2017

Your Prescription
Drug List/Formulary

Effective July 1, 2017

Please read: For a complete list of covered drugs

This document contains or if you have questions:
information about the drugs • Call a customer care representative
covered under your pharmacy toll-free at (855) 828-9834 (TTY 711).
benefit plan.
• Visit www.HealthSelectRx.com
— Locate an OptumRx
in-network pharmacy
— Look up possible lower-cost
medication alternatives.
— Compare medication pricing
and options.

HealthSelect
SM
of Texas

1
Your Prescription Drug List / Formulary
This formulary outlines the most commonly prescribed medications covered under your plan’s
prescription drug benefits. The formulary is also known as the Prescription Drug List (PDL). A
formulary identifies the drugs available for certain conditions and organizes them into cost levels,
also known as tiers. An important part of the formulary is giving you choices so you and your
doctor can choose the best course of treatment for you.

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

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

2
Table of Contents
Drug tiers and cost . . . . . . . . . . . . . . . . . . . 5 Gastrointestinal
Acid Suppression . . . . . . . . . . . . . . . . . . . . 16
Programs and limits . . . . . . . . . . . . . . . . . . 6 Nausea/Vomiting . . . . . . . . . . . . . . . . . . . . . 16
Drugs by category . . . . . . . . . . . . . . . . . . . 9 Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Anti-Infectives HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Inflammatory Conditions . . . . . . . . . . . . . 17

Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Men’s Health

Erectile Dysfunction . . . . . . . . . . . . . . . . . . . 17
Cardiovascular/Heart Disease Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Anticoagulants . . . . . . . . . . . . . . . . . . . . . . . 10 Testosterone Therapy . . . . . . . . . . . . . . . . . 18
High Blood Pressure . . . . . . . . . . . . . . . . . . 10
High Cholesterol . . . . . . . . . . . . . . . . . . . . . 10 Miscellaneous . . . . . . . . . . . . . . . . . . . . . . 18
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Musculoskeletal
Pulmonary Arterial Hypertension . . . . . . . . . 11
Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . 19
Central Nervous System Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Attention Deficit Disorder . . . . . . . . . . . . . . 11 Pain Relief . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Depression . . . . . . . . . . . . . . . . . . . . . . . . . 11
Overactive Bladder . . . . . . . . . . . . . . . . . . 20
Migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . 12 Respiratory
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Asthma/COPD . . . . . . . . . . . . . . . . . . . . . . . 20
Sedatives/Hypnotics . . . . . . . . . . . . . . . . . . 12 Nasal Allergies . . . . . . . . . . . . . . . . . . . . . . . 20
Seizure Disorders . . . . . . . . . . . . . . . . . . . . 12 Oral Allergies . . . . . . . . . . . . . . . . . . . . . . . . 20
Dermatology . . . . . . . . . . . . . . . . . . . . . . . 13 Transplant . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Diabetes/Endocrine Vitamins/Electrolytes . . . . . . . . . . . . . . . . 21
Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Non-Insulin . . . . . . . . . . . . . . . . . . . . . . . . . 14 Women’s Health
Birth Control . . . . . . . . . . . . . . . . . . . . . . . . 21
Endocrine Hormone Replacement . . . . . . . . . . . . . . . . 22
Growth Hormone . . . . . . . . . . . . . . . . . . . . . 14 Vaginal Anti-Infectives . . . . . . . . . . . . . . . . . 22
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Thyroid Hormone Replacement . . . . . . . . . 15 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Eye Conditions
Allergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
3
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 covered by your prescription drug
program for their safety, cost and effectiveness. Drugs are listed by common categories or class.
They are placed into cost levels known as tiers. It includes both brand and generic prescription
medications approved by the U.S. Food and Drug Administration (FDA).
Please note: Where differences are noted between this formulary and your benefit plan documents,
the benefit plan documents will rule. This document is not intended to be a complete list of
medications, and not all medications listed may be covered under your plan. Please look at the
Master Benefit Plan Document (MBPD) provided by your plan to see what medications are covered
under your plan. You may also visit www.HealthSelectRx.com and click on Prescription Drug List
or call a customer care representative toll free at (855) 828-9834 (TTY 711).

How do I use my formulary?

When choosing a medication, you and your doctor should consult the formulary. It will help
you and your doctor choose the most cost-effective prescription drugs. This guide tells you if
a medication is generic or brand, and if special rules apply. Bring this list with you when you
see your doctor. It is organized by common medical conditions. Medications are also listed
alphabetically by name at the end of the formulary.
If your medication is not listed on this document, it may not be covered by the HealthSelect
Prescription Drug Program or Consumer Directed HealthSelect Prescription Drug Program.
Please visit www.HealthSelectRx.com and click on Prescription Drug Tool for the most up to
date list of medications covered under your plan. If you have any questions, call a customer care
representative toll-free at (855) 828-9834 (TTY 711).

4
What are tiers?
Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, which is
determined by your plan. This is how much you will pay when you fill a prescription. The HealthSelect
of Texas Prescription Drug Program has different copays assigned depending on which tier a drug
is. The Consumer Directed HealthSelect Prescription Drug Program has coinsurance assigned for
each drug tier that applies once the annual combined medical and pharmacy deductible is met. Tier
1 medications are your lowest-cost options. If your medication is placed in Tier 2 or 3, look to see if
there is a Tier 1 option available. Discuss these options with your doctor.
Drug names shown in green are preferred for their cost and effectiveness. If there is a  symbol
in the Drug Tier column, check your benefit plan documents to find out your specific pharmacy
plan costs.

$ Drug Tier Includes Helpful Tips

$ Tier 1 Lower-cost, commonly Use Tier 1 drugs for the

Lowest Cost used generic drugs. Some lowest out-of-pocket costs.
low-cost brands may
be included.

$$ Tier 2 Many common brand-name Use Tier 2 drugs, instead of

Mid-range Cost drugs, called Tier 3, to help reduce your
preferred brands. out-of-pocket costs.

$$$ Tier 3 Mostly higher-cost brand Many Tier 3 drugs have

Highest Cost drugs, also known as lower-cost options in Tier 1
non-preferred brands. or 2. Ask your doctor if they
could work for you.

When does the formulary change?

• Medications may move to a lower tier at any time.
• Medications may move to a higher tier when its generic becomes available.
• Medications may move to a higher tier or be excluded from coverage on
January 1 or July 1 of each year.
When a medication changes tiers, you may have to pay a different amount for that medication.
For the most up-to-date list, call a customer care representative, 24 hours a day, seven days
a week toll-free at (855) 828-9834 (TTY 711).

5
Programs and Limits
Some medications are noted with letters or symbols next to them. The letters and symbols refer to
our pharmacy benefit programs and are provided to help you check which medications may have
a program or limit. Your benefit plan determines how these medications may be covered for you.
Programs and Limits

Prior Authorization — Your doctor is required to provide additional information before

PA
the drug will be covered by your prescription drug plan.

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

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

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

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

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

6
Why are some medications excluded from coverage?
Medications may be excluded from coverage under your prescription drug plan when it works the
same as or similar to another prescription medication or an over-the-counter (OTC) medication that
is more cost-effective. There may be other medication options available to treat your condition.

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

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

Should I talk to my doctor about OTC medications?

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

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

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

How can I tell a generic drug from a brand-name drug on this formulary?
This formulary shows brand-name drugs in bold type (for example, Lamictal) and generic drugs
in plain type (for example, lamotrigine).

What if my doctor writes a brand-name prescription?

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

7
Are you taking a specialty medication?
Specialty medications treat rare or complex conditions and are typically higher cost medications.
Please note, not all specialty medications are listed in the Formulary.
BriovaRx®, the OptumRx specialty pharmacy, can provide most of your specialty medications
along with helpful programs and services. Call BriovaRx® at (855) 427-4682 and have your
prescriptions delivered right to your home or office.

How do I get updated information about my pharmacy benefit?

Since the Formulary may change during your plan year, we encourage you to visit
www.HealthSelectRx.com and click on Prescription Drug List or call a customer care
representative at (855) 828-9834 (TTY 711) for the most current drug coverage information.
You can register and create an account at www.Optumrx.com/HealthSelectrx. You can use the
website’s helpful tools and features to:
• Refill and renew mail service prescriptions
• View your order status and claims history
• Sign up for text reminders to take and refill your medicine
• View your benefits in real time
• Look up the price of drugs covered by your plan
• Find lower-cost options

More information

Call a customer care representative

toll-free at (855) 828-9834 (TTY 711).
Or visit www.HealthSelectRx.com.

8
 Drug Programs Drug Programs
Drug Name Drug Name
Tier  and Limits Tier  and Limits
Ofloxacin Otic
Anti-Infectives: Antibiotics 1
Solution
Amoxicillin 1 Oracea 3
Amoxicillin/ Penicillin VK 1
1
Clavulanate Solodyn 3
Azasite 3 Sulfamethoxazole-
1
Azithromycin 1 Trimethoprim
Bethkis 2 SP Sulfamethoxazole-
1
Cefadroxil Cap 1 Trimethoprim DS
Cefdinir 1 TOBI Nebulizer E
Cefuroxime Tab 1 TOBI Podhaler E
Cephalexin 1 Tobramycin Neb E
Ciprodex Otic
2 Anti-Infectives: Antifungals
Suspension
Ciprofloxacin Tab 1 Fluconazole 1
Clarithromycin 1 Jublia Solution 3 PA
Clindamycin Cap 1 Kerydin Solution 3 PA
Doryx MPC 3 Nystatin Suspension 1
Doxycycline Hyclate Terbinafine Tab 1 QL
1
Cap
Doxycycline Hyclate Anti-Infectives: Antivirals
Tab (Immediate 1 Acyclovir Cap, Tab,
1
Release) Suspension
Doxycycline Daklinza 3 PA, QL, SP
1
Monohydrate Cap Entecavir 1 QL, SP
Doxycycline Epclusa 2 PA, QL, SP
Monohydrate Oral 1 Famciclovir Tab 1
Suspension, Tab Harvoni 2 PA, QL, SP
Erythromycin 1 Sovaldi 2 PA, QL, ST, SP
Kitabis E Tamiflu 3 QL
Levofloxacin Tab 1 Valacyclovir 1 QL
Metronidazole Tab 1 Zepatier 2 PA, QL, SP
Minocycline Cap 1 Cancer
Moxifloxacin 1
Neomycin/ Akynzeo 3 QL
Polymyxin/HC Anastrozole Tab 1
1 Capecitabine 1 PA, SP
Otic Suspension,
Letrozole 1
Solution
Revlimid 3 PA, SP
Nitrofurantoin
1 Sprycel 2 PA, SP
Macrocrystalline
Tamoxifen Tab 1
Nitrofurantoin
Tasigna 3 PA, SP
Monohydrate 1 Temozolomide 1 PA, SP
Macrocrystalline Zytiga 3 PA, SP

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits

[Plain type = Generic drug] ST Step Therapy SP Specialty Program
E Excluded 9
 Drug Programs Drug Programs
Drug Name Drug Name
Tier  and Limits Tier  and Limits
Cardiovascular/Heart Disease: Guanfacine Tab
Anticoagulants (Immediate 1
Brilinta 2 Release)
Clopidogrel 1 Hydralazine 1
Effient 2 Hydrochlorothiazide 1
Eliquis 3 QL Irbesartan 1
Enoxaparin 1 QL Irbesartan/HCTZ 1
Pradaxa 2 QL Labetalol 1
Savaysa 3 QL Lisinopril 1
Warfarin 1 Lisinopril/HCTZ 1
Xarelto 2 QL Losartan 1
Cardiovascular/Heart Disease: Losartan/HCTZ 1
High Blood Pressure Metoprolol Succinate 1
Amlodipine 1 Metoprolol Tartrate 1
Amlodipine/Benazepril 1 Nadolol 1
Amlodipine/Valsartan 1 Nifedipine ER 1
Amlodipine/Valsartan/ Propranolol 1
1 Propranolol ER 1
HCTZ
Atenolol 1 Quinapril 1
Atenolol/ Ramipril 1
1 Spironolactone 1
Chlorthalidone
Tekturna 2 ST
Azor 3 ST
Tekturna HCT 2 ST
Benazepril 1
Telmisartan 1
Benazepril/HCTZ 1
Terazosin 1
Benicar 3 ST
Torsemide Tab 1
Benicar HCT 3 ST
Triamterene/HCTZ 1
Bisoprolol 1
Tribenzor 3 ST
Bisoprolol/HCTZ 1
Valsartan 1
Bumetanide 1
Valsartan/HCTZ 1
Bystolic 2
Verapamil ER 1
Cartia XT 1
Carvedilol 1 Cardiovascular/Heart Disease:
Chlorthalidone 1 High Cholesterol
Clonidine Patch 1 Atorvastatin 1
Clonidine Tab 1 Cholestyramine 1
Diltiazem Tab 1 Crestor 3
Doxazosin 1 Fenofibrate 40 mg,
Edarbi 3 ST 43 mg, 48 mg,
Edarbyclor 3 ST 50 mg, 54 mg,
Enalapril 1 67 mg, 120 mg, 1
Enalapril/HCTZ 1 130 mg, 134 mg,
Felodipine 1 145 mg, 150 mg,
Fosinopril 1 160 mg, 200 mg
Furosemide 1

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits

[Plain type = Generic drug] ST Step Therapy SP Specialty Program
E Excluded 10
 Drug Programs Drug Programs
Drug Name Drug Name
Tier  and Limits Tier  and Limits
Gemfibrozil 1 Central Nervous System:
Lipitor 3 ST Attention Deficit Disorder
Lovastatin 1 Adderall XR Cap 3 PA, QL, ST
Lovaza 3 Amphetamine-
Niacin ER Tab 1 Dextro- 1 PA, QL
Omega-3 Acid Cap amphetamine Tab
1
1 gm Amphetamine-
Praluent 2 PA, QL, SP Dextro-
Pravastatin 1 1 PA, QL
amphetamine SR
Rosuvastatin 1
24Hr Cap
Simvastatin 5 mg, 10
1 Dexmethylphenidate
mg, 20 mg, 40 mg 1 PA, QL
ER Cap
Simvastatin 80 mg 1 PA
Evekeo 3 PA, QL, ST
Vascepa 2
Guanfacine ER Tab 1 QL
Vytorin 10-10 mg,
Methylphenidate
10-20 mg, 3 1 PA, QL
ER Cap
10-40 mg
Methylphenidate ER
Vytorin 10-80 mg 3 PA 1 PA, QL
Tab
Welchol 2
Methylphenidate SA
Zetia 3 1 PA, QL
Osmotic ER Tab
Cardiovascular/Heart Disease: Other Methylphenidate Tab 1 PA, QL
Strattera 2 QL
Amiodarone 1
Vyvanse 2 PA, QL
Amlodipine/
1
Atorvastatin Central Nervous System: Depression
Corlanor 3 PA, QL
Digoxin 1 Amitriptyline 1
Flecainide 1 Bupropion 1
Isosorbide Bupropion ER 1
1 Bupropion SR 1
Mononitrate
Bupropion XL 1 QL
Multaq 3
Doxepin 1
Nitrostat 3
Duloxetine Cap 20
Ranexa 2 ST 1 QL
Sotalol 1 mg, 30 mg, 60 mg
Escitalopram Tab 1
Cardiovascular/Heart Disease:
Fluoxetine Cap
Pulmonary Arterial Hypertension 1
(not PMDD)
Adcirca 3 PA, QL, SP
Fluvoxamine Tab 1
Adempas 2 PA, QL, SP
Forfivo XL 2 QL
Letairis 2 PA, QL, SP
Mirtazapine 1
Opsumit 2 PA, QL, SP
Nortriptyline 1
Orenitram 3 PA, SP
Paroxetine Tab 1
Sildenafil Tab 20 mg 1 PA, QL
Pristiq 3 QL
Tracleer 2 PA, QL, SP

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits

[Plain type = Generic drug] ST Step Therapy SP Specialty Program
E Excluded 11
 Drug Programs Drug Programs
Drug Name Drug Name
Tier  and Limits Tier  and Limits
Risperidone Tab 1 QL Carbidopa/Levodopa
Sertraline 1 Tab (Immediate 1
Trazodone 1 Release)
Venlafaxine Tab 1 Diazepam Tab 1
Venlafaxine ER Cap 1 Donepezil Tab 1
Venlafaxine ER Tab 1 Hydroxyzine HCL 1
Viibryd 3 QL, ST Hydroxyzine Pamoate 1
Central Nervous System: Migraine Latuda 3 QL, ST
Invega Sustenna 3
Butalbital- Invega Trinza 3
Acetaminophen- Lithium Carbonate 1
1
Caffeine Cap, Tab Lorazepam Tab 1 QL
50-325-40 mg Modafinil 1 PA, QL
Migranal 3 QL Namenda XR 2 QL
Relpax 3 QL Namzaric 2 QL
Rizatriptan Tab, ODT 1 QL Olanzapine Tab 1 QL
Sumatriptan Tab Prochlorperazine 1
1 QL Quetiapine 1 QL
and Spray
Sumavel Dose 3 QL Rexulti 3 QL
Zolmitriptan Tab 1 QL Risperidone Tab 1 QL
Central Nervous System: Ropinirole
Multiple Sclerosis (Immediate 1
Ampyra 2 PA, QL, SP Release)
Aubagio 3 PA, QL, ST, SP Saphris 2 QL
Avonex Kit 2 PA, QL, SP Seroquel XR 3 QL
Avonex Pen Kit 2 PA, QL, SP Ziprasidone Cap 1 QL
Avonex Prefill Kit 2 PA, QL, SP Central Nervous System:
Betaseron 2 PA, QL, SP Sedatives/Hypnotics
Copaxone 20 mg/mL Eszopiclone Tab 1 QL
2 PA, QL, SP Silenor 3 QL
& 40 mg/mL
Extavia E Temazepam 1 QL
Gilenya 3 PA, QL, ST, SP Triazolam Tab 1 QL
Plegridy E Zolpidem 1 QL
Rebif E Zolpidem ER 1 QL
Rebif Titrtn E Central Nervous System:
Tecfidera 2 PA, QL, SP Seizure Disorders
Carbamazepine Tab 1
Central Nervous System: Other Clonazepam 1 QL
Alprazolam Tab 1 QL Divalproex DR 1
Aripiprazole 1 QL Divalproex ER 1
Benztropine 1 Gabapentin 1
Buspirone 1 Lamotrigine
(Immediate 1
Release)

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits

[Plain type = Generic drug] ST Step Therapy SP Specialty Program
E Excluded 12
 Drug Programs Drug Programs
Drug Name Drug Name
Tier  and Limits Tier  and Limits
Lamotrigine ER 1 Desoximetasone
Levetiracetam 1 Cream, Gel, 1
Levetiracetam ER 1 Ointment
Lyrica Cap 2 QL Differin 3 PA
Onfi 3 PA Duac E
Oxcarbazepine 1 Econazole Cream 1
Phenytoin 1 Elidel 2 ST
Primidone 1 Epiduo & Epiduo
Topiramate Tab 1 3
Forte
Vimpat 3 Finacea 3 ST
Zonisamide 1 Fluocinonide Cream,
1
Dermatology 0.1%
Fluocinonide Cream,
Absorica 3 PA
Gel, Ointment, 1
Acanya Gel E
Solution 0.05%
Acyclovir Ointment
1 Hydrocortisone
5%
Cream, Ointment 1
Aczone Gel 3
Atralin 3 PA 2.5%
Benzaclin E Lidocaine Topical
1
Benzamycin E Ointment, Solution
Betamethasone Lidocaine/Prilocaine
1
Dipropionate 1 Cream
Cream Ketoconazole Cream/
1
Ciclopirox Cream 1 Shampoo
Clindamycin Gel, Metrogel 3
1 Metronidazole Gel
Lotion, Solution 1
Clindamycin/ 0.75%
Benzoyl Peroxide 1 Mirvaso Gel 2
Mupirocin Ointment 1
Gel 1-5%
Nystatin Cream,
Clindamycin/Benzoyl 1
Ointment, Powder
Peroxide Gel 1
Nystatin/Triamcinolone
1.2-5% 1
Cream, Ointment
Clobetasol Cream,
1 Onexton 3
Ointment, Solution
Oxsoralen-UL 2
Clobex 3
Permethrin Cream 5% 1
Clotrimazole/
Proctofoam HC 2
Betamethasone 1 Retin-A Micro 3 PA
Cream, Lotion Soolantra 2
Cortifoam 3 Sulfacetamide/Sulfur
Desonide Cream, 1
1 Emulsion
Ointment Taclonex 3 QL
Tazorac 3

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits

[Plain type = Generic drug] ST Step Therapy SP Specialty Program
E Excluded 13
 Drug Programs Drug Programs
Drug Name Drug Name
Tier  and Limits Tier  and Limits
Tretinoin Cream 1 PA
Tretinoin Microsphere Diabetes/Endocrine: Non-Insulin
1 PA
Gel alogliptin E
Triamcinolone 1 alogliptin/metformin E
Vectical 3 alogliptin/
E
Veltin E pioglitazone
Ziana Gel E Bydureon 2 QL, ST
Zovirax Cream 2 Byetta 2 QL, ST
Zovirax Ointment 3 Farxiga E
Zyclara 3 Glimepiride 1
Glipizide 1
Diabetes/Endocrine: Insulin
Glipizide ER 1
Apidra E Glipizide XL 1
Humalog Mix 50/50 Glumetza 3 PA
2
Vial and KwikPen Glyburide 1
Humalog Mix 75-25 Glyburide/Metformin 1
2 Invokamet 2 ST
Vial and KwikPen
Humalog U-100 Vial Invokamet XR 2 ST
2 Invokana 2 ST
and KwikPen
Humalog U-200 Janumet 2 ST
2 Janumet XR 2 ST
KwikPen
Humulin 70-30 Vial Januvia 2 ST
2 Jardiance 2 ST
and KwikPen
Jentadueto 2 ST
Humulin N Vial and
2 Jentadueto XR 2 ST
KwikPen
Kazano E
Humulin R U-500 Vial
2 Kombiglyze E
and KwikPen Metformin 1
Humulin R Vial 2 Metformin ER 1
Lantus SoloStar 2 Nesina E
Lantus Vial 2 Onglyza E
Levemir FlexTouch E Oseni E
Levemir Vial E Pioglitazone 1
Novolin 70/30 Vial E Synjardy 2 ST
Novolin N Vial E Tanzeum E
Novolin R Vial E Tradjenta 2 ST
Novolog Flexpen E Trulicity 2 QL, ST
Novolog Mix 70/30 Victoza 2 QL, ST
E
Vial and Flexpen Xigduo XR E
Novolog Penfill E
Novolog Vial E Endocrine: Growth Hormone
Toujeo SoloStar 2 Genotropin E
Tresiba E
Humatrope E
Norditropin 2 PA, SP

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits

[Plain type = Generic drug] ST Step Therapy SP Specialty Program
E Excluded 14
 Drug Programs Drug Programs
Drug Name Drug Name
Tier  and Limits Tier  and Limits
Nutropin AQ 2 PA, SP
Omnitrope E Eye Conditions: Antibiotics
Saizen E Besivance 3
Zomacton E Ciprofloxacin
Endocrine: Other Ophthalmic 1
Solution
Calcitriol Cap 1 Erythromycin
Dexamethasone Tab 1 1
Ointment
H.P. Acthar 2 PA, SP Gentamicin 1
Hydrocortisone Tab 1 Moxeza 2
Lupron Depot Neomycin/Polymyxin
3 PA, SP
3.75 mg, 11.25 mg B/Dexamethasone
Lupron Depot 1
Ointment,
7.5 mg, 22.5 mg, 2 PA, SP
Suspension
30 mg, 45 mg Ofloxacin Ophthalmic
Methylprednisolone 1
1 Solution
Tab Polymyxin B/Trim-
Prednisone 1 1
ethoprim Solution
Prednisolone Solution
1 Tobramycin 1
25 mg/5 ml Tobramycin/
Prednisolone Syrup, 1
Dexamethasone
Solution 15 mg/5 1 Vigamox 2
ml
Sensipar 3 PA Eye Conditions: Glaucoma
Endocrine: Alphagan P 2
Thyroid Hormone Replacement Azopt 2
Armour Thyroid 3 Betimol 3
Levothyroxine 1 Brimonidine 1
Liothyronine 1 Combigan 2
Methimazole 1 Cosopt PF 3
Synthroid 3 Dorzolamide-Timolol
Tirosint 3 1
Maleate
Eye Conditions: Allergies Latanoprost 1 QL
Lumigan 2 QL
Azelastine Ophthalmic Rescula E
1
Solution Simbrinza 2
Bepreve 3 ST Timolol 1
Lastacaft 3 ST Timoptic Ocudose 2
Pataday 2 Travatan Z 2 QL
Pazeo 2 Zioptan E

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits

[Plain type = Generic drug] ST Step Therapy SP Specialty Program
E Excluded 15
 Drug Programs Drug Programs
Drug Name Drug Name
Tier  and Limits Tier  and Limits
Eye Conditions: Other Gastrointestinal: Other
Durezol Ophthalmic Amitiza 2 QL, ST
3
Emulsion Apriso 2
Lotemax Ophthalmic Asacol HD E
3 QL Canasa 2
Gel
Ketorolac Ophthalmic Creon 2
1 Delzicol E
Solution
Prednisolone Dipentum 3
Ophthalmic 1 Gavilyte Solution 1
Hyoscyamine
Suspension 1
Restasis 3 PA Sublingual Tab
Lactulose 1
Gastrointestinal: Acid Suppression Lialda 2
Linzess 2 QL, ST
Dexilant 2 QL
mesalamine DR E
Duexis E
Moviprep 3
Esomeprazole (Rx
1 QL Omeclamox Pak 2
only) Pancreaze E
Famotidine Tab 20 mg Pentasa 3
and 40 mg (Rx 1 Pertzye E
only) Polyethylene
Lansoprazole (Rx only) 1 QL Glycol 3350 1
Omeprazole (Rx only) 1 QL Powder
Pantoprazole 1 QL Prepopik 3
Ranitidine Tab, Cap, Protosol HC 1
1
Syrup (Rx only) Pylera 2
Sucralfate Tab 1 Sulfasalazine 1
Vimovo E Suprep Bowel Prep 3
Gastrointestinal: Nausea/Vomiting Uceris Foam 3
Ultresa E
Meclizine 1 Viokace E
Metoclopramide 1 Zenpep 2
Ondansetron Tab,
1 QL
ODT
Transderm-Scop 3
Varubi 3 QL

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits

[Plain type = Generic drug] ST Step Therapy SP Specialty Program
E Excluded 16
 Drug Programs Drug Programs
Drug Name Drug Name
Tier  and Limits Tier  and Limits
HIV/AIDS Inflammatory Conditions
Atripla 2 SP Cimzia Kit 2 PA, SP
Complera 2 SP Cosentyx E
Epzicom 2 SP Depen 2
Genvoya 2 SP Enbrel 3 PA, SP
Intelence 2 SP Humira Kit 2 PA, SP
Isentress 2 SP Humira Pen Kit 2 PA, SP
Kaletra Solution 3 SP Humira Pen Kit
2 PA, SP
Kaletra Tab 2 SP Crohns
Nevirapine 1 SP Humira Pen Kit
2 PA, SP
Norvir 2 SP Psoriasis
Prezcobix 2 SP Hydroxychloroquine 1
Prezista 2 SP Inflectra E
Reyataz 2 SP Methotrexate Tab 1
Stribild 2 SP Orencia SC 3 PA, ST, SP
Sustiva 2 SP Otezla 3 PA, ST, SP
Tivicay 2 SP Otrexup 3 PA, QL
Triumeq 2 SP Rasuvo 2 PA, QL
Truvada 2 SP Simponi 2 PA, SP
Viread 2 SP Stelara 2 PA, SP
Taltz 3 PA, ST, SP
Infertility
Xeljanz 3 PA, ST, SP
Bravelle E
Cetrotide 2 SP
Men’s Health: Erectile Dysfunction
Follistim AQ E Cialis 2 QL
Gonal-f 2 PA, SP Levitra E
Gonal-f RFF 2 PA, SP Staxyn E
Ovidrel 3 SP Stendra E
Viagra 2 QL
Men’s Health: Prostate
Alfuzosin 1
Cialis 2.5 mg & 5 mg 2 QL
Doxazosin 1
Finasteride 5 mg 1
Rapaflo 2
Tamsulosin 1
Terazosin 1

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits

[Plain type = Generic drug] ST Step Therapy SP Specialty Program
E Excluded 17
 Drug Programs Drug Programs
Drug Name Drug Name
Tier  and Limits Tier  and Limits
Guaifenesin/Codeine
Men’s Health: Testosterone Therapy 1
Syrup
Androderm 2 PA Homatropine/
Androgel 1.62% 2 PA Hydrocodone 1
Androgel 1% E Syrup
Axiron E Hydrocodone/
Fortesta E Chlorpheniramine 1
Testim E Liquid
Testosterone Hydrocortisone AC
Cypionate IM 1 PA 1
Suppository 25 mg
Injection Hydromet 1
Vogelxo E Lidocaine Viscous
1
Miscellaneous Solution 2%
Makena 2 PA, SP
Adrenaclick E Narcan 2
Allopurinol 1 Neupogen 2 PA, SP
Antipyrine/Benzocaine Phenazopyridine
1
Otic Solution 1 (Rx only)
5.4 - 1.4% Phentermine Tab 1 PA
Aranesp E Procrit 2 PA, SP
Auryxia 3 Promethazine DM
1
Auvi-Q E Syrup
Benzonatate 1 Promethazine/Codeine
Bunavail 3 PA, QL 1
Syrup
Cerdelga 3 PA, SP Pulmozyme 2 PA, SP, QL
Chantix 3 QL Renvela Tab, Pack 2
Cheratussin 1 Rezira 3
Chlorhexidine 1 Suboxone Film 2 PA, QL
Colcrys 2 Synagis 2 PA, SP
Cyproheptadine 1 Synvisc 2 PA, SP
Desmopressin 1 Synvisc One 2 PA, SP
Epinephrine Uloric 2 ST
Auto-Injector Ursodiol 1
(Authorized 2 Velphoro 3
Generic for EpiPen Zarxio 2 PA, SP
made by Mylan) Zostavax Injection 3
Epinephrine Zubsolv 2 PA, QL
Auto- Injector E Zutripro 3
(made by Impax)
EpiPen & EpiPen Jr E
Epogen E
Fosrenol 3
Granix 2 PA, SP

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits

[Plain type = Generic drug] ST Step Therapy SP Specialty Program
E Excluded 18
 Drug Programs Drug Programs
Drug Name Drug Name
Tier  and Limits Tier  and Limits
Hydrocodone/APAP
Musculoskeletal: Osteoporosis 1 QL
5, 7.5, 10/325 mg
Alendronate Tab 35 Hydromorphone Tab 1 QL
1 QL
mg & 70 mg Hysingla ER E
Binosto 3 QL Ibuprofen Tab 400,
Evista 3 600, 800 mg (Rx 1
Forteo 2 PA, SP only)
Ibandronate Tab 1 QL Indomethacin Cap 1
Raloxifene 1 Kadian E
Ketorolac Tab 1 QL
Musculoskeletal: Other
Lazanda E
Baclofen Tab 1 Lidocaine Patch 5% 1
Carisoprodol 350 mg 1 Meloxicam 1
Cyclobenzaprine Tab Methadone Tab 1
1
5, 10 mg Morphine Sulfate Tab 1 QL
Metaxalone 1 Nabumetone 1
Methocarbamol 1 Naproxen (Rx only) 1
Tizanidine Cap 1 Nucynta ER E
Tizanidine Tab 1 Opana ER E
Oxycodone Tab
Musculoskeletal: Pain Relief
5, 10, 15, 30
1 QL
Abstral E mg (Immediate
Acetaminophen Release)
1 QL
w/ Codeine Oxycodone
1 QL
Cambia E w/ Acetaminophen
Celebrex 3 QL Oxycontin 2 QL
Celecoxib 1 QL Subsys E
Diclofenac Tab 1 Tramadol Tab 50 mg 1
Embeda 2 QL Tramadol
Endocet Tab 1 QL 1
w/ Acetaminophen
Etodolac 1 Vicodin 1 QL
Fentanyl Patch Vicodin ES 1 QL
25 mcg/hr, Voltaren Gel 3 QL
50 mcg/hr, 1 QL Xtampza ER E
75 mcg/hr, Zohydro ER E
100 mcg/hr Zorvolex E
Fentanyl Patch
37.5 mcg/hr,
1 QL
62.5 mcg/hr,
87.5 mcg/hr
Fentora E
Flector patch 3 QL
Gralise 3 QL, ST

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits

[Plain type = Generic drug] ST Step Therapy SP Specialty Program
E Excluded 19
 Drug Programs Drug Programs
Drug Name Drug Name
Tier  and Limits Tier  and Limits
Stiolto 2 QL
Overactive Bladder Symbicort 2 QL
Myrbetriq 2 Tudorza E
Oxybutynin 1 Ventolin HFA 2 QL
Oxybutynin ER 1 Xopenex HFA E
Tolterodine 1
Respiratory: Nasal Allergies
Toviaz 3
Vesicare 2 Astepro 3 QL
Azelastine Spray 1 QL
Respiratory: Asthma/COPD Dymista Spray 2 QL
Advair Diskus 2 QL Fluticasone Spray 1
Advair HFA 2 QL Ipratropium Spray 1 QL
Aerospan 3 QL Mometasone 1 QL
Albuterol Nasonex 2 QL
1 QL Omnaris 3 QL
Nebulizer Solution
Alvesco E QNasl 3 QL
Anoro Ellipta 2 QL Triamcinolone Spray 1 QL
Arnuity Ellipta 2 QL Zetonna 3 QL
Asmanex E Respiratory: Oral Allergies
Breo Ellipta 2 QL
Budesonide Inhalation Cetirizine 1
1 QL Promethazine Tab 1
Suspension
Combivent Respimat 2 QL Desloratadine 1
Dulera E Levocetirizine 1
Flovent Diskus 2 QL Transplant
Flovent HFA 2 QL
Foradil 2 QL Azathioprine Tab 1
Incruse Ellipta 2 QL Cellcept Tab/
3 SP
Ipratropium/Albuterol Suspension
1 QL
Nebulizer Solution Cyclosporine Cap 1 SP
Levalbuterol Inhaler E Mycophenolate Mofetil
Levalbuterol 250 mg Cap/ 1 SP
1 QL
Nebulizer Solution 500 mg Tab
Montelukast 1 Mycophenolate
Perforomist 3 QL Sodium 180 mg, 1 SP
Proair HFA, 360 mg Tab
2 QL
RespiClick Prograf Cap 3 SP
Proventil HFA E Rapamune 3 SP
Pulmicort Flexhaler 2 QL Tacrolimus Cap 1 SP
Qvar E
Seebri 3 QL
Serevent Diskus 2 QL
Spiriva Handihaler 2 QL
Spiriva Respimat 2 QL

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits

[Plain type = Generic drug] ST Step Therapy SP Specialty Program
E Excluded 20
 Drug Programs Drug Programs
Drug Name Drug Name
Tier  and Limits Tier  and Limits
Lomedia Fe 1
Vitamins/Electrolytes Loryna 1
Folic Acid 1 mg Low-Ogestrel 1
1 Lutera 1
(Rx only)
Klor-Con 8 and 10 Medroxyprogesterone
1 1 QL
MEQ Acetate Injection
Klor-Con M10 and Microgestin 1
1 Microgestin Fe 1
M20
Multi-Vit/Fl Chew 1 Minastrin 24 Fe
3
Potassium Chloride Chewable
1 Mono-Linyah 1
ER Tab, Cap
Potassium Chloride Mononessa 1
1 Necon 1
Micro ER Tab
Potassium Citrate Nora-Be 1
Norgest/Ethi Estradio 1
540 mg, 1080 mg 1
Nortrel 1
Tab Nuvaring 2
Vitamin D 50,000 units Ocella 1
1
(Rx only) Orsythia 1
Women’s Health: Birth Control Ortho Tri-Cyclen Lo 3
Previfem 1
Apri 1 Reclipsen 1
Aviane 1 Sprintec 28 1
Azurette 1 Tri-Linyah 1
Cryselle-28 1 Tri-Previfem 1
Falmina 1 Trinessa 1
Generess Fe Tri-Sprintec 1
3
Chewable Vestura 1
Gianvi 1 Viorele 1
Gildess 1 Xulane 1
Jolivette 1 Zarah 1
Junel 1
Kariva 1
Levora 28 1

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits

[Plain type = Generic drug] ST Step Therapy SP Specialty Program
E Excluded 21
 Drug Programs
Drug Name
Tier  and Limits
Women’s Health: Hormone Replacement
Climara Pro 2
Divigel 3
Duavee 2
Elestrin Gel 3
Estrace Vaginal
3
Cream
Estradiol Tab 1
Estradiol/
1
Norethindrone Tab
Medroxyprogesterone
1
Acetate Tab
Minivelle 3
Osphena 3
Premarin Tab 2
Premarin Vaginal
2
Cream
Premphase 2
Prempro 2
Progesterone Cap 1
Vagifem 3
Women’s Health: Vaginal Anti-Infectives
Gynazole-1 Vaginal
3
Cream
Metronidazole
1
Vaginal Gel
Terconazole
1
Vaginal Cream

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits

[Plain type = Generic drug] ST Step Therapy SP Specialty Program
E Excluded 22
Index of Drugs

A Amphetamine-Dextro- Azelastine Ophthalmic

Absorica . . . . . . . . . . 13 amphetamine SR Solution . . . . . . . . . 15
Abstral . . . . . . . . . . . 19 24Hr Cap . . . . . . . . 11 Azelastine Spray . . . . . . . 20
Acanya Gel . . . . . . . . . 13 Amphetamine-Dextro- Azithromycin . . . . . . . . . 9
Acetaminophen w/ Codeine 19 amphetamine Tab . . . . 11 Azopt . . . . . . . . . . . . 15
Acyclovir Cap, Tab, Ampyra . . . . . . . . . . . 12 Azor . . . . . . . . . . . . . 10
Suspension . . . . . . . . 9 Anastrozole Tab . . . . . . . 9 Azurette . . . . . . . . . . . 21
Acyclovir Ointment 5% . . . 13 Androderm . . . . . . . . . 18
Aczone Gel . . . . . . . . . 13 Androgel 1% . . . . . . . . 18 B
Adcirca . . . . . . . . . . . 11 Androgel 1.62% . . . . . . 18 Baclofen Tab . . . . . . . . . 19
Adderall XR Cap . . . . . . 11 Anoro Ellipta . . . . . . . . 20 Benazepril . . . . . . . . . . 10
Adempas . . . . . . . . . . 11 Antipyrine/Benzocaine Otic Benazepril/HCTZ . . . . . . 10
Adrenaclick . . . . . . . . .18 Solution 5.4 - 1.4% . . . 18 Benicar . . . . . . . . . . . 10
Advair Diskus . . . . . . . . 20 Apidra . . . . . . . . . . . . 14 Benicar HCT . . . . . . . . 10
Advair HFA . . . . . . . . . 20 Apri . . . . . . . . . . . . . 21 Benzaclin . . . . . . . . . . 13
Aerospan . . . . . . . . . . 20 Apriso . . . . . . . . . . . . 16 Benzamycin . . . . . . . . .13
Akynzeo . . . . . . . . . . . 9 Aranesp . . . . . . . . . . . 18 Benzonatate . . . . . . . . . 18
Albuterol Nebulizer Solution 20 Aripiprazole . . . . . . . . . 12 Benztropine . . . . . . . . . 12
Alendronate Tab . . . . . . . 19 Armour Thyroid . . . . . . .15 Bepreve . . . . . . . . . . . 15
Alfuzosin . . . . . . . . . . . 17 Arnuity Ellipta . . . . . . . . 20 Besivance . . . . . . . . . .15
Allopurinol . . . . . . . . . . 18 Asacol HD . . . . . . . . . . 16 Betamethasone D
alogliptin . . . . . . . . . . 14 Asmanex . . . . . . . . . . 20 ipropionate Cream . . . . 13
alogliptin/metformin . . . . 14 Astepro . . . . . . . . . . . 20 Betaseron . . . . . . . . . .12
alogliptin/pioglitazone . . . 14 Atenolol . . . . . . . . . . . 10 Bethkis . . . . . . . . . . . . 9
Alphagan P . . . . . . . . . 15 Atenolol/Chlorthalidone . . . 10 Betimol . . . . . . . . . . . 15
Alprazolam Tab . . . . . . . 12 Atorvastatin . . . . . . . . . 10 Binosto . . . . . . . . . . . 19
Alvesco . . . . . . . . . . . 20 Atralin . . . . . . . . . . . . 13 Bisoprolol . . . . . . . . . . 10
Amiodarone . . . . . . . . . 11 Atripla . . . . . . . . . . . . 17 Bisoprolol/HCTZ . . . . . . . 10
Amitiza . . . . . . . . . . . 16 Aubagio . . . . . . . . . . . 12 Bravelle . . . . . . . . . . . 17
Amitriptyline . . . . . . . . . 11 Auryxia . . . . . . . . . . . 18 Breo Ellipta . . . . . . . . . 20
Amlodipine . . . . . . . . . 10 Auvi-Q . . . . . . . . . . . . 18 Brilinta . . . . . . . . . . . 10
Amlodipine/Atorvastatin . . . 11 Aviane . . . . . . . . . . . . 21 Brimonidine . . . . . . . . . 15
Amlodipine/Benazepril . . . 10 Avonex Kit . . . . . . . . . 12 Budesonide Inhalation
Avonex Pen Kit . . . . . . . 12 Suspension . . . . . . . 20
Amlodipine/Valsartan . . . . 10
Avonex Prefill Kit . . . . . . 12 Bumetanide . . . . . . . . . 10
Amlodipine/Valsartan/HCTZ . 10
Axiron . . . . . . . . . . . . 18 Bunavail . . . . . . . . . . .18
Amoxicillin . . . . . . . . . . 9
Azasite . . . . . . . . . . . . 9 Bupropion . . . . . . . . . . 11
Amoxicillin/Clavulanate . . . 9
Azathioprine Tab . . . . . . . 20 Bupropion ER . . . . . . . . 11

Bold type = Brand-name drug

[Plain type = Generic drug] 23
Index of Drugs

Bupropion SR . . . . . . . . 11 Ciprodex Otic Suspension . 9 D

Bupropion XL . . . . . . . . 11 Ciprofloxacin Ophthalmic Daklinza . . . . . . . . . . . 9
Buspirone . . . . . . . . . . 12 Solution . . . . . . . . . 15 Delzicol . . . . . . . . . . . 16
Butalbital-Acetaminophen- Ciprofloxacin Tab . . . . . . . 9 Depen . . . . . . . . . . . . 17
Caffeine Cap, Tab . . . . 12 Clarithromycin . . . . . . . . 9 Desloratadine . . . . . . . . 20
Bydureon . . . . . . . . . . 14 Climara Pro . . . . . . . . . 22 Desmopressin . . . . . . . . 18
Byetta . . . . . . . . . . . . 14 Clindamycin/Benzoyl Desonide Cream, Ointment . 13
Bystolic . . . . . . . . . . . 10 Peroxide Gel 1.2-5% . . 13 Desoximetasone Cream,
Clindamycin/ Gel, Ointment . . . . . . 13
C Benzoyl Peroxide Dexamethasone Tab . . . . 15
Calcitriol Cap . . . . . . . . 15 Gel 1-5% . . . . . . . . 13 Dexilant . . . . . . . . . . . 16
Cambia . . . . . . . . . . . 19 Clindamycin Cap . . . . . . . 9 Dexmethylphenidate ER Cap11
Canasa . . . . . . . . . . . 16 Clindamycin Gel, Lotion, Diazepam Tab . . . . . . . . 12
Capecitabine . . . . . . . . . 9 Solution . . . . . . . . . 13
Diclofenac Tab . . . . . . . . 19
Carbamazepine Tab . . . . . 12 Clobetasol Cream,
Differin . . . . . . . . . . . 13
Carbidopa/Levodopa Tab Ointment, Solution . . . . 13
Digoxin . . . . . . . . . . . 11
(Immediate Release) . . . 12 Clobex . . . . . . . . . . . . 13
Diltiazem Tab . . . . . . . . 10
Carisoprodol . . . . . . . . . 19 Clonazepam . . . . . . . . .12
Dipentum . . . . . . . . . . 16
Cartia XT . . . . . . . . . . .10 Clonidine Patch . . . . . . . 10
Divalproex DR . . . . . . . . 12
Carvedilol . . . . . . . . . . 10 Clonidine Tab . . . . . . . . 10
Divalproex ER . . . . . . . . 12
Cefadroxil Cap . . . . . . . . 9 Clopidogrel . . . . . . . . . 10
Divigel . . . . . . . . . . . . 22
Cefdinir . . . . . . . . . . . . 9 Clotrimazole/Betamethasone
Donepezil Tab . . . . . . . . 12
Cefuroxime Tab . . . . . . . 9 Cream, Lotion . . . . . . 13
Doryx MPC . . . . . . . . . 9
Celebrex . . . . . . . . . . 19 Colcrys . . . . . . . . . . . 18
Dorzolamide-Timolol
Celecoxib . . . . . . . . . . 19 Combigan . . . . . . . . . . 15
Maleate . . . . . . . . . 15
Cellcept Tab/Suspension . 20 Combivent Respimat . . . . 20
Doxazosin . . . . . . . . 10, 17
Cephalexin . . . . . . . . . . 9 Complera . . . . . . . . . . 17
Doxepin . . . . . . . . . . . 11
Cerdelga . . . . . . . . . . 18 Copaxone . . . . . . . . . .12
Doxycycline Hyclate Cap . . 9
Cetirizine . . . . . . . . . . . 20 Corlanor . . . . . . . . . . . 11
Doxycycline Hyclate Tab
Cetrotide . . . . . . . . . . 17 Cortifoam . . . . . . . . . . 13
(Immediate Release) . . . 9
Chantix . . . . . . . . . . . 18 Cosentyx . . . . . . . . . . 17
Doxycycline Monohydrate
Cheratussin . . . . . . . . . 18 Cosopt PF . . . . . . . . . . 15 Cap . . . . . . . . . . . . 9
Chlorhexidine . . . . . . . . 18 Creon . . . . . . . . . . . . 16 Doxycycline Monohydrate Oral
Chlorthalidone . . . . . . . . 10 Crestor . . . . . . . . . . . 10 Suspension, Tab . . . . . 9
Cholestyramine . . . . . . . 10 Cryselle-28 . . . . . . . . . 21 Duac . . . . . . . . . . . . . 13
Cialis . . . . . . . . . . . . 17 Cyclobenzaprine Tab . . . . 19 Duavee . . . . . . . . . . . 22
Ciclopirox Cream . . . . . . 13 Cyclosporine Cap . . . . . . 20 Duexis . . . . . . . . . . . . 16
Cimzia Kit . . . . . . . . . . 17 Cyproheptadine . . . . . . . 18 Dulera . . . . . . . . . . . . 20

Bold type = Brand-name drug

[Plain type = Generic drug] 24
Index of Drugs

Duloxetine Cap . . . . . . . 11 F Genotropin . . . . . . . . . 14

Durezol Ophthalmic Falmina . . . . . . . . . . . 21 Gentamicin . . . . . . . . . 15
Emulsion . . . . . . . . 16 Famciclovir Tab . . . . . . . 9 Genvoya . . . . . . . . . . .17
Dymista Spray . . . . . . . 20 Famotidine Tab (Rx only) . . 16 Gianvi . . . . . . . . . . . . 21
Farxiga . . . . . . . . . . . 14 Gildess . . . . . . . . . . . .21
E Felodipine . . . . . . . . . . 10 Gilenya . . . . . . . . . . . 12
Econazole Cream . . . . . . 13 Fenofibrate . . . . . . . . . 10 Glimepiride . . . . . . . . . 14
Edarbi . . . . . . . . . . . . 10 Fentanyl Patch . . . . . . . . 19 Glipizide . . . . . . . . . . . 14
Edarbyclor . . . . . . . . . 10 Fentora . . . . . . . . . . . 19 Glipizide ER . . . . . . . . . 14
Effient . . . . . . . . . . . . 10 Finacea . . . . . . . . . . . 13 Glipizide XL . . . . . . . . . 14
Elestrin Gel . . . . . . . . . 22 Finasteride . . . . . . . . . . 17 Glumetza . . . . . . . . . . 14
Elidel . . . . . . . . . . . . 13 Flecainide . . . . . . . . . . 11 Glyburide . . . . . . . . . . 14
Eliquis . . . . . . . . . . . . 10 Flector patch . . . . . . . . 19 Glyburide/Metformin . . . . 14
Embeda . . . . . . . . . . . 19 Flovent Diskus . . . . . . . 20 Gonal-f . . . . . . . . . . . 17
Enalapril . . . . . . . . . . . 10 Flovent HFA . . . . . . . . .20 Gonal-f RFF . . . . . . . . . 17
Enalapril/HCTZ . . . . . . . 10 Fluconazole . . . . . . . . . 9 Gralise . . . . . . . . . . . 19
Enbrel . . . . . . . . . . . . 17 Fluocinonide Cream, 0.1% . 13 Granix . . . . . . . . . . . . 18
Endocet Tab . . . . . . . . . 19 Fluocinonide Cream, Guaifenesin/Codeine Syrup . 18
Enoxaparin . . . . . . . . . 10 Gel, Ointment, Guanfacine ER Tab . . . . . 11
Entecavir . . . . . . . . . . . 9 Solution 0.05% . . . . . 13 Guanfacine Tab
Epclusa . . . . . . . . . . . 9 Fluoxetine Cap (not PMDD) . 11 (Immediate Release) . . . 10
Epiduo & Epiduo Forte . . . 13 Fluticasone Spray . . . . . . 20 Gynazole-1 Vaginal Cream 22
Epinephrine Auto-Injector . 18 Fluvoxamine Tab . . . . . . 11
EpiPen & EpiPen Jr . . . . . 18 Folic Acid (Rx only) . . . . . 21 H
Epogen . . . . . . . . . . . 18 Follistim AQ . . . . . . . . .17 Harvoni . . . . . . . . . . . 9
Epzicom . . . . . . . . . . . 17 Foradil . . . . . . . . . . . . 20 Homatropine/Hydrocodone
Erythromycin . . . . . . . . . 9 Forfivo XL . . . . . . . . . .11 Syrup . . . . . . . . . . 18
Erythromycin Ointment . . . 15 Forteo . . . . . . . . . . . . 19 H.P. Acthar . . . . . . . . . 15
Escitalopram Tab . . . . . . 11 Fortesta . . . . . . . . . . .18 Humalog Mix 50/50 Vial and
Esomeprazole (Rx only) . . . 16 Fosinopril . . . . . . . . . . 10 KwikPen . . . . . . . . . 14
Estrace Vaginal Cream . . . 22 Fosrenol . . . . . . . . . . . 18 Humalog Mix 75-25 Vial and
Estradiol/Norethindrone Tab . 22 KwikPen . . . . . . . . . 14
Furosemide . . . . . . . . . 10
Estradiol Tab . . . . . . . . . 22 Humalog U-100 Vial and
G KwikPen . . . . . . . . . 14
Eszopiclone Tab . . . . . . . 12
Gabapentin . . . . . . . . . 12 Humalog U-200 KwikPen . 14
Etodolac . . . . . . . . . . .19
Gavilyte Solution . . . . . . 16 Humatrope . . . . . . . . . 14
Evekeo . . . . . . . . . . . 11
Gemfibrozil . . . . . . . . . 11 Humira Kit . . . . . . . . . 17
Evista . . . . . . . . . . . . 19
Generess Fe Chewable . . 21 Humira Pen Kit . . . . . . . 17
Extavia . . . . . . . . . . . 12

Bold type = Brand-name drug

[Plain type = Generic drug] 25
Index of Drugs

Humira Pen Kit Crohns . . 17 Invokana . . . . . . . . . . 14 L

Humira Pen Kit Psoriasis . 17 Ipratropium/Albuterol Labetalol . . . . . . . . . . .10
Humulin 70-30 Vial and Nebulizer Solution . . . . 20 Lactulose . . . . . . . . . . 16
KwikPen . . . . . . . . . 14 Ipratropium Spray . . . . . . 20 Lamotrigine ER . . . . . . . 13
Humulin N Vial and Irbesartan . . . . . . . . . . 10 Lamotrigine
KwikPen . . . . . . . . . 14 Irbesartan/HCTZ . . . . . . . 10 (Immediate Release) . . . 12
Humulin R U-500 Vial and Isentress . . . . . . . . . . 17 Lansoprazole (Rx only) . . . 16
KwikPen . . . . . . . . . 14 Isosorbide Mononitrate . . . 11 Lantus SoloStar . . . . . . 14
Humulin R Vial . . . . . . . 14 Lantus Vial . . . . . . . . . 14
Hydralazine . . . . . . . . . 10 J Lastacaft . . . . . . . . . . 15
Hydrochlorothiazide . . . . . 10 Janumet . . . . . . . . . . . 14 Latanoprost . . . . . . . . . 15
Hydrocodone/APAP . . . . 19 Janumet XR . . . . . . . . .14 Latuda . . . . . . . . . . . . 12
Hydrocodone/ Januvia . . . . . . . . . . . 14 Lazanda . . . . . . . . . . .19
Chlorpheniramine Liquid . 18 Jardiance . . . . . . . . . . 14 Letairis . . . . . . . . . . . 11
Hydrocortisone AC Jentadueto . . . . . . . . . 14 Letrozole . . . . . . . . . . . 9
Suppository . . . . . . . 18 Jentadueto XR . . . . . . . 14 Levalbuterol Inhaler . . . . 20
Hydrocortisone Cream, Jolivette . . . . . . . . . . . 21 Levalbuterol
Ointment 2.5% . . . . . 13 Jublia Solution . . . . . . . 9 Nebulizer Solution . . . . 20
Hydrocortisone Tab . . . . . 15 Junel . . . . . . . . . . . . . 21 Levemir FlexTouch . . . . . 14
Hydromet . . . . . . . . . . 18
Levemir Vial . . . . . . . . .14
Hydromorphone Tab . . . . . 19 K Levetiracetam . . . . . . . . 13
Hydroxychloroquine . . . . . 17 Kadian . . . . . . . . . . . . 19 Levetiracetam ER . . . . . . 13
Hydroxyzine HCL . . . . . . 12 Kaletra Solution . . . . . . 17 Levitra . . . . . . . . . . . .17
Hydroxyzine Pamoate . . . . 12 Kaletra Tab . . . . . . . . . 17 Levocetirizine . . . . . . . . 20
Hyoscyamine Sublingual Tab 16 Kariva . . . . . . . . . . . . 21 Levofloxacin Tab . . . . . . . 9
Hysingla ER . . . . . . . . .19 Kazano . . . . . . . . . . . 14 Levora 28 . . . . . . . . . . 21
Kerydin Solution . . . . . . 9 Levothyroxine . . . . . . . . 15
I Ketoconazole Cream/ Lialda . . . . . . . . . . . . 16
Ibandronate Tab . . . . . . . 19 Shampoo . . . . . . . . 13
Lidocaine Patch 5% . . . . . 19
Ibuprofen Tab (Rx only) . . . 19 Ketorolac Ophthalmic
Lidocaine/Prilocaine Cream . 13
Incruse Ellipta . . . . . . . 20 Solution . . . . . . . . . 16
Lidocaine Topical Ointment,
Indomethacin Cap . . . . . . 19 Ketorolac Tab . . . . . . . . 19
Solution . . . . . . . . . 13
Inflectra . . . . . . . . . . .17 Kitabis . . . . . . . . . . . . 9
Lidocaine Viscous
Intelence . . . . . . . . . . 17 Klor-Con 8 and 10 MEQ . . . 21 Solution 2% . . . . . . . 18
Invega Sustenna . . . . . . 12 Klor-Con M10 and M20 . . . 21 Linzess . . . . . . . . . . . 16
Invega Trinza . . . . . . . . 12 Kombiglyze . . . . . . . . .14 Liothyronine . . . . . . . . .15
Invokamet . . . . . . . . . .14
Lipitor . . . . . . . . . . . . 11
Invokamet XR . . . . . . . . 14
Lisinopril . . . . . . . . . . .10

Bold type = Brand-name drug

[Plain type = Generic drug] 26
Index of Drugs

Lisinopril/HCTZ . . . . . . . 10 Metoclopramide . . . . . . . 16 N
Lithium Carbonate . . . . . . 12 Metoprolol Succinate . . . . 10 Nabumetone . . . . . . . . .19
Lomedia Fe . . . . . . . . . 21 Metoprolol Tartrate . . . . . 10 Nadolol . . . . . . . . . . . 10
Lorazepam Tab . . . . . . . 12 Metrogel . . . . . . . . . . 13 Namenda XR . . . . . . . . 12
Loryna . . . . . . . . . . . . 21 Metronidazole Gel 0.75% . . 13 Namzaric . . . . . . . . . . 12
Losartan . . . . . . . . . . . 10 Metronidazole Tab . . . . . . 9 Naproxen (Rx only) . . . . . 19
Losartan/HCTZ . . . . . . . 10 Metronidazole Narcan . . . . . . . . . . . 18
Lotemax Ophthalmic Gel . 16 Vaginal Gel . . . . . . . .22 Nasonex . . . . . . . . . . .20
Lovastatin . . . . . . . . . .11 Microgestin . . . . . . . . . 21 Necon . . . . . . . . . . . . 21
Lovaza . . . . . . . . . . . 11 Microgestin Fe . . . . . . . . 21 Neomycin/Polymyxin B/
Low-Ogestrel . . . . . . . . 21 Migranal . . . . . . . . . . . 12 Dexamethasone
Lumigan . . . . . . . . . . .15 Minastrin 24 Fe Chewable . 21 Ointment, Suspension . . 15
Lupron Depot . . . . . . . .15 Minivelle . . . . . . . . . . 22 Neomycin/Polymyxin/HC Otic
Lutera . . . . . . . . . . . . 21 Minocycline Cap . . . . . . . 9 Suspension, Solution . . . 9
Lyrica Cap . . . . . . . . . 13 Mirtazapine . . . . . . . . . 11 Nesina . . . . . . . . . . . . 14
Mirvaso Gel . . . . . . . . .13 Neupogen . . . . . . . . . .18
M Modafinil . . . . . . . . . . .12 Nevirapine . . . . . . . . . . 17
Makena . . . . . . . . . . . 18 Mometasone . . . . . . . . 20 Niacin ER Tab . . . . . . . . 11
Meclizine . . . . . . . . . . 16 Mono-Linyah . . . . . . . . 21 Nifedipine ER . . . . . . . . 10
Medroxyprogesterone Mononessa . . . . . . . . . 21 Nitrofurantoin
Acetate Injection . . . . . 21 Montelukast . . . . . . . . .20 Macrocrystalline . . . . . 9
Medroxyprogesterone Morphine Sulfate Tab . . . . 19 Nitrofurantoin Monohydrate
Acetate Tab . . . . . . . 22 Macrocrystalline . . . . . 9
Moviprep . . . . . . . . . . 16
Meloxicam . . . . . . . . . . 19 Nitrostat . . . . . . . . . . . 11
Moxeza . . . . . . . . . . . 15
mesalamine DR . . . . . . . 16 Nora-Be . . . . . . . . . . . 21
Moxifloxacin . . . . . . . . . 9
Metaxalone . . . . . . . . . 19 Norditropin . . . . . . . . . 14
Multaq . . . . . . . . . . . . 11
Metformin . . . . . . . . . . 14 Norgest/Ethi Estradio . . . . 21
Multi-Vit/Fl Chew . . . . . . 21
Metformin ER . . . . . . . . 14 Nortrel . . . . . . . . . . . . 21
Mupirocin Ointment . . . . . 13
Methadone Tab . . . . . . . 19 Nortriptyline . . . . . . . . . 11
Mycophenolate Mofetil 250 mg
Methimazole . . . . . . . . . 15 Cap/ Norvir . . . . . . . . . . . . 17
Methocarbamol . . . . . . . 19 500 mg Tab . . . . . . . 20 Novolin 70/30 Vial . . . . . 14
Methotrexate Tab . . . . . . 17 Mycophenolate Sodium 180 Novolin N Vial . . . . . . . .14
Methylphenidate ER Cap . . 11 mg, 360 mg Tab . . . . . 20 Novolin R Vial . . . . . . . .14
Methylphenidate ER Tab . . 11 Myrbetriq . . . . . . . . . . 20 Novolog Flexpen . . . . . . 14
Methylphenidate SA Novolog Mix 70/30 Vial
Osmotic ER Tab . . . . . 11 and Flexpen . . . . . . .14
Methylphenidate Tab . . . . 11 Novolog Penfill . . . . . . . 14
Methylprednisolone Tab . . . 15 Novolog Vial . . . . . . . . 14

Bold type = Brand-name drug

[Plain type = Generic drug] 27
Index of Drugs

Nucynta ER . . . . . . . . .19 Oxybutynin . . . . . . . . . 20 Prednisolone Solution . . . . 15

Nutropin AQ . . . . . . . . 15 Oxybutynin ER . . . . . . . . 20 Prednisolone Syrup,
Nuvaring . . . . . . . . . . 21 Oxycodone Tab Solution . . . . . . . . . 15
Nystatin Cream, Ointment, (Immediate Release) . . . 19 Prednisone . . . . . . . . . 15
Powder . . . . . . . . . 13 Oxycodone Premarin Tab . . . . . . . . 22
Nystatin Suspension . . . . . 9 w/ Acetaminophen . . . 19 Premarin Vaginal Cream . . 22
Nystatin/Triamcinolone Oxycontin . . . . . . . . . .19 Premphase . . . . . . . . . 22
Cream, Ointment . . . . 13 Prempro . . . . . . . . . . . 22
P Prepopik . . . . . . . . . . 16
O Pancreaze . . . . . . . . . 16 Previfem . . . . . . . . . . . 21
Ocella . . . . . . . . . . . . 21 Pantoprazole . . . . . . . . 16 Prezcobix . . . . . . . . . . 17
Ofloxacin Ophthalmic Paroxetine Tab . . . . . . . . 11 Prezista . . . . . . . . . . . 17
Solution . . . . . . . . . 15 Pataday . . . . . . . . . . . 15 Primidone . . . . . . . . . . 13
Ofloxacin Otic Solution . . . . 9 Pazeo . . . . . . . . . . . . 15 Pristiq . . . . . . . . . . . . 11
Olanzapine Tab . . . . . . . 12 Penicillin VK . . . . . . . . . 9 Proair HFA, RespiClick . . . 20
Omeclamox Pak . . . . . . 16 Pentasa . . . . . . . . . . . 16 Prochlorperazine . . . . . . 12
Omega-3 Acid Cap . . . . . 11 Perforomist . . . . . . . . .20 Procrit . . . . . . . . . . . . 18
Omeprazole (Rx only) . . . . 16 Permethrin Cream 5% . . . . 13 Proctofoam HC . . . . . . .13
Omnaris . . . . . . . . . . . 20 Pertzye . . . . . . . . . . . 16 Progesterone Cap . . . . . . 22
Omnitrope . . . . . . . . . 15 Phenazopyridine (Rx only) . . 18 Prograf Cap . . . . . . . . . 20
Ondansetron Tab, ODT . . . 16 Phentermine Tab . . . . . . 18 Promethazine/Codeine
Onexton . . . . . . . . . . .13 Phenytoin . . . . . . . . . . 13 Syrup . . . . . . . . . . 18
Onfi . . . . . . . . . . . . . 13 Pioglitazone . . . . . . . . . 14 Promethazine DM Syrup . . 18
Onglyza . . . . . . . . . . . 14 Plegridy . . . . . . . . . . . 12 Promethazine Tab . . . . . . 20
Opana ER . . . . . . . . . . 19 Polyethylene Propranolol . . . . . . . . . 10
Opsumit . . . . . . . . . . . 11 Glycol 3350 Powder . . . 16 Propranolol ER . . . . . . . 10
Oracea . . . . . . . . . . . . 9 Polymyxin B/Trim-ethoprim Protosol HC . . . . . . . . . 16
Orencia SC . . . . . . . . . 17 Solution . . . . . . . . . 15
Proventil HFA . . . . . . . .20
Orenitram . . . . . . . . . . 11 Potassium Chloride ER
Pulmicort Flexhaler . . . . 20
Orsythia . . . . . . . . . . . 21 Tab, Cap . . . . . . . . . 21
Pulmozyme . . . . . . . . . 18
Ortho Tri-Cyclen Lo . . . . 21 Potassium Chloride Micro
Pylera . . . . . . . . . . . . 16
Oseni . . . . . . . . . . . . 14 ER Tab . . . . . . . . . . 21
Osphena . . . . . . . . . . 22 Potassium Citrate Tab . . . . 21
Q
Otezla . . . . . . . . . . . . 17 Pradaxa . . . . . . . . . . .10
QNasl . . . . . . . . . . . . 20
Otrexup . . . . . . . . . . . 17 Praluent . . . . . . . . . . .11
Quetiapine . . . . . . . . . .12
Ovidrel . . . . . . . . . . . 17 Pravastatin . . . . . . . . . .11
Quinapril . . . . . . . . . . .10
Oxcarbazepine . . . . . . . 13 Prednisolone Ophthalmic
Qvar . . . . . . . . . . . . . 20
Suspension . . . . . . . 16
Oxsoralen-UL . . . . . . . .13

Bold type = Brand-name drug

[Plain type = Generic drug] 28
Index of Drugs

R Sildenafil Tab . . . . . . . . 11 Synthroid . . . . . . . . . . 15

Raloxifene . . . . . . . . . . 19 Silenor . . . . . . . . . . . . 12 Synvisc . . . . . . . . . . . 18
Ramipril . . . . . . . . . . . 10 Simbrinza . . . . . . . . . .15 Synvisc One . . . . . . . . 18
Ranexa . . . . . . . . . . . 11 Simponi . . . . . . . . . . . 17
Ranitidine Tab, Cap, Simvastatin . . . . . . . . . 11 T
Syrup (Rx only) . . . . . . 16 Solodyn . . . . . . . . . . . 9 Taclonex . . . . . . . . . . 13
Rapaflo . . . . . . . . . . . 17 Soolantra . . . . . . . . . . 13 Tacrolimus Cap . . . . . . . 20
Rapamune . . . . . . . . . 20 Sotalol . . . . . . . . . . . .11 Taltz . . . . . . . . . . . . .17
Rasuvo . . . . . . . . . . . 17 Sovaldi . . . . . . . . . . . . 9 Tamiflu . . . . . . . . . . . . 9
Rebif . . . . . . . . . . . . . 12 Spiriva Handihaler . . . . . 20 Tamoxifen Tab . . . . . . . . 9
Rebif Titrtn . . . . . . . . . 12 Spiriva Respimat . . . . . . 20 Tamsulosin . . . . . . . . . . 17
Reclipsen . . . . . . . . . . 21 Spironolactone . . . . . . . 10 Tanzeum . . . . . . . . . . 14
Relpax . . . . . . . . . . . . 12 Sprintec 28 . . . . . . . . . 21 Tasigna . . . . . . . . . . . 9
Renvela Tab, Pack . . . . . 18 Sprycel . . . . . . . . . . . . 9 Tazorac . . . . . . . . . . . 13
Rescula . . . . . . . . . . . 15 Staxyn . . . . . . . . . . . . 17 Tecfidera . . . . . . . . . . 12
Restasis . . . . . . . . . . .16 Stelara . . . . . . . . . . . 17 Tekturna . . . . . . . . . . .10
Retin-A Micro . . . . . . . .13 Stendra . . . . . . . . . . . 17 Tekturna HCT . . . . . . . .10
Revlimid . . . . . . . . . . . 9 Stiolto . . . . . . . . . . . . 20 Telmisartan . . . . . . . . . 10
Rexulti . . . . . . . . . . . .12 Strattera . . . . . . . . . . 11 Temazepam . . . . . . . . . 12
Reyataz . . . . . . . . . . . 17 Stribild . . . . . . . . . . . 17 Temozolomide . . . . . . . . 9
Rezira . . . . . . . . . . . . 18 Suboxone Film . . . . . . . 18 Terazosin . . . . . . . . 10, 17
Risperidone Tab . . . . . . . 12 Subsys . . . . . . . . . . . 19 Terbinafine Tab . . . . . . . . 9
Risperidone Tab . . . . . . . 12 Sucralfate Tab . . . . . . . . 16 Terconazole Vaginal Cream . 22
Rizatriptan Tab, ODT . . . . 12 Sulfacetamide/Sulfur Testim . . . . . . . . . . . . 18
Ropinirole Emulsion . . . . . . . . . 13 Testosterone Cypionate IM
(Immediate Release) . . . 12 Sulfamethoxazole- Injection . . . . . . . . . 18
Rosuvastatin . . . . . . . . .11 Trimethoprim . . . . . . . 9 Timolol . . . . . . . . . . . .15
Sulfamethoxazole- Timoptic Ocudose . . . . . 15
S Trimethoprim DS . . . . . 9 Tirosint . . . . . . . . . . . 15
Saizen . . . . . . . . . . . . 15 Sulfasalazine . . . . . . . . 16 Tivicay . . . . . . . . . . . . 17
Saphris . . . . . . . . . . . 12 Sumatriptan Tab and Spray . 12 Tizanidine Cap . . . . . . . . 19
Savaysa . . . . . . . . . . .10 Sumavel Dose . . . . . . . 12 Tizanidine Tab . . . . . . . . 19
Seebri . . . . . . . . . . . . 20 Suprep Bowel Prep . . . . . 16 TOBI Nebulizer . . . . . . . 9
Sensipar . . . . . . . . . . 15 Sustiva . . . . . . . . . . . 17 TOBI Podhaler . . . . . . . 9
Serevent Diskus . . . . . . 20 Symbicort . . . . . . . . . .20 Tobramycin . . . . . . . . . 15
Seroquel XR . . . . . . . . 12 Synagis . . . . . . . . . . . 18 Tobramycin/
Sertraline . . . . . . . . . . 12 Synjardy . . . . . . . . . . . 14 Dexamethasone . . . . . 15

Bold type = Brand-name drug

[Plain type = Generic drug] 29
Index of Drugs

Tobramycin Neb . . . . . . . 9 V X
Tolterodine . . . . . . . . . . 20 Vagifem . . . . . . . . . . . 22 Xarelto . . . . . . . . . . . 10
Topiramate Tab . . . . . . . 13 Valacyclovir . . . . . . . . . . 9 Xeljanz . . . . . . . . . . . 17
Torsemide Tab . . . . . . . . 10 Valsartan . . . . . . . . . . .10 Xigduo XR . . . . . . . . . 14
Toujeo SoloStar . . . . . . 14 Valsartan/HCTZ . . . . . . . 10 Xopenex HFA . . . . . . . .20
Toviaz . . . . . . . . . . . . 20 Varubi . . . . . . . . . . . . 16 Xtampza ER . . . . . . . . 19
Tracleer . . . . . . . . . . . 11 Vascepa . . . . . . . . . . .11 Xulane . . . . . . . . . . . . 21
Tradjenta . . . . . . . . . . 14 Vectical . . . . . . . . . . . 14
Tramadol Tab . . . . . . . . 19 Velphoro . . . . . . . . . . 18 Z
Tramadol Veltin . . . . . . . . . . . . 14 Zarah . . . . . . . . . . . . 21
w/ Acetaminophen . . . 19 Venlafaxine ER Cap . . . . . 12 Zarxio . . . . . . . . . . . . 18
Transderm-Scop . . . . . . 16 Venlafaxine ER Tab . . . . . 12 Zenpep . . . . . . . . . . . 16
Travatan Z . . . . . . . . . 15 Venlafaxine Tab . . . . . . . 12 Zepatier . . . . . . . . . . . 9
Trazodone . . . . . . . . . . 12 Ventolin HFA . . . . . . . . 20 Zetia . . . . . . . . . . . . . 11
Tresiba . . . . . . . . . . . 14 Verapamil ER . . . . . . . . 10 Zetonna . . . . . . . . . . .20
Tretinoin Cream . . . . . . . 14 Vesicare . . . . . . . . . . . 20 Ziana Gel . . . . . . . . . . 14
Tretinoin Microsphere Gel . . 14 Vestura . . . . . . . . . . . . 21 Zioptan . . . . . . . . . . . 15
Triamcinolone . . . . . . . . 14 Viagra . . . . . . . . . . . . 17 Ziprasidone Cap . . . . . . . 12
Triamcinolone Spray . . . . . 20 Vicodin . . . . . . . . . . . . 19 Zohydro ER . . . . . . . . . 19
Triamterene/HCTZ . . . . . . 10 Vicodin ES . . . . . . . . . .19 Zolmitriptan Tab . . . . . . . 12
Triazolam Tab . . . . . . . . 12 Victoza . . . . . . . . . . . 14 Zolpidem . . . . . . . . . . 12
Tribenzor . . . . . . . . . . 10 Vigamox . . . . . . . . . . . 15 Zolpidem ER . . . . . . . . . 12
Tri-Linyah . . . . . . . . . . 21 Viibryd . . . . . . . . . . . . 12 Zomacton . . . . . . . . . 15
Trinessa . . . . . . . . . . . 21 Vimovo . . . . . . . . . . . 16 Zonisamide . . . . . . . . . 13
Tri-Previfem . . . . . . . . . 21 Vimpat . . . . . . . . . . . . 13 Zorvolex . . . . . . . . . . . 19
Tri-Sprintec . . . . . . . . . 21 Viokace . . . . . . . . . . . 16 Zostavax Injection . . . . . 18
Triumeq . . . . . . . . . . . 17 Viorele . . . . . . . . . . . . 21 Zovirax Cream . . . . . . . 14
Trulicity . . . . . . . . . . . 14 Viread . . . . . . . . . . . . 17 Zovirax Ointment . . . . . . 14
Truvada . . . . . . . . . . . 17 Vitamin D (Rx only) . . . . . 21 Zubsolv . . . . . . . . . . . 18
Tudorza . . . . . . . . . . . 20 Vogelxo . . . . . . . . . . . 18 Zutripro . . . . . . . . . . . 18
Voltaren Gel . . . . . . . . 19 Zyclara . . . . . . . . . . . 14
U Vytorin . . . . . . . . . . . . 11 Zytiga . . . . . . . . . . . . 9
Uceris Foam . . . . . . . . 16 Vyvanse . . . . . . . . . . . 11
Uloric . . . . . . . . . . . . 18
Ultresa . . . . . . . . . . . 16 W
Ursodiol . . . . . . . . . . . 18 Warfarin . . . . . . . . . . . 10
Welchol . . . . . . . . . . . 11

Bold type = Brand-name drug

[Plain type = Generic drug] 30
“My Medications” worksheet
Take this worksheet with you each time you visit a doctor. Each of your doctors should be aware
of every drug you take and you should have a list as well.
“My Medications” worksheet

Name of Medicine Drug I Take This

Directions Doctor
and Strength Tier Medicine For

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

31
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SM
of Texas

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