your 2017 formulary - university of...

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 2017 Formulary

OptumRx 1

Effective January 1, 2017

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

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

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

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

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

Cardiovascular/Heart DiseaseAnticoagulants. . . . . . . . . . . . . . . . . . . . . . . . . 9High Blood Pressure . . . . . . . . . . . . . . . . . . . . 10High Cholesterol . . . . . . . . . . . . . . . . . . . . . . 10Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Pulmonary Arterial Hypertension . . . . . . . . . . 11

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

Dermatology . . . . . . . . . . . . . . . . . . . . . . . . 12

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

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

Eye ConditionsAllergies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

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

HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

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

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

Men’s HealthErectile Dysfunction . . . . . . . . . . . . . . . . . . . . 17Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Testosterone Therapy . . . . . . . . . . . . . . . . . . . 17

Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . 17

MusculoskeletalOsteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Pain Relief . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Overactive Bladder . . . . . . . . . . . . . . . . . . . 19

RespiratoryAsthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . 19Nasal Allergies . . . . . . . . . . . . . . . . . . . . . . . . 19Oral Allergies . . . . . . . . . . . . . . . . . . . . . . . . . 19

Transplant . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Vitamins/Electrolytes . . . . . . . . . . . . . . . . . 19

Women’s HealthBirth Control . . . . . . . . . . . . . . . . . . . . . . . . . 20Hormone Replacement . . . . . . . . . . . . . . . . . 20Vaginal Anti-Infectives . . . . . . . . . . . . . . . . . . 20

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

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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.

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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.

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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Programs and Limits

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

PA Prior Authorization – Your doctor is required to provide additional information to determine coverage.

ST Step Therapy – Trial of lower cost medication(s) is required before a higher-cost medication is covered.

QL Quantity Limits – Amount of medication covered per copayment or in a specific time period.

SPSpecialty Medication – Medication is designated as a specialty pharmacy drug.

To learn more about a pharmacy program or to find out if it applies to you, please visit your plan’s member website or call the toll-free member phone number on your ID card.

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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.

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.

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Are you taking a specialty medication?

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

BriovaRx, the OptumRx specialty pharmacy, can provide most of your specialty medications along with helpful programs and services. Call BriovaRx 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

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.

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

PA Prior Authorization ST Step Therapy

QL Quantity LimitsSP Specialty Program

Drug NameDrug Tier

Programs and Limits

Anti-Infectives: Antibiotics

Amoxicillin 1Amoxicillin/Clavulanate 1Azasite 3Azithromycin 1Bethkis 2 SPCefadroxil Cap 1Cefdinir 1Cefuroxime Tab 1Cephalexin 1Ciprodex Otic

Suspension2

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

(Immediate Release)1

Doxycycline Monohydrate Cap

1

Doxycycline Monohydrate Oral Suspension, Tab

1

Erythromycin 1Levofloxacin Tab 1Metronidazole Tab 1Minocycline Cap 1Moxifloxacin 1Neomycin/Polymyxin/

HC Otic Suspension, Solution

1

Nitrofurantoin Macrocrystalline

1

Nitrofurantoin Monohydrate Macrocrystalline

1

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

Trimethoprim1

Drug NameDrug Tier

Programs and Limits

Sulfamethoxazole-Trimethoprim DS

1

Anti-Infectives: Antifungals

Fluconazole 1Jublia Solution 3 PAKerydin Solution 3 PANystatin Suspension 1Terbinafine Tab 1 QL

Anti-Infectives: Antivirals

Acyclovir Cap, Tab, Suspension

1

Daklinza 3 PA, QL, SPEntecavir 1 QL, SPEpclusa 2 PA, QL, SPFamciclovir Tab 1Harvoni 2 PA, QL, SPSovaldi 2 PA, QL, ST, SPTamiflu 3 QLValacyclovir 1 QLZepatier 2 PA, QL, SP

CancerAkynzeo 3 QLAnastrozole Tab 1Capecitabine 1 PA, SPLetrozole 1Revlimid 3 PA, SPSprycel 2 PA, SPTamoxifen Tab 1Tasigna 3 PA, SPTemozolomide 1 PA, SPZytiga 3 PA, SPCardiovascular/Heart Disease: AnticoagulantsBrilinta 2Clopidogrel 1Effient 2Eliquis 3 QLEnoxaparin 1 QL, SPPradaxa 2 QLSavaysa 3 QLWarfarin 1Xarelto 2 QL

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Drug NameDrug Tier

Programs and Limits

Cardiovascular/Heart Disease: High Blood PressureAmlodipine 1Amlodipine/Benazepril 1Amlodipine/Valsartan 1Amlodipine/Valsartan/

HCTZ1

Atenolol 1Atenolol/Chlorthalidone 1Azor 2 STBenazepril 1Benazepril/HCTZ 1Benicar 2 STBenicar HCT 2 STBisoprolol 1Bisoprolol/HCTZ 1Bumetanide 1Bystolic 2Cartia XT 1Carvedilol 1Chlorthalidone 1Clonidine Patch 1Clonidine Tab 1Diltiazem Tab 1Doxazosin 1Edarbi 3 STEdarbyclor 3 STEnalapril 1Enalapril/HCTZ 1Felodipine 1Fosinopril 1Furosemide 1Guanfacine Tab


Hydralazine 1Hydrochlorothiazide 1Irbesartan 1Irbesartan/HCTZ 1Labetalol 1Lisinopril 1Lisinopril/HCTZ 1Losartan 1Losartan/HCTZ 1Metoprolol Succinate 1

Drug NameDrug Tier

Programs and Limits

Metoprolol Tartrate 1Nadolol 1Nifedipine ER 1Propranolol 1Propranolol ER 1Quinapril 1Ramipril 1Spironolactone 1Tekturna 2 STTekturna HCT 2 STTelmisartan 1Terazosin 1Torsemide Tab 1Triamterene/HCTZ 1Tribenzor 2 STValsartan 1Valsartan/HCTZ 1Verapamil ER 1Cardiovascular/Heart Disease: High CholesterolAtorvastatin 1Cholestyramine 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 1Lipitor 3 STLivalo 3 STLovastatin 1Lovaza 3Niacin ER Tab 1Omega-3 Acid Cap

1 gm1

Praluent 2 PA, QL, SPPravastatin 1Rosuvastatin 1Simvastatin 5 mg, 10

mg, 20 mg, 40 mg1

Simvastatin 80 mg 1 PA

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Drug NameDrug Tier

Programs and Limits

Vascepa 2Vytorin 10-10 mg,

10-20 mg, 10-40 mg

2

Vytorin 10-80 mg 2 PAWelchol 2Zetia 3

Cardiovascular/Heart Disease: Other

Amiodarone 1Amlodipine/Atorvastatin 1Corlanor 3 PA, QLDigoxin 1Flecainide 1Isosorbide Mononitrate 1Nitrostat 3Ranexa 2 STSotalol 1Cardiovascular/Heart Disease: Pulmonary Arterial HypertensionAdcirca 3 PA, QL, SPAdempas 2 PA, QL, SPLetairis 2 PA, QL, SPOpsumit 2 PA, QL, SPOrenitram 3 PA, SPSildenafil Tab 20 mg 1 PA, QL, SPTracleer 2 PA, QL, SPCentral Nervous System: Attention Deficit DisorderAdderall XR Cap 3 PA, QL, STAmphetamine-

Dextroamphetamine Tab

1 PA, QL

Amphetamine-Dextroamphetamine SR 24Hr Cap

1 PA, QL

Dexmethylphenidate ER Cap

1 PA, QL

Evekeo 3 PA, QL, STGuanfacine ER Tab 1 QLMethylphenidate

ER Cap1 PA, QL

Methylphenidate ER Tab 1 PA, QL

Drug NameDrug Tier

Programs and Limits

Methylphenidate SA Osmotic ER Tab

1 PA, QL

Methylphenidate Tab 1 PA, QLStrattera 2 QLVyvanse 2 PA, QL

Central Nervous System: Depression

Amitriptyline 1Bupropion 1Bupropion ER 1Bupropion SR 1Bupropion XL 1 QLDoxepin 1Duloxetine Cap 20 mg,

30 mg, 60 mg1 QL

Escitalopram Tab 1Fluoxetine Cap

(not PMDD)1

Fluvoxamine Tab 1Forfivo XL 2 QLMirtazapine 1Nortriptyline 1Paroxetine Tab 1Pristiq 2 QLRisperidone Tab 1 QLSertraline 1Trazodone 1Venlafaxine Tab 1Venlafaxine ER Cap 1Venlafaxine ER Tab 1Viibryd 3 QL, ST

Central Nervous System: Migraine

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

1

Migranal 3 QLRelpax 3 QLRizatriptan Tab, ODT 1 QLSumatriptan Tab

and Spray1 QL

Sumavel Dose 3 QLZolmitriptan Tab 1 QL

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Drug NameDrug Tier

Programs and Limits

Central Nervous System: Multiple SclerosisAmpyra 2 PA, QL, SPAubagio 3 PA, QL, ST, SPAvonex Kit 2 PA, QL, SPAvonex Pen Kit 2 PA, QL, SPAvonex Prefill Kit 2 PA, QL, SPBetaseron 2 PA, QL, SPCopaxone 20 mg/mL

& 40 mg/mL2 PA, QL, SP

Gilenya* 3 PA, QL, ST, SPRebif 3 PA, QL, ST, SPRebif Titrtn 3 PA, QL, ST, SPTecfidera 2 PA, QL, SP

Central Nervous System: Other

Abilify Tab 3 QLAlprazolam Tab 1 QLAripiprazole 1 QLBenztropine 1Buspirone 1Carbidopa/Levodopa

Tab (Immediate Release)

1

Diazepam Tab 1Donepezil Tab 1Hydroxyzine HCL 1Hydroxyzine Pamoate 1Latuda 3 QL, STLithium Carbonate 1Lorazepam Tab 1 QLModafinil 1 PA, QLNamenda XR 2 QLNamzaric 2 QLNuvigil 3 PA, QLOlanzapine Tab 1 QLProchlorperazine 1Quetiapine 1 QLRexulti 3 QLRisperidone Tab 1 QLRopinirole


Saphris 2 QL

Drug NameDrug Tier

Programs and Limits

Seroquel XR 2 QLZiprasidone Cap 1 QLCentral Nervous System: Sedatives/HypnoticsEszopiclone Tab 1 QLSilenor 3 QLTemazepam 1 QLTriazolam Tab 1 QLZolpidem 1 QLZolpidem ER 1 QLCentral Nervous System: Seizure DisordersCarbamazepine Tab 1Clonazepam 1 QLDivalproex DR 1Divalproex ER 1Gabapentin 1Lamotrigine


Lamotrigine ER 1Levetiracetam 1Levetiracetam ER 1Lyrica Cap 2 QLOnfi 3 PAOxcarbazepine 1Phenytoin 1Primidone 1Topiramate Tab 1Vimpat 3Zonisamide 1

Dermatology

Acanya Gel 3 STAcyclovir Ointment 5% 1Aczone Gel 3Atralin 3 PABenzaclin 3 STBetamethasone

Dipropionate Cream1

Ciclopirox Cream 1Clindamycin Gel,

Lotion, Solution1

* Tier 3 Preferred

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Drug NameDrug Tier

Programs and Limits

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

Cortifoam 3Desonide Cream,

Ointment1

Desoximetasone Cream, Gel, Ointment

1

Differin 3 PAEconazole Cream 1Elidel 2 STEpiduo & Epiduo

Forte3

Finacea 3 STFluocinonide Cream,

0.1%1

Fluocinonide Cream, Gel, Ointment, Solution 0.05%

1

Hydrocortisone Cream, Ointment 2.5%

1

Lidocaine Topical Ointment, Solution

1

Lidocaine/Prilocaine Cream

1

Ketoconazole Cream/Shampoo

1

Metrogel 3Metronidazole Gel

0.75%1

Mirvaso Gel 2Mupirocin Ointment 1Nystatin Cream,

Ointment, Powder1

Drug NameDrug Tier

Programs and Limits

Nystatin/Triamcinolone Cream, Ointment

1

Onexton 3Oxsoralen-UL 2Permethrin Cream 5% 1Proctofoam HC 2Retin-A Micro 3 PASoolantra 2Sulfacetamide/Sulfur

Emulsion1

Taclonex 3 QLTazorac 3 QL, ARTretinoin Cream 1 PATretinoin Microsphere

Gel1 PA

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

Glucose Control Liquid

3

Accu-Chek Active Test Strips

2 QL

Accu-Chek Aviva Connect Kit

2

Accu-Chek Aviva Plus Control Liquid

3

Accu-Chek Aviva Plus Kit

2

Accu-Chek Aviva Plus Test Strips

2 QL

Accu-Chek Compact Plus Control Liquid

3

Accu-Chek Compact Plus Test Strips

2 QL

Accu-Chek Compact Plus Kit

2

Accu-Chek FastClix Kit

2

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Drug NameDrug Tier

Programs and Limits

Accu-Chek FastClix Lancets

2

Accu-Chek Multiclix Kit

2

Accu-Chek Multiclix Lancets

2

Accu-Chek Nano SmartView Kit

2

Accu-Chek SmartView Control Liquid

3

Accu-Chek SmartView Test Strips

2 QL

Accu-Chek Soft Touch Lancets

2

Accu-Chek Softclix Kit 2Accu-Chek Softclix

Lancets2

Bayer Contour Test Strips

3 QL, ST

Dexcom G4 Platinum Kit

3

Dexcom G4 Platinum Sensor Kit

3

Dexcom G4 Platinum Transmitter Kit

3

Freestyle Test Strips 3 QL, STInsulin Pen Needle 2Insulin Syringe/

Needle 2

Novofine Pen Needle 3Novofine Autocover

Pen Needle3

Novotwist Pen Needle

3

Onetouch Kit Ultra Smart

2

Onetouch Kit Ultra 2Onetouch Kit Ultra 2 2Onetouch Kit Ultra

Mini2

Onetouch Kit Verio IQ 2Onetouch Test Strips 2 QL

Drug NameDrug Tier

Programs and Limits

Onetouch Ultra Blue Test Strips

2 QL

Onetouch Verio Test Strips

2 QL

Precision Test Strips 3 QL, ST

Diabetes/Endocrine: Insulin

Humalog Mix 50/50 Vial and KwikPen

2

Humalog Mix 75-25 Vial and KwikPen

2

Humalog U-100 Vial and KwikPen

2

Humalog U-200 KwikPen

2

Humulin 70-30 Vial and KwikPen

2

Humulin N Vial and KwikPen

2

Humulin R U-500 Vial and KwikPen

2

Humulin R Vial 2Lantus SoloStar 2Lantus Vial 2Levemir FlexTouch 2Levemir Vial 2Novolin 70/30 Vial 2Novolin N Vial 2Novolin R Vial 2Novolog Flexpen 2Novolog Mix 70/30

Vial and Flexpen2

Novolog Penfill 2Novolog Vial 2Toujeo SoloStar 2Tresiba 3

Diabetes/Endocrine: Non-Insulin

Bydureon 2 QL, STByetta 2 QL, STFarxiga 3 STGlimepiride 1Glipizide 1Glipizide ER 1

15




Drug NameDrug Tier

Programs and Limits

Glipizide XL 1Glumetza 3 PAGlyburide 1Glyburide/Metformin 1Invokamet 2 STInvokamet XR 2 STInvokana 2 STJanumet 2 STJanumet XR 2 STJanuvia 2 STJardiance 2 STJentadueto 2 STJentadueto XR 2 STKombiglyze 3 STMetformin 1Metformin ER 1Onglyza 3 STPioglitazone 1Synjardy 2 STTradjenta 2 STTrulicity 2 QL, STVictoza 2 QL, ST

Endocrine: Growth Hormone

Norditropin 2 PA, SPNutropin AQ 2 PA, SPSaizen 2 PA, SP

Endocrine: Other

Calcitriol Cap 1Dexamethasone Tab 1H.P. Acthar 2 PA, SPHydrocortisone Tab 1Lupron Depot

3.75 mg, 11.25 mg3 PA, SP

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

2 PA, SP

Methylprednisolone Tab 1Prednisone 1Prednisolone Solution

25 mg/5 ml1

Prednisolone Syrup, Solution 15 mg/5 ml

1

Drug NameDrug Tier

Programs and Limits

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

Eye Conditions: Allergies

Azelastine Ophthalmic Solution

1

Bepreve 3 STLastacaft 3 STPataday 2Pazeo 2

Eye Conditions: Antibiotics

Besivance 3Ciprofloxacin

Ophthalmic Solution1

Erythromycin Ointment 1Gentamicin 1Moxeza 2 Neomycin/Polymyxin

B/Dexamethasone Ointment, Suspension

1

Ofloxacin Ophthalmic Solution

1

Polymyxin B/Trimethoprim Solution

1

Tobramycin 1Tobramycin/

Dexamethasone1

Vigamox 2

Eye Conditions: Glaucoma

Alphagan P 2Azopt 2Betimol 3

16




Drug NameDrug Tier

Programs and Limits

Brimonidine 1Combigan 2Cosopt PF 3Dorzolamide-Timolol

Maleate1

Latanoprost 1 QLLumigan 2 QLSimbrinza 2Timolol 1Timoptic Ocudose 2Travatan Z 2 QL

Eye Conditions: Other

Durezol Ophthalmic Emulsion

3

Lotemax Ophthalmic Gel

3 QL

Ketorolac Ophthalmic Solution

1

Prednisolone Ophthalmic Suspension

1

Restasis 3 PA

Gastrointestinal: Acid Suppression

Dexilant 2 QLEsomeprazole (Rx only) 1 QLFamotidine Tab 20 mg

and 40 mg (Rx only)1

Lansoprazole (Rx only) 1 QLOmeprazole (Rx only) 1 QLPantoprazole 1 QLRanitidine Tab, Cap,

Syrup (Rx only)1

Sucralfate Tab 1

Gastrointestinal: Nausea/Vomiting

Meclizine 1Metoclopramide 1Ondansetron Tab, ODT 1 QLTransderm-Scop 3Varubi 3 QL

Drug NameDrug Tier

Programs and Limits

Gastrointestinal: OtherAmitiza 2 QL, STApriso 2Canasa 2Creon 2Delzicol 3 STDipentum 3Gavilyte Solution 1Hyoscyamine Sublingual

Tab1

Lactulose 1Lialda 2Linzess 2 QL, STMoviprep 3Omeclamox Pak 2Pentasa 3Polyethylene

Glycol 3350 Powder1

Prepopik 3Protosol HC 1Pylera 2Sulfasalazine 1Suprep Bowel Prep 3Uceris Foam 3Zenpep 2HIV/AIDSAtripla 2 SP Complera 2 SPEpzicom 2 SPGenvoya 2 SPIntelence 2 SPIsentress 2 SPKaletra 2 SPNevirapine 1 SPNorvir 2 SPPrezcobix 2 SPPrezista 2 SPReyataz 2 SPStribild 2 SPSustiva 2 SPTivicay 2 SPTriumeq 2 SPTruvada 2 SPViread 2 SP

17




Drug NameDrug Tier

Programs and Limits

Infertility

Cetrotide 2 SPGonal-f 2 PA, SPGonal-f RFF 2 PA, SPOvidrel 3 SP

Inflammatory Conditions

Cimzia Kit 2 PA, SPDepen 2Humira Kit 2 PA, SPHumira Pen Kit 2 PA, SPHumira Pen Kit

Crohns2 PA, SP

Humira Pen Kit Psoriasis

2 PA, SP

Hydroxychloroquine 1Methotrexate Tab 1Orencia SC 3 PA, ST, SPOtezla 3 PA, ST, SPOtrexup 3 PA, QLRasuvo 2 PA, QLSimponi 2 PA, SPStelara 2 PA, SPXeljanz 3 PA, ST, SP

Men’s Health: Erectile Dysfunction

Cialis 2 QLLevitra 3 QLStendra 3 QLViagra 2 QL

Men’s Health: Prostate

Alfuzosin 1Cialis 2.5 mg & 5 mg 2 QLDoxazosin 1Finasteride 5 mg 1Rapaflo 2Tamsulosin 1Terazosin 1

Men’s Health: Testosterone Therapy

Androderm 2 PAAndrogel 1.62% 2 PAAndrogel 1% 3 PA, ST

Drug NameDrug Tier

Programs and Limits

Testosterone Cypionate IM Injection

1 PA

Miscellaneous

Allopurinol 1Antipyrine/Benzocaine

Otic Solution 5.4 - 1.4%

1

Aranesp 2 PA, SPAuryxia 3Benzonatate 1Botox 100, 200 unit

Injection (non-cosmetic)

2 PA, SP

Bunavail 3 PA, QLCerdelga 3 PA, SPChantix 3 QLCheratussin 1Chlorhexidine 1Colcrys 2Cyproheptadine 1Desmopressin 1EpiPen & EpiPen Jr 2Euflexxa 2 PA, SPFosrenol 3Granix 2 PA, SPGuaifenesin/Codeine

Syrup1

Homatropine/Hydrocodone Syrup

1

Hydrocodone/Chlorpheniramine Liquid

1

Hydrocortisone AC Suppository 25 mg

1

Hydromet 1Lidocaine Viscous

Solution 2%1

Makena 2 PA, SPNeupogen 2 PA, SPPhenazopyridine

(Rx only)1

Phentermine Tab 1 PA

18




Drug NameDrug Tier

Programs and Limits

Procrit 2 PA, SPPromethazine DM Syrup 1Promethazine/Codeine

Syrup1 AR

Pulmozyme 2 PA, SPRenvela Tab, Pack 2Rezira 3Suboxone Film 2 PA, QLSynagis 2 PA, SPSynvisc 2 PA, SPSynvisc One 2 PA, SPUloric 2 STUrsodiol 1Velphoro 3Zarxio 2 PA, SPZostavax Injection 3Zubsolv 2 PA, QLZutripro 3

Musculoskeletal: Osteoporosis

Alendronate Tab 35 mg & 70 mg

1 QL

Binosto 3 QLEvista 3Forteo 2 PA, SPIbandronate Tab 1Raloxifene 1

Musculoskeletal: Other

Baclofen Tab 1Carisoprodol 350 mg 1Cyclobenzaprine Tab

5, 10 mg1

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

Musculoskeletal: Pain Relief

Acetaminophen w/ Codeine

1

Celebrex 3Celecoxib 1

Drug NameDrug Tier

Programs and Limits

Diclofenac Tab 1Embeda 2 QLEndocet Tab 1Etodolac 1Fentanyl Patch

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

1 QL

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

1 QL

Gralise 3 QL, STHydrocodone/APAP

5, 7.5, 10/325 mg 1

Hydromorphone Tab 1Ibuprofen Tab 400, 600,

800 mg (Rx only)1

Indomethacin Cap 1Ketorolac Tab 1 QLLazanda 3 PA, QLLidocaine Patch 5% 1Meloxicam 1Methadone Tab 1Morphine Sulfate Tab 1 QLNabumetone 1Naproxen (Rx only) 1Opana ER 2 QLOxycodone Tab 5,

10, 15, 30 mg (Immediate Release)

1

Oxycodone w/ Acetaminophen

1

Oxycontin 2 QLTivorbex 3 STTramadol Tab 50 mg 1Tramadol

w/ Acetaminophen 1

Vicodin 1Vicodin ES 1Voltaren Gel 3 QL Zohydro ER 3 QL, STZorvolex 3

19




Drug NameDrug Tier

Programs and Limits

Overactive Bladder

Myrbetriq 3 STOxybutynin 1Oxybutynin ER 1Tolterodine 1Toviaz 3Vesicare 2

Respiratory: Asthma/COPD

Advair Diskus 2 QLAdvair HFA 2 QLAerospan 3 QLAlbuterol

Nebulizer Solution1 QL

Anoro Ellipta 2 QLArnuity Ellipta 2 QLBreo Ellipta 2 QLBudesonide Inhalation

Suspension1 QL

Combivent Respimat 2 QLDulera 3 QL, STFlovent Diskus 2 QLFlovent HFA 2 QLForadil 2 QLIncruse Ellipta 2 QLIpratropium/Albuterol

Nebulizer Solution1 QL

Levalbuterol Nebulizer Solution

1 QL

Montelukast 1Perforomist 3 QLProair HFA, RespiClick 2 QLProventil HFA 3 QL, STPulmicort Flexhaler 2 QLQvar 2 QLSeebri 3 QLSerevent Diskus 2 QLSpiriva Handihaler 2 QLSpiriva Respimat 2 QLStiolto 2 QLSymbicort 2 QLVentolin HFA 2 QL

Drug NameDrug Tier

Programs and Limits

Xolair 2 PA, SPXopenex HFA 3 QL, ST

Respiratory: Nasal Allergies

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

Respiratory: Oral Allergies

Cetirizine 1Promethazine Tab 1Desloratadine 1Levocetirizine 1

Transplant

Azathioprine Tab 1Cellcept Tab/

Suspension3 SP

Cyclosporine Cap 1 SPMycophenolate Mofetil

250 mg Cap/ 500 mg Tab

1 SP

Mycophenolate Sodium 180 mg, 360 mg Tab

1 SP

Prograf Cap 3 SPRapamune 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 1

20




Drug NameDrug Tier

Programs and Limits

Multi-Vit/Fl Chew 1Potassium Chloride ER

Tab, Cap1

Potassium Chloride Micro ER Tab

1

Potassium Citrate 540 mg, 1080 mg Tab

1

Vitamin D 50,000 units (Rx only)

1

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 QL

Microgestin 1Microgestin Fe 1Minastrin 24 Fe

Chewable3

Mono-Linyah 1Mononessa 1Natazia 2Necon 1Nora-Be 1Norgest/Ethi Estradio 1Nortrel 1Nuvaring 2

Drug NameDrug Tier

Programs and Limits

Ocella 1Orsythia 1Ortho Tri-Cyclen Lo 3Previfem 1Reclipsen 1Sprintec 28 1Tri-Linyah 1Tri-Previfem 1Trinessa 1Tri-Sprintec 1Vestura 1Viorele 1Xulane 1Zarah 1

Women’s Health: Hormone Replacement

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

Tab1

Medroxyprogesterone Acetate Tab

1

Minivelle 3Osphena 3Premarin Tab 2Premarin Vaginal

Cream2

Premphase 2Prempro 2Progesterone Cap 1Vagifem 3

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] 21

Index of Covered Drugs

A

Abilify Tab . . . . . . . . . 12Acanya Gel. . . . . . . . . 12Accu-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 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 18Acyclovir Cap, Tab, Suspension 9Acyclovir Ointment 5% . . . 12Aczone Gel. . . . . . . . . 12Adcirca . . . . . . . . . . . 11Adderall XR Cap . . . . . . 11Adempas. . . . . . . . . . 11Advair Diskus . . . . . . . 19Advair HFA . . . . . . . . 19Aerospan . . . . . . . . . 19Akynzeo . . . . . . . . . . . 9Albuterol Nebulizer Solution 19Alendronate Tab . . . . . . 18Alfuzosin . . . . . . . . . . 17Allopurinol . . . . . . . . . 17

Alphagan P . . . . . . . . 15Alprazolam Tab . . . . . . . 12Amiodarone. . . . . . . . . 11Amitiza. . . . . . . . . . . 16Amitriptyline . . . . . . . . 11Amlodipine . . . . . . . . . 10Amlodipine/Atorvastatin . . 11Amlodipine/Benazepril . . . 10Amlodipine/Valsartan . . . . 10Amlodipine/Valsartan/HCTZ . 10Amoxicillin . . . . . . . . . . 9Amoxicillin/Clavulanate . . . . 9Amphetamine-Dextroamph-

etamine SR 24Hr Cap . . 11Amphetamine-

Dextroamphetamine Tab 11Ampyra . . . . . . . . . . 12Anastrozole Tab . . . . . . . . 9Androderm . . . . . . . . 17Androgel 1% . . . . . . . 17Androgel 1.62% . . . . . . 17Anoro Ellipta . . . . . . . 19Antipyrine/Benzocaine Otic

Solution 5.4 - 1.4% . . . 17Apri . . . . . . . . . . . . . 20Apriso . . . . . . . . . . . 16Aranesp . . . . . . . . . . 17Aripiprazole . . . . . . . . . 12Armour Thyroid . . . . . . 15Arnuity Ellipta . . . . . . . 19Astepro . . . . . . . . . . 19Atenolol. . . . . . . . . . . 10Atenolol/Chlorthalidone. . . 10Atorvastatin . . . . . . . . 10Atralin . . . . . . . . . . . 12Atripla . . . . . . . . . . . 16Aubagio . . . . . . . . . . 12Auryxia . . . . . . . . . . 17Aviane . . . . . . . . . . . 20Avonex Kit. . . . . . . . . 12Avonex Pen Kit . . . . . . 12Avonex Prefill Kit . . . . . 12Azasite . . . . . . . . . . . . 9Azathioprine Tab . . . . . . 19Azelastine Ophthalmic

Solution . . . . . . . . . 15Azelastine Spray. . . . . . . 19Azithromycin . . . . . . . . . 9Azopt . . . . . . . . . . . 15Azor . . . . . . . . . . . . 10

Azurette . . . . . . . . . . 20

B

Baclofen Tab . . . . . . . . 18Bayer Contour Test Strips . 14Benazepril. . . . . . . . . . 10Benazepril/HCTZ . . . . . . 10Benicar . . . . . . . . . . . 10Benicar HCT . . . . . . . . 10Benzaclin. . . . . . . . . . 12Benzonatate . . . . . . . . 17Benztropine . . . . . . . . . 12Bepreve . . . . . . . . . . 15Besivance . . . . . . . . . 15Betamethasone Dipropionate

Cream. . . . . . . . . . 12Betaseron . . . . . . . . . 12Bethkis . . . . . . . . . . . . 9Betimol. . . . . . . . . . . 15Binosto. . . . . . . . . . . 18Bisoprolol . . . . . . . . . . 10Bisoprolol/HCTZ . . . . . . . 10Botox 100, 200 unit

Injection . . . . . . . . 17Breo Ellipta . . . . . . . . 19Brilinta . . . . . . . . . . . . 9Brimonidine . . . . . . . . . 16Budesonide Inhalation

Suspension . . . . . . . 19Bumetanide . . . . . . . . . 10Bunavail . . . . . . . . . . 17Bupropion. . . . . . . . . . 11Bupropion ER . . . . . . . . 11Bupropion SR . . . . . . . . 11Bupropion XL . . . . . . . . 11Buspirone . . . . . . . . . . 12Butalbital-Acetaminophen-

Caffeine Cap, Tab . . . . 11Bydureon . . . . . . . . . 14Byetta . . . . . . . . . . . 14Bystolic. . . . . . . . . . . 10

C

Calcitriol Cap . . . . . . . . 15Canasa . . . . . . . . . . . 16Capecitabine . . . . . . . . . 9Carbamazepine Tab . . . . . 12



Carbidopa/Levodopa Tab . . 12Carisoprodol . . . . . . . . 18Cartia XT . . . . . . . . . . 10Carvedilol . . . . . . . . . . 10Cefadroxil Cap . . . . . . . . 9Cefdinir . . . . . . . . . . . . 9Cefuroxime Tab . . . . . . . . 9Celebrex . . . . . . . . . . 18Celecoxib . . . . . . . . . . 18Cellcept Tab/Suspension . 19Cephalexin . . . . . . . . . . 9Cerdelga . . . . . . . . . . 17Cetirizine . . . . . . . . . . 19Cetrotide. . . . . . . . . . 17Chantix. . . . . . . . . . . 17Cheratussin . . . . . . . . . 17Chlorhexidine . . . . . . . . 17Chlorthalidone . . . . . . . 10Cholestyramine . . . . . . . 10Cialis . . . . . . . . . . . . 17Ciclopirox Cream . . . . . . 12Cimzia Kit . . . . . . . . . 17Ciprodex Otic Suspension . 9Ciprofloxacin Ophthalmic

Solution . . . . . . . . . 15Ciprofloxacin Tab . . . . . . . 9Clarithromycin . . . . . . . . 9Climara Pro . . . . . . . . 20Clindamycin/Benzoyl Peroxide

Gel 1.2-5% . . . . . . . 13Clindamycin/Benzoyl Peroxide

Gel 1-5% . . . . . . . . 13Clindamycin Cap . . . . . . . 9Clindamycin Gel, Lotion,

Solution . . . . . . . . . 12Clobetasol Cream, Ointment,

Solution . . . . . . . . . 13Clobex . . . . . . . . . . . 13Clonazepam . . . . . . . . 12Clonidine Patch . . . . . . . 10Clonidine Tab . . . . . . . . 10Clopidogrel . . . . . . . . . . 9Clotrimazole/Betamethasone

Cream, Lotion . . . . . . 13Colcrys . . . . . . . . . . . 17Combigan . . . . . . . . . 16Combivent Respimat . . . 19Complera . . . . . . . . . 16Copaxone . . . . . . . . . 12Corlanor . . . . . . . . . . 11

Cortifoam . . . . . . . . . 13Cosopt PF . . . . . . . . . 16Creon. . . . . . . . . . . . 16Crestor . . . . . . . . . . . 10Cryselle-28 . . . . . . . . . 20Cyanocobalamine Injection . 19Cyclobenzaprine Tab . . . . 18Cyclosporine Cap . . . . . . 19Cyproheptadine . . . . . . . 17

D

Daklinza . . . . . . . . . . . 9Delzicol . . . . . . . . . . 16Depen . . . . . . . . . . . 17Desloratadine . . . . . . . . 19Desmopressin . . . . . . . . 17Desonide Cream, Ointment . 13Desoximetasone Cream, Gel,

Ointment . . . . . . . . 13Dexamethasone Tab . . . . 15Dexcom G4 Platinum Kit . 14Dexcom G4 Platinum

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

Transmitter Kit. . . . . 14Dexilant . . . . . . . . . . 16Dexmethylphenidate ER Cap 11Diazepam Tab . . . . . . . . 12Diclofenac Tab . . . . . . . 18Differin. . . . . . . . . . . 13Digoxin . . . . . . . . . . . 11Diltiazem Tab . . . . . . . . 10Dipentum . . . . . . . . . 16Divalproex DR . . . . . . . . 12Divalproex ER . . . . . . . . 12Divigel . . . . . . . . . . . 20Donepezil Tab . . . . . . . . 12Doryx MPC. . . . . . . . . . 9Dorzolamide-Timolol Maleate 16Doxazosin . . . . . . . . 10, 17Doxepin . . . . . . . . . . . 11Doxycycline Hyclate Cap . . . 9Doxycycline Hyclate Tab . . . . 9Doxycycline Monohydrate Cap 9Doxycycline Monohydrate Oral

Suspension, Tab . . . . . . 9Duavee. . . . . . . . . . . 20Dulera . . . . . . . . . . . 19Duloxetine Cap . . . . . . . 11

Durezol Ophthalmic Emulsion . . . . . . . . 16

Dymista Spray . . . . . . . 19

E

Econazole Cream . . . . . . 13Edarbi . . . . . . . . . . . 10Edarbyclor . . . . . . . . . 10Effient . . . . . . . . . . . . 9Elestrin Gel . . . . . . . . 20Elidel . . . . . . . . . . . . 13Eliquis . . . . . . . . . . . . 9Embeda . . . . . . . . . . 18Enalapril. . . . . . . . . . . 10Enalapril/HCTZ . . . . . . . 10Endocet Tab. . . . . . . . . 18Enoxaparin . . . . . . . . . . 9Entecavir . . . . . . . . . . . 9Epclusa. . . . . . . . . . . . 9Epiduo & Epiduo Forte . . 13EpiPen & EpiPen Jr . . . . 17Epzicom . . . . . . . . . . 16Erythromycin . . . . . . . . . 9Erythromycin Ointment . . . 15Escitalopram Tab . . . . . . 11Esomeprazole . . . . . . . . 16Estrace Vaginal Cream . . 20Estradiol/Norethindrone Tab . 20Estradiol Tab . . . . . . . . 20Eszopiclone Tab . . . . . . . 12Etodolac . . . . . . . . . . 18Euflexxa . . . . . . . . . . 17Evekeo . . . . . . . . . . . 11Evista. . . . . . . . . . . . 18

F

Falmina . . . . . . . . . . . 20Famciclovir Tab . . . . . . . . 9Famotidine Tab . . . . . . . 16Farxiga . . . . . . . . . . . 14Felodipine . . . . . . . . . . 10Fenofibrate . . . . . . . . . 10Fentanyl Patch . . . . . . . 18Finacea. . . . . . . . . . . 13Finasteride . . . . . . . . . 17Flecainide . . . . . . . . . . 11Flovent Diskus. . . . . . . 19Flovent HFA . . . . . . . . 19



Fluconazole . . . . . . . . . . 9Fluocinonide Cream, 0.1% 13Fluocinonide Cream, Gel,

Ointment, Solution 0.05% 13Fluoxetine Cap . . . . . . . 11Fluticasone Spray . . . . . . 19Fluvoxamine Tab . . . . . . 11Folic Acid 1 mg . . . . . . . 19Foradil . . . . . . . . . . . 19Forfivo XL . . . . . . . . . 11Forteo . . . . . . . . . . . 18Fosinopril . . . . . . . . . . 10Fosrenol . . . . . . . . . . 17Freestyle Test Strips . . . . 14Furosemide . . . . . . . . . 10

G

Gabapentin . . . . . . . . . 12Gavilyte Solution . . . . . . 16Gemfibrozil . . . . . . . . . 10Generess Fe Chewable . . 20Gentamicin . . . . . . . . . 15Genvoya . . . . . . . . . . 16Gianvi . . . . . . . . . . . . 20Gildess . . . . . . . . . . . 20Gilenya. . . . . . . . . . . 12Glimepiride . . . . . . . . . 14Glipizide . . . . . . . . . . 14Glipizide ER . . . . . . . . . 14Glipizide XL . . . . . . . . . 15Glumetza . . . . . . . . . 15Glyburide . . . . . . . . . . 15Glyburide/Metformin . . . . 15Gonal-f . . . . . . . . . . . 17Gonal-f RFF . . . . . . . . 17Gralise . . . . . . . . . . . 18Granix . . . . . . . . . . . 17Guaifenesin/Codeine Syrup . 17Guanfacine ER Tab . . . . . 11Guanfacine Tab . . . . . . . 10Gynazole-1 Vaginal Cream 20

H

Harvoni . . . . . . . . . . . 9Homatropine/Hydrocodone

Syrup . . . . . . . . . . 17H.P. Acthar . . . . . . . . . 15

Humalog Mix 50/50 Vial and KwikPen. . . . . . 14

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

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

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

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

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

KwikPen . . . . . . . . 14Humulin R Vial. . . . . . . 14Hydralazine . . . . . . . . . 10Hydrochlorothiazide. . . . . 10Hydrocodone/APAP . . . . . 18Hydrocodone/Chlorpheniramine

Liquid . . . . . . . . . . 17Hydrocortisone AC

Suppository . . . . . . . 17Hydrocortisone Cream,

Ointment 2.5% . . . . . 13Hydrocortisone Tab . . . . . 15Hydromet . . . . . . . . . . 17Hydromorphone Tab . . . . 18Hydroxychloroquine . . . . . 17Hydroxyzine HCL . . . . . . 12Hydroxyzine Pamoate . . . . 12Hyoscyamine Sublingual Tab 16

I

Ibandronate Tab. . . . . . . 18Ibuprofen Tab . . . . . . . . 18Incruse Ellipta . . . . . . . 19Indomethacin Cap . . . . . 18Insulin Pen Needle . . . . 14Insulin Syringe/Needle . . 14Intelence . . . . . . . . . 16Invokamet . . . . . . . . . 15Invokamet XR . . . . . . . 15Invokana. . . . . . . . . . 15Ipratropium/Albuterol Nebulizer

Solution . . . . . . . . . 19Ipratropium Spray . . . . . . 19

Irbesartan . . . . . . . . . . 10Irbesartan/HCTZ. . . . . . . 10Isentress . . . . . . . . . . 16Isosorbide Mononitrate . . . 11

J

Janumet . . . . . . . . . . 15Janumet XR . . . . . . . . 15Januvia. . . . . . . . . . . 15Jardiance. . . . . . . . . . 15Jentadueto. . . . . . . . . 15Jentadueto XR. . . . . . . 15Jolivette . . . . . . . . . . . 20Jublia Solution. . . . . . . . 9Junel . . . . . . . . . . . . 20

K

Kaletra . . . . . . . . . . . 16Kariva . . . . . . . . . . . . 20Kerydin Solution . . . . . . 9Ketoconazole Cream/

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

Solution . . . . . . . . . 16Ketorolac Tab . . . . . . . . 18Klor-Con 8 and 10 MEQ. . . 19Klor-Con M10 and M20. . . 19Kombiglyze . . . . . . . . 15

L

Labetalol . . . . . . . . . . 10Lactulose . . . . . . . . . . 16Lamotrigine ER . . . . . . . 12Lamotrigine . . . . . . . . . 12Lansoprazole . . . . . . . . 16Lantus SoloStar . . . . . . 14Lantus Vial . . . . . . . . . 14Lastacaft . . . . . . . . . . 15Latanoprost . . . . . . . . . 16Latuda . . . . . . . . . . . 12Lazanda . . . . . . . . . . 18Letairis . . . . . . . . . . . 11Letrozole . . . . . . . . . . . 9Levalbuterol

Nebulizer Solution. . . . 19Levemir FlexTouch. . . . . 14Levemir Vial . . . . . . . . 14



Levetiracetam . . . . . . . . 12Levetiracetam ER . . . . . . 12Levitra . . . . . . . . . . . 17Levocetirizine . . . . . . . . 19Levofloxacin Tab. . . . . . . . 9Levora 28 . . . . . . . . . . 20Levothyroxine . . . . . . . . 15Lialda. . . . . . . . . . . . 16Lidocaine Patch 5% . . . . . 18Lidocaine/Prilocaine Cream . 13Lidocaine Topical Ointment,

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

2% . . . . . . . . . . . 17Linzess . . . . . . . . . . . 16Liothyronine . . . . . . . . 15Lipitor . . . . . . . . . . . 10Lisinopril . . . . . . . . . . 10Lisinopril/HCTZ . . . . . . . 10Lithium Carbonate . . . . . 12Livalo. . . . . . . . . . . . 10Lo Loestrin . . . . . . . . . 20Lomedia Fe . . . . . . . . . 20Lorazepam Tab . . . . . . . 12Loryna . . . . . . . . . . . 20Lorzone . . . . . . . . . . 18Losartan. . . . . . . . . . . 10Losartan/HCTZ . . . . . . . 10Lotemax Ophthalmic Gel . 16Lovastatin . . . . . . . . . 10Lovaza . . . . . . . . . . . 10Low-Ogestrel . . . . . . . . 20Lumigan . . . . . . . . . . 16Lupron Depot . . . . . . . 15Lutera . . . . . . . . . . . . 20Lyrica Cap . . . . . . . . . 12

M

Makena . . . . . . . . . . 17Meclizine . . . . . . . . . . 16Medroxyprogesterone Acetate

Injection. . . . . . . . . 20Medroxyprogesterone Acetate

Tab . . . . . . . . . . . 20Meloxicam . . . . . . . . . 18Metaxalone . . . . . . . . . 18Metformin . . . . . . . . . 15Metformin ER . . . . . . . . 15Methadone Tab . . . . . . . 18

Methimazole . . . . . . . . 15Methocarbamol . . . . . . . 18Methotrexate Tab . . . . . . 17Methylphenidate ER Cap . . 11Methylphenidate ER Tab. . . 11Methylphenidate SA

Osmotic ER Tab . . . . . 11Methylphenidate Tab . . . . 11Methylprednisolone Tab . . . 15Metoclopramide . . . . . . 16Metoprolol Succinate . . . . 10Metoprolol Tartrate . . . . . 10Metrogel . . . . . . . . . . 13Metronidazole Gel 0.75%. . 13Metronidazole Tab . . . . . . 9Metronidazole Vaginal Gel . 20Microgestin . . . . . . . . . 20Microgestin Fe . . . . . . . 20Migranal . . . . . . . . . . 11Minastrin 24 Fe Chewable 20Minivelle . . . . . . . . . . 20Minocycline Cap . . . . . . . 9Mirtazapine . . . . . . . . . 11Mirvaso Gel . . . . . . . . 13Modafinil . . . . . . . . . . 12Mometasone . . . . . . . . 19Mono-Linyah . . . . . . . . 20Mononessa . . . . . . . . . 20Montelukast . . . . . . . . 19Morphine Sulfate Tab . . . . 18Moviprep . . . . . . . . . 16Moxeza . . . . . . . . . . 15Moxifloxacin . . . . . . . . . 9Multi-Vit/Fl Chew . . . . . . 20Mupirocin Ointment . . . . 13Mycophenolate Mofetil . . . 19Mycophenolate Sodium . . . 19Myrbetriq . . . . . . . . . 19

N

Nabumetone . . . . . . . . 18Nadolol . . . . . . . . . . . 10Namenda XR. . . . . . . . 12Namzaric . . . . . . . . . . 12Naproxen . . . . . . . . . . 18Nasonex . . . . . . . . . . 19Natazia. . . . . . . . . . . 20Necon. . . . . . . . . . . . 20

Neomycin/Polymyxin B/Dexamethasone Ointment, Suspension . . . . . . . 15

Neomycin/Polymyxin/HC Otic Suspension, Solution . . . 9

Neupogen . . . . . . . . . 17Nevirapine . . . . . . . . . 16Niacin ER Tab . . . . . . . . 10Nifedipine ER . . . . . . . . 10Nitrofurantoin Macrocrystalline 9Nitrofurantoin Monohydrate

Macrocrystalline . . . . . . 9Nitrostat . . . . . . . . . . 11Nora-Be . . . . . . . . . . . 20Norditropin . . . . . . . . 15Norgest/Ethi Estradio . . . . 20Nortrel . . . . . . . . . . . 20Nortriptyline. . . . . . . . . 11Norvir . . . . . . . . . . . 16Novofine Autocover Pen

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

Flexpen. . . . . . . . . 14Novolog Penfill . . . . . . 14Novolog Vial. . . . . . . . 14Novotwist Pen Needle . . 14Nutropin AQ. . . . . . . . 15Nuvaring. . . . . . . . . . 20Nuvigil . . . . . . . . . . . 12Nystatin Cream, Ointment,

Powder . . . . . . . . . 13Nystatin Suspension. . . . . . 9Nystatin/Triamcinolone Cream,

Ointment . . . . . . . . 13

O

Ocella . . . . . . . . . . . . 20Ofloxacin Ophthalmic Solution 15Ofloxacin Otic Solution . . . . 9Olanzapine Tab . . . . . . . 12Omeclamox Pak . . . . . . 16Omega-3 Acid Cap . . . . . 10Omeprazole . . . . . . . . . 16Omnaris . . . . . . . . . . 19



Ondansetron Tab, ODT . . . 16Onetouch Kit Ultra . . . . 14Onetouch Kit Ultra 2 . . . 14Onetouch Kit Ultra Mini . 14Onetouch Kit Ultra Smart. 14Onetouch Kit Verio IQ. . . 14Onetouch Test Strips . . . 14Onetouch Ultra Blue Test

Strips . . . . . . . . . . 14Onetouch Verio Test Strips 14Onexton . . . . . . . . . . 13Onfi . . . . . . . . . . . . 12Onglyza . . . . . . . . . . 15Opana ER . . . . . . . . . 18Opsumit . . . . . . . . . . 11Oracea . . . . . . . . . . . . 9Orencia SC . . . . . . . . . 17Orenitram . . . . . . . . . 11Orsythia . . . . . . . . . . . 20Ortho Tri-Cyclen Lo . . . . 20Osphena . . . . . . . . . . 20Otezla . . . . . . . . . . . 17Otrexup . . . . . . . . . . 17Ovidrel . . . . . . . . . . . 17Oxcarbazepine . . . . . . . 12Oxsoralen-UL . . . . . . . 13Oxybutynin . . . . . . . . . 19Oxybutynin ER . . . . . . . 19Oxycodone Tab . . . . . . . 18Oxycodone

w/ Acetaminophen . . . 18Oxycontin . . . . . . . . . 18

P

Pantoprazole . . . . . . . . 16Paroxetine Tab . . . . . . . 11Pataday . . . . . . . . . . 15Pazeo. . . . . . . . . . . . 15Penicillin VK. . . . . . . . . . 9Pentasa . . . . . . . . . . 16Perforomist . . . . . . . . 19Permethrin Cream 5% . . . 13Phenazopyridine . . . . . . 17Phentermine Tab . . . . . . 17Phenytoin . . . . . . . . . . 12Pioglitazone. . . . . . . . . 15Polyethylene Glycol

3350 Powder . . . . . . 16

Polymyxin B/Trimethoprim Solution . . . . . . . . . 15

Potassium Chloride ER Tab, Cap. . . . . . . . . 20

Potassium Chloride Micro ER Tab. . . . . . . . . . 20

Potassium Citrate . . . . . . 20Pradaxa . . . . . . . . . . . 9Praluent . . . . . . . . . . 10Pravastatin . . . . . . . . . 10Precision Test Strips . . . . 14Prednisolone Ophthalmic

Suspension . . . . . . . 16Prednisolone Solution . . . . 15Prednisolone Syrup, Solution 15Prednisone . . . . . . . . . 15Premarin Tab. . . . . . . . 20Premarin Vaginal Cream . 20Premphase . . . . . . . . . 20Prempro . . . . . . . . . . 20Prepopik . . . . . . . . . . 16Previfem . . . . . . . . . . 20Prezcobix . . . . . . . . . 16Prezista . . . . . . . . . . 16Primidone . . . . . . . . . . 12Pristiq . . . . . . . . . . . 11Proair HFA, RespiClick. . . 19Prochlorperazine . . . . . . 12Procrit . . . . . . . . . . . 18Proctofoam HC . . . . . . 13Progesterone Cap . . . . . . 20Prograf Cap . . . . . . . . 19Promethazine/Codeine Syrup 18Promethazine DM Syrup . . 18Promethazine Tab . . . . . . 19Propranolol . . . . . . . . . 10Propranolol ER . . . . . . . 10Protosol HC . . . . . . . . . 16Proventil HFA . . . . . . . 19Pulmicort Flexhaler . . . . 19Pulmozyme . . . . . . . . 18Pylera . . . . . . . . . . . 16

Q

QNasl. . . . . . . . . . . . 19Quetiapine . . . . . . . . . 12Quinapril . . . . . . . . . . 10Qvar . . . . . . . . . . . . 19

R

Raloxifene. . . . . . . . . . 18Ramipril . . . . . . . . . . . 10Ranexa . . . . . . . . . . . 11Ranitidine Tab, Cap, Syrup . 16Rapaflo. . . . . . . . . . . 17Rapamune . . . . . . . . . 19Rasuvo . . . . . . . . . . . 17Rebif . . . . . . . . . . . . 12Rebif Titrtn . . . . . . . . 12Reclipsen . . . . . . . . . . 20Relpax . . . . . . . . . . . 11Renvela Tab, Pack . . . . . 18Restasis . . . . . . . . . . 16Retin-A Micro . . . . . . . 13Revlimid . . . . . . . . . . . 9Rexulti . . . . . . . . . . . 12Reyataz . . . . . . . . . . 16Rezira . . . . . . . . . . . 18Risperidone Tab . . . . . 11, 12Rizatriptan Tab, ODT . . . . 11Ropinirole . . . . . . . . . . 12Rosuvastatin . . . . . . . . 10

S

Saizen . . . . . . . . . . . 15Saphris . . . . . . . . . . . 12Savaysa . . . . . . . . . . . 9Seebri . . . . . . . . . . . 19Sensipar . . . . . . . . . . 15Serevent Diskus . . . . . . 19Seroquel XR . . . . . . . . 12Sertraline . . . . . . . . . . 11Sildenafil Tab . . . . . . . . 11Silenor . . . . . . . . . . . 12Simbrinza . . . . . . . . . 16Simponi . . . . . . . . . . 17Simvastatin . . . . . . . . . 10Solodyn . . . . . . . . . . . 9Soolantra . . . . . . . . . 13Sotalol . . . . . . . . . . . 11Sovaldi . . . . . . . . . . . . 9Spiriva Handihaler . . . . 19Spiriva Respimat . . . . . 19Spironolactone . . . . . . . 10Sprintec 28 . . . . . . . . . 20Sprycel . . . . . . . . . . . . 9Stelara . . . . . . . . . . . 17



Stendra . . . . . . . . . . 17Stiolto . . . . . . . . . . . 19Strattera . . . . . . . . . . 11Stribild . . . . . . . . . . . 16Suboxone Film. . . . . . . 18Sucralfate Tab . . . . . . . . 16Sulfacetamide/Sulfur Emulsion 13Sulfamethoxazole-Trimethoprim 9Sulfamethoxazole-

Trimethoprim DS . . . . . 9Sulfasalazine . . . . . . . . 16Sumatriptan Tab and Spray . 11Sumavel Dose . . . . . . . 11Suprep Bowel Prep . . . . 16Sustiva . . . . . . . . . . . 16Symbicort . . . . . . . . . 19Synagis. . . . . . . . . . . 18Synjardy . . . . . . . . . . 15Synthroid . . . . . . . . . 15Synvisc . . . . . . . . . . . 18Synvisc One . . . . . . . . 18

T

Taclonex . . . . . . . . . . 13Tacrolimus Cap . . . . . . . 19Tamiflu . . . . . . . . . . . . 9Tamoxifen Tab. . . . . . . . . 9Tamsulosin . . . . . . . . . 17Tasigna. . . . . . . . . . . . 9Tazorac. . . . . . . . . . . 13Tecfidera . . . . . . . . . . 12Tekturna . . . . . . . . . . 10Tekturna HCT . . . . . . . 10Telmisartan . . . . . . . . . 10Temazepam . . . . . . . . . 12Temozolomide . . . . . . . . 9Terazosin . . . . . . . . 10, 17Terbinafine Tab . . . . . . . . 9Terconazole Vaginal Cream . 20Testosterone Cypionate IM

Injection. . . . . . . . . 17Timolol . . . . . . . . . . . 16Timoptic Ocudose . . . . . 16Tirosint. . . . . . . . . . . 15Tivicay . . . . . . . . . . . 16Tivorbex . . . . . . . . . . 18Tizanidine . . . . . . . . . . 18Tobramycin . . . . . . . . . 15Tobramycin/Dexamethasone. 15

Tolterodine . . . . . . . . . 19Topiramate Tab . . . . . . . 12Torsemide Tab. . . . . . . . 10Toujeo SoloStar . . . . . . 14Toviaz . . . . . . . . . . . 19Tracleer . . . . . . . . . . 11Tradjenta. . . . . . . . . . 15Tramadol Tab . . . . . . . . 18Tramadol w/ Acetaminophen 18Transderm-Scop . . . . . . 16Travatan Z . . . . . . . . . 16Trazodone. . . . . . . . . . 11Tresiba . . . . . . . . . . . 14Tretinoin Cream . . . . . . . 13Tretinoin Microsphere Gel . . 13Triamcinolone . . . . . . . . 13Triamcinolone Spray. . . . . 19Triamterene/HCTZ . . . . . . 10Triazolam Tab . . . . . . . . 12Tribenzor. . . . . . . . . . 10Tri-Linyah . . . . . . . . . . 20Trinessa . . . . . . . . . . . 20Tri-Previfem . . . . . . . . . 20Tri-Sprintec . . . . . . . . . 20Triumeq . . . . . . . . . . 16Trulicity . . . . . . . . . . 15Truvada . . . . . . . . . . 16

U

Uceris Foam . . . . . . . . 16Uloric. . . . . . . . . . . . 18Ursodiol . . . . . . . . . . . 18

V

Vagifem . . . . . . . . . . 20Valacyclovir . . . . . . . . . . 9Valsartan . . . . . . . . . . 10Valsartan/HCTZ . . . . . . . 10Varubi . . . . . . . . . . . 16Vascepa . . . . . . . . . . 11Vectical. . . . . . . . . . . 13Velphoro . . . . . . . . . . 18Venlafaxine ER Cap . . . . . 11Venlafaxine ER Tab . . . . . 11Venlafaxine Tab . . . . . . . 11Ventolin HFA . . . . . . . 19Verapamil ER . . . . . . . . 10Vesicare . . . . . . . . . . 19

Vestura . . . . . . . . . . . 20Viagra . . . . . . . . . . . 17Vicodin . . . . . . . . . . . 18Vicodin ES. . . . . . . . . . 18Victoza . . . . . . . . . . . 15Vigamox . . . . . . . . . . 15Viibryd . . . . . . . . . . . 11Vimpat . . . . . . . . . . . 12Viorele . . . . . . . . . . . 20Viread . . . . . . . . . . . 16Vitamin D . . . . . . . . . . 20Voltaren Gel . . . . . . . . 18Vytorin . . . . . . . . . . . 11Vyvanse . . . . . . . . . . 11

W

Warfarin . . . . . . . . . . . 9Welchol . . . . . . . . . . 11

X

Xarelto . . . . . . . . . . . . 9Xeljanz . . . . . . . . . . . 17Xolair. . . . . . . . . . . . 19Xopenex HFA . . . . . . . 19Xulane . . . . . . . . . . . 20

Z

Zarah . . . . . . . . . . . . 20Zarxio . . . . . . . . . . . 18Zenpep . . . . . . . . . . 16Zepatier . . . . . . . . . . . 9Zetia . . . . . . . . . . . . 11Zetonna . . . . . . . . . . 19Ziprasidone Cap. . . . . . . 12Zohydro ER . . . . . . . . 18Zolmitriptan Tab. . . . . . . 11Zolpidem . . . . . . . . . . 12Zolpidem ER. . . . . . . . . 12Zonisamide . . . . . . . . . 12Zorvolex . . . . . . . . . . 18Zostavax Injection. . . . . 18Zovirax Cream . . . . . . . 13Zovirax Ointment . . . . . 13Zubsolv . . . . . . . . . . 18Zutripro . . . . . . . . . . 18Zyclara . . . . . . . . . . . 13Zytiga . . . . . . . . . . . . 9

27

“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

OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an Optum® company — a leading provider of integrated health services. Learn more at optum.com.

All Optum® trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners.

©2016 OptumRx, Inc. ORX6700C_170101 42521D-092016 Select Standard

your 2017 formulary - university of...

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