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Additional Drug Coverage

Additional prescription drug coverage Your plan includes extra coverage for certain drugs and supplies as shown below. This is not a complete list of prescription drugs and supplies covered by our plan. For a complete list, please call Customer Service toll-free at 1-888-803-9217, TTY 711, 8 a.m. – 8 p.m. local time, Monday – Friday. Lower-cost Medicare prescription drugs and supplies Your plan covers some of your Medicare prescription drugs and supplies at a lower drug copay than in your drug list (formulary). The amount you pay for these prescription drugs and supplies does apply to your Medicare prescription drug out-of-pocket costs. Payments for these prescription drugs (made by you or the plan) are treated the same as payments made for drugs in your plan’s drug list (formulary).1 These drugs and supplies are part of your Medicare prescription drug coverage.1

Birth Control Alogliptin Tablet Alogliptin/Metformin Tablet All contraceptive medications and devices Alogliptin/Pioglitazone Tablet Blood Glucose Meters, Test Strips and Amaryl Tablet Lancets Apidra Injection ACCU-CHEK® Aviva Plus Test Strips Avandia Tablet ACCU-CHEK® Guide Meter & Test Strip Baqsimi Nasal Powder ACCU-CHEK® Guide Me Meter & Test Strip Basaglar Injection ACCU-CHEK® SmartView Test Strips Bydureon Injection Lancets Byetta Injection Lancing devices Cycloset Tablet OneTouch Ultra® Test Strips Diazoxide Suspension ™ OneTouch Verio® Flex Meter & Test Strips Duetact Tablet ™ OneTouch Verio® Reflect Meter & Test Strips Farxiga Tablet Diabetes drugs and supplies Fiasp Injection Acarbose Tablet Gauze Pads 2"X2" Actoplus Met (XR) Tablet Glimepiride Tablet Actos Tablet Glipizide (ER & XL) Tablet Adlyxin Injection Glipizide/Metformin Tablet Admelog Injection Glucagen Hypokit Afrezza Inhalation Powder Glucagon Emergency Kit Swabs Glucophage (XR) Tablet

Y0066_200527_081500_C Glucotrol (XL) Tablet Pioglitazone/Glimepiride Tablet Glyburide (Micronized) Tablet Pioglitazone/Metformin Tablet Glyburide/Metformin Tablet Prandin Tablet Glynase Tablet Precose Tablet Glyset Tablet Proglycem Suspension Glyxambi Tablet Qtern Tablet Gvoke Injection Repaglinide Tablet Humalog Injection Riomet Solution Humulin Injection Rybelsus Tablet InPen Insulin Pen Segluromet Tablet Insulin Syringes Soliqua Injection Invokamet (XR) Tablet Starlix Tablet Invokana Tablet Steglatro Tablet Janumet (XR) Tablet Steglujan Tablet Januvia Tablet Symlinpen Injection Jardiance Tablet Synjardy (XR) Tablet Jentadueto (XR) Tablet Tolbutamide Tablet Kazano Tablet Toujeo Injection Kombiglyze XR Tablet Tradjenta Tablet Korlym Tablet Tresiba Injection Lantus Injection Trijardy XR Tablet Levemir Injection Trulicity Injection Metformin (ER) Tablet V-Go Device Miglitol Tablet Victoza Injection Myxredlin Xigduo XR Tablet Nateglinide Tablet Xultophy Injection Nesina Tablet Tobacco Cessation Novolin Injection Bupropion 150 SR Tablet Novolog Injection Chantix Tablet Omnipod System Nicotrol Inhaler Onglyza Tablet Nicotrol Nasal Spray Oseni Tablet Zyban 150mg SR Tablet Ozempic Injection Vaccines Pen Needles Pioglitazone Tablet All vaccines Bold type = Brand name drug Plain type = Generic drug The drugs listed below to treat asthma or COPD, heart disease/heart failure, hypertension and cholesterol are available at a reduced copay. See your Evidence of Coverage for information about copays.

Asthma or Chronic Obstructive Pulmonary Nucala Injection Disease (COPD) Perforomist Inhalation Accolate Tablets Proair HFA & Respiclick Advair Diskus & HFA Proventil HFA Airduo Respiclick Pulmicort Flexhaler & Inhalation Albuterol Inhalation, Syrup and (ER) Tablet Qvar Inhaler & RediHaler Alvesco Inhaler Seebri Neohaler Aminophylline Injection Serevent Diskus Anoro Ellipta Singulair Granules & (Chewable) Tablets Arcapta Neohaler Spiriva Handihaler & Respimat Arnuity Ellipta Stiolto Respimat Asmanex HFA & Twisthaler Striverdi Respimat Atrovent HFA Symbicort Inhaler Bevespi Aerosphere Terbutaline Injection & Tablet Breo Ellipta Theo-24 CR & ER Capsule Brovana Inhalation Theophylline Injection, Oral Solution, CR & ER Tablet Budesonide Inhalation Trelegy Ellipta Cinqair Injection Tudorza Pressair Combivent Respimat Utibron Neohaler Cromolyn Inhalation Ventolin HFA Daliresp Tablet Wixela Inhub Duaklir Inhaler Xolair Injection Dulera Inhaler Xopenex HFA & Inhalation Dupixent Injection Yupelri Inhalation Elixophyllin Elixir Zafirlukast Tablet Fasenra Injection Zileuton ER Tablet Flovent Diskus & HFA Zyflo (CR) Tablet Fluticasone Propionate/Salmeterol Diskus & HFA Hyperlipidemia (high cholesterol) Incruse Ellipta Altoprev ER Tablet Inhalation Antara Capsule Ipratropium Bromide/Albuterol Inhalation Atorvastatin Tablet Levalbuterol Inhalation Cholestyramine (Light) Powder Levalbuterol Tartrate HFA Colesevelam Tablet Lonhala Magnair Solution Colestid Granules & Tablet Metaproterenol Syrup & Tablet Colestipol Granules & Tablet Montelukast Granules & (Chewable) Tablet Crestor Tablet Ezallor Sprinkle Capsule Heart Disease or Heart Failure Ezetimibe Tablet Acetazolamide ER Capsule, Injection and Tablet Ezetimibe/Simvastatin Tablet Aldactazide Tablet Fenofibrate Tablet & Capsule Aldactone Tablet Fenofibric Acid DR Capsule & Tablet Amiloride Tablet Fenoglide Tablet Amiloride/Hydrochlorothiazide Tablet Fibricor Tablet Amlodipine/Atorvastatin Tablet Flolipid Suspension Betapace (AF) Tablet Fluvastatin Capsule & ER Tablet Bidil Tablet Gemfibrozil Tablet Bumetanide Injection & Tablet Juxtapid Capsule Bumex Tablet Lescol XL Tablet Caduet Tablet Lipitor Tablet Carospir Suspension Lipofen Capsule Chlorothiazide Injection & Tablet Livalo Tablet Chlorthalidone Tablet Lopid Tablet Corlanor Tablet Lovastatin Tablet Digitek Tablet Lovaza Capsule Digox Tablet Nexletol Tablet Digoxin Injection, Oral Solution & Tablet Nexlizet Tablet Diuril Suspension Niacin (ER) Tablet Dyazide Capsule Niacor Tablet Dyrenium Capsule Niaspan ER Tablet Edecrin Tablet Omega-3-Acid Ethyl Esters Capsule Eplerenone Tablet Praluent Injection Ethacrynate Sodium Injection Pravachol Tablet Ethacrynic Acid Tablet Pravastatin Tablet Furosemide Injection, Oral Solution & Tablet Prevalite Powder Hydrochlorothiazide Capsule & Tablet Questran (Light) Powder Indapamide Tablet Repatha Injection Inspra Tablet Rosuvastatin Tablet Isoproterenol Injection Simvastatin Tablet Isuprel Injection Tricor Tablet Lanoxin Injection & Tablet Triglide Tablet Lasix Tablet Trilipix Capsule Mannitol Injection Vascepa Capsule Maxzide Tablet Vytorin Tablet Methazolamide Welchol Packet and Tablet Metolazone Tablet Zetia Tablet Osmitrol Injection Zocor Tablet Sodium Diuril Injection Zypitamag Tablet Sodium Edecrin Injection Sorine Tablet Cardura Tablet Sotalol Injection & (AF) Tablet Cartia XT Capsule Sotylize Solution Carvedilol ER Capsule & Tablet Spironolactone Tablet Catapres Tablet & TTS Patch Spironolactone/Hydrochlorothiazide Tablet Cleviprex IV Emulsion Torsemide Tablet Clonidine Tablet & Patch Triamterene/Hydrochlorothiazide Capsule & Coreg CR Capsule & Tablet Tablet Corgard Tablet Hypertension (high blood pressure) Corlopam Injection Accupril Tablet Cozaar Tablet Accuretic Tablet Diltiazem CD & ER Capsule, Injection, & (ER) Tablet Acebutolol Capsule Dilt-XR Capsule Aliskiren Tablet Diovan (HCT) Tablet Altace Capsule Doxazosin Tablet Amlodipine Tablet Dutoprol Tablet Amlodipine/Benazepril Capsule Edarbi Tablet Amlodipine/Olmesartan Tablet Edarbyclor Tablet Amlodipine/Valsartan Tablet Enalapril Tablet Amlodipine/Valsartan/Hydrochlorothiazide Tablet Enalapril/Hydrochlorothiazide Tablet Atacand (HCT) Tablet Enalaprilat Injection Atenolol Tablet Entresto Tablet Atenolol/Chlorthalidone Tablet Epaned Solution Avalide Tablet Esmolol Injection Avapro Tablet Exforge (HCT) Tablet Azor Tablet Felodipine ER Tablet Benazepril Tablet Fosinopril Tablet Benazepril/Hydrochlorothiazide Tablet Fosinopril/Hydrochlorothiazide Tablet Benicar (HCT) Tablet Guanfacine Tablet Betaxolol Tablet Hemangeol Oral Solution Bisoprolol Tablet Hydralazine Injection & Tablet Bisoprolol/Hydrochlorothiazide Tablet Hyzaar Tablet Brevibloc Injection & IV Solution Inderal LA and XL Capsule Bystolic Tablet Innopran XL Capsule Calan (SR) Tablet Irbesartan Tablet Candesartan Tablet Irbesartan/Hydrochlorothiazide Tablet Candesartan/Hydrochlorothiazide Tablet Isradipine Capsule Captopril Tablet Kapspargo Capsule Captopril/Hydrochlorothiazide Tablet Katerzia Suspension Cardene IV Solution Labetalol Tablet & Injection Cardizem (LA) Tablet & CD Capsule Lisinopril Tablet Lisinopril/Hydrochlorothiazide Tablet Sular Tablet Lopressor (HCT) Tablet Tarka CR Tablet Losartan Tablet Taztia XT Capsule Losartan/Hydrochlorothiazide Tablet Tekturna Tablet Lotensin (HCT) Tablet Tekturna (HCT) Tablet Lotrel Capsule Telmisartan Tablet Matzim LA Tablet Telmisartan/Amlodipine Tablet Methyldopa Tablet Telmisartan/Hydrochlorothiazide Tablet Methyldopa/Hydrochlorothiazide Tablet Tenoretic Tablet Metoprolol Succinate ER Tablet Tenormin Tablet Metoprolol Tartrate Injection & (HCT) Tablet Terazosin Capsule Metoprolol/Hydrochlorothiazide Tablet Tiazac Capsule Micardis (HCT) Tablet Timolol Maleate Tablet Minipress Capsule Toprol XL Tablet Minoxidil Tablet Trandolapril Tablet Moexipril Tablet Trandolapril/Verapamil ER Tablet Nadolol Tablet Tribenzor Tablet Nadolol/Bendroflumethiazide Tablet Twynsta Tablet Nicardipine Capsule & Injection Valsartan Tablet Nifedipine Capsule & ER Tablet Valsartan/Hydrochlorothiazide Tablet Nimodipine Capsule Vaseretic Tablet Nisoldipine ER Tablet Vasotec Tablet Nitropress Injection Vecamyl Tablet Norvasc Tablet Verapamil ER & SR Capsule, Injection & (ER) Olmesartan Tablet Tablet Olmesartan/Amlodipine/Hydrochlorothiazide Verelan (PM) Capsule Tablet Zestoretic Tablet Olmesartan/Hydrochlorothiazide Tablet Zestril Tablet Perindopril Tablet Ziac Tablet Pindolol Tablet Prazosin Capsule Prinivil Tablet Procardia Capsule & XL Tablet Propranolol ER Capsule, Injection, Oral Solution & Tablet Propranolol/Hydrochlorothiazide Tablet Qbrelis Oral Solution Quinapril Tablet Quinapril/Hydrochlorothiazide Tablet Ramipril Capsule Sodium Nitroprusside Injection Bold type = Brand name drug Plain type = Generic drug Lower-cost non-Medicare prescription drugs and supplies These prescription drugs and supplies are covered in addition to the drugs in your plan’s drug list (formulary).2 Your plan covers these prescription drugs at a $0 copay.

Drug Name Cholera Vaccine Nicotine Gum Nicotine Lozenges Nicotine Patches Oral Typhoid Vaccine

1Information about the appeals and grievance process for these prescription drugs and supplies can be found in your Evidence of Coverage.

2This non-Medicare drug coverage is in addition to your Medicare drug coverage. Unlike your Medicare drug coverage, you cannot file a Medicare appeal or grievance for non-Medicare drug coverage. If you have questions, please call Customer Service toll-free at 1-888-803-9217, TTY 711, 8 a.m. – 8 p.m. local time, Monday – Friday. Bonus Drug List The Plan offers a bonus drug list. The prescription drugs on this list are covered in addition to the drugs on the plan’s drug list (formulary). The drug tier for each prescription drug is shown on the list. Although you pay the same copay for these drugs as shown in the Summary of Benefits and Evidence of Coverage, the amount you pay for these additional prescription drugs does not apply to your Medicare Part D out-of-pocket costs. Payments for these additional prescription drugs (made by you or the plan) are treated differently from payments made for other prescription drugs. Coverage for the prescription drugs on the bonus drug list is in addition to your Part D drug coverage. Unlike your Part D drug coverage, you are unable to file a Medicare appeal or grievance for drugs on the bonus drug list. If you have questions, please call Customer Service toll-free at 1-888-803-9217, TTY 711, 8 a.m. – 8 p.m. local time, Monday – Friday. If you get Extra Help from Medicare to pay for your prescription drugs, it will not apply to the drugs on this bonus drug list. This is not a complete list of the prescription drugs available to you or the restrictions and limitations that may apply through the bonus drug list. If your drug has any coverage rules or limits, there will be code(s) in the “Coverage Rules or Limits on use” column of the chart. The codes and what they mean are shown below. If you have questions about drug coverage, please call Customer Service toll-free at 1-888-803-9217, TTY 711, 8 a.m. – 8 p.m. local time, Monday – Friday. QL - Quantity limits The plan only covers a certain amount of this drug for one copay or over a certain number of days. These limits may be in place to ensure safe and effective use of the drug.

MME - Morphine milligram equivalent Additional quantity limits may apply across all drugs in the opioid class used for the treatment of pain. This additional limit is called a cumulative morphine milligram equivalent (MME), and is designed to monitor safe dosing levels of opioids for individuals who may be taking more than one opioid drug for pain management. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you or your doctor can ask the plan to cover the additional quantity.

7D - 7-Day limit An opioid drug used for the treatment of acute pain may be limited to a 7-day supply for members with no recent history of opioid use. This limit is intended to minimize long-term opioid use. For members who are new to the plan, and have a recent history of using opioids, the limit may be overridden by having the pharmacy contact the plan.

DL - Dispensing limit Dispensing limits apply to this drug. This drug is limited to a one-month supply per prescription.

Y0066_200527_081500_C Drug Drug Name Coverage Rules or Limits on use Tier Analgesics - drugs to treat pain, inflammation, and muscle and joint conditions Inflammation Salsalate 1 Urinary Tract Pain Phenazopyridine 1 Anticoagulants - drugs to prevent clotting Heparin Lock Flush 1 Dermatological agents - drugs to treat skin conditions Dry, Itchy Scalp Sulfacetamide Sodium Liquid Wash 10% 1 Sulfacetamide Sodium w/Sulfur in Urea 1 Emulsion 10-5% Dry Skin Urea 40% Cream 1 Fungal Infections Iodoquinol-HC Cream 1% 1 Gastrointestinal agents - drugs to treat bowel, intestine and stomach conditions Irritable Bowel or Ulcers Clidinium & Chlordiazepoxide 1

Hyoscyamine Sulfate 1

Levbid 3 Hemorrhoids Hydrocortisone Acetate Suppository 25mg 1

Lidocaine/Hydrocortisone Acetate 1 Genitourinary agents - drugs to treat bladder, genital and kidney conditions Erectile Dysfunction

Bold type = Brand name drug Plain type = Generic drug Drug Drug Name Coverage Rules or Limits on use Tier QL (maximum of 20 cartridges per Edex 4 75 days)

QL (maximum of 20 tablets per 75 Sildenafil (25 mg, 50 mg, 100 mg) 1 days)

QL (maximum of 20 tablets per 75 Tadalafil 1 days)

QL (maximum of 20 tablets per 75 Vardenafil 1 days) Sexual Desire Disorder

Addyi 4 QL (maximum of 1 tablet per day) Urinary Tract Infection Methenamine/Hyoscamine/Methyl Blue/Sod 1 Phosphate/Phenyl Salicylate 120mg Cap Methenamine/Hyoscamine/Methylene Blue/ 1 Sodium Phosphate 81.6mg Tab Urinary Tract Spasm and Pain

Belladonna Alkaloids & Opium Suppositories 1 MME, 7D, DL Hormonal agents - hormone replacement/modifying drugs Thyroid Supplement Armour Thyroid 4 Nutritional supplements - drugs to treat vitamin & mineral deficiencies Potassium Supplement K-Phos Tab 4 Potassium Bicarbonate Effervescent Tab 25 1 mEq Vitamins and Minerals Cyanocobalamin Injection (Vitamin B12) 1

Folic Acid 1mg (Rx only) 1

Bold type = Brand name drug Plain type = Generic drug Drug Drug Name Coverage Rules or Limits on use Tier Folic Acid-Vitamin B6-Vitamin B12 Tab 2.5-25-1 1 mg Phytonadione Tab 1

Renal Cap 1

Vitamin D 50,000 unit (Rx only) 1 Respiratory tract agents - drugs to treat allergies, , cold and lung conditions Cough and Cold Benzonatate (100mg, 200mg) 1 /Pseudoephedrine/ 1 Dextromethorphan Syrup

Guaifenesin/Codeine Syrup 1 DL Hydrocodone Polst/Chlorpheniramine ER Susp 1 DL (generic for Tussionex)

Hydrocodone/ 1 DL

Promethazine/Codeine Syrup 1 DL /Dextromethorphan Syrup 1

Bold type = Brand name drug Plain type = Generic drug

BDL: Custom CT Maintenance Drug List January 1, 2021 The following drugs and supplies may be dispensed in quantities up to but not more than a 90-day supply for members covered under the UnitedHealthcare Maintenance Drug List. Prior authorization may be required for certain drugs. See your Evidence of Coverage for information about copays. Medications in this list are subject to change without notice. If your drug is not included in this Maintenance Drug List or to confirm that your drugs and supplies are covered, please call Customer Service toll-free at 1-888-803-9217, TTY 711, 8 a.m. – 8 p.m. local time, Monday – Friday.

Drug Name Drug Name Abacavir Solution & Tablet Addyi Tablet Abacavir/Lamivudine Tablet Adefovir Dipivoxil Tablet Abacavir/Lamivudine/Zidovudine Tablet Adempas Tablet Abilify Maintenance Injection & Mycite & Tablet Adlyxin Injection Acamprosate DR Tablet Admelog Injection Acarbose Tablet Advair Diskus & HFA Accolate Tablet Adzenys ER Suspension & XR ODT Tablet Accupril Tablet Afrezza Inhalation Powder Accuretic Tablet Aggrenox Capsule Acebutolol Capsule Agrylin Capsule Acetazolamide ER Capsule & Tablet Aimovig Injection Aciphex Sprinkles & Tablet Airduo Respiclick Actemra Injection Ajovy Injection Actigall Capsule Albuterol Inhalation, Syrup and (ER) Tablet Actimmune Injection Alcohol Swabs Activella Tablet Aldactazide Tablet Actonel Tablet Aldactone Tablet Actoplus Met (XR) Tablet Alendronate Solution & Tablet Actos Tablet Alfuzosin ER Tablet Adcirca Tablet Aliskiren Tablet Adderall XR Capsule & Tablet Allopurinol Tablet

Y0066_200527_081500_C Drug Name Drug Name Alogliptin Tablet Amphetamine/Dextroamphetamine ER Capsule & Tablet Alogliptin/Metformin Tablet Ampyra Tablet Alogliptin/Pioglitazone Tablet Anafranil Capsule Alora Patch Anagrelide Capsule Alosetron Tablet Anaspaz Tablet Alphagan P Ophthalmic Solution Anastrozole Tablet Altace Capsule Androderm Patch Altoprev ER Tablet Androgel Gel & Pump Alvesco Inhaler Angeliq Tablet Alyq Tablet Anoro Ellipta Amabelz Tablet Antabuse Tablet Amantadine Capsule, Syrup & Tablet Antara Capsule Amaryl Tablet Apidra Injection Ambrisentan Tablet Aplenzin Tablet Amiloride Tablet Apriso Capsule Amiloride/Hydrochlorothiazide Tablet Aptensio XR Capsule Aminobenzoate Potassium Capsule & Packet Aptiom Tablet Amiodarone Tablet Aptivus Capsule & Solution Amitiza Capsule Arava Tablet Tablet Arcalyst Injection Amlodipine Tablet Arcapta Neohaler Amlodipine/Atorvastatin Tablet Aricept Tablet Amlodipine/Benazepril Capsule Arimidex Tablet Amlodipine/Olmesartan Tablet Aripiprazole Solution & (ODT) Tablet Amlodipine/Valsartan Tablet Aristada Injection Amlodipine/Valsartan/Hydrochlorothiazide Tablet Armodafinil Tablet Tablet Armour Thyroid Tablet Drug Name Drug Name Arnuity Ellipta Azopt Ophthalmic Suspension Aromasin Tablet Azor Tablet Arthrotec Tablet Azulfidine (EN) Tablet Asmanex HFA & Twisthaler Banzel Suspension & Tablet Aspirin/Dipyridamole Capsule Baraclude Solution Astagraf XL Capsule Basaglar Injection Atacand (HCT) Tablet Benazepril (HCT) Tablet Atazanavir Capsule Benicar (HCT) Tablet Atelvia Tablet Benlysta Injection Atenolol Tablet Benztropine Tablet Atenolol/Chlorthalidone Tablet Betapace (AF) Tablet Atomoxetine Capsule Betaseron Injection Atorvastatin Tablet Betaxolol Ophthalmic Solution & Tablet Atripla Tablet Bethkis Inhalation Sulfate Ophthalmic Solution Betimol Ophthalmic Solution Atrovent HFA Betoptic-S Ophthalmic Suspension Aubagio Tablet Bevespi Aerosphere Auryxia Tablet Bevyxxa Capsule Austedo Tablet Bidil Tablet Avalide Tablet Bijuva Capsule Avandia Tablet Biktarvy Tablet Avapro Tablet Bimatoprost Ophthalmic Solution Avodart Capsule Bisoprolol Tablet Avonex Injection Bisoprolol/Hydrochlorothiazide Tablet Aygestin Tablet Boniva Tablet Azasan Tablet Bosentan Tablet Azathioprine Tablet Breo Ellipta Azilect Tablet Brilinta Tablet Drug Name Drug Name Brimonidine Ophthalmic Solution Carbidopa Tablet Brisdelle Capsule Carbidopa/Levodopa (ER & ODT) Tablet Briviact Solution & Tablet Carbidopa/Levodopa/Entacapone Tablet Bromocriptine Capsule & Tablet Cardizem (LA) Tablet & CD Capsule Brovana Inhalation Cardura (XL) Tablet Budesonide Inhalation Carnitor Solution & Tablet Bumetanide Tablet Carospir Suspension Bumex Tablet Carteolol Ophthalmic Solution Buphenyl Oral Powder & Tablet Cartia XT Capsule Bupropion (SR & XL) Tablet Carvedilol ER Capsule & Tablet Bydureon Injection Catapres Tablet & TTS Patch Byetta Injection Celebrex Capsule Bynfezia Injection Celecoxib Capsule Bystolic Tablet Celexa Tablet Caduet Tablet Cellcept Capsule, Suspension & Tablet Calan (SR) Tablet Celontin Capsule Calcitonin Spray Cerdelga Capsule Calcitriol Capsule & Solution Cevimeline Capsule Calcium Acetate Capsule & Tablet Chlordiazepoxide/Amitriptyline Tablet Candesartan (HCT) Tablet Chloroquine Tablet Caplyta Capsule Chlorothiazide Tablet Captopril Tablet Tablet Captopril/Hydrochlorothiazide Tablet Chlorthalidone Tablet Carafate Suspension & Tablet Cholbam Capsule Carbaglu Tablet Cholestyramine (Light) Powder Carbamazepine ER Capaule, Suspension & Cialis Tablet (ER) Tablet Cilostazol Tablet Carbatrol Capsule Cimduo Tablet Drug Name Drug Name Cimetidine Solution & Tablet Covaryx (HS) Tablet Cimzia Injection Cozaar Tablet Cinacalcet Tablet Creon Capsule Cinqair Injection Crestor Tablet Citalopram Solution & Tablet Crixivan Capsule Climara (Pro) Patch Cromolyn Inhalation & Solution Clobazam Tablet Crysvita Injection Capsule Curity Gauze Pads 2"x2" Clonidine Patch & (ER) Tablet Cuvposa Solution Clopidrogel Tablet Cyclogyl Ophthalmic Solution Colesevelam Tablet Ophthalmic Solution Colestid Granules, Powder & Tablet Cycloset Tablet Colestipol Granules & Tablet Cyclosporine Capsule & Oral Solution Combigan Ophthalmic Solution Cymbalta Capsule Combipatch Cystadane Powder Combivent Respimat Cystagon Capsule Combivir Tablet Cystaran Solution Complera Tablet Cytomel Tablet Comtan Tablet Cytotec Tablet Concerta Tablet Dalfampridine ER Tablet Copaxone Injection Daliresp Tablet Coreg CR Capsule & Tablet Dapsone Tablet Corgard Tablet ER Tablet Corlanor Tablet Daypro Tablet Cosentyx Injection Daytrana Patch Cosopt (PF) Ophthalmic Solution DDAVP Nasal Solution & Tablet Cotempla XR ODT Tablet Deferasirox Tablet Coumadin Tablet Delstrigo Tablet Drug Name Drug Name Delzicol Capsule Diuril Suspension Depakote Sprinkles & (ER) Tablet Divalproex Capsule, DR & ER Tablet Descovy Tablet Divigel Tablet Dofetilide Capsule Desmopressin Nasal Spray and Tablet Donepezil (ODT) Tablet Desoxyn Tablet Dorzolamide Ophthamic Solution Desvenlafaxine ER Tablet Dorzolamide/Timolol Ophthamic Solution Detrol LA Capsule & Tablet Dotti Patch Dexedrine Capsule Dovato Tablet Dexilant DR Capsule Doxazosin Tablet Dexmethylphenidate ER Capsule & Tablet Capsule & Solution Dextroamphetamine ER Capsule, Solution & Doxercalciferol Capsule Tablet Drisdol Capsule Diazoxide Suspension Drizalma Capsule Diclofenac (DR & ER) Tablet Droxia Capsule Diclofenac/Misoprostol Tablet Duaklir Inhaler Didanosine Capsule Duavee Tablet Diflunisal Tablet Duetact Tablet Digoxin Solution & Tablet Dulera Inhaler Dilantin Capsule, Suspension & Tablet Duloxetine Capsule Dilatrate SR Capsule Duopa Suspension Diltiazem CD & ER Capsule, and (ER) Tablet Dupixent Injection Diovan (HCT) Tablet Durlaza Capsule Dipentum Capsule Dutasteride Capsule Dipyridamole Tablet Dutasteride/Tamsulosin Capsule Disopyramide Capsule Dutoprol Tablet Disulfiram Tablet Dyanavel XR Suspension Ditropan XL Tablet Dyazide Capsule Drug Name Drug Name Dyrenium Capsule Eplerenone Tablet Edarbi Tablet Epzicom Tablet Edarbyclor Tablet Equetro Capsule Edecrin Tablet Ergoloid Mesylates Tablet Edurant Tablet Esbriet Capsule & Tablet EEMT (HS) Tablet Escitalopram Solution & Tablet Efavirenz Capsule & Tablet Esomeprazole DR Capsule EFFER-K Tablet Esterified Estrogens/Methyltestosterone Tablet Effexor XR Capsule Estrace Vaginal Cream & Tablet Effient Tablet Estradiol Tablet, Patch & Vaginal Tablet Egrifta Solution Estradiol/Norethindrone Acetate Tablet Elestrin Gel Estring Vaginal Insert Eliquis Tablet Estrogel Gel Elixophyllin Elixir Ethacrynic Acid Tablet Emgality Injection Ethosuximide Capsule & Solution Emsam Patch Etodolac Capsule & (ER) Tablet Emtriva Capsule & Solution Evamist Spray Enablex Tablet Evekeo Tablet Enalapril Tablet Everolimus Tablet Enalapril/Hydrochlorothiazide Tablet Evista Tablet Enbrel Injection Evotaz Tablet Entacapone Tablet Evoxac Capsule Entecavir Tablet Exelon Patch Entresto Tablet Exemestane Tablet Envarsus XR Tablet Exforge (HCT) Tablet Epidiolex Solution Exjade Tablet Epitol Tablet Extavia Injection Epivir (HBV) Solution & (HBV) Tablet Ezallor Sprinkle Capsule Drug Name Drug Name Ezetimibe Tablet Fludrocortisone Tablet Ezetimibe/Simvastatin Tablet Fluoxetine (DR) Capsule, Solution & Tablet Famotidine Suspension & Tablet Fluphenazine Concentrate, Elixir & Tablet Fareston Tablet Flurbiprofen Tablet Farxiga Tablet Fluticasone Propionate/Salmeterol Powder for Inhalation Fasenra Injection Fluvastatin Capsule & ER Tablet Febuxostat Tablet Fluvoxamine ER Capsule & Tablet Felbamate Suspension & Tablet Focalin XR Capsule & Tablet Felbatol Suspension & Tablet Folic Acid Tablet Feldene Capsule Forfivo XL Tablet Felodipine ER Tablet Forteo Solution Femara Tablet Fortesta Gel Femhrt Tablet Fosamax (plus D) Tablet Femring Vaginal Insert Fosamprenavir Tablet Fenofibrate Capsule & Tablet Fosinopril (HCT) Tablet Fenofibric Acid DR Capsule & Tablet Fosrenol Chewable Tablet & Powder Fenoglide Tablet Furosemide Solution & Tablet Fenoprofen Capsule & Tablet Fuzeon Injection Ferriprox Solution & Tablet Fycompa Suspension & Tablet Fetzima Capsule Gabapentin Capsule, Solution & Tablet Fiasp Injection Gabitril Tablet Fibricor Tablet Galafold Capsule Finasteride Tablet Galantamine ER Capsule, Solution & Tablet Tablet Ganciclovir Injection Flecainide Tablet Gastrocrom Oral Concentrate Flolipid Suspension Gattex Injection Flomax Capsule Gelnique Pump Flovent Diskus & HFA Drug Name Drug Name Gemfibrozil Tablet Homatropine Ophthalmic Solution Gengraf Capsule & Solution Horizant Tablet Genotropin Injection Humalog Injection Genvoya Tablet Humatrope Injection Geodon Capsule Humira Injection Gilenya Capsule Humulin Injection Glatiramer Injection Hydralazine Tablet Glatopa Injection Hydrochlorothiazide Capsule & Tablet Glimepiride Tablet Hydroxychloroquine Sulfate Tablet Glipizide (ER & XL) Tablet Drops, Elixir, Solution & (SL & ER) Tablet Glipizide/Metformin Tablet Hyzaar Tablet Glucophage (XR) Tablet Ibandronate Tablet Glucotrol (XL) Tablet Ibuprofen Tablet Glyburide (Micronized) Tablet Ilumya Injection Glyburide/Metformin Tablet Capsule & Tablet Glynase Tablet Imuran Tablet Glyset Tablet Imvexxy Suppository Glyxambi Tablet Inbrija Capsule Gocovri Capsule Increlex Injection Gonitro Sublingual Powder Incruse Ellipta Gralise Tablet Indapamide Tablet Grastek Sublingual Tablet Inderal LA & XL Capsule Guanfacine (ER) Tablet Indocin Suppository & Suspension Haloperidol Concentrate & Tablet Indomethacin (ER) Capsule Hemangeol Solution Ingrezza Capsule Hepsera Tablet Innopran XL Capsule Hetlioz Capsule Inspra Tablet Homatropaire Ophthalmic Solution Drug Name Drug Name Insulin Syringes Jardiance Tablet Intelence Tablet Jentadueto (XR) Tablet Intrarosa Vaginal Insert Jinteli Tablet Intron A Injection Jornay PM Capsule Intuniv Tablet Juluca Tablet Invega Tablet Juxtapid Capsule Invirase Capsule & Tablet Kaletra Solution & Tablet Invokamet (XR) Tablet Kalydeco Granules & Tablet Invokana Tablet Kapspargo Sprinkle Capsule Ipratropium Bromide Inhalation Kapvay Tablet Ipratropium Bromide Nasal Spray Katerzia Suspension Ipratropium Bromide/Albuterol Inhalation Kazano Tablet Irbesartan Tablet Keppra Solution and (XR) Tablet Irbesartan/Hydrochlorothiazide Tablet Ketoprofen (ER) Capsule Isentress HD Tablet Kevzara Injection Isentress Suspension & Tablet Kineret Injection Isoniazid Syrup & Tablet Kitabis Inhalation Solution Isopto Atropine Ophthalmic Solution Klor-Con Tablet Isopto Carpine Ophthalmic Solution Kombiglyze XR Tablet Isordil Tablet Korlym Tablet Isosorbide (ER) Tablet K-Phos (Neutral) Tablet Isoxsuprine Tablet Kristalose Packet Isradipine Capsule K-Tab Tablet Istalol Ophthalmic Solution Kuvan Powder & Tablet Jadenu Sprinkles & Tablet Labetalol Tablet Jalyn Capsule Lactulose Solution Janumet (XR) Tablet Lamictal (ODT) Tablet Januvia Tablet Lamivudine Solution & Tablet Drug Name Drug Name Lamivudine/Zidovudine Tablet Lisinopril Tablet Lamotrigine (ER & ODT) Tablet Lisinopril/Hydrochlorothiazide Tablet Lanoxin Tablet Lithium Carbonate Capsule, Solution & (ER) Tablet Lansoprazole DR Capsule & ODT Tablet Lithobid CR Tablet Lanthanum Chew Tablet Lithostat Tablet Lantus Injection Livalo Tablet Lasix Tablet Lodine Tablet Latanoprost Ophthalmic Solution Lodosyn Tablet Latuda Tablet Lokelma Packet Leflunomide Tablet Lonhala Magnair Solution Lescol XL Tablet Lopid Tablet Letairis Tablet Lopinavir/Ritonavir Solution Letrozole Tablet Lopreeza Tablet Levalbuterol Tartrate HFA & Inhalation Lopressor (HCT) Tablet Levbid Tablet Losartan Tablet Levemir Injection Losartan/Hydrochlorothiazide Tablet Levetiracetam Solution & (ER) Tablet Lotensin (HCT) Tablet Levobunolol Ophthalmic Solution Lotrel Capsule Levocarnitine Solution & Tablet Lotronex Tablet Levothyroxine Tablet Lovastatin Tablet Levsin (SL) Tablet Lovaza Capsule Lexapro Oral Solution & Tablet Capsule Lexiva Suspension & Tablet Lumigan Ophthalmic Solution Lialda Tablet Lyrica Capsule, CR Tablet, & Solution Linzess Capsule Tablet Liothyronine Tablet Marplan Tablet Lipitor Tablet Maxzide Tablet Lipofen Capsule Drug Name Drug Name Mayzent Tablet Miglitol Tablet Meclofenamate Capsule Miglustat Capsule Medroxyprogesterone Acetate Tablet Minipress Capsule Mefenamic Acid Capsule Minitran Patch Mefloquine Tablet Minivelle Patch Megesterol Suspension Minoxidil Tablet Meloxicam Tablet Mirapex (ER) Tablet Memantine XR Capsule, Solution & Tablet (ODT) Tablet Menest Tablet Misoprostol Tablet Menostar Patch Mobic Tablet Mesalamine DR Tablet Modafinil Tablet Metadate CD Capsule Moexipril Tablet Metaproterenol Syrup & Tablet Molindone Tablet Metformin (ER) Tablet Montelukast Granules & (Chewable) Tablet Methamphetamine Tablet Motegrity Tablet Methazolamide Tablet Multaq Tablet Methimazole Tablet Myalept Injection Methitest Tablet Mycophenolate Capsule, Suspension & Tablet Methyldopa Tablet Mycophenolic Acid DR Tablet Methyldopa/Hydrochlorothiazide Tablet Mydayis Capsule Methylin Solution Myfortic Tablet Methylphenidate CD & ER Capsule, Solution Myrbetriq Tablet and (ER & SR) Tablet Mysoline Tablet Methyltestosterone Capsule Mytesi Tablet Metolazone Tablet Nabumetone Tablet Metoprolol (ER) & (HCT) Tablet Nadolol Tablet Mexiletine Capsule Nadolol/Bendroflumethiazide Tablet Micardis (HCT) Tablet Nalfon Capsule Drug Name Drug Name Namenda XR Capsule & Tablet Nitroglycerin Patch, SL Tablet & Spray Namzaric Capsule Nitrostat Tablet Naprelan CR Tablet Nityr Tablet Naproxen Suspension and (CR, DR & ER) Nizatidine Capsule & Solution Tablet Nocdurna SL Tablet Naproxen/Esomeprazole Tablet Noctiva Nasal Spray Nardil Tablet Norditropin Injection Nateglinide Tablet Norethindrone Tablet Natesto Gel Norpace (CR) Capsule Natpara Injection Norpramin Tablet Nature-Thyroid Tablet Capsule & Solution Nefazodone Tablet Norvasc Tablet Neoral Capsule & Solution Norvir Capsule, Solution & Tablet Nesina Tablet Nourianz Tablet Neupro Patch Novolin Injection Neurontin Capsule, Solution & Tablet Novolog Injection Nevirapine (ER) Tablet Noxafil Injection, Suspension & Tablet Nexium Capsule & DR Granules NP Thyroid Tablet Nexletol Tablet Nucala Injection Nexlizet Tablet Nuedexta Capsule Niacin ER Tablet Nuplazid Tablet & Capsule Niaspan ER Tablet Nutropin AQ Injection Nicardipine Capsule Nuvigil Tablet Nifedipine Capsule & ER Tablet Ocaliva Tablet Nisoldipine ER Tablet Octreotide Injection Nitisinone Capsule Odactra Sublingual Tablet Nitro-Bid Ointment Odefsey Tablet Nitro-Dur Patch Ofev Capsule Drug Name Drug Name (ODT) Tablet Oxcarbazepine Tablet & Suspension Olanzapine/Fluoxetine Capsule Oxtellar XR Tablet Olmesartan (HCT) Tablet Patch, Syrup and (ER) Tablet Olmesartan/Amlodipine/Hydrochlorothiazide Oxytrol Patch Tablet Ozempic Injection Olumiant Tablet Pacerone Tablet Omega-3-Acid Ethyl Esters Capsule Paliperidone ER Tablet Omeprazole Capsule Palynziq Injection Omeprazole/Sodium Bicarbonate Packet Pamelor Capsule Omnipod System Pancreaze Capsule Omnitrope Injection Pantoprazole Tablet Onfi Suspension & Tablet Paricalcitol Capsule Onglyza Tablet Parlodel Capsule & Tablet Onpattro Injection Parnate Tablet Opsumit Tablet (ER) Tablet Oral Contraceptives Paxil Suspension and (CR) Tablet Oralair IR Tablet Peganone Tablet Orencia Injection Pen Needles Orenitram Tablet Pentasa Capsule Orfadin Capsule & Suspension Pentoxifylline ER Tablet Orkambi Tablet Pepcid Suspension & Tablet Oseni Tablet Perforomist Inhalation Osmolex ER Tablet Perindopril Tablet Osphena Tablet Perphenazine Tablet Otezla Tablet Perphenazine/Amitriptyline Tablet Otrexup Injection Perseris Injection Oxaprozin Tablet Pertzye Capsule Oxbryta Tablet Pexeva Tablet Drug Name Drug Name Phenelzine Tablet Prasugrel Tablet Phenobarbital Tablet Pravachol Tablet Phenytek Capsule Pravastatin Tablet Phenytoin EX Capsule, Suspension & Tablet Prazosin Capsule Phoslyra Solution Precose Tablet Phospha 250 Neutral Tablet Prefest Tablet Phospholine Iodide Ophthalmic Solution Pregabalin Capsule Phosphorous Tablet Premarin Vaginal Cream & Tablet Pifeltro Tablet Premphase Tablet Ophthalmic Solution & Tablet Prempro Tablet Pimozide Tablet Prevacid Capsule & Tablet Pindolol Tablet Prevymis Tablet Pioglitazone Tablet Prezcobix Tablet Pioglitazone/Glimepiride Tablet Prezista Suspension & Tablet Pioglitazone/Metformin Tablet Prilosec Powder Piroxicam Capsule Primidone Tablet Plaquenil Tablet Prinivil Tablet Plavix Tablet Pristiq Tablet Plegridy Injection Proair HFA & Respiclick Posaconazole DR Tablet Probenecid Tablet Potaba Capsule Probenecid/Colchicine Tablet Potassium Chloride ER Capsule, Liquid, Procardia Capsule & XL Tablet Packets and CR, ER & SR Tablet Procentra Solution Potassum Chloride Effervescent Tablet Prochlorperazine Tablet Pradaxa Capsule Procysbi Capsule Praluent Injection Progesterone Capsule Pramiprexole (ER) Tablet Proglycem Suspension Prandin Tablet Prograf Capsule Drug Name Drug Name Promacta Tablet Rabeprazole Tablet Prometrium Capsule Radicava Injection Propafenone ER Capsule & Tablet Ragwitek Sublingual Tablet Propranolol ER Capsule, Solution & Tablet Raloxifene Tablet Propranolol/Hydrochlorothiazide Tablet Ramipril Capsule Propylthiouracil Tablet Ranexa Tablet Proscar Tablet Ranitidine Capsule, Syrup & Tablet Protonix Packet & Tablet Ranolazine ER Tablet Tablet Rapaflo Capsule Proventil HFA Rapamune Solution & Tablet Provera Tablet Rasagiline Tablet Provigil Tablet Rasuvo Injection Prozac Capsule Ravicti Liquid Pulmicort Flexhaler & Inhalation Rayaldee Capsule Pulmozyme Solution Razadyne ER Capsule & Tablet Qbrelis Solution Rebif Injection Qmiiz ODT Tablet Reblozyl Injection Qtern Tablet Relafen DS Tablet Qudexy XR Capsule Relexxii Tablet Questran (Light) Powder Remeron (Solutab) Tablet (ER) Tablet Renagel Tablet Quillichew ER Tablet Renvela Packet & Tablet Quillivant Suspension Repaglinide Tablet Quinapril Tablet Repatha Injection Quinapril/Hydrochlorothiazide Tablet Requip (XL) Tablet Gluconate CR & ER Tablet Rescriptor Tablet Quinidine Sulfate Tablet Restasis Ophthalmic Emulsion Qvar Inhaler Retrovir Capsule & Syrup Drug Name Drug Name Revatio Tablet & Suspension Salsalate Tablet Rexulti Tablet Sandimmune Capsule & Solution Reyataz Capsule & Powder Sandostatin Injection Rhopressa Ophthalmic Solution Saphris Sublingual Tablet Ridaura Capsule Sarafem Tablet Rilutek Tablet Savaysa Tablet Riluzole Tablet Savella Tablet Rinvoq Tablet Secuado Patch Riomet Solution Seebri Neohaler Risedronate (DR) Tablet Segluromet Tablet Risperdal Solution & Tablet Selegiline Capsule & Tablet Risperidone Solution and (ODT) Tablet Selzentry Solution & Tablet Ritalin LA Capsule & Tablet Sensipar Tablet Ritonavir Tablet Serevent Diskus Rivastigmine Capsule & Patch Seroquel (XR) Tablet Rocaltrol Capsule & Solution Serostim Injection Rocklatan Ophthalmic Solution Sertraline Concentrate & Tablet Ropinirole (ER) Tablet Sevelamer Packet & Tablet Rosuvastatin Tablet Signifor Injection Roweepra (XR) Tablet Sildenafil Tablet Ruzurgi Tablet Siliq Injection Rybelsus Tablet Silodosin Capsule Rytary Capsule Simbrinza Ophthalmic Suspension Rythmol SR Capsule Simponi Injection & Simponi Aria Solution Sabril Powder & Tablet Simvastatin Tablet Safyral Tablet Sinemet (CR) Tablet Saizen Injection Singulair Granules & (Chewable) Tablets Salagen Tablet Sirolimus Tablet Drug Name Drug Name Skyrizi Injection Subvenite Tablet Sodium Fluoride Cream, Gel, Paste, Rinse, Sucraid Solution Solution & Tablet Sucralfate Suspension & Tablet Sodium Phenylbutyrate Tablet Sular Tablet Tablet Sulfasalazine (DR) Tablet Soliqua Injection Sulindac Tablet Soltamox Oral Solution Sunosi Tablet Somavert Injection Sustiva Capsule Sotalol (AF) Tablet Sylatron Injection Sotylize Oral Solution Symbicort Inhaler Spinraza Injection Symbyax Capsule Spiriva Handihaler & Respimat Symdeko Tablet Spironolactone Tablet Symfi (Lo) Tablet Spironolactone/Hydrochlorothiazide Tablet Symlinpen Injection Spravato Nasal Solution Sympazan Film Spritam Tablet Symtuza Tablet Stalevo Tablet Synjardy (XR) Tablet Starlix Tablet Synthroid Tablet Stavudine Capsule Tacrolimus Capsule Steglatro Tablet Takhzyro Injection Steglujan Tablet Taltz Injection Stelara Injection Tamoxifen Tablet Stimate Nasal Solution Tamsulosin Capsule Stiolto Respimat Tapazole Tablet Strattera Capsule Tarka CR Tablet Strensiq Injection Tasmar Tablet Stribild Tablet Tavalisse Tablet Striverdi Respimat Tecfidera Capsule Drug Name Drug Name Tegretol Suspension & (XR) Tablet Tivicay Tablet Tegsedi Injection Tobi Inhalation Solution and Podhaler Tekturna (HCT) Tablet Tobramycin Inhalation Solution Telmisartan (HCT) Tablet Tofranil Tablet Telmisartan/Amlodipine Tablet Tolbutamide Tablet Temixys Tablet Tolcapone Tablet Tenofovir Tablet Tolmetin Capsule & Tablet Tenoretic Tablet ER Capsule & Tablet Tenormin Tablet Topamax Sprinkles & Tablet Terazosin Capsule Topiramate (ER) Capsule & Tablet Terbutaline Tablet Toprol XL Tablet Teriparatide Injection Toremifene Tablet Testim Gel Torsemide Tablet Testosterone Gel, Pump & Solution Toujeo Injection Tetrabenazine Tablet Toviaz Tablet Thalomid Capsule Tracleer Tablet Theo-24 CR & ER Capsule Tradjenta Tablet Theophylline Solution, CR & ER Tablet Trandolapril Tablet Thiola EC Tablet Trandolapril/Verapamil ER Tablet Tablet Tranylcypromine Tablet Thiothixene Capsule Travatan Z Ophthalmic Solution Tiagabine Tablet Travoprost Ophthalmic Solution Tiazac Capsule Trazodone Tablet Tiglutik Suspension Trelegy Ellipta Tikosyn Capsule Tremfya Injection Timolol Ophthalmic Gel & Solution, Tablet Tresiba Injection Timoptic (Ocudose & XE) Ophthalmic Solution Triamterene/Hydrochlorothiazide Capsule & Tablet Tirosint Capsule & Solution Drug Name Drug Name Tribenzor Tablet Urso (250 & Forte) Tablet Tricor Tablet Ursodiol Capsule & Tablet Trifluoperazine Tablet Utibron Neohaler Triglide Tablet Vagifem Tablet Elixir & Tablet Valcyte Solution & Tablet Trijardy XR Tablet Valganciclovir Solution & Tablet Trikafta Tablet Valproic Acid Capsule & Solution Trileptal Suspension & Tablet Valsartan (HCT) Tablet Trilipix Capsule Vascepa Capsule Capsule Vaseretic Tablet Trintellix Tablet Vasotec Tablet Triumeq Tablet Vecamyl Tablet Trizivir Tablet Velphoro Chewable Tablet Trogarzo Injection Veltassa Powder for Solution Trokendi XR Capsule Vemlidy Tablet Trospium ER Capsule & Tablet Venlafaxine ER Capsule & (ER) Tablet Trulance Tablet Ventavis Inhalation Solution Trulicity Injection Ventolin HFA Trusopt Ophthalmic Solution Verapamil ER & SR Capsule, (ER) Tablet Truvada Tablet Verelan (PM) Capsule Tudorza Pressair Vesicare Tablet Twynsta Tablet V-Go Kit Tybost Tablet Viberzi Tablet Tymlos Injection Victoza Injection Tyvaso Inhalation Solution Videx EC Capsule & Solution Uloric Tablet Vigabatrin Tablet & Powder for Solution Uptravi Tablet Vigadrone Powder for Solution Uroxatral Tablet Viibryd Tablet Drug Name Drug Name Vimovo Tablet Xenazine Tablet Vimpat Solution & Tablet Xermelo Tablet Viokace Tablet Xifaxan Tablet Viracept Tablet Xigduo XR Tablet Viramune Suspension & (XR) Tablet Xiidra Ophthalmic Solution Viread Powder & Tablet Xopenex HFA & Inhalation Solution Vitamin D Capsule Xulane Patch Vivelle-Dot Patch Xultophy Injection Vivlodex Capsule Xuriden Granules Vogelxo Gel Pump Xyosted Injection Vraylar Capsule Yasmin Tablet Vumerity Capsule Yaz Tablet Vyndamax Capsule Yosprala Tablet Vyndaqel Capsule Yupelri Inhalation Solution Vytorin Tablet Yuvafem Vaginal Tablet Vyvanse Capsule & Chewable Tablet Zafirlukast Tablet Vyzulta Ophthalmic Solution Zarontin Capsule & Solution Wakix Tablet Zavesca Capsule Warfarin Tablet Zegerid Capsule & Powder for Suspension Welchol Packet & Tablet Zelapar Tablet Wellbutrin SR & XL Tablet Zemplar Capsule Wixela Powder for Inhalation Zenpep Capsule Xadago Tablet Zenzedi Tablet Xalatan Ophthalmic Solution Zestoretic Tablet Xarelto Tablet Zestril Tablet Xcopri Tablet Zetia Tablet Xeljanz (XR) Tablet Ziac Tablet Xelpros Ophthalmic Solution Ziagen Solution & Tablet Drug Name Drug Name Zidovudine Capsule, Syrup & Tablet Zontivity Tablet Zileuton ER Tablet Zorbtive Injection Zioptan Ophthalmic Solution Zortress Tablet Ziprasidone Capsule Zorvolex Capsule Zocor Tablet Zurampic Tablet Zoloft Concentrate & Tablet Zyflo (CR) Tablet Zomacton Injection Zyloprim Tablet Zonegran Capsule Zypitamag Tablet Zonisamide Capsule Zyprexa (Zydis) Tablet This is not a complete list of prescription drugs and supplies covered by our plan. For a complete list, please call Customer Service toll-free at 1-888-803-9217, TTY 711, 8 a.m. – 8 p.m. local time, Monday – Friday.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits and/or copayments/coinsurance may change each plan/benefit year. The drug list may change at any time. You will receive notice when necessary. This information is available for free in other languages. Please call our Customer Service number on the cover.

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