2018 Prescription Drug List/Formulary … ERS Prescription...Your Prescription Drug List / Formulary ... in the Drug Tier column, check your benefit plan documents to find out your

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2018

Your Prescription Drug List/Formulary

Effective January 1, 2018

Please read: This document contains information about the drugs covered under your pharmacy benefit plan.

For a complete list of covered drugs or if you have questions:

Call a customer care representativetoll-free at (855) 828-9834 (TTY 711).

Visit www.HealthSelectRx.com

Locate an OptumRxin-network pharmacy

Look up possible lower-cost medication alternatives.

Compare medication pricing and options.

HealthSelectSM of Texas

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Your Prescription Drug List / Formulary

This formulary outlines the most commonly prescribed medications covered under your plans prescription drug benefits. The formulary is also known as the Prescription Drug List (PDL). A formulary identifies the drugs available for certain conditions and organizes them into cost levels, also known as tiers. An important part of the formulary is giving you choices so you and your doctor can choose the best course of treatment for you.

Go to www.HealthSelectRx.com for complete and up-to-date drug information

Since the formulary may change, we encourage you to visit our website, www.HealthSelectRx.com and click on Prescription Drug List. This website is the best source for up-to-date information about all of the medications your pharmacy benefit covers, possible lower-cost options and cost comparisons.

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Table of Contents

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

Programs and limits . . . . . . . . . . . . . . . . . 6

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

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

Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Cardiovascular/Heart DiseaseAnticoagulants . . . . . . . . . . . . . . . . . . . . . . 11High Blood Pressure . . . . . . . . . . . . . . . . . 11High Cholesterol. . . . . . . . . . . . . . . . . . . . . 12Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Pulmonary Arterial Hypertension . . . . . . . . 12

Central Nervous SystemAttention Deficit Disorder . . . . . . . . . . . . . . 12Depression . . . . . . . . . . . . . . . . . . . . . . . . . 12Migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . 13Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Sedatives/Hypnotics . . . . . . . . . . . . . . . . . 14Seizure Disorders . . . . . . . . . . . . . . . . . . . . 14

Dermatology . . . . . . . . . . . . . . . . . . . . . . . 14

Diabetes/EndocrineInsulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Non-Insulin . . . . . . . . . . . . . . . . . . . . . . . . . 15

EndocrineGrowth Hormone . . . . . . . . . . . . . . . . . . . . 16Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Thyroid Hormone Replacement . . . . . . . . . 16

Eye ConditionsAllergies . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Antibiotics. . . . . . . . . . . . . . . . . . . . . . . . . . 16Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

GastrointestinalAcid Suppression . . . . . . . . . . . . . . . . . . . . 17Nausea/Vomiting . . . . . . . . . . . . . . . . . . . . 17Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Inflammatory Conditions . . . . . . . . . . . . . 18

Mens HealthErectile Dysfunction . . . . . . . . . . . . . . . . . . 18Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Testosterone Therapy. . . . . . . . . . . . . . . . . 19

Miscellaneous . . . . . . . . . . . . . . . . . . . . . . 19

MusculoskeletalOsteoporosis . . . . . . . . . . . . . . . . . . . . . . . 20 Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Pain Relief . . . . . . . . . . . . . . . . . . . . . . . . . 20

Overactive Bladder. . . . . . . . . . . . . . . . . . 21

RespiratoryAsthma/COPD . . . . . . . . . . . . . . . . . . . . . . 21Nasal Allergies . . . . . . . . . . . . . . . . . . . . . . 21Oral Allergies . . . . . . . . . . . . . . . . . . . . . . . 21

Transplant . . . . . . . . . . . . . . . . . . . . . . . . . 21

Vitamins/Electrolytes . . . . . . . . . . . . . . . . 22

Womens HealthBirth Control . . . . . . . . . . . . . . . . . . . . . . . . 22Hormone Replacement . . . . . . . . . . . . . . . 22Vaginal Anti-Infectives . . . . . . . . . . . . . . . . 23

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

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At OptumRx, 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 formulary.

What is a formulary?

This document is a list of commonly prescribed medications covered by your prescription drug program for their safety, cost and effectiveness. Drugs are listed by common categories or class. They are placed into cost levels known as tiers. It includes both brand and generic prescription medications approved by the U.S. Food and Drug Administration (FDA).

Please note: Where differences are noted between this formulary and your benefit plan documents, the benefit plan documents will rule. This document is not intended to be a complete list of medications, and not all medications listed may be covered under your plan. Please look at the Master Benefit Plan Document (MBPD) provided by your plan to see what medications are covered under your plan. You may also visit www.HealthSelectRx.com and click on Prescription Drug List or call a customer care representative toll-free at (855) 828-9834 (TTY 711).

How do I use my formulary?

When choosing a medication, you and your doctor should consult the formulary. It will help you and your doctor choose the most cost-effective prescription drugs. This guide tells you if a medication is generic or brand, and if special rules apply. Bring this list with you when you see your doctor. It is organized by common medical conditions. Medications are also listed alphabetically by name at the end of the formulary.

If your medication is not listed on this document, it may not be covered by the HealthSelect Prescription Drug Program or Consumer Directed HealthSelect Prescription Drug Program. Please visit www.HealthSelectRx.com and click on Prescription Drug Tool for the most up to date list of medications covered under your plan. If you have any questions, call a customer care representative toll-free at (855) 828-9834 (TTY 711).

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What are tiers?

Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, which is determined by your plan. This is how much you will pay when you fill a prescription. The HealthSelect of Texas Prescription Drug Program has different copays assigned depending on which tier a drug is. The Consumer Directed HealthSelect Prescription Drug Program has coinsurance assigned for each drug tier that applies once the annual combined medical and pharmacy deductible is met. Tier 1 medications are your lowest-cost options. If your medication is placed in Tier 2 or 3, look to see if there is a Tier 1 option available. Discuss these options with your doctor.

Drug names shown in green are preferred for their cost and effectiveness. If there is a symbol in the Drug Tier column, check your benefit plan documents to find out your specific pharmacy plan costs.

$ Drug Tier Includes Helpful Tips

$ Tier 1 Lowest Cost

Lower-cost, commonly used generic drugs. Some low-cost brands may be included.

Use Tier 1 drugs for the lowest out-of-pocket costs.

$$ Tier 2 Mid-range Cost

Many common brand-name drugs, called preferred brands.

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

$$$ Tier 3 Highest Cost

Mostly higher-cost brand drugs, also known as non-preferred brands.

Many Tier 3 drugs have lower-cost options in Tier 1 or 2. Ask your doctor if they could work for you.

When does the formulary change?

Medications may move to a lower tier at any time.

Medications may move to a higher tier when its generic becomes available.

Medications may move to a higher tier or be excluded from coverage on January 1 or July 1 of each year.

When a medication changes tiers, you may have to pay a different amount for that medication.

For the most up-to-date list, call a customer care representative, 24 hours a day, seven days a week toll-free at (855) 828-9834 (TTY 711).

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Programs and Limits

Some medications are noted with letters or symbols next to them. The letters and symbols refer to our pharmacy benefit programs and are provided to help you check which medications may have a program or limit. Your benefit plan determines how these medications may be covered for you.Programs and Limits

PA Prior AuthorizationYour doctor is required to provide additional information before the drug will be covered by your prescription drug plan.

ST Step TherapyRequires you to first try a cost-effective medication before the more expensive medication will be covered.

QL Quantity LimitsLimits the amount of a medication that will be covered under your prescription drug plan.

SP Specialty Medication

Drugs that are used in the treatment of rare or complex conditions and are typically injected or infused, are high cost, have special delivery and storage requirements, or require close monitoring or care coordination with your doctor.

E ExcludedDrugs that are not covered by your health plan. Lower-cost options are available and covered.

To learn more about a pharmacy program or to find out if it applies to you, please visit www.HealthSelectRx.com and click on Prescription Drug List or call a customer care representative toll-free at (855) 828-9834 (TTY 711).

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Why are some medications excluded from coverage?

Medications may be excluded from coverage under your prescription drug plan when it works the same as or similar to another prescription medication or an over-the-counter (OTC) medication that is more cost-effective. There may be other medication options available to treat your condition.

What if I dont agree with a decision about an excluded medication?

You (or your authorized representative) and your doctor can ask for an appeal to cover an excluded medication by calling a customer care representative toll-free at (855) 828-9834 (TTY 711).

Should I talk to my doctor about OTC medications?

An OTC medication may be the right treatment option for some conditions. Talk to your doctor about available OTC options. Even though these medications may not be covered under your pharmacy benefit, they may cost less than prescription medications covered under your prescription drug plan.

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

Generic medications contain the same active ingredients (what makes the medication work) as brand-name medications, but they often cost less. Once the patent of a brand-name medication ends, the FDA can approve a generic version with the same active ingredients. These types of medications are known as generic medications. Sometimes the same company that makes a brand-name medication also makes the generic version.

How can I tell a generic drug from a brand-name drug on this formulary?

This formulary shows brand-name drugs in bold type (for example, Lamictal) and generic drugs in plain type (for example, lamotrigine).

What if my doctor writes a brand-name prescription?

The next time your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lower-cost option is available and if it might be right for you. Generic medications are usually your lowest-cost option, but not always. Visit www.HealthSelectRx.com and click on Drug Pricing Tool to find out an estimated cost for your medications and if there are lower cost alternatives available.

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Are you taking a specialty medication?

Specialty medications treat rare or complex conditions and are typically higher cost medications. Please note, not all specialty medications are listed in the Formulary.

BriovaRx, the OptumRx specialty pharmacy, can provide most of your specialty medications along with helpful programs and services. Call BriovaRx at (855) 427-4682 and have your prescriptions delivered right to your home or office.

How do I get updated information about my pharmacy benefit?

Since the Formulary may change during your plan year, we encourage you to visit www.HealthSelectRx.com and click on Prescription Drug List or call a customer care representative at (855) 828-9834 (TTY 711) for the most current drug coverage information.

You can register and create an account at www.Optumrx.com/HealthSelectrx. You can use the websites helpful tools and features to:

Refill and renew mail service prescriptions

View your order status and claims history

Sign up for text reminders to take and refill your medicine

View your benefits in real time

Look up the price of drugs covered by your plan

Find lower-cost options

More information

Call a customer care representative toll-free at (855) 828-9834 (TTY 711).

Or visit www.HealthSelectRx.com.

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More information

If you have additional questions please call a cutomer care represntative toll-free at (855) 828-9834 (TTY 711), 24 hours a day, 7 days a week. Or visit www.HealthSelectRx.com.

Excluded brand-name medications with generic equivalents for 2018*

The brand-name medications below are excluded on the formulary. These brand-name medications have been identified to have available generic equivalents covered at Tier 1 on the formulary. Speak with your pharmacist to have your excluded brand-name medication substituted with its generic equivalent.

A generic medication contains the same active ingredient(s) as a brand-name medication. An active ingredient is what makes the medication work. For example, Liptor and its generic both contain atorvastatin, which reduces the amount of bad cholesterol in the blood. Brand-name medications are often protected by a patent. When the patent ends, drug companies can apply to the U.S. Food and Drug Administration (FDA) to begin making generic versions of the medication.

Aciphex

Acticlate

Adderall XR

Alphagan P

Ambien

Ambien CR

Androgel 1%

Azor

Benicar

Benicar HCT

Benzamycin

Benzaclin

Beyaz

Carafate

Celebrex

Concerta

Crestor

Cymbalta

Cytomel

Depo Testost Inj

Dilantin

Dilantin Chewable

Dilantin Suspension

Diovan

Diovan HCT

Duac

Duragesic

Effexor XR

Glumetza

Kadian

Lexapro

Lidoderm

Lipitor

Lovaza

Lunesta

Minastrin

Nasonex

Nexium

Nitrostat

Norco

Norvasc

Nuvigil

Ortho Tri Cyclen

Ortho Tri Cyclen Lo

Percocet

Prevacid

Pristiq

Prozac

Pulmicort Inhalation Suspension

Retin-A Micro Gel

Singulair

Taclonex Ointment

Tamiflu

Tobi Nebulizer

Tobradex

Toprol XL

Tribenzor

Vagifem

Valium

Vitafol

Vivelle-Dot

Voltaren

Vytorin

Wellbutrin

Wellbutrin SR

Wellbutrin XL

Xanax

Xanax XR

Yaz

Zegerid

Zetia

Ziana

Zoloft

Zomig

Zomig ZMT

Zovirax (tab, cap, ointment, suspension)

* These brand-name medications have been identified to have available generic equivalents. Not all brand-name medications have generic equivalents. Brand-name medications without generic equivalents are included in the following medication list.

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Drug Name Drug Tier

Programs andLimits

Anti-Infectives: Antibiotics

Amoxicillin 1

Amoxicillin/Clavulanate 1

Azasite 3Azithromycin 1

Bethkis 2 SPCefdinir 1

Cefuroxime Tab 1

Cephalexin 1

Ciprodex Otic Suspension

2

Ciprofloxacin Tab 1

Clarithromycin 1

Clindamycin Cap 1

Doryx MPC 3Doxycycline Hyclate

Cap1

Doxycycline Hyclate Tab (Immediate Release)

1

Doxycycline Monohydrate Cap

1

Doxycycline Monohydrate Oral Suspension, Tab

1

Erythromycin 1

Kitabis ELevofloxacin Tab 1

Metronidazole Tab 1

Minocycline Cap 1

Nitrofurantoin Macrocrystalline

1

Nitrofurantoin Monohydrate Macrocrystalline

1

Ofloxacin Otic Solution 1

Drug Name Drug Tier

Programs andLimits

Oracea 3Penicillin VK 1

Solodyn 3Sulfamethoxazole-

Trimethoprim1

Sulfamethoxazole-Trimethoprim DS

1

TOBI podhaler ETobramycin E

Anti-Infectives: Antifungals

Fluconazole 1

Jublia Solution 3 PAKerydin Solution 3 PANystatin Suspension 1

Terbinafine Tab 1 QL

Anti-Infectives: Antivirals

Acyclovir Cap, Tab, Suspension

1

Descovy 2 SPEntecavir 1 QL, SP

Epclusa 2 PA, QL, SPFamciclovir Tab 1

Harvoni 2 PA, QL, SPMavyret 2 PA, QL, SPOdefsey 2 SPOseltamivir 1 QL

Valacyclovir 1 QL

Zepatier 3 PA, QL, SP

Cancer

Akynzeo 3 QLAnastrozole Tab 1

Cabometyx 2 PA, SPCapecitabine 1 PA, SP

Letrozole 1

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits[Plain type = Generic drug] ST Step Therapy SP Specialty ProgramE Excluded

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Drug Name Drug Tier

Programs andLimits

Mercaptopurine 1 SPRevlimid 3 PA, SPSprycel 2 PA, SPTamoxifen Tab 1Zytiga 3 PA, SPCardiovascular/Heart Disease: AnticoagulantsBrilinta 2Clopidogrel 1Effient 2Eliquis 3 QLEnoxaparin 1 QL, SPPradaxa 2 QLSavaysa 3 QLWarfarin 1Xarelto 2 QLZontivity 3Cardiovascular/Heart Disease: High Blood PressureAmlodipine 1Amlodipine/Benazepril 1Amlodipine/Valsartan 1Atenolol 1Atenolol/

Chlorthalidone1

Benazepril 1Benazepril/HCTZ 1Bisoprolol 1Bisoprolol/HCTZ 1Bumetanide 1Bystolic 2Byvalson 2Cartia XT 1Carvedilol 1Chlorthalidone 1Clonidine Tab 1Diltiazem ER 1

Drug Name Drug Tier

Programs andLimits

Doxazosin 1Edarbi 3 STEdarbyclor 3 STEnalapril 1Furosemide 1Guanfacine Tab

(Immediate Release)

1

Hydralazine 1Hydrochlorothiazide 1Irbesartan 1Labetalol 1Lisinopril 1Lisinopril/HCTZ 1Losartan 1Losartan/HCTZ 1Metoprolol Succinate 1Metoprolol Tartrate 1Nadolol 1Nifedipine ER 1Olmesartan 1Olmesartan HCT 1Prazosin 1Propranolol 1Propranolol ER 1Quinapril 1Ramipril 1Spironolactone 1Tekturna 2 STTekturna HCT 2 STTelmisartan 1Terazosin 1Torsemide Tab 1Triamterene/HCTZ 1Valsartan 1Valsartan/HCTZ 1

Verapamil ER 1


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Drug Name Drug Tier

Programs andLimits

Cardiovascular/Heart Disease: High CholesterolAtorvastatin 1

Choline Fenofibrate ER 1

Fenofibrate 40 mg, 43 mg, 48 mg, 50 mg, 54 mg, 67 mg, 120 mg, 130 mg, 134 mg, 145 mg, 150 mg, 160 mg, 200 mg

1

Gemfibrozil 1

Livalo 3 STLovastatin 1

Niacin ER Tab 1

Omega-3 Acid Cap 1 gm

1

Praluent 2 PA, QL, SPPravastatin 1

Rosuvastatin 1

Simvastatin 5 mg, 10 mg, 20 mg, 40 mg

1

Simvastatin 80 mg 1 PA

Vascepa 2Welchol 2

Cardiovascular/Heart Disease: Other

Corlanor 3 PA, QLDigoxin 1

Flecainide 1

Isosorbide Mononitrate ER

1

Multaq 3Nitroglycerin SL Tab 1

Ranexa 2 STSotalol 1

Drug Name Drug Tier

Programs andLimits

Cardiovascular/Heart Disease: Pulmonary Arterial HypertensionAdcirca 3 PA, QL, SPAdempas 2 PA, QL, SPLetairis 2 PA, QL, SPOpsumit 2 PA, QL, SPOrenitram 3 PA, SPSildenafil Tab 20 mg 1 PA, QL, SP

Tracleer 2 PA, QL, SP

Central Nervous System: Attention Deficit DisorderAmphetamine-Dextro-

amphetamine Tab 1 PA, QL

Amphetamine-Dextro-amphetamine SR 24Hr Cap

1 PA, QL

Dexmethylphenidate ER Cap

1 PA, QL

Guanfacine ER Tab 1

Methylphenidate ER Cap

1 PA, QL

Methylphenidate ER Tab

1 PA, QL

Methylphenidate SA Osmotic ER Tab

1 PA, QL

Methylphenidate Tab 1 PA, QL

Strattera 3 QLVyvanse 2 QL, PA

Central Nervous System: Depression

Amitriptyline 1

Bupropion 1

Bupropion ER 1 QL

Bupropion SR 1 QL

Bupropion XL 1 QL

Citalopram 1


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Drug Name Drug Tier

Programs andLimits

Doxepin 1

Duloxetine Cap 20 mg, 30 mg, 60 mg

1 QL

Escitalopram Tab 1

Fluoxetine Cap (not PMDD)

1

Forfivo XL 2 QLMirtazapine 1

Nortriptyline 1

Paroxetine Tab 1

Rexulti 3 QLRisperidone Tab 1 QL

Sertraline 1

Trazodone 1

Trintellix 3 QL, STVenlafaxine Tab 1

Venlafaxine ER Cap 1

Venlafaxine ER Tab 1

Viibryd 3 QL

Central Nervous System: Migraine

Butalbital-Acetaminophen-Caffeine Cap, Tab 50-325-40 mg

1

Migranal 3 QLRelpax 3 QLRizatriptan Tab, ODT 1 QL

Sumatriptan Tab and Spray

1 QL

Sumavel Dose 3 QL

Central Nervous System: Multiple SclerosisAmpyra 2 PA, QL, SPAubagio 3 PA, QL, ST, SPAvonex Kit 2 PA, QL, SPAvonex Pen Kit 2 PA, QL, SP

Drug Name Drug Tier

Programs andLimits

Avonex Prefill Kit 2 PA, QL, SPBetaseron 2 PA, QL, SPCopaxone 20 mg/mL

& 40 mg/mL2 PA, QL, SP

Extavia EGilenya 3 PA, QL, ST, SPPlegridy ERebif ERebif Titrtn ETecfidera 2 PA, QL, SP

Central Nervous System: Other

Alprazolam Tab 1 QL

Aripiprazole 1 QL

Aristada 3Buspirone 1

Diazepam Tab 1

Hydroxyzine HCL 1

Hydroxyzine Pamoate 1

Invega Sustenna 3Invega Trinza 3Latuda 3 QL, STLorazepam Tab 1 QL

Modafinil 1 PA, QL

Namenda XR 2 QLNamzaric 2 QLOlanzapine Tab 1 QL

Pramipexole 1

Quetiapine 1 QL

Risperidone Tab 1 QL

Ropinirole (Immediate Release)

1

Saphris 2 QLXyrem 3 PA, QL, SP


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Drug Name Drug Tier

Programs andLimits

Central Nervous System: Sedatives/HypnoticsEszopiclone Tab 1 QL

Silenor 3 QLTemazepam 1 QL

Triazolam Tab 1 QL

Zaleplon 1 QL

Zolpidem 1 QL

Zolpidem ER 1 QL

Central Nervous System: Seizure DisordersClonazepam 1 QL

Divalproex DR 1

Divalproex ER 1

Gabapentin 1

Lamotrigine (Immediate Release)

1

Levetiracetam 1

Levetiracetam ER 1

Lyrica Cap 2 QLOxcarbazepine 1

Primidone 1

Topiramate Tab 1

Trokendi XR EVimpat 3Zonisamide 1

Dermatology

Absorica 3 PAAcanya Gel EAczone Gel 3Aktipak EAtralin 3 PAClaravis 1 PA

Drug Name Drug Tier

Programs andLimits

Clindamycin Gel, Lotion, Solution

1

Clindamycin/ Benzoyl Peroxide Gel 1-5%

1

Clindamycin/Benzoyl Peroxide Gel 1.2-5%

1

Clobetasol Cream, Ointment, Solution

1

Clobex 3Clotrimazole/

Betamethasone Cream, Lotion

1

Dupixent 2 PA, QL, SPElidel 2 STEpiduo & Epiduo

Forte3

Eucrisa 2 STFluocinonide Cream,

0.1%E

Fluocinonide Cream, Gel, Ointment, Solution 0.05%

1

Hydrocortisone Cream, Ointment 2.5%

1

Ketoconazole Cream/Shampoo

1

Lidocaine Topical Ointment, Solution

1

Metrogel 3Metronidazole Gel

0.75%1

Mirvaso Gel 2Mupirocin Ointment 1

Myorisan 1 PA

Nystatin Cream, Ointment, Powder

1


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Drug Name Drug Tier

Programs andLimits

Onexton 3Oxsoralen-UL 2Pennsaid Solution EPermethrin Cream 5% 1

Proctofoam HC 2Soolantra 2Tazorac 3Tretinoin Cream 1 PA

Tretinoin Microsphere Gel

1 PA

Triamcinolone 1

Vectical 3Veltin EZovirax Cream 2Zyclara 3

Diabetes/Endocrine: Insulin

Apidra EBasaglar EHumalog Mix 50/50

Vial and KwikPen2

Humalog Mix 75-25 Vial and KwikPen

2

Humalog U-100 Vial and KwikPen

2

Humalog U-200 KwikPen

2

Humulin 70-30 Vial and KwikPen

2

Humulin N Vial and KwikPen

2

Humulin R U-500 Vial and KwikPen

2

Humulin R Vial 2Lantus SoloStar 2Lantus Vial 2Levemir FlexTouch E

Drug Name Drug Tier

Programs andLimits

Levemir Vial ENovolin 70/30 Vial ENovolin N Vial ENovolin R Vial ENovolog Flexpen ENovolog Mix 70/30

Vial and FlexpenE

Novolog Penfill ENovolog Vial EToujeo SoloStar 2Tresiba E

Diabetes/Endocrine: Non-Insulin

Adlyxin EAlogliptin (M) EAlogliptin/

metformin (M)E

Alogliptin/pioglitazone (M)

E

Bydureon 2 QL, STByetta 2 QL, STFarxiga EGlimepiride 1

Glipizide 1

Glipizide ER 1

Glipizide XL 1

Glyburide 1

Invokamet 2 STInvokamet XR 2 STInvokana 2 STJanumet 2 STJanumet XR 2 STJanuvia 2 STJardiance 2 STJentadueto 2 STJentadueto XR 2 ST


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Drug Name Drug Tier

Programs andLimits

Kazano EKombiglyze EMetformin 1

Metformin ER 1

Nesina EOnglyza EOseni EPioglitazone 1

Soliqua 2 QL, STSynjardy 2 STSynjardy XR 2 STTanzeum ETradjenta 2 STTrulicity 2 QL, STVictoza 2 QL, STXigduo XR E ST

Endocrine: Growth Hormone

Genotropin EHumatrope ENorditropin 2 PA, SPNutropin AQ 2 PA, SPOmnitrope 2 PA, SPSaizen EZomacton E

Endocrine: Other

Calcitriol Cap 1

Clomiphene 1

Dexamethasone Tab 1

H.P. Acthar 2 PA, SPHydrocortisone Tab 1

Lupron Depot 3.75 mg, 11.25 mg

3 PA, SP

Drug Name Drug Tier

Programs andLimits

Lupron Depot 7.5 mg, 22.5 mg, 30 mg, 45 mg

2 PA, SP

Methylprednisolone Tab 1

Prednisone 1

Prednisolone Solution 25 mg/5 ml

1

Prednisolone Syrup, Solution 15 mg/5 ml

1

Endocrine: Thyroid Hormone Replacement Armour Thyroid 3Levothyroxine 1

Liothyronine 1

Methimazole 1

Synthroid 3Tirosint 3

Eye Conditions: Allergies

Azelastine Ophthalmic Solution

1

Pataday 3Pazeo 2

Eye Conditions: Antibiotics

Besivance 3Ciprofloxacin

Ophthalmic Solution

1

Erythromycin Ointment 1

Moxeza 2Ofloxacin Ophthalmic

Solution1

Polymyxin B/Trimethoprim Solution

1

Tobramycin 1


17

Drug Name Drug Tier

Programs andLimits

Tobramycin/Dexamethasone

1

Vigamox 3

Eye Conditions: Glaucoma

Azopt 2Betimol 3Combigan 2Cosopt PF 3Latanoprost 1 QL

Lumigan 2 QLRescula ESimbrinza 2Travatan Z 2 QLZioptan E

Eye Conditions: Other

Ketorolac Ophthalmic Solution

1

Prednisolone Ophthalmic Suspension

1

Restasis 2 PARestasis Multidose 2 PAXiidra 2 PA

Gastrointestinal: Acid Suppression

Dexilant 2 QLDuexis EEsomeprazole

Magnesium (Rx only)

1 QL

Famotidine Tab 20 mg and 40 mg (Rx only)

1

Lansoprazole (Rx only) 1 QL

Omeprazole (Rx only) 1 QL

Drug Name Drug Tier

Programs andLimits

Pantoprazole 1 QL

Ranitidine Tab, Cap, Syrup (Rx only)

1

Sucralfate Tab 1

Vimovo E

Gastrointestinal: Nausea/Vomiting

Meclizine 1

Metoclopramide 1

Ondansetron ODT 1 QL

Ondansetron Tab 1

Varubi 3 QL

Gastrointestinal: Other

Amitiza 2 QL, STApriso 2Asacol HD ECanasa 2Creon 2Delzicol EDicyclomine 1

Dipentum 3Diphenoxylate/

Atropine1

Gavilyte Solution 1

Lialda ELinzess 2 QL, STMesalamine DR (M) EMisoprostol 1

Movantik EPancreaze EPentasa 3Pertzye EPolyethylene

Glycol 3350 Powder

1

Prepopik 3


18

Drug Name Drug Tier

Programs andLimits

Pylera 2Rabeprazole 1 QL

Suprep Bowel Prep 3Uceris Foam 3Ultresa EViokace EZenpep 2

HIV/AIDS

Atripla 2 SP Complera 2 SPGenvoya 2 SPIsentress 2 SPNorvir 2 SPPrezcobix 2 SPPrezista 2 SPReyataz 2 SPStribild 2 SPTivicay 2 SPTriumeq 2 SPTruvada 2 SPViread 2 SP

Infertility

Bravelle ECetrotide 2 PA, SPFollistim AQ EGonal-f 2 PA, SPGonal-f RFF 2 PA, SPOvidrel 3 SP

Inflammatory Conditions

Cimzia Kit 2 PA, SPCosentyx+ 3 PA, SPDepen 2 SPEnbrel 3 PA, ST, SP

Drug Name Drug Tier

Programs andLimits

Humira Kit 2 PA, SPHumira Pen Kit 2 PA, SPHumira Pen Kit

Crohns2 PA, SP

Humira Pen Kit Psoriasis

2 PA, SP

Hydroxychloroquine 1

Inflectra ELeflunomide 1

Methotrexate Tab 1

Orencia SC 3 PA, ST, SPOtezla 2 PA, SPRasuvo 2 PA, QLRemicade 2 PA, SPSimponi 2 PA, SPSimponi Aria 2 PA, SPStelara 2 PA, SPTaltz EXeljanz 3 PA, ST, SP

Mens Health: Erectile Dysfunction

Cialis 2 QLLevitra EStaxyn EStendra EViagra 2 QL

Mens Health: Prostate

Cialis 2.5 mg & 5 mg 2 QLDoxazosin 1

Dutasteride 1

Finasteride 5 mg 1

Rapaflo 2Tamsulosin 1

Terazosin


19

Drug Name Drug Tier

Programs andLimits

Mens Health: Testosterone Therapy

Androderm 2 PAAndrogel 1.62% 2 PAAxiron EFortesta ETestim ETestosterone

Cypionate IM Injection

1 PA

Vogelxo E

Miscellaneous

Adrenaclick EAllopurinol 1Aranesp EArmodafinil 1 PA, QLAuryxia 3Auvi-Q EBenzonatate 1Botox 100, 200 unit

Injection (non-cosmetic)

2 PA, SP

Bunavail 3 QLCerdelga 3 PA, SPCheratussin 1Chlorhexidine 1Colcrys 2Contrave 2 PAEpinephrine

Auto-Injector (Authorized Generic for EpiPen made by Mylan)

2

Epinephrine Auto-Injector (M) (made by Impax)

E

EpiPen & EpiPen Jr E

Drug Name Drug Tier

Programs andLimits

Epogen EEuflexxa 2 PA, SPFosrenol 3Granix 2 PA, SPGuaifenesin/Codeine

Syrup1

Hydrocodone/Chlorpheniramine Liquid

1

Hydrocodone Polistirex/Chlorpheniramine ER Suspension

1

Lidocaine Viscous Solution 2%

1

Makena 2 PA, SPNarcan 2Neupogen 2 PA, SPPhenazopyridine

(Rx only)1

Phentermine Tab 1 PAProcrit 2 PA, SPPromethazine DM

Syrup1

Promethazine/Codeine Syrup

1

Renvela Tab 2Rezira 3Suboxone Film 2 QLSynvisc 2 PA, SPSynvisc One 2 PA, SPUloric 2 STVelphoro 3Zarxio 2 PA, SPZubsolv 2 QLZurampic 3Zutripro 3


20

Drug Name Drug Tier

Programs andLimits

Musculoskeletal: Osteoporosis

Alendronate Tab 35 mg & 70 mg

1 QL

Binosto 3 QLForteo 2 PA, SPTymlos 2 PA, SP

Musculoskeletal: Other

Amrix EBaclofen Tab 1

Carisoprodol 350 mg 1

Cyclobenzaprine Tab 5, 10 mg

1

Lorzone 3Metaxalone 1

Methocarbamol 1

Tizanidine Cap 1

Tizanidine Tab 1

Musculoskeletal: Pain Relief

Abstral EAcetaminophen

w/ Codeine 1 QL

Arymo ER ECambia ECelecoxib 1 QL

Diclofenac Gel 1 QL

Diclofenac Tab 1

Embeda 2 PA, QLEtodolac 1

Fentanyl Patch 25 mcg/hr, 50 mcg/hr, 75 mcg/hr, 100 mcg/hr

1 PA, QL

Drug Name Drug Tier

Programs andLimits

Fentanyl Patch 37.5 mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr

1 PA, QL

Fentora EFlector patch 3 QLGralise 3 QL, STHydrocodone/

Acetaminophen 5, 7.5, 10/325 mg

1 QL

Hydromorphone Tab 1 QL

Hysingla ER 2 PA, QLIbuprofen Tab 400,

600, 800 mg (Rx only)

1

Indomethacin Cap 1

Ketorolac Tab 1 QL

Lazanda ELidocaine Patch 5% 1

Meloxicam 1

Methadone Tab 1 PA

Morphine Sulfate ER 1 PA, QL

Nabumetone 1

Naproxen (Rx only) 1

Nucynta ER EOxycodone Tab 5, 10,

15, 30 mg (Immediate Release)

1 QL

Oxycodone w/ Acetaminophen

1 QL

Oxycontin 2 PA, QLSubsys ETramadol Tab 50 mg 1

Tramadol w/ Acetaminophen

1

Xtampza ER E


21

Drug Name Drug Tier

Programs andLimits

Zohydro ER EZorvolex E

Overactive Bladder

Myrbetriq 2Oxybutynin 1Oxybutynin ER 1Toviaz 3Vesicare 2

Respiratory: Asthma/COPD

Advair Diskus 2 QLAdvair HFA 2 QLAerospan 3 QLAirDuo EAlbuterol

Nebulizer Solution1 QL

Alvesco EAnoro Ellipta 2 QLArnuity Ellipta 2 QLAsmanex EBreo Ellipta 2 QLBudesonide Inhalation

Suspension1 QL

Combivent Respimat 2 QLDulera EFlovent Diskus 2 QLFlovent HFA 2 QLIncruse Ellipta 2 QLIpratropium/Albuterol

Nebulizer Solution1 QL

Levalbuterol Inhaler (M)

E

Montelukast 1Proair HFA,

RespiClick2 QL

Proventil HFA EPulmicort Flexhaler 2 QL

Drug Name Drug Tier

Programs andLimits

Qvar ESerevent Diskus 2 QLSpiriva Handihaler 2 QLSpiriva Respimat 2 QLStiolto 2 QLSymbicort 2 QLTudorza EVentolin HFA 2 QLXolair 2 PA, SPXopenex HFA E

Respiratory: Nasal Allergies

Astepro 3 QLAzelastine Spray 1 QLDymista Spray 2 QLFluticasone Spray 1Ipratropium Spray 1 QLMometasone 1 QLOmnaris 3 QLQNasl 3 QLZetonna 3 QL

Respiratory: Oral Allergies

Cetirizine 1Levocetirizine 1Promethazine Tab 1

Transplant

Azathioprine Tab 1Mycophenolate Mofetil

250 mg Cap/ 500 mg Tab

1 SP

Mycophenolate Sodium 180 mg, 360 mg Tab

1 SP

Prograf Cap 3 SPTacrolimus Cap 1 SP


22

Drug Name Drug Tier

Programs andLimits

Vitamins/Electrolytes

Cyanocobalamine Injection

1

Folic Acid 1 mg (Rx only)

1

Klor-Con 8 and 10 MEQ

1

Klor-Con M10 and M20

1

Ludent 1

Potassium Chloride ER Tab, Cap

1

Potassium Chloride Micro ER Tab

1

Vitamin D 50,000 units (Rx only)

1

Womens Health: Birth Control

Apri 1

Aviane 1

Azurette 1

Cryselle-28 1

Falmina 1

Generess Fe Chewable

3

Gianvi 1

Gildess 1

Jolivette 1

Junel 1

Kariva 1

Levora 28 1

Lomedia Fe 1

Loryna 1

Low-Ogestrel 1

Lutera 1

Drug Name Drug Tier

Programs andLimits

Medroxyprogesterone Acetate Injection

1 QL

Microgestin 1

Microgestin Fe 1

Mono-Linyah 1

Mononessa 1

Necon 1

Nora-Be 1

Norgest/Ethi Estradio 1

Nortrel 1

Nuvaring 2Ocella 1

Orsythia 1

Previfem 1

Reclipsen 1

Sprintec 28 1

Tri-Linyah 1

Tri-Lo-Sprintec 1

Tri-Previfem 1

Trinessa 1

Tri-Sprintec 1

Vestura 1

Viorele 1

Xulane 1

Zarah 1

Womens Health: Hormone Replacement

Climara Pro 2Divigel 3Duavee 2Elestrin Gel 3Estrace Vaginal

Cream3

Estradiol Patch, Tab 1

Estradiol/Norethindrone Tab

1


23

Drug Name Drug Tier

Programs andLimits

Medroxyprogesterone Acetate Tab

1

Minivelle 3Osphena 3Premarin Tab 2Premarin Vaginal

Cream2

Premphase 2Prempro 2Progesterone Cap 1

Yuvafem 1

Drug Name Drug Tier

Programs andLimits

Womens Health: Vaginal Anti-Infectives

Gynazole-1 Vaginal Cream

3

Metronidazole Vaginal Gel

1

Terconazole Vaginal Cream

1


24

A

Absorica . . . . . . . . . . 14Abstral . . . . . . . . . . . 20Acanya Gel . . . . . . . . 14Acetaminophen w/

Codeine . . . . . . . . 20Acyclovir Cap, Tab,

Suspension . . . . . . . 10Aczone Gel . . . . . . . . 14Adcirca . . . . . . . . . . 12Adempas . . . . . . . . . 12Adlyxin . . . . . . . . . . . 15Adrenaclick . . . . . . . . 19Advair Diskus . . . . . . . 21Advair HFA. . . . . . . . . 21Aerospan . . . . . . . . . 21AirDuo . . . . . . . . . . . 21Aktipak . . . . . . . . . . 14Akynzeo . . . . . . . . . . 10Albuterol Nebulizer

Solution. . . . . . . . . 21Alendronate Tab . . . . . . 20Allopurinol . . . . . . . . . 19Alogliptin (M) . . . . . . . 15Alogliptin/metformin (M) . 15Alogliptin/pioglitazone (M) 15Alprazolam Tab. . . . . . . 13Alvesco . . . . . . . . . . 21Amitiza. . . . . . . . . . . 17Amitriptyline . . . . . . . . 12Amlodipine . . . . . . . . . 11Amlodipine/Benazepril . . . 11Amlodipine/Valsartan. . . . 11Amoxicillin . . . . . . . . . 10Amoxicillin/Clavulanate . . 10Amphetamine-

Dextroamphetamine SR 24Hr Cap . . . . . . . . 12

Amphetamine-Dextroamphetamine Tab 12

Ampyra . . . . . . . . . . 13Amrix. . . . . . . . . . . . 20Anastrozole Tab . . . . . . 10Androderm . . . . . . . . 19Androgel 1.62% . . . . . . 19Anoro Ellipta. . . . . . . . 21Apidra . . . . . . . . . . . 15Apri . . . . . . . . . . . . . 22Apriso . . . . . . . . . . . 17Aranesp . . . . . . . . . . 19Aripiprazole . . . . . . . . 13Aristada . . . . . . . . . . 13Armodafinil . . . . . . . . . 19Armour Thyroid . . . . . . 16Arnuity Ellipta . . . . . . . 21Arymo ER . . . . . . . . . 20Asacol HD . . . . . . . . . 17Asmanex. . . . . . . . . . 21Astepro . . . . . . . . . . 21Atenolol . . . . . . . . . . 11Atenolol/Chlorthalidone . . 11Atorvastatin . . . . . . . . 12Atralin . . . . . . . . . . . 14Atripla . . . . . . . . . . . 18Aubagio . . . . . . . . . . 13Auryxia. . . . . . . . . . . 19Auvi-Q . . . . . . . . . . . 19Aviane . . . . . . . . . . . 22Avonex Kit . . . . . . . . . 13Avonex Pen Kit . . . . . . 13Avonex Prefill Kit . . . . . 13Axiron . . . . . . . . . . . 19Azasite . . . . . . . . . . . 10Azathioprine Tab . . . . . . 21Azelastine Ophthalmic

Solution. . . . . . . . . 16

Azelastine Spray . . . . . . 21Azithromycin . . . . . . . . 10Azopt. . . . . . . . . . . . 17Azurette . . . . . . . . . . 22

B

Baclofen Tab . . . . . . . . 20Basaglar . . . . . . . . . . 15Benazepril . . . . . . . . . 11Benazepril/HCTZ . . . . . 11Benzonatate . . . . . . . . 19Besivance . . . . . . . . . 16Betaseron . . . . . . . . . 13Bethkis. . . . . . . . . . . 10Betimol . . . . . . . . . . 17Binosto . . . . . . . . . . 20Bisoprolol . . . . . . . . . 11Bisoprolol/HCTZ . . . . . . 11Botox (non-cosmetic). . . 19Bravelle . . . . . . . . . . 18Breo Ellipta . . . . . . . . 21Brilinta . . . . . . . . . . . 11Budesonide Inhalation

Suspension . . . . . . . 21Bumetanide . . . . . . . . 11Bunavail . . . . . . . . . . 19Bupropion . . . . . . . . . 12Bupropion ER . . . . . . . 12Bupropion SR . . . . . . . 12Bupropion XL. . . . . . . . 12Buspirone . . . . . . . . . 13Butalbital-Acetaminophen-

Caffeine Cap, Tab . . . 13Bydureon . . . . . . . . . 15Byetta . . . . . . . . . . . 15Bystolic . . . . . . . . . . 11Byvalson . . . . . . . . . . 11

Index of Drugs

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

25

C

Cabometyx . . . . . . . . 10Calcitriol Cap. . . . . . . . 16Cambia . . . . . . . . . . 20Canasa. . . . . . . . . . . 17Capecitabine . . . . . . . . 10Carisoprodol . . . . . . . . 20Cartia XT . . . . . . . . . . 11Carvedilol . . . . . . . . . 11Cefdinir . . . . . . . . . . . 10Cefuroxime Tab . . . . . . 10Celecoxib . . . . . . . . . 20Cephalexin . . . . . . . . . 10Cerdelga . . . . . . . . . . 19Cetirizine . . . . . . . . . . 21Cetrotide. . . . . . . . . . 18Cheratussin . . . . . . . . 19Chlorhexidine . . . . . . . 19Chlorthalidone . . . . . . . 11Choline Fenofibrate ER . . 12Cialis . . . . . . . . . . . . 18Cialis . . . . . . . . . . . . 18Cimzia Kit . . . . . . . . . 18Ciprodex Otic Suspension 10Ciprofloxacin Ophthalmic

Solution. . . . . . . . . 16Ciprofloxacin Tab. . . . . . 10Citalopram . . . . . . . . . 12Claravis. . . . . . . . . . . 14Clarithromycin . . . . . . . 10Climara Pro . . . . . . . . 22Clindamycin/Benzoyl Peroxide

Gel 1.2-5% . . . . . . . 14Clindamycin/Benzoyl

Peroxide Gel 1-5% . . . 14Clindamycin Cap . . . . . . 10Clindamycin Gel, Lotion,

Solution. . . . . . . . . 14

Clobetasol Cream, Ointment, Solution . . . 14

Clobex . . . . . . . . . . . 14Clomiphene . . . . . . . . 16Clonazepam . . . . . . . . 14Clonidine Tab. . . . . . . . 11Clopidogrel . . . . . . . . . 11Clotrimazole/Betamethasone

Cream, Lotion . . . . . 14Combigan . . . . . . . . . 17Combivent Respimat . . . 21Complera . . . . . . . . . 18Contrave . . . . . . . . . 19Copaxone . . . . . . . . . 13Corlanor . . . . . . . . . . 12Cosentyx+ . . . . . . . . 18Cosopt PF . . . . . . . . . 17Creon . . . . . . . . . . . 17Cryselle-28 . . . . . . . . . 22Cyanocobalamine Injection 22Cyclobenzaprine Tab. . . . 20

D

Delzicol . . . . . . . . . . 17Depen . . . . . . . . . . . 18Descovy . . . . . . . . . . 10Dexamethasone Tab . . . . 16Dexilant . . . . . . . . . . 17Dexmethylphenidate

ER Cap . . . . . . . . . 12Diazepam Tab . . . . . . . 13Diclofenac Gel . . . . . . . 20Diclofenac Tab . . . . . . . 20Dicyclomine . . . . . . . . 17Digoxin . . . . . . . . . . . 12Diltiazem ER . . . . . . . . 11Dipentum . . . . . . . . . 17Diphenoxylate/Atropine . . 17

Divalproex DR . . . . . . . 14Divalproex ER . . . . . . . 14Divigel . . . . . . . . . . . 22Doryx MPC . . . . . . . . 10Doxazosin . . . . . . . 11, 18Doxepin . . . . . . . . . . 13Doxycycline Hyclate Cap . 10Doxycycline Hyclate Tab

(Immediate Release) . . 10Doxycycline Monohydrate

Cap . . . . . . . . . . . 10Doxycycline Monohydrate

Oral Suspension, Tab. . 10Duavee. . . . . . . . . . . 22Duexis . . . . . . . . . . . 17Dulera . . . . . . . . . . . 21Duloxetine Cap. . . . . . . 13Dupixent . . . . . . . . . . 14Dutasteride . . . . . . . . . 18Dymista Spray. . . . . . . 21

E

Edarbi . . . . . . . . . . . 11Edarbyclor. . . . . . . . . 11Effient . . . . . . . . . . . 11Elestrin Gel . . . . . . . . 22Elidel . . . . . . . . . . . . 14Eliquis . . . . . . . . . . . 11Embeda . . . . . . . . . . 20Enalapril . . . . . . . . . . 11Enbrel . . . . . . . . . . . 18Enoxaparin . . . . . . . . . 11Entecavir . . . . . . . . . . 10Epclusa . . . . . . . . . . 10Epiduo & Epiduo Forte . . 14Epinephrine Auto-Injector

(Authorized Generic for EpiPen made by Mylan) 19

Index of Drugs


26

Epinephrine Auto-Injector (M) (made by Impax) . 19

EpiPen & EpiPen Jr . . . . 19Epogen . . . . . . . . . . 19Erythromycin . . . . . . . . 10Erythromycin Ointment. . . 16Escitalopram Tab. . . . . . 13Esomeprazole Magnesium

(Rx only) . . . . . . . . 17Estrace Vaginal Cream . . 22Estradiol/Norethindrone Tab 22Estradiol Patch, Tab . . . . 22Eszopiclone Tab . . . . . . 14Etodolac . . . . . . . . . . 20Eucrisa . . . . . . . . . . 14Euflexxa . . . . . . . . . . 19Extavia . . . . . . . . . . . 13

F

Falmina. . . . . . . . . . . 22Famciclovir Tab . . . . . . 10Famotidine Tab (Rx only) . . 17Farxiga. . . . . . . . . . . 15Fenofibrate . . . . . . . . 12Fentanyl Patch . . . . . . . 20Fentora . . . . . . . . . . 20Finasteride . . . . . . . . . 18Flecainide . . . . . . . . . 12Flector patch . . . . . . . 20Flovent Diskus . . . . . . 21Flovent HFA . . . . . . . . 21Fluconazole . . . . . . . . 10Fluocinonide Cream, 0.1%. 14Fluocinonide Cream,

Gel, Ointment, Solution 0.05% . . . . . 14

Fluoxetine Cap (not PMDD) . . . . . . . 13

Fluticasone Spray . . . . . 21Folic Acid (Rx only) . . . . 22Follistim AQ . . . . . . . . 18Forfivo XL . . . . . . . . . 13Forteo . . . . . . . . . . . 20Fortesta . . . . . . . . . . 19Fosrenol . . . . . . . . . . 19Furosemide. . . . . . . . . 11

G

Gabapentin. . . . . . . . . 14Gavilyte Solution . . . . . . 17Gemfibrozil . . . . . . . . . 12Generess Fe Chewable . . 22Genotropin . . . . . . . . 16Genvoya . . . . . . . . . . 18Gianvi . . . . . . . . . . . 22Gildess . . . . . . . . . . . 22Gilenya. . . . . . . . . . . 13Glimepiride . . . . . . . . . 15Glipizide . . . . . . . . . . 15Glipizide ER . . . . . . . . 15Glipizide XL . . . . . . . . 15Glyburide . . . . . . . . . . 15Gonal-f. . . . . . . . . . . 18Gonal-f RFF . . . . . . . . 18Gralise . . . . . . . . . . . 20Granix . . . . . . . . . . . 19Guaifenesin/Codeine Syrup 19Guanfacine ER Tab. . . . . 12Guanfacine Tab

(Immediate Release) . . 11Gynazole-1 Vaginal

Cream . . . . . . . . . 23

H

Harvoni . . . . . . . . . . 10H.P. Acthar. . . . . . . . . 16Humalog Mix 50/50 Vial

and KwikPen . . . . . 15Humalog Mix 75-25 Vial

and KwikPen . . . . . 15Humalog U-100 Vial and

KwikPen . . . . . . . . 15Humalog U-200 KwikPen. 15Humatrope . . . . . . . . 16Humira Kit . . . . . . . . . 18Humira Pen Kit . . . . . . 18Humira Pen Kit Crohns . . 18Humira Pen Kit Psoriasis . 18Humulin 70-30 Vial and

KwikPen . . . . . . . . 15Humulin N Vial and

KwikPen . . . . . . . . 15Humulin R U-500 Vial

and KwikPen . . . . . 15Humulin R Vial. . . . . . . 15Hydralazine. . . . . . . . . 11Hydrochlorothiazide . . . . 11Hydrocodone/

Acetaminophe . . . . . 20Hydrocodone/

Chlorpheniramine Liquid 19Hydrocodone Polistirex/

Chlorpheniramine ER Suspension . . . . . . . 19

Hydrocortisone Cream, Ointment 2.5% . . . . . 14

Hydrocortisone Tab . . . . 16Hydromorphone Tab . . . . 20Hydroxychloroquine . . . . 18Hydroxyzine HCL . . . . . 13Hydroxyzine Pamoate . . . 13Hysingla ER . . . . . . . . 20

Index of Drugs


27

I

Ibuprofen Tab (Rx only). . . 20Incruse Ellipta . . . . . . . 21Indomethacin Cap . . . . . 20Inflectra . . . . . . . . . . 18Invega Sustenna . . . . . 13Invega Trinza . . . . . . . 13Invokamet . . . . . . . . . 15Invokamet XR . . . . . . . 15Invokana. . . . . . . . . . 15Ipratropium/Albuterol

Nebulizer Solution . . . 21Ipratropium Spray . . . . . 21Irbesartan . . . . . . . . . 11Isentress. . . . . . . . . . 18Isosorbide Mononitrate ER. 12

J

Janumet . . . . . . . . . . 15Janumet XR . . . . . . . . 15Januvia . . . . . . . . . . 15Jardiance . . . . . . . . . 15Jentadueto . . . . . . . . 15Jentadueto XR . . . . . . 15Jolivette . . . . . . . . . . 22Jublia Solution . . . . . . 10Junel . . . . . . . . . . . . 22

K

Kariva . . . . . . . . . . . 22Kazano. . . . . . . . . . . 16Kerydin Solution . . . . . 10Ketoconazole Cream/

Shampoo . . . . . . . . 14Ketorolac Ophthalmic

Solution. . . . . . . . . 17Ketorolac Tab . . . . . . . 20

Kitabis . . . . . . . . . . . 10Klor-Con . . . . . . . . . . 22Kombiglyze . . . . . . . . 16

L

Labetalol . . . . . . . . . . 11Lamotrigine

(Immediate Release) . . 14Lansoprazole (Rx only) . . . 17Lantus SoloStar . . . . . . 15Lantus Vial. . . . . . . . . 15Latanoprost . . . . . . . . 17Latuda . . . . . . . . . . . 13Lazanda . . . . . . . . . . 20Leflunomide . . . . . . . . 18Letairis. . . . . . . . . . . 12Letrozole . . . . . . . . . . 10Levalbuterol Inhaler (M) . 21Levemir FlexTouch . . . . 15Levemir Vial . . . . . . . . 15Levetiracetam . . . . . . . 14Levetiracetam ER . . . . . 14Levitra . . . . . . . . . . . 18Levocetirizine . . . . . . . 21Levofloxacin Tab . . . . . . 10Levora 28. . . . . . . . . . 22Levothyroxine . . . . . . . 16Lialda . . . . . . . . . . . 17Lidocaine Patch 5% . . . . 20Lidocaine Topical

Ointment, Solution . . . 14Lidocaine Viscous

Solution 2% . . . . . . 19Linzess. . . . . . . . . . . 17Liothyronine . . . . . . . . 16Lisinopril . . . . . . . . . . 11Lisinopril/HCTZ . . . . . . 11Livalo . . . . . . . . . . . 12

Lomedia Fe. . . . . . . . . 22Lorazepam Tab. . . . . . . 13Loryna . . . . . . . . . . . 22Lorzone . . . . . . . . . . 20Losartan . . . . . . . . . . 11Losartan/HCTZ. . . . . . . 11Lovastatin . . . . . . . . . 12Low-Ogestrel. . . . . . . . 22Ludent . . . . . . . . . . . 22Lumigan . . . . . . . . . . 17Lupron Depot . . . . . . . 16Lutera . . . . . . . . . . . 22Lyrica Cap . . . . . . . . . 14

M

Makena . . . . . . . . . . 19Mavyret . . . . . . . . . . 10Meclizine . . . . . . . . . . 17Medroxyprogesterone

Acetate Injection . . . . 22Medroxyprogesterone

Acetate Tab. . . . . . . 23Meloxicam . . . . . . . . . 20Mercaptopurine . . . . . . 11Mesalamine DR (M) . . . . 17Metaxalone. . . . . . . . . 20Metformin . . . . . . . . . 16Metformin ER . . . . . . . 16Methadone Tab. . . . . . . 20Methimazole . . . . . . . . 16Methocarbamol . . . . . . 20Methotrexate Tab . . . . . 18Methylphenidate

ER Cap . . . . . . . . . 12Methylphenidate ER Tab . . 12Methylphenidate SA

Osmotic ER Tab . . . . 12Methylphenidate Tab . . . . 12

Index of Drugs


28

Methylprednisolone Tab . . 16Metoclopramide . . . . . . 17Metoprolol Succinate . . . 11Metoprolol Tartrate . . . . . 11Metrogel . . . . . . . . . . 14Metronidazole Gel 0.75% . 14Metronidazole Tab . . . . . 10Metronidazole

Vaginal Gel . . . . . . . 23Microgestin. . . . . . . . . 22Microgestin Fe . . . . . . . 22Migranal . . . . . . . . . . 13Minivelle . . . . . . . . . . 23Minocycline Cap . . . . . . 10Mirtazapine. . . . . . . . . 13Mirvaso Gel . . . . . . . . 14Misoprostol. . . . . . . . . 17Modafinil . . . . . . . . . . 13Mometasone . . . . . . . . 21Mono-Linyah . . . . . . . . 22Mononessa. . . . . . . . . 22Montelukast . . . . . . . . 21Morphine Sulfate ER . . . . 20Movantik. . . . . . . . . . 17Moxeza . . . . . . . . . . 16Multaq . . . . . . . . . . . 12Mupirocin Ointment . . . . 14Mycophenolate Mofetil

Cap/Tab . . . . . . . . 21Mycophenolate Sodium

Tab . . . . . . . . . . . 21Myorisan . . . . . . . . . . 14Myrbetriq . . . . . . . . . 21

N

Nabumetone . . . . . . . . 20Nadolol . . . . . . . . . . . 11Namenda XR . . . . . . . 13Namzaric . . . . . . . . . 13Naproxen (Rx only) . . . . . 20Narcan . . . . . . . . . . . 19Necon . . . . . . . . . . . 22Nesina . . . . . . . . . . . 16Neupogen . . . . . . . . . 19Niacin ER Tab . . . . . . . 12Nifedipine ER. . . . . . . . 11Nitrofurantoin

Macrocrystalline . . . . 10Nitrofurantoin Monohydrate

Macrocrystalline . . . . 10Nitroglycerin SL Tab . . . . 12Nora-Be . . . . . . . . . . 22Norditropin . . . . . . . . 16Norgest/Ethi Estradio . . . 22Nortrel . . . . . . . . . . . 22Nortriptyline . . . . . . . . 13Norvir . . . . . . . . . . . 18Novolin 70/30 Vial . . . . . 15Novolin N Vial . . . . . . . 15Novolin R Vial . . . . . . . 15Novolog Flexpen . . . . . 15Novolog Mix 70/30 Vial

and Flexpen . . . . . . 15Novolog Penfill . . . . . . 15Novolog Vial . . . . . . . . 15Nucynta ER . . . . . . . . 20Nutropin AQ . . . . . . . . 16Nuvaring . . . . . . . . . . 22Nystatin Cream, Ointment,

Powder . . . . . . . . . 14Nystatin Suspension . . . . 10

O

Ocella . . . . . . . . . . . 22Odefsey . . . . . . . . . . 10Ofloxacin Ophthalmic

Solution. . . . . . . . . 16Ofloxacin Otic Solution. . . 10Olanzapine Tab. . . . . . . 13Olmesartan . . . . . . . . . 11Olmesartan HCT . . . . . . 11Omega-3 Acid Cap. . . . . 12Omeprazole (Rx only) . . . 17Omnaris . . . . . . . . . . 21Omnitrope . . . . . . . . 16Ondansetron ODT . . . . . 17Ondansetron Tab. . . . . . 17Onexton . . . . . . . . . . 15Onglyza . . . . . . . . . . 16Opsumit . . . . . . . . . . 12Oracea . . . . . . . . . . . 10Orencia SC . . . . . . . . 18Orenitram . . . . . . . . . 12Orsythia . . . . . . . . . . 22Oseltamivir . . . . . . . . . 10Oseni. . . . . . . . . . . . 16Osphena . . . . . . . . . . 23Otezla . . . . . . . . . . . 18Ovidrel . . . . . . . . . . . 18Oxcarbazepine . . . . . . . 14Oxsoralen-UL . . . . . . . 15Oxybutynin . . . . . . . . 21Oxybutynin ER . . . . . . . 21Oxycodone Tab

(Immediate Release) . . 20Oxycodone

w/ Acetaminophen . . . 20Oxycontin . . . . . . . . . 20

Index of Drugs


29

P

Pancreaze . . . . . . . . . 17Pantoprazole . . . . . . . . 17Paroxetine Tab . . . . . . . 13Pataday . . . . . . . . . . 16Pazeo . . . . . . . . . . . 16Penicillin VK . . . . . . . . 10Pennsaid Solution. . . . . 15Pentasa . . . . . . . . . . 17Permethrin Cream 5% . . . 15Pertzye. . . . . . . . . . . 17Phenazopyridine (Rx only) . 19Phentermine Tab . . . . . . 19Pioglitazone . . . . . . . . 16Plegridy . . . . . . . . . . 13Polyethylene

Glycol 3350 Powder . . 17Polymyxin B/Trimethoprim

Solution. . . . . . . . . 16Potassium Chloride ER

Tab, Cap . . . . . . . . 22Potassium Chloride

Micro ER Tab . . . . . . 22Pradaxa . . . . . . . . . . 11Praluent . . . . . . . . . . 12Pramipexole . . . . . . . . 13Pravastatin . . . . . . . . . 12Prazosin . . . . . . . . . . 11Prednisolone Ophthalmic

Suspension . . . . . . . 17Prednisolone Solution . . . 16Prednisolone Syrup,

Solution. . . . . . . . . 16Prednisone . . . . . . . . . 16Premarin Tab . . . . . . . 23Premarin Vaginal Cream . 23Premphase . . . . . . . . 23Prempro . . . . . . . . . . 23

Prepopik . . . . . . . . . . 17Previfem . . . . . . . . . . 22Prezcobix . . . . . . . . . 18Prezista . . . . . . . . . . 18Primidone . . . . . . . . . 14Proair HFA, RespiClick . . 21Procrit . . . . . . . . . . . 19Proctofoam HC . . . . . . 15Progesterone Cap . . . . . 23Prograf Cap . . . . . . . . 21Promethazine/

Codeine Syrup . . . . . 19Promethazine DM Syrup . . 19Promethazine Tab . . . . . 21Propranolol . . . . . . . . . 11Propranolol ER . . . . . . . 11Proventil HFA . . . . . . . 21Pulmicort Flexhaler . . . . 21Pylera . . . . . . . . . . . 18

Q

QNasl . . . . . . . . . . . 21Quetiapine . . . . . . . . . 13Quinapril . . . . . . . . . . 11Qvar . . . . . . . . . . . . 21

R

Rabeprazole . . . . . . . . 18Ramipril . . . . . . . . . . 11Ranexa. . . . . . . . . . . 12Ranitidine Tab, Cap,

Syrup (Rx only) . . . . . 17Rapaflo . . . . . . . . . . 18Rasuvo. . . . . . . . . . . 18Rebif . . . . . . . . . . . . 13Rebif Titrtn . . . . . . . . 13Reclipsen. . . . . . . . . . 22

Relpax . . . . . . . . . . . 13Remicade . . . . . . . . . 18Renvela Tab . . . . . . . . 19Rescula . . . . . . . . . . 17Restasis . . . . . . . . . . 17Restasis Multidose . . . . 17Revlimid . . . . . . . . . . 11Rexulti . . . . . . . . . . . 13Reyataz . . . . . . . . . . 18Rezira . . . . . . . . . . . 19Risperidone Tab . . . . . . 13Rizatriptan Tab, ODT . . . . 13Ropinirole

(Immediate Release) . . 13Rosuvastatin . . . . . . . . 12

S

Saizen . . . . . . . . . . . 16Saphris. . . . . . . . . . . 13Savaysa . . . . . . . . . . 11Serevent Diskus. . . . . . 21Sertraline . . . . . . . . . . 13Sildenafil Tab . . . . . . . . 12Silenor . . . . . . . . . . . 14Simbrinza . . . . . . . . . 17Simponi . . . . . . . . . . 18Simponi Aria. . . . . . . . 18Simvastatin . . . . . . . . . 12Soliqua. . . . . . . . . . . 16Solodyn . . . . . . . . . . 10Soolantra . . . . . . . . . 15Sotalol . . . . . . . . . . . 12Spiriva Handihaler . . . . 21Spiriva Respimat . . . . . 21Spironolactone . . . . . . . 11Sprintec 28 . . . . . . . . . 22Sprycel. . . . . . . . . . . 11Staxyn . . . . . . . . . . . 18

Index of Drugs


30

Stelara . . . . . . . . . . . 18Stendra . . . . . . . . . . 18Stiolto . . . . . . . . . . . 21Strattera . . . . . . . . . . 12Stribild . . . . . . . . . . . 18Suboxone Film . . . . . . 19Subsys . . . . . . . . . . . 20Sucralfate Tab . . . . . . . 17Sulfamethoxazole-

Trimethoprim . . . . . . 10Sulfamethoxazole-

Trimethoprim DS . . . . 10Sumatriptan Tab

and Spray . . . . . . . 13Sumavel Dose . . . . . . . 13Suprep Bowel Prep . . . . 18Symbicort . . . . . . . . . 21Synjardy . . . . . . . . . . 16Synjardy XR . . . . . . . . 16Synthroid . . . . . . . . . 16Synvisc . . . . . . . . . . 19Synvisc One . . . . . . . . 19

T

Tacrolimus Cap. . . . . . . 21Taltz . . . . . . . . . . . . 18Tamoxifen Tab . . . . . . . 11Tamsulosin . . . . . . . . . 18Tanzeum . . . . . . . . . . 16Tazorac . . . . . . . . . . 15Tecfidera. . . . . . . . . . 13Tekturna . . . . . . . . . . 11Tekturna HCT . . . . . . . 11Telmisartan . . . . . . . . . 11Temazepam . . . . . . . . 14Terazosin . . . . . . . . 11, 18Terbinafine Tab . . . . . . . 10

Terconazole Vaginal Cream . . . . . 23

Testim . . . . . . . . . . . 19Testosterone Cypionate

IM Injection . . . . . . . 19Tirosint. . . . . . . . . . . 16Tivicay . . . . . . . . . . . 18Tizanidine Cap . . . . . . . 20Tizanidine Tab . . . . . . . 20TOBI podhaler. . . . . . . 10Tobramycin . . . . . . . . 10Tobramycin . . . . . . . . . 16Tobramycin/

Dexamethasone . . . . 17Topiramate Tab. . . . . . . 14Torsemide Tab . . . . . . . 11Toujeo SoloStar . . . . . . 15Toviaz . . . . . . . . . . . 21Tracleer . . . . . . . . . . 12Tradjenta . . . . . . . . . 16Tramadol Tab. . . . . . . . 20Tramadol

w/ Acetaminophen . . . 20Travatan Z . . . . . . . . . 17Trazodone . . . . . . . . . 13Tresiba . . . . . . . . . . . 15Tretinoin Cream . . . . . . 15Tretinoin Microsphere Gel . 15Triamcinolone . . . . . . . 15Triamterene/HCTZ . . . . . 11Triazolam Tab. . . . . . . . 14Tri-Linyah. . . . . . . . . . 22Tri-Lo-Sprintec . . . . . . . 22Trinessa . . . . . . . . . . 22Trintellix . . . . . . . . . . 13Tri-Previfem . . . . . . . . 22Tri-Sprintec. . . . . . . . . 22Triumeq . . . . . . . . . . 18

Trokendi XR . . . . . . . . 14Trulicity . . . . . . . . . . 16Truvada . . . . . . . . . . 18Tudorza . . . . . . . . . . 21Tymlos . . . . . . . . . . . 20

U

Uceris Foam. . . . . . . . 18Uloric . . . . . . . . . . . 19Ultresa . . . . . . . . . . . 18

V

Valacyclovir. . . . . . . . . 10Valsartan . . . . . . . . . . 11Valsartan/HCTZ . . . . . . 11Varubi . . . . . . . . . . . 17Vascepa . . . . . . . . . . 12Vectical . . . . . . . . . . 15Velphoro . . . . . . . . . . 19Veltin . . . . . . . . . . . . 15Venlafaxine ER Cap . . . . 13Venlafaxine ER Tab. . . . . 13Venlafaxine Tab. . . . . . . 13Ventolin HFA. . . . . . . . 21Verapamil ER . . . . . . . . 11Vesicare . . . . . . . . . . 21Vestura . . . . . . . . . . . 22Viagra . . . . . . . . . . . 18Victoza. . . . . . . . . . . 16Vigamox . . . . . . . . . . 17Viibryd . . . . . . . . . . . 13Vimovo. . . . . . . . . . . 17Vimpat . . . . . . . . . . . 14Viokace . . . . . . . . . . 18Viorele . . . . . . . . . . . 22Viread . . . . . . . . . . . 18Vitamin D (Rx only) . . . . . 22

Index of Drugs


31

Vogelxo . . . . . . . . . . 19Vyvanse . . . . . . . . . . 12

W

Warfarin . . . . . . . . . . 11Welchol . . . . . . . . . . 12

X

Xarelto . . . . . . . . . . . 11Xeljanz . . . . . . . . . . . 18Xigduo XR . . . . . . . . . 16Xiidra. . . . . . . . . . . . 17Xolair. . . . . . . . . . . . 21Xopenex HFA . . . . . . . 21Xtampza ER . . . . . . . . 20Xulane . . . . . . . . . . . 22Xyrem . . . . . . . . . . . 13

Y

Yuvafem . . . . . . . . . . 23

Z

Zaleplon . . . . . . . . . . 14Zarah . . . . . . . . . . . . 22Zarxio . . . . . . . . . . . 19Zenpep . . . . . . . . . . 18Zepatier . . . . . . . . . . 10Zetonna . . . . . . . . . . 21Zioptan . . . . . . . . . . 17Zohydro ER . . . . . . . . 21Zolpidem . . . . . . . . . . 14Zolpidem ER . . . . . . . . 14Zomacton . . . . . . . . . 16Zonisamide. . . . . . . . . 14Zontivity . . . . . . . . . . 11Zorvolex . . . . . . . . . . 21Zovirax Cream . . . . . . 15Zubsolv . . . . . . . . . . 19Zurampic . . . . . . . . . 19Zutripro . . . . . . . . . . 19Zyclara. . . . . . . . . . . 15Zytiga . . . . . . . . . . . 11

Index of Drugs


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.

My Medications worksheet

Name of Medicine and Strength

Drug Tier

I Take This Medicine For

Directions Doctor

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

33

Notice of Nondiscrimination

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AbsoricaAbstralAcanya GelAcetaminophen w/ Codeine Acyclovir Cap, Tab, SuspensionAczone GelAdcircaAdempasAdlyxinAdrenaclickAdvair DiskusAdvair HFAAerospanAirDuoAktipakAkynzeoAlbuterol Nebulizer SolutionAlendronate Tab 35 mg & 70 mgAllopurinolAlogliptin (M)Alogliptin/metformin (M)Alogliptin/pioglitazone (M)Alprazolam TabAlvescoAmitizaAmitriptylineAmlodipineAmlodipine/BenazeprilAmlodipine/ValsartanAmoxicillinAmoxicillin/ClavulanateAmphetamine-Dextroamphetamine SR 24Hr CapAmphetamine-Dextroamphetamine Tab AmpyraAmrixAnastrozole TabAndrodermAndrogel 1.62%Anoro ElliptaApidraApriAprisoAranespAripiprazoleAristadaArmodafinilArmour ThyroidArnuity ElliptaArymo ERAsacol HDAsmanexAsteproAtenololAtenolol/ChlorthalidoneAtorvastatin AtralinAtriplaAubagioAuryxiaAuvi-QAvianeAvonex KitAvonex Pen KitAvonex Prefill KitAxiron AzasiteAzathioprine TabAzelastine Ophthalmic SolutionAzelastine SprayAzithromycinAzoptAzuretteBaclofen TabBasaglarBenazeprilBenazepril/HCTZ BenzonatateBesivanceBetaseronBethkisBetimolBinostoBisoprololBisoprolol/HCTZBotox 100, 200 unit Injection (non-cosmetic)Bravelle Breo ElliptaBrilintaBudesonide Inhalation SuspensionBumetanideBunavailBupropionBupropion ERBupropion SRBupropion XLBuspironeButalbital-Acetaminophen-Caffeine Cap, Tab 50-325-40 mgBydureonByettaBystolicByvalsonCabometyxCalcitriol CapCambiaCanasaCapecitabineCarisoprodol 350 mgCartia XTCarvedilolCefdinirCefuroxime TabCelecoxibCephalexinCerdelgaCetirizineCetrotideCheratussinChlorhexidineChlorthalidoneCholine Fenofibrate ER CialisCialis 2.5 mg & 5 mgCimzia KitCiprodex Otic SuspensionCiprofloxacin Ophthalmic SolutionCiprofloxacin TabCitalopramClaravisClarithromycinClimara ProClindamycin/Benzoyl Peroxide Gel 1.2-5%Clindamycin/Benzoyl Peroxide Gel 1-5%Clindamycin CapClindamycin Gel, Lotion, SolutionClobetasol Cream, Ointment, SolutionClobexClomipheneClonazepamClonidine TabClopidogrelClotrimazole/Betamethasone Cream, LotionCombiganCombivent RespimatCompleraContrave Copaxone 20 mg/mL & 40 mg/mLCorlanorCosentyx+ Cosopt PFCreonCryselle-28Cyanocobalamine InjectionCyclobenzaprine Tab 5, 10 mgDelzicolDepenDescovyDexamethasone Tab DexilantDexmethylphenidate ER CapDiazepam TabDiclofenac GelDiclofenac TabDicyclomineDigoxinDiltiazem ERDipentumDiphenoxylate/AtropineDivalproex DRDivalproex ERDivigelDoryx MPCDoxazosinDoxepinDoxycycline Hyclate CapDoxycycline Hyclate Tab (Immediate Release)Doxycycline Monohydrate CapDoxycycline Monohydrate Oral Suspension, TabDuaveeDuexisDuleraDuloxetine Cap 20 mg, 30 mg, 60 mgDupixentDutasterideDymista SprayEdarbiEdarbyclorEffientElestrin GelElidelEliquisEmbedaEnalaprilEnbrelEnoxaparinEntecavirEpclusaEpiduo & Epiduo ForteEpinephrine Auto-Injector (Authorized Generic for EpiPen made by Mylan)Epinephrine Auto-Injector (M) (made by Impax)EpiPen & EpiPen JrEpogenErythromycinErythromycin OintmentEscitalopram TabEsomeprazole Magnesium (Rx only)Estrace Vaginal CreamEstradiol/Norethindrone TabEstradiol Patch, TabEszopiclone TabEtodolacEucrisa EuflexxaExtaviaFalminaFamciclovir TabFamotidine Tab 20 mg and 40 mg (Rx only)FarxigaFenofibrate 40 mg, 43 mg, 48 mg, 50 mg, 54 mg, 67 mg, 120 mg,130 mg, 134 mg, 145 mg, 150 mg, 160 mg, 200 mgFentanyl Patch 25 mcg/hr, 50 mcg/hr, 75 mcg/hr, 100 mcg/hrFentoraFinasteride 5 mgFlecainideFlector patchFlovent DiskusFlovent HFAFluconazoleFluocinonide Cream, 0.1%Fluocinonide Cream, Gel, Ointment, Solution 0.05%Fluoxetine Cap (not PMDD)Fluticasone SprayFolic Acid 1 mg (Rx only) Follistim AQForfivo XLForteoFortestaFosrenolFurosemideGabapentinGavilyte SolutionGemfibrozilGeneress Fe ChewableGenotropinGenvoyaGianviGildessGilenyaGlimepirideGlipizideGlipizide ERGlipizide XLGlyburideGonal-fGonal-f RFFGraliseGranixGuaifenesin/Codeine SyrupGuanfacine ER TabGuanfacine Tab(Immediate Release)Gynazole-1 Vaginal CreamHarvoniH.P. ActharHumalog Mix 50/50 Vial and KwikPenHumalog Mix 75-25 Vial and KwikPenHumalog U-100 Vial and KwikPenHumalog U-200 KwikPenHumatropeHumira KitHumira Pen KitHumira Pen Kit CrohnsHumira Pen Kit PsoriasisHumulin 70-30 Vial and KwikPenHumulin N Vial and KwikPenHumulin R U-500 Vial and KwikPenHumulin R VialHydralazineHydrochlorothiazideHydrocodone/Acetaminophen5, 7.5, 10/325 mg Hydrocodone/Chlorpheniramine LiquidHydrocodone Polistirex/Chlorpheniramine ER SuspensionHydrocortisone Cream, Ointment 2.5%Hydrocortisone TabHydromorphone TabHydroxychloroquineHydroxyzine HCLHydroxyzine PamoateHysingla ER Ibuprofen Tab 400, 600, 800 mg (Rx only)Incruse ElliptaIndomethacin CapInflectraInvega SustennaInvega Trinza InvokametInvokamet XRInvokanaIpratropium/Albuterol Nebulizer SolutionIpratropium SprayIrbesartanIsentressIsosorbide Mononitrate ERJanumetJanumet XRJanuviaJardianceJentaduetoJentadueto XRJolivetteJublia SolutionJunelKarivaKazanoKerydin SolutionKetoconazole Cream/ShampooKetorolac Ophthalmic SolutionKetorolac TabKitabisKlor-Con 8 and 10 MEQKlor-Con M10 and M20KombiglyzeLabetalolLamotrigine (Immediate Release)Lansoprazole (Rx only)Lantus SoloStarLantus VialLatanoprostLatudaLazandaLeflunomideLetairisLetrozoleLevalbuterol Inhaler (M) Levemir FlexTouchLevemir VialLevetiracetamLevetiracetam ERLevitraLevocetirizineLevofloxacin TabLevora 28LevothyroxineLialdaLidocaine Patch 5%Lidocaine Topical Ointment, SolutionLidocaine Viscous Solution 2%LinzessLiothyronine LisinoprilLisinopril/HCTZLivaloLomedia FeLorazepam TabLorynaLorzoneLosartanLosartan/HCTZLovastatin Low-OgestrelLudentLumiganLupron Depot 3.75 mg, 11.25 mgLupron Depot 7.5 mg, 22.5 mg, 30 mg, 45 mgLuteraLyrica CapMakenaMavyretMeclizineMedroxyprogesterone Acetate InjectionMedroxyprogesterone Acetate TabMeloxicamMercaptopurineMesalamine DR (M)MetaxaloneMetforminMetformin ERMethadone TabMethimazoleMethocarbamolMethotrexate TabMethylphenidate ER CapMethylphenidate ER TabMethylphenidate SA Osmotic ER TabMethylphenidate TabMethylprednisolone TabMetoclopramideMetoprolol SuccinateMetoprolol TartrateMetrogelMetronidazole Gel 0.75%Metronidazole TabMetronidazole Vaginal GelMicrogestinMicrogestin FeMigranalMinivelleMinocycline CapMirtazapineMirvaso GelMisoprostolModafinilMometasoneMono-LinyahMononessaMontelukast Morphine Sulfate ERMovantikMoxezaMultaqMupirocin OintmentMycophenolate Mofetil 250 mg Cap/500 mg TabMycophenolate Sodium 180 mg, 360 mg TabMyorisanMyrbetriqNabumetoneNadololNamenda XRNamzaricNaproxen (Rx only)NarcanNeconNesinaNeupogenNiacin ER TabNifedipine ERNitrofurantoin MacrocrystallineNitrofurantoin Monohydrate MacrocrystallineNitroglycerin SL TabNora-BeNorditropinNorgest/Ethi EstradioNortrelNortriptylineNorvirNovolin 70/30 VialNovolin N VialNovolin R VialNovolog FlexpenNovolog Mix 70/30 Vial and FlexpenNovolog PenfillNovolog VialNucynta ERNutropin AQNuvaringNystatin Cream, Ointment, PowderNystatin SuspensionOcellaOdefseyOfloxacin Ophthalmic SolutionOfloxacin Otic SolutionOlanzapine TabOlmesartanOlmesartan HCTOmega-3 Acid Cap 1 gmOmeprazole (Rx only)OmnarisOmnitrope Ondansetron ODTOndansetron TabOnextonOnglyzaOpsumitOraceaOrencia SCOrenitramOrsythiaOseltamivirOseniOsphenaOtezlaOvidrelOxcarbazepineOxsoralen-ULOxybutynin Oxybutynin EROxycodone Tab 5, 10, 15, 30 mg (Immediate Release)Oxycodone w/ Acetaminophen OxycontinPancreazePantoprazoleParoxetine TabPatadayPazeoPenicillin VKPennsaid SolutionPentasaPermethrin Cream 5%PertzyePhenazopyridine (Rx only)Phentermine TabPioglitazonePlegridyPolyethylene Glycol 3350 PowderPolymyxin B/Trimethoprim SolutionPotassium Chloride ER Tab, CapPotassium Chloride Micro ER TabPradaxaPraluentPramipexolePravastatinPrazosinPrednisolone Ophthalmic SuspensionPrednisolone Solution 25 mg/5 mlPrednisolone Syrup, Solution 15 mg/5 mlPrednisonePremarin TabPremarin Vaginal CreamPremphasePremproPrepopikPrevifemPrezcobixPrezistaPrimidoneProair HFA, RespiClickProcritProctofoam HCProgesterone CapPrograf CapPromethazine/Codeine SyrupPromethazine DM SyrupPromethazine TabPropranololPropranolol ERProventil HFAPulmicort FlexhalerPyleraQNaslQuetiapineQuinaprilQvarRabeprazoleRamiprilRanexaRanitidine Tab, Cap, Syrup (Rx only)RapafloRasuvoRebifRebif TitrtnReclipsenRelpaxRemicadeRenvela TabResculaRestasisRestasis MultidoseRevlimidRexultiReyatazReziraRisperidone TabRizatriptan Tab, ODTRopinirole (Immediate Release)RosuvastatinSaizenSaphrisSavaysaSerevent DiskusSertralineSildenafil Tab 20 mgSilenorSimbrinzaSimponiSimponi AriaSimvastatin 5 mg, 10 mg, 20 mg, 40 mgSoliquaSolodynSoolantraSotalolSpiriva HandihalerSpiriva RespimatSpironolactoneSprintec 28SprycelStaxynStelaraStendraStioltoStratteraStribildSuboxone FilmSubsysSucralfate TabSulfamethoxazole-TrimethoprimSulfamethoxazole-Trimethoprim DSSumatriptan Tab and SpraySumavel DoseSuprep Bowel PrepSymbicortSynjardySynjardy XRSynthroidSynviscSynvisc OneTacrolimus CapTaltzTamoxifen TabTamsulosinTanzeumTazoracTecfideraTekturnaTekturna HCTTelmisartanTemazepamTerazosinTerbinafine TabTerconazole Vaginal CreamTestimTestosterone Cypionate IM InjectionTirosintTivicayTizanidine CapTizanidine TabTOBI podhalerTobramycinTobramycinTobramycin/DexamethasoneTopiramate TabTorsemide TabToujeo SoloStarToviazTracleerTradjentaTramadol Tab 50 mgTramadol w/ Acetaminophen Travatan ZTrazodoneTresibaTretinoin CreamTretinoin Microsphere GelTriamcinoloneTriamterene/HCTZTriazolam TabTri-LinyahTri-Lo-SprintecTrinessaTrintellixTri-PrevifemTri-SprintecTriumeqTrokendi XRTrulicityTruvadaTudorzaTymlosUceris FoamUloricUltresaValacyclovirValsartanValsartan/HCTZVarubiVascepaVecticalVelphoroVeltinVenlafaxine ER CapVenlafaxine ER TabVenlafaxine TabVentolin HFAVerapamil ERVesicareVesturaViagraVictozaVigamoxViibrydVimovoVimpatViokaceVioreleVireadVitamin D 50,000 units (Rx only)VogelxoVyvanseWarfarinWelcholXareltoXeljanzXigduo XRXiidraXolairXopenex HFAXtampza ERXulaneXyremYuvafemZaleplonZarahZarxioZenpep ZepatierZetonnaZioptanZohydro ERZolpidemZolpidem ERZomactonZonisamideZontivityZorvolexZovirax CreamZubsolvZurampicZutriproZyclaraZytiga

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2018 Prescription Drug List/Formulary … ERS Prescription...Your Prescription Drug List / Formulary ... in the Drug Tier column, check your benefit plan documents to find out your