Complete Drug List (Formulary) 2021

Complete Drug List(Formulary) 2021

UnitedHealthcare® Group Medicare Advantage (PPO)

Illinois Department of Central Management Services College Insurance Program (CIP)

Important Notes: This document has information about the drugs covered by this plan. For more

up-to-date information or if you have any questions, please call Customer Service at:

Toll-free 1-888-223-1092, TTY 7118 a.m. - 8 p.m. local time, Monday - Friday

www.UHCRetiree.com/soi

Formulary ID Number 00021068, Version 23

Y0066_052820_104500_C Last updated September 1, 2021

Table Of Contents

What is a drug list?......................................................................................................................................3

Note to existing members:......................................................................................................................... 3

How do I use the drug list?.........................................................................................................................4

What are generic drugs?............................................................................................................................ 4

What is a compounded drug?....................................................................................................................4

Drug payment stage and drug tiers...........................................................................................................5

Getting Extra Help.......................................................................................................................................5

Are there any rules or limits on my drug coverage?................................................................................ 6

What if my drug is not on this list?.............................................................................................................8

How can I get an exception?......................................................................................................................8

Can I get my drug while I wait for an exception?......................................................................................9

Can the drug list change?........................................................................................................................ 10

Drugs with dosages other than a 1-month supply..................................................................................11

Covered drugs by name (Drug index)....................................................................................................12

Covered drugs by medical condition...................................................................................................... 40

Covered drugs with a quantity limit (QL).............................................................................................. 157

3What is a drug list?

A drug list, or formulary, is a list of prescription drugs covered by your plan. Your plan and a team

of health care providers work together in selecting drugs that are needed for well-rounded care and

treatment.

Your plan will generally cover the drugs listed in our drug list as long as:

· The drug is used for a medically accepted indication,

· The prescription is filled at a network pharmacy and

· Other plan rules are followed.

For more information about your drug coverage, please review your Evidence of Coverage.

Note to existing members:

This complete list of prescription drugs covered by your plan is current as of September 1, 2021.

For an up-to-date list of covered drugs or if you have questions, please call Customer Service. Our

contact information is on the cover.

This drug list has changed since last year. Please review this document to make sure your

prescription drugs are still covered. In most cases, you must use network pharmacies to have your

prescriptions covered by the plan.

When this drug list refers to “we,” “us,” or “our,” it means UnitedHealthcare. When it refers to

“plan,” “our plan,” or “your plan,” it means UnitedHealthcare Group Medicare Advantage.

4

How do I use the drug list?

There are 2 ways to find your prescription drugs in this drug list:

1. By name. Turn to section “Covered drugs by name (Drug index)” on pages 12–39 to see the

.......list of drug names in alphabetical order. Find the name of your drug. The page number where

.......you can find the drug will be next to it.

2. By medical condition. Turn to section “Covered drugs by medical condition” on pages

.......40–156 to look for drugs based on your medical conditions. For example, if you have a heart

.......condition, you should look in the category Cardiovascular Agents. This is where you will find

.......drugs that treat heart conditions.

What are generic drugs?

Generic drugs have the same active ingredients as brand name drugs. They usually cost less than

brand name drugs and are approved by the Food and Drug Administration (FDA). Our plan covers

both brand name and generic drugs.

Talk with your doctor to see if any of the brand name drugs you take have generic versions. Then

review the drug list to make sure you are getting the drug you need for the least amount of money.

The drug list shows brand name drugs in bold type (for example, Humalog) and generic drugs in

plain type (for example, Simvastatin).

What is a compounded drug?

A compounded drug is created by a pharmacist by combining or mixing ingredients to create a

prescription medication customized to the needs of an individual patient. Compounded drugs may

be Part D eligible. For more information about compounded drugs, please review your Evidence of

Coverage.

5

Drug payment stage and drug tiers

The amount you pay for a covered prescription drug will depend on:

· Your drug payment stage. Your plan has different stages of drug coverage. When you fill a

prescription, the amount you pay depends on the coverage stage you’re in.

· Your drug’s tier. Each covered drug is in 1 of 4 drug tiers. Each tier has a copay or coinsurance

amount. The chart below shows the differences between the tiers.

If you need help or have any questions about your drug costs, please review your Evidence of

Coverage or call Customer Service. Our contact information is on the cover.

Drug Tier Includes

Tier 1:

Preferred generic

Most generic drugs.

Tier 2:

Preferred brand

Many common brand name drugs, called preferred

brands and some higher-cost generic drugs.

Tier 3:

Non-preferred drug

Non-preferred generic and non-preferred brand name

drugs. In addition, Part D eligible compound medications

are covered in Tier 3.

Tier 4:

Specialty tier

Unique and/or very high-cost brand and generic drugs.

Getting Extra Help

If you qualify for Extra Help paying for your prescription drugs, your copays and coinsurance may

be lower. Members who qualify for Extra Help will receive the “Evidence of Coverage Rider for

People Who Get Extra Help Paying for Prescription Drugs” (LIS Rider). Please read it to learn about

your costs. You can also call Customer Service. Our contact information is on the cover.

6

Are there any rules or limits on my drug coverage?Yes, some drugs may have coverage rules or have limits on the amount you can get. If your drug

has any coverage rules or limits, there will be a code(s) in the “Coverage Rules or Limits on use”

column of the “Covered drugs by medical condition” chart starting on page 40. The codes and

what they mean are shown below and on the next page.

You can also get more information about the coverage rules and/or limits applied to specific

covered drugs by visiting our website. We have posted online documents that explain our prior

authorization and step therapy restrictions. If you would like a copy sent to you, please call

Customer Service. Our contact information is on the cover.

Coverage Rules and Limits

PA - Prior authorization

The plan requires you or your doctor to get prior approval for certain drugs. This means the plan

needs more information from your doctor to make sure the drug is being used and covered

correctly by Medicare for your medical condition. Certain drugs may be covered by either Medicare

Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs) depending on

how it is used. If you don’t get prior approval, the plan may not cover the drug.

QL - Quantity limits

The plan will cover only a certain amount of this drug for 1 copay/coinsurance or over a certain

number of days. These limits may be in place to ensure safe and effective use of the drug. 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.

ST - Step therapy

There may be effective, lower-cost drugs that treat the same medical condition as this drug. You

may be required to try 1 or more of these other drugs before the plan will cover your drug. If you

have already tried other drugs or your doctor thinks they are not right for you, you or your doctor

can ask the plan to cover this drug.

7

Other Special Coverage Rules

B/D - Medicare Part B or Part D

Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and

outpatient health care) or Medicare Part D (prescription drugs). 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 by Medicare.

HRM - High-risk medication

This drug is known as a high-risk medication (HRM) for patients 65 years and older. This drug

may cause side effects if taken on a regular basis. We suggest you talk with your doctor to see if

an alternative drug is available to treat your condition.

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.

You and your doctor may ask the plan for an exception to the coverage rules and/or limits for your

drug. See section “How can I get an exception?" on page 8 or see your Evidence of Coverage to

learn more.

If you don’t get approval from the plan before you fill a prescription for a drug with coverage rules

or limits, you may have to pay the full cost of the drug.

8

What if my drug is not on this list?

If your drug is not included in this drug list we may still cover it. Call Customer Service to ask if it’s

covered. Our contact information, along with the date we last updated the drug list is on the cover.

If you find out that your drug is not covered, you can do 1 of these things:

1. Ask Customer Service for a list of similar drugs that are covered by the plan. When you get

the list, show it to your doctor and ask him or her to prescribe a covered drug.

2. Ask the plan to make an exception and cover your drug. Review the next section for more

exception information.

How can I get an exception?

Sometimes you may need to ask for drug coverage that’s not normally provided by your plan. This

is called asking for an exception. When you do, the plan will review your request and give you a

coverage decision known as a coverage determination.

Types of exceptions you can ask for

· Drug list exception: Ask the plan to cover your drug even if it’s not on the drug list. If approved,

this drug will be covered at a pre-determined cost sharing level. You will not be able to ask us to

provide the drug at a lower cost sharing level.

· Utilization exception: Ask the plan to revise the coverage rules or limits on your drug. For

example, if your drug has a quantity limit, you can ask the plan to change the limit and cover

more.

· Tiering exception: Ask the plan to cover your drug on our list at a lower cost sharing level if this

drug is not on the specialty tier.

The plan may approve your request for an exception if the covered alternative drugs wouldn’t be as

effective in treating your condition or would cause adverse medical effects.

Who can ask for an exception?

You, your authorized representative or your doctor can ask for an exception by calling Customer

Service. Your doctor must give us a supporting statement with the reason for the exception.

How long does it take to get an exception?

After we get the statement from your doctor supporting your request for an exception, we’ll give

you a decision within 72 hours. You can ask for an expedited (fast) decision if you or your doctor

believes that your health could be seriously harmed by waiting 72 hours. If your request for an

expedited review is approved, we’ll give you a decision within 24 hours after we get your doctor’s

supporting statement.

9

Can I get my drug while I wait for an exception?

As a new or continuing member in our plan, we may cover a temporary supply of your drug if it’s

not on our drug list or if it has rules or limits. For example, you may need a prior authorization from

us before you can fill your prescription. During the time when you are getting a temporary supply,

you should talk with your doctor to decide if there is a similar drug on the drug list you can take

instead. If you and your doctor decide this is the only drug that will work for you, you will need to

ask for an exception. We may cover your drug in certain cases during the first 90 days of your

membership.

The following chart shows how much of your drug we may cover while you ask for an exception.

If you... And you are… We may cover…

are a new member in the first 90 days of

your membership

OR

were a member last year and it’s the

first 90 days of your plan year

not in a nursing home or

long-term care facility

at least a 30-day

temporary supply

in a nursing home or long-

term care facility

at least a 31-day

temporary supply

have been in the plan for more than 90

days


term care facility and

need a supply right away

at least a 31-day

emergency supply

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

not in a nursing home or

long-term care facility

at least a 30-day

temporary supply


term care facility

at least a 31-day

temporary supply

The prescription must be filled at a network pharmacy. If your prescription is written for fewer days,

we’ll allow refills to provide at least the day supply listed in the chart above. (Please note that the

long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.)

We will not pay for more of your drug after you get this temporary or emergency supply unless you

receive authorization from the plan.

10

Can the drug list change?

Most changes in drug coverage happen on January 1. We may need to make changes during the

plan year for safety or other reasons that can affect you. We must follow the Medicare rules in

making these changes.

The drug list may change during the year if your plan:

· Adds new drugs, including generic drugs, as they become available.

· Removes a drug that has been found to be ineffective or unsafe.

· Changes the coverage rules or limits for a drug.

· Moves a drug into a different cost sharing tier.

If we add new generic drugs

We may immediately remove a brand name drug on our Drug List if we are replacing it with a new

generic drug that will appear on the same or lower cost sharing tier and with the same or fewer

restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug

on our Drug List, but immediately move it to a different cost sharing tier or add new restrictions. If

you are currently taking that brand name drug, we may not tell you in advance before we make that

change, but we will later provide you with information about the specific change(s) we have made.

If we make other changes

We may make other changes that affect members currently taking a drug. For instance, we may

add a generic drug that is not new to market to replace a brand name drug currently on the Drug

List; or add new restrictions to the brand name drug or move it to a different cost sharing tier or

both. Or we may make changes based on new clinical guidelines. If we remove drugs from our

Drug List, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move

a drug to a higher cost sharing tier, we must notify affected members of the change at least 30

days before the change becomes effective, or at the time the member requests a refill of the drug,

at which time the member will receive at least a 30 day supply of the drug.

If we add new generic drugs or make other changes, you or your prescriber can ask us to make

an exception and continue to cover the brand name drug for you. The notice we provide you will

also include information on how to request an exception, and you can also find information in the

section “How can I get an exception?” on page 8.

If we remove a drug from the list

If the Food and Drug Administration (FDA) says a drug you are taking is not effective or is unsafe,

we will let you know and take it off the drug list right away.

Changes that will not affect you if you are currently taking the drug

Usually, if you’re taking a drug on this drug list that was covered at the beginning of the year, we

will not remove or reduce coverage during the year except as described above. You will not get a

notice this year about changes that do not affect you. However, on January 1 of the next year these

changes will affect you, therefore it is important to check the Drug List for any changes to drugs for

the new plan year.

11

Drugs with dosages other than a 1-month supply

Drugs packaged in an extended day supply

Some drugs are packaged from the manufacturer to provide more than a 1-month supply. When

you fill these drugs, you may have to pay more than 1 copay/coinsurance for a single prescription.

For more information, please call Customer Service. Our contact information is on the cover.

Daily cost sharing for oral medications filled for less than a 1-month supply

A daily cost sharing rate may apply when your doctor prescribes less than a full month’s supply of

certain drugs for you and you are required to pay a copayment. A daily cost sharing rate is the

copayment divided by the number of days in a month’s supply.

Daily cost sharing applies only if the drug is in the form of a solid oral dose (e.g., tablet or capsule)

when dispensed for a supply of less than 1-month under applicable law. The daily cost sharing

requirements do not apply to either of the following:

1. Solid oral doses of antibiotics.

2. Solid oral doses that are dispensed in their original container or are usually dispensed in their

original packaging to help patients comply with usage and dosage directions.

For more information

For more detailed information about your plan’s prescription drug coverage, please review your

Evidence of Coverage and other plan materials.

If you have questions about your plan’s prescription drug coverage, please call Customer Service.

Our contact information, along with the date we last updated the drug list, is on the cover.

If you have general questions about Medicare prescription drug coverage, visit www.medicare.gov

or call Medicare at 1-800-633-4227, TTY 1-877-486-2048, 24 hours a day, 7 days a week.

12

Covered drugs by name (Drug index)

A

Abacavir Sulfate..................... 83

Abacavir Sulfate-Lamivudine

.............................................. 83

Abacavir-Lamivudine-

Zidovudine........................... 83

Abelcet....................................64

Abilify...................................... 77

Abilify Maintena......................77

Abilify MyCite......................... 77

Abiraterone Acetate...............69

Absorica................................108

Absorica LD..........................108

Acamprosate Calcium........... 46

Acanya.................................. 108

Acarbose................................ 86

Accolate................................151

Accupril...................................95

Accuretic.................................98

Accutane.............................. 108

Acebutolol HCl....................... 96

Acetaminophen-Caffeine-

Dihydrocodeine................... 44

Acetaminophen-Codeine...... 44

Acetazolamide........................98

Acetazolamide ER..................98

Acetic Acid........................... 149

Acetylcysteine...................... 154

Aciphex.................................123

Acitretin................................ 108

Actemra................................ 138

Actemra ACTPen................. 138

Acthar................................... 127

ActHIB...................................141

Acticlate.................................. 54

Actimmune........................... 139

Actiq........................................44

Actonel..................................143

Actoplus Met.......................... 86

Actos....................................... 86

Acular....................................147

Acular LS.............................. 147

Acuvail.................................. 147

Acyclovir................................. 81

Acyclovir Sodium................... 81

Aczone..................................115

Adacel...................................141

Adapalene....................108, 109

Adapalene-Benzoyl Peroxide

............................................ 109

Adcirca..................................153

Adderall................................ 104

Adderall XR.......................... 104

Adefovir Dipivoxil................... 81

Adempas.............................. 153

Adlyxin.................................... 86

Adlyxin Starter Pack.............. 86

Admelog................................. 89

Admelog SoloStar..................89

Advair Diskus....................... 154

Advair HFA........................... 154

Adzenys ER.......................... 104

Adzenys XR-ODT................. 104

Aemcolo..................................48

Afinitor.....................................70

Afinitor Disperz.......................70

Afrezza.................................... 89

Agrylin.....................................92

Aimovig................................... 67

AirDuo Digihaler...................154

AirDuo RespiClick 113/14

............................................ 154

AirDuo RespiClick 232/14

............................................ 154

AirDuo RespiClick 55/14.... 154

Ajovy........................................67

Aklief..................................... 109

Ala Scalp...............................110

Ala-Cort.................................110

Albendazole............................74

Albenza................................... 74

Albuterol Sulfate.................. 151

Albuterol Sulfate HFA..........151

Alclometasone Dipropionate

............................................ 110

Alcohol Prep Pads............... 144

Aldactazide.............................99

Aldactone............................. 101

Aldara....................................114

Alecensa................................. 71

Alendronate Sodium............143

Alfuzosin HCl ER..................126

Alinia....................................... 74

Aliskiren Fumarate................. 99

Alkindi Sprinkle.................... 127

Allopurinol.............................. 66

Almotriptan Malate.................66

Alocril....................................146

Alogliptin Benzoate................86

Alogliptin-Metformin HCl....... 86

Alogliptin-Pioglitazone...........86

Alomide.................................146

13

Alora...................................... 130

Alosetron HCl........................121

Alphagan P........................... 148

Alprazolam.............................. 85

Alprazolam ER........................ 85

Alprazolam Intensol................85

Alprazolam ODT..................... 85

Alrex.......................................147

Altabax.................................. 115

Altace.......................................95

Altavera................................. 130

Altoprev................................. 102

Altreno...................................109

Alunbrig...................................71

Alvesco..................................150

Alyacen 1/35.........................130

Alyq........................................153

Amantadine HCl..................... 75

Amaryl..................................... 86

Ambien..................................155

AmBisome...............................64

Ambrisentan......................... 153

Amcinonide...........................110

Amerge....................................66

Amethia................................. 130

Amikacin Sulfate.....................47

Amiloride HCl........................101

Amiloride-Hydrochlorothiazide

...............................................99

Aminosyn II........................... 117

Aminosyn-PF.........................117

Amiodarone HCl..................... 95

Amitiza...................................120

Amitriptyline HCl.....................63

Amlodipine Besylate.............. 97

Amlodipine-Atorvastatin.........99

Amlodipine-Benazepril...........99

Amlodipine-Olmesartan......... 99

Amlodipine-Valsartan............. 99

Amlodipine-Valsartan-HCTZ

...............................................99

Ammonium Lactate..............110

Amnesteem...........................109

Amoxapine.............................. 63

Amoxicillin...............................51

Amoxicillin-Clarithromycin-

Lansoprazole......................121

Amoxicillin-Potassium

Clavulanate........................... 51

Amoxicillin-Potassium

Clavulanate ER..................... 51

Amphetamine ER................. 104

Amphetamine Sulfate.......... 104

Amphetamine-

Dextroamphetamine.......... 104

Amphetamine-

Dextroamphetamine ER.... 104

Amphotericin B.......................64

Ampicillin.................................51

Ampicillin Sodium.................. 51

Ampicillin-Sulbactam Sodium

...............................................51

Ampyra..................................107

Amzeeq................................. 115

Anafranil.................................. 63

Anagrelide HCl........................92

Anastrozole............................. 70

Ancobon..................................64

Androderm............................129

AndroGel...............................129

AndroGel Pump....................129

Annovera...............................130

Anoro Ellipta......................... 154

Antara....................................101

Anusol-HC............................. 143

ApexiCon E........................... 110

Apidra...................................... 89

Apidra SoloStar...................... 89

Aplenzin...................................61

Apokyn.................................... 75

Apraclonidine HCl................ 148

Aprepitant................................64

Apri........................................ 130

Apriso.................................... 142

Aptensio XR.......................... 105

Aptiom..................................... 59

Aptivus.....................................84

Aralast NP............................. 124

Aranelle................................. 130

Aranesp.............................92, 93

Arava..................................... 139

Arazlo.................................... 109

Arcalyst..................................138

Aricept..................................... 60

Arikayce...................................47

Arimidex.................................. 70

Aripiprazole.............................77

Aripiprazole ODT.................... 77

Aristada................................... 77

Aristada Initio.......................... 77

Arixtra...................................... 91

Armodafinil............................155

ArmonAir Digihaler...............150

Arnuity Ellipta........................150

14

Aromasin................................. 70

Arthrotec................................. 40

Asacol HD............................. 142

Asenapine Maleate.................77

Ashlyna..................................130

Asmanex............................... 150

Asmanex HFA.......................150

Aspirin-Dipyridamole ER........94

Astagraf XL........................... 139

Atacand................................... 95

Atacand HCT.......................... 99

Atazanavir Sulfate...................84

Atelvia....................................143

Atenolol................................... 96

Atenolol-Chlorthalidone......... 99

Ativan.......................................85

Atomoxetine HCl.................. 105

Atorvastatin Calcium............ 102

Atovaquone.............................74

Atovaquone-Proguanil HCl.... 74

Atralin.................................... 109

Atripla...................................... 82

Atropine Sulfate....................145

Atrovent HFA........................ 151

Aubagio.................................107

Aubra EQ...............................130

Auryxia...................................120

Austedo.................................106

Avalide.....................................99

Avapro..................................... 95

Aveed.................................... 129

Aviane....................................130

Avita.......................................109

Avodart..................................126

Avonex Pen...........................107

Avonex Prefilled....................107

Avycaz..................................... 50

Aygestin................................ 134

Ayvakit..................................... 71

Azactam.................................. 48

Azasan...................................139

Azasite...................................146

Azathioprine..........................139

Azelaic Acid.......................... 109

Azelastine HCl.............. 146, 149

Azelastine-Fluticasone......... 149

Azelex....................................109

Azilect...................................... 76

Azithromycin........................... 53

Azopt..................................... 148

Azor..........................................99

Aztreonam...............................48

Azulfidine.............................. 142

Azulfidine EN-tabs................ 142

B

Bacitracin.............................. 146

Bacitracin-Polymyxin B........ 146

Baclofen.................................. 80

Bactrim.................................... 54

Bactrim DS..............................54

Bafiertam...............................107

Balcoltra................................ 130

Balsalazide Disodium...........142

Balversa...................................71

Balziva................................... 130

Banzel......................................59

Baqsimi Two Pack..................88

Baraclude................................81

Basaglar KwikPen...................89

Baxdela....................................54

BCG Vaccine........................ 141

Beconase AQ........................150

Belbuca................................... 42

Belsomra...............................155

Benazepril HCl........................95

Benazepril-Hydrochlorothiazide

...............................................99

Benicar.................................... 95

Benicar HCT........................... 99

Benlysta.................................138

BenzaClin with Pump...........109

Benzamycin.......................... 109

Benznidazole.......................... 74

Benzoyl Peroxide-Erythromycin

.............................................109

Benztropine Mesylate............ 75

Bepotastine Besilate............ 146

Bepreve................................. 146

Berinert..................................137

Beser..................................... 110

Besivance..............................146

Betamethasone Dipropionate

.............................................110

Betamethasone Dipropionate

Aug......................................110

Betamethasone Valerate.... 110,

111

Betapace AF........................... 96

Betaseron..............................107

Betaxolol HCl..................96, 148

Bethanechol Chloride.......... 126

Bethkis.................................. 152

Betimol.................................. 148

15

Betoptic-S..............................148

Bevespi Aerosphere.............154

Bexarotene..............................73

Bexsero................................. 141

Beyaz.....................................130

Bicalutamide........................... 69

Bicillin C-R...............................52

Bicillin C-R 900/300............... 51

Bicillin L-A............................... 52

BiDil......................................... 99

Biktarvy....................................82

Biltricide.................................. 74

Bimatoprost.......................... 149

Bisoprolol Fumarate...............96

Bisoprolol-Hydrochlorothiazide

...............................................99

BIVIGAM................................137

Bleph-10................................ 146

Blephamide...........................145

Blephamide S.O.P................145

Blisovi 24 Fe..........................130

Blisovi Fe 1.5/30...................130

Boniva....................................143

Boostrix................................. 141

Bosentan...............................153

Bosulif......................................71

Braftovi.................................... 71

Breo Ellipta............................154

Breztri Aerosphere............... 154

Briellyn...................................130

Brilinta..................................... 94

Brimonidine Tartrate............ 148

Brinzolamide.........................148

BRIVIACT................................ 55

Bromfenac Sodium.............. 147

Bromocriptine Mesylate...75, 76

BromSite............................... 147

Bronchitol..............................154

Brovana................................. 151

Brukinsa.................................. 71

Bryhali................................... 111

Budesonide.................. 143, 150

Budesonide ER.....................143

Budesonide-Formoterol

Fumarate.............................154

Bumetanide.......................... 101

Buphenyl............................... 124

Buprenorphine........................42

Buprenorphine HCl................ 47

Buprenorphine HCl-Naloxone

HCl.........................................47

Bupropion HCl........................61

Bupropion HCl ER..................61

Bupropion HCl SR............47, 61

Bupropion HCl XL.................. 61

Buspirone HCl........................ 85

Butorphanol Tartrate..............44

Butrans.................................... 42

Bydureon BCise......................86

Byetta 10MCG Pen.................87

Byetta 5MCG Pen...................87

Bystolic....................................96

C

Cabergoline.......................... 136

Cablivi......................................94

Cabometyx..............................71

Caduet.....................................99

Cafergot...................................67

Calan SR................................. 97

Calcipotriene.........................114

Calcipotriene-Betamethasone

.............................................114

Calcitonin Salmon................ 143

Calcitriol........................114, 144

Calcium Acetate................... 120

Calquence...............................71

Cambia.................................... 40

Camila................................... 134

Camrese Lo.......................... 130

Canasa.................................. 142

Cancidas................................. 64

Candesartan Cilexetil............. 95

Candesartan Cilexetil-HCTZ

...............................................99

Capex.................................... 111

Caplyta.................................... 77

Caprelsa.................................. 71

Captopril..................................95

Carac..................................... 114

Carafate.................................123

Carbaglu................................117

Carbamazepine...................... 59

Carbamazepine ER................ 59

Carbatrol................................. 59

Carbidopa............................... 76

Carbidopa-Levodopa............. 76

Carbidopa-Levodopa ER....... 76

Carbidopa-Levodopa ODT.....76

Carbidopa-Levodopa-

Entacapone.......................... 75

Cardizem................................. 97

Cardizem CD...........................97

Cardizem LA........................... 97

Cardura................................... 94

16

Cardura XL............................126

Carnitor................................. 124

CaroSpir................................ 101

Carteolol HCl........................ 148

Cartia XT..................................97

Carvedilol................................ 96

Carvedilol Phosphate ER.......96

Casodex.................................. 69

Caspofungin Acetate............. 64

Catapres-TTS-1....................... 94

Catapres-TTS-2....................... 94

Catapres-TTS-3....................... 94

Cayston................................. 152

Caziant.................................. 130

Cefaclor...................................50

Cefaclor ER.............................50

Cefadroxil................................50

Cefazolin Sodium................... 50

Cefdinir....................................50

Cefepime HCl......................... 50

Cefixime.................................. 50

Cefotetan Disodium............... 50

Cefoxitin Sodium.................... 50

Cefpodoxime Proxetil.............50

Cefprozil.................................. 50

Ceftazidime............................. 50

Ceftriaxone Sodium................50

Cefuroxime Axetil................... 50

Cefuroxime Sodium............... 50

Celebrex.................................. 40

Celecoxib................................ 40

Celexa......................................62

Cellcept................................. 139

Celontin................................... 58

Cephalexin........................50, 51

Cequa....................................145

Cerdelga................................124

Cetirizine HCl........................149

Cetraxal................................. 149

Cevimeline HCl..................... 108

Chantix.................................... 47

Chantix Continuing Month Pak

...............................................47

Chantix Starting Month Pak...47

Chemet..................................119

Chenodal...............................121

Chlordiazepoxide HCl............ 85

Chlordiazepoxide-Clidinium

.............................................121

Chlorhexidine Gluconate.....108

Chloroquine Phosphate......... 74

Chlorpromazine HCl...............76

Chlorthalidone...................... 101

Chlorzoxazone......................155

Cholbam................................124

Cholestyramine.....................102

Cholestyramine Light........... 102

Cialis......................................126

Ciclopirox......................115, 116

Ciclopirox Olamine...............116

Cilostazol.................................94

Ciloxan.................................. 146

Cimduo....................................83

Cimetidine.............................122

Cimetidine HCl..................... 122

Cimzia....................................139

Cimzia Prefilled.....................139

Cinacalcet HCl......................144

Cinryze.................................. 137

Cipro........................................54

Cipro HC............................... 149

Ciprodex................................149

Ciprofloxacin HCl...54, 146, 149

Ciprofloxacin in D5W............. 54

Ciprofloxacin-Dexamethasone

.............................................149

Ciprofloxacin-Fluocinolone PF

.............................................149

Citalopram Hydrobromide..... 62

Claravis..................................109

Clarinex................................. 149

Clarinex-D 12 Hour............... 154

Clarithromycin.........................53

Clarithromycin ER...................53

Clenpiq..................................121

Cleocin.................................... 48

Cleocin Phosphate................. 48

Cleocin-T............................... 116

Climara Pro........................... 130

Clindacin-P............................116

Clindagel............................... 116

Clindamycin HCl.....................48

Clindamycin Palmitate HCl.... 48

Clindamycin Phosphate........48,

116

Clindamycin Phosphate in D5W

...............................................48

Clindamycin Phosphate-

Benzoyl Peroxide............... 109

Clindamycin-Tretinoin.......... 109

Clindesse.................................48

Clinimix E/Dextrose............. 117

Clinimix/Dextrose.................117

Clinisol SF............................. 117

17

Clobazam................................ 58

Clobetasol Propionate......... 111

Clobetasol Propionate

Emollient Base................... 111

Clobetasol Propionate

Emulsion............................. 111

Clobex................................... 111

Clobex Spray........................ 111

Clocortolone Pivalate........... 111

Clodan...................................111

Cloderm................................ 111

Clomipramine HCl.................. 63

Clonazepam............................85

Clonazepam ODT................... 85

Clonidine................................. 94

Clonidine HCl..........................94

Clonidine HCl ER..................105

Clopidogrel Bisulfate..............94

Clorazepate Dipotassium.......85

Clotrimazole....................64, 116

Clotrimazole-Betamethasone

.............................................114

Clovique................................ 119

Clozapine................................ 80

Clozapine ODT....................... 80

Clozaril.....................................80

Coartem...................................74

Codeine Sulfate...................... 44

Colazal...................................142

Colchicine............................... 66

Colcrys.....................................66

Colesevelam HCl.................. 102

Colestid................................. 102

Colestipol HCl.......................102

Colistimethate Sodium...........48

Combigan............................. 145

Combivent Respimat........... 154

Combivir.................................. 83

Cometriq................................. 71

Complera.................................82

Compro................................... 63

Comtan....................................75

Concerta................................105

Condylox............................... 114

Constulose............................120

ConZip.....................................42

Copaxone..............................107

Copiktra...................................71

Cordran................................. 111

Coreg.......................................96

Coreg CR................................ 96

Corgard................................... 96

Corlanor...................................99

Cortef.....................................127

Cosentyx............................... 138

Cosentyx Sensoready.......... 138

Cosopt...................................145

Cosopt PF............................. 145

Cotellic.....................................71

Cotempla XR-ODT................105

Cozaar..................................... 95

Creon.....................................124

Cresemba................................64

Crestor...................................102

Crinone..................................134

Cromolyn Sodium....... 124, 146,

153

Cryselle-28............................ 130

Cubicin.................................... 48

Cuprimine............................. 126

Cutivate................................. 111

Cuvposa................................ 121

Cyclafem 1/35...................... 130

Cyclafem 7/7/7.....................130

Cyclobenzaprine HCl........... 155

Cyclophosphamide..........68, 69

Cycloset...................................87

Cyclosporine.........................139

Cyclosporine Modified.........139

Cymbalta............................... 106

Cyproheptadine HCl............ 149

Cyred EQ...............................130

Cystadane............................. 124

Cystadrops............................145

Cystagon............................... 124

Cystaran................................ 145

Cytomel................................. 135

Cytotec.................................. 123

D

Dalfampridine ER................. 107

Daliresp................................. 153

Dalvance..................................48

Danazol................................. 129

Dantrium..................................80

Dantrolene Sodium................ 80

Dapsone..........................68, 116

Daptacel................................ 141

Daptomycin.............................48

DARAPRIM............................. 74

Darifenacin Hydrobromide ER

.............................................125

Daurismo.................................71

Daypro..................................... 40

18

Daytrana................................105

DayVigo.................................155

DDAVP.................................. 128

Deblitane...............................135

Deferasirox............................119

Deferasirox Granules........... 119

Deferiprone........................... 119

Delestrogen.......................... 130

Delstrigo.................................. 82

Delzicol..................................142

Demeclocycline HCl...............54

Demser.................................... 99

Denavir.................................... 81

Depakote.................................86

Depakote ER...........................86

Depakote Sprinkles................ 86

Depen Titratabs....................126

Depo-Estradiol...................... 130

Depo-Provera........................135

Depo-SubQ Provera 104......135

Depo-Testosterone...............129

Derma-Smoothe/FS Scalp...111

DermOtic...............................149

Descovy...................................83

Desipramine HCl.................... 63

Desloratadine........................150

Desloratadine ODT...............150

Desmopressin Acetate.........128

Desmopressin Acetate Spray

.............................................128

Desogestrel-Ethinyl Estradiol

.............................................130

Desonate...............................111

Desonide...............................111

DesOwen...............................111

Desoximetasone...................111

Desoxyn.................................104

Desvenlafaxine ER..................62

Desvenlafaxine Succinate ER

...............................................62

Detrol.....................................125

Detrol LA............................... 125

Dexabliss...............................127

Dexamethasone....................127

Dexamethasone Sodium

Phosphate.......................... 147

Dexedrine..............................104

Dexilant................................. 123

Dexmethylphenidate HCl.....105

Dexmethylphenidate HCl ER

.............................................105

Dextroamphetamine Sulfate

.................................... 104, 105

Dextroamphetamine Sulfate ER

.............................................104

Dextrose................................ 118

Dextrose-NaCl.......................118

Diacomit.................................. 58

Diastat AcuDial....................... 58

Diastat Pediatric......................58

Diazepam.......................... 58, 85

Diazepam Intensol..................85

Diazoxide.................................89

Dibenzyline..............................94

Diclofenac Epolamine............ 40

Diclofenac Potassium............ 40

Diclofenac Sodium........40, 114,

147

Diclofenac Sodium ER........... 40

Diclofenac-Misoprostol.......... 40

Dicloxacillin Sodium...............52

Dicyclomine HCl...................121

Differin...................................109

Dificid.......................................53

Diflorasone Diacetate...........112

Diflucan................................... 65

Diflunisal..................................40

Digitek..................................... 99

Digox....................................... 99

Digoxin.................................... 99

Dihydroergotamine Mesylate

...............................................67

Dilantin.................................... 59

Dilantin INFATABS................. 59

Dilaudid.............................44, 45

Dilt-XR......................................98

Diltiazem HCl.......................... 98

Diltiazem HCl ER.................... 98

Diltiazem HCl ER Beads........ 98

Diltiazem HCl ER Coated

Beads.................................... 98

Dimethyl Fumarate............... 107

Dimethyl Fumarate Starter Pack

.............................................107

Diovan......................................95

Diovan HCT.............................99

Dipentum...............................143

Diphenoxylate-Atropine....... 121

Diphtheria-Tetanus Toxoids DT

.............................................141

Diprolene...............................112

Disulfiram................................ 46

Ditropan XL........................... 125

Diuril...................................... 101

Divalproex Sodium................. 86

Divalproex Sodium ER........... 86

19

Dofetilide................................. 96

Dojolvi....................................144

Dolishale................................130

Donepezil HCl.........................60

Donepezil HCl ODT................ 60

Doptelet...................................94

Doryx....................................... 54

Doryx MPC.............................. 54

Dorzolamide HCl.................. 148

Dorzolamide HCl-Timolol

Maleate............................... 145

Dorzolamide HCl-Timolol

Maleate Preservative Free

.............................................145

Dotti....................................... 130

Dovato..................................... 82

Dovonex................................ 114

Doxazosin Mesylate............... 94

Doxepin HCl........... 63, 112, 155

Doxercalciferol......................144

Doxy 100................................. 54

Doxycycline Hyclate.........54, 55

Doxycycline Monohydrate..... 55

Drizalma Sprinkle................. 106

Dronabinol...............................64

Drospirenone-Ethinyl Estradiol

.............................................130

Drospirenone-Ethinyl Estradiol-

Levomefolate......................130

Droxia...................................... 69

Droxidopa................................94

Duaklir Pressair.................... 154

Duetact.................................... 87

Duexis......................................40

Dulera.................................... 154

Duloxetine HCl......................106

Duobrii...................................114

Duopa......................................76

Dupixent................................138

Durezol.................................. 147

Dutasteride............................126

Dutasteride-Tamsulosin HCl

.............................................126

DUTOPROL.............................99

Dyanavel XR..........................105

Dymista................................. 150

Dyrenium...............................101

E

E.E.S. Granules.......................53

Econazole Nitrate................. 116

Edarbi...................................... 95

Edarbyclor...............................99

Edecrin.................................. 101

Edurant....................................82

Efavirenz..................................82

Efavirenz-Emtricitabine-

Tenofovir...............................82

Efavirenz-Lamivudine-Tenofovir

...............................................82

Effexor XR............................... 62

Efudex................................... 114

Egrifta SV.............................. 128

Elestrin...................................130

Eletriptan Hydrobromide........66

Elidel......................................112

Eligard................................... 136

Eliquis...................................... 91

Eliquis Starter Pack................ 91

Elmiron.................................. 126

EluRyng.................................130

Emcyt.......................................69

Emend..................................... 64

Emend Tri-Pack...................... 64

Emflaza..................................127

Emgality............................ 67, 68

Emoquette.............................130

Emsam.....................................61

Emtricitabine...........................83

Emtricitabine-Tenofovir

Disoproxil Fumarate.............83

Emtriva.....................................83

Emverm................................... 74

Enalapril Maleate.................... 95

Enalapril-Hydrochlorothiazide

...............................................99

Enbrel............................139, 140

Enbrel Mini............................139

Enbrel SureClick...................140

Endari.................................... 118

Endocet................................... 45

Engerix-B...............................141

Enoxaparin Sodium................91

Enpresse-28.......................... 131

Enskyce.................................131

Enspryng............................... 140

Enstilar...................................114

Entacapone.............................75

Entecavir..................................81

Entocort EC...........................143

Entresto................................... 99

Enulose................................. 120

Envarsus XR..........................140

Epclusa....................................81

Epidiolex..................................55

Epiduo................................... 109

20

Epiduo Forte......................... 109

Epinastine HCl...................... 146

Epinephrine...........................152

EpiPen 2-Pak.........................152

EpiPen Jr 2-Pak.................... 152

Epitol........................................59

Epivir........................................83

Epivir HBV............................... 81

Eplerenone............................101

Epogen.................................... 93

Epzicom...................................83

Equetro....................................86

Eraxis....................................... 65

Ergotamine-Caffeine...............67

Erivedge.................................. 71

Erleada.................................... 69

Erlotinib HCl............................71

Errin....................................... 135

Ertaczo.................................. 116

Ertapenem Sodium................ 52

Ery..........................................116

Ery-Tab.................................... 53

Erygel.....................................116

EryPed 200..............................53

EryPed 400..............................53

Erythrocin Lactobionate.........53

Erythrocin Stearate.................53

Erythromycin................ 116, 146

Erythromycin Base................. 53

Erythromycin Ethylsuccinate

...............................................53

Esbriet................................... 153

Escitalopram Oxalate............. 62

Esomeprazole Magnesium

.............................................123

Estarylla.................................131

Estrace.................................. 131

Estradiol................................ 131

Estradiol Valerate................. 131

Estring................................... 131

Ethacrynic Acid.....................101

Ethambutol HCl...................... 68

Ethosuximide.......................... 58

Ethynodiol Diacetate-Ethinyl

Estradiol..............................131

Etodolac.................................. 40

Etodolac ER............................ 40

Etonogestrel-Ethinyl Estradiol

.............................................131

Eucrisa...................................112

Euthyrox................................ 135

Evekeo...................................105

Evekeo ODT..........................105

Evenity................................... 144

Everolimus...................... 71, 140

Evista..................................... 135

Evoclin...................................116

Evotaz...................................... 84

Evoxac...................................108

Evrysdi...................................124

Exelon......................................60

Exemestane............................ 70

Exforge.................................... 99

Exforge HCT........................... 99

Exjade....................................119

Extavia................................... 107

Extina.....................................116

Eysuvis.................................. 147

Ezallor Sprinkle.....................102

Ezetimibe.............................. 102

Ezetimibe-Simvastatin.......... 102

F

Fabior.................................... 109

Falmina..................................131

Famciclovir..............................81

Famotidine............................ 122

Fanapt............................... 77, 78

Fanapt Titration Pack............. 78

Fareston.................................. 69

Farxiga.....................................87

Farydak....................................71

Fasenra..................................154

Fasenra Pen..........................154

Fayosim.................................131

Febuxostat.............................. 66

Felbamate......................... 55, 56

Felbatol....................................56

Feldene....................................40

Felodipine ER......................... 97

Femara.................................... 70

Femring................................. 131

Femynor................................ 131

Fenofibrate............................101

Fenofibrate Micronized........101

Fenofibric Acid..................... 101

Fenoglide.............................. 102

Fenoprofen Calcium...............40

Fentanyl...................................42

Fentanyl Citrate.......................45

Fentora.................................... 45

Ferriprox................................119

Fetzima.................................... 62

Fetzima Titration..................... 62

Fexmid...................................155

21

Fiasp........................................ 89

Fiasp FlexTouch..................... 89

Fiasp PenFill............................89

Finacea..................................109

Finasteride............................ 126

Fintepla....................................56

Firazyr....................................137

Firdapse................................ 106

Firmagon...............................136

Firvanq.....................................48

Flac........................................ 149

Flagyl....................................... 48

Flarex.....................................147

Flavoxate HCl........................125

Flebogamma DIF..................137

Flecainide Acetate..................96

Flector......................................40

FloLipid................................. 102

Flomax...................................126

Flovent Diskus...................... 150

Flovent HFA.......................... 150

Fluconazole.............................65

Fluconazole in Sodium

Chloride................................ 65

Flucytosine..............................65

Fludrocortisone Acetate...... 127

Flunisolide.............................150

Fluocinolone Acetonide......112,

149

Fluocinolone Acetonide Scalp

.............................................112

Fluocinonide......................... 112

Fluocinonide Emulsified Base

.............................................112

Fluorometholone.................. 147

Fluoroplex............................. 114

Fluorouracil........................... 114

Fluoxetine HCl........................ 62

Fluphenazine Decanoate....... 76

Fluphenazine HCl................... 77

Flurandrenolide.................... 112

Flurbiprofen.............................40

Flurbiprofen Sodium............ 147

Flutamide................................ 69

Fluticasone Propionate.......112,

150

Fluticasone-Salmeterol........ 154

Fluvastatin Sodium...............102

Fluvastatin Sodium ER.........102

Fluvoxamine Maleate............. 62

Fluvoxamine Maleate ER....... 62

FML........................................147

FML Forte..............................147

FML Liquifilm........................ 147

Focalin...................................105

Focalin XR.............................105

Fondaparinux Sodium............91

Forfivo XL................................ 61

Fortamet.................................. 87

Forteo.................................... 144

Fortesta................................. 129

Fosamax................................144

Fosamax Plus D....................144

Fosamprenavir Calcium......... 84

Fosfomycin Tromethamine....48

Fosinopril Sodium.................. 95

Fosinopril Sodium-HCTZ....... 99

Fosrenol................................ 120

Fotivda.....................................69

Fragmin................................... 92

Frova........................................66

Frovatriptan Succinate........... 66

Fulphila....................................93

Furosemide...........................101

Fuzeon.....................................84

Fyavolv...................................131

Fycompa..................................56

G

Gabapentin............................. 58

Gabitril..................................... 58

Galafold.................................124

Galantamine Hydrobromide

...............................................60

Galantamine Hydrobromide ER

...............................................60

Gammagard..........................137

Gammagard S/D Less IgA

.............................................137

Gammaked........................... 137

Gammaplex...........................137

Gamunex-C........................... 137

Gardasil 9..............................141

Gastrocrom........................... 124

Gatifloxacin........................... 146

Gattex.................................... 121

Gauze.................................... 144

GaviLyte-C.............................121

GaviLyte-G.............................122

GaviLyte-N with Flavor Pack

.............................................122

Gavreto....................................71

Gelnique................................125

Gemfibrozil............................102

Gemmily................................ 131

22

Gemtesa................................125

Generess Fe..........................131

Generlac................................121

Gengraf................................. 140

Genotropin............................128

Genotropin MiniQuick..........128

Gentak...................................146

Gentamicin Sulfate........47, 116,

146

Gentamicin Sulfate-0.9%

Sodium Chloride.................. 47

Genvoya.................................. 82

Geodon....................................78

Gilenya.................................. 107

Gilotrif...................................... 71

Gimoti...................................... 63

Glassia...................................124

Glatiramer Acetate............... 107

Glatopa..................................107

Gleevec................................... 71

Glimepiride..............................87

Glipizide...................................87

Glipizide ER............................ 87

Glipizide-Metformin HCl.........87

Gloperba................................. 66

GlucaGen HypoKit..................89

Glucagon.................................89

Glucotrol XL............................ 87

Glumetza................................. 87

Glycopyrrolate...................... 121

Glyxambi................................. 87

Gocovri.................................... 75

GoLYTELY............................ 122

GoNitro..................................103

Gralise................................... 106

Granisetron HCl...................... 64

Granix...................................... 93

Grastek..................................138

Griseofulvin Microsize............65

Griseofulvin Ultramicrosize....65

Gvoke HypoPen 2-Pack......... 89

Gvoke PFS.............................. 89

Gynazole-1.............................. 65

H

Haegarda.............................. 137

Hailey 24 Fe.......................... 131

Halcinonide...........................112

Haldol...................................... 77

Haldol Decanoate...................77

Halobetasol Propionate....... 112

Halog..................................... 112

Haloperidol..............................77

Haloperidol Decanoate.......... 77

Haloperidol Lactate................ 77

Harvoni.................................... 81

Havrix.....................................141

Helidac Therapy................... 122

Hemady.................................127

Heparin Sodium......................92

HepatAmine.......................... 118

Hepsera...................................81

Hetlioz....................................155

Hetlioz LQ............................. 155

Hiberix................................... 141

Hiprex...................................... 48

Horizant.................................106

Humalog..................................89

Humalog Junior KwikPen...... 89

Humalog KwikPen.................. 89

Humalog Mix 50/50................89

Humalog Mix 50/50 KwikPen

...............................................89

Humalog Mix 75/25................89

Humalog Mix 75/25 KwikPen

...............................................89

Humatin...................................47

Humatrope............................ 128

Humira...................................140

Humira Pediatric Crohns Start

.............................................140

Humira Pen........................... 140

Humira Pen Crohns Disease

Starter................................. 140

Humira Pen Psoriasis Starter

.............................................140

Humira Pen-Pediatric UC Start

.............................................140

Humulin 70/30........................90

Humulin 70/30 KwikPen........ 89

Humulin N............................... 90

Humulin N KwikPen............... 90

Humulin R............................... 90

Humulin R U-500.................... 90

Humulin R U-500 KwikPen.....90

Hydralazine HCl....................103

Hydrea..................................... 69

Hydrochlorothiazide.............101

Hydrocodone Bitartrate ER... 42

Hydrocodone-Acetaminophen

...............................................45

Hydrocodone-Ibuprofen.........45

Hydrocortisone... 112, 113, 127,

143

Hydrocortisone Acetate-

Pramoxine...........................115

23

Hydrocortisone Butyrate......112

Hydrocortisone Valerate...... 113

Hydrocortisone-Acetic Acid

.............................................149

Hydromorphone HCl.............. 45

Hydromorphone HCl ER........ 42

Hydromorphone HCl

Preservative Free..................45

Hydroxychloroquine Sulfate

...............................................74

Hydroxyurea............................69

Hydroxyzine HCl..................... 85

Hydroxyzine Pamoate............ 85

Hysingla ER...................... 42, 43

Hyzaar......................................99

I

Ibandronate Sodium............ 144

Ibrance.................................... 71

Ibu............................................40

Ibuprofen.......................... 40, 41

Icatibant Acetate.................. 137

Iclevia.....................................131

Iclusig...................................... 71

Icosapent Ethyl..................... 103

IDHIFA..................................... 70

Ilevro...................................... 147

Ilumya.................................... 138

Imatinib Mesylate....................71

Imbruvica.................................71

Imipenem-Cilastatin................52

Imipramine HCl.......................63

Imipramine Pamoate.............. 63

Imiquimod............................. 115

Imitrex......................................66

Imitrex STATdose Refill......... 66

Imitrex STATdose System..... 66

Imovax Rabies...................... 141

Impavido..................................74

Impeklo..................................113

Imuran................................... 140

Imvexxy Maintenance Pack

.............................................131

Imvexxy Starter Pack............131

Inbrija.......................................76

Incassia................................. 135

Increlex..................................128

Incruse Ellipta....................... 151

Indapamide...........................101

Inderal LA................................96

Indocin.....................................41

Infanrix...................................142

Ingrezza.................................106

Inlyta........................................ 71

InnoPran XL............................ 96

Inqovi....................................... 71

Inrebic......................................71

Inspra.....................................101

Insulin Aspart.......................... 90

Insulin Aspart FlexPen........... 90

Insulin Aspart PenFill..............90

Insulin Aspart Prot & Aspart

...............................................90

Insulin Aspart Prot & Aspart

FlexPen................................. 90

Insulin Lispro...........................90

Insulin Lispro Junior KwikPen

...............................................90

Insulin Lispro Prot & Lispro... 90

Insulin Syringes, Needles.... 144

Intelence..................................82

Intralipid................................ 118

Intrarosa................................ 129

Intron A..................................139

Introvale.................................131

Invanz...................................... 52

Invega...................................... 78

Invega Sustenna..................... 78

Invega Trinza...........................78

Inveltys.................................. 147

Invirase.................................... 84

Invokamet................................87

Invokamet XR..........................87

Invokana.................................. 87

Iopidine................................. 148

IPOL.......................................142

Ipratropium Bromide............151

Ipratropium-Albuterol........... 154

Irbesartan................................ 95

Irbesartan-Hydrochlorothiazide

.............................................100

Iressa....................................... 71

Isentress.................................. 82

Isentress HD............................82

Isibloom.................................131

Isolyte-P in D5W....................118

Isolyte-S.................................118

Isoniazid.................................. 68

Isopto Carpine...................... 148

Isordil Titradose....................103

Isosorbide Dinitrate.............. 104

Isosorbide Mononitrate........104

Isosorbide Mononitrate ER

.............................................104

Isotretinoin............................ 109

Isradipine.................................97

24

Istalol..................................... 148

Isturisa................................... 136

Itraconazole.............................65

Ivermectin....................... 74, 115

Ixiaro......................................142

J

Jadenu...................................119

Jadenu Sprinkle....................120

Jakafi....................................... 71

Jalyn...................................... 126

Jantoven..................................92

Janumet...................................87

Janumet XR.............................87

Januvia.................................... 87

Jardiance.................................87

Jasmiel.................................. 131

Jatenzo..................................129

Jentadueto.............................. 87

Jentadueto XR........................ 87

Jinteli..................................... 131

Jornay PM............................. 105

Jublia..................................... 116

Juleber...................................131

Juluca...................................... 82

Junel 1.5/30..........................131

Junel 1/20.............................131

Junel Fe 1.5/30.....................131

Junel Fe 1/20........................131

Junel Fe 24........................... 131

Juxtapid.................................103

Jynarque............................... 120

K

K-Tab..................................... 118

Kaitlib Fe............................... 131

Kaletra..................................... 84

Kalydeco............................... 152

Kapvay...................................105

Kariva.....................................131

Katerzia....................................97

Kazano.....................................87

KCl in Dextrose-NaCl............118

KCl-Lactated Ringers-D5W

.............................................118

Kelnor 1/35........................... 131

Kelnor 1/50........................... 132

Kenalog................................. 113

Keppra.....................................56

Keppra XR...............................56

Kerydin.................................. 116

Kesimpta............................... 107

Ketoconazole..................65, 116

Ketodan.................................116

Ketoprofen.............................. 41

Ketoprofen ER........................ 41

Ketorolac Tromethamine...... 41,

147

Keveyis.................................. 124

Kevzara..................................138

Kineret................................... 138

Kinrix......................................142

Kisqali...................................... 72

Kisqali Femara........................ 72

Klaron.................................... 116

Klonopin.................................. 85

Klor-Con................................ 118

Klor-Con 10........................... 118

Klor-Con 8............................. 118

Klor-Con M10........................118

Klor-Con M15........................118

Klor-Con M20........................118

Kombiglyze XR....................... 87

Korlym................................... 129

Koselugo................................. 72

Krintafel................................... 74

Kristalose.............................. 121

Kurvelo.................................. 132

Kuvan.....................................124

Kynmobi.................................. 76

L

Labetalol HCl.......................... 96

Lacrisert................................ 145

Lactulose...............................121

Lamictal...................................56

Lamictal ODT.......................... 56

Lamictal Starter...................... 56

Lamictal XR.............................56

Lamivudine....................... 81, 83

Lamivudine-Zidovudine..........83

Lamotrigine............................. 56

Lamotrigine ER.......................56

Lamotrigine ODT.................... 56

Lamotrigine Starter Kit-Blue

...............................................56

Lamotrigine Starter Kit-Green

...............................................56

Lamotrigine Starter Kit-Orange

...............................................57

Lampit......................................74

Lanoxin..................................100

Lansoprazole........................ 123

Lansoprazole ODT............... 123

Lanthanum Carbonate.........120

Lantus......................................90

Lantus SoloStar...................... 90

25

Lapatinib Ditosylate................72

LARIN 1.5/30........................132

LARIN 1/20........................... 132

LARIN Fe 1.5/30...................132

LARIN Fe 1/20......................132

Larissia.................................. 132

Lasix...................................... 101

Lastacaft................................146

Latanoprost...........................149

Latuda......................................78

Layolis Fe.............................. 132

Lazanda...................................45

Ledipasvir-Sofosbuvir.............81

Leena.....................................132

Leflunomide..........................140

Lenvima 10MG Daily Dose.... 72






Lenvima 4MG Daily Dose...... 72

Lenvima 8MG Daily Dose...... 72

Lescol XL.............................. 102

Lessina.................................. 132

Letairis...................................153

Letrozole..................................70

Leucovorin Calcium............... 74

Leukeran................................. 69

Leukine....................................93

Leuprolide Acetate...............136

Levalbuterol HCl...................152

Levalbuterol Tartrate............152

Levemir....................................90

Levemir FlexTouch.................90

Levetiracetam......................... 57

Levetiracetam ER................... 57

Levo-T....................................135

Levobunolol HCl...................148

Levocarnitine........................ 124

Levocetirizine Dihydrochloride

.............................................150

Levofloxacin....................54, 146

Levofloxacin in D5W...............54

Levonest................................132

Levonorgestrel-Ethinyl Estradiol

.............................................132


& Ethinyl Estradiol.............. 132


91-Day................................. 132

Levora 0.15/30..................... 132

Levorphanol Tartrate..............43

Levothyroxine Sodium......... 135

Levoxyl.................................. 135

Lexapro................................... 62

Lexette...................................113

Lexiva.......................................84

Lialda.....................................143

Librax.....................................121

Licart........................................41

Lidocaine.................................46

Lidocaine HCl......................... 46

Lidocaine Viscous.................. 46

Lidocaine-Prilocaine...............46

Lidoderm.................................46

Lindane................................. 115

Linezolid.................................. 48

Linzess.................................. 121

Liothyronine Sodium............135

Lipitor.................................... 102

Lipofen.................................. 102

Lisinopril..................................95

Lisinopril-Hydrochlorothiazide

.............................................100

Lithium.....................................86

Lithium Carbonate..................86

Lithium Carbonate ER............86

Lithobid................................... 86

Lithostat................................ 127

Livalo..................................... 102

Lo Loestrin Fe.......................132

Locoid................................... 113

Locoid Lipocream................ 113

Lodine......................................41

Lodosyn...................................76

Loestrin 1.5/30..................... 132

Loestrin 1/20........................ 132

Loestrin Fe 1.5/30................ 132

Loestrin Fe 1/20................... 132

Lokelma.................................120

Lomotil.................................. 121

Lonhala Magnair...................151

Lonsurf.................................... 70

Loperamide HCl................... 121

Lopid..................................... 102

Lopinavir-Ritonavir..................84

Lopressor................................ 96

Loprox................................... 116

Lorazepam.............................. 85

Lorazepam Intensol................85

Lorbrena..................................72

Loryna................................... 132

26

Losartan Potassium................95

Losartan Potassium-HCTZ...100

LoSeasonique.......................132

Lotemax................................ 147

Lotemax SM..........................147

Lotensin...................................95

Loteprednol Etabonate........ 147

Lotrel..................................... 100

Lotronex................................ 121

Lovastatin..............................102

Lovaza................................... 103

Lovenox...................................92

Low-Ogestrel.........................132

Loxapine Succinate................77

Lubiprostone.........................121

Lucemyra................................ 47

Luliconazole..........................116

Lumigan................................ 149

Lupaneta Pack......................136

Lupkynis................................140

Lupron Depot........................136

Lutera.................................... 132

Luxiq......................................113

Luzu.......................................117

Lyleq......................................135

Lyllana................................... 132

Lynparza..................................72

Lyrica.............................106, 107

Lyrica CR...............................106

Lysodren............................... 136

Lysteda....................................94

Lyumjev................................... 90

Lyumjev KwikPen................... 90

Lyza....................................... 135

M

M-M-R II................................. 142

Macrobid................................. 48

Macrodantin............................48

Mafenide Acetate................. 117

Magnesium Sulfate.............. 118

Malarone................................. 74

Malathion.............................. 115

Marinol.....................................64

Marlissa................................. 132

Marplan................................... 61

Matulane..................................69

Matzim LA............................... 98

Mavenclad.............................107

Mavyret....................................81

Maxalt...................................... 66

Maxalt-MLT............................. 66

Maxidex.................................147

Maxitrol..................................145

Maxzide................................. 100

Maxzide-25............................100

Mayzent.................................107

Mayzent Starter Pack........... 107

Meclizine HCl..........................63

Meclofenamate Sodium.........41

Medrol................................... 127

Medroxyprogesterone Acetate

.............................................135

Mefenamic Acid......................41

Mefloquine HCl.......................74

Megestrol Acetate................ 135

Mekinist................................... 72

Mektovi....................................72

Meloxicam...............................41

Memantine HCl.......................61

Memantine HCl ER.................61

Memantine HCl Titration Pak

...............................................61

Menactra............................... 142

Menest...................................132

MenQuadfi............................ 142

Mentax...................................117

Menveo..................................142

Mepron.................................... 74

Mercaptopurine...................... 69

Meropenem...................... 52, 53

Merrem.................................... 53

Merzee...................................132

Mesalamine...........................143

Mesalamine ER.....................143

Mesnex.................................... 74

Mestinon..................................68

Metformin HCl.........................88

Metformin HCl ER...................87

Methadone HCl.......................43

Methamphetamine HCl........105

Methazolamide..................... 148

Methenamine Hippurate........ 48

Methimazole......................... 137

Methitest............................... 129

Methotrexate.........................140

Methotrexate Sodium...........140

Methoxsalen Rapid.............. 115

Methscopolamine Bromide

.............................................121

Methyldopa............................. 94

Methylin.................................105

Methylphenidate HCl........... 106

Methylphenidate HCl CD.....105

27

Methylphenidate HCl ER..... 105

Methylphenidate HCl ER

Osmotic Release................105

Methylphenidate HCl LA......105

Methylprednisolone............. 127

Methyltestosterone...............129

Metoclopramide HCl.............. 63

Metoclopramide HCl ODT..... 63

Metolazone........................... 101

Metoprolol Succinate ER.......97

Metoprolol Tartrate.................97

Metoprolol-Hydrochlorothiazide

.............................................100

MetroCream............................48

Metrogel.................................. 48

MetroLotion.............................48

Metronidazole...................48, 49

Metronidazole in NaCl 0.79%

...............................................49

Metyrosine............................ 100

Mexiletine HCl.........................96

Mibelas 24 Fe....................... 132

Micafungin Sodium................ 65

Micardis...................................95

Micardis HCT........................100

Miconazole 3...........................65

Microgestin 1.5/30...............132

Microgestin 1/20.................. 132

Microgestin Fe 1.5/30..........132

Microgestin Fe 1/20.............132

Midodrine HCl.........................94

Migergot.................................. 67

Miglitol.....................................88

Miglustat................................124

Migranal.................................. 67

Mili......................................... 132

Millipred................................ 127

Minastrin 24 Fe.....................132

Minipress.................................94

Minitran................................. 104

Minivelle................................ 133

Minocycline HCl......................55

Minocycline HCl ER................55

Minolira....................................55

Minoxidil................................103

Mirapex....................................76

Mirapex ER..............................76

Mirtazapine............................. 61

Mirtazapine ODT.....................61

Mirvaso..................................109

Misoprostol........................... 123

Mitigare................................... 66

Mobic.......................................41

Modafinil............................... 155

Moexipril HCl.......................... 95

Molindone HCl........................77

Mometasone Furoate..........113,

150

Mondoxyne NL....................... 55

Montelukast Sodium............ 151

Monurol................................... 49

Morphine Sulfate.................... 45

Morphine Sulfate ER.............. 43

Morphine Sulfate ER Beads

...............................................43

Motegrity............................... 121

Movantik................................121

MoviPrep...............................122

Moxeza..................................146

Moxifloxacin HCl............ 54, 146

Moxifloxacin HCl in NaCl....... 54

MS Contin............................... 43

Mulpleta...................................93

Multaq......................................96

Mupirocin.............................. 117

Mupirocin Calcium............... 117

Myalept..................................122

Myambutol.............................. 68

Mycamine................................65

Mycapssa..............................136

Mycobutin............................... 68

Mycophenolate Mofetil........ 140

Mycophenolate Sodium.......140

Mydayis................................. 105

Myfortic................................. 140

Myorisan................................109

Myrbetriq...............................125

Mysoline.................................. 58

Mytesi.................................... 121

N

Nabumetone........................... 41

Nadolol.................................... 97

Nafcillin Sodium..................... 52

Naftifine HCl..........................117

Naftin..................................... 117

Nalfon...................................... 41

Naloxone HCl..........................47

Naltrexone HCl....................... 47

Namenda.................................61

Namenda Titration Pak.......... 61

Namenda XR...........................61

Namzaric................................. 60

Naprelan..................................41

Naproxen.................................41

28

Naproxen DR.......................... 41

Naproxen Sodium.................. 41

Naproxen Sodium ER............ 41

Naproxen-Esomeprazole....... 41

Naratriptan HCl.......................66

Narcan..................................... 47

Nardil....................................... 61

Nasonex................................ 150

Natacyn................................. 146

Natazia...................................133

Nateglinide..............................88

Natesto.................................. 129

Natpara..................................144

Natroba................................. 115

Nayzilam..................................58

Nebupent................................ 74

Necon 0.5/35........................133

Nefazodone HCl..................... 62

Neo-Synalar...........................115

Neomycin Sulfate................... 47

Neomycin-Bacitracin-Polymyxin

.............................................146

Neomycin-Polymyxin-

Bacitracin-Hydrocortisone

.............................................145

Neomycin-Polymyxin-

Dexamethasone................. 145

Neomycin-Polymyxin-

Gramicidin.......................... 146

Neomycin-Polymyxin-HC.... 145,

149

Neoral....................................140

Nerlynx.................................... 72

Nesina......................................88

Neuac.................................... 109

Neulasta.................................. 93

Neupogen............................... 93

Neupro.....................................76

Neurontin................................ 58

Nevanac................................ 147

Nevirapine............................... 82

Nevirapine ER......................... 82

Nexavar................................... 72

Nexium.................................. 123

Nexletol................................. 103

Nexlizet..................................103

Nextstellis..............................133

Niacin ER.............................. 103

Niacor....................................103

Niaspan................................. 103

Nicardipine HCl...................... 97

Nicotrol....................................47

Nicotrol NS..............................47

Nifedipine ER..........................97

Nifedipine ER Osmotic Release

...............................................97

Nikki.......................................133

Nilandron.................................69

Nilutamide...............................69

Nimodipine..............................97

Ninlaro..................................... 70

Nisoldipine ER........................ 97

Nitazoxanide........................... 74

Nitisinone.............................. 124

Nitro-Bid................................ 104

Nitro-Dur................................104

Nitrofurantoin..........................49

Nitrofurantoin Macrocrystal...49

Nitrofurantoin Monohydrate

...............................................49

Nitroglycerin..........................104

Nitrolingual............................104

Nitrostat.................................104

Nityr....................................... 124

Nivestym..................................93

Nizatidine.............................. 122

Nocdurna.............................. 128

Nolix.......................................113

Nora-BE................................. 135

Norditropin FlexPro..............128

Norethindrone...................... 135

Norethindrone Acetate........ 135

Norethindrone Acetate-Ethinyl

Estradiol..............................133

Norethindrone Acetate-Ethinyl

Estradiol-Fe.........................133

Norgestimate-Ethinyl Estradiol

.............................................133

Norgestimate-Ethinyl Estradiol

Triphasic............................. 133

Noritate....................................49

Norpramin............................... 63

Northera.................................. 94

Nortrel 0.5/35....................... 133

Nortrel 1/35.......................... 133

Nortrel 7/7/7.........................133

Nortriptyline HCl..................... 63

Norvasc................................... 97

Norvir....................................... 84

Nourianz.................................. 75

Novolin 70/30......................... 91

Novolin 70/30 FlexPen...........90

Novolin N.................................91

Novolin N FlexPen.................. 91

Novolin R.................................91

Novolin R FlexPen.................. 91

29

NovoLog..................................91

NovoLog FlexPen................... 91

NovoLog Mix 70/30................91

NovoLog Mix 70/30 FlexPen

...............................................91

NovoLog PenFill..................... 91

Noxafil......................................65

Nubeqa....................................69

Nucala................................... 154

Nucynta................................... 45

Nucynta ER............................. 43

Nuedexta...............................106

NuLYTELY Lemon-Lime...... 122

Nuplazid.................................. 78

Nurtec ODT.............................66

Nutrilipid................................118

Nutropin AQ NuSpin 10.......128

Nutropin AQ NuSpin 20.......128

Nutropin AQ NuSpin 5......... 128

NuvaRing.............................. 133

Nuvigil....................................155

Nuzyra..................................... 55

Nyamyc................................. 117

Nylia 7/7/7............................ 133

Nymalize..................................97

Nymyo................................... 133

Nystatin........................... 65, 117

Nystatin-Triamcinolone........ 115

Nystop................................... 117

Nyvepria.................................. 93

O

Ocaliva...................................122

Ocella.................................... 133

Octagam................................137

Octreotide Acetate............... 136

Ocuflox.................................. 146

Odactra................................. 138

Odefsey................................... 83

Odomzo...................................72

Ofev....................................... 154

Ofloxacin................ 54, 146, 149

Olanzapine.............................. 78

Olanzapine ODT..................... 78

Olanzapine-Fluoxetine HCl.... 61

Olmesartan Medoxomil..........95

Olmesartan Medoxomil-HCTZ

.............................................100

Olmesartan-Amlodipine-HCTZ

.............................................100

Olopatadine HCl...........146, 150

Olumiant................................138

Olux....................................... 113

Olux-E.................................... 113

Omeclamox-Pak................... 122

Omega-3-Acid Ethyl Esters

.............................................103

Omeprazole.......................... 123

Omeprazole-Sodium

Bicarbonate........................ 123

Omnaris.................................150

Omnitrope.............................128

Ondansetron HCl....................64

Ondansetron ODT.................. 64

Onexton.................................109

Onfi.......................................... 58

Ongentys.................................75

Onglyza................................... 88

Onureg.................................... 69

Onzetra Xsail...........................66

Opsumit.................................153

Oracea.....................................55

Oralair 300IR.........................138

Orapred ODT........................ 127

Oravig...................................... 65

Orencia..................................138

Orencia ClickJect................. 138

Orenitram.............................. 153

Orfadin.................................. 124

Orgovyx................................. 136

Oriahnn..................................136

Orilissa...................................137

Orkambi................................ 152

Orladeyo................................137

Orsythia................................. 133

Ortikos...................................143

Oseltamivir Phosphate........... 84

Oseni....................................... 88

Osmolex ER............................ 75

OsmoPrep.............................122

Osphena................................135

Otezla.................................... 138

Otovel.................................... 149

Otrexup................................. 140

Ovide..................................... 115

Oxacillin Sodium.....................52

Oxacillin Sodium in Dextrose

...............................................52

Oxandrolone......................... 129

Oxaprozin................................41

Oxazepam............................... 85

Oxbryta.................................... 93

Oxcarbazepine........................59

Oxervate................................ 145

30

Oxiconazole Nitrate..............117

Oxistat................................... 117

Oxtellar XR.............................. 59

Oxybutynin Chloride............ 125

Oxybutynin Chloride ER...... 125

Oxycodone HCl................ 45, 46

Oxycodone HCl ER................ 43

Oxycodone-Acetaminophen

...............................................46

OxyContin............................... 44

Oxymorphone HCl..................46

Oxymorphone HCl ER............44

Oxytrol................................... 126

Ozempic.................................. 88

P

Pacerone................................. 96

Paliperidone ER......................78

Palynziq.................................124

Pamelor................................... 63

Pancreaze............................. 124

Pandel................................... 113

Pantoprazole Sodium...........123

Panzyga.................................137

Paricalcitol............................ 144

Parlodel................................... 76

Parnate.................................... 61

Paromomycin Sulfate.............47

Paroxetine HCl........................62

Paser........................................68

Patanase............................... 150

Paxil......................................... 62

Pediarix................................. 142

Pedvax HIB........................... 142

PEG-3350-Electrolytes......... 122

PEG-3350-NaCl-Na

Bicarbonate-KCl................. 122

PEG-KCl-NaCl-NaSulf-Na Asc-C

.............................................122

Pegasys.................................139

Pemazyre.................................70

Penicillamine.........................127

Penicillin G Potassium........... 52

Penicillin G Potassium in

Dextrose................................52

Penicillin G Procaine.............. 52

Penicillin G Sodium................52

Penicillin V Potassium............52

Pennsaid................................. 41

PENTAM 300.......................... 74

Pentamidine Isethionate........ 75

Pentasa................................. 143

Pentoxifylline ER...................100

Pepcid...........................122, 123

Percocet.................................. 46

Perforomist........................... 152

Perindopril Erbumine............. 95

Periogard.............................. 108

Permethrin............................ 115

Perphenazine..........................63

Perseris....................................78

Pertzye...................................125

Phenelzine Sulfate..................61

Phenobarbital......................... 58

Phenoxybenzamine HCl.........94

Phenytek................................. 60

Phenytoin................................ 60

Phenytoin Sodium Extended

...............................................60

Phoslyra................................ 120

Picato.................................... 115

Pifeltro..................................... 82

Pilocarpine HCl............ 108, 148

Pimecrolimus........................113

Pimozide..................................77

Pimtrea.................................. 133

Pindolol................................... 97

Pioglitazone HCl..................... 88

Pioglitazone HCl-Glimepiride

...............................................88

Pioglitazone HCl-Metformin HCl

...............................................88

Piperacillin-Tazobactam.........52

Piqray................................ 72, 73

Pirmella 1/35........................ 133

Piroxicam................................ 41

Plaquenil..................................75

Plasma-Lyte 148................... 118

Plasma-Lyte A....................... 118

Plavix....................................... 94

Plegridy................................. 107

Plenamine............................. 118

Plenvu....................................122

Pliaglis..................................... 46

Podofilox............................... 115

Polymyxin B Sulfate................49

Polymyxin B-Trimethoprim

.............................................146

Polytrim................................. 146

Pomalyst..................................69

Portia-28................................ 133

Posaconazole......................... 65

Potassium Chloride..............119

Potassium Chloride CR....... 118

Potassium Chloride ER........118

31

Potassium Chloride in Dextrose

.............................................118

Potassium Chloride in NaCl

.................................... 118, 119

Potassium Citrate ER........... 119

Pradaxa................................... 92

Praluent................................. 103

Pramipexole Dihydrochloride

...............................................76

Pramipexole Dihydrochloride

ER..........................................76

Prasugrel HCl..........................94

Pravastatin Sodium.............. 102

Praziquantel............................ 74

Prazosin HCl........................... 94

Pred Forte............................. 147

Pred Mild...............................148

Pred-G................................... 145

Pred-G S.O.P.........................145

Prednicarbate....................... 113

Prednisolone.........................127

Prednisolone Acetate...........148

Prednisolone Sodium

Phosphate.................. 127, 148

Prednisolone Sodium

Phosphate ODT..................127

Prednisone................... 127, 128

Prednisone Intensol............. 127

Pregabalin.............................107

Pregabalin ER.......................107

Premarin................................133

Premasol............................... 119

Pretomanid..............................68

Prevacid................................ 123

Prevacid SoluTab................. 123

Prevalite.................................103

Previfem................................ 133

Prevymis..................................80

Prezcobix................................ 84

Prezista....................................84

Priftin....................................... 68

Prilosec..................................123

Primaquine Phosphate...........75

Primaxin IV.............................. 53

Primidone................................58

Prinivil...................................... 95

Pristiq.......................................62

Privigen................................. 138

ProAir HFA............................ 152

ProAir RespiClick................. 152

Probenecid..............................66

Probenecid-Colchicine...........66

Procalamine..........................119

Procardia XL........................... 97

ProCentra..............................105

Prochlorperazine.................... 63

Prochlorperazine Maleate......63

Procrit...................................... 93

Procto-Med HC.....................143

Procto-Pak.............................143

Proctosol HC.........................143

Proctozone-HC..................... 143

Procysbi................................ 125

Progesterone........................ 135

Proglycem............................... 89

Prograf.......................... 140, 141

Prolastin-C.............................125

Prolate..................................... 46

Prolensa................................ 148

Prolia..................................... 144

Promacta.................................93

Promethazine HCl.................. 64

Prometrium........................... 135

Propafenone HCl....................96

Propafenone HCl ER..............96

Proparacaine HCl................. 145

Propranolol HCl...................... 97

Propranolol HCl ER................ 97

Propylthiouracil.....................137

ProQuad................................142

Proscar.................................. 126

Prosol.................................... 119

Protonix................................. 123

Protopic.................................113

Protriptyline HCl......................63

Proventil HFA........................152

Provera.................................. 135

Provigil...................................155

Prozac......................................62

PRUDOXIN............................113

Psorcon................................. 113

Pulmicort...............................150

Pulmicort Flexhaler.............. 150

Pulmozyme........................... 152

Purixan.................................... 70

Pylera.....................................122

Pyrazinamide.......................... 68

Pyridostigmine Bromide........ 68

Pyridostigmine Bromide ER

...............................................68

Pyrimethamine........................75

Q

Qbrelis..................................... 95

Qbrexza................................. 115

32

Qinlock.................................... 69

Qnasl..................................... 151

Qnasl Childrens.................... 150

Qtern........................................88

Quadracel............................. 142

Qualaquin................................75

Quartette............................... 133

Qudexy XR.............................. 57

Questran................................103

Questran Light...................... 103

Quetiapine Fumarate..............78

Quetiapine Fumarate ER........78

QuilliChew ER.......................106

Quillivant XR......................... 106

Quinapril HCl...........................95

Quinapril-Hydrochlorothiazide

.............................................100

Quinidine Gluconate ER........ 96

Quinidine Sulfate.................... 96

Quinine Sulfate....................... 75

QVAR RediHaler...................151

R

RabAvert............................... 142

Rabeprazole Sodium........... 123

Raloxifene HCl......................135

Ramelteon.............................155

Ramipril................................... 95

Ranexa.................................. 100

Ranolazine ER...................... 100

Rapaflo..................................126

Rapamune............................ 141

Rasagiline Mesylate............... 76

Rasuvo.................................. 141

RAVICTI.................................125

Rayaldee............................... 144

Rayos.....................................128

Razadyne ER.......................... 60

Rebif...................................... 108

Rebif Rebidose.....................108

Rebif Rebidose Titration Pack

.............................................108

Rebif Titration Pack..............108

Reclipsen.............................. 133

Recombivax HB....................142

Rectiv.....................................104

RediTrex................................141

Reglan..................................... 64

Regranex...............................115

Relafen DS.............................. 41

Relenza Diskhaler...................85

Relexxii..................................106

Relistor.................................. 121

Relpax......................................66

Reltone..................................122

Remeron..................................61

Remeron SolTab.................... 61

Renagel................................. 120

Renvela................................. 120

Repaglinide.............................88

Repatha.................................103

Repatha Pushtronex System

.............................................103

Repatha SureClick............... 103

Restasis Single-Use Vials.....145

Restoril.................................. 155

Retacrit.................................... 93

Retevmo.................................. 70

Retin-A...................................109

Retin-A Micro........................ 109

Retin-A Micro Pump.............110

Retrovir....................................83

Revatio.................................. 153

Revlimid...................................69

Rexulti......................................78

Reyataz....................................84

Reyvow.................................... 67

Rhofade.................................110

Rhopressa.............................148

Ribavirin.................................. 81

Ridaura..................................138

Rifabutin.................................. 68

Rifampin.................................. 68

Rilutek................................... 106

Riluzole..................................106

Rimantadine HCl.................... 85

Rinvoq................................... 138

Riomet..................................... 88

Risedronate Sodium............ 144

Risperdal................................. 79

Risperdal Consta....................78

Risperidone.............................79

Risperidone ODT....................79

Ritalin.....................................106

Ritalin LA...............................106

Ritonavir.................................. 84

Rivastigmine........................... 60

Rivastigmine Tartrate............. 60

Rivelsa................................... 133

Rizatriptan Benzoate..............67

Rizatriptan Benzoate ODT..... 67

Rocaltrol................................144

Rocklatan.............................. 145

Ropinirole HCl........................ 76

33

Ropinirole HCl ER.................. 76

Rosuvastatin Calcium.......... 102

Roszet................................... 103

Rotarix................................... 142

RotaTeq.................................142

Rowasa..................................143

Roweepra................................57

Roxicodone.............................46

Rozerem................................155

Rozlytrek................................. 73

Rubraca...................................73

Ruconest...............................137

Rufinamide..............................60

Rukobia................................... 84

Ruzurgi.................................. 106

Rybelsus..................................88

Rydapt..................................... 73

Rytary.......................................76

Rythmol SR............................. 96

S

Sabril........................................59

Safyral....................................133

Saizen....................................128

Saizenprep............................128

Salagen................................. 108

Samsca..................................120

Sancuso.................................. 64

Sandimmune........................ 141

Sandostatin...........................137

Santyl.....................................115

Saphris.................................... 79

Sapropterin Dihydrochloride

.............................................125

Savaysa................................... 92

Savella................................... 107

Savella Titration Pack...........107

Scopolamine...........................64

Seasonique........................... 133

Secuado.................................. 79

Segluromet..............................88

Selegiline HCl......................... 76

Selenium Sulfide.................. 113

Selzentry..................................84

Semglee.................................. 91

Sensipar................................ 144

Serevent Diskus....................152

Seroquel..................................79

Seroquel XR............................79

Serostim................................ 129

Sertraline HCl..........................62

Setlakin..................................133

Sevelamer Carbonate.......... 120

Sevelamer HCl......................120

Seysara....................................55

Sharobel................................135

Shingrix................................. 142

Signifor.................................. 137

Siklos....................................... 93

Sildenafil Citrate................... 153

Silenor................................... 155

Siliq........................................138

Silodosin............................... 126

Silvadene...............................115

Silver Sulfadiazine................ 115

Simbrinza.............................. 149

Simponi................................. 141

Simvastatin............................102

Sinemet................................... 76

Singulair................................ 151

Sirolimus............................... 141

Sirturo......................................68

Sitavig...................................... 81

Sivextro....................................49

Skyrizi.................................... 138

Skyrizi Pen............................ 138

Slynd......................................135

Sodium Chloride.................. 119

Sodium Fluoride................... 119

Sodium Phenylbutyrate........125

Sodium Polystyrene Sulfonate

.............................................120

Sofosbuvir-Velpatasvir............81

Solifenacin Succinate.......... 126

Soliqua.................................... 88

Solodyn................................... 55

Solosec....................................49

Soltamox................................. 69

Somavert............................... 137

Soolantra...............................115

Soriatane...............................110

Sorilux................................... 115

Sorine...................................... 96

Sotalol HCl.............................. 96

Sotalol HCl AF.........................96

Sotylize.................................... 96

Sovaldi.....................................81

Spinosad............................... 115

Spiriva HandiHaler............... 151

Spiriva Respimat.................. 151

Spironolactone..................... 101

Spironolactone-HCTZ.......... 100

Sporanox.................................65

34

Sprintec 28............................133

Spritam ODT........................... 57

Sprix.........................................41

Sprycel.....................................73

SPS........................................120

Sronyx................................... 133

SSD........................................115

Stalevo 100............................. 75

Stalevo 125............................. 75

Stalevo 150............................. 75

Stalevo 200............................. 75

Stalevo 50................................75

Stalevo 75................................75

Steglatro..................................88

Steglujan................................. 88

Stelara................................... 139

Stiolto Respimat................... 154

Stivarga....................................73

Strattera.................................106

Streptomycin Sulfate..............47

Stribild..................................... 82

Striverdi Respimat................152

Stromectol...............................74

Suboxone................................ 47

Subsys.....................................46

Sucraid.................................. 125

Sucralfate..............................123

Sular.........................................97

Sulfacetamide Sodium........117,

146, 147

Sulfacetamide-Prednisolone

.............................................145

Sulfadiazine.............................54

Sulfamethoxazole-

Trimethoprim........................54

Sulfamylon............................ 117

Sulfasalazine.........................143

Sulindac.................................. 41

Sumatriptan.............................67

Sumatriptan Succinate...........67

Sumatriptan Succinate Refill

...............................................67

Sumatriptan-Naproxen Sodium

...............................................67

Sunosi....................................155

Suprax..................................... 51

Suprep Bowel Prep Kit.........122

Sustiva..................................... 82

Sutab..................................... 122

Sutent...................................... 73

Syeda.....................................134

Symbicort..............................155

Symbyax..................................61

Symdeko............................... 152

Symfi........................................83

Symfi Lo.................................. 82

Symjepi..................................152

SymlinPen 120........................88

SymlinPen 60..........................88

Sympazan................................59

Symproic............................... 121

Symtuza...................................84

Synalar...................................113

Synarel.................................. 137

Syndros................................... 64

Synjardy...................................88

Synjardy XR.............................88

Synribo.................................... 70

Synthroid...............................136

Syprine.................................. 120

T

Tabloid.....................................70

Tabrecta.................................. 69

Taclonex................................115

Tacrolimus....................113, 141

Tadalafil........................ 126, 153

Tafinlar.....................................73

Tagrisso...................................73

Takhzyro................................137

Talicia.................................... 122

Taltz....................................... 139

Talzenna..................................73

Tamiflu.....................................85

Tamoxifen Citrate................... 69

Tamsulosin HCl.................... 126

Tapazole................................137

TaperDex 12-Day..................128

TaperDex 6-Day.................... 128

TaperDex 7-Day.................... 128

Tarceva....................................73

TARGADOX............................ 55

Targretin............................73, 74

Tarina 24 Fe..........................134

Tarina Fe 1/20 EQ................ 134

Tasigna....................................73

Tasmar.....................................75

Tavaborole............................ 117

Tavalisse..................................94

Tazarotene............................ 110

Tazicef..................................... 51

Tazorac..................................110

Taztia XT..................................98

Tazverik................................... 70

TDVAX................................... 142

35

Tecfidera............................... 108

Tecfidera Starter Pack......... 108

Teflaro..................................... 51

Tegretol................................... 60

Tegretol XR............................. 60

Tegsedi..................................125

Tekturna................................ 100

Tekturna HCT....................... 100

Telmisartan............................. 95

Telmisartan-Amlodipine.......100

Telmisartan-HCTZ................ 100

Temazepam.......................... 155

Temixys................................... 83

Temovate.............................. 113

Tenivac..................................142

Tenofovir Disoproxil Fumarate

...............................................83

Tenoretic 100........................100

Tenoretic 50..........................100

Tenormin................................. 97

Tepmetko................................ 73

Terazosin HCl....................... 126

Terbinafine HCl.......................65

Terbutaline Sulfate............... 152

Terconazole............................ 65

Teriparatide...........................144

Testim....................................129

Testosterone.........................129

Testosterone Cypionate.......129

Testosterone Enanthate.......129

Testosterone Pump..............129

Tetrabenazine.......................106

Tetracycline HCl..................... 55

Texacort................................ 113

Thalomid................................. 69

Theo-24................................. 153

Theophylline......................... 153

Theophylline ER................... 153

Thiola.....................................127

Thiola EC...............................127

Thioridazine HCl..................... 77

Thiothixene............................. 77

Thyquidity............................. 136

Tiadylt ER................................ 98

Tiagabine HCl......................... 59

Tiazac...................................... 98

Tibsovo....................................73

Tigecycline..............................49

Tiglutik...................................106

Tikosyn.................................... 96

Tilia Fe................................... 134

Timolol Maleate..............68, 148

Timolol Maleate Ophthalmic

Gel Forming........................148

Timolol Maleate PF.............. 148

Timoptic Ocudose................148

Timoptic-XE...........................148

Tinidazole................................49

Tiopronin...............................127

Tirosint.................................. 136

Tirosint-SOL.......................... 136

Tivicay......................................82

Tivicay PD............................... 82

Tizanidine HCl.........................80

TOBI...................................... 152

TOBI Podhaler...................... 152

TobraDex.............................. 145

TobraDex ST.........................145

Tobramycin...................147, 152

Tobramycin Sulfate................ 47

Tobramycin-Dexamethasone

.............................................145

Tobrex................................... 147

Tolcapone............................... 75

Tolsura.....................................65

Tolterodine Tartrate............. 126

Tolterodine Tartrate ER....... 126

Tolvaptan.............................. 120

Topamax................................. 57

Topamax Sprinkle.................. 57

Topicort.................................113

Topicort Spray...................... 113

Topiramate..............................57

Topiramate ER........................57

Toprol XL.................................97

Toremifene Citrate..................69

Torsemide.............................101

Tosymra...................................67

Toujeo Max SoloStar..............91

Toujeo SoloStar...................... 91

Tovet......................................113

Toviaz.................................... 126

TPN Electrolytes................... 119

Tracleer................................. 153

Tradjenta................................. 88

Tramadol HCl..........................46

Tramadol HCl ER....................44

Tramadol-Acetaminophen..... 46

Trandolapril.............................95

Trandolapril-Verapamil HCl ER

.............................................100

Tranexamic Acid.....................94

Transderm-Scop.....................64

36

Tranxene-T.............................. 85

Tranylcypromine Sulfate........ 61

Travasol.................................119

Travatan Z............................. 149

Travoprost.............................149

Trazodone HCl........................62

Trecator...................................68

Trelegy Ellipta....................... 155

Trelstar Mixject..................... 137

Tremfya................................. 139

Tresiba.....................................91

Tresiba FlexTouch..................91

Tretinoin..........................74, 110

Tretinoin Microsphere..........110

Trexall....................................141

Treximet.................................. 67

Trezix....................................... 46

Tri-Estarylla............................134

Tri-Legest Fe......................... 134

Tri-Lo-Estarylla...................... 134

Tri-Lo-Sprintec...................... 134

Tri-Mili....................................134

Tri-Nymyo..............................134

Tri-Previfem...........................134

Tri-Sprintec............................134

Tri-VyLibra.............................134

Tri-VyLibra Lo........................134

Triamcinolone Acetonide... 108,

113, 114

Triamterene...........................101

Triamterene-HCTZ................100

Trianex...................................114

Tribenzor...............................100

Tricor..................................... 102

Triderm..................................114

Trientine HCl.........................120

Trifluoperazine HCl.................77

Trifluridine.............................147

Trihexyphenidyl HCl............... 75

Trijardy XR...............................88

Trikafta.................................. 153

Trileptal....................................60

Trilipix....................................102

TriLyte....................................122

Trimethobenzamide HCl........64

Trimethoprim.......................... 49

Trimipramine Maleate............ 63

Trintellix................................... 63

Triumeq................................... 83

Trivora................................... 134

Trizivir...................................... 83

Trokendi XR............................ 57

TrophAmine.......................... 119

Trospium Chloride............... 126

Trospium Chloride ER......... 126

Trulance................................ 121

Trulicity....................................88

Trumenba..............................142

Trusopt.................................. 149

Truvada................................... 83

Tudorza Pressair.................. 151

Tukysa..................................... 70

Turalio......................................73

Twinrix................................... 142

Twynsta................................. 100

Tybost......................................84

Tydemy..................................134

Tygacil..................................... 49

Tykerb......................................73

Tymlos...................................144

Typhim Vi.............................. 142

U

Ubrelvy.................................... 67

Uceris.................................... 143

Udenyca.................................. 93

Ukoniq..................................... 73

Uloric....................................... 66

Ultracet.................................... 46

Ultram...................................... 46

Ultravate................................ 114

Unasyn.....................................52

Unithroid............................... 136

Uptravi................................... 153

Urocit-K 10............................ 119

Urocit-K 15............................ 119

Urocit-K 5.............................. 119

Uroxatral................................126

Urso 250................................122

Urso Forte............................. 122

Ursodiol.................................122

V

Vabomere................................53

Vagifem................................. 134

Valacyclovir HCl......................81

Valchlor................................... 69

Valcyte.....................................80

Valganciclovir HCl.................. 80

Valium......................................86

Valproic Acid...........................57

Valsartan..................................95

Valsartan-Hydrochlorothiazide

.............................................100

Valtoco 10 MG Dose.............. 59

37

Valtoco 15 MG Dose.............. 59

Valtoco 20 MG Dose.............. 59

Valtoco 5 MG Dose................ 59

Valtrex......................................81

Vancocin................................. 49

Vancocin HCl.......................... 49

Vancomycin HCl..................... 49

Vandazole................................49

Vanos.....................................114

VAQTA...................................142

Varivax...................................142

Varizig....................................138

Varubi...................................... 64

Vascepa................................ 103

Vaseretic............................... 100

Vasotec....................................95

Vecamyl.................................100

Vectical..................................115

Velivet.................................... 134

Velphoro................................120

Veltassa.................................120

Veltin......................................110

Vemlidy....................................81

Venclexta.................................73

Venclexta Starting Pack.........73

Venlafaxine HCl...................... 63

Venlafaxine HCl ER................ 63

Ventavis.................................153

Ventolin HFA.........................152

Verapamil HCl.........................98

Verapamil HCl ER...................98

Verdeso................................. 114

Veregen.................................115

Verelan.................................... 98

Verelan PM..............................98

Verquvo................................. 104

Versacloz.................................80

Verzenio.................................. 73

Vesicare.................................126

Vesicare LS...........................126

Vestura.................................. 134

Vfend....................................... 65

Vfend IV................................... 65

Viberzi....................................121

Vibramycin.............................. 55

Victoza.....................................88

Viekira Pak.............................. 81

Vienva....................................134

Vigabatrin................................ 59

Vigadrone................................59

Vigamox................................ 147

Viibryd......................................63

Viibryd Starter Pack................63

Vimovo.....................................41

Vimpat..................................... 60

Viokace..................................125

Viracept................................... 84

Viramune................................. 83

Viramune XR........................... 83

Viread...................................... 83

Vistaril...................................... 85

Vitrakvi.....................................73

Vivelle-Dot............................. 134

Vivitrol......................................47

Vivlodex................................... 41

Vizimpro.................................. 73

Vogelxo................................. 129

Vogelxo Pump...................... 129

Voriconazole.....................65, 66

Vosevi...................................... 81

Votrient.................................... 73

VP-PNV-DHA......................... 120

Vraylar......................................79

Vumerity................................ 108

Vyfemla..................................134

VyLibra.................................. 134

Vyndamax............................. 125

Vyndaqel............................... 125

Vytorin................................... 103

Vyvanse................................. 105

Vyzulta................................... 149

W

Wakix.....................................156

Warfarin Sodium.....................92

Welchol................................. 103

Wellbutrin SR.......................... 61

Wellbutrin XL...........................61

Wixela Inhub......................... 155

WYMZYA Fe..........................134

X

Xalatan...................................149

Xalkori......................................73

Xanax.......................................86

Xanax XR.................................86

Xarelto..................................... 92

Xarelto Starter Pack............... 92

Xatmep.................................. 141

Xcopri................................ 57, 58

Xeljanz................................... 139

Xeljanz XR............................. 139

Xelpros.................................. 149

Xenazine................................106

38

Xenleta.....................................49

Xepi........................................117

Xerese................................... 115

Xermelo................................. 121

Xgeva.....................................144

Xhance.................................. 151

Xifaxan.....................................49

Xigduo XR............................... 88

Xiidra..................................... 145

Xofluza.....................................85

Xolair......................................139

Xolegel...................................117

Xopenex................................ 152

Xopenex Concentrate.......... 152

Xopenex HFA........................152

Xospata................................... 73

Xpovio......................................70

Xtampza ER............................ 44

Xtandi.......................................69

Xulane....................................134

Xultophy.................................. 88

Xuriden.................................. 125

Xyosted................................. 130

Xyrem.................................... 156

Xywav.................................... 155

Y

Yasmin 28............................. 134

YAZ........................................134

YF-Vax....................................142

Yonsa.......................................69

Yupelri................................... 151

Yuvafem................................ 134

Z

Zafemy.................................. 134

Zafirlukast............................. 151

Zaleplon................................ 155

Zanaflex...................................80

Zarah..................................... 134

Zarontin................................... 58

Zarxio.......................................93

Zavesca................................. 125

Zegerid.................................. 123

Zejula.......................................73

Zelapar ODT........................... 76

Zelboraf................................... 73

Zemaira................................. 125

Zembrace SymTouch.............67

Zemdri..................................... 47

Zemplar................................. 144

Zenatane............................... 110

Zenpep..................................125

Zenzedi..................................105

Zepatier................................... 81

Zeposia..................................108

Zeposia 7-Day Starter Pack

.............................................108

Zeposia Starter Kit................108

Zerbaxa................................... 51

Zerviate..................................146

Zestoretic.............................. 100

Zestril.......................................95

Zetia.......................................103

Zetonna................................. 151

Ziac........................................100

Ziagen......................................83

Ziana......................................110

Zidovudine.............................. 83

Ziextenzo.................................94

Zileuton ER........................... 151

Zilxi........................................ 117

Zioptan.................................. 149

Ziprasidone HCl......................79

Ziprasidone Mesylate.............79

Zipsor...................................... 41

Zirgan...................................... 80

Zithromax................................ 53

Zithromax Tri-Pak................... 53

Zithromax Z-Pak..................... 53

Zocor..................................... 102

Zolinza..................................... 70

Zolmitriptan.............................67

Zolmitriptan ODT....................67

Zoloft....................................... 63

Zolpidem Tartrate.................155

Zomacton..............................129

Zomig...................................... 67

Zomig ZMT..............................67

Zonalon................................. 114

Zonegran.................................60

Zonisamide............................. 60

Zontivity................................... 92

Zorbtive................................. 129

Zortress................................. 141

Zorvolex...................................42

Zosyn.......................................52

Zovia 1/35E...........................134

Zovirax.....................................82

ZTlido...................................... 46

Zubsolv....................................47

Zuplenz....................................64

Zyclara Pump........................115

Zydelig.....................................73

39

Zyflo.......................................151

Zykadia....................................73

Zylet.......................................145

Zyloprim.................................. 66

Zymaxid.................................147

Zypitamag............................. 102

Zyprexa....................................79

Zyprexa Relprevv....................80

Zyprexa Zydis......................... 80

Zytiga.......................................69

Zyvox....................................... 49

40

Covered drugs by medical condition

The list below has information about the drugs covered by this plan. If you have trouble finding your

drug, turn to the “Covered drugs by name (Drug index)” on pages 12-39.

The first column lists the drug name, which may include the dosage form and strength. Brand

name drugs are listed in bold type (for example, Humalog) and generic drugs are listed in plain

type (for example, Simvastatin). The information in the “Coverage Rules or limits on use” column

lists any special requirements for coverage of your drug. If quantity limits (QL) apply to a drug, the

restriction amounts are shown in the chart on pages 157-202.

Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

A1

AnalgesicsB1

Nonsteroidal Anti-inflammatory DrugsC1

Arth

rote

c

Arthrotec (Oral Tablet Delayed Release) B 3

C1

Cam

bia

Cambia (Oral Packet) B 4

C1

Cele

brex

Celebrex (Oral Capsule) B 3 QL C1

Cele

coxi

b

Celecoxib (Oral Capsule) G 2 QL C1

Day

pro

Daypro (Oral Tablet) B 3

C1

Dicl

ofen

ac

Epol

ami

ne Diclofenac Epolamine (External Patch) G 3 PA; QL C1

Dicl

ofen

ac

Pota

ssiu

m Diclofenac Potassium (Oral Tablet) G 2

C1

Dicl

ofen

ac

Sodi

um

ER Diclofenac Sodium ER (Oral Tablet Extended Release 24

Hour)G 1

C1

Dicl

ofen

ac

Sodi

um Diclofenac Sodium (1% External Gel) G 2

C1

Dicl

ofen

ac

Sodi

um Diclofenac Sodium (External Solution) G 2 PA C1

Dicl

ofen

ac

Sodi

um Diclofenac Sodium (Oral Tablet Delayed Release) G 1

C1

Dicl

ofen

ac-

Mis

opr

osto

l Diclofenac-Misoprostol (Oral Tablet Delayed Release) G 3

C1

Diflu

nisal

Diflunisal (Oral Tablet) G 2

C1

Due

xis

Duexis (Oral Tablet) B 4 ST C1

Eto

dola

c

ER

Etodolac ER (Oral Tablet Extended Release 24 Hour) G 3

C1

Eto

dola

c

Etodolac (Oral Capsule) G 2

C1

Eto

dola

c

Etodolac (Oral Tablet Immediate Release) G 2

C1

Feld

ene

Feldene (Oral Capsule) B 3

C1

Fen

opr

ofen

Calc

ium Fenoprofen Calcium (400MG Oral Capsule) G 3

C1

Fen

opr

ofen

Calc

ium Fenoprofen Calcium (Oral Tablet) G 3

C1

Flec

tor

Flector (External Patch) B 3 PA; QL C1

Flur

bipr

ofen

Flurbiprofen (100MG Oral Tablet) G 2

C1

Ibu

Ibu (600MG Oral Tablet, 800MG Oral Tablet) G 1

C1

Ibup

rofe

n

Ibuprofen (Oral Suspension) G 1

You can find information on what the abbreviations in this table mean on pages 6 - 7.

41Last updated September 1, 2021

Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Ibup

rofe

n

Ibuprofen (400MG Oral Tablet, 600MG Oral Tablet,

800MG Oral Tablet)G 1

C1

Indo

cin

Indocin (Rectal Suppository) G 4

C1

Ket

opr

ofen

ER

Ketoprofen ER (Oral Capsule Extended Release 24

Hour)G 3

C1

Ket

opr

ofen

Ketoprofen (Oral Capsule Immediate Release) G 2

C1

Ket

orol

ac

Tro

met

ham

ine Ketorolac Tromethamine (Nasal Solution) G 4 LA C1

Lica

rt

Licart (External Patch 24 Hour) B 3 PA; QL C1

Lodi

ne

Lodine (Oral Tablet) G 4

C1

Mec

lofe

nam

ate

Sodi

um Meclofenamate Sodium (Oral Capsule) G 3

C1

Mef

ena

mic

Acid

Mefenamic Acid (Oral Capsule) G 3

C1

Mel

oxic

am

Meloxicam (Oral Capsule) G 3 QL C1

Mel

oxic

am

Meloxicam (Oral Tablet) G 1

C1

Mob

ic

Mobic (Oral Tablet) B 3

C1

Nab

ume

tone

Nabumetone (Oral Tablet) G 2

C1

Nalf

on

Nalfon (Oral Capsule) B 3

C1

Nalf

on

Nalfon (Oral Tablet) G 3

C1

Nap

rela

n

Naprelan (Oral Tablet Extended Release 24 Hour) B 4

C1

Nap

roxe

n

Naproxen (Oral Suspension) G 4

C1

Nap

roxe

n

Naproxen (Oral Tablet Immediate Release) G 1

C1

Nap

roxe

n

DR

Naproxen DR (Oral Tablet Delayed Release) (Generic

EC-Naprosyn)G 1

C1

Nap

roxe

n

Sodi

um

ER Naproxen Sodium ER (375MG Oral Tablet Extended

Release 24 Hour) (Generic Naprelan)G 4

C1

Nap

roxe

n

Sodi

um

ER Naproxen Sodium ER (500MG Oral Tablet Extended

Release 24 Hour) (Generic Naprelan)G 3

C1

Nap

roxe

n

Sodi

um Naproxen Sodium (275MG Oral Tablet Immediate

Release, 550MG Oral Tablet Immediate Release)G 2

C1

Nap

roxe

n-

Eso

mep

razo

le Naproxen-Esomeprazole (Oral Tablet Delayed Release) G 4 ST C1

Oxa

proz

in

Oxaprozin (Oral Tablet) G 3

C1

Pen

nsai

d

Pennsaid (External Solution) B 4 PA C1

Piro

xica

m

Piroxicam (Oral Capsule) G 2

C1

Rela

fen

DS

Relafen DS (Oral Tablet) G 4 ST C1

Spri

x

Sprix (Nasal Solution) B 4 LA C1

Suli

nda

c

Sulindac (Oral Tablet) G 1

C1

Vim

ovo

Vimovo (Oral Tablet Delayed Release) B 4 ST C1

Vivl

ode

x

Vivlodex (Oral Capsule) B 4 QL C1

Zips

or

Zipsor (Oral Capsule) B 4 ST

42 Last updated September 1, 2021

Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Zorv

olex

Zorvolex (Oral Capsule) B 3 ST B1

Opioid Analgesics, Long-actingC1

Belb

uca

Belbuca (150MCG Buccal Film, 300MCG Buccal Film,

450MCG Buccal Film, 75MCG Buccal Film)B 3 PA; 7D; DL; QL

C1

Belb

uca

Belbuca (600MCG Buccal Film, 750MCG Buccal Film,

900MCG Buccal Film)B 4 PA; 7D; DL; QL

C1

Bup

reno

rphi

ne

Buprenorphine (Transdermal Patch Weekly) G 2 7D; DL; QL C1

Butr

ans

Butrans (Transdermal Patch Weekly) B 2 7D; DL; QL C1

Con

Zip

ConZip (Oral Capsule Extended Release 24 Hour) B 3 7D; MME; DL; QL C1

Fent

anyl

Fentanyl (100MCG/HR Transdermal Patch 72 Hour,

37.5MCG/HR Transdermal Patch 72 Hour, 62.5MCG/HR

Transdermal Patch 72 Hour, 75MCG/HR Transdermal

Patch 72 Hour)

G 3 7D; MME; DL; QL

C1

Fent

anyl

Fentanyl (12MCG/HR Transdermal Patch 72 Hour,

25MCG/HR Transdermal Patch 72 Hour, 50MCG/HR

Transdermal Patch 72 Hour)

G 2 7D; MME; DL; QL

C1

Fent

anyl

Fentanyl (87.5MCG/HR Transdermal Patch 72 Hour) G 4 7D; MME; DL; QL C1

Hyd

roco

don

e

Bitar

trate

ER Hydrocodone Bitartrate ER (10MG Oral Capsule

Extended Release 12 Hour, 15MG Oral Capsule





Extended Release 12 Hour)

G 3 7D; MME; DL; QL

C1

Hyd

roco

don

e

Bitar

trate

ER Hydrocodone Bitartrate ER (100MG Oral Tablet ER 24

Hour Abuse-Deterrent, 120MG Oral Tablet ER 24 Hour

Abuse-Deterrent)

G 4PA; 7D; MME; DL;

QL C1

Hyd

roco

don

e

Bitar

trate

ER Hydrocodone Bitartrate ER (20MG Oral Tablet ER 24

Hour Abuse-Deterrent, 30MG Oral Tablet ER 24 Hour

Abuse-Deterrent, 40MG Oral Tablet ER 24 Hour Abuse-

Deterrent, 60MG Oral Tablet ER 24 Hour Abuse-


Deterrent)

G 3PA; 7D; MME; DL;

QL

C1

Hyd

rom

orph

one

HCl

ER Hydromorphone HCl ER (Oral Tablet Extended Release

24 Hour)G 3 7D; MME; DL; QL

C1

Hysi

ngla

ER

Hysingla ER (100MG Oral Tablet ER 24 Hour Abuse-




Deterrent)

B 4PA; 7D; MME; DL;

QL



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Hysi

ngla

ER

Hysingla ER (20MG Oral Tablet ER 24 Hour Abuse-



Deterrent)

B 3PA; 7D; MME; DL;

QL

C1

Lev

orph

anol

Tartr

ate Levorphanol Tartrate (Oral Tablet) G 4 7D; MME; DL; QL C1

Met

had

one

HCl

Methadone HCl (Oral Solution) G 1 7D; MME; DL; QL C1

Met

had

one

HCl

Methadone HCl (Oral Tablet) G 1 7D; MME; DL; QL C1

Mor

phin

e

Sulf

ate

ER

Bea

ds Morphine Sulfate ER Beads (Oral Capsule Extended

Release 24 Hour) (Generic Avinza)G 3 7D; MME; DL; QL

C1

Mor

phin

e

Sulf

ate

ER Morphine Sulfate ER (100MG Oral Capsule Extended

Release 24 Hour) (Generic Kadian)G 4 7D; MME; DL; QL

C1

Mor

phin

e

Sulf

ate

ER Morphine Sulfate ER (10MG Oral Capsule Extended

Release 24 Hour, 20MG Oral Capsule Extended Release

24 Hour, 30MG Oral Capsule Extended Release 24

Hour, 40MG Oral Capsule Extended Release 24 Hour,

50MG Oral Capsule Extended Release 24 Hour, 60MG

Oral Capsule Extended Release 24 Hour, 80MG Oral

Capsule Extended Release 24 Hour) (Generic Kadian)

G 3 7D; MME; DL; QL

C1

Mor

phin

e

Sulf

ate

ER 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)

G 2 7D; MME; DL; QL

C1

Mor

phin

e

Sulf

ate

ER Morphine Sulfate ER (200MG Oral Tablet Extended

Release) (Generic MS Contin)G 3 7D; MME; DL; QL

C1

MS

Con

tin

MS Contin (100MG Oral Tablet Extended Release,

200MG Oral Tablet Extended Release, 30MG Oral

Tablet Extended Release, 60MG Oral Tablet Extended

Release)

B 4 7D; MME; DL; QL

C1

MS

Con

tin

MS Contin (15MG Oral Tablet Extended Release) B 3 7D; MME; DL; QL C1

Nuc

ynta

ER

Nucynta ER (Oral Tablet Extended Release 12 Hour) B 2 7D; MME; DL; QL C1

Oxy

cod

one

HCl

ER Oxycodone HCl ER (10MG Oral Tablet ER 12 Hour





Deterrent)

G 3 7D; MME; DL; QL

C1

Oxy

cod

one

HCl

ER Oxycodone HCl ER (60MG Oral Tablet ER 12 Hour


Deterrent)

G 4 7D; MME; DL; QL


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Oxy

Con

tin

OxyContin (10MG Oral Tablet ER 12 Hour Abuse-



Deterrent)

B 3PA; 7D; MME; DL;

QL

C1

Oxy

Con

tin

OxyContin (30MG Oral Tablet ER 12 Hour Abuse-




Deterrent)

B 4PA; 7D; MME; DL;

QL

C1

Oxy

mor

pho

ne

HCl

ER Oxymorphone HCl ER (Oral Tablet Extended Release 12

Hour)G 3 7D; MME; DL; QL

C1

Tra

mad

ol

HCl

ER Tramadol HCl ER (Biphasic) (100MG Oral Tablet

Extended Release 24 Hour, 200MG Oral Tablet


G 2 7D; MME; DL; QL

C1

Tra

mad

ol

HCl

ER Tramadol HCl ER (Biphasic) (300MG Oral Tablet

Extended Release 24 Hour)G 3 7D; MME; DL; QL

C1

Tra

mad

ol

HCl

ER Tramadol HCl ER (100MG Oral Capsule Extended

Release 24 Hour, 200MG Oral Capsule Extended


Release 24 Hour)

G 3 7D; MME; DL; QL

C1

Tra

mad

ol

HCl

ER Tramadol HCl ER (100MG Oral Tablet Extended Release

24 Hour, 200MG Oral Tablet Extended Release 24 Hour)G 2 7D; MME; DL; QL

C1

Tra

mad

ol

HCl

ER Tramadol HCl ER (300MG Oral Tablet Extended Release

24 Hour)G 3 7D; MME; DL; QL

C1

Xta

mpz

a

ER

Xtampza ER (Oral Capsule ER 12 Hour Abuse-

Deterrent)B 2 7D; MME; DL; QL

B1

Opioid Analgesics, Short-actingC1

Acet

ami

nop

hen-

Caff

eine

-

Dihy

droc

odei

ne

Acetaminophen-Caffeine-Dihydrocodeine (Oral Capsule) G 3 7D; MME; DL; QL C1

Acet

ami

nop

hen-

Caff

eine

-

Dihy

droc

odei

ne

Acetaminophen-Caffeine-Dihydrocodeine (Oral Tablet) G 3 7D; MME; DL; QL C1

Acet

ami

nop

hen-

Cod

eine Acetaminophen-Codeine (120-12MG/5ML Oral Solution) G 1 7D; MME; DL; QL C1

Acet

ami

nop

hen-

Cod

eine Acetaminophen-Codeine (300-15MG Oral Tablet,

300-30MG Oral Tablet, 300-60MG Oral Tablet)G 1 7D; MME; DL; QL

C1

Acti

q

Actiq (Buccal Lozenge On A Handle) B 4 PA; DL; QL C1

But

orph

anol

Tartr

ate Butorphanol Tartrate (Nasal Solution) G 2 7D; MME; DL; QL C1

Cod

eine

Sulf

ate Codeine Sulfate (15MG Oral Tablet) B 2 7D; MME; DL; QL C1

Cod

eine

Sulf

ate Codeine Sulfate (30MG Oral Tablet) G 2 7D; MME; DL; QL C1

Cod

eine

Sulf

ate Codeine Sulfate (60MG Oral Tablet) G 3 7D; MME; DL; QL C1

Dila

udid

Dilaudid (Oral Liquid) B 3 7D; MME; DL; QL



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Dila

udid

Dilaudid (2MG Oral Tablet, 4MG Oral Tablet) B 3 7D; MME; DL; QL C1

Dila

udid

Dilaudid (8MG Oral Tablet) B 4 7D; MME; DL; QL C1

End

ocet

Endocet (10-325MG Oral Tablet, 5-325MG Oral Tablet,

7.5-325MG Oral Tablet)G 2 7D; MME; DL; QL

C1

Fent

anyl

Citra

te

Fentanyl Citrate (1200MCG Buccal Lozenge On A

Handle, 1600MCG Buccal Lozenge On A Handle,

400MCG Buccal Lozenge On A Handle, 600MCG Buccal

Lozenge On A Handle, 800MCG Buccal Lozenge On A

Handle)

G 4 PA; DL; QL

C1

Fent

anyl

Citra

te

Fentanyl Citrate (200MCG Buccal Lozenge On A Handle) G 3 PA; DL; QL C1

Fent

anyl

Citra

te

Fentanyl Citrate (100MCG Buccal Tablet, 200MCG

Buccal Tablet, 400MCG Buccal Tablet, 600MCG Buccal

Tablet, 800MCG Buccal Tablet)

G 4 PA; DL; QL

C1

Fent

ora

Fentora (Buccal Tablet) B 4 PA; DL; QL C1

Hyd

roco

don

e-

Acet

ami

nop

hen Hydrocodone-Acetaminophen (7.5-325MG/15ML Oral

Solution)G 2 7D; MME; DL; QL

C1

Hyd

roco

don

e-

Acet

ami

nop

hen Hydrocodone-Acetaminophen (10-300MG Oral Tablet,

10-325MG Oral Tablet, 5-300MG Oral Tablet, 5-325MG

Oral Tablet, 7.5-300MG Oral Tablet, 7.5-325MG Oral

Tablet)

G 2 7D; MME; DL; QL

C1

Hyd

roco

don

e-

Ibup

rofe

n Hydrocodone-Ibuprofen (10-200MG Oral Tablet,

5-200MG Oral Tablet)G 3 7D; MME; DL; QL

C1

Hyd

roco

don

e-

Ibup

rofe

n Hydrocodone-Ibuprofen (7.5-200MG Oral Tablet) G 2 7D; MME; DL; QL C1

Hyd

rom

orph

one

HCl Hydromorphone HCl (1MG/ML Oral Liquid) G 2 7D; MME; DL; QL C1

Hyd

rom

orph

one

HCl Hydromorphone HCl (2MG Oral Tablet Immediate

Release, 4MG Oral Tablet Immediate Release, 8MG Oral

Tablet Immediate Release)

G 1 7D; MME; DL; QL

C1

Hyd

rom

orph

one

HCl

Pres

erva

tive

Free Hydromorphone HCl Preservative Free (10MG/ML

Injection Solution, 50MG/5ML Injection Solution)G 3 DL

C1

Laza

nda

Lazanda (Nasal Solution) B 4 PA; DL; QL C1

Mor

phin

e

Sulf

ate Morphine Sulfate (10MG/5ML Oral Solution, 100MG/

5ML Oral Solution, 20MG/5ML Oral Solution)G 1 7D; MME; DL; QL

C1

Mor

phin

e

Sulf

ate Morphine Sulfate (Oral Tablet Immediate Release) G 2 7D; MME; DL; QL C1

Nuc

ynta

Nucynta (100MG Oral Tablet Immediate Release) B 4 7D; MME; DL; QL C1

Nuc

ynta

Nucynta (50MG Oral Tablet Immediate Release,

75MG Oral Tablet Immediate Release)B 3 7D; MME; DL; QL

C1

Oxy

cod

one

HCl

Oxycodone HCl (5MG Oral Capsule) G 2 7D; MME; DL; QL C1

Oxy

cod

one

HCl

Oxycodone HCl (100MG/5ML Oral Concentrate) G 3 7D; MME; DL; QL C1

Oxy

cod

one

HCl

Oxycodone HCl (5MG/5ML Oral Solution) G 2 7D; MME; DL; QL


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Oxy

cod

one

HCl

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)

G 1 7D; MME; DL; QL

C1

Oxy

cod

one-

Acet

ami

nop

hen Oxycodone-Acetaminophen (10-300MG Oral Tablet,

5-300MG Oral Tablet)G 4 7D; MME; DL; QL

C1

Oxy

cod

one-

Acet

ami

nop

hen Oxycodone-Acetaminophen (10-325MG Oral Tablet,

2.5-325MG Oral Tablet, 5-325MG Oral Tablet,

7.5-325MG Oral Tablet)

G 2 7D; MME; DL; QL

C1

Oxy

mor

pho

ne

HCl Oxymorphone HCl (Oral Tablet Immediate Release) G 3 7D; MME; DL; QL C1

Perc

ocet

Percocet (10-325MG Oral Tablet, 5-325MG Oral Tablet,

7.5-325MG Oral Tablet)G 4 7D; MME; DL; QL

C1

Perc

ocet

Percocet (2.5-325MG Oral Tablet) G 3 7D; MME; DL; QL C1

Prol

ate

Prolate (Oral Tablet) G 4 7D; MME; DL; QL C1

Roxi

cod

one

Roxicodone (15MG Oral Tablet, 5MG Oral Tablet) B 3 7D; MME; DL; QL C1

Roxi

cod

one

Roxicodone (30MG Oral Tablet) B 4 7D; MME; DL; QL C1

Sub

sys

Subsys (Sublingual Liquid) B 4 PA; DL; QL C1

Tra

mad

ol

HCl

Tramadol HCl (100MG Oral Tablet Immediate Release) G 2 7D; MME; DL; QL C1

Tra

mad

ol

HCl

Tramadol HCl (50MG Oral Tablet Immediate Release) G 1 7D; MME; DL; QL C1

Tra

mad

ol-

Acet

ami

nop

hen Tramadol-Acetaminophen (Oral Tablet) G 1 7D; MME; DL; QL C1

Trez

ix

Trezix (Oral Capsule) G 3 7D; MME; DL; QL C1

Ultra

cet

Ultracet (Oral Tablet) B 3 7D; MME; DL; QL C1

Ultra

m

Ultram (Oral Tablet Immediate Release) B 3 7D; MME; DL; QL A1

AnestheticsB1

Local AnestheticsC1

Lido

cain

e

Lidocaine (5% External Ointment) G 3 QL C1

Lido

cain

e

Lidocaine (5% External Patch) G 3 PA; QL C1

Lido

cain

e

HCl

Lidocaine HCl (4% External Solution) G 2

C1

Lido

cain

e

Visc

ous Lidocaine Viscous (2% Mouth/Throat Solution) G 1

C1

Lido

cain

e-

Prilo

cain

e Lidocaine-Prilocaine (External Cream) G 2

C1

Lido

der

m

Lidoderm (External Patch) B 4 PA; QL C1

Plia

glis

Pliaglis (External Cream) B 3

C1

ZTli

do

ZTlido (External Patch) B 3 PA; QL A1

Anti-Addiction/Substance Abuse Treatment AgentsB1

Alcohol Deterrents/Anti-cravingC1

Aca

mpr

osat

e

Calc

ium Acamprosate Calcium (Oral Tablet Delayed Release) G 3

C1

Disu

lfira

m

Disulfiram (Oral Tablet) G 2



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Nalt

rexo

ne

HCl

Naltrexone HCl (Oral Tablet) G 2

C1

Vivit

rol

Vivitrol (Intramuscular Suspension Reconstituted) B 4

B1

Opioid DependenceC1

Bup

reno

rphi

ne

HCl Buprenorphine HCl (Tablet Sublingual) G 1 QL C1

Bup

reno

rphi

ne

HCl-

Nalo

xon

e

HCl Buprenorphine HCl-Naloxone HCl (Sublingual Film) G 3 QL C1

Bup

reno

rphi

ne

HCl-

Nalo

xon

e

HCl Buprenorphine HCl-Naloxone HCl (Tablet Sublingual) G 1 QL C1

Luc

emy

ra

Lucemyra (Oral Tablet) B 4 QL C1

Sub

oxo

ne

Suboxone (Sublingual Film) B 3 QL C1

Zub

solv

Zubsolv (Tablet Sublingual) B 3 QL B1

Opioid Reversal AgentsC1

Nalo

xon

e

HCl

Naloxone HCl (0.4MG/ML Injection Solution) G 1

C1

Nalo

xon

e

HCl

Naloxone HCl (Injection Solution Cartridge) G 1

C1

Nalo

xon

e

HCl

Naloxone HCl (Injection Solution Prefilled Syringe) G 1

C1

Nar

can

Narcan (Nasal Liquid) B 2

B1

Smoking Cessation AgentsC1

Bup

ropi

on

HCl

SR Bupropion HCl SR (150MG Oral Tablet Extended

Release 12 Hour Smoking-Deterrent)G 1

C1

Cha

ntix

Con

tinui

ng

Mon

th

Pak Chantix Continuing Month Pak (Oral Tablet) B 2

C1

Cha

ntix

Chantix (Oral Tablet) B 2

C1

Cha

ntix

Start

ing

Mon

th

Pak Chantix Starting Month Pak (Oral Tablet) B 2

C1

Nico

trol

Nicotrol (Inhalation Inhaler) B 3

C1

Nico

trol

NS

Nicotrol NS (Nasal Solution) B 3

A1

AntibacterialsB1

AminoglycosidesC1

Ami

kaci

n

Sulf

ate Amikacin Sulfate (500MG/2ML Injection Solution) G 2

C1

Arik

ayce

Arikayce (Inhalation Suspension) B 4 PA C1

Gen

tami

cin

Sulf

ate-

0.9

%

Sodi

um

Chlo

ride

Gentamicin Sulfate-0.9% Sodium Chloride (Intravenous

Solution)G 1

C1

Gen

tami

cin

Sulf

ate Gentamicin Sulfate (40MG/ML Injection Solution) G 1

C1

Hu

mati

n

Humatin (Oral Capsule) G 4

C1

Neo

myci

n

Sulf

ate Neomycin Sulfate (Oral Tablet) G 1

C1

Paro

mo

myci

n

Sulf

ate Paromomycin Sulfate (Oral Capsule) G 3

C1

Stre

pto

myci

n

Sulf

ate Streptomycin Sulfate (Intramuscular Solution

Reconstituted)G 4

C1

Tob

ram

ycin

Sulf

ate Tobramycin Sulfate (10MG/ML Injection Solution,

80MG/2ML Injection Solution)G 3

C1

Zem

dri

Zemdri (Intravenous Solution) B 4

B1

Antibacterials, Other


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Aem

colo

Aemcolo (Oral Tablet Delayed Release) B 3 PA C1

Aza

cta

m

Azactam (Injection Solution Reconstituted) B 3

C1

Aztr

eon

am

Aztreonam (1GM Injection Solution Reconstituted) G 3

C1

Cleo

cin

Cleocin (Oral Capsule) B 3

C1

Cleo

cin

Cleocin (Oral Solution Reconstituted) G 3

C1

Cleo

cin

Pho

sph

ate Cleocin Phosphate (900MG/6ML Injection Solution) G 3

C1

Cleo

cin

Cleocin (Vaginal Cream) B 3

C1

Cleo

cin

Cleocin (Vaginal Suppository) B 3

C1

Clin

dam

ycin

HCl

Clindamycin HCl (Oral Capsule) G 1

C1

Clin

dam

ycin

Pal

mita

te

HCl Clindamycin Palmitate HCl (Oral Solution Reconstituted) G 3

C1

Clin

dam

ycin

Pho

sph

ate

in

D5

W Clindamycin Phosphate in D5W (Intravenous Solution) G 2

C1

Clin

dam

ycin

Pho

sph

ate Clindamycin Phosphate (300MG/2ML Injection Solution,

600MG/4ML Injection Solution, 900MG/6ML Injection

Solution)

G 2

C1

Clin

dam

ycin

Pho

sph

ate Clindamycin Phosphate (Vaginal Cream) G 2

C1

Clin

des

se

Clindesse (Vaginal Cream) B 3

C1

Coli

stim

etha

te

Sodi

um Colistimethate Sodium (CBA) (Injection Solution

Reconstituted)G 4

C1

Cubi

cin

Cubicin (Intravenous Solution Reconstituted) B 4

C1

Dalv

anc

e

Dalvance (Intravenous Solution Reconstituted) B 4 PA C1

Dap

tom

ycin

Daptomycin (Intravenous Solution Reconstituted) G 4

C1

Firv

anq

Firvanq (Oral Solution Reconstituted) B 3

C1

Flag

yl

Flagyl (Oral Capsule) B 3

C1

Flag

yl

Flagyl (Oral Tablet) B 3

C1

Fosf

omy

cin

Tro

met

ham

ine Fosfomycin Tromethamine (Oral Packet) G 3

C1

Hipr

ex

Hiprex (Oral Tablet) B 3

C1

Line

zoli

d

Linezolid (Intravenous Solution) G 3

C1

Line

zoli

d

Linezolid (Oral Suspension Reconstituted) G 4

C1

Line

zoli

d

Linezolid (Oral Tablet) G 3

C1

Mac

robi

d

Macrobid (Oral Capsule) B 3 HRM C1

Mac

roda

ntin

Macrodantin (Oral Capsule) B 3 HRM C1

Met

hen

ami

ne

Hip

pura

te Methenamine Hippurate (Oral Tablet) G 2

C1

Metr

oCr

eam

MetroCream (External Cream) B 3

C1

Metr

ogel

Metrogel (External Gel) B 3

C1

Metr

oLot

ion

MetroLotion (External Lotion) B 4

C1

Metr

onid

azol

e

Metronidazole (0.75% External Cream) G 2



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Metr

onid

azol

e

Metronidazole (0.75% External Gel, 1% External Gel) G 3

C1

Metr

onid

azol

e

Metronidazole (0.75% External Lotion) G 3

C1

Metr

onid

azol

e in

NaC

l

0.79

% Metronidazole in NaCl 0.79% (Intravenous Solution) G 1

C1

Metr

onid

azol

e

Metronidazole (375MG Oral Capsule) G 3

C1

Metr

onid

azol

e

Metronidazole (250MG Oral Tablet, 500MG Oral Tablet) G 1

C1

Metr

onid

azol

e

Metronidazole (0.75% Vaginal Gel) G 2

C1

Mon

urol

Monurol (Oral Packet) B 3

C1

Nitr

ofur

anto

in

Mac

rocr

ystal Nitrofurantoin Macrocrystal (100MG Oral Capsule,

50MG Oral Capsule) (Generic Macrodantin)G 2 HRM

C1

Nitr

ofur

anto

in

Mac

rocr

ystal Nitrofurantoin Macrocrystal (25MG Oral Capsule)

(Generic Macrodantin)G 3 HRM

C1

Nitr

ofur

anto

in

Mon

ohy

drat

e Nitrofurantoin Monohydrate (Generic Macrobid) G 2 HRM C1

Nitr

ofur

anto

in

Nitrofurantoin (Oral Suspension) G 3 HRM C1

Nori

tate

Noritate (External Cream) B 4

C1

Poly

myxi

n B

Sulf

ate Polymyxin B Sulfate (Injection Solution Reconstituted) G 2

C1

Sive

xtro

Sivextro (Intravenous Solution Reconstituted) B 4 PA C1

Sive

xtro

Sivextro (Oral Tablet) B 4 PA C1

Solo

sec

Solosec (Oral Packet) B 3

C1

Tige

cycli

ne

Tigecycline (Intravenous Solution Reconstituted) G 4

C1

Tini

daz

ole

Tinidazole (Oral Tablet) G 2

C1

Trim

etho

prim

Trimethoprim (Oral Tablet) G 1

C1

Tyg

acil

Tygacil (Intravenous Solution Reconstituted) B 4

C1

Van

coci

n

HCl

Vancocin HCl (125MG Oral Capsule) B 4 QL C1

Van

coci

n

Vancocin (250MG Oral Capsule) B 4 QL C1

Van

com

ycin

HCl

Vancomycin HCl (10GM Intravenous Solution

Reconstituted, 1GM Intravenous Solution Reconstituted,

500MG Intravenous Solution Reconstituted, 750MG

Intravenous Solution Reconstituted)

G 2

C1

Van

com

ycin

HCl

Vancomycin HCl (250MG Intravenous Solution

Reconstituted)B 2

C1

Van

com

ycin

HCl

Vancomycin HCl (Oral Capsule) G 3 QL C1

Van

com

ycin

HCl

Vancomycin HCl (Oral Solution Reconstituted) G 3

C1

Van

daz

ole

Vandazole (Vaginal Gel) B 2

C1

Xenl

eta

Xenleta (Oral Tablet) B 4 PA; QL C1

Xifa

xan

Xifaxan (Oral Tablet) B 4 PA C1

Zyv

ox

Zyvox (600MG/300ML Intravenous Solution) B 3

C1

Zyv

ox

Zyvox (Oral Suspension Reconstituted) B 4

C1

Zyv

ox

Zyvox (Oral Tablet) B 4


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

B1

Beta-lactam, CephalosporinsC1

Avy

caz

Avycaz (Intravenous Solution Reconstituted) B 4 PA C1

Cefa

clor

ER

Cefaclor ER (Oral Tablet Extended Release 12 Hour) G 3

C1

Cefa

clor

Cefaclor (Oral Capsule) G 2

C1

Cefa

clor

Cefaclor (Oral Suspension Reconstituted) G 3

C1

Cefa

drox

il

Cefadroxil (Oral Capsule) G 1

C1

Cefa

drox

il

Cefadroxil (Oral Suspension Reconstituted) G 2

C1

Cefa

drox

il

Cefadroxil (Oral Tablet) G 3

C1

Cefa

zolin

Sodi

um Cefazolin Sodium (10GM Injection Solution

Reconstituted, 1GM Injection Solution Reconstituted,

500MG Injection Solution Reconstituted)

G 2

C1

Cef

dinir

Cefdinir (Oral Capsule) G 2

C1

Cef

dinir

Cefdinir (Oral Suspension Reconstituted) G 2

C1

Cef

epi

me

HCl

Cefepime HCl (Injection Solution Reconstituted) G 3

C1

Cefi

xim

e

Cefixime (Oral Capsule) G 2

C1

Cefi

xim

e

Cefixime (Oral Suspension Reconstituted) G 3

C1

Cef

otet

an

Diso

diu

m Cefotetan Disodium (Injection Solution Reconstituted) G 3

C1

Cef

oxiti

n

Sodi

um Cefoxitin Sodium (Injection Solution Reconstituted) G 2

C1

Cef

oxiti

n

Sodi

um Cefoxitin Sodium (Intravenous Solution Reconstituted) G 2

C1

Cef

pod

oxi

me

Prox

etil Cefpodoxime Proxetil (Oral Suspension Reconstituted) G 3

C1

Cef

pod

oxi

me

Prox

etil Cefpodoxime Proxetil (Oral Tablet) G 2

C1

Cef

proz

il

Cefprozil (Oral Suspension Reconstituted) G 2

C1

Cef

proz

il

Cefprozil (Oral Tablet) G 2

C1

Ceft

azidi

me

Ceftazidime (Injection Solution Reconstituted) G 2

C1

Ceft

riax

one

Sodi

um Ceftriaxone Sodium (1GM Injection Solution

Reconstituted, 250MG Injection Solution Reconstituted)G 1

C1

Ceft

riax

one

Sodi

um Ceftriaxone Sodium (2GM Injection Solution

Reconstituted, 500MG Injection Solution Reconstituted)G 2

C1

Ceft

riax

one

Sodi

um Ceftriaxone Sodium (10GM Intravenous Solution

Reconstituted)G 2

C1

Cef

urox

ime

Axet

il Cefuroxime Axetil (Oral Tablet) G 1

C1

Cef

urox

ime

Sodi

um Cefuroxime Sodium (Injection Solution Reconstituted) G 1

C1

Cef

urox

ime

Sodi

um Cefuroxime Sodium (Intravenous Solution

Reconstituted)G 1

C1

Cep

hale

xin

Cephalexin (250MG Oral Capsule, 500MG Oral Capsule) G 1

C1

Cep

hale

xin

Cephalexin (750MG Oral Capsule) G 3

C1

Cep

hale

xin

Cephalexin (Oral Suspension Reconstituted) G 1



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Cep

hale

xin

Cephalexin (Oral Tablet) G 2

C1

Sup

rax

Suprax (Oral Capsule) B 2

C1

Sup

rax

Suprax (100MG/5ML Oral Suspension Reconstituted,

200MG/5ML Oral Suspension Reconstituted)G 3

C1

Sup

rax

Suprax (500MG/5ML Oral Suspension Reconstituted) B 3

C1

Sup

rax

Suprax (Oral Tablet Chewable) G 2

C1

Tazi

cef

Tazicef (Injection Solution Reconstituted) G 2

C1

Tefl

aro

Teflaro (Intravenous Solution Reconstituted) B 4

C1

Zer

bax

a

Zerbaxa (Intravenous Solution Reconstituted) B 4 PA B1

Beta-lactam, PenicillinsC1

Am

oxici

llin

Amoxicillin (Oral Capsule) G 1

C1

Am

oxici

llin

Amoxicillin (Oral Suspension Reconstituted) G 1

C1

Am

oxici

llin

Amoxicillin (Oral Tablet Immediate Release) G 1

C1

Am

oxici

llin

Amoxicillin (Oral Tablet Chewable) G 1

C1

Am

oxici

llin-

Pota

ssiu

m

Clav

ulan

ate

ERAmoxicillin-Potassium Clavulanate ER (Oral Tablet

Extended Release 12 Hour)G 3

C1

Am

oxici

llin-

Pota

ssiu

m

Clav

ulan

ate Amoxicillin-Potassium Clavulanate (200-28.5MG/5ML

Oral Suspension Reconstituted, 400-57MG/5ML Oral

Suspension Reconstituted, 600-42.9MG/5ML Oral

Suspension Reconstituted)

G 1

C1

Am

oxici

llin-

Pota

ssiu

m

Clav

ulan

ate Amoxicillin-Potassium Clavulanate (250-62.5MG/5ML

Oral Suspension Reconstituted)G 2

C1

Am

oxici

llin-

Pota

ssiu

m

Clav

ulan

ate Amoxicillin-Potassium Clavulanate (250-125MG Oral

Tablet Immediate Release)G 2

C1

Am

oxici

llin-

Pota

ssiu

m

Clav

ulan

ate Amoxicillin-Potassium Clavulanate (500-125MG Oral

Tablet Immediate Release, 875-125MG Oral Tablet

Immediate Release)

G 1

C1

Am

oxici

llin-

Pota

ssiu

m

Clav

ulan

ate Amoxicillin-Potassium Clavulanate (200-28.5MG Oral

Tablet Chewable, 400-57MG Oral Tablet Chewable)G 2

C1

Am

picill

in

Ampicillin (Oral Capsule) G 1

C1

Am

picill

in

Sodi

um Ampicillin Sodium (125MG Injection Solution

Reconstituted, 1GM Injection Solution Reconstituted)G 2

C1

Am

picill

in

Sodi

um Ampicillin Sodium (10GM Intravenous Solution

Reconstituted)G 2

C1

Am

picill

in-

Sulb

acta

m

Sodi

um Ampicillin-Sulbactam Sodium (Injection Solution

Reconstituted)G 2

C1

Am

picill

in-

Sulb

acta

m

Sodi

um Ampicillin-Sulbactam Sodium (15 (10-5)GM Intravenous

Solution Reconstituted)G 2

C1

Bicill

in C-

R

900/

300 Bicillin C-R 900/300 (Intramuscular Suspension) B 3


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Bicill

in C-

R

Bicillin C-R (Intramuscular Suspension) B 3

C1

Bicill

in L-

A

Bicillin L-A (Intramuscular Suspension) B 3

C1

Dicl

oxa

cillin

Sodi

um Dicloxacillin Sodium (250MG Oral Capsule) G 1

C1

Dicl

oxa

cillin

Sodi

um Dicloxacillin Sodium (500MG Oral Capsule) G 2

C1

Nafc

illin

Sodi

um

Nafcillin Sodium (Injection Solution Reconstituted) G 3

C1

Nafc

illin

Sodi

um

Nafcillin Sodium (10GM Intravenous Solution

Reconstituted)G 3

C1

Oxa

cillin

Sodi

um

in

Dext

rose Oxacillin Sodium in Dextrose (1GM/50ML Intravenous

Solution)B 3

C1

Oxa

cillin

Sodi

um

in

Dext

rose Oxacillin Sodium in Dextrose (2GM/50ML Intravenous

Solution)B 4

C1

Oxa

cillin

Sodi

um Oxacillin Sodium (Injection Solution Reconstituted) G 3

C1

Oxa

cillin

Sodi

um Oxacillin Sodium (Intravenous Solution Reconstituted) G 3

C1

Peni

cillin

G

Pota

ssiu

m in

Dext

rose Penicillin G Potassium in Dextrose (40000UNIT/ML

Intravenous Solution, 60000UNIT/ML Intravenous

Solution)

B 3

C1

Peni

cillin

G

Pota

ssiu

m Penicillin G Potassium (20000000UNIT Injection Solution

Reconstituted)G 3

C1

Peni

cillin

G

Proc

aine Penicillin G Procaine (Intramuscular Suspension) G 3

C1

Peni

cillin

G

Sodi

um Penicillin G Sodium (Injection Solution Reconstituted) G 4

C1

Peni

cillin

V

Pota

ssiu

m Penicillin V Potassium (Oral Solution Reconstituted) G 1

C1

Peni

cillin

V

Pota

ssiu

m Penicillin V Potassium (Oral Tablet) G 1

C1

Pipe

racill

in-

Taz

oba

cta

m Piperacillin-Tazobactam (2.25 (2-0.25)GM Intravenous

Solution Reconstituted, 3.375 (3-0.375)GM Intravenous

Solution Reconstituted)

G 2

C1

Pipe

racill

in-

Taz

oba

cta

m Piperacillin-Tazobactam (4.5 (4-0.5)GM Intravenous

Solution Reconstituted, 40.5 (36-4.5)GM Intravenous

Solution Reconstituted)

G 3

C1

Una

syn

Unasyn (3 (2-1)GM Injection Solution Reconstituted) B 3

C1

Una

syn

Unasyn (Intravenous Solution Reconstituted) B 3

C1

Zos

yn

Zosyn (2-0.25GM/50ML Intravenous Solution,

3-0.375GM/50ML Intravenous Solution)B 3

B1

CarbapenemsC1

Erta

pen

em

Sodi

um Ertapenem Sodium (Injection Solution Reconstituted) G 3

C1

Imip

ene

m-

Cila

stati

n Imipenem-Cilastatin (Intravenous Solution Reconstituted) G 3

C1

Inva

nz

Invanz (Injection Solution Reconstituted) B 4

C1

Mer

ope

nem

Meropenem (1GM Intravenous Solution Reconstituted) G 3



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Mer

ope

nem

Meropenem (500MG Intravenous Solution

Reconstituted)G 2

C1

Merr

em

Merrem (500MG Intravenous Solution Reconstituted) B 3

C1

Prim

axin

IV

Primaxin IV (Intravenous Solution Reconstituted) B 3

C1

Vab

ome

re

Vabomere (Intravenous Solution Reconstituted) B 4

B1

MacrolidesC1

Azit

hro

myci

n

Azithromycin (Intravenous Solution Reconstituted) G 1

C1

Azit

hro

myci

n

Azithromycin (Oral Packet) B 1

C1

Azit

hro

myci

n

Azithromycin (Oral Suspension Reconstituted) G 1

C1

Azit

hro

myci

n

Azithromycin (Oral Tablet) G 1

C1

Clari

thro

myci

n

ER Clarithromycin ER (Oral Tablet Extended Release 24

Hour)G 2

C1

Clari

thro

myci

n

Clarithromycin (Oral Suspension Reconstituted) G 3

C1

Clari

thro

myci

n

Clarithromycin (Oral Tablet Immediate Release) G 2

C1

Dific

id

Dificid (Oral Suspension Reconstituted) B 4

C1

Dific

id

Dificid (Oral Tablet) B 4

C1

E.E.

S.

Gra

nule

s E.E.S. Granules (Oral Suspension Reconstituted) B 3

C1

EryP

ed

200

EryPed 200 (Oral Suspension Reconstituted) B 3

C1

EryP

ed

400

EryPed 400 (Oral Suspension Reconstituted) B 4

C1

Ery-

Tab

Ery-Tab (Oral Tablet Delayed Release) G 3

C1

Eryt

hroc

in

Lact

obio

nate Erythrocin Lactobionate (Intravenous Solution

Reconstituted)G 3

C1

Eryt

hroc

in

Stea

rate Erythrocin Stearate (Oral Tablet) G 3

C1

Eryt

hro

myci

n

Bas

e Erythromycin Base (Oral Capsule Delayed Release

Particles)G 3

C1

Eryt

hro

myci

n

Bas

e Erythromycin Base (Oral Tablet Immediate Release) G 3

C1

Eryt

hro

myci

n

Bas

e Erythromycin Base (Oral Tablet Delayed Release) G 3

C1

Eryt

hro

myci

n

Ethy

lsuc

cina

te Erythromycin Ethylsuccinate (200MG/5ML Oral

Suspension Reconstituted)G 3

C1

Eryt

hro

myci

n

Ethy

lsuc

cina

te Erythromycin Ethylsuccinate (400MG/5ML Oral

Suspension Reconstituted)G 4

C1

Eryt

hro

myci

n

Ethy

lsuc

cina

te Erythromycin Ethylsuccinate (Oral Tablet) G 3

C1

Zithr

oma

x

Zithromax (Intravenous Solution Reconstituted) B 3

C1

Zithr

oma

x

Zithromax (Oral Packet) B 3

C1

Zithr

oma

x

Zithromax (Oral Suspension Reconstituted) B 3

C1

Zithr

oma

x

Zithromax (Oral Tablet) B 3

C1

Zithr

oma

x

Tri-

Pak Zithromax Tri-Pak (Oral Tablet) B 3

C1

Zithr

oma

x Z-

Pak

Zithromax Z-Pak (Oral Tablet) B 3


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

B1

QuinolonesC1

Bax

dela

Baxdela (Intravenous Solution Reconstituted) B 4

C1

Bax

dela

Baxdela (Oral Tablet) B 4

C1

Cipr

o

Cipro (Oral Suspension Reconstituted) B 3

C1

Cipr

o

Cipro (Oral Tablet Immediate Release) B 3

C1

Cipr

oflo

xaci

n

HCl Ciprofloxacin HCl (100MG Oral Tablet Immediate

Release)G 3

C1

Cipr

oflo

xaci

n

HCl Ciprofloxacin HCl (250MG Oral Tablet Immediate

Release, 500MG Oral Tablet Immediate Release, 750MG

Oral Tablet Immediate Release)

G 1

C1

Cipr

oflo

xaci

n in

D5

W Ciprofloxacin in D5W (200MG/100ML Intravenous

Solution)G 1

C1

Lev

oflo

xaci

n in

D5

W Levofloxacin in D5W (500MG/100ML Intravenous

Solution, 750MG/150ML Intravenous Solution)G 2

C1

Lev

oflo

xaci

n

Levofloxacin (25MG/ML Intravenous Solution) G 3

C1

Lev

oflo

xaci

n

Levofloxacin (25MG/ML Oral Solution) G 3

C1

Lev

oflo

xaci

n

Levofloxacin (250MG Oral Tablet, 500MG Oral Tablet,


C1

Mox

iflox

acin

HCl

in

NaC

l Moxifloxacin HCl in NaCl (Intravenous Solution) G 3

C1

Mox

iflox

acin

HCl

Moxifloxacin HCl (Oral Tablet) G 2

C1

Oflo

xaci

n

Ofloxacin (Oral Tablet) G 3

B1

SulfonamidesC1

Bact

rim

DS

Bactrim DS (Oral Tablet) B 3

C1

Bact

rim

Bactrim (Oral Tablet) B 3

C1

Sulf

adia

zine

Sulfadiazine (Oral Tablet) G 3

C1

Sulf

ame

thox

azol

e-

Trim

etho

prim Sulfamethoxazole-Trimethoprim (Oral Suspension) G 2

C1

Sulf

ame

thox

azol

e-

Trim

etho

prim Sulfamethoxazole-Trimethoprim (Oral Tablet) G 1

B1

TetracyclinesC1

Acti

clat

e

Acticlate (Oral Tablet) B 3

C1

De

mec

locy

cline

HCl Demeclocycline HCl (Oral Tablet) G 3

C1

Dor

yx

MP

C

Doryx MPC (Oral Tablet Delayed Release) B 3

C1

Dor

yx

Doryx (200MG Oral Tablet Delayed Release) B 4

C1

Dor

yx

Doryx (50MG Oral Tablet Delayed Release) B 3

C1

Dox

y

100

Doxy 100 (Intravenous Solution Reconstituted) G 3

C1

Dox

ycyc

line

Hycl

ate Doxycycline Hyclate (Oral Capsule) G 2

C1

Dox

ycyc

line

Hycl

ate Doxycycline Hyclate (100MG Oral Tablet Immediate




Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Dox

ycyc

line

Hycl

ate Doxycycline Hyclate (150MG Oral Tablet Immediate


C1

Dox

ycyc

line

Hycl

ate Doxycycline Hyclate (100MG Oral Tablet Delayed

Release, 150MG Oral Tablet Delayed Release, 200MG

Oral Tablet Delayed Release, 50MG Oral Tablet Delayed

Release, 75MG Oral Tablet Delayed Release)

G 3

C1

Dox

ycyc

line

Hycl

ate Doxycycline Hyclate (80MG Oral Tablet Delayed

Release)G 4

C1

Dox

ycyc

line

Mon

ohy

drat

e Doxycycline Monohydrate (100MG Oral Capsule, 50MG

Oral Capsule)G 1

C1

Dox

ycyc

line

Mon

ohy

drat

e Doxycycline Monohydrate (150MG Oral Capsule, 75MG

Oral Capsule)G 3

C1

Dox

ycyc

line

Mon

ohy

drat

e Doxycycline Monohydrate (Oral Suspension

Reconstituted)G 3

C1

Dox

ycyc

line

Mon

ohy

drat

e Doxycycline Monohydrate (Oral Tablet) G 2

C1

Min

ocy

cline

HCl

ER Minocycline HCl ER (Oral Tablet Extended Release 24

Hour)G 3 QL

C1

Min

ocy

cline

HCl

Minocycline HCl (Oral Capsule) G 1

C1

Min

ocy

cline

HCl

Minocycline HCl (Oral Tablet Immediate Release) G 3

C1

Min

olira

Minolira (Oral Tablet Extended Release 24 Hour) B 3 QL C1

Mon

dox

yne

NL

Mondoxyne NL (100MG Oral Capsule) G 1

C1

Mon

dox

yne

NL

Mondoxyne NL (75MG Oral Capsule) G 3

C1

Nuz

yra

Nuzyra (Intravenous Solution Reconstituted) B 4 PA C1

Nuz

yra

Nuzyra (Oral Tablet) B 4 PA; QL C1

Ora

cea

Oracea (Oral Capsule Delayed Release) B 4

C1

Sey

sara

Seysara (Oral Tablet) B 4

C1

Solo

dyn

Solodyn (Oral Tablet Extended Release 24 Hour) B 4 QL C1

TAR

GA

DOX

TARGADOX (Oral Tablet) G 3

C1

Tetr

acyc

line

HCl

Tetracycline HCl (Oral Capsule) G 3

C1

Vibr

amy

cin

Vibramycin (Oral Capsule) B 3

C1

Vibr

amy

cin

Vibramycin (Oral Suspension Reconstituted) B 3

C1

Vibr

amy

cin

Vibramycin (50MG/5ML Oral Syrup) B 3

A1

AnticonvulsantsB1

Anticonvulsants, OtherC1

BRI

VIA

CT

BRIVIACT (Oral Solution) B 4 PA; QL C1

BRI

VIA

CT

BRIVIACT (Oral Tablet) B 4 PA; QL C1

Epid

iolex

Epidiolex (Oral Solution) B 4 PA C1

Felb

ama

te

Felbamate (Oral Suspension) G 4


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Felb

ama

te

Felbamate (Oral Tablet) G 3

C1

Felb

atol

Felbatol (Oral Suspension) B 4

C1

Felb

atol

Felbatol (Oral Tablet) B 4

C1

Fint

epla

Fintepla (Oral Solution) B 4 PA; QL C1

Fyc

omp

a

Fycompa (Oral Suspension) B 4 QL C1

Fyc

omp

a

Fycompa (Oral Tablet) B 4 QL C1

Kep

pra

Keppra (Oral Solution) B 4

C1

Kep

pra

Keppra (1000MG Oral Tablet Immediate Release,

500MG Oral Tablet Immediate Release, 750MG Oral


B 4

C1

Kep

pra

Keppra (250MG Oral Tablet Immediate Release) B 3

C1

Kep

pra

XR

Keppra XR (Oral Tablet Extended Release 24 Hour) B 4

C1

Lam

ictal

ODT

Lamictal ODT (Oral Tablet Dispersible) B 4

C1

Lam

ictal

Lamictal (Oral Tablet Immediate Release) B 4

C1

Lam

ictal

Lamictal (Oral Tablet Chewable) B 4

C1

Lam

ictal

Start

er

Lamictal Starter (35 Tablets Oral Kit, 49 Tablets Oral

Kit)B 3

C1

Lam

ictal

Start

er

Lamictal Starter (98 Tablets Oral Kit) B 4

C1

Lam

ictal

XR

Lamictal XR (Oral Kit) B 3

C1

Lam

ictal

XR

Lamictal XR (100MG Oral Tablet Extended Release 24

Hour, 200MG Oral Tablet Extended Release 24 Hour,

250MG Oral Tablet Extended Release 24 Hour, 25MG

Oral Tablet Extended Release 24 Hour, 300MG Oral

Tablet Extended Release 24 Hour, 50MG Oral Tablet


B 4

C1

Lam

otrig

ine

ER

Lamotrigine ER (Oral Tablet Extended Release 24 Hour) G 3

C1

Lam

otrig

ine

ODT

Lamotrigine ODT (25 & 50 & 100MG Oral Tablet

Dispersible Kit)G 3

C1

Lam

otrig

ine

Lamotrigine (100MG Oral Tablet Immediate Release,


Tablet Immediate Release, 25MG Oral Tablet Immediate

Release)

G 1

C1

Lam

otrig

ine

Lamotrigine (25MG Oral Tablet Chewable, 5MG Oral

Tablet Chewable)G 2

C1

Lam

otrig

ine

ODT

Lamotrigine ODT (Oral Tablet Dispersible) G 3

C1

Lam

otrig

ine

Start

er

Kit-

Blue Lamotrigine Starter Kit-Blue (Oral Kit) G 3

C1

Lam

otrig

ine

Start

er

Kit-

Gre

en Lamotrigine Starter Kit-Green (Oral Kit) G 4



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Lam

otrig

ine

Start

er

Kit-

Ora

nge Lamotrigine Starter Kit-Orange (Oral Kit) G 3

C1

Lev

etira

ceta

m

ER Levetiracetam ER (Oral Tablet Extended Release 24

Hour)G 2

C1

Lev

etira

ceta

m

Levetiracetam (Oral Solution) G 1

C1

Lev

etira

ceta

m

Levetiracetam (Oral Tablet Immediate Release) G 1

C1

Qud

exy

XR

Qudexy XR (100MG Oral Capsule ER 24 Hour

Sprinkle, 25MG Oral Capsule ER 24 Hour Sprinkle,

50MG Oral Capsule ER 24 Hour Sprinkle)

B 3 PA

C1

Qud

exy

XR

Qudexy XR (150MG Oral Capsule ER 24 Hour

Sprinkle, 200MG Oral Capsule ER 24 Hour Sprinkle)B 4 PA

C1

Row

eepr

a

Roweepra (Oral Tablet Immediate Release) G 1

C1

Sprit

am

ODT

Spritam ODT (Oral Tablet Disintegrating Soluble) B 3

C1

Top

ama

x

Topamax (100MG Oral Tablet, 200MG Oral Tablet,

50MG Oral Tablet)B 4

C1

Top

ama

x

Topamax (25MG Oral Tablet) B 3

C1

Top

ama

x

Spri

nkle Topamax Sprinkle (15MG Oral Capsule Sprinkle) B 3

C1

Top

ama

x

Spri

nkle Topamax Sprinkle (25MG Oral Capsule Sprinkle) B 4

C1

Topi

ram

ate

ER

Topiramate ER (100MG Oral Capsule ER 24 Hour

Sprinkle, 25MG Oral Capsule ER 24 Hour Sprinkle,

50MG Oral Capsule ER 24 Hour Sprinkle)

G 3 PA

C1

Topi

ram

ate

ER

Topiramate ER (150MG Oral Capsule ER 24 Hour

Sprinkle, 200MG Oral Capsule ER 24 Hour Sprinkle)G 4 PA

C1

Topi

ram

ate

Topiramate (Oral Capsule Sprinkle Immediate Release) G 2

C1

Topi

ram

ate

Topiramate (Oral Tablet) G 1

C1

Trok

endi

XR

Trokendi XR (100MG Oral Capsule Extended Release


Hour)

B 4 PA

C1

Trok

endi

XR

Trokendi XR (25MG Oral Capsule Extended Release


Hour)

B 3 PA

C1

Valp

roic

Acid

Valproic Acid (Oral Capsule) G 2

C1

Valp

roic

Acid

Valproic Acid (Oral Solution) G 1

C1

Xco

pri

Xcopri (250MG Daily Dose) (Oral Tablet Therapy

Pack)B 4 PA; QL

C1

Xco

pri

Xcopri (350MG Daily Dose) (Oral Tablet Therapy

Pack)B 4 PA; QL

C1

Xco

pri

Xcopri (100MG Oral Tablet, 150MG Oral Tablet,

50MG Oral Tablet)B 3 PA; QL

C1

Xco

pri

Xcopri (200MG Oral Tablet) B 4 PA; QL


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Xco

pri

Xcopri (14x12.5MG & 14x25MG Oral Tablet Therapy

Pack)B 3 PA; QL

C1

Xco

pri

Xcopri (14x150MG & 14x200MG Oral Tablet Therapy

Pack, 14x50MG & 14x100MG Oral Tablet Therapy

Pack)

B 4 PA; QL

B1

Calcium Channel Modifying AgentsC1

Celo

ntin

Celontin (Oral Capsule) B 3

C1

Etho

suxi

mid

e

Ethosuximide (Oral Capsule) G 2

C1

Etho

suxi

mid

e

Ethosuximide (Oral Solution) G 2

C1

Zaro

ntin

Zarontin (Oral Capsule) B 3

C1

Zaro

ntin

Zarontin (Oral Solution) G 3

B1

Gamma-aminobutyric Acid (GABA) Augmenting AgentsC1

Clo

baz

am

Clobazam (Oral Suspension) G 3 PA; QL C1

Clo

baz

am

Clobazam (Oral Tablet) G 3 PA; QL C1

Diac

omit

Diacomit (Oral Capsule) B 4 QL C1

Diac

omit

Diacomit (Oral Packet) B 4 QL C1

Dias

tat

Acu

Dial

Diastat AcuDial (Rectal Gel) B 3 QL C1

Dias

tat

Pedi

atric

Diastat Pediatric (Rectal Gel) B 3 QL C1

Diaz

epa

m

Diazepam (10MG Rectal Gel, 2.5MG Rectal Gel, 20MG

Rectal Gel)G 3 QL

C1

Gab

ape

ntin

Gabapentin (Oral Capsule) G 1

C1

Gab

ape

ntin

Gabapentin (250MG/5ML Oral Solution) G 2

C1

Gab

ape

ntin

Gabapentin (Oral Tablet) G 1

C1

Gabi

tril

Gabitril (Oral Tablet) B 4

C1

Mys

olin

e

Mysoline (Oral Tablet) B 4

C1

Nay

zila

m

Nayzilam (Nasal Solution) B 3 QL C1

Neu

ronti

n

Neurontin (100MG Oral Capsule) B 3

C1

Neu

ronti

n

Neurontin (300MG Oral Capsule, 400MG Oral

Capsule)B 4

C1

Neu

ronti

n

Neurontin (Oral Solution) B 3

C1

Neu

ronti

n

Neurontin (Oral Tablet) B 4

C1

Onfi

Onfi (Oral Suspension) B 4 PA; QL C1

Onfi

Onfi (Oral Tablet) B 4 PA; QL C1

Phe

nob

arbit

al

Phenobarbital (Oral Elixir) G 3 PA; HRM C1

Phe

nob

arbit

al

Phenobarbital (Oral Tablet) G 3 PA; HRM C1

Prim

idon

e

Primidone (Oral Tablet) G 1



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Sabr

il

Sabril (Oral Packet) B 4 PA; LA; QL C1

Sabr

il

Sabril (Oral Tablet) B 4 PA; LA; QL C1

Sym

paz

an

Sympazan (10MG Oral Film, 20MG Oral Film) B 4 PA; QL C1

Sym

paz

an

Sympazan (5MG Oral Film) B 3 PA; QL C1

Tiag

abin

e

HCl

Tiagabine HCl (Oral Tablet) G 3

C1

Valt

oco

10

MG

Dos

e Valtoco 10 MG Dose (Nasal Liquid) B 3 QL C1

Valt

oco

15

MG

Dos

e Valtoco 15 MG Dose (Nasal Liquid Therapy Pack) B 3 QL C1

Valt

oco

20

MG

Dos

e Valtoco 20 MG Dose (Nasal Liquid Therapy Pack) B 3 QL C1

Valt

oco

5

MG

Dos

e Valtoco 5 MG Dose (Nasal Liquid) B 3 QL C1

Viga

batri

n

Vigabatrin (Oral Packet) G 4 PA; LA; QL C1

Viga

batri

n

Vigabatrin (Oral Tablet) G 4 PA; LA; QL C1

Viga

dron

e

Vigadrone (Oral Packet) G 4 PA; LA; QL B1

Sodium Channel AgentsC1

Apti

om

Aptiom (Oral Tablet) B 4 QL C1

Ban

zel

Banzel (Oral Suspension) B 4

C1

Ban

zel

Banzel (Oral Tablet) B 4

C1

Car

bam

aze

pine

ER Carbamazepine ER (100MG Oral Capsule Extended



Release 12 Hour)

G 2

C1

Car

bam

aze

pine

ER Carbamazepine ER (100MG Oral Tablet Extended

Release 12 Hour, 200MG Oral Tablet Extended Release

12 Hour, 400MG Oral Tablet Extended Release 12 Hour)

G 3

C1

Car

bam

aze

pine

Carbamazepine (Oral Suspension) G 2

C1

Car

bam

aze

pine

Carbamazepine (Oral Tablet Immediate Release) G 2

C1

Car

bam

aze

pine

Carbamazepine (Oral Tablet Chewable) G 2

C1

Car

batr

ol

Carbatrol (Oral Capsule Extended Release 12 Hour) B 3

C1

Dila

ntin

INF

ATA

BS Dilantin INFATABS (Oral Tablet Chewable) G 2

C1

Dila

ntin

Dilantin (Oral Capsule) G 2

C1

Dila

ntin

Dilantin (Oral Suspension) B 3

C1

Epit

ol

Epitol (Oral Tablet) G 2

C1

Oxc

arba

zepi

ne

Oxcarbazepine (300MG/5ML Oral Suspension) G 3

C1

Oxc

arba

zepi

ne

Oxcarbazepine (150MG Oral Tablet, 300MG Oral Tablet,


C1

Oxt

ellar

XR

Oxtellar XR (150MG Oral Tablet Extended Release 24

Hour, 300MG Oral Tablet Extended Release 24 Hour)B 3

C1

Oxt

ellar

XR

Oxtellar XR (600MG Oral Tablet Extended Release 24

Hour)B 4


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Phe

nyte

k

Phenytek (Oral Capsule) G 1

C1

Phe

nyto

in

Phenytoin (125MG/5ML Oral Suspension) G 1

C1

Phe

nyto

in

Phenytoin (Oral Tablet Chewable) G 1

C1

Phe

nyto

in

Sodi

um

Exte

nde

d Phenytoin Sodium Extended (Oral Capsule) G 1

C1

Rufi

nam

ide

Rufinamide (Oral Suspension) G 4

C1

Rufi

nam

ide

Rufinamide (Oral Tablet) G 4

C1

Tegr

etol

Tegretol (Oral Suspension) B 3

C1

Tegr

etol

Tegretol (Oral Tablet Immediate Release) B 3

C1

Tegr

etol

XR

Tegretol XR (Oral Tablet Extended Release 12 Hour) B 3

C1

Trile

ptal

Trileptal (Oral Suspension) B 4

C1

Trile

ptal

Trileptal (150MG Oral Tablet) B 3

C1

Trile

ptal

Trileptal (300MG Oral Tablet, 600MG Oral Tablet) B 4

C1

Vim

pat

Vimpat (Oral Solution) B 3 QL C1

Vim

pat

Vimpat (Oral Tablet) B 3 QL C1

Zon

egra

n

Zonegran (Oral Capsule) B 4

C1

Zoni

sami

de

Zonisamide (Oral Capsule) G 1

A1

Antidementia AgentsB1

Antidementia Agents, OtherC1

Na

mza

ric

Namzaric (Oral Capsule ER 24 Hour Therapy Pack) B 2 PA; QL C1

Na

mza

ric

Namzaric (Oral Capsule Extended Release 24 Hour) B 2 PA; QL B1

Cholinesterase InhibitorsC1

Aric

ept

Aricept (Oral Tablet) B 3 QL C1

Don

epe

zil

HCl

Donepezil HCl (10MG Oral Tablet, 5MG Oral Tablet) G 1 QL C1

Don

epe

zil

HCl

Donepezil HCl (23MG Oral Tablet) G 2 QL C1

Don

epe

zil

HCl

ODT Donepezil HCl ODT (Oral Tablet Dispersible) G 1 QL C1

Exel

on

Exelon (Transdermal Patch 24 Hour) B 3 ST; QL C1

Gala

nta

min

e

Hyd

robr

omi

de

ER Galantamine Hydrobromide ER (Oral Capsule Extended

Release 24 Hour)G 3

C1

Gala

nta

min

e

Hyd

robr

omi

de Galantamine Hydrobromide (Oral Solution) G 3

C1

Gala

nta

min

e

Hyd

robr

omi

de Galantamine Hydrobromide (Oral Tablet) G 2

C1

Raz

ady

ne

ER

Razadyne ER (Oral Capsule Extended Release 24

Hour)B 3

C1

Riva

stig

min

e

Tartr

ate Rivastigmine Tartrate (Oral Capsule) G 2

C1

Riva

stig

min

e

Rivastigmine (Transdermal Patch 24 Hour) G 3 ST; QL B1

N-methyl-D-aspartate (NMDA) Receptor Antagonist



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Me

man

tine

HCl

ER Memantine HCl ER (Oral Capsule Extended Release 24

Hour)G 3 PA; QL

C1

Me

man

tine

HCl

Memantine HCl (2MG/ML Oral Solution) G 3 PA; QL C1

Me

man

tine

HCl

Memantine HCl (10MG Oral Tablet, 5MG Oral Tablet) G 1 PA; QL C1

Me

man

tine

HCl

Titra

tion

Pak Memantine HCl Titration Pak (Oral Tablet) B 1 PA C1

Na

men

da

Namenda (10MG Oral Tablet, 5MG Oral Tablet) B 3 PA; QL C1

Na

men

da

Titra

tion

Pak Namenda Titration Pak (Oral Tablet) B 3 PA C1

Na

men

da

XR

Namenda XR (Oral Capsule Extended Release 24

Hour)B 3 PA; QL

A1

AntidepressantsB1

Antidepressants, OtherC1

Aple

nzin

Aplenzin (Oral Tablet Extended Release 24 Hour) B 4

C1

Bup

ropi

on

HCl

SR Bupropion HCl SR (Oral Tablet Extended Release 12

Hour)G 1

C1

Bup

ropi

on

HCl

XL Bupropion HCl XL (150MG Oral Tablet Extended


24 Hour)

G 1

C1

Bup

ropi

on

HCl

ER Bupropion HCl ER (XL) (450MG Oral Tablet Extended

Release 24 Hour)G 3

C1

Bup

ropi

on

HCl

Bupropion HCl (Oral Tablet Immediate Release) G 1

C1

Forfi

vo

XL

Forfivo XL (Oral Tablet Extended Release 24 Hour) B 3

C1

Mirt

aza

pine

Mirtazapine (Oral Tablet) G 1

C1

Mirt

aza

pine

ODT Mirtazapine ODT (Oral Tablet Dispersible) G 2

C1

Olan

zapi

ne-

Fluo

xeti

ne

HCl Olanzapine-Fluoxetine HCl (Oral Capsule) G 3

C1

Re

mer

on

Remeron (Oral Tablet) B 3

C1

Re

mer

on

SolT

ab Remeron SolTab (Oral Tablet Dispersible) B 3

C1

Sym

byax

Symbyax (Oral Capsule) B 3

C1

Well

butri

n

SR

Wellbutrin SR (Oral Tablet Extended Release 12 Hour) B 3

C1

Well

butri

n XL

Wellbutrin XL (Oral Tablet Extended Release 24 Hour) B 4

B1

Monoamine Oxidase InhibitorsC1

Ems

am

Emsam (Transdermal Patch 24 Hour) B 4

C1

Mar

plan

Marplan (Oral Tablet) B 3

C1

Nar

dil

Nardil (Oral Tablet) B 3

C1

Parn

ate

Parnate (Oral Tablet) B 4

C1

Phe

nelzi

ne

Sulf

ate Phenelzine Sulfate (Oral Tablet) G 2

C1

Tran

ylcy

pro

min

e

Sulf

ate Tranylcypromine Sulfate (Oral Tablet) G 3

B1

SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine

Reuptake Inhibitors)


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Cele

xa

Celexa (Oral Tablet) B 3

C1

Cital

opra

m

Hyd

robr

omi

de Citalopram Hydrobromide (Oral Solution) G 2

C1

Cital

opra

m

Hyd

robr

omi

de Citalopram Hydrobromide (Oral Tablet) G 1

C1

Des

venl

afaxi

ne

ER Desvenlafaxine ER (Oral Tablet Extended Release 24

Hour) (Brand Equivalent Khedezla)B 3

C1

Des

venl

afaxi

ne

Suc

cina

te

ER Desvenlafaxine Succinate ER (Oral Tablet Extended

Release 24 Hour) (Generic Pristiq)G 2

C1

Effe

xor

XR

Effexor XR (Oral Capsule Extended Release 24 Hour) B 3

C1

Esci

talo

pra

m

Oxal

ate Escitalopram Oxalate (Oral Solution) G 3

C1

Esci

talo

pra

m

Oxal

ate Escitalopram Oxalate (Oral Tablet) G 1

C1

Fetz

ima

Fetzima (Oral Capsule Extended Release 24 Hour) B 3 ST C1

Fetz

ima

Titra

tion

Fetzima Titration (Oral Capsule ER 24 Hour Therapy

Pack)B 3 ST

C1

Fluo

xeti

ne

HCl

Fluoxetine HCl (PMDD) (Oral Tablet) G 3

C1

Fluo

xeti

ne

HCl

Fluoxetine HCl (10MG Oral Capsule Immediate Release,

20MG Oral Capsule Immediate Release, 40MG Oral

Capsule Immediate Release)

G 1

C1

Fluo

xeti

ne

HCl

Fluoxetine HCl (90MG Oral Capsule Delayed Release) G 3

C1

Fluo

xeti

ne

HCl

Fluoxetine HCl (20MG/5ML Oral Solution) G 2

C1

Fluo

xeti

ne

HCl

Fluoxetine HCl (10MG Oral Tablet) G 1

C1

Fluo

xeti

ne

HCl

Fluoxetine HCl (20MG Oral Tablet, 60MG Oral Tablet) G 3

C1

Fluv

oxa

min

e

Mal

eate

ER Fluvoxamine Maleate ER (Oral Capsule Extended

Release 24 Hour)G 3

C1

Fluv

oxa

min

e

Mal

eate Fluvoxamine Maleate (Oral Tablet) G 2

C1

Lex

apro

Lexapro (Oral Tablet) B 3

C1

Nef

azo

don

e

HCl Nefazodone HCl (Oral Tablet) G 3

C1

Paro

xeti

ne

HCl

Paroxetine HCl (Oral Tablet Immediate Release) G 1 PA; HRM C1

Paxil

Paxil (Oral Suspension) B 3 PA; HRM C1

Paxil

Paxil (Oral Tablet Immediate Release) B 3 PA; HRM C1

Prist

iq

Pristiq (Oral Tablet Extended Release 24 Hour) B 3

C1

Proz

ac

Prozac (10MG Oral Capsule) B 3

C1

Proz

ac

Prozac (20MG Oral Capsule, 40MG Oral Capsule) B 4

C1

Sert

ralin

e

HCl

Sertraline HCl (Oral Concentrate) G 2

C1

Sert

ralin

e

HCl

Sertraline HCl (Oral Tablet) G 1

C1

Traz

odo

ne

HCl

Trazodone HCl (100MG Oral Tablet, 150MG Oral Tablet,


C1

Traz

odo

ne

HCl

Trazodone HCl (300MG Oral Tablet) G 2



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Trint

ellix

Trintellix (Oral Tablet) B 3

C1

Venl

afaxi

ne

HCl

ER Venlafaxine HCl ER (Oral Capsule Extended Release 24

Hour)G 1

C1

Venl

afaxi

ne

HCl

ER Venlafaxine HCl ER (Oral Tablet Extended Release 24

Hour)G 3

C1

Venl

afaxi

ne

HCl

Venlafaxine HCl (Oral Tablet Immediate Release) G 1

C1

Viibr

yd

Viibryd (Oral Tablet) B 3

C1

Viibr

yd

Start

er

Pac

k Viibryd Starter Pack (Oral Kit) B 3

C1

Zolo

ft

Zoloft (Oral Concentrate) B 3

C1

Zolo

ft

Zoloft (Oral Tablet) B 3

B1

TricyclicsC1

Amit

ripty

line

HCl

Amitriptyline HCl (Oral Tablet) G 3 HRM C1

Am

oxa

pine

Amoxapine (Oral Tablet) G 2 PA; HRM C1

Anaf

ranil

Anafranil (Oral Capsule) B 4 PA; HRM C1

Clo

mipr

ami

ne

HCl Clomipramine HCl (Oral Capsule) G 3 PA; HRM C1

Desi

pra

min

e

HCl Desipramine HCl (Oral Tablet) G 3 PA; HRM C1

Dox

epin

HCl

Doxepin HCl (Oral Capsule) G 3 PA; HRM C1

Dox

epin

HCl

Doxepin HCl (Oral Concentrate) G 3 PA; HRM C1

Imip

rami

ne

HCl

Imipramine HCl (Oral Tablet) G 3 PA; HRM C1

Imip

rami

ne

Pam

oate Imipramine Pamoate (Oral Capsule) G 3 PA; HRM C1

Nor

pra

min

Norpramin (Oral Tablet) B 3 PA; HRM C1

Nort

ripty

line

HCl

Nortriptyline HCl (Oral Capsule) G 1 PA; HRM C1

Nort

ripty

line

HCl

Nortriptyline HCl (Oral Solution) G 2 PA; HRM C1

Pam

elor

Pamelor (Oral Capsule) B 4 PA; HRM C1

Prot

ripty

line

HCl

Protriptyline HCl (Oral Tablet) G 3 PA; HRM C1

Trim

ipra

min

e

Mal

eate Trimipramine Maleate (Oral Capsule) G 3 PA; HRM A1

AntiemeticsB1

Antiemetics, OtherC1

Co

mpr

o

Compro (Rectal Suppository) G 3

C1

Gim

oti

Gimoti (Nasal Solution) B 4 PA C1

Mec

lizin

e

HCl

Meclizine HCl (12.5MG Oral Tablet) G 1 HRM C1

Met

oclo

pra

mid

e

HCl Metoclopramide HCl (5MG/5ML Oral Solution) G 1

C1

Met

oclo

pra

mid

e

HCl Metoclopramide HCl (Oral Tablet) G 1

C1

Met

oclo

pra

mid

e

HCl

ODT Metoclopramide HCl ODT (Oral Tablet Dispersible) G 3

C1

Per

phe

nazi

ne

Perphenazine (Oral Tablet) G 2

C1

Proc

hlor

pera

zine

Mal

eate Prochlorperazine Maleate (Oral Tablet) G 1

C1

Proc

hlor

pera

zine

Prochlorperazine (Rectal Suppository) G 3


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Pro

met

hazi

ne

HCl Promethazine HCl (Oral Tablet) G 3 PA; HRM C1

Pro

met

hazi

ne

HCl Promethazine HCl (12.5MG Rectal Suppository) G 3 PA; HRM C1

Regl

an

Reglan (Oral Tablet) B 3

C1

Sco

pola

min

e

Scopolamine (Transdermal Patch 72 Hour) G 2 PA; HRM C1

Tran

sder

m-

Sco

p Transderm-Scop (1.5MG) (Transdermal Patch 72

Hour)B 3 PA; HRM

C1

Trim

etho

ben

zami

de

HCl Trimethobenzamide HCl (Oral Capsule) G 2 B/D, PA B1

Emetogenic Therapy AdjunctsC1

Apr

epit

ant

Aprepitant (Oral Therapy Pack, Oral Capsule) G 3 PA C1

Dro

nabi

nol

Dronabinol (Oral Capsule) G 3 PA C1

Eme

nd

Emend (80MG Oral Capsule) B 3 PA C1

Eme

nd

Emend (Oral Suspension Reconstituted) B 3 PA C1

Eme

nd

Tri-

Pac

k Emend Tri-Pack (Oral Capsule) B 4 PA C1

Gra

nise

tron

HCl

Granisetron HCl (Oral Tablet) G 2 B/D, PA C1

Mari

nol

Marinol (10MG Oral Capsule, 5MG Oral Capsule) B 4 PA C1

Mari

nol

Marinol (2.5MG Oral Capsule) B 3 PA C1

Ond

ans

etro

n

HCl Ondansetron HCl (Oral Solution) G 2 B/D, PA C1

Ond

ans

etro

n

HCl Ondansetron HCl (Oral Tablet) G 1 B/D, PA C1

Ond

ans

etro

n

ODT Ondansetron ODT (Oral Tablet Dispersible) G 1 B/D, PA C1

San

cus

o

Sancuso (Transdermal Patch) B 4 QL C1

Syn

dros

Syndros (Oral Solution) B 4 PA C1

Varu

bi

Varubi (180 MG Dose) (Oral Tablet Therapy Pack) B 3 B/D, PA C1

Zupl

enz

Zuplenz (Oral Film) B 4 B/D, PA A1

AntifungalsB1

AntifungalsC1

Abel

cet

Abelcet (Intravenous Suspension) B 3 B/D, PA C1

Am

Biso

me

AmBisome (Intravenous Suspension Reconstituted) B 4 B/D, PA C1

Am

phot

erici

n B

Amphotericin B (Intravenous Solution Reconstituted) G 3 B/D, PA C1

Anc

obo

n

Ancobon (Oral Capsule) B 4

C1

Can

cida

s

Cancidas (Intravenous Solution Reconstituted) B 4

C1

Cas

pofu

ngin

Acet

ate Caspofungin Acetate (50MG Intravenous Solution

Reconstituted)G 4

C1

Cas

pofu

ngin

Acet

ate Caspofungin Acetate (70MG Intravenous Solution

Reconstituted)G 3

C1

Clot

rima

zole

Clotrimazole (Mouth/Throat Troche) G 1

C1

Cres

emb

a

Cresemba (Oral Capsule) B 4 PA



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Diflu

can

Diflucan (Oral Suspension Reconstituted) B 3

C1

Diflu

can

Diflucan (100MG Oral Tablet, 150MG Oral Tablet,

50MG Oral Tablet)B 3

C1

Diflu

can

Diflucan (200MG Oral Tablet) B 4

C1

Erax

is

Eraxis (100MG Intravenous Solution Reconstituted) B 4

C1

Erax

is

Eraxis (50MG Intravenous Solution Reconstituted) B 3

C1

Fluc

ona

zole

in

Sodi

um

Chlo

ride Fluconazole in Sodium Chloride (Intravenous Solution) G 2

C1

Fluc

ona

zole

Fluconazole (Oral Suspension Reconstituted) G 2

C1

Fluc

ona

zole

Fluconazole (Oral Tablet) G 1

C1

Fluc

ytosi

ne

Flucytosine (Oral Capsule) G 4

C1

Gris

eofu

lvin

Micr

osiz

e Griseofulvin Microsize (Oral Suspension) G 3

C1

Gris

eofu

lvin

Micr

osiz

e Griseofulvin Microsize (Oral Tablet) G 3

C1

Gris

eofu

lvin

Ultra

micr

osiz

e Griseofulvin Ultramicrosize (Oral Tablet) G 3

C1

Gyn

azol

e-1

Gynazole-1 (Vaginal Cream) G 3

C1

Itrac

ona

zole

Itraconazole (Oral Capsule) G 3 PA C1

Itrac

ona

zole

Itraconazole (Oral Solution) G 4 PA C1

Ket

oco

naz

ole

Ketoconazole (Oral Tablet) G 1

C1

Mic

afun

gin

Sodi

um Micafungin Sodium (Intravenous Solution Reconstituted) G 3

C1

Mic

ona

zole

3

Miconazole 3 (Vaginal Suppository) G 2

C1

Myc

ami

ne

Mycamine (Intravenous Solution Reconstituted) B 4

C1

Nox

afil

Noxafil (Oral Suspension) B 4 QL C1

Nox

afil

Noxafil (Oral Tablet Delayed Release) B 4 PA; QL C1

Nyst

atin

Nystatin (Mouth/Throat Suspension) G 1

C1

Nyst

atin

Nystatin (Oral Tablet) G 2

C1

Ora

vig

Oravig (Buccal Tablet) B 4

C1

Pos

aco

naz

ole

Posaconazole (Oral Tablet Delayed Release) G 4 PA; QL C1

Spo

rano

x

Sporanox (Oral Capsule) B 4 PA C1

Spo

rano

x

Sporanox (Oral Solution) B 4 PA C1

Terb

inafi

ne

HCl

Terbinafine HCl (Oral Tablet) G 1

C1

Terc

ona

zole

Terconazole (Vaginal Cream) G 2

C1

Terc

ona

zole

Terconazole (Vaginal Suppository) G 2

C1

Tols

ura

Tolsura (Oral Capsule) B 4 PA C1

Vfen

d IV

Vfend IV (Intravenous Solution Reconstituted) B 4

C1

Vfen

d

Vfend (Oral Suspension Reconstituted) B 4

C1

Vfen

d

Vfend (Oral Tablet) B 3

C1

Vori

con

azol

e

Voriconazole (Intravenous Solution Reconstituted) G 4

C1

Vori

con

azol

e

Voriconazole (Oral Suspension Reconstituted) G 4


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Vori

con

azol

e

Voriconazole (Oral Tablet) G 3

A1

Antigout AgentsB1

Antigout AgentsC1

Allo

puri

nol

Allopurinol (Oral Tablet) G 1

C1

Colc

hicin

e

Colchicine (0.6MG Oral Capsule) (Brand Equivalent

Mitigare)B 2

C1

Colc

hicin

e

Colchicine (0.6MG Oral Tablet) (Generic Colcrys) G 2

C1

Colc

rys

Colcrys (Oral Tablet) B 3 PA C1

Feb

uxo

stat

Febuxostat (Oral Tablet) G 3 ST C1

Glo

perb

a

Gloperba (Oral Solution) B 3 PA; QL C1

Miti

gare

Mitigare (Oral Capsule) B 2

C1

Pro

ben

ecid

Probenecid (Oral Tablet) G 1

C1

Pro

ben

ecid

-

Colc

hicin

e Probenecid-Colchicine (Oral Tablet) G 1

C1

Ulori

c

Uloric (Oral Tablet) B 3 ST C1

Zylo

prim

Zyloprim (Oral Tablet) B 3

A1

Antimigraine AgentsB1

AcuteC1

Alm

otrip

tan

Mal

ate Almotriptan Malate (Oral Tablet) G 3 ST; QL C1

Ame

rge

Amerge (Oral Tablet) B 3 QL C1

Eletr

ipta

n

Hyd

robr

omi

de Eletriptan Hydrobromide (Oral Tablet) G 3 ST; QL C1

Frov

a

Frova (Oral Tablet) B 4 ST; QL C1

Frov

atrip

tan

Suc

cina

te Frovatriptan Succinate (Oral Tablet) G 3 ST; QL C1

Imitr

ex

Imitrex (20MG/ACT Nasal Solution) B 4 QL C1

Imitr

ex

Imitrex (5MG/ACT Nasal Solution) B 3 QL C1

Imitr

ex

Imitrex (Oral Tablet) B 3 QL C1

Imitr

ex

STA

Tdo

se

Refil

l Imitrex STATdose Refill (6MG/0.5ML Subcutaneous

Solution Cartridge)B 4 QL

C1

Imitr

ex

STA

Tdo

se

Syst

em Imitrex STATdose System (4MG/0.5ML

Subcutaneous Solution Auto-Injector)B 4 QL

C1

Imitr

ex

Imitrex (Subcutaneous Solution) B 4 QL C1

Max

alt

Maxalt (Oral Tablet) B 3 QL C1

Max

alt-

MLT

Maxalt-MLT (Oral Tablet Dispersible) B 3 QL C1

Nar

atrip

tan

HCl

Naratriptan HCl (Oral Tablet) G 2 QL C1

Nurt

ec

ODT

Nurtec ODT (Oral Tablet Dispersible) B 4 PA; QL C1

Onz

etra

Xsail

Onzetra Xsail (Nasal Exhaler Powder) B 4 QL C1

Relp

ax

Relpax (Oral Tablet) B 3 ST; QL



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Rey

vow

Reyvow (Oral Tablet) B 3 PA; QL C1

Riza

tript

an

Ben

zoat

e Rizatriptan Benzoate (Oral Tablet) G 2 QL C1

Riza

tript

an

Ben

zoat

e

ODT Rizatriptan Benzoate ODT (Oral Tablet Dispersible) G 2 QL C1

Sum

atrip

tan

Sumatriptan (Nasal Solution) G 3 QL C1

Sum

atrip

tan

Suc

cina

te Sumatriptan Succinate (100MG Oral Tablet, 25MG Oral

Tablet, 50MG Oral Tablet)G 1 QL

C1

Sum

atrip

tan

Suc

cina

te

Refil

l Sumatriptan Succinate Refill (Subcutaneous Solution

Cartridge)G 3 QL

C1

Sum

atrip

tan

Suc

cina

te Sumatriptan Succinate (6MG/0.5ML Subcutaneous

Solution)G 3 QL

C1

Sum

atrip

tan

Suc

cina

te Sumatriptan Succinate (4MG/0.5ML Subcutaneous

Solution Auto-Injector, 6MG/0.5ML Subcutaneous

Solution Auto-Injector)

G 3 QL

C1

Sum

atrip

tan-

Nap

roxe

n

Sodi

um Sumatriptan-Naproxen Sodium (Oral Tablet) G 3 QL C1

Tos

ymr

a

Tosymra (Nasal Solution) B 3 QL C1

Trex

imet

Treximet (Oral Tablet) B 4 QL C1

Ubr

elvy

Ubrelvy (Oral Tablet) B 4 PA; QL C1

Zem

brac

e

Sym

Tou

ch Zembrace SymTouch (Subcutaneous Solution Auto-

Injector)B 4 QL

C1

Zol

mitri

ptan

Zolmitriptan (Oral Tablet) G 3 QL C1

Zol

mitri

ptan

ODT Zolmitriptan ODT (Oral Tablet Dispersible) G 3 QL C1

Zom

ig

Zomig (Nasal Solution) B 3 QL C1

Zom

ig

Zomig (Oral Tablet) B 4 QL C1

Zom

ig

ZMT

Zomig ZMT (Oral Tablet Dispersible) B 4 QL B1

Ergot AlkaloidsC1

Cafe

rgot

Cafergot (Oral Tablet) G 3

C1

Dihy

droe

rgot

ami

ne

Mes

ylate Dihydroergotamine Mesylate (Nasal Solution) G 4 PA; QL C1

Erg

ota

min

e-

Caff

eine Ergotamine-Caffeine (Oral Tablet) G 2

C1

Mig

ergo

t

Migergot (Rectal Suppository) G 4

C1

Migr

anal

Migranal (Nasal Solution) B 4 PA; QL B1

ProphylacticC1

Aim

ovig

Aimovig (Subcutaneous Solution Auto-Injector) B 3 PA; QL C1

Ajov

y

Ajovy (Subcutaneous Solution Auto-Injector) B 3 PA; QL C1

Ajov

y

Ajovy (Subcutaneous Solution Prefilled Syringe) B 3 PA; QL C1

Emg

ality

Emgality (300MG Dose) (100MG/ML Subcutaneous

Solution Prefilled Syringe)B 3 PA; QL

C1

Emg

ality

Emgality (Subcutaneous Solution Auto-Injector) B 3 PA; QL


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Emg

ality

Emgality (120MG/ML Subcutaneous Solution

Prefilled Syringe)B 3 PA; QL

C1

Tim

olol

Mal

eate

Timolol Maleate (Oral Tablet) G 2

A1

Antimyasthenic AgentsB1

ParasympathomimeticsC1

Mes

tino

n

Mestinon (Oral Solution) B 4

C1

Mes

tino

n

Mestinon (Oral Tablet Immediate Release) B 4

C1

Mes

tino

n

Mestinon (Oral Tablet Extended Release) B 4

C1

Pyri

dost

igmi

ne

Bro

mid

e

ER Pyridostigmine Bromide ER (Oral Tablet Extended

Release)G 3

C1

Pyri

dost

igmi

ne

Bro

mid

e Pyridostigmine Bromide (Oral Solution) G 4

C1

Pyri

dost

igmi

ne

Bro

mid

e Pyridostigmine Bromide (30MG Oral Tablet Immediate

Release)G 3

C1

Pyri

dost

igmi

ne

Bro

mid

e Pyridostigmine Bromide (60MG Oral Tablet Immediate

Release)G 2

A1

AntimycobacterialsB1

Antimycobacterials, OtherC1

Dap

son

e

Dapsone (Oral Tablet) G 2

C1

Myc

obut

in

Mycobutin (Oral Capsule) B 4

C1

Rifa

buti

n

Rifabutin (Oral Capsule) G 3

B1

AntitubercularsC1

Etha

mbu

tol

HCl

Ethambutol HCl (Oral Tablet) G 2

C1

Ison

iazid

Isoniazid (Oral Syrup) G 3

C1

Ison

iazid

Isoniazid (Oral Tablet) G 1

C1

Mya

mbu

tol

Myambutol (Oral Tablet) B 3

C1

Pas

er

Paser (Oral Packet) G 3

C1

Pret

oma

nid

Pretomanid (Oral Tablet) B 3

C1

Prifti

n

Priftin (Oral Tablet) B 3

C1

Pyra

zina

mid

e

Pyrazinamide (Oral Tablet) G 3

C1

Rifa

mpi

n

Rifampin (600MG Intravenous Solution Reconstituted) G 3

C1

Rifa

mpi

n

Rifampin (150MG Oral Capsule, 300MG Oral Capsule) G 2

C1

Sirtu

ro

Sirturo (Oral Tablet) B 4 PA; LA C1

Trec

ator

Trecator (Oral Tablet) B 3

A1

AntineoplasticsB1

Alkylating AgentsC1

Cycl

oph

osp

ham

ide Cyclophosphamide (Oral Capsule) G 2 B/D, PA



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Cycl

oph

osp

ham

ide Cyclophosphamide (25MG Oral Tablet) G 2 B/D, PA C1

Cycl

oph

osp

ham

ide Cyclophosphamide (50MG Oral Tablet) B 2 B/D, PA C1

Leu

kera

n

Leukeran (Oral Tablet) B 4

C1

Mat

ulan

e

Matulane (Oral Capsule) B 4 LA C1

Valc

hlor

Valchlor (External Gel) B 4 PA; LA; QL B1

AntiandrogensC1

Abir

ater

one

Acet

ate Abiraterone Acetate (Oral Tablet) G 4 PA C1

Bica

luta

mid

e

Bicalutamide (Oral Tablet) G 1

C1

Cas

ode

x

Casodex (Oral Tablet) B 4

C1

Erle

ada

Erleada (Oral Tablet) B 4 PA C1

Flut

ami

de

Flutamide (Oral Capsule) G 3

C1

Nila

ndro

n

Nilandron (Oral Tablet) B 4

C1

Nilut

ami

de

Nilutamide (Oral Tablet) G 4

C1

Nub

eqa

Nubeqa (Oral Tablet) B 4 PA; LA C1

Xtan

di

Xtandi (Oral Capsule) B 4 PA; LA C1

Xtan

di

Xtandi (Oral Tablet) B 4 PA C1

Yon

sa

Yonsa (Oral Tablet) B 4 PA C1

Zyti

ga

Zytiga (Oral Tablet) B 4 PA B1

Antiangiogenic AgentsC1

Foti

vda

Fotivda (Oral Capsule) B 4 PA; QL C1

Pom

alyst

Pomalyst (Oral Capsule) B 4 PA C1

Qinl

ock

Qinlock (Oral Tablet) B 4 PA; QL C1

Revl

imid

Revlimid (Oral Capsule) B 4 PA; LA C1

Tabr

ecta

Tabrecta (Oral Tablet) B 4 PA; QL C1

Thal

omi

d

Thalomid (Oral Capsule) B 4 PA; QL B1

Antiestrogens/ModifiersC1

Emc

yt

Emcyt (Oral Capsule) B 4

C1

Fare

ston

Fareston (Oral Tablet) B 4

C1

Solt

amo

x

Soltamox (Oral Solution) B 4

C1

Tam

oxif

en

Citra

te Tamoxifen Citrate (Oral Tablet) G 1

C1

Tore

mife

ne

Citra

te Toremifene Citrate (Oral Tablet) G 4

B1

AntimetabolitesC1

Dro

xia

Droxia (Oral Capsule) B 3

C1

Hyd

rea

Hydrea (Oral Capsule) B 3

C1

Hyd

roxy

urea

Hydroxyurea (Oral Capsule) G 1

C1

Mer

capt

opur

ine

Mercaptopurine (Oral Tablet) G 2

C1

Onu

reg

Onureg (Oral Tablet) B 4 PA; QL


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Puri

xan

Purixan (Oral Suspension) B 4 PA C1

Tabl

oid

Tabloid (Oral Tablet) B 3 PA B1

Antineoplastics, OtherC1

IDHI

FA

IDHIFA (Oral Tablet) B 4 PA; LA C1

Lon

surf

Lonsurf (Oral Tablet) B 4 PA; LA C1

Ninl

aro

Ninlaro (Oral Capsule) B 4 PA C1

Pem

azyr

e

Pemazyre (Oral Tablet) B 4 PA; QL C1

Ret

evm

o

Retevmo (Oral Capsule) B 4 PA; QL C1

Synr

ibo

Synribo (Subcutaneous Solution Reconstituted) B 4 PA C1

Tazv

erik

Tazverik (Oral Tablet) B 4 PA; LA; QL C1

Tuk

ysa

Tukysa (Oral Tablet) B 4 PA; QL C1

Xpo

vio

Xpovio (100MG Once Weekly) (Oral Tablet Therapy

Pack)B 4 PA; LA; QL

C1

Xpo

vio


Pack)B 4 PA; LA; QL

C1

Xpo

vio

Xpovio (40MG Twice Weekly) (Oral Tablet Therapy

Pack)B 4 PA; LA; QL

C1

Xpo

vio


Pack)B 4 PA; LA; QL

C1

Xpo

vio


Pack)B 4 PA; LA; QL

C1

Xpo

vio


Pack)B 4 PA; LA; QL

C1

Xpo

vio


Pack)B 4 PA; LA; QL

C1

Zoli

nza

Zolinza (Oral Capsule) B 4 PA B1

Aromatase Inhibitors, 3rd GenerationC1

Ana

stro

zole

Anastrozole (Oral Tablet) G 1

C1

Arim

idex

Arimidex (Oral Tablet) B 4

C1

Aro

masi

n

Aromasin (Oral Tablet) B 4

C1

Exe

mes

tane

Exemestane (Oral Tablet) G 3

C1

Fem

ara

Femara (Oral Tablet) B 4

C1

Letr

ozol

e

Letrozole (Oral Tablet) G 1

B1

Molecular Target InhibitorsC1

Afini

tor

Disp

erz

Afinitor Disperz (Oral Tablet Soluble) B 4 PA C1

Afini

tor

Afinitor (Oral Tablet) B 4 PA



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Alec

ens

a

Alecensa (Oral Capsule) B 4 PA; LA C1

Alun

brig

Alunbrig (Oral Tablet) B 4 PA; LA; QL C1

Alun

brig

Alunbrig (Oral Tablet Therapy Pack) B 4 PA; LA; QL C1

Ayv

akit

Ayvakit (100MG Oral Tablet, 200MG Oral Tablet,

300MG Oral Tablet)B 4 PA; LA; QL

C1

Balv

ersa

Balversa (Oral Tablet) B 4 PA; LA; QL C1

Bos

ulif

Bosulif (Oral Tablet) B 4 PA C1

Braf

tovi

Braftovi (Oral Capsule) B 4 PA C1

Bruk

insa

Brukinsa (Oral Capsule) B 4 PA; LA; QL C1

Cab

ome

tyx

Cabometyx (Oral Tablet) B 4 PA; LA C1

Calq

uen

ce

Calquence (Oral Capsule) B 4 PA C1

Cap

rels

a

Caprelsa (Oral Tablet) B 4 PA; LA C1

Co

metr

iq

Cometriq (100MG Daily Dose) (Oral Kit) B 4 PA; LA C1

Co

metr

iq


Co

metr

iq


Cop

iktra

Copiktra (Oral Capsule) B 4 PA; QL C1

Cot

ellic

Cotellic (Oral Tablet) B 4 PA; LA C1

Dau

rism

o

Daurismo (Oral Tablet) B 4 PA; LA; QL C1

Eriv

edg

e

Erivedge (Oral Capsule) B 4 PA; LA C1

Erlot

inib

HCl

Erlotinib HCl (Oral Tablet) G 4 PA C1

Ever

olim

us

Everolimus (2.5MG Oral Tablet, 5MG Oral Tablet, 7.5MG

Oral Tablet)G 4 PA

C1

Fary

dak

Farydak (Oral Capsule) B 4 PA C1

Gavr

eto

Gavreto (Oral Capsule) B 4 PA; QL C1

Gilot

rif

Gilotrif (Oral Tablet) B 4 PA; LA C1

Glee

vec

Gleevec (Oral Tablet) B 4 PA; QL C1

Ibra

nce

Ibrance (Oral Capsule) B 4 PA; LA C1

Ibra

nce

Ibrance (Oral Tablet) B 4 PA; LA C1

Iclus

ig

Iclusig (Oral Tablet) B 4 PA; LA C1

Imat

inib

Mes

ylate

Imatinib Mesylate (Oral Tablet) G 4 PA; QL C1

Imbr

uvic

a

Imbruvica (Oral Capsule) B 4 PA; LA; QL C1

Imbr

uvic

a

Imbruvica (Oral Tablet) B 4 PA; QL C1

Inlyt

a

Inlyta (Oral Tablet) B 4 PA; LA; QL C1

Inqo

vi

Inqovi (Oral Tablet) B 4 PA; QL C1

Inre

bic

Inrebic (Oral Capsule) B 4 PA; QL C1

Ires

sa

Iressa (Oral Tablet) B 4 PA; LA; QL C1

Jaka

fi

Jakafi (Oral Tablet) B 4 PA; LA; QL


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Kisq

ali

Kisqali (200MG Dose) (Oral Tablet) B 4 PA C1

Kisq

ali


Kisq

ali


Kisq

ali

Fem

ara

Kisqali Femara (200MG Dose) (Oral Tablet Therapy

Pack)B 4 PA

C1

Kisq

ali

Fem

ara


Pack)B 4 PA

C1

Kisq

ali

Fem

ara


Pack)B 4 PA

C1

Kos

elug

o

Koselugo (Oral Capsule) B 4 PA; QL C1

Lap

atini

b

Dito

sylat

e Lapatinib Ditosylate (Oral Tablet) G 4 PA C1

Len

vima

10M

G

Dail

y

Dos

e Lenvima 10MG Daily Dose (Oral Capsule Therapy

Pack)B 4 PA; LA

C1

Len

vima

12M

G

Dail

y

Dos


Pack)B 4 PA; LA

C1

Len

vima

14M

G

Dail

y

Dos


Pack)B 4 PA; LA

C1

Len

vima

18M

G

Dail

y

Dos


Pack)B 4 PA; LA

C1

Len

vima

20M

G

Dail

y

Dos


Pack)B 4 PA; LA

C1

Len

vima

24M

G

Dail

y

Dos


Pack)B 4 PA; LA

C1

Len

vima

4M

G

Dail

y

Dos


Pack)B 4 PA; LA

C1

Len

vima

8M

G

Dail

y

Dos


Pack)B 4 PA; LA

C1

Lorb

rena

Lorbrena (Oral Tablet) B 4 PA; LA; QL C1

Lyn

parz

a

Lynparza (Oral Tablet) B 4 PA; LA C1

Mek

inist

Mekinist (Oral Tablet) B 4 PA; LA C1

Mek

tovi

Mektovi (Oral Tablet) B 4 PA C1

Nerl

ynx

Nerlynx (Oral Tablet) B 4 PA; LA; QL C1

Nex

avar

Nexavar (Oral Tablet) B 4 PA; LA C1

Odo

mzo

Odomzo (Oral Capsule) B 4 PA; LA; QL C1

Piqr

ay

Piqray (200MG Daily Dose) (Oral Tablet Therapy

Pack)B 4 PA; QL



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Piqr

ay


Pack)B 4 PA; QL

C1

Piqr

ay


Pack)B 4 PA; QL

C1

Rozl

ytre

k

Rozlytrek (Oral Capsule) B 4 PA; QL C1

Rub

raca

Rubraca (Oral Tablet) B 4 PA; LA C1

Ryd

apt

Rydapt (Oral Capsule) B 4 PA; QL C1

Spry

cel

Sprycel (Oral Tablet) B 4 PA C1

Stiv

arga

Stivarga (Oral Tablet) B 4 PA; LA C1

Sute

nt

Sutent (Oral Capsule) B 4 PA C1

Tafi

nlar

Tafinlar (Oral Capsule) B 4 PA; LA C1

Tagr

isso

Tagrisso (Oral Tablet) B 4 PA; LA C1

Talz

enn

a

Talzenna (Oral Capsule) B 4 PA; LA; QL C1

Tarc

eva

Tarceva (Oral Tablet) B 4 PA C1

Tasi

gna

Tasigna (Oral Capsule) B 4 PA C1

Tep

met

ko

Tepmetko (Oral Tablet) B 4 PA; QL C1

Tibs

ovo

Tibsovo (Oral Tablet) B 4 PA; QL C1

Tura

lio

Turalio (Oral Capsule) B 4 PA; LA; QL C1

Tyk

erb

Tykerb (Oral Tablet) B 4 PA; LA C1

Uko

niq

Ukoniq (Oral Tablet) B 4 PA; QL C1

Ven

clext

a

Venclexta (100MG Oral Tablet, 50MG Oral Tablet) B 4 PA; LA C1

Ven

clext

a

Venclexta (10MG Oral Tablet) B 2 PA; LA C1

Ven

clext

a

Start

ing

Pac

k Venclexta Starting Pack (Oral Tablet Therapy Pack) B 4 PA; LA C1

Verz

enio

Verzenio (Oral Tablet) B 4 PA; LA C1

Vitra

kvi

Vitrakvi (Oral Capsule) B 4 PA; LA; QL C1

Vitra

kvi

Vitrakvi (Oral Solution) B 4 PA; LA; QL C1

Vizi

mpr

o

Vizimpro (Oral Tablet) B 4 PA; LA C1

Votri

ent

Votrient (Oral Tablet) B 4 PA; LA C1

Xalk

ori

Xalkori (Oral Capsule) B 4 PA; LA C1

Xos

pata

Xospata (Oral Tablet) B 4 PA; QL C1

Zeju

la

Zejula (Oral Capsule) B 4 PA; LA C1

Zelb

oraf

Zelboraf (Oral Tablet) B 4 PA; LA; QL C1

Zyd

elig

Zydelig (Oral Tablet) B 4 PA; LA C1

Zyk

adia

Zykadia (Oral Tablet) B 4 PA B1

RetinoidsC1

Bex

arot

ene

Bexarotene (Oral Capsule) G 4 PA C1

Targ

retin

Targretin (External Gel) B 4 PA; QL


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Targ

retin

Targretin (Oral Capsule) B 4 PA C1

Treti

noin

Tretinoin (Oral Capsule) G 4

B1

Treatment AdjunctsC1

Leu

cov

orin

Calc

ium Leucovorin Calcium (10MG Oral Tablet, 15MG Oral

Tablet)G 2

C1

Leu

cov

orin

Calc

ium Leucovorin Calcium (25MG Oral Tablet) G 3

C1

Leu

cov

orin

Calc

ium Leucovorin Calcium (5MG Oral Tablet) G 1

C1

Mes

nex

Mesnex (Oral Tablet) B 4

A1

AntiparasiticsB1

AnthelminticsC1

Albe

nda

zole

Albendazole (Oral Tablet) G 4 QL C1

Albe

nza

Albenza (Oral Tablet) B 4 QL C1

Biltri

cide

Biltricide (Oral Tablet) B 3

C1

Emv

erm

Emverm (Oral Tablet Chewable) G 4

C1

Iver

mec

tin

Ivermectin (Oral Tablet) G 1

C1

Praz

iqua

ntel

Praziquantel (Oral Tablet) G 3

C1

Stro

mec

tol

Stromectol (Oral Tablet) B 3

B1

AntiprotozoalsC1

Alini

a

Alinia (Oral Suspension Reconstituted) B 4

C1

Alini

a

Alinia (Oral Tablet) B 4

C1

Atov

aqu

one

Atovaquone (Oral Suspension) G 4

C1

Atov

aqu

one-

Pro

gua

nil

HCl Atovaquone-Proguanil HCl (Oral Tablet) G 2

C1

Ben

znid

azol

e

Benznidazole (Oral Tablet) B 3

C1

Chlo

roqu

ine

Pho

sph

ate Chloroquine Phosphate (Oral Tablet) G 2 QL C1

Coa

rtem

Coartem (Oral Tablet) B 3

C1

DAR

APR

IM

DARAPRIM (Oral Tablet) B 4

C1

Hyd

roxy

chlo

roqu

ine

Sulf

ate Hydroxychloroquine Sulfate (Oral Tablet) G 1 QL C1

Imp

avid

o

Impavido (Oral Capsule) B 4

C1

Krint

afel

Krintafel (Oral Tablet) B 3

C1

Lam

pit

Lampit (Oral Tablet) B 3 PA C1

Mal

aron

e

Malarone (Oral Tablet) B 3

C1

Mefl

oqui

ne

HCl

Mefloquine HCl (Oral Tablet) G 1

C1

Mep

ron

Mepron (Oral Suspension) B 4

C1

Neb

upe

nt

Nebupent (Inhalation Solution Reconstituted) B 3 B/D, PA; QL C1

Nita

zoxa

nide

Nitazoxanide (Oral Tablet) G 4

C1

PEN

TA

M

300

PENTAM 300 (Injection Solution Reconstituted) B 3



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Pent

ami

dine

Iset

hion

ate Pentamidine Isethionate (Inhalation Solution

Reconstituted)G 3 B/D, PA; QL

C1

Pent

ami

dine

Iset

hion

ate Pentamidine Isethionate (Injection Solution

Reconstituted)G 3

C1

Plaq

ueni

l

Plaquenil (Oral Tablet) B 3 QL C1

Prim

aqui

ne

Pho

sph

ate Primaquine Phosphate (Oral Tablet) G 2

C1

Pyri

met

ham

ine

Pyrimethamine (Oral Tablet) G 4

C1

Qual

aqui

n

Qualaquin (Oral Capsule) B 3 PA C1

Quin

ine

Sulf

ate

Quinine Sulfate (Oral Capsule) G 3 PA A1

Antiparkinson AgentsB1

AnticholinergicsC1

Ben

ztro

pine

Mes

ylate Benztropine Mesylate (Oral Tablet) G 2 PA; HRM C1

Trih

exy

phe

nidyl

HCl Trihexyphenidyl HCl (Oral Solution) G 3 PA; HRM C1

Trih

exy

phe

nidyl

HCl Trihexyphenidyl HCl (Oral Tablet) G 3 PA; HRM B1

Antiparkinson Agents, OtherC1

Ama

ntad

ine

HCl

Amantadine HCl (Oral Capsule) G 2

C1

Ama

ntad

ine

HCl

Amantadine HCl (Oral Syrup) G 1

C1

Ama

ntad

ine

HCl

Amantadine HCl (Oral Tablet) G 2

C1

Car

bido

pa-

Lev

odo

pa-

Enta

cap

one Carbidopa-Levodopa-Entacapone (Oral Tablet) G 3

C1

Co

mta

n

Comtan (Oral Tablet) B 3

C1

Enta

cap

one

Entacapone (Oral Tablet) G 3

C1

Goc

ovri

Gocovri (Oral Capsule Extended Release 24 Hour) B 4 PA C1

Nou

rian

z

Nourianz (Oral Tablet) B 4 PA; QL C1

Ong

enty

s

Ongentys (Oral Capsule) B 3 ST; QL C1

Os

mol

ex

ER

Osmolex ER (Oral Tablet ER 24 Hour Therapy Pack) B 3 PA C1

Os

mol

ex

ER

Osmolex ER (Oral Tablet Extended Release 24 Hour) B 3 PA C1

Stal

evo

100

Stalevo 100 (Oral Tablet) B 4

C1

Stal

evo

125


C1

Stal

evo

150


C1

Stal

evo

200


C1

Stal

evo

50


C1

Stal

evo

75


C1

Tas

mar

Tasmar (Oral Tablet) B 4 QL C1

Tolc

apo

ne

Tolcapone (Oral Tablet) G 4 QL B1

Dopamine AgonistsC1

Apo

kyn

Apokyn (Subcutaneous Solution Cartridge) B 4 PA; LA; QL C1

Bro

moc

ripti

ne

Mes

ylate Bromocriptine Mesylate (Oral Capsule) G 3


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Bro

moc

ripti

ne

Mes

ylate Bromocriptine Mesylate (Oral Tablet) G 3

C1

Kyn

mob

i

Kynmobi (10MG Sublingual Film, 15MG Sublingual

Film, 20MG Sublingual Film, 25MG Sublingual Film,

30MG Sublingual Film)

B 4 PA; QL

C1

Mira

pex

ER

Mirapex ER (Oral Tablet Extended Release 24 Hour) B 3

C1

Mira

pex

Mirapex (Oral Tablet Immediate Release) B 3

C1

Neu

pro

Neupro (Transdermal Patch 24 Hour) B 3

C1

Parl

odel

Parlodel (Oral Capsule) B 3

C1

Parl

odel

Parlodel (Oral Tablet) B 3

C1

Pra

mip

exol

e

Dihy

droc

hlori

de

ER Pramipexole Dihydrochloride ER (Oral Tablet Extended

Release 24 Hour)G 3

C1

Pra

mip

exol

e

Dihy

droc

hlori

de Pramipexole Dihydrochloride (Oral Tablet Immediate

Release)G 1

C1

Rop

iniro

le

HCl

ER Ropinirole HCl ER (Oral Tablet Extended Release 24

Hour)G 3

C1

Rop

iniro

le

HCl

Ropinirole HCl (Oral Tablet Immediate Release) G 1

B1

Dopamine Precursors and/or L-Amino Acid Decarboxylase InhibitorsC1

Car

bido

pa

Carbidopa (Oral Tablet) G 3

C1

Car

bido

pa-

Lev

odo

pa

ER Carbidopa-Levodopa ER (Oral Tablet Extended Release) G 2

C1

Car

bido

pa-

Lev

odo

pa Carbidopa-Levodopa (Oral Tablet Immediate Release) G 1

C1

Car

bido

pa-

Lev

odo

pa

ODT Carbidopa-Levodopa ODT (Oral Tablet Dispersible) G 3

C1

Duo

pa

Duopa (Enteral Suspension) B 4 PA C1

Inbri

ja

Inbrija (Inhalation Capsule) B 4 PA; LA C1

Lod

osy

n

Lodosyn (Oral Tablet) B 4

C1

Ryta

ry

Rytary (Oral Capsule Extended Release) B 3 ST C1

Sine

met

Sinemet (Oral Tablet Immediate Release) B 3

B1

Monoamine Oxidase B (MAO-B) InhibitorsC1

Azil

ect

Azilect (Oral Tablet) B 4

C1

Ras

agili

ne

Mes

ylate Rasagiline Mesylate (Oral Tablet) G 3

C1

Sele

gilin

e

HCl

Selegiline HCl (Oral Capsule) G 2

C1

Sele

gilin

e

HCl

Selegiline HCl (Oral Tablet) G 2

C1

Zela

par

ODT

Zelapar ODT (Oral Tablet Dispersible) B 4

A1

AntipsychoticsB1

1st Generation/TypicalC1

Chlo

rpro

mazi

ne

HCl Chlorpromazine HCl (Oral Tablet) G 3

C1

Flup

hen

azin

e

Dec

ano

ate Fluphenazine Decanoate (Injection Solution) G 2



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Flup

hen

azin

e

HCl Fluphenazine HCl (2.5MG/ML Injection Solution) G 2

C1

Flup

hen

azin

e

HCl Fluphenazine HCl (5MG/ML Oral Concentrate) G 3

C1

Flup

hen

azin

e

HCl Fluphenazine HCl (2.5MG/5ML Oral Elixir) G 2

C1

Flup

hen

azin

e

HCl Fluphenazine HCl (10MG Oral Tablet, 1MG Oral Tablet,

2.5MG Oral Tablet, 5MG Oral Tablet)G 3

C1

Hald

ol

Dec

ano

ate Haldol Decanoate (Intramuscular Solution) B 3

C1

Hald

ol

Haldol (Injection Solution) B 3

C1

Halo

peri

dol

Dec

ano

ate Haloperidol Decanoate (Intramuscular Solution) G 2

C1

Halo

peri

dol

Lact

ate Haloperidol Lactate (Injection Solution) G 1

C1

Halo

peri

dol

Lact

ate Haloperidol Lactate (Oral Concentrate) G 1

C1

Halo

peri

dol

Haloperidol (Oral Tablet) G 1

C1

Lox

apin

e

Suc

cina

te Loxapine Succinate (Oral Capsule) G 2

C1

Moli

ndo

ne

HCl

Molindone HCl (Oral Tablet) G 3

C1

Pim

ozid

e

Pimozide (Oral Tablet) G 2

C1

Thio

rida

zine

HCl

Thioridazine HCl (Oral Tablet) G 2

C1

Thio

thix

ene

Thiothixene (10MG Oral Capsule, 5MG Oral Capsule) G 3

C1

Thio

thix

ene

Thiothixene (1MG Oral Capsule, 2MG Oral Capsule) G 2

C1

Trifl

uop

eraz

ine

HCl Trifluoperazine HCl (Oral Tablet) G 2

B1

2nd Generation/AtypicalC1

Abili

fy

Mai

nten

a Abilify Maintena (Intramuscular Prefilled Syringe) B 4

C1

Abili

fy

Mai

nten

a Abilify Maintena (Intramuscular Suspension

Reconstituted ER)B 4

C1

Abili

fy

MyC

ite

Abilify MyCite (Oral Tablet) B 4 ST; QL C1

Abili

fy

Abilify (Oral Tablet) B 4 QL C1

Aripi

praz

ole

Aripiprazole (1MG/ML Oral Solution) G 3 QL C1

Aripi

praz

ole

Aripiprazole (10MG Oral Tablet, 15MG Oral Tablet,

20MG Oral Tablet, 2MG Oral Tablet, 30MG Oral Tablet,

5MG Oral Tablet)

G 1 QL

C1

Aripi

praz

ole

ODT

Aripiprazole ODT (10MG Oral Tablet Dispersible, 15MG

Oral Tablet Dispersible)G 4 QL

C1

Arist

ada

Initi

o

Aristada Initio (Intramuscular Prefilled Syringe) B 4

C1

Arist

ada

Aristada (Intramuscular Prefilled Syringe) B 4

C1

Ase

napi

ne

Mal

eate Asenapine Maleate (10MG Tablet Sublingual) G 3

C1

Ase

napi

ne

Mal

eate Asenapine Maleate (2.5MG Tablet Sublingual, 5MG

Tablet Sublingual)G 4

C1

Capl

yta

Caplyta (Oral Capsule) B 4 ST; QL C1

Fan

apt

Fanapt (10MG Oral Tablet, 12MG Oral Tablet, 4MG

Oral Tablet, 6MG Oral Tablet, 8MG Oral Tablet)B 4 ST; QL


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Fan

apt

Fanapt (1MG Oral Tablet, 2MG Oral Tablet) B 3 ST; QL C1

Fan

apt

Titra

tion

Pac

k Fanapt Titration Pack (Oral Tablet) B 3 ST C1

Geo

don

Geodon (Intramuscular Solution Reconstituted) B 3

C1

Geo

don

Geodon (Oral Capsule) B 4 QL C1

Inve

ga

Invega (Oral Tablet Extended Release 24 Hour) B 4 PA; QL C1

Inve

ga

Sust

enn

a 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)

B 4

C1

Inve

ga

Sust

enn

a Invega Sustenna (39MG/0.25ML Intramuscular

Suspension Prefilled Syringe)B 3

C1

Inve

ga

Trin

za

Invega Trinza (Intramuscular Suspension Prefilled

Syringe)B 4

C1

Latu

da

Latuda (Oral Tablet) B 4 QL C1

Nup

lazid

Nuplazid (Oral Capsule) B 4 PA; QL C1

Nup

lazid

Nuplazid (Oral Tablet) B 4 PA; QL C1

Olan

zapi

ne

Olanzapine (10MG Intramuscular Solution

Reconstituted)G 3

C1

Olan

zapi

ne

Olanzapine (10MG Oral Tablet, 15MG Oral Tablet,

2.5MG Oral Tablet, 20MG Oral Tablet, 5MG Oral Tablet,

7.5MG Oral Tablet)

G 1 QL

C1

Olan

zapi

ne

ODT

Olanzapine ODT (10MG Oral Tablet Dispersible, 15MG

Oral Tablet Dispersible, 20MG Oral Tablet Dispersible,

5MG Oral Tablet Dispersible)

G 2 QL

C1

Pali

peri

don

e

ER Paliperidone ER (Oral Tablet Extended Release 24 Hour) G 3 QL C1

Pers

eris

Perseris (Subcutaneous Prefilled Syringe) B 4

C1

Que

tiapi

ne

Fum

arat

e

ER Quetiapine Fumarate ER (Oral Tablet Extended Release

24 Hour)G 2 QL

C1

Que

tiapi

ne

Fum

arat

e Quetiapine Fumarate (Oral Tablet Immediate Release) G 1 QL C1

Rex

ulti

Rexulti (Oral Tablet) B 4 QL C1

Risp

erda

l

Con

sta Risperdal Consta (12.5MG Intramuscular Suspension

Reconstituted ER, 25MG Intramuscular Suspension

Reconstituted ER)

B 3

C1

Risp

erda

l

Con

sta Risperdal Consta (37.5MG Intramuscular Suspension

Reconstituted ER, 50MG Intramuscular Suspension

Reconstituted ER)

B 4



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Risp

erda

l

Risperdal (1MG/ML Oral Solution) B 4

C1

Risp

erda

l

Risperdal (0.5MG Oral Tablet) B 3

C1

Risp

erda

l

Risperdal (1MG Oral Tablet, 2MG Oral Tablet, 3MG

Oral Tablet, 4MG Oral Tablet)B 4

C1

Risp

erid

one

Risperidone (1MG/ML Oral Solution) G 2

C1

Risp

erid

one

Risperidone (0.25MG Oral Tablet, 0.5MG Oral Tablet,

1MG Oral Tablet, 2MG Oral Tablet, 3MG Oral Tablet,

4MG Oral Tablet)

G 1

C1

Risp

erid

one

ODT

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)

G 3

C1

Sap

hris

Saphris (Tablet Sublingual) B 4

C1

Sec

uad

o

Secuado (Transdermal Patch 24 Hour) B 4 PA; QL C1

Ser

oqu

el

Seroquel (100MG Oral Tablet Immediate Release,


Tablet Immediate Release, 50MG Oral Tablet

Immediate Release)

B 3 QL

C1

Ser

oqu

el

Seroquel (300MG Oral Tablet Immediate Release,

400MG Oral Tablet Immediate Release)B 4 QL

C1

Ser

oqu

el

XR

Seroquel XR (150MG Oral Tablet Extended Release

24 Hour, 200MG Oral Tablet Extended Release 24

Hour, 50MG Oral Tablet Extended Release 24 Hour)

B 3 QL

C1

Ser

oqu

el

XR

Seroquel XR (300MG Oral Tablet Extended Release

24 Hour, 400MG Oral Tablet Extended Release 24

Hour)

B 4 QL

C1

Vray

lar

Vraylar (1.5MG Oral Capsule, 3MG Oral Capsule,

4.5MG Oral Capsule, 6MG Oral Capsule)B 4 ST; QL

C1

Vray

lar

Vraylar (Oral Capsule Therapy Pack) B 3 ST C1

Zipr

asid

one

HCl

Ziprasidone HCl (Oral Capsule) G 2 QL C1

Zipr

asid

one

Mes

ylate Ziprasidone Mesylate (Intramuscular Solution

Reconstituted)G 3

C1

Zypr

exa

Zyprexa (10MG Intramuscular Solution

Reconstituted)B 3

C1

Zypr

exa

Zyprexa (10MG Oral Tablet, 15MG Oral Tablet, 20MG

Oral Tablet)B 4 QL

C1

Zypr

exa

Zyprexa (2.5MG Oral Tablet, 5MG Oral Tablet, 7.5MG

Oral Tablet)B 3 QL


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Zypr

exa

Relp

revv

Zyprexa Relprevv (210MG Intramuscular Suspension

Reconstituted)B 3

C1

Zypr

exa

Zydi

s

Zyprexa Zydis (10MG Oral Tablet Dispersible, 15MG

Oral Tablet Dispersible, 20MG Oral Tablet

Dispersible)

B 4 QL

C1

Zypr

exa

Zydi

s

Zyprexa Zydis (5MG Oral Tablet Dispersible) B 3 QL B1

Treatment-ResistantC1

Cloz

apin

e

Clozapine (100MG Oral Tablet, 200MG Oral Tablet,

25MG Oral Tablet, 50MG Oral Tablet)G 2

C1

Cloz

apin

e

ODT

Clozapine ODT (100MG Oral Tablet Dispersible, 150MG

Oral Tablet Dispersible, 200MG Oral Tablet Dispersible)G 3

C1

Cloz

apin

e

ODT

Clozapine ODT (12.5MG Oral Tablet Dispersible, 25MG

Oral Tablet Dispersible)G 2

C1

Cloz

aril

Clozaril (100MG Oral Tablet, 200MG Oral Tablet) B 4

C1

Cloz

aril

Clozaril (25MG Oral Tablet, 50MG Oral Tablet) B 3

C1

Vers

aclo

z

Versacloz (Oral Suspension) B 4

A1

Antispasticity AgentsB1

Antispasticity AgentsC1

Bacl

ofen

Baclofen (Oral Tablet) G 1

C1

Dant

rium

Dantrium (Oral Capsule) B 3

C1

Dant

role

ne

Sodi

um Dantrolene Sodium (100MG Oral Capsule, 50MG Oral

Capsule)G 3

C1

Dant

role

ne

Sodi

um Dantrolene Sodium (25MG Oral Capsule) G 2

C1

Tiza

nidi

ne

HCl

Tizanidine HCl (2MG Oral Capsule, 4MG Oral Capsule,

6MG Oral Capsule)G 3

C1

Tiza

nidi

ne

HCl

Tizanidine HCl (2MG Oral Tablet, 4MG Oral Tablet) G 1

C1

Zan

aflex

Zanaflex (Oral Capsule) B 3

C1

Zan

aflex

Zanaflex (Oral Tablet) B 3

A1

AntiviralsB1

Anti-cytomegalovirus (CMV) AgentsC1

Prev

ymis

Prevymis (Oral Tablet) B 4 PA; QL C1

Valc

yte

Valcyte (Oral Solution Reconstituted) B 4 QL C1

Valc

yte

Valcyte (Oral Tablet) B 4 QL C1

Valg

anci

clovi

r

HCl Valganciclovir HCl (50MG/ML Oral Solution

Reconstituted)G 4 QL

C1

Valg

anci

clovi

r

HCl Valganciclovir HCl (450MG Oral Tablet) G 2 QL C1

Zirg

an

Zirgan (Ophthalmic Gel) B 3



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

B1

Anti-hepatitis B (HBV) AgentsC1

Ade

fovir

Dipi

voxil Adefovir Dipivoxil (Oral Tablet) G 4

C1

Bara

clud

e

Baraclude (Oral Solution) B 4

C1

Bara

clud

e

Baraclude (Oral Tablet) B 4

C1

Ente

cavir

Entecavir (Oral Tablet) G 3

C1

Epiv

ir

HBV

Epivir HBV (Oral Solution) B 3

C1

Epiv

ir

HBV

Epivir HBV (Oral Tablet) B 3

C1

Hep

sera

Hepsera (Oral Tablet) B 4

C1

Lam

ivudi

ne

Lamivudine (100MG Oral Tablet) G 2

C1

Vem

lidy

Vemlidy (Oral Tablet) B 4

B1

Anti-hepatitis C (HCV) AgentsC1

Epcl

usa

Epclusa (Oral Tablet) B 4 PA; QL C1

Harv

oni

Harvoni (Oral Packet) B 4 PA; QL C1

Harv

oni

Harvoni (90-400MG Oral Tablet) B 4 PA; QL C1

Ledi

pasv

ir-

Sof

osb

uvir Ledipasvir-Sofosbuvir (Oral Tablet) G 4 PA; QL C1

Mav

yret

Mavyret (Oral Tablet) B 4 PA; QL C1

Riba

virin

Ribavirin (Oral Capsule) G 2

C1

Riba

virin

Ribavirin (Oral Tablet) G 2

C1

Sof

osb

uvir-

Velp

atas

vir Sofosbuvir-Velpatasvir (Oral Tablet) G 4 PA; QL C1

Sov

aldi

Sovaldi (Oral Packet) B 4 PA; QL C1

Sov

aldi

Sovaldi (400MG Oral Tablet) B 4 PA; QL C1

Viek

ira

Pak

Viekira Pak (Oral Tablet Therapy Pack) B 4 PA; QL C1

Vos

evi

Vosevi (Oral Tablet) B 4 PA; QL C1

Zep

atier

Zepatier (Oral Tablet) B 4 PA; QL B1

Antiherpetic AgentsC1

Acy

clovi

r

Acyclovir (External Cream) G 3

C1

Acy

clovi

r

Acyclovir (External Ointment) G 3

C1

Acy

clovi

r

Acyclovir (Oral Capsule) G 1

C1

Acy

clovi

r

Acyclovir (Oral Suspension) G 3

C1

Acy

clovi

r

Acyclovir (Oral Tablet) G 1

C1

Acy

clovi

r

Sodi

um Acyclovir Sodium (Intravenous Solution) G 3 B/D, PA C1

Den

avir

Denavir (External Cream) B 4

C1

Fam

ciclo

vir

Famciclovir (Oral Tablet) G 2

C1

Sita

vig

Sitavig (Buccal Tablet) B 3 ST C1

Vala

cycl

ovir

HCl

Valacyclovir HCl (Oral Tablet) G 2 QL C1

Valtr

ex

Valtrex (1GM Oral Tablet) B 4 QL C1

Valtr

ex

Valtrex (500MG Oral Tablet) B 3 QL


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Zovi

rax

Zovirax (External Cream) B 4

C1

Zovi

rax

Zovirax (External Ointment) B 4

C1

Zovi

rax

Zovirax (Oral Suspension) B 3

B1

Anti-HIV Agents, Integrase Inhibitors (INSTI)C1

Bikt

arvy

Biktarvy (Oral Tablet) B 4 QL C1

Dov

ato

Dovato (Oral Tablet) B 4 QL C1

Gen

voya

Genvoya (Oral Tablet) B 4 QL C1

Isen

tres

s

HD

Isentress HD (Oral Tablet) B 4 QL C1

Isen

tres

s

Isentress (Oral Packet) B 3 QL C1

Isen

tres

s

Isentress (Oral Tablet) B 4 QL C1

Isen

tres

s

Isentress (100MG Oral Tablet Chewable) B 4 QL C1

Isen

tres

s

Isentress (25MG Oral Tablet Chewable) B 2 QL C1

Julu

ca

Juluca (Oral Tablet) B 4 QL C1

Strib

ild

Stribild (Oral Tablet) B 4 QL C1

Tivic

ay

Tivicay (10MG Oral Tablet) B 3 QL C1

Tivic

ay

Tivicay (25MG Oral Tablet, 50MG Oral Tablet) B 4 QL C1

Tivic

ay

PD

Tivicay PD (Oral Tablet Soluble) B 4 QL B1

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)C1

Atri

pla

Atripla (Oral Tablet) B 4 QL C1

Co

mpl

era

Complera (Oral Tablet) B 4 QL C1

Dels

trigo

Delstrigo (Oral Tablet) B 4 QL C1

Edu

rant

Edurant (Oral Tablet) B 4 QL C1

Efav

iren

z

Efavirenz (Oral Capsule) G 3 QL C1

Efav

iren

z

Efavirenz (Oral Tablet) G 3 QL C1

Efav

iren

z-

Emt

ricit

abin

e-

Ten

ofov

irEfavirenz-Emtricitabine-Tenofovir (Oral Tablet) G 4 QL

C1

Efav

iren

z-

Lam

ivudi

ne-

Ten

ofov

ir Efavirenz-Lamivudine-Tenofovir (Oral Tablet) G 4 QL C1

Intel

enc

e

Intelence (100MG Oral Tablet, 200MG Oral Tablet) B 4 QL C1

Intel

enc

e

Intelence (25MG Oral Tablet) B 3 QL C1

Nevi

rapi

ne

ER

Nevirapine ER (Oral Tablet Extended Release 24 Hour) G 3 QL C1

Nevi

rapi

ne

Nevirapine (Oral Suspension) G 3 QL C1

Nevi

rapi

ne

Nevirapine (Oral Tablet Immediate Release) G 2 QL C1

Pifel

tro

Pifeltro (Oral Tablet) B 4 QL C1

Sust

iva

Sustiva (Oral Capsule) B 3 QL C1

Sust

iva

Sustiva (Oral Tablet) B 4 QL C1

Sym

fi Lo

Symfi Lo (Oral Tablet) B 4 QL



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Sym

fi

Symfi (Oral Tablet) B 4 QL C1

Vira

mun

e

Viramune (Oral Suspension) B 4 QL C1

Vira

mun

e

XR

Viramune XR (Oral Tablet Extended Release 24 Hour) B 4 QL B1

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)C1

Aba

cavir

Sulf

ate Abacavir Sulfate (Oral Solution) G 3 QL C1

Aba

cavir

Sulf

ate Abacavir Sulfate (Oral Tablet) G 3 QL C1

Aba

cavir

Sulf

ate-

Lam

ivudi

ne Abacavir Sulfate-Lamivudine (Oral Tablet) G 3 QL C1

Aba

cavir

-

Lam

ivudi

ne-

Zido

vudi

ne Abacavir-Lamivudine-Zidovudine (Oral Tablet) G 4 QL C1

Cim

duo

Cimduo (Oral Tablet) B 4 QL C1

Co

mbi

vir

Combivir (Oral Tablet) B 4 QL C1

Des

covy

Descovy (Oral Tablet) B 4 QL C1

Emt

ricit

abin

e

Emtricitabine (Oral Capsule) G 3 QL C1

Emt

ricit

abin

e-

Ten

ofov

ir

Diso

prox

il

Fum

arat

e

Emtricitabine-Tenofovir Disoproxil Fumarate (Oral Tablet) G 4 QL C1

Emt

riva

Emtriva (Oral Capsule) B 3 QL C1

Emt

riva

Emtriva (Oral Solution) B 3 QL C1

Epiv

ir

Epivir (Oral Solution) B 3 QL C1

Epiv

ir

Epivir (Oral Tablet) B 3 QL C1

Epzi

com

Epzicom (Oral Tablet) B 4 QL C1

Lam

ivudi

ne

Lamivudine (10MG/ML Oral Solution) G 2 QL C1

Lam

ivudi

ne

Lamivudine (150MG Oral Tablet, 300MG Oral Tablet) G 2 QL C1

Lam

ivudi

ne-

Zido

vudi

ne Lamivudine-Zidovudine (Oral Tablet) G 3 QL C1

Ode

fsey

Odefsey (Oral Tablet) B 4 QL C1

Retr

ovir

Retrovir (Oral Capsule) B 3 QL C1

Retr

ovir

Retrovir (Oral Syrup) B 3 QL C1

Tem

ixys

Temixys (Oral Tablet) B 4 QL C1

Ten

ofov

ir

Diso

prox

il

Fum

arat

e Tenofovir Disoproxil Fumarate (Oral Tablet) G 2 QL C1

Triu

meq

Triumeq (Oral Tablet) B 4 QL C1

Trizi

vir

Trizivir (Oral Tablet) B 4 QL C1

Truv

ada

Truvada (Oral Tablet) B 4 QL C1

Vire

ad

Viread (Oral Powder) B 4 QL C1

Vire

ad

Viread (Oral Tablet) B 4 QL C1

Ziag

en

Ziagen (Oral Solution) B 3 QL C1

Ziag

en

Ziagen (Oral Tablet) B 3 QL C1

Zido

vudi

ne

Zidovudine (Oral Capsule) G 3 QL C1

Zido

vudi

ne

Zidovudine (Oral Syrup) G 2 QL C1

Zido

vudi

ne

Zidovudine (Oral Tablet) G 2 QL B1

Anti-HIV Agents, Other


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Fuz

eon

Fuzeon (Subcutaneous Solution Reconstituted) B 4 QL C1

Ruk

obia

Rukobia (Oral Tablet Extended Release 12 Hour) B 4 QL C1

Selz

entr

y

Selzentry (Oral Solution) B 4 QL C1

Selz

entr

y

Selzentry (150MG Oral Tablet, 300MG Oral Tablet,

75MG Oral Tablet)B 4 QL

C1

Selz

entr

y

Selzentry (25MG Oral Tablet) B 2 QL C1

Tyb

ost

Tybost (Oral Tablet) B 3 QL B1

Anti-HIV Agents, Protease InhibitorsC1

Apti

vus

Aptivus (Oral Capsule) B 4 QL C1

Ataz

anav

ir

Sulf

ate Atazanavir Sulfate (Oral Capsule) G 3 QL C1

Evot

az

Evotaz (Oral Tablet) B 4 QL C1

Fos

amp

rena

vir

Calc

ium Fosamprenavir Calcium (Oral Tablet) G 4 QL C1

Invir

ase

Invirase (Oral Tablet) B 4 QL C1

Kale

tra

Kaletra (Oral Solution) B 3 QL C1

Kale

tra

Kaletra (100-25MG Oral Tablet) B 3 QL C1

Kale

tra

Kaletra (200-50MG Oral Tablet) B 4 QL C1

Lexi

va

Lexiva (Oral Suspension) B 3 QL C1

Lexi

va

Lexiva (Oral Tablet) B 4 QL C1

Lopi

navi

r-

Rito

navi

r Lopinavir-Ritonavir (Oral Solution) G 3 QL C1

Nor

vir

Norvir (Oral Packet) B 3 QL C1

Nor

vir

Norvir (Oral Solution) B 3 QL C1

Nor

vir

Norvir (Oral Tablet) B 3 QL C1

Prez

cobi

x

Prezcobix (Oral Tablet) B 4 QL C1

Prez

ista

Prezista (Oral Suspension) B 4 QL C1

Prez

ista

Prezista (150MG Oral Tablet, 600MG Oral Tablet,

800MG Oral Tablet)B 4 QL

C1

Prez

ista

Prezista (75MG Oral Tablet) B 3 QL C1

Rey

ataz

Reyataz (Oral Capsule) B 4 QL C1

Rey

ataz

Reyataz (Oral Packet) B 4 QL C1

Rito

navi

r

Ritonavir (Oral Tablet) G 2 QL C1

Sym

tuza

Symtuza (Oral Tablet) B 4 QL C1

Vira

cept

Viracept (Oral Tablet) B 4 QL B1

Anti-influenza AgentsC1

Osel

tami

vir

Pho

sph

ate Oseltamivir Phosphate (Oral Capsule) G 2

C1

Osel

tami

vir

Pho

sph

ate Oseltamivir Phosphate (Oral Suspension Reconstituted) G 2



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Rele

nza

Disk

hale

r Relenza Diskhaler (Inhalation Aerosol Powder Breath

Activated)B 2

C1

Rim

anta

dine

HCl

Rimantadine HCl (Oral Tablet) G 3

C1

Tam

iflu

Tamiflu (Oral Capsule) B 3

C1

Tam

iflu

Tamiflu (Oral Suspension Reconstituted) B 3

C1

Xofl

uza

Xofluza (40MG Dose) (2 x 20MG Oral Tablet Therapy

Pack)B 2 QL

C1

Xofl

uza

Xofluza (80MG Dose) (2 x 40MG Oral Tablet Therapy

Pack)B 2 QL

A1

AnxiolyticsB1

Anxiolytics, OtherC1

Bus

piro

ne

HCl

Buspirone HCl (Oral Tablet) G 1

C1

Hyd

roxy

zine

HCl

Hydroxyzine HCl (Oral Syrup) G 3 PA; HRM C1

Hyd

roxy

zine

Pam

oate Hydroxyzine Pamoate (Oral Capsule) G 3 PA; HRM C1

Vist

aril

Vistaril (Oral Capsule) B 3 PA; HRM B1

BenzodiazepinesC1

Alpr

azol

am

ER

Alprazolam ER (Oral Tablet Extended Release 24 Hour) G 2 PA; QL C1

Alpr

azol

am

Inte

nsol Alprazolam Intensol (Oral Concentrate) G 3 QL C1

Alpr

azol

am

Alprazolam (Oral Tablet Immediate Release) G 1 QL C1

Alpr

azol

am

ODT

Alprazolam ODT (Oral Tablet Dispersible) G 3 QL C1

Ativ

an

Ativan (Oral Tablet) B 4 QL C1

Chlo

rdia

zep

oxid

e

HCl Chlordiazepoxide HCl (Oral Capsule) G 1

C1

Clon

aze

pam

Clonazepam (0.5MG Oral Tablet, 1MG Oral Tablet, 2MG

Oral Tablet)G 1 QL

C1

Clon

aze

pam

ODT 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)

G 2 QL

C1

Clor

aze

pate

Dip

otas

siu

m Clorazepate Dipotassium (Oral Tablet) G 3 QL C1

Diaz

epa

m

Inte

nsol Diazepam Intensol (5MG/ML Oral Concentrate) G 2 QL C1

Diaz

epa

m

Diazepam (5MG/5ML Oral Solution) G 1

C1

Diaz

epa

m

Diazepam (10MG Oral Tablet, 2MG Oral Tablet, 5MG

Oral Tablet)G 1 QL

C1

Klon

opin

Klonopin (Oral Tablet) B 3 QL C1

Lora

zep

am

Inte

nsol Lorazepam Intensol (Oral Concentrate) G 1 QL C1

Lora

zep

am

Lorazepam (Oral Tablet) G 1 QL C1

Oxa

zep

am

Oxazepam (Oral Capsule) G 2

C1

Tran

xen

e-T

Tranxene-T (Oral Tablet) B 4 QL


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Vali

um

Valium (Oral Tablet) B 3 QL C1

Xan

ax

Xanax (0.25MG Oral Tablet Immediate Release,

0.5MG Oral Tablet Immediate Release, 1MG Oral


B 3 QL

C1

Xan

ax

Xanax (2MG Oral Tablet Immediate Release) B 4 QL C1

Xan

ax

XR

Xanax XR (Oral Tablet Extended Release 24 Hour) B 3 PA; QL A1

Bipolar AgentsB1

Mood StabilizersC1

Dep

akot

e

ER

Depakote ER (Oral Tablet Extended Release 24 Hour) B 3

C1

Dep

akot

e

Depakote (Oral Tablet Delayed Release) B 3

C1

Dep

akot

e

Spri

nkle

s Depakote Sprinkles (Oral Capsule Delayed Release

Sprinkle)B 3

C1

Diva

lpro

ex

Sodi

um

ER Divalproex Sodium ER (Oral Tablet Extended Release 24

Hour)G 1

C1

Diva

lpro

ex

Sodi

um Divalproex Sodium (Oral Capsule Delayed Release

Sprinkle)G 2

C1

Diva

lpro

ex

Sodi

um Divalproex Sodium (Oral Tablet Delayed Release) G 1

C1

Equ

etro

Equetro (Oral Capsule Extended Release 12 Hour) B 3

C1

Lithi

um

Car

bon

ate

ER Lithium Carbonate ER (Oral Tablet Extended Release) G 1

C1

Lithi

um

Car

bon

ate Lithium Carbonate (Oral Capsule) G 1

C1

Lithi

um

Car

bon

ate Lithium Carbonate (Oral Tablet Immediate Release) G 1

C1

Lithi

um

Lithium (8MEQ/5ML Oral Solution) B 2

C1

Lith

obid

Lithobid (Oral Tablet Extended Release) B 4

A1

Blood Glucose RegulatorsB1

Antidiabetic AgentsC1

Acar

bos

e

Acarbose (Oral Tablet) G 1

C1

Acto

plus

Met

Actoplus Met (Oral Tablet Immediate Release) B 3 QL C1

Acto

s

Actos (Oral Tablet) B 3 QL C1

Adly

xin

Start

er

Pac

k Adlyxin Starter Pack (Subcutaneous Pen-Injector Kit) B 3 ST; QL C1

Adly

xin

Adlyxin (Subcutaneous Solution Pen-Injector) B 3 ST; QL C1

Alog

lipti

n

Ben

zoat

e Alogliptin Benzoate (Oral Tablet) G 3 ST; QL C1

Alog

lipti

n-

Metf

ormi

n

HCl Alogliptin-Metformin HCl (Oral Tablet) B 3 ST; QL C1

Alog

lipti

n-

Piog

litaz

one Alogliptin-Pioglitazone (Oral Tablet) G 3 ST; QL C1

Ama

ryl

Amaryl (Oral Tablet) B 3 QL C1

Byd

ureo

n

BCis

e Bydureon BCise (Subcutaneous Auto-Injector) B 3 QL



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Byet

ta

10M

CG

Pen Byetta 10MCG Pen (Subcutaneous Solution Pen-

Injector)B 3 ST; QL

C1

Byet

ta

5M

CG

Pen Byetta 5MCG Pen (Subcutaneous Solution Pen-

Injector)B 3 ST; QL

C1

Cycl

oset

Cycloset (Oral Tablet) B 3 PA C1

Due

tact

Duetact (Oral Tablet) B 3 QL C1

Farx

iga

Farxiga (Oral Tablet) B 2 QL C1

Fort

ame

t

Fortamet (1000MG Oral Tablet Extended Release 24

Hour, 500MG Oral Tablet Extended Release 24 Hour)B 4 PA; QL

C1

Glim

epiri

de

Glimepiride (Oral Tablet) G 1 QL C1

Glipi

zide

ER

Glipizide ER (Oral Tablet Extended Release 24 Hour) G 1 QL C1

Glipi

zide

Glipizide (Oral Tablet Immediate Release) G 1 QL C1

Glipi

zide-

Metf

ormi

n

HCl Glipizide-Metformin HCl (Oral Tablet) G 2 QL C1

Gluc

otrol

XL

Glucotrol XL (Oral Tablet Extended Release 24 Hour) B 3 QL C1

Glu

met

za

Glumetza (Oral Tablet Extended Release 24 Hour) B 4 PA; QL C1

Glyx

amb

i

Glyxambi (Oral Tablet) B 2 QL C1

Invo

kam

et

Invokamet (Oral Tablet Immediate Release) B 3 ST; QL C1

Invo

kam

et

XR

Invokamet XR (Oral Tablet Extended Release 24

Hour)B 3 ST; QL

C1

Invo

kan

a

Invokana (Oral Tablet) B 3 ST; QL C1

Jan

ume

t

Janumet (Oral Tablet Immediate Release) B 2 QL C1

Jan

ume

t XR

Janumet XR (Oral Tablet Extended Release 24 Hour) B 2 QL C1

Jan

uvia

Januvia (Oral Tablet) B 2 QL C1

Jard

ianc

e

Jardiance (Oral Tablet) B 2 QL C1

Jent

adu

eto

Jentadueto (Oral Tablet Immediate Release) B 2 QL C1

Jent

adu

eto

XR

Jentadueto XR (Oral Tablet Extended Release 24

Hour)B 2 QL

C1

Kaz

ano

Kazano (Oral Tablet) B 3 ST; QL C1

Ko

mbi

glyz

e

XR Kombiglyze XR (Oral Tablet Extended Release 24

Hour)B 3 QL

C1

Metf

ormi

n

HCl

ER Metformin HCl ER (1000MG Oral Tablet Extended


24 Hour) (Generic Glumetza)

G 4 PA; QL

C1

Metf

ormi

n

HCl

ER Metformin HCl ER (1000MG Oral Tablet Extended


24 Hour) (Generic Fortamet)

G 3 PA; QL

C1

Metf

ormi

n

HCl

ER Metformin HCl ER (Oral Tablet Extended Release 24

Hour) (Generic Glucophage XR)G 1 QL


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Metf

ormi

n

HCl

Metformin HCl (500MG/5ML Oral Solution) G 3 QL C1

Metf

ormi

n

HCl

Metformin HCl (1000MG Oral Tablet Immediate Release,



G 1 QL

C1

Migl

itol

Miglitol (Oral Tablet) G 3

C1

Nat

egli

nide

Nateglinide (Oral Tablet) G 2 QL C1

Nesi

na

Nesina (Oral Tablet) B 3 ST; QL C1

Ong

lyza

Onglyza (Oral Tablet) B 3 QL C1

Ose

ni

Oseni (Oral Tablet) B 3 ST; QL C1

Oze

mpi

c

Ozempic (0.25MG/DOSE or 0.5MG/DOSE)

(Subcutaneous Solution Pen-Injector)B 2 QL

C1

Oze

mpi

c

Ozempic (1MG/DOSE) (Subcutaneous Solution Pen-

Injector)B 2 QL

C1

Piog

litaz

one

HCl

Pioglitazone HCl (Oral Tablet) G 1 QL C1

Piog

litaz

one

HCl-

Glim

epiri

de Pioglitazone HCl-Glimepiride (Oral Tablet) G 3 QL C1

Piog

litaz

one

HCl-

Metf

ormi

n

HCl Pioglitazone HCl-Metformin HCl (Oral Tablet) G 3 QL C1

Qter

n

Qtern (Oral Tablet) B 3 ST; QL C1

Rep

agli

nide

Repaglinide (Oral Tablet) G 1 QL C1

Rio

met

Riomet (Oral Solution) B 3 QL C1

Ryb

elsu

s

Rybelsus (Oral Tablet) B 2 QL C1

Segl

uro

met

Segluromet (Oral Tablet) B 3 ST; QL C1

Soli

qua

Soliqua (Subcutaneous Solution Pen-Injector) B 2 QL C1

Steg

latro

Steglatro (Oral Tablet) B 3 ST; QL C1

Steg

lujan

Steglujan (Oral Tablet) B 3 ST; QL C1

Sym

linP

en

120

SymlinPen 120 (Subcutaneous Solution Pen-Injector) B 4 PA C1

Sym

linP

en

60

SymlinPen 60 (Subcutaneous Solution Pen-Injector) B 4 PA C1

Synj

ardy

Synjardy (Oral Tablet Immediate Release) B 2 QL C1

Synj

ardy

XR

Synjardy XR (Oral Tablet Extended Release 24 Hour) B 2 QL C1

Trad

jent

a

Tradjenta (Oral Tablet) B 2 QL C1

Trija

rdy

XR

Trijardy XR (Oral Tablet Extended Release 24 Hour) B 2 QL C1

Truli

city

Trulicity (Subcutaneous Solution Pen-Injector) B 2 QL C1

Vict

oza

Victoza (Subcutaneous Solution Pen-Injector) B 2 QL C1

Xigd

uo

XR

Xigduo XR (Oral Tablet Extended Release 24 Hour) B 2 QL C1

Xult

oph

y

Xultophy (Subcutaneous Solution Pen-Injector) B 3 ST; QL B1

Glycemic AgentsC1

Baq

simi

Two

Pac

k Baqsimi Two Pack (Nasal Powder) B 2



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Diaz

oxid

e

Diazoxide (Oral Suspension) G 4

C1

Gluc

aGe

n

Hyp

oKit GlucaGen HypoKit (Injection Solution Reconstituted) B 3

C1

Gluc

ago

n

Glucagon (Injection Kit) (Lilly) B 2

C1

Gvo

ke

Hyp

oPe

n 2-

Pac

k Gvoke HypoPen 2-Pack (Subcutaneous Solution Auto-

Injector)B 2

C1

Gvo

ke

PFS

Gvoke PFS (Subcutaneous Solution Prefilled Syringe) B 2

C1

Pro

glyc

em

Proglycem (Oral Suspension) B 4

B1

InsulinsC1

Ad

mel

og

Solo

Star Admelog SoloStar (Subcutaneous Solution Pen-

Injector)B 3 PA

C1

Ad

mel

og

Admelog (Subcutaneous Solution) B 3 PA C1

Afre

zza

Afrezza (12UNIT Inhalation Powder, 4 & 8 & 12UNIT

Inhalation Powder, 4 & 8UNIT Inhalation Powder, 8 &

12UNIT Inhalation Powder)

B 4 PA

C1

Afre

zza

Afrezza (4UNIT Inhalation Powder, 8UNIT Inhalation

Powder)B 3 PA

C1

Apid

ra

Apidra (Injection Solution) B 3 PA C1

Apid

ra

Solo

Star

Apidra SoloStar (Subcutaneous Solution Pen-Injector) B 3 PA C1

Bas

agla

r

Kwi

kPe

n Basaglar KwikPen (Subcutaneous Solution Pen-

Injector)B 3 ST

C1

Fias

p

Flex

Tou

ch Fiasp FlexTouch (Subcutaneous Solution Pen-

Injector)B 3 PA

C1

Fias

p

Pen

Fill

Fiasp PenFill (Subcutaneous Solution Cartridge) B 3 PA C1

Fias

p

Fiasp (Subcutaneous Solution) B 3 PA C1

Hu

mal

og

Juni

or

Kwi

kPe

n Humalog Junior KwikPen (Subcutaneous Solution

Pen-Injector)B 2

C1

Hu

mal

og

Kwi

kPe

n Humalog KwikPen (Subcutaneous Solution Pen-

Injector)B 2

C1

Hu

mal

og

Mix

50/5

0

Kwi

kPe

n Humalog Mix 50/50 KwikPen (Subcutaneous

Suspension Pen-Injector)B 2

C1

Hu

mal

og

Mix

50/5

0 Humalog Mix 50/50 (Subcutaneous Suspension) B 2

C1

Hu

mal

og

Mix

75/2

5

Kwi

kPe

n Humalog Mix 75/25 KwikPen (Subcutaneous

Suspension Pen-Injector)B 2

C1

Hu

mal

og

Mix

75/2

5 Humalog Mix 75/25 (Subcutaneous Suspension) B 2

C1

Hu

mal

og

Humalog (Subcutaneous Solution) B 2

C1

Hu

mal

og

Humalog (Subcutaneous Solution Cartridge) B 2

C1

Hu

muli

n

70/3

0

Kwi

kPe

n Humulin 70/30 KwikPen (Subcutaneous Suspension

Pen-Injector)B 2


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Hu

muli

n

70/3

0 Humulin 70/30 (Subcutaneous Suspension) B 2

C1

Hu

muli

n N

Kwi

kPe

n Humulin N KwikPen (Subcutaneous Suspension Pen-

Injector)B 2

C1

Hu

muli

n N

Humulin N (Subcutaneous Suspension) B 2

C1

Hu

muli

n R

Humulin R (Injection Solution) B 2

C1

Hu

muli

n R

U-50

0 Humulin R U-500 (Concentrated) (Subcutaneous

Solution)B 2

C1

Hu

muli

n R

U-50

0

Kwi

kPe

n Humulin R U-500 KwikPen (Subcutaneous Solution

Pen-Injector)B 2

C1

Insul

in

Asp

art

Prot

&

Asp

art

Flex

PenInsulin Aspart Prot & Aspart FlexPen (Subcutaneous

Suspension Pen-Injector) (Brand Equivalent Novolog)B 3 PA

C1

Insul

in

Asp

art

Flex

Pen Insulin Aspart FlexPen (Subcutaneous Solution Pen-

Injector) (Brand Equivalent Novolog)B 3 PA

C1

Insul

in

Asp

art

Pen

Fill Insulin Aspart PenFill (Subcutaneous Solution

Cartridge) (Brand Equivalent Novolog)B 3 PA

C1

Insul

in

Asp

art

Prot

&

Asp

art Insulin Aspart Prot & Aspart (Subcutaneous

Suspension) (Brand Equivalent Novolog)B 3 PA

C1

Insul

in

Asp

art

Insulin Aspart (Subcutaneous Solution) (Brand

Equivalent Novolog)B 3 PA

C1

Insul

in

Lisp

ro

Insulin Lispro (1 Unit Dial) (Subcutaneous Solution

Pen-Injector) (Brand Equivalent Humalog)B 2

C1

Insul

in

Lisp

ro

Juni

or

Kwi

kPe

n Insulin Lispro Junior KwikPen (Subcutaneous

Solution Pen-Injector) (Brand Equivalent Humalog)B 2

C1

Insul

in

Lisp

ro

Prot

&

Lisp

ro Insulin Lispro Prot & Lispro (Subcutaneous

Suspension Pen-Injector) (Brand Equivalent Humalog)B 2

C1

Insul

in

Lisp

ro

Insulin Lispro (Subcutaneous Solution) (Brand

Equivalent Humalog)B 2

C1

Lant

us

Solo

Star

Lantus SoloStar (Subcutaneous Solution Pen-Injector) B 2

C1

Lant

us

Lantus (Subcutaneous Solution) B 2

C1

Lev

emir

Flex

Tou

ch Levemir FlexTouch (Subcutaneous Solution Pen-

Injector)B 2

C1

Lev

emir

Levemir (Subcutaneous Solution) B 2

C1

Lyu

mje

v

Lyumjev (Injection Solution) B 2

C1

Lyu

mje

v

Kwi

kPe

n Lyumjev KwikPen (Subcutaneous Solution Pen-

Injector)B 2

C1

Nov

olin

70/3

0

Flex

Pen Novolin 70/30 FlexPen (Subcutaneous Suspension

Pen-Injector)B 3 PA



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Nov

olin

70/3

0

Novolin 70/30 (Subcutaneous Suspension) B 3 PA C1

Nov

olin

N

Flex

Pen Novolin N FlexPen (Subcutaneous Suspension Pen-

Injector)B 3 PA

C1

Nov

olin

N

Novolin N (Subcutaneous Suspension) B 3 PA C1

Nov

olin

R

Flex

Pen Novolin R FlexPen (Injection Solution Pen-Injector) B 3 PA C1

Nov

olin

R

Novolin R (Injection Solution) B 3 PA C1

Nov

oLo

g

Flex

Pen NovoLog FlexPen (Subcutaneous Solution Pen-

Injector)B 3 PA

C1

Nov

oLo

g

Mix

70/3

0

Flex

Pen NovoLog Mix 70/30 FlexPen (Subcutaneous

Suspension Pen-Injector)B 3 PA

C1

Nov

oLo

g

Mix

70/3

0 NovoLog Mix 70/30 (Subcutaneous Suspension) B 3 PA C1

Nov

oLo

g

Pen

Fill NovoLog PenFill (Subcutaneous Solution Cartridge) B 3 PA C1

Nov

oLo

g

NovoLog (Subcutaneous Solution) B 3 PA C1

Sem

glee

Semglee (Subcutaneous Solution) B 3 ST C1

Sem

glee

Semglee (Subcutaneous Solution Pen-Injector) B 3 ST C1

Touj

eo

Max

Solo

Star Toujeo Max SoloStar (Subcutaneous Solution Pen-

Injector)B 2

C1

Touj

eo

Solo

Star

Toujeo SoloStar (Subcutaneous Solution Pen-Injector) B 2

C1

Tres

iba

Flex

Tou

ch Tresiba FlexTouch (Subcutaneous Solution Pen-

Injector)B 2

C1

Tres

iba

Tresiba (Subcutaneous Solution) B 2

A1

Blood Products and ModifiersB1

AnticoagulantsC1

Arixt

ra

Arixtra (Subcutaneous Solution) B 4

C1

Eliq

uis

Eliquis (Oral Tablet) B 2 QL C1

Eliq

uis

Start

er

Pac

k Eliquis Starter Pack (Oral Tablet) B 2 QL C1

Eno

xap

arin

Sodi

um Enoxaparin Sodium (100MG/ML Subcutaneous

Solution, 120MG/0.8ML Subcutaneous Solution,

150MG/ML Subcutaneous Solution, 60MG/0.6ML

Subcutaneous Solution, 80MG/0.8ML Subcutaneous

Solution)

G 3 QL

C1

Eno

xap

arin

Sodi

um Enoxaparin Sodium (30MG/0.3ML Subcutaneous

Solution, 40MG/0.4ML Subcutaneous Solution)G 2 QL

C1

Fon

dap

arin

ux

Sodi

um Fondaparinux Sodium (10MG/0.8ML Subcutaneous

Solution, 5MG/0.4ML Subcutaneous Solution, 7.5MG/

0.6ML Subcutaneous Solution)

G 4

C1

Fon

dap

arin

ux

Sodi

um Fondaparinux Sodium (2.5MG/0.5ML Subcutaneous

Solution)G 3


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Frag

min

Fragmin (10000UNIT/ML Subcutaneous Solution,

12500UNIT/0.5ML Subcutaneous Solution,

15000UNIT/0.6ML Subcutaneous Solution,

18000UNT/0.72ML Subcutaneous Solution,

5000UNIT/0.2ML Subcutaneous Solution, 7500UNIT/

0.3ML Subcutaneous Solution, 95000UNIT/3.8ML

Subcutaneous Solution)

B 4

C1

Frag

min

Fragmin (2500UNIT/0.2ML Subcutaneous Solution) B 3

C1

Hep

arin

Sodi

um

Heparin Sodium (10000UNIT/ML Injection Solution,

20000UNIT/ML Injection Solution, 5000UNIT/ML

Injection Solution)

G 2

C1

Hep

arin

Sodi

um

Heparin Sodium (1000UNIT/ML Injection Solution) G 2 B/D, PA C1

Jant

ove

n

Jantoven (Oral Tablet) G 1

C1

Lov

eno

x

Lovenox (100MG/ML Subcutaneous Solution,

120MG/0.8ML Subcutaneous Solution, 60MG/0.6ML

Subcutaneous Solution, 80MG/0.8ML Subcutaneous

Solution)

B 4 QL

C1

Lov

eno

x

Lovenox (150MG/ML Subcutaneous Solution, 30MG/

0.3ML Subcutaneous Solution, 40MG/0.4ML


B 3 QL

C1

Prad

axa

Pradaxa (Oral Capsule) B 3 ST; QL C1

Sav

aysa

Savaysa (Oral Tablet) B 3 ST; QL C1

Warf

arin

Sodi

um

Warfarin Sodium (Oral Tablet) G 1

C1

Xare

lto

Xarelto (Oral Tablet) B 2 QL C1

Xare

lto

Start

er

Pac

k Xarelto Starter Pack (Oral Tablet Therapy Pack) B 2 QL C1

Zont

ivity

Zontivity (Oral Tablet) B 3 PA B1

Blood Products and Modifiers, OtherC1

Agry

lin

Agrylin (Oral Capsule) B 3

C1

Ana

greli

de

HCl

Anagrelide HCl (Oral Capsule) G 2

C1

Aran

esp

Aranesp (Albumin Free) (100MCG/ML Injection

Solution, 200MCG/ML Injection Solution, 300MCG/

ML Injection Solution)

B 4 PA

C1

Aran

esp

Aranesp (Albumin Free) (25MCG/ML Injection

Solution, 40MCG/ML Injection Solution, 60MCG/ML

Injection Solution)

B 3 PA



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Aran

esp

Aranesp (Albumin Free) (100MCG/0.5ML Injection

Solution Prefilled Syringe, 150MCG/0.3ML Injection



Solution Prefilled Syringe, 500MCG/ML Injection

Solution Prefilled Syringe)

B 4 PA

C1

Aran

esp

Aranesp (Albumin Free) (10MCG/0.4ML Injection




Solution Prefilled Syringe)

B 3 PA

C1

Epo

gen

Epogen (10000UNIT/ML Injection Solution,

2000UNIT/ML Injection Solution, 3000UNIT/ML

Injection Solution, 4000UNIT/ML Injection Solution)

B 3 PA

C1

Epo

gen

Epogen (20000UNIT/ML Injection Solution) B 4 PA C1

Fulp

hila

Fulphila (Subcutaneous Solution Prefilled Syringe) B 4 PA C1

Gra

nix

Granix (Subcutaneous Solution) B 4 ST C1

Gra

nix

Granix (Subcutaneous Solution Prefilled Syringe) B 4 ST C1

Leu

kine

Leukine (Injection Solution Reconstituted) B 4 PA C1

Mul

plet

a

Mulpleta (Oral Tablet) B 4 PA C1

Neul

asta

Neulasta (Subcutaneous Solution Prefilled Syringe) B 4 PA C1

Neu

pog

en

Neupogen (Injection Solution) B 4 ST C1

Neu

pog

en

Neupogen (Injection Solution Prefilled Syringe) B 4 ST C1

Nive

sty

m

Nivestym (Injection Solution) B 4 ST C1

Nive

sty

m

Nivestym (Injection Solution Prefilled Syringe) B 4 ST C1

Nyv

epri

a

Nyvepria (Subcutaneous Solution Prefilled Syringe) B 4 PA C1

Oxb

ryta

Oxbryta (Oral Tablet) B 4 PA; QL C1

Proc

rit

Procrit (10000UNIT/ML Injection Solution, 2000UNIT/

ML Injection Solution, 3000UNIT/ML Injection

Solution, 4000UNIT/ML Injection Solution)

B 3 PA

C1

Proc

rit

Procrit (20000UNIT/ML Injection Solution,

40000UNIT/ML Injection Solution)B 4 PA

C1

Pro

mac

ta

Promacta (Oral Packet) B 4 PA; LA; QL C1

Pro

mac

ta

Promacta (Oral Tablet) B 4 PA; LA; QL C1

Reta

crit

Retacrit (Injection Solution) B 3 PA C1

Sikl

os

Siklos (Oral Tablet) B 4 PA C1

Ude

nyca

Udenyca (Subcutaneous Solution Prefilled Syringe) B 4 PA C1

Zarx

io

Zarxio (Injection Solution Prefilled Syringe) B 4


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Ziex

tenz

o

Ziextenzo (Subcutaneous Solution Prefilled Syringe) B 4 PA B1

Hemostasis AgentsC1

Lyst

eda

Lysteda (Oral Tablet) B 3

C1

Tran

exa

mic

Acid

Tranexamic Acid (Oral Tablet) G 2

B1

Platelet Modifying AgentsC1

Aspi

rin-

Dipy

rida

mol

e

ER Aspirin-Dipyridamole ER (Oral Capsule Extended

Release 12 Hour)G 3 QL

C1

Brili

nta

Brilinta (Oral Tablet) B 2 QL C1

Cabl

ivi

Cablivi (Injection Kit) B 4 PA; LA; QL C1

Cilo

staz

ol

Cilostazol (Oral Tablet) G 1

C1

Clo

pido

grel

Bisu

lfate Clopidogrel Bisulfate (75MG Oral Tablet) G 1 QL C1

Dop

telet

Doptelet (Oral Tablet) B 4 PA C1

Plavi

x

Plavix (Oral Tablet) B 3 QL C1

Pras

ugre

l

HCl

Prasugrel HCl (Oral Tablet) G 2

C1

Tav

aliss

e

Tavalisse (Oral Tablet) B 4 PA; QL A1

Cardiovascular AgentsB1

Alpha-adrenergic AgonistsC1

Cata

pres

-

TTS-

1 Catapres-TTS-1 (Transdermal Patch Weekly) B 3

C1

Cata

pres

-

TTS-


C1

Cata

pres

-

TTS-


C1

Clon

idin

e

HCl

Clonidine HCl (Oral Tablet Immediate Release) G 1

C1

Clon

idin

e

Clonidine (0.1MG/24HR Transdermal Patch Weekly) G 2

C1

Clon

idin

e

Clonidine (0.2MG/24HR Transdermal Patch Weekly,

0.3MG/24HR Transdermal Patch Weekly)G 3

C1

Dro

xido

pa

Droxidopa (Oral Capsule) G 4 PA; QL C1

Met

hyld

opa

Methyldopa (Oral Tablet) G 3 PA; HRM C1

Mid

odri

ne

HCl

Midodrine HCl (Oral Tablet) G 2

C1

Nort

hera

Northera (Oral Capsule) B 4 PA; LA; QL B1

Alpha-adrenergic Blocking AgentsC1

Car

dura

Cardura (Oral Tablet Immediate Release) B 3

C1

Dibe

nzyli

ne

Dibenzyline (Oral Capsule) B 4

C1

Dox

azos

in

Mes

ylate Doxazosin Mesylate (Oral Tablet) G 1

C1

Mini

pres

s

Minipress (Oral Capsule) B 3

C1

Phe

nox

ybe

nza

min

e

HCl Phenoxybenzamine HCl (Oral Capsule) G 4

C1

Praz

osin

HCl

Prazosin HCl (Oral Capsule) G 1

B1

Angiotensin II Receptor Antagonists



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Atac

and

Atacand (Oral Tablet) B 3 QL C1

Ava

pro

Avapro (Oral Tablet) B 3 QL C1

Beni

car

Benicar (Oral Tablet) B 3 QL C1

Can

des

arta

n

Cile

xetil Candesartan Cilexetil (Oral Tablet) G 2 QL C1

Coz

aar

Cozaar (Oral Tablet) B 3 QL C1

Diov

an

Diovan (Oral Tablet) B 3 QL C1

Edar

bi

Edarbi (Oral Tablet) B 3 QL C1

Irbe

sart

an

Irbesartan (Oral Tablet) G 1 QL C1

Los

arta

n

Pota

ssiu

m Losartan Potassium (Oral Tablet) G 1 QL C1

Mic

ardi

s

Micardis (Oral Tablet) B 3 QL C1

Olm

esar

tan

Med

oxo

mil Olmesartan Medoxomil (Oral Tablet) G 1 QL C1

Tel

misa

rtan

Telmisartan (Oral Tablet) G 1 QL C1

Vals

arta

n

Valsartan (Oral Tablet) G 1 QL B1

Angiotensin-converting Enzyme (ACE) InhibitorsC1

Acc

upril

Accupril (Oral Tablet) B 3 QL C1

Alta

ce

Altace (Oral Capsule) B 3 QL C1

Ben

aze

pril

HCl

Benazepril HCl (Oral Tablet) G 1 QL C1

Cap

topri

l

Captopril (100MG Oral Tablet, 50MG Oral Tablet) G 3 QL C1

Cap

topri

l

Captopril (12.5MG Oral Tablet, 25MG Oral Tablet) G 2 QL C1

Enal

april

Mal

eate Enalapril Maleate (Oral Tablet) G 1 QL C1

Fosi

nopr

il

Sodi

um Fosinopril Sodium (Oral Tablet) G 1 QL C1

Lisin

opril

Lisinopril (Oral Tablet) G 1 QL C1

Lote

nsin

Lotensin (Oral Tablet) B 3 QL C1

Moe

xipril

HCl

Moexipril HCl (Oral Tablet) G 1 QL C1

Peri

ndo

pril

Erb

umi

ne Perindopril Erbumine (Oral Tablet) G 2 QL C1

Prini

vil

Prinivil (Oral Tablet) B 3 QL C1

Qbr

elis

Qbrelis (Oral Solution) B 4 QL C1

Quin

april

HCl

Quinapril HCl (Oral Tablet) G 1 QL C1

Ram

ipril

Ramipril (Oral Capsule) G 1 QL C1

Tran

dola

pril

Trandolapril (Oral Tablet) G 1 QL C1

Vas

otec

Vasotec (10MG Oral Tablet, 20MG Oral Tablet) B 4 QL C1

Vas

otec

Vasotec (2.5MG Oral Tablet, 5MG Oral Tablet) B 3 QL C1

Zest

ril

Zestril (Oral Tablet) B 3 QL B1

AntiarrhythmicsC1

Ami

odar

one

HCl

Amiodarone HCl (100MG Oral Tablet, 400MG Oral

Tablet)G 3

C1

Ami

odar

one

HCl

Amiodarone HCl (200MG Oral Tablet) G 1


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Beta

pac

e AF

Betapace AF (120MG Oral Tablet, 160MG Oral Tablet) B 4

C1

Beta

pac

e AF

Betapace AF (80MG Oral Tablet) B 3

C1

Dof

etili

de

Dofetilide (Oral Capsule) G 2

C1

Flec

aini

de

Acet

ate Flecainide Acetate (Oral Tablet) G 1

C1

Mex

iletin

e

HCl

Mexiletine HCl (Oral Capsule) G 2

C1

Mult

aq

Multaq (Oral Tablet) B 2

C1

Pac

eron

e

Pacerone (100MG Oral Tablet, 400MG Oral Tablet) G 3

C1

Pac

eron

e

Pacerone (200MG Oral Tablet) G 1

C1

Pro

pafe

non

e

HCl

ER Propafenone HCl ER (Oral Capsule Extended Release

12 Hour)G 3

C1

Pro

pafe

non

e

HCl Propafenone HCl (Oral Tablet) G 2

C1

Quin

idin

e

Gluc

onat

e

ER Quinidine Gluconate ER (Oral Tablet Extended Release) G 3

C1

Quin

idin

e

Sulf

ate Quinidine Sulfate (Oral Tablet) G 1

C1

Ryth

mol

SR

Rythmol SR (Oral Capsule Extended Release 12 Hour) B 4

C1

Sori

ne

Sorine (Oral Tablet) G 1

C1

Sota

lol

HCl

AF

Sotalol HCl AF (Oral Tablet) G 1

C1

Sota

lol

HCl

Sotalol HCl (Oral Tablet) G 1

C1

Soty

lize

Sotylize (Oral Solution) B 3 PA C1

Tiko

syn

Tikosyn (Oral Capsule) B 3

B1

Beta-adrenergic Blocking AgentsC1

Ace

buto

lol

HCl

Acebutolol HCl (Oral Capsule) G 2

C1

Aten

olol

Atenolol (Oral Tablet) G 1

C1

Beta

xolo

l

HCl

Betaxolol HCl (Oral Tablet) G 2

C1

Biso

prol

ol

Fum

arat

e Bisoprolol Fumarate (Oral Tablet) G 1

C1

Byst

olic

Bystolic (Oral Tablet) B 2 QL C1

Carv

edil

ol

Carvedilol (Oral Tablet) G 1

C1

Carv

edil

ol

Pho

sph

ate

ER Carvedilol Phosphate ER (Oral Capsule Extended

Release 24 Hour)G 3

C1

Cor

eg

CR

Coreg CR (Oral Capsule Extended Release 24 Hour) B 3

C1

Cor

eg

Coreg (Oral Tablet) B 3

C1

Cor

gard

Corgard (Oral Tablet) B 3

C1

Inde

ral

LA

Inderal LA (Oral Capsule Extended Release 24 Hour) B 4

C1

Inno

Pran

XL

InnoPran XL (Oral Capsule Extended Release 24

Hour)B 4

C1

Lab

etal

ol

HCl

Labetalol HCl (Oral Tablet) G 1

C1

Lopr

ess

or

Lopressor (Oral Tablet) B 3



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Met

opr

olol

Suc

cina

te

ER Metoprolol Succinate ER (Oral Tablet Extended Release

24 Hour)G 1

C1

Met

opr

olol

Tartr

ate Metoprolol Tartrate (100MG Oral Tablet, 25MG Oral

Tablet, 50MG Oral Tablet)G 1

C1

Met

opr

olol

Tartr

ate Metoprolol Tartrate (37.5MG Oral Tablet, 75MG Oral

Tablet)G 2

C1

Nad

olol

Nadolol (Oral Tablet) G 2

C1

Pind

olol

Pindolol (Oral Tablet) G 2

C1

Pro

pran

olol

HCl

ER Propranolol HCl ER (Oral Capsule Extended Release 24

Hour)G 2

C1

Pro

pran

olol

HCl

Propranolol HCl (Oral Solution) G 1

C1

Pro

pran

olol

HCl

Propranolol HCl (Oral Tablet) G 1

C1

Ten

ormi

n

Tenormin (Oral Tablet) B 3

C1

Top

rol

XL

Toprol XL (Oral Tablet Extended Release 24 Hour) B 3

B1

Calcium Channel Blocking Agents, DihydropyridinesC1

Aml

odip

ine

Bes

ylate Amlodipine Besylate (Oral Tablet) G 1

C1

Felo

dipi

ne

ER

Felodipine ER (Oral Tablet Extended Release 24 Hour) G 1

C1

Isra

dipi

ne

Isradipine (Oral Capsule) G 3

C1

Kate

rzia

Katerzia (Oral Suspension) B 4 ST C1

Nica

rdipi

ne

HCl

Nicardipine HCl (Oral Capsule) G 3

C1

Nife

dipi

ne

ER

Nifedipine ER (Oral Tablet Extended Release 24 Hour) G 1

C1

Nife

dipi

ne

ER

Os

moti

c

Rele

ase Nifedipine ER Osmotic Release (Oral Tablet Extended

Release 24 Hour)G 1

C1

Nim

odip

ine

Nimodipine (Oral Capsule) G 3

C1

Niso

ldipi

ne

ER

Nisoldipine ER (Oral Tablet Extended Release 24 Hour) G 3

C1

Nor

vasc

Norvasc (Oral Tablet) B 3

C1

Nym

alize

Nymalize (6MG/ML Oral Solution) B 4

C1

Proc

ardi

a XL

Procardia XL (Oral Tablet Extended Release 24 Hour) B 3

C1

Sula

r

Sular (Oral Tablet Extended Release 24 Hour) B 4

B1

Calcium Channel Blocking Agents, NondihydropyridinesC1

Cala

n

SR

Calan SR (Oral Tablet Extended Release) B 3

C1

Car

dize

m

CD

Cardizem CD (Oral Capsule Extended Release 24

Hour)B 4

C1

Car

dize

m

LA

Cardizem LA (Oral Tablet Extended Release 24 Hour) B 3

C1

Car

dize

m

Cardizem (Oral Tablet Immediate Release) B 4

C1

Carti

a XT

Cartia XT (Oral Capsule Extended Release 24 Hour) G 1


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Dilti

aze

m

HCl

ER

Bea

ds Diltiazem HCl ER Beads (360MG Oral Capsule Extended


Release 24 Hour)

G 1

C1

Dilti

aze

m

HCl

ER

Coa

ted

Bea

ds Diltiazem HCl ER Coated Beads (120MG Oral Capsule





G 1

C1

Dilti

aze

m

HCl

ER

Coa

ted

Bea

ds Diltiazem HCl ER Coated Beads (180MG Oral Tablet





G 2

C1

Dilti

aze

m

HCl

ER Diltiazem HCl ER (Oral Capsule Extended Release 12

Hour)G 2

C1

Dilti

aze

m

HCl

Diltiazem HCl (Oral Tablet Immediate Release) G 1

C1

Dilt-

XR

Dilt-XR (Oral Capsule Extended Release 24 Hour) G 1

C1

Mat

zim

LA

Matzim LA (Oral Tablet Extended Release 24 Hour) G 2

C1

Tazt

ia

XT

Taztia XT (Oral Capsule Extended Release 24 Hour) G 1

C1

Tiad

ylt

ER

Tiadylt ER (Oral Capsule Extended Release 24 Hour) G 1

C1

Tiaz

ac

Tiazac (Oral Capsule Extended Release 24 Hour) B 3

C1

Vera

pam

il

HCl

ER Verapamil HCl ER (100MG Oral Capsule Extended




Release 24 Hour)

B 3

C1

Vera

pam

il

HCl

ER Verapamil HCl ER (120MG Oral Capsule Extended



Release 24 Hour)

G 2

C1

Vera

pam

il

HCl

ER Verapamil HCl ER (Oral Tablet Extended Release) G 1

C1

Vera

pam

il

HCl

Verapamil HCl (Oral Tablet Immediate Release) G 1

C1

Vere

lan

Verelan (Oral Capsule Extended Release 24 Hour) B 3

C1

Vere

lan

PM

Verelan PM (Oral Capsule Extended Release 24 Hour) B 3

B1

Cardiovascular Agents, OtherC1

Acc

ureti

c

Accuretic (Oral Tablet) B 3 QL C1

Acet

azol

ami

de

ER Acetazolamide ER (Oral Capsule Extended Release 12

Hour)G 2

C1

Acet

azol

ami

de

Acetazolamide (Oral Tablet) G 2



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Alda

ctazi

de

Aldactazide (Oral Tablet) B 3

C1

Alis

kire

n

Fum

arat

e Aliskiren Fumarate (Oral Tablet) G 3 QL C1

Amil

orid

e-

Hyd

roch

lorot

hiazi

de Amiloride-Hydrochlorothiazide (Oral Tablet) G 1

C1

Aml

odip

ine-

Ator

vast

atin Amlodipine-Atorvastatin (Oral Tablet) G 3 QL C1

Aml

odip

ine-

Ben

aze

pril Amlodipine-Benazepril (Oral Capsule) G 1 QL C1

Aml

odip

ine-

Olm

esar

tan Amlodipine-Olmesartan (Oral Tablet) G 2 QL C1

Aml

odip

ine-

Vals

arta

n Amlodipine-Valsartan (Oral Tablet) G 2 QL C1

Aml

odip

ine-

Vals

arta

n-

HCT

Z Amlodipine-Valsartan-HCTZ (Oral Tablet) G 3

C1

Atac

and

HCT

Atacand HCT (Oral Tablet) B 3 QL C1

Aten

olol-

Chlo

rthal

idon

e Atenolol-Chlorthalidone (Oral Tablet) G 1

C1

Aval

ide

Avalide (Oral Tablet) B 3 QL C1

Azor

Azor (Oral Tablet) B 3 QL C1

Ben

aze

pril-

Hyd

roch

lorot

hiazi

de Benazepril-Hydrochlorothiazide (Oral Tablet) G 2 QL C1

Beni

car

HCT

Benicar HCT (Oral Tablet) B 3 QL C1

BiDil

BiDil (Oral Tablet) B 2

C1

Biso

prol

ol-

Hyd

roch

lorot

hiazi

de Bisoprolol-Hydrochlorothiazide (Oral Tablet) G 1 QL C1

Cad

uet

Caduet (Oral Tablet) B 3 QL C1

Can

des

arta

n

Cile

xetil-

HCT

Z Candesartan Cilexetil-HCTZ (Oral Tablet) G 3 QL C1

Corl

anor

Corlanor (Oral Solution) B 3 PA; QL C1

Corl

anor

Corlanor (Oral Tablet) B 3 PA; QL C1

De

mse

r

Demser (Oral Capsule) B 4

C1

Digit

ek

Digitek (125MCG Oral Tablet) G 3 HRM; QL C1

Digit

ek

Digitek (250MCG Oral Tablet) G 3 PA; HRM C1

Dig

ox

Digox (125MCG Oral Tablet) G 3 HRM; QL C1

Dig

ox

Digox (250MCG Oral Tablet) G 3 PA; HRM C1

Dig

oxin

Digoxin (Oral Solution) G 3 PA; HRM; QL C1

Dig

oxin

Digoxin (125MCG Oral Tablet) G 3 HRM; QL C1

Dig

oxin

Digoxin (250MCG Oral Tablet) G 3 PA; HRM C1

Diov

an

HCT

Diovan HCT (Oral Tablet) B 3 QL C1

DUT

OP

ROL

DUTOPROL (Oral Tablet Extended Release 24 Hour) B 3

C1

Edar

bycl

or

Edarbyclor (Oral Tablet) B 3 QL C1

Enal

april

-

Hyd

roch

lorot

hiazi

de Enalapril-Hydrochlorothiazide (Oral Tablet) G 1 QL C1

Entr

esto

Entresto (Oral Tablet) B 2 QL C1

Exfo

rge

HCT

Exforge HCT (Oral Tablet) B 3

C1

Exfo

rge

Exforge (Oral Tablet) B 3 QL C1

Fosi

nopr

il

Sodi

um-

HCT

Z Fosinopril Sodium-HCTZ (Oral Tablet) G 2 QL C1

Hyz

aar

Hyzaar (Oral Tablet) B 3 QL


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Irbe

sart

an-

Hyd

roch

lorot

hiazi

de Irbesartan-Hydrochlorothiazide (Oral Tablet) G 1 QL C1

Lan

oxin

Lanoxin (125MCG Oral Tablet, 62.5MCG Oral Tablet) B 3 HRM; QL C1

Lan

oxin

Lanoxin (250MCG Oral Tablet) B 3 PA; HRM C1

Lisin

opril

-

Hyd

roch

lorot

hiazi

de Lisinopril-Hydrochlorothiazide (Oral Tablet) G 1 QL C1

Los

arta

n

Pota

ssiu

m-

HCT

Z Losartan Potassium-HCTZ (Oral Tablet) G 1 QL C1

Lotr

el

Lotrel (Oral Capsule) B 3 QL C1

Max

zide

Maxzide (Oral Tablet) B 3

C1

Max

zide-

25

Maxzide-25 (Oral Tablet) B 3

C1

Met

opr

olol-

Hyd

roch

lorot

hiazi

de Metoprolol-Hydrochlorothiazide (Oral Tablet) G 2

C1

Met

yros

ine

Metyrosine (Oral Capsule) G 4

C1

Mic

ardi

s

HCT

Micardis HCT (Oral Tablet) B 3 QL C1

Olm

esar

tan

Med

oxo

mil-

HCT

Z Olmesartan Medoxomil-HCTZ (Oral Tablet) G 1 QL C1

Olm

esar

tan-

Aml

odip

ine-

HCT

Z Olmesartan-Amlodipine-HCTZ (Oral Tablet) G 3 QL C1

Pent

oxify

lline

ER

Pentoxifylline ER (Oral Tablet Extended Release) G 1

C1

Quin

april

-

Hyd

roch

lorot

hiazi

de Quinapril-Hydrochlorothiazide (Oral Tablet) G 1 QL C1

Ran

exa

Ranexa (Oral Tablet Extended Release 12 Hour) B 3 ST C1

Ran

olazi

ne

ER

Ranolazine ER (Oral Tablet Extended Release 12 Hour) G 2

C1

Spir

onol

acto

ne-

HCT

Z Spironolactone-HCTZ (Oral Tablet) G 1

C1

Tekt

urna

HCT

Tekturna HCT (Oral Tablet) B 3 QL C1

Tekt

urna

Tekturna (Oral Tablet) B 3 QL C1

Tel

misa

rtan-

Aml

odip

ine Telmisartan-Amlodipine (Oral Tablet) G 3 QL C1

Tel

misa

rtan-

HCT

Z Telmisartan-HCTZ (Oral Tablet) G 3 QL C1

Ten

oreti

c

100

Tenoretic 100 (Oral Tablet) B 3

C1

Ten

oreti

c 50

Tenoretic 50 (Oral Tablet) B 3

C1

Tran

dola

pril-

Vera

pam

il

HCl

ER Trandolapril-Verapamil HCl ER (Oral Tablet Extended

Release)G 3 QL

C1

Tria

mter

ene-

HCT

Z Triamterene-HCTZ (Oral Capsule) G 1

C1

Tria

mter

ene-

HCT

Z Triamterene-HCTZ (Oral Tablet) G 1

C1

Trib

enz

or

Tribenzor (Oral Tablet) B 3 QL C1

Twy

nsta

Twynsta (Oral Tablet) B 3 QL C1

Vals

arta

n-

Hyd

roch

lorot

hiazi

de Valsartan-Hydrochlorothiazide (Oral Tablet) G 1 QL C1

Vas

ereti

c

Vaseretic (Oral Tablet) B 3 QL C1

Vec

amyl

Vecamyl (Oral Tablet) G 4 PA C1

Zest

oreti

c

Zestoretic (Oral Tablet) B 3 QL C1

Ziac

Ziac (Oral Tablet) B 3 QL B1

Diuretics, Loop



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Bum

etan

ide

Bumetanide (Injection Solution) G 1

C1

Bum

etan

ide

Bumetanide (Oral Tablet) G 2

C1

Ede

crin

Edecrin (Oral Tablet) B 4

C1

Etha

cryn

ic

Acid

Ethacrynic Acid (Oral Tablet) G 3

C1

Furo

sem

ide

Furosemide (Injection Solution) G 1 B/D, PA C1

Furo

sem

ide

Furosemide (Oral Solution) G 1

C1

Furo

sem

ide

Furosemide (Oral Tablet) G 1

C1

Lasi

x

Lasix (Oral Tablet) B 3

C1

Tors

emi

de

Torsemide (Oral Tablet) G 1

B1

Diuretics, Potassium-sparingC1

Alda

cton

e

Aldactone (Oral Tablet) B 3

C1

Amil

orid

e

HCl

Amiloride HCl (Oral Tablet) G 1

C1

Car

oSpi

r

CaroSpir (Oral Suspension) B 3

C1

Dyre

niu

m

Dyrenium (Oral Capsule) B 3

C1

Eple

reno

ne

Eplerenone (25MG Oral Tablet) G 2

C1

Eple

reno

ne

Eplerenone (50MG Oral Tablet) G 3

C1

Insp

ra

Inspra (Oral Tablet) B 3

C1

Spir

onol

acto

ne

Spironolactone (Oral Tablet) G 1

C1

Tria

mter

ene

Triamterene (Oral Capsule) G 3

B1

Diuretics, ThiazideC1

Chlo

rthal

idon

e

Chlorthalidone (Oral Tablet) G 1

C1

Diuri

l

Diuril (Oral Suspension) B 3

C1

Hyd

roch

lorot

hiazi

de Hydrochlorothiazide (Oral Capsule) G 1

C1

Hyd

roch

lorot

hiazi

de Hydrochlorothiazide (Oral Tablet) G 1

C1

Inda

pam

ide

Indapamide (Oral Tablet) G 1

C1

Met

olaz

one

Metolazone (Oral Tablet) G 2

B1

Dyslipidemics, Fibric Acid DerivativesC1

Anta

ra

Antara (Oral Capsule) B 3

C1

Fen

ofibr

ate

Micr

oniz

ed Fenofibrate Micronized (130MG Oral Capsule) G 3

C1

Fen

ofibr

ate

Micr

oniz

ed Fenofibrate Micronized (134MG Oral Capsule, 200MG

Oral Capsule, 43MG Oral Capsule, 67MG Oral Capsule)G 2

C1

Fen

ofibr

ate

Fenofibrate (50MG Oral Capsule) G 2

C1

Fen

ofibr

ate

Fenofibrate (150MG Oral Capsule) G 3

C1

Fen

ofibr

ate

Fenofibrate (120MG Oral Tablet, 40MG Oral Tablet) G 3

C1

Fen

ofibr

ate


C1

Fen

ofibr

ate


C1

Fen

ofibr

ic

Acid

Fenofibric Acid (Oral Capsule Delayed Release) G 2


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Fen

ogli

de

Fenoglide (120MG Oral Tablet) B 4

C1

Fen

ogli

de

Fenoglide (40MG Oral Tablet) B 3

C1

Ge

mfib

rozil

Gemfibrozil (Oral Tablet) G 1

C1

Lipo

fen

Lipofen (Oral Capsule) B 3

C1

Lopi

d

Lopid (Oral Tablet) B 3

C1

Tric

or

Tricor (Oral Tablet) B 3

C1

Trili

pix

Trilipix (Oral Capsule Delayed Release) B 3

B1

Dyslipidemics, HMG CoA Reductase InhibitorsC1

Alto

prev

Altoprev (Oral Tablet Extended Release 24 Hour) B 4 QL C1

Ator

vast

atin

Calc

ium Atorvastatin Calcium (Oral Tablet) G 1 QL C1

Cres

tor

Crestor (Oral Tablet) B 3 QL C1

Ezall

or

Spri

nkle

Ezallor Sprinkle (Oral Capsule Sprinkle) B 3 QL C1

FloL

ipid

FloLipid (Oral Suspension) B 3 QL C1

Fluv

asta

tin

Sodi

um

ER Fluvastatin Sodium ER (Oral Tablet Extended Release 24

Hour)G 3 QL

C1

Fluv

asta

tin

Sodi

um Fluvastatin Sodium (Oral Capsule) G 3 QL C1

Les

col

XL

Lescol XL (Oral Tablet Extended Release 24 Hour) B 3 QL C1

Lipit

or

Lipitor (Oral Tablet) B 3 QL C1

Lival

o

Livalo (Oral Tablet) B 2 QL C1

Lov

asta

tin

Lovastatin (Oral Tablet) G 1 QL C1

Prav

asta

tin

Sodi

um Pravastatin Sodium (Oral Tablet) G 1 QL C1

Ros

uvas

tatin

Calc

ium Rosuvastatin Calcium (Oral Tablet) G 1 QL C1

Sim

vast

atin

Simvastatin (Oral Tablet) G 1 QL C1

Zoc

or

Zocor (Oral Tablet) B 3 QL C1

Zypi

tam

ag

Zypitamag (Oral Tablet) B 3 ST; QL B1

Dyslipidemics, OtherC1

Chol

esty

rami

ne

Ligh

t Cholestyramine Light (Oral Powder) G 3

C1

Chol

esty

rami

ne

Cholestyramine (Oral Packet) G 3

C1

Cole

seve

lam

HCl

Colesevelam HCl (Oral Packet) G 3

C1

Cole

seve

lam

HCl

Colesevelam HCl (Oral Tablet) G 3

C1

Cole

stid

Colestid (Oral Packet) B 3

C1

Cole

stid

Colestid (Oral Tablet) B 3

C1

Cole

stip

ol

HCl

Colestipol HCl (Oral Packet) G 3

C1

Cole

stip

ol

HCl

Colestipol HCl (Oral Tablet) G 2

C1

Ezet

imib

e

Ezetimibe (Oral Tablet) G 1

C1

Ezet

imib

e-

Sim

vast

atin Ezetimibe-Simvastatin (Oral Tablet) G 3 QL



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Icos

ape

nt

Ethy

l Icosapent Ethyl (Oral Capsule) G 3

C1

Juxt

apid

Juxtapid (10MG Oral Capsule, 20MG Oral Capsule,

30MG Oral Capsule, 5MG Oral Capsule)B 4 PA; LA

C1

Lov

aza

Lovaza (Oral Capsule) B 3

C1

Nexl

etol

Nexletol (Oral Tablet) B 3 PA; QL C1

Nexl

izet

Nexlizet (Oral Tablet) B 3 PA; QL C1

Niac

in

ER

Niacin ER (Antihyperlipidemic) (1000MG Oral Tablet

Extended Release, 750MG Oral Tablet Extended

Release)

G 3

C1

Niac

in

ER

Niacin ER (Antihyperlipidemic) (500MG Oral Tablet

Extended Release)G 1

C1

Niac

or

Niacor (Oral Tablet) G 3

C1

Nias

pan

Niaspan (Oral Tablet Extended Release) B 3

C1

Om

ega-

3-

Acid

Ethy

l

Este

rs Omega-3-Acid Ethyl Esters (Oral Capsule) (Generic

Lovaza)G 2

C1

Pral

uent

Praluent (Subcutaneous Solution Auto-Injector) B 2 PA; LA; QL C1

Prev

alite

Prevalite (Oral Packet) G 3

C1

Que

stra

n

Ligh

t Questran Light (Oral Powder) G 3

C1

Que

stra

n

Questran (Oral Packet) G 3

C1

Rep

atha

Pus

htro

nex

Syst

em Repatha Pushtronex System (Subcutaneous Solution

Cartridge)B 2 PA; QL

C1

Rep

atha

Repatha (Subcutaneous Solution Prefilled Syringe) B 2 PA; QL C1

Rep

atha

Sure

Clic

k Repatha SureClick (Subcutaneous Solution Auto-

Injector)B 2 PA; QL

C1

Ros

zet

Roszet (Oral Tablet) B 3 ST; QL C1

Vas

cep

a

Vascepa (Oral Capsule) B 3

C1

Vyto

rin

Vytorin (Oral Tablet) B 3 QL C1

Wel

chol

Welchol (Oral Packet) B 3

C1

Wel

chol

Welchol (Oral Tablet) B 3

C1

Zeti

a

Zetia (Oral Tablet) B 3

B1

Vasodilators, Direct-acting ArterialC1

Hyd

ralaz

ine

HCl

Hydralazine HCl (Oral Tablet) G 1

C1

Min

oxid

il

Minoxidil (Oral Tablet) G 1

B1

Vasodilators, Direct-acting Arterial/VenousC1

GoN

itro

GoNitro (Sublingual Packet) B 3

C1

Isor

dil

Titra

dos

e Isordil Titradose (Oral Tablet) B 4


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Isos

orbi

de

Dinit

rate Isosorbide Dinitrate (10MG Oral Tablet Immediate

Release, 20MG Oral Tablet Immediate Release, 30MG

Oral Tablet Immediate Release, 5MG Oral Tablet

Immediate Release)

G 1

C1

Isos

orbi

de

Dinit

rate Isosorbide Dinitrate (40MG Oral Tablet Immediate

Release)G 4

C1

Isos

orbi

de

Mon

onitr

ate

ER Isosorbide Mononitrate ER (Oral Tablet Extended

Release 24 Hour)G 1

C1

Isos

orbi

de

Mon

onitr

ate Isosorbide Mononitrate (Oral Tablet Immediate Release) G 1

C1

Mini

tran

Minitran (Transdermal Patch 24 Hour) G 1

C1

Nitr

o-

Bid

Nitro-Bid (Transdermal Ointment) G 3

C1

Nitr

o-

Dur

Nitro-Dur (Transdermal Patch 24 Hour) B 3

C1

Nitr

ogly

ceri

n

Nitroglycerin (Tablet Sublingual) G 1

C1

Nitr

ogly

ceri

n

Nitroglycerin (Transdermal Patch 24 Hour) G 1

C1

Nitr

ogly

ceri

n

Nitroglycerin (Translingual Solution) G 3

C1

Nitr

olin

gual

Nitrolingual (Translingual Solution) B 3

C1

Nitr

osta

t

Nitrostat (Tablet Sublingual) B 3

C1

Rect

iv

Rectiv (Rectal Ointment) B 3 QL C1

Ver

quv

o

Verquvo (Oral Tablet) B 3 PA; QL A1

Central Nervous System AgentsB1

Attention Deficit Hyperactivity Disorder Agents, AmphetaminesC1

Add

erall

Adderall (20MG Oral Tablet, 5MG Oral Tablet, 7.5MG

Oral Tablet)G 3 QL

C1

Add

erall

XR

Adderall XR (Oral Capsule Extended Release 24 Hour) B 3 QL C1

Adz

enys

ER

Adzenys ER (Oral Suspension Extended Release) B 3 QL C1

Adz

enys

XR-

ODT

Adzenys XR-ODT (Oral Tablet Extended Release

Dispersible)B 3 QL

C1

Am

phet

ami

ne

ER Amphetamine ER (Oral Suspension Extended Release) G 3 QL C1

Am

phet

ami

ne

Sulf

ate Amphetamine Sulfate (Oral Tablet) G 3

C1

Am

phet

ami

ne-

Dext

roa

mph

eta

min

e

ER

Amphetamine-Dextroamphetamine ER (Oral Capsule

Extended Release 24 Hour)G 2 QL

C1

Am

phet

ami

ne-

Dext

roa

mph

eta

min

eAmphetamine-Dextroamphetamine (Oral Tablet) G 2 QL

C1

Des

oxy

n

Desoxyn (Oral Tablet) B 4 PA C1

Dex

edri

ne

Dexedrine (Oral Capsule Extended Release 24 Hour) B 4 QL C1

Dext

roa

mph

eta

min

e

Sulf

ate

ER Dextroamphetamine Sulfate ER (Oral Capsule Extended

Release 24 Hour)G 3 QL

C1

Dext

roa

mph

eta

min

e

Sulf

ate Dextroamphetamine Sulfate (Oral Solution) G 3



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Dext

roa

mph

eta

min

e

Sulf

ate Dextroamphetamine Sulfate (Oral Tablet) G 2 QL C1

Dya

nav

el

XR

Dyanavel XR (Oral Suspension Extended Release) B 3 QL C1

Eve

keo

ODT

Evekeo ODT (Oral Tablet Dispersible) B 3

C1

Eve

keo

Evekeo (Oral Tablet) G 3

C1

Met

ham

phet

ami

ne

HCl Methamphetamine HCl (Oral Tablet) G 4 PA C1

Myd

ayis

Mydayis (Oral Capsule Extended Release 24 Hour) B 3 QL C1

Pro

Cen

tra

ProCentra (Oral Solution) G 3

C1

Vyv

ans

e

Vyvanse (Oral Capsule) B 3

C1

Vyv

ans

e

Vyvanse (Oral Tablet Chewable) B 3

C1

Zen

zedi

Zenzedi (Oral Tablet) G 3 QL B1

Attention Deficit Hyperactivity Disorder Agents, Non-amphetaminesC1

Apt

ensi

o

XR

Aptensio XR (Oral Capsule Extended Release 24

Hour)B 3 QL

C1

Ato

mox

etin

e

HCl Atomoxetine HCl (Oral Capsule) G 3

C1

Clon

idin

e

HCl

ER Clonidine HCl ER (Oral Tablet Extended Release 12

Hour)G 3 PA

C1

Con

cert

a

Concerta (Oral Tablet Extended Release) B 3 QL C1

Cot

emp

la

XR-

ODT Cotempla XR-ODT (Oral Tablet Extended Release

Dispersible)B 3 QL

C1

Dayt

rana

Daytrana (Transdermal Patch) B 3 QL C1

Dex

met

hylp

heni

date

HCl

ER Dexmethylphenidate HCl ER (Oral Capsule Extended

Release 24 Hour)G 3

C1

Dex

met

hylp

heni

date

HCl Dexmethylphenidate HCl (Oral Tablet) G 2 QL C1

Foc

alin

Focalin (Oral Tablet) B 3 QL C1

Foc

alin

XR

Focalin XR (Oral Capsule Extended Release 24 Hour) B 3

C1

Jorn

ay

PM

Jornay PM (Oral Capsule Extended Release 24 Hour) B 3 QL C1

Kap

vay

Kapvay (Oral Tablet Extended Release 12 Hour) B 3 PA C1

Met

hylin

Methylin (Oral Solution) B 3 QL C1

Met

hylp

heni

date

HCl

CD Methylphenidate HCl CD (Oral Capsule Extended

Release) (Generic Metadate CD)G 3

C1

Met

hylp

heni

date

HCl

LA Methylphenidate HCl LA (Oral Capsule Extended

Release 24 Hour) (Generic Ritalin LA)G 3

C1

Met

hylp

heni

date

HCl

ER Methylphenidate HCl ER (XR) (Oral Capsule Extended

Release 24 Hour) (Brand Equivalent Aptensio XR)G 3 QL

C1

Met

hylp

heni

date

HCl

ER

Os

moti

c

Rele

ase

Methylphenidate HCl ER Osmotic Release (Oral Tablet

Extended Release)G 3 QL

C1

Met

hylp

heni

date

HCl

ER Methylphenidate HCl ER (Oral Tablet Extended Release

24 Hour)G 3 QL


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Met

hylp

heni

date

HCl Methylphenidate HCl (Oral Solution) G 3 QL C1

Met

hylp

heni

date

HCl Methylphenidate HCl (Oral Tablet Immediate Release)

(Generic Ritalin)G 2 QL

C1

Met

hylp

heni

date

HCl Methylphenidate HCl (Oral Tablet Chewable) G 3 QL C1

Quill

iChe

w

ER

QuilliChew ER (Oral Tablet Chewable Extended

Release)B 3 QL

C1

Quill

ivant

XR

Quillivant XR (Oral Suspension Reconstituted) B 3

C1

Rele

xxii

Relexxii (Oral Tablet Extended Release) G 3 QL C1

Rital

in

LA

Ritalin LA (Oral Capsule Extended Release 24 Hour) B 3

C1

Rital

in

Ritalin (Oral Tablet) B 3 QL C1

Strat

tera

Strattera (Oral Capsule) B 3

B1

Central Nervous System, OtherC1

Aust

edo

Austedo (Oral Tablet) B 4 PA; LA; QL C1

Fird

aps

e

Firdapse (Oral Tablet) B 4 PA; LA; QL C1

Grali

se

Gralise (Oral Tablet) B 3 PA C1

Hori

zant

Horizant (Oral Tablet Extended Release) B 3 PA C1

Ingr

ezza

Ingrezza (40MG Oral Capsule, 80MG Oral Capsule) B 4 PA; QL C1

Ingr

ezza

Ingrezza (Oral Capsule Therapy Pack) B 4 PA; QL C1

Nue

dext

a

Nuedexta (Oral Capsule) B 3 PA; QL C1

Rilut

ek

Rilutek (Oral Tablet) B 4

C1

Rilu

zole

Riluzole (Oral Tablet) G 2

C1

Ruz

urgi

Ruzurgi (Oral Tablet) B 4 PA; QL C1

Tetr

abe

nazi

ne

Tetrabenazine (Oral Tablet) G 4 PA; LA C1

Tigl

utik

Tiglutik (Oral Suspension) B 4 PA C1

Xen

azin

e

Xenazine (Oral Tablet) B 4 PA; LA B1

Fibromyalgia AgentsC1

Cym

balt

a

Cymbalta (Oral Capsule Delayed Release Particles) B 3 QL C1

Driz

alm

a

Spri

nkle Drizalma Sprinkle (Oral Capsule Delayed Release

Sprinkle)B 3 ST; QL

C1

Dulo

xeti

ne

HCl

Duloxetine HCl (20MG Oral Capsule Delayed Release

Particles, 30MG Oral Capsule Delayed Release Particles,

60MG Oral Capsule Delayed Release Particles)

G 1 QL

C1

Dulo

xeti

ne

HCl

Duloxetine HCl (40MG Oral Capsule Delayed Release

Particles)G 3 QL

C1

Lyri

ca

CR

Lyrica CR (Oral Tablet Extended Release 24 Hour) B 3 PA; QL C1

Lyri

ca

Lyrica (Oral Capsule) B 3 ST; QL



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Lyri

ca

Lyrica (Oral Solution) B 3 ST; QL C1

Pre

gab

alin

ER

Pregabalin ER (Oral Tablet Extended Release 24 Hour) G 3 PA; QL C1

Pre

gab

alin

Pregabalin (Oral Capsule) G 2 QL C1

Pre

gab

alin

Pregabalin (Oral Solution) G 2 QL C1

Sav

ella

Savella (Oral Tablet) B 2

C1

Sav

ella

Titra

tion

Pac

k Savella Titration Pack (Oral Tablet) B 2

B1

Multiple Sclerosis AgentsC1

Am

pyra

Ampyra (Oral Tablet Extended Release 12 Hour) B 4 QL C1

Aub

agio

Aubagio (Oral Tablet) B 4 LA; QL C1

Avo

nex

Pen

Avonex Pen (Intramuscular Auto-Injector Kit) B 4

C1

Avo

nex

Prefi

lled

Avonex Prefilled (Intramuscular Prefilled Syringe Kit) B 4

C1

Bafi

erta

m

Bafiertam (Oral Capsule Delayed Release) B 4 ST; QL C1

Beta

sero

n

Betaseron (Subcutaneous Kit) B 4

C1

Cop

axo

ne

Copaxone (Subcutaneous Solution Prefilled Syringe) B 4

C1

Dalf

amp

ridin

e

ER Dalfampridine ER (Oral Tablet Extended Release 12

Hour)G 2 QL

C1

Dim

ethy

l

Fum

arat

e Dimethyl Fumarate (120MG Oral Capsule Delayed

Release, 240MG Oral Capsule Delayed Release)G 4 QL

C1

Dim

ethy

l

Fum

arat

e

Start

er

Pac

kDimethyl Fumarate Starter Pack (Oral Capsule) G 4

C1

Exta

via

Extavia (Subcutaneous Kit) B 4

C1

Gile

nya

Gilenya (0.5MG Oral Capsule) B 4 QL C1

Glati

ram

er

Acet

ate Glatiramer Acetate (Subcutaneous Solution Prefilled

Syringe)G 4

C1

Glat

opa

Glatopa (Subcutaneous Solution Prefilled Syringe) G 4

C1

Kesi

mpt

a

Kesimpta (Subcutaneous Solution Auto-Injector) B 4 PA C1

Mav

encl

ad

Mavenclad (10 Tabs) (Oral Tablet Therapy Pack) B 4 PA C1

Mav

encl

ad


Mav

encl

ad


Mav

encl

ad


Mav

encl

ad


Mav

encl

ad


Mav

encl

ad


May

zent

Mayzent (0.25MG Oral Tablet, 2MG Oral Tablet) B 4 LA; QL C1

May

zent

Start

er

Pac

k Mayzent Starter Pack (Oral Tablet Therapy Pack) B 4 LA C1

Pleg

ridy

Plegridy (Subcutaneous Solution Pen-Injector) B 4

C1

Pleg

ridy

Plegridy (Subcutaneous Solution Prefilled Syringe) B 4


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Rebi

f

Rebi

dos

e Rebif Rebidose (Subcutaneous Solution Auto-

Injector)B 4 ST

C1

Rebi

f

Rebi

dos

e

Titra

tion

Pac

k Rebif Rebidose Titration Pack (Subcutaneous

Solution Auto-Injector)B 4 ST

C1

Rebi

f

Rebif (Subcutaneous Solution Prefilled Syringe) B 4 ST C1

Rebi

f

Titra

tion

Pac

k Rebif Titration Pack (Subcutaneous Solution Prefilled

Syringe)B 4 ST

C1

Tecf

ider

a

Start

er

Pac

k Tecfidera Starter Pack (Oral) B 4 LA C1

Tecf

ider

a

Tecfidera (Oral Capsule Delayed Release) B 4 LA; QL C1

Vum

erity

Vumerity (Oral Capsule Delayed Release)

(Maintenance Dose Bottle)B 4 QL

C1

Zep

osia

7-

Day

Start

er

Pac

k Zeposia 7-Day Starter Pack (Oral Capsule Therapy

Pack)B 4 QL

C1

Zep

osia

Zeposia (Oral Capsule) B 4 QL C1

Zep

osia

Start

er

Kit Zeposia Starter Kit (Oral Capsule Therapy Pack) B 4 QL A1

Dental and Oral AgentsB1

Dental and Oral AgentsC1

Cevi

meli

ne

HCl

Cevimeline HCl (Oral Capsule) G 3 ST C1

Chlo

rhex

idin

e

Gluc

onat

e Chlorhexidine Gluconate (Mouth Solution) G 1

C1

Evo

xac

Evoxac (Oral Capsule) B 3 ST C1

Peri

ogar

d

Periogard (Mouth Solution) G 1

C1

Pilo

carp

ine

HCl

Pilocarpine HCl (Oral Tablet) G 3

C1

Sala

gen

Salagen (Oral Tablet) B 3

C1

Tria

mci

nolo

ne

Acet

onid

e Triamcinolone Acetonide (Dental Paste) G 2

A1

Dermatological AgentsB1

Acne and Rosacea AgentsC1

Abs

oric

a LD

Absorica LD (Oral Capsule) B 4 PA C1

Abs

oric

a

Absorica (Oral Capsule) B 4 PA C1

Aca

nya

Acanya (External Gel) B 3 ST C1

Acc

utan

e

Accutane (20MG Oral Capsule, 30MG Oral Capsule,

40MG Oral Capsule)G 3 PA

C1

Acitr

etin

Acitretin (Oral Capsule) G 3

C1

Ada

pale

ne

Adapalene (External Cream) G 3

C1

Ada

pale

ne

Adapalene (0.1% External Gel) G 2

C1

Ada

pale

ne

Adapalene (0.3% External Gel) G 3

C1

Ada

pale

ne

Adapalene (External Pad) G 3



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Ada

pale

ne

Adapalene (External Solution) G 4

C1

Ada

pale

ne-

Ben

zoyl

Per

oxid

e Adapalene-Benzoyl Peroxide (External Gel) G 3 ST C1

Akli

ef

Aklief (External Cream) B 3 PA C1

Altre

no

Altreno (External Lotion) B 3 PA C1

Amn

este

em

Amnesteem (Oral Capsule) G 3 PA C1

Araz

lo

Arazlo (External Lotion) B 3 PA C1

Atral

in

Atralin (External Gel) B 3 PA C1

Avit

a

Avita (External Cream) B 3 PA C1

Avit

a

Avita (External Gel) B 3 PA C1

Azel

aic

Acid

Azelaic Acid (External Gel) G 3

C1

Azel

ex

Azelex (External Cream) B 3

C1

Ben

zaCl

in

with

Pum

p BenzaClin with Pump (External Gel) B 3

C1

Ben

zam

ycin

Benzamycin (External Gel) B 3

C1

Ben

zoyl

Per

oxid

e-

Eryt

hro

myci

n Benzoyl Peroxide-Erythromycin (External Gel) G 3

C1

Clar

avis

Claravis (Oral Capsule) G 3 PA C1

Clin

dam

ycin

Pho

sph

ate-

Ben

zoyl

Per

oxid

e

Clindamycin Phosphate-Benzoyl Peroxide (1.2-2.5%

External Gel)G 3 ST

C1

Clin

dam

ycin

Pho

sph

ate-

Ben

zoyl

Per

oxid

e

Clindamycin Phosphate-Benzoyl Peroxide (1-5% External

Gel, 1.2-5% External Gel)G 3

C1

Clin

dam

ycin-

Treti

noin Clindamycin-Tretinoin (External Gel) G 3 PA C1

Diffe

rin

Differin (External Cream) B 3

C1

Diffe

rin

Differin (0.3% External Gel) B 3

C1

Diffe

rin

Differin (External Lotion) B 3

C1

Epid

uo

Epiduo (External Gel) B 3 ST C1

Epid

uo

Fort

e

Epiduo Forte (External Gel) B 3 ST C1

Fabi

or

Fabior (External Foam) B 3 PA C1

Fina

cea

Finacea (External Foam) B 3

C1

Fina

cea

Finacea (External Gel) B 3

C1

Isotr

etin

oin

Isotretinoin (Oral Capsule) G 3 PA C1

Mirv

aso

Mirvaso (External Gel) B 3

C1

Myo

risa

n

Myorisan (Oral Capsule) G 3 PA C1

Neu

ac

Neuac (External Gel) G 3

C1

One

xton

Onexton (External Gel) B 3

C1

Reti

n-A

Retin-A (External Cream) B 3 PA C1

Reti

n-A

Retin-A (External Gel) B 3 PA C1

Reti

n-A

Micr

o

Retin-A Micro (External Gel) B 4 PA


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Reti

n-A

Micr

o

Pum

p Retin-A Micro Pump (0.06% External Gel, 0.08%

External Gel)B 4 PA

C1

Rho

fade

Rhofade (External Cream) B 3 PA C1

Sori

atan

e

Soriatane (Oral Capsule) B 4

C1

Taz

arot

ene

Tazarotene (External Cream) G 3 PA C1

Taz

arot

ene

Tazarotene (External Foam) G 3 PA C1

Taz

orac

Tazorac (External Cream) B 3 PA C1

Taz

orac

Tazorac (0.05% External Gel) B 4 PA C1

Taz

orac

Tazorac (0.1% External Gel) B 3 PA C1

Treti

noin

Tretinoin (External Cream) G 3 PA C1

Treti

noin

Tretinoin (External Gel) G 3 PA C1

Treti

noin

Micr

osp

here Tretinoin Microsphere (External Gel) G 3 PA C1

Velti

n

Veltin (External Gel) B 4 PA C1

Zen

atan

e

Zenatane (Oral Capsule) G 3 PA C1

Zian

a

Ziana (External Gel) B 4 PA B1

Dermatitis and Pruitus AgentsC1

Ala

Scal

p

Ala Scalp (External Lotion) G 3

C1

Ala-

Cort

Ala-Cort (External Cream) G 1

C1

Alcl

ome

taso

ne

Dipr

opio

nate Alclometasone Dipropionate (External Cream) G 2

C1

Alcl

ome

taso

ne

Dipr

opio

nate Alclometasone Dipropionate (External Ointment) G 2

C1

Amc

inon

ide

Amcinonide (External Cream) G 3

C1

Amc

inon

ide

Amcinonide (External Lotion) G 3

C1

Amc

inon

ide

Amcinonide (External Ointment) G 3

C1

Am

mon

ium

Lact

ate Ammonium Lactate (External Cream) G 1

C1

Am

mon

ium

Lact

ate Ammonium Lactate (External Lotion) G 1

C1

Ape

xiCo

n E

ApexiCon E (External Cream) G 4 QL C1

Bes

er

Beser (External Lotion) G 3

C1

Beta

met

has

one

Dipr

opio

nate

Aug Betamethasone Dipropionate Aug (External Cream) G 1

C1

Beta

met

has

one

Dipr

opio

nate

Aug Betamethasone Dipropionate Aug (External Gel) G 2

C1

Beta

met

has

one

Dipr

opio

nate

Aug Betamethasone Dipropionate Aug (External Lotion) G 2

C1

Beta

met

has

one

Dipr

opio

nate

Aug Betamethasone Dipropionate Aug (External Ointment) G 2

C1

Beta

met

has

one

Dipr

opio

nate Betamethasone Dipropionate (External Cream) G 2

C1

Beta

met

has

one

Dipr

opio

nate Betamethasone Dipropionate (External Lotion) G 2

C1

Beta

met

has

one

Dipr

opio

nate Betamethasone Dipropionate (External Ointment) G 2

C1

Beta

met

has

one

Vale

rate Betamethasone Valerate (External Cream) G 2

C1

Beta

met

has

one

Vale

rate Betamethasone Valerate (External Foam) G 3



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Beta

met

has

one

Vale

rate Betamethasone Valerate (External Lotion) G 2

C1

Beta

met

has

one

Vale

rate Betamethasone Valerate (External Ointment) G 2

C1

Bryh

ali

Bryhali (External Lotion) B 3

C1

Cap

ex

Capex (External Shampoo) B 3

C1

Clo

beta

sol

Pro

pion

ate

Emo

llient

Bas

e

Clobetasol Propionate Emollient Base (External Cream) G 2

C1

Clo

beta

sol

Pro

pion

ate

Emu

lsion Clobetasol Propionate Emulsion (External Foam) G 3

C1

Clo

beta

sol

Pro

pion

ate Clobetasol Propionate (External Cream) G 2

C1

Clo

beta

sol

Pro

pion

ate Clobetasol Propionate (External Foam) G 3 QL C1

Clo

beta

sol

Pro

pion

ate Clobetasol Propionate (External Gel) G 2

C1

Clo

beta

sol

Pro

pion

ate Clobetasol Propionate (External Liquid Spray) G 3 QL C1

Clo

beta

sol

Pro

pion

ate Clobetasol Propionate (External Lotion) G 3 QL C1

Clo

beta

sol

Pro

pion

ate Clobetasol Propionate (External Ointment) G 2

C1

Clo

beta

sol

Pro

pion

ate Clobetasol Propionate (External Shampoo) G 3

C1

Clo

beta

sol

Pro

pion

ate Clobetasol Propionate (External Solution) G 2

C1

Clo

bex

Clobex (External Lotion) B 4 QL C1

Clo

bex

Clobex (External Shampoo) B 4

C1

Clo

bex

Spra

y

Clobex Spray (External Liquid) B 4 QL C1

Cloc

ortol

one

Pival

ate Clocortolone Pivalate (External Cream) G 3

C1

Clo

dan

Clodan (External Shampoo) G 3

C1

Clo

der

m

Cloderm (External Cream) B 3

C1

Cor

dran

Cordran (0.025% External Cream) B 3

C1

Cor

dran

Cordran (0.05% External Cream) B 4

C1

Cor

dran

Cordran (External Lotion) B 3 QL C1

Cor

dran

Cordran (External Ointment) B 4

C1

Cor

dran

Cordran (External Tape) B 4

C1

Cuti

vate

Cutivate (External Lotion) B 4

C1

Der

ma-

Smo

othe

/FS

Scal

p Derma-Smoothe/FS Scalp (External Oil) B 3

C1

Des

onat

e

Desonate (External Gel) B 3 ST C1

Des

onid

e

Desonide (External Cream) G 2

C1

Des

onid

e

Desonide (External Gel) G 3 ST C1

Des

onid

e

Desonide (External Lotion) G 3

C1

Des

onid

e

Desonide (External Ointment) G 2

C1

Des

Owe

n

DesOwen (External Cream) B 3

C1

Des

oxi

met

aso

ne Desoximetasone (External Cream) G 3 QL C1

Des

oxi

met

aso

ne Desoximetasone (External Gel) G 3

C1

Des

oxi

met

aso

ne Desoximetasone (External Liquid) G 3

C1

Des

oxi

met

aso

ne Desoximetasone (External Ointment) G 3


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Diflo

raso

ne

Diac

etat

e Diflorasone Diacetate (External Cream) G 3 QL C1

Diflo

raso

ne

Diac

etat

e Diflorasone Diacetate (External Ointment) G 4 ST; QL C1

Dipr

olen

e

Diprolene (External Ointment) B 3

C1

Dox

epin

HCl

Doxepin HCl (External Cream) G 4 PA; QL C1

Elid

el

Elidel (External Cream) B 3 ST; QL C1

Eucr

isa

Eucrisa (External Ointment) B 3 PA; QL C1

Fluo

cino

lone

Acet

onid

e Fluocinolone Acetonide (External Cream) G 2

C1

Fluo

cino

lone

Acet

onid

e Fluocinolone Acetonide (External Ointment) G 2

C1

Fluo

cino

lone

Acet

onid

e Fluocinolone Acetonide (External Solution) G 2

C1

Fluo

cino

lone

Acet

onid

e

Scal

p Fluocinolone Acetonide Scalp (External Oil) G 2

C1

Fluo

cino

nide

Emu

lsifie

d

Bas

e Fluocinonide Emulsified Base (External Cream) G 2

C1

Fluo

cino

nide

Fluocinonide (0.05% External Cream) G 2

C1

Fluo

cino

nide

Fluocinonide (0.1% External Cream) G 3

C1

Fluo

cino

nide

Fluocinonide (External Gel) G 2

C1

Fluo

cino

nide

Fluocinonide (External Ointment) G 2

C1

Fluo

cino

nide

Fluocinonide (External Solution) G 2

C1

Flur

andr

enol

ide

Flurandrenolide (External Cream) G 3

C1

Flur

andr

enol

ide

Flurandrenolide (External Lotion) G 3 QL C1

Flur

andr

enol

ide

Flurandrenolide (External Ointment) G 3

C1

Fluti

cas

one

Pro

pion

ate Fluticasone Propionate (External Cream) G 2

C1

Fluti

cas

one

Pro

pion

ate Fluticasone Propionate (External Lotion) G 3

C1

Fluti

cas

one

Pro

pion

ate Fluticasone Propionate (External Ointment) G 2

C1

Halc

inon

ide

Halcinonide (External Cream) G 3

C1

Halo

beta

sol

Pro

pion

ate Halobetasol Propionate (External Cream) G 3

C1

Halo

beta

sol

Pro

pion

ate Halobetasol Propionate (External Foam) B 4

C1

Halo

beta

sol

Pro

pion

ate Halobetasol Propionate (External Ointment) G 3

C1

Halo

g

Halog (External Cream) B 4

C1

Halo

g

Halog (External Ointment) B 4

C1

Halo

g

Halog (External Solution) B 3

C1

Hyd

roco

rtiso

ne

Buty

rate Hydrocortisone Butyrate (External Cream) G 3

C1

Hyd

roco

rtiso

ne

Buty

rate Hydrocortisone Butyrate (External Lotion) G 3 QL C1

Hyd

roco

rtiso

ne

Buty

rate Hydrocortisone Butyrate (External Ointment) G 3

C1

Hyd

roco

rtiso

ne

Buty

rate Hydrocortisone Butyrate (External Solution) G 3

C1

Hyd

roco

rtiso

ne

Hydrocortisone (1% External Cream, 2.5% External

Cream)G 1

C1

Hyd

roco

rtiso

ne

Hydrocortisone (2.5% External Lotion) G 2



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Hyd

roco

rtiso

ne

Hydrocortisone (1% External Ointment, 2.5% External

Ointment)G 1

C1

Hyd

roco

rtiso

ne

Vale

rate Hydrocortisone Valerate (External Cream) G 3

C1

Hyd

roco

rtiso

ne

Vale

rate Hydrocortisone Valerate (External Ointment) G 3

C1

Imp

eklo

Impeklo (External Lotion) B 3 QL C1

Ken

alog

Kenalog (External Aerosol Solution) B 4

C1

Lex

ette

Lexette (External Foam) B 4

C1

Loc

oid

Locoid (External Lotion) B 4 QL C1

Loc

oid

Lipo

crea

m Locoid Lipocream (External Cream) B 3

C1

Luxi

q

Luxiq (External Foam) B 3

C1

Mo

met

aso

ne

Furo

ate Mometasone Furoate (External Cream) G 1

C1

Mo

met

aso

ne

Furo

ate Mometasone Furoate (External Ointment) G 1

C1

Mo

met

aso

ne

Furo

ate Mometasone Furoate (External Solution) G 1

C1

Noli

x

Nolix (External Cream) G 3

C1

Noli

x

Nolix (External Lotion) G 3 QL C1

Olux

Olux (External Foam) B 4 QL C1

Olux

-E

Olux-E (External Foam) B 4 QL C1

Pan

del

Pandel (External Cream) B 4

C1

Pim

ecro

limu

s

Pimecrolimus (External Cream) G 3 ST; QL C1

Pre

dnic

arba

te

Prednicarbate (External Ointment) G 3

C1

Prot

opic

Protopic (External Ointment) B 3 ST C1

PRU

DOX

IN

PRUDOXIN (External Cream) B 4 PA; QL C1

Psor

con

Psorcon (External Cream) G 3 QL C1

Sele

niu

m

Sulfi

de Selenium Sulfide (External Lotion) G 1

C1

Syn

alar

Synalar (External Cream) B 3

C1

Tacr

olim

us

Tacrolimus (External Ointment) G 3 ST C1

Tem

ovat

e

Temovate (External Cream) G 3

C1

Tex

acor

t

Texacort (External Solution) G 3

C1

Topi

cort

Topicort (External Cream) G 3 QL C1

Topi

cort

Topicort (External Gel) G 3

C1

Topi

cort

Topicort (0.05% External Ointment) B 3

C1

Topi

cort

Topicort (0.25% External Ointment) G 3

C1

Topi

cort

Spra

y

Topicort Spray (External Liquid) B 3

C1

Tov

et

Tovet (External Foam) G 3

C1

Tria

mci

nolo

ne

Acet

onid

e Triamcinolone Acetonide (External Aerosol Solution)

(Generic Kenalog)G 3

C1

Tria

mci

nolo

ne

Acet

onid

e Triamcinolone Acetonide (External Cream) G 1


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Tria

mci

nolo

ne

Acet

onid

e Triamcinolone Acetonide (External Lotion) G 2

C1

Tria

mci

nolo

ne

Acet

onid

e Triamcinolone Acetonide (0.025% External Ointment,

0.1% External Ointment, 0.5% External Ointment)G 1

C1

Tria

mci

nolo

ne

Acet

onid

e Triamcinolone Acetonide (0.05% External Ointment) G 3

C1

Tria

nex

Trianex (External Ointment) G 3

C1

Trid

erm

Triderm (0.1% External Cream) G 1

C1

Trid

erm

Triderm (0.5% External Cream) G 3

C1

Ultra

vate

Ultravate (External Lotion) B 4

C1

Van

os

Vanos (External Cream) B 4

C1

Ver

des

o

Verdeso (External Foam) B 4 ST C1

Zon

alon

Zonalon (External Cream) B 4 PA; QL B1

Dermatological Agents, OtherC1

Alda

ra

Aldara (External Cream) B 3 QL C1

Calc

ipotr

iene

Calcipotriene (External Cream) G 3

C1

Calc

ipotr

iene

Calcipotriene (External Foam) B 4

C1

Calc

ipotr

iene

Calcipotriene (External Ointment) G 3

C1

Calc

ipotr

iene

Calcipotriene (External Solution) G 2

C1

Calc

ipotr

iene

-

Beta

met

has

one Calcipotriene-Betamethasone (0.005-0.064% External

Ointment)G 3

C1

Calc

ipotr

iene

-

Beta

met

has

one Calcipotriene-Betamethasone (0.005-0.064% External

Suspension)G 4

C1

Calc

itriol

Calcitriol (External Ointment) B 3

C1

Cara

c

Carac (External Cream) B 4

C1

Clot

rima

zole-

Beta

met

has

one Clotrimazole-Betamethasone (External Cream) G 2

C1

Clot

rima

zole-

Beta

met

has

one Clotrimazole-Betamethasone (External Lotion) G 3

C1

Con

dylo

x

Condylox (External Gel) B 4

C1

Dicl

ofen

ac

Sodi

um Diclofenac Sodium (3% External Gel) G 3 PA C1

Dov

one

x

Dovonex (External Cream) B 4

C1

Duo

brii

Duobrii (External Lotion) B 4 PA C1

Efud

ex

Efudex (External Cream) B 3

C1

Enst

ilar

Enstilar (External Foam) B 4 PA C1

Fluo

ropl

ex

Fluoroplex (External Cream) B 4 PA C1

Fluo

rour

acil

Fluorouracil (0.5% External Cream) G 4

C1

Fluo

rour

acil

Fluorouracil (5% External Cream) G 2

C1

Fluo

rour

acil

Fluorouracil (External Solution) G 2



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Hyd

roco

rtiso

ne

Acet

ate-

Pra

mox

ine Hydrocortisone Acetate-Pramoxine (1-1% External

Cream)G 3

C1

Imiq

uim

od

Imiquimod (3.75% External Cream) B 4 PA C1

Imiq

uim

od

Imiquimod (5% External Cream) G 2 QL C1

Met

hox

sale

n

Rapi

d Methoxsalen Rapid (Oral Capsule) G 4

C1

Neo

-

Syn

alar

Neo-Synalar (External Cream) G 4

C1

Nyst

atin-

Tria

mci

nolo

ne Nystatin-Triamcinolone (External Cream) G 2

C1

Nyst

atin-

Tria

mci

nolo

ne Nystatin-Triamcinolone (External Ointment) G 2

C1

Pica

to

Picato (0.015% External Gel, 0.05% External Gel) B 2 QL C1

Pod

ofilo

x

Podofilox (External Solution) G 2

C1

Qbr

exza

Qbrexza (External Pad) B 3

C1

Reg

rane

x

Regranex (External Gel) B 4 PA C1

Sant

yl

Santyl (External Ointment) B 3

C1

Silva

den

e

Silvadene (External Cream) B 3

C1

Silv

er

Sulf

adia

zine Silver Sulfadiazine (External Cream) G 1

C1

Soril

ux

Sorilux (External Foam) B 4

C1

SSD

SSD (External Cream) B 1

C1

Tacl

one

x

Taclonex (External Ointment) B 4

C1

Tacl

one

x

Taclonex (External Suspension) B 4

C1

Vect

ical

Vectical (External Ointment) B 4

C1

Vere

gen

Veregen (External Ointment) B 4

C1

Xere

se

Xerese (External Cream) B 4 PA C1

Zycl

ara

Pum

p

Zyclara Pump (External Cream) B 4 PA B1

Pediculicides/ScabicidesC1

Iver

mec

tin

Ivermectin (External Lotion) G 3

C1

Lind

ane

Lindane (External Shampoo) G 3

C1

Mal

athi

on

Malathion (External Lotion) G 3

C1

Natr

oba

Natroba (External Suspension) B 3

C1

Ovid

e

Ovide (External Lotion) G 3

C1

Per

met

hrin

Permethrin (External Cream) G 2

C1

Sool

antr

a

Soolantra (External Cream) B 3

C1

Spin

osa

d

Spinosad (External Suspension) B 3

B1

Topical Anti-infectivesC1

Acz

one

Aczone (External Gel) B 3

C1

Alta

bax

Altabax (External Ointment) B 3

C1

Amz

eeq

Amzeeq (External Foam) B 3

C1

Cicl

opir

ox

Ciclopirox (External Gel) G 2


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Cicl

opir

ox

Ciclopirox (External Shampoo) G 2

C1

Cicl

opir

ox

Ciclopirox (External Solution) G 2

C1

Cicl

opir

ox

Ola

min

e Ciclopirox Olamine (External Cream) G 2

C1

Cicl

opir

ox

Ola

min

e Ciclopirox Olamine (External Suspension) G 2

C1

Cleo

cin-

T

Cleocin-T (External Lotion) B 3

C1

Clin

daci

n-P

Clindacin-P (External Swab) G 2

C1

Clin

dag

el

Clindagel (External Gel) B 4 QL C1

Clin

dam

ycin

Pho

sph

ate Clindamycin Phosphate (External Foam) G 3

C1

Clin

dam

ycin

Pho

sph

ate Clindamycin Phosphate (External Gel) G 2 QL C1

Clin

dam

ycin

Pho

sph

ate Clindamycin Phosphate (External Lotion) G 2

C1

Clin

dam

ycin

Pho

sph

ate Clindamycin Phosphate (External Solution) G 1

C1

Clin

dam

ycin

Pho

sph

ate Clindamycin Phosphate (External Swab) G 2

C1

Clot

rima

zole

Clotrimazole (External Cream) G 1

C1

Clot

rima

zole

Clotrimazole (External Solution) G 2

C1

Dap

son

e

Dapsone (External Gel) G 3

C1

Eco

naz

ole

Nitr

ate Econazole Nitrate (External Cream) G 2 QL C1

Erta

czo

Ertaczo (External Cream) B 4

C1

Ery

Ery (External Pad) G 2

C1

Eryg

el

Erygel (External Gel) B 3

C1

Eryt

hro

myci

n

Erythromycin (External Gel) G 3

C1

Eryt

hro

myci

n

Erythromycin (External Solution) G 2

C1

Evo

clin

Evoclin (External Foam) B 4

C1

Exti

na

Extina (External Foam) B 4 QL C1

Gen

tami

cin

Sulf

ate Gentamicin Sulfate (External Cream) G 2

C1

Gen

tami

cin

Sulf

ate Gentamicin Sulfate (External Ointment) G 1

C1

Jubli

a

Jublia (External Solution) B 3

C1

Kery

din

Kerydin (External Solution) B 4 ST C1

Ket

oco

naz

ole

Ketoconazole (External Cream) G 1 QL C1

Ket

oco

naz

ole

Ketoconazole (External Foam) G 3 QL C1

Ket

oco

naz

ole

Ketoconazole (External Shampoo) G 1

C1

Ket

oda

n

Ketodan (External Foam) G 3 QL C1

Klar

on

Klaron (External Lotion) B 3 PA C1

Lopr

ox

Loprox (External Cream) B 3

C1

Lopr

ox

Loprox (External Shampoo) B 3

C1

Lulic

ona

zole

Luliconazole (External Cream) B 3 QL



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Luz

u

Luzu (External Cream) B 3 QL C1

Maf

enid

e

Acet

ate Mafenide Acetate (External Packet) G 3

C1

Men

tax

Mentax (External Cream) B 3

C1

Mup

iroci

n

Calc

ium Mupirocin Calcium (External Cream) G 3

C1

Mup

iroci

n

Mupirocin (External Ointment) G 1 QL C1

Nafti

fine

HCl

Naftifine HCl (External Cream) G 3

C1

Nafti

n

Naftin (External Gel) B 3

C1

Nya

myc

Nyamyc (External Powder) G 1 QL C1

Nyst

atin

Nystatin (External Cream) G 1

C1

Nyst

atin

Nystatin (External Ointment) G 1

C1

Nyst

atin

Nystatin (External Powder) G 1 QL C1

Nyst

op

Nystop (External Powder) G 1 QL C1

Oxic

ona

zole

Nitr

ate Oxiconazole Nitrate (External Cream) G 3 QL C1

Oxis

tat

Oxistat (External Cream) B 4 QL C1

Oxis

tat

Oxistat (External Lotion) B 4 QL C1

Sulf

acet

ami

de

Sodi

um Sulfacetamide Sodium (Acne) (External Lotion) G 3 PA C1

Sulf

amyl

on

Sulfamylon (External Cream) B 3

C1

Sulf

amyl

on

Sulfamylon (External Packet) B 4

C1

Tav

abor

ole

Tavaborole (External Solution) G 4 ST C1

Xepi

Xepi (External Cream) B 3

C1

Xole

gel

Xolegel (External Gel) B 4 PA; QL C1

Zilxi

Zilxi (External Foam) B 3

A1

Electrolytes/Minerals/Metals/VitaminsB1

Electrolyte/Mineral ReplacementC1

Ami

nos

yn II

Aminosyn II (15% Intravenous Solution) B 3 B/D, PA C1

Ami

nos

yn-

PF

Aminosyn-PF (7% Intravenous Solution) B 3 B/D, PA C1

Car

bagl

u

Carbaglu (Oral Tablet) B 4 LA C1

Clini

mix

E/

Dext

rose Clinimix E/Dextrose (2.75/5) (Intravenous Solution) B 3 B/D, PA C1

Clini

mix

E/

Dext


Clini

mix

E/

Dext


Clini

mix

E/

Dext

rose Clinimix E/Dextrose (5/15) (Intravenous Solution) B 3 B/D, PA C1

Clini

mix

E/

Dext

rose Clinimix E/Dextrose (5/20) (Intravenous Solution) B 3 B/D, PA C1

Clini

mix/

Dext

rose

Clinimix/Dextrose (4.25/10) (Intravenous Solution) B 3 B/D, PA C1

Clini

mix/

Dext

rose

Clinimix/Dextrose (4.25/5) (Intravenous Solution) B 3 B/D, PA C1

Clini

mix/

Dext

rose

Clinimix/Dextrose (5/15) (Intravenous Solution) B 3 B/D, PA C1

Clini

mix/

Dext

rose

Clinimix/Dextrose (5/20) (Intravenous Solution) B 3 B/D, PA C1

Clini

sol

SF

Clinisol SF (Intravenous Solution) G 3 B/D, PA


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Dext

rose

Dextrose (10% Intravenous Solution) G 2

C1

Dext

rose

Dextrose (5% Intravenous Solution) G 2 B/D, PA C1

Dext

rose

-

NaC

l Dextrose-NaCl (10-0.2% Intravenous Solution,

10-0.45% Intravenous Solution, 2.5-0.45%

Intravenous Solution, 5-0.2% Intravenous Solution,

5-0.45% Intravenous Solution)

B 2

C1

Dext

rose

-

NaC

l Dextrose-NaCl (5-0.9% Intravenous Solution) B 2 B/D, PA C1

End

ari

Endari (Oral Packet) B 4 PA C1

Hep

atA

min

e

HepatAmine (8% Intravenous Solution) B 3 B/D, PA C1

Intra

lipid

Intralipid (Intravenous Emulsion) B 3 B/D, PA C1

Isoly

te-P

in

D5

W Isolyte-P in D5W (Intravenous Solution) B 3

C1

Isoly

te-S

Isolyte-S (Intravenous Solution) B 3

C1

KCl

in

Dext

rose

-

NaC

l KCl in Dextrose-NaCl (Intravenous Solution) B 2

C1

KCl-

Lact

ated

Ring

ers-

D5

W KCl-Lactated Ringers-D5W (Intravenous Solution) B 2

C1

Klor-

Con

10

Klor-Con 10 (Oral Tablet Extended Release) B 1

C1

Klor-

Con

M10

Klor-Con M10 (Oral Tablet Extended Release) G 1

C1

Klor-

Con

M15


C1

Klor-

Con

M20


C1

Klor-

Con

Klor-Con (Oral Packet) G 3

C1

Klor-

Con

8

Klor-Con 8 (Oral Tablet Extended Release) B 1

C1

K-

Tab

K-Tab (Oral Tablet Extended Release) B 3

C1

Mag

nesi

um

Sulf

ate Magnesium Sulfate (50% Injection Solution) B 1

C1

Mag

nesi

um

Sulf

ate Magnesium Sulfate (50% (10ML Syringe) Injection

Solution)G 1

C1

Nutr

ilipid

Nutrilipid (Intravenous Emulsion) B 3 B/D, PA C1

Plas

ma-

Lyte

148

Plasma-Lyte 148 (Intravenous Solution) B 3

C1

Plas

ma-

Lyte

A

Plasma-Lyte A (Intravenous Solution) B 3

C1

Plen

ami

ne

Plenamine (Intravenous Solution) G 3 B/D, PA C1

Pota

ssiu

m

Chlo

ride

CR Potassium Chloride CR (Oral Tablet Extended Release) G 1

C1

Pota

ssiu

m

Chlo

ride

ER Potassium Chloride ER (Oral Capsule Extended

Release)G 1

C1

Pota

ssiu

m

Chlo

ride

in

Dext

rose Potassium Chloride in Dextrose (Intravenous

Solution)B 2 B/D, PA

C1

Pota

ssiu

m

Chlo

ride

in

NaC

l Potassium Chloride in NaCl (20-0.45MEQ/L-%

Intravenous Solution)G 2 B/D, PA



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Pota

ssiu

m

Chlo

ride

in

NaC

l Potassium Chloride in NaCl (20-0.9MEQ/L-%

Intravenous Solution, 40-0.9MEQ/L-% Intravenous

Solution)

B 2 B/D, PA

C1

Pota

ssiu

m

Chlo

ride Potassium Chloride (10MEQ/100ML Intravenous

Solution, 20MEQ/100ML Intravenous Solution,

40MEQ/100ML Intravenous Solution)

B 1 B/D, PA

C1

Pota

ssiu

m

Chlo

ride Potassium Chloride (2MEQ/ML Intravenous Solution,

2MEQ/ML (20ML) Intravenous Solution)G 1 B/D, PA

C1

Pota

ssiu

m

Chlo

ride Potassium Chloride (Oral Packet) G 3

C1

Pota

ssiu

m

Chlo

ride Potassium Chloride (20 MEQ/15ML(10%) Oral Solution,

40 MEQ/15ML(20%) Oral Solution)G 3

C1

Pota

ssiu

m

Citra

te

ER Potassium Citrate ER (Oral Tablet Extended Release) G 3

C1

Pre

mas

ol

Premasol (Intravenous Solution) G 3 B/D, PA C1

Proc

ala

min

e

Procalamine (Intravenous Solution) B 3 B/D, PA C1

Pros

ol

Prosol (Intravenous Solution) B 3 B/D, PA C1

Sodi

um

Chlo

ride

Sodium Chloride (0.45% Intravenous Solution) G 1

C1

Sodi

um

Chlo

ride

Sodium Chloride (0.9% Intravenous Solution, 3%

Intravenous Solution)G 1 B/D, PA

C1

Sodi

um

Chlo

ride

Sodium Chloride (5% Intravenous Solution) B 1 B/D, PA C1

Sodi

um

Chlo

ride

Sodium Chloride (Irrigation Solution) B 1

C1

Sodi

um

Fluo

ride

Sodium Fluoride (Oral Tablet) G 1

C1

TPN

Elec

troly

tes

TPN Electrolytes (Intravenous Concentrate) B 2

C1

Trav

asol

Travasol (Intravenous Solution) B 3 B/D, PA C1

Tro

phA

min

e

TrophAmine (10% Intravenous Solution) B 3 B/D, PA C1

Uro

cit-K

10

Urocit-K 10 (Oral Tablet Extended Release) B 3

C1

Uro

cit-K

15


C1

Uro

cit-K

5


B1

Electrolyte/Mineral/Metal ModifiersC1

Che

met

Chemet (Oral Capsule) B 4

C1

Clov

ique

Clovique (Oral Capsule) G 4 PA; QL C1

Def

eras

irox

Gra

nule

s Deferasirox Granules (Oral Packet) G 4 PA C1

Def

eras

irox

Deferasirox (Oral Tablet) (Generic Jadenu) G 4 PA C1

Def

eras

irox

Deferasirox (Oral Tablet Soluble) (Generic Exjade) G 4 PA C1

Def

eripr

one

Deferiprone (Oral Tablet) G 4 PA C1

Exja

de

Exjade (Oral Tablet Soluble) B 4 PA C1

Ferri

prox

Ferriprox (Oral Solution) B 4 PA C1

Ferri

prox

Ferriprox (Oral Tablet) B 4 PA C1

Jad

enu

Jadenu (Oral Tablet) B 4 PA


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Jad

enu

Spri

nkle

Jadenu Sprinkle (Oral Packet) B 4 PA C1

Jyna

rque

Jynarque (Oral Tablet) B 4 PA C1

Jyna

rque

Jynarque (Oral Tablet Therapy Pack) B 4 PA; QL C1

Sam

sca

Samsca (Oral Tablet) B 4 PA C1

Sypr

ine

Syprine (Oral Capsule) B 4 PA; QL C1

Tolv

apta

n

Tolvaptan (15MG Oral Tablet) B 4 PA C1

Tolv

apta

n

Tolvaptan (30MG Oral Tablet) G 4 PA C1

Trie

ntin

e

HCl

Trientine HCl (Oral Capsule) G 4 PA; QL B1

Phosphate BindersC1

Aury

xia

Auryxia (Oral Tablet) B 4 PA C1

Calc

ium

Acet

ate

Calcium Acetate (Phosphate Binder) (Oral Capsule) G 2

C1

Calc

ium

Acet

ate

Calcium Acetate (Phosphate Binder) (Oral Tablet) G 2

C1

Fosr

enol

Fosrenol (Oral Packet) B 4

C1

Fosr

enol

Fosrenol (Oral Tablet Chewable) B 4

C1

Lant

han

um

Car

bon

ate Lanthanum Carbonate (Oral Tablet Chewable) G 4

C1

Pho

slyra

Phoslyra (Oral Solution) B 2

C1

Ren

agel

Renagel (Oral Tablet) B 4

C1

Ren

vela

Renvela (Oral Packet) B 4

C1

Ren

vela

Renvela (Oral Tablet) B 4

C1

Sev

ela

mer

Car

bon

ate Sevelamer Carbonate (Oral Packet) G 4

C1

Sev

ela

mer

Car

bon

ate Sevelamer Carbonate (Oral Tablet) (Generic Renvela) G 2

C1

Sev

ela

mer

HCl

Sevelamer HCl (Oral Tablet) G 3

C1

Velp

horo

Velphoro (Oral Tablet Chewable) B 4

B1

Potassium BindersC1

Lok

elm

a

Lokelma (Oral Packet) B 3 QL C1

Sodi

um

Poly

styr

ene

Sulf

onat

e Sodium Polystyrene Sulfonate (Oral Powder) G 2

C1

SPS

SPS (Oral Suspension) G 2

C1

Velt

assa

Veltassa (Oral Packet) B 4 QL B1

VitaminsC1

VP-

PNV

-

DHA

VP-PNV-DHA (Oral Capsule) G 1

A1

Gastrointestinal AgentsB1

Anti-Constipation AgentsC1

Amit

iza

Amitiza (Oral Capsule) B 2 QL C1

Con

stul

ose

Constulose (Oral Solution) G 1

C1

Enul

ose

Enulose (Oral Solution) G 1



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Gen

erla

c

Generlac (Oral Solution) G 1

C1

Krist

alos

e

Kristalose (Oral Packet) G 3

C1

Lact

ulos

e

Lactulose (Oral Packet) G 3

C1

Lact

ulos

e

Lactulose (10GM/15ML Oral Solution) G 1

C1

Linz

ess

Linzess (Oral Capsule) B 2 QL C1

Lubi

pros

tone

Lubiprostone (Oral Capsule) G 2 QL C1

Mot

egrit

y

Motegrity (Oral Tablet) B 3 ST; QL C1

Mov

anti

k

Movantik (Oral Tablet) B 3 PA; QL C1

Reli

stor

Relistor (Oral Tablet) B 4 PA C1

Reli

stor

Relistor (Subcutaneous Solution) B 4 PA C1

Sym

proi

c

Symproic (Oral Tablet) B 3 PA; QL C1

Trul

anc

e

Trulance (Oral Tablet) B 3 ST B1

Anti-Diarrheal AgentsC1

Alos

etro

n

HCl

Alosetron HCl (Oral Tablet) G 4 PA C1

Diph

eno

xylat

e-

Atro

pine Diphenoxylate-Atropine (Oral Liquid) G 3 PA; HRM C1

Diph

eno

xylat

e-

Atro

pine Diphenoxylate-Atropine (Oral Tablet) G 3 PA; HRM C1

Lom

otil

Lomotil (Oral Tablet) B 3 PA; HRM C1

Lop

era

mid

e

HCl Loperamide HCl (Oral Capsule) G 1

C1

Lotr

one

x

Lotronex (Oral Tablet) B 4 PA C1

Myt

esi

Mytesi (Oral Tablet Delayed Release) B 3 PA C1

Vibe

rzi

Viberzi (Oral Tablet) B 4 PA; QL C1

Xer

mel

o

Xermelo (Oral Tablet) B 4 PA; LA; QL B1

Antispasmodics, GastrointestinalC1

Chlo

rdia

zep

oxid

e-

Clidi

niu

m Chlordiazepoxide-Clidinium (Oral Capsule) G 1 HRM C1

Cuv

pos

a

Cuvposa (Oral Solution) B 3 PA C1

Dicy

clo

min

e

HCl Dicyclomine HCl (Oral Capsule) G 1 HRM C1

Dicy

clo

min

e

HCl Dicyclomine HCl (Oral Solution) G 3 HRM C1

Dicy

clo

min

e

HCl Dicyclomine HCl (Oral Tablet) G 1 HRM C1

Glyc

opyr

rolat

e

Glycopyrrolate (1MG Oral Tablet, 2MG Oral Tablet) G 2 PA C1

Libr

ax

Librax (Oral Capsule) B 3 HRM C1

Met

hsc

opol

ami

ne

Bro

mid

e Methscopolamine Bromide (Oral Tablet) G 3

B1

Gastrointestinal Agents, OtherC1

Am

oxici

llin-

Clari

thro

myci

n-

Lan

sopr

azol

e

Amoxicillin-Clarithromycin-Lansoprazole (Oral) G 3

C1

Che

nod

al

Chenodal (Oral Tablet) G 4 PA C1

Clen

piq

Clenpiq (Oral Solution) B 2

C1

Gatt

ex

Gattex (Subcutaneous Kit) B 4 PA; LA C1

Gavi

Lyte

-C

GaviLyte-C (Oral Solution Reconstituted) G 1


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Gavi

Lyte

-G

GaviLyte-G (Oral Solution Reconstituted) G 1

C1

Gavi

Lyte

-N

with

Flav

or

Pac

k GaviLyte-N with Flavor Pack (Oral Solution

Reconstituted)G 1

C1

GoL

YTE

LY

GoLYTELY (Oral Solution Reconstituted) B 3

C1

Heli

dac

Ther

apy

Helidac Therapy (Oral) G 4

C1

Mov

iPre

p

MoviPrep (Oral Solution Reconstituted) B 3

C1

Myal

ept

Myalept (Subcutaneous Solution Reconstituted) B 4 PA; LA C1

NuL

YTE

LY

Lem

on-

Lim

e NuLYTELY Lemon-Lime (Oral Solution Reconstituted) B 3

C1

Ocal

iva

Ocaliva (Oral Tablet) B 4 PA; QL C1

Om

ecla

mox

-Pak

Omeclamox-Pak (Oral) B 4

C1

Os

moP

rep

OsmoPrep (Oral Tablet) B 3

C1

PEG

-335

0-

NaC

l-Na

Bica

rbon

ate-

KCl PEG-3350-NaCl-Na Bicarbonate-KCl (Oral Solution)

(Generic NuLYTELY)G 1

C1

PEG

-335

0-

Elec

troly

tes PEG-3350-Electrolytes (Oral Solution) (Generic

GoLYTELY)G 1

C1

PEG

-KCl-

NaC

l-

NaS

ulf-

Na

Asc-

C PEG-KCl-NaCl-NaSulf-Na Asc-C (Oral Solution

Reconstituted) (Generic MoviPrep)G 3

C1

Plen

vu

Plenvu (Oral Solution Reconstituted) B 3

C1

Pyle

ra

Pylera (Oral Capsule) B 4

C1

Relt

one

Reltone (Oral Capsule) G 4

C1

Sup

rep

Bow

el

Pre

p Kit Suprep Bowel Prep Kit (Oral Solution) B 2

C1

Suta

b

Sutab (Oral Tablet) B 3

C1

Talic

ia

Talicia (Oral Capsule Delayed Release) B 3

C1

TriL

yte

TriLyte (420GM Oral Solution Reconstituted) G 1

C1

Urs

o

250

Urso 250 (Oral Tablet) B 3

C1

Urs

o

Fort

e

Urso Forte (Oral Tablet) B 3

C1

Urs

odio

l

Ursodiol (Oral Capsule) G 2

C1

Urs

odio

l

Ursodiol (Oral Tablet) G 3

B1

Histamine2 (H2) Receptor AntagonistsC1

Cim

etidi

ne

HCl

Cimetidine HCl (300MG/5ML Oral Solution) G 2

C1

Cim

etidi

ne

Cimetidine (Oral Tablet) G 2

C1

Fam

otidi

ne

Famotidine (Oral Suspension Reconstituted) G 3

C1

Fam

otidi

ne

Famotidine (20MG Oral Tablet, 40MG Oral Tablet) G 1

C1

Niza

tidin

e

Nizatidine (Oral Capsule) G 2

C1

Niza

tidin

e

Nizatidine (Oral Solution) G 3

C1

Pep

cid

Pepcid (20MG Oral Tablet) G 3



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Pep

cid

Pepcid (40MG Oral Tablet) G 4

B1

ProtectantsC1

Cara

fate

Carafate (Oral Suspension) B 3

C1

Cara

fate

Carafate (Oral Tablet) B 3

C1

Cyto

tec

Cytotec (Oral Tablet) B 3

C1

Mis

opr

osto

l

Misoprostol (Oral Tablet) G 2

C1

Sucr

alfat

e

Sucralfate (Oral Suspension) G 3

C1

Sucr

alfat

e

Sucralfate (Oral Tablet) G 1

B1

Proton Pump InhibitorsC1

Acip

hex

Aciphex (Oral Tablet Delayed Release) B 3

C1

Dexi

lant

Dexilant (Oral Capsule Delayed Release) B 3 QL C1

Eso

mep

razo

le

Mag

nesi

um Esomeprazole Magnesium (Oral Capsule Delayed

Release) (Generic Nexium)G 2 QL

C1

Eso

mep

razo

le

Mag

nesi

um Esomeprazole Magnesium (Oral Packet) G 2

C1

Lan

sopr

azol

e

Lansoprazole (Oral Capsule Delayed Release) G 2 QL C1

Lan

sopr

azol

e

ODT Lansoprazole ODT (Oral Tablet Delayed Release

Dispersible)G 3

C1

Nexi

um

Nexium (20MG Oral Capsule Delayed Release, 40MG

Oral Capsule Delayed Release)B 2 QL

C1

Nexi

um

Nexium (10MG Oral Packet, 2.5MG Oral Packet,

20MG Oral Packet, 40MG Oral Packet, 5MG Oral

Packet)

B 2

C1

Om

epra

zole

Omeprazole (10MG Oral Capsule Delayed Release) G 1 QL C1

Om

epra

zole

Omeprazole (20MG Oral Capsule Delayed Release,

40MG Oral Capsule Delayed Release)G 1

C1

Om

epra

zole-

Sodi

um

Bica

rbon

ate Omeprazole-Sodium Bicarbonate (Oral Capsule) G 3 PA C1

Om

epra

zole-

Sodi

um

Bica

rbon

ate Omeprazole-Sodium Bicarbonate (Oral Packet) G 4 PA C1

Pant

opra

zole

Sodi

um Pantoprazole Sodium (Oral Packet) G 3 ST C1

Pant

opra

zole

Sodi

um Pantoprazole Sodium (Oral Tablet Delayed Release) G 1 QL C1

Prev

acid

Prevacid (Oral Capsule Delayed Release) B 3 QL C1

Prev

acid

Solu

Tab Prevacid SoluTab (Oral Tablet Delayed Release

Dispersible)B 3

C1

Prilo

sec

Prilosec (Oral Packet) B 3 PA C1

Prot

onix

Protonix (Oral Packet) B 3 ST C1

Prot

onix

Protonix (Oral Tablet Delayed Release) B 3 QL C1

Rab

epra

zole

Sodi

um Rabeprazole Sodium (Oral Tablet Delayed Release) G 2

C1

Zeg

erid

Zegerid (Oral Capsule) B 4 PA C1

Zeg

erid

Zegerid (Oral Packet) B 4 PA


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

A1

Genetic or Enzyme or Protein Disorder: Replacement, Modifiers, TreatmentB1

Genetic or Enzyme or Protein Disorder: Replacement, Modifiers, TreatmentC1

Aral

ast

NP

Aralast NP (1000MG Intravenous Solution

Reconstituted)B 4 PA; LA

C1

Bup

hen

yl

Buphenyl (Oral Powder) B 4

C1

Bup

hen

yl

Buphenyl (Oral Tablet) B 4

C1

Car

nitor

Carnitor (Oral Solution) B 3

C1

Car

nitor

Carnitor (Oral Tablet) B 3

C1

Cer

delg

a

Cerdelga (Oral Capsule) B 4 PA C1

Chol

bam

Cholbam (Oral Capsule) B 4 PA C1

Cre

on

Creon (Oral Capsule Delayed Release Particles) B 2

C1

Cro

mol

yn

Sodi

um Cromolyn Sodium (Oral Concentrate) G 2

C1

Cyst

ada

ne

Cystadane (Oral Powder) B 4

C1

Cyst

ago

n

Cystagon (Oral Capsule) B 3 LA C1

Evry

sdi

Evrysdi (Oral Solution Reconstituted) B 4 PA; LA; QL C1

Gala

fold

Galafold (Oral Capsule) B 4 LA C1

Gast

rocr

om

Gastrocrom (Oral Concentrate) B 4

C1

Glas

sia

Glassia (Intravenous Solution) B 4 PA; LA C1

Kev

eyis

Keveyis (Oral Tablet) B 4 PA; QL C1

Kuv

an

Kuvan (Oral Packet) B 4 LA C1

Kuv

an

Kuvan (Oral Tablet) B 4 LA C1

Lev

ocar

nitin

e

Levocarnitine (1GM/10ML Oral Solution) G 3

C1

Lev

ocar

nitin

e

Levocarnitine (330MG Oral Tablet) B 2

C1

Migl

usta

t

Miglustat (Oral Capsule) G 4 PA; LA C1

Nitis

inon

e

Nitisinone (Oral Capsule) G 4

C1

Nityr

Nityr (Oral Tablet) B 4 LA C1

Orfa

din

Orfadin (Oral Capsule) B 4 LA C1

Orfa

din

Orfadin (Oral Suspension) B 4 LA C1

Paly

nziq

Palynziq (Subcutaneous Solution Prefilled Syringe) B 4 PA; QL C1

Pan

crea

ze

Pancreaze (10500-35500UNIT Oral Capsule Delayed

Release Particles, 2600-8800UNIT Oral Capsule

Delayed Release Particles, 4200-14200UNIT Oral

Capsule Delayed Release Particles)

B 3 ST

C1

Pan

crea

ze

Pancreaze (16800-56800UNIT Oral Capsule Delayed


Delayed Release Particles)

B 4 ST



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Pert

zye

Pertzye (16000-57500UNIT Oral Capsule Delayed



B 4 ST

C1

Pert

zye

Pertzye (4000-14375UNIT Oral Capsule Delayed



B 3 ST

C1

Proc

ysbi

Procysbi (Oral Packet) B 4 LA C1

Prol

astin

-C

Prolastin-C (Intravenous Solution Reconstituted) B 4 PA; LA C1

RAV

ICTI

RAVICTI (Oral Liquid) B 4 LA C1

Sapr

opte

rin

Dihy

droc

hlori

de Sapropterin Dihydrochloride (Oral Packet) G 4

C1

Sapr

opte

rin

Dihy

droc

hlori

de Sapropterin Dihydrochloride (Oral Tablet) G 4

C1

Sodi

um

Phe

nylb

utyr

ate Sodium Phenylbutyrate (Oral Powder) G 4

C1

Sodi

um

Phe

nylb

utyr

ate Sodium Phenylbutyrate (Oral Tablet) G 4

C1

Sucr

aid

Sucraid (Oral Solution) B 4 LA C1

Teg

sedi

Tegsedi (Subcutaneous Solution Prefilled Syringe) B 4 PA; LA C1

Viok

ace

Viokace (10440-39150UNIT Oral Tablet) B 3 ST C1

Viok

ace

Viokace (20880-78300UNIT Oral Tablet) B 4 ST C1

Vyn

dam

ax

Vyndamax (Oral Capsule) B 4 PA; LA; QL C1

Vyn

daq

el

Vyndaqel (Oral Capsule) B 4 PA; LA; QL C1

Xuri

den

Xuriden (Oral Packet) B 4 PA; LA C1

Zav

esca

Zavesca (Oral Capsule) B 4 PA; LA C1

Zem

aira

Zemaira (Intravenous Solution Reconstituted) B 4 PA; LA C1

Zen

pep

Zenpep (Oral Capsule Delayed Release Particles) B 2

A1

Genitourinary AgentsB1

Antispasmodics, UrinaryC1

Darif

ena

cin

Hyd

robr

omi

de

ER Darifenacin Hydrobromide ER (Oral Tablet Extended

Release 24 Hour)G 3 ST; QL

C1

Detr

ol

LA

Detrol LA (Oral Capsule Extended Release 24 Hour) B 3

C1

Detr

ol

Detrol (Oral Tablet) B 3

C1

Ditr

opa

n XL

Ditropan XL (Oral Tablet Extended Release 24 Hour) B 3

C1

Flav

oxat

e

HCl

Flavoxate HCl (Oral Tablet) G 2

C1

Geln

ique

Gelnique (Transdermal Gel) B 3

C1

Ge

mte

sa

Gemtesa (Oral Tablet) B 3 ST C1

Myr

betri

q

Myrbetriq (Oral Tablet Extended Release 24 Hour) B 2

C1

Oxy

buty

nin

Chlo

ride

ER Oxybutynin Chloride ER (Oral Tablet Extended Release

24 Hour)G 2

C1

Oxy

buty

nin

Chlo

ride Oxybutynin Chloride (Oral Syrup) G 1

C1

Oxy

buty

nin

Chlo

ride Oxybutynin Chloride (Oral Tablet Immediate Release) G 1


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Oxyt

rol

Oxytrol (Transdermal Patch Twice Weekly) B 4

C1

Solif

ena

cin

Suc

cina

te Solifenacin Succinate (Oral Tablet) G 2 QL C1

Tolt

erod

ine

Tartr

ate

ER Tolterodine Tartrate ER (Oral Capsule Extended Release

24 Hour)G 3

C1

Tolt

erod

ine

Tartr

ate Tolterodine Tartrate (Oral Tablet) G 2

C1

Tovi

az

Toviaz (Oral Tablet Extended Release 24 Hour) B 3 ST; QL C1

Tros

piu

m

Chlo

ride

ER Trospium Chloride ER (Oral Capsule Extended Release

24 Hour)G 3

C1

Tros

piu

m

Chlo

ride Trospium Chloride (Oral Tablet) G 2

C1

Vesi

care

LS

Vesicare LS (Oral Suspension) B 3 PA; QL C1

Vesi

care

Vesicare (Oral Tablet) B 3 QL B1

Benign Prostatic Hypertrophy AgentsC1

Alfu

zosi

n

HCl

ER Alfuzosin HCl ER (Oral Tablet Extended Release 24

Hour)G 1

C1

Avo

dart

Avodart (Oral Capsule) B 3

C1

Car

dura

XL

Cardura XL (Oral Tablet Extended Release 24 Hour) B 3 QL C1

Ciali

s

Cialis (2.5MG Oral Tablet, 5MG Oral Tablet) B 3 PA; QL C1

Duta

steri

de

Dutasteride (Oral Capsule) G 2

C1

Duta

steri

de-

Tam

sulo

sin

HCl Dutasteride-Tamsulosin HCl (Oral Capsule) G 3

C1

Fina

steri

de

Finasteride (5MG Oral Tablet) (Generic Proscar) G 1

C1

Flo

max

Flomax (Oral Capsule) B 3

C1

Jaly

n

Jalyn (Oral Capsule) B 3

C1

Pros

car

Proscar (Oral Tablet) B 3

C1

Rap

aflo

Rapaflo (Oral Capsule) B 3 ST; QL C1

Silo

dosi

n

Silodosin (Oral Capsule) G 2 QL C1

Tad

alafil

Tadalafil (2.5MG Oral Tablet, 5MG Oral Tablet) G 3 PA; QL C1

Tam

sulo

sin

HCl

Tamsulosin HCl (Oral Capsule) G 1

C1

Tera

zosi

n

HCl

Terazosin HCl (Oral Capsule) G 1

C1

Uro

xatr

al

Uroxatral (Oral Tablet Extended Release 24 Hour) B 3

B1

Genitourinary Agents, OtherC1

Beth

ane

chol

Chlo

ride Bethanechol Chloride (10MG Oral Tablet, 25MG Oral


C1

Beth

ane

chol

Chlo

ride Bethanechol Chloride (50MG Oral Tablet) G 3

C1

Cup

rimi

ne

Cuprimine (Oral Capsule) B 4 PA C1

Dep

en

Titra

tabs

Depen Titratabs (Oral Tablet) B 4

C1

Elmi

ron

Elmiron (Oral Capsule) B 4



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Lith

osta

t

Lithostat (Oral Tablet) B 4

C1

Peni

cilla

min

e

Penicillamine (250MG Oral Capsule) G 4 PA C1

Peni

cilla

min

e

Penicillamine (250MG Oral Tablet) G 4

C1

Thio

la

EC

Thiola EC (Oral Tablet Delayed Release) B 4 LA C1

Thio

la

Thiola (Oral Tablet Immediate Release) B 4 LA C1

Tiop

roni

n

Tiopronin (Oral Tablet) G 4

A1

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)B1

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)C1

Acth

ar

Acthar (Injection Gel) B 4 PA; LA C1

Alki

ndi

Spri

nkle

Alkindi Sprinkle (Oral Capsule Sprinkle) B 4

C1

Cort

ef

Cortef (Oral Tablet) B 3

C1

Dex

ablis

s

Dexabliss (Oral Tablet Therapy Pack) G 3

C1

Dex

ame

thas

one

Dexamethasone (Oral Elixir) G 1

C1

Dex

ame

thas

one

Dexamethasone (Oral Tablet) G 1

C1

Dex

ame

thas

one

Dexamethasone (Oral Tablet Therapy Pack) G 3

C1

Emfl

aza

Emflaza (Oral Suspension) B 4 PA; LA C1

Emfl

aza

Emflaza (Oral Tablet) B 4 PA; LA C1

Flud

roco

rtiso

ne

Acet

ate Fludrocortisone Acetate (Oral Tablet) G 1

C1

He

mad

y

Hemady (Oral Tablet) B 3

C1

Hyd

roco

rtiso

ne

Hydrocortisone (Oral Tablet) G 1

C1

Med

rol

Medrol (Oral Tablet) B 3

C1

Med

rol

Medrol (Oral Tablet Therapy Pack) B 3

C1

Met

hylp

redn

isol

one Methylprednisolone (Oral Tablet) G 1

C1

Met

hylp

redn

isol

one Methylprednisolone (Oral Tablet Therapy Pack) G 1

C1

Milli

pred

Millipred (Oral Tablet) G 3

C1

Ora

pred

ODT

Orapred ODT (Oral Tablet Dispersible) B 3

C1

Pre

dnis

olon

e

Prednisolone (Oral Solution) G 1

C1

Pre

dnis

olon

e

Sodi

um

Pho

sph

ate Prednisolone Sodium Phosphate (10MG/5ML Oral

Solution, 20MG/5ML Oral Solution, 25MG/5ML Oral

Solution, 6.7MG/5ML Oral Solution)

G 3

C1

Pre

dnis

olon

e

Sodi

um

Pho

sph

ate

ODTPrednisolone Sodium Phosphate ODT (10MG Oral

Tablet Dispersible, 15MG Oral Tablet Dispersible, 30MG

Oral Tablet Dispersible)

G 3

C1

Pre

dnis

one

Inte

nsol Prednisone Intensol (Oral Concentrate) G 3

C1

Pre

dnis

one

Prednisone (5MG/5ML Oral Solution) G 3

C1

Pre

dnis

one

Prednisone (10MG Oral Tablet, 1MG Oral Tablet, 2.5MG

Oral Tablet, 20MG Oral Tablet, 50MG Oral Tablet, 5MG

Oral Tablet)

G 1


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Pre

dnis

one

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)

G 1

C1

Ray

os

Rayos (Oral Tablet Delayed Release) B 4 PA C1

Tap

erD

ex

12-

Day TaperDex 12-Day (Oral Tablet Therapy Pack) G 3

C1

Tap

erD

ex 6-

Day

TaperDex 6-Day (Oral Tablet Therapy Pack) G 3

C1

Tap

erD

ex 7-

Day

TaperDex 7-Day (Oral Tablet Therapy Pack) G 3

A1

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)B1

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)C1

DDA

VP

DDAVP (0.1MG Oral Tablet) B 3

C1

DDA

VP

DDAVP (0.2MG Oral Tablet) B 4

C1

Des

mop

ressi

n

Acet

ate Desmopressin Acetate (Oral Tablet) G 2

C1

Des

mop

ressi

n

Acet

ate

Spra

y Desmopressin Acetate Spray (Nasal Solution) G 3

C1

Egrif

ta

SV

Egrifta SV (2MG Subcutaneous Solution

Reconstituted)B 4 PA; LA

C1

Gen

otro

pin

Mini

Quic

k Genotropin MiniQuick (Subcutaneous Solution

Reconstituted)B 4 PA

C1

Gen

otro

pin

Genotropin (12MG Subcutaneous Solution


C1

Gen

otro

pin

Genotropin (5MG Subcutaneous Solution


C1

Hu

matr

ope

Humatrope (Injection Solution Renconstituted),

Humatrope Combo Pack (Injection)B 4 PA

C1

Incr

elex

Increlex (Subcutaneous Solution) B 4 PA; LA C1

Noc

durn

a

Nocdurna (Tablet Sublingual) B 3 PA C1

Nor

ditro

pin

Flex

Pro Norditropin FlexPro (Subcutaneous Solution Pen-

Injector)B 4 PA

C1

Nutr

opin

AQ

NuS

pin

10 Nutropin AQ NuSpin 10 (Subcutaneous Solution Pen-

Injector)B 4 PA

C1

Nutr

opin

AQ

NuS

pin


Injector)B 4 PA

C1

Nutr

opin

AQ

NuS

pin


Injector)B 4 PA

C1

Om

nitro

pe

Omnitrope (Subcutaneous Solution Cartridge) B 4 PA C1

Om

nitro

pe

Omnitrope (Subcutaneous Solution Reconstituted) B 4 PA C1

Saiz

en

Saizen (Injection Solution Reconstituted) B 4 PA; LA C1

Saiz

enpr

ep

Saizenprep (Injection Solution Reconstituted) B 4 PA; LA



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Ser

osti

m

Serostim (Subcutaneous Solution Reconstituted) B 4 PA; LA C1

Zom

acto

n

Zomacton (10MG Subcutaneous Solution


C1

Zom

acto

n

Zomacton (5MG Subcutaneous Solution


C1

Zor

btiv

e

Zorbtive (Subcutaneous Solution Reconstituted) B 4 PA; LA A1

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)B1

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)C1

Korl

ym

Korlym (Oral Tablet) B 4 PA; LA A1

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)B1

Anabolic SteroidsC1

Oxa

ndro

lone

Oxandrolone (10MG Oral Tablet) G 3

C1

Oxa

ndro

lone

Oxandrolone (2.5MG Oral Tablet) G 2

B1

AndrogensC1

And

rode

rm

Androderm (Transdermal Patch 24 Hour) B 2

C1

And

roG

el

Pum

p AndroGel Pump (Transdermal Gel) B 4

C1

And

roG

el

AndroGel (Transdermal Gel) B 4

C1

Ave

ed

Aveed (Intramuscular Solution) B 3 PA C1

Dan

azol

Danazol (Oral Capsule) G 3

C1

Dep

o-

Test

oste

rone Depo-Testosterone (Intramuscular Solution) G 3

C1

Fort

esta

Fortesta (Transdermal Gel) B 3

C1

Intra

rosa

Intrarosa (Vaginal Insert) B 3 PA; QL C1

Jate

nzo

Jatenzo (158MG Oral Capsule, 198MG Oral Capsule) B 3 PA C1

Jate

nzo

Jatenzo (237MG Oral Capsule) B 4 PA C1

Met

hite

st

Methitest (Oral Tablet) G 4 PA C1

Met

hylt

esto

ster

one Methyltestosterone (Oral Capsule) G 4 PA C1

Nat

esto

Natesto (Nasal Gel) B 3

C1

Test

im

Testim (Transdermal Gel) B 4

C1

Test

oste

rone

Cypi

onat

e Testosterone Cypionate (Intramuscular Solution) G 1

C1

Test

oste

rone

Ena

ntha

te Testosterone Enanthate (Intramuscular Solution) G 2

C1

Test

oste

rone

Pum

p Testosterone Pump (2% Transdermal Gel, 1%

Transdermal Gel, 1.62% Transdermal Gel), Testosterone

(20.25 MG/1.25GM 1.62% Transdermal Gel, 25 MG/

2.5GM 1% Transdermal Gel, 40.5 MG/2.5GM 1.62%

Transdermal Gel, 50 MG/5GM 1% Transdermal Gel)

G 3

C1

Test

oste

rone

Testosterone (Transdermal Solution) G 3

C1

Vog

elxo

Pum

p Vogelxo Pump (Transdermal Gel) B 3

C1

Vog

elxo

Vogelxo (Transdermal Gel) B 3


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Xyo

sted

Xyosted (Subcutaneous Solution Auto-Injector) B 3 PA B1

EstrogensC1

Alor

a

Alora (Transdermal Patch Twice Weekly) B 3 PA; HRM; QL C1

Alta

vera

Altavera (Oral Tablet) G 3

C1

Alya

cen

1/35

Alyacen 1/35 (Oral Tablet) G 3

C1

Ame

thia

Amethia (Oral Tablet) G 3

C1

Ann

over

a

Annovera (Vaginal Ring) B 3 QL C1

Apri

Apri (Oral Tablet) G 3

C1

Aran

elle

Aranelle (Oral Tablet) G 3

C1

Ashl

yna

Ashlyna (Oral Tablet) G 3

C1

Aub

ra

EQ

Aubra EQ (Oral Tablet) G 3

C1

Avia

ne

Aviane (Oral Tablet) G 3

C1

Balc

oltra

Balcoltra (Oral Tablet) B 3

C1

Balz

iva

Balziva (Oral Tablet) G 3

C1

Bey

az

Beyaz (Oral Tablet) B 3

C1

Blis

ovi

24

Fe

Blisovi 24 Fe (Oral Tablet) G 3

C1

Blis

ovi

Fe

1.5/

30 Blisovi Fe 1.5/30 (Oral Tablet) G 3

C1

Briel

lyn

Briellyn (Oral Tablet) G 3

C1

Cam

rese

Lo

Camrese Lo (Oral Tablet) G 3

C1

Cazi

ant

Caziant (Oral Tablet) G 3

C1

Clim

ara

Pro

Climara Pro (Transdermal Patch Weekly) B 3 PA; HRM C1

Crys

elle-

28

Cryselle-28 (Oral Tablet) G 3

C1

Cycl

afe

m

1/35

Cyclafem 1/35 (Oral Tablet) G 3

C1

Cycl

afe

m

7/7/

7 Cyclafem 7/7/7 (Oral Tablet) G 3

C1

Cyre

d

EQ

Cyred EQ (Oral Tablet) G 3

C1

Dele

stro

gen

Delestrogen (Intramuscular Oil) B 3

C1

Dep

o-

Estr

adio

l Depo-Estradiol (Intramuscular Oil) G 3

C1

Des

oge

strel

-

Ethi

nyl

Estr

adio

l Desogestrel-Ethinyl Estradiol (Oral Tablet) G 3

C1

Doli

shal

e

Dolishale (Oral Tablet) G 3

C1

Dott

i

Dotti (Transdermal Patch Twice Weekly) G 3 PA; HRM; QL C1

Dro

spir

eno

ne-

Ethi

nyl

Estr

adio

l Drospirenone-Ethinyl Estradiol (Oral Tablet) G 3

C1

Dro

spir

eno

ne-

Ethi

nyl

Estr

adio

l-

Lev

ome

folat

e

Drospirenone-Ethinyl Estradiol-Levomefolate

(3-0.02-0.451MG Oral Tablet)G 3

C1

Eles

trin

Elestrin (Transdermal Gel) B 3 PA; HRM C1

Elu

Ryn

g

EluRyng (Vaginal Ring) G 3

C1

Emo

quet

te

Emoquette (Oral Tablet) G 3



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Enp

ress

e-28

Enpresse-28 (Oral Tablet) G 3

C1

Ens

kyce

Enskyce (Oral Tablet) G 3

C1

Esta

rylla

Estarylla (Oral Tablet) G 3

C1

Estr

ace

Estrace (Oral Tablet) G 3 PA; HRM C1

Estr

ace

Estrace (Vaginal Cream) G 3

C1

Estr

adio

l

Estradiol (Oral Tablet) G 3 PA; HRM C1

Estr

adio

l

Estradiol (Transdermal Patch Twice Weekly) G 3 PA; HRM; QL C1

Estr

adio

l

Estradiol (Vaginal Cream) G 3

C1

Estr

adio

l

Estradiol (Vaginal Tablet) G 3

C1

Estr

adio

l

Vale

rate Estradiol Valerate (Intramuscular Oil) G 2

C1

Estri

ng

Estring (Vaginal Ring) B 3

C1

Ethy

nodi

ol

Diac

etat

e-

Ethi

nyl

Estr

adio

l

Ethynodiol Diacetate-Ethinyl Estradiol (Oral Tablet) G 3

C1

Eton

oge

strel

-

Ethi

nyl

Estr

adio

l Etonogestrel-Ethinyl Estradiol (Vaginal Ring) G 3

C1

Fal

min

a

Falmina (Oral Tablet) G 3

C1

Fay

osi

m

Fayosim (Oral Tablet) G 3

C1

Fem

ring

Femring (Vaginal Ring) B 3

C1

Fem

ynor

Femynor (Oral Tablet) G 3

C1

Fyav

olv

Fyavolv (Oral Tablet) G 3 PA; HRM C1

Ge

mmi

ly

Gemmily (Oral Capsule) G 3

C1

Gen

eres

s Fe

Generess Fe (Oral Tablet Chewable) B 3

C1

Hail

ey

24

Fe

Hailey 24 Fe (Oral Tablet) G 3

C1

Iclev

ia

Iclevia (Oral Tablet) G 3

C1

Imv

exxy

Mai

nten

anc

e

Pac

k Imvexxy Maintenance Pack (Vaginal Insert) B 2 PA C1

Imv

exxy

Start

er

Pac

k Imvexxy Starter Pack (Vaginal Insert) B 2 PA C1

Intro

vale

Introvale (Oral Tablet) G 3

C1

Isibl

oom

Isibloom (Oral Tablet) G 3

C1

Jas

miel

Jasmiel (Oral Tablet) G 3

C1

Jint

eli

Jinteli (Oral Tablet) G 3 PA; HRM C1

Jule

ber

Juleber (Oral Tablet) G 3

C1

Jun

el

1.5/

30

Junel 1.5/30 (Oral Tablet) G 3

C1

Jun

el

1/20

Junel 1/20 (Oral Tablet) G 3

C1

Jun

el

Fe

1.5/

30 Junel Fe 1.5/30 (Oral Tablet) G 3

C1

Jun

el

Fe

1/20

Junel Fe 1/20 (Oral Tablet) G 3

C1

Jun

el

Fe

24

Junel Fe 24 (Oral Tablet) G 3

C1

Kaitl

ib

Fe

Kaitlib Fe (Oral Tablet Chewable) G 3

C1

Kari

va

Kariva (Oral Tablet) G 3

C1

Keln

or

1/35

Kelnor 1/35 (Oral Tablet) G 3


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Keln

or

1/50

Kelnor 1/50 (Oral Tablet) G 3

C1

Kurv

elo

Kurvelo (Oral Tablet) G 3

C1

LAR

IN

1.5/

30

LARIN 1.5/30 (Oral Tablet) G 3

C1

LAR

IN

1/20

LARIN 1/20 (Oral Tablet) G 3

C1

LAR

IN

Fe

1.5/

30 LARIN Fe 1.5/30 (Oral Tablet) G 3

C1

LAR

IN

Fe

1/20

LARIN Fe 1/20 (Oral Tablet) G 3

C1

Lari

ssia

Larissia (Oral Tablet) G 3

C1

Lay

olis

Fe

Layolis Fe (Oral Tablet Chewable) B 3

C1

Lee

na

Leena (Oral Tablet) G 3

C1

Less

ina

Lessina (Oral Tablet) G 3

C1

Lev

one

st

Levonest (Oral Tablet) G 3

C1

Lev

onor

gest

rel-

Ethi

nyl

Estr

adio

l &

Ethi

nyl

Estr

adio

l

Levonorgestrel-Ethinyl Estradiol & Ethinyl Estradiol (Oral

Tablet)G 3

C1

Lev

onor

gest

rel-

Ethi

nyl

Estr

adio

l 91-

DayLevonorgestrel-Ethinyl Estradiol 91-Day (Oral Tablet) G 3

C1

Lev

onor

gest

rel-

Ethi

nyl

Estr

adio

l Levonorgestrel-Ethinyl Estradiol (Oral Tablet) G 3

C1

Lev

ora

0.15

/30

Levora 0.15/30 (28) (Oral Tablet) G 3

C1

Lo

Loe

strin

Fe

Lo Loestrin Fe (Oral Tablet) B 3

C1

Loe

strin

1.5/

30 Loestrin 1.5/30 (21) (Oral Tablet) G 3

C1

Loe

strin

1/20

Loestrin 1/20 (21) (Oral Tablet) G 3

C1

Loe

strin

Fe

1.5/

30 Loestrin Fe 1.5/30 (Oral Tablet) G 3

C1

Loe

strin

Fe

1/20

Loestrin Fe 1/20 (Oral Tablet) G 3

C1

Lory

na

Loryna (Oral Tablet) G 3

C1

LoS

eas

oniq

ue

LoSeasonique (Oral Tablet) B 3

C1

Low

-

Oge

strel

Low-Ogestrel (Oral Tablet) G 3

C1

Lute

ra

Lutera (Oral Tablet) G 3

C1

Lylla

na

Lyllana (Transdermal Patch Twice Weekly) G 3 PA; HRM; QL C1

Marl

issa

Marlissa (Oral Tablet) G 3

C1

Men

est

Menest (Oral Tablet) G 3 PA; HRM C1

Mer

zee

Merzee (Oral Capsule) B 3

C1

Mib

elas

24

Fe

Mibelas 24 Fe (Oral Tablet Chewable) G 3

C1

Micr

oge

stin

1.5/

30 Microgestin 1.5/30 (Oral Tablet) G 3

C1

Micr

oge

stin

1/20

Microgestin 1/20 (Oral Tablet) G 3

C1

Micr

oge

stin

Fe

1.5/

30 Microgestin Fe 1.5/30 (Oral Tablet) G 3

C1

Micr

oge

stin

Fe

1/20 Microgestin Fe 1/20 (Oral Tablet) G 3

C1

Mili

Mili (Oral Tablet) G 3

C1

Min

astri

n 24

Fe

Minastrin 24 Fe (Oral Tablet Chewable) B 3



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Mini

velle

Minivelle (Transdermal Patch Twice Weekly) B 3 PA; HRM; QL C1

Nata

zia

Natazia (Oral Tablet) B 3

C1

Nec

on

0.5/

35

Necon 0.5/35 (28) (Oral Tablet) G 3

C1

Next

stelli

s

Nextstellis (Oral Tablet) B 3

C1

Nikk

i

Nikki (Oral Tablet) G 3

C1

Nor

ethi

ndro

ne

Acet

ate-

Ethi

nyl

Estr

adio

l

Norethindrone Acetate-Ethinyl Estradiol (0.5-2.5MG-MCG

Oral Tablet, 1-5MG-MCG Oral Tablet)G 3 PA; HRM

C1

Nor

ethi

ndro

ne

Acet

ate-

Ethi

nyl

Estr

adio

l

Norethindrone Acetate-Ethinyl Estradiol (1-20MG-MCG

Oral Tablet)G 3

C1

Nor

ethi

ndro

ne

Acet

ate-

Ethi

nyl

Estr

adio

l-Fe

Norethindrone Acetate-Ethinyl Estradiol-Fe (1-20MG-

MCG Oral Tablet)G 3

C1

Nor

ethi

ndro

ne

Acet

ate-

Ethi

nyl

Estr

adio

l-Fe

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)

G 3

C1

Nor

gest

imat

e-

Ethi

nyl

Estr

adio

l Norgestimate-Ethinyl Estradiol (Oral Tablet) G 3

C1

Nor

gest

imat

e-

Ethi

nyl

Estr

adio

l

Trip

hasi

c

Norgestimate-Ethinyl Estradiol Triphasic (Oral Tablet) G 3

C1

Nort

rel

0.5/

35

Nortrel 0.5/35 (28) (Oral Tablet) G 3

C1

Nort

rel

1/35

Nortrel 1/35 (21) (Oral Tablet) G 3

C1

Nort

rel

1/35

Nortrel 1/35 (28) (Oral Tablet) G 3

C1

Nort

rel

7/7/

7

Nortrel 7/7/7 (Oral Tablet) G 3

C1

Nuv

aRin

g

NuvaRing (Vaginal Ring) B 3

C1

Nyli

a

7/7/

7

Nylia 7/7/7 (Oral Tablet) G 3

C1

Nym

yo

Nymyo (Oral Tablet) G 3

C1

Ocel

la

Ocella (Oral Tablet) G 3

C1

Orsy

thia

Orsythia (Oral Tablet) G 3

C1

Pimt

rea

Pimtrea (Oral Tablet) G 3

C1

Pirm

ella

1/35

Pirmella 1/35 (Oral Tablet) G 3

C1

Porti

a-28

Portia-28 (Oral Tablet) G 3

C1

Pre

mari

n

Premarin (Vaginal Cream) B 2

C1

Prev

ifem

Previfem (Oral Tablet) G 3

C1

Qua

rtett

e

Quartette (Oral Tablet) B 3

C1

Recl

ipse

n

Reclipsen (Oral Tablet) G 3

C1

Rive

lsa

Rivelsa (Oral Tablet) G 3

C1

Safy

ral

Safyral (Oral Tablet) B 3

C1

Sea

soni

que

Seasonique (Oral Tablet) B 3

C1

Setl

akin

Setlakin (Oral Tablet) G 3

C1

Spri

ntec

28

Sprintec 28 (Oral Tablet) G 3

C1

Sro

nyx

Sronyx (Oral Tablet) G 3


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Sye

da

Syeda (Oral Tablet) G 3

C1

Tari

na

24

Fe

Tarina 24 Fe (Oral Tablet) G 3

C1

Tari

na

Fe

1/20

EQ Tarina Fe 1/20 EQ (Oral Tablet) G 3

C1

Tilia

Fe

Tilia Fe (Oral Tablet) G 3

C1

Tri-

Esta

rylla

Tri-Estarylla (Oral Tablet) G 3

C1

Tri-

Leg

est

Fe

Tri-Legest Fe (Oral Tablet) G 3

C1

Tri-

Lo-

Esta

rylla

Tri-Lo-Estarylla (Oral Tablet) G 3

C1

Tri-

Lo-

Spri

ntec

Tri-Lo-Sprintec (Oral Tablet) G 3

C1

Tri-

Mili

Tri-Mili (Oral Tablet) G 3

C1

Tri-

Nym

yo

Tri-Nymyo (Oral Tablet) G 3

C1

Tri-

Prev

ifem

Tri-Previfem (Oral Tablet) G 3

C1

Tri-

Spri

ntec

Tri-Sprintec (Oral Tablet) G 3

C1

Triv

ora

Trivora (28) (Oral Tablet) G 3

C1

Tri-

VyLi

bra

Lo

Tri-VyLibra Lo (Oral Tablet) G 3

C1

Tri-

VyLi

bra

Tri-VyLibra (Oral Tablet) G 3

C1

Tyd

emy

Tydemy (Oral Tablet) G 3

C1

Vagi

fem

Vagifem (Vaginal Tablet) B 3

C1

Veli

vet

Velivet (Oral Tablet) G 3

C1

Vest

ura

Vestura (Oral Tablet) G 3

C1

Vien

va

Vienva (Oral Tablet) G 3

C1

Vive

lle-

Dot

Vivelle-Dot (Transdermal Patch Twice Weekly) B 3 PA; HRM; QL C1

Vyfe

mla

Vyfemla (Oral Tablet) G 3

C1

VyLi

bra

VyLibra (Oral Tablet) G 3

C1

WY

MZ

YA

Fe

WYMZYA Fe (Oral Tablet Chewable) G 3

C1

Xula

ne

Xulane (Transdermal Patch Weekly) G 3

C1

Yas

min

28

Yasmin 28 (Oral Tablet) B 3

C1

YAZ

YAZ (Oral Tablet) B 3

C1

Yuv

afe

m

Yuvafem (Vaginal Tablet) G 3

C1

Zafe

my

Zafemy (Transdermal Patch Weekly) G 3

C1

Zara

h

Zarah (Oral Tablet) G 3

C1

Zovi

a

1/35

E

Zovia 1/35E (28) (Oral Tablet) G 3

B1

ProgestinsC1

Ayg

esti

n

Aygestin (Oral Tablet) G 3

C1

Cam

ila

Camila (Oral Tablet) G 2

C1

Crin

one

Crinone (Vaginal Gel) B 3 PA



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Debl

itan

e

Deblitane (Oral Tablet) G 2

C1

Dep

o-

Prov

era

Depo-Provera (150MG/ML Intramuscular Suspension) B 3

C1

Dep

o-

Sub

Q

Prov

era

104 Depo-SubQ Provera 104 (Subcutaneous Suspension

Prefilled Syringe)B 3

C1

Errin

Errin (Oral Tablet) G 2

C1

Inca

ssia

Incassia (Oral Tablet) G 2

C1

Lyle

q

Lyleq (Oral Tablet) G 2

C1

Lyza

Lyza (Oral Tablet) G 2

C1

Med

roxy

pro

gest

eron

e

Acet

ate Medroxyprogesterone Acetate (Intramuscular

Suspension)G 1

C1

Med

roxy

pro

gest

eron

e

Acet

ate Medroxyprogesterone Acetate (Intramuscular

Suspension Prefilled Syringe)G 1

C1

Med

roxy

pro

gest

eron

e

Acet

ate Medroxyprogesterone Acetate (Oral Tablet) G 1

C1

Meg

estr

ol

Acet

ate Megestrol Acetate (40MG/ML Oral Suspension, 625MG/

5ML Oral Suspension)G 3 PA; HRM

C1

Meg

estr

ol

Acet

ate Megestrol Acetate (Oral Tablet) G 3 PA; HRM C1

Nor

a-BE

Nora-BE (Oral Tablet) G 2

C1

Nor

ethi

ndro

ne

Acet

ate Norethindrone Acetate (5MG Oral Tablet) G 1

C1

Nor

ethi

ndro

ne

Norethindrone (0.35MG Oral Tablet) G 2

C1

Pro

gest

eron

e

Progesterone (Oral Capsule) G 2

C1

Pro

metr

ium

Prometrium (Oral Capsule) B 3

C1

Prov

era

Provera (Oral Tablet) B 3

C1

Shar

obel

Sharobel (Oral Tablet) G 2

C1

Slyn

d

Slynd (Oral Tablet) B 3

B1

Selective Estrogen Receptor Modifying AgentsC1

Evis

ta

Evista (Oral Tablet) B 3

C1

Osp

hen

a

Osphena (Oral Tablet) B 2 PA; QL C1

Ralo

xife

ne

HCl

Raloxifene HCl (Oral Tablet) G 2

A1

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)B1

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)C1

Cyto

mel

Cytomel (Oral Tablet) B 3

C1

Euth

yrox

Euthyrox (Oral Tablet) B 1

C1

Lev

o-T

Levo-T (Oral Tablet) B 1

C1

Lev

othy

roxi

ne

Sodi

um Levothyroxine Sodium (Oral Capsule) G 3

C1

Lev

othy

roxi

ne

Sodi

um Levothyroxine Sodium (Oral Tablet) G 1

C1

Lev

oxyl

Levoxyl (Oral Tablet) B 1

C1

Liot

hyro

nine

Sodi

um Liothyronine Sodium (Oral Tablet) G 1


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Synt

hroi

d

Synthroid (Oral Tablet) B 2

C1

Thy

quid

ity

Thyquidity (Oral Solution) B 3

C1

Tiro

sint

Tirosint (Oral Capsule) B 3

C1

Tiro

sint-

SOL

Tirosint-SOL (100MCG/ML Oral Solution, 112MCG/

ML Oral Solution, 125MCG/ML Oral Solution,

137MCG/ML Oral Solution, 13MCG/ML Oral Solution,

150MCG/ML Oral Solution, 175MCG/ML Oral

Solution, 200MCG/ML Oral Solution, 25MCG/ML Oral

Solution, 50MCG/ML Oral Solution, 75MCG/ML Oral

Solution, 88MCG/ML Oral Solution)

B 3

C1

Unit

hroi

d

Unithroid (Oral Tablet) B 1

A1

Hormonal Agents, Suppressant (Adrenal)B1

Hormonal Agents, Suppressant (Adrenal)C1

Istur

isa

Isturisa (Oral Tablet) B 4 PA C1

Lys

odre

n

Lysodren (Oral Tablet) B 4

A1

Hormonal Agents, Suppressant (Pituitary)B1

Hormonal Agents, Suppressant (Pituitary)C1

Cab

ergo

line

Cabergoline (Oral Tablet) G 2

C1

Elig

ard

Eligard (Subcutaneous Kit) B 3 PA C1

Firm

ago

n

Firmagon (240MG Dose) (120MG/Vial Subcutaneous

Solution Reconstituted)B 4 PA

C1

Firm

ago

n

Firmagon (80MG Subcutaneous Solution


C1

Leu

proli

de

Acet

ate Leuprolide Acetate (Injection Kit) G 3 PA C1

Lup

anet

a

Pac

k Lupaneta Pack (Combination Kit) B 4 PA C1

Lupr

on

Dep

ot

Lupron Depot (1-Month) (Intramuscular Kit) B 4 PA C1

Lupr

on

Dep

ot


Lupr

on

Dep

ot


Lupr

on

Dep

ot


Myc

apss

a

Mycapssa (Oral Capsule Delayed Release) B 4 PA; QL C1

Octr

eoti

de

Acet

ate Octreotide Acetate (1000MCG/ML Injection Solution,

500MCG/ML Injection Solution)G 4 PA

C1

Octr

eoti

de

Acet

ate Octreotide Acetate (100MCG/ML Injection Solution,

200MCG/ML Injection Solution, 50MCG/ML Injection

Solution)

G 3 PA

C1

Org

ovyx

Orgovyx (Oral Tablet) B 4 PA; QL C1

Oria

hnn

Oriahnn (Oral Capsule Therapy Pack) B 4 PA; QL



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Orili

ssa

Orilissa (Oral Tablet) B 4 PA; QL C1

San

dost

atin

Sandostatin (Injection Solution) B 4 PA C1

Sign

ifor

Signifor (Subcutaneous Solution) B 4 PA; LA C1

Som

aver

t

Somavert (Subcutaneous Solution Reconstituted) B 4 PA; LA; QL C1

Syn

arel

Synarel (Nasal Solution) B 4

C1

Trel

star

Mixj

ect

Trelstar Mixject (Intramuscular Suspension


A1

Hormonal Agents, Suppressant (Thyroid)B1

Antithyroid AgentsC1

Met

him

azol

e

Methimazole (Oral Tablet) G 1

C1

Pro

pylt

hiou

racil

Propylthiouracil (Oral Tablet) G 1

C1

Tap

azol

e

Tapazole (Oral Tablet) G 3

A1

Immunological AgentsB1

Angioedema AgentsC1

Beri

nert

Berinert (Intravenous Kit) B 4 PA; LA C1

Cinr

yze

Cinryze (Intravenous Solution Reconstituted) B 4 PA; LA C1

Fira

zyr

Firazyr (Subcutaneous Solution) B 4 PA; QL C1

Hae

gard

a

Haegarda (Subcutaneous Solution Reconstituted) B 4 PA; LA C1

Icati

bant

Acet

ate Icatibant Acetate (Subcutaneous Solution) G 4 PA; QL C1

Orla

dey

o

Orladeyo (Oral Capsule) B 4 PA; QL C1

Ruc

one

st

Ruconest (Intravenous Solution Reconstituted) B 4 PA; LA C1

Tak

hzyr

o

Takhzyro (Subcutaneous Solution) B 4 PA B1

ImmunoglobulinsC1

BIVI

GA

M

BIVIGAM (Intravenous Solution) B 4 PA C1

Fleb

oga

mm

a

DIF Flebogamma DIF (5GM/50ML Intravenous Solution) B 4 PA C1

Ga

mm

agar

d

Gammagard (2.5GM/25ML Injection Solution) B 4 PA C1

Ga

mm

agar

d S/

D

Less

IgA Gammagard S/D Less IgA (Intravenous Solution


C1

Ga

mm

ake

d

Gammaked (1GM/10ML Injection Solution) B 4 PA C1

Ga

mm

aple

x

Gammaplex (10GM/100ML Intravenous Solution,

10GM/200ML Intravenous Solution, 20GM/200ML

Intravenous Solution, 5GM/50ML Intravenous

Solution)

B 4 PA

C1

Ga

mun

ex-C

Gamunex-C (1GM/10ML Injection Solution) B 4 PA C1

Oct

aga

m

Octagam (1GM/20ML Intravenous Solution, 2GM/

20ML Intravenous Solution)B 4 PA

C1

Pan

zyga

Panzyga (Intravenous Solution) B 4 PA


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Privi

gen

Privigen (20GM/200ML Intravenous Solution) B 4 PA C1

Vari

zig

Varizig (Intramuscular Solution) B 4

B1

Immunological Agents, OtherC1

Acte

mra

ACT

Pen

Actemra ACTPen (Subcutaneous Solution Auto-

Injector)B 4 PA

C1

Acte

mra

Actemra (Subcutaneous Solution Prefilled Syringe) B 4 PA C1

Arca

lyst

Arcalyst (Subcutaneous Solution Reconstituted) B 4 PA; LA C1

Benl

ysta

Benlysta (Subcutaneous Solution Auto-Injector) B 4 PA C1

Benl

ysta

Benlysta (Subcutaneous Solution Prefilled Syringe) B 4 PA C1

Cos

enty

x

Cosentyx (300 MG Dose) (Subcutaneous Solution

Prefilled Syringe)B 4 PA; LA

C1

Cos

enty

x

Sen

sore

ady Cosentyx Sensoready (300 MG) (Subcutaneous

Solution Auto-Injector)B 4 PA; LA

C1

Dupi

xent

Dupixent (300MG/2ML Subcutaneous Solution Pen-

Injector)B 4 PA

C1

Dupi

xent

Dupixent (Subcutaneous Solution Prefilled Syringe) B 4 PA C1

Gras

tek

Grastek (Tablet Sublingual) B 2 PA C1

Ilum

ya

Ilumya (Subcutaneous Solution Prefilled Syringe) B 4 PA C1

Kev

zara

Kevzara (Subcutaneous Solution Auto-Injector) B 4 PA C1

Kev

zara

Kevzara (Subcutaneous Solution Prefilled Syringe) B 4 PA C1

Kine

ret

Kineret (Subcutaneous Solution Prefilled Syringe) B 4 PA C1

Oda

ctra

Odactra (Tablet Sublingual) B 3 PA C1

Olu

mia

nt

Olumiant (Oral Tablet) B 4 PA; QL C1

Oral

air

300I

R

Oralair 300IR (Tablet Sublingual) B 3 PA C1

Ore

ncia

Clic

kJec

t Orencia ClickJect (Subcutaneous Solution Auto-

Injector)B 4 PA

C1

Ore

ncia

Orencia (Subcutaneous Solution Prefilled Syringe) B 4 PA C1

Ote

zla

Otezla (Oral Tablet) B 4 PA; LA C1

Ote

zla

Otezla (Oral Tablet Therapy Pack) B 4 PA; LA C1

Rida

ura

Ridaura (Oral Capsule) B 4

C1

Rinv

oq

Rinvoq (Oral Tablet Extended Release 24 Hour) B 4 PA; QL C1

Siliq

Siliq (Subcutaneous Solution Prefilled Syringe) B 4 PA C1

Skyr

izi

Skyrizi (150 MG Dose) (Subcutaneous Prefilled

Syringe Kit)B 4 PA

C1

Skyr

izi

Pen

Skyrizi Pen (Subcutaneous Solution Auto-Injector) B 4 PA C1

Skyr

izi

Skyrizi (Subcutaneous Solution Prefilled Syringe) B 4 PA



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Stel

ara

Stelara (Subcutaneous Solution) B 4 PA C1

Stel

ara

Stelara (Subcutaneous Solution Prefilled Syringe) B 4 PA C1

Talt

z

Taltz (Subcutaneous Solution Auto-Injector) B 4 PA; LA C1

Talt

z

Taltz (Subcutaneous Solution Prefilled Syringe) B 4 PA; LA C1

Tre

mfy

a

Tremfya (Subcutaneous Solution Pen-Injector) B 4 PA C1

Tre

mfy

a

Tremfya (Subcutaneous Solution Prefilled Syringe) B 4 PA C1

Xelj

anz

Xeljanz (Oral Solution) B 4 PA; QL C1

Xelj

anz

Xeljanz (Oral Tablet Immediate Release) B 4 PA; QL C1

Xelj

anz

XR

Xeljanz XR (Oral Tablet Extended Release 24 Hour) B 4 PA; QL C1

Xola

ir

Xolair (Subcutaneous Solution Prefilled Syringe) B 4 PA; LA C1

Xola

ir

Xolair (Subcutaneous Solution Reconstituted) B 4 PA; LA B1

ImmunostimulantsC1

Acti

mm

une

Actimmune (Subcutaneous Solution) B 4 LA C1

Intro

n A

Intron A (Injection Solution) B 4 PA; LA C1

Intro

n A

Intron A (Injection Solution Reconstituted) B 4 PA; LA C1

Peg

asys

Pegasys (Subcutaneous Solution) B 4 PA B1

ImmunosuppressantsC1

Arav

a

Arava (Oral Tablet) B 4

C1

Asta

graf

XL

Astagraf XL (0.5MG Oral Capsule Extended Release


Hour)

B 3 B/D, PA

C1

Asta

graf

XL

Astagraf XL (5MG Oral Capsule Extended Release 24

Hour)B 4 B/D, PA

C1

Aza

san

Azasan (100MG Oral Tablet) G 3 B/D, PA C1

Aza

san

Azasan (75MG Oral Tablet) G 4 B/D, PA C1

Azat

hiop

rine

Azathioprine (Oral Tablet) G 1 B/D, PA C1

Cell

cept

Cellcept (Oral Capsule) B 4 B/D, PA C1

Cell

cept

Cellcept (Oral Suspension Reconstituted) B 4 B/D, PA C1

Cell

cept

Cellcept (Oral Tablet) B 4 B/D, PA C1

Cim

zia

Prefi

lled

Cimzia Prefilled (Subcutaneous Kit) B 4 PA C1

Cim

zia

Cimzia (Subcutaneous Kit) B 4 PA C1

Cycl

osp

orin

e

Mod

ified Cyclosporine Modified (Oral Capsule) G 2 B/D, PA C1

Cycl

osp

orin

e

Mod

ified Cyclosporine Modified (Oral Solution) G 2 B/D, PA C1

Cycl

osp

orin

e

Cyclosporine (Oral Capsule) G 3 B/D, PA C1

Enb

rel

Mini

Enbrel Mini (Subcutaneous Solution Cartridge) B 4 PA C1

Enb

rel

Enbrel (Subcutaneous Solution) B 4 PA C1

Enb

rel

Enbrel (Subcutaneous Solution Prefilled Syringe) B 4 PA


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Enb

rel

Enbrel (Subcutaneous Solution Reconstituted) B 4 PA C1

Enb

rel

Sure

Clic

k Enbrel SureClick (Subcutaneous Solution Auto-

Injector)B 4 PA

C1

Ens

pryn

g

Enspryng (Subcutaneous Solution Prefilled Syringe) B 4 PA C1

Env

arsu

s XR

Envarsus XR (Oral Tablet Extended Release 24 Hour) B 3 B/D, PA C1

Ever

olim

us

Everolimus (0.25MG Oral Tablet, 0.5MG Oral Tablet,

0.75MG Oral Tablet)G 4 B/D, PA

C1

Gen

graf

Gengraf (Oral Capsule) G 2 B/D, PA C1

Gen

graf

Gengraf (Oral Solution) G 2 B/D, PA C1

Hu

mira

Pedi

atric

Cro

hns

Start Humira Pediatric Crohns Start (Subcutaneous

Prefilled Syringe Kit)B 4 PA

C1

Hu

mira

Pen

Humira Pen (Subcutaneous Pen-Injector Kit) B 4 PA C1

Hu

mira

Pen

Cro

hns

Dise

ase

Start

er Humira Pen Crohns Disease Starter (Subcutaneous

Pen-Injector Kit)B 4 PA

C1

Hu

mira

Pen-

Pedi

atric

UC

Start Humira Pen-Pediatric UC Start (Subcutaneous Pen-

Injector Kit)B 4 PA

C1

Hu

mira

Pen

Psor

iasis

Start

er Humira Pen Psoriasis Starter (Subcutaneous Pen-

Injector Kit)B 4 PA

C1

Hu

mira

Humira (Subcutaneous Prefilled Syringe Kit) B 4 PA C1

Imur

an

Imuran (Oral Tablet) B 3 B/D, PA C1

Lefl

uno

mid

e

Leflunomide (Oral Tablet) G 2

C1

Lup

kyni

s

Lupkynis (Oral Capsule) B 4 PA; QL C1

Met

hotr

exat

e

Methotrexate (Oral Tablet) G 1

C1

Met

hotr

exat

e

Sodi

um Methotrexate Sodium (50MG/2ML Injection Solution

Prefilled Syringe)G 1

C1

Met

hotr

exat

e

Sodi

um Methotrexate Sodium (50MG/2ML Injection Solution) G 1

C1

Myc

oph

enol

ate

Mof

etil Mycophenolate Mofetil (Oral Capsule) G 2 B/D, PA C1

Myc

oph

enol

ate

Mof

etil Mycophenolate Mofetil (Oral Suspension Reconstituted) G 4 B/D, PA C1

Myc

oph

enol

ate

Mof

etil Mycophenolate Mofetil (Oral Tablet) G 2 B/D, PA C1

Myc

oph

enol

ate

Sodi

um Mycophenolate Sodium (Oral Tablet Delayed Release) G 3 B/D, PA C1

Myf

ortic

Myfortic (180MG Oral Tablet Delayed Release) B 3 B/D, PA C1

Myf

ortic

Myfortic (360MG Oral Tablet Delayed Release) B 4 B/D, PA C1

Neo

ral

Neoral (Oral Capsule) B 3 B/D, PA C1

Neo

ral

Neoral (Oral Solution) B 3 B/D, PA C1

Otre

xup

Otrexup (Subcutaneous Solution Auto-Injector) B 3 PA C1

Pro

graf

Prograf (0.5MG Oral Capsule) B 3 B/D, PA



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Pro

graf

Prograf (1MG Oral Capsule, 5MG Oral Capsule) B 4 B/D, PA C1

Pro

graf

Prograf (Oral Packet) B 3 B/D, PA C1

Rap

amu

ne

Rapamune (Oral Solution) B 4 B/D, PA C1

Rap

amu

ne

Rapamune (0.5MG Oral Tablet) B 3 B/D, PA C1

Rap

amu

ne

Rapamune (1MG Oral Tablet, 2MG Oral Tablet) B 4 B/D, PA C1

Ras

uvo

Rasuvo (Subcutaneous Solution Auto-Injector) B 3 PA C1

Redi

Trex

RediTrex (Subcutaneous Solution Prefilled Syringe) B 3 PA C1

San

dim

mun

e

Sandimmune (100MG Oral Capsule) B 4 B/D, PA C1

San

dim

mun

e

Sandimmune (25MG Oral Capsule) B 3 B/D, PA C1

San

dim

mun

e

Sandimmune (100MG/ML Oral Solution) B 4 B/D, PA C1

Sim

poni

Simponi (Subcutaneous Solution Auto-Injector) B 4 PA C1

Sim

poni

Simponi (Subcutaneous Solution Prefilled Syringe) B 4 PA C1

Sirol

imu

s

Sirolimus (Oral Solution) G 4 B/D, PA C1

Sirol

imu

s

Sirolimus (Oral Tablet) G 3 B/D, PA C1

Tacr

olim

us

Tacrolimus (0.5MG Oral Capsule, 1MG Oral Capsule) G 2 B/D, PA C1

Tacr

olim

us

Tacrolimus (5MG Oral Capsule) G 3 B/D, PA C1

Trex

all

Trexall (Oral Tablet) G 3

C1

Xat

mep

Xatmep (Oral Solution) B 3 PA C1

Zort

ress

Zortress (Oral Tablet) B 4 B/D, PA B1

VaccinesC1

Act

HIB

ActHIB (Intramuscular Solution Reconstituted) B 2 QL C1

Ada

cel

Adacel (Intramuscular Suspension) B 2 QL C1

BC

G

Vac

cine

BCG Vaccine (Injection) B 2 QL C1

Bex

sero

Bexsero (Intramuscular Suspension Prefilled Syringe) B 2 QL C1

Boo

strix

Boostrix (5-2.5-18.5 Intramuscular Suspension,

5-2.5-18.5 (0.5ML Syringe) Intramuscular

Suspension)

B 2 QL

C1

Dap

tace

l

Daptacel (Intramuscular Suspension) B 2 QL C1

Diph

theri

a-

Teta

nus

Tox

oids

DT Diphtheria-Tetanus Toxoids DT (Intramuscular

Suspension)B 2 QL

C1

Eng

erix-

B

Engerix-B (Injection Suspension) B 2 B/D, PA; QL C1

Gar

dasil

9

Gardasil 9 (Intramuscular Suspension) B 2 QL C1

Gar

dasil

9

Gardasil 9 (Intramuscular Suspension Prefilled

Syringe)B 2 QL

C1

Havr

ix

Havrix (Intramuscular Suspension) B 2 QL C1

Hibe

rix

Hiberix (Injection Solution Reconstituted) B 2 QL C1

Imo

vax

Rabi

es

Imovax Rabies (Intramuscular Injectable) B 2 B/D, PA; QL


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Infa

nrix

Infanrix (Intramuscular Suspension) B 2 QL C1

IPO

L

IPOL (Injection) B 2 QL C1

Ixiar

o

Ixiaro (Intramuscular Suspension) B 2 QL C1

Kinri

x

Kinrix (Intramuscular Suspension) B 2 QL C1

Men

actr

a

Menactra (Intramuscular Injectable) B 2 QL C1

Men

Qua

dfi

MenQuadfi (Intramuscular Injectable) B 2 QL C1

Men

veo

Menveo (Intramuscular Solution Reconstituted) B 2 QL C1

M-

M-R

II

M-M-R II (Injection Solution Reconstituted) B 2 QL C1

Pedi

arix

Pediarix (Intramuscular Suspension) B 2 QL C1

Ped

vax

HIB

Pedvax HIB (Intramuscular Suspension) B 2 QL C1

Pro

Qua

d

ProQuad (Subcutaneous Suspension Reconstituted) B 2 QL C1

Qua

drac

el

Quadracel (Intramuscular Suspension) B 2 QL C1

Rab

Aver

t

RabAvert (Intramuscular Suspension Reconstituted) B 2 B/D, PA; QL C1

Rec

omb

ivax

HB

Recombivax HB (Injection Suspension) B 2 B/D, PA; QL C1

Rot

arix

Rotarix (Oral Suspension Reconstituted) B 2 QL C1

Rot

aTe

q

RotaTeq (Oral Solution) B 2 QL C1

Shin

grix

Shingrix (Intramuscular Suspension Reconstituted) B 2 PA; QL C1

TDV

AX

TDVAX (Intramuscular Suspension) B 2 QL C1

Teni

vac

Tenivac (Intramuscular Injectable) B 2 QL C1

Tru

men

ba

Trumenba (Intramuscular Suspension Prefilled

Syringe)B 2 QL

C1

Twi

nrix

Twinrix (Intramuscular Suspension Prefilled Syringe) B 2 QL C1

Typ

him

Vi

Typhim Vi (Intramuscular Solution) B 2 QL C1

VAQ

TA

VAQTA (Intramuscular Suspension) B 2 QL C1

Vari

vax

Varivax (Subcutaneous Injectable) B 2 QL C1

YF-

Vax

YF-Vax (Subcutaneous Injectable) B 2 QL A1

Inflammatory Bowel Disease AgentsB1

AminosalicylatesC1

Apri

so

Apriso (Oral Capsule Extended Release 24 Hour) B 2 QL C1

Asa

col

HD

Asacol HD (Oral Tablet Delayed Release) B 4 ST; QL C1

Azul

fidin

e

EN-

tabs Azulfidine EN-tabs (Oral Tablet Delayed Release) B 3

C1

Azul

fidin

e

Azulfidine (Oral Tablet Immediate Release) B 3

C1

Bals

alazi

de

Diso

diu

m Balsalazide Disodium (Oral Capsule) G 3

C1

Can

asa

Canasa (Rectal Suppository) B 4 QL C1

Cola

zal

Colazal (Oral Capsule) G 4

C1

Delz

icol

Delzicol (Oral Capsule Delayed Release) B 3 ST



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Dipe

ntu

m

Dipentum (Oral Capsule) B 4

C1

Lial

da

Lialda (Oral Tablet Delayed Release) B 4 ST; QL C1

Mes

ala

min

e

ER Mesalamine ER (0.375GM Oral Capsule Extended

Release 24 Hour) (Generic Apriso)G 2 QL

C1

Mes

ala

min

e

Mesalamine (400MG Oral Capsule Delayed Release)

(Generic Delzicol)G 3 ST

C1

Mes

ala

min

e

Mesalamine (1.2GM Oral Tablet Delayed Release)

(Generic Lialda)G 3 QL

C1

Mes

ala

min

e

Mesalamine (800MG Oral Tablet Delayed Release)

(Generic Asacol)G 3 ST; QL

C1

Mes

ala

min

e

Mesalamine (Rectal Enema) G 3

C1

Mes

ala

min

e

Mesalamine (Rectal Suppository) G 3 QL C1

Pent

asa

Pentasa (Oral Capsule Extended Release) B 3 QL C1

Row

asa

Rowasa (Rectal Kit) B 4

C1

Sulf

asal

azin

e

Sulfasalazine (Oral Tablet Immediate Release) G 1

C1

Sulf

asal

azin

e

Sulfasalazine (Oral Tablet Delayed Release) G 1

B1

GlucocorticoidsC1

Anu

sol-

HC

Anusol-HC (External Cream) G 3

C1

Bud

eso

nide

ER

Budesonide ER (Oral Tablet Extended Release 24 Hour) G 4 ST C1

Bud

eso

nide

Budesonide (Oral Capsule Delayed Release Particles) G 3

C1

Ento

cort

EC

Entocort EC (Oral Capsule Delayed Release Particles) B 4

C1

Hyd

roco

rtiso

ne

Hydrocortisone (Rectal Enema) G 3

C1

Orti

kos

Ortikos (Oral Capsule Extended Release 24 Hour) B 4 ST C1

Proc

to-

Med

HC

Procto-Med HC (External Cream) G 1

C1

Proc

to-

Pak

Procto-Pak (External Cream) G 1

C1

Proc

toso

l HC

Proctosol HC (2.5% External Cream) G 1

C1

Proc

tozo

ne-

HC

Proctozone-HC (External Cream) G 1

C1

Uce

ris

Uceris (Oral Tablet Extended Release 24 Hour) B 4 ST C1

Uce

ris

Uceris (Rectal Foam) B 3

A1

Metabolic Bone Disease AgentsB1

Metabolic Bone Disease AgentsC1

Acto

nel

Actonel (Oral Tablet) B 3

C1

Alen

dron

ate

Sodi

um Alendronate Sodium (Oral Solution) G 3

C1

Alen

dron

ate

Sodi

um Alendronate Sodium (10MG Oral Tablet, 35MG Oral


C1

Atel

via

Atelvia (Oral Tablet Delayed Release) B 3

C1

Boni

va

Boniva (Oral Tablet) B 3

C1

Calc

itoni

n

Sal

mon Calcitonin Salmon (Nasal Solution) G 2


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Calc

itriol

Calcitriol (Oral Capsule) G 1 B/D, PA C1

Calc

itriol

Calcitriol (Oral Solution) G 3 B/D, PA C1

Cina

calc

et

HCl

Cinacalcet HCl (30MG Oral Tablet) G 3 B/D, PA; QL C1

Cina

calc

et

HCl

Cinacalcet HCl (60MG Oral Tablet, 90MG Oral Tablet) G 4 B/D, PA; QL C1

Dox

erca

lcife

rol

Doxercalciferol (Oral Capsule) G 3 B/D, PA C1

Eve

nity

Evenity (Subcutaneous Solution Prefilled Syringe) B 4 PA; QL C1

Fort

eo

Forteo (Subcutaneous Solution Pen-Injector) B 4 PA C1

Fos

ama

x

Fosamax (Oral Tablet) B 3

C1

Fos

ama

x

Plus

D Fosamax Plus D (Oral Tablet) B 3

C1

Iban

dron

ate

Sodi

um Ibandronate Sodium (Oral Tablet) G 2

C1

Nat

para

Natpara (Subcutaneous Cartridge) B 4 PA; LA C1

Pari

calci

tol

Paricalcitol (Oral Capsule) G 3 B/D, PA C1

Proli

a

Prolia (Subcutaneous Solution Prefilled Syringe) B 3 QL C1

Ray

alde

e

Rayaldee (Oral Capsule Extended Release) B 4 QL C1

Rise

dron

ate

Sodi

um Risedronate Sodium (150MG Oral Tablet, 30MG Oral


C1

Rise

dron

ate

Sodi

um Risedronate Sodium (35MG Oral Tablet Immediate

Release, 35MG (12 PACK) Oral Tablet Immediate

Release, 35MG (4 PACK) Oral Tablet Immediate

Release)

G 2

C1

Rise

dron

ate

Sodi

um Risedronate Sodium (Oral Tablet Delayed Release) G 3

C1

Roc

altro

l

Rocaltrol (Oral Capsule) B 3 B/D, PA C1

Roc

altro

l

Rocaltrol (Oral Solution) B 3 B/D, PA C1

Sen

sipa

r

Sensipar (Oral Tablet) B 4 B/D, PA; QL C1

Teri

para

tide

Teriparatide (Recombinant) (Subcutaneous Solution

Pen-Injector)B 4 PA

C1

Tym

los

Tymlos (Subcutaneous Solution Pen-Injector) B 4 PA C1

Xge

va

Xgeva (Subcutaneous Solution) B 4 PA C1

Zem

plar

Zemplar (1MCG Oral Capsule) B 3 B/D, PA C1

Zem

plar

Zemplar (2MCG Oral Capsule) B 4 B/D, PA A1

Miscellaneous Therapeutic AgentsB1

Miscellaneous Therapeutic AgentsC1

Alco

hol

Pre

p

Pad

s Alcohol Prep Pads G 2

C1

Doj

olvi

Dojolvi (Oral Liquid) B 4 PA C1

Gau

ze

Gauze (Non-medicated 2X2 Pad) G 2

C1

Insul

in

Syri

nge

s,

Nee

dles Insulin Syringes, Needles G 2



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

A1

Ophthalmic AgentsB1

Ophthalmic Agents, OtherC1

Atro

pine

Sulf

ate Atropine Sulfate (1% Ophthalmic Solution) B 2

C1

Neo

myci

n-

Poly

myxi

n-

Baci

traci

n-

Hyd

roco

rtiso

ne

Neomycin-Polymyxin-Bacitracin-Hydrocortisone

(Ophthalmic Ointment)G 2

C1

Blep

ham

ide

Blephamide (Ophthalmic Suspension) B 3

C1

Blep

ham

ide

S.O.

P. Blephamide S.O.P. (Ophthalmic Ointment) G 3

C1

Ceq

ua

Cequa (Ophthalmic Solution) B 3 PA; QL C1

Co

mbi

gan

Combigan (Ophthalmic Solution) B 2

C1

Cos

opt

Cosopt (Ophthalmic Solution) B 3

C1

Cos

opt

PF

Cosopt PF (Ophthalmic Solution) B 3

C1

Cyst

adro

ps

Cystadrops (Ophthalmic Solution) B 4

C1

Cyst

aran

Cystaran (Ophthalmic Solution) B 4 LA C1

Dor

zola

mid

e

HCl-

Tim

olol

Mal

eate Dorzolamide HCl-Timolol Maleate (Ophthalmic Solution) G 1

C1

Dor

zola

mid

e

HCl-

Tim

olol

Mal

eate

Pres

erva

tive

Free

Dorzolamide HCl-Timolol Maleate Preservative Free

(Ophthalmic Solution)G 3

C1

Lacr

isert

Lacrisert (Ophthalmic Insert) B 3

C1

Maxi

trol

Maxitrol (Ophthalmic Ointment) B 3

C1

Maxi

trol

Maxitrol (Ophthalmic Suspension) B 3

C1

Neo

myci

n-

Poly

myxi

n-

Dex

ame

thas

oneNeomycin-Polymyxin-Dexamethasone (Ophthalmic

Ointment)G 1

C1

Neo

myci

n-

Poly

myxi

n-

Dex

ame

thas

oneNeomycin-Polymyxin-Dexamethasone (3.5-10000-0.1

Ophthalmic Suspension)G 1

C1

Neo

myci

n-

Poly

myxi

n-

HC Neomycin-Polymyxin-HC (Ophthalmic Suspension) G 3

C1

Oxe

rvat

e

Oxervate (Ophthalmic Solution) B 4 PA; QL C1

Pre

d-G

Pred-G (Ophthalmic Suspension) B 3

C1

Pre

d-G

S.O.

P.

Pred-G S.O.P. (Ophthalmic Ointment) B 3

C1

Pro

para

cain

e

HCl Proparacaine HCl (Ophthalmic Solution) G 1

C1

Rest

asis

Sing

le-

Use

Vials Restasis Single-Use Vials (Ophthalmic Emulsion) B 2 QL C1

Roc

klata

n

Rocklatan (Ophthalmic Solution) B 2 ST C1

Sulf

acet

ami

de-

Pre

dnis

olon

e Sulfacetamide-Prednisolone (Ophthalmic Solution) G 1

C1

Tob

raD

ex

TobraDex (Ophthalmic Ointment) B 2

C1

Tob

raD

ex

TobraDex (Ophthalmic Suspension) B 3

C1

Tob

raD

ex

ST

TobraDex ST (Ophthalmic Suspension) B 3

C1

Tob

ram

ycin-

Dex

ame

thas

one Tobramycin-Dexamethasone (Ophthalmic Suspension) G 2

C1

Xiidr

a

Xiidra (Ophthalmic Solution) B 3 QL C1

Zyle

t

Zylet (Ophthalmic Suspension) B 3

B1

Ophthalmic Anti-allergy Agents


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Aloc

ril

Alocril (Ophthalmic Solution) B 3

C1

Alo

mid

e

Alomide (Ophthalmic Solution) B 3

C1

Azel

astin

e

HCl

Azelastine HCl (Ophthalmic Solution) G 1

C1

Bep

otas

tine

Besi

late Bepotastine Besilate (Ophthalmic Solution) G 3

C1

Bep

reve

Bepreve (Ophthalmic Solution) B 3

C1

Cro

mol

yn

Sodi

um Cromolyn Sodium (Ophthalmic Solution) G 1

C1

Epin

astin

e

HCl

Epinastine HCl (Ophthalmic Solution) G 2

C1

Last

acaf

t

Lastacaft (Ophthalmic Solution) B 2

C1

Olo

pata

dine

HCl

Olopatadine HCl (Ophthalmic Solution) G 2

C1

Zerv

iate

Zerviate (Ophthalmic Solution) B 3

B1

Ophthalmic Anti-InfectivesC1

Aza

site

Azasite (Ophthalmic Solution) B 3

C1

Baci

traci

n

Bacitracin (Ophthalmic Ointment) G 2

C1

Baci

traci

n-

Poly

myxi

n B Bacitracin-Polymyxin B (Ophthalmic Ointment) G 1

C1

Besi

vanc

e

Besivance (Ophthalmic Suspension) B 3

C1

Blep

h-10

Bleph-10 (Ophthalmic Solution) G 3

C1

Cilo

xan

Ciloxan (Ophthalmic Ointment) B 3

C1

Cilo

xan

Ciloxan (Ophthalmic Solution) B 3

C1

Cipr

oflo

xaci

n

HCl Ciprofloxacin HCl (Ophthalmic Solution) G 1

C1

Eryt

hro

myci

n

Erythromycin (Ophthalmic Ointment) G 1

C1

Gatif

loxa

cin

Gatifloxacin (Ophthalmic Solution) G 2

C1

Gen

tak

Gentak (Ophthalmic Ointment) G 1

C1

Gen

tami

cin

Sulf

ate Gentamicin Sulfate (Ophthalmic Solution) G 1

C1

Lev

oflo

xaci

n

Levofloxacin (0.5% Ophthalmic Solution) G 2

C1

Mox

eza

Moxeza (Ophthalmic Solution) B 3

C1

Mox

iflox

acin

HCl

Moxifloxacin HCl (Ophthalmic Solution) (Generic

Vigamox)G 2

C1

Nata

cyn

Natacyn (Ophthalmic Suspension) B 3

C1

Neo

myci

n-

Baci

traci

n-

Poly

myxi

n Neomycin-Bacitracin-Polymyxin (5-400-10000

Ophthalmic Ointment)G 2

C1

Neo

myci

n-

Poly

myxi

n-

Gra

mici

din Neomycin-Polymyxin-Gramicidin (Ophthalmic Solution) G 2

C1

Ocu

flox

Ocuflox (Ophthalmic Solution) B 3

C1

Oflo

xaci

n

Ofloxacin (Ophthalmic Solution) G 1

C1

Poly

myxi

n B-

Trim

etho

prim Polymyxin B-Trimethoprim (Ophthalmic Solution) G 1

C1

Poly

trim

Polytrim (Ophthalmic Solution) B 3

C1

Sulf

acet

ami

de

Sodi

um Sulfacetamide Sodium (Ophthalmic Ointment) G 1



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Sulf

acet

ami

de

Sodi

um Sulfacetamide Sodium (Ophthalmic Solution) G 1

C1

Tob

ram

ycin

Tobramycin (Ophthalmic Solution) G 1

C1

Tob

rex

Tobrex (Ophthalmic Ointment) B 3

C1

Tob

rex

Tobrex (Ophthalmic Solution) B 3

C1

Trifl

uridi

ne

Trifluridine (Ophthalmic Solution) G 2

C1

Viga

mox

Vigamox (Ophthalmic Solution) B 3

C1

Zym

axid

Zymaxid (Ophthalmic Solution) B 3

B1

Ophthalmic Anti-inflammatoriesC1

Acul

ar

LS

Acular LS (Ophthalmic Solution) B 3

C1

Acul

ar

Acular (Ophthalmic Solution) B 3

C1

Acu

vail

Acuvail (Ophthalmic Solution) B 3 ST C1

Alre

x

Alrex (Ophthalmic Suspension) B 3

C1

Bro

mfe

nac

Sodi

um Bromfenac Sodium (Once-Daily) (Ophthalmic Solution) G 3

C1

Bro

mSit

e

BromSite (Ophthalmic Solution) B 3 ST C1

Dex

ame

thas

one

Sodi

um

Pho

sph

ate Dexamethasone Sodium Phosphate (Ophthalmic

Solution)G 2

C1

Dicl

ofen

ac

Sodi

um Diclofenac Sodium (Ophthalmic Solution) G 1

C1

Dur

ezol

Durezol (Ophthalmic Emulsion) B 3

C1

Eys

uvis

Eysuvis (Ophthalmic Suspension) B 3 PA C1

Flar

ex

Flarex (Ophthalmic Suspension) B 3

C1

Fluo

rom

etho

lone

Fluorometholone (Ophthalmic Suspension) G 2

C1

Flur

bipr

ofen

Sodi

um Flurbiprofen Sodium (Ophthalmic Solution) G 1

C1

FML

Fort

e

FML Forte (Ophthalmic Suspension) B 3

C1

FML

Liqu

ifilm

FML Liquifilm (Ophthalmic Suspension) B 3

C1

FML

FML (Ophthalmic Ointment) B 3

C1

Ilevr

o

Ilevro (Ophthalmic Suspension) B 2

C1

Invel

tys

Inveltys (Ophthalmic Suspension) B 3

C1

Ket

orol

ac

Tro

met

ham

ine Ketorolac Tromethamine (Ophthalmic Solution) G 2

C1

Lote

max

Lotemax (Ophthalmic Gel) B 3

C1

Lote

max

Lotemax (Ophthalmic Ointment) B 3

C1

Lote

max

Lotemax (Ophthalmic Suspension) B 3

C1

Lote

max

SM

Lotemax SM (Ophthalmic Gel) B 3

C1

Lote

pred

nol

Etab

onat

e Loteprednol Etabonate (Ophthalmic Gel) G 3

C1

Lote

pred

nol

Etab

onat

e Loteprednol Etabonate (Ophthalmic Suspension) G 3

C1

Maxi

dex

Maxidex (Ophthalmic Suspension) B 3

C1

Nev

ana

c

Nevanac (Ophthalmic Suspension) B 3

C1

Pre

d

Fort

e

Pred Forte (Ophthalmic Suspension) B 3


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Pre

d

Mild

Pred Mild (Ophthalmic Suspension) B 3

C1

Pre

dnis

olon

e

Acet

ate Prednisolone Acetate (Ophthalmic Suspension) G 2

C1

Pre

dnis

olon

e

Sodi

um

Pho

sph

ate Prednisolone Sodium Phosphate (1% Ophthalmic

Solution)G 1

C1

Prol

ens

a

Prolensa (Ophthalmic Solution) B 3

B1

Ophthalmic Beta-Adrenergic Blocking AgentsC1

Beta

xolo

l

HCl

Betaxolol HCl (Ophthalmic Solution) G 2

C1

Beti

mol

Betimol (Ophthalmic Solution) B 3

C1

Bet

opti

c-S

Betoptic-S (Ophthalmic Suspension) B 3

C1

Cart

eolo

l

HCl

Carteolol HCl (Ophthalmic Solution) G 1

C1

Istal

ol

Istalol (Ophthalmic Solution) B 3

C1

Lev

obu

nolo

l

HCl Levobunolol HCl (Ophthalmic Solution) G 1

C1

Tim

olol

Mal

eate

Oph

thal

mic

Gel

For

min

g

Timolol Maleate Ophthalmic Gel Forming (Ophthalmic

Solution) (Generic Timoptic-XE)G 2

C1

Tim

olol

Mal

eate

Timolol Maleate (0.25% Ophthalmic Solution, 0.5%

Ophthalmic Solution) (Generic Timoptic)G 1

C1

Tim

olol

Mal

eate

Timolol Maleate (0.5% (DAILY) Ophthalmic Solution)

(Generic Istalol)G 3

C1

Tim

olol

Mal

eate

PF Timolol Maleate PF (Ophthalmic Solution) (Generic

Timoptic Ocudose)G 3

C1

Tim

opti

c

Ocu

dos

e Timoptic Ocudose (Ophthalmic Solution) B 3

C1

Tim

opti

c-XE

Timoptic-XE (Ophthalmic Gel Forming Solution) B 3

B1

Ophthalmic Intraocular Pressure Lowering Agents, OtherC1

Alph

aga

n P

Alphagan P (0.1% Ophthalmic Solution) B 2

C1

Alph

aga

n P

Alphagan P (0.15% Ophthalmic Solution) B 3

C1

Apr

aclo

nidi

ne

HCl Apraclonidine HCl (Ophthalmic Solution) G 2

C1

Azo

pt

Azopt (Ophthalmic Suspension) B 2

C1

Brim

onid

ine

Tartr

ate Brimonidine Tartrate (0.15% Ophthalmic Solution) B 3

C1

Brim

onid

ine

Tartr

ate Brimonidine Tartrate (0.2% Ophthalmic Solution) G 1

C1

Brin

zola

mid

e

Brinzolamide (Ophthalmic Suspension) G 2

C1

Dor

zola

mid

e

HCl Dorzolamide HCl (Ophthalmic Solution) G 1

C1

Iopi

dine

Iopidine (1% Ophthalmic Solution) B 4

C1

Isop

to

Car

pine

Isopto Carpine (Ophthalmic Solution) B 3

C1

Met

haz

ola

mid

e Methazolamide (Oral Tablet) G 3

C1

Pilo

carp

ine

HCl

Pilocarpine HCl (Ophthalmic Solution) G 2

C1

Rho

pres

sa

Rhopressa (Ophthalmic Solution) B 2 ST



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Sim

brin

za

Simbrinza (Ophthalmic Suspension) B 2

C1

Trus

opt

Trusopt (Ophthalmic Solution) B 3

B1

Ophthalmic Prostaglandin and Prostamide AnalogsC1

Bim

atop

rost

Bimatoprost (Ophthalmic Solution) G 3

C1

Lata

nopr

ost

Latanoprost (Ophthalmic Solution) G 1

C1

Lum

igan

Lumigan (Ophthalmic Solution) B 2

C1

Trav

atan

Z

Travatan Z (Ophthalmic Solution) B 3

C1

Trav

opr

ost

Travoprost (BAK Free) (Ophthalmic Solution) G 2

C1

Vyz

ulta

Vyzulta (Ophthalmic Solution) B 3

C1

Xala

tan

Xalatan (Ophthalmic Solution) B 3

C1

Xelp

ros

Xelpros (Ophthalmic Emulsion) B 3 ST C1

Ziop

tan

Zioptan (Ophthalmic Solution) B 3

A1

Otic AgentsB1

Otic AgentsC1

Acet

ic

Acid

Acetic Acid (Otic Solution) G 1

C1

Cetr

axal

Cetraxal (Otic Solution) B 3

C1

Cipr

o

HC

Cipro HC (Otic Suspension) B 3

C1

Cipr

ode

x

Ciprodex (Otic Suspension) B 3

C1

Cipr

oflo

xaci

n

HCl Ciprofloxacin HCl (Otic Solution) B 3

C1

Cipr

oflo

xaci

n-

Dex

ame

thas

one Ciprofloxacin-Dexamethasone (Otic Suspension) G 2

C1

Cipr

oflo

xaci

n-

Fluo

cino

lone

PF Ciprofloxacin-Fluocinolone PF (Otic Solution) B 3

C1

Der

mOt

ic

DermOtic (Otic Oil) B 3

C1

Flac

Flac (Otic Oil) G 3

C1

Fluo

cino

lone

Acet

onid

e Fluocinolone Acetonide (Otic Oil) G 2

C1

Hyd

roco

rtiso

ne-

Acet

ic

Acid Hydrocortisone-Acetic Acid (Otic Solution) G 2

C1

Neo

myci

n-

Poly

myxi

n-

HC Neomycin-Polymyxin-HC (1% Otic Solution) G 2

C1

Neo

myci

n-

Poly

myxi

n-

HC Neomycin-Polymyxin-HC (Otic Suspension) G 2

C1

Oflo

xaci

n

Ofloxacin (Otic Solution) G 2

C1

Oto

vel

Otovel (Otic Solution) B 3

A1

Respiratory Tract/Pulmonary AgentsB1

AntihistaminesC1

Azel

astin

e

HCl

Azelastine HCl (0.1% Nasal Solution, 0.15% Nasal

Solution)G 2

C1

Azel

astin

e-

Fluti

cas

one Azelastine-Fluticasone (Nasal Suspension) G 3

C1

Ceti

rizin

e

HCl

Cetirizine HCl (1MG/ML Oral Solution) G 1

C1

Clari

nex

Clarinex (Oral Tablet) B 3

C1

Cyp

rohe

ptad

ine

HCl Cyproheptadine HCl (Oral Tablet) G 3 PA; HRM


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Desl

orat

adin

e

Desloratadine (Oral Tablet) G 2

C1

Desl

orat

adin

e

ODT Desloratadine ODT (Oral Tablet Dispersible) G 3

C1

Dym

ista

Dymista (Nasal Suspension) B 3

C1

Lev

ocet

irizin

e

Dihy

droc

hlori

de Levocetirizine Dihydrochloride (Oral Solution) G 2

C1

Lev

ocet

irizin

e

Dihy

droc

hlori

de Levocetirizine Dihydrochloride (Oral Tablet) G 1

C1

Olo

pata

dine

HCl

Olopatadine HCl (Nasal Solution) G 3

C1

Pata

nas

e

Patanase (Nasal Solution) B 3

B1

Anti-inflammatories, Inhaled CorticosteroidsC1

Alve

sco

Alvesco (Inhalation Aerosol Solution) B 3 ST; QL C1

Arm

onAi

r

Digi

hale

r ArmonAir Digihaler (Inhalation Aerosol Powder Breath

Activated)B 3 ST; QL

C1

Arn

uity

Ellip

ta

Arnuity Ellipta (Inhalation Aerosol Powder Breath

Activated)B 2 QL

C1

Asm

ane

x

Asmanex (120 Metered Doses) (Inhalation Aerosol

Powder Breath Activated)B 3 ST; QL

C1

Asm

ane

x



C1

Asm

ane

x



C1

Asm

ane

x

HFA

Asmanex HFA (Inhalation Aerosol) B 3 ST; QL C1

Bec

ona

se

AQ

Beconase AQ (Nasal Suspension) B 3 ST C1

Bud

eso

nide

Budesonide (Inhalation Suspension) G 3 B/D, PA C1

Flov

ent

Disk

us

Flovent Diskus (Inhalation Aerosol Powder Breath

Activated)B 2

C1

Flov

ent

HFA

Flovent HFA (Inhalation Aerosol) B 2 QL C1

Flun

isoli

de

Flunisolide (Nasal Solution) G 2

C1

Fluti

cas

one

Pro

pion

ate Fluticasone Propionate (Nasal Suspension) G 1

C1

Mo

met

aso

ne

Furo

ate Mometasone Furoate (Nasal Suspension) G 3

C1

Nas

one

x

Nasonex (Nasal Suspension) B 3

C1

Om

nari

s

Omnaris (Nasal Suspension) B 3 ST C1

Pul

mic

ort

Flex

hale

r Pulmicort Flexhaler (Inhalation Aerosol Powder

Breath Activated)B 3 ST

C1

Pul

mic

ort

Pulmicort (0.25MG/2ML Inhalation Suspension,

0.5MG/2ML Inhalation Suspension)B 3 B/D, PA

C1

Pul

mic

ort

Pulmicort (1MG/2ML Inhalation Suspension) B 4 B/D, PA C1

Qna

sl

Chil

dren

s Qnasl Childrens (Nasal Aerosol Solution) B 3 ST



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Qna

sl

Qnasl (Nasal Aerosol Solution) B 3 ST C1

QVA

R

Redi

Hale

r QVAR RediHaler (Inhalation Aerosol Breath Activated) B 3 ST; QL C1

Xha

nce

Xhance (Nasal Exhaler Suspension) B 3

C1

Zeto

nna

Zetonna (Nasal Aerosol Solution) B 3 ST B1

AntileukotrienesC1

Acc

olat

e

Accolate (Oral Tablet) B 3

C1

Mon

telu

kast

Sodi

um Montelukast Sodium (Oral Packet) G 2 QL C1

Mon

telu

kast

Sodi

um Montelukast Sodium (Oral Tablet) G 1 QL C1

Mon

telu

kast

Sodi

um Montelukast Sodium (Oral Tablet Chewable) G 1 QL C1

Sing

ulair

Singulair (Oral Packet) B 3 QL C1

Sing

ulair

Singulair (Oral Tablet) B 3 QL C1

Sing

ulair

Singulair (Oral Tablet Chewable) B 3 QL C1

Zafir

luka

st

Zafirlukast (Oral Tablet) G 2

C1

Zile

uton

ER

Zileuton ER (Oral Tablet Extended Release 12 Hour) G 4 ST C1

Zyfl

o

Zyflo (Oral Tablet Immediate Release) B 4 ST B1

Bronchodilators, AnticholinergicC1

Atro

vent

HFA

Atrovent HFA (Inhalation Aerosol Solution) B 3

C1

Incr

use

Ellip

ta

Incruse Ellipta (Inhalation Aerosol Powder Breath


C1

Iprat

ropi

um

Bro

mid

e Ipratropium Bromide (Inhalation Solution) G 1 B/D, PA C1

Iprat

ropi

um

Bro

mid

e Ipratropium Bromide (Nasal Solution) G 2

C1

Lon

hala

Mag

nair

Lonhala Magnair (Inhalation Solution) B 4 QL C1

Spiri

va

Han

diHa

ler Spiriva HandiHaler (Inhalation Capsule) B 2 QL C1

Spiri

va

Res

pim

at Spiriva Respimat (Inhalation Aerosol Solution) B 2 QL C1

Tud

orza

Pres

sair Tudorza Pressair (Inhalation Aerosol Powder Breath

Activated)B 3 ST

C1

Yup

elri

Yupelri (Inhalation Solution) B 4 B/D, PA; QL B1

Bronchodilators, SympathomimeticC1

Albu

terol

Sulf

ate

HFA Albuterol Sulfate HFA (108 (90 Base)MCG/ACT

Inhalation Aerosol Solution) (Brand Equivalent Ventolin)G 3 ST

C1

Albu

terol

Sulf

ate

HFA Albuterol Sulfate HFA (108 (90 Base)MCG/ACT

Inhalation Aerosol Solution (Generic Proair), 108 (90

Base)MCG/ACT Inhalation Aerosol Solution) (Generic

Proventil)

G 2

C1

Albu

terol

Sulf

ate Albuterol Sulfate (Inhalation Nebulization Solution) G 1 B/D, PA C1

Albu

terol

Sulf

ate Albuterol Sulfate (Oral Syrup) G 3

C1

Albu

terol

Sulf

ate Albuterol Sulfate (Oral Tablet Immediate Release) G 3

C1

Brov

ana

Brovana (Inhalation Nebulization Solution) B 4 PA; QL


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Epin

ephr

ine

Epinephrine (Injection Solution Auto-Injector) G 2 QL C1

EpiP

en

2-

Pak

EpiPen 2-Pak (Injection Solution Auto-Injector) B 3 QL C1

EpiP

en

Jr 2-

Pak

EpiPen Jr 2-Pak (Injection Solution Auto-Injector) B 3 QL C1

Lev

albu

terol

HCl

Levalbuterol HCl (Inhalation Nebulization Solution) G 3 B/D, PA C1

Lev

albu

terol

Tartr

ate Levalbuterol Tartrate (Inhalation Aerosol) G 3 ST C1

Perf

oro

mist

Perforomist (Inhalation Nebulization Solution) B 3 B/D, PA; QL C1

Pro

Air

HFA

ProAir HFA (Inhalation Aerosol Solution) B 2

C1

Pro

Air

Res

piCli

ck ProAir RespiClick (Inhalation Aerosol Powder Breath

Activated)B 2

C1

Prov

entil

HFA

Proventil HFA (Inhalation Aerosol Solution) B 3 ST C1

Sere

vent

Disk

us Serevent Diskus (Inhalation Aerosol Powder Breath

Activated)B 2 QL

C1

Striv

erdi

Res

pim

at Striverdi Respimat (Inhalation Aerosol Solution) B 3 ST C1

Sym

jepi

Symjepi (Injection Solution Prefilled Syringe) B 3 QL C1

Terb

utali

ne

Sulf

ate Terbutaline Sulfate (Oral Tablet) G 3

C1

Vent

olin

HFA

Ventolin HFA (Inhalation Aerosol Solution) B 3 ST C1

Xop

ene

x

Con

cent

rate Xopenex Concentrate (Inhalation Nebulization


C1

Xop

ene

x

HFA

Xopenex HFA (Inhalation Aerosol) B 3 ST C1

Xop

ene

x

Xopenex (0.31MG/3ML Inhalation Nebulization

Solution, 0.63MG/3ML Inhalation Nebulization

Solution)

B 3 B/D, PA

C1

Xop

ene

x

Xopenex (1.25MG/3ML Inhalation Nebulization


B1

Cystic Fibrosis AgentsC1

Beth

kis

Bethkis (Inhalation Nebulization Solution) B 4 B/D, PA; QL C1

Cay

ston

Cayston (Inhalation Solution Reconstituted) B 4 PA; LA C1

Kaly

dec

o

Kalydeco (Oral Packet) B 4 PA; LA C1

Kaly

dec

o

Kalydeco (Oral Tablet) B 4 PA; LA C1

Ork

amb

i

Orkambi (Oral Packet) B 4 PA; LA; QL C1

Ork

amb

i

Orkambi (Oral Tablet) B 4 PA; LA; QL C1

Pul

moz

yme

Pulmozyme (Inhalation Solution) B 4 B/D, PA; QL C1

Sym

dek

o

Symdeko (Oral Tablet Therapy Pack) B 4 PA; QL C1

TOB

I

TOBI (Inhalation Nebulization Solution) B 4 B/D, PA; QL C1

TOB

I

Pod

hale

r TOBI Podhaler (Inhalation Capsule) B 4 PA; QL C1

Tob

ram

ycin

Tobramycin (Inhalation Nebulization Solution) G 4 B/D, PA; QL



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Trik

afta

Trikafta (100-50-75 & 150MG Oral Tablet Therapy

Pack)B 4 PA; LA; QL

B1

Mast Cell StabilizersC1

Cro

mol

yn

Sodi

um Cromolyn Sodium (Inhalation Nebulization Solution) G 4 B/D, PA B1

Phosphodiesterase Inhibitors, Airways DiseaseC1

Dalir

esp

Daliresp (Oral Tablet) B 3 PA C1

The

o-24

Theo-24 (Oral Capsule Extended Release 24 Hour) G 3

C1

The

oph

yllin

e

ER Theophylline ER (300MG Oral Tablet Extended Release

12 Hour)G 3

C1

The

oph

yllin

e

ER Theophylline ER (Oral Tablet Extended Release 24 Hour) G 1

C1

The

oph

yllin

e

Theophylline (Oral Solution) G 3

B1

Pulmonary AntihypertensivesC1

Adci

rca

Adcirca (Oral Tablet) B 4 PA C1

Ade

mpa

s

Adempas (Oral Tablet) B 4 PA; LA C1

Alyq

Alyq (Oral Tablet) G 3 PA C1

Am

bris

enta

n

Ambrisentan (Oral Tablet) G 4 PA; LA; QL C1

Bos

enta

n

Bosentan (Oral Tablet) G 4 PA; LA; QL C1

Leta

iris

Letairis (Oral Tablet) B 4 PA; LA; QL C1

Ops

umit

Opsumit (Oral Tablet) B 4 PA; LA C1

Ore

nitra

m

Orenitram (0.125MG Oral Tablet Extended Release) B 3 PA; LA C1

Ore

nitra

m

Orenitram (0.25MG Oral Tablet Extended Release,

1MG Oral Tablet Extended Release, 2.5MG Oral

Tablet Extended Release, 5MG Oral Tablet Extended

Release)

B 4 PA; LA

C1

Rev

atio

Revatio (Oral Suspension Reconstituted) B 4 PA C1

Rev

atio

Revatio (Oral Tablet) B 4 PA C1

Sild

enaf

il

Citra

te Sildenafil Citrate (Oral Suspension Reconstituted) G 4 PA C1

Sild

enaf

il

Citra

te Sildenafil Citrate (20MG Oral Tablet) (Generic Revatio) G 2 PA C1

Tad

alafil

Tadalafil (PAH) (20MG Oral Tablet) G 3 PA C1

Trac

leer

Tracleer (Oral Tablet) B 4 PA; LA; QL C1

Trac

leer

Tracleer (Oral Tablet Soluble) B 4 PA; LA; QL C1

Uptr

avi

Uptravi (Oral Tablet) B 4 PA; LA; QL C1

Uptr

avi

Uptravi (Oral Tablet Therapy Pack) B 4 PA; LA C1

Vent

avis

Ventavis (Inhalation Solution) B 4 PA; LA B1

Pulmonary Fibrosis AgentsC1

Esbr

iet

Esbriet (Oral Capsule) B 4 PA; LA; QL C1

Esbr

iet

Esbriet (Oral Tablet) B 4 PA; LA; QL


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Ofe

v

Ofev (Oral Capsule) B 4 PA; LA; QL B1

Respiratory Tract Agents, OtherC1

Acet

ylcy

stei

ne

Acetylcysteine (Inhalation Solution) G 1 B/D, PA C1

Adv

air

Disk

us

Advair Diskus (Inhalation Aerosol Powder Breath

Activated)B 2 QL

C1

Adv

air

HFA

Advair HFA (Inhalation Aerosol) B 2 QL C1

AirD

uo

Digi

hale

r AirDuo Digihaler (Inhalation Aerosol Powder Breath


C1

AirD

uo

Res

piCli

ck

113/

14 AirDuo RespiClick 113/14 (Inhalation Aerosol Powder

Breath Activated)B 3 ST; QL

C1

AirD

uo

Res

piCli

ck

232/



C1

AirD

uo

Res

piCli

ck

55/1



C1

Ano

ro

Ellip

ta

Anoro Ellipta (Inhalation Aerosol Powder Breath

Activated)B 2 QL

C1

Bev

espi

Aer

osp

here Bevespi Aerosphere (Inhalation Aerosol) B 3 ST C1

Bre

o

Ellip

ta

Breo Ellipta (Inhalation Aerosol Powder Breath

Activated)B 2 QL

C1

Brez

tri

Aer

osp

here Breztri Aerosphere (Inhalation Aerosol) B 2 QL C1

Bro

nchi

tol

Bronchitol (Inhalation Capsule) B 4 PA; QL C1

Bud

eso

nide

-

For

mot

erol

Fum

arat

eBudesonide-Formoterol Fumarate (Inhalation Aerosol) G 3 ST; QL

C1

Clari

nex-

D 12

Hou

r Clarinex-D 12 Hour (Oral Tablet Extended Release 12

Hour)B 3

C1

Co

mbi

vent

Res

pim

at Combivent Respimat (Inhalation Aerosol Solution) B 2 QL C1

Dua

klir

Pres

sair

Duaklir Pressair (Inhalation Aerosol Powder Breath


C1

Dule

ra

Dulera (Inhalation Aerosol) B 3 QL C1

Fas

enra

Pen

Fasenra Pen (Subcutaneous Solution Auto-Injector) B 4 PA; LA C1

Fas

enra

Fasenra (Subcutaneous Solution Prefilled Syringe) B 4 PA; LA C1

Fluti

cas

one-

Sal

met

erol Fluticasone-Salmeterol (Inhalation Aerosol Powder

Breath Activated)G 2 QL

C1

Iprat

ropi

um-

Albu

terol Ipratropium-Albuterol (Inhalation Solution) G 1 B/D, PA C1

Nuc

ala

Nucala (Subcutaneous Solution Auto-Injector) B 4 PA; LA; QL C1

Nuc

ala

Nucala (Subcutaneous Solution Prefilled Syringe) B 4 PA; LA; QL C1

Nuc

ala

Nucala (Subcutaneous Solution Reconstituted) B 4 PA; LA; QL C1

Stiol

to

Res

pim

at Stiolto Respimat (Inhalation Aerosol Solution) B 2



Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Sym

bico

rt

Symbicort (Inhalation Aerosol) B 2 QL C1

Trel

egy

Ellip

ta

Trelegy Ellipta (Inhalation Aerosol Powder Breath

Activated)B 2 QL

C1

Wix

ela

Inhu

b

Wixela Inhub (Inhalation Aerosol Powder Breath

Activated) (Generic Advair)G 2 QL

A1

Skeletal Muscle RelaxantsB1

Skeletal Muscle RelaxantsC1

Chlo

rzox

azo

ne

Chlorzoxazone (500MG Oral Tablet) G 3 PA; HRM C1

Cycl

obe

nza

prin

e

HCl Cyclobenzaprine HCl (7.5MG Oral Tablet) G 3 PA; HRM C1

Fex

mid

Fexmid (Oral Tablet) G 3 PA; HRM A1

Sleep Disorder AgentsB1

Sleep Disorder AgentsC1

Xyw

av

Xywav (Oral Solution) B 4 PA; QL B1

Sleep Promoting AgentsC1

Am

bien

Ambien (Oral Tablet Immediate Release) B 3 PA; HRM; QL C1

Bels

omr

a

Belsomra (Oral Tablet) B 2 QL C1

Day

Vigo

DayVigo (Oral Tablet) B 2 QL C1

Dox

epin

HCl

Doxepin HCl (Oral Tablet) G 3

C1

Hetli

oz

LQ

Hetlioz LQ (Oral Suspension) B 4 PA; LA; QL C1

Hetli

oz

Hetlioz (Oral Capsule) B 4 PA; LA; QL C1

Ram

elte

on

Ramelteon (Oral Tablet) G 3

C1

Rest

oril

Restoril (22.5MG Oral Capsule) B 4 HRM; QL C1

Roz

ere

m

Rozerem (Oral Tablet) B 3 ST C1

Sile

nor

Silenor (Oral Tablet) B 3

C1

Tem

aze

pam

Temazepam (15MG Oral Capsule, 30MG Oral Capsule) G 2 HRM; QL C1

Tem

aze

pam

Temazepam (22.5MG Oral Capsule, 7.5MG Oral

Capsule)G 3 HRM; QL

C1

Zale

plon

Zaleplon (Oral Capsule) G 2 HRM; QL C1

Zolp

ide

m

Tartr

ate Zolpidem Tartrate (Oral Tablet Immediate Release) G 3 PA; HRM; QL B1

Wakefulness Promoting AgentsC1

Arm

odaf

inil

Armodafinil (Oral Tablet) G 2 PA; QL C1

Mod

afinil

Modafinil (Oral Tablet) G 2 PA; QL C1

Nuvi

gil

Nuvigil (150MG Oral Tablet, 200MG Oral Tablet,

250MG Oral Tablet)B 4 PA; QL

C1

Nuvi

gil

Nuvigil (50MG Oral Tablet) B 3 PA; QL C1

Prov

igil

Provigil (Oral Tablet) B 4 PA; QL C1

Sun

osi

Sunosi (Oral Tablet) B 3 PA; QL


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Wak

ix

Wakix (Oral Tablet) B 4 PA; QL C1

Xyre

m

Xyrem (Oral Solution) B 4 PA; LA; QL


157

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 chart below. Brand name drugs in bold type (for

example, Humalog) and generic drugs in plain type (for example, Simvastatin).

Drug Name

Brand

or

Generic

Quantity Limit

Abacavir Sulfate (Oral Solution) G Maximum of 32 ml per day

Abacavir Sulfate (Oral Tablet) G Maximum of 2 tablets per day

Abacavir Sulfate-Lamivudine (Oral Tablet) G Maximum of 1 tablet per day

Abacavir-Lamivudine-Zidovudine (Oral Tablet) G Maximum of 2 tablets per day

Abilify MyCite (Oral Tablet) B Maximum of 1 tablet per day

Abilify (Oral Tablet) B Maximum of 1 tablet per day

Accupril (Oral Tablet) B Maximum of 2 tablets per day

Accuretic (10-12.5MG Oral Tablet) B Maximum of 1 tablet per day

Accuretic (20-12.5MG Oral Tablet,

20-25MG Oral Tablet)B Maximum of 2 tablets per day

Acetaminophen-Caffeine-Dihydrocodeine

(320.5-30-16MG Oral Capsule)G Maximum of 10 capsules per day

Acetaminophen-Caffeine-Dihydrocodeine

(325-30-16MG Oral Tablet)G Maximum of 10 tablets per day

Acetaminophen-Codeine (120-12MG/5ML

Oral Solution)G Maximum of 150 ml per day

Acetaminophen-Codeine (300-15MG Oral

Tablet, 300-30MG Oral Tablet, 300-60MG

Oral Tablet)

G Maximum of 13 tablets per day

ActHIB (Intramuscular Solution

Reconstituted)B

1 vaccination dose (1 injection) per

day

Actiq (Buccal Lozenge On A Handle) B Maximum of 4 lozenges per day

Actoplus Met (Oral Tablet Immediate

Release)B Maximum of 3 tablets per day

Actos (15MG Oral Tablet) B Maximum of 3 tablets per day

Actos (30MG Oral Tablet, 45MG Oral

Tablet)B Maximum of 1 tablet per day

Adacel (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per day

Adderall (20MG Oral Tablet) G Maximum of 3 tablets per day


Drug Name

Brand

or

Generic

Quantity Limit

Adderall (5MG Oral Tablet, 7.5MG Oral

Tablet)G Maximum of 2 tablets per day

Adderall XR (Oral Capsule Extended

Release 24 Hour)B Maximum of 2 capsules per day

Adlyxin Starter Pack (Subcutaneous Pen-

Injector Kit)B Maximum of 1 kit (6 ml) per 28 days

Adlyxin (Subcutaneous Solution Pen-

Injector)B

Maximum of 2 pens (6 ml) per 28

days

Advair Diskus (Inhalation Aerosol Powder

Breath Activated)B

Maximum of 1 inhaler (60 blisters) per

30 days

Advair HFA (Inhalation Aerosol) BMaximum of 1 inhaler (12 grams) per

30 days

Adzenys ER (Oral Suspension Extended

Release)B Maximum of 15 ml per day

Adzenys XR-ODT (Oral Tablet Extended

Release Dispersible)B Maximum of 1 tablet per day

Aimovig (140MG/ML Subcutaneous

Solution Auto-Injector)B Maximum of 1 pen (1 ml) per 30 days

Aimovig (70MG/ML Subcutaneous Solution

Auto-Injector)B


days

AirDuo Digihaler (Inhalation Aerosol

Powder Breath Activated)B Maximum of 1 inhaler per 30 days

AirDuo RespiClick 113/14 (Inhalation

Aerosol Powder Breath Activated)B Maximum of 1 inhaler per 30 days





Ajovy (Subcutaneous Solution Auto-

Injector)B

Maximum of 1 pen (1.5 ml) per 30

days

Ajovy (Subcutaneous Solution Prefilled

Syringe)B

Maximum of 1 syringe (1.5 ml) per 30

days

Albendazole (Oral Tablet) G Maximum of 16 tablets per day

Albenza (Oral Tablet) B Maximum of 16 tablets per day

Aldara (External Cream) B Maximum of 24 grams per 30 days

Aliskiren Fumarate (Oral Tablet) G Maximum of 1 tablet per day

Almotriptan Malate (Oral Tablet) G Maximum of 12 tablets per 30 days

Alogliptin Benzoate (Oral Tablet) G Maximum of 1 tablet per day

Alogliptin-Metformin HCl (Oral Tablet) B Maximum of 2 tablets per day

Alogliptin-Pioglitazone (Oral Tablet) G Maximum of 1 tablet per day


Drug Name

Brand

or

Generic

Quantity Limit

Alora (Transdermal Patch Twice Weekly) B Maximum of 8 patches per 28 days

Alprazolam ER (0.5MG Oral Tablet Extended

Release 24 Hour, 1MG Oral Tablet Extended

Release 24 Hour)

G Maximum of 1 tablet per day

Alprazolam ER (2MG Oral Tablet Extended

Release 24 Hour)G Maximum of 5 tablets per day

Alprazolam ER (3MG Oral Tablet Extended


Alprazolam Intensol (Oral Concentrate) G Maximum of 10 ml per day

Alprazolam (0.25MG Oral Tablet Immediate

Release, 0.5MG Oral Tablet Immediate

Release, 1MG Oral Tablet Immediate

Release)


Alprazolam (2MG Oral Tablet Immediate

Release)G Maximum of 5 tablets per day

Alprazolam ODT (0.25MG Oral Tablet

Dispersible, 0.5MG Oral Tablet Dispersible,

1MG Oral Tablet Dispersible)


Alprazolam ODT (2MG Oral Tablet

Dispersible)G Maximum of 5 tablets per day

Altace (Oral Capsule) B Maximum of 2 capsules per day

Altoprev (Oral Tablet Extended Release 24

Hour)B Maximum of 1 tablet per day

Alunbrig (180MG Oral Tablet, 90MG Oral


Alunbrig (30MG Oral Tablet) B Maximum of 4 tablets per day

Alunbrig (Oral Tablet Therapy Pack) BMaximum of 1 pack (30 tablets) per

30 days

Alvesco (160MCG/ACT Inhalation Aerosol

Solution)B

Maximum of 2 inhalers (12.2 grams)

per 30 days

Alvesco (80MCG/ACT Inhalation Aerosol

Solution)B

Maximum of 1 inhaler (6.1 grams) per

30 days

Amaryl (1MG Oral Tablet) B Maximum of 8 tablets per day



Ambien (Oral Tablet Immediate Release) B Maximum of 1 tablet per day

Ambrisentan (Oral Tablet) G Maximum of 1 tablet per day

Amerge (Oral Tablet) B Maximum of 12 tablets per 30 days

Amitiza (Oral Capsule) B Maximum of 2 capsules per day

Amlodipine-Atorvastatin (Oral Tablet) G Maximum of 1 tablet per day


Drug Name

Brand

or

Generic

Quantity Limit

Amlodipine-Benazepril (Oral Capsule) G Maximum of 1 capsule per day

Amlodipine-Olmesartan (Oral Tablet) G Maximum of 1 tablet per day

Amlodipine-Valsartan (Oral Tablet) G Maximum of 1 tablet per day

Amphetamine ER (Oral Suspension Extended

Release)G Maximum of 15 ml per day

Amphetamine-Dextroamphetamine ER (Oral

Capsule Extended Release 24 Hour)G 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)


Amphetamine-Dextroamphetamine (20MG

Oral Tablet)G Maximum of 3 tablets per day

Ampyra (Oral Tablet Extended Release 12

Hour)B Maximum of 2 tablets per day

Annovera (Vaginal Ring) B Maximum of 1 ring per 365 days

Anoro Ellipta (Inhalation Aerosol Powder

Breath Activated)B


30 days

ApexiCon E (External Cream) G Maximum of 240 grams per 30 days

Apokyn (Subcutaneous Solution Cartridge) B Maximum of 3 ml per day

Apriso (Oral Capsule Extended Release 24

Hour)B Maximum of 4 capsules per day

Aptensio XR (Oral Capsule Extended

Release 24 Hour)B Maximum of 1 capsule per day

Aptiom (200MG Oral Tablet, 400MG Oral


Aptiom (600MG Oral Tablet, 800MG Oral

Tablet)B Maximum of 2 tablets per day

Aptivus (Oral Capsule) B Maximum of 4 capsules per day

Aricept (10MG Oral Tablet) B Maximum of 2 tablets per day

Aricept (23MG Oral Tablet, 5MG Oral


Aripiprazole (1MG/ML Oral Solution) G Maximum of 25 ml per day

Aripiprazole (10MG Oral Tablet, 15MG Oral


30MG Oral Tablet, 5MG Oral Tablet)


Aripiprazole ODT (10MG Oral Tablet


Aripiprazole ODT (15MG Oral Tablet



Drug Name

Brand

or

Generic

Quantity Limit

Armodafinil (150MG Oral Tablet, 200MG Oral

Tablet, 250MG Oral Tablet)G Maximum of 1 tablet per day

Armodafinil (50MG Oral Tablet) G Maximum of 2 tablets per day

ArmonAir Digihaler (Inhalation Aerosol

Powder Breath Activated)B Maximum of 1 inhaler per 30 days

Arnuity Ellipta (Inhalation Aerosol Powder

Breath Activated)B


30 days

Asacol HD (Oral Tablet Delayed Release) B Maximum of 6 tablets per day

Asmanex (120 Metered Doses) (Inhalation


Asmanex (30 Metered Doses) (110MCG/

INH Inhalation Aerosol Powder Breath

Activated)

B Maximum of 2 inhalers per 30 days

Asmanex (30 Metered Doses) (220MCG/

INH Inhalation Aerosol Powder Breath

Activated)

B Maximum of 1 inhaler per 30 days

Asmanex (60 Metered Doses) (Inhalation


Asmanex HFA (Inhalation Aerosol) BMaximum of 1 inhaler (13 grams) per

30 days

Aspirin-Dipyridamole ER (Oral Capsule

Extended Release 12 Hour)G Maximum of 2 capsules per day

Atacand HCT (Oral Tablet) B Maximum of 1 tablet per day

Atacand (16MG Oral Tablet, 32MG Oral

Tablet, 4MG Oral Tablet)B Maximum of 1 tablet per day

Atacand (8MG Oral Tablet) B Maximum of 3 tablets per day

Atazanavir Sulfate (150MG Oral Capsule,

300MG Oral Capsule)G Maximum of 1 capsule per day

Atazanavir Sulfate (200MG Oral Capsule) G Maximum of 2 capsules per day

Ativan (0.5MG Oral Tablet, 1MG Oral


Ativan (2MG Oral Tablet) B Maximum of 5 tablets per day

Atorvastatin Calcium (Oral Tablet) G Maximum of 1 tablet per day

Atripla (Oral Tablet) B Maximum of 1 tablet per day

Aubagio (Oral Tablet) B Maximum of 1 tablet per day

Austedo (Oral Tablet) B Maximum of 4 tablets per day

Avalide (Oral Tablet) B Maximum of 1 tablet per day

Avapro (150MG Oral Tablet, 300MG Oral


Avapro (75MG Oral Tablet) B Maximum of 3 tablets per day


Drug Name

Brand

or

Generic

Quantity Limit

Ayvakit (100MG Oral Tablet, 200MG Oral


Azor (Oral Tablet) B Maximum of 1 tablet per day

Bafiertam (Oral Capsule Delayed Release) B Maximum of 4 capsules per day

Balversa (3MG Oral Tablet) B Maximum of 3 tablets per day

Balversa (4MG Oral Tablet) B Maximum of 2 tablets per day

Balversa (5MG Oral Tablet) B Maximum of 1 tablet per day

BCG Vaccine (Injection) B 1 vaccination dose (1 vial) per day

Belbuca (Buccal Film) B Maximum of 2 films per day

Belsomra (Oral Tablet) B Maximum of 1 tablet per day

Benazepril HCl (Oral Tablet) G Maximum of 2 tablets per day

Benazepril-Hydrochlorothiazide (Oral Tablet) G Maximum of 1 tablet per day

Benicar HCT (Oral Tablet) B Maximum of 1 tablet per day

Benicar (20MG Oral Tablet, 40MG Oral


Benicar (5MG Oral Tablet) B Maximum of 2 tablets per day

Bethkis (Inhalation Nebulization Solution) B Maximum of 2 ampules (8 ml) per day

Bexsero (Intramuscular Suspension

Prefilled Syringe)B 1 vaccination dose (0.5 ml) per day

Biktarvy (Oral Tablet) B Maximum of 1 tablet per day

Bisoprolol-Hydrochlorothiazide (Oral Tablet) G Maximum of 2 tablets per day

Boostrix (5-2.5-18.5 Intramuscular

Suspension, 5-2.5-18.5 (0.5ML Syringe)

Intramuscular Suspension)

B 1 vaccination dose (0.5 ml) per day

Bosentan (Oral Tablet) G Maximum of 2 tablets per day

Breo Ellipta (Inhalation Aerosol Powder

Breath Activated)B


30 days

Breztri Aerosphere (120 Inhalation Aerosol) BMaximum of 1 inhaler (10.7 grams)

per 30 days

Brilinta (Oral Tablet) B Maximum of 2 tablets per day

BRIVIACT (10MG/ML Oral Solution) B Maximum of 20 ml per day

BRIVIACT (100MG Oral Tablet, 10MG Oral

Tablet, 25MG Oral Tablet, 50MG Oral

Tablet, 75MG Oral Tablet)

B Maximum of 2 tablets per day

Bronchitol (Inhalation Capsule) B Maximum of 20 capsules per day

Brovana (Inhalation Nebulization Solution) B Maximum of 2 vials (4 ml) per day

Brukinsa (Oral Capsule) B Maximum of 4 capsules per day

Budesonide-Formoterol Fumarate (Inhalation

Aerosol)G

Maximum of 1 inhaler (10.2 grams)

per 30 days


Drug Name

Brand

or

Generic

Quantity Limit

Buprenorphine HCl (Tablet Sublingual) G Maximum of 3 tablets per day

Buprenorphine HCl-Naloxone HCl (12-3MG

Sublingual Film, 4-1MG Sublingual Film)G Maximum of 2 films per day

Buprenorphine HCl-Naloxone HCl (2-0.5MG

Sublingual Film, 8-2MG Sublingual Film)G Maximum of 3 films per day

Buprenorphine HCl-Naloxone HCl (Tablet

Sublingual)G Maximum of 3 tablets per day

Buprenorphine (Transdermal Patch Weekly) G Maximum of 4 patches per 28 days

Butorphanol Tartrate (Nasal Solution) GMaximum of 2 bottles (5 ml) per 30

days

Butrans (Transdermal Patch Weekly) B Maximum of 4 patches per 28 days

Bydureon BCise (Subcutaneous Auto-

Injector)B

Maximum of 4 pens (3.4 ml) per 28

days

Byetta 10MCG Pen (Subcutaneous Solution

Pen-Injector)B


days

Byetta 5MCG Pen (Subcutaneous Solution

Pen-Injector)B


days

Bystolic (10MG Oral Tablet, 2.5MG Oral


Bystolic (20MG Oral Tablet) B Maximum of 2 tablets per day

Cablivi (Injection Kit) B Maximum of 1 kit per day

Caduet (Oral Tablet) B Maximum of 1 tablet per day

Canasa (Rectal Suppository) B Maximum of 1 suppository per day

Candesartan Cilexetil (16MG Oral Tablet,

32MG Oral Tablet, 4MG Oral Tablet)G Maximum of 1 tablet per day

Candesartan Cilexetil (8MG Oral Tablet) G Maximum of 3 tablets per day

Candesartan Cilexetil-HCTZ (Oral Tablet) G Maximum of 1 tablet per day

Caplyta (Oral Capsule) B Maximum of 1 capsule per day

Captopril (100MG Oral Tablet) G Maximum of 4 tablets per day

Captopril (12.5MG Oral Tablet, 25MG Oral


Captopril (50MG Oral Tablet) G Maximum of 9 tablets per day

Cardura XL (Oral Tablet Extended Release

24 Hour)B Maximum of 1 tablet per day

Celebrex (Oral Capsule) B Maximum of 2 capsules per day

Celecoxib (Oral Capsule) G Maximum of 2 capsules per day

Cequa (Ophthalmic Solution) B Maximum of 2 vials per day

Chloroquine Phosphate (Oral Tablet) G Maximum of 2 tablets per day

Cialis (2.5MG Oral Tablet, 5MG Oral Tablet) B Maximum of 1 tablet per day


Drug Name

Brand

or

Generic

Quantity Limit

Cimduo (Oral Tablet) B Maximum of 1 tablet per day

Cinacalcet HCl (30MG Oral Tablet, 60MG


Cinacalcet HCl (90MG Oral Tablet) G Maximum of 4 tablets per day

Clindagel (External Gel) B Maximum of 75 ml per 30 days

Clindamycin Phosphate (External Gel) G Maximum of 75 grams per 30 days

Clobazam (2.5MG/ML Oral Suspension) G Maximum of 16 ml per day

Clobazam (10MG Oral Tablet, 20MG Oral


Clobetasol Propionate (External Foam) G Maximum of 100 grams per 30 days

Clobetasol Propionate (External Liquid Spray) G Maximum of 125 ml per 30 days

Clobetasol Propionate (External Lotion) G Maximum of 118 ml per 30 days

Clobex (External Lotion) B Maximum of 118 ml per 30 days

Clobex Spray (External Liquid) B Maximum of 125 ml per 30 days

Clonazepam (0.5MG Oral Tablet, 1MG Oral


Clonazepam (2MG Oral Tablet) G 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)


Clonazepam ODT (2MG Oral Tablet


Clopidogrel Bisulfate (75MG Oral Tablet) G Maximum of 4 tablets per day

Clorazepate Dipotassium (15MG Oral Tablet) G Maximum of 6 tablets per day

Clorazepate Dipotassium (3.75MG Oral


Clorazepate Dipotassium (7.5MG Oral Tablet) G Maximum of 12 tablets per day

Clovique (Oral Capsule) G Maximum of 8 capsules per day

Codeine Sulfate (15MG Oral Tablet) B Maximum of 6 tablets per day

Codeine Sulfate (30MG Oral Tablet, 60MG


Combivent Respimat (Inhalation Aerosol

Solution)B

Maximum of 1 inhaler (4 grams) per

20 days

Combivir (Oral Tablet) B Maximum of 2 tablets per day

Complera (Oral Tablet) B Maximum of 1 tablet per day

Concerta (18MG Oral Tablet Extended



Drug Name

Brand

or

Generic

Quantity Limit


Release, 36MG Oral Tablet Extended

Release)



Release)B Maximum of 1 tablet per day

ConZip (Oral Capsule Extended Release 24

Hour)B Maximum of 1 capsule per day

Copiktra (Oral Capsule) B Maximum of 2 capsules per day

Cordran (External Lotion) B Maximum of 240 ml per 30 days

Corlanor (Oral Solution) B Maximum of 15 ml per day

Corlanor (Oral Tablet) B Maximum of 2 tablets per day

Cotempla XR-ODT (Oral Tablet Extended

Release Dispersible)B Maximum of 2 tablets per day

Cozaar (100MG Oral Tablet) B Maximum of 1 tablet per day

Cozaar (25MG Oral Tablet, 50MG Oral


Crestor (Oral Tablet) B Maximum of 1 tablet per day

Cymbalta (20MG Oral Capsule Delayed

Release Particles)B Maximum of 4 capsules per day

Cymbalta (30MG Oral Capsule Delayed

Release Particles, 60MG Oral Capsule


B Maximum of 2 capsules per day

Dalfampridine ER (Oral Tablet Extended


Daptacel (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per day

Darifenacin Hydrobromide ER (Oral Tablet

Extended Release 24 Hour)G Maximum of 1 tablet per day

Daurismo (100MG Oral Tablet) B Maximum of 1 tablet per day

Daurismo (25MG Oral Tablet) B Maximum of 2 tablets per day

Daytrana (Transdermal Patch) B Maximum of 1 patch per day

DayVigo (Oral Tablet) B Maximum of 1 tablet per day

Delstrigo (Oral Tablet) B Maximum of 1 tablet per day

Descovy (Oral Tablet) B Maximum of 1 tablet per day

Desoximetasone (External Cream) G Maximum of 100 grams per 30 days

Dexedrine (10MG Oral Capsule Extended







Drug Name

Brand

or

Generic

Quantity Limit

Dexilant (Oral Capsule Delayed Release) B Maximum of 1 capsule per day

Dexmethylphenidate HCl (Oral Tablet) G Maximum of 2 tablets per day

Dextroamphetamine Sulfate ER (10MG Oral






Dextroamphetamine Sulfate (Oral Tablet) G Maximum of 6 tablets per day

Diacomit (250MG Oral Capsule) B Maximum of 12 capsules per day

Diacomit (500MG Oral Capsule) B Maximum of 6 capsules per day

Diacomit (250MG Oral Packet) B Maximum of 12 packets per day

Diacomit (500MG Oral Packet) B Maximum of 6 packets per day

Diastat AcuDial (Rectal Gel) B Maximum of 5 packages per 30 days

Diastat Pediatric (Rectal Gel) B Maximum of 5 packages per 30 days

Diazepam Intensol (5MG/ML Oral

Concentrate)G Maximum of 8 ml per day

Diazepam (10MG Oral Tablet, 2MG Oral

Tablet, 5MG Oral Tablet)G Maximum of 4 tablets per day

Diazepam (10MG Rectal Gel, 2.5MG Rectal

Gel, 20MG Rectal Gel)G Maximum of 5 packages per 30 days

Diclofenac Epolamine (External Patch) G Maximum of 2 patches per day

Diflorasone Diacetate (External Cream) G Maximum of 240 grams per 30 days

Diflorasone Diacetate (External Ointment) G Maximum of 240 grams per 30 days

Digitek (125MCG Oral Tablet) G Maximum of 1 tablet per day

Digox (125MCG Oral Tablet) G Maximum of 1 tablet per day

Digoxin (Oral Solution) G Maximum of 5 ml per day

Digoxin (125MCG Oral Tablet) G Maximum of 1 tablet per day

Dihydroergotamine Mesylate (Nasal Solution) GMaximum of 16 vials (16 ml) per 28

days

Dilaudid (Oral Liquid) B Maximum of 50 ml per day

Dilaudid (2MG Oral Tablet, 4MG Oral


Dilaudid (8MG Oral Tablet) B Maximum of 6 tablets per day

Dimethyl Fumarate (120MG Oral Capsule

Delayed Release, 240MG Oral Capsule

Delayed Release)

G Maximum of 2 capsules per day

Diovan HCT (Oral Tablet) B Maximum of 1 tablet per day


Drug Name

Brand

or

Generic

Quantity Limit

Diovan (160MG Oral Tablet, 40MG Oral

Tablet, 80MG Oral Tablet)B Maximum of 2 tablets per day

Diovan (320MG Oral Tablet) B Maximum of 1 tablet per day

Diphtheria-Tetanus Toxoids DT

(Intramuscular Suspension)B 1 vaccination dose (0.5 ml) per day

Donepezil HCl (10MG Oral Tablet) G Maximum of 2 tablets per day

Donepezil HCl (23MG Oral Tablet, 5MG Oral

Tablet)G Maximum of 1 tablet per day

Donepezil HCl ODT (10MG Oral Tablet


Donepezil HCl ODT (5MG Oral Tablet

Dispersible)G Maximum of 1 tablet per day

Dotti (Transdermal Patch Twice Weekly) G Maximum of 8 patches per 28 days

Dovato (Oral Tablet) B Maximum of 1 tablet per day

Doxepin HCl (External Cream) G Maximum of 90 grams per 30 days

Drizalma Sprinkle (20MG Oral Capsule

Delayed Release Sprinkle, 30MG Oral

Capsule Delayed Release Sprinkle, 60MG

Oral Capsule Delayed Release Sprinkle)


Drizalma Sprinkle (40MG Oral Capsule

Delayed Release Sprinkle)B Maximum of 3 capsules per day

Droxidopa (100MG Oral Capsule) G Maximum of 3 capsules per day

Droxidopa (200MG Oral Capsule, 300MG

Oral Capsule)G Maximum of 6 capsules per day

Duaklir Pressair (Inhalation Aerosol Powder

Breath Activated)B Maximum of 1 inhaler per 30 days

Duetact (Oral Tablet) B Maximum of 1 tablet per day

Dulera (120 Inhalation Aerosol) BMaximum of 1 inhaler (13 grams) per

30 days

Duloxetine HCl (20MG Oral Capsule Delayed

Release Particles)G Maximum of 4 capsules per day


Release Particles, 60MG Oral Capsule




Release Particles)G Maximum of 3 capsules per day

Dyanavel XR (Oral Suspension Extended

Release)B Maximum of 8 ml per day

Econazole Nitrate (External Cream) G Maximum of 90 grams per 30 days

Edarbi (Oral Tablet) B Maximum of 1 tablet per day


Drug Name

Brand

or

Generic

Quantity Limit

Edarbyclor (Oral Tablet) B Maximum of 1 tablet per day

Edurant (Oral Tablet) B Maximum of 1 tablet per day

Efavirenz (Oral Capsule) G Maximum of 3 capsules per day

Efavirenz (Oral Tablet) G Maximum of 1 tablet per day

Efavirenz-Emtricitabine-Tenofovir (Oral Tablet) G Maximum of 1 tablet per day

Efavirenz-Lamivudine-Tenofovir (Oral Tablet) G Maximum of 1 tablet per day

Eletriptan Hydrobromide (Oral Tablet) G Maximum of 12 tablets per 30 days

Elidel (External Cream) B Maximum of 100 grams per 30 days

Eliquis (Oral Tablet) B Maximum of 2 tablets per day

Eliquis Starter Pack (Oral Tablet) BMaximum of 1 pack (74 tablets) per

30 days

Emgality (300MG Dose) (100MG/ML

Subcutaneous Solution Prefilled Syringe)B

Maximum of 3 syringes or pens (3 ml)

per 30 days

Emgality (Subcutaneous Solution Auto-

Injector)B


per 30 days

Emgality (120MG/ML Subcutaneous

Solution Prefilled Syringe)B


per 30 days

Emtricitabine (Oral Capsule) G Maximum of 1 capsule per day

Emtricitabine-Tenofovir Disoproxil Fumarate

(Oral Tablet)G Maximum of 1 tablet per day

Emtriva (Oral Capsule) B Maximum of 1 capsule per day

Emtriva (Oral Solution) BMaximum of 5 bottles (850 ml) per 30

days

Enalapril Maleate (Oral Tablet) G Maximum of 2 tablets per day

Enalapril-Hydrochlorothiazide (10-25MG Oral


Enalapril-Hydrochlorothiazide (5-12.5MG Oral


Endocet (10-325MG Oral Tablet, 5-325MG

Oral Tablet, 7.5-325MG Oral Tablet)G Maximum of 12 tablets per day

Engerix-B (10MCG/0.5ML Injection

Suspension)B 1 vaccination dose (0.5 ml) per day

Engerix-B (20MCG/ML Injection

Suspension)B 1 vaccination dose (1 ml) per day

Enoxaparin Sodium (100MG/ML

Subcutaneous Solution, 150MG/ML


G Maximum of 2 syringes (2 ml) per day

Enoxaparin Sodium (120MG/0.8ML

Subcutaneous Solution, 80MG/0.8ML


GMaximum of 2 syringes (1.6 ml) per

day


Drug Name

Brand

or

Generic

Quantity Limit


Subcutaneous Solution)G

Maximum of 2 syringes (0.6 ml) per

day




day




day

Entresto (Oral Tablet) B Maximum of 2 tablets per day

Epclusa (200-50MG Oral Tablet) B Maximum of 2 tablets per day

Epclusa (400-100MG Oral Tablet) B Maximum of 1 tablet per day

Epinephrine (Injection Solution Auto-Injector) GMaximum of 4 pens (2 boxes) per 30

days

EpiPen 2-Pak (Injection Solution Auto-

Injector)B

Maximum of 4 pens (2 boxes) per 30

days

EpiPen Jr 2-Pak (Injection Solution Auto-

Injector)B

Maximum of 4 pens (2 boxes) per 30

days

Epivir (10MG/ML Oral Solution) B Maximum of 32 ml per day

Epivir (150MG Oral Tablet) B Maximum of 2 tablets per day

Epivir (300MG Oral Tablet) B Maximum of 1 tablet per day

Epzicom (Oral Tablet) B Maximum of 1 tablet per day

Esbriet (Oral Capsule) B Maximum of 9 capsules per day

Esbriet (267MG Oral Tablet) B Maximum of 9 tablets per day

Esbriet (801MG Oral Tablet) B Maximum of 3 tablets per day

Esomeprazole Magnesium (20MG Oral

Capsule Delayed Release) (Generic Nexium)G Maximum of 3 capsules per day

Esomeprazole Magnesium (40MG Oral

Capsule Delayed Release) (Generic Nexium)G Maximum of 2 capsules per day

Estradiol (Transdermal Patch Twice Weekly) G Maximum of 8 patches per 28 days

Eucrisa (External Ointment) B Maximum of 100 grams per 30 days

Evenity (Subcutaneous Solution Prefilled

Syringe)B


28 days

Evotaz (Oral Tablet) B Maximum of 1 tablet per day

Evrysdi (Oral Solution Reconstituted) B Maximum of 8 ml per day

Exelon (Transdermal Patch 24 Hour) B Maximum of 1 patch per day

Exforge (Oral Tablet) B Maximum of 1 tablet per day

Extina (External Foam) B Maximum of 100 grams per 28 days

Ezallor Sprinkle (Oral Capsule Sprinkle) B Maximum of 1 capsule per day

Ezetimibe-Simvastatin (Oral Tablet) G Maximum of 1 tablet per day


Drug Name

Brand

or

Generic

Quantity Limit

Fanapt (10MG Oral Tablet, 12MG Oral


4MG Oral Tablet, 6MG Oral Tablet, 8MG

Oral Tablet)


Farxiga (Oral Tablet) B Maximum of 1 tablet per day

Fentanyl Citrate (1200MCG Buccal Lozenge

On A Handle, 1600MCG Buccal Lozenge On

A Handle, 200MCG Buccal Lozenge On A

Handle, 400MCG Buccal Lozenge On A



Handle)

G Maximum of 4 lozenges per day

Fentanyl Citrate (100MCG Buccal Tablet,

200MCG Buccal Tablet, 400MCG Buccal

Tablet, 600MCG Buccal Tablet, 800MCG

Buccal Tablet)


Fentanyl (Transdermal Patch 72 Hour) G Maximum of 15 patches per 30 days

Fentora (Buccal Tablet) B Maximum of 4 tablets per day

Fintepla (Oral Solution) B Maximum of 12 ml per day

Firazyr (Subcutaneous Solution) B Maximum of 3 syringes (9 ml) per day

Firdapse (Oral Tablet) B Maximum of 8 tablets per day

Flector (External Patch) B Maximum of 2 patches per day

FloLipid (20MG/5ML Oral Suspension) B Maximum of 5 ml per day

FloLipid (40MG/5ML Oral Suspension) B Maximum of 10 ml per day

Flovent HFA (110MCG/ACT Inhalation

Aerosol)B


30 days


Aerosol)B

Maximum of 2 inhalers (24 grams)

per 30 days


Aerosol)B

Maximum of 1 inhaler (10.6 grams)

per 30 days

Flurandrenolide (External Lotion) G Maximum of 240 ml 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)

GMaximum of 1 inhaler (60 blisters) per

30 days


Drug Name

Brand

or

Generic

Quantity Limit

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)

G Maximum of 1 inhaler per 30 days

Fluvastatin Sodium ER (Oral Tablet Extended

Release 24 Hour)G Maximum of 1 tablet per day

Fluvastatin Sodium (20MG Oral Capsule) G Maximum of 1 capsule per day

Fluvastatin Sodium (40MG Oral Capsule) G Maximum of 2 capsules per day

Focalin (Oral Tablet) B Maximum of 2 tablets per day

Fortamet (1000MG Oral Tablet Extended

Release 24 Hour)B Maximum of 2 tablets per day

Fortamet (500MG Oral Tablet Extended


Fosamprenavir Calcium (Oral Tablet) G Maximum of 4 tablets per day

Fosinopril Sodium (Oral Tablet) G Maximum of 2 tablets per day

Fosinopril Sodium-HCTZ (Oral Tablet) G Maximum of 4 tablets per day

Fotivda (Oral Capsule) B Maximum of 1 capsule per day

Frova (Oral Tablet) B Maximum of 12 tablets per 30 days

Frovatriptan Succinate (Oral Tablet) G Maximum of 12 tablets per 30 days

Fuzeon (Subcutaneous Solution

Reconstituted)B Maximum of 2 vials per day

Fycompa (Oral Suspension) B Maximum of 24 ml per day

Fycompa (Oral Tablet) B Maximum of 1 tablet per day

Gardasil 9 (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per day

Gardasil 9 (Intramuscular Suspension


Gavreto (Oral Capsule) B Maximum of 4 capsules per day

Genvoya (Oral Tablet) B Maximum of 1 tablet per day

Geodon (Oral Capsule) B Maximum of 2 capsules per day

Gilenya (0.5MG Oral Capsule) BMaximum of 1 pack (30 capsules) per

30 days

Gleevec (Oral Tablet) B Maximum of 3 tablets per day

Glimepiride (1MG Oral Tablet) G Maximum of 8 tablets per day



Glipizide ER (10MG Oral Tablet Extended



Drug Name

Brand

or

Generic

Quantity Limit

Glipizide ER (2.5MG Oral Tablet Extended


Glipizide ER (5MG Oral Tablet Extended


Glipizide (10MG Oral Tablet Immediate


Glipizide (5MG Oral Tablet Immediate


Glipizide-Metformin HCl (2.5-250MG Oral


Glipizide-Metformin HCl (2.5-500MG Oral

Tablet, 5-500MG Oral Tablet)G Maximum of 4 tablets per day

Gloperba (Oral Solution) B Maximum of 20 ml per day

Glucotrol XL (10MG Oral Tablet Extended


Glucotrol XL (2.5MG Oral Tablet Extended


Glucotrol XL (5MG Oral Tablet Extended


Glumetza (1000MG Oral Tablet Extended


Glumetza (500MG Oral Tablet Extended


Glyxambi (Oral Tablet) B Maximum of 1 tablet per day

Harvoni (33.75-150MG Oral Packet) BMaximum of 1 carton (28 packets)

per 28 days

Harvoni (45-200MG Oral Packet) BMaximum of 2 cartons (56 packets)

per 28 days

Harvoni (90-400MG Oral Tablet) B Maximum of 1 tablet per day

Havrix (Intramuscular Suspension) B Maximum of 2 vaccines per lifetime

Hetlioz LQ (Oral Suspension) B Maximum of 158 ml per 30 days

Hetlioz (Oral Capsule) B Maximum of 1 capsule per day

Hiberix (Injection Solution Reconstituted) B1 vaccination dose (1 injection) per

day


Drug Name

Brand

or

Generic

Quantity Limit

Hydrocodone Bitartrate ER (10MG Oral

Capsule Extended Release 12 Hour, 15MG

Oral Capsule Extended Release 12 Hour,

20MG Oral Capsule Extended Release 12

Hour, 30MG Oral Capsule Extended Release

12 Hour, 40MG Oral Capsule Extended

Release 12 Hour, 50MG Oral Capsule



Hydrocodone Bitartrate ER (100MG Oral

Tablet ER 24 Hour Abuse-Deterrent, 120MG

Oral Tablet ER 24 Hour Abuse-Deterrent,

20MG Oral Tablet ER 24 Hour Abuse-

Deterrent, 30MG Oral Tablet ER 24 Hour

Abuse-Deterrent, 40MG Oral Tablet ER 24

Hour Abuse-Deterrent, 60MG Oral Tablet ER

24 Hour Abuse-Deterrent, 80MG Oral Tablet

ER 24 Hour Abuse-Deterrent)


Hydrocodone-Acetaminophen (7.5-325MG/

15ML Oral Solution)G Maximum of 180 ml per day

Hydrocodone-Acetaminophen (10-300MG

Oral Tablet, 5-300MG Oral Tablet, 7.5-300MG

Oral Tablet)


Hydrocodone-Acetaminophen (10-325MG

Oral Tablet, 5-325MG Oral Tablet, 7.5-325MG

Oral Tablet)


Hydrocodone-Ibuprofen (Oral Tablet) G Maximum of 5 tablets per day

Hydrocortisone Butyrate (External Lotion) G Maximum of 118 ml per 30 days

Hydromorphone HCl ER (Oral Tablet

Extended Release 24 Hour)G Maximum of 2 tablets per day

Hydromorphone HCl (1MG/ML Oral Liquid) G Maximum of 50 ml per day

Hydromorphone HCl (2MG Oral Tablet

Immediate Release, 4MG Oral Tablet

Immediate Release)


Hydromorphone HCl (8MG Oral Tablet

Immediate Release)G Maximum of 6 tablets per day

Hydroxychloroquine Sulfate (Oral Tablet) G Maximum of 3 tablets per day

Hysingla ER (Oral Tablet ER 24 Hour

Abuse-Deterrent)B Maximum of 1 tablet per day

Hyzaar (100-12.5MG Oral Tablet,

100-25MG Oral Tablet)B Maximum of 1 tablet per day

Hyzaar (50-12.5MG Oral Tablet) B Maximum of 2 tablets per day


Drug Name

Brand

or

Generic

Quantity Limit

Icatibant Acetate (Subcutaneous Solution) G Maximum of 3 syringes (9 ml) per day

Imatinib Mesylate (Oral Tablet) G Maximum of 3 tablets per day

Imbruvica (140MG Oral Capsule) B Maximum of 4 capsules per day

Imbruvica (70MG Oral Capsule) B Maximum of 1 capsule per day

Imbruvica (Oral Tablet) B Maximum of 1 tablet per day

Imiquimod (5% External Cream) G Maximum of 24 grams per 30 days

Imitrex (Nasal Solution) B Maximum of 12 devices per 30 days

Imitrex (Oral Tablet) B Maximum of 12 tablets per 30 days

Imitrex STATdose Refill (6MG/0.5ML

Subcutaneous Solution Cartridge)B

Maximum of 12 injections (6 ml) per

30 days

Imitrex STATdose System (4MG/0.5ML

Subcutaneous Solution Auto-Injector)B


30 days

Imitrex (Subcutaneous Solution) BMaximum of 12 injections (6 ml) per

30 days

Imovax Rabies (Intramuscular Injectable) B1 vaccination dose (1 injection) per

day

Impeklo (External Lotion) B Maximum of 68 grams per 30 days

Incruse Ellipta (Inhalation Aerosol Powder

Breath Activated)B


30 days

Infanrix (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per day

Ingrezza (40MG Oral Capsule, 80MG Oral

Capsule)B Maximum of 1 capsule per day

Ingrezza (Oral Capsule Therapy Pack) BMaximum of 1 pack (28 capsules) per

28 days

Inlyta (Oral Tablet) B Maximum of 4 tablets per day

Inqovi (Oral Tablet) BMaximum of 1 pack (5 tablets) per 28

days

Inrebic (Oral Capsule) B Maximum of 4 capsules per day

Intelence (100MG Oral Tablet, 200MG Oral


Intelence (25MG Oral Tablet) B Maximum of 4 tablets per day

Intrarosa (Vaginal Insert) B Maximum of 1 vaginal insert per day

Invega (1.5MG Oral Tablet Extended

Release 24 Hour, 3MG Oral Tablet

Extended Release 24 Hour, 9MG Oral

Tablet Extended Release 24 Hour)

B Maximum of 1 tablet per day

Invega (6MG Oral Tablet Extended Release

24 Hour)B Maximum of 2 tablets per day

Invirase (Oral Tablet) B Maximum of 4 tablets per day


Drug Name

Brand

or

Generic

Quantity Limit

Invokamet (Oral Tablet Immediate Release) B Maximum of 2 tablets per day

Invokamet XR (Oral Tablet Extended


Invokana (Oral Tablet) B Maximum of 1 tablet per day

IPOL (Injection) B 1 vaccination dose (0.5 ml) per day

Irbesartan (150MG Oral Tablet, 300MG Oral


Irbesartan (75MG Oral Tablet) G Maximum of 3 tablets per day

Irbesartan-Hydrochlorothiazide (Oral Tablet) G Maximum of 1 tablet per day

Iressa (Oral Tablet) B Maximum of 2 tablets per day

Isentress HD (Oral Tablet) B Maximum of 2 tablets per day

Isentress (Oral Packet) B Maximum of 2 packets per day

Isentress (Oral Tablet) B Maximum of 2 tablets per day

Isentress (Oral Tablet Chewable) B Maximum of 6 tablets per day

Ixiaro (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per day

Jakafi (Oral Tablet) B Maximum of 2 tablets per day

Janumet (Oral Tablet Immediate Release) B Maximum of 2 tablets per day

Janumet XR (100-1000MG Oral Tablet

Extended Release 24 Hour)B Maximum of 1 tablet per day

Janumet XR (50-1000MG Oral Tablet

Extended Release 24 Hour, 50-500MG Oral



Januvia (Oral Tablet) B Maximum of 1 tablet per day

Jardiance (Oral Tablet) B Maximum of 1 tablet per day

Jentadueto (Oral Tablet Immediate


Jentadueto XR (2.5-1000MG Oral Tablet

Extended Release 24 Hour)B Maximum of 2 tablets per day

Jentadueto XR (5-1000MG Oral Tablet

Extended Release 24 Hour)B Maximum of 1 tablet per day

Jornay PM (Oral Capsule Extended Release

24 Hour)B Maximum of 1 capsule per day

Juluca (Oral Tablet) B Maximum of 1 tablet per day

Jynarque (Oral Tablet Therapy Pack) B Maximum of 2 tablets per day

Kaletra (Oral Solution) BMaximum of 3 bottles (480 ml) per 30

days

Kaletra (100-25MG Oral Tablet) B Maximum of 8 tablets per day

Kaletra (200-50MG Oral Tablet) B Maximum of 4 tablets per day

Kazano (Oral Tablet) B Maximum of 2 tablets per day


Drug Name

Brand

or

Generic

Quantity Limit

Ketoconazole (External Cream) G Maximum of 90 grams per 30 days

Ketoconazole (External Foam) G Maximum of 100 grams per 28 days

Ketodan (External Foam) G Maximum of 100 grams per 28 days

Keveyis (Oral Tablet) B Maximum of 4 tablets per day

Kinrix (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per day

Klonopin (0.5MG Oral Tablet, 1MG Oral


Klonopin (2MG Oral Tablet) B Maximum of 10 tablets per day

Kombiglyze XR (2.5-1000MG Oral Tablet

Extended Release 24 Hour)B Maximum of 2 tablets per day

Kombiglyze XR (5-1000MG Oral Tablet




Koselugo (10MG Oral Capsule) B Maximum of 8 capsules per day

Koselugo (25MG Oral Capsule) B Maximum of 4 capsules per day

Kynmobi (10MG Sublingual Film, 15MG

Sublingual Film, 20MG Sublingual Film,

25MG Sublingual Film, 30MG Sublingual

Film)

B Maximum of 5 films per day

Lamivudine (10MG/ML Oral Solution) G Maximum of 32 ml per day

Lamivudine (150MG Oral Tablet) G Maximum of 2 tablets per day

Lamivudine (300MG Oral Tablet) G Maximum of 1 tablet per day

Lamivudine-Zidovudine (Oral Tablet) G Maximum of 2 tablets per day

Lanoxin (125MCG Oral Tablet) B Maximum of 1 tablet per day

Lanoxin (62.5MCG Oral Tablet) B Maximum of 2 tablets per day

Lansoprazole (Oral Capsule Delayed

Release)G Maximum of 2 capsules per day

Latuda (120MG Oral Tablet, 20MG Oral

Tablet, 40MG Oral Tablet, 60MG Oral

Tablet)


Latuda (80MG Oral Tablet) B Maximum of 2 tablets per day

Lazanda (Nasal Solution) B Maximum of 30 bottles per 30 days

Ledipasvir-Sofosbuvir (Oral Tablet) G Maximum of 1 tablet per day

Lescol XL (Oral Tablet Extended Release


Letairis (Oral Tablet) B Maximum of 1 tablet per day

Levorphanol Tartrate (Oral Tablet) G Maximum of 6 tablets per day

Lexiva (Oral Suspension) B Maximum of 60 ml per day

Lexiva (Oral Tablet) B Maximum of 4 tablets per day


Drug Name

Brand

or

Generic

Quantity Limit

Lialda (Oral Tablet Delayed Release) B Maximum of 4 tablets per day

Licart (External Patch 24 Hour) B Maximum of 1 patch per day

Lidocaine (5% External Ointment) G Maximum of 152 grams per 30 days

Lidocaine (5% External Patch) G Maximum of 3 patches per day

Lidoderm (External Patch) B Maximum of 3 patches per day

Linzess (Oral Capsule) B Maximum of 1 capsule per day

Lipitor (Oral Tablet) B Maximum of 1 tablet per day

Lisinopril (Oral Tablet) G Maximum of 2 tablets per day

Lisinopril-Hydrochlorothiazide (10-12.5MG

Oral Tablet)G Maximum of 1 tablet per day

Lisinopril-Hydrochlorothiazide (20-12.5MG


Lisinopril-Hydrochlorothiazide (20-25MG Oral


Livalo (Oral Tablet) B Maximum of 1 tablet per day

Locoid (External Lotion) B Maximum of 118 ml per 30 days

Lokelma (Oral Packet) B Maximum of 90 packets per 30 days

Lonhala Magnair (Inhalation Solution) B Maximum of 2 vials (2 ml) per day

Lopinavir-Ritonavir (Oral Solution) GMaximum of 3 bottles (480 ml) per 30

days

Lorazepam Intensol (Oral Concentrate) G Maximum of 5 ml per day

Lorazepam (0.5MG Oral Tablet, 1MG Oral


Lorazepam (2MG Oral Tablet) G Maximum of 5 tablets per day

Lorbrena (100MG Oral Tablet) B Maximum of 1 tablet per day

Lorbrena (25MG Oral Tablet) B Maximum of 3 tablets per day

Losartan Potassium (100MG Oral Tablet) G Maximum of 1 tablet per day

Losartan Potassium (25MG Oral Tablet,

50MG Oral Tablet)G Maximum of 2 tablets per day

Losartan Potassium-HCTZ (100-12.5MG Oral

Tablet, 100-25MG Oral Tablet)G Maximum of 1 tablet per day

Losartan Potassium-HCTZ (50-12.5MG Oral


Lotensin (Oral Tablet) B Maximum of 2 tablets per day

Lotrel (Oral Capsule) B Maximum of 1 capsule per day

Lovastatin (10MG Oral Tablet, 20MG Oral


Lovastatin (40MG Oral Tablet) G Maximum of 2 tablets per day


Drug Name

Brand

or

Generic

Quantity Limit

Lovenox (100MG/ML Subcutaneous

Solution, 150MG/ML Subcutaneous

Solution)

B Maximum of 2 syringes (2 ml) per day

Lovenox (120MG/0.8ML Subcutaneous

Solution, 80MG/0.8ML Subcutaneous

Solution)

BMaximum of 2 syringes (1.6 ml) per

day


Solution)B


day


Solution)B


day


Solution)B


day

Lubiprostone (Oral Capsule) G Maximum of 2 capsules per day

Lucemyra (Oral Tablet) B Maximum of 16 tablets per day

Luliconazole (External Cream) B Maximum of 60 grams per 28 days

Lupkynis (Oral Capsule) B Maximum of 6 capsules per day

Luzu (External Cream) B Maximum of 60 grams per 28 days

Lyllana (Transdermal Patch Twice Weekly) G Maximum of 8 patches per 28 days

Lyrica CR (165MG Oral Tablet Extended

Release 24 Hour, 82.5MG Oral Tablet



Lyrica CR (330MG Oral Tablet Extended


Lyrica (100MG Oral Capsule, 150MG Oral

Capsule, 25MG Oral Capsule, 50MG Oral

Capsule, 75MG Oral Capsule)


Lyrica (200MG Oral Capsule) B Maximum of 3 capsules per day

Lyrica (225MG Oral Capsule, 300MG Oral

Capsule)B Maximum of 2 capsules per day

Lyrica (Oral Solution) B Maximum of 30 ml per day

Mavyret (Oral Tablet) B Maximum of 3 tablets per day

Maxalt (Oral Tablet) B Maximum of 12 tablets per 30 days

Maxalt-MLT (Oral Tablet Dispersible) B Maximum of 12 tablets per 30 days

Mayzent (0.25MG Oral Tablet) B Maximum of 8 tablets per day

Mayzent (2MG Oral Tablet) B Maximum of 1 tablet per day

Meloxicam (Oral Capsule) G Maximum of 1 capsule per day

Memantine HCl ER (Oral Capsule Extended

Release 24 Hour)G Maximum of 1 capsule per day

Memantine HCl (2MG/ML Oral Solution) G Maximum of 10 ml per day


Drug Name

Brand

or

Generic

Quantity Limit

Memantine HCl (10MG Oral Tablet) G Maximum of 2 tablets per day

Memantine HCl (5MG Oral Tablet) G Maximum of 3 tablets per day

Menactra (Intramuscular Injectable) B 1 vaccination dose (0.5 ml) per day

MenQuadfi (Intramuscular Injectable) B 1 vaccination dose (0.5 ml) per day

Menveo (Intramuscular Solution

Reconstituted)B


day

Mesalamine ER (0.375GM Oral Capsule

Extended Release 24 Hour) (Generic Apriso)G Maximum of 4 capsules per day

Mesalamine (1.2GM Oral Tablet Delayed

Release) (Generic Lialda)G Maximum of 4 tablets per day

Mesalamine (800MG Oral Tablet Delayed

Release) (Generic Asacol)G Maximum of 6 tablets per day

Mesalamine (Rectal Suppository) G Maximum of 1 suppository per day

Metformin HCl ER (1000MG Oral Tablet

Extended Release 24 Hour) (Generic

Glumetza)




Glumetza)




Fortamet)




Fortamet)




Glucophage XR)




Glucophage XR)


Metformin HCl (500MG/5ML Oral Solution) G Maximum of 25.5 ml per day

Metformin HCl (1000MG Oral Tablet

Immediate Release)G Maximum of 2.5 tablets per day





Methadone HCl (10MG/5ML Oral Solution) G Maximum of 60 ml per day

Methadone HCl (5MG/5ML Oral Solution) G Maximum of 120 ml per day


Drug Name

Brand

or

Generic

Quantity Limit

Methadone HCl (10MG Oral Tablet) G Maximum of 12 tablets per day

Methadone HCl (5MG Oral Tablet) G Maximum of 8 tablets per day

Methylin (10MG/5ML Oral Solution) B Maximum of 30 ml per day

Methylin (5MG/5ML Oral Solution) B Maximum of 60 ml per day

Methylphenidate HCl ER (XR) (Oral Capsule

Extended Release 24 Hour) (Brand

Equivalent Aptensio XR)

G Maximum of 1 capsule per day

Methylphenidate HCl ER (10MG Oral Tablet

Extended Release)G Maximum of 4 tablets per day

Methylphenidate HCl ER Osmotic Release

(18MG Oral Tablet Extended Release)

(Generic Concerta), Methylphenidate HCl ER

(20MG Oral Tablet Extended Release)

(Generic Metadate ER)











(27MG Oral Tablet Extended Release, 36MG

Oral Tablet Extended Release) (Generic

Concerta)



(54MG Oral Tablet Extended Release, 72MG

Oral Tablet Extended Release) (Generic

Concerta)


Methylphenidate HCl (10MG/5ML Oral

Solution)G Maximum of 30 ml per day

Methylphenidate HCl (5MG/5ML Oral

Solution)G Maximum of 60 ml per day

Methylphenidate HCl (Oral Tablet Immediate

Release) (Generic Ritalin)G Maximum of 3 tablets per day

Methylphenidate HCl (10MG Oral Tablet

Chewable)G Maximum of 6 tablets per day

Methylphenidate HCl (2.5MG Oral Tablet

Chewable, 5MG Oral Tablet Chewable)G Maximum of 3 tablets per day

Micardis HCT (40-12.5MG Oral Tablet,

80-25MG Oral Tablet)B Maximum of 1 tablet per day


Drug Name

Brand

or

Generic

Quantity Limit

Micardis HCT (80-12.5MG Oral Tablet) B Maximum of 2 tablets per day

Micardis (Oral Tablet) B Maximum of 1 tablet per day

Migranal (Nasal Solution) BMaximum of 16 vials (16 ml) per 28

days

Minivelle (Transdermal Patch Twice

Weekly)B Maximum of 8 patches per 28 days

Minocycline HCl ER (Oral Tablet Extended


Minolira (Oral Tablet Extended Release 24


M-M-R II (Injection Solution Reconstituted) B1 vaccination dose (1 injection) per

day

Modafinil (100MG Oral Tablet) G Maximum of 1 tablet per day

Modafinil (200MG Oral Tablet) G Maximum of 2 tablets per day

Moexipril HCl (Oral Tablet) G Maximum of 2 tablets per day

Montelukast Sodium (Oral Packet) G Maximum of 1 packet per day

Montelukast Sodium (Oral Tablet) G Maximum of 1 tablet per day

Montelukast Sodium (Oral Tablet Chewable) G Maximum of 1 tablet per day

Morphine Sulfate (100MG/5ML Oral Solution) G Maximum of 10 ml per day

Morphine Sulfate ER Beads (120MG Oral

Capsule Extended Release 24 Hour) (Generic

Avinza)






Hour) (Generic Avinza)




Oral Capsule Extended Release 24 Hour)

(Generic Avinza)


Morphine Sulfate ER (100MG Oral Capsule




(Generic Kadian)



Drug Name

Brand

or

Generic

Quantity Limit

Morphine Sulfate ER (10MG Oral Capsule





Hour, 50MG Oral Capsule Extended Release

24 Hour) (Generic Kadian)


Morphine Sulfate ER (100MG Oral Tablet

Extended Release, 15MG Oral Tablet




Extended Release) (Generic MS Contin)G Maximum of 2 tablets per day


Extended Release, 60MG Oral Tablet





Morphine Sulfate (15MG Oral Tablet


Morphine Sulfate (30MG Oral Tablet


Motegrity (Oral Tablet) B Maximum of 1 tablet per day

Movantik (Oral Tablet) B Maximum of 1 tablet per day

MS Contin (100MG Oral Tablet Extended


Release)






Release)


Mupirocin (External Ointment) G Maximum of 110 grams per 30 days

Mycapssa (Oral Capsule Delayed Release) BMaximum of 112 capsules per 28

days

Mydayis (12.5MG Oral Capsule Extended




Mydayis (37.5MG Oral Capsule Extended



B Maximum of 1 capsule per day

Namenda (10MG Oral Tablet) B Maximum of 2 tablets per day


Drug Name

Brand

or

Generic

Quantity Limit

Namenda (5MG Oral Tablet) B Maximum of 3 tablets per day

Namenda XR (Oral Capsule Extended

Release 24 Hour)B Maximum of 1 capsule per day

Namzaric (Oral Capsule ER 24 Hour

Therapy Pack)B Maximum of 1 capsule per day

Namzaric (Oral Capsule Extended Release

24 Hour)B Maximum of 1 capsule per day

Naratriptan HCl (Oral Tablet) G Maximum of 12 tablets per 30 days

Nateglinide (120MG Oral Tablet) G Maximum of 3 tablets per day

Nateglinide (60MG Oral Tablet) G Maximum of 6 tablets per day

Nayzilam (Nasal Solution) B Maximum of 10 devices per 30 days

Nebupent (Inhalation Solution

Reconstituted)B

Maximum of 1 vial (300 mg) per 28

days

Nerlynx (Oral Tablet) B Maximum of 6 tablets per day

Nesina (Oral Tablet) B Maximum of 1 tablet per day

Nevirapine ER (100MG Oral Tablet Extended


Nevirapine ER (400MG Oral Tablet Extended


Nevirapine (Oral Suspension) G Maximum of 40 ml per day

Nevirapine (Oral Tablet Immediate Release) G Maximum of 2 tablets per day

Nexium (20MG Oral Capsule Delayed

Release)B Maximum of 3 capsules per day

Nexium (40MG Oral Capsule Delayed


Nexletol (Oral Tablet) B Maximum of 1 tablet per day

Nexlizet (Oral Tablet) B Maximum of 1 tablet per day

Nolix (External Lotion) G Maximum of 240 ml per 30 days

Northera (100MG Oral Capsule) B Maximum of 3 capsules per day

Northera (200MG Oral Capsule, 300MG

Oral Capsule)B Maximum of 6 capsules per day

Norvir (Oral Packet) B Maximum of 12 packets per day

Norvir (Oral Solution) B Maximum of 16 ml per day

Norvir (Oral Tablet) B Maximum of 12 tablets per day

Nourianz (Oral Tablet) B Maximum of 1 tablet per day

Noxafil (Oral Suspension) B Maximum of 20 ml per day

Noxafil (Oral Tablet Delayed Release) B Maximum of 6 tablets per day

Nucala (Subcutaneous Solution Auto-

Injector)B Maximum of 3 ml per 28 days


Drug Name

Brand

or

Generic

Quantity Limit

Nucala (Subcutaneous Solution Prefilled

Syringe)B Maximum of 3 ml per 28 days

Nucala (Subcutaneous Solution

Reconstituted)B Maximum of 3 vials per 28 days

Nucynta ER (Oral Tablet Extended Release

12 Hour)B Maximum of 2 tablets per day

Nucynta (Oral Tablet Immediate Release) B Maximum of 6 tablets per day

Nuedexta (Oral Capsule) B Maximum of 2 capsules per day

Nuplazid (Oral Capsule) B Maximum of 1 capsule per day

Nuplazid (Oral Tablet) B Maximum of 1 tablet per day

Nurtec ODT (Oral Tablet Dispersible) B Maximum of 18 tablets per 30 days

Nuvigil (150MG Oral Tablet, 200MG Oral


Nuvigil (50MG Oral Tablet) B Maximum of 2 tablets per day

Nuzyra (Oral Tablet) B Maximum of 2 tablets per day

Nyamyc (External Powder) G Maximum of 120 grams per 30 days

Nystatin (External Powder) G Maximum of 120 grams per 30 days

Nystop (External Powder) G Maximum of 120 grams per 30 days

Ocaliva (Oral Tablet) B Maximum of 1 tablet per day

Odefsey (Oral Tablet) B Maximum of 1 tablet per day

Odomzo (Oral Capsule) B Maximum of 1 capsule per day

Ofev (Oral Capsule) B 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)


Olanzapine ODT (10MG Oral Tablet

Dispersible, 15MG Oral Tablet Dispersible,

20MG Oral Tablet Dispersible, 5MG Oral

Tablet Dispersible)


Olmesartan Medoxomil (20MG Oral Tablet,

40MG Oral Tablet)G Maximum of 1 tablet per day

Olmesartan Medoxomil (5MG Oral Tablet) G Maximum of 2 tablets per day

Olmesartan Medoxomil-HCTZ (Oral Tablet) G Maximum of 1 tablet per day

Olmesartan-Amlodipine-HCTZ (Oral Tablet) G Maximum of 1 tablet per day

Olumiant (Oral Tablet) B Maximum of 1 tablet per day

Olux (External Foam) B Maximum of 100 grams per 30 days

Olux-E (External Foam) B Maximum of 100 grams per 30 days

Omeprazole (10MG Oral Capsule Delayed

Release)G Maximum of 3 capsules per day


Drug Name

Brand

or

Generic

Quantity Limit

Onfi (Oral Suspension) B Maximum of 16 ml per day

Onfi (Oral Tablet) B Maximum of 2 tablets per day

Ongentys (Oral Capsule) B Maximum of 1 capsule per day

Onglyza (Oral Tablet) B Maximum of 1 tablet per day

Onureg (Oral Tablet) B Maximum of 14 tablets per 28 days

Onzetra Xsail (Nasal Exhaler Powder) BMaximum of 1 kit (16 exhalers) per 30

days

Orgovyx (Oral Tablet) B Maximum of 1 tablet per day

Oriahnn (Oral Capsule Therapy Pack) BMaximum of 1 pack (56 capsules) per

28 days

Orilissa (150MG Oral Tablet) B Maximum of 1 tablet per day

Orilissa (200MG Oral Tablet) B Maximum of 2 tablets per day

Orkambi (Oral Packet) B Maximum of 56 packets per 28 days

Orkambi (Oral Tablet) B Maximum of 112 tablets per 28 days

Orladeyo (Oral Capsule) B Maximum of 1 capsule per day

Oseni (Oral Tablet) B Maximum of 1 tablet per day

Osphena (Oral Tablet) B Maximum of 1 tablet per day

Oxbryta (Oral Tablet) B Maximum of 5 tablets per day

Oxervate (Ophthalmic Solution) B Maximum of 2 vials (2 ml) per day

Oxiconazole Nitrate (External Cream) G Maximum of 90 grams per 30 days

Oxistat (External Cream) B Maximum of 90 grams per 30 days

Oxistat (External Lotion) B Maximum of 60 ml per 30 days

Oxycodone HCl ER (Oral Tablet ER 12 Hour

Abuse-Deterrent)G Maximum of 3 tablets per day

Oxycodone HCl (5MG Oral Capsule) G Maximum of 12 capsules per day

Oxycodone HCl (100MG/5ML Oral

Concentrate)G Maximum of 6 ml per day

Oxycodone HCl (5MG/5ML Oral Solution) G Maximum of 130 ml per day

Oxycodone HCl (10MG Oral Tablet


Immediate Release)






Immediate Release)


Oxycodone-Acetaminophen (10-300MG Oral

Tablet, 5-300MG Oral Tablet)G Maximum of 13 tablets per day


Drug Name

Brand

or

Generic

Quantity Limit

Oxycodone-Acetaminophen (10-325MG Oral

Tablet, 2.5-325MG Oral Tablet, 5-325MG Oral

Tablet, 7.5-325MG Oral Tablet)


OxyContin (Oral Tablet ER 12 Hour Abuse-

Deterrent)B Maximum of 3 tablets per day

Oxymorphone HCl ER (10MG Oral Tablet




Extended Release 12 Hour, 7.5MG Oral







Oxymorphone HCl (Oral Tablet Immediate


Ozempic (0.25MG/DOSE or 0.5MG/DOSE)

(Subcutaneous Solution Pen-Injector)B


days

Ozempic (1MG/DOSE) (2MG/1.5ML

Subcutaneous Solution Pen-Injector)B


days

Ozempic (1MG/DOSE) (4MG/3ML

Subcutaneous Solution Pen-Injector)B Maximum of 1 pen (3 ml) per 28 days

Paliperidone ER (1.5MG Oral Tablet





Paliperidone ER (6MG Oral Tablet Extended


Palynziq (10MG/0.5ML Subcutaneous

Solution Prefilled Syringe)B Maximum of 28 syringes per 28 days

Palynziq (2.5MG/0.5ML Subcutaneous


Palynziq (20MG/ML Subcutaneous


Pantoprazole Sodium (20MG Oral Tablet

Delayed Release)G Maximum of 3 tablets per day

Pantoprazole Sodium (40MG Oral Tablet

Delayed Release)G Maximum of 2 tablets per day

Pediarix (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per day

Pedvax HIB (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per day


Drug Name

Brand

or

Generic

Quantity Limit

Pemazyre (Oral Tablet) B Maximum of 1 tablet per day

Pentamidine Isethionate (Inhalation Solution

Reconstituted)G

Maximum of 1 vial (300 mg) per 28

days

Pentasa (250MG Oral Capsule Extended


Pentasa (500MG Oral Capsule Extended


Percocet (Oral Tablet) G Maximum of 12 tablets per day

Perforomist (Inhalation Nebulization

Solution)B Maximum of 2 vials (4 ml) per day

Perindopril Erbumine (Oral Tablet) G Maximum of 2 tablets per day

Picato (0.015% External Gel) B Maximum of 3 tubes per 30 days

Picato (0.05% External Gel) B Maximum of 2 tubes per 30 days

Pifeltro (Oral Tablet) B Maximum of 1 tablet per day

Pimecrolimus (External Cream) G Maximum of 100 grams per 30 days

Pioglitazone HCl (15MG Oral Tablet) G Maximum of 3 tablets per day

Pioglitazone HCl (30MG Oral Tablet, 45MG


Pioglitazone HCl-Glimepiride (Oral Tablet) G Maximum of 1 tablet per day

Pioglitazone HCl-Metformin HCl (Oral Tablet) G Maximum of 3 tablets per day

Piqray (200MG Daily Dose) (Oral Tablet

Therapy Pack)B Maximum of 1 tablet per day


Therapy Pack)B Maximum of 2 tablets per day


Therapy Pack)B Maximum of 2 tablets per day

Plaquenil (Oral Tablet) B Maximum of 3 tablets per day

Plavix (Oral Tablet) B Maximum of 4 tablets per day

Posaconazole (Oral Tablet Delayed Release) G Maximum of 6 tablets per day

Pradaxa (Oral Capsule) B Maximum of 2 capsules per day

Praluent (Subcutaneous Solution Auto-

Injector)B


days

Pravastatin Sodium (Oral Tablet) G Maximum of 1 tablet per day

Pregabalin ER (165MG Oral Tablet Extended

Release 24 Hour, 82.5MG Oral Tablet



Pregabalin ER (330MG Oral Tablet Extended



Drug Name

Brand

or

Generic

Quantity Limit

Pregabalin (100MG Oral Capsule, 150MG

Oral Capsule, 25MG Oral Capsule, 50MG

Oral Capsule, 75MG Oral Capsule)


Pregabalin (200MG Oral Capsule) G Maximum of 3 capsules per day

Pregabalin (225MG Oral Capsule, 300MG

Oral Capsule)G Maximum of 2 capsules per day

Pregabalin (Oral Solution) G Maximum of 30 ml per day

Prevacid (Oral Capsule Delayed Release) B Maximum of 2 capsules per day

Prevymis (Oral Tablet) B Maximum of 1 tablet per day

Prezcobix (Oral Tablet) B Maximum of 1 tablet per day

Prezista (Oral Suspension) BMaximum of 2 bottles (400 ml) per 30

days

Prezista (150MG Oral Tablet) B Maximum of 6 tablets per day

Prezista (600MG Oral Tablet, 75MG Oral


Prezista (800MG Oral Tablet) B Maximum of 1 tablet per day

Prinivil (Oral Tablet) B Maximum of 2 tablets per day

Prolate (Oral Tablet) G Maximum of 13 tablets per day

Prolia (Subcutaneous Solution Prefilled

Syringe)B Maximum of 1 syringe per 180 days

Promacta (Oral Packet) B Maximum of 6 packets per day

Promacta (12.5MG Oral Tablet, 25MG Oral


Promacta (50MG Oral Tablet, 75MG Oral


ProQuad (Subcutaneous Suspension

Reconstituted)B


day

Protonix (20MG Oral Tablet Delayed


Protonix (40MG Oral Tablet Delayed


Provigil (100MG Oral Tablet) B Maximum of 1 tablet per day

Provigil (200MG Oral Tablet) B Maximum of 2 tablets per day

PRUDOXIN (External Cream) B Maximum of 90 grams per 30 days

Psorcon (External Cream) G Maximum of 240 grams per 30 days

Pulmozyme (Inhalation Solution) B Maximum of 2 ampules (5 ml) per day

Qbrelis (Oral Solution) B Maximum of 80 ml per day

Qinlock (Oral Tablet) B Maximum of 3 tablets per day

Qtern (Oral Tablet) B Maximum of 1 tablet per day


Drug Name

Brand

or

Generic

Quantity Limit

Quadracel (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per day

Quetiapine Fumarate ER (150MG Oral Tablet




Quetiapine Fumarate ER (300MG Oral Tablet


Tablet Extended Release 24 Hour, 50MG Oral



Quetiapine Fumarate (100MG Oral Tablet



Immediate Release)






Immediate Release)


QuilliChew ER (20MG Oral Tablet

Chewable Extended Release, 40MG Oral

Tablet Chewable Extended Release)


QuilliChew ER (30MG Oral Tablet

Chewable Extended Release)B Maximum of 2 tablets per day

Quinapril HCl (Oral Tablet) G Maximum of 2 tablets per day

Quinapril-Hydrochlorothiazide (10-12.5MG


Quinapril-Hydrochlorothiazide (20-12.5MG

Oral Tablet, 20-25MG Oral Tablet)G Maximum of 2 tablets per day

QVAR RediHaler (Inhalation Aerosol Breath

Activated)B

Maximum of 2 inhalers (21.2 grams)

per 30 days

RabAvert (Intramuscular Suspension

Reconstituted)B


day

Ramipril (Oral Capsule) G Maximum of 2 capsules per day

Rapaflo (Oral Capsule) B Maximum of 1 capsule per day

Rayaldee (Oral Capsule Extended Release) B Maximum of 2 capsules per day

Recombivax HB (10MCG/ML Injection

Suspension, 10MCG/ML (1ML Syringe)

Injection Suspension, 40MCG/ML Injection

Suspension)

B 1 vaccination dose (1 ml) per day

Recombivax HB (5MCG/0.5ML Injection

Suspension)B 1 vaccination dose (0.5 ml) per day

Rectiv (Rectal Ointment) B Maximum of 30 grams per 30 days


Drug Name

Brand

or

Generic

Quantity Limit

Relexxii (Oral Tablet Extended Release) G Maximum of 1 tablet per day

Relpax (Oral Tablet) B Maximum of 12 tablets per 30 days

Repaglinide (0.5MG Oral Tablet) G Maximum of 32 tablets per day

Repaglinide (1MG Oral Tablet) G Maximum of 16 tablets per day

Repaglinide (2MG Oral Tablet) G Maximum of 8 tablets per day

Repatha Pushtronex System

(Subcutaneous Solution Cartridge)B

Maximum of 1 cartridge (3.5 ml) per

28 days

Repatha (Subcutaneous Solution Prefilled

Syringe)B

Maximum of 3 syringes (3 ml) per 28

days

Repatha SureClick (Subcutaneous Solution

Auto-Injector)B


days

Restasis Single-Use Vials (Ophthalmic

Emulsion)B Maximum of 2 vials per day

Restoril (22.5MG Oral Capsule) B Maximum of 1 capsule per day

Retevmo (40MG Oral Capsule) B Maximum of 6 capsules per day

Retevmo (80MG Oral Capsule) B Maximum of 4 capsules per day

Retrovir (Oral Capsule) B Maximum of 6 capsules per day

Retrovir (Oral Syrup) B Maximum of 64 ml per day

Rexulti (Oral Tablet) B Maximum of 1 tablet per day

Reyataz (150MG Oral Capsule, 300MG Oral


Reyataz (200MG Oral Capsule) B Maximum of 2 capsules per day

Reyataz (Oral Packet) B Maximum of 6 packets per day

Reyvow (100MG Oral Tablet) B Maximum of 8 tablets per 30 days

Reyvow (50MG Oral Tablet) B Maximum of 4 tablets per 30 days

Rinvoq (Oral Tablet Extended Release 24


Riomet (Oral Solution) B Maximum of 25.5 ml per day

Ritalin (Oral Tablet) B Maximum of 3 tablets per day

Ritonavir (Oral Tablet) G Maximum of 12 tablets per day

Rivastigmine (Transdermal Patch 24 Hour) G Maximum of 1 patch per day

Rizatriptan Benzoate (Oral Tablet) G Maximum of 12 tablets per 30 days

Rizatriptan Benzoate ODT (Oral Tablet

Dispersible)G Maximum of 12 tablets per 30 days

Rosuvastatin Calcium (Oral Tablet) G Maximum of 1 tablet per day

Roszet (Oral Tablet) B Maximum of 1 tablet per day

Rotarix (Oral Suspension Reconstituted) B 1 vaccination dose (1 ml) per day

RotaTeq (Oral Solution) B 1 vaccination dose (2 ml) per day


Drug Name

Brand

or

Generic

Quantity Limit

Roxicodone (15MG Oral Tablet) B Maximum of 8 tablets per day



Rozlytrek (100MG Oral Capsule) B Maximum of 5 capsules per day

Rozlytrek (200MG Oral Capsule) B Maximum of 3 capsules per day

Rukobia (Oral Tablet Extended Release 12

Hour)B Maximum of 2 tablets per day

Ruzurgi (Oral Tablet) B Maximum of 10 tablets per day

Rybelsus (Oral Tablet) B Maximum of 1 tablet per day

Rydapt (Oral Capsule) B Maximum of 8 capsules per day

Sabril (Oral Packet) B Maximum of 6 packets per day

Sabril (Oral Tablet) B Maximum of 6 tablets per day

Sancuso (Transdermal Patch) B Maximum of 4 patches per 28 days

Savaysa (Oral Tablet) B Maximum of 1 tablet per day

Secuado (Transdermal Patch 24 Hour) B Maximum of 1 patch per day

Segluromet (2.5-1000MG Oral Tablet,

7.5-1000MG Oral Tablet, 7.5-500MG Oral

Tablet)


Segluromet (2.5-500MG Oral Tablet) B Maximum of 4 tablets per day

Selzentry (Oral Solution) BMaximum of 8 bottles (1840 ml) per

30 days

Selzentry (150MG Oral Tablet, 75MG Oral


Selzentry (25MG Oral Tablet, 300MG Oral


Sensipar (30MG Oral Tablet, 60MG Oral


Sensipar (90MG Oral Tablet) B Maximum of 4 tablets per day

Serevent Diskus (60 Inhalation Aerosol

Powder Breath Activated)B

Maximum of 1 inhaler (60 inhalations)

per 30 days

Seroquel (100MG Oral Tablet Immediate



Release)






Release)



Drug Name

Brand

or

Generic

Quantity Limit

Seroquel XR (150MG Oral Tablet Extended




Seroquel XR (300MG Oral Tablet Extended





Shingrix (Intramuscular Suspension

Reconstituted)B


day

Silodosin (Oral Capsule) G Maximum of 1 capsule per day

Simvastatin (Oral Tablet) G Maximum of 1 tablet per day

Singulair (Oral Packet) B Maximum of 1 packet per day

Singulair (Oral Tablet) B Maximum of 1 tablet per day

Singulair (Oral Tablet Chewable) B Maximum of 1 tablet per day

Sofosbuvir-Velpatasvir (Oral Tablet) G Maximum of 1 tablet per day

Solifenacin Succinate (Oral Tablet) G Maximum of 1 tablet per day

Soliqua (Subcutaneous Solution Pen-

Injector)B


days

Solodyn (Oral Tablet Extended Release 24


Somavert (Subcutaneous Solution

Reconstituted)B Maximum of 1 vial per day

Sovaldi (150MG Oral Packet) BMaximum of 1 carton (28 packets)

per 28 days

Sovaldi (200MG Oral Packet) BMaximum of 2 cartons (56 packets)

per 28 days

Sovaldi (400MG Oral Tablet) B Maximum of 1 tablet per day

Spiriva HandiHaler (Inhalation Capsule) B Maximum of 1 capsule per day

Spiriva Respimat (Inhalation Aerosol

Solution)B


30 days

Steglatro (15MG Oral Tablet) B Maximum of 1 tablet per day

Steglatro (5MG Oral Tablet) B Maximum of 2 tablets per day

Steglujan (Oral Tablet) B Maximum of 1 tablet per day

Stribild (Oral Tablet) B Maximum of 1 tablet per day

Suboxone (12-3MG Sublingual Film, 4-1MG

Sublingual Film)B Maximum of 2 films per day

Suboxone (2-0.5MG Sublingual Film,

8-2MG Sublingual Film)B Maximum of 3 films per day


Drug Name

Brand

or

Generic

Quantity Limit

Subsys (100MCG Sublingual Liquid,

200MCG Sublingual Liquid, 400MCG

Sublingual Liquid, 600MCG Sublingual

Liquid, 800MCG Sublingual Liquid)

B Maximum of 4 sprays per day

Subsys (1200 (600 X 2)MCG Sublingual

Liquid, 1600 (800 X 2)MCG Sublingual

Liquid)

B Maximum of 8 sprays per day

Sumatriptan (Nasal Solution) G Maximum of 12 devices per 30 days

Sumatriptan Succinate (100MG Oral Tablet,

25MG Oral Tablet, 50MG Oral Tablet)G Maximum of 12 tablets per 30 days

Sumatriptan Succinate Refill (Subcutaneous

Solution Cartridge)G


30 days

Sumatriptan Succinate (6MG/0.5ML



30 days

Sumatriptan Succinate (4MG/0.5ML

Subcutaneous Solution Auto-Injector, 6MG/

0.5ML Subcutaneous Solution Auto-Injector)

GMaximum of 12 injections (6 ml) per

30 days

Sumatriptan-Naproxen Sodium (Oral Tablet) G Maximum of 9 tablets per 30 days

Sunosi (Oral Tablet) B Maximum of 1 tablet per day

Sustiva (Oral Capsule) B Maximum of 3 capsules per day

Sustiva (Oral Tablet) B Maximum of 1 tablet per day

Symbicort (120 Inhalation Aerosol) BMaximum of 1 inhaler (10.2 grams)

per 30 days

Symdeko (Oral Tablet Therapy Pack) BMaximum of 1 pack (56 tablets) per

28 days

Symfi Lo (Oral Tablet) B Maximum of 1 tablet per day

Symfi (Oral Tablet) B Maximum of 1 tablet per day

Symjepi (Injection Solution Prefilled

Syringe)B Maximum of 4 syringes per 30 days

Sympazan (Oral Film) B Maximum of 2 films per day

Symproic (Oral Tablet) B Maximum of 1 tablet per day

Symtuza (Oral Tablet) B Maximum of 1 tablet per day

Synjardy (Oral Tablet Immediate Release) B Maximum of 2 tablets per day

Synjardy XR (10-1000MG Oral Tablet

Extended Release 24 Hour, 25-1000MG

Oral Tablet Extended Release 24 Hour)


Synjardy XR (12.5-1000MG Oral Tablet




Syprine (Oral Capsule) B Maximum of 8 capsules per day


Drug Name

Brand

or

Generic

Quantity Limit

Tabrecta (Oral Tablet) B Maximum of 4 tablets per day

Tadalafil (2.5MG Oral Tablet, 5MG Oral


Talzenna (0.25MG Oral Capsule) B Maximum of 3 capsules per day

Talzenna (1MG Oral Capsule) B Maximum of 1 capsule per day

Targretin (External Gel) B Maximum of 60 grams per 30 days

Tasmar (Oral Tablet) B Maximum of 6 tablets per day

Tavalisse (Oral Tablet) B Maximum of 2 tablets per day

Tazverik (Oral Tablet) B Maximum of 8 tablets per day

TDVAX (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per day

Tecfidera (Oral Capsule Delayed Release) B Maximum of 2 capsules per day

Tekturna HCT (Oral Tablet) B Maximum of 1 tablet per day

Tekturna (Oral Tablet) B Maximum of 1 tablet per day

Telmisartan (Oral Tablet) G Maximum of 1 tablet per day

Telmisartan-Amlodipine (Oral Tablet) G Maximum of 1 tablet per day

Telmisartan-HCTZ (40-12.5MG Oral Tablet,

80-25MG Oral Tablet)G Maximum of 1 tablet per day

Telmisartan-HCTZ (80-12.5MG Oral Tablet) G Maximum of 2 tablets per day

Temazepam (Oral Capsule) G Maximum of 1 capsule per day

Temixys (Oral Tablet) B Maximum of 1 tablet per day

Tenivac (Intramuscular Injectable) B 1 vaccination dose (0.5 ml) per day

Tenofovir Disoproxil Fumarate (Oral Tablet) G Maximum of 1 tablet per day

Tepmetko (Oral Tablet) B Maximum of 2 tablets per day

Thalomid (100MG Oral Capsule, 50MG Oral


Thalomid (150MG Oral Capsule, 200MG

Oral Capsule)B Maximum of 2 capsules per day

Tibsovo (Oral Tablet) B Maximum of 2 tablets per day

Tivicay (10MG Oral Tablet, 25MG Oral


Tivicay (50MG Oral Tablet) B Maximum of 2 tablets per day

Tivicay PD (Oral Tablet Soluble) B Maximum of 6 tablets per day

TOBI (Inhalation Nebulization Solution) BMaximum of 2 ampules (10 ml) per

day

TOBI Podhaler (Inhalation Capsule) B Maximum of 8 capsules per day

Tobramycin (300MG/4ML Inhalation

Nebulization Solution)G Maximum of 2 ampules (8 ml) per day

Tobramycin (300MG/5ML Inhalation

Nebulization Solution)G

Maximum of 2 ampules (10 ml) per

day


Drug Name

Brand

or

Generic

Quantity Limit

Tolcapone (Oral Tablet) G Maximum of 6 tablets per day

Topicort (External Cream) G Maximum of 100 grams per 30 days

Tosymra (Nasal Solution) B Maximum of 12 devices per 30 days

Toviaz (Oral Tablet Extended Release 24


Tracleer (Oral Tablet) B Maximum of 2 tablets per day

Tracleer (Oral Tablet Soluble) B Maximum of 8 tablets per day

Tradjenta (Oral Tablet) B Maximum of 1 tablet per day

Tramadol HCl ER (Biphasic) (Oral Tablet


Tramadol HCl ER (100MG Oral Capsule




G Maximum of 1 capsule per day

Tramadol HCl ER (100MG Oral Tablet


Tablet Extended Release 24 Hour, 300MG



Tramadol HCl (100MG Oral Tablet Immediate


Tramadol HCl (50MG Oral Tablet Immediate


Tramadol-Acetaminophen (Oral Tablet) G Maximum of 8 tablets per day

Trandolapril (1MG Oral Tablet, 2MG Oral


Trandolapril (4MG Oral Tablet) G Maximum of 2 tablets per day

Trandolapril-Verapamil HCl ER (Oral Tablet

Extended Release)G Maximum of 1 tablet per day

Tranxene-T (Oral Tablet) B Maximum of 12 tablets per day

Trelegy Ellipta (Inhalation Aerosol Powder

Breath Activated)B


30 days

Treximet (Oral Tablet) B Maximum of 9 tablets per 30 days

Trezix (Oral Capsule) G Maximum of 10 capsules per day

Tribenzor (Oral Tablet) B Maximum of 1 tablet per day

Trientine HCl (Oral Capsule) G Maximum of 8 capsules per day

Trijardy XR (10-5-1000MG Oral Tablet

Extended Release 24 Hour, 25-5-1000MG




Drug Name

Brand

or

Generic

Quantity Limit

Trijardy XR (12.5-2.5-1000MG Oral Tablet

Extended Release 24 Hour, 5-2.5-1000MG



Trikafta (100-50-75 & 150MG Oral Tablet

Therapy Pack)B

Maximum of 1 pack (84 tablets) per

28 days

Triumeq (Oral Tablet) B Maximum of 1 tablet per day

Trizivir (Oral Tablet) B Maximum of 2 tablets per day

Trulicity (Subcutaneous Solution Pen-

Injector)B


days

Trumenba (Intramuscular Suspension


Truvada (Oral Tablet) B Maximum of 1 tablet per day

Tukysa (150MG Oral Tablet) B Maximum of 4 tablets per day

Tukysa (50MG Oral Tablet) B Maximum of 12 tablets per day

Turalio (Oral Capsule) B Maximum of 4 capsules per day

Twinrix (Intramuscular Suspension

Prefilled Syringe)B 1 vaccination dose (1 ml) per day

Twynsta (Oral Tablet) B Maximum of 1 tablet per day

Tybost (Oral Tablet) B Maximum of 1 tablet per day

Typhim Vi (Intramuscular Solution) B 1 vaccination dose (0.5 ml) per day

Ubrelvy (Oral Tablet) B Maximum of 16 tablets per 30 days

Ukoniq (Oral Tablet) B Maximum of 4 tablets per day

Ultracet (Oral Tablet) B Maximum of 8 tablets per day

Ultram (Oral Tablet Immediate Release) B Maximum of 8 tablets per day

Uptravi (1000MCG Oral Tablet, 1200MCG

Oral Tablet, 1400MCG Oral Tablet,

1600MCG Oral Tablet, 400MCG Oral

Tablet, 600MCG Oral Tablet, 800MCG Oral

Tablet)


Uptravi (200MCG Oral Tablet) B Maximum of 5 tablets per day

Valacyclovir HCl (1GM Oral Tablet) G Maximum of 4 tablets per day

Valacyclovir HCl (500MG Oral Tablet) G Maximum of 2 tablets per day

Valchlor (External Gel) B Maximum of 60 grams per 30 days

Valcyte (Oral Solution Reconstituted) B Maximum of 36 ml per day

Valcyte (Oral Tablet) B Maximum of 4 tablets per day

Valganciclovir HCl (50MG/ML Oral Solution

Reconstituted)G Maximum of 36 ml per day

Valganciclovir HCl (450MG Oral Tablet) G Maximum of 4 tablets per day

Valium (Oral Tablet) B Maximum of 4 tablets per day


Drug Name

Brand

or

Generic

Quantity Limit

Valsartan (160MG Oral Tablet, 40MG Oral

Tablet, 80MG Oral Tablet)G Maximum of 2 tablets per day

Valsartan (320MG Oral Tablet) G Maximum of 1 tablet per day

Valsartan-Hydrochlorothiazide (Oral Tablet) G Maximum of 1 tablet per day

Valtoco 10 MG Dose (Nasal Liquid) BMaximum of 10 blister packs (10

spray devices) per 30 days

Valtoco 15 MG Dose (Nasal Liquid Therapy

Pack)B

Maximum of 10 blister packs (20


Valtoco 20 MG Dose (Nasal Liquid Therapy

Pack)B

Maximum of 10 blister packs (20


Valtoco 5 MG Dose (Nasal Liquid) BMaximum of 10 blister packs (10


Valtrex (1GM Oral Tablet) B Maximum of 4 tablets per day

Valtrex (500MG Oral Tablet) B Maximum of 2 tablets per day

Vancocin HCl (125MG Oral Capsule) B Maximum of 4 capsules per day

Vancocin (250MG Oral Capsule) B Maximum of 8 capsules per day

Vancomycin HCl (125MG Oral Capsule) G Maximum of 4 capsules per day

Vancomycin HCl (250MG Oral Capsule) G Maximum of 8 capsules per day

VAQTA (Intramuscular Suspension) B Maximum of 2 vaccines per lifetime

Varivax (Subcutaneous Injectable) B1 vaccination dose (1 injection) per

day

Vaseretic (Oral Tablet) B Maximum of 2 tablets per day

Vasotec (Oral Tablet) B Maximum of 2 tablets per day

Veltassa (Oral Packet) B Maximum of 1 packet per day

Verquvo (Oral Tablet) B Maximum of 1 tablet per day

Vesicare LS (Oral Suspension) B Maximum of 10 ml per day

Vesicare (Oral Tablet) B Maximum of 1 tablet per day

Viberzi (Oral Tablet) B Maximum of 2 tablets per day

Victoza (Subcutaneous Solution Pen-

Injector)B


days

Viekira Pak (Oral Tablet Therapy Pack) BMaximum of 1 pack (112 tablets) per

28 days

Vigabatrin (Oral Packet) G Maximum of 6 packets per day

Vigabatrin (Oral Tablet) G Maximum of 6 tablets per day

Vigadrone (Oral Packet) G Maximum of 6 packets per day

Vimpat (Oral Solution) B Maximum of 40 ml per day

Vimpat (Oral Tablet) B Maximum of 2 tablets per day

Viracept (250MG Oral Tablet) B Maximum of 10 tablets per day

Viracept (625MG Oral Tablet) B Maximum of 4 tablets per day


Drug Name

Brand

or

Generic

Quantity Limit

Viramune (Oral Suspension) B Maximum of 40 ml per day

Viramune XR (Oral Tablet Extended

Release 24 Hour)B Maximum of 1 tablet per day

Viread (Oral Powder) BMaximum of 4 bottles (240 grams)

per 30 days

Viread (Oral Tablet) B Maximum of 1 tablet per day

Vitrakvi (100MG Oral Capsule) B Maximum of 4 capsules per day

Vitrakvi (25MG Oral Capsule) B Maximum of 6 capsules per day

Vitrakvi (Oral Solution) B Maximum of 20 ml per day

Vivelle-Dot (Transdermal Patch Twice

Weekly)B Maximum of 8 patches per 28 days

Vivlodex (Oral Capsule) B Maximum of 1 capsule per day

Vosevi (Oral Tablet) B Maximum of 1 tablet per day

Vraylar (1.5MG Oral Capsule, 3MG Oral

Capsule, 4.5MG Oral Capsule, 6MG Oral

Capsule)

B Maximum of 1 capsule per day

Vumerity (Oral Capsule Delayed Release)

(Maintenance Dose Bottle)B Maximum of 4 capsules per day

Vyndamax (Oral Capsule) B Maximum of 1 capsule per day

Vyndaqel (Oral Capsule) B Maximum of 4 capsules per day

Vytorin (Oral Tablet) B Maximum of 1 tablet per day

Wakix (Oral Tablet) B Maximum of 2 tablets per day

Wixela Inhub (Inhalation Aerosol Powder

Breath Activated) (Generic Advair)G


30 days

Xanax (0.25MG Oral Tablet Immediate

Release, 0.5MG Oral Tablet Immediate


Release)


Xanax (2MG Oral Tablet Immediate


Xanax XR (0.5MG Oral Tablet Extended




Xanax XR (2MG Oral Tablet Extended


Xanax XR (3MG Oral Tablet Extended


Xarelto (10MG Oral Tablet, 20MG Oral



Drug Name

Brand

or

Generic

Quantity Limit

Xarelto (15MG Oral Tablet, 2.5MG Oral


Xarelto Starter Pack (Oral Tablet Therapy

Pack)B


30 days

Xcopri (250MG Daily Dose) (Oral Tablet

Therapy Pack)B


28 days

Xcopri (350MG Daily Dose) (Oral Tablet

Therapy Pack)B


28 days

Xcopri (100MG Oral Tablet, 50MG Oral


Xcopri (150MG Oral Tablet, 200MG Oral


Xcopri (Oral Tablet Titration Therapy Pack) BMaximum of 1 pack (28 tablets) per

28 days

Xeljanz (Oral Solution) B Maximum of 10 ml per day

Xeljanz (Oral Tablet Immediate Release) B Maximum of 2 tablets per day

Xeljanz XR (Oral Tablet Extended Release


Xenleta (Oral Tablet) B Maximum of 2 tablets per day

Xermelo (Oral Tablet) B Maximum of 3 tablets per day

Xigduo XR (10-1000MG Oral Tablet


Tablet Extended Release 24 Hour,

5-500MG Oral Tablet Extended Release 24

Hour)


Xigduo XR (2.5-1000MG Oral Tablet




Xiidra (Ophthalmic Solution) B Maximum of 2 vials per day

Xofluza (40MG Dose) (2 x 20MG Oral

Tablet Therapy Pack)B Maximum of 2 tablets per 30 days

Xofluza (80MG Dose) (2 x 40MG Oral


Xolegel (External Gel) B Maximum of 90 grams per 30 days

Xospata (Oral Tablet) B Maximum of 3 tablets per day

Xpovio (100MG Once Weekly) (20MG Oral





Drug Name

Brand

or

Generic

Quantity Limit





Xpovio (40MG Twice Weekly) (20MG Oral


Xpovio (40MG Twice Weekly) (40MG Oral






Xpovio (60MG Twice Weekly) (Oral Tablet

Therapy Pack)B Maximum of 24 tablets per 28 days





Xpovio (80MG Twice Weekly) (Oral Tablet

Therapy Pack)B 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)


Xtampza ER (27MG Oral Capsule ER 12

Hour Abuse-Deterrent, 36MG Oral Capsule

ER 12 Hour Abuse-Deterrent)


Xultophy (Subcutaneous Solution Pen-

Injector)B


days

Xyrem (Oral Solution) B Maximum of 18 ml per day

Xywav (Oral Solution) B Maximum of 18 ml per day

YF-Vax (Subcutaneous Injectable) B1 vaccination dose (1 injection) per

day

Yupelri (Inhalation Solution) B Maximum of 1 vial (3 ml) per day

Zaleplon (10MG Oral Capsule) G Maximum of 2 capsules per day

Zaleplon (5MG Oral Capsule) G Maximum of 1 capsule per day

Zelboraf (Oral Tablet) B Maximum of 8 tablets per day

Zembrace SymTouch (Subcutaneous

Solution Auto-Injector)B

Maximum of 16 syringes (8 ml) per 30

days

Zenzedi (10MG Oral Tablet, 2.5MG Oral

Tablet, 5MG Oral Tablet, 7.5MG Oral Tablet)G Maximum of 6 tablets per day


Drug Name

Brand

or

Generic

Quantity Limit

Zenzedi (15MG Oral Tablet, 20MG Oral


Zenzedi (30MG Oral Tablet) G Maximum of 2 tablets per day

Zepatier (Oral Tablet) B Maximum of 1 tablet per day

Zeposia 7-Day Starter Pack (Oral Capsule

Therapy Pack)B

Maximum of 1 pack (7 capsules) per

7 days

Zeposia (Oral Capsule) B Maximum of 1 capsule per day

Zeposia Starter Kit (Oral Capsule Therapy

Pack)B

Maximum of 1 pack (37 capsules) per

37 days

Zestoretic (10-12.5MG Oral Tablet) B Maximum of 1 tablet per day

Zestoretic (20-12.5MG Oral Tablet) B Maximum of 4 tablets per day

Zestoretic (20-25MG Oral Tablet) B Maximum of 2 tablets per day

Zestril (Oral Tablet) B Maximum of 2 tablets per day

Ziac (Oral Tablet) B Maximum of 2 tablets per day

Ziagen (Oral Solution) B Maximum of 32 ml per day

Ziagen (Oral Tablet) B Maximum of 2 tablets per day

Zidovudine (Oral Capsule) G Maximum of 6 capsules per day

Zidovudine (Oral Syrup) G Maximum of 64 ml per day

Zidovudine (Oral Tablet) G Maximum of 2 tablets per day

Ziprasidone HCl (Oral Capsule) G Maximum of 2 capsules per day

Zocor (Oral Tablet) B Maximum of 1 tablet per day

Zolmitriptan (Oral Tablet) G Maximum of 12 tablets per 30 days

Zolmitriptan ODT (Oral Tablet Dispersible) G Maximum of 12 tablets per 30 days

Zolpidem Tartrate (Oral Tablet Immediate

Release)G Maximum of 1 tablet per day

Zomig (2.5MG Nasal Solution) B Maximum of 18 devices per 30 days

Zomig (5MG Nasal Solution) B Maximum of 12 devices per 30 days

Zomig (Oral Tablet) B Maximum of 12 tablets per 30 days

Zomig ZMT (Oral Tablet Dispersible) B Maximum of 12 tablets per 30 days

Zonalon (External Cream) B Maximum of 90 grams per 30 days

ZTlido (External Patch) B Maximum of 3 patches per day

Zubsolv (0.7-0.18MG Tablet Sublingual,

1.4-0.36MG Tablet Sublingual, 5.7-1.4MG

Tablet Sublingual)


Zubsolv (11.4-2.9MG Tablet Sublingual) B Maximum of 1 tablet per day

Zubsolv (2.9-0.71MG Tablet Sublingual) B Maximum of 5 tablets per day

Zubsolv (8.6-2.1MG Tablet Sublingual) B Maximum of 2 tablets per day

Zypitamag (Oral Tablet) B Maximum of 1 tablet per day


Drug Name

Brand

or

Generic

Quantity Limit

Zyprexa (10MG Oral Tablet, 15MG Oral

Tablet, 2.5MG Oral Tablet, 20MG Oral

Tablet, 5MG Oral Tablet, 7.5MG Oral

Tablet)


Zyprexa Zydis (Oral Tablet Dispersible) B Maximum of 1 tablet per day

Required information

Benefits, drug list (formulary), pharmacy network and/or copayments/coinsurance may change

from time to time during each plan year. You will receive notice when necessary.

This information is available for free in other languages. Please call our Customer Service number

located on the cover.

UnitedHealthcare Insurance Company complies with applicable Federal civil rights laws, and does

not discriminate on the basis of race, color, national origin, age, disability, or sex.

203

For more up-to-date information or if you have other questions, please call Customer Service at:

Toll-free 1-888-223-1092, TTY 7118 a.m. - 8 p.m. local time, Monday - Friday

www.UHCRetiree.com/soi

OVEX21PP4738358_010 Last updated September 1, 2021

Date post:	07-Dec-2021
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Complete Drug List (Formulary) 2021

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