Your 2012 Prescription Drug List Quick-Reference Guide

Traditional Three-Tier

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.

Table of Contents
1 Introduction Prescription Drug List - 2012 Gastrointestinal 15 Acid Suppression 16 Nausea/Vomiting 16 Other Mens Health 16 Erectile Dysfunction 16 Prostate Miscellaneous 17 Miscellaneous 17 Overactive Bladder Musculoskeletal 17 Osteoporosis 18 Pain Relief 18 Rheumatoid Arthritis 19 Other Respiratory 19 Asthma/COPD 19 Nasal Allergy 20 Oral Allergy Womens Health 20 Contraceptives 21 Estrogen/Progesterone 21 Prenatal Vitamins 22 Additional Tier 3 Drugs with a generic equivalent in Tier 1

Anti-Infectives 6 Antibiotics 6 Antifungals 7 Antivirals Cardiovascular/ Heart Disease 7 Coagulation Therapy 7 High Blood Pressure 8 High Cholesterol 9 Other Central Nervous System 9 Attention Deficit Disorder 9 Depression 10 Migraine 10 Multiple Sclerosis 10 Sedatives/Hypnotics 11 Seizure Disorders 11 Other 12 Dermatology Diabetes/Endocrine 13 Blood Glucose Monitoring 13 Insulin 13 Non-Insulin Endocrine 14 Growth Hormone 14 Other Eye Conditions 14 Anti-Allergy 15 Antibiotics 15 Glaucoma

24 Index

Welcome

to your 2012 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 created at a point in time, 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. If you are not currently enrolled with UnitedHealthcare for pharmacy benet coverage, you may go to welcometomyuhc.com for additional information during your open enrollment period or you may contact your employer or health plan for additional information.

2012 Prescription Drug List Traditional Three-Tier

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.

What are Tiers?

Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, which is determined by your employer or health plan. This is how much you will pay when you fill a prescription. Tier 1 medications are your lowest-cost options. If your medication is placed in Tier 2 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 lowest-cost

Tier 2 Your midrange-cost

Tier 3 Your highest-cost

medications medications medications

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. Who determines medication tier placements? The UnitedHealthcare PDL Management Committee makes tier placement decisions. The PDL Management Committee is comprised of senior level UnitedHealth Group physicians and business leaders. The Committees goal is to help ensure access to a wide range of medications, while helping to control health care costs for you and your employer or health plan.

Visit www.myuhc.com for updates

What factors impact tier placement decisions? The PDL Management Committee decides tier placement based on several factors including:
u

Clinical information from the UnitedHealthcare Pharmacy and Therapeutics Committee about the safety and effectiveness of different medications. u The medications costs and other economic factors.

When do medications change tiers? Medications may change tiers once per calendar year ( January 1). When a generic medication becomes available, the tier placement of both the brand and generic medication are evaluated. Medications may change tiers with this evaluation.

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.

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. 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*

P RS

Progression Rx May be eligible for the Refill and Save Program

DSN Designated Specialty Network E N MC Multiple copay applies

SDP Select Designated Pharmacy SL Supply limit

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

2012 Prescription Drug List Traditional Three-Tier

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.

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 and chemically-equivalent 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.

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.

Visit www.myuhc.com for updates

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 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.

2012 Prescription Drug List Traditional Three-Tier

Anti-Infectives Antibiotics
Tier 1 A-B Otic Amoxicillin Amoxicillin/Potassium Clavulanate Amoxicillin-Clavulanate ER E Ampicillin Azithromycin Cefadroxil Cefdinir Cefprozil Cefuroxime Cephalexin Ciprofloxacin Sustained-Release 24 Hour Tablet Ciprofloxacin Tablet Tier 2 Augmentin Cipro Suspension Ciprodex Otic Cleocin HCl 75 mg Tier 3 Adoxa E Augmentin XR E Avelox

(Oral, inhaled and ear antibiotics are listed)

Clarithromycin Suspension Clarithromycin Sustained-Release Tablet Clarithromycin Tablet Clindamycin HCl Clindamycin Palmitate Dicloxacillin Sodium Doxycycline Hyclate Enteric-Coated Tablet E Doxycycline Monohydrate Doxycycline Monohydrate Capsule 150 mg E Erythromycin Erythromycin Base Enteric-Coated Tablet 250, 333 mg Levofloxacin Dapsone Ery-Tab 500 mg Macrodantin 25 mg Tobi DSN Cetraxal Cipro HC Doryx E

Metronidazole Minocycline HCl Neomycin/Polymyxin/HC Otic Nitrofurantoin Macrocrystal Nitrofurantoin Suspension Nitrofurantoin/Nitrofurantoin Macrocrystal Ofloxacin Otic Penicillin V Potassium Sulfamethoxazole/ Trimethoprim Tetracycline

Vancocin HCl SL Velosef Suspension 250 mg Zyvox SL Oracea Solodyn Suprax

Anti-Infectives Antifungals
Tier 1 Clotrimazole Fluconazole Itraconazole Capsule SL Tier 2 Clindesse Vaginal Mycostatin Tier 3 Extina SL

(Oral and topical antifungals are listed)

Ketoconazole Metronidazole Vaginal Nystatin Noxafil Sporanox Oral Solution Gynazole-1 Vaginal

Terbinafine Tablet SL Terconazole Vaginal Voriconazole SL

Lamisil Granules SL

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

Visit www.myuhc.com for updates

Anti-Infectives Antivirals
Tier 1 Acyclovir Amantadine Tier 2 Baraclude DSN Epivir HBV DSN Tier 3 Relenza SL Famciclovir SL Ribavirin DSN N Hepsera DSN Rebetol Solution DSN N Tamiflu SL Valacyclovir SL

Valcyte SL

Valtrex SL

Cardiovascular/Heart Disease Coagulation Therapy

Tier 1 Cilostazol Enoxaparin SL Tier 2 Coumadin Tier 3 Aggrenox Arixtra SL Fondaparinux SL Pentoxifylline Plavix Effient Fragmin SL Innohep SL Lovenox SL Warfarin Sodium

Cardiovascular/Heart Disease High Blood Pressure

Tier 1 Amlodipine Amlodipine/Benazepril SL Atenolol Atenolol/Chlorthalidone Benazepril Benazepril/ Hydrochlorothiazide Bisoprolol Bisoprolol/ Hydrochlorothiazide Bumetanide Captopril Captopril/ Hydrochlorothiazide Carvedilol Chlorthalidone Clonidine Clonidine Transdermal Weekly Patch SL Diltiazem Diltiazem Controlled-Release Capsule Diltiazem Sustained-Action Capsule Diltiazem Sustained-Release 12 Hour Capsule Diltiazem Sustained-Release 24 Hour Capsule Diltiazem Sustained-Release 24 Hour Tablet Doxazosin Enalapril Enalapril/Hydrochlorothiazide Eplerenone Felodipine Fosinopril Fosinopril/ Hydrochlorothiazide Furosemide Guanfacine Hydralazine Hydrochlorothiazide Indapamide Labetalol Lisinopril Lisinopril/ Hydrochlorothiazide Losartan 1/2T Losartan/ Hydrochlorothiazide SL Methyldopa Methyldopa/ Hydrochlorothiazide Metolazone Metoprolol Succinate Sustained-Release Tablet Metoprolol Tartrate Metoprolol/ Hydrochlorothiazide Minoxidil Moexipril 1/2T Nadolol Nifedipine Nisoldipine Perindopril Erbumine 1/2T Propranolol Propranolol Sustained-Action Capsule Propranolol/ Hydrochlorothiazide Quinapril Quinapril/ Hydrochlorothiazide Ramipril Spironolactone Spironolactone/ Hydrochlorothiazide

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

2012 Prescription Drug List Traditional Three-Tier

Cardiovascular/Heart Disease High Blood Pressure (cont. from page 7)

Tier 1 cont. Terazosin Timolol Maleate Torsemide Trandolapril 1/2T Tier 2 Aldactazide 50-50 mg Benicar 1/2T SL Benicar HCT SL BiDil Bystolic Tier 3 Aceon 1/2T Amturnide E SL Atacand 1/2T SDP SL Atacand HCT SDP SL Avalide SDP SL Avapro 1/2T SDP SL Azor SL Cardizem LA 180, 240, 300, 360, 420 mg Trandolapril/Verapamil Triamterene/ Hydrochlorothiazide Verapamil Cardizem CD 360 mg Cardizem LA 120 mg Clorpres Dibenzyline Verapamil Sustained-Release 24 Hour Pellets

Diuril Suspension 250 mg/5 ml Micardis SL Micardis HCT SL Thalitone Tekamlo E SL Tekturna SDP SL Tekturna HCT SDP SL Teveten SL Teveten HCT SL Tribenzor E SL Twynsta E SL Valturna E SL

Catapres-TTS SL Coreg CR E SL Diovan 1/2T SL Diovan HCT SL Exforge SL Exforge HCT SL Lotrel SL Sular Tarka

Cardiovascular/Heart Disease High Cholesterol

Tier 1 Cholestyramine Colestipol Fenofibrate Tier 2 Altoprev SL Antara Tier 3 Advicor SL Atorvastatin 1/2T SL Caduet E SL Fenoglide Lescol SL Fenofibric Acid Gemfibrozil Lipitor 1/2T SL Crestor 1/2T SL Lipofen Lescol XL SL Livalo SL Lovaza N Niaspan Simcor SL Lovastatin Pravastatin 1/2T Simvastatin 1/2T Welchol

Tricor E Triglide Trilipix E Vytorin SL Zetia SL

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

Visit www.myuhc.com for updates

Cardiovascular/Heart Disease Other

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

Central Nervous System Attention Deficit Disorder

Tier 1 Amphetamine Aspartate/ Amphetamine Sulfate/ Dextroamphetamine Sustained-Release 24 Hour Capsule SL Tier 2 Intuniv SL Tier 3 Adderall XR SL Concerta SL Daytrana SL Amphetamine Salt Combo Dextroamphetamine Sulfate Methamphetamine Methylphenidate Methylphenidate Extended-Release 24 Hour Tablet SL

Vyvanse SL Focalin XR SL Metadate CD SL Methylin Ritalin LA SL Strattera SL

Central Nervous System Depression

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

Pristiq RS SL

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

2012 Prescription Drug List Traditional Three-Tier

Central Nervous System Migraine

Tier 1 Acetaminophen/Butalbital/ Caffeine SL Acetaminophen/ Dichloralphenazone/ Isometheptene Mucate Tier 2 Cafergot Tier 3 Alsuma E SL Axert SDP SL Cambia E SL Frova SDP SL Aspirin/Butalbital/Caffeine Naratriptan SL Relpax SL Sumatriptan Succinate Injection, Tablet SL Ergomar 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 Nasal Spray SL

Central Nervous System Multiple Sclerosis

Tier 2 Ampyra DSN N SL Avonex DSN N SL Tier 3 Betaseron DSN N P SL Copaxone DSN N SL Rebif DSN N SL Extavia DSN E N P SL Gilenya DSN N P SL

Central Nervous System Sedatives/Hypnotics

Tier 1 Temazepam Triazolam Zaleplon SL Tier 3 Ambien P SL Ambien CR P SL Edluar E P SL Zolpidem Multiphasic-Release Tablet P SL Lunesta P SL Rozerem P SL Silenor E SL Zolpidem Tablet SL

Sonata P SL

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

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Central Nervous System Seizure Disorders

Tier 1 Carbamazepine Carbamazepine Extended-Release 12 Hour Capsule Carbamazepine Sustained-Release 12 Hour Tablet Clonazepam Diazepam Rectal Gel SL Tier 2 Celontin Dilantin Felbatol Tier 3 Carbatrol Depakote ER P Keppra P Keppra XR P Divalproex Sodium Sprinkle Capsule Divalproex Sodium Sustained-Release Tablet Divalproex Sodium Tablet Gabapentin Lamotrigine Levetiracetam Levetiracetam Extended-Release 24 Hour Tablet P Oxcarbazepine Phenobarbital Phenytoin Sodium Primidone Topiramate Zonisamide Sabril Tegretol

Gabitril Mysoline Peganone Lamictal P Lamictal Dose Pack P SL Lamictal ODT P Lamictal XR P

Lyrica SDP SL Stavzor P Topamax P

Central Nervous System Other

Tier 1 Alprazolam Benztropine Mesylate Buspirone Carbidopa/Levodopa Clorazepate Dipotassium Tier 2 Akineton Apokyn DSN Comtan FazaClo Tier 3 Abilify 1/2T SL Aricept 23 mg E Exelon Solution Fanapt SL Clozapine Diazepam Donepezil 5, 10 mg Galantamine Lithium Carbonate Geodon SL Navane 20 mg Seroquel SL Symbyax SL Invega SL Mirapex ER E Namenda Nuvigil N SL Lorazepam Pramipexole Risperidone Rivastigmine Ropinirole Tasmar Xyrem N SL Zyprexa SL

Provigil E N SL Requip XL E Seroquel XR SL Zyprexa Zydis SL

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

2012 Prescription Drug List Traditional Three-Tier

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Dermatology
Tier 1 Adapalene N SL Alclometasone Dipropionate Betamethasone Dipropionate Betamethasone Valerate Ciclopirox Cream, Gel, Lotion Ciclopirox Non-Oral Solution Ciclopirox Shampoo 1% MC Clindamycin Foam 1% SL Clindamycin Gel, Lotion, Solution, Swabs Clindamycin Phosphate/ Benzoyl Peroxide Gel 1%-5% SL Clobetasol Propionate Tier 2 Azelex SL Benzamycin Condylox Gel Tier 3 Acanya Aczone Aldara SL Altabax SL Atralin MC N SL Avita Gel N SL Bactroban SL Benzaclin Gel 1%-5% SL Clindagel SL Clobex SL Clobex Shampoo E SL Cutivate Lotion MC Denavir Derma-Smoothe/FS Desonate SL Differin Cream, Gel 0.1% N SL Clobetasol Propionate Foam SL Clotrimazole/Betamethasone Desonide Desoximetasone Econazole Nitrate Erythromycin Erythromycin/Benzoyl Peroxide Fluocinonide Fluticasone Propionate Halobetasol Propionate Hydrocortisone Hydrocortisone Valerate Imiquimod SL Isotretinoin Dovonex Cream SL Oxsoralen-Ultra Protopic N SL Differin Gel 0.3% N SL Differin Lotion N SL Duac SL Elidel N SL Epiduo E SL Evoclin SL Finacea Finacea Plus Locoid Lipocream SL Locoid Lotion SL Loprox Shampoo MC Metrogel 1% MC Metrolotion Naftin Noritate MC Olux-E SL Oxistat Ketoconazole Lidocaine Metronidazole Mometasone Furoate Mupirocin Nystatin Nystatin/Triamcinolone Acetonide Permethrin Silver Sulfadiazine Sulfacetamide Sodium/ Sulfur Tretinoin N Triamcinolone Acetonide Urea

Regranex N Stelara DSN N SL

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

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

12

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Diabetes/Endocrine Blood Glucose Monitoring

Tier 1 Accu-Chek Active Test Strips SL Accu-Chek Aviva Care Kit Accu-Chek Aviva Test Strips SL Accu-Chek Comfort Curve Test Strips SL Tier 3 Ascensia Autodisc Test Strips SDP SL Ascensia Breeze 2 Test Strips SDP SL Ascensia Elite Test Strips SDP SL Accu-Chek Compact Care Kit Accu-Chek Compact Test Strips 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 Freestyle Test Strips SDP SL One Touch Ultra Test Strips 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 Lantus Solostar Pens/ Cartridges Humulin 70-30 Vials Humulin Vials Humulin KwikPen Lantus Vials Levemir Flexpen Novolin Vials SDP NovoLog SDP Levemir Vials

Diabetes/Endocrine Non-Insulin
Tier 1 Acarbose Glimepiride Glipizide Tier 2 Actoplus Met SL Actos 1/2T SL Byetta SL Tier 3 Avandamet SL Avandaryl SL Avandia SL Glipizide/Metformin Glyburide Glyburide/Metformin Duetact SL Glyset Janumet SL Fortamet Glumetza Onglyza SL Metformin Nateglinide SL

Januvia SL Prandin SL

Starlix SL Symlin SL Victoza SL

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

2012 Prescription Drug List Traditional Three-Tier

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Endocrine Growth Hormone

Tier 2 Nutropin, AQ, NuSpin DSN N SL Tier 3 Genotropin DSN E N SL Humatrope DSN E N SL Saizen DSN N SL Serostim DSN N SL Norditropin DSN E N SL Omnitrope DSN E N SL Tev-Tropin DSN N SL

Zorbtive DSN N SL

Endocrine Other
Tier 1 Cabergoline Calcitriol Desmopressin Dexamethasone Fludrocortisone Hydrocortisone Tablet Tier 2 Androderm SL Android Hectorol Kuvan DSN N SL Tier 3 Androgel E SL Levothyroxine Sodium Liothyronine Sodium Methimazole Methylprednisolone Dosepak Tablet 4 mg Octreotide Acetate DSN N Medrol 2, 8, 24, 32 mg Pediapred Sandostatin Vial DSN N Synarel Armour Thyroid Orapred Oxandrolone Prednisolone Prednisone Testosterone

Synthroid Testim SL Tirosint Zemplar DSN Orapred ODT

Eye Conditions Anti-Allergy

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

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

14

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Eye Conditions Antibiotics

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

Eye Conditions Glaucoma

Tier 1 Acetazolamide Apraclonidine Brimonidine Tartrate Tier 2 Alphagan P 0.1% SL Azopt SL Betimol SL Tier 3 Iopidine 1% Brimonidine Tartrate 0.15% SL Dorzolamide HCl Dorzolamide HCl/Timolol Maleate Latanoprost SL Timolol Maleate Pilopine HS Travatan Z SL

Combigan SL Lumigan SL Phospholine Iodide

Gastrointestinal Acid Suppression

Tier 1 Cimetidine Lansoprazole E SL Misoprostol Nizatidine Oral Solution Tier 2 Helidac Tier 3 Aciphex SL Carafate Oral Suspension Dexilant SL Nexium Capsule E SL Omeprazole Omeprazole/Sodium Bicarbonate Capsule E SL Pantoprazole Prevpac SL Nexium Suspension SL Prevacid Delayed-Release Enteric-Coated Capsule E SL Ranitidine Syrup Sucralfate Tablet Zegerid Capsule SL

Pylera Prevacid Solutab E SL Prilosec Rx 10, 20 mg E Prilosec Rx 40 mg E Zegerid Packet SL

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

2012 Prescription Drug List Traditional Three-Tier

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Gastrointestinal Nausea/Vomiting
Tier 1 Granisetron Tablet SL Tier 2 Emend SL Tier 3 Anzemet SL Cesamet Sancuso E SL Transderm-Scop Zuplenz E SL Ondansetron Prochlorperazine Maleate

Gastrointestinal Other
Tier 1 Balsalazide Belladona/Phenobarbital Budesonide Extended-Release 24 Hour Capsule Tier 2 Apriso Canasa Creon Tier 3 Amitiza N SL Asacol SDP Asacol HD E SDP Dipentum Chlordiazepoxide/Clidinium Diphenoxylate/Atropine Lactulose Mesalamine Metoclopramide GoLYTELY Packet Lialda Lotronex SL Entocort EC Halflytely-Bisacodyl Metozolv ODT E Moviprep Polyethylene Glycol Sulfasalazine Trilyte with Flavor Packets Ursodiol

Relistor Zenpep

Pancreaze SDP Pentasa

Mens Health Erectile Dysfunction

Tier 3 Caverject SL Cialis SL Edex SL Levitra SL Muse SL Viagra SL

Mens Health Prostate

Tier 1 Alfuzosin Doxazosin Tier 3 Avodart N SDP Jalyn E Finasteride Tamsulosin Rapaflo Uroxatral Terazosin

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

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Miscellaneous
Tier 1 Anastrozole Antipyrine/Benzocaine Azathioprine Benzonatate Chlorhexidine Gluconate Epinephrine Pen Injector SL Tier 2 Cellcept Suspension DSN Epipen SL Epipen Jr SL Tier 3 Acuvail E SL Aromasin Infergen DSN N SL Exemestane Hydrocodone/ Chlorpheniramine Suspension SL Letrozole Megestrol Acetate Fareston Lidoderm SL Myfortic DSN Intron A DSN N Restasis N SL Tussionex SL Mycophenolate Capsule, Tablet DSN Phenazopyridine Tacrolimus DSN Tamoxifen

Neoral DSN Rapamune DSN Sandimmune DSN Twinject SL

Miscellaneous Overactive Bladder

Tier 1 Dicyclomine Tablet Hyoscyamine Sulfate Tier 2 Enablex Gelnique Tier 3 Detrol SDP Oxybutynin Trospium Oxytrol Sanctura XR Detrol LA E Vesicare

Toviaz SDP

Musculoskeletal Osteoporosis
Tier 1 Alendronate SL Tier 2 Actonel SL Boniva Tablet SL Tier 3 Fosamax Plus D SL Calcitonin Salmon Nasal Spray Evista Forteo DSN N Fortical

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

2012 Prescription Drug List Traditional Three-Tier

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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 Butorphanol Nasal Spray SL Diclofenac Potassium Diclofenac Sodium Etodolac Fentanyl Citrate Lollipop N SL Tier 2 Codeine Phosphate MSIR Capsule Tier 3 Arthrotec Avinza SL Celebrex SL Duragesic SL Embeda SL Exalgo SL Fentanyl Transdermal SL Hydromorphone Ibuprofen Ibuprofen/Hydrocodone Ibuprofen/Oxycodone Indomethacin Ketorolac Tromethamine Mefenamic Acid Meloxicam Meperidine Methadone Morphine Sulfate Morphine Sulfate Sustained-Action Tablet SL Nabumetone Naproxen Opana ER SL OxyContin SL Fentora N SL Flector E Kadian E SL Naprelan E Onsolis N SL Opana SL Naproxen Sodium Oxaprozin Oxycodone Oxymorphone SL Oxymorphone Extended-Release 12 Hour Tablet SL Piroxicam Sulindac Tolmetin Sodium Tramadol Tramadol Sustained-Release 24 Hour Tablet SL Tramadol/Acetaminophen SL

Voltaren Gel

Pennsaid E Rybix ODT E SL Ryzolt 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 P SL Leflunomide Methotrexate Enbrel DSN N SL Simponi DSN N SL Kineret DSN N SL Sulfasalazine

Trexall

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

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Musculoskeletal Other
Tier 1 Allopurinol Baclofen Carisoprodol 250 mg E Carisoprodol 350 mg Cyclobenzaprine Tier 2 Colcrys Tier 3 Amrix E Savella SL Skelaxin Soma 250 mg E Uloric SL Cyclobenzaprine Extended-Release 24 Hour Capsule E Metaxalone Methocarbamol Orphenadrine Orphenadrine Compound Tizanidine

Respiratory Asthma/COPD
Tier 1 Albuterol Sulfate Albuterol Sulfate/Ipratropium Non-Oral Solution Alvesco SL Asmanex SL Tier 2 Foradil SL Tier 3 Advair Diskus RS SL Advair HFA RS SL Atrovent HFA SL Combivent SL Dulera RS SL Flovent Diskus SDP SL Budesonide Inhalation Suspension 0.25 mg/ 2 ml, 0.5 mg/2 ml SL Ipratropium Bromide QVAR SL Pulmicort Respules 1 mg/2 ml SL Flovent HFA SDP SL Maxair Autohaler SL Perforomist SL Proair HFA SL Proventil HFA SL Pulmicort Flexhaler SDP SL Theophylline Ventolin HFA SL Zafirlukast SL

Singulair SL Spiriva SL Serevent Diskus SL Symbicort SDP SL Xopenex HFA SL Xopenex Vial, Nebulizer E SL

Respiratory Nasal Allergy

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

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

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Respiratory Oral Allergy

Tier 1 Cyproheptadine Hydroxyzine Tier 3 Clarinex E SL Levocetirizine SL Promethazine Clarinex-D E SL

Womens Health Contraceptives

Tier 1 Amethia MC Amethyst Apri Aviane Azurette Balziva Camila Camrese MC Enpresse Errin Gianvi Heather Introvale MC Jolessa MC Jolivette Junel Tier 2 Depo-SubQ Provera MC Tier 3 Beyaz E Femcon Fe Lo Loestrin Fe Loestrin 24 Fe LoSeasonique MC Lybrel Junel Fe Kariva Levora Low-Ogestrel Lutera Medroxyprogesterone 150 mg/ml MC Microgestin Microgestin Fe Mononessa Necon 7/7/7 Nora-Be Norethindrone Nortrel 7/7/7 Ocella Portia NuvaRing Ortho Evra Ortho Micronor Ortho Tri-Cyclen Ortho Tri-Cyclen Lo Ortho-Cyclen Ortho-Novum 7/7/7 Previfem Quasense MC Reclipsen Sprintec Tilia Fe Tri-Legest Fe Tri-Previfem Tri-Sprintec Trinessa Trivora Zarah Zenchent Zeosa Zovia

Ovrette Safyral E Seasonique MC Yasmin Yaz

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

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Womens Health Estrogen/Progesterone

Tier 1 Estradiol Estradiol/Norethindrone Acetate 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 Estrogel SL Estropipate Medroxyprogesterone Norethindrone Acetate Norethindrone Acetate/ Ethinyl Estradiol Tablet 1 mg/5 mcg

Estrace Cream with Applicator Estraderm SL Estring SL Evamist Femhrt Femring MC SL First-Progesterone N Menostar Transdermal Weekly Patch SL Premarin

Prefest Prometrium Vagifem Vivelle SL Vivelle-Dot SL Premphase Prempro Prochieve N

Womens Health Prenatal Vitamins

Tier 1 Advanced Care Plus Cavan-EC Sod DHA Folcal DHA Folic Acid Multi-Nate 30 Multinatal Plus Natalcare Plus PR Natal 430 PR Natal 430 EC Tier 3 Brand Prenatal Vitamins PR Natal 440 EC Prenatal 19 Prenatal Advantage Prenatal Plus Pruet DHA 29-1-430 mg Pruet DHA EC 29-1-430 mg Setonet Setonet-EC Taron A Prenatal Vemavite-PRX 2 Vinate III Vitanatal OB+DHA Zatean-PN Zatean-PN DHA Zatean-PN Plus

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

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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 P SL (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) Capoten (Captopril) Cardizem CD except for 360 mg strength (Diltiazem Capsule, SustainedRelease 24 Hour) 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 P (Divalproex Sodium Sustained-Release 24 Hour Tablet) Depo-Provera MC (Medroxyprogesterone 150 mg/ml MC ) DiaBeta, Micronase, Glynase (Glyburide) Diastat Acudial SL (Diazepam Rectal Gel SL) Didronel (Etidronate Disodium) Diflucan (Fluconazole) Ditropan XL (Oxybutynin Sustained-Release Tablet) Duricef (Cefadroxil) Dyazide (Triamterene/ Hydrochlorothiazide) Dynacirc (Isradipine) Effexor (Venlafaxine) Effexor XR SL (Venlafaxine Sustained-Release Capsule SL) Eskalith CR (Lithium Carbonate Controlled-Release Tablet) Femara (Letrozole) Fioricet SL (Acetaminophen/ Butalbital/Caffeine SL) Flomax (Tamsulosin) Flonase SL (Fluticasone Nasal Spray SL) Floxin Otic (Ofloxacin Otic Drops) Fosamax SL (Alendronate SL) Glucophage, XR (Metformin) Glucotrol, XL (Glipizide) Glucovance (Glyburide/ Metformin) Hytrin (Terazosin) Hyzaar SL (Losartan/ Hydrochlorothiazide SL) Imitrex SL (Sumatriptan Succinate Injection, Tablet SL) Inderal (Propranolol) Keflex (Cephalexin) Keppra P (Levetiracetam) Klonopin (Clonazepam) Lamictal P (Lamotrigine) Lamisil SL (Terbinafine Tablet SL) Lasix (Furosemide) Levaquin (Levofloxacin) Lopid (Gemfibrozil) Lopressor (Metoprolol) Mavik 1/2T (Trandolapril 1/2T ) Medrol (Methylprednisolone Dosepak Tablet 4 mg) Mevacor (Lovastatin) Mobic (Meloxicam) Monopril (Fosinopril) Monopril HCT (Fosinopril/ Hydrochlorothiazide) Motrin (Ibuprofen) Prescription strengths only Naprosyn (Naproxen) Prescription strengths only Nardil (Phenelzine) Nasarel SL (Flunisolide Nasal Spray SL) 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) Plan B (Levonorgestrel) 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 P SL (Zaleplon SL)

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

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Additional Tier 3 Drugs with a generic equivalent in Tier 1 (cont. from page 22)
Surmontil (Trimipramine Maleate) Tenoretic (Atenolol/ Chlorthalidone) Tenormin (Atenolol) Tiazac (Diltiazem) Topamax P (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) 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)

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

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Index
A A-B Otic 6 Abilify 11 Acanya 12 Acarbose 13, 22 Accolate 22 Accu-Chek Active Test Strips 13 Accu-Chek Aviva Care Kit 13 Accu-Chek Aviva Test Strips 13 Accu-Chek Comfort Curve Test Strips 13 Accu-Chek Compact Care Kit 13 Accu-Chek Compact Test Strips 13 Accupril 22 Aceon 8 Acetaminophen/Butalbital/ Caffeine 10, 22 Acetaminophen/Butalbital/ Caffeine/Codeine 18 Acetaminophen/ Codeine 18, 23 Acetaminophen/ Dichloralphenazone/ Isometheptene Mucate 10 Acetaminophen/ Hydrocodone 18, 23 Acetaminophen/ Hydrocodone Bit 18 Acetaminophen/ Oxycodone 18, 22 Acetazolamide 15 Aciphex 15 Activella 21 Actonel 17 Actoplus Met 13 Actos 13 Acular 22 Acuvail 17 Acyclovir 7, 23 Acyclovir Capsule, Suspension, Tablet 23 Aczone 12 Adapalene 12 Adderall 9, 22 Adderall XR 9 Adoxa 6 Advair Diskus 19 Advair HFA 19 Advanced Care Plus 21 Advicor 8 Aggrenox 7 Akineton 11 Albuterol Sulfate 19 Albuterol Sulfate/Ipratropium Non-Oral Solution 19 Alclometasone Dipropionate 12 Aldactazide 50-50 mg 8 Aldactone 22 Aldara 12 Alendronate 17, 22 Alfuzosin 16 Allopurinol 19 Alora 21 Alphagan P 0.1% 15 Alprazolam 11, 23 Alsuma 10 Altabax 12 Altace 22 Altoprev 8 Alvesco 19 Amantadine 7 Amaryl 22 Ambien 10, 22 Ambien CR 10 Amerge 22 Amethia 20 Amethyst 20 Amiodarone 9 Amitiza 16 Amitriptyline 9 Amitriptyline/Perphenazine 9 Amlodipine 7, 22 Amlodipine/Benazepril 7 Amoxicillin 6, 22 Amoxicillin-Clavulanate ER 6 Amoxicillin/Potassium Clavulanate 6, 22 Amphetamine Aspartate/ Amphetamine Sulfate/ Dextroamphetamine Sustained-Release 24 Hour Capsule 9 Amphetamine Salt Combo 9 Amphetamine/ Dextroamphetamine Salt Combination 22 Ampicillin 6 Ampyra 10 Amrix 19 Amturnide 8 Anaprox 22 Anastrozole 17, 22 Androderm 14 Androgel 14 Android 14 Antara 8 Antipyrine/Benzocaine 17 Anzemet 16 Apidra 13 Aplenzin 9 Apokyn 11 Apraclonidine 15 Apri 20 Apriso 16 Aricept 11, 22 Aricept 23 mg 11 Arimidex 22 Arixtra 7 Armour Thyroid 14 Aromasin 17 Arthrotec 18 Asacol 16 Asacol HD 16 Ascensia Autodisc Test Strips 13 Ascensia Breeze 2 Test Strips 13 Ascensia Elite Test Strips 13 Asmanex 19 Aspirin/Butalbital/ Caffeine 10, 18 Aspirin/Butalbital/ Caffeine/Codeine 18 Aspirin/Oxycodone 18 Astelin 19 Astepro 19 Atacand 8 Atacand HCT 8 Atenolol 7, 23 Atenolol/Chlorthalidone 7, 23 Ativan 22 Atorvastatin 8 Atralin 12 Atrovent HFA 19 Augmentin 6, 22 Augmentin ES 22 Augmentin XR 6 Avalide 8 Avandamet 13 Avandaryl 13 Avandia 13 Avapro 8 Avelox 6 Aviane 20 Avinza 18 Avita Gel 12 Avodart 16 Avonex 10 Axert 10 Azasite 15 Azathioprine 17-18 Azelastine HCl 14, 19 Azelex 12 Azithromycin 6, 23 Azopt 15 Azor 8 Azurette 20 B Baclofen 19 Bactroban 12 Balsalazide 16, 22 Balziva 20 Baraclude 7 Beconase AQ 19

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Belladona/Phenobarbital 16 Benazepril 7 Benazepril/ Hydrochlorothiazide 7 Benicar 8 Benicar HCT 8 Benzaclin Gel 1%-5% 12 Benzamycin 12 Benzonatate 17 Benztropine Mesylate 11 Bepreve 14 Betamethasone Dipropionate 12 Betamethasone Valerate 12 Betaseron 10 Betimol 15 Beyaz 20 Biaxin Tablet 22 BiDil 8 Bisoprolol 7, 23 Bisoprolol/ Hydrochlorothiazide 7, 23 Blephamide S.O.P. 15 Boniva Tablet 17 Brand Prenatal Vitamins 21 Brimonidine Tartrate 15 Brimonidine Tartrate 0.15% 15 Budesonide Extended-Release 24 Hour Capsule 16 Budesonide Inhalation Suspension 0.25 mg/ 2 ml, 0.5 mg/2 ml 19 Bumetanide 7 Bupropion 9, 23 Bupropion HCl 23 Bupropion HCl Sustained-Action Tablet 23 Bupropion HCl Sustained-Release 24 Hour Tablet 23 Bupropion XL 9 Buspar 22 Buspirone 11, 22 Butorphanol Nasal Spray 18 Byetta 13 Bystolic 8 C Cabergoline 14 Caduet 8 Cafergot 10 Calan, Calan SR 22 Calcitonin Salmon Nasal Spray 17 Calcitriol 14 Cambia 10 Camila 20 Camrese 20 Canasa 16 Capoten 22 Captopril 7, 22

Captopril/ Hydrochlorothiazide 7 Carafate Oral Suspension 15 Carbamazepine 11 Carbamazepine Extended-Release 12 Hour Capsule 11 Carbamazepine Sustained-Release 12 Hour Tablet 11 Carbatrol 11 Carbidopa/Levodopa 11 Cardizem CD 360 mg 8 Cardizem CD except for 360 mg strength 22 Cardizem LA 120 mg 8 Cardizem LA 180, 240, 300, 360, 420 mg 8 Cardura 22 Carisoprodol 250 mg 19 Carisoprodol 350 mg 19 Carvedilol 7, 22 Catapres-TTS 8 Cavan-EC Sod DHA 21 Caverject 16 Cefadroxil 6, 22 Cefdinir 6 Cefprozil 6, 22 Ceftin 22 Cefuroxime 6, 22 Cefzil 22 Celebrex 18 Celexa 22 Cellcept Suspension 17 Celontin 11 Cenestin 21 Cephalexin 6, 22 Cesamet 16 Cetraxal 6 Chlordiazepoxide/ Clidinium 16 Chlorhexidine Gluconate 17 Chlorthalidone 7, 23 Cholestyramine 8 Cialis 16 Ciclopirox Cream, Gel, Lotion 12 Ciclopirox Non-Oral Solution 12 Ciclopirox Shampoo 1% 12 Ciclopirox Solution, Non-Oral 22 Cilostazol 7, 22 Ciloxan Eye Drops 22 Cimetidine 15 Cimzia 18 Cipro 6, 22 Cipro HC 6 Cipro Suspension 6 Ciprodex Otic 6 Ciprofloxacin 6, 15, 22 Ciprofloxacin

Sustained-Release 24 Hour Tablet 6 Ciprofloxacin Tablet 6 Citalopram 9, 22 Citalopram Hydrobromide 9 Clarinex 20 Clarinex-D 20 Clarithromycin Suspension 6 Clarithromycin Sustained-Release Tablet 6 Clarithromycin Tablet 6, 22 Cleocin HCl 75 mg 6 Cleocin T 22 Climara 21 Climara Pro 21 Clindagel 12 Clindamycin Foam 1% 12 Clindamycin Gel, Lotion, Solution, Swabs 12, 22 Clindamycin HCl 6 Clindamycin Palmitate 6 Clindamycin Phosphate/ Benzoyl Peroxide Gel 1%-5% 12 Clindesse Vaginal 6 Clobetasol Propionate 12 Clobetasol Propionate Foam 12 Clobex 12 Clobex Shampoo 12 Clonazepam 11, 22 Clonidine 7 Clonidine Transdermal Weekly Patch 7 Clorazepate Dipotassium 11 Clorpres 8 Clotrimazole 6, 12 Clotrimazole/ Betamethasone 12 Clozapine 11, 22 Clozaril 22 Codeine Phosphate 18 Colazal 22 Colcrys 19 Colestid 22 Colestipol 8, 22 Combigan 15 Combipatch 21 Combivent 19 Comtan 11 Concerta 9 Condylox Gel 12 Contour Test Strips 13 Copaxone 10 Coreg 8, 22 Coreg CR 8 Coumadin 7 Cozaar 22 Creon 16 Crestor 8 Crinone 21 Cuprimine 18

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Cutivate Lotion 12 Cyclobenzaprine 19 Cyclobenzaprine Extended-Release 24 Hour Capsule 19 Cymbalta 9 Cyproheptadine 20 D Dapsone 6 Daytrana 9 DDAVP 22 Denavir 12 Depakote 11, 22 Depakote ER 11, 22 Depo-Provera 22 Depo-SubQ Provera 20 Derma-Smoothe/FS 12 Desmopressin 14, 22 Desonate 12 Desonide 12 Desoximetasone 12 Detrol 17 Detrol LA 17 Dexamethasone 14-15 Dexilant 15 Dextroamphetamine Sulfate 9 DiaBeta 22 Diastat Acudial 22 Diazepam 11, 22-23 Diazepam Rectal Gel 11, 22 Dibenzyline 8 Diclofenac 18, 23 Diclofenac Potassium 18 Diclofenac Sodium 18 Dicloxacillin Sodium 6 Dicyclomine Tablet 17 Didronel 22 Differin Cream, Gel 0.1% 12 Differin Gel 0.3% 12 Differin Lotion 12 Diflucan 22 Digoxin 9 Dilantin 11 Diltiazem 7, 22-23 Diltiazem Capsule, Sustained-Release 24 Hour 22 Diltiazem Controlled-Release Capsule 7 Diltiazem Sustained-Action Capsule 7 Diltiazem Sustained-Release 12 Hour Capsule 7 Diltiazem Sustained-Release 24 Hour Capsule 7 Diltiazem Sustained-Release 24 Hour Tablet 7 Diovan 8 Diovan HCT 8 Dipentum 16 Diphenoxylate/Atropine 16

Ditropan XL 22 Diuril Suspension 250 mg/5 ml 8 Divalproex Sodium Sprinkle Capsule 11 Divalproex Sodium Sustained-Release 24 Hour Tablet 22 Divalproex Sodium Sustained-Release Tablet 11 Divalproex Sodium Tablet 11, 22 Divigel 21 Donepezil 11, 22 Donepezil 5, 10 mg 11 Doryx 6 Dorzolamide Eye Drops 23 Dorzolamide HCl 15 Dorzolamide HCl/Timolol Maleate 15 Dovonex Cream 12 Doxazosin 7, 16, 22 Doxepin 9 Doxycycline Hyclate Enteric-Coated Tablet 6 Doxycycline Monohydrate 6 Doxycycline Monohydrate Capsule 150 mg 6 Duac 12 Duetact 13 Dulera 19 Duragesic 18 Duricef 22 Dyazide 22 Dynacirc 22 E Econazole Nitrate 12 Edex 16 Edluar 10 Effexor 22 Effexor XR 22 Effient 7 Elestat 14 Elidel 12 Emadine 14 Embeda 18 Emend 16 Enablex 17 Enalapril 7, 23 Enalapril/ Hydrochlorothiazide 7, 23 Enbrel 18 Enjuvia 21 Enoxaparin 7 Enpresse 20 Entocort EC 16 Epiduo 12 Epinastine 14 Epinephrine Pen Injector 17 Epipen 17 Epipen Jr 17 Epivir HBV 7

Eplerenone 7 Ergomar 10 Errin 20 Ery-Tab 500 mg 6 Erythromycin 6, 12, 15 Erythromycin/Benzoyl Peroxide 12 Erythromycin Base Enteric-Coated Tablet 250, 333 mg 6 Eskalith CR 22 Estrace Cream with Applicator 21 Estraderm 21 Estradiol 21 Estradiol/Norethindrone Acetate 21 Estradiol Transdermal Weekly Patch 21 Estrasorb 21 Estring 21 Estrogel 21 Estropipate 21 Etidronate Disodium 22 Etodolac 18 Evamist 21 Evista 17 Evoclin 12 Exalgo 18 Exelon Solution 11 Exemestane 17 Exforge 8 Exforge HCT 8 Extavia 10 Extina 6 F Famciclovir 7 Fanapt 11 Fareston 17 FazaClo 11 Felbatol 11 Felodipine 7 Femara 22 Femcon Fe 20 Femhrt 21 Femring 21 Fenofibrate 8 Fenofibric Acid 8 Fenoglide 8 Fentanyl Citrate Lollipop 18 Fentanyl Transdermal 18 Fentora 18 Finacea 12 Finacea Plus 12 Finasteride 16, 22 Fioricet 22 First-Progesterone 21 Flecainide Acetate 9 Flector 18 Flomax 22 Flonase 22 Flovent Diskus 19

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Flovent HFA 19 Floxin Otic 22 Fluconazole 6, 22 Fludrocortisone 14 Flunisolide 19, 22 Flunisolide Nasal Spray 22 Fluocinonide 12 Fluoxetine 9, 22 Fluoxetine Capsule 22 Fluoxetine Delayed-Release Capsule 9, 22 Fluticasone Nasal Spray 22 Fluticasone Propionate 12, 19 Fluvoxamine Maleate 9 Focalin XR 9 Folcal DHA 21 Folic Acid 21 Fondaparinux 7 Foradil 19 Fortamet 13 Forteo 17 Fortical 17 Fosamax 17, 22 Fosamax Plus D 17 Fosinopril 7, 22 Fosinopril/ Hydrochlorothiazide 7, 22 Fragmin 7 Freestyle Lite Test Strips 13 Freestyle Test Strips 13 Frova 10 Furosemide 7, 22 G Gabapentin 11, 22 Gabitril 11 Galantamine 11 Gelnique 17 Gemfibrozil 8, 22 Genotropin 14 Gentamicin Sulfate 15 Geodon 11 Gianvi 20 Gilenya 10 Glimepiride 13, 22 Glipizide 13, 22 Glipizide/Metformin 13 Glucophage, XR 22 Glucotrol, XL 22 Glucovance 22 Glumetza 13 Glyburide 13, 22 Glyburide/Metformin 13, 22 Glynase 22 Glyset 13 GoLYTELY Packet 16 Granisetron Tablet 16 Guanfacine 7 Gynazole-1 Vaginal 6 H Halflytely-Bisacodyl 16 Halobetasol Propionate 12 Heather 20

Hectorol 14 Helidac 15 Hepsera 7 Humalog-Mix KwikPen 13 Humalog-Mix Vials 13 Humalog KwikPen 13 Humalog Vials 13 Humatrope 14 Humira 18 Humulin 70-30 Vials 13 Humulin KwikPen 13 Humulin Vials 13 Hydralazine 7 Hydrochlorothiazide 7-8, 22-23 Hydrocodone/ Chlorpheniramine Suspension 17 Hydrocortisone 12, 14 Hydrocortisone Tablet 14 Hydrocortisone Valerate 12 Hydromorphone 18 Hydroxychloroquine Sulfate 18 Hydroxyzine 20 Hyoscyamine Sulfate 17 Hytrin 22 Hyzaar 22 I Ibuprofen 18, 22-23 Ibuprofen/ Hydrocodone 18, 23 Ibuprofen/Oxycodone 18 Ibuprofen - Prescription strengths only 22 Imipramine 9 Imiquimod 12 Imitrex 22 Indapamide 7 Inderal 22 Indomethacin 18 Infergen 17 Innohep 7 Intron A 17 Introvale 20 Intuniv 9 Invega 11 Iopidine 1% 15 Ipratropium Bromide 19 Isosorbide Dinitrate 9 Isosorbide Mononitrate 9 Isotretinoin 12 Isradipine 22 Itraconazole Capsule 6 J Jalyn 16 Janumet 13 Januvia 13 Jolessa 20 Jolivette 20 Junel 20 Junel Fe 20

K Kadian 18 Kariva 20 Keflex 22 Keppra 11, 22 Keppra XR 11 Ketoconazole 6, 12 Ketorolac Tromethamine 14, 18, 22 Kineret 18 Klonopin 22 Kuvan 14 L Labetalol 7 Lactulose 16 Lamictal 11, 22 Lamictal Dose Pack 11 Lamictal ODT 11 Lamictal XR 11 Lamisil 6, 22 Lamisil Granules 6 Lamotrigine 11, 22 Lanoxin 9 Lansoprazole 15 Lantus Solostar Pens/ Cartridges 13 Lantus Vials 13 Lasix 22 Lastacaft 14 Latanoprost 15, 23 Leflunomide 18 Lescol 8 Lescol XL 8 Letrozole 17, 22 Levaquin 22 Levemir Flexpen 13 Levemir Vials 13 Levetiracetam 11, 22 Levetiracetam Extended-Release 24 Hour Tablet 11 Levitra 16 Levocetirizine 20 Levofloxacin 6, 15, 22 Levonorgestrel 22 Levora 20 Levothyroxine Sodium 14 Lexapro 9 Lialda 16 Lidocaine 12 Lidoderm 17 Liothyronine Sodium 14 Lipitor 8 Lipofen 8 Lisinopril 7, 22 Lisinopril/ Hydrochlorothiazide 7, 22 Lithium Carbonate 11, 22 Lithium Carbonate Controlled-Release Tablet 22 Livalo 8 Lo Loestrin Fe 20

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Locoid Lipocream 12 Locoid Lotion 12 Loestrin 24 Fe 20 Lopid 22 Lopressor 22 Loprox Shampoo 12 Lorazepam 11, 22 Losartan 7, 22 Losartan/ Hydrochlorothiazide 7, 22 LoSeasonique 20 Lotrel 8 Lotronex 16 Lovastatin 8, 22 Lovaza 8 Lovenox 7 Low-Ogestrel 20 Lumigan 15 Lunesta 10 Lutera 20 Luvox CR 9 Lybrel 20 Lyrica 11 M Macrodantin 25 mg 6 Mavik 22 Maxair Autohaler 19 Maxalt 10 Maxalt MLT 10 Medrol 14, 22 Medrol 2, 8, 24, 32 mg 14 Medroxyprogesterone 20-22 Medroxyprogesterone 150 mg/ml 20, 22 Mefenamic Acid 18 Megestrol Acetate 17 Meloxicam 18, 22 Menostar Transdermal Weekly Patch 21 Meperidine 18 Mesalamine 16 Metadate CD 9 Metaxalone 19 Metformin 13, 22 Methadone 18 Methamphetamine 9 Methimazole 14 Methocarbamol 19 Methotrexate 18 Methyldopa 7 Methyldopa/ Hydrochlorothiazide 7 Methylin 9 Methylphenidate 9, 22 Methylphenidate Extended-Release 24 Hour Tablet 9 Methylphenidate Extended-Release Tablet 22 Methylprednisolone Dosepak Tablet 4 mg 14, 22 Metoclopramide 16

Metolazone 7 Metoprolol 7, 22-23 Metoprolol/ Hydrochlorothiazide 7 Metoprolol Succinate Sustained-Release Tablet 7, 23 Metoprolol Tartrate 7 Metozolv ODT 16 Metrogel 1% 12 Metrolotion 12 Metronidazole 6, 12 Metronidazole Vaginal 6 Mevacor 22 Mexiletine 9 Micardis 8 Micardis HCT 8 Microgestin 20 Microgestin Fe 20 Micronase 22 Migranal 10 Minocycline HCl 6 Minoxidil 7 Mirapex ER 11 Mirtazapine 9, 22 Mirtazapine Dispersible Tablet 22 Misoprostol 15 Mobic 22 Moexipril 7 Mometasone Furoate 12 Mononessa 20 Monopril 22 Monopril HCT 22 Morphine Sulfate 18 Morphine Sulfate Sustained-Action Tablet 18 Motrin - Prescription strengths only 22 Moviprep 16 MSIR Capsule 18 Multaq 9 Multi-Nate 30 21 Multinatal Plus 21 Mupirocin 12 Muse 16 Mycophenolate Capsule, Tablet 17 Mycostatin 6 Myfortic 17 Mysoline 11 N Nabumetone 18 Nadolol 7 Naftin 12 Namenda 11 Naprelan 18 Naprosyn - Prescription strengths only 22 Naproxen 18, 22 Naproxen - Prescription strengths only 22

Naproxen Sodium 18 Naratriptan 10, 22 Nardil 22 Nasacort AQ 19 Nasarel 22 Nasonex 19 Natalcare Plus 21 Nateglinide 13 Navane 20 mg 11 Necon 7/7/7 20 Nefazodone 9 Neomycin/Polymyxin/ HC Otic 6 Neomycin/Polymyxin B Sulfate/Dexamethasone 15 Neoral 17 Neurontin 22 Nexium Capsule 15 Nexium Suspension 15 Niaspan 8 Nifedipine 7, 22 Nifedipine Extended-Release Tablet 22 Nisoldipine 7 Nitrofurantoin/Nitrofurantoin Macrocrystal 6 Nitrofurantoin Macrocrystal 6 Nitrofurantoin Suspension 6 Nitroglycerin 9 Nitroglycerin Spray 9 Nitroglycerin Transdermal Patch 9 Nitrolingual 9 Nitromist 9 Nitrostat 9 Nizatidine Oral Solution 15 Nora-Be 20 Norditropin 14 Norethindrone 20-21 Norethindrone Acetate 21 Norethindrone Acetate/ Ethinyl Estradiol Tablet 1 mg/5 mcg 21 Noritate 12 Nortrel 7/7/7 20 Nortriptyline 9 Norvasc 22 Novolin Vials 13 NovoLog 13 Noxafil 6 Nutropin, AQ, NuSpin 14 NuvaRing 20 Nuvigil 11 Nystatin 6, 12 Nystatin/Triamcinolone Acetonide 12 O Ocella 20 Octreotide Acetate 14 Ocuflox Eye Drops 22 Ofloxacin 6, 15, 22 Ofloxacin Otic 6, 22

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Ofloxacin Otic Drops 22 Oleptro 9 Olux-E 12 Omeprazole 15, 22 Omeprazole/Sodium Bicarbonate Capsule 15 Omnaris 19 Omnitrope 14 Ondansetron 16, 23 One Touch Test Strips 13 One Touch Ultra 2 System 13 One Touch Ultra Mini System 13 One Touch Ultra Test Strips 13 Onglyza 13 Onsolis 18 Opana 18 Opana ER 18 Optivar 14 Oracea 6 Orapred 14 Orapred ODT 14 Orphenadrine 19 Orphenadrine Compound 19 Ortho-Cyclen 20 Ortho-Novum 7/7/7 20 Ortho Evra 20 Ortho Micronor 20 Ortho Tri-Cyclen 20 Ortho Tri-Cyclen Lo 20 Ovrette 20 Oxandrolone 14 Oxaprozin 18 Oxcarbazepine 11, 23 Oxistat 12 Oxsoralen-Ultra 12 Oxybutynin 17, 22 Oxybutynin Sustained-Release Tablet 22 Oxycodone 18, 22 OxyContin 18 Oxymorphone 18 Oxymorphone Extended-Release 12 Hour Tablet 18 Oxytrol 17 P Pancreaze 16 Pantoprazole 15, 22 Paroxetine 9, 22 Paroxetine Sustained-Release 24 Hour Tablet 9 Paroxetine Tablet 9 Pataday 14 Patanase 19 Patanol 14 Paxil 22 Pediapred 14 Peganone 11

Penicillin V Potassium 6 Penlac 22 Pennsaid 18 Pentasa 16 Pentoxifylline 7 Percocet 5-325, 7.5-500, 10-650 22 Perforomist 19 Perindopril Erbumine 7 Permethrin 12 Pexeva 9 Phenazopyridine 17 Phenelzine 9, 22 Phenobarbital 11, 16 Phenytoin Sodium 11 Phospholine Iodide 15 Pilopine HS 15 Piroxicam 18 Plan B 22 Plavix 7 Pletal 22 Polyethylene Glycol 16 Polymyxin B Sulfate/ Trimethoprim 15 Portia 20 PR Natal 430 21 PR Natal 430 EC 21 PR Natal 440 EC 21 Pramipexole 11 Prandin 13 Pravachol 22 Pravastatin 8, 22 Precision Xtra Test Strips 13 Precose 22 Prednisolone 14 Prednisone 14 Prefest 21 Premarin 21 Premphase 21 Prempro 21 Prenatal 19 21 Prenatal Advantage 21 Prenatal Plus 21 Prevacid Delayed-Release Enteric-Coated Capsule 15 Prevacid Solutab 15 Previfem 20 Prevpac 15 Prilosec 15, 22 Prilosec Rx 10, 20 mg 15 Prilosec Rx 40 mg 15 Primidone 11 Prinivil 22 Prinzide 22 Pristiq 9 Proair HFA 19 Procardia XL 22 Prochieve 21 Prochlorperazine Maleate 16 Promethazine 20 Prometrium 21

Propafenone Sustained-Release 12 Hour Capsule 9 Propranolol 7, 22 Propranolol/ Hydrochlorothiazide 7 Propranolol Sustained-Action Capsule 7 Proscar 22 Protonix 22 Protopic 12 Proventil HFA 19 Provera 20, 22 Provigil 11 Prozac 22 Prozac Weekly 22 Pruet DHA 29-1-430 mg 21 Pruet DHA EC 29-1-430 mg 21 Pulmicort Flexhaler 19 Pulmicort Respules 1 mg/2 ml 19 Pylera 15 Q Quasense 20 Quinapril 7, 22 Quinapril/ Hydrochlorothiazide 7 QVAR 19 R Ramipril 7, 22 Ranexa 9 Ranitidine Syrup 15, 23 Rapaflo 16 Rapamune 17 Rebetol Solution 7 Rebif 10 Reclipsen 20 Regranex 12 Relenza 7 Relistor 16 Relpax 10 Remeron 22 Remeron SolTab 22 Requip 11, 22 Requip XL 11 Restasis 17 Restoril 22 Retin-A Micro 12 Rhinocort Aqua 19 Ribavirin 7 Risperdal 22 Risperidone 11, 22 Ritalin 9, 22 Ritalin LA 9 Ritalin SR 22 Rivastigmine 11 Ropinirole 11, 22 Rozerem 10 Rybix ODT 18 Ryzolt 18

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S Sabril 11 Safyral 20 Saizen 14 Sanctura XR 17 Sancuso 16 Sandimmune 17 Sandostatin Vial 14 Savella 19 Seasonique 20 Serevent Diskus 19 Seroquel 11 Seroquel XR 11 Serostim 14 Sertraline 9, 23 Setonet 21 Setonet-EC 21 Silenor 10 Silver Sulfadiazine 12 Simcor 8 Simponi 18 Simvastatin 8, 23 Singulair 19 Skelaxin 19 Solodyn 6 Soma 250 mg 19 Sonata 10, 22 Sotalol 9 Spiriva 19 Spironolactone 7, 22 Spironolactone/ Hydrochlorothiazide 7 Sporanox Oral Solution 6 Sprintec 20 Starlix 13 Stavzor 11 Stelara 12 Strattera 9 Sucralfate Tablet 15 Sular 8 Sulfacetamide Sodium 12, 15 Sulfacetamide Sodium/ Sulfur 12 Sulfamethoxazole/ Trimethoprim 6 Sulfasalazine 16, 18 Sulindac 18 Sumatriptan Succinate Injection, Tablet 10, 22 Sumatriptan Succinate Nasal Spray 10 Sumavel DosePro 10 Suprax 6 Surmontil 23 Symbicort 19 Symbyax 11 Symlin 13 Synarel 14 Synthroid 14 T Taclonex 12 Taclonex Scalp 12

Tacrolimus 17 Tamiflu 7 Tamoxifen 17 Tamsulosin 16, 22 Tarka 8 Taron A Prenatal 21 Tasmar 11 Tazorac 12 Tegretol 11 Tekamlo 8 Tekturna 8 Tekturna HCT 8 Temazepam 10, 22 Tenoretic 23 Tenormin 23 Terazosin 8, 16, 22 Terbinafine Tablet 6, 22 Terconazole Vaginal 6 Testim 14 Testosterone 14 Tetracycline 6 Tev-Tropin 14 Teveten 8 Teveten HCT 8 Thalitone 8 Theophylline 19 Tiazac 23 Tilia Fe 20 Timolol Maleate 8, 15 Tirosint 14 Tizanidine 19 Tobi 6 Tobradex ST 15 Tobramycin/ Dexamethasone 15 Tobramycin Sulfate Drops 15 Tolmetin Sodium 18 Topamax 11, 23 Topiramate 11, 23 Toprol XL 25 mg 23 Torsemide 8 Toviaz 17 Tramadol 18, 23 Tramadol/ Acetaminophen 18, 23 Tramadol Sustained-Release 24 Hour Tablet 18 Trandolapril 8, 22 Trandolapril/Verapamil 8 Transderm-Scop 16 Travatan Z 15 Trazodone 9 Tretin-X 12 Tretinoin 12 Trexall 18 Treximet 10 Tri-Legest Fe 20 Tri-Previfem 20 Tri-Sprintec 20 Triamcinolone Acetonide 12, 19

Triamterene/ Hydrochlorothiazide 8, 22 Triazolam 10 Tribenzor 8 Tricor 8 Triglide 8 Trileptal 23 Trilipix 8 Trilyte with Flavor Packets 16 Trimipramine Maleate 23 Trinessa 20 Trivora 20 Trospium 17 Trusopt 23 Tussionex 17 Twinject 17 Twynsta 8 Tylenol #3 23 U Uloric 19 Ultracet 23 Ultram 23 Urea 12 Uroxatral 16 Ursodiol 16 V Vagifem 21 Valacyclovir 7 Valcyte 7 Valium 23 Valtrex 7 Valturna 8 Vancocin HCl 6 Vanos 12 Vaseretic 23 Vasotec 23 Vectical 12 Velosef Suspension 250 mg 6 Veltin 12 Vemavite-PRX 2 21 Venlafaxine 9, 22 Venlafaxine Extended-Release Tablet 9 Venlafaxine Sustained-Release Capsule 9, 22 Venlafaxine Tablet 9 Ventolin HFA 19 Veramyst 19 Verapamil 8, 22 Verapamil Sustained-Release 24 Hour Pellets 8 Verdeso 12 Vesicare 17 Vfend 23 Viagra 16 Vicodin 23 Vicodin ES 23 Vicoprofen 23 Victoza 13 Vigamox 15 Vimovo 18

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Vinate III 21 Vitanatal OB+DHA 21 Vivelle 21 Vivelle-Dot 21 Voltaren Gel 18 Voltaren Tablet 23 Voriconazole 6, 23 Vusion 12 Vytorin 8 Vyvanse 9 W Warfarin Sodium 7 Welchol 8 Wellbutrin 23 Wellbutrin SR 23 Wellbutrin XL 23 X Xalatan 23 Xanax, Xanax XR 23 Xerese 12 Xolegel 12 Xopenex HFA 19 Xopenex Vial, Nebulizer 19 Xyrem 11 Y Yasmin 20 Yaz 20 Z Zafirlukast 19, 22 Zaleplon 10, 22 Zantac Syrup 23 Zarah 20 Zatean-PN 21 Zatean-PN DHA 21 Zatean-PN Plus 21 Zegerid Capsule 15 Zegerid Packet 15 Zemplar 14 Zenchent 20 Zenpep 16 Zeosa 20 Zestoretic 22 Zestril 22 Zetia 8 Ziac 23 Ziana 12 Zipsor 18 Zithromax 23 Zocor 23 Zofran 23 Zoloft 23 Zolpidem 10, 22 Zolpidem Multiphasic-Release Tablet 10 Zolpidem Tablet 10 Zomig 10 Zomig Nasal Spray 10 Zomig ZMT 10 Zonegran 23 Zonisamide 11, 23 Zorbtive 14

Zovia 20 Zovirax 12, 23 Zuplenz 16 Zyclara 12 Zylet 15 Zymaxid 15 Zyprexa 11 Zyprexa Zydis 11 Zyvox 6

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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.

2011 United HealthCare Services, Inc. / Medco Health Solutions, Inc. All rights reserved. Created September, 2011. 2012 Prescription Drug List Traditional Three-Tier 100-10841 DL3088A 1/12