Uhc_prescription_drug_list.pdf

2010 Three-Tier Prescription Drug List Reference Guide Table of Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-6
Prescription Drug List - 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7-25
Anti-Infectives
Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Cardiovascular/Heart Disease
Coagulation Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
High Blood Pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-9
High Cholesterol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
Central Nervous System
Attention Defi cit Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
Migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
Sedatives/Hypnotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
Seizure Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-14
Endocrine/Diabetes
Blood Glucose Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14
Growth Hormone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14
Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14
Non-Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
Eye Conditions
Anti-Allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16
Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16
Gastrointestinal
Acid Suppression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16
Nausea/Vomiting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17
Men’s Health
Erectile Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17
Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17
Miscellaneous
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18
Overactive Bladder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18
Musculoskeletal
Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18
Pain Relief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19
Rheumatoid Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20
Respiratory
Asthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20
Nasal Allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
Oral Allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
Women’s Health
Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22
Estrogen/Progesterone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
Prenatal Vitamins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
Additional Tier 3 Drugs with a generic equivalent in Tier 1 . . . . . . . . . . . . . . . . . 24-25
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26-32
Created May, 2010. For the most current PDL updates, visit myuhc.com or call the phone number on the back of your ID card.
2010 Three-Tier Prescription Drug List Reference Guide Your UnitedHealthcare pharmacy benefi t offers fl exibility and choice in fi nding the right medication for you. 1. Help you understand your medication choices and make 2. Help you understand which questions to ask your doctor What is a Prescription Drug List (PDL)?A PDL is a list that categorizes medications, products or devices that have been approved by the U.S. Food and Drug Administration into tiers. Your UnitedHealthcare pharmacy benefi t provides coverage for a comprehensive selection of prescription medications. Below you will fi nd some commonly prescribed medications for certain conditions. You and your doctor can refer to this list to select the right medication to meet your needs. The benefi t plan documents provided by your employer or health plan include a Summary Plan Description (SPD) or a Certifi cate of Coverage (COC). Please refer to these documents to determine which medications are covered under your individual plan.
If you have pharmacy benefi t coverage with UnitedHealthcare, you may learn more about your benefi t by
visiting myuhc.com or by cal ing the tol -free member phone number on the back of your ID card. If you are
not currently enrol ed with UnitedHealthcare for pharmacy benefi t coverage, you may access myuhc.com for
additional information during your open enrol ment period or you may contact your employer or health plan for
additional information.
In certain documents, the Prescription Drug List (PDL) was referred to as the “Preferred Drug List (PDL).” This
change in descriptive terms does not affect your benefi t coverage.
Medications are categorized by common therapeutic conditions in this PDL reference guide for ease of
reference only. These categories do not determine coverage for the medication for your condition. Your benefi t
plan determines how these medications may be covered for you.
Where differences are noted between this PDL reference guide and your benefi t plan documents, the benefi t
plan documents wil govern.
Understanding Tiers
Prescription medications are categorized within three tiers. Each
tier is assigned a copayment, the amount you pay when you fi ll
a prescription, which is determined by your employer or health
plan. Consult your benefi t plan documents to fi nd out the specifi c
copayments, coinsurance, and deductibles that are part of your plan.
Some plans may require you to pay the entire cost of the
medication until the plan deductible has been met.
Tier 1 – Your Lowest-Cost OptionTier 1 medications are your lowest copayment option. For the lowest out-of-pocket expense, always consider Tier 1 medications if you and your doctor decide they are right for your treatment. Tier 2 – Your Midrange-Cost OptionTier 2 medications are your middle copayment option. Tier 3 – Your Highest-Cost OptionTier 3 medications are your highest copayment option. If you are currently taking a medication in Tier 3, ask your doctor whether there are lower-cost Tier 1 or Tier 2 medications that may be right for your treatment.
Note: Compounded medications are medications with one or
more ingredients that are prepared “on-site” by a pharmacist. These
are classifi ed at the Tier 3 level.
Please note: Some plans have a two-tier pharmacy benefi t rather than a three-
tier pharmacy benefi t. Generally, a two-tier closed pharmacy benefi t plan does
not cover medications classifi ed in Tier 3 of this PDL. A two-tier open pharmacy
benefi t plan covers one tier at the lower copayment and covers a second tier at a
higher copayment.
In addition, some plans have a four-tier prescription plan. Refer to your enrollment
materials, check the Drug Pricing/Coverage information on myuhc.com®, or
call the toll-free member phone number on the back of your ID card for more
information about your benefi t plan.
If you have pharmacy benefi t coverage with UnitedHealthcare, you may learn more about your benefi t by
visiting myuhc.com or by cal ing the tol -free member phone number on the back of your ID card. If you are
not currently enrol ed with UnitedHealthcare for pharmacy benefi t coverage, you may access myuhc.com for
additional information during your open enrol ment period or you may contact your employer or health plan for
additional information.
In certain documents, the Prescription Drug List (PDL) was referred to as the “Preferred Drug List (PDL).” This
change in descriptive terms does not affect your benefi t coverage.
Medications are categorized by common therapeutic conditions in this PDL reference guide for ease of
reference only. These categories do not determine coverage for the medication for your condition. Your benefi t
plan determines how these medications may be covered for you.
Where differences are noted between this PDL reference guide and your benefi t plan documents, the benefi t
plan documents wil govern.
Who decides which medications get placed in which tier?The UnitedHealthcare PDL Management Committee makes tier placement decisions. The Committee’s goal is to help ensure access to a wide range of medications, while controlling health care costs for you and your employer or health plan. The PDL Management Committee is comprised of senior level UnitedHealth Group physicians and business leaders. You and your doctor decide which medication is appropriate for you.
What factors does the PDL Management Committee look at to make tier placement decisions?The PDL Management Committee decides the tier placement of a particular prescription medication based on clinical information from the UnitedHealthcare Pharmacy and Therapeutics (P&T) Committee and economic considerations. The Committee looks at the overall health care value of a particular medication, balancing the need for fl exibility and choice for you and an affordable pharmacy benefi t for employer groups and health plans.
How often will prescription medications
change tiers?
Medications may change tiers up to six times per calendar year,
depending on your benefi t. Most changes will occur on January 1
and July 1. Additionally, when a brand-name medication becomes
available as a generic, the tier status of the brand-name medication
and its corresponding generic will be evaluated. When a medication
changes tiers, you may be required to pay more or less for that
medication. These changes may occur without prior notice to you.
For the most current information on your pharmacy coverage, please
call the toll-free member phone number on the back of your ID card
or visit myuhc.com.
If you have pharmacy benefi t coverage with UnitedHealthcare, you may learn more about your benefi t by
visiting myuhc.com or by cal ing the tol -free member phone number on the back of your ID card. If you are
not currently enrol ed with UnitedHealthcare for pharmacy benefi t coverage, you may access myuhc.com for
additional information during your open enrol ment period or you may contact your employer or health plan for
additional information.
In certain documents, the Prescription Drug List (PDL) was referred to as the “Preferred Drug List (PDL).” This
change in descriptive terms does not affect your benefi t coverage.
Medications are categorized by common therapeutic conditions in this PDL reference guide for ease of
reference only. These categories do not determine coverage for the medication for your condition. Your benefi t
plan determines how these medications may be covered for you.
Where differences are noted between this PDL reference guide and your benefi t plan documents, the benefi t
plan documents wil govern.
What is the difference between brand-name and generic medications?Generic medications contain the same active ingredients as brand-name medications, but they often cost less. Generic medications become available after the patent on the brand-name medication expires. At that time, other companies are permitted to manufacture an FDA-approved, chemical y equivalent medication. Many companies that make brand-name medications also produce and market generic medications.
The next time your doctor gives you a prescription for a brand-name
medication, ask if a generic equivalent or lower tier alternative is
available and if it might be appropriate for you. While there are
exceptions, generic medications are usually your lowest-cost
option. Please note that some generic medications may be in Tier
2 or Tier 3 and will not have the lowest copayment available under
your pharmacy benefi t plan. Go to myuhc.com to determine the
copayment for your generic medication.
Why is the medication that I am currently taking no longer covered?Medications may be excluded from coverage under your pharmacy benefi t. For example, a prescription medication may be excluded from coverage when it is therapeutically equivalent to another prescription medication or an over-the-counter medication. There may be alternatives on the PDL or over-the-counter medications that are appropriate for your treatment.
If you have pharmacy benefi t coverage with UnitedHealthcare, you may learn more about your benefi t by
visiting myuhc.com or by cal ing the tol -free member phone number on the back of your ID card. If you are
not currently enrol ed with UnitedHealthcare for pharmacy benefi t coverage, you may access myuhc.com for
additional information during your open enrol ment period or you may contact your employer or health plan for
additional information.
In certain documents, the Prescription Drug List (PDL) was referred to as the “Preferred Drug List (PDL).” This
change in descriptive terms does not affect your benefi t coverage.
Medications are categorized by common therapeutic conditions in this PDL reference guide for ease of
reference only. These categories do not determine coverage for the medication for your condition. Your benefi t
plan determines how these medications may be covered for you.
Where differences are noted between this PDL reference guide and your benefi t plan documents, the benefi t
plan documents wil govern.
When should I consider discussing over-the-counter or non-prescription medications with my doctor?An over-the-counter medication can be an appropriate treatment for some conditions. Consult your doctor about over-the-counter alternatives to treat your condition. These medications are not covered under your pharmacy benefi t, but they may cost less than your out-of-pocket expense for prescription medications.
Why are there notations next to certain
medications in the PDL, and what do
they mean?
The specifi c defi nitions for these notations (SL, N, etc.) are listed
at the bottom of each page of the PDL and refer to our pharmacy
programs. These programs as well as our drug utilization review
processes can help confi rm coverage based on your benefi t plan.
Please call the toll-free member phone number on the back of your ID card if you need additional information about these notations.
What should I do if I use a self-administered injectable medication?You may have coverage for self-administered injectable medications through your pharmacy benefi t plan. UnitedHealthcare has developed a specialty pharmacy network for these medications. Please call our toll-free Specialty Pharmacy Referral Line at 1-866-429-8177. A representative will answer questions about our program and then transfer you to a specialty pharmacy based on your particular specialty medication prescription.
If you have pharmacy benefi t coverage with UnitedHealthcare, you may learn more about your benefi t by
visiting myuhc.com or by cal ing the tol -free member phone number on the back of your ID card. If you are
not currently enrol ed with UnitedHealthcare for pharmacy benefi t coverage, you may access myuhc.com for
additional information during your open enrol ment period or you may contact your employer or health plan for
additional information.
In certain documents, the Prescription Drug List (PDL) was referred to as the “Preferred Drug List (PDL).” This
change in descriptive terms does not affect your benefi t coverage.
Medications are categorized by common therapeutic conditions in this PDL reference guide for ease of
reference only. These categories do not determine coverage for the medication for your condition. Your benefi t
plan determines how these medications may be covered for you.
Where differences are noted between this PDL reference guide and your benefi t plan documents, the benefi t
plan documents wil govern.
How do I access updated information about
my pharmacy benefi t?
Since the PDL may change periodically, we encourage you to visit
myuhc.com or call the toll-free member phone number on the back
of your ID card for more current information.
Log on to myuhc.com for the following pharmacy resources and
tools:
 Pharmacy benefi t and coverage information  Specifi c copayment amounts for prescription medications  Possible lower-cost medication alternatives  A list of medications based on a specifi c medical condition  Medication interactions and side effects  Locate a participating retail pharmacy by zip code And, if mail order is included in your pharmacy benefi t, you can also: What if I still have questions?Please call the toll-free member phone number on the back of your ID card. Representatives are available to assist you 24 hours a day (except Thanksgiving and Christmas).
If you have pharmacy benefi t coverage with UnitedHealthcare, you may learn more about your benefi t by
visiting myuhc.com or by cal ing the tol -free member phone number on the back of your ID card. If you are
not currently enrol ed with UnitedHealthcare for pharmacy benefi t coverage, you may access myuhc.com for
additional information during your open enrol ment period or you may contact your employer or health plan for
additional information.
In certain documents, the Prescription Drug List (PDL) was referred to as the “Preferred Drug List (PDL).” This
change in descriptive terms does not affect your benefi t coverage.
Medications are categorized by common therapeutic conditions in this PDL reference guide for ease of
reference only. These categories do not determine coverage for the medication for your condition. Your benefi t
plan determines how these medications may be covered for you.
Where differences are noted between this PDL reference guide and your benefi t plan documents, the benefi t
plan documents wil govern.
2010 Three-Tier Prescription Drug List Reference Guide Anti-Infectives Antibiotics (Oral, inhaled and ear antibiotics are listed)
Cefdinir SL
Augmentin XR E
Metronidazole Minocycline HCl Neomycin/Polymyxin/HC Nitrofurantoin Macrocrystal Nitrofurantoin/Nitrofurantoin Ofl oxacin Otic Penicillin V PotassiumSulfamethoxazole/TrimethoprimTetracycline HCl Anti-Infectives Antifungals (Oral and topical antifungals are listed)
Lamisil Granules SL
Itraconazole Capsule SL
Terbinafi ne HCl Tablet SL
Some medications are noted with the symbols below. Your benefi t plan determines how these medications may be covered for you.
1/2T Eligible for Half Tablet Program E May be excluded from coverage MC Multiple copay applies N Notifi cation required
P Progression Rx RS May be eligible for Refi l and Save Program SDP Select Designated Pharmacy SL Supply limit
2010 Three-Tier Prescription Drug List Reference Guide Anti-Infectives Antivirals
Relenza SL
Tamifl u SL
Ribavirin N
Famciclovir SL
Hepsera
Rebetol Solution N
Valacyclovir SL
Valcyte SL
Valtrex SL
Cardiovascular/Heart Disease Coagulation Therapy
Arixtra SL
Fragmin SL
Lovenox SL
Innohep SL
Cardiovascular/Heart Disease High Blood Pressure
Aceon 1/2T
Amlodipine/Benazepril SL
Atacand 1/2T SDP SL
Benicar 1/2T SL
Atacand HCT SDP SL
Benicar HCT SL
Avalide SDP SL
Avapro 1/2T SDP SL
Catapres-TTS SL
Transdermal Weekly SL
Coreg CR E SL
Cozaar 1/2T SL
Diovan 1/2T SL
Diovan HCT SL
Exforge SL
Exforge HCT SL
Hyzaar SL
Tekturna SL
Losartan 1/2T SL
Tekturna HCT SL
Teveten SL
Hydrochlorothiazide SL
Micardis SL
Some medications are noted with the symbols below. Your benefi t plan determines how these medications may be covered for you.
1/2T Eligible for Half Tablet Program E May be excluded from coverage MC Multiple copay applies N Notifi cation required
P Progression Rx RS May be eligible for Refi l and Save Program SDP Select Designated Pharmacy SL Supply limit
2010 Three-Tier Prescription Drug List Reference Guide Cardiovascular/Heart Disease High Blood Pressure (cont. from page 8)
Micardis HCT SL
Moexipril HCl 1/2T
Perindopril Erbumine 1/2T
Minoxidil Nadolol Nifedipine Propranolol HCl Tablet Propranolol HCl/ Terazosin HCl
Timolol Maleate
Torsemide
Trandolapril 1/2T
Triamterene/
Some medications are noted with the symbols below. Your benefi t plan determines how these medications may be covered for you.
1/2T Eligible for Half Tablet Program E May be excluded from coverage MC Multiple copay applies N Notifi cation required
P Progression Rx RS May be eligible for Refi l and Save Program SDP Select Designated Pharmacy SL Supply limit
2010 Three-Tier Prescription Drug List Reference Guide Cardiovascular/Heart Disease High Cholesterol
Caduet E SL
Lescol SL
Lescol XL SL
Crestor 1/2T SL
Lipitor 1/2T SL
Vytorin SL
Pravastatin Sodium 1/2T
Simvastatin 1/2T
Niaspan
Simcor SL
Tricor 48, 145 mg
Triglide
Welchol
Cardiovascular/Heart Disease Other
Flecanide AcetateIsosorbide DinitrateIsosorbide MononitrateMexiletineNitroglycerinSotalol Central Nervous System Attention Defi cit Disorder
Adderall XR SL
Intuniv SL
Vyvanse SL
Capsule, Sustained-Release
24 Hour SL
Concerta SL
Daytrana SL
Focalin XR SL
Metadate CD SL
Methylin
Ritalin LA SL
Strattera SL
Some medications are noted with the symbols below. Your benefi t plan determines how these medications may be covered for you.
1/2T Eligible for Half Tablet Program E May be excluded from coverage MC Multiple copay applies N Notifi cation required
P Progression Rx RS May be eligible for Refi l and Save Program SDP Select Designated Pharmacy SL Supply limit
2010 Three-Tier Prescription Drug List Reference Guide Central Nervous System Depression
Aplenzin E
Cymbalta RS SL
24 Hour SL
Effexor XR RS SL
Lexapro 1/2T SL
Luvox CR SL
24 Hour SL
Delayed-Release SL
Pexeva 1/2T SL
Pristiq RS SL
Extended-Release E SL
Mirtazapine
Nefazodone HCl
Nortriptyline HCl
Paroxetine HCl Tablet
Sertraline HCl 1/2T
Trazodone HCl
Venlafaxine HCl
Central Nervous System Migraine
Amerge SDP SL
Axert SDP SL
Frova SDP SL
Nasal Spray SL
Maxalt SDP SL
Maxalt MLT SDP SL
Relpax SL
Treximet E SL
Zomig SDP SL
Injection, Tablet SL
Zomig Nasal Spray SDP SL
Zomig ZMT SDP SL
Central Nervous System Multiple Sclerosis
Avonex SL
Betaseron P SL
Copaxone SL
Rebif SL
Some medications are noted with the symbols below. Your benefi t plan determines how these medications may be covered for you.
1/2T Eligible for Half Tablet Program E May be excluded from coverage MC Multiple copay applies N Notifi cation required
P Progression Rx RS May be eligible for Refi l and Save Program SDP Select Designated Pharmacy SL Supply limit
2010 Three-Tier Prescription Drug List Reference Guide Central Nervous System Sedatives/Hypnotics
Ambien P SL
Ambien CR SL
Zaleplon SL
Edluar E SL
Zolpidem Tartrate SL
Lunesta P SL
Rozerem P SL
Sonata P SL
Central Nervous System Seizure Disorders
Keppra XR E
Lamictal Dose Pack SL
Lamictal ODT E
Diastat SL
Lamictal XR E
Lyrica SDP SL
Stavzor E
Central Nervous System Other
Abilify SL
Invega SL
Nuvigil N SL
Provigil E N SL
Geodon SL
Requip XL E
Seroquel XR SL
Zyprexa Zydis SL
Seroquel SL
Risperidone SL
Symbyax SL
Tasmar
Xyrem N SL
Zyprexa SL
Some medications are noted with the symbols below. Your benefi t plan determines how these medications may be covered for you.
1/2T Eligible for Half Tablet Program E May be excluded from coverage MC Multiple copay applies N Notifi cation required
P Progression Rx RS May be eligible for Refi l and Save Program SDP Select Designated Pharmacy SL Supply limit
2010 Three-Tier Prescription Drug List Reference Guide Dermatology
Azelex SL
Altabax SL
Atralin MC N SL
Avita Gel N SL
Bactroban SL
Benzaclin SL
Cleanser E
Brevoxyl E
Protopic N SL
Clindagel SL
Regranex N
Retin-A Micro N SL
Foam 1% SL
Clobex SL
Clobex Shampoo E
Cutivate Lotion MC
Desonate SL
Differin Gel 0.3% N SL
Duac-CS SL
Elidel N SL
Epiduo E SL
Evoclin SL
Extina SL
Tretinoin N
Loprox Shampoo MC
Metrogel 1% MC
Metrolotion
Naftin
NeoBenz Micro E
NeoBenz Micro SD E
Noritate MC
Olux-E SL
Olux-Olux-E E
Oscion
Oxistat
Taclonex SL
Taclonex Scalp SL
Tazorac N SL
Tretin-X N SL
Triaz E SL
Vanos SL
Vectical SL
Verdeso SL
Some medications are noted with the symbols below. Your benefi t plan determines how these medications may be covered for you.
1/2T Eligible for Half Tablet Program E May be excluded from coverage MC Multiple copay applies N Notifi cation required
P Progression Rx RS May be eligible for Refi l and Save Program SDP Select Designated Pharmacy SL Supply limit
2010 Three-Tier Prescription Drug List Reference Guide Dermatology (cont. from page 13)
Tier 3
Vusion MC
Xolegel MC
Ziana E SL
Endocrine/Diabetes Blood Glucose Monitoring
Fast Take Test Strips SL
Accu-Chek Test Strips SL
Ascensia Test Strips SL
Freestyle Lite Test Strips SL
Assure Test Strips SL
Freestyle Test Strips SL
Prestige Test Strips SL
One Touch Test Strips SL
One Touch Ultra 2 System
One Touch Ultra Mini System
One Touch Ultra System
One Touch Ultra Test Strips SL
Precision Q-I-D System
Precision Q-I-D Test Strips SL
Precision Xtra System
Precision Xtra Test Strips SL
Surestep System
Surestep Test Strips SL
Endocrine/Diabetes Growth Hormone
Nutropin, AQ, NuSpin N SL
Genotropin E N SL
Saizen N SL
Humatrope E N SL
Serostim N SL
Norditropin E N SL
Tev-Tropin N SL
Omnitrope E N SL
Zorbtive N SL
Endocrine/Diabetes Insulin
Some medications are noted with the symbols below. Your benefi t plan determines how these medications may be covered for you.
1/2T Eligible for Half Tablet Program E May be excluded from coverage MC Multiple copay applies N Notifi cation required
P Progression Rx RS May be eligible for Refi l and Save Program SDP Select Designated Pharmacy SL Supply limit
2010 Three-Tier Prescription Drug List Reference Guide Endocrine/Diabetes Non-Insulin
Actoplus Met SL
Actos 1/2T SL
Avandamet SL
Starlix SL
Avandaryl SL
Avandia 1/2T SL
Byetta SL
Duetact SL
Glipizide/Metformin HCl
Glyset
Janumet SL
Januvia SL
Nateglinide SL
Prandin SL
Endocrine/Diabetes Other
Androgel SL
Testim E SL
Kuvan N SL
Octreotide Acetate N
Sandostatin Vial N
Eye Conditions Anti-Allergy
Elestat SL
Azelastine HCl SL
Optivar SL
Pataday SL
Patanol SL
Some medications are noted with the symbols below. Your benefi t plan determines how these medications may be covered for you.
1/2T Eligible for Half Tablet Program E May be excluded from coverage MC Multiple copay applies N Notifi cation required
P Progression Rx RS May be eligible for Refi l and Save Program SDP Select Designated Pharmacy SL Supply limit
2010 Three-Tier Prescription Drug List Reference Guide Eye Conditions Antibiotics
Sulfacetamide SodiumTobramycin Sulfate Drops Eye Conditions Glaucoma
Alphagan P 0.1% SL
Xalatan SL
Betimol SL
Dorzolamide HCl SL
Combigan SL
Dorzolamide HCl/Timolol
Maleate SL
Lumigan SL
Phospholine Iodide
Pilopine HS
Travatan SL
Travatan Z SL
Gastrointestinal Acid Suppression
Aciphex SL
Prevpac SL
Dexilant SL
Lansoprazole E SL
Nexium Capsule E SL
Nexium Suspension SL
Pantoprazole E SL
Prevacid Capsule,
Delayed-Release
Enteric-Coated E SL
Prevacid Naprapac SL
Prevacid Solutab E SL
Prilosec Rx 10, 20 mg E
Prilosec Rx 40 mg E SL
Protonix SL
Zegerid SL
Some medications are noted with the symbols below. Your benefi t plan determines how these medications may be covered for you.
1/2T Eligible for Half Tablet Program E May be excluded from coverage MC Multiple copay applies N Notifi cation required
P Progression Rx RS May be eligible for Refi l and Save Program SDP Select Designated Pharmacy SL Supply limit
2010 Three-Tier Prescription Drug List Reference Guide Gastrointestinal Nausea/Vomiting
Anzemet SL
Granisetron HCl Tablet SL
Cesamet
Sancuso E SL
Transderm-Scop
Gastrointestinal Other
Amitiza N SL
Asacol SDP
Asacol HD E SDP
Lotronex SL
SulfasalazineTrilyte with Flavor Packets Ursodiol Men’s Health Erectile Dysfunction
Caverject SL
Cialis SL
Edex SL
Levitra SL
Muse SL
Viagra SL
Men’s Health Prostate
Avodart N SDP
Finasteride N
Rapafl o
Uroxatral SDP
Some medications are noted with the symbols below. Your benefi t plan determines how these medications may be covered for you.
1/2T Eligible for Half Tablet Program E May be excluded from coverage MC Multiple copay applies N Notifi cation required
P Progression Rx RS May be eligible for Refi l and Save Program SDP Select Designated Pharmacy SL Supply limit
2010 Three-Tier Prescription Drug List Reference Guide Miscellaneous
Epinephrine Pen Injector SL
Epipen SL
Epipen Jr SL
Restasis N SL
Tussionex SL
Lidoderm SL
Twinject SL
Miscellaneous Overactive Bladder
Detrol SDP
Detrol LA E
Toviaz SDP
Musculoskeletal Osteoporosis
Alendronate Sodium SL
Actonel SL
Fosamax Plus D SL
Boniva Tablet SL
Calcitonin Salmon Nasal
Evista
Forteo N
Fortical
Some medications are noted with the symbols below. Your benefi t plan determines how these medications may be covered for you.
1/2T Eligible for Half Tablet Program E May be excluded from coverage MC Multiple copay applies N Notifi cation required
P Progression Rx RS May be eligible for Refi l and Save Program SDP Select Designated Pharmacy SL Supply limit
2010 Three-Tier Prescription Drug List Reference Guide Musculoskeletal Pain Relief
Hydrochloride N SL
Butorphanol Tartrate Aerosol, Avinza SL
Celebrex SL
Codeine SL
Fentora N SL
Lollipop N SL
Flector E
Acetaminophen SL
Kadian SL
Opana ER SL
OxyContin SL
Butalbital SL
Ryzolt E SL
24 Hour SL
Fentanyl Transdermal SL
Hydrocodone Bit/
Acetaminophen SL
Hydromorphone HClIbuprofen Ibuprofen/HydrocodoneIndomethacin Ketorolac Tromethamine Meloxicam Meperidine HCl Methadone HCl Morphine SulfateMorphine Sulfate Tablet, Sustained-Action SL
NabumetoneNaproxenNaproxen Sodium Oxaprozin Oxycodone HCl Oxycodone HCl/ Acetaminophen SL
Oxycodone HCl/IbuprofenOxycodone/AspirinPiroxicam Propoxyphene Napsylate/ Acetaminophen SL
Acetaminophen SL
Some medications are noted with the symbols below. Your benefi t plan determines how these medications may be covered for you.
1/2T Eligible for Half Tablet Program E May be excluded from coverage MC Multiple copay applies N Notifi cation required
P Progression Rx RS May be eligible for Refi l and Save Program SDP Select Designated Pharmacy SL Supply limit
2010 Three-Tier Prescription Drug List Reference Guide Musculoskeletal Rheumatoid Arthritis
Cimzia N SL
Kineret N SL
Enbrel N SL
Humira N SL
Simponi N SL
Trexall
Musculoskeletal Other
Savella SL
Soma 250 mg E
Respiratory Asthma/COPD
Accolate SL
Asmanex SL
Advair Diskus RS SL
Foradil SL
Advair HFA RS SL
0.5 mg/2 ml SL
Pulmicort Flexhaler SL
Alvesco SL
Atrovent HFA SL
Ventolin HFA SL
1 mg/2 ml SL
Azmacort SL
Singulair SL
Combivent SL
Spiriva SL
Flovent Diskus SL
Flovent HFA SL
Maxair Autohaler SL
Perforomist SL
Proair HFA SL
Proventil HFA SL
Serevent Diskus SL
Symbicort RS SL
Xopenex HFA SL
Xopenex Vial, Nebulizer E SL
Some medications are noted with the symbols below. Your benefi t plan determines how these medications may be covered for you.
1/2T Eligible for Half Tablet Program E May be excluded from coverage MC Multiple copay applies N Notifi cation required
P Progression Rx RS May be eligible for Refi l and Save Program SDP Select Designated Pharmacy SL Supply limit
2010 Three-Tier Prescription Drug List Reference Guide Respiratory Nasal Allergy
Astelin SL
Fluticasone Propionate SL
Nasonex SL
Beconase AQ SL
Nasacort AQ SL
Omnaris SL
Patanase
Rhinocort Aqua SL
Veramyst E SL
Respiratory Oral Allergy
Allegra ODT E SL
Allegra Suspension E SL
Allegra-D E SL
Clarinex E SL
Clarinex-D E SL
Fexofenadine HCl
Pseudoephedrine HCl/
Fexofenadine E SL
Some medications are noted with the symbols below. Your benefi t plan determines how these medications may be covered for you.
1/2T Eligible for Half Tablet Program E May be excluded from coverage MC Multiple copay applies N Notifi cation required
P Progression Rx RS May be eligible for Refi l and Save Program SDP Select Designated Pharmacy SL Supply limit
2010 Three-Tier Prescription Drug List Reference Guide Women’s Health Contraceptives
Depo-SubQ Provera MC
Jolessa MC
LoSeasonique MC
150 mg/ml MC
Quasense MC
Seasonique MC
Some medications are noted with the symbols below. Your benefi t plan determines how these medications may be covered for you.
1/2T Eligible for Half Tablet Program E May be excluded from coverage MC Multiple copay applies N Notifi cation required
P Progression Rx RS May be eligible for Refi l and Save Program SDP Select Designated Pharmacy SL Supply limit
2010 Three-Tier Prescription Drug List Reference Guide Women’s Health Estrogen/Progesterone
Combipatch SL
Weekly SL
Climara SL
Estrasorb SL
Crinone N
Estrogel SL
Femring SL
Estraderm SL
Weekly SL
Prochieve N
Estratest H.S.
Estring SL
Evamist
Prefest
Prometrium
Vagifem
Vivelle SL
Vivelle-Dot SL
Women’s Health Prenatal Vitamins
Some medications are noted with the symbols below. Your benefi t plan determines how these medications may be covered for you.
1/2T Eligible for Half Tablet Program E May be excluded from coverage MC Multiple copay applies N Notifi cation required
P Progression Rx RS May be eligible for Refi l and Save Program SDP Select Designated Pharmacy SL Supply limit
2010 Three-Tier Prescription Drug List Reference Guide Additional Tier 3 Drugs with a generic equivalent in Tier 1
Depo-Provera MC
Acular, Acular LS SL
Acetate 150 mg/ml MC)
Tromethamine SL)
Mavik 1/2T (Trandolapril 1/2T)
Ambien P SL
(Zolpidem SL)
Duragesic SL (Fentanyl
Transdermal SL)
Nasarel SL (Flunisolide
Nasal Spray SL)
Flonase SL (Fluticasone
Nasal Spray SL)
Fosamax SL
10-650 SL (Oxycodone
(Alendronate SL)
with Acetaminophen SL)
Pravachol 1/2T
(Pravastatin 1/2T)
Imitrex Injection SL
Injection SL)
Darvocet-N SL
Imitrex Tablet SL
Acetaminophen SL)
Tablet SL)
Proscar N (Finasteride N)
Prozac Weekly SL
Lamisil Tablet SL (Terbinafi ne
Tablet SL)
Delayed-Release SL)
Some medications are noted with the symbols below. Your benefi t plan determines how these medications may be covered for you.
1/2T Eligible for Half Tablet Program E May be excluded from coverage MC Multiple copay applies N Notifi cation required
P Progression Rx RS May be eligible for Refi l and Save Program SDP Select Designated Pharmacy SL Supply limit
2010 Three-Tier Prescription Drug List Reference Guide Additional Tier 3 Drugs with a generic equivalent in Tier 1
Zocor 1/2T (Simvastatin 1/2T)
Zoloft 1/2T (Sertraline 1/2T)
Risperdal SL
(Risperidone SL)
Ritalin (Methylphenidate)Ritalin SR (Methylphenidate Sonata P SL
(Zaleplon SL)
Tenormin (Atenolol)Tiazac (Diltiazem)Topamax (Topiramate)Toprol XL 25 mg Trusopt SL (Dorzolamide Eye
Drops SL)
Tylenol #3 SL
(Acetaminophen with
Codeine SL)
Ultracet SL (Tramadol with
Acetaminophen SL)
Ultram (Tramadol)Valium (Diazepam)Vaseretic (Enalapril with Vasotec (Enalapril)
Vicodin SL, Vicodin ES SL
(Acetaminophen with
Hydrocodone SL)
Voltaren Tablet (Diclofenac)Wellbutrin (Bupropion)Wellbutrin SR (Bupropion Some medications are noted with the symbols below. Your benefi t plan determines how these medications may be covered for you.
1/2T Eligible for Half Tablet Program E May be excluded from coverage MC Multiple copay applies N Notifi cation required
P Progression Rx RS May be eligible for Refi l and Save Program SDP Select Designated Pharmacy SL Supply limit
2010 Three-Tier Prescription Drug List Reference Guide Index Avapro . . . . . . . . . . . . . . . . . . . . 8 A-B Otic . . . . . . . . . . . . . . . . . . . 7 Avelox . . . . . . . . . . . . . . . . . . . . . 7 Abilify . . . . . . . . . . . . . . . . . . . . 12 Aviane. . . . . . . . . . . . . . . . . . . . 22 Acanya . . . . . . . . . . . . . . . . . . . 13 Avinza . . . . . . . . . . . . . . . . . . . . 19 Acarbose . . . . . . . . . . . . . 15, 24 Avita Gel. . . . . . . . . . . . . . . . . . 13 Accolate . . . . . . . . . . . . . . . . . . 20 Avodart . . . . . . . . . . . . . . . . . . . 17 Accu-Chek . . . . . . . . . . . . . . . 14 Avonex . . . . . . . . . . . . . . . . . . . 11 Accupril . . . . . . . . . . . . . . . . . . 24 Axert . . . . . . . . . . . . . . . . . . . . . 11 Accutane . . . . . . . . . . . . . . . . . 13 Azasite . . . . . . . . . . . . . . . . . . . 16 Aceon . . . . . . . . . . . . . . . . . . . . . 8 Azelastine HCl . . . . . . . . . . . . 15 24 Hour . . . . . . . . . . . . . . . . 10 Azelex . . . . . . . . . . . . . . . . . . . . 13 Azithromycin . . . . . . . . . . . . 7, 25 Codeine . . . . . . . . . . . . . . . . 25 Azmacort . . . . . . . . . . . . . . . . . 20 Azopt. . . . . . . . . . . . . . . . . . . . . 16 Azor . . . . . . . . . . . . . . . . . . . . . . . 8 Amrix. . . . . . . . . . . . . . . . . . . . . 20 Azurette . . . . . . . . . . . . . . . . . . 22 Aciphex . . . . . . . . . . . . . . . . . . 16 Anaprox . . . . . . . . . . . . . . . . . . 24 Androderm . . . . . . . . . . . . . . . 15 Baclofen. . . . . . . . . . . . . . . . . . 20 Actonel . . . . . . . . . . . . . . . . . . . 18 Androgel . . . . . . . . . . . . . . . . . 15 Bactroban . . . . . . . . . . . . . . . . 13 Actoplus Met . . . . . . . . . . . . . 15 Android. . . . . . . . . . . . . . . . . . . 15 Balziva. . . . . . . . . . . . . . . . . . . . 22 Actos. . . . . . . . . . . . . . . . . . . . . 15 Antara . . . . . . . . . . . . . . . . . . . . 10 Baraclude . . . . . . . . . . . . . . . . . 8 Acular . . . . . . . . . . . . . . . . . . . . 24 Acyclovir. . . . . . . . . . . . . . . 8, 25 Anzemet. . . . . . . . . . . . . . . . . . 17 Aczone . . . . . . . . . . . . . . . . . . . 13 Apidra . . . . . . . . . . . . . . . . . . . . 14 Adderal . . . . . . . . . . . . . . 10, 24 Aplenzin . . . . . . . . . . . . . . . . . . 11 Adoxa . . . . . . . . . . . . . . . . . . . . . 7 Apokyn . . . . . . . . . . . . . . . . . . . 12 Benazepril HCl. . . . . . . . . . . . . 8 Advair . . . . . . . . . . . . . . . . . . . . 20 Apraclonidine . . . . . . . . . . . . . 16 Benicar . . . . . . . . . . . . . . . . . . . . 8 Apri . . . . . . . . . . . . . . . . . . . . . . 22 Benicar HCT. . . . . . . . . . . . . . . 8 Advicor . . . . . . . . . . . . . . . . . . . 10 Apriso . . . . . . . . . . . . . . . . . . . . 17 Benzaclin . . . . . . . . . . . . . . . . . 13 Aggrenox . . . . . . . . . . . . . . . . . . 8 Aricept . . . . . . . . . . . . . . . . . . . 12 Benzamycin. . . . . . . . . . . . . . . 13 Akineton. . . . . . . . . . . . . . . . . . 12 Arimidex . . . . . . . . . . . . . . . . . . 18 Benzonatate . . . . . . . . . . . . . . 18 Arixtra . . . . . . . . . . . . . . . . . . . . . 8 Cleanser . . . . . . . . . . . . . . . . 13 Ipratropium. . . . . . . . . . . . . . 20 Aromasin . . . . . . . . . . . . . . . . . 18 Arthrotec . . . . . . . . . . . . . . . . . 19 Asacol. . . . . . . . . . . . . . . . . . . . 17 Asacol HD. . . . . . . . . . . . . . . . 17 Aldactone . . . . . . . . . . . . . . . . 24 Ascensia . . . . . . . . . . . . . . . . . 14 Betaseron . . . . . . . . . . . . . . . . 11 Aldara . . . . . . . . . . . . . . . . . . . . 13 Asmanex . . . . . . . . . . . . . . . . . 20 Betimol . . . . . . . . . . . . . . . . . . . 16 Biaxin Tablet . . . . . . . . . . . . . . 24 Al egra . . . . . . . . . . . . . . . . . . . 21 Butalbital . . . . . . . . . . . . . . . 11 BiDil. . . . . . . . . . . . . . . . . . . . . . . 8 Al opurinol . . . . . . . . . . . . . . . . 20 Assure . . . . . . . . . . . . . . . . . . . 14 Alora . . . . . . . . . . . . . . . . . . . . . 23 Astelin. . . . . . . . . . . . . . . . . . . . 21 Astepro. . . . . . . . . . . . . . . . . . . 21 Atacand . . . . . . . . . . . . . . . . . . . 8 Altabax . . . . . . . . . . . . . . . . . . . 13 Atacand HCT . . . . . . . . . . . . . . 8 Boniva Tablet . . . . . . . . . . . . . 18 Altace . . . . . . . . . . . . . . . . . 8, 24 Atenolol . . . . . . . . . . . . . . . 8, 25 Altoprev . . . . . . . . . . . . . . . . . . 10 Brevoxyl . . . . . . . . . . . . . . . . . . 13 Alvesco. . . . . . . . . . . . . . . . . . . 20 Ativan . . . . . . . . . . . . . . . . . . . . 24 Brondil . . . . . . . . . . . . . . . . . . . 20 Amaryl. . . . . . . . . . . . . . . . . . . . 24 Atralin . . . . . . . . . . . . . . . . . . . . 13 Ambien . . . . . . . . . . . . . . . 12, 24 Atrovent HFA . . . . . . . . . . . . . 20 Amerge. . . . . . . . . . . . . . . . . . . 11 Augmentin. . . . . . . . . . . . . . 7, 24 Bumetanide. . . . . . . . . . . . . . . . 8 Avalide . . . . . . . . . . . . . . . . . . . . 8 Amitiza . . . . . . . . . . . . . . . . . . . 17 Avandamet . . . . . . . . . . . . . . . 15 Avandaryl . . . . . . . . . . . . . . . . . 15 Avandia. . . . . . . . . . . . . . . . . . . 15 Buspar . . . . . . . . . . . . . . . . . . . 24 2010 Three-Tier Prescription Drug List Reference Guide Index Cimetidine . . . . . . . . . . . . . . . . 16 Daytrana. . . . . . . . . . . . . . . . . . 10 Cimzia . . . . . . . . . . . . . . . . . . . . 20 DDAVP. . . . . . . . . . . . . . . . . . . 24 Codeine . . . . . . . . . . . . . . . . 19 Cipro . . . . . . . . . . . . . . . . . . . 7, 24 Denavir . . . . . . . . . . . . . . . . . . . 13 Cipro HC . . . . . . . . . . . . . . . . . . 7 Depakote . . . . . . . . . . . . . . . . . 24 Ciprodex Otic . . . . . . . . . . . . . . 7 Depo-Provera . . . . . . . . . . . . . 24 Caffeine . . . . . . . . . . . . . . . . 24 Citalopram . . . . . . . . . . . . 11, 24 Clarinex . . . . . . . . . . . . . . . . . . 21 Byetta . . . . . . . . . . . . . . . . . . . . 15 Desonate . . . . . . . . . . . . . . . . . 13 Bystolic. . . . . . . . . . . . . . . . . . . . 8 Desonide . . . . . . . . . . . . . . . . . 13 Cleocin T . . . . . . . . . . . . . . . . . 24 Climara . . . . . . . . . . . . . . . . . . . 23 Detrol . . . . . . . . . . . . . . . . . . . . 18 Caduet . . . . . . . . . . . . . . . . . . . 10 Clindagel . . . . . . . . . . . . . . . . . 13 Detrol LA . . . . . . . . . . . . . . . . . 18 Cafergot. . . . . . . . . . . . . . . . . . 11 Calan. . . . . . . . . . . . . . . . . . . . . 24 Dexilant . . . . . . . . . . . . . . . . . . 16 Spray . . . . . . . . . . . . . . . . . . . 18 Sulfate. . . . . . . . . . . . . . . . . . 10 Calcitriol . . . . . . . . . . . . . . . . . . 15 DiaBeta . . . . . . . . . . . . . . . . . . 24 Camila. . . . . . . . . . . . . . . . . . . . 22 Diastat . . . . . . . . . . . . . . . . . . . 12 Canasa . . . . . . . . . . . . . . . . . . . 17 Clobex. . . . . . . . . . . . . . . . . . . . 13 Capoten . . . . . . . . . . . . . . . . . . 24 Dibenzyline . . . . . . . . . . . . . . . . 8 Captopril. . . . . . . . . . . . . . . 8, 24 Clonidine . . . . . . . . . . . . . . . . . . 8 Diclofenac . . . . . . . . . . . . 19, 25 Clorpres . . . . . . . . . . . . . . . . . . . 8 Clotrimazole . . . . . . . . . . . . 7, 13 Didronel . . . . . . . . . . . . . . . . . . 24 Carbatrol . . . . . . . . . . . . . . . . . 12 Difl ucan . . . . . . . . . . . . . . . . . . 24 Clozapine . . . . . . . . . . . . . 12, 24 Digoxin . . . . . . . . . . . . . . . . . . . 10 Clozaril . . . . . . . . . . . . . . . . . . . 24 Dilantin . . . . . . . . . . . . . . . . . . . 12 Cardizem LA . . . . . . . . . . . . . . . 8 Cardura . . . . . . . . . . . . . . . . . . 24 Diovan. . . . . . . . . . . . . . . . . . . . . 8 Carisoprodol . . . . . . . . . . . . . . 20 Diovan HCT. . . . . . . . . . . . . . . . 8 Carvedilol . . . . . . . . . . . . . . 8, 24 Dipentum . . . . . . . . . . . . . . . . . 17 Catapres-TTS . . . . . . . . . . . . . . 8 Ditropan XL . . . . . . . . . . . . . . 24 Caverject . . . . . . . . . . . . . . . . . 17 Colchicine . . . . . . . . . . . . . . . . 20 Cefadroxil . . . . . . . . . . . . . . 7, 24 Colestid . . . . . . . . . . . . . . . . . . 24 Cefdinir. . . . . . . . . . . . . . . . . . . . 7 Colestipol. . . . . . . . . . . . . 10, 24 Cefprozil. . . . . . . . . . . . . . . . 7, 24 Combigan . . . . . . . . . . . . . . . . 16 Divigel. . . . . . . . . . . . . . . . . . . . 23 Ceftin . . . . . . . . . . . . . . . . . . . . 24 Combipatch. . . . . . . . . . . . . . . 23 Doryx. . . . . . . . . . . . . . . . . . . . . . 7 Cefuroxime . . . . . . . . . . . . . 7, 24 Combivent . . . . . . . . . . . . . . . . 20 Cefzil . . . . . . . . . . . . . . . . . . . . . 24 Comtan. . . . . . . . . . . . . . . . . . . 12 Celebrex. . . . . . . . . . . . . . . . . . 19 Concerta . . . . . . . . . . . . . . . . . 10 Celexa. . . . . . . . . . . . . . . . . . . . 24 Condylox Gel . . . . . . . . . . . . . 13 Copaxone . . . . . . . . . . . . . . . . 11 Doxepin HCl . . . . . . . . . . . . . . 11 Celontin . . . . . . . . . . . . . . . . . . 12 Coreg . . . . . . . . . . . . . . . . . 8, 24 Doxycycline . . . . . . . . . . . . . . . . 7 Cenestin. . . . . . . . . . . . . . . . . . 23 Coumadin . . . . . . . . . . . . . . . . . 8 Duac-CS . . . . . . . . . . . . . . . . . 13 Cephalexin. . . . . . . . . . . . . . 7, 24 Cozaar. . . . . . . . . . . . . . . . . . . . . 8 Duetact. . . . . . . . . . . . . . . . . . . 15 Cesamet. . . . . . . . . . . . . . . . . . 17 Crestor . . . . . . . . . . . . . . . . . . . 10 Duragesic . . . . . . . . . . . . . . . . 24 Crinone. . . . . . . . . . . . . . . . . . . 23 Duricef . . . . . . . . . . . . . . . . . . . 24 Clidinium. . . . . . . . . . . . . . . . 17 Cuprimine . . . . . . . . . . . . . . . . 20 Dyazide. . . . . . . . . . . . . . . . . . . 24 Cutivate Lotion. . . . . . . . . . . . 13 Dynacirc . . . . . . . . . . . . . . . . . . 24 Chlorthalidone . . . . . . . . . . . . . 8 Cymbalta . . . . . . . . . . . . . . . . . 11 Cialis . . . . . . . . . . . . . . . . . . . . . 17 Edex . . . . . . . . . . . . . . . . . . . . . 17 Ciclopirox . . . . . . . . . . . . . 13, 24 Edluar . . . . . . . . . . . . . . . . . . . . 12 Cilostazol . . . . . . . . . . . . . . 8, 24 Dapsone. . . . . . . . . . . . . . . . . . . 7 Effexor . . . . . . . . . . . . . . . 11, 24 Darvocet-N . . . . . . . . . . . . . . . 24 Effexor XR. . . . . . . . . . . . . . . . 11 2010 Three-Tier Prescription Drug List Reference Guide Index Elestat. . . . . . . . . . . . . . . . . . . . 15 Fenoglide. . . . . . . . . . . . . . . . . 10 Glumetza . . . . . . . . . . . . . . . . . 15 Elidel . . . . . . . . . . . . . . . . . . . . . 13 Fentanyl . . . . . . . . . . . . . 19, 24 Glyburide . . . . . . . . . . . . . 15, 24 Elixophyl in GG. . . . . . . . . . . . 20 Fentora . . . . . . . . . . . . . . . . . . . 19 Emend . . . . . . . . . . . . . . . . . . . 17 Enablex. . . . . . . . . . . . . . . . . . . 18 Finacea. . . . . . . . . . . . . . . . . . . 13 Glynase . . . . . . . . . . . . . . . . . . 24 Enalapril . . . . . . . . . . . . . . . 8, 25 Finacea Plus . . . . . . . . . . . . . . 13 Glyset . . . . . . . . . . . . . . . . . . . . 15 Finasteride. . . . . . . . . . . . 17, 24 Fioricet . . . . . . . . . . . . . . . . . . . 24 Enbrel . . . . . . . . . . . . . . . . . . . . 20 Enjuvia . . . . . . . . . . . . . . . . . . . 23 Enpresse . . . . . . . . . . . . . . . . . 22 Flector. . . . . . . . . . . . . . . . . . . . 19 Entocort EC . . . . . . . . . . . . . . 17 Flomax . . . . . . . . . . . . . . . . . . . 17 Epiduo. . . . . . . . . . . . . . . . . . . . 13 Flonase. . . . . . . . . . . . . . . . . . . 24 Flovent . . . . . . . . . . . . . . . . . . . 20 Hectorol . . . . . . . . . . . . . . . . . . 15 Epipen. . . . . . . . . . . . . . . . . . . . 18 Floxin Otic . . . . . . . . . . . . . . . . 24 Helidac . . . . . . . . . . . . . . . . . . . 16 Epivir HBV. . . . . . . . . . . . . . . . . 8 Fluconazole. . . . . . . . . . . . . 7, 24 Hepsera . . . . . . . . . . . . . . . . . . . 8 Eplerenone . . . . . . . . . . . . . . . . 8 Humalog . . . . . . . . . . . . . . . . . 14 Ergomar . . . . . . . . . . . . . . . . . . 11 Flunisolide . . . . . . . . . . . . 21, 24 Humatrope . . . . . . . . . . . . . . . 14 Errin. . . . . . . . . . . . . . . . . . . . . . 22 Fluocinonide . . . . . . . . . . . . . . 13 Humira . . . . . . . . . . . . . . . . . . . 20 Fluoxetine . . . . . . . . . . . . 11, 24 Humulin . . . . . . . . . . . . . . . . . . 14 Peroxide . . . . . . . . . . . . . . . . 13 Eskalith CR . . . . . . . . . . . . . . . 24 Focalin XR. . . . . . . . . . . . . . . . 10 Applicator. . . . . . . . . . . . . . . 23 Folic Acid . . . . . . . . . . . . . . . . . 23 Estraderm . . . . . . . . . . . . . . . . 23 Foradil. . . . . . . . . . . . . . . . . . . . 20 Estradiol . . . . . . . . . . . . . . . . . . 23 Fortamet. . . . . . . . . . . . . . . . . . 15 Forteo . . . . . . . . . . . . . . . . . . . . 18 Fortical . . . . . . . . . . . . . . . . . . . 18 Sulfate. . . . . . . . . . . . . . . . . . 20 0.5 mg. . . . . . . . . . . . . . . . . . 23 Fosamax. . . . . . . . . . . . . . 18, 24 Estrasorb . . . . . . . . . . . . . . . . . 23 Hydroxyzine. . . . . . . . . . . . . . . 21 Estratest. . . . . . . . . . . . . . . . . . 23 Fosinopril . . . . . . . . . . . . . . 8, 24 Estring . . . . . . . . . . . . . . . . . . . 23 Hytrin . . . . . . . . . . . . . . . . . . . . 24 Estrogel . . . . . . . . . . . . . . . . . . 23 Hyzaar. . . . . . . . . . . . . . . . . . . . . 8 Estropipate . . . . . . . . . . . . . . . 23 Fragmin . . . . . . . . . . . . . . . . . . . 8 Freestyle . . . . . . . . . . . . . . . . . 14 Ibuprofen . . . . . . . . . . . . . 19, 24 Etodolac . . . . . . . . . . . . . . . . . . 19 Evamist. . . . . . . . . . . . . . . . . . . 23 Freestyle Lite . . . . . . . . . . . . . 14 Evista . . . . . . . . . . . . . . . . . . . . 18 Frova . . . . . . . . . . . . . . . . . . . . . 11 Imipramine. . . . . . . . . . . . . . . . 11 Evoclin . . . . . . . . . . . . . . . . . . . 13 Imiquimod . . . . . . . . . . . . . . . . 13 Exelon. . . . . . . . . . . . . . . . . . . . 12 Oral . . . . . . . . . . . . . . . . . . . . . 7 Imitrex . . . . . . . . . . . . . . . . . . . . 24 Exforge. . . . . . . . . . . . . . . . . . . . 8 Indapamide . . . . . . . . . . . . . . . . 9 Exforge HCT. . . . . . . . . . . . . . . 8 Inderal. . . . . . . . . . . . . . . . . . . . 24 Extina . . . . . . . . . . . . . . . . . . . . 13 Indomethacin . . . . . . . . . . . . . 19 Gabitril . . . . . . . . . . . . . . . . . . . 12 Innohep . . . . . . . . . . . . . . . . . . . 8 Famciclovir . . . . . . . . . . . . . . . . 8 Galantamine . . . . . . . . . . . . . . 12 Intal . . . . . . . . . . . . . . . . . . . . . . 20 Fareston. . . . . . . . . . . . . . . . . . 18 Gelnique. . . . . . . . . . . . . . . . . . 18 Intuniv . . . . . . . . . . . . . . . . . . . . 10 Fast Take . . . . . . . . . . . . . . . . . 14 Gemfi brozil . . . . . . . . . . . 10, 24 Invega . . . . . . . . . . . . . . . . . . . . 12 FazaClo . . . . . . . . . . . . . . . . . . 12 Genotropin . . . . . . . . . . . . . . . 14 Iopidine 1%. . . . . . . . . . . . . . . 16 Felbatol. . . . . . . . . . . . . . . . . . . 12 Felodipine . . . . . . . . . . . . . . . . . 8 Geodon. . . . . . . . . . . . . . . . . . . 12 Femara . . . . . . . . . . . . . . . . . . . 18 Femcon Fe . . . . . . . . . . . . . . . 22 Glipizide . . . . . . . . . . . . . . 15, 24 Femhrt . . . . . . . . . . . . . . . . . . . 23 Isosorbide . . . . . . . . . . . . . . . . 10 Femring . . . . . . . . . . . . . . . . . . 23 Isotretinoin. . . . . . . . . . . . . . . . 13 Fenofi brate . . . . . . . . . . . 10, 24 Glucotrol, XL. . . . . . . . . . . . . . 24 Isradipine . . . . . . . . . . . . . . . . . 24 Fenofi bric Acid . . . . . . . . . . . . 10 Glucovance . . . . . . . . . . . . . . . 24 2010 Three-Tier Prescription Drug List Reference Guide Index Misoprostol . . . . . . . . . . . . . . . 16 Janumet . . . . . . . . . . . . . . . . . . 15 Lotronex. . . . . . . . . . . . . . . . . . 17 Moban. . . . . . . . . . . . . . . . . . . . 12 Januvia . . . . . . . . . . . . . . . . . . . 15 Lovastatin . . . . . . . . . . . . 10, 24 Mobic . . . . . . . . . . . . . . . . . . . . 24 Jolessa . . . . . . . . . . . . . . . . . . . 22 Lovaza. . . . . . . . . . . . . . . . . . . . 10 Moexipril HCl . . . . . . . . . . . . . . 9 Jolivette . . . . . . . . . . . . . . . . . . 22 Lovenox . . . . . . . . . . . . . . . . . . . 8 Junel . . . . . . . . . . . . . . . . . . . . . 22 Low-Ogestrel . . . . . . . . . . . . . 22 Mononessa . . . . . . . . . . . . . . . 22 Junel Fe . . . . . . . . . . . . . . . . . . 22 Lumigan . . . . . . . . . . . . . . . . . . 16 Monopril . . . . . . . . . . . . . . . . . . 24 Lunesta . . . . . . . . . . . . . . . . . . 12 Monopril HCT . . . . . . . . . . . . . 24 Kadian. . . . . . . . . . . . . . . . . . . . 19 Lutera . . . . . . . . . . . . . . . . . . . . 22 Kariva . . . . . . . . . . . . . . . . . . . . 22 Luvox CR . . . . . . . . . . . . . . . . . 11 Motrin . . . . . . . . . . . . . . . . . . . . 24 Kefl ex . . . . . . . . . . . . . . . . . . . . 24 Lyrica. . . . . . . . . . . . . . . . . . . . . 12 Moviprep . . . . . . . . . . . . . . . . . 17 Keppra . . . . . . . . . . . . . . . 12, 24 Multi-Nate 30. . . . . . . . . . . . . 23 Mavik. . . . . . . . . . . . . . . . . . . . . 24 Multinatal Plus . . . . . . . . . . . . 23 Mupirocin. . . . . . . . . . . . . . . . . 13 Kineret . . . . . . . . . . . . . . . . . . . 20 Maxalt . . . . . . . . . . . . . . . . . . . . 11 Muse . . . . . . . . . . . . . . . . . . . . . 17 Klonopin. . . . . . . . . . . . . . . . . . 24 Medrol. . . . . . . . . . . . . . . . 15, 24 Kuvan . . . . . . . . . . . . . . . . . . . . 15 Mycostatin . . . . . . . . . . . . . . . . . 7 Myfortic . . . . . . . . . . . . . . . . . . 18 Labetalol HCl . . . . . . . . . . . . . . 9 Mysoline. . . . . . . . . . . . . . . . . . 12 Lactulose . . . . . . . . . . . . . . . . . 17 Lamictal . . . . . . . . . . . . . . 12, 24 Menostar . . . . . . . . . . . . . . . . . 23 Lamisil . . . . . . . . . . . . . . . . . 7, 24 Nadolol . . . . . . . . . . . . . . . . . . . . 9 Mesalamine. . . . . . . . . . . . . . . 17 Naftin . . . . . . . . . . . . . . . . . . . . 13 Lanoxin. . . . . . . . . . . . . . . . . . . 10 Namenda . . . . . . . . . . . . . . . . . 12 Lansoprazole . . . . . . . . . . . . . 16 Metaxalone . . . . . . . . . . . . . . . 20 Naprosyn . . . . . . . . . . . . . . . . . 24 Lantus. . . . . . . . . . . . . . . . . . . . 14 Naproxen . . . . . . . . . . . . . 19, 24 Lasix . . . . . . . . . . . . . . . . . . . . . 24 Nasacort AQ . . . . . . . . . . . . . . 21 Lefl unomide . . . . . . . . . . . . . . 20 Nasarel . . . . . . . . . . . . . . . . . . . 24 Lescol . . . . . . . . . . . . . . . . . . . . 10 Methimazole . . . . . . . . . . . . . . 15 Nasonex. . . . . . . . . . . . . . . . . . 21 Levaquin. . . . . . . . . . . . . . . . . . . 7 Natalcare Plus . . . . . . . . . . . . 23 Levemir. . . . . . . . . . . . . . . . . . . 14 Nateglinide . . . . . . . . . . . . . . . 15 Methyldopa . . . . . . . . . . . . . . . . 9 Levitra. . . . . . . . . . . . . . . . . . . . 17 Necon 7/7/7. . . . . . . . . . . . . . 22 Levonorgestrel . . . . . . . . . . . . 24 Levora. . . . . . . . . . . . . . . . . . . . 22 Methylin . . . . . . . . . . . . . . . . . . 10 Lexapro . . . . . . . . . . . . . . . . . . 11 HC Otic. . . . . . . . . . . . . . . . . . 7 Lialda . . . . . . . . . . . . . . . . . . . . 17 Lidocaine HCl. . . . . . . . . . . . . 13 Lidoderm . . . . . . . . . . . . . . . . . 18 Metolazone . . . . . . . . . . . . . . . . 9 Neoral . . . . . . . . . . . . . . . . . . . . 18 Lipitor . . . . . . . . . . . . . . . . . . . . 10 Neurontin. . . . . . . . . . . . . 12, 24 Lipofen . . . . . . . . . . . . . . . . . . . 10 Nexium . . . . . . . . . . . . . . . . . . . 16 Lisinopril. . . . . . . . . . . . . . . 9, 24 Niaspan . . . . . . . . . . . . . . . . . . 10 Metrogel 1%. . . . . . . . . . . . . . 13 Nifedipine . . . . . . . . . . . . . 9, 24 Metrolotion . . . . . . . . . . . . . . . 13 Nisoldipine. . . . . . . . . . . . . . . . . 9 Mevacor . . . . . . . . . . . . . . . . . . 24 Loestrin 24 Fe . . . . . . . . . . . . 22 Mexiletine . . . . . . . . . . . . . . . . 10 Lofi bra . . . . . . . . . . . . . . . . . . . 24 Micardis . . . . . . . . . . . . . . . . . . . 8 Lopid . . . . . . . . . . . . . . . . . . . . . 24 Micardis HCT . . . . . . . . . . . . . . 9 Lopressor. . . . . . . . . . . . . . . . . 24 Microgestin . . . . . . . . . . . . . . . 22 Nitroglycerin . . . . . . . . . . . . . . 10 Micronase . . . . . . . . . . . . . . . . 24 Migranal . . . . . . . . . . . . . . . . . . 11 Nora-Be . . . . . . . . . . . . . . . . . . 22 Losartan . . . . . . . . . . . . . . . . . . . 8 Norditropin . . . . . . . . . . . . . . . 14 Minoxidil . . . . . . . . . . . . . . . . . . . 9 Noritate . . . . . . . . . . . . . . . . . . 13 2010 Three-Tier Prescription Drug List Reference Guide Index Nortrel 7/7/7 . . . . . . . . . . . . . 22 Prinzide. . . . . . . . . . . . . . . . . . . 24 Pantoprazole. . . . . . . . . . . . . . 16 Pristiq . . . . . . . . . . . . . . . . . . . . 11 Norvasc . . . . . . . . . . . . . . . . . . 24 Paroxetine . . . . . . . . . . . . 11, 24 Proair HFA. . . . . . . . . . . . . . . . 20 Novolin . . . . . . . . . . . . . . . . . . . 14 Pataday . . . . . . . . . . . . . . . . . . 15 Procardia XL. . . . . . . . . . . . . . 24 NovoLog . . . . . . . . . . . . . . . . . 14 Patanase . . . . . . . . . . . . . . . . . 21 Prochieve. . . . . . . . . . . . . . . . . 23 Noxafi l. . . . . . . . . . . . . . . . . . . . . 7 Patanol . . . . . . . . . . . . . . . . . . . 15 Paxil. . . . . . . . . . . . . . . . . . . . . . 24 NuvaRing . . . . . . . . . . . . . . . . . 22 Pediapred . . . . . . . . . . . . . . . . 15 Prometrium . . . . . . . . . . . . . . . 23 Nuvigil. . . . . . . . . . . . . . . . . . . . 12 Peganone . . . . . . . . . . . . . . . . 12 Nystatin . . . . . . . . . . . . . . . . 7, 13 Penlac. . . . . . . . . . . . . . . . . . . . 24 Acetonide. . . . . . . . . . . . . . . 13 Pentasa . . . . . . . . . . . . . . . . . . 17 Pentoxifyl ine. . . . . . . . . . . . . . . 8 Ocel a . . . . . . . . . . . . . . . . . . . . 22 Percocet. . . . . . . . . . . . . . . . . . 24 Proscar . . . . . . . . . . . . . . . . . . . 24 Perforomist . . . . . . . . . . . . . . . 20 Protonix . . . . . . . . . . . . . . . . . . 16 Protopic . . . . . . . . . . . . . . . . . . 13 Ofl oxacin . . . . . . . . . . . 7, 16, 24 Permethrin. . . . . . . . . . . . . . . . 13 Proventil HFA . . . . . . . . . . . . . 20 Olux-E. . . . . . . . . . . . . . . . . . . . 13 Pexeva . . . . . . . . . . . . . . . . . . . 11 Provera . . . . . . . . . . . . . . . 22, 24 Olux-Olux-E . . . . . . . . . . . . . . 13 Provigil . . . . . . . . . . . . . . . . . . . 12 Prozac. . . . . . . . . . . . . . . . . . . . 24 Omnaris . . . . . . . . . . . . . . . . . . 21 Pruet DHA. . . . . . . . . . . . . . . . 23 Omnitrope . . . . . . . . . . . . . . . . 14 Pilopine HS. . . . . . . . . . . . . . . 16 One Touch . . . . . . . . . . . . . . . . 14 Piroxicam . . . . . . . . . . . . . . . . . 19 Pulmicort . . . . . . . . . . . . . . . . . 20 Plan B. . . . . . . . . . . . . . . . . . . . 24 Pylera . . . . . . . . . . . . . . . . . . . . 16 Plavix. . . . . . . . . . . . . . . . . . . . . . 8 Pletal. . . . . . . . . . . . . . . . . . . . . 24 Quasense . . . . . . . . . . . . . . . . 22 PNV-DHA . . . . . . . . . . . . . . . . 23 Opana . . . . . . . . . . . . . . . . . . . . 19 Quinapril. . . . . . . . . . . . . . . 9, 24 PNV-Select. . . . . . . . . . . . . . . 23 Opana ER . . . . . . . . . . . . . . . . 19 Optivar . . . . . . . . . . . . . . . . . . . 15 Oracea . . . . . . . . . . . . . . . . . . . . 7 QVAR . . . . . . . . . . . . . . . . . . . . 20 Orap . . . . . . . . . . . . . . . . . . . . . 12 Portia. . . . . . . . . . . . . . . . . . . . . 22 Orapred . . . . . . . . . . . . . . . . . . 15 PR Natal . . . . . . . . . . . . . . . . . 23 Ramipril . . . . . . . . . . . . . . . 9, 24 Orphenadrine . . . . . . . . . . . . . 20 Pramipexole . . . . . . . . . . . . . . 12 Ranexa . . . . . . . . . . . . . . . . . . . 10 Prandin . . . . . . . . . . . . . . . . . . . 15 Ranitidine. . . . . . . . . . . . . 16, 25 Ortho-Cyclen . . . . . . . . . . . . . 22 Pravachol . . . . . . . . . . . . . . . . . 24 Rapafl o . . . . . . . . . . . . . . . . . . . 17 Pravastatin. . . . . . . . . . . . 10, 24 Rapamune . . . . . . . . . . . . . . . . 18 Ortho Evra . . . . . . . . . . . . . . . . 22 Precision Xtra. . . . . . . . . . . . . 14 Rebif . . . . . . . . . . . . . . . . . . . . . 11 Precose . . . . . . . . . . . . . . . . . . 24 Reclipsen . . . . . . . . . . . . . . . . . 22 Prednisolone. . . . . . . . . . . . . . 15 Regranex . . . . . . . . . . . . . . . . . 13 Oscion. . . . . . . . . . . . . . . . . . . . 13 Prednisone . . . . . . . . . . . . . . . 15 Relenza. . . . . . . . . . . . . . . . . . . . 8 Ovrette . . . . . . . . . . . . . . . . . . . 22 Prefest . . . . . . . . . . . . . . . . . . . 23 Relistor . . . . . . . . . . . . . . . . . . . 17 Oxandrolone . . . . . . . . . . . . . . 15 Premarin. . . . . . . . . . . . . . . . . . 23 Relpax. . . . . . . . . . . . . . . . . . . . 11 Oxaprozin. . . . . . . . . . . . . . . . . 19 Premphase . . . . . . . . . . . . . . . 23 Remeron . . . . . . . . . . . . . . . . . 24 Prempro . . . . . . . . . . . . . . . . . . 23 Requip . . . . . . . . . . . . . . . 12, 25 Oxistat . . . . . . . . . . . . . . . . . . . 13 Prenatal 19 . . . . . . . . . . . . . . . 23 Restasis . . . . . . . . . . . . . . . . . . 18 Restoril . . . . . . . . . . . . . . . . . . . 25 Prenatal Plus . . . . . . . . . . . . . 23 Retin-A Micro . . . . . . . . . . . . . 13 Prestige . . . . . . . . . . . . . . . . . . 14 Prevacid . . . . . . . . . . . . . . . . . . 16 Ribavirin . . . . . . . . . . . . . . . . . . . 8 Risperdal . . . . . . . . . . . . . . . . . 25 Previfem. . . . . . . . . . . . . . . . . . 22 Prevpac . . . . . . . . . . . . . . . . . . 16 Ritalin . . . . . . . . . . . . . . . . 10, 25 Ibuprofen . . . . . . . . . . . . . . . 19 Prilosec. . . . . . . . . . . . . . . 16, 24 Ropinirole. . . . . . . . . . . . . 12, 25 OxyContin . . . . . . . . . . . . . . . . 19 Primidone. . . . . . . . . . . . . . . . . 12 Rozerem. . . . . . . . . . . . . . . . . . 12 Oxytrol . . . . . . . . . . . . . . . . . . . 18 Prinivil . . . . . . . . . . . . . . . . . . . . 24 Ryzolt . . . . . . . . . . . . . . . . . . . . 19 2010 Three-Tier Prescription Drug List Reference Guide Index Triglide . . . . . . . . . . . . . . . . . . . 10 Saizen . . . . . . . . . . . . . . . . . . . . 14 Tamsulosin. . . . . . . . . . . . . . . . 17 Trilipix . . . . . . . . . . . . . . . . . . . . 10 Sanctura. . . . . . . . . . . . . . . . . . 18 Tarka . . . . . . . . . . . . . . . . . . . . . . 8 Sanctura XR . . . . . . . . . . . . . . 18 Sancuso . . . . . . . . . . . . . . . . . . 17 Tasmar . . . . . . . . . . . . . . . . . . . 12 Trinessa . . . . . . . . . . . . . . . . . . 22 Tazorac . . . . . . . . . . . . . . . . . . . 13 Trivora . . . . . . . . . . . . . . . . . . . . 22 Sandostatin . . . . . . . . . . . . . . . 15 Tegretol . . . . . . . . . . . . . . . . . . 12 Trusopt . . . . . . . . . . . . . . . . . . . 25 Savel a . . . . . . . . . . . . . . . . . . . 20 Tekturna . . . . . . . . . . . . . . . . . . . 8 Tussionex . . . . . . . . . . . . . . . . . 18 Seasonique . . . . . . . . . . . . . . . 22 Tekturna HCT . . . . . . . . . . . . . . 8 Twinject . . . . . . . . . . . . . . . . . . 18 Tylenol #3 . . . . . . . . . . . . . . . . 25 Seroquel. . . . . . . . . . . . . . . . . . 12 Tenoretic . . . . . . . . . . . . . . . . . 25 Seroquel XR . . . . . . . . . . . . . . 12 Tenormin . . . . . . . . . . . . . . . . . 25 Ultracet. . . . . . . . . . . . . . . . . . . 25 Serostim. . . . . . . . . . . . . . . . . . 14 Terazosin . . . . . . . . . . . 9, 17, 24 Ultram . . . . . . . . . . . . . . . . . . . . 25 Sertraline . . . . . . . . . . . . . 11, 25 Terbinafi ne. . . . . . . . . . . . . . 7, 24 Urea. . . . . . . . . . . . . . . . . . . . . . 13 Setonet. . . . . . . . . . . . . . . . . . . 23 Uroxatral . . . . . . . . . . . . . . . . . 17 Testim . . . . . . . . . . . . . . . . . . . . 15 Ursodiol . . . . . . . . . . . . . . . . . . 17 Simcor. . . . . . . . . . . . . . . . . . . . 10 Testosterone . . . . . . . . . . . . . . 15 Simponi . . . . . . . . . . . . . . . . . . 20 Tetracycline HCl. . . . . . . . . . . . 7 Vagifem . . . . . . . . . . . . . . . . . . 23 Tev-Tropin. . . . . . . . . . . . . . . . . 14 Valacyclovir . . . . . . . . . . . . . . . . 8 Singulair . . . . . . . . . . . . . . . . . . 20 Teveten . . . . . . . . . . . . . . . . . . . . 8 Valcyte . . . . . . . . . . . . . . . . . . . . 8 Skelaxin . . . . . . . . . . . . . . . . . . 20 Thalitone . . . . . . . . . . . . . . . . . . 9 Valium . . . . . . . . . . . . . . . . . . . . 25 Solodyn . . . . . . . . . . . . . . . . . . . 7 Theo-Dur . . . . . . . . . . . . . . . . . 20 Valtrex. . . . . . . . . . . . . . . . . . . . . 8 Theophyl ine . . . . . . . . . . . . . . 20 Vancocin HCl . . . . . . . . . . . . . . 7 Sonata . . . . . . . . . . . . . . . 12, 25 Tiazac . . . . . . . . . . . . . . . . . . . . 25 Vanos . . . . . . . . . . . . . . . . . . . . 13 Sotalol. . . . . . . . . . . . . . . . . . . . 10 Tilia Fe . . . . . . . . . . . . . . . . . . . 22 Vaseretic . . . . . . . . . . . . . . . . . 25 Spiriva . . . . . . . . . . . . . . . . . . . . 20 Vasotec. . . . . . . . . . . . . . . . . . . 25 Tizanidine. . . . . . . . . . . . . . . . . 20 Vectical. . . . . . . . . . . . . . . . . . . 13 Tobi . . . . . . . . . . . . . . . . . . . . . . . 7 Velosef . . . . . . . . . . . . . . . . . . . . 7 Sporanox . . . . . . . . . . . . . . . . . . 7 Ventolin HFA. . . . . . . . . . . . . . 20 Sprintec . . . . . . . . . . . . . . . . . . 22 Veramyst . . . . . . . . . . . . . . . . . 21 Starlix . . . . . . . . . . . . . . . . . . . . 15 Stavzor . . . . . . . . . . . . . . . . . . . 12 Topamax. . . . . . . . . . . . . . . . . . 25 Verdeso . . . . . . . . . . . . . . . . . . 13 Strattera . . . . . . . . . . . . . . . . . . 10 Vesicare . . . . . . . . . . . . . . . . . . 18 Vfend. . . . . . . . . . . . . . . . . . . . . . 7 Sular . . . . . . . . . . . . . . . . . . . . . . 9 Torsemide . . . . . . . . . . . . . . . . . 9 Viagra . . . . . . . . . . . . . . . . . . . . 17 Toviaz. . . . . . . . . . . . . . . . . . . . . 18 Vicodin . . . . . . . . . . . . . . . . . . . 25 Tramadol . . . . . . . . . . . . . 19, 25 Vicoprofen . . . . . . . . . . . . . . . . 25 Vigamox . . . . . . . . . . . . . . . . . . 16 Sulfur. . . . . . . . . . . . . . . . . . . 13 Vinate . . . . . . . . . . . . . . . . . . . . 23 Trandolapril . . . . . . . . . . . . 9, 24 Vivel e . . . . . . . . . . . . . . . . . . . . 23 Travatan . . . . . . . . . . . . . . . . . . 16 Vivel e-Dot . . . . . . . . . . . . . . . . 23 Voltaren Gel . . . . . . . . . . . . . . 19 Sulindac . . . . . . . . . . . . . . . . . . 19 Tretin-X. . . . . . . . . . . . . . . . . . . 13 Voltaren Tablet . . . . . . . . . . . . 25 Tretinoin . . . . . . . . . . . . . . . . . . 13 Vusion . . . . . . . . . . . . . . . . . . . . 14 Suprax . . . . . . . . . . . . . . . . . . . . 7 Trexal . . . . . . . . . . . . . . . . . . . . 20 Vytorin. . . . . . . . . . . . . . . . . . . . 10 Surestep. . . . . . . . . . . . . . . . . . 14 Treximet . . . . . . . . . . . . . . . . . . 11 Vyvanse . . . . . . . . . . . . . . . . . . 10 Surmontil . . . . . . . . . . . . . . . . . 25 Tri-Legest Fe. . . . . . . . . . . . . . 22 Symbicort. . . . . . . . . . . . . . . . . 20 Tri-Lo-Sprintec . . . . . . . . . . . . 22 Symbyax. . . . . . . . . . . . . . . . . . 12 Tri-Previfem. . . . . . . . . . . . . . . 22 Welchol. . . . . . . . . . . . . . . . . . . 10 Symlin . . . . . . . . . . . . . . . . . . . . 15 Tri-Sprintec . . . . . . . . . . . . . . . 22 Wel butrin. . . . . . . . . . . . . . . . . 25 Synarel . . . . . . . . . . . . . . . . . . . 15 Synthroid . . . . . . . . . . . . . . . . . 15 Xalatan . . . . . . . . . . . . . . . . . . . 16 Xanax . . . . . . . . . . . . . . . . . . . . 25 Taclonex . . . . . . . . . . . . . . . . . . 13 Triaz . . . . . . . . . . . . . . . . . . . . . . 13 Xolegel . . . . . . . . . . . . . . . . . . . 14 Triazolam . . . . . . . . . . . . . . . . . 12 Xopenex. . . . . . . . . . . . . . . . . . 20 Tamifl u . . . . . . . . . . . . . . . . . . . . 8 Tricor . . . . . . . . . . . . . . . . . . . . . 10 Xyrem . . . . . . . . . . . . . . . . . . . . 12 2010 Three-Tier Prescription Drug List Reference Guide Index Xyzal . . . . . . . . . . . . . . . . . . . . . 21YYasmin . . . . . . . . . . . . . . . . . . . 22Yaz . . . . . . . . . . . . . . . . . . . . . . . 22ZZaleplon . . . . . . . . . . . . . . 12, 25Zantac Syrup . . . . . . . . . . . . . 25Zatean-PN. . . . . . . . . . . . . . . . 23Zegerid . . . . . . . . . . . . . . . . . . . 16Zemplar . . . . . . . . . . . . . . . . . . 15Zenchent . . . . . . . . . . . . . . . . . 22Zestoretic. . . . . . . . . . . . . . . . . 24Zestril . . . . . . . . . . . . . . . . . . . . 24Zetia . . . . . . . . . . . . . . . . . . . . . 10Ziac . . . . . . . . . . . . . . . . . . . . . . 25Ziana . . . . . . . . . . . . . . . . . . . . . 14Zithromax. . . . . . . . . . . . . . . . . 25Zocor. . . . . . . . . . . . . . . . . . . . . 25Zofran . . . . . . . . . . . . . . . . . . . . 25Zoloft. . . . . . . . . . . . . . . . . . . . . 25Zolpidem . . . . . . . . . . . . . 12, 24Zomig . . . . . . . . . . . . . . . . . . . . 11Zonegran . . . . . . . . . . . . . . . . . 25Zonisamide . . . . . . . . . . . 12, 25Zorbtive . . . . . . . . . . . . . . . . . . 14Zovia . . . . . . . . . . . . . . . . . . . . . 22Zovirax . . . . . . . . . . . . . . . 13, 25Zylet. . . . . . . . . . . . . . . . . . . . . . 16Zymar . . . . . . . . . . . . . . . . . . . . 16Zyprexa. . . . . . . . . . . . . . . . . . . 12Zyvox. . . . . . . . . . . . . . . . . . . . . . 7 Created May, 2010. For the most current PDL updates, visit myuhc.com or call the phone number on the back of your ID card.

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