Your 2019 Prescription Drug List Traditional Three-Tier
EffectiveEffective January Jan. 1, 1, 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 UnitedHealthcare, River Valley and Oxford 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...... 16 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 Medications for Sexual Dysfunction. . 18 Cardiovascular/Heart Disease Coagulation Therapy...... 10 Men’s Health Prostate...... 18 High Blood Pressure...... 10 Testosterone Therapy...... 18 High Cholesterol ...... 11 Other...... 11 Miscellaneous...... 19 Central Nervous System Musculoskeletal Attention Deficit Disorder...... 11 Muscle Spasms...... 19 Depression ...... 12 Osteoporosis...... 19 Migraine...... 12 Pain Relief...... 19 Multiple Sclerosis...... 12 Overactive Bladder...... 20 Other...... 12 Sedatives/Hypnotics...... 13 Respiratory Seizure Disorders ...... 13 Allergies...... 20 Asthma/COPD...... 20 Dermatology ...... 13 Pulmonary Arterial Hypertension...... 21 Diabetes Smoking Cessation...... 21 Blood Glucose Monitoring...... 14 Insulin ...... 14 Transplant ...... 21 Non-Insulin ...... 15 Vitamins/Electrolytes...... 21 Endocrine Women’s Health Growth Hormone...... 15 Contraceptives...... 21 Other...... 16 Hormone Replacement...... 24 Thyroid Hormone Replacement. . . . . 16 Miscellaneous...... 24 Eye Conditions Prenatal Vitamins ...... 24 Allergies...... 16 Index...... 25 Antibiotics ...... 16 Dry Eye Disease...... 16 Glaucoma ...... 16 2 Understanding 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.
3 Understanding your Prescription Drug List (continued)
Why are some medications excluded from coverage? We review medications based on their total value, including effectiveness and safety, how much they cost, and the availability of alternative medications to treat the same or similar medical conditions. Certain medications may be excluded from coverage or subject to prior authorization (sometimes referred to as precertification)1 if similar alternatives are available at a lower cost. Examples include medications that work the same way, but one is much more expensive than the other, or options that are available without a prescription (also referred to as over-the-counter medications2). There are also some instances where the same product can be made by two or more manufacturers, but greatly vary in cost. In these instances, only the lower-cost product may be covered. You should review your benefit plan documents to confirm if any medications are excluded from your plan. You can log in to the member website listed on your 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.
1. Depending on your benefit, you may have notification or medical necessity requirements for select medications. 2. For New York and New Jersey plans, a prescription drug product that is therapeutically equivalent to an over-the-counter drug may be covered if it is determined to be medically necessary. 4 Medication 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.
5 Reading your PDL
The PDL gives you choices so you and your doctor can determine your best course of treatment. In this PDL, brand-name medications are shown in 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.
6 Reading your PDL (continued)
Drug list information. In this drug list, some medications are noted with letters next to them to help you see which ones may have coverage requirements or limits. Your benefit plan determines how these medications may be covered for you.
E May be excluded from coverage or subject to Prior Authorization in Connecticut, New Jersey and New York. (Referred to as First Start in New Jersey) Lower-cost options are available and covered.
H Health Care Reform Preventive This medication is part of a health care reform preventive benefit and may be available at no additional cost to you.
H-PA Health Care Reform Preventive with Prior Authorization May be part of health care reform preventive and available at no additional cost to you if prior authorization criteria is met.
PA Prior Authorization (sometimes referred to as Precertification)3 Requires your doctor to provide information about why you are taking a medication to determine how it may be covered by your plan.
RS Refill and Save Program4 Save money on your copayment when you refill your prescription on time as prescribed. Program eligibility may vary.
SP Specialty Medication Specialty medications treat complex or rare conditions and may require special storage and handling. You may be required to obtain these medications from a specialty pharmacy.
ST Step Therapy (referred to as First Start in New Jersey) Requires prior authorization and may require you to try one or more other medications before the medication you are requesting may be covered.
SL Supply Limits Specifies the largest quantity of medication covered per copayment or in a defined period of time.
3. Depending on your benefit, you may have notification or medical necessity requirements for select medications. 4. Not applicable to Oxford plans. 7 Questions
For the most current list of covered medications or if you have questions:
Call the toll-free member phone number on your health plan ID card.
Visit your plan’s member website listed 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
8 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Anti-Infectives: Antibiotics Anti-Infectives: Antifungals Amoxicillin Capsule, Chewable 1 Cresemba 3 SL 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 PA, SL, ST 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, ST Nitrofurantoin Macrocrystal 1 Braftovi 3 PA, SL, SP 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 3 Idhifa 2 PA, SL, SP Tablet, Tablet Imantinib Tablet 1 PA, SL, SP Imbruvica 2 PA, SL, SP
Bold type = Brand-name drug [Plain type = Generic drug] PA = Prior authorization required E = May be excluded from coverage RS = May be eligible for the refill and save program H = May be part of health care reform preventive SL = Supply limit H-PA = May be part of health care reform preventive with SP = Specialty medication prior authorization ST = Step therapy Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY. 9 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Leucovorin Calcium Tablet 1 Bystolic 2 Mektovi 3 PA, SL, SP Byvalson 2 SL Mercaptopurine Tablet 1 Cartia XT 1 Carvedilol Immediate-Release Nerlynx 2 PA, SL, SP 1 Tablet Revlimid 2 PA, SL, SP Chlorthalidone 1 Rydapt 2 PA, SL, SP Clonidine Tablet 1 Sutent 2 PA, SL, SP Diltiazem 24 Hour CD 1 Targretin Capsule 1 SP Diltiazem Sustained-Release 1 Targretin Gel 3 SL Capsule Diltiazem Sustained-Release Tasigna 2 PA, SL, SP, ST 1 Tablet Verzenio 2 PA, SL, SP Doxazosin 1 Xeloda 1 SL, SP Edarbi 3 SL Zykadia 2 PA, SL, SP Edarbyclor 3 SL Zytiga 2 PA, SL, SP Enalapril 1 Cardiovascular/Heart Disease: Coagulation Therapy Furosemide 1 Bevyxxa 3 SL Guanfacine 1 Brilinta 3 SL Hydralazine 1 Clopidogrel 1 Hydrochlorothiazide 1 Eliquis 3 SL Irbesartan 1 Enoxaparin Sodium 1 SL Labetalol 1 Pradaxa 2 SL Lisinopril 1 Prasugrel 1 SL Lisinopril-Hydrochlorothiazide 1 Savaysa 3 SL Losartan 1 Warfarin Sodium 1 Losartan-Hydrochlorothiazide 1 Xarelto 2 SL Metoprolol Succinate Extended- 1 Cardiovascular/Heart Disease: High Blood Pressure Release Metoprolol Tartrate 25, 50, Amlodipine 1 1 100 mg Amlodipine-Benazepril 1 Nadolol 1 Amlodipine-Valsartan 1 Nifedipine Extended-Release 1 Atenolol 1 Olmesartan 1 SL Atenolol-Chlorthalidone 1 Olmesartan-Hydrochlorothiazide 1 SL Benazepril 1 Propranolol Extended-Release 1 Benazepril-Hydrochlorothiazide 1 Capsule Bidil 2 Propranolol Tablet 1 Bisoprolol 1 Quinapril 1 Bisoprolol-Hydrochlorothiazide 1 Ramipril 1
Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY. 10 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Spironolactone 1 Cardiovascular/Heart Disease: Other Telmisartan 1 Amiodarone 1 Telmisartan-Hydrochlorothiazide 1 Corlanor 3 PA, SL Terazosin 1 Digoxin 1 Triamterene-Hydrochlorothiazide 1 Entresto 3 PA, SL Valsartan 1 Flecainide 1 Valsartan-Hydrochlorothiazide 1 Isosorbide Mononitrate ER 1 Verapamil 1 Multaq 3 PA 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 PA, SL Ezetimibe Tablet 1 SL Amphetamine Salt Combo 1 PA Ezetimibe/Simvastatin 1 SL Atomoxetine 1 SL Fenofibrate 54, 160 mg Tablet 1 Concerta 1 PA, SL Fluvastatin Extended-Release Dexmethylphenidate Immediate- 1 SL, ST 1 PA Tablet Release Tablet Gemfibrozil 1 Dextroamphetamine- Amphetamine Immediate-Release 1 PA Lovastatin 1 H Tablet Dextroamphetamine Sulfate Niacin Extended-Release Tablet 1 1 PA Immediate-Release Tablet Niaspan 3 Guanfacine Extended-Release 1 SL Omega-3-Acid Ethyl Esters 1 PA Capsule Methylphenidate Chewable Tablet 1 PA Praluent 2 PA, SL, SP, ST Methylphenidate Extended- Release Capsule (generic 1 PA, SL Pravastatin 1 Metadate CD, Ritalin LA) Repatha 3 PA, SL, SP, ST Methylphenidate Extended- Release Capsule (Metadate ER, 1 PA, SL Rosuvastatin 1 SL generic Ritalin SR) Simvastatin 1 H-PA Methylphenidate Extended- Vascepa 3 PA Release Tablet (generic 3 E, PA, SL Concerta) Welchol Packet for Suspension, 1 Methylphenidate Immediate- Tablet 1 PA Release Tablet Vyvanse 2 PA, SL
Bold type = Brand-name drug [Plain type = Generic drug] PA = Prior authorization required E = May be excluded from coverage RS = May be eligible for the refill and save program H = May be part of health care reform preventive SL = Supply limit H-PA = May be part of health care reform preventive with SP = Specialty medication prior authorization ST = Step therapy Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY. 11 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Central Nervous System: Depression Central Nervous System: Multiple Sclerosis Amitriptyline Tablet 1 Ampyra 2 PA, SL, SP Bupropion Extended-Release 1 Aubagio 3 PA, SL, SP Tablet Avonex 2 PA, SL, SP Bupropion Sustained-Release 1 Tablet Betaseron 2 PA, SL, SP Bupropion Tablet 1 Gilenya 3 PA, SL, SP Citalopram Tablet 1 Glatiramer (generic Copaxone) 1 PA, SL, SP Desvenlafaxine Extended- [Mylan version only] 1 SL Release Tablet (generic Pristiq) Plegridy 3 PA, SL, SP Doxepin 1 Rebif 3 PA, SL, SP, ST Duloxetine Capsule 1 SL Tecfidera 2 PA, SL, SP Escitalopram Tablet 1 Central Nervous System: Other 3 SL, ST Alprazolam Extended-Release Fetzima 1 Fluoxetine Capsule (generic Tablet 1 Prozac) Alprazolam Tablet 1 Fluvoxamine Tablet 1 Aripiprazole Tablet 1 SL Mirtazapine Tablet 1 Armodafinil 1 PA, SL Nortriptyline Capsule 1 Austedo 2 PA, SL, SP Paroxetine Tablet 1 Buprenorphine Sublingual Tablet 1 Sertraline Tablet 1 Buspirone Tablet 1 Trazodone Tablet 1 Carbidopa-Levodopa 1 Trintellix 3 SL, ST Diazepam Tablet 1 Venlafaxine Extended-Release 1 Donepezil ODT, 5, 10 mg Tablet 1 Capsule Latuda 3 SL Venlafaxine Tablet 1 Lithium Capsule 1 Viibryd 3 SL Lorazepam Tablet 1 Central Nervous System: Migraine Memantine Immediate-Release Acetaminophen/Butalbital/ 1 1 SL Tablet Caffeine 325 mg/50 mg/40 mg Modafinil 1 PA, SL Eletriptan 1 SL Naloxone Vial 1 Frovatriptan 1 SL Narcan Nasal Spray 2 SL Naratriptan 1 SL Olanzapine Tablet 1 SL Rizatriptan ODT, Tablet 1 SL Pramipexole Tablet 1 Sumatriptan Nasal Spray 1 SL Quetiapine Extended-Release Sumatriptan Succinate Tablet, 1 SL 1 SL Tablet Injection
Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY. 12 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Quetiapine Immediate-Release 1 Lyrica CR 3 E, SL, ST Tablet Oxcarbazepine Tablet 1 Risperidone Tablet 1 Phenytoin Capsule, Suspension 1 Ropinirole Tablet 1 Topiramate Immediate-Release 1 Suboxone Film 3 E, PA, SL Tablet Tolcapone 1 Zonisamide Capsule 1 Xyrem 3 PA, SL Dermatology Zelapar 3 Aczone 1 SL Ziprasidone Capsule 1 SL Betamethasone Dipropionate 0.05% Augmented Lotion, 1 Zubsolv 1 SL Ointment Central Nervous System: Sedatives/Hypnotics Betamethasone Dipropionate 1 0.05% Cream, Ointment Eszopiclone Tablet 1 SL Calcipotriene/Betamethasone 1 SL Temazepam Capsule 1 Ointment Triazolam Tablet 1 Carac 2 Zaleplon Capsule 1 SL Ciclopirox Cream, Gel, Lotion, 1 Zolpidem Immediate-Release Solution 1 SL Tablet Claravis 1 PA Central Nervous System: Seizure Disorders Clindamycin 1.2%/Benzoyl 1 SL Carbamazepine Extended- Peroxide 5% Gel 1 Release Capsule, Tablet Clindamycin Gel 1 SL Carbamazepine Immediate- 1 Clindamycin Lotion, Swabs 1 Release Tablet Clindamycin Solution 1 SL Clonazepam Tablet 1 Clobetasol Propionate Cream, 1 SL Diazepam Tablet 1 Ointment, Solution Divalproex Delayed-Release Clotrimazole-Betamethasone 1 1 SL Tablet Cream Divalproex Extended-Release Clotrimazole-Betamethasone 1 1 Tablet Lotion Gabapentin Capsule, Tablet 1 Dapsone 5% Gel 3 E, SL Lamotrigine Immediate-Release Desonide 0.05% Cream, Lotion, 1 1 SL Tablet Ointment Levetiracetam Extended-Release Desoximetasone Cream, Gel, 1 1 SL Tablet Ointment Levetiracetam Immediate-Release Diflorasone Diacetate 0.05% 1 1 SL Tablet Cream, Ointment Lyrica 3 SL, ST Dupixent 3 PA, SL, SP, ST
Bold type = Brand-name drug [Plain type = Generic drug] PA = Prior authorization required E = May be excluded from coverage RS = May be eligible for the refill and save program H = May be part of health care reform preventive SL = Supply limit H-PA = May be part of health care reform preventive with SP = Specialty medication prior authorization ST = Step therapy Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY. 13 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Elidel 3 SL, ST Diabetes: Blood Glucose Monitoring5 Enstilar Foam 3 SL Accu-Chek Test Strips 3 E, SL Eucrisa 3 SL, ST Contour Next EZ Meter 2 Finacea 3 Contour Next Meter 2 Fluocinonide 0.05% Cream 1 Contour Next One Meter 2 Fluocinolone Cream, Oil, 1 SL Contour Next Test Strips 2 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 OneTouch Ultra 2 Meter 1 Hydrocortisone 2.5% Cream, 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 1 E, PA OneTouch Verio IQ Meter 1 (generic Solodyn) OneTouch Verio Meter 1 Mirvaso 3 SL OneTouch Verio Sync Meter 1 Mometasone Furoate Cream, 1 Lotion, Ointment OneTouch Verio Test Strips 1 SL Mupirocin Ointment 1 SL 5 Diabetic supplies and prescription medications may be subject to different cost-share arrangements for Oracea 3 Oxford plans. Please see your Summary of Benefits and Oxsoralen-Ultra 2 Coverage (SBC) for specifics. Medications that require step therapy may require prior authorization (sometimes 3 SL Picato referred to as precertification) if covered under another Regranex 2 PA, SL benefit. 5 Rhofade 3 PA, SL Diabetes: Insulin Taclonex Suspension 3 SL Admelog SoloStar, Vials 3 E, SL Tacrolimus Ointment 1 SL, ST Apidra SoloStar, Vials 3 E, SL Tazarotene 0.1% Cream (generic Basaglar 1 SL 3 E, PA, SL ) Tazorac Fiasp FlexTouch, Vials 3 E, SL 1 PA, SL Tazorac 0.1% Cream Humalog KwikPens 2 SL Tazorac Gel, 0.05% Cream 3 PA, SL (all formulations) Tretinoin Cream 1 PA, SL Humalog Vials (all formulations) 1 SL Triamcinolone Acetonide Cream, Humulin KwikPens 1 2 SL Lotion, Ointment (all formulations) Vectical 3 SL Humulin Vials (all formulations) 1 SL Lantus SoloStar 3 E, SL Lantus Vials 3 E, SL
Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY. 14 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Levemir FlexTouch, Vials 3 SL Nesina 2 SL Novolin Vials (all formulations) 3 E, SL Onglyza 2 SL Novolog FlexPen, Vials 3 E, SL Oseni 2 SL (all formulations) Ozempic 3 SL Tresiba FlexTouch 2 SL Pioglitazone 1 SL 5 Diabetic supplies and prescription medications may be subject to different cost-share arrangements for Qtern 3 E, SL, ST Oxford plans. Please see your Summary of Benefits and Segluromet 3 E, SL, ST Coverage (SBC) for specifics. Medications that require step therapy may require prior authorization (sometimes Soliqua 2 PA, SL referred to as precertification) if covered under another 3 E, SL, ST benefit. Steglatro Diabetes: Non-Insulin5 Steglujan 3 E, SL, ST 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, ST Victoza 2-Pak 2 SL Glimepiride 1 Victoza 3-Pak 3 SL Glipizide 1 Xigduo XR 3 E, SL, ST 5 Diabetic supplies and prescription medications may Glipizide Extended-Release 1 be subject to different cost-share arrangements for Glyburide 1 Oxford plans. Please see your Summary of Benefits and Coverage (SBC) for specifics. Medications that require Glyxambi 2 SL, ST step therapy may require prior authorization (sometimes Invokamet, Invokamet XR 2 SL referred to as precertification) if covered under another benefit. Invokana 2 SL, ST Endocrine: Growth Hormone6 Janumet 3 SL, ST Nutropin, Nutropin AQ 2 PA, SL, SP Januvia 3 SL, ST 6 Coverage is determined by the consumer’s prescription Jardiance 2 SL, ST drug benefit plan. Please consult plan documents regarding benefit coverage and cost-share. Prior Jentadueto, Jentadueto XR 2 SL authorization (sometimes referred to as precertification) Kazano 2 SL may be required for Oxford plans. Kombiglyze XR 2 SL Metformin 1 Metformin Extended-Release 1 Tablet (generic Glucophage XR)
Bold type = Brand-name drug [Plain type = Generic drug] PA = Prior authorization required E = May be excluded from coverage RS = May be eligible for the refill and save program H = May be part of health care reform preventive SL = Supply limit H-PA = May be part of health care reform preventive with SP = Specialty medication prior authorization ST = Step therapy Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY. 15 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Endocrine: Other Eye Conditions: Glaucoma Calcitriol Capsule 1 Alphagan P 0.1% 2 SL Desmopressin Tablet 1 Azopt 2 SL Dexamethasone Tablet 1 Combigan 2 SL Latanoprost 0.005% Ophthalmic Methylprednisolone Tablet 1 1 Solution Prenisolone Oral Solution 1 Lumigan 2 SL Prednisone Tablet 1 Timolol 0.25%, 0.5% Ophthalmic 1 Endocrine: Thyroid Hormone Replacement Solution Armour Thyroid 3 Travatan Z 2 SL Levothyroxine Sodium Tablet 1 Gastrointestinal: Acid Suppression Liothyronine Sodium Tablet 1 Dexilant 3 SL Methimazole Tablet 1 Omeclamox-Pak 3 SL NP Thyroid Tablet 1 Omeprazole Capsule 1 Synthroid 2 Pantoprazole Tablet 1 Eye Conditions: Allergies Pylera 3 SL Azelastine 0.05% Ophthalmic Rabeprazole Tablet 1 SL 1 Solution Ranitadine Syrup 1 Lastacaft 3 SL Sucralfate Tablet 1 Olopatadine 0.1% Ophthalmic 1 SL Solution Gastrointestinal: Nausea/Vomiting Eye Conditions: Antibiotics Akynzeo 3 SL Erythromycin 0.5% Ophthalmic 1 Aprepitant Capsule 1 SL Ointment Emend Suspension 2 SL Gentamicin Ophthalmic Ointment, 1 Solution Ondansetron 1 Moxeza 3 Ondansetron ODT 1 Moxifloxacin Ophthalmic Solution 1 Scopolamine Transdermal Patch 1 Ofloxacin 0.3% Ophthalmic 1 Varubi 2 SL Solution Gastrointestinal: Other Tobramycin/Dexamethasone 0.3%-0.1% Ophthalmic 1 Amitiza 3 PA, SL, ST Suspension Apriso 2 Tobramycin Ophthalmic Solution 1 Budesonide Extended-Release 3 E Eye Conditions: Dry Eye Disease Tablet (generic Uceris) Restasis Single Use Vial 3 PA, SL Canasa 2 Xiidra 3 PA, SL Clenpiq 3 Cortifoam 2 Creon 2
Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY. 16 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Diphenoxylate-Atropine Tablet 1 Sovaldi 3 PA, SL, SP, ST Golytely 2 Technivie 3 PA, SL, SP, ST Hyoscyamine Tablet 1 Viekira Pak 3 PA, SL, SP, ST Lialda 1 Viekira XR 3 PA, SL, SP, ST Linzess 2 PA, SL Vosevi 2 PA, SL, SP Mesalmine Delayed-Release 3 E Zepatier 3 PA, SL, SP, ST Tablet (generic Lialda) HIV/AIDS Metoclopramide Tablet 1 Abacavir-Lamivudine 1 SP Movantik 3 E, PA, SL Atazanavir Capsule 1 SP Moviprep 3 Atripla 3 E, SP Polyethylene Glycol 3350 1 Cimduo 2 SP Prepopik 3 Complera 3 SP Sulfasalazine Tablet 1 Descovy 3 SP Suprep 3 Efavirenz 1 SP Symproic 2 PA, SL Evotaz 2 SP Uceris Foam 2 Genvoya 3 SP Uceris Tablet 1 Intelence 2 SP Viberzi 3 PA, SL Isentress 2 SP Zenpep 2 Juluca 2 SP Gout Kaletra Tablet 2 SP Allopurinol Tablet 1 Lamivudine-Zidovudine 1 SP Duzallo 3 PA, SL Lopinavir-Ritonavir Oral Solution 1 SP Mitigare 2 Nevirapine 1 SP Uloric 3 SL, ST Nevirapine Extended-Release 1 E, SP Zurampic 3 PA, SL Odefsey 3 SP Hepatitis C Prezcobix 2 SP Daklinza 3 PA, SL, SP, ST Prezista 2 SP Epclusa 2 PA, SL, SP Ritonavir Tablet 1 SP Harvoni 2 PA, SL, SP Selzentry 2 PA, SP Mavyret 2 PA, SL, SP Stribild 3 SP Ribavirin Tablet 1 SP
Bold type = Brand-name drug [Plain type = Generic drug] PA = Prior authorization required E = May be excluded from coverage RS = May be eligible for the refill and save program H = May be part of health care reform preventive SL = Supply limit H-PA = May be part of health care reform preventive with SP = Specialty medication prior authorization ST = Step therapy Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY. 17 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits 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, ST Tivicay 3 SP Tremfya 2 PA, SL, SP Triumeq 2 SP Xeljanz, Xeljanz XR 3 PA, SL, SP, ST Truvada 3 SP Medications for Sexual Dysfunction6 Tybost 2 SP Addyi 3 PA, SL Vitekta 2 SP Cialis 3 SL Infertility6 Intrarosa 3 SL Cetrotide 2 PA, SP Levitra 3 SL Clomiphene 1 PA Osphena 3 SL Endometrin 2 PA Sildenafil Tablet (genericViagra ) 1 SL Gonal-F 2 PA, SP Stendra 3 PA, SL Gonal-F RFF 2 PA, SP 6 Coverage is determined by the consumer’s prescription drug benefit plan. Please consult plan documents Ovidrel 3 PA, SP regarding benefit coverage and cost-share. Prior 6 Coverage is determined by the consumer’s prescription authorization (sometimes referred to as precertification) drug benefit plan. Please consult plan documents may be required for Oxford plans. regarding benefit coverage and cost-share. Prior Men’s Health: Prostate authorization (sometimes referred to as precertification) may be required for Oxford plans. Alfuzosin Tablet 1 Inflammatory Conditions: Rheumatoid Arthritis, Doxazosin Tablet 1 Crohn’s Disease, Psoriasis, Ulcerative Colitis Dutasteride Capsule 1 Actemra 3 PA, SL, SP, ST Finasteride Tablet 1 Cimzia 2 PA, SL, SP Rapaflo 3 Cosentyx 3 PA, SL, SP, ST Tamsulosin Capsule 1 Enbrel 3 PA, SL, SP, ST Terazosin Capsule, Tablet 1 Humira 2 PA, SL, SP Men’s Health: Testosterone Therapy Hydroxychloroquine Sulfate 1 Androderm 2 PA, SL Kevzara 3 PA, SL, SP, ST Androgel 3 E, PA, SL Leflunomide 1 Methyltestosterone Capsule 1 Methotrexate Tablet 1 Testim 1 PA, SL Orencia 3 PA, SL, SP, ST Testosterone 1% Topical Gel 1 E, PA, SL Otezla 2 PA, SL, SP Testosterone Cypionate Injection 1 Rasuvo 3 SL, ST Siliq 3 PA, SL, SP, ST
Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY. 18 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits 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 PA, 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/ 1 PA, SL Cyclobenzaprine 1 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 1 PA, SL Musculoskeletal: Osteoporosis Suspension Alendronate Sodium Tablet 1 Lanthanum Chewable Tablet 1 Forteo 3 PA, SP Letrozole 1 Ibandronate Tablet 1 SL Lidocaine Transdermal Patch 1 PA, SL (generic Lidoderm) Raloxifene Tablet 1 Nityr 2 PA, SP Risedronate Sodium Tablet 1 SL Nuedexta 2 PA Tymlos 3 PA, SP Obredon 3 PA, SL, ST Musculoskeletal: Pain Relief Pegasys 2 PA, SL, SP Acetaminophen/Codeine Tablet 1 SL Phenazopyridine 1 Belbuca 3 PA, SL Procrit 2 SL, SP Celecoxib 1 SL Promethazine/Codeine 1 PA, SL Diclofenac Tablet 1 Promethazine/Dextromethorphan 1 Etodolac Capsule 1 Pulmozyme 2 PA, SL, SP Fentanyl 12, 25, 50, 75, 100 mcg 1 PA, SL, ST Patch Rectiv 3 SL Fentanyl Citrate Lozenge 1 PA, SL Rezira 3 Hydrocodone/Acetaminophen 1 SL Sevelamer 1 5/325, 7.5/325, 10/325 mg Tablet Syprine 1 PA, SP Hydrocodone/Ibuprofen Tablet 1
Bold type = Brand-name drug [Plain type = Generic drug] PA = Prior authorization required E = May be excluded from coverage RS = May be eligible for the refill and save program H = May be part of health care reform preventive SL = Supply limit H-PA = May be part of health care reform preventive with SP = Specialty medication prior authorization ST = Step therapy Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY. 19 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Hydromorphone Immediate- 1 Respiratory: Allergies Release Tablet Azelastine 0.1% Nasal Spray 1 Ibuprofen Tablet 1 Fluticasone Nasal Spray 1 SL Indomethacin Capsule 1 Zetonna 3 SL Ketorolac Tablet 1 Respiratory: Asthma/COPD Lazanda 3 PA, SL Advair Diskus/HFA 3 RS, SL Meloxicam Tablet 1 Albuterol Nebs 1 Methadone Tablet, Oral Solution, 1 PA, SL Concentrate Solution Alvesco 1 SL Morphine Sulfate Extended- 1 PA, SL Anoro Ellipta 3 SL Release Tablet Arnuity Ellipta 3 SL Morphine Sulfate Oral Solution 1 Asmanex TwistHaler, HFA 1 SL Nabumetone Tablet 1 Bevespi Aerosphere 2 SL Naproxen Tablet 1 Breo Ellipta 3 RS, SL Nucynta 3 SL Budesonide Nebs 1 SL Nucynta ER 3 PA, SL Combivent Respimat 3 SL Oxycodone/Acetaminophen 1 SL 5/325, 7.5/325, 10/325 mg Tablet Flovent Diskus/HFA 3 SL Oxycodone Tablet 1 Fluticasone/Salmeterol RespiClick 1 SL (generic AirDuo RespiClick) Oxycontin 3 E, PA, SL, ST Incruse Ellipta 2 SL Sprix 3 Ipratropium-Albuterol Nebs 1 Tramadol-Acetaminophen 1 SL Ipratropium Nebs 1 Tramadol Immediate-Release 1 Tablet Montelukast 1 Tramadol Sustained-Release 1 SL Perforomist 3 SL Tablet ProAir HFA/RespiClick 3 SL Trezix 1 SL Vicodin 5/300, 7.5/300, 10/300 Proventil HFA 3 SL 1 E, SL mg Tablet Pulmicort Flexhaler 3 SL, ST Voltaren Gel 2 QVAR Redihaler 1 SL Xtampza ER 2 PA, SL Seebri Neohaler 3 SL, ST Zohydro ER 3 PA, SL, ST Serevent Diskus 3 SL Overactive Bladder Spiriva Handihaler/Respimat 2 SL Dicyclomine Tablet 1 Striverdi Respimat 2 SL Oxybutynin Extended-Release 1 Symbicort 3 RS, SL Tablet 3 RS, SL Oxybutynin Tablet 1 Trelegy Ellipta Tudorza 2 SL Toviaz 3 Ventolin HFA 2 SL Xopenex HFA 3 SL
Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY. 20 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Respiratory: Pulmonary Arterial Hypertension Vitamins/Electrolytes Adempas 2 PA, SL, SP Fluoride 1 Letairis 2 PA, SL, SP Folic Acid 1 Opsumit 2 PA, SL, SP Klor-Con M10 1 Orenitram 3 PA, SL, SP Klor-Con M20 1 Sildenafil Tablet (genericRevatio ) 1 PA, SL, SP Potassium Chloride 1 Tadalafil (genericAdcirca ) 1 PA, SL, SP Potassium Citrate 1 Tracleer 2 PA, SL, SP Women’s Health: Contraceptives Tyvaso 2 PA, SP Aftera 1 H Uptravi 3 PA, SL, SP Altavera 1 H Smoking Cessation Alyacen 7/7/7, 1/35 1 H Bupropion Sustained-Release 1 H-PA Amethia 1 H Tablet Amethia Lo 1 H Chantix Tablet 3 H-PA Amethyst 1 H Nicoderm CQ 3 H-PA Apri 1 H Nicorette Gum 3 H-PA Aranelle 1 H Nicorette Lozenge 2 H-PA Ashlyna 1 H Nicorette Mini-Lozenge 2 H-PA Aubra 1 H Nicotine Gum 1 H-PA Aviane 1 H Nicotine Lozenge 1 H-PA Azurette 1 H Nicotine Patch 1 H-PA Balziva 1 H Nicotrol Inhaler 3 H-PA Bekyree 1 H Nicotrol Nasal Spray 3 H-PA Blisovi Fe 1 H Transplant Blisovi 24 Fe 1 H Azathioprine Tablet 1 Briellyn 1 H Cyclosporine Modified Capsule 1 SP Camila 1 H Mycophenolate Capsule, 1 SP Suspension Camrese 1 H Mycophenolic Acid Tablet 1 SP Camrese Lo 1 H Sirolimus Tablet 1 SP Caziant 1 H Tacrolimus Capsule 1 SP Chateal 1 H
Bold type = Brand-name drug [Plain type = Generic drug] PA = Prior authorization required E = May be excluded from coverage RS = May be eligible for the refill and save program H = May be part of health care reform preventive SL = Supply limit H-PA = May be part of health care reform preventive with SP = Specialty medication prior authorization ST = Step therapy Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY. 21 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Cryselle 1 H Kurvelo 1 H Cyclafem 7/7/7, 1/35 1 H Larin 1 H Cyred 1 H Larin 24 Fe 1 H Dasetta 7/7/7, 1/35 1 H Larin Fe 1 H Daysee 1 H Larissia 1 H Deblitane 1 H Leena 1 H Delyla 1 H Lessina 1 H Desogestrel-Ethinyl Estradiol 1 H Levonest 1 H Drospirenone-Ethinyl Estradiol 1 H Levonorgestrel 1.5 mg 1 H Econtra EZ 1 H Levonorgestrel-Ethinyl Estradiol 1 H Elinest 1 H Levora-28 1 H Ella 1 H, SL Lillow 1 H Emoquette 1 H Lo Loestrin Fe 3 Enpresse 1 H LoMedia 24 Fe 1 H Enskyce 1 H Loryna 1 H Errin 1 H Low-Ogestrel 1 H Estarylla 1 H Lutera 1 H Fallback 1 H Lyza 1 H Falmina 1 H Marlissa 1 H Gianvi 1 H Medroxyprogesterone Acetate 1 H Gildagia 1 H Microgestin 1 H Heather 1 H Microgestin Fe 1 H Introvale 1 H Mono-Linyah 1 H Isibloom 1 H Mononessa 1 H Jencycla 1 H My Choice 1 H Jolessa 1 H My Way 1 H Jolivette 1 H Myzilra 1 H Juleber 1 H Natazia 2 Necon 7/7/7, 0.5/35, 1/35, 1/50, Junel 1 H 1 H 10/11 Junel 24 Fe 1 H Next Choice One Dose 1 H Junel Fe 1 H Nikki 1 H Kariva 1 H Nora BE 1 H Kelnor 1/35 1 H Norethindrone 0.35 mg 1 H Kimidess 1 H
Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY. 22 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Norethindrone-Ethinyl Estradiol- 1 H Tri-Legest Fe 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 Ocella 1 H Tri-Vylibra 1 H Ogestrel 1 H Trinessa 1 H Opcicon One Step 1 H Trinessa Lo 1 H Option 2 1 H Trivora-28 1 H Orsythia 1 H Velivet 1 H Philith 1 H Vestura 1 H Pimtrea 1 H Vienva 1 H Pirmella 7/7/7, 1/35 1 H Viorele 1 H Plan B One Step 1 H Vyfemla 1 H Portia 1 H Vylibra 1 H Previfem 1 H Wera 1 H Quasense 1 H Wymza Fe 1 H Reclipsen 1 H Xulane 1 H Setlakin 1 H Yasmin 28 3 Sharobel 1 H Yaz 3 Solia 1 H Zarah 1 H Sprintec 1 H Zenchent 1 H Sronyx 1 H Zenchent Fe 1 H Syeda 1 H Zovia 1/35E, 1/50E 1 H Take Action 1 H Tarina Fe 1 H Tilia Fe 1 H Tri Femynor 1 H Tri-Estarylla 1 H
Bold type = Brand-name drug [Plain type = Generic drug] PA = Prior authorization required E = May be excluded from coverage RS = May be eligible for the refill and save program H = May be part of health care reform preventive SL = Supply limit H-PA = May be part of health care reform preventive with SP = Specialty medication prior authorization ST = Step therapy Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY. 23 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Women’s Health: Hormone Replacement Women’s Health: Miscellaneous Climara Pro 3 SL Raloxifene 1 H-PA Divigel 3 Tamoxifen 1 H-PA Duavee 3 SL Women’s Health: Prenatal Vitamins Estrace Cream 1 Brand Prenatal Vitamins 3 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 Estrogen/Methyltestosterone 1 Tablet Evamist 2 Medroxyprogesterone 1 Minivelle 3 SL Premarin 3 Premphase 3 Prempro 3 Progesterone Micronized Capsule 1 Vivelle-Dot 1 SL Yuvafem 1
Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY. 24 Index
A Amoxicillin/Potassium Clavulanate Bekyree...... 21 Abacavir-Lamivudine...... 17 Chewable Tablet, Tablet...... 9 Belbuca...... 19 Accu-Chek Test Strips...... 14 Amphetamine Salt Combo...... 11 Benazepril...... 10 Acetaminophen/Butalbital/Caffeine Ampyra...... 12 Benazepril-Hydrochlorothiazide..... 10 325 mg/50 mg/40 mg...... 12 Anastrozole Tablet...... 19 Betamethasone Dipropionate Acetaminophen/Codeine Tablet..... 19 Androderm...... 18 0.05% Augmented Lotion, Actemra...... 18 Androgel...... 18 Ointment...... 13 Acyclovir Ointment...... 9 Anoro Ellipta...... 20 Betamethasone Dipropionate Acyclovir Tablet...... 9 Apidra SoloStar, Vials...... 14 0.05% Cream, Ointment...... 13 Aczone...... 13 Aprepitant Capsule...... 16 Betaseron...... 12 Adcirca...... 21 Apri...... 21 Bethkis...... 19 Adderall XR...... 11 Apriso...... 16 Bevespi Aerosphere...... 20 Addyi...... 18 Aranelle...... 21 Bevyxxa...... 10 Adempas...... 21 Aranesp...... 19 Bexarotene Capsule...... 9 Adlyxin...... 15 Aripiprazole Tablet...... 12 Bicalutamide...... 9 Admelog SoloStar, Vials...... 14 Armodafinil...... 12 Bidil...... 10 Advair Diskus/HFA...... 20 Armour Thyroid...... 16 Bisoprolol...... 10 Aftera...... 21 Arnuity Ellipta...... 20 Bisoprolol-Hydrochlorothiazide...... 10 AirDuo RespiClick...... 20 Ashlyna...... 21 Blisovi 24 Fe...... 21 Akynzeo...... 16 Asmanex TwistHaler, HFA...... 20 Blisovi Fe...... 21 Albuterol Nebs...... 20 Atazanavir Capsule...... 17 Bosulif...... 9 Alendronate Sodium Tablet...... 19 Atenolol...... 10 Braftovi...... 9 Alfuzosin Tablet...... 18 Atenolol-Chlorthalidone...... 10 Brand Prenatal Vitamins...... 24 Allopurinol Tablet...... 17 Atomoxetine...... 11 Breo Ellipta...... 20 Alphagan P 0.1%...... 16 Atorvastatin...... 11 Briellyn...... 21 Alprazolam Extended-Release Atripla...... 17 Brilinta...... 10 Tablet...... 12 Aubagio...... 12 Budesonide Extended-Release Alprazolam Tablet...... 12 Aubra...... 21 Tablet...... 16 Altavera...... 21 Auryxia...... 19 Budesonide Nebs...... 20 Alunbrig...... 9 Austedo...... 12 Buprenorphine Sublingual Tablet... 12 Alvesco...... 20 Aviane...... 21 Bupropion Extended-Release Alyacen 7/7/7, 1/35...... 21 Avonex...... 12 Tablet...... 12 Amethia...... 21 Azathioprine Tablet...... 21 Bupropion Sustained-Release Amethia Lo...... 21 Azelastine 0.05% Ophthalmic Tablet...... 12, 21 Amethyst...... 21 Solution...... 16 Bupropion Tablet...... 12 Amiodarone...... 11 Azelastine 0.1% Nasal Spray...... 20 Buspirone Tablet...... 12 Amitiza...... 16 Azithromycin Tablet...... 9 Bydureon, Bydureon Bcise...... 15 Amitriptyline Tablet...... 12 Azopt...... 16 Byetta...... 15 Amlodipine...... 10 Azurette...... 21 Bystolic...... 10 Amlodipine-Benazepril...... 10 Byvalson...... 10 Amlodipine-Valsartan...... 10 B Amoxicillin Capsule, Chewable Baclofen Tablet...... 19 C Tablet...... 9 Balziva...... 21 Calcipotriene/Betamethasone Basaglar...... 14 Ointment...... 13
25 Calcitriol Capsule...... 16 Clindamycin 1.2%/Benzoyl Descovy...... 17 Calquence...... 9 Peroxide 5% Gel...... 13 Desmopressin Tablet...... 16 Camila...... 21 Clindamycin Capsule...... 9 Desogestrel-Ethinyl Estradiol...... 22 Camrese...... 21 Clindamycin Gel...... 13 Desonide 0.05% Cream, Lotion, Camrese Lo...... 21 Clindamycin Lotion, Swabs...... 13 Ointment...... 13 Canasa...... 16 Clindamycin Solution...... 13 Desoximetasone Cream, Gel, Carac...... 13 Clobetasol Propionate Cream, Ointment...... 13 Carbamazepine Extended-Release Ointment, Solution...... 13 Desvenlafaxine Extended-Release Capsule, Tablet...... 13 Clomiphene...... 18 Tablet...... 12 Carbamazepine Immediate-Release Clonazepam Tablet...... 13 Dexamethasone Tablet...... 16 Tablet...... 13 Clonidine Tablet...... 10 Dexilant...... 16 Carbidopa-Levodopa...... 12 Clopidogrel...... 10 Dexmethylphenidate Immediate- Carisoprodol 350 mg Tablet...... 19 Clotrimazole-Betamethasone Release Tablet...... 11 Cartia XT...... 10 Cream...... 13 Dextroamphetamine Sulfate Carvedilol Immediate-Release Clotrimazole-Betamethasone Immediate-Release Tablet...... 11 Tablet...... 10 Lotion...... 13 Dextroamphetamine-Amphetamine Cayston...... 19 Colesevelam Packet for Immediate-Release Tablet...... 11 Caziant...... 21 Suspension, Tablet...... 11 Diazepam Tablet...... 12, 13 Cefadroxil Capsule, Tablet...... 9 Combigan...... 16 Diclofenac Tablet...... 19 Cefdinir Capsule...... 9 Combivent Respimat...... 20 Dicyclomine Tablet...... 20 Cefixime Suspension...... 9 Complera...... 17 Dificid...... 9 Cefprozil Tablet...... 9 Concerta...... 11 Diflorasone Diacetate 0.05% Cefuroxime Tablet...... 9 Contour Next EZ Meter...... 14 Cream, Ointment...... 13 Celecoxib...... 19 Contour Next Meter...... 14 Digoxin...... 11 Cephalexin Capsule...... 9 Contour Next One Meter...... 14 Diltiazem 24 Hour CD...... 10 Cerdelga...... 19 Contour Next Test Strips...... 14 Diltiazem Sustained-Release Cetrotide...... 18 Contour Test Strips...... 14 Capsule...... 10 Chantix Tablet...... 21 Copaxone...... 12 Diltiazem Sustained-Release Chateal...... 21 Corlanor...... 11 Tablet...... 10 Chlorhexidine Gluconate...... 19 Cortifoam...... 16 Diphenoxylate-Atropine Tablet...... 17 Chlorpheniramine/Hydrocodone/ Cosentyx...... 18 Divalproex Delayed-Release Pseudoephedrine Solution...... 19 Creon...... 16 Tablet...... 13 Chlorthalidone...... 10 Cresemba...... 9 Divalproex Extended-Release Cialis...... 18 Cryselle...... 22 Tablet...... 13 Ciclopirox Cream, Gel, Lotion, Cyclafem 7/7/7, 1/35...... 22 Divigel...... 24 Solution...... 13 Cyclobenzaprine...... 19 Donepezil ODT, 5, 10 mg Tablet.... 12 Cimduo...... 17 Cyclophosphamide Capsule...... 9 Doxazosin...... 10, 18 Cimzia...... 18 Cyclosporine Modified Capsule..... 21 Doxazosin Tablet...... 18 Ciprodex...... 9 Cyred...... 22 Doxepin...... 12 Ciprofloxacin Tablet...... 9 Doxycycline Capsule, Tablet...... 9 Citalopram Tablet...... 12 D Drospirenone-Ethinyl Estradiol...... 22 Claravis...... 13 Daklinza...... 17 Duavee...... 24 Clarithromycin Tablet...... 9 Dapsone 5% Gel...... 13 Duloxetine Capsule...... 12 Clenpiq...... 16 Dasetta 7/7/7, 1/35...... 22 Dupixent...... 13 Climara...... 24 Daysee...... 22 Dutasteride Capsule...... 18 Climara Pro...... 24 Deblitane...... 22 Duzallo...... 17 Delyla...... 22
26 E Evamist...... 24 Gildagia...... 22 Econazole Cream...... 9 Evotaz...... 17 Gilenya...... 12 Econtra EZ...... 22 Ezetimibe Tablet...... 11 Glatiramer...... 12 Edarbi...... 10 Ezetimibe/Simvastatin...... 11 Glimepiride...... 15 Edarbyclor...... 10 Glipizide...... 15 Efavirenz...... 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...... 19 Guanfacine...... 10, 11 Enalapril...... 10 Fentanyl Citrate Lozenge...... 19 Guanfacine Extended-Release...... 11 Enbrel...... 18 Fetzima...... 12 Endometrin...... 18 Fiasp FlexTouch, Vials...... 14 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...... 14 Entresto...... 11 Fluconazole Tablet...... 9 Humalog Vials...... 14 Epclusa...... 17 Fluocinolone Cream, Oil, Ointment, Humira...... 18 Epinephrine...... 19 Solution...... 14 Humulin KwikPens...... 14 EpiPen/EpiPen Jr...... 19 Fluocinonide 0.05% Cream...... 14 Humulin Vials...... 14 EpiPen/EpiPen-Jr...... 19 Fluoride...... 21 Hydralazine...... 10 Erleada...... 9 Fluorouracil 0.5% Cream...... 14 Hydrochlorothiazide...... 10 Errin...... 22 Fluoxetine Capsule...... 12 Hydrocodone/Acetaminophen Erythromycin 0.5% Ophthalmic Fluticasone Nasal Spray...... 20 5/325, 7.5/325, 10/325 mg Ointment...... 16 Fluticasone/Salmeterol Tablet...... 19 Escitalopram Tablet...... 12 RespiClick...... 20 Hydrocodone/Chlorpheniramine Estarylla...... 22 Fluvastatin Extended-Release Suspension...... 19 Estrace...... 24 Tablet...... 11 Hydrocodone/Ibuprofen Tablet...... 19 Estrace Cream...... 24 Fluvoxamine Tablet...... 12 Hydrocortisone 2.5% Cream, Estradiol Cream...... 24 Folic Acid...... 21 Ointment...... 14 Estradiol Tablet...... 24 Forteo...... 19 Hydromorphone Immediate-Release Estradiol Twice-Weekly FreeStyle Test Strips...... 14 Tablet...... 20 Transdermal Patch...... 24 Frovatriptan...... 12 Hydroxychloroquine Sulfate...... 18 Estradiol Weekly Transdermal Furosemide...... 10 Hyoscyamine Tablet...... 17 Patch...... 24 Estradiol/Norethindrone Acetate G I Tablet...... 24 Gabapentin Capsule, Tablet...... 13 Ibandronate Tablet...... 19 Estring...... 24 Gemfibrozil...... 11 Ibrance...... 9 Estrogen/Methyltestosterone Gentamicin Ophthalmic Ointment, Ibuprofen Tablet...... 19, 20 Tablet...... 24 Solution...... 16 Idhifa...... 9 Eszopiclone Tablet...... 13 Genvoya...... 17 Imantinib Tablet...... 9 Etodolac Capsule...... 19 Gianvi...... 22 Imbruvica...... 9 Eucrisa...... 14
27 Imiquimod 5% Cream...... 14 Lamivudine-Zidovudine...... 17 Losartan...... 10 Incruse Ellipta...... 20 Lamotrigine Immediate-Release Losartan-Hydrochlorothiazide...... 10 Indomethacin Capsule...... 20 Tablet...... 13 Lovastatin...... 11 Intelence...... 17 Lanthanum Chewable Tablet...... 19 Low-Ogestrel...... 22 Intrarosa...... 18 Lantus SoloStar...... 14 Lumigan...... 16 Introvale...... 22 Lantus Vials...... 14 Lutera...... 22 Invokamet, Invokamet XR...... 15 Larin...... 22 Lyrica...... 13 Invokana...... 15 Larin 24 Fe...... 22 Lyrica CR...... 13 Ipratropium Nebs...... 20 Larin Fe...... 22 Lyza...... 22 Ipratropium-Albuterol Nebs...... 20 Larissia...... 22 Irbesartan...... 10 Lastacaft...... 16 M Isentress...... 17 Latanoprost 0.005% Ophthalmic Marlissa...... 22 Isibloom...... 22 Solution...... 16 Mavyret...... 17 Isosorbide Mononitrate ER...... 11 Latuda...... 12 Medroxyprogesterone...... 22, 24 Itraconazole Capsule...... 9 Lazanda...... 20 Medroxyprogesterone Acetate...... 22 Leena...... 22 Mektovi...... 10 J Leflunomide...... 18 Meloxicam Tablet...... 20 Janumet...... 15 Lessina...... 22 Memantine Immediate-Release Januvia...... 15 Letairis...... 21 Tablet...... 12 Jardiance...... 15 Letrozole...... 19 Mercaptopurine Tablet...... 10 Jencycla...... 22 Leucovorin Calcium Tablet...... 10 Mesalmine Delayed-Release Jentadueto, Jentadueto XR...... 15 Levemir FlexTouch, Vials...... 15 Tablet...... 17 Jolessa...... 22 Levetiracetam Extended-Release Metadate CD...... 11 Jolivette...... 22 Tablet...... 13 Metadate ER...... 11 Juleber...... 22 Levetiracetam Immediate-Release Metaxalone Tablet...... 19 Juluca...... 17 Tablet...... 13 Metformin...... 15 Junel...... 22 Levitra...... 18 Metformin Extended-Release Junel 24 Fe...... 22 Levofloxacin Tablet...... 9 Tablet...... 15 Junel Fe...... 22 Levonest...... 22 Methadone Tablet, Oral Solution, Levonorgestrel 1.5 mg...... 22 Concentrate Solution...... 20 Levonorgestrel-Ethinyl Estradiol.... 22 K Methimazole Tablet...... 16 Levora-28...... 22 Kaletra Tablet...... 17 Methocarbamol Tablet...... 19 Levothyroxine Sodium Tablet...... 16 Kariva...... 22 Methotrexate Tablet...... 18 Lialda...... 17 Kazano...... 15 Methylphenidate Chewable Tablet..11 Lidocaine Transdermal Patch...... 19 Kelnor 1/35...... 22 Methylphenidate Extended-Release Lidoderm...... 19 Ketoconazole Cream...... 9 Capsule...... 11 Lillow...... 22 Ketorolac Tablet...... 20 Methylphenidate Extended-Release Linzess...... 17 Kevzara...... 18 Tablet...... 11 Liothyronine Sodium Tablet...... 16 Kimidess...... 22 Methylphenidate Lisinopril...... 10 Klor-Con M10...... 21 Immediate-Release Tablet...... 11 Lisinopril-Hydrochlorothiazide...... 10 Klor-Con M20...... 21 Methylprednisolone Tablet...... 16 Lithium Capsule...... 12 Kombiglyze XR...... 15 Methyltestosterone Capsule...... 18 Lo Loestrin Fe...... 22 Kurvelo...... 22 Metoclopramide Tablet...... 17 LoMedia 24 Fe...... 22 Metoprolol Succinate Extended- Lopinavir-Ritonavir Oral Solution.... 17 Release...... 10 L Lorazepam Tablet...... 12 Metoprolol Tartrate 25, 50, Labetalol...... 10 Loryna...... 22 100 mg...... 10
28 Metronidazole 0.75% Topical Gel... 14 Niacin Extended-Release Tablet.....11 Olanzapine Tablet...... 12 Microgestin...... 22 Niaspan...... 11 Olmesartan...... 10 Microgestin Fe...... 22 Nicoderm CQ...... 21 Olmesartan-Hydrochlorothiazide... 10 Minivelle...... 24 Nicorette Gum...... 21 Olopatadine 0.1% Ophthalmic Minocycline Capsule...... 9 Nicorette Lozenge...... 21 Solution...... 16 Minocycline Extended-Release...... 14 Nicorette Mini-Lozenge...... 21 Omeclamox-Pak...... 16 Mirtazapine Tablet...... 12 Nicotine Gum...... 21 Omega-3-Acid Ethyl Esters Mirvaso...... 14 Nicotine Lozenge...... 21 Capsule...... 11 Mitigare...... 17 Nicotine Patch...... 21 Omeprazole Capsule...... 16 Modafinil...... 12 Nicotrol Inhaler...... 21 Ondansetron...... 16 Mometasone Furoate Cream, Nicotrol Nasal Spray...... 21 Ondansetron ODT...... 16 Lotion, Ointment...... 14 Nifedipine Extended-Release...... 10 OneTouch Ultra 2 Meter...... 14 Mono-Linyah...... 22 Nikki...... 22 OneTouch Ultra Test Strips...... 14 Mononessa...... 22 Nitrofurantoin Capsule...... 9 OneTouch UltraMini Meter...... 14 Montelukast...... 20 Nitrofurantoin Macrocrystal OneTouch Verio Flex Meter...... 14 Morphine Sulfate Capsule...... 9 OneTouch Verio IQ Meter...... 14 Extended-Release Tablet...... 20 Nitroglycerin Sublingual Tablet...... 11 OneTouch Verio Meter...... 14 Morphine Sulfate Oral Solution...... 20 Nityr...... 19 OneTouch Verio Sync Meter...... 14 Movantik...... 17 Nora BE...... 22 OneTouch Verio Test Strips...... 14 Moviprep...... 17 Norethindrone 0.35 mg...... 22 Onglyza...... 15 Moxeza...... 16 Norethindrone-Ethinyl Estradiol- Opcicon One Step...... 23 Moxifloxacin Ophthalmic Solution.. 16 Ferrous Fumarate...... 23 Opsumit...... 21 Moxifloxacin Tablet...... 9 Norgestimate-Ethinyl Estradiol...... 23 Option 2...... 23 Multaq...... 11 Norlyda...... 23 Oracea...... 14 Mupirocin Ointment...... 14 Norlyroc...... 23 Orencia...... 18 My Choice...... 22 Nortrel 7/7/7, 0.5/35, 1/35...... 23 Orenitram...... 21 My Way...... 22 Nortriptyline Capsule...... 12 Orsythia...... 23 Mycophenolate Capsule, Novolin Vials...... 15 Oseltamivir Capsule, Suspension.... 9 Suspension...... 21 Novolog FlexPen, Vials...... 15 Oseni...... 15 Mycophenolic Acid Tablet...... 21 Noxafil Tablet, Suspension...... 9 Osphena...... 18 Myzilra...... 22 NP Thyroid Tablet...... 16 Otezla...... 18 Nucynta...... 20 Ovidrel...... 18 N Nucynta ER...... 20 Oxcarbazepine Tablet...... 13 Nabumetone Tablet...... 20 Nuedexta...... 19 Oxsoralen-Ultra...... 14 Nadolol...... 10 Nutropin, Nutropin AQ...... 15 Oxybutynin Extended-Release Naloxone Vial...... 12 Nuvaring...... 23 Tablet...... 20 Naproxen Tablet...... 20 Nystatin Cream, Ointment...... 9 Oxybutynin Tablet...... 20 Naratriptan...... 12 Oxycodone Tablet...... 20 Narcan Nasal Spray...... 12 O Oxycodone/Acetaminophen 5/325, Natazia...... 22 Obredon...... 19 7.5/325, 10/325 mg Tablet...... 20 Necon 7/7/7, 0.5/35, 1/35, Ocella...... 23 Oxycontin...... 20 1/50, 10/11...... 22 Odefsey...... 17 Ozempic...... 15 Nerlynx...... 10 Ofloxacin 0.3% Ophthalmic Nesina...... 15 Solution...... 16 P Nevirapine...... 17 Ofloxacin Otic Solution...... 9 Pantoprazole Tablet...... 16 Nevirapine Extended-Release...... 17 Ofloxacin Tablet...... 9 Paroxetine Tablet...... 12 Next Choice One Dose...... 22 Ogestrel...... 23 Pegasys...... 19
29 Penicillin V Potassium Tablet...... 9 Quasense...... 23 Setlakin...... 23 Perforomist...... 20 Quetiapine Extended-Release Sevelamer...... 19 Phenazopyridine...... 19 Tablet...... 12 Sharobel...... 23 Phenytoin Capsule, Suspension.... 13 Quetiapine Immediate-Release Sildenafil Tablet...... 18, 21 Philith...... 23 Tablet...... 13 Siliq...... 18 Picato...... 14 Quinapril...... 10 Simponi...... 18 Pimtrea...... 23 QVAR Redihaler...... 20 Simvastatin...... 11 Pioglitazone...... 15 Sirolimus Tablet...... 21 Pirmella 7/7/7, 1/35...... 23 R Solia...... 23 Plan B One Step...... 23 Rabeprazole Tablet...... 16 Soliqua...... 15 Plegridy...... 12 Raloxifene...... 19, 24 Solodyn...... 14 Polyethylene Glycol 3350...... 17 Raloxifene Tablet...... 19 Sotalol...... 11 Portia...... 23 Ramipril...... 10 Sovaldi...... 17 Potassium Chloride...... 21 Ranexa...... 11 Spiriva Handihaler/Respimat...... 20 Potassium Citrate...... 21 Ranitadine Syrup...... 16 Spironolactone...... 11 Pradaxa...... 10 Rapaflo...... 18 Sprintec...... 23 Praluent...... 11 Rasuvo...... 18 Sprix...... 20 Pramipexole Tablet...... 12 Rebif...... 12 Sronyx...... 23 Prasugrel...... 10 Reclipsen...... 23 Steglatro...... 15 Pravastatin...... 11 Rectiv...... 19 Steglujan...... 15 Prednisone Tablet...... 16 Regranex...... 14 Stelara...... 18 Premarin...... 24 Repatha...... 11 Stendra...... 18 Premphase...... 24 Restasis Single Use Vial...... 16 Stribild...... 17 Prempro...... 24 Revatio...... 21 Striverdi Respimat...... 20 Prenisolone Oral Solution...... 16 Revlimid...... 10 Suboxone Film...... 13 Prepopik...... 17 Rezira...... 19 Sucralfate Tablet...... 16 Previfem...... 23 Rhofade...... 14 Sulfamethoxazole-Trimethoprim Prezcobix...... 17 Ribavirin Tablet...... 17 Tablet...... 9 Prezista...... 17 Risedronate Sodium Tablet...... 19 Sulfasalazine Tablet...... 17 Pristiq...... 12 Risperidone Tablet...... 13 Sumatriptan Nasal Spray...... 12 ProAir HFA/RespiClick...... 20 Ritalin LA...... 11 Sumatriptan Succinate Tablet, Procrit...... 19 Ritalin SR...... 11 Injection...... 12 Progesterone Micronized Ritonavir Tablet...... 17 Suprax Capsule, Chewable Tablet, Capsule...... 24 Rizatriptan ODT, Tablet...... 12 Tablet...... 9 Promethazine/Codeine...... 19 Ropinirole Tablet...... 13 Suprep...... 17 Promethazine/Dextromethorphan.. 19 Rosuvastatin...... 11 Sutent...... 10 Propranolol Extended-Release Rydapt...... 10 Syeda...... 23 Capsule...... 10 Symbicort...... 20 Propranolol Tablet...... 10 Symfi...... 18 S Proventil HFA...... 20 Symfi Lo...... 18 Savaysa...... 10 Prozac...... 12 Symproic...... 17 Scopolamine Transdermal Patch... 16 Pulmicort Flexhaler...... 20 Synjardy, Synjardy XR...... 15 Seebri Neohaler...... 20 Pulmozyme...... 19 Synthroid...... 16 Segluromet...... 15 Pylera...... 16 Syprine...... 19 Selzentry...... 17 Serevent Diskus...... 20 Q T Sertraline Tablet...... 12 Qtern...... 15 Taclonex Suspension...... 14
30 Tacrolimus Capsule...... 21 Tramadol-Acetaminophen...... 20 Valsartan-Hydrochlorothiazide...... 11 Tacrolimus Ointment...... 14 Travatan Z...... 16 Varubi...... 16 Tadalafil...... 21 Trazodone Tablet...... 12 Vascepa...... 11 Take Action...... 23 Trelegy Ellipta...... 20 Vectical...... 14 Taltz...... 18 Tremfya...... 18 Velivet...... 23 Tamoxifen...... 24 Tresiba FlexTouch...... 15 Velphoro...... 19 Tamsulosin Capsule...... 18 Tretinoin Cream...... 14 Veltassa...... 19 Targretin Capsule...... 10 Trezix...... 20 Venlafaxine Extended-Release Targretin Gel...... 10 Tri Femynor...... 23 Capsule...... 12 Tarina Fe...... 23 Tri-Estarylla...... 23 Venlafaxine Tablet...... 12 Tasigna...... 10 Tri-Legest Fe...... 23 Ventolin HFA...... 20 Tazarotene 0.1% Cream...... 14 Tri-Linyah...... 23 Verapamil...... 11 Tazorac...... 14 Tri-Lo-Estarylla...... 23 Verapamil Sustained-Release...... 11 Tazorac 0.1% Cream...... 14 Tri-Lo-Marzia...... 23 Verzenio...... 10 Tazorac Gel, 0.05% Cream...... 14 Tri-Lo-Sprintec...... 23 Vestura...... 23 Tecfidera...... 12 Tri-Previfem...... 23 Viagra...... 18 Technivie...... 17 Tri-Sprintec...... 23 Viberzi...... 17 Telmisartan...... 11 Tri-Vylibra...... 23 Vicodin 5/300, 7.5/300, 10/300 mg Telmisartan-Hydrochlorothiazide....11 Triamcinolone Acetonide Cream, Tablet...... 20 Temazepam Capsule...... 13 Lotion, Ointment...... 14 Victoza 2-Pak...... 15 Tenofovir Tablet...... 18 Triamterene-Hydrochlorothiazide....11 Victoza 3-Pak...... 15 Terazosin...... 11, 18 Triazolam Tablet...... 13 Viekira Pak...... 17 Terazosin Capsule, Tablet...... 18 Trientine...... 19 Viekira XR...... 17 Terbinafine Tablet...... 9 Trinessa...... 23 Vienva...... 23 Testim...... 18 Trinessa Lo...... 23 Viibryd...... 12 Testosterone 1% Topical Gel...... 18 Trintellix...... 12 Viorele...... 23 Testosterone Cypionate Injection... 18 Triumeq...... 18 Vitekta...... 18 Tilia Fe...... 23 Trivora-28...... 23 Vivelle-Dot...... 24 Timolol 0.25%, 0.5% Ophthalmic Trulicity...... 15 Voltaren Gel...... 20 Solution...... 16 Truvada...... 18 Vosevi...... 17 Tivicay...... 18 Tudorza...... 20 Vyfemla...... 23 Tizanidine Tablet...... 19 Tybost...... 18 Vylibra...... 23 Tobi Podhaler...... 19 Tymlos...... 19 Vyvanse...... 11 Tobramycin Ophthalmic Solution.... 16 Tyvaso...... 21 Tobramycin/Dexamethasone 0.3%- W 0.1% Ophthalmic Suspension..... 16 U Warfarin Sodium...... 10 Tolcapone...... 13 Uceris...... 16, 17 Welchol...... 11 Topiramate Immediate-Release Uceris Foam...... 17 Welchol Packet for Suspension, Tablet...... 13 Uceris Tablet...... 17 Tablet...... 11 Toviaz...... 20 Uloric...... 17 Wera...... 23 Tracleer...... 21 Uptravi...... 21 Wymza Fe...... 23 Tradjenta...... 15 Tramadol Immediate-Release V X Tablet...... 20 Valacyclovir Tablet...... 9 Xarelto...... 10 Tramadol Sustained-Release Valganciclovir...... 9 Xeljanz, Xeljanz XR...... 18 Tablet...... 20 Valsartan...... 11 Xeloda...... 10
31 Xigduo XR...... 15 Xiidra...... 16 Xopenex HFA...... 20 Xtampza ER...... 20 Xulane...... 23 Xyrem...... 13
Y Yasmin 28...... 23 Yaz...... 23 Yuvafem...... 24
Z Zaleplon Capsule...... 13 Zarah...... 23 Zarxio...... 19 Zelapar...... 13 Zenchent...... 23 Zenchent Fe...... 23 Zenpep...... 17 Zepatier...... 17 Zetonna...... 20 Ziprasidone Capsule...... 13 Zohydro ER...... 20 Zolpidem Immediate-Release Tablet...... 13 Zonisamide Capsule...... 13 Zovia 1/35E, 1/50E...... 23 Zubsolv...... 13 Zurampic...... 17 Zykadia...... 10 Zytiga...... 10
32 Nondiscrimination notice and access to communication services
UnitedHealthcare® and its subsidiaries do not discriminate on the basis of race, color, national origin, age, disability or sex in its health programs or activities. If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to the Civil Rights Coordinator.
Online: [email protected]
Mail: Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box 30608 Salt Lake City, UT 84130
You must send the complaint within 60 days of your experience. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, please call the toll-free phone number listed on your ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m., or at the times listed in your health plan documents.
You can also file a complaint with the U.S. Dept. of Health and Human Services.
Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html
Phone: Toll-free 1-800-368-1019, 800-537-7697 (TDD)
Mail: U.S. Dept. of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201
We provide free services to help you communicate with us, including letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the toll-free phone number listed on your ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m., or at the times listed in your health plan documents.
33 Multi-language interpreter services
ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Please call the toll-free phone number listed on your identification card. ATENCIÓN: Si habla español (Spanish), hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame al número de teléfono gratuito que aparece en su tarjeta de identificación. 請注意:如果您說中文 (Chinese),我們免費為您提供語言協助服務。請撥打會員卡所列的免付費會員電話號 碼。
XIN LƯU Ý: Nếu quý vị nói tiếng Việt (Vietnamese), quý vị sẽ được cung cấp dịch vụ trợ giúp về ngôn ngữ miễn phí. Vui lòng gọi số điện thoại miễn phí ở mặt sau thẻ hội viên của quý vị. 알림: 한국어(Korean)를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다. 귀하의 신분증 카드에 기재된 무료 회원 전화번호로 문의하십시오. PAALALA: Kung nagsasalita ka ng Tagalog (Tagalog), may makukuha kang mga libreng serbisyo ng tulong sa wika. Pakitawagan ang toll-free na numero ng telepono na nasa iyong identification card. ВНИМАНИЕ: бесплатные услуги перевода доступны для людей, чей родной язык является русском (Russian). Позвоните по бесплатному номеру телефона, указанному на вашей идентификационной карте. تنبيه: إذا كنت تتحدث العربية (Arabic ،) فإن خدمات المساعدة اللغوية المجانية متاحة لك. الرجاء االتصال على رقم الهاتف المجاني الموجود على ّمعرف العضوية. ATANSYON: Si w pale Kreyòl ayisyen (Haitian Creole), ou kapab benefisye sèvis ki gratis pou ede w nan lang pa w. Tanpri rele nimewo gratis ki sou kat idantifikasyon w. ATTENTION : Si vous parlez français (French), des services d’aide linguistique vous sont proposés gratuitement. Veuillez appeler le numéro de téléphone gratuit figurant sur votre carte d’identification. UWAGA: Jeżeli mówisz po polsku (Polish), udostępniliśmy darmowe usługi tłumacza. Prosimy zadzwonić pod bezpłatny numer telefonu podany na karcie identyfikacyjnej. ATENÇÃO: Se você fala português (Portuguese), contate o serviço de assistência de idiomas gratuito. Ligue gratuitamente para o número encontrado no seu cartão de identificação. ATTENZIONE: in caso la lingua parlata sia l’italiano (Italian), sono disponibili servizi di assistenza linguistica gratuiti. Per favore chiamate il numero di telefono verde indicato sulla vostra tessera identificativa. ACHTUNG: Falls Sie Deutsch (German) sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Bitte rufen Sie die gebührenfreie Rufnummer auf der Rückseite Ihres Mitgliedsausweises an. 注意事項:日本語(Japanese)を話される場合、無料の言語支援サービスをご利用いただけます。健康保険証 に記載されているフリーダイヤルにお電話ください。
توجه: اگر زبان شما فارسی (Farsi) است، خدمات امداد زبانی به طور رايگان در اختيار شما می باشد. لطفا با شماره تلفن رايگانی که روی کارت شناسايی شما قيد شده تماس بگيريد. ध्यान दें: यदि आप हिंदी (Hindi) बोलते है, आपको भाषा सहायता सेबाएं, नि:शुल्क उपलब्ध हैं। कृपया अपने पहचान पत्र पर सूचीबद्ध टोल-फ्री फोन नंबर पर कॉल करें। CEEB TOOM: Yog koj hais Lus Hmoob (Hmong), muaj kev pab txhais lus pub dawb rau koj. Thov hu rau tus xov tooj hu deb dawb uas teev muaj nyob rau ntawm koj daim yuaj cim qhia tus kheej. ចំណាប់អារម្មណ៍ៈ បើសិនអ្នកនិយាយភាសាខ្មែរ(Khmer)សេវាជំនួយភាសាដោយឥតគិតថ្លៃ គឺមានសំរាប់អ្នក។ សូមទូរស័ព្ទទៅលេខឥតគិតថ្លៃ ដែលមាននៅលើអត្ដសញ្ញាណប័ណ្ណរបស់អ្នក។ PAKDAAR: Nu saritaem ti Ilocano (Ilocano), ti serbisyo para ti baddang ti lengguahe nga awanan bayadna, ket sidadaan para kenyam. Maidawat nga awagan iti toll-free a numero ti telepono nga nakalista ayan iti identification card mo. DÍÍ BAA’ÁKONÍNÍZIN: Diné (Navajo) bizaad bee yániłti’go, saad bee áka›anída›awo›ígíí, t’áá jíík’eh, bee ná’ahóót’i’. T’áá shǫǫdí ninaaltsoos nitł’izí bee nééhozinígíí bine’dę́ ę́› t’áá jíík’ehgo béésh bee hane’í biká’ígíí bee hodíilnih. OGOW: Haddii aad ku hadasho Soomaali (Somali), adeegyada taageerada luqadda, oo bilaash ah, ayaad heli kartaa. Fadlan wac lambarka telefonka khadka bilaashka ee ku yaalla kaarkaaga aqoonsiga.
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