Your 2018 Formulary - teamhmh.com€¦ · Diabetes/Endocrine Blood Glucose Monitoring ... Drugs are listed by common categories or class. They are placed into cost levels known as

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

Call the toll-free member phone number on your ID card.

Visit your plan’s member website listed on your ID card.• Locate a participating retail pharmacy by zip code.• Look up possible lower-cost medication alternatives.• Compare medication pricing and options.

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

Your 2018 Formulary

OptumRx 1

Effective January 1, 2018

Premium Select Standard

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Your Formulary

This Formulary outlines the most commonly prescribed medications from your plan’s complete pharmacy benefit coverage list, also known as a Prescription Drug List (PDL). A formulary identifies the drugs available for certain conditions and organizes them into cost levels, also known as tiers. An important part of the Formulary is giving you choices so you and your doctor can choose the best course of treatment for you.

Go to your plan’s member website for complete and up-to-date drug information

Since the Formulary may change, we encourage you to visit our website, your plan’s member website, which should be listed on your ID card. This website is the best source for up-to-date information about all of the medications your pharmacy benefit covers, possible lower-cost options and cost comparisons.

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Table of Contents

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

Drugs by category . . . . . . . . . . . . . . . . . . . . 9

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

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

Cardiovascular/Heart DiseaseAnticoagulants. . . . . . . . . . . . . . . . . . . . . . . . 10High Blood Pressure . . . . . . . . . . . . . . . . . . . . 10High Cholesterol . . . . . . . . . . . . . . . . . . . . . . 10Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Pulmonary Arterial Hypertension . . . . . . . . . . 11

Central Nervous SystemAttention Deficit Disorder . . . . . . . . . . . . . . . 11Depression. . . . . . . . . . . . . . . . . . . . . . . . . . . 11Migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . 12Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Sedatives/Hypnotics . . . . . . . . . . . . . . . . . . . . 12Seizure Disorders . . . . . . . . . . . . . . . . . . . . . . 12

Dermatology . . . . . . . . . . . . . . . . . . . . . . . . 13

Diabetes/EndocrineBlood Glucose Monitoring . . . . . . . . . . . . . . . 13Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Non-Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . 15

EndocrineGrowth Hormone . . . . . . . . . . . . . . . . . . . . . 15Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Thyroid Hormone Replacement . . . . . . . . . . . 16

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

GastrointestinalAcid Suppression . . . . . . . . . . . . . . . . . . . . . . 16Nausea/Vomiting . . . . . . . . . . . . . . . . . . . . . . 17Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Inflammatory Conditions . . . . . . . . . . . . . . 17

Men’s HealthErectile Dysfunction . . . . . . . . . . . . . . . . . . . . 18Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Testosterone Therapy . . . . . . . . . . . . . . . . . . . 18

Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . 18

MusculoskeletalOsteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . 19 Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Pain Relief . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Overactive Bladder . . . . . . . . . . . . . . . . . . . 20

RespiratoryAsthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . 20Nasal Allergies . . . . . . . . . . . . . . . . . . . . . . . . 21Oral Allergies . . . . . . . . . . . . . . . . . . . . . . . . . 21

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

Vitamins/Electrolytes . . . . . . . . . . . . . . . . . 21

Women’s HealthBirth Control . . . . . . . . . . . . . . . . . . . . . . . . . 21Hormone Replacement . . . . . . . . . . . . . . . . . 22Vaginal Anti-Infectives . . . . . . . . . . . . . . . . . . 22

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

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

What is a Formulary?

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

Please note: Where differences are noted between this Formulary and your benefit plan documents, the benefit plan documents will rule. It is not intended to be 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 plan sponsor to see what medications are covered under your plan. You may also log on to your plan’s member website or call the toll-free member phone number on your ID card for more information.

How do I use my Formulary?

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

If your medication is not listed in this document, please visit your plan’s member website or call the toll-free member phone number on your ID card.

When does the Formulary change?

• Medications may move to a lower tier at any time. • Medications may move to a higher tier when its generic becomes available.• Medications may move to a higher tier or be excluded from coverage

on January 1 or July 1 of each year.

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

For the most up-to-date list, call customer service at the toll-free member phone number on your ID card.

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What are tiers?

Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, which is determined by your employer or plan sponsor. This is how much you will pay when you fill a prescription. Tier 1 medications are your lowest-cost options. If your medication is placed in Tier 2 or 3, look to see if there is a Tier 1 option available. Discuss these options with your doctor.

Check your benefit plan documents to find out your specific pharmacy plan costs.

$ Drug Tier Includes Helpful Tips

Tier 1 Lowest Cost

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

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

Tier 2 Mid-range Cost

Many common brand-name drugs, called preferred brands.

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

Tier 3 Highest Cost

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

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

Please note: Some plans may have two or four tiers, while others may not have any. If you have a high deductible plan, the tier cost levels will apply once you hit your deductible. Refer to your enrollment and plan materials on your plan’s member website, or call the toll-free member phone number on your ID card for more information about your benefit plan.

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Why are some medications excluded from coverage?

Medications may be excluded from coverage under your pharmacy benefit when it works the same as or similar to another prescription medication or an over-the-counter (OTC) medication. There may be other medication options available.

What if I don’t agree with a decision about an excluded medication?

You (or your authorized representative) and your doctor can ask for an initial coverage decision by calling the toll-free member phone number on the back of your ID card.

Should I talk to my doctor about OTC medications?

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

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

Generic medications contain the same active ingredients (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.

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Is it a generic or brand-name drug?

The drug list shows brand-name drugs in bold type (for example, Clobex) and generic drugs in plain type (for example, clobetasol).

What if my doctor writes a brand-name prescription?

The next time your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lower-cost option is available and if it might be right for you. Generic medications are usually your lowest-cost option, but not always. Visit your plan’s member website to make sure.

Are you taking a specialty medication?

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

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

How do I get updated information about my pharmacy benefit?

Since the Formulary may change during your plan year, we encourage you to visit your plan’s member website or call the toll-free member phone number on your ID card for more current information.

When you register at on our website and open an account, you can use the website’s helpful tools and features to:

• Look up the price of drugs covered by your plan

• Find lower-cost options

• Refill and renew home delivery prescriptions

• View your order status and claims history

• View your benefits in real time

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Excluded brand-name medications with generic equivalents for 2018*

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

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

Aciphex

Acticlate

Adderall XR

Alphagan P

Ambien

Ambien CR

Androgel 1%

Azor

Benicar

Benicar HCT

Benzamycin

Benzaclin

Beyaz

Carafate

Celebrex

Concerta

Crestor

Cymbalta

Cytomel

Depo — Testost Inj

Dilantin

Dilantin Chewable

Dilantin Suspension

Diovan

Diovan HCT

Duac

Duragesic

Effexor XR

Glumetza

Kadian

Lexapro

Lidoderm

Lipitor

Lovaza

Lunesta

Minastrin

Nasonex

Nexium

Nitrostat

Norco

Norvasc

Nuvigil

Ortho Tri Cyclen

Ortho Tri Cyclen Lo

Percocet

Prevacid

Pristiq

Prozac

Pulmicort Inh Suspension

Retin-A Micro Gel

Singulair

Taclonex

Tamiflu

Tobi Nebulizer

Tobradex

Toprol XL

Tribenzor

Vagifem

Valium

Vitafol

Vivelle-Dot

Voltaren

Vytorin

Wellbutrin

Wellbutrin SR

Wellbutrin XL

Xanax

Xanax XR

Yaz

Zegerid

Zetia

Ziana

Zoloft

Zomig

Zomig ZMT

Zovirax

More informationIf you have additional questions please call customer service, 24 hours a day, 7 days a week using the toll-free member phone number on your ID card. Or visit your plan’s member website.

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

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

SP Specialty Program: Medication is designated as a specialty pharmacy drug.

Drug NameDrug Tier

Specialty Program

Anti-Infectives: Antibiotics

Amoxicillin 1Amoxicillin/Clavulanate 1Azasite 3Azithromycin 1Bethkis 2 SPCefdinir 1Cefuroxime Tab 1Cephalexin 1Ciprodex Otic

Suspension2

Ciprofloxacin Tab 1Clarithromycin 1Clindamycin Cap 1Doryx MPC 3Doxycycline Hyclate Cap 1Doxycycline Hyclate Tab

(Immediate Release)1

Doxycycline Monohydrate Cap

1

Doxycycline Monohydrate Oral Suspension, Tab

1

Erythromycin 1Kitabis E SPLevofloxacin Tab 1Metronidazole Tab 1Minocycline Cap 1Nitrofurantoin

Macrocrystalline1

Nitrofurantoin Monohydrate Macrocrystalline

1

Ofloxacin Otic Solution 1Oracea 3Penicillin VK 1Solodyn 3Sulfamethoxazole-

Trimethoprim1

Drug NameDrug Tier

Specialty Program

Sulfamethoxazole-Trimethoprim DS

1

TOBI podhaler E SPTobramycin (M) E SP

Anti-Infectives: Antifungals

Fluconazole 1Jublia Solution 3Kerydin Solution 3Nystatin Suspension 1Terbinafine Tab 1

Anti-Infectives: Antivirals

Acyclovir Cap, Tab, Suspension

1

Descovy 2 SPEntecavir 1 SPEpclusa 2 SPFamciclovir Tab 1Harvoni 2 SPMavyret 2 SPOdefsey 2 SPOseltamivir 1Valacyclovir 1Zepatier 3 SP

CancerAkynzeo 3Anastrozole Tab 1Cabometyx 2 SPCapecitabine 1 SPLetrozole 1Mercaptopurine 1 SPRevlimid 3 SPSprycel 2 SPTamoxifen Tab 1Zytiga 3 SP

(M) Co-Branded Product

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Drug NameDrug Tier

Specialty Program

Cardiovascular/Heart Disease: AnticoagulantsBrilinta 2Clopidogrel 1Effient 2Eliquis 3Enoxaparin 1 SPPradaxa 2Savaysa 3Warfarin 1Xarelto 2Zontivity 3Cardiovascular/Heart Disease: High Blood PressureAmlodipine 1Amlodipine/Benazepril 1Amlodipine/Valsartan 1Atenolol 1Atenolol/Chlorthalidone 1Benazepril 1Benazepril/HCTZ 1Bisoprolol 1Bisoprolol/HCTZ 1Bumetanide 1Bystolic 2Byvalson 2Cartia XT 1Carvedilol 1Chlorthalidone 1Clonidine Tab 1Diltiazem ER 1Doxazosin 1Edarbi 3Edarbyclor 3Enalapril 1Furosemide 1Guanfacine Tab


Hydralazine 1Hydrochlorothiazide 1Irbesartan 1

Drug NameDrug Tier

Specialty Program

Labetalol 1Lisinopril 1Lisinopril/HCTZ 1Losartan 1Losartan/HCTZ 1Metoprolol Succinate 1Metoprolol Tartrate 1Nadolol 1Nifedipine ER 1Olmesartan 1Olmesartan HCT 1Prazosin 1Propranolol 1Propranolol ER 1Quinapril 1Ramipril 1Spironolactone 1Tekturna 2Tekturna HCT 2Telmisartan 1Terazosin 1Torsemide Tab 1Triamterene/HCTZ 1Valsartan 1Valsartan/HCTZ 1Verapamil ER 1Cardiovascular/Heart Disease: High CholesterolAtorvastatin 1Choline Fenofibrate ER 1Crestor 3Fenofibrate 40 mg,

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

1

Gemfibrozil 1Livalo 3Lovastatin 1Niacin ER Tab 1

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Drug NameDrug Tier

Specialty Program

Omega-3 Acid Cap 1 gm

1

Praluent 2 SPPravastatin 1Rosuvastatin 1Simvastatin 5 mg, 10

mg, 20 mg, 40 mg1

Simvastatin 80 mg 1Vascepa 2Welchol 2

Cardiovascular/Heart Disease: Other

Corlanor 3Digoxin 1Flecainide 1Isosorbide Mononitrate

ER1

Multaq 3Nitroglycerin SL Tab 1Ranexa 2Sotalol 1Cardiovascular/Heart Disease: Pulmonary Arterial HypertensionAdcirca 3 SPAdempas 2 SPLetairis 2 SPOpsumit 2 SPOrenitram 3 SPSildenafil Tab 20 mg 1 SPTracleer 2 SP

Drug NameDrug Tier

Specialty Program

Central Nervous System: Attention Deficit DisorderAmphetamine-

Dextroamphetamine Tab

1

Amphetamine-Dextroamphetamine SR 24Hr Cap

1

Dexmethylphenidate ER Cap

1

Guanfacine ER Tab 1Methylphenidate

ER Cap1

Methylphenidate ER Tab 1Methylphenidate SA

Osmotic ER Tab1

Methylphenidate Tab 1Strattera 3Vyvanse 2

Central Nervous System: Depression

Amitriptyline 1Bupropion 1Bupropion ER 1Bupropion SR 1Bupropion XL 1Citalopram 1Doxepin 1Duloxetine Cap 20 mg,

30 mg, 60 mg1

Escitalopram Tab 1Fluoxetine Cap

(not PMDD)1

Forfivo XL 2Mirtazapine 1Nortriptyline 1Paroxetine Tab 1Rexulti 3Risperidone Tab 1Sertraline 1

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Drug NameDrug Tier

Specialty Program

Trazodone 1Trintellix 3Venlafaxine Tab 1Venlafaxine ER Cap 1Venlafaxine ER Tab 1Viibryd 3

Central Nervous System: Migraine

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

1

Migranal 3Relpax 3Rizatriptan Tab, ODT 1Sumatriptan Tab

and Spray1

Sumavel Dose 3Central Nervous System: Multiple SclerosisAmpyra 2 SPAubagio 3 SPAvonex Kit 2 SPAvonex Pen Kit 2 SPAvonex Prefill Kit 2 SPBetaseron 2 SPCopaxone 20 mg/mL

& 40 mg/mL2 SP

Extavia E SPGilenya+ 3 SPPlegridy E SPRebif E SPRebif Titrtn E SPTecfidera 2 SP

Central Nervous System: Other

Alprazolam Tab 1Aripiprazole 1Aristada 3Buspirone 1Diazepam Tab 1Hydroxyzine HCL 1

Drug NameDrug Tier

Specialty Program

Hydroxyzine Pamoate 1Invega Sustenna 3Invega Trinza 3Latuda 3Lorazepam Tab 1Modafinil 1Namenda XR 2Namzaric 2Olanzapine Tab 1Pramipexole 1Quetiapine 1Risperidone Tab 1Ropinirole


Saphris 2Xyrem 3 SPCentral Nervous System: Sedatives/HypnoticsEszopiclone Tab 1Silenor 3Temazepam 1Triazolam Tab 1Zaleplon 1Zolpidem 1Zolpidem ER 1Central Nervous System: Seizure DisordersClonazepam 1Divalproex DR 1Divalproex ER 1Gabapentin 1Lamotrigine


Levetiracetam 1Levetiracetam ER 1Lyrica Cap 2Oxcarbazepine 1Primidone 1Topiramate Tab 1Trokendi XR EVimpat 3Zonisamide 1

+ Tier 3 Preferred

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Drug NameDrug Tier

Specialty Program

Dermatology

Absorica 3Acanya Gel EAczone Gel 3Aktipak EAtralin 3Claravis 1Clindamycin Gel,

Lotion, Solution1

Clindamycin/ Benzoyl Peroxide Gel 1-5%

1

Clindamycin/Benzoyl Peroxide Gel 1.2-5%

1

Clobetasol Cream, Ointment, Solution

1

Clobex 3Clotrimazole/

Betamethasone Cream, Lotion

1

Dupixent 2 SPElidel 2Epiduo & Epiduo

Forte3

Eucrisa 2Fluocinonide Cream,

0.1%1

Fluocinonide Cream, Gel, Ointment, Solution 0.05%

1

Hydrocortisone Cream, Ointment 2.5%

1

Ketoconazole Cream/Shampoo

1

Lidocaine Topical Ointment, Solution

1

Metrogel 3Metronidazole Gel

0.75%1

Drug NameDrug Tier

Specialty Program

Mirvaso Gel 2Mupirocin Ointment 1Myorisan 1Nystatin Cream,

Ointment, Powder1

Onexton 3Oxsoralen-UL 2Pennsaid Solution EPermethrin Cream 5% 1Proctofoam HC 2Soolantra 2Tazorac 3Tretinoin Cream 1Tretinoin Microsphere

Gel1

Triamcinolone 1Vectical 3Veltin EZovirax Cream 2Zyclara 3Diabetes/Endocrine Blood: Glucose MonitoringAccu-Chek Active

Glucose Control Liquid

E

Accu-Chek Active Test Strips

E

Accu-Chek Aviva Connect Kit

E

Accu-Chek Aviva Plus Control Liquid

E

Accu-Chek Aviva Plus Kit

E

Accu-Chek Aviva Plus Test Strips

E

Accu-Chek Compact Plus Control Liquid

E

Accu-Chek Compact Plus Test Strips

E

Accu-Chek Compact Plus Kit

E

Accu-Chek FastClix Kit

2

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Drug NameDrug Tier

Specialty Program

Accu-Chek FastClix Lancets

2

Accu-Chek Guide Control Liquid

E

Accu-Chek Guide Kit EAccu-Chek Guide Test

StripsE

Accu-Chek Multiclix Kit

2

Accu-Chek Multiclix Lancets

2

Accu-Chek Nano SmartView Kit

E

Accu-Chek SmartView Control Liquid

E

Accu-Chek SmartView Test Strips

E

Accu-Chek Soft Touch Lancets

2

Accu-Chek Softclix Kit 2Accu-Chek Softclix

Lancets2

Bayer Contour Test Strips

E

Dexcom G4 Platinum Kit

3

Dexcom G4 Platinum Sensor Kit

3

Dexcom G4 Platinum Transmitter Kit

3

Dexcom G5 Kit 3Dexcom G5 Sensor

Kit3

Dexcom G5 Transmitter Kit

3

Freestyle Test Strips EInsulin Pen Needle 2Insulin Syringe/

Needle 2

Novofine Pen Needle 3

Drug NameDrug Tier

Specialty Program

Novofine Autocover Pen Needle

3

Novotwist Pen Needle

3

OneTouch Ultra 2 System

2

OneTouch UltraMini System Kit

2

OneTouch Verio IQ System Kit

2

OneTouch Verio Sync System Kit

2

OneTouch Verio System Kit

2

OneTouch Verio Flex System Kit

2

OneTouch Ultra Test Strips

2

OneTouch Verio Test Strips

2

Precision Test Strips E

Diabetes/Endocrine: Insulin

Apidra EBasaglar EHumalog Mix 50/50

Vial and KwikPen2

Humalog Mix 75-25 Vial and KwikPen

2

Humalog U-100 Vial and KwikPen

2

Humalog U-200 KwikPen

2

Humulin 70-30 Vial and KwikPen

2

Humulin N Vial and KwikPen

2

Humulin R U-500 Vial and KwikPen

2

Humulin R Vial 2Lantus SoloStar 2Lantus Vial 2

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Drug NameDrug Tier

Specialty Program

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

Vial and FlexpenE

Novolog Penfill ENovolog Vial EToujeo SoloStar 2Tresiba E

Diabetes/Endocrine: Non-Insulin

Adlyxin EAlogliptin (M) EAlogliptin/

metformin (M)E

Alogliptin/pioglitazone (M)

E

Bydureon 2Byetta 2Farxiga EGlimepiride 1Glipizide 1Glipizide ER 1Glipizide XL 1Glumetza 3Glyburide 1Invokamet 2Invokamet XR 2Invokana 2Janumet 2Janumet XR 2Januvia 2Jardiance 2Jentadueto 2Jentadueto XR 2Kazano EKombiglyze E

Drug NameDrug Tier

Specialty Program

Metformin 1Metformin ER 1Nesina EOnglyza EOseni EPioglitazone 1Soliqua 2Synjardy 2Synjardy XR 2Tanzeum ETradjenta 2Trulicity 2Victoza 2Xigduo XR E

Endocrine: Growth Hormone

Genotropin E SPHumatrope E SPNorditropin 2 SPNutropin AQ 2 SPOmnitrope 2 SPSaizen E SPZomacton E SP

Endocrine: Other

Calcitriol Cap 1Clomiphene 1Dexamethasone Tab 1H.P. Acthar 2 SP


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Drug NameDrug Tier

Specialty Program

Hydrocortisone Tab 1Lupron Depot

3.75 mg, 11.25 mg3 SP

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

2 SP

Methylprednisolone Tab 1Prednisone 1Prednisolone Solution

25 mg/5 ml1

Prednisolone Syrup, Solution 15 mg/5 ml

1

Endocrine: Thyroid Hormone Replacement Armour Thyroid 3Levothyroxine 1Liothyronine 1Methimazole 1Synthroid 3Tirosint 3

Eye Conditions: Allergies

Azelastine Ophthalmic Solution

1

Pataday 3Pazeo 2

Eye Conditions: Antibiotics

Besivance 3Ciprofloxacin

Ophthalmic Solution1

Erythromycin Ointment 1Moxeza 2Ofloxacin Ophthalmic

Solution1

Polymyxin B/Trimethoprim Solution

1

Tobramycin 1Tobramycin/

Dexamethasone1

Vigamox 3

Drug NameDrug Tier

Specialty Program

Eye Conditions: Glaucoma

Azopt 2Betimol 3Combigan 2Cosopt PF 3Latanoprost 1Lumigan 2Rescula ESimbrinza 2Travatan Z 2Zioptan E

Eye Conditions: Other

Ketorolac Ophthalmic Solution

1

Prednisolone Ophthalmic Suspension

1

Restasis 2Restasis Multidose 2Xiidra 2

Gastrointestinal: Acid Suppression

Dexilant 2Duexis EEsomeprazole

Magnesium (Rx only)

1

Famotidine Tab 20 mg and 40 mg (Rx only)

1

Lansoprazole (Rx only) 1Omeprazole (Rx only) 1Pantoprazole 1Ranitidine Tab, Cap,

Syrup (Rx only)1

Sucralfate Tab 1Vimovo E

17



Drug NameDrug Tier

Specialty Program

Gastrointestinal: Nausea/Vomiting

Meclizine 1Metoclopramide 1Ondansetron ODT 1Ondansetron Tab 1Varubi 3

Gastrointestinal: OtherAmitiza 2Apriso 2Asacol HD ECanasa 2Creon 2Delzicol EDicyclomine 1Dipentum 3Diphenoxylate/Atropine 1Gavilyte Solution 1Lialda ELinzess 2Mesalamine DR (M) EMisoprostol 1Pancreaze EPentasa 3Pertzye EPolyethylene

Glycol 3350 Powder1

Prepopik 3Pylera 2Rabeprazole 1Suprep Bowel Prep 3Uceris Foam 3Ultresa EViokace EZenpep 2

Drug NameDrug Tier

Specialty Program

HIV/AIDS

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

Infertility

Bravelle E SPCetrotide 2 SPFollistim AQ E SPGonal-f 2 SPGonal-f RFF 2 SPOvidrel 3 SP

Inflammatory Conditions

Cimzia Kit 2 SPCosentyx+ 3 SPDepen 2 SPEnbrel 3 SPHumira Kit 2 SPHumira Pen Kit 2 SPHumira Pen Kit

Crohns2 SP

Humira Pen Kit Psoriasis

2 SP

Hydroxychloroquine 1Inflectra E SPLeflunomide 1Methotrexate Tab 1

+ Tier 3 Preferred (M) Co-Branded Product

18



Drug NameDrug Tier

Specialty Program

Orencia SC 3 SPOtezla 2 SPRasuvo 2Remicade 2 SPSimponi 2 SPSimponi Aria 2 SPStelara 2 SPTaltz E SPXeljanz 3 SP

Men’s Health: Erectile Dysfunction

Cialis 2Levitra EStaxyn EStendra EViagra 2

Men’s Health: Prostate

Cialis 2.5 mg & 5 mg 2Doxazosin 1Dutasteride 1Finasteride 5 mg 1Rapaflo 2Tamsulosin 1Terazosin

Men’s Health: Testosterone Therapy

Androderm 2Androgel 1.62% 2Axiron EFortesta ETestim ETestosterone Cypionate

IM Injection1

Vogelxo E

Drug NameDrug Tier

Specialty Program

Miscellaneous

Adrenaclick EAllopurinol 1Aranesp E SPArmodafinil 1Auryxia 3Auvi-Q EBenzonatate 1Botox 100, 200 unit

Injection (non-cosmetic)

2 SP

Bunavail 3Cerdelga 3 SPCheratussin 1Chlorhexidine 1Colcrys 2Contrave 2Epinephrine

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

2

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

E

EpiPen & EpiPen Jr EEpogen E SPEuflexxa 2 SPFosrenol 3Granix 2 SPGuaifenesin/Codeine

Syrup1

Hydrocodone/Chlorpheniramine Liquid

1


19



Drug NameDrug Tier

Specialty Program

Hydrocodone Polistirex/Chlorpheniramine ER Suspension

1

Lidocaine Viscous Solution 2%

1

Makena 2 SPNarcan 2Neupogen 2 SPPhenazopyridine

(Rx only)1

Phentermine Tab 1Procrit 2 SPPromethazine DM Syrup 1Promethazine/Codeine

Syrup1

Renvela Tab 2Rezira 3Suboxone Film 2Synvisc 2 SPSynvisc One 2 SPUloric 2Velphoro 3Zarxio 2 SPZubsolv 2Zurampic 3Zutripro 3

Musculoskeletal: Osteoporosis

Alendronate Tab 35 mg & 70 mg

1

Binosto 3Forteo 2 SPTymlos 2 SP

Musculoskeletal: Other

Amrix EBaclofen Tab 1Carisoprodol 350 mg 1

Drug NameDrug Tier

Specialty Program

Cyclobenzaprine Tab 5, 10 mg

1

Lorzone 3Metaxalone 1Methocarbamol 1Tizanidine Cap 1Tizanidine Tab 1

Musculoskeletal: Pain Relief

Abstral EAcetaminophen

w/ Codeine 1

Arymo ER ECambia ECelecoxib 1Diclofenac Gel 1Diclofenac Tab 1Embeda 2Etodolac 1Fentanyl Patch

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

1

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

1

Fentora EFlector patch 3Gralise 3Hydrocodone/

Acetaminophen 5, 7.5, 10/325 mg

1

Hydromorphone Tab 1Hysingla ER 2Ibuprofen Tab 400, 600,

800 mg (Rx only)1

20



Drug NameDrug Tier

Specialty Program

Indomethacin Cap 1Ketorolac Tab 1Lazanda ELidocaine Patch 5% 1Meloxicam 1Methadone Tab 1Morphine Sulfate ER 1Nabumetone 1Naproxen (Rx only) 1Nucynta ER EOxycodone Tab 5,

10, 15, 30 mg (Immediate Release)

1

Oxycodone w/ Acetaminophen

1

Oxycontin 2Subsys ETramadol Tab 50 mg 1Tramadol

w/ Acetaminophen 1

Xtampza ER EZohydro ER EZorvolex E

Overactive Bladder

Myrbetriq 2Oxybutynin 1Oxybutynin ER 1Toviaz 3Vesicare 2

Respiratory: Asthma/COPD

Advair Diskus 2Advair HFA 2Aerospan 3

Drug NameDrug Tier

Specialty Program

AirDuo EAlbuterol

Nebulizer Solution1

Alvesco EAnoro Ellipta 2Arnuity Ellipta 2Asmanex EBreo Ellipta 2Budesonide Inhalation

Suspension1

Combivent Respimat 2Dulera EFlovent Diskus 2Flovent HFA 2Incruse Ellipta 2Ipratropium/Albuterol

Nebulizer Solution1

Levalbuterol Inhaler (M)

E

Montelukast 1Proair HFA, RespiClick 2Proventil HFA EPulmicort Flexhaler 2Qvar ESerevent Diskus 2Spiriva Handihaler 2Spiriva Respimat 2Stiolto 2Symbicort 2Tudorza EVentolin HFA 2Xolair 2 SPXopenex HFA E


21



Drug NameDrug Tier

Specialty Program

Respiratory: Nasal Allergies

Astepro 3Azelastine Spray 1Dymista Spray 2Fluticasone Spray 1Ipratropium Spray 1Mometasone 1Omnaris 3QNasl 3Zetonna 3

Respiratory: Oral Allergies

Cetirizine 1Levocetirizine 1Promethazine Tab 1

Transplant

Azathioprine Tab 1Mycophenolate Mofetil

250 mg Cap/ 500 mg Tab

1 SP

Mycophenolate Sodium 180 mg, 360 mg Tab

1 SP

Prograf Cap 3 SPTacrolimus Cap 1 SP

Vitamins/Electrolytes

Cyanocobalamine Injection

1

Folic Acid 1 mg (Rx only)

1

Klor-Con 8 and 10 MEQ 1Klor-Con M10 and M20 1Ludent 1Potassium Chloride ER

Tab, Cap1

Potassium Chloride Micro ER Tab

1

Vitamin D 50,000 units (Rx only)

1

Drug NameDrug Tier

Specialty Program

Women’s Health: Birth Control

Apri 1Aviane 1Azurette 1Cryselle-28 1Falmina 1Generess Fe

Chewable3

Gianvi 1Gildess 1Jolivette 1Junel 1Kariva 1Levora 28 1Lo Loestrin 3Lomedia Fe 1Loryna 1Low-Ogestrel 1Lutera 1Medroxyprogesterone

Acetate Injection1

Microgestin 1Microgestin Fe 1Mono-Linyah 1Mononessa 1Natazia 2Necon 1Nora-Be 1Norgest/Ethi Estradio 1Nortrel 1Nuvaring 2Ocella 1Orsythia 1Previfem 1Reclipsen 1Sprintec 28 1Tri-Linyah 1Tri-Lo-Sprintec 1Tri-Previfem 1Trinessa 1Tri-Sprintec 1

22



Drug NameDrug Tier

Specialty Program

Vestura 1Viorele 1Xulane 1Zarah 1

Women’s Health: Hormone Replacement

Climara Pro 2Divigel 3Duavee 2Elestrin Gel 3Estrace Vaginal Cream 3Estradiol Patch, Tab 1Estradiol/Norethindrone

Tab1

Medroxyprogesterone Acetate Tab

1

Minivelle 3Osphena 3Premarin Tab 2Premarin Vaginal

Cream2

Premphase 2Prempro 2Progesterone Cap 1Yuvafem 1

Drug NameDrug Tier

Specialty Program

Women’s Health: Vaginal Anti-Infectives

Gynazole-1 Vaginal Cream

3

Metronidazole Vaginal Gel

1

Terconazole Vaginal Cream

1

Bold type = Brand-name drug [Plain type = Generic drug] 23

Index of Drugs

A

Absorica . . . . . . . . . . 13Abstral . . . . . . . . . . . 19Acanya Gel. . . . . . . . . 13Accu-Chek Active Glucose

Control Liquid . . . . . 13Accu-Chek Active

Test Strips . . . . . . . 13Accu-Chek Aviva

Connect Kit . . . . . . 13Accu-Chek Aviva

Plus Control Liquid . . 13Accu-Chek Aviva Plus Kit . 13Accu-Chek Aviva

Plus Test Strips. . . . . 13Accu-Chek Compact Plus

Control Liquid . . . . . 13Accu-Chek Compact

Plus Kit . . . . . . . . . 13Accu-Chek Compact

Plus Test Strips. . . . . 13Accu-Chek FastClix Kit . . 13Accu-Chek FastClix Lancets . 14Accu-Chek Guide

Control Liquid . . . . . 14Accu-Chek Guide Kit . . . 14Accu-Chek Guide Test Strips 14Accu-Chek Multiclix Kit . . 14Accu-Chek Multiclix Lancets 14Accu-Chek Nano

SmartView Kit . . . . . 14Accu-Chek SmartView

Control Liquid . . . . . 14Accu-Chek SmartView

Test Strips . . . . . . . 14Accu-Chek Softclix Kit. . . 14Accu-Chek Softclix Lancets . 14Accu-Chek Soft Touch

Lancets . . . . . . . . . 14Acetaminophen w/ Codeine 19Acyclovir Cap, Tab, Suspension. .9Aczone Gel. . . . . . . . . 13Adcirca . . . . . . . . . . . 11Adempas. . . . . . . . . . 11Adlyxin. . . . . . . . . . . 15Adrenaclick . . . . . . . . 18Advair Diskus . . . . . . . 20Advair HFA . . . . . . . . 20Aerospan . . . . . . . . . 20AirDuo . . . . . . . . . . . 20

Aktipak . . . . . . . . . . 13Akynzeo . . . . . . . . . . . 9Albuterol Nebulizer Solution . . 20Alendronate Tab . . . . . . 19Allopurinol . . . . . . . . . 18Alogliptin (M) . . . . . . . 15Alogliptin/

metformin (M) . . . . . 15Alogliptin/pioglitazone (M) 15Alprazolam Tab . . . . . . . 12Alvesco. . . . . . . . . . . 20Amitiza. . . . . . . . . . . 17Amitriptyline . . . . . . . . 11Amlodipine . . . . . . . . . 10Amlodipine/Benazepril . . . 10Amlodipine/Valsartan . . . . 10Amoxicillin . . . . . . . . . . 9Amoxicillin/Clavulanate . . . . 9Amphetamine-

Dextroamphetamine SR . 11Amphetamine-

Dextroamphetamine Tab . 11Ampyra . . . . . . . . . . 12Amrix . . . . . . . . . . . . 19Anastrozole Tab . . . . . . . . 9Androderm . . . . . . . . 18Androgel 1.62% . . . . . . 18Anoro Ellipta . . . . . . . 20Apidra . . . . . . . . . . . 14Apri . . . . . . . . . . . . . 21Apriso . . . . . . . . . . . 17Aranesp . . . . . . . . . . 18Aripiprazole . . . . . . . . . 12Aristada. . . . . . . . . . . 12Armodafinil . . . . . . . . . 18Armour Thyroid . . . . . . 16Arnuity Ellipta . . . . . . . 20Arymo ER . . . . . . . . . 19Asacol HD . . . . . . . . . 17Asmanex. . . . . . . . . . 20Astepro . . . . . . . . . . 21Atenolol. . . . . . . . . . . 10Atenolol/Chlorthalidone. . . 10Atorvastatin . . . . . . . . 10Atralin . . . . . . . . . . . 13Atripla . . . . . . . . . . . 17Aubagio . . . . . . . . . . 12Auryxia . . . . . . . . . . 18Auvi-Q . . . . . . . . . . . 18Aviane . . . . . . . . . . . 21Avonex Kit. . . . . . . . . 12

Avonex Pen Kit . . . . . . 12Avonex Prefill Kit . . . . . 12Axiron . . . . . . . . . . . 18Azasite . . . . . . . . . . . . 9Azathioprine Tab . . . . . . 21Azelastine Ophthalmic Solution 16Azelastine Spray. . . . . . . 21Azithromycin . . . . . . . . . 9Azopt . . . . . . . . . . . 16Azurette . . . . . . . . . . 21

B

Baclofen Tab . . . . . . . . 19Basaglar . . . . . . . . . . 14Bayer Contour Test Strips . . 14Benazepril. . . . . . . . . . 10Benazepril/HCTZ . . . . . . 10Benzonatate . . . . . . . . 18Besivance . . . . . . . . . 16Betaseron . . . . . . . . . 12Bethkis . . . . . . . . . . . . 9Betimol. . . . . . . . . . . 16Binosto. . . . . . . . . . . 19Bisoprolol . . . . . . . . . . 10Bisoprolol/HCTZ . . . . . . . 10Botox. . . . . . . . . . . . 18Bravelle . . . . . . . . . . 17Breo Ellipta . . . . . . . . 20Brilinta . . . . . . . . . . . 10Budesonide Inhalation

Suspension . . . . . . . 20Bumetanide . . . . . . . . . 10Bunavail . . . . . . . . . . 18Bupropion. . . . . . . . . . 11Bupropion ER . . . . . . . . 11Bupropion SR . . . . . . . . 11Bupropion XL . . . . . . . . 11Buspirone . . . . . . . . . . 12Butalbital-Acetaminophen-

Caffeine Cap, Tab . . . . 12Bydureon . . . . . . . . . 15Byetta . . . . . . . . . . . 15Bystolic. . . . . . . . . . . 10Byvalson . . . . . . . . . . 10

C

Cabometyx . . . . . . . . . . 9Calcitriol Cap . . . . . . . . 15Cambia. . . . . . . . . . . 19


Index of Drugs

Canasa . . . . . . . . . . . 17Capecitabine . . . . . . . . . 9Carisoprodol . . . . . . . . 19Cartia XT . . . . . . . . . . 10Carvedilol . . . . . . . . . . 10Cefdinir . . . . . . . . . . . . 9Cefuroxime Tab . . . . . . . . 9Celecoxib . . . . . . . . . . 19Cephalexin . . . . . . . . . . 9Cerdelga . . . . . . . . . . 18Cetirizine . . . . . . . . . . 21Cetrotide. . . . . . . . . . 17Cheratussin . . . . . . . . . 18Chlorhexidine . . . . . . . . 18Chlorthalidone . . . . . . . 10Choline Fenofibrate ER . . . 10Cialis . . . . . . . . . . . . 18Cimzia Kit . . . . . . . . . 17Ciprodex Otic Suspension . . .9Ciprofloxacin Ophthalmic

Solution . . . . . . . . . 16Ciprofloxacin Tab . . . . . . . 9Citalopram . . . . . . . . . 11Claravis . . . . . . . . . . . 13Clarithromycin . . . . . . . . 9Climara Pro . . . . . . . . 22Clindamycin/Benzoyl

Peroxide Gel. . . . . . . 13Clindamycin Cap . . . . . . . 9Clindamycin Gel, Lotion,

Solution . . . . . . . . . 13Clobetasol Cream,

Ointment, Solution . . . 13Clobex . . . . . . . . . . . 13Clomiphene. . . . . . . . . 15Clonazepam . . . . . . . . 12Clonidine Tab . . . . . . . . 10Clopidogrel . . . . . . . . . 10Clotrimazole/Betamethasone

Cream, Lotion . . . . . . 13Colcrys . . . . . . . . . . . 18Combigan . . . . . . . . . 16Combivent Respimat . . . 20Complera . . . . . . . . . 17Contrave . . . . . . . . . 18Copaxone . . . . . . . . . 12Corlanor . . . . . . . . . . 11Cosentyx+ . . . . . . . . . 17Cosopt PF . . . . . . . . . 16Creon. . . . . . . . . . . . 17Crestor . . . . . . . . . . . 10

Cryselle-28 . . . . . . . . . 21Cyanocobalamine Injection . 21Cyclobenzaprine Tab . . . . 19

D

Delzicol . . . . . . . . . . 17Depen . . . . . . . . . . . 17Descovy . . . . . . . . . . . 9Dexamethasone Tab . . . . 15Dexcom G4 Platinum Kit . 14Dexcom G4 Platinum

Sensor Kit . . . . . . . 14Dexcom G4 Platinum

Transmitter Kit. . . . . 14Dexcom G5 Kit. . . . . . . 14Dexcom G5 Sensor Kit . . 14Dexcom G5 Transmitter Kit . 14Dexilant . . . . . . . . . . 16Dexmethylphenidate ER Cap . . 11Diazepam Tab . . . . . . . . 12Diclofenac Gel . . . . . . . 19Diclofenac Tab . . . . . . . 19Dicyclomine . . . . . . . . . 17Digoxin . . . . . . . . . . . 11Diltiazem ER. . . . . . . . . 10Dipentum . . . . . . . . . 17Diphenoxylate/Atropine . . . 17Divalproex DR . . . . . . . . 12Divalproex ER . . . . . . . . 12Divigel . . . . . . . . . . . 22Doryx MPC. . . . . . . . . . 9Doxazosin . . . . . . . . 10, 18Doxepin . . . . . . . . . . . 11Doxycycline Hyclate Cap . . . 9Doxycycline Hyclate Tab . . . . 9Doxycycline Monohydrate Cap. .9Doxycycline Monohydrate

Oral Suspension, Tab . . . 9Duavee. . . . . . . . . . . 22Duexis . . . . . . . . . . . 16Dulera . . . . . . . . . . . 20Duloxetine Cap . . . . . . . 11Dupixent . . . . . . . . . . 13Dutasteride . . . . . . . . . 18Dymista Spray . . . . . . . 21

E

Edarbi . . . . . . . . . . . 10Edarbyclor . . . . . . . . . 10

Effient . . . . . . . . . . . 10Elestrin Gel . . . . . . . . 22Elidel . . . . . . . . . . . . 13Eliquis . . . . . . . . . . . 10Embeda . . . . . . . . . . 19Enalapril. . . . . . . . . . . 10Enbrel . . . . . . . . . . . 17Enoxaparin . . . . . . . . . 10Entecavir . . . . . . . . . . . 9Epclusa. . . . . . . . . . . . 9Epiduo & Epiduo Forte . . 13Epinephrine Auto-Injector. . 18EpiPen & EpiPen Jr . . . . 18Epogen. . . . . . . . . . . 18Erythromycin . . . . . . . . . 9Erythromycin Ointment . . . 16Escitalopram Tab . . . . . . 11Esomeprazole Magnesium . 16Estrace Vaginal Cream . . 22Estradiol/Norethindrone Tab . 22Estradiol Patch, Tab . . . . . 22Eszopiclone Tab . . . . . . . 12Etodolac . . . . . . . . . . 19Eucrisa . . . . . . . . . . . 13Euflexxa . . . . . . . . . . 18Extavia . . . . . . . . . . . 12

F

Falmina . . . . . . . . . . . 21Famciclovir Tab . . . . . . . . 9Famotidine Tab . . . . . . . 16Farxiga . . . . . . . . . . . 15Fenofibrate . . . . . . . . . 10Fentanyl Patch . . . . . . . 19Fentora. . . . . . . . . . . 19Finasteride . . . . . . . . . 18Flecainide . . . . . . . . . . 11Flector patch. . . . . . . . 19Flovent Diskus. . . . . . . 20Flovent HFA . . . . . . . . 20Fluconazole . . . . . . . . . . 9Fluocinonide Cream. . . . . 13Fluocinonide Cream, Gel,

Ointment, Solution . . . 13Fluoxetine Cap . . . . . . . 11Fluticasone Spray . . . . . . 21Folic Acid . . . . . . . . . . 21Follistim AQ . . . . . . . . 17Forfivo XL . . . . . . . . . 11Forteo . . . . . . . . . . . 19


Index of Drugs

Fortesta . . . . . . . . . . 18Fosrenol . . . . . . . . . . 18Freestyle Test Strips . . . . 14Furosemide . . . . . . . . . 10

G

Gabapentin . . . . . . . . . 12Gavilyte Solution . . . . . . 17Gemfibrozil . . . . . . . . . 10Generess Fe Chewable . . 21Genotropin . . . . . . . . 15Genvoya . . . . . . . . . . 17Gianvi . . . . . . . . . . . . 21Gildess . . . . . . . . . . . 21Gilenya+ . . . . . . . . . . . . . . . . . . . 12

Glimepiride . . . . . . . . . 15Glipizide . . . . . . . . . . 15Glipizide ER . . . . . . . . . 15Glipizide XL . . . . . . . . . 15Glumetza . . . . . . . . . 15Glyburide . . . . . . . . . . 15Gonal-f . . . . . . . . . . . 17Gonal-f RFF . . . . . . . . 17Gralise . . . . . . . . . . . 19Granix . . . . . . . . . . . 18Guaifenesin/Codeine Syrup . 18Guanfacine ER Tab . . . . . 11Guanfacine Tab . . . . . . . 10Gynazole-1 Vaginal Cream . 22

H

Harvoni . . . . . . . . . . . 9H.P. Acthar . . . . . . . . . 15Humalog Mix 50/50 Vial

and KwikPen. . . . . . 14Humalog Mix 75-25 Vial

and KwikPen. . . . . . 14Humalog U-100 Vial

and KwikPen. . . . . . 14Humalog U-200 KwikPen . 14Humatrope . . . . . . . . 15Humira Kit . . . . . . . . . 17Humira Pen Kit . . . . . . 17Humira Pen Kit Crohns . . 17Humira Pen Kit Psoriasis . 17Humulin 70-30 Vial and

KwikPen . . . . . . . . 14Humulin N Vial and

KwikPen . . . . . . . . 14

Humulin R U-500 Vial and KwikPen. . . . . . 14

Humulin R Vial. . . . . . . 14Hydralazine . . . . . . . . . 10Hydrochlorothiazide. . . . . 10Hydrocodone/Acetaminophen . 19Hydrocodone/

Chlorpheniramine Liquid 18Hydrocodone Polistirex/

Chlorpheniramine ER Suspension . . . . . . . 19

Hydrocortisone Cream, Ointment . . . . . . . . 13

Hydrocortisone Tab . . . . . 16Hydromorphone Tab . . . . 19Hydroxychloroquine . . . . . 17Hydroxyzine HCL . . . . . . 12Hydroxyzine Pamoate . . . . 12Hysingla ER . . . . . . . . 19

I

Ibuprofen Tab . . . . . . . . 19Incruse Ellipta . . . . . . . 20Indomethacin Cap . . . . . 20Inflectra . . . . . . . . . . 17Insulin Pen Needle . . . . 14Insulin Syringe/Needle . . 14Invega Sustenna. . . . . . 12Invega Trinza . . . . . . . 12Invokamet . . . . . . . . . 15Invokamet XR . . . . . . . 15Invokana. . . . . . . . . . 15Ipratropium/Albuterol

Nebulizer Solution. . . . 20Ipratropium Spray . . . . . . 21Irbesartan . . . . . . . . . . 10Isentress . . . . . . . . . . 17Isosorbide Mononitrate ER . 11

J

Janumet . . . . . . . . . . 15Janumet XR . . . . . . . . 15Januvia. . . . . . . . . . . 15Jardiance. . . . . . . . . . 15Jentadueto. . . . . . . . . 15Jentadueto XR. . . . . . . 15Jolivette . . . . . . . . . . . 21Jublia Solution. . . . . . . . 9Junel . . . . . . . . . . . . 21

K

Kariva . . . . . . . . . . . . 21Kazano. . . . . . . . . . . 15Kerydin Solution . . . . . . 9Ketoconazole Cream/

Shampoo . . . . . . . . 13Ketorolac Ophthalmic

Solution . . . . . . . . . 16Ketorolac Tab . . . . . . . . 20Kitabis . . . . . . . . . . . . 9Klor-Con 8 and 10 MEQ. . . 21Klor-Con M10 and M20. . . 21Kombiglyze . . . . . . . . 15

L

Labetalol . . . . . . . . . . 10Lamotrigine . . . . . . . . . 12Lansoprazole . . . . . . . . 16Lantus SoloStar . . . . . . 14Lantus Vial . . . . . . . . . 14Latanoprost . . . . . . . . . 16Latuda . . . . . . . . . . . 12Lazanda . . . . . . . . . . 20Leflunomide. . . . . . . . . 17Letairis . . . . . . . . . . . 11Letrozole . . . . . . . . . . . 9Levalbuterol Inhaler (M) . 20Levemir FlexTouch. . . . . 15Levemir Vial . . . . . . . . 15Levetiracetam . . . . . . . . 12Levetiracetam ER . . . . . . 12Levitra . . . . . . . . . . . 18Levocetirizine . . . . . . . . 21Levofloxacin Tab. . . . . . . . 9Levora 28 . . . . . . . . . . 21Levothyroxine . . . . . . . . 16Lialda. . . . . . . . . . . . 17Lidocaine Patch 5% . . . . . 20Lidocaine Topical Ointment,

Solution . . . . . . . . . 13Lidocaine Viscous

Solution 2%. . . . . . . 19Linzess . . . . . . . . . . . 17Liothyronine . . . . . . . . 16Lisinopril . . . . . . . . . . 10Lisinopril/HCTZ . . . . . . . 10Livalo. . . . . . . . . . . . 10Lo Loestrin . . . . . . . . . 21Lomedia Fe . . . . . . . . . 21


Index of Drugs

Lorazepam Tab . . . . . . . 12Loryna . . . . . . . . . . . 21Lorzone . . . . . . . . . . 19Losartan. . . . . . . . . . . 10Losartan/HCTZ . . . . . . . 10Lovastatin . . . . . . . . . 10Low-Ogestrel . . . . . . . . 21Ludent . . . . . . . . . . . 21Lumigan . . . . . . . . . . 16Lupron Depot . . . . . . . 16Lutera . . . . . . . . . . . . 21Lyrica Cap . . . . . . . . . 12

M

Makena . . . . . . . . . . 19Mavyret . . . . . . . . . . . 9Meclizine . . . . . . . . . . 17Medroxyprogesterone

Acetate Injection . . . . 21Medroxyprogesterone

Acetate Tab . . . . . . . 22Meloxicam . . . . . . . . . 20Mercaptopurine . . . . . . . . 9Mesalamine DR (M) . . . . 17Metaxalone . . . . . . . . . 19Metformin . . . . . . . . . 15Metformin ER . . . . . . . . 15Methadone Tab . . . . . . . 20Methimazole . . . . . . . . 16Methocarbamol . . . . . . . 19Methotrexate Tab . . . . . . 17Methylphenidate ER Cap . . 11Methylphenidate ER Tab. . . 11Methylphenidate SA

Osmotic ER Tab . . . . . 11Methylphenidate Tab . . . . 11Methylprednisolone Tab . . . 16Metoclopramide . . . . . . 17Metoprolol Succinate . . . . 10Metoprolol Tartrate . . . . . 10Metrogel . . . . . . . . . . 13Metronidazole Gel 0.75%. . 13Metronidazole Tab . . . . . . 9Metronidazole Vaginal Gel . 22Microgestin . . . . . . . . . 21Microgestin Fe . . . . . . . 21Migranal . . . . . . . . . . 12Minivelle . . . . . . . . . . 22Minocycline Cap . . . . . . . 9Mirtazapine . . . . . . . . . 11

Mirvaso Gel . . . . . . . . 13Misoprostol . . . . . . . . . 17Modafinil . . . . . . . . . . 12Mometasone . . . . . . . . 21Mono-Linyah . . . . . . . . 21Mononessa . . . . . . . . . 21Montelukast . . . . . . . . 20Morphine Sulfate ER . . . . 20Moxeza . . . . . . . . . . 16Multaq . . . . . . . . . . . 11Mupirocin Ointment . . . . 13Mycophenolate Mofetil . . . 21Mycophenolate Sodium . . . 21Myorisan . . . . . . . . . . 13Myrbetriq . . . . . . . . . 20

N

Nabumetone . . . . . . . . 20Nadolol . . . . . . . . . . . 10Namenda XR. . . . . . . . 12Namzaric . . . . . . . . . . 12Naproxen . . . . . . . . . . 20Narcan . . . . . . . . . . . 19Natazia. . . . . . . . . . . 21Necon. . . . . . . . . . . . 21Nesina . . . . . . . . . . . 15Neupogen . . . . . . . . . 19Niacin ER Tab . . . . . . . . 10Nifedipine ER . . . . . . . . 10Nitrofurantoin Macrocrystalline .9Nitrofurantoin Monohydrate

Macrocrystalline . . . . . . 9Nitroglycerin SL Tab. . . . . 11Nora-Be . . . . . . . . . . . 21Norditropin . . . . . . . . 15Norgest/Ethi Estradio . . . . 21Nortrel . . . . . . . . . . . 21Nortriptyline. . . . . . . . . 11Norvir . . . . . . . . . . . 17Novofine Autocover

Pen Needle. . . . . . . 14Novofine Pen Needle . . . 14Novolin 70/30 Vial. . . . . 15Novolin N Vial . . . . . . . 15Novolin R Vial . . . . . . . 15Novolog Flexpen . . . . . 15Novolog Mix 70/30 Vial

and Flexpen . . . . . . 15Novolog Penfill . . . . . . 15Novolog Vial. . . . . . . . 15

Novotwist Pen Needle . . 14Nucynta ER . . . . . . . . 20Nutropin AQ. . . . . . . . 15Nuvaring. . . . . . . . . . 21Nystatin Cream, Ointment,

Powder . . . . . . . . . 13Nystatin Suspension. . . . . . 9

O

Ocella . . . . . . . . . . . . 21Odefsey . . . . . . . . . . . 9Ofloxacin Ophthalmic Solution 16Ofloxacin Otic Solution . . . . 9Olanzapine Tab . . . . . . . 12Olmesartan . . . . . . . . . 10Olmesartan HCT . . . . . . 10Omega-3 Acid Cap . . . . . 11Omeprazole . . . . . . . . . 16Omnaris . . . . . . . . . . 21Omnitrope . . . . . . . . 15Ondansetron ODT. . . . . . 17Ondansetron Tab . . . . . . 17OneTouch Ultra 2 System . 14OneTouch UltraMini

System Kit . . . . . . . 14OneTouch Ultra

Test Strips . . . . . . . 14OneTouch Verio Flex

System Kit . . . . . . . 14OneTouch Verio IQ

System Kit . . . . . . . 14OneTouch Verio

Sync System Kit . . . . 14OneTouch Verio System Kit . 14OneTouch Verio Test Strips . 14Onexton . . . . . . . . . . 13Onglyza . . . . . . . . . . 15Opsumit . . . . . . . . . . 11Oracea . . . . . . . . . . . . 9Orencia SC . . . . . . . . . 18Orenitram . . . . . . . . . 11Orsythia . . . . . . . . . . . 21Oseltamivir . . . . . . . . . . 9Oseni . . . . . . . . . . . . 15Osphena . . . . . . . . . . 22Otezla . . . . . . . . . . . 18Ovidrel . . . . . . . . . . . 17Oxcarbazepine . . . . . . . 12Oxsoralen-UL . . . . . . . 13Oxybutynin . . . . . . . . . 20


Index of Drugs

Oxybutynin ER . . . . . . . 20Oxycodone Tab . . . . . . . 20Oxycodone w/ Acetaminophen 20Oxycontin . . . . . . . . . 20

P

Pancreaze . . . . . . . . . 17Pantoprazole . . . . . . . . 16Paroxetine Tab . . . . . . . 11Pataday . . . . . . . . . . 16Pazeo. . . . . . . . . . . . 16Penicillin VK. . . . . . . . . . 9Pennsaid Solution . . . . . . 13Pentasa . . . . . . . . . . 17Permethrin Cream 5% . . . 13Pertzye. . . . . . . . . . . 17Phenazopyridine . . . . . . 19Phentermine Tab . . . . . . 19Pioglitazone. . . . . . . . . 15Plegridy . . . . . . . . . . 12Polyethylene Glycol 3350

Powder . . . . . . . . . 17Polymyxin B/Trimethoprim

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

Tab, Cap. . . . . . . . . 21Potassium Chloride

Micro ER Tab . . . . . . 21Pradaxa . . . . . . . . . . 10Praluent . . . . . . . . . . 11Pramipexole . . . . . . . . . 12Pravastatin . . . . . . . . . 11Prazosin . . . . . . . . . . . 10Precision Test Strips . . . . 14Prednisolone Ophthalmic

Suspension . . . . . . . 16Prednisolone Solution . . . . 16Prednisolone Syrup, Solution . . 16Prednisone . . . . . . . . . 16Premarin Tab. . . . . . . . 22Premarin Vaginal Cream . 22Premphase . . . . . . . . . 22Prempro . . . . . . . . . . 22Prepopik . . . . . . . . . . 17Previfem . . . . . . . . . . 21Prezcobix . . . . . . . . . 17Prezista . . . . . . . . . . 17Primidone . . . . . . . . . . 12Proair HFA, RespiClick. . . 20Procrit . . . . . . . . . . . 19

Proctofoam HC . . . . . . 13Progesterone Cap . . . . . . 22Prograf Cap . . . . . . . . 21Promethazine/Codeine Syrup . 19Promethazine DM Syrup . . 19Promethazine Tab . . . . . . 21Propranolol . . . . . . . . . 10Propranolol ER . . . . . . . 10Proventil HFA . . . . . . . 20Pulmicort Flexhaler . . . . 20Pylera . . . . . . . . . . . 17

Q

QNasl. . . . . . . . . . . . 21Quetiapine . . . . . . . . . 12Quinapril . . . . . . . . . . 10Qvar . . . . . . . . . . . . 20

R

Rabeprazole. . . . . . . . . 17Ramipril . . . . . . . . . . . 10Ranexa . . . . . . . . . . . 11Ranitidine Tab, Cap, Syrup . 16Rapaflo. . . . . . . . . . . 18Rasuvo . . . . . . . . . . . 18Rebif . . . . . . . . . . . . 12Rebif Titrtn . . . . . . . . 12Reclipsen . . . . . . . . . . 21Relpax . . . . . . . . . . . 12Remicade . . . . . . . . . 18Renvela Tab . . . . . . . . 19Rescula. . . . . . . . . . . 16Restasis . . . . . . . . . . 16Restasis Multidose . . . . 16Revlimid . . . . . . . . . . . 9Rexulti . . . . . . . . . . . 11Reyataz . . . . . . . . . . 17Rezira . . . . . . . . . . . 19Risperidone Tab . . . . . 11, 12Rizatriptan Tab, ODT . . . . 12Ropinirole . . . . . . . . . . 12Rosuvastatin . . . . . . . . 11

S

Saizen . . . . . . . . . . . 15Saphris . . . . . . . . . . . 12Savaysa . . . . . . . . . . 10Serevent Diskus . . . . . . 20

Sertraline . . . . . . . . . . 11Sildenafil Tab 20 mg. . . . . 11Silenor . . . . . . . . . . . 12Simbrinza . . . . . . . . . 16Simponi . . . . . . . . . . 18Simponi Aria. . . . . . . . 18Simvastatin . . . . . . . . . 11Soliqua. . . . . . . . . . . 15Solodyn . . . . . . . . . . . 9Soolantra . . . . . . . . . 13Sotalol . . . . . . . . . . . 11Spiriva Handihaler . . . . 20Spiriva Respimat . . . . . 20Spironolactone . . . . . . . 10Sprintec 28 . . . . . . . . . 21Sprycel . . . . . . . . . . . . 9Staxyn . . . . . . . . . . . 18Stelara . . . . . . . . . . . 18Stendra . . . . . . . . . . 18Stiolto . . . . . . . . . . . 20Strattera . . . . . . . . . . 11Stribild . . . . . . . . . . . 17Suboxone Film. . . . . . . 19Subsys . . . . . . . . . . . 20Sucralfate Tab . . . . . . . . 16Sulfamethoxazole-Trimethoprim .9Sulfamethoxazole-

Trimethoprim DS . . . . . 9Sumatriptan Tab and Spray . 12Sumavel Dose . . . . . . . 12Suprep Bowel Prep . . . . 17Symbicort . . . . . . . . . 20Synjardy . . . . . . . . . . 15Synjardy XR . . . . . . . . 15Synthroid . . . . . . . . . 16Synvisc . . . . . . . . . . . 19Synvisc One . . . . . . . . 19

T

Tacrolimus Cap . . . . . . . 21Taltz . . . . . . . . . . . . 18Tamoxifen Tab. . . . . . . . . 9Tamsulosin . . . . . . . . . 18Tanzeum . . . . . . . . . . 15Tazorac. . . . . . . . . . . 13Tecfidera . . . . . . . . . . 12Tekturna . . . . . . . . . . 10Tekturna HCT . . . . . . . . 10Telmisartan . . . . . . . . . 10Temazepam . . . . . . . . . 12


Index of Drugs

Terazosin . . . . . . . . 10, 18Terbinafine Tab . . . . . . . . 9Terconazole Vaginal Cream . 22Testim . . . . . . . . . . . 18Testosterone Cypionate IM

Injection. . . . . . . . . 18Tirosint. . . . . . . . . . . 16Tivicay . . . . . . . . . . . 17Tizanidine Cap . . . . . . . 19Tizanidine Tab. . . . . . . . 19TOBI podhaler . . . . . . . . 9Tobramycin . . . . . . . . . 16Tobramycin/Dexamethasone. 16Tobramycin (M) . . . . . . . 9Topiramate Tab . . . . . . . 12Torsemide Tab. . . . . . . . 10Toujeo SoloStar . . . . . . 15Toviaz . . . . . . . . . . . 20Tracleer . . . . . . . . . . 11Tradjenta. . . . . . . . . . 15Tramadol Tab . . . . . . . . 20Tramadol

w/ Acetaminophen . . . 20Travatan Z . . . . . . . . . 16Trazodone. . . . . . . . . . 12Tresiba . . . . . . . . . . . 15Tretinoin Cream . . . . . . . 13Tretinoin Microsphere Gel . . 13Triamcinolone . . . . . . . . 13Triamterene/HCTZ . . . . . . 10Triazolam Tab . . . . . . . . 12Tri-Linyah . . . . . . . . . . 21Tri-Lo-Sprintec. . . . . . . . 21Trinessa . . . . . . . . . . . 21Trintellix . . . . . . . . . . 12Tri-Previfem . . . . . . . . . 21Tri-Sprintec . . . . . . . . . 21Triumeq . . . . . . . . . . 17Trokendi XR . . . . . . . . . 12Trulicity . . . . . . . . . . 15Truvada . . . . . . . . . . 17Tudorza . . . . . . . . . . 20Tymlos . . . . . . . . . . . 19

U

Uceris Foam . . . . . . . . 17Uloric. . . . . . . . . . . . 19Ultresa . . . . . . . . . . . 17

V

Valacyclovir . . . . . . . . . . 9Valsartan . . . . . . . . . . 10Valsartan/HCTZ . . . . . . . 10Varubi . . . . . . . . . . . 17Vascepa . . . . . . . . . . 11Vectical. . . . . . . . . . . 13Velphoro . . . . . . . . . . 19Veltin. . . . . . . . . . . . 13Venlafaxine ER Cap . . . . . 12Venlafaxine ER Tab . . . . . 12Venlafaxine Tab . . . . . . . 12Ventolin HFA . . . . . . . 20Verapamil ER . . . . . . . . 10Vesicare . . . . . . . . . . 20Vestura . . . . . . . . . . . 22Viagra . . . . . . . . . . . 18Victoza . . . . . . . . . . . 15Vigamox . . . . . . . . . . 16Viibryd . . . . . . . . . . . 12Vimovo. . . . . . . . . . . 16Vimpat . . . . . . . . . . . 12Viokace . . . . . . . . . . 17Viorele . . . . . . . . . . . 22Viread . . . . . . . . . . . 17Vitamin D . . . . . . . . . . 21Vogelxo . . . . . . . . . . 18Vyvanse . . . . . . . . . . 11

W

Warfarin . . . . . . . . . . 10Welchol . . . . . . . . . . 11

X

Xarelto . . . . . . . . . . . 10Xeljanz . . . . . . . . . . . 18Xigduo XR . . . . . . . . . 15Xiidra. . . . . . . . . . . . 16Xolair. . . . . . . . . . . . 20Xopenex HFA . . . . . . . 20Xtampza ER . . . . . . . . 20Xulane . . . . . . . . . . . 22Xyrem . . . . . . . . . . . 12

Y

Yuvafem . . . . . . . . . . 22

Z

Zaleplon. . . . . . . . . . . 12Zarah . . . . . . . . . . . . 22Zarxio . . . . . . . . . . . 19Zenpep . . . . . . . . . . 17Zepatier . . . . . . . . . . . 9Zetonna . . . . . . . . . . 21Zioptan. . . . . . . . . . . 16Zohydro ER . . . . . . . . 20Zolpidem . . . . . . . . . . 12Zolpidem ER. . . . . . . . . 12Zomacton . . . . . . . . . 15Zonisamide . . . . . . . . . 12Zontivity . . . . . . . . . . 10Zorvolex . . . . . . . . . . 20Zovirax Cream . . . . . . . 13Zubsolv . . . . . . . . . . 19Zurampic . . . . . . . . . . 19Zutripro . . . . . . . . . . 19Zyclara . . . . . . . . . . . 13Zytiga . . . . . . . . . . . . 9

29

“My Medications” worksheet

Take this worksheet with you each time you visit a doctor. Each of your doctors should be aware of every drug you take and you should have a list as well.

Name of Medicine and Strength

Drug Tier

I Take This Medicine For

Directions Doctor

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

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DÍÍ BAA’ÁKONÍNÍZIN: Diné (Navajo) bizaad bee yániłti’go, saad bee áka›anída›awo›ígíí, t’áá jíík’eh, bee ná’ahóót’i’. T’áá shǫǫdí ninaaltsoos nitł’izí bee nééhozinígíí bine’dę́ę́› t’áá jíík’ehgo béésh bee hane’í biká’ígíí bee hodíilnih.

OGOW: Haddii aad ku hadasho Soomaali (Somali), adeegyada taageerada luqadda, oo bilaash ah, ayaad heli kartaa. Fadlan wac lambarka telefonka khadka bilaashka ee ku yaalla kaarkaaga aqoonsiga.

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Your 2018 Formulary - teamhmh.com€¦ · Diabetes/Endocrine Blood Glucose Monitoring ... Drugs are listed by common categories or class. They are placed into cost levels known as