City Of Austin Drug List - AustinTexas.gov

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City Of Austin Drug List
(This is intended to be a partial listing of those medications that are often the most commonly prescribed.)

January 2021
Please consider talking to your doctor about prescribing preferred medications, which
may help reduce your out-of-pocket costs. This list may help guide you and your doctor
in selecting an appropriate medication for you.
Introduction
Blue Cross and Blue Shield of Texas (BCBSTX) is pleased to present the 2021 Drug List. This is a list of
preferred drugs which includes brand drugs and a partial listing of generic drugs. Members are encouraged to
show this list to their physicians and pharmacists. Physicians are encouraged to prescribe drugs on this list,
when right for the member. However, decisions regarding therapy and treatment are always between members
and their physician.

Drug List updates – This list is regularly updated as generic drugs become available and changes take place in
the pharmaceuticals market. For the most up-to-date information, visit myprime.com or bcbstx.com and log in to
Blue Access for MembersSM (BAMSM) or call the number on your ID card. Physicians can access the list from the
provider portal at bcbstx.com.

How drugs are selected
Drugs on this list are selected based on the recommendations of a committee made up of physicians and
pharmacists from throughout the country and reviews drugs regulated by the U.S. Food and Drug
Administration (FDA). Drugs are selected based on safety, efficacy, cost and how they compare to other
drugs currently on the list.

How member payment is determined
This list shows prescription drug products in tiers. Generally, each drug is placed into one of up to three member
payment tiers: Preferred Generic (Tier 1), Preferred Brand (Tier 2), Non-Preferred Brand (Tier 3). Non-Preferred
Brand or Non- Preferred Specialty drugs are not listed in this document. To verify your payment amount for a
drug, visit MyPrime.com and log in or call the number on your ID card.

Your pharmacy benefit includes coverage for many prescription drugs, although some exclusions may
apply. For example, drugs indicated for cosmetic purposes, e.g., Propecia, for hair growth, may not be covered.
Prescription products that have over-the-counter (OTC) equivalents may not be covered. Drugs that are not FDA-
approved for self-administration may be available through your medical benefit.
How to use this list
Generic drugs are shown in regular type.
Example: Atorvastatin
Preferred brand drugs are listed in bold-face
type. Example: Januvia
Non-preferred brands are not listed.
This list is not meant to be an exhaustive list of all drugs covered. Please refer to myprime.com to find specific
information about your coverage.
Also please note: Drugs that need a health care provider to administer them and are often given to you in a
hospital, doctor’s office or other health care setting may be covered under your medical benefit. Some types of
these drugs are contraceptive implants and chemo infusions. If you are taking or are prescribed a drug that is
not on this drug list, call the number on your ID card to see if the drug may be covered.
                                                                                                                     1
Coverage considerations
Drug coverage may be limited to recommendations based on FDA-approved labeling and recognized evidence-
based or clinical practice guidelines.
Specialty drugs
Specialty drugs are used in the treatment of medical conditions such as hepatitis, hemophilia, multiple sclerosis
and rheumatoid arthritis. Specialty drugs may be oral, topical or injectable medications that can either be self-
administered or administered by a health care professional. For a current list of specialty medications,
visit myprime.com or bcbstx.com and log in to Blue Access for Members.
Prior Authorization (PA): Your benefit plan may require prior authorization for certain drugs. This means that
your doctor will need to submit a prior authorization request for coverage of these medications, and the request
will need to be approved, before the medication may be covered under your plan. For the medications listed in
this document, if a prior authorization is commonly required, it will generally be noted next to the medication with a
(PA) reference beside the name.

Step Therapy (ST): Your benefit plan may include a step therapy program. This means you may need to try
another proven, cost-effective medication before coverage may be available for the drug included in the program.
Many brand drugs have less-expensive generic or brand alternatives that might be an option for you. For the
medications listed in this document, if a step therapy is commonly required, it will generally be noted next to the
medication it will generally be noted next to the medication with a (ST) reference beside the name.
Remember, medication decisions are between you and your doctor. Only you and your doctor can
determine which medication is right for you. Discuss any questions or concerns you have about medications you
are taking or are prescribed with your doctor. BCBSTX does not provide health care services and, therefore,
cannot guarantee any results or outcomes.

                                                                                                                         2
Drug Name
Tier                                     Anti-Infectives: Viral Infections including
                                         Hepatitis
Anti-Infectives: Antibiotics

Amoxicillin Capsule, Chewable            Acyclovir Ointment                      1
                                     1
Tablet                                   Acyclovir Tablet                        1

Amoxicillin/Potassium Clavulanate        Baraclude Soln                          2
                                     1   Dovato                                  2
Chewable Tablet, Tablet
                                         Epclusa (PA)                            2
Azithromycin Tablet                  1
                                         Famciclovir Tablet                      1
Cefadroxil Capsule, Tablet           1
                                         Harvoni (PA)                            2
Cefdinir Capsule                     1
                                         Juluca                                  2
Cefixime Suspension                  1
                                         Mavyret (PA)                            2
Cefprozil Tablet                     1
                                         Oseltamivir Capsule                     1
Cefuroxime Tablet                    1
                                         Pegasys (PA)                            2
Cephalexin Capsule                   1
                                         Solvaldi (PA)                           2
Ciprofloxacin Tablet                 1
                                         Ribavirin (PA)                          1
Clarithromycin Tablet                1
                                         Valacyclovir Tablet                     1
Clindamycin Capsule                  1
                                         Valganciclovir                          1
Doxycycline Hyclate 50, 100 mg
                                     1   Vosevi (PA)                             2
Capsule, Tablet
                                         Cancer
Doxycycline Monohydrate 50, 100
                                     1   abiraterone Tablet                      1
mg Capsule
Metronidazole Tablet                 1   Actimmune                               2
Minocycline Capsule                  1   Ayvakit                                 2
Moxifloxacin Tablet                  1   Bicalutamide                            1
Nitrofurantoin Capsule               1   Bosulif                                 2
Nitrofurantoin Macrocrystal              Cotellic                                2
                                     1
Capsule                                  Cyclophosphamide Capsule                2
Ofloxacin Otic Solution              1   Emcyt                                   2
Ofloxacin Tablet                     1   Erleada                                 2
Penicillin V Potassium Tablet        1   Erivedge                                2
Sulfamethoxazole-Trimethoprim            Erlotinib                               1
                                     1
Tablet                                   Everolimus                              1
Anti-Infectives: Fungal Infections       Hydroxyurea Capsule                     1
                                         Ibrance                                 2
Econazole Cream                      1
                                         Imantinib Tablet                        1
Fluconazole Tablet                   1
                                         Kisqali                                 2
Itraconazole Capsule                 1
                                         Leucovorin Calcium Tablet               1
Ketoconazole Cream                   1
                                         Mekinist                                2
Nystatin Cream, Ointment             1
                                         Mercaptopurine Tablet                   1
Terbinafine Tablet                   1
                                         Mesnex                                  2
                                         Myleran                                 2

                                                                                       3
Nexavar                              2      Carvedilol                           1
Piqray                               2      Chlorthalidone                       1
Purixan                              2      Clonidine Tablet                     1
Rydapt                               2      Diltiazem 24 Hour CD                 1
Sprycel                              2      Diltiazem Sustained-Release
                                                                                 1
Sutent                               2      Capsule
Sylarton                             2      Diltiazem Sustained-Release
                                                                                 1
                                            Tablet
Tabloid                              2
                                            Doxazosin                            1
Tafinlar                             2
                                            Enalapril                            1
Talzenna                             2
                                            Furosemide                           1
Tasigna                              2
                                            Guanfacine                           1
toremifene citrate Tablet            1
                                            Hydralazine                          1
Trexall                              2
                                            Hydrochlorothiazide                  1
Verzenio                             2
                                            Irbesartan                           1
Vitraki                              2
                                            Innopran XL                          2
Votrient                             2
                                            Labetalol                            1
Xalkori                              2
                                            Lisinopril                           1
Xtandi                               2
                                            Lisinopril-Hydrochlorothiazide       1
Yonsa                                2
                                            Losartan                             1
Zelboraf                             2
                                            Losartan-Hydrochlorothiazide         1
Cardiovascular/Heart Disease:
Coagulation Therapy                         Metoprolol Succinate Extended-
                                                                                 1
                                            Release 50, 100, 200 mg
Brilinta                             2
Clopidogrel                          1      Metoprolol Tartrate 25, 50, 100 mg   1
Eliquis                              2
                                            Nadolol                              1
Enoxaparin Sodium                    1
                                            Nifedipine Extended-Release          1
Warfarin Sodium                      1
                                            Olmesartan                           1
Xarelto                              2
                                            Olmesartan-Hydrochlorothiazide       1
Heart and Circulatory Disease: High Blood
Pressure                                    Propranolol Extended-Release
                                                                                 1
                                            Capsule
Amlodipine                           1
                                            Propranolol Tablet                   1
Amlodipine-Benazepril                1
                                            Quinapril                            1
Amlodipine-Valsartan                 1
                                            Ramipril                             1
Atenolol                             1
                                            Spironolactone                       1
Atenolol-Chlorthalidone              1
                                            Telmisartan                          1
Benazepril                           1
                                            Telmisartan-Hydrochlorothiazide      1
Benazepril-Hydrochlorothiazide       1      Terazosin                            1
Bisoprolol                           1      Triamterene-Hydrochlorothiazide      1
Bisoprolol-Hydrochlorothiazide       1
                                            Valsartan                            1
Cartia XT                            1
                                                                                     4
Valsartan-Hydrochlorothiazide         1   Dextroamphetamine Sulfate
                                                                               1
Verapamil                             1   Immediate-Release Tablet
Verapamil Sustained-Release           1   Guanfacine Extended-Release          1
                                          Methylphenidate Extended-
Cardiovascular/Heart Disease: High                                             1
                                          Release
Cholesterol
                                          Methylphenidate HCl ER osmotic
                                                                               1
Atorvastatin                          1   release
colesevelam packet                    1   Methylphenidate Immediate-
                                                                               1
                                          Release Tablet
Ezetimibe Tablet                      1
                                          Vyvanse                              2
Ezetimibe/Simvastatin                 1
Fenofibrate 54, 160 mg Tablet         1   Central Nervous System: Depression
Fluvastatin Extended-Release
                                      1   Amitriptyline Tablet                 1
Tablet
                                          Bupropion Extended-Release
Gemfibrozil                           1                                        1
                                          Tablet
Lovastatin                            1
                                          Bupropion Sustained-Release
Nexletol                              2                                        1
                                          Tablet
Niacin Extended-Release Tablet        1   Bupropion Tablet                     1
Omega-3-Acid Ethyl Esters                 Citalopram Tablet                    1
                                      1
Capsule
                                          Desvenlafaxine Extended-Release
Pravastatin                           1                                        1
                                          Tablet
Repatha (PA)                          2   Doxepin                              1
Rosuvastatin                          1   Duloxetine Capsule                   1
Simvastatin                           1   Escitalopram Tablet                  1
                                          Fluoxetine Capsule                   1
Cardiovascular/Heart Disease: Other
                                          Fluvoxamine Tablet                   1
Amiodarone                            1   Mirtazapine Tablet                   1
Digoxin                               1   Nortriptyline Capsule                1
Entresto                              2   Paroxetine Tablet                    1
Flecainide                            1   Sertraline Tablet                    1
Isosorbide Mononitrate ER             1   Trazodone Tablet                     1
Multaq                                2   Venlafaxine Extended-Release
                                                                               1
Nitroglycerin Sublingual Tablet       1   Capsule
Opsumit (PA)                          2   Venlafaxine Tablet                   1
Sotalol                               1   Central Nervous System: Migraine
tadalafil Tablet                      1
                                          Acetaminophen/Butalbital/Caffeine
                                                                               1
                                          325 mg/50 mg/40 mg
Central Nervous System: Hyperactivity
                                          Aimovig (PA)                         2
Amphetamine Salt Combo                1   Eletriptan                           1
Atomoxetine                           1   Emgality (PA)                        2
Dexmethylphenidate Immediate-             Frovatriptan                         1
                                      1
Release Tablet                            Naratriptan                          1
Dextroamphetamine-Amphetamine             Rizatriptan ODT, Tablet              1
                                      1
Immediate-Release Tablet
                                                                                   5
Sumatriptan Nasal Spray            1   Ziprasidone Capsule                 1
Sumatriptan Succinate Tablet,
                                   1   Central Nervous System:
Injection
                                       Sedatives/Hypnotics
Central Nervous System: Multiple
Sclerosis                              Belsomra                            2
Aubagio (PA)                       2   Eszopiclone Tablet
Avonex (PA)                        2   Temazepam Capsule                   1
Betaseron (PA)                     2   Triazolam Tablet                    1
Copaxone (PA)                      2   Zaleplon Capsule                    1
dimethyl fumerate capsule DR       1   Zolpidem Immediate-Release
                                                                           1
                                       Tablet
Gilenya (PA)                       2
Mavenclad (PA)                     2   Central Nervous System: Seizure
Mayzent (PA)                       2   Disorders
Plegridy (PA)                      2   Carbamazepine Extended-Release
                                                                           1
Rebif (PA)                         2   Capsule, Tablet
Zeposia                            2   Carbamazepine Immediate-
                                                                           1
                                       Release Tablet
Central Nervous System: Other
                                       Celontin                            2
Alprazolam Extended-Release            Clonazepam Tablet                   1
                                   1
Tablet                                 Diastat                             2
Alprazolam Tablet                  1   Dilantin Extended 30mg              2
Aripiprazole Tablet                1   Diazepam Tablet                     1
Armodafinil                        1   Divalproex Delayed-Release Tablet   1
Buspirone Tablet                   1   Divalproex Extended-Release
Carbidopa-Levodopa                 1                                       1
                                       Tablet
Diazepam Tablet                    1   Epidiolex (PA)                      2
Donepezil ODT, 5, 10 mg Tablet     1   Gabapentin Capsule, Tablet          1
Lithium Capsule                    1   Lamotrigine Immediate-Release
                                                                           1
Lorazepam Tablet                   1   Tablet
Memantine                          1   Levetiracetam Extended-Release
                                                                           1
Modafinil Tablet                   1   Tablet

Naloxone Vial                      1   Levetiracetam Immediate-Release
                                                                           1
                                       Tablet
Narcan Nasal Spray                 2
                                       Lyrica                              2
Olanzapine Tablet                  1
                                       Oxcarbazepine Tablet                1
Pramipexole Tablet                 1
                                       Phenytoin Capsule, Suspension       1
Sunosi                             2
                                       Pregabalin                          1
Quetiapine Extended-Release
                                   1   Topiramate Immediate-Release
Tablet                                                                     1
                                       Tablet
Quetiapine Immediate-Release
                                   1   vigabatrin Tablet                   1
Tablet
Risperidone Tablet                 1   Zonisamide Capsule                  1
Ropinirole Tablet                  1   Dermatology
Tolcapone                          1   azelaic acid                        1

                                                                               6
Betamethasone Dipropionate               Triamcinolone Acetonide Cream,
                                                                              1
0.05% Augmented Lotion,              1   Lotion, Ointment
Ointment                                 Valchlor                             2
Betamethasone Dipropionate               Zyclara                              2
                                     1
0.05% Cream, Ointment
Calcipotriene/Betamethasone              Diabetes: Blood Glucose Monitoring
                                     1
Ointment
Carac (PA)                           2   Test Strips - Ascencia Breeze 2,
                                                                              2
                                         Contour, Contour 2
Ciclopirox Cream, Gel, Lotion,
                                     1   Diabetes: Insulin
Solution
Claravis                             1   Fiasp                                2
Clindamycin 1.2%/Benzoyl                 Humulin R-500                        2
                                     1
Peroxide 5% Gel                          Lantus                               2
Clindamycin Gel                      1   Lantus Solostar                      2
Clindamycin Lotion, Solution,            Levemir FlexTouch                    2
                                     1
Swabs                                    Levemir Vials                        2
Clobetasol Propionate Cream,             Novolin Vials (all formulations)     2
                                     1
Ointment, Solution
Clotrimazole-Betamethasone               Novolog FlexPen (all formulations)   2
                                     1
Cream
                                         Novolog Vials (all formulations)     2
Clotrimazole-Betamethasone
                                     1   Soliqua                              2
Lotion
                                         Toujeo Solostar and Max
Desonide 0.05% Cream, Lotion,                                                 2
                                     1   Solostar
Ointment
Desoximetasone Cream, Gel,               Tresiba Flextouch                    2
                                     1   Xultophy                             2
Ointment
Diflorasone Diacetate 0.05%              Diabetes: Non-Insulin
                                     1
Cream, Ointment
Flouroplex                           2   Baqsimi                              2
Fluocinolone Cream, Oil, Ointment,       Glimepiride                          1
                                     1   Glipizide                            1
Solution
Fluocinonide 0.05% Cream             1   Glipizide Extended-Release           1
Halobetasol Ointment                 1   Glyburide                            1
Hydrocortisone 2.5% Cream,               Glyxambi                             2
                                     1
Ointment                                 Gvoke Hypopen                        2
Imiquimod 5% Cream                   1   Invokamet                            2
Metronidazole 0.75% Topical Gel      1   Invokamet XR                         2
Mometasone Furoate Cream,                Invokana                             2
                                     1
Lotion, Ointment                         Janumet                              2
Mupirocin Ointment                   1   Januvia                              2
pimecrolimus cream 1%                1   Jardiance                            2
Soolantra                            2   Metformin                            1
Tacrolimus Ointment                  1   Metformin Extended-Release
Tazorac                              2                                        1
                                         Tablet
Tretinoin Cream                      1   Pioglitazone                         1
                                                                                  7
Synjardy                           2
                                       Eye Conditions: Glaucoma
Synjardy XR                        2
Trulicity (ST)                     2   Alphagan P 0.1%                      2
Victoza (ST)                       2   Azopt                                2
                                       Latanoprost 0.005% Ophthalmic
Endocrine: Growth Hormone (PA)                                              1
                                       Solution
Increlex (PA)                      2   Lumigan                              2
Norditropin (PA)                   2   Simbrinza                            2
Endocrine: Other                       Timolol Maleate 0.25%, 0.5%
                                                                            1
Calcitriol Capsule                 1   Ophthalmic Solution
Desmopressin Tablet                1   travoprost ophth solution            1
Dexamethasone Tablet               1   Gastrointestinal: Acid Suppression
Methylprednisolone Tablet          1
Prenisolone Oral Solution          1   Pantoprazole Tablet                  1
Prednisone Tablet                  1   Rabeprazole Tablet                   1

Endocrine: Thyroid Hormone             Gastrointestinal: Nausea/Vomiting
Replacement
                                       Aprepitant Capsule                   1
Levothyroxine Sodium Tablet        1
                                       Emend Suspension                     2
Liothyronine Sodium Tablet         1
                                       Ondansetron                          1
Methimazole Tablet                 1
                                       Ondansetron ODT                      1
NP Thyroid Tablet                  1
                                       Scopolamine Transdermal Patch        1
Eye Conditions: Miscellaneous
                                       Gastrointestinal: Other
Azelastine ophth soln              1
                                       Chenodal                             2
Cromolyn Sodium                    1
                                       Creon                                2
Ketorolac ophth soln               1
                                       Diphenoxylate-Atropine Tablet        1
Olopatadine ophth soln             1
                                       Hyoscyamine Tablet                   1
Pazeo                              2
                                       mesalamine tab, suppository          1
Prednisone ophth susp              1
                                       Metoclopramide Tablet                1
Zylet                              2
                                       Polyethylene Glycol 3350             1
Eye Conditions: Anti-infectives        Sulfasalazine Tablet                 1
Bacitracin                         2   Symproic                             2
Erythromycin 0.5% Ophthalmic           Trulance                             2
                                   1
Ointment                               Velphoro                             2
Gentamicin Ophthalmic Ointment,        Viberzi                              2
                                   1
Solution
                                       Zenpep                               2
Natacyn                            2
                                       Gout
Moxifloxacin Ophthalmic Solution   1
                                       Allopurinol Tablet                   1
Ofloxacin 0.3% Ophthalmic
                                   1   Mitigare                             2
Solution
                                       HIV/AIDS
Tobramycin/Dexamethasone 0.3%-
                                   1   Abacavir-Lamivudine                  1
0.1% Ophthalmic Suspension
                                       Atripla                              2
Tobramycin Ophthalmic Solution     1

                                                                                8
Descovy                                  2
                                             Men’s Health: Testosterone Therapy
Genvoya                                  2
Intelence                                2   Danazol                              1
Isentress                                2   Methyltestosterone Capsule           1
Kaletra Tablet                           2   Testosterone Gel                     1
Lamivudine-Zidovudine                    1   Testosterone Cypionate Injection     1
Lopinavir-Ritonavir Oral Solution        1   Miscellaneous
Nevirapine                               1   Anastrozole Tablet                   1
Norvir                                   2   Aranesp                              2
Odefsey                                  2   Benzonatate Capsule                  1
Prezista                                 2   Chlorhexidine Gluconate              1
Symfi                                    2   Chlorpheniramine/Hydrocodone/
                                                                                  1
Symflo                                   2   Pseudoephedrine Solution
Tivicay                                  2   Epinephrine soln auto-injector       1
Truvada                                  2   Fuphila (PA)                         2
Viex                                     2   Granix (PA)                          2
Viread                                   2   Hydrocodone/Chlorpheniramine
                                                                                  1
                                             Suspension
Inflammatory Conditions: Rheumatoid          Kalydeco (PA)                        2
Arthritis, Crohn’s Disease, Psoriasis,       Letrozole                            1
Ulcerative Colitis
                                             Neulasta (PA)                        2
                                             Neupogen (PA)                        2
Actemra (PA)                             2
                                             Phenazopyridine                      1
Enbrel (PA)                              2
                                             Procrit (PA)                         2
Cosentyx (PA)                            2
                                             Promethazine/Codeine                 1
Humira (PA)                              2
                                             Promethazine/Dextromethorphan        1
Hydroxychloroquine Sulfate               1
                                             Pulmozyme (PA)                       2
Leflunomide                              1
                                             Sevelamer                            1
Methotrexate Tablet                      1
                                             Zarxio (PA)                          2
Otezla (PA)                              2
                                             Ziextenzo                            2
Rinvoq (PA)                              2
Skyrizi (PA)                             2   Musculoskeletal: Muscle Spasms
Stelara (PA)                             2   Baclofen Tablet                      1
Xeljanxz, Xeljanz XR                     2   Carisoprodol 350 mg Tablet           1
Men’s Health: Prostate                       Cyclobenzaprine                      1
                                             Metaxalone Tablet                    1
Alfuzosin Tablet                         1
                                             Methocarbamol Tablet                 1
Doxazosin Tablet                         1
                                             Tizanidine Tablet                    1
Dutasteride Capsule                      1
Finasteride Tablet                       1   Musculoskeletal: Pain Relief (These drugs
Tamsulosin Capsule                       1   may fall under our Opioid Abuse Potential
                                             Program)
Terazosin Capsule, Tablet                1
                                             Acetaminophen/Codeine Tablet         1

                                                                                         9
Belbuca                            2   Levocetirizine Tablet               1
Celecoxib                          1   Promethazine Tablet                 1
Diclofenac Tablet                  1   Respiratory: Asthma/COPD
Etodolac Capsule                   1
                                       Advair Diskus/HFA                   1
Fentanyl 12, 25, 50, 75, 100 mcg
                                   1   Albuterol HFA, Nebulizer            1
Patch
Fentanyl Citrate Lozenge           1   Anoro Ellipta                       1
Hydrocodone/Acetaminophen              Arnuity Ellipta                     1
                                   1
5/325, 7.5/325, 10/325 mg Tablet       Asmanex TwistHaler, HFA             1
Hydrocodone/Ibuprofen Tablet       1   Breo Ellipta                        1
Hydromorphone Immediate-               Budesonide Nebs                     1
                                   1
Release Tablet                         Combivent Respimat                  2
Indomethacin Capsule               1   Dulera                              1
Ketorolac Tablet                   1   Flovent Diskus/HFA                  1
Meloxicam Tablet                   1   Fluticasone/Salmeterol RespiClick   1
Methadone Tablet, Oral Solution,       Incruse Ellipta                     1
                                   1
Concentrate Solution                   Ipratropium Nebs                    1
Morphine Sulfate Extended-             Ipratropium-Albuterol Nebs          1
                                   1
Release Tablet
                                       Montelukast                         1
Morphine Sulfate Oral Solution     1
                                       QVAR                                1
Nabumetone Tablet                  1
                                       Serevent Diskus                     1
Oxycodone/Acetaminophen 5/325,
                                   1   Spiriva Handihaler/Respimat         1
7.5/325, 10/325 mg Tablet
                                       Stiolto                             1
Oxycodone Tablet                   1
                                       Striverdi Respimat                  1
Tramadol-Acetaminophen             1
                                       Symbicort                           1
Tramadol Immediate-Release
                                   1   Trelegy Ellipta                     1
Tablet
                                       Ventolin HFA                        1
Tramadol Sustained-Release
                                   1
Tablet
                                       Respiratory: Pulmonary Arterial
Trezix                             1   Hypertension
Xtampza ER                         2
                                       Ambrisentan                         1
Overactive Bladder
                                       Opsumit (PA)                        2
Dicyclomine Tablet                 1   Sildenafil Tablet                   1
Oxybutynin Extended-Release            tadalafil Tablet                    1
                                   1
Tablet                                 Uptravi (PA)                        2
Oxybutynin Tablet                  1   Vyndaqel                            2
Solifenacin                        1   Transplant
Respiratory: Allergies                 Azathioprine Tablet                 1
Azelastine 0.1% Nasal Spray        1   Cyclosporine Modified Capsule       1
Cyproheptadine Tablet              1   Mycophenolate Capsule,
                                                                           1
                                       Suspension
Fluticasone Nasal Spray            1
                                       Mycophenolic Acid Tablet            1
Hydroxyzine Capsule, Tablet        1
                                       Sirolimus Tablet                    1
                                                                               10
Tacrolimus Capsule                    1   ethynodiol diacetate & ethinyl
                                                                               1
                                          estradiol
Vitamins/Electrolytes
                                          Falmina                              2
Fluoride                              1
                                          Femynor                              2
Folic Acid                            1
                                          Gianvi                               2
Klor-Con M10                          1
                                          Gildagia                             2
Klor-Con M20                          1
                                          Gildess                              2
Potassium Chloride                    1
                                          Gildess 24 Fe                        2
Potassium Citrate                     1
                                          Gildess Fe                           2
                                          Isibloom                             2
Women’s Health: Contraceptives (Generic
contraceptives may process at $0          Juleber                              2
depending on your plan)                   Junel                                2
                                          Junel Fe                             2
Altavera                              2
                                          Junel Fe 24                          2
Alyacen                               2
                                          Kaitlib Fe                           2
Apri                                  2
                                          Kariva                               2
Aranelle                              2
                                          Kelnor 1/35, 1/50                    2
Aubra                                 2
                                          Kimidess                             2
Aviane                                2
                                          Kurvelo                              2
Azurette                              2
                                          Larin                                2
Balziva                               2
                                          Larin 24 Fe                          2
Bekyree                               2
                                          Larin Fe                             2
Blisovi 24 Fe                         2
                                          Larissia                             2
Blisovi Fe                            2
                                          Layolis Fe                           2
Briellyn                              2
                                          Leena                                2
Caziant                               2
                                          Lessina                              2
Chateal                               2
                                          Levonest                             2
Cryselle                              2
                                          levonorgestrel & ethinyl estradiol   1
Cyclafem                              2
                                          levonorgestrel-eth estra tab 0.05-
Cyred                                 2                                        1
                                          30/
Dasetta                               2   Levora                               2
Delyla                                2   Lillow                               2
desogest-eth estrad & eth estrad          Lomedia 24 Fe                        2
                                      1
tab
                                          Loryna                               2
desogestrel & ethinyl estradiol tab   1
                                          Low-Ogestrel                         2
drospirenone-ethinyl estradiol        1
                                          Lutera                               2
drospirenone-ethinyl
                                      1   Marlissa                             2
estradlevomefolate
                                          Melodetta 24 Fe                      2
Elinest                               2
                                          Mibelas 24 Fe                        2
Emoquette                             2
                                          Microgestin                          2
Enpresse                              2
                                          Microgestin 24 Fe                    2
Enskyce                               2
                                          Microgestin Fe                       2
Estarylla                             2
                                                                                   11
Mili                                   2   Tri-Vylibra                          2
Mono-Linyah                            2   Tydemy                               2
Mononessa                              2   Velivet                              2
Myzilra                                2   Vestura                              2
Necon 0.5/35, 1/35, 7/7/7              2   Vienva                               2
Nikki                                  2   Viorele                              2
norethindrone & ethinyl estradiol      1   Vyfemla                              2
norethindrone & ethinyl estradiol +        Vylibra                              2
                                       1
fe                                         Wera                                 2
norethindrone ace & ethinyl                Wymzya Fe                            2
                                       1
estradiol
                                           Zarah                                2
norethindrone ac-ethinyl estradfe      1
                                           Zenchent                             2
norethindrone-eth estradiol            1
                                           Zenchent Fe                          2
norgestimate & ethinyl estradiol tab   1
                                           Zovia                                2
Nortrel                                2
Ocella                                 2   Women’s Health: Hormone Replacement
Orsythia                               2
                                           Combipatch                           2
Philith                                2
                                           Divigel                              2
Pimtrea                                2
                                           Duavee                               2
Pirmella                               2
                                           Estradiol Patch                      1
Portia                                 2
                                           Estradiol Tablet                     1
Previfem                               2
                                           Estring                              2
Rajani                                 2
Reclipsen                              2   Estrogen/Methyltestosterone Tablet   1
Sprintec                               2   Medroxyprogesterone                  1
Sronyx                                 2   Premarin                             2
Syeda                                  2   Premphase                            2
Tarina Fe                              2   Prempro                              2
Tilia Fe                               2
Tri Femynor                            2   Progesterone Micronized Capsule      1
Tri-Estarylla                          2   Vivelle-Dot                          1
Tri-Legest Fe                          2
                                           Women's Health: Other
Tri-Linyah                             2
Tri-Lo-Estarylla                       2   Alendronate Sodium Tablet            1
Tri-Lo-Marzia                          2   Ibandronate Tablet                   1
Tri-Lo-Sprintec                        2   nitisinone                           1
Tri-Mili                               2   Nityr (PA)                           2
Trinessa                               2   Raloxifene Tablet                    1
Trinessa Lo                            2   Risedronate Sodium Tablet            1
Tri-Previfem                           2   Strensiq (PA)                        2
Tri-Sprintec                           2   Tymlos (PA)                          2
Trivora                                2

                                                                                    12
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