Your 2019 Prescription Drug List - Student Resources Traditional Three-Tier - Advantage Four-Tier
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Your 2019 Prescription Drug List
Student Resources Traditional Three-Tier
Effective
Effective Jan. 1,1,
January 2019
2019
This Prescription Drug List (PDL) is accurate as of Jan.1, 2019 and is subject to change after
this date. The next anticipated update will be July 1, 2019. This PDL applies to members of our
Student Resources medical plans with a pharmacy benefit subject to the Traditional Three-Tier
PDL. Your estimated coverage and copayment/coinsurance may vary based on the benefit plan
you choose and the effective date of the plan.Table of Contents
Understanding your Prescription Gastrointestinal
Drug List. . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Acid Suppression. . . . . . . . . . . . . . . . . . . . . 16
Nausea/Vomiting. . . . . . . . . . . . . . . . . . . . . 16
Medication tips . . . . . . . . . . . . . . . . . . . . . . 5
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Reading your PDL. . . . . . . . . . . . . . . . . . . . 6
Gout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Hepatitis C. . . . . . . . . . . . . . . . . . . . . . . . . 17
Drugs by category . . . . . . . . . . . . . . . . . . . 9
HIV/AIDS. . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Anti-Infectives Infertility. . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Antifungals. . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Inflammatory Conditions: Rheumatoid
Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Arthritis, Crohn’s Disease, Psoriasis,
Ulcerative Colitis. . . . . . . . . . . . . . . . . . . . 18
Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Men’s Health
Cardiovascular/Heart Disease Prostate. . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Coagulation Therapy. . . . . . . . . . . . . . . . . . 10 Testosterone Therapy. . . . . . . . . . . . . . . . . 19
High Blood Pressure. . . . . . . . . . . . . . . . . . 10
Miscellaneous. . . . . . . . . . . . . . . . . . . . . . 19
High Cholesterol . . . . . . . . . . . . . . . . . . . . . 11
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Musculoskeletal
Muscle Spasms. . . . . . . . . . . . . . . . . . . . . . 19
Central Nervous System
Osteoporosis. . . . . . . . . . . . . . . . . . . . . . . . 19
Attention Deficit Disorder. . . . . . . . . . . . . . . 11
Pain Relief. . . . . . . . . . . . . . . . . . . . . . . . . . 20
Depression . . . . . . . . . . . . . . . . . . . . . . . . . 12
Migraine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Overactive Bladder. . . . . . . . . . . . . . . . . . 20
Multiple Sclerosis. . . . . . . . . . . . . . . . . . . . . 12
Respiratory
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Allergies. . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Sedatives/Hypnotics . . . . . . . . . . . . . . . . . . 13
Asthma/COPD. . . . . . . . . . . . . . . . . . . . . . . 20
Seizure Disorders . . . . . . . . . . . . . . . . . . . . 13
Pulmonary Arterial Hypertension. . . . . . . . 21
Dermatology . . . . . . . . . . . . . . . . . . . . . . . 13
Smoking Cessation. . . . . . . . . . . . . . . . . . 21
Diabetes
Transplant . . . . . . . . . . . . . . . . . . . . . . . . . 21
Blood Glucose Monitoring. . . . . . . . . . . . . . 14
Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Vitamins/Electrolytes. . . . . . . . . . . . . . . . 21
Non-Insulin . . . . . . . . . . . . . . . . . . . . . . . . . 15 Women’s Health
Endocrine Contraceptives. . . . . . . . . . . . . . . . . . . . . . . 22
Growth Hormone. . . . . . . . . . . . . . . . . . . . . 15 Hormone Replacement. . . . . . . . . . . . . . . . 24
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Miscellaneous. . . . . . . . . . . . . . . . . . . . . . . 24
Thyroid Hormone Replacement. . . . . . . . . . 16 Prenatal Vitamins . . . . . . . . . . . . . . . . . . . . 24
Eye Conditions Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Allergies. . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Dry Eye Disease. . . . . . . . . . . . . . . . . . . . . 16
Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . 16
2Understanding your Prescription Drug List (PDL)
What is a PDL?
This document is a list of the most commonly About this PDL
prescribed medications. It includes both brand-name Where differences exist between
and generic prescription medications approved by the this PDL and your benefit plan
Food and Drug Administration (FDA). Medications are documents, the benefit plan
listed by common categories or classes and placed documents rule. This PDL is not
in tiers that represent the cost you pay out-of-pocket. a complete list of medications,
They are then listed in alphabetical order. and not all medications listed
may be covered by your plan.
How do I use my PDL? Please look at the benefit plan
You and your doctor can consult the PDL to help you documents provided by your
select the most cost-effective prescription medications. employer or health plan to see
This guide tells you if a medication is generic or a which medications are covered
brand-name, and if there are coverage requirements or under your plan.
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 health plan ID card at any time to check your
medication coverage and lower-cost options.
3Understanding 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
if similar alternatives are available at a lower cost. Examples include medications that work the
same way, but one is much more expensive than the other, or options that are available without
a prescription (also referred to as over-the-counter medications). There are also some instances
where the same product can be made by two or more manufacturers, but greatly vary in cost. In
these instances, only the lower-cost product may be covered.
You should review your benefit plan documents to confirm if any medications are excluded from
your plan. You can log in to the member website listed on your health plan ID card at any time to
check your medication coverage. Talk to your doctor to see if there are lower-cost options or over-
the-counter medications available.
Who decides which medications are covered?
Thousands of medications are already available and more come to the market regularly.
Often, several medications are available to treat the same condition. The UnitedHealthcare®
Pharmacy and Therapeutics Committee, which includes both internal and external physicians and
pharmacists, meets regularly to provide clinical reviews of all medications. Using this information,
the 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.
4Medication tips
What is the difference between brand-name and
generic medications? Over-the-counter
Generic medications contain the same active (OTC) medications
ingredients (what makes the medication work) as An OTC medication may be
brand-name medications, but they often cost less. the right treatment option for
Once the patent for a brand-name medication ends, some conditions. Talk to your
the FDA can approve a generic version with the same doctor about available OTC
active ingredients. These types of medications are options. Even though these
known as generic medications. Sometimes, the same medications may not be
company that makes a brand-name medication also covered by your pharmacy
makes the generic version. benefit, they may cost less
than a prescription medication.
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.
What if I am taking a specialty medication?
Specialty medications are high-cost and are used to treat rare or complex conditions that require
additional care and support. For most plans, these medications are managed through the specialty
pharmacy program. Take advantage of personalized support designed to help you get the most out
of your treatment plan. Visit the member website listed on your health plan ID card or call the toll-free
phone number on your ID card to learn more.
Please note, not all specialty medications are listed here. If you’re taking a specialty medication that
is on a higher tier, call the toll-free phone number on your ID card to talk with a pharmacist about
finding lower-cost options or a financial assistance program.
5Reading 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 bold type and generic medications in plain type.
Tier information.
Using lower-tier medications can help you pay your lowest out-of-pocket cost. Your plan may have
multiple or no tiers. Please note: If you have a high deductible plan, the tier cost levels may apply
once you hit your deductible.
Drug Tier Includes Helpful Tips
Tier 1 $
Lower-cost Use Tier 1 drugs for the
Medications that provide the highest lowest out-of-pocket costs.
overall value. Mostly generic drugs. Some
brand-name drugs may also be included.
Tier 2 $$
Mid-range cost Use Tier 2 drugs, instead of
Medications that provide good overall value. Tier 3, to help reduce your
Mainly preferred brand-name drugs. out-of-pocket costs.
Tier 3 $$$ Highest-cost Ask your doctor if a Tier 1 or Tier 2
Medications that provide the lowest option could work for you.
overall value.
6Reading 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 ay be excluded from coverage or subject to prior authorization and/or trial/
M
failure of another medication(s). (Referred to as First Start in New Jersey)
Lower-cost options are available and covered.
H ealth Care Reform Preventive
H
This medication is part of a health care reform preventive benefit and may be
available at no additional cost to you.
H-PA ealth Care Reform Preventive with Prior Authorization
H
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
Requires your doctor to provide information about why you are taking
a medication to determine how it may be covered by your plan.
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.
SL Supply Limits
Specifies the largest quantity of medication covered per copayment
or in a defined period of time.
7Questions
For the most current list of covered medications or if you have questions:
all the toll-free member phone number
C
on your health plan ID card.
isit your plan’s member website listed
V And, if home delivery services
on your health plan ID card to: are included in your pharmacy
benefit, you can also:
• View your pharmacy benefit and coverage
information, including prescription history • Refill prescriptions
• View medication interactions and side effects • Check the status of your order
• Locate a participating retail pharmacy • Set up reminders for refills
by ZIP code
• Manage your account
• Look up possible lower-cost medication
alternatives
• Compare medication pricing and options
8Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Anti-Infectives: Antibiotics Anti-Infectives: Antifungals
Amoxicillin Capsule, Chewable Cresemba 3 SL
1
Tablet
Econazole Cream 1 SL
Amoxicillin/Potassium Clavulanate
1
Chewable Tablet, Tablet Fluconazole Tablet 1
Azithromycin Tablet 1 Itraconazole Capsule 1 SL
Cefadroxil Capsule, Tablet 1 Ketoconazole Cream 1 SL
Cefdinir Capsule 1 Noxafil Tablet, Suspension 2
Cefixime Suspension 1 Nystatin Cream, Ointment 1
Cefprozil Tablet 1 Terbinafine Tablet 1 SL
Cefuroxime Tablet 1 Anti-Infectives: Antivirals
Cephalexin Capsule 1 Acyclovir Ointment 1 SL
Ciprodex 3 Acyclovir Tablet 1
Ciprofloxacin Tablet 1 Famciclovir Tablet 1
Clarithromycin Tablet 1 Oseltamivir Capsule, Suspension 1 SL
Clindamycin Capsule 1 Valacyclovir Tablet 1 SL
Dificid 3 SL Valganciclovir 1 SL
Doxycycline Capsule, Tablet 1 Cancer
Levofloxacin Tablet 1 Alunbrig 2 PA, SL, SP
Minocycline Capsule 1 Bexarotene Capsule 3 E, SP
Moxifloxacin Tablet 1 Bicalutamide 1
Nitrofurantoin Capsule 1 Bosulif 2 PA, SL, SP
Nitrofurantoin Macrocrystal Braftovi 3 PA, SL, SP
1
Capsule
Calquence 2 PA, SL, SP
Ofloxacin Otic Solution 1
Cyclophosphamide Capsule 1
Ofloxacin Tablet 1
Erleada 3 PA, SL, SP
Penicillin V Potassium Tablet 1
Calquence 2 PA, SL, SP
Sulfamethoxazole-Trimethoprim
1
Tablet Ibrance 2 PA, SL, SP
Suprax Capsule, Chewable Idhifa 2 PA, SL, SP
3
Tablet, Tablet
Imantinib Tablet 1 PA, SL, SP
Imbruvica 2 PA, SL, SP
Bold type = Brand-name drug
[Plain type = Generic drug]
E = May be excluded from coverage PA = Prior authorization required
H = May be part of health care reform preventive SL = Supply limit
H-PA = May be part of health care reform preventive with prior authorization SP = Specialty medication
9Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Leucovorin Calcium Tablet 1 Bisoprolol 1
Mektovi 3 PA, SL, SP Bisoprolol-Hydrochlorothiazide 1
Mercaptopurine Tablet 1 Bystolic 2
Nerlynx 2 PA, SL, SP Byvalson 2 SL
Revlimid 2 PA, SL, SP Cartia XT 1
Rydapt 2 PA, SL, SP Carvedilol Immediate-Release
1
Tablet
Sutent 2 PA, SL, SP
Chlorthalidone 1
Targretin Capsule 1 SP
Clonidine Tablet 1
Targretin Gel 3 SL
Diltiazem 24 Hour CD 1
Tasigna 2 PA, SL, SP
Diltiazem Sustained-Release
1
Verzenio 2 PA, SL, SP Capsule
Xeloda 1 SL, SP Diltiazem Sustained-Release
1
Tablet
Zykadia 2 PA, SL, SP
Doxazosin 1
Zytiga 2 PA, SL, SP
Edarbi 3 SL
Cardiovascular/Heart Disease: Coagulation Therapy
Edarbyclor 3 SL
Bevyxxa 3 SL
Enalapril 1
Brilinta 3 SL
Furosemide 1
Clopidogrel 1
Guanfacine 1
Eliquis 3 SL
Hydralazine 1
Enoxaparin Sodium 1 SL
Hydrochlorothiazide 1
Pradaxa 2 SL
Irbesartan 1
Prasugrel 1 SL
Labetalol 1
Savaysa 3 SL
Lisinopril 1
Warfarin Sodium 1
Lisinopril-Hydrochlorothiazide 1
Xarelto 2 SL
Losartan 1
Cardiovascular/Heart Disease: High Blood Pressure
Losartan-Hydrochlorothiazide 1
Amlodipine 1
Metoprolol Succinate Extended-
1
Amlodipine-Benazepril 1 Release
Amlodipine-Valsartan 1 Metoprolol Tartrate 25, 50,
1
100 mg
Atenolol 1
Nadolol 1
Atenolol-Chlorthalidone 1
Nifedipine Extended-Release 1
Benazepril 1
Olmesartan 1 SL
Benazepril-Hydrochlorothiazide 1
Olmesartan-Hydrochlorothiazide 1 SL
Bidil 2
10Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Propranolol Extended-Release Rosuvastatin 1 SL
1
Capsule
Simvastatin 1 H-PA
Propranolol Tablet 1
Vascepa 3
Quinapril 1
Welchol Packet for Suspension,
Ramipril 1 1
Tablet
Spironolactone 1 Cardiovascular/Heart Disease: Other
Telmisartan 1 Amiodarone 1
Telmisartan-Hydrochlorothiazide 1 Corlanor 3 SL
Terazosin 1 Digoxin 1
Triamterene-Hydrochlorothiazide 1 Entresto 3 SL
Valsartan 1 Flecainide 1
Valsartan-Hydrochlorothiazide 1 Isosorbide Mononitrate ER 1
Verapamil 1 Multaq 3
Verapamil Sustained-Release 1 Nitroglycerin Sublingual Tablet 1
Cardiovascular/Heart Disease: High Cholesterol Ranexa 2
Atorvastatin 1 H-PA, SL Sotalol 1
Colesevelam Packet for Central Nervous System: Attention Deficit Disorder
Suspension, Tablet 3 E
(generic Welchol) Adderall XR 1 SL
Ezetimibe Tablet 1 SL Amphetamine Salt Combo 1
Ezetimibe/Simvastatin 1 SL Atomoxetine 1 SL
Fenofibrate 54, 160 mg Tablet 1 Concerta 1 SL
Fluvastatin Extended-Release Dexmethylphenidate Immediate-
1 SL 1
Tablet Release Tablet
Gemfibrozil 1 Dextroamphetamine-
Amphetamine Immediate-Release 1
Lovastatin 1 H Tablet
Niacin Extended-Release Tablet 1 Dextroamphetamine Sulfate
1
Immediate-Release Tablet
Niaspan 3
Guanfacine Extended-Release 1 SL
Omega-3-Acid Ethyl Esters
1 Methylphenidate Chewable Tablet 1
Capsule
Praluent 2 PA, SL, SP Methylphenidate Extended-
Release Capsule (generic 1 SL
Pravastatin 1 Metadate CD, Ritalin LA)
Repatha 3 PA, SL, SP
Bold type = Brand-name drug
[Plain type = Generic drug]
E = May be excluded from coverage PA = Prior authorization required
H = May be part of health care reform preventive SL = Supply limit
H-PA = May be part of health care reform preventive with prior authorization SP = Specialty medication
11Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Methylphenidate Extended- Central Nervous System: Migraine
Release Capsule (Metadate ER, 1 SL
Acetaminophen/Butalbital/
generic Ritalin SR) 1 SL
Caffeine 325 mg/50 mg/40 mg
Methylphenidate Extended-
Release Tablet (generic 3 E, SL Eletriptan 1 SL
Concerta) Frovatriptan 1 SL
Methylphenidate Immediate-
1 Naratriptan 1 SL
Release Tablet
Vyvanse 2 SL Rizatriptan ODT, Tablet 1 SL
Central Nervous System: Depression Sumatriptan Nasal Spray 1 SL
Sumatriptan Succinate Tablet,
Amitriptyline Tablet 1 1 SL
Injection
Bupropion Extended-Release
1 Central Nervous System: Multiple Sclerosis
Tablet
Bupropion Sustained-Release Ampyra 2 PA, SL, SP
1
Tablet Aubagio 3 PA, SL, SP
Bupropion Tablet 1 Avonex 2 PA, SL, SP
Citalopram Tablet 1 Betaseron 2 PA, SL, SP
Desvenlafaxine Extended-
1 SL Gilenya 3 PA, SL, SP
Release Tablet (generic Pristiq)
Glatiramer (generic Copaxone)
Doxepin 1 1 PA, SL, SP
[Mylan version only]
Duloxetine Capsule 1 SL Plegridy 3 PA, SL, SP
Escitalopram Tablet 1 Rebif 3 PA, SL, SP
Fetzima 3 SL Tecfidera 2 PA, SL, SP
Fluoxetine Capsule (generic
1 Central Nervous System: Other
Prozac)
Alprazolam Extended-Release
Fluvoxamine Tablet 1 1
Tablet
Mirtazapine Tablet 1 Alprazolam Tablet 1
Nortriptyline Capsule 1 Aripiprazole Tablet 1 SL
Paroxetine Tablet 1 Armodafinil 1 SL
Sertraline Tablet 1 Austedo 2 PA, SL, SP
Trazodone Tablet 1 Buprenorphine Sublingual Tablet 1
Trintellix 3 SL Buspirone Tablet 1
Venlafaxine Extended-Release
1 Carbidopa-Levodopa 1
Capsule
Venlafaxine Tablet 1 Diazepam Tablet 1
Viibryd 3 SL Donepezil ODT, 5, 10 mg Tablet 1
Latuda 3 SL
Lithium Capsule 1
12Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Lorazepam Tablet 1 Divalproex Delayed-Release
1
Tablet
Memantine Immediate-Release
1 Divalproex Extended-Release
Tablet 1
Tablet
Modafinil 1 SL
Gabapentin Capsule, Tablet 1
Naloxone Vial 1
Lamotrigine Immediate-Release
1
Narcan Nasal Spray 2 SL Tablet
Olanzapine Tablet 1 SL Levetiracetam Extended-Release
1
Tablet
Pramipexole Tablet 1
Levetiracetam Immediate-Release
Quetiapine Extended-Release 1
1 SL Tablet
Tablet
Lyrica 3 SL
Quetiapine Immediate-Release
1 Lyrica CR 3 E, SL
Tablet
Risperidone Tablet 1 Oxcarbazepine Tablet 1
Ropinirole Tablet 1 Phenytoin Capsule, Suspension 1
Suboxone Film 3 E, SL Topiramate Immediate-Release
1
Tablet
Tolcapone 1
Zonisamide Capsule 1
Xyrem 3 PA, SL
Dermatology
Zelapar 3
Aczone 1 SL
Ziprasidone Capsule 1 SL
Betamethasone Dipropionate
Zubsolv 1 SL 0.05% Augmented Lotion, 1
Ointment
Central Nervous System: Sedatives/Hypnotics
Betamethasone Dipropionate
Eszopiclone Tablet 1 SL 1
0.05% Cream, Ointment
Temazepam Capsule 1 Calcipotriene/Betamethasone
1 SL
Ointment
Triazolam Tablet 1
Carac 2
Zaleplon Capsule 1 SL
Ciclopirox Cream, Gel, Lotion,
Zolpidem Immediate-Release 1
1 SL Solution
Tablet
Claravis 1
Central Nervous System: Seizure Disorders
Clindamycin 1.2%/Benzoyl
Carbamazepine Extended- 1 SL
1 Peroxide 5% Gel
Release Capsule, Tablet
Clindamycin Gel 1 SL
Carbamazepine Immediate-
1 Clindamycin Lotion, Swabs 1
Release Tablet
Clonazepam Tablet 1 Clindamycin Solution 1 SL
Diazepam Tablet 1
Bold type = Brand-name drug
[Plain type = Generic drug]
E = May be excluded from coverage PA = Prior authorization required
H = May be part of health care reform preventive SL = Supply limit
H-PA = May be part of health care reform preventive with prior authorization SP = Specialty medication
13Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Clobetasol Propionate Cream, Regranex 2 SL
1 SL
Ointment, Solution
Rhofade 3 SL
Clotrimazole-Betamethasone
1 SL
Cream Taclonex Suspension 3 SL
Clotrimazole-Betamethasone Tacrolimus Ointment 1 SL
1
Lotion
Tazarotene 0.1% Cream (generic
Dapsone 5% Gel 3 E, SL 3 E, PA, SL
Tazorac)
Desonide 0.05% Cream, Lotion, Tazorac 0.1% Cream 1 PA, SL
1 SL
Ointment
Tazorac Gel, 0.05% Cream 3 PA, SL
Desoximetasone Cream, Gel,
1 SL
Ointment Tretinoin Cream 1 PA, SL
Diflorasone Diacetate 0.05% Triamcinolone Acetonide Cream,
1 SL 1
Cream, Ointment Lotion, Ointment
Dupixent 3 PA, SL, SP Vectical 3 SL
Elidel 3 SL Diabetes: Blood Glucose Monitoring
Enstilar Foam 3 SL Accu-Chek Test Strips 3 E, SL
Eucrisa 3 SL Contour Next EZ Meter 2
Finacea 3 Contour Next Meter 2
Fluocinonide 0.05% Cream 1 Contour Next One Meter 2
Fluocinolone Cream, Oil, Contour Next Test Strips 2 SL
1 SL
Ointment, Solution
Contour Test Strips 3 E, SL
Fluorouracil 0.5% Cream 3 SL
FreeStyle Test Strips 3 E, SL
Halobetasol Ointment 1 SL
Hydrocortisone 2.5% Cream, OneTouch Ultra 2 Meter 1
1
Ointment OneTouch Ultra Test Strips 1 SL
Imiquimod 5% Cream 1 SL OneTouch UltraMini Meter 1
Metronidazole 0.75% Topical Gel 1 OneTouch Verio Flex Meter 1
Minocycline Extended-Release OneTouch Verio IQ Meter 1
1 E
(generic Solodyn)
OneTouch Verio Meter 1
Mirvaso 3 SL
Mometasone Furoate Cream, OneTouch Verio Sync Meter 1
1
Lotion, Ointment OneTouch Verio Test Strips 1 SL
Mupirocin Ointment 1 SL
Oracea 3
Oxsoralen-Ultra 2
Picato 3 SL
14Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Diabetes: Insulin Januvia 3 SL
Admelog SoloStar, Vials 3 E, SL Jardiance 2 SL
Apidra SoloStar, Vials 3 E, SL Jentadueto, Jentadueto XR 2 SL
Basaglar 1 SL Kazano 2 SL
Fiasp FlexTouch, Vials 3 E, SL Kombiglyze XR 2 SL
Humalog KwikPens Metformin 1
2 SL
(all formulations)
Metformin Extended-Release
Humalog Vials (all formulations) 1 SL 1
Tablet (generic Glucophage XR)
Humulin KwikPens Nesina 2 SL
2 SL
(all formulations)
Onglyza 2 SL
Humulin Vials (all formulations) 1 SL
Oseni 2 SL
Lantus SoloStar 3 E, SL
Ozempic 3 SL
Lantus Vials 3 E, SL
Pioglitazone 1 SL
Levemir FlexTouch, Vials 3 SL
Qtern 3 E, SL
Novolin Vials (all formulations) 3 E, SL
Segluromet 3 E, SL
Novolog FlexPen, Vials
3 E, SL
(all formulations) Soliqua 2 SL
Tresiba FlexTouch 2 E, SL Steglatro 3 E, SL
Diabetes: Non-Insulin Steglujan 3 E, SL
Adlyxin 3 SL Synjardy, Synjardy XR 2 SL
Bydureon, Bydureon Bcise 2 SL Tradjenta 2 SL
Byetta 2 SL Trulicity 3 SL
Farxiga 3 E, SL Victoza 2-Pak 2 SL
Glimepiride 1 Victoza 3-Pak 3 SL
Glipizide 1 Xigduo XR 3 E, SL
Glipizide Extended-Release 1 Endocrine: Growth Hormone 1
Glyburide 1 Nutropin, Nutropin AQ 2 PA, SL, SP
Glyxambi 2 SL 1
Coverage is determined by the consumer’s prescription
drug benefit plan. Please consult plan documents
Invokamet, Invokamet XR 2 SL regarding benefit coverage and cost-share.
Invokana 2 SL
Janumet 3 SL
Bold type = Brand-name drug
[Plain type = Generic drug]
E = May be excluded from coverage PA = Prior authorization required
H = May be part of health care reform preventive SL = Supply limit
H-PA = May be part of health care reform preventive with prior authorization SP = Specialty medication
15Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Endocrine: Other Eye Conditions: Dry Eye Disease
Calcitriol Capsule 1 Restasis Single Use Vial 3 SL
Desmopressin Tablet 1 Xiidra 3 SL
Dexamethasone Tablet 1 Eye Conditions: Glaucoma
Methylprednisolone Tablet 1 Alphagan P 0.1% 2 SL
Prenisolone Oral Solution 1 Azopt 2 SL
Prednisone Tablet 1 Combigan 2 SL
Endocrine: Thyroid Hormone Replacement Latanoprost 0.005% Ophthalmic
1
Solution
Armour Thyroid 3
Lumigan 2 SL
Levothyroxine Sodium Tablet 1
Timolol 0.25%, 0.5% Ophthalmic
1
Liothyronine Sodium Tablet 1 Solution
Methimazole Tablet 1 Travatan Z 2 SL
NP Thyroid Tablet 1 Gastrointestinal: Acid Suppression
Synthroid 2 Dexilant 3 SL
Eye Conditions: Allergies Omeclamox-Pak 3 SL
Azelastine 0.05% Ophthalmic Omeprazole Capsule 1
1
Solution
Pantoprazole Tablet 1
Lastacaft 3 SL
Pylera 3 SL
Olopatadine 0.1% Ophthalmic
1 SL Rabeprazole Tablet 1 SL
Solution
Eye Conditions: Antibiotics Ranitadine Syrup 1
Erythromycin 0.5% Ophthalmic Sucralfate Tablet 1
1
Ointment
Gastrointestinal: Nausea/Vomiting
Gentamicin Ophthalmic Ointment,
1
Solution Akynzeo 3 SL
Moxeza 3 Aprepitant Capsule 1 SL
Moxifloxacin Ophthalmic Solution 1 Emend Suspension 2 SL
Ofloxacin 0.3% Ophthalmic Ondansetron 1
1
Solution
Ondansetron ODT 1
Tobramycin/Dexamethasone
0.3%-0.1% Ophthalmic 1 Scopolamine Transdermal Patch 1
Suspension
Varubi 2 SL
Tobramycin Ophthalmic Solution 1
16Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Gastrointestinal: Other Gout
Amitiza 3 SL Allopurinol Tablet 1
Apriso 2 Duzallo 3 SL
Budesonide Extended-Release Mitigare 2
3 E
Tablet (generic Uceris)
Uloric 3 SL
Canasa 2
Zurampic 3 SL
Clenpiq 3
Hepatitis C
Cortifoam 2
Daklinza 3 PA, SL, SP
Creon 2
Epclusa 2 PA, SL, SP
Diphenoxylate-Atropine Tablet 1
Harvoni 2 PA, SL, SP
Golytely 2
Mavyret 2 PA, SL, SP
Hyoscyamine Tablet 1
Ribavirin Tablet 1 SP
Lialda 1
Sovaldi 3 PA, SL, SP
Linzess 2 SL
Technivie 3 PA, SL, SP
Mesalmine Delayed-Release
3 E
Tablet (generic Lialda) Viekira Pak 3 PA, SL, SP
Metoclopramide Tablet 1 Viekira XR 3 PA, SL, SP
Movantik 3 E, SL Vosevi 2 PA, SL, SP
Moviprep 3 Zepatier 3 PA, SL, SP
Polyethylene Glycol 3350 1 HIV/AIDS
Prepopik 3 Abacavir-Lamivudine 1 SP
Sulfasalazine Tablet 1 Atazanavir Capsule 1 SP
Suprep 3 Atripla 3 E, SP
Symproic 2 SL Cimduo 2 SP
Uceris Foam 2 Complera 3 SP
Uceris Tablet 1 Descovy 3 SP
Viberzi 3 SL Efavirenz 1 SP
Zenpep 2 Evotaz 2 SP
Genvoya 3 SP
Bold type = Brand-name drug
[Plain type = Generic drug]
E = May be excluded from coverage PA = Prior authorization required
H = May be part of health care reform preventive SL = Supply limit
H-PA = May be part of health care reform preventive with prior authorization SP = Specialty medication
17Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Intelence 2 SP Inflammatory Conditions: Rheumatoid Arthritis,
Crohn’s Disease, Psoriasis, Ulcerative Colitis
Isentress 2 SP
Actemra 3 PA, SL, SP
Juluca 2 SP
Cimzia 2 PA, SL, SP
Kaletra Tablet 2 SP
Cosentyx 3 PA, SL, SP
Lamivudine-Zidovudine 1 SP
Enbrel 3 PA, SL, SP
Lopinavir-Ritonavir Oral Solution 1 SP
Humira 2 PA, SL, SP
Nevirapine 1 SP
Hydroxychloroquine Sulfate 1
Nevirapine Extended-Release 1 E, SP
Kevzara 3 PA, SL, SP
Odefsey 3 SP
Leflunomide 1
Prezcobix 2 SP
Methotrexate Tablet 1
Prezista 2 SP
Orencia 3 PA, SL, SP
Ritonavir Tablet 1 SP
Otezla 2 PA, SL, SP
Selzentry 2 PA, SP
Rasuvo 3 SL
Stribild 3 SP
Siliq 3 PA, SL, SP
Symfi 2 SP
Simponi 2 PA, SL, SP
Symfi Lo 2 SP
Stelara 2 PA, SL, SP
Tenofovir Tablet 1 SP
Taltz 3 PA, SL, SP
Tivicay 3 SP
Tremfya 2 PA, SL, SP
Triumeq 2 SP
Xeljanz, Xeljanz XR 3 PA, SL, SP
Truvada 3 SP
Men’s Health: Prostate
Tybost 2 SP
Alfuzosin Tablet 1
Vitekta 2 SP
Doxazosin Tablet 1
Infertility1
Dutasteride Capsule 1
Cetrotide 2 SP
Finasteride Tablet 1
Clomiphene 1
Rapaflo 3
Endometrin 2
Tamsulosin Capsule 1
Gonal-F 2 SP
Terazosin Capsule, Tablet 1
Gonal-F RFF 2 SP
Ovidrel 3 SP
1
Coverage is determined by the consumer’s prescription
drug benefit plan. Please consult plan documents
regarding benefit coverage and cost-share.
18Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Men’s Health: Testosterone Therapy Promethazine/Codeine 1 SL
Androderm 2 SL Promethazine/Dextromethorphan 1
Androgel 3 E, SL Pulmozyme 2 PA, SL, SP
Methyltestosterone Capsule 1 Rectiv 3 SL
Testim 1 SL Rezira 3
Testosterone 1% Topical Gel 1 E, SL Sevelamer 1
Testosterone Cypionate Injection 1 Syprine 1 PA, SP
Miscellaneous Tobi Podhaler 3 PA, SL, SP
Anastrozole Tablet 1 Trientine (generic Syprine) 3 E, PA, SP
Aranesp 2 SL, SP Velphoro 2
Auryxia 3 Veltassa 3 SL
Bethkis 1 PA, SL, SP Zarxio 2 SP
Cayston 2 PA, SL, SP Musculoskeletal: Muscle Spasms
Cerdelga 2 PA, SP Baclofen Tablet 1
Chlorhexidine Gluconate 1 Carisoprodol 350 mg Tablet 1
Chlorpheniramine/Hydrocodone/ Cyclobenzaprine 1
1 SL
Pseudoephedrine Solution
Metaxalone Tablet 1
Epinephrine (generic EpiPen/
2 SL
EpiPen-Jr.) Methocarbamol Tablet 1
EpiPen/EpiPen Jr. 3 E, SL Tizanidine Tablet 1
Hydrocodone/Chlorpheniramine Musculoskeletal: Osteoporosis
1 SL
Suspension
Alendronate Sodium Tablet 1
Lanthanum Chewable Tablet 1
Forteo 3 PA, SP
Letrozole 1
Ibandronate Tablet 1 SL
Lidocaine Transdermal Patch
1 SL
(generic Lidoderm) Raloxifene Tablet 1
Nityr 2 PA, SP Risedronate Sodium Tablet 1 SL
Nuedexta 2 Tymlos 3 PA, SP
Obredon 3 SL
Pegasys 2 PA, SL, SP
Phenazopyridine 1
Procrit 2 SL, SP
Bold type = Brand-name drug
[Plain type = Generic drug]
E = May be excluded from coverage PA = Prior authorization required
H = May be part of health care reform preventive SL = Supply limit
H-PA = May be part of health care reform preventive with prior authorization SP = Specialty medication
19Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Musculoskeletal: Pain Relief Tramadol Immediate-Release
1
Tablet
Acetaminophen/Codeine Tablet 1 SL
Tramadol Sustained-Release
1 SL
Belbuca 3 SL Tablet
Celecoxib 1 SL Trezix 1 SL
Diclofenac Tablet 1 Vicodin 5/300, 7.5/300, 10/300
1 E, SL
mg Tablet
Etodolac Capsule 1
Voltaren Gel 2
Fentanyl 12, 25, 50, 75, 100 mcg
1 SL Xtampza ER 2 SL
Patch
Fentanyl Citrate Lozenge 1 SL Zohydro ER 3 SL
Hydrocodone/Acetaminophen Overactive Bladder
1 SL
5/325, 7.5/325, 10/325 mg Tablet
Dicyclomine Tablet 1
Hydrocodone/Ibuprofen Tablet 1
Oxybutynin Extended-Release
Hydromorphone Immediate- 1
1 Tablet
Release Tablet
Oxybutynin Tablet 1
Ibuprofen Tablet 1
Toviaz 3
Indomethacin Capsule 1
Respiratory: Allergies
Ketorolac Tablet 1
Azelastine 0.1% Nasal Spray 1
Lazanda 3 SL
Fluticasone Nasal Spray 1 SL
Meloxicam Tablet 1
Zetonna 3 SL
Methadone Tablet, Oral Solution,
1 SL Respiratory: Asthma/COPD
Concentrate Solution
Morphine Sulfate Extended- Advair Diskus/HFA 3 SL
1 SL
Release Tablet
Albuterol Nebs 1
Morphine Sulfate Oral Solution 1
Alvesco 1 SL
Nabumetone Tablet 1
Anoro Ellipta 3 SL
Naproxen Tablet 1
Arnuity Ellipta 3 SL
Nucynta 3 SL
Asmanex TwistHaler, HFA 1 SL
Nucynta ER 3 SL
Bevespi Aerosphere 2 SL
Oxycodone/Acetaminophen
1 SL
5/325, 7.5/325, 10/325 mg Tablet Breo Ellipta 3 SL
Oxycodone Tablet 1 Budesonide Nebs 1 SL
Oxycontin 3 E, SL Combivent Respimat 3 SL
Sprix 3 Flovent Diskus/HFA 3 SL
Tramadol-Acetaminophen 1 SL Fluticasone/Salmeterol RespiClick
1 SL
(generic AirDuo RespiClick)
20Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Incruse Ellipta 2 SL Smoking Cessation
Ipratropium-Albuterol Nebs 1 Bupropion Sustained-Release
1 H-PA
Tablet
Ipratropium Nebs 1
Chantix Tablet 3 H-PA
Montelukast 1
Nicoderm CQ 3 H-PA
Perforomist 3 SL
Nicorette Gum 3 H-PA
ProAir HFA/RespiClick 3 SL
Nicorette Lozenge 2 H-PA
Proventil HFA 3 SL
Nicorette Mini-Lozenge 2 H-PA
Pulmicort Flexhaler 3 SL
Nicotine Gum 1 H-PA
QVAR Redihaler 1 SL
Nicotine Lozenge 1 H-PA
Seebri Neohaler 3 SL
Nicotine Patch 1 H-PA
Serevent Diskus 3 SL
Nicotrol Inhaler 3 H-PA
Spiriva Handihaler/Respimat 2 SL
Nicotrol Nasal Spray 3 H-PA
Striverdi Respimat 2 SL
Transplant
Symbicort 3 SL
Azathioprine Tablet 1
Trelegy Ellipta 3 SL
Cyclosporine Modified Capsule 1 SP
Tudorza 2 SL
Mycophenolate Capsule,
1 SP
Ventolin HFA 2 SL Suspension
Xopenex HFA 3 SL Mycophenolic Acid Tablet 1 SP
Respiratory: Pulmonary Arterial Hypertension Sirolimus Tablet 1 SP
Adempas 2 PA, SL, SP Tacrolimus Capsule 1 SP
Letairis 2 PA, SL, SP Vitamins/Electrolytes
Opsumit 2 PA, SL, SP Fluoride 1
Orenitram 3 PA, SL, SP Folic Acid 1
Sildenafil Tablet (generic Revatio) 1 PA, SL, SP Klor-Con M10 1
Tadalafil (generic Adcirca) 1 PA, SL, SP Klor-Con M20 1
Tracleer 2 PA, SL, SP Potassium Chloride 1
Tyvaso 2 PA, SP Potassium Citrate 1
Uptravi 3 PA, SL, SP
Bold type = Brand-name drug
[Plain type = Generic drug]
E = May be excluded from coverage PA = Prior authorization required
H = May be part of health care reform preventive SL = Supply limit
H-PA = May be part of health care reform preventive with prior authorization SP = Specialty medication
21Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Women’s Health: Contraceptives Elinest 1 H
Aftera 1 H Ella 1 H, SL
Altavera 1 H Emoquette 1 H
Alyacen 7/7/7, 1/35 1 H Enpresse 1 H
Amethia 1 H Enskyce 1 H
Amethia Lo 1 H Errin 1 H
Amethyst 1 H Estarylla 1 H
Apri 1 H Fallback 1 H
Aranelle 1 H Falmina 1 H
Ashlyna 1 H Gianvi 1 H
Aubra 1 H Gildagia 1 H
Aviane 1 H Heather 1 H
Azurette 1 H Introvale 1 H
Balziva 1 H Isibloom 1 H
Bekyree 1 H Jencycla 1 H
Blisovi Fe 1 H Jolessa 1 H
Blisovi 24 Fe 1 H Jolivette 1 H
Briellyn 1 H Juleber 1 H
Camila 1 H Junel 1 H
Camrese 1 H Junel 24 Fe 1 H
Camrese Lo 1 H Junel Fe 1 H
Caziant 1 H Kariva 1 H
Chateal 1 H Kelnor 1/35 1 H
Cryselle 1 H Kimidess 1 H
Cyclafem 7/7/7, 1/35 1 H Kurvelo 1 H
Cyred 1 H Larin 1 H
Dasetta 7/7/7, 1/35 1 H Larin 24 Fe 1 H
Daysee 1 H Larin Fe 1 H
Deblitane 1 H Larissia 1 H
Delyla 1 H Leena 1 H
Desogestrel-Ethinyl Estradiol 1 H Lessina 1 H
Drospirenone-Ethinyl Estradiol 1 H Levonest 1 H
Econtra EZ 1 H Levonorgestrel 1.5 mg 1 H
22Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Levonorgestrel-Ethinyl Estradiol 1 H Ocella 1 H
Levora-28 1 H Ogestrel 1 H
Lillow 1 H Opcicon One Step 1 H
Lo Loestrin Fe 3 Option 2 1 H
LoMedia 24 Fe 1 H Orsythia 1 H
Loryna 1 H Philith 1 H
Low-Ogestrel 1 H Pimtrea 1 H
Lutera 1 H Pirmella 7/7/7, 1/35 1 H
Lyza 1 H Plan B One Step 1 H
Marlissa 1 H Portia 1 H
Medroxyprogesterone Acetate 1 H Previfem 1 H
Microgestin 1 H Quasense 1 H
Microgestin Fe 1 H Reclipsen 1 H
Mono-Linyah 1 H Setlakin 1 H
Mononessa 1 H Sharobel 1 H
My Choice 1 H Solia 1 H
My Way 1 H Sprintec 1 H
Myzilra 1 H Sronyx 1 H
Natazia 2 Syeda 1 H
Necon 7/7/7, 0.5/35, 1/35, 1/50, Take Action 1 H
1 H
10/11
Tarina Fe 1 H
Next Choice One Dose 1 H
Tilia Fe 1 H
Nikki 1 H
Tri Femynor 1 H
Nora BE 1 H
Tri-Estarylla 1 H
Norethindrone 0.35 mg 1 H
Tri-Legest Fe 1 H
Norethindrone-Ethinyl Estradiol-
1 H
Ferrous Fumarate Tri-Linyah 1 H
Norgestimate-Ethinyl Estradiol 1 H Tri-Lo-Estarylla 1 H
Norlyda 1 H Tri-Lo-Marzia 1 H
Norlyroc 1 H Tri-Lo-Sprintec 1 H
Nortrel 7/7/7, 0.5/35, 1/35 1 H Tri-Previfem 1 H
Nuvaring 2 H Tri-Sprintec 1 H
Bold type = Brand-name drug
[Plain type = Generic drug]
E = May be excluded from coverage PA = Prior authorization required
H = May be part of health care reform preventive SL = Supply limit
H-PA = May be part of health care reform preventive with prior authorization SP = Specialty medication
23Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Tri-Vylibra 1 H Estrogen/Methyltestosterone
1
Tablet
Trinessa 1 H
Evamist 2
Trinessa Lo 1 H
Medroxyprogesterone 1
Trivora-28 1 H
Minivelle 3 SL
Velivet 1 H
Premarin 3
Vestura 1 H
Premphase 3
Vienva 1 H
Prempro 3
Viorele 1 H
Progesterone Micronized Capsule 1
Vyfemla 1 H
Vivelle-Dot 1 SL
Vylibra 1 H
Yuvafem 1
Wera 1 H
Women’s Health: Miscellaneous
Wymza Fe 1 H
Raloxifene 1 H-PA
Xulane 1 H
Tamoxifen 1 H-PA
Yasmin 28 3
Women’s Health: Prenatal Vitamins
Yaz 3
Brand Prenatal Vitamins 3
Zarah 1 H
Zenchent 1 H
Zenchent Fe 1 H
Zovia 1/35E, 1/50E 1 H
Women’s Health: Hormone Replacement
Climara Pro 3 SL
Divigel 3
Duavee 3 SL
Estrace Cream 1
Estradiol Cream (generic
3 E
Estrace)
Estradiol/Norethindrone Acetate
1
Tablet
Estradiol Tablet 1
Estradiol Twice-Weekly
Transdermal Patch (generic 3 E, SL
Vivelle-Dot)
Estradiol Weekly Transdermal
1 SL
Patch (generic Climara)
Estring 2 SL
24Index
A Amphetamine Salt Combo..............11 Benazepril...................................... 10
Abacavir-Lamivudine...................... 17 Ampyra........................................... 12 Benazepril-Hydrochlorothiazide..... 10
Accu-Chek Test Strips.................... 14 Anastrozole Tablet.......................... 19 Betamethasone Dipropionate 0.05%
Acetaminophen/Butalbital/Caffeine Androderm...................................... 19 Augmented Lotion, Ointment...... 13
325 mg/50 mg/40 mg.................. 12 Androgel......................................... 19 Betamethasone Dipropionate 0.05%
Acetaminophen/Codeine Tablet..... 20 Anoro Ellipta................................... 20 Cream, Ointment......................... 13
Actemra.......................................... 18 Apidra SoloStar, Vials.................... 15 Betaseron....................................... 12
Acyclovir Ointment........................... 9 Aprepitant Capsule......................... 16 Bethkis............................................ 19
Acyclovir Tablet................................ 9 Apri................................................. 22 Bevespi Aerosphere....................... 20
Aczone........................................... 13 Apriso............................................. 17 Bevyxxa.......................................... 10
Adcirca........................................... 21 Aranelle.......................................... 22 Bexarotene Capsule......................... 9
Adderall XR.....................................11 Aranesp.......................................... 19 Bicalutamide..................................... 9
Adempas........................................ 21 Aripiprazole Tablet.......................... 12 Bidil................................................. 10
Adlyxin............................................ 15 Armodafinil..................................... 12 Bisoprolol........................................ 10
Admelog SoloStar, Vials................. 15 Armour Thyroid............................... 16 Bisoprolol-Hydrochlorothiazide...... 10
Advair Diskus/HFA......................... 20 Arnuity Ellipta................................. 20 Blisovi 24 Fe................................... 22
Aftera.............................................. 22 Ashlyna........................................... 22 Blisovi Fe........................................ 22
AirDuo RespiClick.......................... 20 Asmanex TwistHaler, HFA.............. 20 Bosulif............................................... 9
Akynzeo.......................................... 16 Atazanavir Capsule........................ 17 Braftovi............................................. 9
Albuterol Nebs................................ 20 Atenolol.......................................... 10 Brand Prenatal Vitamins................ 24
Alendronate Sodium Tablet............ 19 Atenolol-Chlorthalidone.................. 10 Breo Ellipta..................................... 20
Alfuzosin Tablet.............................. 18 Atomoxetine.....................................11 Briellyn............................................ 22
Allopurinol Tablet............................ 17 Atorvastatin.....................................11 Brilinta............................................ 10
Alphagan P 0.1%............................ 16 Atripla............................................. 17 Budesonide Extended-Release
Alprazolam Extended-Release Aubagio.......................................... 12 Tablet........................................... 17
Tablet........................................... 12 Aubra.............................................. 22 Budesonide Nebs........................... 20
Alprazolam Tablet........................... 12 Auryxia........................................... 19 Buprenorphine Sublingual Tablet... 12
Altavera.......................................... 22 Austedo.......................................... 12 Bupropion Extended-Release
Alunbrig............................................ 9 Aviane............................................. 22 Tablet........................................... 12
Alvesco........................................... 20 Avonex............................................ 12 Bupropion Sustained-Release
Alyacen 7/7/7, 1/35......................... 22 Azathioprine Tablet........................ 21 Tablet......................................12, 21
Amethia.......................................... 22 Azelastine 0.05% Ophthalmic Bupropion Tablet............................ 12
Amethia Lo..................................... 22 Solution....................................... 16 Buspirone Tablet............................. 12
Amethyst........................................ 22 Azelastine 0.1% Nasal Spray......... 20 Bydureon, Bydureon Bcise............. 15
Amiodarone.....................................11 Azithromycin Tablet.......................... 9 Byetta............................................. 15
Amitiza............................................ 17 Azopt.............................................. 16 Bystolic........................................... 10
Amitriptyline Tablet......................... 12 Azurette.......................................... 22 Byvalson......................................... 10
Amlodipine...................................... 10
Amlodipine-Benazepril................... 10 B C
Amlodipine-Valsartan..................... 10 Baclofen Tablet............................... 19 Calcipotriene/Betamethasone
Amoxicillin Capsule, Chewable Balziva............................................ 22 Ointment...................................... 13
Tablet............................................. 9 Basaglar......................................... 15 Calcitriol Capsule........................... 16
Amoxicillin/Potassium Clavulanate Bekyree.......................................... 22 Calquence........................................ 9
Chewable Tablet, Tablet................ 9 Belbuca.......................................... 20 Camila............................................ 22
25Camrese......................................... 22 Clindamycin Solution...................... 13 Desoximetasone Cream, Gel,
Camrese Lo.................................... 22 Clobetasol Propionate Cream, Ointment...................................... 14
Canasa........................................... 17 Ointment, Solution...................... 14 Desvenlafaxine Extended-Release
Carac.............................................. 13 Clomiphene.................................... 18 Tablet........................................... 12
Carbamazepine Extended-Release Clonazepam Tablet........................ 13 Dexamethasone Tablet................... 16
Capsule, Tablet........................... 13 Clonidine Tablet.............................. 10 Dexilant........................................... 16
Carbamazepine Immediate-Release Clopidogrel..................................... 10 Dexmethylphenidate Immediate-
Tablet........................................... 13 Clotrimazole-Betamethasone Release Tablet.............................11
Carbidopa-Levodopa...................... 12 Cream......................................... 14 Dextroamphetamine Sulfate
Carisoprodol 350 mg Tablet........... 19 Clotrimazole-Betamethasone Immediate-Release Tablet...........11
Cartia XT........................................ 10 Lotion.......................................... 14 Dextroamphetamine-Amphetamine
Carvedilol Immediate-Release Colesevelam Packet for Suspension, Immediate-Release Tablet...........11
Tablet........................................... 10 Tablet............................................11 Diazepam Tablet........................12, 13
Cayston.......................................... 19 Combigan....................................... 16 Diclofenac Tablet............................ 20
Caziant........................................... 22 Combivent Respimat...................... 20 Dicyclomine Tablet......................... 20
Cefadroxil Capsule, Tablet............... 9 Complera........................................ 17 Dificid................................................ 9
Cefdinir Capsule............................... 9 Concerta....................................11, 12 Diflorasone Diacetate 0.05% Cream,
Cefixime Suspension....................... 9 Contour Next EZ Meter.................. 14 Ointment...................................... 14
Cefprozil Tablet................................. 9 Contour Next Meter........................ 14 Digoxin............................................11
Cefuroxime Tablet............................ 9 Contour Next One Meter................ 14 Diltiazem 24 Hour CD..................... 10
Celecoxib........................................ 20 Contour Next Test Strips................ 14 Diltiazem Sustained-Release
Cephalexin Capsule......................... 9 Contour Test Strips......................... 14 Capsule....................................... 10
Cerdelga......................................... 19 Copaxone....................................... 12 Diltiazem Sustained-Release
Cetrotide......................................... 18 Corlanor...........................................11 Tablet........................................... 10
Chantix Tablet................................. 21 Cortifoam........................................ 17 Diphenoxylate-Atropine Tablet....... 17
Chateal........................................... 22 Cosentyx........................................ 18 Divalproex Delayed-Release
Chlorhexidine Gluconate................ 19 Creon.............................................. 17 Tablet........................................... 13
Chlorpheniramine/Hydrocodone/ Cresemba......................................... 9 Divalproex Extended-Release
Pseudoephedrine Solution.......... 19 Cryselle.......................................... 22 Tablet........................................... 13
Chlorthalidone................................ 10 Cyclafem 7/7/7, 1/35....................... 22 Divigel............................................. 24
Ciclopirox Cream, Gel, Lotion, Cyclobenzaprine............................ 19 Donepezil ODT, 5, 10 mg Tablet.... 12
Solution....................................... 13 Cyclophosphamide Capsule............ 9 Doxazosin..................................10, 18
Cimduo........................................... 17 Cyclosporine Modified Capsule..... 21 Doxazosin Tablet............................ 18
Cimzia............................................ 18 Cyred.............................................. 22 Doxepin.......................................... 12
Ciprodex........................................... 9 Doxycycline Capsule, Tablet............ 9
Ciprofloxacin Tablet.......................... 9 D Drospirenone-Ethinyl Estradiol....... 22
Citalopram Tablet........................... 12 Daklinza.......................................... 17 Duavee........................................... 24
Claravis.......................................... 13 Dapsone 5% Gel............................ 14 Duloxetine Capsule........................ 12
Clarithromycin Tablet........................ 9 Dasetta 7/7/7, 1/35.......................... 22 Dupixent......................................... 14
Clenpiq........................................... 17 Daysee........................................... 22 Dutasteride Capsule....................... 18
Climara........................................... 24 Deblitane........................................ 22 Duzallo........................................... 17
Climara Pro.................................... 24 Delyla............................................. 22
Clindamycin 1.2%/Benzoyl Peroxide Descovy.......................................... 17 E
5% Gel........................................ 13 Desmopressin Tablet...................... 16 Econazole Cream............................. 9
Clindamycin Capsule........................ 9 Desogestrel-Ethinyl Estradiol......... 22 Econtra EZ..................................... 22
Clindamycin Gel............................. 13 Desonide 0.05% Cream, Lotion, Edarbi............................................. 10
Clindamycin Lotion, Swabs............ 13 Ointment...................................... 14 Edarbyclor...................................... 10
26Efavirenz......................................... 17 F Glipizide Extended-Release........... 15
Eletriptan........................................ 12 Fallback.......................................... 22 Glucophage XR.............................. 15
Elidel............................................... 14 Falmina........................................... 22 Glyburide........................................ 15
Elinest............................................. 22 Famciclovir Tablet............................. 9 Glyxambi........................................ 15
Eliquis............................................. 10 Farxiga........................................... 15 Golytely.......................................... 17
Ella.................................................. 22 Fenofibrate 54, 160 mg Tablet.........11 Gonal-F.......................................... 18
Emend Suspension........................ 16 Fentanyl 12, 25, 50, 75, 100 mcg Gonal-F RFF.................................. 18
Emoquette...................................... 22 Patch........................................... 20 Guanfacine................................10, 11
Enalapril......................................... 10 Fentanyl Citrate Lozenge............... 20 Guanfacine Extended-Release.......11
Enbrel............................................. 18 Fetzima........................................... 12
Endometrin..................................... 18 Fiasp FlexTouch, Vials.................... 15 H
Enoxaparin Sodium........................ 10 Finacea........................................... 14 Halobetasol Ointment..................... 14
Enpresse........................................ 22 Finasteride Tablet........................... 18 Harvoni........................................... 17
Enskyce.......................................... 22 Flecainide........................................11 Heather........................................... 22
Enstilar Foam................................. 14 Flovent Diskus/HFA........................ 20 Humalog KwikPens........................ 15
Entresto...........................................11 Fluconazole Tablet........................... 9 Humalog Vials................................ 15
Epclusa........................................... 17 Fluocinolone Cream, Oil, Ointment, Humira............................................ 18
Epinephrine.................................... 19 Solution....................................... 14 Humulin KwikPens.......................... 15
EpiPen/EpiPen Jr........................... 19 Fluocinonide 0.05% Cream............ 14 Humulin Vials................................. 15
EpiPen/EpiPen-Jr........................... 19 Fluoride.......................................... 21 Hydralazine.................................... 10
Erleada............................................. 9 Fluorouracil 0.5% Cream................ 14 Hydrochlorothiazide....................... 10
Errin................................................ 22 Fluoxetine Capsule......................... 12 Hydrocodone/Acetaminophen 5/325,
Erythromycin 0.5% Ophthalmic Fluticasone Nasal Spray................ 20 7.5/325, 10/325 mg Tablet........... 20
Ointment...................................... 16 Fluticasone/Salmeterol Hydrocodone/Chlorpheniramine
Escitalopram Tablet........................ 12 RespiClick................................... 20 Suspension................................. 19
Estarylla......................................... 22 Fluvastatin Extended-Release Hydrocodone/Ibuprofen Tablet....... 20
Estrace........................................... 24 Tablet............................................11 Hydrocortisone 2.5% Cream,
Estrace Cream............................... 24 Fluvoxamine Tablet........................ 12 Ointment...................................... 14
Estradiol Cream.............................. 24 Folic Acid........................................ 21 Hydromorphone Immediate-Release
Estradiol Tablet............................... 24 Forteo............................................. 19 Tablet........................................... 20
Estradiol Twice-Weekly FreeStyle Test Strips...................... 14 Hydroxychloroquine Sulfate........... 18
Transdermal Patch...................... 24 Frovatriptan.................................... 12 Hyoscyamine Tablet....................... 17
Estradiol Weekly Transdermal Furosemide..................................... 10
Patch........................................... 24 I
Estradiol/Norethindrone Acetate G Ibandronate Tablet.......................... 19
Tablet........................................... 24
Gabapentin Capsule, Tablet........... 13 Ibrance............................................. 9
Estring............................................ 24
Gemfibrozil......................................11 Ibuprofen Tablet.............................. 20
Estrogen/Methyltestosterone
Gentamicin Ophthalmic Ointment, Idhifa................................................. 9
Tablet........................................... 24
Solution....................................... 16 Imantinib Tablet................................ 9
Eszopiclone Tablet......................... 13
Genvoya......................................... 17 Imbruvica.......................................... 9
Etodolac Capsule........................... 20
Gianvi............................................. 22 Imiquimod 5% Cream..................... 14
Eucrisa........................................... 14
Gildagia.......................................... 22 Incruse Ellipta................................. 21
Evamist........................................... 24
Gilenya........................................... 12 Indomethacin Capsule.................... 20
Evotaz............................................. 17
Glatiramer....................................... 12 Intelence......................................... 18
Ezetimibe Tablet..............................11
Glimepiride..................................... 15 Introvale.......................................... 22
Ezetimibe/Simvastatin.....................11
Glipizide.......................................... 15 Invokamet, Invokamet XR.............. 15
27You can also read
