Your 2018 Formulary - Cookies Not Enabled January 1, 2018 Your 2018 Formulary SignatureValue Three-Tier This formulary is accurate as of January 2018 and is subject to change after

Effective January 1, 2018

Your 2018 FormularySignatureValue Three-TierThis formulary is accurate as of January 2018 and is subject to change after this date. The next anticipated update will be July 2018. This formulary applies to members of our UnitedHealthcare West HMO medical plans with a pharmacy benefit. Your estimated coverage and copayment/coinsurance may vary based on the benefit plan you choose and the effective date of the plan.

Drug tiers and cost . . . . . . . . . . . . . . . . . . . . . . 4

Restrictions on what medications are covered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Drugs by category . . . . . . . . . . . . . . . . . . . . . . . 8

Anti-InfectivesAntibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Cardiovascular/Heart DiseaseCoagulation Therapy . . . . . . . . . . . . . . . . . . . . . 10High Blood Pressure . . . . . . . . . . . . . . . . . . . . . 10High Cholesterol . . . . . . . . . . . . . . . . . . . . . . . . . 11Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

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

Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

DiabetesBlood Glucose Monitoring . . . . . . . . . . . . . . . . . 16Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Non-Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

EndocrineGrowth Hormone . . . . . . . . . . . . . . . . . . . . . . . . 17Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Thyroid Hormone Replacement . . . . . . . . . . . . 18

Eye ConditionsAllergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

GastrointestinalAcid Suppression . . . . . . . . . . . . . . . . . . . . . . . . 19

Nausea/Vomiting . . . . . . . . . . . . . . . . . . . . . . . . 19

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Inflammatory Conditions: RheumatoidArthritis, Crohn’s Disease, Psoriasis,Ulcerative Colitis . . . . . . . . . . . . . . . . . . . . . . . . 21

Medications for Sexual Dysfuntion . . . . . . . 21

Men’s HealthProstate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Testosterone Therapy . . . . . . . . . . . . . . . . . . . . . 21

Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . 21

MusculoskeletalOsteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Pain Relief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Overactive Bladder . . . . . . . . . . . . . . . . . . . . . . 24

RespiratoryAsthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Nasal Allergies . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Oral Allergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Pulmonary Arterial Hypertension . . . . . . . . . . . 25

Smoking Cessation . . . . . . . . . . . . . . . . . . . . . 25

Transplant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Vitamins/Electrolytes . . . . . . . . . . . . . . . . . . . 25

Women’s HealthContraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Hormone Replacement . . . . . . . . . . . . . . . . . . . 28

Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Prenatal Vitamins . . . . . . . . . . . . . . . . . . . . . . . . 28

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Table of Contents

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We want to help you better understand your medication options.Your pharmacy benefit offers flexibility and choice in determining the right medication for you. To help you get the most out of your pharmacy benefit, we’ve included some of the most commonly asked questions about the formulary.

What is a formulary?This document is a list of the most commonly prescribed medications. It includes both brand-name and generic prescription medications approved by the Food and Drug Administration (FDA). Medications are listed by common categories or classes and placed in tiers that represent the cost you pay out-of-pocket. They are then listed in alphabetical order. Bring this list with you when you see your doctor. It makes it easier for you and your doctor to make informed decisions about your medications and may help you save money.

Please note: Where differences are noted between this formulary and your benefit plan documents, the benefit plan documents will rule. This formulary is not a complete list of medications, and not all medications listed may be covered under your plan. Please look at your benefit plan documents provided by your employer or health plan to see which medications are covered under your plan.

What is a tier?Tiers indicate the amount you pay for your prescription, which is determined by your employer or benefit plan. Formulary Generic medications provide the highest overall value with the lowest out-of-pocket costs. Choosing medications in lower tiers may save you money. Ask your doctor if a Formulary Generic or Formulary Brand option could work for you.

Your Cost Drug Tier* What’s Covered Helpful Hints

$ Lowest

Formulary Generic

Medications that provide the highest overall value. Mostly generic drugs. Some brand-name drugs may also be included.

Use Formulary Generic drugs for the lowest out-of-pocket costs.

$$ Mid-range

Formulary Brand

Medications that provide good overall value. A mix of brand-name and generic drugs.

Use Formulary Brand drugs, instead of Non-Formulary drugs, to help reduce your out-of-pocket costs.

$$$ Higher

Non-Formulary

Medications that provide the lowest overall value. Mostly brand-name drugs, as well as some generics.

Ask your doctor if a Formulary Generic or Formulary Brand option could work for you.

* Some plans may have different tiers. If you have a high deductible plan, the tier cost levels may apply once you hit your deductible.

Who decides what medications are covered? Thousands of medications are already available and more come to the market regularly. Often, several medications are available to treat the same condition.

The UnitedHealthcare® Pharmacy and Therapeutics Committee, which includes both internal and external physicians and pharmacists, meets regularly to provide clinical reviews of all medications. Using this information, the Prescription Drug List Management Committee, which includes senior UnitedHealth Group® physicians and business leaders, meets to evaluate overall health care value. They also determine coverage and tier status for all medications.

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How is the overall value of a medication determined?Many sources and factors are considered, including:

• Clinical Value: How safe and effective a medication is compared to other medications used to treat the same or similar medical conditions.

• Cost: How much a medication costs compared to other medications used to treat similar medical conditions.

• Outcomes Data: Studies that show how a medication may affect total health care costs.

Why are certain medications excluded?We review medications based on their total value, including effectiveness and safety, how much they cost, and the availability of alternative medications to treat the same or similar medical conditions. Certain medications may be excluded from the formulary or subject to prior authorization (sometimes referred to as precertification)* if similar alternatives are available at a lower cost.

Examples include medications that work the same way, but one is much more expensive than the other, or options that are available without a prescription (also referred to as over-the-counter medications). There are also some instances where the same product can be made by two or more manufacturers, but greatly vary in cost. In these instances, only the lower-cost product may be covered. You should review your benefit plan documents to confirm if any medications are not part of the formulary for your plan. You can log in to the member website listed on your health plan ID card at any time to check your medication coverage. Talk to your doctor to see if there are lower-cost options or over-the-counter medications available.

*Depending on your benefit, you may have notification or medical necessity requirements for select medications.

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

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. For some benefit plans, if a brand-name drug is prescribed and a generic equivalent is available, your cost-share may be the copayment PLUS the cost difference between the brand-name drug and the generic equivalent.

How often are formularies updated?Formulary changes typically occur twice per year. However, changes that have a positive impact for you — such as new medications or cost savings — may occur at any time. You can log in to the member website listed on your health plan ID card at any time to check your medication coverage and lower-cost options. The complete formulary is also publicly available here on optumrx.com and is updated on a monthly basis.

https://chp.optumrx.com/RxSolWeb/mvc/rxExternalFormularySearch/displaySearch.do?type=ClientFormulary&&var=PHSCA&infoid=PHSCA

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Can a medication change tiers?Yes. Tier changes may generally occur two times per year. When a medication changes tiers, you may pay more or less for that medication, depending on the tier change. If one of your medications changes tiers, speak with your doctor to determine if a lower-cost option may be available for you.

Are there other restrictions on what medications are covered?Yes. Some medications may have additional requirements or limits depending on your benefit plan. You should review your benefit plan documents to confirm if any of these programs apply to your plan. The medications that have programs that apply are noted with letters next to them. Examples include:

Age edit (AE) This medication applies to a specific age group. Members outside of this age group need to meet specific criteria for approval.

Exceptions required for select markets in California and Oklahoma (E) Your doctor is required to provide additional information to UnitedHealthcare to verify medical necessity of certain medications.

Formulary brand (FB)

Formulary generic (FG)

Health care reform preventive (H) This medication is part of a health care reform preventive benefit and may be available at no additional cost to you.

Health care reform preventive with prior authorization (H-PA) May be part of health care reform preventive and available at no additional cost to you if prior authorization criteria is met.

Medical (M) The medication may be covered under medical with prior authorization.

Non-formulary (NF) Non-Formulary drugs are available on your highest cost tier (Tier 3).

Prior authorization (PA) Requires your doctor to provide information about why you are taking a medication to determine how it may be covered by your plan.

Quantity limits (QL) Amount of medication covered per copayment or in a specific time period.

Step therapy (ST) Requires you to try one or more other medications before the medication you are requesting may be covered.

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I’m taking a specialty medication. Who can I contact for more information?Specialty medications are high-cost and are used to treat rare or complex conditions that require additional care and support. For most plans, these medications are managed through the Specialty Pharmacy Program. Take advantage of personalized support designed to help you get the most out of your treatment plan. Visit UHCSpecialtyRx.com or call the toll-free phone number on your health plan ID card to learn more.

Please note, not all specialty medications are listed here. If you’re taking a specialty medication that is on a higher tier, call the toll-free phone number on your health plan ID card to talk with a pharmacist about finding lower-cost options or a financial assistance program.

Who can I contact if I have questions about my formulary?Online

Log in to the member website listed on your health plan ID card. Once online, you’ll have access to the following information and tools:• Pharmacy benefit and coverage information• Possible lower-cost medication options• Medication interactions and side effects• Participating retail pharmacies by ZIP code• Your prescription history

And, if home delivery services are included in your pharmacy benefit, you can also:• Refill prescriptions• Check the status of your order• Set up reminders for refills• Manage your account

Check your formulary often for updates.

By phone

Call the toll-free phone number on your health plan ID card to speak with a customer service representative. We can answer any questions you have about your pharmacy benefit plan, including lower-cost options.

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

AE = Age editE = Exceptions requiredFB = Formulary brandFG = Formulary generic

H = May be part of health care reform preventiveH-PA = May be part of health care reform preventive with prior authorizationM = Medical

NF = Non-formularyPA = Prior authorization requiredQL = Quantity limitST = Step therapy

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Drug Name Drug Tier Requirements & Limits

Anti-Infectives: Antibiotics

Amoxicillin FG

Amoxicillin/Potassium Clavulanate FG

Antipyrine/Benzocaine Otic FG

Azithromycin FG

Bethkis FB

Cefaclor Suspension FB

Cefaclor Tablet FG

Cefadroxil FG QL

Cefdinir FG

Cefpodoxime FG

Cefprozil FG

Cefuroxime FG

Cephalexin FG

Chloroxylenol/Hydrocortisone/Pramoxine Otic FG

Ciprofloxacin FG

Clarithromycin IR/ER FG

Cleocin Vaginal Suppository FB

Clindamycin FG

Clindesse NF

Dapsone FB

Demeclocycline FG

Dicloxacillin FG

Doxycycline Hyclate FG

Doxycycline Monohydrate Tablet FG QL

Erythromycin FG

Erythromycin/Sulfisoxazole FG

Ethambutol FG

Isoniazid FG

Levofloxacin FG

Linezolid Tablet FG QL

Methenamine FG


Metronidazole Tablet FG

Minocycline Capsule FG

Mycobutin FB

NebuPent Nebs FB QL

Neomycin FG

Neomycin/Polymixin/Hydrocortisone Otic FG

Nitrofurantoin FG

Nitrofurantoin Macrocrystal FG

Ofloxacin Otic FG

Oracea NF

Paromomycin FG

Penicillin VK FG

Pramoxine-HC Otic FG

Pyrazinamide FG

Rifampin FG

Sulfadiazine FG

Sulfamethoxazole/Trimethoprim, Sulfamethoxazole/Trimethoprim DS

FG

Tetracycline FG

Trimethoprim FG

Zmax FB

Anti-Infectives: Antifungals

Clotrimazole Troche FG

Cresemba NF

Fluconazole FG

Griseofulvin FG

Itraconazole FG PA

Jublia NF PA

Kerydin NF PA

Ketoconazole Cream, Shampoo FG

Metronidazole Vaginal Gel FG

Nystatin FG

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Terbinafine FG QL

Terconazole FG

Vandazole Gel FG

Anti-Infectives: Antivirals

Acyclovir FG

Adefovir FG

Amantadine Capsule, Syrup FG

Baraclude NF E, QL

Daklinza NF PA, QL, ST

Entecavir FG QL

Epclusa FB PA, QL

Epivir HBV Solution FB

Famciclovir FG

Harvoni FB PA, QL

Lamivudine FG

Mavyret FB PA, QL

Pegasys M

Ribavirin Tablet FG PA

Rimantidine FG

Sovaldi NF PA, QL, ST

Technivie NF PA, QL, ST

Valacyclovir FG QL

Valganciclovir Solution FG

Valganciclovir Tablet FG QL

Viekira Pak, Viekira XR NF PA, QL, ST

Vosevi FB PA, QL

Zepatier NF PA, QL, ST

Zovirax Cream FB E

Zovirax Ointment NF E

Cancer

Bicalutamide FG

Cabometyx FB PA

Capecitabine FG

Caprelsa FB PA, QL

Cotellic FB PA, QL


Cyclophosphamide FG

Emcyt FB

Etoposide FG

Erivedge FB PA, QL

Exemestane FG

Fareston FB

Farydak FB PA, QL

Flutamide FG

Hexalen FB

Hydroxyurea FG

Ibrance FB PA, QL

Imatinib FG PA, QL

Letrozole FG PA

Leucovorin Calcium FG

Leukeran FB

Lomustine FG

Lysodren FB

Lonsurf FB PA, QL

Matulane FB

Melphalan FG

Mercaptopurine FG

Myleran FB

Nilandrone FB

Ninlaro FB PA, QL

Odomzo FB PA, QL

Sprycel FB PA, QL

Tabloid FB

Targretin FB

Tasigna NF PA, QL

Temozolomide FG PA

Tretinoin Capsule FG

Tykerb FB PA

Xeloda NF E

Zytiga FB PA

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Cardiovascular/Heart Disease: Coagulation Therapy

Aggrenox NF

Brilinta FB

Clopidogrel FG

Disopyramide FG

Eliquis NF QL

Jantoven FG

Pradaxa FB QL

Prasugrel FG QL

Savaysa NF QL

Ticlopidine FG QL

Warfarin FG

Xarelto FB QL

Zontivity NF PA, QL

Cardiovascular/Heart Disease: High Blood Pressure

Acebutolol FG

Acetazolamide FG

Acetazolamide ER FG

Afeditab CR FG

Aldactazide 25/25 mg FB

Amiloride FG

Amiloride/Hydrochlorothiazide FG

Amlodipine FG

Amlodipine/Benazepril FG QL

Atenolol FG

Atenolol/Chlorthalidone FG

Benazepril FG

Benazepril/Hydrochlorothiazide FG

Betaxolol FG

Bisoprolol FG

Bisoprolol/Hydrochlorothiazide FG

Bumetanide FG


Bystolic FB

Byvalson FB

Captopril FG

Captopril/Hydrochlorothiazide FG

Cartia XT FG

Carvedilol FG

Chlorothiazide FG

Chlorthalidone FG

Clonidine Tablet FG

Diltiazem Sustained-Release Capsule FG

Diltiazem Tablet FG

Doxazosin FG

Edarbi NF E, QL

Edarbyclor NF QL

Enalapril FG

Enalapril/Hydrochlorothiazide FG

Eprosartan FG QL

Ezide FG

Felodipine FG

Fosinopril FG

Fosinopril/Hydrochlorothiazide FG

Furosemide FG

Guanfacine FG

Hydralazine FG

Hydrochlorothiazide FG

Indapamide FG

Irbesartan FG QL

Irbesartan/Hydrochlorothiazide FG QL

Isradipine FG

Labetalol FG

Lisinopril FG

Lisinopril/Hydrochlorothiazide FG

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Losartan FG

Losartan/Hydrochlorothiazide FG

Methazolamide FG

Methyclothia FG

Methyldopa FG

Methyldopa/Hydrochlorothiazide FG

Metolazone FG

Metoprolol Succinate ER FG

Metoprolol Tartrate FG

Minoxidil FG

Moexipril FG

Moexipril/Hydrochlorothiazide FG

Nadolol FG

Nicardipine FG

Nifediac CC FG

Nifedical XL FG

Nifedipine IR/ER FG

Olmesartan FG QL

Olmesartan/Hydrochlorothiazide FG QL

Perindopril FG

Phenoxybenzamine FG

Pindolol FG

Prazosin FG

Propranolol/Hydrochlorothiazide FG

Propranolol IR/ER FG

Quinapril FG

Ramipril FG

Reserpine FG

Sotalol FG

Sotalol AF FG

Spironolactone FG

Spironolactone/Hydrochlorothiazide FG

Taztia XT FG

Telmisartan FB QL

Telmisartan/Hydrochlorothiazide FG QL

Terazosin FG QL


Timolol FG

Torsemide FG

Trandolapril/Verapamil CR FG

Triamterene/Hydrochlorothiazide FG

Valsartan FG QL

Valsartan/Hydrochlorothiazide FG QL

Verapamil Sustained-Release Capsule FG QL

Verapamil Sustained-Release Tablet FG

Verapamil Tablet FG

Cardiovascular/Heart Disease: High Cholesterol

Antara NF QL

Atorvastatin FG H-PA, QL

Cholestyramine FG

Choline Fenofibrate Capsule FG E

Colestipol FG

Ezetimibe NF QL

Ezetimibe/Simvastatin NF QL

Fenofibrate 48, 145 mg Tablet FG E

Fenofibrate 54, 160 mg Tablet FG

Fenofibrate Capsule FG

Fenofibrate Micronized FG

Gemfibrozil FG

Lipofen FB

Livalo NF E, QL

Lovastatin FG H

Niacin ER FG QL

Niaspan NF

Omega-3-Acid Ethyl Esters Capsule FG PA, QL

Praluent M QL

Pravastatin FG

Prevalite FG

Rosuvastatin FG QL

Simvastatin FG H-PA

Vascepa FB

Welchol FB

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Cardiovascular/Heart Disease: Other

Amiodarone FG

Anagrelide FG

Cilostazol FG

Corlanor NF PA, QL

Digoxin FG

Dilatrate SR FB

Disopyramide FG

Flecainide FG

Isochron FG

Isoditrate ER FG

Isordil FB

Isosorbide Dinitrate IR/ER FG

Isosorbide Mononitrate IR/ER FG

Isoxsuprine FG

Mexiletine FG

Midodrine FG

Multaq NF PA

NitroBid FB

Nitroglycerin ER FG

Nitroglycerin Tablet FG

Nitrolingual Pump Spray FG

NitroTime FG

Norpace CR FB

Pacerone NF

Pentoxifylline FG

Propafenone FG

Quinidine IR/ER FG

Ranexa FB QL

Sotalol FG


Central Nervous System: Attention Deficit Disorder

Adderall XR FB AE, QL

Atomoxetine NF QL

Dextroamphetamine/Amphetamine FG AE, QL

Dextroamphetamine/Amphetamine Extended-Release

NF AE, E, QL

Dextroamphetamine Sulfate Extended-Release FG AE, PA, QL

Dextroamphetamine Sulfate Tablet FG AE, PA, QL

Guanfacine ER FG AE, QL

Intuniv NF AE, E, QL

Methylphenidate Controlled-Release Capsule FG AE, QL

Methylphenidate Tablet FG AE, PA, QL

Vyvanse FB AE, QL

Central Nervous System: Depression

Amitriptyline FG

Amoxapine FG

Bupropion FG

Bupropion SR FG H

Bupropion XL FG QL

Citalopram FG

Clomipramine NF

Cymbalta NF E, QL

Desipramine FG

Desvenlafaxine Succinate ER FG QL

Doxepin FG

Duloxetine 20, 30, 60 mg FG QL

Escitalopram FG

Fluoxetine Capsule (generic Prozac) FG

Fluvoxamine FG

Forfivo XL FB QL

Imipramine FG

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Maprotiline FG

Mirtazapine, Mirtazapine ODT FG

Nefazodone FG

Nortriptyline FG

Paroxetine FG

Paroxetine ER FG QL

Paxil Suspension FB

Phenelzine FG

Protriptyline FG

Sertraline FG

Tranylcypromine FG

Trazodone FG

Venlafaxine FG

Venlafaxine Extended-Release Capsule FG

Venlafaxine Extended-Release Tablet FG QL

Viibryd NF QL

Central Nervous System: MigraineAcetaminophen/Butalbital/Caffeine FG QL

Isometheptene/Acetaminophen/Dichloralphenazone

FG

Migragesic FG

Migranal NF E, QL

Nodolor FG

Phrenilin Forte NF QL

Rizatriptan FG QL

Sumatriptan Nasal Spray, Tablet FG QL

Sumavel DosePro M

Zecuity NF E, QL

Zolmitriptan FG QL

Zomig Spray NF E, QL


Central Nervous System: Multiple Sclerosis

Ampyra FB PA, QL

Avonex M QL

Betaseron M QL

Copaxone M QL

Gilenya NF PA, QL

Tecfidera FB PA, QL

Central Nervous System: Other

Alprazolam IR/ER FG QL

Aripiprazole ODT FG QL

Aripiprazole Solution, Tablet FG QL

Aristada M

Benztropine FG

Bromocriptine FG

Buspirone FG

Carbidopa/Levodopa IR/ER FG

Chlordiazepoxide FG QL

Chlordiazepoxide/Amitriptyline FG

Chlorpromazine FG

Clorazepate FG QL

Clozapine FG QL

Compro Suppository FG

Diazepam FG

Donepezil, Donepezil ODT FG

Entaone FG

Ergoloid Mesylate FG

Fluphenazine FG

Galantamine IR/ER FG

Galantamine Solution FG QL

Haloperidol FG

Hydroxyzine FG

Invega Sustenna, Invega Trinza M

Latuda NF QL, ST

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Lithium IR/ER FG

Lorazepam FG QL

Loxapine FG

Memantine Solution, Tablet FG

Meprobamate FG

Namzaric FB QL

Olanzapine, Olanzapine ODT FG QL

Oxazepam FG QL

Perphenazine/Amitriptyline FG

Pramipexole FG

Prochlorperazine FG

Quetiapine, Quetiapine ER FG QL

Rexulti NF PA, QL

Risperidone, Risperidone ODT FG QL

Rivastigmine FG

Ropinirole FG

Saphris FB PA, QL

Suboxone Film FB QL

Thioridazine FG

Thiothixene FG

Trifluoperazine FG

Trihexyphenidyl FG

Vraylar NF QL, ST

Xyrem NF PA, QL

Zelapar NF QL

Ziprasidone FG QL

Zubsolv FB QL

Central Nervous System: Sedatives/Hypnotics

Eszopiclone FG QL

Flurazepam FG PA, QL

Silenor NF QL

Temazepam FG QL


Triazolam FG QL

Zaleplon FG QL

Zolpidem FG QL

Central Nervous System: Seizure Disorders

Carbamazepine ER Capsules FG

Carbamazepine IR FG

Clonazepam, Clonazepam ODT FG QL

Diazepam Gel FG QL

Divalproex DR FG

Epitol FG

Ethosuximide FG

Gabapentin FG

Lamotrigine Chewable, Tablet FG

Lamotrigine ER FG

Lamotrigine ODT NF

Levetiracetam ER NF

Levetiracetam IR FG

Lyrica Capsule FB QL

Lyrica Solution NF QL

Oxcarbazepine FG

Phenobarbital FG

Phenytoin FG

Topiragen FG

Topiramate FG

Valproic Acid FG

Vimpat Injection M

Vimpat Tablet, Solution NF PA

Zonisamide FG

15


Dermatology

Absorica NF PA

Acanya NF E, QL

Acitretin FG

Acyclovir FG

Aczone Gel NF

Ala Quin FG

Alclometasone FG

Alphatrex FG

Amnesteem FG PA, QL

Benzaclin NF E, QL

Betamethasone FG

Calcipotriene-Betamethasone FB QL

Calcipotriene Ointment FG QL

Calcitriol Ointment FG

Cerovel FG

Ciclodan FG

Ciclopirox Cream, Gel, Lotion, Solution FG

Claravis FG E, PA

Clindamax Lotion FG

Clindamycin Gel, Lotion, Solution, Swabs FG

Clindareach Kit FG

Clobetasol, Clobetasol E FG

Clobex Lotion, Shampoo NF E

Clobex Spray NF E, QL

Cloderm NF

Cloderm Pump NF

Cormax FG

Dermazene FG

Desonide FG

Desoximetasone FG

DrithoCreme HP FB

DrithoScalp FB

Dupixent M QL


Econazole NF

Elidel FB QL, ST

Enstilar NF QL

Ery Pad FG

Erythromycin FG

Erythromycin/Benzoyl Peroxide FG

Ethyl Chloride FG

Eurax FB

Exoderm FG

Finacea NF ST

Fluocinolone FG

Fluocinonide, Fluocinonide E FG

Fluoroplex NF

Fluorouracil Solution, 5% Cream FG

Fluticasone FG

Gentamicin FG

Hydrocortisone FG

Hypercare FG

Imiquimod FG QL

Laclotion FG

Lidocaine FG

Lidocaine/Prilocaine FG

Lindane FG

Lokara FG

Metrogel 1% NF E

Metronidazole 0.75% Cream, Lotion FG

Mirvaso FB QL

Mometasone Furoate FG

Mupirocin Calcium Cream FG QL

Mupirocin Ointment FG

Myorisan FG PA

Nystatin FG

Nystop FG

Onexton NF E, QL

Otezla FB PA, QL

16






Permethrin FG

Picato NF

Podofilox FG

Pramcort FG

Pramosone Cream, Ointment NF

Pramosone E Cream NF

Pramosone Lotion NF

Protopic NF AE, PA, QL

Rhofade NF PA, QL

Rosadan Cream FG

Selenium Sulfide FG

Silver Nitrate FG

Silver Sulfadiazine FG

Soolantra FB

Sulfacetamide Sodium FG

Sulfacetamide Sodium-Sulfur FG

Taclonex Ointment NF E, QL

Taclonex Scalp NF QL

Tacrolimus Ointment FG AE, QL

Tazorac NF AE, QL

Tretinoin Cream NF AE

Triamcinolone Acetonide FG

Trianex FB

Triderm FG

Urea 40% Lotion FG

Vectical NF E

Vitazol FG

Zenatane FG E, PA

Zyclara Cream, Pump NF QL


Diabetes: Blood Glucose Monitoring

Accu-Chek Test Strips NF PA, QL

Bayer Breeze2 Test Strips NF PA, QL

Bayer Contour Test Strips NF PA, QL

Freestyle Test Strips NF PA, QL

Glucocard Test Strips NF PA, QL

Novofine Autocover Pen Needles NF

Novofine Pen Needles NF

Novofine Plus Pen Needles NF

Novotwist Pen Needles NF

OneTouch Lancets FB QL

OneTouch Test Strips FB QL

OneTouch Ultra Blue Test Strips FB QL

OneTouch Verio IQ Test Strips FB QL

Relion Test Strips NF PA, QL

Diabetes: Insulin

Apidra Solostar NF ST

Apidra Vial NF ST

Basaglar FG

Humalog KwikPen FB

Humalog Mix 50-50 KwikPen FB

Humalog Mix 50-50 Vial FB

Humalog Mix 75-25 KwikPen FB

Humalog Mix 75-25 Vial FB

Humalog U-200 KwikPen FB

Humalog Vial FB

Humulin 70-30 KwikPen FB

Humulin 70-30 Vial FB

Humulin KwikPen FB

Humulin N KwikPen FB

Humulin N Vial FB

17


Humulin R U-500 KwikPen FB

Humulin R U-500 Vial FB

Humulin R Vial FB

Levemir Flexpen FB

Levemir Vial FB

Novolin N Vial FB E

Novolin R Vial FB E

Novolin Vial FB E

Novolog Flexpen FB E

Novolog Mix FB E

Novolog Vial FB E

Soliqua FB PA, QL

Diabetes: Non-Insulin

Acarbose FG

Adlyxin NF QL

Bydureon FB QL, ST

Byetta FB QL, ST

Chlorpropamide FG

Farxiga NF QL, ST

Glimepiride FG

Glipizide IR/XL FG

Glipizide/Metformin FG

Glucagen FB

Glucagon FB QL

Glumetza NF PA

Glyburide FG

Glyburide/Metformin FG

Glyxambi NF QL, ST

Invokamet, Invokamet XR FB QL, ST

Invokana FB QL, ST

Janumet FB QL

Janumet XR FB QL

Januvia FB QL

Jardiance FB QL, ST

Jentadueto FB QL

Jentadueto XR FB QL


Juvisync FB QL, ST

Metformin FG

Metformin Extended-Release FG

Nateglinide FG QL

Pioglitazone FG QL, ST

Pioglitazone/Glimepiride FG QL, ST

Pioglitazone/Metformin FG QL, ST

Repaglinide FG QL, ST

Symlin NF PA

Synjardy FB QL, ST

Synjardy XR FB QL, ST

Tolazamide FG ST

Tolbutamide FG ST

Tradjenta FB QL

Trulicity FB QL, ST

Victoza FB QL, ST

Endocrine: Growth Hormone

Lupron Depot M

Nutropin AQ, Nutropin AQ NuSpin M

Endocrine: Other

Asmalpred, Asmalpred Plus FB

Calcitriol FG

Cortisone FG

Desmopressin FG

Dexamethasone FG

Fludrocortisone FG

Hydrocortisone Tablet FG

Medrol 2 mg FB

Methylergonovine FG

Methylprednisolone FG

Millipred Tablet FG

Paricalcitol FG

Prednisolone Solution, Tablet FG

Prednisone FG

Zemplar FB

18






Endocrine: Thyroid Hormone Replacement

Levothyroxine Sodium FG

Levoxyl FG

Liothyronine Sodium FG

Methimazole FG

Propylthiouracil FG

Tirosint NF

Unithroid FG

Eye Conditions: Allergies

Azelastine 0.05% Solution FG

Cromolyn FG

Epinastine FG E

Lastacaft NF QL

Naphazoline 0.1% FG

Olopatadine 0.1% FG QL

Pataday NF E

Phenylephrine FG

Eye Conditions: Antibiotics

Azasite NF

Bacitracin FG

Bacitracin/Polymyxin FG

Besivance NF

Ciprodex NF

Ciprofloxacin FG

Erythromycin FG

Gentamicin FG

Ilotycin FG

Moxeza FB

Moxifloxacin FG

Natacyn FB

Neomycin/Bacitracin/Polymyxin FG


Neomycin/Polymixin/Gramicidin FG

Ofloxacin FG

Polymyxin B/Trimethoprim FG

Sulfacetamide Sodium FG

Tobradex Ointment NF

Tobramycin/Dexamethasone FG

Tobramycin Ophth Solution FG E

Tobrex NF E

Trifluridine FG

Eye Conditions: Glaucoma

Alphagan P FB QL

Azopt FB QL

Betaxolol FG

Betimol NF QL

Betoptic-S FB

Carteolol FG

Combigan FB QL

Cosopt, Cosopt PF NF

Dorzolamide FG QL

Dorzolamide/Timolol FG

Istalol FB

Latanoprost FG QL

Levobunolol FG

Lumigan FB QL

Metipranolol FG

Simbrinza FB QL

Timolol Maleate FG

Timoptic Ocudose FB

Travatan Z FB QL

Zioptan NF QL

19


Eye Conditions: Other

Atropine FG

Blephamide SOP NF

Brimonidine FG

Cyclopentolate FG

Dexamethasone FG

Diclofenac FG QL

Fluorometholone FG

Flurbiprofen FG

FML Forte FB

Homatropine FG

Iso Carbachol FB

Iso Homatropine FB

Ketorolac FG

Neomycin/Bacitracin/Polymyxin/Hydrocortisone FG

Neomycin/Polymixin/Dexamethasone FG

Phospholine FB

Pred Mild FB

Prednisolone Solution, Tablet FG

Proparacaine FG

Restasis FB PA

Sulfacetamide Sodium/Prednisolone FG

Tetracaine FG

Tropicamide FG

Xiidra FB PA

Gastrointestinal: Acid Suppression

Cimetidine FG

Dexilant FB QL

Misoprostol FG

Nizatidine FG

Omeclamox-Pak FB QL

Omeprazole FG QL

Pantoprazole FG QL

Pylera FB QL

Sucralfate Tablet FG


Gastrointestinal: Nausea/Vomiting

Akynzeo NF

Antivert 50 mg FB

Dronabinol FG PA

Ondansetron FG QL

Ondansetron ODT FG

Promethazine FG

Trimethobenzamide FG

Varubi NF QL

Gastrointestinal: Other

Amitiza FB QL, ST

Analpram Advanced NF

Analpram-HC Cream NF

Analpram-HC Lotion NF

Analpram-HC Shingles NF

Apriso FB

Auryxia NF

B-donna FG

Belladonna Alkaloids/Phenobarbital FG

Budesonide FG

Calcium Acetate FG

Canasa FB

Cortifoam NF

Creon FB

Delzicol NF E, ST

Dicyclomine FG

Dificid NF

Digex NF FB

Dipentum NF

Diphenoxylate/Atropine FG

Gavilyte FG H, QL

Halflytely NF

Hyoscyamine FG

Lactulose FG

Lialda FB

20






Linzess FB QL, ST

Mesalamine Enema FG

Metoclopramide Solution, Tablet FG

Movantik NF QL, ST

Moviprep NF QL

Pancrelipase FG

Paregoric Tincture FG

Pentasa NF E

Polyethylene Glycol 3350 FG H, QL

Prepopik NF

Propantheline FG

Rowasa Enema NF

Sevelamer FG

Sulfasalazine FG

Suprep NF

Trilyte FG QL

Uceris Foam FB

Uceris Tablet NF

Ursodiol FG

Viberzi NF PA, QL

Zenpep FB

HIV/AIDS

Abacavir FG

Abacavir/Lamivudine FG

Aptivus FB

Atripla FB

Complera FB

Crixivan FB

Descovy FB

Didanosine FG

Edurant FB


Emtriva FB

Epivir Solution FB

Evotaz FB

Fuzeon FB QL

Genvoya FB

Intelence FB

Invirase FB

Isentress FB

Kaletra Tablet FB

Lamivudine FG

Lamivudine/Zidovudine FG

Lexiva FB

Lopinavir-Ritonavir Solution FG

Nevirapine FG

Norvir FB

Odefsey FB

Prezcobix FB

Prezista FB

Rescriptor FB

Retrovir FB

Reyataz FB

Selzentry FB PA

Stavudine Capsule FG

Stribild FB

Sustiva FB

Tivicay FB

Triumeq FB

Trizivir NF

Truvada FB

Videx Solution FB

Viracept FB

21


Viread FB

Vitekta FB

Zerit Solution FB

Ziagen Solution FB

Zidovudine FG

Infertility*

Cetrotide M

Clomiphene FG

Gonal-F M

Gonal-F Rff M

Ovidrel M

Inflammatory Conditions: Rheumatoid Arthritis, Crohn’s Disease, Psoriasis, Ulcerative ColitisCimzia M QL

Cosentyx M

Cuprimine NF PA

Depen FB

Humira M

Hydroxychloroquine Sulfate FG

Leflunomide FG QL

Methotrexate FG

Orencia M

Otrexup M

Rasuvo M

Remicade M

Rheumatrex NF

Simponi M QL

Stelara M QL

Trexall NF

Medications for Sexual Dysfunction*

Cialis NF PA, QL

Levitra NF PA, QL

Viagra FB PA, QL


Men’s Health: Prostate

Alfuzosin FG

Cialis 2.5, 5 mg NF PA, QL

Doxazosin FG

Dutasteride FG

Dutasteride/Tamsulosin FG

Finasteride FG

Rapaflo FB

Tamsulosin FG

Terazosin FG

Men’s Health: Testosterone Therapy

Androderm FB PA, QL

Androgel 1% NF PA, QL

Androgel 1.62% FB PA, QL

Androxy FG

Fortesta NF PA, QL

Testim NF PA, QL

Testosterone Gel 1% FG PA, QL

Testred NF

Miscellaneous

Acetic Acid Otic FG

Acetylcysteine FG

Aerochamber FB QL

Albenza NF PA, QL

Alinia FB QL

Anastrozole FG

Antipyrine/Benzocaine FG

Anucort-HC FG

Aranesp M

Benzocaine Otic FG

Benzonatate FG

Biltricide FB

Bunavail NF PA, QL

* Coverage is determined by the consumer’s prescription drug benefit plan. Please consult plan documents regarding benefit coverage and cost-share.

22






Cerdelga NF PA

Cetylev NF

Chloroquine FG

Citric Acid/Sodium Citrate FG

Danazol FG

Daraprim NF PA

Difil-G Forte Liquid FG

Disulfiram FG

Easivent FB QL

Elmiron FB

Emverm NF PA, QL

Epinephrine Auto-injector (generic Epipen, Epipen Jr) FB QL

Ergocalciferol 50,000 Unit Capsule FG

Euflexxa M

Exemestane FG

EZ Spacer FB QL

Fosrenol NF

Granix M

Guaifenesin/Codeine FG

Guanidine FB

Hydrocodone/Homatropine FG

Hydrocortisone/Acetic Acid Otic FG

Hydrocortisone Pramoxine FG

Hydrocortisone Suppository FG

Hypersal Nebs FB

Impavido FB PA

Inspirease FB

Kuvan FB PA, QL

Letrozole FG

Lidocaine Viscous FG

Mebendazole FG


Mefloquine FG

Megestrol AC FG

Mephyton FB

Mestinon Syrup FB

Methylergonovine FG

Multigen Folic FB

Multigen Plus FB

Naltrexone FG

Narcan Nasal Spray FB

Nessi Spacer FB QL

Nuwiq M

Optihaler FB QL

Orkambi FB PA, QL

Phenazopyridine FG

Pilocarpine FG

Primaquine FG

Procrit M

Proctocream HC FG

Proctofoam HC FB

Proctosol HC FG

Proctozone HC FG

Proglycem FB

Promethazine/Codeine FG

Promethazine/Dextromethorphan FG

Promethazine Suppository FG

Promethazine VC/Codeine FG

Pyridostigmine FG

Rezira NF

Sevelamer FG

Sodium Polystyrene Sulfonate Powder FG

SSKI FB

23


Strensiq M

Synarel FB

Synvisc M

Synvisc One M

Triamcinolone/Orabase FG

Velphoro NF

Veltassa NF

Vistogard FB

Vitamin D 50,000 Unit FG

Vortex FB QL

WatchHaler FB QL

Xuriden FB QL

Yodoxin FB

Zarxio M

Zemplar FB

Zutripro NF

Musculoskeletal: Osteoporosis

Actonel NF E

Alendronate Oral Solution FG QL

Alendronate Tablet FG QL

Binosto NF QL

Calcitonin Spray FG QL

Forteo M

Fortical NF QL

Ibandronate FG QL

Musculoskeletal: Other

Allopurinol FG

Baclofen FG

Carisoprodol FG

Colcrys FB

Cyclobenzaprine FG

Dantrolene FG

Lorzone NF

Methocarbamol FG

Orphenadrine/Aspirin/Caffeine FG

Orphenadrine ER FG


Probenecid FG

Tizanidine Tablet FG

Uloric FB QL, ST

Zurampic NF PA

Musculoskeletal: Pain Relief

Acetaminophen/Codeine FG QL

Acetaminophen/Oxycodone FG QL

Ascomp/Codeine FG

Belbuca NF PA, QL

Butalbital/Acetaminophen FG

Butalbital/Acetaminophen/Caffeine

FG QL

Butalbital/Acetaminophen/Caffeine/Codeine FG QL

Butalbital/Aspirin/Caffeine FG

Butalbital/Aspirin/Caffeine/Codeine FG

Celecoxib NF QL

Choline Magnesium Trisalicylate FG

Codeine FG

Diclofenac Sodium FG

Diflunisal FG

Duraxin FG

Etodolac IR/ER FG

Fenoprofen FG

Fentanyl Patch 12, 25, 50, 75, 100 mcg FG QL

Flector Patch NF E, QL

Flurbiprofen FG

Fortigan FG

Gralise NF QL, ST

Hydrocodone/Acetaminophen FG QL

Hydrocodone/Ibuprofen FG

Hydromorphone IR FG QL

Ibuprofen FG

Indocin Suppository FB QL

Indomethacin IR/ER FG

24






Ketoprofen IR/ER FG

Ketorolac FG QL

Levorphanol FG

Meclofenamate FG

Meloxicam FG

Meperidine FG

Methadone FG QL

Morphine Sulfate Controlled-Release Tablet FG QL

Morphine Sulfate Immediate-Release Tablet, Solution FG

Nabumetone FG

Naproxen FG

Nucynta NF QL

Nucynta ER NF PA, QL

Oxaprozin FG

Oxycodone IR FG

Oxycodone/Acetaminophen FG QL

Oxymorphone FG QL

Pentazocine/Naloxone FG

Piroxicam FG

Salsalate FG

Sulindac FG

Tivorbex NF E

Tolmetin FG

Tramadol FG

Trezix NF E, QL

Vivlodex NF E, QL

Voltaren Gel FB QL

Xtampza ER FB PA, QL

Zorvolex NF E


Overactive Bladder

Bethanechol FG

Myrbetriq NF ST

Oxybutynin FG

Oxybutynin Extended-Release FG

Toviaz NF

Vesicare NF E

Respiratory: Asthma/COPD

Advair Diskus FB QL

Advair HFA FB QL

Aerospan NF QL

Albuterol Sulfate FG

Aminophylline FG

Arcapta NF QL, ST

Arnuity Ellipta FB QL

Asmanex NF QL, ST

Atrovent HFA NF QL

Bevespi Aerosphere FB QL

Breo Ellipta FB QL

Budesonide Nebs FG QL

Combivent Respimat FB QL

Cromolyn Nebs FG

Flovent Diskus FB QL

Flovent HFA FB QL

Fluticasone/Salmeterol Powder Inhaler FG QL

Foradil FB QL

Incruse Ellipta FB QL

Ipratropium FG

Ipratropium/Albuterol Nebs FG

Montelukast FG QL

25


Perforomist NF QL

Proair HFA FB QL

Proair RespiClick FB QL

Pulmicort Flexhaler FB QL

Pulmicort Respules NF QL

QVAR FB QL

Serevent FB QL

Spiriva HandiHaler, Respimat FB QL

Striverdi Respimat NF QL, ST

Symbicort FB QL

Terbutaline FG

Theophylline SR FG

Tudorza NF QL, ST

Ventolin HFA FB QL

Xopenex HFA NF QL, ST

Respiratory: Nasal Allergies

Azelastine 0.1% Solution FG QL

Dymista Spray FB E, QL

Flunisolide FG QL

Fluticasone Propionate FG QL

Ipratropium FG

Omnaris NF E, QL

QNasl NF QL

Veramyst NF E, QL

Zetonna NF E, QL

Respiratory: Oral Allergies

Carbinoxamine FG

Clemastine FG

Cyproheptadine FG

Dexchlorpheniramine FG

Hydroxyzine FG

Promethazine FG


Respiratory: Pulmonary Arterial Hypertension

Adcirca NF PA, QL

Adempas FB PA, QL

Letairis FB PA, QL

Opsumit FB PA, QL

Orenitram NF PA

Sildenafil Tablet 20 mg FG PA, QL

Tracleer FB PA, QL

Smoking CessationBupropion Sustained-Release Tablet FG H

Chantix Tablet NF H-PA

Nicoderm CQ NF H

Nicorette Gum NF H

Nicorette Lozenge NF H

Nicorette Mini-Lozenge NF H

Nicotine Gum FG H

Nicotine Lozenge FG H

Nicotine Patch FG H

Nicotrol Inhaler NF H-PA

Nicotrol Nasal Spray NF H-PA

Thrive Gum FG H

Transplant

Azathioprine FG

Cyclosporine, Cyclosporine Modified FG

Gengraf FG

Tacrolimus FG

Vitamins/ElectrolytesFluoride Chewable Tablet, Drops FG H

Folic Acid 1 mg FG

Klor-Con 10 FG

Klor-Con M10 FG

Klor-Con M20 FG

Potassium Chloride FG

Potassium Citrate FG

26






Women’s Health: Contraceptives

Aftera FG H

Altavera FG H

Alyacen FG H

Apri FG H

Aranelle FG H

Aubra FG H

Aviane FG H

Azurette FG H

Balziva FG H

Bekyree FG H

Blisovi FE FG H

Briellyn FG H

Camila FG H

Caziant FG H

Cesia FG H

Chateal FG H

Cryselle FG H

Cyclafem FG H

Cyred FG H

Dasetta FG H

Deblitane FG H

Delyla FG H

Desogestrel/Ethinyl Estradiol FG H

Drospirenone/Ethinyl Estradiol FG H

EContra EZ FG H

Elinest FG H

Ella FG H, QL

Emoquette FG H

Enpresse FG H

Enskyce FG H


Errin FG H

Estarylla FG H

Ethynodiol 1/50 FG H

Falmina FG H

Fallback Solo FG H

Femynor FG H

Gianvi FG H

Gildagia FG H

Gildess, Gildess Fe FG H

Heather FG H

Implanon FG H

Introvale FG H

Isibloom FG H

Jencycla FG H

Jolessa FG H

Jolivette FG H

Juleber FG H

Junel FG H

Junel Fe FG H

Kariva FG H

Kelnor FG H

Kimidess FG H

Kurvelo FG H

Larin, Larin FE FG H

Larissia FG H

Leena FG H

Lessina FG H

Levonest FG H

Levonorgestrel FG H, QL

Levonorgestrel/Ethinyl Estradiol FG H

Levora-28 FG H

27


Lo Loestrin NF H

Loryna FG H

Low-Ogestrel FG H

Lutera FG H

Lyza FG H

Marlissa FG H

Medroxyprogesterone Acetate Injection FG H, PA

Microgestin FG H

Microgestin FE FG H

Mono-Linyah FG H

Mononessa FG H

My Way FG H

Myzilra FG H

Natazia FB H

Necon 0.5/35, 1/35, 1/50, 10/11 FG H

Next Choice One Dose FG H

Nikki FG H

Nora-BE FG H

Norethindrone FG H

Norethindrone/Ethinyl Estradiol FG H

Norgestimate/Ethinyl Estradiol FG H

Norethindrone/Ethinyl Estradiol/Ferrous Fumarate FG H

Norgestrel/Ethinyl Estradiol FG H

Norlyda FG H

Norlyroc FG H

Nortrel FG H

Nuvaring FB H

Ocella FG H

Ogestrel FG H

Opcicon One-Step FG H

Option 2 FG H

Orsythia FG H

Ortho Coil FG H

Ortho Flat FG H


Ortho Flex FG H

Philith FG H

Pimtrea FG H

Plan B One Step FG H

Portia FG H

Previfem FG H

Primella FG H

Quasense FG H

React FG H

Reclipsen FG H

Safyral NF H

Setlakin FG H

Sharobel FG H

Solia FG H

Sprintec FG H

Sronyx FG H

Syeda FG H

Take Action FG H

Tarina FE FG H

Taytulla NF H

Tri Femynor FG H

Tri-Estarylla FG H

Tri-Linyah FG H

Tri-Previfem FG H

Tri-Sprintec FG H

Trinessa FG H

Trinessa Lo NF H

Trivora-28 FG H

Velivet FG H

Vestura FG H

Vienva FG H

Viorele FG H

Vyfemla FG H

Wera FG H

28






Wide-Seal FG H

Xulane FG H

Yasmin 28 NF E, H

Yaz NF E, H

Zarah FG H

Zenchent FG H

Zovia FG H

Women’s Health: Hormone Replacement

Amabelz FG

Cenestin NF QL

Climara Pro FB QL

Covaryx, Covaryx HS FG QL

Divigel NF

Duavee FB QL

Elestrin NF

Enjuvia NF

Estradiol Tablet FG

Estradiol Twice Weekly Patch FG QL

Estradiol Weekly Patch FG QL

Estrogen/Methyltestosterone, Estrogen/Methyltestosterone HS

FG QL

Estropipate FG

Evamist NF

Fyavolv FG

Jinteli FG

Lopreeza FG

Makena M

Medroxyprogesterone FG

Menest FB

Mimvey FG


Minivelle NF QL

Norethindrone FG

Norethindrone/Ethinyl Estradiol FG

Osphena NF

Premarin FB

Premarin Vaginal Cream FB

Premphase FB

Prempro FB

Vivelle-Dot NF E, QL

Yuvafem FG

Women’s Health: Miscellaneous

Raloxifene FG H-PA, QL

Tamoxifen FG H-PA

Women’s Health: Prenatal VitaminsBrand Prenatal Vitamins/Folic Acid 1 mg FB

Generic Prenatal Vitamins/Folic Acid 1 mg FG

29

IndexA

Abacavir ....................................................20Abacavir/Lamivudine .............................20Absorica .................................................... 15Acanya ....................................................... 15Acarbose .................................................. 17Accu-Chek Test Strips ........................... 16Acebutolol ................................................ 10Acetaminophen/Butalbital/Caffeine .. 13Acetaminophen/Codeine .....................23Acetaminophen/Oxycodone ...............23Acetazolamide ......................................... 10Acetazolamide ER .................................. 10Acetic Acid Otic ............................... 21, 22Acetylcysteine ......................................... 21Acitretin ..................................................... 15Actonel ......................................................23Acyclovir ................................................9, 15Aczone Gel ............................................... 15Adcirca ......................................................25Adderall XR .............................................. 12Adefovir ....................................................... 9Adempas ..................................................25Adlyxin ....................................................... 17Advair Diskus ........................................... 24Advair HFA................................................ 24Aerochamber ........................................... 21Aerospan .................................................. 24Afeditab CR .............................................. 10Aftera .........................................................26Aggrenox .................................................. 10Akynzeo .................................................... 19Ala Quin .................................................... 15Albenza ..................................................... 21Albuterol Sulfate ...................................... 24Alclometasone ........................................ 15Aldactazide 25/25 mg........................... 10Alendronate Oral Solution ....................23Alendronate Tablet .................................23Alfuzosin ................................................... 21Alinia .......................................................... 21Allopurinol ................................................23Alphagan P ............................................... 18Alphatrex ................................................... 15Alprazolam IR/ER ................................... 13Altavera .....................................................26Alyacen......................................................26Amabelz ....................................................28Amantadine Capsule, Syrup .................. 9Amiloride ................................................... 10Amiloride/Hydrochlorothiazide ........... 10

Aminophylline .......................................... 24Amiodarone ............................................. 12Amitiza ....................................................... 19Amitriptyline ........................................12-14Amlodipine ............................................... 10Amlodipine/Benazepril ......................... 10Amnesteem .............................................. 15Amoxapine ............................................... 12Amoxicillin .................................................. 8Amoxicillin/Potassium Clavulanate ...... 8Ampyra ...................................................... 13Anagrelide ................................................ 12Analpram Advanced .............................. 19Analpram-HC Cream ............................. 19Analpram-HC Lotion .............................. 19Analpram-HC Shingles.......................... 19Anastrozole .............................................. 21Androderm ............................................... 21Androgel 1% ............................................ 21Androgel 1.62% ...................................... 21Androxy ..................................................... 21Antara ........................................................ 11Antipyrine/Benzocaine ..................... 8, 21Antipyrine/Benzocaine Otic ................... 8Antivert 50 mg ......................................... 19Anucort-HC .............................................. 21Apidra Solostar ....................................... 16Apidra Vial ................................................ 16Apri .............................................................26Apriso ........................................................ 19Aptivus .......................................................20Aranelle .....................................................26Aranesp ..................................................... 21Arcapta ...................................................... 24Aripiprazole ODT .................................... 13Aripiprazole Solution, Tablet ................ 13Aristada ..................................................... 13Arnuity Ellipta ........................................... 24Ascomp/Codeine ...................................23Asmalpred, Asmalpred Plus ................ 17Asmanex ................................................... 24Atenolol ..................................................... 10Atenolol/Chlorthalidone ........................ 10Atomoxetine ............................................. 12Atorvastatin .............................................. 11Atripla.........................................................20Atropine ..................................................... 19Atrovent HFA ............................................ 24Aubra .........................................................26Auryxia ...................................................... 19Aviane ........................................................26

Avonex ....................................................... 13Azasite ....................................................... 18Azathioprine .............................................25Azelastine 0.05% Solution .................... 18Azelastine 0.1% Solution .......................25Azithromycin .............................................. 8Azopt.......................................................... 18Azurette .....................................................26

B

B-donna .................................................... 19Bacitracin ........................................... 18, 19Bacitracin/Polymyxin ...................... 18, 19Baclofen ....................................................23Balziva .......................................................26Baraclude ................................................... 9Basaglar .................................................... 16Bayer Breeze2 Test Strips .................... 16Bayer Contour Test Strips .................... 16Bekyree .....................................................26Belbuca .....................................................23Belladonna Alkaloids/

Phenobarbital ...................................... 19Benazepril ................................................ 10Benazepril/Hydrochlorothiazide ......... 10Benzaclin .................................................. 15Benzocaine Otic................................. 8, 21Benzonatate ............................................. 21Benztropine .............................................. 13Besivance ................................................. 18Betamethasone ....................................... 15Betaseron ................................................. 13Betaxolol ............................................ 10, 18Bethanechol ............................................. 24Bethkis ........................................................ 8Betimol ...................................................... 18Betoptic-S ................................................. 18Bevespi Aerosphere............................... 24Bicalutamide .............................................. 9Biltricide .................................................... 21Binosto ......................................................23Bisoprolol .................................................. 10Bisoprolol/Hydrochlorothiazide .......... 10Blephamide SOP .................................... 19Blisovi FE ..................................................26Brand Prenatal Vitamins/

Folic Acid 1 mg ...................................28Breo Ellipta ............................................... 24Briellyn .......................................................26Brilinta........................................................ 10Brimonidine .............................................. 19Bromocriptine .......................................... 13

30

Budesonide ....................................... 19, 24Budesonide Nebs ................................... 24Bumetanide .............................................. 10Bunavail ..................................................... 21Bupropion .......................................... 12, 25Bupropion SR .......................................... 12Bupropion Sustained-Release

Tablet .....................................................25Bupropion XL .......................................... 12Buspirone ................................................. 13Butalbital/Acetaminophen ...................23Butalbital/Acetaminophen/Caffeine ..23Butalbital/Acetaminophen/Caffeine/

Codeine.................................................23Butalbital/Aspirin/Caffeine ...................23Butalbital/Aspirin/Caffeine/Codeine ..23Bydureon .................................................. 17Byetta ........................................................ 17Bystolic ...................................................... 10Byvalson ................................................... 10

C

Cabometyx ................................................. 9Calcipotriene Ointment ......................... 15Calcipotriene-Betamethasone ............ 15Calcitonin Spray ......................................23Calcitriol ............................................. 15, 17Calcitriol Ointment .................................. 15Calcium Acetate ...................................... 19Camila........................................................26Canasa ...................................................... 19Capecitabine ............................................. 9Caprelsa ...................................................... 9Captopril ................................................... 10Captopril/Hydrochlorothiazide ............ 10Carbamazepine ER Capsules ............. 14Carbamazepine IR ................................. 14Carbidopa/Levodopa IR/ER ............... 13Carbinoxamine ........................................25Carisoprodol ............................................23Carteolol ................................................... 18Cartia XT ................................................... 10Carvedilol .................................................. 10Caziant ......................................................26Cefaclor Suspension ............................... 8Cefaclor Tablet .......................................... 8Cefadroxil .................................................... 8Cefdinir ........................................................ 8Cefpodoxime ............................................. 8Cefprozil ...................................................... 8Cefuroxime ................................................. 8Celecoxib ..................................................23Cenestin ....................................................28Cephalexin ................................................. 8

Cerdelga ...................................................22Cerovel ...................................................... 15Cesia ..........................................................26Cetrotide ................................................... 21Cetylev .......................................................22Chantix Tablet ..........................................25Chateal ......................................................26Chlordiazepoxide .................................... 13Chlordiazepoxide/Amitriptyline ........... 13Chloroquine .............................................22Chlorothiazide ......................................... 10Chloroxylenol/Hydrocortisone/

Pramoxine Otic ...................................... 8Chlorpromazine ...................................... 13Chlorpropamide ...................................... 17Chlorthalidone ......................................... 10Cholestyramine ....................................... 11Choline Fenofibrate Capsule ............... 11Choline Magnesium Trisalicylate ........23Cialis .......................................................... 21Cialis 2.5, 5 mg ....................................... 21Ciclodan .................................................... 15Ciclopirox Cream, Gel, Lotion,

Solution ................................................. 15Cilostazol .................................................. 12Cimetidine ................................................ 19Cimzia ........................................................ 21Ciprodex ................................................... 18Ciprofloxacin ....................................... 8, 18Citalopram ................................................ 12Citric Acid/Sodium Citrate ...................22Claravis ...................................................... 15Clarithromycin IR/ER ............................... 8Clemastine ...............................................25Cleocin Vaginal Suppository .................. 8Climara Pro ..............................................28Clindamax Lotion ................................... 15Clindamycin .........................................8, 15Clindamycin Gel, Lotion, Solution,

Swabs .................................................... 15Clindareach Kit ........................................ 15Clindesse .................................................... 8Clobetasol, Clobetasol E ...................... 15Clobex Lotion, Shampoo ...................... 15Clobex Spray ........................................... 15Cloderm .................................................... 15Cloderm Pump ........................................ 15Clomiphene .............................................. 21Clomipramine .......................................... 12Clonazepam, Clonazepam ODT ......... 14Clonidine Tablet ...................................... 10Clopidogrel ............................................... 10Clorazepate .............................................. 13Clotrimazole Troche ................................. 8

Clozapine .................................................. 13Codeine ..............................................22, 23Colcrys ......................................................23Colestipol .................................................. 11Combigan ................................................. 18Combivent Respimat ............................. 24Complera ..................................................20Compro Suppository ............................. 13Copaxone ................................................. 13Corlanor .................................................... 12Cormax ..................................................... 15Cortifoam .................................................. 19Cortisone .................................................. 17Cosentyx ................................................... 21Cosopt, Cosopt PF ................................. 18Cotellic ......................................................... 9Covaryx, Covaryx HS .............................28Creon ......................................................... 19Cresemba ................................................... 8Crixivan .....................................................20Cromolyn ........................................... 18, 24Cromolyn Nebs ....................................... 24Cryselle .....................................................26Cuprimine ................................................. 21Cyclafem ...................................................26Cyclobenzaprine .....................................23Cyclopentolate ........................................ 19Cyclophosphamide .................................. 9Cyclosporine, Cyclosporine

Modified ................................................25Cymbalta .................................................. 12Cyproheptadine ......................................25Cyred .........................................................26

D

Daklinza ...................................................... 9Danazol .....................................................22Dantrolene ................................................23Dapsone...................................................... 8Daraprim ...................................................22Dasetta ......................................................26Deblitane ...................................................26Delyla .........................................................26Delzicol ...................................................... 19Demeclocycline ......................................... 8Depen ........................................................ 21Dermazene ............................................... 15Descovy ....................................................20Desipramine ............................................. 12Desmopressin ......................................... 17Desogestrel/Ethinyl Estradiol ..............26Desonide ................................................... 15Desoximetasone ..................................... 15Desvenlafaxine Succinate ER .............. 12

31

Dexamethasone .................................17-19Dexchlorpheniramine ............................25Dexilant ..................................................... 19Dextroamphetamine Sulfate

Extended-Release .............................. 12Dextroamphetamine Sulfate Tablet .... 12Dextroamphetamine/

Amphetamine ...................................... 12Dextroamphetamine/Amphetamine

Extended-Release .............................. 12Diazepam........................................... 13, 14Diazepam Gel .......................................... 14Diclofenac ..........................................19, 23Diclofenac Sodium .................................23Dicloxacillin ................................................ 8Dicyclomine.............................................. 19Didanosine ...............................................20Dificid ......................................................... 19Difil-G Forte Liquid .................................22Diflunisal ...................................................23Digex NF ................................................... 19Digoxin ...................................................... 12Dilatrate SR .............................................. 12Diltiazem Sustained-Release

Capsule ................................................. 10Diltiazem Tablet ....................................... 10Dipentum .................................................. 19Diphenoxylate/Atropine ........................ 19Disopyramide.................................... 10, 12Disulfiram ..................................................22Divalproex DR .......................................... 14Divigel ........................................................28Donepezil, Donepezil ODT ................... 13Dorzolamide ............................................. 18Dorzolamide/Timolol ............................. 18Doxazosin .......................................... 10, 21Doxepin ..................................................... 12Doxycycline Hyclate ................................. 8Doxycycline Monohydrate Tablet ......... 8DrithoCreme HP ..................................... 15DrithoScalp .............................................. 15Dronabinol ................................................ 19Drospirenone/Ethinyl Estradiol ...........26Duavee ......................................................28Duloxetine 20, 30, 60 mg ..................... 12Dupixent .................................................... 15Duraxin ......................................................23Dutasteride ............................................... 21Dutasteride/Tamsulosin ........................ 21Dymista Spray .........................................25

E

Easivent .....................................................22Econazole ................................................. 15

EContra EZ ...............................................26Edarbi ........................................................ 10Edarbyclor ................................................ 10Edurant ......................................................20Elestrin .......................................................28Elidel .......................................................... 15Elinest ........................................................26Eliquis ........................................................ 10Ella ..............................................................26Elmiron ......................................................22Emcyt ........................................................... 9Emoquette ................................................26Emtriva ......................................................20Emverm .....................................................22Enalapril .................................................... 10Enalapril/Hydrochlorothiazide ............. 10Enjuvia .......................................................28Enpresse ...................................................26Enskyce.....................................................26Enstilar ....................................................... 15Entaone ..................................................... 13Entecavir ..................................................... 9Epclusa ....................................................... 9Epinastine ................................................. 18Epinephrine Auto-injector .....................22Epipen, Epipen Jr ...................................22 Epitol .......................................................... 14Epivir HBV Solution .................................. 9Epivir Solution ..........................................20Eprosartan ................................................ 10Ergocalciferol 50,000 Unit Capsule...22Ergoloid Mesylate ................................... 13Erivedge ...................................................... 9Errin ............................................................26Ery Pad ...................................................... 15Erythromycin .................................8, 15, 18Erythromycin/Benzoyl Peroxide ......... 15Erythromycin/Sulfisoxazole ................... 8Escitalopram ............................................ 12Estarylla .....................................................26Estradiol Tablet ........................................28Estradiol Twice Weekly Patch .............28Estradiol Weekly Patch .........................28Estrogen/Methyltestosterone,

Estrogen/Methyltestosterone HS ...28Estropipate ...............................................28Eszopiclone .............................................. 14Ethambutol ................................................. 8Ethosuximide ........................................... 14Ethyl Chloride .......................................... 15Ethynodiol 1/50 .......................................26Etodolac IR/ER .......................................23Etoposide .................................................... 9Euflexxa .....................................................22

Eurax .......................................................... 15Evamist ......................................................28Evotaz ........................................................20Exemestane ........................................ 9, 22Exoderm ................................................... 15EZ Spacer .................................................22Ezetimibe .................................................. 11Ezetimibe/Simvastatin ........................... 11Ezide .......................................................... 10

F

Fallback Solo ...........................................26Falmina ......................................................26Famciclovir ................................................. 9Fareston ...................................................... 9Farxiga ....................................................... 17Farydak ....................................................... 9Felodipine ................................................. 10Femynor .............................................26, 27Fenofibrate 48, 145 mg Tablet ............ 11Fenofibrate 54, 160 mg Tablet ............ 11Fenofibrate Capsule ............................... 11Fenofibrate Micronized ......................... 11Fenoprofen ...............................................23Fentanyl Patch 12, 25, 50,

75, 100 mcg ........................................23Finacea ...................................................... 15Finasteride ................................................ 21Flecainide ................................................. 12Flector Patch ............................................23Flovent Diskus ......................................... 24Flovent HFA .............................................. 24Fluconazole ................................................ 8Fludrocortisone ....................................... 17Flunisolide ................................................25Fluocinolone ............................................ 15Fluocinonide, Fluocinonide E .............. 15Fluoride Chewable Tablet, Drops .......25Fluorometholone .................................... 19Fluoroplex ................................................. 15Fluorouracil Solution, 5% Cream ........ 15Fluoxetine Capsule ................................. 12Fluphenazine ........................................... 13Flurazepam .............................................. 14Flurbiprofen .......................................19, 23Flutamide .................................................... 9Fluticasone ................................. 15, 24, 25Fluticasone Propionate .........................25Fluticasone/Salmeterol

Powder Inhaler .................................... 24Fluvoxamine ............................................. 12FML Forte ................................................. 19Folic Acid 1 mg ................................25, 28Foradil ........................................................ 24

32

Forfivo XL.................................................. 12Forteo ........................................................23Fortesta ..................................................... 21Fortical .......................................................23Fortigan .....................................................23Fosinopril .................................................. 10Fosinopril/Hydrochlorothiazide........... 10Fosrenol ....................................................22Freestyle Test Strips ............................... 16Furosemide .............................................. 10Fuzeon .......................................................20Fyavolv .......................................................28

G

Gabapentin .............................................. 14Galantamine IR/ER ................................ 13Galantamine Solution ............................ 13Gavilyte ...................................................... 19Gemfibrozil ............................................... 11Generic Prenatal Vitamins/

Folic Acid 1 mg ...................................28Gengraf .....................................................25Gentamicin ........................................ 15, 18Genvoya ....................................................20Gianvi .........................................................26Gildagia .....................................................26Gildess, Gildess Fe ................................26Gilenya ....................................................... 13Glimepiride ............................................... 17Glipizide IR/XL ........................................ 17Glipizide/Metformin ............................... 17Glucagen .................................................. 17Glucagon .................................................. 17Glucocard Test Strips ............................ 16Glumetza .................................................. 17Glyburide .................................................. 17Glyburide/Metformin ............................. 17Glyxambi ................................................... 17Gonal-F ...................................................... 21Gonal-F Rff ............................................... 21Gralise .......................................................23Granix ........................................................22Griseofulvin ................................................ 8Guaifenesin/Codeine.............................22Guanfacine ........................................ 10, 12Guanfacine ER ........................................ 12Guanidine .................................................22

H

Halflytely ................................................... 19Haloperidol ............................................... 13Harvoni ........................................................ 9Heather......................................................26Hexalen ....................................................... 9

Homatropine .....................................19, 22Humalog KwikPen .................................. 16Humalog Mix 50-50 KwikPen ............. 16Humalog Mix 50-50 Vial ....................... 16Humalog Mix 75-25 KwikPen .............. 16Humalog Mix 75-25 Vial ....................... 16Humalog U-200 KwikPen ..................... 16Humalog Vial ........................................... 16Humira ....................................................... 21Humulin 70-30 KwikPen ....................... 16Humulin 70-30 Vial ................................ 16Humulin KwikPen ................................... 16Humulin N KwikPen ............................... 16Humulin N Vial ......................................... 16Humulin R U-500 KwikPen .................. 17Humulin R U-500 Vial ............................ 17Humulin R Vial ......................................... 17Hydralazine .............................................. 10Hydrochlorothiazide ........................ 10, 11Hydrocodone/Acetaminophen ...........23Hydrocodone/Homatropine ................22Hydrocodone/Ibuprofen .......................23Hydrocortisone .............. 8, 15, 17, 19, 22Hydrocortisone Pramoxine ............. 8, 22Hydrocortisone Suppository ................22Hydrocortisone Tablet ........................... 17Hydrocortisone/Acetic Acid Otic ........22Hydromorphone IR ................................23Hydroxychloroquine Sulfate ................. 21Hydroxyurea ............................................... 9Hydroxyzine ......................................13, 25Hyoscyamine ........................................... 19Hypercare ................................................. 15Hypersal Nebs .........................................22

I

Ibandronate ..............................................23Ibrance ........................................................ 9Ibuprofen ..................................................23Ilotycin ....................................................... 18Imatinib ........................................................ 9Imipramine................................................ 12Imiquimod................................................. 15Impavido ...................................................22Implanon ...................................................26Incruse Ellipta .......................................... 24Indapamide .............................................. 10Indocin Suppository ...............................23Indomethacin IR/ER ..............................23Inspirease .................................................22Intelence ...................................................20Introvale .....................................................26Intuniv ........................................................ 12Invega Sustenna, Invega Trinza .......... 13

Invirase ......................................................20Invokamet, Invokamet XR ..................... 17Invokana .................................................... 17Ipratropium ........................................ 24, 25Ipratropium/Albuterol Nebs ................. 24Irbesartan ................................................. 10Irbesartan/Hydrochlorothiazide .......... 10Isentress ....................................................20Isibloom .....................................................26Iso Carbachol .......................................... 19Iso Homatropine ..................................... 19Isochron .................................................... 12Isoditrate ER ............................................ 12Isometheptene/Acetaminophen/

Dichloralphenazone ........................... 13Isoniazid ...................................................... 8Isordil ......................................................... 12Isosorbide Dinitrate IR/ER .................... 12Isosorbide Mononitrate IR/ER............. 12Isoxsuprine ............................................... 12Isradipine .................................................. 10Istalol .......................................................... 18Itraconazole................................................ 8

J

Jantoven .................................................... 10Janumet .................................................... 17Janumet XR ............................................. 17Januvia ...................................................... 17Jardiance .................................................. 17Jencycla ....................................................26Jentadueto ............................................... 17Jentadueto XR ......................................... 17Jinteli ..........................................................28Jolessa ......................................................26Jolivette .....................................................26Jublia ........................................................... 8Juleber .......................................................26Junel ..........................................................26Junel Fe .....................................................26Juvisync .................................................... 17

K

Kaletra Tablet ...........................................20Kariva .........................................................26Kelnor ........................................................26Kerydin ........................................................ 8Ketoconazole Cream, Shampoo .......... 8Ketoprofen IR/ER ................................... 24Ketorolac ............................................ 19, 24Kimidess ...................................................26Klor-Con 10 ..............................................25Klor-Con M10 ..........................................25Klor-Con M20 ..........................................25

33

Kurvelo ......................................................26Kuvan .........................................................22

L

Labetalol ................................................... 10Laclotion ................................................... 15Lactulose .................................................. 19Lamivudine .......................................... 9, 20Lamivudine/Zidovudine ........................20Lamotrigine Chewable, Tablet............. 14Lamotrigine ER ....................................... 14Lamotrigine ODT .................................... 14Larin, Larin FE .........................................26Larissia ......................................................26Lastacaft ................................................... 18Latanoprost .............................................. 18Latuda ....................................................... 13Leena .........................................................26Leflunomide ............................................. 21Lessina ......................................................26Letairis .......................................................25Letrozole .............................................. 9, 22Leucovorin Calcium ................................. 9Leukeran ..................................................... 9Levemir Flexpen ...................................... 17Levemir Vial .............................................. 17Levetiracetam ER ................................... 14Levetiracetam IR ..................................... 14Levitra ........................................................ 21Levobunolol ............................................. 18Levofloxacin ............................................... 8Levonest ...................................................26Levonorgestrel.........................................26Levonorgestrel/Ethinyl Estradiol .........26Levora-28 ..................................................26Levorphanol ............................................. 24Levothyroxine Sodium ........................... 18Levoxyl ...................................................... 18Lexiva .........................................................20Lialda ......................................................... 19Lidocaine ...........................................15, 22Lidocaine Viscous ..................................22Lidocaine/Prilocaine .............................. 15Lindane ..................................................... 15Linezolid Tablet ......................................... 8Linzess ......................................................20Liothyronine Sodium .............................. 18Lipofen ...................................................... 11Lisinopril .................................................... 10Lisinopril/Hydrochlorothiazide ............ 10Lithium IR/ER .......................................... 14Livalo .......................................................... 11Lo Loestrin ...............................................27Lokara........................................................ 15

Lomustine ................................................... 9Lonsurf ........................................................ 9Lopinavir-Ritonavir Solution .................20Lopreeza ...................................................28Lorazepam ............................................... 14Loryna .......................................................27Lorzone .....................................................23Losartan .................................................... 11Losartan/Hydrochlorothiazide ............ 11Lovastatin ................................................. 11Low-Ogestrel ...........................................27Loxapine ................................................... 14Lumigan .................................................... 18Lupron Depot .......................................... 17Lutera .........................................................27Lyrica Capsule ......................................... 14Lyrica Solution ......................................... 14Lysodren ..................................................... 9Lyza ............................................................27

M

Makena .....................................................28Maprotiline ................................................ 13Marlissa .....................................................27Matulane ..................................................... 9Mavyret ........................................................ 9Mebendazole ...........................................22Meclofenamate ....................................... 24Medrol 2 mg ............................................ 17Medroxyprogesterone .................... 27, 28Medroxyprogesterone Acetate

Injection .................................................27Mefloquine ...............................................22Megestrol AC ...........................................22Meloxicam ................................................ 24Melphalan ................................................... 9Memantine Solution, Tablet ................. 14Menest.......................................................28Meperidine ............................................... 24Mephyton..................................................22Meprobamate .......................................... 14Mercaptopurine......................................... 9Mesalamine Enema ...............................20Mestinon Syrup .......................................22Metformin ................................................. 17Metformin Extended-Release ............. 17Methadone ............................................... 24Methazolamide ........................................ 11Methenamine ............................................. 8Methimazole ............................................ 18Methocarbamol .......................................23Methotrexate ............................................ 21Methyclothia ............................................. 11Methyldopa .............................................. 11

Methyldopa/Hydrochlorothiazide ....... 11Methylergonovine .............................17, 22Methylphenidate Controlled-Release

Capsule ................................................. 12Methylphenidate Tablet ......................... 12Methylprednisolone ............................... 17Metipranolol ............................................. 18Metoclopramide Solution, Tablet ........20Metolazone ............................................... 11Metoprolol Succinate ER ...................... 11Metoprolol Tartrate ................................. 11Metrogel 1% ............................................. 15Metronidazole 0.75% Cream,

Lotion ..................................................... 15Metronidazole Tablet ............................... 8Metronidazole Vaginal Gel ..................... 8Mexiletine .................................................. 12Microgestin ..............................................27Microgestin FE ........................................27Midodrine ................................................. 12Migragesic ................................................ 13Migranal .................................................... 13Millipred Tablet ........................................ 17Mimvey ......................................................28Minivelle ....................................................28Minocycline Capsule ............................... 8Minoxidil .................................................... 11Mirtazapine, Mirtazapine ODT ............ 13Mirvaso ...................................................... 15Misoprostol .............................................. 19Moexipril ................................................... 11Moexipril/Hydrochlorothiazide ............ 11Mometasone Furoate ............................ 15Mono-Linyah ............................................27Mononessa ..............................................27Montelukast ............................................. 24Morphine Sulfate Controlled-Release

Tablet ..................................................... 24Morphine Sulfate Immediate-Release

Tablet, Solution.................................... 24Movantik ...................................................20Moviprep ...................................................20Moxeza ...................................................... 18Moxifloxacin ............................................. 18Multaq........................................................ 12Multigen Folic ..........................................22Multigen Plus ...........................................22Mupirocin Calcium Cream ................... 15Mupirocin Ointment ............................... 15My Way ......................................................27Mycobutin ................................................... 8Myleran........................................................ 9Myorisan ................................................... 15Myrbetriq .................................................. 24

34

Myzilra .......................................................27

N

Nabumetone ............................................ 24Nadolol ...................................................... 11Naltrexone ................................................22Namzaric ................................................... 14Naphazoline 0.1% ................................... 18Naproxen .................................................. 24Narcan Nasal Spray ...............................22Natacyn ..................................................... 18Natazia ......................................................27Nateglinide ............................................... 17NebuPent Nebs ........................................ 8Necon 0.5/35, 1/35, 1/50, 10/11 .......27Nefazodone.............................................. 13Neomycin.......................................8, 18, 19Neomycin/Bacitracin/

Polymyxin ...................................... 18, 19Neomycin/Bacitracin/Polymyxin/

Hydrocortisone ................................... 19Neomycin/Polymixin/

Dexamethasone .................................. 19Neomycin/Polymixin/Gramicidin ........ 18Neomycin/Polymixin/

Hydrocortisone Otic ............................. 8Nessi Spacer ...........................................22Nevirapine ................................................20Next Choice One Dose .........................27Niacin ER .................................................. 11Niaspan ..................................................... 11Nicardipine ............................................... 11Nicoderm CQ ..........................................25Nicorette Gum .........................................25Nicorette Lozenge ..................................25Nicorette Mini-Lozenge .........................25Nicotine Gum ...........................................25Nicotine Lozenge ....................................25Nicotine Patch .........................................25Nicotrol Inhaler ........................................25Nicotrol Nasal Spray ..............................25Nifediac CC .............................................. 11Nifedical XL .............................................. 11Nifedipine IR/ER ..................................... 11Nikki ...........................................................27Nilandrone .................................................. 9Ninlaro ......................................................... 9NitroBid ..................................................... 12Nitrofurantoin ............................................. 8Nitrofurantoin Macrocrystal ................... 8Nitroglycerin ER ...................................... 12Nitroglycerin Tablet ................................ 12Nitrolingual Pump Spray ....................... 12NitroTime .................................................. 12

Nizatidine .................................................. 19Nodolor ..................................................... 13Nora-BE ....................................................27Norethindrone .................................. 27, 28Norethindrone/Ethinyl Estradiol ... 27, 28Norethindrone/Ethinyl Estradiol/

Ferrous Fumarate ...............................27Norgestimate/Ethinyl Estradiol ............27Norgestrel/Ethinyl Estradiol .................27Norlyda ......................................................27Norlyroc.....................................................27Norpace CR ............................................. 12Nortrel ........................................................27Nortriptyline ............................................. 13Norvir .........................................................20Novofine Autocover Pen Needles ...... 16Novofine Pen Needles ........................... 16Novofine Plus Pen Needles ................. 16Novolin N Vial .......................................... 17Novolin R Vial .......................................... 17Novolin Vial............................................... 17Novolog Flexpen ..................................... 17Novolog Mix ............................................. 17Novolog Vial ............................................. 17Novotwist Pen Needles ......................... 16Nucynta ..................................................... 24Nucynta ER .............................................. 24Nutropin AQ, Nutropin AQ NuSpin .... 17Nuvaring ....................................................27Nuwiq ........................................................22Nystatin .................................................8, 15Nystop ....................................................... 15

O

Ocella .........................................................27Odefsey .....................................................20Odomzo ...................................................... 9Ofloxacin .............................................. 8, 18Ofloxacin Otic ............................................ 8Ogestrel .....................................................27Olanzapine, Olanzapine ODT .............. 14Olmesartan .............................................. 11Olmesartan/Hydrochlorothiazide ....... 11Olopatadine 0.1% .................................... 18Omeclamox-Pak ..................................... 19Omega-3-Acid Ethyl Esters

Capsule ................................................. 11Omeprazole ............................................. 19Omnaris.....................................................25Ondansetron ............................................ 19Ondansetron ODT .................................. 19OneTouch Lancets ................................. 16OneTouch Test Strips ............................ 16OneTouch Ultra Blue Test Strips ......... 16

OneTouch Verio IQ Test Strips ............ 16Onexton .................................................... 15Opcicon One-Step .................................27Opsumit ....................................................25Optihaler ...................................................22Option 2 ....................................................27Oracea ......................................................... 8Orencia ...................................................... 21Orenitram ..................................................25Orkambi ....................................................22Orphenadrine ER ....................................23Orphenadrine/Aspirin/Caffeine ...........23Orsythia .....................................................27Ortho Coil .................................................27Ortho Flat ..................................................27Ortho Flex .................................................27Osphena ...................................................28Otezla ......................................................... 15Otrexup ..................................................... 21Ovidrel ....................................................... 21Oxaprozin ................................................. 24Oxazepam ................................................ 14Oxcarbazepine ........................................ 14Oxybutynin ............................................... 24Oxybutynin Extended-Release ........... 24Oxycodone IR .......................................... 24Oxycodone/Acetaminophen ............... 24Oxymorphone ......................................... 24

P

Pacerone .................................................. 12Pancrelipase ............................................20Pantoprazole ............................................ 19Paregoric Tincture ..................................20Paricalcitol ................................................ 17Paromomycin............................................. 8Paroxetine ................................................. 13Paroxetine ER .......................................... 13Pataday ..................................................... 18Paxil Suspension .................................... 13Pegasys ....................................................... 9Penicillin VK ............................................... 8Pentasa .....................................................20Pentazocine/Naloxone .......................... 24Pentoxifylline ............................................ 12Perforomist ...............................................25Perindopril ................................................ 11Permethrin ................................................ 16Perphenazine/Amitriptyline .................. 14Phenazopyridine .....................................22Phenelzine ................................................ 13Phenobarbital ................................... 14, 19Phenoxybenzamine ............................... 11Phenylephrine ......................................... 18

35

Phenytoin .................................................. 14Philith .........................................................27Phospholine ............................................. 19Phrenilin Forte ......................................... 13Picato ......................................................... 16Pilocarpine ...............................................22Pimtrea ......................................................27Pindolol ..................................................... 11Pioglitazone ............................................. 17Pioglitazone/Glimepiride ...................... 17Pioglitazone/Metformin ........................ 17Piroxicam .................................................. 24Plan B One Step .....................................27Podofilox ................................................... 16Polyethylene Glycol 3350.....................20Polymyxin B/Trimethoprim .................. 18Portia .........................................................27Potassium Chloride ................................25Potassium Citrate ...................................25Pradaxa ..................................................... 10Praluent ..................................................... 11Pramcort ................................................... 16Pramipexole ............................................. 14Pramosone Cream, Ointment ............. 16Pramosone E Cream ............................. 16Pramosone Lotion .................................. 16Pramoxine-HC Otic .................................. 8Prasugrel ................................................... 10Pravastatin ................................................ 11Prazosin .................................................... 11Pred Mild .................................................. 19Prednisolone Solution, Tablet ........17, 19Prednisone ............................................... 17Premarin ...................................................28Premarin Vaginal Cream .......................28Premphase ...............................................28Prempro ....................................................28Prepopik ...................................................20Prevalite ..................................................... 11Previfem ....................................................27Prezcobix ..................................................20Prezista ......................................................20Primaquine ...............................................22Primella .....................................................27Proair HFA ................................................25Proair RespiClick ....................................25Probenecid ...............................................23Prochlorperazine .................................... 14Procrit ........................................................22Proctocream HC .....................................22Proctofoam HC .......................................22Proctosol HC ...........................................22Proctozone HC ........................................22Proglycem ................................................22Promethazine ............................19, 22, 25

Promethazine Suppository ...................22Promethazine VC/Codeine ..................22Promethazine/Codeine .........................22Promethazine/Dextromethorphan .....22Propafenone ............................................ 12Propantheline ..........................................20Proparacaine ........................................... 19Propranolol IR/ER .................................. 11Propranolol/Hydrochlorothiazide ....... 11Propylthiouracil ....................................... 18Protopic ..................................................... 16Protriptyline .............................................. 13Prozac........................................................ 12Pulmicort Flexhaler ................................25Pulmicort Respules ................................25Pylera ......................................................... 19Pyrazinamide ............................................. 8Pyridostigmine ........................................22

Q

QNasl .........................................................25Quasense .................................................27Quetiapine, Quetiapine ER ................... 14Quinapril ................................................... 11Quinidine IR/ER ...................................... 12QVAR .........................................................25

R

Raloxifene .................................................28Ramipril ..................................................... 11Ranexa ...................................................... 12Rapaflo ...................................................... 21Rasuvo ...................................................... 21React..........................................................27Reclipsen ..................................................27Relion Test Strips .................................... 16Remicade ................................................. 21Repaglinide .............................................. 17Rescriptor .................................................20Reserpine ................................................. 11Restasis ..................................................... 19Retrovir ......................................................20Rexulti ........................................................ 14Reyataz......................................................20Rezira .........................................................22Rheumatrex .............................................. 21Rhofade..................................................... 16Ribavirin Tablet .......................................... 9Rifampin ...................................................... 8Rimantidine ................................................ 9Risperidone, Risperidone ODT ........... 14Rivastigmine ............................................ 14Rizatriptan ................................................ 13Ropinirole ................................................. 14Rosadan Cream ...................................... 16

Rosuvastatin ............................................ 11Rowasa Enema .......................................20

S

Safyral ........................................................27Salsalate .................................................... 24Saphris ...................................................... 14Savaysa ..................................................... 10Selenium Sulfide ..................................... 16Selzentry ...................................................20Serevent ....................................................25Sertraline ................................................... 13Setlakin ......................................................27Sevelamer ..........................................20, 22Sharobel ....................................................27Sildenafil Tablet 20 mg ..........................25Silenor........................................................ 14Silver Nitrate ............................................. 16Silver Sulfadiazine .................................. 16Simbrinza .................................................. 18Simponi ..................................................... 21Simvastatin ............................................... 11Sodium Polystyrene Sulfonate

Powder ..................................................22Solia ...........................................................27Soliqua ...................................................... 17Soolantra................................................... 16Sotalol ..................................................11, 12Sotalol AF ................................................. 11Sovaldi ......................................................... 9Spiriva HandiHaler, Respimat ..............25Spironolactone ........................................ 11Spironolactone/

Hydrochlorothiazide ........................... 11Sprintec .....................................................27Sprycel ........................................................ 9Sronyx........................................................27SSKI ...........................................................22Stavudine Capsule .................................20Stelara ....................................................... 21Strensiq .....................................................23Stribild .......................................................20Striverdi Respimat ..................................25Suboxone Film ........................................ 14Sucralfate Tablet ..................................... 19Sulfacetamide Sodium ............ 16, 18, 19Sulfacetamide Sodium-Sulfur .............. 16Sulfacetamide Sodium/

Prednisolone ........................................ 19Sulfadiazine ......................................... 8, 16Sulfamethoxazole/Trimethoprim,

Sulfamethoxazole/ Trimethoprim DS ................................... 8

Sulfasalazine ............................................20Sulindac .................................................... 24

36

Sumatriptan Nasal Spray, Tablet ........ 13Sumavel DosePro ................................... 13Suprep .......................................................20Sustiva .......................................................20Syeda .........................................................27Symbicort .................................................25Symlin ........................................................ 17Synarel.......................................................23Synjardy .................................................... 17Synjardy XR .............................................. 17Synvisc ......................................................23Synvisc One .............................................23

T

Tabloid ......................................................... 9Taclonex Ointment ................................. 16Taclonex Scalp ........................................ 16Tacrolimus .........................................16, 25Tacrolimus Ointment .............................. 16Take Action ..............................................27Tamoxifen .................................................28Tamsulosin ............................................... 21Targretin ...................................................... 9Tarina FE ...................................................27Tasigna ........................................................ 9Taytulla ......................................................27Tazorac ...................................................... 16Taztia XT ................................................... 11Tecfidera ................................................... 13Technivie ..................................................... 9Telmisartan ............................................... 11Telmisartan/Hydrochlorothiazide ....... 11Temazepam ............................................. 14Temozolomide ........................................... 9Terazosin.............................................11, 21Terbinafine .................................................. 9Terbutaline ................................................25Terconazole ................................................ 9Testim ........................................................ 21Testosterone Gel 1% .............................. 21Testred....................................................... 21Tetracaine ................................................. 19Tetracycline ................................................ 8Theophylline SR ......................................25Thioridazine ............................................. 14Thiothixene ............................................... 14Thrive Gum ...............................................25Ticlopidine ................................................ 10Timolol .................................................11, 18Timolol Maleate ....................................... 18Timoptic Ocudose .................................. 18Tirosint ....................................................... 18Tivicay ........................................................20Tivorbex .................................................... 24Tizanidine Tablet .....................................23

Tobradex Ointment ................................ 18Tobramycin Ophth Solution ................. 18Tobramycin/Dexamethasone .............. 18Tobrex ........................................................ 18Tolazamide ............................................... 17Tolbutamide ............................................. 17Tolmetin ..................................................... 24Topiragen .................................................. 14Topiramate ............................................... 14Torsemide ................................................. 11Toviaz ......................................................... 24Tracleer .....................................................25Tradjenta ................................................... 17Tramadol ................................................... 24Trandolapril/Verapamil CR .................. 11Tranylcypromine ..................................... 13Travatan Z ................................................. 18Trazodone................................................. 13Tretinoin Capsule ...................................... 9Tretinoin Cream ....................................... 16Trexall ......................................................... 21Trezix .......................................................... 24Tri Femynor ..............................................27Tri-Estarylla ...............................................27Tri-Linyah ..................................................27Tri-Previfem ..............................................27Tri-Sprintec ...............................................27Triamcinolone Acetonide ...................... 16Triamcinolone/Orabase ........................23Triamterene/Hydrochlorothiazide ....... 11Trianex ....................................................... 16Triazolam .................................................. 14Triderm ...................................................... 16Trifluoperazine ......................................... 14Trifluridine ................................................. 18Trihexyphenidyl ....................................... 14Trilyte .........................................................20Trimethobenzamide ............................... 19Trimethoprim ...................................... 8, 18Trinessa .....................................................27Trinessa Lo ...............................................27Triumeq .....................................................20Trivora-28 ..................................................27Trizivir .........................................................20Tropicamide ............................................. 19Trulicity ...................................................... 17Truvada......................................................20Tudorza .....................................................25Tykerb .......................................................... 9

U

Uceris Foam .............................................20Uceris Tablet ............................................20Uloric ..........................................................23Unithroid ................................................... 18

Urea 40% Lotion ..................................... 16Ursodiol .....................................................20

V

Valacyclovir................................................. 9Valganciclovir Solution ............................ 9Valganciclovir Tablet ................................ 9Valproic Acid ............................................ 14Valsartan ................................................... 11Valsartan/Hydrochlorothiazide ........... 11Vandazole Gel ........................................... 9Varubi......................................................... 19Vascepa .................................................... 11Vectical ...................................................... 16Velivet ........................................................27Velphoro ....................................................23Veltassa .....................................................23Venlafaxine ............................................... 13Venlafaxine Extended-Release

Capsule ................................................. 13Venlafaxine Extended-Release

Tablet ..................................................... 13Ventolin HFA ............................................25Veramyst ...................................................25Verapamil Sustained-Release

Capsule ................................................. 11Verapamil Sustained-Release

Tablet ..................................................... 11Verapamil Tablet ..................................... 11Vesicare..................................................... 24Vestura ......................................................27Viagra......................................................... 21Viberzi ........................................................20Victoza ....................................................... 17Videx Solution ..........................................20Viekira Pak, Viekira XR ............................ 9Vienva ........................................................27Viibryd ....................................................... 13Vimpat Injection ...................................... 14Vimpat Tablet, Solution ......................... 14Viorele ........................................................27Viracept .....................................................20Viread ........................................................ 21Vistogard ...................................................23Vitamin D 50,000 Unit ...........................23Vitazol ........................................................ 16Vitekta........................................................ 21Vivelle-Dot ................................................28Vivlodex ..................................................... 24Voltaren Gel ............................................. 24Vortex .........................................................23Vosevi .......................................................... 9Vraylar ........................................................ 14Vyfemla .....................................................27Vyvanse ..................................................... 12

37

W

Warfarin ..................................................... 10WatchHaler ...............................................23Welchol ..................................................... 11Wera ...........................................................27Wide-Seal .................................................28

X

Xarelto ....................................................... 10Xeloda .......................................................... 9Xiidra .......................................................... 19Xopenex HFA ...........................................25Xtampza ER ............................................. 24Xulane ........................................................28Xuriden ......................................................23Xyrem ......................................................... 14

Y

Yasmin 28 .................................................28Yaz ..............................................................28Yodoxin......................................................23Yuvafem ....................................................28

Z

Zaleplon .................................................... 14Zarah..........................................................28Zarxio .........................................................23Zecuity ....................................................... 13Zelapar ...................................................... 14Zemplar ...............................................17, 23Zenatane ................................................... 16Zenchent ...................................................28Zenpep ......................................................20Zepatier ....................................................... 9Zerit Solution............................................ 21Zetonna .....................................................25Ziagen Solution ....................................... 21Zidovudine .........................................20, 21Zioptan ...................................................... 18Ziprasidone .............................................. 14Zmax ............................................................ 8Zolmitriptan .............................................. 13

Zolpidem ................................................... 14Zomig Spray ............................................. 13Zonisamide............................................... 14Zontivity ..................................................... 10Zorvolex .................................................... 24Zovia ..........................................................28Zovirax Cream ........................................... 9Zovirax Ointment ...................................... 9Zubsolv ...................................................... 14Zurampic ...................................................23Zutripro ......................................................23Zyclara Cream, Pump ............................ 16Zytiga ........................................................... 9

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Nondiscrimination notice and access to communication servicesUnitedHealthcare® and its subsidiaries do not discriminate on the basis of race, color, national origin, age, disability or sex in its health programs or activities.

If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to the Civil Rights Coordinator.

Online: [email protected]

Mail: Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box 30608 Salt Lake City, UT 84130

You must send the complaint within 60 days of your experience. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, please call the toll-free phone number listed on your ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m., or at the times listed in your health plan documents.

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

Phone: Toll free 1-800-368-1019, 1-800-537-7697 (TDD)

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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., or at the times listed in your health plan documents.

39

This document applies to commercial group members of UnitedHealthcare West.

Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. 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® is a registered trademark owned by UnitedHealth Group Incorporated. All other trademarks are the property of their respective owners.

2018 Prescription Drug List — SignatureValue Three-Tier Coverage Level Formulary

M56950 8/17 ©2017 United HealthCare Services, Inc.

Documents

Your 2018 Formulary - Cookies Not Enabled January 1, 2018 Your 2018 Formulary SignatureValue Three-Tier This formulary is accurate as of January 2018 and is subject to change after