Prescription Drug List - Your 2015
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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
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.
2Table 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
34
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.
5What 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.
6Programs 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.
7Why 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.
8What 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.
9Drug 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
10Drug 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
11Drug 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
12Drug 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
13Drug 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
14Drug 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
15Drug 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
16Drug 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
17Drug 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
18Drug 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
19Drug 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
20Drug 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
21Drug 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
22Drug 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
23Drug 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
24Index
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
25Bupropion 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
26Diphenoxylate-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
27Hydralazine............................ 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
28Methylphenidate 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
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