Prescription Drug List - Your 2015

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Prescription Drug List - Your 2015
Your 2015
                           Prescription Drug List
                           Effective July 1, 2015
                           Oxford New York and New Jersey Advantage Three-Tier
                           Please read: This document contains information about commonly prescribed medications.

                           For additional information:
                                      Call us at the toll-free phone number on your health plan ID card. TTY users
                                      can dial 711. Si usted necesita ayuda en español llame al número de teléfono
                                      en su tarjeta de identificación,                      1-800-303-6719,
                                                                1-888-201-4746, or the phone number on your ID card
                                      for help in English and other languages.

                                      Visit oxfordhealth.com, click the Pharmacies & Prescriptions tab and
                                      then “Online Pharmacy” to log in to the OptumRx1 website and:
                                      • Locate a participating retail pharmacy by ZIP code.
                                      • Look up possible lower-cost medication alternatives.
                                      • Compare medication pricing and options.

OptumRx Pharmacy is the administrator of your Oxford pharmacy benefit plan.
1

                                                                              1
Prescription Drug List - Your 2015
Your Prescription Drug List
This Prescription Drug List (PDL) outlines the most commonly prescribed medications for certain
conditions and organizes them into cost levels, also known as tiers. An important part of the PDL is
giving you choices so you and your doctor can choose the best course of treatment for you.

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

                                                   2
Table of Contents
Commonly asked questions                                                                                                            Gastrointestinal
about the PDL . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 5                                Acid Suppression. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 18
Programs and Limits . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 7                                               Nausea/Vomiting.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 18
                                                                                                                                    Other.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 18
Drugs by category .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 10
                                                                                                                                    Hepatitis C.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 18
Anti-Infectives
Antibiotics.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 10                  HIV/AIDS.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 19
Antifungals .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 10                    Infertility .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 19
Antivirals .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 10               Inflammatory Conditions: Rheumatoid
Cancer. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 10               Arthritis, Crohn’s Disease, Psoriasis,
                                                                                                                                    Ulcerative Colitis.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 19
Cardiovascular/Heart Disease
Coagulation Therapy .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .                                 11       Men’s Health
High Blood Pressure.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .                                  11       Erectile Dysfunction.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 19
High Cholesterol.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .                         12       Prostate.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 19
Other.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .   12       Testosterone Therapy .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 20

Central Nervous System                                                                                                              Miscellaneous.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 20
Attention Deficit Disorder.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .                                       12       Musculoskeletal
Depression .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .               13       Osteoporosis. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 20
Migraine.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .         13       Other.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 21
Multiple Sclerosis. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .                        13       Pain Relief.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 21
Other.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .   14       Overactive Bladder.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 21
Sedatives/Hypnotics.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .                                  14
                                                                                                                                    Respiratory
Seizure Disorders .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .                          14
                                                                                                                                    Allergies.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 22
Dermatology.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 15                              Asthma/COPD. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 22
Diabetes/Endocrine                                                                                                                  Pulmonary Arterial Hypertension. .  .  .  .  .  .  .  .  .  .  .  . 22
Blood Glucose Monitoring.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 16                                                  Transplant.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 23
Insulin .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 16
                                                                                                                                    Vitamins/Electrolytes.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 23
Non-Insulin .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 17
                                                                                                                                    Women’s Health
Endocrine
                                                                                                                                    Contraceptives.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 23
Growth Hormone. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 17
                                                                                                                                    Hormone Replacement.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 24
Other.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 17
                                                                                                                                    Prenatal Vitamins .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 24
Thyroid Hormone Replacement.  .  .  .  .  .  .  .  .  .  .  .  .  . 17
                                                                                                                                    Index .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 25
Eye Conditions
Allergies.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 17
Antibiotics.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 17
Glaucoma. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 18

                                                                                                                                3
4
We want to help you better understand your medication
options.
Your pharmacy benefit offers flexibility and choice in determining the right medication
for you. To help you get the most out of your pharmacy benefit, we’ve included some of
the most commonly asked questions about the Prescription Drug List (PDL).

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

How do I use my PDL?
When choosing a medication, you and your doctor should consult the PDL. It will help you and your
doctor choose the most cost-effective prescription drugs. This guide tells you if a medication is a generic
or brand name and if special programs apply. Bring this guide with you when you see your doctor. It is
organized by common medical conditions. Medications are then listed alphabetically.
If your medication is not listed in this guide, please visit oxfordhealth.com or call us at the
toll-free phone number on your health plan ID card. TTY users can dial 711. Si usted necesita ayuda en
español llame al número de teléfono en su tarjeta de identificación,                        1-800-303-6719,
                        1-888-201-4746, or the phone number on your ID card for help in English and
other languages.

                                                     5
What are tiers?
Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, which is
determined by your employer or health plan. This is how much you will pay when you fill a prescription.
Tier 1 medications are your lowest-cost options. If your medication is placed in Tier 2 or 3, look to see if
there is a Tier 1 option available. Discuss these options with your doctor.
Check your benefit plan documents for your specific pharmacy plan costs.

      $       Drug Tier               Includes                        Helpful Tips
              Tier 1                  Lower-cost drugs.               Use Tier 1 drugs for the lowest
              Lowest Cost             Some brand names and            out‑of-pocket costs.
                                      generics are also included.

              Tier 2                  Mix of brand name               Use Tier 2 drugs, instead of
              Mid-range Cost          and generics.                   Tier 3, to help reduce your
                                                                      out-of-pocket costs.

              Tier 3                  Mostly higher-cost brand        Many Tier 3 drugs have
              Highest Cost            names as well as select         lower‑cost options in Tier 1 or 2.
                                      generic drugs.                  Ask your doctor if they could
                                                                      work for you.

Please note: Some plans may have two or four tiers, while others may not have any. If you have a high
deductible plan, the tier cost levels may apply once you hit your deductible. Refer to your enrollment and
plan materials on oxfordhealth.com, or call us at the toll-free phone number on your health plan ID
card for more information about your benefit plan.

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 on
    January 1 or July 1.
When a medication changes tiers, you may have to pay a different amount for that medication.
For the most up-to-date list, call us at the toll-free phone number on your health plan ID card.

                                                     6
Programs and Limits
Some medications are noted with letters next to them. The letters refer to our pharmacy benefit
programs. Your benefit plan determines how these medications are covered and may differ from what
is noted in the PDL. Call us at the toll-free phone number on your health plan ID card if you have any
questions about your prescription drug coverage.

                   Designated Specialty Program – Specialty medications need to be filled at a
       DSP         designated specialty pharmacy for in-network coverage. Call us at the toll-free phone
                   number on your health plan ID card or call 1-888-739-5820 for more information.

                   May be excluded from coverage or subject to prior authorization and/or trial/
         E
                   failure of another medication(s). Lower-cost options are available and covered.

                   Multiple Copayment – More than one month’s worth of medication included in
       MC
                   package so additional copayment applies.

                   Notification or Precertification (sometimes referred to as preauthorization)
         N         required2 – Your doctor is required to provide additional information to us to
                   determine coverage.

                   Refill and Save Program – Save money on your copayment when you refill your
        RS
                   prescription on time as prescribed. Program eligibility may vary.

                   Select Designated Pharmacy – Must use a lower cost medication at retail or
       SDP         transfer the impacted medication to the mail service pharmacy for in-network
                   coverage.

                   Supply Limit – Amount of medication covered per copayment or in a specific
        SL
                   time period.

                   Step Therapy 3 – Trial of a lower-cost medication is required before a higher-cost
        ST
                   medication is covered.
2
    Depending on your benefit, you may have notification or precertification requirements for select medications.
3
    For New Jersey members, this program is referred to as First Start.

To learn more about a pharmacy program or to find out if it applies to you, please visit
oxfordhealth.com or call us at the toll-free phone number on your health plan ID card. TTY users can
dial 711. Si usted necesita ayuda en español llame al número de teléfono en su tarjeta de identificación,
                         1-800-303-6719,                          1-888-201-4746, or the phone number on
your ID card for help in English and other languages.

                                                               7
Why are some medications excluded from coverage?
A medication may be excluded from coverage under your pharmacy benefit when it works the same or
similar as another prescription medication or an over-the-counter (OTC) medication.4 There may be
other medication options available.

Should I talk to my doctor about over-the-counter (OTC)
medications?
An over-the-counter (OTC) medication may be the right treatment for some conditions. Talk to your
doctor about available OTC options.

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

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

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

Are you taking a specialty medication?
Specialty medications are high-cost and may be used to treat rare or complex conditions. For most
plans, these medications are managed through the Specialty Pharmacy Program.5 Take advantage
of personalized support designed to help you get the most out of your treatment plan. Visit
UHCSpecialtyRx.com or call the toll-free phone number on your health plan ID card to learn more.
Please note, not all specialty medications are listed here. If you’re taking a specialty medication that is on
Tier 3, call us at the toll-free phone number on your health plan ID card to talk with a pharmacist about
finding lower-cost options or a financial assistance program.

4
    This is not applicable for plans written in New Jersey. For New York plans, a prescription drug product that is therapeutically equivalent to an over-the counter drug may be covered
    if it is determined to be medically necessary.
5
    Not all plans require use of the specialty network. Please refer to your Prescription Drug List Rider to determine if the specialty network is required as part of your plan.

                                                                                               8
What is Mail Service Member Select?
Your plan may include a home delivery program called Mail Service Member Select, which encourages you
to use the OptumRx® Mail Service Pharmacy for medication you take regularly. Choosing home delivery
can help you better manage the medication you take on a regular basis, and may save you time and money.
You can either confirm enrollment in the OptumRx Mail Service Pharmacy or you can disenroll from
mail service and continue to fill your maintenance medications at a retail pharmacy. You can get up to
two fills at a retail pharmacy before you have to decide. However, please be aware that you must make a
decision about whether or not to enroll in Mail Service Member Select.
If you do nothing and continue to fill your medications at a retail pharmacy, you may pay up to
100 percent of your drug cost until you make a decision and take action. You must confirm your decision
every year. To learn more, you may log on to oxfordhealth.com or call us at the toll-free phone number
on your health plan ID card for more information.

How do I get updated information about my pharmacy benefit?
Since the PDL may change during your plan year, we encourage you to visit oxfordhealth.com or call us
at the toll-free phone number on your health plan ID card for more current information.

      For more information
                   Call us at the toll-free phone number on your health plan ID card. TTY users
                   can dial 711. Si usted necesita ayuda en español llame al número de teléfono
                   en su tarjeta de identificación,                      1-800-303-6719,
                                             1-888-201-4746, or the phone number on your ID card for
                   help in English and other languages.

                   Or, visit oxfordhealth.com

In certain documents, the Prescription Drug List (PDL) was referred to as the “Preferred Drug List (PDL).” This change in terms does not affect your benefit coverage.
Medications are categorized by common therapeutic conditions in this PDL for ease of reference only. These categories do not determine coverage for the medication for your condition.
Your health plan determines coverage for these medications.

                                                                                           9
Drug Requirements                                Drug Requirements
Drug Name                                         Drug Name
                         Tier & Limits                                    Tier & Limits
                                                  Sulfamethoxazole-
Anti-Infectives: Antibiotics                                               1
                                                  Trimethoprim Tablet
Amoxicillin Capsule,                              Suprax Capsule,
                          1                                                3
Chewable Tablet                                   Suspension, Tablet
Amoxicillin/Potassium
                                                  Anti-Infectives: Antifungals
Clavulanate Chewable      1
Tablet, Tablet                                    Econazole Cream          1
Azithromycin Tablet       1                       Fluconazole Tablet       1
Cefadroxil Capsule,                               Itraconazole Capsule     1          SL
                          1
Tablet                                            Ketoconazole Cream       1
Cefdinir Capsule          2                       Nystatin Cream,
                                                                           1
Cefprozil Tablet          1                       Ointment
Cefuroxime Tablet         1                       Terbinafine Tablet       1          SL
Cephalexin Capsule        1
                                                  Anti-Infectives: Antivirals
Ciprofloxacin Tablet      1
Clarithromycin Tablet     1                       Acyclovir Ointment       3       N, SL, ST
Clindamycin Capsule       1                       Acyclovir Tablet         1
Dificid                   3          SL           Famciclovir Tablet       1
Doryx                     3          E            Tamiflu                  3          SL
Doxycycline Hyclate                               Valacyclovir Tablet      2          SL
                          2
Capsule, Tablet                                   Zovirax Cream            3         E, SL
Doxycycline
Monohydrate               1                       Cancer
50, 100 mg Capsule                                Bicalutamide             1
Levofloxacin Tablet       1                       Bosulif                  2     DSP, N, SL, ST
Metronidazole Tablet      1                       Capecitabine Tablet      1       DSP, SL
Minocycline Capsule       1                       Cyclophosphamide
Minocycline Tablet        3                                                3
                                                  Capsule
Moxifloxacin Tablet       3                       Gleevec                  2      DSP, N, SL
Nitrofurantoin Capsule    1                       Hydroxyurea Capsule      1
Nitrofurantoin                                    Imbruvica                2      DSP, N, SL
                          1
Macrocrystal Capsule                              Leucovorin Calcium
Ofloxacin Tablet          1                                                1
                                                  Tablet
Oracea                    3                       Mercaptopurine Tablet    1
Penicillin V Potassium                            Revlimid                 2      DSP, N, SL
                          1
Tablet                                            Sutent                   2      DSP, N, SL
Solodyn                   3                       Tasigna                  2      DSP, N, SL
                                                  Zytiga                   2      DSP, N, SL

Bold type = Brand-name drug               N = Notification or precertification (sometimes
[Plain type = Generic drug]               referred to as preauthorization) required
                                          RS = May be eligible for the Refill and Save Program
DSP = Designated Specialty Program        SDP = Select Designated Pharmacy
E = May be excluded from coverage         SL = Supply Limit
MC = Multiple Copayment                   ST = Step Therapy
                                             10
Drug Requirements                                Drug Requirements
Drug Name                                     Drug Name
                     Tier & Limits                                    Tier & Limits
Cardiovascular/Heart Disease:                 Edarbi                   3        SL
Coagulation Therapy                           Edarbyclor               3        SL
Clopidogrel             1                     Enalapril                1
Effient                 3        SL           Furosemide               1
Eliquis                 3        SL           Guanfacine               1
Enoxaparin Sodium       2        SL           Hydralazine              1
Pradaxa                 2        SL           Hydrochlorothiazide      1
Warfarin Sodium         1                     Irbesartan               1        SL
Xarelto                 2        SL           Labetalol                1
Cardiovascular/Heart Disease:                 Lisinopril               1
High Blood Pressure                           Lisinopril-
                                                                       1
Amlodipine              1                     Hydrochlorothiazide
Amlodipine                                    Losartan                 1
                        2        SL
Besylate-Benazepril                           Losartan-
                                                                       1
Amlodipine-Valsartan    3       E, SL         Hydrochlorothiazide
Atenolol                1                     Metoprolol Succinate
                                                                       2
Atenolol-Chlorthalidone 1                     50, 100, 200 mg
Azor                    3       E, SL         Metoprolol Tartrate      1
Benazepril              1                     Nadolol                  1
Benazepril-                                   Nifedipine
                        1                                              1
Hydrochlorothiazide                           Extended-Release
Benicar                 2        SL           Propranolol Extended-
                                                                       2
Benicar HCT             2        SL           Release Capsule
Bidil                   2                     Propranolol Tablet       1
Bisoprolol              1                     Quinapril                1
Bisoprolol-                                   Ramipril                 1
                        1
Hydrochlorothiazide                           Spironolactone           1
Bystolic                2                     Telmisartan              2        SL
Cartia XT               2                     Telmisartan-
                                                                       2        SL
Carvedilol              1                     Hydrochlorothiazide
Chlorthalidone          1                     Terazosin                1
Clonidine Tablet        1                     Triamterene-
                                                                       1
Diltiazem 24 Hour CD    2                     Hydrochlorothiazide
Diltiazem Sustained-                          Valsartan                2        SL
                        2                     Valsartan-
Release Capsule                                                        1        SL
Diltiazem Sustained-                          Hydrochlorothiazide
                        2                     Verapamil                1
Release Tablet
Diovan                  3       E, SL         Verapamil
                                                                       3
Doxazosin               1                     Sustained-Release
Dutoprol                2        SL

                                         11
Drug Requirements                                   Drug Requirements
Drug Name                                          Drug Name
                       Tier & Limits                                       Tier & Limits
Cardiovascular/Heart Disease:                      Cardiovascular/Heart Disease:
High Cholesterol                                   Other
Atorvastatin             1            SL           Amiodarone              1
Choline Fenofibrate      3            E            Digoxin                 1
Crestor                  2            SL           Flecainide              1
Fenofibrate 43, 50 , 67,                           Isosorbide
                                                                           1
130, 134, 150, 200 mg    3            E            Mononitrate ER
Capsule                                            Nitrostat               2
Fenofibrate                                        Ranexa                  2
                         3            E
48, 145 mg Tablet                                  Sotalol                 1
Fenofibrate                                        Central Nervous System:
                         2
54, 160 mg Tablet                                  Attention Deficit Disorder
Fenoglide                3            E            Adderall XR             2          N, SL
Gemfibrozil              1                         Amphetamine Salt
                                                                           1            N
Lipitor                  3           E, SL         Combo
Lipofen                  3             E           Concerta                2          N, SL
Livalo                   3            SL           Daytrana                3         E, N, SL
Lovastatin               1                         Dexmethylphenidate
Niacin Extended-                                   Extended-Release        3         E, N, SL
                         3
Release Tablet                                     Capsule
Niaspan                  2                         Dexmethylphenidate
                                                                           1            N
Omega-3-Acid Ethyl                                 Tablet
                         3            N
Esters Capsule                                     Dextroamphetamine-
Pravastatin              1                         Amphetamine             3         E, N, SL
Simcor                   3            SL           Extended-Release
Simvastatin              1                         Dextroamphetamine-
                                                                           1            N
Tricor 48, 145 mg        3            E            Amphetamine Tablet
Trilipix                 3            E            Dextroamphetamine
                                                                           3            N
Vascepa                  3            N            Sulfate Tablet
Vytorin                  3            SL           Focalin XR              3         E, N, SL
Welchol                  2                         Guanfacine
                                                                           3          E, SL
Zetia                    3            SL           Extended-Release

Bold type = Brand-name drug                  N = Notification or precertification (sometimes
[Plain type = Generic drug]                  referred to as preauthorization) required
                                             RS = May be eligible for the Refill and Save Program
DSP = Designated Specialty Program           SDP = Select Designated Pharmacy
E = May be excluded from coverage            SL = Supply Limit
MC = Multiple Copayment                      ST = Step Therapy
                                              12
Drug Requirements                                Drug Requirements
Drug Name                                        Drug Name
                        Tier & Limits                                    Tier & Limits
Intuniv                  3      E, SL            Sertraline Tablet        1
Metadate CD              2      N, SL            Trazodone Tablet         1
Methylphenidate          1        N              Venlafaxine Extended-
                                                                          1
Methylphenidate                                  Release Capsule
Extended-Release         3     E, N, SL          Venlafaxine Tablet       1
Capsule                                          Viibryd                  3        SL
Methylphenidate                                  Wellbutrin XL            3        E
Extended-Release         3     E, N, SL
                                                 Central Nervous System: Migraine
Tablet
Strattera                3       SL              Acetaminophen/
Vyvanse                  2      N, SL            Butalbital/Caffeine     1         SL
                                                 325 mg/50 mg/40mg
Central Nervous System: Depression
                                                 Naratriptan             1         SL
Amitriptyline Tablet     1                       Relpax                  2         SL
Brintellix               3      SL, ST           Rizatriptan Tablet      2         SL
Bupropion Extended-                              Sumatriptan Nasal Spray 2         SL
                         1
Release Tablet                                   Sumatriptan
Bupropion Sustained-                             Succinate Tablet,       1         SL
                         1
Release Tablet                                   Injection
Bupropion Tablet         1                       Sumavel DosePro         3         SL
Citalopram Tablet        1                       Central Nervous System:
Cymbalta                 3       E, SL           Multiple Sclerosis
Doxepin                  1                       Ampyra                  2     DSP, N, SL
Duloxetine Capsule       3        SL             Aubagio                 3    DSP, N, SL, ST
Escitalopram Tablet      1                       Avonex                  2     DSP, N, SL
Fetzima                  3      SL, ST           Betaseron               2     DSP, N, SL
Fluoxetine Tablet,                               Copaxone                2     DSP, N, SL
                         1
Capsule                                                                         DSP, E, N,
                                                 Extavia                  3
Fluvoxamine Tablet       1                                                       SL, ST
Lexapro                  3        E              Gilenya                  3   DSP, N, SL, ST
Mirtazapine Tablet       1                       Rebif                    3   DSP, N, SL, ST
Nortriptyline Capsule    1                       Tecfidera                2    DSP, N, SL
Paroxetine Tablet        1
Pristiq ER               3      RS, SL

                                            13
Drug Requirements                                   Drug Requirements
Drug Name                                          Drug Name
                       Tier & Limits                                       Tier & Limits
                                                   Central Nervous System:
Central Nervous System: Other
                                                   Sedatives/Hypnotics
Abilify                  3            SL           Eszopiclone Tablet    3             SL
Alprazolam Extended-                               Lunesta               3            E, SL
                         1
Release Tablet                                     Temazepam Capsule     1
Alprazolam Tablet        1                         Triazolam Tablet      1
Buprenorphine/                                     Zaleplon Capsule      1             SL
                         3      E, N, SL
Naloxone Tablet                                    Zolpidem Extended-
                                                                         3            E, SL
Buspirone Tablet         1                         Release Tablet
Carbidopa-Levodopa       1                         Zolpidem Tablet       1             SL
Diazepam Tablet          1                         Central Nervous System:
Donepezil 5, 10 mg                                 Seizure Disorders
                         1
ODT, Tablet                                        Carbamazepine Tablet  1
Latuda                   3            SL           Clonazepam Tablet     1
Lithium Capsule          1                         Diazepam Tablet       1
Lorazepam Tablet         1                         Divalproex Delayed-
                                                                         1
Modafinil Tablet         3      E, N, SL           Release Tablet
Namenda XR               3                         Divalproex Extended-
                                                                         1
Nuvigil                  3           N, SL         Release Tablet
Olanzapine Tablet        1            SL           Gabapentin Capsule,
                                                                         1
Pramipexole Tablet       1                         Tablet
Quetiapine Tablet        1            SL           Lamotrigine Tablet    1
Risperidone Tablet       1                         Levetiracetam
Ropinirole Tablet        1                         Extended-Release      2
Seroquel XR              3         SL              Tablet
Suboxone Film            3      E, N, SL           Levetiracetam Tablet  1
Tasmar                   2                         Lyrica                3         SDP, SL, ST
Xyrem                    3           N, SL         Oxcarbazepine Tablet  1
Zelapar                  3                         Phenytoin Capsule,
                                                                         1
Ziprasidone Capsule      2            SL           Suspension
Zubsolv                  2           N, SL         Topiramate Tablet     1
                                                   Zonisamide Capsule    1

Bold type = Brand-name drug                  N = Notification or precertification (sometimes
[Plain type = Generic drug]                  referred to as preauthorization) required
                                             RS = May be eligible for the Refill and Save Program
DSP = Designated Specialty Program           SDP = Select Designated Pharmacy
E = May be excluded from coverage            SL = Supply Limit
MC = Multiple Copayment                      ST = Step Therapy
                                              14
Drug Requirements                                   Drug Requirements
Drug Name                                          Drug Name
                          Tier & Limits                                       Tier & Limits
                                                   Desoximetasone Gel,
Dermatology                                                                    3        SL
                                                   Ointment
Absorica                   3       E, N            Differin 1%                 2      N, SL
Aczone                     3       SL              Diflorasone Diacetate
                                                                               3        SL
Adapalene 0.1%                                     0.05% Cream, Ointment
                           3      N, SL
Cream, Gel                                         Epiduo                      3        SL
Adapalene 0.3% Gel         3      N, SL            Finacea                     3
Betamethasone                                      Fluocinolone Cream, Oil,
                                                                               3        SL
Diproionate 0.05%                                  Ointment, Solution
                           3
Augmented Lotion,                                  Fluocinonide 0.05%
                                                                               1
Ointment                                           Cream
Betamethasone                                      Hydrocortisone 2.5%
                                                                               1
Dipropionate 0.05%         2                       Cream, Ointment
Cream, Ointment                                    Imiquimod 5% Cream          2        SL
Carac                      2                       Metronidazole Gel 0.75%     1
Ciclopirox Cream, Gel,                             Mirvaso                     3        SL
                           1
Lotion, Solution                                   Mometasone Furoate
                                                                               1
Claravis                   2        N              Cream, Lotion, Ointment
Clindamycin 1%/                                    Mupirocin Ointment          1
                           3       E, SL
Benzoyl Peroxide 5% Gel                            Nystatin-Triamcinolone
Clindamycin 1.2%/                                  Acetonide Cream,            3        E
                           3        SL
Benzoyl Peroxide 5% Gel                            Ointment
Clindamycin Gel            3        SL             Oxsoralen-Ul                2
Clindamycin Lotion         3                       Picato                      3       SL
Clindamycin Solution,                              Regranex                    2      N, SL
                           1
Swabs                                              Sodium
                                                                               1
Clobetasol Propionate                              Sulfacetamide-Sulfur
Cream, Ointment,           1                       Tacrolimus Ointment         2      N, SL
Solution                                           Tazorac                     3        SL
Clotrimazole-                                      Tretinoin                   1      N, SL
                           1        SL
Betamethasone Cream                                Tretinoin Microspheres      3     E, N, SL
Clotrimazole-                                      Triamcinolone Acetonide
                           1                                                   1
Betamethasone Lotion                               Cream, Lotion, Ointment
Condylox Gel               3                       Vectical                    3        SL
Desonide 0.05% Cream,
                           3        SL
Lotion, Ointment

                                              15
Drug Requirements                                                           Drug Requirements
Drug Name                                                                   Drug Name
                                     Tier & Limits                                                               Tier & Limits

Diabetes: Blood Glucose Monitoring*                                         Diabetes: Insulin*
Accu-Chek Active                                                            Humalog KwikPen                        2               SL
                                       1               SL
Test Strips                                                                 Humalog Mix 50-50
                                                                                                                   2               SL
Accu-Chek Aviva                                                             KwikPen
                                       1
Plus                                                                        Humalog Mix 75-25
                                                                                                                   2               SL
Accu-Chek Aviva                                                             KwikPen
                                       1               SL
Plus Test Strips                                                            Humalog Vials                          1               SL
Accu-Chek Comfort                                                           Humulin 70-30
                                       1               SL                                                          2               SL
Curve Test Strips                                                           KwikPen
Accu-Chek Compact                                                           Humulin 70-30 Vials                    1             SL
                                       1               SL
Test Strips                                                                 Humulin N KwikPen                      2             SL
Accu-Chek Nano                                                              Humulin N Vials                        1             SL
                                       1
SmartView                                                                   Humulin R Vials                        1             SL
Accu-Chek Nano                                                              Lantus Solostar                        3             SL
SmartView                              1               SL                   Lantus Vials                           3             SL
Test Strips                                                                 Levemir FlexTouch                      1             SL
Contour Test Strips                    3             N, SL                  Levemir Vials                          1             SL
Freestyle Test Strips                  3             N, SL                  Novolin 70-30 Vials                    3          N, SL, ST
One Touch                                                                   Novolin N Vials                        3          N, SL, ST
                                       1               SL
Test Strips                                                                 Novolin R Vials                        3          N, SL, ST
One Touch Ultra                                                             Novolog Flexpen                        3          N, SL, ST
                                       1
Meter                                                                       Novolog Mix
One Touch Ultra Mini                   1                                                                           3          N, SL, ST
                                                                            70/30 Flexpen
One Touch Ultra                                                             Novolog Mix
                                       1               SL                                                          3          N, SL, ST
Test Strips                                                                 70/30 Vials
One Touch Verio                        1                                    Novolog Vials                          3          N, SL, ST
One Touch Verio IQ                     1                                    *Note: Diabetic supplies and prescription medications may be subject
                                                                             to different cost share arrangements. Please see your Summary of
One Touch Verio IQ                                                           Benefits and Coverage (SBC) for specifics.
                                       1               SL
Test Strips
One Touch Verio
                                       1
Sync
*Note: Diabetic supplies and prescription medications may be subject
 to different cost share arrangements. Please see your Summary of
 Benefits and Coverage (SBC) for specifics.

Bold type = Brand-name drug                                       N = Notification or precertification (sometimes
[Plain type = Generic drug]                                       referred to as preauthorization) required
                                                                  RS = May be eligible for the Refill and Save Program
DSP = Designated Specialty Program                                SDP = Select Designated Pharmacy
E = May be excluded from coverage                                 SL = Supply Limit
MC = Multiple Copayment                                           ST = Step Therapy
                                                                       16
Drug Requirements                                              Drug Requirements
Drug Name                                                                   Drug Name
                                     Tier & Limits                                                  Tier & Limits

Diabetes: Non-Insulin*                                                      Endocrine: Other
Bydureon                               2             SL                     Calcitriol Capsule    1
Byetta                                 2             SL                     Desmopressin Tablet   1
Farxiga                                3          N, SL, ST                 Dexamethasone Tablet  1
Glimepiride                            1                                    Methylprednisolone
                                                                                                  1
Glipizide                              1                                    Tablet
Glipizide                                                                   Prenisolone Oral
                                       1                                                          1
Extended-Release                                                            Solution
Glyburide                              1                                    Prednisone Tablet     1
Invokamet                              2             SL                     Endocrine:
Invokana                               2          N, SL, ST                 Thyroid Hormone Replacement
Janumet                                3          N, SL, ST                 Armour Thyroid        3
Januvia                                3          N, SL, ST                 Levothyroxine Sodium
                                                                                                  1
Jardiance                              2          N, SL, ST                 Tablet
Jentadueto                             2             SL                     Liothyronine Sodium
                                                                                                  2
Kazano                                 2             SL                     Tablet
Kombiglyze XR                          2             SL                     Methimazole Tablet    1
Metformin                              1                                    NP Thyroid Tablet     1
Metformin Extended-                                                         Synthroid             2
                                       1
Release Tablet                                                              Tirosint              2
Nesina                                 2             SL
                                                                            Eye Conditions: Allergies
Onglyza                                2             SL
Oseni                                  2             SL                     Azelastine 0.05%
                                                                                                     2        SL
Pioglitazone                           1             SL                     Ophthalmic Solution
Tanzeum                                2             SL                     Lastacaft                3        SL
Tradjenta                              2             SL                     Patanol                  3       E, SL
Trulicity                              3          N, SL, ST
                                                                            Eye Conditions: Antibiotics
Victoza 2-Pak                          2             SL
Victoza 3-Pak                          3             SL                     Erythromycin 0.5%
                                                                                                     1
*Note: Diabetic supplies and prescription medications may be subject        Ophthalmic Ointment
 to different cost share arrangements. Please see your Summary of
 Benefits and Coverage (SBC) for specifics.                                 Gentamicin Ophthalmic
                                                                                                     1
                                                                            Ointment, Solution
Endocrine: Growth Hormone                                                   Moxeza                   3
Genotropin                             3       DSP, E, N, SL                Ofloxacin 0.3%
                                                                                                     1
Humatrope                              3       DSP, E, N, SL                Ophthalmic Solution
Norditropin                            3       DSP, E, N, SL                Tobramycin/
Nutropin,                                                                   Dexamethasone
                                       2         DSP, N, SL                                          2
Nutropin AQ                                                                 0.3%-0.1% Ophthalmic
Omnitrope                              3       DSP, E, N, SL                Suspension
Saizen                                 3       DSP, E, N, SL                Tobramycin Ophthalmic
                                                                                                     1
Tev-Tropin                             3       DSP, E, N, SL                Solution
                                                                            Vigamox                  3

                                                                       17
Drug Requirements                                  Drug Requirements
Drug Name                                          Drug Name
                         Tier & Limits                                      Tier & Limits

Eye Conditions: Glaucoma                           Gastrointestinal: Other
Alphagan P 0.1%           2           SL           Amitiza                   3      N, SL, ST
Azopt                     2           SL           Apriso                    2
Combigan                  2           SL           Asacol HD Tablet          3          E
Latanoprost 0.005%                                 Canasa                    2
                          1
Ophthalmic Solution                                Cortifoam                 2
Lumigan                   2           SL           Creon                     2
Timolol Maleate 0.25%,                             Delzicol                  3          E
0.5% Ophthalmic           1                        Diphenoxylate-Atropine
                                                                             1
Solution                                           Tablet
Travatan Z                2           SL           Golytely                  2
                                                   Hyoscyamine Tablet        1
Gastrointestinal: Acid Suppression
                                                   Lialda                    2
Dexilant                  3           SL           Linzess                   2        N, SL
Esomeprazole Capsule      3          E, SL         Metoclopramide Tablet     1
Lansoprazole Capsules     3          E, SL         Moviprep                  3
Nexium Capsule            3          E, SL         Polyethylene
                                                                             2
Omeclamox-Pak             3           SL           Glycol 3350
Omeprazole Capsule        1                        Prepopik                  3
Pantoprazole Tablet       1                        Suclear                   3
Pylera                    3           SL           Sulfasalazine Tablet      1
Ranitadine Syrup          1                        Suprep                    3
Rabeprazole Tablet        3           SL           Uceris                    3
Sucralfate Tablet         1                        Zenpep                    2
Gastrointestinal: Nausea/Vomiting                  Hepatitis C
Ondansetron               1                        Harvoni                   2     DSP, N, SL
Ondansetron ODT           1                        Olysio                    3    DSP, N, SL, ST
Transderm-Scop            3                        Ribapak                   3       DSP, E
                                                   Ribavirin Tablet          1         DSP
                                                   Sovaldi                   2    DSP, N, SL, ST
                                                   Viekira Pak               3    DSP, N, SL, ST

Bold type = Brand-name drug                  N = Notification or precertification (sometimes
[Plain type = Generic drug]                  referred to as preauthorization) required
                                             RS = May be eligible for the Refill and Save Program
DSP = Designated Specialty Program           SDP = Select Designated Pharmacy
E = May be excluded from coverage            SL = Supply Limit
MC = Multiple Copayment                      ST = Step Therapy
                                              18
Drug Requirements                                          Drug Requirements
Drug Name                                                              Drug Name
                                        Tier & Limits                                              Tier & Limits
                                                                       Inflammatory Conditions: Rheumatoid
HIV/AIDS
                                                                       Arthritis, Crohn’s Disease, Psoriasis,
Atripla                                    2              DSP          Ulcerative Colitis
Complera                                   2              DSP          Actemra                  3 DSP, N, SL, ST
Epzicom                                    2              DSP          Cimzia                   2     DSP, N, SL
Intelence                                  2              DSP          Enbrel                   3 DSP, N, SL, ST
Isentress                                  2              DSP          Humira                   2     DSP, N, SL
Kaletra                                    2              DSP          Hydroxychloroquine
                                                                                                1
Lamivudine-Zidovudine                      1              DSP          Sulfate
Nevirapine                                 1              DSP          Leflunomide              1
Nevirapine                                                             Methotrexate Tablet      1
                                           1              DSP
Extended-Release                                                       Orencia                  3 DSP, N, SL, ST
Norvir                                     2             DSP           Otezla                   3 DSP, N, SL, ST
Prezista                                   2             DSP           Otrexup                  3      E, SL, ST
Reyataz                                    2             DSP           Rasuvo                   3       SL, ST
Stribild                                   3            DSP, ST        Simponi                  2     DSP, N, SL
Sustiva                                    2             DSP           Stelara                  2     DSP, N, SL
Tivicay                                    3             DSP           Xeljanz                  3 DSP, N, SL, ST
Triumeq                                    2             DSP
                                                                       Men’s Health: Erectile Dysfunction
Truvada                                    2             DSP
Viread                                     2             DSP           Cialis                       3      N, SL
                                                                       Levitra                      3      N, SL
Infertility*
                                                                       Stendra                      3      N, SL
Cetrotide                                  2            DSP, N         Viagra                       3      N, SL
Clomiphene                                 1            DSP, N
                                                                       Men’s Health: Prostate
Gonal-F                                    2            DSP, N
Gonal-F RFF                                2            DSP, N         Alfuzosin Tablet             1
Ovidrel                                    3            DSP, N         Doxazosin Tablet             1
*Coverage is determined by your prescription drug benefit plan.        Finasteride Tablet           1
                                                                       Rapaflo                      3
                                                                       Tamsulosin Capsule           1
                                                                       Terazosin Capsule, Tablet    1

                                                                  19
Drug Requirements                                Drug Requirements
Drug Name                                          Drug Name
                          Tier & Limits                                    Tier & Limits
                                                   Hydrocodone/
Men’s Health: Testosterone Therapy                                           1
                                                   Homatropine
Androderm                  2      N, SL            Letrozole Tablet          1
Androgel                   3     E, N, SL          Lidocaine Transdermal
                                                                             2         SL
Android                    2                       Patch
Testim                     2         N, SL         Nuedexta                  2
Testosterone Cypionate                             Pegasys                   2     DSP, N, SL
                           1
Injection                                          Phenazopyridine           1
                                                   Procrit                   2       DSP, SL
Miscellaneous
                                                   Promethazine/Codeine      1
Anastrozole Tablet         1                       Promethazine/
                                                                             1
Antipyrine/Benzocaine                              Dextromethorphan
                           1
Otic Solution                                      Pulmozyme                 2     DSP, N, SL
Aranesp                    2     DSP, SL           Rectiv                    3       N, SL
Benzonatate Capsule        1                       Renvela                   2
Bethkis                    2    DSP, N, SL         Restasis                  3        N, SL
Bromfed DM                 3                       Rezira                    3
Cayston                    2      N, SL            Tamoxifen Tablet          1
Cerdelga                   2      DSP, N           Tobi Podhaler             3     DSP, N, SL
Chlorhexidine Gluconate    1                       Tobramycin Nebulized
                                                                             3    DSP, E, N, SL
Chlorpheniramine/                                  Solution
Hydrocodone/                                       Velphoro                  2
                           2          SL
Pseudoephedrine
                                                   Musculoskeletal: Osteoporosis
Solution
Ciprodex                   2                       Actonel                   3         SL
Epipen                     2          SL           Alendronate Sodium
                                                                             1         SL
Epipen-Jr                  2          SL           Tablet
Fosrenol                   2                       Forteo                    2       DSP, N
Hydrocodone/                                       Ibandronate Tablet        2        SL
Chlorpheniramine           3          SL           Raloxifene Tablet         2
Suspension

Bold type = Brand-name drug                  N = Notification or precertification (sometimes
[Plain type = Generic drug]                  referred to as preauthorization) required
                                             RS = May be eligible for the Refill and Save Program
DSP = Designated Specialty Program           SDP = Select Designated Pharmacy
E = May be excluded from coverage            SL = Supply Limit
MC = Multiple Copayment                      ST = Step Therapy
                                              20
Drug Requirements                                Drug Requirements
Drug Name                                          Drug Name
                          Tier & Limits                                    Tier & Limits
                                                   Morphine Sulfate Oral
Musculoskeletal: Other                                                      1
                                                   Solution
                                                   Nabumetone Tablet        1
Allopurinol Tablet         1
                                                   Naproxen Tablet          1
Baclofen Tablet            1
                                                   Nucynta                  3       SL
Carisoprodol 350 mg
                           1                       Nucynta ER               3      N, SL
Tablet
                                                   Opana ER                 2      N, SL
Colcrys                    2
                                                   Oxycodone Tablet         1
Cyclobenzaprine            1
                                                   Oxycodone/
Metaxalone Tablet          3
                                                   Acetaminophen
Methocarbamol Tablet       1                                                1        SL
                                                   5/325 mg, 7.5/325 mg,
Tizanidine Tablet          1
                                                   10/325 mg Tablet
Uloric                     3        SL
                                                   Oxycontin                3     N, SL, ST
Musculoskeletal: Pain Relief                       Sprix                    3
                                                   Subsys                   3      N, SL
Acetaminophen/
                           1        SL             Tramadol-
Codeine Tablet                                                              1        SL
                                                   Acetaminophen
Celecoxib                  3        SL
                                                   Tramadol Sustained-
Diclofenac Tablet          1                                                2        SL
                                                   Release Tablet
Etodolac Capsule           1                       Tramadol Tablet          1
Fentanyl Patches           2        SL             Vicodin
Hydrocodone/                                       5/300 mg, 7.5/300 mg,    3       E, SL
Acetaminophen                                      10/300 mg Tablet
                           1        SL
5/325 mg, 7.5/325 mg,                              Voltaren Gel             2
10/325 mg Tablet
                                                   Zohydro ER               3     N, SL, ST
Hydrocodone/Ibuprofen
                           1
Tablet                                             Overactive Bladder
Hydromorphone Tablet       1
                                                   Dicyclomine Tablet       1
Ibuprofen Tablet           1
                                                   Oxybutynin Extended-
Indomethacin Capsule       1                                                2
                                                   Release Tablet
Ketorolac Tablet           1
                                                   Oxybutynin Tablet        1
Lazanda                    3      N, SL
                                                   Tolterodine Extended-
Meloxicam Tablet           1                                                3        E
                                                   Release Tablet
Methadone Tablet           1                       Tolterodine Tablet       3        E
Morphine Sulfate                                   Toviaz                   3
                           1        SL
Extended-Release Tablet
                                                   Vesicare                 3        E

                                              21
Drug Requirements                               Drug Requirements
Drug Name                                           Drug Name
                           Tier & Limits                                   Tier & Limits
                                                    Incruse Ellipta        2        SL
Respiratory: Allergies
                                                    Ipratropium-Albuterol
                                                                           1
Azelastine 0.1%                                     Nebs
                            3         SL
Nasal Spray                                         Ipratropium Nebs       1
Clarinex                    3        E, SL          Levalbuterol Nebs      3       E, SL
Clarinex-D                  3        E, SL          Montelukast Chewable
                                                                           1        SL
Cyproheptadine Tablet       1                       Tablet, Tablet
Dymista                     3        E, SL          Montelukast Granules   2        SL
Fluticasone Nasal Spray     2         SL            Perforomist            3        SL
Hydroxyzine Capsule,                                Proair HFA             3        SL
                            1
Tablet                                              Proventil HFA          3        SL
Levocetirizine Tablet       1         SL            Pulmicort Flexhaler    3      SDP, SL
Nasonex                     3        E, SL          QVAR                   1        SL
Promethazine Tablet         1                       Spiriva Handihaler     3        SL
Qnasl                       3        E, SL          Spiriva Respimat       3        SL
Triamcinolone                                       Symbicort              3       E, SL
                            3        E, SL
Nasal Spray                                         Tudorza                2        SL
Zetonna                     3         SL            Ventolin HFA           1        SL
                                                    Xopenex HFA            3        SL
Respiratory: Asthma/COPD
                                                    Xopenex Nebs           3       E, SL
Advair Diskus/HFA           3      RS, SL           Respiratory:
Aerospan                    3       SL              Pulmonary Arterial Hypertension
Albuterol Nebs              1                       Adcirca                3     DSP, N, SL
Albuterol Sulfate Tablet    1                       Adempas                2     DSP, N, SL
Alvesco                     1       SL              Letairis               2     DSP, N, SL
Asmanex                     1       SL              Opsumit                2     DSP, N, SL
Breo Ellipta                3      RS, SL           Sildenafil Tablet      1     DSP, N, SL
Budesonide Nebs             2       SL              Tracleer               2     DSP, N, SL
Combivent Respimat          3       SL              Tyvaso                 2      DSP, N
Dulera                      3      RS, SL
Flovent Diskus/HFA          3       SL
Foradil                     2       SL

Bold type = Brand-name drug                  N = Notification or precertification (sometimes
[Plain type = Generic drug]                  referred to as preauthorization) required
                                             RS = May be eligible for the Refill and Save Program
DSP = Designated Specialty Program           SDP = Select Designated Pharmacy
E = May be excluded from coverage            SL = Supply Limit
MC = Multiple Copayment                      ST = Step Therapy
                                               22
Drug Requirements                           Drug Requirements
Drug Name                                     Drug Name
                         Tier & Limits                               Tier & Limits
                                              Junel Fe                1
Transplant
                                              Levora-28               1
Azathioprine Tablet       1                   Lo Loestrin Fe          3
Cellcept                  3       DSP         Loryna                  3
Cyclosporine Modified                         Low-Ogestrel            1
                          1       DSP
Capsule                                       Lutera                  1
Mycophenolate Capsule,                        Microgestin             2
                          1       DSP
Suspension                                    Microgestin FE          1
Mycophenolic Acid                             Minastrin 24 FE         3        E
                          2       DSP
Tablet                                        Mononessa               3
Myfortic                  3       DSP         Natazia                 1
Neoral                    3       DSP         Necon 0.5/35, 1/35,
                                                                      1
Prograf                   3       DSP         1/50, 10/11
Rapamune                  3       DSP         Norgestimate-Ethinyl
                                                                      3
Sirolimus Tablet          1       DSP         Estradiol
Tacrolimus Capsule        1       DSP         Nortrel 0.5/35          1
                                              Nuvaring                2
Vitamins/Electrolytes
                                              Orsythia                1
Fluoride                  1                   Ortho-Cyclen            1
Folic Acid                1                   Ortho Micronor          1
Klor-Con M10              1                   Ortho-Novum             3
Klor-Con M20              1                   Ortho-Novum 7/7/7       1
Potassium Chloride        1                   Ortho Tri-Cyclen        1
Potassium Citrate         1                   Ortho Tri-Cyclen Lo     3
                                              Reclipsen               1
Women’s Health: Contraceptives
                                              Sprintec                3
Apri                      1                   Sronyx                  1
Aviane                    1                   Tri-Previfem            3
Azurette                  2                   Tri-Sprintec            3
Cryselle                  1                   Trinessa                3
Cyclafem                  1                   Vestura                 3
Enskyce                   1                   Viorele                 2
Gildess                   2                   Xulane                  3
Gildess Fe                1                   Yasmin 28               1
Junel                     2                   Yaz                     2

                                             23
Drug Requirements                                Drug Requirements
Drug Name                                          Drug Name
                          Tier & Limits                                    Tier & Limits

Women’s Health: Hormone Replacement                Women’s Health: Prenatal Vitamins
Cenestin                   3          E            Brand Prenatal
                                                                             3
Climara                    2          SL           Vitamins
Climara Pro                3          SL           Prenatal Plus             1
Divigel                    2
Duavee                     3
Enjuvia                    3
Estrace Cream              3
Estradiol/Norethindrone
                           2
Acetate Tablet
Estradiol Tablet           1
Estradiol Twice-Weekly
                           3         E, SL
Transdermal Patch
Estring                    2      MC, SL
Estrogen/
Methyltestosterone         1
Tablet
Evamist                    2
Medroxyprogesterone        1
Minivelle                  3          SL
Premarin                   3
Premphase                  3
Prempro                    3
Progesterone
                           2
Micronized Capsule
Vagifem                    2
Vivelle-Dot                2          SL

Bold type = Brand-name drug                  N = Notification or precertification (sometimes
[Plain type = Generic drug]                  referred to as preauthorization) required
                                             RS = May be eligible for the Refill and Save Program
DSP = Designated Specialty Program           SDP = Select Designated Pharmacy
E = May be excluded from coverage            SL = Supply Limit
MC = Multiple Copayment                      ST = Step Therapy
                                              24
Index
                      A                          Alprazolam Extended-Release                      Azelastine 0.05%
Abilify.................................... 14    Tablet................................... 14     Ophthalmic Solution........... 17
Absorica..................................15     Alprazolam Tablet.................. 14           Azelastine 0.1%
Accu-Chek Active                                 Alvesco...................................22      Nasal Spray..........................22
 Test Strips............................ 16      Amiodarone............................12         Azithromycin Tablet............... 10
Accu-Chek Aviva Plus............ 16              Amitiza..................................18      Azopt......................................18
Accu-Chek Aviva Plus                             Amitriptyline Tablet...............13            Azor....................................... 11
 Test Strips............................ 16      Amlodipine............................ 11        Azurette.................................23
Accu-Chek Comfort Curve                          Amlodipine-Valsartan............ 11                                     B
 Test Strips............................ 16      Amlodipine Besylate-
                                                                                                  Baclofen Tablet.......................21
Accu-Chek Compact                                 Benazepril............................ 11
                                                                                                  Benazepril.............................. 11
 Test Strips............................ 16      Amoxicillin/Potassium
                                                                                                  Benazepril-
Accu-Chek Nano                                    Clavulanate Chewable
                                                                                                   Hydrochlorothiazide............ 11
 SmartView........................... 16          Tablet, Tablet....................... 10
                                                                                                  Benicar................................... 11
Accu-Chek Nano                                   Amoxicillin Capsule,
                                                                                                  Benicar HCT......................... 11
 SmartView Test Strips......... 16                Chewable Tablet..................10
Acetaminophen/Butalbital/                                                                         Benzonatate Capsule..............20
                                                 Amphetamine Salt Combo.....12
 Caffeine 325 mg/                                                                                 Betamethasone Diproionate
                                                 Ampyra..................................13
 50 mg/40mg........................13                                                              0.05% Augmented Lotion,
                                                 Anastrozole Tablet.................20             Ointment.............................15
Acetaminophen/Codeine
                                                 Androderm.............................20         Betamethasone Dipropionate
 Tablet...................................21
                                                 Androgel................................20        0.05% Cream, Ointment.....15
Actemra.................................. 19
                                                 Android..................................20      Betaseron................................13
Actonel...................................20
                                                 Antipyrine/Benzocaine                            Bethkis...................................20
Acyclovir Ointment................10
                                                  Otic Solution.......................20          Bicalutamide...........................10
Acyclovir Tablet.....................10
                                                 Apri........................................23   Bidil........................................ 11
Aczone....................................15
                                                 Apriso.....................................18    Bisoprolol................................ 11
Adapalene 0.1% Cream, Gel..15
                                                 Aranesp..................................20      Bisoprolol-
Adapalene 0.3% Gel...............15
Adcirca...................................22     Armour Thyroid..................... 17            Hydrochlorothiazide............ 11
Adderall XR...........................12         Asacol HD Tablet.................. 18            Bosulif.................................... 10
Adempas.................................22       Asmanex.................................22       Brand Prenatal Vitamins........24
Advair Diskus/HFA...............22               Atenolol.................................. 11    Breo Ellipta............................22
Aerospan................................22       Atenolol-Chlorthalidone........ 11               Brintellix................................13
Albuterol Nebs.......................22          Atorvastatin............................12       Bromfed DM..........................20
Albuterol Sulfate Tablet..........22             Atripla.................................... 19   Budesonide Nebs....................22
Alendronate Sodium Tablet...20                   Aubagio..................................13      Buprenorphine/Naloxone
Alfuzosin Tablet..................... 19         Aviane....................................23      Tablet................................... 14
Allopurinol Tablet..................21           Avonex....................................13     Bupropion Extended-Release
Alphagan P 0.1%.................... 18           Azathioprine Tablet................23             Tablet...................................13
                                                                      25
Bupropion Sustained-Release                       Citalopram Tablet...................13          Cyclosporine Modified
 Tablet...................................13      Claravis...................................15    Capsule................................23
Bupropion Tablet....................13            Clarinex..................................22    Cymbalta................................13
Buspirone Tablet..................... 14          Clarinex-D.............................22       Cyproheptadine Tablet...........22
Bydureon................................ 17       Clarithromycin Tablet............10
                                                                                                                       D
Byetta..................................... 17    Climara..................................24
Bystolic................................... 11    Climara Pro............................24       Daytrana.................................12
                                                  Clindamycin 1%/Benzoyl                          Delzicol..................................18
                      C
                                                   Peroxide 5% Gel..................15            Desmopressin Tablet.............. 17
Calcitriol Capsule................... 17                                                          Desonide 0.05% Cream,
                                                  Clindamycin 1.2%/Benzoyl
Canasa....................................18                                                       Lotion, Ointment................15
                                                   Peroxide 5% Gel..................15
Capecitabine Tablet................ 10                                                            Desoximetasone Gel,
                                                  Clindamycin Capsule............. 10
Carac......................................15                                                      Ointment.............................15
                                                  Clindamycin Gel....................15
Carbamazepine Tablet............ 14                                                               Dexamethasone Tablet........... 17
                                                  Clindamycin Lotion...............15
Carbidopa-Levodopa.............. 14                                                               Dexilant..................................18
                                                  Clindamycin Solution, Swabs.15
Carisoprodol 350 mg Tablet...21
                                                  Clobetasol Propionate Cream,                    Dexmethylphenidate
Cartia XT............................... 11
                                                   Ointment, Solution..............15              Extended-Release
Carvedilol............................... 11
                                                  Clomiphene............................ 19        Capsule................................12
Cayston...................................20
                                                  Clonazepam Tablet................. 14           Dexmethylphenidate Tablet....12
Cefadroxil Capsule, Tablet..... 10
                                                  Clonidine Tablet..................... 11        Dextroamphetamine-
Cefdinir Capsule.................... 10
                                                  Clopidogrel............................. 11      Amphetamine
Cefprozil Tablet......................10
                                                  Clotrimazole-Betamethasone                       Extended-Release................12
Cefuroxime Tablet..................10
                                                   Cream..................................15      Dextroamphetamine-
Celecoxib................................21
                                                  Clotrimazole-Betamethasone                       Amphetamine Tablet...........12
Cellcept..................................23
                                                   Lotion..................................15     Dextroamphetamine Sulfate
Cenestin.................................24
                                                  Colcrys...................................21     Tablet...................................12
Cephalexin Capsule................ 10
Cerdelga.................................20       Combigan...............................18       Diazepam Tablet.................... 14
Cetrotide................................ 19      Combivent Respimat..............22              Diclofenac Tablet....................21
Chlorhexidine Gluconate........20                 Complera................................ 19     Dicyclomine Tablet................21
Chlorpheniramine/                                 Concerta.................................12     Differin 1%.............................15
 Hydrocodone/                                     Condylox Gel.........................15         Dificid....................................10
 Pseudoephedrine Solution...20                    Contour Test Strips................ 16          Diflorasone Diacetate 0.05%
Chlorthalidone....................... 11          Copaxone...............................13        Cream, Ointment................15
Choline Fenofibrate................12             Cortifoam...............................18      Digoxin..................................12
Cialis...................................... 19   Creon......................................18   Diltiazem 24 Hour CD.......... 11
Ciclopirox Cream, Gel, Lotion,                    Crestor....................................12   Diltiazem Sustained-Release
 Solution...............................15        Cryselle...................................23    Capsule................................ 11
Cimzia.................................... 19     Cyclafem................................23      Diltiazem Sustained-Release
Ciprodex.................................20       Cyclobenzaprine.....................21           Tablet................................... 11
Ciprofloxacin Tablet............... 10            Cyclophosphamide Capsule....10                  Diovan.................................... 11
                                                                      26
Diphenoxylate-Atropine                           Esomeprazole Capsule............ 18              Foradil....................................22
 Tablet...................................18     Estrace Cream........................24          Forteo.....................................20
Divalproex Delayed-Release                       Estradiol/Norethindrone                          Fosrenol..................................20
 Tablet................................... 14     Acetate Tablet......................24          Freestyle Test Strips............... 16
Divalproex Extended-Release                      Estradiol Tablet......................24         Furosemide............................. 11
 Tablet................................... 14    Estradiol Twice-Weekly                                                G
Divigel....................................24     Transdermal Patch...............24
                                                                                                  Gabapentin Capsule, Tablet... 14
Donepezil 5, 10 mg ODT,                          Estring....................................24
                                                                                                  Gemfibrozil............................12
 Tablet................................... 14    Estrogen/Methyltestosterone
                                                                                                  Genotropin............................. 17
Doryx.....................................10      Tablet...................................24
                                                                                                  Gentamicin Ophthalmic
Doxazosin......................... 11, 19        Eszopiclone Tablet.................. 14
                                                                                                   Ointment, Solution.............. 17
Doxazosin Tablet.................... 19          Etodolac Capsule....................21
                                                                                                  Gildess....................................23
Doxepin..................................13      Evamist...................................24
                                                                                                  Gildess Fe...............................23
Doxycycline Hyclate Capsule,                     Extavia...................................13
                                                                                                  Gilenya...................................13
 Tablet...................................10
                                                                       F                          Gleevec................................... 10
Doxycycline Monohydrate
                                                 Famciclovir Tablet..................10           Glimepiride............................ 17
 50, 100 mg Capsule............. 10
                                                 Farxiga.................................... 17   Glipizide................................. 17
Duavee....................................24
                                                 Fenofibrate 43, 50 , 67, 130,                    Glipizide Extended-Release... 17
Dulera.....................................22
                                                   134, 150, 200 mg Capsule...12                  Glyburide............................... 17
Duloxetine Capsule................13
                                                 Fenofibrate 48, 145 mg                           Golytely.................................. 18
Dutoprol................................. 11                                                      Gonal-F.................................. 19
Dymista..................................22        Tablet...................................12
                                                                                                  Gonal-F RFF......................... 19
                                                 Fenofibrate 54, 160 mg
                      E                                                                           Guanfacine....................... 11, 12
                                                   Tablet...................................12
                                                                                                  Guanfacine
Econazole Cream................... 10            Fenoglide................................12
                                                                                                   Extended-Release................12
Edarbi..................................... 11   Fentanyl Patches.....................21
Edarbyclor.............................. 11      Fetzima...................................13                          H
Effient.................................... 11   Finacea...................................15     Harvoni..................................18
Eliquis.................................... 11   Finasteride Tablet................... 19         Humalog KwikPen................. 16
Enalapril................................. 11    Flecainide...............................12      Humalog Mix 50-50
Enbrel..................................... 19   Flovent Diskus/HFA..............22                KwikPen.............................. 16
Enjuvia...................................24     Fluconazole Tablet..................10           Humalog Mix 75-25
Enoxaparin Sodium................ 11             Fluocinolone Cream, Oil,                          KwikPen.............................. 16
Enskyce..................................23        Ointment, Solution..............15             Humalog Vials....................... 16
Epiduo....................................15     Fluocinonide 0.05% Cream....15                   Humatrope............................. 17
Epipen....................................20     Fluoride..................................23     Humira................................... 19
Epipen-Jr................................20      Fluoxetine Tablet, Capsule.....13                Humulin 70-30 KwikPen....... 16
Epzicom................................. 19      Fluticasone Nasal Spray..........22              Humulin 70-30 Vials............. 16
Erythromycin 0.5%                                Fluvoxamine Tablet................13             Humulin N KwikPen............. 16
 Ophthalmic Ointment......... 17                 Focalin XR.............................12        Humulin N Vials.................... 16
Escitalopram Tablet................13            Folic Acid...............................23      Humulin R Vials.................... 16
                                                                     27
Hydralazine............................ 11       Jentadueto............................... 17      Lialda..................................... 18
Hydrochlorothiazide............... 11            Junel........................................23   Lidocaine Transdermal
Hydrocodone/Acetaminophen                        Junel Fe...................................23      Patch....................................20
 5/325 mg, 7.5/325 mg,                                                                             Linzess...................................18
                                                                       K
 10/325 mg Tablet.................21                                                               Liothyronine Sodium
Hydrocodone/                                     Kaletra.................................... 19
                                                                                                    Tablet................................... 17
 Chlorpheniramine                                Kazano................................... 17
                                                                                                   Lipitor.....................................12
 Suspension...........................20         Ketoconazole Cream..............10
                                                                                                   Lipofen...................................12
Hydrocodone/Homatropine...20                     Ketorolac Tablet......................21
                                                 Klor-Con M10.......................23             Lisinopril.......................... 11, 33
Hydrocodone/Ibuprofen
                                                 Klor-Con M20.......................23             Lisinopril-
 Tablet...................................21
                                                 Kombiglyze XR...................... 17             Hydrochlorothiazide............ 11
Hydrocortisone 2.5% Cream,
                                                                                                   Lithium Capsule..................... 14
 Ointment.............................15                               L                           Livalo.....................................12
Hydromorphone Tablet..........21
                                                 Labetalol................................. 11     Lo Loestrin Fe.......................23
Hydroxychloroquine Sulfate... 19
                                                 Lamivudine-Zidovudine........ 19                  Lorazepam Tablet................... 14
Hydroxyurea Capsule.............10
                                                 Lamotrigine Tablet................. 14            Loryna....................................23
Hydroxyzine Capsule,
                                                 Lansoprazole Capsules...........18                Losartan................................. 11
 Tablet...................................22
                                                 Lantus Solostar....................... 16         Losartan-
Hyoscyamine Tablet...............18
                                                 Lantus Vials........................... 16
                                                                                                    Hydrochlorothiazide............ 11
                      I                          Lastacaft................................. 17
                                                                                                   Lovastatin...............................12
Ibandronate Tablet.................20            Latanoprost 0.005%
                                                                                                   Low-Ogestrel.........................23
Ibuprofen Tablet.....................21           Ophthalmic Solution...........18
                                                                                                   Lumigan.................................18
Imbruvica...............................10       Latuda.................................... 14
                                                                                                   Lunesta................................... 14
Imiquimod 5% Cream............15                 Lazanda..................................21
                                                                                                   Lutera.....................................23
Incruse Ellipta........................22        Leflunomide........................... 19
                                                 Letairis...................................22     Lyrica..................................... 14
Indomethacin Capsule............21
Intelence................................. 19    Letrozole Tablet.....................20                                M
Intuniv....................................13    Leucovorin Calcium Tablet....10
                                                                                                   Medroxyprogesterone.............24
Invokamet............................... 17      Levalbuterol Nebs...................22
                                                                                                   Meloxicam Tablet...................21
Invokana................................. 17     Levemir FlexTouch................ 16
                                                                                                   Mercaptopurine Tablet........... 10
Ipratropium-Albuterol Nebs...22                  Levemir Vials......................... 16
                                                                                                   Metadate CD.........................13
Ipratropium Nebs...................22            Levetiracetam
                                                                                                   Metaxalone Tablet..................21
Irbesartan............................... 11      Extended-Release Tablet..... 14
                                                 Levetiracetam Tablet.............. 14             Metformin.............................. 17
Isentress.................................. 19
                                                 Levitra.................................... 19    Metformin Extended-Release
Isosorbide Mononitrate ER....12
                                                 Levocetirizine Tablet..............22              Tablet................................... 17
Itraconazole Capsule...............10
                                                 Levofloxacin Tablet................10             Methadone Tablet..................21
                      J                          Levora-28...............................23        Methimazole Tablet............... 17
Janumet.................................. 17     Levothyroxine Sodium                              Methocarbamol Tablet...........21
Januvia.................................... 17    Tablet................................... 17     Methotrexate Tablet............... 19
Jardiance................................. 17    Lexapro..................................13       Methylphenidate.....................13
                                                                     28
Methylphenidate                                                      N                          Nuedexta................................20
 Extended-Release                              Nabumetone Tablet................21              Nutropin, Nutropin AQ......... 17
 Capsule................................13     Nadolol................................... 11    Nuvaring................................23
Methylphenidate                                Namenda XR.......................... 14          Nuvigil................................... 14
 Extended-Release Tablet.....13                Naproxen Tablet.....................21           Nystatin-Triamcinolone
Methylprednisolone Tablet..... 17              Naratriptan.............................13        Acetonide Cream,
Metoclopramide Tablet..........18              Nasonex..................................22       Ointment.............................15
Metoprolol Succinate 50, 100,                  Natazia...................................23     Nystatin Cream, Ointment....10
 200 mg................................ 11     Necon 0.5/35, 1/35, 1/50,                                             O
Metoprolol Tartrate................ 11          10/11....................................23
                                                                                                Ofloxacin 0.3% Ophthalmic
Metronidazole Gel 0.75%.......15               Neoral.....................................23
                                                                                                 Solution............................... 17
                                               Nesina..................................... 17
Metronidazole Tablet............. 10                                                            Ofloxacin Tablet..................... 10
                                               Nevirapine.............................. 19
Microgestin............................23                                                       Olanzapine Tablet.................. 14
                                               Nevirapine
Microgestin FE......................23                                                          Olysio.....................................18
                                                Extended-Release................ 19
Minastrin 24 FE....................23                                                           Omeclamox-Pak.....................18
                                               Nexium Capsule..................... 18
Minivelle................................24                                                     Omega-3-Acid Ethyl Esters
                                               Niacin Extended-Release
Minocycline Capsule.............. 10            Tablet...................................12      Capsule................................12
Minocycline Tablet.................10          Niaspan..................................12      Omeprazole Capsule.............. 18
Mirtazapine Tablet.................13          Nifedipine Extended-Release.11                   Omnitrope.............................. 17
Mirvaso..................................15    Nitrofurantoin Capsule...........10              Ondansetron...........................18
Modafinil Tablet..................... 14       Nitrofurantoin Macrocrystal                      Ondansetron ODT................. 18
Mometasone Furoate Cream,                       Capsule................................10       One Touch Test Strips............ 16
 Lotion, Ointment................15            Nitrostat.................................12     One Touch Ultra Meter.......... 16
Mononessa..............................23      Norditropin............................ 17       One Touch Ultra Mini........... 16
                                               Norgestimate-Ethinyl                             One Touch Ultra Test Strips.. 16
Montelukast Chewable Tablet,
                                                Estradiol..............................23       One Touch Verio.................... 16
 Tablet...................................22
                                               Nortrel 0.5/35.........................23        One Touch Verio IQ............... 16
Montelukast Granules............22
                                               Nortriptyline Capsule.............13             One Touch Verio IQ
Morphine Sulfate
                                               Norvir..................................... 19    Test Strips............................ 16
 Extended-Release Tablet.....21
                                               Novolin 70-30 Vials............... 16            One Touch Verio Sync............ 16
Morphine Sulfate Oral
                                               Novolin N Vials..................... 16          Onglyza.................................. 17
 Solution...............................21                                                      Opana ER..............................21
                                               Novolin R Vials...................... 16
Moviprep................................18                                                      Opsumit.................................22
                                               Novolog Flexpen.................... 16
Moxeza................................... 17   Novolog Mix 70/30                                Oracea.................................... 10
Moxifloxacin Tablet................10           Flexpen................................ 16      Orencia................................... 19
Mupirocin Ointment..............15             Novolog Mix 70/30 Vials....... 16                Orsythia.................................23
Mycophenolate Capsule,                         Novolog Vials......................... 16        Ortho-Cyclen.........................23
 Suspension...........................23       NP Thyroid Tablet................. 17            Ortho-Novum........................23
Mycophenolic Acid Tablet......23               Nucynta..................................21      Ortho-Novum 7/7/7...............23
Myfortic.................................23    Nucynta ER............................21         Ortho Micronor.....................23
                                                                   29
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