex E

Overactive Bladder

Myrbetriq 2Oxybutynin 1Oxybutynin ER 1Toviaz 3Vesicare 2

Respiratory: Asthma/COPD

Advair Diskus 2 QLAdvair HFA 2 QLAerospan 3 QL

Drug NameDrug Tier

Programs and Limits

AirDuo E QL, STAlbuterol

Nebulizer Solution1 QL

Alvesco E QL, STAnoro Ellipta 2 QLArnuity Ellipta 2 QLAsmanex E QL, STBreo Ellipta 2 QLBudesonide Inhalation

Suspension1 QL

Combivent Respimat 2 QLDulera E QL, STFlovent Diskus 2 QLFlovent HFA 2 QLIncruse Ellipta 2 QLIpratropium/Albuterol

Nebulizer Solution1 QL

Levalbuterol Inhaler (M)

E QL, ST

Montelukast 1Proair HFA, RespiClick 2 QLProventil HFA E QL, STPulmicort Flexhaler 2 QLQvar E QLSerevent Diskus 2 QLSpiriva Handihaler 2 QLSpiriva Respimat 2 QLStiolto 2 QLSymbicort 2 QLTudorza E QL, STVentolin HFA 2 QLXolair 2 PA, SPXopenex HFA E QL, ST


21




Drug NameDrug Tier

Programs and Limits

Respiratory: Nasal Allergies

Astepro 3 QLAzelastine Spray 1 QLDymista Spray 2 QLFluticasone Spray 1Ipratropium Spray 1 QLMometasone 1 QLOmnaris 3 QLQNasl 3 QLZetonna 3 QL

Respiratory: Oral Allergies

Cetirizine 1Levocetirizine 1Promethazine Tab 1

Transplant

Azathioprine Tab 1Mycophenolate Mofetil

250 mg Cap/ 500 mg Tab

1 SP

Mycophenolate Sodium 180 mg, 360 mg Tab

1 SP

Prograf Cap 3 SPTacrolimus Cap 1 SP

Vitamins/Electrolytes

Cyanocobalamine Injection

1

Folic Acid 1 mg (Rx only)

1

Klor-Con 8 and 10 MEQ 1Klor-Con M10 and M20 1Ludent 1Potassium Chloride ER

Tab, Cap1

Potassium Chloride Micro ER Tab

1

Vitamin D 50,000 units (Rx only)

1

Drug NameDrug Tier

Programs and Limits

Women’s Health: Birth Control

Apri 1Aviane 1Azurette 1Cryselle-28 1Falmina 1Generess Fe

Chewable3

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

Acetate Injection1 QL

Microgestin 1Microgestin Fe 1Mono-Linyah 1Mononessa 1Natazia 2Necon 1Nora-Be 1Norgest/Ethi Estradio 1Nortrel 1Nuvaring 2Ocella 1Orsythia 1Previfem 1Reclipsen 1Sprintec 28 1Tri-Linyah 1Tri-Lo-Sprintec 1Tri-Previfem 1Trinessa 1Tri-Sprintec 1

22




Drug NameDrug Tier

Programs and Limits

Vestura 1Viorele 1Xulane 1Zarah 1

Women’s Health: Hormone Replacement

Climara Pro 2Divigel 3Duavee 2Elestrin Gel 3Estrace Vaginal Cream 3Estradiol Patch, Tab 1Estradiol/Norethindrone

Tab1

Medroxyprogesterone Acetate Tab

1

Minivelle 3Osphena 3Premarin Tab 2Premarin Vaginal

Cream2

Premphase 2Prempro 2Progesterone Cap 1Yuvafem 1

Drug NameDrug Tier

Programs and Limits

Women’s Health: Vaginal Anti-Infectives

Gynazole-1 Vaginal Cream

3

Metronidazole Vaginal Gel

1

Terconazole Vaginal Cream

1

Bold type = Brand-name drug [Plain type = Generic drug] 23

Index of Drugs

A

Absorica . . . . . . . . . . 13Abstral . . . . . . . . . . . 19Acanya Gel. . . . . . . . . 13Accu-Chek Active Glucose

Control Liquid . . . . . 13Accu-Chek Active

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

Connect Kit . . . . . . 13Accu-Chek Aviva

Plus Control Liquid . . 13Accu-Chek Aviva Plus Kit . 13Accu-Chek Aviva

Plus Test Strips. . . . . 13Accu-Chek Compact Plus

Control Liquid . . . . . 13Accu-Chek Compact

Plus Kit . . . . . . . . . 13Accu-Chek Compact

Plus Test Strips. . . . . 13Accu-Chek FastClix Kit . . 13Accu-Chek FastClix Lancets . 14Accu-Chek Guide

Control Liquid . . . . . 14Accu-Chek Guide Kit . . . 14Accu-Chek Guide Test Strips 14Accu-Chek Multiclix Kit . . 14Accu-Chek Multiclix Lancets 14Accu-Chek Nano

SmartView Kit . . . . . 14Accu-Chek SmartView

Control Liquid . . . . . 14Accu-Chek SmartView

Test Strips . . . . . . . 14Accu-Chek Softclix Kit. . . 14Accu-Chek Softclix Lancets . 14Accu-Chek Soft Touch

Lancets . . . . . . . . . 14Acetaminophen w/ Codeine 19Acyclovir Cap, Tab, Suspension. .9Aczone Gel. . . . . . . . . 13Adcirca . . . . . . . . . . . 11Adempas. . . . . . . . . . 11Adlyxin. . . . . . . . . . . 15Adrenaclick . . . . . . . . 18Advair Diskus . . . . . . . 20Advair HFA . . . . . . . . 20Aerospan . . . . . . . . . 20AirDuo . . . . . . . . . . . 20

Aktipak . . . . . . . . . . 13Akynzeo . . . . . . . . . . . 9Albuterol Nebulizer Solution . . 20Alendronate Tab . . . . . . 19Allopurinol . . . . . . . . . 18Alogliptin (M) . . . . . . . 15Alogliptin/

metformin (M) . . . . . 15Alogliptin/pioglitazone (M) 15Alprazolam Tab . . . . . . . 12Alvesco. . . . . . . . . . . 20Amitiza. . . . . . . . . . . 17Amitriptyline . . . . . . . . 11Amlodipine . . . . . . . . . 10Amlodipine/Benazepril . . . 10Amlodipine/Valsartan . . . . 10Amoxicillin . . . . . . . . . . 9Amoxicillin/Clavulanate . . . . 9Amphetamine-

Dextroamphetamine SR . 11Amphetamine-

Dextroamphetamine Tab . 11Ampyra . . . . . . . . . . 12Amrix . . . . . . . . . . . . 19Anastrozole Tab . . . . . . . . 9Androderm . . . . . . . . 18Androgel 1.62% . . . . . . 18Anoro Ellipta . . . . . . . 20Apidra . . . . . . . . . . . 14Apri . . . . . . . . . . . . . 21Apriso . . . . . . . . . . . 17Aranesp . . . . . . . . . . 18Aripiprazole . . . . . . . . . 12Aristada. . . . . . . . . . . 12Armodafinil . . . . . . . . . 18Armour Thyroid . . . . . . 16Arnuity Ellipta . . . . . . . 20Arymo ER . . . . . . . . . 19Asacol HD . . . . . . . . . 17Asmanex. . . . . . . . . . 20Astepro . . . . . . . . . . 21Atenolol. . . . . . . . . . . 10Atenolol/Chlorthalidone. . . 10Atorvastatin . . . . . . . . 10Atralin . . . . . . . . . . . 13Atripla . . . . . . . . . . . 17Aubagio . . . . . . . . . . 12Auryxia . . . . . . . . . . 18Auvi-Q . . . . . . . . . . . 18Aviane . . . . . . . . . . . 21Avonex Kit. . . . . . . . . 12

Avonex Pen Kit . . . . . . 12Avonex Prefill Kit . . . . . 12Axiron . . . . . . . . . . . 18Azasite . . . . . . . . . . . . 9Azathioprine Tab . . . . . . 21Azelastine Ophthalmic Solution 16Azelastine Spray. . . . . . . 21Azithromycin . . . . . . . . . 9Azopt . . . . . . . . . . . 16Azurette . . . . . . . . . . 21

B

Baclofen Tab . . . . . . . . 19Basaglar . . . . . . . . . . 14Bayer Contour Test Strips . . 14Benazepril. . . . . . . . . . 10Benazepril/HCTZ . . . . . . 10Benzonatate . . . . . . . . 18Besivance . . . . . . . . . 16Betaseron . . . . . . . . . 12Bethkis . . . . . . . . . . . . 9Betimol. . . . . . . . . . . 16Binosto. . . . . . . . . . . 19Bisoprolol . . . . . . . . . . 10Bisoprolol/HCTZ . . . . . . . 10Botox. . . . . . . . . . . . 18Bravelle . . . . . . . . . . 17Breo Ellipta . . . . . . . . 20Brilinta . . . . . . . . . . . 10Budesonide Inhalation

Suspension . . . . . . . 20Bumetanide . . . . . . . . . 10Bunavail . . . . . . . . . . 18Bupropion. . . . . . . . . . 11Bupropion ER . . . . . . . . 11Bupropion SR . . . . . . . . 11Bupropion XL . . . . . . . . 11Buspirone . . . . . . . . . . 12Butalbital-Acetaminophen-

Caffeine Cap, Tab . . . . 12Bydureon . . . . . . . . . 15Byetta . . . . . . . . . . . 15Bystolic. . . . . . . . . . . 10Byvalson . . . . . . . . . . 10

C

Cabometyx . . . . . . . . . . 9Calcitriol Cap . . . . . . . . 15Cambia. . . . . . . . . . . 19


Index of Drugs

Canasa . . . . . . . . . . . 17Capecitabine . . . . . . . . . 9Carisoprodol . . . . . . . . 19Cartia XT . . . . . . . . . . 10Carvedilol . . . . . . . . . . 10Cefdinir . . . . . . . . . . . . 9Cefuroxime Tab . . . . . . . . 9Celecoxib . . . . . . . . . . 19Cephalexin . . . . . . . . . . 9Cerdelga . . . . . . . . . . 18Cetirizine . . . . . . . . . . 21Cetrotide. . . . . . . . . . 17Cheratussin . . . . . . . . . 18Chlorhexidine . . . . . . . . 18Chlorthalidone . . . . . . . 10Choline Fenofibrate ER . . . 10Cialis . . . . . . . . . . . . 18Cimzia Kit . . . . . . . . . 17Ciprodex Otic Suspension . . .9Ciprofloxacin Ophthalmic

Solution . . . . . . . . . 16Ciprofloxacin Tab . . . . . . . 9Citalopram . . . . . . . . . 11Claravis . . . . . . . . . . . 13Clarithromycin . . . . . . . . 9Climara Pro . . . . . . . . 22Clindamycin/Benzoyl

Peroxide Gel. . . . . . . 13Clindamycin Cap . . . . . . . 9Clindamycin Gel, Lotion,

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

Ointment, Solution . . . 13Clobex . . . . . . . . . . . 13Clomiphene. . . . . . . . . 15Clonazepam . . . . . . . . 12Clonidine Tab . . . . . . . . 10Clopidogrel . . . . . . . . . 10Clotrimazole/Betamethasone

Cream, Lotion . . . . . . 13Colcrys . . . . . . . . . . . 18Combigan . . . . . . . . . 16Combivent Respimat . . . 20Complera . . . . . . . . . 17Contrave . . . . . . . . . 18Copaxone . . . . . . . . . 12Corlanor . . . . . . . . . . 11Cosentyx+ . . . . . . . . . 17Cosopt PF . . . . . . . . . 16Creon. . . . . . . . . . . . 17Crestor . . . . . . . . . . . 10

Cryselle-28 . . . . . . . . . 21Cyanocobalamine Injection . 21Cyclobenzaprine Tab . . . . 19

D

Delzicol . . . . . . . . . . 17Depen . . . . . . . . . . . 17Descovy . . . . . . . . . . . 9Dexamethasone Tab . . . . 15Dexcom G4 Platinum Kit . 14Dexcom G4 Platinum

Sensor Kit . . . . . . . 14Dexcom G4 Platinum

Transmitter Kit. . . . . 14Dexcom G5 Kit. . . . . . . 14Dexcom G5 Sensor Kit . . 14Dexcom G5 Transmitter Kit . 14Dexilant . . . . . . . . . . 16Dexmethylphenidate ER Cap . . 11Diazepam Tab . . . . . . . . 12Diclofenac Gel . . . . . . . 19Diclofenac Tab . . . . . . . 19Dicyclomine . . . . . . . . . 17Digoxin . . . . . . . . . . . 11Diltiazem ER. . . . . . . . . 10Dipentum . . . . . . . . . 17Diphenoxylate/Atropine . . . 17Divalproex DR . . . . . . . . 12Divalproex ER . . . . . . . . 12Divigel . . . . . . . . . . . 22Doryx MPC. . . . . . . . . . 9Doxazosin . . . . . . . . 10, 18Doxepin . . . . . . . . . . . 11Doxycycline Hyclate Cap . . . 9Doxycycline Hyclate Tab . . . . 9Doxycycline Monohydrate Cap. .9Doxycycline Monohydrate

Oral Suspension, Tab . . . 9Duavee. . . . . . . . . . . 22Duexis . . . . . . . . . . . 16Dulera . . . . . . . . . . . 20Duloxetine Cap . . . . . . . 11Dupixent . . . . . . . . . . 13Dutasteride . . . . . . . . . 18Dymista Spray . . . . . . . 21

E

Edarbi . . . . . . . . . . . 10Edarbyclor . . . . . . . . . 10

Effient . . . . . . . . . . . 10Elestrin Gel . . . . . . . . 22Elidel . . . . . . . . . . . . 13Eliquis . . . . . . . . . . . 10Embeda . . . . . . . . . . 19Enalapril. . . . . . . . . . . 10Enbrel . . . . . . . . . . . 17Enoxaparin . . . . . . . . . 10Entecavir . . . . . . . . . . . 9Epclusa. . . . . . . . . . . . 9Epiduo & Epiduo Forte . . 13Epinephrine Auto-Injector. . 18EpiPen & EpiPen Jr . . . . 18Epogen. . . . . . . . . . . 18Erythromycin . . . . . . . . . 9Erythromycin Ointment . . . 16Escitalopram Tab . . . . . . 11Esomeprazole Magnesium . 16Estrace Vaginal Cream . . 22Estradiol/Norethindrone Tab . 22Estradiol Patch, Tab . . . . . 22Eszopiclone Tab . . . . . . . 12Etodolac . . . . . . . . . . 19Eucrisa . . . . . . . . . . . 13Euflexxa . . . . . . . . . . 18Extavia . . . . . . . . . . . 12

F

Falmina . . . . . . . . . . . 21Famciclovir Tab . . . . . . . . 9Famotidine Tab . . . . . . . 16Farxiga . . . . . . . . . . . 15Fenofibrate . . . . . . . . . 10Fentanyl Patch . . . . . . . 19Fentora. . . . . . . . . . . 19Finasteride . . . . . . . . . 18Flecainide . . . . . . . . . . 11Flector patch. . . . . . . . 19Flovent Diskus. . . . . . . 20Flovent HFA . . . . . . . . 20Fluconazole . . . . . . . . . . 9Fluocinonide Cream. . . . . 13Fluocinonide Cream, Gel,

Ointment, Solution . . . 13Fluoxetine Cap . . . . . . . 11Fluticasone Spray . . . . . . 21Folic Acid . . . . . . . . . . 21Follistim AQ . . . . . . . . 17Forfivo XL . . . . . . . . . 11Forteo . . . . . . . . . . . 19


Index of Drugs

Fortesta . . . . . . . . . . 18Fosrenol . . . . . . . . . . 18Freestyle Test Strips . . . . 14Furosemide . . . . . . . . . 10

G

Gabapentin . . . . . . . . . 12Gavilyte Solution . . . . . . 17Gemfibrozil . . . . . . . . . 10Generess Fe Chewable . . 21Genotropin . . . . . . . . 15Genvoya . . . . . . . . . . 17Gianvi . . . . . . . . . . . . 21Gildess . . . . . . . . . . . 21Gilenya+ . . . . . . . . . . . . . . . . . . . 12

Glimepiride . . . . . . . . . 15Glipizide . . . . . . . . . . 15Glipizide ER . . . . . . . . . 15Glipizide XL . . . . . . . . . 15Glumetza . . . . . . . . . 15Glyburide . . . . . . . . . . 15Gonal-f . . . . . . . . . . . 17Gonal-f RFF . . . . . . . . 17Gralise . . . . . . . . . . . 19Granix . . . . . . . . . . . 18Guaifenesin/Codeine Syrup . 18Guanfacine ER Tab . . . . . 11Guanfacine Tab . . . . . . . 10Gynazole-1 Vaginal Cream . 22

H

Harvoni . . . . . . . . . . . 9H.P. Acthar . . . . . . . . . 15Humalog Mix 50/50 Vial

and KwikPen. . . . . . 14Humalog Mix 75-25 Vial

and KwikPen. . . . . . 14Humalog U-100 Vial

and KwikPen. . . . . . 14Humalog U-200 KwikPen . 14Humatrope . . . . . . . . 15Humira Kit . . . . . . . . . 17Humira Pen Kit . . . . . . 17Humira Pen Kit Crohns . . 17Humira Pen Kit Psoriasis . 17Humulin 70-30 Vial and

KwikPen . . . . . . . . 14Humulin N Vial and

KwikPen . . . . . . . . 14

Humulin R U-500 Vial and KwikPen. . . . . . 14

Humulin R Vial. . . . . . . 14Hydralazine . . . . . . . . . 10Hydrochlorothiazide. . . . . 10Hydrocodone/Acetaminophen . 19Hydrocodone/

Chlorpheniramine Liquid 18Hydrocodone Polistirex/

Chlorpheniramine ER Suspension . . . . . . . 19

Hydrocortisone Cream, Ointment . . . . . . . . 13

Hydrocortisone Tab . . . . . 16Hydromorphone Tab . . . . 19Hydroxychloroquine . . . . . 17Hydroxyzine HCL . . . . . . 12Hydroxyzine Pamoate . . . . 12Hysingla ER . . . . . . . . 19

I

Ibuprofen Tab . . . . . . . . 19Incruse Ellipta . . . . . . . 20Indomethacin Cap . . . . . 20Inflectra . . . . . . . . . . 17Insulin Pen Needle . . . . 14Insulin Syringe/Needle . . 14Invega Sustenna. . . . . . 12Invega Trinza . . . . . . . 12Invokamet . . . . . . . . . 15Invokamet XR . . . . . . . 15Invokana. . . . . . . . . . 15Ipratropium/Albuterol

Nebulizer Solution. . . . 20Ipratropium Spray . . . . . . 21Irbesartan . . . . . . . . . . 10Isentress . . . . . . . . . . 17Isosorbide Mononitrate ER . 11

J

Janumet . . . . . . . . . . 15Janumet XR . . . . . . . . 15Januvia. . . . . . . . . . . 15Jardiance. . . . . . . . . . 15Jentadueto. . . . . . . . . 15Jentadueto XR. . . . . . . 15Jolivette . . . . . . . . . . . 21Jublia Solution. . . . . . . . 9Junel . . . . . . . . . . . . 21

K

Kariva . . . . . . . . . . . . 21Kazano. . . . . . . . . . . 15Kerydin Solution . . . . . . 9Ketoconazole Cream/

Shampoo . . . . . . . . 13Ketorolac Ophthalmic

Solution . . . . . . . . . 16Ketorolac Tab . . . . . . . . 20Kitabis . . . . . . . . . . . . 9Klor-Con 8 and 10 MEQ. . . 21Klor-Con M10 and M20. . . 21Kombiglyze . . . . . . . . 15

L

Labetalol . . . . . . . . . . 10Lamotrigine . . . . . . . . . 12Lansoprazole . . . . . . . . 16Lantus SoloStar . . . . . . 14Lantus Vial . . . . . . . . . 14Latanoprost . . . . . . . . . 16Latuda . . . . . . . . . . . 12Lazanda . . . . . . . . . . 20Leflunomide. . . . . . . . . 17Letairis . . . . . . . . . . . 11Letrozole . . . . . . . . . . . 9Levalbuterol Inhaler (M) . 20Levemir FlexTouch. . . . . 15Levemir Vial . . . . . . . . 15Levetiracetam . . . . . . . . 12Levetiracetam ER . . . . . . 12Levitra . . . . . . . . . . . 18Levocetirizine . . . . . . . . 21Levofloxacin Tab. . . . . . . . 9Levora 28 . . . . . . . . . . 21Levothyroxine . . . . . . . . 16Lialda. . . . . . . . . . . . 17Lidocaine Patch 5% . . . . . 20Lidocaine Topical Ointment,

Solution . . . . . . . . . 13Lidocaine Viscous

Solution 2%. . . . . . . 19Linzess . . . . . . . . . . . 17Liothyronine . . . . . . . . 16Lisinopril . . . . . . . . . . 10Lisinopril/HCTZ . . . . . . . 10Livalo. . . . . . . . . . . . 10Lo Loestrin . . . . . . . . . 21Lomedia Fe . . . . . . . . . 21


Index of Drugs

Lorazepam Tab . . . . . . . 12Loryna . . . . . . . . . . . 21Lorzone . . . . . . . . . . 19Losartan. . . . . . . . . . . 10Losartan/HCTZ . . . . . . . 10Lovastatin . . . . . . . . . 10Low-Ogestrel . . . . . . . . 21Ludent . . . . . . . . . . . 21Lumigan . . . . . . . . . . 16Lupron Depot . . . . . . . 16Lutera . . . . . . . . . . . . 21Lyrica Cap . . . . . . . . . 12

M

Makena . . . . . . . . . . 19Mavyret . . . . . . . . . . . 9Meclizine . . . . . . . . . . 17Medroxyprogesterone

Acetate Injection . . . . 21Medroxyprogesterone

Acetate Tab . . . . . . . 22Meloxicam . . . . . . . . . 20Mercaptopurine . . . . . . . . 9Mesalamine DR (M) . . . . 17Metaxalone . . . . . . . . . 19Metformin . . . . . . . . . 15Metformin ER . . . . . . . . 15Methadone Tab . . . . . . . 20Methimazole . . . . . . . . 16Methocarbamol . . . . . . . 19Methotrexate Tab . . . . . . 17Methylphenidate ER Cap . . 11Methylphenidate ER Tab. . . 11Methylphenidate SA

Osmotic ER Tab . . . . . 11Methylphenidate Tab . . . . 11Methylprednisolone Tab . . . 16Metoclopramide . . . . . . 17Metoprolol Succinate . . . . 10Metoprolol Tartrate . . . . . 10Metrogel . . . . . . . . . . 13Metronidazole Gel 0.75%. . 13Metronidazole Tab . . . . . . 9Metronidazole Vaginal Gel . 22Microgestin . . . . . . . . . 21Microgestin Fe . . . . . . . 21Migranal . . . . . . . . . . 12Minivelle . . . . . . . . . . 22Minocycline Cap . . . . . . . 9Mirtazapine . . . . . . . . . 11

Mirvaso Gel . . . . . . . . 13Misoprostol . . . . . . . . . 17Modafinil . . . . . . . . . . 12Mometasone . . . . . . . . 21Mono-Linyah . . . . . . . . 21Mononessa . . . . . . . . . 21Montelukast . . . . . . . . 20Morphine Sulfate ER . . . . 20Moxeza . . . . . . . . . . 16Multaq . . . . . . . . . . . 11Mupirocin Ointment . . . . 13Mycophenolate Mofetil . . . 21Mycophenolate Sodium . . . 21Myorisan . . . . . . . . . . 13Myrbetriq . . . . . . . . . 20

N

Nabumetone . . . . . . . . 20Nadolol . . . . . . . . . . . 10Namenda XR. . . . . . . . 12Namzaric . . . . . . . . . . 12Naproxen . . . . . . . . . . 20Narcan . . . . . . . . . . . 19Natazia. . . . . . . . . . . 21Necon. . . . . . . . . . . . 21Nesina . . . . . . . . . . . 15Neupogen . . . . . . . . . 19Niacin ER Tab . . . . . . . . 10Nifedipine ER . . . . . . . . 10Nitrofurantoin Macrocrystalline .9Nitrofurantoin Monohydrate

Macrocrystalline . . . . . . 9Nitroglycerin SL Tab. . . . . 11Nora-Be . . . . . . . . . . . 21Norditropin . . . . . . . . 15Norgest/Ethi Estradio . . . . 21Nortrel . . . . . . . . . . . 21Nortriptyline. . . . . . . . . 11Norvir . . . . . . . . . . . 17Novofine Autocover

Pen Needle. . . . . . . 14Novofine Pen Needle . . . 14Novolin 70/30 Vial. . . . . 15Novolin N Vial . . . . . . . 15Novolin R Vial . . . . . . . 15Novolog Flexpen . . . . . 15Novolog Mix 70/30 Vial

and Flexpen . . . . . . 15Novolog Penfill . . . . . . 15Novolog Vial. . . . . . . . 15

Novotwist Pen Needle . . 14Nucynta ER . . . . . . . . 20Nutropin AQ. . . . . . . . 15Nuvaring. . . . . . . . . . 21Nystatin Cream, Ointment,

Powder . . . . . . . . . 13Nystatin Suspension. . . . . . 9

O

Ocella . . . . . . . . . . . . 21Odefsey . . . . . . . . . . . 9Ofloxacin Ophthalmic Solution 16Ofloxacin Otic Solution . . . . 9Olanzapine Tab . . . . . . . 12Olmesartan . . . . . . . . . 10Olmesartan HCT . . . . . . 10Omega-3 Acid Cap . . . . . 11Omeprazole . . . . . . . . . 16Omnaris . . . . . . . . . . 21Omnitrope . . . . . . . . 15Ondansetron ODT. . . . . . 17Ondansetron Tab . . . . . . 17OneTouch Ultra 2 System . 14OneTouch UltraMini

System Kit . . . . . . . 14OneTouch Ultra

Test Strips . . . . . . . 14OneTouch Verio Flex

System Kit . . . . . . . 14OneTouch Verio IQ

System Kit . . . . . . . 14OneTouch Verio

Sync System Kit . . . . 14OneTouch Verio System Kit . 14OneTouch Verio Test Strips . 14Onexton . . . . . . . . . . 13Onglyza . . . . . . . . . . 15Opsumit . . . . . . . . . . 11Oracea . . . . . . . . . . . . 9Orencia SC . . . . . . . . . 18Orenitram . . . . . . . . . 11Orsythia . . . . . . . . . . . 21Oseltamivir . . . . . . . . . . 9Oseni . . . . . . . . . . . . 15Osphena . . . . . . . . . . 22Otezla . . . . . . . . . . . 18Ovidrel . . . . . . . . . . . 17Oxcarbazepine . . . . . . . 12Oxsoralen-UL . . . . . . . 13Oxybutynin . . . . . . . . . 20


Index of Drugs

Oxybutynin ER . . . . . . . 20Oxycodone Tab . . . . . . . 20Oxycodone w/ Acetaminophen 20Oxycontin . . . . . . . . . 20

P

Pancreaze . . . . . . . . . 17Pantoprazole . . . . . . . . 16Paroxetine Tab . . . . . . . 11Pataday . . . . . . . . . . 16Pazeo. . . . . . . . . . . . 16Penicillin VK. . . . . . . . . . 9Pennsaid Solution . . . . . . 13Pentasa . . . . . . . . . . 17Permethrin Cream 5% . . . 13Pertzye. . . . . . . . . . . 17Phenazopyridine . . . . . . 19Phentermine Tab . . . . . . 19Pioglitazone. . . . . . . . . 15Plegridy . . . . . . . . . . 12Polyethylene Glycol 3350

Powder . . . . . . . . . 17Polymyxin B/Trimethoprim

Solution . . . . . . . . . 16Potassium Chloride ER

Tab, Cap. . . . . . . . . 21Potassium Chloride

Micro ER Tab . . . . . . 21Pradaxa . . . . . . . . . . 10Praluent . . . . . . . . . . 11Pramipexole . . . . . . . . . 12Pravastatin . . . . . . . . . 11Prazosin . . . . . . . . . . . 10Precision Test Strips . . . . 14Prednisolone Ophthalmic

Suspension . . . . . . . 16Prednisolone Solution . . . . 16Prednisolone Syrup, Solution . . 16Prednisone . . . . . . . . . 16Premarin Tab. . . . . . . . 22Premarin Vaginal Cream . 22Premphase . . . . . . . . . 22Prempro . . . . . . . . . . 22Prepopik . . . . . . . . . . 17Previfem . . . . . . . . . . 21Prezcobix . . . . . . . . . 17Prezista . . . . . . . . . . 17Primidone . . . . . . . . . . 12Proair HFA, RespiClick. . . 20Procrit . . . . . . . . . . . 19

Proctofoam HC . . . . . . 13Progesterone Cap . . . . . . 22Prograf Cap . . . . . . . . 21Promethazine/Codeine Syrup . 19Promethazine DM Syrup . . 19Promethazine Tab . . . . . . 21Propranolol . . . . . . . . . 10Propranolol ER . . . . . . . 10Proventil HFA . . . . . . . 20Pulmicort Flexhaler . . . . 20Pylera . . . . . . . . . . . 17

Q

QNasl. . . . . . . . . . . . 21Quetiapine . . . . . . . . . 12Quinapril . . . . . . . . . . 10Qvar . . . . . . . . . . . . 20

R

Rabeprazole. . . . . . . . . 17Ramipril . . . . . . . . . . . 10Ranexa . . . . . . . . . . . 11Ranitidine Tab, Cap, Syrup . 16Rapaflo. . . . . . . . . . . 18Rasuvo . . . . . . . . . . . 18Rebif . . . . . . . . . . . . 12Rebif Titrtn . . . . . . . . 12Reclipsen . . . . . . . . . . 21Relpax . . . . . . . . . . . 12Remicade . . . . . . . . . 18Renvela Tab . . . . . . . . 19Rescula. . . . . . . . . . . 16Restasis . . . . . . . . . . 16Restasis Multidose . . . . 16Revlimid . . . . . . . . . . . 9Rexulti . . . . . . . . . . . 11Reyataz . . . . . . . . . . 17Rezira . . . . . . . . . . . 19Risperidone Tab . . . . . 11, 12Rizatriptan Tab, ODT . . . . 12Ropinirole . . . . . . . . . . 12Rosuvastatin . . . . . . . . 11

S

Saizen . . . . . . . . . . . 15Saphris . . . . . . . . . . . 12Savaysa . . . . . . . . . . 10Serevent Diskus . . . . . . 20

Sertraline . . . . . . . . . . 11Sildenafil Tab 20 mg. . . . . 11Silenor . . . . . . . . . . . 12Simbrinza . . . . . . . . . 16Simponi . . . . . . . . . . 18Simponi Aria. . . . . . . . 18Simvastatin . . . . . . . . . 11Soliqua. . . . . . . . . . . 15Solodyn . . . . . . . . . . . 9Soolantra . . . . . . . . . 13Sotalol . . . . . . . . . . . 11Spiriva Handihaler . . . . 20Spiriva Respimat . . . . . 20Spironolactone . . . . . . . 10Sprintec 28 . . . . . . . . . 21Sprycel . . . . . . . . . . . . 9Staxyn . . . . . . . . . . . 18Stelara . . . . . . . . . . . 18Stendra . . . . . . . . . . 18Stiolto . . . . . . . . . . . 20Strattera . . . . . . . . . . 11Stribild . . . . . . . . . . . 17Suboxone Film. . . . . . . 19Subsys . . . . . . . . . . . 20Sucralfate Tab . . . . . . . . 16Sulfamethoxazole-Trimethoprim .9Sulfamethoxazole-

Trimethoprim DS . . . . . 9Sumatriptan Tab and Spray . 12Sumavel Dose . . . . . . . 12Suprep Bowel Prep . . . . 17Symbicort . . . . . . . . . 20Synjardy . . . . . . . . . . 15Synjardy XR . . . . . . . . 15Synthroid . . . . . . . . . 16Synvisc . . . . . . . . . . . 19Synvisc One . . . . . . . . 19

T

Tacrolimus Cap . . . . . . . 21Taltz . . . . . . . . . . . . 18Tamoxifen Tab. . . . . . . . . 9Tamsulosin . . . . . . . . . 18Tanzeum . . . . . . . . . . 15Tazorac. . . . . . . . . . . 13Tecfidera . . . . . . . . . . 12Tekturna . . . . . . . . . . 10Tekturna HCT . . . . . . . . 10Telmisartan . . . . . . . . . 10Temazepam . . . . . . . . . 12


Index of Drugs

Terazosin . . . . . . . . 10, 18Terbinafine Tab . . . . . . . . 9Terconazole Vaginal Cream . 22Testim . . . . . . . . . . . 18Testosterone Cypionate IM

Injection. . . . . . . . . 18Tirosint. . . . . . . . . . . 16Tivicay . . . . . . . . . . . 17Tizanidine Cap . . . . . . . 19Tizanidine Tab. . . . . . . . 19TOBI podhaler . . . . . . . . 9Tobramycin . . . . . . . . . 16Tobramycin/Dexamethasone. 16Tobramycin (M) . . . . . . . 9Topiramate Tab . . . . . . . 12Torsemide Tab. . . . . . . . 10Toujeo SoloStar . . . . . . 15Toviaz . . . . . . . . . . . 20Tracleer . . . . . . . . . . 11Tradjenta. . . . . . . . . . 15Tramadol Tab . . . . . . . . 20Tramadol

w/ Acetaminophen . . . 20Travatan Z . . . . . . . . . 16Trazodone. . . . . . . . . . 12Tresiba . . . . . . . . . . . 15Tretinoin Cream . . . . . . . 13Tretinoin Microsphere Gel . . 13Triamcinolone . . . . . . . . 13Triamterene/HCTZ . . . . . . 10Triazolam Tab . . . . . . . . 12Tri-Linyah . . . . . . . . . . 21Tri-Lo-Sprintec. . . . . . . . 21Trinessa . . . . . . . . . . . 21Trintellix . . . . . . . . . . 12Tri-Previfem . . . . . . . . . 21Tri-Sprintec . . . . . . . . . 21Triumeq . . . . . . . . . . 17Trokendi XR . . . . . . . . . 12Trulicity . . . . . . . . . . 15Truvada . . . . . . . . . . 17Tudorza . . . . . . . . . . 20Tymlos . . . . . . . . . . . 19

U

Uceris Foam . . . . . . . . 17Uloric. . . . . . . . . . . . 19Ultresa . . . . . . . . . . . 17

V

Valacyclovir . . . . . . . . . . 9Valsartan . . . . . . . . . . 10Valsartan/HCTZ . . . . . . . 10Varubi . . . . . . . . . . . 17Vascepa . . . . . . . . . . 11Vectical. . . . . . . . . . . 13Velphoro . . . . . . . . . . 19Veltin. . . . . . . . . . . . 13Venlafaxine ER Cap . . . . . 12Venlafaxine ER Tab . . . . . 12Venlafaxine Tab . . . . . . . 12Ventolin HFA . . . . . . . 20Verapamil ER . . . . . . . . 10Vesicare . . . . . . . . . . 20Vestura . . . . . . . . . . . 22Viagra . . . . . . . . . . . 18Victoza . . . . . . . . . . . 15Vigamox . . . . . . . . . . 16Viibryd . . . . . . . . . . . 12Vimovo. . . . . . . . . . . 16Vimpat . . . . . . . . . . . 12Viokace . . . . . . . . . . 17Viorele . . . . . . . . . . . 22Viread . . . . . . . . . . . 17Vitamin D . . . . . . . . . . 21Vogelxo . . . . . . . . . . 18Vyvanse . . . . . . . . . . 11

W

Warfarin . . . . . . . . . . 10Welchol . . . . . . . . . . 11

X

Xarelto . . . . . . . . . . . 10Xeljanz . . . . . . . . . . . 18Xigduo XR . . . . . . . . . 15Xiidra. . . . . . . . . . . . 16Xolair. . . . . . . . . . . . 20Xopenex HFA . . . . . . . 20Xtampza ER . . . . . . . . 20Xulane . . . . . . . . . . . 22Xyrem . . . . . . . . . . . 12

Y

Yuvafem . . . . . . . . . . 22

Z

Zaleplon. . . . . . . . . . . 12Zarah . . . . . . . . . . . . 22Zarxio . . . . . . . . . . . 19Zenpep . . . . . . . . . . 17Zepatier . . . . . . . . . . . 9Zetonna . . . . . . . . . . 21Zioptan. . . . . . . . . . . 16Zohydro ER . . . . . . . . 20Zolpidem . . . . . . . . . . 12Zolpidem ER. . . . . . . . . 12Zomacton . . . . . . . . . 15Zonisamide . . . . . . . . . 12Zontivity . . . . . . . . . . 10Zorvolex . . . . . . . . . . 20Zovirax Cream . . . . . . . 13Zubsolv . . . . . . . . . . 19Zurampic . . . . . . . . . . 19Zutripro . . . . . . . . . . 19Zyclara . . . . . . . . . . . 13Zytiga . . . . . . . . . . . . 9

29

“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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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.

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