Your 2015 Four-Tier Prescription Drug List - myNHP.com 4T Adv 115_4.pdf · Your 2015 Four-Tier Prescription Drug List effective January 1, 2015 ... Crestor) and generic drugs in plain

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Your 2015 Four-TierPrescription Drug Listeffective January 1, 2015NHP Advantage Four-Tier

Please read: This document contains information about commonly prescribed medications.

For additional information:

Call the toll-free member phone number on the back of your health plan ID card.

Visiting www.mynhp.com, clicking on the “Members” link and then selecting the “Pharmacy” tab on the left hand side of the page provides you access to:

•LocateaparticipatingretailpharmacybyZIPcode.

•Lookuppossiblelower-costmedicationalternatives.

•Comparemedicationpricingandoptions.

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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 www.mynhp.com for complete drug informationSince the PDL may change, we encourage you to visit our website, www.mynhp.com. Click on the “Members” link and then select the “Pharmacy” tab on the left hand side of the page. This website is the best source for up-to-date information about the medications your pharmacy benefi t covers, possible lower-cost options, and cost comparisons.

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Table of Contents

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

Programs and Limits . . . . . . . . . . . . . . . . . . . . . .7

Drugs by category . . . . . . . . . . . . . . . . . . . . . . 10

Anti-InfectivesAntibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Cardiovascular/Heart DiseaseCoagulation Therapy . . . . . . . . . . . . . . . . . . . . . . . .11High Blood Pressure . . . . . . . . . . . . . . . . . . . . . . . .11High Cholesterol . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Central Nervous SystemAttention Deficit Disorder . . . . . . . . . . . . . . . . . . . 13Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Sedatives/Hypnotics . . . . . . . . . . . . . . . . . . . . . . . 15Seizure Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Diabetes/EndocrineBlood Glucose Monitoring . . . . . . . . . . . . . . . . . . 17Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Non-Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

EndocrineGrowth Hormone . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Thyroid Hormone Replacement . . . . . . . . . . . . . 18

Eye ConditionsAllergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

GastrointestinalAcid Suppression . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Nausea/Vomiting . . . . . . . . . . . . . . . . . . . . . . . . . . 19Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Inflammatory Conditions: Rheumatoid Arthritis, Crohn’s Disease, Psoriasis, Ulcerative Colitis . . . . . . . . . . . . . . . . . . . . . . . . 20

Men’s HealthProstate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Testosterone Therapy . . . . . . . . . . . . . . . . . . . . . . 20

Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

MusculoskeletalOsteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Pain Relief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Overactive Bladder . . . . . . . . . . . . . . . . . . . . . . 23

RespiratoryAllergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Asthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Pulmonary Arterial Hypertension . . . . . . . . . . . . 24

Transplant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Vitamins/Electrolytes . . . . . . . . . . . . . . . . . . . 24

Women’s HealthContraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Hormone Replacement . . . . . . . . . . . . . . . . . . . . . 25Prenatal Vitamins . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Brand Only Exclusions . . . . . . . . . . . . . . . . . . 26

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

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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.

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. It 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 www.mynhp.com or call the toll-free member phone number on the back of your health plan ID card for more information.

How do I use my Prescription Drug List? 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 generic or brand, and if special programs apply. Bring this list 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 document, please visit www.mynhp.com or call the toll-free member phone number on the back of your health plan ID card.

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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 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, 3 or 4, look to see if there is a Tier 1 option available. Discuss these options with your doctor.

Check your benefit plan documents to find out your specific pharmacy plan costs.

$ Drug Tier Includes Helpful Tips

Tier 1Lowest Cost

Lower-cost drugs . Some brands and generics are also included .

Use Tier 1 drugs for the lowestout-of-pocket costs .

Tier 2 and 3Mid-range Cost

Mix of brands and generics .

Use Tier 2 or Tier 3 drugs instead of Tier 4 to help reduce your out-of-pocket costs .

Tier 4Highest Cost

Mostly higher-cost brand as well as select generic drugs .

Many Tier 4 drugs have lower-costoptions in Tier 1, 2 or 3 . Ask yourdoctor if they could work for you .

Please note: Some plans may have two or three 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 www.mynhp.com, or call the toll-free number of the back of your health plan ID card for more information about your benefit plan.

When does the Prescription Drug List 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 customer service at the number on the back of your ID card.

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Programs and LimitsSome medications are noted with letters next to them. The letters refer to our pharmacy benefit programs. Your benefit plan determines how these medications may be covered for you.

DSPDesignated Specialty Program* – Specialty medications need to be filled at a designated specialty pharmacy for network coverage . Call the number on your ID card or call 1-888-739-5820 for more information .

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

NNotification or Prior Authorization required*** – Your doctor is required to provide additional information to us to determine coverage .

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

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

STStep Therapy – Trial of a lower cost medication is required before a higher cost medication is covered .

* Specialty medications may have a different cost share, please consult your benefit documents .

** Some medications may require tried/failed criteria instead of being excluded from coverage .

*** Depending on your benefit you may have notification or prior authorization requirements for select medications .

To learn more about a pharmacy program or to find out if it applies to you, please visit www.mynhp.com or call the toll-free member phone number on the back of your health plan ID card.

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Why are some medications excluded from coverage? Medications 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. 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 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.mynhp.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. 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 the back of 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 or Tier 4, call the toll-free number on the back of your health plan ID card to talk with a pharmacist about finding lower-cost options or a financial assistance program.

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What is Mail Service Member Select? Your plan may include a home delivery program called Mail Service Member Select, which encourages you to use the OptumRx® Mail Service Pharmacy for medication you take regularly. Choosing home delivery can help you better manage the medication you take on a regular basis, and may save you time and money.

You can either confirm enrollment in the OptumRx Mail Service Pharmacy or you can disenroll from mail service and continue to fill your maintenance medications at a retail pharmacy. You can get up to two fills at a retail pharmacy before you have to decide. However, please be aware that you must make a decision about whether or not to enroll in Mail Service Member Select.

If you do nothing and continue to fill your medications at a retail pharmacy, you may pay up to 100% 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 www.mynhp.com or call the toll-free member phone number on the back of 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 www.mynhp.com or call the toll-free member phone number on the back of your health plan ID card for more current information.

Si usted esta interesado en conocer mas sobre su beneficio de farmacia o si necesita asistencia leyendo esta información, por favor llame al numero de telefono en la parte de atras de su tarjeta de identificacion.

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 benefit plan determines coverage for these medications .

For more information


Or, visit www.mynhp.com

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

DSP = Designated Specialty ProgramE = May be excluded from coverage

N = Notification or Prior Authorization requiredSDP = Select Designated PharmacySL = Supply LimitST = Step Therapy

Drug NameDrug Tier

Requirements & Limits

Anti-Infectives: Antibiotics

Adoxa Capsule 4 EAmoxicillin Capsule, Chewable Tablet

1

Amoxicillin/Potassium Clavulanate Chewable Tablet, Tablet

1

Augmentin XR 4 EAzithromycin Tablet 1Cefdinir Capsule 2Cefuroxime Tablet 1Centany AT 4 ECephalexin Capsule 1Ciprofloxacin Tablet 1Clarithromycin Tablet 1Clindamycin Capsule 1Dificid 3 SLDoryx 4 EDoxycycline Hyclate Capsule, Tablet

2

Doxycycline Monohydrate 50, 100 mg Capsule

1

Doxycycline Monohydrate 75 mg Capsule

4 E

Levofloxacin Tablet 1Metronidazole Tablet 1Minocycline Capsule 1Minocycline Tablet 3Nitrofurantoin Capsule 1Nitrofurantoin Macrocrystal Capsule

1

Oracea 4

Drug NameDrug Tier


Penicillin V Potassium Tablet 1

Solodyn 4Sulfamethoxazole-Trimethoprim Tablet

1

Zyvox 2 N, SL

Anti-Infectives: Antifungals

Ertaczo 4 EFluconazole Tablet 1Itraconazole Capsule 1 SLKetoconazole Cream 1Luzu 4 E, SLNaftin 1%, 2% Cream, Gel

4 E, SL

Nystatin Cream, Ointment

1

Onmel 4 E, SLOxistat Cream 4 N, SL, STOxistat Lotion 4 ETerbinafine Tablet 1 SL

Anti-Infectives: Antivirals

Acyclovir Ointment 4 N, SL, STAcyclovir Tablet 1Baraclude 2 DSPDenavir Cream 4 EOlysio 2 DSP, N, SLRibapak 4 DSP, ERibavirin Tablet 1 DSPTamiflu 3 SLValacyclovir Tablet 2 SLZovirax Cream 4 E, SL

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Drug NameDrug Tier


Cancer

Bosulif 2 DSP, N, SL, STCapecitabine Tablet 1 DSP, SLGleevec 2 DSP, N, SLHydroxyurea Capsule 3Leucovorin Calcium Tablet

1

Mercaptopurine Tablet 1Sutent 2 DSP, N, SLTasigna 2 DSP, N, SLZytiga 2 DSP, N, SLCardiovascular/Heart Disease: Coagulation TherapyClopidogrel 1Coumadin 2Effient 4 SLEliquis 4 SLEnoxaparin Sodium 2 SLPradaxa 2 SLWarfarin Sodium 1Xarelto 2 SLCardiovascular/Heart Disease: High Blood PressureAmlodipine 1Amlodipine Besylate-Benazepril

2 SL

Amlodipine/Telmisartan 4 E, SLAmturnide 4 E, SLAtenolol 1Atenolol-Chlorthalidone 1Azor 4 E, SLBenazepril 1Benazepril-Hydrochlorothiazide

1

Benicar 2 SLBenicar HCT 2 SLBidil 2Bisoprolol 1Bisoprolol-Hydrochlorothiazide

1

Bystolic 2Cartia XT 2

Drug NameDrug Tier


Carvedilol 1Chlorthalidone 1Clonidine Tablet 1Coreg CR 4 E, SLDiltiazem 24 Hour CD 2Diltiazem Sustained-Release Capsule

2

Diltiazem Sustained-Release Tablet

2

Diovan 3 SLDoxazosin 1Dutoprol 2 SLEdarbi 3 SLEdarbyclor 3 SLEnalapril 1Enalapril-Hydrochlorothiazide

1

Epaned 3 NExforge 4 E, SLExforge HCT 4 E, SLFelodipine 1Fosinopril Sodium 1Furosemide 1Guanfacine 1Hydralazine 1Hydrochlorothiazide 1Indapamide 1Irbesartan 2 SLLabetalol 1Lisinopril 1Lisinopril-Hydrochlorothiazide

1

Losartan 1Losartan-Hydrochlorothiazide

1

Metoprolol Succinate 50, 100, 200 mg

2

Metoprolol Tartrate 1Nadolol 1Nifedipine Extended-Release

1

Propranolol Tablet 1Quinapril 1

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Drug NameDrug Tier


Ramipril 1Spironolactone 1Tekamlo 4 E, SLTelmisartan 2 SLTelmisartan/Hydrochlorothiazide

2 SL

Terazosin 1Torsemide 1Triamterene-Hydrochlorothiazide

1

Tribenzor 4 E, SLTwynsta 4 E, SLValsartan 3 SLValsartan-Hydrochlorothiazide

2 SL

Verapamil 1Verapamil Sustained-Release

3

Cardiovascular/Heart Disease: High CholesterolAltoprev 4 E, SLAntara 4 EAtorvastatin 1 SLCaduet 4 E, SLCholine Fenofibrate 4 ECrestor 2 SLFenofibrate 43, 50 , 67, 130, 134, 150, 200 mg Capsule

4 E

Fenofibrate 48, 145 mg Tablet

4 E

Fenofibrate 54, 160 mg Tablet

2

Fenofibric Acid 4 EFenoglide 4 E

Drug NameDrug Tier


Gemfibrozil 1Lipofen 4 ELiptruzet 4 E, SLLivalo 4 SLLovastatin 1Niacin Extended-Release Tablet

4

Niaspan 2Omega-3-Acid Ethyl Esters Capsule

3 N

Pravastatin 1Simcor 4 SLSimvastatin 1Tricor 48, 145 mg 4 ETriglide 4 EVascepa 4 NVytorin 4 SLWelchol 2Zetia 4 SLCardiovascular/Heart Disease: OtherAmiodarone 1Digoxin 1Flecainide 1Isosorbide Mononitrate ER

1

Multaq 2Nitroglycerin Sublingual Spray

3 SL

Nitrolingual Pump Spray

4 E, SL

Ranexa 2Sotalol 1

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Drug NameDrug Tier


Central Nervous System: Attention Deficit DisorderAdderall XR 2 N, SLAmphetamine Salt Combo

1 N

Clonidine Extended-Release Tablet

4 E

Concerta 2 N, SLDaytrana 4 E, N, SLDexmethylphenidate Extended-Release Capsule

4 E, N, SL

Dexmethylphenidate Tablet

1 N

Dextroamphetamine Sulfate Tablet

3 N

Dextroamphetamine-Amphetamine Extended-Release

4 E, N, SL

Dextroamphetamine-Amphetamine Tablet

1 N

Focalin XR 4 E, N, SLIntuniv 4 E, SLKapvay 4 EMetadate CD 2 N, SLMethylphenidate 1 NMethylphenidate Extended-Release Capsule

4 E, N, SL

Methylphenidate Extended-Release Tablet

4 E, N, SL

Quillivant XR 4 E, N, SLRitalin LA 4 E, N, SLStrattera 4 SLVyvanse 2 N, SLZenzedi 4 E, N

Drug NameDrug Tier


Central Nervous System: Depression

Amitriptyline Tablet 1Aplenzin 4 E, SLBupropion Extended-Release Tablet

1

Bupropion Sustained-Release Tablet

1

Bupropion Tablet 1Citalopram Tablet 1Desvenlafaxine 4 E, SLDoxepin Capsule 1Duloxetine Capsule 3 SLEscitalopram Tablet 1Fluoxetine Capsule, Tablet

1

Fluvoxamine Tablet 1Forfivo XL 4 E, SLImipramine Tablet 1Khedezla 4 E Mirtazapine Tablet 1Nortriptyline Capsule 1Oleptro 4 E, SLParoxetine Tablet 1Pexeva 4 E, SLPristiq ER 3 SLSertraline Tablet 1Trazodone Tablet 1Venlafaxine Extended-Release Capsule

1 SL

Venlafaxine Extended-Release Tablet

3 E, SL

Venlafaxine Tablet 1Viibryd 4 SL

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Drug NameDrug Tier


Central Nervous System: Migraine

Acetaminophen/Butalbital/Caffeine 325 mg/50 mg/40 mg

1 SL

Acetaminophen/Butalbital/Caffeine/Codeine 325 mg/ 50 mg/40 mg/30 mg

1 SL

Alsuma 4 E, SLCambia 4 E, SLRelpax 2 SLRizatriptan Orally Disintegrating Tablet

3 SL

Rizatriptan Tablet 2 SLSumatriptan Nasal Spray 2 SLSumatriptan Succinate Tablet, Injection

1 SL

Sumavel DosePro 3 SLTreximet 4 E, SLCentral Nervous System: Multiple SclerosisAmpyra 2 DSP, N, SLAubagio 4 DSP, N, SL, STAvonex 2 DSP, N, SLBetaseron 2 DSP, N, SLCopaxone 2 DSP, N, SL

Extavia 4DSP, E, N,

SL, STGilenya 3 DSP, N, SL, STRebif 4 DSP, N, SL, STTecfidera 2 DSP, N, SL

Drug NameDrug Tier


Central Nervous System: Other

Abilify 4 SLAlprazolam Extended-Release Tablet

1

Alprazolam Tablet 1Aricept 23 mg 4 EBuprenorphine/Naloxone Tablet

4 E, N, SL

Buspirone Tablet 1Carbidopa-Levodopa 1Diazepam Tablet 1Donepezil 5, 10 mg Tablet

1

Latuda 4 SLLithium Capsule 1Lorazepam Tablet 1Modafinil Tablet 4 E, N, SLMirapex ER 4 ENamenda XR 4Nuvigil 4 N, SLOlanzapine Tablet 1 SLPramipexole Tablet 1Provigil 4 E, N, SLQuetiapine Tablet 2 SLRequip XL 4 ERisperidone Tablet 1Ropinirole Tablet 1Seroquel XR 4 SLSuboxone Film 4 E, N, SLTasmar 2Xyrem 4 N, SLZelapar 3Ziprasidone Capsule 2 SLZubsolv 2 N, SL

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Drug NameDrug Tier


Central Nervous System: Sedatives/HypnoticsAmbien CR 4 E, SL, STEdluar 4 E, SL, STEszopiclone Tablet 3 SL, STIntermezzo 4 E, SL, STSilenor 4 E, SLTemazepam Capsule 1Zaleplon Capsule 1 SLZolpidem Extended-Release Tablet

4 E, SL, ST

Zolpidem Tablet 1 SLZolpimist 3 SL, STCentral Nervous System: Seizure DisordersCarbamazepine Tablet 1Clonazepam Tablet 1Depakote 4 N, STDepakote ER 4 N, STDiazepam Tablet 1Divalproex Delayed-Release Tablet

1

Divalproex Extended-Release Tablet

1

Gabapentin Capsule, Tablet

1

Keppra 4 N, STKeppra XR 4 N, STLamictal 4 N, STLamictal XR 4 N, STLamotrigine Tablet 1Levetiracetam Extended-Release Tablet

2

Levetiracetam Tablet 1Lyrica 4 SDP, SLNeurontin 4 N, STOxcarbazepine Tablet 1Oxtellar XR 4 E, N, STPhenytoin Capsule, Suspension

1

Topamax 4 N, STTopiramate Tablet 1Trileptal 4 N, ST

Drug NameDrug Tier


Trokendi XR 4 E, N, STZonegran 4 N, STZonisamide Capsule 1

Dermatology

Absorica 4 E, NAcanya 4 E, SLAczone 4 SLAdapalene 0 .1% Cream, Gel

3 N, SL

Adapalene 0 .3% Gel 3 N, SLAtralin 4 E, N, SLAzelex 3 SLBenzaclin 4 E, SLBethamethasone Dipropionate 0 .05% Augmented Lotion, Ointment

3

Betamethasone Dipropionate 0 .05% Cream, Ointment

2

Betamethasone Valerate 0 .12% Foam

4 E, SL

Betamethasone/Calcipotriene Ointment

3 SL

Carac 2Ciclopirox Cream, Gel, Lotion, Solution

1

Claravis 2 NClindagel 4 E, SLClindamycin 1%/Benzoyl Peroxide 5% Gel

4 E, SL

Clindamycin 1 .2%/Benzoyl Peroxide 5% Gel

3 SL

Clindamycin Gel 3 SLClindamycin Lotion 3Clindamycin Solution, Swabs

1

Clobetasol Propionate Cream, Ointment, Solution

1

Clobetasol Propionate Foam, Lotion, Shampoo

4 E

Clocortolone Cream 3 SL, ST

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Drug NameDrug Tier


Clotrimazole-Betamethasone Cream

1 SL

Clotrimazole-Betamethasone Lotion

1

Condylox Gel 3Desonide 0 .05% Cream, Lotion, Ointment

3 SL

Desoximetasone Gel, Ointment

3 SL

Differin 1% 2 N, SLDiflorasone Diacetate 0 .05% Cream, Ointment

3 SL

Epiduo 3 SLFabior 4 E, SLFinacea 4Fluocinonide 0 .05% Cream

1

Fluocinonide 0 .1% Cream

4 E, SL

Fluocinolone Cream, Oil, Ointment, Solution

3 SL

Hydrocortisone 2 .5%Cream, Ointment

1

Hydrocortisone Butyrate Cream

4 E, SL

Keralyt Scalp Kit 4 ELocoid Lipocream 4 E, SLLocoid Lotion 4 E, SLLuxiq 4 E, SLMetrogel 1% 4 EMetronidazole Gel 0 .75% 1Metronidazole Gel 1% 4 EMirvaso 4 SL

Drug NameDrug Tier


Mometasone Furoate Cream, Lotion, Ointment

1

Mupirocin Ointment 1Noritate 4 ENystatin-Triamcinolone Acetonide Cream, Ointment

4 E

Oxsoralen-Ul 2Picato 3 SLProtopic 2 N, SLRetin-A Micro 4 E, N, SLSodium Sulfacetamide-Sulfur

1

Sorilux 4 E, SLTopicort Spray 4 E, SLTretin-X 4 E, N, SLTretinoin 1 NTretinoin Microspheres 4 E, N, SLTriamcinolone Acetonide Cream, Lotion, Ointment

1

Urea 40% 1Vanos 4 E, SLVectical 3 SLVeltin 4 E, SLVerdeso 4 E, SLVirasal 4 EVusion 4 EXerese 4 EZiana 4 E, SLZyclara 4 E, SL

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Drug NameDrug Tier


Diabetes: Blood Glucose Monitoring

Accu-Chek Active Test Strips

1 SL

Accu-Chek Aviva Plus

1

Accu-Chek Aviva Plus Test Strips

1 SL

Accu-Chek Comfort Curve Test Strips

1 SL

Accu-Chek Compact Test Strips

1 SL

Accu-Chek Nano SmartView

1

Accu-Chek Nano SmartView Test Strips

1 SL

Contour Test Strips 4 SDP, SLFreestyle Test Strips 4 SDP, SLOne Touch Test Strips

1 SL

One Touch Ultra Meter

1

One Touch Ultra Mini 1One Touch Ultra Test Strips

1 SL

One Touch Verio IQ 1One Touch Verio IQ Test Strips

1 SL

One Touch Verio Sync

1

Diabetes: Insulin

Humalog KwikPen 2Humalog Mix 75-25 KwikPen

2

Humalog Vials 1Humulin 70-30 Vials 1Humulin KwikPen 2Humulin N KwikPen 2Humulin N Vials 1Humulin R Vials 1

Drug NameDrug Tier


Lantus Solostar 3Lantus Vials 3Levemir Flexpen 1Levemir Vials 1Novolog 4 SDPNovolog Flexpen 4 SDP

Diabetes: Non-Insulin

Bydureon 3 SLByetta 2 SLFarxiga 4 SL, STGlimepiride 1Glipizide 1Glipizide Extended-Release

1

Glumetza 4 NGlyburide 1Glyburide-Metformin 1Invokamet 2 SLInvokana 2 SL, STJanumet 4 SL, STJanuvia 4 SL, STJentadueto 2 SLKazano 2 SLKombiglyze XR 2 SLMetformin 1Metformin Extended-Release Osmotic Tablet

3 N

Metformin Extended-Release Tablet

1

Nesina 2 SLOnglyza 2 SLOseni 2 SLPioglitazone 2 SLPioglitazone-Metformin 2 SLPrandimet 3Prandin 4 SLRepaglinide 2 SLTanzeum 2 SLTradjenta 2 SLVictoza 3 SL

18




Drug NameDrug Tier


Endocrine: Growth Hormone*

Genotropin 4 DSP, E, N, SLHumatrope 4 DSP, E, N, SLNorditropin 4 DSP, E, N, SLNutropin AQ NuSpin 2 DSP, N, SLOmnitrope 4 DSP, E, N, SLSaizen 2 DSP, N, SLTev-Tropin 2 DSP, N, SL*Benefit coverage and your cost share for growth hormone drugs are determined by your prescription drug benefit plan . Please consult your plan documents .

Endocrine: Other

Calcitriol Capsule 1Desmopressin Tablet 1Dexamethasone Tablet 1Methylprednisolone Tablet

1

Prednisolone Solution, Syrup

1

Prednisone Tablet 1Rayos 4 EEndocrine: Thyroid Hormone ReplacementArmour Thyroid 3Levothyroxine Sodium Tablet

1

Levoxyl 2Liothyronine Sodium Tablet

2

Methimazole Tablet 1NP Thyroid Tablet 1Synthroid 2Tirosint 2

Drug NameDrug Tier


Eye Conditions: Allergies

Azelastine 0 .05% Ophthalmic Solution

3 SL

Bepreve 4 E, SLElestat 4 E, SLEmadine 4 ELastacaft 3 SLPataday 4 E, SLPatanol 4 E, SL

Eye Conditions: Antibiotics

Erythromycin 0 .5% Ophthalmic Ointment

1

Ofloxacin 0 .3% Ophthalmic Solution

1

Tobradex ST 4 E, SLTobramycin/Dexamethasone 0 .3%-0 .1% Ophthalmic Suspension

2

Eye Conditions: Glaucoma

Alphagan P 0.1% 2 SLAzopt 2 SLCombigan 2 SLCosopt PF 4 E, SLDorzolamide-Timolol 2%-0 .5% Ophthalmic Solution

2

Latanoprost 0 .005% Ophthalmic Solution

1

19

Drug NameDrug Tier


Lumigan 2 SLSimbrinza 4 E, SLTimolol Maleate 0 .25%, 0 .5% Ophthalmic Solution

1

Travatan Z 2 SL

Eye Conditions: Other

Acuvail 4 E, SLBromday 4 E, SLIlevro 4 ELotemax Gel 4 E, SLLotemax Solution 4 SLProlensa 4 E, SL

Gastrointestinal: Acid Suppression

Aciphex Sprinkle 4 E, SLDexilant 3 SLHelidac 4 E, SLLansoprazole Capsules 3 E, SLNexium Capsule 4 E, SLNexium Suspension Packet

3 N, SL, ST

Omeclamox-Pak 3 SLOmeprazole Capsule 1Pantoprazole Tablet 1Prevacid Solutab 3 N, SL, STPrevpac 4 E, SLPrilosec Suspension 4 E, SLProtonix Suspension 4 E, SLPylera 3 SLRabeprazole Tablet 3 SLSucralfate Tablet 1Zegerid Capsule 4 E, SL

Gastrointestinal: Nausea/Vomiting

Ondansetron 1Ondansetron ODT 1Sancuso 4 E, SLZuplenz 4 E, SL

Drug NameDrug Tier


Gastrointestinal: Other

Amitiza 4 N, SL, STApriso 2 SLAsacol HD Tablet 4 E, SLCanasa 2Cortifoam 2Creon 2Delzicol 4 E, SLGiazo 4 EGolytely 2Halflytely 3Hyoscyamine Tablet 1Lialda 2 SLLinzess 2 N, SLMetoclopramide Tablet 1Metozolv ODT 4 EMoviprep 3Pentasa 4 E, SLPertzye 4 STPolyethylene Glycol 3350

2

Prepopik 3Procort 4 ESuclear 3Sulfasalazine Tablet 1Suprep 3Uceris 3Ultresa 4 STUrsodiol Capsule, Tablet 1Viokace 4 STZenpep 2

20




Drug NameDrug Tier


HIV/AIDS

Atripla 2 DSPComplera 2 DSPEpzicom 2 DSPIntelence 2 DSPIsentress 2 DSPKaletra 2 DSPNorvir 2 DSPPrezista 2 DSPReyataz 2 DSPStribild 3 DSP, NSustiva 2 DSPTruvada 2 DSP, NViread 2 DSPInflammatory Conditions: Rheumatoid Arthritis, Crohn’s Disease, Psoriasis, Ulcerative ColitisActemra 4 DSP, N, SL, STCimzia 2 DSP, N, SLEnbrel 4 DSP, N, SL, STHumira 2 DSP, N, SLHydroxychloroquine Sulfate Tablet

1

Leflunomide Tablet 1Methotrexate Tablet 1Orencia 4 DSP, N, SL, STOtezla 4 DSP, N, SL, STSimponi 2 DSP, N, SLStelara 2 DSP, N, SLXeljanz 4 DSP, N, SL, ST

Drug NameDrug Tier


Men’s Health: Prostate

Alfuzosin Tablet 1Avodart 4 N, SDPDoxazosin Tablet 1Finasteride Tablet 1Jalyn 4 ERapaflo 4Tamsulosin Capsule 1Terazosin Capsule, Tablet 1

Men’s Health: Testosterone Therapy

Androderm 2 N, SLAndrogel 4 E, N, SLAndroid 2Axiron 4 E, N, SLDepo-Testosterone 4Fortesta 4 E, N, SLTestim 2 N, SLTestosterone Cypionate Injection

1

Testosterone Enanthate Injection

1

Testosterone Topical Gel 4 E, N, SLTestred 2

21

Drug NameDrug Tier


Miscellaneous

Anastrozole Tablet 1Antipyrine/Benzocaine Otic Solution

1

Aranesp 2 DSP, SLAuvi-Q 4 E, SLBenzonatate Capsule 1Bethkis 2 DSP, N, SLBrisdelle 4 E, SLBromfed DM 3Chlorpheniramine/Hydrocodone/Pseudoephedrine Solution

3 SL

Ciprodex 2Epipen 2 SLEpipen-Jr 2 SLExemestane Tablet 2Fosrenol 2Hydrocodone/Chlorpheniramine Suspension

3 SL

Hydrocodone/Homatropine

1

Letrozole Tablet 1Lidocaine Transdermal Patch

2 SL

Nuedexta 2Pegasys 2 DSP, N, SLProcrit 2 DSP, SLPromethazine/Codeine 1Promethazine/Dextromethorphan

1

Pulmozyme 2 DSP, N, SLRectiv 3 N, SLRestasis 4 N, SLRezira 3Sevelamer Carbonate 2Soltamox 4 ETamoxifen Tablet 1Tobi 4 DSP, E, N, SLTobi Podhaler 3 DSP, N, SL

Drug NameDrug Tier


Tobramycin Nebulized Solution

4 DSP, E, N, SL

Zonatuss 4 E

Musculoskeletal: Osteoporosis

Actonel 3 SLAlendronate Sodium Tablet

1 SL

Atelvia 4 E, SLBinosto 4 E, SLForteo 2 DSP, NIbandronate Tablet 2 SLRaloxifene Tablet 2Risedronate 150 mg Tablet

3 SL

Musculoskeletal: Other

Allopurinol Tablet 1Amrix 4 EBaclofen Tablet 1Carisoprodol 350 mg Tablet

1

Colcrys 2Cyclobenzaprine Tablet 1Gralise 4 E, SLHorizant 4 E, SLLorzone 4 E, SLMethocarbamol Tablet 1Soma 250 4 ETizanidine Tablet 1Uloric 4 SL

Musculoskeletal: Pain Relief

Abstral 4 E, N, SLAcetaminophen/Codeine Tablet

1 SL

Celebrex 4 N, SL, STConzip 4 E, SLDiclofenac 1 .5% Topical Solution

4 E

Diclofenac Sodium Tablet

1

22




Drug NameDrug Tier


Duexis 4 E, SLEtodolac Capsule 1Fentanyl Patches 2 SLFentora 4 E, N, SLFlector 4 EHydrocodone/Acetaminophen 5/325, 7 .5/325, 10/325 mg Tablet

1 SL

Hydrocodone/Ibuprofen Tablet

1

Hydromorphone Extended-Release Tablet

3 N, SL

Hydromorphone Tablet 1Ibuprofen Tablet 1Indomethacin Capsule 1Kadian 4 E, N, SLKetorolac Tablet 1Lazanda 3 N, SLMeloxicam Tablet 1Methadone Tablet 1Morphine Sulfate Extended-Release 10, 20, 30, 50, 60, 80, 100, 200 mg Capsule

3 E, N, SL

Morphine Sulfate Extended-Release 30, 45, 60, 75, 90, 120 mg Capsule

3 N, SL

Morphine Sulfate Extended-Release Tablet

1 SL

Nabumetone Tablet 1Naprelan 4 E

Drug NameDrug Tier


Naproxen Tablet 1Nucynta 4 SLNucynta ER 4 N, SLOnsolis 3 N, SLOpana ER 2 N, SLOxycodone Tablet 1Oxycodone/Acetaminophen 5/325, 7 .5/325, 10/325 mg Tablet

1 SL

Oxycontin 2 N, SLOxymorphone Extended-Release Tablet

3 N, SL

Rybix ODT 4 E, SLSprix 3Subsys 3 N, SLTramadol Extended-Release Tablet

4 E, SL

Tramadol Sustained-Release Tablet

2 SL

Tramadol Tablet 1Vicodin 5/300, 7 .5/300, 10/300 mg Tablet

4 E, SL

Vimovo 4 E, SLVoltaren Gel 2Zipsor 4 EZohydro ER 4 N, SLZolvit 4 E, SLZorvolex 4 E

23

Drug NameDrug Tier


Overactive Bladder

Detrol 4 EDetrol LA 4 EDicyclomine Tablet 1Enablex 4 EGelnique 4 EMyrbetriq 4 EOxybutynin Extended-Release Tablet

2

Oxybutynin Tablet 1Oxytrol 4 ESanctura 4 ESanctura XR 4 ETolterodine Extended-Release Tablet

4 E

Tolterodine Tablet 4 EToviaz 3Trospium Extended-Release Capsule

4 E

Trospium Tablet 4 EVesicare 4 E

Respiratory: Allergies

Azelastine 0 .1% Nasal Spray

3 SL

Azelastine 0 .15% Nasal Spray

3 E, SL

Beconase AQ 4 E, SLBudesonide Nasal Spray

4 E, SL

Clarinex 4 E, SLClarinex-D 3 E, SLCyproheptadine Tablet 1Desloratadine Orally Disintegrating Tablet, Tablet

3 E, SL

Dymista 4 E, SLFlunisolide Nasal Spray 3Fluticasone Nasal Spray 2 SLHydroxyzine Capsule, Tablet

1

Drug NameDrug Tier


Levocetirizine Tablet 1 SLNasacort AQ 4 E, SLNasonex 4 E, SLOmnaris 4 E, SLPromethazine Tablet 1Qnasl 4 E, SLTriamcinolone Nasal Spray

4 E, SL

Veramyst 4 E, SLZetonna 3 SL

Respiratory: Asthma/COPD

Advair Diskus/HFA 3 SLAerospan 3 SLAlbuterol Sulfate Tablet 1Alvesco 1 SLAsmanex 1 SLBreo Ellipta 3 SLBudesonide Nebs 2 SLCombivent Respimat 3 SLDulera 3 SLFlovent Diskus/HFA 3 SLForadil 2 SLIpratropium Nebs 1Levalbuterol Nebs 4 E, SLMontelukast Chewable Tablet, Tablet

1 SL

Montelukast Granules 2 SLPerforomist 3 SLProair HFA 3 SLProventil HFA 3 SLPulmicort Flexhaler 4 SDP, SLQVAR 1 SLSpiriva 2 SLSymbicort 4 E, SLTudorza 2 SLVentolin HFA 1 SLXopenex HFA 3 SLXopenex Nebs 4 E, SL

24




Drug NameDrug Tier


Respiratory: Pulmonary Arterial HypertensionAdcirca 4 DSP, N, SLLetairis 2 DSP, N, SLRevatio 4 DSP, E, N, SLSildenafil Tablet 1 DSP, N, SLTracleer 2 DSP, N, SLTyvaso 2 DSP, N

Transplant

Astagraf XL 4 DSP, EAzathioprine Tablet 1Cellcept 4 DSPCyclosporine Modified Capsule

1 DSP

Mycophenolate Capsule 1 DSPMycophenolic Acid Tablet

2 DSP

Myfortic 4 DSPNeoral 4 DSPPrograf 4 DSPRapamune 4 DSPSirolimus Tablet 2 DSPTacrolimus Capsule 1 DSP

Vitamins/Electrolytes

Fluoride 1Folic Acid 1Klor-Con M10 1Klor-Con M20 1Potassium Chloride 1Potassium Citrate 1

Drug NameDrug Tier


Women’s Health: Contraceptives

Altavera 1Amethia 3Apri 1Aviane 1Azurette 2Beyaz 4 ECamrese 3Cryselle 1Cyclafem 1Emoquette 1Enpresse 1Generess Fe 4 EGianvi 3Gildess Fe 1Jolessa 2Jolivette 3Junel 2Junel Fe 1Kariva 2Levora-28 1Lo Loestrin Fe 3Lo Minastrin 24 FE 4 ELoMedia 24 FE 3Loryna 3Low-Ogestrel 1Lutera 1Microgestin 2Microgestin FE 1Minastrin 24 FE 4 EMononessa 3

25

Drug NameDrug Tier


Natazia 1Necon 0 .5/35, 1/35, 1/50, 10/11

1

Norgestimate-Ethinyl Estradiol

3

Nortrel 0 .5/35 1Nuvaring 2Orsythia 1Ortho Micronor 1Ortho Tri-Cyclen 1Ortho Tri-Cyclen Lo 3Ortho-Cyclen 1Ortho-Novum 3Ortho-Novum 7/7/7 1Portia 1Previfem 3Quartette 4 EQuasense 2Reclipsen 1Safyral 4 ESprintec 3Syeda 3Tri-Previfem 3Tri-Sprintec 3Trinessa 3Trivora-28 1Viorele 2Xulane 3Yasmin 28 1Yaz 2Zovia 1-35E 1

Drug NameDrug Tier


Women’s Health: Hormone Replacement

Cenestin 4 EClimara 2 SLClimara Pro 3 SLDivigel 2Enjuvia 3Estrace Cream 3Estradiol Tablet 1Estradiol/Norethindrone Acetate Tablet

2

Estring 2 SLEstrogen/Methyltestosterone Tablet

1

Evamist 2Medroxyprogesterone Tablet

1

Minivelle 3 SLPremarin 3Prempro 3Progesterone Micronized Capsule

2

Vagifem 2Vivelle-Dot 2 SL

Women’s Health: Prenatal Vitamins

Brand Prenatal Vitamins

3

Prenatal Plus 1

26

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

Common Brand medications excluded from coverage under many benefit plans

Lower-cost option(s)

AciphexOmeprazole (generic Prilosec), Pantoprazole (generic Protonix), Rabeprazole (generic Aciphex), Dexilant

Actiq Fentanyl Lozenge (generic Actiq)Actos Pioglitazone (generic Actos)

AdderallAmphetamine/Dextroamphetamine Immediate-Release (generic Adderall)

Adoxa TabletDoxycycline Hyclate (generic Vibra-Tab), Doxycycline Monohydrate Tablet (generic Adoxa Tablet)

Ambien Zolpidem (generic Ambien)Arimidex Anastrozole (generic Arimidex)Astelin Azelastine Nasal Spray (generic Astelin)Ativan Lorazepam (generic Ativan)Avelox Tablet Moxifloxacin Tablet (generic Avelox)

AvinzaMorphine Sulfate Extended-Release Tablet (generic MS Contin), Morphine Sulfate Extended-Release Capsule (generic Avinza)

Celexa Citalopram (generic Celexa)Cipro Suspension Ciprofloxacin Oral Suspension (generic Cipro Suspension)

Cloderm CreamClocortolone 0 .1% Cream (generic Cloderm), Mometasone Furoate Cream 0 .1 % (generic Elocon)

Cymbalta Duloxetine (generic Cymbalta)Diovan HCT Valsartan/Hydrochlorothiazide (generic Diovan HCT)

DuacClindamycin Solution (generic Cleocin T) plus OTC Benzoyl Peroxide, Clindamycin 1 .2%/Benzoyl Peroxide 5% (generic Duac)

Duragesic Fentanyl Transdermal Patch (generic Duragesic) Effexor XR Venlafaxine Extended-Release Capsule (generic Effexor XR)Entocort EC Budesonide (generic Entocort EC)Evista Raloxifene (generic Evista)Femara Letrozole (generic Femara)Fioricet with Codeine 50 mg/325 mg/40 mg/ 30 mg

Butalbital/Acetaminophen/Caffeine/Codeine Phosphate 50 mg/325 mg/40 mg/30 mg (generic Fioricet with Codeine)

Flomax Tamsulosin (generic Flomax)Geodon Ziprasidone (generic Geodon)Imitrex Injection & Tablets

Sumatriptan Injection, Tablet (generic Imitrex)

Lexapro Escitalopram (generic Lexapro)Lidoderm Lidocaine Transdermal Patch (generic Lidoderm)Lipitor Atorvastatin (generic Lipitor)Lofibra 54, 160 mg Fenofibrate 54, 160 mg (generic Lofibra) Lovaza Omega-3-Acid Ethyl Esters (generic Lovaza)

LunestaEszopiclone (generic Lunesta), Zaleplon (generic Sonata), Zolpidem (generic Ambien)

27

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

Common Brand medications excluded from coverage under many benefit plans

Lower-cost option(s)

Maxalt Rizatriptan (generic Maxalt)

Maxalt-MLTRizatriptan (generic Maxalt), Rizatriptan Orally Disintegrating Tablet (generic Maxalt MLT)

Mepron Suspension Atovaquone Suspension (generic Mepron)Micardis Losartan (generic Cozaar), Telmisartan (generic Micardis)

Micardis HCTLosartan/Hydrochlorothiazide (generic Hyzaar), Telmisartan/Hydrochlorothiazide (generic Micardis HCT)

MonodoxDoxycycline Hyclate (generic Vibramycin), Doxycycline Monohydrate (generic Monodox)

NatrobaMalathion (generic Ovide), Permethrin (generic Elimite), Spinosad (generic Natroba)

Optivar Azelastine (generic Optivar), Lastacaft

Ortho EvraNorelgestromin/Ethinyl Estradiol Topical Patch, Xulane (generic Ortho Evra)

Percocet Acetaminophen/Oxycodone (generic Percocet)Plavix Clopidogrel (generic Plavix)Prilosec Omeprazole (generic Prilosec)Protonix Pantoprazole (generic Protonix)Prozac Fluoxetine (generic Prozac)Revatio Sildenafil (generic Revatio)Risperdal Risperidone (generic Risperdal)Seroquel Quetiapine (generic Seroquel)Singulair Chewable Tablet

Montelukast Chewable Tablet (generic Singulair)

Singulair Tablet Montelukast (generic Singulair)Skelaxin Metaxalone (generic Skelaxin)Taclonex Ointment Betamethasone/Calcipotriene Ointment (generic Taclonex)Valium Diazepam (generic Valium)Valtrex Valacyclovir (generic Valtrex)Viramune XR 400 mg Nevirapine Extended-Release (generic Viramune XR)Wellbutrin SR Bupropion Extended-Release (generic Wellbutrin SR)Wellbutrin XL Bupropion Extended-Release (generic Wellbutrin XL)Xanax Alprazolam (generic Xanax)Xanax XR Alprazolam Extended-Release (generic Xanax XR)Zoloft Sertraline (generic Zoloft)

ZutriproChlorpheniramine/Hydrocodone/Pseudoephedrine (generic Zutripro)

Zyprexa Olanzapine (generic Zyprexa)

Zyprexa ZydisOlanzapine (generic Zyprexa), Olanzapine Orally Disintegrating Tablet (generic Zyprexa Zydis)

28

IndexA

Abilify .............................................. 14Absorica ...........................................15Abstral ..............................................21Acanya ..............................................15Accu-Chek Active Test Strips ......... 17Accu-Chek Aviva Plus ..................... 17Accu-Chek Aviva Plus Test Strips ...17Accu-Chek Comfort Curve

Test Strips ..................................... 17Accu-Chek Compact Test Strips ..... 17Accu-Chek Nano SmartView .......... 17Accu-Chek Nano SmartView

Test Strips ..................................... 17Acetaminophen/Butalbital/

Caffeine/Codeine 325 mg/ 50 mg/40 mg/30 mg ..................... 14

Acetaminophen/Butalbital/Caffeine 325 mg/50 mg/40 mg ................... 14

Acetaminophen/Codeine Tablet ......21Acetaminophen/Oxycodone ............27Aciphex ...................................... 19, 26Aciphex Sprinkle ..............................19Actemra ............................................20Actiq.................................................26Actonel .............................................21Actos ................................................26Acuvail .............................................19Acyclovir Ointment .........................10Acyclovir Tablet ...............................10Aczone .............................................15Adapalene 0.1% Cream, Gel ............15Adapalene 0.3% Gel ........................15Adcirca .............................................24Adderall .....................................13, 26Adderall XR .....................................13Adoxa Capsule .................................10Adoxa Tablet ....................................26Advair Diskus/HFA ........................23Aerospan ..........................................23Albuterol Sulfate Tablet ...................23Alendronate Sodium Tablet .............21Alfuzosin Tablet ..............................20Allopurinol Tablet ............................21Alphagan P 0.1% ..............................18Alprazolam ................................. 14, 27Alprazolam Extended-Release ... 14, 27Alprazolam Extended-Release

Tablet ............................................ 14Alprazolam Tablet ........................... 14Alsuma ............................................. 14Altavera ............................................24Altoprev ...........................................12Alvesco .............................................23

Ambien .......................................15, 26Ambien CR ......................................15Amethia ...........................................24Amiodarone .....................................12Amitiza ............................................19Amitriptyline Tablet ........................13Amlodipine ......................................11Amlodipine/Telmisartan .................11Amlodipine Besylate-Benazepril .....11Amoxicillin/Potassium Clavulanate

Chewable Tablet, Tablet ...............10Amoxicillin Capsule, Chewable

Tablet ............................................10Amphetamine/Dextroamphetamine

Immediate-Release .......................26Amphetamine Salt Combo ..............13Ampyra ............................................ 14Amrix ...............................................21Amturnide........................................11Anastrozole ................................21, 26Anastrozole Tablet ...........................21Androderm .......................................20Androgel ..........................................20Android ............................................20Antara ..............................................12Antipyrine/Benzocaine

Otic Solution ................................21Aplenzin ...........................................13Apri ..................................................24Apriso ...............................................19Aranesp ............................................21Aricept 23 mg .................................. 14Arimidex ..........................................26Armour Thyroid ..............................18Asacol HD Tablet ............................19Asmanex ...........................................23Astagraf XL .....................................24Astelin ..............................................26Atelvia ..............................................21Atenolol ............................................11Atenolol-Chlorthalidone .................11Ativan ...............................................26Atorvastatin ...............................12, 26Atovaquone Suspension ...................27Atralin ..............................................15Atripla ..............................................20Aubagio ............................................ 14Augmentin XR.................................10Auvi-Q .............................................21Avelox ...............................................26Avelox Tablet ....................................26Aviane ..............................................24Avinza ..............................................26Avodart ............................................20Avonex.............................................. 14

Axiron ..............................................20Azathioprine Tablet .........................24Azelastine .......................18, 23, 26, 27Azelastine 0.05% Ophthalmic

Solution.........................................18Azelastine 0.15% Nasal Spray ..........23Azelastine 0.1% Nasal Spray ............23Azelastine Nasal Spray.....................26Azelex ..............................................15Azithromycin Tablet ........................10Azopt ...............................................18Azor .................................................11Azurette ...........................................24

B

Baclofen Tablet .................................21Baraclude ..........................................10Beconase AQ ....................................23Benazepril ........................................11Benazepril-Hydrochlorothiazide .....11Benicar .............................................11Benicar HCT ...................................11Benzaclin ..........................................15Benzonatate Capsule ........................21Bepreve .............................................18Betamethasone/Calcipotriene

Ointment ................................15, 27Betamethasone Dipropionate

0.05% Cream, Ointment ..............15Betamethasone Valerate

0.12% Foam ..................................15Betaseron .......................................... 14Bethamethasone Dipropionate

0.05% Augmented Lotion, Ointment ......................................15

Bethkis .............................................21Beyaz ................................................24Bidil ..................................................11Binosto .............................................21Bisoprolol .........................................11Bisoprolol-Hydrochlorothiazide ......11Bosulif ..............................................11Brand Prenatal Vitamins ..................25Breo Ellipta ......................................23Brisdelle ...........................................21Bromday ...........................................19Bromfed DM ...................................21Budesonide .................................23, 26Budesonide Nasal Spray ...................23Budesonide Nebs ..............................23Buprenorphine/Naloxone Tablet ..... 14Bupropion Extended-Release .....13, 27Bupropion Extended-Release

Tablet ............................................13

29

Bupropion Sustained-Release Tablet ............................................13

Bupropion Tablet ..............................13Buspirone Tablet .............................. 14Butalbital/Acetaminophen/

Caffeine/Codeine Phosphate 50 mg/325 mg/40 mg/30 mg ........26

Bydureon .......................................... 17Byetta ............................................... 17Bystolic .............................................11

C

Caduet ..............................................12Calcitriol Capsule.............................18Cambia ............................................. 14Camrese ...........................................24Canasa ..............................................19Capecitabine Tablet ..........................11Carac ................................................15Carbamazepine Tablet .....................15Carbidopa-Levodopa ....................... 14Carisoprodol 350 mg Tablet .............21Cartia XT .........................................11Carvedilol .........................................11Cefdinir Capsule ..............................10Cefuroxime Tablet ...........................10Celebrex ...........................................21Celexa ...............................................26Cellcept ............................................24Cenestin ...........................................25Centany AT .....................................10Cephalexin Capsule .........................10Chlorpheniramine/Hydrocodone/

Pseudoephedrine.....................21, 27Chlorpheniramine/Hydrocodone/

Pseudoephedrine Solution ............21Chlorthalidone .................................11Choline Fenofibrate ..........................12Ciclopirox Cream, Gel, Lotion,

Solution.........................................15Cimzia ..............................................20Cipro Suspension .............................26Ciprodex ...........................................21Ciprofloxacin Oral Suspension ........26Ciprofloxacin Tablet .........................10Citalopram .................................13, 26Citalopram Tablet ............................13Claravis ............................................15Clarinex ............................................23Clarinex-D .......................................23Clarithromycin Tablet ......................10Cleocin T .........................................26Climara ............................................25Climara Pro ......................................25Clindagel ..........................................15Clindamycin 1%/Benzoyl

Peroxide 5% Gel ...........................15

Clindamycin 1.2%/Benzoyl Peroxide 5% ............................15, 26

Clindamycin 1.2%/Benzoyl Peroxide 5% Gel ...........................15

Clindamycin Capsule .......................10Clindamycin Gel ..............................15Clindamycin Lotion .........................15Clindamycin Solution ................15, 26Clindamycin Solution, Swabs ..........15Clobetasol Propionate Cream,

Ointment, Solution .......................15Clobetasol Propionate Foam,

Lotion, Shampoo ..........................15Clocortolone 0.1% Cream ................26Clocortolone Cream .........................15Cloderm ...........................................26Cloderm Cream ...............................26Clonazepam Tablet ..........................15Clonidine Extended-Release

Tablet ............................................13Clonidine Tablet ..............................11Clopidogrel................................. 11, 27Clotrimazole-Betamethasone

Cream ...........................................16Clotrimazole-Betamethasone

Lotion ...........................................16Colcrys .............................................21Combigan .........................................18Combivent Respimat ........................23Complera ..........................................20Concerta ...........................................13Condylox Gel ...................................16Contour Test Strips .......................... 17Conzip ..............................................21Copaxone ......................................... 14Coreg CR .........................................11Cortifoam .........................................19Cosopt PF ........................................18Coumadin ........................................11Cozaar ..............................................27Creon ................................................19Crestor ..........................................8, 12Cryselle ............................................24Cyclafem ..........................................24Cyclobenzaprine Tablet....................21Cyclosporine Modified Capsule .......24Cymbalta ..........................................26Cyproheptadine Tablet .....................23

D

Daytrana ..........................................13Delzicol ............................................19Denavir Cream .................................10Depakote ..........................................15Depakote ER ...................................15Depo-Testosterone ...........................20

Desloratadine Orally Disintegrating Tablet, Tablet ................................23

Desmopressin Tablet ........................18Desonide 0.05% Cream, Lotion,

Ointment ......................................16Desoximetasone Gel, Ointment ......16Desvenlafaxine .................................13Detrol ...............................................23Detrol LA ........................................23Dexamethasone Tablet .....................18Dexilant ..................................... 19, 26Dexmethylphenidate

Extended-Release Capsule ...........13Dexmethylphenidate Tablet .............13Dextroamphetamine-Amphetamine

Extended-Release .........................13Dextroamphetamine-Amphetamine

Tablet ............................................13Dextroamphetamine

Sulfate Tablet ................................13Diazepam ............................. 14, 15, 27Diazepam Tablet ........................ 14, 15Diclofenac 1.5% Topical Solution ....21Diclofenac Sodium Tablet ................21Dicyclomine Tablet ..........................23Differin 1% .......................................16Dificid ..............................................10Diflorasone Diacetate 0.05%

Cream, Ointment .........................16Digoxin ............................................12Diltiazem 24 Hour CD....................11Diltiazem Sustained-Release

Capsule .........................................11Diltiazem Sustained-Release

Tablet ............................................11Diovan ........................................ 11, 26Diovan HCT ....................................26Divalproex Delayed-Release

Tablet ............................................15Divalproex Extended-Release

Tablet ............................................15Divigel ..............................................25Donepezil 5, 10 mg Tablet ............... 14Doryx ...............................................10Dorzolamide-Timolol 2%-0.5%

Ophthalmic Solution ....................18Doxazosin ..................................11, 20Doxazosin Tablet .............................20Doxepin Capsule ..............................13Doxycycline Hyclate ............10, 26, 27Doxycycline Hyclate Capsule,

Tablet ............................................10Doxycycline Monohydrate ...10, 26, 27Doxycycline Monohydrate

50, 100 mg Capsule ......................10Doxycycline Monohydrate

75 mg Capsule ..............................10

30

Doxycycline Monohydrate Tablet ....26Duac .................................................26Duexis ..............................................22Dulera ..............................................23Duloxetine ..................................13, 26Duloxetine Capsule ..........................13Duragesic .........................................26Dutoprol ...........................................11Dymista ............................................23

E

Edarbi ..............................................11Edarbyclor ........................................11Edluar ..............................................15Effexor XR .......................................26Effient ..............................................11Elestat ..............................................18Elimite .............................................27Eliquis ..............................................11Elocon ..............................................26Emadine ...........................................18Emoquette ........................................24Enablex .............................................23Enalapril ...........................................11Enalapril-Hydrochlorothiazide ........11Enbrel ...............................................20Enjuvia .............................................25Enoxaparin Sodium .........................11Enpresse ...........................................24Entocort EC .....................................26Epaned .............................................11Epiduo ..............................................16Epipen ..............................................21Epipen-Jr ..........................................21Epzicom ...........................................20Ertaczo .............................................10Erythromycin 0.5% Ophthalmic

Ointment ......................................18Escitalopram ..............................13, 26Escitalopram Tablet .........................13Estrace Cream ..................................25Estradiol/Norethindrone Acetate

Tablet ............................................25Estradiol Tablet ................................25Estring .............................................25Estrogen/Methyltestosterone

Tablet ............................................25Eszopiclone ................................15, 26Eszopiclone Tablet ...........................15Etodolac Capsule .............................22Evamist ............................................25Evista ................................................26Exemestane Tablet ...........................21Exforge .............................................11Exforge HCT ...................................11Extavia ............................................. 14

F

Fabior ...............................................16Farxiga ............................................. 17Felodipine .........................................11Femara ..............................................26Fenofibrate 43, 50 , 67, 130,

134, 150, 200 mg Capsule ............12Fenofibrate 48, 145 mg Tablet ..........12Fenofibrate 54, 160 mg ...............12, 26Fenofibrate 54, 160 mg Tablet .........12Fenofibric Acid .................................12Fenoglide ..........................................12Fentanyl Lozenge .............................26Fentanyl Patches ...............................22Fentanyl Transdermal Patch ............26Fentora .............................................22Finacea .............................................16Finasteride Tablet.............................20Fioricet with Codeine ......................26Fioricet with Codeine

50 mg/325 mg/40 mg/30 mg ........26Flecainide .........................................12Flector ..............................................22Flomax .............................................26Flovent Diskus/HFA .......................23Fluconazole Tablet ...........................10Flunisolide Nasal Spray ...................23Fluocinolone Cream, Oil,

Ointment, Solution .......................16Fluocinonide 0.05% Cream ..............16Fluocinonide 0.1% Cream ................16Fluoride ............................................24Fluoxetine...................................13, 27Fluoxetine Capsule, Tablet...............13Fluticasone Nasal Spray ...................23Fluvoxamine Tablet ..........................13Focalin XR .......................................13Folic Acid .........................................24Foradil ..............................................23Forfivo XL ........................................13Forteo ...............................................21Fortesta .............................................20Fosinopril Sodium ............................11Fosrenol ............................................21Freestyle Test Strips ......................... 17Furosemide .......................................11

G

Gabapentin Capsule, Tablet .............15Gelnique ...........................................23Gemfibrozil ......................................12Generess Fe ......................................24Genotropin .......................................18Geodon ............................................26Gianvi...............................................24Giazo ................................................19

Gildess Fe .........................................24Gilenya ............................................. 14Gleevec .............................................11Glimepiride ...................................... 17Glipizide ........................................... 17Glipizide Extended-Release .............17Glumetza .......................................... 17Glyburide ......................................... 17Glyburide-Metformin ...................... 17Golytely ............................................19Gralise ..............................................21Guanfacine .......................................11

H

Halflytely .........................................19Helidac .............................................19Horizant ...........................................21Humalog KwikPen .......................... 17Humalog Mix 75-25 KwikPen ........ 17Humalog Vials ................................. 17Humatrope .......................................18Humira .............................................20Humulin 70-30 Vials ....................... 17Humulin KwikPen ...........................17Humulin N KwikPen ....................... 17Humulin N Vials ............................. 17Humulin R Vials .............................. 17Hydralazine ......................................11Hydrochlorothiazide ......11, 12, 26, 27Hydrocodone/Acetaminophen

5/325, 7.5/325, 10/325 mg Tablet ............................................22

Hydrocodone/Chlorpheniramine Suspension ....................................21

Hydrocodone/Homatropine ............21Hydrocodone/Ibuprofen Tablet .......22Hydrocortisone 2.5% Cream,

Ointment ......................................16Hydrocortisone Butyrate Cream ......16Hydromorphone Extended-Release

Tablet ............................................22Hydromorphone Tablet ....................22Hydroxychloroquine Sulfate Tablet .20Hydroxyurea Capsule .......................11Hydroxyzine Capsule, Tablet ...........23Hyoscyamine Tablet .........................19Hyzaar ..............................................27

I

Ibandronate Tablet ...........................21Ibuprofen Tablet ...............................22Ilevro ................................................19Imipramine Tablet ...........................13Imitrex ..............................................26Imitrex Injection & Tablets ..............26Indapamide ......................................11

31

Indomethacin Capsule .....................22Intelence ...........................................20Intermezzo .......................................15Intuniv ..............................................13Invokamet ........................................ 17Invokana ........................................... 17Ipratropium Nebs .............................23Irbesartan .........................................11Isentress ............................................20Isosorbide Mononitrate ER..............12Itraconazole Capsule ........................10

J

Jalyn .................................................20Janumet ............................................ 17Januvia .............................................. 17Jentadueto ......................................... 17Jolessa ...............................................24Jolivette ............................................24Junel .................................................24Junel Fe .............................................24

K

Kadian ..............................................22Kaletra ..............................................20Kapvay ..............................................13Kariva ...............................................24Kazano ............................................. 17Keppra ..............................................15Keppra XR .......................................15Keralyt Scalp Kit ..............................16Ketoconazole Cream ........................10Ketorolac Tablet ...............................22Khedezla ..........................................13Klor-Con M10 .................................24Klor-Con M20 .................................24Kombiglyze XR ................................ 17

L

Labetalol ..........................................11Lamictal ...........................................15Lamictal XR ....................................15Lamotrigine Tablet ..........................15Lansoprazole Capsules .....................19Lantus Solostar ................................17Lantus Vials ..................................... 17Lastacaft .....................................18, 27Latanoprost 0.005% Ophthalmic

Solution.........................................18Latuda .............................................. 14Lazanda ............................................22Leflunomide Tablet ..........................20Letairis .............................................24Letrozole ....................................21, 26Letrozole Tablet ...............................21Leucovorin Calcium Tablet ..............11

Levalbuterol Nebs ............................23Levemir Flexpen .............................. 17Levemir Vials ................................... 17Levetiracetam Extended-Release

Tablet ............................................15Levetiracetam Tablet .......................15Levocetirizine Tablet .......................23Levofloxacin Tablet ..........................10Levora-28 .........................................24Levothyroxine Sodium Tablet .........18Levoxyl .............................................18Lexapro ............................................26Lialda ...............................................19Lidocaine Transdermal Patch ....21, 26Lidoderm .........................................26Linzess .............................................19Liothyronine Sodium Tablet ............18Lipitor ..............................................26Lipofen .............................................12Liptruzet ..........................................12Lisinopril .................................... 11, 35Lisinopril-Hydrochlorothiazide .......11Lithium Capsule .............................. 14Livalo ...............................................12Lo Loestrin Fe .................................24Lo Minastrin 24 FE ........................24Locoid Lipocream ............................16Locoid Lotion ..................................16Lofibra ..............................................26Lofibra 54, 160 mg ...........................26LoMedia 24 FE ...............................24Lorazepam .................................14, 26Lorazepam Tablet ............................ 14Loryna ..............................................24Lorzone ............................................21Losartan ..................................... 11, 27Losartan-Hydrochlorothiazide ........11Losartan/Hydrochlorothiazide ........27Lotemax Gel ....................................19Lotemax Solution .............................19Lovastatin ........................................12Lovaza ..............................................26Low-Ogestrel ...................................24Lumigan ...........................................19Lunesta .............................................26Lutera ...............................................24Luxiq ................................................16Luzu .................................................10Lyrica ...............................................15

M

Malathion.........................................27Maxalt ..............................................27Maxalt-MLT ....................................27Maxalt MLT ....................................27Medroxyprogesterone Tablet ...........25Meloxicam Tablet.............................22

Mepron .............................................27Mepron Suspension ..........................27Mercaptopurine Tablet .....................11Metadate CD ...................................13Metaxalone .......................................27Metformin ........................................ 17Metformin Extended-Release

Osmotic Tablet ............................. 17Metformin Extended-Release

Tablet ............................................ 17Methadone Tablet ............................22Methimazole Tablet .........................18Methocarbamol Tablet .....................21Methotrexate Tablet .........................20Methylphenidate ..............................13Methylphenidate Extended-Release

Capsule .........................................13Methylphenidate Extended-Release

Tablet ............................................13Methylprednisolone Tablet ..............18Metoclopramide Tablet ....................19Metoprolol Succinate

50, 100, 200 mg ............................11Metoprolol Tartrate ..........................11Metozolv ODT ................................19Metrogel 1% .....................................16Metronidazole Gel 0.75% ................16Metronidazole Gel 1% .....................16Metronidazole Tablet .......................10Micardis ...........................................27Micardis HCT .................................27Microgestin ......................................24Microgestin FE ................................24Minastrin 24 FE ..............................24Minivelle ..........................................25Minocycline Capsule .......................10Minocycline Tablet ..........................10Mirapex ER ..................................... 14Mirtazapine Tablet ...........................13Mirvaso ............................................16Modafinil Tablet .............................. 14Mometasone Furoate

Cream 0.1 % .................................26Mometasone Furoate Cream,

Lotion, Ointment .........................16Monodox ..........................................27Mononessa .......................................24Montelukast ...............................23, 27Montelukast Chewable Tablet ...23, 27Montelukast Chewable Tablet,

Tablet ............................................23Montelukast Granules ......................23Morphine Sulfate Extended-Release

10, 20, 30, 50, 60, 80, 100, 200 mg Capsule ............................22

32

Morphine Sulfate Extended-Release 30, 45, 60, 75, 90, 120 mg Capsule .........................................22

Morphine Sulfate Extended-Release Capsule .........................................26

Morphine Sulfate Extended-Release Tablet ......................................22, 26

Moviprep ..........................................19Moxifloxacin Tablet .........................26MS Contin .......................................26Multaq ..............................................12Mupirocin Ointment........................16Mycophenolate Capsule ...................24Mycophenolic Acid Tablet ...............24Myfortic ...........................................24Myrbetriq .........................................23

N

Nabumetone Tablet ..........................22Nadolol .............................................11Naftin 1%, 2% Cream, Gel ..............10Namenda XR ................................... 14Naprelan ...........................................22Naproxen Tablet ...............................22Nasacort AQ ....................................23Nasonex ............................................23Natazia .............................................25Natroba ............................................27Necon 0.5/35, 1/35, 1/50, 10/11 ......25Neoral ...............................................24Nesina .............................................. 17Neurontin .........................................15Nevirapine Extended-Release ..........27Nexium Capsule ...............................19Nexium Suspension Packet ..............19Niacin Extended-Release Tablet ......12Niaspan ............................................12Nifedipine Extended-Release ..........11Nitrofurantoin Capsule ....................10Nitrofurantoin Macrocrystal

Capsule .........................................10Nitroglycerin Sublingual Spray ........12Nitrolingual Pump Spray .................12Norditropin ......................................18Norelgestromin/Ethinyl Estradiol

Topical Patch, Xulane ...................27Norgestimate-Ethinyl Estradiol ......25Noritate ............................................16Nortrel 0.5/35 ..................................25Nortriptyline Capsule ......................13Norvir ...............................................20Novolog ............................................ 17Novolog Flexpen .............................. 17NP Thyroid Tablet ...........................18Nucynta ............................................22Nucynta ER .....................................22Nuedexta ..........................................21

Nutropin AQ NuSpin ......................18Nuvaring ..........................................25Nuvigil ............................................. 14Nystatin-Triamcinolone Acetonide

Cream, Ointment .........................16Nystatin Cream, Ointment ..............10

O

Ofloxacin 0.3% Ophthalmic Solution.........................................18

Olanzapine ................................. 14, 27Olanzapine Orally Disintegrating

Tablet ............................................27Olanzapine Tablet ............................ 14Oleptro .............................................13Olysio ...............................................10Omeclamox-Pak ...............................19Omega-3-Acid Ethyl Esters.......12, 26Omega-3-Acid Ethyl Esters

Capsule .........................................12Omeprazole .......................... 19, 26, 27Omeprazole Capsule ........................19Omnaris ...........................................23Omnitrope........................................18Ondansetron ....................................19Ondansetron ODT ..........................19One Touch Test Strips ..................... 17One Touch Ultra Meter ................... 17One Touch Ultra Mini ..................... 17One Touch Ultra Test Strips ............ 17One Touch Verio IQ ........................ 17One Touch Verio IQ Test Strips ...... 17One Touch Verio Sync ..................... 17Onglyza ............................................ 17Onmel ..............................................10Onsolis .............................................22Opana ER ........................................22Optivar .............................................27Oracea ..............................................10Orencia .............................................20Orsythia ...........................................25Ortho-Cyclen ...................................25Ortho-Novum ..................................25Ortho-Novum 7/7/7 ........................25Ortho Evra .......................................27Ortho Micronor ...............................25Ortho Tri-Cyclen .............................25Ortho Tri-Cyclen Lo .......................25Oseni ................................................ 17OTC Benzoyl Peroxide ....................26Otezla ...............................................20Ovide ................................................27Oxcarbazepine Tablet ......................15Oxistat Cream ..................................10Oxistat Lotion ..................................10Oxsoralen-Ul....................................16Oxtellar XR .....................................15

Oxybutynin Extended-Release Tablet ............................................23

Oxybutynin Tablet ...........................23Oxycodone/Acetaminophen 5/325,

7.5/325, 10/325 mg Tablet ............22Oxycodone Tablet ............................22Oxycontin ........................................22Oxymorphone Extended-Release

Tablet ............................................22Oxytrol .............................................23

P

Pantoprazole ......................... 19, 26, 27Pantoprazole Tablet ..........................19Paroxetine Tablet .............................13Pataday .............................................18Patanol..............................................18Pegasys .............................................21Penicillin V Potassium Tablet ..........10Pentasa .............................................19Percocet ............................................27Perforomist .......................................23Permethrin .......................................27Pertzye..............................................19Pexeva ...............................................13Phenytoin Capsule, Suspension .......15Picato ................................................16Pioglitazone ................................ 17, 26Pioglitazone-Metformin .................. 17Plavix ................................................27Polyethylene Glycol 3350 .................19Portia ................................................25Potassium Chloride ..........................24Potassium Citrate .............................24Pradaxa .............................................11Pramipexole Tablet........................... 14Prandimet ......................................... 17Prandin ............................................. 17Pravastatin ........................................12Prednisolone Solution, Syrup ...........18Prednisone Tablet.............................18Premarin...........................................25Prempro ............................................25Prenatal Plus ....................................25Prepopik ...........................................19Prevacid Solutab ...............................19Previfem ...........................................25Prevpac .............................................19Prezista .............................................20Prilosec ................................. 19, 26, 27Prilosec Suspension ..........................19Pristiq ER ........................................13Proair HFA ......................................23Procort..............................................19Procrit ..............................................21Progesterone Micronized Capsule ...25Prograf .............................................24

33

Prolensa ............................................19Promethazine/Codeine ....................21Promethazine/Dextromethorphan ..21Promethazine Tablet ........................23Propranolol Tablet ............................11Protonix ................................ 19, 26, 27Protonix Suspension .........................19Protopic ............................................16Proventil HFA .................................23Provigil ............................................. 14Prozac ...............................................27Pulmicort Flexhaler .........................23Pulmozyme ......................................21Pylera................................................19

Q

Qnasl ................................................23Quartette ..........................................25Quasense ..........................................25Quetiapine .................................. 14, 27Quetiapine Tablet ............................. 14Quillivant XR ..................................13Quinapril ..........................................11QVAR ..............................................23

R

Rabeprazole ................................ 19, 26Rabeprazole Tablet ...........................19Raloxifene ..................................21, 26Raloxifene Tablet .............................21Ramipril ...........................................12Ranexa ..............................................12Rapaflo .............................................20Rapamune ........................................24Rayos ................................................18Rebif ................................................. 14Reclipsen ..........................................25Rectiv ...............................................21Relpax .............................................. 14Repaglinide ...................................... 17Requip XL ....................................... 14Restasis .............................................21Retin-A Micro .................................16Revatio .......................................24, 27Reyataz .............................................20Rezira ...............................................21Ribapak ............................................10Ribavirin Tablet ...............................10Risedronate 150 mg Tablet ..............21Risperdal ..........................................27Risperidone ................................ 14, 27Risperidone Tablet ........................... 14Ritalin LA ........................................13Rizatriptan ................................. 14, 27Rizatriptan Orally Disintegrating

Tablet ...................................... 14, 27

Rizatriptan Tablet ............................ 14Ropinirole Tablet ............................. 14Rybix ODT ......................................22

S

Safyral ..............................................25Saizen ...............................................18Sanctura ...........................................23Sanctura XR .....................................23Sancuso ............................................19Seroquel ...................................... 14, 27Seroquel XR ..................................... 14Sertraline ....................................13, 27Sertraline Tablet ...............................13Sevelamer Carbonate .......................21Sildenafil ....................................24, 27Sildenafil Tablet ...............................24Silenor ..............................................15Simbrinza .........................................19Simcor ..............................................12Simponi ............................................20Simvastatin ...................................8, 12Singulair ...........................................27Singulair Chewable Tablet ...............27Singulair Tablet ................................27Sirolimus Tablet ...............................24Skelaxin ............................................27Sodium Sulfacetamide-Sulfur .........16Solodyn ............................................10Soltamox...........................................21Soma 250 ..........................................21Sonata ...............................................26Sorilux ..............................................16Sotalol ..............................................12Spinosad ...........................................27Spiriva ..............................................23Spironolactone ..................................12Sprintec ............................................25Sprix .................................................22Stelara...............................................20Strattera ............................................13Stribild .............................................20Suboxone Film ................................. 14Subsys ...............................................22Suclear ..............................................19Sucralfate Tablet ..............................19Sulfamethoxazole-Trimethoprim

Tablet ............................................10Sulfasalazine Tablet .........................19Sumatriptan Injection, Tablet ..........26Sumatriptan Nasal Spray ................. 14Sumatriptan Succinate Tablet,

Injection ........................................ 14Sumavel DosePro ............................. 14Suprep ..............................................19Sustiva ..............................................20Sutent ...............................................11

Syeda ................................................25Symbicort .........................................23Synthroid ..........................................18

T

Taclonex ...........................................27Taclonex Ointment ..........................27Tacrolimus Capsule ..........................24Tamiflu .............................................10Tamoxifen Tablet .............................21Tamsulosin .................................20, 26Tamsulosin Capsule .........................20Tanzeum .......................................... 17Tasigna .............................................11Tasmar .............................................. 14Tecfidera ........................................... 14Tekamlo ...........................................12Telmisartan ..........................11, 12, 27Telmisartan/

Hydrochlorothiazide ..............12, 27Temazepam Capsule ........................15Terazosin ....................................12, 20Terazosin Capsule, Tablet ................20Terbinafine Tablet ............................10Testim ..............................................20Testosterone Cypionate Injection .....20Testosterone Enanthate Injection ....20Testosterone Topical Gel ..................20Testred..............................................20Tev-Tropin ........................................18Timolol Maleate 0.25%, 0.5%

Ophthalmic Solution ....................19Tirosint ............................................18Tizanidine Tablet .............................21Tobi ..................................................21Tobi Podhaler ...................................21Tobradex ST .....................................18Tobramycin/Dexamethasone

0.3%-0.1% Ophthalmic Suspension ....................................18

Tobramycin Nebulized Solution ......21Tolterodine Extended-Release

Tablet ............................................23Tolterodine Tablet ............................23Topamax ...........................................15Topicort Spray ..................................16Topiramate Tablet ............................15Torsemide .........................................12Toviaz ...............................................23Tracleer ............................................24Tradjenta .......................................... 17Tramadol Extended-Release

Tablet ............................................22Tramadol Sustained-Release

Tablet ............................................22Tramadol Tablet ...............................22Travatan Z ........................................19

34

Trazodone Tablet .............................13Tretin-X ...........................................16Tretinoin ..........................................16Tretinoin Microspheres ....................16Treximet ........................................... 14Tri-Previfem .....................................25Tri-Sprintec ......................................25Triamcinolone Acetonide Cream,

Lotion, Ointment .........................16Triamcinolone Nasal Spray ..............23Triamterene-Hydrochlorothiazide ...12Tribenzor ..........................................12Tricor 48, 145 mg .............................12Triglide .............................................12Trileptal ............................................15Trinessa ............................................25Trivora-28.........................................25Trokendi XR ....................................15Trospium Extended-Release

Capsule .........................................23Trospium Tablet ...............................23Truvada ............................................20Tudorza ............................................23Twynsta ............................................12Tyvaso ..............................................24

U

Uceris ...............................................19Uloric ...............................................21Ultresa ..............................................19Urea 40% ..........................................16Ursodiol Capsule, Tablet ..................19

V

Vagifem ............................................25Valacyclovir ................................10, 27Valacyclovir Tablet ...........................10Valium ..............................................27Valsartan ....................................12, 26Valsartan-Hydrochlorothiazide .......12Valsartan/Hydrochlorothiazide .......26Valtrex ..............................................27Vanos ................................................16Vascepa .............................................12Vectical .............................................16Veltin ................................................16Venlafaxine Extended-Release

Capsule ...................................13, 26

Venlafaxine Extended-Release Tablet ............................................13

Venlafaxine Tablet ...........................13Ventolin HFA ..................................23Veramyst ...........................................23Verapamil .........................................12Verapamil Sustained-Release ...........12Verdeso .............................................16Vesicare ............................................23Vibra-Tab .........................................26Vibramycin .......................................27Vicodin 5/300, 7.5/300,

10/300 mg Tablet..........................22Victoza ............................................. 17Viibryd .............................................13Vimovo .............................................22Viokace .............................................19Viorele ..............................................25Viramune XR ...................................27Viramune XR 400 mg......................27Virasal ..............................................16Viread ...............................................20Vivelle-Dot ......................................25Voltaren Gel .....................................22Vusion ..............................................16Vytorin .............................................12Vyvanse ............................................13

W

Warfarin Sodium .............................11Welchol ............................................12Wellbutrin SR ..................................27Wellbutrin XL .................................27

X

Xanax ...............................................27Xanax XR .........................................27Xarelto ..............................................11Xeljanz..............................................20Xerese ...............................................16Xopenex HFA ..................................23Xopenex Nebs ..................................23Xulane ........................................25, 27Xyrem ............................................... 14

Y

Yasmin 28 .........................................25Yaz ....................................................25

Z

Zaleplon .....................................15, 26Zaleplon Capsule .............................15Zegerid Capsule ...............................19Zelapar ............................................. 14Zenpep .............................................19Zenzedi ............................................13Zetia .................................................12Zetonna ............................................23Ziana ................................................16Ziprasidone ................................14, 26Ziprasidone Capsule ......................... 14Zipsor ...............................................22Zohydro ER .....................................22Zoloft ...............................................27Zolpidem ....................................15, 26Zolpidem Extended-Release

Tablet ............................................15Zolpidem Tablet ...............................15Zolpimist ..........................................15Zolvit ................................................22Zonatuss ...........................................21Zonegran ..........................................15Zonisamide Capsule ........................15Zorvolex ...........................................22Zovia 1-35E .....................................25Zovirax Cream .................................10Zubsolv ............................................. 14Zuplenz ............................................19Zutripro ............................................27Zyclara .............................................16Zyprexa ............................................27Zyprexa Zydis ..................................27Zytiga ...............................................11Zyvox ...............................................10

35

“My Medications” worksheetTake 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.

Name of Medicineand Strength

DrugTier

I Take ThisMedicine For

Directions Doctor

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

All branded medications are trademarks or registered trademarks of their respective owners .

© 2014 United HealthCare Services, Inc . All rights reserved . Created October, 2014 . 2015 Prescription Drug List – NHP Advantage Four-Tier 100-15374 1/15

For more information


Or, visit www.mynhp.com

Documents

Your 2015 Four-Tier Prescription Drug List - myNHP.com 4T Adv 115_4.pdf · Your 2015 Four-Tier Prescription Drug List effective January 1, 2015 ... Crestor) and generic drugs in plain