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January 2015
2015 Prescription Drug List
AmWINS Rx Prescription Drug List
The AmWINS Rx Prescription Drug List is a guide within select therapeutic categories for clients, plan members
and health care providers. Generics should be considered the first line of prescribing. Generic medications contain
the same active ingredients (what makes the medication work) as brand-name medications, but they often cost
less. If there is no generic available, there may be more than one brand-name medicine to treat a condition. These
preferred brand-name medicines are listed to help identify products that are clinically appropriate and costeffective. Generics listed in therapeutic categories are for representational purposes only. This is not an allinclusive list. The drug list shows brand name drugs in bold type (for example, Coumadin) and generic drugs in
plain type (for example, Warfarin).
PLAN MEMBER
Your benefit plan provides you with a prescription benefit program. Ask your doctor to consider prescribing, when
medically appropriate, a preferred medicine from this list. Take this list along when you or a covered family
member sees a doctor. Your specific prescription benefit plan design may not cover certain products or categories,
regardless of their appearance in this document.
For specific information regarding your prescription benefit coverage and copay' information, please contact an
AmWINS Rx Customer Care representative toll-free at 1-800-717-6614.
AmWINS Rx may contact your doctor after receiving your prescription to request consideration of a drug list
product or generic equivalent. This may result in your doctor prescribing, when medically appropriate, a different
brand-name product or generic equivalent in place of your original prescription.
Any brand drug for which a generic product becomes available may be designated as a non-preferred product.
HEALTH CARE PROVIDER
Your patient is covered under a prescription benefit plan. As a way to help manage health care costs, authorize
generic substitution whenever possible. If you believe a brand-name product is necessary, consider prescribing a
brand name on this list.
Please note:
Generics should be considered the first line of prescribing.
This drug list represents a summary of prescription coverage. It is not inclusive and does not guarantee coverage.
The member’s prescription benefit plan may have a different copay for specific products on the list. Unless
specifically indicated, drug list products will include all dosage forms.
1
January 2015
2015 Prescription Drug List
Drug Name
Drug
Tier
Programs
and Limits
Anti-Infectives: Antibiotics
Drug Name
Drug
Tier
Anti-Infectives: Antifungals
Amoxicillin
1
Fluconazole
1
Amoxicillin/Clavulanate
1
Nystatin Suspension
1
Azithromycin
Bethkis
1
Terbinafine Tab
1
2
Cefdinir
Cefuroxime Tab
1
1
Cephalexin
Ciprodex Otic Suspension
Ciprofloxacin Tab
1
Clarithromycin
Clindamycin Cap
Dificid
1
1
Doxycycline Hyclate Cap
Doxycycline Hyclate Tab
Programs
and Limits
SP
Anti-Infectives: Antivirals
Acyclovir Tab, Cap, Suspension
1
1
Baraclude
3
3
Famciclovir Tab
Olysio
1
3
1
Pegasys
Sovaldi
PA
Valacyclovir
Cancer
1
Doxycycline
Monohydrate Cap
1
Levofloxacin Tab
Tamiflu
2
PA, QL, SP
2
2
PA, SP
PA, QL, SP
3
1
QL
Anastrozole
1
1
Gleevec
2
PA, QL, SP
Metronidazole Tab
1
1
PA
Minocycline Cap
Neomycin/Polymyxin/ HC Otic
Suspension, Solution
1
Letrozole
Revlimid
3
PA, QL, SP
Nitrofurantoin
Macrocrystalline
Nitrofurantoin Monohydrate
Macrocrystalline
Ofloxacin Otic Solution
Oracea
QL
QL, SP
Tamoxifen Tab
Tasigna
Zytiga
1
1
1
2
3
PA, QL, SP
PA, SP
Cardiovascular/Heart Disease: Anticoagulants
1
1
Aggrenox
2
QL
Brilinta
2
QL
3
1
QL
Clopidogrel
Coumadin
1
3
QL
Solodyn
Sulfamethoxazole Trimethoprim
3
QL
Effient
2
QL
1
Eliquis
3
QL
Sulfamethoxazole Trimethoprim DS
1
Enoxaparin
Pradaxa
1
2
1
2
Penicillin VK
Warfarin
Xarelto
Bold type = Brand-name drug
[Plain type = Generic drug]
PA Prior Authorization
ST Step Therapy
QL Quantity Limits
QL
QL
AR Age Restrictions
SP Specialty Program
GR Gender
Restrictions
2
January 2015
2015 Prescription Drug List
Drug Name
Drug
Tier
Programs
and Limits
Cardiovascular/Heart Disease: High Blood Pressure
Amlodipine
Amlodipine/Benazepril
Atenolol
Atenolol/Chlorthalidone
Azor
Benazepril
Benazepril/HCTZ
Benicar
Benicar HCT
Bisoprolol
Bisoprolol/HCTZ
Bumetanide
Bystolic
Cartia XT
Carvedilol
Chlorthalidone
Clonidine Tab
Coreg CR
Diovan
Doxazosin
Dutoprol
Edarbi
Edarbyclor
Enalapril
Exforge
Exforge HCT
Felodipine
Fosinopril
Furosemide
Guanfacine Tab
Hydralazine
Hydrochlorothiazide
Irbesartan
Irbesartan/HCTZ
Labetalol
Lisinopril
Lisinopril/HCTZ
Losartan
Losartan/HCTZ
Metoprolol Succinate
Metoprolol Tartrate
Bold type = Brand-name drug
[Plain type = Generic drug]
1
1
1
1
2
1
1
2
2
1
1
1
2
1
1
1
1
3
3
1
2
3
3
1
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
QL
QL
QL, ST
QL, ST
QL, ST
QL
QL
Drug Name
Nadolol
Nifedipine ER
Propranolol
Propranolol ER
Quinapril
Ramipril
Spironolactone
Tarka
Tekturna
Tekturna HCT
Telmisartan
Terazosin
Torsemide Tab
Triamterene/HCTZ
Tribenzor
Valsartan
Valsartan/HCTZ
Verapamil ER
Drug
Tier
1
1
1
1
1
1
1
2
2
2
1
1
1
1
2
1
1
1
Programs
and Limits
QL
QL, ST
QL, ST
QL
QL, ST
QL
QL
QL, ST
QL, ST
Cardiovascular/Heart Disease: High Cholesterol
QL
QL, ST
QL, ST
Fenofibrate
Gemfibrozil
Lipitor
Lipofen
Livalo
QL, ST
QL, ST
QL
Atorvastatin
Crestor
Lovastatin
Lovaza
Niacin ER Tab
Omega-3 Acid Cap 1 gm
Pravastatin
Simcor
QL
QL
QL
QL
Simvastatin
Simvastatin 80 mg
Vascepa
Vytorin
Vytorin Tab 10-80 mg
Welchol
Zetia
PA Prior Authorization
ST Step Therapy
QL Quantity Limits
1
2
1
1
3
3
3
1
3
1
1
1
2
1
1
2
2
2
2
3
QL
QL
QL
QL
QL, ST
QL
QL, ST
QL
QL
QL
QL
QL
PA, QL
QL
QL
PA, QL
QL
QL
AR Age Restrictions
SP Specialty Program
GR Gender Restrictions
3
January 2015
2015 Prescription Drug List
Drug Name
Drug
Tier
Programs
and Limits
Drug Name
Drug
Tier
Programs
and Limits
Cardiovascular/Heart Disease: Other
Central Nervous System: Depression
Amiodarone
Amlodipine/Atorvastatin
1
1
Amitriptyline
Budeprion XL
1
1
Digoxin
1
Bupropion
1
Flecainide
1
Bupropion SR
1
Isosorbide Mononitrate
Nitrostat
1
1
QL
2
Citalopram
Cymbalta
3
QL
Ranexa
2
Doxepin
1
Sotalol
1
Duloxetine
1
QL
Escitalopram Tab
Fluoxetine Cap (not PMDD)
1
QL
Forfivo XL
2
1
1
1
QL
QL
Sertraline
2
1
Trazodone
1
QL
ST
Cardiovascular/Heart Disease: Pulmonary Arterial
Hypertension
Adcirca
Letairis
Opsumit
Sildenafil Tab 20 mg
Tracleer
3
2
2
1
PA, QL, SP
PA, QL, SP
PA, QL, SP
PA, QL, SP
2
PA, QL, SP
Central Nervous System: Attention Deficit
Disorder
Mirtazapine
Nortriptyline
Paroxetine
Pristiq
QL
1
1
QL, AR
Venlafaxine
Venlafaxine ER Cap
1
1
QL
1
QL, AR
Viibryd
3
QL, ST
1
QL, AR
Focalin XR
3
QL, ST, AR
Intuniv
Methylphenidate Cap ER
2
1
QL, AR
QL, AR
ButalbitalAcetaminophen-Caffeine Tab
1
QL
Methylphenidate ER Tab
Methylphenidate HCL Sa Osm
ER Tab
Methylphenidate Tab
Strattera
1
QL, AR
Migranal
3
QL
1
QL, AR
Phrenilin
3
QL
1
2
QL, AR
QL, AR
Relpax
3
1
QL
QL
Vyvanse
2
QL, AR
1
3
2
QL
QL
QL
AmphetamineDextroamphetamine
AmphetamineDextroamphetamine SR Cap
24Hr
Dexmethylphenidate
Central Nervous System: Migraine
Rizatriptan Tab, ODT
Sumatriptan Tab and Spray
Sumavel Dose
Zomig Nasal Spray
Bold type = Brand-name drug
PA Prior Authorization
[Plain type = Generic drug]
ST Step Therapy
QL Quantity Limits
AR Age Restrictions
SP Specialty
Program
GR Gender
Restrictions
4
January 2015
2015 Prescription Drug List
Drug Name
Drug
Tier
Programs
and Limits
Central Nervous System: Multiple Sclerosis
Ampyra
Avonex Kit
Avonex Pen Kit
Avonex Prefill Kit
Betaseron
Copaxone
2
2
2
2
2
2
Gilenya*
3
Rebif
3
Rebif Titrtn
3
Tecfidera
2
PA, QL, SP
PA, QL, SP
PA, QL, SP
PA, QL, SP
PA, QL, SP
PA, QL, SP
PA, QL, ST,
SP
PA, QL, ST,
SP
PA, QL, ST,
SP
PA, QL, SP
Central Nervous System: Other
Abilify Tab
Abilify Disc
Abilify Solution
Alprazolam Tab
Benztropine
Buspirone
Carbidopa/Levodopa Tab
Diazepam Tab
Donepezil Tab
Hydroxyzine HCL
Hydroxyzine Pamoate
Lithium Carbonate
Lorazepam Tab
Modafinil
Namenda Tab
Namenda XR
Olanzapine Tab
Pramipexole
Prochlorperazine
Quetiapine
Risperidone Tab
Ropinirole
Bold type = Brand-name drug
[Plain type = Generic drug]
2
2
2
1
1
1
1
1
1
1
1
1
1
1
2
2
1
1
1
1
1
1
QL
QL
QL
QL
QL
QL
PA, QL
QL
QL
QL
Drug
Tier
Programs
and Limits
Saphris
2
QL
Seroquel XR
2
QL
Zelapar
3
1
QL
Drug Name
Ziprasidone Cap
Central Nervous System: Sedatives/Hypnotics
Eszopiclone Tab
Lunesta
1
3
QL
QL
Silenor
3
QL
Temazepam
1
QL
Triazolam Tab
1
QL
Zolpidem
Zolpidem ER
1
1
QL
QL
Central Nervous System: Sedatives/Hypnotics
Carbamazepine Tab
Clonazepam
Divalproex DR
Divalproex ER
Gabapentin
Lamictal
Lamictal ODT
Lamictal XR
1
1
1
1
1
2
2
3
Lamotrigine
Lamotrigine ER
Levetiracetam
Levetiracetam ER
Lyrica Cap
Onfi
1
1
1
1
2
3
Oxcarbazepine
Phenytoin
Topiramate Tab
1
1
1
QL
QL
QL
QL
QL
PA, SP
QL
QL
PA Prior Authorization
ST Step Therapy
QL Quantity Limits
AR Age Restrictions
SP Specialty Program
GR Gender Restrictions
* Tier 3 Preferred
5
January 2015
2015 Prescription Drug List
Drug Name
Drug
Tier
Programs
and Limits
Dermatology
Programs
and Limits
Protopic Ointment
Retin-A Micro
Silver Sulfadiazine Cream 1%
Taclonex
Tretinoin Microsphere Gel
Triamcinolone
Vectical
Zovirax Cream
2
3
1
3
1
1
3
2
QL, ST, AR
QL, AR
Zovirax Ointment
3
Zyclara
3
Acanya Gel
Acyclovir Ointment 5%
Aczone Gel
Atralin
Benzach
Carac
Clindamycin Gel, Lotion,
Solution
Clindamycin/Benzoyl Peroxide
Gel 1-5%
Clobetasol Cream, Gel,
Ointment
Clobex
Cloderm
Clotrimazole/Betamethasone
Cream, Lotion
3
1
3
2
3
2
Condylox
3
Econazole Cream
1
Accu-Chek Act/Gluc
Calibration Liquid
Accu-Chek Aviva Plus Test
Strips
Accu-Chek Aviva Test Strips
Desonide Cream
1
Accu-Chek Comfort Test Strips
Differin
QL
Drug
Tier
Drug Name
QL, AR
QL
1
1
QL
Diabetes/Endocrine Blood: Glucose Monitoring
3
3
1
QL
Elidel
Epiduo
Finacea
Fluocinonide Cream, Gel,
Ointment 0.05%
Hydrocortisone Cream 2.5%
2
3
2
QL, ST, AR
QL
Ketoconazole Cream/Shampoo
1
Metrogel
Metronidazole Gel 0.75%
3
1
Monetasone
1
Mupirocin
Nystatin Cream, Ointment,
Powder
Nystatin/Triamcinolone Cream,
Ointment
Oxsoralen-UI
Permethrin Cream 5%
1
[Plain type = Generic drug]
QL
1
3
Bold type = Brand-name drug
QL
QL, AR
Accu-Chek Cpt/Gluc
Calibration Liquid
Accu-Chek Drum Test Strips
Accu-Chek Kit Aviva Plus
Accu-Chek Kit Compact
3
2
2
2
2
2
2
Accu-Chek Kit Fastclix
2
1
Accu-Chek Kit Multiclix
2
Accu-Chek Kit Nano
2
Accu-Chek Kit Softclix
Accu-Chek Multiclix Lancets
Accu-Chek Smart Calibration
Liquid
Accu-Chek Smart Test Strips
Accu-Chek Sol Calibration
Liquid
2
2
QL
1
QL
QL
3
1
PA
QL
QL
3
2
QL
3
1
2
1
PA
PA Prior Authorization
ST Step Therapy
QL Quantity Limits
AR Age Restrictions
SP Specialty Program
GR Gender Restrictions
6
January 2015
2015 Prescription Drug List
Drug Name
Drug
Tier
Programs
and Limits
Drug Name
Drug
Tier
Accu-Chek Sol Comfort
Calibration Liquid
3
Humulin R Vials
2
Fastclix Lancets
2
Lantus Solostar
2
Glucocard Test Strips
1
Lantus Vials
2
Insulin Pen Needle
Insulin Syringe/ Needle
2
Levemir Flexpen
2
2
Levemir Vials
2
Novofine Auto
3
Novolin 70/30 Vials
2
Novofine
3
Novolin N Vials
2
Novotwist
3
Novolin R Vials
2
Onetouch Kit Ultra Smart
2
Novolog Flexpen
2
Onetouch Kit Ultra
2
2
Onetouch Kit Ultra 2
Onetouch Kit Ultra Mini
2
Novolog Mix Flexpen
Novolog Mix 70/30 Vials
2
Novolog Penfill
2
Onetouch Kit Verio IQ
2
Novolog Vials
2
Onetouch Test Strips
Onetouch Ultra Blue Test
Strips
Onetouch Verio IQ Test Strips
2
QL
2
QL
2
2
2
QL
QL
Onetouch Verio Test Strips
Soft Touch Lancets
Softclix Lan Mis Device
Softclix Lancets
3
2
Surestep Test Strips
Truetrack Test Strips
2
3
Diabetes/Endocrine: Insulin
Humalog Vials
Humalog Kwik Pen
Humalog Mix 50/50 Kwik Pen
Humalog Mix 50/50 Vials
Humalog Mix 75/25 Kwik Pen
Humalog Mix 75/25 Vials
Humulin 70/30 Vials
Humulin N Vials
Humulin N Pen
Humulin Pen 70/30
Humulin R U-500
Bold type = Brand-name drug
[Plain type = Generic drug]
2
2
2
2
2
2
2
2
2
2
2
QL
QL
Programs
and Limits
2
Diabetes/Endocrine: Non-Insulin
Glimepiride
Glipizide
2
1
1
Glipizide ER
Glipizide XL
1
1
Glyburide
Glyburide/Metformin
Invokamet
Invokana
Janumet
Janumet XR
Januvia
Jentadueto
Kombiglyze
Metformin
Metformin ER
Onglyza
Pioglitazone
Tradjenta
Victoza
1
1
2
2
2
2
2
2
2
1
1
2
1
2
3
Byetta
PA Prior Authorization
ST Step Therapy
QL Quantity Limits
QL, ST
QL, ST
QL, ST
QL, ST
QL, ST
QL, ST
QL, ST
QL, ST
QL, ST
QL
QL, ST
QL, ST
AR Age Restrictions
SP Specialty Program
GR Gender Restrictions
7
January 2015
2015 Prescription Drug List
Drug Name
Drug
Tier
Programs
and Limits
Endocrine: Growth Hormone
Nutropin
2
PA, SP
Nutropin AQ
Saizen
2
PA, SP
2
2
PA, SP
PA, SP
Tev-Tropin
Endocrine: Other
Drug Name
Drug
Tier
Tobramycin/
Dexamethasone
1
Vigamox
2
QL
Alphagan P
2
QL
Azopt
2
QL
1
QL
2
QL
Eye Conditions: Glaucoma
Calcitriol Cap
1
Brimonidine
Combigan
Dexamethasone Tab
1
Dorzolamide-Timolol Maleate
1
Lupron Depot 3.75 mg 11.25
mg
Lupron Depot 7.5 mg, 22.5
mg, 30 mg, 45 mg
Methylprednisolone Tab
Prednisolone
Prednisone (5 mg/5 mL and 15
mg/5 mL)
Sensipar
Endocrine:
Thyroid Hormone Replacement
Armour Thyroid
Levothyroxine
Liothyronine
Methimazole
Synthroid
3
PA, SP
Latanoprost
1
QL
2
PA, SP
Lumigan
2
QL
1
1
Timolol
Timoptic Ocudose
Travatan Z
1
2
2
QL
1
Eye Conditions: Other
3
SP
3
1
1
1
3
Azelastine Solution
Pataday
1
2
Patanol
2
QL
1
1
1
2
QL
Eye Conditions: Antibiotics
Bold type = Brand-name drug
[Plain type = Generic drug]
1
1
1
Ketorolac Opthalmic Solution
Prednisolone Opth
Restasis
1
1
3
QL
PA
Gastrointestinal: Acid Suppression
Eye Conditions: Allergies
Ciprofloxacin
Erythromycin Ointment
Gentamicin
Moxeza
Polymyxin B/
Trimethoprim
Ofloxacin
Tobramycin
Programs
and Limits
QL
QL
Carafate Suspension
Dexilant
Famotidine Tab 20 mg and 40
mg (Rx only)
Lansoprazole (Rx only)
2
2
1
QL
Nexium (Rx only)
2
QL
Omeprazole (Rx only)
Pantoprazole
Rabeprazole
Ranitidine Tab, Cap, Syrup (Rx
only)
Sucralfate Tab
1
1
1
QL
QL
QL
QL
1
1
1
Gastrointestinal: Nausea/Vomiting
Meclizine
Metoclopramide
Ondansetron Tab
Transderm-Scop
PA Prior Authorization
ST Step Therapy
QL Quantity Limits
1
1
1
3
QL
QL
AR Age Restrictions
SP Specialty Program
GR Gender Restrictions
8
January 2015
2015 Prescription Drug List
Drug Name
Drug
Tier
Programs
and Limits
Gastrointestinal: Other
Drug Name
Drug
Tier
Programs
and Limits
Gonal-f RFF
2
PA, SP
Ovidrel
3
SP
Cimzia
2
Enbrel
3
Enbrel SureClick
3
Humira Kit
Humira Pen Kit
Humira Pen Kit Crohns
2
2
2
PA, QL, SP
PA, QL, ST,
SP
PA, QL, ST,
SP
PA, QL, SP
PA, QL, SP
PA, QL, SP
Humira Pen Kit Psoriasis
2
PA, QL, SP
Hydroxychloroquine
1
Amitiza
2
QL, ST, AR
Apriso
Asacol HD
2
QL
3
QL
Canasa
2
QL
Creon
2
Delzicol
3
Dicyclomine
Diphenoxylate/Atropine
Halflytely Kit
1
1
3
QL
Moviprep
3
QL
Omeclamox Pak
2
QL
Pentasa
Polyethylene Glycol 3350
Pylera
3
1
2
QL
QL
Methotrexate Tab
1
Suclear Bowel Prep
3
QL
Orencia SC
3
Suprep Bowel Prep
Uceris
3
3
2
QL
Simponi
Stelara
2
2
Zenpep (not 5,000 units)
QL
PA, QL, ST,
SP
PA, QL, SP
PA, QL, SP
Men’s Health: Erectile Dysfunction
HIV/AIDS
Atripla
Complera
Epzicom
Intelence
Isentress
Kaletra
Norvir
Prezista
Reyataz
Stribild
Truvada
Viread
Inflammatory Conditions
2
2
2
2
2
2
2
2
2
2
2
2
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
PA, SP
SP
2
2
PA, SP
PA, SP
Cialis
2
QL, AR, GR
Levitra
Viagra
3
3
QL, AR, GR
QL, AR, GR
1
2
1
1
2
2
1
1
QL
QL
Men’s Health: Prostate
Alfuzosin
Avodart
Doxazosin
Finasteride 5 mg
Jalyn
Rapaflo
Tamsulosin
Terazosin
QL
QL
QL
QL
Infertility
Follistim AQ
Gonal-f
Bold type = Brand-name drug
[Plain type = Generic drug]
PA Prior Authorization
ST Step Therapy
AR Age Restrictions
SP Specialty Program
GR Gender Restrictions
9
January 2015
2015 Prescription Drug List
Drug Name
Drug Programs
Tier
and
Limits
Men’s Health: Testosterone Therapy
Androderm
Androgel
Fortesta
Testim
Testosterone Cypionate IM
Injection
2
PA, QL, GR
2
PA, QL, GR
3
PA, QL, GR
2
PA, QL, GR
1
PA
Miscellaneous
Allopurinol
Antipyrine/Benzocaine Otic
Solution
5.4 - 1.4%
1
Aranesp
Benzonatate
2
Botox 100, 200 unit
Injection
2
PA, SP
Chantix
Cheratussin
Chlorhexidine
Colcrys
3
QL
2
QL
Epipen 2-Pak
Euflexxa
Fosrenol
Hydrocortisone AC Suppository
25 mg
2
QL
3
3
PA, SP
Hydromet
1
Lidocaine Viscous Solution 2%
1
Makena
2
Phenazopyridine (Rx only)
1
Phentermine Tab
1
Bold type = Brand-name drug
[Plain type = Generic drug]
1
PA, SP
1
1
1
Drug Name
Procrit
Promethazine DM Syrup
Promethazine/Codeine Syrup
2
1
PA, SP
AR
1
AR
Pulmozyme
Rectiv
Renvela
Rezira
Suboxone Film
Synagis
Synvisc
Uloric
Zubsolv
2
SP
Zutripro
3
Actonel
Alendronate Tab
Evista
Forteo
Ibandronate Tab
Raloxifene
2
3
2
PA, QL
2
PA, SP
2
2
2
PA, SP
QL, ST
PA, QL
3
QL
1
3
QL
2
PA, SP
1
QL
1
QL
Musculoskeletal: Other
Cyclobenzaprine Tab 5, 10 mg
PA, SP
3
Musculoskeletal: Osteoporosis
Baclofen Tab
Carisoprodol
1
Drug Programs
Tier
and
Limits
1
1
1
Metaxalone
1
Methocarbamol
1
Tizanidine
1
PA Prior Authorization
ST Step Therapy
AR Age Restrictions
SP Specialty Program
GR Gender Restrictions
10
January 2015
2015 Prescription Drug List
Drug Name
Drug Programs
Tier
and
Limits
Musculoskeletal: Pain Relief
Acetaminophen w/ Codeine
Diclofenac Tab
Endocet Tab
Etodolac
Fentanyl Patch
QL
QL
QL
QL
QL
QL
QL
Gralise
3
QL, ST
1
QL
1
QL
Hydrocodone w/ Ibuprofen Tab
7.5-200 mg
Hydrocodone/APAP
5, 7.5, 10/325 mg
Hydromorphone Tab
Ibuprofen Tab 400, 600,
800 mg (Rx only)
Indomethacin Cap
Lazanda
Lidocaine Patch 5%
Meloxicam
Methadone Tab
Morphine Sulfate ER Tab
Nabumetone
Naproxen (Rx only)
Nucynta
Nucynta ER
Oxycodone Tab
5, 15, 30 mg
Oxycodone
w/ Acetaminophen
Oxycontin
Sprix
Subsys
Tramadol Tab 50 mg
Tramadol
w/ Acetaminophen
Vicodin
Vicodin ES
Voltaren Gel
Bold type = Brand-name drug
[Plain type = Generic drug]
Drug Programs
Tier
and
Limits
Overactive Bladder
1
3
3
1
1
1
1
Cambia
Celebrex
Drug Name
1
1
QL
1
3
1
1
1
1
QL
PA, QL
QL
QL
1
1
3
2
QL
QL
QL
QL
QL
1
3
2
1
1
1
3
2
QL
QL
Advair Diskus
2
QL
Advair HFA
2
QL
Aerospan
QL
Perforomist
Proair HFA
Proventil
Pulmicort Flexhaler
Qvar
Serevent Diskus
Spiriva
Symbicort
3
1
2
2
1
2
3
2
2
2
1
1
1
3
2
3
2
2
2
2
2
Enablex
Gelnique
Oxybutynin
Oxybutynin ER
Tolterodine ER
Toviaz
Vesicare
QL
QL
QL
QL
Respiratory: Asthma/COPD
Albuterol Nebulizer Solution
Asmanex
Breo Ellipta
Budesonide
Combivent Respimat
Dulera
Flovent Diskus
Flovent HFA
Foradil
Ipratropium/Albuterol
Levalbuterol Nebulizer Solution
Montelukast
QL
QL
QL
QL, ST
QL
QL
QL, ST
QL
QL
QL
QL
QL
QL
QL, ST
QL
QL
1
QL
2
3
3
1
QL
QL
PA, QL
QL
1
QL
Tudorza Pressair
2
QL
1
1
2
QL
QL
QL
Ventolin HFA
Xolair
2
2
QL
PA, SP
PA Prior Authorization
ST Step Therapy
QL Quantity Limits
AR Age Restrictions
SP Specialty Program
GR Gender Restrictions
11
January 2015
2015 Prescription Drug List
Drug Name
Xopenex HFA
Drug
Tier
Programs
and Limits
Drug
Tier
Programs
and Limits
3
QL
1
3
1
1
2
3
1
2
3
QL
QL
1
1
2
1
3
1
1
1
1
1
1
3
1
1
1
GR
GR
GR
GR
GR
GR
GR
GR
GR
GR
GR
GR
GR
GR
GR
3
QL
GR
GR
GR
GR
GR
GR
GR
GR
1
1
1
1
Mononessa
Natazia
Necon
Norgest/Ethi Estradio
Nortrel
Nuvaring
Ocella
Orsythia
Ortho Tri-Cyclen Lo
Previfem
Reclipsen
Safyral
Sprintec 28
1
1
3
1
2
1
1
1
2
1
1
3
1
1
2
1
1
Trinessa
1
GR
1
Tri-Sprintec
1
GR
1
Vestura
1
GR
Viorele
1
GR
Respiratory: Nasal Allergies
Azelastine Spray
Dymista Spray
Fluticasone Spray
Ipratropium Spray
Nasonex
Omnaris
Triamcinolone Spray
Veramyst
Zetonna
QL
QL
QL
QL
QL
Respiratory: Oral Allergies
Cetirizine
Promethazine Tab
Desloratadine
Levocetirizine
Loratadine
1
1
1
1
1
AR
QL
QL
Azathioprine
Cellcept Tab/ Suspension
Cyclosporine Cap
Mycophenolate 250 mg
Cap/500 mg Tab
1
3
1
SP
SP
1
SP
Prograf Cap
Rapamune
Tacrolimus Cap
3
3
1
SP
SP
SP
Cyanocobalamine Injection
Folic Acid 1 mg (Rx only)
Klor-Con M10 and M20
Multi-Vit/Fl Chew
Potassium Chloride ER Tab,
Cap
Potassium Chloride Micro ER
Vitamin D 50,000 Units (Rx
only)
Bold type = Brand-name drug
[Plain type = Generic drug]
Women’s Health: Birth Control
Apri
Aviane
Beyaz
Cryselle-28
Generess Fe Chewable
Gianvi
Gildess Fe
Jolivette
Junel Fe
Kariva
Levora 28
Lo Loestrin
Loryna
Low-Ogestrel
Lutera
Medroxyprogesterone
Acetate Injection
Microgestin
Microgestin Fe
Minastrin 24 Fe Chewable
Transplant
Vitamins/Electrolytes
Drug Name
PA Prior Authorization
ST Step Therapy
QL Quantity Limits
GR
GR
GR
GR
GR
GR
GR
AR Age Restrictions
SP Specialty Program
GR Gender Restrictions
12
January 2015
2015 Prescription Drug List
Drug Name
Drug
Tier
Programs
and Limits
Women’s Health: Hormone Replacement
Climara Pro
Divigel
Enjuvia
Estrace Vaginal Cream
Estradiol Tab
Estradiol/Norethindrone Tab
Medroxyprogesterone Acetate
Tab
Premarin Tab
Premarin
Vaginal Cream
Bold type = Brand-name drug
[Plain type = Generic drug]
2
2
2
3
1
1
QL, GR
GR
QL, GR
QL, GR
QL, GR
1
2
Drug Name
Premphase
Prempro
Progesterone Cap
Vagifem
Vivelle-Dot
Drug
Tier
Programs
and Limits
2
2
1
3
2
QL, GR
QL, GR
GR
QL, GR
Women’s Health: Vaginal Anti-Infectives
Metronidazole Vaginal Gel
Terconazole Vaginal Cream
1
1
QL
QL, GR
2
PA Prior Authorization
ST Step Therapy
QL Quantity Limits
AR Age Restrictions
SP Specialty Program
GR Gender Restrictions
13
January 2015
2015 Prescription Drug List
Index of Covered Drugs
Drug Name
Page
A
Drug Name
Page
Drug Name
Page
Alphagan P
8
Azopt
8
3
Abilify Disc
5
Alprazolam Tab
5
Azor
Abilify Solution
5
Amiodarone
4
B
Abilify Tab
5
Amitiza
9
Baclofen Tab
10
Acanya Gel
Accu-Chek Act/Gluc
Calibration Liquid
Accu-Chek Aviva Plus Test
Strips
Accu-Chek Aviva Test Strips
6
Amitriptyline
4
Baraclude
2
6
Amlodipine
4
Benazepril
3
6
Amlodipine/Atorvastatin
4
Benazepril/HCTZ
3
6
Amlodipine/Benazepril
3
Benicar
3
Accu-Chek Comfort Test Strips
Accu-Chek Cpt/Gluc
Calibration Liquid
6
Amoxicillin
2
Benicar HCT
3
6
Amoxicillin/Clavulanate
2
Benzach
6
Accu-Chek Drum Test Strips
6
4
Benzonatate
10
Accu-Chek Kit Aviva Plus
6
4
Benztropine
1
Accu-Chek Kit Compact
6
AmphetamineDextroamphetamine
AmphetamineDextroamphetamine SR Cap
24Hr
Ampyra
5
Betaseron
5
Accu-Chek Kit Fastclix
6
Anastrozole
2
Bethkis
2
Accu-Chek Kit Multiclix
6
Androderm
10
Beyaz
12
Accu-Chek Kit Nano
6
10
Bisoprolol
3
Accu-Chek Kit Softclix
6
10
Bisoprolol/HCTZ
3
Accu-Chek Multiclix Lancets
Accu-Chek Smart Calibration
Liquid
Accu-Chek Smart Test Strips
Accu-Chek Sol Calibration
Liquid
Accu-Chek Sol
Comfort
Calibration Liquid
Acetaminophen w/ Codeine
6
Androgel
Antipyrine/Benzocaine Otic
Solution
5.4 - 1.4%
Apri
12
Botox 100, 200 unit Injection
10
6
Apriso
9
Breo Ellipta
11
6
Aranesp
10
Brilinta
2
6
Asacol HD
9
Brimonidine
8
7
Asmanex
11
Budeprion XL
4
11
Atenolol
14
Budesonide
11
Actonel
10
Atenolol/Chlorthalidone
3
Bumetanide
3
Acyclovir Ointment 5%
6
Atorvastatin
3
Bupropion
4
Acyclovir Tab, Cap, Suspension
2
Atralin
6
Bupropion SR
4
Aczone Gel
6
Atripla
9
5
Adcirca
4
Aviane
12
Advair Diskus
11
Avodart
9
Buspirone
Butalbital-AcetaminophenCaffeine Tab
Byetta
Advair HFA
11
Avonex Kit
5
Bystolic
3
Aerospan
11
Avonex Pen Kit
5
C
Aggrenox
2
Avonex Prefill Kit
5
Calcitriol Cap
8
Albuterol Nebulizer Solution
11
Azathioprine
12
Cambia
11
Alendronate Tab
10
Azelastine Solution
8
Canasa
9
Alfuzosin
10
Azelastine Spray
12
Carac
6
Allopurinol
10
Azithromycin
2
Carafate Suspension
8
4
7
14
January 2015
2015 Prescription Drug List
Drug Name
Carbamazepine Tab
5
Complera
9
Carbidopa/Levodopa Tab
5
Condylox
6
Carisoprodol
10
Copaxone
5
Drug Name
Doxycycline Hyclate Tab
(immediate Release)
Doxycycline
Monohydrate Cap
Dulera
Cartia XT
3
Coreg CR
3
Duloxetine
4
Carvedilol
3
Coumadin
2
Dutoprol
3
Cefdinir
2
Creon
10
Dymista Spray
12
Cefuroxime Tab
2
Crestor
3
E
Celebrex
11
Cellcept Tab/ Suspension
12
Cryselle-28
12
Cephalexin
2
Cetirizine
12
Chantix
10
Cyanocobalamine Injection
Cyclobenzaprine Tab 5, 10
mg
Cyclosporine Cap
Cheratussin
10
Cymbalta
Chlorhexidine
10
D
Chlorthalidone
3
Delzicol
Cialis
9
Desloratadine
Cimzia
9
Desonide Cream
Ciprodex Otic Suspension
2
Ciprofloxacin
Page
2, 8
Drug Name
Page
Page
2
2
11
Econazole Cream
6
Edarbi
3
12
Edarbyclor
3
10
Effient
2
12
Elidel
6
4
Eliquis
2
Enablex
11
9
Enalapril
3
12
Enbrel
9
6
Enbrel SureClick
9
Dexamethasone Tab
8
Endocet Tab
11
Dexilant
8
Enjuvia
13
Ciprofloxacin Tab
2
Dexmethylphenidate
4
Enoxaparin
2
Citalopram
4
Diazepam Tab
5
Epiduo
6
Clarithromycin
2
Diclofenac Tab
11
Epipen 2-Pak
10
Climara Pro
13
Dicyclomine
9
Epzicom
9
Clindamycin Cap
Clindamycin Gel, Lotion,
Solution
Clindamycin/Benzoyl Peroxide
Gel 1-5%
Clobetasol Cream, Gel,
Ointment
Clobex
2
Differin
6
Erythromycin Ointment
8
6
Dificid
2
Escitalopram Tab
4
6
Digoxin
4
Estrace Vaginal Cream
13
6
Diovan
3
Estradiol Tab
13
6
Diphenoxylate/Atropine
9
Estradiol/Norethindrone Tab
13
Cloderm
6
Divalproex DR
5
Eszopiclone Tab
5
Clonazepam
5
Divalproex ER
5
Etodolac
11
Clonidine Tab
3
Divigel
13
Euflexxa
10
Clopidogrel
Clotrimazole/Betamethasone
Cream, Lotion
Colcrys
2
5
Evista
10
8
Exforge
3
10
Donepezil Tab
Dorzolamide-Timolol
Maleate
Doxazosin
Exforge HCT
3
Combigan
9
Doxepin
4
F
Combivent Respimat
11
Doxycycline Hyclate Cap
2
Famciclovir Tab
6
3, 9
2
15
January 2015
2015 Prescription Drug List
Drug Name
Page
Drug Name
Page
Drug Name
Page
Famciclovir Tab
Famotidine Tab 20 mg and
40 mg (Rx only)
Fastclix Lancets
2
Glimepiride
7
Hydroxyzine Pamoate
8
Glipizide
7
I
7
Glipizide ER
7
10
Felodipine
3
Glipizide XL
7
Fenofibrate
3
Glucocard Test Strips
7
Ibandronate Tab
Ibuprofen Tab 400, 600, 800
mg (Rx only)
Indomethacin Cap
Fentanyl Patch
11
Glyburide
7
Insulin Pen Needle
7
Finacea
6
Glyburide/Metformin
7
Insulin Syringe/ Needle
7
Finasteride 5 mg
9
Gonal-f
9
Intelence
9
Flecainide
4
Gonal-f RFF
9
Intuniv
4
Flovent Diskus
11
Gralise
11
Invokamet
7
Flovent HFA
11
Guanfacine Tab
3
Invokana
7
Fluconazole
Fluocinonide Cream, Gel,
Ointment 0.05%
Fluoxetine Cap (not PMDD)
2
H
Ipratropium Spray
11
6
Halflytely Kit
9
Ipratropium/Albuterol
12
4
Humalog Mix 50/50 Kwik Pen
7
Irbesartan
3
Fluticasone Spray
12
Humalog Mix 50/50 Vials
7
Irbesartan/HCTZ
3
Focalin XR
4
Humalog Mix 75/25 Kwik Pen
7
Isentress
9
Folic Acid 1 mg (Rx only)
12
Humalog Mix 75/25 Vials
7
Isosorbide Mononitrate
4
Follistim AQ
9
Humalog Vials
7
J
Foradil
11
9
Jalyn
9
Forfivo XL
4
9
Janumet
7
Forteo
10
Humira Kit
Humira Pen Kit
Crohns/Psoriasis
Humulin 70/30 Vials
7
Janumet XR
7
Fortesta
10
Humulin N Pen
7
Januvia
7
Fosinopril
3
Humulin N Vials
7
Jentadueto
7
Fosrenol
10
Humulin Pen 70/30
7
Jolivette
12
Furosemide
3
Humulin R U-500
7
Junel Fe
12
Gabapentin
5
Humulin R Vials
7
K
Hydralazine
3
Kaletra
9
3
Kariva
Ketoconazole
Cream/Shampoo
12
11
Ketorolac Opthalmic Solution
8
10
Klor-Con M10 and M20
12
6
Kombiglyze
7
G
5
10
10
Gabapentin
5
Gelnique
11
Gemfibrozil
3
Generess Fe Chewable
12
Gentamicin
8
Hydrochlorothiazide
Hydrocodone w/ Ibuprofen
Tab 7.5-200 mg
Hydrocodone/APAP
5, 7.5, 10/325 mg
Hydrocortisone AC
Suppository 25 mg
Hydrocortisone Cream 2.5%
Gianvi
12
Hydromet
10
L
Gildess Fe
12
Hydromorphone Tab
11
Labetalol
3
Gilenya
5
Hydroxychloroquine
9
Lamictal
5
Gleevec
2
Hydroxyzine HCL
5
Lamictal ODT
5
11
6
16
January 2015
2015 Prescription Drug List
Drug Name
Lamictal XR
Lamotrigine
Lamotrigine ER
Lansoprazole (Rx only)
Page
5
5
5
10
Drug Name
Page
3
12
8
5
Lantus Solostar
7
Lantus Vials
7
Latanoprost
Lazanda
Letairis
Letrozole
Levalbuterol Nebulizer
Solution
8
11
4
2
Lovaza
Low-Ogestrel
Lumigan
Lunesta
Lupron Depot 3.75 mg 11.25
mg
Lupron Depot
7.5 mg, 22.5 mg, 30 mg, 45
mg
Lutera
Lyrica Cap
M
Makena
11
Levemir Flexpen
7
Levemir Vials
7
Levetiracetam
Levetiracetam ER
Levitra
Levocetirizine
Levofloxacin Tab
Levora 28
Levothyroxine
Lidocaine Patch 5%
Lidocaine Viscous Solution
2%
5
5
9
12
2
12
8
11
Medroxyprogesterone
Acetate Injection
Meloxicam
Metaxalone
Metformin
Metformin ER
Methadone Tab
Methimazole
Methocarbamol
Methotrexate Tab
10
Liothyronine
8
Lipitor
3
Lipofen
Lisinopril
3
3
Methylphenidate HCL Sa Osm
ER Tab
Methylphenidate Tab
Methylprednisolone Tab
Lisinopril/HCTZ
3
Metoclopramide
8
Lithium Carbonate
5
Metoprolol Succinate
3
Livalo
Lo Loestrin
Loratadine
Lorazepam Tab
Loryna
Losartan
Losartan/HCTZ
Lovastatin
3
12
12
5
12
3
3
3
Metoprolol Tartrate
Metrogel
Metronidazole Gel 0.75%
Metronidazole Tab
Metronidazole Vaginal Gel
Microgestin
Microgestin Fe
Migranal
3
6
6
2
13
12
12
4
Drug Name
Minastrin 24 Fe Chewable
Minocycline Cap
Mirtazapine
Modafinil
Page
12
2
4
5
8
Monetasone
6
8
Mononessa
12
12
5
10
Montelukast
Morphine Sulfate ER Tab
Moviprep
Moxeza
11
11
9
8
Meclizine
8
Multi-Vit/Fl Chew
12
Medroxyprogesterone
Acetate Tab
12
Mupirocin
6
11
10
7
7
11
8
10
9
Mycophenolate 250 mg
Cap/500 mg Tab
N
Nabumetone
Nadolol
Namenda Tab
Namenda XR
Naproxen (Rx only)
Nasonex
Natazia
Methylphenidate Cap ER
4
Necon
12
Methylphenidate ER Tab
4
Neomycin/Polymyxin/ HC Otic
Suspension, Solution
2
4
Nexium (Rx only)
8
4
8
Niacin ER Tab
Nifedipine ER
Nitrofurantoin Monohydrate
Macrocrystalline
3
3
13
Nitrofurantoin
Macrocrystalline
Nitrostat
Norgest/Ethi Estradio
Nortrel
Nortriptyline
Norvir
Novofine
Novofine Auto
Novolin 70/30 Vials
12
11
3
5
5
11
12
12
2
2
4
12
12
4
9
7
7
7
17
January 2015
2015 Prescription Drug List
Drug Name
Novolin N Vials
Novolin R Vials
Novolog Flexpen
Page
7
7
7
Onfi
Onglyza
Opsumit
Page
3
7
4
Novolog Mix 70/30 Vials
7
Oracea
2
Novolog Mix Flexpen
7
Orencia SC
9
Novolog Penfill
7
Orsythia
12
Novolog Vials
Novotwist
Nucynta
Nucynta ER
Nutropin
Nutropin AQ
Nuvaring
Nystatin Cream, Ointment,
Powder
Nystatin Suspension
Nystatin/Triamcinolone
Cream, Ointment
O
Ocella
Ofloxacin
Ofloxacin Otic Solution
Olanzapine Tab
Olysio
Omeclamox Pak
Omega-3 Acid Cap 1 gm
Omeprazole (Rx only)
Omnaris
Ondansetron Tab
Onetouch Kit Ultra
Onetouch Kit Ultra 2
Onetouch Kit Ultra Mini
Onetouch Kit Ultra Smart
7
7
11
11
8
8
12
Ortho Tri-Cyclen Lo
Ovidrel
Oxcarbazepine
Oxsoralen-UI
Oxybutynin
Oxybutynin ER
Oxycodone
12
9
5
6
11
11
11
Drug Name
Pravastatin
Prednisolone
Prednisolone Opth
Prednisone (5 mg/5 mL and
15 mg/5 mL)
Premarin Tab
Premarin
Vaginal Cream
Premphase
Prempro
Previfem
Prezista
Pristiq
Proair HFA
Prochlorperazine
6
Oxycodone Tab 5, 15, 30 mg
11
Procrit
10
2
Oxycontin
11
Progesterone Cap
13
6
P
Prograf Cap
12
Onetouch Kit Verio IQ
7
Onetouch Test Strips
7
Onetouch Ultra Blue Test
Strips
Onetouch Verio IQ Test Strips
Onetouch Verio Test Strips
Drug Name
Page
3
8
8
8
13
13
13
13
12
9
4
11
5
Pantoprazole
Paroxetine
Pataday
Patanol
Pegasys
Penicillin VK
Pentasa
Perforomist
Permethrin Cream 5%
Phenazopyridine (Rx only)
Phentermine Tab
Phenytoin
Phrenilin
Pioglitazone
Polyethylene Glycol 3350
Polymyxin B/Trimethoprim
Solution
Potassium Chloride ER Tab,
Cap
8
4
8
8
2
2
9
11
6
10
10
5
4
7
9
Promethazine DM Syrup
Promethazine Tab
Promethazine/Codeine Syrup
Propranolol
Propranolol ER
Protopic Ointment
Proventil
10
12
10
3
3
6
11
Pulmicort Flexhaler
11
Pulmozyme
Pylera
Q
Quetiapine
Quinapril
Qvar
10
9
8
R
12
Rabeprazole
8
7
Potassium Chloride Micro ER
12
Raloxifene
10
7
7
Pradaxa
Pramipexole
2
5
Ramipril
Ranexa
3
4
12
8
2
5
2
9
3
8
12
8
7
7
7
7
5
3
11
18
January 2015
2015 Prescription Drug List
Drug Name
Ranitidine Tab, Cap, Syrup
(Rx only)
Rapaflo
Rapamune
Rebif
Rebif Titrtn
Page
Drug Name
Page
Drug Name
Page
4
Sotalol
4
Terazosin
3
9
12
5
5
Sovaldi
Spiriva
Spironolactone
Sprintec 28
2
11
3
12
9
2
13
10
Reclipsen
12
Sprix
11
Rectiv
Relpax
Renvela
Restasis
Retin-A Micro
10
4
10
8
6
Stelara
Strattera
Stribild
Suboxone Film
Subsys
9
4
9
11
11
Revlimid
2
Suclear Bowel Prep
11
Reyataz
9
8
Rezira
10
2
Topiramate Tab
5
Risperidone Tab
5
2
Torsemide Tab
3
Rizatriptan Tab, ODT
Ropinirole
S
Safyral
4
5
12
Sucralfate Tab
Sulfamethoxazole
Trimethoprim
Sulfamethoxazole
Trimethoprim DS
Sumatriptan Tab and Spray
Sumavel Dose
Suprep Bowel Prep
Surestep Test Strips
Terazosin
Terbinafine Tab
Terconazole Vaginal Cream
Testim
Testosterone Cypionate IM
Injection
Tev-Tropin
Timolol
Timoptic Ocudose
Tizanidine
Tobramycin
Tobramycin/
Dexamethasone
Tolterodine ER
4
4
9
7
11
4
7
11
Saizen
8
Symbicort
11
Saphris
Sensipar
Serevent Diskus
Seroquel XR
Sertraline
Sildenafil Tab 20 mg
Silenor
Silver Sulfadiazine Cream 1%
Simcor
Simponi
Simvastatin
Simvastatin 80 mg
Soft Touch Lancets
Softclix Lan Mis Device
Softclix Lancets
Solodyn
5
8
11
5
4
4
5
6
3
9
3
3
7
7
7
2
Synagis
Synthroid
Synvisc
T
Taclonex
Tacrolimus Cap
Tamiflu
Tamoxifen Tab
Tamsulosin
Tarka
Tasigna
Tecfidera
Tekturna
Tekturna HCT
Telmisartan
Temazepam
10
8
10
Toviaz
Tracleer
Tradjenta
Tramadol Tab 50 mg
Tramadol
w/ Acetaminophen
Transderm-Scop
Travatan Z
Trazodone
Tretinoin Microsphere Gel
Triamcinolone
Triamcinolone Spray
Triamterene/HCTZ
Triazolam Tab
Tribenzor
Trinessa
Tri-Sprintec
Truetrack Test Strips
Truvada
Tudorza Pressair
U
Uceris
6
12
2
2
9
3
2
5
3
3
3
5
10
8
8
8
10
8
8
10
11
8
8
4
6
6
12
3
5
3
12
12
7
9
11
9
19
January 2015
2015 Prescription Drug List
Drug Name
Uloric
V
Vagifem
Valacyclovir
Valsartan
Valsartan/HCTZ
Vascepa
Vectical
Venlafaxine
Venlafaxine ER Cap
Ventolin HFA
Veramyst
Verapamil ER
Vesicare
Vestura
Viagra
Vicodin
Vicodin ES
Victoza
Vigamox
Viibryd
Viorele
Viread
Vitamin D 50,000 Units (Rx
only)
Vivelle-Dot
Voltaren Gel
Vytorin
Vytorin Tab 10-80 mg
Vyvanse
W
Warfarin
Welchol
X
Xarelto
Xolair
Xopenex HFA
Page
10
13
2
3
3
3
13
4
4
11
12
3
11
12
9
11
11
7
8
4
12
9
Drug Name
Z
Zelapar
Zenpep
Zetia
Zetonna
Ziprasidone Cap
Zolpidem
Zolpidem ER
Zomig Nasal Spray
Zovirax Cream
Zovirax Ointment
Zubsolv
Zutripro
Zyclara
Zytiga
Page
5
9
3
12
5
5
5
4
6
6
10
10
6
2
12
13
11
3
3
4
2
3
2
11
12
20
January 2015
2015 Prescription Drug List
21