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General Prescription Programs, Inc.
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Please read: This document contains information about the drugs covered under your pharmacy benefit plan.
Your 2017 Formulary
Effective July 1, 2017
For a complete list of covered drugs or if you have questions:
Call the toll-free member phone number on the back of your ID card.
Visit your plan’s member website listed on your ID card. • Locate a participating retail pharmacy by zip code. • Look up possible lower-cost medication alternatives. • Compare medication pricing and options.
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Your Formulary
This Formulary outlines the most commonly prescribed medications from your plan’s complete pharmacy benefit coverage list, also known as a Prescription Drug List (PDL). A formulary identifies the drugs available for certain conditions and organizes them into cost levels, also known as tiers. An important part of the Formulary is giving you choices so you and your doctor can choose the best course of treatment for you.
Go to your plan’s member website for complete and up-to-date drug information
Since the Formulary may change, we encourage you to your plan’s member website, which should be listed on your ID card. This website is the best source for up-to-date information about all of the medications your pharmacy benefit covers, possible lower-cost options and cost comparisons.
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Table of Contents
Drug tiers and cost . . . . . . . . . . . . . . . . . . . . 5
Programs and limits . . . . . . . . . . . . . . . . . . . 6
Drugs by category . . . . . . . . . . . . . . . . . . . . 9
Anti-InfectivesAntibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Cardiovascular/Heart DiseaseAnticoagulants. . . . . . . . . . . . . . . . . . . . . . . . 10High Blood Pressure . . . . . . . . . . . . . . . . . . . . 10High Cholesterol . . . . . . . . . . . . . . . . . . . . . . 10Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Pulmonary Arterial Hypertension . . . . . . . . . . 11
Central Nervous SystemAttention Deficit Disorder . . . . . . . . . . . . . . . 11Depression. . . . . . . . . . . . . . . . . . . . . . . . . . . 11Migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . 12Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Sedatives/Hypnotics . . . . . . . . . . . . . . . . . . . . 12Seizure Disorders . . . . . . . . . . . . . . . . . . . . . . 12
Dermatology . . . . . . . . . . . . . . . . . . . . . . . . 13
Diabetes/EndocrineBlood Glucose Monitoring . . . . . . . . . . . . . . . 14Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Non-Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . 15
EndocrineGrowth Hormone . . . . . . . . . . . . . . . . . . . . . 15Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Thyroid Hormone Replacement . . . . . . . . . . . 16
Eye ConditionsAllergies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
GastrointestinalAcid Suppression . . . . . . . . . . . . . . . . . . . . . . 16Nausea/Vomiting . . . . . . . . . . . . . . . . . . . . . . 17Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Inflammatory Conditions . . . . . . . . . . . . . . 17
Men’s HealthErectile Dysfunction . . . . . . . . . . . . . . . . . . . . 18Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Testosterone Therapy . . . . . . . . . . . . . . . . . . . 18
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . 18
MusculoskeletalOsteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . 19 Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Pain Relief . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Overactive Bladder . . . . . . . . . . . . . . . . . . . 19
RespiratoryAsthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . 20Nasal Allergies . . . . . . . . . . . . . . . . . . . . . . . . 20Oral Allergies . . . . . . . . . . . . . . . . . . . . . . . . . 20
Transplant . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Vitamins/Electrolytes . . . . . . . . . . . . . . . . . 20
Women’s HealthBirth Control . . . . . . . . . . . . . . . . . . . . . . . . . 21Hormone Replacement . . . . . . . . . . . . . . . . . 22Vaginal Anti-Infectives . . . . . . . . . . . . . . . . . . 22
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
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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 Formulary.
What is a Formulary?
This document is a list of commonly prescribed medications preferred by your plan sponsor for their safety, cost and effectiveness. Drugs are listed by common categories or class. They are placed into cost levels known as tiers. It includes both brand and generic prescription medications approved by the U.S. Food and Drug Administration (FDA).
Please note: Where differences are noted between this Formulary and your benefit plan documents, the benefit plan documents will rule. It is not intended to be 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 plan sponsor to see what medications are covered under your plan. You may also log on to your plan’s member website or call the toll-free member phone number on your ID card for more information.
How do I use my Formulary?
When choosing a medication, you and your doctor should consult the Formulary. It will help you and your doctor choose the most cost-effective prescription drugs. This guide tells you if a medication is generic or brand, and if special rules apply. Bring this list with you when you see your doctor. It is organized by common medical conditions. Medications are then listed alphabetically.
If your medication is not listed in this document, please visit your plan’s member website or call the toll-free member phone number on your 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 plan sponsor. This is how much you will pay when you fill a prescription. Tier 1 medications are your lowest-cost options. If your medication is placed in Tier 2 or 3, look to see if there is a Tier 1 option available. Discuss these options with your doctor.
Drug names shown in orange are preferred for their cost and effectiveness. If there is a symbol in the Drug Tier column, check your benefit plan documents to find out your specific pharmacy plan costs.
$ Drug Tier Includes Helpful Tips
$ Tier 1 Lowest Cost
Lower-cost, commonly used generic drugs. Some low-cost brands may be included.
Use Tier 1 drugs for the lowest out-of- pocket costs.
$$ Tier 2 Mid-range Cost
Many common brand-name drugs, called preferred brands.
Use Tier 2 drugs, instead of Tier 3, to help reduce your out-of-pocket costs.
$$$ Tier 3 Highest Cost
Mostly higher-cost brand drugs, also known as non-preferred brands.
Many Tier 3 drugs have lower-cost options in Tier 1 or 2. Ask your doctor if they could work for you.
Please note: Some plans may have two or four tiers, while others may not have any. If you have a high deductible plan, the tier cost levels will apply once you hit your deductible. Refer to your enrollment and plan materials on your plan’s member website or call the toll-free member phone number on your ID card for more information about your benefit plan.
When does the Formulary change?
• Medications may move to a lower tier at any time.• Medications may move to a higher tier when its generic becomes available.• Medications may move to a higher tier or be excluded from coverage
on January 1 or July 1 of each year.
When a medication changes tiers, you may have to pay a different amount for that medication.
For the most up-to-date list, call customer service at the toll-free member phone number on your ID card.
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Programs and Limits
Some medications are noted with letters or symbols next to them. The letters and symbols refer to our pharmacy benefit programs and are provided to help you check which medications may have a program or limit. Your benefit plan determines how these medications may be covered for you.
AR Age Restrictions – Some restrictions may apply based on patient age.
PA Prior Authorization – Your doctor is required to provide additional information to determine coverage.
ST Step Therapy – Trial of lower cost medication(s) is required before a higher-cost medication is covered.
QL Quantity Limits – Amount of medication covered per copayment or in a specific time period.
SPSpecialty Medication – Medication is designated as a specialty pharmacy drug.
To learn more about a pharmacy program or to find out if it applies to you, please visit your plan’s member website or call the toll-free member phone number on your 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 as or similar to another prescription medication or an over-the-counter (OTC) medication. There may be other medication options available.
What if I don’t agree with a decision about an excluded medication?
You (or your authorized representative) and your doctor can ask for an initial coverage decision by calling the toll-free member phone number on the back of your ID card.
Should I talk to my doctor about OTC medications?
An OTC medication may be the right treatment option for some conditions. Talk to your doctor about available OTC options. Even though these medications may not be covered under your pharmacy benefit, they may cost less than your out-of-pocket expense for prescription medications.
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, Clobex) and generic drugs in plain type (for example, clobetasol).
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 your plan’s member website to make sure.
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<<Are you taking a specialty medication?
Specialty medications treat rare or complex conditions and are typically higher cost medications. Please note, not all specialty medications are listed in the Formulary.
How do I get updated information about my pharmacy benefit?
Since the Formulary may change during your plan year, we encourage you to visit your plan’s member website or call the toll-free member phone number on the back of your ID card for more current information.
When you register on our website and open an account, you can use the website’s helpful tools and features to:
• Look up the price of drugs covered by your plan
• Find lower-cost options
• Refill and renew home delivery prescriptions
• View your order status and claims history
• View your benefits in real time
More informationIf you have additional questions please call customer service, 24 hours a day, 7 days a week using the toll-free member phone number on your ID card. Or visit your plan’s member website.
**Attention Client, this section only applies to Members with Mandatory Specialty benefits:**
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Bold type = Brand-name drug [Plain type = Generic drug] Call customer service for pricing
AR Age Restrictions PA Prior Authorization ST Step Therapy
QL Quantity LimitsSP Specialty Program
Drug NameDrug Tier
Programs and Limits
Anti-Infectives: Antibiotics
Amoxicillin 1Amoxicillin/Clavulanate 1Azasite 3Azithromycin 1Bethkis 2 SPCefadroxil Cap 1Cefdinir 1Cefuroxime Tab 1Cephalexin 1Ciprodex Otic
Suspension2
Ciprofloxacin Tab 1Clarithromycin 1Clindamycin Cap 1Doryx MPC 3Doxycycline Hyclate Cap 1Doxycycline Hyclate Tab
(Immediate Release)1
Doxycycline Monohydrate Cap
1
Doxycycline Monohydrate Oral Suspension, Tab
1
Erythromycin 1Levofloxacin Tab 1Metronidazole Tab 1Minocycline Cap 1Moxifloxacin 1Neomycin/Polymyxin/
HC Otic Suspension, Solution
1
Nitrofurantoin Macrocrystalline
1
Nitrofurantoin Monohydrate Macrocrystalline
1
Ofloxacin Otic Solution 1
Drug NameDrug Tier
Programs and Limits
Oracea 3Penicillin VK 1Solodyn 3Sulfamethoxazole-
Trimethoprim1
Sulfamethoxazole-Trimethoprim DS
1
Anti-Infectives: Antifungals
Fluconazole 1Jublia Solution 3 PAKerydin Solution 3 PANystatin Suspension 1Terbinafine Tab 1 QL
Anti-Infectives: Antivirals
Acyclovir Cap, Tab, Suspension
1
Daklinza 3 PA, QL, SPEntecavir 1 QL, SPEpclusa 2 PA, QL, SPFamciclovir Tab 1Harvoni 2 PA, QL, SPSovaldi 2 PA, QL, ST, SPTamiflu 3 QLValacyclovir 1 QLZepatier 2 PA, QL, SP
Cancer
Akynzeo 3 QLAnastrozole Tab 1Capecitabine 1 PA, SPLetrozole 1Revlimid 3 PA, SPSprycel 2 PA, SPTamoxifen Tab 1Tasigna 3 PA, SPTemozolomide 1 PA, SPZytiga 3 PA, SP
10
Bold type = Brand-name drug [Plain type = Generic drug] Call customer service for pricing
AR Age Restrictions PA Prior Authorization ST Step Therapy
QL Quantity LimitsSP Specialty Program
Drug NameDrug Tier
Programs and Limits
Cardiovascular/Heart Disease: AnticoagulantsBrilinta 2Clopidogrel 1Effient 2Eliquis 3 QLEnoxaparin QL, SPPradaxa 2 QLSavaysa 3 QLWarfarin 1Xarelto 2 QLCardiovascular/Heart Disease: High Blood PressureAmlodipine 1Amlodipine/Benazepril 1Amlodipine/Valsartan 1Amlodipine/Valsartan/
HCTZ1
Atenolol 1Atenolol/Chlorthalidone 1Azor 3 STBenazepril 1Benazepril/HCTZ 1Benicar 3 STBenicar HCT 3 STBisoprolol 1Bisoprolol/HCTZ 1Bumetanide 1Bystolic 2Cartia XT 1Carvedilol 1Chlorthalidone 1Clonidine Patch 1Clonidine Tab 1Diltiazem Tab 1Doxazosin 1Edarbi 3 STEdarbyclor 3 STEnalapril 1Enalapril/HCTZ 1Felodipine 1Fosinopril 1Furosemide 1
Drug NameDrug Tier
Programs and Limits
Guanfacine Tab (Immediate Release)
1
Hydralazine 1Hydrochlorothiazide 1Irbesartan 1Irbesartan/HCTZ 1Labetalol 1Lisinopril 1Lisinopril/HCTZ 1Losartan 1Losartan/HCTZ 1Metoprolol Succinate 1Metoprolol Tartrate 1Nadolol 1Nifedipine ER 1Propranolol 1Propranolol ER 1Quinapril 1Ramipril 1Spironolactone 1Tekturna 2 STTekturna HCT 2 STTelmisartan 1Terazosin 1Torsemide Tab 1Triamterene/HCTZ 1Tribenzor 3 STValsartan 1Valsartan/HCTZ 1Verapamil ER 1Cardiovascular/Heart Disease: High CholesterolAtorvastatin 1Cholestyramine 1Crestor 3Fenofibrate 40 mg,
43 mg, 48 mg, 50 mg, 54 mg, 67 mg, 120 mg, 130 mg, 134 mg, 145 mg, 150 mg, 160 mg, 200 mg
1
Gemfibrozil 1Lipitor 3 ST
11
Bold type = Brand-name drug [Plain type = Generic drug] Call customer service for pricing
AR Age Restrictions PA Prior Authorization ST Step Therapy
QL Quantity LimitsSP Specialty Program
Drug NameDrug Tier
Programs and Limits
Lovastatin 1Lovaza 3Niacin ER Tab 1Omega-3 Acid Cap
1 gm1
Praluent PA, QL, SPPravastatin 1Rosuvastatin 1Simvastatin 5 mg, 10
mg, 20 mg, 40 mg1
Simvastatin 80 mg 1 PAVascepa 2Vytorin 10-10 mg,
10-20 mg, 10-40 mg
2
Vytorin 10-80 mg 2 PAWelchol 2Zetia 3
Cardiovascular/Heart Disease: Other
Amiodarone 1Amlodipine/Atorvastatin 1Corlanor 3 PA, QLDigoxin 1Flecainide 1Isosorbide Mononitrate 1Multaq 3Nitrostat 3Ranexa 2 STSotalol 1Cardiovascular/Heart Disease: Pulmonary Arterial HypertensionAdcirca 3 PA, QL, SPAdempas 2 PA, QL, SPLetairis 2 PA, QL, SPOpsumit 2 PA, QL, SPOrenitram 3 PA, SPSildenafil Tab 20 mg 1 PA, QL, SPTracleer 2 PA, QL, SP
Drug NameDrug Tier
Programs and Limits
Central Nervous System: Attention Deficit DisorderAdderall XR Cap 3 PA, QL, STAmphetamine-
Dextroamphetamine Tab
1 PA, QL
Amphetamine-Dextroamphetamine SR 24Hr Cap
1 PA, QL
Dexmethylphenidate ER Cap
1 PA, QL
Evekeo 3 PA, QL, STGuanfacine ER Tab 1 QLMethylphenidate
ER Cap1 PA, QL
Methylphenidate ER Tab 1 PA, QLMethylphenidate SA
Osmotic ER Tab1 PA, QL
Methylphenidate Tab 1 PA, QLStrattera 2 QLVyvanse 2 PA, QL
Central Nervous System: Depression
Amitriptyline 1Bupropion 1Bupropion ER 1Bupropion SR 1Bupropion XL 1 QLDoxepin 1Duloxetine Cap 20 mg,
30 mg, 60 mg1 QL
Escitalopram Tab 1Fluoxetine Cap
(not PMDD)1
Fluvoxamine Tab 1Forfivo XL 2 QLMirtazapine 1Nortriptyline 1Paroxetine Tab 1Pristiq 3 QLRexulti 3 QL
12
Bold type = Brand-name drug [Plain type = Generic drug] Call customer service for pricing
AR Age Restrictions PA Prior Authorization ST Step Therapy
QL Quantity LimitsSP Specialty Program
Drug NameDrug Tier
Programs and Limits
Risperidone Tab 1 QLSertraline 1Trazodone 1Venlafaxine Tab 1Venlafaxine ER Cap 1Venlafaxine ER Tab 1Viibryd 3 QL, ST
Central Nervous System: Migraine
Butalbital-Acetaminophen-Caffeine Cap, Tab 50-325-40 mg
1
Migranal 3 QLRelpax 3 QLRizatriptan Tab, ODT 1 QLSumatriptan Tab
and Spray1 QL
Sumavel Dose 3 QLZolmitriptan Tab 1 QLCentral Nervous System: Multiple SclerosisAmpyra 2 PA, QL, SPAubagio 3 PA, QL, ST, SPAvonex Kit PA, QL, SPAvonex Pen Kit PA, QL, SPAvonex Prefill Kit PA, QL, SPBetaseron PA, QL, SPCopaxone 20 mg/mL
& 40 mg/mL PA, QL, SP
Gilenya* 3 PA, QL, ST, SPRebif PA, QL, ST, SPRebif Titrtn PA, QL, ST, SPTecfidera 2 PA, QL, SP
Central Nervous System: Other
Alprazolam Tab 1 QLAripiprazole 1 QLBenztropine 1Buspirone 1
Drug NameDrug Tier
Programs and Limits
Carbidopa/Levodopa Tab (Immediate Release)
1
Diazepam Tab 1Donepezil Tab 1Hydroxyzine HCL 1Hydroxyzine Pamoate 1Invega Sustenna 3Invega Trinza 3Latuda 3 QL, STLithium Carbonate 1Lorazepam Tab 1 QLModafinil 1 PA, QLNamenda XR 2 QLNamzaric 2 QLOlanzapine Tab 1 QLProchlorperazine 1Quetiapine 1 QLRisperidone Tab 1 QLRopinirole
(Immediate Release)1
Saphris 2 QLSeroquel XR 3 QLZiprasidone Cap 1 QLCentral Nervous System: Sedatives/HypnoticsEszopiclone Tab 1 QLSilenor 3 QLTemazepam 1 QLTriazolam Tab 1 QLZolpidem 1 QLZolpidem ER 1 QLCentral Nervous System: Seizure DisordersCarbamazepine Tab 1Clonazepam 1 QLDivalproex DR 1Divalproex ER 1Gabapentin 1Lamotrigine
(Immediate Release)1
Lamotrigine ER 1Levetiracetam 1Levetiracetam ER 1
* Tier 3 Preferred
13
Bold type = Brand-name drug [Plain type = Generic drug] Call customer service for pricing
AR Age Restrictions PA Prior Authorization ST Step Therapy
QL Quantity LimitsSP Specialty Program
Drug NameDrug Tier
Programs and Limits
Lyrica Cap 2 QLOnfi 3 PAOxcarbazepine 1Phenytoin 1Primidone 1Topiramate Tab 1Vimpat 3Zonisamide 1
Dermatology
Absorica 3 PAAcanya Gel 3 STAcyclovir Ointment 5% 1Aczone Gel 3Atralin 3 PABenzaclin 3 STBetamethasone
Dipropionate Cream1
Ciclopirox Cream 1Clindamycin Gel,
Lotion, Solution1
Clindamycin/ Benzoyl Peroxide Gel 1-5%
1
Clindamycin/Benzoyl Peroxide Gel 1.2-5%
1
Clobetasol Cream, Ointment, Solution
1
Clobex 3Clotrimazole/
Betamethasone Cream, Lotion
1
Cortifoam 3Desonide Cream,
Ointment1
Desoximetasone Cream, Gel, Ointment
1
Differin 3 AREconazole Cream 1Elidel 2 STEpiduo & Epiduo
Forte3
Finacea 3 ST
Drug NameDrug Tier
Programs and Limits
Fluocinonide Cream, 0.1%
1
Fluocinonide Cream, Gel, Ointment, Solution 0.05%
1
Hydrocortisone Cream, Ointment 2.5%
1
Lidocaine Topical Ointment, Solution
1
Lidocaine/Prilocaine Cream
1
Ketoconazole Cream/Shampoo
1
Metrogel 3Metronidazole Gel
0.75%1
Mirvaso Gel 2Mupirocin Ointment 1Nystatin Cream,
Ointment, Powder1
Nystatin/Triamcinolone Cream, Ointment
1
Onexton 3Oxsoralen-UL 2Permethrin Cream 5% 1Proctofoam HC 2Retin-A Micro gel
0.1%, 0.04%3 PA
Soolantra 2Sulfacetamide/Sulfur
Emulsion1
Taclonex 3 QLTazorac 3 QLTretinoin Cream 1 PATretinoin Microsphere
Gel1 PA
Triamcinolone 1Vectical 3Zovirax Cream 2Zovirax Ointment 3Zyclara 3
14
Bold type = Brand-name drug [Plain type = Generic drug] Call customer service for pricing
AR Age Restrictions PA Prior Authorization ST Step Therapy
QL Quantity LimitsSP Specialty Program
Drug NameDrug Tier
Programs and Limits
Diabetes/Endocrine Blood: Glucose MonitoringAccu-Chek Active
Glucose Control Liquid
3
Accu-Chek Active Test Strips
2 QL
Accu-Chek Aviva Connect Kit
2
Accu-Chek Aviva Plus Control Liquid
3
Accu-Chek Aviva Plus Kit
2
Accu-Chek Aviva Plus Test Strips
2 QL
Accu-Chek Compact Plus Control Liquid
3
Accu-Chek Compact Plus Test Strips
2 QL
Accu-Chek Compact Plus Kit
2
Accu-Chek FastClix Kit
2
Accu-Chek FastClix Lancets
2
Accu-Chek Guide Control Liquid
3
Accu-Chek Guide Kit 2Accu-Chek Guide Test
Strips2 QL
Accu-Chek Multiclix Kit
2
Accu-Chek Multiclix Lancets
2
Accu-Chek Nano SmartView Kit
2
Accu-Chek SmartView Control Liquid
3
Accu-Chek SmartView Test Strips
2 QL
Drug NameDrug Tier
Programs and Limits
Accu-Chek Soft Touch Lancets
2
Accu-Chek Softclix Kit 2Accu-Chek Softclix
Lancets2
Bayer Contour Test Strips
3 QL, ST
Dexcom G4 Platinum Kit
3
Dexcom G4 Platinum Sensor Kit
3
Dexcom G4 Platinum Transmitter Kit
3
Dexcom G5 Kit 3Dexcom G5 Sensor
Kit3
Dexcom G5 Transmitter Kit
3
Freestyle Test Strips 3 QL, STInsulin Pen Needle 2Insulin Syringe/
Needle 2
Novofine Pen Needle 3Novofine Autocover
Pen Needle3
Novotwist Pen Needle 3
Onetouch Kit Ultra Smart
2
Onetouch Kit Ultra 2Onetouch Kit Ultra 2 2Onetouch Kit Ultra
Mini2
Onetouch Kit Verio IQ 2Onetouch Test Strips 2 QLOnetouch Ultra Blue
Test Strips2 QL
Onetouch Verio Test Strips
2 QL
Precision Test Strips 3 QL, ST
15
Bold type = Brand-name drug [Plain type = Generic drug] Call customer service for pricing
AR Age Restrictions PA Prior Authorization ST Step Therapy
QL Quantity LimitsSP Specialty Program
Drug NameDrug Tier
Programs and Limits
Diabetes/Endocrine: Insulin
Basaglar 3 STHumalog Mix 50/50
Vial and KwikPen2
Humalog Mix 75-25 Vial and KwikPen
2
Humalog U-100 Vial and KwikPen
2
Humalog U-200 KwikPen
2
Humulin 70-30 Vial and KwikPen
2
Humulin N Vial and KwikPen
2
Humulin R U-500 Vial and KwikPen
2
Humulin R Vial 2Lantus SoloStar 2Lantus Vial 2Levemir FlexTouch 2Levemir Vial 2Novolin 70/30 Vial 2Novolin N Vial 2Novolin R Vial 2Novolog Flexpen 2Novolog Mix 70/30
Vial and Flexpen2
Novolog Penfill 2Novolog Vial 2Toujeo SoloStar 2Tresiba 3
Diabetes/Endocrine: Non-Insulin
Bydureon 2 QL, STByetta 2 QL, STFarxiga 3 STGlimepiride 1Glipizide 1Glipizide ER 1Glipizide XL 1Glumetza 3 PAGlyburide 1
Drug NameDrug Tier
Programs and Limits
Glyburide/Metformin 1Invokamet 2 STInvokamet XR 2 STInvokana 2 STJanumet 2 STJanumet XR 2 STJanuvia 2 STJardiance 2 STJentadueto 2 STJentadueto XR 2 STKombiglyze 3 STMetformin 1Metformin ER 1Onglyza 3 STPioglitazone 1Synjardy 2 STTradjenta 2 STTrulicity 2 QL, STVictoza 2 QL, ST
Endocrine: Growth Hormone
Norditropin PA, SPNutropin AQ PA, SP
Endocrine: Other
Calcitriol Cap 1Dexamethasone Tab 1H.P. Acthar PA, SPHydrocortisone Tab 1Lupron Depot
3.75 mg, 11.25 mg PA, SP
Lupron Depot 7.5 mg, 22.5 mg, 30 mg, 45 mg
PA, SP
Methylprednisolone Tab 1Prednisone 1Prednisolone Solution
25 mg/5 ml1
Prednisolone Syrup, Solution 15 mg/5 ml
1
Sensipar 3 PA
16
Bold type = Brand-name drug [Plain type = Generic drug] Call customer service for pricing
AR Age Restrictions PA Prior Authorization ST Step Therapy
QL Quantity LimitsSP Specialty Program
Drug NameDrug Tier
Programs and Limits
Endocrine: Thyroid Hormone Replacement Armour Thyroid 3Levothyroxine 1Liothyronine 1Methimazole 1Synthroid 3Tirosint 3
Eye Conditions: Allergies
Azelastine Ophthalmic Solution
1
Bepreve 3 STLastacaft 3 STPataday 2Pazeo 2
Eye Conditions: Antibiotics
Besivance 3Ciprofloxacin
Ophthalmic Solution1
Erythromycin Ointment 1Gentamicin 1Moxeza 2 Neomycin/Polymyxin
B/Dexamethasone Ointment, Suspension
1
Ofloxacin Ophthalmic Solution
1
Polymyxin B/Trimethoprim Solution
1
Tobramycin 1Tobramycin/
Dexamethasone1
Vigamox 2
Eye Conditions: Glaucoma
Alphagan P 2
Drug NameDrug Tier
Programs and Limits
Azopt 2Betimol 3Brimonidine 1Combigan 2Cosopt PF 3Dorzolamide-Timolol
Maleate1
Latanoprost 1 QLLumigan 2 QLSimbrinza 2Timolol 1Timoptic Ocudose 2Travatan Z 2 QL
Eye Conditions: Other
Durezol Ophthalmic Emulsion
3
Lotemax Ophthalmic Gel
3 QL
Ketorolac Ophthalmic Solution
1
Prednisolone Ophthalmic Suspension
1
Restasis 2 PAXiidra 2 PA
Gastrointestinal: Acid Suppression
Dexilant 2 QLEsomeprazole
Magnesium (Rx only)
1 QL
Famotidine Tab 20 mg and 40 mg (Rx only)
1
Lansoprazole (Rx only) 1 QLOmeprazole (Rx only) 1 QLPantoprazole 1 QLRanitidine Tab, Cap,
Syrup (Rx only)1
Sucralfate Tab 1
17
Bold type = Brand-name drug [Plain type = Generic drug] Call customer service for pricing
AR Age Restrictions PA Prior Authorization ST Step Therapy
QL Quantity LimitsSP Specialty Program
Drug NameDrug Tier
Programs and Limits
Gastrointestinal: Nausea/Vomiting
Meclizine 1Metoclopramide 1Ondansetron Tab, ODT 1Transderm-Scop 3Varubi 3 QL
Gastrointestinal: Other
Amitiza 2 QL, STApriso 2Canasa 2Creon 2Delzicol 3 STDipentum 3Gavilyte Solution 1Hyoscyamine Sublingual
Tab1
Lactulose 1Lialda 2Linzess 2 QL, STMoviprep 3Omeclamox Pak 2Pentasa 3Polyethylene
Glycol 3350 Powder1
Protosol HC 1Prepopik 3Pylera 2Sulfasalazine 1Suprep Bowel Prep 3Uceris Foam 3Zenpep 2
HIV/AIDS
Atripla 2 SP Complera 2 SPEpzicom 3 SPGenvoya 2 SPIntelence 2 SPIsentress 2 SPKaletra Solution 2 SPKaletra Tablet 3 SP
Drug NameDrug Tier
Programs and Limits
Nevirapine 1 SPNorvir 2 SPPrezcobix 2 SPPrezista 2 SPReyataz 2 SPStribild 2 SPSustiva 2 SPTivicay 2 SPTriumeq 2 SPTruvada 2 SPViread 2 SP
InfertilityCetrotide SPGonal-f PA, SPGonal-f RFF PA, SPOvidrel SP
Inflammatory Conditions
Cimzia Kit PA, SPDepen 2 SPEnbrel PA, SPHumira Kit PA, SPHumira Pen Kit PA, SPHumira Pen Kit
Crohns PA, SP
Humira Pen Kit Psoriasis
PA, SP
Hydroxychloroquine 1Methotrexate Tab 1Orencia SC PA, ST, SPOtezla 3 PA, ST, SPOtrexup 3 PA, QLRasuvo 2 PA, QLRemicade PA, SPSimponi Aria PA, SPSimponi PA, SPStelara PA, SPTaltz* PA, ST, SPXeljanz 3 PA, ST, SP
* Tier 3 Preferred
18
Bold type = Brand-name drug [Plain type = Generic drug] Call customer service for pricing
AR Age Restrictions PA Prior Authorization ST Step Therapy
QL Quantity LimitsSP Specialty Program
Drug NameDrug Tier
Programs and Limits
Men’s Health: Erectile Dysfunction
Cialis 2 QLLevitra 3 QLStendra 3 QLViagra 2 QL
Men’s Health: Prostate
Alfuzosin 1Cialis 2.5 mg & 5 mg 2 QLDoxazosin 1Finasteride 5 mg 1Rapaflo 2Tamsulosin 1Terazosin 1
Men’s Health: Testosterone Therapy
Androderm 2 PAAndrogel 1.62% 2 PAAndrogel 1% 3 PA, STTestosterone Cypionate
IM Injection1 PA
Miscellaneous
Allopurinol 1Antipyrine/Benzocaine
Otic Solution 5.4 - 1.4%
1
Aranesp PA, SPAuryxia 3Benzonatate 1Botox 100, 200 unit
Injection (non-cosmetic)
PA, SP
Bunavail 3 PA, QLCerdelga 3 PA, SPChantix 3 QLCheratussin 1Chlorhexidine 1Colcrys 2Cyproheptadine 1Desmopressin 1
Drug NameDrug Tier
Programs and Limits
Epinephrine Auto-Injector (Authorized Generic of EpiPen made by Mylan)
2
EpiPen & EpiPen Jr 3 STEuflexxa PA, SPFosrenol 3Granix PA, SPGuaifenesin/Codeine
Syrup1
Homatropine/Hydrocodone Syrup
1
Hydrocodone/Chlorpheniramine Liquid
1
Hydrocortisone AC Suppository 25 mg
1
Hydromet 1Lidocaine Viscous
Solution 2%1
Makena PA, SPNarcan 2Neupogen PA, SPPhenazopyridine
(Rx only)1
Phentermine Tab 1 PAProcrit PA, SPPromethazine DM Syrup 1Promethazine/Codeine
Syrup1
Pulmozyme 2 PA, QL, SPRenvela Tab, Pack 2Rezira 3Suboxone Film 2 PA, QLSynagis PA, SPSynvisc PA, SPSynvisc One PA, SPUloric 2 ST
19
Bold type = Brand-name drug [Plain type = Generic drug] Call customer service for pricing
AR Age Restrictions PA Prior Authorization ST Step Therapy
QL Quantity LimitsSP Specialty Program
Drug NameDrug Tier
Programs and Limits
Ursodiol 1Velphoro 3Zarxio PA, SPZostavax Injection 3Zubsolv 2 PA, QLZutripro 3
Musculoskeletal: Osteoporosis
Alendronate Tab 35 mg & 70 mg
1 QL
Binosto 3 QLEvista 3Forteo PA, SPIbandronate Tab 1 QLRaloxifene 1
Musculoskeletal: Other
Baclofen Tab 1Carisoprodol 350 mg 1Cyclobenzaprine Tab
5, 10 mg1
Lorzone 3Metaxalone 1Methocarbamol 1Tizanidine Cap 1Tizanidine Tab 1
Musculoskeletal: Pain Relief
Acetaminophen w/ Codeine
1 PA, QL
Celebrex 3 QLCelecoxib 1 QLDiclofenac Tab 1Embeda 2 QLEndocet Tab 1 PA, QLEtodolac 1Flector patch 3 QLFentanyl Patch
25 mcg/hr, 50 mcg/hr, 75 mcg/hr, 100 mcg/hr
1 QL
Drug NameDrug Tier
Programs and Limits
Fentanyl Patch 37.5 mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr
1 QL
Gralise 3 QL, STHydrocodone/APAP
5, 7.5, 10/325 mg 1 PA, QL
Hydromorphone Tab 1 PA, QLIbuprofen Tab 400, 600,
800 mg (Rx only)1
Indomethacin Cap 1Ketorolac Tab 1 QLLidocaine Patch 5% 1Meloxicam 1Methadone Tab 1Morphine Sulfate Tab 1 PA, QLNabumetone 1Naproxen (Rx only) 1Opana ER 2 QLOxycodone Tab 5,
10, 15, 30 mg (Immediate Release)
1 PA, QL
Oxycodone w/ Acetaminophen
1 PA, QL
Oxycontin 2 QLTivorbex 3 STTramadol Tab 50 mg 1Tramadol
w/ Acetaminophen 1
Vicodin 1 PA, QLVicodin ES 1 PA, QLVoltaren Gel 3 QL Zohydro ER 3 QL, STZorvolex 3
Overactive Bladder
Myrbetriq 3 STOxybutynin 1Oxybutynin ER 1Tolterodine 1Toviaz 3Vesicare 2
20
Bold type = Brand-name drug [Plain type = Generic drug] Call customer service for pricing
AR Age Restrictions PA Prior Authorization ST Step Therapy
QL Quantity LimitsSP Specialty Program
Drug NameDrug Tier
Programs and Limits
Respiratory: Asthma/COPD
Advair Diskus 2 QLAdvair HFA 2 QLAerospan 3 QLAlbuterol
Nebulizer Solution1 QL
Anoro Ellipta 2 QLArnuity Ellipta 2 QLBreo Ellipta 2 QLBudesonide Inhalation
Suspension1 QL
Combivent Respimat 2 QLDulera 3 QL, STFlovent Diskus 2 QLFlovent HFA 2 QLForadil 2 QLIncruse Ellipta 2 QLIpratropium/Albuterol
Nebulizer Solution1 QL
Levalbuterol Nebulizer Solution
1 QL
Montelukast 1Perforomist 3 QLProair HFA, RespiClick 2 QLProventil HFA 3 QL, STPulmicort Flexhaler 2 QLQvar 2 QLSeebri 3 QLSerevent Diskus 2 QLSpiriva Handihaler 2 QLSpiriva Respimat 2 QLStiolto 2 QLSymbicort 2 QLVentolin HFA 2 QLXolair PA, SPXopenex HFA 3 QL, ST
Respiratory: Nasal Allergies
Astepro 3 QLAzelastine Spray 1 QLDymista Spray 2 QL
Drug NameDrug Tier
Programs and Limits
Fluticasone Spray 1Ipratropium Spray 1 QLMometasone 1 QLNasonex 2 QLOmnaris 3 QLQNasl 3 QLTriamcinolone Spray 1 QLZetonna 3 QL
Respiratory: Oral Allergies
Cetirizine 1Promethazine Tab 1Desloratadine 1Levocetirizine 1
Transplant
Azathioprine Tab 1Cellcept Tab/
Suspension3 SP
Cyclosporine Cap 1 SPMycophenolate Mofetil
250 mg Cap/ 500 mg Tab
1 SP
Mycophenolate Sodium 180 mg, 360 mg Tab
1 SP
Prograf Cap 3 SPRapamune 3 SPTacrolimus Cap 1 SP
Vitamins/Electrolytes
Cyanocobalamine Injection
1
Folic Acid 1 mg (Rx only)
1
Klor-Con 8 and 10 MEQ 1Klor-Con M10 and M20 1Multi-Vit/Fl Chew 1Potassium Chloride ER
Tab, Cap1
Potassium Chloride Micro ER Tab
1
21
Bold type = Brand-name drug [Plain type = Generic drug] Call customer service for pricing
AR Age Restrictions PA Prior Authorization ST Step Therapy
QL Quantity LimitsSP Specialty Program
Drug NameDrug Tier
Programs and Limits
Potassium Citrate 540 mg, 1080 mg Tab
1
Vitamin D 50,000 units (Rx only)
1
Women’s Health: Birth Control
Apri 1Aviane 1Azurette 1Cryselle-28 1Falmina 1Generess Fe
Chewable3
Gianvi 1Gildess 1Jolivette 1Junel 1Kariva 1Levora 28 1Lo Loestrin 3Lomedia Fe 1Loryna 1Low-Ogestrel 1Lutera 1Medroxyprogesterone
Acetate Injection1 QL
Microgestin 1Microgestin Fe 1Minastrin 24 Fe
Chewable3
Mono-Linyah 1Mononessa 1Natazia 2Necon 1Nora-Be 1Norgest/Ethi Estradio 1Nortrel 1
Drug NameDrug Tier
Programs and Limits
Nuvaring 2Ocella 1Orsythia 1Ortho Tri-Cyclen Lo 3Previfem 1Reclipsen 1Sprintec 28 1Tri-Linyah 1Tri-Previfem 1Trinessa 1Tri-Sprintec 1Vestura 1Viorele 1Xulane 1Zarah 1
22
Bold type = Brand-name drug [Plain type = Generic drug] Call customer service for pricing
AR Age Restrictions PA Prior Authorization ST Step Therapy
QL Quantity LimitsSP Specialty Program
Drug NameDrug Tier
Programs and Limits
Women’s Health: Hormone Replacement
Climara Pro 2Divigel 3Duavee 2Elestrin Gel 3Estrace Vaginal Cream 3Estradiol Tab 1Estradiol/Norethindrone
Tab1
Medroxyprogesterone Acetate Tab
1
Minivelle 3Osphena 3Premarin Tab 2Premarin Vaginal
Cream2
Premphase 2Prempro 2Progesterone Cap 1Vagifem 3
Women’s Health: Vaginal Anti-Infectives
Gynazole-1 Vaginal Cream
3
Metronidazole Vaginal Gel
1
Terconazole Vaginal Cream
1
Bold type = Brand-name drug [Plain type = Generic drug] 23
Index of Covered Drugs
A
Absorica . . . . . . . . . . 13Acanya Gel. . . . . . . . . 13Accu-Chek Active Glucose
Control Liquid . . . . . 14Accu-Chek Active
Test Strips . . . . . . . 14Accu-Chek Aviva Connect
Kit . . . . . . . . . . . 14Accu-Chek Aviva Plus
Control Liquid . . . . . 14Accu-Chek Aviva Plus Kit . 14Accu-Chek Aviva Plus Test
Strips . . . . . . . . . . 14Accu-Chek Compact Plus
Control Liquid . . . . . 14Accu-Chek Compact
Plus Kit . . . . . . . . . 14Accu-Chek Compact Plus
Test Strips . . . . . . . 14Accu-Chek FastClix Kit . . 14Accu-Chek FastClix Lancets 14Accu-Chek Guide Control
Liquid. . . . . . . . . . 14Accu-Chek Guide Kit . . . 14Accu-Chek Guide Test Strips 14Accu-Chek Multiclix Kit . . 14Accu-Chek Multiclix Lancets 14Accu-Chek Nano SmartView
Kit . . . . . . . . . . . 14Accu-Chek SmartView
Control Liquid . . . . . 14Accu-Chek SmartView
Test Strips . . . . . . . 14Accu-Chek Softclix Kit. . . 14Accu-Chek Softclix Lancets 14Accu-Chek Soft Touch
Lancets . . . . . . . . . 14Acetaminophen w/ Codeine 19Acyclovir Cap, Tab, Suspension 9Acyclovir Ointment 5% . . . 13Aczone Gel. . . . . . . . . 13Adcirca . . . . . . . . . . . 11Adderall XR Cap . . . . . . 11Adempas. . . . . . . . . . 11Advair Diskus . . . . . . . 20Advair HFA . . . . . . . . 20Aerospan . . . . . . . . . 20Akynzeo . . . . . . . . . . . 9Albuterol Nebulizer Solution 20
Alendronate Tab . . . . . . 19Alfuzosin . . . . . . . . . . 18Allopurinol . . . . . . . . . 18Alphagan P . . . . . . . . 16Alprazolam Tab . . . . . . . 12Amiodarone. . . . . . . . . 11Amitiza. . . . . . . . . . . 17Amitriptyline . . . . . . . . 11Amlodipine . . . . . . . . . 10Amlodipine/Atorvastatin . . 11Amlodipine/Benazepril . . . 10Amlodipine/Valsartan . . . . 10Amlodipine/Valsartan/HCTZ . 10Amoxicillin . . . . . . . . . . 9Amoxicillin/Clavulanate . . . . 9Amphetamine Dextroamph-
etamine SR 24Hr Cap . . 11Amphetamine-
Dextroamphetamine Tab 11Ampyra . . . . . . . . . . 12Anastrozole Tab . . . . . . . . 9Androderm . . . . . . . . 18Androgel 1% . . . . . . . 18Androgel 1.62% . . . . . . 18Anoro Ellipta . . . . . . . 20Antipyrine/Benzocaine Otic
Solution 5.4 - 1.4% . . . 18Apri . . . . . . . . . . . . . 21Apriso . . . . . . . . . . . 17Aranesp . . . . . . . . . . 18Aripiprazole . . . . . . . . . 12Armour Thyroid . . . . . . 16Arnuity Ellipta . . . . . . . 20Astepro . . . . . . . . . . 20Atenolol. . . . . . . . . . . 10Atenolol/Chlorthalidone. . . 10Atorvastatin . . . . . . . . 10Atralin . . . . . . . . . . . 13Atripla . . . . . . . . . . . 17Aubagio . . . . . . . . . . 12Auryxia . . . . . . . . . . 18Aviane . . . . . . . . . . . 21Avonex Kit. . . . . . . . . 12Avonex Pen Kit . . . . . . 12Avonex Prefill Kit . . . . . 12Azasite . . . . . . . . . . . . 9Azathioprine Tab . . . . . . 20Azelastine Ophthalmic
Solution . . . . . . . . . 16Azelastine Spray. . . . . . . 20Azithromycin . . . . . . . . . 9
Azopt . . . . . . . . . . . 16Azor . . . . . . . . . . . . 10Azurette . . . . . . . . . . 21
B
Baclofen Tab . . . . . . . . 19Basaglar . . . . . . . . . . 15Bayer Contour Test Strips . 14Benazepril. . . . . . . . . . 10Benazepril/HCTZ . . . . . . 10Benicar . . . . . . . . . . . 10Benicar HCT . . . . . . . . 10Benzaclin. . . . . . . . . . 13Benzonatate . . . . . . . . 18Benztropine . . . . . . . . . 12Bepreve . . . . . . . . . . 16Besivance . . . . . . . . . 16Betamethasone Dipropionate
Cream. . . . . . . . . . 13Betaseron . . . . . . . . . 12Bethkis . . . . . . . . . . . . 9Betimol. . . . . . . . . . . 16Binosto. . . . . . . . . . . 19Bisoprolol . . . . . . . . . . 10Bisoprolol/HCTZ . . . . . . . 10Botox 100, 200 unit
Injection . . . . . . . . 18Breo Ellipta . . . . . . . . 20Brilinta . . . . . . . . . . . 10Brimonidine . . . . . . . . . 16Budesonide Inhalation
Suspension . . . . . . . 20Bumetanide . . . . . . . . . 10Bunavail . . . . . . . . . . 18Bupropion. . . . . . . . . . 11Bupropion ER . . . . . . . . 11Bupropion SR . . . . . . . . 11Bupropion XL . . . . . . . . 11Buspirone . . . . . . . . . . 12Butalbital-Acetaminophen-
Caffeine Cap, Tab . . . . 12Bydureon . . . . . . . . . 15Byetta . . . . . . . . . . . 15Bystolic. . . . . . . . . . . 10
C
Calcitriol Cap . . . . . . . . 15Canasa . . . . . . . . . . . 17Capecitabine . . . . . . . . . 9
Bold type = Brand-name drug [Plain type = Generic drug] 24
Index of Covered Drugs
Carbamazepine Tab . . . . . 12Carbidopa/Levodopa Tab . . 12Carisoprodo. . . . . . . . . 19Cartia XT . . . . . . . . . . 10Carvedilol . . . . . . . . . . 10Cefadroxil Cap . . . . . . . . 9Cefdinir . . . . . . . . . . . . 9Cefuroxime Tab . . . . . . . . 9Celebrex . . . . . . . . . . 19Celecoxib . . . . . . . . . . 19Cellcept Tab/Suspension . 20Cephalexin . . . . . . . . . . 9Cerdelga . . . . . . . . . . 18Cetirizine . . . . . . . . . . 20Cetrotide. . . . . . . . . . 17Chantix. . . . . . . . . . . 18Cheratussin . . . . . . . . . 18Chlorhexidine . . . . . . . . 18Chlorthalidone . . . . . . . 10Cholestyramine . . . . . . . 10Cialis . . . . . . . . . . . . 18Ciclopirox Cream . . . . . . 13Cimzia Kit . . . . . . . . . 17Ciprodex Otic Suspension . 9Ciprofloxacin Ophthalmic
Solution . . . . . . . . . 16Ciprofloxacin Tab . . . . . . . 9Clarithromycin . . . . . . . . 9Climara Pro . . . . . . . . 22Clindamycin/Benzoyl Peroxide
Gel 1.2-5% . . . . . . . 13Clindamycin/Benzoyl Peroxide
Gel 1-5% . . . . . . . . 13Clindamycin Cap . . . . . . . 9Clindamycin Gel, Lotion,
Solution . . . . . . . . . 13Clobetasol Cream, Ointment,
Solution . . . . . . . . . 13Clobex . . . . . . . . . . . 13Clonazepam . . . . . . . . 12Clonidine Patch . . . . . . . 10Clonidine Tab . . . . . . . . 10Clopidogrel . . . . . . . . . 10Clotrimazole/Betamethasone
Cream, Lotion . . . . . . 13Colcrys . . . . . . . . . . . 18Combigan . . . . . . . . . 16Combivent Respimat . . . 20Complera . . . . . . . . . 17Copaxone . . . . . . . . . 12Corlanor . . . . . . . . . . 11
Cortifoam . . . . . . . . . 13Cosopt PF . . . . . . . . . 16Creon. . . . . . . . . . . . 17Crestor . . . . . . . . . . . 10Cryselle-28 . . . . . . . . . 21Cyanocobalamine Injection . 20Cyclobenzaprine Tab . . . . 19Cyclosporine Cap . . . . . . 20Cyproheptadine . . . . . . . 18
D
Daklinza . . . . . . . . . . . 9Delzicol . . . . . . . . . . 17Depen . . . . . . . . . . . 17Desloratadine . . . . . . . . 20Desmopressin . . . . . . . . 18Desonide Cream, Ointment . 13Desoximetasone Cream, Gel,
Ointment . . . . . . . . 13Dexamethasone Tab . . . . 15Dexcom G4 Platinum Kit . 14Dexcom G4 Platinum
Sensor Kit . . . . . . . 14 Dexcom G4 Platinum
Transmitter Kit. . . . . 14Dexcom G5 Kit. . . . . . . 14Dexcom G5 Sensor Kit . . 14Dexcom G5 Transmitter Kit 14Dexilant . . . . . . . . . . 16Dexmethylphenidate ER Cap 11Diazepam Tab . . . . . . . . 12Diclofenac Tab . . . . . . . 19Differin. . . . . . . . . . . 13Digoxin . . . . . . . . . . . 11Diltiazem Tab . . . . . . . . 10Dipentum . . . . . . . . . 17Divalproex DR . . . . . . . . 12Divalproex ER . . . . . . . . 12Divigel . . . . . . . . . . . 22Donepezil Tab . . . . . . . . 12Doryx MPC. . . . . . . . . . 9Dorzolamide-Timolol Maleate 16Doxazosin . . . . . . . . 10, 18Doxepin . . . . . . . . . . . 11Doxycycline Hyclate . . . . . . 9Doxycycline Monohydrate Cap 9Doxycycline Monohydrate Oral
Suspension, Tab . . . . . . 9Duavee. . . . . . . . . . . 22Dulera . . . . . . . . . . . 20
Duloxetine Cap . . . . . . . 11Durezol Ophthalmic
Emulsion . . . . . . . . 16Dymista Spray . . . . . . . 20
E
Econazole Cream . . . . . . 13Edarbi . . . . . . . . . . . 10Edarbyclor . . . . . . . . . 10Effient . . . . . . . . . . . 10Elestrin Gel . . . . . . . . 22Elidel . . . . . . . . . . . . 13Eliquis . . . . . . . . . . . 10Embeda . . . . . . . . . . 19Enalapril. . . . . . . . . . . 10Enalapril/HCTZ . . . . . . . 10Enbrel . . . . . . . . . . . 17Endocet Tab. . . . . . . . . 19Enoxaparin . . . . . . . . . 10Entecavir . . . . . . . . . . . 9Epclusa. . . . . . . . . . . . 9Epiduo & Epiduo Forte . . 13Epinephrine Auto-Injector 18EpiPen & EpiPen Jr . . . . 18Epzicom . . . . . . . . . . 17Erythromycin . . . . . . . . . 9Erythromycin Ointment . . . 16Escitalopram Tab . . . . . . 11Esomeprazole Magnesium . 16Estrace Vaginal Cream . . 22Estradiol/Norethindrone Tab . 22Estradiol Tab . . . . . . . . 22Eszopiclone Tab . . . . . . . 12Etodolac . . . . . . . . . . 19Euflexxa . . . . . . . . . . 18Evekeo . . . . . . . . . . . 11Evista. . . . . . . . . . . . 19
F
Falmina . . . . . . . . . . . 21Famciclovir Tab . . . . . . . . 9Famotidine Tab . . . . . . . 16Farxiga . . . . . . . . . . . 15Felodipine . . . . . . . . . . 10Fenofibrate . . . . . . . . . 10Fentanyl Patch . . . . . . . 19Finacea. . . . . . . . . . . 13Finasteride . . . . . . . . . 18Flecainide . . . . . . . . . . 11
Bold type = Brand-name drug [Plain type = Generic drug] 25
Index of Covered Drugs
Flector patch. . . . . . . . 19Flovent Diskus. . . . . . . 20Flovent HFA . . . . . . . . 20Fluconazole . . . . . . . . . . 9Fluocinonide Cream, 0.1% 13Fluocinonide Cream, Gel,
Ointment, Solution 0.05% 13Fluoxetine Cap . . . . . . . 11Fluticasone Spray . . . . . . 20Fluvoxamine Tab . . . . . . 11Folic Acid . . . . . . . . . . 20Foradil . . . . . . . . . . . 20Forfivo XL . . . . . . . . . 11Forteo . . . . . . . . . . . 19Fosinopril . . . . . . . . . . 10Fosrenol . . . . . . . . . . 18Freestyle Test Strips . . . . 14Furosemide . . . . . . . . . 10
G
Gabapentin . . . . . . . . . 12Gavilyte Solution . . . . . . 17Gemfibrozil . . . . . . . . . 10Generess Fe Chewable . . 21Gentamicin . . . . . . . . . 16Genvoya . . . . . . . . . . 17Gianvi . . . . . . . . . . . . 21Gildess . . . . . . . . . . . 21Gilenya. . . . . . . . . . . 12Glimepiride . . . . . . . . . 15Glipizide . . . . . . . . . . 15Glipizide ER . . . . . . . . . 15Glipizide XL . . . . . . . . . 15Glumetza . . . . . . . . . 15Glyburide . . . . . . . . . . 15Glyburide/Metformin . . . . 15Gonal-f . . . . . . . . . . . 17Gonal-f RFF . . . . . . . . 17Gralise . . . . . . . . . . . 19Granix . . . . . . . . . . . 18Guaifenesin/Codeine Syrup . 18Guanfacine ER Tab . . . . . 11Guanfacine Tab . . . . . . . 10Gynazole-1 Vaginal Cream 22
H
Harvoni . . . . . . . . . . . 9Homatropine/Hydrocodone
Syrup . . . . . . . . . . 18
H.P. Acthar . . . . . . . . . 15Humalog Mix 50/50 Vial
and KwikPen. . . . . . 15Humalog Mix 75-25 Vial
and KwikPen. . . . . . 15Humalog U-100 Vial and
KwikPen . . . . . . . . 15Humalog U-200 KwikPen . 15Humira Kit . . . . . . . . . 17Humira Pen Kit . . . . . . 17Humira Pen Kit Crohns . . 17Humira Pen Kit Psoriasis . 17Humulin 70-30 Vial and
KwikPen . . . . . . . . 15Humulin N Vial and
KwikPen . . . . . . . . 15Humulin R U-500 Vial and
KwikPen . . . . . . . . 15Humulin R Vial. . . . . . . 15Hydralazine . . . . . . . . . 10Hydrochlorothiazide. . . . . 10Hydrocodone/APAP . . . . . 19Hydrocodone/Chlorpheniramine
Liquid . . . . . . . . . . 18Hydrocortisone AC
Suppository . . . . . . . 18Hydrocortisone Cream,
Ointment 2.5% . . . . . 13Hydrocortisone Tab . . . . . 15Hydromet . . . . . . . . . . 18Hydromorphone Tab . . . . 19Hydroxychloroquine . . . . . 17Hydroxyzine HCL . . . . . . 12Hydroxyzine Pamoate . . . . 12Hyoscyamine Sublingual Tab 17
I
Ibandronate Tab. . . . . . . 19Ibuprofen Tab . . . . . . . . 19Incruse Ellipta . . . . . . . 20Indomethacin Cap . . . . . 19Insulin Pen Needle . . . . 14Insulin Syringe/Needle . . 14Intelence . . . . . . . . . 17Invega Sustenna. . . . . . 12Invega Trinza . . . . . . . 12Invokamet . . . . . . . . . 15Invokamet XR . . . . . . . 15Invokana. . . . . . . . . . 15
Ipratropium/Albuterol Nebulizer Solution . . . . . . . . . 20
Ipratropium Spray . . . . . . 20Irbesartan . . . . . . . . . . 10Irbesartan/HCTZ. . . . . . . 10Isentress . . . . . . . . . . 17Isosorbide Mononitrate . . . 11
J
Janumet . . . . . . . . . . 15Janumet XR . . . . . . . . 15Januvia. . . . . . . . . . . 15Jardiance. . . . . . . . . . 15Jentadueto. . . . . . . . . 15Jentadueto XR. . . . . . . 15Jolivette . . . . . . . . . . . 21Jublia Solution. . . . . . . . 9Junel . . . . . . . . . . . . 21
K
Kaletra Solution . . . . . . 17Kaletra Tablet . . . . . . . 17Kariva . . . . . . . . . . . . 21Kerydin Solution . . . . . . 9Ketoconazole Cream/
Shampoo . . . . . . . . 13Ketorolac Ophthalmic
Solution . . . . . . . . . 16Ketorolac Tab . . . . . . . . 19Klor-Con 8 and 10 MEQ. . . 20Klor-Con M10 and M20. . . 20Kombiglyze . . . . . . . . 15
L
Labetalol . . . . . . . . . . 10Lactulose . . . . . . . . . . 17Lamotrigine ER . . . . . . . 12Lamotrigine . . . . . . . . 12Lansoprazole . . . . . . . . 16Lantus SoloStar . . . . . . 15Lantus Vial . . . . . . . . . 15Lastacaft . . . . . . . . . . 16Latanoprost . . . . . . . . . 16Latuda . . . . . . . . . . . 12Letairis . . . . . . . . . . . 11Letrozole . . . . . . . . . . . 9Levalbuterol
Nebulizer Solution. . . . 20
Bold type = Brand-name drug [Plain type = Generic drug] 26
Index of Covered Drugs
Levemir FlexTouch. . . . . 15Levemir Vial . . . . . . . . 15Levetiracetam . . . . . . . . 12Levetiracetam ER . . . . . . 12Levitra . . . . . . . . . . . 18Levocetirizine . . . . . . . . 20Levofloxacin Tab. . . . . . . . 9Levora 28 . . . . . . . . . . 21Levothyroxine . . . . . . . . 16Lialda. . . . . . . . . . . . 17Lidocaine Patch 5% . . . . . 19Lidocaine/Prilocaine Cream . 13Lidocaine Topical Ointment,
Solution . . . . . . . . . 13Lidocaine Viscous
Solution 2%. . . . . . . 18Linzess . . . . . . . . . . . 17Liothyronine . . . . . . . . 16Lipitor . . . . . . . . . . . 10Lisinopril . . . . . . . . . . 10Lisinopril/HCTZ . . . . . . . 10Lithium Carbonate . . . . . 12Lo Loestrin . . . . . . . . . 21Lomedia Fe . . . . . . . . . 21Lorazepam Tab . . . . . . . 12Loryna . . . . . . . . . . . 21Lorzone . . . . . . . . . . 19Losartan. . . . . . . . . . . 10Losartan/HCTZ . . . . . . . 10Lotemax Ophthalmic Gel . 16Lovastatin . . . . . . . . . 11Lovaza . . . . . . . . . . . 11Low-Ogestrel . . . . . . . . 21Lumigan . . . . . . . . . . 16Lupron Depot . . . . . . . 15Lutera . . . . . . . . . . . . 21Lyrica Cap . . . . . . . . . 13
M
Makena . . . . . . . . . . 18Meclizine . . . . . . . . . . 17Medroxyprogesterone Acetate
Injection. . . . . . . . . 21Medroxyprogesterone Acetate
Tab . . . . . . . . . . . 22Meloxicam . . . . . . . . . 19Metaxalone . . . . . . . . . 19Metformin . . . . . . . . . 15Metformin ER . . . . . . . . 15Methadone Tab . . . . . . . 19
Methimazole . . . . . . . . 16Methocarbamol . . . . . . . 19Methotrexate Tab . . . . . . 17Methylphenidate ER. . . . . 11Methylphenidate SA Osmotic
ER Tab. . . . . . . . . . 11Methylphenidate Tab . . . . 11Methylprednisolone Tab . . . 15Metoclopramide . . . . . . 17Metoprolol Succinate . . . . 10Metoprolol Tartrate . . . . . 10Metrogel . . . . . . . . . . 13Metronidazole Gel 0.75%. . 13Metronidazole Tab . . . . . . 9Metronidazole Vaginal Gel . 22Microgestin . . . . . . . . . 21Microgestin Fe . . . . . . . 21Migranal . . . . . . . . . . 12Minastrin 24 Fe Chewable 21Minivelle . . . . . . . . . . 22Minocycline Cap . . . . . . . 9Mirtazapine . . . . . . . . . 11Mirvaso Gel . . . . . . . . 13Modafinil . . . . . . . . . . 12Mometasone . . . . . . . . 20Mono-Linyah . . . . . . . . 21Mononessa . . . . . . . . . 21Montelukast . . . . . . . . 20Morphine Sulfate Tab . . . . 19Moviprep . . . . . . . . . 17Moxeza . . . . . . . . . . 16Moxifloxacin . . . . . . . . . 9Multaq . . . . . . . . . . . 11Multi-Vit/Fl Chew . . . . . . 20Mupirocin Ointment . . . . 13Mycophenolate Mofetil . . . 20Mycophenolate Sodium . . . 20Myrbetriq . . . . . . . . . 19
N
Nabumetone . . . . . . . . 19Nadolol . . . . . . . . . . . 10Namenda XR. . . . . . . . 12Namzaric . . . . . . . . . . 12Naproxen . . . . . . . . . . 19Narcan . . . . . . . . . . . 18Nasonex . . . . . . . . . . 20Natazia. . . . . . . . . . . 21Necon. . . . . . . . . . . . 21
Neomycin/Polymyxin B/Dexamethasone Ointment, Suspension . . . . . . . 16
Neomycin/Polymyxin/HC Otic Suspension, Solution . . . 9
Neupogen . . . . . . . . . 18Nevirapine . . . . . . . . . 17Niacin ER Tab . . . . . . . . 11Nifedipine ER . . . . . . . . 10Nitrofurantoin Macrocrystalline 9Nitrofurantoin Monohydrate
Macrocrystalline . . . . . . 9Nitrostat . . . . . . . . . . 11Nora-Be . . . . . . . . . . . 21Norditropin . . . . . . . . 15Norgest/Ethi Estradio . . . . 21Nortrel . . . . . . . . . . . 21Nortriptyline. . . . . . . . . 11Norvir . . . . . . . . . . . 17Novofine Autocover Pen
Needle . . . . . . . . . 14Novofine Pen Needle . . . 14Novolin 70/30 Vial. . . . . 15Novolin N Vial . . . . . . . 15Novolin R Vial . . . . . . . 15Novolog Flexpen . . . . . 15Novolog Mix 70/30 Vial
and Flexpen . . . . . . 15Novolog Penfill . . . . . . 15Novolog Vial. . . . . . . . 15Novotwist Pen Needle . . 14Nutropin AQ. . . . . . . . 15Nuvaring. . . . . . . . . . 21Nystatin Cream, Ointment,
Powder . . . . . . . . . 13Nystatin Suspension. . . . . . 9Nystatin/Triamcinolone Cream,
Ointment . . . . . . . . 13
O
Ocella . . . . . . . . . . . . 21Ofloxacin Ophthalmic Solution 16Ofloxacin Otic Solution . . . . 9Olanzapine Tab . . . . . . . 12Omeclamox Pak . . . . . . 17Omega-3 Acid Cap . . . . . 11Omeprazole . . . . . . . . . 16Omnaris . . . . . . . . . . 20Ondansetron Tab, ODT . . . 17Onetouch Kit Ultra . . . . 14
Bold type = Brand-name drug [Plain type = Generic drug] 27
Index of Covered Drugs
Onetouch Kit Ultra 2 . . . 14Onetouch Kit Ultra Mini . 14Onetouch Kit Ultra Smart. 14Onetouch Kit Verio IQ. . . 14Onetouch Test Strips . . . 14Onetouch Ultra Blue Test
Strips . . . . . . . . . . 14Onetouch Verio Test Strips 14Onexton . . . . . . . . . . 13Onfi . . . . . . . . . . . . 13Onglyza . . . . . . . . . . 15Opana ER . . . . . . . . . 19Opsumit . . . . . . . . . . 11Oracea . . . . . . . . . . . . 9Orencia SC . . . . . . . . . 17Orenitram . . . . . . . . . 11Orsythia . . . . . . . . . . . 21Ortho Tri-Cyclen Lo . . . . 21Osphena . . . . . . . . . . 22Otezla . . . . . . . . . . . 17Otrexup . . . . . . . . . . 17Ovidrel . . . . . . . . . . . 17Oxcarbazepine . . . . . . . 13Oxsoralen-UL . . . . . . . 13Oxybutynin . . . . . . . . . 19Oxybutynin ER . . . . . . . 19Oxycodone Tab . . . . . . . 19Oxycodone
w/ Acetaminophen . . . 19Oxycontin . . . . . . . . . 19
P
Pantoprazole . . . . . . . . 16Paroxetine Tab . . . . . . . 11Pataday . . . . . . . . . . 16Pazeo. . . . . . . . . . . . 16Penicillin VK. . . . . . . . . . 9Pentasa . . . . . . . . . . 17Perforomist . . . . . . . . 20Permethrin Cream 5% . . . 13Phenazopyridine . . . . . . 18Phentermine Tab . . . . . . 18Phenytoin . . . . . . . . . . 13Pioglitazone. . . . . . . . . 15Polyethylene
Glycol 3350 Powder. . . 17Polymyxin B/Trimethoprim
Solution . . . . . . . . . 16Potassium Chloride ER . . . 20Potassium Chloride Micro ER 20
Potassium Citrate . . . . . . 21Pradaxa . . . . . . . . . . 10Praluent . . . . . . . . . . 11Pravastatin . . . . . . . . . 11Precision Test Strips . . . . 14Prednisolone Ophthalmic
Suspension . . . . . . . 16Prednisolone Solution . . . . 15Prednisolone Syrup, Solution 15Prednisone . . . . . . . . . 15Premarin Tab. . . . . . . . 22Premarin Vaginal Cream . 22Premphase . . . . . . . . . 22Prempro . . . . . . . . . . 22Prepopik . . . . . . . . . . 17Previfem . . . . . . . . . . 21Prezcobix . . . . . . . . . 17Prezista . . . . . . . . . . 17Primidone . . . . . . . . . . 13Pristiq . . . . . . . . . . . 11Proair HFA, RespiClick. . . 20Prochlorperazine . . . . . . 12Procrit . . . . . . . . . . . 18Proctofoam HC . . . . . . 13Progesterone Cap . . . . . . 22Prograf Cap . . . . . . . . 20Promethazine/Codeine Syrup 18Promethazine DM Syrup . . 18Promethazine Tab . . . . . . 20Propranolol . . . . . . . . . 10Propranolol ER . . . . . . . 10Protosol HC . . . . . . . . . 17Proventil HFA . . . . . . . 20Pulmicort Flexhaler . . . . 20Pulmozyme . . . . . . . . 18Pylera . . . . . . . . . . . 17
Q
QNasl. . . . . . . . . . . . 20Quetiapine . . . . . . . . . 12Quinapril . . . . . . . . . . 10Qvar . . . . . . . . . . . . 20
R
Raloxifene. . . . . . . . . . 19Ramipril . . . . . . . . . . . 10Ranexa . . . . . . . . . . . 11Ranitidine Tab, Cap, Syrup . 16Rapaflo. . . . . . . . . . . 18
Rapamune . . . . . . . . . 20Rasuvo . . . . . . . . . . . 17Rebif . . . . . . . . . . . . 12Rebif Titrtn . . . . . . . . 12Reclipsen . . . . . . . . . . 21Relpax . . . . . . . . . . . 12Remicade . . . . . . . . . 17Renvela Tab, Pack . . . . . 18Restasis . . . . . . . . . . 16Retin-A Micro gel 0.1%,
0.04% . . . . . . . . . 13Revlimid . . . . . . . . . . . 9Rexulti . . . . . . . . . . . 11Reyataz . . . . . . . . . . 17Rezira . . . . . . . . . . . 18Risperidone . . . . . . . . . 12Rizatriptan Tab, ODT . . . . 12Ropinirole . . . . . . . . . . 12Rosuvastatin . . . . . . . . 11
S
Saphris . . . . . . . . . . . 12Savaysa . . . . . . . . . . 10Seebri . . . . . . . . . . . 20Sensipar . . . . . . . . . . 15Serevent Diskus . . . . . . 20Seroquel XR . . . . . . . . 12Sertraline . . . . . . . . . . 12Sildenafil Tab . . . . . . . . 11Silenor . . . . . . . . . . . 12Simbrinza . . . . . . . . . 16Simponi . . . . . . . . . . 17Simponi Aria. . . . . . . . 17Simvastatin . . . . . . . . . 11Solodyn . . . . . . . . . . . 9Soolantra . . . . . . . . . 13Sotalol . . . . . . . . . . . 11Sovaldi . . . . . . . . . . . . 9Spiriva Handihaler . . . . 20Spiriva Respimat . . . . . 20Spironolactone . . . . . . . 10Sprintec 28 . . . . . . . . . 21Sprycel . . . . . . . . . . . . 9Stelara . . . . . . . . . . . 17Stendra . . . . . . . . . . 18Stiolto . . . . . . . . . . . 20Strattera . . . . . . . . . . 11Stribild . . . . . . . . . . . 17Suboxone Film. . . . . . . 18Sucralfate Tab . . . . . . . . 16
Bold type = Brand-name drug [Plain type = Generic drug] 28
Index of Covered Drugs
Sulfacetamide/Sulfur Emulsion 13Sulfamethoxazole-Trimethoprim 9Sulfamethoxazole-
Trimethoprim DS . . . . . 9Sulfasalazine . . . . . . . . 17Sumatriptan Tab and Spray . 12Sumavel Dose . . . . . . . 12Suprep Bowel Prep . . . . 17Sustiva . . . . . . . . . . . 17Symbicort . . . . . . . . . 20Synagis. . . . . . . . . . . 18Synjardy . . . . . . . . . . 15Synthroid . . . . . . . . . 16Synvisc . . . . . . . . . . . 18Synvisc One . . . . . . . . 18
T
Taclonex . . . . . . . . . . 13Tacrolimus Cap . . . . . . . 20Taltz . . . . . . . . . . . . 17Tamiflu . . . . . . . . . . . . 9Tamoxifen Tab. . . . . . . . . 9Tamsulosin . . . . . . . . . 18Tasigna. . . . . . . . . . . . 9Tazorac. . . . . . . . . . . 13Tecfidera . . . . . . . . . . 12Tekturna . . . . . . . . . . 10Tekturna HCT . . . . . . . 10Telmisartan . . . . . . . . . 10Temazepam . . . . . . . . . 12Temozolomide . . . . . . . . 9Terazosin . . . . . . . . 10, 18Terbinafine Tab . . . . . . . . 9Terconazole Vaginal Cream . 22Testosterone Cypionate IM
Injection. . . . . . . . . 18Timolol . . . . . . . . . . . 16Timoptic Ocudose . . . . . 16Tirosint. . . . . . . . . . . 16Tivicay . . . . . . . . . . . 17Tivorbex . . . . . . . . . . 19Tizanidine . . . . . . . . . . 19Tobramycin . . . . . . . . . 16Tobramycin/Dexamethasone. 16Tolterodine . . . . . . . . . 19Topiramate Tab . . . . . . . 13Torsemide Tab. . . . . . . . 10Toujeo SoloStar . . . . . . 15
Toviaz . . . . . . . . . . . 19Tracleer . . . . . . . . . . 11Tradjenta. . . . . . . . . . 15Tramadol Tab . . . . . . . . 19Tramadol w/ Acetaminophen 19Transderm-Scop . . . . . . 17Travatan Z . . . . . . . . . 16Trazodone. . . . . . . . . . 12Tresiba . . . . . . . . . . . 15Tretinoin Cream . . . . . . . 13Tretinoin Microsphere Gel . . 13Triamcinolone . . . . . . 13, 20Triamterene/HCTZ . . . . . . 10Triazolam Tab . . . . . . . . 12Tribenzor. . . . . . . . . . 10Tri-Linyah . . . . . . . . . . 21Trinessa . . . . . . . . . . . 21Tri-Previfem . . . . . . . . . 21Tri-Sprintec . . . . . . . . . 21Triumeq . . . . . . . . . . 17Trulicity . . . . . . . . . . 15Truvada . . . . . . . . . . 17
U
Uceris Foam . . . . . . . . 17Uloric. . . . . . . . . . . . 18Ursodiol . . . . . . . . . . . 19
V
Vagifem . . . . . . . . . . 22Valacyclovir . . . . . . . . . . 9Valsartan . . . . . . . . . . 10Valsartan/HCTZ . . . . . . . 10Varubi . . . . . . . . . . . 17Vascepa . . . . . . . . . . 11Vectical. . . . . . . . . . . 13Velphoro . . . . . . . . . . 19Venlafaxine ER . . . . . . . 12Venlafaxine Tab . . . . . . . 12Ventolin HFA . . . . . . . 20Verapamil ER . . . . . . . . 10Vesicare . . . . . . . . . . 19Vestura . . . . . . . . . . . 21Viagra . . . . . . . . . . . 18Vicodin . . . . . . . . . . . 19Vicodin ES. . . . . . . . . . 19Victoza . . . . . . . . . . . 15
Vigamox . . . . . . . . . . 16Viibryd . . . . . . . . . . . 12Vimpat . . . . . . . . . . . 13Viorele . . . . . . . . . . . 21Viread . . . . . . . . . . . 17Vitamin D . . . . . . . . . . 21Voltaren Gel . . . . . . . . 19Vytorin . . . . . . . . . . . 11Vyvanse . . . . . . . . . . 11
W
Warfarin . . . . . . . . . . 10Welchol . . . . . . . . . . 11
X
Xarelto . . . . . . . . . . . 10Xeljanz . . . . . . . . . . . 17Xiidra. . . . . . . . . . . . 16Xolair. . . . . . . . . . . . 20Xopenex HFA . . . . . . . 20Xulane . . . . . . . . . . . 21
Z
Zarah . . . . . . . . . . . . 21Zarxio . . . . . . . . . . . 19Zenpep . . . . . . . . . . 17Zepatier . . . . . . . . . . . 9Zetia . . . . . . . . . . . . 11Zetonna . . . . . . . . . . 20Ziprasidone Cap. . . . . . . 12Zohydro ER . . . . . . . . 19Zolmitriptan Tab. . . . . . . 12Zolpidem . . . . . . . . . . 12Zolpidem ER. . . . . . . . . 12Zonisamide . . . . . . . . . 13Zorvolex . . . . . . . . . . 19Zostavax Injection. . . . . 19Zovirax. . . . . . . . . . . 13Zubsolv . . . . . . . . . . 19Zutripro . . . . . . . . . . 19Zyclara . . . . . . . . . . . 13Zytiga . . . . . . . . . . . . 9
29
“My Medications” worksheet
Take this worksheet with you each time you visit a doctor. Each of your doctors should be aware of every drug you take and you should have a list as well.
Name of Medicine and Strength
Drug Tier
I Take This Medicine For
Directions Doctor
Example: Lisinopril, 20 mg Tier 1 High blood pressure One tablet daily Dr. Johnson
WL6700D_170701 Select Choice