2017 Prescription Drug List/Formulary … ERS Prescription...2 Your Prescription Drug List / Formulary This formulary outlines the most commonly prescribed medications covered under

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Please read: This document contains information about the drugs covered under your pharmacy benefit plan.

Your Prescription Drug List/Formulary

Effective July 1, 2017

HealthSelectSM

of Te

xas

2017

For a complete list of covered drugs or if you have questions:

• Call a customer care representative toll-free at (855) 828-9834 (TTY 711).

• Visit www.HealthSelectRx.com

— Locate an OptumRx in-network pharmacy

— Look up possible lower-cost medication alternatives.

— Compare medication pricing and options.

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Your Prescription Drug List / Formulary

This formulary outlines the most commonly prescribed medications covered under your plan’s prescription drug benefits. The formulary is also known as the Prescription Drug List (PDL). A formulary identifies the drugs available for certain conditions and organizes them into cost levels, also known as tiers. An important part of the formulary is giving you choices so you and your doctor can choose the best course of treatment for you.

Go to www.HealthSelectRx.com for complete and up-to-date drug information

Since the formulary may change, we encourage you to visit our website, www.HealthSelectRx.com and click on Prescription Drug List. This website is the best source for up-to-date information about all of the medications your pharmacy benefit covers, possible lower-cost options and cost comparisons.

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Table of Contents

Drug tiers and cost . . . . . . . . . . . . . . . . . . 5

Programs and limits . . . . . . . . . . . . . . . . . 6

Drugs by category . . . . . . . . . . . . . . . . . . . 9

Anti-InfectivesAntibiotics. . . . . . . . . . . . . . . . . . . . . . . . . . . 9Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . 9Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Cardiovascular/Heart DiseaseAnticoagulants . . . . . . . . . . . . . . . . . . . . . . 10High Blood Pressure . . . . . . . . . . . . . . . . . 10High Cholesterol. . . . . . . . . . . . . . . . . . . . . 10Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Pulmonary Arterial Hypertension . . . . . . . . 11

Central Nervous SystemAttention Deficit Disorder . . . . . . . . . . . . . . 11Depression . . . . . . . . . . . . . . . . . . . . . . . . . 11Migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . 12Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Sedatives/Hypnotics . . . . . . . . . . . . . . . . . 12Seizure Disorders . . . . . . . . . . . . . . . . . . . . 12

Dermatology . . . . . . . . . . . . . . . . . . . . . . . 13

Diabetes/EndocrineInsulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Non-Insulin . . . . . . . . . . . . . . . . . . . . . . . . . 14

EndocrineGrowth Hormone . . . . . . . . . . . . . . . . . . . . 14Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Thyroid Hormone Replacement . . . . . . . . . 15

Eye ConditionsAllergies . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Antibiotics. . . . . . . . . . . . . . . . . . . . . . . . . . 15Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

GastrointestinalAcid Suppression . . . . . . . . . . . . . . . . . . . . 16Nausea/Vomiting . . . . . . . . . . . . . . . . . . . . 16Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Inflammatory Conditions . . . . . . . . . . . . . 17

Men’s HealthErectile Dysfunction . . . . . . . . . . . . . . . . . . 17Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Testosterone Therapy. . . . . . . . . . . . . . . . . 18

Miscellaneous . . . . . . . . . . . . . . . . . . . . . . 18

MusculoskeletalOsteoporosis . . . . . . . . . . . . . . . . . . . . . . . 19 Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Pain Relief . . . . . . . . . . . . . . . . . . . . . . . . . 19

Overactive Bladder. . . . . . . . . . . . . . . . . . 20

RespiratoryAsthma/COPD . . . . . . . . . . . . . . . . . . . . . . 20Nasal Allergies . . . . . . . . . . . . . . . . . . . . . . 20Oral Allergies . . . . . . . . . . . . . . . . . . . . . . . 20

Transplant . . . . . . . . . . . . . . . . . . . . . . . . . 20

Vitamins/Electrolytes . . . . . . . . . . . . . . . . 21

Women’s HealthBirth Control . . . . . . . . . . . . . . . . . . . . . . . . 21Hormone Replacement . . . . . . . . . . . . . . . 22Vaginal Anti-Infectives . . . . . . . . . . . . . . . . 22

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

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At OptumRx, 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 formulary.

What is a formulary?

This document is a list of commonly prescribed medications covered by your prescription drug program for their safety, cost and effectiveness. 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 formulary and your benefit plan documents, the benefit plan documents will rule. This document is not intended to be a complete list of medications, and not all medications listed may be covered under your plan. Please look at the Master Benefit Plan Document (MBPD) provided by your plan to see what medications are covered under your plan. You may also visit www.HealthSelectRx.com and click on Prescription Drug List or call a customer care representative toll free at (855) 828-9834 (TTY 711).

How do I use my formulary?

When choosing a medication, you and your doctor should consult the formulary. It will help you and your doctor choose the most cost-effective prescription drugs. This guide tells you if a medication is generic or brand, and if special rules apply. Bring this list with you when you see your doctor. It is organized by common medical conditions. Medications are also listed alphabetically by name at the end of the formulary.

If your medication is not listed on this document, it may not be covered by the HealthSelect Prescription Drug Program or Consumer Directed HealthSelect Prescription Drug Program. Please visit www.HealthSelectRx.com and click on Prescription Drug Tool for the most up to date list of medications covered under your plan. If you have any questions, call a customer care representative toll-free at (855) 828-9834 (TTY 711).

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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 plan. This is how much you will pay when you fill a prescription. The HealthSelect of Texas Prescription Drug Program has different copays assigned depending on which tier a drug is. The Consumer Directed HealthSelect Prescription Drug Program has coinsurance assigned for each drug tier that applies once the annual combined medical and pharmacy deductible is met. 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.

Drug names shown in green are preferred for their cost and effectiveness. If there is a symbol in the Drug Tier column, check your benefit plan documents to find out your specific pharmacy plan costs.

$ Drug Tier Includes Helpful Tips

$ Tier 1 Lowest Cost

Lower-cost, commonly used generic drugs. Some low-cost brands may be included.

Use Tier 1 drugs for the lowest out-of-pocket costs.

$$ Tier 2 Mid-range Cost

Many common brand-name drugs, called preferred brands.

Use Tier 2 drugs, instead of Tier 3, to help reduce your out-of-pocket costs.

$$$ Tier 3 Highest Cost

Mostly higher-cost brand drugs, also known as non-preferred brands.

Many Tier 3 drugs have lower-cost options in Tier 1 or 2. Ask your doctor if they could work for you.

When does the formulary change?

• Medications may move to a lower tier at any time.

• Medications may move to a higher tier when its generic becomes available.

• Medications may move to a higher tier or be excluded from coverage on January 1 or July 1 of each year.

When a medication changes tiers, you may have to pay a different amount for that medication.

For the most up-to-date list, call a customer care representative, 24 hours a day, seven days a week toll-free at (855) 828-9834 (TTY 711).

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Programs and Limits

Some medications are noted with letters or symbols next to them. The letters and symbols refer to our pharmacy benefit programs and are provided to help you check which medications may have a program or limit. Your benefit plan determines how these medications may be covered for you.Programs and Limits

PA Prior Authorization — Your doctor is required to provide additional information before

the drug will be covered by your prescription drug plan.

ST Step Therapy — Requires you to first try a cost-effective medication before the

more expensive medication will be covered.

QL Quantity Limits — Limits the amount of a medication that will be covered under

your prescription drug plan.

SP

Specialty Medication — Drugs that are used in the treatment of rare or complex conditions and are typically injected or infused, are high cost, have special delivery and storage requirements, or require close monitoring or care coordination with your doctor.

EExcluded — Drugs that are not covered by your health plan. Lower-cost options

are available and covered.

To learn more about a pharmacy program or to find out if it applies to you, please visit www.HealthSelectRx.com and click on Prescription Drug List or call a customer care representative toll-free at (855) 828-9834 (TTY 711).

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Why are some medications excluded from coverage?

Medications may be excluded from coverage under your prescription drug plan when it works the same as or similar to another prescription medication or an over-the-counter (OTC) medication that is more cost-effective. There may be other medication options available to treat your condition.

What if I don’t agree with a decision about an excluded medication?

You (or your authorized representative) and your doctor can ask for an appeal to cover an excluded medication by calling a customer care representative toll-free at (855) 828-9834 (TTY 711).

Should I talk to my doctor about OTC medications?

An OTC medication may be the right treatment option for some conditions. Talk to your doctor about available OTC options. Even though these medications may not be covered under your pharmacy benefit, they may cost less than prescription medications covered under your prescription drug plan.

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.

How can I tell a generic drug from a brand-name drug on this formulary?

This formulary shows brand-name drugs in bold type (for example, Lamictal) and generic drugs in plain type (for example, lamotrigine).

What if my doctor writes a brand-name prescription?

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 www.HealthSelectRx.com and click on Drug Pricing Tool to find out an estimated cost for your medications and if there are lower cost alternatives available.

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Are you taking a specialty medication?

Specialty medications treat rare or complex conditions and are typically higher cost medications. Please note, not all specialty medications are listed in the Formulary.

BriovaRx®, the OptumRx specialty pharmacy, can provide most of your specialty medications along with helpful programs and services. Call BriovaRx® at (855) 427-4682 and have your prescriptions delivered right to your home or office.

How do I get updated information about my pharmacy benefit?

Since the Formulary may change during your plan year, we encourage you to visit www.HealthSelectRx.com and click on Prescription Drug List or call a customer care representative at (855) 828-9834 (TTY 711) for the most current drug coverage information.

You can register and create an account at www.Optumrx.com/HealthSelectrx. You can use the website’s helpful tools and features to:

• Refill and renew mail service prescriptions

• View your order status and claims history

• Sign up for text reminders to take and refill your medicine

• View your benefits in real time

• Look up the price of drugs covered by your plan

• Find lower-cost options

Call a customer care representative toll-free at (855) 828-9834 (TTY 711).

Or visit www.HealthSelectRx.com.

More information

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Drug Name Drug Tier

Programs and Limits

Anti-Infectives: Antibiotics

Amoxicillin 1Amoxicillin/

Clavulanate1

Azasite 3Azithromycin 1Bethkis 2 SPCefadroxil Cap 1Cefdinir 1Cefuroxime Tab 1Cephalexin 1Ciprodex Otic

Suspension2

Ciprofloxacin Tab 1Clarithromycin 1Clindamycin Cap 1Doryx MPC 3Doxycycline Hyclate

Cap1

Doxycycline Hyclate Tab (Immediate Release)

1

Doxycycline Monohydrate Cap

1

Doxycycline Monohydrate Oral Suspension, Tab

1

Erythromycin 1Kitabis ELevofloxacin Tab 1Metronidazole Tab 1Minocycline Cap 1Moxifloxacin 1Neomycin/

Polymyxin/HC Otic Suspension, Solution

1

Nitrofurantoin Macrocrystalline

1

Nitrofurantoin Monohydrate Macrocrystalline

1

Drug Name Drug Tier

Programs and Limits

Ofloxacin Otic Solution

1

Oracea 3Penicillin VK 1Solodyn 3Sulfamethoxazole-

Trimethoprim1

Sulfamethoxazole-Trimethoprim DS

1

TOBI Nebulizer ETOBI Podhaler ETobramycin Neb E

Anti-Infectives: Antifungals

Fluconazole 1Jublia Solution 3 PAKerydin Solution 3 PANystatin Suspension 1Terbinafine Tab 1 QL

Anti-Infectives: Antivirals

Acyclovir Cap, Tab, Suspension

1

Daklinza 3 PA, QL, SPEntecavir 1 QL, SPEpclusa 2 PA, QL, SPFamciclovir Tab 1Harvoni 2 PA, QL, SPSovaldi 2 PA, QL, ST, SPTamiflu 3 QLValacyclovir 1 QLZepatier 2 PA, QL, SP

Cancer

Akynzeo 3 QLAnastrozole Tab 1Capecitabine 1 PA, SPLetrozole 1Revlimid 3 PA, SPSprycel 2 PA, SPTamoxifen Tab 1Tasigna 3 PA, SPTemozolomide 1 PA, SPZytiga 3 PA, SP

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits[Plain type = Generic drug] ST Step Therapy SP Specialty ProgramE Excluded

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Drug Name Drug Tier

Programs and Limits

Cardiovascular/Heart Disease: AnticoagulantsBrilinta 2Clopidogrel 1Effient 2Eliquis 3 QLEnoxaparin 1 QLPradaxa 2 QLSavaysa 3 QLWarfarin 1Xarelto 2 QLCardiovascular/Heart Disease: High Blood PressureAmlodipine 1Amlodipine/Benazepril 1Amlodipine/Valsartan 1Amlodipine/Valsartan/

HCTZ1

Atenolol 1Atenolol/

Chlorthalidone1

Azor 3 STBenazepril 1Benazepril/HCTZ 1Benicar 3 STBenicar HCT 3 STBisoprolol 1Bisoprolol/HCTZ 1Bumetanide 1Bystolic 2Cartia XT 1Carvedilol 1Chlorthalidone 1Clonidine Patch 1Clonidine Tab 1Diltiazem Tab 1Doxazosin 1Edarbi 3 STEdarbyclor 3 STEnalapril 1Enalapril/HCTZ 1Felodipine 1Fosinopril 1Furosemide 1

Drug Name Drug Tier

Programs and Limits

Guanfacine Tab (Immediate Release)

1

Hydralazine 1Hydrochlorothiazide 1Irbesartan 1Irbesartan/HCTZ 1Labetalol 1Lisinopril 1Lisinopril/HCTZ 1Losartan 1Losartan/HCTZ 1Metoprolol Succinate 1Metoprolol Tartrate 1Nadolol 1Nifedipine ER 1Propranolol 1Propranolol ER 1Quinapril 1Ramipril 1Spironolactone 1Tekturna 2 STTekturna HCT 2 STTelmisartan 1Terazosin 1Torsemide Tab 1Triamterene/HCTZ 1Tribenzor 3 STValsartan 1Valsartan/HCTZ 1Verapamil ER 1Cardiovascular/Heart Disease: High CholesterolAtorvastatin 1Cholestyramine 1Crestor 3Fenofibrate 40 mg,

43 mg, 48 mg, 50 mg, 54 mg, 67 mg, 120 mg, 130 mg, 134 mg, 145 mg, 150 mg, 160 mg, 200 mg

1


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Drug Name Drug Tier

Programs and Limits

Gemfibrozil 1Lipitor 3 STLovastatin 1Lovaza 3Niacin ER Tab 1Omega-3 Acid Cap

1 gm1

Praluent 2 PA, QL, SPPravastatin 1Rosuvastatin 1Simvastatin 5 mg, 10

mg, 20 mg, 40 mg1

Simvastatin 80 mg 1 PAVascepa 2Vytorin 10-10 mg,

10-20 mg, 10-40 mg

3

Vytorin 10-80 mg 3 PAWelchol 2Zetia 3

Cardiovascular/Heart Disease: Other

Amiodarone 1Amlodipine/

Atorvastatin1

Corlanor 3 PA, QLDigoxin 1Flecainide 1Isosorbide

Mononitrate1

Multaq 3Nitrostat 3Ranexa 2 STSotalol 1Cardiovascular/Heart Disease: Pulmonary Arterial HypertensionAdcirca 3 PA, QL, SPAdempas 2 PA, QL, SPLetairis 2 PA, QL, SPOpsumit 2 PA, QL, SPOrenitram 3 PA, SPSildenafil Tab 20 mg 1 PA, QLTracleer 2 PA, QL, SP

Drug Name Drug Tier

Programs and Limits

Central Nervous System: Attention Deficit DisorderAdderall XR Cap 3 PA, QL, STAmphetamine-

Dextro-amphetamine Tab

1 PA, QL

Amphetamine- Dextro-amphetamine SR 24Hr Cap

1 PA, QL

Dexmethylphenidate ER Cap

1 PA, QL

Evekeo 3 PA, QL, STGuanfacine ER Tab 1 QLMethylphenidate

ER Cap1 PA, QL

Methylphenidate ER Tab

1 PA, QL

Methylphenidate SA Osmotic ER Tab

1 PA, QL

Methylphenidate Tab 1 PA, QLStrattera 2 QLVyvanse 2 PA, QL

Central Nervous System: Depression

Amitriptyline 1Bupropion 1Bupropion ER 1Bupropion SR 1Bupropion XL 1 QLDoxepin 1Duloxetine Cap 20

mg, 30 mg, 60 mg1 QL

Escitalopram Tab 1Fluoxetine Cap

(not PMDD)1

Fluvoxamine Tab 1Forfivo XL 2 QLMirtazapine 1Nortriptyline 1Paroxetine Tab 1Pristiq 3 QL


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Drug Name Drug Tier

Programs and Limits

Risperidone Tab 1 QLSertraline 1Trazodone 1Venlafaxine Tab 1Venlafaxine ER Cap 1Venlafaxine ER Tab 1Viibryd 3 QL, ST

Central Nervous System: Migraine

Butalbital-Acetaminophen-Caffeine Cap, Tab 50-325-40 mg

1

Migranal 3 QLRelpax 3 QLRizatriptan Tab, ODT 1 QLSumatriptan Tab

and Spray1 QL

Sumavel Dose 3 QLZolmitriptan Tab 1 QLCentral Nervous System: Multiple SclerosisAmpyra 2 PA, QL, SPAubagio 3 PA, QL, ST, SPAvonex Kit 2 PA, QL, SPAvonex Pen Kit 2 PA, QL, SPAvonex Prefill Kit 2 PA, QL, SPBetaseron 2 PA, QL, SPCopaxone 20 mg/mL

& 40 mg/mL2 PA, QL, SP

Extavia EGilenya 3 PA, QL, ST, SPPlegridy ERebif ERebif Titrtn ETecfidera 2 PA, QL, SP

Central Nervous System: Other

Alprazolam Tab 1 QLAripiprazole 1 QLBenztropine 1Buspirone 1

Drug Name Drug Tier

Programs and Limits

Carbidopa/Levodopa Tab (Immediate Release)

1

Diazepam Tab 1Donepezil Tab 1Hydroxyzine HCL 1Hydroxyzine Pamoate 1Latuda 3 QL, STInvega Sustenna 3Invega Trinza 3Lithium Carbonate 1Lorazepam Tab 1 QLModafinil 1 PA, QLNamenda XR 2 QLNamzaric 2 QLOlanzapine Tab 1 QLProchlorperazine 1Quetiapine 1 QLRexulti 3 QLRisperidone Tab 1 QLRopinirole

(Immediate Release)

1

Saphris 2 QLSeroquel XR 3 QLZiprasidone Cap 1 QLCentral Nervous System: Sedatives/HypnoticsEszopiclone Tab 1 QLSilenor 3 QLTemazepam 1 QLTriazolam Tab 1 QLZolpidem 1 QLZolpidem ER 1 QLCentral Nervous System: Seizure DisordersCarbamazepine Tab 1Clonazepam 1 QLDivalproex DR 1Divalproex ER 1Gabapentin 1Lamotrigine

(Immediate Release)

1


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Drug Name Drug Tier

Programs and Limits

Lamotrigine ER 1Levetiracetam 1Levetiracetam ER 1Lyrica Cap 2 QLOnfi 3 PAOxcarbazepine 1Phenytoin 1Primidone 1Topiramate Tab 1Vimpat 3Zonisamide 1

Dermatology

Absorica 3 PAAcanya Gel EAcyclovir Ointment

5%1

Aczone Gel 3Atralin 3 PABenzaclin EBenzamycin EBetamethasone

Dipropionate Cream

1

Ciclopirox Cream 1Clindamycin Gel,

Lotion, Solution1

Clindamycin/ Benzoyl Peroxide Gel 1-5%

1

Clindamycin/Benzoyl Peroxide Gel 1.2-5%

1

Clobetasol Cream, Ointment, Solution

1

Clobex 3Clotrimazole/

Betamethasone Cream, Lotion

1

Cortifoam 3Desonide Cream,

Ointment1

Drug Name Drug Tier

Programs and Limits

Desoximetasone Cream, Gel, Ointment

1

Differin 3 PADuac EEconazole Cream 1Elidel 2 STEpiduo & Epiduo

Forte3

Finacea 3 STFluocinonide Cream,

0.1%1

Fluocinonide Cream, Gel, Ointment, Solution 0.05%

1

Hydrocortisone Cream, Ointment 2.5%

1

Lidocaine Topical Ointment, Solution

1

Lidocaine/Prilocaine Cream

1

Ketoconazole Cream/Shampoo

1

Metrogel 3Metronidazole Gel

0.75%1

Mirvaso Gel 2Mupirocin Ointment 1Nystatin Cream,

Ointment, Powder1

Nystatin/Triamcinolone Cream, Ointment

1

Onexton 3Oxsoralen-UL 2Permethrin Cream 5% 1Proctofoam HC 2Retin-A Micro 3 PASoolantra 2Sulfacetamide/Sulfur

Emulsion1

Taclonex 3 QLTazorac 3


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Drug Name Drug Tier

Programs and Limits

Tretinoin Cream 1 PATretinoin Microsphere

Gel1 PA

Triamcinolone 1Vectical 3Veltin EZiana Gel EZovirax Cream 2Zovirax Ointment 3Zyclara 3

Diabetes/Endocrine: Insulin

Apidra EHumalog Mix 50/50

Vial and KwikPen2

Humalog Mix 75-25 Vial and KwikPen

2

Humalog U-100 Vial and KwikPen

2

Humalog U-200 KwikPen

2

Humulin 70-30 Vial and KwikPen

2

Humulin N Vial and KwikPen

2

Humulin R U-500 Vial and KwikPen

2

Humulin R Vial 2Lantus SoloStar 2Lantus Vial 2Levemir FlexTouch ELevemir Vial ENovolin 70/30 Vial ENovolin N Vial ENovolin R Vial ENovolog Flexpen ENovolog Mix 70/30

Vial and FlexpenE

Novolog Penfill ENovolog Vial EToujeo SoloStar 2Tresiba E

Drug Name Drug Tier

Programs and Limits

Diabetes/Endocrine: Non-Insulin

alogliptin Ealogliptin/metformin Ealogliptin/

pioglitazoneE

Bydureon 2 QL, STByetta 2 QL, STFarxiga EGlimepiride 1Glipizide 1Glipizide ER 1Glipizide XL 1Glumetza 3 PAGlyburide 1Glyburide/Metformin 1Invokamet 2 STInvokamet XR 2 STInvokana 2 STJanumet 2 STJanumet XR 2 STJanuvia 2 STJardiance 2 STJentadueto 2 STJentadueto XR 2 STKazano EKombiglyze EMetformin 1Metformin ER 1Nesina EOnglyza EOseni EPioglitazone 1Synjardy 2 STTanzeum ETradjenta 2 STTrulicity 2 QL, STVictoza 2 QL, STXigduo XR E

Endocrine: Growth Hormone

Genotropin EHumatrope ENorditropin 2 PA, SP


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Drug Name Drug Tier

Programs and Limits

Nutropin AQ 2 PA, SPOmnitrope ESaizen EZomacton E

Endocrine: Other

Calcitriol Cap 1Dexamethasone Tab 1H.P. Acthar 2 PA, SPHydrocortisone Tab 1Lupron Depot

3.75 mg, 11.25 mg3 PA, SP

Lupron Depot 7.5 mg, 22.5 mg, 30 mg, 45 mg

2 PA, SP

Methylprednisolone Tab

1

Prednisone 1Prednisolone Solution

25 mg/5 ml1

Prednisolone Syrup, Solution 15 mg/5 ml

1

Sensipar 3 PAEndocrine: Thyroid Hormone Replacement Armour Thyroid 3Levothyroxine 1Liothyronine 1Methimazole 1Synthroid 3Tirosint 3

Eye Conditions: Allergies

Azelastine Ophthalmic Solution

1

Bepreve 3 STLastacaft 3 STPataday 2Pazeo 2

Drug Name Drug Tier

Programs and Limits

Eye Conditions: Antibiotics

Besivance 3Ciprofloxacin

Ophthalmic Solution

1

Erythromycin Ointment

1

Gentamicin 1Moxeza 2 Neomycin/Polymyxin

B/Dexamethasone Ointment, Suspension

1

Ofloxacin Ophthalmic Solution

1

Polymyxin B/Trim-ethoprim Solution

1

Tobramycin 1Tobramycin/

Dexamethasone1

Vigamox 2

Eye Conditions: Glaucoma

Alphagan P 2Azopt 2Betimol 3Brimonidine 1Combigan 2Cosopt PF 3Dorzolamide-Timolol

Maleate1

Latanoprost 1 QLLumigan 2 QLRescula ESimbrinza 2Timolol 1Timoptic Ocudose 2Travatan Z 2 QLZioptan E


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Drug Name Drug Tier

Programs and Limits

Eye Conditions: Other

Durezol Ophthalmic Emulsion

3

Lotemax Ophthalmic Gel

3 QL

Ketorolac Ophthalmic Solution

1

Prednisolone Ophthalmic Suspension

1

Restasis 3 PA

Gastrointestinal: Acid Suppression

Dexilant 2 QLDuexis EEsomeprazole (Rx

only)1 QL

Famotidine Tab 20 mg and 40 mg (Rx only)

1

Lansoprazole (Rx only) 1 QLOmeprazole (Rx only) 1 QLPantoprazole 1 QLRanitidine Tab, Cap,

Syrup (Rx only)1

Sucralfate Tab 1Vimovo E

Gastrointestinal: Nausea/Vomiting

Meclizine 1Metoclopramide 1Ondansetron Tab,

ODT1 QL

Transderm-Scop 3Varubi 3 QL

Drug Name Drug Tier

Programs and Limits

Gastrointestinal: Other

Amitiza 2 QL, STApriso 2Asacol HD ECanasa 2Creon 2Delzicol EDipentum 3Gavilyte Solution 1Hyoscyamine

Sublingual Tab1

Lactulose 1Lialda 2Linzess 2 QL, STmesalamine DR EMoviprep 3Omeclamox Pak 2Pancreaze EPentasa 3Pertzye EPolyethylene

Glycol 3350 Powder

1

Prepopik 3Protosol HC 1Pylera 2Sulfasalazine 1Suprep Bowel Prep 3Uceris Foam 3Ultresa EViokace EZenpep 2


17

Drug Name Drug Tier

Programs and Limits

HIV/AIDS

Atripla 2 SP Complera 2 SPEpzicom 2 SPGenvoya 2 SPIntelence 2 SPIsentress 2 SPKaletra Solution 3 SPKaletra Tab 2 SPNevirapine 1 SPNorvir 2 SPPrezcobix 2 SPPrezista 2 SPReyataz 2 SPStribild 2 SPSustiva 2 SPTivicay 2 SPTriumeq 2 SPTruvada 2 SPViread 2 SP

Infertility

Bravelle ECetrotide 2 SPFollistim AQ EGonal-f 2 PA, SPGonal-f RFF 2 PA, SPOvidrel 3 SP

Drug Name Drug Tier

Programs and Limits

Inflammatory Conditions

Cimzia Kit 2 PA, SPCosentyx EDepen 2Enbrel 3 PA, SPHumira Kit 2 PA, SPHumira Pen Kit 2 PA, SPHumira Pen Kit

Crohns2 PA, SP

Humira Pen Kit Psoriasis

2 PA, SP

Hydroxychloroquine 1Inflectra EMethotrexate Tab 1Orencia SC 3 PA, ST, SPOtezla 3 PA, ST, SPOtrexup 3 PA, QLRasuvo 2 PA, QLSimponi 2 PA, SPStelara 2 PA, SPTaltz 3 PA, ST, SPXeljanz 3 PA, ST, SP

Men’s Health: Erectile Dysfunction

Cialis 2 QLLevitra EStaxyn EStendra EViagra 2 QL

Men’s Health: Prostate

Alfuzosin 1Cialis 2.5 mg & 5 mg 2 QLDoxazosin 1Finasteride 5 mg 1Rapaflo 2Tamsulosin 1Terazosin 1


18

Drug Name Drug Tier

Programs and Limits

Men’s Health: Testosterone Therapy

Androderm 2 PAAndrogel 1.62% 2 PAAndrogel 1% EAxiron EFortesta ETestim ETestosterone

Cypionate IM Injection

1 PA

Vogelxo E

Miscellaneous

Adrenaclick EAllopurinol 1Antipyrine/Benzocaine

Otic Solution 5.4 - 1.4%

1

Aranesp EAuryxia 3Auvi-Q EBenzonatate 1Bunavail 3 PA, QLCerdelga 3 PA, SPChantix 3 QLCheratussin 1Chlorhexidine 1Colcrys 2Cyproheptadine 1Desmopressin 1Epinephrine

Auto-Injector (Authorized Generic for EpiPen made by Mylan)

2

Epinephrine Auto- Injector (made by Impax)

E

EpiPen & EpiPen Jr EEpogen EFosrenol 3Granix 2 PA, SP

Drug Name Drug Tier

Programs and Limits

Guaifenesin/Codeine Syrup

1

Homatropine/Hydrocodone Syrup

1

Hydrocodone/Chlorpheniramine Liquid

1

Hydrocortisone AC Suppository 25 mg

1

Hydromet 1Lidocaine Viscous

Solution 2%1

Makena 2 PA, SPNarcan 2Neupogen 2 PA, SPPhenazopyridine

(Rx only)1

Phentermine Tab 1 PAProcrit 2 PA, SPPromethazine DM

Syrup1

Promethazine/Codeine Syrup

1

Pulmozyme 2 PA, SP, QLRenvela Tab, Pack 2Rezira 3Suboxone Film 2 PA, QLSynagis 2 PA, SPSynvisc 2 PA, SPSynvisc One 2 PA, SPUloric 2 STUrsodiol 1Velphoro 3Zarxio 2 PA, SPZostavax Injection 3Zubsolv 2 PA, QLZutripro 3


19

Drug Name Drug Tier

Programs and Limits

Musculoskeletal: Osteoporosis

Alendronate Tab 35 mg & 70 mg

1 QL

Binosto 3 QLEvista 3Forteo 2 PA, SPIbandronate Tab 1 QLRaloxifene 1

Musculoskeletal: Other

Baclofen Tab 1Carisoprodol 350 mg 1Cyclobenzaprine Tab

5, 10 mg1

Metaxalone 1Methocarbamol 1Tizanidine Cap 1Tizanidine Tab 1

Musculoskeletal: Pain Relief

Abstral EAcetaminophen

w/ Codeine 1 QL

Cambia ECelebrex 3 QLCelecoxib 1 QLDiclofenac Tab 1Embeda 2 QLEndocet Tab 1 QLEtodolac 1Fentanyl Patch

25 mcg/hr, 50 mcg/hr, 75 mcg/hr, 100 mcg/hr

1 QL

Fentanyl Patch 37.5 mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr

1 QL

Fentora EFlector patch 3 QLGralise 3 QL, ST

Drug Name Drug Tier

Programs and Limits

Hydrocodone/APAP 5, 7.5, 10/325 mg

1 QL

Hydromorphone Tab 1 QLHysingla ER EIbuprofen Tab 400,

600, 800 mg (Rx only)

1

Indomethacin Cap 1Kadian EKetorolac Tab 1 QLLazanda ELidocaine Patch 5% 1Meloxicam 1Methadone Tab 1Morphine Sulfate Tab 1 QLNabumetone 1Naproxen (Rx only) 1Nucynta ER EOpana ER EOxycodone Tab

5, 10, 15, 30 mg (Immediate Release)

1 QL

Oxycodone w/ Acetaminophen

1 QL

Oxycontin 2 QLSubsys ETramadol Tab 50 mg 1Tramadol

w/ Acetaminophen 1

Vicodin 1 QLVicodin ES 1 QLVoltaren Gel 3 QL Xtampza ER EZohydro ER EZorvolex E


20

Drug Name Drug Tier

Programs and Limits

Overactive Bladder

Myrbetriq 2Oxybutynin 1Oxybutynin ER 1Tolterodine 1Toviaz 3Vesicare 2

Respiratory: Asthma/COPD

Advair Diskus 2 QLAdvair HFA 2 QLAerospan 3 QLAlbuterol

Nebulizer Solution1 QL

Alvesco EAnoro Ellipta 2 QLArnuity Ellipta 2 QLAsmanex E Breo Ellipta 2 QLBudesonide Inhalation

Suspension1 QL

Combivent Respimat 2 QLDulera EFlovent Diskus 2 QLFlovent HFA 2 QLForadil 2 QLIncruse Ellipta 2 QLIpratropium/Albuterol


Levalbuterol Inhaler ELevalbuterol


Montelukast 1Perforomist 3 QLProair HFA,

RespiClick2 QL

Proventil HFA EPulmicort Flexhaler 2 QLQvar ESeebri 3 QLSerevent Diskus 2 QLSpiriva Handihaler 2 QLSpiriva Respimat 2 QL

Drug Name Drug Tier

Programs and Limits

Stiolto 2 QLSymbicort 2 QLTudorza EVentolin HFA 2 QLXopenex HFA E

Respiratory: Nasal Allergies

Astepro 3 QLAzelastine Spray 1 QLDymista Spray 2 QLFluticasone Spray 1Ipratropium Spray 1 QLMometasone 1 QLNasonex 2 QLOmnaris 3 QLQNasl 3 QLTriamcinolone Spray 1 QLZetonna 3 QL

Respiratory: Oral Allergies

Cetirizine 1Promethazine Tab 1Desloratadine 1Levocetirizine 1

Transplant

Azathioprine Tab 1Cellcept Tab/

Suspension3 SP

Cyclosporine Cap 1 SPMycophenolate Mofetil

250 mg Cap/ 500 mg Tab

1 SP

Mycophenolate Sodium 180 mg, 360 mg Tab

1 SP

Prograf Cap 3 SPRapamune 3 SPTacrolimus Cap 1 SP


21

Drug Name Drug Tier

Programs and Limits

Vitamins/Electrolytes

Folic Acid 1 mg (Rx only)

1

Klor-Con 8 and 10 MEQ

1

Klor-Con M10 and M20

1

Multi-Vit/Fl Chew 1Potassium Chloride

ER Tab, Cap1

Potassium Chloride Micro ER Tab

1

Potassium Citrate 540 mg, 1080 mg Tab

1

Vitamin D 50,000 units (Rx only)

1

Women’s Health: Birth Control

Apri 1Aviane 1Azurette 1Cryselle-28 1Falmina 1Generess Fe

Chewable3

Gianvi 1Gildess 1Jolivette 1Junel 1Kariva 1Levora 28 1

Drug Name Drug Tier

Programs and Limits

Lomedia Fe 1Loryna 1Low-Ogestrel 1Lutera 1Medroxyprogesterone

Acetate Injection1 QL

Microgestin 1Microgestin Fe 1Minastrin 24 Fe

Chewable3

Mono-Linyah 1Mononessa 1Necon 1Nora-Be 1Norgest/Ethi Estradio 1Nortrel 1Nuvaring 2Ocella 1Orsythia 1Ortho Tri-Cyclen Lo 3Previfem 1Reclipsen 1Sprintec 28 1Tri-Linyah 1Tri-Previfem 1Trinessa 1Tri-Sprintec 1Vestura 1Viorele 1Xulane 1Zarah 1


22

Drug Name Drug Tier

Programs and Limits

Women’s Health: Hormone Replacement

Climara Pro 2Divigel 3Duavee 2Elestrin Gel 3Estrace Vaginal

Cream3

Estradiol Tab 1Estradiol/

Norethindrone Tab1

Medroxyprogesterone Acetate Tab

1

Minivelle 3Osphena 3Premarin Tab 2Premarin Vaginal

Cream2

Premphase 2Prempro 2Progesterone Cap 1Vagifem 3

Women’s Health: Vaginal Anti-Infectives

Gynazole-1 Vaginal Cream

3

Metronidazole Vaginal Gel

1

Terconazole Vaginal Cream

1


23

AAbsorica . . . . . . . . . . 13Abstral . . . . . . . . . . . 19Acanya Gel . . . . . . . . 13Acetaminophen w/ Codeine 19Acyclovir Cap, Tab,

Suspension . . . . . . . . 9Acyclovir Ointment 5% . . 13Aczone Gel . . . . . . . . 13Adcirca . . . . . . . . . . 11Adderall XR Cap . . . . . 11Adempas . . . . . . . . . 11Adrenaclick . . . . . . . . 18Advair Diskus . . . . . . . 20Advair HFA. . . . . . . . . 20Aerospan . . . . . . . . . 20Akynzeo . . . . . . . . . . . 9Albuterol Nebulizer Solution 20Alendronate Tab . . . . . . 19Alfuzosin . . . . . . . . . . 17Allopurinol . . . . . . . . . 18alogliptin. . . . . . . . . . 14alogliptin/metformin . . . 14alogliptin/pioglitazone . . 14Alphagan P . . . . . . . . 15Alprazolam Tab. . . . . . . 12Alvesco . . . . . . . . . . 20Amiodarone . . . . . . . . 11Amitiza. . . . . . . . . . . 16Amitriptyline . . . . . . . . 11Amlodipine . . . . . . . . . 10Amlodipine/Atorvastatin . . 11Amlodipine/Benazepril . . . 10Amlodipine/Valsartan. . . . 10Amlodipine/Valsartan/HCTZ 10Amoxicillin . . . . . . . . . . 9Amoxicillin/Clavulanate . . . 9

Amphetamine-Dextro-amphetamine SR 24Hr Cap . . . . . . . . 11

Amphetamine-Dextro-amphetamine Tab . . . 11

Ampyra . . . . . . . . . . 12Anastrozole Tab . . . . . . . 9Androderm . . . . . . . . 18Androgel 1% . . . . . . . 18Androgel 1.62% . . . . . . 18Anoro Ellipta. . . . . . . . 20Antipyrine/Benzocaine Otic

Solution 5.4 - 1.4%. . . 18Apidra . . . . . . . . . . . 14Apri . . . . . . . . . . . . . 21Apriso . . . . . . . . . . . 16Aranesp . . . . . . . . . . 18Aripiprazole . . . . . . . . 12Armour Thyroid . . . . . . 15Arnuity Ellipta . . . . . . . 20Asacol HD . . . . . . . . . 16Asmanex. . . . . . . . . . 20Astepro . . . . . . . . . . 20Atenolol . . . . . . . . . . 10Atenolol/Chlorthalidone . . 10Atorvastatin . . . . . . . . 10Atralin . . . . . . . . . . . 13Atripla . . . . . . . . . . . 17Aubagio . . . . . . . . . . 12Auryxia. . . . . . . . . . . 18Auvi-Q . . . . . . . . . . . 18Aviane . . . . . . . . . . . 21Avonex Kit . . . . . . . . . 12Avonex Pen Kit . . . . . . 12Avonex Prefill Kit . . . . . 12Axiron . . . . . . . . . . . 18Azasite . . . . . . . . . . . . 9Azathioprine Tab . . . . . . 20

Azelastine Ophthalmic Solution. . . . . . . . . 15

Azelastine Spray . . . . . . 20Azithromycin . . . . . . . . . 9Azopt. . . . . . . . . . . . 15Azor . . . . . . . . . . . . 10Azurette . . . . . . . . . . 21

BBaclofen Tab . . . . . . . . 19Benazepril . . . . . . . . . 10Benazepril/HCTZ . . . . . 10Benicar . . . . . . . . . . 10Benicar HCT. . . . . . . . 10Benzaclin . . . . . . . . . 13Benzamycin . . . . . . . . 13Benzonatate . . . . . . . . 18Benztropine . . . . . . . . 12Bepreve . . . . . . . . . . 15Besivance . . . . . . . . . 15Betamethasone D

ipropionate Cream . . . 13Betaseron . . . . . . . . . 12Bethkis. . . . . . . . . . . . 9Betimol . . . . . . . . . . 15Binosto . . . . . . . . . . 19Bisoprolol . . . . . . . . . 10Bisoprolol/HCTZ . . . . . . 10Bravelle . . . . . . . . . . 17Breo Ellipta . . . . . . . . 20Brilinta . . . . . . . . . . . 10Brimonidine . . . . . . . . 15Budesonide Inhalation

Suspension . . . . . . . 20Bumetanide . . . . . . . . 10Bunavail . . . . . . . . . . 18Bupropion . . . . . . . . . 11Bupropion ER . . . . . . . 11

Bold type = Brand-name drug[Plain type = Generic drug]

Index of Drugs

24

Bupropion SR . . . . . . . 11Bupropion XL. . . . . . . . 11Buspirone . . . . . . . . . 12Butalbital-Acetaminophen-

Caffeine Cap, Tab . . . 12Bydureon . . . . . . . . . 14Byetta . . . . . . . . . . . 14Bystolic . . . . . . . . . . 10

CCalcitriol Cap. . . . . . . . 15Cambia . . . . . . . . . . 19Canasa. . . . . . . . . . . 16Capecitabine . . . . . . . . . 9Carbamazepine Tab . . . . 12Carbidopa/Levodopa Tab

(Immediate Release) . . 12Carisoprodol . . . . . . . . 19Cartia XT . . . . . . . . . . 10Carvedilol . . . . . . . . . 10Cefadroxil Cap . . . . . . . . 9Cefdinir . . . . . . . . . . . . 9Cefuroxime Tab . . . . . . . 9Celebrex . . . . . . . . . . 19Celecoxib . . . . . . . . . 19Cellcept Tab/Suspension. 20Cephalexin . . . . . . . . . . 9Cerdelga . . . . . . . . . . 18Cetirizine . . . . . . . . . . 20Cetrotide. . . . . . . . . . 17Chantix . . . . . . . . . . 18Cheratussin . . . . . . . . 18Chlorhexidine . . . . . . . 18Chlorthalidone . . . . . . . 10Cholestyramine . . . . . . 10Cialis . . . . . . . . . . . . 17Ciclopirox Cream. . . . . . 13Cimzia Kit . . . . . . . . . 17

Ciprodex Otic Suspension . 9Ciprofloxacin Ophthalmic

Solution. . . . . . . . . 15Ciprofloxacin Tab. . . . . . . 9Clarithromycin . . . . . . . . 9Climara Pro . . . . . . . . 22Clindamycin/Benzoyl

Peroxide Gel 1.2-5% . . 13Clindamycin/

Benzoyl Peroxide Gel 1-5% . . . . . . . . 13

Clindamycin Cap . . . . . . . 9Clindamycin Gel, Lotion,

Solution. . . . . . . . . 13Clobetasol Cream,

Ointment, Solution . . . 13Clobex . . . . . . . . . . . 13Clonazepam . . . . . . . . 12Clonidine Patch . . . . . . 10Clonidine Tab. . . . . . . . 10Clopidogrel . . . . . . . . . 10Clotrimazole/Betamethasone

Cream, Lotion . . . . . 13Colcrys . . . . . . . . . . 18Combigan . . . . . . . . . 15Combivent Respimat . . . 20Complera . . . . . . . . . 17Copaxone . . . . . . . . . 12Corlanor . . . . . . . . . . 11Cortifoam . . . . . . . . . 13Cosentyx . . . . . . . . . . 17Cosopt PF . . . . . . . . . 15Creon . . . . . . . . . . . 16Crestor. . . . . . . . . . . 10Cryselle-28 . . . . . . . . . 21Cyclobenzaprine Tab. . . . 19Cyclosporine Cap . . . . . 20Cyproheptadine . . . . . . 18

DDaklinza . . . . . . . . . . . 9Delzicol . . . . . . . . . . 16Depen . . . . . . . . . . . 17Desloratadine . . . . . . . 20Desmopressin . . . . . . . 18Desonide Cream, Ointment 13Desoximetasone Cream,

Gel, Ointment. . . . . . 13Dexamethasone Tab . . . . 15Dexilant . . . . . . . . . . 16Dexmethylphenidate ER Cap 11Diazepam Tab . . . . . . . 12Diclofenac Tab . . . . . . . 19Differin . . . . . . . . . . . 13Digoxin . . . . . . . . . . . 11Diltiazem Tab . . . . . . . . 10Dipentum . . . . . . . . . 16Divalproex DR . . . . . . . 12Divalproex ER . . . . . . . 12Divigel . . . . . . . . . . . 22Donepezil Tab . . . . . . . 12Doryx MPC . . . . . . . . . 9Dorzolamide-Timolol

Maleate . . . . . . . . . 15Doxazosin . . . . . . . 10, 17Doxepin . . . . . . . . . . 11Doxycycline Hyclate Cap . . 9Doxycycline Hyclate Tab

(Immediate Release) . . . 9Doxycycline Monohydrate

Cap . . . . . . . . . . . . 9Doxycycline Monohydrate Oral

Suspension, Tab . . . . . 9Duac . . . . . . . . . . . . 13Duavee. . . . . . . . . . . 22Duexis . . . . . . . . . . . 16Dulera . . . . . . . . . . . 20


Index of Drugs

25

Duloxetine Cap. . . . . . . 11Durezol Ophthalmic

Emulsion . . . . . . . . 16Dymista Spray. . . . . . . 20

EEconazole Cream . . . . . 13Edarbi . . . . . . . . . . . 10Edarbyclor. . . . . . . . . 10Effient . . . . . . . . . . . 10Elestrin Gel . . . . . . . . 22Elidel . . . . . . . . . . . . 13Eliquis . . . . . . . . . . . 10Embeda . . . . . . . . . . 19Enalapril . . . . . . . . . . 10Enalapril/HCTZ . . . . . . . 10Enbrel . . . . . . . . . . . 17Endocet Tab . . . . . . . . 19Enoxaparin . . . . . . . . . 10Entecavir . . . . . . . . . . . 9Epclusa . . . . . . . . . . . 9Epiduo & Epiduo Forte . . 13Epinephrine Auto-Injector 18EpiPen & EpiPen Jr . . . . 18Epogen . . . . . . . . . . 18Epzicom . . . . . . . . . . 17Erythromycin . . . . . . . . . 9Erythromycin Ointment. . . 15Escitalopram Tab. . . . . . 11Esomeprazole (Rx only) . . 16Estrace Vaginal Cream . . 22Estradiol/Norethindrone Tab 22Estradiol Tab . . . . . . . . 22Eszopiclone Tab . . . . . . 12Etodolac . . . . . . . . . . 19Evekeo. . . . . . . . . . . 11Evista . . . . . . . . . . . 19Extavia . . . . . . . . . . . 12

FFalmina. . . . . . . . . . . 21Famciclovir Tab . . . . . . . 9Famotidine Tab (Rx only) . . 16Farxiga. . . . . . . . . . . 14Felodipine . . . . . . . . . 10Fenofibrate . . . . . . . . . 10Fentanyl Patch . . . . . . . 19Fentora . . . . . . . . . . 19Finacea . . . . . . . . . . 13Finasteride . . . . . . . . . 17Flecainide . . . . . . . . . 11Flector patch . . . . . . . 19Flovent Diskus . . . . . . 20Flovent HFA . . . . . . . . 20Fluconazole . . . . . . . . . 9Fluocinonide Cream, 0.1%. 13Fluocinonide Cream,

Gel, Ointment, Solution 0.05% . . . . . 13

Fluoxetine Cap (not PMDD) 11Fluticasone Spray . . . . . 20Fluvoxamine Tab . . . . . . 11Folic Acid (Rx only) . . . . 21Follistim AQ . . . . . . . . 17Foradil . . . . . . . . . . . 20Forfivo XL . . . . . . . . . 11Forteo . . . . . . . . . . . 19Fortesta . . . . . . . . . . 18Fosinopril. . . . . . . . . . 10Fosrenol . . . . . . . . . . 18Furosemide. . . . . . . . . 10

GGabapentin. . . . . . . . . 12Gavilyte Solution . . . . . . 16Gemfibrozil . . . . . . . . . 11Generess Fe Chewable . . 21

Genotropin . . . . . . . . 14Gentamicin . . . . . . . . . 15Genvoya . . . . . . . . . . 17Gianvi . . . . . . . . . . . 21Gildess . . . . . . . . . . . 21Gilenya. . . . . . . . . . . 12Glimepiride . . . . . . . . . 14Glipizide . . . . . . . . . . 14Glipizide ER . . . . . . . . 14Glipizide XL . . . . . . . . 14Glumetza . . . . . . . . . 14Glyburide . . . . . . . . . . 14Glyburide/Metformin . . . . 14Gonal-f. . . . . . . . . . . 17Gonal-f RFF . . . . . . . . 17Gralise . . . . . . . . . . . 19Granix . . . . . . . . . . . 18Guaifenesin/Codeine Syrup 18Guanfacine ER Tab. . . . . 11Guanfacine Tab

(Immediate Release) . . 10Gynazole-1 Vaginal Cream 22

HHarvoni . . . . . . . . . . . 9Homatropine/Hydrocodone

Syrup . . . . . . . . . . 18H.P. Acthar. . . . . . . . . 15Humalog Mix 50/50 Vial and

KwikPen . . . . . . . . 14Humalog Mix 75-25 Vial and

KwikPen . . . . . . . . 14Humalog U-100 Vial and

KwikPen . . . . . . . . 14Humalog U-200 KwikPen. 14Humatrope . . . . . . . . 14Humira Kit . . . . . . . . . 17Humira Pen Kit . . . . . . 17


Index of Drugs

26

Humira Pen Kit Crohns . . 17Humira Pen Kit Psoriasis . 17Humulin 70-30 Vial and

KwikPen . . . . . . . . 14Humulin N Vial and

KwikPen . . . . . . . . 14Humulin R U-500 Vial and

KwikPen . . . . . . . . 14Humulin R Vial. . . . . . . 14Hydralazine. . . . . . . . . 10Hydrochlorothiazide . . . . 10Hydrocodone/APAP . . . 19Hydrocodone/

Chlorpheniramine Liquid 18Hydrocortisone AC

Suppository . . . . . . 18Hydrocortisone Cream,

Ointment 2.5% . . . . . 13Hydrocortisone Tab . . . . 15Hydromet. . . . . . . . . . 18Hydromorphone Tab . . . . 19Hydroxychloroquine . . . . 17Hydroxyzine HCL . . . . . 12Hydroxyzine Pamoate . . . 12Hyoscyamine Sublingual Tab 16Hysingla ER . . . . . . . . 19

IIbandronate Tab . . . . . . 19Ibuprofen Tab (Rx only). . . 19Incruse Ellipta . . . . . . . 20Indomethacin Cap . . . . . 19Inflectra . . . . . . . . . . 17Intelence . . . . . . . . . 17Invega Sustenna . . . . . 12Invega Trinza . . . . . . . 12Invokamet . . . . . . . . . 14Invokamet XR . . . . . . . 14

Invokana. . . . . . . . . . 14Ipratropium/Albuterol

Nebulizer Solution . . . 20Ipratropium Spray . . . . . 20Irbesartan . . . . . . . . . 10Irbesartan/HCTZ . . . . . . 10Isentress. . . . . . . . . . 17Isosorbide Mononitrate . . 11

JJanumet . . . . . . . . . . 14Janumet XR . . . . . . . . 14Januvia . . . . . . . . . . 14Jardiance . . . . . . . . . 14Jentadueto . . . . . . . . 14Jentadueto XR . . . . . . 14Jolivette . . . . . . . . . . 21Jublia Solution . . . . . . . 9Junel . . . . . . . . . . . . 21

KKadian . . . . . . . . . . . 19Kaletra Solution . . . . . . 17Kaletra Tab . . . . . . . . 17Kariva . . . . . . . . . . . 21Kazano. . . . . . . . . . . 14Kerydin Solution . . . . . . 9Ketoconazole Cream/

Shampoo . . . . . . . . 13Ketorolac Ophthalmic

Solution. . . . . . . . . 16Ketorolac Tab . . . . . . . 19Kitabis . . . . . . . . . . . . 9Klor-Con 8 and 10 MEQ . . 21Klor-Con M10 and M20 . . 21Kombiglyze . . . . . . . . 14

LLabetalol . . . . . . . . . . 10Lactulose. . . . . . . . . . 16Lamotrigine ER. . . . . . . 13Lamotrigine

(Immediate Release) . . 12Lansoprazole (Rx only) . . . 16Lantus SoloStar . . . . . . 14Lantus Vial. . . . . . . . . 14Lastacaft . . . . . . . . . 15Latanoprost . . . . . . . . 15Latuda . . . . . . . . . . . 12Lazanda . . . . . . . . . . 19Letairis. . . . . . . . . . . 11Letrozole . . . . . . . . . . . 9Levalbuterol Inhaler. . . . 20Levalbuterol

Nebulizer Solution . . . 20Levemir FlexTouch . . . . 14Levemir Vial . . . . . . . . 14Levetiracetam . . . . . . . 13Levetiracetam ER . . . . . 13Levitra . . . . . . . . . . . 17Levocetirizine . . . . . . . 20Levofloxacin Tab . . . . . . . 9Levora 28. . . . . . . . . . 21Levothyroxine . . . . . . . 15Lialda . . . . . . . . . . . 16Lidocaine Patch 5% . . . . 19Lidocaine/Prilocaine Cream 13Lidocaine Topical Ointment,

Solution. . . . . . . . . 13Lidocaine Viscous

Solution 2% . . . . . . 18Linzess. . . . . . . . . . . 16Liothyronine . . . . . . . . 15Lipitor . . . . . . . . . . . 11Lisinopril . . . . . . . . . . 10


Index of Drugs

27

Lisinopril/HCTZ . . . . . . 10Lithium Carbonate . . . . . 12Lomedia Fe. . . . . . . . . 21Lorazepam Tab. . . . . . . 12Loryna . . . . . . . . . . . 21Losartan . . . . . . . . . . 10Losartan/HCTZ. . . . . . . 10Lotemax Ophthalmic Gel . 16Lovastatin . . . . . . . . . 11Lovaza . . . . . . . . . . . 11Low-Ogestrel. . . . . . . . 21Lumigan . . . . . . . . . . 15Lupron Depot . . . . . . . 15Lutera . . . . . . . . . . . 21Lyrica Cap . . . . . . . . . 13

MMakena . . . . . . . . . . 18Meclizine . . . . . . . . . . 16Medroxyprogesterone

Acetate Injection . . . . 21Medroxyprogesterone

Acetate Tab. . . . . . . 22Meloxicam . . . . . . . . . 19mesalamine DR . . . . . . 16Metaxalone. . . . . . . . . 19Metformin . . . . . . . . . 14Metformin ER . . . . . . . 14Methadone Tab. . . . . . . 19Methimazole . . . . . . . . 15Methocarbamol . . . . . . 19Methotrexate Tab . . . . . 17Methylphenidate ER Cap . 11Methylphenidate ER Tab . . 11Methylphenidate SA

Osmotic ER Tab . . . . 11Methylphenidate Tab . . . . 11Methylprednisolone Tab . . 15

Metoclopramide . . . . . . 16Metoprolol Succinate . . . 10Metoprolol Tartrate . . . . . 10Metrogel . . . . . . . . . . 13Metronidazole Gel 0.75% . 13Metronidazole Tab . . . . . . 9Metronidazole

Vaginal Gel . . . . . . . 22Microgestin. . . . . . . . . 21Microgestin Fe . . . . . . . 21Migranal . . . . . . . . . . 12Minastrin 24 Fe Chewable 21Minivelle . . . . . . . . . . 22Minocycline Cap . . . . . . . 9Mirtazapine. . . . . . . . . 11Mirvaso Gel . . . . . . . . 13Modafinil . . . . . . . . . . 12Mometasone . . . . . . . . 20Mono-Linyah . . . . . . . . 21Mononessa. . . . . . . . . 21Montelukast . . . . . . . . 20Morphine Sulfate Tab . . . 19Moviprep . . . . . . . . . 16Moxeza . . . . . . . . . . 15Moxifloxacin . . . . . . . . . 9Multaq . . . . . . . . . . . 11Multi-Vit/Fl Chew. . . . . . 21Mupirocin Ointment . . . . 13Mycophenolate Mofetil 250 mg

Cap/ 500 mg Tab . . . . . . . 20

Mycophenolate Sodium 180 mg, 360 mg Tab . . . . 20

Myrbetriq . . . . . . . . . 20

NNabumetone . . . . . . . . 19Nadolol . . . . . . . . . . . 10Namenda XR . . . . . . . 12Namzaric . . . . . . . . . 12Naproxen (Rx only) . . . . . 19Narcan . . . . . . . . . . . 18Nasonex . . . . . . . . . . 20Necon . . . . . . . . . . . 21 Neomycin/Polymyxin B/

Dexamethasone Ointment, Suspension . 15

Neomycin/Polymyxin/HC Otic Suspension, Solution. . . 9

Nesina . . . . . . . . . . . 14Neupogen . . . . . . . . . 18Nevirapine . . . . . . . . . 17Niacin ER Tab . . . . . . . 11Nifedipine ER. . . . . . . . 10Nitrofurantoin

Macrocrystalline . . . . . 9Nitrofurantoin Monohydrate

Macrocrystalline . . . . . 9Nitrostat . . . . . . . . . . 11Nora-Be . . . . . . . . . . 21Norditropin . . . . . . . . 14Norgest/Ethi Estradio . . . 21Nortrel . . . . . . . . . . . 21Nortriptyline . . . . . . . . 11Norvir . . . . . . . . . . . 17Novolin 70/30 Vial . . . . . 14Novolin N Vial . . . . . . . 14Novolin R Vial . . . . . . . 14Novolog Flexpen . . . . . 14Novolog Mix 70/30 Vial

and Flexpen . . . . . . 14Novolog Penfill . . . . . . 14Novolog Vial . . . . . . . . 14


Index of Drugs

28

Nucynta ER . . . . . . . . 19Nutropin AQ . . . . . . . . 15Nuvaring . . . . . . . . . . 21Nystatin Cream, Ointment,

Powder . . . . . . . . . 13Nystatin Suspension . . . . . 9Nystatin/Triamcinolone

Cream, Ointment . . . . 13

OOcella . . . . . . . . . . . 21Ofloxacin Ophthalmic

Solution. . . . . . . . . 15Ofloxacin Otic Solution. . . . 9Olanzapine Tab. . . . . . . 12Omeclamox Pak . . . . . 16Omega-3 Acid Cap. . . . . 11Omeprazole (Rx only) . . . 16Omnaris . . . . . . . . . . 20Omnitrope . . . . . . . . . 15Ondansetron Tab, ODT. . . 16Onexton . . . . . . . . . . 13Onfi . . . . . . . . . . . . 13Onglyza . . . . . . . . . . 14Opana ER . . . . . . . . . 19Opsumit . . . . . . . . . . 11Oracea . . . . . . . . . . . . 9Orencia SC . . . . . . . . 17Orenitram . . . . . . . . . 11Orsythia . . . . . . . . . . 21Ortho Tri-Cyclen Lo . . . . 21Oseni. . . . . . . . . . . . 14Osphena . . . . . . . . . . 22Otezla . . . . . . . . . . . 17Otrexup . . . . . . . . . . 17Ovidrel . . . . . . . . . . . 17Oxcarbazepine . . . . . . . 13Oxsoralen-UL . . . . . . . 13

Oxybutynin . . . . . . . . 20Oxybutynin ER . . . . . . . 20Oxycodone Tab

(Immediate Release) . . 19Oxycodone

w/ Acetaminophen . . . 19Oxycontin . . . . . . . . . 19

PPancreaze . . . . . . . . . 16Pantoprazole . . . . . . . . 16Paroxetine Tab . . . . . . . 11Pataday . . . . . . . . . . 15Pazeo . . . . . . . . . . . 15Penicillin VK . . . . . . . . . 9Pentasa . . . . . . . . . . 16Perforomist . . . . . . . . 20Permethrin Cream 5% . . . 13Pertzye. . . . . . . . . . . 16Phenazopyridine (Rx only) . 18Phentermine Tab . . . . . . 18Phenytoin . . . . . . . . . 13Pioglitazone . . . . . . . . 14Plegridy . . . . . . . . . . 12Polyethylene

Glycol 3350 Powder . . 16Polymyxin B/Trim-ethoprim

Solution. . . . . . . . . 15Potassium Chloride ER

Tab, Cap . . . . . . . . 21Potassium Chloride Micro

ER Tab . . . . . . . . . 21Potassium Citrate Tab . . . 21Pradaxa . . . . . . . . . . 10Praluent . . . . . . . . . . 11Pravastatin . . . . . . . . . 11Prednisolone Ophthalmic

Suspension . . . . . . . 16

Prednisolone Solution . . . 15Prednisolone Syrup,

Solution. . . . . . . . . 15Prednisone . . . . . . . . . 15Premarin Tab . . . . . . . 22Premarin Vaginal Cream . 22Premphase . . . . . . . . 22Prempro . . . . . . . . . . 22Prepopik . . . . . . . . . . 16Previfem . . . . . . . . . . 21Prezcobix . . . . . . . . . 17Prezista . . . . . . . . . . 17Primidone . . . . . . . . . 13Pristiq . . . . . . . . . . . 11Proair HFA, RespiClick . . 20Prochlorperazine . . . . . . 12Procrit . . . . . . . . . . . 18Proctofoam HC . . . . . . 13Progesterone Cap . . . . . 22Prograf Cap . . . . . . . . 20Promethazine/Codeine

Syrup . . . . . . . . . . 18Promethazine DM Syrup . . 18Promethazine Tab . . . . . 20Propranolol . . . . . . . . . 10Propranolol ER . . . . . . . 10Protosol HC . . . . . . . . 16Proventil HFA . . . . . . . 20Pulmicort Flexhaler . . . . 20Pulmozyme . . . . . . . . 18Pylera . . . . . . . . . . . 16

QQNasl . . . . . . . . . . . 20Quetiapine . . . . . . . . . 12Quinapril . . . . . . . . . . 10Qvar . . . . . . . . . . . . 20


Index of Drugs

29

RRaloxifene . . . . . . . . . 19Ramipril . . . . . . . . . . 10Ranexa. . . . . . . . . . . 11Ranitidine Tab, Cap,

Syrup (Rx only) . . . . . 16Rapaflo . . . . . . . . . . 17Rapamune . . . . . . . . . 20Rasuvo. . . . . . . . . . . 17Rebif . . . . . . . . . . . . 12Rebif Titrtn . . . . . . . . 12Reclipsen. . . . . . . . . . 21Relpax . . . . . . . . . . . 12Renvela Tab, Pack . . . . 18Rescula . . . . . . . . . . 15Restasis . . . . . . . . . . 16Retin-A Micro . . . . . . . 13Revlimid . . . . . . . . . . . 9Rexulti . . . . . . . . . . . 12Reyataz . . . . . . . . . . 17Rezira . . . . . . . . . . . 18Risperidone Tab . . . . . . 12Risperidone Tab . . . . . . 12Rizatriptan Tab, ODT . . . . 12Ropinirole

(Immediate Release) . . 12Rosuvastatin . . . . . . . . 11

SSaizen . . . . . . . . . . . 15Saphris. . . . . . . . . . . 12Savaysa . . . . . . . . . . 10Seebri . . . . . . . . . . . 20Sensipar . . . . . . . . . . 15Serevent Diskus. . . . . . 20Seroquel XR . . . . . . . . 12Sertraline . . . . . . . . . . 12

Sildenafil Tab . . . . . . . . 11Silenor . . . . . . . . . . . 12Simbrinza . . . . . . . . . 15Simponi . . . . . . . . . . 17Simvastatin. . . . . . . . . 11Solodyn . . . . . . . . . . . 9Soolantra . . . . . . . . . 13Sotalol . . . . . . . . . . . 11Sovaldi . . . . . . . . . . . . 9Spiriva Handihaler . . . . 20Spiriva Respimat . . . . . 20Spironolactone . . . . . . . 10Sprintec 28 . . . . . . . . . 21Sprycel. . . . . . . . . . . . 9Staxyn . . . . . . . . . . . 17Stelara . . . . . . . . . . . 17Stendra . . . . . . . . . . 17Stiolto . . . . . . . . . . . 20Strattera . . . . . . . . . . 11Stribild . . . . . . . . . . . 17Suboxone Film . . . . . . 18Subsys . . . . . . . . . . . 19Sucralfate Tab . . . . . . . 16Sulfacetamide/Sulfur

Emulsion . . . . . . . . 13Sulfamethoxazole-

Trimethoprim . . . . . . . 9Sulfamethoxazole-

Trimethoprim DS . . . . . 9Sulfasalazine . . . . . . . . 16Sumatriptan Tab and Spray 12Sumavel Dose . . . . . . . 12Suprep Bowel Prep . . . . 16Sustiva . . . . . . . . . . . 17Symbicort . . . . . . . . . 20Synagis . . . . . . . . . . 18Synjardy . . . . . . . . . . 14

Synthroid . . . . . . . . . 15Synvisc . . . . . . . . . . 18Synvisc One . . . . . . . . 18

TTaclonex . . . . . . . . . . 13Tacrolimus Cap. . . . . . . 20Taltz . . . . . . . . . . . . 17Tamiflu . . . . . . . . . . . . 9Tamoxifen Tab . . . . . . . . 9Tamsulosin . . . . . . . . . 17Tanzeum . . . . . . . . . . 14Tasigna . . . . . . . . . . . 9Tazorac . . . . . . . . . . 13Tecfidera. . . . . . . . . . 12Tekturna . . . . . . . . . . 10Tekturna HCT . . . . . . . 10Telmisartan . . . . . . . . . 10Temazepam . . . . . . . . 12Temozolomide . . . . . . . . 9Terazosin . . . . . . . . 10, 17Terbinafine Tab . . . . . . . . 9Terconazole Vaginal Cream 22Testim . . . . . . . . . . . 18Testosterone Cypionate IM

Injection . . . . . . . . 18Timolol . . . . . . . . . . . 15Timoptic Ocudose . . . . 15Tirosint. . . . . . . . . . . 15Tivicay . . . . . . . . . . . 17Tizanidine Cap . . . . . . . 19Tizanidine Tab . . . . . . . 19TOBI Nebulizer . . . . . . . 9TOBI Podhaler . . . . . . . 9Tobramycin . . . . . . . . . 15Tobramycin/

Dexamethasone . . . . 15


Index of Drugs

30

Tobramycin Neb . . . . . . . 9Tolterodine . . . . . . . . . 20Topiramate Tab. . . . . . . 13Torsemide Tab . . . . . . . 10Toujeo SoloStar . . . . . . 14Toviaz . . . . . . . . . . . 20Tracleer . . . . . . . . . . 11Tradjenta . . . . . . . . . 14Tramadol Tab. . . . . . . . 19Tramadol

w/ Acetaminophen . . . 19Transderm-Scop . . . . . 16Travatan Z . . . . . . . . . 15Trazodone . . . . . . . . . 12Tresiba . . . . . . . . . . . 14Tretinoin Cream . . . . . . 14Tretinoin Microsphere Gel . 14Triamcinolone . . . . . . . 14Triamcinolone Spray . . . . 20Triamterene/HCTZ . . . . . 10Triazolam Tab. . . . . . . . 12Tribenzor . . . . . . . . . 10Tri-Linyah. . . . . . . . . . 21Trinessa . . . . . . . . . . 21Tri-Previfem . . . . . . . . 21Tri-Sprintec. . . . . . . . . 21Triumeq . . . . . . . . . . 17Trulicity . . . . . . . . . . 14Truvada . . . . . . . . . . 17Tudorza . . . . . . . . . . 20

UUceris Foam. . . . . . . . 16Uloric . . . . . . . . . . . 18Ultresa . . . . . . . . . . . 16Ursodiol . . . . . . . . . . 18

VVagifem . . . . . . . . . . 22Valacyclovir. . . . . . . . . . 9Valsartan . . . . . . . . . . 10Valsartan/HCTZ . . . . . . 10Varubi . . . . . . . . . . . 16Vascepa . . . . . . . . . . 11Vectical . . . . . . . . . . 14Velphoro . . . . . . . . . . 18Veltin . . . . . . . . . . . . 14Venlafaxine ER Cap . . . . 12Venlafaxine ER Tab. . . . . 12Venlafaxine Tab. . . . . . . 12Ventolin HFA. . . . . . . . 20Verapamil ER . . . . . . . . 10Vesicare . . . . . . . . . . 20Vestura . . . . . . . . . . . 21Viagra . . . . . . . . . . . 17Vicodin . . . . . . . . . . . 19Vicodin ES . . . . . . . . . 19Victoza. . . . . . . . . . . 14Vigamox . . . . . . . . . . 15Viibryd . . . . . . . . . . . 12Vimovo . . . . . . . . . . 16Vimpat . . . . . . . . . . . 13Viokace . . . . . . . . . . 16Viorele . . . . . . . . . . . 21Viread . . . . . . . . . . . 17Vitamin D (Rx only) . . . . . 21Vogelxo . . . . . . . . . . 18Voltaren Gel . . . . . . . . 19Vytorin . . . . . . . . . . . 11Vyvanse . . . . . . . . . . 11

WWarfarin . . . . . . . . . . 10Welchol . . . . . . . . . . 11

XXarelto . . . . . . . . . . . 10Xeljanz . . . . . . . . . . . 17Xigduo XR . . . . . . . . . 14Xopenex HFA . . . . . . . 20Xtampza ER . . . . . . . . 19Xulane . . . . . . . . . . . 21

ZZarah . . . . . . . . . . . . 21Zarxio . . . . . . . . . . . 18Zenpep . . . . . . . . . . 16Zepatier . . . . . . . . . . . 9Zetia . . . . . . . . . . . . 11Zetonna . . . . . . . . . . 20Ziana Gel . . . . . . . . . 14Zioptan . . . . . . . . . . 15Ziprasidone Cap . . . . . . 12Zohydro ER . . . . . . . . 19Zolmitriptan Tab . . . . . . 12Zolpidem . . . . . . . . . . 12Zolpidem ER . . . . . . . . 12Zomacton . . . . . . . . . 15Zonisamide. . . . . . . . . 13Zorvolex . . . . . . . . . . 19Zostavax Injection . . . . 18Zovirax Cream . . . . . . 14Zovirax Ointment . . . . . 14Zubsolv . . . . . . . . . . 18Zutripro . . . . . . . . . . 18Zyclara. . . . . . . . . . . 14Zytiga . . . . . . . . . . . . 9


Index of Drugs

31

“My Medications” worksheet

Take this worksheet with you each time you visit a doctor. Each of your doctors should be aware of every drug you take and you should have a list as well.

“My Medications” worksheet

Name of Medicine and Strength

Drug Tier

I Take This Medicine For

Directions Doctor

Example: Lisinopril, 20 mg Tier 1 High blood pressure One tablet daily Dr. Johnson

32Premium standard65919-062017

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Documents

2017 Prescription Drug List/Formulary … ERS Prescription...2 Your Prescription Drug List / Formulary This formulary outlines the most commonly prescribed medications covered under