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Your 2016 Four-Tier
Prescription Drug List
effective July 1, 2016 Please read: This document contains information about commonly prescribed medications.
For additional information: Call the tol -free member phone number on 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 . . . . . . . . . . . . 19
Men's Health
Erectile Dysfunction . . . . . . . . . . . . 19 Central Nervous System
Attention Deficit Disorder . . . . . . . . . . 13
Miscellaneous . . . . . . . . . . . . . . 20
Sedatives/Hypnotics . . . . . . . . . . . . 14 Overactive Bladder . . . . . . . . . . . 22
Dermatology . . . . . . . . . . . . . . . 15
Blood Glucose Monitoring . . . . . . . . . 16 Pulmonary Arterial Hypertension . . . . . . 23 Smoking Cessation . . . . . . . . . . . 23
Transplant . . . . . . . . . . . . . . . . 23
Endocrine
Growth Hormone . . . . . . . . . . . . . . 17
Vitamins/Electrolytes . . . . . . . . . . 23
Thyroid Hormone Replacement . . . . . . . 17 Hormone Replacement . . . . . . . . . . . 24 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 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 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, 3 or 4, 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 .
Tier 2 and 3
Mix of brands and Use Tier 2 or Tier 3 drugs instead of Tier 4 to help reduce your out-of-pocket costs .
Mostly higher-cost brand Many Tier 4 drugs have lower-cost Highest Cost
as well as select generic options in Tier 1, 2 or 3 . Ask your doctor if they could work for you .
Please note: Some plans may have two or three 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 on 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 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 may be covered for you.
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 . Health Care Reform Preventive – This medication is part of a Health Care Reform preventive benefit and may be available at no cost to you . – More than one month's worth of medication included in package so additional copay applies .
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 medical necessity requirements for select medications .
+For New Jersey fully insured members this program is referred to as First Start .
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 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. For some benefit plans if a brand-name drug
is prescribed and a generic equivalent is available, your cost share may be the copay PLUS the cost
difference between the brand-name drug and generic equivalent. 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. For most
plans, these medications are managed through the Specialty Pharmacy Program. Take advantage
of personalized support designed to help you get the most out of your treatment plan. Visit
UHCSpecialtyRx.com or call the toll-free phone number on your health plan ID card to learn more.
Please note, not all specialty medications are listed here. If you're taking a specialty medication that is on
Tier 3 or Tier 4, call the toll-free number on your health plan ID card to talk with a pharmacist about
finding lower-cost options or a financial assistance program.
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 more for your
medication 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 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 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 tol -free member phone number on 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 Requirements
Drug Name
Drug Requirements
Drug Name
Ofloxacin Tablets Amoxicillin Capsule, Penicil in V Potassium Amoxicillin/Potassium Clavulanate Chewable Trimethoprim Tablet Azithromycin Tablet Suprax Capsule,
Cefadroxil Capsule, Chewable Tablet,
Cefixime Suspension Cefuroxime Tablet Cephalexin Capsule Fluconazole Tablet Ciprofloxacin Tablet Itraconazole Capsule Clarithromycin Tablet Ketoconazole Cream Clindamycin Capsule Noxafil Tablet,
Doxycycline Hyclate 50, 100 mg Capsule, Terbinafine Tablet Doxycycline Monohydrate Acyclovir Ointment 50, 100 mg Capsule Levofloxacin Tablet Metronidazole Tablet Minocycline Capsule Valacyclovir Tablet Minocycline Tablet Moxifloxacin Tablet Nitrofurantoin Capsule Macrocrystal Capsule Bold type = Brand-name drug[Plain type = Generic drug] PA = Prior Authorization required DSP = Designated Specialty Program RS = May be eligible for the Refill and Save Program E = May be excluded from coverage SDP = Select Designated Pharmacy H = Health Care Reform Preventive SL = Supply Limit MC = Multiple Copay ST = Step Therapy Drug Requirements
Drug Requirements
Drug Name
Drug Name
Benicar HCT
Bexarotene Capsule Hydroxyurea Capsule Leucovorin Calcium Diltiazem 24 Hour CD Diltiazem Sustained- Mercaptopurine Tablet Diltiazem Sustained- Cardiovascular/Heart Disease:
Enoxaparin Sodium Cardiovascular/Heart Disease:
High Blood Pressure
Metoprolol Succinate Metoprolol Tartrate Propranolol Extended- Drug Requirements
Drug Requirements
Drug Name
Drug Name
Propranolol Tablet Omega-3-Acid Ethyl Tricor 48, 145 mg
Cardiovascular/Heart Disease:
Choline Fenofibrate Cardiovascular/Heart Disease: Other
Fenofibrate 43, 50 , 67, 130, 134, 150, 200 mg Fenofibrate 48, 145 mg Fenofibrate 54, 160 mg Fluvastatin Extended- Lescol XL
Bold type = Brand-name drug[Plain type = Generic drug] PA = Prior Authorization required DSP = Designated Specialty Program RS = May be eligible for the Refill and Save Program E = May be excluded from coverage SDP = Select Designated Pharmacy H = Health Care Reform Preventive SL = Supply Limit MC = Multiple Copay ST = Step Therapy Drug Requirements
Drug Requirements
Drug Name
Drug Name
Central Nervous System:
Attention Deficit Disorder
Central Nervous System: Depression
Adderall XR
Amitriptyline Tablet Amphetamine Salt Bupropion Extended- Aptensio XR
Bupropion Sustained- Dexmethylphenidate Extended-Release Citalopram Tablet Dexmethylphenidate Duloxetine Capsule Escitalopram Tablet Extended-Release Fluoxetine Capsule, Amphetamine Tablet Fluvoxamine Tablet Dextroamphetamine Mirtazapine Tablet Focalin XR
Nortriptyline Capsule Paroxetine Tablet Pristiq ER
Metadate CD
Sertraline Tablet Venlafaxine Extended- Extended-Release Venlafaxine Tablet Methylphenidate Extended-Release Drug Requirements
Drug Requirements
Drug Name
Drug Name
Central Nervous System: Migraine
Donepezil 5, 10 mg Butalbital/Caffeine 325 mg/50 mg/40 mg Rizatriptan ODT, Tablet Sumatriptan Nasal Spray Sumatriptan Succinate Namenda XR
Tablet, Injection Olanzapine Tablet Central Nervous System:
Pramipexole Tablet Quetiapine Tablet Risperidone Tablet Ropinirole Tablet Seroquel XR
Ziprasidone Capsule Central Nervous System:
Central Nervous System: Other
Temazepam Capsule Alprazolam Extended- Alprazolam Tablet Zolpidem Extended- Aripiprazole Tablet Naloxone TabletBuspirone Tablet Bold type = Brand-name drug[Plain type = Generic drug] PA = Prior Authorization required DSP = Designated Specialty Program RS = May be eligible for the Refill and Save Program E = May be excluded from coverage SDP = Select Designated Pharmacy H = Health Care Reform Preventive SL = Supply Limit MC = Multiple Copay ST = Step Therapy Drug Requirements
Drug Requirements
Drug Name
Drug Name
Central Nervous System:
Clindamycin 1 .2%/ Benzoyl Peroxide 5% Gel Carbamazepine Tablet Clonazepam Tablet Clindamycin Lotion Clindamycin Solution, Divalproex Delayed- Clobetasol Propionate Divalproex Extended- Clobetasol Propionate Gabapentin Capsule, Lamotrigine Tablet Betamethasone Cream Extended-Release Betamethasone Lotion Condylox Gel
Levetiracetam Tablet Desonide 0 .05% Cream, Oxcarbazepine Tablet Desoximetasone Gel, Phenytoin Capsule, Differin 1%
Topiramate Tablet Cream, Gel
Zonisamide Capsule Diflorasone Diacetate 0 .05% Cream, Ointment Fluocinonide 0 .05% Fluocinolone Cream, Oil, Adapalene 0 .3% Gel Ointment, Solution Halobetasol Ointment Dipropionate 0 .05%  Hydrocortisone 2 .5% Augmented Lotion, Imiquimod 5% Cream Metronidazole 0 .75% Dipropionate 0 .05% Mometasone Furoate Ciclopirox Cream, Gel, Cream, Lotion, Ointment Mupirocin Ointment Nystatin-Triamcinolone Acetonide Cream, Benzoyl Peroxide 5% Gel Drug Requirements
Drug Requirements
Drug Name
Drug Name
Tacrolimus Ointment Humalog Mix 50-50
Tretinoin Microspheres Humalog Mix 75-25
Triamcinolone Acetonide Cream, Lotion, Ointment Humulin 70-30
KwikPen
Diabetes: Blood Glucose Monitoring
Humulin 70-30 Vials
Accu-Chek
Humulin N KwikPen
Test Strips
Humulin N Vials
Contour Test Strips
Humulin R Vials
Dexcom Continuous
Glucose Monitoring
Lantus Vials
Novolin 70-30 Vials
FreeStyle Test Strips
Novolin N Vials
OneTouch
Novolin R Vials
Test Strips
OneTouch Ultra
Novolog Mix 70/30
OneTouch Ultra Mini
Novolog Mix 70/30
OneTouch Ultra
Test Strips
OneTouch Verio IQ
OneTouch Verio Sync
OneTouch Verio
Test Strips
Bold type = Brand-name drug[Plain type = Generic drug] PA = Prior Authorization required DSP = Designated Specialty Program RS = May be eligible for the Refill and Save Program E = May be excluded from coverage SDP = Select Designated Pharmacy H = Health Care Reform Preventive SL = Supply Limit MC = Multiple Copay ST = Step Therapy Drug Requirements
Drug Requirements
Drug Name
Drug Name
Calcitriol Capsule Desmopressin Tablet Dexamethasone Tablet Methylprednisolone Prenisolone Oral Prednisone Tablet Endocrine: Thyroid Hormone
Levothyroxine Sodium Liothyronine Sodium Methimazole Tablet NP Thyroid Tablet Metformin Extended- Release Tablet (generic Eye Conditions: Allergies
Azelastine 0 .05% Ophthalmic Solution Olopatadine 0 .1% Ophthalmic Solution Eye Conditions: Antibiotics
Victoza 2-Pak
Erythromycin 0 .5% Xigduo XR
Ophthalmic OintmentGentamicin Ophthalmic Endocrine: Growth Hormone
Ointment, Solution Nutropin,
Nutropin AQ
Ophthalmic Solution Drug Requirements
Drug Requirements
Drug Name
Drug Name
0 .3%-0 .1% Ophthalmic Tobramycin Ophthalmic Eye Conditions: Glaucoma
Alphagan P 0.1%
Asacol HD Tablet
Latanoprost 0 .005% Ophthalmic Solution Timolol Maleate 0 .25%, 0 .5% Ophthalmic Diphenoxylate-Atropine Travatan Z
Gastrointestinal: Acid Suppression
Hyoscyamine Tablet Esomeprazole Capsule Metoclopramide Tablet Lansoprazole Capsules Omeprazole Capsule Pantoprazole Tablet Rabeprazole Tablet Sulfasalazine Tablet Sucralfate Tablet Bold type = Brand-name drug[Plain type = Generic drug] PA = Prior Authorization required DSP = Designated Specialty Program RS = May be eligible for the Refill and Save Program E = May be excluded from coverage SDP = Select Designated Pharmacy H = Health Care Reform Preventive SL = Supply Limit MC = Multiple Copay ST = Step Therapy Drug Requirements
Drug Requirements
Drug Name
Drug Name
Hepatitis C
Gonal-F RFF
*Coverage is determined by the consumer's prescription drug benefit plan .
Viekira Pak
Inflammatory Conditions: Rheumatoid
Arthritis, Crohn's Disease, Psoriasis,
Hydroxychloroquine Leflunomide Tablet Methotrexate Tablet Men's Health: Erectile Dysfunction
Drug Requirements
Drug Requirements
Drug Name
Drug Name
Men's Health: Prostate
Dutasteride Capsule Finasteride Tablet Tamsulosin Capsule Terazosin Capsule, Tablet Chlorpheniramine Men's Health: Testosterone Therapy
Methyltestosterone Lidocaine Transdermal Testosterone Cypionate Anastrozole Tablet Antipyrine/Benzocaine Benzonatate Capsule Bromfed DM
Nebulized Solution Bold type = Brand-name drug[Plain type = Generic drug] PA = Prior Authorization required DSP = Designated Specialty Program RS = May be eligible for the Refill and Save Program E = May be excluded from coverage SDP = Select Designated Pharmacy H = Health Care Reform Preventive SL = Supply Limit MC = Multiple Copay ST = Step Therapy Drug Requirements
Drug Requirements
Drug Name
Drug Name
Hydrocodone/Ibuprofen Alendronate Sodium Hydromorphone Tablet Ibandronate Tablet Indomethacin Capsule Raloxifene Tablet Risedronate Sodium Methadone Tablet, Oral Solution, Allopurinol Tablet Concentrate Solution Morphine Sulfate Carisoprodol 350 mg Extended-Release Tablet Morphine Sulfate Oral Cyclobenzaprine Tablet Nabumetone Tablet Metaxalone Tablet Methocarbamol Tablet Nucynta ER
Tizanidine Tablet Oxycodone/Acetaminophen Musculoskeletal: Pain Relief
5/325, 7 .5/325, Diclofenac Tablet Fentanyl 12, 25, 50, 75, 100 mcg Patch Tramadol Sustained- Fentanyl 37 .5, 62 .5, Fentanyl Citrate Vicodin 5/300, 7 .5/300, Acetaminophen 5/325, Voltaren Gel
7 .5/325, 10/325 mg Zohydro ER
Drug Requirements
Drug Requirements
Drug Name
Drug Name
Dicyclomine Tablet Oxybutynin Extended- Breo Ellipta
Oxybutynin Tablet Tolterodine Extended- Tolterodine Tablet Ipratropium-Albuterol NebsIpratropium Nebs Azelastine 0 .1% Levalbuterol Nebs Montelukast Chewable Montelukast Granules Cyproheptadine Tablet Perforomist
Fluticasone Nasal Spray ProAir HFA
Hydroxyzine Capsule, Levocetirizine Tablet Promethazine Tablet Ventolin HFA
Albuterol Sulfate Tablet Xopenex HFA
Xopenex Nebs
Bold type = Brand-name drug[Plain type = Generic drug] PA = Prior Authorization required DSP = Designated Specialty Program RS = May be eligible for the Refill and Save Program E = May be excluded from coverage SDP = Select Designated Pharmacy H = Health Care Reform Preventive SL = Supply Limit MC = Multiple Copay ST = Step Therapy Drug Requirements
Drug Requirements
Drug Name
Drug Name
Respiratory: Pulmonary Arterial
Hypertension
Potassium Chloride Sildenafil Tablet Potassium Citrate Women's Health: Contraceptives
Bupropion Sustained- Chantix Tablet
Nicoderm CQ
Nicorette
Nicotrol Nasal Spray
Lo Loestrin Fe
Azathioprine Tablet Cyclosporine Modified Minastrin 24 FE
Mycophenolate Capsule, Mycophenolic Acid Necon 0 .5/35, 1/35, Tacrolimus Capsule Drug Requirements
Drug Requirements
Drug Name
Drug Name
Norgestimate-Ethinyl Estradiol/Norethindrone Estradiol Twice-Weekly Transdermal Patch Methyltestosterone Plan B One Step
Medroxyprogesterone Micronized Capsule Women's Health: Miscellaneous
Yasmin 28
Women's Health: Hormone Replacement
Women's Health: Prenatal Vitamins
Brand Prenatal
Climara Pro
Bold type = Brand-name drug[Plain type = Generic drug] PA = Prior Authorization required DSP = Designated Specialty Program RS = May be eligible for the Refill and Save Program E = May be excluded from coverage SDP = Select Designated Pharmacy H = Health Care Reform Preventive SL = Supply Limit MC = Multiple Copay ST = Step Therapy Amoxicillin/Potassium Abilify Tablet .14 Clavulanate Chewable Baclofen Tablet .21 Tablet, Tablet .10 Accu-Chek Test Strips .16 Amoxicillin Capsule, Chewable Tablet .10 Hydrochlorothiazide .11 Caffeine 325 mg/50 mg/ Amphetamine Salt Combo . 13 Acetaminophen/Codeine Anastrozole Tablet . 20 Benzonatate Capsule . 20 Betamethasone Dipropionate 0.05% Cream, Ointment . 15 Acyclovir Ointment .10 Anoro Ellipta. 22 Acyclovir Tablet .10 Antipyrine/Benzocaine Bethamethasone Dipropionate Otic Solution . 20 0.05% Augmented Lotion, Adapalene 0.1% Cream, Gel. 15 Adapalene 0.3% Gel . 15 Bexarotene Capsule .11 Aripiprazole Tablet .14 Advair Diskus/HFA . 22 Armour Thyroid .17 Arnuity Ellipta . 22 Asacol HD Tablet .18 Hydrochlorothiazide .11 Albuterol Nebs . 22 Brand Prenatal Vitamins . 24 Albuterol Sulfate Tablet . 22 Breo Ellipta . 22 Alendronate Sodium Tablet.21 Atorvastatin . 12 Alfuzosin Tablet . 20 Allopurinol Tablet .21 Budesonide Nebs . 22 Alphagan P 0.1% .18 Buprenorphine/Naloxone Alprazolam Extended-Release Bupropion Extended-Release Alprazolam Tablet .14 Azathioprine Tablet . 23 Azelastine 0.05% Ophthalmic Bupropion Sustained-Release Bupropion Tablet . 13 Amitriptyline Tablet . 13 Buspirone Tablet .14 Azithromycin Tablet .10 Amlodipine-Valsartan .11 Clindamycin 1%/Benzoyl Cyclosporine Modified Calcitriol Capsule .17 Peroxide 5% Gel . 15 Clindamycin 1.2%/Benzoyl Peroxide 5% Gel . 15 Cyproheptadine Tablet . 22 Carbamazepine Tablet . 15 Clindamycin Capsule .10 Carbidopa-Levodopa .14 Clindamycin Gel . 15 Carisoprodol 350 mg Tablet .21 Clindamycin Lotion . 15 Clindamycin Solution, Desmopressin Tablet .17 Clobetasol Propionate Cream, Desonide 0.05% Cream, Cefadroxil Capsule, Tablet .10 Lotion, Ointment . 15 Cefdinir Capsule .10 Clobetasol Propionate Desoximetasone Gel, Cefixime Suspension .10 Cefprozil Tablet .10 Dexamethasone Tablet .17 Cefuroxime Tablet .10 Clonazepam Tablet . 15 Dexcom Continuous Glucose Clonidine Tablet .11 Monitoring System .16 Dexcom Sensor .16 Cephalexin Capsule .10 Dexcom Transmitter .16 Dexmethylphenidate Chantix Tablet . 23 Extended-Release Dexmethylphenidate Tablet . 13 Pseudoephedrine Solution . 20 Combivent Respimat . 22 Chlorthalidone .11 Choline Fenofibrate . 12 Extended-Release . 13 Condylox Gel . 15 Ciclopirox Cream, Gel, Lotion, Contour Test Strips .16 Amphetamine Tablet . 13 Dextroamphetamine Sulfate Diazepam Tablet .14, 15 Ciprofloxacin Tablet .10 Diclofenac Tablet .21 Citalopram Tablet . 13 Dicyclomine Tablet . 22 Differin 1% Cream, Gel . 15 Diflorasone Diacetate 0.05% Clarithromycin Tablet .10 Cream, Ointment . 15 Cyclobenzaprine Tablet .21 Cyclophosphamide Capsule .11 Diltiazem 24 Hour CD .11 Diltiazem Sustained-Release Finasteride Tablet . 20 Diltiazem Sustained-Release Flovent Diskus/HFA . 22 Fluconazole Tablet .10 Diphenoxylate-Atropine Fluocinolone Cream, Oil, Ointment, Solution . 15 Divalproex Delayed-Release Erythromycin 0.5% Fluocinonide 0.05% Cream . 15 Ophthalmic Ointment .17 Divalproex Extended-Release Escitalopram Tablet . 13 Fluoxetine Capsule, Tablet . 13 Esomeprazole Capsule .18 Fluticasone Nasal Spray . 22 Estrace Cream . 24 Fluvastatin Extended-Release Donepezil 5, 10 mg ODT, Estradiol/Norethindrone Acetate Tablet . 24 Fluvoxamine Tablet . 13 Estradiol Tablet . 24 Doxazosin .11, 20 Estradiol Twice-Weekly Doxazosin Tablet . 20 Transdermal Patch . 24 Doxepin Capsule . 13 Doxycycline Hyclate 50, 100 mg Capsule, FreeStyle Test Strips .16 Eszopiclone Tablet .14 Doxycycline Monohydrate Etodolac Capsule .21 50, 100 mg Capsule .10 Gabapentin Capsule, Tablet . 15 Duloxetine Capsule . 13 Gentamicin Ophthalmic Dutasteride Capsule . 20 Ointment, Solution .17 Farxiga .17Fenofibrate 43, 50 , 67, 130, 134, 150, 200 mg Capsule . 12 Econazole Cream .10 Fenofibrate 48, 145 mg Fenofibrate 54, 160 mg Fentanyl 12, 25, 50, 75, Glipizide Extended-Release .17 100 mcg Patch .21 Fentanyl 37.5, 62.5, 87.5 mcg Fentanyl Citrate Lozenge .21 Enoxaparin Sodium .11 Guanfacine .11, 13 Ibuprofen Tablet .21 Extended-Release . 13 Imatnib Tablet .11 Latanoprost 0.005% Imiquimod 5% Cream . 15 Ophthalmic Solution .18 Halobetasol Ointment . 15 Incruse Ellipta . 22 Indomethacin Capsule .21 Humalog KwikPen .16 Leflunomide Tablet .19 Humalog Mix 50-50 Humalog Mix 75-25 Letrozole Tablet . 20 Ipratropium-Albuterol Nebs . 22 Leucovorin Calcium Tablet .11 Humalog Vials .16 Ipratropium Nebs . 22 Levalbuterol Nebs . 22 Levemir FlexTouch .16 Humulin 70-30 KwikPen .16 Levemir Vials .16 Humulin 70-30 Vials .16 Isosorbide Mononitrate ER . 12 Humulin N KwikPen .16 Itraconazole Capsule .10 Extended-Release Tablet . 15 Humulin N Vials .16 Levetiracetam Tablet . 15 Humulin R Vials .16 Levocetirizine Tablet . 22 Hydrochlorothiazide .11 Levofloxacin Tablet .10 5/325, 7.5/325, 10/325 mg Levothyroxine Sodium Chlorpheniramine Lidocaine Transdermal Hydrocodone/Homatropine . 20 Hydrocodone/Ibuprofen Hydrocortisone 2.5% Cream, Ketoconazole Cream .10 Liothyronine Sodium Tablet .17 Ketorolac Tablet .21 Hydromorphone Tablet .21 Klor-Con M10 . 23 Hydroxychloroquine Sulfate Klor-Con M20 . 23 Lisinopril .11, 34 Kombiglyze XR .17 Hydroxyurea Capsule .11 Hydrochlorothiazide .11 Hydroxyzine Capsule, Tablet 22 Lithium Capsule .14 Hyoscyamine Tablet .18 Lo Loestrin Fe . 23 Lamotrigine Tablet . 15 Lorazepam Tablet .14 Lansoprazole Capsules .18 Ibandronate Tablet .21 Lantus Solostar .16 Metronidazole 0.75% Necon 0.5/35, 1/35, Hydrochlorothiazide .11 Metronidazole Tablet .10 Low-Ogestrel . 23 Microgestin FE . 23 Minastrin 24 FE . 23 Extended-Release .19 Nexium Capsule .18 Minocycline Capsule .10 Minocycline Tablet .10 Niacin Extended-Release Medroxyprogesterone Mirtazapine Tablet . 13 Meloxicam Tablet .21 Memantine Tablet .14 Modafinil Tablet .14 Nicorette Gum . 23 Mercaptopurine Tablet .11 Mometasone Furoate Cream, Nicorette Lozenge . 23 Lotion, Ointment . 15 Nicorette Mini-Lozenge . 23 Metaxalone Tablet .21 Nicotine Gum . 23 Montelukast Chewable Tablet, Nicotine Lozenge . 23 Metformin Extended-Release Nicotine Patch . 23 Tablet (generic Glucophage Montelukast Granules . 22 Nicotrol Inhaler . 23 Morphine Sulfate Nicotrol Nasal Spray . 23 Methadone Tablet, Oral Extended-Release Tablet .21 Solution, Concentrate Morphine Sulfate Extended-Release .11 Oral Solution .21 Nitrofurantoin Capsule .10 Methimazole Tablet .17 Nitrofurantoin Macrocrystal Methocarbamol Tablet .21 Methotrexate Tablet .19 Methylphenidate Chewable Moxifloxacin Tablet .10 Norgestimate-Ethinyl Mupirocin Ointment . 15 Mycophenolate Capsule, Nortrel 0.5/35 . 24 Extended-Release Nortriptyline Capsule . 13 Mycophenolic Acid Tablet . 23 Novolin 70-30 Vials .16 Extended-Release Tablet . 13 Novolin N Vials .16 Methylphenidate Tablet . 13 Nabumetone Tablet .21 Novolin R Vials .16 Methylprednisolone Tablet .17 Novolog FlexTouch .16 Methyltestosterone Capsule . 20 Novolog Mix 70/30 Metoclopramide Tablet .18 Naproxen Tablet .21 Metoprolol Succinate Novolog Mix 70/30 Vials .16 50, 100, 200 mg .11 Novolog Vials .16 Metoprolol Tartrate .11 Noxafil Tablet, Suspension .10 NP Thyroid Tablet .17 Ortho-Cyclen . 24 Prednisone Tablet .17 Ortho-Novum 7/7/7 . 24 Ortho Micronor . 24 Nutropin, Nutropin AQ .17 Ortho Tri-Cyclen . 24 Prenisolone Oral Solution.17 Nystatin-Triamcinolone Acetonide Cream, Nystatin Cream, Ointment.10 Oxcarbazepine Tablet . 15 Oxsoralen-Ul . 15 ProAir Respiclick . 22 Oxybutynin Extended-Release Progesterone Micronized Ofloxacin 0.3% Ophthalmic Oxybutynin Tablet . 22 Oxycodone/Acetaminophen Promethazine/Codeine . 20 Ofloxacin Tablets .10 5/325, 7.5/325, 10/325 mg Olanzapine Tablet .14 Dextromethorphan . 20 Olopatadine 0.1% Ophthalmic Oxycodone Tablet .21 Promethazine Tablet . 22 Propranolol Extended-Release Omeclamox-Pak .18 Omega-3-Acid Ethyl Esters Propranolol Tablet . 12 Pantoprazole Tablet .18 Proventil HFA . 22 Omeprazole Capsule .18 Paroxetine Tablet . 13 Pulmicort Flexhaler . 22 Ondansetron ODT .18 OneTouch Test Strips .16 Penicillin V Potassium OneTouch Ultra Meter .16 OneTouch Ultra Mini .16 OneTouch Ultra Test Strips .16 Phenazopyridine . 20 OneTouch Verio .16 Phenytoin Capsule, Quetiapine Tablet .14 OneTouch Verio IQ .16 OneTouch Verio Sync .16 OneTouch Verio Test Strips .16 Plan B One Step . 24 Polyethylene Glycol 3350 .18 Rabeprazole Tablet .18 Potassium Chloride . 23 Raloxifene .21, 24 Potassium Citrate . 23 Raloxifene Tablet .21 Pramipexole Tablet .14 Ranitadine Syrup .18 Terazosin . 12, 20 Stiolto Respimat . 22 Terazosin Capsule, Tablet . 20 Terbinafine Tablet .10 Striverdi Respimat . 22 Testosterone 1% Topical Suboxone Film .14 Testosterone Cypionate Sucralfate Tablet .18 Sulfamethoxazole- Timolol Maleate 0.25%, 0.5% Trimethoprim Tablet .10 Ophthalmic Solution .18 Sulfasalazine Tablet .18 Sumatriptan Nasal Spray .14 Sumatriptan Succinate Tablet, Tizanidine Tablet .21 Ribavirin Tablet .19 Tobi Podhaler . 20 Risedronate Sodium Tablet .21 Sumavel DosePro .14 Risperidone Tablet .14 Suprax Capsule, Chewable 0.3%-0.1% Ophthalmic Rizatriptan ODT, Tablet .14 Tablet, Tablet .10 Ropinirole Tablet .14 Tobramycin Nebulized Tobramycin Ophthalmic Seebri Neohaler . 22 Serevent Diskus . 22 Tolterodine Extended-Release Sertraline Tablet . 13 Tacrolimus Capsule . 23 Sildenafil Tablet . 23 Tacrolimus Ointment .16 Tolterodine Tablet . 22 Topiramate Tablet . 15 Toujeo SoloStar .16 Tamsulosin Capsule . 20 Sirolimus Tablet . 23 Targretin Capsule .11 Targretin Gel .11 Tramadol Sustained-Release Spiriva Handihaler . 22 Spiriva Respimat. 22 Tramadol Tablet .21 Spironolactone . 12 Transderm-Scop .18 Trazodone Tablet . 13 Hydrochlorothiazide . 12 Temazepam Capsule .14 Tretinoin Microspheres .16 Tri-Lo-Estarylla . 24 Hydrochlorothiazide . 12 Tri-Lo-Marzia . 24 Tri-Lo-Sprintec . 24 Tri-Previfem . 24 Tri-Sprintec . 24 Venlafaxine Extended-Release Triamcinolone Acetonide Xopenex Nebs . 22 Cream, Lotion, Ointment .16 Venlafaxine Tablet . 13 Triamcinolone Nasal Spray . 22 Ventolin HFA . 22 Hydrochlorothiazide . 12 Verapamil Sustained-Release . 12 Triazolam Tablet .14 Tricor 48, 145 mg . 12 Vicodin 5/300, 7.5/300, 10/300 mg Tablet .21 Zaleplon Capsule .14 Victoza 2-Pak .17 Victoza 3-Pak .17 Ziprasidone Capsule .14Zohydro ER .21 Viorele . 24Viread .19 Zolpidem Extended-Release Zolpidem Tablet .14 Utibron Neohaler . 22 Zonisamide Capsule . 15 Zovirax Cream .10Zubsolv .14 Valacyclovir Tablet .10 Valaganciclovir .10 Warfarin Sodium .11 "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, 20 mg High blood pressure For more information Call the tol -free member phone number on 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 . 2016 United HealthCare Services, Inc . All rights reserved . Created February, 2016 . 2016 Prescription Drug List – Advantage Four-Tier

Source: http://www.co.madison.il.us/document_center/SafetyManagement/2015-16MedicalPlans/PDL%207-1-2016.pdf