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Your 2013 Prescription Drug List Quick-Reference Guide

Table of Contents Welcome to Your Prescription Drug List. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Frequently Asked Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Information About Tiers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Prescription Drug List. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Anti-Infectives Antibiotics. . . . . . . . . . . . . . . . . . . . . . . 5 Antifungals. . . . . . . . . . . . . . . . . . . . . . 5 Antivirals . . . . . . . . . . . . . . . . . . . . . . . 5

Diabetes/Endocrine Blood Glucose Monitoring. . . . . . . . . 9 Insulin. . . . . . . . . . . . . . . . . . . . . . . . . 10 Non-Insulin. . . . . . . . . . . . . . . . . . . . . 10

Miscellaneous

Cardiovascular/Heart Disease Coagulation Therapy. . . . . . . . . . . . . . 5 High Blood Pressure. . . . . . . . . . . . . . 6 High Cholesterol. . . . . . . . . . . . . . . . . 6 Other. . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Endocrine Growth Hormone. . . . . . . . . . . . . . . . 10 Other. . . . . . . . . . . . . . . . . . . . . . . . . . 10

Musculoskeletal

Central Nervous System Attention Deficit Disorder. . . . . . . . . . 7 Depression. . . . . . . . . . . . . . . . . . . . . . 7 Migraine. . . . . . . . . . . . . . . . . . . . . . . . 7 Multiple Sclerosis . . . . . . . . . . . . . . . . 8 Sedatives/Hypnotics. . . . . . . . . . . . . . 8 Seizure Disorders . . . . . . . . . . . . . . . . 8 Other. . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Dermatology. . . . . . . . . . . . . . . . . . . 9

Eye Conditions Allergies. . . . . . . . . . . . . . . . . . . . . . . 11 Antibiotics. . . . . . . . . . . . . . . . . . . . . . 11 Glaucoma. . . . . . . . . . . . . . . . . . . . . . 11

Miscellaneous . . . . . . . . . . . . . . . . . . 12 Overactive Bladder. . . . . . . . . . . . . . 12

Osteoporosis. . . . . . . . . . . . . . . . . . . 13 Pain Relief . . . . . . . . . . . . . . . . . . . . . 13 Rheumatoid Arthritis. . . . . . . . . . . . . 13 Other. . . . . . . . . . . . . . . . . . . . . . . . . . 14 Respiratory Asthma/COPD. . . . . . . . . . . . . . . . . . 14

Gastrointestinal Acid Suppression . . . . . . . . . . . . . . . 11 Nausea/Vomiting. . . . . . . . . . . . . . . . 11 Other. . . . . . . . . . . . . . . . . . . . . . . . . . 12

Nasal Allergies. . . . . . . . . . . . . . . . . . 14

Men’s Health Erectile Dysfunction. . . . . . . . . . . . . . 12 Prostate . . . . . . . . . . . . . . . . . . . . . . . 12

Contraceptives. . . . . . . . . . . . . . . . . . 14

Oral Allergies. . . . . . . . . . . . . . . . . . . 14 Women’s Health Estrogen/Progesterone. . . . . . . . . . . 15 Prenatal Vitamins. . . . . . . . . . . . . . . . 15

Additional Tier 3 drugs with a generic equivalent in Tier 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

For the most current PDL updates, visit myuhc.com or call the toll-free member phone number on the back of your health plan ID card. Created March, 2013. 2013 Prescription Drug List – Traditional Three-Tier 7/13


Your Prescription Drug List Helping you get the most out of your pharmacy benefit. This Prescription Drug List (PDL) outlines the most commonly prescribed medications for certain conditions and organizes them into cost levels, also known as tiers.

Go to myuhc.comÂŽ for complete and up-to-date 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 benefit covers, possible lower-cost options, and cost comparisons.

Visit www.myuhc.com for updates

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2013 Prescription Drug List – Three-Tier


Welcome to your 2013 Prescription Drug List

At UnitedHealthcare, we want to help you better understand your medication choices. 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)?

What are tiers?

This document is a list of commonly prescribed medications placed into cost levels, also known as tiers. It includes both brand and generic prescription medications approved by the U.S. Food and Drug Administration (FDA). The PDL is reviewed periodically and may change.

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 lowestcost 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.

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 a 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.

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

How do I use my Prescription Drug List? When choosing a medication, you and your doctor should consult the PDL. It is organized by common medical conditions. Then, within each medical condition section, medications are listed by cost level, known as tiers.

Tier 2

Tier 3

Your lowest-cost medications

Your midrange-cost medications

Your highest-cost medications

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

If your medication is not listed in this document, please log on to myuhc.com or call the toll-free member phone number on the back of your health plan ID card.

Visit www.myuhc.com for updates

Tier 1

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2013 Prescription Drug List – Three-Tier


When does the Prescription Drug List change?

Why are some medications excluded from coverage?

• 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 on January 1. • Medications may be excluded from coverage on January 1 or July 1.

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?

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

An over-the-counter (OTC) medication may be the right treatment for some conditions. Talk to your doctor about available OTC options. These medications are not covered under your pharmacy benefit, but they may cost less than your out-of-pocket expense for prescription medications.

Why are there letters (SL, N, etc.) next to certain medications in the PDL, and what do they mean? Some medications are noted with letters next to them. The symbols refer to our pharmacy benefit programs and are provided to help you check which medications may have a program. Your benefit plan determines how these medications may be covered for you.

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.

PDL Symbols / T May be eligible for Half Tablet Program DSN Designated Specialty Network E May be excluded from coverage MC Multiple Copay N Notification or Prior Authorization required* RS May be eligible for the Refill and Save Program SDP Select Designated Pharmacy SL Supply Limit ST Step Therapy 1 2

What if my doctor writes a brand-name prescription?

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

The next time your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lowertier alternative is available and if it might be right for you. Generic medications are usually your lowest-cost option, but not always. Check myuhc.com to make sure.

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.

Visit www.myuhc.com for updates

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2013 Prescription Drug List – Three-Tier


Are you taking a specialty medication?

What if I still have questions?

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

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

If you are taking a specialty medication that is on Tier 2 or 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.

Where else can I go for information? • myuhc.com for the most up-to-date information about your specific benefit plan and medication information.

OptumRx is the specialty pharmacy that can provide most of your specialty medications along with helpful programs and services. Call OptumRx Specialty Pharmacy at 1-888-702-8423 and have your prescriptions delivered right to your home or office.

• HealthCareLane.com has 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.

How do I get updated information about my pharmacy benefit? Since the PDL may change, 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 • A list of medications based on a specific medical condition • 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

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.

Visit www.myuhc.com for updates

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2013 Prescription Drug List – Three-Tier


Anti-Infectives Antibiotics

(Oral, inhaled and ear antibiotics are listed)

Tier 1 Amoxicillin Amoxicillin/Potassium Clavulanate Amoxicillin-Clavulanate ER E Ampicillin Azithromycin Cefadroxil Cefdinir Cefprozil Cefuroxime Cephalexin Ciprofloxacin Sustained-Release 24 Hour Tablet Ciprofloxacin Tablet

Clarithromycin Suspension Clarithromycin Sustained-Release Tablet Clarithromycin Tablet Clindamycin HCl Clindamycin Palmitate Dicloxacillin Sodium Doxycycline Hyclate Enteric-Coated Tablet E Doxycycline Monohydrate Doxycycline Monohydrate Capsule 150 mg E Erythromycin Erythromycin Base Enteric-Coated Tablet Levofloxacin Metronidazole

Minocycline Extended-Release 24 Hour Tablet Minocycline HCl Neomycin/Polymyxin/HC Otic Nitrofurantoin Macrocrystal Nitrofurantoin Suspension Nitrofurantoin/Nitrofurantoin Macrocrystal Ofloxacin Otic Penicillin V Potassium Solodyn 45, 90, 135 mg Sulfamethoxazole/Trimethoprim Tetracycline Vancomycin SL

Tier 2 Augmentin Cayston N Cipro Suspension Ciprodex Otic

Cleocin HCl 75 mg Dapsone Ery-Tab 500 mg Macrodantin 25 mg

Tobi DSN Zyvox SL

Tier 3 Adoxa E Augmentin XR E Avelox Cetraxal

Cipro HC Doryx E Monodox E Oracea

Solodyn 55, 65, 80, 105, 115 mg Suprax

Anti-Infectives Antifungals

(Oral and topical antifungals are listed)

Tier 1 Clotrimazole Fluconazole Griseofulvin Itraconazole Capsule SL

Ketoconazole Ketoconazole Foam SL Metronidazole Vaginal Nystatin

Terbinafine Tablet SL Terconazole Vaginal Voriconazole SL

Tier 2 Clindesse Vaginal

Noxafil

Sporanox Oral Solution

Tier 3 Gynazole-1 Vaginal

Lamisil Granules SL

Anti-Infectives Antivirals Tier 1 Acyclovir Amantadine

Famciclovir SL Ribapak DSN E

Ribavirin DSN Valacyclovir SL

Tier 2 Baraclude DSN Epivir HBV DSN

Hepsera DSN Incivek DSN N SL

Rebetol Solution DSN Valcyte SL

Tier 3 Relenza SL Tamiflu SL

Valtrex E SL Victrelis DSN N SL

Cardiovascular/Heart Disease Coagulation Therapy Tier 1 Cilostazol Clopidogrel

Enoxaparin SL Fondaparinux SL

Tier 2 Coumadin

Xarelto SL

Tier 3 Aggrenox Brilinta N SL

Effient SL Fragmin SL

Pentoxifylline Warfarin Sodium

Innohep SL Pradaxa SL

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

Visit www.myuhc.com for updates

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2013 Prescription Drug List – Three-Tier


Cardiovascular/Heart Disease High Blood Pressure Tier 1 Amlodipine Amlodipine/Benazepril SL Atenolol Atenolol/Chlorthalidone Benazepril Benazepril/Hydrochlorothiazide Bisoprolol Bisoprolol/Hydrochlorothiazide Bumetanide Candesartan/Hydrochlorothiazide SDP SL Captopril Captopril/Hydrochlorothiazide Carvedilol Chlorthalidone Clonidine Clonidine Transdermal Weekly Patch SL Diltiazem Diltiazem Controlled-Release Capsule Diltiazem Sustained-Action Capsule Diltiazem Sustained-Release 12 Hour Capsule Diltiazem Sustained-Release 24 Hour Capsule

Diltiazem Sustained-Release 24 Hour Tablet Doxazosin Enalapril Enalapril/Hydrochlorothiazide Eplerenone Eprosartan SL Felodipine Furosemide Guanfacine Hydralazine Hydrochlorothiazide Irbesartan 1/2T SL Irbesartan/Hydrochlorothiazide SL Labetalol Lisinopril Lisinopril/Hydrochlorothiazide Losartan 1/2T Losartan/Hydrochlorothiazide Metolazone Metoprolol Succinate Sustained-Release Tablet Metoprolol Tartrate

Metoprolol/Hydrochlorothiazide Moexipril 1/2T Nadolol Nifedipine Nisoldipine Perindopril Erbumine 1/2T Propranolol Propranolol Sustained-Action Capsule Propranolol/Hydrochlorothiazide Quinapril/Hydrochlorothiazide Ramipril Spironolactone Spironolactone/Hydrochlorothiazide Terazosin Torsemide Trandolapril 1/2T Trandolapril/Verapamil Triamterene/Hydrochlorothiazide Valsartan/Hydrochlorothiazide SL Verapamil Verapamil Sustained-Release 24 Hour Pellets

Tier 2 Aldactazide 50-50 mg Benicar 1/2T SL Benicar HCT SL BiDil Bystolic

Cardizem LA 120 mg Clorpres Dibenzyline Diuril Suspension 250 mg/5 ml Dutoprol SL

Micardis SL Micardis HCT SL Thalitone

Tier 3 Aceon 1/2T Amturnide E SL Atacand 1/2T SDP SL Azor E SL Coreg CR E SL Diovan 1/2T SL

Diovan HCT E SL Edarbi SL Edarbyclor SL Exforge E SL Exforge HCT E SL Nexiclon XR E

Tekamlo E SL Tekturna SDP SL Tekturna HCT SDP SL Teveten HCT SL Tribenzor E SL Twynsta E SL

Cardiovascular/Heart Disease High Cholesterol Tier 1 Amlodipine/Atorvastatin E SL Atorvastatin 1/2T SL Cholestyramine Colestipol

Fenofibrate 48, 145 mg E Fenofibrate 54, 160 mg Fenofibric Acid Fluvastatin SL

Tier 2 Antara Crestor 1/2T SL

Lipofen Welchol

Tier 3 Advicor SL Altoprev E SL Caduet E SL Fenoglide Lescol XL SL

Lipitor 1/2T E SL Livalo SL Lovaza N Niaspan Simcor SL

Gemfibrozil Lovastatin Pravastatin 1/2T Simvastatin 1/2T

Tricor E Triglide Trilipix E Vytorin SL Zetia SL

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

Visit www.myuhc.com for updates

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2013 Prescription Drug List – Three-Tier


Cardiovascular/Heart Disease Other Tier 1 Amiodarone Digoxin Flecainide Acetate Isosorbide Dinitrate

Isosorbide Mononitrate Mexiletine Nitroglycerin Nitroglycerin Transdermal Patch

Nitroglycerin Spray E SL Propafenone Sustained-Release 12 Hour Capsule Sotalol

Tier 2 Lanoxin Multaq

Nitrostat Norpace CR

Ranexa

Tier 3 Nitrolingual E SL

Nitromist SL

Central Nervous System Attention Deficit Disorder Tier 1 Amphetamine Aspartate/Amphetamine Sulfate/ Dextroamphetamine Sustained-Release 24 Hour Capsule SL Amphetamine Salt Combo

Dextroamphetamine Sulfate Methamphetamine Methylphenidate

Methylphenidate Extended-Release 24 Hour Tablet SL Methylphenidate Extended-Release Capsule SL

Tier 2 Intuniv SL

Vyvanse SL

Tier 3 Adderall XR SL Daytrana SL

Focalin XR SL Kapvay E

Methylin Tablet Strattera SL

Tier 1 Amitriptyline Bupropion Bupropion XL Citalopram Hydrobromide Doxepin Escitalopram 1/2T SL Fluoxetine

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

Paroxetine Tablet Phenelzine Sertraline 1/2T Trazodone Venlafaxine Extended-Release Tablet E SL Venlafaxine Sustained-Release Capsule SL

Tier 3 Aplenzin E SL Cymbalta SDP SL Lexapro 1/2T E SL

Luvox CR SL Oleptro E SL Pexeva 1/2T SL

Pristiq RS SL Viibryd SDP SL

Aspirin/Butalbital/Caffeine Naratriptan SL Relpax SL

Rizatriptan SL Sumatriptan Succinate Injection, Tablet SL Sumatriptan Succinate Nasal Spray SL

Frova SDP SL Migranal Sumavel DosePro SL Treximet E SL

Zomig SDP SL Zomig Nasal Spray SL Zomig ZMT SDP SL

Central Nervous System Depression

Central Nervous System Migraine Tier 1 Acetaminophen/Butalbital/Caffeine SL Acetaminophen/Dichloralphenazone/ Isometheptene Mucate Tier 2 Ergomar Tier 3 Alsuma E SL Axert SDP SL Cafergot Cambia E SL

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

Visit www.myuhc.com for updates

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2013 Prescription Drug List – Three-Tier


Central Nervous System Multiple Sclerosis Tier 2 Ampyra DSN N SL Avonex DSN N SL

Copaxone DSN N SL Rebif DSN N SL

Tier 3 Betaseron DSN N SL ST

Extavia DSN E N SL ST

Gilenya DSN N SL ST

Central Nervous System Sedatives/Hypnotics Tier 1 Temazepam Zaleplon SL

Zolpidem Multiphasic-Release Tablet SL ST Zolpidem Tablet SL

Tier 3 Ambien E SL ST Ambien CR E SL ST Edluar E SL ST

Intermezzo E SL ST Lunesta SL ST Rozerem SL ST

Silenor E SL Sonata SL ST Zolpimist E SL ST

Central Nervous System Seizure Disorders Tier 1 Carbamazepine Carbamazepine Extended-Release 12 Hour Capsule Carbamazepine Sustained-Release 12 Hour Tablet Clonazepam Diazepam Rectal Gel SL Divalproex Sodium Sprinkle Capsule

Divalproex Sodium Sustained-Release Tablet Divalproex Sodium Tablet Felbamate Gabapentin Lamotrigine Lamotrigine Extended-Release 24 Hour Tablet ST Levetiracetam

Levetiracetam Extended-Release 24 Hour Tablet Oxcarbazepine Phenobarbital Phenytoin Sodium Primidone Tiagabine Topiramate Zonisamide

Tier 2 Celontin Dilantin

Mysoline Peganone

Sabril Tegretol

Tier 3 Carbatrol Depakote ER ST Keppra ST Keppra XR ST

Lamictal ST Lamictal Dose Pack SL ST Lamictal ODT ST Lamictal XR ST

Lyrica SDP SL Stavzor ST Topamax ST

Tier 1 Alprazolam Benztropine Mesylate Buspirone Carbidopa/Levodopa Clozapine Diazepam Donepezil 5, 10 mg Entacapone

Galantamine Lithium Carbonate Lithium Carbonate Controlled-Release Tablet Lorazepam Modafinil E N SL Olanzapine Rapid Dissolve Tablet SL Olanzapine Tablet SL Olanzapine/Fluoxetine SL

Pramipexole Quetiapine SL Risperidone Rivastigmine Ropinirole Ropinirole Extended-Release 24 Hour Tablet E Ziprasidone SL

Tier 2 Apokyn DSN Nuedexta

Tasmar Xyrem N SL

Tier 3 Abilify 1/2T SL Aricept 23 mg E Fanapt SL Invega SL

Latuda SL Mirapex ER E Namenda Nuvigil N SL

Central Nervous System Other

Provigil E N SL Requip XL E Seroquel XR SL

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

Visit www.myuhc.com for updates

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2013 Prescription Drug List – Three-Tier


Dermatology Tier 1 Adapalene N SL Alclometasone Dipropionate Betamethasone Dipropionate Betamethasone Valerate Betamethasone Valerate Foam SL Calcipotriene Cream, Ointment SL Ciclopirox Cream, Gel, Lotion Ciclopirox Non-Oral Solution Ciclopirox Shampoo 1% MC Clindamycin Foam 1% SL Clindamycin Gel, Lotion, Solution, Swabs Clindamycin Phosphate/Benzoyl Peroxide Extended-Release Gel E SL Clindamycin Phosphate/Benzoyl Peroxide Gel 1%-5% SL Clobetasol Propionate

Clobetasol Propionate Foam SL Clobetasol Propionate Lotion SL Clobetasol Propionate Shampoo E SL Clotrimazole/Betamethasone Desonide Desoximetasone Econazole Nitrate Erythromycin Erythromycin/Benzoyl Peroxide Fluocinolone Fluocinonide Fluticasone Propionate Fluticasone Propionate Lotion MC Halobetasol Propionate Hydrocortisone Hydrocortisone Valerate

Imiquimod SL Isotretinoin N Ketoconazole Lidocaine Metronidazole Gel 0.75% Mometasone Furoate Mupirocin Mupirocin Cream SL Nystatin Nystatin/Triamcinolone Acetonide Permethrin Silver Sulfadiazine Sulfacetamide Sodium/Sulfur Tretinoin N Triamcinolone Acetonide Urea

Tier 2 Azelex SL Benzamycin

Oxsoralen-Ultra Protopic N SL

Regranex N Stelara DSN N SL

Tier 3 Acanya SL Aczone SL Altabax SL Atralin MC N SL Avita Gel N SL Benzaclin Pump SL Clindagel E SL Clobex Shampoo E SL Condylox Gel Cutivate Lotion MC Denavir Desonate SL Differin Cream, Gel 0.1% N SL Differin Gel 0.3% N SL

Differin Lotion N SL Duac E SL Elidel N SL Epiduo E SL Finacea Locoid Lipocream SL Locoid Lotion SL Metrogel 1% E MC Naftin Noritate MC Oxistat Retin-A Micro N SL Taclonex SL Taclonex Scalp SL

Tazorac N SL Tretin-X N SL Vanos SL Vectical SL Veltin E SL Verdeso SL Vusion MC Xerese E Xolegel MC Ziana E SL Zovirax SL Zyclara E SL

Diabetes/Endocrine Blood Glucose Monitoring Tier 1 Accu-Chek Active Test Strips SL Accu-Chek Aviva Plus Accu-Chek Aviva Plus Test Strips SL Accu-Chek Comfort Curve Test Strips SL Accu-Chek Compact Test Strips SL

Accu-Chek Nano SmartView Accu-Chek SmartView Test Strip SL One Touch Test Strips SL One Touch Ultra 2 System One Touch Ultra Mini System

One Touch Ultra Test Strips SL One Touch Verio IQ System One Touch Verio IQ Test Strips SL

Tier 3 Ascensia Autodisc Test Strips SDP SL Ascensia Breeze 2 Test Strips SDP SL Contour Next Test Strips SDP SL

Contour Test Strips SDP SL Freestyle Insulinx SDP SL Freestyle Lite Test Strips SDP SL

Freestyle Test Strips SDP SL Precision Xtra Test Strips SDP SL

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

Visit www.myuhc.com for updates

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2013 Prescription Drug List – Three-Tier


Diabetes/Endocrine Insulin Tier 1 Humalog Vials Humalog-Mix Vials

Humulin 70-30 Vials Humulin Vials

Tier 2 Humalog KwikPen Humalog-Mix KwikPen

Humulin KwikPen Lantus Vials

Levemir Vials

Tier 3 Apidra Solostar SDP Apidra Vial SDP Lantus Solostar Pens/Cartridges

Levemir Flexpen Novolin Vials SDP NovoLog Pens, Vials SDP

NovoLog 70-30 Pens, Vials SDP

Tier 1 Acarbose Glimepiride Glipizide Glipizide/Metformin

Glyburide Glyburide/Metformin Metformin Metformin Extended-Release 24 Hour Tablet

Nateglinide SL Pioglitazone 1/2T SL Pioglitazone/Glimepiride SL Pioglitazone/Metformin SL

Tier 2 Byetta SL Glyset Jentadueto SL

Kombiglyze XR SL Onglyza SL Prandin SL

Tradjenta SL

Tier 3 Actoplus Met XR SDP SL Avandamet SL Avandaryl SL Avandia SL

Bydureon SL Glumetza Janumet SDP SL Janumet XR SDP SL

Januvia SDP SL Juvisync SDP SL Symlin SL Victoza SL

Diabetes/Endocrine Non-Insulin

Endocrine Growth Hormone Tier 2 Nutropin, AQ, NuSpin DSN N SL Saizen DSN N SL

Serostim DSN N SL Tev-Tropin DSN N SL

Tier 3 Genotropin DSN E N SL Humatrope DSN E N SL

Norditropin DSN E N SL Omnitrope DSN E N SL

Zorbtive DSN N SL

Tier 1 Cabergoline Calcitriol Desmopressin Dexamethasone Fludrocortisone Hydrocortisone Tablet

Levothyroxine Sodium Levoxyl Liothyronine Sodium Methimazole Methylprednisolone Dosepak Tablet 4 mg Octreotide Acetate DSN N

Orapred Oxandrolone Prednisolone Prednisone Testosterone

Tier 2 Androderm SL Android Hectorol Kuvan DSN N SL

Medrol 2, 8, 24 mg Pediapred Synarel Synthroid

Testim SL Tirosint Zemplar DSN

Tier 3 Androgel E SL Armour Thyroid

Axiron E SL Fortesta E SL

Orapred ODT

Endocrine Other

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

Visit www.myuhc.com for updates

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2013 Prescription Drug List – Three-Tier


Eye Conditions Allergies Tier 1 Azelastine HCl SL

Epinastine E SL

Ketorolac Tromethamine

Tier 3 Bepreve E SL Elestat E SL Emadine E

Lastacaft SL Optivar E SL Pataday E SL

Patanol E SL

Neomycin/Polymyxin B Sulfate/Dexamethasone Ofloxacin Polymyxin B Sulfate/Trimethoprim Sulfacetamide Sodium

Tobramycin Sulfate Drops Tobramycin/Dexamethasone

Tobradex ST E SL Vigamox

Zylet Zymaxid SL

Tier 1 Acetazolamide Apraclonidine Brimonidine Tartrate SL

Dorzolamide HCl Dorzolamide HCl/Timolol Maleate Latanoprost SL

Timolol Maleate

Tier 2 Alphagan P 0.1% SL Azopt SL Betimol SL

Combigan SL Lumigan SL Pilopine HS

Travatan Z SL

Tier 3 Cosopt PF E SL

Iopidine 1%

Eye Conditions Antibiotics Tier 1 Ciprofloxacin Erythromycin Gentamicin Sulfate Levofloxacin Tier 2 Blephamide S.O.P. Tier 3 Azasite SL Moxeza

Eye Conditions Glaucoma

Gastrointestinal Acid Suppression Tier 1 Cimetidine Lansoprazole E SL Misoprostol

Nizatidine Oral Solution Omeprazole Omeprazole/Sodium Bicarbonate Capsule E SL

Pantoprazole Ranitidine Syrup Sucralfate Tablet

Tier 2 Helidac

Prevpac SL

Pylera

Tier 3 Aciphex SL Carafate Oral Suspension Dexilant SL Nexium Capsule E SL

Nexium Suspension Prevacid Delayed-Release Enteric-Coated Capsule E SL Prevacid Solutab E SL

Prilosec Rx E Protonix Granules E SL Zegerid Capsule E SL Zegerid Packet SL

Ondansetron

Prochlorperazine Maleate

Sancuso E SL Transderm-Scop

Zuplenz E SL

Gastrointestinal Nausea/Vomiting Tier 1 Granisetron Tablet SL Tier 2 Emend SL Tier 3 Anzemet SL Cesamet

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

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11

2013 Prescription Drug List – Three-Tier


Gastrointestinal Other Tier 1 Balsalazide Belladonna/Phenobarbital Budesonide Extended-Release 24 Hour Capsule Chlordiazepoxide/Clidinium

Diphenoxylate/Atropine Lactulose Mesalamine Metoclopramide

Polyethylene Glycol Sulfasalazine Trilyte with Flavor Packets Ursodiol

Tier 2 Apriso Canasa Creon

GoLYTELY Packet Lialda Lotronex SL

Relistor Zenpep

Tier 3 Amitiza N SL Asacol SDP Asacol HD E SDP

Dipentum Halflytely-Bisacodyl Metozolv ODT E

Moviprep Pancreaze SDP Pentasa

Levitra SL Muse SL Staxyn E SL

Viagra SL

Tier 1 Alfuzosin Doxazosin

Finasteride Tamsulosin

Terazosin

Tier 3 Avodart N SDP

Jalyn E

Rapaflo

Tier 1 Anastrozole Antipyrine/Benzocaine Azathioprine Benzonatate Bromfenac SL

Chlorhexidine Gluconate Exemestane Hydrocodone/Chlorpheniramine Suspension SL Letrozole Megestrol Acetate

Mycophenolate Capsule, Tablet DSN Phenazopyridine Tacrolimus DSN Tamoxifen Tranexamic Acid SL

Tier 2 Cellcept Suspension DSN Epipen SL Epipen Jr SL Fareston

Lidoderm SL Myfortic DSN Neoral DSN Pegasys DSN N SL

Rapamune DSN Sandimmune DSN

Tier 3 Acuvail E SL Aromasin Bromday E SL Durezol SL

Infergen DSN N SL Intron A DSN N Nevanac SL Peg-Intron DSN N SL ST

Rectiv N SL Restasis N SL Soltamox E

Tier 1 Dicyclomine Tablet Hyoscyamine Sulfate

Oxybutynin Tolterodine

Trospium Trospium Extended-Release 24 Hour Capsule

Tier 2 Gelnique

Oxytrol

Vesicare

Tier 3 Detrol LA E Enablex

Myrbetriq SDP Toviaz SDP

Men’s Health Erectile Dysfunction Tier 3 Caverject SL Cialis SL Edex SL

Men’s Health Prostate

Miscellaneous

Miscellaneous Overactive Bladder

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

Visit www.myuhc.com for updates

12

2013 Prescription Drug List – Three-Tier


Musculoskeletal Osteoporosis Tier 1 Alendronate SL

Calcitonin Salmon Nasal Spray Fortical

Tier 2 Evista

Forteo DSN N

Tier 3 Actonel SL Atelvia E SL

Binosto E SL Fosamax Plus D SL

Ibandronate Tablet SL

Musculoskeletal Pain Relief Tier 1 Acetaminophen/Butalbital/Caffeine/Codeine SL Acetaminophen/Codeine SL Acetaminophen/Hydrocodone Bit SL Acetaminophen/Oxycodone SL Aspirin/Butalbital/Caffeine/Codeine Aspirin/Oxycodone Butorphanol Nasal Spray SL Diclofenac Potassium Diclofenac Sodium Diclofenac/Misoprostol Etodolac Fentanyl Citrate Lollipop N SL Fentanyl Transdermal SL Hydromorphone Ibuprofen

Ibuprofen/Hydrocodone Ibuprofen/Oxycodone Indomethacin Ketorolac Tromethamine Mefenamic Acid Meloxicam Meperidine Methadone Morphine Sulfate Morphine Sulfate Extended-Release Pellets E SL Morphine Sulfate Sustained-Action Tablet SL Nabumetone Naproxen Naproxen Sodium Oxaprozin

Oxycodone Oxymorphone SL Oxymorphone Extended-Release 12 Hour Tablet SL Piroxicam Sulindac Tolmetin Sodium Tramadol Tramadol Extended-Release Multiphase 24 Hour Tablet E SL Tramadol Sustained-Release 24 Hour Tablet SL Tramadol/Acetaminophen SL

Tier 2 Codeine Phosphate MSIR Capsule

Opana ER SL OxyContin SL

Voltaren Gel

Tier 3 Abstral N SL Avinza SL Butrans SL ST Celebrex SL Conzip E SL Duexis E SL Duragesic SL Embeda SL

Exalgo SL Fentora E N SL Flector E Kadian E SL Lazanda N SL Naprelan E Nucynta SL Nucynta ER SL

Onsolis N SL Pennsaid E Rybix ODT E SL Sprix SL Subsys N SL Vimovo E SL Zipsor E

Tier 1 Azathioprine Hydroxychloroquine Sulfate

Leflunomide Methotrexate

Sulfasalazine

Tier 2 Cimzia DSN N SL Cuprimine

Enbrel DSN N SL Simponi DSN N SL

Trexall

Tier 3 Humira DSN N SL ST Kineret DSN N SL

Orencia DSN N SL Xeljanz DSN N SL ST

Musculoskeletal Rheumatoid Arthritis

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

Visit www.myuhc.com for updates

13

2013 Prescription Drug List – Three-Tier


Musculoskeletal Other Tier 1 Allopurinol Baclofen Carisoprodol 250 mg E Carisoprodol 350 mg

Cyclobenzaprine Cyclobenzaprine Extended-Release 24 Hour Capsule E Metaxalone

Methocarbamol Orphenadrine Orphenadrine/Aspirin/Caffeine Tizanidine

Savella SL Skelaxin E Soma 250 mg E

Uloric SL

Budesonide Inhalation Suspension 0.25 mg/2 ml, 0.5 mg/2 ml SL Ipratropium Bromide Levalbuterol Vial, Nebulizer E SL Montelukast SL

QVAR SL Theophylline Ventolin HFA SL Zafirlukast SL

Tier 2 Foradil SL

Pulmicort Respules 1 mg/2 ml SL

Spiriva SL

Tier 3 Advair Diskus RS SL Advair HFA RS SL Atrovent HFA SL Combivent SL Combivent Respimat SL Daliresp N SL Dulera RS SL

Flovent Diskus SDP SL Flovent HFA SDP SL Maxair Autohaler SL Perforomist SL Proair HFA SL Proventil HFA SL Pulmicort Flexhaler SDP SL

Serevent Diskus SL Singulair E SL Symbicort SDP SL Xopenex HFA SL Xopenex Vial, Nebulizer E SL

Tier 2 Colcrys Tier 3 Amrix E Gralise E SL Horizant E SL

Respiratory Asthma/COPD Tier 1 Albuterol Sulfate Albuterol Sulfate/Ipratropium Non-Oral Solution Alvesco SL Asmanex SL

Respiratory Nasal Allergies Tier 1 Azelastine HCl SL Flunisolide

Fluticasone Propionate SL Triamcinolone Acetonide SL

Tier 2 Nasonex SL

Omnaris SL

Zetonna SL

Tier 3 Astelin E SL Astepro E SL Beconase AQ SL

Dymista E SL Patanase SL Rhinocort Aqua SL

Veramyst E SL

Tier 1 Cyproheptadine Desloratadine E SL

Hydroxyzine Levocetirizine SL

Promethazine

Tier 3 Clarinex E SL

Clarinex-D E SL

Respiratory Oral Allergies

Women’s Health Contraceptives Tier 1 Altavera Alyacen 7/7/7 Amethia MC Amethia Lo MC Amethyst Apri Aranelle Aviane Azurette Balziva

Briellyn Camila Camrese MC Camrese Lo MC Caziant Cryselle Cyclafem 1/35 Cyclafem 7/7/7 Ella SL Emoquette

Enpresse Errin Gianvi Gildess FE Heather Introvale MC Jolessa MC Jolivette Junel Junel Fe

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

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14

2013 Prescription Drug List – Three-Tier


Women’s Health Contraceptives (cont. from page 14) Tier 1 - cont. Kariva Kelnor Leena Lessina Levora Loryna Low-Ogestrel Lutera Marlissa Medroxyprogesterone 150 mg/ml MC Microgestin Microgestin Fe Mononessa Myzilra Natazia Necon 0.5/35 Necon 1/35 Necon 1/50

Necon 7/7/7 Necon 10/11 Next Choice One Dose Nora-Be Norethindrone Nortrel 0.5/35 Nortrel 1/35 Nortrel 7/7/7 Ocella Ogestrel Orsythia Philith Plan B Portia Previfem Quasense MC Reclipsen Sprintec

Tier 2 Depo-SubQ Provera MC

NuvaRing

Tier 3 Beyaz E Generess Fe E Lo Loestrin Fe Loestrin 24 Fe Ortho Evra

Ortho Micronor Ortho Tri-Cyclen Ortho Tri-Cyclen Lo Ortho-Cyclen Ortho-Novum 7/7/7

Sronyx Syeda Tilia Fe Tri-Legest Fe Tri-Previfem Tri-Sprintec Trinessa Trivora Velivet Vestura Viorele Wymzya Fe Zarah Zenchent Zenchent Fe Zeosa Zovia 1/35E Zovia 1/50E

Safyral E Yasmin Yaz

Women’s Health Estrogen/Progesterone Tier 1 Estradiol Estradiol/Norethindrone Acetate Estradiol Transdermal Weekly Patch SL

Estropipate Medroxyprogesterone Norethindrone Acetate

Progesterone Micronized Capsule

Tier 2 Cenestin Climara SL Crinone N Divigel

Enjuvia Estrace Cream with Applicator Estring MC SL Evamist

Prefest Vagifem Vivelle-Dot SL

Tier 3 Alora SL Climara Pro SL Combipatch SL Estrasorb SL

Estrogel SL Femhrt Femring MC SL Menostar Transdermal Weekly Patch SL

Premarin Premphase Prempro

PR Natal 430 PR Natal 430 EC Prenatal 19 Prenatal Advantage Prenatal Plus Setonet

Setonet-EC Taron A Prenatal Zatean-PN Zatean-PN DHA Zatean-PN Plus

Women’s Health Prenatal Vitamins Tier 1 Advanced Care Plus Cavan-EC Sod DHA Folcal DHA Folic Acid Multi-Nate 30 Multinatal Plus Tier 3 Brand Prenatal Vitamins

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

Visit www.myuhc.com for updates

15

2013 Prescription Drug List – Three-Tier


Additional Tier 3 Drugs with a generic equivalent in Tier 1 Accolate SL (Zafirlukast SL) Accupril (Quinapril) Acular (Ketorolac Tromethamine) Adderall (Amphetamine/Dextroamphetamine Salt Combination) Aldactone (Spironolactone) Altace (Ramipril) Amaryl (Glimepiride) Ambien E SL ST (Zolpidem SL) Amerge SL (Naratriptan SL) Anaprox (Naproxen) Aricept (Donepezil) Arimidex (Anastrozole) Ativan (Lorazepam) Augmentin ES (Amoxicillin/Potassium Clavulanate) Biaxin Tablet (Clarithromycin Tablet) Buspar (Buspirone) Calan, Calan SR (Verapamil) Cardizem CD except for 360 mg strength (Diltiazem Capsule, Sustained-Release 24 Hour) Cardura (Doxazosin) Ceftin (Cefuroxime) Cefzil (Cefprozil) Celexa (Citalopram) Ciloxan Eye Drops (Ciprofloxacin) Cipro (Ciprofloxacin) Cleocin T (Clindamycin Gel, Lotion, Solution, Swabs) Clozaril (Clozapine) Colazal (Balsalazide) Colestid (Colestipol) Coreg (Carvedilol) Cozaar 1/2T (Losartan 1/2T) DDAVP (Desmopressin) Depakote (Divalproex Sodium Tablet) Depakote ER ST (Divalproex Sodium SustainedRelease 24 Hour Tablet) Depo-Provera MC (Medroxyprogesterone 150 mg/ml MC) Derma-Smoothe/FS (Fluocinolone) DiaBeta, Glynase (Glyburide) Diastat Acudial SL (Diazepam Rectal Gel SL) Didronel (Etidronate Disodium) Diflucan (Fluconazole) Ditropan XL (Oxybutynin Sustained-Release Tablet) Dyazide (Triamterene/Hydrochlorothiazide) Effexor (Venlafaxine) Effexor XR E SL (Venlafaxine Sustained-Release Capsule SL) Felbatol (Felbamate) Femara (Letrozole) Fioricet SL (Acetaminophen/Butalbital/Caffeine SL) Flomax E (Tamsulosin) Flonase SL (Fluticasone Nasal Spray SL) Fosamax SL (Alendronate SL) Glucophage, XR (Metformin) Glucotrol, XL (Glipizide) Glucovance (Glyburide/Metformin) Hyzaar SL (Losartan/Hydrochlorothiazide SL) Imitrex SL (Sumatriptan Succinate Injection, Tablet SL) Keflex (Cephalexin)

Keppra ST (Levetiracetam) Klonopin (Clonazepam) Lamictal ST (Lamotrigine) Lamisil SL (Terbinafine Tablet SL) Lasix (Furosemide) Levaquin (Levofloxacin) Lipitor 1/2T E SL (Atorvastatin 1/2T SL) Lopid (Gemfibrozil) Lopressor (Metoprolol) Mavik 1/2T (Trandolapril 1/2T) Medrol (Methylprednisolone Dosepak Tablet 4 mg) Metrogel Vaginal (Metronidazole) Mevacor (Lovastatin) Mobic (Meloxicam) Monopril (Fosinopril) Naprosyn (Naproxen) - Prescription strengths only Nardil (Phenelzine) Neurontin (Gabapentin) Norvasc (Amlodipine) Ocuflox Eye Drops (Ofloxacin) Paxil (Paroxetine) Penlac (Ciclopirox Solution, Non-Oral) Percocet 5-325, 7.5-500, 10-650 E SL (Acetaminophen/Oxycodone SL) Plavix E (Clopidogrel) Pletal (Cilostazol) Pravachol 1/2T (Pravastatin 1/2T) Precose (Acarbose) Prilosec (Omeprazole) Prinivil, Zestril (Lisinopril) Prinzide, Zestoretic (Lisinopril/ Hydrochlorothiazide) Procardia XL (Nifedipine Extended-Release Tablet) Proscar (Finasteride) Protonix E (Pantoprazole) Provera (Medroxyprogesterone) Prozac E (Fluoxetine Capsule) Prozac Weekly SL (Fluoxetine Delayed-Release Capsule SL) Remeron (Mirtazapine) Remeron SolTab (Mirtazapine Dispersible Tablet) Requip (Ropinirole) Restoril (Temazepam) Risperdal (Risperidone) Ritalin (Methylphenidate) Ritalin SR (Methylphenidate Extended-Release Tablet) Sonata SL ST (Zaleplon SL) Surmontil (Trimipramine Maleate) Tenoretic (Atenolol/Chlorthalidone) Tenormin (Atenolol) Teveten SL (Eprosartan SL) Tiazac (Diltiazem) Topamax ST (Topiramate) Toprol XL 25 mg (Metoprolol Succinate Sustained-Release Tablet) Trileptal (Oxcarbazepine) Trusopt (Dorzolamide Eye Drops) Tylenol #3 SL (Acetaminophen/ Codeine SL) Ultracet SL (Tramadol/Acetaminophen SL) Ultram (Tramadol)

Uroxatral (Alfuzosin) Valium (Diazepam) Vaseretic (Enalapril/Hydrochlorothiazide) Vasotec (Enalapril) Vfend SL (Voriconazole SL) Vicodin SL, Vicodin ES SL (Acetaminophen/ Hydrocodone SL) Vicoprofen (Ibuprofen/Hydrocodone) Voltaren Tablet (Diclofenac) Wellbutrin (Bupropion HCl) Wellbutrin SR E (Bupropion HCl SustainedAction Tablet) Wellbutrin XL E (Bupropion HCl SustainedRelease 24 Hour Tablet) Xalatan SL (Latanoprost SL) Xanax, Xanax XR (Alprazolam) Zantac Syrup (Ranitidine Syrup) Ziac (Bisoprolol/Hydrochlorothiazide) Zithromax (Azithromycin) Zocor 1/2T (Simvastatin 1/2T) Zofran (Ondansetron) Zoloft 1/2T E (Sertraline 1/2T) Zonegran (Zonisamide) Zovirax (Acyclovir Capsule, Suspension, Tablet)

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

Visit www.myuhc.com for updates

16

2013 Prescription Drug List – Three-Tier


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

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

17

Baraclude 5 Beconase AQ 14 Belladonna/Phenobarbital 12 Benazepril 6 Benazepril/Hydrochlorothiazide 6 Benicar 6 Benicar HCT 6 Benzaclin Pump 9 Benzamycin 9 Benzonatate 12 Benztropine Mesylate 8 Bepreve 11 Betamethasone Dipropionate 9 Betamethasone Valerate 9 Betamethasone Valerate Foam 9 Betaseron 8 Betimol 11 Beyaz 15 Biaxin Tablet 16 BiDil 6 Binosto 13 Bisoprolol 6, 16 Bisoprolol/Hydrochlorothiazide 6, 16 Blephamide S.O.P. 11 Brand Prenatal Vitamins 15 Briellyn 14 Brilinta 5 Brimonidine Tartrate 11 Bromday 12 Bromfenac 12 Budesonide Extended-Release 24 Hour Capsule 12 Budesonide Inhalation Suspension 0.25 mg/2 ml, 0.5 mg/2 ml 14 Bumetanide 6 Bupropion 7, 16 Bupropion HCl 16 Bupropion HCl Sustained-Action Tablet 16 Bupropion HCl Sustained-Release 24 Hour Tablet 16 Bupropion XL 7 Buspar 16 Buspirone 8, 16 Butorphanol Nasal Spray 13 Butrans 13 Bydureon 10 Byetta 10 Bystolic 6 C Cabergoline 10 Caduet 6 Cafergot 7 Calan, Calan SR 16 Calcipotriene Cream, Ointment 9 Calcitonin Salmon Nasal Spray 13 Calcitriol 10 Cambia 7 Camila 14 Camrese 14 Camrese Lo 14 Canasa 12 Candesartan/Hydrochlorothiazide 6 Captopril 6 Captopril/Hydrochlorothiazide 6 Carafate Oral Suspension 11 Carbamazepine 8 Carbamazepine Extended-Release 12 Hour Capsule 8 Carbamazepine Sustained-Release 12 Hour Tablet 8 Carbatrol 8 Carbidopa/Levodopa 8 Cardizem CD except for 360 mg strength 16 Cardizem LA 120 mg 6 Cardura 16 Carisoprodol 250 mg 14

2013 Prescription Drug List – Three-Tier


Carisoprodol 350 mg 14 Carvedilol 6, 16 Cavan-EC Sod DHA 15 Caverject 12 Cayston 5 Caziant 14 Cefadroxil 5 Cefdinir 5 Cefprozil 5, 16 Ceftin 16 Cefuroxime 5, 16 Cefzil 16 Celebrex 13 Celexa 16 Cellcept Suspension 12 Celontin 8 Cenestin 15 Cephalexin 5, 16 Cesamet 11 Cetraxal 5 Chlordiazepoxide/Clidinium 12 Chlorhexidine Gluconate 12 Chlorthalidone 6, 16 Cholestyramine 6 Cialis 12 Ciclopirox Cream, Gel, Lotion 9 Ciclopirox Non-Oral Solution 9 Ciclopirox Shampoo 1% 9 Ciclopirox Solution, Non-Oral 16 Cilostazol 5, 16 Ciloxan Eye Drops 16 Cimetidine 11 Cimzia 13 Cipro 5, 16 Cipro HC 5 Cipro Suspension 5 Ciprodex Otic 5 Ciprofloxacin 5, 11, 16 Ciprofloxacin Sustained-Release 24 Hour Tablet 5 Ciprofloxacin Tablet 5 Citalopram 7, 16 Citalopram Hydrobromide 7 Clarinex 14 Clarinex-D 14 Clarithromycin Suspension 5 Clarithromycin Sustained-Release Tablet 5 Clarithromycin Tablet 5, 16 Cleocin HCl 75 mg 5 Cleocin T 16 Climara 15 Climara Pro 15 Clindagel 9 Clindamycin Foam 1% 9 Clindamycin Gel, Lotion, Solution, Swabs 9, 16 Clindamycin HCl 5 Clindamycin Palmitate 5 Clindamycin Phosphate/Benzoyl Peroxide Extended-Release Gel 9 Clindamycin Phosphate/Benzoyl Peroxide Gel 1%-5% 9 Clindesse Vaginal 5 Clobetasol Propionate 9 Clobetasol Propionate Foam 9 Clobetasol Propionate Lotion 9 Clobetasol Propionate Shampoo 9 Clobex Shampoo 9 Clonazepam 8, 16 Clonidine 6 Clonidine Transdermal Weekly Patch 6 Clopidogrel 5, 16 Clorpres 6 Clotrimazole 5, 9 Clotrimazole/Betamethasone 9 Clozapine 8, 16 Clozaril 16 Codeine Phosphate 13 Colazal 16 Colcrys 14

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Colestid 16 Colestipol 6, 16 Combigan 11 Combipatch 15 Combivent 14 Combivent Respimat 14 Condylox Gel 9 Contour Next Test Strips 9 Contour Test Strips 9 Conzip 13 Copaxone 8 Coreg 6, 16 Coreg CR 6 Cosopt PF 11 Coumadin 5 Cozaar 16 Creon 12 Crestor 6 Crinone 15 Cryselle 14 Cuprimine 13 Cutivate Lotion 9 Cyclafem 1/35 14 Cyclafem 7/7/7 14 Cyclobenzaprine 14 Cyclobenzaprine Extended-Release 24 Hour Capsule 14 Cymbalta 7 Cyproheptadine 14 D Daliresp 14 Dapsone 5 Daytrana 7 DDAVP 16 Denavir 9 Depakote 8, 16 Depakote ER 8, 16 Depo-Provera 16 Depo-SubQ Provera 15 Derma-Smoothe/FS 16 Desloratadine 14 Desmopressin 10, 16 Desonate 9 Desonide 9 Desoximetasone 9 Detrol LA 12 Dexamethasone 10, 11 Dexilant 11 Dextroamphetamine Sulfate 7 DiaBeta 16 Diastat Acudial 16 Diazepam 8, 16 Diazepam Rectal Gel 8, 16 Dibenzyline 6 Diclofenac 13, 16 Diclofenac/Misoprostol 13 Diclofenac Potassium 13 Diclofenac Sodium 13 Dicloxacillin Sodium 5 Dicyclomine Tablet 12 Didronel 16 Differin Cream, Gel 0.1% 9 Differin Gel 0.3% 9 Differin Lotion 9 Diflucan 16 Digoxin 7 Dilantin 8 Diltiazem 6, 16 Diltiazem Capsule, Sustained-Release 24 Hour 16 Diltiazem Controlled-Release Capsule 6 Diltiazem Sustained-Action Capsule 6 Diltiazem Sustained-Release 12 Hour Capsule 6 Diltiazem Sustained-Release 24 Hour Capsule 6 Diltiazem Sustained-Release 24 Hour Tablet 6 Diovan 6 Diovan HCT 6 Dipentum 12 Diphenoxylate/Atropine 12

18

Ditropan XL 16 Diuril Suspension 250 mg/5 ml 6 Divalproex Sodium Sprinkle Capsule 8 Divalproex Sodium Sustained-Release 24 Hour Tablet 16 Divalproex Sodium Sustained-Release Tablet 8 Divalproex Sodium Tablet 8, 16 Divigel 15 Donepezil 8, 16 Donepezil 5, 10 mg 8 Doryx 5 Dorzolamide Eye Drops 16 Dorzolamide HCl 11 Dorzolamide HCl/Timolol Maleate 11 Doxazosin 6, 12, 16 Doxepin 7 Doxycycline Hyclate Enteric-Coated Tablet 5 Doxycycline Monohydrate 5 Doxycycline Monohydrate Capsule 150 mg 5 Duac 9 Duexis 13 Dulera 14 Duragesic 13 Durezol 12 Dutoprol 6 Dyazide 16 Dymista 14 E Econazole Nitrate 9 Edarbi 6 Edarbyclor 6 Edex 12 Edluar 8 Effexor 16 Effexor XR 16 Effient 5 Elestat 11 Elidel 9 Ella 14 Emadine 11 Embeda 13 Emend 11 Emoquette 14 Enablex 12 Enalapril 6, 16 Enalapril/Hydrochlorothiazide 6, 16 Enbrel 13 Enjuvia 15 Enoxaparin 5 Enpresse 14 Entacapone 8 Epiduo 9 Epinastine 11 Epipen 12 Epipen Jr 12 Epivir HBV 5 Eplerenone 6 Eprosartan 6, 16 Ergomar 7 Errin 14 Ery-Tab 500 mg 5 Erythromycin 5, 9, 11 Erythromycin/Benzoyl Peroxide 9 Erythromycin Base Enteric-Coated Tablet 5 Escitalopram 7 Estrace Cream with Applicator 15 Estradiol 15 Estradiol/Norethindrone Acetate 15 Estradiol Transdermal Weekly Patch 15 Estrasorb 15 Estring 15 Estrogel 15 Estropipate 15 Etidronate Disodium 16 Etodolac 13 Evamist 15 Evista 13 Exalgo 13

2013 Prescription Drug List – Three-Tier


Exemestane 12 Exforge 6 Exforge HCT 6 Extavia 8 F Famciclovir 5 Fanapt 8 Fareston 12 Felbamate 8, 16 Felbatol 16 Felodipine 6 Femara 16 Femhrt 15 Femring 15 Fenofibrate 48, 145 mg 6 Fenofibrate 54, 160 mg 6 Fenofibric Acid 6 Fenoglide 6 Fentanyl Citrate Lollipop 13 Fentanyl Transdermal 13 Fentora 13 Finacea 9 Finasteride 12, 16 Fioricet 16 Flecainide Acetate 7 Flector 13 Flomax 16 Flonase 16 Flovent Diskus 14 Flovent HFA 14 Fluconazole 5, 16 Fludrocortisone 10 Flunisolide 14 Fluocinolone 9, 16 Fluocinonide 9 Fluoxetine 7, 8, 16 Fluoxetine Capsule 16 Fluoxetine Delayed-Release Capsule 7, 16 Fluticasone Nasal Spray 16 Fluticasone Propionate 9, 14 Fluticasone Propionate Lotion 9 Fluvastatin 6 Fluvoxamine Maleate 7 Focalin XR 7 Folcal DHA 15 Folic Acid 15 Fondaparinux 5 Foradil 14 Forteo 13 Fortesta 10 Fortical 13 Fosamax 13, 16 Fosamax Plus D 13 Fosinopril 16 Fragmin 5 Freestyle Insulinx 9 Freestyle Lite Test Strips 9 Freestyle Test Strips 9 Frova 7 Furosemide 6, 16 G Gabapentin 8, 16 Galantamine 8 Gelnique 12 Gemfibrozil 6, 16 Generess Fe 15 Genotropin 10 Gentamicin Sulfate 11 Gianvi 14 Gildess FE 14 Gilenya 8 Glimepiride 10, 16 Glipizide 10, 16 Glipizide/Metformin 10 Glucophage, XR 16 Glucotrol, XL 16 Glucovance 16 Glumetza 10

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Glyburide 10, 16 Glyburide/Metformin 10, 16 Glynase 16 Glyset 10 GoLYTELY Packet 12 Gralise 14 Granisetron Tablet 11 Griseofulvin 5 Guanfacine 6 Gynazole-1 Vaginal 5 H Halflytely-Bisacodyl 12 Halobetasol Propionate 9 Heather 14 Hectorol 10 Helidac 11 Hepsera 5 Horizant 14 Humalog-Mix KwikPen 10 Humalog-Mix Vials 10 Humalog KwikPen 10 Humalog Vials 10 Humatrope 10 Humira 13 Humulin 70-30 Vials 10 Humulin KwikPen 10 Humulin Vials 10 Hydralazine 6 Hydrochlorothiazide 6, 16 Hydrocodone/Chlorpheniramine Suspension 12 Hydrocortisone 9, 10 Hydrocortisone Tablet 10 Hydrocortisone Valerate 9 Hydromorphone 13 Hydroxychloroquine Sulfate 13 Hydroxyzine 14 Hyoscyamine Sulfate 12 Hyzaar 16 I Ibandronate Tablet 13 Ibuprofen 13, 16 Ibuprofen/Hydrocodone 13, 16 Ibuprofen/Oxycodone 13 Imiquimod 9 Imitrex 16 Incivek 5 Indomethacin 13 Infergen 12 Innohep 5 Intermezzo 8 Intron A 12 Introvale 14 Intuniv 7 Invega 8 Iopidine 1% 11 Ipratropium Bromide 14 Irbesartan 6 Irbesartan/Hydrochlorothiazide 6 Isosorbide Dinitrate 7 Isosorbide Mononitrate 7 Isotretinoin 9 Itraconazole Capsule 5 J Jalyn 12 Janumet 10 Janumet XR 10 Januvia 10 Jentadueto 10 Jolessa 14 Jolivette 14 Junel 14 Junel Fe 14 Juvisync 10 K Kadian 13 Kapvay 7 Kariva 15 Keflex 16

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Kelnor 15 Keppra 8, 16 Keppra XR 8 Ketoconazole 5, 9 Ketoconazole Foam 5 Ketorolac Tromethamine 11, 13, 16 Kineret 13 Klonopin 16 Kombiglyze XR 10 Kuvan 10 L Labetalol 6 Lactulose 12 Lamictal 8, 16 Lamictal Dose Pack 8 Lamictal ODT 8 Lamictal XR 8 Lamisil 5, 16 Lamisil Granules 5 Lamotrigine 8, 16 Lamotrigine Extended-Release 24 Hour Tablet 8 Lanoxin 7 Lansoprazole 11 Lantus Solostar Pens/Cartridges 10 Lantus Vials 10 Lasix 16 Lastacaft 11 Latanoprost 11, 16 Latuda 8 Lazanda 13 Leena 15 Leflunomide 13 Lescol XL 6 Lessina 15 Letrozole 12, 16 Levalbuterol Vial, Nebulizer 14 Levaquin 16 Levemir Flexpen 10 Levemir Vials 10 Levetiracetam 8, 16 Levetiracetam Extended-Release 24 Hour Tablet 8 Levitra 12 Levocetirizine 14 Levofloxacin 5, 11, 16 Levora 15 Levothyroxine Sodium 10 Levoxyl 10 Lexapro 7 Lialda 12 Lidocaine 9 Lidoderm 12 Liothyronine Sodium 10 Lipitor 6, 16 Lipofen 6 Lisinopril 6, 16 Lisinopril/Hydrochlorothiazide 6, 16 Lithium Carbonate 8 Lithium Carbonate Controlled-Release Tablet 8 Livalo 6 Lo Loestrin Fe 15 Locoid Lipocream 9 Locoid Lotion 9 Loestrin 24 Fe 15 Lopid 16 Lopressor 16 Lorazepam 8, 16 Loryna 15 Losartan 6, 16 Losartan/Hydrochlorothiazide 6, 16 Lotronex 12 Lovastatin 6, 16 Lovaza 6 Low-Ogestrel 15 Lumigan 11 Lunesta 8 Lutera 15 Luvox CR 7 Lyrica 8

2013 Prescription Drug List – Three-Tier


M Macrodantin 25 mg 5 Marlissa 15 Mavik 16 Maxair Autohaler 14 Medrol 10, 16 Medrol 2, 8, 24 mg 10 Medroxyprogesterone 15, 16 Medroxyprogesterone 150 mg/ml 15, 16 Mefenamic Acid 13 Megestrol Acetate 12 Meloxicam 13, 16 Menostar Transdermal Weekly Patch 15 Meperidine 13 Mesalamine 12 Metaxalone 14 Metformin 10, 16 Metformin Extended-Release 24 Hour Tablet 10 Methadone 13 Methamphetamine 7 Methimazole 10 Methocarbamol 14 Methotrexate 13 Methylin Tablet 7 Methylphenidate 7, 16 Methylphenidate Extended-Release 24 Hour Tablet 7 Methylphenidate Extended-Release Capsule 7 Methylphenidate Extended-Release Tablet 16 Methylprednisolone Dosepak Tablet 4 mg 10, 16 Metoclopramide 12 Metolazone 6 Metoprolol 6, 16 Metoprolol/Hydrochlorothiazide 6 Metoprolol Succinate Sustained-Release Tablet 6, 16 Metoprolol Tartrate 6 Metozolv ODT 12 Metrogel 1% 9 Metrogel Vaginal 16 Metronidazole 5, 9, 16 Metronidazole Gel 0.75% 9 Metronidazole Vaginal 5 Mevacor 16 Mexiletine 7 Micardis 6 Micardis HCT 6 Microgestin 15 Microgestin Fe 15 Migranal 7 Minocycline Extended-Release 24 Hour Tablet 5 Minocycline HCl 5 Mirapex ER 8 Mirtazapine 7, 16 Mirtazapine Dispersible Tablet 16 Misoprostol 11, 13 Mobic 16 Modafinil 8 Moexipril 6 Mometasone Furoate 9 Monodox 5 Mononessa 15 Monopril 16 Montelukast 14 Morphine Sulfate 13 Morphine Sulfate Extended-Release Pellets 13 Morphine Sulfate Sustained-Action Tablet 13 Moviprep 12 Moxeza 11 MSIR Capsule 13 Multaq 7 Multi-Nate 30 15 Multinatal Plus 15 Mupirocin 9 Mupirocin Cream 9 Muse 12 Mycophenolate Capsule, Tablet 12 Myfortic 12

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Myrbetriq 12 Mysoline 8 Myzilra 15 N Nabumetone 13 Nadolol 6 Naftin 9 Namenda 8 Naprelan 13 Naprosyn 16 Naproxen 13, 16 Naproxen - Prescription strengths only 16 Naproxen Sodium 13 Naratriptan 7, 16 Nardil 16 Nasonex 14 Natazia 15 Nateglinide 10 Necon 0.5/35 15 Necon 1/35 15 Necon 1/50 15 Necon 10/11 15 Necon 7/7/7 15 Nefazodone 7 Neomycin/Polymyxin/HC Otic 5 Neomycin/Polymyxin B Sulfate/ Dexamethasone 11 Neoral 12 Neurontin 16 Nevanac 12 Nexiclon XR 6 Nexium Capsule 11 Nexium Suspension 11 Next Choice One Dose 15 Niaspan 6 Nifedipine 6, 16 Nifedipine Extended-Release Tablet 16 Nisoldipine 6 Nitrofurantoin/Nitrofurantoin Macrocrystal 5 Nitrofurantoin Macrocrystal 5 Nitrofurantoin Suspension 5 Nitroglycerin 7 Nitroglycerin Spray 7 Nitroglycerin Transdermal Patch 7 Nitrolingual 7 Nitromist 7 Nitrostat 7 Nizatidine Oral Solution 11 Nora-Be 15 Norditropin 10 Norethindrone 15 Norethindrone Acetate 15 Noritate 9 Norpace CR 7 Nortrel 0.5/35 15 Nortrel 1/35 15 Nortrel 7/7/7 15 Nortriptyline 7 Norvasc 16 Novolin Vials 10 NovoLog 70-30 Pens, Vials 10 NovoLog Pens, Vials 10 Noxafil 5 Nucynta 13 Nucynta ER 13 Nuedexta 8 Nutropin, AQ, NuSpin 10 NuvaRing 15 Nuvigil 8 Nystatin 5, 9 Nystatin/Triamcinolone Acetonide 9 O Ocella 15 Octreotide Acetate 10 Ocuflox Eye Drops 16 Ofloxacin 5, 11, 16 Ofloxacin Otic 5 Ogestrel 15

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Olanzapine/Fluoxetine 8 Olanzapine Rapid Dissolve Tablet 8 Olanzapine Tablet 8 Oleptro 7 Omeprazole 11, 16 Omeprazole/Sodium Bicarbonate Capsule 11 Omnaris 14 Omnitrope 10 Ondansetron 11, 16 One Touch Test Strips 9 One Touch Ultra 2 System 9 One Touch Ultra Mini System 9 One Touch Ultra Test Strips 9 One Touch Verio IQ System 9 One Touch Verio IQ Test Strips 9 Onglyza 10 Onsolis 13 Opana ER 13 Optivar 11 Oracea 5 Orapred 10 Orapred ODT 10 Orencia 13 Orphenadrine 14 Orphenadrine/Aspirin/Caffeine 14 Orsythia 15 Ortho-Cyclen 15 Ortho-Novum 7/7/7 15 Ortho Evra 15 Ortho Micronor 15 Ortho Tri-Cyclen 15 Ortho Tri-Cyclen Lo 15 Oxandrolone 10 Oxaprozin 13 Oxcarbazepine 8, 16 Oxistat 9 Oxsoralen-Ultra 9 Oxybutynin 12, 16 Oxybutynin Sustained-Release Tablet 16 Oxycodone 13, 16 OxyContin 13 Oxymorphone 13 Oxymorphone Extended-Release 12 Hour Tablet 13 Oxytrol 12 P Pancreaze 12 Pantoprazole 11, 16 Paroxetine 7, 16 Paroxetine Sustained-Release 24 Hour Tablet 7 Paroxetine Tablet 7 Pataday 11 Patanase 14 Patanol 11 Paxil 16 Pediapred 10 Peg-Intron 12 Peganone 8 Pegasys 12 Penicillin V Potassium 5 Penlac 16 Pennsaid 13 Pentasa 12 Pentoxifylline 5 Percocet 5-325, 7.5-500, 10-650 16 Perforomist 14 Perindopril Erbumine 6 Permethrin 9 Pexeva 7 Phenazopyridine 12 Phenelzine 7, 16 Phenobarbital 8, 12 Phenytoin Sodium 8 Philith 15 Pilopine HS 11 Pioglitazone 10 Pioglitazone/Glimepiride 10 Pioglitazone/Metformin 10

2013 Prescription Drug List – Three-Tier


Piroxicam 13 Plan B 15 Plavix 16 Pletal 16 Polyethylene Glycol 12 Polymyxin B Sulfate/Trimethoprim 11 Portia 15 PR Natal 430 15 PR Natal 430 EC 15 Pradaxa 5 Pramipexole 8 Prandin 10 Pravachol 16 Pravastatin 6, 16 Precision Xtra Test Strips 9 Precose 16 Prednisolone 10 Prednisone 10 Prefest 15 Premarin 15 Premphase 15 Prempro 15 Prenatal 19 15 Prenatal Advantage 15 Prenatal Plus 15 Prevacid Delayed-Release Enteric-Coated Capsule 11 Prevacid Solutab 11 Previfem 15 Prevpac 11 Prilosec 11, 16 Prilosec Rx 11 Primidone 8 Prinivil 16 Prinzide 16 Pristiq 7 Proair HFA 14 Procardia XL 16 Prochlorperazine Maleate 11 Progesterone Micronized Capsule 15 Promethazine 14 Propafenone Sustained-Release 12 Hour Capsule 7 Propranolol 6 Propranolol/Hydrochlorothiazide 6 Propranolol Sustained-Action Capsule 6 Proscar 16 Protonix 11, 16 Protonix Granules 11 Protopic 9 Proventil HFA 14 Provera 15, 16 Provigil 8 Prozac 16 Prozac Weekly 16 Pulmicort Flexhaler 14 Pulmicort Respules 1 mg/2 ml 14 Pylera 11 Q Quasense 15 Quetiapine 8 Quinapril 6, 16 Quinapril/Hydrochlorothiazide 6 QVAR 14 R Ramipril 6, 16 Ranexa 7 Ranitidine Syrup 11, 16 Rapaflo 12 Rapamune 12 Rebetol Solution 5 Rebif 8 Reclipsen 15 Rectiv 12 Regranex 9 Relenza 5 Relistor 12 Relpax 7

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Remeron 16 Remeron SolTab 16 Requip 8, 16 Requip XL 8 Restasis 12 Restoril 16 Retin-A Micro 9 Rhinocort Aqua 14 Ribapak 5 Ribavirin 5 Risperdal 16 Risperidone 8, 16 Ritalin 16 Ritalin SR 16 Rivastigmine 8 Rizatriptan 7 Ropinirole 8, 16 Ropinirole Extended-Release 24 Hour Tablet 8 Rozerem 8 Rybix ODT 13 S Sabril 8 Safyral 15 Saizen 10 Sancuso 11 Sandimmune 12 Savella 14 Serevent Diskus 14 Seroquel XR 8 Serostim 10 Sertraline 7, 16 Setonet 15 Setonet-EC 15 Silenor 8 Silver Sulfadiazine 9 Simcor 6 Simponi 13 Simvastatin 6, 16 Singulair 14 Skelaxin 14 Solodyn 45, 90, 135 mg 5 Solodyn 55, 65, 80, 105, 115 mg 5 Soltamox 12 Soma 250 mg 14 Sonata 8, 16 Sotalol 7 Spiriva 14 Spironolactone 6, 16 Spironolactone/Hydrochlorothiazide 6 Sporanox Oral Solution 5 Sprintec 15 Sprix 13 Sronyx 15 Stavzor 8 Staxyn 12 Stelara 9 Strattera 7 Subsys 13 Sucralfate Tablet 11 Sulfacetamide Sodium 9, 11 Sulfacetamide Sodium/Sulfur 9 Sulfamethoxazole/Trimethoprim 5 Sulfasalazine 12, 13 Sulindac 13 Sumatriptan Succinate Injection, Tablet 7, 16 Sumatriptan Succinate Nasal Spray 7 Sumavel DosePro 7 Suprax 5 Surmontil 16 Syeda 15 Symbicort 14 Symlin 10 Synarel 10 Synthroid 10 T Taclonex 9 Taclonex Scalp 9 Tacrolimus 12

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Tamiflu 5 Tamoxifen 12 Tamsulosin 12, 16 Taron A Prenatal 15 Tasmar 8 Tazorac 9 Tegretol 8 Tekamlo 6 Tekturna 6 Tekturna HCT 6 Temazepam 8, 16 Tenoretic 16 Tenormin 16 Terazosin 6, 12 Terbinafine Tablet 5, 16 Terconazole Vaginal 5 Testim 10 Testosterone 10 Tetracycline 5 Tev-Tropin 10 Teveten 6, 16 Teveten HCT 6 Thalitone 6 Theophylline 14 Tiagabine 8 Tiazac 16 Tilia Fe 15 Timolol Maleate 11 Tirosint 10 Tizanidine 14 Tobi 5 Tobradex ST 11 Tobramycin/Dexamethasone 11 Tobramycin Sulfate Drops 11 Tolmetin Sodium 13 Tolterodine 12 Topamax 8, 16 Topiramate 8, 16 Toprol XL 25 mg 16 Torsemide 6 Toviaz 12 Tradjenta 10 Tramadol 13, 16 Tramadol/Acetaminophen 13, 16 Tramadol Extended-Release Multiphase 24 Hour Tablet 13 Tramadol Sustained-Release 24 Hour Tablet 13 Trandolapril 6, 16 Trandolapril/Verapamil 6 Tranexamic Acid 12 Transderm-Scop 11 Travatan Z 11 Trazodone 7 Tretin-X 9 Tretinoin 9 Trexall 13 Treximet 7 Tri-Legest Fe 15 Tri-Previfem 15 Tri-Sprintec 15 Triamcinolone Acetonide 9, 14 Triamterene/Hydrochlorothiazide 6, 16 Tribenzor 6 Tricor 6 Triglide 6 Trileptal 16 Trilipix 6 Trilyte with Flavor Packets 12 Trimipramine Maleate 16 Trinessa 15 Trivora 15 Trospium 12 Trospium Extended-Release 24 Hour Capsule 12 Trusopt 16 Twynsta 6 Tylenol #3 16 U Uloric 14

2013 Prescription Drug List – Three-Tier


Ultracet 16 Ultram 16 Urea 9 Uroxatral 16 Ursodiol 12 V Vagifem 15 Valacyclovir 5 Valcyte 5 Valium 16 Valsartan/Hydrochlorothiazide 6 Valtrex 5 Vancomycin 5 Vanos 9 Vaseretic 16 Vasotec 16 Vectical 9 Velivet 15 Veltin 9 Venlafaxine 7, 16 Venlafaxine Extended-Release Tablet 7 Venlafaxine Sustained-Release Capsule 7, 16 Ventolin HFA 14 Veramyst 14 Verapamil 6, 16 Verapamil Sustained-Release 24 Hour Pellets 6 Verdeso 9 Vesicare 12 Vestura 15 Vfend 16 Viagra 12 Vicodin, Vicodin ES 16 Vicoprofen 16 Victoza 10 Victrelis 5 Vigamox 11 Viibryd 7 Vimovo 13 Viorele 15 Vivelle-Dot 15 Voltaren Gel 13 Voltaren Tablet 16 Voriconazole 5, 16 Vusion 9 Vytorin 6 Vyvanse 7 W Warfarin Sodium 5 Welchol 6 Wellbutrin 16 Wellbutrin SR 16 Wellbutrin XL 16 Wymzya Fe 15 X Xalatan 16 Xanax, Xanax XR 16 Xarelto 5 Xeljanz 13 Xerese 9 Xolegel 9 Xopenex HFA 14 Xopenex Vial, Nebulizer 14 Xyrem 8 Y Yasmin 15 Yaz 15 Z Zafirlukast 14, 16 Zaleplon 8, 16 Zantac Syrup 16 Zarah 15 Zatean-PN 15 Zatean-PN DHA 15 Zatean-PN Plus 15 Zegerid Capsule 11 Zegerid Packet 11 Zemplar 10 Zenchent 15

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Zenchent Fe 15 Zenpep 12 Zeosa 15 Zestoretic 16 Zestril 16 Zetia 6 Zetonna 14 Ziac 16 Ziana 9 Ziprasidone 8 Zipsor 13 Zithromax 16 Zocor 16 Zofran 16 Zoloft 16 Zolpidem 8, 16 Zolpidem Multiphasic-Release Tablet 8 Zolpidem Tablet 8 Zolpimist 8 Zomig 7 Zomig Nasal Spray 7 Zomig ZMT 7 Zonegran 16 Zonisamide 8, 16 Zorbtive 10 Zovia 1/35E 15 Zovia 1/50E 15 Zovirax 9, 16 Zuplenz 11 Zyclara 9 Zylet 11 Zymaxid 11 Zyvox 5

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2013 Prescription Drug List – Three-Tier

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