your 2019 formulary - myuhc.com · 2019-07-01 · your 2019 formulary signaturevalue three-tier...

Your 2019 FormularySignatureValue Three-Tier

This formulary is accurate as of Jan. 1, 2019 and is subject to change after this date. The next anticipated update will be July 1, 2019. This formulary applies to members of our UnitedHealthcare West HMO medical plans with a pharmacy benefit. Your estimated coverage and copayment/coinsurance may vary based on the benefit plan you choose and the effective date of the plan.

Effective January 1, 2019Effective Jan. 1, 2019

2

Table of Contents

Understanding your formulary . . . . . . . . 3

Medication tips . . . . . . . . . . . . . . . . . . . . . 5

Reading your formulary . . . . . . . . . . . . . . 6

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . 8

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

Anti-InfectivesAntibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . 9Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . 9Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Cardiovascular/Heart DiseaseCoagulation Therapy . . . . . . . . . . . . . . . . . 11High Blood Pressure . . . . . . . . . . . . . . . . . 11High Cholesterol . . . . . . . . . . . . . . . . . . . . 12Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Central Nervous SystemAttention Deficit Disorder . . . . . . . . . . . . . . 13Depression . . . . . . . . . . . . . . . . . . . . . . . . 14Migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . 14Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Sedatives/Hypnotics . . . . . . . . . . . . . . . . . 15Seizure Disorders . . . . . . . . . . . . . . . . . . . 15

Dermatology . . . . . . . . . . . . . . . . . . . . . . 16

DiabetesBlood Glucose Monitoring . . . . . . . . . . . . . 17Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Non-Insulin . . . . . . . . . . . . . . . . . . . . . . . . 18

EndocrineGrowth Hormone . . . . . . . . . . . . . . . . . . . . 18Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Thyroid Hormone Replacement . . . . . . . . . 19

Eye ConditionsAllergies . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . 19 Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . 19Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

GastrointestinalAcid Suppression . . . . . . . . . . . . . . . . . . . . 20Nausea/Vomiting . . . . . . . . . . . . . . . . . . . . 20Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Inflammatory Conditions: Rheumatoid Arthritis, Crohn’s Disease, Psoriasis, Ulcerative Colitis . . . . . . . . . . . . . . . . . . . 22

Medications for Sexual Dysfunction . . . 22

Men’s HealthProstate . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Testosterone Therapy . . . . . . . . . . . . . . . . 22

Miscellaneous . . . . . . . . . . . . . . . . . . . . . 22

MusculoskeletalOsteoporosis . . . . . . . . . . . . . . . . . . . . . . . 24Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Pain Relief . . . . . . . . . . . . . . . . . . . . . . . . . 24

Overactive Bladder . . . . . . . . . . . . . . . . . 25

RespiratoryAsthma/COPD . . . . . . . . . . . . . . . . . . . . . . 25Nasal Allergies . . . . . . . . . . . . . . . . . . . . . . 26Oral Allergies . . . . . . . . . . . . . . . . . . . . . . . 26Pulmonary Arterial Hypertension. . . . . . . . 26

Smoking Cessation . . . . . . . . . . . . . . . . . 26

Transplant . . . . . . . . . . . . . . . . . . . . . . . . 27

Vitamins/Electrolytes . . . . . . . . . . . . . . . 27

Women’s HealthContraceptives . . . . . . . . . . . . . . . . . . . . . . 27Hormone Replacement . . . . . . . . . . . . . . . 29Miscellaneous . . . . . . . . . . . . . . . . . . . . . . 30Prenatal Vitamins . . . . . . . . . . . . . . . . . . . 30

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

3

Understanding your formulary

What is a formulary?This document is a list of the most commonly prescribed medications. It includes both brand-name and generic prescription medications approved by the Food and Drug Administration (FDA). Medications are listed by common categories or classes and placed in tiers that represent the cost you pay out-of-pocket. They are then listed in alphabetical order.

About this formularyWhere differences exist between this formulary and your benefit plan documents, the benefit plan documents rule. This formulary is not a complete list of medications. Please look at the benefit plan documents provided by your employer or health plan to see which medications are covered under your plan.

How do I use my formulary?You and your doctor can consult the formulary to help you select the most cost-effective prescription medications. This guide tells you if a medication is generic or a brand-name, and if there are coverage requirements or limits. Bring this list with you when you see your doctor. If your medication is not listed here, please visit your plan’s member website or call the toll-free member phone number on your health plan ID card.

What are tiers?Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, determined by your employer or benefit plan. This is how much you will pay when you fill a prescription. See page 6 for additional information.

When does the formulary change?Formulary changes including tier status changes resulting in higher copayments of maintenance medications occur twice per contract or plan year. Tier changes that result in a lower copayment may occur at any time. You can log in to the member website listed on your health plan ID card at any time to check your medication coverage and lower-cost options.

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Understanding your formulary (continued)

Why are some medications excluded from coverage?We review medications based on their total value, including effectiveness and safety, how much they cost, and the availability of alternative medications to treat the same or similar medical conditions. Certain medications may be excluded from coverage or subject to prior authorization (sometimes referred to as precertification) if similar alternatives are available at a lower cost. Examples include medications that work the same way, but one is much more expensive than the other, or options that are available without a prescription (also referred to as over-the-counter medications). There are also some instances where the same product can be made by two or more manufacturers, but greatly vary in cost. In these instances, only the lower-cost product may be covered.

You should review your benefit plan documents to confirm if any medications are excluded from your plan. You can log in to the member website listed on your health plan ID card at any time to check your medication coverage. Talk to your doctor to see if there are lower-cost options or over-the-counter medications available.

Who decides which medications are covered?Thousands of medications are already available and more come to the market regularly. Often, several medications are available to treat the same condition. The UnitedHealthcare® Pharmacy and Therapeutics Committee, which includes both internal and external physicians and pharmacists, meets regularly to provide clinical reviews of all medications. Using this information, the Prescription Drug List Management Committee, which includes senior UnitedHealth Group® physicians and business leaders, meets to evaluate overall health care value. They also determine coverage and tier status for all medications.

5

Medication tips

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 for 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.

What if my doctor writes a brand-name prescription?If your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lower-cost option is available and could be right for you. Generic medications are usually your lowest-cost option, but not always. For some benefit plans, if a brand-name drug is prescribed and a generic equivalent is available, your cost-share may be the copayment PLUS the cost difference between the brand-name drug and the generic equivalent.

Over-the-counter (OTC) medicationsAn 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 by your pharmacy benefit, they may cost less than a prescription medication.

What if I am taking a specialty medication?Specialty medications are high-cost and are used to treat rare or complex conditions that require additional care and support. For most plans, these medications are managed through the specialty pharmacy program. Take advantage of personalized support designed to help you get the most out of your treatment plan. Visit the member website listed on your health plan ID card or call the toll-free phone number on your ID card to learn more.

Please note, not all specialty medications are listed here. If you’re taking a specialty medication that is on a higher tier, call the toll-free phone number on your ID card to talk with a pharmacist about finding lower-cost options or a financial assistance program.

6

Reading your formulary

The formulary gives you choices so you and your doctor can determine your best course of treatment. In this formulary, brand-name medications are shown in bold type and generic medications in plain type.

Tier information.Using lower-tier medications can help you pay your lowest out-of-pocket cost. Your plan may have multiple or no tiers. Please note: If you have a high deductible plan, the tier cost levels may apply once you hit your deductible.

Drug Tier Includes Helpful Tips

Tier 1 $ Lower-cost Medications that provide the highest overall value. Mostly generic drugs. Some brand-name drugs may also be included.

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

Tier 2 $$ Mid-range cost Medications that provide good overall value. A mix of brand-name and generic drugs.

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

Tier 3 $$$ Highest-cost Medications that provide the lowest overall value. Mostly brand-name drugs, as well as some generics.

Ask your doctor if a Tier 1 or Tier 2 option could work for you.

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Reading your formulary (continued)

Drug list information.In this drug list, some medications are noted with letters next to them to help you see which ones may have coverage requirements or limits. Your benefit plan determines how these medications may be covered for you.

AE Age edit This medication applies to a specific age group. Members outside of this age group need to meet specific criteria for approval.

E Exceptions required for select markets in California and Oklahoma Your doctor is required to provide additional information to UnitedHealthcare to verify medical necessity of certain medications.

H Health care reform preventive This medication is part of a health care reform preventive benefit and may be available at no additional cost to you.

H-PA Health care reform preventive with prior authorization

May be part of health care reform preventive and available at no additional cost to you if prior authorization criteria is met.

M Medical The medication may be covered under medical with prior authorization.

PA Prior authorization Requires your doctor to provide information about why you are taking a medication to determine how it may be covered by your plan.

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

ST Step therapy Requires you to try one or more other medications before the medication you are requesting may be covered.

8

Questions

For the most current list of covered medications or if you have questions:

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

Visit your plan’s member website listed on your health plan ID card to:

• View your pharmacy benefit and coverage information, including prescription history

• View medication interactions and side effects

• Locate a participating retail pharmacy by ZIP code

• Look up possible lower-cost medication alternatives

• Compare medication pricing and options

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

• Refill prescriptions

• Check the status of your order

• Set up reminders for refills

• Manage your account

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Bold type = Brand-name drug[Plain type = Generic drug]AE = Age editE = Exceptions requiredH = May be part of health care reform preventiveH-PA = May be part of health care reform preventive with prior authorization

M = MedicalPA = Prior authorization requiredQL = Quantity limitST = Step therapy

Drug Name Drug Tier

Requirements & Limits

Anti-Infectives: Antibiotics

Amoxicillin 1Amoxicillin/Potassium Clavulanate 1

Antipyrine/Benzocaine Otic 1

Azithromycin 1

Bethkis 2

Cefaclor Suspension 2

Cefaclor Tablet 1

Cefadroxil 1 QL

Cefdinir 1

Cefpodoxime 1

Cefprozil 1

Cefuroxime 1

Cephalexin 1Chloroxylenol/Hydrocortisone/Pramoxine Otic 1

Ciprofloxacin 1

Clarithromycin IR/ER 1

Cleocin Vaginal Suppository 2

Clindamycin Capsule 1

Clindamycin Vaginal Cream 1

Clindesse 3

Dapsone Tablet 1

Demeclocycline 1

Dicloxacillin 1

Doxycycline Hyclate 1

Doxycycline Monohydrate Tablet 1 QL

Erythromycin 1

Erythromycin/Sulfisoxazole 1

Ethambutol 1

Firvanq 1

Isoniazid 1

Drug Name Drug Tier


Levofloxacin 1

Linezolid Tablet 1 QL

Methenamine 1

Metronidazole Tablet 1

Minocycline Capsule 1

Mycobutin 2

NebuPent Nebs 2 QL

Neomycin 1Neomycin/Polymixin/Hydrocortisone Otic 1

Nitrofurantoin 1

Nitrofurantoin Macrocrystal 1

Ofloxacin Otic 1

Oracea 3

Paromomycin 1

Penicillin VK 1

Pramoxine-HC Otic 1

Pyrazinamide 1

Rifampin 1

Sulfadiazine 1Sulfamethoxazole/Trimethoprim, Sulfamethoxazole/Trimethoprim DS

1

Tetracycline 1

Tobi Podhaler 3 QL

Trimethoprim 1

Zmax 2

Anti-Infectives: Antifungals

Clotrimazole Troche 1

Cresemba 3

Fluconazole 1

Griseofulvin 1

Itraconazole 1 PA

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Drug Name Drug Tier


Jublia 3 PA

Kerydin 3 PA

Ketoconazole Cream 1 QL

Ketoconazole Shampoo 1

Metronidazole Vaginal Gel 1

Nystatin 1

Terbinafine 1 QL

Terconazole 1

Vandazole Gel 1

Anti-Infectives: Antivirals

Acyclovir 1

Adefovir 1

Amantadine Capsule, Syrup 1

Baraclude 3 E, QL

Daklinza 3 PA, QL

Entecavir 1 QL

Epclusa 2 PA, QL

Epivir HBV Solution 2

Famciclovir 1

Harvoni 2 PA, QL

Lamivudine 1

Mavyret 2 PA, QL

Pegasys M

Prevymis Tablet 2 PA

Ribavirin Tablet 1 PA

Rimantidine 1

Sovaldi 3 PA, QL

Technivie 3 PA, QL

Valacyclovir 1 QL

Valganciclovir Solution 1

Valganciclovir Tablet 1 QL

Viekira Pak, Viekira XR 3 PA, QL

Vosevi 2 PA, QL

Zepatier 3 PA, QL

Zovirax Cream 2 E

Zovirax Ointment 3 E

Drug Name Drug Tier


Cancer

Alunbrig 2 PA, QL

Bicalutamide 1

Bosulif 2 PA, QL

Cabometyx 2 PA

Calquence 2 PA, QL

Capecitabine 1

Caprelsa 2 PA, QL

Cometriq 2 PA

Cotellic 2 PA, QL

Cyclophosphamide 3

Emcyt 2

Etoposide 1

Erivedge 2 PA, QL

Exemestane 1

Fareston 2

Farydak 2 PA, QL

Flutamide 1

Hexalen 2

Hydroxyurea 1

Ibrance 2 PA, QL

Idhifa 2 QL

Imatinib 1 PA, QL

Imbruvica Capsule 2 PA, QL

Imbruvica Tablet 2 PA

Letrozole 1 PA

Leucovorin Calcium 1

Leukeran 2

Lomustine 1

Lysodren 2

Lonsurf 2 PA, QL

Matulane 2

Melphalan 1

Mercaptopurine 1

Myleran 2

Nerlynx 2 PA, QL

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Drug Name Drug Tier


Nexavar 2 PA

Nilandrone 2

Ninlaro 2 PA, QL

Odomzo 2 PA, QL

Rydapt 2 PA, QL

Sprycel 3 PA, QL

Stivarga 2 PA

Sutent 2 PA

Tabloid 2

Targretin Capsule 2

Tasigna 2 PA, QL

Temozolomide 1 PA

Tretinoin Capsule 1

Tykerb 2 PA

Verzenio 2 PA, QL

Xeloda 3 E

Xtandi 3 PA, QL

Zykadia 2 PA, QL

Zytiga 2 PA

Cardiovascular/Heart Disease: Coagulation Therapy

Aggrenox 3

Brilinta 2

Clopidogrel 1

Disopyramide 1

Eliquis 3 QL

Jantoven 1

Pradaxa 2 QL

Prasugrel 1 QL

Savaysa 3 QL

Ticlopidine 1 QL

Warfarin 1

Drug Name Drug Tier


Xarelto 2 QL

Zontivity 3 QL

Cardiovascular/Heart Disease: High Blood Pressure

Acebutolol 1

Acetazolamide 1

Acetazolamide ER 1

Afeditab CR 1

Aldactazide 25/25 mg 2

Amiloride 1

Amiloride/Hydrochlorothiazide 1

Amlodipine 1

Amlodipine/Benazepril 1 QL

Atenolol 1

Atenolol/Chlorthalidone 1

Benazepril 1

Benazepril/Hydrochlorothiazide 1

Betaxolol 1

Bisoprolol 1

Bisoprolol/Hydrochlorothiazide 1

Bumetanide 1

Bystolic 2

Byvalson 2

Captopril 1

Captopril/Hydrochlorothiazide 1

Cartia XT 1

Carvedilol 1

Chlorothiazide 1

Chlorthalidone 1

Clonidine Tablet 1Diltiazem Sustained-Release Capsule 1

Diltiazem Tablet 1

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Drug Name Drug Tier


Doxazosin 1

Edarbi 3 E, QL

Edarbyclor 3 QL

Enalapril 1

Enalapril/Hydrochlorothiazide 1

Eprosartan 1 QL

Ezide 1

Felodipine 1

Fosinopril 1

Fosinopril/Hydrochlorothiazide 1

Furosemide 1

Guanfacine 1

Hydralazine 1

Hydrochlorothiazide 1

Indapamide 1

Irbesartan 1 QL

Irbesartan/Hydrochlorothiazide 1 QL

Isradipine 1

Labetalol 1

Lisinopril 1

Lisinopril/Hydrochlorothiazide 1

Losartan 1

Losartan/Hydrochlorothiazide 1

Methazolamide 1

Methyclothia 1

Methyldopa 1

Methyldopa/Hydrochlorothiazide 1

Metolazone 1

Metoprolol Succinate ER 1

Metoprolol Tartrate 1

Minoxidil 1

Moexipril 1

Moexipril/Hydrochlorothiazide 1

Nadolol 1

Nicardipine 1

Nifediac CC 1

Drug Name Drug Tier


Nifedical XL 1

Nifedipine IR/ER 1

Olmesartan 1 QL

Olmesartan/Hydrochlorothiazide 1 QL

Perindopril 1

Phenoxybenzamine 1

Pindolol 1

Prazosin 1

Propranolol/Hydrochlorothiazide 1

Propranolol IR/ER 1

Quinapril 1

Ramipril 1

Reserpine 1

Sotalol 1

Sotalol AF 1

Spironolactone 1Spironolactone/Hydrochlorothiazide 1

Taztia XT 1

Telmisartan 2 QL

Telmisartan/Hydrochlorothiazide 1 QL

Terazosin 1 QL

Timolol 1

Torsemide 1

Trandolapril/Verapamil CR 1

Triamterene/Hydrochlorothiazide 1

Valsartan 1 QL

Valsartan/Hydrochlorothiazide 1 QLVerapamil Sustained-Release Capsule 1 QL

Verapamil Sustained-Release Tablet 1

Verapamil Tablet 1

Cardiovascular/Heart Disease: High Cholesterol

Antara 3 QL

Atorvastatin 1 H-PA, QL

Cholestyramine 1

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Drug Name Drug Tier


Choline Fenofibrate Capsule 1 E

Colestipol 1

Ezetimibe 3 QL

Ezetimibe/Simvastatin 3 QL

Fenofibrate 48, 145 mg Tablet 1 E

Fenofibrate 54, 160 mg Tablet 1

Fenofibrate Capsule 1

Fenofibrate Micronized 1

Gemfibrozil 1

Lipofen 3 E

Livalo 3 E, QL

Lovastatin 1 H

Niacin ER 1 QL

Niaspan 3Omega-3-Acid Ethyl Esters Capsule 1 PA, QL

Praluent M QL

Pravastatin 1

Prevalite 1

Rosuvastatin 1 QL

Simvastatin 1 H-PA

Vascepa 2

Welchol 2

Cardiovascular/Heart Disease: Other

Amiodarone 1

Anagrelide 1

Cilostazol 1

Corlanor 3 PA, QL

Digoxin 1

Dilatrate SR 2

Disopyramide 1

Flecainide 1

Drug Name Drug Tier


Isochron 1

Isoditrate ER 1

Isordil 2

Isosorbide Dinitrate IR/ER 1

Isosorbide Mononitrate IR/ER 1

Isoxsuprine 1

Mexiletine 1

Midodrine 1

Multaq 3 PA

NitroBid 2

Nitroglycerin ER 1

Nitroglycerin Tablet 1

Nitrolingual Pump Spray 1

NitroTime 1

Norpace CR 2

Pacerone 3

Pentoxifylline 1

Propafenone 1

Quinidine IR/ER 1

Ranexa 2 QL

Sotalol 1

Central Nervous System: Attention Deficit Disorder

Adderall XR 2 AE, QL

Atomoxetine 3 QLDextroamphetamine/Amphetamine 1 AE, QL

Dextroamphetamine/Amphetamine Extended-Release 3 AE, E, QL

Dextroamphetamine Sulfate Extended-Release 1 AE, QL

Dextroamphetamine Sulfate Tablet 1 AE, QL

Guanfacine ER 1 AE, QL

Intuniv 3 AE, E, QL

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Drug Name Drug Tier


Methylphenidate Controlled-Release Capsule 1 AE, QL

Methylphenidate Tablet 1 AE, QL

Vyvanse 2 AE, QL

Central Nervous System: Depression

Amitriptyline 1

Amoxapine 1

Bupropion 1

Bupropion SR 1 H

Bupropion XL 1 QL

Citalopram 1

Clomipramine 3

Cymbalta 3 E, QL

Desipramine 1

Desvenlafaxine Succinate ER 1 QL

Doxepin 1

Duloxetine 20, 30, 60 mg 1 QL

Escitalopram 1Fluoxetine Capsule (generic Prozac) 1

Fluvoxamine 1

Forfivo XL 2 QL

Imipramine 1

Maprotiline 1

Mirtazapine, Mirtazapine ODT 1

Nefazodone 1

Nortriptyline 1

Paroxetine Tablet (generic Paxil) 1

Paroxetine ER 1 QL

Paxil Suspension 2

Phenelzine 1

Protriptyline 1

Sertraline 1

Tranylcypromine 1

Trazodone 1

Trintellix 3 QL, ST

Venlafaxine 1

Drug Name Drug Tier


Venlafaxine Extended-Release Capsule 1

Venlafaxine Extended-Release Tablet 1 QL

Viibryd 3 QL

Central Nervous System: MigraineAcetaminophen/Butalbital/Caffeine 1 QL

Isometheptene/Acetaminophen/Dichloralphenazone 1

Migragesic 1

Migranal 3 E, PA, QL

Nodolor 1

Phrenilin Forte 3 QL

Rizatriptan 1 QL

Sumatriptan Nasal Spray, Tablet 1 QL

Sumavel DosePro M

Zecuity 3 E, QL

Zolmitriptan 1 QL

Zomig Spray 3 E, QL

Central Nervous System: Multiple Sclerosis

Ampyra 2 PA, QL

Avonex M QL

Betaseron M QL

Gilenya 3 PA, QL

Glatiramer M QL

Glatopa M QL

Tecfidera 2 PA, QL

Central Nervous System: Other

Alprazolam IR/ER 1 QL

Aripiprazole ODT 1 QL

Aripiprazole Solution, Tablet 1 QL

Aristada M

Benztropine 1

Bromocriptine 1

Buspirone 1

Carbidopa/Levodopa IR/ER 1

Chlordiazepoxide 1 QL

15



Drug Name Drug Tier


Chlordiazepoxide/Amitriptyline 1

Chlorpromazine 1

Clorazepate 1 QL

Clozapine 1 QL

Compro Suppository 1

Diazepam 1

Donepezil, Donepezil ODT 1

Entaone 1

Ergoloid Mesylate 1

Fluphenazine 1

Galantamine IR/ER 1

Galantamine Solution 1 QL

Haloperidol 1

Hydroxyzine 1

Invega Sustenna, Invega Trinza M

Latuda 3 QL, ST

Lithium IR/ER 1

Lorazepam 1 QL

Loxapine 1

Memantine Solution, Tablet 1

Meprobamate 1

Namzaric 2 QL

Olanzapine, Olanzapine ODT 1 QL

Oxazepam 1 QL

Perphenazine/Amitriptyline 1

Pramipexole 1

Prochlorperazine 1

Quetiapine 1 QL

Rexulti 3 PA, QL

Risperidone, Risperidone ODT 1 QL

Rivastigmine 1

Drug Name Drug Tier


Ropinirole 1

Saphris 2 PA, QL

Suboxone Film 2 QL

Thioridazine 1

Thiothixene 1

Trifluoperazine 1

Trihexyphenidyl 1

Vraylar 3 QL, ST

Xyrem 3 PA, QL

Zelapar 3 QL

Ziprasidone 1 QL

Zubsolv 2 QL

Central Nervous System: Sedatives/Hypnotics

Eszopiclone 1 QL

Flurazepam 1 PA, QL

Silenor 3 QL

Temazepam 1 QL

Triazolam 1 QL

Zaleplon 1 QL

Zolpidem 1 QL

Central Nervous System: Seizure Disorders

Carbamazepine ER Capsules 1

Carbamazepine IR 1

Clonazepam, Clonazepam ODT 1 QL

Diazepam Gel 1 QL

Divalproex DR 1

Epitol 1

Ethosuximide 1

Gabapentin 1

Lamotrigine Chewable, Tablet 1

Lamotrigine ER 1

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Drug Name Drug Tier


Lamotrigine ODT 3

Levetiracetam ER 3

Levetiracetam IR 1

Lyrica Capsule 2 QL

Lyrica Solution 3 QL

Oxcarbazepine 1

Phenobarbital 1

Phenytoin 1

Topiragen 1

Topiramate 1

Valproic Acid 1

Vimpat Injection M

Vimpat Tablet, Solution 3 PA

Zonisamide 1

Dermatology

Absorica 3 PA

Acanya 3 E, QL

Acitretin 1

Acyclovir 1

Aczone Gel 3

Ala Quin 1

Alclometasone 1

Alphatrex 1

Amnesteem 1 PA, QL

Benzaclin 3 E, QL

Betamethasone 1

Calcipotriene-Betamethasone 2 QL

Calcipotriene Ointment 1 QL

Calcitriol Ointment 1

Cerovel 1

Ciclodan 1Ciclopirox Cream, Gel, Lotion, Solution 1

Claravis 1 E, PA

Clindamycin Gel, Lotion, Swabs 1

Clindamycin Solution 1 QL

Drug Name Drug Tier


Clobetasol, Clobetasol E 1

Clobex Lotion, Shampoo 3 E

Clobex Spray 3 E, QL

Cloderm 3

Cloderm Pump 3

Cormax 1

Dermazene 1

Desonide 1

Desoximetasone 1

DrithoScalp 2

Dupixent M QL

Econazole 3

Elidel 2 QL, ST

Enstilar 3 QL

Ery Pad 1

Erythromycin 1

Erythromycin/Benzoyl Peroxide 1

Ethyl Chloride 1

Eurax 2

Exoderm 1

Finacea 3 ST

Fluocinolone 1

Fluocinonide, Fluocinonide E 1

Fluoroplex 3

Fluorouracil Solution, 5% Cream 1

Fluticasone 1

Gentamicin 1

Hydrocortisone 1

Hypercare 1

Imiquimod 1 QL

Laclotion 1

Lidocaine 1

Lidocaine/Prilocaine 1

Lindane 1

Lokara 1

17



Drug Name Drug Tier


Metrogel 1% 3 EMetronidazole 0.75% Cream, Lotion 1

Mirvaso 2 QL

Mometasone Furoate 1

Mupirocin Calcium Cream 1 QL

Mupirocin Ointment 1

Myorisan 1 PA

Nystatin 1

Nystop 1

Onexton 3 E, QL

Otezla 2 PA, QL

Permethrin 1

Picato 3

Podofilox 1

Pramcort 1

Pramosone Cream, Ointment 3

Pramosone E Cream 3

Pramosone Lotion 3

Protopic 3 AE, QL, ST

Rhofade 3 PA, QL

Rosadan Cream 1

Selenium Sulfide 1

Silver Nitrate 1

Silver Sulfadiazine 1

Soolantra 2

Sulfacetamide Sodium 1

Sulfacetamide Sodium-Sulfur 1

Taclonex Ointment 3 E, QL

Taclonex Scalp 3 QL

Taclonex Suspension 3 QL

Tacrolimus Ointment 1 AE, QL

Drug Name Drug Tier


Tazorac 3 AE, QL

Tretinoin Cream 3 AE

Triamcinolone Acetonide 1 QL

Trianex 2

Triderm 1

Urea 40% Lotion 1

Vectical 3 E

Vitazol 1

Zenatane 1 E, PA

Zyclara Cream, Pump 3 QL

Diabetes: Blood Glucose Monitoring

Accu-Chek Test Strips 3 PA, QL

Bayer Contour Next Test Strips 2 QL

Bayer Contour Test Strips 3 PA, QL

FreeStyle Test Strips 3 PA, QLNovofine Autocover Pen Needles 2

Novofine Pen Needles 2

Novofine Plus Pen Needles 2

Novotwist Pen Needles 2

OneTouch Lancets 1 QL

OneTouch Test Strips 2 QLOneTouch Ultra Blue Test Strips 2 QL

Diabetes: Insulin

Apidra Solostar, Vials 3 E, QL, ST

Basaglar 1

Humalog KwikPen 2

Humalog Mix 50-50 KwikPen 2

Humalog Mix 50-50 Vial 2

Humalog Mix 75-25 KwikPen 2

Humalog Mix 75-25 Vial 2

18

Drug Name Drug Tier


Humalog U-200 KwikPen 2

Humalog Vial 2

Humulin 70-30 KwikPen 2

Humulin 70-30 Vial 2

Humulin KwikPen 2

Humulin N KwikPen 2

Humulin N Vial 2

Humulin R U-500 KwikPen 2

Humulin R U-500 Vial 2

Humulin R Vial 2

Levemir FlexTouch, Vials 3 QL

Novolin Vials (all formulations) 2 ENovolog FlexPen, Vials (all formulations) 2 E

Soliqua 2 PA, QL

Tresiba 2 QL

Diabetes: Non-Insulin

Acarbose 1

Adlyxin 3 QL, ST

Bydureon, Bydureon Bcise 2 QL, ST

Byetta 2 QL, ST

Chlorpropamide 1

Farxiga 3 E, QL, ST

Glimepiride 1

Glipizide IR/XL 1

Glipizide/Metformin 1

Glucagen 2

Glucagon 2 QL

Glumetza 3 PA

Glyburide 1

Glyburide/Metformin 1

Glyxambi 2 QL, ST

Invokamet, Invokamet XR 2 QL, ST

Invokana 2 QL, ST

Janumet 2 QL

Janumet XR 2 QL

Drug Name Drug Tier


Januvia 2 QL

Jardiance 2 QL, ST

Jentadueto 2 QL

Jentadueto XR 2 QL

Juvisync 2 QL, ST

Metformin 1

Metformin Extended-Release 1

Nateglinide 1 QL

Ozempic 2 QL, ST

Pioglitazone 1 QL, ST

Pioglitazone/Glimepiride 1 QL, ST

Pioglitazone/Metformin 1 QL, ST

Repaglinide 1 QL, ST

Symlin 3 PA

Synjardy 2 QL, ST

Synjardy XR 2 QL, ST

Tolazamide 1 ST

Tolbutamide 1 ST

Tradjenta 2 QL

Trulicity 2 QL, ST

Victoza 2 QL, ST

Endocrine: Growth Hormone

Lupron Depot MNutropin AQ, Nutropin AQ NuSpin M

Endocrine: Other

Asmalpred, Asmalpred Plus 2

Calcitriol 1

Cortisone 1

Desmopressin 1

Dexamethasone 1

Fludrocortisone 1

Hydrocortisone Tablet 1

Medrol 2 mg 2

Methylergonovine 1

Methylprednisolone 1

19



Drug Name Drug Tier


Millipred Tablet 1

Paricalcitol 1

Prednisolone Solution, Tablet 1

Prednisone 1

Zemplar 2

Endocrine: Thyroid Hormone Replacement

Levothyroxine Sodium 1

Levoxyl 1

Liothyronine Sodium 1

Methimazole 1

Propylthiouracil 1

Tirosint 3

Unithroid 1

Eye Conditions: Allergies

Azelastine 0.05% Solution 1

Cromolyn 1

Epinastine 1 E

Lastacaft 3 QL

Naphazoline 0.1% 1

Olopatadine 0.1% 1 QL

Pataday 3 E

Phenylephrine 1

Eye Conditions: Antibiotics

Azasite 3

Bacitracin 1

Bacitracin/Polymyxin 1

Besivance 3

Ciprodex 3

Ciprofloxacin 1

Erythromycin 1

Gentamicin 1

Drug Name Drug Tier


Ilotycin 1

Moxeza 2

Moxifloxacin 1

Natacyn 2

Neomycin/Bacitracin/Polymyxin 1

Neomycin/Polymixin/Gramicidin 1

Ofloxacin 1

Polymyxin B/Trimethoprim 1

Sulfacetamide Sodium 1

Tobradex Ointment 3

Tobramycin/Dexamethasone 1

Tobramycin Ophth Solution 1 E

Tobrex 3 E

Trifluridine 1

Eye Conditions: Glaucoma

Alphagan P 2 QL

Azopt 2 QL

Betaxolol 1

Betimol 3 QL

Betoptic-S 3

Carteolol 1

Combigan 2 QL

Cosopt, Cosopt PF 3

Dorzolamide 1 QL

Dorzolamide/Timolol 1

Latanoprost 1 QL

Levobunolol 1

Lumigan 2 QL

Metipranolol 1

Simbrinza 2 QL

Timolol Maleate 1

20

Drug Name Drug Tier


Timoptic Ocudose 2

Travatan Z 2 QL

Zioptan 3 QL

Eye Conditions: Other

Atropine 1

Blephamide SOP 3

Brimonidine 1

Cyclopentolate 1

Dexamethasone 1

Diclofenac 1 QL

Fluorometholone 1

Flurbiprofen 1

FML Forte 2

Homatropine 1

Iso Carbachol 2

Iso Homatropine 2

Ketorolac 1Neomycin/Bacitracin/Polymyxin/Hydrocortisone 1

Neomycin/Polymixin/Dexamethasone 1

Phospholine 2

Pred Mild 2

Prednisolone Solution, Tablet 1

Proparacaine 1

Restasis 2 PASulfacetamide Sodium/Prednisolone 1

Tetracaine 1

Tropicamide 1

Xiidra 2 PA

Gastrointestinal: Acid Suppression

Cimetidine 1

Dexilant 2 QL

Misoprostol 1

Nizatidine 1

Omeclamox-Pak 2 QL

Omeprazole 1 QL

Drug Name Drug Tier


Pantoprazole 1 QL

Pylera 2 QL

Sucralfate Tablet 1

Gastrointestinal: Nausea/Vomiting

Akynzeo 3

Antivert 50 mg 2

Dronabinol 1

Ondansetron 1 QL

Ondansetron ODT 1

Promethazine 1

Trimethobenzamide 1

Varubi 3 QL

Gastrointestinal: Other

Amitiza 3 PA, QL

Analpram Advanced 3

Analpram-HC Cream 3

Analpram-HC Lotion 3

Analpram-HC Shingles 3

Apriso 2

Auryxia 3

B-donna 1Belladonna Alkaloids/Phenobarbital 1

Budesonide 1

Calcium Acetate 1

Canasa 2

Cortifoam 3

Creon 2

Delzicol 3 E, ST

Dicyclomine 1

Dificid 3

Digex NF 2

Dipentum 3

Diphenoxylate/Atropine 1

Gavilyte 1 H, QL

Halflytely 3

Hyoscyamine 1

21



Drug Name Drug Tier


Lactulose 1

Lialda 2

Linzess 2 PA, QL

Mesalamine Enema 1

Metoclopramide Solution, Tablet 1

Movantik 3 E, PA, QL

Moviprep 3 QL

Pancrelipase 1

Paregoric Tincture 1

Pentasa 3 E

Polyethylene Glycol 3350 1 H, QL

Prepopik 3

Propantheline 1

Sevelamer 1

Sulfasalazine 1

Suprep 3

Symproic 2 PA, QL

Trilyte 1 QL

Uceris Foam 2

Uceris Tablet 3

Ursodiol 1

Viberzi 3 PA, QL

Zenpep 2

HIV/AIDS

Abacavir 1

Abacavir/Lamivudine 1

Aptivus 2

Atazanavir Capsule 1

Atripla 3

Cimduo 2

Complera 2

Drug Name Drug Tier


Crixivan 2

Descovy 3

Didanosine 1

Edurant 2

Efavirenz 1

Emtriva 2

Epivir Solution 2

Evotaz 2

Fosamprenavir 1

Fuzeon 2 QL

Genvoya 3

Intelence 2

Invirase 2

Isentress 2

Juluca 2

Kaletra Tablet 2

Lamivudine 1

Lamivudine/Zidovudine 1

Lopinavir-Ritonavir Solution 1

Nevirapine 1Norvir Capsule, Powder Packet, Solution 2

Odefsey 3

Prezcobix 2

Prezista 2

Rescriptor 2

Retrovir 2

Reyataz Powder Packet 2

Ritonavir Tablet 1

Selzentry 2 PA

Stavudine Capsule 1

22

Drug Name Drug Tier


Stribild 3

Symfi 2

Symfi Lo 2

Tenofovir Tablet 1

Tivicay 3

Triumeq 2

Trizivir 3

Truvada 3

Videx Solution 2

Viracept 2

Viread Oral Powder 2

Vitekta 2

Zerit Solution 2

Zidovudine 1

Infertility1

Cetrotide M

Clomiphene 1

Endometrin 2 PA

Gonal-F M

Gonal-F Rff M

Ovidrel M1 Coverage is determined by the consumer’s prescription

drug benefit plan. Please consult plan documents regarding benefit coverage and cost-share.

Inflammatory Conditions: Rheumatoid Arthritis, Crohn’s Disease, Psoriasis, Ulcerative ColitisCimzia M QL

Cosentyx M

Cuprimine 3 PA

Depen 2

Humira M

Hydroxychloroquine Sulfate 1

Kevzara M

Leflunomide 1 QL

Methotrexate 1

Orencia M

Otrexup M

Drug Name Drug Tier


Rasuvo M

Remicade M

Rheumatrex 3

Simponi M QL

Stelara M QL

Trexall 3

Xeljanz, Xeljanz XR 3 PA, QL

Medications for Sexual Dysfunction1

Cialis 3 PA, QL

Levitra 3 PA, QL

Sildenafil Tablet (generic Viagra) 3 PA, QL1 Coverage is determined by the consumer’s prescription

drug benefit plan. Please consult plan documents regarding benefit coverage and cost-share.

Men’s Health: Prostate

Alfuzosin 1

Cialis 2.5, 5 mg 3 PA, QL

Doxazosin 1

Dutasteride 1

Dutasteride/Tamsulosin 1

Finasteride 1

Rapaflo 2

Tamsulosin 1

Terazosin 1

Men’s Health: Testosterone Therapy

Androderm 2 PA, QL

Androgel 1% 3 PA, QL

Androgel 1.62% 2 PA, QL

Androxy 1

Fortesta 3 PA, QL

Testim 3 PA, QL

Testosterone 1% Gel Pump 1 PA, QL

Testred 3

Miscellaneous

Acetic Acid Otic 1

Acetylcysteine 1

23



Drug Name Drug Tier


Aerochamber 2 QL

Albenza 3 PA, QL

Alinia 2 QL

Anastrozole 1

Antipyrine/Benzocaine 1

Anucort-HC 1

Aranesp M

Austedo 2 PA, QL

Benznidazole 2 PA, QL

Benzocaine Otic 1

Benzonatate 1

Bunavail 3 PA, QL

Cerdelga 3 PA

Cetylev 3

Chloroquine 1

Citric Acid/Sodium Citrate 1

Cystagon 2

Danazol 1

Daraprim 3 PA

Difil-G Forte Liquid 1

Disulfiram 1

Easivent 2 QL

Elmiron 2

Emverm 3 PA, QLEpinephrine Auto-injector (generic Epipen, Epipen Jr) 2 QL

Ergocalciferol 50,000 Unit Capsule 1

Euflexxa M

Exemestane 1

EZ Spacer 2 QL

Fosrenol 3 E

Granix M

Drug Name Drug Tier


Guaifenesin/Codeine 1

Guanidine 2

Hydrocodone/Homatropine 1 AE, QL

Hydrocortisone/Acetic Acid Otic 1

Hydrocortisone Pramoxine 1

Hydrocortisone Suppository 1

Hypersal Nebs 2

Impavido 2 PA

Inspirease 2

Kuvan 2 PA, QL

Letrozole 1

Lidocaine Viscous 1

Mebendazole 1

Mefloquine 1

Megestrol AC 1

Mephyton 2

Mestinon Syrup 2

Methylergonovine 1

Multigen Folic 2

Multigen Plus 2

Naltrexone 1

Narcan Nasal Spray 2

Nessi Spacer 2 QL

Nityr 2 PA

Nuwiq M

Optihaler 2 QL

Orkambi 2 PA, QL

Phenazopyridine 1

Phytonadione 3 QL

Pilocarpine 1

Praziquantel 1

24

Drug Name Drug Tier


Primaquine 1

Procrit M

Proctocream HC 1

Proctofoam HC 2

Proctosol HC 1

Proctozone HC 1

Proglycem 2

Promethazine/Codeine 1 AE, QL

Promethazine/Dextromethorphan 1

Promethazine Suppository 1

Promethazine VC/Codeine 1 AE, QL

Pyridostigmine 1

Rezira 3

Sevelamer 1Sodium Polystyrene Sulfonate Powder 1

SSKI 2

Strensiq M

Symdeko 2 PA, QL

Synarel 2

Synvisc M

Synvisc One M

Triamcinolone/Orabase 1

Tuzistra XR 3 AE, E, QL

Velphoro 3

Veltassa 3

Vistogard 2

Vitamin D 50,000 Unit 1

Vortex 2 QL

WatchHaler 2 QL

Xuriden 2 PA, QL

Yodoxin 2

Zarxio M

Zemplar 2

Zutripro 3 AE, E, QL

Drug Name Drug Tier


Musculoskeletal: Osteoporosis

Actonel 3 E

Alendronate Oral Solution 1 QL

Alendronate Tablet 1 QL

Binosto 3 QL

Calcitonin Spray 1 QL

Forteo M

Fortical 3 QL

Ibandronate 1 QL

Musculoskeletal: Other

Allopurinol 1

Baclofen 1

Carisoprodol 1

Colcrys 2

Cyclobenzaprine 1

Dantrolene 1

Duzallo 3 QL, ST

Lorzone 3

Methocarbamol 1

Orphenadrine/Aspirin/Caffeine 1

Orphenadrine ER 1

Probenecid 1

Tizanidine Tablet 1

Uloric 2 QL, ST

Zurampic 3 PA

Musculoskeletal: Pain Relief

Acetaminophen/Codeine 1 QL

Acetaminophen/Oxycodone 1 QL

Ascomp/Codeine 1

Belbuca 3 PA, QL

Butalbital/Acetaminophen 1Butalbital/Acetaminophen/Caffeine

1 QL

Butalbital/Acetaminophen/Caffeine/Codeine 1 QL

Butalbital/Aspirin/Caffeine Capsule 1

25



Drug Name Drug Tier


Butalbital/Aspirin/Caffeine/Codeine 1

Celecoxib 3 QL

Choline Magnesium Trisalicylate 1

Codeine 1

Diclofenac Sodium 1

Diflunisal 1

Duraxin 1

Etodolac IR/ER 1

Fenoprofen 3 E, STFentanyl Patch 12, 25, 50, 75, 100 mcg 1 PA, QL

Flector Patch 3 E, QL

Flurbiprofen 1

Fortigan 1

Gralise 3 QL, ST

Hydrocodone/Acetaminophen 1 QL

Hydrocodone/Ibuprofen 1

Hydromorphone IR 1 QL

Ibuprofen 1

Indocin Suppository 2 QL

Indomethacin IR/ER 1

Ketoprofen ER 3

Ketoprofen IR 1

Ketorolac 1 QL

Levorphanol 3

Meclofenamate 1

Meloxicam 1

Meperidine 1

Methadone Tablet, Oral Solution 1 PA, QLMorphine Sulfate Controlled-Release Tablet 1 PA, QL

Morphine Sulfate Immediate-Release Tablet, Solution 1

Drug Name Drug Tier


Nabumetone 1

Naproxen 1

Nucynta 3 QL

Nucynta ER 3 PA, QL

Oxaprozin 1

Oxycodone IR 1

Oxycodone/Acetaminophen 1 QL

Oxymorphone 1 QL

Pentazocine/Naloxone 1

Piroxicam 1

Salsalate 1

Sulindac 1

Tivorbex 3 E

Tolmetin 1

Tramadol 1

Trezix 3 E, QL

Vivlodex 3 E, QL

Voltaren Gel 2 QL

Xtampza ER 2 PA, QL

Zohydro ER 3 PA, QL

Zorvolex 3 E

Overactive Bladder

Bethanechol 1

Myrbetriq 3 ST

Oxybutynin 1

Oxybutynin Extended-Release 1

Toviaz 3

Vesicare 3 E

Respiratory: Asthma/COPD

Advair Diskus 2 QL

Advair HFA 2 QL

Aerospan 3 QL

26

Drug Name Drug Tier


Albuterol Sulfate 1

Aminophylline 1

Arcapta 3 QL, ST

Arnuity Ellipta 2 QL

Asmanex 3 QL, ST

Atrovent HFA 3 QL

Bevespi Aerosphere 2 QL

Breo Ellipta 2 QL

Budesonide Nebs 1 QL

Combivent Respimat 2 QL

Cromolyn Nebs 1

Flovent Diskus 2 QL

Flovent HFA 2 QLFluticasone/Salmeterol Powder Inhaler 1 QL

Foradil 2 QL

Incruse Ellipta 2 QL

Ipratropium 1

Ipratropium/Albuterol Nebs 1

Montelukast 1 QL

Perforomist 3 QL

Proair HFA 2 QL

Proair RespiClick 2 QL

Pulmicort Flexhaler 2 QL

Pulmicort Respules 3 QL

QVAR 2 QL

QVAR RediHaler 2 QL

Serevent 2 QL

Spiriva HandiHaler, Respimat 2 QL

Striverdi Respimat 3 QL, ST

Symbicort 2 QL

Terbutaline 1

Theophylline SR 1

Trelegy Ellipta 2 QL

Tudorza 3 QL, ST

Ventolin HFA 2 QL

Drug Name Drug Tier


Xopenex HFA 3 QL, ST

Respiratory: Nasal Allergies

Azelastine 0.1% Solution 1 QL

Dymista Spray 2 E, QL

Flunisolide 1 QL

Fluticasone Propionate 1 QL

Ipratropium 1

Omnaris 3 E, QL

QNasl 3 QL

Veramyst 3 E, QL

Zetonna 3 E, QL

Respiratory: Oral AllergiesCarbinoxamine Solution, 4 mg Tablet 1

Clemastine 1

Cyproheptadine 1

Dexchlorpheniramine 1

Hydroxyzine 1

Promethazine 1

Respiratory: Pulmonary Arterial Hypertension

Adcirca 3 PA, QL

Adempas 2 PA, QL

Letairis 2 PA, QL

Opsumit 2 PA, QL

Orenitram 3 PA, QLSildenafil Tablet 20 mg (generic Revatio) 1 PA, QL

Tracleer 2 PA, QL

Smoking CessationBupropion Sustained-Release Tablet 1 H

Chantix Tablet 3 H-PA

Nicoderm CQ 3 H

Nicorette Gum 3 H

Nicorette Lozenge 3 H

Nicorette Mini-Lozenge 3 H

Nicotine Gum 1 H

27



Drug Name Drug Tier


Nicotine Lozenge 1 H

Nicotine Patch 1 H

Nicotrol Inhaler 3 H-PA

Nicotrol Nasal Spray 3 H-PA

Thrive Gum 1 H

Transplant

Azathioprine 1Cyclosporine, Cyclosporine Modified 1

Gengraf 1

Tacrolimus 1

Vitamins/Electrolytes

Fluoride Chewable Tablet, Drops 1 H

Folic Acid 1 mg 1

Klor-Con 10 1

Klor-Con M10 1

Klor-Con M20 1

Potassium Chloride 1

Potassium Citrate 1

Women’s Health: Contraceptives

Aftera 1 H

Altavera 1 H

Alyacen 1 H

Apri 1 H

Aranelle 1 H

Aubra 1 H

Aviane 1 H

Azurette 1 H

Balcoltra 3 H

Balziva 1 H

Bekyree 1 H

Blisovi FE 1 H

Drug Name Drug Tier


Briellyn 1 H

Camila 1 H

Caziant 1 H

Chateal 1 H

Cryselle 1 H

Cyclafem 1 H

Cyred 1 H

Dasetta 1 H

Deblitane 1 H

Delyla 1 H

Desogestrel/Ethinyl Estradiol 1 H

Drospirenone/Ethinyl Estradiol 1 HDrospirenone/Ethinyl Estradiol/Levomefolate 3 H

EContra EZ 1 H

EContra One-Step 1 H

Elinest 1 H

Ella 1 H, QL

Emoquette 1 H

Enpresse 1 H

Enskyce 1 H

Errin 1 H

Estarylla 1 HEthynodiol Diacetate/Ethinyl Estradiol 1 H

Falmina 1 H

Fallback Solo 1 H

Femynor 1 H

Gianvi 1 H

Gildagia 1 H

Heather 1 H

Implanon 1 H

28

Drug Name Drug Tier


Introvale 1 H

Isibloom 1 H

Jencycla 1 H

Jolessa 1 H

Jolivette 1 H

Juleber 1 H

Junel 1 H

Junel Fe 1 H

Kariva 1 H

Kelnor 1/35, 1/50 1 H

Kimidess 1 H

Kurvelo 1 H

Larin, Larin FE 1 H

Larissia 1 H

Leena 1 H

Lessina 1 H

Levonest 1 H

Levonorgestrel 1 H, QL

Levonorgestrel/Ethinyl Estradiol 1 HLevonorgestrel/Ethinyl Estradiol (generic Quartette) 3 H

Levora-28 1 H

Lillow 1 H

Lo Loestrin 3 H

Loestrin 2

Loryna 1 H

Low-Ogestrel 1 H

Lutera 1 H

Lyza 1 H

Marlissa 1 HMedroxyprogesterone Acetate Injection 1 H, PA

Melodetta 24 FE 3 H

Mibelas 24 FE 3 H

Microgestin 1 H

Microgestin FE 1 H

Mono-Linyah 1 H

Drug Name Drug Tier


MonoNessa 1 H

My Choice 1 H

My Way 1 H

Myzilra 1 H

Natazia 2 H

Necon 0.5/35, 1/50, 10/11 1 H

Next Choice One Dose 1 H

Nikki 1 H

Nora-BE 1 H

Norethindrone 1 H

Norethindrone/Ethinyl Estradiol 1 H

Norgestimate/Ethinyl Estradiol 1 HNorethindrone/Ethinyl Estradiol/Ferrous Fumarate 1 H

Norgestrel/Ethinyl Estradiol 1 H

Norlyda 1 H

Norlyroc 1 H

Nortrel 1 H

Nuvaring 2 H

Ocella 1 H

Ogestrel 1 H

Opcicon One-Step 1 H

Option 2 1 H

Orsythia 1 H

Ortho Coil 1 H

Ortho Flat 1 H

Ortho Flex 1 H

Philith 1 H

Pimtrea 1 H

Plan B One Step 1 H

Portia 1 H

Previfem 1 H

Primella 1 H

Quasense 1 H

React 1 H

Reclipsen 1 H

29



Drug Name Drug Tier


Setlakin 1 H

Sharobel 1 H

Sprintec 1 H

Sronyx 1 H

Syeda 1 H

Take Action 1 H

Tarina FE 1 H

Taytulla 3 H

Tri Femynor 1 H

Tri-Estarylla 1 H

Tri-Linyah 1 H

Tri-Previfem 1 H

Tri-Sprintec 1 H

Tri-Vylibra 1 H

Trinessa 1 H

Trinessa Lo 3 H

Trivora-28 1 H

Tydemy 3 H

Velivet 1 H

Vestura 1 H

Vienva 1 H

Viorele 1 H

Vyfemla 1 H

Vylibra 1 H

Wera 1 H

Wide-Seal 1 H

Xulane 1 H

Yasmin 28 3 E, H

Yaz 3 E, H

Zarah 1 H

Zenchent 1 H

Zovia 1 H

Drug Name Drug Tier


Women’s Health: Hormone Replacement

Amabelz 1

Cenestin 3 QL

Climara Pro 2 QL

Covaryx, Covaryx HS 1 QL

Divigel 3

Duavee 2 QL

Elestrin 3

Enjuvia 3

Estradiol Tablet 1

Estradiol Twice Weekly Patch 1 QL

Estradiol Weekly Patch 1 QLEstrogen/Methyltestosterone, Estrogen/Methyltestosterone HS 1 QL

Estropipate 1

Evamist 3

Fyavolv 1

Intrarosa 3

Jinteli 1

Lopreeza 1

Makena M

Medroxyprogesterone 1

Menest 2

Mimvey 1

Minivelle 3 QL

Norethindrone 1

Norethindrone/Ethinyl Estradiol 1

Osphena 3 QL

Premarin 2

Premarin Vaginal Cream 2

Premphase 2

Prempro 2

Vivelle-Dot 3 E, QL

Yuvafem 1

30

Drug Name Drug Tier


Women’s Health: Miscellaneous

Raloxifene 1 H-PA, QL

Tamoxifen 1 H-PA

Women’s Health: Prenatal VitaminsBrand Prenatal Vitamins/Folic Acid 1 mg 2

Generic Prenatal Vitamins/Folic Acid 1 mg 1

31

A

Abacavir ........................................ 21Abacavir/Lamivudine ..................... 21Absorica ........................................ 16Acanya ........................................... 16Acarbose ....................................... 18Accu-Chek Test Strips ................... 17Acebutolol .......................................11Acetaminophen/Butalbital/

Caffeine ...................................... 14Acetaminophen/Codeine ............... 24Acetaminophen/Oxycodone .......... 24Acetazolamide ................................11Acetazolamide ER ..........................11Acetic Acid Otic ....................... 22, 23Acetylcysteine ............................... 22Acitretin ......................................... 16Actonel .......................................... 24Acyclovir ...................................10, 16Aczone Gel .................................... 16Adcirca .......................................... 26Adderall XR ................................... 13Adefovir ......................................... 10Adempas ....................................... 26Adlyxin ........................................... 18Advair Diskus................................. 25Advair HFA .................................... 25Aerochamber ................................. 23Aerospan ....................................... 25Afeditab CR ....................................11Aftera ............................................. 27Aggrenox ........................................11Akynzeo ......................................... 20Ala Quin ......................................... 16Albenza ......................................... 23Albuterol Sulfate ............................ 26Alclometasone ............................... 16Aldactazide 25/25 mg .....................11Alendronate Oral Solution ............. 24Alendronate Tablet ........................ 24Alfuzosin ........................................ 22Alinia .............................................. 23Allopurinol...................................... 24Alphagan P .................................... 19Alphatrex ....................................... 16Alprazolam IR/ER .......................... 14Altavera ......................................... 27

Alunbrig ......................................... 10Alyacen .......................................... 27Amabelz ........................................ 29Amantadine Capsule, Syrup.......... 10Amiloride ........................................11Amiloride/Hydrochlorothiazide .......11Aminophylline ................................ 26Amiodarone ................................... 13Amitiza ........................................... 20Amitriptyline ..............................14, 15Amlodipine ......................................11Amlodipine/Benazepril ...................11Amnesteem ................................... 16Amoxapine .................................... 14Amoxicillin ....................................... 9Amoxicillin/Potassium Clavulanate.. 9Ampyra .......................................... 14Anagrelide ..................................... 13Analpram Advanced ...................... 20Analpram-HC Cream ..................... 20Analpram-HC Lotion ...................... 20Analpram-HC Shingles.................. 20Anastrozole ................................... 23Androderm ..................................... 22Androgel 1% .................................. 22Androgel 1.62% ............................. 22Androxy ......................................... 22Antara ............................................ 12Antipyrine/Benzocaine .............. 9, 23Antipyrine/Benzocaine Otic ............. 9Antivert 50 mg ............................... 20Anucort-HC ................................... 23Apidra Solostar, Vials .................... 17Apri ................................................ 27Apriso ............................................ 20Aptivus ........................................... 21Aranelle ......................................... 27Aranesp ......................................... 23Arcapta .......................................... 26Aripiprazole ODT ........................... 14Aripiprazole Solution, Tablet ......... 14Aristada ......................................... 14Arnuity Ellipta ................................ 26Ascomp/Codeine ........................... 24Asmalpred, Asmalpred Plus .......... 18Asmanex........................................ 26Atazanavir Capsule ....................... 21Atenolol ..........................................11

Atenolol/Chlorthalidone ..................11Atomoxetine ................................... 13Atorvastatin ................................... 12Atripla ............................................ 21Atropine ......................................... 20Atrovent HFA ................................. 26Aubra ............................................. 27Auryxia .......................................... 20Austedo ......................................... 23Aviane ............................................ 27Avonex ........................................... 14Azasite ........................................... 19Azathioprine .................................. 27Azelastine 0.05% Solution ............ 19Azelastine 0.1% Solution ............... 26Azithromycin .................................... 9Azopt ............................................. 19Azurette ......................................... 27

B

B-donna ......................................... 20Bacitracin ................................. 19, 20Bacitracin/Polymyxin ............... 19, 20Baclofen ........................................ 24Balcoltra ........................................ 27Balziva ........................................... 27Baraclude ...................................... 10Basaglar ........................................ 17Bayer Contour Next Test Strips ..... 17Bayer Contour Test Strips ............. 17Bekyree ......................................... 27Belbuca ......................................... 24Belladonna Alkaloids/

Phenobarbital ............................. 20Benazepril ......................................11Benazepril/Hydrochlorothiazide .....11Benzaclin ....................................... 16Benznidazole ................................. 23Benzocaine Otic ........................ 9, 23Benzonatate .................................. 23Benztropine ................................... 14Besivance ...................................... 19Betamethasone ............................. 16Betaseron ...................................... 14Betaxolol ...................................11, 19Bethanechol .................................. 25Bethkis ............................................. 9Betimol .......................................... 19

Index

32

Betoptic-S ...................................... 19Bevespi Aerosphere ...................... 26Bicalutamide .................................. 10Binosto .......................................... 24Bisoprolol ........................................11Bisoprolol/Hydrochlorothiazide ......11Blephamide SOP ........................... 20Blisovi FE....................................... 27Bosulif ............................................ 10Brand Prenatal Vitamins/

Folic Acid 1 mg ........................... 30Breo Ellipta .................................... 26Briellyn ........................................... 27Brilinta ............................................11Brimonidine ................................... 20Bromocriptine ................................ 14Budesonide ............................. 20, 26Budesonide Nebs .......................... 26Bumetanide ....................................11Bunavail ......................................... 23Bupropion ................................ 14, 26Bupropion SR ................................ 14Bupropion Sustained-Release

Tablet .......................................... 26Bupropion XL ................................. 14Buspirone ...................................... 14Butalbital/Acetaminophen ............. 24Butalbital/Acetaminophen/

Caffeine ...................................... 24Butalbital/Acetaminophen/

Caffeine/Codeine ....................... 24Butalbital/Aspirin/Caffeine

Capsule ...................................... 24Butalbital/Aspirin/Caffeine/

Codeine ...................................... 25Bydureon, Bydureon Bcise ............ 18Byetta ............................................ 18Bystolic ...........................................11Byvalson .........................................11

C

Cabometyx .................................... 10Calcipotriene Ointment .................. 16Calcipotriene-Betamethasone ....... 16Calcitonin Spray ............................ 24Calcitriol................................... 16, 18Calcitriol Ointment ......................... 16Calcium Acetate ............................ 20Calquence ..................................... 10Camila ........................................... 27

Canasa .......................................... 20Capecitabine ................................. 10Caprelsa ........................................ 10Captopril .........................................11Captopril/Hydrochlorothiazide ........11Carbamazepine ER Capsules ....... 15Carbamazepine IR ........................ 15Carbidopa/Levodopa IR/ER .......... 14Carbinoxamine Solution, 4 mg

Tablet .......................................... 26Carisoprodol .................................. 24Carteolol ........................................ 19Cartia XT ........................................11Carvedilol .......................................11Caziant .......................................... 27Cefaclor Suspension ....................... 9Cefaclor Tablet ................................ 9Cefadroxil ........................................ 9Cefdinir ............................................ 9Cefpodoxime ................................... 9Cefprozil .......................................... 9Cefuroxime ...................................... 9Celecoxib ....................................... 25Cenestin ........................................ 29Cephalexin ...................................... 9Cerdelga ........................................ 23Cerovel .......................................... 16Cetrotide ........................................ 22Cetylev .......................................... 23Chantix Tablet ................................ 26Chateal .......................................... 27Chlordiazepoxide ......................14, 15Chlordiazepoxide/Amitriptyline ...... 15Chloroquine ................................... 23Chlorothiazide ................................11Chloroxylenol/Hydrocortisone/

Pramoxine Otic ............................. 9Chlorpromazine ............................. 15Chlorpropamide ............................. 18Chlorthalidone ................................11Cholestyramine ............................. 12Choline Fenofibrate Capsule ......... 13Choline Magnesium Trisalicylate ... 25Cialis .............................................. 22Cialis 2.5, 5 mg .............................. 22Ciclodan ........................................ 16Ciclopirox Cream, Gel, Lotion,

Solution ...................................... 16Cilostazol ....................................... 13Cimduo .......................................... 21

Cimetidine ..................................... 20Cimzia............................................ 22Ciprodex ........................................ 19Ciprofloxacin .............................. 9, 19Citalopram ..................................... 14Citric Acid/Sodium Citrate ............. 23Claravis.......................................... 16Clarithromycin IR/ER ....................... 9Clemastine .................................... 26Cleocin Vaginal Suppository ........... 9Climara Pro ................................... 29Clindamycin Capsule ....................... 9Clindamycin Gel, Lotion, Swabs .... 16Clindamycin Solution ..................... 16Clindamycin Vaginal Cream ............ 9Clindesse ......................................... 9Clobetasol, Clobetasol E ............... 16Clobex Lotion, Shampoo ............... 16Clobex Spray ................................. 16Cloderm ......................................... 16Cloderm Pump .............................. 16Clomiphene ................................... 22Clomipramine ................................ 14Clonazepam, Clonazepam ODT ... 15Clonidine Tablet ..............................11Clopidogrel .....................................11Clorazepate ................................... 15Clotrimazole Troche ........................ 9Clozapine ...................................... 15Codeine ....................................23-25Colcrys .......................................... 24Colestipol ....................................... 13Combigan ...................................... 19Combivent Respimat ..................... 26Cometriq ........................................ 10Complera ....................................... 21Compro Suppository ..................... 15Corlanor ......................................... 13Cormax .......................................... 16Cortifoam ....................................... 20Cortisone ....................................... 18Cosentyx ....................................... 22Cosopt, Cosopt PF ........................ 19Cotellic ........................................... 10Covaryx, Covaryx HS .................... 29Creon ............................................. 20Cresemba ........................................ 9Crixivan ......................................... 21Cromolyn ................................. 19, 26Cromolyn Nebs .............................. 26

33

Cryselle ......................................... 27Cuprimine ...................................... 22Cyclafem ....................................... 27Cyclobenzaprine ........................... 24Cyclopentolate ............................... 20Cyclophosphamide ........................ 10Cyclosporine, Cyclosporine

Modified...................................... 27Cymbalta ....................................... 14Cyproheptadine ............................. 26Cyred ............................................. 27Cystagon ....................................... 23

D

Daklinza ......................................... 10Danazol ......................................... 23Dantrolene ..................................... 24Dapsone Tablet ............................... 9Daraprim ........................................ 23Dasetta .......................................... 27Deblitane ....................................... 27Delyla ............................................ 27Delzicol .......................................... 20Demeclocycline ............................... 9Depen ............................................ 22Dermazene .................................... 16Descovy ......................................... 21Desipramine .................................. 14Desmopressin ............................... 18Desogestrel/Ethinyl Estradiol ........ 27Desonide ....................................... 16Desoximetasone ............................ 16Desvenlafaxine Succinate ER ....... 14Dexamethasone ....................... 18-20Dexchlorpheniramine .................... 26Dexilant .......................................... 20Dextroamphetamine Sulfate

Extended-Release ..................... 13Dextroamphetamine Sulfate

Tablet .......................................... 13Dextroamphetamine/

Amphetamine ............................. 13Dextroamphetamine/Amphetamine

Extended-Release ..................... 13Diazepam ...................................... 15Diazepam Gel ................................ 15Diclofenac ................................ 20, 25Diclofenac Sodium ........................ 25Dicloxacillin ...................................... 9Dicyclomine ................................... 20

Didanosine .................................... 21Dificid ............................................. 20Difil-G Forte Liquid ........................ 23Diflunisal ........................................ 25Digex NF ....................................... 20Digoxin .......................................... 13Dilatrate SR ................................... 13Diltiazem Sustained-Release

Capsule .......................................11Diltiazem Tablet ..............................11Dipentum ....................................... 20Diphenoxylate/Atropine ................. 20Disopyramide ...........................11, 13Disulfiram ...................................... 23Divalproex DR ............................... 15Divigel ............................................ 29Donepezil, Donepezil ODT ............ 15Dorzolamide .................................. 19Dorzolamide/Timolol ..................... 19Doxazosin ................................ 12, 22Doxepin ......................................... 14Doxycycline Hyclate ........................ 9Doxycycline Monohydrate Tablet ..... 9DrithoScalp .................................... 16Dronabinol ..................................... 20Drospirenone/Ethinyl Estradiol ...... 27Drospirenone/Ethinyl Estradiol/

Levomefolate .............................. 27Duavee .......................................... 29Duloxetine 20, 30, 60 mg .............. 14Dupixent ........................................ 16Duraxin .......................................... 25Dutasteride .................................... 22Dutasteride/Tamsulosin ................. 22Duzallo .......................................... 24Dymista Spray ............................... 26

E

Easivent ......................................... 23Econazole ...................................... 16EContra EZ .................................... 27EContra One-Step ......................... 27Edarbi ............................................ 12Edarbyclor ..................................... 12Edurant .......................................... 21Efavirenz ........................................ 21Elestrin .......................................... 29Elidel .............................................. 16Elinest ............................................ 27Eliquis .............................................11

Ella ................................................. 27Elmiron .......................................... 23Emcyt ............................................ 10Emoquette ..................................... 27Emtriva .......................................... 21Emverm ......................................... 23Enalapril ........................................ 12Enalapril/Hydrochlorothiazide ....... 12Endometrin .................................... 22Enjuvia ........................................... 29Enpresse ....................................... 27Enskyce ......................................... 27Enstilar ........................................... 16Entaone ......................................... 15Entecavir ........................................ 10Epclusa .......................................... 10Epinastine ...................................... 19Epinephrine Auto-injector .............. 23Epipen, Epipen Jr .......................... 23Epitol .............................................. 15Epivir HBV Solution ....................... 10Epivir Solution ............................... 21Eprosartan ..................................... 12Ergocalciferol 50,000 Unit

Capsule ...................................... 23Ergoloid Mesylate .......................... 15Erivedge ........................................ 10Errin ............................................... 27Ery Pad .......................................... 16Erythromycin ........................9, 16, 19Erythromycin/Benzoyl Peroxide .... 16Erythromycin/Sulfisoxazole ............. 9Escitalopram .................................. 14Estarylla......................................... 27Estradiol Tablet .............................. 29Estradiol Twice Weekly Patch ....... 29Estradiol Weekly Patch ................. 29Estrogen/Methyltestosterone,

Estrogen/Methyltestosterone HS .............................................. 29

Estropipate .................................... 29Eszopiclone ................................... 15Ethambutol ...................................... 9Ethosuximide ................................. 15Ethyl Chloride ................................ 16Ethynodiol Diacetate/Ethinyl

Estradiol ..................................... 27Etodolac IR/ER .............................. 25Etoposide....................................... 10Euflexxa ......................................... 23

34

Eurax ............................................. 16Evamist .......................................... 29Evotaz ............................................ 21Exemestane ............................ 10, 23Exoderm ........................................ 16EZ Spacer ..................................... 23Ezetimibe ....................................... 13Ezetimibe/Simvastatin ................... 13Ezide ............................................. 12

F

Fallback Solo ................................. 27Falmina .......................................... 27Famciclovir .................................... 10Fareston ........................................ 10Farxiga .......................................... 18Farydak.......................................... 10Felodipine ...................................... 12Femynor ...................................27, 29Fenofibrate 48, 145 mg Tablet ....... 13Fenofibrate 54, 160 mg Tablet ....... 13Fenofibrate Capsule ...................... 13Fenofibrate Micronized .................. 13Fenoprofen .................................... 25Fentanyl Patch 12, 25, 50,

75, 100 mcg ............................... 25Finacea .......................................... 16Finasteride ..................................... 22Firvanq ............................................ 9Flecainide ...................................... 13Flector Patch ................................. 25Flovent Diskus ............................... 26Flovent HFA ................................... 26Fluconazole ..................................... 9Fludrocortisone ............................. 18Flunisolide ..................................... 26Fluocinolone .................................. 16Fluocinonide, Fluocinonide E ........ 16Fluoride Chewable Tablet, Drops .. 27Fluorometholone ........................... 20Fluoroplex ...................................... 16Fluorouracil Solution, 5% Cream ... 16Fluoxetine Capsule ........................ 14Fluphenazine ................................. 15Flurazepam ................................... 15Flurbiprofen ............................. 20, 25Flutamide ....................................... 10Fluticasone .............................. 16, 26Fluticasone Propionate .................. 26

Fluticasone/Salmeterol Powder Inhaler ........................................ 26

Fluvoxamine .................................. 14FML Forte ...................................... 20Folic Acid 1 mg .........................27, 30Foradil ............................................ 26Forfivo XL ...................................... 14Forteo ............................................ 24Fortesta ......................................... 22Fortical........................................... 24Fortigan ......................................... 25Fosamprenavir ............................... 21Fosinopril ....................................... 12Fosinopril/Hydrochlorothiazide ...... 12Fosrenol......................................... 23FreeStyle Test Strips ..................... 17Furosemide .................................... 12Fuzeon ........................................... 21Fyavolv .......................................... 29

G

Gabapentin .................................... 15Galantamine IR/ER ....................... 15Galantamine Solution .................... 15Gavilyte ......................................... 20Gemfibrozil .................................... 13Generic Prenatal Vitamins/

Folic Acid 1 mg ........................... 30Gengraf ......................................... 27Gentamicin .............................. 16, 19Genvoya ........................................ 21Gianvi ............................................ 27Gildagia ......................................... 27Gilenya .......................................... 14Glatiramer ...................................... 14Glatopa .......................................... 14Glimepiride .................................... 18Glipizide IR/XL .............................. 18Glipizide/Metformin ....................... 18Glucagen ....................................... 18Glucagon ....................................... 18Glumetza ....................................... 18Glyburide ....................................... 18Glyburide/Metformin ...................... 18Glyxambi ....................................... 18Gonal-F ......................................... 22Gonal-F Rff.................................... 22Gralise ........................................... 25Granix ............................................ 23Griseofulvin ..................................... 9

Guaifenesin/Codeine ..................... 23Guanfacine ...............................12, 13Guanfacine ER .............................. 13Guanidine ...................................... 23

H

Halflytely ........................................ 20Haloperidol .................................... 15Harvoni .......................................... 10Heather .......................................... 27Hexalen ......................................... 10Homatropine ............................ 20, 23Humalog KwikPen ......................... 17Humalog Mix 50-50 KwikPen ........ 17Humalog Mix 50-50 Vial ................ 17Humalog Mix 75-25 KwikPen ........ 17Humalog Mix 75-25 Vial ................ 17Humalog U-200 KwikPen .............. 18Humalog Vial ................................. 18Humira ........................................... 22Humulin 70-30 KwikPen ................ 18Humulin 70-30 Vial ........................ 18Humulin KwikPen .......................... 18Humulin N KwikPen ....................... 18Humulin N Vial ............................... 18Humulin R U-500 KwikPen ............ 18Humulin R U-500 Vial ................... 18Humulin R Vial ............................... 18Hydralazine ................................... 12Hydrochlorothiazide..................11, 12Hydrocodone/Acetaminophen ....... 25Hydrocodone/Homatropine ........... 23Hydrocodone/Ibuprofen ................. 25Hydrocortisone .........9, 16, 18, 20, 23Hydrocortisone Pramoxine ........ 9, 23Hydrocortisone Suppository .......... 23Hydrocortisone Tablet ................... 18Hydrocortisone/Acetic Acid Otic .... 23Hydromorphone IR ........................ 25Hydroxychloroquine Sulfate .......... 22Hydroxyurea .................................. 10Hydroxyzine ............................. 15, 26Hyoscyamine ................................. 20Hypercare ...................................... 16Hypersal Nebs ............................... 23

I

Ibandronate ................................... 24Ibrance .......................................... 10Ibuprofen ....................................... 25

35

Idhifa .............................................. 10Ilotycin ........................................... 19Imatinib .......................................... 10Imbruvica Capsule......................... 10Imbruvica Tablet ............................ 10Imipramine ..................................... 14Imiquimod ...................................... 16Impavido ........................................ 23Implanon ........................................ 27Incruse Ellipta ................................ 26Indapamide .................................... 12Indocin Suppository ....................... 25Indomethacin IR/ER ...................... 25Inspirease ...................................... 23Intelence ........................................ 21Intrarosa ........................................ 29Introvale ......................................... 28Intuniv ............................................ 13Invega Sustenna ............................ 15Invega Trinza ................................. 15Invirase .......................................... 21Invokamet, Invokamet XR ............. 18Invokana ........................................ 18Ipratropium .................................... 26Ipratropium/Albuterol Nebs............ 26Irbesartan ...................................... 12Irbesartan/Hydrochlorothiazide ..... 12Isentress ........................................ 21Isibloom ......................................... 28Iso Carbachol ................................ 20Iso Homatropine ............................ 20Isochron ......................................... 13Isoditrate ER .................................. 13Isometheptene/Acetaminophen/

Dichloralphenazone ................... 14Isoniazid .......................................... 9Isordil ............................................. 13Isosorbide Dinitrate IR/ER ............ 13Isosorbide Mononitrate IR/ER ....... 13Isoxsuprine .................................... 13Isradipine ....................................... 12Itraconazole ..................................... 9

J

Jantoven .........................................11Janumet ......................................... 18Janumet XR ................................... 18Januvia .......................................... 18Jardiance ....................................... 18Jencycla ........................................ 28

Jentadueto ..................................... 18Jentadueto XR ............................... 18Jinteli ............................................. 29Jolessa .......................................... 28Jolivette ......................................... 28Jublia ............................................. 10Juleber ........................................... 28Juluca ............................................ 21Junel .............................................. 28Junel Fe ......................................... 28Juvisync ......................................... 18

K

Kaletra Tablet ................................ 21Kariva ............................................ 28Kelnor 1/35, 1/50 ........................... 28Kerydin .......................................... 10Ketoconazole Cream ..................... 10Ketoconazole Shampoo ................ 10Ketoprofen ER ............................... 25Ketoprofen IR ................................ 25Ketorolac ................................. 20, 25Kevzara ......................................... 22Kimidess ........................................ 28Klor-Con 10 ................................... 27Klor-Con M10 ................................ 27Klor-Con M20 ................................ 27Kurvelo .......................................... 28Kuvan ............................................ 23

L

Labetalol ........................................ 12Laclotion ........................................ 16Lactulose ....................................... 21Lamivudine .............................. 10, 21Lamivudine/Zidovudine ................. 21Lamotrigine Chewable, Tablet ....... 15Lamotrigine ER .............................. 15Lamotrigine ODT ........................... 16Larin, Larin FE ............................... 28Larissia .......................................... 28Lastacaft ........................................ 19Latanoprost ................................... 19Latuda ........................................... 15Leena............................................. 28Leflunomide ................................... 22Lessina .......................................... 28Letairis ........................................... 26Letrozole .................................. 10, 23Leucovorin Calcium ....................... 10

Leukeran ........................................ 10Levemir FlexTouch, Vials ............... 18Levetiracetam ER .......................... 16Levetiracetam IR ........................... 16Levitra ............................................ 22Levobunolol ................................... 19Levofloxacin ..................................... 9Levonest ........................................ 28Levonorgestrel ............................... 28Levonorgestrel/Ethinyl Estradiol .... 28Levora-28 ...................................... 28Levorphanol ................................... 25Levothyroxine Sodium ................... 19Levoxyl .......................................... 19Lialda ............................................. 21Lidocaine ................................. 16, 23Lidocaine Viscous ......................... 23Lidocaine/Prilocaine ...................... 16Lillow.............................................. 28Lindane .......................................... 16Linezolid Tablet ................................ 9Linzess .......................................... 21Liothyronine Sodium ...................... 19Lipofen ........................................... 13Lisinopril ........................................ 12Lisinopril/Hydrochlorothiazide ....... 12Lithium IR/ER ................................ 15Livalo ............................................. 13Lo Loestrin ..................................... 28Loestrin .......................................... 28Lokara............................................ 16Lomustine ...................................... 10Lonsurf .......................................... 10Lopinavir-Ritonavir Solution .......... 21Lopreeza ....................................... 29Lorazepam .................................... 15Loryna ........................................... 28Lorzone ......................................... 24Losartan ........................................ 12Losartan/Hydrochlorothiazide ....... 12Lovastatin ...................................... 13Low-Ogestrel ................................. 28Loxapine ........................................ 15Lumigan ......................................... 19Lupron Depot ................................. 18Lutera ............................................ 28Lyrica Capsule ............................... 16Lyrica Solution ............................... 16Lysodren ........................................ 10Lyza ............................................... 28

36

M

Makena .......................................... 29Maprotiline ..................................... 14Marlissa ......................................... 28Matulane ........................................ 10Mavyret .......................................... 10Mebendazole ................................. 23Meclofenamate .............................. 25Medrol 2 mg .................................. 18Medroxyprogesterone ............. 28, 29Medroxyprogesterone Acetate

Injection ...................................... 28Mefloquine ..................................... 23Megestrol AC ................................. 23Melodetta 24 FE ............................ 28Meloxicam ..................................... 25Melphalan ...................................... 10Memantine Solution, Tablet ........... 15Menest ........................................... 29Meperidine ..................................... 25Mephyton ....................................... 23Meprobamate ................................ 15Mercaptopurine ............................. 10Mesalamine Enema ....................... 21Mestinon Syrup ............................. 23Metformin ...................................... 18Metformin Extended-Release ....... 18Methadone Tablet, Oral Solution ... 25Methazolamide .............................. 12Methenamine ................................... 9Methimazole .................................. 19Methocarbamol ............................. 24Methotrexate .................................. 22Methyclothia .................................. 12Methyldopa .................................... 12Methyldopa/Hydrochlorothiazide ... 12Methylergonovine .................... 18, 23Methylphenidate Controlled-

Release Capsule ........................ 14Methylphenidate Tablet ................. 14Methylprednisolone ....................... 18Metipranolol ................................... 19Metoclopramide Solution, Tablet ... 21Metolazone .................................... 12Metoprolol Succinate ER ............... 12Metoprolol Tartrate ........................ 12Metrogel 1% .................................. 17Metronidazole 0.75% Cream,

Lotion ......................................... 17Metronidazole Tablet ....................... 9

Metronidazole Vaginal Gel ............ 10Mexiletine ...................................... 13Mibelas 24 FE................................ 28Microgestin .................................... 28Microgestin FE .............................. 28Midodrine ....................................... 13Migragesic ..................................... 14Migranal ......................................... 14Millipred Tablet .............................. 19Mimvey .......................................... 29Minivelle......................................... 29Minocycline Capsule ....................... 9Minoxidil......................................... 12Mirtazapine, Mirtazapine ODT ...... 14Mirvaso .......................................... 17Misoprostol .................................... 20Moexipril ........................................ 12Moexipril/Hydrochlorothiazide ....... 12Mometasone Furoate .................... 17Mono-Linyah ................................. 28MonoNessa ................................... 28Montelukast ................................... 26Morphine Sulfate Controlled-

Release Tablet ........................... 25Morphine Sulfate Immediate-

Release Tablet, Solution ............ 25Movantik ........................................ 21Moviprep ........................................ 21Moxeza .......................................... 19Moxifloxacin ................................... 19Multaq ............................................ 13Multigen Folic ................................ 23Multigen Plus ................................. 23Mupirocin Calcium Cream ............. 17Mupirocin Ointment ....................... 17My Choice ..................................... 28My Way .......................................... 28Mycobutin ........................................ 9Myleran .......................................... 10Myorisan ........................................ 17Myrbetriq ....................................... 25Myzilra ........................................... 28

N

Nabumetone .................................. 25Nadolol .......................................... 12Naltrexone ..................................... 23Namzaric ....................................... 15Naphazoline 0.1% .......................... 19Naproxen ....................................... 25

Narcan Nasal Spray ...................... 23Natacyn ......................................... 19Natazia .......................................... 28Nateglinide .................................... 18NebuPent Nebs ............................... 9Necon 0.5/35, 1/50, 10/11 ............. 28Nefazodone ................................... 14Neomycin............................. 9, 19, 20Neomycin/Bacitracin/

Polymyxin ............................. 19, 20Neomycin/Bacitracin/Polymyxin/

Hydrocortisone ........................... 20Neomycin/Polymixin/

Dexamethasone ......................... 20Neomycin/Polymixin/Gramicidin .... 19Neomycin/Polymixin/

Hydrocortisone Otic ..................... 9Nerlynx .......................................... 10Nessi Spacer ................................. 23Nevirapine ..................................... 21Nexavar ..........................................11Next Choice One Dose ................. 28Niacin ER ...................................... 13Niaspan ......................................... 13Nicardipine .................................... 12Nicoderm CQ................................. 26Nicorette Gum ............................... 26Nicorette Lozenge ......................... 26Nicorette Mini-Lozenge ................. 26Nicotine Gum ................................. 26Nicotine Lozenge ........................... 27Nicotine Patch ............................... 27Nicotrol Inhaler .............................. 27Nicotrol Nasal Spray ...................... 27Nifediac CC ................................... 12Nifedical XL ................................... 12Nifedipine IR/ER ............................ 12Nikki ............................................... 28Nilandrone ......................................11Ninlaro ............................................11NitroBid .......................................... 13Nitrofurantoin ................................... 9Nitrofurantoin Macrocrystal ............. 9Nitroglycerin ER ............................ 13Nitroglycerin Tablet ........................ 13Nitrolingual Pump Spray ................ 13NitroTime ....................................... 13Nityr ............................................... 23Nizatidine ....................................... 20Nodolor .......................................... 14

37

Nora-BE ........................................ 28Norethindrone .......................... 28, 29Norethindrone/Ethinyl

Estradiol ............................... 28, 29Norethindrone/Ethinyl Estradiol/

Ferrous Fumarate ....................... 28Norgestimate/Ethinyl Estradiol ...... 28Norgestrel/Ethinyl Estradiol ........... 28Norlyda .......................................... 28Norlyroc ......................................... 28Norpace CR................................... 13Nortrel ........................................... 28Nortriptyline ................................... 14Norvir Capsule, Powder Packet,

Solution ...................................... 21Novofine Autocover Pen

Needles ...................................... 17Novofine Pen Needles ................... 17Novofine Plus Pen Needles ........... 17Novolin Vials .................................. 18Novolog FlexPen, Vials ................. 18Novotwist Pen Needles ................. 17Nucynta ......................................... 25Nucynta ER ................................... 25Nutropin AQ, Nutropin AQ

NuSpin ....................................... 18Nuvaring ........................................ 28Nuwiq ............................................ 23Nystatin ....................................10, 17Nystop ........................................... 17

O

Ocella ............................................ 28Odefsey ......................................... 21Odomzo ..........................................11Ofloxacin ................................... 9, 19Ofloxacin Otic .................................. 9Ogestrel ......................................... 28Olanzapine, Olanzapine ODT ....... 15Olmesartan .................................... 12Olmesartan/Hydrochlorothiazide... 12Olopatadine 0.1% .......................... 19Omeclamox-Pak ............................ 20Omega-3-Acid Ethyl Esters

Capsule ...................................... 13Omeprazole ................................... 20Omnaris ......................................... 26Ondansetron .................................. 20Ondansetron ODT ......................... 20

OneTouch Lancets ........................ 17OneTouch Test Strips .................... 17OneTouch Ultra Blue Test Strips ... 17Onexton ......................................... 17Opcicon One-Step ........................ 28Opsumit ......................................... 26Optihaler ........................................ 23Option 2 ......................................... 28Oracea ............................................. 9Orencia .......................................... 22Orenitram ...................................... 26Orkambi ......................................... 23Orphenadrine ER .......................... 24Orphenadrine/Aspirin/Caffeine ...... 24Orsythia ......................................... 28Ortho Coil ...................................... 28Ortho Flat ...................................... 28Ortho Flex ...................................... 28Osphena ........................................ 29Otezla ............................................ 17Otrexup .......................................... 22Ovidrel ........................................... 22Oxaprozin ...................................... 25Oxazepam ..................................... 15Oxcarbazepine .............................. 16Oxybutynin .................................... 25Oxybutynin Extended-Release ..... 25Oxycodone IR................................ 25Oxycodone/Acetaminophen .......... 25Oxymorphone ................................ 25Ozempic ........................................ 18

P

Pacerone ....................................... 13Pancrelipase .................................. 21Pantoprazole ................................. 20Paregoric Tincture ......................... 21Paricalcitol ..................................... 19Paromomycin ................................... 9Paroxetine ER ............................... 14Paroxetine Tablet ........................... 14Pataday ......................................... 19Paxil ............................................... 14Paxil Suspension ........................... 14Pegasys ......................................... 10Penicillin VK .................................... 9Pentasa ......................................... 21Pentazocine/Naloxone .................. 25Pentoxifylline ................................. 13

Perforomist .................................... 26Perindopril ..................................... 12Permethrin ..................................... 17Perphenazine/Amitriptyline ........... 15Phenazopyridine ............................ 23Phenelzine ..................................... 14Phenobarbital .......................... 16, 20Phenoxybenzamine ....................... 12Phenylephrine ............................... 19Phenytoin ...................................... 16Philith ............................................. 28Phospholine ................................... 20Phrenilin Forte ............................... 14Phytonadione ................................ 23Picato ............................................ 17Pilocarpine ..................................... 23Pimtrea .......................................... 28Pindolol .......................................... 12Pioglitazone ................................... 18Pioglitazone/Glimepiride ............... 18Pioglitazone/Metformin ................. 18Piroxicam ....................................... 25Plan B One Step ............................ 28Podofilox ........................................ 17Polyethylene Glycol 3350 .............. 21Polymyxin B/Trimethoprim ............ 19Portia ............................................. 28Potassium Chloride ....................... 27Potassium Citrate .......................... 27Pradaxa ..........................................11Praluent ......................................... 13Pramcort ........................................ 17Pramipexole ................................... 15Pramosone Cream, Ointment ........ 17Pramosone E Cream ..................... 17Pramosone Lotion ......................... 17Pramoxine-HC Otic ......................... 9Prasugrel ........................................11Pravastatin ..................................... 13Praziquantel .................................. 23Prazosin ........................................ 12Pred Mild ....................................... 20Prednisolone Solution, Tablet .. 19, 20Prednisone .................................... 19Premarin ........................................ 29Premarin Vaginal Cream ............... 29Premphase .................................... 29Prempro ......................................... 29Prepopik ........................................ 21Prevalite ......................................... 13

38

Previfem ........................................ 28Prevymis Tablet ............................. 10Prezcobix ....................................... 21Prezista.......................................... 21Primaquine .................................... 24Primella ......................................... 28Proair HFA ..................................... 26Proair RespiClick ........................... 26Probenecid .................................... 24Prochlorperazine ........................... 15Procrit ............................................ 24Proctocream HC ............................ 24Proctofoam HC .............................. 24Proctosol HC ................................. 24Proctozone HC .............................. 24Proglycem ..................................... 24Promethazine .................... 20, 24, 26Promethazine Suppository ............ 24Promethazine VC/Codeine ............ 24Promethazine/Codeine .................. 24Promethazine/

Dextromethorphan ..................... 24Propafenone .................................. 13Propantheline ................................ 21Proparacaine ................................. 20Propranolol IR/ER ......................... 12Propranolol/Hydrochlorothiazide ... 12Propylthiouracil .............................. 19Protopic ......................................... 17Protriptyline ................................... 14Prozac ........................................... 14Pulmicort Flexhaler........................ 26Pulmicort Respules ....................... 26Pylera ............................................ 20Pyrazinamide ................................... 9Pyridostigmine ............................... 24

Q

QNasl ............................................ 26Quartette ....................................... 28Quasense ...................................... 28Quetiapine ..................................... 15Quinapril ........................................ 12Quinidine IR/ER ............................ 13QVAR............................................. 26QVAR RediHaler ........................... 26

R

Raloxifene...................................... 30Ramipril ......................................... 12Ranexa .......................................... 13

Rapaflo .......................................... 22Rasuvo .......................................... 22React ............................................. 28Reclipsen ....................................... 28Remicade ...................................... 22Repaglinide.................................... 18Rescriptor ...................................... 21Reserpine ...................................... 12Restasis ......................................... 20Retrovir .......................................... 21Revatio .......................................... 26Rexulti ............................................ 15Reyataz Powder Packet ................ 21Rezira ............................................ 24Rheumatrex ................................... 22Rhofade ......................................... 17Ribavirin Tablet .............................. 10Rifampin .......................................... 9Rimantidine ................................... 10Risperidone, Risperidone ODT ..... 15Ritonavir Tablet .............................. 21Rivastigmine .................................. 15Rizatriptan ..................................... 14Ropinirole ...................................... 15Rosadan Cream ............................ 17Rosuvastatin .................................. 13Rydapt ............................................11

S

Salsalate ........................................ 25Saphris .......................................... 15Savaysa ..........................................11Selenium Sulfide ........................... 17Selzentry ....................................... 21Serevent ........................................ 26Sertraline ....................................... 14Setlakin .......................................... 29Sevelamer ................................21, 24Sharobel ........................................ 29Sildenafil Tablet ....................... 22, 26Sildenafil Tablet 20 mg .................. 26Silenor ........................................... 15Silver Nitrate .................................. 17Silver Sulfadiazine ......................... 17Simbrinza ...................................... 19Simponi ......................................... 22Simvastatin .................................... 13Sodium Polystyrene Sulfonate

Powder ....................................... 24Soliqua .......................................... 18Soolantra ....................................... 17

Sotalol ......................................12, 13Sotalol AF ...................................... 12Sovaldi ........................................... 10Spiriva HandiHaler, Respimat ....... 26Spironolactone .............................. 12Spironolactone/

Hydrochlorothiazide ................... 12Sprintec ......................................... 29Sprycel ...........................................11Sronyx ........................................... 29SSKI .............................................. 24Stavudine Capsule ........................ 21Stelara ........................................... 22Stivarga ..........................................11Strensiq ......................................... 24Stribild ........................................... 22Striverdi Respimat ......................... 26Suboxone Film ............................... 15Sucralfate Tablet ............................ 20Sulfacetamide Sodium ....... 17, 19, 20Sulfacetamide Sodium-Sulfur ....... 17Sulfacetamide Sodium/

Prednisolone .............................. 20Sulfadiazine ................................9, 17Sulfamethoxazole/Trimethoprim,

Sulfamethoxazole/ Trimethoprim DS .......................... 9

Sulfasalazine ................................. 21Sulindac ......................................... 25Sumatriptan Nasal Spray, Tablet ... 14Sumavel DosePro ......................... 14Suprep ........................................... 21Sutent .............................................11Syeda ............................................ 29Symbicort ...................................... 26Symdeko........................................ 24Symfi ............................................. 22Symfi Lo ........................................ 22Symlin ............................................ 18Symproic ....................................... 21Synarel .......................................... 24Synjardy ........................................ 18Synjardy XR .................................. 18Synvisc .......................................... 24Synvisc One .................................. 24

T

Tabloid ............................................11Taclonex Ointment ......................... 17Taclonex Scalp .............................. 17Taclonex Suspension .................... 17

39

Tacrolimus ................................17, 27Tacrolimus Ointment ..................... 17Take Action .................................... 29Tamoxifen ...................................... 30Tamsulosin .................................... 22Targretin Capsule ...........................11Tarina FE ....................................... 29Tasigna ...........................................11Taytulla .......................................... 29Tazorac .......................................... 17Taztia XT ....................................... 12Tecfidera ........................................ 14Technivie ....................................... 10Telmisartan .................................... 12Telmisartan/Hydrochlorothiazide ... 12Temazepam ................................... 15Temozolomide ................................11Tenofovir Tablet ............................. 22Terazosin ................................. 12, 22Terbinafine ..................................... 10Terbutaline ..................................... 26Terconazole ................................... 10Testim ............................................ 22Testosterone 1% Gel Pump ........... 22Testred ........................................... 22Tetracaine ...................................... 20Tetracycline ..................................... 9Theophylline SR ............................ 26Thioridazine ................................... 15Thiothixene .................................... 15Thrive Gum .................................... 27Ticlopidine ......................................11Timolol ......................................12, 19Timolol Maleate ............................. 19Timoptic Ocudose ......................... 20Tirosint ........................................... 19Tivicay ........................................... 22Tivorbex ......................................... 25Tizanidine Tablet ........................... 24Tobi Podhaler .................................. 9Tobradex Ointment ........................ 19Tobramycin Ophth Solution ........... 19Tobramycin/Dexamethasone ......... 19Tobrex ............................................ 19Tolazamide .................................... 18Tolbutamide ................................... 18Tolmetin ......................................... 25Topiragen....................................... 16Topiramate ..................................... 16Torsemide ...................................... 12Toviaz ............................................ 25

Tracleer.......................................... 26Tradjenta ........................................ 18Tramadol ........................................ 25Trandolapril/Verapamil CR ............ 12Tranylcypromine ............................ 14Travatan Z ..................................... 20Trazodone...................................... 14Trelegy Ellipta ................................ 26Tresiba ........................................... 18Tretinoin Capsule ............................11Tretinoin Cream ............................. 17Trexall ............................................ 22Trezix ............................................. 25Tri Femynor ................................... 29Tri-Estarylla ................................... 29Tri-Linyah ....................................... 29Tri-Previfem ................................... 29Tri-Sprintec .................................... 29Tri-Vylibra ...................................... 29Triamcinolone Acetonide ............... 17Triamcinolone/Orabase ................. 24Triamterene/Hydrochlorothiazide .. 12Trianex ........................................... 17Triazolam ....................................... 15Triderm .......................................... 17Trifluoperazine ............................... 15Trifluridine ...................................... 19Trihexyphenidyl ............................. 15Trilyte ............................................. 21Trimethobenzamide ....................... 20Trimethoprim ............................. 9, 19Trinessa ......................................... 29Trinessa Lo .................................... 29Trintellix ......................................... 14Triumeq.......................................... 22Trivora-28 ...................................... 29Trizivir ............................................ 22Tropicamide ................................... 20Trulicity .......................................... 18Truvada .......................................... 22Tudorza ......................................... 26Tuzistra XR .................................... 24Tydemy .......................................... 29Tykerb .............................................11

U

Uceris Foam .................................. 21Uceris Tablet ................................. 21Uloric ............................................. 24Unithroid ........................................ 19Urea 40% Lotion ............................ 17

Ursodiol ......................................... 21

V

Valacyclovir ................................... 10Valganciclovir Solution .................. 10Valganciclovir Tablet ...................... 10Valproic Acid .................................. 16Valsartan ....................................... 12Valsartan/Hydrochlorothiazide ...... 12Vandazole Gel ............................... 10Varubi ............................................ 20Vascepa ......................................... 13Vectical .......................................... 17Velivet ............................................ 29Velphoro ........................................ 24Veltassa ......................................... 24Venlafaxine .................................... 14Venlafaxine Extended-Release

Capsule ...................................... 14Venlafaxine Extended-Release

Tablet .......................................... 14Ventolin HFA .................................. 26Veramyst........................................ 26Verapamil Sustained-Release

Capsule ...................................... 12Verapamil Sustained-Release

Tablet .......................................... 12Verapamil Tablet ............................ 12Verzenio .........................................11Vesicare ......................................... 25Vestura .......................................... 29Viagra ............................................ 22Viberzi ........................................... 21Victoza ........................................... 18Videx Solution ............................... 22Viekira Pak, Viekira XR ................. 10Vienva ............................................ 29Viibryd ........................................... 14Vimpat Injection ............................. 16Vimpat Tablet, Solution ................. 16Viorele ........................................... 29Viracept ......................................... 22Viread Oral Powder ....................... 22Vistogard ....................................... 24Vitamin D 50,000 Unit ................... 24Vitazol ............................................ 17Vitekta ........................................... 22Vivelle-Dot ..................................... 29Vivlodex ......................................... 25Voltaren Gel................................... 25Vortex ............................................ 24

40

Vosevi ............................................ 10Vraylar ........................................... 15Vyfemla ......................................... 29Vylibra ........................................... 29Vyvanse ......................................... 14

W

Warfarin ..........................................11WatchHaler .................................... 24Welchol .......................................... 13Wera .............................................. 29Wide-Seal ...................................... 29

X

Xarelto ............................................11Xeljanz, Xeljanz XR ....................... 22Xeloda ............................................11Xiidra ............................................. 20Xopenex HFA ................................ 26Xtampza ER .................................. 25Xtandi .............................................11Xulane ........................................... 29Xuriden .......................................... 24Xyrem ............................................ 15

Y

Yasmin 28 ...................................... 29Yaz ................................................. 29Yodoxin .......................................... 24Yuvafem ......................................... 29

Z

Zaleplon ......................................... 15Zarah ............................................. 29Zarxio ............................................ 24Zecuity ........................................... 14Zelapar .......................................... 15Zemplar ................................... 19, 24Zenatane ....................................... 17Zenchent ....................................... 29Zenpep .......................................... 21Zepatier ......................................... 10Zerit Solution ................................. 22Zetonna ......................................... 26Zidovudine ............................... 21, 22Zioptan .......................................... 20Ziprasidone .................................... 15Zmax ............................................... 9Zohydro ER ................................... 25Zolmitriptan .................................... 14Zolpidem ........................................ 15

Zomig Spray .................................. 14Zonisamide .................................... 16Zontivity ..........................................11Zorvolex ......................................... 25Zovia .............................................. 29Zovirax Cream ............................... 10Zovirax Ointment ........................... 10Zubsolv .......................................... 15Zurampic ....................................... 24Zutripro .......................................... 24Zyclara Cream, Pump .................... 17Zykadia ...........................................11Zytiga ..............................................11

41

Nondiscrimination notice and access to communication services

UnitedHealthcare® and its subsidiaries do not discriminate on the basis of race, color, national origin, age, disability or sex in its health programs or activities.

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

Online: [email protected]

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

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

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

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

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

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

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

Multi-language interpreter servicesMulti-language interpreter services

ATTENTION: 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.

알림: 한국어(Korean)를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다. 귀하의 신분증 카드에 기재된 무료 회원 전화번호로 문의하십시오.

PAALALA: Kung nagsasalita ka ng Tagalog (Tagalog), may makukuha kang mga libreng serbisyo ng tulong sa wika. Pakitawagan ang toll-free na numero ng telepono na nasa iyong identification card.

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

تنبيه: إذا كنت تتحدث العربية (Arabic)، فإن خدمات المساعدة اللغوية المجانية متاحة لك. الرجاء االتصال على رقم الهاتف المجاني الموجود على معّرف العضوية.

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.

UWAGA: Jeżeli mówisz po polsku (Polish), udostępniliśmy darmowe usługi tłumacza. Prosimy zadzwonić pod bezpłatny numer telefonu podany na karcie identyfikacyjnej.

ATENÇÃO: Se você fala português (Portuguese), contate o serviço de assistência de idiomas gratuito. Ligue gratuitamente para o número encontrado no seu cartão de identificação.

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.

注意事項：日本語(Japanese)を話される場合、無料の言語支援サービスをご利用いただけます。健康保険証に記載されているフリーダイヤルにお電話ください。

توجه: اگر زبان شما فارسی (Farsi) است، خدمات امداد زبانی به طور رايگان در اختيار شما می باشد. لطفا با شماره تلفن رايگانی که روی کارت شناسايی شما قيد شده تماس بگيريد.

ध्यान दें: यदि आप हिंदी (Hindi) बोलते है, आपको भाषा सहायता सेबाए,ं नि:शुल्क उपलब्ध हैं। कृपया अपने 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.

This document applies to commercial group members of UnitedHealthcare West.Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by UnitedHealthcare Insurance Company, UnitedHealthcare Services, Inc. or their affiliates. Health Plan coverage provided by or through a UnitedHealthcare company. OptumRx is an affiliate of UnitedHealthcare Insurance Company.UnitedHealthcare® is a registered trademark owned by UnitedHealth Group Incorporated. All other trademarks are the property of their respective owners.

©2018 United HealthCare Services, Inc. 77813-092018 2019 Formulary — SignatureValue Three-Tier 9/18

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