your 2019 prescription drug list - conroe isd · select the most cost-effective prescription...

Effective January 1, 2019

This Prescription Drug List (PDL) is accurate as of July 1, 2019 and is subject to change after this date. The next anticipated update will be Jan. 1, 2020. This PDL applies to members of our UnitedHealthcare and Oxford medical plans with a pharmacy benefit subject to the Flex Base 3-Tier PDL. Your estimated coverage and copayment/coinsurance may vary based on the benefit plan you choose and the effective date of the plan.

Your 2019 Prescription Drug ListFlex Base 3-Tier

Effective July 1, 2019

2

Understanding your Prescription Drug List . . .3Medication tips . . . . . . . . . . . . . . . . . . . . . . . . . .5Reading your PDL . . . . . . . . . . . . . . . . . . . . . . . .6Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Drugs by category . . . . . . . . . . . . . . . . . . . . . .10Analgesics Drugs for Pain . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Drugs for Pain and Inflammation . . . . . . . . . . . . . 11Anti-Addiction / Substance Abuse Treatment Agents . . . . . . . . . . . . . . . . . . . . . . . 11Antibacterials Drugs for Infections . . . . . . . . . . . . . . . . . . . . . . . 12Anticoagulants Drugs to Treat or Prevent Blood Clots . . . . . . . . . 13Anticonvulsants Drugs for Seizures . . . . . . . . . . . . . . . . . . . . . . . . 13Antidementia Agents Drugs for Alzheimer’s Disease and Dementia . . . 14Antidepressants Drugs for Depression . . . . . . . . . . . . . . . . . . . . . 14Antiemetics Drugs for Nausea and Vomiting . . . . . . . . . . . . . 15Antifungals Drugs for Fungal Infections . . . . . . . . . . . . . . . . . 15Antigout Agents Drugs for Gout . . . . . . . . . . . . . . . . . . . . . . . . . . .15Antimigraine Agents Drugs for Migraines . . . . . . . . . . . . . . . . . . . . . . . 15Antineoplastics Drugs for Cancer . . . . . . . . . . . . . . . . . . . . . . . . .16Antiparasitics Drugs for Parasitic Infections . . . . . . . . . . . . . . .16Antiparkinson Agents Drugs for Parkinson’s Disease . . . . . . . . . . . . . .16Antiplatelets Drugs for Heart Attack and Stroke Prevention . .16Antipsychotics Drugs for Mood Disorders . . . . . . . . . . . . . . . . . . 17Antivirals Drugs for Viral Infections . . . . . . . . . . . . . . . . . . . 17AnxiolyticsDrugs for Anxiety . . . . . . . . . . . . . . . . . . . . . . . . .18Bipolar Agents Drugs for Mood Disorders . . . . . . . . . . . . . . . . . .18Cardiovascular Agents Drugs for Heart and Circulation Conditions . . . . 18Central Nervous System Agents Drugs for Attention Deficit Disorder . . . . . . . . . .21 Drugs for Multiple Sclerosis . . . . . . . . . . . . . . . .21 Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . .22

Dental and Oral Agents Drugs for Mouth and Throat Conditions . . . . . . .22Dermatological Agents Drugs for Skin Conditions . . . . . . . . . . . . . . . . . .22Diabetes Glucose Monitoring . . . . . . . . . . . . . . . . . . . . . . .24 Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 Non-Insulin Agents . . . . . . . . . . . . . . . . . . . . . . .26Drugs for Blood Disorders . . . . . . . . . . . . . . . .27Drugs for Sexual Dysfunction . . . . . . . . . . . . .27Electrolytes / Vitamins . . . . . . . . . . . . . . . . . . .27Gastrointestinal Agents Drugs for Acid Reflux and Ulcer . . . . . . . . . . . . .28 Drugs for Bowel, Intestine and Stomach Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28Genetic or Enzyme Disorder Drugs for Replacement, Modifiers, Treatment. . . .29Genitourinary Agents Drugs for Bladder, Genital and Kidney Condition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 Drugs for Prostate Conditions . . . . . . . . . . . . . . .29Hormonal Agents Hormone Replacement and Birth Control . . . . . .29 Oral Steroids . . . . . . . . . . . . . . . . . . . . . . . . . . . .33 Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33 Testosterone Replacement . . . . . . . . . . . . . . . . .33 Thyroid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34Immunological Agents Drugs for Immune System Stimulation or Suppression . . . . . . . . . . . . . . . . . . . . . . . . . .34Infertility Agents . . . . . . . . . . . . . . . . . . . . . . . .35Inflammatory Bowel Disease Agents . . . . . . .35Metabolic Bone Disease Agents Drugs for Osteoporosis . . . . . . . . . . . . . . . . . . . .35Ophthalmic Agents Drugs for Eye Allergy, Infection and Inflammation . . . . . . . . . . . . . . . . . . . . . . . . . . . .36 Drugs for Glaucoma . . . . . . . . . . . . . . . . . . . . . .36 Drugs for Miscellaneous Eye Conditions . . . . . .36Otic Agents Drugs for Ear Conditions . . . . . . . . . . . . . . . . . . .37Respiratory Tract / Pulmonary Agents Drugs for Allergies, Cough, Cold. . . . . . . . . . . . .37 Drugs for Asthma and COPD . . . . . . . . . . . . . . .37 Drugs for Cystic Fibrosis . . . . . . . . . . . . . . . . . . .38 Drugs for Pulmonary Hypertension . . . . . . . . . . .38Skeletal Muscle Relaxants Drugs for Muscle Pain and Spasm . . . . . . . . . . .38Sleep Disorder Agents . . . . . . . . . . . . . . . . . . .39Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40

Table of Contents

3

Understanding your Prescription Drug List (PDL)

What is a PDL?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 PDLWhere differences exist between this PDL and your benefit plan documents, the benefit plan documents rule. This PDL is not a complete list of medications, and not all medications listed may be covered by your plan. 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 PDL?You and your doctor can consult the PDL 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 PDL change?PDL changes typically occur twice per year. However, changes that have a positive impact for you — such as coverage for new medications or cost savings — may occur at any time. You can log in to the member website listed on your ID card at any time to check your medication coverage and lower-cost options.

4

Understanding your Prescription Drug List (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)1 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 medications2). 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 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 PDL 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.

1. Depending on your benefit, you may have notification or medical necessity requirements for select medications.

2. For New York and New Jersey plans, a prescription drug product that is therapeutically equivalent to an over-the-counter drug may be covered if it is determined to be medically necessary.

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 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 PDL

The PDL gives you choices so you and your doctor can determine your best course of treatment. In this PDL, brand-name medications are shown in UPPERCASE and generic medications in lowercase.

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.

In the chart below, overall value indicates medications’ effectiveness and safety, cost, and the availability of alternative medications to treat the same or similar medical condition(s).

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. Mainly preferred brand-name 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.

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

7

Reading your PDL (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.

E May be excluded from coverage or subject to Prior Authorization in Connecticut, New Jersey and New York. (Referred to as First Start in New Jersey) Lower-cost options are available and covered.

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.

PA Prior Authorization (sometimes referred to as Precertification)3

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 Specifies the largest quantity of medication covered per copayment or in a defined period of time.

RS Refill and Save Program4 Save money on your copayment when you refill your prescription on time as prescribed. Program eligibility may vary.

SP Specialty Medication Specialty medications treat complex or rare conditions and may require special storage and handling. You may be required to obtain these medications from a specialty pharmacy.

ST Step Therapy (referred to as First Start in New Jersey) Requires prior authorization and may require you to try one or more other medications before the medication you are requesting may be covered.

3. Depending on your benefit, you may have notification or medical necessity requirements for select medications.

4. Not applicable to Oxford plans.

8

Reading your PDL (continued)

Coverage details.Some drug classes in this PDL have additional/important coverage details. Review this list to determine if drug classes that apply to you are noted.

Diabetes: Blood Glucose Monitoring; Insulin; Non-Insulin Diabetic supplies and prescription medications may be subject to different cost-share arrangements for Oxford plans. Please see your Summary of Benefits and Coverage (SBC) for specifics. Medications that require step therapy may require prior authorization (sometimes referred to as precertification) if covered under another benefit.

Endocrine: Growth Hormone Coverage is determined by the consumer’s prescription drug benefit plan. Please consult plan documents regarding benefit coverage and cost-share.

Infertility

Coverage is determined by the consumer’s prescription drug benefit plan. Please consult plan documents regarding benefit coverage and cost-share. Prior authorization (sometimes referred to as precertification) may be required for Oxford plans.

Medications for Sexual Dysfunction Coverage is determined by the consumer’s prescription drug benefit plan. Please consult plan documents regarding benefit coverage and cost-share. Prior authorization (sometimes referred to as precertification) may be required for Oxford plans.

9

Questions

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

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

Visit your plan’s member website listed on your ID card 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

10See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY.

Drug Name Drug Tier

Requirements& Limits

Analgesics - Drugs for Pain

acetaminophen-codeine 1

acetaminophen-codeine #2 1

acetaminophen-codeine #3 1

acetaminophen-codeine #4 1apap-caff-dihydrocodeine oral capsule 1

ARYMO ER 3 PA, ST, QL

BELBUCA 3 PA, QL

butalbital-apap-caffeine 1

CONZIP 3 QL

DILAUDID ORAL 3

DURAGESIC-100 E PA, ST, QL




DURAGESIC-75 E PA, ST, QLDVORAH TABLET 325-30-16 MG ORAL E

endocet 1

ESGIC 3

fentanyl 1 PA, QL

FIORICET 3hydrocodone-acetaminophen oral solution 10-325 mg/15ml, 7.5-325 mg/15ml

1

hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg

1

hydromorphone hcl er 1 PA, ST, QL

hydromorphone hcl oral 1

HYSINGLA ER E PA, QL

KADIAN E PA, ST, QL

lidocaine external ointment 1

lidocaine external patch 1

Drug Name Drug Tier


lidocaine pak 1lidocaine-prilocaine cream 2.5-2.5 % external 1

LIDODERM E

lorcet 1

lorcet hd 1

lorcet plus 1

LORTAB 3

MORPHABOND ER 3 PA, ST, QLmorphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml

1

morphine sulfate er oral capsule extended release 24 hour 1 PA, ST, QL

morphine sulfate er oral tablet extended release 1 PA, QL

morphine sulfate oral 1

MS CONTIN 3 PA, ST, QL

NALOCET 3

NORCO 3

NUCYNTA 2 QL

NUCYNTA ER 3 PA, QL

OXAYDO E QL

OXYCODONE HCL ER E PA, QL

oxycodone hcl oral capsule 1oxycodone hcl oral concentrate 100 mg/5ml 1

oxycodone hcl oral solution 1

oxycodone hcl oral tablet 1

oxycodone-acetaminophen 1

OXYCONTIN E PA, QL

PERCOCET E

phrenilin forte 1

premium lidocaine 1

PRIMLEV 3

ROXICODONE 3


Drug Name Drug Tier


ROXYBOND 3 QL

SUBSYS 3 PA, QL

tramadol hcl er (biphasic) 1 QLTRAMADOL HCL ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 300 MG

3 QL

tramadol hcl er oral capsule extended release 24 hour 150 mg 1 QL

tramadol hcl er oral tablet extended release 24 hour 1 QL

tramadol hcl ir 1

trezix 1

TYLENOL WITH CODEINE #3 3

TYLENOL WITH CODEINE #4 3

ULTRAM 3

VANATOL LQ 2

VANATOL S 2

verdrocet 1

vicodin 1

vicodin es 1

vicodin hp 1

XTAMPZA ER 2 PA, QL

zebutal 1

ZOHYDRO ER 3 PA, ST, QL

ZTLIDO E

Analgesics - Drugs for Pain and Inflammation

CELEBREX E

celecoxib oral 1

diclofenac potassium 1

diclofenac sodium er 1

diclofenac sodium oral 1diclofenac sodium transdermal gel 1 % E

diclofenac sodium transdermal solution 1

EC-NAPROSYN ORAL TABLET DELAYED RELEASE 375 MG 3

Drug Name Drug Tier


etodolac 1

etodolac er 1

hydromorphone hcl rectal 1ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1

INDOCIN 3

indomethacin er 1

indomethacin oral 1

ketorolac tromethamine oral 1

klofensaid ii 1

LODINE E

meloxicam oral 1

MOBIC 3MORPHINE SULFATE RECTAL SUPPOSITORY 10 MG 3

morphine sulfate rectal suppository 20 mg, 30 mg, 5 mg 1

nabumetone oral 1

NAPRELAN ENAPROSYN ORAL SUSPENSION 3

naproxen dr 1

naproxen oral 1

naproxen sodium er 1naproxen sodium oral tablet 275 mg, 550 mg 1

PENNSAID 3

SPRIX 3

TIVORBEX 3

VIVLODEX 3

VOLTAREN 1

ZIPSOR 3

Anti-Addiction / Substance Abuse Treatment Agents

BUNAVAIL E

buprenorphine hcl sublingual 1

buprenorphine hcl-naloxone hcl E

CHANTIX 2 PA, H


Drug Name Drug Tier


CHANTIX CONTINUING MONTH PAK 2 PA, H

CHANTIX STARTING MONTH PAK 2 PA, H

EVZIO 3

naloxone hcl injection 1

naltrexone hcl oral 1

NARCAN 2

SUBOXONE E

ZUBSOLV 1

Antibacterials - Drugs for Infections

ACTICLATE E

amoxicillin 1amoxicillin-potassium clavulanate er 1

amoxicillin-potassium clavulanate oral 1

AUGMENTIN ES-600 EAUGMENTIN ORAL SUSPENSION RECONSTITUTED 125-31.25 MG/5ML

3

AUGMENTIN ORAL SUSPENSION RECONSTITUTED 250-62.5 MG/5ML

E

AUGMENTIN ORAL TABLET E

avidoxy 1

azithromycin oral 1

BACTRIM 3

BACTRIM DS 3

BACTROBAN 3

cefadroxil 1

cefdinir 1

cefuroxime axetil 1

CENTANY 3

CENTANY AT 3

Drug Name Drug Tier


cephalexin 1

CIPRO ORAL TABLET 3

ciprofloxacin hcl oral 1

clarithromycin er 1

clarithromycin oral 1CLEOCIN ORAL CAPSULE 150 MG, 300 MG 3

CLEOCIN ORAL CAPSULE 75 MG 2

clindamycin hcl oral 1

CLINDESSE 2

coremino 1

DIFICID 3

DORYX E

DORYX MPC 3

doxycycline hyclate oral 1

doxycycline monohydrate oral 1

FLAGYL 3

KEFLEX 3LEVAQUIN ORAL TABLET 500 MG, 750 MG 3

levofloxacin oral 1

MACROBID 3

MACRODANTIN 3

METROGEL-VAGINAL E

metronidazole oral 1

metronidazole vaginal 1MINOCIN ORAL CAPSULE 50 MG E

minocycline hcl er oral tablet extended release 24 hour 115 mg, 135 mg, 45 mg, 65 mg, 90 mg

1

MINOCYCLINE HCL ER ORAL TABLET EXTENDED RELEASE 24 HOUR 55 MG

3

minocycline hcl oral 1


Drug Name Drug Tier


MINOLIRA E

mondoxyne nl 1

morgidox oral 1

mupirocin calcium 1

mupirocin external 1

nitrofurantoin macrocrystal oral 1nitrofurantoin monohydrate macrocrystals 1

NUVESSA 3

okebo 1

penicillin v potassium 1SOLODYN ORAL TABLET EXTENDED RELEASE 24 HOUR 105 MG, 80 MG

2

SOLODYN ORAL TABLET EXTENDED RELEASE 24 HOUR 115 MG, 55 MG, 65 MG

3

soloxide 1sulfamethoxazole-trimethoprim oral 1

sulfatrim pediatric 1

TARGADOX 3

vandazole 1

VIBRAMYCIN ORAL CAPSULE 3VIBRAMYCIN ORAL SUSPENSION RECONSTITUTED

3

XIMINO 3

ZITHROMAX ORAL 3

ZITHROMAX TRI-PAK 3

ZITHROMAX Z-PAK 3

Anticoagulants - Drugs to Treat or Prevent Blood ClotsBEVYXXA 3

COUMADIN 3

ELIQUIS 3

ELIQUIS STARTER PACK 3

Drug Name Drug Tier


enoxaparin sodium 1

jantoven 1

LOVENOX 3

PRADAXA 2

SAVAYSA 3

warfarin sodium oral 1

XARELTO 2

XARELTO STARTER PACK 2

Anticonvulsants - Drugs for Seizures

carbamazepine er 1

carbamazepine oral 1

CARBATROL 3

DEPAKOTE 3

DEPAKOTE ER 3

DEPAKOTE SPRINKLES 3

divalproex sodium er 1

divalproex sodium oral 1

epitol 1

gabapentin oral capsule 1gabapentin oral solution 250 mg/5ml 1

gabapentin oral tablet 1

KEPPRA ORAL 3

KEPPRA XR 3

LAMICTAL 3

LAMICTAL ODT 3

LAMICTAL STARTER 3

LAMICTAL XR 3

lamotrigine er 1

lamotrigine oral 1

lamotrigine starter kit-blue 1

lamotrigine starter kit-green 1

lamotrigine starter kit-orange 1


Drug Name Drug Tier


levetiracetam er 1

levetiracetam oral 1

NEURONTIN 3

oxcarbazepine 1

OXTELLAR XR 3

QUDEXY XR 3

roweepra 1

roweepra xr 1

SPRITAM 3

subvenite 1

subvenite starter kit-blue 1

subvenite starter kit-green 1

subvenite starter kit-orange 1

TEGRETOL 3

TEGRETOL-XR 3

TOPAMAX 3

TOPAMAX SPRINKLE 3

topiramate er 3

topiramate oral 1

TRILEPTAL 3

TROKENDI XR 3

VIMPAT ORAL 2

ZONEGRAN 3

zonisamide oral 1

Antidementia Agents - Drugs for Alzheimer's Disease and DementiaARICEPT ORAL TABLET 10 MG, 5 MG 3

ARICEPT ORAL TABLET 23 MG E

donepezil hcl 1

Antidepressants - Drugs for Depression

amitriptyline hcl oral 1

bupropion hcl er (sr) 1bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg

1

Drug Name Drug Tier


BUPROPION HCL ER (XL) ORAL TABLET EXTENDED RELEASE 24 HOUR 450 MG

3

bupropion hcl oral 1

CELEXA E

citalopram hydrobromide 1

CYMBALTA E

desvenlafaxine succinate er 1

doxepin hcl oral 1

duloxetine hcl oral 1

EFFEXOR XR E

escitalopram oxalate 1

fluoxetine hcl oral 1

fluvoxamine maleate 1

fluvoxamine maleate er 1

FORFIVO XL 3

LEXAPRO E

mirtazapine oral 1

nortriptyline hcl oral 1

PAMELOR 3

paroxetine hcl 1

paroxetine hcl er 3

PAXIL 3

PAXIL CR 3

PRISTIQ E

PROZAC E

REMERON 3

REMERON SOLTAB 3

sertraline hcl oral 1

trazodone hcl oral 1

TRINTELLIX 3

venlafaxine hcl 1venlafaxine hcl er oral capsule extended release 24 hour 1

venlafaxine hcl er oral tablet extended release 24 hour 3


Drug Name Drug Tier


VIIBRYD 2

VIIBRYD STARTER PACK 2

WELLBUTRIN SR E

WELLBUTRIN XL E

ZOLOFT E

Antiemetics - Drugs for Nausea and Vomiting

AKYNZEO ORAL 3metoclopramide hcl oral solution 5 mg/5ml 1

metoclopramide hcl oral tablet 1metoclopramide hcl oral tablet dispersible 1

ondansetron hcl oral 1

ondansetron odt 1

prochlorperazine maleate oral 1

REGLAN 3

TRANSDERM-SCOP (1.5 MG) 3

VARUBI ORAL 2

ZOFRAN 3

ZUPLENZ 3

Antifungals - Drugs for Fungal Infections

ciclodan 1

CICLODAN SOLUTION 3

ciclopirox 1

ciclopirox treatment 1

CRESEMBA ORAL 3

DIFLUCAN 3

EXTINA 3

fluconazole oral 1

GYNAZOLE-1 3

ketoconazole external 1

LOPROX EXTERNAL SHAMPOO E

NIZORAL 3

nyamyc 1

Drug Name Drug Tier


nystatin external 1

nystatin mouth/throat 1

nystop 1

PENLAC E

terbinafine hcl oral 1

terconazole 1

XOLEGEL 3

Antigout Agents - Drugs for Gout

allopurinol oral 1

COLCHICINE ORAL CAPSULE E

COLCHICINE ORAL TABLET E

COLCRYS E

DUZALLO 3

MITIGARE 2

ULORIC 3

ZURAMPIC 3

ZYLOPRIM 3

Antimigraine Agents - Drugs for Migraines

AIMOVIG 2 PA

AMERGE 3

eletriptan hydrobromide 1

EMGALITY 2 PA

IMITREX ORAL E

IMITREX STATDOSE REFILL E

IMITREX STATDOSE SYSTEM E

IMITREX SUBCUTANEOUS E

MAXALT E

MAXALT-MLT E

naratriptan hcl 1

ONZETRA XSAIL 3

RELPAX E

rizatriptan benzoate 1


Drug Name Drug Tier


sumatriptan succinate oral 1

sumatriptan succinate refill 1sumatriptan succinate subcutaneous 1

ZEMBRACE SYMTOUCH 3

Antineoplastics - Drugs for Cancer

abiraterone acetate E PA, SP

anastrozole oral 1

bexarotene E SP

BOSULIF 2 PA, ST, SP

capecitabine E SP

ERLEADA 2 PA, SP

FEMARA E

GLEEVEC E PA, SP

IBRANCE 2 PA, SP

IDHIFA 2 PA, SP

imatinib mesylate 1 PA, SP

letrozole oral 1

mercaptopurine oral 1 SP

PURIXAN 3 PA, SP

raloxifene 1 H-PA

REVLIMID 2 PA, SP

SOLTAMOX 3

tamoxifen citrate oral tablet 10 mg 1

tamoxifen citrate oral tablet 20 mg 1 H-PA

TARGRETIN EXTERNAL 3 SP

TARGRETIN ORAL 1 SP

TASIGNA 2 PA, ST, SP

VERZENIO 2 PA, SP

XELODA 1 SP

YONSA E PA, SP

ZYTIGA ORAL TABLET 250 MG 1 PA, SP

ZYTIGA ORAL TABLET 500 MG 2 PA, SP

Drug Name Drug Tier


Antiparasitics - Drugs for Parasitic Infections

atovaquone-proguanil hcl 1

ELIMITE 3

hydroxychloroquine sulfate oral 1

MALARONE 3

permethrin external 1

PLAQUENIL 3

Antiparkinson Agents - Drugs for Parkinson’s Diseasecarbidopa-levodopa 1

carbidopa-levodopa er 1

DUOPA 3

MIRAPEX 3

MIRAPEX ER E

pramipexole dihydrochloride 1

pramipexole dihydrochloride er 1REQUIP ORAL TABLET 0.25 MG, 1 MG, 4 MG, 5 MG 3

REQUIP XL E

ropinirole hcl 1

ropinirole hcl er 1

RYTARY 3

selegiline hcl oral 1

SINEMET 3

SINEMET CR 3

ZELAPAR 3

Antiplatelets - Drugs for Heart Attack and Stroke PreventionBRILINTA 2

clopidogrel bisulfate oral 1

PLAVIX E

ZONTIVITY 3


Drug Name Drug Tier


Antipsychotics - Drugs for Mood Disorders

ABILIFY E

ABILIFY MYCITE E

aripiprazole 1

GEODON ORAL E

LATUDA 2

olanzapine oral 1

quetiapine fumarate 1

quetiapine fumarate er 1

RISPERDAL E

risperidone 1

risperidone m-tab 1

SAPHRIS 3

SEROQUEL E

SEROQUEL XR E

ziprasidone hcl 1

ZYPREXA E

ZYPREXA ZYDIS E

Antivirals - Drugs for Viral Infections

acyclovir oral 1

ATRIPLA E SP, ST

BARACLUDE ORAL SOLUTION 2 SP

BARACLUDE ORAL TABLET E SP

CIMDUO 2 SP

DESCOVY 3 SP

entecavir 1 SP

EPCLUSA 2 PA, SP

GENVOYA 3 SP

HARVONI 2 PA, SP

ISENTRESS 2 SP

ISENTRESS HD 2 SP

JULUCA 2 SP

Drug Name Drug Tier


LEDIPASVIR-SOFOSBUVIR 2 PA, SP

MAVYRET 2 PA, SP

NORVIR ORAL PACKET 2 SP

NORVIR ORAL SOLUTION 2 SP

NORVIR ORAL TABLET E SP

ODEFSEY 3 SP

oseltamivir phosphate oral 1

PREZCOBIX 2 SP

PREZISTA 2 SP

ritonavir 1 SP

SITAVIG 3

SOFOSBUVIR-VELPATASVIR 2 PA, SP

STRIBILD 3 SP

SYMFI 2 SP

SYMFI LO 2 SP

TAMIFLU E

tenofovir disoproxil fumarate 1 SP

TIVICAY 3 SP

TRIUMEQ 2 SP

TRUVADA 3 SP

valacyclovir hcl oral 1

VALTREX E

VEMLIDY 3 ST, SP

VIREAD ORAL POWDER 3 SPVIREAD ORAL TABLET 150 MG, 200 MG, 250 MG 2 SP

VIREAD ORAL TABLET 300 MG E SP

VOSEVI 2 PA, SP

ZEPATIER 2 PA, ST, SP

ZOVIRAX ORAL 3


Drug Name Drug Tier


Anxiolytics - Drugs for Anxiety

alprazolam er 1

alprazolam intensol 1

alprazolam oral 1

alprazolam xr 1

ATIVAN ORAL E

buspirone hcl oral 1

clonazepam oral 1

diazepam intensol 1

diazepam oral concentrate 1

diazepam oral solution 1 mg/ml 1

diazepam oral tablet 1

HALCION 3

hydroxyzine hcl oral 1

hydroxyzine pamoate oral 1

KLONOPIN 3

lorazepam intensol 1

lorazepam oral 1

triazolam 1

VALIUM E

VISTARIL 3

XANAX E

XANAX XR E

Bipolar Agents - Drugs for Mood Disorders

lithium carbonate er 1

lithium carbonate oral 1

LITHOBID 3

Cardiovascular Agents - Drugs for Heart and Circulation ConditionsACCUPRIL 3

acetazolamide er 1

acetazolamide oral 1

ADALAT CC 3

Drug Name Drug Tier


ALDACTONE 3

ALTACE 3

ALTOPREV 3

amiodarone hcl oral 1

amlodipine besylate oral 1amlodipine besylate-benazepril hcl 1

amlodipine besylate-valsartan 1

atenolol oral 1

atenolol-chlorthalidone 1atorvastatin calcium oral tablet 10 mg, 20 mg 1 H-PA, H

atorvastatin calcium oral tablet 40 mg, 80 mg 1

AVALIDE 3

AVAPRO 3

benazepril hcl oral 1

benazepril-hydrochlorothiazide 1

BENICAR E

BENICAR HCT E

BETAPACE E

BIDIL 2

bisoprolol fumarate 1

bisoprolol-hydrochlorothiazide 1

BYSTOLIC 2

BYVALSON 2

CALAN 3

CALAN SR 3

CARDIZEM ECARDIZEM CD ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 360 MG

E

CARDIZEM LA E

CARDURA 3

CAROSPIR 3


Drug Name Drug Tier


cartia xt 1

carvedilol 1

CATAPRES 3

chlorthalidone 1

clonidine hcl oral 1

colesevelam hcl E

COREG 3

CORGARD 3

CORLANOR 3

COZAAR 3

CRESTOR E

DEMADEX 3

diltiazem hcl er 1

diltiazem hcl er coated beads 1

diltiazem hcl oral 1

dilt-xr 1

DIOVAN E

DIOVAN HCT E

doxazosin mesylate oral 1

DYAZIDE 3

EDARBI 2

EDARBYCLOR 2

enalapril maleate oral 1

EPANED 3

EXFORGE E

ezetimibe 1

ezetimibe-simvastatin 1fenofibrate oral capsule 150 mg, 50 mg 1

fenofibrate oral tablet 1

FENOGLIDE E

flecainide acetate 1

FLOLIPID 3

Drug Name Drug Tier


furosemide oral 1

gemfibrozil oral 1

GONITRO 3

guanfacine hcl 1

HEMANGEOL 3

hydralazine hcl oral 1

hydrochlorothiazide oral 1

HYZAAR 3

INDERAL LA E

irbesartan 1

irbesartan-hydrochlorothiazide 1

isosorbide mononitrate 1

isosorbide mononitrate er 1

KAPSPARGO SPRINKLE 3

labetalol hcl oral 1

LASIX 3

LIPITOR E

LIPOFEN 3

lisinopril oral 1

lisinopril-hydrochlorothiazide 1

LOPID 3

LOPRESSOR 3

losartan potassium 1

losartan potassium-hctz 1

LOTENSIN 3

LOTENSIN HCT 3

LOTREL 3

lovastatin 1 H-PA, H

LOVAZA E

matzim la 1

MAXZIDE 3

MAXZIDE-25 3


Drug Name Drug Tier


metoprolol succinate er 1

metoprolol tartrate oral 1

MICARDIS E

MINIPRESS 3

minitran 1

MULTAQ 3

nadolol oral 1

niacin er (antihyperlipidemic) 1

niacor 1

NIASPAN 3

nifedipine er 1

nifedipine er osmotic release 1

nifedipine oral 1

NITRO-BID 2

NITRO-DUR 3

nitroglycerin er 1

nitroglycerin sublingual 1

nitroglycerin transdermal 1

nitroglycerin translingual 1

NITROLINGUAL E

NITROMIST 3

NITROSTAT 3

nitro-time 1

NORVASC 3

olmesartan medoxomil oral 1

olmesartan medoxomil-hctz 1

omega-3-acid ethyl esters 1PACERONE ORAL TABLET 100 MG, 400 MG 3

pacerone oral tablet 200 mg 1

PRALUENT 2 PA, ST, SP

PRAVACHOL 3

pravastatin sodium 1

Drug Name Drug Tier


prazosin hcl oral 1

PRINIVIL 3

PROCARDIA 3

PROCARDIA XL 3

propranolol hcl er 1

propranolol hcl oral 1

QBRELIS 3

quinapril hcl 1

ramipril 1

RANEXA 2

REPATHA 2 PA, ST, SP

rosuvastatin calcium 1simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 H-PA

simvastatin oral tablet 80 mg 1

sotalol hcl oral 1

SOTYLIZE 3

spironolactone oral 1

TEKTURNA 3

TEKTURNA HCT 3

telmisartan 1

TENORETIC 100 E

TENORETIC 50 E

TENORMIN E

TOPROL XL 3

torsemide 1

triamterene-hctz 1

TRICOR E

valsartan 1

valsartan-hydrochlorothiazide 1

VASCEPA 2

VASOTEC E

verapamil hcl er 1


Drug Name Drug Tier


verapamil hcl oral 1

VERELAN 3

VERELAN PM 3

VYTORIN E

WELCHOL 1

ZESTORETIC E

ZESTRIL E

ZETIA E

ZIAC 3

ZOCOR 3

Central Nervous System Agents - Drugs for Attention Deficit DisorderADDERALL E

ADDERALL XR 1amphetamine-dextroamphetamine 1

amphetamine-dextroamphetamine er E

APTENSIO XR 3

atomoxetine hcl 1

CONCERTA 1

DEXEDRINE 3

dexmethylphenidate hcl 1

dexmethylphenidate hcl er 1

dextroamphetamine sulfate 1

dextroamphetamine sulfate er 1

FOCALIN 3

FOCALIN XR E

guanfacine hcl er 1

INTUNIV E

metadate er 1

METHYLIN 3

methylphenidate hcl er (cd) 1

methylphenidate hcl er (la) 1

Drug Name Drug Tier


methylphenidate hcl er oral tablet extended release 10 mg, 20 mg 1

methylphenidate hcl er oral tablet extended release 18 mg, 27 mg, 36 mg, 54 mg, 72 mg

E

methylphenidate hcl er oral tablet extended release 24 hour E

methylphenidate hcl oral 1

MYDAYIS 2

PROCENTRA 3

QUILLICHEW ER 3

QUILLIVANT XR 3

relexxii E

RITALIN 3

RITALIN LA E

STRATTERA E

VYVANSE 2

ZENZEDI E

Central Nervous System Agents - Drugs for Multiple SclerosisAMPYRA E PA, SP

AUBAGIO 3 PA, SP

AVONEX PEN 2 PA, SP

AVONEX PREFILLED 2 PA, SPAVONEX VIAL INTRAMUSCULAR KIT 2 PA, SP

BETASERON 2 PA, SP

COPAXONE E PA, SP

dalfampridine er 1 PA, SP

EXTAVIA E PA, ST, SPGILENYA ORAL CAPSULE 0.25 MG 3 PA, SP

GILENYA ORAL CAPSULE 0.5 MG 3 PA, SP

glatiramer acetate 1 PA, SP

glatopa E PA, SP

PLEGRIDY 3 PA, SP


Drug Name Drug Tier


PLEGRIDY STARTER PACK 3 PA, SP

REBIF 3 PA, ST, SP

REBIF REBIDOSE 3 PA, ST, SPREBIF REBIDOSE TITRATION PACK 3 PA, ST, SP

REBIF TITRATION PACK 3 PA, ST, SP

TECFIDERA 2 PA, SP

Central Nervous System Agents - Miscellaneous

AUSTEDO 2 PA, SP

LYRICA 3

NUEDEXTA 2

Dental and Oral Agents - Drugs for Mouth and Throat Conditionscavarest 1chlorhexidine gluconate mouth/throat 1

clinpro 5000 1

denta 5000 plus 1

dentagel 1

fluoridex 1

fluoridex enhanced whitening 1

lidocaine hcl mouth/throat 1

lidocaine viscous 1

NAFRINSE DAILY/NEUTRAL 2

NAFRINSE WEEKLY 3

neutral sodium fluoride 1

paroex 1

PERIDEX 3

PREVIDENT 3PREVIDENT 5000 BOOSTER PLUS 3

PREVIDENT 5000 DRY MOUTH 3

PREVIDENT 5000 PLUS 3

sf 1

sf 5000 plus 1

Drug Name Drug Tier


Dermatological Agents - Drugs for Skin Conditions

ABSORICA 3

ACZONE EXTERNAL GEL 5 % 1

ACZONE EXTERNAL GEL 7.5 % 2

ALA SCALP 3

ala-cort external cream 1 % E

ala-cort external cream 2.5 % 1

ALDARA 3

ALTRENO E PA

amnesteem 1

ATRALIN E

avar cleanser 1

AVAR EXTERNAL FOAM E

AVAR EXTERNAL PAD 3

AVAR LS CLEANSER 3

AVAR LS EXTERNAL FOAM E

AVAR LS EXTERNAL PAD 3

AVAR-E EMOLLIENT 3

AVAR-E GREEN 3

AVAR-E LS 3

avita 1 PA

azelaic acid external 1

betamethasone dipropionate aug 1betamethasone dipropionate external 1

bp 10-1 1

calcipotriene-betameth diprop 1

calcitriol external 1

CAPEX 2

CARAC 2

claravis 1

CLEOCIN-T 3

clindacin etz external swab 1


Drug Name Drug Tier


clindacin-p 1

CLINDAGEL 3clindamycin phos-benzoyl perox external gel 1.2-5 % 1

clindamycin phosphate external foam 1

clindamycin phosphate external lotion 1

clindamycin phosphate external solution 1

clindamycin phosphate external swab 1

CLINDAMYCIN PHOSPHATE GEL 1 % EXTERNAL 3

clindamycin phosphate gel 1 % external 1

clobetasol propionate external 1

CLOBEX E

CLOBEX SPRAY 3

clodan external shampoo 1

clotrimazole-betamethasone 1

dapsone external E

DERMA-SMOOTHE/FS BODY 3

DERMA-SMOOTHE/FS SCALP 3

DESONATE 3

desonide external 1

DESOWEN 3

DIPROLENE 3

DIPROLENE AF 3

DUAC EDUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 300 MG/2ML

3 PA, ST, SP

EFUDEX 3

ELIDEL 3

ELOCON 3

ENSTILAR 3

EUCRISA 3 ST

Drug Name Drug Tier


EVOCLIN 3

FINACEA EXTERNAL FOAM 2

FINACEA EXTERNAL GEL 3

fluocinolone acetonide body 1

fluocinolone acetonide external 1

fluocinolone acetonide scalp 1

fluocinonide external 1

FLUOROPLEX 3FLUOROURACIL EXTERNAL CREAM 0.5 % 3

fluorouracil external cream 5 % 1hydrocortisone external cream 1 % E

hydrocortisone external cream 2.5 % 1

hydrocortisone external lotion 2.5 % 1

hydrocortisone external ointment 1 %, 2.5 % 1

hydrocortisone in absorbase 1

imiquimod external 1

IMIQUIMOD PUMP 3

IMPOYZ 3

isotretinoin oral 1 PA

KENALOG EXTERNAL E

LIDOTREX E

LOTRISONE 3

methoxsalen oral 1

methoxsalen rapid 1

METROCREAM 3

METROGEL E

METROLOTION 3

metronidazole external 1

MIRVASO 3

mometasone furoate external 1

myorisan 1


Drug Name Drug Tier


neuac external gel 1

NORITATE 3

OLUX E

ORACEA 3

OXSORALEN ULTRA 2

PICATO 3

pimecrolimus 1

PLEXION 3

PLEXION CLEANSER 3

PLEXION CLEANSING CLOTH 3

RETIN-A E

RHOFADE 3

rosadan external cream 1

rosadan external gel 1

rosanil cleanser 1

SERNIVO 3

sss 10-5 1

sulfacetamide sodium-sulfur 1

sulfacleanse 8/4 1

sulfamez wash 1

SUMADAN WASH E

SUMAXIN 3

SUMAXIN WASH 3

SYNALAR 3TACLONEX EXTERNAL OINTMENT E

TACLONEX EXTERNAL SUSPENSION 3

tazarotene external ETAZORAC EXTERNAL CREAM 0.05 % 2 PA

TAZORAC EXTERNAL CREAM 0.1 % 1 PA

TAZORAC EXTERNAL GEL 2 PA

TEMOVATE 3

Drug Name Drug Tier


TEXACORT 2

TOLAK 3

tretinoin external cream 1 PA

tretinoin external gel 0.01 % 1 PA

tretinoin external gel 0.025 % E

tretinoin external gel 0.05 % 3 PA

triamcinolone acetonide external 1

TRIANEX 3

triderm 1

tridesilon 1

VANOS E

VECTICAL 3

VERDESO 3

zenatane 1

ZYCLARA 3

ZYCLARA PUMP 3

Diabetes - Glucose Monitoring

ACCU-CHEK AVIVA DEVICE EACCU-CHEK AVIVA CONNECT KIT W/DEVICE E

ACCU-CHEK AVIVA PLUS EACCU-CHEK COMPACT PLUS CARE KIT E

ACCU-CHEK COMPACT PLUS TEST STRIPS E

ACCU-CHEK GUIDE EACCU-CHEK NANO SMARTVIEW KIT W/DEVICE E

ACCU-CHEK SMARTVIEW TEST STRIPS E

BAYER BREEZE 2 SYSTEM E

BAYER BREEZE 2 TEST EBAYER CONTOUR LINK MONITOR E

BAYER CONTOUR MONITOR KIT E


Drug Name Drug Tier


BAYER CONTOUR NEXT MONITOR KIT W/DEVICE 2

BAYER CONTOUR NEXT TEST IN VITRO STRIP 2

BAYER CONTOUR TEST E

BD INSULIN PEN NEEDLES 2

ENLITE GLUCOSE SENSOR EFREESTYLE PRECISION NEO TEST E

ONETOUCH ULTRA 2 1ONETOUCH ULTRA BLUE TEST STRIPS 1

ONETOUCH ULTRA MINI 1

ONETOUCH VERIO 1ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE 1

ONETOUCH VERIO TEST STRIPS 1

ONETOUCH VERIO IQ SYSTEM 1

PRECISION LINK E

PRECISION PCX PLUS TEST E

PRECISION QID MONITOR E

PRECISION QID TEST EPRECISION SOF-TACT MONITOR E

PRECISION SOF-TACT TEST EPRECISION XTRA BLOOD GLUCOSE E

PRECISION XTRA DEVICE E

PRECISION XTRA KIT E

PRECISION XTRA MONITOR ERELION BLOOD GLUCOSE TEST E

RELION ULTIMA TEST 3TRUE METRIX BLOOD GLUCOSE TEST 3

TRUEPLUS 5-BEVEL PEN NEEDLES 29G X 12.7MM 2

TRUETRACK TEST 3

Drug Name Drug Tier


Diabetes - Insulin

ADMELOG E

ADMELOG SOLOSTAR E

AFREZZA 3

BASAGLAR KWIKPEN 1

FIASP E ST

FIASP FLEXTOUCH E ST

HUMALOG KWIKPEN 2

HUMALOG MIX 50/50 KWIKPEN 2

HUMALOG MIX 50/50 VIAL 1

HUMALOG MIX 75/25 KWIKPEN 2

HUMALOG MIX 75/25 VIAL 1HUMALOG U-100 JUNIOR KWIKPEN 2

HUMALOG U-100 VIAL AND CARTRIDGE SUBCUTANEOUS SOLUTION 100 UNIT/ML

1

HUMALOG U-100 VIAL AND CARTRIDGE SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML

2

HUMULIN 70/30 KWIKPEN 2

HUMULIN 70/30 VIAL 1

HUMULIN N KWIKPEN 2

HUMULIN N VIAL 1

HUMULIN R U-500 KWIKPEN 2HUMULIN R U-500 VIAL (CONCENTRATED) 1

HUMULIN R VIAL 1

LANTUS SOLOSTAR E

LANTUS U-100 VIAL E

LEVEMIR U-100 FLEXTOUCH 3

LEVEMIR U-100 VIAL 3

NOVOLIN 70/30 RELION E

NOVOLIN 70/30 VIAL E

NOVOLIN N RELION E


Drug Name Drug Tier


NOVOLIN N VIAL E

NOVOLIN R RELION E

NOVOLIN R VIAL E

NOVOLOG FLEXPEN E PA

NOVOLOG PENFILL E PA

NOVOLOG U-100 VIAL E

TOUJEO MAX SOLOSTAR E

TOUJEO SOLOSTAR E

TRESIBA 2

TRESIBA FLEXTOUCH 2

Diabetes - Non-Insulin Agents

ACTOS E

ADLYXIN 3

ADLYXIN STARTER PACK 3

ALOGLIPTIN BENZOATE E

ALOGLIPTIN-METFORMIN HCL E

ALOGLIPTIN-PIOGLITAZONE E

AMARYL 3

BYDUREON 2BYDUREON BCISE AUTOINJECTOR 2

BYETTA 10 MCG PEN 2

BYETTA 5 MCG PEN 2

FARXIGA E ST

FORTAMET E

glimepiride 1

glipizide er 1

glipizide ir 1

glipizide xl 1

GLUCAGON 2

GLUCOPHAGE 3

GLUCOPHAGE XR 3

GLUCOTROL 3

Drug Name Drug Tier


GLUCOTROL XL 3GLUCOVANCE ORAL TABLET 5-500 MG 3

GLUMETZA 3

glyburide oral 1

glyburide-metformin 1

GLYXAMBI 2 ST

INVOKAMET 2

INVOKAMET XR 2

INVOKANA 2

JANUVIA 3 ST

JARDIANCE 2

JENTADUETO 2

JENTADUETO XR 2

KAZANO 2

KOMBIGLYZE XR 2

metformin hcl er 1

metformin hcl er (mod) 1

metformin hcl er (osm) 1METFORMIN HCL ORAL SOLUTION 3

metformin hcl oral tablet 1

NESINA 2

ONGLYZA 2

OSENI 2

OZEMPIC 3

pioglitazone hcl 1

RIOMET 3

SOLIQUA 2

SYNJARDY 2

SYNJARDY XR 2

TRADJENTA 2

TRULICITY 3


Drug Name Drug Tier


VICTOZA SOLUTION PEN-INJECTOR 18 MG/3ML SUBCUTANEOUS 2-PACK

2

VICTOZA SOLUTION PEN-INJECTOR 18 MG/3ML SUBCUTANEOUS 3-PACK

3

Drugs for Blood Disorders

AFSTYLA 3 PA, SP

ARANESP (ALBUMIN FREE) 2 SP

ELOCTATE 3 PA, SP

EPOGEN 2 SP

JIVI 3 PA, SP

KOGENATE FS 2 SP

KOVALTRY 2 SP

MULPLETA 3 PA, SP

NEULASTA 3 SP

NOVOEIGHT 2 SP

NUWIQ 2 SP

PROCRIT 2 SP

ZARXIO 2 SP

Drugs for Sexual Dysfunction

ADDYI 3

CIALIS E QLIMVEXXY VAGINAL INSERT 10 MCG, 4 MCG 3 QL

INTRAROSA 2 QL

LEVITRA E QL

OSPHENA 2sildenafil citrate oral tablet 100 mg, 25 mg, 50 mg 1 QL

STAXYN 3 QL

STENDRA 2 QL

tadalafil oral 1 ST

vardenafil hcl 1 QL

VIAGRA E

Drug Name Drug Tier


Electrolytes / Vitamins

DRISDOL 3

ERGOCAL 3

ergocalciferol oral capsule 1

FLORIVA PLUS 3

folic acid oral tablet 1 mg 1

klor-con 1

klor-con 10 1

klor-con m10 1

KLOR-CON M15 3

klor-con m20 1

klor-con sprinkle 1

K-TAB 3

LOKELMA 3

multi-vitamin/fluoride 1

multivitamin/fluoride oral solution 1multivitamin/fluoride oral tablet chewable 0.5 mg, 1 mg 1

MULTIVITAMIN/FLUORIDE TABLET CHEWABLE 0.25 MG ORAL

3

multivitamin/fluoride tablet chewable 0.25 mg oral 1

multivitamins/fluoride 1

mvc-fluoride 1

POLY-VI-FLOR 3

potassium chloride crys er 1

potassium chloride er 1

potassium chloride oral 1

potassium citrate er 1

QUFLORA PEDIATRIC 3

SYPRINE 1 PA, SP

trientine hcl E PA, SP

UROCIT-K 10 3


Drug Name Drug Tier


UROCIT-K 15 3

UROCIT-K 5 3

VELTASSA 3vitamin d (ergocalciferol) oral capsule 50000 unit 1

Gastrointestinal Agents - Drugs for Acid Reflux and UlcerACIPHEX E

ACIPHEX SPRINKLE 3

CARAFATE ORAL SUSPENSION 2

CARAFATE ORAL TABLET 3

CYTOTEC 3

DEXILANT 2

misoprostol oral 1omeprazole oral capsule delayed release 1

pantoprazole sodium oral 1

PROTONIX ORAL PACKET 3PROTONIX ORAL TABLET DELAYED RELEASE E

rabeprazole sodium 1

ranitidine hcl oral capsule E

ranitidine hcl oral syrup 1ranitidine hcl oral tablet 150 mg, 300 mg E

sucralfate oral tablet 1

Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach ConditionsACTIGALL 3

ANASPAZ 2

CLENPIQ 2

COLYTE WITH FLAVOR PACKS 3

dicyclomine hcl oral 1

diphenoxylate-atropine 1

ed-spaz 1

ENDARI 3

Drug Name Drug Tier


gavilyte-c 1 H

gavilyte-g 1 HGOLYTELY ORAL SOLUTION RECONSTITUTED 227.1 GM 2

GOLYTELY ORAL SOLUTION RECONSTITUTED 236 GM 3

hyoscyamine sulfate er 1

hyoscyamine sulfate oral 1

hyoscyamine sulfate sl 1

hyoscyamine sulfate sublingual 1

hyosyne 1

LEVBID 3

LEVSIN ORAL 3

LEVSIN/SL 3

LINZESS 2

LOMOTIL 3

MOVANTIK E

MOVIPREP 2

NULEV 3

OMECLAMOX-PAK 3

oscimin 1

oscimin sr 1

peg 3350/electrolytes 1 H

PLENVU 2

PREPOPIK 2

PYLERA 3

SUPREP BOWEL PREP KIT 2

SYMAX DUOTAB 3

symax-sl 1

symax-sr 1

SYMPROIC 2

URSO 250 3

URSO FORTE 3

ursodiol oral 1

VIBERZI 3


Drug Name Drug Tier


Genetic or Enzyme Disorder: Drugs for Replacement, Modifiers, TreatmentCERDELGA 2 PA, SP

CREON 2

NITYR 2 PA, SP

ORFADIN E PA, SP

PANCREAZE 3 ST

PERTZYE 3 ST

STRENSIQ 2 PA, SP

VIOKACE 3 ST

ZENPEP 2

Genitourinary Agents - Drugs for Bladder, Genital and Kidney ConditionAURYXIA 3

CUPRIMINE 3 SP

DEPEN TITRATABS 2 SP

DITROPAN XL 3

D-PENAMINE E

FOSRENOL ORAL PACKET 3FOSRENOL ORAL TABLET CHEWABLE E

GELNIQUE 3

GELNIQUE PUMP 3

lanthanum carbonate 1

oxybutynin chloride er 1

oxybutynin chloride oral 1

phenazo oral tablet 200 mg 1phenazopyridine hcl oral tablet 100 mg, 200 mg 1

PYRIDIUM 3

TOVIAZ 2

VELPHORO 2

Drug Name Drug Tier


Genitourinary Agents - Drugs for Prostate Conditionsalfuzosin hcl er 1

finasteride oral tablet 5 mg 1

FLOMAX E

PROSCAR 3

RAPAFLO 3

silodosin 1

tamsulosin hcl 1

terazosin hcl 1

UROXATRAL 3

Hormonal Agents - Hormone Replacement and Birth ControlALORA 3

altavera 1 H

alyacen 1/35 1 H

amethia 1 H

amethia lo 1 H

apri 1 H

ashlyna 1 H

aubra 1 H

aubra eq 1 H

aviane 1 H

AYGESTIN 3

azurette 1 H

balziva 1 H

bekyree 1 H

BEYAZ E

blisovi 24 fe 1 H

blisovi fe 1.5/30 1 H

blisovi fe 1/20 1 H

briellyn 1 H


Drug Name Drug Tier


camila 1 H

camrese 1 H

camrese lo 1 H

chateal 1 H

chateal eq 1 H

CLIMARA E

CLIMARA PRO 2

CRINONE 3 PA, ST

cryselle-28 1 H

cyclafem 1/35 1 H

cyred 1 H

cyred eq 1 H

dasetta 1/35 1 H

daysee 1 H

deblitane 1 H

delyla 1 HDEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 MG/ML

3

DEPO-PROVERA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

3

DEPO-SUBQ PROVERA 104 2

desogestrel-ethinyl estradiol 1 HDIVIGEL TRANSDERMAL GEL 0.25 MG/0.25GM, 0.5 MG/0.5GM, 1 MG/GM

2

DIVIGEL TRANSDERMAL GEL 0.75 MG/0.75GM E

drospiren-eth estrad-levomefol 1

drospirenone-ethinyl estradiol 1 H

DUAVEE 3

ELESTRIN 3

elinest 1 H

Drug Name Drug Tier


emoquette 1 H

enskyce 1 H

errin 1 H

estarylla 1 H

ESTRACE ORAL 3

ESTRACE VAGINAL 1

estradiol oral 1estradiol patch twice weekly 0.025 mg/24hr transdermal (generic Minivelle)

1

estradiol patch twice weekly 0.0375 mg/24hr transdermal (generic Minivelle)

1


1


1


1

estradiol transdermal patch weekly 1

estradiol vaginal cream E

estradiol vaginal tablet 1

ESTRING 2

ESTROGEL 3

EVAMIST 2

falmina 1 H

fayosim 1

femynor 1 H

gianvi 1 H

hailey 24 fe 1 H

heather 1 H

incassia 1 H

introvale 1 H


Drug Name Drug Tier


isibloom 1 H

jencycla 1 H

jolessa 1 H

jolivette 1 H

juleber 1 H

junel 1.5/30 1 H

junel 1/20 1 H

junel fe 1.5/30 1 H

junel fe 1/20 1 H

junel fe 24 1 H

kariva 1 H

kurvelo 1 H

larin 1.5/30 1 H

larin 1/20 1 H

larin 24 fe 1 H

larin fe 1.5/30 1 H

larin fe 1/20 1 H

larissia 1 H

lessina 1 H

levonorgest-eth est & eth est 1

levonorgest-eth estrad 91-day 1 Hlevonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg

1 H

levora 0.15/30 (28) 1 H

lillow 1 H

LO LOESTRIN FE 2

LOESTRIN 1.5/30 (21) 3

LOESTRIN 1/20 (21) 3

LOESTRIN FE 1.5/30 3

LOESTRIN FE 1/20 3

loryna 1 H

LOSEASONIQUE 3

Drug Name Drug Tier


low-ogestrel 1 H

lutera 1 H

lyza 1 H

marlissa 1 Hmedroxyprogesterone acetate intramuscular 1 H

medroxyprogesterone acetate oral 1

melodetta 24 fe 1

MENOSTAR 3

mibelas 24 fe 1

microgestin 1.5/30 1 H

microgestin 1/20 1 H

microgestin fe 1.5/30 1 H

microgestin fe 1/20 1 H

mili 1 H

MINASTRIN 24 FE EMINIVELLE PATCH TWICE WEEKLY 0.025 MG/24HR TRANSDERMAL

3

MINIVELLE PATCH TWICE WEEKLY 0.0375 MG/24HR TRANSDERMAL

3


3


3


3

MIRCETTE 3

mono-linyah 1 H

mononessa 1 H

NATAZIA 2

necon 0.5/35 (28) 1 H

nikki 1 H


Drug Name Drug Tier


nora-be 1 Hnorethin ace-eth estrad-fe oral tablet 1 H

norethin ace-eth estrad-fe oral tablet chewable 1

norethindrone acetate oral 1norethindrone acet-ethinyl est oral tablet 1 H

norethindrone acet-ethinyl est oral tablet chewable 1

norethindrone oral 1 H

norgestimate-eth estradiol 1 Hnorgestimate-ethinyl estradiol triphasic 1 H

norlyda 1 H

norlyroc 1 H

nortrel 0.5/35 (28) 1 H

nortrel 1/35 (21) 1 H

nortrel 1/35 (28) 1 H

NUVARING 2 H

ocella 1 H

ogestrel 1 H

orsythia 1 H

ORTHO MICRONOR 3

ORTHO TRI-CYCLEN (28) 3

ORTHO TRI-CYCLEN LO E

ORTHO-CYCLEN (28) 3

ORTHO-NOVUM 1/35 (28) 3

philith 1 H

pimtrea 1 H

pirmella 1/35 1 H

portia-28 1 H

PREMARIN ORAL 2

PREMARIN VAGINAL 3

PREMPHASE 3

PREMPRO 2

Drug Name Drug Tier


previfem 1 H

progesterone micronized oral 1

PROMETRIUM 3

PROVERA 3

QUARTETTE E

reclipsen 1 H

rivelsa 1

SAFYRAL E

SEASONIQUE 3

setlakin 1 H

sharobel 1 H

sprintec 28 1 H

sronyx 1 H

syeda 1 H

tarina fe 1/20 1 H

tarina fe 1/20 eq 1 H

TAYTULLA 3

tri femynor 1 H

tri-estarylla 1 H

tri-linyah 1 H

tri-lo-estarylla 1 H

tri-lo-marzia 1 H

tri-lo-sprintec 1 H

tri-mili 1 H

tri-previfem 1 H

tri-sprintec 1 H

tri-vylibra 1 H

tri-vylibra lo 1 H

tulana 1 H

tydemy 1

VAGIFEM E

vienva 1 H


Drug Name Drug Tier


viorele 1 H

VIVELLE-DOT 1

vyfemla 1 H

vylibra 1 H

wera 1 H

xulane 1 H

YASMIN 28 3

YAZ 3

yuvafem 1

zarah 1 H

Hormonal Agents - Oral Steroids

CORTEF 3

DECADRON ORAL ELIXIR E

DECADRON ORAL TABLET 3

deltasone 1

dexamethasone intensol 1

dexamethasone oral 1

hydrocortisone oral 1MEDROL ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG 3

MEDROL ORAL TABLET 2 MG 2MEDROL ORAL TABLET THERAPY PACK 3

methylprednisolone oral 1

MILLIPRED DP 2

MILLIPRED DP 12-DAY 2

MILLIPRED ORAL SOLUTION 3

MILLIPRED ORAL TABLET 2

ORAPRED ODT 3

prednisolone oral solution 1prednisolone sodium phosphate oral 1

prednisone intensol 1

prednisone oral 1

RAYOS 3

VERIPRED 20 3

Drug Name Drug Tier


Hormonal Agents - Other

cabergoline 1

CETROTIDE E SP

DDAVP INJECTION 3

DDAVP ORAL 3

desmopressin acetate injection 1

desmopressin acetate oral 1

GENOTROPIN E PA, SP

GENOTROPIN MINIQUICK E PA, SP

HUMATROPE E PA, SP

NOCDURNA 3

NOCTIVA E

NORDITROPIN FLEXPRO E PA, SP

NUTROPIN AQ NUSPIN 10 2 PA, SP



OMNITROPE E PA, SP

ORILISSA 3

STIMATE 3

ZOMACTON E PA, SP

Hormonal Agents - Testosterone Replacement

ANDRODERM 2

ANDROGEL E

ANDROGEL PUMP E

DEPO-TESTOSTERONE 3

FORTESTA E

METHITEST 2

methyltestosterone oral 1

NATESTO E

STRIANT 3

TESTIM 1testosterone cypionate intramuscular solution 100 mg/ml 1


Drug Name Drug Tier


TESTOSTERONE CYPIONATE SOLUTION 200 MG/ML INTRAMUSCULAR

3

testosterone cypionate solution 200 mg/ml intramuscular 1

testosterone transdermal E

VOGELXO E

VOGELXO PUMP E

Hormonal Agents - Thyroid

ARMOUR THYROID 2

CYTOMEL 3

euthyrox 1

levo-t 1

levothyroxine sodium oral 1

levothyroxine-liothyronine 1

levoxyl 1

liothyronine sodium oral 1

methimazole oral 1

NATURE-THROID 2

np thyroid 1

SYNTHROID 2

TAPAZOLE 3

TIROSINT 3

unithroid 1

unithroid direct 1

WESTHROID 3

WP THYROID 3

Immunological Agents - Drugs for Immune System Stimulation or SuppressionACTEMRA ACTPEN 3 PA, ST, SP

ACTEMRA SUBCUTANEOUS 3 PA, ST, SP

ASTAGRAF XL 3 SP

AZASAN 3

azathioprine oral 1

Drug Name Drug Tier


CELLCEPT E SP

CIMZIA PREFILLED KIT 2 PA, SP

CIMZIA STARTER KIT 2 PA, SP

COSENTYX 150 MG/ML 3 PA, ST, SP

COSENTYX 300 DOSE 3 PA, ST, SPCOSENTYX SENSOREADY 300 DOSE 3 PA, ST, SP

COSENTYX SENSOREADY PEN 3 PA, ST, SP

cyclosporine modified 1 SP

ENBREL 3 PA, ST, SP

ENBREL MINI 3 PA, ST, SP

ENBREL SURECLICK 3 PA, ST, SP

ENVARSUS XR 3 SP

FIRAZYR 3 PA, SP

gengraf 1 SP

HAEGARDA 2 PA, SP

HUMIRA 2 PA, SPHUMIRA PEDIATRIC CROHNS START 2 PA, SP

HUMIRA PEN 2 PA, SPHUMIRA PEN-CD/UC/HS STARTER 2 PA, SP

HUMIRA PEN-PS/UV/ADOL HS START 2 PA, SP

IMURAN E

methotrexate oral 1

methotrexate sodium oral 1

mycophenolate mofetil 1 SP

mycophenolate sodium 1 SP

MYFORTIC E SP

NEORAL E SP

OTEZLA 2 PA, SP


Drug Name Drug Tier


OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 MG/0.4ML, 12.5 MG/0.4ML, 15 MG/0.4ML, 17.5 MG/0.4ML, 22.5 MG/0.4ML, 25 MG/0.4ML

3

OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR 20 MG/0.4ML

E

PROGRAF ORAL E SP

RAPAMUNE ORAL SOLUTION 2 SP

RAPAMUNE ORAL TABLET E SP

RASUVO 3

SIMPONI 2 PA, SP

sirolimus oral tablet 1 SPSTELARA SUBCUTANEOUS SOLUTION 2 PA, SP

STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

2 PA, SP

tacrolimus oral 1 SP

TAKHZYRO 2 PA, SP

TREMFYA 2 PA, SP

TREXALL 2

XELJANZ 3 PA, ST, SP

XELJANZ XR 3 PA, ST, SP

Infertility Agents

CRINONE VAGINAL GEL 4 % 3 ST

CRINONE VAGINAL GEL 8 % 3 PA, ST

ENDOMETRIN 2 PA

GONAL-F E SP

GONAL-F RFF E SP

GONAL-F RFF REDIJECT E SP

OVIDREL E SP

Inflammatory Bowel Disease Agents

ANALPRAM HC 3

ANALPRAM HC SINGLES 3

ANALPRAM-HC 3

Drug Name Drug Tier


APRISO 2

ASACOL HD E

AZULFIDINE 3

AZULFIDINE EN-TABS 3

budesonide er E

budesonide oral 1

CANASA E

CORTIFOAM 2

DELZICOL E

DIPENTUM 3

ENTOCORT EC Ehydrocortisone ace-pramoxine rectal 1

LIALDA 1

mesalamine oral E

mesalamine rectal enema 1

mesalamine rectal suppository 1

PENTASA E

pramcort 1

PROCORT 3

PROCTOFOAM HC 2

SFROWASA 3

sulfasalazine oral 1

UCERIS ORAL 1

UCERIS RECTAL 2

Metabolic Bone Disease Agents - Drugs for Osteoporosisalendronate sodium 1

BINOSTO 3

BONIVA ORAL 3

calcitriol oral 1

FORTEO 3 PA, SP

FOSAMAX 3

ibandronate sodium oral 1


Drug Name Drug Tier


ROCALTROL 3

TYMLOS 3 PA, SP

Ophthalmic Agents - Drugs for Eye Allergy, Infection and InflammationACULAR 3

ACULAR LS 3

ACUVAIL 3

ALREX 3

AZASITE 3

azelastine hcl ophthalmic 1

BESIVANCE 3

CILOXAN 3

ciprofloxacin hcl ophthalmic 1

erythromycin ophthalmic 1

INVELTYS Eketorolac tromethamine ophthalmic 1

LOTEMAX 3

MOXEZA 3

moxifloxacin hcl ophthalmic 1

OCUFLOX 3

ofloxacin ophthalmic 1

olopatadine hcl ophthalmic 1

OMNIPRED 3

PATADAY E

PATANOL E

PAZEO 3

PRED FORTE 3

PRED MILD 2

prednisolone acetate ophthalmic 1

prednisolone acetate p-f E

tobramycin ophthalmic 1

TOBREX 3

VIGAMOX E

Drug Name Drug Tier


Ophthalmic Agents - Drugs for GlaucomaALPHAGAN P OPHTHALMIC SOLUTION 0.1 % 2

ALPHAGAN P OPHTHALMIC SOLUTION 0.15 % 3

AZOPT 2

BETIMOL 2

bimatoprost ophthalmic 1

brimonidine tartrate ophthalmic 1

COMBIGAN 2

COSOPT 3

COSOPT PF E

dorzolamide hcl-timolol mal 1

dorzolamide hcl-timolol mal pf 1

ISTALOL 3

latanoprost ophthalmic 1

LUMIGAN 2

timolol maleate ophthalmic 1

TIMOPTIC 3

TIMOPTIC OCUDOSE 2

TIMOPTIC-XE 3

TRAVATAN Z 2

XALATAN 3

XELPROS E

Ophthalmic Agents - Drugs for Miscellaneous Eye ConditionsCEQUA E

LASTACAFT 3

MAXITROL 3neomycin-polymyxin-dexameth ophthalmic ointment 1

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1

1

polymyxin b-trimethoprim 1

POLYTRIM 3


Drug Name Drug Tier


RESTASIS 2

RESTASIS MULTIDOSE 3

TOBRADEX 3

TOBRADEX ST 3

tobramycin-dexamethasone 1

XIIDRA 2

Otic Agents - Drugs for Ear Conditions

CIPRODEX 3

FLOXIN OTIC E

neomycin-polymyxin-hc otic 1

ofloxacin otic 1

Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, ColdASTEPRO E

azelastine hcl nasal 1

benzonatate 1

bromfed dm 1

cyproheptadine hcl oral 1

fluticasone propionate nasal 1

hydrocodone polst-cpm polst er 1 PA, QL

ipratropium bromide nasal 1

levocetirizine dihydrochloride oral 1

OMNARIS 3

phenadoz 1

promethazine-codeine oral syrup 1 PA

promethazine-dm 1

pseudoephedrine-bromphen-dm 1

TESSALON PERLES 3

TUSSICAPS 3

TUSSIONEX PENNKINETIC ER 3 PA, QL

XHANCE 3

ZETONNA 3

Drug Name Drug Tier


Respiratory Tract / Pulmonary Agents - Drugs for Asthma and COPDADVAIR DISKUS 1

ADVAIR HFA 2 RS

AIRDUO RESPICLICK 113/14 E



albuterol sulfate er 1ALBUTEROL SULFATE HFA (PROAIR HFA authorized generic)

3

albuterol sulfate inhalation 1

albuterol sulfate oral 1

ALVESCO 1

ANORO ELLIPTA 3

ARCAPTA NEOHALER 3

ARNUITY ELLIPTA 3ASMANEX 120 METERED DOSES 1

ASMANEX 14 METERED DOSES 1




ASMANEX HFA 1

ATROVENT HFA 2

AUVI-Q 3

BEVESPI AEROSPHERE 2

BREO ELLIPTA 2 RS

budesonide inhalation 1

CETYLEV 3

COMBIVENT RESPIMAT 2


Drug Name Drug Tier


EPINEPHRINE INJECTION SOLUTION AUTO-INJECTOR 0.15 MG/0.15ML (ADRENACLICK authorized generic)

E

EPINEPHRINE SOLUTION AUTO-INJECTOR 0.3 MG/0.3ML INJECTION (ADRENACLICK authorized generic)

E

epinephrine solution auto-injector 0.3 mg/0.3ml injection (generic EPIPEN)

1

EPIPEN 2-PAK E

EPIPEN JR 2-PAK E

FLOVENT DISKUS 3

FLOVENT HFA 2

FLUTICASONE-SALMETEROL 1

INCRUSE ELLIPTA 2

ipratropium-albuterol 1LEVALBUTEROL HFA INHALATION AEROSOL 45 MCG/ACT

3

montelukast sodium oral 1

PERFOROMIST 3

PROAIR HFA 2

PROAIR RESPICLICK 2

PROVENTIL HFA 3

PULMICORT FLEXHALER 3

PULMICORT SUSPENSION 3

QVAR REDIHALER 1

SINGULAIR ORAL PACKET 3

SINGULAIR ORAL TABLET ESINGULAIR ORAL TABLET CHEWABLE E

SPIRIVA HANDIHALER 2

SPIRIVA RESPIMAT 2

STRIVERDI RESPIMAT 2

SYMBICORT 2 RS

TRELEGY ELLIPTA 3 RS

Drug Name Drug Tier


TUDORZA PRESSAIR 2

VENTOLIN HFA 2

XOPENEX HFA 3

Respiratory Tract / Pulmonary Agents - Drugs for Cystic FibrosisBETHKIS 1 PA, SP

KITABIS PAK E PA, SP

PULMOZYME 2 PA, SP

TOBI NEBULIZER E PA, SP

TOBI PODHALER 3 PA, SPtobramycin nebulization solution 300 mg/5ml inhalation E PA, SP

TOBRAMYCIN NEBULIZATION SOLUTION 300 MG/5ML INHALATION

E PA, SP

Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary HypertensionADCIRCA E PA, SP

ADEMPAS 2 PA, SP

LETAIRIS 2 PA, SP

OPSUMIT 2 PA, SP

ORENITRAM 3 PA, SP

tadalafil (pah) 1 PA, SP

TRACLEER 2 PA, SP

TYVASO 2 PA, SP

Skeletal Muscle Relaxants - Drugs for Muscle Pain and SpasmAMRIX 3

baclofen oral 1

carisoprodol oral 1

cyclobenzaprine hcl oral 1

FEXMID 3

metaxall 1

metaxalone 1

methocarbamol oral 1


Drug Name Drug Tier


ROBAXIN ORAL 3

ROBAXIN-750 3

SKELAXIN E

SOMA ORAL TABLET 250 MG E

SOMA ORAL TABLET 350 MG 3

tizanidine hcl oral 1

ZANAFLEX 3

Sleep Disorder Agents

AMBIEN E

AMBIEN CR E

EDLUAR 3

eszopiclone 1

INTERMEZZO E

LUNESTA E

modafinil 1

PROVIGIL E

RESTORIL 3

temazepam 1

zolpidem tartrate 1

zolpidem tartrate er 1

ZOLPIMIST 3

40

A

ABILIFY ......................................... 17ABILIFY MYCITE .......................... 17abiraterone acetate ....................... 16ABSORICA .................................... 22ACCU-CHEK AVIVA CONNECT KIT

W/DEVICE ................................. 24ACCU-CHEK AVIVA DEVICE ....... 24ACCU-CHEK AVIVA PLUS ........... 24ACCU-CHEK COMPACT PLUS

CARE KIT ................................... 24ACCU-CHEK COMPACT PLUS

TEST STRIPS ............................ 24ACCU-CHEK GUIDE .................... 24ACCU-CHEK NANO SMARTVIEW

KIT W/DEVICE ........................... 24ACCU-CHEK SMARTVIEW TEST

STRIPS ...................................... 24ACCUPRIL .................................... 18acetaminophen-codeine ................ 10acetaminophen-codeine #2 ........... 10acetaminophen-codeine #3 ........... 10acetaminophen-codeine #4 .......... 10acetazolamide er ........................... 18acetazolamide oral ........................ 18ACIPHEX ....................................... 28ACIPHEX SPRINKLE .................... 28ACTEMRA ACTPEN ..................... 34ACTEMRA SUBCUTANEOUS ...... 34ACTICLATE ................................... 12ACTIGALL ..................................... 28ACTOS .......................................... 26ACULAR ........................................ 36ACULAR LS .................................. 36ACUVAIL ....................................... 36acyclovir oral ................................. 17ACZONE EXTERNAL GEL 5 % .... 22ACZONE EXTERNAL GEL 7.5 % . 22ADALAT CC .................................. 18ADCIRCA ...................................... 38ADDERALL ................................... 21ADDERALL XR ............................. 21ADDYI ............................................ 27ADEMPAS ..................................... 38ADLYXIN ....................................... 26ADLYXIN STARTER PACK ........... 26

ADMELOG .................................... 25ADMELOG SOLOSTAR ................ 25ADRENACLICK ............................. 38ADVAIR DISKUS ........................... 37ADVAIR HFA ................................. 37AFREZZA ...................................... 25AFSTYLA ...................................... 27AIMOVIG ....................................... 15AIRDUO RESPICLICK 113/14 ....... 37AIRDUO RESPICLICK 232/14 ...... 37AIRDUO RESPICLICK 55/14 ........ 37AKYNZEO ORAL .......................... 15ALA SCALP ................................... 22ala-cort external cream 1 % .......... 22ala-cort external cream 2.5 % ....... 22albuterol sulfate er ......................... 37ALBUTEROL SULFATE HFA ........ 37albuterol sulfate inhalation ............. 37albuterol sulfate oral ...................... 37ALDACTONE ................................. 18ALDARA ........................................ 22alendronate sodium ....................... 35alfuzosin hcl er .............................. 29allopurinol oral ............................... 15ALOGLIPTIN BENZOATE ............. 26ALOGLIPTIN-METFORMIN HCL .. 26ALOGLIPTIN-PIOGLITAZONE ..... 26ALORA .......................................... 29ALPHAGAN P OPHTHALMIC

SOLUTION 0.1 % ....................... 36ALPHAGAN P OPHTHALMIC

SOLUTION 0.15 % ..................... 36alprazolam er ................................. 18alprazolam intensol ....................... 18alprazolam oral .............................. 18alprazolam xr ................................. 18ALREX ........................................... 36ALTACE ......................................... 18altavera .......................................... 29ALTOPREV.................................... 18ALTRENO ...................................... 22ALVESCO ...................................... 37alyacen 1/35 .................................. 29AMARYL ........................................ 26AMBIEN ......................................... 39AMBIEN CR .................................. 39

AMERGE ....................................... 15amethia .......................................... 29amethia lo ...................................... 29amiodarone hcl oral ....................... 18amitriptyline hcl oral ...................... 14amlodipine besylate oral ................ 18amlodipine besylate-benazepril

hcl ............................................... 18amlodipine besylate-valsartan ....... 18amnesteem .................................... 22amoxicillin ...................................... 12amoxicillin-potassium

clavulanate er ............................. 12amoxicillin-potassium

clavulanate oral .......................... 12amphetamine-

dextroamphetamine ................... 21amphetamine-

dextroamphetamine er ............... 21AMPYRA ....................................... 21AMRIX ........................................... 38ANALPRAM HC ............................ 35ANALPRAM HC SINGLES ........... 35ANALPRAM-HC ............................ 35ANASPAZ ...................................... 28anastrozole oral ............................. 16ANDRODERM ............................... 33ANDROGEL .................................. 33ANDROGEL PUMP ....................... 33ANORO ELLIPTA .......................... 37apap-caff-dihydrocodeine oral

capsule ....................................... 10apri ................................................ 29APRISO ......................................... 35APTENSIO XR .............................. 21ARANESP (ALBUMIN FREE) ....... 27ARCAPTA NEOHALER ................. 37ARICEPT ORAL TABLET 10 MG, 5 MG ................................. 14ARICEPT ORAL TABLET

23 MG ........................................ 14aripiprazole .................................... 17ARMOUR THYROID ..................... 34ARNUITY ELLIPTA ....................... 37ARYMO ER ................................... 10ASACOL HD .................................. 35

Index

41

ashlyna .......................................... 29ASMANEX 120 METERED

DOSES ....................................... 37ASMANEX 14 METERED




DOSES ....................................... 37ASMANEX HFA ............................. 37ASTAGRAF XL .............................. 34ASTEPRO ..................................... 37atenolol oral ................................... 18atenolol-chlorthalidone .................. 18ATIVAN ORAL ............................... 18atomoxetine hcl ............................. 21atorvastatin calcium oral tablet

10 mg, 20 mg ............................. 18atorvastatin calcium oral tablet

40 mg, 80 mg ............................. 18atovaquone-proguanil hcl .............. 16ATRALIN ....................................... 22ATRIPLA ........................................ 17ATROVENT HFA ........................... 37AUBAGIO ...................................... 21aubra ............................................. 29aubra eq ........................................ 29AUGMENTIN ES-600 ................... 12AUGMENTIN ORAL SUSPENSION

RECONSTITUTED 125-31.25 MG/5ML .................... 12

AUGMENTIN ORAL SUSPENSION RECONSTITUTED 250-62.5 MG/5ML ...................... 12

AUGMENTIN ORAL TABLET ....... 12AURYXIA ....................................... 29AUSTEDO ..................................... 22AUVI-Q .......................................... 37AVALIDE ........................................ 18AVAPRO ........................................ 18avar cleanser ................................. 22AVAR EXTERNAL FOAM ............. 22AVAR EXTERNAL PAD ................ 22AVAR LS CLEANSER ................... 22AVAR LS EXTERNAL FOAM ........ 22AVAR LS EXTERNAL PAD ........... 22

AVAR-E EMOLLIENT .................... 22AVAR-E GREEN ........................... 22AVAR-E LS .................................... 22aviane ............................................ 29avidoxy .......................................... 12avita ............................................... 22AVONEX PEN ............................... 21AVONEX PREFILLED ................... 21AVONEX VIAL INTRAMUSCULAR

KIT .............................................. 21AYGESTIN ..................................... 29AZASAN ........................................ 34AZASITE ....................................... 36azathioprine oral ............................ 34azelaic acid external ...................... 22azelastine hcl nasal ....................... 37azelastine hcl ophthalmic .............. 36azithromycin oral ........................... 12AZOPT .......................................... 36AZULFIDINE ................................. 35AZULFIDINE EN-TABS ................. 35azurette ......................................... 29

B

baclofen oral .................................. 38BACTRIM ...................................... 12BACTRIM DS ................................ 12BACTROBAN ................................ 12balziva ........................................... 29BARACLUDE ORAL SOLUTION .. 17BARACLUDE ORAL TABLET ....... 17BASAGLAR KWIKPEN ................. 25BAYER BREEZE 2 SYSTEM ........ 24BAYER BREEZE 2 TEST .............. 24BAYER CONTOUR LINK

MONITOR .................................. 24BAYER CONTOUR MONITOR

KIT .............................................. 24BAYER CONTOUR NEXT

MONITOR KIT W/DEVICE ......... 25BAYER CONTOUR NEXT TEST IN

VITRO STRIP ............................. 25BAYER CONTOUR TEST ............. 25BD INSULIN PEN NEEDLES ........ 25bekyree .......................................... 29BELBUCA ...................................... 10benazepril hcl oral ......................... 18benazepril-hydrochlorothiazide ..... 18

BENICAR ...................................... 18BENICAR HCT .............................. 18benzonatate ................................... 37BESIVANCE .................................. 36betamethasone dipropionate aug .. 22betamethasone dipropionate

external ...................................... 22BETAPACE .................................... 18BETASERON ................................ 21BETHKIS ....................................... 38BETIMOL ....................................... 36BEVESPI AEROSPHERE ............. 37BEVYXXA ..................................... 13bexarotene ..................................... 16BEYAZ ........................................... 29BIDIL ............................................. 18bimatoprost ophthalmic ................. 36BINOSTO ...................................... 35bisoprolol fumarate ........................ 18bisoprolol-hydrochlorothiazide ...... 18blisovi 24 fe .................................... 29blisovi fe 1/20 ................................. 29blisovi fe 1.5/30.............................. 29BONIVA ORAL .............................. 35BOSULIF ....................................... 16bp 10-1 .......................................... 22BREO ELLIPTA ............................. 37briellyn ........................................... 29BRILINTA ...................................... 16brimonidine tartrate ophthalmic ..... 36bromfed dm ................................... 37budesonide er ................................ 35budesonide inhalation ................... 37budesonide oral ............................. 35BUNAVAIL ......................................11buprenorphine hcl sublingual .........11buprenorphine hcl-naloxone hcl .....11bupropion hcl er (sr) ...................... 14bupropion hcl er (xl) oral tablet

extended release 24 hour 150 mg, 300 mg ....................................... 14

BUPROPION HCL ER (XL) ORAL TABLET EXTENDED RELEASE 24 HOUR 450 MG .... 14

bupropion hcl oral .......................... 14buspirone hcl oral .......................... 18butalbital-apap-caffeine ................ 10BYDUREON .................................. 26

42

BYDUREON BCISE AUTOINJECTOR ....................... 26

BYETTA 10 MCG PEN .................. 26BYETTA 5 MCG PEN .................... 26BYSTOLIC ..................................... 18BYVALSON ................................... 18

C

cabergoline .................................... 33CALAN .......................................... 18CALAN SR .................................... 18calcipotriene-betameth diprop ....... 22calcitriol external ........................... 22calcitriol oral .................................. 35camila ............................................ 30camrese ......................................... 30camrese lo ..................................... 30CANASA ........................................ 35capecitabine .................................. 16CAPEX .......................................... 22CARAC .......................................... 22CARAFATE ORAL

SUSPENSION ............................ 28CARAFATE ORAL TABLET .......... 28carbamazepine er.......................... 13carbamazepine oral ....................... 13CARBATROL ................................. 13carbidopa-levodopa ....................... 16carbidopa-levodopa er .................. 16CARDIZEM .................................... 18CARDIZEM CD ORAL CAPSULE

EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 360 MG ...................................... 18

CARDIZEM LA .............................. 18CARDURA .................................... 18carisoprodol oral ............................ 38CAROSPIR .................................... 18cartia xt .......................................... 19carvedilol ....................................... 19CATAPRES .................................... 19cavarest ......................................... 22cefadroxil ....................................... 12cefdinir ........................................... 12cefuroxime axetil ........................... 12CELEBREX ....................................11celecoxib oral .................................11CELEXA ........................................ 14

CELLCEPT .................................... 34CENTANY ..................................... 12CENTANY AT ................................ 12cephalexin ..................................... 12CEQUA .......................................... 36CERDELGA ................................... 29CETROTIDE .................................. 33CETYLEV ...................................... 37CHANTIX ..................................11, 12CHANTIX CONTINUING MONTH

PAK ............................................ 12CHANTIX STARTING MONTH

PAK ............................................ 12chateal ........................................... 30chateal eq ...................................... 30chlorhexidine gluconate

mouth/throat ............................... 22chlorthalidone ................................ 19CIALIS ........................................... 27ciclodan ......................................... 15CICLODAN SOLUTION ................ 15ciclopirox ....................................... 15ciclopirox treatment ....................... 15CILOXAN ....................................... 36CIMDUO ........................................ 17CIMZIA PREFILLED KIT ............... 34CIMZIA STARTER KIT .................. 34CIPRO ORAL TABLET .................. 12CIPRODEX .................................... 37ciprofloxacin hcl ophthalmic .......... 36ciprofloxacin hcl oral ...................... 12citalopram hydrobromide ............... 14claravis .......................................... 22clarithromycin er ............................ 12clarithromycin oral ......................... 12CLENPIQ ....................................... 28CLEOCIN ORAL CAPSULE

150 MG, 300 MG ........................ 12CLEOCIN ORAL CAPSULE

75 MG ......................................... 12CLEOCIN-T ................................... 22CLIMARA ...................................... 30CLIMARA PRO ............................. 30clindacin etz external swab ........... 22clindacin-p ..................................... 23CLINDAGEL .................................. 23clindamycin hcl oral ....................... 12

clindamycin phos-benzoyl perox external gel 1.2-5 % ................... 23

clindamycin phosphate external foam ........................................... 23

clindamycin phosphate external lotion .............................................. 23clindamycin phosphate external

solution ....................................... 23clindamycin phosphate external

swab ........................................... 23CLINDAMYCIN PHOSPHATE

GEL 1 % EXTERNAL ................ 23CLINDESSE .................................. 12clinpro 5000 ................................... 22clobetasol propionate external ...... 23CLOBEX ........................................ 23CLOBEX SPRAY ........................... 23clodan external shampoo .............. 23clonazepam oral ............................ 18clonidine hcl oral............................ 19clopidogrel bisulfate oral ............... 16clotrimazole-betamethasone ......... 23COLCHICINE ORAL CAPSULE ... 15COLCHICINE ORAL TABLET ....... 15COLCRYS ..................................... 15colesevelam hcl ............................. 19COLYTE WITH FLAVOR PACKS .. 28COMBIGAN ................................... 36COMBIVENT RESPIMAT .............. 37CONCERTA .................................. 21CONZIP ......................................... 10COPAXONE .................................. 21COREG ......................................... 19coremino ........................................ 12CORGARD .................................... 19CORLANOR .................................. 19CORTEF ........................................ 33CORTIFOAM ................................. 35COSENTYX 150 MG/ML .............. 34COSENTYX 300 DOSE ................ 34COSENTYX SENSOREADY 300

DOSE ......................................... 34COSENTYX SENSOREADY

PEN ............................................ 34COSOPT ....................................... 36COSOPT PF .................................. 36COUMADIN ................................... 13COZAAR ....................................... 19

43

CREON ......................................... 29CRESEMBA ORAL ....................... 15CRESTOR ..................................... 19CRINONE ................................ 30, 35CRINONE VAGINAL GEL 4 % ...... 35CRINONE VAGINAL GEL 8 % ...... 35cryselle-28 ..................................... 30CUPRIMINE .................................. 29cyclafem 1/35 ................................ 30cyclobenzaprine hcl oral ................ 38cyclosporine modified .................... 34CYMBALTA .................................... 14cyproheptadine hcl oral ................. 37cyred .............................................. 30cyred eq ......................................... 30CYTOMEL ..................................... 34CYTOTEC ..................................... 28

D

D-PENAMINE ............................... 29dalfampridine er ............................. 21dapsone external ........................... 23dasetta 1/35 ................................... 30daysee ........................................... 30DDAVP INJECTION ...................... 33DDAVP ORAL ............................... 33deblitane ........................................ 30DECADRON ORAL ELIXIR .......... 33DECADRON ORAL TABLET ........ 33deltasone ....................................... 33delyla ............................................. 30DELZICOL ..................................... 35DEMADEX .................................... 19denta 5000 plus ............................. 22dentagel ......................................... 22DEPAKOTE ................................... 13DEPAKOTE ER ............................. 13DEPAKOTE SPRINKLES .............. 13DEPEN TITRATABS ...................... 29DEPO-PROVERA

INTRAMUSCULAR SUSPENSION 150 MG/ML ................................ 30

DEPO-PROVERA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE .............. 30

DEPO-SUBQ PROVERA 104 ....... 30DEPO-TESTOSTERONE .............. 33DERMA-SMOOTHE/FS BODY ..... 23

DERMA-SMOOTHE/FS SCALP ... 23DESCOVY ..................................... 17desmopressin acetate injection ..... 33desmopressin acetate oral ............ 33desogestrel-ethinyl estradiol ......... 30DESONATE ................................... 23desonide external .......................... 23DESOWEN .................................... 23desvenlafaxine succinate er .......... 14dexamethasone intensol................ 33dexamethasone oral ...................... 33DEXEDRINE ................................. 21DEXILANT ..................................... 28dexmethylphenidate hcl ................. 21dexmethylphenidate hcl er ............ 21dextroamphetamine sulfate ........... 21dextroamphetamine sulfate er ....... 21diazepam intensol ......................... 18diazepam oral concentrate ............ 18diazepam oral solution 1 mg/ml..... 18diazepam oral tablet ...................... 18diclofenac potassium ......................11diclofenac sodium er ......................11diclofenac sodium oral ....................11diclofenac sodium transdermal

gel 1 % ........................................11diclofenac sodium transdermal

solution ........................................11dicyclomine hcl oral ....................... 28DIFICID.......................................... 12DIFLUCAN..................................... 15DILAUDID ORAL .......................... 10dilt-xr .............................................. 19diltiazem hcl er .............................. 19diltiazem hcl er coated beads ........ 19diltiazem hcl oral ............................ 19DIOVAN ......................................... 19DIOVAN HCT ................................ 19DIPENTUM .................................... 35diphenoxylate-atropine .................. 28DIPROLENE .................................. 23DIPROLENE AF ............................ 23DITROPAN XL............................... 29divalproex sodium er ..................... 13divalproex sodium oral .................. 13DIVIGEL TRANSDERMAL GEL

0.25 MG/0.25GM, 0.5 MG/0.5GM, 1 MG/GM .................................... 30

DIVIGEL TRANSDERMAL GEL 0.75 MG/0.75GM ................................ 30

donepezil hcl ................................. 14DORYX .......................................... 12DORYX MPC ................................. 12dorzolamide hcl-timolol mal .......... 36dorzolamide hcl-timolol mal pf ...... 36doxazosin mesylate oral ................ 19doxepin hcl oral ............................. 14doxycycline hyclate oral ................. 12doxycycline monohydrate oral ....... 12DRISDOL ...................................... 27drospiren-eth estrad-levomefol ..... 30drospirenone-ethinyl estradiol ....... 30DUAC ............................................ 23DUAVEE ........................................ 30duloxetine hcl oral.......................... 14DUOPA .......................................... 16DUPIXENT SUBCUTANEOUS

SOLUTION PREFILLED SYRINGE 300 MG/2ML .............................. 23

DURAGESIC-100 .......................... 10DURAGESIC-12 ............................ 10DURAGESIC-25 ............................ 10DURAGESIC-50 ........................... 10DURAGESIC-75 ............................ 10DUZALLO ...................................... 15DVORAH TABLET 325-30-16 MG

ORAL ......................................... 10DYAZIDE ....................................... 19

E

EC-NAPROSYN ORAL TABLET DELAYED RELEASE 375 MG ....11

ed-spaz.......................................... 28EDARBI ......................................... 19EDARBYCLOR .............................. 19EDLUAR ........................................ 39EFFEXOR XR................................ 14EFUDEX ........................................ 23ELESTRIN ..................................... 30eletriptan hydrobromide ................. 15ELIDEL .......................................... 23ELIMITE ........................................ 16elinest ............................................ 30ELIQUIS ........................................ 13ELIQUIS STARTER PACK ............ 13ELOCON ....................................... 23

44

ELOCTATE .................................... 27EMGALITY .................................... 15emoquette ..................................... 30enalapril maleate oral .................... 19ENBREL ........................................ 34ENBREL MINI ............................... 34ENBREL SURECLICK .................. 34ENDARI ......................................... 28endocet .......................................... 10ENDOMETRIN .............................. 35ENLITE GLUCOSE SENSOR ....... 25enoxaparin sodium ........................ 13enskyce ......................................... 30ENSTILAR ..................................... 23entecavir ........................................ 17ENTOCORT EC ............................ 35ENVARSUS XR ............................. 34EPANED ........................................ 19EPCLUSA ...................................... 17EPINEPHRINE INJECTION

SOLUTION AUTO-INJECTOR 0.15 MG/0.15ML ......................... 38

EPINEPHRINE SOLUTION AUTO-INJECTOR 0.3 MG/0.3ML INJECTION ................................ 38

EPIPEN ......................................... 38EPIPEN 2-PAK .............................. 38EPIPEN JR 2-PAK ......................... 38epitol .............................................. 13EPOGEN ....................................... 27ERGOCAL ..................................... 27ergocalciferol oral capsule .......27, 28ERLEADA ...................................... 16errin ............................................... 30erythromycin ophthalmic ............... 36escitalopram oxalate ..................... 14ESGIC ........................................... 10estarylla ......................................... 30ESTRACE ORAL .......................... 30ESTRACE VAGINAL ..................... 30estradiol oral .................................. 30estradiol patch twice weekly

0.025 mg/24hr transdermal ........ 30estradiol patch twice weekly

0.0375 mg/24hr transdermal ...... 30estradiol patch twice weekly

0.05 mg/24hr transdermal .......... 30

estradiol patch twice weekly 0.075 mg/24hr transdermal ........ 30

estradiol patch twice weekly 0.1 mg/24hr transdermal ............ 30

estradiol transdermal patch weekly ........................................ 30

estradiol vaginal cream ................. 30estradiol vaginal tablet ................... 30ESTRING....................................... 30ESTROGEL ................................... 30eszopiclone ................................... 39etodolac ..........................................11etodolac er ......................................11EUCRISA....................................... 23euthyrox ......................................... 34EVAMIST ....................................... 30EVOCLIN ....................................... 23EVZIO ............................................ 12EXFORGE ..................................... 19EXTAVIA ....................................... 21EXTINA ......................................... 15ezetimibe ....................................... 19ezetimibe-simvastatin .................... 19

F

falmina ........................................... 30FARXIGA ....................................... 26fayosim .......................................... 30FEMARA ....................................... 16femynor.................................... 30, 32fenofibrate oral capsule 150 mg, 50

mg .............................................. 19fenofibrate oral tablet ..................... 19FENOGLIDE .................................. 19fentanyl .......................................... 10FEXMID ......................................... 38FIASP ............................................ 25FIASP FLEXTOUCH ..................... 25FINACEA EXTERNAL FOAM ....... 23FINACEA EXTERNAL GEL .......... 23finasteride oral tablet 5 mg ............ 29FIORICET ...................................... 10FIRAZYR ....................................... 34FLAGYL ......................................... 12flecainide acetate .......................... 19FLOLIPID ....................................... 19FLOMAX ........................................ 29FLORIVA PLUS ............................. 27

FLOVENT DISKUS ........................ 38FLOVENT HFA .............................. 38FLOXIN OTIC ................................ 37fluconazole oral ............................. 15fluocinolone acetonide body .......... 23fluocinolone acetonide external ..... 23fluocinolone acetonide scalp ......... 23fluocinonide external ..................... 23fluoridex ......................................... 22fluoridex enhanced whitening ........ 22FLUOROPLEX .............................. 23FLUOROURACIL EXTERNAL

CREAM 0.5 % ............................ 23fluorouracil external cream 5 % ..... 23fluoxetine hcl oral .......................... 14fluticasone propionate nasal ......... 37FLUTICASONE-SALMETEROL .... 38fluvoxamine maleate ...................... 14fluvoxamine maleate er ................. 14FOCALIN ....................................... 21FOCALIN XR ................................. 21folic acid oral tablet 1 mg............... 27FORFIVO XL ................................. 14FORTAMET ................................... 26FORTEO ........................................ 35FORTESTA .................................... 33FOSAMAX ..................................... 35FOSRENOL ORAL PACKET ........ 29FOSRENOL ORAL TABLET

CHEWABLE ............................... 29FREESTYLE PRECISION NEO

TEST .......................................... 25furosemide oral .............................. 19

G

gabapentin oral capsule ................ 13gabapentin oral solution

250 mg/5ml ................................ 13gabapentin oral tablet .................... 13gavilyte-c ....................................... 28gavilyte-g ....................................... 28GELNIQUE .................................... 29GELNIQUE PUMP ........................ 29gemfibrozil oral .............................. 19gengraf .......................................... 34GENOTROPIN .............................. 33GENOTROPIN MINIQUICK .......... 33GENVOYA ..................................... 17

45

GEODON ORAL ........................... 17gianvi ............................................. 30GILENYA ORAL CAPSULE

0.25 MG ..................................... 21GILENYA ORAL CAPSULE

0.5 MG ....................................... 21glatiramer acetate .......................... 21glatopa ........................................... 21GLEEVEC ..................................... 16glimepiride ..................................... 26glipizide er ..................................... 26glipizide ir ...................................... 26glipizide xl ...................................... 26GLUCAGON .................................. 26GLUCOPHAGE ............................. 26GLUCOPHAGE XR ....................... 26GLUCOTROL ................................ 26GLUCOTROL XL ........................... 26GLUCOVANCE ORAL TABLET

5-500 MG ................................... 26GLUMETZA ................................... 26glyburide oral ................................. 26glyburide-metformin ...................... 26GLYXAMBI .................................... 26GOLYTELY ORAL SOLUTION

RECONSTITUTED 227.1 GM .... 28GOLYTELY ORAL SOLUTION

RECONSTITUTED 236 GM ....... 28GONAL-F ...................................... 35GONAL-F RFF .............................. 35GONAL-F RFF REDIJECT ............ 35GONITRO ...................................... 19guanfacine hcl ..........................19, 21guanfacine hcl er ........................... 21GYNAZOLE-1 ................................ 15

H

HAEGARDA .................................. 34hailey 24 fe .................................... 30HALCION ...................................... 18HARVONI ...................................... 17heather .......................................... 30HEMANGEOL ............................... 19HUMALOG KWIKPEN .................. 25HUMALOG MIX 50/50

KWIKPEN .................................. 25HUMALOG MIX 50/50 VIAL .......... 25

HUMALOG MIX 75/25 KWIKPEN .................................. 25

HUMALOG MIX 75/25 VIAL .......... 25HUMALOG U-100 JUNIOR

KWIKPEN .................................. 25HUMALOG U-100 VIAL AND

CARTRIDGE SUBCUTANEOUS SOLUTION 100 UNIT/ML .......... 25

HUMALOG U-100 VIAL AND CARTRIDGE SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML .............................. 25

HUMATROPE ................................ 33HUMIRA ........................................ 34HUMIRA PEDIATRIC CROHNS

START ........................................ 34HUMIRA PEN ................................ 34HUMIRA PEN-CD/UC/HS

STARTER ................................... 34HUMIRA PEN-PS/UV/ADOL HS

START ........................................ 34HUMULIN 70/30 KWIKPEN .......... 25HUMULIN 70/30 VIAL ................... 25HUMULIN N KWIKPEN ................. 25HUMULIN N VIAL ......................... 25HUMULIN R U-500 KWIKPEN ..... 25HUMULIN R U-500 VIAL

(CONCENTRATED) ................... 25HUMULIN R VIAL ......................... 25hydralazine hcl oral ....................... 19hydrochlorothiazide oral ................ 19hydrocodone polst-cpm polst er .... 37hydrocodone-acetaminophen oral

solution 10-325 mg/15ml, 7.5-325 mg/15ml......................... 10

hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg ................................. 10

hydrocortisone ace-pramoxine rectal .......................................... 35

hydrocortisone external cream 1 % ............................................. 23

hydrocortisone external cream 2.5 % .......................................... 23

hydrocortisone external lotion 2.5 % .......................................... 23

hydrocortisone external ointment 1 %, 2.5 % .................................. 23

hydrocortisone in absorbase ......... 23hydrocortisone oral ........................ 33hydromorphone hcl er ................... 10hydromorphone hcl oral................. 10hydromorphone hcl rectal ...............11hydroxychloroquine sulfate oral ..... 16hydroxyzine hcl oral ....................... 18hydroxyzine pamoate oral ............. 18hyoscyamine sulfate er .................. 28hyoscyamine sulfate oral ............... 28hyoscyamine sulfate sl .................. 28hyoscyamine sulfate sublingual ..... 28hyosyne ......................................... 28HYSINGLA ER .............................. 10HYZAAR ....................................... 19

I

ibandronate sodium oral ................ 35IBRANCE ...................................... 16ibuprofen oral tablet 400 mg,

600 mg, 800 mg ..........................11IDHIFA ........................................... 16imatinib mesylate ........................... 16imiquimod external ........................ 23IMIQUIMOD PUMP ....................... 23IMITREX ORAL ............................. 15IMITREX STATDOSE REFILL ....... 15IMITREX STATDOSE SYSTEM .... 15IMITREX SUBCUTANEOUS ......... 15IMPOYZ ......................................... 23IMURAN ........................................ 34IMVEXXY VAGINAL INSERT

10 MCG, 4 MCG ........................ 27incassia ......................................... 30INCRUSE ELLIPTA ....................... 38INDERAL LA ................................. 19INDOCIN ........................................11indomethacin er ..............................11indomethacin oral ...........................11INTERMEZZO ............................... 39INTRAROSA ................................. 27introvale ......................................... 30INTUNIV ........................................ 21INVELTYS ..................................... 36INVOKAMET ................................. 26INVOKAMET XR ........................... 26

46

INVOKANA .................................... 26ipratropium bromide nasal ............. 37ipratropium-albuterol ..................... 38irbesartan ...................................... 19irbesartan-hydrochlorothiazide...... 19ISENTRESS .................................. 17ISENTRESS HD ............................ 17isibloom ......................................... 31isosorbide mononitrate .................. 19isosorbide mononitrate er .............. 19isotretinoin oral .............................. 23ISTALOL ........................................ 36

J

jantoven ......................................... 13JANUVIA ....................................... 26JARDIANCE .................................. 26jencycla ......................................... 31JENTADUETO ............................... 26JENTADUETO XR ......................... 26JIVI ................................................ 27jolessa ........................................... 31jolivette .......................................... 31juleber ............................................ 31JULUCA......................................... 17junel 1/20 ....................................... 31junel 1.5/30 .................................... 31junel fe 1/20 ................................... 31junel fe 1.5/30 ................................ 31junel fe 24 ...................................... 31

K

K-TAB ............................................ 27KADIAN ......................................... 10KAPSPARGO SPRINKLE ............. 19kariva ............................................. 31KAZANO ....................................... 26KEFLEX ......................................... 12KENALOG EXTERNAL ................. 23KEPPRA ORAL ............................. 13KEPPRA XR .................................. 13ketoconazole external ................... 15ketorolac tromethamine

ophthalmic .................................. 36ketorolac tromethamine oral ...........11KITABIS PAK ................................. 38klofensaid ii .....................................11

KLONOPIN .................................... 18klor-con .......................................... 27klor-con 10 ..................................... 27klor-con m10 .................................. 27KLOR-CON M15 ............................ 27klor-con m20 .................................. 27klor-con sprinkle ............................ 27KOGENATE FS ............................. 27KOMBIGLYZE XR ......................... 26KOVALTRY .................................... 27kurvelo ........................................... 31

L

labetalol hcl oral ............................ 19LAMICTAL ..................................... 13LAMICTAL ODT ............................ 13LAMICTAL STARTER ................... 13LAMICTAL XR ............................... 13lamotrigine er ................................. 13lamotrigine oral .............................. 13lamotrigine starter kit-blue ............. 13lamotrigine starter kit-green .......... 13lamotrigine starter kit-orange ........ 13lanthanum carbonate ..................... 29LANTUS SOLOSTAR .................... 25LANTUS U-100 VIAL .................... 25larin 1/20 ........................................ 31larin 1.5/30 ..................................... 31larin 24 fe ....................................... 31larin fe 1/20 .................................... 31larin fe 1.5/30 ................................. 31larissia ........................................... 31LASIX ............................................ 19LASTACAFT .................................. 36latanoprost ophthalmic .................. 36LATUDA ........................................ 17LEDIPASVIR-SOFOSBUVIR ........ 17lessina ........................................... 31LETAIRIS ....................................... 38letrozole oral .................................. 16LEVALBUTEROL HFA INHALATION

AEROSOL 45 MCG/ACT ........... 38LEVAQUIN ORAL TABLET

500 MG, 750 MG ....................... 12LEVBID .......................................... 28LEVEMIR U-100 FLEXTOUCH ..... 25LEVEMIR U-100 VIAL ................... 25levetiracetam er ............................. 14

levetiracetam oral .......................... 14LEVITRA ....................................... 27levo-t .............................................. 34levocetirizine dihydrochloride

oral ............................................. 37levofloxacin oral ............................. 12levonorgest-eth est & eth est ......... 31levonorgest-eth estrad 91-day ....... 31levonorgestrel-ethinyl estrad oral

tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg ......................... 31

levora 0.15/30 (28) ......................... 31levothyroxine sodium oral .............. 34levothyroxine-liothyronine .............. 34levoxyl ............................................ 34LEVSIN ORAL ............................... 28LEVSIN/SL .................................... 28LEXAPRO ..................................... 14LIALDA .......................................... 35lidocaine external ointment ........... 10lidocaine external patch ................ 10lidocaine hcl mouth/throat ............. 22lidocaine pak ................................. 10lidocaine viscous ........................... 22lidocaine-prilocaine cream

2.5-2.5 % external ...................... 10LIDODERM ................................... 10LIDOTREX .................................... 23lillow ............................................... 31LINZESS........................................ 28liothyronine sodium oral ................ 34LIPITOR ......................................... 19LIPOFEN ....................................... 19lisinopril oral .................................. 19lisinopril-hydrochlorothiazide ......... 19lithium carbonate er ....................... 18lithium carbonate oral .................... 18LITHOBID ...................................... 18LO LOESTRIN FE ......................... 31LODINE ..........................................11LOESTRIN 1/20 (21) ...................... 31LOESTRIN 1.5/30 (21) ................... 31LOESTRIN FE 1/20 ....................... 31LOESTRIN FE 1.5/30 .................... 31LOKELMA ..................................... 27LOMOTIL ....................................... 28LOPID ............................................ 19LOPRESSOR ................................ 19

47

LOPROX EXTERNAL SHAMPOO ................................. 15

lorazepam intensol ........................ 18lorazepam oral ............................... 18lorcet .............................................. 10lorcet hd ......................................... 10lorcet plus ...................................... 10LORTAB ........................................ 10loryna............................................. 31losartan potassium ........................ 19losartan potassium-hctz ................ 19LOSEASONIQUE .......................... 31LOTEMAX ..................................... 36LOTENSIN ..................................... 19LOTENSIN HCT ............................ 19LOTREL ......................................... 19LOTRISONE .................................. 23lovastatin ....................................... 19LOVAZA ........................................ 19LOVENOX ..................................... 13low-ogestrel ................................... 31LUMIGAN ...................................... 36LUNESTA ...................................... 39lutera.............................................. 31LYRICA .......................................... 22lyza ................................................ 31

M

MACROBID ................................... 12MACRODANTIN ............................ 12MALARONE .................................. 16marlissa ......................................... 31matzim la ....................................... 19MAVYRET ..................................... 17MAXALT ........................................ 15MAXALT-MLT ................................ 15MAXITROL .................................... 36MAXZIDE ...................................... 19MAXZIDE-25 ................................. 19MEDROL ORAL TABLET 16 MG,

32 MG, 4 MG, 8 MG ................... 33MEDROL ORAL TABLET 2 MG .... 33MEDROL ORAL TABLET

THERAPY PACK ....................... 33medroxyprogesterone acetate

intramuscular .............................. 31medroxyprogesterone acetate

oral ............................................. 31melodetta 24 fe .............................. 31

meloxicam oral ...............................11MENOSTAR .................................. 31mercaptopurine oral ...................... 16mesalamine oral ............................ 35mesalamine rectal enema ............. 35mesalamine rectal suppository...... 35metadate er ................................... 21metaxall ......................................... 38metaxalone .................................... 38metformin hcl er ............................ 26metformin hcl er (mod) .................. 26metformin hcl er (osm) ................... 26METFORMIN HCL ORAL

SOLUTION ................................. 26metformin hcl oral tablet ................ 26methimazole oral ........................... 34METHITEST .................................. 33methocarbamol oral ...................... 38methotrexate oral ........................... 34methotrexate sodium oral .............. 34methoxsalen oral ........................... 23methoxsalen rapid ......................... 23METHYLIN .................................... 21methylphenidate hcl er (cd) ........... 21methylphenidate hcl er (la) ............ 21methylphenidate hcl er oral tablet

extended release 10 mg, 20 mg ......................................... 21

methylphenidate hcl er oral tablet extended release 18 mg, 27 mg, 36 mg, 54 mg, 72 mg ..... 21

methylphenidate hcl er oral tablet extended release 24 hour .......... 21

methylphenidate hcl oral ............... 21methylprednisolone oral ................ 33methyltestosterone oral ................. 33metoclopramide hcl oral solution

5 mg/5ml .................................... 15metoclopramide hcl oral tablet ...... 15metoclopramide hcl oral tablet

dispersible .................................. 15metoprolol succinate er ................. 20metoprolol tartrate oral .................. 20METROCREAM ............................ 23METROGEL .................................. 23METROGEL-VAGINAL .................. 12METROLOTION ............................ 23metronidazole external .................. 23metronidazole oral ......................... 12

metronidazole vaginal ................... 12mibelas 24 fe ................................. 31MICARDIS ..................................... 20microgestin 1/20 ............................ 31microgestin 1.5/30 ......................... 31microgestin fe 1/20 ........................ 31microgestin fe 1.5/30 ..................... 31mili ................................................. 31MILLIPRED DP ............................. 33MILLIPRED DP 12-DAY ................ 33MILLIPRED ORAL SOLUTION ..... 33MILLIPRED ORAL TABLET .......... 33MINASTRIN 24 FE ........................ 31MINIPRESS ................................... 20minitran .......................................... 20Minivelle................................... 30, 31MINIVELLE PATCH TWICE

WEEKLY 0.025 MG/24HR TRANSDERMAL ........................ 31

MINIVELLE PATCH TWICE WEEKLY 0.0375 MG/24HR TRANSDERMAL ........................ 31




MINOCIN ORAL CAPSULE 50 MG ........................................ 12

minocycline hcl er oral tablet extended release 24 hour 115 mg, 135 mg, 45 mg, 65 mg, 90 mg ... 12

MINOCYCLINE HCL ER ORAL TABLET EXTENDED RELEASE 24 HOUR 55 MG ........................ 12

minocycline hcl oral ....................... 12MINOLIRA ..................................... 13MIRAPEX ...................................... 16MIRAPEX ER ................................ 16MIRCETTE .................................... 31mirtazapine oral ............................. 14MIRVASO ...................................... 23misoprostol oral ............................. 28MITIGARE ..................................... 15MOBIC ............................................11

48

modafinil ........................................ 39mometasone furoate external ....... 23mondoxyne nl ................................ 13mono-linyah ................................... 31mononessa .................................... 31montelukast sodium oral ............... 38morgidox oral ................................. 13MORPHABOND ER ...................... 10morphine sulfate (concentrate) oral

solution 100 mg/5ml, 20 mg/ml .. 10morphine sulfate er oral capsule

extended release 24 hour .......... 10morphine sulfate er oral tablet

extended release ........................ 10morphine sulfate oral ..................... 10MORPHINE SULFATE RECTAL

SUPPOSITORY 10 MG ...............11morphine sulfate rectal

suppository 20 mg, 30 mg, 5 mg ............................................11

MOVANTIK .................................... 28MOVIPREP.................................... 28MOXEZA ....................................... 36moxifloxacin hcl ophthalmic ........... 36MS CONTIN .................................. 10MULPLETA .................................... 27MULTAQ ........................................ 20multi-vitamin/fluoride ..................... 27multivitamin/fluoride oral solution .. 27multivitamin/fluoride oral tablet

chewable 0.5 mg, 1 mg .............. 27MULTIVITAMIN/FLUORIDE TABLET

CHEWABLE 0.25 MG ORAL ..... 27multivitamins/fluoride ..................... 27mupirocin calcium.......................... 13mupirocin external ......................... 13mvc-fluoride ................................... 27mycophenolate mofetil .................. 34mycophenolate sodium ................. 34MYDAYIS....................................... 21MYFORTIC .................................... 34myorisan ........................................ 23

N

nabumetone oral ............................11nadolol oral .................................... 20NAFRINSE DAILY/NEUTRAL ....... 22NAFRINSE WEEKLY .................... 22NALOCET ..................................... 10

naloxone hcl injection .................... 12naltrexone hcl oral ......................... 12NAPRELAN ....................................11NAPROSYN ORAL

SUSPENSION .............................11naproxen dr ....................................11naproxen oral ..................................11naproxen sodium er ........................11naproxen sodium oral tablet

275 mg, 550 mg ..........................11naratriptan hcl ................................ 15NARCAN ....................................... 12NATAZIA ........................................ 31NATESTO ...................................... 33NATURE-THROID ......................... 34necon 0.5/35 (28) .......................... 31neomycin-polymyxin-dexameth

ophthalmic ointment ................... 36neomycin-polymyxin-dexameth

ophthalmic suspension 3.5-10000-0.1 ............................. 36

neomycin-polymyxin-hc otic .......... 37NEORAL ....................................... 34NESINA ......................................... 26neuac external gel ......................... 24NEULASTA .................................... 27NEURONTIN ................................. 14neutral sodium fluoride .................. 22niacin er (antihyperlipidemic) ......... 20niacor ............................................. 20NIASPAN ....................................... 20nifedipine er ................................... 20nifedipine er osmotic release ......... 20nifedipine oral ................................ 20nikki ............................................... 31NITRO-BID .................................... 20NITRO-DUR .................................. 20nitro-time ....................................... 20nitrofurantoin macrocrystal oral ..... 13nitrofurantoin monohydrate

macrocrystals ............................. 13nitroglycerin er ............................... 20nitroglycerin sublingual .................. 20nitroglycerin transdermal ............... 20nitroglycerin translingual ............... 20NITROLINGUAL ............................ 20NITROMIST ................................... 20NITROSTAT ................................... 20NITYR............................................ 29

NIZORAL ....................................... 15NOCDURNA ................................. 33NOCTIVA ....................................... 33nora-be .......................................... 32NORCO ......................................... 10NORDITROPIN FLEXPRO ........... 33norethin ace-eth estrad-fe oral

tablet .......................................... 32norethin ace-eth estrad-fe oral

tablet chewable .......................... 32norethindrone acet-ethinyl est oral

tablet .......................................... 32norethindrone acet-ethinyl est oral

tablet chewable .......................... 32norethindrone acetate oral ............ 32norethindrone oral ......................... 32norgestimate-eth estradiol............. 32norgestimate-ethinyl estradiol

triphasic ...................................... 32NORITATE ..................................... 24norlyda ........................................... 32norlyroc .......................................... 32nortrel 0.5/35 (28) .......................... 32nortrel 1/35 (21) ............................. 32nortrel 1/35 (28) ............................. 32nortriptyline hcl oral ....................... 14NORVASC ..................................... 20NORVIR ORAL PACKET .............. 17NORVIR ORAL SOLUTION .......... 17NORVIR ORAL TABLET ............... 17NOVOEIGHT ................................. 27NOVOLIN 70/30 RELION .............. 25NOVOLIN 70/30 VIAL ................... 25NOVOLIN N RELION .................... 25NOVOLIN N VIAL .......................... 26NOVOLIN R RELION .................... 26NOVOLIN R VIAL .......................... 26NOVOLOG FLEXPEN ................... 26NOVOLOG PENFILL ..................... 26NOVOLOG U-100 VIAL ................. 26np thyroid ....................................... 34NUCYNTA ..................................... 10NUCYNTA ER ............................... 10NUEDEXTA ................................... 22NULEV .......................................... 28NUTROPIN AQ NUSPIN 10 .......... 33NUTROPIN AQ NUSPIN 20 .......... 33NUTROPIN AQ NUSPIN 5 ............ 33NUVARING ................................... 32

49

NUVESSA ..................................... 13NUWIQ .......................................... 27nyamyc .......................................... 15nystatin external ............................ 15nystatin mouth/throat ..................... 15nystop ............................................ 15

O

ocella ............................................. 32OCUFLOX ..................................... 36ODEFSEY ..................................... 17ofloxacin ophthalmic ...................... 36ofloxacin otic .................................. 37ogestrel .......................................... 32okebo ............................................. 13olanzapine oral .............................. 17olmesartan medoxomil oral ........... 20olmesartan medoxomil-hctz .......... 20olopatadine hcl ophthalmic ............ 36OLUX ............................................. 24OMECLAMOX-PAK ....................... 28omega-3-acid ethyl esters ............. 20omeprazole oral capsule delayed

release ....................................... 28OMNARIS ..................................... 37OMNIPRED ................................... 36OMNITROPE ................................. 33ondansetron hcl oral ...................... 15ondansetron odt ............................ 15ONETOUCH ULTRA 2 .................. 25ONETOUCH ULTRA BLUE TEST

STRIPS ...................................... 25ONETOUCH ULTRA MINI ............ 25ONETOUCH VERIO ...................... 25ONETOUCH VERIO FLEX

SYSTEM KIT W/DEVICE ........... 25ONETOUCH VERIO IQ

SYSTEM ..................................... 25ONETOUCH VERIO TEST

STRIPS ...................................... 25ONGLYZA ..................................... 26ONZETRA XSAIL .......................... 15OPSUMIT ...................................... 38ORACEA ....................................... 24ORAPRED ODT ............................ 33ORENITRAM ................................. 38ORFADIN ...................................... 29ORILISSA ...................................... 33orsythia .......................................... 32

ORTHO MICRONOR .................... 32ORTHO TRI-CYCLEN (28) ............ 32ORTHO TRI-CYCLEN LO ............. 32ORTHO-CYCLEN (28) .................. 32ORTHO-NOVUM 1/35 (28) ........... 32oscimin .......................................... 28oscimin sr ...................................... 28oseltamivir phosphate oral ............ 17OSENI ........................................... 26OSPHENA ..................................... 27OTEZLA ........................................ 34OTREXUP SUBCUTANEOUS

SOLUTION AUTO-INJECTOR 10 MG/0.4ML, 12.5 MG/0.4ML, 15 MG/0.4ML, 17.5 MG/0.4ML, 22.5 MG/0.4ML, 25 MG/0.4ML .. 35

OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR 20 MG/0.4ML ............................. 35

OVIDREL ....................................... 35OXAYDO ....................................... 10oxcarbazepine ............................... 14OXSORALEN ULTRA ................... 24OXTELLAR XR ............................. 14oxybutynin chloride er ................... 29oxybutynin chloride oral ................ 29OXYCODONE HCL ER ................. 10oxycodone hcl oral capsule ........... 10oxycodone hcl oral concentrate 100

mg/5ml ....................................... 10oxycodone hcl oral solution ........... 10oxycodone hcl oral tablet .............. 10oxycodone-acetaminophen ........... 10OXYCONTIN ................................. 10OZEMPIC ...................................... 26

P

PACERONE ORAL TABLET 100 MG, 400 MG ...................................... 20

pacerone oral tablet 200 mg ......... 20PAMELOR ..................................... 14PANCREAZE ................................ 29pantoprazole sodium oral .............. 28paroex ............................................ 22paroxetine hcl ................................ 14paroxetine hcl er ............................ 14PATADAY ....................................... 36PATANOL ...................................... 36PAXIL ............................................ 14

PAXIL CR ...................................... 14PAZEO .......................................... 36peg 3350/electrolytes .................... 28penicillin v potassium .................... 13PENLAC ........................................ 15PENNSAID .....................................11PENTASA ...................................... 35PERCOCET .................................. 10PERFOROMIST ............................ 38PERIDEX ....................................... 22permethrin external ....................... 16PERTZYE ...................................... 29phenadoz ....................................... 37phenazo oral tablet 200 mg ........... 29phenazopyridine hcl oral tablet

100 mg, 200 mg ......................... 29philith ............................................. 32phrenilin forte ................................. 10PICATO ......................................... 24pimecrolimus ................................. 24pimtrea .......................................... 32pioglitazone hcl.............................. 26pirmella 1/35 .................................. 32PLAQUENIL .................................. 16PLAVIX .......................................... 16PLEGRIDY .............................. 21, 22PLEGRIDY STARTER PACK ........ 22PLENVU ........................................ 28PLEXION ....................................... 24PLEXION CLEANSER .................. 24PLEXION CLEANSING CLOTH .... 24POLY-VI-FLOR .............................. 27polymyxin b-trimethoprim .............. 36POLYTRIM .................................... 36portia-28 ........................................ 32potassium chloride crys er ............ 27potassium chloride er .................... 27potassium chloride oral ................. 27potassium citrate er ....................... 27PRADAXA ..................................... 13PRALUENT ................................... 20pramcort ........................................ 35pramipexole dihydrochloride ......... 16pramipexole dihydrochloride er ..... 16PRAVACHOL ................................ 20pravastatin sodium ........................ 20prazosin hcl oral ............................ 20PRECISION LINK .......................... 25PRECISION PCX PLUS TEST ...... 25

50

PRECISION QID MONITOR ......... 25PRECISION QID TEST ................. 25PRECISION SOF-TACT

MONITOR .................................. 25PRECISION SOF-TACT TEST ...... 25PRECISION XTRA BLOOD

GLUCOSE .................................. 25PRECISION XTRA DEVICE ......... 25PRECISION XTRA KIT ................. 25PRECISION XTRA MONITOR ...... 25PRED FORTE ............................... 36PRED MILD ................................... 36prednisolone acetate ophthalmic .. 36prednisolone acetate p-f ................ 36prednisolone oral solution ............. 33prednisolone sodium phosphate

oral ............................................. 33prednisone intensol ....................... 33prednisone oral .............................. 33PREMARIN ORAL ........................ 32PREMARIN VAGINAL ................... 32premium lidocaine ......................... 10PREMPHASE ................................ 32PREMPRO .................................... 32PREPOPIK .................................... 28PREVIDENT .................................. 22PREVIDENT 5000 BOOSTER

PLUS .......................................... 22PREVIDENT 5000 DRY MOUTH .. 22PREVIDENT 5000 PLUS .............. 22previfem ......................................... 32PREZCOBIX .................................. 17PREZISTA ..................................... 17PRIMLEV ....................................... 10PRINIVIL ....................................... 20PRISTIQ ........................................ 14PROAIR HFA ............................37, 38PROAIR RESPICLICK .................. 38PROCARDIA ................................. 20PROCARDIA XL............................ 20PROCENTRA ................................ 21prochlorperazine maleate oral ....... 15PROCORT .................................... 35PROCRIT ...................................... 27PROCTOFOAM HC ....................... 35progesterone micronized oral ........ 32PROGRAF ORAL ......................... 35promethazine-codeine oral syrup .. 37promethazine-dm .......................... 37

PROMETRIUM .............................. 32propranolol hcl er........................... 20propranolol hcl oral ........................ 20PROSCAR ..................................... 29PROTONIX ORAL PACKET ......... 28PROTONIX ORAL TABLET

DELAYED RELEASE ................. 28PROVENTIL HFA .......................... 38PROVERA ............................... 30, 32PROVIGIL ...................................... 39PROZAC ........................................ 14pseudoephedrine-bromphen-dm .. 37PULMICORT FLEXHALER ........... 38PULMICORT SUSPENSION ........ 38PULMOZYME ............................... 38PURIXAN ...................................... 16PYLERA ........................................ 28PYRIDIUM ..................................... 29

Q

QBRELIS ....................................... 20QUARTETTE................................. 32QUDEXY XR ................................. 14quetiapine fumarate ....................... 17quetiapine fumarate er .................. 17QUFLORA PEDIATRIC ................. 27QUILLICHEW ER .......................... 21QUILLIVANT XR ........................... 21quinapril hcl ................................... 20QVAR REDIHALER ....................... 38

R

rabeprazole sodium ....................... 28raloxifene ....................................... 16ramipril ........................................... 20RANEXA ....................................... 20ranitidine hcl oral capsule .............. 28ranitidine hcl oral syrup ................. 28ranitidine hcl oral tablet 150 mg,

300 mg ....................................... 28RAPAFLO ...................................... 29RAPAMUNE ORAL SOLUTION ... 35RAPAMUNE ORAL TABLET ........ 35RASUVO ....................................... 35RAYOS .......................................... 33REBIF ............................................ 22REBIF REBIDOSE ........................ 22

REBIF REBIDOSE TITRATION PACK .......................................... 22

REBIF TITRATION PACK ............. 22reclipsen ........................................ 32REGLAN........................................ 15relexxii ........................................... 21RELION BLOOD GLUCOSE TEST 25RELION ULTIMA TEST ................. 25RELPAX ........................................ 15REMERON .................................... 14REMERON SOLTAB ..................... 14REPATHA ...................................... 20REQUIP ORAL TABLET 0.25 MG, 1

MG, 4 MG, 5 MG ........................ 16REQUIP XL ................................... 16RESTASIS ..................................... 37RESTASIS MULTIDOSE ............... 37RESTORIL ..................................... 39RETIN-A ........................................ 24REVLIMID ..................................... 16RHOFADE ..................................... 24RIOMET ........................................ 26RISPERDAL .................................. 17risperidone..................................... 17risperidone m-tab .......................... 17RITALIN ......................................... 21RITALIN LA ................................... 21ritonavir .......................................... 17rivelsa ............................................ 32rizatriptan benzoate ....................... 15ROBAXIN ORAL ........................... 39ROBAXIN-750 ............................... 39ROCALTROL ................................. 36ropinirole hcl .................................. 16ropinirole hcl er .............................. 16rosadan external cream................. 24rosadan external gel ...................... 24rosanil cleanser ............................. 24rosuvastatin calcium ...................... 20roweepra ....................................... 14roweepra xr ................................... 14ROXICODONE .............................. 10ROXYBOND ...................................11RYTARY ........................................ 16

S

SAFYRAL ...................................... 32SAPHRIS ....................................... 17SAVAYSA ...................................... 13

51

SEASONIQUE .............................. 32selegiline hcl oral ........................... 16SERNIVO ...................................... 24SEROQUEL .................................. 17SEROQUEL XR ............................ 17sertraline hcl oral ........................... 14setlakin .......................................... 32sf ................................................... 22sf 5000 plus ................................... 22SFROWASA .................................. 35sharobel ......................................... 32sildenafil citrate oral tablet

100 mg, 25 mg, 50 mg ............... 27silodosin ........................................ 29SIMPONI ....................................... 35simvastatin oral tablet 10 mg,

20 mg, 40 mg, 5 mg ................... 20simvastatin oral tablet 80 mg ......... 20SINEMET ...................................... 16SINEMET CR ................................ 16SINGULAIR ORAL PACKET ........ 38SINGULAIR ORAL TABLET ......... 38SINGULAIR ORAL TABLET

CHEWABLE ............................... 38sirolimus oral tablet ....................... 35SITAVIG ......................................... 17SKELAXIN .................................... 39SOFOSBUVIR-VELPATASVIR ...... 17SOLIQUA....................................... 26SOLODYN ORAL TABLET

EXTENDED RELEASE 24 HOUR 105 MG, 80 MG .......................... 13

SOLODYN ORAL TABLET EXTENDED RELEASE 24 HOUR 115 MG, 55 MG, 65 MG ............. 13

soloxide ......................................... 13SOLTAMOX ................................... 16SOMA ORAL TABLET 250 MG .... 39SOMA ORAL TABLET 350 MG .... 39sotalol hcl oral ............................... 20SOTYLIZE ..................................... 20SPIRIVA HANDIHALER ................ 38SPIRIVA RESPIMAT ..................... 38spironolactone oral ........................ 20sprintec 28 ..................................... 32SPRITAM ....................................... 14SPRIX .............................................11sronyx ............................................ 32sss 10-5 ......................................... 24

STAXYN ........................................ 27STELARA SUBCUTANEOUS

SOLUTION ................................. 35STELARA SUBCUTANEOUS

SOLUTION PREFILLED SYRINGE ................................... 35

STENDRA ..................................... 27STIMATE ....................................... 33STRATTERA ................................. 21STRENSIQ .................................... 29STRIANT ....................................... 33STRIBILD ...................................... 17STRIVERDI RESPIMAT ................ 38SUBOXONE .................................. 12SUBSYS .........................................11subvenite ....................................... 14subvenite starter kit-blue ............... 14subvenite starter kit-green ............. 14subvenite starter kit-orange ........... 14sucralfate oral tablet ...................... 28sulfacetamide sodium-sulfur ......... 24sulfacleanse 8/4 ............................ 24sulfamethoxazole-trimethoprim

oral ............................................. 13sulfamez wash ............................... 24sulfasalazine oral ........................... 35sulfatrim pediatric .......................... 13SUMADAN WASH ......................... 24sumatriptan succinate oral ............ 16sumatriptan succinate refill ............ 16sumatriptan succinate

subcutaneous ............................. 16SUMAXIN ...................................... 24SUMAXIN WASH .......................... 24SUPREP BOWEL PREP KIT ........ 28syeda ............................................. 32SYMAX DUOTAB .......................... 28symax-sl ........................................ 28symax-sr ........................................ 28SYMBICORT ................................. 38SYMFI ............................................ 17SYMFI LO ...................................... 17SYMPROIC ................................... 28SYNALAR ..................................... 24SYNJARDY ................................... 26SYNJARDY XR ............................. 26SYNTHROID ................................. 34SYPRINE ....................................... 27

T

TACLONEX EXTERNAL OINTMENT ................................ 24

TACLONEX EXTERNAL SUSPENSION ............................ 24

tacrolimus oral ............................... 35tadalafil (pah) ................................. 38tadalafil oral ................................... 27TAKHZYRO ................................... 35TAMIFLU ....................................... 17tamoxifen citrate oral tablet

10 mg ......................................... 16tamoxifen citrate oral tablet

20 mg ......................................... 16tamsulosin hcl ................................ 29TAPAZOLE .................................... 34TARGADOX................................... 13TARGRETIN EXTERNAL ............. 16TARGRETIN ORAL ....................... 16tarina fe 1/20.................................. 32tarina fe 1/20 eq ............................ 32TASIGNA ....................................... 16TAYTULLA .................................... 32tazarotene external........................ 24TAZORAC EXTERNAL CREAM

0.05 % ........................................ 24TAZORAC EXTERNAL CREAM

0.1 % .......................................... 24TAZORAC EXTERNAL GEL ......... 24TECFIDERA .................................. 22TEGRETOL ................................... 14TEGRETOL-XR ............................. 14TEKTURNA ................................... 20TEKTURNA HCT .......................... 20telmisartan ..................................... 20temazepam .................................... 39TEMOVATE ................................... 24tenofovir disoproxil fumarate ......... 17TENORETIC 100 ........................... 20TENORETIC 50............................. 20TENORMIN ................................... 20terazosin hcl .................................. 29terbinafine hcl oral ......................... 15terconazole .................................... 15TESSALON PERLES .................... 37TESTIM ......................................... 33testosterone cypionate intramuscular

solution 100 mg/ml ..................... 33

52

TESTOSTERONE CYPIONATE SOLUTION 200 MG/ML INTRAMUSCULAR .................... 34

testosterone transdermal ............... 34TEXACORT ................................... 24timolol maleate ophthalmic ............ 36TIMOPTIC ..................................... 36TIMOPTIC OCUDOSE .................. 36TIMOPTIC-XE ............................... 36TIROSINT ...................................... 34TIVICAY ......................................... 17TIVORBEX .....................................11tizanidine hcl oral ........................... 39TOBI NEBULIZER ......................... 38TOBI PODHALER ......................... 38TOBRADEX .................................. 37TOBRADEX ST ............................. 37tobramycin nebulization solution 300

mg/5ml inhalation ....................... 38tobramycin ophthalmic .................. 36tobramycin-dexamethasone .......... 37TOBREX ........................................ 36TOLAK ........................................... 24TOPAMAX ..................................... 14TOPAMAX SPRINKLE .................. 14topiramate er ................................. 14topiramate oral .............................. 14TOPROL XL .................................. 20torsemide ....................................... 20TOUJEO MAX SOLOSTAR ........... 26TOUJEO SOLOSTAR .................... 26TOVIAZ ......................................... 29TRACLEER ................................... 38TRADJENTA ................................. 26tramadol hcl er (biphasic) ...............11TRAMADOL HCL ER ORAL

CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 300 MG .......................................11

tramadol hcl er oral capsule extended release 24 hour 150 mg ........................................11

tramadol hcl er oral tablet extended release 24 hour ...........................11

tramadol hcl ir .................................11TRANSDERM-SCOP (1.5 MG) ..... 15TRAVATAN Z ................................. 36trazodone hcl oral .......................... 14TRELEGY ELLIPTA ....................... 38

TREMFYA ..................................... 35TRESIBA ....................................... 26TRESIBA FLEXTOUCH ................ 26tretinoin external cream ................. 24tretinoin external gel 0.01 % .......... 24tretinoin external gel 0.025 % ........ 24tretinoin external gel 0.05 % .......... 24TREXALL ...................................... 35trezix ...............................................11tri femynor ..................................... 32tri-estarylla .................................... 32tri-linyah ......................................... 32tri-lo-estarylla ................................ 32tri-lo-marzia ................................... 32tri-lo-sprintec ................................. 32tri-mili ............................................. 32tri-previfem .................................... 32tri-sprintec ..................................... 32tri-vylibra ........................................ 32tri-vylibra lo .................................... 32triamcinolone acetonide external .. 24triamterene-hctz ............................ 20TRIANEX ....................................... 24triazolam ........................................ 18TRICOR ......................................... 20triderm ........................................... 24tridesilon ........................................ 24trientine hcl .................................... 27TRILEPTAL ................................... 14TRINTELLIX .................................. 14TRIUMEQ ...................................... 17TROKENDI XR .............................. 14TRUE METRIX BLOOD GLUCOSE

TEST .......................................... 25TRUEPLUS 5-BEVEL PEN

NEEDLES 29G X 12.7MM ......... 25TRUETRACK TEST ...................... 25TRULICITY .................................... 26TRUVADA ..................................... 17TUDORZA PRESSAIR ................. 38tulana ............................................. 32TUSSICAPS .................................. 37TUSSIONEX PENNKINETIC ER .. 37tydemy ........................................... 32TYLENOL WITH CODEINE #3 ......11TYLENOL WITH CODEINE #4 ......11TYMLOS ........................................ 36TYVASO ........................................ 38

U

UCERIS ORAL .............................. 35UCERIS RECTAL .......................... 35ULORIC ......................................... 15ULTRAM .........................................11unithroid ......................................... 34unithroid direct ............................... 34UROCIT-K 10 ................................ 27UROCIT-K 15 ................................ 28UROCIT-K 5 .................................. 28UROXATRAL ................................ 29URSO 250 ..................................... 28URSO FORTE ............................... 28ursodiol oral ................................... 28

V

VAGIFEM ....................................... 32valacyclovir hcl oral ....................... 17VALIUM ......................................... 18valsartan ........................................ 20valsartan-hydrochlorothiazide ....... 20VALTREX ...................................... 17VANATOL LQ .................................11VANATOL S ....................................11vandazole ...................................... 13VANOS .......................................... 24vardenafil hcl ................................. 27VARUBI ORAL .............................. 15VASCEPA ...................................... 20VASOTEC ...................................... 20VECTICAL ..................................... 24VELPHORO .................................. 29VELTASSA .................................... 28VEMLIDY ....................................... 17venlafaxine hcl ............................... 14venlafaxine hcl er oral capsule

extended release 24 hour .......... 14venlafaxine hcl er oral tablet

extended release 24 hour .......... 14VENTOLIN HFA ............................ 38verapamil hcl er ............................. 20verapamil hcl oral .......................... 21VERDESO ..................................... 24verdrocet ........................................11VERELAN ..................................... 21VERELAN PM ............................... 21VERIPRED 20 ............................... 33VERZENIO .................................... 16

53

VIAGRA ......................................... 27VIBERZI ........................................ 28VIBRAMYCIN ORAL CAPSULE ... 13VIBRAMYCIN ORAL SUSPENSION

RECONSTITUTED ..................... 13vicodin ............................................11vicodin es .......................................11vicodin hp .......................................11VICTOZA SOLUTION PEN-

INJECTOR 18 MG/3ML SUBCUTANEOUS 2-PACK........ 27

VICTOZA SOLUTION PEN-INJECTOR 18 MG/3ML SUBCUTANEOUS 3-PACK ....... 27

vienva ............................................ 32VIGAMOX ...................................... 36VIIBRYD ........................................ 15VIIBRYD STARTER PACK ............ 15VIMPAT ORAL .............................. 14VIOKACE ...................................... 29viorele ............................................ 33VIREAD ORAL POWDER ............. 17VIREAD ORAL TABLET 150 MG,

200 MG, 250 MG ....................... 17VIREAD ORAL TABLET

300 MG ...................................... 17VISTARIL ....................................... 18vitamin d (ergocalciferol) oral

capsule 50000 unit ..................... 28VIVELLE-DOT ............................... 33VIVLODEX .....................................11VOGELXO ..................................... 34VOGELXO PUMP ......................... 34VOLTAREN .....................................11VOSEVI ......................................... 17vyfemla .......................................... 33vylibra ............................................ 33VYTORIN ...................................... 21VYVANSE ..................................... 21

W

warfarin sodium oral ...................... 13WELCHOL ..................................... 21WELLBUTRIN SR ......................... 15WELLBUTRIN XL .......................... 15wera ............................................... 33WESTHROID ................................ 34WP THYROID ............................... 34

X

XALATAN ...................................... 36XANAX .......................................... 18XANAX XR .................................... 18XARELTO ...................................... 13XARELTO STARTER PACK .......... 13XELJANZ ....................................... 35XELJANZ XR................................. 35XELODA ........................................ 16XELPROS...................................... 36XHANCE ....................................... 37XIIDRA .......................................... 37XIMINO .......................................... 13XOLEGEL ...................................... 15XOPENEX HFA ............................. 38XTAMPZA ER ................................11xulane ............................................ 33

Y

YASMIN 28 .................................... 33YAZ ................................................ 33YONSA .......................................... 16yuvafem ......................................... 33

Z

ZANAFLEX.................................... 39zarah ............................................. 33ZARXIO ......................................... 27zebutal ............................................11ZELAPAR ...................................... 16ZEMBRACE SYMTOUCH ............. 16zenatane ........................................ 24ZENPEP ........................................ 29ZENZEDI ....................................... 21ZEPATIER ..................................... 17ZESTORETIC ................................ 21ZESTRIL ........................................ 21ZETIA ............................................ 21ZETONNA ..................................... 37ZIAC .............................................. 21ziprasidone hcl .............................. 17ZIPSOR ..........................................11ZITHROMAX ORAL ...................... 13ZITHROMAX TRI-PAK .................. 13ZITHROMAX Z-PAK ...................... 13ZOCOR.......................................... 21ZOFRAN ........................................ 15ZOHYDRO ER ...............................11

ZOLOFT ........................................ 15zolpidem tartrate ........................... 39zolpidem tartrate er ....................... 39ZOLPIMIST .................................... 39ZOMACTON .................................. 33ZONEGRAN .................................. 14zonisamide oral ............................. 14ZONTIVITY .................................... 16ZOVIRAX ORAL ........................... 17ZTLIDO ...........................................11ZUBSOLV ...................................... 12ZUPLENZ ...................................... 15ZURAMPIC ................................... 15ZYCLARA ...................................... 24ZYCLARA PUMP .......................... 24ZYLOPRIM .................................... 15ZYPREXA ..................................... 17ZYPREXA ZYDIS ......................... 17ZYTIGA ORAL TABLET 250 MG .. 16ZYTIGA ORAL TABLET 500 MG .. 16

54

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.

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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 and Oxford New York and New Jersey plans.Insurance coverage provided by or through UnitedHealthcare Insurance Company, UnitedHealthcare Insurance Company of New York, or Oxford Health Insurance, Inc. Oxford HMO products are underwritten by Oxford Health Plans (NJ), Inc. Administrative services provided by United HealthCare Services, Inc., UnitedHealthcare Service LLC, Oxford Health Plans LLC, or their affiliates.UnitedHealthcare® is a registered trademark owned by UnitedHealth Group Incorporated. All other trademarks are the property of their respective owners.

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