2019 Prescription Drug List Student Resources Texas Advantage Three-Tier

Your 2019 Prescription Drug List Student Resources Texas Advantage 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 Student Resources medical plans with a pharmacy benefit subject to theAdvantage Three-Tier PDL. Your estimated coverage and copayment/coinsurance may vary based on the benefit plan you choose and the effective date of the plan. Table of Contents

Understanding your Prescription Gastrointestinal Drug List...... 3 Acid Suppression...... 16 Nausea/Vomiting...... 16 Medication tips ...... 5 Other...... 17 Reading your PDL...... 6 Gout ...... 17 Questions...... 8 Hepatitis C...... 17 Drugs by category ...... 9 HIV/AIDS...... 17 Anti-Infectives Infertility...... 18 Antibiotics ...... 9 Antifungals...... 9 Inflammatory Conditions: Rheumatoid Antivirals ...... 9 Arthritis, Crohn’s Disease, Psoriasis, Ulcerative Colitis...... 18 Cancer ...... 9 Men’s Health Cardiovascular/Heart Disease Prostate...... 18 Coagulation Therapy...... 10 Testosterone Therapy...... 19 High Blood Pressure...... 10 ...... 19 High Cholesterol ...... 11 Miscellaneous Other...... 11 Musculoskeletal Muscle Spasms...... 19 Central Nervous System Osteoporosis...... 19 Attention Deficit Disorder...... 11 Pain Relief...... 20 Depression ...... 12 Migraine...... 12 Overactive Bladder...... 20 Multiple Sclerosis...... 12 Respiratory Other...... 12 Allergies...... 20 Sedatives/Hypnotics...... 13 Asthma/COPD...... 20 Seizure Disorders ...... 13 Pulmonary Arterial Hypertension...... 21 Dermatology ...... 13 Smoking Cessation...... 21 Diabetes Transplant ...... 21 Blood Glucose Monitoring...... 14 Insulin ...... 14 Vitamins/Electrolytes...... 21 Non-Insulin ...... 15 Women’s Health Endocrine Contraceptives...... 22 Growth Hormone...... 15 Hormone Replacement...... 24 Other...... 16 Miscellaneous...... 24 Thyroid Hormone Replacement. . . . . 16 Prenatal Vitamins ...... 24 Eye Conditions Index...... 25 Allergies...... 16 Antibiotics ...... 16 Dry Eye Disease...... 16 Glaucoma ...... 16 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? • Medications may move to a lower tier at any time. • Medications may move to a higher tier when a generic becomes available. • Medications may move to a higher tier or be excluded from coverage most often upon your group’s renewal. When a medication changes tiers, you may have to pay a different amount for that medication. 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 if similar alternatives are available at a lower cost. Examples include medications that work the same way, but one is much more expensive than the other, or options that are available without a prescription (also referred to as over-the-counter medications). There are also some instances where the same product can be made by two or more manufacturers, but greatly vary in cost. In these instances, only the lower-cost product may be covered. You should review your benefit plan documents to confirm if any medications are excluded from your plan. You can log in to the member website listed on your health plan ID card at any time to check your medication coverage. Talk to your doctor to see if there are lower-cost options or over- the-counter medications available.

Who decides which medications are covered? Thousands of medications are already available and more come to the market regularly. Often, several medications are available to treat the same condition. The UnitedHealthcare® Pharmacy and Therapeutics Committee, which includes both internal and external physicians and pharmacists, meets regularly to provide clinical reviews of all medications. Using this information, the PDL Management Committee, which includes senior UnitedHealth Group® physicians and business leaders, meets to evaluate overall health care value. They also determine coverage and tier status for all medications.

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 Medications that provide the highest Use Tier 1 drugs for the overall value. Mostly generic drugs. Some lowest out-of-pocket costs. brand-name drugs may also be included. Tier 2 $$ Mid-range cost Use Tier 2 drugs, instead of Medications that provide good overall value. Tier 3, to help reduce your A mix of brand-name and generic drugs. out-of-pocket costs. Tier 3 $$$ Highest-cost Medications that provide the lowest Ask your doctor if a Tier 1 or Tier 2 overall value. Mostly brand-name drugs, option could work for you. as well as some generics.

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 and/or trial/ failure of another medication(s). (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 Requires your doctor to provide information about why you are taking a medication to determine how it may be covered by your plan.

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

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

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 3 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 3 Nystatin Cream, Ointment 1 Cefprozil Tablet 1 Terbinafine Tablet 1 SL Cefuroxime Tablet 1 Anti-Infectives: Antivirals Cephalexin Capsule 1 Acyclovir Ointment 3 SL Ciprodex 3 Acyclovir Tablet 1 Ciprofloxacin Tablet 1 Famciclovir Tablet 2 Clarithromycin Tablet 1 Oseltamivir Capsule, Suspension 2 SL Clindamycin Capsule 1 Valacyclovir Tablet 1 SL Dificid 3 SL Valganciclovir 1 SL Doxycycline Hyclate 50, 100 mg 2 Cancer Capsule, Tablet Alunbrig 2 PA, SL, SP Doxycycline Monohydrate 1 50, 100 mg Capsule Bexarotene Capsule 3 E, SP Levofloxacin Tablet 1 Bicalutamide 1 Metronidazole Tablet 1 Bosulif 2 PA, SL, SP Minocycline Capsule 1 Braftovi 3 PA, SL, SP Moxifloxacin Tablet 3 Calquence 2 PA, SL, SP Nitrofurantoin Capsule 1 Cyclophosphamide Capsule 2 Nitrofurantoin Macrocrystal 1 Erleada 3 PA, SL, SP Capsule Hydroxyurea Capsule 1 Ofloxacin Otic Solution 2 Ibrance 2 PA, SL, SP Ofloxacin Tablet 1 Idhifa 2 PA, SL, SP Penicillin V Potassium Tablet 1 Imatinib Tablet 1 PA, SL, SP Sulfamethoxazole-Trimethoprim 1 Tablet Imbruvica 2 PA, SL, SP Suprax Capsule, Chewable 3 Leucovorin Calcium Tablet 1 Tablet, Tablet

Bold type = Brand-name drug [Plain type = Generic drug] E = May be excluded from coverage PA = Prior authorization required H = May be part of health care reform preventive SL = Supply limit H-PA = May be part of health care reform preventive with prior authorization SP = Specialty medication 9 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Mektovi 3 PA, SL, SP Bisoprolol-Hydrochlorothiazide 1 Mercaptopurine Tablet 1 Bystolic 2 Nerlynx 2 PA, SL, SP Byvalson 2 SL Revlimid 2 PA, SL, SP Cartia XT 2 Carvedilol Immediate-Release Rydapt 2 PA, SL, SP 1 Tablet Sutent 2 PA, SL, SP Chlorthalidone 1 Targretin Capsule 2 SP Clonidine Tablet 1 Targretin Gel 3 SL Diltiazem 24 Hour CD 2 Tasigna 2 PA, SL, SP Diltiazem Sustained-Release 2 Verzenio 2 PA, SL, SP Capsule Diltiazem Sustained-Release Xeloda 1 SL, SP 2 Tablet Zykadia 2 PA, SL, SP Doxazosin 1 Zytiga 2 PA, SL, SP Edarbi 3 SL Cardiovascular/Heart Disease: Coagulation Therapy Edarbyclor 3 SL Bevyxxa 3 SL Enalapril 1 Brilinta 3 SL Furosemide 1 Clopidogrel 1 Guanfacine 1 Eliquis 3 SL Hydralazine 1 Enoxaparin Sodium 2 SL Hydrochlorothiazide 1 Pradaxa 2 SL Irbesartan 1 Prasugrel 3 SL Labetalol 1 Savaysa 3 SL Lisinopril 1 Warfarin Sodium 1 Lisinopril-Hydrochlorothiazide 1 Xarelto 2 SL Losartan 1 Cardiovascular/Heart Disease: High Blood Pressure Losartan-Hydrochlorothiazide 1 Amlodipine 1 Metoprolol Succinate Extended- 2 Amlodipine-Benazepril 1 Release 50, 100, 200 mg Metoprolol Tartrate 25, 50, Amlodipine-Valsartan 2 1 100 mg Atenolol 1 Nadolol 1 Atenolol-Chlorthalidone 1 Nifedipine Extended-Release 1 Benazepril 1 Olmesartan 2 SL Benazepril-Hydrochlorothiazide 1 Olmesartan-Hydrochlorothiazide 2 SL Bidil 2 Propranolol Extended-Release 2 Bisoprolol 1 Capsule

10 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Propranolol Tablet 1 Vascepa 3 Welchol Packet for Suspension, Quinapril 1 2 Tablet Ramipril 1 Cardiovascular/Heart Disease: Other Spironolactone 1 Amiodarone 1 Telmisartan 2 Corlanor 3 SL Telmisartan-Hydrochlorothiazide 2 Digoxin 1 Terazosin 1 Entresto 3 SL Triamterene-Hydrochlorothiazide 1 Flecainide 1 Valsartan 2 Isosorbide Mononitrate ER 1 Valsartan-Hydrochlorothiazide 1 Multaq 3 Verapamil 1 Nitroglycerin Sublingual Tablet 1 Verapamil Sustained-Release 3 Ranexa 2 Cardiovascular/Heart Disease: High Cholesterol Sotalol 1 Atorvastatin 1 H-PA, SL Central Nervous System: Attention Deficit Disorder Colesevelam Packet for Suspension, Tablet (generic 3 E Adderall XR 2 SL Welchol) Amphetamine Salt Combo 1 Ezetimibe Tablet 3 SL Atomoxetine 3 SL Ezetimibe/Simvastatin 3 SL Concerta 2 SL Fenofibrate 54, 160 mg Tablet 2 Dexmethylphenidate Immediate- 1 Fluvastatin Extended-Release Release Tablet 3 SL Tablet Dextroamphetamine- Gemfibrozil 1 Amphetamine Immediate-Release 1 Tablet Lovastatin 1 H Dextroamphetamine Sulfate 3 Niacin Extended-Release Tablet 3 Immediate-Release Tablet Niaspan 2 Guanfacine Extended-Release 2 SL Omega-3-Acid Ethyl Esters Methylphenidate Chewable Tablet 3 3 Capsule Methylphenidate Extended- Praluent 2 PA, SL, SP Release Capsule (generic 2 SL ) Pravastatin 1 Metadate CD, Ritalin LA Methylphenidate Extended- Repatha 3 PA, SL, SP Release Tablet (generic 3 E, SL Rosuvastatin 2 SL Concerta) Simvastatin 1 H-PA

Bold type = Brand-name drug [Plain type = Generic drug] E = May be excluded from coverage PA = Prior authorization required H = May be part of health care reform preventive SL = Supply limit H-PA = May be part of health care reform preventive with prior authorization SP = Specialty medication 11 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Methylphenidate Extended- Rizatriptan ODT, Tablet 1 SL Release Tablet (Metadate ER, 3 SL generic Ritalin SR) Sumatriptan Nasal Spray 2 SL Methylphenidate Immediate- Sumatriptan Succinate Tablet, 1 1 SL Release Tablet Injection Vyvanse 2 SL Central Nervous System: Multiple Sclerosis Central Nervous System: Depression Ampyra 2 PA, SL, SP Amitriptyline Tablet 1 Aubagio 3 PA, SL, SP Bupropion Extended-Release Avonex 2 PA, SL, SP 1 Tablet Betaseron 2 PA, SL, SP Bupropion Sustained-Release 1 Tablet Gilenya 3 PA, SL, SP Glatiramer (generic Copaxone) Bupropion Tablet 1 2 PA, SL, SP [Mylan version only] Citalopram Tablet 1 Plegridy 3 PA, SL, SP Desvenlafaxine Extended- 2 SL Release Tablet (generic Pristiq) Rebif 3 PA, SL, SP Doxepin 1 Tecfidera 2 PA, SL, SP Duloxetine Capsule 3 SL Central Nervous System: Other Alprazolam Extended-Release Escitalopram Tablet 1 1 Tablet Fetzima 3 SL Alprazolam Tablet 1 Fluoxetine Capsule (generic 1 Prozac) Aripiprazole Tablet 2 SL Fluvoxamine Tablet 1 Armodafinil 3 SL Mirtazapine Tablet 1 Austedo 2 PA, SL, SP Nortriptyline Capsule 1 Buprenorphine Sublingual Tablet 1 Paroxetine Tablet 1 Buspirone Tablet 1 Sertraline Tablet 1 Carbidopa-Levodopa 1 Trazodone Tablet 1 Diazepam Tablet 1 Trintellix 3 SL Donepezil 5, 10 mg ODT, Tablet 1 Venlafaxine Extended-Release Latuda 3 SL 1 Capsule Lithium Capsule 1 Venlafaxine Tablet 1 Lorazepam Tablet 1 Viibryd 3 SL Memantine Immediate-Release 2 Central Nervous System: Migraine Tablet Acetaminophen/Butalbital/ Modafinil 3 SL 1 SL Caffeine 325 mg/50 mg/40 mg Naloxone Vials 1 Eletriptan 2 SL Narcan Nasal Spray 2 SL Frovatriptan 3 SL Naratriptan 1 SL

12 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Lamotrigine Immediate-Release Olanzapine Tablet 1 SL 1 Tablet Pramipexole Tablet 1 Levetiracetam Extended-Release Quetiapine Extended-Release 2 3 SL Tablet Tablet Levetiracetam Immediate-Release Quetiapine Immediate-Release 1 1 Tablet Tablet Lyrica 3 SL Risperidone Tablet 1 Lyrica CR 3 E, SL Ropinirole Tablet 1 Oxcarbazepine Tablet 1 Suboxone Film 3 E, SL Phenytoin Capsule, Suspension 1 Tolcapone 2 Topiramate Immediate-Release 1 Xyrem 3 PA, SL, SP Tablet Zelapar 3 Zonisamide Capsule 1 Ziprasidone Capsule 2 SL Dermatology Zubsolv 2 SL Aczone 3 SL Central Nervous System: Sedatives/Hypnotics Betamethasone Dipropionate 0.05% Augmented Lotion, 3 Eszopiclone Tablet 2 SL Ointment Temazepam Capsule 1 Betamethasone Dipropionate 2 0.05% Cream, Ointment Triazolam Tablet 1 Calcipotriene/Betamethasone 3 SL Zaleplon Capsule 1 SL Ointment Zolpidem Immediate-Release 1 SL Carac 2 Tablet Ciclopirox Cream, Gel, Lotion, 1 Central Nervous System: Seizure Disorders Solution Carbamazepine Extended- 2 Claravis 2 Release Capsule Clindamycin 1.2%/Benzoyl Carbamazepine Extended- 3 SL 3 Peroxide 5% Gel Release Tablet Clindamycin Gel 3 SL Carbamazepine Immediate- 1 Release Tablet Clindamycin Lotion 3 Clonazepam Tablet 1 Clindamycin Solution 1 SL Diazepam Tablet 1 Clindamycin Swabs 1 Divalproex Delayed-Release Clobetasol Propionate Cream, 1 2 SL Tablet Ointment Divalproex Extended-Release 2 Clobetasol Propionate Solution 1 SL Tablet Clotrimazole-Betamethasone 1 SL Gabapentin Capsule, Tablet 1 Cream

Bold type = Brand-name drug [Plain type = Generic drug] E = May be excluded from coverage PA = Prior authorization required H = May be part of health care reform preventive SL = Supply limit H-PA = May be part of health care reform preventive with prior authorization SP = Specialty medication 13 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Clotrimazole-Betamethasone 1 Tacrolimus Ointment 2 SL Lotion Tazarotene 0.1% Cream (generic 3 E, PA, SL Dapsone 5% Gel 3 E, SL Tazorac) Desonide 0.05% Cream, Lotion, 3 SL Tazorac 3 PA, SL Ointment Tretinoin Cream 3 PA, SL Desoximetasone Gel, Ointment 3 SL Triamcinolone Acetonide Cream, Diflorasone Diacetate 0.05% 1 3 SL Lotion, Ointment Cream, Ointment Vectical 3 SL Dupixent 3 PA, SL, SP Diabetes: Blood Glucose Monitoring Elidel 3 SL Accu-Chek Test Strips 3 E, SL Enstilar Foam 3 SL Contour Next EZ Meter 2 Eucrisa 3 SL Contour Next Meter 2 Finacea 3 Contour Next One Meter 2 Fluocinolone Cream, Oil, Solution 3 SL Contour Next Test Strips 2 SL Fluocinolone Ointment 2 SL Contour Test Strips 3 E, SL Fluocinonide 0.05% Cream 1 FreeStyle Test Strips 3 E, SL Fluorouracil 0.5% Cream 3 SL OneTouch Ultra 2 Meter 1 Halobetasol Ointment 2 SL OneTouch Ultra Test Strips 1 SL Hydrocortisone 2.5% Cream, 1 Ointment OneTouch UltraMini Meter 1 Imiquimod 5% Cream 1 SL OneTouch Verio Flex Meter 1 Metronidazole 0.75% Topical Gel 1 OneTouch Verio IQ Meter 1 Minocycline Extended-Release 3 E OneTouch Verio Meter 1 (generic Solodyn) OneTouch Verio Sync Meter 1 Mirvaso 3 SL OneTouch Verio Test Strips 1 SL Mometasone Furoate Cream, 1 Lotion, Ointment Diabetes: Insulin Mupirocin Ointment 1 SL Admelog SoloStar, Vials 3 E, SL Oracea 3 Apidra SoloStar, Vials 3 E, SL Oxsoralen-Ultra 2 Basaglar 1 SL Picato 3 SL Fiasp FlexTouch, Vials 3 E, SL Regranex 2 SL Humalog KwikPens 2 SL (all formulations) Rhofade 3 SL Humalog Vials (all formulations) 1 SL Taclonex Suspension 3 SL

14 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Humulin KwikPens 2 SL Metformin 1 (all formulations) Metformin Extended-Release 1 Humulin Vials (all formulations) 1 SL Tablet (generic Glucophage XR) Lantus SoloStar 3 E, SL Nesina 2 SL Lantus Vials 3 E, SL Onglyza 2 SL Levemir FlexTouch, Vials 3 SL Oseni 2 SL Novolin Vials (all formulations) 3 E, SL Ozempic 3 SL Novolog FlexPen, Vials 3 E, SL Pioglitazone 1 SL (all formulations) Qtern 3 E, SL Tresiba FlexTouch 2 SL Segluromet 3 E, SL Diabetes: Non-Insulin Soliqua 2 SL Adlyxin 3 SL Steglatro 3 E, SL Bydureon, Bydureon Bcise 2 SL Steglujan 3 E, SL Byetta 2 SL Synjardy, Synjardy XR 2 SL Farxiga 3 E, SL Tradjenta 2 SL Glimepiride 1 Trulicity 3 SL Glipizide 1 Victoza 2-Pak 2 SL Glipizide Extended-Release 1 Victoza 3-Pak 3 SL Glyburide 1 Xigduo XR 3 E, SL Glyxambi 2 SL Endocrine: Growth Hormone1 Invokamet, Invokamet XR 2 SL Nutropin, Nutropin AQ 2 PA, SL, SP Invokana 2 SL 1 Coverage is determined by the consumer’s prescription Janumet 3 SL drug benefit plan. Please consult plan documents regarding benefit coverage and cost-share. Januvia 3 SL Jardiance 2 SL Jentadueto 2 SL Jentadueto XR 2 SL Kazano 2 SL Kombiglyze XR 2 SL

Bold type = Brand-name drug [Plain type = Generic drug] E = May be excluded from coverage PA = Prior authorization required H = May be part of health care reform preventive SL = Supply limit H-PA = May be part of health care reform preventive with prior authorization SP = Specialty medication 15 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Endocrine: Other Eye Conditions: Dry Eye Disease Calcitriol Capsule 1 Restasis Single Use Vials 3 SL Desmopressin Tablet 1 Xiidra 3 SL Dexamethasone Tablet 1 Eye Conditions: Glaucoma Methylprednisolone Tablet 1 Alphagan P 0.1% 2 SL Prenisolone Oral Solution 1 Azopt 2 SL Prednisone Tablet 1 Combigan 2 SL Latanoprost 0.005% Ophthalmic Endocrine: Thyroid Hormone Replacement 1 Solution Armour Thyroid 3 Lumigan 2 SL Levothyroxine Sodium Tablet 1 Timolol 0.25%, 0.5% Ophthalmic 1 Liothyronine Sodium Tablet 2 Solution (generic Timoptic) Methimazole Tablet 1 Travatan Z 2 SL NP Thyroid Tablet 1 Gastrointestinal: Acid Suppression Synthroid 2 Dexilant 3 SL Eye Conditions: Allergies Omeclamox-Pak 3 SL Azelastine 0.05% Ophthalmic Omeprazole Capsule 1 1 Solution Pantoprazole Tablet 1 Lastacaft 3 SL Pylera 3 SL Olopatadine 0.1% Ophthalmic 3 SL Solution Ranitadine Syrup 1 Eye Conditions: Antibiotics Rabeprazole Tablet 3 SL Erythromycin 0.5% Ophthalmic 1 Sucralfate Tablet 1 Ointment Gastrointestinal: Nausea/Vomiting Gentamicin Ophthalmic Ointment, 1 Solution Akynzeo 3 SL Moxeza 3 Aprepitant Capsule 2 SL Moxifloxacin Ophthalmic Solution 3 Emend Suspension 2 SL Ofloxacin 0.3% Ophthalmic 1 Ondansetron 1 Solution Scopolamine Transdermal Patch 3 Tobramycin/Dexamethasone 0.3%-0.1% Ophthalmic 2 Varubi 2 SL Suspension Tobramycin Ophthalmic Solution 1

16 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Gastrointestinal: Other Gout Amitiza 3 SL Allopurinol Tablet 1 Apriso 2 Duzallo 3 SL Budesonide Extended-Release 3 E Mitigare 2 Tablet (generic Uceris) Uloric 3 SL Canasa 2 Zurampic 3 SL Clenpiq 3 Hepatitis C Cortifoam 2 Daklinza 3 PA, SL, SP Creon 2 Epclusa 2 PA, SL, SP Diphenoxylate-Atropine Tablet 1 Harvoni 2 PA, SL, SP Golytely 2 Mavyret 2 PA, SL, SP Hyoscyamine Tablet 1 Ribavirin Tablet 1 SP Lialda 2 Sovaldi 3 PA, SL, SP Linzess 2 SL Technivie 3 PA, SL, SP Mesalmine Delayed-Release 3 E Tablet (generic Lialda) Viekira Pak 3 PA, SL, SP Metoclopramide Tablet 1 Viekira XR 3 PA, SL, SP Movantik 3 E, SL Vosevi 2 PA, SL, SP Moviprep 3 Zepatier 3 PA, SL, SP Polyethylene Glycol 3350 2 HIV/AIDS Prepopik 3 Abacavir-Lamivudine 2 SP Sulfasalazine Tablet 1 Atazanavir Capsule 2 SP Suprep 3 Atripla 3 E, SP Symproic 2 SL Cimduo 2 SP Uceris Foam 2 Complera 3 SP Uceris Tablet 3 Descovy 3 SP Viberzi 3 SL Efavirenz 2 SP Zenpep 2 Evotaz 2 SP Genvoya 3 SP Intelence 2 SP

Bold type = Brand-name drug [Plain type = Generic drug] E = May be excluded from coverage PA = Prior authorization required H = May be part of health care reform preventive SL = Supply limit H-PA = May be part of health care reform preventive with prior authorization SP = Specialty medication 17 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Isentress 2 SP Inflammatory Conditions: Rheumatoid Arthritis, Crohn’s Disease, Psoriasis, Ulcerative Colitis Juluca 2 SP Actemra 3 PA, SL, SP Kaletra Tablet 2 SP Cimzia 2 PA, SL, SP Lamivudine-Zidovudine 1 SP Cosentyx 3 PA, SL, SP Lopinavir-Ritonavir Oral Solution 2 SP Enbrel 3 PA, SL, SP Nevirapine 1 SP Humira 2 PA, SL, SP Nevirapine Extended-Release 3 E, SP Hydroxychloroquine Sulfate 1 Odefsey 3 SP Kevzara 3 PA, SL, SP Prezcobix 2 SP Leflunomide 1 Prezista 2 SP Methotrexate Tablet 1 Ritonavir Tablet 2 SP Orencia 3 PA, SL, SP Selzentry 2 PA, SP Otezla 2 PA, SL, SP Stribild 3 SP Rasuvo 3 SL Symfi 2 SP Siliq 3 PA, SL, SP Symfi Lo 2 SP Simponi 2 PA, SL, SP Tenofovir Tablet 2 SP Stelara 2 PA, SL, SP Tivicay 3 SP Taltz 3 PA, SL, SP Triumeq 2 SP Tremfya 2 PA, SL, SP Truvada 3 SP Xeljanz, Xeljanz XR 3 PA, SL, SP Tybost 2 SP Men’s Health: Prostate Vitekta 2 SP Alfuzosin Tablet 1 Infertility1 Doxazosin Tablet 1 Cetrotide 2 SP Dutasteride Capsule 3 Clomiphene 1 Finasteride Tablet 1 Endometrin 2 Rapaflo 3 Gonal-F 2 SP Tamsulosin Capsule 1 Gonal-F RFF 2 SP Terazosin Capsule, Tablet 1 Ovidrel 3 SP 1 Coverage is determined by the consumer’s prescription drug benefit plan. Please consult plan documents regarding benefit coverage and cost-share.

18 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Men’s Health: Testosterone Therapy Procrit 2 SL, SP Androderm 2 SL Promethazine/Codeine 1 SL Androgel 3 E, SL Promethazine/Dextromethorphan 1 Methyltestosterone Capsule 2 Pulmozyme 2 PA, SL, SP Testim 2 SL Rectiv 3 SL Testosterone 1% Topical Gel 3 E, SL Rezira 3 Testosterone Cypionate Injection 1 Sevelamer 2 Miscellaneous Syprine 3 PA, SP Anastrozole Tablet 1 Tobi Podhaler 3 PA, SL, SP Aranesp 2 SL, SP Trientine (generic Syprine) 3 E, PA, SP Auryxia 3 Velphoro 2 Bethkis 2 PA, SL, SP Veltassa 3 SL Cayston 2 PA, SL, SP Zarxio 2 SP Cerdelga 2 PA, SP Musculoskeletal: Muscle Spasms Chlorhexidine Gluconate 1 Baclofen Tablet 1 Chlorpheniramine/Hydrocodone/ 2 SL Carisoprodol 350 mg Tablet 1 Pseudoephedrine Solution Cyclobenzaprine 1 Epinephrine (generic EpiPen/ 2 SL EpiPen-Jr.) Metaxalone Tablet 3 EpiPen/EpiPen-Jr. 3 E, SL Methocarbamol Tablet 1 Hydrocodone/Chlorpheniramine 3 SL Tizanidine Tablet 1 Suspension Musculoskeletal: Osteoporosis Lanthanum Chewable Tablet 3 Alendronate Sodium Tablet 1 Letrozole Tablet 1 Forteo 3 PA, SP Lidocaine Transdermal Patch 3 SL (generic Lidoderm) Ibandronate Tablet 2 SL Nityr 2 PA, SP Raloxifene Tablet 2 Nuedexta 2 Risedronate Sodium Tablet 3 SL Obredon 3 SL Tymlos 3 PA, SP Pegasys 2 PA, SP, SL Phenazopyridine 1

Bold type = Brand-name drug [Plain type = Generic drug] E = May be excluded from coverage PA = Prior authorization required H = May be part of health care reform preventive SL = Supply limit H-PA = May be part of health care reform preventive with prior authorization SP = Specialty medication 19 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Musculoskeletal: Pain Relief Trezix 3 SL Vicodin 5/300, 7.5/300, Acetaminophen/Codeine Tablet 1 SL 3 E, SL 10/300 mg Tablet Belbuca 3 SL Voltaren Gel 2 Celecoxib 2 SL Xtampza ER 2 SL Diclofenac Tablet 1 Zohydro ER 3 SL Etodolac Capsule 1 Overactive Bladder Fentanyl 12, 25, 50, 75, 100 mcg 2 SL Patch Dicyclomine Tablet 1 Oxybutynin Extended-Release Fentanyl Citrate Lozenge 2 SL 2 Tablet Hydrocodone/Acetaminophen 1 SL 5/325, 7.5/325, 10/325 mg Tablet Oxybutynin Tablet 1 Hydrocodone/Ibuprofen Tablet 1 Toviaz 3 Hydromorphone Immediate- 1 Respiratory: Allergies Release Tablet Azelastine 0.1% Nasal Spray 3 Ibuprofen Tablet 1 Fluticasone Nasal Spray 2 SL Indomethacin Capsule 1 Zetonna 3 SL Ketorolac Tablet 1 Respiratory: Asthma/COPD Lazanda 3 SL Advair Diskus/HFA 3 SL Meloxicam Tablet 1 Albuterol Nebs 1 Methadone Tablet, Oral Solution, 1 SL Concentrate Solution Alvesco 1 SL Morphine Sulfate Extended- 1 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 SL Nucynta 3 SL Budesonide Nebs 2 SL Nucynta ER 3 SL Combivent Respimat 3 SL Oxycodone Tablet 1 Flovent Diskus/HFA 3 SL Oxycodone/Acetaminophen 1 SL Fluticasone/Salmeterol RespiClick 5/325, 7.5/325, 10/325 mg Tablet 2 SL (generic AirDuo RespiClick) Oxycontin 3 E, SL Incruse Ellipta 2 SL Sprix 3 Ipratropium-Albuterol Nebs 2 Tramadol-Acetaminophen 1 SL Ipratropium Nebs 1 Tramadol Immediate-Release 1 Montelukast Chewable Tablet, Tablet 1 Tramadol Sustained-Release Tablet 2 SL Tablet

20 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Montelukast Granules 2 Smoking Cessation Bupropion Sustained-Release Perforomist 3 SL 1 H-PA Tablet ProAir HFA/RespiClick 3 SL Chantix Tablet 3 H-PA Proventil HFA 3 SL Nicoderm CQ 3 H-PA Pulmicort Flexhaler 3 SL Nicorette Gum 3 H-PA QVAR Redihaler 1 SL Nicorette Lozenge 2 H-PA Seebri Neohaler 3 SL Nicorette Mini-Lozenge 2 H-PA Serevent Diskus 3 SL Nicotine Gum 1 H-PA Spiriva Handihaler/Respimat 2 SL Nicotine Lozenge 1 H-PA Striverdi Respimat 2 SL Nicotine Patch 1 H-PA Symbicort 3 SL Nicotrol Inhaler 3 H-PA Trelegy Ellipta 3 SL Nicotrol Nasal Spray 3 H-PA Tudorza 2 SL Transplant Ventolin HFA 2 SL Azathioprine Tablet 1 Xopenex HFA 3 SL Cyclosporine Modified Capsule 1 SP Respiratory: Pulmonary Arterial Hypertension Mycophenolate Capsule, 1 SP Adempas 2 PA, SL, SP Suspension Letairis 2 PA, SL, SP Mycophenolic Acid Tablet 2 SP Opsumit 2 PA, SL, SP Sirolimus Tablet 1 SP Orenitram 3 PA, SL, SP Tacrolimus Capsule 1 SP Sildenafil Tablet (genericRevatio ) 1 PA, SL, SP Vitamins/Electrolytes Tadalafil (genericAdcirca ) 3 PA, SL, SP Fluoride 1 Tracleer 2 PA, SL, SP Folic Acid 1 Tyvaso 2 PA, SP Klor-Con M10 1 Uptravi 3 PA, SL, SP Klor-Con M20 1 Potassium Chloride 1 Potassium Citrate 1

Bold type = Brand-name drug [Plain type = Generic drug] E = May be excluded from coverage PA = Prior authorization required H = May be part of health care reform preventive SL = Supply limit H-PA = May be part of health care reform preventive with prior authorization SP = Specialty medication 21 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Women’s Health: Contraceptives Isibloom 1 H Aftera 1 H Jencycla 1 H Altavera 1 H Jolessa 2 H Alyacen 7/7/7, 1/35 1 H Jolivette 1 H Apri 1 H Juleber 1 H Aranelle 1 H Junel 2 Aubra 1 H Junel Fe 1 H Aviane 1 H Kelnor 1/35 1 H Azurette 2 Kurvelo 1 H Blisovi Fe 1 H Larin Fe 1 H Camila 1 H Larissia 1 H Caziant 1 H Leena 1 H Chateal 1 H Lessina 1 H Cryselle 1 H Levonest 1 H Cyclafem 7/7/7, 1/35 1 H Levonorgestrel 1.5 mg 1 H Cyred 1 H Levonorgestrel-Ethinyl Estradiol (generic Alesse, Nordette, 1 H Dasetta 7/7/7, 1/35 1 H Triphasil) Deblitane 1 H Levonorgestrel-Ethinyl Estradiol 2 H (generic ) Delyla 1 H Seasonale Levora-28 1 H Desogestrel-Ethinyl Estradiol 1 H (generic Ortho-Cept) Lillow 1 H Econtra EZ 1 H Lo Loestrin Fe 3 Elinest 1 H Loryna 3 Ella 1 H, SL Low-Ogestrel 1 H Emoquette 1 H Lutera 1 H Enpresse 1 H Lyza 1 H Enskyce 1 H Marlissa 1 H Errin 1 H Medroxyprogesterone Acetate 1 H Estarylla 1 H Microgestin 2 Fallback 1 H Microgestin Fe 1 H Falmina 1 H Mono-Linyah 1 H Heather 1 H MonoNessa 1 H Introvale 2 H My Choice 1 H

22 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits My Way 1 H Solia 1 H Myzilra 1 H Sprintec 1 H Natazia 2 Sronyx 1 H Necon 7/7/7, 0.5/35, 1/35, 1/50, 1 H Take Action 1 H 10/11 Tarina Fe 1 H Next Choice One Choice 1 H Tri Femynor 1 H Nora BE 1 H Tri-Estarylla 1 H Norethindrone 0.35 mg 1 H Tri-Linyah 1 H Norethindrone-Ethinyl Estradiol- 1 H Ferrous Fumarate Tri-Lo-Estarylla 2 Norgestimate-Ethinyl Estradiol Tri-Lo-Marzia 2 (generic Ortho-Cyclen, Ortho 1 H Tri-Cyclen) Tri-Lo-Sprintec 2 Norgestimate-Ethinyl Estradiol Lo Tri-Previfem 1 H 2 (generic Ortho Tri-Cyclen Lo) Tri-Sprintec 1 H Norlyda 1 H Tri-Vylibra 1 H Norlyroc 1 H Trinessa 1 H Nortrel 7/7/7, 0.5/35, 1/35 1 H Trinessa Lo 2 Nuvaring 2 H Trivora-28 1 H Opcicon One Step 1 H Velivet 1 H Option 2 1 H Vestura 3 Orsythia 1 H Vienva 1 H Pirmella 7/7/7, 1/35 1 H Viorele 2 Plan B One Step 1 H Vylibra 1 H Portia 1 H Wera 1 H Previfem 1 H Xulane 3 H Quasense 2 H Yasmin 28 2 Rajani 3 E Yaz 2 React 1 H Zovia 1/35E, 1/50E 1 H Reclipsen 1 H Setlakin 2 H Sharobel 1 H

24 Index

A Anastrozole Tablet...... 19 Betamethasone Dipropionate 0.05% Abacavir-Lamivudine...... 17 Androderm...... 19 Cream, Ointment...... 13 Accu-Chek Test Strips...... 14 Androgel...... 19 Betaseron...... 12 Acetaminophen/Butalbital/Caffeine Anoro Ellipta...... 20 Bethkis...... 19 325 mg/50 mg/40 mg...... 12 Apidra SoloStar, Vials...... 14 Bevespi Aerosphere...... 20 Acetaminophen/Codeine Tablet..... 20 Aprepitant Capsule...... 16 Bevyxxa...... 10 Actemra...... 18 Apri...... 22 Bexarotene Capsule...... 9 Acyclovir Ointment...... 9 Apriso...... 17 Bicalutamide...... 9 Acyclovir Tablet...... 9 Aranelle...... 22 Bidil...... 10 Aczone...... 13 Aranesp...... 19 Bisoprolol...... 10 Adcirca...... 21 Aripiprazole Tablet...... 12 Bisoprolol-Hydrochlorothiazide...... 10 Adderall XR...... 11 Armodafinil...... 12 Blisovi Fe...... 22 Adempas...... 21 Armour Thyroid...... 16 Bosulif...... 9 Adlyxin...... 15 Arnuity Ellipta...... 20 Braftovi...... 9 Admelog SoloStar, Vials...... 14 Asmanex TwistHaler, HFA...... 20 Brand Prenatal Vitamins...... 24 Advair Diskus/HFA...... 20 Atazanavir Capsule...... 17 Breo Ellipta...... 20 Aftera...... 22 Atenolol...... 10 Brilinta...... 10 AirDuo RespiClick...... 20 Atenolol-Chlorthalidone...... 10 Budesonide Extended-Release Akynzeo...... 16 Atomoxetine...... 11 Tablet...... 17 Albuterol Nebs...... 20 Atorvastatin...... 11 Budesonide Nebs...... 20 Alendronate Sodium Tablet...... 19 Atripla...... 17 Buprenorphine Sublingual Tablet... 12 Alesse...... 22 Aubagio...... 12 Bupropion Extended-Release Alfuzosin Tablet...... 18 Aubra...... 22 Tablet...... 12 Allopurinol Tablet...... 17 Auryxia...... 19 Bupropion Sustained-Release Alphagan P 0.1%...... 16 Austedo...... 12 Tablet...... 12, 21 Alprazolam Extended-Release Aviane...... 22 Bupropion Tablet...... 12 Tablet...... 12 Avonex...... 12 Buspirone Tablet...... 12 Alprazolam Tablet...... 12 Azathioprine Tablet...... 21 Bydureon, Bydureon Bcise...... 15 Altavera...... 22 Azelastine 0.05% Ophthalmic Byetta...... 15 Alunbrig...... 9 Solution...... 16 Bystolic...... 10 Alvesco...... 20 Azelastine 0.1% Nasal Spray...... 20 Byvalson...... 10 Alyacen 7/7/7, 1/35...... 22 Azithromycin Tablet...... 9 Amiodarone...... 11 Azopt...... 16 C Amitiza...... 17 Azurette...... 22 Calcipotriene/Betamethasone Amitriptyline Tablet...... 12 Ointment...... 13 Amlodipine...... 10 B Calcitriol Capsule...... 16 Amlodipine-Benazepril...... 10 Baclofen Tablet...... 19 Calquence...... 9 Amlodipine-Valsartan...... 10 Basaglar...... 14 Camila...... 22 Amoxicillin Capsule, Chewable Belbuca...... 20 Canasa...... 17 Tablet...... 9 Benazepril...... 10 Carac...... 13 Amoxicillin/Potassium Clavulanate Benazepril-Hydrochlorothiazide..... 10 Carbamazepine Extended-Release Chewable Tablet, Tablet...... 9 Betamethasone Dipropionate 0.05% Capsule...... 13 Amphetamine Salt Combo...... 11 Augmented Lotion, Ointment...... 13 Carbamazepine Extended-Release Ampyra...... 12 Tablet...... 13

25 Carbamazepine Immediate-Release Clonazepam Tablet...... 13 Dexmethylphenidate Immediate- Tablet...... 13 Clonidine Tablet...... 10 Release Tablet...... 11 Carbidopa-Levodopa...... 12 Clopidogrel...... 10 Dextroamphetamine Sulfate Carisoprodol 350 mg Tablet...... 19 Clotrimazole-Betamethasone Immediate-Release Tablet...... 11 Cartia XT...... 10 Cream...... 13 Dextroamphetamine-Amphetamine Carvedilol Immediate-Release Clotrimazole-Betamethasone Immediate-Release Tablet...... 11 Tablet...... 10 Lotion...... 14 Diazepam Tablet...... 12, 13 Cayston...... 19 Colesevelam Packet for Suspension, Diclofenac Tablet...... 20 Caziant...... 22 Tablet...... 11 Dicyclomine Tablet...... 20 Cefadroxil Capsule, Tablet...... 9 Combigan...... 16 Dificid...... 9 Cefdinir Capsule...... 9 Combivent Respimat...... 20 Diflorasone Diacetate 0.05% Cream, Cefixime Suspension...... 9 Complera...... 17 Ointment...... 14 Cefprozil Tablet...... 9 Concerta...... 11 Digoxin...... 11 Cefuroxime Tablet...... 9 Contour Next EZ Meter...... 14 Diltiazem 24 Hour CD...... 10 Celecoxib...... 20 Contour Next Meter...... 14 Diltiazem Sustained-Release Cephalexin Capsule...... 9 Contour Next One Meter...... 14 Capsule...... 10 Cerdelga...... 19 Contour Next Test Strips...... 14 Diltiazem Sustained-Release Cetrotide...... 18 Contour Test Strips...... 14 Tablet...... 10 Chantix Tablet...... 21 Copaxone...... 12 Diphenoxylate-Atropine Tablet...... 17 Chateal...... 22 Corlanor...... 11 Divalproex Delayed-Release Chlorhexidine Gluconate...... 19 Cortifoam...... 17 Tablet...... 13 Chlorpheniramine/Hydrocodone/ Cosentyx...... 18 Divalproex Extended-Release Pseudoephedrine Solution...... 19 Creon...... 17 Tablet...... 13 Chlorthalidone...... 10 Cresemba...... 9 Divigel...... 24 Ciclopirox Cream, Gel, Lotion, Cryselle...... 22 Donepezil 5, 10 mg ODT, Tablet.... 12 Solution...... 13 Cyclafem 7/7/7, 1/35...... 22 Doxazosin...... 10, 18 Cimduo...... 17 Cyclobenzaprine...... 19 Doxazosin Tablet...... 18 Cimzia...... 18 Cyclophosphamide Capsule...... 9 Doxepin...... 12 Ciprodex...... 9 Cyclosporine Modified Capsule..... 21 Doxycycline Hyclate 50, 100 mg Ciprofloxacin Tablet...... 9 Cyred...... 22 Capsule, Tablet...... 9 Citalopram Tablet...... 12 Doxycycline Monohydrate Claravis...... 13 D 50, 100 mg Capsule...... 9 Clarithromycin Tablet...... 9 Daklinza...... 17 Duavee...... 24 Clenpiq...... 17 Dapsone 5% Gel...... 14 Duloxetine Capsule...... 12 Climara...... 24 Dasetta 7/7/7, 1/35...... 22 Dupixent...... 14 Climara Pro...... 24 Deblitane...... 22 Dutasteride Capsule...... 18 Clindamycin 1.2%/Benzoyl Peroxide Delyla...... 22 Duzallo...... 17 5% Gel...... 13 Descovy...... 17 Clindamycin Capsule...... 9 Desmopressin Tablet...... 16 E Clindamycin Gel...... 13 Desogestrel-Ethinyl Estradiol...... 22 Econazole Cream...... 9 Clindamycin Lotion...... 13 Desonide 0.05% Cream, Lotion, Econtra EZ...... 22 Clindamycin Solution...... 13 Ointment...... 14 Edarbi...... 10 Clindamycin Swabs...... 13 Desoximetasone Gel, Ointment..... 14 Edarbyclor...... 10 Clobetasol Propionate Cream, Desvenlafaxine Extended-Release Efavirenz...... 17 Ointment...... 13 Tablet...... 12 Eletriptan...... 12 Clobetasol Propionate Solution...... 13 Dexamethasone Tablet...... 16 Elidel...... 14 Clomiphene...... 18 Dexilant...... 16 Elinest...... 22

26 Eliquis...... 10 Fenofibrate 54, 160 mg Tablet...... 11 Guanfacine...... 10, 11 Ella...... 22 Fentanyl 12, 25, 50, 75, 100 mcg Guanfacine Extended-Release...... 11 Emend Suspension...... 16 Patch...... 20 Emoquette...... 22 Fentanyl Citrate Lozenge...... 20 H Enalapril...... 10 Fetzima...... 12 Halobetasol Ointment...... 14 Enbrel...... 18 Fiasp FlexTouch, Vials...... 14 Harvoni...... 17 Endometrin...... 18 Finacea...... 14 Heather...... 22 Enoxaparin Sodium...... 10 Finasteride Tablet...... 18 Humalog KwikPens...... 14 Enpresse...... 22 Flecainide...... 11 Humalog Vials...... 14 Enskyce...... 22 Flovent Diskus/HFA...... 20 Humira...... 18 Enstilar Foam...... 14 Fluconazole Tablet...... 9 Humulin KwikPens...... 15 Entresto...... 11 Fluocinolone Cream, Oil, Humulin Vials...... 15 Epclusa...... 17 Solution...... 14 Hydralazine...... 10 Epinephrine...... 19 Fluocinolone Ointment...... 14 Hydrochlorothiazide...... 10 EpiPen/EpiPen-Jr...... 19 Fluocinonide 0.05% Cream...... 14 Hydrocodone/Acetaminophen 5/325, Erleada...... 9 Fluoride...... 21 7.5/325, 10/325 mg Tablet...... 20 Errin...... 22 Fluorouracil 0.5% Cream...... 14 Hydrocodone/Chlorpheniramine Erythromycin 0.5% Ophthalmic Fluoxetine Capsule...... 12 Suspension...... 19 Ointment...... 16 Fluticasone Nasal Spray...... 20 Hydrocodone/Ibuprofen Tablet...... 20 Escitalopram Tablet...... 12 Fluticasone/Salmeterol Hydrocortisone 2.5% Cream, Estarylla...... 22 RespiClick...... 20 Ointment...... 14 Estrace...... 24 Fluvastatin Extended-Release Hydromorphone Immediate-Release Estrace Cream...... 24 Tablet...... 11 Tablet...... 20 Estradiol Cream...... 24 Fluvoxamine Tablet...... 12 Hydroxychloroquine Sulfate...... 18 Estradiol Tablet...... 24 Folic Acid...... 21 Hydroxyurea Capsule...... 9 Estradiol Twice-Weekly Transdermal Forteo...... 19 Hyoscyamine Tablet...... 17 Patch...... 24 FreeStyle Test Strips...... 14 Estradiol Weekly Transdermal Frovatriptan...... 12 I Patch...... 24 Furosemide...... 10 Ibandronate Tablet...... 19 Estradiol/Norethindrone Acetate Ibrance...... 9 Tablet...... 24 G Ibuprofen Tablet...... 20 Estring...... 24 Gabapentin Capsule, Tablet...... 13 Idhifa...... 9 Estrogen/Methyltestosterone Gemfibrozil...... 11 Imatinib Tablet...... 9 Tablet...... 24 Gentamicin Ophthalmic Ointment, Imbruvica...... 9 Eszopiclone Tablet...... 13 Solution...... 16 Imiquimod 5% Cream...... 14 Etodolac Capsule...... 20 Genvoya...... 17 Incruse Ellipta...... 20 Eucrisa...... 14 Gilenya...... 12 Indomethacin Capsule...... 20 Evamist...... 24 Glatiramer...... 12 Intelence...... 17 Evotaz...... 17 Glimepiride...... 15 Introvale...... 22 Ezetimibe Tablet...... 11 Glipizide...... 15 Invokamet, Invokamet XR...... 15 Ezetimibe/Simvastatin...... 11 Glipizide Extended-Release...... 15 Invokana...... 15 Glucophage XR...... 15 Ipratropium Nebs...... 20 F Glyburide...... 15 Ipratropium-Albuterol Nebs...... 20 Fallback...... 22 Glyxambi...... 15 Irbesartan...... 10 Falmina...... 22 Golytely...... 17 Isentress...... 18 Famciclovir Tablet...... 9 Gonal-F...... 18 Isibloom...... 22 Farxiga...... 15 Gonal-F RFF...... 18

27 Isosorbide Mononitrate ER...... 11 Lessina...... 22 Mercaptopurine Tablet...... 10 Itraconazole Capsule...... 9 Letairis...... 21 Mesalmine Delayed-Release Letrozole Tablet...... 19 Tablet...... 17 J Leucovorin Calcium Tablet...... 9 Metadate CD...... 11 Janumet...... 15 Levemir FlexTouch, Vials...... 15 Metadate ER...... 12 Januvia...... 15 Levetiracetam Extended-Release Metaxalone Tablet...... 19 Jardiance...... 15 Tablet...... 13 Metformin...... 15 Jencycla...... 22 Levetiracetam Immediate-Release Metformin Extended-Release Jentadueto...... 15 Tablet...... 13 Tablet...... 15 Jentadueto XR...... 15 Levofloxacin Tablet...... 9 Methadone Tablet, Oral Solution, Jolessa...... 22 Levonest...... 22 Concentrate Solution...... 20 Jolivette...... 22 Levonorgestrel 1.5 mg...... 22 Methimazole Tablet...... 16 Juleber...... 22 Levonorgestrel-Ethinyl Estradiol.... 22 Methocarbamol Tablet...... 19 Juluca...... 18 Levora-28...... 22 Methotrexate Tablet...... 18 Junel...... 22 Levothyroxine Sodium Tablet...... 16 Methylphenidate Chewable Junel Fe...... 22 Lialda...... 17 Tablet...... 11 Lidocaine Transdermal Patch...... 19 Methylphenidate Extended-Release Lidoderm...... 19 Capsule...... 11 K Lillow...... 22 Methylphenidate Extended-Release Kaletra Tablet...... 18 Linzess...... 17 Tablet...... 11, 12 Kazano...... 15 Liothyronine Sodium Tablet...... 16 Methylphenidate Immediate-Release Kelnor 1/35...... 22 Lisinopril...... 10 Tablet...... 12 Ketoconazole Cream...... 9 Lisinopril-Hydrochlorothiazide...... 10 Methylprednisolone Tablet...... 16 Ketorolac Tablet...... 20 Lithium Capsule...... 12 Methyltestosterone Capsule...... 19 Kevzara...... 18 Lo Loestrin Fe...... 22 Metoclopramide Tablet...... 17 Klor-Con M10...... 21 Lopinavir-Ritonavir Oral Solution.... 18 Metoprolol Succinate Extended- Klor-Con M20...... 21 Lorazepam Tablet...... 12 Release 50, 100, 200 mg...... 10 Kombiglyze XR...... 15 Loryna...... 22 Metoprolol Tartrate 25, 50, Kurvelo...... 22 Losartan...... 10 100 mg...... 10 Losartan-Hydrochlorothiazide...... 10 Metronidazole 0.75% Topical Gel... 14 L Lovastatin...... 11 Metronidazole Tablet...... 9 Labetalol...... 10 Low-Ogestrel...... 22 Microgestin...... 22 Lamivudine-Zidovudine...... 18 Lumigan...... 16 Microgestin Fe...... 22 Lamotrigine Immediate-Release Lutera...... 22 Minivelle...... 24 Tablet...... 13 Lyrica...... 13 Minocycline Capsule...... 9 Lanthanum Chewable Tablet...... 19 Lyrica CR...... 13 Minocycline Extended-Release...... 14 Lantus SoloStar...... 15 Lyza...... 22 Mirtazapine Tablet...... 12 Lantus Vials...... 15 Mirvaso...... 14 Larin Fe...... 22 M Mitigare...... 17 Larissia...... 22 Marlissa...... 22 Modafinil...... 12 Lastacaft...... 16 Mavyret...... 17 Mometasone Furoate Cream, Latanoprost 0.005% Ophthalmic Medroxyprogesterone...... 22, 24 Lotion, Ointment...... 14 Solution...... 16 Medroxyprogesterone Acetate...... 22 Mono-Linyah...... 22 Latuda...... 12 Mektovi...... 10 MonoNessa...... 22 Lazanda...... 20 Meloxicam Tablet...... 20 Montelukast Chewable Tablet, Leena...... 22 Memantine Immediate-Release Tablet...... 20 Leflunomide...... 18 Tablet...... 12 Montelukast Granules...... 21

28 Morphine Sulfate Extended-Release Nitroglycerin Sublingual Tablet...... 11 OneTouch Verio Meter...... 14 Tablet...... 20 Nityr...... 19 OneTouch Verio Sync Meter...... 14 Morphine Sulfate Oral Solution...... 20 Nora BE...... 23 OneTouch Verio Test Strips...... 14 Movantik...... 17 Nordette...... 22 Onglyza...... 15 Moviprep...... 17 Norethindrone 0.35 mg...... 23 Opcicon One Step...... 23 Moxeza...... 16 Norethindrone-Ethinyl Estradiol- Opsumit...... 21 Moxifloxacin Ophthalmic Solution.. 16 Ferrous Fumarate...... 23 Option 2...... 23 Moxifloxacin Tablet...... 9 Norgestimate-Ethinyl Estradiol...... 23 Oracea...... 14 Multaq...... 11 Norgestimate-Ethinyl Orencia...... 18 Mupirocin Ointment...... 14 Estradiol Lo...... 23 Orenitram...... 21 My Choice...... 22 Norlyda...... 23 Orsythia...... 23 My Way...... 23 Norlyroc...... 23 Ortho Tri-Cyclen Lo...... 23 Mycophenolate Capsule, Nortrel 7/7/7, 0.5/35, 1/35...... 23 Ortho-Cept...... 22 Suspension...... 21 Nortriptyline Capsule...... 12 Ortho-Cyclen, Ortho Tri-Cyclen..... 23 Mycophenolic Acid Tablet...... 21 Novolin Vials...... 15 Oseltamivir Capsule, Suspension.... 9 Myzilra...... 23 Novolog FlexPen, Vials...... 15 Oseni...... 15 Noxafil Tablet, Suspension...... 9 Otezla...... 18 N NP Thyroid Tablet...... 16 Ovidrel...... 18 Nabumetone Tablet...... 20 Nucynta...... 20 Oxcarbazepine Tablet...... 13 Nadolol...... 10 Nucynta ER...... 20 Oxsoralen-Ultra...... 14 Naloxone Vials...... 12 Nuedexta...... 19 Oxybutynin Extended-Release Naproxen Tablet...... 20 Nutropin, Nutropin AQ...... 15 Tablet...... 20 Naratriptan...... 12 Nuvaring...... 23 Oxybutynin Tablet...... 20 Narcan Nasal Spray...... 12 Nystatin Cream, Ointment...... 9 Oxycodone Tablet...... 20 Natazia...... 23 Oxycodone/Acetaminophen 5/325, Necon 7/7/7, 0.5/35, 1/35, O 7.5/325, 10/325 mg Tablet...... 20 1/50, 10/11...... 23 Obredon...... 19 Oxycontin...... 20 Nerlynx...... 10 Odefsey...... 18 Ozempic...... 15 Nesina...... 15 Ofloxacin 0.3% Ophthalmic Nevirapine...... 18 Solution...... 16 P Nevirapine Extended-Release...... 18 Ofloxacin Otic Solution...... 9 Pantoprazole Tablet...... 16 Next Choice One Choice...... 23 Ofloxacin Tablet...... 9 Paroxetine Tablet...... 12 Niacin Extended-Release Tablet.....11 Olanzapine Tablet...... 13 Pegasys...... 19 Niaspan...... 11 Olmesartan...... 10 Penicillin V Potassium Tablet...... 9 Nicoderm CQ...... 21 Olmesartan-Hydrochlorothiazide... 10 Perforomist...... 21 Nicorette Gum...... 21 Olopatadine 0.1% Ophthalmic Phenazopyridine...... 19 Nicorette Lozenge...... 21 Solution...... 16 Phenytoin Capsule, Suspension.... 13 Nicorette Mini-Lozenge...... 21 Omeclamox-Pak...... 16 Picato...... 14 Nicotine Gum...... 21 Omega-3-Acid Ethyl Esters Pioglitazone...... 15 Nicotine Lozenge...... 21 Capsule...... 11 Pirmella 7/7/7, 1/35...... 23 Nicotine Patch...... 21 Omeprazole Capsule...... 16 Plan B One Step...... 23 Nicotrol Inhaler...... 21 Ondansetron...... 16 Plegridy...... 12 Nicotrol Nasal Spray...... 21 OneTouch Ultra 2 Meter...... 14 Polyethylene Glycol 3350...... 17 Nifedipine Extended-Release...... 10 OneTouch Ultra Test Strips...... 14 Portia...... 23 Nitrofurantoin Capsule...... 9 OneTouch UltraMini Meter...... 14 Potassium Chloride...... 21 Nitrofurantoin Macrocrystal OneTouch Verio Flex Meter...... 14 Potassium Citrate...... 21 Capsule...... 9 OneTouch Verio IQ Meter...... 14 Pradaxa...... 10

29 Praluent...... 11 Ranitadine Syrup...... 16 Spiriva Handihaler/Respimat...... 21 Pramipexole Tablet...... 13 Rapaflo...... 18 Spironolactone...... 11 Prasugrel...... 10 Rasuvo...... 18 Sprintec...... 23 Pravastatin...... 11 React...... 23 Sprix...... 20 Prednisone Tablet...... 16 Rebif...... 12 Sronyx...... 23 Premarin...... 24 Reclipsen...... 23 Steglatro...... 15 Premphase...... 24 Rectiv...... 19 Steglujan...... 15 Prempro...... 24 Regranex...... 14 Stelara...... 18 Prenisolone Oral Solution...... 16 Repatha...... 11 Stribild...... 18 Prepopik...... 17 Restasis Single Use Vials...... 16 Striverdi Respimat...... 21 Previfem...... 23 Revatio...... 21 Suboxone Film...... 13 Prezcobix...... 18 Revlimid...... 10 Sucralfate Tablet...... 16 Prezista...... 18 Rezira...... 19 Sulfamethoxazole-Trimethoprim Pristiq...... 12 Rhofade...... 14 Tablet...... 9 ProAir HFA/RespiClick...... 21 Ribavirin Tablet...... 17 Sulfasalazine Tablet...... 17 Procrit...... 19 Risedronate Sodium Tablet...... 19 Sumatriptan Nasal Spray...... 12 Progesterone Micronized Risperidone Tablet...... 13 Sumatriptan Succinate Tablet, Capsule...... 24 Ritalin LA...... 11 Injection...... 12 Promethazine/Codeine...... 19 Ritalin SR...... 12 Suprax Capsule, Chewable Tablet, Promethazine/Dextromethorphan.. 19 Ritonavir Tablet...... 18 Tablet...... 9 Propranolol Extended-Release Rizatriptan ODT, Tablet...... 12 Suprep...... 17 Capsule...... 10 Ropinirole Tablet...... 13 Sutent...... 10 Propranolol Tablet...... 11 Rosuvastatin...... 11 Symbicort...... 21 Proventil HFA...... 21 Rydapt...... 10 Symfi...... 18 Prozac...... 12 Symfi Lo...... 18 Pulmicort Flexhaler...... 21 S Symproic...... 17 Pulmozyme...... 19 Savaysa...... 10 Synjardy, Synjardy XR...... 15 Pylera...... 16 Scopolamine Transdermal Patch... 16 Synthroid...... 16 Seasonale...... 22 Syprine...... 19 Q Seebri Neohaler...... 21 Qtern...... 15 Segluromet...... 15 T Quasense...... 23 Selzentry...... 18 Taclonex Suspension...... 14 Quetiapine Extended-Release Serevent Diskus...... 21 Tacrolimus Capsule...... 21 Tablet...... 13 Sertraline Tablet...... 12 Tacrolimus Ointment...... 14 Quetiapine Immediate-Release Setlakin...... 23 Tadalafil...... 21 Tablet...... 13 Sevelamer...... 19 Take Action...... 23 Quinapril...... 11 Sharobel...... 23 Taltz...... 18 QVAR Redihaler...... 21 Sildenafil Tablet...... 21 Tamoxifen...... 24 Siliq...... 18 Tamsulosin Capsule...... 18 R Simponi...... 18 Targretin Capsule...... 10 Rabeprazole Tablet...... 16 Simvastatin...... 11 Targretin Gel...... 10 Rajani...... 23 Sirolimus Tablet...... 21 Tarina Fe...... 23 Raloxifene...... 19, 24 Solia...... 23 Tasigna...... 10 Raloxifene Tablet...... 19 Soliqua...... 15 Tazarotene 0.1% Cream...... 14 Ramipril...... 11 Solodyn...... 14 Tazorac...... 14 Ranexa...... 11 Sotalol...... 11 Tecfidera...... 12 Sovaldi...... 17 Technivie...... 17

30 Telmisartan...... 11 Triamcinolone Acetonide Cream, Vicodin 5/300, 7.5/300, 10/300 mg Telmisartan-Hydrochlorothiazide....11 Lotion, Ointment...... 14 Tablet...... 20 Temazepam Capsule...... 13 Triamterene-Hydrochlorothiazide....11 Victoza 2-Pak...... 15 Tenofovir Tablet...... 18 Triazolam Tablet...... 13 Victoza 3-Pak...... 15 Terazosin...... 11, 18 Trientine...... 19 Viekira Pak...... 17 Terazosin Capsule, Tablet...... 18 Trinessa...... 23 Viekira XR...... 17 Terbinafine Tablet...... 9 Trinessa Lo...... 23 Vienva...... 23 Testim...... 19 Trintellix...... 12 Viibryd...... 12 Testosterone 1% Topical Gel...... 19 Triphasil...... 22 Viorele...... 23 Testosterone Cypionate Injection... 19 Triumeq...... 18 Vitekta...... 18 Timolol 0.25%, 0.5% Ophthalmic Trivora-28...... 23 Vivelle-Dot...... 24 Solution...... 16 Trulicity...... 15 Voltaren Gel...... 20 Timoptic...... 16 Truvada...... 18 Vosevi...... 17 Tivicay...... 18 Tudorza...... 21 Vylibra...... 23 Tizanidine Tablet...... 19 Tybost...... 18 Vyvanse...... 12 Tobi Podhaler...... 19 Tymlos...... 19 Tobramycin Ophthalmic Solution.... 16 Tyvaso...... 21 W Tobramycin/Dexamethasone 0.3%- Warfarin Sodium...... 10 0.1% Ophthalmic Suspension..... 16 U Welchol...... 11 Tolcapone...... 13 Uceris...... 17 Welchol Packet for Suspension, Topiramate Immediate-Release Uceris Foam...... 17 Tablet...... 11 Tablet...... 13 Uceris Tablet...... 17 Wera...... 23 Toviaz...... 20 Uloric...... 17 Tracleer...... 21 Uptravi...... 21 X Tradjenta...... 15 Xarelto...... 10 Tramadol Immediate-Release V Xeljanz, Xeljanz XR...... 18 Tablet...... 20 Valacyclovir Tablet...... 9 Xeloda...... 10 Tramadol Sustained-Release Valganciclovir...... 9 Xigduo XR...... 15 Tablet...... 20 Valsartan...... 11 Xiidra...... 16 Tramadol-Acetaminophen...... 20 Valsartan-Hydrochlorothiazide...... 11 Xopenex HFA...... 21 Travatan Z...... 16 Varubi...... 16 Xtampza ER...... 20 Trazodone Tablet...... 12 Vascepa...... 11 Xulane...... 23 Trelegy Ellipta...... 21 Vectical...... 14 Xyrem...... 13 Tremfya...... 18 Velivet...... 23 Tresiba FlexTouch...... 15 Velphoro...... 19 Y Tretinoin Cream...... 14 Veltassa...... 19 Trezix...... 20 Yasmin 28...... 23 Venlafaxine Extended-Release Tri Femynor...... 23 Yaz...... 23 Capsule...... 12 Tri-Estarylla...... 23 Yuvafem...... 24 Venlafaxine Tablet...... 12 Tri-Linyah...... 23 Ventolin HFA...... 21 Tri-Lo-Estarylla...... 23 Z Verapamil...... 11 Tri-Lo-Marzia...... 23 Zaleplon Capsule...... 13 Verapamil Sustained-Release...... 11 Tri-Lo-Sprintec...... 23 Zarxio...... 19 Verzenio...... 10 Tri-Previfem...... 23 Zelapar...... 13 Vestura...... 23 Tri-Sprintec...... 23 Zenpep...... 17 Viberzi...... 17 Tri-Vylibra...... 23 Zepatier...... 17

31 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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