Quick-Reference Guide: Your 2013 Prescription Drug List

Your 2013 Prescription Drug List Quick-Reference Guide
Advantage Three-Tier
Table of Contents
Welcome to Your Prescription Drug List. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Frequently Asked Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Information About Tiers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Prescription Drug List. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Anti-Infectives Antibiotics. . . . . . . . . . . . . . . . . . . . . . . 5 Antifungals. . . . . . . . . . . . . . . . . . . . . . 5 Antivirals . . . . . . . . . . . . . . . . . . . . . . . 5 Cardiovascular/Heart Disease Coagulation Therapy. . . . . . . . . . . . . . 5 High Blood Pressure. . . . . . . . . . . . . . 6 High Cholesterol. . . . . . . . . . . . . . . . . 6 Other. . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Central Nervous System Attention Deficit Disorder. . . . . . . . . . 7 Depression. . . . . . . . . . . . . . . . . . . . . . 7 Migraine. . . . . . . . . . . . . . . . . . . . . . . . 7 Multiple Sclerosis . . . . . . . . . . . . . . . . 8 Sedatives/Hypnotics. . . . . . . . . . . . . . 8 Seizure Disorders . . . . . . . . . . . . . . . . 8 Other. . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Dermatology . . . . . . . . . . . . . . . . . . . 9 Diabetes/Endocrine Blood Glucose Monitoring. . . . . . . . . 9 Insulin. . . . . . . . . . . . . . . . . . . . . . . . . . 9 Non-Insulin. . . . . . . . . . . . . . . . . . . . . 10 Endocrine Growth Hormone. . . . . . . . . . . . . . . . 10 Other. . . . . . . . . . . . . . . . . . . . . . . . . . 10 Eye Conditions Allergies. . . . . . . . . . . . . . . . . . . . . . . 10 Antibiotics. . . . . . . . . . . . . . . . . . . . . . 10 Glaucoma. . . . . . . . . . . . . . . . . . . . . . 11 Gastrointestinal Acid Suppression . . . . . . . . . . . . . . . 11 Nausea/Vomiting. . . . . . . . . . . . . . . . 11 Other. . . . . . . . . . . . . . . . . . . . . . . . . . 11 Mens Health Erectile Dysfunction. . . . . . . . . . . . . . 11 Prostate . . . . . . . . . . . . . . . . . . . . . . . 12 Miscellaneous Miscellaneous . . . . . . . . . . . . . . . . . . 12 Overactive Bladder. . . . . . . . . . . . . . 12 Musculoskeletal Osteoporosis. . . . . . . . . . . . . . . . . . . 12 Pain Relief . . . . . . . . . . . . . . . . . . . . . 12 Rheumatoid Arthritis. . . . . . . . . . . . . 13 Other. . . . . . . . . . . . . . . . . . . . . . . . . . 13 Respiratory Asthma/COPD. . . . . . . . . . . . . . . . . .13 Nasal Allergies. . . . . . . . . . . . . . . . . . 14 Oral Allergies. . . . . . . . . . . . . . . . . . . 14 Womens Health Contraceptives. . . . . . . . . . . . . . . . . . 14 Estrogen/Progesterone. . . . . . . . . . . 15 Prenatal Vitamins. . . . . . . . . . . . . . . . 15
Additional Tier 3 drugs with a generic equivalent in Tier 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
For the most current PDL updates, visit myuhc.com or call the toll-free member phone number on the back of your health plan ID card.
Created September, 2012. 2013 Prescription Drug List Advantage Three-Tier 1/13
Your Prescription Drug List: Helping you get the most out of your pharmacy benefit.
This Prescription Drug List (PDL) outlines the most commonly prescribed medications for certain conditions and divides them into tiers. Your costs may change depending on a medications tier placement. To help you better use your UnitedHealthcare pharmacy benefit, this guide answers commonly asked questions about your PDL.
Go to myuhc.com for complete and up-to-date PDL information

Since the PDL may change, we encourage you to visit our website, myuhc.com. This website is the best source for up-to-date information about the medications your pharmacy benefit covers, possible lower-cost options, and how the cost of medications compare.
Visit www.myuhc.com for updates
2013 Prescription Drug List Advantage Three-Tier
Welcome to your 2013 Prescription Drug List
At UnitedHealthcare, we want to help you better understand your medication choices. 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, weve included some of the most commonly asked questions about the PDL. What is a PDL?
A PDL is a list of commonly prescribed medications placed into tiers. The PDL includes both brand and generic prescription medications approved by the U.S. Food and Drug Administration (FDA). The PDL is reviewed periodically and may change. It is not a complete list of medications and not all medications listed may be covered under your plan. If you have pharmacy benet coverage with UnitedHealthcare, please look at your benefit plan documents provided by your employer or health plan to see what medications are covered under your plan. Where differences are noted between this PDL quick-reference guide and your benet plan documents, the benet plan documents will govern. You may also log on to myuhc.com or call the toll-free member phone number on the back of your health plan ID card for more information.
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 lowestcost options. If your medication is placed in Tier 2 or 3, look to see if there is a Tier 1 alternative. Discuss your options with your doctor. Check your benefit plan documents to find out your pharmacy plan costs.
Tier 1 Your
Tier 2 Your
Tier 3 Your
lowest-cost midrange-cost highest-cost medications medications medications
How do I use my PDL?

When choosing a medication, you and your doctor should consult the PDL. This guide is organized by common medical conditions. Then, within each medical condition section, medications are listed by tier. If your medication is not located in the PDL please log on to myuhc.com or call the toll-free member phone number on the back of your health plan ID card.
Are there plans that dont have three tiers?

Some plans have a two-tier pharmacy benet rather than a three-tier pharmacy benet. Generally, a two-tier pharmacy benet plan does not cover medications listed in Tier 3 of this PDL. A two-tier pharmacy benet plan covers one tier at the lower-cost and covers a second tier at a higher-cost. In addition, some plans have a four-tier prescription plan or additional medication lists that should be referenced. Check your benefit plan documents or log on to myuhc.com for information about your benefits.
When do medications change tiers?

The PDL quick-guide is updated twice a year, January 1st and July 1st. Medications may move to a higher tier or be excluded from benefit coverage on these dates. Medications can move to a lower tier at any time throughout the year. Throughout the year we also review generic and brand-name medications and decide which tier each should be placed. If a new generic launches, tier changes can occur at that time for its brand counterpart. These reviews may cause medications to change tiers at any time. When a medication changes tiers, you may have to pay a different amount for that medication. These changes may occur without prior notice to you. For the most current information on your pharmacy coverage, please call the toll-free member phone number on the back of your health plan ID card or visit myuhc.com.
Here is a quick symbol overview: PDL Symbols

1 2
/ T Eligible for Half Tablet Program May be excluded from coverage Notification or Prior Authorization required* May be eligible for the Refill and Save Program
DSN Designated Specialty Network E N RS MC Multiple copay
SDP Select Designated Pharmacy SL Supply limit ST Step Therapy
*Depending on your benefit you may have notification or prior authorization requirements for select medications.
Why is the medication that I am currently taking no longer covered?

Medications may be excluded from coverage under your pharmacy benet. For example, a medication may be excluded from coverage when it is therapeutically equivalent to another prescription medication or an over-the-counter (OTC) medication. There may be alternatives on the PDL or OTC medications that are right for your treatment.
Why are there notations (SL, N, etc.) next to certain medications in the PDL, and what do they mean?
As you go through this list, you might notice some medications are noted with symbols next to them. The notations refer to our pharmacy programs. Your benefit plan determines how these medications may be covered for you but the symbols are guidelines to help you check what medications may be impacted. To learn more about a pharmacy program or to find out if it applies to you, please visit myuhc.com or call the toll-free member phone number on the back of your health plan ID card.
Should I talk to my doctor about OTC medications?

An OTC medication may be the right treatment for some conditions. Talk to your doctor about OTC options. These medications are not covered under your pharmacy benet, but 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 as brand-name medications, but they often cost less. After the patent on a brand-name medication expires, other companies can manufacture an FDA-approved version of the medication. These types of medications are called generic medications. Many times, the same company that makes a brand-name medication also makes the generic version.
How do I access updated information about my pharmacy benet?

Since the PDL may change, we encourage you to visit myuhc.com or call the toll-free member phone number on the back of your health plan ID card for more current information. Log on to myuhc.com for the following pharmacy information and tools: u Pharmacy benefit and coverage information u Possible lower-cost medication alternatives u A list of medications based on a specific medical condition u Medication interactions and side effects u Locate a participating retail pharmacy by zip code u View your prescription history And, if mail order is included in your pharmacy benefit, you can also: u Refill prescriptions u Check the status of your order u Set up e-mail reminders for refills u Manage your account
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-tier alternative is available and if it might be right for you. Generic medications are usually your lowest-cost option, but not always. Check myuhc.com to make sure.
Are you taking a specialty medication?

Specialty medications are managed through our Specialty Pharmacy Program which offers personalized member support. The program also offers access to on-call pharmacists available 24 hours a day, robust clinical and adherence programs and support coaching on lower-cost medication options. Visit www.uhcspecialtyrx.com or call 1-866-429-8177 to learn more. Please note your specialty medication may not be listed in this guide. Please log on to myuhc.com for more information.
What if I still have questions?

Please call the toll-free member phone number on the back of your health plan ID card. Representatives are available 24 hours a day (except Thanksgiving and Christmas).
In certain documents, the Prescription Drug List (PDL) was referred to as the Preferred Drug List (PDL). This change in descriptive terms does not affect your benet 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 benet plan determines how these medications may be covered for you.
Anti-Infectives Antibiotics
Tier 1 Amoxicillin Amoxicillin/Potassium Clavulanate Ampicillin Azithromycin Cefadroxil Cefprozil Cefuroxime Cephalexin Ciprofloxacin Tablet Tier 2 Augmentin Cayston N Cefdinir Cipro Suspension Ciprodex Otic Tier 3 Adoxa E Amoxicillin-Clavulanate ER E Augmentin XR E Avelox Cetraxal
(Oral, inhaled and ear antibiotics are listed)
Clarithromycin Tablet Clindamycin HCl Dicloxacillin Sodium Doxycycline Monohydrate Erythromycin Erythromycin Base Enteric-Coated Tablet Levofloxacin Metronidazole Minocycline HCl Clarithromycin Suspension Clarithromycin Sustained-Release Tablet Cleocin HCl 75 mg Clindamycin Palmitate Dapsone Cipro HC Ciprofloxacin Sustained-Release 24 Hour Tablet Doryx E Doxycycline Hyclate Enteric-Coated Tablet E Doxycycline Monohydrate Capsule 150 mg E
(Oral and topical antifungals are listed)
Neomycin/Polymyxin/HC Otic Nitrofurantoin Macrocrystal Nitrofurantoin Suspension Nitrofurantoin/Nitrofurantoin Macrocrystal Ofloxacin Otic Penicillin V Potassium Sulfamethoxazole/Trimethoprim Tetracycline Vancomycin SL Ery-Tab 500 mg Macrodantin 25 mg Tobi DSN Zyvox SL
Minocycline Extended-Release 24 Hour Tablet Oracea Solodyn Suprax
Anti-Infectives Antifungals
Tier 1 Clotrimazole Fluconazole Itraconazole Capsule SL Tier 2 Clindesse Vaginal Tier 3 Gynazole-1 Vaginal Ketoconazole Foam SL
Ketoconazole Metronidazole Vaginal Nystatin Noxafil Lamisil Granules SL Mycostatin
Terbinafine Tablet SL Terconazole Vaginal Voriconazole SL Sporanox Oral Solution
Anti-Infectives Antivirals
Tier 1 Acyclovir Tier 2 Baraclude DSN Epivir HBV DSN Famciclovir SL Tier 3 Relenza SL Ribapak DSN E N Amantadine Hepsera DSN Incivek DSN N SL Rebetol Solution DSN N Tamiflu SL Victrelis DSN N SL Ribavirin DSN N Valacyclovir SL Valcyte SL
Cardiovascular/Heart Disease Coagulation Therapy

Tier 1 Cilostazol Clopidogrel Tier 2 Coumadin Enoxaparin SL Tier 3 Aggrenox Effient SL Pentoxifylline Warfarin Sodium Fondaparinux SL Xarelto SL Fragmin SL Innohep SL Pradaxa SL
Please refer to page 3 for a definition of notations/symbols.
Cardiovascular/Heart Disease High Blood Pressure

Tier 1 Amlodipine Atenolol Atenolol/Chlorthalidone Benazepril Benazepril/Hydrochlorothiazide Bisoprolol Bisoprolol/Hydrochlorothiazide Bumetanide Captopril Captopril/Hydrochlorothiazide Carvedilol Chlorthalidone Clonidine Diltiazem Diltiazem Controlled-Release Capsule Diltiazem Sustained-Release 12 Hour Capsule Doxazosin Tier 2 Aldactazide 50-50 mg Benicar 1/2T SL Benicar HCT SL BiDil Bystolic Cardizem LA 120 mg Clorpres Dibenzyline Tier 3 Aceon 1/2T Amlodipine/Benazepril SL Amturnide E SL Atacand 1/2T SDP SL Atacand HCT SDP SL Avalide SL Avapro 1/2T SL Azor SL Cardizem LA 180, 240, 300, 360, 420 mg Clonidine Transdermal Weekly Patch SL Enalapril Enalapril/Hydrochlorothiazide Eprosartan SL Felodipine Furosemide Guanfacine Hydralazine Hydrochlorothiazide Labetalol Lisinopril Lisinopril/Hydrochlorothiazide Losartan 1/2T Losartan/Hydrochlorothiazide Metolazone Metoprolol Succinate Sustained-Release Tablet 25 mg Metoprolol Tartrate Diltiazem Sustained-Action Capsule Diltiazem Sustained-Release 24 Hour Capsule Diltiazem Sustained-Release 24 Hour Tablet Diuril Suspension 250 mg/5 ml Dutoprol SL Eplerenone Metoprolol Succinate Sustained-Release Tablet 50, 100, 200 mg Coreg CR E SL Diovan 1/2T SL Diovan HCT SL Edarbi SL Edarbyclor SL Exforge E SL Exforge HCT E SL Irbesartan 1/2T SL Irbesartan/Hydrochlorothiazide SL Nexiclon XR E Metoprolol/Hydrochlorothiazide Moexipril 1/2T Nadolol Nifedipine Propranolol Tablet Propranolol/Hydrochlorothiazide Ramipril Spironolactone Spironolactone/Hydrochlorothiazide Terazosin Torsemide Trandolapril 1/2T Triamterene/Hydrochlorothiazide Verapamil
Micardis SL Micardis HCT SL Nisoldipine Perindopril Erbumine 1/2T Propranolol Sustained-Action Capsule Quinapril/Hydrochlorothiazide Thalitone
Sular Tekamlo E SL Tekturna SDP SL Tekturna HCT SDP SL Teveten HCT SL Trandolapril/Verapamil Tribenzor E SL Twynsta E SL Verapamil Sustained-Release 24 Hour Pellets
Cardiovascular/Heart Disease High Cholesterol

Tier 1 Atorvastatin 1/2T SL Cholestyramine Colestipol Tier 2 Antara Crestor 1/2T SL Tier 3 Advicor SL Altoprev E SL Amlodipine/Atorvastatin E SL Caduet E SL Fenoglide Lescol XL SL Fenofibric Acid Fluvastatin SL Gemfibrozil Fenofibrate Lipofen Lipitor 1/2T E SL Livalo SL Lovaza N Niaspan Simcor SL Tricor E Lovastatin Pravastatin 1/2T Simvastatin 1/2T Welchol
Triglide Trilipix E Vytorin SL Zetia SL
Cardiovascular/Heart Disease Other

Tier 1 Amiodarone Digoxin Flecainide Acetate Tier 2 Lanoxin Multaq Tier 3 Nitroglycerin Spray E SL Nitrolingual E SL Isosorbide Dinitrate Isosorbide Mononitrate Mexiletine Nitrostat Ranexa Nitromist SL Propafenone Sustained-Release 12 Hour Capsule Nitroglycerin Transdermal Patch Sotalol
Central Nervous System Attention Deficit Disorder

Tier 1 Amphetamine Salt Combo Dextroamphetamine Sulfate Tier 2 Adderall XR SL Tier 3 Amphetamine Aspartate/Amphetamine Sulfate/ Dextroamphetamine Sustained-Release 24 Hour Capsule SL Concerta SL Daytrana SL Methamphetamine Methylphenidate Intuniv SL Focalin XR SL Kapvay E Metadate CD SL Methylin Tablet Vyvanse SL Methylphenidate Extended-Release 24 Hour Tablet SL Methylphenidate Extended-Release Capsule SL Ritalin LA SL Strattera SL
Central Nervous System Depression

Tier 1 Amitriptyline Bupropion Bupropion XL Citalopram Hydrobromide Doxepin Fluoxetine Tier 3 Aplenzin E SL Cymbalta SDP SL Escitalopram 1/2T SL Lexapro 1/2T SL Fluoxetine Delayed-Release Capsule SL Fluvoxamine Maleate Mirtazapine Nefazodone Nortriptyline Paroxetine Tablet Luvox CR SL Oleptro E SL Paroxetine Sustained-Release 24 Hour Tablet SL Pexeva 1/2T SL Phenelzine Sertraline 1/2T Trazodone Venlafaxine Sustained-Release Capsule SL
Pristiq RS SL Venlafaxine Extended-Release Tablet E SL
Central Nervous System Migraine

Tier 1 Acetaminophen/Butalbital/Caffeine SL Acetaminophen/Dichloralphenazone/ Isometheptene Mucate Tier 2 Ergomar Tier 3 Alsuma E SL Axert SDP SL Cafergot Cambia E SL Frova SDP SL Aspirin/Butalbital/Caffeine Naratriptan SL Relpax SL Sumatriptan Succinate Nasal Spray SL Maxalt SDP SL Maxalt MLT SDP SL Migranal Sumavel DosePro SL Treximet E SL Zomig SDP SL Zomig Nasal Spray SL Zomig ZMT SDP SL Sumatriptan Succinate Injection, Tablet SL
Central Nervous System Multiple Sclerosis

Tier 2 Ampyra DSN N SL Avonex DSN N SL Tier 3 Betaseron DSN N SL ST Copaxone DSN N SL Rebif DSN N SL Extavia DSN E N SL ST Gilenya DSN N SL ST
Central Nervous System Sedatives/Hypnotics

Tier 1 Temazepam Tier 3 Ambien SL ST Ambien CR SL ST Edluar E SL ST Zaleplon SL Lunesta SL ST Rozerem SL ST Silenor E SL Zolpidem Tablet SL Sonata SL ST Zolpidem Multiphasic-Release Tablet SL ST Zolpimist E SL ST
Central Nervous System Seizure Disorders

Tier 1 Carbamazepine Clonazepam Diazepam Rectal Gel SL Divalproex Sodium Sustained-Release Tablet Divalproex Sodium Tablet Tier 2 Carbamazepine Sustained-Release 12 Hour Tablet Celontin Dilantin Tier 3 Carbamazepine Extended-Release 12 Hour Capsule Carbatrol Depakote ER ST Keppra ST Felbamate Gabapentin Lamotrigine Levetiracetam Oxcarbazepine Divalproex Sodium Sprinkle Capsule Gabitril Levetiracetam Extended-Release 24 Hour Tablet ST Keppra XR ST Lamictal ST Lamictal Dose Pack SL ST Lamictal ODT ST Lamictal XR ST Phenobarbital Phenytoin Sodium Primidone Topiramate Zonisamide Mysoline Peganone Sabril Tegretol Lyrica SDP SL Stavzor ST Topamax ST
Central Nervous System Other

Tier 1 Alprazolam Benztropine Mesylate Buspirone Carbidopa/Levodopa Clozapine Tier 2 Apokyn DSN Comtan FazaClo Nuedexta Tier 3 Abilify 1/2T SL Aricept 23 mg E Exelon Solution Fanapt SL Geodon SL Invega SL Mirapex ER E Diazepam Donepezil 5, 10 mg Galantamine Lithium Carbonate Lithium Carbonate Controlled-Release Tablet Olanzapine Tablet SL Olanzapine/Fluoxetine SL Quetiapine SL Tasmar Modafinil E N SL Namenda Nuvigil N SL Olanzapine Rapid Dissolve Tablet SL Provigil E N SL Requip XL E Ropinirole Extended-Release 24 Hour Tablet E Lorazepam Pramipexole Risperidone Rivastigmine Ropinirole Xyrem N SL Ziprasidone SL
Seroquel SL Seroquel XR SL Symbyax SL Zyprexa SL Zyprexa Zydis SL
Dermatology
Tier 1 Alclometasone Dipropionate Betamethasone Dipropionate Betamethasone Valerate Ciclopirox Cream, Gel, Lotion Ciclopirox Non-Oral Solution Clindamycin Gel, Lotion, Solution, Swabs Clobetasol Propionate Clotrimazole/Betamethasone Desonide Desoximetasone Econazole Nitrate Tier 2 Azelex SL Benzaclin Gel 1%-5% 25 g SL Benzamycin Calcipotriene Cream, Ointment SL Tier 3 Acanya SL Aczone SL Adapalene N SL Altabax SL Atralin MC N SL Avita Gel N SL Bactroban SL Benzaclin Gel 1%-5% SL Clindagel E SL Clindamycin Foam 1% SL Clindamycin Phosphate/Benzoyl Peroxide Extended-Release Gel E SL Clindamycin Phosphate/Benzoyl Peroxide Gel 1%-5% SL Clobetasol Propionate Foam SL Clobetasol Propionate Lotion SL Clobetasol Propionate Shampoo E SL Clobex SL Clobex Shampoo E SL Erythromycin Erythromycin/Benzoyl Peroxide Fluocinolone Fluocinonide Fluticasone Propionate Halobetasol Propionate Hydrocortisone Hydrocortisone Valerate Ketoconazole Lidocaine Metronidazole Gel 0.75% Ciclopirox Shampoo 1% MC Differin Cream, Gel 0.1% N SL Imiquimod SL Isotretinoin Condylox Gel Cutivate Lotion MC Denavir Desonate SL Differin Gel 0.3% N SL Differin Lotion N SL Dovonex SL Duac E SL Elidel N SL Epiduo E SL Evoclin SL Finacea Finacea Plus Fluticasone Propionate Lotion MC Locoid Lipocream SL Locoid Lotion SL Loprox Shampoo MC Metrogel 1% E MC Metrolotion Mometasone Furoate Mupirocin Nystatin Nystatin/Triamcinolone Acetonide Permethrin Silver Sulfadiazine Sulfacetamide Sodium/Sulfur Tretinoin N Triamcinolone Acetonide Urea
Oxsoralen-Ultra Protopic N SL Regranex N Stelara DSN N SL Naftin Noritate MC Olux-E SL Oxistat Retin-A Micro N SL Taclonex SL Taclonex Scalp SL Tazorac N SL Tretin-X N SL Vanos SL Vectical SL Veltin E SL Verdeso SL Vusion MC Xerese E Xolegel MC Ziana E SL Zovirax SL Zyclara E SL
Diabetes/Endocrine Blood Glucose Monitoring

Tier 1 Accu-Chek Active Test Strips SL Accu-Chek Aviva Plus Accu-Chek Aviva Plus Test Strips SL Accu-Chek Comfort Curve Test Strips SL Accu-Chek Compact Test Strips SL Tier 3 Ascensia Autodisc Test Strips SDP SL Ascensia Breeze 2 Test Strips SDP SL Accu-Chek Nano SmartView Accu-Chek SmartView Test Strip SL One Touch Test Strips SL One Touch Ultra 2 System One Touch Ultra Mini System Contour Test Strips SDP SL Freestyle Lite Test Strips SDP SL One Touch Ultra Test Strips SL One Touch Verio IQ System One Touch Verio IQ Test Strips SL
Freestyle Test Strips SDP SL Precision Xtra Test Strips SDP SL
Diabetes/Endocrine Insulin
Tier 1 Humalog Vials Humalog-Mix Vials Tier 2 Humalog KwikPen Humalog-Mix KwikPen Tier 3 Apidra Solostar SDP Apidra Vial SDP Humulin 70-30 Vials Humulin Vials Humulin KwikPen Lantus Vials Lantus Solostar Pens/Cartridges Levemir Flexpen Levemir Vials
Novolin Vials SDP NovoLog SDP
Diabetes/Endocrine Non-Insulin
Tier 1 Acarbose Glimepiride Tier 2 Byetta SL Duetact SL Glipizide/Metformin Glyset Tier 3 Actoplus Met SL Actoplus Met XR SDP SL Actos 1/2T SL Avandamet SL Avandaryl SL Glipizide Glyburide Jentadueto SL Kombiglyze XR SL Nateglinide SL Onglyza SL Avandia SL Fortamet Glumetza Janumet SDP SL Janumet XR SDP SL Glyburide/Metformin Metformin Pioglitazone 1/2T SL Pioglitazone/Metformin SL Prandin SL Tradjenta SL Januvia SDP SL Juvisync SDP SL Metformin Extended-Release 24 Hour Tablet Symlin SL Victoza SL
Endocrine Growth Hormone

Tier 2 Nutropin, AQ, NuSpin DSN N SL Saizen DSN N SL Tier 3 Genotropin DSN E N SL Humatrope DSN E N SL Serostim DSN N SL Tev-Tropin DSN N SL Norditropin DSN E N SL Omnitrope DSN E N SL Zorbtive DSN N SL
Endocrine Other
Tier 1 Calcitriol Desmopressin Dexamethasone Fludrocortisone Hydrocortisone Tablet Tier 2 Androderm SL Android Cabergoline Hectorol Kuvan DSN N SL Tier 3 Androgel E SL Armour Thyroid Levothyroxine Sodium Methimazole Methylprednisolone Dosepak Tablet 4 mg Octreotide Acetate DSN N Orapred Levoxyl Liothyronine Sodium Medrol 2, 8, 24, 32 mg Oxandrolone Pediapred Axiron E SL Fortesta E SL Prednisolone Prednisone Testosterone
Synarel Synthroid Testim SL Tirosint Zemplar DSN Orapred ODT
Eye Conditions Allergies

Tier 1 Ketorolac Tromethamine Tier 3 Azelastine HCl SL Bepreve E SL Elestat E SL Emadine E Epinastine E SL Lastacaft SL Optivar E SL Pataday E SL Patanol E SL
Eye Conditions Antibiotics

Tier 1 Ciprofloxacin Erythromycin Gentamicin Sulfate Tier 2 Blephamide S.O.P. Tier 3 Azasite SL Moxeza
Levofloxacin Neomycin/Polymyxin B Sulfate/Dexamethasone Ofloxacin Tobramycin/Dexamethasone Tobradex ST E SL Vigamox
Polymyxin B Sulfate/Trimethoprim Sulfacetamide Sodium Tobramycin Sulfate Drops
Zylet Zymaxid SL
10
Eye Conditions Glaucoma

Tier 1 Acetazolamide Apraclonidine Tier 2 Alphagan P 0.1% SL Azopt SL Betimol SL Tier 3 Iopidine 1% Dorzolamide HCl Latanoprost SL Brimonidine Tartrate SL Combigan SL Dorzolamide HCl/Timolol Maleate Timolol Maleate
Lumigan SL Pilopine HS Travatan Z SL
Gastrointestinal Acid Suppression

Tier 1 Cimetidine Misoprostol Tier 2 Helidac Nizatidine Oral Solution Tier 3 Aciphex SL Carafate Oral Suspension Dexilant SL Lansoprazole E SL Nexium Capsule E SL Omeprazole Pantoprazole Prevpac SL Pylera Nexium Suspension Omeprazole/Sodium Bicarbonate Capsule E SL Prevacid Delayed-Release Enteric-Coated Capsule E SL Prevacid Solutab E SL Prilosec Rx 10, 20 mg E Prilosec Rx 40 mg E Protonix Granules SL Zegerid Capsule E SL Zegerid Packet SL Ranitidine Syrup Sucralfate Tablet
Gastrointestinal Nausea/Vomiting
Tier 1 Ondansetron Tier 2 Emend SL Tier 3 Anzemet SL Cesamet Prochlorperazine Maleate Granisetron Tablet SL Sancuso E SL Transderm-Scop Zuplenz E SL
Gastrointestinal Other
Tier 1 Balsalazide Belladonna/Phenobarbital Chlordiazepoxide/Clidinium Diphenoxylate/Atropine Tier 2 Apriso Budesonide Extended-Release 24 Hour Capsule Canasa Tier 3 Amitiza N SL Asacol SDP Asacol HD E SDP Lactulose Mesalamine Metoclopramide Polyethylene Glycol Creon GoLYTELY Packet Lialda Dipentum Halflytely-Bisacodyl Metozolv ODT E Sulfasalazine Trilyte with Flavor Packets Ursodiol
Lotronex SL Relistor Zenpep Moviprep Pancreaze SDP Pentasa
Mens Health Erectile Dysfunction

Tier 3 Caverject SL Cialis SL Edex SL Levitra SL Muse SL Staxyn E SL Viagra SL
11
Mens Health Prostate

Tier 1 Alfuzosin Doxazosin Tier 3 Avodart N SDP Finasteride Tamsulosin Jalyn E Terazosin
Rapaflo
Miscellaneous
Tier 1 Anastrozole Antipyrine/Benzocaine Azathioprine Benzonatate Tier 2 Cellcept Suspension DSN Epipen SL Epipen Jr SL Exemestane Tier 3 Acuvail E SL Aromasin Bromday E SL Bromfenac SL Chlorhexidine Gluconate Letrozole Megestrol Acetate Mycophenolate Capsule, Tablet DSN Fareston Lidoderm SL Lysteda SL Myfortic DSN Hydrocodone/Chlorpheniramine Suspension SL Infergen DSN N SL Intron A DSN N Peg-Intron DSN N SL ST Phenazopyridine Tacrolimus DSN Tamoxifen
Neoral DSN Pegasys DSN N SL Rapamune DSN Sandimmune DSN Restasis N SL Tussionex SL
Miscellaneous Overactive Bladder

Tier 1 Dicyclomine Tablet Hyoscyamine Sulfate Tier 2 Gelnique Oxytrol Tier 3 Detrol Detrol LA E Oxybutynin Trospium Sanctura XR Vesicare Enablex Tolterodine Toviaz SDP
Musculoskeletal Osteoporosis
Tier 1 Alendronate SL Tier 2 Calcitonin Salmon Nasal Spray Evista Tier 3 Actonel SL Forteo DSN N Fortical Atelvia E SL Ibandronate Tablet SL
Fosamax Plus D SL
Musculoskeletal Pain Relief

Tier 1 Acetaminophen/Butalbital/Caffeine/Codeine SL Acetaminophen/Codeine SL Acetaminophen/Hydrocodone Bit SL Acetaminophen/Oxycodone SL Aspirin/Butalbital/Caffeine/Codeine Aspirin/Oxycodone Diclofenac Potassium Diclofenac Sodium Duragesic SL Etodolac Hydromorphone Ibuprofen Ibuprofen/Hydrocodone Ibuprofen/Oxycodone Indomethacin Ketorolac Tromethamine Meloxicam Meperidine Methadone Morphine Sulfate Morphine Sulfate Sustained-Action Tablet SL Nabumetone Naproxen Naproxen Sodium Oxaprozin Oxycodone Piroxicam Sulindac Tramadol Tramadol/Acetaminophen SL
12
Musculoskeletal Pain Relief (cont. from page 12)

Tier 2 Acetaminophen/Hydrocodone Bit 7.5 - 325 mg/15 ml Oral Solution SL Butorphanol Nasal Spray SL Codeine Phosphate Fentanyl Citrate Lollipop N SL MSIR Capsule Tier 3 Abstral N SL Arthrotec Avinza SL Celebrex SL Conzip E SL Duexis E SL Embeda SL Exalgo SL Fentanyl Transdermal SL Fentora E N SL Opana ER SL OxyContin SL Oxymorphone SL Oxymorphone Extended-Release 12 Hour Tablet SL Tolmetin Sodium Flector E Hycet SL Kadian E SL Lazanda N SL Mefenamic Acid Morphine Sulfate Extended-Release Pellets E SL Naprelan E Nucynta SL Nucynta ER SL Onsolis N SL Tramadol Sustained-Release 24 Hour Tablet SL Voltaren Gel
Opana SL Pennsaid E Rybix ODT E SL Ryzolt E SL Sprix SL Tramadol Extended-Release Multiphase 24 Hour Tablet E SL Vimovo E SL Zipsor E
Musculoskeletal Rheumatoid Arthritis

Tier 1 Azathioprine Hydroxychloroquine Sulfate Tier 2 Cimzia DSN N SL Cuprimine Tier 3 Humira DSN N SL ST Leflunomide Methotrexate Enbrel DSN N SL Simponi DSN N SL Kineret DSN N SL Sulfasalazine
Trexall
Orencia DSN N SL
Musculoskeletal Other
Tier 1 Allopurinol Baclofen Tier 2 Colcrys Tier 3 Amrix E Carisoprodol 250 mg E Cyclobenzaprine Extended-Release 24 Hour Capsule E Carisoprodol 350 mg Cyclobenzaprine Orphenadrine Gralise E SL Horizant E SL Metaxalone Savella SL Methocarbamol Tizanidine Tablet Orphenadrine/Aspirin/Caffeine Skelaxin E Soma 250 mg E Tizanidine Capsule Uloric SL
Respiratory Asthma/COPD
Tier 1 Albuterol Sulfate Alvesco SL Asmanex SL Tier 2 Albuterol Sulfate/Ipratropium Non-Oral Solution Budesonide Inhalation Suspension 0.25 mg/ 2 ml, 0.5 mg/2 ml SL Tier 3 Advair Diskus RS SL Advair HFA RS SL Atrovent HFA SL Combivent SL Combivent Respimat SL Daliresp N SL Dulera RS SL Ipratropium Bromide QVAR SL Theophylline Foradil SL Montelukast SL Pulmicort Respules 1 mg/2 ml SL Flovent Diskus SDP SL Flovent HFA SDP SL Levalbuterol Vial, Nebulizer E SL Maxair Autohaler SL Perforomist SL Proair HFA SL Proventil HFA SL Ventolin HFA SL Zafirlukast SL
Spiriva SL
Pulmicort Flexhaler SDP SL Serevent Diskus SL Singulair SL Symbicort SDP SL Xopenex HFA SL Xopenex Vial, Nebulizer E SL
13
Respiratory Nasal Allergies

Tier 1 Flunisolide Tier 2 Nasonex SL Tier 3 Astelin E SL Astepro SL Azelastine HCl SL Beconase AQ SL Nasacort AQ SL Omnaris SL Patanase SL Rhinocort Aqua SL Triamcinolone Acetonide SL Veramyst E SL Fluticasone Propionate SL
Respiratory Oral Allergies

Tier 1 Cyproheptadine Hydroxyzine Tier 3 Clarinex E SL Clarinex-D E SL Levocetirizine Tablet SL Promethazine Desloratadine E SL Levocetirizine Oral Solution SL
Womens Health Contraceptives

Tier 1 Apri Altavera Aranelle Aviane Caziant Cryselle Cyclafem 1/35 Ella SL Emoquette Enpresse Gildess FE Junel Fe Kelnor Leena Lessina Tier 2 Azurette Balziva Briellyn Depo-SubQ Provera MC Introvale MC Jolessa MC Tier 3 Alyacen 7/7/7 Amethia MC Amethia Lo MC Amethyst Beyaz E Camila Camrese MC Camrese Lo MC Cyclafem 7/7/7 Errin Femcon Fe Generess Fe E Gianvi Heather Levora Low-Ogestrel Lutera Marlissa Medroxyprogesterone 150 mg/ml MC Microgestin Fe Myzilra Natazia Necon 0.5/35 Necon 1/35 Necon 1/50 Necon 10/11 Next Choice One Dose Nortrel 0.5/35 Nortrel 1/35 Junel Kariva Microgestin NuvaRing Ogestrel Philith Jolivette Lo Loestrin Fe Loestrin 24 Fe Loryna Mononessa Necon 7/7/7 Nora-Be Norethindrone Nortrel 7/7/7 Ocella Ortho Evra Ortho Tri-Cyclen Lo Previfem Safyral E Orsythia Ortho Micronor Ortho Tri-Cyclen Ortho-Cyclen Ortho-Novum 7/7/7 Plan B Portia Reclipsen Sronyx Trivora Velivet Yasmin Zovia 1/35E Zovia 1/50E
Quasense MC Viorele Yaz Zenchent
Sprintec Syeda Tilia Fe Tri-Legest Fe Tri-Previfem Tri-Sprintec Trinessa Vestura Wymzya Fe Zarah Zenchent Fe Zeosa
14
Womens Health Estrogen/Progesterone

Tier 1 Estradiol Estradiol Transdermal Weekly Patch SL Tier 2 Cenestin Climara SL Crinone N Divigel Enjuvia Tier 3 Activella Alora SL Climara Pro SL Combipatch SL Estrasorb SL Estropipate Medroxyprogesterone Estrace Cream with Applicator Estradiol/Norethindrone Acetate Estring MC SL Evamist Prefest Estrogel SL Femhrt Femring MC SL First-Progesterone N Menostar Transdermal Weekly Patch SL Norethindrone Acetate
Progesterone Micronized Capsule Vagifem Vivelle-Dot SL
Premarin Premphase Prempro
Womens Health Prenatal Vitamins

Tier 1 Folic Acid Multinatal Plus Tier 2 Advanced Care Plus Cavan-EC Sod DHA Multi-Nate 30 Tier 3 Brand Prenatal Vitamins Folcal DHA Prenatal 19 Prenatal Advantage PR Natal 430 PR Natal 430 EC Setonet Taron A Prenatal Zatean-PN Prenatal Plus
Setonet-EC
Zatean-PN DHA Zatean-PN Plus
15
Additional Tier 3 Drugs with a generic equivalent in Tier 1

Accolate SL (Zafirlukast SL) Accupril (Quinapril) Acular (Ketorolac Tromethamine) Adderall (Amphetamine/Dextroamphetamine Salt Combination) Aldactone (Spironolactone) Altace (Ramipril) Amaryl (Glimepiride) Ambien SL ST (Zolpidem SL) Amerge SL (Naratriptan SL) Anaprox (Naproxen) Aricept (Donepezil) Arimidex (Anastrozole) Ativan (Lorazepam) Augmentin ES (Amoxicillin/Potassium Clavulanate) Biaxin Tablet (Clarithromycin Tablet) Buspar (Buspirone) Calan, Calan SR (Verapamil) Cardizem CD except for 360 mg strength (Diltiazem Sustained-Release 24 Hour Capsule) Cardura (Doxazosin) Ceftin (Cefuroxime) Cefzil (Cefprozil) Celexa (Citalopram) Ciloxan Eye Drops (Ciprofloxacin) Cipro (Ciprofloxacin) Cleocin T (Clindamycin Gel, Lotion, Solution, Swabs) Clozaril (Clozapine) Colazal (Balsalazide) Colestid (Colestipol) Coreg (Carvedilol) Cozaar 1/2T (Losartan 1/2T ) DDAVP (Desmopressin) Depakote (Divalproex Sodium Tablet) Depakote ER ST (Divalproex Sodium Sustained-Release 24 Hour Tablet) Depo-Provera MC (Medroxyprogesterone 150 mg/ml MC ) Derma-Smoothe/FS (Fluocinolone) DiaBeta, Glynase (Glyburide) Diastat Acudial SL (Diazepam Rectal Gel SL) Didronel (Etidronate Disodium) Diflucan (Fluconazole) Ditropan XL (Oxybutynin Sustained-Release Tablet) Dyazide (Triamterene/Hydrochlorothiazide) Effexor (Venlafaxine) Effexor XR SL (Venlafaxine Sustained-Release Capsule SL) Felbatol (Felbamate) Femara (Letrozole) Fioricet SL (Acetaminophen/Butalbital/ Caffeine SL) Flomax (Tamsulosin) Flonase SL (Fluticasone Nasal Spray SL) Fosamax SL (Alendronate SL) Glucophage, XR (Metformin) Glucotrol, XL (Glipizide) Glucovance (Glyburide/Metformin) Hyzaar SL (Losartan/Hydrochlorothiazide SL) Imitrex SL (Sumatriptan Succinate Injection, Tablet SL) Keflex (Cephalexin) Keppra ST (Levetiracetam) Klonopin (Clonazepam) Lamictal ST (Lamotrigine) Lamisil SL (Terbinafine Tablet SL) Lasix (Furosemide) Levaquin (Levofloxacin) Lipitor 1/2T E SL (Atorvastatin 1/2T SL) Lopid (Gemfibrozil) Lopressor (Metoprolol) Mavik 1/2T (Trandolapril 1/2T ) Medrol (Methylprednisolone Dosepak Tablet 4 mg) Metrogel Vaginal (Metronidazole) Mevacor (Lovastatin) Mobic (Meloxicam) Monopril (Fosinopril) Naprosyn (Naproxen) - Prescription strengths only Nardil (Phenelzine) Neurontin (Gabapentin) Norvasc (Amlodipine) Ocuflox Eye Drops (Ofloxacin) Paxil (Paroxetine) Penlac (Ciclopirox Solution, Non-Oral) Percocet 5-325, 7.5-500, 10-650 SL (Acetaminophen/Oxycodone SL) Plavix (Clopidogrel) Pletal (Cilostazol) Pravachol 1/2T (Pravastatin 1/2T ) Precose (Acarbose) Prilosec (Omeprazole) Prinivil, Zestril (Lisinopril) Prinzide, Zestoretic (Lisinopril/ Hydrochlorothiazide) Procardia XL (Nifedipine Extended-Release Tablet) Proscar (Finasteride) Protonix (Pantoprazole) Provera (Medroxyprogesterone) Prozac (Fluoxetine Capsule) Prozac Weekly SL (Fluoxetine Delayed-Release Capsule SL) Remeron (Mirtazapine) Remeron SolTab (Mirtazapine Dispersible Tablet) Requip (Ropinirole) Restoril (Temazepam) Risperdal (Risperidone) Ritalin (Methylphenidate) Ritalin SR (Methylphenidate Extended-Release Tablet) Sonata ST SL (Zaleplon SL) Surmontil (Trimipramine Maleate) Tenoretic (Atenolol/Chlorthalidone) Tenormin (Atenolol) Teveten SL (Eprosartan SL) Tiazac (Diltiazem) Topamax ST (Topiramate) Toprol XL 25 mg (Metoprolol Succinate Sustained-Release Tablet) Trileptal (Oxcarbazepine) Trusopt (Dorzolamide Eye Drops) Tylenol #3 SL (Acetaminophen/Codeine SL) Ultracet SL (Tramadol/Acetaminophen SL) Ultram (Tramadol) Uroxatral (Alfuzosin) Valium (Diazepam) Vaseretic (Enalapril/Hydrochlorothiazide) Vasotec (Enalapril) Vfend SL (Voriconazole SL) Vicodin SL , Vicodin ES SL (Acetaminophen/ Hydrocodone SL) Vicoprofen (Ibuprofen/Hydrocodone) Voltaren Tablet (Diclofenac) Wellbutrin (Bupropion HCl) Wellbutrin SR (Bupropion HCl Sustained-Action Tablet) Wellbutrin XL (Bupropion HCl Sustained-Release 24 Hour Tablet) Xalatan SL (Latanoprost SL) Xanax, Xanax XR (Alprazolam) Zantac Syrup (Ranitidine Syrup) Ziac (Bisoprolol/Hydrochlorothiazide) Zithromax (Azithromycin) Zocor 1/2T (Simvastatin 1/2T ) Zofran (Ondansetron) Zoloft 1/2T (Sertraline 1/2T ) Zonegran (Zonisamide) Zovirax (Acyclovir Capsule, Suspension, Tablet)
16
Index
A Abilify 8 Abstral 13 Acanya 9 Acarbose 10, 16 Accolate 16 Accu-Chek Active Test Strips 9 Accu-Chek Aviva Plus 9 Accu-Chek Aviva Plus Test Strips 9 Accu-Chek Comfort Curve Test Strips 9 Accu-Chek Compact Test Strips 9 Accu-Chek Nano SmartView 9 Accu-Chek SmartView Test Strip 9 Accupril 16 Aceon 6 Acetaminophen/Butalbital/Caffeine 7, 12, 16 Acetaminophen/Butalbital/Caffeine/Codeine 12 Acetaminophen/Codeine 12, 16 Acetaminophen/Dichloralphenazone/ Isometheptene Mucate 7 Acetaminophen/Hydrocodone 12-13, 16 Acetaminophen/Hydrocodone Bit 12-13 Acetaminophen/Hydrocodone Bit 7.5 - 325 mg/ 15 ml Oral Solution 13 Acetaminophen/Oxycodone 12, 16 Acetazolamide 11 Aciphex 11 Activella 15 Actonel 12 Actoplus Met 10 Actoplus Met XR 10 Actos 10 Acular 16 Acuvail 12 Acyclovir 5, 16 Acyclovir Capsule, Suspension, Tablet 16 Aczone 9 Adapalene 9 Adderall 7, 16 Adderall XR 7 Adoxa 5 Advair Diskus 13 Advair HFA 13 Advanced Care Plus 15 Advicor 6 Aggrenox 5 Albuterol Sulfate 13 Albuterol Sulfate/Ipratropium Non-Oral Solution 13 Alclometasone Dipropionate 9 Aldactazide 50-50 mg 6 Aldactone 16 Alendronate 12, 16 Alfuzosin 12, 16 Allopurinol 13 Alora 15 Alphagan P 0.1% 11 Alprazolam 8, 16 Alsuma 7 Altabax 9 Altace 16 Altavera 14 Altoprev 6 Alvesco 13 Alyacen 7/7/7 14 Amantadine 5 Amaryl 16 Ambien 8, 16 Ambien CR 8 Amerge 16 Amethia 14 Amethia Lo 14 Amethyst 14 Amiodarone 7 Amitiza 11 Amitriptyline 7 Amlodipine 6, 16 Amlodipine/Atorvastatin 6 Amlodipine/Benazepril 6 Amoxicillin 5, 16 Amoxicillin-Clavulanate ER 5 Amoxicillin/Potassium Clavulanate 5, 16 Amphetamine/Dextroamphetamine Salt Combination 16 Amphetamine Aspartate/Amphetamine Sulfate/ Dextroamphetamine Sustained-Release 24 Hour Capsule 7 Amphetamine Salt Combo 7 Ampicillin 5 Ampyra 8 Amrix 13 Amturnide 6 Anaprox 16 Anastrozole 12, 16 Androderm 10 Androgel 10 Android 10 Antara 6 Antipyrine/Benzocaine 12 Anzemet 11 Apidra Solostar 9 Apidra Vial 9 Aplenzin 7 Apokyn 8 Apraclonidine 11 Apri 14 Apriso 11 Aranelle 14 Aricept 8, 16 Aricept 23 mg 8 Arimidex 16 Armour Thyroid 10 Aromasin 12 Arthrotec 13 Asacol 11 Asacol HD 11 Ascensia Autodisc Test Strips 9 Ascensia Breeze 2 Test Strips 9 Asmanex 13 Aspirin/Butalbital/Caffeine 7, 12 Aspirin/Butalbital/Caffeine/Codeine 12 Aspirin/Oxycodone 12 Astelin 14 Astepro 14 Atacand 6 Atacand HCT 6 Atelvia 12 Atenolol 6, 16 Atenolol/Chlorthalidone 6, 16 Ativan 16 Atorvastatin 6, 16 Atralin 9 Atrovent HFA 13 Augmentin 5, 16 Augmentin ES 16 Augmentin XR 5 Avalide 6 Avandamet 10 Avandaryl 10 Avandia 10 Avapro 6 Avelox 5 Aviane 14 Avinza 13 Avita Gel 9 Avodart 12 Avonex 8 Axert 7 Axiron 10 Azasite 10 Azathioprine 12-13 Azelastine HCl 10, 14 Azelex 9 Azithromycin 5, 16 Azopt 11 Azor 6 Azurette 14 B Baclofen 13 Bactroban 9 Balsalazide 11, 16 Balziva 14 Baraclude 5 Beconase AQ 14 Belladonna/Phenobarbital 11 Benazepril 6 Benazepril/Hydrochlorothiazide 6 Benicar 6 Benicar HCT 6 Benzaclin Gel 1%-5% 9 Benzaclin Gel 1%-5% 25 g 9 Benzamycin 9 Benzonatate 12 Benztropine Mesylate 8 Bepreve 10 Betamethasone Dipropionate 9 Betamethasone Valerate 9 Betaseron 8 Betimol 11 Beyaz 14 Biaxin Tablet 16 BiDil 6 Bisoprolol 6, 16 Bisoprolol/Hydrochlorothiazide 6, 16 Blephamide S.O.P. 10 Brand Prenatal Vitamins 15 Briellyn 14 Brimonidine Tartrate 11 Bromday 12 Bromfenac 12 Budesonide Extended-Release 24 Hour Capsule 11 Budesonide Inhalation Suspension 0.25 mg/2 ml, 0.5 mg/2 ml 13 Bumetanide 6 Bupropion 7, 16 Bupropion HCl 16 Bupropion HCl Sustained-Action Tablet 16 Bupropion HCl Sustained-Release 24 Hour Tablet 16 Bupropion XL 7 Buspar 16 Buspirone 8, 16 Butorphanol Nasal Spray 13 Byetta 10 Bystolic 6 C Cabergoline 10 Caduet 6 Cafergot 7 Calan, Calan SR 16 Calcipotriene Cream, Ointment 9 Calcitonin Salmon Nasal Spray 12 Calcitriol 10 Cambia 7 Camila 14 Camrese 14 Camrese Lo 14 Canasa 11 Captopril 6 Captopril/Hydrochlorothiazide 6 Carafate Oral Suspension 11 Carbamazepine 8 Carbamazepine Extended-Release 12 Hour Capsule 8 Carbamazepine Sustained-Release 12 Hour Tablet 8 Carbatrol 8
17
Carbidopa/Levodopa 8 Cardizem CD except for 360 mg strength 16 Cardizem LA 120 mg 6 Cardizem LA 180, 240, 300, 360, 420 mg 6 Cardura 16 Carisoprodol 250 mg 13 Carisoprodol 350 mg 13 Carvedilol 6, 16 Cavan-EC Sod DHA 15 Caverject 11 Cayston 5 Caziant 14 Cefadroxil 5 Cefdinir 5 Cefprozil 5, 16 Ceftin 16 Cefuroxime 5, 16 Cefzil 16 Celebrex 13 Celexa 16 Cellcept Suspension 12 Celontin 8 Cenestin 15 Cephalexin 5, 16 Cesamet 11 Cetraxal 5 Chlordiazepoxide/Clidinium 11 Chlorhexidine Gluconate 12 Chlorthalidone 6, 16 Cholestyramine 6 Cialis 11 Ciclopirox Cream, Gel, Lotion 9 Ciclopirox Non-Oral Solution 9 Ciclopirox Shampoo 1% 9 Ciclopirox Solution, Non-Oral 16 Cilostazol 5, 16 Ciloxan Eye Drops 16 Cimetidine 11 Cimzia 13 Cipro 5, 16 Cipro HC 5 Cipro Suspension 5 Ciprodex Otic 5 Ciprofloxacin 5, 10, 16 Ciprofloxacin Sustained-Release 24 Hour Tablet 5 Ciprofloxacin Tablet 5 Citalopram 7, 16 Citalopram Hydrobromide 7 Clarinex 14 Clarinex-D 14 Clarithromycin Suspension 5 Clarithromycin Sustained-Release Tablet 5 Clarithromycin Tablet 5, 16 Cleocin HCl 75 mg 5 Cleocin T 16 Climara 15 Climara Pro 15 Clindagel 9 Clindamycin Foam 1% 9 Clindamycin Gel, Lotion, Solution, Swabs 9, 16 Clindamycin HCl 5 Clindamycin Palmitate 5 Clindamycin Phosphate/Benzoyl Peroxide Extended-Release Gel 9 Clindamycin Phosphate/Benzoyl Peroxide Gel 1%-5% 9 Clindesse Vaginal 5 Clobetasol Propionate 9 Clobetasol Propionate Foam 9 Clobetasol Propionate Lotion 9 Clobetasol Propionate Shampoo 9 Clobex 9 Clobex Shampoo 9 Clonazepam 8, 16 Clonidine 6 Clonidine Transdermal Weekly Patch 6 Clopidogrel 5, 16 Clorpres 6
Clotrimazole 5, 9 Clotrimazole/Betamethasone 9 Clozapine 8, 16 Clozaril 16 Codeine Phosphate 13 Colazal 16 Colcrys 13 Colestid 16 Colestipol 6, 16 Combigan 11 Combipatch 15 Combivent 13 Combivent Respimat 13 Comtan 8 Concerta 7 Condylox Gel 9 Contour Test Strips 9 Conzip 13 Copaxone 8 Coreg 6, 16 Coreg CR 6 Coumadin 5 Cozaar 16 Creon 11 Crestor 6 Crinone 15 Cryselle 14 Cuprimine 13 Cutivate Lotion 9 Cyclafem 1/35 14 Cyclafem 7/7/7 14 Cyclobenzaprine 13 Cyclobenzaprine Extended-Release 24 Hour Capsule 13 Cymbalta 7 Cyproheptadine 14 D Daliresp 13 Dapsone 5 Daytrana 7 DDAVP 16 Denavir 9 Depakote 8, 16 Depakote ER 8, 16 Depo-Provera 16 Depo-SubQ Provera 14 Derma-Smoothe/FS 16 Desloratadine 14 Desmopressin 10, 16 Desonate 9 Desonide 9 Desoximetasone 9 Detrol 12 Detrol LA 12 Dexamethasone 10 Dexilant 11 Dextroamphetamine Sulfate 7 DiaBeta 16 Diastat Acudial 16 Diazepam 8, 16 Diazepam Rectal Gel 8, 16 Dibenzyline 6 Diclofenac 12, 16 Diclofenac Potassium 12 Diclofenac Sodium 12 Dicloxacillin Sodium 5 Dicyclomine Tablet 12 Didronel 16 Differin Cream, Gel 0.1% 9 Differin Gel 0.3% 9 Differin Lotion 9 Diflucan 16 Digoxin 7 Dilantin 8 Diltiazem 6, 16 Diltiazem Controlled-Release Capsule 6 Diltiazem Sustained-Action Capsule 6 Diltiazem Sustained-Release 12 Hour Capsule 6
Diltiazem Sustained-Release 24 Hour Capsule 6, 16 Diltiazem Sustained-Release 24 Hour Tablet 6 Diovan 6 Diovan HCT 6 Dipentum 11 Diphenoxylate/Atropine 11 Ditropan XL 16 Diuril Suspension 250 mg/5 ml 6 Divalproex Sodium Sprinkle Capsule 8 Divalproex Sodium Sustained-Release 24 Hour Tablet 16 Divalproex Sodium Sustained-Release Tablet 8 Divalproex Sodium Tablet 8, 16 Divigel 15 Donepezil 8, 16 Donepezil 5, 10 mg 8 Doryx 5 Dorzolamide Eye Drops 16 Dorzolamide HCl 11 Dorzolamide HCl/Timolol Maleate 11 Dovonex 9 Doxazosin 6, 12, 16 Doxepin 7 Doxycycline Hyclate Enteric-Coated Tablet 5 Doxycycline Monohydrate 5 Doxycycline Monohydrate Capsule 150 mg 5 Duac 9 Duetact 10 Duexis 13 Dulera 13 Duragesic 12 Dutoprol 6 Dyazide 16 E Econazole Nitrate 9 Edarbi 6 Edarbyclor 6 Edex 11 Edluar 8 Effexor 16 Effexor XR 16 Effient 5 Elestat 10 Elidel 9 Ella 14 Emadine 10 Embeda 13 Emend 11 Emoquette 14 Enablex 12 Enalapril 6, 16 Enalapril/Hydrochlorothiazide 6, 16 Enbrel 13 Enjuvia 15 Enoxaparin 5 Enpresse 14 Epiduo 9 Epinastine 10 Epipen 12 Epipen Jr 12 Epivir HBV 5 Eplerenone 6 Eprosartan 6, 16 Ergomar 7 Errin 14 Ery-Tab 500 mg 5 Erythromycin 5, 9-10 Erythromycin/Benzoyl Peroxide 9 Erythromycin Base Enteric-Coated Tablet 5 Escitalopram 7 Estrace Cream with Applicator 15 Estradiol 15 Estradiol/Norethindrone Acetate 15 Estradiol Transdermal Weekly Patch 15 Estrasorb 15 Estring 15
18
Estrogel 15 Estropipate 15 Etidronate Disodium 16 Etodolac 12 Evamist 15 Evista 12 Evoclin 9 Exalgo 13 Exelon Solution 8 Exemestane 12 Exforge 6 Exforge HCT 6 Extavia 8 F Famciclovir 5 Fanapt 8 Fareston 12 FazaClo 8 Felbamate 8, 16 Felbatol 16 Felodipine 6 Femara 16 Femcon Fe 14 Femhrt 15 Femring 15 Fenofibrate 6 Fenofibric Acid 6 Fenoglide 6 Fentanyl Citrate Lollipop 13 Fentanyl Transdermal 13 Fentora 13 Finacea 9 Finacea Plus 9 Finasteride 12, 16 Fioricet 16 First-Progesterone 15 Flecainide Acetate 7 Flector 13 Flomax 16 Flonase 16 Flovent Diskus 13 Flovent HFA 13 Fluconazole 5, 16 Fludrocortisone 10 Flunisolide 14 Fluocinolone 9, 16 Fluocinonide 9 Fluoxetine 7-8, 16 Fluoxetine Capsule 16 Fluoxetine Delayed-Release Capsule 7, 16 Fluticasone Nasal Spray 16 Fluticasone Propionate 9, 14 Fluticasone Propionate Lotion 9 Fluvastatin 6 Fluvoxamine Maleate 7 Focalin XR 7 Folcal DHA 15 Folic Acid 15 Fondaparinux 5 Foradil 13 Fortamet 10 Forteo 12 Fortesta 10 Fortical 12 Fosamax 12, 16 Fosamax Plus D 12 Fosinopril 16 Fragmin 5 Freestyle Lite Test Strips 9 Freestyle Test Strips 9 Frova 7 Furosemide 6, 16 G Gabapentin 8, 16 Gabitril 8 Galantamine 8 Gelnique 12 Gemfibrozil 6, 16
Generess Fe 14 Genotropin 10 Gentamicin Sulfate 10 Geodon 8 Gianvi 14 Gildess FE 14 Gilenya 8 Glimepiride 10, 16 Glipizide 10, 16 Glipizide/Metformin 10 Glucophage, XR 16 Glucotrol, XL 16 Glucovance 16 Glumetza 10 Glyburide 10, 16 Glyburide/Metformin 10, 16 Glynase 16 Glyset 10 GoLYTELY Packet 11 Gralise 13 Granisetron Tablet 11 Guanfacine 6 Gynazole-1 Vaginal 5 H Halflytely-Bisacodyl 11 Halobetasol Propionate 9 Heather 14 Hectorol 10 Helidac 11 Hepsera 5 Horizant 13 Humalog-Mix KwikPen 9 Humalog-Mix Vials 9 Humalog KwikPen 9 Humalog Vials 9 Humatrope 10 Humira 13 Humulin 70-30 Vials 9 Humulin KwikPen 9 Humulin Vials 9 Hycet 13 Hydralazine 6 Hydrochlorothiazide 6, 16 Hydrocodone/Chlorpheniramine Suspension 12 Hydrocortisone 9-10 Hydrocortisone Tablet 10 Hydrocortisone Valerate 9 Hydromorphone 12 Hydroxychloroquine Sulfate 13 Hydroxyzine 14 Hyoscyamine Sulfate 12 Hyzaar 16 I Ibandronate Tablet 12 Ibuprofen 12, 16 Ibuprofen/Hydrocodone 12, 16 Ibuprofen/Oxycodone 12 Imiquimod 9 Imitrex 16 Incivek 5 Indomethacin 12 Infergen 12 Innohep 5 Intron A 12 Introvale 14 Intuniv 7 Invega 8 Iopidine 1% 11 Ipratropium Bromide 13 Irbesartan 6 Irbesartan/Hydrochlorothiazide 6 Isosorbide Dinitrate 7 Isosorbide Mononitrate 7 Isotretinoin 9 Itraconazole Capsule 5 J Jalyn 12 Janumet 10
Janumet XR 10 Januvia 10 Jentadueto 10 Jolessa 14 Jolivette 14 Junel 14 Junel Fe 14 Juvisync 10 K Kadian 13 Kapvay 7 Kariva 14 Keflex 16 Kelnor 14 Keppra 8, 16 Keppra XR 8 Ketoconazole 5, 9 Ketoconazole Foam 5 Ketorolac Tromethamine 10, 12, 16 Kineret 13 Klonopin 16 Kombiglyze XR 10 Kuvan 10 L Labetalol 6 Lactulose 11 Lamictal 8, 16 Lamictal Dose Pack 8 Lamictal ODT 8 Lamictal XR 8 Lamisil 5, 16 Lamisil Granules 5 Lamotrigine 8, 16 Lanoxin 7 Lansoprazole 11 Lantus Solostar Pens/Cartridges 9 Lantus Vials 9 Lasix 16 Lastacaft 10 Latanoprost 11, 16 Lazanda 13 Leena 14 Leflunomide 13 Lescol XL 6 Lessina 14 Letrozole 12, 16 Levalbuterol Vial, Nebulizer 13 Levaquin 16 Levemir Flexpen 9 Levemir Vials 9 Levetiracetam 8, 16 Levetiracetam Extended-Release 24 Hour Tablet 8 Levitra 11 Levocetirizine Oral Solution 14 Levocetirizine Tablet 14 Levofloxacin 5, 10, 16 Levora 14 Levothyroxine Sodium 10 Levoxyl 10 Lexapro 7 Lialda 11 Lidocaine 9 Lidoderm 12 Liothyronine Sodium 10 Lipitor 6, 16 Lipofen 6 Lisinopril 6, 16 Lisinopril/Hydrochlorothiazide 6, 16 Lithium Carbonate 8 Lithium Carbonate Controlled-Release Tablet 8 Livalo 6 Lo Loestrin Fe 14 Locoid Lipocream 9 Locoid Lotion 9 Loestrin 24 Fe 14 Lopid 16 Lopressor 16 Loprox Shampoo 9
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Lorazepam 8, 16 Loryna 14 Losartan 6, 16 Losartan/Hydrochlorothiazide 6, 16 Lotronex 11 Lovastatin 6, 16 Lovaza 6 Low-Ogestrel 14 Lumigan 11 Lunesta 8 Lutera 14 Luvox CR 7 Lyrica 8 Lysteda 12 M Macrodantin 25 mg 5 Marlissa 14 Mavik 16 Maxair Autohaler 13 Maxalt 7 Maxalt MLT 7 Medrol 10, 16 Medrol 2, 8, 24, 32 mg 10 Medroxyprogesterone 14-16 Medroxyprogesterone 150 mg/ml 14, 16 Mefenamic Acid 13 Megestrol Acetate 12 Meloxicam 12, 16 Menostar Transdermal Weekly Patch 15 Meperidine 12 Mesalamine 11 Metadate CD 7 Metaxalone 13 Metformin 10, 16 Metformin Extended-Release 24 Hour Tablet 10 Methadone 12 Methamphetamine 7 Methimazole 10 Methocarbamol 13 Methotrexate 13 Methylin Tablet 7 Methylphenidate 7, 16 Methylphenidate Extended-Release 24 Hour Tablet 7 Methylphenidate Extended-Release Capsule 7 Methylphenidate Extended-Release Tablet 16 Methylprednisolone Dosepak Tablet 4 mg 10, 16 Metoclopramide 11 Metolazone 6 Metoprolol 6, 16 Metoprolol/Hydrochlorothiazide 6 Metoprolol Succinate Sustained-Release Tablet 6, 16 Metoprolol Succinate Sustained-Release Tablet 25 mg 6 Metoprolol Succinate Sustained-Release Tablet 50, 100, 200 mg 6 Metoprolol Tartrate 6 Metozolv ODT 11 Metrogel 1% 9 Metrogel Vaginal 16 Metrolotion 9 Metronidazole 5, 9, 16 Metronidazole Gel 0.75% 9 Metronidazole Vaginal 5 Mevacor 16 Mexiletine 7 Micardis 6 Micardis HCT 6 Microgestin 14 Microgestin Fe 14 Migranal 7 Minocycline Extended-Release 24 Hour Tablet 5 Minocycline HCl 5 Mirapex ER 8 Mirtazapine 7, 16 Mirtazapine Dispersible Tablet 16 Misoprostol 11
Mobic 16 Modafinil 8 Moexipril 6 Mometasone Furoate 9 Mononessa 14 Monopril 16 Montelukast 13 Morphine Sulfate 12-13 Morphine Sulfate Extended-Release Pellets 13 Morphine Sulfate Sustained-Action Tablet 12 Moviprep 11 Moxeza 10 MSIR Capsule 13 Multaq 7 Multi-Nate 30 15 Multinatal Plus 15 Mupirocin 9 Muse 11 Mycophenolate Capsule, Tablet 12 Mycostatin 5 Myfortic 12 Mysoline 8 Myzilra 14 N Nabumetone 12 Nadolol 6 Naftin 9 Namenda 8 Naprelan 13 Naprosyn - Prescription strengths only 16 Naproxen 12, 16 Naproxen - Prescription strengths only 16 Naproxen Sodium 12 Naratriptan 7, 16 Nardil 16 Nasacort AQ 14 Nasonex 14 Natazia 14 Nateglinide 10 Necon 0.5/35 14 Necon 1/35 14 Necon 1/50 14 Necon 10/11 14 Necon 7/7/7 14 Nefazodone 7 Neomycin/Polymyxin/HC Otic 5 Neomycin/Polymyxin B Sulfate/ Dexamethasone 10 Neoral 12 Neurontin 16 Nexiclon XR 6 Nexium Capsule 11 Nexium Suspension 11 Next Choice One Dose 14 Niaspan 6 Nifedipine 6, 16 Nifedipine Extended-Release Tablet 16 Nisoldipine 6 Nitrofurantoin/Nitrofurantoin Macrocrystal 5 Nitrofurantoin Macrocrystal 5 Nitrofurantoin Suspension 5 Nitroglycerin Spray 7 Nitroglycerin Transdermal Patch 7 Nitrolingual 7 Nitromist 7 Nitrostat 7 Nizatidine Oral Solution 11 Nora-Be 14 Norditropin 10 Norethindrone 14-15 Norethindrone Acetate 15 Noritate 9 Nortrel 0.5/35 14 Nortrel 1/35 14 Nortrel 7/7/7 14 Nortriptyline 7 Norvasc 16 Novolin Vials 9
NovoLog 9 Noxafil 5 Nucynta 13 Nucynta ER 13 Nuedexta 8 Nutropin, AQ, NuSpin 10 NuvaRing 14 Nuvigil 8 Nystatin 5, 9 Nystatin/Triamcinolone Acetonide 9 O Ocella 14 Octreotide Acetate 10 Ocuflox Eye Drops 16 Ofloxacin 5, 10, 16 Ofloxacin Otic 5 Ogestrel 14 Olanzapine/Fluoxetine 8 Olanzapine Rapid Dissolve Tablet 8 Olanzapine Tablet 8 Oleptro 7 Olux-E 9 Omeprazole 11, 16 Omeprazole/Sodium Bicarbonate Capsule 11 Omnaris 14 Omnitrope 10 Ondansetron 11, 16 One Touch Test Strips 9 One Touch Ultra 2 System 9 One Touch Ultra Mini System 9 One Touch Ultra Test Strips 9 One Touch Verio IQ System 9 One Touch Verio IQ Test Strips 9 Onglyza 10 Onsolis 13 Opana 13 Opana ER 13 Optivar 10 Oracea 5 Orapred 10 Orapred ODT 10 Orencia 13 Orphenadrine 13 Orphenadrine/Aspirin/Caffeine 13 Orsythia 14 Ortho-Cyclen 14 Ortho-Novum 7/7/7 14 Ortho Evra 14 Ortho Micronor 14 Ortho Tri-Cyclen 14 Ortho Tri-Cyclen Lo 14 Oxandrolone 10 Oxaprozin 12 Oxcarbazepine 8, 16 Oxistat 9 Oxsoralen-Ultra 9 Oxybutynin 12, 16 Oxybutynin Sustained-Release Tablet 16 Oxycodone 12, 16 OxyContin 13 Oxymorphone 13 Oxymorphone Extended-Release 12 Hour Tablet 13 Oxytrol 12 P Pancreaze 11 Pantoprazole 11, 16 Paroxetine 7, 16 Paroxetine Sustained-Release 24 Hour Tablet 7 Paroxetine Tablet 7 Pataday 10 Patanase 14 Patanol 10 Paxil 16 Pediapred 10 Peg-Intron 12 Peganone 8 Pegasys 12
20
Penicillin V Potassium 5 Penlac 16 Pennsaid 13 Pentasa 11 Pentoxifylline 5 Percocet 5-325, 7.5-500, 10-650 16 Perforomist 13 Perindopril Erbumine 6 Permethrin 9 Pexeva 7 Phenazopyridine 12 Phenelzine 7, 16 Phenobarbital 8, 11 Phenytoin Sodium 8 Philith 14 Pilopine HS 11 Pioglitazone 10 Pioglitazone/Metformin 10 Piroxicam 12 Plan B 14 Plavix 16 Pletal 16 Polyethylene Glycol 11 Polymyxin B Sulfate/Trimethoprim 10 Portia 14 PR Natal 430 15 PR Natal 430 EC 15 Pradaxa 5 Pramipexole 8 Prandin 10 Pravachol 16 Pravastatin 6, 16 Precision Xtra Test Strips 9 Precose 16 Prednisolone 10 Prednisone 10 Prefest 15 Premarin 15 Premphase 15 Prempro 15 Prenatal 19 15 Prenatal Advantage 15 Prenatal Plus 15 Prevacid Delayed-Release Enteric-Coated Capsule 11 Prevacid Solutab 11 Previfem 14 Prevpac 11 Prilosec 11, 16 Prilosec Rx 10, 20 mg 11 Prilosec Rx 40 mg 11 Primidone 8 Prinivil 16 Prinzide 16 Pristiq 7 Proair HFA 13 Procardia XL 16 Prochlorperazine Maleate 11 Progesterone Micronized Capsule 15 Promethazine 14 Propafenone Sustained-Release 12 Hour Capsule 7 Propranolol/Hydrochlorothiazide 6 Propranolol Sustained-Action Capsule 6 Propranolol Tablet 6 Proscar 16 Protonix 11, 16 Protonix Granules 11 Protopic 9 Proventil HFA 13 Provera 14, 16 Provigil 8 Prozac 16 Prozac Weekly 16 Pulmicort Flexhaler 13 Pulmicort Respules 1 mg/2 ml 13 Pylera 11
Q Quasense 14 Quetiapine 8 Quinapril 6, 16 Quinapril/Hydrochlorothiazide 6 QVAR 13 R Ramipril 6, 16 Ranexa 7 Ranitidine Syrup 11, 16 Rapaflo 12 Rapamune 12 Rebetol Solution 5 Rebif 8 Reclipsen 14 Regranex 9 Relenza 5 Relistor 11 Relpax 7 Remeron 16 Remeron SolTab 16 Requip 8, 16 Requip XL 8 Restasis 12 Restoril 16 Retin-A Micro 9 Rhinocort Aqua 14 Ribapak 5 Ribavirin 5 Risperdal 16 Risperidone 8, 16 Ritalin 7, 16 Ritalin LA 7 Ritalin SR 16 Rivastigmine 8 Ropinirole 8, 16 Ropinirole Extended-Release 24 Hour Tablet 8 Rozerem 8 Rybix ODT 13 Ryzolt 13 S Sabril 8 Safyral 14 Saizen 10 Sanctura XR 12 Sancuso 11 Sandimmune 12 Savella 13 Serevent Diskus 13 Seroquel 8 Seroquel XR 8 Serostim 10 Sertraline 7, 16 Setonet 15 Setonet-EC 15 Silenor 8 Silver Sulfadiazine 9 Simcor 6 Simponi 13 Simvastatin 6, 16 Singulair 13 Skelaxin 13 Solodyn 5 Soma 250 mg 13 Sonata 8, 16 Sotalol 7 Spiriva 13 Spironolactone 6, 16 Spironolactone/Hydrochlorothiazide 6 Sporanox Oral Solution 5 Sprintec 14 Sprix 13 Sronyx 14 Stavzor 8 Staxyn 11 Stelara 9 Strattera 7 Sucralfate Tablet 11
Sular 6 Sulfacetamide Sodium 9-10 Sulfacetamide Sodium/Sulfur 9 Sulfamethoxazole/Trimethoprim 5 Sulfasalazine 11, 13 Sulindac 12 Sumatriptan Succinate Injection, Tablet 7, 16 Sumatriptan Succinate Nasal Spray 7 Sumavel DosePro 7 Suprax 5 Surmontil 16 Syeda 14 Symbicort 13 Symbyax 8 Symlin 10 Synarel 10 Synthroid 10 T Taclonex 9 Taclonex Scalp 9 Tacrolimus 12 Tamiflu 5 Tamoxifen 12 Tamsulosin 12, 16 Taron A Prenatal 15 Tasmar 8 Tazorac 9 Tegretol 8 Tekamlo 6 Tekturna 6 Tekturna HCT 6 Temazepam 8, 16 Tenoretic 16 Tenormin 16 Terazosin 6, 12 Terbinafine Tablet 5, 16 Terconazole Vaginal 5 Testim 10 Testosterone 10 Tetracycline 5 Tev-Tropin 10 Teveten 6, 16 Teveten HCT 6 Thalitone 6 Theophylline 13 Tiazac 16 Tilia Fe 14 Timolol Maleate 11 Tirosint 10 Tizanidine Capsule 13 Tizanidine Tablet 13 Tobi 5 Tobradex ST 10 Tobramycin/Dexamethasone 10 Tobramycin Sulfate Drops 10 Tolmetin Sodium 13 Tolterodine 12 Topamax 8, 16 Topiramate 8, 16 Toprol XL 25 mg 16 Torsemide 6 Toviaz 12 Tradjenta 10 Tramadol 12-13, 16 Tramadol/Acetaminophen 12, 16 Tramadol Extended-Release Multiphase 24 Hour Tablet 13 Tramadol Sustained-Release 24 Hour Tablet 13 Trandolapril 6, 16 Trandolapril/Verapamil 6 Transderm-Scop 11 Travatan Z 11 Trazodone 7 Tretin-X 9 Tretinoin 9 Trexall 13 Treximet 7 Tri-Legest Fe 14
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Tri-Previfem 14 Tri-Sprintec 14 Triamcinolone Acetonide 9, 14 Triamterene/Hydrochlorothiazide 6, 16 Tribenzor 6 Tricor 6 Triglide 6 Trileptal 16 Trilipix 6 Trilyte with Flavor Packets 11 Trimipramine Maleate 16 Trinessa 14 Trivora 14 Trospium 12 Trusopt 16 Tussionex 12 Twynsta 6 Tylenol #3 16 U Uloric 13 Ultracet 16 Ultram 16 Urea 9 Uroxatral 16 Ursodiol 11 V Vagifem 15 Valacyclovir 5 Valcyte 5 Valium 16 Vancomycin 5 Vanos 9 Vaseretic 16 Vasotec 16 Vectical 9 Velivet 14 Veltin 9 Venlafaxine 7, 16 Venlafaxine Extended-Release Tablet 7 Venlafaxine Sustained-Release Capsule 7, 16 Ventolin HFA 13 Veramyst 14 Verapamil 6, 16 Verapamil Sustained-Release 24 Hour Pellets 6 Verdeso 9 Vesicare 12 Vestura 14 Vfend 16 Viagra 11 Vicodin, Vicodin ES 16 Vicoprofen 16 Victoza 10 Victrelis 5 Vigamox 10 Vimovo 13 Viorele 14 Vivelle-Dot 15 Voltaren Gel 13 Voltaren Tablet 16 Voriconazole 5, 16 Vusion 9 Vytorin 6 Vyvanse 7 W Warfarin Sodium 5 Welchol 6 Wellbutrin 16 Wellbutrin SR 16 Wellbutrin XL 16 Wymzya Fe 14 X Xalatan 16 Xanax, Xanax XR 16 Xarelto 5 Xerese 9 Xolegel 9 Xopenex HFA 13 Xopenex Vial, Nebulizer 13
Xyrem 8 Y Yasmin 14 Yaz 14 Z Zafirlukast 13, 16 Zaleplon 8, 16 Zantac Syrup 16 Zarah 14 Zatean-PN 15 Zatean-PN DHA 15 Zatean-PN Plus 15 Zegerid Capsule 11 Zegerid Packet 11 Zemplar 10 Zenchent 14 Zenchent Fe 14 Zenpep 11 Zeosa 14 Zestoretic 16 Zestril 16 Zetia 6 Ziac 16 Ziana 9 Ziprasidone 8 Zipsor 13 Zithromax 16 Zocor 16 Zofran 16 Zoloft 16 Zolpidem 8, 16 Zolpidem Multiphasic-Release Tablet 8 Zolpidem Tablet 8 Zolpimist 8 Zomig 7 Zomig Nasal Spray 7 Zomig ZMT 7 Zonegran 16 Zonisamide 8, 16 Zorbtive 10 Zovia 1/35E 14 Zovia 1/50E 14 Zovirax 9, 16 Zuplenz 11 Zyclara 9 Zylet 10 Zymaxid 10 Zyprexa 8 Zyprexa Zydis 8 Zyvox 5
22

Quick-Reference Guide: Your 2013 Prescription Drug List

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Your 2013 Prescription Drug List Quick-Reference Guide

Go to myuhc.com for complete and up-to-date PDL information

Visit www.myuhc.com for updates

2013 Prescription Drug List Advantage Three-Tier

Welcome to your 2013 Prescription Drug List

What are Tiers?

lowest-cost midrange-cost highest-cost medications medications medications

How do I use my PDL?

Are there plans that dont have three tiers?

Visit www.myuhc.com for updates

2013 Prescription Drug List Advantage Three-Tier

When do medications change tiers?

Here is a quick symbol overview: PDL Symbols

DSN Designated Specialty Network E N RS MC Multiple copay

SDP Select Designated Pharmacy SL Supply limit ST Step Therapy

Why is the medication that I am currently taking no longer covered?

Should I talk to my doctor about OTC medications?

Visit www.myuhc.com for updates

2013 Prescription Drug List Advantage Three-Tier

What is the difference between brand-name and generic medications?

How do I access updated information about my pharmacy benet?

What if my doctor writes a brand-name prescription?

Are you taking a specialty medication?

What if I still have questions?

Visit www.myuhc.com for updates

2013 Prescription Drug List Advantage Three-Tier

(Oral, inhaled and ear antibiotics are listed)

Minocycline Extended-Release 24 Hour Tablet Oracea Solodyn Suprax

Ketoconazole Metronidazole Vaginal Nystatin Noxafil Lamisil Granules SL Mycostatin

Terbinafine Tablet SL Terconazole Vaginal Voriconazole SL Sporanox Oral Solution

Cardiovascular/Heart Disease Coagulation Therapy

Please refer to page 3 for a definition of notations/symbols.

Visit www.myuhc.com for updates

2013 Prescription Drug List Advantage Three-Tier

Cardiovascular/Heart Disease High Blood Pressure

Cardiovascular/Heart Disease High Cholesterol

Triglide Trilipix E Vytorin SL Zetia SL

Please refer to page 3 for a definition of notations/symbols.

Visit www.myuhc.com for updates

2013 Prescription Drug List Advantage Three-Tier

Cardiovascular/Heart Disease Other

Central Nervous System Attention Deficit Disorder

Central Nervous System Depression

Pristiq RS SL Venlafaxine Extended-Release Tablet E SL

Central Nervous System Migraine

Please refer to page 3 for a definition of notations/symbols.

Visit www.myuhc.com for updates

2013 Prescription Drug List Advantage Three-Tier

Central Nervous System Multiple Sclerosis

Central Nervous System Sedatives/Hypnotics

Central Nervous System Seizure Disorders

Central Nervous System Other

Seroquel SL Seroquel XR SL Symbyax SL Zyprexa SL Zyprexa Zydis SL

Please refer to page 3 for a definition of notations/symbols.

Visit www.myuhc.com for updates

2013 Prescription Drug List Advantage Three-Tier

Diabetes/Endocrine Blood Glucose Monitoring

Freestyle Test Strips SDP SL Precision Xtra Test Strips SDP SL