Your 2013 Prescription Drug List

Quick-Reference Guide
Advantage Three-Tier

Table of Contents

Welcome to Your Prescription Drug List. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Frequently Asked Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Information About Tiers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Prescription Drug List. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Anti-Infectives Diabetes/Endocrine Miscellaneous

Antibiotics. . . . . . . . . . . . . . . . . . . . . . . 5 Blood Glucose Monitoring. . . . . . . . . 9 Miscellaneous . . . . . . . . . . . . . . . . . . 12
Antifungals. . . . . . . . . . . . . . . . . . . . . . 5 Insulin. . . . . . . . . . . . . . . . . . . . . . . . . . 9 Overactive Bladder. . . . . . . . . . . . . . 12
Antivirals . . . . . . . . . . . . . . . . . . . . . . . 5 Non-Insulin. . . . . . . . . . . . . . . . . . . . . 10

Cardiovascular/Heart Disease
Coagulation Therapy. . . . . . . . . . . . . . 5
High Blood Pressure. . . . . . . . . . . . . . 6
High Cholesterol. . . . . . . . . . . . . . . . . 6
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Central Nervous System
Attention Deficit Disorder. . . . . . . . . . 7
Depression. . . . . . . . . . . . . . . . . . . . . . 7
Migraine. . . . . . . . . . . . . . . . . . . . . . . . 7
Multiple Sclerosis . . . . . . . . . . . . . . . . 8
Sedatives/Hypnotics. . . . . . . . . . . . . . 8
Seizure Disorders . . . . . . . . . . . . . . . . 8
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Dermatology. . . . . . . . . . . . . . . . . . . 9
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
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

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

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

For the most current PDL updates, visit myuhc.com or call the toll-free member phone number on the back of your health plan ID card.
Created September, 2012. 2013 Prescription Drug List Advantage Three-Tier 1/13
 Your Prescription Drug List:
Helping you get the most out of your pharmacy benefit.
This Prescription Drug List (PDL) outlines the most commonly prescribed medications for certain conditions
and divides them into tiers. Your costs may change depending on a medications tier placement.
To help you better use your UnitedHealthcare pharmacy benefit, 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. This website is the best source
for up-to-date information about the medications your pharmacy benefit covers, possible lower-cost options,
and how the cost of medications compare.

Visit www.myuhc.com for updates 1 2013 Prescription Drug List Advantage Three-Tier
 Welcome to your 2013 Prescription Drug List

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

Your pharmacy benefit offers flexibility and choice in determining the right medication for you.
To help you get the most out of your pharmacy benefit, weve included some of the most commonly
asked questions about the PDL.

What is a PDL? What are Tiers?

A PDL is a list of commonly prescribed medications
placed into tiers. The PDL includes both brand and generic
prescription medications approved by the U.S. Food
and Drug Administration (FDA). The PDL is reviewed
periodically and may change. 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 benefit plan
documents provided by your employer or health plan to
see what medications are covered under your plan. Where
differences 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. This guide is organized by common
medical conditions. Then, 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.
Tiers are the different cost levels you pay for a medication.
Each tier is assigned a cost, which is determined by your
employer or health plan. This is how much you will pay when
you fill a prescription. Tier 1 medications are your lowest-
cost options. If your medication is placed in Tier 2 or 3, look
to see if there is a Tier 1 alternative. Discuss your options
with your doctor.
Check your benefit plan documents to find 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 benefit plan documents or log on to myuhc.com for
information about your benefits.

Visit www.myuhc.com for updates 2 2013 Prescription Drug List Advantage Three-Tier
 When do medications change tiers?
The PDL quick-guide is updated twice a year, January 1st
and July 1st. Medications may move to a higher tier or be
excluded from benefit coverage on these dates. Medications
can move to a lower tier at any time throughout the year.
Throughout 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. These reviews may cause medications
to change tiers at any time.
When a medication changes tiers, you may have to pay a
different amount for that medication. These changes may
occur without prior notice to you. For the most current
information on your pharmacy coverage, please call the
toll-free member phone number on the back of your 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. The
notations refer to our pharmacy programs. Your benefit
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 find out if
it applies to you, please visit myuhc.com or call the toll-free
member phone number on the back of your health plan ID
card.
Visit www.myuhc.com for updates 3
Here is a quick symbol overview:
PDL Symbols
/ T Eligible for Half Tablet Program
1 2
DSN Designated Specialty Network
E May be excluded from coverage
MC Multiple copay
N Notification or Prior Authorization required*
RS May be eligible for the Refill and Save Program
SDP Select Designated Pharmacy
SL Supply limit
ST Step Therapy
*Depending on your benefit you may have notification or prior authorization
requirements for select medications.
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. There 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. These
medications are not covered under your pharmacy benet,
but they may cost less than your out-of-pocket expense for
prescription medications.
2013 Prescription Drug List Advantage Three-Tier
 What is the difference between How do I access updated information
brand-name and generic medications? about my pharmacy benet?
Generic medications contain the same active ingredients Since the PDL may change, we encourage you to visit
as brand-name medications, but they often cost less. After myuhc.com or call the toll-free member phone number
the patent on a brand-name medication expires, other on the back of your health plan ID card for more current
companies can manufacture an FDA-approved version of information.
the medication. These types of medications are called generic Log on to myuhc.com for the following pharmacy
medications. Many times, the same company that makes a information and tools:
brand-name medication also makes the generic version. u Pharmacy benefit and coverage information
u Possible lower-cost medication alternatives
What if my doctor writes a brand-name
u A list of medications based on a specific medical
prescription?
condition
The next time your doctor gives you a prescription for a u Medication interactions and side effects
brand-name medication, ask if a generic equivalent or u Locate a participating retail pharmacy by zip code
lower-tier alternative is available and if it might be right for u View your prescription history
you. Generic medications are usually your lowest-cost option,
but not always. Check myuhc.com to make sure. And, if mail order is included in your pharmacy benefit, you
can also:
Are you taking a specialty medication? u Refill prescriptions
u Check the status of your order
Specialty medications are managed through our Specialty
u Set up e-mail reminders for refills
Pharmacy Program which offers personalized member
u Manage your account
support. The program also offers access to on-call
pharmacists available 24 hours a day, robust clinical and
adherence programs and support coaching on lower-cost
What if I still have questions?
medication options. Visit www.uhcspecialtyrx.com or call Please call the toll-free member phone number on the back
1-866-429-8177 to learn more. Please note your specialty of your health plan ID card. Representatives are available
medication may not be listed in this guide. Please log on to 24 hours a day (except Thanksgiving and Christmas).
myuhc.com for more information.

In certain documents, the Prescription Drug List (PDL) was referred to as the Preferred Drug List (PDL). This change in descriptive terms does not affect your 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.

Visit www.myuhc.com for updates 4 2013 Prescription Drug List Advantage Three-Tier
 Anti-Infectives Antibiotics (Oral, inhaled and ear antibiotics are listed)

Tier 1
Amoxicillin Clarithromycin Tablet Neomycin/Polymyxin/HC Otic
Amoxicillin/Potassium Clavulanate Clindamycin HCl Nitrofurantoin Macrocrystal
Ampicillin Dicloxacillin Sodium Nitrofurantoin Suspension
Azithromycin Doxycycline Monohydrate Nitrofurantoin/Nitrofurantoin Macrocrystal
Cefadroxil Erythromycin Ofloxacin Otic
Cefprozil Erythromycin Base Enteric-Coated Tablet Penicillin V Potassium
Cefuroxime Levofloxacin Sulfamethoxazole/Trimethoprim
Cephalexin Metronidazole Tetracycline
Ciprofloxacin Tablet Minocycline HCl Vancomycin SL
Tier 2
Augmentin Clarithromycin Suspension Ery-Tab 500 mg
Cayston N Clarithromycin Sustained-Release Tablet Macrodantin 25 mg
Cefdinir Cleocin HCl 75 mg Tobi DSN
Cipro Suspension Clindamycin Palmitate Zyvox SL
Ciprodex Otic Dapsone

Tier 3
Adoxa E Cipro HC Minocycline Extended-Release 24 Hour Tablet
Amoxicillin-Clavulanate ER E Ciprofloxacin Sustained-Release 24 Hour Tablet Oracea
Augmentin XR E Doryx E Solodyn
Avelox Doxycycline Hyclate Enteric-Coated Tablet E Suprax
Cetraxal Doxycycline Monohydrate Capsule 150 mg E

Anti-Infectives Antifungals (Oral and topical antifungals are listed)

Tier 1
Clotrimazole Ketoconazole Terbinafine Tablet SL
Fluconazole Metronidazole Vaginal Terconazole Vaginal
Itraconazole Capsule SL Nystatin Voriconazole SL
Tier 2
Clindesse Vaginal Noxafil Sporanox Oral Solution
Tier 3
Gynazole-1 Vaginal Lamisil Granules SL
Ketoconazole Foam SL Mycostatin

Anti-Infectives Antivirals
Tier 1
Acyclovir Amantadine Ribavirin DSN N
Tier 2
Baraclude DSN Hepsera DSN Valacyclovir SL
Epivir HBV DSN Incivek DSN N SL Valcyte SL
Famciclovir SL Rebetol Solution DSN N
Tier 3
Relenza SL Tamiflu SL
Ribapak DSN E N Victrelis DSN N SL

Cardiovascular/Heart Disease Coagulation Therapy

Tier 1
Cilostazol Pentoxifylline
Clopidogrel Warfarin Sodium
Tier 2
Coumadin Fondaparinux SL
Enoxaparin SL Xarelto SL
Tier 3
Aggrenox Fragmin SL Pradaxa SL
Effient SL Innohep SL

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

Visit www.myuhc.com for updates 5 2013 Prescription Drug List Advantage Three-Tier
 Cardiovascular/Heart Disease High Blood Pressure
Tier 1
Amlodipine Enalapril Metoprolol/Hydrochlorothiazide
Atenolol Enalapril/Hydrochlorothiazide Moexipril 1/2T
Atenolol/Chlorthalidone Eprosartan SL Nadolol
Benazepril Felodipine Nifedipine
Benazepril/Hydrochlorothiazide Furosemide Propranolol Tablet
Bisoprolol Guanfacine Propranolol/Hydrochlorothiazide
Bisoprolol/Hydrochlorothiazide Hydralazine Ramipril
Bumetanide Hydrochlorothiazide Spironolactone
Captopril Labetalol Spironolactone/Hydrochlorothiazide
Captopril/Hydrochlorothiazide Lisinopril Terazosin
Carvedilol Lisinopril/Hydrochlorothiazide Torsemide
Chlorthalidone Losartan 1/2T Trandolapril 1/2T
Clonidine Losartan/Hydrochlorothiazide Triamterene/Hydrochlorothiazide
Diltiazem Metolazone Verapamil
Diltiazem Controlled-Release Capsule Metoprolol Succinate Sustained-Release
Diltiazem Sustained-Release 12 Hour Capsule Tablet 25 mg
Doxazosin Metoprolol Tartrate

Tier 2
Aldactazide 50-50 mg Diltiazem Sustained-Action Capsule Micardis SL
Benicar 1/2T SL Diltiazem Sustained-Release 24 Hour Capsule Micardis HCT SL
Benicar HCT SL Diltiazem Sustained-Release 24 Hour Tablet Nisoldipine
BiDil Diuril Suspension 250 mg/5 ml Perindopril Erbumine 1/2T
Bystolic Dutoprol SL Propranolol Sustained-Action Capsule
Cardizem LA 120 mg Eplerenone Quinapril/Hydrochlorothiazide
Clorpres Metoprolol Succinate Sustained-Release Tablet Thalitone
Dibenzyline 50, 100, 200 mg
Tier 3
Aceon 1/2T Coreg CR E SL Sular
Amlodipine/Benazepril SL Diovan 1/2T SL Tekamlo E SL
Amturnide E SL Diovan HCT SL Tekturna SDP SL
Atacand 1/2T SDP SL Edarbi SL Tekturna HCT SDP SL
Atacand HCT SDP SL Edarbyclor SL Teveten HCT SL
Avalide SL Exforge E SL Trandolapril/Verapamil
Avapro 1/2T SL Exforge HCT E SL Tribenzor E SL
Azor SL Irbesartan 1/2T SL Twynsta E SL
Cardizem LA 180, 240, 300, 360, 420 mg Irbesartan/Hydrochlorothiazide SL Verapamil Sustained-Release 24 Hour Pellets
Clonidine Transdermal Weekly Patch SL Nexiclon XR E

Cardiovascular/Heart Disease High Cholesterol

Tier 1
Atorvastatin 1/2T SL Fenofibric Acid Lovastatin
Cholestyramine Fluvastatin SL Pravastatin 1/2T
Colestipol Gemfibrozil Simvastatin 1/2T
Tier 2
Antara Fenofibrate Welchol
Crestor 1/2T SL Lipofen

Tier 3
Advicor SL Lipitor 1/2T E SL Triglide
Altoprev E SL Livalo SL Trilipix E
Amlodipine/Atorvastatin E SL Lovaza N Vytorin SL
Caduet E SL Niaspan Zetia SL
Fenoglide Simcor SL
Lescol XL SL Tricor E

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

Visit www.myuhc.com for updates 6 2013 Prescription Drug List Advantage Three-Tier
 Cardiovascular/Heart Disease Other
Tier 1
Amiodarone Isosorbide Dinitrate Nitroglycerin Transdermal Patch
Digoxin Isosorbide Mononitrate Sotalol
Flecainide Acetate Mexiletine

Tier 2
Lanoxin Nitrostat
Multaq Ranexa
Tier 3
Nitroglycerin Spray E SL Nitromist SL Propafenone Sustained-Release
Nitrolingual E SL 12 Hour Capsule

Central Nervous System Attention Deficit Disorder

Tier 1
Amphetamine Salt Combo Methamphetamine
Dextroamphetamine Sulfate Methylphenidate
Tier 2
Adderall XR SL Intuniv SL Vyvanse SL
Tier 3
Amphetamine Aspartate/Amphetamine Sulfate/ Focalin XR SL Methylphenidate Extended-Release
Dextroamphetamine Sustained-Release Kapvay E 24 Hour Tablet SL
24 Hour Capsule SL Metadate CD SL Methylphenidate Extended-Release Capsule SL
Concerta SL Methylin Tablet Ritalin LA SL
Daytrana SL Strattera SL

Central Nervous System Depression

Tier 1
Amitriptyline Fluoxetine Delayed-Release Capsule SL Phenelzine
Bupropion Fluvoxamine Maleate Sertraline 1/2T
Bupropion XL Mirtazapine Trazodone
Citalopram Hydrobromide Nefazodone Venlafaxine Sustained-Release Capsule SL
Doxepin Nortriptyline
Fluoxetine Paroxetine Tablet

Tier 3
Aplenzin E SL Luvox CR SL Pristiq RS SL
Cymbalta SDP SL Oleptro E SL Venlafaxine Extended-Release Tablet E SL
Escitalopram 1/2T SL Paroxetine Sustained-Release 24 Hour Tablet SL
Lexapro 1/2T SL Pexeva 1/2T SL

Central Nervous System Migraine

Tier 1
Acetaminophen/Butalbital/Caffeine SL Aspirin/Butalbital/Caffeine Sumatriptan Succinate Injection, Tablet SL
Acetaminophen/Dichloralphenazone/ Naratriptan SL
Isometheptene Mucate Relpax SL
Tier 2
Ergomar Sumatriptan Succinate Nasal Spray SL

Tier 3
Alsuma E SL Maxalt SDP SL Zomig SDP SL
Axert SDP SL Maxalt MLT SDP SL Zomig Nasal Spray SL
Cafergot Migranal Zomig ZMT SDP SL
Cambia E SL Sumavel DosePro SL
Frova SDP SL Treximet E SL

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

Visit www.myuhc.com for updates 7 2013 Prescription Drug List Advantage Three-Tier
 Central Nervous System Multiple Sclerosis
Tier 2
Ampyra DSN N SL Copaxone DSN N SL
Avonex DSN N SL Rebif DSN N SL
Tier 3
Betaseron DSN N SL ST Extavia DSN E N SL ST Gilenya DSN N SL ST

Central Nervous System Sedatives/Hypnotics

Tier 1
Temazepam Zaleplon SL Zolpidem Tablet SL
Tier 3
Ambien SL ST Lunesta SL ST Sonata SL ST
Ambien CR SL ST Rozerem SL ST Zolpidem Multiphasic-Release Tablet SL ST
Edluar E SL ST Silenor E SL Zolpimist E SL ST

Central Nervous System Seizure Disorders

Tier 1
Carbamazepine Felbamate Phenobarbital
Clonazepam Gabapentin Phenytoin Sodium
Diazepam Rectal Gel SL Lamotrigine Primidone
Divalproex Sodium Sustained-Release Tablet Levetiracetam Topiramate
Divalproex Sodium Tablet Oxcarbazepine Zonisamide

Tier 2
Carbamazepine Sustained-Release Divalproex Sodium Sprinkle Capsule Mysoline
12 Hour Tablet Gabitril Peganone
Celontin Levetiracetam Extended-Release Sabril
Dilantin 24 Hour Tablet ST Tegretol
Tier 3
Carbamazepine Extended-Release Keppra XR ST Lyrica SDP SL
12 Hour Capsule Lamictal ST Stavzor ST
Carbatrol Lamictal Dose Pack SL ST Topamax ST
Depakote ER ST Lamictal ODT ST
Keppra ST Lamictal XR ST

Central Nervous System Other

Tier 1
Alprazolam Diazepam Lorazepam
Benztropine Mesylate Donepezil 5, 10 mg Pramipexole
Buspirone Galantamine Risperidone
Carbidopa/Levodopa Lithium Carbonate Rivastigmine
Clozapine Lithium Carbonate Controlled-Release Tablet Ropinirole

Tier 2
Apokyn DSN Olanzapine Tablet SL Xyrem N SL
Comtan Olanzapine/Fluoxetine SL Ziprasidone SL
FazaClo Quetiapine SL
Nuedexta Tasmar

Tier 3
Abilify 1/2T SL Modafinil E N SL Seroquel SL
Aricept 23 mg E Namenda Seroquel XR SL
Exelon Solution Nuvigil N SL Symbyax SL
Fanapt SL Olanzapine Rapid Dissolve Tablet SL Zyprexa SL
Geodon SL Provigil E N SL Zyprexa Zydis SL
Invega SL Requip XL E
Mirapex ER E Ropinirole Extended-Release 24 Hour Tablet E

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

Visit www.myuhc.com for updates 8 2013 Prescription Drug List Advantage Three-Tier
 Dermatology
Tier 1
Alclometasone Dipropionate Erythromycin Mometasone Furoate
Betamethasone Dipropionate Erythromycin/Benzoyl Peroxide Mupirocin
Betamethasone Valerate Fluocinolone Nystatin
Ciclopirox Cream, Gel, Lotion Fluocinonide Nystatin/Triamcinolone Acetonide
Ciclopirox Non-Oral Solution Fluticasone Propionate Permethrin
Clindamycin Gel, Lotion, Solution, Swabs Halobetasol Propionate Silver Sulfadiazine
Clobetasol Propionate Hydrocortisone Sulfacetamide Sodium/Sulfur
Clotrimazole/Betamethasone Hydrocortisone Valerate Tretinoin N
Desonide Ketoconazole Triamcinolone Acetonide
Desoximetasone Lidocaine Urea
Econazole Nitrate Metronidazole Gel 0.75%
Tier 2
Azelex SL Ciclopirox Shampoo 1% MC Oxsoralen-Ultra
Benzaclin Gel 1%-5% 25 g SL Differin Cream, Gel 0.1% N SL Protopic N SL
Benzamycin Imiquimod SL Regranex N
Calcipotriene Cream, Ointment SL Isotretinoin Stelara DSN N SL
Tier 3
Acanya SL Condylox Gel Naftin
Aczone SL Cutivate Lotion MC Noritate MC
Adapalene N SL Denavir Olux-E SL
Altabax SL Desonate SL Oxistat
Atralin MC N SL Differin Gel 0.3% N SL Retin-A Micro N SL
Avita Gel N SL Differin Lotion N SL Taclonex SL
Bactroban SL Dovonex SL Taclonex Scalp SL
Benzaclin Gel 1%-5% SL Duac E SL Tazorac N SL
Clindagel E SL Elidel N SL Tretin-X N SL
Clindamycin Foam 1% SL Epiduo E SL Vanos SL
Clindamycin Phosphate/Benzoyl Peroxide Evoclin SL Vectical SL
Extended-Release Gel E SL Finacea Veltin E SL
Clindamycin Phosphate/Benzoyl Peroxide Gel Finacea Plus Verdeso SL
1%-5% SL Fluticasone Propionate Lotion MC Vusion MC
Clobetasol Propionate Foam SL Locoid Lipocream SL Xerese E
Clobetasol Propionate Lotion SL Locoid Lotion SL Xolegel MC
Clobetasol Propionate Shampoo E SL Loprox Shampoo MC Ziana E SL
Clobex SL Metrogel 1% E MC Zovirax SL
Clobex Shampoo E SL Metrolotion Zyclara E SL

Diabetes/Endocrine Blood Glucose Monitoring

Tier 1
Accu-Chek Active Test Strips SL Accu-Chek Nano SmartView One Touch Ultra Test Strips SL
Accu-Chek Aviva Plus Accu-Chek SmartView Test Strip SL One Touch Verio IQ System
Accu-Chek Aviva Plus Test Strips SL One Touch Test Strips SL One Touch Verio IQ Test Strips SL
Accu-Chek Comfort Curve Test Strips SL One Touch Ultra 2 System
Accu-Chek Compact Test Strips SL One Touch Ultra Mini System

Tier 3
Ascensia Autodisc Test Strips SDP SL Contour Test Strips SDP SL Freestyle Test Strips SDP SL
Ascensia Breeze 2 Test Strips SDP SL Freestyle Lite Test Strips SDP SL Precision Xtra Test Strips SDP SL

Diabetes/Endocrine Insulin
Tier 1
Humalog Vials Humulin 70-30 Vials
Humalog-Mix Vials Humulin Vials
Tier 2
Humalog KwikPen Humulin KwikPen Levemir Vials
Humalog-Mix KwikPen Lantus Vials
Tier 3
Apidra Solostar SDP Lantus Solostar Pens/Cartridges Novolin Vials SDP
Apidra Vial SDP Levemir Flexpen NovoLog SDP

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

Visit www.myuhc.com for updates 9 2013 Prescription Drug List Advantage Three-Tier
 Diabetes/Endocrine Non-Insulin
Tier 1
Acarbose Glipizide Glyburide/Metformin
Glimepiride Glyburide Metformin

Tier 2
Byetta SL Jentadueto SL Pioglitazone 1/2T SL
Duetact SL Kombiglyze XR SL Pioglitazone/Metformin SL
Glipizide/Metformin Nateglinide SL Prandin SL
Glyset Onglyza SL Tradjenta SL

Tier 3
Actoplus Met SL Avandia SL Januvia SDP SL
Actoplus Met XR SDP SL Fortamet Juvisync SDP SL
Actos 1/2T SL Glumetza Metformin Extended-Release 24 Hour Tablet
Avandamet SL Janumet SDP SL Symlin SL
Avandaryl SL Janumet XR SDP SL Victoza SL

Endocrine Growth Hormone

Tier 2
Nutropin, AQ, NuSpin DSN N SL Serostim DSN N SL
Saizen DSN N SL Tev-Tropin DSN N SL

Tier 3
Genotropin DSN E N SL Norditropin DSN E N SL Zorbtive DSN N SL
Humatrope DSN E N SL Omnitrope DSN E N SL

Endocrine Other
Tier 1
Calcitriol Levothyroxine Sodium Prednisolone
Desmopressin Methimazole Prednisone
Dexamethasone Methylprednisolone Dosepak Tablet 4 mg Testosterone
Fludrocortisone Octreotide Acetate DSN N
Hydrocortisone Tablet Orapred
Tier 2
Androderm SL Levoxyl Synarel
Android Liothyronine Sodium Synthroid
Cabergoline Medrol 2, 8, 24, 32 mg Testim SL
Hectorol Oxandrolone Tirosint
Kuvan DSN N SL Pediapred Zemplar DSN
Tier 3
Androgel E SL Axiron E SL Orapred ODT
Armour Thyroid Fortesta E SL

Eye Conditions Allergies

Tier 1
Ketorolac Tromethamine
Tier 3
Azelastine HCl SL Emadine E Optivar E SL
Bepreve E SL Epinastine E SL Pataday E SL
Elestat E SL Lastacaft SL Patanol E SL

Eye Conditions Antibiotics

Tier 1
Ciprofloxacin Levofloxacin Polymyxin B Sulfate/Trimethoprim
Erythromycin Neomycin/Polymyxin B Sulfate/Dexamethasone Sulfacetamide Sodium
Gentamicin Sulfate Ofloxacin Tobramycin Sulfate Drops
Tier 2
Blephamide S.O.P. Tobramycin/Dexamethasone

Tier 3
Azasite SL Tobradex ST E SL Zylet
Moxeza Vigamox Zymaxid SL

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

Visit www.myuhc.com for updates 10 2013 Prescription Drug List Advantage Three-Tier
 Eye Conditions Glaucoma
Tier 1
Acetazolamide Dorzolamide HCl Timolol Maleate
Apraclonidine Latanoprost SL
Tier 2
Alphagan P 0.1% SL Brimonidine Tartrate SL Lumigan SL
Azopt SL Combigan SL Pilopine HS
Betimol SL Dorzolamide HCl/Timolol Maleate Travatan Z SL
Tier 3
Iopidine 1%

Gastrointestinal Acid Suppression

Tier 1
Cimetidine Omeprazole Ranitidine Syrup
Misoprostol Pantoprazole Sucralfate Tablet
Tier 2
Helidac Prevpac SL
Nizatidine Oral Solution Pylera

Tier 3
Aciphex SL Nexium Suspension Prilosec Rx 10, 20 mg E
Carafate Oral Suspension Omeprazole/Sodium Bicarbonate Capsule E SL Prilosec Rx 40 mg E
Dexilant SL Prevacid Delayed-Release Enteric-Coated Protonix Granules SL
Lansoprazole E SL Capsule E SL Zegerid Capsule E SL
Nexium Capsule E SL Prevacid Solutab E SL Zegerid Packet SL

Gastrointestinal Nausea/Vomiting
Tier 1
Ondansetron Prochlorperazine Maleate
Tier 2
Emend SL Granisetron Tablet SL
Tier 3
Anzemet SL Sancuso E SL Zuplenz E SL
Cesamet Transderm-Scop

Gastrointestinal Other
Tier 1
Balsalazide Lactulose Sulfasalazine
Belladonna/Phenobarbital Mesalamine Trilyte with Flavor Packets
Chlordiazepoxide/Clidinium Metoclopramide Ursodiol
Diphenoxylate/Atropine Polyethylene Glycol

Tier 2
Apriso Creon Lotronex SL
Budesonide Extended-Release 24 Hour Capsule GoLYTELY Packet Relistor
Canasa Lialda Zenpep

Tier 3
Amitiza N SL Dipentum Moviprep
Asacol SDP Halflytely-Bisacodyl Pancreaze SDP
Asacol HD E SDP Metozolv ODT E Pentasa

Mens Health Erectile Dysfunction

Tier 3
Caverject SL Levitra SL Viagra SL
Cialis SL Muse SL
Edex SL Staxyn E SL

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

Visit www.myuhc.com for updates 11 2013 Prescription Drug List Advantage Three-Tier
 Mens Health Prostate
Tier 1
Alfuzosin Finasteride Terazosin
Doxazosin Tamsulosin

Tier 3
Avodart N SDP Jalyn E Rapaflo

Miscellaneous
Tier 1
Anastrozole Chlorhexidine Gluconate Phenazopyridine
Antipyrine/Benzocaine Letrozole Tacrolimus DSN
Azathioprine Megestrol Acetate Tamoxifen
Benzonatate Mycophenolate Capsule, Tablet DSN
Tier 2
Cellcept Suspension DSN Fareston Neoral DSN
Epipen SL Lidoderm SL Pegasys DSN N SL
Epipen Jr SL Lysteda SL Rapamune DSN
Exemestane Myfortic DSN Sandimmune DSN
Tier 3
Acuvail E SL Hydrocodone/Chlorpheniramine Suspension SL Restasis N SL
Aromasin Infergen DSN N SL Tussionex SL
Bromday E SL Intron A DSN N
Bromfenac SL Peg-Intron DSN N SL ST

Miscellaneous Overactive Bladder

Tier 1
Dicyclomine Tablet Oxybutynin
Hyoscyamine Sulfate Trospium
Tier 2
Gelnique Sanctura XR
Oxytrol Vesicare
Tier 3
Detrol Enablex Toviaz SDP
Detrol LA E Tolterodine

Musculoskeletal Osteoporosis
Tier 1
Alendronate SL

Tier 2
Calcitonin Salmon Nasal Spray Forteo DSN N Ibandronate Tablet SL
Evista Fortical
Tier 3
Actonel SL Atelvia E SL Fosamax Plus D SL

Musculoskeletal Pain Relief

Tier 1
Acetaminophen/Butalbital/Caffeine/Codeine SL Hydromorphone Morphine Sulfate Sustained-Action Tablet SL
Acetaminophen/Codeine SL Ibuprofen Nabumetone
Acetaminophen/Hydrocodone Bit SL Ibuprofen/Hydrocodone Naproxen
Acetaminophen/Oxycodone SL Ibuprofen/Oxycodone Naproxen Sodium
Aspirin/Butalbital/Caffeine/Codeine Indomethacin Oxaprozin
Aspirin/Oxycodone Ketorolac Tromethamine Oxycodone
Diclofenac Potassium Meloxicam Piroxicam
Diclofenac Sodium Meperidine Sulindac
Duragesic SL Methadone Tramadol
Etodolac Morphine Sulfate Tramadol/Acetaminophen SL

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

Visit www.myuhc.com for updates 12 2013 Prescription Drug List Advantage Three-Tier
 Musculoskeletal Pain Relief (cont. from page 12)

Tier 2
Acetaminophen/Hydrocodone Bit Opana ER SL Tramadol Sustained-Release
7.5 - 325 mg/15 ml Oral Solution SL OxyContin SL 24 Hour Tablet SL
Butorphanol Nasal Spray SL Oxymorphone SL Voltaren Gel
Codeine Phosphate Oxymorphone Extended-Release
Fentanyl Citrate Lollipop N SL 12 Hour Tablet SL
MSIR Capsule Tolmetin Sodium

Tier 3
Abstral N SL Flector E Opana SL
Arthrotec Hycet SL Pennsaid E
Avinza SL Kadian E SL Rybix ODT E SL
Celebrex SL Lazanda N SL Ryzolt E SL
Conzip E SL Mefenamic Acid Sprix SL
Duexis E SL Morphine Sulfate Extended-Release Pellets E SL Tramadol Extended-Release Multiphase
Embeda SL Naprelan E 24 Hour
Exalgo SL Nucynta SL Tablet E SL
Fentanyl Transdermal SL Nucynta ER SL Vimovo E SL
Fentora E N SL Onsolis N SL Zipsor E

Musculoskeletal Rheumatoid Arthritis

Tier 1
Azathioprine Leflunomide Sulfasalazine
Hydroxychloroquine Sulfate Methotrexate
Tier 2
Cimzia DSN N SL Enbrel DSN N SL Trexall
Cuprimine Simponi DSN N SL
Tier 3
Humira DSN N SL ST Kineret DSN N SL Orencia DSN N SL

Musculoskeletal Other
Tier 1
Allopurinol Carisoprodol 350 mg Methocarbamol
Baclofen Cyclobenzaprine Tizanidine Tablet

Tier 2
Colcrys Orphenadrine Orphenadrine/Aspirin/Caffeine

Tier 3
Amrix E Gralise E SL Skelaxin E
Carisoprodol 250 mg E Horizant E SL Soma 250 mg E
Cyclobenzaprine Extended-Release Metaxalone Tizanidine Capsule
24 Hour Capsule E Savella SL Uloric SL

Respiratory Asthma/COPD
Tier 1
Albuterol Sulfate Ipratropium Bromide Ventolin HFA SL
Alvesco SL QVAR SL Zafirlukast SL
Asmanex SL Theophylline
Tier 2
Albuterol Sulfate/Ipratropium Non-Oral Solution Foradil SL Spiriva SL
Budesonide Inhalation Suspension 0.25 mg/ Montelukast SL
2 ml, 0.5 mg/2 ml SL Pulmicort Respules 1 mg/2 ml SL
Tier 3
Advair Diskus RS SL Flovent Diskus SDP SL Pulmicort Flexhaler SDP SL
Advair HFA RS SL Flovent HFA SDP SL Serevent Diskus SL
Atrovent HFA SL Levalbuterol Vial, Nebulizer E SL Singulair SL
Combivent SL Maxair Autohaler SL Symbicort SDP SL
Combivent Respimat SL Perforomist SL Xopenex HFA SL
Daliresp N SL Proair HFA SL Xopenex Vial, Nebulizer E SL
Dulera RS SL Proventil HFA SL

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

Visit www.myuhc.com for updates 13 2013 Prescription Drug List Advantage Three-Tier
 Respiratory Nasal Allergies
Tier 1
Flunisolide Fluticasone Propionate SL
Tier 2
Nasonex SL
Tier 3
Astelin E SL Nasacort AQ SL Triamcinolone Acetonide SL
Astepro SL Omnaris SL Veramyst E SL
Azelastine HCl SL Patanase SL
Beconase AQ SL Rhinocort Aqua SL

Respiratory Oral Allergies

Tier 1
Cyproheptadine Levocetirizine Tablet SL
Hydroxyzine Promethazine

Tier 3
Clarinex E SL Desloratadine E SL
Clarinex-D E SL Levocetirizine Oral Solution SL

Womens Health Contraceptives

Tier 1
Apri Levora Orsythia
Altavera Low-Ogestrel Ortho Micronor
Aranelle Lutera Ortho Tri-Cyclen
Aviane Marlissa Ortho-Cyclen
Caziant Medroxyprogesterone 150 mg/ml MC Ortho-Novum 7/7/7
Cryselle Microgestin Fe Plan B
Cyclafem 1/35 Myzilra Portia
Ella SL Natazia Reclipsen
Emoquette Necon 0.5/35 Sronyx
Enpresse Necon 1/35 Trivora
Gildess FE Necon 1/50 Velivet
Junel Fe Necon 10/11 Yasmin
Kelnor Next Choice One Dose Zovia 1/35E
Leena Nortrel 0.5/35 Zovia 1/50E
Lessina Nortrel 1/35
Tier 2
Azurette Junel Quasense MC
Balziva Kariva Viorele
Briellyn Microgestin Yaz
Depo-SubQ Provera MC NuvaRing Zenchent
Introvale MC Ogestrel
Jolessa MC Philith
Tier 3
Alyacen 7/7/7 Jolivette Sprintec
Amethia MC Lo Loestrin Fe Syeda
Amethia Lo MC Loestrin 24 Fe Tilia Fe
Amethyst Loryna Tri-Legest Fe
Beyaz E Mononessa Tri-Previfem
Camila Necon 7/7/7 Tri-Sprintec
Camrese MC Nora-Be Trinessa
Camrese Lo MC Norethindrone Vestura
Cyclafem 7/7/7 Nortrel 7/7/7 Wymzya Fe
Errin Ocella Zarah
Femcon Fe Ortho Evra Zenchent Fe
Generess Fe E Ortho Tri-Cyclen Lo Zeosa
Gianvi Previfem
Heather Safyral E

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

Visit www.myuhc.com for updates 14 2013 Prescription Drug List Advantage Three-Tier
 Womens Health Estrogen/Progesterone
Tier 1
Estradiol Estropipate Norethindrone Acetate
Estradiol Transdermal Weekly Patch SL Medroxyprogesterone

Tier 2
Cenestin Estrace Cream with Applicator Progesterone Micronized Capsule
Climara SL Estradiol/Norethindrone Acetate Vagifem
Crinone N Estring MC SL Vivelle-Dot SL
Divigel Evamist
Enjuvia Prefest

Tier 3
Activella Estrogel SL Premarin
Alora SL Femhrt Premphase
Climara Pro SL Femring MC SL Prempro
Combipatch SL First-Progesterone N
Estrasorb SL Menostar Transdermal Weekly Patch SL

Womens Health Prenatal Vitamins

Tier 1
Folic Acid Prenatal 19 Prenatal Plus
Multinatal Plus Prenatal Advantage

Tier 2
Advanced Care Plus PR Natal 430 Setonet-EC
Cavan-EC Sod DHA PR Natal 430 EC
Multi-Nate 30 Setonet

Tier 3
Brand Prenatal Vitamins Taron A Prenatal Zatean-PN DHA
Folcal DHA Zatean-PN Zatean-PN Plus

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

Visit www.myuhc.com for updates 15 2013 Prescription Drug List Advantage Three-Tier
 Additional Tier 3 Drugs with a generic equivalent in Tier 1

Accolate SL (Zafirlukast SL) Lamisil SL (Terbinafine Tablet SL) Wellbutrin (Bupropion HCl)
Accupril (Quinapril) Lasix (Furosemide) Wellbutrin SR (Bupropion HCl Sustained-Action
Acular (Ketorolac Tromethamine) Levaquin (Levofloxacin) Tablet)
Adderall (Amphetamine/Dextroamphetamine Salt Lipitor 1/2T E SL (Atorvastatin 1/2T SL) Wellbutrin XL (Bupropion HCl Sustained-Release
Combination) Lopid (Gemfibrozil) 24 Hour Tablet)
Aldactone (Spironolactone) Lopressor (Metoprolol) Xalatan SL (Latanoprost SL)
Altace (Ramipril) Mavik 1/2T (Trandolapril 1/2T) Xanax, Xanax XR (Alprazolam)
Amaryl (Glimepiride) Medrol (Methylprednisolone Dosepak Zantac Syrup (Ranitidine Syrup)
Ambien SL ST (Zolpidem SL) Tablet 4 mg) Ziac (Bisoprolol/Hydrochlorothiazide)
Amerge SL (Naratriptan SL) Metrogel Vaginal (Metronidazole) Zithromax (Azithromycin)
Anaprox (Naproxen) Mevacor (Lovastatin) Zocor 1/2T (Simvastatin 1/2T)
Aricept (Donepezil) Mobic (Meloxicam) Zofran (Ondansetron)
Arimidex (Anastrozole) Monopril (Fosinopril) Zoloft 1/2T (Sertraline 1/2T)
Ativan (Lorazepam) Naprosyn (Naproxen) - Prescription strengths Zonegran (Zonisamide)
Augmentin ES (Amoxicillin/Potassium only Zovirax (Acyclovir Capsule, Suspension, Tablet)
Clavulanate) Nardil (Phenelzine)
Biaxin Tablet (Clarithromycin Tablet) Neurontin (Gabapentin)
Buspar (Buspirone) Norvasc (Amlodipine)
Calan, Calan SR (Verapamil) Ocuflox Eye Drops (Ofloxacin)
Cardizem CD except for 360 mg strength Paxil (Paroxetine)
(Diltiazem Sustained-Release Penlac (Ciclopirox Solution, Non-Oral)
24 Hour Capsule) Percocet 5-325, 7.5-500, 10-650 SL
Cardura (Doxazosin) (Acetaminophen/Oxycodone SL)
Ceftin (Cefuroxime) Plavix (Clopidogrel)
Cefzil (Cefprozil) Pletal (Cilostazol)
Celexa (Citalopram) Pravachol 1/2T (Pravastatin 1/2T)
Ciloxan Eye Drops (Ciprofloxacin) Precose (Acarbose)
Cipro (Ciprofloxacin) Prilosec (Omeprazole)
Cleocin T (Clindamycin Gel, Lotion, Solution, Prinivil, Zestril (Lisinopril)
Swabs) Prinzide, Zestoretic (Lisinopril/
Clozaril (Clozapine) Hydrochlorothiazide)
Colazal (Balsalazide) Procardia XL (Nifedipine Extended-Release
Colestid (Colestipol) Tablet)
Coreg (Carvedilol) Proscar (Finasteride)
Cozaar 1/2T (Losartan 1/2T) Protonix (Pantoprazole)
DDAVP (Desmopressin) Provera (Medroxyprogesterone)
Depakote (Divalproex Sodium Tablet) Prozac (Fluoxetine Capsule)
Depakote ER ST (Divalproex Sodium Prozac Weekly SL (Fluoxetine Delayed-Release
Sustained-Release 24 Hour Tablet) Capsule SL)
Depo-Provera MC (Medroxyprogesterone Remeron (Mirtazapine)
150 mg/ml MC) Remeron SolTab (Mirtazapine Dispersible Tablet)
Derma-Smoothe/FS (Fluocinolone) Requip (Ropinirole)
DiaBeta, Glynase (Glyburide) Restoril (Temazepam)
Diastat Acudial SL (Diazepam Rectal Gel SL) Risperdal (Risperidone)
Didronel (Etidronate Disodium) Ritalin (Methylphenidate)
Diflucan (Fluconazole) Ritalin SR (Methylphenidate Extended-Release
Ditropan XL (Oxybutynin Sustained-Release Tablet)
Tablet) Sonata ST SL (Zaleplon SL)
Dyazide (Triamterene/Hydrochlorothiazide) Surmontil (Trimipramine Maleate)
Effexor (Venlafaxine) Tenoretic (Atenolol/Chlorthalidone)
Effexor XR SL (Venlafaxine Sustained-Release Tenormin (Atenolol)
Capsule SL) Teveten SL (Eprosartan SL)
Felbatol (Felbamate) Tiazac (Diltiazem)
Femara (Letrozole) Topamax ST (Topiramate)
Fioricet SL (Acetaminophen/Butalbital/ Toprol XL 25 mg (Metoprolol Succinate
Caffeine SL) Sustained-Release Tablet)
Flomax (Tamsulosin) Trileptal (Oxcarbazepine)
Flonase SL (Fluticasone Nasal Spray SL) Trusopt (Dorzolamide Eye Drops)
Fosamax SL Tylenol #3 SL (Acetaminophen/Codeine SL)
(Alendronate SL) Ultracet SL (Tramadol/Acetaminophen SL)
Glucophage, XR (Metformin) Ultram (Tramadol)
Glucotrol, XL (Glipizide) Uroxatral (Alfuzosin)
Glucovance (Glyburide/Metformin) Valium (Diazepam)
Hyzaar SL (Losartan/Hydrochlorothiazide SL) Vaseretic (Enalapril/Hydrochlorothiazide)
Imitrex SL (Sumatriptan Succinate Injection, Vasotec (Enalapril)
Tablet SL) Vfend SL (Voriconazole SL)
Keflex (Cephalexin) Vicodin SL, Vicodin ES SL (Acetaminophen/
Keppra ST (Levetiracetam) Hydrocodone SL)
Klonopin (Clonazepam) Vicoprofen (Ibuprofen/Hydrocodone)
Lamictal ST (Lamotrigine) Voltaren Tablet (Diclofenac)

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

Visit www.myuhc.com for updates 16 2013 Prescription Drug List Advantage Three-Tier
Index
A Amlodipine 6, 16 Azelex 9
Abilify 8 Amlodipine/Atorvastatin 6 Azithromycin 5, 16
Abstral 13 Amlodipine/Benazepril 6 Azopt 11
Acanya 9 Amoxicillin 5, 16 Azor 6
Acarbose 10, 16 Amoxicillin-Clavulanate ER 5 Azurette 14
Accolate 16 Amoxicillin/Potassium Clavulanate 5, 16 B
Accu-Chek Active Test Strips 9 Amphetamine/Dextroamphetamine Baclofen 13
Accu-Chek Aviva Plus 9 Salt Combination 16 Bactroban 9
Accu-Chek Aviva Plus Test Strips 9 Amphetamine Aspartate/Amphetamine Sulfate/ Balsalazide 11, 16
Accu-Chek Comfort Curve Test Strips 9 Dextroamphetamine Sustained-Release Balziva 14
Accu-Chek Compact Test Strips 9 24 Hour Capsule 7 Baraclude 5
Accu-Chek Nano SmartView 9 Amphetamine Salt Combo 7 Beconase AQ 14
Accu-Chek SmartView Test Strip 9 Ampicillin 5 Belladonna/Phenobarbital 11
Accupril 16 Ampyra 8 Benazepril 6
Aceon 6 Amrix 13 Benazepril/Hydrochlorothiazide 6
Acetaminophen/Butalbital/Caffeine 7, 12, 16 Amturnide 6 Benicar 6
Acetaminophen/Butalbital/Caffeine/Codeine 12 Anaprox 16 Benicar HCT 6
Acetaminophen/Codeine 12, 16 Anastrozole 12, 16 Benzaclin Gel 1%-5% 9
Acetaminophen/Dichloralphenazone/ Androderm 10 Benzaclin Gel 1%-5% 25 g 9
Isometheptene Mucate 7 Androgel 10 Benzamycin 9
Acetaminophen/Hydrocodone 12-13, 16 Android 10 Benzonatate 12
Acetaminophen/Hydrocodone Bit 12-13 Antara 6 Benztropine Mesylate 8
Acetaminophen/Hydrocodone Bit 7.5 - 325 mg/ Antipyrine/Benzocaine 12 Bepreve 10
15 ml Oral Solution 13 Anzemet 11 Betamethasone Dipropionate 9
Acetaminophen/Oxycodone 12, 16 Apidra Solostar 9 Betamethasone Valerate 9
Acetazolamide 11 Apidra Vial 9 Betaseron 8
Aciphex 11 Aplenzin 7 Betimol 11
Activella 15 Apokyn 8 Beyaz 14
Actonel 12 Apraclonidine 11 Biaxin Tablet 16
Actoplus Met 10 Apri 14 BiDil 6
Actoplus Met XR 10 Apriso 11 Bisoprolol 6, 16
Actos 10 Aranelle 14 Bisoprolol/Hydrochlorothiazide 6, 16
Acular 16 Aricept 8, 16 Blephamide S.O.P. 10
Acuvail 12 Aricept 23 mg 8 Brand Prenatal Vitamins 15
Acyclovir 5, 16 Arimidex 16 Briellyn 14
Acyclovir Capsule, Suspension, Tablet 16 Armour Thyroid 10 Brimonidine Tartrate 11
Aczone 9 Aromasin 12 Bromday 12
Adapalene 9 Arthrotec 13 Bromfenac 12
Adderall 7, 16 Asacol 11 Budesonide Extended-Release
Adderall XR 7 Asacol HD 11 24 Hour Capsule 11
Adoxa 5 Ascensia Autodisc Test Strips 9 Budesonide Inhalation Suspension
Advair Diskus 13 Ascensia Breeze 2 Test Strips 9 0.25 mg/2 ml, 0.5 mg/2 ml 13
Advair HFA 13 Asmanex 13 Bumetanide 6
Advanced Care Plus 15 Aspirin/Butalbital/Caffeine 7, 12 Bupropion 7, 16
Advicor 6 Aspirin/Butalbital/Caffeine/Codeine 12 Bupropion HCl 16
Aggrenox 5 Aspirin/Oxycodone 12 Bupropion HCl Sustained-Action Tablet 16
Albuterol Sulfate 13 Astelin 14 Bupropion HCl Sustained-Release
Albuterol Sulfate/Ipratropium Non-Oral Astepro 14 24 Hour Tablet 16
Solution 13 Atacand 6 Bupropion XL 7
Alclometasone Dipropionate 9 Atacand HCT 6 Buspar 16
Aldactazide 50-50 mg 6 Atelvia 12 Buspirone 8, 16
Aldactone 16 Atenolol 6, 16 Butorphanol Nasal Spray 13
Alendronate 12, 16 Atenolol/Chlorthalidone 6, 16 Byetta 10
Alfuzosin 12, 16 Ativan 16 Bystolic 6
Allopurinol 13 Atorvastatin 6, 16 C
Alora 15 Atralin 9 Cabergoline 10
Alphagan P 0.1% 11 Atrovent HFA 13 Caduet 6
Alprazolam 8, 16 Augmentin 5, 16 Cafergot 7
Alsuma 7 Augmentin ES 16 Calan, Calan SR 16
Altabax 9 Augmentin XR 5 Calcipotriene Cream, Ointment 9
Altace 16 Avalide 6 Calcitonin Salmon Nasal Spray 12
Altavera 14 Avandamet 10 Calcitriol 10
Altoprev 6 Avandaryl 10 Cambia 7
Alvesco 13 Avandia 10 Camila 14
Alyacen 7/7/7 14 Avapro 6 Camrese 14
Amantadine 5 Avelox 5 Camrese Lo 14
Amaryl 16 Aviane 14 Canasa 11
Ambien 8, 16 Avinza 13 Captopril 6
Ambien CR 8 Avita Gel 9 Captopril/Hydrochlorothiazide 6
Amerge 16 Avodart 12 Carafate Oral Suspension 11
Amethia 14 Avonex 8 Carbamazepine 8
Amethia Lo 14 Axert 7 Carbamazepine Extended-Release
Amethyst 14 Axiron 10 12 Hour Capsule 8
Amiodarone 7 Azasite 10 Carbamazepine Sustained-Release
Amitiza 11 Azathioprine 12-13 12 Hour Tablet 8
Amitriptyline 7 Azelastine HCl 10, 14 Carbatrol 8

Visit www.myuhc.com for updates 17 2013 Prescription Drug List Advantage Three-Tier
Carbidopa/Levodopa 8 Clotrimazole 5, 9 Diltiazem Sustained-Release
Cardizem CD except for 360 mg strength 16 Clotrimazole/Betamethasone 9 24 Hour Capsule 6, 16
Cardizem LA 120 mg 6 Clozapine 8, 16 Diltiazem Sustained-Release
Cardizem LA 180, 240, 300, 360, 420 mg 6 Clozaril 16 24 Hour Tablet 6
Cardura 16 Codeine Phosphate 13 Diovan 6
Carisoprodol 250 mg 13 Colazal 16 Diovan HCT 6
Carisoprodol 350 mg 13 Colcrys 13 Dipentum 11
Carvedilol 6, 16 Colestid 16 Diphenoxylate/Atropine 11
Cavan-EC Sod DHA 15 Colestipol 6, 16 Ditropan XL 16
Caverject 11 Combigan 11 Diuril Suspension 250 mg/5 ml 6
Cayston 5 Combipatch 15 Divalproex Sodium Sprinkle Capsule 8
Caziant 14 Combivent 13 Divalproex Sodium Sustained-Release
Cefadroxil 5 Combivent Respimat 13 24 Hour Tablet 16
Cefdinir 5 Comtan 8 Divalproex Sodium Sustained-Release Tablet 8
Cefprozil 5, 16 Concerta 7 Divalproex Sodium Tablet 8, 16
Ceftin 16 Condylox Gel 9 Divigel 15
Cefuroxime 5, 16 Contour Test Strips 9 Donepezil 8, 16
Cefzil 16 Conzip 13 Donepezil 5, 10 mg 8
Celebrex 13 Copaxone 8 Doryx 5
Celexa 16 Coreg 6, 16 Dorzolamide Eye Drops 16
Cellcept Suspension 12 Coreg CR 6 Dorzolamide HCl 11
Celontin 8 Coumadin 5 Dorzolamide HCl/Timolol Maleate 11
Cenestin 15 Cozaar 16 Dovonex 9
Cephalexin 5, 16 Creon 11 Doxazosin 6, 12, 16
Cesamet 11 Crestor 6 Doxepin 7
Cetraxal 5 Crinone 15 Doxycycline Hyclate Enteric-Coated Tablet 5
Chlordiazepoxide/Clidinium 11 Cryselle 14 Doxycycline Monohydrate 5
Chlorhexidine Gluconate 12 Cuprimine 13 Doxycycline Monohydrate Capsule 150 mg 5
Chlorthalidone 6, 16 Cutivate Lotion 9 Duac 9
Cholestyramine 6 Cyclafem 1/35 14 Duetact 10
Cialis 11 Cyclafem 7/7/7 14 Duexis 13
Ciclopirox Cream, Gel, Lotion 9 Cyclobenzaprine 13 Dulera 13
Ciclopirox Non-Oral Solution 9 Cyclobenzaprine Extended-Release Duragesic 12
Ciclopirox Shampoo 1% 9 24 Hour Capsule 13 Dutoprol 6
Ciclopirox Solution, Non-Oral 16 Cymbalta 7 Dyazide 16
Cilostazol 5, 16 Cyproheptadine 14 E
Ciloxan Eye Drops 16 D Econazole Nitrate 9
Cimetidine 11 Daliresp 13 Edarbi 6
Cimzia 13 Dapsone 5 Edarbyclor 6
Cipro 5, 16 Daytrana 7 Edex 11
Cipro HC 5 DDAVP 16 Edluar 8
Cipro Suspension 5 Denavir 9 Effexor 16
Ciprodex Otic 5 Depakote 8, 16 Effexor XR 16
Ciprofloxacin 5, 10, 16 Depakote ER 8, 16 Effient 5
Ciprofloxacin Sustained-Release 24 Hour Tablet 5 Depo-Provera 16 Elestat 10
Ciprofloxacin Tablet 5 Depo-SubQ Provera 14 Elidel 9
Citalopram 7, 16 Derma-Smoothe/FS 16 Ella 14
Citalopram Hydrobromide 7 Desloratadine 14 Emadine 10
Clarinex 14 Desmopressin 10, 16 Embeda 13
Clarinex-D 14 Desonate 9 Emend 11
Clarithromycin Suspension 5 Desonide 9 Emoquette 14
Clarithromycin Sustained-Release Tablet 5 Desoximetasone 9 Enablex 12
Clarithromycin Tablet 5, 16 Detrol 12 Enalapril 6, 16
Cleocin HCl 75 mg 5 Detrol LA 12 Enalapril/Hydrochlorothiazide 6, 16
Cleocin T 16 Dexamethasone 10 Enbrel 13
Climara 15 Dexilant 11 Enjuvia 15
Climara Pro 15 Dextroamphetamine Sulfate 7 Enoxaparin 5
Clindagel 9 DiaBeta 16 Enpresse 14
Clindamycin Foam 1% 9 Diastat Acudial 16 Epiduo 9
Clindamycin Gel, Lotion, Solution, Swabs 9, 16 Diazepam 8, 16 Epinastine 10
Clindamycin HCl 5 Diazepam Rectal Gel 8, 16 Epipen 12
Clindamycin Palmitate 5 Dibenzyline 6 Epipen Jr 12
Clindamycin Phosphate/Benzoyl Peroxide Diclofenac 12, 16 Epivir HBV 5
Extended-Release Gel 9 Diclofenac Potassium 12 Eplerenone 6
Clindamycin Phosphate/Benzoyl Peroxide Diclofenac Sodium 12 Eprosartan 6, 16
Gel 1%-5% 9 Dicloxacillin Sodium 5 Ergomar 7
Clindesse Vaginal 5 Dicyclomine Tablet 12 Errin 14
Clobetasol Propionate 9 Didronel 16 Ery-Tab 500 mg 5
Clobetasol Propionate Foam 9 Differin Cream, Gel 0.1% 9 Erythromycin 5, 9-10
Clobetasol Propionate Lotion 9 Differin Gel 0.3% 9 Erythromycin/Benzoyl Peroxide 9
Clobetasol Propionate Shampoo 9 Differin Lotion 9 Erythromycin Base Enteric-Coated Tablet 5
Clobex 9 Diflucan 16 Escitalopram 7
Clobex Shampoo 9 Digoxin 7 Estrace Cream with Applicator 15
Clonazepam 8, 16 Dilantin 8 Estradiol 15
Clonidine 6 Diltiazem 6, 16 Estradiol/Norethindrone Acetate 15
Clonidine Transdermal Weekly Patch 6 Diltiazem Controlled-Release Capsule 6 Estradiol Transdermal Weekly Patch 15
Clopidogrel 5, 16 Diltiazem Sustained-Action Capsule 6 Estrasorb 15
Clorpres 6 Diltiazem Sustained-Release 12 Hour Capsule 6 Estring 15

Visit www.myuhc.com for updates 18 2013 Prescription Drug List Advantage Three-Tier
Estrogel 15 Generess Fe 14 Janumet XR 10
Estropipate 15 Genotropin 10 Januvia 10
Etidronate Disodium 16 Gentamicin Sulfate 10 Jentadueto 10
Etodolac 12 Geodon 8 Jolessa 14
Evamist 15 Gianvi 14 Jolivette 14
Evista 12 Gildess FE 14 Junel 14
Evoclin 9 Gilenya 8 Junel Fe 14
Exalgo 13 Glimepiride 10, 16 Juvisync 10
Exelon Solution 8 Glipizide 10, 16 K
Exemestane 12 Glipizide/Metformin 10 Kadian 13
Exforge 6 Glucophage, XR 16 Kapvay 7
Exforge HCT 6 Glucotrol, XL 16 Kariva 14
Extavia 8 Glucovance 16 Keflex 16
F Glumetza 10 Kelnor 14
Famciclovir 5 Glyburide 10, 16 Keppra 8, 16
Fanapt 8 Glyburide/Metformin 10, 16 Keppra XR 8
Fareston 12 Glynase 16 Ketoconazole 5, 9
FazaClo 8 Glyset 10 Ketoconazole Foam 5
Felbamate 8, 16 GoLYTELY Packet 11 Ketorolac Tromethamine 10, 12, 16
Felbatol 16 Gralise 13 Kineret 13
Felodipine 6 Granisetron Tablet 11 Klonopin 16
Femara 16 Guanfacine 6 Kombiglyze XR 10
Femcon Fe 14 Gynazole-1 Vaginal 5 Kuvan 10
Femhrt 15 H L
Femring 15 Halflytely-Bisacodyl 11 Labetalol 6
Fenofibrate 6 Halobetasol Propionate 9 Lactulose 11
Fenofibric Acid 6 Heather 14 Lamictal 8, 16
Fenoglide 6 Hectorol 10 Lamictal Dose Pack 8
Fentanyl Citrate Lollipop 13 Helidac 11 Lamictal ODT 8
Fentanyl Transdermal 13 Hepsera 5 Lamictal XR 8
Fentora 13 Horizant 13 Lamisil 5, 16
Finacea 9 Humalog-Mix KwikPen 9 Lamisil Granules 5
Finacea Plus 9 Humalog-Mix Vials 9 Lamotrigine 8, 16
Finasteride 12, 16 Humalog KwikPen 9 Lanoxin 7
Fioricet 16 Humalog Vials 9 Lansoprazole 11
First-Progesterone 15 Humatrope 10 Lantus Solostar Pens/Cartridges 9
Flecainide Acetate 7 Humira 13 Lantus Vials 9
Flector 13 Humulin 70-30 Vials 9 Lasix 16
Flomax 16 Humulin KwikPen 9 Lastacaft 10
Flonase 16 Humulin Vials 9 Latanoprost 11, 16
Flovent Diskus 13 Hycet 13 Lazanda 13
Flovent HFA 13 Hydralazine 6 Leena 14
Fluconazole 5, 16 Hydrochlorothiazide 6, 16 Leflunomide 13
Fludrocortisone 10 Hydrocodone/Chlorpheniramine Suspension 12 Lescol XL 6
Flunisolide 14 Hydrocortisone 9-10 Lessina 14
Fluocinolone 9, 16 Hydrocortisone Tablet 10 Letrozole 12, 16
Fluocinonide 9 Hydrocortisone Valerate 9 Levalbuterol Vial, Nebulizer 13
Fluoxetine 7-8, 16 Hydromorphone 12 Levaquin 16
Fluoxetine Capsule 16 Hydroxychloroquine Sulfate 13 Levemir Flexpen 9
Fluoxetine Delayed-Release Capsule 7, 16 Hydroxyzine 14 Levemir Vials 9
Fluticasone Nasal Spray 16 Hyoscyamine Sulfate 12 Levetiracetam 8, 16
Fluticasone Propionate 9, 14 Hyzaar 16 Levetiracetam Extended-Release 24 Hour Tablet 8
Fluticasone Propionate Lotion 9 I Levitra 11
Fluvastatin 6 Ibandronate Tablet 12 Levocetirizine Oral Solution 14
Fluvoxamine Maleate 7 Ibuprofen 12, 16 Levocetirizine Tablet 14
Focalin XR 7 Ibuprofen/Hydrocodone 12, 16 Levofloxacin 5, 10, 16
Folcal DHA 15 Ibuprofen/Oxycodone 12 Levora 14
Folic Acid 15 Imiquimod 9 Levothyroxine Sodium 10
Fondaparinux 5 Imitrex 16 Levoxyl 10
Foradil 13 Incivek 5 Lexapro 7
Fortamet 10 Indomethacin 12 Lialda 11
Forteo 12 Infergen 12 Lidocaine 9
Fortesta 10 Innohep 5 Lidoderm 12
Fortical 12 Intron A 12 Liothyronine Sodium 10
Fosamax 12, 16 Introvale 14 Lipitor 6, 16
Fosamax Plus D 12 Intuniv 7 Lipofen 6
Fosinopril 16 Invega 8 Lisinopril 6, 16
Fragmin 5 Iopidine 1% 11 Lisinopril/Hydrochlorothiazide 6, 16
Freestyle Lite Test Strips 9 Ipratropium Bromide 13 Lithium Carbonate 8
Freestyle Test Strips 9 Irbesartan 6 Lithium Carbonate Controlled-Release Tablet 8
Frova 7 Irbesartan/Hydrochlorothiazide 6 Livalo 6
Furosemide 6, 16 Isosorbide Dinitrate 7 Lo Loestrin Fe 14
G Isosorbide Mononitrate 7 Locoid Lipocream 9
Gabapentin 8, 16 Isotretinoin 9 Locoid Lotion 9
Gabitril 8 Itraconazole Capsule 5 Loestrin 24 Fe 14
Galantamine 8 J Lopid 16
Gelnique 12 Jalyn 12 Lopressor 16
Gemfibrozil 6, 16 Janumet 10 Loprox Shampoo 9

Visit www.myuhc.com for updates 19 2013 Prescription Drug List Advantage Three-Tier
Lorazepam 8, 16 Mobic 16 NovoLog 9
Loryna 14 Modafinil 8 Noxafil 5
Losartan 6, 16 Moexipril 6 Nucynta 13
Losartan/Hydrochlorothiazide 6, 16 Mometasone Furoate 9 Nucynta ER 13
Lotronex 11 Mononessa 14 Nuedexta 8
Lovastatin 6, 16 Monopril 16 Nutropin, AQ, NuSpin 10
Lovaza 6 Montelukast 13 NuvaRing 14
Low-Ogestrel 14 Morphine Sulfate 12-13 Nuvigil 8
Lumigan 11 Morphine Sulfate Extended-Release Pellets 13 Nystatin 5, 9
Lunesta 8 Morphine Sulfate Sustained-Action Tablet 12 Nystatin/Triamcinolone Acetonide 9
Lutera 14 Moviprep 11 O
Luvox CR 7 Moxeza 10 Ocella 14
Lyrica 8 MSIR Capsule 13 Octreotide Acetate 10
Lysteda 12 Multaq 7 Ocuflox Eye Drops 16
M Multi-Nate 30 15 Ofloxacin 5, 10, 16
Macrodantin 25 mg 5 Multinatal Plus 15 Ofloxacin Otic 5
Marlissa 14 Mupirocin 9 Ogestrel 14
Mavik 16 Muse 11 Olanzapine/Fluoxetine 8
Maxair Autohaler 13 Mycophenolate Capsule, Tablet 12 Olanzapine Rapid Dissolve Tablet 8
Maxalt 7 Mycostatin 5 Olanzapine Tablet 8
Maxalt MLT 7 Myfortic 12 Oleptro 7
Medrol 10, 16 Mysoline 8 Olux-E 9
Medrol 2, 8, 24, 32 mg 10 Myzilra 14 Omeprazole 11, 16
Medroxyprogesterone 14-16 N Omeprazole/Sodium Bicarbonate Capsule 11
Medroxyprogesterone 150 mg/ml 14, 16 Nabumetone 12 Omnaris 14
Mefenamic Acid 13 Nadolol 6 Omnitrope 10
Megestrol Acetate 12 Naftin 9 Ondansetron 11, 16
Meloxicam 12, 16 Namenda 8 One Touch Test Strips 9
Menostar Transdermal Weekly Patch 15 Naprelan 13 One Touch Ultra 2 System 9
Meperidine 12 Naprosyn - Prescription strengths only 16 One Touch Ultra Mini System 9
Mesalamine 11 Naproxen 12, 16 One Touch Ultra Test Strips 9
Metadate CD 7 Naproxen - Prescription strengths only 16 One Touch Verio IQ System 9
Metaxalone 13 Naproxen Sodium 12 One Touch Verio IQ Test Strips 9
Metformin 10, 16 Naratriptan 7, 16 Onglyza 10
Metformin Extended-Release 24 Hour Tablet 10 Nardil 16 Onsolis 13
Methadone 12 Nasacort AQ 14 Opana 13
Methamphetamine 7 Nasonex 14 Opana ER 13
Methimazole 10 Natazia 14 Optivar 10
Methocarbamol 13 Nateglinide 10 Oracea 5
Methotrexate 13 Necon 0.5/35 14 Orapred 10
Methylin Tablet 7 Necon 1/35 14 Orapred ODT 10
Methylphenidate 7, 16 Necon 1/50 14 Orencia 13
Methylphenidate Extended-Release Necon 10/11 14 Orphenadrine 13
24 Hour Tablet 7 Necon 7/7/7 14 Orphenadrine/Aspirin/Caffeine 13
Methylphenidate Extended-Release Capsule 7 Nefazodone 7 Orsythia 14
Methylphenidate Extended-Release Tablet 16 Neomycin/Polymyxin/HC Otic 5 Ortho-Cyclen 14
Methylprednisolone Dosepak Tablet 4 mg 10, 16 Neomycin/Polymyxin B Sulfate/ Ortho-Novum 7/7/7 14
Metoclopramide 11 Dexamethasone 10 Ortho Evra 14
Metolazone 6 Neoral 12 Ortho Micronor 14
Metoprolol 6, 16 Neurontin 16 Ortho Tri-Cyclen 14
Metoprolol/Hydrochlorothiazide 6 Nexiclon XR 6 Ortho Tri-Cyclen Lo 14
Metoprolol Succinate Sustained-Release Nexium Capsule 11 Oxandrolone 10
Tablet 6, 16 Nexium Suspension 11 Oxaprozin 12
Metoprolol Succinate Sustained-Release Next Choice One Dose 14 Oxcarbazepine 8, 16
Tablet 25 mg 6 Niaspan 6 Oxistat 9
Metoprolol Succinate Sustained-Release Nifedipine 6, 16 Oxsoralen-Ultra 9
Tablet 50, 100, 200 mg 6 Nifedipine Extended-Release Tablet 16 Oxybutynin 12, 16
Metoprolol Tartrate 6 Nisoldipine 6 Oxybutynin Sustained-Release Tablet 16
Metozolv ODT 11 Nitrofurantoin/Nitrofurantoin Macrocrystal 5 Oxycodone 12, 16
Metrogel 1% 9 Nitrofurantoin Macrocrystal 5 OxyContin 13
Metrogel Vaginal 16 Nitrofurantoin Suspension 5 Oxymorphone 13
Metrolotion 9 Nitroglycerin Spray 7 Oxymorphone Extended-Release
Metronidazole 5, 9, 16 Nitroglycerin Transdermal Patch 7 12 Hour Tablet 13
Metronidazole Gel 0.75% 9 Nitrolingual 7 Oxytrol 12
Metronidazole Vaginal 5 Nitromist 7 P
Mevacor 16 Nitrostat 7 Pancreaze 11
Mexiletine 7 Nizatidine Oral Solution 11 Pantoprazole 11, 16
Micardis 6 Nora-Be 14 Paroxetine 7, 16
Micardis HCT 6 Norditropin 10 Paroxetine Sustained-Release 24 Hour Tablet 7
Microgestin 14 Norethindrone 14-15 Paroxetine Tablet 7
Microgestin Fe 14 Norethindrone Acetate 15 Pataday 10
Migranal 7 Noritate 9 Patanase 14
Minocycline Extended-Release 24 Hour Tablet 5 Nortrel 0.5/35 14 Patanol 10
Minocycline HCl 5 Nortrel 1/35 14 Paxil 16
Mirapex ER 8 Nortrel 7/7/7 14 Pediapred 10
Mirtazapine 7, 16 Nortriptyline 7 Peg-Intron 12
Mirtazapine Dispersible Tablet 16 Norvasc 16 Peganone 8
Misoprostol 11 Novolin Vials 9 Pegasys 12

Visit www.myuhc.com for updates 20 2013 Prescription Drug List Advantage Three-Tier
Penicillin V Potassium 5 Q Sular 6
Penlac 16 Quasense 14 Sulfacetamide Sodium 9-10
Pennsaid 13 Quetiapine 8 Sulfacetamide Sodium/Sulfur 9
Pentasa 11 Quinapril 6, 16 Sulfamethoxazole/Trimethoprim 5
Pentoxifylline 5 Quinapril/Hydrochlorothiazide 6 Sulfasalazine 11, 13
Percocet 5-325, 7.5-500, 10-650 16 QVAR 13 Sulindac 12
Perforomist 13 R Sumatriptan Succinate Injection, Tablet 7, 16
Perindopril Erbumine 6 Ramipril 6, 16 Sumatriptan Succinate Nasal Spray 7
Permethrin 9 Ranexa 7 Sumavel DosePro 7
Pexeva 7 Ranitidine Syrup 11, 16 Suprax 5
Phenazopyridine 12 Rapaflo 12 Surmontil 16
Phenelzine 7, 16 Rapamune 12 Syeda 14
Phenobarbital 8, 11 Rebetol Solution 5 Symbicort 13
Phenytoin Sodium 8 Rebif 8 Symbyax 8
Philith 14 Reclipsen 14 Symlin 10
Pilopine HS 11 Regranex 9 Synarel 10
Pioglitazone 10 Relenza 5 Synthroid 10
Pioglitazone/Metformin 10 Relistor 11 T
Piroxicam 12 Relpax 7 Taclonex 9
Plan B 14 Remeron 16 Taclonex Scalp 9
Plavix 16 Remeron SolTab 16 Tacrolimus 12
Pletal 16 Requip 8, 16 Tamiflu 5
Polyethylene Glycol 11 Requip XL 8 Tamoxifen 12
Polymyxin B Sulfate/Trimethoprim 10 Restasis 12 Tamsulosin 12, 16
Portia 14 Restoril 16 Taron A Prenatal 15
PR Natal 430 15 Retin-A Micro 9 Tasmar 8
PR Natal 430 EC 15 Rhinocort Aqua 14 Tazorac 9
Pradaxa 5 Ribapak 5 Tegretol 8
Pramipexole 8 Ribavirin 5 Tekamlo 6
Prandin 10 Risperdal 16 Tekturna 6
Pravachol 16 Risperidone 8, 16 Tekturna HCT 6
Pravastatin 6, 16 Ritalin 7, 16 Temazepam 8, 16
Ritalin LA 7 Tenoretic 16
Precision Xtra Test Strips 9
Ritalin SR 16 Tenormin 16
Precose 16
Rivastigmine 8 Terazosin 6, 12
Prednisolone 10
Ropinirole 8, 16 Terbinafine Tablet 5, 16
Prednisone 10
Ropinirole Extended-Release 24 Hour Tablet 8 Terconazole Vaginal 5
Prefest 15
Rozerem 8 Testim 10
Premarin 15
Rybix ODT 13 Testosterone 10
Premphase 15
Ryzolt 13 Tetracycline 5
Prempro 15
S Tev-Tropin 10
Prenatal 19 15
Sabril 8 Teveten 6, 16
Prenatal Advantage 15
Safyral 14 Teveten HCT 6
Prenatal Plus 15
Saizen 10 Thalitone 6
Prevacid Delayed-Release Enteric-Coated
Sanctura XR 12 Theophylline 13
Capsule 11 Sancuso 11 Tiazac 16
Prevacid Solutab 11 Sandimmune 12 Tilia Fe 14
Previfem 14 Savella 13 Timolol Maleate 11
Prevpac 11 Serevent Diskus 13 Tirosint 10
Prilosec 11, 16 Seroquel 8 Tizanidine Capsule 13
Prilosec Rx 10, 20 mg 11 Seroquel XR 8 Tizanidine Tablet 13
Prilosec Rx 40 mg 11 Serostim 10 Tobi 5
Primidone 8 Sertraline 7, 16 Tobradex ST 10
Prinivil 16 Setonet 15 Tobramycin/Dexamethasone 10
Prinzide 16 Setonet-EC 15 Tobramycin Sulfate Drops 10
Pristiq 7 Silenor 8 Tolmetin Sodium 13
Proair HFA 13 Silver Sulfadiazine 9 Tolterodine 12
Procardia XL 16 Simcor 6 Topamax 8, 16
Prochlorperazine Maleate 11 Simponi 13 Topiramate 8, 16
Progesterone Micronized Capsule 15 Simvastatin 6, 16 Toprol XL 25 mg 16
Promethazine 14 Singulair 13 Torsemide 6
Propafenone Sustained-Release Skelaxin 13 Toviaz 12
12 Hour Capsule 7 Solodyn 5 Tradjenta 10
Propranolol/Hydrochlorothiazide 6 Soma 250 mg 13 Tramadol 12-13, 16
Propranolol Sustained-Action Capsule 6 Sonata 8, 16 Tramadol/Acetaminophen 12, 16
Propranolol Tablet 6 Sotalol 7 Tramadol Extended-Release Multiphase
Proscar 16 Spiriva 13 24 Hour Tablet 13
Protonix 11, 16 Spironolactone 6, 16 Tramadol Sustained-Release 24 Hour Tablet 13
Protonix Granules 11 Spironolactone/Hydrochlorothiazide 6 Trandolapril 6, 16
Protopic 9 Sporanox Oral Solution 5 Trandolapril/Verapamil 6
Proventil HFA 13 Sprintec 14 Transderm-Scop 11
Provera 14, 16 Sprix 13 Travatan Z 11
Provigil 8 Sronyx 14 Trazodone 7
Prozac 16 Stavzor 8 Tretin-X 9
Prozac Weekly 16 Staxyn 11 Tretinoin 9
Pulmicort Flexhaler 13 Stelara 9 Trexall 13
Pulmicort Respules 1 mg/2 ml 13 Strattera 7 Treximet 7
Pylera 11 Sucralfate Tablet 11 Tri-Legest Fe 14

Visit www.myuhc.com for updates 21 2013 Prescription Drug List Advantage Three-Tier
Tri-Previfem 14 Xyrem 8
Tri-Sprintec 14 Y
Triamcinolone Acetonide 9, 14 Yasmin 14
Triamterene/Hydrochlorothiazide 6, 16 Yaz 14
Tribenzor 6 Z
Tricor 6 Zafirlukast 13, 16
Triglide 6 Zaleplon 8, 16
Trileptal 16 Zantac Syrup 16
Trilipix 6 Zarah 14
Trilyte with Flavor Packets 11 Zatean-PN 15
Trimipramine Maleate 16 Zatean-PN DHA 15
Trinessa 14 Zatean-PN Plus 15
Trivora 14 Zegerid Capsule 11
Trospium 12 Zegerid Packet 11
Trusopt 16 Zemplar 10
Tussionex 12 Zenchent 14
Twynsta 6 Zenchent Fe 14
Tylenol #3 16 Zenpep 11
U Zeosa 14
Uloric 13 Zestoretic 16
Ultracet 16 Zestril 16
Ultram 16 Zetia 6
Urea 9 Ziac 16
Uroxatral 16 Ziana 9
Ursodiol 11 Ziprasidone 8
V Zipsor 13
Vagifem 15 Zithromax 16
Valacyclovir 5 Zocor 16
Valcyte 5 Zofran 16
Valium 16 Zoloft 16
Vancomycin 5 Zolpidem 8, 16
Vanos 9 Zolpidem Multiphasic-Release Tablet 8
Vaseretic 16 Zolpidem Tablet 8
Vasotec 16 Zolpimist 8
Vectical 9 Zomig 7
Velivet 14 Zomig Nasal Spray 7
Veltin 9 Zomig ZMT 7
Venlafaxine 7, 16 Zonegran 16
Venlafaxine Extended-Release Tablet 7 Zonisamide 8, 16
Venlafaxine Sustained-Release Capsule 7, 16 Zorbtive 10
Ventolin HFA 13 Zovia 1/35E 14
Veramyst 14 Zovia 1/50E 14
Verapamil 6, 16 Zovirax 9, 16
Verapamil Sustained-Release 24 Hour Pellets 6 Zuplenz 11
Verdeso 9 Zyclara 9
Vesicare 12 Zylet 10
Vestura 14 Zymaxid 10
Vfend 16 Zyprexa 8
Viagra 11 Zyprexa Zydis 8
Vicodin, Vicodin ES 16 Zyvox 5
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

Visit www.myuhc.com for updates 22 2013 Prescription Drug List Advantage Three-Tier