Table of Contents

Advantage Three-Tier
Your 2013 Prescription Drug List
Quick-Reference Guide
For the most current PDL updates, visit myuhc.com or call the toll-free member phone number on the back of your health plan ID card.
Created September, 2012. 2013 Prescription Drug List Advantage Three-Tier 1/13
Anti-Infectives
Antibiotics . . . . . . . . . . . . . . . . . . . . . . . 5
Antifungals . . . . . . . . . . . . . . . . . . . . . . 5
Antivirals . . . . . . . . . . . . . . . . . . . . . . . 5
Cardiovascular/Heart Disease
Coagulation Therapy . . . . . . . . . . . . . . 5
High Blood Pressure . . . . . . . . . . . . . . 6
High Cholesterol . . . . . . . . . . . . . . . . . 6
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Central Nervous System
Attention Decit Disorder . . . . . . . . . . 7
Depression . . . . . . . . . . . . . . . . . . . . . . 7
Migraine . . . . . . . . . . . . . . . . . . . . . . . . 7
Multiple Sclerosis . . . . . . . . . . . . . . . . 8
Sedatives/Hypnotics . . . . . . . . . . . . . . 8
Seizure Disorders . . . . . . . . . . . . . . . . 8
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Dermatology . . . . . . . . . . . . . . . . . . . 9
Diabetes/Endocrine
Blood Glucose Monitoring . . . . . . . . . 9
Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Non-Insulin . . . . . . . . . . . . . . . . . . . . .10
Endocrine
Growth Hormone . . . . . . . . . . . . . . . .10
Other . . . . . . . . . . . . . . . . . . . . . . . . . .10
Eye Conditions
Allergies . . . . . . . . . . . . . . . . . . . . . . .10
Antibiotics . . . . . . . . . . . . . . . . . . . . . .10
Glaucoma . . . . . . . . . . . . . . . . . . . . . .11
Gastrointestinal
Acid Suppression . . . . . . . . . . . . . . .11
Nausea/Vomiting . . . . . . . . . . . . . . . .11
Other . . . . . . . . . . . . . . . . . . . . . . . . . .11
Mens Health
Erectile Dysfunction . . . . . . . . . . . . . .11
Prostate . . . . . . . . . . . . . . . . . . . . . . .12
Miscellaneous
Miscellaneous . . . . . . . . . . . . . . . . . .12
Overactive Bladder . . . . . . . . . . . . . .12
Musculoskeletal
Osteoporosis . . . . . . . . . . . . . . . . . . .12
Pain Relief . . . . . . . . . . . . . . . . . . . . .12
Rheumatoid Arthritis . . . . . . . . . . . . .13
Other . . . . . . . . . . . . . . . . . . . . . . . . . .13
Respiratory
Asthma/COPD. . . . . . . . . . . . . . . . . .13
Nasal Allergies . . . . . . . . . . . . . . . . . .14
Oral Allergies . . . . . . . . . . . . . . . . . . .14
Womens Health
Contraceptives . . . . . . . . . . . . . . . . . .14
Estrogen/Progesterone . . . . . . . . . . .15
Prenatal Vitamins . . . . . . . . . . . . . . . .15
Welcome to Your Prescription Drug List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Frequently Asked Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Information About Tiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Prescription Drug List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Additional Tier 3 drugs with a generic equivalent in Tier 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
1 Visit www.myuhc.com for updates 2013 Prescription Drug List Advantage Three-Tier
Your Prescription Drug List:
Helping you get the most out of your pharmacy benet.
Tis Prescription Drug List (PDL) outlines the most commonly prescribed medications for certain conditions
and divides them into tiers. Your costs may change depending on a medications tier placement.
To help you better use your UnitedHealthcare pharmacy beneft, this guide answers commonly asked questions
about your PDL.
Go to myuhc.com

for complete and up-to-date PDL

information
Since the PDL may change, we encourage you to visit our website, myuhc.com. Tis website is the best source
for up-to-date information about the medications your pharmacy beneft covers, possible lower-cost options,
and how the cost of medications compare.
2 Visit www.myuhc.com for updates 2013 Prescription Drug List Advantage Three-Tier
Welcome to your 2013 Prescription Drug List
What is a PDL?
A PDL is a list of commonly prescribed medications
placed into tiers. Te PDL includes both brand and generic
prescription medications approved by the U.S. Food
and Drug Administration (FDA). Te PDL is reviewed
periodically and may change. It is not a complete list of
medications and not all medications listed may be covered
under your plan. If you have pharmacy benet coverage
with UnitedHealthcare, please look at your beneft plan
documents provided by your employer or health plan to
see what medications are covered under your plan. Where
diferences are noted between this PDL quick-reference
guide and your benet plan documents, the benet plan
documents will govern. You may also log on to myuhc.com
or call the toll-free member phone number on the back of
your health plan ID card for more information.
How do I use my PDL?
When choosing a medication, you and your doctor should
consult the PDL. Tis guide is organized by common
medical conditions. Ten, within each medical condition
section, medications are listed by tier.
If your medication is not located in the PDL please log on
to myuhc.com or call the toll-free member phone number on
the back of your health plan ID card.
What are Tiers?
Tiers are the diferent cost levels you pay for a medication.
Each tier is assigned a cost, which is determined by your
employer or health plan. Tis is how much you will pay when
you fll a prescription. Tier 1 medications are your lowest-
cost options. If your medication is placed in Tier 2 or 3, look
to see if there is a Tier 1 alternative. Discuss your options
with your doctor.
Check your beneft plan documents to fnd out your
pharmacy plan costs.
Tier 1 Tier 2 Tier 3
Your Your Your
lowest-cost midrange-cost highest-cost
medications medications medications
Are there plans that dont have three tiers?
Some plans have a two-tier pharmacy benet rather than a
three-tier pharmacy benet. Generally, a two-tier pharmacy
benet plan does not cover medications listed in Tier 3 of
this PDL. A two-tier pharmacy benet plan covers one tier
at the lower-cost and covers a second tier at a higher-cost.
In addition, some plans have a four-tier prescription plan or
additional medication lists that should be referenced. Check
your beneft plan documents or log on to myuhc.com for
information about your benefts.
At UnitedHealthcare, we want to help you better understand your medication choices.
Your pharmacy benet offers exibility and choice in determining the right medication for you.
To help you get the most out of your pharmacy benet, weve included some of the most commonly
asked questions about the PDL.
3 Visit www.myuhc.com for updates 2013 Prescription Drug List Advantage Three-Tier
When do medications change tiers?
Te PDL quick-guide is updated twice a year, January 1st
and July 1st. Medications may move to a higher tier or be
excluded from beneft coverage on these dates. Medications
can move to a lower tier at any time throughout the year.
Troughout the year we also review generic and brand-name
medications and decide which tier each should be placed. If a
new generic launches, tier changes can occur at that time for
its brand counterpart. Tese reviews may cause medications
to change tiers at any time.
When a medication changes tiers, you may have to pay a
diferent amount for that medication. Tese 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 health
plan ID card or visit myuhc.com.
Why are there notations (SL, N, etc.) next
to certain medications in the PDL, and
what do they mean?
As you go through this list, you might notice some
medications are noted with symbols next to them. Te
notations refer to our pharmacy programs. Your beneft
plan determines how these medications may be covered for
you but the symbols are guidelines to help you check what
medications may be impacted.
To learn more about a pharmacy program or to fnd out if
it applies to you, please visit myuhc.com or call the toll-free
member phone number on the back of your health plan ID
card.
Here is a quick symbol overview:
Why is the medication that I am currently
taking no longer covered?
Medications may be excluded from coverage under your
pharmacy benet. For example, a medication may be
excluded from coverage when it is therapeutically equivalent
to another prescription medication or an over-the-counter
(OTC) medication. Tere may be alternatives on the PDL or
OTC medications that are right for your treatment.
Should I talk to my doctor about OTC
medications?
An OTC medication may be the right treatment for some
conditions. Talk to your doctor about OTC options. Tese
medications are not covered under your pharmacy benet,
but they may cost less than your out-of-pocket expense for
prescription medications.
PDL Symbols
1
/2T Eligible for Half Tablet Program
DSN Designated Specialty Network
E May be excluded from coverage
MC Multiple copay
N Notication or Prior Authorization required*
RS May be eligible for the Rell and Save Program
SDP Select Designated Pharmacy
SL Supply limit
ST Step Therapy
*Depending on your benet you may have notication or prior authorization
requirements for select medications.
4 Visit www.myuhc.com for updates 2013 Prescription Drug List Advantage Three-Tier
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. After
the patent on a brand-name medication expires, other
companies can manufacture an FDA-approved version of
the medication. Tese types of medications are called generic
medications. Many times, the same company that makes a
brand-name medication also makes the generic version.
What if my doctor writes a brand-name
prescription?
Te 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 right for
you. Generic medications are usually your lowest-cost option,
but not always. Check myuhc.com to make sure.
Are you taking a specialty medication?
Specialty medications are managed through our Specialty
Pharmacy Program which ofers personalized member
support. Te program also ofers access to on-call
pharmacists available 24 hours a day, robust clinical and
adherence programs and support coaching on lower-cost
medication options. Visit www.uhcspecialtyrx.com or call
1-866-429-8177 to learn more. Please note your specialty
medication may not be listed in this guide. Please log on to
myuhc.com for more information.
How do I access updated information
about my pharmacy benet?
Since the PDL may change, we encourage you to visit
myuhc.com or call the toll-free member phone number
on the back of your health plan ID card for more current
information.
Log on to myuhc.com for the following pharmacy
information and tools:
u
Pharmacy beneft and coverage information
u
Possible lower-cost medication alternatives
u
A list of medications based on a specifc medical
condition
u
Medication interactions and side efects
u
Locate a participating retail pharmacy by zip code
u
View your prescription history
And, if mail order is included in your pharmacy beneft, you
can also:
u
Refll prescriptions
u
Check the status of your order
u
Set up e-mail reminders for reflls
u
Manage your account
What if I still have questions?
Please call the toll-free member phone number on the back
of your health plan ID card. Representatives are available
24 hours a day (except Tanksgiving and Christmas).
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 benet coverage.
Medications are categorized by common therapeutic conditions in this PDL for ease of reference only. These categories do not determine coverage for the medication for your
condition. Your benet plan determines how these medications may be covered for you.
5 Visit www.myuhc.com for updates 2013 Prescription Drug List Advantage Three-Tier
Please refer to page 3 for a denition of notations/symbols.
Anti-Infectives Antibiotics (Oral, inhaled and ear antibiotics are listed)
Amoxicillin
Amoxicillin/Potassium Clavulanate
Ampicillin
Azithromycin
Cefadroxil
Cefprozil
Cefuroxime
Cephalexin
Ciprooxacin Tablet
Clarithromycin Tablet
Clindamycin HCl
Dicloxacillin Sodium
Doxycycline Monohydrate
Erythromycin
Erythromycin Base Enteric-Coated Tablet
Levooxacin
Metronidazole
Minocycline HCl
Neomycin/Polymyxin/HC Otic
Nitrofurantoin Macrocrystal
Nitrofurantoin Suspension
Nitrofurantoin/Nitrofurantoin Macrocrystal
Ooxacin Otic
Penicillin V Potassium
Sulfamethoxazole/Trimethoprim
Tetracycline
Vancomycin SL
Augmentin
Cayston N
Cefdinir
Cipro Suspension
Ciprodex Otic
Clarithromycin Suspension
Clarithromycin Sustained-Release Tablet
Cleocin HCl 75 mg
Clindamycin Palmitate
Dapsone
Ery-Tab 500 mg
Macrodantin 25 mg
Tobi DSN
Zyvox SL
Tier 2
Adoxa E
Amoxicillin-Clavulanate ER E
Augmentin XR E
Avelox
Cetraxal
Cipro HC
Ciprooxacin Sustained-Release 24 Hour Tablet
Doryx E
Doxycycline Hyclate Enteric-Coated Tablet E
Doxycycline Monohydrate Capsule 150 mg E
Minocycline Extended-Release 24 Hour Tablet
Oracea
Solodyn
Suprax
Tier 3
Tier 1
Clotrimazole
Fluconazole
Itraconazole Capsule SL
Ketoconazole
Metronidazole Vaginal
Nystatin
Terbinane Tablet SL
Terconazole Vaginal
Voriconazole SL
Clindesse Vaginal Noxal Sporanox Oral Solution
Tier 2
Gynazole-1 Vaginal
Ketoconazole Foam SL
Lamisil Granules SL
Mycostatin
Tier 3
Tier 1
Anti-Infectives Antifungals (Oral and topical antifungals are listed)
Anti-Infectives Antivirals
Cardiovascular/Heart Disease Coagulation Therapy
Acyclovir Amantadine Ribavirin DSN N
Baraclude DSN
Epivir HBV DSN
Famciclovir SL
Hepsera DSN
Incivek DSN N SL
Rebetol Solution DSN N
Valacyclovir SL
Valcyte SL
Tier 2
Relenza SL
Ribapak DSN E N
Tamiu SL
Victrelis DSN N SL
Tier 3
Tier 1
Cilostazol
Clopidogrel
Pentoxifylline
Warfarin Sodium
Coumadin
Enoxaparin SL
Fondaparinux SL
Xarelto SL
Tier 2
Aggrenox
Efent SL
Fragmin SL
Innohep SL
Pradaxa SL
Tier 3
Tier 1
6 Visit www.myuhc.com for updates 2013 Prescription Drug List Advantage Three-Tier
Please refer to page 3 for a denition of notations/symbols.
Cardiovascular/Heart Disease High Blood Pressure
Amlodipine
Atenolol
Atenolol/Chlorthalidone
Benazepril
Benazepril/Hydrochlorothiazide
Bisoprolol
Bisoprolol/Hydrochlorothiazide
Bumetanide
Captopril
Captopril/Hydrochlorothiazide
Carvedilol
Chlorthalidone
Clonidine
Diltiazem
Diltiazem Controlled-Release Capsule
Diltiazem Sustained-Release 12 Hour Capsule
Doxazosin
Enalapril
Enalapril/Hydrochlorothiazide
Eprosartan SL
Felodipine
Furosemide
Guanfacine
Hydralazine
Hydrochlorothiazide
Labetalol
Lisinopril
Lisinopril/Hydrochlorothiazide
Losartan
1
/2T
Losartan/Hydrochlorothiazide
Metolazone
Metoprolol Succinate Sustained-Release
Tablet 25 mg
Metoprolol Tartrate
Metoprolol/Hydrochlorothiazide
Moexipril
1
/2T
Nadolol
Nifedipine
Propranolol Tablet
Propranolol/Hydrochlorothiazide
Ramipril
Spironolactone
Spironolactone/Hydrochlorothiazide
Terazosin
Torsemide
Trandolapril
1
/2T
Triamterene/Hydrochlorothiazide
Verapamil
Tier 1
Aldactazide 50-50 mg
Benicar
1
/2T SL
Benicar HCT SL
BiDil
Bystolic
Cardizem LA 120 mg
Clorpres
Dibenzyline
Diltiazem Sustained-Action Capsule
Diltiazem Sustained-Release 24 Hour Capsule
Diltiazem Sustained-Release 24 Hour Tablet
Diuril Suspension 250 mg/5 ml
Dutoprol SL
Eplerenone
Metoprolol Succinate Sustained-Release Tablet
50, 100, 200 mg
Micardis SL
Micardis HCT SL
Nisoldipine
Perindopril Erbumine
1
/2T
Propranolol Sustained-Action Capsule
Quinapril/Hydrochlorothiazide
Thalitone
Tier 2
Aceon
1
/2T
Amlodipine/Benazepril SL
Amturnide E SL
Atacand
1
/2T SDP SL
Atacand HCT SDP SL
Avalide SL
Avapro
1
/2T SL
Azor SL
Cardizem LA 180, 240, 300, 360, 420 mg
Clonidine Transdermal Weekly Patch SL
Coreg CR E SL
Diovan
1
/2T SL
Diovan HCT SL
Edarbi SL
Edarbyclor SL
Exforge E SL
Exforge HCT E SL
Irbesartan
1
/2T SL
Irbesartan/Hydrochlorothiazide SL
Nexiclon XR E
Sular
Tekamlo E SL
Tekturna SDP SL
Tekturna HCT SDP SL
Teveten HCT SL
Trandolapril/Verapamil
Tribenzor E SL
Twynsta E SL
Verapamil Sustained-Release 24 Hour Pellets
Tier 3
Cardiovascular/Heart Disease High Cholesterol
Atorvastatin
1
/2T SL
Cholestyramine
Colestipol
Fenobric Acid
Fluvastatin SL
Gembrozil
Lovastatin
Pravastatin
1
/2T
Simvastatin
1
/2T
Tier 1
Antara
Crestor
1
/2T SL
Fenobrate
Lipofen
Welchol
Tier 2
Advicor SL
Altoprev E SL
Amlodipine/Atorvastatin E SL
Caduet E SL
Fenoglide
Lescol XL SL
Lipitor
1
/2T E SL
Livalo SL
Lovaza N
Niaspan
Simcor SL
Tricor E
Triglide
Trilipix E
Vytorin SL
Zetia SL
Tier 3
7 Visit www.myuhc.com for updates 2013 Prescription Drug List Advantage Three-Tier
Please refer to page 3 for a denition of notations/symbols.
Central Nervous System Attention Decit Disorder
Central Nervous System Depression
Cardiovascular/Heart Disease Other
Amiodarone
Digoxin
Flecainide Acetate
Isosorbide Dinitrate
Isosorbide Mononitrate
Mexiletine
Nitroglycerin Transdermal Patch
Sotalol
Tier 1
Lanoxin
Multaq
Nitrostat
Ranexa
Tier 2
Amphetamine Salt Combo
Dextroamphetamine Sulfate
Methamphetamine
Methylphenidate
Tier 1
Adderall XR SL Intuniv SL Vyvanse SL
Tier 2
Amphetamine Aspartate/Amphetamine Sulfate/
Dextroamphetamine Sustained-Release
24 Hour Capsule SL
Concerta SL
Daytrana SL
Focalin XR SL
Kapvay E
Metadate CD SL
Methylin Tablet
Methylphenidate Extended-Release
24 Hour Tablet SL
Methylphenidate Extended-Release Capsule SL
Ritalin LA SL
Strattera SL
Tier 3
Amitriptyline
Bupropion
Bupropion XL
Citalopram Hydrobromide
Doxepin
Fluoxetine
Fluoxetine Delayed-Release Capsule SL
Fluvoxamine Maleate
Mirtazapine
Nefazodone
Nortriptyline
Paroxetine Tablet
Phenelzine
Sertraline
1
/2T
Trazodone
Venlafaxine Sustained-Release Capsule SL
Tier 1
Aplenzin E SL
Cymbalta SDP SL
Escitalopram
1
/2T SL
Lexapro
1
/2T SL
Luvox CR SL
Oleptro E SL
Paroxetine Sustained-Release 24 Hour Tablet SL
Pexeva
1
/2T SL
Pristiq RS SL
Venlafaxine Extended-Release Tablet E SL
Tier 3
Nitroglycerin Spray E SL
Nitrolingual E SL
Nitromist SL Propafenone Sustained-Release
12 Hour Capsule
Tier 3
Central Nervous System Migraine
Acetaminophen/Butalbital/Caffeine SL
Acetaminophen/Dichloralphenazone/
Isometheptene Mucate
Aspirin/Butalbital/Caffeine
Naratriptan SL
Relpax SL
Sumatriptan Succinate Injection, Tablet SL
Tier 1
Ergomar Sumatriptan Succinate Nasal Spray SL
Tier 2
Alsuma E SL
Axert SDP SL
Cafergot
Cambia E SL
Frova SDP SL
Maxalt SDP SL
Maxalt MLT SDP SL
Migranal
Sumavel DosePro SL
Treximet E SL
Zomig SDP SL
Zomig Nasal Spray SL
Zomig ZMT SDP SL
Tier 3
8 Visit www.myuhc.com for updates 2013 Prescription Drug List Advantage Three-Tier
Please refer to page 3 for a denition of notations/symbols.
Central Nervous System Multiple Sclerosis
Ampyra DSN N SL
Avonex DSN N SL
Copaxone DSN N SL
Rebif DSN N SL
Tier 2
Betaseron DSN N SL ST Extavia DSN E N SL ST Gilenya DSN N SL ST
Tier 3
Central Nervous System Sedatives/Hypnotics
Temazepam Zaleplon SL Zolpidem Tablet SL
Tier 1
Ambien SL ST
Ambien CR SL ST
Edluar E SL ST
Lunesta SL ST
Rozerem SL ST
Silenor E SL
Sonata SL ST
Zolpidem Multiphasic-Release Tablet SL ST
Zolpimist E SL ST
Tier 3
Central Nervous System Seizure Disorders
Carbamazepine
Clonazepam
Diazepam Rectal Gel SL
Divalproex Sodium Sustained-Release Tablet
Divalproex Sodium Tablet
Felbamate
Gabapentin
Lamotrigine
Levetiracetam
Oxcarbazepine
Phenobarbital
Phenytoin Sodium
Primidone
Topiramate
Zonisamide
Tier 1
Carbamazepine Sustained-Release
12 Hour Tablet
Celontin
Dilantin
Divalproex Sodium Sprinkle Capsule
Gabitril
Levetiracetam Extended-Release
24 Hour Tablet ST
Mysoline
Peganone
Sabril
Tegretol
Tier 2
Carbamazepine Extended-Release
12 Hour Capsule
Carbatrol
Depakote ER ST
Keppra ST
Keppra XR ST
Lamictal ST
Lamictal Dose Pack SL ST
Lamictal ODT ST
Lamictal XR ST
Lyrica SDP SL
Stavzor ST
Topamax ST
Tier 3
Central Nervous System Other
Alprazolam
Benztropine Mesylate
Buspirone
Carbidopa/Levodopa
Clozapine
Diazepam
Donepezil 5, 10 mg
Galantamine
Lithium Carbonate
Lithium Carbonate Controlled-Release Tablet
Lorazepam
Pramipexole
Risperidone
Rivastigmine
Ropinirole
Tier 1
Apokyn DSN
Comtan
FazaClo
Nuedexta
Olanzapine Tablet SL
Olanzapine/Fluoxetine SL
Quetiapine SL
Tasmar
Xyrem N SL
Ziprasidone SL
Tier 2
Abilify
1
/2T SL
Aricept 23 mg E
Exelon Solution
Fanapt SL
Geodon SL
Invega SL
Mirapex ER E
Modanil E N SL
Namenda
Nuvigil N SL
Olanzapine Rapid Dissolve Tablet SL
Provigil E N SL
Requip XL E
Ropinirole Extended-Release 24 Hour Tablet E
Seroquel SL
Seroquel XR SL
Symbyax SL
Zyprexa SL
Zyprexa Zydis SL
Tier 3
9 Visit www.myuhc.com for updates 2013 Prescription Drug List Advantage Three-Tier
Please refer to page 3 for a denition of notations/symbols.
Dermatology
Alclometasone Dipropionate
Betamethasone Dipropionate
Betamethasone Valerate
Ciclopirox Cream, Gel, Lotion
Ciclopirox Non-Oral Solution
Clindamycin Gel, Lotion, Solution, Swabs
Clobetasol Propionate
Clotrimazole/Betamethasone
Desonide
Desoximetasone
Econazole Nitrate
Erythromycin
Erythromycin/Benzoyl Peroxide
Fluocinolone
Fluocinonide
Fluticasone Propionate
Halobetasol Propionate
Hydrocortisone
Hydrocortisone Valerate
Ketoconazole
Lidocaine
Metronidazole Gel 0.75%
Mometasone Furoate
Mupirocin
Nystatin
Nystatin/Triamcinolone Acetonide
Permethrin
Silver Sulfadiazine
Sulfacetamide Sodium/Sulfur
Tretinoin N
Triamcinolone Acetonide
Urea
Tier 1
Azelex SL
Benzaclin Gel 1%-5% 25 g SL
Benzamycin
Calcipotriene Cream, Ointment SL
Ciclopirox Shampoo 1% MC
Differin Cream, Gel 0.1% N SL
Imiquimod SL
Isotretinoin
Oxsoralen-Ultra
Protopic N SL
Regranex N
Stelara DSN N SL
Tier 2
Acanya SL
Aczone SL
Adapalene N SL
Altabax SL
Atralin MC N SL
Avita Gel N SL
Bactroban SL
Benzaclin Gel 1%-5% SL
Clindagel E SL
Clindamycin Foam 1% SL
Clindamycin Phosphate/Benzoyl Peroxide
Extended-Release Gel E SL
Clindamycin Phosphate/Benzoyl Peroxide Gel
1%-5% SL
Clobetasol Propionate Foam SL
Clobetasol Propionate Lotion SL
Clobetasol Propionate Shampoo E SL
Clobex SL
Clobex Shampoo E SL
Condylox Gel
Cutivate Lotion MC
Denavir
Desonate SL
Differin Gel 0.3% N SL
Differin Lotion N SL
Dovonex SL
Duac E SL
Elidel N SL
Epiduo E SL
Evoclin SL
Finacea
Finacea Plus
Fluticasone Propionate Lotion MC
Locoid Lipocream SL
Locoid Lotion SL
Loprox Shampoo MC
Metrogel 1% E MC
Metrolotion
Naftin
Noritate MC
Olux-E SL
Oxistat
Retin-A Micro N SL
Taclonex SL
Taclonex Scalp SL
Tazorac N SL
Tretin-X N SL
Vanos SL
Vectical SL
Veltin E SL
Verdeso SL
Vusion MC
Xerese E
Xolegel MC
Ziana E SL
Zovirax SL
Zyclara E SL
Tier 3
Diabetes/Endocrine Blood Glucose Monitoring
Accu-Chek Active Test Strips SL
Accu-Chek Aviva Plus
Accu-Chek Aviva Plus Test Strips SL
Accu-Chek Comfort Curve Test Strips SL
Accu-Chek Compact Test Strips SL
Accu-Chek Nano SmartView
Accu-Chek SmartView Test Strip SL
One Touch Test Strips SL
One Touch Ultra 2 System
One Touch Ultra Mini System
One Touch Ultra Test Strips SL
One Touch Verio IQ System
One Touch Verio IQ Test Strips SL
Tier 1
Ascensia Autodisc Test Strips SDP SL
Ascensia Breeze 2 Test Strips SDP SL
Contour Test Strips SDP SL
Freestyle Lite Test Strips SDP SL
Freestyle Test Strips SDP SL
Precision Xtra Test Strips SDP SL
Tier 3
Diabetes/Endocrine Insulin
Humalog Vials
Humalog-Mix Vials
Humulin 70-30 Vials
Humulin Vials
Tier 1
Humalog KwikPen
Humalog-Mix KwikPen
Humulin KwikPen
Lantus Vials
Levemir Vials
Tier 2
Apidra Solostar SDP
Apidra Vial SDP
Lantus Solostar Pens/Cartridges
Levemir Flexpen
Novolin Vials SDP
NovoLog SDP
Tier 3
10 Visit www.myuhc.com for updates 2013 Prescription Drug List Advantage Three-Tier
Please refer to page 3 for a denition of notations/symbols.
Diabetes/Endocrine Non-Insulin
Acarbose
Glimepiride
Glipizide
Glyburide
Glyburide/Metformin
Metformin
Tier 1
Byetta SL
Duetact SL
Glipizide/Metformin
Glyset
Jentadueto SL
Kombiglyze XR SL
Nateglinide SL
Onglyza SL
Pioglitazone
1
/2T SL
Pioglitazone/Metformin SL
Prandin SL
Tradjenta SL
Tier 2
Actoplus Met SL
Actoplus Met XR SDP SL
Actos
1
/2T SL
Avandamet SL
Avandaryl SL
Avandia SL
Fortamet
Glumetza
Janumet SDP SL
Janumet XR SDP SL
Januvia SDP SL
Juvisync SDP SL
Metformin Extended-Release 24 Hour Tablet
Symlin SL
Victoza SL
Tier 3
Endocrine Growth Hormone
Nutropin, AQ, NuSpin DSN N SL
Saizen DSN N SL
Serostim DSN N SL
Tev-Tropin DSN N SL
Tier 2
Genotropin DSN E N SL
Humatrope DSN E N SL
Norditropin DSN E N SL
Omnitrope DSN E N SL
Zorbtive DSN N SL
Tier 3
Eye Conditions Allergies
Ketorolac Tromethamine
Tier 1
Azelastine HCl SL
Bepreve E SL
Elestat E SL
Emadine E
Epinastine E SL
Lastacaft SL
Optivar E SL
Pataday E SL
Patanol E SL
Tier 3
Endocrine Other
Calcitriol
Desmopressin
Dexamethasone
Fludrocortisone
Hydrocortisone Tablet
Levothyroxine Sodium
Methimazole
Methylprednisolone Dosepak Tablet 4 mg
Octreotide Acetate DSN N
Orapred
Prednisolone
Prednisone
Testosterone
Tier 1
Androderm SL
Android
Cabergoline
Hectorol
Kuvan DSN N SL
Levoxyl
Liothyronine Sodium
Medrol 2, 8, 24, 32 mg
Oxandrolone
Pediapred
Synarel
Synthroid
Testim SL
Tirosint
Zemplar DSN
Tier 2
Androgel E SL
Armour Thyroid
Axiron E SL
Fortesta E SL
Orapred ODT
Tier 3
Eye Conditions Antibiotics
Ciprooxacin
Erythromycin
Gentamicin Sulfate
Levooxacin
Neomycin/Polymyxin B Sulfate/Dexamethasone
Ooxacin
Polymyxin B Sulfate/Trimethoprim
Sulfacetamide Sodium
Tobramycin Sulfate Drops
Tier 1
Blephamide S.O.P. Tobramycin/Dexamethasone
Tier 2
Azasite SL
Moxeza
Tobradex ST E SL
Vigamox
Zylet
Zymaxid SL
Tier 3
11 Visit www.myuhc.com for updates 2013 Prescription Drug List Advantage Three-Tier
Please refer to page 3 for a denition of notations/symbols.
Eye Conditions Glaucoma
Acetazolamide
Apraclonidine
Dorzolamide HCl
Latanoprost SL
Timolol Maleate
Tier 1
Alphagan P 0.1% SL
Azopt SL
Betimol SL
Brimonidine Tartrate SL
Combigan SL
Dorzolamide HCl/Timolol Maleate
Lumigan SL
Pilopine HS
Travatan Z SL
Tier 2
Iopidine 1%
Tier 3
Gastrointestinal Acid Suppression
Cimetidine
Misoprostol
Omeprazole
Pantoprazole
Ranitidine Syrup
Sucralfate Tablet
Tier 1
Helidac
Nizatidine Oral Solution
Prevpac SL
Pylera
Tier 2
Aciphex SL
Carafate Oral Suspension
Dexilant SL
Lansoprazole E SL
Nexium Capsule E SL
Nexium Suspension
Omeprazole/Sodium Bicarbonate Capsule E SL
Prevacid Delayed-Release Enteric-Coated
Capsule E SL
Prevacid Solutab E SL
Prilosec Rx 10, 20 mg E
Prilosec Rx 40 mg E
Protonix Granules SL
Zegerid Capsule E SL
Zegerid Packet SL
Tier 3
Gastrointestinal Nausea/Vomiting
Ondansetron Prochlorperazine Maleate
Tier 1
Emend SL Granisetron Tablet SL
Tier 2
Anzemet SL
Cesamet
Sancuso E SL
Transderm-Scop
Zuplenz E SL
Tier 3
Gastrointestinal Other
Balsalazide
Belladonna/Phenobarbital
Chlordiazepoxide/Clidinium
Diphenoxylate/Atropine
Lactulose
Mesalamine
Metoclopramide
Polyethylene Glycol
Sulfasalazine
Trilyte with Flavor Packets
Ursodiol
Tier 1
Apriso
Budesonide Extended-Release 24 Hour Capsule
Canasa
Creon
GoLYTELY Packet
Lialda
Lotronex SL
Relistor
Zenpep
Tier 2
Amitiza N SL
Asacol SDP
Asacol HD E SDP
Dipentum
Halytely-Bisacodyl
Metozolv ODT E
Moviprep
Pancreaze SDP
Pentasa
Tier 3
Mens Health Erectile Dysfunction
Caverject SL
Cialis SL
Edex SL
Levitra SL
Muse SL
Staxyn E SL
Viagra SL
Tier 3
12 Visit www.myuhc.com for updates 2013 Prescription Drug List Advantage Three-Tier
Please refer to page 3 for a denition of notations/symbols.
Miscellaneous Overactive Bladder
Miscellaneous
Musculoskeletal Osteoporosis
Anastrozole
Antipyrine/Benzocaine
Azathioprine
Benzonatate
Chlorhexidine Gluconate
Letrozole
Megestrol Acetate
Mycophenolate Capsule, Tablet DSN
Phenazopyridine
Tacrolimus DSN
Tamoxifen
Tier 1
Cellcept Suspension DSN
Epipen SL
Epipen Jr SL
Exemestane
Fareston
Lidoderm SL
Lysteda SL
Myfortic DSN
Neoral DSN
Pegasys DSN N SL
Rapamune DSN
Sandimmune DSN
Tier 2
Acuvail E SL
Aromasin
Bromday E SL
Bromfenac SL
Hydrocodone/Chlorpheniramine Suspension SL
Infergen DSN N SL
Intron A DSN N
Peg-Intron DSN N SL ST
Restasis N SL
Tussionex SL
Tier 3
Dicyclomine Tablet
Hyoscyamine Sulfate
Oxybutynin
Trospium
Tier 1
Gelnique
Oxytrol
Sanctura XR
Vesicare
Tier 2
Detrol
Detrol LA E
Enablex
Tolterodine
Toviaz SDP
Tier 3
Alendronate SL
Tier 1
Calcitonin Salmon Nasal Spray
Evista
Forteo DSN N
Fortical
Ibandronate Tablet SL
Tier 2
Actonel SL Atelvia E SL Fosamax Plus D SL
Tier 3
Musculoskeletal Pain Relief
Acetaminophen/Butalbital/Caffeine/Codeine SL
Acetaminophen/Codeine SL
Acetaminophen/Hydrocodone Bit SL
Acetaminophen/Oxycodone SL
Aspirin/Butalbital/Caffeine/Codeine
Aspirin/Oxycodone
Diclofenac Potassium
Diclofenac Sodium
Duragesic SL
Etodolac
Hydromorphone
Ibuprofen
Ibuprofen/Hydrocodone
Ibuprofen/Oxycodone
Indomethacin
Ketorolac Tromethamine
Meloxicam
Meperidine
Methadone
Morphine Sulfate
Morphine Sulfate Sustained-Action Tablet SL
Nabumetone
Naproxen
Naproxen Sodium
Oxaprozin
Oxycodone
Piroxicam
Sulindac
Tramadol
Tramadol/Acetaminophen SL
Tier 1
Mens Health Prostate
Alfuzosin
Doxazosin
Finasteride
Tamsulosin
Terazosin
Tier 1
Avodart N SDP Jalyn E Rapao
Tier 3
13 Visit www.myuhc.com for updates 2013 Prescription Drug List Advantage Three-Tier
Please refer to page 3 for a denition of notations/symbols.
Acetaminophen/Hydrocodone Bit
7.5 - 325 mg/15 ml Oral Solution SL
Butorphanol Nasal Spray SL
Codeine Phosphate
Fentanyl Citrate Lollipop N SL
MSIR Capsule
Opana ER SL
OxyContin SL
Oxymorphone SL
Oxymorphone Extended-Release
12 Hour Tablet SL
Tolmetin Sodium
Tramadol Sustained-Release
24 Hour Tablet SL
Voltaren Gel
Tier 2
Abstral N SL
Arthrotec
Avinza SL
Celebrex SL
Conzip E SL
Duexis E SL
Embeda SL
Exalgo SL
Fentanyl Transdermal SL
Fentora E N SL
Flector E
Hycet SL
Kadian E SL
Lazanda N SL
Mefenamic Acid
Morphine Sulfate Extended-Release Pellets E SL
Naprelan E
Nucynta SL
Nucynta ER SL
Onsolis N SL
Opana SL
Pennsaid E
Rybix ODT E SL
Ryzolt E SL
Sprix SL
Tramadol Extended-Release Multiphase
24 Hour
Tablet E SL
Vimovo E SL
Zipsor E
Tier 3
Musculoskeletal Rheumatoid Arthritis
Azathioprine
Hydroxychloroquine Sulfate
Leunomide
Methotrexate
Sulfasalazine
Tier 1
Cimzia DSN N SL
Cuprimine
Enbrel DSN N SL
Simponi DSN N SL
Trexall
Tier 2
Humira DSN N SL ST Kineret DSN N SL Orencia DSN N SL
Tier 3
Musculoskeletal Pain Relief (cont. from page 12)
Musculoskeletal Other
Allopurinol
Baclofen
Carisoprodol 350 mg
Cyclobenzaprine
Methocarbamol
Tizanidine Tablet
Tier 1
Colcrys Orphenadrine Orphenadrine/Aspirin/Caffeine
Tier 2
Amrix E
Carisoprodol 250 mg E
Cyclobenzaprine Extended-Release
24 Hour Capsule E
Gralise E SL
Horizant E SL
Metaxalone
Savella SL
Skelaxin E
Soma 250 mg E
Tizanidine Capsule
Uloric SL
Tier 3
Respiratory Asthma/COPD
Albuterol Sulfate
Alvesco SL
Asmanex SL
Ipratropium Bromide
QVAR SL
Theophylline
Ventolin HFA SL
Zarlukast SL
Tier 1
Albuterol Sulfate/Ipratropium Non-Oral Solution
Budesonide Inhalation Suspension 0.25 mg/
2 ml, 0.5 mg/2 ml SL
Foradil SL
Montelukast SL
Pulmicort Respules 1 mg/2 ml SL
Spiriva SL
Tier 2
Advair Diskus RS SL
Advair HFA RS SL
Atrovent HFA SL
Combivent SL
Combivent Respimat SL
Daliresp N SL
Dulera RS SL
Flovent Diskus SDP SL
Flovent HFA SDP SL
Levalbuterol Vial, Nebulizer E SL
Maxair Autohaler SL
Perforomist SL
Proair HFA SL
Proventil HFA SL
Pulmicort Flexhaler SDP SL
Serevent Diskus SL
Singulair SL
Symbicort SDP SL
Xopenex HFA SL
Xopenex Vial, Nebulizer E SL
Tier 3
14 Visit www.myuhc.com for updates 2013 Prescription Drug List Advantage Three-Tier
Please refer to page 3 for a denition of notations/symbols.
Respiratory Nasal Allergies
Flunisolide Fluticasone Propionate SL
Tier 1
Nasonex SL
Tier 2
Astelin E SL
Astepro SL
Azelastine HCl SL
Beconase AQ SL
Nasacort AQ SL
Omnaris SL
Patanase SL
Rhinocort Aqua SL
Triamcinolone Acetonide SL
Veramyst E SL
Tier 3
Respiratory Oral Allergies
Cyproheptadine
Hydroxyzine
Levocetirizine Tablet SL
Promethazine
Tier 1
Clarinex E SL
Clarinex-D E SL
Desloratadine E SL
Levocetirizine Oral Solution SL
Tier 3
Womens Health Contraceptives
Apri
Altavera
Aranelle
Aviane
Caziant
Cryselle
Cyclafem 1/35
Ella SL
Emoquette
Enpresse
Gildess FE
Junel Fe
Kelnor
Leena
Lessina
Levora
Low-Ogestrel
Lutera
Marlissa
Medroxyprogesterone 150 mg/ml MC
Microgestin Fe
Myzilra
Natazia
Necon 0.5/35
Necon 1/35
Necon 1/50
Necon 10/11
Next Choice One Dose
Nortrel 0.5/35
Nortrel 1/35
Orsythia
Ortho Micronor
Ortho Tri-Cyclen
Ortho-Cyclen
Ortho-Novum 7/7/7
Plan B
Portia
Reclipsen
Sronyx
Trivora
Velivet
Yasmin
Zovia 1/35E
Zovia 1/50E
Tier 1
Azurette
Balziva
Briellyn
Depo-SubQ Provera MC
Introvale MC
Jolessa MC
Junel
Kariva
Microgestin
NuvaRing
Ogestrel
Philith
Quasense MC
Viorele
Yaz
Zenchent
Tier 2
Alyacen 7/7/7
Amethia MC
Amethia Lo MC
Amethyst
Beyaz E
Camila
Camrese MC
Camrese Lo MC
Cyclafem 7/7/7
Errin
Femcon Fe
Generess Fe E
Gianvi
Heather
Jolivette
Lo Loestrin Fe
Loestrin 24 Fe
Loryna
Mononessa
Necon 7/7/7
Nora-Be
Norethindrone
Nortrel 7/7/7
Ocella
Ortho Evra
Ortho Tri-Cyclen Lo
Previfem
Safyral E
Sprintec
Syeda
Tilia Fe
Tri-Legest Fe
Tri-Previfem
Tri-Sprintec
Trinessa
Vestura
Wymzya Fe
Zarah
Zenchent Fe
Zeosa
Tier 3
15 Visit www.myuhc.com for updates 2013 Prescription Drug List Advantage Three-Tier
Please refer to page 3 for a denition of notations/symbols.
Womens Health Estrogen/Progesterone
Womens Health Prenatal Vitamins
Estradiol
Estradiol Transdermal Weekly Patch SL
Estropipate
Medroxyprogesterone
Norethindrone Acetate
Tier 1
Cenestin
Climara SL
Crinone N
Divigel
Enjuvia
Estrace Cream with Applicator
Estradiol/Norethindrone Acetate
Estring MC SL
Evamist
Prefest
Progesterone Micronized Capsule
Vagifem
Vivelle-Dot SL
Tier 2
Activella
Alora SL
Climara Pro SL
Combipatch SL
Estrasorb SL
Estrogel SL
Femhrt
Femring MC SL
First-Progesterone N
Menostar Transdermal Weekly Patch SL
Premarin
Premphase
Prempro
Tier 3
Folic Acid
Multinatal Plus
Prenatal 19
Prenatal Advantage
Prenatal Plus
Tier 1
Advanced Care Plus
Cavan-EC Sod DHA
Multi-Nate 30
PR Natal 430
PR Natal 430 EC
Setonet
Setonet-EC
Tier 2
Brand Prenatal Vitamins
Folcal DHA
Taron A Prenatal
Zatean-PN
Zatean-PN DHA
Zatean-PN Plus
Tier 3
16 Visit www.myuhc.com for updates 2013 Prescription Drug List Advantage Three-Tier
Please refer to page 3 for a denition of notations/symbols.
Accolate SL (Zarlukast SL)
Accupril (Quinapril)
Acular (Ketorolac Tromethamine)
Adderall (Amphetamine/Dextroamphetamine Salt
Combination)
Aldactone (Spironolactone)
Altace (Ramipril)
Amaryl (Glimepiride)
Ambien SL ST (Zolpidem SL)
Amerge SL (Naratriptan SL)
Anaprox (Naproxen)
Aricept (Donepezil)
Arimidex (Anastrozole)
Ativan (Lorazepam)
Augmentin ES (Amoxicillin/Potassium
Clavulanate)
Biaxin Tablet (Clarithromycin Tablet)
Buspar (Buspirone)
Calan, Calan SR (Verapamil)
Cardizem CD except for 360 mg strength
(Diltiazem Sustained-Release
24 Hour Capsule)
Cardura (Doxazosin)
Ceftin (Cefuroxime)
Cefzil (Cefprozil)
Celexa (Citalopram)
Ciloxan Eye Drops (Ciprooxacin)
Cipro (Ciprooxacin)
Cleocin T (Clindamycin Gel, Lotion, Solution,
Swabs)
Clozaril (Clozapine)
Colazal (Balsalazide)
Colestid (Colestipol)
Coreg (Carvedilol)
Cozaar
1
/2T (Losartan
1
/2T)
DDAVP (Desmopressin)
Depakote (Divalproex Sodium Tablet)
Depakote ER ST (Divalproex Sodium
Sustained-Release 24 Hour Tablet)
Depo-Provera MC (Medroxyprogesterone
150 mg/ml MC)
Derma-Smoothe/FS (Fluocinolone)
DiaBeta, Glynase (Glyburide)
Diastat Acudial SL (Diazepam Rectal Gel SL)
Didronel (Etidronate Disodium)
Diucan (Fluconazole)
Ditropan XL (Oxybutynin Sustained-Release
Tablet)
Dyazide (Triamterene/Hydrochlorothiazide)
Effexor (Venlafaxine)
Effexor XR SL (Venlafaxine Sustained-Release
Capsule SL)
Felbatol (Felbamate)
Femara (Letrozole)
Fioricet SL (Acetaminophen/Butalbital/
Caffeine SL)
Flomax (Tamsulosin)
Flonase SL (Fluticasone Nasal Spray SL)
Fosamax SL
(Alendronate SL)
Glucophage, XR (Metformin)
Glucotrol, XL (Glipizide)
Glucovance (Glyburide/Metformin)
Hyzaar SL (Losartan/Hydrochlorothiazide SL)
Imitrex SL (Sumatriptan Succinate Injection,
Tablet SL)
Keex (Cephalexin)
Keppra ST (Levetiracetam)
Klonopin (Clonazepam)
Lamictal ST (Lamotrigine)
Lamisil SL (Terbinane Tablet SL)
Lasix (Furosemide)
Levaquin (Levooxacin)
Lipitor
1
/2T E SL (Atorvastatin
1
/2T SL)
Lopid (Gembrozil)
Lopressor (Metoprolol)
Mavik
1
/2T (Trandolapril
1
/2T)
Medrol (Methylprednisolone Dosepak
Tablet 4 mg)
Metrogel Vaginal (Metronidazole)
Mevacor (Lovastatin)
Mobic (Meloxicam)
Monopril (Fosinopril)
Naprosyn (Naproxen) - Prescription strengths
only
Nardil (Phenelzine)
Neurontin (Gabapentin)
Norvasc (Amlodipine)
Ocuox Eye Drops (Ooxacin)
Paxil (Paroxetine)
Penlac (Ciclopirox Solution, Non-Oral)
Percocet 5-325, 7.5-500, 10-650 SL
(Acetaminophen/Oxycodone SL)
Plavix (Clopidogrel)
Pletal (Cilostazol)
Pravachol
1
/2T (Pravastatin
1
/2T)
Precose (Acarbose)
Prilosec (Omeprazole)
Prinivil, Zestril (Lisinopril)
Prinzide, Zestoretic (Lisinopril/
Hydrochlorothiazide)
Procardia XL (Nifedipine Extended-Release
Tablet)
Proscar (Finasteride)
Protonix (Pantoprazole)
Provera (Medroxyprogesterone)
Prozac (Fluoxetine Capsule)
Prozac Weekly SL (Fluoxetine Delayed-Release
Capsule SL)
Remeron (Mirtazapine)
Remeron SolTab (Mirtazapine Dispersible Tablet)
Requip (Ropinirole)
Restoril (Temazepam)
Risperdal (Risperidone)
Ritalin (Methylphenidate)
Ritalin SR (Methylphenidate Extended-Release
Tablet)
Sonata ST SL (Zaleplon SL)
Surmontil (Trimipramine Maleate)
Tenoretic (Atenolol/Chlorthalidone)
Tenormin (Atenolol)
Teveten SL (Eprosartan SL)
Tiazac (Diltiazem)
Topamax ST (Topiramate)
Toprol XL 25 mg (Metoprolol Succinate
Sustained-Release Tablet)
Trileptal (Oxcarbazepine)
Trusopt (Dorzolamide Eye Drops)
Tylenol #3 SL (Acetaminophen/Codeine SL)
Ultracet SL (Tramadol/Acetaminophen SL)
Ultram (Tramadol)
Uroxatral (Alfuzosin)
Valium (Diazepam)
Vaseretic (Enalapril/Hydrochlorothiazide)
Vasotec (Enalapril)
Vfend SL (Voriconazole SL)
Vicodin SL, Vicodin ES SL (Acetaminophen/
Hydrocodone SL)
Vicoprofen (Ibuprofen/Hydrocodone)
Voltaren Tablet (Diclofenac)
Wellbutrin (Bupropion HCl)
Wellbutrin SR (Bupropion HCl Sustained-Action
Tablet)
Wellbutrin XL (Bupropion HCl Sustained-Release
24 Hour Tablet)
Xalatan SL (Latanoprost SL)
Xanax, Xanax XR (Alprazolam)
Zantac Syrup (Ranitidine Syrup)
Ziac (Bisoprolol/Hydrochlorothiazide)
Zithromax (Azithromycin)
Zocor
1
/2T (Simvastatin
1
/2T)
Zofran (Ondansetron)
Zoloft
1
/2T (Sertraline
1
/2T)
Zonegran (Zonisamide)
Zovirax (Acyclovir Capsule, Suspension, Tablet)
Additional Tier 3 Drugs with a generic equivalent in Tier 1
17 Visit www.myuhc.com for updates 2013 Prescription Drug List Advantage Three-Tier
Index
A
Abilify 8
Abstral 13
Acanya 9
Acarbose 10, 16
Accolate 16
Accu-Chek Active Test Strips 9
Accu-Chek Aviva Plus 9
Accu-Chek Aviva Plus Test Strips 9
Accu-Chek Comfort Curve Test Strips 9
Accu-Chek Compact Test Strips 9
Accu-Chek Nano SmartView 9
Accu-Chek SmartView Test Strip 9
Accupril 16
Aceon 6
Acetaminophen/Butalbital/Caffeine 7, 12, 16
Acetaminophen/Butalbital/Caffeine/Codeine 12
Acetaminophen/Codeine 12, 16
Acetaminophen/Dichloralphenazone/
Isometheptene Mucate 7
Acetaminophen/Hydrocodone 12-13, 16
Acetaminophen/Hydrocodone Bit 12-13
Acetaminophen/Hydrocodone Bit 7.5 - 325 mg/
15 ml Oral Solution 13
Acetaminophen/Oxycodone 12, 16
Acetazolamide 11
Aciphex 11
Activella 15
Actonel 12
Actoplus Met 10
Actoplus Met XR 10
Actos 10
Acular 16
Acuvail 12
Acyclovir 5, 16
Acyclovir Capsule, Suspension, Tablet 16
Aczone 9
Adapalene 9
Adderall 7, 16
Adderall XR 7
Adoxa 5
Advair Diskus 13
Advair HFA 13
Advanced Care Plus 15
Advicor 6
Aggrenox 5
Albuterol Sulfate 13
Albuterol Sulfate/Ipratropium Non-Oral
Solution 13
Alclometasone Dipropionate 9
Aldactazide 50-50 mg 6
Aldactone 16
Alendronate 12, 16
Alfuzosin 12, 16
Allopurinol 13
Alora 15
Alphagan P 0.1% 11
Alprazolam 8, 16
Alsuma 7
Altabax 9
Altace 16
Altavera 14
Altoprev 6
Alvesco 13
Alyacen 7/7/7 14
Amantadine 5
Amaryl 16
Ambien 8, 16
Ambien CR 8
Amerge 16
Amethia 14
Amethia Lo 14
Amethyst 14
Amiodarone 7
Amitiza 11
Amitriptyline 7
Amlodipine 6, 16
Amlodipine/Atorvastatin 6
Amlodipine/Benazepril 6
Amoxicillin 5, 16
Amoxicillin-Clavulanate ER 5
Amoxicillin/Potassium Clavulanate 5, 16
Amphetamine/Dextroamphetamine
Salt Combination 16
Amphetamine Aspartate/Amphetamine Sulfate/
Dextroamphetamine Sustained-Release
24 Hour Capsule 7
Amphetamine Salt Combo 7
Ampicillin 5
Ampyra 8
Amrix 13
Amturnide 6
Anaprox 16
Anastrozole 12, 16
Androderm 10
Androgel 10
Android 10
Antara 6
Antipyrine/Benzocaine 12
Anzemet 11
Apidra Solostar 9
Apidra Vial 9
Aplenzin 7
Apokyn 8
Apraclonidine 11
Apri 14
Apriso 11
Aranelle 14
Aricept 8, 16
Aricept 23 mg 8
Arimidex 16
Armour Thyroid 10
Aromasin 12
Arthrotec 13
Asacol 11
Asacol HD 11
Ascensia Autodisc Test Strips 9
Ascensia Breeze 2 Test Strips 9
Asmanex 13
Aspirin/Butalbital/Caffeine 7, 12
Aspirin/Butalbital/Caffeine/Codeine 12
Aspirin/Oxycodone 12
Astelin 14
Astepro 14
Atacand 6
Atacand HCT 6
Atelvia 12
Atenolol 6, 16
Atenolol/Chlorthalidone 6, 16
Ativan 16
Atorvastatin 6, 16
Atralin 9
Atrovent HFA 13
Augmentin 5, 16
Augmentin ES 16
Augmentin XR 5
Avalide 6
Avandamet 10
Avandaryl 10
Avandia 10
Avapro 6
Avelox 5
Aviane 14
Avinza 13
Avita Gel 9
Avodart 12
Avonex 8
Axert 7
Axiron 10
Azasite 10
Azathioprine 12-13
Azelastine HCl 10, 14
Azelex 9
Azithromycin 5, 16
Azopt 11
Azor 6
Azurette 14
B
Baclofen 13
Bactroban 9
Balsalazide 11, 16
Balziva 14
Baraclude 5
Beconase AQ 14
Belladonna/Phenobarbital 11
Benazepril 6
Benazepril/Hydrochlorothiazide 6
Benicar 6
Benicar HCT 6
Benzaclin Gel 1%-5% 9
Benzaclin Gel 1%-5% 25 g 9
Benzamycin 9
Benzonatate 12
Benztropine Mesylate 8
Bepreve 10
Betamethasone Dipropionate 9
Betamethasone Valerate 9
Betaseron 8
Betimol 11
Beyaz 14
Biaxin Tablet 16
BiDil 6
Bisoprolol 6, 16
Bisoprolol/Hydrochlorothiazide 6, 16
Blephamide S.O.P. 10
Brand Prenatal Vitamins 15
Briellyn 14
Brimonidine Tartrate 11
Bromday 12
Bromfenac 12
Budesonide Extended-Release
24 Hour Capsule 11
Budesonide Inhalation Suspension
0.25 mg/2 ml, 0.5 mg/2 ml 13
Bumetanide 6
Bupropion 7, 16
Bupropion HCl 16
Bupropion HCl Sustained-Action Tablet 16
Bupropion HCl Sustained-Release
24 Hour Tablet 16
Bupropion XL 7
Buspar 16
Buspirone 8, 16
Butorphanol Nasal Spray 13
Byetta 10
Bystolic 6
C
Cabergoline 10
Caduet 6
Cafergot 7
Calan, Calan SR 16
Calcipotriene Cream, Ointment 9
Calcitonin Salmon Nasal Spray 12
Calcitriol 10
Cambia 7
Camila 14
Camrese 14
Camrese Lo 14
Canasa 11
Captopril 6
Captopril/Hydrochlorothiazide 6
Carafate Oral Suspension 11
Carbamazepine 8
Carbamazepine Extended-Release
12 Hour Capsule 8
Carbamazepine Sustained-Release
12 Hour Tablet 8
Carbatrol 8
18 Visit www.myuhc.com for updates 2013 Prescription Drug List Advantage Three-Tier
Carbidopa/Levodopa 8
Cardizem CD except for 360 mg strength 16
Cardizem LA 120 mg 6
Cardizem LA 180, 240, 300, 360, 420 mg 6
Cardura 16
Carisoprodol 250 mg 13
Carisoprodol 350 mg 13
Carvedilol 6, 16
Cavan-EC Sod DHA 15
Caverject 11
Cayston 5
Caziant 14
Cefadroxil 5
Cefdinir 5
Cefprozil 5, 16
Ceftin 16
Cefuroxime 5, 16
Cefzil 16
Celebrex 13
Celexa 16
Cellcept Suspension 12
Celontin 8
Cenestin 15
Cephalexin 5, 16
Cesamet 11
Cetraxal 5
Chlordiazepoxide/Clidinium 11
Chlorhexidine Gluconate 12
Chlorthalidone 6, 16
Cholestyramine 6
Cialis 11
Ciclopirox Cream, Gel, Lotion 9
Ciclopirox Non-Oral Solution 9
Ciclopirox Shampoo 1% 9
Ciclopirox Solution, Non-Oral 16
Cilostazol 5, 16
Ciloxan Eye Drops 16
Cimetidine 11
Cimzia 13
Cipro 5, 16
Cipro HC 5
Cipro Suspension 5
Ciprodex Otic 5
Ciprooxacin 5, 10, 16
Ciprooxacin Sustained-Release 24 Hour Tablet 5
Ciprooxacin Tablet 5
Citalopram 7, 16
Citalopram Hydrobromide 7
Clarinex 14
Clarinex-D 14
Clarithromycin Suspension 5
Clarithromycin Sustained-Release Tablet 5
Clarithromycin Tablet 5, 16
Cleocin HCl 75 mg 5
Cleocin T 16
Climara 15
Climara Pro 15
Clindagel 9
Clindamycin Foam 1% 9
Clindamycin Gel, Lotion, Solution, Swabs 9, 16
Clindamycin HCl 5
Clindamycin Palmitate 5
Clindamycin Phosphate/Benzoyl Peroxide
Extended-Release Gel 9
Clindamycin Phosphate/Benzoyl Peroxide
Gel 1%-5% 9
Clindesse Vaginal 5
Clobetasol Propionate 9
Clobetasol Propionate Foam 9
Clobetasol Propionate Lotion 9
Clobetasol Propionate Shampoo 9
Clobex 9
Clobex Shampoo 9
Clonazepam 8, 16
Clonidine 6
Clonidine Transdermal Weekly Patch 6
Clopidogrel 5, 16
Clorpres 6
Clotrimazole 5, 9
Clotrimazole/Betamethasone 9
Clozapine 8, 16
Clozaril 16
Codeine Phosphate 13
Colazal 16
Colcrys 13
Colestid 16
Colestipol 6, 16
Combigan 11
Combipatch 15
Combivent 13
Combivent Respimat 13
Comtan 8
Concerta 7
Condylox Gel 9
Contour Test Strips 9
Conzip 13
Copaxone 8
Coreg 6, 16
Coreg CR 6
Coumadin 5
Cozaar 16
Creon 11
Crestor 6
Crinone 15
Cryselle 14
Cuprimine 13
Cutivate Lotion 9
Cyclafem 1/35 14
Cyclafem 7/7/7 14
Cyclobenzaprine 13
Cyclobenzaprine Extended-Release
24 Hour Capsule 13
Cymbalta 7
Cyproheptadine 14
D
Daliresp 13
Dapsone 5
Daytrana 7
DDAVP 16
Denavir 9
Depakote 8, 16
Depakote ER 8, 16
Depo-Provera 16
Depo-SubQ Provera 14
Derma-Smoothe/FS 16
Desloratadine 14
Desmopressin 10, 16
Desonate 9
Desonide 9
Desoximetasone 9
Detrol 12
Detrol LA 12
Dexamethasone 10
Dexilant 11
Dextroamphetamine Sulfate 7
DiaBeta 16
Diastat Acudial 16
Diazepam 8, 16
Diazepam Rectal Gel 8, 16
Dibenzyline 6
Diclofenac 12, 16
Diclofenac Potassium 12
Diclofenac Sodium 12
Dicloxacillin Sodium 5
Dicyclomine Tablet 12
Didronel 16
Differin Cream, Gel 0.1% 9
Differin Gel 0.3% 9
Differin Lotion 9
Diucan 16
Digoxin 7
Dilantin 8
Diltiazem 6, 16
Diltiazem Controlled-Release Capsule 6
Diltiazem Sustained-Action Capsule 6
Diltiazem Sustained-Release 12 Hour Capsule 6
Diltiazem Sustained-Release
24 Hour Capsule 6, 16
Diltiazem Sustained-Release
24 Hour Tablet 6
Diovan 6
Diovan HCT 6
Dipentum 11
Diphenoxylate/Atropine 11
Ditropan XL 16
Diuril Suspension 250 mg/5 ml 6
Divalproex Sodium Sprinkle Capsule 8
Divalproex Sodium Sustained-Release
24 Hour Tablet 16
Divalproex Sodium Sustained-Release Tablet 8
Divalproex Sodium Tablet 8, 16
Divigel 15
Donepezil 8, 16
Donepezil 5, 10 mg 8
Doryx 5
Dorzolamide Eye Drops 16
Dorzolamide HCl 11
Dorzolamide HCl/Timolol Maleate 11
Dovonex 9
Doxazosin 6, 12, 16
Doxepin 7
Doxycycline Hyclate Enteric-Coated Tablet 5
Doxycycline Monohydrate 5
Doxycycline Monohydrate Capsule 150 mg 5
Duac 9
Duetact 10
Duexis 13
Dulera 13
Duragesic 12
Dutoprol 6
Dyazide 16
E
Econazole Nitrate 9
Edarbi 6
Edarbyclor 6
Edex 11
Edluar 8
Effexor 16
Effexor XR 16
Efent 5
Elestat 10
Elidel 9
Ella 14
Emadine 10
Embeda 13
Emend 11
Emoquette 14
Enablex 12
Enalapril 6, 16
Enalapril/Hydrochlorothiazide 6, 16
Enbrel 13
Enjuvia 15
Enoxaparin 5
Enpresse 14
Epiduo 9
Epinastine 10
Epipen 12
Epipen Jr 12
Epivir HBV 5
Eplerenone 6
Eprosartan 6, 16
Ergomar 7
Errin 14
Ery-Tab 500 mg 5
Erythromycin 5, 9-10
Erythromycin/Benzoyl Peroxide 9
Erythromycin Base Enteric-Coated Tablet 5
Escitalopram 7
Estrace Cream with Applicator 15
Estradiol 15
Estradiol/Norethindrone Acetate 15
Estradiol Transdermal Weekly Patch 15
Estrasorb 15
Estring 15
19 Visit www.myuhc.com for updates 2013 Prescription Drug List Advantage Three-Tier
Estrogel 15
Estropipate 15
Etidronate Disodium 16
Etodolac 12
Evamist 15
Evista 12
Evoclin 9
Exalgo 13
Exelon Solution 8
Exemestane 12
Exforge 6
Exforge HCT 6
Extavia 8
F
Famciclovir 5
Fanapt 8
Fareston 12
FazaClo 8
Felbamate 8, 16
Felbatol 16
Felodipine 6
Femara 16
Femcon Fe 14
Femhrt 15
Femring 15
Fenobrate 6
Fenobric Acid 6
Fenoglide 6
Fentanyl Citrate Lollipop 13
Fentanyl Transdermal 13
Fentora 13
Finacea 9
Finacea Plus 9
Finasteride 12, 16
Fioricet 16
First-Progesterone 15
Flecainide Acetate 7
Flector 13
Flomax 16
Flonase 16
Flovent Diskus 13
Flovent HFA 13
Fluconazole 5, 16
Fludrocortisone 10
Flunisolide 14
Fluocinolone 9, 16
Fluocinonide 9
Fluoxetine 7-8, 16
Fluoxetine Capsule 16
Fluoxetine Delayed-Release Capsule 7, 16
Fluticasone Nasal Spray 16
Fluticasone Propionate 9, 14
Fluticasone Propionate Lotion 9
Fluvastatin 6
Fluvoxamine Maleate 7
Focalin XR 7
Folcal DHA 15
Folic Acid 15
Fondaparinux 5
Foradil 13
Fortamet 10
Forteo 12
Fortesta 10
Fortical 12
Fosamax 12, 16
Fosamax Plus D 12
Fosinopril 16
Fragmin 5
Freestyle Lite Test Strips 9
Freestyle Test Strips 9
Frova 7
Furosemide 6, 16
G
Gabapentin 8, 16
Gabitril 8
Galantamine 8
Gelnique 12
Gembrozil 6, 16
Generess Fe 14
Genotropin 10
Gentamicin Sulfate 10
Geodon 8
Gianvi 14
Gildess FE 14
Gilenya 8
Glimepiride 10, 16
Glipizide 10, 16
Glipizide/Metformin 10
Glucophage, XR 16
Glucotrol, XL 16
Glucovance 16
Glumetza 10
Glyburide 10, 16
Glyburide/Metformin 10, 16
Glynase 16
Glyset 10
GoLYTELY Packet 11
Gralise 13
Granisetron Tablet 11
Guanfacine 6
Gynazole-1 Vaginal 5
H
Halytely-Bisacodyl 11
Halobetasol Propionate 9
Heather 14
Hectorol 10
Helidac 11
Hepsera 5
Horizant 13
Humalog-Mix KwikPen 9
Humalog-Mix Vials 9
Humalog KwikPen 9
Humalog Vials 9
Humatrope 10
Humira 13
Humulin 70-30 Vials 9
Humulin KwikPen 9
Humulin Vials 9
Hycet 13
Hydralazine 6
Hydrochlorothiazide 6, 16
Hydrocodone/Chlorpheniramine Suspension 12
Hydrocortisone 9-10
Hydrocortisone Tablet 10
Hydrocortisone Valerate 9
Hydromorphone 12
Hydroxychloroquine Sulfate 13
Hydroxyzine 14
Hyoscyamine Sulfate 12
Hyzaar 16
I
Ibandronate Tablet 12
Ibuprofen 12, 16
Ibuprofen/Hydrocodone 12, 16
Ibuprofen/Oxycodone 12
Imiquimod 9
Imitrex 16
Incivek 5
Indomethacin 12
Infergen 12
Innohep 5
Intron A 12
Introvale 14
Intuniv 7
Invega 8
Iopidine 1% 11
Ipratropium Bromide 13
Irbesartan 6
Irbesartan/Hydrochlorothiazide 6
Isosorbide Dinitrate 7
Isosorbide Mononitrate 7
Isotretinoin 9
Itraconazole Capsule 5
J
Jalyn 12
Janumet 10
Janumet XR 10
Januvia 10
Jentadueto 10
Jolessa 14
Jolivette 14
Junel 14
Junel Fe 14
Juvisync 10
K
Kadian 13
Kapvay 7
Kariva 14
Keex 16
Kelnor 14
Keppra 8, 16
Keppra XR 8
Ketoconazole 5, 9
Ketoconazole Foam 5
Ketorolac Tromethamine 10, 12, 16
Kineret 13
Klonopin 16
Kombiglyze XR 10
Kuvan 10
L
Labetalol 6
Lactulose 11
Lamictal 8, 16
Lamictal Dose Pack 8
Lamictal ODT 8
Lamictal XR 8
Lamisil 5, 16
Lamisil Granules 5
Lamotrigine 8, 16
Lanoxin 7
Lansoprazole 11
Lantus Solostar Pens/Cartridges 9
Lantus Vials 9
Lasix 16
Lastacaft 10
Latanoprost 11, 16
Lazanda 13
Leena 14
Leunomide 13
Lescol XL 6
Lessina 14
Letrozole 12, 16
Levalbuterol Vial, Nebulizer 13
Levaquin 16
Levemir Flexpen 9
Levemir Vials 9
Levetiracetam 8, 16
Levetiracetam Extended-Release 24 Hour Tablet 8
Levitra 11
Levocetirizine Oral Solution 14
Levocetirizine Tablet 14
Levooxacin 5, 10, 16
Levora 14
Levothyroxine Sodium 10
Levoxyl 10
Lexapro 7
Lialda 11
Lidocaine 9
Lidoderm 12
Liothyronine Sodium 10
Lipitor 6, 16
Lipofen 6
Lisinopril 6, 16
Lisinopril/Hydrochlorothiazide 6, 16
Lithium Carbonate 8
Lithium Carbonate Controlled-Release Tablet 8
Livalo 6
Lo Loestrin Fe 14
Locoid Lipocream 9
Locoid Lotion 9
Loestrin 24 Fe 14
Lopid 16
Lopressor 16
Loprox Shampoo 9
20 Visit www.myuhc.com for updates 2013 Prescription Drug List Advantage Three-Tier
Lorazepam 8, 16
Loryna 14
Losartan 6, 16
Losartan/Hydrochlorothiazide 6, 16
Lotronex 11
Lovastatin 6, 16
Lovaza 6
Low-Ogestrel 14
Lumigan 11
Lunesta 8
Lutera 14
Luvox CR 7
Lyrica 8
Lysteda 12
M
Macrodantin 25 mg 5
Marlissa 14
Mavik 16
Maxair Autohaler 13
Maxalt 7
Maxalt MLT 7
Medrol 10, 16
Medrol 2, 8, 24, 32 mg 10
Medroxyprogesterone 14-16
Medroxyprogesterone 150 mg/ml 14, 16
Mefenamic Acid 13
Megestrol Acetate 12
Meloxicam 12, 16
Menostar Transdermal Weekly Patch 15
Meperidine 12
Mesalamine 11
Metadate CD 7
Metaxalone 13
Metformin 10, 16
Metformin Extended-Release 24 Hour Tablet 10
Methadone 12
Methamphetamine 7
Methimazole 10
Methocarbamol 13
Methotrexate 13
Methylin Tablet 7
Methylphenidate 7, 16
Methylphenidate Extended-Release
24 Hour Tablet 7
Methylphenidate Extended-Release Capsule 7
Methylphenidate Extended-Release Tablet 16
Methylprednisolone Dosepak Tablet 4 mg 10, 16
Metoclopramide 11
Metolazone 6
Metoprolol 6, 16
Metoprolol/Hydrochlorothiazide 6
Metoprolol Succinate Sustained-Release
Tablet 6, 16
Metoprolol Succinate Sustained-Release
Tablet 25 mg 6
Metoprolol Succinate Sustained-Release
Tablet 50, 100, 200 mg 6
Metoprolol Tartrate 6
Metozolv ODT 11
Metrogel 1% 9
Metrogel Vaginal 16
Metrolotion 9
Metronidazole 5, 9, 16
Metronidazole Gel 0.75% 9
Metronidazole Vaginal 5
Mevacor 16
Mexiletine 7
Micardis 6
Micardis HCT 6
Microgestin 14
Microgestin Fe 14
Migranal 7
Minocycline Extended-Release 24 Hour Tablet 5
Minocycline HCl 5
Mirapex ER 8
Mirtazapine 7, 16
Mirtazapine Dispersible Tablet 16
Misoprostol 11
Mobic 16
Modanil 8
Moexipril 6
Mometasone Furoate 9
Mononessa 14
Monopril 16
Montelukast 13
Morphine Sulfate 12-13
Morphine Sulfate Extended-Release Pellets 13
Morphine Sulfate Sustained-Action Tablet 12
Moviprep 11
Moxeza 10
MSIR Capsule 13
Multaq 7
Multi-Nate 30 15
Multinatal Plus 15
Mupirocin 9
Muse 11
Mycophenolate Capsule, Tablet 12
Mycostatin 5
Myfortic 12
Mysoline 8
Myzilra 14
N
Nabumetone 12
Nadolol 6
Naftin 9
Namenda 8
Naprelan 13
Naprosyn - Prescription strengths only 16
Naproxen 12, 16
Naproxen - Prescription strengths only 16
Naproxen Sodium 12
Naratriptan 7, 16
Nardil 16
Nasacort AQ 14
Nasonex 14
Natazia 14
Nateglinide 10
Necon 0.5/35 14
Necon 1/35 14
Necon 1/50 14
Necon 10/11 14
Necon 7/7/7 14
Nefazodone 7
Neomycin/Polymyxin/HC Otic 5
Neomycin/Polymyxin B Sulfate/
Dexamethasone 10
Neoral 12
Neurontin 16
Nexiclon XR 6
Nexium Capsule 11
Nexium Suspension 11
Next Choice One Dose 14
Niaspan 6
Nifedipine 6, 16
Nifedipine Extended-Release Tablet 16
Nisoldipine 6
Nitrofurantoin/Nitrofurantoin Macrocrystal 5
Nitrofurantoin Macrocrystal 5
Nitrofurantoin Suspension 5
Nitroglycerin Spray 7
Nitroglycerin Transdermal Patch 7
Nitrolingual 7
Nitromist 7
Nitrostat 7
Nizatidine Oral Solution 11
Nora-Be 14
Norditropin 10
Norethindrone 14-15
Norethindrone Acetate 15
Noritate 9
Nortrel 0.5/35 14
Nortrel 1/35 14
Nortrel 7/7/7 14
Nortriptyline 7
Norvasc 16
Novolin Vials 9
NovoLog 9
Noxal 5
Nucynta 13
Nucynta ER 13
Nuedexta 8
Nutropin, AQ, NuSpin 10
NuvaRing 14
Nuvigil 8
Nystatin 5, 9
Nystatin/Triamcinolone Acetonide 9
O
Ocella 14
Octreotide Acetate 10
Ocuox Eye Drops 16
Ooxacin 5, 10, 16
Ooxacin Otic 5
Ogestrel 14
Olanzapine/Fluoxetine 8
Olanzapine Rapid Dissolve Tablet 8
Olanzapine Tablet 8
Oleptro 7
Olux-E 9
Omeprazole 11, 16
Omeprazole/Sodium Bicarbonate Capsule 11
Omnaris 14
Omnitrope 10
Ondansetron 11, 16
One Touch Test Strips 9
One Touch Ultra 2 System 9
One Touch Ultra Mini System 9
One Touch Ultra Test Strips 9
One Touch Verio IQ System 9
One Touch Verio IQ Test Strips 9
Onglyza 10
Onsolis 13
Opana 13
Opana ER 13
Optivar 10
Oracea 5
Orapred 10
Orapred ODT 10
Orencia 13
Orphenadrine 13
Orphenadrine/Aspirin/Caffeine 13
Orsythia 14
Ortho-Cyclen 14
Ortho-Novum 7/7/7 14
Ortho Evra 14
Ortho Micronor 14
Ortho Tri-Cyclen 14
Ortho Tri-Cyclen Lo 14
Oxandrolone 10
Oxaprozin 12
Oxcarbazepine 8, 16
Oxistat 9
Oxsoralen-Ultra 9
Oxybutynin 12, 16
Oxybutynin Sustained-Release Tablet 16
Oxycodone 12, 16
OxyContin 13
Oxymorphone 13
Oxymorphone Extended-Release
12 Hour Tablet 13
Oxytrol 12
P
Pancreaze 11
Pantoprazole 11, 16
Paroxetine 7, 16
Paroxetine Sustained-Release 24 Hour Tablet 7
Paroxetine Tablet 7
Pataday 10
Patanase 14
Patanol 10
Paxil 16
Pediapred 10
Peg-Intron 12
Peganone 8
Pegasys 12
21 Visit www.myuhc.com for updates 2013 Prescription Drug List Advantage Three-Tier
Penicillin V Potassium 5
Penlac 16
Pennsaid 13
Pentasa 11
Pentoxifylline 5
Percocet 5-325, 7.5-500, 10-650 16
Perforomist 13
Perindopril Erbumine 6
Permethrin 9
Pexeva 7
Phenazopyridine 12
Phenelzine 7, 16
Phenobarbital 8, 11
Phenytoin Sodium 8
Philith 14
Pilopine HS 11
Pioglitazone 10
Pioglitazone/Metformin 10
Piroxicam 12
Plan B 14
Plavix 16
Pletal 16
Polyethylene Glycol 11
Polymyxin B Sulfate/Trimethoprim 10
Portia 14
PR Natal 430 15
PR Natal 430 EC 15
Pradaxa 5
Pramipexole 8
Prandin 10
Pravachol 16
Pravastatin 6, 16
Precision Xtra Test Strips 9
Precose 16
Prednisolone 10
Prednisone 10
Prefest 15
Premarin 15
Premphase 15
Prempro 15
Prenatal 19 15
Prenatal Advantage 15
Prenatal Plus 15
Prevacid Delayed-Release Enteric-Coated
Capsule 11
Prevacid Solutab 11
Previfem 14
Prevpac 11
Prilosec 11, 16
Prilosec Rx 10, 20 mg 11
Prilosec Rx 40 mg 11
Primidone 8
Prinivil 16
Prinzide 16
Pristiq 7
Proair HFA 13
Procardia XL 16
Prochlorperazine Maleate 11
Progesterone Micronized Capsule 15
Promethazine 14
Propafenone Sustained-Release
12 Hour Capsule 7
Propranolol/Hydrochlorothiazide 6
Propranolol Sustained-Action Capsule 6
Propranolol Tablet 6
Proscar 16
Protonix 11, 16
Protonix Granules 11
Protopic 9
Proventil HFA 13
Provera 14, 16
Provigil 8
Prozac 16
Prozac Weekly 16
Pulmicort Flexhaler 13
Pulmicort Respules 1 mg/2 ml 13
Pylera 11
Q
Quasense 14
Quetiapine 8
Quinapril 6, 16
Quinapril/Hydrochlorothiazide 6
QVAR 13
R
Ramipril 6, 16
Ranexa 7
Ranitidine Syrup 11, 16
Rapao 12
Rapamune 12
Rebetol Solution 5
Rebif 8
Reclipsen 14
Regranex 9
Relenza 5
Relistor 11
Relpax 7
Remeron 16
Remeron SolTab 16
Requip 8, 16
Requip XL 8
Restasis 12
Restoril 16
Retin-A Micro 9
Rhinocort Aqua 14
Ribapak 5
Ribavirin 5
Risperdal 16
Risperidone 8, 16
Ritalin 7, 16
Ritalin LA 7
Ritalin SR 16
Rivastigmine 8
Ropinirole 8, 16
Ropinirole Extended-Release 24 Hour Tablet 8
Rozerem 8
Rybix ODT 13
Ryzolt 13
S
Sabril 8
Safyral 14
Saizen 10
Sanctura XR 12
Sancuso 11
Sandimmune 12
Savella 13
Serevent Diskus 13
Seroquel 8
Seroquel XR 8
Serostim 10
Sertraline 7, 16
Setonet 15
Setonet-EC 15
Silenor 8
Silver Sulfadiazine 9
Simcor 6
Simponi 13
Simvastatin 6, 16
Singulair 13
Skelaxin 13
Solodyn 5
Soma 250 mg 13
Sonata 8, 16
Sotalol 7
Spiriva 13
Spironolactone 6, 16
Spironolactone/Hydrochlorothiazide 6
Sporanox Oral Solution 5
Sprintec 14
Sprix 13
Sronyx 14
Stavzor 8
Staxyn 11
Stelara 9
Strattera 7
Sucralfate Tablet 11
Sular 6
Sulfacetamide Sodium 9-10
Sulfacetamide Sodium/Sulfur 9
Sulfamethoxazole/Trimethoprim 5
Sulfasalazine 11, 13
Sulindac 12
Sumatriptan Succinate Injection, Tablet 7, 16
Sumatriptan Succinate Nasal Spray 7
Sumavel DosePro 7
Suprax 5
Surmontil 16
Syeda 14
Symbicort 13
Symbyax 8
Symlin 10
Synarel 10
Synthroid 10
T
Taclonex 9
Taclonex Scalp 9
Tacrolimus 12
Tamiu 5
Tamoxifen 12
Tamsulosin 12, 16
Taron A Prenatal 15
Tasmar 8
Tazorac 9
Tegretol 8
Tekamlo 6
Tekturna 6
Tekturna HCT 6
Temazepam 8, 16
Tenoretic 16
Tenormin 16
Terazosin 6, 12
Terbinane Tablet 5, 16
Terconazole Vaginal 5
Testim 10
Testosterone 10
Tetracycline 5
Tev-Tropin 10
Teveten 6, 16
Teveten HCT 6
Thalitone 6
Theophylline 13
Tiazac 16
Tilia Fe 14
Timolol Maleate 11
Tirosint 10
Tizanidine Capsule 13
Tizanidine Tablet 13
Tobi 5
Tobradex ST 10
Tobramycin/Dexamethasone 10
Tobramycin Sulfate Drops 10
Tolmetin Sodium 13
Tolterodine 12
Topamax 8, 16
Topiramate 8, 16
Toprol XL 25 mg 16
Torsemide 6
Toviaz 12
Tradjenta 10
Tramadol 12-13, 16
Tramadol/Acetaminophen 12, 16
Tramadol Extended-Release Multiphase
24 Hour Tablet 13
Tramadol Sustained-Release 24 Hour Tablet 13
Trandolapril 6, 16
Trandolapril/Verapamil 6
Transderm-Scop 11
Travatan Z 11
Trazodone 7
Tretin-X 9
Tretinoin 9
Trexall 13
Treximet 7
Tri-Legest Fe 14
22 Visit www.myuhc.com for updates 2013 Prescription Drug List Advantage Three-Tier
Tri-Previfem 14
Tri-Sprintec 14
Triamcinolone Acetonide 9, 14
Triamterene/Hydrochlorothiazide 6, 16
Tribenzor 6
Tricor 6
Triglide 6
Trileptal 16
Trilipix 6
Trilyte with Flavor Packets 11
Trimipramine Maleate 16
Trinessa 14
Trivora 14
Trospium 12
Trusopt 16
Tussionex 12
Twynsta 6
Tylenol #3 16
U
Uloric 13
Ultracet 16
Ultram 16
Urea 9
Uroxatral 16
Ursodiol 11
V
Vagifem 15
Valacyclovir 5
Valcyte 5
Valium 16
Vancomycin 5
Vanos 9
Vaseretic 16
Vasotec 16
Vectical 9
Velivet 14
Veltin 9
Venlafaxine 7, 16
Venlafaxine Extended-Release Tablet 7
Venlafaxine Sustained-Release Capsule 7, 16
Ventolin HFA 13
Veramyst 14
Verapamil 6, 16
Verapamil Sustained-Release 24 Hour Pellets 6
Verdeso 9
Vesicare 12
Vestura 14
Vfend 16
Viagra 11
Vicodin, Vicodin ES 16
Vicoprofen 16
Victoza 10
Victrelis 5
Vigamox 10
Vimovo 13
Viorele 14
Vivelle-Dot 15
Voltaren Gel 13
Voltaren Tablet 16
Voriconazole 5, 16
Vusion 9
Vytorin 6
Vyvanse 7
W
Warfarin Sodium 5
Welchol 6
Wellbutrin 16
Wellbutrin SR 16
Wellbutrin XL 16
Wymzya Fe 14
X
Xalatan 16
Xanax, Xanax XR 16
Xarelto 5
Xerese 9
Xolegel 9
Xopenex HFA 13
Xopenex Vial, Nebulizer 13
Xyrem 8
Y
Yasmin 14
Yaz 14
Z
Zarlukast 13, 16
Zaleplon 8, 16
Zantac Syrup 16
Zarah 14
Zatean-PN 15
Zatean-PN DHA 15
Zatean-PN Plus 15
Zegerid Capsule 11
Zegerid Packet 11
Zemplar 10
Zenchent 14
Zenchent Fe 14
Zenpep 11
Zeosa 14
Zestoretic 16
Zestril 16
Zetia 6
Ziac 16
Ziana 9
Ziprasidone 8
Zipsor 13
Zithromax 16
Zocor 16
Zofran 16
Zoloft 16
Zolpidem 8, 16
Zolpidem Multiphasic-Release Tablet 8
Zolpidem Tablet 8
Zolpimist 8
Zomig 7
Zomig Nasal Spray 7
Zomig ZMT 7
Zonegran 16
Zonisamide 8, 16
Zorbtive 10
Zovia 1/35E 14
Zovia 1/50E 14
Zovirax 9, 16
Zuplenz 11
Zyclara 9
Zylet 10
Zymaxid 10
Zyprexa 8
Zyprexa Zydis 8
Zyvox 5