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Your 2016 Formulary

Effective July 1, 2016

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

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

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

Visit optumrx.com • Locate a participating pharmacy by zip code. • Look up possible lower-cost alternatives. • Compare medication pricing and options.

OptumRx | optumrx.com 1 Your Formulary This Formulary outlines the most commonly prescribed from your plan’s complete pharmacy benefit coverage list, also known as a Prescription List (PDL). A formulary identifies the drugs available for certain conditions and organizes them into cost levels, also known as tiers. An important part of the Formulary is giving you choices so you and your doctor can choose the best course of treatment for you.

Go to optumrx.com for complete and up-to-date drug information Since the Formulary may change, we encourage you to visit our website, optumrx.com. This website is the best source for up-to-date information about all of the medications your pharmacy benefit covers, possible lower-cost options and cost comparisons.

John Smith

John Smith

JOHN SMITH

2 Table of Contents

Drug tiers and cost ...... 5 Gastrointestinal Acid Suppression ...... 16 Programs and limits ...... 6 Nausea/Vomiting ...... 16 Drugs by category ...... 9 Other ...... 16

Anti-Infectives HIV/AIDS ...... 16 Antibiotics ...... 9 Infertility ...... 17 Antifungals ...... 9 Antivirals ...... 9 Inflammatory Conditions ...... 17

Cancer ...... 9 Men’s Health Erectile Dysfunction ...... 17 Cardiovascular/Heart Disease Prostate ...... 17 Anticoagulants ...... 9 Therapy ...... 17 High Blood Pressure ...... 10 High Cholesterol ...... 10 Miscellaneous ...... 17 Other ...... 11 Musculoskeletal Pulmonary Arterial Hypertension . . . . . 11 Osteoporosis ...... 18 Central Nervous System Other ...... 18 Attention Deficit Disorder ...... 11 Pain Relief ...... 18 Depression ...... 11 Overactive Bladder ...... 19 Migraine ...... 11 Multiple Sclerosis ...... 12 Respiratory Other ...... 12 Asthma/COPD ...... 19 Sedatives/Hypnotics ...... 12 Nasal Allergies ...... 19 Seizure Disorders ...... 12 Oral Allergies ...... 19

Dermatology ...... 12 Transplant ...... 19

Diabetes/Endocrine Vitamins/Electrolytes ...... 19 Blood Glucose Monitoring ...... 13 Insulin ...... 14 Women’s Health Non-Insulin ...... 15 Birth Control ...... 20 Hormone Replacement ...... 20 Endocrine Vaginal Anti-Infectives ...... 20 Growth Hormone ...... 15 Other ...... 15 Index ...... 21 Thyroid Hormone Replacement ...... 15

Eye Conditions Allergies ...... 15 Antibiotics ...... 15 Glaucoma ...... 15 Other ...... 16 3 At OptumRx, we want to help you better understand your medication options. Your pharmacy benefit offers flexibility and choice in determining the right medication for you. To help you get the most out of your pharmacy benefit, we’ve included some of the most commonly asked questions about the Formulary.

What is a Formulary? This document is a list of commonly prescribed medications preferred by your plan sponsor for their safety, cost and effectiveness. Drugs are listed by common categories or class. They are placed into cost levels known as tiers. It includes both brand and generic prescription medications approved by the U.S. Food and Drug Administration (FDA). Please note: Where differences are noted between this Formulary and your benefit plan documents, the benefit plan documents will rule. It is not intended to be a complete list of medications, and not all medications listed may be covered under your plan. Please look at your benefit plan documents provided by your employer or plan sponsor to see what medications are covered under your plan. You may also log on to optumrx.com or call the toll-free member phone number on the back of your ID card for more information.

How do I use my Formulary? When choosing a medication, you and your doctor should consult the Formulary. It will help you and your doctor choose the most cost-effective prescription drugs. This guide tells you if a medication is generic or brand, and if special rules apply. Bring this list with you when you see your doctor. It is organized by common medical conditions. Medications are then listed alphabetically. If your medication is not listed in this document, please visit optumrx.com or call the toll-free member phone number on the back of your ID card.

4 What are tiers? Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, which is determined by your employer or plan sponsor. This is how much you will pay when you fill a prescription. Tier 1 medications are your lowest-cost options. If your medication is placed in Tier 2 or 3, look to see if there is a Tier 1 option available. Discuss these options with your doctor. Drug names shown in orange are preferred for their cost and effectiveness. If there is a  symbol in the Drug Tier column, check your benefit plan documents to find out your specific pharmacy plan costs.

$ Drug Tier Includes Helpful Tips

Tier 1 Lower-cost, commonly Use Tier 1 drugs for $ Lowest Cost used generic drugs. the lowest out-of- Some low-cost brands pocket costs. may be included. $$$ $ Tier 2 Many common brand- Use Tier 2 drugs, instead $$$$$ Mid-range name drugs, called of Tier 3, to help reduce Cost preferred brands. your out-of-pocket costs. $$ $$$ $$$$ Tier 3 Mostly higher-cost Many Tier 3 drugs have $$$ Highest Cost brand drugs, also lower-cost options in Tier $$$$ known as non- 1 or 2. Ask your doctor if $$$$$ preferred brands. they could work for you. $$$$ $$$$$ Please$$$$$ note: Some plans may have two or four tiers, while others may not have any. If you have a high deductible plan, the tier cost levels will apply once you hit your deductible. Refer to your enrollment and plan materials on optumrx.com, or call the toll-free member phone number of the back of your ID card for more information about your benefit plan.

When does the Formulary change? • Medications may move to a lower tier at any time. • Medications may move to a higher tier when its generic becomes available. • Medications may move to a higher tier or be excluded from coverage on January 1 or July 1 of each year. When a medication changes tiers, you may have to pay a different amount for that medication. For the most up-to-date list, call customer service at the toll-free member phone number on the back of your ID card. 5 Programs and Limits Some medications are noted with letters or symbols next to them. The letters and symbols refer to our pharmacy benefit programs and are provided to help you check which medications may have a program or limit. Your benefit plan determines how these medications may be covered for you.

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

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

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

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

Specialty Medication – Medication is designated as a specialty SP pharmacy drug.

Gender Restrictions – Some restrictions may apply based GR on patient gender.

To learn more about a pharmacy program or to find out if it applies to you, please visit optumrx.com or call the toll-free member phone number on the back of your ID card.

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

What if I don’t agree with a decision about an excluded medication? You (or your authorized representative) and your doctor can ask for an initial coverage decision by calling the toll-free member phone number on the back of your ID card.

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

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

Is it a generic or brand-name drug? The drug list shows brand-name drugs in bold type (for example, Lamictal) and generic drugs in plain type (for example, lamotrigine).

What if my doctor writes a brand-name prescription? The next time your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lower-cost option is available and if it might be right for you. Generic medications are usually your lowest-cost option, but not always. Visit optumrx.com to make sure.

7 Are you taking a specialty medication? Specialty medications treat rare or complex conditions and are typically higher cost medications. Please note, not all specialty medications are listed in the Formulary. OptumRx is the specialty pharmacy that can provide most of your specialty medications along with helpful programs and services. Call OptumRx® Specialty Pharmacy at 1-888-702-8423 and have your prescriptions delivered right to your home or office.

How do I get updated information about my pharmacy benefit? Since the Formulary may change during your plan year, we encourage you to visit optumrx.com or call the toll-free member phone number on the back of your ID card for more current information. When you register at optumrx.com and open an account, you can use the website’s helpful tools and features to: • Look up the price of drugs covered by your plan • Find lower-cost options • Refill and renew mail service prescriptions • View your order status and claims history • Sign up for text reminders to take and refill your medicine • View your benefits in real time • Order medical supplies • Shop for health and wellness products

More information If you have additional questions please call customer service, 24 hours a day, 7 days a week using the toll-free member phone number on the back of your ID card. Or visit optumrx.com.

8 Drug Programs Drug Programs Drug Name Drug Name Tier and Limits Tier and Limits Sulfamethoxazole- Anti-Infectives: Antibiotics 1 Trimethoprim 1 Sulfamethoxazole- 1 Amoxicillin/Clavulanate 1 Trimethoprim DS 1 Bethkis 2 SP Anti-Infectives: Antifungals Cefadroxil Cap 1 1 Cefdinir 1 Suspension 1 Cefuroxime Tab 1 Terbinafine Tab 1 QL Cephalexin 1 Ciprodex Otic Anti-Infectives: Antivirals 3 Suspension Acyclovir Cap, Tab, 1 Tab 1 Suspension 1 Baraclude 3 QL, SP Cap 1 Daklinza 2 PA, QL, SP Dificid 3 1 QL, SP Hyclate Cap 1 Famciclovir Tab 1 Doxycycline Hyclate Tab 1 Harvoni 2 PA, QL, SP (Immediate Release) Sovaldi 2 PA, QL, ST, SP Doxycycline 1 Tamiflu 3 QL Monohydrate Cap Valacyclovir 1 QL Doxycycline Cancer Monohydrate Oral 1 Suspension, Tab Tab 1 1 Capecitabine 1 SP Tab 1 Letrozole 1 Metronidazole Tab 1 Revlimid 2 PA, QL, SP Cap 1 Tab 1 Moxifloxacin 1 Tasigna 2 PA, QL, SP Neomycin/Polymyxin/ Temozolomide 1 PA, SP HC Otic Suspension, 1 Zytiga 3 PA, SP Solution Cardiovascular/Heart Disease: Anticoagulants 1 Macrocrystalline Brilinta 2 QL Nitrofurantoin 1 QL Monohydrate 1 Effient 2 QL Macrocrystalline Eliquis 3 QL Otic Solution 1 Enoxaparin  QL, SP Oracea 3 QL Pradaxa 2 QL Penicillin VK 1 Savaysa 3 QL Solodyn 3 QL 1 Xarelto 2 QL

Bold type = Brand-name drug PA Prior Authorization AR Age Restrictions [Plain type = Generic drug] ST Step Therapy SP Specialty Program  Call customer service for pricing QL Quantity Limits GR Gender Restrictions 9 Drug Programs Drug Programs Drug Name Drug Name Tier and Limits Tier and Limits Cardiovascular/Heart Disease: /HCTZ 1 QL High Blood Pressure Succinate 1 1 QL Metoprolol Tartrate 1 Amlodipine/Benazepril 1 QL Nadolol 1 Amlodipine/ 1 QL ER 1 Amlodipine/Valsartan/ 1 1 QL HCTZ Propranolol ER 1 Atenolol 1 Quinapril 1 Atenolol/Chlorthalidone 1 1 QL Azor 2 QL, ST 1 Benazepril 1 Tekturna 2 QL, ST Benazepril/HCTZ 1 Tekturna HCT 2 QL, ST Benicar 2 QL, ST 1 QL Benicar HCT 2 QL, ST Terazosin 1 1 Torsemide Tab 1 Bisoprolol/HCTZ 1 Triamterene/HCTZ 1 1 Tribenzor 2 QL, ST Bystolic 2 QL Valsartan 1 QL Cartia XT 1 QL Valsartan/HCTZ 1 QL 1 ER 1 Chlorthalidone 1 Cardiovascular/Heart Disease: Patch 1 QL High Cholesterol Clonidine Tab 1 1 QL Coreg CR 3 QL, ST Cholestyramine 1 Tab 1 Crestor 2 QL Diovan 3 QL 43 mg, 1 48 mg, 50 mg, Edarbi 3 QL, ST 54 mg, 67 mg, 1 QL Edarbyclor 3 QL, ST 130 mg, 134 mg, Enalapril 1 145 mg, 150 mg, Enalapril/HCTZ 1 160 mg, 200 mg Felodipine 1 QL Fenofibrate 40 mg, 3 QL, ST Fosinopril 1 120 mg 1 Gemfibrozil 1 QL Tab 1 Lipitor 3 QL, ST (Immediate Release) Livalo 3 QL, ST Hydralazine 1 1 1 Lovaza 3 QL Irbesartan 1 QL Niacin ER Tab 1 QL Irbesartan/HCTZ 1 QL Omega-3 Acid Cap 1 QL 1 1 gm 1 Praluent  PA, QL, SP Lisinopril/HCTZ 1 Pravastatin 1 Losartan 1 QL

Bold type = Brand-name drug PA Prior Authorization AR Age Restrictions [Plain type = Generic drug] ST Step Therapy SP Specialty Program  Call customer service for pricing QL Quantity Limits GR Gender Restrictions 10 Drug Programs Drug Programs Drug Name Drug Name Tier and Limits Tier and Limits 5 mg, 10 1 QL 1 QL mg, 20 mg, 40 mg ER Cap Simvastatin 80 mg 1 PA, QL Methylphenidate ER Tab 1 QL Vascepa 2 QL Methylphenidate SA 1 QL Vytorin 10-10 mg, Osmotic ER Tab 10-20 mg, 2 QL Methylphenidate Tab 1 QL 10-40 mg Strattera 2 QL Vytorin 10-80 mg 2 PA, QL Vyvanse 2 QL Welchol 2 QL Central Nervous System: Depression Zetia 3 QL 1 Cardiovascular/Heart Disease: Other 1 1 Bupropion ER 1 Amlodipine/Atorvastatin 1 QL Bupropion SR 1 Corlanor 3 PA, QL Bupropion XL 1 QL Digoxin 1 1 QL 1 1 Isosorbide Mononitrate 1 Cap 20 mg, 1 QL Nitrostat 2 30 mg, 60 mg Ranexa 2 ST Escitalopram Tab 1 QL 1 Cap 1 Cardiovascular/Heart Disease: (not PMDD) Pulmonary Arterial Hypertension Fluvoxamine Tab 1 Adcirca 3 PA, QL, SP Forfivo XL 2 QL Adempas 2 PA, QL, SP 1 Letairis 2 PA, QL, SP 1 Opsumit 2 PA, QL, SP Tab 1 Orenitram 3 PA, SP Pristiq 2 QL Tab 20 mg 1 PA, QL, SP 1 Tracleer 2 PA, QL, SP 1 Central Nervous System: Tab 1 Attention Deficit Disorder Venlafaxine ER Cap 1 QL XR Cap 3 QL, ST Venlafaxine ER Tab 1 QL Amphetamine- Viibryd 3 QL, ST 1 QL Central Nervous System: Migraine Tab Amphetamine- Butalbital- Acetaminophen- Dextroamphetamine 1 QL 1 QL SR 24Hr Cap Caffeine Cap, Tab ER 50-325-40 mg 1 QL Cap Migranal 3 QL Focalin XR 3 QL, ST Relpax 3 QL Guanfacine ER Tab 1 QL Tab, ODT 1 QL

Bold type = Brand-name drug PA Prior Authorization AR Age Restrictions [Plain type = Generic drug] ST Step Therapy SP Specialty Program  Call customer service for pricing QL Quantity Limits GR Gender Restrictions 11 Drug Programs Drug Programs Drug Name Drug Name Tier and Limits Tier and Limits Tab 1 QL 1 and Spray (Immediate Release) Sumavel Dose 3 QL Saphris 2 QL Zolmitriptan Tab 1 QL Seroquel XR 2 QL Zomig Nasal Spray 2 QL Zelapar 3 Central Nervous System: Ziprasidone Cap 1 QL Multiple Sclerosis Central Nervous System: Ampyra 2 PA, QL, SP Sedatives/Hypnotics Avonex Kit  PA, QL, SP Tab 1 QL Avonex Pen Kit  PA, QL, SP Silenor 3 QL Avonex Prefill Kit  PA, QL, SP 1 QL Copaxone  PA, QL, SP Triazolam Tab 1 QL Gilenya* 3 PA, QL, ST, SP 1 QL Plegridy  PA, QL, SP Zolpidem ER 1 QL Rebif  PA, QL, ST, SP Central Nervous System: Rebif Titrtn  PA, QL, ST, SP Seizure Disorders Tecfidera 2 PA, QL, SP Tab 1 1 QL Central Nervous System: Other Divalproex DR 1 Divalproex ER 1 Abilify Tab 3 QL 1 Tab 1 QL Lamictal Starter Kit 2 QL 1 QL Lamictal XR 3 QL Benztropine 1 Lamotrigine 1 1 (Immediate Release) Carbidopa/Levodopa Lamotrigine ER 1 QL Tab (Immediate 1 1 Release) Levetiracetam ER 1 QL Diazepam Tab 1 Lyrica Cap 2 QL Tab 1 QL Onfi 3 PA Hydroxyzine HCL 1 1 Hydroxyzine Pamoate 1 1 Latuda 3 QL, ST 1 Carbonate 1 Tab 1 Tab 1 QL Zonisamide 1 1 PA, QL Namenda XR 2 QL Dermatology Nuvigil 3 PA, QL Acanya Gel 3 QL Tab 1 QL Acyclovir Ointment 5% 1 1 Aczone Gel 3 1 Atralin 3 QL , AR 1 QL Benzaclin 3 QL Tab 1 QL 1 * Tier 3 Preferred Dipropionate Cream

Bold type = Brand-name drug PA Prior Authorization AR Age Restrictions [Plain type = Generic drug] ST Step Therapy SP Specialty Program  Call customer service for pricing QL Quantity Limits GR Gender Restrictions 12 Drug Programs Drug Programs Drug Name Drug Name Tier and Limits Tier and Limits Ciclopirox Cream 1 Nystatin Cream, 1 Clindamycin Gel, Ointment, Powder 1 Lotion, Solution Nystatin/ 1 Clindamycin/ Cream, Ointment Benzoyl Peroxide 1 QL Oxsoralen-UL 2 PA Gel 1-5% Permethrin Cream 5% 1 Clindamycin/Benzoyl Proctofoam HC 2 Peroxide Gel 1 QL Retin-A Micro 3 QL, AR Sulfacetamide/Sulfur 1.2-5% 1 Clobetasol Cream, Emulsion 1 Ointment, Solution Taclonex 3 QL Clobex 3 Tazorac 3 AR Cloderm 3 Cream 1 AR Tretinoin Microsphere / 1 QL, AR Betamethasone 1 Gel Cream, Lotion Triamcinolone 1 Desonide Cream, Vectical 3 1 Ointment Zovirax Cream 2 Desoximetasone Cream, Zovirax Ointment 3 1 Zyclara 3 QL Gel, Ointment Differin 3 QL, AR Diabetes/Endocrine Blood: Econazole Cream 1 Glucose Monitoring Elidel 2 QL , ST, AR Accu-Chek Active Epiduo 3 QL, AR Glucose Control 2 Finacea 2 Liquid Fluocinonide Cream, Accu-Chek Active Test 1 2 QL 0.1% Strips Accu-Chek Aviva Plus Fluocinonide Cream, 2 Gel, Ointment, 1 Control Liquid Accu-Chek Aviva Plus Solution 0.05% 2 Cream, Kit 1 Accu-Chek Aviva Plus Ointment 2.5% 2 QL Lidocaine Topical Test Strips 1 Ointment, Solution Accu-Chek Comfort Lidocaine/Prilocaine Curve Control 2 1 Cream Liquid Cream/ Accu-Chek Comfort 1 2 QL Shampoo Curve Test Strips Accu-Chek Compact Metrogel 3 2 Metronidazole Gel Plus Control Liquid 1 Accu-Chek Compact 0.75% 2 QL 1 Plus Test Strips Mupirocin Ointment 1

Bold type = Brand-name drug PA Prior Authorization AR Age Restrictions [Plain type = Generic drug] ST Step Therapy SP Specialty Program  Call customer service for pricing QL Quantity Limits GR Gender Restrictions 13 Drug Programs Drug Programs Drug Name Drug Name Tier and Limits Tier and Limits Accu-Chek Compact Onetouch Kit Verio IQ 2 2 Plus Kit Onetouch Lancets 2 Accu-Chek FastClix Onetouch Test Strips 2 QL 2 Onetouch Ultra Blue Kit 2 QL Accu-Chek FastClix Test Strips 2 Onetouch Verio Lancets 2 QL Accu-Chek Multiclix Test Strips 2 Kit Precision Test Strips 3 QL, ST Accu-Chek Multiclix Truetest Test Strips 3 QL, ST 2 Lancets Truetrack Test Strips 3 QL, ST Accu-Chek Nano 2 Diabetes/Endocrine: Insulin SmartView Kit Accu-Chek SmartView Humalog Vials 2 2 Humalog Kwik Pen Control Liquid 2 Accu-Chek SmartView 100 unit/ml 2 QL Humalog Mix Test Strips 2 Accu-Chek Soft Touch 50/50 Kwik Pen 2 Humalog Mix Lancets 2 Accu-Chek Softclix Kit 2 50/50 Vials Accu-Chek Softclix Humalog Mix 2 2 Lancets 75/25 Kwik Pen Bayer Contour Test Humalog Mix 3 QL, ST 2 Strips 75/25 Vials Dexcom G4 Platinum Humulin 70/30 Vials 2 3 Kit Humulin N Vials 2 Dexcom G4 Platinum Humulin N Pen 2 3 Sensor Kit Humulin Pen 70/30 2 Dexcom G4 Platinum Humulin R U-500 2 3 Humulin R Vials 2 Transmitter Kit Lantus Solostar 2 Freestyle Test Strips 3 QL, ST Lantus Vials 2 Insulin Pen Needle 2 Levemir FlexTouch 2 Insulin Syringe/ 2 Levemir Vials 2 Needle Novolin 70/30 Vials 2 Novofine Pen Needle 2 Novolin N Vials 2 Novofine Autocover 2 Novolin R Vials 2 Pen Needle Novolog Flexpen 2 Novotwist Pen 2 Novolog Mix Flexpen 2 Needle Novolog Mix Onetouch Kit Ultra 2 2 70/30 Vials Smart Novolog Penfill 2 Onetouch Kit Ultra 2 Novolog Vials 2 Onetouch Kit Ultra 2 2 Onetouch Kit Ultra 2 Mini

Bold type = Brand-name drug PA Prior Authorization AR Age Restrictions [Plain type = Generic drug] ST Step Therapy SP Specialty Program  Call customer service for pricing QL Quantity Limits GR Gender Restrictions 14 Drug Programs Drug Programs Drug Name Drug Name Tier and Limits Tier and Limits Prednisolone Solution Diabetes/Endocrine: Non-Insulin 1 25 mg/5 ml Bydureon 2 QL, ST Prednisolone Syrup, 1 Byetta 2 QL, ST Solution 15 mg/5 ml Glimepiride 1 Sensipar 3 Glipizide 1 Endocrine: Glipizide ER 1 Thyroid Hormone Replacement Glipizide XL 1 Armour Thyroid 3 Glumetza 3 PA 1 Glyburide 1 Liothyronine 1 Glyburide/ 1 Methimazole 1 Invokamet 2 QL, ST Synthroid 3 Invokana 2 QL, ST Tirosint 3 Janumet 2 QL, ST Janumet XR 2 QL, ST Eye Conditions: Allergies Januvia 2 QL, ST Azelastine Ophthalmic 1 Jardiance 2 QL, ST Solution Kombiglyze 2 QL, ST Pataday 2 Metformin 1 Patanol 3 QL Metformin ER 1 Onglyza 2 QL, ST Eye Conditions: Antibiotics 1 QL Ciprofloxacin 1 QL Synjardy 2 QL, ST Ophthalmic Solution Trulicity 2 QL, ST Erythromycin Ointment 1 Victoza 2 QL, ST 1 Endocrine: Growth Hormone Moxeza 2 QL Neomycin/Polymyxin Norditropin  PA, SP B/Dexamethasone 1 Nutropin AQ  PA, SP Ointment, Omnitrope  PA, ST, SP Suspension Saizen  PA, SP Ofloxacin Ophthalmic 1 QL Zomacton  PA, ST, SP Solution Endocrine: Other Polymyxin B/ Trimethoprim 1 Cap 1 Solution Dexamethasone Tab 1 Tobramycin 1 Hydrocortisone Tab 1 Tobramycin/ Lupron Depot 1  PA, SP Dexamethasone 3.75 mg, 11.25 mg Vigamox 2 QL Lupron Depot 7.5 mg, 22.5 mg,  PA, SP Eye Conditions: Glaucoma 30 mg, 45 mg Alphagan P 2 QL Methylprednisolone Tab 1 Azopt 2 QL 1 Brimonidine 1

Bold type = Brand-name drug PA Prior Authorization AR Age Restrictions [Plain type = Generic drug] ST Step Therapy SP Specialty Program  Call customer service for pricing QL Quantity Limits GR Gender Restrictions 15 Drug Programs Drug Programs Drug Name Drug Name Tier and Limits Tier and Limits Combigan 2 QL Creon 2 Dorzolamide- Delzicol 3 QL, ST 1 Maleate Dicyclomine 1 1 QL Diphenoxylate/ 1 Lumigan 2 QL Gavilyte Solution 1 QL Timolol 1 Hyoscyamine Sublingual 1 Timoptic Ocudose 2 Tab Travatan Z 2 QL 1 Lialda 2 QL Eye Conditions: Other Linzess 2 QL, ST, AR Durezol Ophthalmic Movantik 2 QL 3 Emulsion Moviprep 3 QL Lotemax Ophthalmic Omeclamox Pak 2 QL 3 QL Gel Pentasa 3 QL Ophthalmic Polyethylene 1 QL 1 Solution Glycol 3350 Powder Prednisolone Protosol HC 1 Ophthalmic 1 Prepopik 3 Suspension Pylera 2 QL Restasis 3 PA 1 Suprep Bowel Prep 3 QL Gastrointestinal: Acid Suppression Uceris 3 Zenpep 2 Carafate Suspension 2 Dexilant 2 QL HIV/AIDS (Rx only) 1 QL Famotidine Tab 20 mg Atripla 2 SP 1 Complera 2 SP and 40 mg (Rx only) Epzicom 2 SP (Rx only) 1 QL (Rx only) 1 QL Intelence 2 SP 1 QL Isentress 2 SP 1 QL Kaletra 2 SP Ranitidine Tab, Cap, 1 SP 1 Norvir 2 SP Syrup (Rx only) Prezcobix 2 SP Sucralfate Tab 1 Prezista 2 SP Gastrointestinal: Nausea/Vomiting Reyataz 2 SP Stribild 2 SP 1 QL Sustiva 2 SP Tab 1 QL Tivicay 2 SP Transderm-Scop 3 Triumeq 2 SP Gastrointestinal: Other Truvada 2 SP Amitiza 2 QL, ST, AR Viread 2 SP Asacol HD 3 QL, ST Canasa 2 QL

Bold type = Brand-name drug PA Prior Authorization AR Age Restrictions [Plain type = Generic drug] ST Step Therapy SP Specialty Program  Call customer service for pricing QL Quantity Limits GR Gender Restrictions 16 Drug Programs Drug Programs Drug Name Drug Name Tier and Limits Tier and Limits Testosterone Cypionate Infertility 1 PA IM Injection Cetrotide  PA, SP Miscellaneous Follistim AQ  PA, SP Gonal-f  PA, SP 1 Gonal-f RFF  PA, SP Antipyrine/Benzocaine Ovidrel  PA, SP Otic Solution 1 5.4 - 1.4% Inflammatory Conditions Aranesp  PA, SP Cimzia Kit  PA, QL, SP 1 Depen 2 Botox 100, 200 unit Humira Kit  PA, QL, SP Injection 2 PA, SP Humira Pen Kit  PA, QL, SP (non-cosmetic) Humira Pen Kit Bunavail 3 PA, QL  PA, QL, SP Crohns Cerdelga 3 PA, QL, SP Humira Pen Kit Chantix 3 QL  PA, QL, SP Psoriasis Cheratussin 1 Hydroxychloroquine 1 Chlorhexidine 1 Tab 1 Colcrys 2 QL Orencia SC  PA, QL, ST, SP Cyproheptadine 1 1 Rasuvo 2 PA, QL Epipen 2-Pak 2 QL Simponi  PA, QL, SP Euflexxa  PA, SP Stelara  PA, QL, SP Fosrenol 3 Men’s Health: Erectile Dysfunction Granix  PA, SP /Codeine Cialis 2 QL, AR, GR 1 Syrup Levitra 3 QL, AR, GR Homatropine/ Stendra 2 QL, AR, GR 1 Hydrocodone Syrup Viagra 3 QL, AR, GR Hydrocodone/ Men’s Health: Prostate Chlorpheniramine 1 Liquid Alfuzosin 1 QL Hydrocortisone AC Avodart 3 QL 1 Doxazosin 1 Suppository 25 mg 5 mg 1 QL Hydromet 1 Lidocaine Viscous Rapaflo 2 QL 1 1 QL Solution 2% Terazosin 1 Makena  PA, SP Neupogen  PA, SP Men’s Health: Testosterone Therapy Phenazopyridine 1 Androderm 2 PA, QL, GR (Rx only) Androgel 1.62% 2 PA, QL, GR Tab 1 PA Androgel 1% 3 PA, QL, ST, GR Procrit  PA, SP

Bold type = Brand-name drug PA Prior Authorization AR Age Restrictions [Plain type = Generic drug] ST Step Therapy SP Specialty Program  Call customer service for pricing QL Quantity Limits GR Gender Restrictions 17 Drug Programs Drug Programs Drug Name Drug Name Tier and Limits Tier and Limits DM Syrup 1 AR Fentanyl Patch Promethazine/Codeine 25 mcg/hr, 1 AR Syrup 50 mcg/hr, 1 QL Pulmozyme 2 SP 75 mcg/hr, Rectiv 3 100 mcg/hr Renvela Tab 2 Fentanyl Patch Rezira 3 37.5 mcg/hr, 1 QL Suboxone Film 2 PA, QL 62.5 mcg/hr, Synagis  PA, SP 87.5 mcg/hr Synvisc  PA, SP Gralise 3 QL, ST Uloric 2 QL, ST Hydrocodone Ursodiol 1 w/ 1 QL Velphoro 3 Tab 7.5-200 mg Zubsolv 2 PA, QL Hydrocodone/APAP Zutripro 3 1 QL 5, 7.5, 10/325 mg Musculoskeletal: Osteoporosis Tab 1 Ibuprofen Tab 400, 600, Alendronate Tab 1 QL 1 QL 800 mg (Rx only) Evista 3 QL Indomethacin Cap 1 QL Forteo  QL, PA, SP Ketorolac Tab 1 QL Ibandronate Tab 1 QL Lazanda 3 PA, QL 1 QL Lidocaine Patch 5% 1 QL Musculoskeletal: Other 1 QL Methadone Tab 1 Tab 1 Morphine Sulfate Tab 1 QL Carisoprodol 350 mg 1 Nabumetone 1 QL Tab 1 (Rx only) 1 QL 5, 10 mg Opana ER 2 QL Metaxalone 1 Tab 5, Methocarbamol 1 10, 15, 30 mg 1 Tizanidine Cap 1 (Immediate Release) Tizanidine Tab 1 Oxycodone 1 QL Musculoskeletal: Pain Relief w/ Acetaminophen Oxycontin 2 QL Acetaminophen 1 QL Subsys 3 PA, QL w/ Codeine Tivorbex 3 QL, ST Cambia 3 QL Tab 50 mg 1 QL Celebrex 3 QL Tramadol 1 QL 1 QL w/ Acetaminophen Tab 1 QL Vicodin 1 QL Embeda 2 QL Vicodin ES 1 QL Endocet Tab 1 QL Voltaren Gel 2 QL Etodolac 1 QL Zohydro ER 3 QL, ST Zorvolex 3 QL

Bold type = Brand-name drug PA Prior Authorization AR Age Restrictions [Plain type = Generic drug] ST Step Therapy SP Specialty Program  Call customer service for pricing QL Quantity Limits GR Gender Restrictions 18 Drug Programs Drug Programs Drug Name Drug Name Tier and Limits Tier and Limits Ventolin HFA 2 QL Overactive Bladder Xolair  PA, SP Enablex 3 QL Xopenex HFA 3 QL, ST Gelnique 2 QL Respiratory: Nasal Allergies Myrbetriq 3 QL, ST Oxybutynin 1 Astepro 3 QL Oxybutynin ER 1 QL Azelastine Spray 1 QL Tolterodine 1 QL Dymista Spray 2 QL Toviaz 3 QL Fluticasone Spray 1 Vesicare 2 QL Ipratropium Spray 1 Nasonex 2 QL Respiratory: Asthma/COPD Omnaris 3 QL Advair Diskus 2 QL QNasl 3 QL Advair HFA 2 QL Triamcinolone Spray 1 Aerospan 3 QL Zetonna 3 QL Albuterol 1 QL Respiratory: Oral Allergies Nebulizer Solution Anoro Ellipta 2 QL Promethazine Tab 1 AR Arnuity Ellipta 2 QL Desloratadine 1 QL Breo Ellipta 2 QL 1 QL Inhalation 1 QL Transplant Suspension Combivent Respimat 2 QL Azathioprine Tab 1 Dulera 3 QL, ST Cellcept Tab/ 3 SP Flovent Diskus 2 QL Suspension Flovent HFA 2 QL Cyclosporine Cap 1 SP Foradil 2 QL Mycophenolate Mofetil Incruse Ellipta 2 QL 250 mg Cap/ 1 SP Ipratropium/Albuterol 1 QL 500 mg Tab Nebulizer Solution Mycophenolate Sodium Levalbuterol 1 QL 180 mg, 360 mg 1 SP Nebulizer Solution Tab 1 QL Prograf Cap 3 SP Perforomist 3 QL Rapamune 3 SP Proair HFA, RespiClick 2 QL Tacrolimus Cap 1 SP Proventil HFA 3 QL, ST Pulmicort Flexhaler 2 QL Vitamins/Electrolytes Qvar 2 QL Cyanocobalamine 1 Serevent Diskus 2 QL Injection Spiriva Handihaler 2 QL Folic Acid 1 mg Spiriva Respimat 2 QL 1 (Rx only) Stiolto 2 QL Klor-Con 8 and 10 MEQ 1 Symbicort 2 QL Klor-Con M10 and M20 1 Tudorza Pressair 2 QL

Bold type = Brand-name drug PA Prior Authorization AR Age Restrictions [Plain type = Generic drug] ST Step Therapy SP Specialty Program  Call customer service for pricing QL Quantity Limits GR Gender Restrictions 19 Drug Programs Drug Programs Drug Name Drug Name Tier and Limits Tier and Limits Potassium Chloride ER Orsythia 1 GR 1 Tab, Cap Ortho Tri-Cyclen Lo 3 GR Potassium Chloride Previfem 1 GR 1 Micro ER Tab Reclipsen 1 GR Potassium Citrate Sprintec 28 1 GR 540 mg, 1080 mg 1 Tri-Linyah 1 GR Tab Tri-Previfem 1 GR Vitamin D 50,000 units Trinessa 1 GR 1 (Rx only) Tri-Sprintec 1 GR Vestura 1 GR Women’s Health: Birth Control Viorele 1 GR Apri 1 GR Xulane 1 GR Aviane 1 GR Zarah 1 GR Azurette 1 GR Women’s Health: Hormone Replacement Cryselle-28 1 GR Falmina 1 GR Climara Pro 2 QL, GR Generess Fe Divigel 3 GR 3 GR Chewable Duavee 2 QL, GR Gianvi 1 GR Elestrin Gel 3 GR Gildess 1 GR Estrace Vaginal Cream 3 Jolivette 1 GR Tab 1 QL, GR Estradiol/Norethindrone Junel 1 GR 1 QL, GR Kariva 1 GR Tab Medroxyprogesterone Levora 28 1 GR 1 Lo Loestrin 3 GR Acetate Tab Lomedia Fe 1 GR Minivelle 3 QL, GR Loryna 1 GR Osphena 3 Low-Ogestrel 1 GR Premarin Tab 2 QL, GR Premarin Vaginal Lutera 1 GR 2 Medroxyprogesterone Cream 1 QL Acetate Injection Premphase 2 QL, GR Microgestin 1 GR Prempro 2 QL, GR Microgestin Fe 1 GR Progesterone Cap 1 Minastrin 24 Fe Vagifem 3 GR 3 GR Chewable Women’s Health: Vaginal Anti-Infectives Mono-Linyah 1 GR Gynazole-1 Vaginal Mononessa 1 GR 3 Cream Natazia 2 GR Metronidazole Necon 1 GR 1 Nora-Be 1 GR Vaginal Gel Terconazole Norgest/Ethi Estradio 1 GR 1 QL Nortrel 1 GR Vaginal Cream Nuvaring 2 Ocella 1 GR

Bold type = Brand-name drug PA Prior Authorization AR Age Restrictions [Plain type = Generic drug] ST Step Therapy SP Specialty Program  Call customer service for pricing QL Quantity Limits GR Gender Restrictions 20 Index of Covered Drugs

A Allopurinol ...... 17 B Alphagan P ...... 15 Abilify Tab ...... 12 Alprazolam Tab . . . . . 12 Baclofen Tab ...... 18 Acanya Gel 12 Amiodarone 11 Baraclude ...... 9 Accu-Chek Active Glucose Amitiza 16 Bayer Contour Test Strips 14 Control Liquid . . . .13 Amitriptyline ...... 11 Benazepril 10 Accu-Chek Active Amlodipine ...... 10 Benazepril/HCTZ . . . . 10 Test Strips . . . . . 13 Amlodipine/Atorvastatin . .11 Benicar 10 Accu-Chek Aviva Plus Amlodipine/Benazepril . . 10 Benicar HCT ...... 10 Control Liquid . . . .13 Amlodipine/Valsartan . . . 10 Benzaclin 12 Accu-Chek Aviva Plus Kit . 13 Amlodipine/Valsartan/HCTZ . 10 Benzonatate ...... 17 Accu-Chek Aviva Plus Test Amoxicillin ...... 9 Benztropine 12 Strips 13 Amoxicillin/Clavulanate . . . 9 Betamethasone Dipropionate 12 Accu-Chek Comfort Curve Amphetamine-Dextroamph- Bethkis 9 Control Liquid . . . .13 etamine SR 24Hr Cap . . 11 Bisoprolol ...... 10 Accu-Chek Comfort Curve Amphetamine- Bisoprolol/HCTZ 10 Test Strips . . . . . 13 Dextroamphetamine Tab 11 Botox 100, 200 unit Accu-Chek Compact Plus Ampyra ...... 12 Injection 17 Control Liquid . . . .13 Anastrozole Tab 9 Breo Ellipta ...... 19 Accu-Chek Compact Androderm ...... 17 Brilinta 9 Plus Kit 14 Androgel 1% . . . . . 17 Brimonidine 15 Accu-Chek Compact Plus Androgel 1.62% 17 Budesonide Inhalation Test Strips . . . . . 13 Anoro Ellipta . . . . . 19 Suspension . . . . . 19 Accu-Chek FastClix Kit . .14 Antipyrine/Benzocaine Otic Bumetanide 10 Accu-Chek FastClix Lancets 14 Solution 5.4 - 1.4% . . . 17 Bunavail ...... 17 Accu-Chek Multiclix Kit . . 14 Apri 20 Bupropion 11 Accu-Chek Multiclix Lancets 14 Aranesp ...... 17 Bupropion ER ...... 11 Accu-Chek Nano Aripiprazole 12 Bupropion SR ...... 11 SmartView Kit 14 Armour Thyroid . . . . 15 Bupropion XL ...... 11 Accu-Chek SmartView Arnuity Ellipta 19 Buspirone 12 Control Liquid . . . .14 Asacol HD ...... 16 Butalbital-Acetaminophen- Accu-Chek SmartView Astepro ...... 19 Caffeine Cap, Tab . . . 11 Test Strips . . . . . 14 Atenolol 10 Bydureon ...... 15 Accu-Chek Softclix Kit 14 Atenolol/Chlorthalidone 10 Byetta ...... 15 Accu-Chek Softclix Lancets 14 Atorvastatin ...... 10 Bystolic 10 Accu-Chek Soft Atralin ...... 12 Touch Lancets . . . .14 Atripla ...... 16 C Acetaminophen w/ Codeine 18 Aviane ...... 20 Acyclovir Cap, Tab, Suspension 9 Avodart ...... 17 Calcitriol Cap ...... 15 Acyclovir Ointment 5% . . 12 Avonex Kit 12 Cambia 18 Aczone Gel 12 Avonex Pen Kit . . . . 12 Canasa ...... 16 Adcirca 11 Avonex Prefill Kit . . . .12 Capecitabine ...... 9 Adderall XR Cap 11 Azathioprine Tab . . . . 19 Carafate Suspension . . 16 Adempas 11 Azelastine Ophthalmic Carbamazepine Tab 12 Advair Diskus . . . . . 19 Solution 15 Carbidopa/Levodopa Tab . .12 Advair HFA ...... 19 Azelastine Spray 19 Carisoprodol ...... 18 Aerospan ...... 19 Azithromycin ...... 9 Cartia XT ...... 10 Albuterol Nebulizer Solution 19 Azopt ...... 15 Carvedilol 10 Alendronate Tab . . . . 18 Azor ...... 10 Cefadroxil Cap . . . . . 9 Alfuzosin ...... 17 Azurette ...... 20 Cefdinir 9 Bold type = Brand-name drug [Plain type = Generic drug] 21 Index of Covered Drugs

Cefuroxime Tab . . . . . 9 Cyclobenzaprine Tab . . . 18 E Celebrex ...... 18 Cyclosporine Cap . . . . 19 Celecoxib ...... 18 Cyproheptadine 17 Econazole Cream . . . . 13 Cellcept Tab/Suspension . 19 Edarbi ...... 10 Edarbyclor ...... 10 Cephalexin ...... 9 D Cerdelga ...... 17 Effient ...... 9 Cetrotide 17 Daklinza ...... 9 Elestrin Gel ...... 20 Chantix 17 Delzicol ...... 16 Elidel 13 Cheratussin ...... 17 Depen ...... 17 Eliquis ...... 9 Chlorhexidine 17 Desloratadine ...... 19 Embeda ...... 18 Chlorthalidone . . . . . 10 Desmopressin 17 Enablex ...... 19 Cholestyramine . . . . . 10 Desonide Cream, Ointment . 13 Enalapril 10 Cialis ...... 17 Desoximetasone Cream, Gel, Enalapril/HCTZ . . . . . 10 Ciclopirox Cream . . . . 13 Ointment ...... 13 Endocet Tab 18 Cimzia Kit ...... 17 Dexamethasone Tab . . . 15 Enoxaparin ...... 9 Ciprodex Otic Suspension . 9 Dexcom G4 Platinum Kit . 14 Entecavir ...... 9 Ciprofloxacin Ophthalmic Dexcom G4 Platinum Epiduo ...... 13 Solution 15 Sensor Kit . . . . . 14 Epipen 2-Pak 17 Ciprofloxacin Tab . . . . . 9 Dexcom G4 Platinum Epzicom ...... 16 Citalopram ...... 11 Transmitter Kit 14 Erythromycin . . . . . 9, 15 Clarithromycin . . . . . 9 Dexilant ...... 16 Escitalopram Tab . . . . 11 Climara Pro ...... 20 Dexmethylphenidate ER Cap 11 Esomeprazole 16 Clindamycin/Benzoyl Peroxide Diazepam Tab 12 Estrace Vaginal Cream . .20 Gel 1.2-5% . . . . . 13 Diclofenac Tab . . . . . 18 Estradiol/Norethindrone Tab 20 Clindamycin/Benzoyl Peroxide Dicyclomine ...... 16 Estradiol Tab ...... 20 Gel 1-5% ...... 13 Differin 13 Eszopiclone Tab . . . . . 12 Clindamycin Cap . . . . . 9 Dificid ...... 9 Etodolac ...... 18 Clindamycin Gel, Lotion, Digoxin ...... 11 Euflexxa ...... 17 Solution 13 Diltiazem Tab ...... 10 Evista 18 Clobetasol Cream, Ointment, Diovan ...... 10 Solution 13 Diphenoxylate/Atropine 16 F Clobex ...... 13 Divalproex DR 12 Cloderm ...... 13 Divalproex ER ...... 12 Falmina ...... 20 Clonazepam ...... 12 Divigel ...... 20 Famciclovir Tab . . . . . 9 Clonidine Patch . . . . . 10 Donepezil Tab 12 Famotidine Tab . . . . . 16 Clonidine Tab ...... 10 Dorzolamide-Timolol Maleate 16 Felodipine 10 Clopidogrel ...... 9 Doxazosin 10, 17 Fenofibrate ...... 10 Clotrimazole/Betamethasone Doxepin 11 Fenofibrate 10 Cream, Lotion 13 Doxycycline Hyclate . . . . 9 Fentanyl Patch . . . . . 18 Colcrys ...... 17 Doxycycline Monohydrate 9 Finacea 13 Combigan ...... 16 Duavee 20 Finasteride ...... 17 Combivent Respimat . . 19 Dulera ...... 19 Flecainide ...... 11 Complera ...... 16 Duloxetine Cap . . . . . 11 Flovent Diskus 19 Copaxone ...... 12 Durezol Ophthalmic Flovent HFA ...... 19 Coreg CR 10 Emulsion ...... 16 Fluconazole ...... 9 Corlanor ...... 11 Dymista Spray 19 Fluocinonide Cream, 0.1% 13 Creon 16 Fluocinonide Cream, Gel, Crestor 10 Ointment, Solution 0.05% 13 Cryselle-28 ...... 20 Fluoxetine Cap . . . . . 11 Cyanocobalamine Injection . 19 Fluticasone Spray . . . . 19 Bold type = Brand-name drug [Plain type = Generic drug] 22 Index of Covered Drugs

Fluvoxamine Tab . . . . 11 Humalog Mix Isosorbide Mononitrate . . 11 Focalin XR ...... 11 75/25 Kwik Pen . . . 14 Folic Acid ...... 19 Humalog Mix 75/25 Vials 14 J Follistim AQ ...... 17 Humalog Vials 14 Foradil ...... 19 Humira Kit 17 Janumet ...... 15 Forfivo XL ...... 11 Humira Pen Kit . . . . 17 Janumet XR ...... 15 Forteo ...... 18 Humira Pen Kit Crohns . . 17 Januvia 15 Fosinopril ...... 10 Humira Pen Kit Psoriasis . 17 Jardiance 15 Fosrenol ...... 17 Humulin 70/30 Vials 14 Jolivette 20 Freestyle Test Strips 14 Humulin N Pen . . . . 14 Junel ...... 20 Furosemide ...... 10 Humulin N Vials ...... 14 Humulin Pen 70/30 . . . 14 K G Humulin R U-500 . . . .14 Humulin R Vials . . . . 14 Kaletra 16 Gabapentin ...... 12 Hydralazine ...... 10 Kariva 20 Gavilyte Solution . . . . 16 Hydrochlorothiazide 10 Ketoconazole Gelnique 19 Hydrocodone/APAP . . . 18 Cream/Shampoo . . . 13 Gemfibrozil ...... 10 Hydrocodone/ Ketorolac Ophthalmic Generess Fe Chewable . .20 Chlorpheniramine Liquid 17 Solution 16 Gentamicin ...... 15 Hydrocodone w/ Ibuprofen . 18 Ketorolac Tab ...... 18 Gianvi 20 Hydrocortisone AC Klor-Con 8 and 10 MEQ 19 Gildess ...... 20 Suppository . . . . . 17 Klor-Con M10 and M20 19 Gilenya 12 Hydrocortisone Cream, Kombiglyze ...... 15 Glimepiride ...... 15 Ointment 2.5% . . . .13 Glipizide ...... 15 Hydrocortisone Tab . . . .15 L Glipizide ER ...... 15 Hydromet 17 Glipizide XL ...... 15 Hydromorphone Tab . . . 18 Labetalol ...... 10 Glumetza ...... 15 Hydroxychloroquine 17 Lactulose ...... 16 Glyburide ...... 15 Hydroxyzine HCL . . . . 12 Lamictal Starter Kit . . . 12 Glyburide/Metformin . . . 15 Hydroxyzine Pamoate . . . 12 Lamictal XR ...... 12 Gonal-f 17 Hyoscyamine Sublingual Tab 16 Lamotrigine ER . . . . . 12 Gonal-f RFF ...... 17 Lamotrigine 12 Gralise ...... 18 Lansoprazole ...... 16 I Granix ...... 17 Lantus Solostar . . . . 14 Guaifenesin/Codeine Syrup . 17 Ibandronate Tab 18 Lantus Vials ...... 14 Guanfacine ER Tab . . . .11 Ibuprofen Tab 4 18 Latanoprost 16 Guanfacine Tab . . . . . 10 Incruse Ellipta . . . . . 19 Latuda ...... 12 Gynazole-1 Vaginal Cream 20 Indomethacin Cap . . . .18 Lazanda ...... 18 Insulin Pen Needle . . . 14 Letairis 11 H Insulin Syringe/Needle 14 Letrozole ...... 9 Intelence ...... 16 Levalbuterol Harvoni ...... 9 Invokamet ...... 15 Nebulizer Solution 19 Homatropine/Hydrocodone Invokana 15 Levemir FlexTouch 14 Syrup ...... 17 Ipratropium/Albuterol Levemir Vials . . . . . 14 Humalog Kwik Pen Nebulizer Solution 19 Levetiracetam 12 100 unit/ml 14 Ipratropium Spray 19 Levetiracetam ER . . . . 12 Humalog Mix Irbesartan 10 Levitra ...... 17 50/50 Kwik Pen . . . 14 Irbesartan/HCTZ 10 Levocetirizine ...... 19 Humalog Mix 50/50 Vials 14 Isentress ...... 16 Levofloxacin Tab 9

Bold type = Brand-name drug [Plain type = Generic drug] 23 Index of Covered Drugs

Levora 28 ...... 20 Metoclopramide . . . . 16 Nitrofurantoin Monohydrate Levothyroxine 15 Metoprolol Succinate . . . 10 Macrocrystalline 9 Lialda 16 Metoprolol Tartrate . . . .10 Nitrostat ...... 11 Lidocaine Patch 5% 18 Metrogel 13 Nora-Be 20 Lidocaine/Prilocaine Cream . 13 Metronidazole Gel 0.75% 13 Norditropin ...... 15 Lidocaine Topical Ointment, Metronidazole Tab . . . . 9 Norgest/Ethi Estradio . . . 20 Solution 13 Metronidazole Vaginal Gel . 20 Nortrel ...... 20 Lidocaine Viscous Microgestin ...... 20 Nortriptyline 11 Solution 2% 17 Microgestin Fe . . . . . 20 Norvir ...... 16 Linzess ...... 16 Migranal 11 Novofine Autocover Liothyronine ...... 15 Minastrin 24 Fe Chewable 20 Pen Needle 14 Lipitor ...... 10 Minivelle 20 Novofine Pen Needle . . 14 Lisinopril ...... 10 Minocycline Cap . . . . . 9 Novolin 70/30 Vials . . . 14 Lisinopril/HCTZ . . . . . 10 Mirtazapine 11 Novolin N Vials . . . . 14 Lithium Carbonate . . . .12 Modafinil ...... 12 Novolin R Vials . . . . 14 Livalo 10 Mometasone ...... 13 Novolog Flexpen . . . .14 Lo Loestrin 20 Mono-Linyah ...... 20 Novolog Mix 70/30 Vials . 14 Lomedia Fe ...... 20 Mononessa ...... 20 Novolog Mix Flexpen . . 14 Lorazepam Tab . . . . . 12 Montelukast ...... 19 Novolog Penfill . . . . 14 Loryna ...... 20 Morphine Sulfate Tab . . . 18 Novolog Vials . . . . . 14 Losartan 10 Movantik ...... 16 Novotwist Pen Needle . .14 Losartan/HCTZ . . . . . 10 Moviprep ...... 16 Nutropin AQ 15 Lotemax Ophthalmic Gel . 16 Moxeza ...... 15 Nuvaring 20 Lovastatin ...... 10 Moxifloxacin ...... 9 Nuvigil ...... 12 Lovaza ...... 10 Mupirocin Ointment . . . 13 Nystatin 13 Low-Ogestrel ...... 20 Mycophenolate Mofetil . . 19 Nystatin Suspension 9 Lumigan ...... 16 Mycophenolate Sodium 19 Nystatin/Triamcinolone Cream, Lupron Depot 15 Myrbetriq ...... 19 Ointment ...... 13 Lutera 20 Lyrica Cap ...... 12 N O

M Nabumetone ...... 18 Ocella 20 Nadolol ...... 10 Ofloxacin Ophthalmic Solution 15 Makena ...... 17 Namenda XR 12 Ofloxacin Otic Solution . . . 9 Medroxyprogesterone Acetate 20 Naproxen ...... 18 Olanzapine Tab . . . . . 12 Meloxicam ...... 18 Nasonex ...... 19 Omeclamox Pak . . . . 16 Metaxalone ...... 18 Natazia 20 Omega-3 Acid Cap . . . .10 Metformin ...... 15 Necon 20 Omeprazole 16 Metformin ER 15 Neomycin/Polymyxin B/ Omnaris ...... 19 Methadone Tab . . . . . 18 Dexamethasone Ointment, Omnitrope 15 Methimazole ...... 15 Suspension . . . . . 15 Ondansetron Tab . . . . 16 Methocarbamol 18 Neomycin/Polymyxin/HC Otic Onetouch Kit Ultra . . . 14 Methotrexate Tab . . . . 17 Suspension, Solution . . 9 Onetouch Kit Ultra 2 . . 14 Methylphenidate ER 11 Neupogen ...... 17 Onetouch Kit Ultra Mini . 14 Methylphenidate SA Nevirapine ...... 16 Onetouch Kit Ultra Smart 14 Osmotic ER Tab . . . .11 Niacin ER Tab ...... 10 Onetouch Kit Verio IQ 14 Methylphenidate Tab . . . 11 Nifedipine ER ...... 10 Onetouch Lancets 14 Methylprednisolone Tab 15 Nitrofurantoin Macrocrystalline 9 Onetouch Test Strips . . 14

Bold type = Brand-name drug [Plain type = Generic drug] 24 Index of Covered Drugs

Onetouch Ultra Blue Pravastatin ...... 10 Rasuvo 17 Test Strips . . . . . 14 Precision Test Strips 14 Rebif ...... 12 Onetouch Verio Test Strips 14 Prednisolone Ophthalmic Rebif Titrtn ...... 12 Onfi ...... 12 Suspension . . . . . 16 Reclipsen ...... 20 Onglyza ...... 15 Prednisolone ...... 15 Rectiv ...... 18 Opana ER ...... 18 Prednisone ...... 15 Relpax ...... 11 Opsumit ...... 11 Premarin Tab 20 Renvela Tab ...... 18 Oracea ...... 9 Premarin Vaginal Cream . 20 Restasis ...... 16 Orencia SC 17 Premphase 20 Retin-A Micro . . . . . 13 Orenitram ...... 11 Prempro ...... 20 Revlimid ...... 9 Orsythia 20 Prepopik ...... 16 Reyataz ...... 16 Ortho Tri-Cyclen Lo . . . 20 Previfem ...... 20 Rezira ...... 18 Osphena ...... 20 Prezcobix ...... 16 Risperidone Tab . . . . . 12 Ovidrel 17 Prezista ...... 16 Rizatriptan Tab, ODT . . . 11 Oxcarbazepine . . . . . 12 Primidone 12 Ropinirole 12 Oxsoralen-UL . . . . . 13 Pristiq ...... 11 Oxybutynin 19 Proair HFA, RespiClick 19 S Oxybutynin ER . . . . . 19 Prochlorperazine . . . . 12 Oxycodone Tab . . . . . 18 Procrit ...... 17 Saizen ...... 15 Oxycodone Proctofoam HC . . . . 13 Saphris 12 w/ Acetaminophen . . 18 Progesterone Cap 20 Savaysa ...... 9 Oxycontin ...... 18 Prograf Cap ...... 19 Sensipar ...... 15 Promethazine/Codeine Syrup 18 Serevent Diskus . . . . 19 P Promethazine DM Syrup . .18 Seroquel XR ...... 12 Promethazine Tab 19 Sertraline ...... 11 Pantoprazole ...... 16 Propranolol ...... 10 Sildenafil Tab ...... 11 Paroxetine Tab . . . . . 11 Propranolol ER . . . . . 10 Silenor ...... 12 Pataday ...... 15 Protosol HC 16 Simponi ...... 17 Patanol 15 Proventil HFA . . . . . 19 Simvastatin ...... 11 Penicillin VK 9 Pulmicort Flexhaler . . . 19 Solodyn ...... 9 Pentasa ...... 16 Pulmozyme ...... 18 Sotalol ...... 11 Perforomist ...... 19 Pylera ...... 16 Sovaldi 9 Permethrin Cream 5% . . 13 Spiriva Handihaler . . . 19 Phenazopyridine . . . . 17 Q Spiriva Respimat . . . .19 Phentermine Tab . . . . 17 Spironolactone . . . . . 10 Phenytoin 12 QNasl 19 Sprintec 28 ...... 20 Pioglitazone 15 Quetiapine ...... 12 Stelara ...... 17 Plegridy ...... 12 Quinapril ...... 10 Stendra ...... 17 Polyethylene Glycol Qvar ...... 19 Stiolto ...... 19 3350 Powder . . . . 16 Strattera ...... 11 Polymyxin B/Trimethoprim R Stribild 16 Solution 15 Suboxone Film 18 Potassium Chloride ER . . 20 Rabeprazole 16 Subsys ...... 18 Potassium Chloride Micro ER 20 Raloxifene 18 Sucralfate Tab 16 Potassium Citrate . . . . 20 Ramipril 10 Sulfacetamide/Sulfur Emulsion 13 Pradaxa ...... 9 Ranexa 11 Sulfamethoxazole-Trimethoprim 9 Praluent ...... 10 Ranitidine 16 Sulfamethoxazole- Pramipexole 12 Rapaflo 17 Trimethoprim DS . . . 9 Rapamune ...... 19

Bold type = Brand-name drug [Plain type = Generic drug] 25 Index of Covered Drugs

Sulfasalazine ...... 16 Tramadol w/ Acetaminophen 18 Vicodin ES 18 Sumatriptan Tab and Spray . 12 Transderm-Scop . . . . 16 Victoza 15 Sumavel Dose . . . . . 12 Travatan Z ...... 16 Vigamox ...... 15 Suprep Bowel Prep . . . 16 Trazodone 11 Viibryd 11 Sustiva 16 Tretinoin Cream 13 Viorele ...... 20 Symbicort ...... 19 Tretinoin Microsphere Gel 13 Viread ...... 16 Synagis 18 Triamcinolone 13 Vitamin D 20 Synjardy ...... 15 Triamcinolone Spray 19 Voltaren Gel 18 Synthroid ...... 15 Triamterene/HCTZ 10 Vytorin 11 Synvisc 18 Triazolam Tab ...... 12 Vyvanse ...... 11 Tribenzor 10 T Tri-Linyah ...... 20 W Trinessa ...... 20 Taclonex ...... 13 Tri-Previfem ...... 20 Warfarin ...... 9 Tacrolimus Cap . . . . . 19 Tri-Sprintec ...... 20 Welchol ...... 11 Tamiflu 9 Triumeq ...... 16 Tamoxifen Tab 9 Truetest Test Strips . . . 14 X Tamsulosin ...... 17 Truetrack Test Strips 14 Tasigna 9 Trulicity ...... 15 Xarelto 9 Tazorac 13 Truvada ...... 16 Xolair 19 Tecfidera 12 Tudorza Pressair 19 Xopenex HFA . . . . . 19 Tekturna ...... 10 Xulane ...... 20 Tekturna HCT . . . . . 10 U Telmisartan ...... 10 Z Temazepam 12 Uceris ...... 16 Temozolomide . . . . . 9 Uloric 18 Zarah ...... 20 Terazosin ...... 10, 17 Ursodiol 18 Zelapar 12 Terbinafine Tab . . . . . 9 Zenpep ...... 16 Terconazole Vaginal Cream . 20 V Zetia ...... 11 Testosterone Cypionate IM Zetonna ...... 19 Injection 17 Vagifem ...... 20 Ziprasidone Cap 12 Timolol ...... 16 Valacyclovir ...... 9 Zohydro ER ...... 18 Timoptic Ocudose 16 Valsartan ...... 10 Zolmitriptan Tab 12 Tirosint 15 Valsartan/HCTZ . . . . . 10 Zolpidem ...... 12 Tivicay ...... 16 Vascepa ...... 11 Zolpidem ER 12 Tivorbex ...... 18 Vectical 13 Zomacton ...... 15 Tizanidine 18 Velphoro 18 Zomig Nasal Spray . . . 12 Tobramycin ...... 15 Venlafaxine ER . . . . . 11 Zonisamide ...... 12 Tobramycin/Dexamethasone 15 Venlafaxine Tab . . . . . 11 Zorvolex ...... 18 Tolterodine ...... 19 Ventolin HFA . . . . . 19 Zovirax 13 Topiramate Tab . . . . . 12 Verapamil ER ...... 10 Zubsolv ...... 18 Torsemide Tab 10 Vesicare ...... 19 Zutripro ...... 18 Toviaz ...... 19 Vestura ...... 20 Zyclara ...... 13 Tracleer ...... 11 Viagra ...... 17 Zytiga ...... 9 Tramadol Tab ...... 18 Vicodin ...... 18

Bold type = Brand-name drug [Plain type = Generic drug] 26 “My Medications” worksheet Take this worksheet with you each time you visit a doctor. Each of your doctors should be aware of every drug you take and you should have a list as well.

Name of Medicine Drug I Take This Directions Doctor and Strength Tier Medicine For

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

27 optumrx.com

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