HM Medical Clinic

 

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Your 2015
Prescription Drug List
effective January 1, 2015 Please read: This document contains information about commonly prescribed medications.
For additional information: Call the toll-free member phone number on the back of your health plan ID card.
Visit myuhc.com®
• Locate a participating retail pharmacy by ZIP code.
• Look up possible lower-cost medication alternatives.
• Compare medication pricing and options.
Your Prescription Drug List
This Prescription Drug List (PDL) outlines the most commonly prescribed medications for certain
conditions and organizes them into cost levels, also known as tiers. An important part of the PDL is
giving you choices so you and your doctor can choose the best course of treatment for you.
Go to myuhc.com® for complete drug information
Since the PDL may change, we encourage you to visit our website, myuhc.com. This website is the
best source for up-to-date information about the medications your pharmacy benefi t covers, possible
lower-cost options, and cost comparisons.
Table of Contents
Drug tiers and cost . . . . . . . . . . . . 5
Programs and Limits . . . . . . . . . . . 7
Drugs by category . . . . . . . . . . . . 10
Inflammatory Conditions: Rheumatoid
Arthritis, Crohn's Disease, Psoriasis,
Ulcerative Colitis . . . . . . . . . . . . 20
Men's Health
Erectile Dysfunction . . . . . . . . . . . . 20 Testosterone Therapy . . . . . . . . . . . 20 Miscellaneous . . . . . . . . . . . . . . 21
Central Nervous System
Attention Deficit Disorder . . . . . . . . . . 13
Overactive Bladder . . . . . . . . . . . 23
Sedatives/Hypnotics . . . . . . . . . . . . 15 Dermatology . . . . . . . . . . . . . . . 15
Pulmonary Arterial Hypertension . . . . . . 24 Blood Glucose Monitoring . . . . . . . . . 17 Transplant . . . . . . . . . . . . . . . . 24
Vitamins/Electrolytes . . . . . . . . . . 24
Hormone Replacement . . . . . . . . . . . 25 Thyroid Hormone Replacement . . . . . . . 18 Brand Only Exclusions . . . . . . . . . 26
At UnitedHealthcare, 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 Prescription Drug List.
What is a Prescription Drug List (PDL)?
This document is a list of commonly prescribed medications. 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 PDL and your benefit plan documents, the
benefit plan documents will rule. It is not a complete list of medications, and not all medications listed
may be covered under your plan. Please look at your benefit plan documents provided by your employer
or health plan to see what medications are covered under your plan. You may also log on to myuhc.com or
call the toll-free member phone number on the back of your health plan ID card for more information.
How do I use my Prescription Drug List?
When choosing a medication, you and your doctor should consult the PDL. 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 programs 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 myuhc.com or call the toll-free member
phone number on the back of your health plan ID card.
What are tiers?
Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, which is
determined by your employer or health plan. 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
Helpful Tips
Lower-cost drugs . Use Tier 1 drugs for the lowest Lowest Cost
Some brands and generics out-of-pocket costs .
are also included .
Mix of brands and Use Tier 2 drugs, instead of Tier 3 to help reduce yourout-of-pocket costs .
Mostly higher-cost brand Many Tier 3 drugs have Highest Cost
as well as select generic 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 may apply once you hit your deductible. Refer to your enrollment and
plan materials on myuhc.com, or call the toll-free number of the back of your health plan ID card for
more information about your benefit plan.
When does the Prescription Drug List change?
• Medications may move to a lower tier at any time. • Medications may move to a higher tier when a generic becomes available.
• Medications may move to a higher tier or be excluded from coverage most often on January 1 or July 1.
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 number on the back of your ID card.
Programs and Limits
Some medications are noted with letters next to them. The letters refer to our pharmacy benefit
programs. Your benefit plan determines how these medications are covered and may differ than what is
noted in the PDL. Call the number for Member Services listed on the back of your ID card if you have
any questions about your prescription drug coverage.
Designated Specialty Program – Specialty medications need to be fil ed at a designated specialty pharmacy for network coverage . Call the number on your ID card or call 1-888-739-5820 for more information .
May be excluded from coverage or subject to prior authorization and/or trial/ failure of another medication(s) . Lower-cost options are available and covered . – More than one month's worth of medication included in package so additional copay applies .
Notification or Prior Authorization required * – Your doctor is required to provide additional information to us to determine coverage . Refill and Save Program – Save money on your copayment when you refill your prescription on time as prescribed . Program eligibility may vary .
Select Designated Pharmacy – Must use a lower cost medication at retail or transfer the impacted medication to the mail service pharmacy for network coverage . – Amount of medication covered per copayment or in a specific – Trial of a lower cost medication is required before a higher cost medication is covered . *Depending on your benefit you may have notification or prior authorization requirements for select medications .
To learn more about a pharmacy program or to find out if it applies to you, please visit myuhc.com or
call the toll-free member phone number on the back of your health plan ID card.
Why are some medications excluded from coverage?
Medications may be excluded from coverage under your pharmacy benefit when it works the same or
similar as another prescription medication or an over-the-counter (OTC) medication. There may be
other medication options available.
Should I talk to my doctor about over-the-counter (OTC)
medications?
An over-the-counter (OTC) medication may be the right treatment for some conditions. Talk to your
doctor about available OTC options.
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, Crestor) and generic drugs in plain
type (for example, simvastatin).
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 myuhc.com to make sure.
Are you taking a specialty medication?
Specialty medications are high cost and may be used to treat rare or complex conditions. Please note, not
all specialty medications are listed in the PDL.
If you are taking a specialty medication that is on Tier 3, call the toll-free number on the back of your
health plan ID card to talk to a representative about finding lower-cost options.
OptumRx is the specialty pharmacy that can provide most of your specialty medications along with
helpful programs and services. Call OptumRx Specialty Pharmacy at 1-888-739-5820 and have your
prescriptions delivered right to your home or office.
What is Mail Service Member Select?
Your plan may include a home delivery program called Mail Service Member Select, which encourages you
to use the OptumRx® Mail Service Pharmacy for medication you take regularly. Choosing home delivery
can help you better manage the medication you take on a regular basis, and may save you time and money.
You can either confirm enrollment in the OptumRx Mail Service Pharmacy or you can disenroll from
mail service and continue to fill your maintenance medications at a retail pharmacy. You can get up to
two fills at a retail pharmacy before you have to decide. However, please be aware that you must make a
decision about whether or not to enroll in Mail Service Member Select.
If you do nothing and continue to fill your medications at a retail pharmacy, you may pay up to 100%
of your drug cost until you make a decision and take action. You must confirm your decision every year.
To learn more, you may log on to myuhc.com or call the toll-free member phone number on the back of
your health plan ID card for more information.
How do I get updated information about my pharmacy benefit?
Since the PDL may change during your plan year, we encourage you to visit myuhc.com or call the
toll-free member phone number on the back of your health plan ID card for more current information.
Log on to myuhc.com for the following pharmacy information and tools:
• Pharmacy benefit and coverage information• Possible lower-cost medication options• Medication interactions and side effects• Participating retail pharmacies by zip code• Your prescription history And, if Mail Service is included in your pharmacy benefit, you can also:
• Refill prescriptions• Check the status of your order• Set-up e-mail reminders for refills• Manage your account For more information Call the toll-free member phone number on the back of your health plan ID card.
Or, visit myuhc.com®
Where else can I go for information?
HealthCareLane.com includes short videos to help you learn more about UnitedHealthcare
benefits and health insurance information.
UHCTV.com is a fun and easy way to learn about health terms and other health-related topics.
In certain documents, the Prescription Drug List (PDL) was referred to as the "Preferred Drug List (PDL) ." This change in terms does not affect your benefit coverage . Medications are categorized by common therapeutic conditions in this PDL for ease of reference only . These categories do not determine coverage for the medication for your condition . Your benefit plan determines coverage for these medications .
Drug Name
Drug Requirements
Tier & Limits
Drug Name
Tier & Limits
Penicil in V Potassium Amoxicillin Capsule, Trimethoprim Tablet Amoxicillin/Potassium Clavulanate Chewable Augmentin XR
Fluconazole Tablet Azithromycin Tablet Itraconazole Capsule Ketoconazole Cream Cefuroxime Tablet Centany AT
Naftin 1%, 2%
Cephalexin Capsule Cream, Gel
Ciprofloxacin Tablet Clarithromycin Tablet Clindamycin Capsule Doxycycline Hyclate Terbinafine Tablet Doxycycline Monohydrate Acyclovir Ointment 50, 100 mg Capsule Monohydrate 75 mg Levofloxacin Tablet Metronidazole Tablet Minocycline Capsule Minocycline Tablet Valacyclovir Tablet Nitrofurantoin Capsule Bold type = Brand name drug[Plain type = Generic drug] N = Notification or Prior Authorization requiredRS = May be eligible for the Refill and Save Program DSP = Designated Specialty Program SDP = Select Designated Pharmacy E = May be excluded from coverage SL = Supply Limit MC = Multiple Copay ST = Step Therapy Drug Name
Drug Requirements
Tier & Limits
Drug Name
Tier & Limits
Capecitabine Tablet Diltiazem 24 Hour CD Hydroxyurea Capsule Diltiazem Sustained- Leucovorin Calcium Diltiazem Sustained- Mercaptopurine Tablet Cardiovascular/Heart Disease:
Enoxaparin Sodium Exforge HCT
Fosinopril Sodium Cardiovascular/Heart Disease:
High Blood Pressure
Amturnide
Metoprolol Succinate Benicar HCT
Metoprolol Tartrate Propranolol Tablet Drug Name
Drug Requirements
Tier & Limits
Drug Name
Tier & Limits
Omega-3-Acid Ethyl Tricor 48, 145 mg
Cardiovascular/Heart Disease:
Cardiovascular/Heart Disease:
Choline Fenofibrate Fenofibrate 43, 50 , 67, 130, 134, 150, 200 mg 48, 145 mg Tablet Pump Spray
54, 160 mg Tablet Bold type = Brand name drug[Plain type = Generic drug] N = Notification or Prior Authorization requiredRS = May be eligible for the Refill and Save Program DSP = Designated Specialty Program SDP = Select Designated Pharmacy E = May be excluded from coverage SL = Supply Limit MC = Multiple Copay ST = Step Therapy Drug Name
Drug Requirements
Tier & Limits
Drug Name
Tier & Limits
Central Nervous System:
Attention Deficit Disorder
Central Nervous System: Depression
Adderall XR
Amitriptyline Tablet Amphetamine Salt Bupropion Extended- Clonidine Extended- Bupropion Sustained- Dexmethylphenidate Citalopram Tablet Extended-Release Dexmethylphenidate Duloxetine Capsule Escitalopram Tablet Dextroamphetamine Fluoxetine Tablet, Fluvoxamine Tablet Forfivo XL
Extended-Release Imipramine Tablet Amphetamine Tablet Mirtazapine Tablet Focalin XR
Nortriptyline Capsule Paroxetine Tablet Metadate CD
Pristiq ER
Sertraline Tablet Extended-Release Venlafaxine Extended- Extended-Release Venlafaxine Extended- Venlafaxine Tablet Ritalin LA
Drug Name
Drug Requirements
Tier & Limits
Drug Name
Tier & Limits
Central Nervous System: Migraine
Central Nervous System: Other
Butalbital/Caffeine Alprazolam Extended- 325 mg/50 mg/40mg Alprazolam Tablet Aricept 23 mg
50 mg/40 mg/30 mg Rizatriptan Orally Donepezil 5, 10 mg Disintegrating Tablet Rizatriptan Tablet Sumatriptan Nasal Spray Succinate Tablet, Mirapex ER
Namenda XR
Central Nervous System:
Olanzapine Tablet Pramipexole Tablet Quetiapine Tablet Requip XL
Risperidone Tablet Ropinirole Tablet Seroquel XR
Ziprasidone Capsule Bold type = Brand name drug[Plain type = Generic drug] N = Notification or Prior Authorization requiredRS = May be eligible for the Refill and Save Program DSP = Designated Specialty Program SDP = Select Designated Pharmacy E = May be excluded from coverage SL = Supply Limit MC = Multiple Copay ST = Step Therapy Drug Name
Drug Requirements
Tier & Limits
Drug Name
Tier & Limits
Central Nervous System:
Trokendi XR
Ambien CR
Zonisamide Capsule Eszopiclone Tablet Temazepam Capsule Zolpidem Extended- Adapalene 0 .3% Gel Central Nervous System:
Carbamazepine Tablet Diproionate 0 .05% Clonazepam Tablet Augmented Lotion, Depakote ER
Dipropionate 0 .05% Divalproex Delayed- Divalproex Extended- Valerate 0 .12% Foam Gabapentin Capsule, Calcipotriene Ointment Ciclopirox Cream, Gel, Keppra XR
Lamictal XR
Lamotrigine Tablet Benzoyl Peroxide 5% Gel Extended-Release Clindamycin 1 .2%/ Benzoyl Peroxide 5% Gel Levetiracetam Tablet Clindamycin Lotion Clindamycin Solution, Oxcarbazepine Tablet Oxtellar XR
Clobetasol Propionate Phenytoin Capsule, Cream, Ointment, Clobetasol Propionate Topiramate Tablet Foam, Lotion, Shampoo Clocortolone Cream Drug Name
Drug Requirements
Tier & Limits
Drug Name
Tier & Limits
Mometasone Furoate Betamethasone Cream Cream, Lotion, Ointment Mupirocin Ointment Betamethasone Lotion Condylox Gel
Nystatin-Triamcinolone Desonide 0 .05% Cream, Acetonide Cream, Desoximetasone Gel, Olux, Olux-E
Differin 1%
Diflorasone Diacetate 0 .05% Cream, Ointment Fluocinolone Cream, Oil, Ointment, Solution Fluocinonide 0 .05% Tretinoin Microspheres Fluocinonide 0 .1% Triamcinolone Acetonide Cream, Lotion, Ointment Hydrocortisone 2 .5% Hydrocortisone Butyrate Keralyt Scalp Kit
Metrogel 1%
Metronidazole Gel 0 .75% Metronidazole Gel 1% Bold type = Brand name drug[Plain type = Generic drug] N = Notification or Prior Authorization requiredRS = May be eligible for the Refill and Save Program DSP = Designated Specialty Program SDP = Select Designated Pharmacy E = May be excluded from coverage SL = Supply Limit MC = Multiple Copay ST = Step Therapy Drug Name
Drug Requirements
Tier & Limits
Drug Name
Tier & Limits
Diabetes: Blood Glucose Monitoring
Lantus Vials
Accu-Chek Active
Test Strips
Accu-Chek Aviva
Accu-Chek Aviva
Plus Test Strips
Accu-Chek Comfort
Curve Test Strips
Accu-Chek Compact
Test Strips
Accu-Chek Nano
Accu-Chek Nano
SmartView
Test Strips
Contour Test Strips
Freestyle Test Strips
One Touch
Test Strips
One Touch Ultra
One Touch Ultra Mini
One Touch Ultra
Test Strips
One Touch Verio IQ
Metformin Extened- One Touch Verio IQ
Release Osmotic Tablet Test Strips
Metformin Extended- One Touch Verio
Humalog Mix 75-25
Humulin 70-30 Vials
Humulin N KwikPen
Humulin N Vials
Humulin R Vials
Drug Name
Drug Requirements
Tier & Limits
Drug Name
Tier & Limits
Endocrine: Growth Hormone
Eye Conditions: Allergies
Azelastine 0 .05% Ophthalmic Solution Nutropin AQ NuSpin
Eye Conditions: Antibiotics
Calcitriol Capsule Desmopressin Tablet Erythromycin 0 .5% Dexamethasone Tablet Ophthalmic Ointment Methylprednisolone Ophthalmic Solution Prednisolone Solution, Tobradex ST
Prednisone Tablet 0 .3%-0 .1% Ophthalmic Endocrine:
Thyroid Hormone Replacement
Eye Conditions: Glaucoma
Levothyroxine Sodium Alphagan P 0.1%
Liothyronine Sodium Cosopt PF
Dorzolamide-Timolol Methimazole Tablet 2%-0 .5% Ophthalmic NP Thyroid Tablet Latanoprost 0 .005% Ophthalmic Solution Bold type = Brand name drug[Plain type = Generic drug] N = Notification or Prior Authorization requiredRS = May be eligible for the Refill and Save Program DSP = Designated Specialty Program SDP = Select Designated Pharmacy E = May be excluded from coverage SL = Supply Limit MC = Multiple Copay ST = Step Therapy Drug Name
Drug Requirements
Tier & Limits
Drug Name
Tier & Limits
Timolol Maleate 0 .25%, 0 .5% Ophthalmic Asacol HD Tablet
Travatan Z
Eye Conditions: Other
Lotemax Gel
Hyoscyamine Tablet Gastrointestinal: Acid Suppression
Metoclopramide Tablet Metozolv ODT
Lansoprazole Capsules Nexium Suspension
Omeprazole Capsule Pantoprazole Tablet Sulfasalazine Tablet Ursodiol Capsule, Tablet Rabeprazole Tablet Sucralfate Tablet Drug Name
Drug Requirements
Tier & Limits
Drug Name
Tier & Limits
Men's Health: Erectile Dysfunction
Men's Health: Prostate
Finasteride Tablet Tamsulosin Capsule Terazosin Capsule, Tablet Gonal-F RFF
Men's Health: Testosterone Therapy
*Coverage is determined by the consumer's prescription drug benefit plan .
Inflammatory Conditions: Rheumatoid
Arthritis, Crohn's Disease, Psoriasis,
Testosterone Cypionate Testosterone Enanthate Testosterone Topical Bold type = Brand name drug[Plain type = Generic drug] N = Notification or Prior Authorization requiredRS = May be eligible for the Refill and Save Program DSP = Designated Specialty Program SDP = Select Designated Pharmacy E = May be excluded from coverage SL = Supply Limit MC = Multiple Copay ST = Step Therapy Drug Name
Drug Requirements
Tier & Limits
Drug Name
Tier & Limits
Sevelamer Carbonate Anastrozole Tablet Antipyrine/Benzocaine Tobramycin Nebulized Benzonatate Capsule Bromfed DM
Chlorhexidine Gluconate Alendronate Sodium Ibandronate Tablet Raloxifene Tablet Risedronate 150 mg Exemestane Tablet Chlorpheniramine Allopurinol Tablet Carisoprodol 350 mg Lidocaine Transdermal Methocarbamol Tablet Tizanidine Tablet Drug Name
Drug Requirements
Tier & Limits
Drug Name
Tier & Limits
Musculoskeletal: Pain Relief
Morphine Sulfate Extended-Release 30, 45, 60, 75, 90, Morphine Sulfate Extended-Release Tablet Nabumetone Tablet Diclofenac 1 .5% Topical Diclofenac Sodium Nucynta ER
5/325 mg, 7 .5/325 mg, 5/325 mg, 7 .5/325 mg, Hydrocodone/Ibuprofen Extended-Release Rybix ODT
Extended-Release Tablet Hydromorphone Tablet Tramadol Extended- Indomethacin Capsule Tramadol Sustained- 5/300 mg, 7 .5/300 mg, Morphine Sulfate Extended-Release 10, 20, 30, 50, 60, 80, Voltaren Gel
100, 200 mg Capsule Bold type = Brand name drug[Plain type = Generic drug] N = Notification or Prior Authorization requiredRS = May be eligible for the Refill and Save Program DSP = Designated Specialty Program SDP = Select Designated Pharmacy E = May be excluded from coverage SL = Supply Limit MC = Multiple Copay ST = Step Therapy Drug Name
Drug Requirements
Tier & Limits
Drug Name
Tier & Limits
Zohydro ER
Hydroxyzine Capsule, Levocetirizine Tablet Nasacort AQ
Detrol LA
Promethazine Tablet Dicyclomine Tablet Oxybutynin Extended- Oxybutynin Tablet Sanctura XR
Albuterol Sulfate Tablet Tolterodine Extended- Tolterodine Tablet Breo Ellipta
Trospium Extended- Levalbuterol Nebs Azelastine 0 .1% Montelukast Chewable Azelastine 0 .15% Montelukast Granules Perforomist
Beconase AQ
Proair HFA
Budesonide Nasal Cyproheptadine Tablet Desloratadine Orally Disintegrating Tablet, Ventolin HFA
Xopenex HFA
Xopenex Nebs
Flunisolide Nasal Spray Fluticasone Nasal Spray Drug Name
Drug Requirements
Tier & Limits
Drug Name
Tier & Limits
Pulmonary Arterial Hypertension
Women's Health: Contraceptives
Sildenafil Tablet Astagraf XL
Azathioprine Tablet Cyclosporine Modified Generess Fe
Mycophenolate Capsule Mycophenolic Acid Lo Loestrin Fe
Tacrolimus Capsule Lo Minastrin 24 FE
LoMedia 24 FE
Potassium Chloride Minastrin 24 FE
Potassium Citrate Bold type = Brand name drug[Plain type = Generic drug] N = Notification or Prior Authorization requiredRS = May be eligible for the Refill and Save Program DSP = Designated Specialty Program SDP = Select Designated Pharmacy E = May be excluded from coverage SL = Supply Limit MC = Multiple Copay ST = Step Therapy Drug Name
Drug Requirements
Tier & Limits
Drug Name
Tier & Limits
Women's Health: Hormone Replacement
Necon 0 .5/35, 1/35, Norgestimate-Ethinyl Climara Pro
Estradiol/Norethindrone Ortho Tri-Cyclen Lo
Methyltestosterone Medroxyprogesterone Micronized Capsule Women's Health: Prenatal Vitamins
Brand Prenatal
Yasmin 28
Common Brand medications
excluded from coverage under Lower-cost option(s)
many benefit plans
Omeprazole (generic Prilosec), Pantoprazole (generic Protonix),
Rabeprazole (generic Aciphex), Dexilant
Fentanyl Lozenge (generic Actiq) Pioglitazone (generic Actos) Amphetamine/Dextroamphetamine Immediate-Release (generic Adderal ) Adoxa Tablet
Doxycycline Hyclate (generic Vibra-Tab), Doxycycline Monohydrate Tablet (generic Adoxa Tablet) Zolpidem (generic Ambien) Anastrozole (generic Arimidex) Azelastine Nasal Spray (generic Astelin) Lorazepam (generic Ativan) Moxifloxacin Tablet (generic Avelox) Morphine Sulfate Extended-Release Tablet (generic MS Contin), Morphine Sulfate Extended-Release Capsule (generic Avinza) Citalopram (generic Celexa) Ciprofloxacin Oral Suspension (generic Cipro Suspension) Clocortolone 0 .1% Cream (generic Cloderm), Mometasone Furoate Cream 0 .1 % (generic Elocon) Duloxetine (generic Cymbalta) Diovan HCT
Valsartan/Hydrochlorothiazide (generic Diovan HCT) Clindamycin Solution (generic Cleocin T) plus OTC Benzoyl Peroxide, Clindamycin 1 .2%/Benzoyl Peroxide 5% (generic Duac) Fentanyl Transdermal Patch (generic Duragesic) Effexor XR
Venlafaxine Extended-Release Capsule (generic Effexor XR) Entocort EC
Budesonide (generic Entocort EC) Raloxifene (generic Evista) Letrozole (generic Femara) Fioricet with Codeine
50 mg/325 mg/40 mg/
50 mg/325 mg/40 mg/30 mg (generic Fioricet with Codeine) Tamsulosin (generic Flomax) Ziprasidone (generic Geodon) Imitrex Injection &
Sumatriptan Injection, Tablet (generic Imitrex) Escitalopram (generic Lexapro) Lidocaine Transdermal Patch (generic Lidoderm) Atorvastatin (generic Lipitor) Lofibra 54, 160 mg
Fenofibrate 54, 160 mg (generic Lofibra) Omega-3-Acid Ethyl Esters (generic Lovaza) Eszopiclone (generic Lunesta), Zaleplon (generic Sonata), Zolpidem (generic Ambien) Bold type = Brand name drug [Plain type = Generic drug] Common Brand medications
excluded from coverage under Lower-cost option(s)
many benefit plans
Maxalt
Rizatriptan (generic Maxalt) Rizatriptan (generic Maxalt), Rizatriptan Oral y Disintegrating Tablet (generic Maxalt MLT) Atovaquone Suspension (generic Mepron) Losartan (generic Cozaar), Telmisartan (generic Micardis) Micardis HCT
Losartan/Hydrochlorothiazide (generic Hyzaar), Telmisartan/Hydrochlorothiazide (generic Micardis HCT) Doxycycline Hyclate (generic Vibramycin), Doxycycline Monohydrate (generic Monodox) Malathion (generic Ovide), Permethrin (generic Elimite), Spinosad (generic Natroba) Azelastine (generic Optivar), Lastacaft
Ortho Evra
Norelgestromin/Ethinyl Estradiol Topical Patch, Xulane (generic Ortho Evra) Acetaminophen/Oxycodone (generic Percocet) Clopidogrel (generic Plavix) Omeprazole (generic Prilosec) Pantoprazole (generic Protonix) Fluoxetine (generic Prozac) Sildenafil (generic Revatio) Risperidone (generic Risperdal) Quetiapine (generic Seroquel) Singulair Chewable
Montelukast Chewable Tablet (generic Singulair) Montelukast (generic Singulair) Metaxalone (generic Skelaxin) Betamethasone/Calcipotriene Ointment (generic Taclonex) Diazepam (generic Valium) Valacyclovir (generic Valtrex) Viramune XR 400 mg
Nevirapine Extended-Release (generic Viramune XR) Bupropion Extended-Release (generic Wel butrin SR) Bupropion Extended-Release (generic Wel butrin XL) Alprazolam (generic Xanax) Alprazolam Extended-Release (generic Xanax XR) Sertraline (generic Zoloft) Olanzapine (generic Zyprexa) Olanzapine (generic Zyprexa), Olanzapine Orally Disintegrating Tablet (generic Zyprexa Zydis) Bold type = Brand name drug [Plain type = Generic drug] Azathioprine Tablet .24 Azelastine . 18, 23, 26, 27 Accu-Chek Active Test Strips . 17 Azelastine 0.05% Ophthalmic Accu-Chek Aviva Plus . 17 Amitriptyline Tablet . 13 Accu-Chek Aviva Plus Test Strips . 17 Azelastine 0.15% Nasal Spray .23 Amlodipine/Telmisartan . 11 Accu-Chek Comfort Curve Azelastine 0.1% Nasal Spray .23 Amlodipine Besylate-Benazepril . 11 Azelastine Nasal Spray.26 Amoxicillin/Potassium Clavulanate Accu-Chek Compact Test Strips . 17 Chewable Tablet, Tablet . 10 Accu-Chek Nano SmartView . 17 Azithromycin Tablet . 10 Amoxicillin Capsule, Chewable Accu-Chek Nano SmartView Immediate-Release .26 Caffeine/Codeine 325 mg/ Amphetamine Salt Combo . 13 50 mg/40 mg/30 mg . 14 Baclofen Tablet . 21 Caffeine 325 mg/50 mg/40mg . 14 Acetaminophen/Codeine Tablet .22 Anastrozole . 21, 26 Acetaminophen/Oxycodone . 27 Anastrozole Tablet . 21 Benazepril-Hydrochlorothiazide . 11 Aciphex Sprinkle . 19 Antipyrine/Benzocaine Benzonatate Capsule . 21 Otic Solution . 21 Acyclovir Ointment . 10 Ointment . 15, 27 Acyclovir Tablet . 10 Betamethasone Diproionate 0.05% Augmented Lotion, Ointment .15 Adapalene 0.1% Cream, Gel .15 Aricept 23 mg . 14 Betamethasone Dipropionate Adapalene 0.3% Gel .15 0.05% Cream, Ointment .15 Armour Thyroid . 18 Betamethasone Valerate 0.12% Adderall . 13, 26 Asacol HD Tablet . 19 Adoxa Capsule . 10 Advair Diskus/HFA .23 Albuterol Sulfate Tablet .23 Atenolol-Chlorthalidone . 11 Alendronate Sodium Tablet . 21 Bisoprolol-Hydrochlorothiazide . 11 Alfuzosin Tablet .20 Atorvastatin .12, 26 Allopurinol Tablet . 21 Atovaquone Suspension . 27 Brand Prenatal Vitamins .25 Alphagan P 0.1% . 18 Alprazolam . 14, 27 Alprazolam Extended-Release . 14, 27 Alprazolam Extended-Release Budesonide .23, 26 Alprazolam Tablet . 14 Budesonide Nasal Spray .23 Avelox Tablet .26 Budesonide Nebs .23 Buprenorphine/Naloxone Tablet . 14 Bupropion Extended-Release . 13, 27 Bupropion Extended-Release Denavir Cream . 10 Bupropion Sustained-Release Clindamycin 1%/Benzoyl Depo-Testosterone .20 Bupropion Tablet . 13 Peroxide 5% Gel .15 Desloratadine Orally Disintegrating Buspirone Tablet . 14 Clindamycin 1.2%/Benzoyl Tablet, Tablet .23 Peroxide 5% . 15, 26 Desmopressin Tablet . 18 Caffeine/Codeine Phosphate Clindamycin 1.2%/Benzoyl Desonide 0.05% Cream, Lotion, 50 mg/325 mg/40 mg/30 mg .26 Peroxide 5% Gel .15 Clindamycin Capsule . 10 Desoximetasone Gel, Ointment . 16 Clindamycin Gel .15 Desvenlafaxine . 13 Clindamycin Lotion .15 Clindamycin Solution . 15, 26 Clindamycin Solution, Swabs .15 Dexamethasone Tablet . 18 Clobetasol Propionate Cream, Dexilant . 19, 26 Calcitriol Capsule. 18 Ointment, Solution .15 Dexmethylphenidate Clobetasol Propionate Foam, Lotion, Extended-Release Capsule . 13 Dexmethylphenidate Tablet . 13 Clocortolone 0.1% Cream .26 Capecitabine Tablet . 11 Clocortolone Cream .15 Extended-Release . 13 Carbamazepine Tablet .15 Cloderm Cream .26 Carbidopa-Levodopa . 14 Clonazepam Tablet .15 Dextroamphetamine Sulfate Carisoprodol 350 mg Tablet . 21 Clonidine Extended-Release Diazepam . 14, 15, 27 Clonidine Tablet . 11 Diazepam Tablet . 14, 15 Cefdinir Capsule . 10 Clopidogrel. 11, 27 Diclofenac 1.5% Topical Solution .22 Cefuroxime Tablet . 10 Diclofenac Sodium Tablet .22 Dicyclomine Tablet .23 Diflorasone Diacetate 0.05% Cream, Ointment . 16 Cephalexin Capsule . 10 Combivent Respimat .23 Diltiazem 24 Hour CD. 11 Chlorhexidine Gluconate . 21 Diltiazem Sustained-Release Condylox Gel . 16 Pseudoephedrine. 21, 27 Contour Test Strips . 17 Diltiazem Sustained-Release Pseudoephedrine Solution . 21 Chlorthalidone . 11 Choline Fenofibrate .12 Divalproex Delayed-Release Ciclopirox Cream, Gel, Lotion, Divalproex Extended-Release Cipro Suspension .26 Donepezil 5, 10 mg Tablet . 14 Ciprofloxacin Oral Suspension .26 Dorzolamide-Timolol 2%-0.5% Ciprofloxacin Tablet . 10 Cyclobenzaprine . 21 Ophthalmic Solution . 18 Citalopram . 13, 26 Cyclosporine Modified Capsule .24 Doxazosin . 11, 20 Citalopram Tablet . 13 Doxazosin Tablet .20 Cyproheptadine Tablet .23 Doxycycline Hyclate . 10, 26, 27 Doxycycline Hyclate Capsule, Clarithromycin Tablet . 10 Doxycycline Monohydrate . 10, 26, 27 Doxycycline Monohydrate 50, 100 mg Capsule . 10 Doxycycline Monohydrate 75 mg Capsule . 10 Doxycycline Monohydrate Tablet .26 Duloxetine . 13, 26 Duloxetine Capsule . 13 Fenofibrate 43, 50 , 67, 130, Glipizide Extended-Release . 17 134, 150, 200 mg Capsule .12 Fenofibrate 48, 145 mg Tablet .12 Fenofibrate 54, 160 mg .12, 26 Glyburide-Metformin . 17Golytely . 19 Fenofibrate 54, 160 mg Tablet .12Fenofibric Acid .12 Fentanyl Lozenge .26 Fentanyl Patches .22 Fentanyl Transdermal Patch .26 Finasteride Tablet.20 Fioricet with Codeine .26 Fioricet with Codeine Humalog KwikPen . 17 50 mg/325 mg/40 mg/30 mg .26 Humalog Mix 75-25 KwikPen . 17 Humalog Vials . 17 Enalapril-Hydrochlorothiazide . 11 Flovent Diskus/HFA .23 Humulin 70-30 Vials . 17 Fluconazole Tablet . 10 Humulin KwikPen . 17 Flunisolide Nasal Spray .23 Humulin N KwikPen . 17 Enoxaparin Sodium . 11 Fluocinolone Cream, Oil, Humulin N Vials . 17 Ointment, Solution . 16 Humulin R Vials . 17 Fluocinonide 0.05% Cream . 16 Fluocinonide 0.1% Cream . 16 Hydrochlorothiazide . 11, 12, 26, 27 Epiduo . 16Epipen . 21 Fluoxetine. 13, 27 5/325 mg, 7.5/325 mg, Fluoxetine Tablet, Capsule. 13 10/325 mg Tablet .22 Fluticasone Nasal Spray .23 Erythromycin 0.5% Ophthalmic Fluvoxamine Tablet . 13 Hydrocodone/Homatropine . 21 Escitalopram . 13, 26 Hydrocodone/Ibuprofen Tablet .22 Escitalopram Tablet . 13 Hydrocortisone 2.5% Cream, Estrace Cream .25 Estradiol/Norethindrone Acetate Hydrocortisone Butyrate Cream . 16 Hydromorphone Extended-Release Estradiol Tablet .25 Fosinopril Sodium . 11 Hydromorphone Tablet .22 Freestyle Test Strips . 17 Hydroxychloroquine Sulfate .20 Hydroxyurea Capsule . 11 Eszopiclone . 15, 26 Hydroxyzine Capsule, Tablet .23 Eszopiclone Tablet .15 Hyoscyamine Tablet . 19 Etodolac Capsule .22 Gabapentin Capsule, Tablet .15 Exemestane Tablet . 21 Ibandronate Tablet . 21 Ibuprofen Tablet .22 Imipramine Tablet . 13 Letrozole . 21, 26 Imitrex Injection & Tablets .26 Letrozole Tablet . 21 Leucovorin Calcium Tablet . 11 Medroxyprogesterone .25 Indomethacin Capsule .22 Levalbuterol Nebs .23 Meloxicam Tablet.22 Levemir Flexpen . 17 Levemir Vials . 17 Mepron Suspension . 27 Levetiracetam Extended-Release Mercaptopurine Tablet . 11 Levetiracetam Tablet .15 Ipratropium Nebs .23 Levocetirizine Tablet .23 Levofloxacin Tablet . 10 Metformin Extended-Release Isosorbide Mononitrate ER.12 Levothyroxine Sodium Tablet . 18 Metformin Extened-Release Itraconazole Capsule . 10 Osmotic Tablet . 17 Methadone Tablet .22 Methimazole Tablet . 18 Lidocaine Transdermal Patch . 21, 26 Methocarbamol Tablet . 21 Methylphenidate . 13 Liothyronine Sodium Tablet . 18 Methylphenidate Extended-Release Methylphenidate Extended-Release Liptruzet .12Lisinopril . 11, 35 Methylprednisolone Tablet . 18 Lisinopril-Hydrochlorothiazide . 11 Metoclopramide Tablet . 19 Lithium Capsule . 14 Metoprolol Succinate 50, 100, 200 mg . 11 Lo Loestrin Fe .24 Metoprolol Tartrate . 11 Metozolv ODT . 19 Lo Minastrin 24 FE .24 Locoid Lipocream . 16 Metronidazole Gel 0.75% . 16 Locoid Lotion . 16 Metronidazole Gel 1% . 16 Metronidazole Tablet . 10 Keralyt Scalp Kit . 16 Lofibra 54, 160 mg .26 Ketoconazole Cream . 10 LoMedia 24 FE .24 Micardis HCT . 27 Ketorolac Tablet .22 Lorazepam . 14, 26 Lorazepam Tablet . 14 Microgestin FE .24 Minastrin 24 FE .24 Kombiglyze XR . 17 Losartan . 11, 27 Minocycline Capsule . 10 Losartan-Hydrochlorothiazide . 11 Minocycline Tablet . 10 Losartan/Hydrochlorothiazide . 27 Mirtazapine Tablet . 13 Lotemax Solution . 19 Modafinil Tablet . 14 Lamotrigine Tablet .15 Mometasone Furoate Lansoprazole Capsules . 19 Lantus Solostar . 17 Mometasone Furoate Lantus Vials . 17 Cream, Lotion, Ointment . 16 Lastacaft . 18, 27 Latanoprost 0.005% Ophthalmic Montelukast . 23, 27 Montelukast Chewable Tablet . 23, 27 Montelukast Chewable Tablet, Novolog Flexpen . 17 Montelukast Granules .23 NP Thyroid Tablet . 18 Morphine Sulfate Extended-Release Oxcarbazepine Tablet .15 10, 20, 30, 50, 60, 80, Oxistat Cream . 10 100, 200 mg Capsule .22 Oxistat Lotion . 10 Morphine Sulfate Extended-Release Nutropin AQ NuSpin . 18 30, 45, 60, 75, 90, 120 mg Oxybutynin Extended-Release Morphine Sulfate Extended-Release Nystatin-Triamcinolone Acetonide Cream, Ointment . 16 Oxybutynin Tablet .23 Morphine Sulfate Extended-Release Nystatin Cream, Ointment . 10 Oxycodone/Acetaminophen 5/325 mg, 7.5/325 mg, 10/325 mg Tablet .22 Moxifloxacin Tablet .26 Ofloxacin 0.3% Ophthalmic Oxycodone Tablet .22 Olanzapine . 14, 27 Oxymorphone Extended-Release Mupirocin Ointment. 16 Olanzapine Orally Disintegrating Mycophenolate Capsule .24 Mycophenolic Acid Tablet .24 Olanzapine Tablet . 14 Olux, Olux-E . 16 Pantoprazole . 19, 26, 27 Pantoprazole Tablet . 19 Omeclamox-Pak . 19 Paroxetine Tablet . 13 Nabumetone Tablet .22 Omega-3-Acid Ethyl Esters.12, 26 Omega-3-Acid Ethyl Esters Naftin 1%, 2% Cream, Gel . 10 Omeprazole . 19, 26, 27 Penicillin V Potassium Tablet . 10 Omeprazole Capsule . 19 Naproxen Tablet .22 Ondansetron ODT . 19 One Touch Test Strips . 17 Necon 0.5/35, 1/35, 1/50, 10/11 .25 One Touch Ultra Meter . 17 Phenytoin Capsule, Suspension .15 One Touch Ultra Mini . 17 One Touch Ultra Test Strips . 17 Pioglitazone .17, 26 One Touch Verio IQ . 17 Pioglitazone-Metformin . 17 Nevirapine Extended-Release . 27 One Touch Verio IQ Test Strips . 17 Nexium Capsule . 19 One Touch Verio Sync . 17 Polyethylene Glycol 3350 . 19 Nexium Suspension Packet . 19 Niacin Extended-Release Tablet .12 Potassium Chloride .24 Potassium Citrate .24 Nifedipine Extended-Release . 11 Nitrofurantoin Capsule . 10 Pramipexole Tablet. 14 Nitrofurantoin Macrocrystal Nitroglycerin Sublingual Spray .12 Nitrolingual Pump Spray .12 Prednisolone Solution, Syrup . 18 Prednisone Tablet. 18 Norelgestromin/Ethinyl Estradiol Ortho-Novum 7/7/7 .25 Topical Patch . 27 Norgestimate-Ethinyl Estradiol .25 Ortho Micronor .25 Prenatal Plus .25 Ortho Tri-Cyclen .25 Nortrel 0.5/35 .25 Ortho Tri-Cyclen Lo .25 Prevacid Solutab . 19 Nortriptyline Capsule . 13 OTC Benzoyl Peroxide .26 Sucralfate Tablet . 19 Prilosec . 19, 26, 27 Prilosec Suspension . 19 Ribavirin Tablet . 10 Risedronate 150 mg Tablet . 21 Sulfasalazine Tablet . 19 Sumatriptan Injection, Tablet .26 Risperidone . 14, 27 Sumatriptan Nasal Spray . 14 Risperidone Tablet . 14 Sumatriptan Succinate Tablet, Progesterone Micronized Rizatriptan . 14, 27 Sumavel DosePro . 14 Rizatriptan Orally Disintegrating Tablet . 14, 27 Promethazine/Codeine . 21 Rizatriptan Tablet . 14 Ropinirole Tablet . 14 Dextromethorphan . 21 Promethazine Tablet .23 Propranolol Tablet . 11 Protonix . 19, 26, 27 Protonix Suspension . 19 Taclonex Ointment . 27 Proventil HFA .23 Tacrolimus Capsule .24 Seroquel . 14, 27 Tamoxifen Tablet . 21 Pulmicort Flexhaler .23 Tamsulosin .20, 26 Sertraline . 13, 27 Tamsulosin Capsule .20 Sertraline Tablet . 13 Sevelamer Carbonate . 21 Sildenafil .24, 27 Sildenafil Tablet .24 Telmisartan . 11, 12, 27 Quetiapine . 14, 27 Quetiapine Tablet . 14 Hydrochlorothiazide .12, 27 Quillivant XR . 13 Simvastatin .8, 12 Temazepam Capsule .15 Terazosin .12, 20 Singulair Chewable Tablet . 27 Terazosin Capsule, Tablet .20 Singulair Tablet . 27 Terbinafine Tablet . 10 Sirolimus Tablet .24 Testosterone Cypionate Injection .20 Rabeprazole . 19, 26 Sodium Sulfacetamide-Sulfur . 16 Testosterone Enanthate Injection .20 Rabeprazole Tablet . 19 Testosterone Topical Gel .20 Raloxifene . 21, 26 Raloxifene Tablet . 21 Timolol Maleate 0.25%, 0.5% Ophthalmic Solution . 19 Tizanidine Tablet . 21 Spironolactone .12 Tobi Podhaler . 21 0.3%-0.1% Ophthalmic Tobramycin Nebulized Solution . 21 Tolterodine Extended-Release Retin-A Micro . 16 Suboxone Film . 14 Tolterodine Tablet .23 Topicort Spray . 16 Topiramate Tablet .15 Tramadol Extended-Release Venlafaxine Extended-Release Zaleplon . 15, 26 Zaleplon Capsule .15 Tramadol Sustained-Release Venlafaxine Extended-Release Zegerid Capsule . 19 Tramadol Tablet .22 Venlafaxine Tablet . 13 Trazodone Tablet . 13 Verapamil Sustained-Release .12 Tretinoin Microspheres . 16 Ziprasidone . 14, 26 Ziprasidone Capsule . 14 Triamcinolone Acetonide Cream, Lotion, Ointment . 16 Vicodin 5/300 mg, 7.5/300 mg, Zolpidem . 15, 26 Triamcinolone Nasal Spray .23 10/300 mg Tablet.22 Zolpidem Extended-Release Zolpidem Tablet .15 Tricor 48, 145 mg .12 Viramune XR 400 mg. 27 Zonisamide Capsule .15 Trospium Extended-Release Zovirax Cream . 10 Trospium Tablet .23 Zyprexa Zydis . 27 Warfarin Sodium . 11 Wellbutrin SR . 27 Wellbutrin XL . 27 Ursodiol Capsule, Tablet . 19 Valacyclovir . 10, 27 Valacyclovir Tablet . 10 Valsartan .12, 26 "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.
Example: Lisinopril, 20mg High blood pressure For more information Call the toll-free member phone number on the back of your health plan ID card.
Or, visit myuhc.com®
Where else can I go for information? HealthCareLane.com includes short videos to help you learn more about
UnitedHealthcare benefi ts and health insurance information.
UHCTV.com is a fun and easy way to learn about health terms and other
All branded medications are trademarks or registered trademarks of their respective owners . 2014 United HealthCare Services, Inc . All rights reserved . Created September, 2014 . 2015 Prescription Drug List – Advantage Three-Tier

Source: http://www.pkwy.k12.mo.us/inside/benefits/health/UHC_High_Deductible_Prescription_Drug_List.pdf