2020 LIST OF COVERED DRUGS (FORMULARY)
Prescription drug list information
UnitedHealthcare Dual Complete® ONE (HMO D-SNP)
Important Notes: This document has information about the drugs covered by this plan. For more recent information or if you have questions, please call Customer Service at:
Toll-free 1-800-514-4911, TTY 711 8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept
www.UHCCommunityPlan.com
Formulary ID Number 00020047, Version 11 H3113_190701_012345_C v01.03
Last updated March 1, 2020
UnitedHealthcare Dual Complete® ONE (HMO D-SNP)
2020 List of Covered Drugs (Formulary)
IntroductionThis document is called the List of Covered Drugs (also known as the Drug List). It tells you which prescription drugs and over-the-counter (OTC) drugs are covered by UnitedHealthcare Dual Complete ONE. The Drug List also tells you if there are any special rules or restrictions on any drugs covered by UnitedHealthcare Dual Complete ONE. Key terms and their definitions appear in the last chapter of the Evidence of Coverage.
Our contact information, along with the date we last updated the Drug List, appears on the front and back cover pages.
Table of Contents
A. Disclaimers..............................................................................................................................................4
B. Frequently Asked Questions (FAQ)...................................................................................................... 5
B1. What prescription drugs are on the List of Covered Drugs? (We call the List of CoveredDrugs the �� Drug List � for short.)................................................................................................ 5
B2. Does the Drug List ever change?...............................................................................................5
B3. What happens when there is a change to the Drug List?........................................................ 6
B4. Are there any restrictions or limits on drug coverage or any required actions to take to getcertain drugs?.............................................................................................................................. 7
B5. How will you know if the drug you want has limitations or if there are any actions requiredto get the drug?........................................................................................................................... 7
B6. What happens if we change our rules about how we cover some drugs (for example, priorauthorization (approval), quantity limits, and/or step therapy restrictions)?.......................... 8
B7. How can you find a drug on the Drug List?...............................................................................8
B8. What if the drug you want to take is not on the Drug List?...................................................... 8
B9. What if you are a new UnitedHealthcare Dual Complete ONE member and can � t find yourdrug on the Drug List or have a problem getting your drug?.................................................. 8
B10. Can you ask for an exception to cover your drug?...................................................................9
B11. How can you ask for an exception?.........................................................................................10
B12. How long does it take to get an exception?............................................................................10
B13. What are generic drugs?.......................................................................................................... 10
This section is continued on the next page.
B14. What are over-the-counter (OTC) drugs?................................................................................ 10
B15. Does UnitedHealthcare Dual Complete ONE cover non-drug OTC products?................... 10
B16. Can you get a long-term supply of drugs?.............................................................................. 10
B17. What is your copay?..................................................................................................................11
C. Overview of the List of Covered Drugs...............................................................................................12
C1. List of Drugs by Medical Condition......................................................................................... 12
C2. Covered drugs with a quantity limit (QL).................................................................................90
C3. Over-the-counter (OTC) Drug List.......................................................................................... 117
D. Index of Covered Drugs.....................................................................................................................150
If you have questions, please call UnitedHealthcare Dual Complete ONE Customer Service at 1-800-514-4911, TTY 711, 8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept. The call is free. For more
information, visit www.UHCCommunityPlan.com.
A. Disclaimers
This is a list of drugs that members can get in UnitedHealthcare Dual Complete ONE.
v Plans are insured through UnitedHealthcare Dual Complete® ONE (HMO D-SNP), a Medicare Advantage organization with a Medicare contract and a contract with the state Medicaid program. Enrollment in the plan depends on the plan� s contract renewal.
Members must use network plan providers, pharmacies, DME (Durable Medical Equipment) suppliers, and follow the rules on referrals. Members will be enrolled into Medicare Part D prescription drug coverage under the plan and will be automatically disenrolled from any other Medicare Advantage or Medicare Part D prescription drug coverage.
v The Drug List (formulary) may change on January 1 of each year, and from time to time during the plan year. You will receive notice when necessary.
v You can always check UnitedHealthcare Dual Complete ONE� s up-to-date List of Covered Drugs online at www.UHCCommunityPlan.com or by calling Customer Service toll-free at 1-800-514-4911, TTY 711, 8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept.
v ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Call UnitedHealthcare Dual Complete ONE Customer Service at 1-800-514-4911, TTY 711, 8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept. The call is free.
v ATENCIÓN: Si habla español, hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame a Servicio al Cliente de UnitedHealthcare Dual Complete ONE al 1-800-514-4911, TTY 711, de 8 a.m. a 8 p.m.: los 7 días de la semana, de octubre a marzo; de lunes a viernes, de abril a septiembre. La llamada es gratuita.
v You can get this document for free in other formats, such as large print, braille, or audio. Call Customer Service at 1-800-514-4911, TTY 711, 8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept.
v You can call Customer Service and ask us to make a note in our system that you would like materials in Spanish, large print, braille or audio now and in the future.
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B. Frequently Asked Questions (FAQ)
Find answers to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more or look for a question and answer.
B1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the “Drug List” for short.)
The drugs on the Drug List that starts on page 12 are the drugs covered by UnitedHealthcare Dual Complete ONE. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as � network pharmacies.�
· UnitedHealthcare Dual Complete ONE will cover all medically necessary drugs on the Drug List if:
o Your doctor or other prescriber says you need them to get better or stay healthy, and
o You fill the prescription at a UnitedHealthcare Dual Complete ONE network pharmacy.
· UnitedHealthcare Dual Complete ONE may have additional steps to access certain drugs. See question B4 for more information.
You can also see an up-to-date list of drugs we cover on our website at www.UHCCommunityPlan.com or call Customer Service at 1-800-514-4911, TTY 711, 8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept.
B2. Does the Drug List ever change?
Yes. UnitedHealthcare Dual Complete ONE may add or remove drugs on the Drug List during the year. We must follow Medicare rules in making these changes.
We may also change our rules about drugs. For example we could:
· Decide to require or not require prior authorization (approval) for a drug. (Prior authorization (approval) is permission from UnitedHealthcare Dual Complete ONE before you can get a drug.)
· Add or change the amount of a drug you can get (called quantity limits).
· Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.)
For more information on these drug rules, see question B4.
If you are taking a drug that was covered at the beginning of the year, we will generally not remove or change coverage of that drug during the rest of the year unless:
This section is continued on the next page.
If you have questions, please call UnitedHealthcare Dual Complete ONE Customer Service at 1-800-514-4911, TTY 711, 8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept. The call is free. For more
information, visit www.UHCCommunityPlan.com.
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· A new, cheaper drug comes on the market that works as well as a drug on the Drug List now, or
· We learn that a drug is not safe, or
· A drug is removed from the market.
Questions B3 and B6 have more information on what happens when the Drug List changes.
· You can always check UnitedHealthcare Dual Complete ONE� s current Drug List online at www.UHCCommunityPlan.com.
· You can also call Customer Service at 1-800-514-4911, TTY 711, 8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept to check the current Drug List.
B3. What happens when there is a change to the Drug List?
Some changes to the Drug List will happen immediately. For example:
· A new generic drug becomes available. Sometimes, a new generic drug comes on the market that works as well as a brand name drug on the Drug List now. When that happens, we may remove the brand name drug and add the new generic drug. When we add the new generic drug, we may also decide to keep the brand name drug on the list but change its coverage rules or limits.
o We may not tell you before we make this change, but we will send you information about the specific change we made once it happens.
o You or your provider can ask for an exception from these changes. We will send you a notice with the steps you can take to ask for an exception. Please see questions B10 - B12 for more information on exceptions.
· A drug is taken off the market. If the Food and Drug Administration (FDA) says a drug you are taking is not safe or the drug � s manufacturer takes a drug off the market, we will take it off the Drug List. If you are taking the drug, we will let you know. Contact your doctor or other prescriber and ask about your other options.
We may make other changes that affect the drugs you take. We will tell you in advance about these other changes to the Drug List. These changes might happen if:
· The FDA provides new guidance or there are new clinical guidelines about a drug.
· We add a generic drug that is new to the market and
· Replace a brand name drug currently on the Drug List or
· Change the coverage rules or limits for the brand name drug.
When these changes happen, we will:
· Tell you at least 30 days before we make the change to the Drug List or
· Let you know and give you a 30-day supply of the drug after you ask for a refill.
This section is continued on the next page.
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This will give you time to talk to your doctor or other prescriber. He or she can help you decide:
· If there is a similar drug on the Drug List you can take instead or
· Whether to ask for an exception from these changes. To learn more about exceptions, see questions B10 - B12 for more information about exceptions.
B4. Are there any restrictions or limits on drug coverage or any required actions to take to get certain drugs?
Yes. Some drugs have coverage rules or have limits on the amount you can get. In some cases you or your doctor or other prescriber must do something before you can get the drug. For example:
· Prior authorization (approval): For some drugs, you, your doctor or other prescriber must get authorization (approval) from UnitedHealthcare Dual Complete ONE before you fill your prescription. Prior authorization is different from a referral. UnitedHealthcare Dual Complete ONE may not cover the drug if you don � t get authorization (approval).
· Quantity limits: Sometimes UnitedHealthcare Dual Complete ONE limits the amount of a drug you can get.
· Step therapy: Sometimes UnitedHealthcare Dual Complete ONE requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor or other prescriber thinks the first drug doesn � t work for you, then we will cover the second.
You can find out if your drug has any additional requirements or limits by looking in the tables on pages 14 - 89. You can also get more information by visiting our website at www.UHCCommunityPlan.com. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy.
You can ask for an exception to these limits. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Please see questions B10 - B12 for more information about exceptions.
B5. How will you know if the drug you want has limitations or if there are any actions required to get the drug?
The Drug List on pages 14 - 89 has a column labeled � Necessary actions, restrictions, or limits on use.�
This section is continued on the next page.
If you have questions, please call UnitedHealthcare Dual Complete ONE Customer Service at 1-800-514-4911, TTY 711, 8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept. The call is free. For more
information, visit www.UHCCommunityPlan.com.
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B6. What happens if we change our rules about how we cover some drugs (for
example, prior authorization (approval), quantity limits, and/or step therapy
restrictions)?
In some cases, we will tell you in advance if we add or change prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug. See question B3 for more information about this advance notice and situations where we may not be able to tell you in advance when our rules about drugs on the Drug List change.
B7. How can you find a drug on the Drug List?
There are two ways to find a drug:
· You can search alphabetically (if you know how to spell the drug), or
· You can search by medical condition.
To search alphabetically, go to the Index of Covered Drugs section that begins on page 150. The Index is an alphabetical list of all of the drugs included in the Drug List. Both brand name drugs and generic drugs are listed. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. To search by medical condition, find the section labeled � List of Drugs by Medical Condition � on page 12. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in that category. That is where you will find drugs that treat heart conditions.
B8. What if the drug you want to take is not on the Drug List?
If you don� t see your drug on the Drug List, call Customer Service at 1-800-514-4911, TTY 711 and ask about it. If you learn that UnitedHealthcare Dual Complete ONE will not cover the drug, you can do one of these things:
· Ask Customer Service for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or
· You can ask the health plan to make an exception to cover your drug. Please see questions B10 - B12 for more information about exceptions.
B9. What if you are a new UnitedHealthcare Dual Complete ONE member and can’t find your drug on the Drug List or have a problem getting your drug?
We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of UnitedHealthcare Dual Complete ONE. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead, or whether to ask for an exception.
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If your prescription is written for fewer days, we will allow multiple refills to provide up to a maximum of 30 days of medication.
We will cover a temporary 30-day supply of your drug if:
.
If
1-
in
· You are taking a drug that is not on our Drug List, or
· Health plan rules do not let you get the amount ordered by your prescriber, or
· The drug requires prior authorization (approval) by UnitedHealthcare Dual Complete ONE, or
· You are taking a drug that is part of a step therapy restriction.
If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List or if you cannot easily get the drug you need, we can help. If you have been in the plan for more than 90 days, live in a long-term care facility, and need a supply right away:
· We will cover one 31-day supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new UnitedHealthcare Dual Complete ONE member.
· This is in addition to the temporary supply during the first 90 days you are a member of UnitedHealthcare Dual Complete ONE.
If you are going through a change in your level of care, such as being transferred from a hospital to a long-term care facility, any time during the year, we may cover a temporary 31-day supply of the drug you need. This will give you time to talk to your doctor or other prescriber about other treatment options or to try to get an exception. Please see questions B10 - B12 for more information about exceptions.
We will not pay for more of your drug after you get a temporary supply unless you receive authorization from the plan.
B10. Can you ask for an exception to cover your drug?
Yes. You can ask UnitedHealthcare Dual Complete ONE to make an exception to cover a drug that is not on the Drug List.
You can also ask us to change the rules on your drug.
· For example, UnitedHealthcare Dual Complete ONE may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more.
· Other examples: You can ask us to drop step therapy restrictions or prior authorization (approval) requirements.
This section is continued on the next page
you have questions, please call UnitedHealthcare Dual Complete ONE Customer Service at 800-514-4911, TTY 711, 8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept. The call is free. For more
formation, visit www.UHCCommunityPlan.com.
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B14. What are over-the-counter (OTC) drugs?
OTC stands for � over-the-counter. � UnitedHealthcare Dual Complete ONE offers some OTC drugs through the NJ FamilyCare (Medicaid) portion of the plan � s coverage at no cost to you. You need a prescription for OTC drugs to be covered. These OTC drugs are listed in this Drug List starting on page 117.
B15. Does UnitedHealthcare Dual Complete ONE cover non-drug OTC products?
Yes. UnitedHealthcare Dual Complete ONE covers some non-drug OTC products when they are prescribed for you by your provider. These non-drug OTC products are listed in the Drug List.
B16. Can you get a long-term supply of drugs?
Yes. UnitedHealthcare Dual Complete ONE offers two ways to get a long-term supply of � maintenance � drugs on our plan � s Drug List. (Maintenance drugs are drugs that you take on a regular basis, for a chronic or long-term medical condition.)
· Retail pharmacy. Some retail pharmacies in our network allow you to get a long-term supply of maintenance drugs. Your Provider and Pharmacy Directory tells you which pharmacies in our network can give you a long-term supply of maintenance drugs.
B11. How can you ask for an exception?
To ask for an exception, call Customer Service. A Customer Service representative will work with you and your provider to help you ask for an exception. You can also read Chapter 8 of the Evidence of Coverage to learn more about exceptions.
B12. How long does it take to get an exception?
First, we must get a statement from your prescriber supporting your request for an exception. After we get the statement, we will give you a decision on your exception request within 72 hours.
If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of getting your prescriber� s supporting statement.
B13. What are generic drugs?
Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don� t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA).
UnitedHealthcare Dual Complete ONE covers both brand name drugs and generic drugs.
· Mail-order. For certain kinds of drugs, you can use the plan � s network mail-order services. Our plan � s mail-order service allows you to get up to a 90-day supply. To get order forms
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and information about filling your prescriptions by mail, please reference your Provider and
Pharmacy Directory to find the mail service pharmacies in our network.
For more information about getting a long-term supply of drugs, call Customer Service at 1-800-514-4911, TTY 711.
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B17. What is your copay?
UnitedHealthcare Dual Complete ONE members have no copays for prescription and over-the-counter (OTC) drugs and non-drug products as long as the member follows the plan� s rules. See questions B14 and B15 for more information about OTC drugs and non-drug products.
Tiers are groups of drugs on our Drug List. Your plan has 1 tier named � Covered Drugs.� All covered drugs are in this tier.
· Tier 1 Generic drugs have $0 copay.
· Tier 1 Brand name drugs have $0 copay.
OTCs have $0 copay.
f you have questions, call Customer Service at 1-800-514-4911, TTY 711.
f you have questions, please call UnitedHealthcare Dual Complete ONE Customer Service at 1-800-514-4911, TTY 711, 8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept. The call is free. For more
nformation, visit www.UHCCommunityPlan.com.
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C. Overview of the List of Covered Drugs
The List of Covered Drugs gives you information about the drugs covered by UnitedHealthcare Dual Complete ONE. If you have trouble finding your drug in the list, turn to the Index of Covered Drugs that begins on page 150. The index alphabetically lists all drugs covered by UnitedHealthcare Dual Complete ONE.
C1. List of Drugs by Medical Condition
The drugs in this section are grouped into categories by type. For example, if you are taking a medicine for migraines, you should look in the � Antimigraine Agents � category. That is where you will find drugs that treat migraines.
The first column of the table lists the name of the drug. Generic drugs are listed in plain type (e.g., Simvastatin) and brand name drugs are in bold type (e.g., Humalog).
The second column lists the Medicare Part D drug tier. Your plan has 1 tier named � Covered Drugs.� All covered drugs are in this tier. As a member of this plan, you have no copays for
covered, prescribed drugs when obtained from network pharmacies.
The information in the � Necessary actions, restrictions, or limits on use� column tells you if UnitedHealthcare Dual Complete ONE has any rules for covering your drug.
Coverage Rules and Limits
PA – Prior authorization (approval)
For some drugs, you, your doctor or other prescriber must get authorization (approval) from UnitedHealthcare Dual Complete ONE before you fill your prescription. Prior authorization is different from a referral. UnitedHealthcare Dual Complete ONE may not cover the drug if you don� t get authorization (approval).
QL – Quantity limits
Sometimes UnitedHealthcare Dual Complete ONE limits the amount of a drug you can get.
ST – Step therapy
Sometimes UnitedHealthcare Dual Complete ONE requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor or other prescriber thinks the first drug doesn � t work for you, then we will cover the second.
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2Other Special Coverage Rules
B/D – Medicare Part B or Part D
Depending on how this drug is used, it may be covered by either the Medicare Part B (doctor and outpatient health care) or the Medicare Part D (prescription drugs) portion of the plan� s coverage. Your doctor may need to provide the plan with more information about how this drug will be used to make sure it� s correctly covered.
LA – Limited access
Drugs are considered � limited access� if the FDA says the drug can be given out only by certain facilities or doctors. These drugs may require extra handling, provider coordination or patient education that can� t be done at a network pharmacy.
MME – Morphine milligram equivalent
Additional quantity limits may apply across all drugs in the opioid class used for the treatment of pain. This additional limit is called a cumulative morphine milligram equivalent (MME), and is designed to monitor safe dosing levels of opioids for individuals who may be taking more than 1 opioid drug for pain management. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you or your doctor can ask the plan to cover the additional quantity.
7D – 7-Day limit
An opioid drug used for the treatment of acute pain may be limited to a 7-day supply for members with no recent history of opioid use. This limit is intended to minimize long-term opioid use. For members who are new to the plan, and have a recent history of using opioids, the limit may be overridden by having the pharmacy contact the plan.
DL – Dispensing limit
Dispensing limits apply to this drug. This drug is limited to a 1 month supply per prescription.
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You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
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A1
B1
C1Butalbital-Acetaminophen-Caffeine
C1Butalbital-Aspirin-Caffeine
B1
C1Celecoxib
C1Diclofenac Epolamine
C1Diclofenac Potassium
C1Diclofenac Sodium ER
C1Diclofenac Sodium
C1Diclofenac Sodium
C1Diflunisal
C1Etodolac ER
C1Etodolac
C1Etodolac
C1Flector
C1Flurbiprofen
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Ibu
C1Ibuprofen
C1Ibuprofen
C1Indomethacin
C1Ketoprofen
C1Meloxicam
C1Nabumetone
C1Naproxen DR
C1Naproxen
C1Naproxen
C1Piroxicam
C1Sulindac
B1
C1Buprenorphine
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Analgesics
Analgesics
Butalbital-Acetaminophen-Caffeine (Oral Tablet)
1 QL
Butalbital-Aspirin-Caffeine (Oral Capsule)
1 QL
Nonsteroidal Anti-inflammatory Drugs
Celecoxib (Oral Capsule)
1 QL
Diclofenac Epolamine (Transdermal Patch)
1 PA; QL
Diclofenac Potassium (Oral Tablet)
1
Diclofenac Sodium ER (Oral Tablet Extended Release 24 Hour)
1
Diclofenac Sodium (Oral Tablet Delayed Release)
1
Diclofenac Sodium (1% Transdermal Gel)
1
Diflunisal (Oral Tablet) 1
Etodolac ER (Oral Tablet Extended Release 24 Hour)
1
Etodolac (Oral Capsule)
1
Etodolac (Oral Tablet Immediate Release)
1
Flector (Transdermal
Patch)1 PA; QL
Flurbiprofen (Oral Tablet)
1
Ibu (600MG Oral Tablet, 800MG Oral Tablet)
1
Ibuprofen (Oral Suspension)
1
Ibuprofen (400MG Oral Tablet, 600MG Oral Tablet, 800MG Oral Tablet)
1
Indomethacin (Oral Capsule Immediate Release)
1
Ketoprofen (Oral Capsule Immediate Release)
1
Meloxicam (Oral Tablet)
1
Nabumetone (Oral Tablet)
1
Naproxen DR (Oral Tablet Delayed Release) (Generic EC-Naprosyn)
1
Naproxen (Oral Suspension)
1
Naproxen (Oral Tablet Immediate Release)
1
Piroxicam (Oral Capsule)
1
Sulindac (Oral Tablet) 1
Opioid Analgesics, Long-acting
Buprenorphine (Transdermal Patch Weekly)
1 7D; DL; QL
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Bold type = Brand name drug Plain type = Generic drug
C1Fentanyl
C1Hydromorphone HCl ER
C1Hysingla ER
C1Levorphanol Tartrate
C1Methadone HCl
C1Methadone HCl
C1Morphine Sulfate ER
C1Morphine Sulfate ER
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Nucynta ER
C1Tramadol HCl ER
C1Tramadol HCl ER
C1Xtampza ER
B1
C1Acetaminophen-Codeine
C1Acetaminophen-Codeine
C1Butorphanol Tartrate
C1Codeine Sulfate
C1Duramorph
C1Endocet
C1Fentanyl Citrate
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Fentanyl (100MCG/HR Transdermal Patch 72 Hour, 12MCG/HR Transdermal Patch 72 Hour, 25MCG/HR Transdermal Patch 72 Hour, 50MCG/HR Transdermal Patch 72 Hour, 75MCG/HR Transdermal Patch 72 Hour)
17D; MME;
DL; QL
Hydromorphone HCl ER (Oral Tablet ER 24 Hour Abuse-Deterrent)
17D; MME;
DL; QL
Hysingla ER (Oral
Tablet ER 24 Hour
Abuse-Deterrent)
17D; MME;
DL; QL
Levorphanol Tartrate (Oral Tablet)
17D; MME;
DL; QL
Methadone HCl (Oral Solution)
17D; MME;
DL; QL
Methadone HCl (Oral Tablet)
17D; MME;
DL; QL
Morphine Sulfate ER (100MG Oral Tablet Extended Release, 15MG Oral Tablet Extended Release, 30MG Oral Tablet Extended Release, 60MG Oral Tablet Extended Release) (Generic MS Contin)
17D; MME;
DL; QL
Morphine Sulfate ER (200MG Oral Tablet Extended Release) (Generic MS Contin)
17D; MME;
DL; QL
Nucynta ER (Oral
Tablet Extended
Release 12 Hour)
17D; MME;
DL; QL
Tramadol HCl ER (Biphasic) (Oral Tablet Extended Release 24 Hour)
17D; MME;
DL; QL
Tramadol HCl ER (Oral Tablet Extended Release 24 Hour)
17D; MME;
DL; QL
Xtampza ER (Oral
Capsule ER 12 Hour
Abuse-Deterrent)
17D; MME;
DL; QL
Opioid Analgesics, Short-acting
Acetaminophen-Codeine (120-12MG/ 5ML Oral Solution)
17D; MME;
DL; QL
Acetaminophen-Codeine (300-15MG Oral Tablet, 300-30MG Oral Tablet, 300-60MG Oral Tablet)
17D; MME;
DL; QL
Butorphanol Tartrate (Nasal Solution)
17D; MME;
DL; QL
Codeine Sulfate (Oral Tablet)
17D; MME;
DL; QL
Duramorph (Injection
Solution)1 DL
Endocet (10-325MG Oral Tablet, 5-325MG Oral Tablet, 7.5-325MG Oral Tablet)
17D; MME;
DL; QL
Fentanyl Citrate (Buccal Lozenge On A Handle)
1 PA; DL; QL
tRACK 15
5
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Hydrocodone-Acetaminophen
C1Hydrocodone-Acetaminophen
C1Hydrocodone-Ibuprofen
C1Hydromorphone HCl
C1Hydromorphone HCl
C1Hydromorphone HCl
C1Hydromorphone HCl Preservative Free
C1Lorcet HD
C1Lorcet
C1Lorcet Plus
C1Morphine Sulfate
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Morphine Sulfate
C1Morphine Sulfate
C1Oxycodone HCl
C1Oxycodone HCl
C1Oxycodone HCl
C1Oxycodone-Acetaminophen
C1Oxycodone-Aspirin
C1Oxycodone-Ibuprofen
C1Tramadol HCl
C1Tramadol-Acetaminophen
C1Trezix
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Hydrocodone-Acetaminophen (7.5-325MG/15ML Oral Solution)
17D; MME;
DL; QL
Hydrocodone-Acetaminophen (10-325MG Oral Tablet, 5-325MG Oral Tablet, 7.5-325MG Oral Tablet)
17D; MME;
DL; QL
Hydrocodone-Ibuprofen (7.5-200MG Oral Tablet)
17D; MME;
DL; QL
Hydromorphone HCl (2MG/ML Injection Solution)
1 DL
Hydromorphone HCl (1MG/ML Oral Liquid)
17D; MME;
DL; QL
Hydromorphone HCl (2MG Oral Tablet Immediate Release, 4MG Oral Tablet Immediate Release, 8MG Oral Tablet Immediate Release)
17D; MME;
DL; QL
Hydromorphone HCl Preservative Free (10MG/ML Injection Solution, 50MG/5ML Injection Solution)
1 DL
Lorcet HD (Oral Tablet) 17D; MME;
DL; QL
Lorcet (Oral Tablet) 17D; MME;
DL; QL
Lorcet Plus (Oral Tablet)
17D; MME;
DL; QL
Morphine Sulfate (Oral Solution)
17D; MME;
DL; QL
Morphine Sulfate (8MG/ML Intravenous Solution Prefilled Syringe)
1 DL
Morphine Sulfate
(Oral Tablet
Immediate Release)
17D; MME;
DL; QL
Oxycodone HCl (100MG/5ML Oral Concentrate)
17D; MME;
DL; QL
Oxycodone HCl (5MG/ 5ML Oral Solution)
17D; MME;
DL; QL
Oxycodone HCl (10MG Oral Tablet Immediate Release, 15MG Oral Tablet Immediate Release, 20MG Oral Tablet Immediate Release, 30MG Oral Tablet Immediate Release, 5MG Oral Tablet Immediate Release)
17D; MME;
DL; QL
Oxycodone-Acetaminophen (Oral Tablet)
17D; MME;
DL; QL
Oxycodone-Aspirin (Oral Tablet)
17D; MME;
DL; QL
Oxycodone-Ibuprofen (Oral Tablet)
17D; MME;
DL; QL
Tramadol HCl (50MG Oral Tablet Immediate Release)
17D; MME;
DL; QL
Tramadol-Acetaminophen (Oral Tablet)
17D; MME;
DL; QL
Trezix (Oral Capsule) 17D; MME;
DL; QL
tRACK16
6
Bold type = Brand name drug Plain type = Generic drug
A1
B1
C1Lidocaine
C1Lidocaine
C1Lidocaine HCl
C1Lidocaine HCl
C1Lidocaine Viscous
C1Lidocaine-Prilocaine
A1
B1
C1Acamprosate Calcium
C1Disulfiram
C1Naltrexone HCl
C1Vivitrol
B1
C1Buprenorphine HCl
C1Buprenorphine HCl-Naloxone HCl
C1Buprenorphine HCl-Naloxone HCl
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Suboxone
B1
C1Naloxone HCl
C1Naloxone HCl
C1Naloxone HCl
C1Narcan
B1
C1Bupropion HCl SR
C1Chantix Continuing Month Pak
C1Chantix
C1Chantix Starting Month Pak
C1Nicotrol
C1Nicotrol NS
A1
B1
C1Amikacin Sulfate
C1Gentak
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Anesthetics
Local Anesthetics
Lidocaine (5% External Ointment)
1 QL
Lidocaine (5% External Patch)
1 PA; QL
Lidocaine HCl (4% External Solution)
1
Lidocaine HCl (External Gel)
1
Lidocaine Viscous (2% Mouth/Throat Solution)
1
Lidocaine-Prilocaine (External Cream)
1
Anti-Addiction/Substance Abuse Treatment Agents
Alcohol Deterrents/Anti-craving
Acamprosate Calcium (Oral Tablet Delayed Release)
1
Disulfiram (Oral Tablet) 1
Naltrexone HCl (Oral Tablet)
1
Vivitrol (Intramuscular
Suspension
Reconstituted)
1
Opioid Dependence Treatments
Buprenorphine HCl (Tablet Sublingual)
1 QL
Buprenorphine HCl-Naloxone HCl (Sublingual Film)
1 QL
Buprenorphine HCl-Naloxone HCl (Tablet Sublingual)
1 QL
Suboxone (Sublingual
Film)1 QL
Opioid Reversal Agents
Naloxone HCl (0.4MG/ ML Injection Solution)
1
Naloxone HCl (Injection Solution Cartridge)
1
Naloxone HCl (Injection Solution Prefilled Syringe)
1
Narcan (Nasal Liquid) 1
Smoking Cessation Agents
Bupropion HCl SR (150MG Oral Tablet Extended Release 12 Hour Smoking-Deterrent)
1
Chantix Continuing
Month Pak (Oral
Tablet)
1
Chantix (Oral Tablet) 1
Chantix Starting
Month Pak (Oral
Tablet)
1
Nicotrol (Inhalation
Inhaler)1
Nicotrol NS (Nasal
Solution)1
Antibacterials
Aminoglycosides
Amikacin Sulfate (500MG/2ML Injection Solution)
1
Gentak (Ophthalmic Ointment)
1
tRACK 17
7
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Gentamicin Sulfate-0.9% Sodium Chloride
C1Gentamicin Sulfate
C1Gentamicin Sulfate
C1Gentamicin Sulfate
C1Gentamicin Sulfate
C1Neomycin Sulfate
C1Paromomycin Sulfate
C1Streptomycin Sulfate
C1Tobramycin
C1Tobramycin Sulfate
C1Tobrex
B1
C1Bacitracin
C1Clindamycin HCl
C1Clindamycin Palmitate HCl
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Clindamycin Phosphate in D5W
C1Clindamycin Phosphate
C1Clindamycin Phosphate
C1Colistimethate Sodium
C1Dalvance
C1Daptomycin
C1Daptomycin
C1Linezolid
C1Linezolid
C1Linezolid
C1Methenamine Hippurate
C1Metronidazole
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Gentamicin Sulfate-0.9% Sodium Chloride (Intravenous Solution)
1
Gentamicin Sulfate (External Cream)
1
Gentamicin Sulfate (External Ointment)
1
Gentamicin Sulfate (40MG/ML Injection Solution)
1
Gentamicin Sulfate (Ophthalmic Solution)
1
Neomycin Sulfate (Oral Tablet)
1
Paromomycin Sulfate (Oral Capsule)
1
Streptomycin Sulfate (Intramuscular Solution Reconstituted)
1
Tobramycin (Ophthalmic Solution)
1
Tobramycin Sulfate (10MG/ML Injection Solution, 80MG/2ML Injection Solution)
1
Tobrex (Ophthalmic
Ointment)1
Antibacterials, Other
Bacitracin (Ophthalmic Ointment)
1
Clindamycin HCl (Oral Capsule)
1
Clindamycin Palmitate HCl (Oral Solution Reconstituted)
1
Clindamycin Phosphate in D5W (Intravenous Solution)
1
Clindamycin Phosphate (300MG/ 2ML Injection Solution, 600MG/4ML Injection Solution, 900MG/6ML Injection Solution)
1
Clindamycin Phosphate (Vaginal Cream)
1
Colistimethate Sodium (CBA) (Injection Solution Reconstituted)
1
Dalvance (Intravenous
Solution
Reconstituted)
1 PA
Daptomycin (350MG
Intravenous Solution
Reconstituted)
1
Daptomycin (500MG Intravenous Solution Reconstituted)
1
Linezolid (Intravenous Solution)
1
Linezolid (Oral Suspension Reconstituted)
1
Linezolid (Oral Tablet) 1 QL
Methenamine Hippurate (Oral Tablet)
1
Metronidazole (0.75% External Cream)
1
tRACK18
8
Bold type = Brand name drug Plain type = Generic drug
C1Metronidazole
C1Metronidazole
C1Metronidazole in NaCl 0.79%
C1Metronidazole
C1Metronidazole
C1Mupirocin Calcium
C1Mupirocin
C1Nitrofurantoin Macrocrystal
C1Nitrofurantoin Monohydrate
C1Nitrofurantoin
C1Polymyxin B Sulfate
C1Sulfamylon
C1Tigecycline
C1Tinidazole
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Trimethoprim
C1Vancomycin HCl
C1Vancomycin HCl
C1Vancomycin HCl
C1Vandazole
B1
C1Cefaclor
C1Cefadroxil
C1Cefadroxil
C1Cefazolin Sodium
C1Cefdinir
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Metronidazole (0.75% External Gel, 1% External Gel)
1
Metronidazole (0.75% External Lotion)
1
Metronidazole in NaCl 0.79% (Intravenous Solution)
1
Metronidazole (250MG Oral Tablet, 500MG Oral Tablet)
1
Metronidazole (0.75% Vaginal Gel)
1
Mupirocin Calcium (External Cream)
1
Mupirocin (External Ointment)
1
Nitrofurantoin Macrocrystal (100MG Oral Capsule, 50MG Oral Capsule) (Generic Macrodantin)
1
Nitrofurantoin Monohydrate (Generic Macrobid)
1
Nitrofurantoin (Oral Suspension)
1
Polymyxin B Sulfate (Injection Solution Reconstituted)
1
Sulfamylon (External
Cream)1
Tigecycline (Intravenous Solution Reconstituted)
1
Tinidazole (Oral Tablet) 1
Trimethoprim (Oral Tablet)
1
Vancomycin HCl (10GM Intravenous Solution Reconstituted, 1GM Intravenous Solution Reconstituted, 500MG Intravenous Solution Reconstituted, 750MG Intravenous Solution Reconstituted)
1
Vancomycin HCl
(250MG Intravenous
Solution
Reconstituted)
1
Vancomycin HCl (Oral Capsule)
1 QL
Vandazole (Vaginal
Gel)1
Beta-lactam, Cephalosporins
Cefaclor (Oral Capsule)
1
Cefadroxil (Oral Capsule)
1
Cefadroxil (Oral Suspension Reconstituted)
1
Cefazolin Sodium (10GM Injection Solution Reconstituted, 1GM Injection Solution Reconstituted, 500MG Injection Solution Reconstituted)
1
Cefdinir (Oral Capsule) 1
tRACK 19
9
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Cefdinir
C1Cefepime HCl
C1Cefixime
C1Cefixime
C1Cefotetan Disodium
C1Cefoxitin Sodium
C1Cefoxitin Sodium
C1Cefpodoxime Proxetil
C1Cefpodoxime Proxetil
C1Cefprozil
C1Cefprozil
C1Ceftazidime
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Ceftriaxone Sodium
C1Ceftriaxone Sodium
C1Cefuroxime Axetil
C1Cefuroxime Sodium
C1Cefuroxime Sodium
C1Cephalexin
C1Cephalexin
C1Suprax
C1Suprax
C1Suprax
C1Tazicef
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Cefdinir (Oral Suspension Reconstituted)
1
Cefepime HCl (Injection Solution Reconstituted)
1
Cefixime (Oral Capsule)
1
Cefixime (Oral Suspension Reconstituted)
1
Cefotetan Disodium (Injection Solution Reconstituted)
1
Cefoxitin Sodium (Injection Solution Reconstituted)
1
Cefoxitin Sodium (Intravenous Solution Reconstituted)
1
Cefpodoxime Proxetil (Oral Suspension Reconstituted)
1
Cefpodoxime Proxetil (Oral Tablet)
1
Cefprozil (Oral Suspension Reconstituted)
1
Cefprozil (Oral Tablet) 1
Ceftazidime (Injection Solution Reconstituted)
1
Ceftriaxone Sodium (1GM Injection Solution Reconstituted, 250MG Injection Solution Reconstituted, 2GM Injection Solution Reconstituted, 500MG Injection Solution Reconstituted)
1
Ceftriaxone Sodium (10GM Intravenous Solution Reconstituted)
1
Cefuroxime Axetil (Oral Tablet)
1
Cefuroxime Sodium (Injection Solution Reconstituted)
1
Cefuroxime Sodium (Intravenous Solution Reconstituted)
1
Cephalexin (Oral Capsule)
1
Cephalexin (Oral Suspension Reconstituted)
1
Suprax (Oral Capsule) 1
Suprax (500MG/5ML
Oral Suspension
Reconstituted)
1
Suprax (Oral Tablet Chewable)
1
Tazicef (Injection Solution Reconstituted)
1
tRACK20
10
Bold type = Brand name drug Plain type = Generic drug
C1Zerbaxa
B1
C1Aztreonam
C1Ertapenem Sodium
C1Imipenem-Cilastatin
C1Meropenem
B1
C1Amoxicillin
C1Amoxicillin
C1Amoxicillin
C1Amoxicillin
C1Amoxicillin-Potassium Clavulanate ER
C1Amoxicillin-Potassium Clavulanate
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Amoxicillin-Potassium Clavulanate
C1Amoxicillin-Potassium Clavulanate
C1Ampicillin
C1Ampicillin Sodium
C1Ampicillin Sodium
C1Ampicillin-Sulbactam Sodium
C1Ampicillin-Sulbactam Sodium
C1Bicillin C-R 900/300
C1Bicillin C-R
C1Bicillin L-A
C1Dicloxacillin Sodium
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Zerbaxa (Intravenous
Solution
Reconstituted)
1 PA
Beta-lactam, Other
Aztreonam (1GM Injection Solution Reconstituted)
1
Ertapenem Sodium (Injection Solution Reconstituted)
1
Imipenem-Cilastatin (Intravenous Solution Reconstituted)
1
Meropenem (Intravenous Solution Reconstituted)
1
Beta-lactam, Penicillins
Amoxicillin (Oral Capsule)
1
Amoxicillin (Oral Suspension Reconstituted)
1
Amoxicillin (Oral Tablet)
1
Amoxicillin (Oral Tablet Chewable)
1
Amoxicillin-Potassium Clavulanate ER (Oral Tablet Extended Release 12 Hour)
1
Amoxicillin-Potassium Clavulanate (Oral Suspension Reconstituted)
1
Amoxicillin-Potassium Clavulanate (Oral Tablet Immediate Release)
1
Amoxicillin-Potassium Clavulanate (Oral Tablet Chewable)
1
Ampicillin (Oral Capsule)
1
Ampicillin Sodium (125MG Injection Solution Reconstituted, 1GM Injection Solution Reconstituted)
1
Ampicillin Sodium (10GM Intravenous Solution Reconstituted)
1
Ampicillin-Sulbactam Sodium (Injection Solution Reconstituted)
1
Ampicillin-Sulbactam Sodium (15 (10-5)GM Intravenous Solution Reconstituted)
1
Bicillin C-R 900/300
(Intramuscular
Suspension)
1
Bicillin C-R
(Intramuscular
Suspension)
1
Bicillin L-A
(Intramuscular
Suspension)
1
Dicloxacillin Sodium (Oral Capsule)
1
tRACK 21
11
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Nafcillin Sodium
C1Nafcillin Sodium
C1Oxacillin Sodium in Dextrose
C1Oxacillin Sodium
C1Penicillin G Potassium
C1Penicillin G Procaine
C1Penicillin G Sodium
C1Penicillin V Potassium
C1Penicillin V Potassium
C1Piperacillin-Tazobactam
B1
C1Azasite
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Azithromycin
C1Azithromycin
C1Azithromycin
C1Clarithromycin ER
C1Clarithromycin
C1Clarithromycin
C1Dificid
C1E.E.S. Granules
C1Erythrocin Lactobionate
C1Erythromycin Base
C1Erythromycin Base
C1Erythromycin Base
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Nafcillin Sodium (1GM Injection Solution Reconstituted, 2GM Injection Solution Reconstituted)
1
Nafcillin Sodium (10GM Intravenous Solution Reconstituted)
1
Oxacillin Sodium in
Dextrose (Intravenous
Solution)
1
Oxacillin Sodium (Injection Solution Reconstituted)
1
Penicillin G Potassium (20000000UNIT Injection Solution Reconstituted)
1
Penicillin G Procaine (Intramuscular Suspension)
1
Penicillin G Sodium (Injection Solution Reconstituted)
1
Penicillin V Potassium (Oral Solution Reconstituted)
1
Penicillin V Potassium (Oral Tablet)
1
Piperacillin-Tazobactam (Intravenous Solution Reconstituted)
1
Macrolides
Azasite (Ophthalmic
Solution)1
Azithromycin (Intravenous Solution Reconstituted)
1
Azithromycin (Oral Suspension Reconstituted)
1
Azithromycin (Oral Tablet)
1
Clarithromycin ER (Oral Tablet Extended Release 24 Hour)
1
Clarithromycin (Oral Suspension Reconstituted)
1
Clarithromycin (Oral Tablet Immediate Release)
1
Dificid (Oral Tablet) 1
E.E.S. Granules (Oral
Suspension
Reconstituted)
1
Erythrocin Lactobionate (Intravenous Solution Reconstituted)
1
Erythromycin Base (Oral Capsule Delayed Release Particles)
1
Erythromycin Base (Oral Tablet Immediate Release)
1
Erythromycin Base (Oral Tablet Delayed Release)
1
tRACK22
12
Bold type = Brand name drug Plain type = Generic drug
C1Erythromycin Ethylsuccinate
C1Erythromycin Ethylsuccinate
C1Erythromycin
B1
C1Besivance
C1Ciloxan
C1Ciprofloxacin HCl
C1Ciprofloxacin HCl
C1Ciprofloxacin HCl
C1Ciprofloxacin in D5W
C1Gatifloxacin
C1Levofloxacin in D5W
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Levofloxacin
C1Levofloxacin
C1Levofloxacin
C1Levofloxacin
C1Moxifloxacin HCl in NaCl
C1Moxifloxacin HCl
C1Moxifloxacin HCl
C1Ofloxacin
C1Ofloxacin
C1Ofloxacin
B1
C1Silver Sulfadiazine
C1SSD
C1Sulfacetamide Sodium
C1Sulfacetamide Sodium
C1Sulfadiazine
C1Sulfamethoxazole-Trimethoprim
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Erythromycin Ethylsuccinate (200MG/5ML Oral Suspension Reconstituted)
1
Erythromycin Ethylsuccinate (Oral Tablet)
1
Erythromycin (Ophthalmic Ointment)
1
Quinolones
Besivance
(Ophthalmic
Suspension)
1
Ciloxan (Ophthalmic
Ointment)1
Ciprofloxacin HCl (Ophthalmic Solution)
1
Ciprofloxacin HCl (100MG Oral Tablet Immediate Release)
1
Ciprofloxacin HCl (250MG Oral Tablet Immediate Release, 500MG Oral Tablet Immediate Release, 750MG Oral Tablet Immediate Release)
1
Ciprofloxacin in D5W (200MG/100ML Intravenous Solution)
1
Gatifloxacin (Ophthalmic Solution)
1
Levofloxacin in D5W (500MG/100ML Intravenous Solution, 750MG/150ML Intravenous Solution)
1
Levofloxacin (25MG/ ML Intravenous Solution)
1
Levofloxacin (0.5% Ophthalmic Solution)
1
Levofloxacin (25MG/ ML Oral Solution)
1
Levofloxacin (250MG Oral Tablet, 500MG Oral Tablet, 750MG Oral Tablet)
1
Moxifloxacin HCl in NaCl (Intravenous Solution)
1
Moxifloxacin HCl (Ophthalmic Solution)
1
Moxifloxacin HCl (Oral Tablet)
1
Ofloxacin (Ophthalmic Solution)
1
Ofloxacin (Oral Tablet) 1
Ofloxacin (Otic Solution)
1
Sulfonamides
Silver Sulfadiazine (External Cream)
1
SSD (External Cream) 1
Sulfacetamide Sodium (Ophthalmic Ointment)
1
Sulfacetamide Sodium (Ophthalmic Solution)
1
Sulfadiazine (Oral Tablet)
1
Sulfamethoxazole-Trimethoprim (Oral Suspension)
1
tRACK 23
13
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Sulfamethoxazole-Trimethoprim
B1
C1Demeclocycline HCl
C1Doxy 100
C1Doxycycline Hyclate
C1Doxycycline Hyclate
C1Doxycycline Monohydrate
C1Doxycycline Monohydrate
C1Doxycycline Monohydrate
C1Minocycline HCl
C1Minocycline HCl
C1Tetracycline HCl
C1Vibramycin
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useA1
B1
C1BRIVIACT
C1BRIVIACT
C1Epidiolex
C1Levetiracetam ER
C1Levetiracetam
C1Levetiracetam
C1Nayzilam
C1Roweepra
C1Roweepra XR
C1Spritam
B1
C1Celontin
C1Ethosuximide
C1Ethosuximide
C1Zonisamide
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Sulfamethoxazole-Trimethoprim (Oral Tablet)
1
Tetracyclines
Demeclocycline HCl (Oral Tablet)
1
Doxy 100 (Intravenous Solution Reconstituted)
1
Doxycycline Hyclate (Oral Capsule)
1
Doxycycline Hyclate (100MG Oral Tablet Immediate Release, 20MG Oral Tablet Immediate Release)
1
Doxycycline Monohydrate (100MG Oral Capsule, 50MG Oral Capsule)
1
Doxycycline Monohydrate (Oral Suspension Reconstituted)
1
Doxycycline Monohydrate (100MG Oral Tablet, 50MG Oral Tablet, 75MG Oral Tablet)
1
Minocycline HCl (Oral Capsule)
1
Minocycline HCl (Oral Tablet Immediate Release)
1
Tetracycline HCl (Oral Capsule)
1
Vibramycin (50MG/
5ML Oral Syrup)1
Anticonvulsants
Anticonvulsants, Other
BRIVIACT (Oral
Solution)1 PA; QL
BRIVIACT (Oral
Tablet)1 PA; QL
Epidiolex (Oral
Solution)1 PA
Levetiracetam ER (Oral Tablet Extended Release 24 Hour)
1
Levetiracetam (Oral Solution)
1
Levetiracetam (Oral Tablet Immediate Release)
1
Nayzilam (Nasal
Solution)1
Roweepra (Oral Tablet Immediate Release)
1
Roweepra XR (Oral Tablet Extended Release 24 Hour)
1
Spritam (Oral Tablet
Disintegrating
Soluble)
1
Calcium Channel Modifying Agents
Celontin (Oral
Capsule)1
Ethosuximide (Oral Capsule)
1
Ethosuximide (Oral Solution)
1
Zonisamide (Oral Capsule)
1
tRACK24
14
Bold type = Brand name drug Plain type = Generic drug
B1
C1Clobazam
C1Clobazam
C1Clobazam
C1Diastat AcuDial
C1Diastat Pediatric
C1Gabapentin
C1Gabapentin
C1Gabapentin
C1Phenobarbital
C1Phenobarbital
C1Primidone
C1Sympazan
C1Tiagabine HCl
C1Valproic Acid
C1Valproic Acid
C1Vigabatrin
C1Vigabatrin
C1Vigadrone
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useB1
C1Felbamate
C1Felbamate
C1Fycompa
C1Fycompa
C1Lamotrigine
C1Lamotrigine
C1Topiramate
C1Topiramate
B1
C1Aptiom
C1Banzel
C1Banzel
C1Carbamazepine ER
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Gamma-aminobutyric Acid (GABA) Augmenting Agents
Clobazam (2.5MG/ML Oral Suspension)
1 PA; QL
Clobazam (10MG Oral Tablet)
1 PA; QL
Clobazam (20MG Oral Tablet)
1 PA; QL
Diastat AcuDial
(Rectal Gel)1
Diastat Pediatric
(Rectal Gel)1
Gabapentin (Oral Capsule)
1
Gabapentin (250MG/ 5ML Oral Solution)
1
Gabapentin (Oral Tablet)
1
Phenobarbital (Oral Elixir)
1
Phenobarbital (Oral Tablet)
1
Primidone (Oral Tablet) 1
Sympazan (Oral Film) 1 PA; QL
Tiagabine HCl (Oral Tablet)
1
Valproic Acid (Oral Capsule)
1
Valproic Acid (Oral Solution)
1
Vigabatrin (Oral Packet)
1 PA; LA; QL
Vigabatrin (Oral Tablet) 1 PA; LA; QL
Vigadrone (Oral Packet)
1 PA; LA; QL
Glutamate Reducing Agents
Felbamate (Oral Suspension)
1
Felbamate (Oral Tablet)
1
Fycompa (Oral
Suspension)1
Fycompa (Oral Tablet) 1
Lamotrigine (100MG Oral Tablet Immediate Release, 150MG Oral Tablet Immediate Release, 200MG Oral Tablet Immediate Release, 25MG Oral Tablet Immediate Release)
1
Lamotrigine (25MG Oral Tablet Chewable, 5MG Oral Tablet Chewable)
1
Topiramate (Oral Capsule Sprinkle Immediate Release)
1
Topiramate (Oral Tablet)
1
Sodium Channel Agents
Aptiom (Oral Tablet) 1 QL
Banzel (Oral
Suspension)1
Banzel (Oral Tablet) 1
Carbamazepine ER (Oral Capsule Extended Release 12 Hour)
1
tRACK 25
15
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Carbamazepine ER
C1Carbamazepine
C1Carbamazepine
C1Carbamazepine
C1Dilantin INFATABS
C1Dilantin
C1Epitol
C1Oxcarbazepine
C1Oxcarbazepine
C1Peganone
C1Phenytek
C1Phenytoin
C1Phenytoin
C1Phenytoin Sodium Extended
C1Vimpat
C1Vimpat
A1
B1
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Donepezil HCl
C1Donepezil HCl ODT
C1Galantamine Hydrobromide ER
C1Galantamine Hydrobromide
C1Galantamine Hydrobromide
C1Rivastigmine Tartrate
C1Rivastigmine
B1
C1Memantine HCl ER
C1Memantine HCl
C1Memantine HCl
C1Memantine HCl Titration Pak
A1
B1
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Carbamazepine ER (Oral Tablet Extended Release 12 Hour)
1
Carbamazepine (Oral Suspension)
1
Carbamazepine (Oral Tablet Immediate Release)
1
Carbamazepine (Oral Tablet Chewable)
1
Dilantin INFATABS (Oral Tablet Chewable)
1
Dilantin (Oral Capsule) 1
Epitol (Oral Tablet) 1
Oxcarbazepine (300MG/5ML Oral Suspension)
1
Oxcarbazepine (150MG Oral Tablet, 300MG Oral Tablet, 600MG Oral Tablet)
1
Peganone (Oral
Tablet)1
Phenytek (Oral Capsule)
1
Phenytoin (Oral Suspension)
1
Phenytoin (Oral Tablet Chewable)
1
Phenytoin Sodium Extended (Oral Capsule)
1
Vimpat (Oral Solution) 1 QL
Vimpat (Oral Tablet) 1 QL
Antidementia Agents
Cholinesterase Inhibitors
Donepezil HCl (Oral Tablet)
1 QL
Donepezil HCl ODT (Oral Tablet Dispersible)
1 QL
Galantamine Hydrobromide ER (Oral Capsule Extended Release 24 Hour)
1 QL
Galantamine Hydrobromide (Oral Solution)
1 QL
Galantamine Hydrobromide (Oral Tablet)
1 QL
Rivastigmine Tartrate (Oral Capsule)
1 QL
Rivastigmine (Transdermal Patch 24 Hour)
1 ST; QL
N-methyl-D-aspartate (NMDA) Receptor Antagonist
Memantine HCl ER (Oral Capsule Extended Release 24 Hour)
1 PA; QL
Memantine HCl (2MG/ ML Oral Solution)
1 PA; QL
Memantine HCl (10MG Oral Tablet, 5MG Oral Tablet)
1 PA; QL
Memantine HCl
Titration Pak (Oral
Tablet)
1 PA
Antidepressants
Antidepressants, Other
tRACK26
16
Bold type = Brand name drug Plain type = Generic drug
C1Bupropion HCl SR
C1Bupropion HCl XL
C1Bupropion HCl
C1Mirtazapine
C1Mirtazapine ODT
B1
C1Emsam
C1Marplan
C1Phenelzine Sulfate
C1Tranylcypromine Sulfate
B1
C1Citalopram Hydrobromide
C1Citalopram Hydrobromide
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Desvenlafaxine Succinate ER
C1Escitalopram Oxalate
C1Escitalopram Oxalate
C1Fetzima
C1Fetzima Titration
C1Fluoxetine HCl
C1Fluoxetine HCl
C1Fluoxetine HCl
C1Fluvoxamine Maleate
C1Maprotiline HCl
C1Nefazodone HCl
C1Paroxetine HCl
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Bupropion HCl SR (Oral Tablet Extended Release 12 Hour)
1
Bupropion HCl XL (150MG Oral Tablet Extended Release 24 Hour, 300MG Oral Tablet Extended Release 24 Hour)
1
Bupropion HCl (Oral Tablet Immediate Release)
1
Mirtazapine (Oral Tablet)
1
Mirtazapine ODT (Oral Tablet Dispersible)
1
Monoamine Oxidase Inhibitors
Emsam (Transdermal
Patch 24 Hour)1 QL
Marplan (Oral Tablet) 1
Phenelzine Sulfate (Oral Tablet)
1
Tranylcypromine Sulfate (Oral Tablet)
1
SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors)
Citalopram Hydrobromide (Oral Solution)
1
Citalopram Hydrobromide (Oral Tablet)
1
Desvenlafaxine Succinate ER (Oral Tablet Extended Release 24 Hour) (Generic Pristiq)
1 QL
Escitalopram Oxalate (Oral Solution)
1
Escitalopram Oxalate (Oral Tablet)
1
Fetzima (Oral Capsule
Extended Release 24
Hour)
1 ST; QL
Fetzima Titration
(Oral Capsule ER 24
Hour Therapy Pack)
1 ST
Fluoxetine HCl (10MG Oral Capsule Immediate Release, 20MG Oral Capsule Immediate Release, 40MG Oral Capsule Immediate Release)
1
Fluoxetine HCl (90MG Oral Capsule Delayed Release)
1
Fluoxetine HCl (20MG/ 5ML Oral Solution)
1
Fluvoxamine Maleate (Oral Tablet)
1
Maprotiline HCl (Oral Tablet)
1
Nefazodone HCl (Oral Tablet)
1
Paroxetine HCl (Oral Tablet Immediate Release)
1
tRACK 27
17
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Paxil
C1Sertraline HCl
C1Sertraline HCl
C1Trazodone HCl
C1Trazodone HCl
C1Trintellix
C1Venlafaxine HCl ER
C1Venlafaxine HCl
C1Viibryd
C1Viibryd Starter Pack
B1
C1Amitriptyline HCl
C1Amoxapine
C1Clomipramine HCl
C1Desipramine HCl
C1Doxepin HCl
C1Doxepin HCl
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Imipramine HCl
C1Imipramine Pamoate
C1Nortriptyline HCl
C1Nortriptyline HCl
C1Protriptyline HCl
C1Trimipramine Maleate
A1
B1
C1Compro
C1Hydroxyzine Pamoate
C1Meclizine HCl
C1Metoclopramide HCl
C1Metoclopramide HCl
C1Perphenazine
C1Prochlorperazine Maleate
C1Prochlorperazine
C1Scopolamine
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Paxil (Oral
Suspension)1
Sertraline HCl (Oral Concentrate)
1
Sertraline HCl (Oral Tablet)
1
Trazodone HCl (100MG Oral Tablet, 150MG Oral Tablet, 50MG Oral Tablet)
1
Trazodone HCl (300MG Oral Tablet)
1
Trintellix (Oral Tablet) 1 QL
Venlafaxine HCl ER (Oral Capsule Extended Release 24 Hour)
1
Venlafaxine HCl (Oral Tablet Immediate Release)
1
Viibryd (Oral Tablet) 1 QL
Viibryd Starter Pack
(Oral Kit)1 QL
Tricyclics
Amitriptyline HCl (Oral Tablet)
1
Amoxapine (Oral Tablet)
1
Clomipramine HCl (Oral Capsule)
1
Desipramine HCl (Oral Tablet)
1
Doxepin HCl (Oral Capsule)
1
Doxepin HCl (Oral Concentrate)
1
Imipramine HCl (Oral Tablet)
1
Imipramine Pamoate (Oral Capsule)
1
Nortriptyline HCl (Oral Capsule)
1
Nortriptyline HCl (Oral Solution)
1
Protriptyline HCl (Oral Tablet)
1
Trimipramine Maleate (Oral Capsule)
1
Antiemetics
Antiemetics, Other
Compro (Rectal Suppository)
1
Hydroxyzine Pamoate (Oral Capsule)
1
Meclizine HCl (Oral Tablet)
1
Metoclopramide HCl (5MG/5ML Oral Solution)
1
Metoclopramide HCl (Oral Tablet)
1
Perphenazine (Oral Tablet)
1
Prochlorperazine Maleate (Oral Tablet)
1
Prochlorperazine (Rectal Suppository)
1
Scopolamine (Transdermal Patch 72 Hour)
1
tRACK28
18
Bold type = Brand name drug Plain type = Generic drug
C1Transderm-Scop
B1
C1Aprepitant
C1Cesamet
C1Dronabinol
C1Granisetron HCl
C1Ondansetron HCl
C1Ondansetron HCl
C1Ondansetron ODT
C1Sancuso
A1
B1
C1Abelcet
C1AmBisome
C1Amphotericin B
C1Ciclopirox
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Ciclopirox
C1Ciclopirox
C1Ciclopirox Olamine
C1Ciclopirox Olamine
C1Clotrimazole
C1Clotrimazole
C1Clotrimazole
C1Econazole Nitrate
C1Eraxis
C1Eraxis
C1Exelderm
C1Exelderm
C1Fluconazole in Sodium Chloride
C1Fluconazole
C1Fluconazole
C1Flucytosine
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Transderm-Scop
(1.5MG) (Transdermal
Patch 72 Hour)
1
Emetogenic Therapy Adjuncts
Aprepitant (Oral Therapy Pack, Oral Capsule)
1 PA
Cesamet (1MG Oral
Capsule)1 PA
Dronabinol (Oral Capsule)
1 PA
Granisetron HCl (Oral Tablet)
1 B/D, PA; QL
Ondansetron HCl (Oral Solution)
1 B/D, PA
Ondansetron HCl (Oral Tablet)
1 B/D, PA
Ondansetron ODT (Oral Tablet Dispersible)
1 B/D, PA
Sancuso
(Transdermal Patch)1
Antifungals
Antifungals
Abelcet (Intravenous
Suspension)1 B/D, PA
AmBisome
(Intravenous
Suspension
Reconstituted)
1 B/D, PA
Amphotericin B (Intravenous Solution Reconstituted)
1 B/D, PA
Ciclopirox (External Gel)
1
Ciclopirox (External Shampoo)
1
Ciclopirox (External Solution)
1
Ciclopirox Olamine (External Cream)
1
Ciclopirox Olamine (External Suspension)
1
Clotrimazole (External Cream)
1
Clotrimazole (External Solution)
1
Clotrimazole (Mouth/ Throat Lozenge)
1
Econazole Nitrate (External Cream)
1 QL
Eraxis (100MG
Intravenous Solution
Reconstituted)
1
Eraxis (50MG
Intravenous Solution
Reconstituted)
1
Exelderm (External
Cream)1
Exelderm (External
Solution)1
Fluconazole in Sodium Chloride (Intravenous Solution)
1
Fluconazole (Oral Suspension Reconstituted)
1
Fluconazole (Oral Tablet)
1
Flucytosine (Oral Capsule)
1
tRACK 29
19
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Griseofulvin Microsize
C1Griseofulvin Microsize
C1Griseofulvin Ultramicrosize
C1Itraconazole
C1Itraconazole
C1Jublia
C1Ketoconazole
C1Ketoconazole
C1Ketoconazole
C1Mentax
C1Miconazole 3
C1Mycamine
C1Naftifine HCl
C1Naftin
C1Natacyn
C1Noxafil
C1Noxafil
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Nyamyc
C1Nystatin
C1Nystatin
C1Nystatin
C1Nystatin
C1Nystatin
C1Nystop
C1Posaconazole
C1Terbinafine HCl
C1Terconazole
C1Terconazole
C1Voriconazole
C1Voriconazole
C1Voriconazole
A1
B1
C1Allopurinol
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Griseofulvin Microsize (Oral Suspension)
1
Griseofulvin Microsize (Oral Tablet)
1
Griseofulvin Ultramicrosize (Oral Tablet)
1
Itraconazole (Oral Capsule)
1 PA; QL
Itraconazole (Oral Solution)
1 PA
Jublia (External
Solution)1
Ketoconazole (External Cream)
1 QL
Ketoconazole (External Shampoo)
1
Ketoconazole (Oral Tablet)
1
Mentax (External
Cream)1
Miconazole 3 (Vaginal Suppository)
1
Mycamine
(Intravenous Solution
Reconstituted)
1
Naftifine HCl (External Cream)
1
Naftin (External Gel) 1
Natacyn (Ophthalmic
Suspension)1
Noxafil (Oral
Suspension)1 QL
Noxafil (Oral Tablet
Delayed Release)1 PA; QL
Nyamyc (External Powder)
1
Nystatin (External Cream)
1
Nystatin (External Ointment)
1
Nystatin (External Powder)
1
Nystatin (Mouth/Throat Suspension)
1
Nystatin (Oral Tablet) 1
Nystop (External Powder)
1
Posaconazole (Oral Tablet Delayed Release)
1 PA; QL
Terbinafine HCl (Oral Tablet)
1
Terconazole (Vaginal Cream)
1
Terconazole (Vaginal Suppository)
1
Voriconazole (Intravenous Solution Reconstituted)
1
Voriconazole (Oral Suspension Reconstituted)
1
Voriconazole (Oral Tablet)
1
Antigout Agents
Antigout Agents
Allopurinol (Oral Tablet)
1
tRACK30
20
Bold type = Brand name drug Plain type = Generic drug
C1Colchicine
C1Colchicine
C1Colcrys
C1Febuxostat
C1Probenecid
C1Probenecid-Colchicine
A1
B1
C1Dihydroergotamine Mesylate
C1Ergotamine-Caffeine
C1Migergot
B1
C1Aimovig
C1Emgality
C1Emgality
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Emgality
C1Timolol Maleate
B1
C1Naratriptan HCl
C1Rizatriptan Benzoate
C1Rizatriptan Benzoate ODT
C1Sumatriptan
C1Sumatriptan Succinate
C1Sumatriptan Succinate Refill
C1Sumatriptan Succinate
C1Sumatriptan Succinate
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Colchicine (0.6MG
Oral Capsule) (Brand
Equivalent Mitigare)
1 QL
Colchicine (0.6MG Oral Tablet) (Generic Colcrys)
1 QL
Colcrys (Oral Tablet) 1 QL
Febuxostat (Oral Tablet)
1 ST
Probenecid (Oral Tablet)
1
Probenecid-Colchicine (Oral Tablet)
1
Antimigraine Agents
Ergot Alkaloids
Dihydroergotamine Mesylate (Nasal Solution)
1
Ergotamine-Caffeine (Oral Tablet)
1
Migergot (Rectal Suppository)
1
Prophylactic
Aimovig
(Subcutaneous
Solution Auto-
Injector)
1 PA; QL
Emgality (300 MG
Dose) (100 MG/ML
Subcutaneous
Solution Prefilled
Syringe)
1 PA; QL
Emgality
(Subcutaneous
Solution Auto-
Injector)
1 PA; QL
Emgality (120 MG/ML
Subcutaneous
Solution Prefilled
Syringe)
1 PA; QL
Timolol Maleate (Oral Tablet)
1
Serotonin (5-HT) 1b/1d Receptor Agonists
Naratriptan HCl (Oral Tablet)
1 QL
Rizatriptan Benzoate (Oral Tablet)
1 QL
Rizatriptan Benzoate ODT (Oral Tablet Dispersible)
1 QL
Sumatriptan (Nasal Solution)
1 QL
Sumatriptan Succinate (100MG Oral Tablet, 25MG Oral Tablet, 50MG Oral Tablet)
1 QL
Sumatriptan
Succinate Refill
(Subcutaneous
Solution Cartridge)
1 QL
Sumatriptan Succinate (6MG/0.5ML Subcutaneous Solution)
1 QL
Sumatriptan Succinate (4MG/0.5ML Subcutaneous Solution Auto-Injector, 6MG/ 0.5ML Subcutaneous Solution Auto-Injector)
1 QL
tRACK 31
21
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Sumatriptan Succinate
C1Sumatriptan Succinate
A1
B1
C1Guanidine HCl
C1Pyridostigmine Bromide ER
C1Pyridostigmine Bromide
C1Pyridostigmine Bromide
A1
B1
C1Dapsone
C1Rifabutin
B1
C1Ethambutol HCl
C1Isoniazid
C1Isoniazid
C1Paser
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Priftin
C1Pyrazinamide
C1Rifampin
C1Rifampin
C1Rifater
C1Sirturo
C1Trecator
A1
B1
C1Cyclophosphamide
C1Gleostine
C1Gleostine
C1Leukeran
C1Matulane
C1Valchlor
B1
C1Abiraterone Acetate
C1Bicalutamide
C1Erleada
C1Flutamide
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Sumatriptan
Succinate (6MG/
0.5ML Subcutaneous
Solution Auto-
Injector) (Generic
Imitrex STATdose)
1 QL
Sumatriptan Succinate (6MG/0.5ML Subcutaneous Solution Prefilled Syringe)
1 QL
Antimyasthenic Agents
Parasympathomimetics
Guanidine HCl (Oral
Tablet)1
Pyridostigmine Bromide ER (Oral Tablet Extended Release)
1
Pyridostigmine Bromide (Oral Solution)
1
Pyridostigmine Bromide (60MG Oral Tablet Immediate Release)
1
Antimycobacterials
Antimycobacterials, Other
Dapsone (Oral Tablet) 1
Rifabutin (Oral Capsule)
1
Antituberculars
Ethambutol HCl (Oral Tablet)
1
Isoniazid (Oral Syrup) 1
Isoniazid (Oral Tablet) 1
Paser (Oral Packet) 1
Priftin (Oral Tablet) 1
Pyrazinamide (Oral Tablet)
1
Rifampin (Intravenous Solution Reconstituted)
1
Rifampin (Oral Capsule)
1
Rifater (Oral Tablet) 1
Sirturo (Oral Tablet) 1 PA; LA
Trecator (Oral Tablet) 1
Antineoplastics
Alkylating Agents
Cyclophosphamide (Oral Capsule)
1 B/D, PA
Gleostine (100MG
Oral Capsule)1
Gleostine (10MG Oral
Capsule, 40MG Oral
Capsule)
1
Leukeran (Oral
Tablet)1
Matulane (Oral
Capsule)1 LA
Valchlor (External
Gel)1 PA; LA
Antiandrogens
Abiraterone Acetate (Oral Tablet)
1 PA; QL
Bicalutamide (Oral Tablet)
1
Erleada (Oral Tablet) 1 PA; QL
Flutamide (Oral Capsule)
1
tRACK32
22
Bold type = Brand name drug Plain type = Generic drug
C1Nilutamide
C1Nubeqa
C1Xtandi
B1
C1Pomalyst
C1Revlimid
C1Thalomid
B1
C1Emcyt
C1Soltamox
C1Tamoxifen Citrate
C1Toremifene Citrate
B1
C1Droxia
C1Hydroxyurea
C1Mercaptopurine
C1Purixan
C1Tabloid
B1
C1Xpovio
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Xpovio
C1Xpovio
C1Xpovio
B1
C1Copiktra
C1Inrebic
C1Kisqali
C1Kisqali
C1Kisqali
C1Kisqali Femara
C1Kisqali Femara
C1Kisqali Femara
C1Leucovorin Calcium
C1Leucovorin Calcium
C1Lonsurf
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Nilutamide (Oral Tablet)
1
Nubeqa (Oral Tablet) 1 PA; QL
Xtandi (Oral Capsule) 1 PA; LA; QL
Antiangiogenic Agents
Pomalyst (Oral
Capsule)1 PA; QL
Revlimid (Oral
Capsule)1 PA; LA; QL
Thalomid (Oral
Capsule)1 PA; QL
Antiestrogens/Modifiers
Emcyt (Oral Capsule) 1
Soltamox (Oral
Solution)1
Tamoxifen Citrate (Oral Tablet)
1
Toremifene Citrate (Oral Tablet)
1
Antimetabolites
Droxia (Oral Capsule) 1
Hydroxyurea (Oral Capsule)
1
Mercaptopurine (Oral Tablet)
1
Purixan (Oral
Suspension)1 PA
Tabloid (Oral Tablet) 1 PA
Antineoplastics
Xpovio (100MG Once
Weekly) (Oral Tablet
Therapy Pack)
1 PA; QL
Xpovio (60MG Once
Weekly) (Oral Tablet
Therapy Pack)
1 PA; QL
Xpovio (80MG Once
Weekly) (Oral Tablet
Therapy Pack)
1 PA; QL
Xpovio (80MG Twice
Weekly) (Oral Tablet
Therapy Pack)
1 PA; QL
Antineoplastics, Other
Copiktra (Oral
Capsule)1 PA; QL
Inrebic (Oral Capsule) 1 PA; QL
Kisqali (200MG Dose)
(Oral Tablet)1 PA; QL
Kisqali (400MG Dose)
(Oral Tablet)1 PA; QL
Kisqali (600MG Dose)
(Oral Tablet)1 PA; QL
Kisqali Femara
(400MG Dose) (Oral
Tablet Therapy Pack)
1 PA; QL
Kisqali Femara
(600MG Dose) (Oral
Tablet Therapy Pack)
1 PA; QL
Kisqali Femara
(200MG Dose) (Oral
Tablet Therapy Pack)
1 PA; QL
Leucovorin Calcium (10MG Oral Tablet, 15MG Oral Tablet, 5MG Oral Tablet)
1
Leucovorin Calcium (25MG Oral Tablet)
1
Lonsurf (Oral Tablet) 1 PA; LA; QL
tRACK 33
23
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Lorbrena
C1Ninlaro
C1Piqray
C1Piqray
C1Piqray
C1Rozlytrek
C1Synribo
C1Verzenio
C1Zolinza
B1
C1Anastrozole
C1Exemestane
C1Letrozole
B1
C1Balversa
C1Rubraca
C1Talzenna
C1Zejula
B1
C1Afinitor Disperz
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Afinitor
C1Alecensa
C1Alunbrig
C1Alunbrig
C1Bosulif
C1Braftovi
C1Brukinsa
C1Cabometyx
C1Calquence
C1Caprelsa
C1Cometriq
C1Cometriq
C1Cometriq
C1Cotellic
C1Daurismo
C1Erivedge
C1Erlotinib HCl
C1Everolimus
C1Farydak
C1Gilotrif
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Lorbrena (Oral Tablet) 1 PA; QL
Ninlaro (Oral Capsule) 1 PA; QL
Piqray (200MG Daily
Dose) (Oral Tablet
Therapy Pack)
1 PA; QL
Piqray (250MG Daily
Dose) (Oral Tablet
Therapy Pack)
1 PA; QL
Piqray (300MG Daily
Dose) (Oral Tablet
Therapy Pack)
1 PA; QL
Rozlytrek (Oral
Capsule)1 PA; QL
Synribo
(Subcutaneous
Solution
Reconstituted)
1 PA
Verzenio (Oral Tablet) 1 PA; LA; QL
Zolinza (Oral Capsule) 1 PA
Aromatase Inhibitors, 3rd Generation
Anastrozole (Oral Tablet)
1
Exemestane (Oral Tablet)
1
Letrozole (Oral Tablet) 1
Enzyme Inhibitors
Balversa (Oral Tablet) 1 PA; QL
Rubraca (Oral Tablet) 1 PA; LA; QL
Talzenna (Oral
Capsule)1 PA; LA; QL
Zejula (Oral Capsule) 1 PA; LA; QL
Molecular Target Inhibitors
Afinitor Disperz (Oral
Tablet Soluble)1 PA
Afinitor (Oral Tablet) 1 PA
Alecensa (Oral
Capsule)1 PA; LA; QL
Alunbrig (Oral Tablet) 1 PA; LA; QL
Alunbrig (Oral Tablet
Therapy Pack)1 PA; LA; QL
Bosulif (Oral Tablet) 1 PA; QL
Braftovi (Oral
Capsule)1 PA
Brukinsa (Oral
Capsule)1 PA; LA; QL
Cabometyx (Oral
Tablet)1 PA; LA; QL
Calquence (Oral
Capsule)1 PA; QL
Caprelsa (Oral Tablet) 1 PA; LA
Cometriq (100MG
Daily Dose) (Oral Kit)1 PA; LA
Cometriq (140MG
Daily Dose) (Oral Kit)1 PA; LA
Cometriq (60MG Daily
Dose) (Oral Kit)1 PA; LA
Cotellic (Oral Tablet) 1 PA; LA; QL
Daurismo (Oral
Tablet)1 PA; LA; QL
Erivedge (Oral
Capsule)1 PA; LA; QL
Erlotinib HCl (Oral Tablet)
1 PA; QL
Everolimus (Oral Tablet)
1 PA
Farydak (Oral
Capsule)1 PA
Gilotrif (Oral Tablet) 1 PA; LA
tRACK34
24
Bold type = Brand name drug Plain type = Generic drug
C1Ibrance
C1Iclusig
C1IDHIFA
C1Imatinib Mesylate
C1Imbruvica
C1Imbruvica
C1Inlyta
C1Iressa
C1Jakafi
C1Lenvima 10MG Daily Dose
C1Lenvima 12MG Daily Dose
C1Lenvima 14MG Daily Dose
C1Lenvima 18MG Daily Dose
C1Lenvima 20MG Daily Dose
C1Lenvima 24MG Daily Dose
C1Lenvima 4MG Daily Dose
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Lenvima 8MG Daily Dose
C1Lynparza
C1Mekinist
C1Mektovi
C1Nerlynx
C1Nexavar
C1Odomzo
C1Rydapt
C1Sprycel
C1Stivarga
C1Sutent
C1Tafinlar
C1Tagrisso
C1Tasigna
C1Tibsovo
C1Turalio
C1Tykerb
C1Venclexta
C1Venclexta
C1Venclexta Starting Pack
C1Vitrakvi
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Ibrance (Oral
Capsule)1 PA; LA; QL
Iclusig (Oral Tablet) 1 PA; LA; QL
IDHIFA (Oral Tablet) 1 PA; LA; QL
Imatinib Mesylate (Oral Tablet)
1 PA; QL
Imbruvica (Oral
Capsule)1 PA; LA; QL
Imbruvica (Oral
Tablet)1 PA; QL
Inlyta (Oral Tablet) 1 PA; LA; QL
Iressa (Oral Tablet) 1 PA; LA; QL
Jakafi (Oral Tablet) 1 PA; LA; QL
Lenvima 10MG Daily
Dose (Oral Capsule
Therapy Pack)
1 PA; LA
Lenvima 12MG Daily
Dose (Oral Capsule
Therapy Pack)
1 PA; LA
Lenvima 14MG Daily
Dose (Oral Capsule
Therapy Pack)
1 PA; LA
Lenvima 18MG Daily
Dose (Oral Capsule
Therapy Pack)
1 PA; LA
Lenvima 20MG Daily
Dose (Oral Capsule
Therapy Pack)
1 PA; LA
Lenvima 24MG Daily
Dose (Oral Capsule
Therapy Pack)
1 PA; LA
Lenvima 4MG Daily
Dose (Oral Capsule
Therapy Pack)
1 PA; LA
Lenvima 8MG Daily
Dose (Oral Capsule
Therapy Pack)
1 PA; LA
Lynparza (Oral Tablet) 1 PA; LA; QL
Mekinist (Oral Tablet) 1 PA; LA
Mektovi (Oral Tablet) 1 PA
Nerlynx (Oral Tablet) 1 PA; LA; QL
Nexavar (Oral Tablet) 1 PA; LA
Odomzo (Oral
Capsule)1 PA; LA; QL
Rydapt (Oral Capsule) 1 PA; QL
Sprycel (Oral Tablet) 1 PA; QL
Stivarga (Oral Tablet) 1 PA; LA; QL
Sutent (Oral Capsule) 1 PA; QL
Tafinlar (Oral
Capsule)1 PA; LA
Tagrisso (Oral Tablet) 1 PA; LA; QL
Tasigna (Oral
Capsule)1 PA; QL
Tibsovo (Oral Tablet) 1 PA; QL
Turalio (Oral Capsule) 1 PA; LA; QL
Tykerb (Oral Tablet) 1 PA; LA
Venclexta (100MG
Oral Tablet, 50MG
Oral Tablet)
1 PA; LA; QL
Venclexta (10MG Oral
Tablet)1 PA; LA; QL
Venclexta Starting
Pack (Oral Tablet
Therapy Pack)
1 PA; LA
Vitrakvi (Oral
Capsule)1 PA; LA; QL
tRACK 35
25
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Vitrakvi
C1Vizimpro
C1Votrient
C1Xalkori
C1Xospata
C1Zelboraf
C1Zydelig
C1Zykadia
B1
C1Bexarotene
C1Panretin
C1Targretin
C1Tretinoin
B1
C1Mesnex
A1
B1
C1Albendazole
C1Ivermectin
C1Praziquantel
B1
C1Alinia
C1Alinia
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Atovaquone
C1Atovaquone-Proguanil HCl
C1Benznidazole
C1Chloroquine Phosphate
C1Coartem
C1DARAPRIM
C1Hydroxychloroquine Sulfate
C1Mefloquine HCl
C1Nebupent
C1PENTAM 300
C1Pentamidine Isethionate
C1Pentamidine Isethionate
C1Primaquine Phosphate
C1Quinine Sulfate
B1
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Vitrakvi (Oral
Solution)1 PA; LA; QL
Vizimpro (Oral Tablet) 1 PA; LA; QL
Votrient (Oral Tablet) 1 PA; LA; QL
Xalkori (Oral Capsule) 1 PA; LA
Xospata (Oral Tablet) 1 PA; QL
Zelboraf (Oral Tablet) 1 PA; LA; QL
Zydelig (Oral Tablet) 1 PA; LA; QL
Zykadia (Oral Tablet) 1 PA; QL
Retinoids
Bexarotene (Oral Capsule)
1 PA
Panretin (External
Gel)1
Targretin (External
Gel)1 PA
Tretinoin (Oral Capsule)
1
Treatment Adjuncts
Mesnex (Oral Tablet) 1
Antiparasitics
Anthelmintics
Albendazole (Oral Tablet)
1 QL
Ivermectin (Oral Tablet)
1
Praziquantel (Oral Tablet)
1
Antiprotozoals
Alinia (Oral
Suspension
Reconstituted)
1
Alinia (Oral Tablet) 1
Atovaquone (Oral Suspension)
1
Atovaquone-Proguanil HCl (Oral Tablet)
1
Benznidazole (Oral
Tablet)1
Chloroquine Phosphate (Oral Tablet)
1
Coartem (Oral Tablet) 1
DARAPRIM (Oral
Tablet)1
Hydroxychloroquine Sulfate (Oral Tablet)
1
Mefloquine HCl (Oral Tablet)
1
Nebupent (Inhalation
Solution
Reconstituted)
1 B/D, PA; QL
PENTAM 300
(Injection Solution
Reconstituted)
1
Pentamidine Isethionate (Inhalation Solution Reconstituted)
1 B/D, PA; QL
Pentamidine Isethionate (Injection Solution Reconstituted)
1
Primaquine Phosphate (Oral Tablet)
1
Quinine Sulfate (Oral Capsule)
1 PA
Pediculicides/Scabicides
tRACK36
26
Bold type = Brand name drug Plain type = Generic drug
C1Eurax
C1Eurax
C1Lindane
C1Malathion
C1Permethrin
A1
B1
C1Benztropine Mesylate
C1Trihexyphenidyl HCl
C1Trihexyphenidyl HCl
B1
C1Amantadine HCl
C1Amantadine HCl
C1Amantadine HCl
C1Entacapone
C1Tolcapone
B1
C1Apokyn
C1Bromocriptine Mesylate
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Bromocriptine Mesylate
C1Neupro
C1Pramipexole Dihydrochloride
C1Ropinirole HCl
B1
C1Carbidopa
C1Carbidopa-Levodopa ER
C1Carbidopa-Levodopa
C1Carbidopa-Levodopa ODT
C1Carbidopa-Levodopa-Entacapone
C1Rytary
B1
C1Rasagiline Mesylate
C1Selegiline HCl
C1Selegiline HCl
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Eurax (External
Cream)1
Eurax (External
Lotion)1
Lindane (External Shampoo)
1
Malathion (External Lotion)
1
Permethrin (External Cream)
1
Antiparkinson Agents
Anticholinergics
Benztropine Mesylate (Oral Tablet)
1
Trihexyphenidyl HCl (Oral Solution)
1
Trihexyphenidyl HCl (Oral Tablet)
1
Antiparkinson Agents, Other
Amantadine HCl (Oral Capsule)
1
Amantadine HCl (Oral Syrup)
1
Amantadine HCl (Oral Tablet)
1
Entacapone (Oral Tablet)
1
Tolcapone (Oral Tablet)
1 QL
Dopamine Agonists
Apokyn
(Subcutaneous
Solution Cartridge)
1 PA; LA; QL
Bromocriptine Mesylate (Oral Capsule)
1
Bromocriptine Mesylate (Oral Tablet)
1
Neupro (Transdermal
Patch 24 Hour)1
Pramipexole Dihydrochloride (Oral Tablet Immediate Release)
1
Ropinirole HCl (Oral Tablet Immediate Release)
1
Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors
Carbidopa (Oral Tablet)
1
Carbidopa-Levodopa ER (Oral Tablet Extended Release)
1
Carbidopa-Levodopa (Oral Tablet Immediate Release)
1
Carbidopa-Levodopa ODT (Oral Tablet Dispersible)
1
Carbidopa-Levodopa-Entacapone (Oral Tablet)
1
Rytary (Oral Capsule
Extended Release)1 ST
Monoamine Oxidase B (MAO-B) Inhibitors
Rasagiline Mesylate (Oral Tablet)
1
Selegiline HCl (Oral Capsule)
1
Selegiline HCl (Oral Tablet)
1
tRACK 37
27
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Zelapar
A1
B1
C1Chlorpromazine HCl
C1Fluphenazine Decanoate
C1Fluphenazine HCl
C1Fluphenazine HCl
C1Fluphenazine HCl
C1Fluphenazine HCl
C1Haloperidol Decanoate
C1Haloperidol Lactate
C1Haloperidol Lactate
C1Haloperidol
C1Loxapine Succinate
C1Molindone HCl
C1Pimozide
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Thioridazine HCl
C1Thiothixene
C1Trifluoperazine HCl
B1
C1Abilify Maintena
C1Abilify Maintena
C1Aripiprazole
C1Aripiprazole
C1Aripiprazole ODT
C1Aristada Initio
C1Aristada
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Zelapar (Oral Tablet
Dispersible)1
Antipsychotics
1st Generation/Typical
Chlorpromazine HCl (Oral Tablet)
1
Fluphenazine Decanoate (Injection Solution)
1
Fluphenazine HCl (2.5MG/ML Injection Solution)
1
Fluphenazine HCl (5MG/ML Oral Concentrate)
1
Fluphenazine HCl (2.5MG/5ML Oral Elixir)
1
Fluphenazine HCl (10MG Oral Tablet, 1MG Oral Tablet, 2.5MG Oral Tablet, 5MG Oral Tablet)
1
Haloperidol Decanoate (Intramuscular Solution)
1
Haloperidol Lactate (Injection Solution)
1
Haloperidol Lactate (Oral Concentrate)
1
Haloperidol (Oral Tablet)
1
Loxapine Succinate (Oral Capsule)
1
Molindone HCl (Oral Tablet)
1
Pimozide (Oral Tablet) 1
Thioridazine HCl (Oral Tablet)
1
Thiothixene (Oral Capsule)
1
Trifluoperazine HCl (Oral Tablet)
1
2nd Generation/Atypical
Abilify Maintena
(Intramuscular
Prefilled Syringe)
1
Abilify Maintena
(Intramuscular
Suspension
Reconstituted ER)
1
Aripiprazole (1MG/ML Oral Solution)
1 QL
Aripiprazole (10MG Oral Tablet, 15MG Oral Tablet, 20MG Oral Tablet, 2MG Oral Tablet, 30MG Oral Tablet, 5MG Oral Tablet)
1 QL
Aripiprazole ODT (10MG Oral Tablet Dispersible, 15MG Oral Tablet Dispersible)
1 QL
Aristada Initio
(Intramuscular
Prefilled Syringe)
1
Aristada
(Intramuscular
Prefilled Syringe)
1
tRACK38
28
Bold type = Brand name drug Plain type = Generic drug
C1Fanapt
C1Fanapt
C1Fanapt Titration Pack
C1Geodon
C1Invega Sustenna
C1Invega Sustenna
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Invega Trinza
C1Latuda
C1Nuplazid
C1Nuplazid
C1Olanzapine
C1Olanzapine
C1Olanzapine ODT
C1Paliperidone ER
C1Perseris
C1Quetiapine Fumarate ER
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Fanapt (10MG Oral
Tablet, 12MG Oral
Tablet, 4MG Oral
Tablet, 6MG Oral
Tablet, 8MG Oral
Tablet)
1 ST; QL
Fanapt (1MG Oral
Tablet, 2MG Oral
Tablet)
1 ST; QL
Fanapt Titration Pack
(Oral Tablet)1 ST
Geodon
(Intramuscular
Solution
Reconstituted)
1
Invega Sustenna
(117MG/0.75ML
Intramuscular
Suspension Prefilled
Syringe, 156MG/ML
Intramuscular
Suspension Prefilled
Syringe, 234MG/
1.5ML Intramuscular
Suspension Prefilled
Syringe, 78MG/0.5ML
Intramuscular
Suspension Prefilled
Syringe)
1
Invega Sustenna
(39MG/0.25ML
Intramuscular
Suspension Prefilled
Syringe)
1
Invega Trinza
(Intramuscular
Suspension Prefilled
Syringe)
1
Latuda (Oral Tablet) 1 QL
Nuplazid (Oral
Capsule)1 PA; QL
Nuplazid (Oral Tablet) 1 PA; QL
Olanzapine (10MG Intramuscular Solution Reconstituted)
1
Olanzapine (10MG Oral Tablet, 15MG Oral Tablet, 2.5MG Oral Tablet, 20MG Oral Tablet, 5MG Oral Tablet, 7.5MG Oral Tablet)
1 QL
Olanzapine ODT (10MG Oral Tablet Dispersible, 15MG Oral Tablet Dispersible, 20MG Oral Tablet Dispersible, 5MG Oral Tablet Dispersible)
1 QL
Paliperidone ER (Oral Tablet Extended Release 24 Hour)
1 QL
Perseris
(Subcutaneous
Prefilled Syringe)
1
Quetiapine Fumarate ER (Oral Tablet Extended Release 24 Hour)
1 QL
tRACK 39
29
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Quetiapine Fumarate
C1Rexulti
C1Risperdal Consta
C1Risperdal Consta
C1Risperidone
C1Risperidone
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Risperidone ODT
C1Saphris
C1Vraylar
C1Vraylar
C1Ziprasidone HCl
C1Zyprexa Relprevv
B1
C1Clozapine
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Quetiapine Fumarate (Oral Tablet Immediate Release)
1 QL
Rexulti (Oral Tablet) 1 QL
Risperdal Consta
(12.5MG
Intramuscular
Suspension
Reconstituted ER,
25MG Intramuscular
Suspension
Reconstituted ER)
1
Risperdal Consta
(37.5MG
Intramuscular
Suspension
Reconstituted ER,
50MG Intramuscular
Suspension
Reconstituted ER)
1
Risperidone (1MG/ML Oral Solution)
1
Risperidone (0.25MG Oral Tablet, 0.5MG Oral Tablet, 1MG Oral Tablet, 2MG Oral Tablet, 3MG Oral Tablet, 4MG Oral Tablet)
1
Risperidone ODT (0.25MG Oral Tablet Dispersible, 0.5MG Oral Tablet Dispersible, 1MG Oral Tablet Dispersible, 2MG Oral Tablet Dispersible, 3MG Oral Tablet Dispersible, 4MG Oral Tablet Dispersible)
1
Saphris (Tablet
Sublingual)1 QL
Vraylar (1.5MG Oral
Capsule, 3MG Oral
Capsule, 4.5MG Oral
Capsule, 6MG Oral
Capsule)
1 ST; QL
Vraylar (Oral Capsule
Therapy Pack)1 ST
Ziprasidone HCl (Oral Capsule)
1 QL
Zyprexa Relprevv
(210MG
Intramuscular
Suspension
Reconstituted)
1
Treatment-Resistant
Clozapine (100MG Oral Tablet, 200MG Oral Tablet, 25MG Oral Tablet, 50MG Oral Tablet)
1
tRACK40
30
Bold type = Brand name drug Plain type = Generic drug
C1Clozapine ODT
C1Versacloz
A1
B1
C1Valganciclovir HCl
C1Valganciclovir HCl
C1Zirgan
B1
C1Adefovir Dipivoxil
C1Baraclude
C1Entecavir
C1Epivir HBV
C1Lamivudine
C1Vemlidy
B1
C1Intron A
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Intron A
C1Pegasys ProClick
C1Pegasys
C1Ribavirin
C1Sylatron
B1
C1Epclusa
C1Mavyret
C1Sofosbuvir-Velpatasvir
C1Sovaldi
C1Vosevi
B1
C1Acyclovir
C1Acyclovir
C1Acyclovir
C1Acyclovir
C1Acyclovir Sodium
C1Denavir
C1Famciclovir
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Clozapine ODT (100MG Oral Tablet Dispersible, 12.5MG Oral Tablet Dispersible, 150MG Oral Tablet Dispersible, 200MG Oral Tablet Dispersible, 25MG Oral Tablet Dispersible)
1 QL
Versacloz (Oral
Suspension)1
Antivirals
Anti-cytomegalovirus (CMV) Agents
Valganciclovir HCl (Oral Solution Reconstituted)
1 QL
Valganciclovir HCl (Oral Tablet)
1 QL
Zirgan (Ophthalmic
Gel)1
Anti-hepatitis B (HBV) Agents
Adefovir Dipivoxil (Oral Tablet)
1
Baraclude (Oral
Solution)1
Entecavir (Oral Tablet) 1
Epivir HBV (Oral
Solution)1
Lamivudine (100MG Oral Tablet)
1
Vemlidy (Oral Tablet) 1 QL
Anti-hepatitis C (HCV) Agents, Other
Intron A (Injection
Solution)1 PA; LA
Intron A (Injection
Solution
Reconstituted)
1 PA; LA
Pegasys ProClick
(Subcutaneous
Solution)
1 PA
Pegasys
(Subcutaneous
Solution)
1 PA
Ribavirin (Oral Tablet) 1
Sylatron
(Subcutaneous Kit)1 PA
Anti-hepatitis C (HCV) Direct Acting Agents
Epclusa (Oral Tablet) 1 PA; QL
Mavyret (Oral Tablet) 1 PA; QL
Sofosbuvir-Velpatasvir (Oral Tablet)
1 PA; QL
Sovaldi (400MG Oral
Tablet)1 PA; QL
Vosevi (Oral Tablet) 1 PA; QL
Antiherpetic Agents
Acyclovir (External Ointment)
1 QL
Acyclovir (Oral Capsule)
1
Acyclovir (Oral Suspension)
1
Acyclovir (Oral Tablet) 1
Acyclovir Sodium (Intravenous Solution)
1 B/D, PA
Denavir (External
Cream)1 QL
Famciclovir (Oral Tablet)
1 QL
tRACK 41
31
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Trifluridine
C1Valacyclovir HCl
B1
C1Dovato
C1Genvoya
C1Isentress HD
C1Isentress
C1Isentress
C1Isentress
C1Isentress
C1Stribild
C1Tivicay
C1Tivicay
C1Triumeq
C1Tybost
B1
C1Atripla
C1Complera
C1Delstrigo
C1Edurant
C1Efavirenz
C1Efavirenz
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Intelence
C1Intelence
C1Juluca
C1Nevirapine ER
C1Nevirapine
C1Nevirapine
C1Odefsey
C1Pifeltro
C1Rescriptor
C1Symfi Lo
C1Symfi
B1
C1Abacavir Sulfate
C1Abacavir Sulfate
C1Abacavir Sulfate-Lamivudine
C1Abacavir-Lamivudine-Zidovudine
C1Biktarvy
C1Cimduo
C1Descovy
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Trifluridine (Ophthalmic Solution)
1
Valacyclovir HCl (Oral Tablet)
1 QL
Anti-HIV Agents, Integrase Inhibitors (INSTI)
Dovato (Oral Tablet) 1 QL
Genvoya (Oral Tablet) 1 QL
Isentress HD (Oral
Tablet)1 QL
Isentress (Oral
Packet)1 QL
Isentress (Oral Tablet) 1 QL
Isentress (100MG
Oral Tablet Chewable)1 QL
Isentress (25MG Oral
Tablet Chewable)1 QL
Stribild (Oral Tablet) 1 QL
Tivicay (10MG Oral
Tablet)1 QL
Tivicay (25MG Oral
Tablet, 50MG Oral
Tablet)
1 QL
Triumeq (Oral Tablet) 1 QL
Tybost (Oral Tablet) 1 QL
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)
Atripla (Oral Tablet) 1 QL
Complera (Oral
Tablet)1 QL
Delstrigo (Oral Tablet) 1 QL
Edurant (Oral Tablet) 1 QL
Efavirenz (Oral Capsule)
1 QL
Efavirenz (Oral Tablet) 1 QL
Intelence (100MG
Oral Tablet, 200MG
Oral Tablet)
1 QL
Intelence (25MG Oral
Tablet)1 QL
Juluca (Oral Tablet) 1 QL
Nevirapine ER (Oral Tablet Extended Release 24 Hour)
1 QL
Nevirapine (Oral Suspension)
1 QL
Nevirapine (Oral Tablet Immediate Release)
1 QL
Odefsey (Oral Tablet) 1 QL
Pifeltro (Oral Tablet) 1 QL
Rescriptor (Oral
Tablet)1 QL
Symfi Lo (Oral Tablet) 1 QL
Symfi (Oral Tablet) 1 QL
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)
Abacavir Sulfate (Oral Solution)
1 QL
Abacavir Sulfate (Oral Tablet)
1 QL
Abacavir Sulfate-Lamivudine (Oral Tablet)
1 QL
Abacavir-Lamivudine-Zidovudine (Oral Tablet)
1 QL
Biktarvy (Oral Tablet) 1 QL
Cimduo (Oral Tablet) 1 QL
Descovy (Oral Tablet) 1 QL
tRACK42
32
Bold type = Brand name drug Plain type = Generic drug
C1Didanosine
C1Emtriva
C1Emtriva
C1Lamivudine
C1Lamivudine
C1Lamivudine-Zidovudine
C1Stavudine
C1Tenofovir Disoproxil Fumarate
C1Truvada
C1Videx EC
C1Videx
C1Viread
C1Viread
C1Zidovudine
C1Zidovudine
C1Zidovudine
B1
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Fuzeon
C1Selzentry
C1Selzentry
C1Selzentry
B1
C1Aptivus
C1Aptivus
C1Atazanavir Sulfate
C1Crixivan
C1Evotaz
C1Fosamprenavir Calcium
C1Invirase
C1Kaletra
C1Kaletra
C1Lexiva
C1Lopinavir-Ritonavir
C1Norvir
C1Norvir
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Didanosine (Oral Capsule Delayed Release)
1 QL
Emtriva (Oral
Capsule)1 QL
Emtriva (Oral
Solution)1 QL
Lamivudine (10MG/ML Oral Solution)
1 QL
Lamivudine (150MG Oral Tablet, 300MG Oral Tablet)
1 QL
Lamivudine-Zidovudine (Oral Tablet)
1 QL
Stavudine (Oral Capsule)
1 QL
Tenofovir Disoproxil Fumarate (Oral Tablet)
1 QL
Truvada (Oral Tablet) 1 QL
Videx EC (125MG
Oral Capsule Delayed
Release)
1 QL
Videx (Oral Solution
Reconstituted)1 QL
Viread (Oral Powder) 1 QL
Viread (150MG Oral
Tablet, 200MG Oral
Tablet, 250MG Oral
Tablet)
1 QL
Zidovudine (Oral Capsule)
1 QL
Zidovudine (Oral Syrup)
1 QL
Zidovudine (Oral Tablet)
1 QL
Anti-HIV Agents, Other
Fuzeon
(Subcutaneous
Solution
Reconstituted)
1 QL
Selzentry (Oral
Solution)1 QL
Selzentry (150MG
Oral Tablet, 300MG
Oral Tablet, 75MG
Oral Tablet)
1 QL
Selzentry (25MG Oral
Tablet)1 QL
Anti-HIV Agents, Protease Inhibitors
Aptivus (Oral
Capsule)1 QL
Aptivus (Oral
Solution)1 QL
Atazanavir Sulfate (Oral Capsule)
1 QL
Crixivan (Oral
Capsule)1 QL
Evotaz (Oral Tablet) 1 QL
Fosamprenavir Calcium (Oral Tablet)
1 QL
Invirase (Oral Tablet) 1 QL
Kaletra (100-25MG
Oral Tablet)1 QL
Kaletra (200-50MG
Oral Tablet)1 QL
Lexiva (Oral
Suspension)1 QL
Lopinavir-Ritonavir (Oral Solution)
1 QL
Norvir (Oral Packet) 1 QL
Norvir (Oral Solution) 1 QL
tRACK 43
33
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Prezcobix
C1Prezista
C1Prezista
C1Prezista
C1Reyataz
C1Ritonavir
C1Symtuza
C1Viracept
B1
C1Oseltamivir Phosphate
C1Oseltamivir Phosphate
C1Relenza Diskhaler
C1Rimantadine HCl
C1Xofluza
A1
B1
C1Buspirone HCl
C1Hydroxyzine HCl
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Hydroxyzine HCl
B1
C1Alprazolam
C1Chlordiazepoxide HCl
C1Clonazepam
C1Clonazepam ODT
C1Clorazepate Dipotassium
C1Diazepam Intensol
C1Diazepam
C1Diazepam
C1Lorazepam
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Prezcobix (Oral
Tablet)1 QL
Prezista (Oral
Suspension)1 QL
Prezista (150MG Oral
Tablet, 75MG Oral
Tablet)
1 QL
Prezista (600MG Oral
Tablet, 800MG Oral
Tablet)
1 QL
Reyataz (Oral Packet) 1 QL
Ritonavir (Oral Tablet) 1 QL
Symtuza (Oral Tablet) 1 QL
Viracept (Oral Tablet) 1 QL
Anti-influenza Agents
Oseltamivir Phosphate (Oral Capsule)
1 QL
Oseltamivir Phosphate (Oral Suspension Reconstituted)
1 QL
Relenza Diskhaler
(Inhalation Aerosol
Powder Breath
Activated)
1 QL
Rimantadine HCl (Oral Tablet)
1
Xofluza (Oral Tablet
Therapy Pack)1 QL
Anxiolytics
Anxiolytics, Other
Buspirone HCl (Oral Tablet)
1
Hydroxyzine HCl (Oral Syrup)
1
Hydroxyzine HCl (Oral Tablet)
1
Benzodiazepines
Alprazolam (Oral Tablet Immediate Release)
1 QL
Chlordiazepoxide HCl (Oral Capsule)
1
Clonazepam (0.5MG Oral Tablet, 1MG Oral Tablet, 2MG Oral Tablet)
1 QL
Clonazepam ODT (0.125MG Oral Tablet Dispersible, 0.25MG Oral Tablet Dispersible, 0.5MG Oral Tablet Dispersible, 1MG Oral Tablet Dispersible, 2MG Oral Tablet Dispersible)
1 QL
Clorazepate Dipotassium (Oral Tablet)
1 QL
Diazepam Intensol (5MG/ML Oral Concentrate)
1 QL
Diazepam (5MG/5ML Oral Solution)
1
Diazepam (10MG Oral Tablet, 2MG Oral Tablet, 5MG Oral Tablet)
1 QL
Lorazepam (2MG/ML Oral Concentrate)
1 QL
tRACK44
34
Bold type = Brand name drug Plain type = Generic drug
C1Lorazepam
A1
B1
C1Divalproex Sodium ER
C1Divalproex Sodium
C1Divalproex Sodium
C1Lithium Carbonate ER
C1Lithium Carbonate
C1Lithium Carbonate
C1Lithium
A1
B1
C1Acarbose
C1Bydureon BCise
C1Bydureon
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Byetta 10MCG Pen
C1Byetta 5MCG Pen
C1Cycloset
C1Glimepiride
C1Glipizide ER
C1Glipizide
C1Glipizide-Metformin HCl
C1Glyxambi
C1Invokamet
C1Invokamet XR
C1Invokana
C1Janumet
C1Janumet XR
C1Januvia
C1Jardiance
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Lorazepam (0.5MG Oral Tablet, 1MG Oral Tablet, 2MG Oral Tablet)
1 QL
Bipolar Agents
Mood Stabilizers
Divalproex Sodium ER (Oral Tablet Extended Release 24 Hour)
1
Divalproex Sodium (Oral Capsule Delayed Release Sprinkle)
1
Divalproex Sodium (Oral Tablet Delayed Release)
1
Lithium Carbonate ER (Oral Tablet Extended Release)
1
Lithium Carbonate (Oral Capsule)
1
Lithium Carbonate (Oral Tablet Immediate Release)
1
Lithium (Oral
Solution)1
Blood Glucose Regulators
Antidiabetic Agents
Acarbose (Oral Tablet) 1 QL
Bydureon BCise
(Subcutaneous Auto-
Injector)
1 QL
Bydureon
(Subcutaneous Pen-
Injector)
1 QL
Byetta 10MCG Pen
(Subcutaneous
Solution Pen-Injector)
1 QL
Byetta 5MCG Pen
(Subcutaneous
Solution Pen-Injector)
1 QL
Cycloset (Oral Tablet) 1 PA; QL
Glimepiride (Oral Tablet)
1 QL
Glipizide ER (Oral Tablet Extended Release 24 Hour)
1 QL
Glipizide (Oral Tablet Immediate Release)
1 QL
Glipizide-Metformin HCl (Oral Tablet)
1 QL
Glyxambi (Oral
Tablet)1 QL
Invokamet (Oral
Tablet Immediate
Release)
1 QL
Invokamet XR (Oral
Tablet Extended
Release 24 Hour)
1 QL
Invokana (Oral Tablet) 1 QL
Janumet (Oral Tablet
Immediate Release)1 QL
Janumet XR (Oral
Tablet Extended
Release 24 Hour)
1 QL
Januvia (Oral Tablet) 1 QL
Jardiance (Oral
Tablet)1 QL
tRACK 45
35
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Jentadueto
C1Jentadueto XR
C1Metformin HCl ER
C1Metformin HCl
C1Miglitol
C1Nateglinide
C1Ozempic
C1Ozempic
C1Pioglitazone HCl
C1Pioglitazone HCl-Glimepiride
C1Pioglitazone HCl-Metformin HCl
C1Repaglinide
C1Riomet
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Rybelsus
C1Soliqua
C1SymlinPen 120
C1SymlinPen 60
C1Synjardy
C1Synjardy XR
C1Tradjenta
C1Trulicity
C1Victoza
B1
C1Baqsimi Two Pack
C1GlucaGen HypoKit
C1Glucagon Emergency
C1Gvoke PFS
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Jentadueto (Oral
Tablet Immediate
Release)
1 QL
Jentadueto XR (Oral
Tablet Extended
Release 24 Hour)
1 QL
Metformin HCl ER (Oral Tablet Extended Release 24 Hour) (Generic Glucophage XR)
1 QL
Metformin HCl (Oral Tablet Immediate Release)
1 QL
Miglitol (Oral Tablet) 1 QL
Nateglinide (Oral Tablet)
1 QL
Ozempic (0.25 or 0.5
MG/DOSE)
(Subcutaneous
Solution Pen-Injector)
1 QL
Ozempic (1 MG/
DOSE)
(Subcutaneous
Solution Pen-Injector)
1 QL
Pioglitazone HCl (Oral Tablet)
1 QL
Pioglitazone HCl-Glimepiride (Oral Tablet)
1 QL
Pioglitazone HCl-Metformin HCl (Oral Tablet)
1 QL
Repaglinide (Oral Tablet)
1 QL
Riomet (Oral Solution) 1 QL
Rybelsus (Oral Tablet) 1 QL
Soliqua
(Subcutaneous
Solution Pen-Injector)
1 QL
SymlinPen 120
(Subcutaneous
Solution Pen-Injector)
1 PA
SymlinPen 60
(Subcutaneous
Solution Pen-Injector)
1 PA
Synjardy (Oral Tablet
Immediate Release)1 QL
Synjardy XR (Oral
Tablet Extended
Release 24 Hour)
1 QL
Tradjenta (Oral
Tablet)1 QL
Trulicity
(Subcutaneous
Solution Pen-Injector)
1 QL
Victoza
(Subcutaneous
Solution Pen-Injector)
1 QL
Glycemic Agents
Baqsimi Two Pack
(Nasal Powder)1
GlucaGen HypoKit
(Injection Solution
Reconstituted)
1
Glucagon Emergency
(Injection Kit)1
Gvoke PFS
(Subcutaneous
Solution Prefilled
Syringe)
1
tRACK46
36
Bold type = Brand name drug Plain type = Generic drug
C1Proglycem
B1
C1Humalog Junior KwikPen
C1Humalog KwikPen
C1Humalog Mix 50/50 KwikPen
C1Humalog Mix 50/50
C1Humalog Mix 75/25 KwikPen
C1Humalog Mix 75/25
C1Humalog
C1Humalog
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Humulin 70/30 KwikPen
C1Humulin 70/30
C1Humulin N KwikPen
C1Humulin N
C1Humulin R
C1Humulin R U-500
C1Humulin R U-500 KwikPen
C1Insulin Lispro
C1Insulin Lispro
C1Lantus SoloStar
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Proglycem (Oral
Suspension)1
Insulins
Humalog Junior
KwikPen
(Subcutaneous
Solution Pen-Injector)
1
Humalog KwikPen
(Subcutaneous
Solution Pen-Injector)
1
Humalog Mix 50/50
KwikPen
(Subcutaneous
Suspension Pen-
Injector)
1
Humalog Mix 50/50
(Subcutaneous
Suspension)
1
Humalog Mix 75/25
KwikPen
(Subcutaneous
Suspension Pen-
Injector)
1
Humalog Mix 75/25
(Subcutaneous
Suspension)
1
Humalog
(Subcutaneous
Solution)
1
Humalog
(Subcutaneous
Solution Cartridge)
1
Humulin 70/30
KwikPen
(Subcutaneous
Suspension Pen-
Injector)
1
Humulin 70/30
(Subcutaneous
Suspension)
1
Humulin N KwikPen
(Subcutaneous
Suspension Pen-
Injector)
1
Humulin N
(Subcutaneous
Suspension)
1
Humulin R (Injection
Solution)1
Humulin R U-500
(Concentrated)
(Subcutaneous
Solution)
1
Humulin R U-500
KwikPen
(Subcutaneous
Solution Pen-Injector)
1
Insulin Lispro (1 Unit Dial) (Subcutaneous Solution Pen-Injector)
1
Insulin Lispro (Subcutaneous Solution)
1
Lantus SoloStar
(Subcutaneous
Solution Pen-Injector)
1
tRACK 47
37
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Lantus
C1Levemir FlexTouch
C1Levemir
C1Toujeo Max SoloStar
C1Toujeo SoloStar
C1Tresiba FlexTouch
C1Tresiba
A1
B1
C1Coumadin
C1Eliquis Starter Pack
C1Eliquis
C1Enoxaparin Sodium
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Fondaparinux Sodium
C1Fondaparinux Sodium
C1Heparin Sodium
C1Heparin Sodium
C1Jantoven
C1Warfarin Sodium
C1Xarelto
C1Xarelto Starter Pack
B1
C1Anagrelide HCl
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Lantus
(Subcutaneous
Solution)
1
Levemir FlexTouch
(Subcutaneous
Solution Pen-Injector)
1
Levemir
(Subcutaneous
Solution)
1
Toujeo Max SoloStar
(Subcutaneous
Solution Pen-Injector)
1
Toujeo SoloStar
(Subcutaneous
Solution Pen-Injector)
1
Tresiba FlexTouch
(Subcutaneous
Solution Pen-Injector)
1
Tresiba
(Subcutaneous
Solution)
1
Blood Products/Modifiers/Volume Expanders
Anticoagulants
Coumadin (Oral
Tablet)1
Eliquis Starter Pack
(Oral Tablet)1 QL
Eliquis (Oral Tablet) 1 QL
Enoxaparin Sodium (Subcutaneous Solution)
1 QL
Fondaparinux Sodium (10MG/0.8ML Subcutaneous Solution, 5MG/0.4ML Subcutaneous Solution, 7.5MG/ 0.6ML Subcutaneous Solution)
1
Fondaparinux Sodium (2.5MG/0.5ML Subcutaneous Solution)
1
Heparin Sodium (10000UNIT/ML Injection Solution, 20000UNIT/ML Injection Solution, 5000UNIT/ML Injection Solution)
1
Heparin Sodium (1000UNIT/ML Injection Solution)
1 B/D, PA
Jantoven (Oral Tablet) 1
Warfarin Sodium (Oral Tablet)
1
Xarelto (Oral Tablet) 1 QL
Xarelto Starter Pack
(Oral Tablet Therapy
Pack)
1 QL
Blood Formation Modifiers
Anagrelide HCl (Oral Capsule)
1
tRACK48
38
Bold type = Brand name drug Plain type = Generic drug
C1Aranesp
C1Aranesp
C1Aranesp
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Aranesp
C1Granix
C1Granix
C1Leukine
C1Neulasta
C1Neupogen
C1Neupogen
C1Procrit
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Aranesp (Albumin
Free) (100MCG/ML
Injection Solution,
200MCG/ML
Injection Solution,
300MCG/ML
Injection Solution,
60MCG/ML Injection
Solution)
1 PA
Aranesp (Albumin
Free) (25MCG/ML
Injection Solution,
40MCG/ML Injection
Solution)
1 PA
Aranesp (Albumin
Free) (100MCG/
0.5ML Injection
Solution Prefilled
Syringe, 150MCG/
0.3ML Injection
Solution Prefilled
Syringe, 200MCG/
0.4ML Injection
Solution Prefilled
Syringe, 300MCG/
0.6ML Injection
Solution Prefilled
Syringe, 500MCG/ML
Injection Solution
Prefilled Syringe,
60MCG/0.3ML
Injection Solution
Prefilled Syringe)
1 PA
Aranesp (Albumin
Free) (10MCG/0.4ML
Injection Solution
Prefilled Syringe,
25MCG/0.42ML
Injection Solution
Prefilled Syringe,
40MCG/0.4ML
Injection Solution
Prefilled Syringe)
1 PA
Granix (Subcutaneous
Solution)1 ST
Granix (Subcutaneous
Solution Prefilled
Syringe)
1 ST
Leukine (Injection
Solution
Reconstituted)
1 PA
Neulasta
(Subcutaneous
Solution Prefilled
Syringe)
1 PA
Neupogen (Injection
Solution)1 ST
Neupogen (Injection
Solution Prefilled
Syringe)
1 ST
Procrit (10000UNIT/
ML Injection Solution,
2000UNIT/ML
Injection Solution,
3000UNIT/ML
Injection Solution,
4000UNIT/ML
Injection Solution)
1 PA
tRACK 49
39
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Procrit
C1Promacta
C1Promacta
C1Retacrit
C1Retacrit
C1Udenyca
C1Zarxio
B1
C1Tranexamic Acid
B1
C1Aspirin-Dipyridamole ER
C1Brilinta
C1Cablivi
C1Cilostazol
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Clopidogrel Bisulfate
C1Prasugrel HCl
A1
B1
C1Clonidine HCl
C1Clonidine
C1Methyldopa
C1Midodrine HCl
C1Northera
B1
C1Doxazosin Mesylate
C1Phenoxybenzamine HCl
C1Prazosin HCl
B1
C1Candesartan Cilexetil
C1Edarbi
C1Eprosartan Mesylate
C1Irbesartan
C1Losartan Potassium
C1Olmesartan Medoxomil
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Procrit (20000UNIT/
ML Injection Solution,
40000UNIT/ML
Injection Solution)
1 PA
Promacta (Oral
Packet)1 PA; LA; QL
Promacta (Oral
Tablet)1 PA; LA; QL
Retacrit (10000UNIT/
ML Injection Solution,
2000UNIT/ML
Injection Solution,
3000UNIT/ML
Injection Solution,
4000UNIT/ML
Injection Solution)
1 PA
Retacrit (40000UNIT/
ML Injection Solution)1 PA
Udenyca
(Subcutaneous
Solution Prefilled
Syringe)
1 PA
Zarxio (Injection
Solution Prefilled
Syringe)
1
Hemostasis Agents
Tranexamic Acid (Oral Tablet)
1
Platelet Modifying Agents
Aspirin-Dipyridamole ER (Oral Capsule Extended Release 12 Hour)
1 QL
Brilinta (Oral Tablet) 1 QL
Cablivi (Injection Kit) 1 PA; QL
Cilostazol (Oral Tablet) 1
Clopidogrel Bisulfate (75MG Oral Tablet)
1 QL
Prasugrel HCl (Oral Tablet)
1 QL
Cardiovascular Agents
Alpha-adrenergic Agonists
Clonidine HCl (Oral Tablet Immediate Release)
1
Clonidine (Transdermal Patch Weekly)
1
Methyldopa (Oral Tablet)
1
Midodrine HCl (Oral Tablet)
1
Northera (Oral
Capsule)1 PA; LA; QL
Alpha-adrenergic Blocking Agents
Doxazosin Mesylate (Oral Tablet)
1
Phenoxybenzamine HCl (Oral Capsule)
1
Prazosin HCl (Oral Capsule)
1
Angiotensin II Receptor Antagonists
Candesartan Cilexetil (Oral Tablet)
1 QL
Edarbi (Oral Tablet) 1 QL
Eprosartan Mesylate (Oral Tablet)
1 QL
Irbesartan (Oral Tablet) 1 QL
Losartan Potassium (Oral Tablet)
1 QL
Olmesartan Medoxomil (Oral Tablet)
1 QL
tRACK50
40
Bold type = Brand name drug Plain type = Generic drug
C1Telmisartan
C1Valsartan
B1
C1Benazepril HCl
C1Captopril
C1Enalapril Maleate
C1Fosinopril Sodium
C1Lisinopril
C1Moexipril HCl
C1Perindopril Erbumine
C1Quinapril HCl
C1Ramipril
C1Trandolapril
B1
C1Amiodarone HCl
C1Dofetilide
C1Flecainide Acetate
C1Mexiletine HCl
C1Multaq
C1Pacerone
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Propafenone HCl ER
C1Propafenone HCl
C1Quinidine Gluconate ER
C1Quinidine Sulfate
C1Sotalol HCl
C1Sotalol HCl
B1
C1Acebutolol HCl
C1Atenolol
C1Betaxolol HCl
C1Bisoprolol Fumarate
C1Bystolic
C1Carvedilol
C1Labetalol HCl
C1Metoprolol Succinate ER
C1Metoprolol Tartrate
C1Nadolol
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Telmisartan (Oral Tablet)
1 QL
Valsartan (Oral Tablet) 1 QL
Angiotensin-converting Enzyme (ACE) Inhibitors
Benazepril HCl (Oral Tablet)
1 QL
Captopril (Oral Tablet) 1 QL
Enalapril Maleate (Oral Tablet)
1 QL
Fosinopril Sodium (Oral Tablet)
1 QL
Lisinopril (Oral Tablet) 1 QL
Moexipril HCl (Oral Tablet)
1 QL
Perindopril Erbumine (Oral Tablet)
1 QL
Quinapril HCl (Oral Tablet)
1 QL
Ramipril (Oral Capsule) 1 QL
Trandolapril (Oral Tablet)
1 QL
Antiarrhythmics
Amiodarone HCl (200MG Oral Tablet)
1
Dofetilide (Oral Capsule)
1
Flecainide Acetate (Oral Tablet)
1
Mexiletine HCl (Oral Capsule)
1
Multaq (Oral Tablet) 1 QL
Pacerone (200MG Oral Tablet)
1
Propafenone HCl ER (Oral Capsule Extended Release 12 Hour)
1
Propafenone HCl (Oral Tablet)
1
Quinidine Gluconate ER (Oral Tablet Extended Release)
1
Quinidine Sulfate (Oral Tablet)
1
Sotalol HCl (AF) (120MG Oral Tablet)
1
Sotalol HCl (Oral Tablet)
1
Beta-adrenergic Blocking Agents
Acebutolol HCl (Oral Capsule)
1
Atenolol (Oral Tablet) 1
Betaxolol HCl (Oral Tablet)
1
Bisoprolol Fumarate (Oral Tablet)
1
Bystolic (Oral Tablet) 1 QL
Carvedilol (Oral Tablet) 1
Labetalol HCl (Oral Tablet)
1
Metoprolol Succinate ER (Oral Tablet Extended Release 24 Hour)
1
Metoprolol Tartrate (100MG Oral Tablet, 25MG Oral Tablet, 50MG Oral Tablet)
1
Nadolol (Oral Tablet) 1
tRACK 51
41
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Pindolol
C1Propranolol HCl ER
C1Propranolol HCl
C1Propranolol HCl
B1
C1Amlodipine Besylate
C1Cartia XT
C1Diltiazem HCl ER Beads
C1Diltiazem HCl ER Coated Beads
C1Diltiazem HCl ER
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Diltiazem HCl
C1Dilt-XR
C1Felodipine ER
C1Matzim LA
C1Nicardipine HCl
C1Nifedipine ER
C1Nifedipine ER Osmotic Release
C1Nimodipine
C1Nymalize
C1Taztia XT
C1Tiadylt ER
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Pindolol (Oral Tablet) 1
Propranolol HCl ER (Oral Capsule Extended Release 24 Hour)
1
Propranolol HCl (Oral Solution)
1
Propranolol HCl (Oral Tablet)
1
Calcium Channel Blocking Agents
Amlodipine Besylate (Oral Tablet)
1
Cartia XT (Oral Capsule Extended Release 24 Hour)
1
Diltiazem HCl ER Beads (360MG Oral Capsule Extended Release 24 Hour, 420MG Oral Capsule Extended Release 24 Hour)
1
Diltiazem HCl ER Coated Beads (120MG Oral Capsule Extended Release 24 Hour, 180MG Oral Capsule Extended Release 24 Hour, 240MG Oral Capsule Extended Release 24 Hour, 300MG Oral Capsule Extended Release 24 Hour)
1
Diltiazem HCl ER (Oral Capsule Extended Release 12 Hour)
1
Diltiazem HCl (Oral Tablet Immediate Release)
1
Dilt-XR (Oral Capsule Extended Release 24 Hour)
1
Felodipine ER (Oral Tablet Extended Release 24 Hour)
1
Matzim LA (Oral Tablet Extended Release 24 Hour)
1
Nicardipine HCl (Oral Capsule)
1
Nifedipine ER (Oral Tablet Extended Release 24 Hour)
1 QL
Nifedipine ER Osmotic Release (Oral Tablet Extended Release 24 Hour)
1 QL
Nimodipine (Oral Capsule)
1
Nymalize (60MG/
20ML Oral Solution)1
Taztia XT (Oral Capsule Extended Release 24 Hour)
1
Tiadylt ER (360MG Oral Capsule Extended Release 24 Hour)
1
tRACK52
42
Bold type = Brand name drug Plain type = Generic drug
C1Verapamil HCl ER
C1Verapamil HCl ER
C1Verapamil HCl ER
C1Verapamil HCl
B1
C1Aliskiren Fumarate
C1Amiloride-Hydrochlorothiazide
C1Amlodipine-Atorvastatin
C1Amlodipine-Benazepril
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Amlodipine-Olmesartan
C1Amlodipine-Valsartan
C1Amlodipine-Valsartan-HCTZ
C1Atenolol-Chlorthalidone
C1Benazepril-Hydrochlorothiazide
C1BiDil
C1Bisoprolol-Hydrochlorothiazide
C1Candesartan Cilexetil-HCTZ
C1Captopril-Hydrochlorothiazide
C1Corlanor
C1Corlanor
C1Demser
C1Digitek
C1Digox
C1Digoxin
C1Digoxin
C1Edarbyclor
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Verapamil HCl ER (100MG Oral Capsule Extended Release 24 Hour, 120MG Oral Capsule Extended Release 24 Hour, 180MG Oral Capsule Extended Release 24 Hour, 200MG Oral Capsule Extended Release 24 Hour, 240MG Oral Capsule Extended Release 24 Hour, 300MG Oral Capsule Extended Release 24 Hour)
1
Verapamil HCl ER
(360MG Oral Capsule
Extended Release 24
Hour)
1
Verapamil HCl ER (Oral Tablet Extended Release)
1
Verapamil HCl (Oral Tablet Immediate Release)
1
Cardiovascular Agents, Other
Aliskiren Fumarate (Oral Tablet)
1 QL
Amiloride-Hydrochlorothiazide (Oral Tablet)
1
Amlodipine-Atorvastatin (Oral Tablet)
1 QL
Amlodipine-Benazepril (Oral Capsule)
1 QL
Amlodipine-Olmesartan (Oral Tablet)
1 QL
Amlodipine-Valsartan (Oral Tablet)
1 QL
Amlodipine-Valsartan-HCTZ (Oral Tablet)
1 QL
Atenolol-Chlorthalidone (Oral Tablet)
1
Benazepril-Hydrochlorothiazide (Oral Tablet)
1 QL
BiDil (Oral Tablet) 1 QL
Bisoprolol-Hydrochlorothiazide (Oral Tablet)
1 QL
Candesartan Cilexetil-HCTZ (Oral Tablet)
1 QL
Captopril-Hydrochlorothiazide (Oral Tablet)
1 QL
Corlanor (Oral
Solution)1 PA; QL
Corlanor (Oral Tablet) 1 PA; QL
Demser (Oral
Capsule)1
Digitek (Oral Tablet) 1
Digox (Oral Tablet) 1
Digoxin (Oral
Solution)1
Digoxin (Oral Tablet) 1
Edarbyclor (Oral
Tablet)1 QL
tRACK 53
43
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Enalapril-Hydrochlorothiazide
C1Entresto
C1Fosinopril Sodium-HCTZ
C1Irbesartan-Hydrochlorothiazide
C1Lanoxin
C1Lisinopril-Hydrochlorothiazide
C1Losartan Potassium-HCTZ
C1Methyldopa-Hydrochlorothiazide
C1Metoprolol-Hydrochlorothiazide
C1Olmesartan Medoxomil-HCTZ
C1Olmesartan-Amlodipine-HCTZ
C1Pentoxifylline ER
C1Propranolol-HCTZ
C1Quinapril-Hydrochlorothiazide
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Ranolazine ER
C1Spironolactone-HCTZ
C1Telmisartan-Amlodipine
C1Telmisartan-HCTZ
C1Triamterene-HCTZ
C1Triamterene-HCTZ
C1Valsartan-Hydrochlorothiazide
C1Vyndamax
C1Vyndaqel
B1
C1Acetazolamide ER
C1Acetazolamide
C1Methazolamide
B1
C1Bumetanide
C1Bumetanide
C1Ethacrynic Acid
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Enalapril-Hydrochlorothiazide (Oral Tablet)
1 QL
Entresto (Oral Tablet) 1 QL
Fosinopril Sodium-HCTZ (Oral Tablet)
1 QL
Irbesartan-Hydrochlorothiazide (Oral Tablet)
1 QL
Lanoxin (Oral Tablet) 1
Lisinopril-Hydrochlorothiazide (Oral Tablet)
1 QL
Losartan Potassium-HCTZ (Oral Tablet)
1 QL
Methyldopa-Hydrochlorothiazide (Oral Tablet)
1
Metoprolol-Hydrochlorothiazide (Oral Tablet)
1
Olmesartan Medoxomil-HCTZ (Oral Tablet)
1 QL
Olmesartan-Amlodipine-HCTZ (Oral Tablet)
1 QL
Pentoxifylline ER (Oral Tablet Extended Release)
1
Propranolol-HCTZ (Oral Tablet)
1
Quinapril-Hydrochlorothiazide (Oral Tablet)
1 QL
Ranolazine ER (Oral Tablet Extended Release 12 Hour)
1 QL
Spironolactone-HCTZ (Oral Tablet)
1
Telmisartan-Amlodipine (Oral Tablet)
1 QL
Telmisartan-HCTZ (Oral Tablet)
1 QL
Triamterene-HCTZ (Oral Capsule)
1
Triamterene-HCTZ (Oral Tablet)
1
Valsartan-Hydrochlorothiazide (Oral Tablet)
1 QL
Vyndamax (Oral
Capsule)1 PA; QL
Vyndaqel (Oral
Capsule)1 PA; QL
Diuretics, Carbonic Anhydrase Inhibitors
Acetazolamide ER (Oral Capsule Extended Release 12 Hour)
1
Acetazolamide (Oral Tablet)
1
Methazolamide (Oral Tablet)
1
Diuretics, Loop
Bumetanide (Injection Solution)
1
Bumetanide (Oral Tablet)
1
Ethacrynic Acid (Oral Tablet)
1
tRACK54
44
Bold type = Brand name drug Plain type = Generic drug
C1Furosemide
C1Furosemide
C1Furosemide
C1Torsemide
B1
C1Amiloride HCl
C1Eplerenone
C1Spironolactone
C1Triamterene
B1
C1Chlorothiazide
C1Chlorthalidone
C1Diuril
C1Hydrochlorothiazide
C1Hydrochlorothiazide
C1Indapamide
C1Metolazone
B1
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Fenofibrate Micronized
C1Fenofibrate
C1Fenofibrate
C1Fenofibric Acid
C1Fenofibric Acid
C1Fenofibric Acid
C1Gemfibrozil
B1
C1Atorvastatin Calcium
C1Fluvastatin Sodium
C1Livalo
C1Lovastatin
C1Pravastatin Sodium
C1Rosuvastatin Calcium
C1Simvastatin
B1
C1Cholestyramine Light
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Furosemide (Injection Solution)
1 B/D, PA
Furosemide (Oral Solution)
1
Furosemide (Oral Tablet)
1
Torsemide (Oral Tablet)
1
Diuretics, Potassium-sparing
Amiloride HCl (Oral Tablet)
1
Eplerenone (Oral Tablet)
1
Spironolactone (Oral Tablet)
1
Triamterene (Oral Capsule)
1
Diuretics, Thiazide
Chlorothiazide (Oral Tablet)
1
Chlorthalidone (Oral Tablet)
1
Diuril (Oral
Suspension)1
Hydrochlorothiazide (Oral Capsule)
1
Hydrochlorothiazide (Oral Tablet)
1
Indapamide (Oral Tablet)
1
Metolazone (Oral Tablet)
1
Dyslipidemics, Fibric Acid Derivatives
Fenofibrate Micronized (134MG Oral Capsule, 200MG Oral Capsule, 67MG Oral Capsule)
1
Fenofibrate (145MG Oral Tablet, 48MG Oral Tablet)
1
Fenofibrate (160MG Oral Tablet, 54MG Oral Tablet)
1
Fenofibric Acid (Oral Capsule Delayed Release)
1
Fenofibric Acid
(105MG Oral Tablet)1
Fenofibric Acid (35MG Oral Tablet)
1
Gemfibrozil (Oral Tablet)
1
Dyslipidemics, HMG CoA Reductase Inhibitors
Atorvastatin Calcium (Oral Tablet)
1 QL
Fluvastatin Sodium (Oral Capsule)
1 QL
Livalo (Oral Tablet) 1 QL
Lovastatin (Oral Tablet) 1 QL
Pravastatin Sodium (Oral Tablet)
1 QL
Rosuvastatin Calcium (Oral Tablet)
1 QL
Simvastatin (Oral Tablet)
1 QL
Dyslipidemics, Other
Cholestyramine Light (Oral Powder)
1
tRACK 55
45
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Cholestyramine
C1Colesevelam HCl
C1Colesevelam HCl
C1Colestipol HCl
C1Colestipol HCl
C1Ezetimibe
C1Ezetimibe-Simvastatin
C1Juxtapid
C1Niacin ER
C1Niacor
C1Omega-3-Acid Ethyl Esters
C1Praluent
C1Prevalite
C1Repatha Pushtronex System
C1Repatha
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Repatha SureClick
C1Vascepa
B1
C1Hydralazine HCl
C1Minoxidil
B1
C1Isosorbide Dinitrate
C1Isosorbide Mononitrate ER
C1Isosorbide Mononitrate
C1Minitran
C1Nitro-Bid
C1Nitroglycerin
C1Nitroglycerin
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Cholestyramine (Oral Packet)
1
Colesevelam HCl (Oral Packet)
1
Colesevelam HCl (Oral Tablet)
1
Colestipol HCl (Oral Packet)
1
Colestipol HCl (Oral Tablet)
1
Ezetimibe (Oral Tablet) 1 QL
Ezetimibe-Simvastatin (Oral Tablet)
1 QL
Juxtapid (Oral
Capsule)1 PA; LA
Niacin ER (Antihyperlipidemic) (Oral Tablet Extended Release)
1
Niacor (Oral Tablet) 1
Omega-3-Acid Ethyl Esters (Oral Capsule) (Generic Lovaza)
1 QL
Praluent
(Subcutaneous
Solution Auto-
Injector)
1 PA; LA; QL
Prevalite (Oral Packet) 1
Repatha Pushtronex
System
(Subcutaneous
Solution Cartridge)
1 PA; QL
Repatha
(Subcutaneous
Solution Prefilled
Syringe)
1 PA; QL
Repatha SureClick
(Subcutaneous
Solution Auto-
Injector)
1 PA; QL
Vascepa (Oral
Capsule)1
Vasodilators, Direct-acting Arterial
Hydralazine HCl (Oral Tablet)
1
Minoxidil (Oral Tablet) 1
Vasodilators, Direct-acting Arterial/Venous
Isosorbide Dinitrate (10MG Oral Tablet Immediate Release, 20MG Oral Tablet Immediate Release, 30MG Oral Tablet Immediate Release, 5MG Oral Tablet Immediate Release)
1
Isosorbide Mononitrate ER (Oral Tablet Extended Release 24 Hour)
1
Isosorbide Mononitrate (Oral Tablet Immediate Release)
1
Minitran (Transdermal Patch 24 Hour)
1
Nitro-Bid (Transdermal Ointment)
1
Nitroglycerin (Tablet Sublingual)
1
Nitroglycerin (Transdermal Patch 24 Hour)
1
tRACK56
46
Bold type = Brand name drug Plain type = Generic drug
C1Nitroglycerin
C1Nitrostat
C1Rectiv
A1
B1
C1Amphetamine-Dextroamphetamine ER
C1Amphetamine-Dextroamphetamine
C1Dextroamphetamine Sulfate ER
C1Dextroamphetamine Sulfate
C1Vyvanse
C1Vyvanse
B1
C1Atomoxetine HCl
C1Clonidine HCl ER
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Dexmethylphenidate HCl ER
C1Dexmethylphenidate HCl
C1Guanfacine HCl ER
C1Metadate ER
C1Methylphenidate HCl ER
C1Methylphenidate HCl
C1Methylphenidate HCl
B1
C1Austedo
C1Ingrezza
C1Ingrezza
C1Namzaric
C1Namzaric
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Nitroglycerin (Translingual Solution)
1
Nitrostat (Tablet
Sublingual)1
Rectiv (Rectal
Ointment)1
Central Nervous System Agents
Attention Deficit Hyperactivity Disorder Agents, Amphetamines
Amphetamine-Dextroamphetamine ER (Oral Capsule Extended Release 24 Hour)
1 QL
Amphetamine-Dextroamphetamine (Oral Tablet)
1 QL
Dextroamphetamine Sulfate ER (Oral Capsule Extended Release 24 Hour)
1 QL
Dextroamphetamine Sulfate (Oral Tablet)
1 QL
Vyvanse (Oral
Capsule)1
Vyvanse (Oral Tablet
Chewable)1
Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines
Atomoxetine HCl (Oral Capsule)
1 QL
Clonidine HCl ER (Oral Tablet Extended Release 12 Hour)
1 PA
Dexmethylphenidate HCl ER (Oral Capsule Extended Release 24 Hour)
1
Dexmethylphenidate HCl (Oral Tablet)
1 QL
Guanfacine HCl ER (Oral Tablet Extended Release 24 Hour)
1
Metadate ER (Oral Tablet Extended Release)
1 QL
Methylphenidate HCl ER (10MG Oral Tablet Extended Release, 20MG Oral Tablet Extended Release)
1 QL
Methylphenidate HCl (Oral Solution)
1 QL
Methylphenidate HCl (Oral Tablet Immediate Release) (Generic Ritalin)
1 QL
Central Nervous System, Other
Austedo (Oral Tablet) 1 PA; LA; QL
Ingrezza (Oral
Capsule)1 PA; QL
Ingrezza (Oral
Capsule Therapy
Pack)
1 PA; QL
Namzaric (Oral
Capsule ER 24 Hour
Therapy Pack)
1 PA; QL
Namzaric (Oral
Capsule Extended
Release 24 Hour)
1 PA; QL
tRACK 57
47
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Nuedexta
C1Riluzole
C1Tetrabenazine
B1
C1Drizalma Sprinkle
C1Duloxetine HCl
C1Pregabalin
C1Pregabalin
C1Savella
C1Savella Titration Pack
B1
C1Ampyra
C1Aubagio
C1Avonex Pen
C1Avonex Prefilled
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Betaseron
C1Dalfampridine ER
C1Gilenya
C1Glatiramer Acetate
C1Glatopa
C1Mayzent
C1Rebif Rebidose
C1Rebif Rebidose Titration Pack
C1Rebif
C1Rebif Titration Pack
C1Tecfidera Starter Pack
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Nuedexta (Oral
Capsule)1 PA
Riluzole (Oral Tablet) 1
Tetrabenazine (Oral Tablet)
1 PA; LA; QL
Fibromyalgia Agents
Drizalma Sprinkle
(Oral Capsule
Delayed Release
Sprinkle)
1 ST; QL
Duloxetine HCl (20MG Oral Capsule Delayed Release Particles, 30MG Oral Capsule Delayed Release Particles, 60MG Oral Capsule Delayed Release Particles)
1 QL
Pregabalin (Oral Capsule)
1 QL
Pregabalin (Oral Solution)
1 QL
Savella (Oral Tablet) 1
Savella Titration Pack
(Oral Tablet)1
Multiple Sclerosis Agents
Ampyra (Oral Tablet
Extended Release 12
Hour)
1 QL
Aubagio (Oral Tablet) 1 LA; QL
Avonex Pen
(Intramuscular Auto-
Injector Kit)
1 QL
Avonex Prefilled
(Intramuscular
Prefilled Syringe Kit)
1 QL
Betaseron
(Subcutaneous Kit)1 QL
Dalfampridine ER (Oral Tablet Extended Release 12 Hour)
1 QL
Gilenya (0.5MG Oral
Capsule)1 QL
Glatiramer Acetate (Subcutaneous Solution Prefilled Syringe)
1 QL
Glatopa (Subcutaneous Solution Prefilled Syringe)
1 QL
Mayzent (Oral Tablet) 1 QL
Rebif Rebidose
(Subcutaneous
Solution Auto-
Injector)
1 QL
Rebif Rebidose
Titration Pack
(Subcutaneous
Solution Auto-
Injector)
1 QL
Rebif (Subcutaneous
Solution Prefilled
Syringe)
1 QL
Rebif Titration Pack
(Subcutaneous
Solution Prefilled
Syringe)
1 QL
Tecfidera Starter
Pack (Oral)1 LA
tRACK58
48
Bold type = Brand name drug Plain type = Generic drug
C1Tecfidera
A1
B1
C1Chlorhexidine Gluconate
C1Pilocarpine HCl
C1Triamcinolone Acetonide
A1
B1
C1Acitretin
C1Adapalene
C1Adapalene
C1Ammonium Lactate
C1Ammonium Lactate
C1Azelaic Acid
C1Benzoyl Peroxide-Erythromycin
C1Calcipotriene
C1Calcipotriene
C1Calcipotriene
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Calcitriol
C1Carac
C1Claravis
C1Clindamycin Phosphate
C1Clindamycin Phosphate
C1Clindamycin Phosphate
C1Clindamycin Phosphate
C1Clindamycin Phosphate-Benzoyl Peroxide
C1Clotrimazole-Betamethasone
C1Clotrimazole-Betamethasone
C1Cortisporin
C1Cortisporin
C1Cosentyx
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Tecfidera (Oral
Capsule Delayed
Release)
1 LA; QL
Dental and Oral Agents
Dental and Oral Agents
Chlorhexidine Gluconate (Mouth Solution)
1
Pilocarpine HCl (Oral Tablet)
1
Triamcinolone Acetonide (Dental Paste)
1
Dermatological Agents
Dermatological Agents
Acitretin (Oral Capsule) 1
Adapalene (External Cream)
1
Adapalene (0.1% External Gel)
1
Ammonium Lactate (External Cream)
1
Ammonium Lactate (External Lotion)
1
Azelaic Acid (External Gel)
1
Benzoyl Peroxide-Erythromycin (External Gel)
1
Calcipotriene (External Cream)
1
Calcipotriene (External Ointment)
1
Calcipotriene (External Solution)
1
Calcitriol (External
Ointment)1
Carac (External
Cream)1 PA
Claravis (Oral Capsule) 1 PA
Clindamycin Phosphate (External Gel)
1
Clindamycin Phosphate (External Lotion)
1
Clindamycin Phosphate (External Solution)
1
Clindamycin Phosphate (External Swab)
1
Clindamycin Phosphate-Benzoyl Peroxide (1-5% External Gel)
1
Clotrimazole-Betamethasone (External Cream)
1
Clotrimazole-Betamethasone (External Lotion)
1
Cortisporin (External
Cream)1
Cortisporin (External
Ointment)1
Cosentyx (300 MG
Dose) (Subcutaneous
Solution Prefilled
Syringe)
1 PA; LA
tRACK 59
49
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Cosentyx Sensoready
C1Diclofenac Sodium
C1Doxepin HCl
C1Ery
C1Erythromycin
C1Erythromycin
C1Finacea
C1Fluorouracil
C1Fluorouracil
C1Fluorouracil
C1Imiquimod
C1Imiquimod Pump
C1Isotretinoin
C1Methoxsalen Rapid
C1Mirvaso
C1Oxsoralen Ultra
C1Picato
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Pimecrolimus
C1Podofilox
C1Regranex
C1Santyl
C1Selenium Sulfide
C1Stelara
C1Stelara
C1Tacrolimus
C1Tazarotene
C1Tazorac
C1Tazorac
C1Tazorac
C1Tolak
C1Tretinoin
C1Tretinoin
C1Tretinoin Microsphere
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Cosentyx Sensoready
(300 MG)
(Subcutaneous
Solution Auto-
Injector)
1 PA; LA
Diclofenac Sodium (3% Transdermal Gel)
1 PA
Doxepin HCl (External Cream)
1 PA; QL
Ery (External Pad) 1
Erythromycin (External Gel)
1
Erythromycin (External Solution)
1
Finacea (External
Foam)1
Fluorouracil (0.5% External Cream)
1
Fluorouracil (5% External Cream)
1
Fluorouracil (External Solution)
1
Imiquimod (5% External Cream)
1
Imiquimod Pump (3.75% External Cream)
1 PA
Isotretinoin (Oral Capsule)
1 PA
Methoxsalen Rapid (Oral Capsule)
1
Mirvaso (External Gel) 1
Oxsoralen Ultra (Oral
Capsule)1
Picato (External Gel) 1
Pimecrolimus (External Cream)
1 ST
Podofilox (External Solution)
1
Regranex (External
Gel)1 PA
Santyl (External
Ointment)1
Selenium Sulfide (External Lotion)
1
Stelara
(Subcutaneous
Solution)
1 PA
Stelara
(Subcutaneous
Solution Prefilled
Syringe)
1 PA
Tacrolimus (External Ointment)
1 ST
Tazarotene (External Cream)
1 PA
Tazorac (0.05%
External Cream)1 PA
Tazorac (0.05%
External Gel)1 PA
Tazorac (0.1%
External Gel)1 PA
Tolak (External
Cream)1
Tretinoin (External Cream)
1 PA
Tretinoin (0.01% External Gel, 0.025% External Gel)
1 PA
Tretinoin Microsphere (External Gel)
1 PA
tRACK60
50
Bold type = Brand name drug Plain type = Generic drug
C1Zyclara Pump
A1
B1
C1Aminosyn II
C1Aminosyn-PF
C1Carbaglu
C1Dextrose
C1Dextrose
C1Dextrose-NaCl
C1Dextrose-NaCl
C1FreAmine HBC
C1HepatAmine
C1Intralipid
C1Ionosol-MB in D5W
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Isolyte-P in D5W
C1Isolyte-S
C1KCl in Dextrose-NaCl
C1KCl-Lactated Ringers-D5W
C1Klor-Con 10
C1Klor-Con M10
C1Klor-Con M15
C1Klor-Con M20
C1Klor-Con
C1Klor-Con 8
C1Klor-Con Sprinkle
C1Levocarnitine
C1Levocarnitine
C1Magnesium Sulfate
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Zyclara Pump
(External Cream)1 PA
Electrolytes/Minerals/Metals/Vitamins
Electrolyte/Mineral Replacement
Aminosyn II
(Intravenous Solution)1 B/D, PA
Aminosyn-PF
(Intravenous Solution)1 B/D, PA
Carbaglu (Oral Tablet) 1 LA
Dextrose (10%
Intravenous Solution)1
Dextrose (5% Intravenous Solution)
1 B/D, PA
Dextrose-NaCl
(10-0.2% Intravenous
Solution, 10-0.45%
Intravenous Solution,
2.5-0.45%
Intravenous Solution,
5-0.2% Intravenous
Solution, 5-0.225%
Intravenous Solution,
5-0.45% Intravenous
Solution)
1
Dextrose-NaCl
(5-0.9% Intravenous
Solution)
1 B/D, PA
FreAmine HBC
(Intravenous Solution)1 B/D, PA
HepatAmine
(Intravenous Solution)1 B/D, PA
Intralipid (Intravenous
Emulsion)1 B/D, PA
Ionosol-MB in D5W
(Intravenous Solution)1
Isolyte-P in D5W
(Intravenous Solution)1
Isolyte-S (Intravenous
Solution)1
KCl in Dextrose-NaCl
(Intravenous Solution)1
KCl-Lactated Ringers-
D5W (Intravenous
Solution)
1
Klor-Con 10 (Oral
Tablet Extended
Release)
1
Klor-Con M10 (Oral Tablet Extended Release)
1
Klor-Con M15 (Oral Tablet Extended Release)
1
Klor-Con M20 (Oral Tablet Extended Release)
1
Klor-Con (Oral Packet) 1
Klor-Con 8 (Oral
Tablet Extended
Release)
1
Klor-Con Sprinkle (8MEQ Oral Capsule Extended Release)
1
Levocarnitine (1GM/ 10ML Oral Solution)
1
Levocarnitine (330MG
Oral Tablet)1
Magnesium Sulfate
(50% Injection
Solution)
1
tRACK 61
51
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Magnesium Sulfate
C1NephrAmine
C1Normosol-M in D5W
C1Normosol-R in D5W
C1Normosol-R pH 7.4
C1Nutrilipid
C1Plasma-Lyte 148
C1Plasma-Lyte A
C1Plenamine
C1Potassium Chloride CR
C1Potassium Chloride ER
C1Potassium Chloride in Dextrose
C1Potassium Chloride in NaCl
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Potassium Chloride in NaCl
C1Potassium Chloride
C1Potassium Chloride
C1Potassium Chloride
C1Potassium Chloride
C1Potassium Citrate ER
C1Premasol
C1Procalamine
C1Prosol
C1Sodium Chloride
C1Sodium Chloride
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Magnesium Sulfate (50% (10ML Syringe) Injection Solution)
1
NephrAmine
(Intravenous Solution)1 B/D, PA
Normosol-M in D5W
(Intravenous Solution)1
Normosol-R in D5W
(Intravenous Solution)1
Normosol-R pH 7.4
(Intravenous Solution)1
Nutrilipid
(Intravenous
Emulsion)
1 B/D, PA
Plasma-Lyte 148
(Intravenous Solution)1
Plasma-Lyte A
(Intravenous Solution)1
Plenamine (Intravenous Solution)
1 B/D, PA
Potassium Chloride CR (Oral Tablet Extended Release)
1
Potassium Chloride ER (Oral Capsule Extended Release)
1
Potassium Chloride in
Dextrose (Intravenous
Solution)
1 B/D, PA
Potassium Chloride in NaCl (20-0.45MEQ/L-% Intravenous Solution)
1 B/D, PA
Potassium Chloride in
NaCl (20-0.9MEQ/L-%
Intravenous Solution,
40-0.9MEQ/L-%
Intravenous Solution)
1 B/D, PA
Potassium Chloride
(10MEQ/100ML
Intravenous Solution,
20MEQ/100ML
Intravenous Solution,
40MEQ/100ML
Intravenous Solution)
1 B/D, PA
Potassium Chloride (2MEQ/ML Intravenous Solution, 2MEQ/ML (20ML) Intravenous Solution)
1 B/D, PA
Potassium Chloride (Oral Packet)
1
Potassium Chloride (Oral Solution)
1
Potassium Citrate ER (Oral Tablet Extended Release)
1
Premasol (Intravenous Solution)
1 B/D, PA
Procalamine
(Intravenous Solution)1 B/D, PA
Prosol (Intravenous
Solution)1 B/D, PA
Sodium Chloride
(0.45% Intravenous
Solution)
1
Sodium Chloride (0.9% Intravenous Solution)
1 B/D, PA
tRACK62
52
Bold type = Brand name drug Plain type = Generic drug
C1Sodium Chloride
C1Sodium Chloride
C1Sodium Fluoride
C1Sodium Lactate
C1TPN Electrolytes
C1Travasol
C1TrophAmine
B1
C1Chemet
C1Deferasirox
C1Deferasirox
C1Ferriprox
C1Ferriprox
C1Jadenu
C1Jadenu Sprinkle
C1Kionex
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Lokelma
C1Sodium Polystyrene Sulfonate
C1Sodium Polystyrene Sulfonate
C1SPS
C1Trientine HCl
C1Veltassa
B1
C1Auryxia
C1Calcium Acetate
C1Calcium Acetate
C1Lanthanum Carbonate
C1Phoslyra
C1Sevelamer Carbonate
C1Sevelamer Carbonate
C1Velphoro
B1
C1VP-PNV-DHA
A1
B1
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Sodium Chloride (3%
Intravenous Solution,
5% Intravenous
Solution)
1 B/D, PA
Sodium Chloride
(Irrigation Solution)1
Sodium Fluoride (Oral Tablet)
1
Sodium Lactate
(5MEQ/ML
Intravenous Solution)
1
TPN Electrolytes
(Intravenous Solution)1
Travasol (Intravenous
Solution)1 B/D, PA
TrophAmine (10%
Intravenous Solution)1 B/D, PA
Electrolyte/Mineral/Metal Modifiers
Chemet (Oral
Capsule)1
Deferasirox (360MG Oral Tablet, 90MG Oral Tablet) (Generic Jadenu)
1 PA
Deferasirox (Oral Tablet Soluble) (Generic Exjade)
1 PA
Ferriprox (Oral
Solution)1 PA
Ferriprox (Oral Tablet) 1 PA
Jadenu (Oral Tablet) 1 PA
Jadenu Sprinkle (Oral
Packet)1 PA
Kionex (Oral Suspension)
1
Lokelma (Oral Packet) 1 QL
Sodium Polystyrene Sulfonate (Oral Powder)
1
Sodium Polystyrene Sulfonate (Oral Suspension)
1
SPS (Oral Suspension) 1
Trientine HCl (Oral Capsule)
1 PA; QL
Veltassa (Oral Packet) 1 QL
Phosphate Binders
Auryxia (Oral Tablet) 1 PA
Calcium Acetate (Phosphate Binder) (Oral Capsule)
1
Calcium Acetate (Phosphate Binder) (Oral Tablet)
1
Lanthanum Carbonate (Oral Tablet Chewable)
1
Phoslyra (Oral
Solution)1
Sevelamer Carbonate (Oral Packet)
1
Sevelamer Carbonate (Oral Tablet) (Generic Renvela)
1
Velphoro (Oral Tablet
Chewable)1
Vitamins
VP-PNV-DHA (Oral Capsule)
1
Gastrointestinal Agents
Antispasmodics, Gastrointestinal
tRACK 63
53
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Cuvposa
C1Dicyclomine HCl
C1Dicyclomine HCl
C1Dicyclomine HCl
C1Methscopolamine Bromide
B1
C1Chenodal
C1Cromolyn Sodium
C1Diphenoxylate-Atropine
C1Diphenoxylate-Atropine
C1Gattex
C1Loperamide HCl
C1Myalept
C1Relistor
C1Relistor
C1Serostim
C1Ursodiol
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Ursodiol
C1Zorbtive
B1
C1Cimetidine HCl
C1Cimetidine
C1Famotidine
C1Famotidine
C1Ranitidine HCl
C1Ranitidine HCl
B1
C1Alosetron HCl
C1Amitiza
C1Linzess
C1Xifaxan
B1
C1Clenpiq
C1Constulose
C1Enulose
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Cuvposa (Oral
Solution)1 PA
Dicyclomine HCl (Oral Capsule)
1
Dicyclomine HCl (Oral Solution)
1
Dicyclomine HCl (Oral Tablet)
1
Methscopolamine Bromide (Oral Tablet)
1
Gastrointestinal Agents, Other
Chenodal (Oral Tablet) 1
Cromolyn Sodium (Oral Concentrate)
1
Diphenoxylate-Atropine (Oral Liquid)
1
Diphenoxylate-Atropine (Oral Tablet)
1
Gattex (Subcutaneous
Kit)1 PA; LA
Loperamide HCl (Oral Capsule)
1
Myalept
(Subcutaneous
Solution
Reconstituted)
1 PA; LA
Relistor (Oral Tablet) 1 PA; QL
Relistor
(Subcutaneous
Solution)
1 PA
Serostim
(Subcutaneous
Solution
Reconstituted)
1 PA; LA
Ursodiol (Oral Capsule)
1
Ursodiol (Oral Tablet) 1
Zorbtive
(Subcutaneous
Solution
Reconstituted)
1 PA; LA
Histamine2 (H2) Receptor Antagonists
Cimetidine HCl (Oral Solution)
1
Cimetidine (Oral Tablet)
1
Famotidine (Oral Suspension Reconstituted)
1
Famotidine (20MG Oral Tablet, 40MG Oral Tablet)
1
Ranitidine HCl (75MG/ 5ML Oral Syrup)
1
Ranitidine HCl (150MG Oral Tablet, 300MG Oral Tablet)
1
Irritable Bowel Syndrome Agents
Alosetron HCl (Oral Tablet)
1 PA
Amitiza (Oral
Capsule)1 QL
Linzess (Oral
Capsule)1 QL
Xifaxan (Oral Tablet) 1 PA
Laxatives
Clenpiq (Oral
Solution)1
Constulose (Oral Solution)
1
Enulose (Oral Solution) 1
tRACK64
54
Bold type = Brand name drug Plain type = Generic drug
C1GaviLyte-C
C1GaviLyte-G
C1GaviLyte-N with Flavor Pack
C1Generlac
C1Lactulose
C1PEG 3350/Electrolytes
C1PEG-3350-NaCl-Na Bicarbonate-KCl
C1PEG-3350-Electrolytes
C1Suprep Bowel Prep Kit
C1TriLyte
B1
C1Carafate
C1Misoprostol
C1Sucralfate
C1Sucralfate
B1
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Dexilant
C1Esomeprazole Magnesium
C1Lansoprazole
C1Omeprazole
C1Omeprazole
C1Pantoprazole Sodium
C1Prilosec
C1Rabeprazole Sodium
A1
B1
C1Aralast NP
C1Cholbam
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
GaviLyte-C (Oral Solution Reconstituted)
1
GaviLyte-G (Oral Solution Reconstituted)
1
GaviLyte-N with Flavor Pack (Oral Solution Reconstituted)
1
Generlac (Oral Solution)
1
Lactulose (10GM/ 15ML Oral Solution)
1
PEG 3350/Electrolytes (240GM Oral Solution Reconstituted) (Generic Colyte)
1
PEG-3350-NaCl-Na Bicarbonate-KCl (Oral Solution) (Generic NuLYTELY)
1
PEG-3350-Electrolytes (Oral Solution) (Generic GoLYTELY)
1
Suprep Bowel Prep
Kit (Oral Solution)1
TriLyte (Oral Solution Reconstituted)
1
Protectants
Carafate (Oral
Suspension)1
Misoprostol (Oral Tablet)
1
Sucralfate (Oral Suspension)
1
Sucralfate (Oral Tablet) 1
Proton Pump Inhibitors
Dexilant (Oral
Capsule Delayed
Release)
1 QL
Esomeprazole Magnesium (Oral Capsule Delayed Release) (Generic Nexium)
1 QL
Lansoprazole (Oral Capsule Delayed Release)
1 QL
Omeprazole (10MG Oral Capsule Delayed Release)
1 QL
Omeprazole (20MG Oral Capsule Delayed Release, 40MG Oral Capsule Delayed Release)
1
Pantoprazole Sodium (Oral Tablet Delayed Release)
1 QL
Prilosec (Oral Packet) 1 PA
Rabeprazole Sodium (Oral Tablet Delayed Release)
1
Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment
Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment
Aralast NP (1000MG
Intravenous Solution
Reconstituted)
1 PA; LA
Cholbam (Oral
Capsule)1 PA
tRACK 65
55
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Creon
C1Cystadane
C1Cystagon
C1Glassia
C1Kuvan
C1Kuvan
C1Miglustat
C1Ocaliva
C1Orfadin
C1Orfadin
C1Prolastin-C
C1RAVICTI
C1Sodium Phenylbutyrate
C1Sodium Phenylbutyrate
C1Sucraid
C1Tegsedi
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Zemaira
C1Zenpep
A1
B1
C1Myrbetriq
C1Oxybutynin Chloride ER
C1Oxybutynin Chloride
C1Oxybutynin Chloride
C1Solifenacin Succinate
B1
C1Alfuzosin HCl ER
C1Dutasteride
C1Finasteride
C1Silodosin
C1Tamsulosin HCl
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Creon (Oral Capsule
Delayed Release
Particles)
1
Cystadane (Oral
Powder)1
Cystagon (Oral
Capsule)1 LA
Glassia (Intravenous
Solution)1 PA; LA
Kuvan (Oral Packet) 1 LA
Kuvan (Oral Tablet
Soluble)1 LA
Miglustat (Oral Capsule)
1 PA; LA
Ocaliva (Oral Tablet) 1 PA; QL
Orfadin (Oral
Capsule)1 LA
Orfadin (Oral
Suspension)1 LA
Prolastin-C
(Intravenous Solution
Reconstituted)
1 PA; LA
RAVICTI (Oral Liquid) 1 LA; QL
Sodium Phenylbutyrate (Oral Powder)
1
Sodium Phenylbutyrate (Oral Tablet)
1
Sucraid (Oral
Solution)1 LA
Tegsedi
(Subcutaneous
Solution Prefilled
Syringe)
1 PA; LA
Zemaira (Intravenous
Solution
Reconstituted)
1 PA; LA
Zenpep (Oral Capsule
Delayed Release
Particles)
1
Genitourinary Agents
Antispasmodics, Urinary
Myrbetriq (Oral Tablet
Extended Release 24
Hour)
1
Oxybutynin Chloride ER (Oral Tablet Extended Release 24 Hour)
1 QL
Oxybutynin Chloride (Oral Syrup)
1
Oxybutynin Chloride (Oral Tablet Immediate Release)
1
Solifenacin Succinate (Oral Tablet)
1 QL
Benign Prostatic Hypertrophy Agents
Alfuzosin HCl ER (Oral Tablet Extended Release 24 Hour)
1
Dutasteride (Oral Capsule)
1 QL
Finasteride (5MG Oral Tablet) (Generic Proscar)
1
Silodosin (Oral Capsule)
1 QL
Tamsulosin HCl (Oral Capsule)
1
tRACK66
56
Bold type = Brand name drug Plain type = Generic drug
C1Terazosin HCl
B1
C1Bethanechol Chloride
C1Depen Titratabs
C1Elmiron
C1Lithostat
C1Penicillamine
A1
B1
C1Ala-Cort
C1Alclometasone Dipropionate
C1Alclometasone Dipropionate
C1Betamethasone Dipropionate Aug
C1Betamethasone Dipropionate Aug
C1Betamethasone Dipropionate Aug
C1Betamethasone Dipropionate Aug
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Betamethasone Dipropionate
C1Betamethasone Dipropionate
C1Betamethasone Dipropionate
C1Betamethasone Valerate
C1Betamethasone Valerate
C1Betamethasone Valerate
C1Clobetasol Propionate Emollient Base
C1Clobetasol Propionate
C1Clobetasol Propionate
C1Clobetasol Propionate
C1Clobetasol Propionate
C1Clobetasol Propionate
C1Cordran
C1Cortisone Acetate
C1Desonide
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Terazosin HCl (Oral Capsule)
1
Genitourinary Agents, Other
Bethanechol Chloride (Oral Tablet)
1
Depen Titratabs (Oral
Tablet)1
Elmiron (Oral
Capsule)1
Lithostat (Oral Tablet) 1
Penicillamine (Oral Capsule)
1 PA
Hormonal Agents, Stimulant/Replacement/ Modifying (Adrenal)
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
Ala-Cort (External Cream)
1
Alclometasone Dipropionate (External Cream)
1
Alclometasone Dipropionate (External Ointment)
1
Betamethasone Dipropionate Aug (External Cream)
1
Betamethasone Dipropionate Aug (External Gel)
1
Betamethasone Dipropionate Aug (External Lotion)
1
Betamethasone Dipropionate Aug (External Ointment)
1
Betamethasone Dipropionate (External Cream)
1
Betamethasone Dipropionate (External Lotion)
1
Betamethasone Dipropionate (External Ointment)
1
Betamethasone Valerate (External Cream)
1
Betamethasone Valerate (External Lotion)
1
Betamethasone Valerate (External Ointment)
1
Clobetasol Propionate Emollient Base (External Cream)
1
Clobetasol Propionate (External Cream)
1
Clobetasol Propionate (External Gel)
1
Clobetasol Propionate (External Ointment)
1
Clobetasol Propionate (External Shampoo)
1
Clobetasol Propionate (External Solution)
1
Cordran (External
Tape)1
Cortisone Acetate (Oral Tablet)
1
Desonide (External Ointment)
1
tRACK 67
57
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Desoximetasone
C1Dexamethasone Intensol
C1Dexamethasone
C1Dexamethasone
C1Fludrocortisone Acetate
C1Fluocinolone Acetonide
C1Fluocinolone Acetonide
C1Fluocinolone Acetonide
C1Fluocinolone Acetonide Scalp
C1Fluocinonide Emulsified Base
C1Fluocinonide
C1Fluocinonide
C1Fluocinonide
C1Fluticasone Propionate
C1Fluticasone Propionate
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Halobetasol Propionate
C1Halobetasol Propionate
C1Hydrocortisone Butyrate
C1Hydrocortisone
C1Hydrocortisone
C1Hydrocortisone
C1Hydrocortisone
C1Hydrocortisone Valerate
C1Hydrocortisone Valerate
C1Methylprednisolone
C1Methylprednisolone
C1Mometasone Furoate
C1Mometasone Furoate
C1Mometasone Furoate
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Desoximetasone (External Cream)
1
Dexamethasone Intensol (Oral Concentrate)
1
Dexamethasone (Oral Elixir)
1
Dexamethasone (Oral Tablet)
1
Fludrocortisone Acetate (Oral Tablet)
1
Fluocinolone Acetonide (External Cream)
1
Fluocinolone Acetonide (External Ointment)
1
Fluocinolone Acetonide (External Solution)
1
Fluocinolone Acetonide Scalp (External Oil)
1
Fluocinonide Emulsified Base (External Cream)
1
Fluocinonide (External Gel)
1
Fluocinonide (External Ointment)
1
Fluocinonide (External Solution)
1
Fluticasone Propionate (External Cream)
1
Fluticasone Propionate (External Ointment)
1
Halobetasol Propionate (External Cream)
1
Halobetasol Propionate (External Ointment)
1
Hydrocortisone Butyrate (External Ointment)
1
Hydrocortisone (1% External Cream, 2.5% External Cream)
1
Hydrocortisone (2.5% External Lotion)
1
Hydrocortisone (1% External Ointment, 2.5% External Ointment)
1
Hydrocortisone (Oral Tablet)
1
Hydrocortisone Valerate (External Cream)
1
Hydrocortisone Valerate (External Ointment)
1
Methylprednisolone (Oral Tablet)
1
Methylprednisolone (Oral Tablet Therapy Pack)
1
Mometasone Furoate (External Cream)
1
Mometasone Furoate (External Ointment)
1
Mometasone Furoate (External Solution)
1
tRACK68
58
Bold type = Brand name drug Plain type = Generic drug
C1Prednicarbate
C1Prednicarbate
C1Prednisolone
C1Prednisolone Sodium Phosphate
C1Prednisone Intensol
C1Prednisone
C1Prednisone
C1Prednisone
C1Triamcinolone Acetonide
C1Triamcinolone Acetonide
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Triamcinolone Acetonide
C1Triderm
A1
B1
C1Desmopressin Acetate
C1Desmopressin Acetate Spray
C1Genotropin MiniQuick
C1Genotropin
C1Humatrope
C1Increlex
C1Norditropin FlexPro
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Prednicarbate (External Cream)
1
Prednicarbate (External Ointment)
1
Prednisolone (Oral Solution)
1
Prednisolone Sodium Phosphate (25MG/ 5ML Oral Solution, 6.7MG/5ML Oral Solution)
1
Prednisone Intensol (Oral Concentrate)
1
Prednisone (5MG/5ML Oral Solution)
1
Prednisone (10MG Oral Tablet, 1MG Oral Tablet, 2.5MG Oral Tablet, 20MG Oral Tablet, 50MG Oral Tablet, 5MG Oral Tablet)
1
Prednisone (10MG (21) Oral Tablet Therapy Pack, 10MG (48) Oral Tablet Therapy Pack, 5MG (21) Oral Tablet Therapy Pack, 5MG (48) Oral Tablet Therapy Pack)
1
Triamcinolone Acetonide (External Cream)
1
Triamcinolone Acetonide (External Lotion)
1
Triamcinolone Acetonide (0.025% External Ointment, 0.1% External Ointment, 0.5% External Ointment)
1
Triderm (0.1% External Cream)
1
Hormonal Agents, Stimulant/Replacement/ Modifying (Pituitary)
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
Desmopressin Acetate (Oral Tablet)
1
Desmopressin Acetate Spray (Nasal Solution)
1
Genotropin MiniQuick
(Subcutaneous
Solution
Reconstituted)
1 PA
Genotropin
(Subcutaneous
Solution
Reconstituted)
1 PA
Humatrope (Injection
Solution
Renconstituted),
Humatrope Combo
Pack (Injection)
1 PA
Increlex
(Subcutaneous
Solution)
1 PA; LA
Norditropin FlexPro
(Subcutaneous
Solution)
1 PA
tRACK 69
59
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Nutropin AQ NuSpin 10
C1Nutropin AQ NuSpin 20
C1Nutropin AQ NuSpin 5
C1Saizen
C1Saizenprep
A1
B1
C1Korlym
A1
B1
C1Anadrol-50
C1Androderm
C1Danazol
C1Oxandrolone
C1Oxandrolone
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Testosterone Cypionate
C1Testosterone Enanthate
C1Testosterone
C1Testosterone
B1
C1Altavera
C1Alyacen 1/35
C1Amethia Lo
C1Amethia
C1Apri
C1Aranelle
C1Ashlyna
C1Aubra
C1Aviane
C1Balziva
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Nutropin AQ NuSpin
10 (Subcutaneous
Solution)
1 PA
Nutropin AQ NuSpin
20 (Subcutaneous
Solution)
1 PA
Nutropin AQ NuSpin 5
(Subcutaneous
Solution)
1 PA
Saizen (Injection
Solution
Reconstituted)
1 PA; LA
Saizenprep (Injection
Solution
Reconstituted)
1 PA; LA
Hormonal Agents, Stimulant/Replacement/ Modifying (Prostaglandins)
Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)
Korlym (Oral Tablet) 1 PA; LA; QL
Hormonal Agents, Stimulant/Replacement/ Modifying (Sex Hormones/Modifiers)
Androgens
Anadrol-50 (Oral
Tablet)1 PA
Androderm
(Transdermal Patch
24 Hour)
1 QL
Danazol (Oral Capsule) 1
Oxandrolone (10MG Oral Tablet)
1 PA; QL
Oxandrolone (2.5MG Oral Tablet)
1 PA; QL
Testosterone Cypionate (Intramuscular Solution)
1
Testosterone Enanthate (Intramuscular Solution)
1
Testosterone (25MG/ 2.5GM 1% Transdermal Gel, 50MG/5GM 1% Transdermal Gel), Testosterone Pump (1% Transdermal Gel)
1
Testosterone (20.25MG/1.25GM 1.62% Transdermal Gel, 40.5MG/2.5GM 1.62% Transdermal Gel), Testosterone Pump (1.62% Transdermal Gel)
1
Estrogens
Altavera (Oral Tablet) 1
Alyacen 1/35 (Oral Tablet)
1
Amethia Lo (Oral Tablet)
1
Amethia (Oral Tablet) 1
Apri (Oral Tablet) 1
Aranelle (Oral Tablet) 1
Ashlyna (Oral Tablet) 1
Aubra (Oral Tablet) 1
Aviane (Oral Tablet) 1
Balziva (Oral Tablet) 1
tRACK70
60
Bold type = Brand name drug Plain type = Generic drug
C1Blisovi 24 Fe
C1Blisovi Fe 1.5/30
C1Briellyn
C1Camrese Lo
C1Caziant
C1Climara Pro
C1Cryselle-28
C1Cyclafem 1/35
C1Cyclafem 7/7/7
C1Cyred
C1Depo-Estradiol
C1Desogestrel-Ethinyl Estradiol
C1Drospirenone-Ethinyl Estradiol
C1Duavee
C1Elestrin
C1EluRyng
C1Emoquette
C1Enpresse-28
C1Enskyce
C1Estarylla
C1Estradiol
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Estradiol
C1Estradiol
C1Estradiol
C1Estradiol Valerate
C1Estring
C1Ethynodiol Diacetate-Ethinyl Estradiol
C1Etonogestrel-Ethinyl Estradiol
C1Falmina
C1Fayosim
C1Femring
C1Femynor
C1Fyavolv
C1Gianvi
C1Hailey 24 Fe
C1Imvexxy Maintenance Pack
C1Imvexxy Starter Pack
C1Introvale
C1Isibloom
C1Jasmiel
C1Jinteli
C1Juleber
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Blisovi 24 Fe (Oral Tablet)
1
Blisovi Fe 1.5/30 (Oral Tablet)
1
Briellyn (Oral Tablet) 1
Camrese Lo (Oral Tablet)
1
Caziant (Oral Tablet) 1
Climara Pro
(Transdermal Patch
Weekly)
1
Cryselle-28 (Oral Tablet)
1
Cyclafem 1/35 (Oral Tablet)
1
Cyclafem 7/7/7 (Oral Tablet)
1
Cyred (Oral Tablet) 1
Depo-Estradiol (Intramuscular Oil)
1
Desogestrel-Ethinyl Estradiol (Oral Tablet)
1
Drospirenone-Ethinyl Estradiol (Oral Tablet)
1
Duavee (Oral Tablet) 1
Elestrin (Transdermal
Gel)1
EluRyng (Vaginal Ring) 1
Emoquette (Oral Tablet)
1
Enpresse-28 (Oral Tablet)
1
Enskyce (Oral Tablet) 1
Estarylla (Oral Tablet) 1
Estradiol (Oral Tablet) 1
Estradiol (Transdermal Patch Weekly)
1 QL
Estradiol (Vaginal Cream)
1
Estradiol (Vaginal Tablet)
1 QL
Estradiol Valerate (Intramuscular Oil)
1
Estring (Vaginal Ring) 1
Ethynodiol Diacetate-Ethinyl Estradiol (Oral Tablet)
1
Etonogestrel-Ethinyl Estradiol (Vaginal Ring)
1
Falmina (Oral Tablet) 1
Fayosim (Oral Tablet) 1
Femring (Vaginal
Ring)1
Femynor (Oral Tablet) 1
Fyavolv (Oral Tablet) 1
Gianvi (Oral Tablet) 1
Hailey 24 Fe (Oral Tablet)
1
Imvexxy Maintenance
Pack (Vaginal Insert)1 PA; QL
Imvexxy Starter Pack
(Vaginal Insert)1 PA; QL
Introvale (Oral Tablet) 1
Isibloom (Oral Tablet) 1
Jasmiel (Oral Tablet) 1
Jinteli (Oral Tablet) 1
Juleber (Oral Tablet) 1
tRACK 71
61
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Junel 1.5/30
C1Junel 1/20
C1Junel Fe 1.5/30
C1Junel Fe 1/20
C1Junel Fe 24
C1Kaitlib Fe
C1Kariva
C1Kelnor 1/35
C1Kelnor 1/50
C1Kurvelo
C1LARIN 1.5/30
C1LARIN 1/20
C1LARIN Fe 1.5/30
C1LARIN Fe 1/20
C1Larissia
C1Layolis Fe
C1Leena
C1Lessina
C1Levonest
C1Levonorgestrel-Ethinyl Estradiol & Ethinyl Estradiol
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Levonorgestrel-Ethinyl Estradiol 91-Day
C1Levonorgestrel-Ethinyl Estradiol
C1Levora 0.15/30
C1Loryna
C1Low-Ogestrel
C1Lutera
C1Marlissa
C1Melodetta 24 Fe
C1Menest
C1Mibelas 24 Fe
C1Microgestin 1.5/30
C1Microgestin 1/20
C1Microgestin Fe 1.5/30
C1Microgestin Fe 1/20
C1Mili
C1Necon 0.5/35
C1Nikki
C1Norethindrone Acetate-Ethinyl Estradiol
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Junel 1.5/30 (Oral Tablet)
1
Junel 1/20 (Oral Tablet)
1
Junel Fe 1.5/30 (Oral Tablet)
1
Junel Fe 1/20 (Oral Tablet)
1
Junel Fe 24 (Oral Tablet)
1
Kaitlib Fe (Oral Tablet Chewable)
1
Kariva (Oral Tablet) 1
Kelnor 1/35 (Oral Tablet)
1
Kelnor 1/50 (Oral Tablet)
1
Kurvelo (Oral Tablet) 1
LARIN 1.5/30 (Oral Tablet)
1
LARIN 1/20 (Oral Tablet)
1
LARIN Fe 1.5/30 (Oral Tablet)
1
LARIN Fe 1/20 (Oral Tablet)
1
Larissia (Oral Tablet) 1
Layolis Fe (Oral
Tablet Chewable)1
Leena (Oral Tablet) 1
Lessina (Oral Tablet) 1
Levonest (Oral Tablet) 1
Levonorgestrel-Ethinyl Estradiol & Ethinyl Estradiol (Oral Tablet)
1
Levonorgestrel-Ethinyl Estradiol 91-Day (Oral Tablet)
1
Levonorgestrel-Ethinyl Estradiol (Oral Tablet)
1
Levora 0.15/30 (28) (Oral Tablet)
1
Loryna (Oral Tablet) 1
Low-Ogestrel (Oral Tablet)
1
Lutera (Oral Tablet) 1
Marlissa (Oral Tablet) 1
Melodetta 24 Fe (Oral Tablet Chewable)
1
Menest (Oral Tablet) 1
Mibelas 24 Fe (Oral Tablet Chewable)
1
Microgestin 1.5/30 (Oral Tablet)
1
Microgestin 1/20 (Oral Tablet)
1
Microgestin Fe 1.5/30 (Oral Tablet)
1
Microgestin Fe 1/20 (Oral Tablet)
1
Mili (Oral Tablet) 1
Necon 0.5/35 (28) (Oral Tablet)
1
Nikki (Oral Tablet) 1
Norethindrone Acetate-Ethinyl Estradiol (0.5-2.5MG-MCG Oral Tablet, 1-5MG-MCG Oral Tablet)
1
tRACK72
62
Bold type = Brand name drug Plain type = Generic drug
C1Norethindrone Acetate-Ethinyl Estradiol
C1Norethindrone Acetate-Ethinyl Estradiol-Fe
C1Norethindrone Acetate-Ethinyl Estradiol-Fe
C1Norgestimate-Ethinyl Estradiol
C1Norgestimate-Ethinyl Estradiol Triphasic
C1Nortrel 0.5/35
C1Nortrel 1/35
C1Nortrel 1/35
C1Nortrel 7/7/7
C1Ocella
C1Ogestrel
C1Orsythia
C1Pimtrea
C1Pirmella 1/35
C1Portia-28
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Premarin
C1Premarin
C1Premphase
C1Prempro
C1Previfem
C1Reclipsen
C1Rivelsa
C1Setlakin
C1Sprintec 28
C1Sronyx
C1Syeda
C1Tarina 24 Fe
C1Tarina Fe 1/20
C1Tri-Estarylla
C1Tri-Legest Fe
C1Tri-Lo-Estarylla
C1Tri-Lo-Sprintec
C1Tri-Mili
C1Tri-Previfem
C1Tri-Sprintec
C1Trivora
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Norethindrone Acetate-Ethinyl Estradiol (1-20MG-MCG Oral Tablet)
1
Norethindrone Acetate-Ethinyl Estradiol-Fe (1-20MG-MCG(24) Oral Tablet)
1
Norethindrone Acetate-Ethinyl Estradiol-Fe (0.4-35MG-MCG Oral Tablet Chewable, 0.8-25MG-MCG Oral Tablet Chewable, 1-20MG-MCG(24) Oral Tablet Chewable)
1
Norgestimate-Ethinyl Estradiol (Oral Tablet)
1
Norgestimate-Ethinyl Estradiol Triphasic (Oral Tablet)
1
Nortrel 0.5/35 (28) (Oral Tablet)
1
Nortrel 1/35 (21) (Oral Tablet)
1
Nortrel 1/35 (28) (Oral Tablet)
1
Nortrel 7/7/7 (Oral Tablet)
1
Ocella (Oral Tablet) 1
Ogestrel (Oral Tablet) 1
Orsythia (Oral Tablet) 1
Pimtrea (Oral Tablet) 1
Pirmella 1/35 (Oral Tablet)
1
Portia-28 (Oral Tablet) 1
Premarin (Oral Tablet) 1 QL
Premarin (Vaginal
Cream)1
Premphase (Oral
Tablet)1 QL
Prempro (Oral Tablet) 1 QL
Previfem (Oral Tablet) 1
Reclipsen (Oral Tablet) 1
Rivelsa (Oral Tablet) 1
Setlakin (Oral Tablet) 1
Sprintec 28 (Oral Tablet)
1
Sronyx (Oral Tablet) 1
Syeda (Oral Tablet) 1
Tarina 24 Fe (Oral Tablet)
1
Tarina Fe 1/20 (Oral Tablet)
1
Tri-Estarylla (Oral Tablet)
1
Tri-Legest Fe (Oral Tablet)
1
Tri-Lo-Estarylla (Oral Tablet)
1
Tri-Lo-Sprintec (Oral Tablet)
1
Tri-Mili (Oral Tablet) 1
Tri-Previfem (Oral Tablet)
1
Tri-Sprintec (Oral Tablet)
1
Trivora (28) (Oral Tablet)
1
tRACK 73
63
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Tri-VyLibra Lo
C1Tri-VyLibra
C1Velivet
C1Vienva
C1Vyfemla
C1VyLibra
C1WYMZYA Fe
C1Xulane
C1Yuvafem
C1Zarah
C1Zovia 1/35E
B1
C1Camila
C1Crinone
C1Deblitane
C1Depo-Provera
C1Errin
C1Incassia
C1Lyza
C1Medroxyprogesterone Acetate
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Medroxyprogesterone Acetate
C1Medroxyprogesterone Acetate
C1Megestrol Acetate
C1Megestrol Acetate
C1Megestrol Acetate
C1Nora-BE
C1Norethindrone Acetate
C1Norethindrone
C1Progesterone Micronized
C1Sharobel
B1
C1Osphena
C1Raloxifene HCl
A1
B1
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Tri-VyLibra Lo (Oral Tablet)
1
Tri-VyLibra (Oral Tablet)
1
Velivet (Oral Tablet) 1
Vienva (Oral Tablet) 1
Vyfemla (Oral Tablet) 1
VyLibra (Oral Tablet) 1
WYMZYA Fe (Oral Tablet Chewable)
1
Xulane (Transdermal Patch Weekly)
1
Yuvafem (Vaginal Tablet)
1 QL
Zarah (Oral Tablet) 1
Zovia 1/35E (28) (Oral Tablet)
1
Progestins
Camila (Oral Tablet) 1
Crinone (Vaginal Gel) 1 PA
Deblitane (Oral Tablet) 1
Depo-Provera
(400MG/ML
Intramuscular
Suspension)
1
Errin (Oral Tablet) 1
Incassia (Oral Tablet) 1
Lyza (Oral Tablet) 1
Medroxyprogesterone Acetate (150MG/ML Intramuscular Suspension)
1
Medroxyprogesterone Acetate (150MG/ML Intramuscular Suspension Prefilled Syringe)
1
Medroxyprogesterone Acetate (10MG Oral Tablet, 2.5MG Oral Tablet, 5MG Oral Tablet)
1
Megestrol Acetate (40MG/ML Oral Suspension)
1
Megestrol Acetate (625MG/5ML Oral Suspension)
1
Megestrol Acetate (Oral Tablet)
1
Nora-BE (Oral Tablet) 1
Norethindrone Acetate (5MG Oral Tablet)
1
Norethindrone (0.35MG Oral Tablet)
1
Progesterone Micronized (Oral Capsule)
1
Sharobel (Oral Tablet) 1
Selective Estrogen Receptor Modifying Agents
Osphena (Oral Tablet) 1 PA; QL
Raloxifene HCl (Oral Tablet)
1 QL
Hormonal Agents, Stimulant/Replacement/ Modifying (Thyroid)
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
tRACK74
64
Bold type = Brand name drug Plain type = Generic drug
C1Levo-T
C1Levothyroxine Sodium
C1Levoxyl
C1Liothyronine Sodium
C1Synthroid
C1Unithroid
A1
B1
C1Lysodren
A1
B1
C1Cabergoline
C1Egrifta
C1Firmagon
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Firmagon
C1Leuprolide Acetate
C1Lupaneta Pack
C1Lupron Depot
C1Lupron Depot
C1Lupron Depot
C1Lupron Depot
C1Octreotide Acetate
C1Octreotide Acetate
C1Signifor
C1Somatuline Depot
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Levo-T (Oral Tablet) 1
Levothyroxine Sodium (Oral Tablet)
1
Levoxyl (Oral Tablet) 1
Liothyronine Sodium (Oral Tablet)
1
Synthroid (Oral
Tablet)1
Unithroid (100MCG
Oral Tablet, 112MCG
Oral Tablet, 125MCG
Oral Tablet, 150MCG
Oral Tablet, 175MCG
Oral Tablet, 200MCG
Oral Tablet, 25MCG
Oral Tablet, 300MCG
Oral Tablet, 50MCG
Oral Tablet, 75MCG
Oral Tablet, 88MCG
Oral Tablet)
1
Hormonal Agents, Suppressant (Adrenal)
Hormonal Agents, Suppressant (Adrenal)
Lysodren (Oral
Tablet)1
Hormonal Agents, Suppressant (Pituitary)
Hormonal Agents, Suppressant (Pituitary)
Cabergoline (Oral Tablet)
1
Egrifta (1MG
Subcutaneous
Solution
Reconstituted)
1 PA; LA
Firmagon (120MG
Subcutaneous
Solution
Reconstituted)
1 PA
Firmagon (80MG
Subcutaneous
Solution
Reconstituted)
1 PA
Leuprolide Acetate (Injection Kit)
1 PA
Lupaneta Pack
(Combination Kit)1 PA
Lupron Depot (1-
Month)
(Intramuscular Kit)
1 PA
Lupron Depot (3-
Month)
(Intramuscular Kit)
1 PA
Lupron Depot (4-
Month)
(Intramuscular Kit)
1 PA
Lupron Depot (6-
Month)
(Intramuscular Kit)
1 PA
Octreotide Acetate (1000MCG/ML Injection Solution, 500MCG/ML Injection Solution)
1 PA
Octreotide Acetate (100MCG/ML Injection Solution, 200MCG/ML Injection Solution, 50MCG/ML Injection Solution)
1 PA
Signifor
(Subcutaneous
Solution)
1 PA; LA
Somatuline Depot
(Subcutaneous
Solution)
1
tRACK 75
65
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Somavert
C1Synarel
C1Trelstar Mixject
A1
B1
C1Methimazole
C1Propylthiouracil
A1
B1
C1Berinert
C1Cinryze
C1Firazyr
C1Haegarda
C1Icatibant Acetate
C1Ruconest
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useB1
C1Azathioprine
C1Cimzia Prefilled
C1Cimzia
C1Cyclosporine Modified
C1Cyclosporine Modified
C1Cyclosporine
C1Enbrel Mini
C1Enbrel
C1Enbrel
C1Enbrel SureClick
C1Envarsus XR
C1Gengraf
C1Gengraf
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Somavert
(Subcutaneous
Solution
Reconstituted)
1 PA; LA; QL
Synarel (Nasal
Solution)1
Trelstar Mixject
(Intramuscular
Suspension
Reconstituted)
1 PA
Hormonal Agents, Suppressant (Thyroid)
Antithyroid Agents
Methimazole (Oral Tablet)
1
Propylthiouracil (Oral Tablet)
1
Immunological Agents
Angioedema Agents
Berinert (Intravenous
Kit)1 PA; LA
Cinryze (Intravenous
Solution
Reconstituted)
1 PA; LA
Firazyr
(Subcutaneous
Solution)
1 PA; QL
Haegarda
(Subcutaneous
Solution
Reconstituted)
1 PA; LA
Icatibant Acetate (Subcutaneous Solution)
1 PA; QL
Ruconest
(Intravenous Solution
Reconstituted)
1 PA; LA
Immune Suppressants
Azathioprine (Oral Tablet)
1 B/D, PA
Cimzia Prefilled
(Subcutaneous Kit)1 PA
Cimzia
(Subcutaneous Kit)1 PA
Cyclosporine Modified (Oral Capsule)
1 B/D, PA
Cyclosporine Modified (Oral Solution)
1 B/D, PA
Cyclosporine (Oral Capsule)
1 B/D, PA
Enbrel Mini
(Subcutaneous
Solution Cartridge)
1 PA
Enbrel
(Subcutaneous
Solution Prefilled
Syringe)
1 PA
Enbrel
(Subcutaneous
Solution
Reconstituted)
1 PA
Enbrel SureClick
(Subcutaneous
Solution Auto-
Injector)
1 PA
Envarsus XR (Oral
Tablet Extended
Release 24 Hour)
1 B/D, PA
Gengraf (Oral Capsule) 1 B/D, PA
Gengraf (Oral Solution) 1 B/D, PA
tRACK76
66
Bold type = Brand name drug Plain type = Generic drug
C1Humira Pediatric Crohns Start
C1Humira Pen
C1Humira Pen Crohns Disease Starter
C1Humira Pen Psoriasis Starter
C1Humira
C1Kineret
C1Methotrexate
C1Methotrexate Sodium
C1Methotrexate Sodium
C1Mycophenolate Mofetil
C1Mycophenolate Mofetil
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Mycophenolate Mofetil
C1Mycophenolate Sodium
C1Orencia ClickJect
C1Orencia
C1Prograf
C1Rasuvo
C1Sandimmune
C1Simponi
C1Simponi
C1Sirolimus
C1Sirolimus
C1Tacrolimus
C1Trexall
C1Xatmep
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Humira Pediatric
Crohns Start
(Subcutaneous
Prefilled Syringe Kit)
1 PA
Humira Pen
(Subcutaneous Pen-
Injector Kit)
1 PA
Humira Pen Crohns
Disease Starter
(Subcutaneous Pen-
Injector Kit)
1 PA
Humira Pen Psoriasis
Starter
(Subcutaneous Pen-
Injector Kit)
1 PA
Humira
(Subcutaneous
Prefilled Syringe Kit)
1 PA
Kineret
(Subcutaneous
Solution Prefilled
Syringe)
1 PA
Methotrexate (Oral Tablet)
1
Methotrexate Sodium (50MG/2ML Injection Solution Prefilled Syringe)
1
Methotrexate Sodium (50MG/2ML Injection Solution)
1
Mycophenolate Mofetil (Oral Capsule)
1 B/D, PA
Mycophenolate Mofetil (Oral Suspension Reconstituted)
1 B/D, PA
Mycophenolate Mofetil (Oral Tablet)
1 B/D, PA
Mycophenolate Sodium (Oral Tablet Delayed Release)
1 B/D, PA
Orencia ClickJect
(Subcutaneous
Solution Auto-
Injector)
1 PA
Orencia
(Subcutaneous
Solution Prefilled
Syringe)
1 PA
Prograf (Oral Packet) 1 B/D, PA
Rasuvo
(Subcutaneous
Solution Auto-
Injector)
1 PA
Sandimmune (Oral
Solution)1 B/D, PA
Simponi
(Subcutaneous
Solution Auto-
Injector)
1 PA
Simponi
(Subcutaneous
Solution Prefilled
Syringe)
1 PA
Sirolimus (Oral Solution)
1 B/D, PA
Sirolimus (Oral Tablet) 1 B/D, PA
Tacrolimus (Oral Capsule)
1 B/D, PA
Trexall (Oral Tablet) 1
Xatmep (Oral
Solution)1 PA
tRACK 77
67
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Xeljanz
C1Xeljanz XR
C1Zortress
B1
C1Flebogamma DIF
C1Gammagard
C1Gammagard S/D Less IgA
C1Gammaked
C1Gammaplex
C1Gamunex-C
C1Octagam
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Panzyga
C1Privigen
C1Varizig
B1
C1Actemra ACTPen
C1Actemra
C1Actimmune
C1Arcalyst
C1Benlysta
C1Benlysta
C1Leflunomide
C1Otezla
C1Otezla
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Xeljanz (Oral Tablet
Immediate Release)1 PA; QL
Xeljanz XR (11MG
Oral Tablet Extended
Release 24 Hour)
1 PA; QL
Zortress (Oral Tablet) 1 B/D, PA
Immunizing Agents, Passive
Flebogamma DIF
(5GM/50ML
Intravenous Solution)
1 PA
Gammagard (2.5GM/
25ML Injection
Solution)
1 PA
Gammagard S/D Less
IgA (Intravenous
Solution
Reconstituted)
1 PA
Gammaked (1GM/
10ML Injection
Solution)
1 PA
Gammaplex (10GM/
100ML Intravenous
Solution, 10GM/
200ML Intravenous
Solution, 20GM/
200ML Intravenous
Solution, 5GM/50ML
Intravenous Solution)
1 PA
Gamunex-C (1GM/
10ML Injection
Solution)
1 PA
Octagam (1GM/20ML
Intravenous Solution,
2GM/20ML
Intravenous Solution)
1 PA
Panzyga (Intravenous
Solution)1 PA
Privigen (20GM/
200ML Intravenous
Solution)
1 PA
Varizig (Intramuscular
Solution)1
Immunomodulators
Actemra ACTPen
(Subcutaneous
Solution Auto-
Injector)
1 PA
Actemra
(Subcutaneous
Solution Prefilled
Syringe)
1 PA
Actimmune
(Subcutaneous
Solution)
1 LA
Arcalyst
(Subcutaneous
Solution
Reconstituted)
1 PA; LA
Benlysta
(Subcutaneous
Solution Auto-
Injector)
1 PA
Benlysta
(Subcutaneous
Solution Prefilled
Syringe)
1 PA
Leflunomide (Oral Tablet)
1
Otezla (Oral Tablet) 1 PA; LA
Otezla (Oral Tablet
Therapy Pack)1 PA; LA
tRACK78
68
Bold type = Brand name drug Plain type = Generic drug
C1Ridaura
C1Xolair
C1Xolair
B1
C1ActHIB
C1Adacel
C1BCG Vaccine
C1Bexsero
C1Boostrix
C1Daptacel
C1Diphtheria-Tetanus Toxoids DT
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Engerix-B
C1Gardasil 9
C1Gardasil 9
C1Havrix
C1Hiberix
C1Imovax Rabies
C1Infanrix
C1IPOL
C1Ixiaro
C1Kinrix
C1Menactra
C1Menveo
C1M-M-R II
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Ridaura (Oral
Capsule)1
Xolair (Subcutaneous
Solution Prefilled
Syringe)
1 PA; LA
Xolair (Subcutaneous
Solution
Reconstituted)
1 PA; LA
Vaccines
ActHIB
(Intramuscular
Solution
Reconstituted)
1
Adacel (Intramuscular
Suspension)1
BCG Vaccine
(Injection)1
Bexsero
(Intramuscular
Suspension Prefilled
Syringe)
1
Boostrix (5-2.5-18.5
Intramuscular
Suspension,
5-2.5-18.5 (0.5ML
Syringe)
Intramuscular
Suspension)
1
Daptacel
(Intramuscular
Suspension)
1
Diphtheria-Tetanus
Toxoids DT
(Intramuscular
Suspension)
1
Engerix-B (Injection
Suspension)1 B/D, PA
Gardasil 9
(Intramuscular
Suspension)
1
Gardasil 9
(Intramuscular
Suspension Prefilled
Syringe)
1
Havrix (Intramuscular
Suspension)1 PA
Hiberix (Injection
Solution
Reconstituted)
1
Imovax Rabies
(Intramuscular
Injectable)
1 B/D, PA
Infanrix
(Intramuscular
Suspension)
1
IPOL (Injection) 1
Ixiaro (Intramuscular
Suspension)1
Kinrix (Intramuscular
Suspension)1
Menactra
(Intramuscular
Injectable)
1
Menveo
(Intramuscular
Solution
Reconstituted)
1
M-M-R II (Injection
Solution
Reconstituted)
1
tRACK 79
69
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Pediarix
C1Pedvax HIB
C1ProQuad
C1Quadracel
C1RabAvert
C1Recombivax HB
C1Rotarix
C1RotaTeq
C1Shingrix
C1TDVAX
C1Tenivac
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Trumenba
C1Twinrix
C1Typhim Vi
C1VAQTA
C1Varivax
C1YF-Vax
C1Zostavax
A1
B1
C1Apriso
C1Balsalazide Disodium
C1Canasa
C1Dipentum
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Pediarix
(Intramuscular
Suspension)
1
Pedvax HIB
(Intramuscular
Suspension)
1
ProQuad
(Subcutaneous
Suspension
Reconstituted)
1
Quadracel
(Intramuscular
Suspension)
1
RabAvert
(Intramuscular
Suspension
Reconstituted)
1 B/D, PA
Recombivax HB
(Injection
Suspension)
1 B/D, PA
Rotarix (Oral
Suspension
Reconstituted)
1
RotaTeq (Oral
Solution)1
Shingrix
(Intramuscular
Suspension
Reconstituted)
1 PA
TDVAX
(Intramuscular
Suspension)
1
Tenivac
(Intramuscular
Injectable)
1
Trumenba
(Intramuscular
Suspension Prefilled
Syringe)
1
Twinrix
(Intramuscular
Suspension Prefilled
Syringe)
1
Typhim Vi
(Intramuscular
Solution)
1
VAQTA
(Intramuscular
Suspension)
1 PA
Varivax
(Subcutaneous
Injectable)
1
YF-Vax
(Subcutaneous
Injectable)
1
Zostavax
(Subcutaneous
Suspension
Reconstituted)
1 PA
Inflammatory Bowel Disease Agents
Aminosalicylates
Apriso (Oral Capsule
Extended Release 24
Hour)
1 QL
Balsalazide Disodium (Oral Capsule)
1
Canasa (Rectal
Suppository)1
Dipentum (Oral
Capsule)1
tRACK80
70
Bold type = Brand name drug Plain type = Generic drug
C1Mesalamine ER
C1Mesalamine
C1Mesalamine
C1Mesalamine
C1Pentasa
B1
C1Budesonide ER
C1Budesonide
C1Colocort
C1Hydrocortisone
C1Procto-Med HC
C1Procto-Pak
C1Proctosol HC
C1Proctozone-HC
B1
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Sulfasalazine
C1Sulfasalazine
A1
B1
C1Alendronate Sodium
C1Alendronate Sodium
C1Binosto
C1Calcitonin Salmon
C1Calcitriol
C1Calcitriol
C1Cinacalcet HCl
C1Cinacalcet HCl
C1Doxercalciferol
C1Forteo
C1Ibandronate Sodium
C1Natpara
C1Paricalcitol
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Mesalamine ER (0.375MG Oral Capsule Extended Release 24 Hour) (Generic Apriso)
1 QL
Mesalamine (1.2GM Oral Tablet Delayed Release) (Generic Lialda)
1 QL
Mesalamine (Rectal Enema)
1 QL
Mesalamine (Rectal Suppository)
1
Pentasa (Oral
Capsule Extended
Release)
1 QL
Glucocorticoids
Budesonide ER (Oral Tablet Extended Release 24 Hour)
1 ST
Budesonide (Oral Capsule Delayed Release Particles)
1
Colocort (Rectal Enema)
1
Hydrocortisone (Rectal Enema)
1
Procto-Med HC (Rectal Cream)
1
Procto-Pak (Rectal Cream)
1
Proctosol HC (Rectal Cream)
1
Proctozone-HC (Rectal Cream)
1
Sulfonamides
Sulfasalazine (Oral Tablet Immediate Release)
1
Sulfasalazine (Oral Tablet Delayed Release)
1
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
Alendronate Sodium (Oral Solution)
1
Alendronate Sodium (Oral Tablet)
1 QL
Binosto (Oral Tablet
Effervescent)1 QL
Calcitonin Salmon (Nasal Solution)
1 QL
Calcitriol (Oral Capsule)
1 B/D, PA
Calcitriol (Oral Solution)
1 B/D, PA
Cinacalcet HCl (30MG Oral Tablet)
1 B/D, PA; QL
Cinacalcet HCl (60MG Oral Tablet, 90MG Oral Tablet)
1 B/D, PA; QL
Doxercalciferol (Oral Capsule)
1 B/D, PA; QL
Forteo (Subcutaneous
Solution)1 PA; QL
Ibandronate Sodium (Oral Tablet)
1 QL
Natpara
(Subcutaneous
Cartridge)
1 PA; LA
Paricalcitol (Oral Capsule)
1 B/D, PA
tRACK 81
71
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Prolia
C1Rayaldee
C1Risedronate Sodium
C1Tymlos
C1Xgeva
A1
B1
C1Alcohol Prep Pads
C1Gauze
C1Insulin Syringes, Needles
A1
B1
C1Atropine Sulfate
C1Bacitracin-Polymyxin B
C1Neomycin-Polymyxin-Bacitracin-Hydrocortisone
C1Blephamide
C1Blephamide S.O.P.
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Cystaran
C1Lacrisert
C1Lastacaft
C1Neomycin-Bacitracin-Polymyxin
C1Neomycin-Polymyxin-Dexamethasone
C1Neomycin-Polymyxin-Dexamethasone
C1Neomycin-Polymyxin-Gramicidin
C1Neomycin-Polymyxin-HC
C1Polymyxin B-Trimethoprim
C1Pred-G
C1Pred-G S.O.P.
C1Proparacaine HCl
C1Restasis
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Prolia (Subcutaneous
Solution Prefilled
Syringe)
1 QL
Rayaldee (Oral
Capsule Extended
Release)
1 QL
Risedronate Sodium (Oral Tablet Immediate Release)
1 QL
Tymlos
(Subcutaneous
Solution Pen-Injector)
1 PA; QL
Xgeva (Subcutaneous
Solution)1 PA
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
Alcohol Prep Pads 1
Gauze (Non-medicated 2X2 Pad)
1
Insulin Syringes, Needles
1
Ophthalmic Agents
Ophthalmic Agents, Other
Atropine Sulfate
(Ophthalmic Solution)1
Bacitracin-Polymyxin B (Ophthalmic Ointment)
1
Neomycin-Polymyxin-Bacitracin-Hydrocortisone (Ophthalmic Ointment)
1
Blephamide
(Ophthalmic
Suspension)
1
Blephamide S.O.P. (Ophthalmic Ointment)
1
Cystaran (Ophthalmic
Solution)1 LA
Lacrisert (Ophthalmic
Insert)1
Lastacaft (Ophthalmic
Solution)1
Neomycin-Bacitracin-Polymyxin (5-400-10000 Ophthalmic Ointment)
1
Neomycin-Polymyxin-Dexamethasone (Ophthalmic Ointment)
1
Neomycin-Polymyxin-Dexamethasone (3.5-10000-0.1 Ophthalmic Suspension)
1
Neomycin-Polymyxin-Gramicidin (Ophthalmic Solution)
1
Neomycin-Polymyxin-HC (Ophthalmic Suspension)
1
Polymyxin B-Trimethoprim (Ophthalmic Solution)
1
Pred-G (Ophthalmic
Suspension)1
Pred-G S.O.P.
(Ophthalmic
Ointment)
1
Proparacaine HCl (Ophthalmic Solution)
1
Restasis (Ophthalmic
Emulsion)1 QL
tRACK82
72
Bold type = Brand name drug Plain type = Generic drug
C1Rhopressa
C1Sulfacetamide-Prednisolone
C1TobraDex
C1TobraDex ST
C1Tobramycin-Dexamethasone
C1Xiidra
B1
C1Alocril
C1Alomide
C1Azelastine HCl
C1Bepreve
C1Cromolyn Sodium
C1Epinastine HCl
C1Olopatadine HCl
C1Pazeo
B1
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Alphagan P
C1Apraclonidine HCl
C1Azopt
C1Betaxolol HCl
C1Betimol
C1Brimonidine Tartrate
C1Brimonidine Tartrate
C1Carteolol HCl
C1Combigan
C1Cosopt PF
C1Dorzolamide HCl
C1Dorzolamide HCl-Timolol Maleate
C1Dorzolamide HCl-Timolol Maleate Preservative Free
C1Levobunolol HCl
C1Phospholine Iodide
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Rhopressa
(Ophthalmic Solution)1 ST
Sulfacetamide-Prednisolone (Ophthalmic Solution)
1
TobraDex
(Ophthalmic
Ointment)
1
TobraDex ST
(Ophthalmic
Suspension)
1
Tobramycin-Dexamethasone (Ophthalmic Suspension)
1
Xiidra (Ophthalmic
Solution)1 QL
Ophthalmic Anti-allergy Agents
Alocril (Ophthalmic
Solution)1
Alomide (Ophthalmic
Solution)1
Azelastine HCl (Ophthalmic Solution)
1
Bepreve (Ophthalmic
Solution)1
Cromolyn Sodium (Ophthalmic Solution)
1
Epinastine HCl (Ophthalmic Solution)
1
Olopatadine HCl (Ophthalmic Solution)
1
Pazeo (Ophthalmic
Solution)1
Ophthalmic Antiglaucoma Agents
Alphagan P (0.1%
Ophthalmic Solution)1
Apraclonidine HCl (Ophthalmic Solution)
1
Azopt (Ophthalmic
Suspension)1
Betaxolol HCl (Ophthalmic Solution)
1
Betimol (Ophthalmic
Solution)1
Brimonidine Tartrate
(0.15% Ophthalmic
Solution)
1
Brimonidine Tartrate (0.2% Ophthalmic Solution)
1
Carteolol HCl (Ophthalmic Solution)
1
Combigan
(Ophthalmic Solution)1
Cosopt PF
(Ophthalmic Solution)1
Dorzolamide HCl (Ophthalmic Solution)
1
Dorzolamide HCl-Timolol Maleate (Ophthalmic Solution)
1
Dorzolamide HCl-Timolol Maleate Preservative Free (Ophthalmic Solution)
1
Levobunolol HCl (Ophthalmic Solution)
1
Phospholine Iodide
(Ophthalmic Solution
Reconstituted)
1
tRACK 83
73
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Pilocarpine HCl
C1Rocklatan
C1Simbrinza
C1Timolol Maleate Ophthalmic Gel Forming
C1Timolol Maleate
B1
C1Dexamethasone Sodium Phosphate
C1Diclofenac Sodium
C1Durezol
C1Flarex
C1Fluorometholone
C1Flurbiprofen Sodium
C1FML Forte
C1FML
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Ilevro
C1Ketorolac Tromethamine
C1Lotemax
C1Lotemax
C1Lotemax
C1Lotemax SM
C1Loteprednol Etabonate
C1Pred Mild
C1Prednisolone Acetate
C1Prednisolone Sodium Phosphate
C1Prolensa
B1
C1Latanoprost
C1Lumigan
C1Travoprost
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Pilocarpine HCl (Ophthalmic Solution)
1
Rocklatan
(Ophthalmic Solution)1 ST
Simbrinza
(Ophthalmic
Suspension)
1
Timolol Maleate Ophthalmic Gel Forming (Ophthalmic Solution) (Generic Timoptic-XE)
1
Timolol Maleate (0.25% Ophthalmic Solution, 0.5% Ophthalmic Solution) (Generic Timoptic)
1
Ophthalmic Anti-inflammatories
Dexamethasone Sodium Phosphate (Ophthalmic Solution)
1
Diclofenac Sodium (Ophthalmic Solution)
1
Durezol (Ophthalmic
Emulsion)1
Flarex (Ophthalmic
Suspension)1
Fluorometholone (Ophthalmic Suspension)
1
Flurbiprofen Sodium (Ophthalmic Solution)
1
FML Forte
(Ophthalmic
Suspension)
1
FML (Ophthalmic
Ointment)1
Ilevro (Ophthalmic
Suspension)1
Ketorolac Tromethamine (Ophthalmic Solution)
1
Lotemax (Ophthalmic
Gel)1
Lotemax (Ophthalmic
Ointment)1
Lotemax (Ophthalmic
Suspension)1
Lotemax SM
(Ophthalmic Gel)1
Loteprednol Etabonate (Ophthalmic Suspension)
1
Pred Mild
(Ophthalmic
Suspension)
1
Prednisolone Acetate (Ophthalmic Suspension)
1
Prednisolone Sodium Phosphate (1% Ophthalmic Solution)
1
Prolensa (Ophthalmic
Solution)1
Ophthalmic Prostaglandin and Prostamide Analogs
Latanoprost (Ophthalmic Solution)
1
Lumigan (Ophthalmic
Solution)1
Travoprost (BAK Free) (Ophthalmic Solution)
1
tRACK84
74
Bold type = Brand name drug Plain type = Generic drug
C1Vyzulta
C1Zioptan
A1
B1
C1Acetic Acid
C1Cipro HC
C1Ciprodex
C1Flac
C1Fluocinolone Acetonide
C1Hydrocortisone-Acetic Acid
C1Neomycin-Polymyxin-HC
C1Neomycin-Polymyxin-HC
A1
B1
C1Azelastine HCl
C1Cetirizine HCl
C1Cyproheptadine HCl
C1Cyproheptadine HCl
C1Levocetirizine Dihydrochloride
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Phenadoz
C1Promethazine HCl
C1Promethazine HCl
C1Promethazine HCl
C1Promethegan
B1
C1Arnuity Ellipta
C1Budesonide
C1Flovent Diskus
C1Flovent HFA
C1Flunisolide
C1Fluticasone Propionate
C1Mometasone Furoate
B1
C1Montelukast Sodium
C1Montelukast Sodium
C1Montelukast Sodium
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Vyzulta (Ophthalmic
Solution)1
Zioptan (Ophthalmic
Solution)1
Otic Agents
Otic Agents
Acetic Acid (Otic Solution)
1
Cipro HC (Otic
Suspension)1
Ciprodex (Otic
Suspension)1
Flac (Otic Oil) 1
Fluocinolone Acetonide (Otic Oil)
1
Hydrocortisone-Acetic Acid (Otic Solution)
1
Neomycin-Polymyxin-HC (1% Otic Solution)
1
Neomycin-Polymyxin-HC (Otic Suspension)
1
Respiratory Tract/Pulmonary Agents
Antihistamines
Azelastine HCl (0.1% Nasal Solution, 0.15% Nasal Solution)
1
Cetirizine HCl (1MG/ ML Oral Solution)
1
Cyproheptadine HCl (Oral Syrup)
1
Cyproheptadine HCl (Oral Tablet)
1
Levocetirizine Dihydrochloride (Oral Tablet)
1 QL
Phenadoz (12.5MG Rectal Suppository)
1
Promethazine HCl (Oral Syrup)
1
Promethazine HCl (Oral Tablet)
1
Promethazine HCl (Rectal Suppository)
1
Promethegan (25MG Rectal Suppository)
1
Anti-inflammatories, Inhaled Corticosteroids
Arnuity Ellipta
(Inhalation Aerosol
Powder Breath
Activated)
1 QL
Budesonide (Inhalation Suspension)
1 B/D, PA
Flovent Diskus
(Inhalation Aerosol
Powder Breath
Activated)
1 QL
Flovent HFA
(Inhalation Aerosol)1 QL
Flunisolide (Nasal Solution)
1
Fluticasone Propionate (Nasal Suspension)
1
Mometasone Furoate (Nasal Suspension)
1
Antileukotrienes
Montelukast Sodium (Oral Packet)
1 QL
Montelukast Sodium (Oral Tablet)
1 QL
Montelukast Sodium (Oral Tablet Chewable)
1 QL
tRACK 85
75
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Zafirlukast
C1Zileuton ER
C1Zyflo
B1
C1Atrovent HFA
C1Incruse Ellipta
C1Ipratropium Bromide
C1Ipratropium Bromide
C1Lonhala Magnair Refill Kit
C1Spiriva HandiHaler
C1Spiriva Respimat
B1
C1Albuterol Sulfate
C1Albuterol Sulfate
C1Albuterol Sulfate
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Epinephrine
C1EpiPen 2-Pak
C1EpiPen Jr 2-Pak
C1Levalbuterol HCl
C1Metaproterenol Sulfate
C1Perforomist
C1ProAir HFA
C1ProAir RespiClick
C1Serevent Diskus
B1
C1Bethkis
C1Cayston
C1Orkambi
C1Orkambi
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Zafirlukast (Oral Tablet)
1 QL
Zileuton ER (Oral Tablet Extended Release 12 Hour)
1 ST
Zyflo (Oral Tablet
Immediate Release)1 ST
Bronchodilators, Anticholinergic
Atrovent HFA
(Inhalation Aerosol
Solution)
1
Incruse Ellipta
(Inhalation Aerosol
Powder Breath
Activated)
1 QL
Ipratropium Bromide (Inhalation Solution)
1 B/D, PA
Ipratropium Bromide (Nasal Solution)
1
Lonhala Magnair
Refill Kit (Inhalation
Solution)
1 QL
Spiriva HandiHaler
(Inhalation Capsule)1 QL
Spiriva Respimat
(Inhalation Aerosol
Solution)
1 QL
Bronchodilators, Sympathomimetic
Albuterol Sulfate (Inhalation Nebulization Solution)
1 B/D, PA
Albuterol Sulfate (Oral Syrup)
1
Albuterol Sulfate (Oral Tablet Immediate Release)
1
Epinephrine (Injection Solution Auto-Injector)
1 QL
EpiPen 2-Pak
(Injection Solution
Auto-Injector)
1 QL
EpiPen Jr 2-Pak
(Injection Solution
Auto-Injector)
1 QL
Levalbuterol HCl (Inhalation Nebulization Solution)
1 B/D, PA
Metaproterenol Sulfate (Oral Syrup)
1
Perforomist
(Inhalation
Nebulization Solution)
1 B/D, PA; QL
ProAir HFA
(Inhalation Aerosol
Solution)
1
ProAir RespiClick
(Inhalation Aerosol
Powder Breath
Activated)
1
Serevent Diskus
(Inhalation Aerosol
Powder Breath
Activated)
1 QL
Cystic Fibrosis Agents
Bethkis (Inhalation
Nebulization Solution)1 B/D, PA; QL
Cayston (Inhalation
Solution
Reconstituted)
1 PA; LA
Orkambi (Oral Packet) 1 PA; LA; QL
Orkambi (Oral Tablet) 1 PA; LA; QL
tRACK86
76
Bold type = Brand name drug Plain type = Generic drug
C1TOBI Podhaler
C1Tobramycin
B1
C1Cromolyn Sodium
B1
C1Daliresp
C1Theophylline ER
C1Theophylline ER
C1Theophylline
B1
C1Adempas
C1Alyq
C1Ambrisentan
C1Bosentan
C1Opsumit
C1Orenitram
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Orenitram
C1Sildenafil Citrate
C1Tadalafil
C1Tracleer
C1Ventavis
B1
C1Esbriet
C1Esbriet
C1Ofev
B1
C1Acetylcysteine
C1Advair Diskus
C1Advair HFA
C1Anoro Ellipta
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
TOBI Podhaler
(Inhalation Capsule)1 PA; QL
Tobramycin (Inhalation Nebulization Solution)
1 B/D, PA; QL
Mast Cell Stabilizers
Cromolyn Sodium (Inhalation Nebulization Solution)
1 B/D, PA
Phosphodiesterase Inhibitors, Airways Disease
Daliresp (Oral Tablet) 1 PA; QL
Theophylline ER (300MG Oral Tablet Extended Release 12 Hour)
1
Theophylline ER (Oral Tablet Extended Release 24 Hour)
1
Theophylline (Oral Solution)
1
Pulmonary Antihypertensives
Adempas (Oral
Tablet)1 PA; LA
Alyq (Oral Tablet) 1 PA; QL
Ambrisentan (Oral Tablet)
1 PA; LA; QL
Bosentan (Oral Tablet) 1 PA; LA; QL
Opsumit (Oral Tablet) 1 PA; LA
Orenitram (0.125MG
Oral Tablet Extended
Release)
1 PA; LA
Orenitram (0.25MG
Oral Tablet Extended
Release, 1MG Oral
Tablet Extended
Release, 2.5MG Oral
Tablet Extended
Release, 5MG Oral
Tablet Extended
Release)
1 PA; LA
Sildenafil Citrate (20MG Oral Tablet) (Generic Revatio)
1 PA; QL
Tadalafil (PAH) (20MG Oral Tablet)
1 PA; QL
Tracleer (Oral Tablet
Soluble)1 PA; LA; QL
Ventavis (Inhalation
Solution)1 PA; LA; QL
Pulmonary Fibrosis Agents
Esbriet (Oral Capsule) 1 PA; LA; QL
Esbriet (801MG Oral
Tablet)1 PA; LA; QL
Ofev (Oral Capsule) 1 PA; LA; QL
Respiratory Tract Agents, Other
Acetylcysteine (Inhalation Solution)
1 B/D, PA
Advair Diskus
(Inhalation Aerosol
Powder Breath
Activated)
1 QL
Advair HFA
(Inhalation Aerosol)1 QL
Anoro Ellipta
(Inhalation Aerosol
Powder Breath
Activated)
1 QL
tRACK 87
77
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Bevespi Aerosphere
C1Breo Ellipta
C1Combivent Respimat
C1Dulera
C1Dymista
C1Fluticasone-Salmeterol
C1Ipratropium-Albuterol
C1Kalydeco
C1Kalydeco
C1Nucala
C1Nucala
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Nucala
C1Pulmozyme
C1Stiolto Respimat
C1Symbicort
C1Trelegy Ellipta
C1Wixela Inhub
A1
B1
C1Baclofen
C1Chlorzoxazone
C1Cyclobenzaprine HCl
C1Cyclobenzaprine HCl
C1Dantrolene Sodium
C1Tizanidine HCl
A1
B1
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Bevespi Aerosphere
(Inhalation Aerosol)1 QL
Breo Ellipta
(Inhalation Aerosol
Powder Breath
Activated)
1 QL
Combivent Respimat
(Inhalation Aerosol
Solution)
1 QL
Dulera (100-5MCG/
ACT Inhalation
Aerosol, 200-5MCG/
ACT Inhalation
Aerosol)
1 QL
Dymista (Nasal
Suspension)1
Fluticasone-Salmeterol (Inhalation Aerosol Powder Breath Activated)
1 QL
Ipratropium-Albuterol (Inhalation Solution)
1 B/D, PA
Kalydeco (Oral
Packet)1 PA; LA; QL
Kalydeco (Oral
Tablet)1 PA; LA; QL
Nucala
(Subcutaneous
Solution Auto-
Injector)
1 PA; LA; QL
Nucala
(Subcutaneous
Solution Prefilled
Syringe)
1 PA; LA; QL
Nucala
(Subcutaneous
Solution
Reconstituted)
1 PA; LA; QL
Pulmozyme
(Inhalation Solution)1 B/D, PA; QL
Stiolto Respimat
(Inhalation Aerosol
Solution)
1 QL
Symbicort (Inhalation
Aerosol)1 QL
Trelegy Ellipta
(Inhalation Aerosol
Powder Breath
Activated)
1 QL
Wixela Inhub (Inhalation Aerosol Powder Breath Activated) (Generic Advair)
1 QL
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
Baclofen (Oral Tablet) 1
Chlorzoxazone (500MG Oral Tablet)
1
Cyclobenzaprine HCl (10MG Oral Tablet, 5MG Oral Tablet)
1
Cyclobenzaprine HCl (7.5MG Oral Tablet)
1
Dantrolene Sodium (Oral Capsule)
1
Tizanidine HCl (Oral Tablet)
1
Sleep Disorder Agents
GABA Receptor Modulators
tRACK88
78
Bold type = Brand name drug Plain type = Generic drug
C1Temazepam
C1Zaleplon
C1Zolpidem Tartrate
B1
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Belsomra
C1Hetlioz
C1Modafinil
C1Ramelteon
C1Xyrem
tRACK
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Temazepam (15MG Oral Capsule, 30MG Oral Capsule)
1 QL
Zaleplon (Oral Capsule)
1 QL
Zolpidem Tartrate (Oral Tablet Immediate Release)
1 QL
Sleep Disorders, Other
Belsomra (Oral
Tablet)1 QL
Hetlioz (Oral Capsule) 1 PA; LA; QL
Modafinil (Oral Tablet) 1 PA; QL
Ramelteon (Oral Tablet)
1 QL
Xyrem (Oral Solution) 1 PA; LA; QL
tRACK 89
Bold type = Brand name drug Plain type = Generic drug
C2. Covered drugs with a quantity limit (QL)
This list shows drugs that have a quantity limit. Some drugs come in several strengths. Each strength may have a different quantity limit. If quantity limits for a drug vary by strength, the different strengths are listed on separate lines. These limits may be in place to ensure your safety.
Your plan will cover only a certain amount of these drugs or will only cover these drugs for a certain number of days. For more information about quantity limits, talk with your doctor or pharmacist. You can also call Customer Service. Our contact information is on the cover.
Drugs are listed in alphabetical order in the tables below.
Drug Name Quantity Limit
Abacavir Sulfate (Oral Solution) Maximum of 32 ml per day
Abacavir Sulfate (Oral Tablet) Maximum of 2 tablets per day
Abacavir Sulfate-Lamivudine (Oral Tablet) Maximum of 1 tablet per day
Abacavir-Lamivudine-Zidovudine (Oral Tablet) Maximum of 2 tablets per day
Abiraterone Acetate (Oral Tablet) Maximum of 4 tablets per day
Acarbose (100MG Oral Tablet) Maximum of 3 tablets per day
Acarbose (25MG Oral Tablet) Maximum of 12 tablets per day
Acarbose (50MG Oral Tablet) Maximum of 6 tablets per day
Acetaminophen-Codeine (120-12MG/5ML Oral Solution)
Maximum of 150 ml per day
Acetaminophen-Codeine (300-15MG Oral Tablet, 300-30MG Oral Tablet, 300-60MG Oral Tablet)
Maximum of 13 tablets per day
Acyclovir (External Ointment) Maximum of 1 tube (30 grams) per 30 days
Advair Diskus (Inhalation Aerosol Powder
Breath Activated)Maximum of 1 inhaler (60 blisters) per 30 days
Advair HFA (Inhalation Aerosol) Maximum of 1 inhaler (12 grams) per 30 days
Aimovig (140MG/ML Subcutaneous Solution
Auto-Injector)Maximum of 1 ml (1 pen) per 30 days
Aimovig (70MG/ML Subcutaneous Solution
Auto-Injector)Maximum of 2 ml per 30 days
Albendazole (Oral Tablet) Maximum of 16 tablets per day
Alecensa (Oral Capsule) Maximum of 8 capsules per day
Alendronate Sodium (10MG Oral Tablet, 40MG Oral Tablet, 5MG Oral Tablet)
Maximum of 1 tablet per day
Alendronate Sodium (35MG Oral Tablet) Maximum of 8 tablets per 28 days
Alendronate Sodium (70MG Oral Tablet) Maximum of 4 tablets per 28 days
Aliskiren Fumarate (Oral Tablet) Maximum of 1 tablet per day
90
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Alprazolam (0.25MG Oral Tablet Immediate Release, 0.5MG Oral Tablet Immediate Release, 1MG Oral Tablet Immediate Release)
Maximum of 4 tablets per day
Alprazolam (2MG Oral Tablet Immediate Release)
Maximum of 5 tablets per day
Alunbrig (180MG Oral Tablet, 90MG Oral
Tablet)Maximum of 1 tablet per day
Alunbrig (30MG Oral Tablet) Maximum of 4 tablets per day
Alunbrig (Oral Tablet Therapy Pack) Maximum of 1 pack (30 tablets) per 30 days
Alyq (Oral Tablet) Maximum of 2 tablets per day
Ambrisentan (Oral Tablet) Maximum of 1 tablet per day
Amitiza (Oral Capsule) Maximum of 2 capsules per day
Amlodipine-Atorvastatin (Oral Tablet) Maximum of 1 tablet per day
Amlodipine-Benazepril (Oral Capsule) Maximum of 1 capsule per day
Amlodipine-Olmesartan (Oral Tablet) Maximum of 1 tablet per day
Amlodipine-Valsartan (Oral Tablet) Maximum of 1 tablet per day
Amlodipine-Valsartan-HCTZ (Oral Tablet) Maximum of 1 tablet per day
Amphetamine-Dextroamphetamine ER (Oral Capsule Extended Release 24 Hour)
Maximum of 2 capsules per day
Amphetamine-Dextroamphetamine (10MG Oral Tablet, 12.5MG Oral Tablet, 15MG Oral Tablet, 30MG Oral Tablet, 5MG Oral Tablet, 7.5MG Oral Tablet)
Maximum of 2 tablets per day
Amphetamine-Dextroamphetamine (20MG Oral Tablet)
Maximum of 3 tablets per day
Ampyra (Oral Tablet Extended Release 12
Hour)Maximum of 2 tablets per day
Androderm (Transdermal Patch 24 Hour) Maximum of 1 patch per day
Anoro Ellipta (Inhalation Aerosol Powder
Breath Activated)Maximum of 1 inhaler (60 blisters) per 30 days
Apokyn (Subcutaneous Solution Cartridge) Maximum of 3 ml per day
Apriso (Oral Capsule Extended Release 24
Hour)Maximum of 4 capsules per day
Aptiom (200MG Oral Tablet, 400MG Oral
Tablet)Maximum of 1 tablet per day
Aptiom (600MG Oral Tablet, 800MG Oral
Tablet)Maximum of 2 tablets per day
Aptivus (Oral Capsule) Maximum of 4 capsules per day
Aptivus (Oral Solution) Maximum of 4 bottles (380 ml) per 30 days
Aripiprazole (1MG/ML Oral Solution) Maximum of 25 ml per day
91
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Aripiprazole (10MG Oral Tablet, 15MG Oral Tablet, 20MG Oral Tablet, 2MG Oral Tablet, 30MG Oral Tablet, 5MG Oral Tablet)
Maximum of 1 tablet per day
Aripiprazole ODT (10MG Oral Tablet Dispersible)
Maximum of 3 tablets per day
Aripiprazole ODT (15MG Oral Tablet Dispersible)
Maximum of 2 tablets per day
Arnuity Ellipta (Inhalation Aerosol Powder
Breath Activated)Maximum of 1 inhaler (30 blisters) per 30 days
Aspirin-Dipyridamole ER (Oral Capsule Extended Release 12 Hour)
Maximum of 2 capsules per day
Atazanavir Sulfate (150MG Oral Capsule, 300MG Oral Capsule)
Maximum of 1 capsule per day
Atazanavir Sulfate (200MG Oral Capsule) Maximum of 2 capsules per day
Atomoxetine HCl (100MG Oral Capsule, 60MG Oral Capsule, 80MG Oral Capsule)
Maximum of 1 capsule per day
Atomoxetine HCl (10MG Oral Capsule, 18MG Oral Capsule, 25MG Oral Capsule, 40MG Oral Capsule)
Maximum of 2 capsules per day
Atorvastatin Calcium (Oral Tablet) Maximum of 1 tablet per day
Atripla (Oral Tablet) Maximum of 1 tablet per day
Aubagio (Oral Tablet) Maximum of 1 tablet per day
Austedo (Oral Tablet) Maximum of 4 tablets per day
Avonex Pen (Intramuscular Auto-Injector Kit) Maximum of 1 kit per 28 days
Avonex Prefilled (Intramuscular Prefilled
Syringe Kit)Maximum of 1 kit per 28 days
Balversa (3MG Oral Tablet) Maximum of 3 tablets per day
Balversa (4MG Oral Tablet) Maximum of 2 tablets per day
Balversa (5MG Oral Tablet) Maximum of 1 tablet per day
Belsomra (Oral Tablet) Maximum of 1 tablet per day
Benazepril HCl (Oral Tablet) Maximum of 2 tablets per day
Benazepril-Hydrochlorothiazide (Oral Tablet) Maximum of 1 tablet per day
Betaseron (Subcutaneous Kit) Maximum of 1 kit (15 vials) per 30 days
Bethkis (Inhalation Nebulization Solution) Maximum of 8 ml (2 ampules) per day
Bevespi Aerosphere (Inhalation Aerosol) Maximum of 1 inhaler (10.7 grams) per 30 days
BiDil (Oral Tablet) Maximum of 6 tablets per day
Biktarvy (Oral Tablet) Maximum of 1 tablet per day
Binosto (Oral Tablet Effervescent) Maximum of 4 tablets per 28 days
Bisoprolol-Hydrochlorothiazide (Oral Tablet) Maximum of 2 tablets per day
92
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Bosentan (Oral Tablet) Maximum of 2 tablets per day
Bosulif (100MG Oral Tablet) Maximum of 6 tablets per day
Bosulif (400MG Oral Tablet, 500MG Oral
Tablet)Maximum of 1 tablet per day
Breo Ellipta (Inhalation Aerosol Powder
Breath Activated)Maximum of 1 inhaler (60 blisters) per 30 days
Brilinta (Oral Tablet) Maximum of 2 tablets per day
BRIVIACT (10MG/ML Oral Solution) Maximum of 20 ml per day
BRIVIACT (100MG Oral Tablet, 10MG Oral
Tablet, 25MG Oral Tablet, 50MG Oral Tablet,
75MG Oral Tablet)
Maximum of 2 tablets per day
Brukinsa (Oral Capsule) Maximum of 4 capsules per day
Buprenorphine HCl (Tablet Sublingual) Maximum of 3 tablets per day
Buprenorphine HCl-Naloxone HCl (12-3MG Sublingual Film, 4-1MG Sublingual Film)
Maximum of 2 films per day
Buprenorphine HCl-Naloxone HCl (2-0.5MG Sublingual Film, 8-2MG Sublingual Film)
Maximum of 3 films per day
Buprenorphine HCl-Naloxone HCl (Tablet Sublingual)
Maximum of 3 tablets per day
Buprenorphine (Transdermal Patch Weekly) Maximum of 4 patches per 28 days
Butalbital-Acetaminophen-Caffeine (Oral Tablet)
Maximum of 6 tablets per day
Butalbital-Aspirin-Caffeine (Oral Capsule) Maximum of 6 capsules per day
Butorphanol Tartrate (Nasal Solution) Maximum of 2 bottles (5 ml) per 30 days
Bydureon BCise (Subcutaneous Auto-
Injector)Maximum of 4 pens (3.4 ml) per 28 days
Bydureon (Subcutaneous Pen-Injector) Maximum of 4 pens per 28 days
Byetta 10MCG Pen (Subcutaneous Solution
Pen-Injector)Maximum of 1 pen (2.4 ml) per 30 days
Byetta 5MCG Pen (Subcutaneous Solution
Pen-Injector)Maximum of 1 pen (1.2 ml) per 30 days
Bystolic (10MG Oral Tablet, 2.5MG Oral
Tablet, 5MG Oral Tablet)Maximum of 1 tablet per day
Bystolic (20MG Oral Tablet) Maximum of 2 tablets per day
Cablivi (Injection Kit) Maximum of 1 kit per day
Cabometyx (20MG Oral Tablet, 60MG Oral
Tablet)Maximum of 1 tablet per day
Cabometyx (40MG Oral Tablet) Maximum of 2 tablets per day
Calcitonin Salmon (Nasal Solution) Maximum of 1 bottle per 28 days
Calquence (Oral Capsule) Maximum of 2 capsules per day
93
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Candesartan Cilexetil (16MG Oral Tablet, 32MG Oral Tablet, 4MG Oral Tablet)
Maximum of 1 tablet per day
Candesartan Cilexetil (8MG Oral Tablet) Maximum of 3 tablets per day
Candesartan Cilexetil-HCTZ (Oral Tablet) Maximum of 1 tablet per day
Captopril (100MG Oral Tablet) Maximum of 4 tablets per day
Captopril (12.5MG Oral Tablet, 25MG Oral Tablet)
Maximum of 3 tablets per day
Captopril (50MG Oral Tablet) Maximum of 9 tablets per day
Captopril-Hydrochlorothiazide (25-15MG Oral Tablet, 50-15MG Oral Tablet)
Maximum of 3 tablets per day
Captopril-Hydrochlorothiazide (25-25MG Oral Tablet, 50-25MG Oral Tablet)
Maximum of 2 tablets per day
Celecoxib (Oral Capsule) Maximum of 2 capsules per day
Cimduo (Oral Tablet) Maximum of 1 tablet per day
Cinacalcet HCl (30MG Oral Tablet, 60MG Oral Tablet)
Maximum of 2 tablets per day
Cinacalcet HCl (90MG Oral Tablet) Maximum of 4 tablets per day
Clobazam (2.5MG/ML Oral Suspension) Maximum of 16 ml per day
Clobazam (10MG Oral Tablet, 20MG Oral Tablet)
Maximum of 2 tablets per day
Clonazepam (0.5MG Oral Tablet, 1MG Oral Tablet)
Maximum of 4 tablets per day
Clonazepam (2MG Oral Tablet) Maximum of 10 tablets per day
Clonazepam ODT (0.125MG Oral Tablet Dispersible, 0.25MG Oral Tablet Dispersible, 0.5MG Oral Tablet Dispersible, 1MG Oral Tablet Dispersible)
Maximum of 4 tablets per day
Clonazepam ODT (2MG Oral Tablet Dispersible)
Maximum of 10 tablets per day
Clopidogrel Bisulfate (75MG Oral Tablet) Maximum of 4 tablets per day
Clorazepate Dipotassium (15MG Oral Tablet) Maximum of 6 tablets per day
Clorazepate Dipotassium (3.75MG Oral Tablet) Maximum of 24 tablets per day
Clorazepate Dipotassium (7.5MG Oral Tablet) Maximum of 12 tablets per day
Clozapine ODT (100MG Oral Tablet Dispersible)
Maximum of 9 tablets per day
Clozapine ODT (12.5MG Oral Tablet Dispersible)
Maximum of 2 tablets per day
Clozapine ODT (150MG Oral Tablet Dispersible)
Maximum of 6 tablets per day
94
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Clozapine ODT (200MG Oral Tablet Dispersible)
Maximum of 4 tablets per day
Clozapine ODT (25MG Oral Tablet Dispersible) Maximum of 3 tablets per day
Codeine Sulfate (Oral Tablet) Maximum of 6 tablets per day
Colchicine (0.6MG Oral Capsule) (Brand
Equivalent Mitigare)Maximum of 4 capsules per day
Colchicine (0.6MG Oral Tablet) (Generic Colcrys)
Maximum of 4 tablets per day
Colcrys (Oral Tablet) Maximum of 4 tablets per day
Combivent Respimat (Inhalation Aerosol
Solution)Maximum of 1 inhaler (4 grams) per 20 days
Complera (Oral Tablet) Maximum of 1 tablet per day
Copiktra (Oral Capsule) Maximum of 2 capsules per day
Corlanor (Oral Solution) Maximum of 15 ml per day
Corlanor (Oral Tablet) Maximum of 2 tablets per day
Cotellic (Oral Tablet) Maximum of 3 tablets per day
Crixivan (200MG Oral Capsule) Maximum of 9 capsules per day
Crixivan (400MG Oral Capsule) Maximum of 6 capsules per day
Cycloset (Oral Tablet) Maximum of 6 tablets per day
Dalfampridine ER (Oral Tablet Extended Release 12 Hour)
Maximum of 2 tablets per day
Daliresp (Oral Tablet) Maximum of 1 tablet per day
Daurismo (100MG Oral Tablet) Maximum of 1 tablet per day
Daurismo (25MG Oral Tablet) Maximum of 2 tablets per day
Delstrigo (Oral Tablet) Maximum of 1 tablet per day
Denavir (External Cream) Maximum of 1 tube (5 grams) per 30 days
Descovy (Oral Tablet) Maximum of 1 tablet per day
Desvenlafaxine Succinate ER (100MG Oral Tablet Extended Release 24 Hour) (Generic Pristiq)
Maximum of 4 tablets per day
Desvenlafaxine Succinate ER (25MG Oral Tablet Extended Release 24 Hour, 50MG Oral Tablet Extended Release 24 Hour) (Generic Pristiq)
Maximum of 1 tablet per day
Dexilant (Oral Capsule Delayed Release) Maximum of 1 capsule per day
Dexmethylphenidate HCl (Oral Tablet) Maximum of 2 tablets per day
Dextroamphetamine Sulfate ER (10MG Oral Capsule Extended Release 24 Hour)
Maximum of 6 capsules per day
95
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Dextroamphetamine Sulfate ER (15MG Oral Capsule Extended Release 24 Hour)
Maximum of 4 capsules per day
Dextroamphetamine Sulfate ER (5MG Oral Capsule Extended Release 24 Hour)
Maximum of 3 capsules per day
Dextroamphetamine Sulfate (Oral Tablet) Maximum of 6 tablets per day
Diazepam Intensol (5MG/ML Oral Concentrate) Maximum of 8 ml per day
Diazepam (10MG Oral Tablet, 2MG Oral Tablet, 5MG Oral Tablet)
Maximum of 4 tablets per day
Diclofenac Epolamine (Transdermal Patch) Maximum of 2 patches per day
Didanosine (200MG Oral Capsule Delayed Release)
Maximum of 2 capsules per day
Didanosine (250MG Oral Capsule Delayed Release, 400MG Oral Capsule Delayed Release)
Maximum of 1 capsule per day
Donepezil HCl (10MG Oral Tablet) Maximum of 2 tablets per day
Donepezil HCl (23MG Oral Tablet, 5MG Oral Tablet)
Maximum of 1 tablet per day
Donepezil HCl ODT (10MG Oral Tablet Dispersible)
Maximum of 2 tablets per day
Donepezil HCl ODT (5MG Oral Tablet Dispersible)
Maximum of 1 tablet per day
Dovato (Oral Tablet) Maximum of 1 tablet per day
Doxepin HCl (External Cream) Maximum of 90 grams per 30 days
Doxercalciferol (0.5MCG Oral Capsule) Maximum of 3 capsules per day
Doxercalciferol (1MCG Oral Capsule, 2.5MCG Oral Capsule)
Maximum of 4 capsules per day
Drizalma Sprinkle (20MG Oral Capsule
Delayed Release Sprinkle, 30MG Oral
Capsule Delayed Release Sprinkle, 60MG
Oral Capsule Delayed Release Sprinkle)
Maximum of 2 capsules per day
Drizalma Sprinkle (40MG Oral Capsule
Delayed Release Sprinkle)Maximum of 3 capsules per day
Dulera (100-5MCG/ACT Inhalation Aerosol,
200-5MCG/ACT Inhalation Aerosol)Maximum of 1 inhaler (13 grams) per 30 days
Duloxetine HCl (20MG Oral Capsule Delayed Release Particles, 30MG Oral Capsule Delayed Release Particles, 60MG Oral Capsule Delayed Release Particles)
Maximum of 2 capsules per day
Dutasteride (Oral Capsule) Maximum of 1 capsule per day
Econazole Nitrate (External Cream) Maximum of 90 grams per 30 days
96
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Edarbi (Oral Tablet) Maximum of 1 tablet per day
Edarbyclor (Oral Tablet) Maximum of 1 tablet per day
Edurant (Oral Tablet) Maximum of 1 tablet per day
Efavirenz (Oral Capsule) Maximum of 3 capsules per day
Efavirenz (Oral Tablet) Maximum of 1 tablet per day
Eliquis Starter Pack (Oral Tablet) Maximum of 1 pack (74 tablets) per 30 days
Eliquis (Oral Tablet) Maximum of 2 tablets per day
Emgality (300 MG Dose) (100 MG/ML
Subcutaneous Solution Prefilled Syringe)
Maximum of 3 ml (3 syringes or pens) per 30 days
Emgality (Subcutaneous Solution Auto-
Injector)
Maximum of 2 ml (2 syringes or pens) per 30 days
Emgality (120 MG/ML Subcutaneous
Solution Prefilled Syringe)
Maximum of 2 ml (2 syringes or pens) per 30 days
Emsam (Transdermal Patch 24 Hour) Maximum of 1 patch per day
Emtriva (Oral Capsule) Maximum of 1 capsule per day
Emtriva (Oral Solution) Maximum of 5 bottles (850 ml) per 30 days
Enalapril Maleate (Oral Tablet) Maximum of 2 tablets per day
Enalapril-Hydrochlorothiazide (10-25MG Oral Tablet)
Maximum of 2 tablets per day
Enalapril-Hydrochlorothiazide (5-12.5MG Oral Tablet)
Maximum of 1 tablet per day
Endocet (10-325MG Oral Tablet, 5-325MG Oral Tablet, 7.5-325MG Oral Tablet)
Maximum of 12 tablets per day
Enoxaparin Sodium (100MG/ML Subcutaneous Solution, 150MG/ML Subcutaneous Solution)
Maximum of 2 syringes (2 ml) per day
Enoxaparin Sodium (120MG/0.8ML Subcutaneous Solution, 80MG/0.8ML Subcutaneous Solution)
Maximum of 2 syringes (1.6 ml) per day
Enoxaparin Sodium (30MG/0.3ML Subcutaneous Solution)
Maximum of 2 syringes (0.6 ml) per day
Enoxaparin Sodium (40MG/0.4ML Subcutaneous Solution)
Maximum of 2 syringes (0.8 ml) per day
Enoxaparin Sodium (60MG/0.6ML Subcutaneous Solution)
Maximum of 2 syringes (1.2 ml) per day
Entresto (Oral Tablet) Maximum of 2 tablets per day
Epclusa (Oral Tablet) Maximum of 1 tablet per day
Epinephrine (Injection Solution Auto-Injector) Maximum of 4 pens (2 boxes) per 30 days
EpiPen 2-Pak (Injection Solution Auto-
Injector)Maximum of 4 pens (2 boxes) per 30 days
97
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
EpiPen Jr 2-Pak (Injection Solution Auto-
Injector)Maximum of 4 pens (2 boxes) per 30 days
Eprosartan Mesylate (Oral Tablet) Maximum of 1 tablet per day
Erivedge (Oral Capsule) Maximum of 1 capsule per day
Erleada (Oral Tablet) Maximum of 4 tablets per day
Erlotinib HCl (100MG Oral Tablet, 150MG Oral Tablet)
Maximum of 1 tablet per day
Erlotinib HCl (25MG Oral Tablet) Maximum of 3 tablets per day
Esbriet (Oral Capsule) Maximum of 9 capsules per day
Esbriet (801MG Oral Tablet) Maximum of 3 tablets per day
Esomeprazole Magnesium (20MG Oral Capsule Delayed Release) (Generic Nexium)
Maximum of 3 capsules per day
Esomeprazole Magnesium (40MG Oral Capsule Delayed Release) (Generic Nexium)
Maximum of 2 capsules per day
Estradiol (Transdermal Patch Weekly) Maximum of 4 patches per 28 days
Estradiol (Vaginal Tablet) Maximum of 1 tablet per day
Evotaz (Oral Tablet) Maximum of 1 tablet per day
Ezetimibe (Oral Tablet) Maximum of 1 tablet per day
Ezetimibe-Simvastatin (Oral Tablet) Maximum of 1 tablet per day
Famciclovir (125MG Oral Tablet, 250MG Oral Tablet)
Maximum of 2 tablets per day
Famciclovir (500MG Oral Tablet) Maximum of 3 tablets per day
Fanapt (10MG Oral Tablet, 12MG Oral
Tablet, 1MG Oral Tablet, 2MG Oral Tablet,
4MG Oral Tablet, 6MG Oral Tablet, 8MG Oral
Tablet)
Maximum of 2 tablets per day
Fentanyl Citrate (Buccal Lozenge On A Handle) Maximum of 4 lozenges per day
Fentanyl (100MCG/HR Transdermal Patch 72 Hour, 12MCG/HR Transdermal Patch 72 Hour, 25MCG/HR Transdermal Patch 72 Hour, 50MCG/HR Transdermal Patch 72 Hour, 75MCG/HR Transdermal Patch 72 Hour)
Maximum of 15 patches per 30 days
Fetzima (Oral Capsule Extended Release 24
Hour)Maximum of 1 capsule per day
Firazyr (Subcutaneous Solution) Maximum of 9 ml per day
Flector (Transdermal Patch) Maximum of 2 patches per day
Flovent Diskus (Inhalation Aerosol Powder
Breath Activated)
Maximum of 2 inhalers (120 blisters) per 30 days
Flovent HFA (110MCG/ACT Inhalation
Aerosol)Maximum of 1 inhaler (12 grams) per 30 days
98
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Flovent HFA (220MCG/ACT Inhalation
Aerosol)Maximum of 2 inhalers (24 grams) per 30 days
Flovent HFA (44MCG/ACT Inhalation
Aerosol)Maximum of 1 inhaler (10.6 grams) per 30 days
Fluticasone-Salmeterol (100-50MCG/DOSE Inhalation Aerosol Powder Breath Activated, 250-50MCG/DOSE Inhalation Aerosol Powder Breath Activated, 500-50MCG/DOSE Inhalation Aerosol Powder Breath Activated) (Generic Advair)
Maximum of 1 inhaler (60 blisters) per 30 days
Fluticasone-Salmeterol (113-14MCG/ACT Inhalation Aerosol Powder Breath Activated, 232-14MCG/ACT Inhalation Aerosol Powder Breath Activated, 55-14MCG/ACT Inhalation Aerosol Powder Breath Activated) (Brand Equivalent AirDuo)
Maximum of 1 inhaler per 30 days
Fluvastatin Sodium (20MG Oral Capsule) Maximum of 1 capsule per day
Fluvastatin Sodium (40MG Oral Capsule) Maximum of 2 capsules per day
Forteo (Subcutaneous Solution) Maximum of 1 pen (2.4 ml) per 28 days
Fosamprenavir Calcium (Oral Tablet) Maximum of 4 tablets per day
Fosinopril Sodium (Oral Tablet) Maximum of 2 tablets per day
Fosinopril Sodium-HCTZ (Oral Tablet) Maximum of 4 tablets per day
Fuzeon (Subcutaneous Solution
Reconstituted)Maximum of 2 vials per day
Galantamine Hydrobromide ER (Oral Capsule Extended Release 24 Hour)
Maximum of 1 capsule per day
Galantamine Hydrobromide (Oral Solution) Maximum of 2 bottles (200 ml) per 30 days
Galantamine Hydrobromide (Oral Tablet) Maximum of 2 tablets per day
Genvoya (Oral Tablet) Maximum of 1 tablet per day
Gilenya (0.5MG Oral Capsule) Maximum of 1 pack (30 capsules) per 30 days
Glatiramer Acetate (20MG/ML Subcutaneous Solution Prefilled Syringe)
Maximum of 1 syringe (1 ml) per day
Glatiramer Acetate (40MG/ML Subcutaneous Solution Prefilled Syringe)
Maximum of 12 syringes (12 ml) per 28 days
Glatopa (20MG/ML Subcutaneous Solution Prefilled Syringe)
Maximum of 1 syringe (1 ml) per day
Glatopa (40MG/ML Subcutaneous Solution Prefilled Syringe)
Maximum of 12 syringes (12 ml) per 28 days
Glimepiride (1MG Oral Tablet) Maximum of 8 tablets per day
Glimepiride (2MG Oral Tablet) Maximum of 4 tablets per day
99
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Glimepiride (4MG Oral Tablet) Maximum of 2 tablets per day
Glipizide ER (10MG Oral Tablet Extended Release 24 Hour)
Maximum of 2 tablets per day
Glipizide ER (2.5MG Oral Tablet Extended Release 24 Hour)
Maximum of 8 tablets per day
Glipizide ER (5MG Oral Tablet Extended Release 24 Hour)
Maximum of 4 tablets per day
Glipizide (10MG Oral Tablet Immediate Release)
Maximum of 4 tablets per day
Glipizide (5MG Oral Tablet Immediate Release) Maximum of 8 tablets per day
Glipizide-Metformin HCl (2.5-250MG Oral Tablet)
Maximum of 8 tablets per day
Glipizide-Metformin HCl (2.5-500MG Oral Tablet, 5-500MG Oral Tablet)
Maximum of 4 tablets per day
Glyxambi (Oral Tablet) Maximum of 1 tablet per day
Granisetron HCl (Oral Tablet) Maximum of 2 tablets per day
Hetlioz (Oral Capsule) Maximum of 1 capsule per day
Hydrocodone-Acetaminophen (7.5-325MG/15ML Oral Solution)
Maximum of 180 ml per day
Hydrocodone-Acetaminophen (10-325MG Oral Tablet, 5-325MG Oral Tablet, 7.5-325MG Oral Tablet)
Maximum of 12 tablets per day
Hydrocodone-Ibuprofen (7.5-200MG Oral Tablet)
Maximum of 5 tablets per day
Hydromorphone HCl ER (Oral Tablet ER 24 Hour Abuse-Deterrent)
Maximum of 2 tablets per day
Hydromorphone HCl (1MG/ML Oral Liquid) Maximum of 50 ml per day
Hydromorphone HCl (2MG Oral Tablet Immediate Release, 4MG Oral Tablet Immediate Release)
Maximum of 8 tablets per day
Hydromorphone HCl (8MG Oral Tablet Immediate Release)
Maximum of 6 tablets per day
Hysingla ER (Oral Tablet ER 24 Hour Abuse-
Deterrent)Maximum of 1 tablet per day
Ibandronate Sodium (Oral Tablet) Maximum of 1 tablet per 28 days
Ibrance (Oral Capsule) Maximum of 1 capsule per day
Icatibant Acetate (Subcutaneous Solution) Maximum of 9 ml per day
Iclusig (15MG Oral Tablet) Maximum of 2 tablets per day
Iclusig (45MG Oral Tablet) Maximum of 1 tablet per day
IDHIFA (Oral Tablet) Maximum of 1 tablet per day
100
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Imatinib Mesylate (Oral Tablet) Maximum of 3 tablets per day
Imbruvica (140MG Oral Capsule) Maximum of 4 capsules per day
Imbruvica (70MG Oral Capsule) Maximum of 1 capsule per day
Imbruvica (Oral Tablet) Maximum of 1 tablet per day
Imvexxy Maintenance Pack (Vaginal Insert) Maximum of 1 vaginal insert per day
Imvexxy Starter Pack (Vaginal Insert) Maximum of 1 vaginal insert per day
Incruse Ellipta (Inhalation Aerosol Powder
Breath Activated)Maximum of 1 inhaler (30 blisters) per 30 days
Ingrezza (Oral Capsule) Maximum of 1 capsule per day
Ingrezza (Oral Capsule Therapy Pack) Maximum of 28 capsules (1 pack) per 28 days
Inlyta (Oral Tablet) Maximum of 4 tablets per day
Inrebic (Oral Capsule) Maximum of 4 capsules per day
Intelence (100MG Oral Tablet, 200MG Oral
Tablet)Maximum of 2 tablets per day
Intelence (25MG Oral Tablet) Maximum of 4 tablets per day
Invirase (Oral Tablet) Maximum of 4 tablets per day
Invokamet (Oral Tablet Immediate Release) Maximum of 2 tablets per day
Invokamet XR (Oral Tablet Extended Release
24 Hour)Maximum of 2 tablets per day
Invokana (Oral Tablet) Maximum of 1 tablet per day
Irbesartan (150MG Oral Tablet, 300MG Oral Tablet)
Maximum of 1 tablet per day
Irbesartan (75MG Oral Tablet) Maximum of 3 tablets per day
Irbesartan-Hydrochlorothiazide (Oral Tablet) Maximum of 1 tablet per day
Iressa (Oral Tablet) Maximum of 2 tablets per day
Isentress HD (Oral Tablet) Maximum of 2 tablets per day
Isentress (Oral Packet) Maximum of 2 packets per day
Isentress (Oral Tablet) Maximum of 2 tablets per day
Isentress (Oral Tablet Chewable) Maximum of 6 tablets per day
Itraconazole (Oral Capsule) Maximum of 4 capsules per day
Jakafi (Oral Tablet) Maximum of 2 tablets per day
Janumet (Oral Tablet Immediate Release) Maximum of 2 tablets per day
Janumet XR (100-1000MG Oral Tablet
Extended Release 24 Hour)Maximum of 1 tablet per day
Janumet XR (50-1000MG Oral Tablet
Extended Release 24 Hour, 50-500MG Oral
Tablet Extended Release 24 Hour)
Maximum of 2 tablets per day
Januvia (Oral Tablet) Maximum of 1 tablet per day
101
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Jardiance (Oral Tablet) Maximum of 1 tablet per day
Jentadueto (Oral Tablet Immediate Release) Maximum of 2 tablets per day
Jentadueto XR (2.5-1000MG Oral Tablet
Extended Release 24 Hour)Maximum of 2 tablets per day
Jentadueto XR (5-1000MG Oral Tablet
Extended Release 24 Hour)Maximum of 1 tablet per day
Juluca (Oral Tablet) Maximum of 1 tablet per day
Kaletra (100-25MG Oral Tablet) Maximum of 2 tablets per day
Kaletra (200-50MG Oral Tablet) Maximum of 4 tablets per day
Kalydeco (Oral Packet) Maximum of 2 packets per day
Kalydeco (Oral Tablet) Maximum of 2 tablets per day
Ketoconazole (External Cream) Maximum of 90 grams per 30 days
Kisqali (200MG Dose) (Oral Tablet) Maximum of 3 tablets per day
Kisqali (400MG Dose) (Oral Tablet) Maximum of 3 tablets per day
Kisqali (600MG Dose) (Oral Tablet) Maximum of 3 tablets per day
Kisqali Femara (400MG Dose) (Oral Tablet
Therapy Pack)Maximum of 1 pack (91 tablets) per 28 days
Kisqali Femara (600MG Dose) (Oral Tablet
Therapy Pack)Maximum of 1 pack (91 tablets) per 28 days
Kisqali Femara (200MG Dose) (Oral Tablet
Therapy Pack)Maximum of 1 pack (91 tablets) per 28 days
Korlym (Oral Tablet) Maximum of 4 tablets per day
Lamivudine (10MG/ML Oral Solution) Maximum of 32 ml per day
Lamivudine (150MG Oral Tablet) Maximum of 2 tablets per day
Lamivudine (300MG Oral Tablet) Maximum of 1 tablet per day
Lamivudine-Zidovudine (Oral Tablet) Maximum of 2 tablets per day
Lansoprazole (Oral Capsule Delayed Release) Maximum of 2 capsules per day
Latuda (120MG Oral Tablet, 20MG Oral
Tablet, 40MG Oral Tablet, 60MG Oral Tablet)Maximum of 1 tablet per day
Latuda (80MG Oral Tablet) Maximum of 2 tablets per day
Levocetirizine Dihydrochloride (Oral Tablet) Maximum of 1 tablet per day
Levorphanol Tartrate (Oral Tablet) Maximum of 6 tablets per day
Lexiva (Oral Suspension) Maximum of 60 ml per day
Lidocaine (5% External Ointment) Maximum of 152 grams per 30 days
Lidocaine (5% External Patch) Maximum of 3 patches per day
Linezolid (Oral Tablet) Maximum of 2 tablets per day
Linzess (Oral Capsule) Maximum of 1 capsule per day
Lisinopril (Oral Tablet) Maximum of 2 tablets per day
102
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Lisinopril-Hydrochlorothiazide (10-12.5MG Oral Tablet)
Maximum of 1 tablet per day
Lisinopril-Hydrochlorothiazide (20-12.5MG Oral Tablet)
Maximum of 4 tablets per day
Lisinopril-Hydrochlorothiazide (20-25MG Oral Tablet)
Maximum of 2 tablets per day
Livalo (Oral Tablet) Maximum of 1 tablet per day
Lokelma (Oral Packet) Maximum of 90 packets per 30 days
Lonhala Magnair Refill Kit (Inhalation
Solution)Maximum of 2 vials (2 ml) per day
Lonsurf (15-6.14MG Oral Tablet) Maximum of 10 tablets per day
Lonsurf (20-8.19MG Oral Tablet) Maximum of 8 tablets per day
Lopinavir-Ritonavir (Oral Solution) Maximum of 2 bottles (320 ml) per 30 days
Lorazepam (2MG/ML Oral Concentrate) Maximum of 5 ml per day
Lorazepam (0.5MG Oral Tablet, 1MG Oral Tablet)
Maximum of 4 tablets per day
Lorazepam (2MG Oral Tablet) Maximum of 5 tablets per day
Lorbrena (100MG Oral Tablet) Maximum of 1 tablet per day
Lorbrena (25MG Oral Tablet) Maximum of 3 tablets per day
Lorcet HD (Oral Tablet) Maximum of 12 tablets per day
Lorcet (Oral Tablet) Maximum of 12 tablets per day
Lorcet Plus (Oral Tablet) Maximum of 12 tablets per day
Losartan Potassium (100MG Oral Tablet) Maximum of 1 tablet per day
Losartan Potassium (25MG Oral Tablet, 50MG Oral Tablet)
Maximum of 2 tablets per day
Losartan Potassium-HCTZ (100-12.5MG Oral Tablet, 100-25MG Oral Tablet)
Maximum of 1 tablet per day
Losartan Potassium-HCTZ (50-12.5MG Oral Tablet)
Maximum of 2 tablets per day
Lovastatin (10MG Oral Tablet, 20MG Oral Tablet)
Maximum of 1 tablet per day
Lovastatin (40MG Oral Tablet) Maximum of 2 tablets per day
Lynparza (Oral Tablet) Maximum of 4 tablets per day
Mavyret (Oral Tablet) Maximum of 3 tablets per day
Mayzent (0.25MG Oral Tablet) Maximum of 8 tablets per day
Mayzent (2MG Oral Tablet) Maximum of 1 tablet per day
Memantine HCl ER (Oral Capsule Extended Release 24 Hour)
Maximum of 1 capsule per day
Memantine HCl (2MG/ML Oral Solution) Maximum of 10 ml per day
103
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Memantine HCl (10MG Oral Tablet) Maximum of 2 tablets per day
Memantine HCl (5MG Oral Tablet) Maximum of 3 tablets per day
Mesalamine ER (0.375MG Oral Capsule Extended Release 24 Hour) (Generic Apriso)
Maximum of 4 capsules per day
Mesalamine (1.2GM Oral Tablet Delayed Release) (Generic Lialda)
Maximum of 4 tablets per day
Mesalamine (Rectal Enema) Maximum of 1 bottle (60 ml) per day
Metadate ER (Oral Tablet Extended Release) Maximum of 3 tablets per day
Metformin HCl ER (500MG Oral Tablet Extended Release 24 Hour) (Generic Glucophage XR)
Maximum of 4 tablets per day
Metformin HCl ER (750MG Oral Tablet Extended Release 24 Hour) (Generic Glucophage XR)
Maximum of 2 tablets per day
Metformin HCl (1000MG Oral Tablet Immediate Release)
Maximum of 2.5 tablets per day
Metformin HCl (500MG Oral Tablet Immediate Release)
Maximum of 5 tablets per day
Metformin HCl (850MG Oral Tablet Immediate Release)
Maximum of 3 tablets per day
Methadone HCl (10MG/5ML Oral Solution) Maximum of 60 ml per day
Methadone HCl (5MG/5ML Oral Solution) Maximum of 120 ml per day
Methadone HCl (10MG Oral Tablet) Maximum of 12 tablets per day
Methadone HCl (5MG Oral Tablet) Maximum of 8 tablets per day
Methylphenidate HCl ER (10MG Oral Tablet Extended Release)
Maximum of 4 tablets per day
Methylphenidate HCl ER (20MG Oral Tablet Extended Release)
Maximum of 3 tablets per day
Methylphenidate HCl (10MG/5ML Oral Solution)
Maximum of 30 ml per day
Methylphenidate HCl (5MG/5ML Oral Solution) Maximum of 60 ml per day
Methylphenidate HCl (Oral Tablet Immediate Release) (Generic Ritalin)
Maximum of 3 tablets per day
Miglitol (100MG Oral Tablet) Maximum of 3 tablets per day
Miglitol (25MG Oral Tablet) Maximum of 12 tablets per day
Miglitol (50MG Oral Tablet) Maximum of 6 tablets per day
Modafinil (100MG Oral Tablet) Maximum of 1 tablet per day
Modafinil (200MG Oral Tablet) Maximum of 2 tablets per day
Moexipril HCl (Oral Tablet) Maximum of 2 tablets per day
Montelukast Sodium (Oral Packet) Maximum of 1 packet per day
104
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Montelukast Sodium (Oral Tablet) Maximum of 1 tablet per day
Montelukast Sodium (Oral Tablet Chewable) Maximum of 1 tablet per day
Morphine Sulfate (100MG/5ML Oral Solution) Maximum of 10 ml per day
Morphine Sulfate ER (100MG Oral Tablet Extended Release, 15MG Oral Tablet Extended Release) (Generic MS Contin)
Maximum of 3 tablets per day
Morphine Sulfate ER (200MG Oral Tablet Extended Release) (Generic MS Contin)
Maximum of 2 tablets per day
Morphine Sulfate ER (30MG Oral Tablet Extended Release, 60MG Oral Tablet Extended Release) (Generic MS Contin)
Maximum of 4 tablets per day
Morphine Sulfate (10MG/5ML Oral Solution) Maximum of 100 ml per day
Morphine Sulfate (20MG/5ML Oral Solution) Maximum of 50 ml per day
Morphine Sulfate (15MG Oral Tablet
Immediate Release)Maximum of 8 tablets per day
Morphine Sulfate (30MG Oral Tablet
Immediate Release)Maximum of 6 tablets per day
Multaq (Oral Tablet) Maximum of 2 tablets per day
Namzaric (Oral Capsule ER 24 Hour Therapy
Pack)Maximum of 1 capsule per day
Namzaric (Oral Capsule Extended Release
24 Hour)Maximum of 1 capsule per day
Naratriptan HCl (Oral Tablet) Maximum of 12 tablets per 30 days
Nateglinide (120MG Oral Tablet) Maximum of 3 tablets per day
Nateglinide (60MG Oral Tablet) Maximum of 6 tablets per day
Nebupent (Inhalation Solution Reconstituted) Maximum of 300 mg (1 vial) per 28 days
Nerlynx (Oral Tablet) Maximum of 6 tablets per day
Nevirapine ER (100MG Oral Tablet Extended Release 24 Hour)
Maximum of 2 tablets per day
Nevirapine ER (400MG Oral Tablet Extended Release 24 Hour)
Maximum of 1 tablet per day
Nevirapine (Oral Suspension) Maximum of 40 ml per day
Nevirapine (Oral Tablet Immediate Release) Maximum of 2 tablets per day
Nifedipine ER (Oral Tablet Extended Release 24 Hour)
Maximum of 2 tablets per day
Nifedipine ER Osmotic Release (Oral Tablet Extended Release 24 Hour)
Maximum of 2 tablets per day
Ninlaro (Oral Capsule) Maximum of 3 capsules per 28 days
Northera (100MG Oral Capsule) Maximum of 3 capsules per day
105
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Northera (200MG Oral Capsule, 300MG Oral
Capsule)Maximum of 6 capsules per day
Norvir (Oral Packet) Maximum of 12 packets per day
Norvir (Oral Solution) Maximum of 16 ml per day
Noxafil (Oral Suspension) Maximum of 20 ml per day
Noxafil (Oral Tablet Delayed Release) Maximum of 6 tablets per day
Nubeqa (Oral Tablet) Maximum of 4 tablets per day
Nucala (Subcutaneous Solution Auto-
Injector)Maximum of 3 ml per 28 days
Nucala (Subcutaneous Solution Prefilled
Syringe)Maximum of 3 ml per 28 days
Nucala (Subcutaneous Solution
Reconstituted)Maximum of 3 vials per 28 days
Nucynta ER (Oral Tablet Extended Release
12 Hour)Maximum of 2 tablets per day
Nuplazid (Oral Capsule) Maximum of 1 capsule per day
Nuplazid (10MG Oral Tablet) Maximum of 1 tablet per day
Ocaliva (Oral Tablet) Maximum of 1 tablet per day
Odefsey (Oral Tablet) Maximum of 1 tablet per day
Odomzo (Oral Capsule) Maximum of 1 capsule per day
Ofev (Oral Capsule) Maximum of 2 capsules per day
Olanzapine (10MG Oral Tablet, 15MG Oral Tablet, 2.5MG Oral Tablet, 20MG Oral Tablet, 5MG Oral Tablet, 7.5MG Oral Tablet)
Maximum of 1 tablet per day
Olanzapine ODT (10MG Oral Tablet Dispersible, 15MG Oral Tablet Dispersible, 20MG Oral Tablet Dispersible, 5MG Oral Tablet Dispersible)
Maximum of 1 tablet per day
Olmesartan Medoxomil (20MG Oral Tablet, 40MG Oral Tablet)
Maximum of 1 tablet per day
Olmesartan Medoxomil (5MG Oral Tablet) Maximum of 2 tablets per day
Olmesartan Medoxomil-HCTZ (Oral Tablet) Maximum of 1 tablet per day
Olmesartan-Amlodipine-HCTZ (Oral Tablet) Maximum of 1 tablet per day
Omega-3-Acid Ethyl Esters (Oral Capsule) (Generic Lovaza)
Maximum of 4 capsules per day
Omeprazole (10MG Oral Capsule Delayed Release)
Maximum of 3 capsules per day
Orkambi (Oral Packet) Maximum of 56 packets per 28 days
Orkambi (Oral Tablet) Maximum of 112 tablets per 28 days
106
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Oseltamivir Phosphate (Oral Capsule) Maximum of 2 capsules per day
Oseltamivir Phosphate (Oral Suspension Reconstituted)
Maximum of 26 ml per day
Osphena (Oral Tablet) Maximum of 1 tablet per day
Oxandrolone (10MG Oral Tablet) Maximum of 2 tablets per day
Oxandrolone (2.5MG Oral Tablet) Maximum of 4 tablets per day
Oxybutynin Chloride ER (10MG Oral Tablet Extended Release 24 Hour)
Maximum of 3 tablets per day
Oxybutynin Chloride ER (15MG Oral Tablet Extended Release 24 Hour)
Maximum of 2 tablets per day
Oxybutynin Chloride ER (5MG Oral Tablet Extended Release 24 Hour)
Maximum of 1 tablet per day
Oxycodone HCl (100MG/5ML Oral Concentrate)
Maximum of 6 ml per day
Oxycodone HCl (5MG/5ML Oral Solution) Maximum of 130 ml per day
Oxycodone HCl (10MG Oral Tablet Immediate Release, 5MG Oral Tablet Immediate Release)
Maximum of 12 tablets per day
Oxycodone HCl (15MG Oral Tablet Immediate Release)
Maximum of 8 tablets per day
Oxycodone HCl (20MG Oral Tablet Immediate Release, 30MG Oral Tablet Immediate Release)
Maximum of 6 tablets per day
Oxycodone-Acetaminophen (Oral Tablet) Maximum of 12 tablets per day
Oxycodone-Aspirin (Oral Tablet) Maximum of 12 tablets per day
Oxycodone-Ibuprofen (Oral Tablet) Maximum of 4 tablets per day
Ozempic (0.25 or 0.5 MG/DOSE)
(Subcutaneous Solution Pen-Injector)Maximum of 1 pen (1.5 ml) per 28 days
Ozempic (1 MG/DOSE) (Subcutaneous
Solution Pen-Injector)Maximum of 2 pens (3 ml) per 28 days
Paliperidone ER (1.5MG Oral Tablet Extended Release 24 Hour, 3MG Oral Tablet Extended Release 24 Hour, 9MG Oral Tablet Extended Release 24 Hour)
Maximum of 1 tablet per day
Paliperidone ER (6MG Oral Tablet Extended Release 24 Hour)
Maximum of 2 tablets per day
Pantoprazole Sodium (20MG Oral Tablet Delayed Release)
Maximum of 3 tablets per day
Pantoprazole Sodium (40MG Oral Tablet Delayed Release)
Maximum of 2 tablets per day
Pentamidine Isethionate (Inhalation Solution Reconstituted)
Maximum of 300 mg (1 vial) per 28 days
107
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Pentasa (250MG Oral Capsule Extended
Release)Maximum of 12 capsules per day
Pentasa (500MG Oral Capsule Extended
Release)Maximum of 8 capsules per day
Perforomist (Inhalation Nebulization
Solution)Maximum of 2 vials (4 ml) per day
Perindopril Erbumine (Oral Tablet) Maximum of 2 tablets per day
Pifeltro (Oral Tablet) Maximum of 1 tablet per day
Pioglitazone HCl (15MG Oral Tablet) Maximum of 3 tablets per day
Pioglitazone HCl (30MG Oral Tablet, 45MG Oral Tablet)
Maximum of 1 tablet per day
Pioglitazone HCl-Glimepiride (Oral Tablet) Maximum of 1 tablet per day
Pioglitazone HCl-Metformin HCl (Oral Tablet) Maximum of 3 tablets per day
Piqray (200MG Daily Dose) (Oral Tablet
Therapy Pack)Maximum of 1 tablet per day
Piqray (250MG Daily Dose) (Oral Tablet
Therapy Pack)Maximum of 2 tablets per day
Piqray (300MG Daily Dose) (Oral Tablet
Therapy Pack)Maximum of 2 tablets per day
Pomalyst (Oral Capsule) Maximum of 1 capsule per day
Posaconazole (Oral Tablet Delayed Release) Maximum of 6 tablets per day
Praluent (Subcutaneous Solution Auto-
Injector)Maximum of 2 pens (2 ml) per 28 days
Prasugrel HCl (Oral Tablet) Maximum of 1 tablet per day
Pravastatin Sodium (Oral Tablet) Maximum of 1 tablet per day
Pregabalin (100MG Oral Capsule, 150MG Oral Capsule, 200MG Oral Capsule, 25MG Oral Capsule, 50MG Oral Capsule, 75MG Oral Capsule)
Maximum of 3 capsules per day
Pregabalin (225MG Oral Capsule, 300MG Oral Capsule)
Maximum of 2 capsules per day
Pregabalin (Oral Solution) Maximum of 30 ml per day
Premarin (Oral Tablet) Maximum of 1 tablet per day
Premphase (Oral Tablet) Maximum of 1 tablet per day
Prempro (Oral Tablet) Maximum of 1 tablet per day
Prezcobix (Oral Tablet) Maximum of 1 tablet per day
Prezista (Oral Suspension) Maximum of 2 bottles (400 ml) per 30 days
Prezista (150MG Oral Tablet) Maximum of 6 tablets per day
Prezista (600MG Oral Tablet, 75MG Oral
Tablet)Maximum of 2 tablets per day
108
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Drug Name Quantity Limit
Prezista (800MG Oral Tablet) Maximum of 1 tablet per day
Prolia (Subcutaneous Solution Prefilled
Syringe)Maximum of 1 syringe per 180 days
Promacta (Oral Packet) Maximum of 6 packets per day
Promacta (12.5MG Oral Tablet, 25MG Oral
Tablet)Maximum of 1 tablet per day
Promacta (50MG Oral Tablet, 75MG Oral
Tablet)Maximum of 2 tablets per day
Pulmozyme (Inhalation Solution) Maximum of 5 ml (2 ampules) per day
Quetiapine Fumarate ER (150MG Oral Tablet Extended Release 24 Hour, 200MG Oral Tablet Extended Release 24 Hour)
Maximum of 1 tablet per day
Quetiapine Fumarate ER (300MG Oral Tablet Extended Release 24 Hour, 400MG Oral Tablet Extended Release 24 Hour, 50MG Oral Tablet Extended Release 24 Hour)
Maximum of 2 tablets per day
Quetiapine Fumarate (100MG Oral Tablet Immediate Release, 200MG Oral Tablet Immediate Release, 50MG Oral Tablet Immediate Release)
Maximum of 3 tablets per day
Quetiapine Fumarate (25MG Oral Tablet Immediate Release)
Maximum of 4 tablets per day
Quetiapine Fumarate (300MG Oral Tablet Immediate Release, 400MG Oral Tablet Immediate Release)
Maximum of 2 tablets per day
Quinapril HCl (Oral Tablet) Maximum of 2 tablets per day
Quinapril-Hydrochlorothiazide (10-12.5MG Oral Tablet)
Maximum of 1 tablet per day
Quinapril-Hydrochlorothiazide (20-12.5MG Oral Tablet, 20-25MG Oral Tablet)
Maximum of 2 tablets per day
Raloxifene HCl (Oral Tablet) Maximum of 1 tablet per day
Ramelteon (Oral Tablet) Maximum of 1 tablet per day
Ramipril (Oral Capsule) Maximum of 2 capsules per day
Ranolazine ER (Oral Tablet Extended Release 12 Hour)
Maximum of 2 tablets per day
RAVICTI (Oral Liquid) Maximum of 17.5 ml per day
Rayaldee (Oral Capsule Extended Release) Maximum of 2 capsules per day
Rebif Rebidose (Subcutaneous Solution
Auto-Injector)Maximum of 12 pens (6 ml) per 28 days
109
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Rebif Rebidose Titration Pack
(Subcutaneous Solution Auto-Injector)Maximum of 1 pack (4.2 ml) per 28 days
Rebif (Subcutaneous Solution Prefilled
Syringe)Maximum of 12 syringes (6 ml) per 28 days
Rebif Titration Pack (Subcutaneous Solution
Prefilled Syringe)Maximum of 1 pack (4.2 ml) per 28 days
Relenza Diskhaler (Inhalation Aerosol
Powder Breath Activated)Maximum of 3 inhalers (60 blisters) per 30 days
Relistor (Oral Tablet) Maximum of 3 tablets per day
Repaglinide (0.5MG Oral Tablet) Maximum of 32 tablets per day
Repaglinide (1MG Oral Tablet) Maximum of 16 tablets per day
Repaglinide (2MG Oral Tablet) Maximum of 8 tablets per day
Repatha Pushtronex System (Subcutaneous
Solution Cartridge)Maximum of 1 cartridge (3.5 ml) per 28 days
Repatha (Subcutaneous Solution Prefilled
Syringe)Maximum of 3 syringes (3 ml) per 28 days
Repatha SureClick (Subcutaneous Solution
Auto-Injector)Maximum of 3 pens (3 ml) per 28 days
Rescriptor (Oral Tablet) Maximum of 6 tablets per day
Restasis (Ophthalmic Emulsion) Maximum of 2 vials per day
Revlimid (Oral Capsule) Maximum of 1 capsule per day
Rexulti (Oral Tablet) Maximum of 1 tablet per day
Reyataz (Oral Packet) Maximum of 6 packets per day
Riomet (Oral Solution) Maximum of 25.5 ml per day
Risedronate Sodium (150MG Oral Tablet Immediate Release)
Maximum of 1 tablet per 30 days
Risedronate Sodium (30MG Oral Tablet Immediate Release, 5MG Oral Tablet Immediate Release)
Maximum of 1 tablet per day
Risedronate Sodium (35MG Oral Tablet Immediate Release, 35MG (12 PACK) Oral Tablet Immediate Release, 35MG (4 PACK) Oral Tablet Immediate Release)
Maximum of 4 tablets per 28 days
Ritonavir (Oral Tablet) Maximum of 12 tablets per day
Rivastigmine Tartrate (Oral Capsule) Maximum of 2 capsules per day
Rivastigmine (Transdermal Patch 24 Hour) Maximum of 1 patch per day
Rizatriptan Benzoate (Oral Tablet) Maximum of 12 tablets per 30 days
Rizatriptan Benzoate ODT (Oral Tablet Dispersible)
Maximum of 12 tablets per 30 days
Rosuvastatin Calcium (Oral Tablet) Maximum of 1 tablet per day
110
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Rozlytrek (100MG Oral Capsule) Maximum of 5 capsules per day
Rozlytrek (200MG Oral Capsule) Maximum of 3 capsules per day
Rubraca (Oral Tablet) Maximum of 4 tablets per day
Rybelsus (Oral Tablet) Maximum of 1 tablet per day
Rydapt (Oral Capsule) Maximum of 8 capsules per day
Saphris (Tablet Sublingual) Maximum of 2 tablets per day
Selzentry (Oral Solution) Maximum of 8 bottles (1840 ml) per 30 days
Selzentry (150MG Oral Tablet, 75MG Oral
Tablet)Maximum of 2 tablets per day
Selzentry (25MG Oral Tablet, 300MG Oral
Tablet)Maximum of 4 tablets per day
Serevent Diskus (Inhalation Aerosol Powder
Breath Activated)
Maximum of 1 inhaler (60 inhalations) per 30 days
Sildenafil Citrate (20MG Oral Tablet) (Generic Revatio)
Maximum of 3 tablets per day
Silodosin (Oral Capsule) Maximum of 1 capsule per day
Simvastatin (Oral Tablet) Maximum of 1 tablet per day
Sofosbuvir-Velpatasvir (Oral Tablet) Maximum of 1 tablet per day
Solifenacin Succinate (Oral Tablet) Maximum of 1 tablet per day
Soliqua (Subcutaneous Solution Pen-
Injector)Maximum of 18 ml (6 pens) per 30 days
Somavert (Subcutaneous Solution
Reconstituted)Maximum of 1 vial per day
Sovaldi (400MG Oral Tablet) Maximum of 1 tablet per day
Spiriva HandiHaler (Inhalation Capsule) Maximum of 1 capsule per day
Spiriva Respimat (Inhalation Aerosol
Solution)Maximum of 1 inhaler (4 grams) per 30 days
Sprycel (100MG Oral Tablet, 140MG Oral
Tablet, 70MG Oral Tablet)Maximum of 1 tablet per day
Sprycel (20MG Oral Tablet, 50MG Oral
Tablet)Maximum of 3 tablets per day
Sprycel (80MG Oral Tablet) Maximum of 2 tablets per day
Stavudine (Oral Capsule) Maximum of 2 capsules per day
Stiolto Respimat (Inhalation Aerosol
Solution)Maximum of 1 inhaler (4 grams) per 30 days
Stivarga (Oral Tablet) Maximum of 4 tablets per day
Stribild (Oral Tablet) Maximum of 1 tablet per day
Suboxone (12-3MG Sublingual Film, 4-1MG
Sublingual Film)Maximum of 2 films per day
111
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Suboxone (2-0.5MG Sublingual Film, 8-2MG
Sublingual Film)Maximum of 3 films per day
Sumatriptan (Nasal Solution) Maximum of 12 devices per 30 days
Sumatriptan Succinate (100MG Oral Tablet, 25MG Oral Tablet, 50MG Oral Tablet)
Maximum of 12 tablets per 30 days
Sumatriptan Succinate Refill (Subcutaneous
Solution Cartridge)Maximum of 12 injections (6 ml) per 30 days
Sumatriptan Succinate (6MG/0.5ML Subcutaneous Solution)
Maximum of 12 injections (6 ml) per 30 days
Sumatriptan Succinate (4MG/0.5ML Subcutaneous Solution Auto-Injector, 6MG/0.5ML Subcutaneous Solution Auto-Injector)
Maximum of 12 injections (6 ml) per 30 days
Sumatriptan Succinate (6MG/0.5ML
Subcutaneous Solution Auto-Injector)
(Generic Imitrex STATdose)
Maximum of 12 injections (6 ml) per 30 days
Sumatriptan Succinate (6MG/0.5ML Subcutaneous Solution Prefilled Syringe)
Maximum of 12 injections (6 ml) per 30 days
Sutent (12.5MG Oral Capsule, 25MG Oral
Capsule, 50MG Oral Capsule)Maximum of 1 capsule per day
Sutent (37.5MG Oral Capsule) Maximum of 2 capsules per day
Symbicort (Inhalation Aerosol) Maximum of 1 inhaler (10.2 grams) per 30 days
Symfi Lo (Oral Tablet) Maximum of 1 tablet per day
Symfi (Oral Tablet) Maximum of 1 tablet per day
Sympazan (Oral Film) Maximum of 2 films per day
Symtuza (Oral Tablet) Maximum of 1 tablet per day
Synjardy (Oral Tablet Immediate Release) Maximum of 2 tablets per day
Synjardy XR (10-1000MG Oral Tablet
Extended Release 24 Hour, 25-1000MG Oral
Tablet Extended Release 24 Hour)
Maximum of 1 tablet per day
Synjardy XR (12.5-1000MG Oral Tablet
Extended Release 24 Hour, 5-1000MG Oral
Tablet Extended Release 24 Hour)
Maximum of 2 tablets per day
Tadalafil (PAH) (20MG Oral Tablet) Maximum of 2 tablets per day
Tagrisso (Oral Tablet) Maximum of 1 tablet per day
Talzenna (0.25MG Oral Capsule) Maximum of 3 capsules per day
Talzenna (1MG Oral Capsule) Maximum of 1 capsule per day
Tasigna (150MG Oral Capsule) Maximum of 5 capsules per day
Tasigna (200MG Oral Capsule) Maximum of 4 capsules per day
Tasigna (50MG Oral Capsule) Maximum of 14 capsules per day
Tecfidera (Oral Capsule Delayed Release) Maximum of 2 capsules per day
112
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Telmisartan (Oral Tablet) Maximum of 1 tablet per day
Telmisartan-Amlodipine (Oral Tablet) Maximum of 1 tablet per day
Telmisartan-HCTZ (40-12.5MG Oral Tablet, 80-25MG Oral Tablet)
Maximum of 1 tablet per day
Telmisartan-HCTZ (80-12.5MG Oral Tablet) Maximum of 2 tablets per day
Temazepam (15MG Oral Capsule, 30MG Oral Capsule)
Maximum of 1 capsule per day
Tenofovir Disoproxil Fumarate (Oral Tablet) Maximum of 1 tablet per day
Tetrabenazine (12.5MG Oral Tablet) Maximum of 3 tablets per day
Tetrabenazine (25MG Oral Tablet) Maximum of 4 tablets per day
Thalomid (100MG Oral Capsule, 50MG Oral
Capsule)Maximum of 1 capsule per day
Thalomid (150MG Oral Capsule, 200MG Oral
Capsule)Maximum of 2 capsules per day
Tibsovo (Oral Tablet) Maximum of 2 tablets per day
Tivicay (10MG Oral Tablet, 25MG Oral
Tablet)Maximum of 1 tablet per day
Tivicay (50MG Oral Tablet) Maximum of 2 tablets per day
TOBI Podhaler (Inhalation Capsule) Maximum of 8 capsules per day
Tobramycin (Inhalation Nebulization Solution) Maximum of 10 ml (2 ampules) per day
Tolcapone (Oral Tablet) Maximum of 6 tablets per day
Tracleer (Oral Tablet Soluble) Maximum of 8 tablets per day
Tradjenta (Oral Tablet) Maximum of 1 tablet per day
Tramadol HCl ER (Biphasic) (Oral Tablet Extended Release 24 Hour)
Maximum of 1 tablet per day
Tramadol HCl ER (Oral Tablet Extended Release 24 Hour)
Maximum of 1 tablet per day
Tramadol HCl (50MG Oral Tablet Immediate Release)
Maximum of 8 tablets per day
Tramadol-Acetaminophen (Oral Tablet) Maximum of 8 tablets per day
Trandolapril (1MG Oral Tablet, 2MG Oral Tablet)
Maximum of 1 tablet per day
Trandolapril (4MG Oral Tablet) Maximum of 2 tablets per day
Trelegy Ellipta (Inhalation Aerosol Powder
Breath Activated)Maximum of 1 inhaler (60 blisters) per 30 days
Trezix (Oral Capsule) Maximum of 10 capsules per day
Trientine HCl (Oral Capsule) Maximum of 8 capsules per day
Trintellix (Oral Tablet) Maximum of 1 tablet per day
Triumeq (Oral Tablet) Maximum of 1 tablet per day
113
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Trulicity (Subcutaneous Solution Pen-
Injector)Maximum of 4 pens (2 ml) per 28 days
Truvada (Oral Tablet) Maximum of 1 tablet per day
Turalio (Oral Capsule) Maximum of 4 capsules per day
Tybost (Oral Tablet) Maximum of 1 tablet per day
Tymlos (Subcutaneous Solution Pen-Injector) Maximum of 1.56 ml per 30 days
Valacyclovir HCl (1GM Oral Tablet) Maximum of 4 tablets per day
Valacyclovir HCl (500MG Oral Tablet) Maximum of 2 tablets per day
Valganciclovir HCl (50MG/ML Oral Solution Reconstituted)
Maximum of 36 ml per day
Valganciclovir HCl (450MG Oral Tablet) Maximum of 4 tablets per day
Valsartan (160MG Oral Tablet, 40MG Oral Tablet, 80MG Oral Tablet)
Maximum of 2 tablets per day
Valsartan (320MG Oral Tablet) Maximum of 1 tablet per day
Valsartan-Hydrochlorothiazide (Oral Tablet) Maximum of 1 tablet per day
Vancomycin HCl (125MG Oral Capsule) Maximum of 4 capsules per day
Vancomycin HCl (250MG Oral Capsule) Maximum of 8 capsules per day
Veltassa (Oral Packet) Maximum of 1 packet per day
Vemlidy (Oral Tablet) Maximum of 1 tablet per day
Venclexta (100MG Oral Tablet) Maximum of 6 tablets per day
Venclexta (10MG Oral Tablet) Maximum of 2 tablets per day
Venclexta (50MG Oral Tablet) Maximum of 1 tablet per day
Ventavis (10MCG/ML Inhalation Solution) Maximum of 7 ml per day
Ventavis (20MCG/ML Inhalation Solution) Maximum of 3 ml per day
Verzenio (Oral Tablet) Maximum of 2 tablets per day
Victoza (Subcutaneous Solution Pen-Injector) Maximum of 3 pens (9 ml) per 30 days
Videx EC (125MG Oral Capsule Delayed
Release)Maximum of 4 capsules per day
Videx (Oral Solution Reconstituted) Maximum of 40 ml per day
Vigabatrin (Oral Packet) Maximum of 6 packets per day
Vigabatrin (Oral Tablet) Maximum of 6 tablets per day
Vigadrone (Oral Packet) Maximum of 6 packets per day
Viibryd (Oral Tablet) Maximum of 1 tablet per day
Viibryd Starter Pack (Oral Kit) Maximum of 1 pack (30 tablets) per 30 days
Vimpat (Oral Solution) Maximum of 40 ml per day
Vimpat (Oral Tablet) Maximum of 2 tablets per day
Viracept (250MG Oral Tablet) Maximum of 10 tablets per day
Viracept (625MG Oral Tablet) Maximum of 4 tablets per day
114
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Viread (Oral Powder) Maximum of 4 bottles (240 grams) per 30 days
Viread (150MG Oral Tablet, 200MG Oral
Tablet, 250MG Oral Tablet)Maximum of 1 tablet per day
Vitrakvi (100MG Oral Capsule) Maximum of 4 capsules per day
Vitrakvi (25MG Oral Capsule) Maximum of 6 capsules per day
Vitrakvi (Oral Solution) Maximum of 20 ml per day
Vizimpro (Oral Tablet) Maximum of 1 tablet per day
Vosevi (Oral Tablet) Maximum of 1 tablet per day
Votrient (Oral Tablet) Maximum of 4 tablets per day
Vraylar (1.5MG Oral Capsule, 3MG Oral
Capsule, 4.5MG Oral Capsule, 6MG Oral
Capsule)
Maximum of 1 capsule per day
Vyndamax (Oral Capsule) Maximum of 1 capsule per day
Vyndaqel (Oral Capsule) Maximum of 4 capsules per day
Wixela Inhub (Inhalation Aerosol Powder Breath Activated) (Generic Advair)
Maximum of 1 inhaler (60 blisters) per 30 days
Xarelto (10MG Oral Tablet, 20MG Oral
Tablet)Maximum of 1 tablet per day
Xarelto (15MG Oral Tablet, 2.5MG Oral
Tablet)Maximum of 2 tablets per day
Xarelto Starter Pack (Oral Tablet Therapy
Pack)Maximum of 1 pack (51 tablets) per 30 days
Xeljanz (Oral Tablet Immediate Release) Maximum of 2 tablets per day
Xeljanz XR (11MG Oral Tablet Extended
Release 24 Hour)Maximum of 1 tablet per day
Xiidra (Ophthalmic Solution) Maximum of 2 vials per day
Xofluza (Oral Tablet Therapy Pack) Maximum of 2 tablets per 30 days
Xospata (Oral Tablet) Maximum of 3 tablets per day
Xpovio (100MG Once Weekly) (Oral Tablet
Therapy Pack)Maximum of 20 tablets per 28 days
Xpovio (60MG Once Weekly) (Oral Tablet
Therapy Pack)Maximum of 12 tablets per 28 days
Xpovio (80MG Once Weekly) (Oral Tablet
Therapy Pack)Maximum of 16 tablets per 28 days
Xpovio (80MG Twice Weekly) (Oral Tablet
Therapy Pack)Maximum of 32 tablets per 28 days
Xtampza ER (13.5MG Oral Capsule ER 12
Hour Abuse-Deterrent, 18MG Oral Capsule
ER 12 Hour Abuse-Deterrent, 9MG Oral
Capsule ER 12 Hour Abuse-Deterrent)
Maximum of 3 capsules per day
115
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Xtampza ER (27MG Oral Capsule ER 12 Hour
Abuse-Deterrent, 36MG Oral Capsule ER 12
Hour Abuse-Deterrent)
Maximum of 6 capsules per day
Xtandi (Oral Capsule) Maximum of 4 capsules per day
Xyrem (Oral Solution) Maximum of 18 ml per day
Yuvafem (Vaginal Tablet) Maximum of 1 tablet per day
Zafirlukast (Oral Tablet) Maximum of 2 tablets per day
Zaleplon (10MG Oral Capsule) Maximum of 2 capsules per day
Zaleplon (5MG Oral Capsule) Maximum of 1 capsule per day
Zejula (Oral Capsule) Maximum of 3 capsules per day
Zelboraf (Oral Tablet) Maximum of 8 tablets per day
Zidovudine (Oral Capsule) Maximum of 6 capsules per day
Zidovudine (Oral Syrup) Maximum of 64 ml per day
Zidovudine (Oral Tablet) Maximum of 2 tablets per day
Ziprasidone HCl (Oral Capsule) Maximum of 2 capsules per day
Zolpidem Tartrate (Oral Tablet Immediate Release)
Maximum of 1 tablet per day
Zydelig (Oral Tablet) Maximum of 2 tablets per day
Zykadia (Oral Tablet) Maximum of 3 tablets per day
116
A1
B1
C1
C1
C1
C1
C1
C1
C1
C1
C1
C1
C1
C1
C3. Over-the-counter (OTC) Drug List
UnitedHealthcare Dual Complete ONE covers some prescription OTC drugs that aren � t normally covered under our Medicare Part D benefit.
You need a prescription from your doctor to have drugs on this list covered. If your prescription is for a brand name drug, you will get the generic version of the drug if it� s available, unless otherwise prescribed or directed by your doctor.
Some of these drugs may need prior authorization. Please check with your doctor and the plan. If the drug requires a prior authorization, you or your doctor will need to get approval from the plan before the drug may be covered.
The list below shows the prescription OTC drugs covered by the plan.
tRACK
OTC Drug Name OTC Drug Name C1
Analgesics ED-Apap (Liquid) C1
Analgesics Extra Strength Pain Relief (Tablet) C1
8 Hour Arthritis Pain Reliever (Tablet Feverall Adults (Suppository) C1 Extended-Release)
Feverall Childrens (Suppository) C1 8 Hour Pain Relief (Tablet Extended-
Feverall Infants (Suppository) Release) C1
Feverall Junior Strength (Suppository) 8Hr Muscle Aches & Pain (Tablet C1
GNP 8 Hour Pain Reliever (Tablet Extended-Release) Extended-Release) Acephen (120mg Suppository, 325mg
C1
GNP Acetaminophen (Tablet) Suppository, 650mg Suppository) C1
Acetaminophen (325mg Tablet, 500mg GNP Acetaminophen Extra Strength Tablet, 160mg/5ml Liquid, 160mg/5ml (Capsule)
C1
Solution, 120mg Suppository, 650mg GNP Arthritis Pain Relief (Tablet Extended-Suppository) Release)
C1
Acetaminophen ER (Tablet Extended- GNP Childrens Pain Relief (Suspension) C1 Release)
GNP Infants Pain Relief (Suspension) C1 Acetaminophen Extra Strength (Tablet)
GNP Infants Pain/Fever (Suspension) C1 Arthritis Pain Relief (Tablet Extended-
GNP Pain & Fever Childrens (Suspension) C1 Release)
GNP Pain Relief (325mg Tablet, 160mg Chewable Acetaminophen Childrens Tablet Chewable)
C1 (Tablet Chewable) GNP Pain Relief Extra Strength (167mg/ Childrens Acetaminophen (Suspension) 5ml Liquid, 500mg Tablet)
C1 Childrens Chewable Acetaminophen Goodsense Arthritis Pain (Tablet Extended-
(Tablet Chewable) Release)
Childrens Silapap (Liquid)
Bold type = Brand name drug Plain type = Generic drug
117
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Goodsense Pain & Fever Childrens (Suspension)
C1
Goodsense Pain & Fever Infants (Suspension)
C1
Goodsense Pain Relief (Tablet Extended-Release)
C1
Goodsense Pain Relief Extra Strength (Tablet)
C1
HM Acetaminophen Childrens (Tablet Chewable)
C1
HM Arthritis Pain Relief (Tablet Extended-Release)
C1
HM Pain & Fever Childrens (Suspension)C1
HM Pain & Fever Infants (Suspension)C1
HM Pain Relief (Tablet Extended-Release)C1
HM Pain Relief Extra Strength (Tablet)C1
HM Pain Reliever (Tablet)C1
HM Rapid Melts Junior (Tablet Disintegrating)
C1
Infants Pain Relief (Suspension)C1
Mapap (500mg Capsule, 325mg Tablet, 500mg Tablet, 80mg Tablet Chewable, 160mg/5ml Liquid)
C1
Mapap Acetaminophen Extra Strength (Liquid)
C1
Mapap Arthritis Pain (Tablet Extended-Release)
C1
Mapap Childrens (80mg Tablet Disintegrating, 160mg Tablet Chewable, 160mg/5ml Suspension)
C1
Mapap Extra Strength (Tablet)C1
Non-Aspirin Childrens (Suspension)C1
Pain & Fever (Tablet)C1
Pain & Fever Childrens (80mg Tablet Chewable, 160mg/5ml Solution, 160mg/5ml Suspension)
C1
Pain & Fever Childrens Dye-Free (Suspension)
OTC Drug NameC1
Pain & Fever Extra Strength (Tablet)C1
Pain & Fever Infants (Suspension)C1
Pain Relief (325mg Tablet, 500mg Tablet)C1
Pain Relief Childrens (Suspension)C1
Pain Relief Extra Strength (Tablet)C1
Pharbetol (Tablet)C1
Pharbetol Extra Strength (Tablet)C1
QC Acetaminophen 8 Hours (Tablet Extended-Release)
C1
QC Arthritis Pain Relief (Tablet Extended-Release)
C1
QC Non-Aspirin Childrens (Suspension)C1
QC Non-Aspirin Extra Strength (Tablet)C1
QC Non-Aspirin Jr Strength (Tablet Disintegrating)
C1
QC Pain Relief (Tablet)C1
QC Pain Relief Childrens (Suspension)C1
QC Pain Relief Extra Strength (Tablet)C1
QC Pain Relief Infants (Suspension)C1
SM 8 Hour Pain Relief (Tablet Extended-Release)
C1
SM Arthritis Pain Relief (Tablet Extended-Release)
C1
SM Arthritis Pain Reliever (Tablet Extended-Release)
C1
SM Pain & Fever Childrens (Suspension)C1
SM Pain & Fever Infants (Suspension)C1
SM Pain Reliever (Tablet)C1
SM Pain Reliever Extra Strength (500mg Capsule, 500mg Tablet, 650mg Tablet Extended-Release)
C1
SM Rapid Melts Junior (Tablet Disintegrating)
C1
Tactinal (Tablet)C1
Tactinal Extra Strength (Tablet)C1
Tri-Buffered Aspirin (Tablet)
118
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameB1
Analgesics, CombinationC1
Acetaminophen/Aspirin/Caffeine (Tablet)C1
Back & Body Extra Strength (Tablet)C1
Dologesic (Tablet)C1
Excedrin Extra Strength (Tablet)C1
Excedrin Migraine (Tablet)C1
Excedrin Tension Headache (Tablet)C1
GNP Headache Relief (Tablet)C1
GNP Headache Relief Extra Strength (Tablet)
C1
GNP Migraine Relief (Tablet)C1
Goodsense Migraine Formula (Tablet)C1
Headache Formula Added Strength (Tablet)
C1
Headache Relief (Tablet)C1
Headache Relief/Extra Strength (Tablet)C1
HM Migraine Relief (Tablet)C1
Menstrual Pain Relief Multi-Symptom Maximum Strength (Tablet)
C1
Migraine Formula (Tablet)C1
Migraine Relief (Tablet)C1
Pain Reliever Plus (Tablet)C1
QC Headache Relief (Tablet)C1
SM Migraine Relief (Tablet)C1
Tension Headache (Tablet)B1
Analgesics, TopicalC1
Arthritis Pain Relieving (Cream)C1
Blue Gel (Gel)C1
Capsaicin (Cream)C1
Cool Therapy Pain Gel (Gel)C1
GNP Capsaicin (Liquid)C1
GNP Cold & Hot Therapy Balm Extra Strength (Ointment)
C1
GNP Muscle Rub (Cream)C1
GNP Therapeutic Blue Gel (Gel)
OTC Drug NameC1
HM Muscle Rub (Cream)C1
HM Pain Relief Therapy Patch (Patch)C1
HM Salonpas Pain Relief Patch (Patch)C1
Mineral Ice (Gel)C1
Muscle Rub (Cream)C1
Muscle Rub Ultra Strength (Cream)C1
Pain Relieving Cream (Cream)C1
Pain Relieving Patch Ultra Strength (Patch)C1
SM Muscle Rub (Cream)C1
Thera-Gesic (Cream)C1
Thera-Gesic Plus (Cream)C1
Ziks Arthritis Pain Relief (Cream)B1
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
C1
Adult Aspirin Regimen (Tablet Delayed-Release)
C1
All Day Pain Relief (Tablet)C1
All Day Relief (Tablet)C1
Aspirin (325mg Tablet, 300mg Suppository, 600mg Suppository, 81mg Tablet Chewable, 81mg Tablet Delayed-Release, 325mg Tablet Delayed-Release)
C1
Aspirin 81 (Tablet Delayed-Release)C1
Aspirin Adult Low Dose (81mg Tablet Chewable, 81mg Tablet Delayed-Release)
C1
Aspirin Adult Low Strength (Tablet Chewable)
C1
Aspirin EC (81mg Tablet Delayed-Release, 325mg Tablet Delayed-Release)
C1
Aspirin Low Dose (81mg Tablet Chewable, 81mg Tablet Delayed-Release)
C1
Aspirin Low Strength (Tablet Chewable)C1
Aspir-Low (Tablet Delayed-Release)C1
Childrens Aspirin Low Strength (Tablet Chewable)
C1
Childrens Ibuprofen (Suspension)
119
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Ecpirin (Tablet Delayed-Release)C1
EQ Aspirin EC (Tablet Delayed-Release)C1
GNP Adult Aspirin Low Strength (Tablet Chewable)
C1
GNP All Day Pain Relief (Tablet)C1
GNP Aspirin (81mg Tablet Delayed-Release, 325mg Tablet Delayed-Release, 325mg Tablet)
C1
GNP Aspirin Low Dose (Tablet Delayed-Release)
C1
GNP Childrens Ibuprofen (Suspension)C1
GNP Ibuprofen (200mg Capsule, 200mg Tablet)
C1
GNP Ibuprofen Infants (Suspension)C1
GNP Ibuprofen Junior Strength (Tablet Chewable)
C1
GNP Naproxen Sodium (220mg Capsule, 220mg Tablet)
C1
Goodsense Aspirin (81mg Tablet Chewable, 325mg Tablet)
C1
Goodsense Aspirin Adult Low Strength (Tablet Chewable)
C1
Goodsense Ibuprofen (Tablet)C1
Goodsense Ibuprofen Childrens (Suspension)
C1
Goodsense Ibuprofen Infants (Suspension)C1
Goodsense Ibuprofen Junior Strength (Tablet Chewable)
C1
Goodsense Naproxen Sodium (Tablet)C1
HM Aspirin (81mg Tablet Chewable, 325mg Tablet)
C1
HM Aspirin EC (Tablet Delayed-Release)C1
HM Aspirin EC Low Dose (Tablet Delayed-Release)
C1
HM Ibuprofen (100mg Tablet Chewable, 200mg Tablet, 200mg Capsule)
C1
HM Ibuprofen Childrens (Suspension)C1
HM Ibuprofen IB (Tablet)
OTC Drug NameC1
HM Ibuprofen Infants (Suspension)C1
HM Naproxen Sodium (220mg Capsule, 220mg Tablet)
C1
Ibu-200 (Tablet)C1
Ibuprofen (200mg Capsule, 200mg Tablet)C1
Ibuprofen Childrens (Suspension)C1
Ibuprofen Infants (Suspension)C1
Ibuprofen Junior Strength (Tablet Chewable)
C1
Infants Ibuprofen (Suspension)C1
Naproxen Sodium (220mg Capsule, 220mg Tablet)
C1
Provil (Tablet)C1
QC Aspirin (Tablet)C1
QC Aspirin Low Dose (Tablet Delayed-Release)
C1
QC Chewable Aspirin Low Dose (Tablet Chewable)
C1
QC Childrens Ibuprofen (Suspension)C1
QC Enteric Aspirin (Tablet Delayed-Release)
C1
QC Ibuprofen (200mg Capsule, 200mg Tablet)
C1
QC Ibuprofen IB (Tablet)C1
QC Ibuprofen Infants (Suspension)C1
QC Naproxen Sodium (Tablet)C1
SB Aspirin (Tablet)C1
SB Naproxen Sodium (Tablet)C1
SM Aspirin (Tablet)C1
SM Aspirin Adult Low Strength (81mg Tablet Chewable, 81mg Tablet Delayed-Release)
C1
SM Aspirin Enteric Coated (Tablet Delayed-Release)
C1
SM Aspirin Low Dose (Tablet Chewable)C1
SM Childrens Aspirin (Tablet Chewable)
120
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
SM Childrens Ibuprofen (Suspension)C1
SM Ibuprofen (200mg Capsule, 200mg Tablet)
C1
SM Ibuprofen IB (100mg Tablet Chewable, 200mg Tablet)
C1
SM Infants Ibuprofen (Suspension)C1
SM Naproxen Sodium (Tablet)C1
St Joseph Low Dose Aspirin (Tablet Chewable)
A1
Anti-Addiction / Substance Abuse Treatment Agents
B1
Smoking Cessation AgentsC1
GNP Nicotine Mini Lozenge (Lozenge)C1
GNP Nicotine Polacrilex (2mg Gum, 4mg Gum)
C1
GNP Nicotine Polacrilex (2mg Lozenge, 4mg Lozenge)
C1
GNP Nicotine Polacrilex Mini (Lozenge)C1
GNP Nicotine Transdermal System (Patch)C1
GNP Nicotine Transdermal System Step 2 (Patch)
C1
Goodsense Nicotine (2mg Lozenge, 4mg Lozenge)
C1
Goodsense Nicotine Gum (Gum)C1
Goodsense Nicotine Polacrilex (Lozenge)C1
HM Nicotine Polacrilex (2mg Gum, 4mg Gum)
C1
HM Nicotine Polacrilex (2mg Lozenge, 4mg Lozenge)
C1
HM Nicotine Transdermal System (14mg/24hr Patch, 21mg/24hr Patch)
C1
HM Nicotine Transdermal System Step 1 (Patch)
C1
HM Nicotine Transdermal System Step 2 (Patch)
C1
HM Nicotine Transdermal System Step 3 (Patch)
OTC Drug NameC1
Nicoderm CQ (7mg/24hr Patch, 14mg/
24hr Patch, 21mg/24hr Patch)C1
Nicorelief (2mg Gum, 4mg Gum)C1
Nicorette (2mg Gum, 4mg Gum)C1
Nicorette (2mg Lozenge, 4mg Lozenge)C1
Nicorette Mini (2mg Lozenge, 4mg
Lozenge)C1
Nicorette Starter Kit (2mg Gum, 4mg
Gum)C1
Nicotine Polacrilex (2mg Gum, 4mg Gum)C1
Nicotine Polacrilex (2mg Lozenge, 4mg Lozenge)
C1
Nicotine Polacrilex (Lozenge)C1
Nicotine Transdermal System (7mg/24hr
Patch, 14mg/24hr Patch, 21mg/24hr
Patch, 21-14-7mg/24hr Kit)C1
Nicotine Transdermal System Step 1 (Patch)
C1
Nicotine Transdermal System Step 2 (Patch)
C1
Nicotine Transdermal System Step 3 (Patch)
C1
SM Nicotine (Gum)C1
SM Nicotine (Lozenge)C1
SM Nicotine Polacrilex (2mg Gum, 4mg Gum)
C1
SM Nicotine Polacrilex (Lozenge)C1
SM Nicotine Transdermal System (7mg/24hr Patch, 14mg/24hr Patch, 21mg/24hr Patch)
C1
SM Nicotine Transdermal System/Step 1/Clear (Patch)
C1
SM Nicotine Transdermal System/Step 2/Clear (Patch)
C1
SM Nicotine Transdermal System/Step 3/Clear (Patch)
A1
Antimicrobial AgentsB1
Antimicrobials, Topical
121
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Advanced Hand Sanitizer (Gel)C1
Advanced Hand Sanitizer/Aloe (Liquid)C1
Alevazol (Ointment)C1
Aloe Vesta Antifungal (Ointment)C1
Aloe Vesta Clear Antifungal (Ointment)C1
Antifungal (1% Cream, 2% Cream)C1
Antifungal Powder (Powder)C1
Anti-Fungal Powder (Powder)C1
Antiseptic Skin Cleanser (Solution)C1
Athletes Foot AF Cream (Cream)C1
Athletes Foot Powder Spray (Aerosol Powder)
C1
Athletes Foot Spray (Aerosol)C1
Bacitracin (Ointment)C1
Bacitracin Zinc (Ointment)C1
Betadine (5% Solution, 10% Solution)C1
Betadine Skin Cleanser (Solution)C1
Betadine Surgical Scrub (Solution)C1
Betadine Swabsticks (Swab)C1
Betasept Surgical Scrub (Liquid)C1
Butenafine Hydrochloride (Cream)C1
Carrington Antifungal (Cream)C1
Castellani Paint Modified/Color C1
Castellani Paint Modified/Colorless C1
Clotrimazole (Solution)C1
Clotrimazole Antifungal (Cream)C1
Clotrimazole Anti-Fungal (Cream)C1
Desenex Shake Powder (Powder)C1
Desenex Spray Liquid (Aerosol)C1
Desenex Spray Powder (Aerosol Powder)C1
Ethyl Rubbing Alcohol C1
Fungoid Tincture (2% Solution, 2% Kit)C1
Germbloc Health (Foam)C1
Germbloc Health Hand Sanitizer (Lotion)
OTC Drug NameC1
GNP Antiseptic Skin Cleanser (Solution)C1
GNP Athletes Foot (Cream)C1
GNP Athletes Foot Relief (Aerosol Powder)C1
GNP Bacitracin Zinc (Ointment)C1
GNP Hydrogen Peroxide (Solution)C1
GNP Iodides Tincture (Tincture)C1
GNP Iodine Tincture (Tincture)C1
GNP Isopropyl Alcohol C1
GNP Miconazorb AF (Powder)C1
GNP Povidone-Iodine (Solution)C1
GNP Rubbing Alcohol C1
GNP Terbinafine Hydrochloride (Cream)C1
GNP Tolnaftate (Cream)C1
GNP Triple Antibiotic (Ointment)C1
GNP Triple Antibiotic Plus (Ointment)C1
HM Antiseptic Skin Cleanser (Solution)C1
HM Bacitracin (Ointment)C1
HM Double Antibiotic (Ointment)C1
HM Hydrogen Peroxide (Solution)C1
HM Iodides Tincture (Tincture)C1
HM Iodine Tincture (Tincture)C1
HM Isopropyl Rubbing Alcohol (91% Alcohol)
C1
HM Isopropyl Rubbing Alcohol (70%
Alcohol)C1
HM Povidone-Iodine (Solution)C1
HM Triple Antibiotic (Ointment)C1
HM Triple Antibiotic Plus Maximum Strength (Ointment)
C1
Hydrogen Peroxide (Solution)C1
Iodides Tincture (Tincture)C1
Isagel (Gel)C1
Isopropyl Alcohol (70% Alcohol)C1
Jock Itch Spray (Aerosol Powder)
122
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Lamisil Advanced (Gel)C1
Lamisil AF Defense (Aerosol Powder)C1
Lamisil AT (Cream)C1
Lamisil AT Jock Itch (Cream)C1
Lamisil AT Spray (Solution)C1
Pediaderm AF Complete Kit (Kit)C1
Povidone-Iodine (10% Solution, 10% Ointment)
C1
QC Hydrogen Peroxide (Solution)C1
QC Iodides Tincture (Tincture)C1
QC Iodine Tincture (Tincture)C1
QC Isopropyl Rubbing Alcohol C1
QC Isopropyl Rubbing Alcohol Wintergreen
C1
QC Povidone Iodine (Solution)C1
QC Tolnaftate (Cream)C1
Remedy Antifungal (Cream)C1
Remedy Antimicrobial Cleanser (Liquid)C1
SM Advanced Hand Sanitizer (Liquid)C1
SM Advanced Hand Sanitizer/Aloe (Liquid)C1
SM Alcohol C1
SM Antibiotic (Ointment)C1
SM Antibiotic Plus Pain Relief Maximum Strength (Cream)
C1
SM Antifungal Clotrimazole (Cream)C1
SM Antifungal Miconazole (Cream)C1
SM Antifungal Tolnaftate (Cream)C1
SM Athletes Foot (Cream)C1
SM Double Antibiotic (Ointment)C1
SM Hydrogen Peroxide (Solution)C1
SM Iodides Tincture (Tincture)C1
SM Isopropyl Alcohol (70% Alcohol)C1
SM Isopropyl Alcohol (91% Alcohol, 99% Alcohol)
C1
SM Isopropyl Alcohol Rubbing
OTC Drug NameC1
SM Povidone-Iodine (Solution)C1
SM Triple Antibiotic (Ointment)C1
SM Triple Antibiotic Original Strength (Ointment)
C1
SM Triple Antibiotic Plus Maximum Strength (Ointment)
C1
Soothe & Cool Inzo Antifungal Cream (Cream)
C1
Terbinafine HCL (Cream)C1
Tolnaftate (Powder)C1
Tolnaftate (Cream)C1
Triple Antibiotic (Ointment)C1
Triple Antibiotic Plus (Ointment)C1
Zeasorb-AF (Powder)B1
Antimicrobials, VaginalC1
3 Day Vaginal (Cream)C1
Clotrimazole (Cream)C1
Clotrimazole 3 (Cream)C1
GNP Clotrimazole 3 (Cream)C1
GNP Miconazole 3 (Kit)C1
GNP Miconazole 3 Combination Pack (Kit)C1
GNP Miconazole 7 (Cream)C1
GNP Tioconazole 1 (Ointment)C1
Goodsense Miconazole 1 (Kit)C1
Medicated Feminine Douche (Solution)C1
Miconazole (Cream)C1
Miconazole 1 (Kit)C1
Miconazole 3 (Cream)C1
Miconazole 3 Combination Pack (Kit)C1
Miconazole 3 Combo Pack (Kit)C1
Miconazole 7 (Cream)C1
Miconazole 7 (Suppository)C1
Miconazole Nitrate (Cream)C1
Miconazole Nitrate (Suppository)C1
QC 3 Day Vaginal Cream (Cream)
123
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
QC Miconazole 7 (Cream)C1
SM 3-Day Vaginal (Cream)C1
SM Clotrimazole Vaginal (Cream)C1
SM Miconazole 3 (Kit)C1
SM Miconazole 7 (Cream)C1
SM Miconazole 7 (Suppository)C1
SM Tioconazole-1 (Ointment)C1
Tioconazole 1 (Ointment)C1
Tioconazole-1 (Ointment)C1
Vagistat-3 (Kit)A1
AntiparasiticsB1
Pediculicides / ScabicidesC1
GNP Lice Solution Kit (Gel)C1
GNP Lice Treatment (Rinse)C1
GNP Lice Treatment (Shampoo)C1
HM Lice Killing Maximum Strength (Shampoo)
C1
HM Lice Treatment C1
Lice Killing Maximum Strength (Shampoo)C1
Lice Killing Shampoo (Shampoo)C1
Lice Treatment (Lotion)C1
Licemd Complete Kit (Gel)C1
SM Lice Killing Maximum Strength (Shampoo)
C1
SM Lice Solution Kit (Gel)C1
SM Lice Treatment (Lotion)C1
Vanalice (Gel)A1
Dermatological AgentsB1
Dermatologic Agents, TopicalC1
Abreva (Cream)C1
Acne Medication 10 (Gel)C1
Acne Medication 10 (Lotion)C1
Acne Medication 5 (Gel)C1
Acne Medication 5 (Lotion)C1
Aloe Vesta Clear Barrier Spray (Aerosol)
OTC Drug NameC1
Aloe Vesta Daily Moisturizer (Lotion)C1
Aloe Vesta Protective (Ointment)C1
Aloe Vesta Skin Conditioner (Lotion)C1
Aloe Vesta Skin Protectant (Aerosol)C1
Aluminum Acetate Astringent (Powder Packet)
C1
Ammonium Lactate (12% Cream, 12% Lotion)
C1
Anti-Dandruff Shampoo (Lotion)C1
Anti-Itch (Cream)C1
Anti-Itch Maximum Strength (Solution)C1
Anti-Itch Maximum Strength (Cream)C1
Baby Sunscreen SPF50 (Lotion)C1
Banophen (Cream)C1
Benzoin Compound Tincture (Tincture)C1
Benzoyl Peroxide (5.3% Foam, 9.8% Foam, 2.5% Gel, 5% Gel, 10% Gel))
C1
Benzoyl Peroxide Cleanser (Liquid)C1
Benzoyl Peroxide Wash (5% Liquid, 10% Liquid)
C1
BPO Foaming Cloths C1
Calamine (Lotion)C1
Calamine Medicated (Lotion)C1
Caldyphen (Lotion)C1
Caldyphen Clear (Lotion)C1
Callergy Clear (Lotion)C1
Campho-Phenique (Gel)C1
Carrington Moisture Barrier (Cream)C1
Carrington Moisture Barrier/Zinc
(Cream)C1
Clear Anti-Itch (Lotion)C1
Coats Aloe Creme (Cream)C1
Coats Aloe Gelly (Gel)C1
Coats Aloe Liniment (Lotion)C1
Coats Aloe Moisturizing Lotion (Lotion)
124
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Corn And Callus Remover (Liquid)C1
DHS Sal (Shampoo)C1
DHS Tar (Shampoo)C1
DHS Tar Gel (Shampoo)C1
DHS Zinc (Shampoo)C1
Diaper Rash (Ointment)C1
Differin (Gel)C1
Diphenhydramine HCL/Zinc Acetate (Cream)
C1
Dr Smiths Adult Barrier Spray (Aerosol)C1
Dr Smiths Diaper (Ointment)C1
Dr Smiths Diaper Rash Spray (Aerosol)C1
Dr Smiths Rash + Skin (Aerosol)C1
General Protection Sunscreen
Continuous Spray SPF30 (Aerosol)C1
General Protection Sunscreen
Continuous Spray SPF70 (Aerosol)C1
General Protection Sunscreen SPF30 (Lotion)
C1
General Protection Sunscreen SPF50 (Lotion)
C1
GNP Aloe Vera/Lidocaine (Gel)C1
GNP Anti-Itch (Cream)C1
GNP Anti-Itch (Lotion)C1
GNP Arthricream (Cream)C1
GNP Burn Relief Spray Aloe Extra (Aerosol)
C1
GNP Calamine (Lotion)C1
GNP Calamine Phenolated (Lotion)C1
GNP Caldyphen (Lotion)C1
GNP Caldyphen Clear (Lotion)C1
GNP Diaper Rash (Cream)C1
GNP Hydrocortisone (Cream)C1
GNP Hydrocortisone Maximum Strength (Ointment)
C1
GNP Hydrocortisone Plus (Cream)
OTC Drug NameC1
GNP Hydrocortisone/Aloe (Cream)C1
GNP Hydro-Lotion (Lotion)C1
GNP Hygienic Cleansing (Pad)C1
GNP Itch Relief Extra Strength (Liquid)C1
GNP Lidocaine Pain Relief (Patch)C1
GNP Medicated First Aid Spray (Aerosol)C1
GNP Medicated Wipes (Pad)C1
GNP Scalp Relief (Liquid)C1
GNP Vitamin A & D (Ointment)C1
GNP Wart Remover (Liquid)C1
GNP Zinc Oxide (Ointment)C1
Hair Regrowth Treatment For Men Extra Strength (Solution)
C1
HM Arthritis Creme (Cream)C1
HM Calamine (Lotion)C1
HM Glycerin (Liquid)C1
HM Hydrocortisone Plus (Cream)C1
HM Hydrocortisone/Aloe Maximum Strength (Cream)
C1
HM Medicated Cooling Pads (Pad)C1
HM Witch Hazel (Liquid)C1
Hydrocortisone (0.5% Cream, 1% Cream, 0.5% Ointment, 1% Ointment)
C1
Hydrocortisone In Absorbase (Ointment)C1
Hydrocortisone Maximum Strength (Cream)
C1
Hydrocortisone Maximum Strength Plus 12 Moisturizers (Cream)
C1
Hydrocortisone/Aloe (0.5% Cream, 1% Cream)
C1
Hydroskin (Lotion)C1
Itch Relief Extra Strength (Cream)C1
Itch-X (Solution)C1
Itch-X (Gel)C1
Kids Sunscreen Clear Continuous Spray
SPR50 (Aerosol)
125
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Lidocaine (Kit)C1
Lidocaine/Transparent Dressing (Kit)C1
Medi Pads (Pad)C1
Medicated Callus Removers (Pad)C1
Medicated Corn Removers (Pad)C1
Minoxidil For Men (Solution)C1
Mobisyl (Cream)C1
Moisturel Therapeutic (Lotion)C1
Panoxyl (3% Gel, 10% Bar)C1
Panoxyl Wash (Liquid)C1
Panoxyl-4 Creamy Wash (Liquid)C1
Pediaderm HC (Kit)C1
Pediaderm TA (Kit)C1
Pedi-Boro Soak Paks (Powder Packet)C1
Petrolatum (Ointment)C1
Proshield Plus Skin Protectant (Cream)C1
QC Anti-Itch Extra Strength (Cream)C1
QC Antiseptic Pain Relief (Liquid)C1
QC Calamine (Lotion)C1
QC Witch Hazel (Liquid)C1
Remedy Cleansing Body Lotion (Lotion)C1
Remedy Dimethicone Moisture Barrier
(Cream)C1
Remedy Nutrashield (Cream)C1
Remedy Skin Repair (Cream)C1
Salactic Film (Solution)C1
Sal-Plant (Gel)C1
Sarna (Lotion)C1
Sarna Sensitive Anti-Itch (Lotion)C1
Scalpicin 2 In 1 (Liquid)C1
Scalpicin Maximum Strength (Solution)C1
Sebex (Shampoo)C1
Sensi-Care Body Cream (Cream)
OTC Drug NameC1
Sensi-Care Clear Zinc Diaper Rash Skin
Protectant (Ointment)C1
Sensi-Care Moisturizing (Cream)C1
Sensi-Care Protective Barrier (Ointment)C1
SM Alcohol Prep Pads/Benzocaine (Pad)C1
SM Anti-Dandruff Coal Tartherapeutic (Shampoo)
C1
SM Anti-Itch Extra Strength (Cream)C1
SM Arthricream Rub (Cream)C1
SM Benzoin Tincture (Tincture)C1
SM Calamine (Lotion)C1
SM Calamine Phenolated (Lotion)C1
SM Caldyphen (Lotion)C1
SM Caldyphen Clear (Lotion)C1
SM Camphor Spirit C1
SM Glycerin (Liquid)C1
SM Hydrocortisone (Cream)C1
SM Hydrocortisone Maximum Strength (Ointment)
C1
SM Hydrocortisone Plus (Cream)C1
Solbar Avo (Lotion)C1
Solbar Fifty (Cream)C1
Solbar PF Liquid/Gel SPF30 (Gel)C1
Solbar SPF40 (Cream)C1
Solbar Zinc SPF38 (Cream)C1
Soothe & Cool Body Powder (Powder)C1
Soothe & Cool Free Medseptic
(Ointment)C1
Soothe & Cool Free Moisture Barrier
(Ointment)C1
Soothe & Cool Free Skin Paste
(Ointment)C1
Soothe & Cool Inzo Barrier (Cream)C1
Soothe & Cool Protect Moisture Barrier
(Ointment)C1
Sport Sunscreen SPF50 (Lotion)
126
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Therapeutic Shampoo (Shampoo)C1
Tippy Toes Diaper Rash (Ointment)C1
Trolamine Salicylate (Cream)C1
Vitamin A & D (Ointment)C1
Wart Remover Maximum Strength (Liquid)C1
Wart Remover Maximum Strenth One-Step (Strip)
C1
White Petrolatum (Ointment)C1
White Petroleum Jelly (Gel)C1
Z-Bum (Cream)C1
Zinc Oxide (Ointment)A1
Gastrointestinal AgentsB1
AntacidsC1
Acid Gone (Suspension)C1
Acid Gone (Tablet Chewable)C1
Acid Reducer (Capsule Delayed-Release)C1
Acid Reducer (Tablet)C1
Acid Reducer Complete (Tablet Chewable)C1
Acid Reducer Maximum Strength (Tablet)C1
Antacid (Suspension)C1
Antacid (Tablet Chewable)C1
Antacid Anti-Gas Maximum Strength (Suspension)
C1
Antacid Calcium Extra Strength (Tablet Chewable)
C1
Antacid Calcium Regular Strength (Tablet Chewable)
C1
Antacid Extra Strength (Tablet Chewable)C1
Antacid Fast Acting (Suspension)C1
Antacid Fast Relief (Suspension)C1
Antacid Maximum Strength (Suspension)C1
Antacid Plus Anti-Gas Fast Acting (Suspension)
C1
Antacid Plus Anti-Gas Relief (Suspension)C1
Antacid Plus Anti-Gas Relief Maximum Strength (Suspension)
OTC Drug NameC1
Antacid Regular Strength (Suspension)C1
Calcium Antacid (Tablet Chewable)C1
Calcium Antacid Extra Strength (Tablet Chewable)
C1
Calcium Antacid Ultra (Tablet Chewable)C1
Calcium Antacid Ultra Maximum Strength (Tablet Chewable)
C1
Calcium Antacid Ultra Strength (Tablet Chewable)
C1
Cal-Gest Antacid (Tablet Chewable)C1
Chewable Antacid (Tablet Chewable)C1
Cimetidine (Tablet)C1
Dual Action Complete (Tablet Chewable)C1
Esomeprazole Magnesium (Capsule Delayed-Release)
C1
Famotidine (Tablet)C1
Fast Acting Antacid Plus Anti-Gas Maximum Strength (Suspension)
C1
GNP Acid Control 150 Maximum Strength (Tablet)
C1
GNP Acid Reducer (10mg Tablet, 75mg Tablet)
C1
GNP Acid Reducer Maximum Strength (Tablet)
C1
GNP Antacid & Anti-Gas Maximum Strength (Tablet Chewable)
C1
GNP Antacid & Anti-Gas/Regular Strength (Suspension)
C1
GNP Antacid (Tablet Chewable)C1
GNP Antacid And Anti-Gas/Maximum Strength (Suspension)
C1
GNP Antacid Anti-Gas (Suspension)C1
GNP Antacid Anti-Gas/Maximum Strength (Suspension)
C1
GNP Antacid Extra Strength (Tablet Chewable)
C1
GNP Antacid Maximum Strength (Suspension)
127
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
GNP Antacid/Regular Strength (Suspension)
C1
GNP Esomeprazole Magnesium (Capsule Delayed-Release)
C1
GNP Heartburn Relief (Tablet)C1
GNP Lansoprazole (Capsule Delayed-Release)
C1
GNP Omeprazole (Tablet Delayed-Release)C1
Goodsense Acid Reducer (75mg Tablet, 150mg Tablet)
C1
Goodsense Esomeprazole Magnesium (Capsule Delayed-Release)
C1
Goodsense Lansoprazole (Capsule Delayed-Release)
C1
Heartburn Relief (10mg Tablet, 75mg Tablet, 200mg Tablet)
C1
Heartburn Relief 150 Maximum Strength (Tablet)
C1
Heartburn Relief Maximum Strength (Tablet)
C1
Heartburn Treatment 24 Hour (Capsule Delayed-Release)
C1
HM Acid Reducer (Tablet)C1
HM Acid Reducer Maximum Strength (Tablet)
C1
HM Advanced Antacid Maximum Strength (Suspension)
C1
HM Antacid (Suspension)C1
HM Antacid Anti-Gas Extrastrength (Suspension)
C1
HM Antacid/Antigas (Suspension)C1
HM Calcium Antacid (Tablet Chewable)C1
HM Calcium Antacid Extra Strength (Tablet Chewable)
C1
HM Calcium Antacid Smoothdissolve (Tablet Chewable)
C1
HM Calcium Antacid Smoothdissolve Extra Strength (Tablet Chewable)
OTC Drug NameC1
HM Calcium Antacid Ultra Strength (Tablet Chewable)
C1
HM Esomeprazole Magnesium Delayed Release (Capsule Delayed-Release)
C1
HM Famotidine (10mg Tablet, 20mg Tablet)
C1
HM Lansoprazole (Capsule Delayed-Release)
C1
HM Omeprazole (Tablet Delayed-Release)C1
Lansoprazole (Capsule Delayed-Release)C1
Omeprazole (20mg Capsule Delayed-Release, 20mg Tablet Delayed-Release)
C1
Omeprazole Magnesium (Capsule Delayed-Release)
C1
Prevacid 24Hr (Capsule Delayed-
Release)C1
QC Acid Controller (Tablet)C1
QC Acid Controller Maximum Strength (Tablet)
C1
QC Antacid (Suspension)C1
QC Antacid (Tablet Chewable)C1
QC Antacid/Anti-Gas (Suspension)C1
QC Heartburn 150 Maximum Strength (Tablet)
C1
QC Omeprazole Magnesium (Capsule Delayed-Release)
C1
QC Ranitidine HCL (Tablet)C1
Ranitidine 150 Maximum Strength (Tablet)C1
Ranitidine 75 (Tablet)C1
Ranitidine HCL (Tablet)C1
Ranitidine Maximum Strength (Tablet)C1
SM Acid Reducer (10mg Tablet, 75mg Tablet, 200mg Tablet)
C1
SM Acid Reducer Maximum Strength (Tablet)
C1
SM Antacid Advanced (Suspension)
128
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
SM Antacid Advanced Maxi Mum Strength (Suspension)
C1
SM Antacid/Antigas (Suspension)C1
SM Calcium Antacid (Tablet Chewable)C1
SM Calcium Antacid Extra Strength (Tablet Chewable)
C1
SM Calcium Antacid Ultra Strength (Tablet Chewable)
C1
SM Esomeprazole Magnesium (Capsule Delayed-Release)
C1
SM Lansoprazole (Capsule Delayed-Release)
C1
SM Omeprazole (Tablet Delayed-Release)C1
Tums (Tablet Chewable)C1
Tums Chewy Bites (Tablet Chewable)C1
Tums Chewy Delights (Tablet Chewable)C1
Tums E-X 750 (Tablet Chewable)C1
Tums Extra Strength 750 (Tablet
Chewable)C1
Tums Freshers (Tablet Chewable)C1
Tums Gas Relief Chewy Bites (Tablet Chewable)
C1
Tums Kids (Tablet Chewable)C1
Tums Smoothies (Tablet Chewable)C1
Tums Ultra 1000 (Tablet Chewable)B1
Hemmoroidal AgentsC1
Anu-Med (Suppository)C1
Dibucaine (Ointment)C1
GNP Hemorrhoidal (Ointment)C1
GNP Hemorrhoidal Cooling (Gel)C1
Goodsense Hemorrhoidal Ointment (Ointment)
C1
Goodsense Hemorrhoidal (Suppository)C1
Hemorrhoidal (Cream)C1
Hemorrhoidal (Ointment)C1
Hemorrhoidal (Suppository)
OTC Drug NameC1
Hemorrhoidal Maximum Strength/Aloe (Cream)
C1
Hemorrhoidal Suppositories (Suppository)C1
HM Hemorrhoidal (Ointment)C1
Lidocaine 5% (Cream)C1
Major-Prep Hemorrhoidal (Ointment)C1
Proctofoam (Foam)C1
QC Hemorrhoidal (Ointment)C1
QC Hemorrhoidal (Suppository)B1
LaxativesC1
Adult Suppository (Suppository)C1
Bisac-Evac (Suppository)C1
Bisacodyl (Suppository)C1
Bisacodyl EC (Tablet Delayed-Release)C1
Biscolax (Suppository)C1
Citrucel (Tablet)C1
Citrucel Fiber Laxative (Powder)C1
Clearlax (Packet)C1
Clearlax (Powder)C1
Colace (Capsule)C1
Colace 2-In-1 (Tablet)C1
Colace Clear (Capsule)C1
Docu (Liquid)C1
Docusate Sodium & Senna Stimulant Laxative/Stool Softener (Tablet)
C1
Docusate Sodium (100mg Capsule)C1
Docusate Sodium (150mg/15ml Liquid, 100mg Tablet)
C1
Docusil (Capsule)C1
Docusol Kids (Enema)C1
Docusol Mini (Enema)C1
Docusol Plus Mini-Enema (Enema)C1
Dok (100mg Capsule)C1
Dok (100mg Tablet)C1
Dok (250mg Capsule)
129
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Dok Plus (Tablet)C1
Ducodyl (Tablet Delayed-Release)C1
Enema (Enema)C1
Enema Mineral Oil Ready-To-Use (Enema)C1
Enema Ready-To-Use (Enema)C1
Enemeez Mini (Enema)C1
Enemeez Plus (Enema)C1
Ex-Lax (15mg Tablet Chewable, 15mg
Tablet)C1
Ex-Lax Maximum Strength (Tablet)C1
Fiber Laxative (0.52gm Capsule, 625mg Tablet)
C1
Fiber Tabs (Tablet)C1
Fiber-Lax (Tablet)C1
Fleet Bisacodyl (Enema)C1
Fleet Enema (Enema)C1
Fleet Liquid Glycerin Suppositories
(Enema)C1
Fleet Oil (Enema)C1
Fleet Pediatric (Enema)C1
Gavilax (Powder)C1
Glycerin Adult (2gm Suppository, 2.1gm Suppository)
C1
Glycerin Pediatric (Suppository)C1
Glycolax (Powder)C1
GNP Bisa-Lax (Tablet Delayed-Release)C1
GNP Clearlax (Packet)C1
GNP Clearlax (Powder)C1
GNP Docusate Calcium (Capsule)C1
GNP Enema (Enema)C1
GNP Enema Mineral Oil Laxative (Enema)C1
GNP Fiber Therapy (Tablet)C1
GNP Fiber-Caps (Tablet)C1
GNP Gentle Laxative (Suppository)C1
GNP Laxative (Tablet Delayed-Release)
OTC Drug NameC1
GNP Laxative Pills (Tablet)C1
GNP Milk Of Magnesia (Suspension)C1
GNP Mineral Oil Heavy (Oil)C1
GNP Natural Fiber (Powder)C1
GNP Senna Lax (Tablet)C1
GNP Senna Plus (Tablet)C1
GNP Senna-Lax (Tablet)C1
GNP Stool Softener (100mg Capsule, 250mg Capsule, 150mg/15ml Liquid, 60mg/15ml Syrup)
C1
GNP Stool Softener Extra Strength (Capsule)
C1
GNP Stool Softener/Stimulant Laxative (Tablet)
C1
GNP Womens Gentle Laxative (Tablet Delayed-Release)
C1
GNP Womens Laxative (Tablet Delayed-Release)
C1
Goodsense Clearlax (Powder)C1
Healthylax (Packet)C1
HM Castor Oil (Oil)C1
HM Clearlax (Powder)C1
HM Enema Saline Laxative (Enema)C1
HM Enema (Enema)C1
HM Enema Mineral Oil (Enema)C1
HM Enema Ready-To-Use (Enema)C1
HM Fiber (0.52gm Capsule, 28.3% Powder, 30.9% Powder, 48.57% Powder, 58.6% Powder, 500mg Tablet)
C1
HM Laxative (Tablet Delayed-Release)C1
HM Stool Softener (100mg Capsule, 100mg Tablet)
C1
HM Stool Softener Maximum Strength (Capsule)
C1
HM Stool Softener/Stimulant Laxative (Tablet)
C1
Konsyl (Capsule)
130
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Konsyl (Powder Packet)C1
Konsyl (Powder)C1
Konsyl Daily Fiber (Powder Packet)C1
Konsyl Daily Fiber (Powder)C1
Konsyl Fiber (Tablet)C1
Konsyl-D (Powder)C1
Laxative (25mg Tablet)C1
Laxative (5mg Tablet Delayed-Release, 10mg Suppository)
C1
Laxative Feminine (Tablet Delayed-Release)
C1
Mineral Oil (Oil)C1
Natural Fiber Laxative (58.6% Powder, 48.57% Powder)
C1
Natural Fiber (Powder)C1
Natural Fiber Therapy (Powder)C1
Pedia-Lax (Liquid)C1
Pedia-Lax (Suppository)C1
Pedia-Lax (Tablet Chewable)C1
Peg 3350 (Packet)C1
Polyethylene Glycol 3350 (Packet)C1
Polyethylene Glycol 3350 (Powder)C1
QC Castor Oil (Oil)C1
QC Enema (Enema)C1
QC Gentle Laxative (Suppository)C1
QC Mineral Oil Heavy (Oil)C1
QC Natural Vegetable Laxative (Tablet)C1
QC Natura-Lax (Powder)C1
QC Stool Softener (Capsule)C1
QC Stool Softener Plus Laxative (Tablet)C1
QC Stool Softener Plus Stimulant Laxative (Tablet)
C1
Sani-Supp Adult (Suppository)C1
Sani-Supp Pediatric (Suppository)C1
Senexon (Tablet)
OTC Drug NameC1
Senexon-S (Tablet)C1
Senna (Tablet)C1
Senna Plus (Tablet)C1
Senna Prompt (Capsule)C1
Senna-S (Tablet)C1
Senna-Tabs (Tablet)C1
Senna-Time (Tablet)C1
Senna-Time S (Tablet)C1
Senno (Tablet)C1
Sennosides/Docusate Sodium (Tablet)C1
Senokot (Tablet)C1
Senokot Extra Strength (Tablet)C1
Senokot S (Tablet)C1
Senna Lax (Tablet)C1
Senna Laxative (Tablet)C1
Senna-Lax (Tablet)C1
Silace (150mg/15ml Liquid, 60mg/15ml Syrup)
C1
SM Castor Oil (Oil)C1
SM Clearlax (Powder)C1
SM Enema (Enema)C1
SM Fiber (Powder)C1
SM Fiber (Tablet)C1
SM Fiber Laxative (Capsule)C1
SM Fiber Laxative (Tablet)C1
SM Gentle Laxative (Tablet Delayed-Release)
C1
SM Laxative Maximum Strength (Tablet)C1
SM Senna Laxative (Tablet)C1
SM Senna-S (Tablet)C1
Soluble Fiber (Powder)C1
Stimulant Laxative (Tablet Delayed-Release)
C1
Stool Softener (Capsule)
131
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Stool Softener Extra Strength (Capsule)C1
Stool Softener Plus Laxative (Tablet)C1
Vegetable Laxative+Stool Softener (Tablet)C1
Womans Laxative (Tablet Delayed-Release)B1
Gastrointestinal Agents, OtherC1
Actidose/Sorbitol (Liquid)C1
Actidose-Aqua (Liquid)C1
Almacone (Suspension)C1
Almacone (Tablet Chewable)C1
Almacone Double Strength (Suspension)C1
Aluminum Hydroxide (Suspension)C1
Anti-Diarrheal (2mg Capsule, 2mg Tablet)C1
Anti-Nausea (Solution)C1
Bismatrol (262mg/15ml Suspension, 262mg Tablet Chewable)
C1
Bismatrol Maximum Strength (Suspension)C1
Calcium Carbonate (1250mg/5ml Suspension, 648mg Tablet)
C1
Driminate (Tablet)C1
EZ Char (Suspension)C1
Formula EM (Solution)C1
Gas Relief (40mg/0.6ml Suspension, 60mg Tablet Chewable)
C1
Gas Relief Extra Strength (Capsule)C1
Gas Relief Maximum Strength (Tablet Chewable)
C1
Gas Relief Ultra Strength (Capsule)C1
Gas-X (Tablet Chewable)C1
Gas-X Extra Strength (Capsule)C1
Gas-X Extra Strength (Tablet Chewable)C1
Gas-X Ultra Strength (Capsule)C1
Gaviscon (Suspension)C1
Gaviscon (Tablet Chewable)C1
Gaviscon Extra Strength (Suspension)
OTC Drug NameC1
Gaviscon Extra Strength (Tablet
Chewable)C1
Gaviscon Extra Strength Relief Formula
(Suspension)C1
GNP Anti-Diarrheal (2mg Capsule, 2mg Tablet)
C1
GNP Anti-Gas (Capsule)C1
GNP Gas Relief (Tablet Chewable)C1
GNP Gas Relief Extra Strength (125mg Capsule, 125mg Tablet Chewable)
C1
GNP Infants Gas Relief (Suspension)C1
GNP Loperamide HCL (Liquid)C1
GNP Masanti Maximum Strength (Suspension)
C1
GNP Masanti Regular Strength (Suspension)
C1
GNP Motion Sickness Relief (25mg Tablet, 50mg Tablet)
C1
GNP Motion Sickness Relief (Tablet)C1
GNP Nausea Relief (Solution)C1
GNP Pink Bismuth (262mg Tablet Chewable, 262mg Tablet)
C1
GNP Stomach Relief (Suspension)C1
Goodsense Stomach Relief (Tablet Chewable)
C1
HM Anti-Diarrheal (Tablet)C1
HM Anti-Nausea (Solution)C1
HM Gas Relief (80mg Tablet Chewable, 125mg Tablet Chewable)
C1
HM Gas Relief Extra Strength (Capsule)C1
HM Gas Relief Infants (Suspension)C1
HM Loperamide HCL (2mg Capsule, 1mg/7.5ml Liquid)
C1
HM Milk Of Magnesia (Suspension)C1
HM Motion Relief (Tablet)C1
HM Motion Sickness (Tablet)C1
HM Motion Sickness Relief (Tablet)
132
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
HM Senna (Tablet)C1
HM Senna-S (Tablet)C1
HM Stomach Relief (262mg/15ml Suspension, 262mg Tablet Chewable)
C1
HM Stomach Relief Maximumstrength (Suspension)
C1
Infants Gas Relief (Suspension)C1
Infants Simethicone (Suspension)C1
Kao-Tin (240mg Capsule, 262mg/15ml Suspension)
C1
Loperamide HCL (Liquid)C1
Loperamide Hydrochloride (Tablet)C1
Mag-AL (Suspension)C1
Mag-AL Plus (Suspension)C1
Mag-AL Plus XS (Suspension)C1
Magnesium Oxide (Tablet)C1
Meclizine HCL (12.5mg Tablet, 25mg Tablet Chewable)
C1
Mi-Acid (Suspension)C1
Mi-Acid (Tablet Chewable)C1
Mi-Acid Gas Relief (Tablet Chewable)C1
Mi-Acid Maximum Strength (Suspension)C1
Milk Of Magnesia (Suspension)C1
Milk Of Magnesia Concentrate (Suspension)
C1
Mintox (Suspension)C1
Mintox Maximum Strength (Suspension)C1
Mintox Plus (Tablet Chewable)C1
Motion Sickness Relief (Tablet)C1
Motion-Time (Tablet Chewable)C1
Peptic Relief (262mg/15ml Suspension, 262mg Tablet Chewable)
C1
Perdiem Overnight Relief (Tablet)C1
Pink Bismuth (Tablet Chewable)C1
Potassium Iodide (Solution)
OTC Drug NameC1
QC Anti-Diarrheal (Tablet)C1
QC Milk Of Magnesia (Suspension)C1
Reguloid (28.3% Powder, 48.57% Powder, 58.6% Powder)
C1
Rulox (Suspension)C1
Simethicone (40mg/0.6ml Suspension, 80mg Tablet Chewable, 125mg Tablet Chewable, 180mg Capsule)
C1
SM Anti-Diarrheal (2mg Capsule, 2mg Tablet)
C1
SM Gas Relief (Tablet Chewable)C1
SM Gas Relief Antiflatuent (Capsule)C1
SM Gas Relief Drops Infants (Suspension)C1
SM Gas Relief Extra Strength (Capsule)C1
SM Loperamide HCL (Liquid)C1
SM Milk Of Magnesia (Suspension)C1
SM Motion Sickness (Tablet)C1
SM Motion Sickness Relief (Tablet)C1
SM Stomach Relief (262mg Tablet Chewable, 262mg Tablet)
C1
SM Stomach Relief Liquid (Suspension)C1
SM Stool Softener (Capsule)C1
SM Stool Softener (Tablet)C1
Sodium Bicarbonate (Tablet)C1
Stomach Relief (Suspension)C1
Stomach Relief (Tablet Chewable)C1
Stomach Relief Maximum Strength (Suspension)
C1
Travel Sickness (25mg Tablet Chewable, 50mg Tablet)
A1
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)
B1
Contraceptives, OralC1
Aftera (Tablet)C1
Econtra EZ (Tablet)C1
Econtra One-Step (Tablet)
133
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Fallback Solo (Tablet)C1
Levonorgestrel (Tablet)C1
My Choice (Tablet)C1
My Way (Tablet)C1
New Day (Tablet)C1
Opcicon One-Step (Tablet)C1
Option 2 (Tablet)C1
Plan B One-Step (Tablet)C1
Take Action (Tablet)A1
Miscellaneous Therapeutic AgentsB1
Devices / Other Therapeutic AgentsC1
GNP Chest Rub (Ointment)C1
GNP Epsom Salt C1
HM Chest Rub (Ointment)C1
HM Epsom Salt C1
Medicated Chest Rub (Ointment)C1
SM Epsom Salt C1
SM Medicated Chest Rub (Ointment)B1
Tear / Saliva Replacement AgentsC1
Akwa Tears (Ointment)C1
Artificial Tears (Ointment)C1
Artificial Tears (Solution)C1
Bion Tears (Solution)C1
Genteal Severe (Gel)C1
Genteal Tears Liquid Drops Moderate (Solution)
C1
Genteal Tears Mild (Solution)C1
Genteal Tears Moderate PF (Solution)C1
Genteal Tears Moderate PF (Solution)C1
GNP Artificial Tears (Solution)C1
GNP Eye Drops (Solution)C1
GNP Lubricant PM (Ointment)C1
GNP Lubricating Plus Eye Drops (Solution)C1
Goodsense Lubricant Eye Drops (Solution)
OTC Drug NameC1
Goodsense Lubricating Plus Eye Drops (Solution)
C1
HM Dry Eye Relief (Solution)C1
HM Lubricating Plus (Solution)C1
HM Lubricating Tears (Solution)C1
Isopto Tears (Solution)C1
Liquitears (Solution)C1
Lubricant Eye Drops (Solution)C1
Lubricating Plus Eye Drops (Solution)C1
Lubrifresh P.M. (Ointment)C1
Natural Balance Tears (Solution)C1
Natures Tears (Solution)C1
Puralube (Ointment)C1
Refresh (Solution)C1
Refresh Celluvisc (Gel)C1
Refresh Lacri-Lube (Ointment)C1
Refresh Liquigel (Gel)C1
Refresh Optive (Gel)C1
Refresh Optive (Solution)C1
Refresh Optive Advanced (Solution)C1
Refresh Optive Advanced Sensitive
(Solution)C1
Refresh Optive Mega-3 (Solution)C1
Refresh Optive Sensitive (Solution)C1
Refresh P.M. (Ointment)C1
Refresh Plus (Solution)C1
Refresh Tears (Solution)C1
SM Lubricant Eye Drops (Solution)C1
SM Lubricating Plus (Solution)C1
SM Lubricating Tears (Solution)C1
Systane (Solution)C1
Systane Balance Restorative Formula
(Solution)C1
Systane Complete (Solution)
134
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Systane Gel (Gel)C1
Systane Nighttime (Ointment)C1
Systane Overnight Therapy Lubricant
Eye (Gel)C1
Systane Preservative Free (Solution)C1
Systane Ultra (Solution)C1
Systane Ultra Preservative Free
(Solution)C1
Ultra Lubricant Eye Drops (Solution)A1
Ophthalmic AgentsB1
Allergy Agents, OphthalmicC1
Alaway (Solution)C1
Alaway Childrens Allergy Eye Itch Relief
(Solution)C1
Eye Drops (Solution)C1
Eye Itch Relief (Solution)C1
GNP Redness Relief (Solution)C1
HM Eye Drops (Solution)C1
HM Eye Drops Advanced Relief (Solution)C1
HM Eye Drops Redness Relief (Solution)C1
HM Eye Itch Relief (Solution)C1
Ketotifen Fumarate (Solution)C1
Naphcon-A (Solution)C1
Opti-Clear (Solution)C1
SM Eye Drops (Solution)C1
SM Eye Itch Relief (Solution)C1
SM Redness Relief (Solution)C1
Zaditor (Solution)B1
Ophthalmic Agents, OtherC1
Ear Drops (Solution)C1
Earwax Removal Kit (Solution)C1
Eye Irrigating Solution (Solution)C1
Eye Stream (Solution)C1
Eye Wash (Solution)C1
GNP Ear Systems (Solution)
OTC Drug NameC1
HM Earwax Removal Aid (Solution)C1
HM Earwax Removal Kit (Solution)C1
Lumify (Solution)C1
Muro 128 (2% Solution, 5% Solution, 5%
Ointment)C1
SM Ear Drops (Solution)C1
Sodium Chloride (5% Ointment, 5% Solution)
A1
Oral HealthB1
Oral Health AgentsC1
Aquafresh Cavity Protection (Paste)C1
Aquafresh Extreme Clean (Paste)C1
Aquafresh For Kids (Paste)C1
Aquafresh Sensitive (Paste)C1
Aquafresh Toothpaste C1
Aquafresh Whitening (Paste)C1
Biotene Dry Mouth (Paste)C1
Biotene Dry Mouth Gentle Formula
(Paste)C1
Biotene PBF Dry Mouth (Paste)C1
Parodontax (Paste)C1
Sensodyne Complete Protection (Paste)C1
Sensodyne Maximum Strength (Paste)C1
Sensodyne Pronamel (Paste)C1
Sensodyne Pronamel Fresh Breath
(Paste)C1
Sensodyne Rapid Relief (Paste)C1
Sensodyne Repair & Protect Whitening
(Paste)A1
Otic AgentsB1
Otic AgentsC1
Swim Ear (Liquid)A1
Personal Care ProductsB1
Personal Care ProductsC1
Overnight Ultra Thin A1
Respiratory Tract/Pulmonary Agents
135
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameB1
Antihistamines / Decongestants / Cough and Cold
C1
12 Hour Decongestant (Tablet Extended-Release)
C1
12 Hour Nasal Decongestant/Maximum Strength (Tablet Extended-Release)
C1
24Hr Allergy Relief (Tablet)C1
Aceta-Gesic (Tablet)C1
Ahist (Tablet)C1
Alahist CF (Tablet)C1
Alahist DM (Liquid)C1
Ala-Hist IR (Tablet)C1
Ala-Hist PE (Tablet)C1
All Day Allergy (Tablet)C1
All Day Allergy Childrens (Solution)C1
All Day Allergy D (Tablet Extended-Release)
C1
All-Day Allergy Childrens (Solution)C1
Aller-Chlor (Tablet)C1
Aller-Ease (Tablet)C1
Allergy & Congestion Relief (Tablet Extended-Release)
C1
Allergy (Tablet)C1
Allergy Childrens (Syrup)C1
Allergy Multi-Symptom (Tablet)C1
Allergy Non-Drowsy (Tablet)C1
Allergy Relief (4mg Tablet, 10mg Tablet, 25mg Capsule, 25mg Tablet, 180mg Tablet)
C1
Allergy Relief 24Hr (Tablet)C1
Allergy Relief Childrens (Liquid)C1
Allergy Relief D-24 (Tablet Extended-Release)
C1
Allergy Relief/Nasal Decongestant (Tablet Extended-Release)
C1
Allergy Relief-D (Tablet Extended-Release)
OTC Drug NameC1
Allergy/Congestion Relief (Tablet Extended-Release)
C1
Allergy-Time (Tablet)C1
Allfen DM (Tablet)C1
All-Nite Cold & Flu Nighttime Relief (Liquid)C1
Aprodine (Tablet)C1
Aquanaz (Tablet)C1
Atuss DA (Liquid)C1
Banophen (25mg Capsule, 50mg Capsule, 25mg Tablet)
C1
Banophen (Liquid)C1
Bronkaid (Tablet)C1
Brotapp (Elixir)C1
Brotapp DM (Elixir)C1
Capcof (Syrup)C1
Capmist DM (30-30-400mg Tablet)C1
Capmist DM (60-15-400mg Tablet)C1
Capron DM (Liquid)C1
Capron DMT (Tablet)C1
Cepacol Sore Throat & Cough (Lozenge)C1
Cepacol Sore Throat & Cough Extra
Strength (Lozenge)C1
Cepacol Sore Throat (Lozenge)C1
Cepacol Sore Throat Extra Strength
(Lozenge)C1
Cetirizine HCL (1mg/1ml Solution, 5mg Tablet Chewable, 10mg Tablet Chewable, 5mg Tablet, 10mg Tablet)
C1
Cetirizine HCL Allergy Childrens (Solution)C1
Cetirizine HCL Childrens (1mg/1ml Solution, 5mg Tablet Chewable, 10mg Tablet Chewable)
C1
Cetirizine HCL Childrens Allergy (Solution)C1
Cetirizine HCL/Pseudoephedrine HCL Er (Tablet Extended-Release)
C1
Cetirizine Hydrochloride (Tablet)
136
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Cheratussin Ac (Solution)C1
Chest Congestion Relief (Tablet)C1
Childrens Allergy (Liquid)C1
Childrens Cold & Allergy (Elixir)C1
Childrens Loratadine (Syrup)C1
Childrens Mucus Relief Cough (Liquid)C1
Childrens Mucus Relief Expectorant (Liquid)
C1
Childrens Pain Relief Plus Multi-Symptom Cold (Suspension)
C1
Childrens Pain Relief Plus Multi-Symptom Flu Relief (Suspension)
C1
Childrens Silfedrine (Liquid)C1
Chlo Hist (Solution)C1
Chlo Tuss (Liquid)C1
Chlorphen SR (Tablet Extended-Release)C1
Codeine/Guaifenesin (Solution)C1
Cold & Allergy (Tablet)C1
Cold & Allergy Childrens (Elixir)C1
Cold & Cough Childrens (Liquid)C1
Cold & Sinus Relief (Tablet)C1
Cold Head Congestion Daytime (Tablet)C1
Cold Head Congestion Nighttime (Tablet)C1
Cold Head Congestion Severe Daytime (Tablet)
C1
Cold Multi-Symptom Daytime (Tablet)C1
Cold Multi-Symptom Nighttime (Tablet)C1
Cold Multi-Symptom Severe Daytime (Tablet)
C1
Cold Relief Plus (Tablet)C1
Cold Relief/Non-Drowsy/Daytime (Tablet)C1
Cold/Cough Childrens (Elixir)C1
Complete Allergy Medicine (Capsule)C1
Conex Cold/Allergy (1-30mg/5ml
Solution, 2-60mg Tablet)
OTC Drug NameC1
Congestac (Tablet)C1
Cough & Cold (Tablet)C1
Cough & Cold HBP (Tablet)C1
Cough & Sore Throat Day Time (Liquid)C1
Cough & Sore Throat Nighttime (Liquid)C1
Cough DM (Suspension)C1
Cough DM Childrens (Suspension)C1
Cough Drops (Lozenge)C1
Cough Syrup (Syrup)C1
Cromolyn Sodium (Solution)C1
Day Time Cold/Flu Relief (Liquid)C1
Day Time Cough (Liquid)C1
Day Time Multi-Symptom Cold/Flu Relief
(Capsule)C1
Day Time/Nite Time Cold & Flu Relief (Liquid)
C1
Dayclear Allergy Relief (Tablet)C1
Dayhist Allergy 12 Hour Relief (Tablet)C1
Daytime Cold & Flu Relief (10-5-325mg Capsule, 10-5-325mg/15ml Liquid)
C1
Day-Time PE (Capsule)C1
Daytime PE Multi-Symptom Cold/Flu Relief (Capsule)
C1
Daytime Severe Cold & Flu (Liquid)C1
Deconex DMX (Tablet)C1
Deconex IR (Tablet)C1
Decongestant 12Hour Maximum Strength (Tablet Extended-Release)
C1
Delsym (Suspension)C1
Delsym Cough + Chest Congestion DM (Liquid)
C1
Delsym Cough + Chest Congestion DM Childrens (Liquid)
C1
Delsym Cough + Cold Daytime (Liquid)C1
Delsym Cough + Cold Nighttime (Liquid)
137
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Delsym Cough + Cold Nighttime Childrens (Liquid)
C1
Delsym Cough Childrens (Suspension)C1
Delsym Cough + Soothing Action (Lozenge)
C1
Dextromethorphan Polistirex (Suspension)C1
Dextromethorphan/Guaifenesin (Liquid)C1
Dextromethorphan/Guaifenesin/Phenylephrine (Liquid)
C1
Diabetic Siltussin Das-Na (Liquid)C1
Diabetic Siltussin-DM (Liquid)C1
Diabetic Siltussin-DM Maximum Strength (Liquid)
C1
Dimaphen Childrens (Elixir)C1
Dimaphen DM Cold & Cough (Elixir)C1
Diphenhist (25mg Capsule, 12.5mg/5ml Liquid, 25mg Tablet)
C1
Diphenhydramine HCL (25mg Capsule, 50mg Capsule, 25mg Tablet)
C1
Diphenhydramine Hydrochloride (Liquid)C1
Duraflu (Tablet)C1
Dye-Free Allergy Relief Childrens (Liquid)C1
ED A-Hist (Liquid)C1
ED A-Hist (Tablet)C1
ED A-Hist DM (Liquid)C1
ED A-Hist DM (Tablet)C1
ED A-Hist PSE (Tablet)C1
ED Bron GP (Liquid)C1
ED Chlorped (Liquid)C1
ED Chlorped D (Liquid)C1
ED Chlorped Jr (Syrup)C1
Endacof-DM (Liquid)C1
Extra Action Cough (Syrup)C1
Fexofenadine HCL (60mg Tablet, 180mg Tablet)
OTC Drug NameC1
Fexofenadine HCL Childrens Allergy (Suspension)
C1
Fexofenadine HCL/Pseudoephedrine HCL ER (Tablet Extended-Release)
C1
Fexofenadine Hydrochloride (Tablet)C1
Fexofenadine/Pseudoephedrine (Tablet Extended-Release)
C1
Flu & Severe Cold Daytime (Powder Packet)
C1
Flu & Sore Throat (Powder Packet)C1
Flu HBP (Tablet)C1
Flu/Severe Cold & Cough Daytime (Powder Packet)
C1
GNP All Day Allergy (Tablet)C1
GNP All Day Allergy Childrens (Solution)C1
GNP All Day Allergy-D (Tablet Extended-Release)
C1
GNP Allergy & Congestion Relief (Tablet Extended-Release)
C1
GNP Allergy (25mg Capsule, 4mg Tablet, 25mg Tablet)
C1
GNP Allergy Antihistamine Childrens (Liquid)
C1
GNP Allergy Multi-Symptom (Tablet)C1
GNP Allergy Plus Severe Sinus Headache Maximum Strength (Tablet)
C1
GNP Allergy Plus Sinus Headache (Tablet)C1
GNP Allergy Relief (25mg Capsule, 12.5mg Tablet Chewable, 180mg Tablet, 10mg Tablet Disintegrating)
C1
GNP Allergy Relief For Kids (Tablet)C1
GNP Childrens Allergy (Liquid)C1
GNP Childrens Pain Relief Plus Cold (Suspension)
C1
GNP Cold & Allergy Childrens (Elixir)C1
GNP Cold & Allergy Maximum Strength (Tablet)
C1
GNP Cold & Cough Childrens (Elixir)
138
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
GNP Cold Head Congestion Day/Night (Tablet)
C1
GNP Cold Head Congestion Night Time (Tablet)
C1
GNP Cold Multi-Symptom Day/Night (Tablet)
C1
GNP Cold Relief Head Congestion Severe Daytime (Tablet)
C1
GNP Cold Relief Multi-Symptom Daytime (Tablet)
C1
GNP Cold Relief Multi-Symptom Severe Daytime (Tablet)
C1
GNP Cough DM ER (Suspension)C1
GNP Cough Gels (Capsule)C1
GNP Cough Relief (Liquid)C1
GNP Day Time Cold/Flu (Capsule)C1
GNP Day Time Cold/Flu Relief (Liquid)C1
GNP Dayhist Allergy (Tablet)C1
GNP Flu & Severe Cold & Cough Nighttime (Packet)
C1
GNP Flu Relief Therapy Severe Cold Nighttime (Liquid)
C1
GNP Ibuprofen Cold/Sinus (Tablet)C1
GNP Loratadine (5mg/5ml Syrup, 10mg Tablet)
C1
GNP Loratadine Childrens (Syrup)C1
GNP Loratadine-D 12Hr (Tablet Extended-Release)
C1
GNP Loratadine-D 24 Hour (Tablet Extended-Release)
C1
GNP Mucus D 12 Hr (Tablet Extended-Release)
C1
GNP Mucus DM Maximum Strength (Tablet Extended-Release)
C1
GNP Mucus ER (Tablet Extended-Release)C1
GNP Mucus Relief Childrens (Liquid)C1
GNP Mucus Relief Cold & Sinus (Tablet)
OTC Drug NameC1
GNP Mucus Relief Cold Flu & Sore Throat (Tablet)
C1
GNP Mucus Relief Cough Childrens (Liquid)
C1
GNP Mucus Relief DM (Tablet)C1
GNP Mucus Relief PE (Tablet)C1
GNP Mucus-ER (Tablet Extended-Release)C1
GNP Multi-Symptom Cold Nighttime (Liquid)
C1
GNP Nasal Decongestant (Tablet)C1
GNP Nasal Decongestant PE Maximum Strength (Tablet)
C1
GNP Nasal Decongestant/Maximum Strength (Tablet)
C1
GNP Night Time Cold & Flu (Capsule)C1
GNP Night Time Cold & Flu Multi-Symptom (Liquid)
C1
GNP Night Time Cough (Liquid)C1
GNP Pseudoephedrine HCL 12 Hour (Tablet Extended-Release)
C1
GNP Pseudoephedrine HCL ER (Tablet Extended-Release)
C1
GNP Sinus & Allergy Pe (Tablet)C1
GNP Sinus & Cold-D (Tablet Extended-Release)
C1
GNP Sinus Congestion & Pain Daytime (Tablet)
C1
GNP Sinus Relief Congestion & Pain Daytime/Nighttime (Tablet)
C1
GNP Sinus Relief Congestion & Pain Nighttime (Tablet)
C1
GNP Sinus Relief Pressure & Pain (Tablet)C1
GNP Sinus Relief Severe Congestion Relief (Tablet)
C1
GNP Sore Throat (Liquid)C1
GNP Sore Throat Spray (Liquid)C1
GNP Tab Tussin (Tablet)
139
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
GNP Tab Tussin DM (Tablet)C1
GNP Tussin (Syrup)C1
GNP Tussin CF Cough & Cold (Syrup)C1
GNP Tussin CF Max Multi-Symptom Cold (Liquid)
C1
GNP Tussin Cough Long Acting (Syrup)C1
GNP Tussin DM (Liquid)C1
GNP Tussin DM Cough (Liquid)C1
GNP Tussin DM Max (Liquid)C1
GNP Tussin DM Max Cough & Chest Congestion (Liquid)
C1
GNP Tussin Mucus & Chest Congestion (Liquid)
C1
Goodsense All Day Allergy (Tablet)C1
Goodsense All Day Allergy Childrens (Solution)
C1
Goodsense Aller-Ease (Tablet)C1
Goodsense Cold & Flu Severe For Adults (Tablet)
C1
Goodsense Cough DM (Suspension)C1
Goodsense Cough DM Childrens (Suspension)
C1
Goodsense Day Time Cold & Flu Severe Non-Drowsy (5-10-200-325mg Capsule, 5-10-200-325mg/15ml Liquid)
C1
Goodsense Daytime Cold & Flu (10-5-325mg/15ml Liquid, 10-5-325mg Capsule)
C1
Goodsense Flu & Severe Cold & Cough Nighttime (Packet)
C1
Goodsense Flu & Severe Cold Daytime (Powder Packet)
C1
Goodsense Mucus Relief Childrens (Liquid)
C1
Goodsense Mucus-D (Tablet Extended-Release)
C1
Goodsense Nighttime Cold & Flu (Capsule)
OTC Drug NameC1
Goodsense Nighttime Cold & Flu Severe (Liquid)
C1
Goodsense Nighttime Cold & Flu Severe Maximum Strength (Liquid)
C1
Goodsense Severe Sinus Congestion (Capsule)
C1
Goodsense Sinus Relief Maximum Strength (Tablet)
C1
Goodsense Tussin CF (Liquid)C1
Guaiatussin AC (Solution)C1
Guaifenesin (Liquid)C1
Guaifenesin (Tablet)C1
Guaifenesin AC (Solution)C1
Guaifenesin DCA (Solution)C1
Guaifenesin ER (Tablet Extended-Release)C1
Guaifenesin/Codeine (Solution)C1
Guaifenesin/Dextromethorphan Hydrobromide (Syrup)
C1
Guaifenesin/Pseudoephedrine Hydrochloride (Tablet Extended-Release)
C1
Guaifenesin-DM (Syrup)C1
Histex (Syrup)C1
Histex PD (Solution)C1
Histex-AC (Syrup)C1
Histex-DM (Syrup)C1
Histex-PE (Liquid)C1
HM All Day Allergy (Tablet)C1
HM All Day Allergy Childrens (Solution)C1
HM Allergy & Congestion (Tablet Extended-Release)
C1
HM Allergy Complete-D (Tablet Extended-Release)
C1
HM Allergy Relief & Nasaldecongestant (Tablet Extended-Release)
C1
HM Allergy Relief (25mg Capsule, 4mg Tablet, 25mg Tablet)
140
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
HM Allergy Relief Childrens (Liquid)C1
HM Cetirizine HCL Childrens (Solution)C1
HM Cetirizine Hydrochloride (Tablet)C1
HM Chest Congestion Relief (Tablet)C1
HM Chest Congestion Relief DM (Tablet)C1
HM Cold & Allergy Childrens (Elixir)C1
HM Cold & Cough Childrens (Elixir)C1
HM Cold & Sinus Relief (Tablet)C1
HM Cough DM (Suspension)C1
HM Day Time Liquid Caps (Capsule)C1
HM Daytime Cold & Flu (Liquid)C1
HM Fexofenadine HCL (Tablet)C1
HM Fexofenadine Hydrochloride (Tablet)C1
HM Loratadine (Tablet)C1
HM Loratadine Childrens (Syrup)C1
HM Mucus Relief D (Tablet Extended-Release)
C1
HM Mucus Relief DM Maximum Strength (Tablet Extended-Release)
C1
HM Nasal Decongestant (Tablet)C1
HM Nasal Decongestant 12 Hour (Tablet Extended-Release)
C1
HM Nasal Decongestant PE (Tablet)C1
HM Night Time Cold & Flu (Liquid)C1
HM Night Time Multi-Symptom Cold & Flu (Capsule)
C1
HM Severe Cold & Flu (Tablet)C1
HM Severe Cold/Cough/Flu Daytime (Powder Packet)
C1
HM Sinus & Cold-D (Tablet Extended-Release)
C1
HM Tussin Adult (Liquid)C1
HM Tussin Adult Cough & Chest Congestion DM (Liquid)
C1
HM Tussin Adult Multi-Symptom Cold (Liquid)
OTC Drug NameC1
HM Tussin Cough/Chest Congestion DM Max/Adult (Liquid)
C1
Ibuprofen Cold & Sinus (Tablet)C1
J-Max (Syrup)C1
J-Tan D PD (Liquid)C1
J-Tan PD (Liquid)C1
Kidkare Cough/Cold (Liquid)C1
Levocetirizine Dihydrochloride (Tablet)C1
Lodrane D (Capsule)C1
Lohist-D (Liquid)C1
Lohist-DM (Syrup)C1
Loratadine (10mg Capsule, 10mg Tablet)C1
Loratadine Childrens (5mg/5ml Syrup, 5mg Tablet Chewable)
C1
Loratadine Hives Relief (Syrup)C1
Loratadine-D 12Hr (Tablet Extended-Release)
C1
Loratadine-D 24Hr (Tablet Extended-Release)
C1
Mapap Cold Formula Multi-Symptom (Tablet)
C1
Mapap Sinus Maximum Strength Congestion And Pain (Tablet)
C1
Mar-Cof CG Expectorant (Liquid)C1
Maxichlor PEH DM (Tablet)C1
Maxifed (Tablet)C1
Maxiphen (Tablet)C1
Maxiphen DM (Tablet)C1
Maxi-Tuss CD (Liquid)C1
Maxi-Tuss DM (Liquid)C1
M-Clear WC (Solution)C1
M-End DMX (Liquid)C1
M-End PE (Liquid)C1
M-Hist PD (Liquid)C1
Mucinex (Tablet Extended-Release)
141
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Mucinex Allergy (Tablet)C1
Mucinex Chest Congestion Childrens (Liquid)
C1
Mucinex Childrens Cold Cough & Sore
Throat (Liquid)C1
Mucinex Childrens Multi-Symptom Cold
& Fever (Liquid)C1
Mucinex Childrens Multi-Symptom Cold
(Liquid)C1
Mucinex Congestion & Cough Childrens
(Liquid)C1
Mucinex Cough Childrens (Liquid)C1
Mucinex Cough For Kids (Packet)C1
Mucinex D (Tablet Extended-Release)C1
Mucinex D Maximum Strength (Tablet
Extended-Release)C1
Mucinex DM (Tablet Extended-Release)C1
Mucinex DM Maximum Strength (Tablet
Extended-Release)C1
Mucinex Fast-Max Cold & Sinus (Liquid)C1
Mucinex Fast-Max Cold & Sinus (Tablet)C1
Mucinex Fast-Max Cold Flu& Sore Throat (Liquid)
C1
Mucinex Fast-Max Cold Flu& Sore Throat
(Tablet)C1
Mucinex Fast-Max Cold Flu& Sore Throat
Clear & Cool (Liquid)C1
Mucinex Fast-Max Cold/Flu/Sore Throat
(Capsule)C1
Mucinex Fast-Max Cold/Flu/Sore Throat
(Packet)C1
Mucinex Fast-Max Congestion & Headache (Capsule)
C1
Mucinex Fast-Max Day Time/Night Time
(Liquid)C1
Mucinex Fast-Max Day Time/Night Time
(Tablet)C1
Mucinex Fast-Max Day/Night (Capsule)
OTC Drug NameC1
Mucinex Fast-Max Day/Night Maximum
Strength (Tablet)C1
Mucinex Fast-Max Day/Nite M/S (Tablet)C1
Mucinex Fast-Max DM Max (Liquid)C1
Mucinex Fast-Max Night Time Cold & Flu (Capsule)
C1
Mucinex Fast-Max Night Time Cold & Flu (Liquid)
C1
Mucinex Fast-Max Night Time Cold & Flu (Packet)
C1
Mucinex Fast-Max Night Time Cold & Flu (Tablet)
C1
Mucinex Fast-Max Severe Cold & Sinus (Capsule)
C1
Mucinex Fast-Max Severe Cold (Liquid)C1
Mucinex Fast-Max Severe Cold (Packet)C1
Mucinex Fast-Max Severe Cold (Tablet)C1
Mucinex Fast-Max Severe Congestion & Cold (Tablet)
C1
Mucinex Fast-Max Severe Congestion &
Cough (Liquid)C1
Mucinex Fast-Max Severe Congestion &
Cough (Tablet)C1
Mucinex Fast-Max Severe Congestion &
Cough Clear & Cool (Liquid)C1
Mucinex For Kids (Packet)C1
Mucinex Maximum Strength (Tablet
Extended-Release)C1
Mucinex Multi-Symptom Cold Day/Night
Pack (Liquid)C1
Mucinex Multi-Symptom Cold Night Time Childrens (Liquid)
C1
Mucinex Sinus-Max Day/Night (Capsule)C1
Mucinex Sinus-Max Day/Night (Tablet)C1
Mucinex Sinus-Max Night Time Congestion & Cough (Liquid)
C1
Mucinex Sinus-Max Pressure & Pain
(Liquid)
142
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Mucinex Sinus-Max Pressure & Pain (Tablet)
C1
Mucinex Sinus-Max Severe Congestion
Relief (Capsule)C1
Mucinex Sinus-Max Severe Congestion Relief (Liquid)
C1
Mucinex Sinus-Max Severe Congestion Relief (Tablet)
C1
Mucinex Stuffy Nose & Cold Childrens
(Liquid)C1
Mucosa (Tablet)C1
Mucosa DM (Tablet)C1
Mucus & Cough Relief Childrens (Liquid)C1
Mucus D (Tablet Extended-Release)C1
Mucus Relief (Tablet)C1
Mucus Relief Chest Congestion (Tablet)C1
Mucus Relief Childrens (Liquid)C1
Mucus Relief Cold & Sinusmaximum Strength (Tablet)
C1
Mucus Relief Cold Flu & Sore Throat (Tablet)
C1
Mucus Relief Cough Childrens (Liquid)C1
Mucus Relief DM (Tablet)C1
Mucus Relief DM Cough (Tablet)C1
Mucus Relief DM Maximum Strength (Liquid)
C1
Mucus Relief Multi Symptom Cold Childrens (Liquid)
C1
Mucus Relief PE Sinus Congestion (Tablet)C1
Mucus Relief Severe Cold Maximum Strength (Tablet)
C1
Mucus-DM Maximum Strength (Tablet Extended-Release)
C1
Mucus-ER (Tablet Extended-Release)C1
Mucusrelief Sinus (Tablet)C1
Multi Symptom Flu & Severe Cold/Daytime (Powder Packet)
OTC Drug NameC1
Multi-Symptom Allergy (Capsule)C1
Nasal Decongestant (Liquid)C1
Nasal Decongestant (Syrup)C1
Nasal Decongestant (Tablet)C1
Nasal Decongestant Maximum Strength (Tablet)
C1
Nasal Decongestant PE (Tablet)C1
Nasal Decongestant PE Maximum Strength (Tablet)
C1
Nasopen PE (Liquid)C1
Night Time Multi-Symptom Cold/Flu Relief (Capsule)
C1
Nighttime Cold/Flu Relief (Capsule)C1
Nighttime Cold/Flu Relief (Liquid)C1
Nighttime Cold/Flu Reliefmulti-Symptom (Liquid)
C1
Nighttime Cold/Flu/Maximum Strength (Liquid)
C1
Nighttime Cough (Liquid)C1
Nighttime Severe Cold & Flu/Maximum Strength (Liquid)
C1
Nighttime Sinus Congestion & Pain (Tablet)
C1
Ninjacof (Liquid)C1
Ninjacof-A (Liquid)C1
Ninjacof-XG (Liquid)C1
Nite Time Cough (Liquid)C1
Nite Time Multi-Symptom Cold/Flu Relief (Liquid)
C1
Nite Time Multi-Symptom Cold/Flu Relief (Capsule)
C1
Nite Time-D (Liquid)C1
Nite-Time Multi-Symptom Cold/Flu Relief (Liquid)
C1
Niva-Hist DM (Liquid)C1
Nivanex DMX (Tablet)
143
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Nohist-DM (Liquid)C1
Nohist-LQ (Liquid)C1
Norel AD (Tablet)C1
Orasep (Solution)C1
Organ-I NR (Tablet)C1
Pedia Relief Cough/Cold (Liquid)C1
Pediatric Cough/Cold (Liquid)C1
Pharbedryl (Capsule)C1
Phenaseptic (Liquid)C1
Phenylephrine HCL/Pyrilamine Maleate (Tablet)
C1
Poly Hist Forte (Tablet)C1
Poly-Hist DM (Liquid)C1
Poly-Hist PD (Liquid)C1
Poly-Tussin AC (Liquid)C1
Polytussin DM (Syrup)C1
Poly-Vent DM (Tablet)C1
Poly-Vent IR (Tablet)C1
Pro-Red AC (Syrup)C1
Pseudoephedr Tab 60mg (Tablet)C1
Pseudoephedrine HCL (Tablet)C1
Pseudoephedrine HCL ER (Tablet Extended-Release)
C1
QC All Day Allergy (Tablet)C1
QC Allergy Relief Multi-Symptom Daytime (Tablet)
C1
QC Allergy/Sinus Headache (Tablet)C1
QC Childrens Allergy (Solution)C1
QC Cold Head Congestion Nighttime (Tablet)
C1
QC Cold Multi-Symptom Nighttime (Tablet)C1
QC Cold Multi-Symptom Severe Daytime (Tablet)
C1
QC Complete Allergy Medicine (Capsule)C1
QC Cough & Cold HBP (Tablet)
OTC Drug NameC1
QC Daytime Cold & Flu (Liquid)C1
QC Fexofenadine Hydrochloride (Tablet)C1
QC Ibuprofen Cold/Sinus (Tablet)C1
QC Loratadine Allergy Relief (Tablet)C1
QC Loratadine-D (Tablet Extended-Release)
C1
QC Medifin 400 (Tablet)C1
QC Medifin DM (Tablet)C1
QC Medifin PE (Tablet)C1
QC Mucus Relief (Tablet Extended-Release)
C1
QC Mucus Relief ER 12 Hour Maximum Strength (Tablet Extended-Release)
C1
QC Severe Cold & Cough Daytime (Powder Packet)
C1
QC Severe Cold & Cough Nighttime (Packet)
C1
QC Sinus Congestion & Pain Severe Daytime (Tablet)
C1
QC Sinus Pain Relief (Tablet)C1
QC Sore Throat Spray (Liquid)C1
QC Suphedrine Maximum Strength (Tablet Extended-Release)
C1
QC Tussin CF (Liquid)C1
QC Tussin DM Cough & Chest Congestion/Adult (Liquid)
C1
Relcof IR (Tablet)C1
Relhist BP (Tablet)C1
Relhist DMX (Tablet)C1
Rescon (Tablet)C1
Rescon DM (Syrup)C1
Rescon-GG (Liquid)C1
Respaire-30 (Capsule)C1
Robafen (Syrup)C1
Robafen AC (Solution)C1
Robafen CF Multi-Symptom Cold (Liquid)
144
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Robafen Cough (Capsule)C1
Robafen DM (Syrup)C1
Robafen DM Cough Clear (Syrup)C1
Robafen DM Cough/Chest Congestion (Liquid)
C1
Rondec-D (Liquid)C1
Ru-Hist D (Tablet)C1
Rydex (Liquid)C1
Rymed (Tablet)C1
Rynex DM (Liquid)C1
Rynex PE (Elixir)C1
Rynex PSE (Elixir)C1
Sb Cold Multi-Symptom Day/Night (Tablet)C1
Severe Cold & Cough Nighttime (Packet)C1
Severe Cold & Flu (Tablet)C1
Siladryl Allergy (Liquid)C1
Silphen Cough (Syrup)C1
Siltussin DM Das (Liquid)C1
Siltussin SA (Syrup)C1
Siltussin-DM (Syrup)C1
Sinus & Allergy PE Maximum Strength (Tablet)
C1
Sinus & Cold-D Non-Drowsy (Tablet Extended-Release)
C1
Sinus And Headache Daytime (Tablet)C1
Sinus Congestion & Pain Daytime (Tablet)C1
Sinus Congestion & Pain Severe Daytime (Tablet)
C1
Sinus Pressure/Pain/Adult (Tablet)C1
SM 12 Hour Sinus Decongestant (Tablet Extended-Release)
C1
SM All Day Allergy (Tablet)C1
SM All Day Allergy Childrens (Solution)C1
SM All Day Allergy-D (Tablet Extended-Release)
OTC Drug NameC1
SM Allergy 4 Hour (Tablet)C1
SM Allergy Multi-Symptom (Tablet)C1
SM Allergy Relief (25mg Capsule, 12.5mg/5ml Liquid, 1.34mg Tablet, 25mg Tablet)
C1
SM Chest Congestion Relief (Tablet)C1
SM Chest Congestion Relief DM (Tablet)C1
SM Chest Congestion Relief PE (Tablet)C1
SM Childrens Loratadine (Syrup)C1
SM Cold & Allergy Childrens (Elixir)C1
SM Cold & Cough DM Childrens (Elixir)C1
SM Cold & Flu Severe (Tablet)C1
SM Cold & Sinus Relief (Tablet)C1
SM Cough Drops (Lozenge)C1
SM Day Time Cold & Flu Relief (Liquid)C1
SM Day Time Liquid Caps (Capsule)C1
SM Daytime Liquid Caps (Capsule)C1
SM Fexofenadine HCL (Tablet)C1
SM Loratadine (5mg/5ml Syrup, 10mg Tablet)
C1
SM Lorata-Dine D (Tablet Extended-Release)
C1
SM Loratadine D 12Hr (Tablet Extended-Release)
C1
SM Mucus Relief (Tablet Extended-Release)
C1
SM Mucus Relief Cough Childrens (Liquid)C1
SM Mucus Relief D (Tablet Extended-Release)
C1
SM Mucus Relief Maximum Strength (Tablet Extended-Release)
C1
SM Mucus Relief/12 Hour (Tablet Extended-Release)
C1
SM Nasal Decongestant Maximum Strength (Tablet)
C1
SM Nasal Decongestant PE (Tablet)C1
SM Night Time Liquid Caps (Capsule)
145
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
SM Nite Time Cold & Flu (Liquid)C1
SM Sinus & Cold-D (Tablet Extended-Release)
C1
SM Sore Throat Spray (Liquid)C1
SM Tussin CF (Liquid)C1
SM Tussin DM (Syrup)C1
SM Tussin DM Cough/Chest Congestion (Syrup)
C1
SM Tussin Mucus + Chest Congestion Adult (Liquid)
C1
Sore Throat (Lozenge)C1
Sore Throat Spray (Liquid)C1
SSKI (Solution)C1
Stahist AD (Tablet)C1
Sudogest (Tablet)C1
Sudogest 12 Hour (Tablet Extended-Release)
C1
Sudogest PE (Tablet)C1
Sudogest Sinus & Allergy (Tablet)C1
TGT Allergy Relief Non-Drowsy (Tablet)C1
Theraflu Expressmax (Liquid)C1
Theraflu Expressmax Severe Cold & Cough Daytime (Tablet)
C1
Theraflu Expressmax Severe Cold & Cough Nighttime (Tablet)
C1
Theraflu Expressmax Severe Cold & Cough/Daytime (Liquid)
C1
Theraflu Expressmax Severe Cold & Flu (Liquid)
C1
Theraflu Expressmax Severe Cold & Flu (Tablet)
C1
Theraflu Flu & Sore Throat (Powder
Packet)C1
Theraflu Powerpods Daytime Severe
Cold (Powder)C1
Theraflu Powerpods Nighttime Severe
Cold (Powder)
OTC Drug NameC1
Theraflu Severe Cold & Cough Daytime/
Nighttime (Packet)C1
Theraflu Severe Cold & Cough Nighttime
(Packet)C1
Theraflu Severe Cold Multi Symptom
(Powder Packet)C1
Theraflu Severe Cold Multi Symptom
Nighttime (Packet)C1
Triacting Day Time Cold/Cough Childrens (Solution)
C1
Triacting Nightime Cold & Cough Childrens (Liquid)
C1
Triaminic Cold & Allergy (Syrup)C1
Triaminic Cold & Cough Day Time
Childrens (Syrup)C1
Triaminic Cough & Congestion Childrens
(Syrup)C1
Triaminic Cough & Sore Throat
(Suspension)C1
Triaminic Fever & Cold Multi-Symptom Childrens (Suspension)
C1
Triaminic Night Time Cold & Cough
(Syrup)C1
Triprolidine HCL (Liquid)C1
Triprolidine Hydrochloride (Liquid)C1
Tusnel (30-15-200mg/5ml Liquid,
60-30-400mg Tablet)C1
Tusnel C (Syrup)C1
Tusnel Diabetic (Liquid)C1
Tusnel Pediatric (Liquid)C1
Tusnel-DM Pediatric (Liquid)C1
Tussin CF (Liquid)C1
Tussin CF Cough & Cold (Liquid)C1
Tussin CF Max Multi-Symptom (Liquid)C1
Tussin CF Severe Multi-Symptom Cough Cold/Flu (Liquid)
C1
Tussin Chest Congestion (Syrup)
146
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Tussin Cough (Syrup)C1
Tussin DM (1-100mg/5ml Liquid, 10-100mg/5ml Syrup)
C1
Tussin DM Cough + Chest Congestion (Liquid)
C1
Tussin DM Max (Liquid)C1
Tussin DM Max Adult (Liquid)C1
Tussin Mucus + Chest Congestion (100mg/5ml Liquid, 100mg/5ml Syrup)
C1
Tussin Mucus + Chest Congestion Adult (Liquid)
C1
Tussin Multi-Symptom Cold CF (Liquid)C1
Vanaclear PD (Liquid)C1
Vanacof (Liquid)C1
Vanacof AC (Liquid)C1
Vanacof DM (Liquid)C1
Vanacof-8 (Liquid)C1
Vanahist PD (Liquid)C1
Vanamine PD (Liquid)C1
Vanatab AC (Tablet)C1
Vanatab DM (Tablet)C1
Virtussin A/C (Solution)C1
Virtussin DAC (Solution)C1
Z-Tuss AC (Liquid)B1
Intranasal SpraysC1
12 Hour Nasal Spray (Solution)C1
4-Way Fast Acting (Solution)C1
Allergy Relief (Suspension)C1
Benzedrex Inhaler (Device)C1
Budesonide Nasal Spray (Suspension)C1
Flonase Allergy Relief (Suspension)C1
Flonase Allergy Relief Childrens
(Suspension)C1
Flonase Sensimist (Suspension)C1
Fluticasone Propionate (Suspension)
OTC Drug NameC1
GNP 12 Hour Nasal Spray (Solution)C1
GNP 24 Hour Nasal Allergy Spray (Suspension)
C1
GNP Budesonide Nasal Spray (Suspension)
C1
GNP Fluticasone Propionate (Suspension)C1
GNP Nasal Spray (Solution)C1
GNP Nasal Spray Extra Moisturizing (Solution)
C1
GNP Nasal Spray Fast Acting (Solution)C1
GNP No Drip Nasal Spray (Solution)C1
GNP Nose Drops Extra Strength (Solution)C1
Goodsense Nasal Allergy Spray (Suspension)
C1
Goodsense Nasoflow (Suspension)C1
HM Allergy Relief Nasal Spray 24Hr (Suspension)
C1
HM Nasal Spray (Solution)C1
HM Nose Drops Extra Strength (Solution)C1
HM Sinus Nasal Spray (Solution)C1
Mucinex Sinus-Max Full Force (Solution)C1
Mucinex Sinus-Max Moisture Smart (Solution)
C1
Nasal Allergy 24 Hour Multi-Symptom (Suspension)
C1
Nasal Decongestant Spray (Solution)C1
Nasal Four (Solution)C1
Nasal Relief (Solution)C1
Nasal Spray 12 Hour (Solution)C1
Nasal Spray Extra Moisturizing 12 Hour (Solution)
C1
No Drip Nasal Spray (Solution)C1
Nose Drops Extra Strength (Solution)C1
QC Fluticasone Propionate (Suspension)C1
Sinus Nasal Spray (Solution)C1
Sinus Relief Extra Strength (Solution)
147
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Sinus Relief Nasal Spray 12 Hour (Solution)
C1
SM Allergy Relief Nasal Spray (Suspension)
C1
SM Nasal Spray (Solution)C1
SM Nasal Spray 12 Hour (Solution)C1
SM Nasal Spray Moisturizing (Solution)C1
SM Nasal Spray Sinus (Solution)C1
SM Nose Drops Nasal Decongestant Extra Strength (Solution)
C1
Triamcinolone Acetonide (Suspension)B1
Respiratory AgentsC1
Aromatic Ammonia Inhalant A1
Sleep RegulatorsB1
Sleep AidsC1
Acetaminophen PM Extra Strength (Tablet)C1
Acetaminophen/Diphenhydramine (Tablet)C1
GNP Headache PM (Tablet)C1
GNP Ibuprofen PM (Tablet)C1
GNP Nighttime Sleep Aid (Tablet)C1
GNP Pain Relief PM Extra Strength (Tablet)C1
GNP Sleep Aid (Tablet)C1
GNP Sleep Time (Liquid)C1
Goodsense Headache PM (Tablet)C1
Goodsense Ibuprofen PM (Tablet)C1
Goodsense Pain Relief PM Extra Strength (Tablet)
C1
Goodsense Sleeptime (25mg Capsule, 50mg/30ml Liquid)
C1
Headache PM (Tablet)C1
Headache PM Formula (Tablet)C1
Headache Relief PM (Tablet)C1
HM Ibuprofen PM (Tablet)C1
HM Nighttime Sleep Aid (Tablet)C1
HM Pain Reliever PM Extrastrength (Tablet)
OTC Drug NameC1
HM Sleep Aid (Tablet)C1
HM Z-Sleep (25mg Capsule, 50mg/30ml Liquid)
C1
Ibuprofen PM (Tablet)C1
Mapap PM (Tablet)C1
Night Time Sleep Aid (Tablet)C1
Nighttime Sleep Aid (Tablet)C1
Pain Relief PM Extra Strength (Tablet)C1
Pain Reliever PM Extra Strength (Tablet)C1
Sleep Aid (25mg Capsule, 50mg Capsule, 50mg/30ml Liquid, 25mg Tablet)
C1
Sleep Tabs (Tablet)C1
SM Ibuprofen PM (Tablet)C1
SM Nighttime Sleep Aid (Tablet)C1
SM Pain Reliever PM Extra Strength (Tablet)
C1
SM Sleep Aid (Tablet)C1
SM Sleep Aid Night Time (Tablet)C1
TGT Nighttime Sleep Aid (Tablet)B1
StimulantsC1
Alertness Aid (Tablet)C1
Caffeine (Tablet)C1
GNP Stay Awake (Tablet)C1
HM Stay Awake (Tablet)C1
No Doz Maximum Strength (Tablet)C1
SM Stay Awake (Tablet)C1
SM Stay Awake Maximum Strength (Tablet)
C1
Stay Awake (Tablet)C1
Stay Awake Maximum Strength (Tablet)A1
Therapeutic Nutrients/Minerals/ElectrolytesB1
Vitamins / Nutrients / SupplementsC1
Calcium Carbonate (Tablet)C1
Calcium Gluconate (Tablet)C1
Calphron (Tablet)
148
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
GNP Magnesium Citrate (Solution)C1
HM Magnesium Citrate (Solution)C1
Iferex 150 (Capsule)C1
Magnebind 300 (Tablet)C1
Magnesium Citrate (Solution)C1
Niacin Cap 500mg SR (Capsule Extended-Release)
C1
Niacin SR (Capsule Extended-Release)C1
QC Magnesium Citrate (Solution)C1
SM Magnesium Citrate (Solution)C1
Sodium Chloride (Solution)C1
Vitamin D3 (Capsule)C1
Wee Care (Suspension)A1
Urinary AgentsB1
Urinary Agents
OTC Drug NameC1
Oxytrol For Women (Patch)B1
Urinary AnagelsicsC1
GNP Urinary Pain Relief (Tablet)C1
SM Urinary Pain Relief (Tablet)C1
SM Urinary Pain Relief Maximum Strength (Tablet)
C1
Urinary Pain Relief (Tablet)C1
Urinary Pain Relief Maximum Strength (Tablet)
B1
Urinary Misc AgentsC1
Cytra-2 (Solution)C1
Cytra-3 (Syrup)C1
Cytra-K (Solution)C1
Potassium Citrate/Citric Acid (Solution)C1
Sodium Citrate/Citric Acid (Solution)
149
Trackedtrack
D. Index of Covered Drugs
In this section, you can find a drug by searching for its name alphabetically. This will tell you the page number where you can find additional coverage information for your drug.
A
Abacavir Sulfate...................... 42
Abacavir Sulfate-Lamivudine............................................... 42
Abacavir-Lamivudine-Zidovudine............................ 42
Abelcet.....................................29
Abilify Maintena...................... 38
Abiraterone Acetate................32
Acamprosate Calcium............ 17
Acarbose................................. 45
Acebutolol HCl........................ 51
Acetaminophen-Codeine....... 15
Acetazolamide........................ 54
Acetazolamide ER.................. 54
Acetic Acid.............................. 85
Acetylcysteine......................... 87
Acitretin................................... 59
Actemra................................... 78
Actemra ACTPen.................... 78
ActHIB......................................79
Actimmune.............................. 78
Acyclovir.................................. 41
Acyclovir Sodium.................... 41
Adacel......................................79
Adapalene............................... 59
Adefovir Dipivoxil.................... 41
Adempas................................. 87
Advair Diskus.......................... 87
Advair HFA.............................. 87
Afinitor..................................... 34
Afinitor Disperz........................34
Aimovig.................................... 31
Ala-Cort.................................... 67
Albendazole............................ 36
Albuterol Sulfate..................... 86
Alclometasone Dipropionate............................................... 67
Alcohol Prep Pads.................. 82
Alecensa.................................. 34
Alendronate Sodium...............81
Alfuzosin HCl ER.....................66
Alinia........................................ 36
Aliskiren Fumarate..................53
Allopurinol............................... 30
Alocril....................................... 83
Alomide....................................83
Alosetron HCl.......................... 64
Alphagan P.............................. 83
Alprazolam.............................. 44
Altavera....................................70
Alunbrig................................... 34
Alyacen 1/35........................... 70
Alyq.......................................... 87
Amantadine HCl......................37
AmBisome............................... 29
Ambrisentan............................ 87
Amethia....................................70
Amethia Lo.............................. 70
Amikacin Sulfate..................... 17
Amiloride HCl.......................... 55
Amiloride-Hydrochlorothiazide............................................... 53
Aminosyn II.............................. 61
Aminosyn-PF........................... 61
Amiodarone HCl..................... 51
Amitiza..................................... 64
Amitriptyline HCl..................... 28
Amlodipine Besylate...............52
Amlodipine-Atorvastatin......... 53
Amlodipine-Benazepril........... 53
Amlodipine-Olmesartan..........53
Amlodipine-Valsartan............. 53
Amlodipine-Valsartan-HCTZ...53
Ammonium Lactate................ 59
Amoxapine.............................. 28
Amoxicillin............................... 21
Amoxicillin-Potassium Clavulanate........................... 21
Amoxicillin-Potassium Clavulanate ER..................... 21
Amphetamine-Dextroamphetamine.............57
Amphetamine-Dextroamphetamine ER.......57
Amphotericin B....................... 29
Ampicillin................................. 21
Ampicillin Sodium...................21
Ampicillin-Sulbactam Sodium............................................... 21
Ampyra.................................... 58
150
Tracked
Anadrol-50............................... 70
Anagrelide HCl........................ 48
Anastrozole............................. 34
Androderm.............................. 70
Anoro Ellipta............................ 87
Apokyn.....................................37
Apraclonidine HCl...................83
Aprepitant................................ 29
Apri...........................................70
Apriso.......................................80
Aptiom..................................... 25
Aptivus..................................... 43
Aralast NP................................65
Aranelle....................................70
Aranesp................................... 49
Arcalyst.................................... 78
Aripiprazole............................. 38
Aripiprazole ODT.................... 38
Aristada....................................38
Aristada Initio.......................... 38
Arnuity Ellipta.......................... 85
Ashlyna.................................... 70
Aspirin-Dipyridamole ER........ 50
Atazanavir Sulfate................... 43
Atenolol....................................51
Atenolol-Chlorthalidone..........53
Atomoxetine HCl.....................57
Atorvastatin Calcium.............. 55
Atovaquone............................. 36
Atovaquone-Proguanil HCl.....36
Atripla.......................................42
Atropine Sulfate...................... 82
Atrovent HFA........................... 86
Aubagio................................... 58
Aubra....................................... 70
Auryxia..................................... 63
Austedo................................... 57
Aviane...................................... 70
Avonex Pen............................. 58
Avonex Prefilled...................... 58
Azasite..................................... 22
Azathioprine............................ 76
Azelaic Acid.............................59
Azelastine HCl...................83, 85
Azithromycin........................... 22
Azopt........................................83
Aztreonam............................... 21
B
Bacitracin.................................18
Bacitracin-Polymyxin B...........82
Baclofen...................................88
Balsalazide Disodium............. 80
Balversa................................... 34
Balziva......................................70
Banzel...................................... 25
Baqsimi Two Pack.................. 46
Baraclude................................ 41
BCG Vaccine...........................79
Belsomra................................. 89
Benazepril HCl........................ 51
Benazepril-Hydrochlorothiazide............................................... 53
Benlysta................................... 78
Benznidazole...........................36
Benzoyl Peroxide-Erythromycin............................................... 59
Benztropine Mesylate.............37
Bepreve................................... 83
Berinert.................................... 76
Besivance................................ 23
Betamethasone Dipropionate............................................... 67
Betamethasone Dipropionate Aug........................................ 67
Betamethasone Valerate........ 67
Betaseron................................ 58
Betaxolol HCl.................... 51, 83
Bethanechol Chloride.............67
Bethkis..................................... 86
Betimol.....................................83
Bevespi Aerosphere............... 88
Bexarotene.............................. 36
Bexsero....................................79
Bicalutamide........................... 32
Bicillin C-R............................... 21
Bicillin C-R 900/300................21
Bicillin L-A................................ 21
BiDil..........................................53
Biktarvy.................................... 42
Binosto.....................................81
Bisoprolol Fumarate............... 51
Bisoprolol-Hydrochlorothiazide............................................... 53
Blephamide............................. 82
Blephamide S.O.P.................. 82
Blisovi 24 Fe............................ 71
Blisovi Fe 1.5/30..................... 71
Boostrix....................................79
Bosentan................................. 87
Bosulif...................................... 34
Braftovi.....................................34
Breo Ellipta.............................. 88
Briellyn..................................... 71
151
Tracked
Brilinta......................................50
Brimonidine Tartrate...............83
BRIVIACT.................................24
Bromocriptine Mesylate......... 37
Brukinsa...................................34
Budesonide.......................81, 85
Budesonide ER....................... 81
Bumetanide............................. 54
Buprenorphine........................ 14
Buprenorphine HCl.................17
Buprenorphine HCl-Naloxone HCl......................................... 17
Bupropion HCl........................ 27
Bupropion HCl SR............ 17, 27
Bupropion HCl XL...................27
Buspirone HCl.........................44
Butalbital-Acetaminophen-Caffeine................................. 14
Butalbital-Aspirin-Caffeine......14
Butorphanol Tartrate.............. 15
Bydureon................................. 45
Bydureon BCise...................... 45
Byetta 10MCG Pen................. 45
Byetta 5MCG Pen................... 45
Bystolic.................................... 51
C
Cabergoline.............................75
Cablivi...................................... 50
Cabometyx.............................. 34
Calcipotriene........................... 59
Calcitonin Salmon...................81
Calcitriol............................ 59, 81
Calcium Acetate......................63
Calquence............................... 34
Camila......................................74
Camrese Lo............................. 71
Canasa.....................................80
Candesartan Cilexetil............. 50
Candesartan Cilexetil-HCTZ............................................... 53
Caprelsa.................................. 34
Captopril.................................. 51
Captopril-Hydrochlorothiazide............................................... 53
Carac........................................59
Carafate................................... 65
Carbaglu.................................. 61
Carbamazepine.......................26
Carbamazepine ER.......... 25, 26
Carbidopa................................37
Carbidopa-Levodopa..............37
Carbidopa-Levodopa ER........37
Carbidopa-Levodopa ODT..... 37
Carbidopa-Levodopa-Entacapone...........................37
Carteolol HCl........................... 83
Cartia XT.................................. 52
Carvedilol.................................51
Cayston....................................86
Caziant..................................... 71
Cefaclor................................... 19
Cefadroxil................................ 19
Cefazolin Sodium....................19
Cefdinir.............................. 19, 20
Cefepime HCl..........................20
Cefixime...................................20
Cefotetan Disodium................20
Cefoxitin Sodium.................... 20
Cefpodoxime Proxetil............. 20
Cefprozil.................................. 20
Ceftazidime............................. 20
Ceftriaxone Sodium................ 20
Cefuroxime Axetil....................20
Cefuroxime Sodium................20
Celecoxib.................................14
Celontin................................... 24
Cephalexin...............................20
Cesamet.................................. 29
Cetirizine HCl.......................... 85
Chantix.....................................17
Chantix Continuing Month Pak............................................... 17
Chantix Starting Month Pak... 17
Chemet.................................... 63
Chenodal................................. 64
Chlordiazepoxide HCl............ 44
Chlorhexidine Gluconate....... 59
Chloroquine Phosphate......... 36
Chlorothiazide......................... 55
Chlorpromazine HCl............... 38
Chlorthalidone.........................55
Chlorzoxazone........................ 88
Cholbam.................................. 65
Cholestyramine....................... 56
Cholestyramine Light............. 55
Ciclopirox................................ 29
Ciclopirox Olamine................. 29
Cilostazol................................. 50
Ciloxan..................................... 23
Cimduo.................................... 42
Cimetidine............................... 64
Cimetidine HCl........................ 64
Cimzia...................................... 76
152
Tracked
Cimzia Prefilled....................... 76
Cinacalcet HCl........................ 81
Cinryze..................................... 76
Cipro HC.................................. 85
Ciprodex.................................. 85
Ciprofloxacin HCl....................23
Ciprofloxacin in D5W..............23
Citalopram Hydrobromide..... 27
Claravis.................................... 59
Clarithromycin......................... 22
Clarithromycin ER................... 22
Clenpiq.................................... 64
Climara Pro..............................71
Clindamycin HCl..................... 18
Clindamycin Palmitate HCl.... 18
Clindamycin Phosphate... 18, 59
Clindamycin Phosphate in D5W............................................... 18
Clindamycin Phosphate-Benzoyl Peroxide..................59
Clobazam................................ 25
Clobetasol Propionate............67
Clobetasol Propionate Emollient Base...................... 67
Clomipramine HCl.................. 28
Clonazepam............................ 44
Clonazepam ODT................... 44
Clonidine................................. 50
Clonidine HCl.......................... 50
Clonidine HCl ER.................... 57
Clopidogrel Bisulfate.............. 50
Clorazepate Dipotassium....... 44
Clotrimazole............................ 29
Clotrimazole-Betamethasone............................................... 59
Clozapine.................................40
Clozapine ODT........................41
Coartem................................... 36
Codeine Sulfate...................... 15
Colchicine................................31
Colcrys..................................... 31
Colesevelam HCl.................... 56
Colestipol HCl......................... 56
Colistimethate Sodium........... 18
Colocort................................... 81
Combigan................................ 83
Combivent Respimat.............. 88
Cometriq..................................34
Complera................................. 42
Compro....................................28
Constulose.............................. 64
Copiktra................................... 33
Cordran....................................67
Corlanor................................... 53
Cortisone Acetate................... 67
Cortisporin...............................59
Cosentyx..................................59
Cosentyx Sensoready.............60
Cosopt PF................................83
Cotellic..................................... 34
Coumadin................................ 48
Creon....................................... 66
Crinone.................................... 74
Crixivan.................................... 43
Cromolyn Sodium...... 64, 83, 87
Cryselle-28...............................71
Cuvposa...................................64
Cyclafem 1/35.........................71
Cyclafem 7/7/7....................... 71
Cyclobenzaprine HCl..............88
Cyclophosphamide.................32
Cycloset................................... 45
Cyclosporine........................... 76
Cyclosporine Modified........... 76
Cyproheptadine HCl............... 85
Cyred....................................... 71
Cystadane................................66
Cystagon..................................66
Cystaran...................................82
D
Dalfampridine ER....................58
Daliresp....................................87
Dalvance.................................. 18
Danazol.................................... 70
Dantrolene Sodium.................88
Dapsone.................................. 32
Daptacel.................................. 79
Daptomycin............................. 18
DARAPRIM.............................. 36
Daurismo................................. 34
Deblitane................................. 74
Deferasirox.............................. 63
Delstrigo.................................. 42
Demeclocycline HCl............... 24
Demser.................................... 53
Denavir.....................................41
Depen Titratabs...................... 67
Depo-Estradiol.........................71
Depo-Provera.......................... 74
Descovy................................... 42
Desipramine HCl.....................28
Desmopressin Acetate........... 69
153
Tracked
Desmopressin Acetate Spray............................................... 69
Desogestrel-Ethinyl Estradiol............................................... 71
Desonide................................. 67
Desoximetasone..................... 68
Desvenlafaxine Succinate ER............................................... 27
Dexamethasone...................... 68
Dexamethasone Intensol........68
Dexamethasone Sodium Phosphate............................. 84
Dexilant.................................... 65
Dexmethylphenidate HCl....... 57
Dexmethylphenidate HCl ER............................................... 57
Dextroamphetamine Sulfate............................................... 57
Dextroamphetamine Sulfate ER............................................... 57
Dextrose.................................. 61
Dextrose-NaCl......................... 61
Diastat AcuDial........................25
Diastat Pediatric...................... 25
Diazepam.................................44
Diazepam Intensol.................. 44
Diclofenac Epolamine............ 14
Diclofenac Potassium.............14
Diclofenac Sodium.....14, 60, 84
Diclofenac Sodium ER........... 14
Dicloxacillin Sodium............... 21
Dicyclomine HCl..................... 64
Didanosine.............................. 43
Dificid....................................... 22
Diflunisal.................................. 14
Digitek......................................53
Digox........................................53
Digoxin.....................................53
Dihydroergotamine Mesylate............................................... 31
Dilantin.....................................26
Dilantin INFATABS..................26
Dilt-XR...................................... 52
Diltiazem HCl...........................52
Diltiazem HCl ER.....................52
Diltiazem HCl ER Beads.........52
Diltiazem HCl ER Coated Beads............................................... 52
Dipentum................................. 80
Diphenoxylate-Atropine.......... 64
Diphtheria-Tetanus Toxoids DT............................................... 79
Disulfiram.................................17
Diuril.........................................55
Divalproex Sodium................. 45
Divalproex Sodium ER........... 45
Dofetilide................................. 51
Donepezil HCl......................... 26
Donepezil HCl ODT................ 26
Dorzolamide HCl.....................83
Dorzolamide HCl-Timolol Maleate..................................83
Dorzolamide HCl-Timolol Maleate Preservative Free... 83
Dovato......................................42
Doxazosin Mesylate................50
Doxepin HCl...................... 28, 60
Doxercalciferol........................ 81
Doxy 100..................................24
Doxycycline Hyclate............... 24
Doxycycline Monohydrate......24
Drizalma Sprinkle....................58
Dronabinol............................... 29
Drospirenone-Ethinyl Estradiol............................................... 71
Droxia.......................................33
Duavee..................................... 71
Dulera...................................... 88
Duloxetine HCl........................ 58
Duramorph.............................. 15
Durezol.....................................84
Dutasteride.............................. 66
Dymista.................................... 88
E
E.E.S. Granules....................... 22
Econazole Nitrate....................29
Edarbi.......................................50
Edarbyclor............................... 53
Edurant.................................... 42
Efavirenz.................................. 42
Egrifta.......................................75
Elestrin..................................... 71
Eliquis...................................... 48
Eliquis Starter Pack................ 48
Elmiron.....................................67
EluRyng................................... 71
Emcyt....................................... 33
Emgality................................... 31
Emoquette............................... 71
Emsam..................................... 27
Emtriva..................................... 43
Enalapril Maleate.................... 51
Enalapril-Hydrochlorothiazide............................................... 54
Enbrel.......................................76
154
Tracked
Enbrel Mini.............................. 76
Enbrel SureClick..................... 76
Endocet................................... 15
Engerix-B................................. 79
Enoxaparin Sodium................ 48
Enpresse-28............................ 71
Enskyce................................... 71
Entacapone............................. 37
Entecavir.................................. 41
Entresto................................... 54
Enulose.................................... 64
Envarsus XR............................ 76
Epclusa.................................... 41
Epidiolex.................................. 24
Epinastine HCl.........................83
Epinephrine............................. 86
EpiPen 2-Pak........................... 86
EpiPen Jr 2-Pak.......................86
Epitol........................................ 26
Epivir HBV............................... 41
Eplerenone.............................. 55
Eprosartan Mesylate............... 50
Eraxis....................................... 29
Ergotamine-Caffeine............... 31
Erivedge...................................34
Erleada.....................................32
Erlotinib HCl............................ 34
Errin..........................................74
Ertapenem Sodium.................21
Ery............................................ 60
Erythrocin Lactobionate......... 22
Erythromycin..................... 23, 60
Erythromycin Base..................22
Erythromycin Ethylsuccinate............................................... 23
Esbriet......................................87
Escitalopram Oxalate............. 27
Esomeprazole Magnesium.... 65
Estarylla................................... 71
Estradiol...................................71
Estradiol Valerate....................71
Estring......................................71
Ethacrynic Acid....................... 54
Ethambutol HCl.......................32
Ethosuximide...........................24
Ethynodiol Diacetate-Ethinyl Estradiol................................ 71
Etodolac...................................14
Etodolac ER.............................14
Etonogestrel-Ethinyl Estradiol............................................... 71
Eurax........................................ 37
Everolimus............................... 34
Evotaz...................................... 43
Exelderm..................................29
Exemestane.............................34
Ezetimibe................................. 56
Ezetimibe-Simvastatin............ 56
F
Falmina.................................... 71
Famciclovir.............................. 41
Famotidine...............................64
Fanapt......................................39
Fanapt Titration Pack............. 39
Farydak.................................... 34
Fayosim................................... 71
Febuxostat...............................31
Felbamate................................25
Felodipine ER..........................52
Femring....................................71
Femynor...................................71
Fenofibrate.............................. 55
Fenofibrate Micronized.......... 55
Fenofibric Acid........................ 55
Fentanyl................................... 15
Fentanyl Citrate....................... 15
Ferriprox.................................. 63
Fetzima.................................... 27
Fetzima Titration..................... 27
Finacea.................................... 60
Finasteride...............................66
Firazyr...................................... 76
Firmagon................................. 75
Flac...........................................85
Flarex....................................... 84
Flebogamma DIF.................... 78
Flecainide Acetate.................. 51
Flector...................................... 14
Flovent Diskus.........................85
Flovent HFA............................. 85
Fluconazole............................. 29
Fluconazole in Sodium Chloride............................................... 29
Flucytosine.............................. 29
Fludrocortisone Acetate.........68
Flunisolide............................... 85
Fluocinolone Acetonide... 68, 85
Fluocinolone Acetonide Scalp............................................... 68
Fluocinonide............................68
Fluocinonide Emulsified Base............................................... 68
Fluorometholone.....................84
155
Tracked
Fluorouracil............................. 60
Fluoxetine HCl.........................27
Fluphenazine Decanoate....... 38
Fluphenazine HCl................... 38
Flurbiprofen............................. 14
Flurbiprofen Sodium...............84
Flutamide.................................32
Fluticasone Propionate.... 68, 85
Fluticasone-Salmeterol........... 88
Fluvastatin Sodium................. 55
Fluvoxamine Maleate..............27
FML.......................................... 84
FML Forte................................ 84
Fondaparinux Sodium............ 48
Forteo.......................................81
Fosamprenavir Calcium......... 43
Fosinopril Sodium...................51
Fosinopril Sodium-HCTZ........54
FreAmine HBC........................ 61
Furosemide............................. 55
Fuzeon..................................... 43
Fyavolv..................................... 71
Fycompa.................................. 25
G
Gabapentin..............................25
Galantamine Hydrobromide............................................... 26
Galantamine Hydrobromide ER............................................... 26
Gammagard............................ 78
Gammagard S/D Less IgA..... 78
Gammaked..............................78
Gammaplex............................. 78
Gamunex-C..............................78
Gardasil 9................................ 79
Gatifloxacin..............................23
Gattex.......................................64
Gauze.......................................82
GaviLyte-C............................... 65
GaviLyte-G............................... 65
GaviLyte-N with Flavor Pack............................................... 65
Gemfibrozil.............................. 55
Generlac.................................. 65
Gengraf....................................76
Genotropin.............................. 69
Genotropin MiniQuick............ 69
Gentak..................................... 17
Gentamicin Sulfate................. 18
Gentamicin Sulfate-0.9% Sodium Chloride...................18
Genvoya...................................42
Geodon.................................... 39
Gianvi....................................... 71
Gilenya..................................... 58
Gilotrif...................................... 34
Glassia..................................... 66
Glatiramer Acetate..................58
Glatopa.................................... 58
Gleostine................................. 32
Glimepiride.............................. 45
Glipizide................................... 45
Glipizide ER.............................45
Glipizide-Metformin HCl......... 45
GlucaGen HypoKit.................. 46
Glucagon Emergency.............46
Glyxambi..................................45
Granisetron HCl...................... 29
Granix.......................................49
Griseofulvin Microsize............ 30
Griseofulvin Ultramicrosize.... 30
Guanfacine HCl ER.................57
Guanidine HCl.........................32
Gvoke PFS...............................46
H
Haegarda................................. 76
Hailey 24 Fe.............................71
Halobetasol Propionate..........68
Haloperidol.............................. 38
Haloperidol Decanoate.......... 38
Haloperidol Lactate................ 38
Havrix....................................... 79
Heparin Sodium...................... 48
HepatAmine............................ 61
Hetlioz...................................... 89
Hiberix......................................79
Humalog.................................. 47
Humalog Junior KwikPen.......47
Humalog KwikPen.................. 47
Humalog Mix 50/50................ 47
Humalog Mix 50/50 KwikPen............................................... 47
Humalog Mix 75/25................ 47
Humalog Mix 75/25 KwikPen............................................... 47
Humatrope.............................. 69
Humira..................................... 77
Humira Pediatric Crohns Start............................................... 77
Humira Pen..............................77
Humira Pen Crohns Disease Starter.................................... 77
156
Tracked
Humira Pen Psoriasis Starter............................................... 77
Humulin 70/30........................ 47
Humulin 70/30 KwikPen........ 47
Humulin N................................47
Humulin N KwikPen................47
Humulin R................................47
Humulin R U-500.....................47
Humulin R U-500 KwikPen..... 47
Hydralazine HCl...................... 56
Hydrochlorothiazide............... 55
Hydrocodone-Acetaminophen............................................... 16
Hydrocodone-Ibuprofen......... 16
Hydrocortisone................. 68, 81
Hydrocortisone Butyrate........ 68
Hydrocortisone Valerate.........68
Hydrocortisone-Acetic Acid... 85
Hydromorphone HCl.............. 16
Hydromorphone HCl ER........ 15
Hydromorphone HCl Preservative Free.................. 16
Hydroxychloroquine Sulfate............................................... 36
Hydroxyurea............................ 33
Hydroxyzine HCl..................... 44
Hydroxyzine Pamoate.............28
Hysingla ER............................. 15
I
Ibandronate Sodium............... 81
Ibrance.....................................35
Ibu............................................ 14
Ibuprofen................................. 14
Icatibant Acetate..................... 76
Iclusig.......................................35
IDHIFA......................................35
Ilevro........................................ 84
Imatinib Mesylate....................35
Imbruvica................................. 35
Imipenem-Cilastatin................ 21
Imipramine HCl....................... 28
Imipramine Pamoate.............. 28
Imiquimod............................... 60
Imiquimod Pump.................... 60
Imovax Rabies.........................79
Imvexxy Maintenance Pack... 71
Imvexxy Starter Pack.............. 71
Incassia....................................74
Increlex.................................... 69
Incruse Ellipta..........................86
Indapamide............................. 55
Indomethacin.......................... 14
Infanrix..................................... 79
Ingrezza................................... 57
Inlyta.........................................35
Inrebic...................................... 33
Insulin Lispro........................... 47
Insulin Syringes, Needles.......82
Intelence.................................. 42
Intralipid................................... 61
Intron A.................................... 41
Introvale................................... 71
Invega Sustenna..................... 39
Invega Trinza........................... 39
Invirase.....................................43
Invokamet................................ 45
Invokamet XR.......................... 45
Invokana.................................. 45
Ionosol-MB in D5W................. 61
IPOL......................................... 79
Ipratropium Bromide.............. 86
Ipratropium-Albuterol..............88
Irbesartan................................ 50
Irbesartan-Hydrochlorothiazide............................................... 54
Iressa........................................35
Isentress.................................. 42
Isentress HD............................ 42
Isibloom................................... 71
Isolyte-P in D5W...................... 61
Isolyte-S................................... 61
Isoniazid...................................32
Isosorbide Dinitrate................ 56
Isosorbide Mononitrate.......... 56
Isosorbide Mononitrate ER.... 56
Isotretinoin...............................60
Itraconazole............................. 30
Ivermectin................................ 36
Ixiaro........................................ 79
J
Jadenu..................................... 63
Jadenu Sprinkle...................... 63
Jakafi........................................35
Jantoven.................................. 48
Janumet................................... 45
Janumet XR............................. 45
Januvia.....................................45
Jardiance................................. 45
Jasmiel.....................................71
Jentadueto...............................46
Jentadueto XR.........................46
Jinteli........................................71
Jublia........................................30
157
Tracked
Juleber..................................... 71
Juluca...................................... 42
Junel 1.5/30............................ 72
Junel 1/20............................... 72
Junel Fe 1.5/30....................... 72
Junel Fe 1/20.......................... 72
Junel Fe 24.............................. 72
Juxtapid................................... 56
K
Kaitlib Fe.................................. 72
Kaletra......................................43
Kalydeco.................................. 88
Kariva....................................... 72
KCl in Dextrose-NaCl.............. 61
KCl-Lactated Ringers-D5W.... 61
Kelnor 1/35............................. 72
Kelnor 1/50............................. 72
Ketoconazole.......................... 30
Ketoprofen...............................14
Ketorolac Tromethamine....... 84
Kineret......................................77
Kinrix........................................ 79
Kionex...................................... 63
Kisqali...................................... 33
Kisqali Femara........................ 33
Klor-Con................................... 61
Klor-Con 10..............................61
Klor-Con 8................................61
Klor-Con M10.......................... 61
Klor-Con M15.......................... 61
Klor-Con M20.......................... 61
Klor-Con Sprinkle....................61
Korlym......................................70
Kurvelo.....................................72
Kuvan....................................... 66
L
Labetalol HCl...........................51
Lacrisert................................... 82
Lactulose................................. 65
Lamivudine........................41, 43
Lamivudine-Zidovudine.......... 43
Lamotrigine............................. 25
Lanoxin.................................... 54
Lansoprazole...........................65
Lanthanum Carbonate........... 63
Lantus...................................... 48
Lantus SoloStar.......................47
LARIN 1.5/30.......................... 72
LARIN 1/20............................. 72
LARIN Fe 1.5/30..................... 72
LARIN Fe 1/20........................ 72
Larissia.....................................72
Lastacaft.................................. 82
Latanoprost............................. 84
Latuda......................................39
Layolis Fe.................................72
Leena....................................... 72
Leflunomide............................ 78
Lenvima 10MG Daily Dose.....35
Lenvima 12MG Daily Dose.....35
Lenvima 14MG Daily Dose.....35
Lenvima 18MG Daily Dose.....35
Lenvima 20MG Daily Dose.....35
Lenvima 24MG Daily Dose.....35
Lenvima 4MG Daily Dose.......35
Lenvima 8MG Daily Dose.......35
Lessina.....................................72
Letrozole..................................34
Leucovorin Calcium................33
Leukeran..................................32
Leukine.................................... 49
Leuprolide Acetate................. 75
Levalbuterol HCl..................... 86
Levemir.................................... 48
Levemir FlexTouch................. 48
Levetiracetam..........................24
Levetiracetam ER....................24
Levo-T...................................... 75
Levobunolol HCl..................... 83
Levocarnitine...........................61
Levocetirizine Dihydrochloride............................................... 85
Levofloxacin............................ 23
Levofloxacin in D5W............... 23
Levonest.................................. 72
Levonorgestrel-Ethinyl Estradiol............................................... 72
Levonorgestrel-Ethinyl Estradiol & Ethinyl Estradiol................ 72
Levonorgestrel-Ethinyl Estradiol 91-Day....................................72
Levora 0.15/30........................72
Levorphanol Tartrate.............. 15
Levothyroxine Sodium............75
Levoxyl..................................... 75
Lexiva....................................... 43
Lidocaine................................. 17
Lidocaine HCl..........................17
Lidocaine Viscous...................17
Lidocaine-Prilocaine............... 17
Lindane.................................... 37
Linezolid.................................. 18
Linzess..................................... 64
158
Tracked
Liothyronine Sodium.............. 75
Lisinopril.................................. 51
Lisinopril-Hydrochlorothiazide............................................... 54
Lithium..................................... 45
Lithium Carbonate.................. 45
Lithium Carbonate ER............ 45
Lithostat................................... 67
Livalo........................................55
Lokelma................................... 63
Lonhala Magnair Refill Kit...... 86
Lonsurf.....................................33
Loperamide HCl......................64
Lopinavir-Ritonavir.................. 43
Lorazepam........................ 44, 45
Lorbrena.................................. 34
Lorcet.......................................16
Lorcet HD................................ 16
Lorcet Plus.............................. 16
Loryna...................................... 72
Losartan Potassium................ 50
Losartan Potassium-HCTZ..... 54
Lotemax................................... 84
Lotemax SM............................ 84
Loteprednol Etabonate...........84
Lovastatin................................ 55
Low-Ogestrel........................... 72
Loxapine Succinate................ 38
Lumigan...................................84
Lupaneta Pack........................ 75
Lupron Depot.......................... 75
Lutera.......................................72
Lynparza.................................. 35
Lysodren..................................75
Lyza.......................................... 74
M
M-M-R II....................................79
Magnesium Sulfate...........61, 62
Malathion................................. 37
Maprotiline HCl....................... 27
Marlissa................................... 72
Marplan....................................27
Matulane..................................32
Matzim LA................................52
Mavyret.................................... 41
Mayzent................................... 58
Meclizine HCl.......................... 28
Medroxyprogesterone Acetate............................................... 74
Mefloquine HCl....................... 36
Megestrol Acetate...................74
Mekinist................................... 35
Mektovi.................................... 35
Melodetta 24 Fe...................... 72
Meloxicam............................... 14
Memantine HCl....................... 26
Memantine HCl ER................. 26
Memantine HCl Titration Pak............................................... 26
Menactra..................................79
Menest..................................... 72
Mentax..................................... 30
Menveo.................................... 79
Mercaptopurine...................... 33
Meropenem............................. 21
Mesalamine............................. 81
Mesalamine ER....................... 81
Mesnex.................................... 36
Metadate ER............................57
Metaproterenol Sulfate...........86
Metformin HCl......................... 46
Metformin HCl ER................... 46
Methadone HCl....................... 15
Methazolamide........................54
Methenamine Hippurate........ 18
Methimazole............................ 76
Methotrexate........................... 77
Methotrexate Sodium............. 77
Methoxsalen Rapid.................60
Methscopolamine Bromide....64
Methyldopa..............................50
Methyldopa-Hydrochlorothiazide............. 54
Methylphenidate HCl.............. 57
Methylphenidate HCl ER........ 57
Methylprednisolone................ 68
Metoclopramide HCl.............. 28
Metolazone.............................. 55
Metoprolol Succinate ER....... 51
Metoprolol Tartrate................. 51
Metoprolol-Hydrochlorothiazide............................................... 54
Metronidazole................... 18, 19
Metronidazole in NaCl 0.79%............................................... 19
Mexiletine HCl......................... 51
Mibelas 24 Fe.......................... 72
Miconazole 3........................... 30
Microgestin 1.5/30................. 72
Microgestin 1/20.....................72
Microgestin Fe 1.5/30............ 72
Microgestin Fe 1/20............... 72
Midodrine HCl......................... 50
159
Tracked
Migergot.................................. 31
Miglitol..................................... 46
Miglustat.................................. 66
Mili............................................72
Minitran....................................56
Minocycline HCl...................... 24
Minoxidil.................................. 56
Mirtazapine..............................27
Mirtazapine ODT..................... 27
Mirvaso.................................... 60
Misoprostol..............................65
Modafinil.................................. 89
Moexipril HCl...........................51
Molindone HCl........................ 38
Mometasone Furoate....... 68, 85
Montelukast Sodium...............85
Morphine Sulfate.................... 16
Morphine Sulfate ER.............. 15
Moxifloxacin HCl..................... 23
Moxifloxacin HCl in NaCl....... 23
Multaq...................................... 51
Mupirocin................................ 19
Mupirocin Calcium................. 19
Myalept.................................... 64
Mycamine................................ 30
Mycophenolate Mofetil...........77
Mycophenolate Sodium......... 77
Myrbetriq................................. 66
N
Nabumetone........................... 14
Nadolol.................................... 51
Nafcillin Sodium...................... 22
Naftifine HCl............................ 30
Naftin........................................30
Naloxone HCl.......................... 17
Naltrexone HCl........................ 17
Namzaric..................................57
Naproxen................................. 14
Naproxen DR...........................14
Naratriptan HCl....................... 31
Narcan..................................... 17
Natacyn....................................30
Nateglinide.............................. 46
Natpara.................................... 81
Nayzilam.................................. 24
Nebupent.................................36
Necon 0.5/35.......................... 72
Nefazodone HCl......................27
Neomycin Sulfate....................18
Neomycin-Bacitracin-Polymyxin............................................... 82
Neomycin-Polymyxin-Bacitracin-Hydrocortisone..................... 82
Neomycin-Polymyxin-Dexamethasone....................82
Neomycin-Polymyxin-Gramicidin.............................82
Neomycin-Polymyxin-HC....... 82, 85
NephrAmine............................ 62
Nerlynx.....................................35
Neulasta...................................49
Neupogen................................49
Neupro..................................... 37
Nevirapine............................... 42
Nevirapine ER......................... 42
Nexavar....................................35
Niacin ER................................. 56
Niacor...................................... 56
Nicardipine HCl.......................52
Nicotrol.................................... 17
Nicotrol NS.............................. 17
Nifedipine ER.......................... 52
Nifedipine ER Osmotic Release............................................... 52
Nikki......................................... 72
Nilutamide............................... 33
Nimodipine.............................. 52
Ninlaro..................................... 34
Nitro-Bid...................................56
Nitrofurantoin.......................... 19
Nitrofurantoin Macrocrystal... 19
Nitrofurantoin Monohydrate...19
Nitroglycerin......................56, 57
Nitrostat................................... 57
Nora-BE....................................74
Norditropin FlexPro................ 69
Norethindrone......................... 74
Norethindrone Acetate........... 74
Norethindrone Acetate-Ethinyl Estradiol.......................... 72, 73
Norethindrone Acetate-Ethinyl Estradiol-Fe........................... 73
Norgestimate-Ethinyl Estradiol............................................... 73
Norgestimate-Ethinyl Estradiol Triphasic................................73
Normosol-M in D5W............... 62
Normosol-R in D5W................ 62
Normosol-R pH 7.4................. 62
Northera...................................50
Nortrel 0.5/35.......................... 73
Nortrel 1/35............................. 73
Nortrel 7/7/7........................... 73
160
Tracked
Nortriptyline HCl......................28
Norvir....................................... 43
Noxafil...................................... 30
Nubeqa.................................... 33
Nucala......................................88
Nucynta ER..............................15
Nuedexta................................. 58
Nuplazid...................................39
Nutrilipid.................................. 62
Nutropin AQ NuSpin 10......... 70
Nutropin AQ NuSpin 20......... 70
Nutropin AQ NuSpin 5............70
Nyamyc.................................... 30
Nymalize.................................. 52
Nystatin.................................... 30
Nystop......................................30
O
Ocaliva..................................... 66
Ocella....................................... 73
Octagam.................................. 78
Octreotide Acetate..................75
Odefsey................................... 42
Odomzo................................... 35
Ofev..........................................87
Ofloxacin..................................23
Ogestrel................................... 73
Olanzapine.............................. 39
Olanzapine ODT......................39
Olmesartan Medoxomil.......... 50
Olmesartan Medoxomil-HCTZ............................................... 54
Olmesartan-Amlodipine-HCTZ............................................... 54
Olopatadine HCl..................... 83
Omega-3-Acid Ethyl Esters.....56
Omeprazole.............................65
Ondansetron HCl.................... 29
Ondansetron ODT.................. 29
Opsumit................................... 87
Orencia.................................... 77
Orencia ClickJect....................77
Orenitram.................................87
Orfadin..................................... 66
Orkambi................................... 86
Orsythia....................................73
Oseltamivir Phosphate........... 44
Osphena.................................. 74
Otezla.......................................78
Oxacillin Sodium..................... 22
Oxacillin Sodium in Dextrose............................................... 22
Oxandrolone............................70
Oxcarbazepine........................ 26
Oxsoralen Ultra....................... 60
Oxybutynin Chloride............... 66
Oxybutynin Chloride ER......... 66
Oxycodone HCl.......................16
Oxycodone-Acetaminophen............................................... 16
Oxycodone-Aspirin................. 16
Oxycodone-Ibuprofen.............16
Ozempic.................................. 46
P
Pacerone................................. 51
Paliperidone ER...................... 39
Panretin................................... 36
Pantoprazole Sodium............. 65
Panzyga................................... 78
Paricalcitol............................... 81
Paromomycin Sulfate............. 18
Paroxetine HCl........................ 27
Paser........................................ 32
Paxil..........................................28
Pazeo....................................... 83
Pediarix.................................... 80
Pedvax HIB.............................. 80
PEG 3350/Electrolytes........... 65
PEG-3350-Electrolytes............ 65
PEG-3350-NaCl-Na Bicarbonate-KCl....................65
Peganone................................ 26
Pegasys................................... 41
Pegasys ProClick.................... 41
Penicillamine........................... 67
Penicillin G Potassium............22
Penicillin G Procaine.............. 22
Penicillin G Sodium................ 22
Penicillin V Potassium............ 22
PENTAM 300...........................36
Pentamidine Isethionate.........36
Pentasa.................................... 81
Pentoxifylline ER..................... 54
Perforomist.............................. 86
Perindopril Erbumine..............51
Permethrin...............................37
Perphenazine.......................... 28
Perseris.................................... 39
Phenadoz.................................85
Phenelzine Sulfate.................. 27
Phenobarbital.......................... 25
Phenoxybenzamine HCl......... 50
Phenytek..................................26
161
Tracked
Phenytoin.................................26
Phenytoin Sodium Extended............................................... 26
Phoslyra................................... 63
Phospholine Iodide.................83
Picato....................................... 60
Pifeltro......................................42
Pilocarpine HCl................. 59, 84
Pimecrolimus.......................... 60
Pimozide.................................. 38
Pimtrea.....................................73
Pindolol....................................52
Pioglitazone HCl..................... 46
Pioglitazone HCl-Glimepiride............................................... 46
Pioglitazone HCl-Metformin HCl............................................... 46
Piperacillin-Tazobactam......... 22
Piqray....................................... 34
Pirmella 1/35...........................73
Piroxicam.................................14
Plasma-Lyte 148......................62
Plasma-Lyte A......................... 62
Plenamine................................62
Podofilox..................................60
Polymyxin B Sulfate................ 19
Polymyxin B-Trimethoprim.....82
Pomalyst.................................. 33
Portia-28.................................. 73
Posaconazole..........................30
Potassium Chloride................ 62
Potassium Chloride CR.......... 62
Potassium Chloride ER.......... 62
Potassium Chloride in Dextrose............................................... 62
Potassium Chloride in NaCl... 62
Potassium Citrate ER..............62
Praluent................................... 56
Pramipexole Dihydrochloride............................................... 37
Prasugrel HCl.......................... 50
Pravastatin Sodium.................55
Praziquantel............................ 36
Prazosin HCl............................50
Pred Mild................................. 84
Pred-G......................................82
Pred-G S.O.P........................... 82
Prednicarbate..........................69
Prednisolone........................... 69
Prednisolone Acetate............. 84
Prednisolone Sodium Phosphate.......................69, 84
Prednisone.............................. 69
Prednisone Intensol................69
Pregabalin............................... 58
Premarin.................................. 73
Premasol..................................62
Premphase.............................. 73
Prempro...................................73
Prevalite................................... 56
Previfem...................................73
Prezcobix................................. 44
Prezista.................................... 44
Priftin........................................32
Prilosec.................................... 65
Primaquine Phosphate...........36
Primidone................................ 25
Privigen.................................... 78
ProAir HFA...............................86
ProAir RespiClick....................86
Probenecid.............................. 31
Probenecid-Colchicine........... 31
Procalamine............................ 62
Prochlorperazine.....................28
Prochlorperazine Maleate...... 28
Procrit................................ 49, 50
Procto-Med HC....................... 81
Procto-Pak............................... 81
Proctosol HC........................... 81
Proctozone-HC........................ 81
Progesterone Micronized.......74
Proglycem............................... 47
Prograf..................................... 77
Prolastin-C............................... 66
Prolensa...................................84
Prolia........................................ 82
Promacta................................. 50
Promethazine HCl................... 85
Promethegan...........................85
Propafenone HCl.................... 51
Propafenone HCl ER.............. 51
Proparacaine HCl....................82
Propranolol HCl...................... 52
Propranolol HCl ER................ 52
Propranolol-HCTZ................... 54
Propylthiouracil....................... 76
ProQuad.................................. 80
Prosol....................................... 62
Protriptyline HCl...................... 28
Pulmozyme..............................88
Purixan..................................... 33
Pyrazinamide...........................32
Pyridostigmine Bromide.........32
162
Tracked
Pyridostigmine Bromide ER...32
Q
Quadracel................................ 80
Quetiapine Fumarate.............. 40
Quetiapine Fumarate ER........ 39
Quinapril HCl........................... 51
Quinapril-Hydrochlorothiazide............................................... 54
Quinidine Gluconate ER.........51
Quinidine Sulfate.................... 51
Quinine Sulfate........................36
R
RabAvert..................................80
Rabeprazole Sodium.............. 65
Raloxifene HCl........................ 74
Ramelteon............................... 89
Ramipril................................... 51
Ranitidine HCl......................... 64
Ranolazine ER.........................54
Rasagiline Mesylate................37
Rasuvo..................................... 77
RAVICTI................................... 66
Rayaldee..................................82
Rebif.........................................58
Rebif Rebidose....................... 58
Rebif Rebidose Titration Pack............................................... 58
Rebif Titration Pack................ 58
Reclipsen.................................73
Recombivax HB...................... 80
Rectiv....................................... 57
Regranex................................. 60
Relenza Diskhaler................... 44
Relistor.....................................64
Repaglinide............................. 46
Repatha................................... 56
Repatha Pushtronex System............................................... 56
Repatha SureClick..................56
Rescriptor................................ 42
Restasis................................... 82
Retacrit.................................... 50
Revlimid................................... 33
Rexulti...................................... 40
Reyataz.................................... 44
Rhopressa............................... 83
Ribavirin...................................41
Ridaura.................................... 79
Rifabutin.................................. 32
Rifampin.................................. 32
Rifater...................................... 32
Riluzole.................................... 58
Rimantadine HCl.....................44
Riomet..................................... 46
Risedronate Sodium...............82
Risperdal Consta.................... 40
Risperidone............................. 40
Risperidone ODT.................... 40
Ritonavir...................................44
Rivastigmine............................26
Rivastigmine Tartrate............. 26
Rivelsa..................................... 73
Rizatriptan Benzoate.............. 31
Rizatriptan Benzoate ODT..... 31
Rocklatan................................ 84
Ropinirole HCl.........................37
Rosuvastatin Calcium.............55
Rotarix......................................80
RotaTeq................................... 80
Roweepra................................ 24
Roweepra XR.......................... 24
Rozlytrek..................................34
Rubraca................................... 34
Ruconest................................. 76
Rybelsus.................................. 46
Rydapt..................................... 35
Rytary....................................... 37
S
Saizen...................................... 70
Saizenprep.............................. 70
Sancuso................................... 29
Sandimmune........................... 77
Santyl....................................... 60
Saphris.....................................40
Savella......................................58
Savella Titration Pack............. 58
Scopolamine........................... 28
Selegiline HCl..........................37
Selenium Sulfide..................... 60
Selzentry.................................. 43
Serevent Diskus...................... 86
Serostim...................................64
Sertraline HCl.......................... 28
Setlakin.................................... 73
Sevelamer Carbonate............. 63
Sharobel.................................. 74
Shingrix....................................80
Signifor.................................... 75
Sildenafil Citrate......................87
Silodosin.................................. 66
Silver Sulfadiazine...................23
Simbrinza.................................84
163
Tracked
Simponi....................................77
Simvastatin.............................. 55
Sirolimus..................................77
Sirturo...................................... 32
Sodium Chloride...............62, 63
Sodium Fluoride......................63
Sodium Lactate....................... 63
Sodium Phenylbutyrate.......... 66
Sodium Polystyrene Sulfonate............................................... 63
Sofosbuvir-Velpatasvir............ 41
Solifenacin Succinate............. 66
Soliqua..................................... 46
Soltamox..................................33
Somatuline Depot................... 75
Somavert................................. 76
Sotalol HCl...............................51
Sovaldi..................................... 41
Spiriva HandiHaler.................. 86
Spiriva Respimat..................... 86
Spironolactone........................55
Spironolactone-HCTZ.............54
Sprintec 28.............................. 73
Spritam.................................... 24
Sprycel..................................... 35
SPS.......................................... 63
Sronyx...................................... 73
SSD.......................................... 23
Stavudine.................................43
Stelara......................................60
Stiolto Respimat......................88
Stivarga.................................... 35
Streptomycin Sulfate.............. 18
Stribild......................................42
Suboxone................................ 17
Sucraid.....................................66
Sucralfate................................ 65
Sulfacetamide Sodium........... 23
Sulfacetamide-Prednisolone............................................... 83
Sulfadiazine............................. 23
Sulfamethoxazole-Trimethoprim......................................... 23, 24
Sulfamylon...............................19
Sulfasalazine........................... 81
Sulindac...................................14
Sumatriptan.............................31
Sumatriptan Succinate.....31, 32
Sumatriptan Succinate Refill............................................... 31
Suprax......................................20
Suprep Bowel Prep Kit........... 65
Sutent.......................................35
Syeda....................................... 73
Sylatron....................................41
Symbicort................................ 88
Symfi........................................ 42
Symfi Lo...................................42
SymlinPen 120........................ 46
SymlinPen 60.......................... 46
Sympazan................................ 25
Symtuza................................... 44
Synarel..................................... 76
Synjardy................................... 46
Synjardy XR............................. 46
Synribo.....................................34
Synthroid................................. 75
T
Tabloid..................................... 33
Tacrolimus........................ 60, 77
Tadalafil................................... 87
Tafinlar..................................... 35
Tagrisso................................... 35
Talzenna.................................. 34
Tamoxifen Citrate................... 33
Tamsulosin HCl.......................66
Targretin.................................. 36
Tarina 24 Fe............................ 73
Tarina Fe 1/20.........................73
Tasigna.................................... 35
Tazarotene...............................60
Tazicef..................................... 20
Tazorac.................................... 60
Taztia XT.................................. 52
TDVAX..................................... 80
Tecfidera..................................59
Tecfidera Starter Pack............58
Tegsedi.................................... 66
Telmisartan..............................51
Telmisartan-Amlodipine......... 54
Telmisartan-HCTZ...................54
Temazepam.............................89
Tenivac.................................... 80
Tenofovir Disoproxil Fumarate............................................... 43
Terazosin HCl..........................67
Terbinafine HCl....................... 30
Terconazole.............................30
Testosterone........................... 70
Testosterone Cypionate......... 70
Testosterone Enanthate......... 70
Tetrabenazine......................... 58
Tetracycline HCl......................24
164
Tracked
Thalomid..................................33
Theophylline............................87
Theophylline ER......................87
Thioridazine HCl..................... 38
Thiothixene..............................38
Tiadylt ER................................ 52
Tiagabine HCl......................... 25
Tibsovo.................................... 35
Tigecycline.............................. 19
Timolol Maleate................ 31, 84
Timolol Maleate Ophthalmic Gel Forming.......................... 84
Tinidazole................................ 19
Tivicay...................................... 42
Tizanidine HCl......................... 88
TOBI Podhaler.........................87
TobraDex................................. 83
TobraDex ST........................... 83
Tobramycin....................... 18, 87
Tobramycin Sulfate.................18
Tobramycin-Dexamethasone............................................... 83
Tobrex......................................18
Tolak........................................ 60
Tolcapone................................37
Topiramate.............................. 25
Toremifene Citrate.................. 33
Torsemide............................... 55
Toujeo Max SoloStar.............. 48
Toujeo SoloStar...................... 48
TPN Electrolytes..................... 63
Tracleer....................................87
Tradjenta................................. 46
Tramadol HCl.......................... 16
Tramadol HCl ER.................... 15
Tramadol-Acetaminophen..... 16
Trandolapril............................. 51
Tranexamic Acid..................... 50
Transderm-Scop..................... 29
Tranylcypromine Sulfate........ 27
Travasol................................... 63
Travoprost............................... 84
Trazodone HCl........................ 28
Trecator................................... 32
Trelegy Ellipta..........................88
Trelstar Mixject........................76
Tresiba..................................... 48
Tresiba FlexTouch.................. 48
Tretinoin............................ 36, 60
Tretinoin Microsphere............ 60
Trexall...................................... 77
Trezix....................................... 16
Tri-Estarylla.............................. 73
Tri-Legest Fe............................73
Tri-Lo-Estarylla.........................73
Tri-Lo-Sprintec.........................73
Tri-Mili...................................... 73
Tri-Previfem............................. 73
Tri-Sprintec.............................. 73
Tri-VyLibra............................... 74
Tri-VyLibra Lo.......................... 74
Triamcinolone Acetonide...... 59, 69
Triamterene............................. 55
Triamterene-HCTZ.................. 54
Triderm.................................... 69
Trientine HCl........................... 63
Trifluoperazine HCl................. 38
Trifluridine............................... 42
Trihexyphenidyl HCl............... 37
TriLyte...................................... 65
Trimethoprim...........................19
Trimipramine Maleate............ 28
Trintellix................................... 28
Triumeq................................... 42
Trivora...................................... 73
TrophAmine.............................63
Trulicity.................................... 46
Trumenba................................ 80
Truvada....................................43
Turalio...................................... 35
Twinrix......................................80
Tybost...................................... 42
Tykerb...................................... 35
Tymlos..................................... 82
Typhim Vi.................................80
U
Udenyca...................................50
Unithroid.................................. 75
Ursodiol................................... 64
V
Valacyclovir HCl...................... 42
Valchlor....................................32
Valganciclovir HCl...................41
Valproic Acid........................... 25
Valsartan.................................. 51
Valsartan-Hydrochlorothiazide............................................... 54
Vancomycin HCl..................... 19
Vandazole................................ 19
VAQTA..................................... 80
Varivax..................................... 80
165
Tracked
Varizig...................................... 78
Vascepa................................... 56
Velivet...................................... 74
Velphoro.................................. 63
Veltassa................................... 63
Vemlidy.................................... 41
Venclexta................................. 35
Venclexta Starting Pack......... 35
Venlafaxine HCl.......................28
Venlafaxine HCl ER.................28
Ventavis................................... 87
Verapamil HCl......................... 53
Verapamil HCl ER................... 53
Versacloz................................. 41
Verzenio................................... 34
Vibramycin...............................24
Victoza..................................... 46
Videx........................................ 43
Videx EC.................................. 43
Vienva...................................... 74
Vigabatrin................................ 25
Vigadrone................................ 25
Viibryd...................................... 28
Viibryd Starter Pack................ 28
Vimpat......................................26
Viracept....................................44
Viread.......................................43
Vitrakvi............................... 35, 36
Vivitrol...................................... 17
Vizimpro...................................36
Voriconazole............................30
Vosevi...................................... 41
Votrient.................................... 36
VP-PNV-DHA............................63
Vraylar...................................... 40
Vyfemla.................................... 74
VyLibra.....................................74
Vyndamax................................54
Vyndaqel..................................54
Vyvanse....................................57
Vyzulta..................................... 85
W
Warfarin Sodium..................... 48
Wixela Inhub............................88
WYMZYA Fe............................ 74
X
Xalkori...................................... 36
Xarelto......................................48
Xarelto Starter Pack................48
Xatmep.....................................77
Xeljanz..................................... 78
Xeljanz XR............................... 78
Xgeva....................................... 82
Xifaxan..................................... 64
Xiidra........................................ 83
Xofluza..................................... 44
Xolair........................................ 79
Xospata....................................36
Xpovio...................................... 33
Xtampza ER.............................15
Xtandi.......................................33
Xulane...................................... 74
Xyrem.......................................89
Y
YF-Vax...................................... 80
Yuvafem................................... 74
Z
Zafirlukast................................ 86
Zaleplon................................... 89
Zarah........................................74
Zarxio....................................... 50
Zejula....................................... 34
Zelapar.....................................38
Zelboraf................................... 36
Zemaira....................................66
Zenpep.................................... 66
Zerbaxa....................................21
Zidovudine...............................43
Zileuton ER..............................86
Zioptan.....................................85
Ziprasidone HCl...................... 40
Zirgan.......................................41
Zolinza..................................... 34
Zolpidem Tartrate................... 89
Zonisamide..............................24
Zorbtive....................................64
Zortress....................................78
Zostavax.................................. 80
Zovia 1/35E............................. 74
Zyclara Pump.......................... 61
Zydelig..................................... 36
Zyflo......................................... 86
Zykadia.................................... 36
Zyprexa Relprevv.................... 40
166
UHNJ20HM4535869_003 Last updated March 1, 2020
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