your 2012 prescription drug list - university health plans...fill a prescription. tier 1 medications...

Table of Contents

Traditional Three-TierStudent Resources

Your 2012 Prescription Drug ListQuick-Reference Guide

For the most current PDL updates, visit www.uhcsr.com or call the toll-free member phone number on the back of your health plan ID card.

Created October, 2011. 2012 Prescription Drug List – Student Resources Traditional Three-Tier 1/12

1 Your Prescription Drug List

2 Introduction

Prescription Drug List - 2012

Anti-Infectives 5 Antibiotics 5 Antifungals 5 Antivirals Cardiovascular/ Heart Disease 5 Coagulation Therapy 6 High Blood Pressure 6 High Cholesterol 7 Other

Central Nervous System 7 Attention Deficit Disorder 7 Depression 7 Migraine 8 Multiple Sclerosis 8 Sedatives/Hypnotics 8 Seizure Disorders 8 Other

9 Dermatology

Diabetes/Endocrine 9 Blood Glucose Monitoring10 Insulin10 Non-Insulin

Endocrine10 Growth Hormone10 Other

Eye Conditions11 Anti-Allergy11 Antibiotics11 Glaucoma

Gastrointestinal11 Acid Suppression11 Nausea/Vomiting12 Other

Men’s Health12 Erectile Dysfunction12 Prostate

Miscellaneous12 Miscellaneous12 Overactive Bladder

Musculoskeletal13 Osteoporosis13 Pain Relief13 Rheumatoid Arthritis13 Other

Respiratory14 Asthma/COPD14 Nasal Allergy14 Oral Allergy

Women’s Health14 Contraceptives15 Estrogen/Progesterone15 Prenatal Vitamins

16 Additional Tier 3 Drugs with a generic equivalent in Tier 1

17 Index

1Visit www.uhcsr.com for updates 2012 Prescription Drug List – Student Resources Traditional Three-Tier

Your Prescription Drug List:Helping you get the most out of your pharmacy benefit.

This Prescription Drug List (PDL) outlines the most commonly prescribed medications for certain conditions and divides them into tiers. Your costs may change depending on a medication’s tier placement. To help you better use your pharmacy benefit, this guide answers commonly asked questions about your PDL.

Go to www.uhcsr.com for complete and up-to-date PDL informationSince the PDL may change, we encourage you to click on “Login To My Account” at our website, www.uhcsr.com. This website is the best source for up-to-date information about the medications your pharmacy benefit covers, possible lower-cost options, and how the costs of medications compare.


Welcome to your 2012 Three-Tier Prescription Drug List

What is a PDL? A PDL is a list of commonly prescribed medications placed into tiers. The PDL includes both brand and generic prescription medications approved by the U.S. Food and Drug Administration (FDA). The PDL is reviewed periodically and may change. It is created at a point in time, it is not a complete list of medications and not all medications listed may be covered under your plan. If you have pharmacy benefit coverage with UnitedHealthcare Student Resources, please look at your benefit plan documents provided by your university or school to see what medications are covered under your plan. Where differences are noted between this PDL quick-reference guide and your benefit plan documents, the benefit plan documents will govern. You may also click on “Login To My Account” at www.uhcsr.com or call the toll-free member phone number on the back of your health plan ID card for more information.

How do I use my PDL? When choosing a medication, you and your doctor should consult the PDL. This guide is organized by common medical conditions. Then, within each medical condition section, medications are listed by tier. If your medication is not located in the PDL please click on “Login To My Account” at www.uhcsr.com or call the toll-free member phone number on the back of your health plan ID card.

What are Tiers? Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, which is determined by your university or school. This is how much you will pay when you fill a prescription. Tier 1 medications are your lowest-cost options. If your medication is placed in Tier 2 or 3 look to see if there is a Tier 1 alternative. Discuss your options with your doctor.Check your benefit plan documents to find out your pharmacy plan costs.

Tier 1 Tier 2 Tier 3Your Your Yourlowest-cost midrange-cost highest-costmedications medications medications

Who determines medication tier placements?

The UnitedHealthcare PDL Management Committee makes tier placement decisions. The PDL Management Committee is comprised of senior level UnitedHealth Group physicians and business leaders. The Committee’s goal is to help ensure access to a wide range of medications, while helping to control health care costs for you and your university or school.

We want to help you better understand your medication choices. Your pharmacy benefit offers flexibility and choice in finding 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 PDL.


What factors impact tier placement decisions?

The PDL Management Committee decides tier placement based on several factors including: u Clinical information from the UnitedHealthcare

Pharmacy and Therapeutics Committee about the safety and effectiveness of different medications.

u The medication’s costs and other economic factors.

When do medications change tiers?

Medications may change tiers once per calendar year ( January 1). When a generic medication becomes available, the tier placement of both the brand and generic medication are evaluated. Medications may change tiers with this evaluation. When a medication changes tiers, you may have to pay a different amount for that medication. These changes may occur without prior notice to you. For the most current information on your pharmacy coverage, please call the toll-free member phone number on the back of your health plan ID card or click on “Login To My Account” at www.uhcsr.com.

Why are there notations (SL, N, etc.) next to certain medications in the PDL, and what do they mean? As you go through this list, you might notice some medications are noted with symbols next to them. The notations refer to our pharmacy programs. Your benefit plan determines how these medications may be covered for you but the symbols are guidelines to help you check what medications may be impacted. To learn more about a pharmacy program or to find out if it applies to you, please click on “Login To My Account” at www.uhcsr.com or call the toll-free member phone number on the back of your health plan ID card. Here is a quick symbol overview:

Why is the medication that I am currently taking no longer covered? Medications may be excluded from coverage under your pharmacy benefit. For example, a medication may be excluded from coverage when it is therapeutically equivalent to another prescription medication or an over-the-counter (OTC) medication. There may be alternatives on the PDL or OTC medications that are right for your treatment.

Should I talk to my doctor about OTC medications? An OTC medication may be the right treatment for some conditions. Talk to your doctor about OTC options. These medications are not covered under your pharmacy benefit, but they may cost less than your out-of-pocket expense for prescription medications.

What is the difference between brand-name and generic medications? Generic medications contain the same active ingredients as brand-name medications, but they often cost less. After the patent on a brand-name medication expires, other companies can manufacture an FDA-approved and chemically-equivalent version of the medication. These types of medications are called generic medications. Many times, the same company that makes a brand-name medication also makes the generic version.

What if my doctor writes a brand-name prescription?

The next time your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lower-tier alternative is available and if it might be right for you. Generic medications are usually your lowest-cost option, but not always. Click on “Login To My Account” at www.uhcsr.com to make sure.

PDL Symbols

1/2T Eligible for Half Tablet ProgramN Notification or Prior Authorization required*SL Supply limit

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


Are you taking a specialty medication? Specialty medications are managed through our Specialty Pharmacy Program which offers personalized member support. The program also offers access to on-call pharmacists available 24 hours a day, robust clinical and adherence programs and support coaching on lower-cost medication options. Please note your specialty medication may not be listed in this guide. Please click on “Login To My Account” at www.uhcsr.com for more information.

How do I access updated information about my pharmacy benefit? Since the PDL may change, we encourage you to click on “Login To My Account” at www.uhcsr.com or call the toll-free member phone number on the back of your health plan ID card for more current information.

What if I still have questions? Please call the toll-free member phone number on the back of your health plan ID card. Representatives are available 24 hours a day (except Thanksgiving and Christmas).

Medications are categorized by common therapeutic conditions in this PDL for ease of reference only. These categories do not determine coverage for the medication for your condition. Your benefit plan determines how these medications may be covered for you.

In certain documents, the Prescription Drug List (PDL) was referred to as the “Preferred Drug List (PDL).” This change in descriptive terms does not affect your benefit coverage.

Where differences are noted between this PDL reference guide and your benefit plan documents, the benefit plan documents will govern. For the most current PDL information, log on to www.uhcsr.com.


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

Anti-Infectives Antibiotics (Oral, inhaled and ear antibiotics are listed)

A-B Otic Amoxicillin Amoxicillin/Potassium ClavulanateAmoxicillin-Clavulanate ERAmpicillinAzithromycin Cefadroxil CefdinirCefprozil Cefuroxime Cephalexin Ciprofloxacin Sustained-Release 24 Hour TabletCiprofloxacin Tablet

Clarithromycin SuspensionClarithromycin Sustained-Release TabletClarithromycin TabletClindamycin HClClindamycin PalmitateDicloxacillin Sodium Doxycycline Hyclate Enteric-Coated TabletDoxycycline MonohydrateDoxycycline Monohydrate Capsule 150 mgErythromycin Erythromycin Base Enteric-Coated Tablet

250, 333 mgLevofloxacin

Metronidazole Minocycline HCl Neomycin/Polymyxin/HC OticNitrofurantoin Macrocrystal Nitrofurantoin Suspension Nitrofurantoin/Nitrofurantoin Macrocrystal Ofloxacin Otic Penicillin V PotassiumSulfamethoxazole/TrimethoprimTetracycline

Augmentin Cipro Suspension Ciprodex Otic Cleocin HCl 75 mg

Dapsone Ery-Tab 500 mgMacrodantin 25 mg Tobi

Vancocin HCl SL Velosef Suspension 250 mg Zyvox SL

Tier 2

AdoxaAugmentin XRAvelox

CetraxalCipro HCDoryx

OraceaSolodynSuprax

Tier 3

Tier 1

ClotrimazoleFluconazole Itraconazole Capsule SL

Ketoconazole Metronidazole Vaginal Nystatin

Terbinafine Tablet SLTerconazole VaginalVoriconazole SL

Clindesse Vaginal Mycostatin

Noxafil Sporanox Oral Solution

Tier 2

Extina SL Gynazole-1 Vaginal Lamisil Granules SLTier 3

Tier 1

Anti-Infectives Antifungals (Oral and topical antifungals are listed)

Anti-Infectives Antivirals

Cardiovascular/Heart Disease Coagulation Therapy

Acyclovir Amantadine

Famciclovir SLRibavirin

Valacyclovir SL

BaracludeEpivir HBV

Hepsera Rebetol Solution

Valcyte SLTier 2

Relenza SL Tamiflu SL Valtrex SLTier 3

Tier 1

CilostazolEnoxaparin SL

Fondaparinux SLPentoxifylline

Warfarin Sodium

Coumadin PlavixTier 2

AggrenoxArixtra SL

EffientFragmin SL

Innohep SL Lovenox SL

Tier 3

Tier 1



Cardiovascular/Heart Disease High Blood Pressure

AmlodipineAmlodipine/Benazepril SLAtenolol Atenolol/ChlorthalidoneBenazepril Benazepril/HydrochlorothiazideBisoprololBisoprolol/Hydrochlorothiazide Bumetanide Captopril Captopril/Hydrochlorothiazide Carvedilol Chlorthalidone ClonidineClonidine Transdermal Weekly Patch SL Diltiazem Diltiazem Controlled-Release CapsuleDiltiazem Sustained-Action CapsuleDiltiazem Sustained-Release 12 Hour CapsuleDiltiazem Sustained-Release 24 Hour CapsuleDiltiazem Sustained-Release 24 Hour TabletDoxazosin

EnalaprilEnalapril/Hydrochlorothiazide Eplerenone Felodipine Fosinopril Fosinopril/Hydrochlorothiazide FurosemideGuanfacine Hydralazine Hydrochlorothiazide Indapamide Labetalol Lisinopril Lisinopril/HydrochlorothiazideLosartan 1/2TLosartan/Hydrochlorothiazide SLMethyldopaMethyldopa/Hydrochlorothiazide MetolazoneMetoprolol Succinate Sustained-Release TabletMetoprolol Tartrate Metoprolol/Hydrochlorothiazide

Minoxidil Moexipril 1/2TNadolol Nifedipine Nisoldipine Perindopril Erbumine 1/2TPropranolol Propranolol Sustained-Action CapsulePropranolol/HydrochlorothiazideQuinapril Quinapril/Hydrochlorothiazide Ramipril Spironolactone Spironolactone/HydrochlorothiazideTerazosin Timolol Maleate TorsemideTrandolapril 1/2TTrandolapril/VerapamilTriamterene/Hydrochlorothiazide Verapamil Verapamil Sustained-Release 24 Hour Pellets

Tier 1

Aldactazide 50-50 mg Benicar 1/2T SLBenicar HCT SLBiDilBystolic

Cardizem CD 360 mg Cardizem LA 120 mgClorpresDibenzyline Diuril Suspension 250 mg/5 ml

Micardis SLMicardis HCT SLThalitone

Tier 2

Aceon 1/2TAmturnide SLAtacand 1/2T SLAtacand HCT SLAvalide SLAvapro 1/2T SLAzor SLCardizem LA 180, 240, 300, 360, 420 mgCatapres-TTS SL

Coreg CR SLDiovan 1/2T SLDiovan HCT SLExforge SLExforge HCT SLLotrel SLSularTarkaTekamlo SL

Tekturna SLTekturna HCT SLTeveten SLTeveten HCT SLTribenzor SLTwynsta SLValturna SL

Tier 3

Cardiovascular/Heart Disease High Cholesterol

CholestyramineColestipol Fenofibrate

Fenofibric AcidGemfibrozil Lipitor 1/2T SL

Lovastatin Pravastatin 1/2TSimvastatin 1/2T

Tier 1

Altoprev SLAntara

Crestor 1/2T SLLipofen

WelcholTier 2

Advicor SL Atorvastatin 1/2T SLCaduet SLFenoglideLescol SL

Lescol XL SLLivalo SLLovazaNiaspan Simcor SL

Tricor Triglide TrilipixVytorin SLZetia SL

Tier 3



Central Nervous System Attention Deficit Disorder

Central Nervous System Depression

Cardiovascular/Heart Disease Other

AmiodaroneDigoxinFlecainide AcetateIsosorbide Dinitrate

Isosorbide MononitrateMexiletineNitroglycerinNitroglycerin Transdermal Patch

Nitroglycerin Spray SLPropafenone Sustained-Release

12 Hour Capsule Sotalol

Tier 1

LanoxinMultaq

NitrostatRanexa

Tier 2

Amphetamine Aspartate/Amphetamine Sulfate/Dextroamphetamine Sustained-Release 24 Hour Capsule SL

Amphetamine Salt ComboDextroamphetamine Sulfate Methamphetamine

MethylphenidateMethylphenidate Extended-Release

24 Hour Tablet SL

Tier 1

Intuniv SL Vyvanse SLTier 2

Adderall XR SLConcerta SLDaytrana SL

Focalin XR SLMetadate CD SLMethylin

Ritalin LA SLStrattera SL

Tier 3

Amitriptyline Amitriptyline/Perphenazine BupropionBupropion XLCitalopram Hydrobromide Doxepin Fluoxetine

Fluoxetine Delayed-Release Capsule SLFluvoxamine Maleate Imipramine Mirtazapine Nefazodone Nortriptyline Paroxetine Sustained-Release 24 Hour Tablet SL

Paroxetine Tablet PhenelzineSertraline 1/2TTrazodone Venlafaxine Extended-Release Tablet SL Venlafaxine Sustained-Release Capsule SL Venlafaxine Tablet

Tier 1

Aplenzin SLCymbalta SLLexapro 1/2T SL

Luvox CR SLOleptro SLPexeva 1/2T SL

Pristiq SLTier 3

Nitrolingual SL Nitromist SLTier 3

Central Nervous System Migraine

Acetaminophen/Butalbital/Caffeine SLAcetaminophen/Dichloralphenazone/

Isometheptene Mucate

Aspirin/Butalbital/CaffeineNaratriptan SLRelpax SL

Sumatriptan Succinate Injection, Tablet SLSumatriptan Succinate Nasal Spray SL

Tier 1

Cafergot ErgomarTier 2

Alsuma SLAxert SLCambia SLFrova SL

Maxalt SLMaxalt MLT SLMigranalSumavel DosePro SL

Treximet SLZomig SLZomig Nasal Spray SL Zomig ZMT SL

Tier 3



Central Nervous System Multiple Sclerosis

Ampyra SLAvonex SL

Copaxone SLRebif SL

Tier 2

Betaseron SL Extavia SL Gilenya SLTier 3

Central Nervous System Sedatives/Hypnotics

Temazepam Triazolam

Zaleplon SL Zolpidem Multiphasic-Release Tablet SL

Zolpidem Tablet SLTier 1

Ambien SLAmbien CR SLEdluar SL

Lunesta SLRozerem SLSilenor SL

Sonata SLTier 3

Central Nervous System Seizure Disorders

Carbamazepine Carbamazepine Extended-Release

12 Hour CapsuleCarbamazepine Sustained-Release

12 Hour TabletClonazepam Diazepam Rectal Gel SL

Divalproex Sodium Sprinkle CapsuleDivalproex Sodium Sustained-Release TabletDivalproex Sodium TabletGabapentinLamotrigine Levetiracetam Levetiracetam Extended-Release 24 Hour Tablet

Oxcarbazepine Phenobarbital Phenytoin SodiumPrimidone Topiramate Zonisamide

Tier 1

Celontin DilantinFelbatol

Gabitril Mysoline Peganone

Sabril Tegretol

Tier 2

CarbatrolDepakote ERKeppraKeppra XR

LamictalLamictal Dose Pack SLLamictal ODT Lamictal XR

Lyrica SLStavzorTopamax

Tier 3

Central Nervous System Other

AlprazolamBenztropine MesylateBuspirone Carbidopa/Levodopa Clorazepate Dipotassium

ClozapineDiazepam Donepezil 5, 10 mgGalantamineLithium Carbonate

Lorazepam PramipexoleRisperidoneRivastigmine Ropinirole

Tier 1

Akineton Apokyn Comtan FazaClo

Geodon SLNavane 20 mg Seroquel SLSymbyax SL

Tasmar Xyrem SLZyprexa SL

Tier 2

Abilify 1/2T SLAricept 23 mgExelon SolutionFanapt SL

Invega SLMirapex ERNamendaNuvigil SL

Provigil SLRequip XLSeroquel XR SLZyprexa Zydis SL

Tier 3



Dermatology

Adapalene N SL Alclometasone DipropionateBetamethasone DipropionateBetamethasone ValerateCiclopirox Cream, Gel, Lotion Ciclopirox Non-Oral SolutionCiclopirox Shampoo 1% Clindamycin Foam 1% SLClindamycin Gel, Lotion, Solution, SwabsClindamycin Phosphate/Benzoyl Peroxide Gel

1%-5% SLClobetasol PropionateClobetasol Propionate Foam SL

Clotrimazole/BetamethasoneDesonide Desoximetasone Econazole Nitrate ErythromycinErythromycin/Benzoyl PeroxideFluocinonideFluticasone PropionateHalobetasol PropionateHydrocortisoneHydrocortisone ValerateImiquimod SLIsotretinoin

KetoconazoleLidocaineMetronidazoleMometasone FuroateMupirocinNystatin Nystatin/Triamcinolone Acetonide PermethrinSilver SulfadiazineSulfacetamide Sodium/Sulfur Tretinoin NTriamcinolone AcetonideUrea

Tier 1

Azelex SLBenzamycin Condylox Gel

Dovonex Cream SLOxsoralen-Ultra Protopic SL

RegranexStelara SL

Tier 2

AcanyaAczoneAldara SLAltabax SLAtralin N SLAvita Gel N SL Bactroban SLBenzaclin Gel 1%-5% SLClindagel SLClobex SLClobex Shampoo SLCutivate LotionDenavirDerma-Smoothe/FSDesonate SLDifferin Cream, Gel 0.1% N SL

Differin Gel 0.3% N SL Differin Lotion N SLDuac SLElidel SL Epiduo SLEvoclin SLFinaceaFinacea PlusLocoid Lipocream SL Locoid Lotion SLLoprox ShampooMetrogel 1% Metrolotion NaftinNoritateOlux-E SL

OxistatRetin-A Micro N SLTaclonex SLTaclonex Scalp SLTazorac N SLTretin-X N SLVanos SLVectical SLVeltin SLVerdeso SLVusionXereseXolegelZiana SLZovirax SLZyclara SL

Tier 3

Diabetes/Endocrine Blood Glucose Monitoring

Accu-Chek Active Test Strips SLAccu-Chek Aviva Care KitAccu-Chek Aviva Test Strips SLAccu-Chek Comfort Curve Test Strips SL

Accu-Chek Compact Care KitAccu-Chek Compact Test Strips SLOne Touch Test Strips SLOne Touch Ultra 2 System

One Touch Ultra Mini System One Touch Ultra Test Strips SL

Tier 1

Ascensia Autodisc Test Strips SLAscensia Breeze 2 Test Strips SLAscensia Elite Test Strips SL

Contour Test Strips SLFreestyle Lite Test Strips SLFreestyle Test Strips SL

Precision Xtra Test Strips SLTier 3



Diabetes/Endocrine Insulin

Humalog VialsHumalog-Mix Vials

Humulin 70-30 Vials Humulin Vials

Tier 1

Humalog KwikPenHumalog-Mix KwikPen

Humulin KwikPen Lantus Vials

Levemir VialsTier 2

ApidraLantus Solostar Pens/Cartridges

Levemir FlexpenNovolin Vials

NovoLogTier 3

Diabetes/Endocrine Non-Insulin

Acarbose Glimepiride Glipizide

Glipizide/Metformin Glyburide Glyburide/Metformin

Metformin Nateglinide SL

Tier 1

Actoplus Met SLActos 1/2T SLByetta SL

Duetact SLGlyset Janumet SL

Januvia SLPrandin SL

Tier 2

Avandamet SLAvandaryl SLAvandia SL

FortametGlumetzaOnglyza SL

Starlix SLSymlin SLVictoza SL

Tier 3

Endocrine Growth Hormone

Nutropin, AQ, NuSpin SLSaizen SL

Serostim SLTev-Tropin SL

Tier 2

Genotropin SLHumatrope SL

Norditropin SLOmnitrope SL

Zorbtive SLTier 3

Endocrine Other

Cabergoline Calcitriol Desmopressin Dexamethasone Fludrocortisone Hydrocortisone Tablet

Levothyroxine Sodium Liothyronine Sodium Methimazole Methylprednisolone Dosepak Tablet 4 mgOctreotide Acetate Orapred

Oxandrolone Prednisolone Prednisone Testosterone

Tier 1

Androderm SL Android Hectorol Kuvan SL

Medrol 2, 8, 24, 32 mg Pediapred Sandostatin VialSynarel

Synthroid Testim SLTirosintZemplar

Tier 2

Androgel SL Armour Thyroid Orapred ODTTier 3



Eye Conditions Anti-Allergy

Azelastine HCl SL Epinastine SL Ketorolac TromethamineTier 1

Bepreve SLElestat SL Emadine SL

Lastacaft SLOptivar SL Pataday SL

Patanol SLTier 3

Eye Conditions Glaucoma

Eye Conditions Antibiotics

CiprofloxacinErythromycinGentamicin SulfateLevofloxacin

Neomycin/Polymyxin B Sulfate/Dexamethasone OfloxacinPolymyxin B Sulfate/TrimethoprimSulfacetamide Sodium

Tobramycin Sulfate DropsTobramycin/Dexamethasone

Tier 1

Blephamide S.O.P.Tier 2

Azasite SLTobradex ST SL

VigamoxZylet

Zymaxid SLTier 3

Acetazolamide ApraclonidineBrimonidine Tartrate

Brimonidine Tartrate 0.15% SLDorzolamide HClDorzolamide HCl/Timolol Maleate

Latanoprost SLTimolol Maleate

Tier 1

Alphagan P 0.1% SLAzopt SLBetimol SL

Combigan SLLumigan SLPhospholine Iodide

Pilopine HS Travatan Z SL

Tier 2

Iopidine 1%Tier 3

Gastrointestinal Acid Suppression

CimetidineLansoprazole SL MisoprostolNizatidine Oral Solution

Omeprazole Omeprazole/Sodium Bicarbonate Capsule SLPantoprazoleRanitidine Syrup

Sucralfate Tablet Zegerid Capsule SL

Tier 1

Helidac Prevpac SL PyleraTier 2

Aciphex SLCarafate Oral SuspensionDexilant SLNexium Capsule SL

Nexium Suspension SLPrevacid Delayed-Release Enteric-Coated

Capsule SLPrevacid Solutab SL

Prilosec Rx 10, 20 mgPrilosec Rx 40 mg Zegerid Packet SL

Tier 3

Gastrointestinal Nausea/Vomiting

Granisetron Tablet SL Ondansetron Prochlorperazine MaleateTier 1

Emend SLTier 2

Anzemet SLCesamet

Sancuso SLTransderm-Scop

Zuplenz SLTier 3



Gastrointestinal Other

Men’s Health Prostate

Men’s Health Erectile Dysfunction

BalsalazideBelladona/PhenobarbitalBudesonide Extended-Release

24 Hour CapsuleChlordiazepoxide/Clidinium

Diphenoxylate/AtropineLactuloseMesalamineMetoclopramidePolyethylene Glycol

SulfasalazineTrilyte with Flavor PacketsUrsodiol

Tier 1

AprisoCanasaCreon

GoLYTELY PacketLialdaLotronex SL

RelistorZenpep

Tier 2

Amitiza SLAsacolAsacol HD Dipentum

Entocort ECHalflytely-BisacodylMetozolv ODTMoviprep

Pancreaze Pentasa

Tier 3

Caverject SLCialis N SL

Edex SLLevitra N SL

Muse SLViagra N SL

Tier 3

AlfuzosinDoxazosin

Finasteride Tamsulosin

TerazosinTier 1

Avodart NJalyn

RapafloUroxatral

Tier 3

Miscellaneous Overactive Bladder

Miscellaneous

Anastrozole Antipyrine/BenzocaineAzathioprineBenzonatateChlorhexidine Gluconate

Epinephrine Pen Injector SLExemestaneHydrocodone/Chlorpheniramine Suspension SLLetrozoleMegestrol Acetate

Mycophenolate Capsule, TabletPhenazopyridineTacrolimusTamoxifen

Tier 1

Cellcept SuspensionEpipen SLEpipen Jr SL

FarestonLidoderm SLMyfortic

NeoralRapamuneSandimmune

Tier 2

Acuvail SLAromasinInfergen SL

Intron ARestasis SLTussionex SL

Twinject SLTier 3

Dicyclomine Tablet Hyoscyamine Sulfate

OxybutyninTrospium

Tier 1

Enablex Gelnique

Oxytrol Sanctura XR

VesicareTier 2

Detrol Detrol LA ToviazTier 3



Musculoskeletal Osteoporosis

Alendronate SL Calcitonin Salmon Nasal Spray ForticalTier 1

Actonel SLBoniva Tablet SL

EvistaForteo

Tier 2

Fosamax Plus D SLTier 3

Musculoskeletal Pain Relief

Acetaminophen/Butalbital/Caffeine/Codeine SLAcetaminophen/Codeine SLAcetaminophen/Hydrocodone Bit SLAcetaminophen/Oxycodone SLAspirin/Butalbital/Caffeine/CodeineAspirin/OxycodoneButorphanol Nasal Spray SLDiclofenac Potassium Diclofenac Sodium Etodolac Fentanyl Citrate Lollipop SLFentanyl Transdermal SLHydromorphone

Ibuprofen Ibuprofen/HydrocodoneIbuprofen/OxycodoneIndomethacin Ketorolac Tromethamine Mefenamic Acid Meloxicam Meperidine Methadone Morphine SulfateMorphine Sulfate Sustained-Action Tablet SLNabumetoneNaproxen

Naproxen Sodium Oxaprozin Oxycodone Oxymorphone SLOxymorphone Extended-Release

12 Hour Tablet SLPiroxicam Sulindac Tolmetin Sodium Tramadol Tramadol Sustained-Release

24 Hour Tablet SL Tramadol/Acetaminophen SL

Tier 1

Codeine Phosphate MSIR Capsule

Opana ER SLOxyContin SL

Voltaren GelTier 2

ArthrotecAvinza SLCelebrex SLDuragesic SLEmbeda SLExalgo SL

Fentora SLFlectorKadian SLNaprelan Onsolis SLOpana SL

PennsaidRybix ODT SLRyzolt SLVimovo SLZipsor

Tier 3

Musculoskeletal Rheumatoid Arthritis

Azathioprine Hydroxychloroquine Sulfate

Leflunomide Methotrexate

SulfasalazineTier 1

Cimzia SLCuprimine

Enbrel SL Simponi SL

TrexallTier 2

Humira SL Kineret SLTier 3

Musculoskeletal Other

AllopurinolBaclofenCarisoprodol 250 mgCarisoprodol 350 mg

CyclobenzaprineCyclobenzaprine Extended-Release

24 Hour CapsuleMetaxalone

MethocarbamolOrphenadrine Orphenadrine Compound Tizanidine

Tier 1

ColcrysTier 2

AmrixSavella SL

SkelaxinSoma 250 mg

Uloric SLTier 3



Respiratory Asthma/COPD

Respiratory Nasal Allergy

Albuterol Sulfate Albuterol Sulfate/Ipratropium Non-Oral SolutionAlvesco SLAsmanex SL

Budesonide Inhalation Suspension 0.25 mg/ 2 ml, 0.5 mg/2 ml SL

Ipratropium BromideQVAR SL

Theophylline Ventolin HFA SLZafirlukast SL

Tier 1

Foradil SLPulmicort Respules 1 mg/2 ml SL

Singulair SLSpiriva SL

Tier 2

Advair Diskus SLAdvair HFA SLAtrovent HFA SLCombivent SLDulera SLFlovent Diskus SL

Flovent HFA SLMaxair Autohaler SLPerforomist SLProair HFA SLProventil HFA SLPulmicort Flexhaler SL

Serevent Diskus SLSymbicort SLXopenex HFA SLXopenex Vial, Nebulizer SL

Tier 3

Azelastine HCl SLFlunisolide

Fluticasone Propionate SLTriamcinolone Acetonide SL

Tier 1

Nasonex SLTier 2

Astelin SLAsteproBeconase AQ SL

Nasacort AQ SLOmnaris SLPatanase

Rhinocort Aqua SLVeramyst

Tier 3

Respiratory Oral Allergy

CyproheptadineHydroxyzine

Levocetirizine SLPromethazine

Tier 1

Clarinex SL Clarinex-D SLTier 3

Women’s Health Contraceptives

AmethiaAmethystApriAvianeAzuretteBalzivaCamilaCamreseEnpresseErrinGianviHeatherIntrovaleJolessaJolivette

JunelJunel FeKarivaLevoraLow-OgestrelLuteraMedroxyprogesterone 150 mg/mlMicrogestinMicrogestin FeMononessa Necon 7/7/7Nora-BeNorethindrone Nortrel 7/7/7Ocella

PortiaPrevifemQuasenseReclipsenSprintecTilia FeTri-Legest FeTri-PrevifemTri-SprintecTrinessa TrivoraZarah ZenchentZeosa Zovia

Tier 1

Depo-SubQ Provera NuvaRing OvretteTier 2

BeyazFemcon FeLo Loestrin FeLoestrin 24 FeLoSeasoniqueLybrel

Ortho EvraOrtho MicronorOrtho Tri-Cyclen Ortho Tri-Cyclen LoOrtho-CyclenOrtho-Novum 7/7/7

SafyralSeasoniqueYasminYaz

Tier 3



Women’s Health Estrogen/Progesterone

Women’s Health Prenatal Vitamins

EstradiolEstradiol/Norethindrone AcetateEstradiol Transdermal Weekly Patch SL

Estropipate Medroxyprogesterone Norethindrone Acetate

Norethindrone Acetate/Ethinyl Estradiol Tablet 1 mg/5 mcg

Tier 1

Cenestin Climara SLCrinoneDivigelEnjuvia

Estrace Cream with ApplicatorEstraderm SLEstring SLEvamistPrefest

PrometriumVagifemVivelle SLVivelle-Dot SL

Tier 2

ActivellaAlora SLClimara Pro SLCombipatch SLEstrasorb SL

Estrogel SLFemhrtFemring SLFirst-ProgesteroneMenostar Transdermal Weekly Patch SL

PremarinPremphasePremproProchieve

Tier 3

Advanced Care PlusCavan-EC Sod DHAFolcal DHAFolic AcidMulti-Nate 30Multinatal PlusNatalcare PlusPR Natal 430

PR Natal 430 ECPR Natal 440 EC Prenatal 19Prenatal AdvantagePrenatal PlusPruet DHA 29-1-430 mgPruet DHA EC 29-1-430 mgSetonet

Setonet-ECTaron A PrenatalVemavite-PRX 2Vinate III Vitanatal OB+DHAZatean-PNZatean-PN DHAZatean-PN Plus

Tier 1

Brand Prenatal VitaminsTier 3



Accolate SL (Zafirlukast SL)Accupril (Quinapril)Acular (Ketorolac Tromethamine)Adderall (Amphetamine/Dextroamphetamine Salt

Combination)Aldactone (Spironolactone)Altace (Ramipril)Amaryl (Glimepiride)Ambien SL (Zolpidem SL)Amerge SL (Naratriptan SL)Anaprox (Naproxen)Aricept (Donepezil)Arimidex (Anastrozole)Ativan (Lorazepam)Augmentin ES (Amoxicillin/Potassium

Clavulanate)Biaxin Tablet (Clarithromycin Tablet)Buspar (Buspirone)Calan, Calan SR (Verapamil)Capoten (Captopril)Cardizem CD except for 360 mg strength

(Diltiazem Capsule, Sustained-Release 24 Hour)

Cardura (Doxazosin)Ceftin (Cefuroxime)Cefzil (Cefprozil)Celexa (Citalopram)Ciloxan Eye Drops (Ciprofloxacin)Cipro (Ciprofloxacin)Cleocin T (Clindamycin Gel, Lotion, Solution,

Swabs)Clozaril (Clozapine)Colazal (Balsalazide)Colestid (Colestipol)Coreg (Carvedilol)Cozaar 1/2T (Losartan 1/2T)DDAVP (Desmopressin)Depakote (Divalproex Sodium Tablet)Depakote ER (Divalproex Sodium

Sustained-Release 24 Hour Tablet)Depo-Provera (Medroxyprogesterone

150 mg/ml)DiaBeta, Micronase, Glynase (Glyburide)Diastat Acudial SL (Diazepam Rectal Gel SL)Didronel (Etidronate Disodium)Diflucan (Fluconazole) Ditropan XL (Oxybutynin Sustained-Release

Tablet)Duricef (Cefadroxil)Dyazide (Triamterene/Hydrochlorothiazide)Dynacirc (Isradipine)Effexor (Venlafaxine)Effexor XR SL (Venlafaxine Sustained-Release

Capsule SL)Eskalith CR (Lithium Carbonate

Controlled-Release Tablet)Femara (Letrozole)Fioricet SL (Acetaminophen/Butalbital/

Caffeine SL)Flomax (Tamsulosin)Flonase SL (Fluticasone Nasal Spray SL)Floxin Otic (Ofloxacin Otic Drops)Fosamax SL (Alendronate SL)Glucophage, XR (Metformin)Glucotrol, XL (Glipizide)Glucovance (Glyburide/Metformin)Hytrin (Terazosin)Hyzaar SL (Losartan/Hydrochlorothiazide SL)Imitrex SL (Sumatriptan Succinate Injection,

Tablet SL)

Inderal (Propranolol)Keflex (Cephalexin)Keppra (Levetiracetam)Klonopin (Clonazepam)Lamictal (Lamotrigine)Lamisil SL (Terbinafine Tablet SL)Lasix (Furosemide)Levaquin (Levofloxacin)Lopid (Gemfibrozil)Lopressor (Metoprolol)Mavik 1/2T (Trandolapril 1/2T)Medrol (Methylprednisolone Dosepak

Tablet 4 mg)Mevacor (Lovastatin)Mobic (Meloxicam)Monopril (Fosinopril)Monopril HCT (Fosinopril/Hydrochlorothiazide)Motrin (Ibuprofen) - Prescription strengths onlyNaprosyn (Naproxen) - Prescription

strengths onlyNardil (Phenelzine)Nasarel SL (Flunisolide Nasal Spray SL)Neurontin (Gabapentin)Norvasc (Amlodipine)Ocuflox Eye Drops (Ofloxacin)Paxil (Paroxetine)Penlac (Ciclopirox Solution, Non-Oral)Percocet 5-325, 7.5-500, 10-650 SL

(Acetaminophen/Oxycodone SL)Plan B (Levonorgestrel)Pletal (Cilostazol)Pravachol 1/2T (Pravastatin 1/2T)Precose (Acarbose)Prilosec (Omeprazole)Prinivil, Zestril (Lisinopril)Prinzide, Zestoretic (Lisinopril/

Hydrochlorothiazide)Procardia XL (Nifedipine Extended-Release

Tablet)Proscar (Finasteride)Protonix (Pantoprazole)Provera (Medroxyprogesterone)Prozac (Fluoxetine Capsule)Prozac Weekly SL (Fluoxetine Delayed-Release

Capsule SL) Remeron (Mirtazapine)Remeron SolTab (Mirtazapine Dispersible Tablet)Requip (Ropinirole)Restoril (Temazepam)Risperdal (Risperidone)Ritalin (Methylphenidate)Ritalin SR (Methylphenidate Extended-Release

Tablet)Sonata SL (Zaleplon SL)Surmontil (Trimipramine Maleate)Tenoretic (Atenolol/Chlorthalidone)Tenormin (Atenolol)Tiazac (Diltiazem)Topamax (Topiramate)Toprol XL 25 mg (Metoprolol Succinate

Sustained-Release Tablet)Trileptal (Oxcarbazepine)Trusopt (Dorzolamide Eye Drops)Tylenol #3 SL (Acetaminophen/Codeine SL)Ultracet SL (Tramadol/Acetaminophen SL)Ultram (Tramadol)Valium (Diazepam)Vaseretic (Enalapril/Hydrochlorothiazide)Vasotec (Enalapril)Vfend SL (Voriconazole SL)

Vicodin SL, Vicodin ES SL (Acetaminophen/Hydrocodone SL)

Vicoprofen (Ibuprofen/Hydrocodone)Voltaren Tablet (Diclofenac)Wellbutrin (Bupropion HCl)Wellbutrin SR (Bupropion HCl Sustained-Action

Tablet)Wellbutrin XL (Bupropion HCl Sustained-Release

24 Hour Tablet)Xalatan SL (Latanoprost SL)Xanax, Xanax XR (Alprazolam)Zantac Syrup (Ranitidine Syrup)Ziac (Bisoprolol/Hydrochlorothiazide)Zithromax (Azithromycin)Zocor 1/2T (Simvastatin 1/2T)Zofran (Ondansetron)Zoloft 1/2T (Sertraline 1/2T)Zonegran (Zonisamide)Zovirax (Acyclovir Capsule, Suspension, Tablet)

Additional Tier 3 Drugs with a generic equivalent in Tier 1


IndexAA-B Otic 5Abilify 8Acanya 9Acarbose 10, 16Accolate 16Accu-Chek Active Test Strips 9Accu-Chek Aviva Care Kit 9Accu-Chek Aviva Test Strips 9Accu-Chek Comfort Curve Test Strips 9Accu-Chek Compact Care Kit 9Accu-Chek Compact Test Strips 9Accupril 16Aceon 6Acetaminophen/Butalbital/Caffeine 7, 13, 16Acetaminophen/Butalbital/Caffeine/Codeine 13Acetaminophen/Codeine 13, 16Acetaminophen/Dichloralphenazone/Isometheptene Mucate 7Acetaminophen/Hydrocodone 13, 16Acetaminophen/Hydrocodone Bit 13Acetaminophen/Oxycodone 13, 16Acetazolamide 11Aciphex 11Activella 15Actonel 13Actoplus Met 10Actos 10Acular 16Acuvail 12Acyclovir 5, 16Acyclovir Capsule, Suspension, Tablet 16Aczone 9Adapalene 9Adderall 7, 16Adderall XR 7Adoxa 5Advair Diskus 14Advair HFA 14Advanced Care Plus 15Advicor 6Aggrenox 5Akineton 8Albuterol Sulfate 14Albuterol Sulfate/Ipratropium Non-Oral Solution 14Alclometasone Dipropionate 9Aldactazide 50-50 mg 6Aldactone 16Aldara 9Alendronate 13, 16Alfuzosin 12Allopurinol 13Alora 15Alphagan P 0.1% 11Alprazolam 8, 16Alsuma 7Altabax 9Altace 16Altoprev 6Alvesco 14Amantadine 5Amaryl 16Ambien 8, 16Ambien CR 8Amerge 16Amethia 14Amethyst 14Amiodarone 7Amitiza 12Amitriptyline 7Amitriptyline/Perphenazine 7Amlodipine 6, 16Amlodipine/Benazepril 6Amoxicillin 5, 16Amoxicillin-Clavulanate ER 5

Amoxicillin/Potassium Clavulanate 5, 16Amphetamine/Dextroamphetamine Salt Combination 16Amphetamine Aspartate/Amphetamine Sulfate/Dextroamphetamine Sustained-Release 24 Hour Capsule 7Amphetamine Salt Combo 7Ampicillin 5Ampyra 8Amrix 13Amturnide 6Anaprox 16Anastrozole 12, 16Androderm 10Androgel 10Android 10Antara 6Antipyrine/Benzocaine 12Anzemet 11Apidra 10Aplenzin 7Apokyn 8Apraclonidine 11Apri 14Apriso 12Aricept 8, 16Aricept 23 mg 8Arimidex 16Arixtra 5Armour Thyroid 10Aromasin 12Arthrotec 13Asacol 12Asacol HD 12Ascensia Autodisc Test Strips 9Ascensia Breeze 2 Test Strips 9Ascensia Elite Test Strips 9Asmanex 14Aspirin/Butalbital/Caffeine 7, 13Aspirin/Butalbital/Caffeine/Codeine 13Aspirin/Oxycodone 13Astelin 14Astepro 14Atacand 6Atacand HCT 6Atenolol 6, 16Atenolol/Chlorthalidone 6, 16Ativan 16Atorvastatin 6Atralin 9Atrovent HFA 14Augmentin 5, 16Augmentin ES 16Augmentin XR 5Avalide 6Avandamet 10Avandaryl 10Avandia 10Avapro 6Avelox 5Aviane 14Avinza 13Avita Gel 9Avodart 12Avonex 8Axert 7Azasite 11Azathioprine 12-13Azelastine HCl 11, 14Azelex 9Azithromycin 5, 16Azopt 11Azor 6Azurette 14BBaclofen 13

Bactroban 9Balsalazide 12, 16Balziva 14Baraclude 5Beconase AQ 14Belladona/Phenobarbital 12Benazepril 6Benazepril/Hydrochlorothiazide 6Benicar 6Benicar HCT 6Benzaclin Gel 1%-5% 9Benzamycin 9Benzonatate 12Benztropine Mesylate 8Bepreve 11Betamethasone Dipropionate 9Betamethasone Valerate 9Betaseron 8Betimol 11Beyaz 14Biaxin Tablet 16BiDil 6Bisoprolol 6, 16Bisoprolol/Hydrochlorothiazide 6, 16Blephamide S.O.P. 11Boniva Tablet 13Brand Prenatal Vitamins 15Brimonidine Tartrate 11Brimonidine Tartrate 0.15% 11Budesonide Extended-Release 24 Hour Capsule 12Budesonide Inhalation Suspension 0.25 mg/2 ml, 0.5 mg/2 ml 14Bumetanide 6Bupropion 7, 16Bupropion HCl 16Bupropion HCl Sustained-Action Tablet 16Bupropion HCl Sustained-Release 24 Hour Tablet 16Bupropion XL 7Buspar 16Buspirone 8, 16Butorphanol Nasal Spray 13Byetta 10Bystolic 6CCabergoline 10Caduet 6Cafergot 7Calan, Calan SR 16Calcitonin Salmon Nasal Spray 13Calcitriol 10Cambia 7Camila 14Camrese 14Canasa 12Capoten 16Captopril 6, 16Captopril/Hydrochlorothiazide 6Carafate Oral Suspension 11Carbamazepine 8Carbamazepine Extended-Release 12 Hour Capsule 8Carbamazepine Sustained-Release 12 Hour Tablet 8Carbatrol 8Carbidopa/Levodopa 8Cardizem CD 360 mg 6Cardizem CD except for 360 mg strength 16Cardizem LA 120 mg 6Cardizem LA 180, 240, 300, 360, 420 mg 6Cardura 16Carisoprodol 250 mg 13Carisoprodol 350 mg 13Carvedilol 6, 16Catapres-TTS 6


Cavan-EC Sod DHA 15Caverject 12Cefadroxil 5, 16Cefdinir 5Cefprozil 5, 16Ceftin 16Cefuroxime 5, 16Cefzil 16Celebrex 13Celexa 16Cellcept Suspension 12Celontin 8Cenestin 15Cephalexin 5, 16Cesamet 11Cetraxal 5Chlordiazepoxide/Clidinium 12Chlorhexidine Gluconate 12Chlorthalidone 6, 16Cholestyramine 6Cialis 12Ciclopirox Cream, Gel, Lotion 9Ciclopirox Non-Oral Solution 9Ciclopirox Shampoo 1% 9Ciclopirox Solution, Non-Oral 16Cilostazol 5, 16Ciloxan Eye Drops 16Cimetidine 11Cimzia 13Cipro 5, 16Cipro HC 5Cipro Suspension 5Ciprodex Otic 5Ciprofloxacin 5, 11, 16Ciprofloxacin Sustained-Release 24 Hour Tablet 5Ciprofloxacin Tablet 5Citalopram 7, 16Citalopram Hydrobromide 7Clarinex 14Clarinex-D 14Clarithromycin Suspension 5Clarithromycin Sustained-Release Tablet 5Clarithromycin Tablet 5, 16Cleocin HCl 75 mg 5Cleocin T 16Climara 15Climara Pro 15Clindagel 9Clindamycin Foam 1% 9Clindamycin Gel, Lotion, Solution, Swabs 9, 16Clindamycin HCl 5Clindamycin Palmitate 5Clindamycin Phosphate/Benzoyl Peroxide Gel 1%-5% 9Clindesse Vaginal 5Clobetasol Propionate 9Clobetasol Propionate Foam 9Clobex 9Clobex Shampoo 9Clonazepam 8, 16Clonidine 6Clonidine Transdermal Weekly Patch 6Clorazepate Dipotassium 8Clorpres 6Clotrimazole 5, 9Clotrimazole/Betamethasone 9Clozapine 8, 16Clozaril 16Codeine Phosphate 13Colazal 16Colcrys 13Colestid 16Colestipol 6, 16Combigan 11Combipatch 15Combivent 14Comtan 8Concerta 7

Condylox Gel 9Contour Test Strips 9Copaxone 8Coreg 6, 16Coreg CR 6Coumadin 5Cozaar 16Creon 12Crestor 6Crinone 15Cuprimine 13Cutivate Lotion 9Cyclobenzaprine 13Cyclobenzaprine Extended-Release 24 Hour Capsule 13Cymbalta 7Cyproheptadine 14DDapsone 5Daytrana 7DDAVP 16Denavir 9Depakote 8, 16Depakote ER 8, 16Depo-Provera 16Depo-SubQ Provera 14Derma-Smoothe/FS 9Desmopressin 10, 16Desonate 9Desonide 9Desoximetasone 9Detrol 12Detrol LA 12Dexamethasone 10-11Dexilant 11Dextroamphetamine Sulfate 7DiaBeta 16Diastat Acudial 16Diazepam 8, 16Diazepam Rectal Gel 8, 16Dibenzyline 6Diclofenac 13, 16Diclofenac Potassium 13Diclofenac Sodium 13Dicloxacillin Sodium 5Dicyclomine Tablet 12Didronel 16Differin Cream, Gel 0.1% 9Differin Gel 0.3% 9Differin Lotion 9Diflucan 16Digoxin 7Dilantin 8Diltiazem 6, 16Diltiazem Capsule, Sustained-Release 24 Hour 16Diltiazem Controlled-Release Capsule 6Diltiazem Sustained-Action Capsule 6Diltiazem Sustained-Release 12 Hour Capsule 6Diltiazem Sustained-Release 24 Hour Capsule 6Diltiazem Sustained-Release 24 Hour Tablet 6Diovan 6Diovan HCT 6Dipentum 12Diphenoxylate/Atropine 12Ditropan XL 16Diuril Suspension 250 mg/5 ml 6Divalproex Sodium Sprinkle Capsule 8Divalproex Sodium Sustained-Release 24 Hour Tablet 16Divalproex Sodium Sustained-Release Tablet 8Divalproex Sodium Tablet 8, 16Divigel 15Donepezil 8, 16Donepezil 5, 10 mg 8Doryx 5Dorzolamide Eye Drops 16Dorzolamide HCl 11Dorzolamide HCl/Timolol Maleate 11

Dovonex Cream 9Doxazosin 6, 12, 16Doxepin 7Doxycycline Hyclate Enteric-Coated Tablet 5Doxycycline Monohydrate 5Doxycycline Monohydrate Capsule 150 mg 5Duac 9Duetact 10Dulera 14Duragesic 13Duricef 16Dyazide 16Dynacirc 16EEconazole Nitrate 9Edex 12Edluar 8Effexor 16Effexor XR 16Effient 5Elestat 11Elidel 9Emadine 11Embeda 13Emend 11Enablex 12Enalapril 6, 16Enalapril/Hydrochlorothiazide 6, 16Enbrel 13Enjuvia 15Enoxaparin 5Enpresse 14Entocort EC 12Epiduo 9Epinastine 11Epinephrine Pen Injector 12Epipen 12Epipen Jr 12Epivir HBV 5Eplerenone 6Ergomar 7Errin 14Ery-Tab 500 mg 5Erythromycin 5, 9, 11Erythromycin/Benzoyl Peroxide 9Erythromycin Base Enteric-Coated Tablet 250, 333 mg 5Eskalith CR 16Estrace Cream with Applicator 15Estraderm 15Estradiol 15Estradiol/Norethindrone Acetate 15Estradiol Transdermal Weekly Patch 15Estrasorb 15Estring 15Estrogel 15Estropipate 15Etidronate Disodium 16Etodolac 13Evamist 15Evista 13Evoclin 9Exalgo 13Exelon Solution 8Exemestane 12Exforge 6Exforge HCT 6Extavia 8Extina 5FFamciclovir 5Fanapt 8Fareston 12FazaClo 8Felbatol 8Felodipine 6Femara 16Femcon Fe 14


Femhrt 15Femring 15Fenofibrate 6Fenofibric Acid 6Fenoglide 6Fentanyl Citrate Lollipop 13Fentanyl Transdermal 13Fentora 13Finacea 9Finacea Plus 9Finasteride 12, 16Fioricet 16First-Progesterone 15Flecainide Acetate 7Flector 13Flomax 16Flonase 16Flovent Diskus 14Flovent HFA 14Floxin Otic 16Fluconazole 5, 16Fludrocortisone 10Flunisolide 14, 16Flunisolide Nasal Spray 16Fluocinonide 9Fluoxetine 7, 16Fluoxetine Capsule 16Fluoxetine Delayed-Release Capsule 7, 16Fluticasone Nasal Spray 16Fluticasone Propionate 9, 14Fluvoxamine Maleate 7Focalin XR 7Folcal DHA 15Folic Acid 15Fondaparinux 5Foradil 14Fortamet 10Forteo 13Fortical 13Fosamax 13, 16Fosamax Plus D 13Fosinopril 6, 16Fosinopril/Hydrochlorothiazide 6, 16Fragmin 5Freestyle Lite Test Strips 9Freestyle Test Strips 9Frova 7Furosemide 6, 16GGabapentin 8, 16Gabitril 8Galantamine 8Gelnique 12Gemfibrozil 6, 16Genotropin 10Gentamicin Sulfate 11Geodon 8Gianvi 14Gilenya 8Glimepiride 10, 16Glipizide 10, 16Glipizide/Metformin 10Glucophage, XR 16Glucotrol, XL 16Glucovance 16Glumetza 10Glyburide 10, 16Glyburide/Metformin 10, 16Glynase 16Glyset 10GoLYTELY Packet 12Granisetron Tablet 11Guanfacine 6Gynazole-1 Vaginal 5HHalflytely-Bisacodyl 12Halobetasol Propionate 9Heather 14

Hectorol 10Helidac 11Hepsera 5Humalog-Mix KwikPen 10Humalog-Mix Vials 10Humalog KwikPen 10Humalog Vials 10Humatrope 10Humira 13Humulin 70-30 Vials 10Humulin KwikPen 10Humulin Vials 10Hydralazine 6Hydrochlorothiazide 6, 16Hydrocodone/Chlorpheniramine Suspension 12Hydrocortisone 9-10Hydrocortisone Tablet 10Hydrocortisone Valerate 9Hydromorphone 13Hydroxychloroquine Sulfate 13Hydroxyzine 14Hyoscyamine Sulfate 12Hytrin 16Hyzaar 16IIbuprofen 13, 16Ibuprofen/Hydrocodone 13, 16Ibuprofen/Oxycodone 13Ibuprofen - Prescription strengths only 16Imipramine 7Imiquimod 9Imitrex 16Indapamide 6Inderal 16Indomethacin 13Infergen 12Innohep 5Intron A 12Introvale 14Intuniv 7Invega 8Iopidine 1% 11Ipratropium Bromide 14Isosorbide Dinitrate 7Isosorbide Mononitrate 7Isotretinoin 9Isradipine 16Itraconazole Capsule 5JJalyn 12Janumet 10Januvia 10Jolessa 14Jolivette 14Junel 14Junel Fe 14KKadian 13Kariva 14Keflex 16Keppra 8, 16Keppra XR 8Ketoconazole 5, 9Ketorolac Tromethamine 11, 13, 16Kineret 13Klonopin 16Kuvan 10LLabetalol 6Lactulose 12Lamictal 8, 16Lamictal Dose Pack 8Lamictal ODT 8Lamictal XR 8Lamisil 5, 16Lamisil Granules 5Lamotrigine 8, 16Lanoxin 7

Lansoprazole 11Lantus Solostar Pens/Cartridges 10Lantus Vials 10Lasix 16Lastacaft 11Latanoprost 11, 16Leflunomide 13Lescol 6Lescol XL 6Letrozole 12, 16Levaquin 16Levemir Flexpen 10Levemir Vials 10Levetiracetam 8, 16Levetiracetam Extended-Release 24 Hour Tablet 8Levitra 12Levocetirizine 14Levofloxacin 5, 11, 16Levonorgestrel 16Levora 14Levothyroxine Sodium 10Lexapro 7Lialda 12Lidocaine 9Lidoderm 12Liothyronine Sodium 10Lipitor 6Lipofen 6Lisinopril 6, 16Lisinopril/Hydrochlorothiazide 6, 16Lithium Carbonate 8, 16Lithium Carbonate Controlled-Release Tablet 16Livalo 6Lo Loestrin Fe 14Locoid Lipocream 9Locoid Lotion 9Loestrin 24 Fe 14Lopid 16Lopressor 16Loprox Shampoo 9Lorazepam 8, 16Losartan 6, 16Losartan/Hydrochlorothiazide 6, 16LoSeasonique 14Lotrel 6Lotronex 12Lovastatin 6, 16Lovaza 6Lovenox 5Low-Ogestrel 14Lumigan 11Lunesta 8Lutera 14Luvox CR 7Lybrel 14Lyrica 8MMacrodantin 25 mg 5Mavik 16Maxair Autohaler 14Maxalt 7Maxalt MLT 7Medrol 10, 16Medrol 2, 8, 24, 32 mg 10Medroxyprogesterone 14-16Medroxyprogesterone 150 mg/ml 14, 16Mefenamic Acid 13Megestrol Acetate 12Meloxicam 13, 16Menostar Transdermal Weekly Patch 15Meperidine 13Mesalamine 12Metadate CD 7Metaxalone 13Metformin 10, 16Methadone 13Methamphetamine 7Methimazole 10


Methocarbamol 13Methotrexate 13Methyldopa 6Methyldopa/Hydrochlorothiazide 6Methylin 7Methylphenidate 7, 16Methylphenidate Extended-Release 24 Hour Tablet 7Methylphenidate Extended-Release Tablet 16Methylprednisolone Dosepak Tablet 4 mg 10, 16Metoclopramide 12Metolazone 6Metoprolol 6, 16Metoprolol/Hydrochlorothiazide 6Metoprolol Succinate Sustained-Release Tablet 6, 16Metoprolol Tartrate 6Metozolv ODT 12Metrogel 1% 9Metrolotion 9Metronidazole 5, 9Metronidazole Vaginal 5Mevacor 16Mexiletine 7Micardis 6Micardis HCT 6Microgestin 14Microgestin Fe 14Micronase 16Migranal 7Minocycline HCl 5Minoxidil 6Mirapex ER 8Mirtazapine 7, 16Mirtazapine Dispersible Tablet 16Misoprostol 11Mobic 16Moexipril 6Mometasone Furoate 9Mononessa 14Monopril 16Monopril HCT 16Morphine Sulfate 13Morphine Sulfate Sustained-Action Tablet 13Motrin - Prescription strengths only 16Moviprep 12MSIR Capsule 13Multaq 7Multi-Nate 30 15Multinatal Plus 15Mupirocin 9Muse 12Mycophenolate Capsule, Tablet 12Mycostatin 5Myfortic 12Mysoline 8NNabumetone 13Nadolol 6Naftin 9Namenda 8Naprelan 13Naprosyn - Prescription strengths only 16Naproxen 13, 16Naproxen - Prescription strengths only 16Naproxen Sodium 13Naratriptan 7, 16Nardil 16Nasacort AQ 14Nasarel 16Nasonex 14Natalcare Plus 15Nateglinide 10Navane 20 mg 8Necon 7/7/7 14Nefazodone 7Neomycin/Polymyxin/HC Otic 5

Neomycin/Polymyxin B Sulfate/Dexamethasone 11Neoral 12Neurontin 16Nexium Capsule 11Nexium Suspension 11Niaspan 6Nifedipine 6, 16Nifedipine Extended-Release Tablet 16Nisoldipine 6Nitrofurantoin/Nitrofurantoin Macrocrystal 5Nitrofurantoin Macrocrystal 5Nitrofurantoin Suspension 5Nitroglycerin 7Nitroglycerin Spray 7Nitroglycerin Transdermal Patch 7Nitrolingual 7Nitromist 7Nitrostat 7Nizatidine Oral Solution 11Nora-Be 14Norditropin 10Norethindrone 14-15Norethindrone Acetate 15Norethindrone Acetate/Ethinyl Estradiol Tablet 1 mg/5 mcg 15Noritate 9Nortrel 7/7/7 14Nortriptyline 7Norvasc 16Novolin Vials 10NovoLog 10Noxafil 5Nutropin, AQ, NuSpin 10NuvaRing 14Nuvigil 8Nystatin 5, 9Nystatin/Triamcinolone Acetonide 9OOcella 14Octreotide Acetate 10Ocuflox Eye Drops 16Ofloxacin 5, 11, 16Ofloxacin Otic 5, 16Ofloxacin Otic Drops 16Oleptro 7Olux-E 9Omeprazole 11, 16Omeprazole/Sodium Bicarbonate Capsule 11Omnaris 14Omnitrope 10Ondansetron 11, 16One Touch Test Strips 9One Touch Ultra 2 System 9One Touch Ultra Mini System 9One Touch Ultra Test Strips 9Onglyza 10Onsolis 13Opana 13Opana ER 13Optivar 11Oracea 5Orapred 10Orapred ODT 10Orphenadrine 13Orphenadrine Compound 13Ortho-Cyclen 14Ortho-Novum 7/7/7 14Ortho Evra 14Ortho Micronor 14Ortho Tri-Cyclen 14Ortho Tri-Cyclen Lo 14Ovrette 14Oxandrolone 10Oxaprozin 13Oxcarbazepine 8, 16Oxistat 9Oxsoralen-Ultra 9

Oxybutynin 12, 16Oxybutynin Sustained-Release Tablet 16Oxycodone 13, 16OxyContin 13Oxymorphone 13Oxymorphone Extended-Release 12 Hour Tablet 13Oxytrol 12PPancreaze 12Pantoprazole 11, 16Paroxetine 7, 16Paroxetine Sustained-Release 24 Hour Tablet 7Paroxetine Tablet 7Pataday 11Patanase 14Patanol 11Paxil 16Pediapred 10Peganone 8Penicillin V Potassium 5Penlac 16Pennsaid 13Pentasa 12Pentoxifylline 5Percocet 5-325, 7.5-500, 10-650 16Perforomist 14Perindopril Erbumine 6Permethrin 9Pexeva 7Phenazopyridine 12Phenelzine 7, 16Phenobarbital 8, 12Phenytoin Sodium 8Phospholine Iodide 11Pilopine HS 11Piroxicam 13Plan B 16Plavix 5Pletal 16Polyethylene Glycol 12Polymyxin B Sulfate/Trimethoprim 11Portia 14PR Natal 430 15PR Natal 430 EC 15PR Natal 440 EC 15Pramipexole 8Prandin 10Pravachol 16Pravastatin 6, 16Precision Xtra Test Strips 9Precose 16Prednisolone 10Prednisone 10Prefest 15Premarin 15Premphase 15Prempro 15Prenatal 19 15Prenatal Advantage 15Prenatal Plus 15Prevacid Delayed-Release Enteric-Coated Capsule 11Prevacid Solutab 11Previfem 14Prevpac 11Prilosec 11, 16Prilosec Rx 10, 20 mg 11Prilosec Rx 40 mg 11Primidone 8Prinivil 16Prinzide 16Pristiq 7Proair HFA 14Procardia XL 16Prochieve 15Prochlorperazine Maleate 11Promethazine 14


Prometrium 15Propafenone Sustained-Release 12 Hour Capsule 7Propranolol 6, 16Propranolol/Hydrochlorothiazide 6Propranolol Sustained-Action Capsule 6Proscar 16Protonix 16Protopic 9Proventil HFA 14Provera 14, 16Provigil 8Prozac 16Prozac Weekly 16Pruet DHA 29-1-430 mg 15Pruet DHA EC 29-1-430 mg 15Pulmicort Flexhaler 14Pulmicort Respules 1 mg/2 ml 14Pylera 11QQuasense 14Quinapril 6, 16Quinapril/Hydrochlorothiazide 6QVAR 14RRamipril 6, 16Ranexa 7Ranitidine Syrup 11, 16Rapaflo 12Rapamune 12Rebetol Solution 5Rebif 8Reclipsen 14Regranex 9Relenza 5Relistor 12Relpax 7Remeron 16Remeron SolTab 16Requip 8, 16Requip XL 8Restasis 12Restoril 16Retin-A Micro 9Rhinocort Aqua 14Ribavirin 5Risperdal 16Risperidone 8, 16Ritalin 7, 16Ritalin LA 7Ritalin SR 16Rivastigmine 8Ropinirole 8, 16Rozerem 8Rybix ODT 13Ryzolt 13SSabril 8Safyral 14Saizen 10Sanctura XR 12Sancuso 11Sandimmune 12Sandostatin Vial 10Savella 13Seasonique 14Serevent Diskus 14Seroquel 8Seroquel XR 8Serostim 10Sertraline 7, 16Setonet 15Setonet-EC 15Silenor 8Silver Sulfadiazine 9Simcor 6Simponi 13Simvastatin 6, 16

Singulair 14Skelaxin 13Solodyn 5Soma 250 mg 13Sonata 8, 16Sotalol 7Spiriva 14Spironolactone 6, 16Spironolactone/Hydrochlorothiazide 6Sporanox Oral Solution 5Sprintec 14Starlix 10Stavzor 8Stelara 9Strattera 7Sucralfate Tablet 11Sular 6Sulfacetamide Sodium 9, 11Sulfacetamide Sodium/Sulfur 9Sulfamethoxazole/Trimethoprim 5Sulfasalazine 12-13Sulindac 13Sumatriptan Succinate Injection, Tablet 7, 16Sumatriptan Succinate Nasal Spray 7Sumavel DosePro 7Suprax 5Surmontil 16Symbicort 14Symbyax 8Symlin 10Synarel 10Synthroid 10TTaclonex 9Taclonex Scalp 9Tacrolimus 12Tamiflu 5Tamoxifen 12Tamsulosin 12, 16Tarka 6Taron A Prenatal 15Tasmar 8Tazorac 9Tegretol 8Tekamlo 6Tekturna 6Tekturna HCT 6Temazepam 8, 16Tenoretic 16Tenormin 16Terazosin 6, 12, 16Terbinafine Tablet 5, 16Terconazole Vaginal 5Testim 10Testosterone 10Tetracycline 5Tev-Tropin 10Teveten 6Teveten HCT 6Thalitone 6Theophylline 14Tiazac 16Tilia Fe 14Timolol Maleate 6, 11Tirosint 10Tizanidine 13Tobi 5Tobradex ST 11Tobramycin/Dexamethasone 11Tobramycin Sulfate Drops 11Tolmetin Sodium 13Topamax 8, 16Topiramate 8, 16Toprol XL 25 mg 16Torsemide 6Toviaz 12Tramadol 13, 16Tramadol/Acetaminophen 13, 16

Tramadol Sustained-Release 24 Hour Tablet 13Trandolapril 6, 16Trandolapril/Verapamil 6Transderm-Scop 11Travatan Z 11Trazodone 7Tretin-X 9Tretinoin 9Trexall 13Treximet 7Tri-Legest Fe 14Tri-Previfem 14Tri-Sprintec 14Triamcinolone Acetonide 9, 14Triamterene/Hydrochlorothiazide 6, 16Triazolam 8Tribenzor 6Tricor 6Triglide 6Trileptal 16Trilipix 6Trilyte with Flavor Packets 12Trimipramine Maleate 16Trinessa 14Trivora 14Trospium 12Trusopt 16Tussionex 12Twinject 12Twynsta 6Tylenol #3 16UUloric 13Ultracet 16Ultram 16Urea 9Uroxatral 12Ursodiol 12VVagifem 15Valacyclovir 5Valcyte 5Valium 16Valtrex 5Valturna 6Vancocin HCl 5Vanos 9Vaseretic 16Vasotec 16Vectical 9Velosef Suspension 250 mg 5Veltin 9Vemavite-PRX 2 15Venlafaxine 7, 16Venlafaxine Extended-Release Tablet 7Venlafaxine Sustained-Release Capsule 7, 16Venlafaxine Tablet 7Ventolin HFA 14Veramyst 14Verapamil 6, 16Verapamil Sustained-Release 24 Hour Pellets 6Verdeso 9Vesicare 12Vfend 16Viagra 12Vicodin 16Vicodin ES 16Vicoprofen 16Victoza 10Vigamox 11Vimovo 13Vinate III 15Vitanatal OB+DHA 15Vivelle 15Vivelle-Dot 15Voltaren Gel 13Voltaren Tablet 16Voriconazole 5, 16


Vusion 9Vytorin 6Vyvanse 7WWarfarin Sodium 5Welchol 6Wellbutrin 16Wellbutrin SR 16Wellbutrin XL 16XXalatan 16Xanax, Xanax XR 16Xerese 9Xolegel 9Xopenex HFA 14Xopenex Vial, Nebulizer 14Xyrem 8YYasmin 14Yaz 14ZZafirlukast 14, 16Zaleplon 8, 16Zantac Syrup 16Zarah 14Zatean-PN 15Zatean-PN DHA 15Zatean-PN Plus 15Zegerid Capsule 11Zegerid Packet 11Zemplar 10Zenchent 14Zenpep 12Zeosa 14Zestoretic 16Zestril 16Zetia 6Ziac 16Ziana 9Zipsor 13Zithromax 16Zocor 16Zofran 16Zoloft 16Zolpidem 8, 16Zolpidem Multiphasic-Release Tablet 8Zolpidem Tablet 8Zomig 7Zomig Nasal Spray 7Zomig ZMT 7Zonegran 16Zonisamide 8, 16Zorbtive 10Zovia 14Zovirax 9, 16Zuplenz 11Zyclara 9Zylet 11Zymaxid 11Zyprexa 8Zyprexa Zydis 8Zyvox 5

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