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This Prescription Drug List (PDL) outlines the most commonly prescribed medications
for certain conditions and organizes them into cost levels, also known as tiers.
Call the toll-free member phone number on your health plan ID card.
1
Table of Contents
Drug tiers and cost . . . . . . . . . . . . . . . . . . . . . . . 3 Gastrointestinal
Programs and Limits . . . . . . . . . . . . . . . . . . . . . . 5 Acid Suppression. . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Drugs by category . . . . . . . . . . . . . . . . . . . . . . . . 8 Nausea/Vomiting. . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Anti-Infectives
Antibiotics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Gout. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Hepatitis C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 HIV/AIDS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Cardiovascular/Heart Disease Inflammatory Conditions: Rheumatoid
Coagulation Therapy . . . . . . . . . . . . . . . . . . . . . . . . . 9 Arthritis, Crohns Disease, Psoriasis,
High Blood Pressure. . . . . . . . . . . . . . . . . . . . . . . . . 9 Ulcerative Colitis. . . . . . . . . . . . . . . . . . . . . . . . . 17
High Cholesterol. . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Mens Health
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Erectile Dysfunction. . . . . . . . . . . . . . . . . . . . . . . . . 18
Central Nervous System Prostate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Attention Deficit Disorder. . . . . . . . . . . . . . . . . . . . 11 Testosterone Therapy . . . . . . . . . . . . . . . . . . . . . . . 18
Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Miscellaneous. . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Migraine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Musculoskeletal
Multiple Sclerosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Muscle Spasms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Osteoporosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Sedatives/Hypnotics. . . . . . . . . . . . . . . . . . . . . . . . 12 Pain Relief. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Seizure Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Overactive Bladder. . . . . . . . . . . . . . . . . . . . . . . 20
Dermatology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Respiratory
Diabetes/Endocrine
Allergies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Blood Glucose Monitoring. . . . . . . . . . . . . . . . . . . 14
Asthma/COPD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Pulmonary Arterial Hypertension. . . . . . . . . . . . . 21
Non-Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Smoking Cessation . . . . . . . . . . . . . . . . . . . . . . 21
Endocrine
Transplant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Growth Hormone. . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Vitamins/Electrolytes. . . . . . . . . . . . . . . . . . . . 21
Thyroid Hormone Replacement. . . . . . . . . . . . . . 15 Womens Health
Eye Conditions Contraceptives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Allergies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Hormone Replacement. . . . . . . . . . . . . . . . . . . . . . 23
Antibiotics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Miscellaneous. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Dry Eye Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Prenatal Vitamins . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Glaucoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
2
At UnitedHealthcare, we want to help you better
understand your medication options.
Your pharmacy benefit offers flexibility and choice in determining the right medication
for you. To help you get the most out of your pharmacy benefit, weve included some of
the most commonly asked questions about the Prescription Drug List.
3
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 option available. Discuss these options with your doctor.
Check your benefit plan documents to find out your specific pharmacy plan costs.
Please note: Some plans may have two or four tiers, while others may not have any. If you have a high
deductible plan, the tier cost levels may apply once you hit your deductible. Refer to your enrollment
and plan materials on myuhc.com, or call the toll-free number on your health plan ID card for more
information about your benefit plan.
4
Programs and limits
Some medications are noted with letters next to them. The letters refer to our pharmacy benefit
programs. Your benefit plan determines how these medications are covered and may differ than what
is noted in the PDL. Call the number for Member Services listed on your ID card if you have any
questions about your prescription drug coverage.
Health care reform preventive This medication is part of a health care reform
H
preventive benefit and may be available at no cost to you.
Multiple copay More than one months worth of medication included in package so
MC
additional copay applies.
Refill and save program Save money on your copayment when you refill your
RS
prescription on time as prescribed. Program eligibility may vary.
*Depending on your benefit, you may have notification or medical necessity requirements for select medications.
+
For New Jersey fully insured members, this program is referred to as First Start.
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 your health plan ID card.
5
Why are some medications excluded from coverage?
A medication may be excluded from coverage under your pharmacy benefit when it works the same or
similar as another prescription medication or an over-the-counter (OTC) medication. Other medication
options may be available.
6
What is OptumRx Mail Service Member Select?
Your plan may include a home delivery program called Mail Service Member Select. The program
encourages you to use the home delivery through OptumRx for maintenance medications, which are
medications you take regularly. Home delivery can help you better manage the medication you take on a
regular basis, and may save you time and money.
Once the program starts, you have a limited number of fills at your retail pharmacy. If you do not
confirm your home delivery enrollment, you may pay more for your medication until you do. You can also
choose to disenroll from the program to continue filling at your retail pharmacy for your standard copay or
cost share.
In certain documents, the Prescription Drug List (PDL) was referred to as the Preferred Drug List (PDL). This change in terms does not affect your 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 coverage for these medications.
7
Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Ofloxacin Tablet 1
Anti-Infectives: Antibiotics
Oracea 3
Amoxicillin Capsule, Penicillin V Potassium
1 1
Chewable Tablet Tablet
Amoxicillin/Potassium Sulfamethoxazole-
1
Clavulanate Chewable 1 Trimethoprim Tablet
Tablet, Tablet Suprax Capsule,
Azithromycin Tablet 1 Chewable Tablet, 3
Cefadroxil Capsule, Tablet
1
Tablet
Anti-Infectives: Antifungals
Cefdinir Capsule 1
Cefixime Suspension 3 Cresemba 3 SL
Cefprozil Tablet 1 Econazole Cream 3 SL
Cefuroxime Tablet 1 Fluconazole Tablet 1
Cephalexin Capsule 1 Itraconazole Capsule 1 SL
Ciprodex 3 Ketoconazole Cream 1
Ciprofloxacin Tablet 1 Noxafil Tablet,
2
Clarithromycin Tablet 1 Suspension
Clindamycin Capsule 1 Nystatin Cream,
1
Dificid 3 SL Ointment
Doxycycline Hyclate Terbinafine Tablet 1 SL
50, 100 mg Capsule, 2
Anti-Infectives: Antivirals
Tablet
Doxycycline Monohydrate Acyclovir Ointment 3 PA, SL, ST
1
50, 100 mg Capsule Acyclovir Tablet 1
Levofloxacin Tablet 1 Famciclovir Tablet 2
Metronidazole Tablet 1 Oseltamivir Capsule 2 SL
Minocycline Capsule 1 Valacyclovir Tablet 1 SL
Minocycline Tablet 3 E Valganciclovir 1 SL
Moxifloxacin Tablet 3 Zovirax Cream 3 E, SL
Nitrofurantoin Capsule 1
Nitrofurantoin
1
Macrocrystal Capsule
Ofloxacin Otic Solution 2
9
Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Nadolol 1 Fluvastatin Extended-
3 SL, ST
Nifedipine Release Tablet
1
Extended-Release Gemfibrozil 1
Olmesartan 2 SL Lipofen 3 E
Olmesartan- Livalo 3 SL, ST
2 SL
Hydrochlorothiazide Lovastatin 1
Propranolol Extended- Niacin Extended-
2 3
Release Capsule Release Tablet
Propranolol Tablet 1 Niaspan 2
Quinapril 1 Omega-3-Acid Ethyl
3 PA
Ramipril 1 Esters Capsule
Spironolactone 1 Praluent 2 DSP, PA, SL, ST
Telmisartan 2 Pravastatin 1
Telmisartan- Repatha 140 mg 3 DSP, PA, SL, ST
2
Hydrochlorothiazide Rosuvastatin 2 SL
Terazosin 1 Simvastatin 1
Triamterene- Vascepa 3 PA
1
Hydrochlorothiazide Vytorin 3 SL
Valsartan 2 Welchol 2
Valsartan- Zetia 3 E, SL
1
Hydrochlorothiazide
Cardiovascular/Heart Disease: Other
Verapamil 1
Verapamil Amiodarone 1
3
Sustained-Release Corlanor 3 PA, SL
Cardiovascular/Heart Disease: Digoxin 1
High Cholesterol Entresto 3 PA, SL
Atorvastatin 1 SL Flecainide 1
Choline Fenofibrate 3 E Isosorbide
Ezetimibe Tablet 3 SL 1
Mononitrate ER
Fenofibrate 43, 50, 67, Multaq 3 PA
130, 134, 150, 200 mg 3 E Nitroglycerin Sublingual
Capsule 1
Tablet
Fenofibrate 40, 48, 120, Ranexa 2
3 E
145 mg Tablet Sotalol 1
Fenofibrate
2
54, 160 mg Tablet
11
Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Sumatriptan Naloxone Vials 1
Succinate Tablet, 1 SL Narcan Nasal Spray 2 SL
Injection Olanzapine Tablet 1 SL
Central Nervous System: Pramipexole Tablet 1
Multiple Sclerosis Quetiapine Extended-
3 SL
Ampyra 2 DSP, PA, SL Release Tablet
Aubagio 3 DSP, PA, SL Quetiapine Tablet 1
Avonex 2 DSP, PA, SL Risperidone Tablet 1
Betaseron 2 DSP, PA, SL Ropinirole Tablet 1
Copaxone 2 DSP, PA, SL Suboxone Film 3 E, PA, SL
Gilenya 3 DSP, PA, SL Tolcapone 2
DSP, E, PA, Xyrem 3 PA, SL
Glatopa 3
SL, ST Zelapar 3
Plegridy 3 DSP, PA, SL Ziprasidone Capsule 2 SL
Rebif 3 DSP, PA, SL, ST Zubsolv 2 SL
Tecfidera 2 DSP, PA, SL Central Nervous System:
Zinbryta 3 DSP, PA, SL Sedatives/Hypnotics
Eszopiclone Tablet 2 SL
Central Nervous System: Other
Temazepam Capsule 1
Alprazolam Extended- Triazolam Tablet 1
1
Release Tablet Zaleplon Capsule 1 SL
Alprazolam Tablet 1 Zolpidem Extended-
3 E, SL
Aripiprazole Tablet 2 SL Release Tablet
Armodafanil 3 E, PA, SL Zolpidem Tablet 1 SL
Buprenorphine/ Central Nervous System:
3 E, PA, SL
Naloxone Tablet Seizure Disorders
Buspirone Tablet 1 Carbamazepine
Carbidopa-Levodopa 1 Extended-Release 2
Diazepam Tablet 1 Capsule
Donepezil 5, 10 mg Carbamazepine
1
ODT, Tablet Extended-Release 3
Latuda 3 SL Tablet
Lithium Capsule 1 Carbamazepine
Lorazepam Tablet 1 Immediate-Release 1
Memantine Tablet 2 Tablet
Modafinil Tablet 3 PA, SL Clonazepam Tablet 1
13
Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Mirvaso 3 SL OneTouch Ultra Mini 1
Mometasone Furoate OneTouch Ultra
1 1 SL
Cream, Lotion, Ointment Test Strips
Mupirocin Ointment 1 SL OneTouch Verio 1
Nystatin-Triamcinolone OneTouch Verio Flex 1
Acetonide Cream, 3 E OneTouch Verio IQ 1
Ointment OneTouch Verio Sync 1
Oxsoralen-Ultra 2 OneTouch Verio
1 SL
Picato 3 SL Test Strips
Regranex 2 PA, SL
Diabetes: Insulin
Solodyn 3 E, PA
Taclonex Suspension 3 SL Afrezza 3 E, PA, SL, ST
Tacrolimus Ointment 2 PA, SL Basaglar 1 SL
Tazorac 3 PA, SL Humalog KwikPens
2 SL
Tretinoin Cream 3 PA, SL (all formulations)
Tretinoin Gel 3 E, PA, SL Humalog Vials
1 SL
Tretinoin Microspheres 3 E, PA, SL (all formulations)
Triamcinolone Acetonide Humulin KwikPens
1 2 SL
Cream, Lotion, Ointment (all formulations)
Vectical 3 SL Humulin Vials
1 SL
(all formulations)
Diabetes: Blood Glucose Monitoring
Lantus Solostar 3 E, SL
Accu-Chek Lantus Vials 3 E, SL
3 E, SL
Test Strips Levemir FlexTouch 2 SL
Contour Test Strips 3 E, SL Levemir Vials 2 SL
Dexcom Continuous Novolin Vials
3 SL, ST
Glucose Monitoring 3 PA, SL (all formulations)
System Novolog FlexTouch
3 SL, ST
Dexcom Sensor 3 PA, SL (all formulations)
Dexcom Transmitter 3 PA, SL Novolog Vials
3 SL, ST
FreeStyle Test Strips 3 E, SL (all formulations)
OneTouch Soliqua 2 PA, SL
1 SL
Test Strips Toujeo SoloStar 3 E, SL
OneTouch Ultra Tresiba FlexTouch 3 E, SL
1
Meter
15
Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Tobramycin Ophthalmic
1 Gastrointestinal: Nausea/Vomiting
Solution
Vigamox 3 Akynzeo 3 SL
Aprepitant Capsule 2 SL
Eye Conditions: Dry Eye Disease
Emend Suspension 2 SL
Restasis Single Use Ondansetron 1
3 PA, SL
Vials Ondansetron ODT 1
Xiidra 3 PA, SL Transderm-Scop 3
Varubi 2 SL
Eye Conditions: Glaucoma
Gastrointestinal: Other
Alphagan P 0.1% 2 SL
Azopt 2 SL Amitiza 3 PA, SL, ST
Combigan 2 SL Apriso 2
Latanoprost 0.005% Asacol HD Tablet 3 E
1
Ophthalmic Solution Canasa 2
Lumigan 2 SL Cortifoam 2
Timolol Maleate 0.25%, Creon 2
0.5% Ophthalmic 1 Delzicol 3 E
Solution Diphenoxylate-Atropine
Travatan Z 2 SL 1
Tablet
Gastrointestinal: Acid Suppression Golytely 2
Hyoscyamine Tablet 1
Dexilant 3 SL Lialda 2
Esomeprazole Capsule 3 E, SL Linzess 2 PA, SL
Lansoprazole Capsule 3 E, SL Metoclopramide Tablet 1
Omeclamox-Pak 3 SL Movantik 2 PA, SL
Omeprazole Capsule 1 Moviprep 3
Pantoprazole Tablet 1 Polyethylene
Pylera 3 SL 2
Glycol 3350
Ranitadine Syrup 1 Prepopik 3
Rabeprazole Tablet 3 SL Suclear 3
Sucralfate Tablet 1 Sulfasalazine Tablet 1
Suprep 3
Uceris Foam 2
Uceris Tablet 3
Viberzi 3 PA, SL
Zenpep 2
17
Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Bethkis 2 DSP, PA, SL
Mens Health: Erectile Dysfunction
Bromfed DM 3
Cialis 3 SL Cayston 2 PA, SL
Levitra 3 SL Cerdelga 2 DSP, PA
Stendra 3 PA, SL Chlorhexidine Gluconate 1
Viagra 3 SL Chlorpheniramine/
Hydrocodone/
Mens Health: Prostate 2 SL
Pseudoephedrine
Alfuzosin Tablet 1 Solution
Cialis 3 SL, ST Epinephrine (generic
2 SL
Doxazosin Tablet 1 EpiPen/EpiPen-Jr.)
Dutasteride Capsule 3 PA EpiPen/EpiPen-Jr. 3 E, SL
Finasteride Tablet 1 Fosrenol 3
Rapaflo 3 Hydrocodone/
Tamsulosin Capsule 1 Chlorpheniramine 3 SL
Terazosin Capsule, Tablet 1 Suspension
Hydrocodone/
Mens Health: Testosterone Therapy 1
Homatropine
Androderm 2 PA, SL Letrozole Tablet 1
Androgel 3 E, PA, SL Lidocaine Transdermal
3 PA, SL
Patch
Methyltestosterone
2 Nuedexta 2
Capsule
Testim 2 PA, SL Obredon 3 SL, ST
Testosterone 1% Pegasys 2 DSP, PA, SL
3 E, PA, SL Phenazopyridine 1
Topical Gel
Testosterone Cypionate Procrit 2 DSP, SL
1 Promethazine/Codeine 1
Injection
Promethazine/
Miscellaneous 1
Dextromethorphan
Anastrozole Tablet 1 Pulmozyme 2 DSP, PA, SL
Antipyrine/Benzocaine Rectiv 3 SL
1 Renvela 2
Otic Solution
Aranesp 2 DSP, SL Rezira 3
Auryxia 3 Tobi Podhaler 3 DSP, PA, SL
Auvi-Q 3 E, SL Tobramycin Nebulized
3 DSP, E, PA, SL
Benzonatate Capsule 1 Solution
19
Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Alvesco 1 SL
Overactive Bladder
Anoro Ellipta 3 SL
Dicyclomine Tablet 1 Arnuity Ellipta 3 SL
Oxybutynin Extended- Asmanex 1 SL
2
Release Tablet Bevespi Aerosphere 2 SL
Oxybutynin Tablet 1 Breo Ellipta 3 RS, SL
Tolterodine Extended- Budesonide Nebs 2 SL
3 E
Release Tablet Combivent Respimat 3 SL
Tolterodine Tablet 3 E Dulera 3 SL, ST
Toviaz 3 Flovent Diskus/HFA 3 SL
Vesicare 3 E Incruse Ellipta 2 SL
Ipratropium-Albuterol
Respiratory: Allergies 1
Nebs
Azelastine 0.1% Ipratropium Nebs 1
3
Nasal Spray Levalbuterol Nebs 3 E, SL
Clarinex 3 E Montelukast Chewable
1
Clarinex-D 3 E Tablet, Tablet
Cyproheptadine Tablet 1 Montelukast Granules 2
Fluticasone Nasal Spray 2 SL Perforomist 3 SL
Hydroxyzine Capsule, ProAir HFA 3 SL
1
Tablet ProAir RespiClick 3 SL
Levocetirizine Tablet 1 Proventil HFA 3 SL
Mometasone Pulmicort Flexhaler 3 SL, ST
3 E, SL
Nasal Spray QVAR 1 SL
Promethazine Tablet 1 Serevent Diskus 3 SL
Triamcinolone Spiriva Handihaler 3 SL
3 E, SL
Nasal Spray Spiriva Respimat 3 SL
Zetonna 3 SL Stiolto Respimat 3 E, SL
Respiratory: Asthma/COPD Striverdi Respimat 2 SL
Symbicort 3 RS, SL
Advair Diskus/HFA 3 RS, SL Tudorza 2 SL
Aerospan 3 SL Ventolin HFA 2 SL
Albuterol Nebs 1 Xopenex HFA 3 SL
Albuterol Sulfate Tablet 1 Xopenex Nebs 3 E, SL
21
Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Enskyce 1 H Lyza 1 H
Errin 1 H Marlissa 1 H
Estarylla 1 H Medroxyprogesterone
1 H
Fallback 1 H Acetate
Falmina 1 H Microgestin 2
Gildess 2 Microgestin Fe 1 H
Gildess Fe 1 H Minastrin 24 Fe 3 E
Heather 1 H Mono-Linyah 1 H
Introvale 2 H MonoNessa 1 H
Jencycla 1 H My Way 1 H
Jolessa 2 H Myzilra 1 H
Jolivette 1 H Natazia 2
Juleber 1 H Necon 7/7/7, 0.5/35,
1 H
Junel 2 1/35, 1/50, 10/11
Junel Fe 1 H Next Choice 1 H
Kurvelo 1 H Nora BE 1 H
Kelnor 1/35 1 H Norethindrone 0.35 mg 1 H
Larin Fe 1 H Norethindrone-Ethinyl
Larissia 1 H Estradiol-Ferrous 1 H
Leena 1 H Fumarate
Lessina 1 H Norgestimate-Ethinyl
Levonest 1 H Estradiol (generic
1 H
Levonorgestrel 1.5 mg 1 H Ortho-Cyclen, Ortho
Levonorgestrel-Ethinyl Tri-Cyclen)
Estradiol (generic Norgestimate-Ethinyl
1 H Estradiol Lo (generic 3
Alesse, Nordette,
Triphasil) Ortho Tri-Cyclen Lo)
Levonorgestrel-Ethinyl Norlyroc 1 H
Estradiol (generic 2 H Nortrel 7/7/7, 0.5/35,
1 H
Seasonale) 1/35
Levora-28 1 H Nuvaring 2 H
Lo Loestrin Fe 3 Opcicon 1 H
Loryna 3 Orsythia 1 H
Low-Ogestrel 1 H Ortho Tri-Cyclen Lo 3 E
Lutera 1 H Pirmella 7/7/7, 1/35 1 H
23
Index
A Amitiza.................................. 16 Azathioprine Tablet................21
Abacavir-Lamivudine............. 17 Amitriptyline Tablet............... 11 Azelastine 0.05% Ophthalmic
Accu-Chek Test Strips........... 14 Amlodipine..............................9 Solution...............................15
Acetaminophen/Butalbital/ Amlodipine-Benazepril............9 Azelastine 0.1%
Caffeine 325 mg/50 mg/ Amlodipine-Valsartan..............9 Nasal Spray..........................20
40 mg.................................. 11 Amoxicillin Capsule, Azithromycin Tablet.................8
Chewable Tablet....................8 Azopt...................................... 16
Acetaminophen/
Amoxicillin/Potassium Azurette.................................21
Codeine Tablet.................... 19
Actemra.................................. 17 Clavulanate Chewable B
Acyclovir Ointment..................8 Tablet, Tablet........................8
Baclofen Tablet....................... 19
Acyclovir Tablet.......................8 Amphetamine Salt Combo..... 11
Basaglar.................................. 14
Aczone....................................13 Ampyra..................................12
Belbuca................................... 19
Adapalene 0.1% Cream, Gel, Anastrozole Tablet.................18
Benazepril................................9
Lotion..................................13 Androderm.............................18
Benazepril-
Adapalene 0.3% Gel...............13 Androgel................................18
Hydrochlorothiazide..............9
Adcirca...................................21 Anoro Ellipta.........................20
Benicar.....................................9
Adderall XR........................... 11 Antipyrine/Benzocaine
Benicar HCT...........................9
Addyi......................................23 Otic Solution.......................18
Benzonatate Capsule.............. 18
Adempas.................................21 Aprepitant Capsule................. 16
Betamethasone Dipropionate
Adlyxin...................................15 Apri........................................21 0.05% Augmented Lotion,
Advair Diskus/HFA...............20 Apriso..................................... 16 Ointment.............................13
Aerospan................................20 Aranelle..................................21 Betamethasone Dipropionate
Afrezza................................... 14 Aranesp..................................18 0.05% Cream, Ointment.....13
Aftera.....................................21 Aripiprazole Tablet.................12 Betaseron................................12
Akynzeo................................. 16 Armodafanil...........................12 Bethkis...................................18
Albuterol Nebs.......................20 Armour Thyroid.....................15 Bevespi Aerosphere................20
Albuterol Sulfate Tablet..........20 Arnuity Ellipta.......................20 Bexarotene Capsule..................9
Alendronate Sodium Tablet... 19 Asacol HD Tablet.................. 16 Bicalutamide.............................9
Alesse.....................................22 Asmanex.................................20 Bidil..........................................9
Alfuzosin Tablet.....................18 Atenolol....................................9 Bisoprolol..................................9
Allopurinol Tablet.................. 17 Atenolol-Chlorthalidone..........9 Bisoprolol-
Alphagan P 0.1%.................... 16 Atorvastatin............................10 Hydrochlorothiazide..............9
Alprazolam Extended-Release Atripla.................................... 17 Blisovi Fe................................21
Tablet...................................12 Aubagio..................................12 Bosulif......................................9
Alprazolam Tablet..................12 Aubra......................................21 Brand Prenatal Vitamins........23
Altavera..................................21 Auryxia...................................18 Breo Ellipta............................20
Alvesco...................................20 Auvi-Q...................................18 Brilinta.....................................9
Alyacen 7/7/7, 1/35.................21 Aviane....................................21 Bromfed DM..........................18
Amiodarone............................10 Avonex....................................12 Budesonide Nebs....................20
24
Buprenorphine/ Cesia.......................................21 Clotrimazole-Betamethasone
Naloxone Tablet...................12 Cetrotide................................ 17 Cream..................................13
Bupropion Extended-Release Chantix Tablet........................21 Clotrimazole-Betamethasone
Tablet................................... 11 Chateal...................................21 Lotion..................................13
Bupropion Sustained-Release Chlorhexidine Gluconate........18 Colcrys................................... 17
Tablet............................. 11, 21 Chlorpheniramine/ Combigan............................... 16
Bupropion Tablet.................... 11 Hydrocodone/ Combivent Respimat..............20
Buspirone Tablet.....................12 Pseudoephedrine Solution... 18 Complera................................ 17
Butrans................................... 19 Chlorthalidone.........................9 Concerta................................. 11
Bydureon................................15 Choline Fenofibrate................10 Contour Test Strips................ 14
Byetta.....................................15 Cialis......................................18 Copaxone...............................12
Bystolic.....................................9 Ciclopirox Cream, Gel, Corlanor.................................10
C Lotion, Solution..................13 Cortifoam............................... 16
Cimzia.................................... 17 Cosentyx................................ 17
Calcipotriene/Betamethasone
Ciprodex...................................8 Creon...................................... 16
Ointment.............................13
Ciprofloxacin Tablet.................8 Cresemba..................................8
Calcitriol Capsule...................15
Citalopram Tablet................... 11 Cryselle...................................21
Camila....................................21
Claravis...................................13 Cyclafem 7/7/7, 1/35..............21
Canasa.................................... 16
Clarinex..................................20 Cyclobenzaprine..................... 19
Carac......................................13
Clarinex-D.............................20 Cyclophosphamide Capsule......9
Carbamazepine Extended-
Release Capsule...................12 Clarithromycin Tablet..............8 Cyclosporine Modified
Carbamazepine Extended- Climara..................................23 Capsule................................21
Release Tablet......................12 Climara Pro............................23 Cyproheptadine Tablet...........20
Carbamazepine Immediate- Clindamycin 1%/Benzoyl Cyred......................................21
Release Tablet......................12 Peroxide 5% Gel..................13
Clindamycin 1.2%/Benzoyl
D
Carbidopa-Levodopa..............12
Carisoprodol 350 mg Tablet... 19 Peroxide 5% Gel..................13 Daklinza................................. 17
Cartia XT.................................9 Clindamycin Capsule...............8 Dasetta 7/7/7, 1/35.................21
Carvedilol.................................9 Clindamycin Gel....................13 Daytrana................................. 11
Cayston...................................18 Clindamycin Lotion...............13 Deblitane................................21
Caziant...................................21 Clindamycin Solution, Delyla.....................................21
Cefadroxil Capsule, Tablet.......8 Swabs...................................13 Delzicol.................................. 16
Cefdinir Capsule......................8 Clobetasol Propionate Descovy.................................. 17
Cefixime Suspension................8 Cream, Ointment................13 Desmopressin Tablet..............15
Cefprozil Tablet........................8 Clobetasol Propionate Desogestrel-Ethinyl
Cefuroxime Tablet....................8 Solution...............................13 Estradiol..............................21
Celecoxib................................ 19 Clomiphene............................ 17 Desonide 0.05% Cream,
Cenestin.................................23 Clonazepam Tablet.................12 Lotion, Ointment................13
Cephalexin Capsule..................8 Clonidine Tablet.......................9 Desoximetasone Gel,
Cerdelga.................................18 Clopidogrel...............................9 Ointment.............................13
25
Desvenlafaxine Extended- Divigel....................................23 Epinephrine............................18
Release Tablet...................... 11 Donepezil 5, 10 mg ODT, EpiPen/EpiPen-Jr...................18
Dexamethasone Tablet...........15 Tablet...................................12 Epzicom................................. 17
Dexcom Continuous Glucose Doxazosin........................... 9, 18 Errin.......................................22
Monitoring System.............. 14 Doxazosin Tablet....................18 Erythromycin 0.5%
Dexcom Sensor....................... 14 Doxepin.................................. 11 Ophthalmic Ointment.........15
Dexcom Transmitter.............. 14 Doxycycline Hyclate Escitalopram Tablet................ 11
Dexilant.................................. 16 50, 100 mg Capsule, Tablet...8 Esomeprazole Capsule............ 16
Dexmethylphenidate Doxycycline Monohydrate Estarylla.................................22
Extended-Release Capsule.. 11 50, 100 mg Capsule...............8 Estrace Cream........................23
Dexmethylphenidate Drospirenone-Ethinyl Estradiol Tablet......................23
Immediate-Release Estradiol-Levomefolate Estradiol Twice-Weekly
Tablet................................... 11 Calcium...............................21 Transdermal Patch...............23
Dextroamphetamine Sulfate Duavee....................................23 Estradiol/Norethindrone
Immediate-Release Tablet... 11 Dulera.....................................20 Acetate Tablet......................23
Dextroamphetamine- Duloxetine Capsule................ 11 Estring....................................23
Amphetamine Dutasteride Capsule...............18 Estrogen/Methyltestosterone
Extended-Release................ 11 Dutoprol...................................9 Tablet...................................23
Dextroamphetamine- Eszopiclone Tablet..................12
E
Amphetamine Immediate- Etodolac Capsule.................... 19
Release Capsule................... 11 Econazole Cream.....................8 Evamist...................................23
Diazepam Tablet..............12, 13 Econtra EZ............................21 Evotaz..................................... 17
Diclofenac Tablet.................... 19 Edarbi.......................................9 Ezetimibe Tablet.................... 10
Dicyclomine Tablet................20 Edarbyclor................................9
Effient......................................9 F
Differin 0.1% Cream, Gel,
Lotion..................................13 Elinest....................................21 Fallback..................................22
Dificid......................................8 Eliquis......................................9 Falmina..................................22
Diflorasone Diacetate 0.05% Ella.........................................21 Famciclovir Tablet....................8
Cream, Ointment................13 Embeda.................................. 19 Farxiga....................................15
Digoxin..................................10 Emend Suspension................. 16 Fenofibrate 40, 48, 120,
Diltiazem 24 Hour CD............9 Emoquette..............................21 145 mg Tablet......................10
Diltiazem Sustained-Release Enalapril...................................9 Fenofibrate 43, 50 , 67, 130,
Capsule..................................9 Enbrel..................................... 17 134, 150, 200 mg Capsule... 10
Diltiazem Sustained-Release Enjuvia...................................23 Fenofibrate 54, 160 mg
Tablet.....................................9 Enoxaparin Sodium..................9 Tablet...................................10
Diphenoxylate-Atropine Enpresse.................................21 Fentanyl 12, 25, 50,
Tablet................................... 16 Enskyce..................................22 75, 100 mcg Patch............... 19
Divalproex Delayed-Release Enstilar Foam.........................13 Fentanyl 37.5, 62.5, 87.5 mcg
Tablet...................................13 Entresto..................................10 Patch.................................... 19
Divalproex Extended-Release Epclusa................................... 17 Fentanyl Citrate Lozenge....... 19
Tablet...................................13 Epiduo/Epiduo Forte..............13 Fetzima................................... 11
26
Finacea...................................13 Gonal-F RFF......................... 17 Intelence................................. 17
Finasteride Tablet...................18 Guanfacine......................... 9, 11 Introvale.................................22
Flecainide...............................10 Guanfacine Invokamet...............................15
Flovent Diskus/HFA..............20 Extended-Release................ 11 Invokamet XR........................15
Fluconazole Tablet....................8 Invokana.................................15
H
Fluocinolone Cream, Oil, Ipratropium Nebs...................20
Halobetasol Ointment............13 Ipratropium-Albuterol Nebs...20
Solution...............................13
Harvoni.................................. 17 Irbesartan.................................9
Fluocinolone Ointment..........13
Heather...................................22 Isentress.................................. 17
Fluocinonide 0.05% Cream....13
Humalog KwikPens............... 14 Isosorbide Mononitrate ER....10
Fluoride..................................21
Humalog Vials....................... 14 Itraconazole Capsule.................8
Fluoxetine Tablet, Capsule..... 11
Humira................................... 17
Fluticasone Nasal Spray..........20 J
Humulin KwikPens................ 14
Fluvastatin Extended-Release
Humulin Vials........................ 14 Janumet..................................15
Tablet...................................10
Hydralazine..............................9 Januvia....................................15
Fluvoxamine Tablet................ 11
Hydrochlorothiazide.................9 Jardiance.................................15
Focalin XR............................. 11
Hydrocodone/Acetaminophen Jencycla...................................22
Folic Acid...............................21
5/325, 7.5/325, 10/325 mg Jentadueto...............................15
Forteo..................................... 19
Tablet................................... 19 Jentadueto XR........................15
Fosrenol..................................18
Hydrocodone/ Jolessa.....................................22
FreeStyle Test Strips............... 14
Chlorpheniramine Jolivette...................................22
Frovatriptan............................ 11 Suspension...........................18 Juleber.....................................22
Furosemide...............................9 Hydrocodone/Homatropine...18 Junel........................................22
G Hydrocodone/ Junel Fe...................................22
Ibuprofen Tablet.................. 19
Gabapentin Capsule, Tablet...13 K
Hydrocortisone 2.5% Cream,
Gemfibrozil............................10
Ointment.............................13 Kaletra Tablet......................... 17
Gentamicin Ophthalmic
Hydromorphone Tablet.......... 19 Kazano...................................15
Ointment, Solution..............15
Hydroxychloroquine Sulfate... 17 Kelnor 1/35.............................22
Genvoya.................................. 17
Hydroxyurea Capsule...............9 Ketoconazole Cream................8
Gildess....................................22
Hydroxyzine Capsule, Tablet.20 Ketorolac Tablet...................... 19
Gildess Fe...............................22
Hyoscyamine Tablet............... 16 Klor-Con M10.......................21
Gilenya...................................12
Hysingla................................. 19 Klor-Con M20.......................21
Glatopa...................................12
Kombiglyze XR......................15
Glimepiride............................15 I
Kurvelo...................................22
Glipizide.................................15 Ibandronate Tablet................. 19
Glipizide Extended-Release...15 Ibuprofen Tablet..................... 19 L
Glucophage XR......................15 Imatinib Tablet.........................9 Labetalol...................................9
Glyburide...............................15 Imbruvica.................................9 Lamivudine-Zidovudine........ 17
Glyxambi................................15 Imiquimod 5% Cream............13 Lamotrigine
Golytely.................................. 16 Incruse Ellipta........................20 Immediate-Release Tablet...13
Gonal-F.................................. 17 Indomethacin Capsule............ 19 Lansoprazole Capsule............. 16
27
Lantus Solostar....................... 14 Lisinopril- Methylphenidate Extended-
Lantus Vials........................... 14 Hydrochlorothiazide..............9 Release Capsule................... 11
Larin Fe..................................22 Lithium Capsule.....................12 Methylphenidate Extended-
Larissia...................................22 Livalo.....................................10 Release Tablet...................... 11
Lastacaft.................................15 Lo Loestrin Fe.......................22 Methylphenidate Tablet.......... 11
Latanoprost 0.005% Lopinavir-Ritonavir Methylprednisolone Tablet.....15
Ophthalmic Solution........... 16 Oral Solution....................... 17 Methyltestosterone Capsule....18
Latuda....................................12 Lorazepam Tablet...................12 Metoclopramide Tablet.......... 16
Lazanda.................................. 19 Loryna....................................22 Metoprolol Succinate
Leena......................................22 Losartan...................................9 50, 100, 200 mg.....................9
Leflunomide........................... 17 Losartan- Metoprolol Tartrate
Lessina....................................22 Hydrochlorothiazide..............9 25, 50, 100 mg.......................9
Letairis...................................21 Lovastatin...............................10 Metronidazole 0.75%
Letrozole Tablet.....................18 Low-Ogestrel.........................22 Topical Gel..........................13
Lumigan................................. 16 Metronidazole Tablet...............8
Leucovorin Calcium Tablet......9
Lutera.....................................22 Microgestin............................22
Levalbuterol Nebs...................20
Lyrica.....................................13 Microgestin Fe.......................22
Levemir FlexTouch................ 14
Lyza........................................22 Minastrin 24 Fe......................22
Levemir Vials......................... 14
Minivelle................................23
Levetiracetam M
Minocycline Capsule................8
Extended-Release Tablet.....13
Marlissa..................................22 Minocycline
Levetiracetam Immediate- Medroxyprogesterone.......22, 23 Extended-Release Capsule..13
Release Tablet......................13 Medroxyprogesterone Minocycline Tablet...................8
Levitra....................................18 Acetate.................................22 Mirtazapine Tablet................. 11
Levocetirizine Tablet..............20 Meloxicam Tablet................... 19 Mirvaso.................................. 14
Levofloxacin Tablet..................8 Memantine Tablet..................12 Mitigare.................................. 17
Levonest.................................22 Mercaptopurine Tablet.............9 Modafinil Tablet.....................12
Levonorgestrel 1.5 mg............22 Metadate CD......................... 11 Mometasone Furoate Cream,
Levonorgestrel-Ethinyl Metadate ER.......................... 11 Lotion, Ointment................ 14
Estradiol..............................22 Metaxalone Tablet.................. 19 Mometasone Nasal Spray.......20
Levora-28...............................22 Metformin..............................15 Mono-Linyah.........................22
Levothyroxine Sodium Metformin Extended-Release MonoNessa.............................22
Tablet...................................15 Tablet...................................15 Montelukast Chewable Tablet,
Lialda..................................... 16 Methadone Tablet, Tablet...................................20
Lidocaine Transdermal Oral Solution, Concentrate Montelukast Granules............20
Patch....................................18 Solution............................... 19 Morphine Sulfate
Linzess................................... 16 Methimazole Tablet...............15 Extended-Release Tablet..... 19
Liothyronine Sodium Methocarbamol Tablet........... 19 Morphine Sulfate
Tablet...................................15 Methotrexate Tablet............... 17 Oral Solution....................... 19
Lipofen...................................10 Methylphenidate Chewable Movantik................................ 16
Lisinopril............................ 9, 32 Tablet................................... 11 Moviprep................................ 16
28
Moxeza...................................15 Nitrofurantoin Macrocrystal Olmesartan.............................10
Moxifloxacin Tablet..................8 Capsule..................................8 Olmesartan-
Multaq....................................10 Nitroglycerin Sublingual Hydrochlorothiazide............10
Mupirocin Ointment.............. 14 Tablet...................................10 Olopatadine 0.1%
My Way..................................22 Nora BE.................................22 Ophthalmic Solution...........15
Mycophenolate Capsule, Nordette.................................22 Omeclamox-Pak..................... 16
Suspension...........................21 Norethindrone 0.35 mg..........22 Omega-3-Acid Ethyl Esters
Mycophenolic Acid Tablet......21 Norethindrone-Ethinyl Capsule................................ 10
Myzilra...................................22 Estradiol-Ferrous Omeprazole Capsule.............. 16
Fumarate.............................22 Ondansetron........................... 16
N Norgestimate-Ethinyl Ondansetron ODT................. 16
Nabumetone Tablet................ 19 Estradiol..............................22 OneTouch Test Strips............. 14
Nadolol...................................10 Norgestimate-Ethinyl OneTouch Ultra Meter........... 14
Naloxone Vials.......................12 Estradiol Lo........................22 OneTouch Ultra Mini............ 14
Naproxen Tablet..................... 19 Norlyroc..................................22 OneTouch Ultra Test Strips.... 14
Naratriptan............................. 11 Nortrel 7/7/7, 0.5/35, 1/35......22 OneTouch Verio..................... 14
Narcan Nasal Spray................12 Nortriptyline Capsule............. 11 OneTouch Verio Flex.............. 14
Natazia...................................22 Norvir..................................... 17 OneTouch Verio IQ................ 14
Necon 7/7/7, 0.5/35, 1/35, Novolin Vials.......................... 14 OneTouch Verio Sync............. 14
1/50, 10/11...........................22 Novolog FlexTouch................ 14 OneTouch Verio Test Strips.... 14
Nesina.....................................15 Novolog Vials......................... 14
Onglyza..................................15
Nevirapine.............................. 17 Noxafil Tablet, Suspension.......8
Opana ER.............................. 19
Nevirapine NP Thyroid Tablet.................15
Opcicon..................................22
Extended-Release................ 17 Nucynta.................................. 19
Opsumit.................................21
Next Choice...........................22 Nucynta ER............................ 19
Oracea......................................8
Niacin Extended-Release Nuedexta................................18
Orencia................................... 17
Nutropin, Nutropin AQ.........15
Tablet...................................10 Orenitram...............................21
Nuvaring................................22
Niaspan.................................. 10 Orsythia.................................22
Nystatin Cream, Ointment......8
Nicoderm CQ........................21 Ortho Tri-Cyclen...................22
Nystatin-Triamcinolone
Nicorette Gum.......................21 Ortho Tri-Cyclen Lo.............22
Acetonide Cream,
Nicorette Lozenge..................21 Ortho-Cept............................21
Ointment............................. 14
Nicorette Mini-Lozenge........21 Ortho-Cyclen.........................22
Nicotine Gum........................21 O Oseltamivir Capsule.................8
Nicotine Lozenge...................21 Obredon.................................18 Oseni......................................15
Nicotine Patch........................21 Odefsey................................... 17 Osphena.................................23
Nicotrol Inhaler......................21 Ofloxacin 0.3% Ophthalmic Otezla..................................... 17
Nicotrol Nasal Spray...............21 Solution...............................15 Otrexup.................................. 17
Nifedipine Ofloxacin Otic Solution............8 Ovidrel................................... 17
Extended-Release................10 Ofloxacin Tablet.......................8 Oxcarbazepine Tablet.............13
Nitrofurantoin Capsule.............8 Olanzapine Tablet..................12 Oxsoralen-Ultra...................... 14
29
Oxybutynin Extended-Release Pristiq..................................... 11 Relpax..................................... 11
Tablet...................................20 ProAir HFA...........................20 Renvela................................... 18
Oxybutynin Tablet.................20 ProAir RespiClick..................20 Repatha 140 mg..................... 10
Oxycodone Tablet................... 19 Procrit.....................................18 Restasis Single Use Vials........ 16
Oxycodone/Acetaminophen Progesterone Micronized Revlimid...................................9
5/325, 7.5/325, 10/325 mg Capsule................................23 Reyataz................................... 17
Tablet................................... 19 Promethazine Tablet...............20 Rezira.....................................18
Oxycontin............................... 19 Promethazine/Codeine...........18 Ribavirin Tablet...................... 17
Promethazine/ Risedronate Sodium Tablet.... 19
P
Dextromethorphan..............18 Risperidone Tablet..................12
Pantoprazole Tablet................ 16 Propranolol Extended-Release Ritalin LA.............................. 11
Paroxetine Tablet.................... 11 Capsule................................10 Rizatriptan ODT, Tablet........ 11
Pataday...................................15 Propranolol Tablet..................10 Ropinirole Tablet....................12
Pegasys...................................18 Proventil HFA........................20 Rosuvastatin...........................10
Penicillin V Potassium Tablet...8 Prozac..................................... 11
Perforomist.............................20 Pulmicort Flexhaler................20 S
Phenazopyridine.....................18 Pulmozyme............................ 18 Savaysa.....................................9
Phenytoin Capsule, Pylera...................................... 16 Seasonale................................22
Suspension...........................13 Selzentry................................. 17
Q
Picato...................................... 14 Serevent Diskus......................20
Pioglitazone............................15 Quasense................................23 Sertraline Tablet..................... 11
Quetiapine Extended-Release
Pirmella 7/7/7, 1/35................22 Setlakin..................................23
Tablet...................................12
Plan B One Step.....................23 Sharobel..................................23
Quetiapine Tablet...................12
Plegridy..................................12 Sildenafil Tablet......................21
Quinapril................................10
Polyethylene Glycol 3350........ 16 Simponi.................................. 17
QVAR....................................20
Portia......................................23 Simvastatin.............................10
Potassium Chloride................21 R Sirolimus Tablet......................21
Potassium Citrate...................21 Rabeprazole Tablet................. 16 Solia........................................23
Pradaxa.....................................9 Rajani.....................................23 Soliqua.................................... 14
Praluent..................................10 Raloxifene......................... 19, 23 Solodyn................................... 14
Pramipexole Tablet.................12 Raloxifene Tablet.................... 19 Sotalol....................................10
Pravastatin.............................. 10 Ramipril.................................10 Sovaldi.................................... 17
Prednisone Tablet...................15 Ranexa.................................... 10 Spiriva Handihaler.................20
Premarin.................................23 Ranitadine Syrup.................... 16 Spiriva Respimat....................20
Premphase..............................23 Rapaflo...................................18 Spironolactone........................ 10
Prempro..................................23 Rasuvo.................................... 17 Sprintec..................................23
Prenisolone Oral Solution......15 React......................................23 Sprix....................................... 19
Prepopik................................. 16 Rebif.......................................12 Sronyx....................................23
Previfem.................................23 Reclipsen................................23 Stelara..................................... 17
Prezcobix................................ 17 Rectiv..................................... 18 Stendra...................................18
Prezista................................... 17 Regranex................................. 14 Stiolto Respimat.....................20
30
Strattera.................................. 11 Telmisartan- Trazodone Tablet.................... 11
Stribild.................................... 17 Hydrochlorothiazide............10 Tresiba FlexTouch.................. 14
Striverdi Respimat..................20 Temazepam Capsule...............12 Tretinoin Cream..................... 14
Suboxone Film.......................12 Terazosin.......................... 10, 18 Tretinoin Gel.......................... 14
Subsys..................................... 19 Terazosin Capsule, Tablet....... 18 Tretinoin Microspheres.......... 14
Suclear.................................... 16 Terbinafine Tablet....................8 Trezix..................................... 19
Sucralfate Tablet..................... 16 Testim.....................................18 Tri-Estarylla...........................23
Sulfamethoxazole- Testosterone 1% Tri-Linyah..............................23
Topical Gel.......................... 18 Tri-Lo-Estarylla.....................23
Trimethoprim Tablet.............8
Testosterone Cypionate Tri-Lo-Marzia........................23
Sulfasalazine Tablet................ 16
Injection...............................18 Tri-Lo-Sprintec......................23
Sumatriptan Nasal Spray........ 11
Thrive Gum...........................21 Tri-Previfem...........................23
Sumatriptan Succinate Tablet,
Timolol Maleate 0.25%, 0.5% Tri-Sprintec............................23
Injection...............................12
Ophthalmic Solution........... 16 Triamcinolone Acetonide
Suprax Capsule, Chewable
Tivicay.................................... 17 Cream, Lotion, Ointment... 14
Tablet, Tablet.........................8
Tizanidine Tablet................... 19 Triamcinolone Nasal Spray.....20
Suprep.................................... 16 Triamterene-
Tobi Podhaler......................... 18
Sustiva.................................... 17 Hydrochlorothiazide............10
Tobramycin Nebulized
Sutent.......................................9 Triazolam Tablet....................12
Solution...............................18
Symbicort...............................20 Trinessa..................................23
Tobramycin Ophthalmic
Synjardy..................................15 Trinessa Lo.............................23
Solution............................... 16
Synthroid................................15 Tobramycin/Dexamethasone Trintellix................................. 11
0.3%-0.1% Ophthalmic Triphasil.................................22
T
Suspension...........................15 Triumeq.................................. 17
Taclonex Suspension............... 14 Trivora-28...............................23
Tolcapone...............................12
Tacrolimus Capsule................21 Trulicity..................................15
Tolterodine Extended-Release
Tacrolimus Ointment............. 14 Truvada.................................. 17
Tablet...................................20
Take Action............................23 Tudorza..................................20
Tolterodine Tablet..................20
Taltz....................................... 17 Tybost..................................... 17
Topiramate Immediate-Release
Tamoxifen..............................23 Tyvaso....................................21
Tablet...................................13
Tamsulosin Capsule................18 Toujeo SoloStar...................... 14 U
Tanzeum.................................15 Toviaz.....................................20
Targretin Capsule.....................9 Uceris Foam............................ 16
Tracleer...................................21
Uceris Tablet........................... 16
Targretin Gel............................9 Tradjenta................................15 Uloric...................................... 17
Tarina Fe................................23 Tramadol Immediate-Release Uptravi...................................21
Tasigna.....................................9 Tablet................................... 19
Taytulla..................................23 Tramadol Sustained-Release V
Tazorac................................... 14 Tablet................................... 19 Vagifem..................................23
Tecfidera.................................12 Tramadol-Acetaminophen...... 19 Valacyclovir Tablet...................8
Technivie................................ 17 Transderm-Scop..................... 16 Valganciclovir...........................8
Telmisartan............................10 Travatan Z.............................. 16 Valsartan.................................10
31
Valsartan- Viorele....................................23 Y
Hydrochlorothiazide............10 Viread..................................... 17 Yasmin 28...............................23
Varubi..................................... 16 Vitekta.................................... 17 Yaz..........................................23
Vascepa...................................10 Vivelle-Dot.............................23 Yuvafem..................................23
Vectical................................... 14 Voltaren Gel........................... 19
Velivet.....................................23 Vytorin...................................10 Z
Velphoro................................. 19 Vyvanse.................................. 11 Zaleplon Capsule....................12
Veltassa................................... 19 Zarxio..................................... 19
W
Venlafaxine Extended-Release Zelapar...................................12
Capsule................................ 11 Warfarin Sodium.....................9 Zenpep................................... 16
Venlafaxine Tablet.................. 11 Welchol..................................10 Zepatier.................................. 17
Ventolin HFA.........................20 Wera.......................................23 Zetia.......................................10
Verapamil...............................10 X Zetonna..................................20
Verapamil Sustained-Release.. 10 Zinbryta.................................12
Xarelto......................................9
Vesicare...................................20 Ziprasidone Capsule...............12
Xeljanz.................................... 17
Vestura....................................23 Zohydro ER........................... 19
Xeljanz XR............................. 17
Viagra.....................................18 Zolpidem Extended-Release
Xeloda......................................9
Viberzi.................................... 16 Tablet...................................12
Xigduo XR.............................15
Vicodin 5/300, 7.5/300, Zolpidem Tablet.....................12
Xiidra..................................... 16
10/300 mg Tablet................ 19 Zonisamide Capsule...............13
Xopenex HFA........................20
Victoza 2-Pak.........................15 Zovia 1/35E, 1/50E...............23
Xopenex Nebs.........................20
Victoza 3-Pak.........................15 Zovirax Cream.........................8
Xtampza ER........................... 19
Viekira Pak............................. 17 Zubsolv...................................12
Xulane....................................23
Vienva.....................................23 Zurampic................................ 17
Xyrem.....................................12
Vigamox................................. 16 Zytiga.......................................9
Viibryd................................... 11
32
My medications worksheet
Take this worksheet with you each time you visit a doctor. Each of your doctors should be aware of every
drug you take and you should have a list as well.
Example: Lisinopril, 20 mg Tier 1 High blood pressure One tablet daily Dr. Johnson
33
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Online: UHC_Civil_Rights@uhc.com
You can also file a complaint with the U.S. Dept. of Health and Human Services.
Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
Complaint forms are available at
http://www.hhs.gov/ocr/office/file/index.html
We provide free services to help you communicate with us, including letters in other languages or
large print. Or, you can ask for an interpreter. To ask for help, please call the toll-free phone number
listed on your ID card TTY 711, Monday through Friday, 8 a.m. to 8 p.m.
34
35
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Administrative services provided by UnitedHealthcare Insurance Company, UnitedHealthcare Services, Inc. or their affiliates.
Health Plan coverage provided by or through a UnitedHealthcare company. OptumRx is an affiliate of UnitedHealthcare Insurance Company.
UnitedHealthcare and the dimensional U logo are registered trademarks owned by UnitedHealth Group Incorporated.
All other trademarks are the property of their respective owners.
Created February, 2017. 2017 Prescription Drug List Advantage Three-Tier
100-17540 7/17