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2016 Comprehensive FORMULARY (Complete list of covered drugs) UnitedHealthcare Dual Complete® (PPO SNP) UnitedHealthcare Dual Complete® RP (Regional PPO SNP) Please read: This document contains information about the drugs we cover in this plan. For more recent information or if you have other questions, please contact UnitedHealthcare Dual Complete Customer Service at: Toll-Free 1-866-622-8054, TTY 711 8 a.m. to 8 p.m. local time, 7 days a week www.UHCCommunityPlan.com Medicare Approved Formulary File ID 00016005, Version 21 Y0066_150714_123219A_FINAL_M32.10 Approved Last updated November 1, 2016 1
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Page 1: FORMULARY - Home | UnitedHealthcare Community … The UnitedHealthcare Dual Complete 3 COMPREHENSIVE FORMULARY (drug list) A formulary is a list of covered drugs selected by your …

2016 Comprehensive

FORMULARY(Complete list of covered drugs)

UnitedHealthcare Dual Complete® (PPO SNP)

UnitedHealthcare Dual Complete® RP (Regional PPO SNP)

Please read: This document contains information about the drugs we cover in this plan.

For more recent information or if you have other questions, please contact UnitedHealthcare Dual

Complete Customer Service at:

Toll-Free 1-866-622-8054, TTY 711

8 a.m. to 8 p.m. local time, 7 days a week

www.UHCCommunityPlan.com

Medicare Approved Formulary File ID 00016005, Version 21

Y0066_150714_123219A_FINAL_M32.10 Approved Last updated November 1, 2016

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This document includes a complete list of the drugs (formulary) for our plan and is current as of

November 1, 2016. For an updated formulary (drug list), please contact us. Our contact

information, along with the date we last updated the formulary, appears on the cover.

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

refers to “plan” or “our plan,” it means UnitedHealthcare Dual Complete.

Note to existing members: Our list of covered drugs is called a Formulary. We call it the "Drug List"

for short. This complete drug list has changed since last year. Please review this document to

make sure the plan still covers the drugs you take. You must generally use network pharmacies to

use your prescription drug benefit.

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The UnitedHealthcare Dual Complete

COMPREHENSIVE FORMULARY (drug list)

A formulary is a list of covered drugs selected by your plan in consultation with a team of health

care providers, which represents the prescription therapies believed to be a necessary part of a

quality treatment program. We call it the "Drug List" for short. Your plan will generally cover the

drugs listed in our formulary (drug list) as long as the drug is medically necessary, the prescription

is filled at a plan network pharmacy and other plan rules are followed. For more information on

how to fill your prescriptions, please review your Evidence of Coverage.

This document is a complete drug list of the drugs covered by your plan.

For your drug to be covered by your plan, it must be included in the complete drug list. In most

cases, your prescription must also be filled at one of our network pharmacies.

To find out if your drug is covered:

1. See if your drug is included in this complete drug list.

2. Visit your plan website. Use the online tools to look up your drugs. The information is updated

on a regular basis. The Web address appears on the cover.

3. Call Customer Service. Our contact information appears on the cover.

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When the drug list may changeWe try to make as few changes to the drug list as possible during the plan year. If there are

changes to the drug list, such as regular or necessary updates, members may see information in

their Explanation of Benefits (EOB) statements, member newsletters or other member mailings. If

there are changes to the drug list outside of regular or necessary updates, members may receive a

special mailing.

The drug list may change throughout the year when your plan:

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

· Removes a drug from the list because it has been found to be ineffective or unsafe.

· Changes the requirements or limits for a drug.

Generally, if you are taking a drug on the 2016 drug list that was covered at the beginning of the

year, we will not discontinue or reduce coverage of the drug during the 2016 coverage year except

when a new, less expensive generic drug becomes available or when new information about the

safety or effectiveness of a drug is released.

Other types of drug list changes, such as removing a drug from the drug list, will not affect

members who are currently taking the drug. For those members it will remain available at the

same cost for the remainder of the coverage year. We feel it is important for you to have access for

the entire coverage year to the list of drugs that were available when you chose your plan, except

when you can save additional money or your safety is a concern.

If we remove drugs from our drug list, or add prior authorization, quantity limits and/or step

therapy restrictions on a drug during the coverage year we must notify affected members at least

60 days before the change becomes effective, or when the member requests a refill of the drug. At

this time the member will receive a 60-day supply of the drug.

If the Food and Drug Administration (FDA) declares a drug on our drug list to be unsafe, or if the

drug’s manufacturer removes the drug from the market, your plan will immediately remove the

drug from the drug list and notify members who take the drug. The enclosed drug list is current as

of the date printed on the cover. To get updated information about the drugs covered by your

plan, please call Customer Service or visit our website using the information provided on the

cover of this drug list.

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Drug tiers and drug payment stagesThe amount you pay for a covered 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.

· The drug tier for your drug. Your plan has one tier named “Covered Drugs.” All covered drugs

are in this Tier. The chart below shows your cost-sharing amount.

For more information about drug coverage and cost-sharing amount, please review your Evidence

of Coverage.

Drug Tier Cost-Share

Tier 1 “Covered Drugs” 25% co-insurance

If you qualify for Extra Help If you qualify for Extra Help for your prescription drugs, your co-pays and co-insurance 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 contact Customer Service. Our contact information appears on the cover.

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How to use the drug listThere are two ways to find your prescription drugs in this complete drug list:

1. Medical condition: Turn to the “Covered drugs by medical condition” section, whichbegins on page 12, to look for drugs based on your medical conditions. For example,if you want to find drugs used to treat high cholesterol, go to the “Cardiovascular Agents”category and look under “Dyslipidemics, HMG CoA Reductase Inhibitors.”

2. Alphabetical list (index): If you are not sure what category to look under, turn to the“Index of covered drugs” section, which begins on page 93. Find the name of yourdrug. The page number where you can find the drug will be next to it.

Generic drugsYour plan covers both brand name drugs and generic drugs. Generic drugs are approved by the

Food and Drug Administration (FDA) as having the same active ingredients as brand name drugs.

Generic drugs usually cost less than brand name drugs. Talk with your doctor to see if any of the

brand name drugs you take have generic versions.

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

plain type (for example, Simvastatin).

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Required actions, restrictions or limitsSome covered drugs may have additional requirements or limits on coverage. If your drug has any

requirements or limits, there will be a code(s) in the “Required actions, restrictions or limits”

column of the drug list. The codes and what they mean are shown below.

Utilization Management Restrictions

PA - Prior authorization

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

more information from your doctor to make sure the drug is being used correctly for a medical condition

covered by Medicare. If you don’t get approval, the plan may not cover the drug.

QL - Quantity limits

The plan will cover only a certain amount of this drug for one co-pay/co-insurance 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 one 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.

Other Special Requirements for Coverage

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 Medicare members 65 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.

Note: If you are 65 or older, you may need to get a prior authorization (PA) or formulary exception from the

health plan before the plan will cover a high risk medication (HRM). If you are under 65, the prior

authorization (PA) will not apply to you until the first time you get your prescription filled after turning 65.

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.

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You can find out if your drug has any additional requirements, restrictions or limits by looking it up in the “Covered drugs by medical condition” section that begins on page 12. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may ask us to send you a copy. Our contact information, along with the date we last updated the drug list, appears on the cover.

You and your doctor may ask the plan for an exception to these requirements, restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the, “How to request an exception to the UnitedHealthcare Dual Complete drug list” section on the next page or review your Evidence of Coverage to learn more. If you do not get prior approval from the plan for a drug with a requirement, restriction or limit, you may have to pay the full cost of the drug.

If your drug is not on the drug listIf your drug is not included in this complete formulary (list of covered drugs), you should contact

Customer Service and ask if your drug is covered. Our contact information, along with the date we

last updated the drug list, appears on the cover.

If you learn that your plan does not cover your drug, you have two options:

1. Ask your plan for a list of similar drugs that it covers. Show the list to your doctor and ask

him or her to prescribe one of the appropriate drugs from the list.

2. Ask your plan to make an exception and cover your drug. See next page for information

about how to request an exception.

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How to request an exception to the

UnitedHealthcare Dual Complete drug list

At times you may need to ask for drug coverage that’s not normally provided by your plan. When

you do, your plan will consider your request and respond with a coverage decision (coverage

determination).

You can ask your plan to make an exception to the coverage rules. There are several types of

exceptions that you can ask your plan to make.

· Formulary exception: You can ask your plan to cover your drug even if it is not on the drug

list. If approved, this drug will be covered at a pre-determined cost-sharing level, and you

would not be able to ask us to provide the drug at a lower cost-sharing level.

· Utilization exception: You can ask your plan to waive coverage restrictions or limits on your

drug. For example, your plan limits the amount it will cover for certain drugs. If your drug

has a quantity limit, you can ask your plan to waive the limit and cover more.

Generally, your plan will approve your request for an exception only if the alternative drugs

included in your plan’s drug list or additional utilization restrictions would not be as effective in

treating your condition and/or would cause adverse medical effects.

Who can ask for a coverage decision

You, your authorized representative or your doctor can ask for an initial coverage decision for a

formulary exception or utilization restriction exception.

When you are requesting a formulary exception or utilization restriction exception, your

prescriber or physician should submit a statement supporting your request.

Receiving a coverage decision

Generally, your plan will make a coverage decision within 72 hours after receiving your

prescribing physician’s statement. You can request an expedited, or fast, decision if you or your

doctor believes your health requires it. If your plan agrees to a fast decision, you will receive a

decision within 24 hours after your plan receives your doctor’s or prescribing physician’s

supporting statement.

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What to do while you talk to your doctor about changing your drugs

or requesting an exception

New or continuing members

As a new or continuing member in your plan, you may be taking drugs that are not on the drug

list. Or you may be taking a drug that is on the drug list, but your ability to get it is limited. For

example, you may need prior authorization before you can fill your prescription. You should talk

to your doctor to decide if you should switch to an appropriate drug that your plan covers, or

request a formulary exception so your plan will cover the drug you are currently taking. While you

talk to your doctor to decide what to do, your plan may cover your drug in certain cases during the

first 90 days you are a member of your plan.

For each of your drugs that is not on the drug list, or if your ability to get your drugs is limited,

your plan may cover a temporary 30-day supply (unless you have a prescription written for fewer

days) from a network pharmacy. After your first 30-day supply, your plan will not pay for these

drugs, even if you have been a member of your plan less than 90 days.

Long-term care facility residents

If you’re a resident of a long-term care facility, your plan may allow you to refill your prescription

until we have provided you with a maximum of a 91- and may be up to a 98-day transition supply

of the drug consistent with dispensing increment (unless your prescription is written for fewer

days). Your plan will also cover more than one refill of these drugs for the first 90 days you are a

member of your plan. If you need a drug that’s not on the drug list or if you have limited ability to

get your drugs, but you are past the first 90 days of membership in the plan, your plan will cover a

31-day emergency supply of the drug (unless your prescription is written for fewer days) while you

request a formulary exception.

Other transitions

You may have an unplanned transition, like a hospital discharge or a change in your level of care,

after the first 90 days of your plan membership. If this happens and your doctor prescribes a drug

that’s not on the drug list, or if it’s difficult for you to get your drugs, you are required to use your

plan’s exception process. You may ask for a one-time emergency supply of up to 30 days to give

you time to talk to your doctor about other treatment options or to try to get a formulary

exception.

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Drugs with dosages other than 30 days

Drugs packaged in an extended day supply

Some drugs are packaged from the manufacturer to provide greater than a 30-day supply. When

you fill these drugs, you may have to pay more than one co-pay/co-insurance for a single

prescription. For more information, please contact Customer Service using the information on the

cover.

Daily cost share for oral medications filled for less than a 30-day supply

Daily cost share 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 30 days under applicable law. The daily cost share

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 informationFor more 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, please call us toll-

free at 1-866-622-8054, TTY 711, 8 a.m. to 8 p.m. local time, 7 days a week. Or visit us online at

www.UHCCommunityPlan.com.

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.

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Bold type = Brand name drug Plain type = Generic drug

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Covered drugs by medical condition

The Comprehensive Formulary (drug list) below provides coverage information about the drugs covered by your plan. If you have trouble finding your drug in the list, turn to the “Index of covered drugs,” which begins on page 93.

The first column of the chart lists the drug name. Brand name drugs are listed in bold type (for

example, Crestor) and generic drugs are listed in plain type (for example, Simvastatin).

The second column of the chart lists which coverage level (Tier) your drug is in. Your plan has one

tier named “Covered Drugs”. All covered drugs are in this Tier.

The “Required actions, restrictions or limits” column shows you if your plan has any special coverage requirements for the drug. If quantity limits (QL) apply to a drug, the restriction amounts are shown in the chart on pages 74-92.tRACK

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Analgesics

Nonsteroidal Anti-inflammatory DrugsCelecoxib

Celecoxib (Capsule) 1 QL Diclofenac Potassium

Diclofenac Potassium

(Tablet Immediate-

Release)

1

Diclofenac Sodium

Diclofenac Sodium (1%

Gel)1 PA

Diclofenac Sodium DR

Diclofenac Sodium DR

(Tablet Delayed-Release)1

Diclofenac Sodium ER

Diclofenac Sodium ER

(Tablet Extended-Release

24 Hour)

1

Diflunisal

Diflunisal (Tablet) 1

Etodolac

Etodolac (200mg

Capsule, 300mg Capsule,

400mg Tablet Immediate-

Release, 500mg Tablet

Immediate-Release)

1

Etodolac ER

Etodolac ER (Tablet

Extended-Release 24

Hour)

1

Flector

Flector (Patch) 1 PA, QL

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Flurbiprofen

Flurbiprofen (Tablet) 1

Ibuprofen

Ibuprofen (100mg/5ml

Suspension, 400mg

Tablet, 600mg Tablet,

800mg Tablet)

1

Ketoprofen

Ketoprofen (Capsule

Immediate-Release)1

Ketorolac Tromethamine

Ketorolac Tromethamine

(15mg/ml Injection,

30mg/ml Injection,

60mg/2ml Injection)

1

Meloxicam

Meloxicam (15mg Tablet,

7.5mg Tablet)1

Meloxicam

Meloxicam (7.5mg/5ml

Suspension)1

Nabumetone

Nabumetone (Tablet) 1

Naproxen

Naproxen (125mg/5ml

Suspension, 250mg

Tablet Immediate-

Release, 375mg Tablet

Immediate-Release,

500mg Tablet Immediate-

Release)

1

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Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Naproxen DR

Naproxen DR (Tablet

Delayed-Release)

(Generic EC-Naprosyn)

1

Naproxen Sodium

Naproxen Sodium (Tablet

Immediate-Release)

(Generic Anaprox DS)

1

Oxaprozin

Oxaprozin (Tablet) 1

Piroxicam

Piroxicam (Capsule) 1

Sulindac

Sulindac (Tablet) 1

Voltaren

Voltaren (Gel) 1 PA

Opioid Analgesics, Long-actingEmbeda

Embeda (Capsule

Extended-Release)1 QL

Fentanyl

Fentanyl (100mcg/hr

Patch 72 Hour, 12mcg/hr

Patch 72 Hour, 25mcg/hr

Patch 72 Hour, 50mcg/hr

Patch 72 Hour, 75mcg/hr

Patch 72 Hour)

1 QL

Hydromorphone HCl ER

Hydromorphone HCl ER

(12mg Tablet Extended-

Release 24 Hour Abuse-

Deterrent, 16mg Tablet

Extended-Release 24

Hour Abuse-Deterrent)

1 QL

Hydromorphone HCl ER

Hydromorphone HCl ER

(32mg Tablet Extended-

Release 24 Hour Abuse-

Deterrent)

1 QL

Hydromorphone HCl ER

Hydromorphone HCl ER

(8mg Tablet Extended-

Release 24 Hour Abuse-

Deterrent)

1 QL

Levorphanol Tartrate

Levorphanol Tartrate

(Tablet)1 QL

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Methadone HCl

Methadone HCl (10mg

Tablet, 5mg Tablet,

10mg/5ml Oral Solution,

5mg/5ml Oral Solution)

1 QL

Methadone HCl

Methadone HCl (10mg/

ml Injection)1

Morphine Sulfate ER

Morphine Sulfate ER

(Tablet Extended-Release)

(Generic MS Contin)

1 QL

Nucynta ER

Nucynta ER (Tablet

Extended-Release 12

Hour)

1 QL

Opana ER

Opana ER (Tablet

Extended-Release 12

Hour Abuse-Deterrent)

1 QL

Tramadol HCl ER

Tramadol HCl ER (100mg

Tablet Extended-Release

24 Hour, 200mg Tablet

Extended-Release 24

Hour) (Generic Ultram

ER), (300mg Tablet

Extended-Release 24

Hour) (Generic Ryzolt)

1 QL

Opioid Analgesics, Short-actingAbstral

Abstral (Tablet

Sublingual)1 PA, QL

Acetaminophen/Codeine

Acetaminophen/Codeine

(120mg-12mg/5ml Oral

Solution, 300mg-15mg

Tablet, 300mg-30mg

Tablet, 300mg-60mg

Tablet)

1 QL

Butorphanol Tartrate

Butorphanol Tartrate

(10mg/ml Nasal Solution)1 QL

Butorphanol Tartrate

Butorphanol Tartrate

(1mg/ml Injection, 2mg/

ml Injection)

1

Codeine Sulfate

Codeine Sulfate (Tablet) 1 QL

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Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Duramorph

Duramorph (Injection) 1

Endocet

Endocet (Tablet) 1 QL Hydrocodone Bitartrate/Acetaminophen

Hydrocodone Bitartrate/

Acetaminophen

(7.5mg-325mg/15ml Oral

Solution)

1 QL

Hydrocodone/Acetaminophen

Hydrocodone/

Acetaminophen

(10mg-325mg Tablet,

2.5mg-325mg Tablet,

5mg-325mg Tablet,

7.5mg-325mg Tablet)

1 QL

Hydrocodone/Ibuprofen

Hydrocodone/Ibuprofen

(7.5mg-200mg Tablet)1 QL

Hydromorphone HCl

Hydromorphone HCl

(1mg/ml Liquid)1 QL

Hydromorphone HCl

Hydromorphone HCl

(2mg Tablet Immediate-

Release, 4mg Tablet

Immediate-Release, 8mg

Tablet Immediate-

Release)

1 QL

Hydromorphone HCl

Hydromorphone HCl

(2mg/ml Injection)1

Hydromorphone HCl

Hydromorphone HCl

(500mg/50ml Injection)1

Lorcet

Lorcet (Tablet) 1 QL Lorcet HD

Lorcet HD (Tablet) 1 QL Lorcet Plus

Lorcet Plus (Tablet) 1 QL Lortab

Lortab (10mg-325mg

Tablet, 5mg-325mg

Tablet, 7.5mg-325mg

Tablet)

1 QL

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Morphine Sulfate

Morphine Sulfate

(100mg/5ml Oral

Solution, 10mg/5ml Oral

Solution, 20mg/5ml Oral

Solution)

1 QL

Morphine Sulfate

Morphine Sulfate

(10mg/ml Injection,

2mg/ml Injection, 4mg/

ml Injection, 8mg/ml

Injection)

1

Morphine Sulfate

Morphine Sulfate (15mg

Tablet Immediate-

Release, 30mg Tablet

Immediate-Release)

1 QL

Nalbuphine HCl

Nalbuphine HCl (Injection) 1

Oxycodone HCl

Oxycodone HCl (100mg/

5ml Concentrate, 5mg/

5ml Oral Solution)

1 QL

Oxycodone HCl

Oxycodone HCl (10mg

Tablet Immediate-

Release, 15mg Tablet

Immediate-Release, 20mg

Tablet Immediate-

Release, 30mg Tablet

Immediate-Release, 5mg

Tablet Immediate-

Release)

1 QL

Oxycodone/Acetaminophen

Oxycodone/

Acetaminophen

(10mg-325mg Tablet,

2.5mg-325mg Tablet,

5mg-325mg Tablet,

7.5mg-325mg Tablet)

1 QL

Oxycodone/Acetaminophen

Oxycodone/

Acetaminophen

(325mg-5mg/5ml Oral

Solution)

1 QL

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Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Oxycodone/Aspirin

Oxycodone/Aspirin

(Tablet)1 QL

Oxycodone/Ibuprofen

Oxycodone/Ibuprofen

(Tablet)1 QL

Tramadol HCl

Tramadol HCl (Tablet

Immediate-Release)1 QL

Tramadol HCl/Acetaminophen

Tramadol HCl/

Acetaminophen (Tablet)1 QL

Trezix

Trezix (Capsule) 1 QL

Anesthetics

Local AnestheticsLidocaine

Lidocaine (5% Ointment) 1

Lidocaine

Lidocaine (5% Patch) 1 PA, QL Lidocaine HCl

Lidocaine HCl (0.5%

Injection, 2% Injection)1 B/D, PA

Lidocaine HCl

Lidocaine HCl (4%

External Solution)1

Lidocaine HCl

Lidocaine HCl (Gel) 1

Lidocaine Viscous

Lidocaine Viscous

(Solution)1

Lidocaine/Prilocaine

Lidocaine/Prilocaine

(2.5%-2.5% Cream)1

Anti-Addiction/Substance Abuse Treatment

Agents

Alcohol Deterrents/Anti-cravingAcamprosate Calcium DR

Acamprosate Calcium DR

(Tablet Delayed-Release)1

Disulfiram

Disulfiram (Tablet) 1

Naltrexone HCl

Naltrexone HCl (Tablet) 1

Vivitrol

Vivitrol (Injection) 1 PA

Opioid Dependence TreatmentsBuprenorphine HCl

Buprenorphine HCl

(0.3mg/ml Injection)1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Buprenorphine HCl

Buprenorphine HCl (2mg

Tablet Sublingual, 8mg

Tablet Sublingual)

1 QL

Buprenorphine HCl/Naloxone HCl

Buprenorphine HCl/

Naloxone HCl (Tablet

Sublingual)

1 PA, QL

Naloxone HCl

Naloxone HCl (Injection) 1

Narcan

Narcan (Liquid) 1

Suboxone

Suboxone (Film) 1 PA, QL

Smoking Cessation AgentsBupropion HCl SR

Bupropion HCl SR

(150mg Tablet Extended-

Release 12 Hour)

1

Chantix

Chantix (Tablet) 1

Chantix Continuing Month Pak

Chantix Continuing

Month Pak (Tablet)1

Chantix Starting Month Pak

Chantix Starting Month

Pak (Tablet)1

Nicotrol Inhaler

Nicotrol Inhaler 1

Antibacterials

AminoglycosidesAmikacin Sulfate

Amikacin Sulfate

(Injection)1

Bethkis

Bethkis (Nebulized

Solution)1 B/D, PA

Gentak

Gentak (Ophthalmic

Ointment)1

Gentamicin Sulfate

Gentamicin Sulfate (0.1%

Cream, 0.1% Ointment,

0.3% Ophthalmic

Ointment, 0.3%

Ophthalmic Solution)

1

Gentamicin Sulfate

Gentamicin Sulfate

(10mg/ml Injection,

40mg/ml Injection)

1

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Bold type = Brand name drug Plain type = Generic drug

5

16

5tRACK

16 Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Gentamicin Sulfate/0.9% Sodium Chloride

Gentamicin Sulfate/0.9%

Sodium Chloride

(Injection)

1

Isotonic Gentamicin

Isotonic Gentamicin

(Injection)1

Neomycin Sulfate

Neomycin Sulfate (Tablet) 1

Paromomycin Sulfate

Paromomycin Sulfate

(Capsule)1

Streptomycin Sulfate

Streptomycin Sulfate

(Injection)1

TOBI

TOBI (Nebulized

Solution)1 B/D, PA

TOBI Podhaler

TOBI Podhaler

(Capsule)1 PA

Tobradex

Tobradex (Ophthalmic

Ointment)1

Tobramycin

Tobramycin (Nebulized

Solution)1 B/D, PA

Tobramycin Sulfate

Tobramycin Sulfate (0.3%

Ophthalmic Solution)1

Tobramycin Sulfate

Tobramycin Sulfate

(10mg/ml Injection,

80mg/2ml Injection)

1

Tobrex

Tobrex (0.3%

Ophthalmic Ointment)1

Antibacterials, OtherBACiiM

BACiiM (Injection) 1

Bacitracin

Bacitracin (50000unit

Injection)1

Bacitracin

Bacitracin (500unit/gm

Ophthalmic Ointment)1

Bactroban Nasal

Bactroban Nasal

(Ointment)1 PA

Chloramphenicol Sodium Succinate

Chloramphenicol Sodium

Succinate (Injection)1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Clindamycin HCl

Clindamycin HCl

(Capsule Immediate-

Release)

1

Clindamycin Palmitate HCl

Clindamycin Palmitate

HCl (Oral Solution)1

Clindamycin Phosphate

Clindamycin Phosphate

(2% Cream)1

Clindamycin Phosphate

Clindamycin Phosphate

(600mg/4ml Injection)1

Clindamycin Phosphate in D5W

Clindamycin Phosphate in

D5W (Injection)1

Colistimethate Sodium

Colistimethate Sodium

(Injection)1

Cubicin

Cubicin (Injection) 1

Dalvance

Dalvance (Injection) 1 PA Lincocin

Lincocin (Injection) 1

Lincomycin HCl

Lincomycin HCl (Injection) 1

Linezolid

Linezolid (100mg/5ml

Suspension, 600mg/

300ml Injection)

1 PA

Linezolid

Linezolid (600mg

Tablet)1 PA, QL

Methenamine Hippurate

Methenamine Hippurate

(Tablet)1

Metronidazole

Metronidazole (0.75%

Cream, 0.75% Gel, 1%

Gel, 0.75% Lotion)

1

Metronidazole

Metronidazole (250mg

Tablet Immediate-

Release, 500mg Tablet

Immediate-Release,

375mg Capsule

Immediate-Release)

1

Metronidazole in NaCl 0.79%

Metronidazole in NaCl

0.79% (Injection)1

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You can find information on what the symbols and abbreviations in this table mean by going to page 7.

6

17

6tRACK

17Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Metronidazole Vaginal

Metronidazole Vaginal

(Gel)1

Mupirocin

Mupirocin (2% Cream) 1

Mupirocin

Mupirocin (2% Ointment) 1

Neomycin/Polymyxin B Sulfates

Neomycin/Polymyxin B

Sulfates (Irrigation

Solution)

1

Nitrofurantoin

Nitrofurantoin

(Suspension)1

Nitrofurantoin Macrocrystals

Nitrofurantoin

Macrocrystals (100mg

Capsule, 50mg Capsule)

(Generic Macrodantin)

1

Nitrofurantoin Monohydrate

Nitrofurantoin

Monohydrate (100mg

Capsule) (Generic

Macrobid)

1

Polymyxin B Sulfate

Polymyxin B Sulfate

(Injection)1

Sulfamylon

Sulfamylon (85mg/gm

Cream)1

Synercid

Synercid (Injection) 1

Tinidazole

Tinidazole (Tablet) 1

Trimethoprim

Trimethoprim (Tablet) 1

Tygacil

Tygacil (Injection) 1

Vancocin HCl

Vancocin HCl (Capsule) 1 PA Vancomycin HCl

Vancomycin HCl

(1000mg Injection, 10gm

Injection, 500mg

Injection)

1

Vancomycin HCl

Vancomycin HCl (125mg

Capsule, 250mg Capsule)1 PA

Vandazole

Vandazole (Gel) 1

Xifaxan

Xifaxan (Tablet) 1 PA

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Zyvox

Zyvox (100mg/5ml

Suspension, 600mg/

300ml Injection)

1 PA

Zyvox

Zyvox (600mg Tablet) 1 PA, QL

Beta-lactam, CephalosporinsCefaclor

Cefaclor (250mg Capsule

Immediate-Release,

500mg Capsule

Immediate-Release)

1

Cefadroxil

Cefadroxil (250mg/5ml

Suspension, 500mg/5ml

Suspension, 500mg

Capsule)

1

Cefazolin Sodium

Cefazolin Sodium (10gm

Injection, 1gm Injection,

500mg Injection, 1gm/

50ml Injection)

1

Cefdinir

Cefdinir (125mg/5ml

Suspension, 250mg/5ml

Suspension, 300mg

Capsule)

1

Cefepime

Cefepime (1gm Injection,

2gm Injection)1

Cefepime/Dextrose

Cefepime/Dextrose

(1gm/50ml Injection,

2gm/50ml Injection)

1

Cefixime

Cefixime (Suspension) 1

Cefotaxime Sodium

Cefotaxime Sodium

(Injection)1

Cefotetan

Cefotetan (Injection) 1

Cefoxitin Sodium

Cefoxitin Sodium (10gm

Injection, 1gm Injection,

2gm Injection)

1

Cefoxitin Sodium

Cefoxitin Sodium

(1gm-4% Injection,

2gm-2.2% Injection)

1

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18

7tRACK

18 Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Cefpodoxime Proxetil

Cefpodoxime Proxetil

(100mg Tablet, 200mg

Tablet, 100mg/5ml

Suspension, 50mg/5ml

Suspension)

1

Cefprozil

Cefprozil (125mg/5ml

Suspension, 250mg/5ml

Suspension, 250mg

Tablet, 500mg Tablet)

1

Ceftazidime

Ceftazidime (Injection) 1

Ceftazidime/Dextrose

Ceftazidime/Dextrose

(Injection)1

Ceftriaxone Sodium

Ceftriaxone Sodium

(10gm Injection, 1gm

Injection, 2gm Injection,

250mg Injection, 500mg

Injection)

1

Cefuroxime Axetil

Cefuroxime Axetil (Tablet) 1

Cefuroxime Sodium

Cefuroxime Sodium

(Injection)1

Cephalexin

Cephalexin (125mg/5ml

Suspension, 250mg/5ml

Suspension, 250mg

Capsule, 500mg Capsule,

750mg Capsule)

1

Fortaz

Fortaz (1gm Injection,

2gm Injection, 2gm

Injection, 6gm Injection)

1

Suprax

Suprax (100mg Tablet

Chewable, 200mg Tablet

Chewable, 100mg/5ml

Suspension, 200mg/5ml

Suspension)

1

Suprax

Suprax (400mg

Capsule, 500mg/5ml

Suspension)

1

Tazicef

Tazicef (Injection) 1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Zerbaxa

Zerbaxa (Injection) 1 PA

Beta-lactam, OtherAzactam in Iso-Osmotic Dextrose

Azactam in Iso-Osmotic

Dextrose (Injection)1

Aztreonam

Aztreonam (Injection) 1

Doribax

Doribax (Injection) 1

Imipenem/Cilastatin

Imipenem/Cilastatin

(Injection)1

Invanz

Invanz (Injection) 1

Meropenem

Meropenem (Injection) 1

Beta-lactam, PenicillinsAmoxicillin

Amoxicillin (Capsule, Oral

Suspension, Tablet,

Tablet Chewable)

1

Amoxicillin/Clavulanate Potassium

Amoxicillin/Clavulanate

Potassium (Oral

Suspension, Tablet

Chewable, Tablet

Immediate-Release)

(Generic Augmentin)

1

Amoxicillin/Clavulanate Potassium ER

Amoxicillin/Clavulanate

Potassium ER (Tablet

Extended-Release 12

Hour)

1

Ampicillin

Ampicillin (125mg/5ml

Suspension, 250mg/5ml

Suspension, 250mg

Capsule, 500mg Capsule)

1

Ampicillin Sodium

Ampicillin Sodium (10gm

Injection, 125mg

Injection, 1gm Injection)

1

Ampicillin-Sulbactam

Ampicillin-Sulbactam

(10gm-5gm Injection,

1gm-0.5gm Injection,

2gm-1gm Injection)

1

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You can find information on what the symbols and abbreviations in this table mean by going to page 7.

8

19

8tRACK

19Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Bactocill in Dextrose

Bactocill in Dextrose

(1gm/50ml Injection)1

Bactocill in Dextrose

Bactocill in Dextrose

(2gm/50ml Injection)1

Bicillin C-R

Bicillin C-R (Injection) 1

Bicillin L-A

Bicillin L-A (Injection) 1

Dicloxacillin Sodium

Dicloxacillin Sodium

(Capsule)1

Nafcillin in Dextrose

Nafcillin in Dextrose

(Injection)1

Nafcillin Sodium

Nafcillin Sodium

(Injection)1

Oxacillin Sodium

Oxacillin Sodium (10gm

Injection)1

Oxacillin Sodium

Oxacillin Sodium (2gm

Injection)1

Penicillin G Potassium

Penicillin G Potassium

(Injection)1

Penicillin G Procaine

Penicillin G Procaine

(Injection)1

Penicillin G Sodium

Penicillin G Sodium

(Injection)1

Penicillin V Potassium

Penicillin V Potassium

(125mg/5ml Oral

Solution, 250mg/5ml Oral

Solution, 250mg Tablet,

500mg Tablet)

1

Piperacillin/Tazobactam

Piperacillin/Tazobactam

(Injection)1

MacrolidesAzasite

Azasite (Ophthalmic

Solution)1

Azithromycin

Azithromycin (100mg/5ml

Oral Suspension, 200mg/

5ml Oral Suspension,

250mg Tablet, 500mg

Tablet, 600mg Tablet)

1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Azithromycin

Azithromycin (500mg

Injection)1

Clarithromycin

Clarithromycin (125mg/

5ml Suspension, 250mg/

5ml Suspension, 250mg

Tablet, 500mg Tablet)

1

Clarithromycin ER

Clarithromycin ER (Tablet

Extended-Release 24

Hour)

1

Dificid

Dificid (Tablet) 1 PA E.E.S. 400

E.E.S. 400 (Tablet) 1

E.E.S. Granules

E.E.S. Granules

(Suspension)1

EryPed 200

EryPed 200

(Suspension)1

EryPed 400

EryPed 400

(Suspension)1

Ery-Tab

Ery-Tab (Tablet Delayed-

Release)1

Erythrocin Lactobionate

Erythrocin Lactobionate

(Injection)1

Erythromycin

Erythromycin (250mg

Capsule Delayed-Release)1

Erythromycin

Erythromycin (5mg/gm

Ophthalmic Ointment)1

Erythromycin Base

Erythromycin Base

(Tablet)1

Erythromycin Ethylsuccinate

Erythromycin

Ethylsuccinate (Tablet)1

Ilotycin

Ilotycin (Ophthalmic

Ointment)1

Zmax

Zmax (Suspension) 1

QuinolonesAvelox

Avelox (400mg/

250ml-0.8% Injection)1

Besivance

Besivance (Suspension) 1

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Bold type = Brand name drug Plain type = Generic drug

9

20

9tRACK

20 Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Ciloxan

Ciloxan (0.3%

Ointment)1

Ciprofloxacin

Ciprofloxacin (250mg/

5ml Suspension, 500mg/

5ml Suspension, 400mg/

40ml Injection)

1

Ciprofloxacin ER

Ciprofloxacin ER (Tablet

Extended-Release 24

Hour)

1

Ciprofloxacin HCl

Ciprofloxacin HCl (0.3%

Ophthalmic Solution,

100mg Tablet Immediate-

Release, 250mg Tablet

Immediate-Release,

500mg Tablet Immediate-

Release, 750mg Tablet

Immediate-Release)

1

Ciprofloxacin I.V. in D5W

Ciprofloxacin I.V. in D5W

(Injection)1

Gatifloxacin

Gatifloxacin (Ophthalmic

Solution)1

Levofloxacin

Levofloxacin (0.5%

Ophthalmic Solution,

25mg/ml Oral Solution)

1

Levofloxacin

Levofloxacin (250mg

Tablet, 500mg Tablet,

750mg Tablet)

1

Levofloxacin

Levofloxacin (25mg/ml

Injection)1

Levofloxacin in D5W

Levofloxacin in D5W

(Injection)1

Moxeza

Moxeza (Ophthalmic

Solution)1

Moxifloxacin HCl

Moxifloxacin HCl (400mg

Tablet)1

Moxifloxacin HCl

Moxifloxacin HCl

(400mg/250ml

Injection)

1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Ofloxacin

Ofloxacin (0.3%

Ophthalmic Solution,

0.3% Otic Solution,

400mg Tablet)

1

Vigamox

Vigamox (Ophthalmic

Solution)1

SulfonamidesSilver Sulfadiazine

Silver Sulfadiazine

(Cream)1

Sodium Sulfacetamide

Sodium Sulfacetamide

(10% Ophthalmic

Solution)

1

SSD

SSD (Cream) 1

Sulfacetamide Sodium

Sulfacetamide Sodium

(Ophthalmic Ointment)1

Sulfadiazine

Sulfadiazine (Tablet) 1

Sulfamethoxazole/Trimethoprim

Sulfamethoxazole/

Trimethoprim

(200mg-40mg/5ml

Suspension,

400mg-80mg Tablet)

1

Sulfamethoxazole/Trimethoprim

Sulfamethoxazole/

Trimethoprim

(400mg-80mg/5ml

Injection)

1

Sulfamethoxazole/Trimethoprim DS

Sulfamethoxazole/

Trimethoprim DS (Tablet)1

TetracyclinesDemeclocycline HCl

Demeclocycline HCl

(Tablet)1

Doxy 100

Doxy 100 (Injection) 1

Doxycycline

Doxycycline (150mg

Capsule, 75mg Capsule)1

Doxycycline

Doxycycline (25mg/5ml

Suspension)1

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10

You can find information on what the symbols and abbreviations in this table mean by going to page 7.

10

21

10tRACK

21Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Doxycycline Hyclate

Doxycycline Hyclate

(100mg Capsule

Immediate-Release, 50mg

Capsule Immediate-

Release)

1

Doxycycline Hyclate

Doxycycline Hyclate

(100mg Injection, 100mg

Tablet Immediate-

Release, 20mg Tablet

Immediate-Release)

1

Doxycycline Monohydrate

Doxycycline Monohydrate

(100mg Capsule, 50mg

Capsule, 100mg Tablet,

150mg Tablet, 50mg

Tablet, 75mg Tablet)

1

Minocycline HCl

Minocycline HCl (100mg

Capsule Immediate-

Release, 50mg Capsule

Immediate-Release, 75mg

Capsule Immediate-

Release)

1

Minocycline HCl

Minocycline HCl (100mg

Tablet Immediate-

Release, 50mg Tablet

Immediate-Release, 75mg

Tablet Immediate-

Release)

1

Tetracycline HCl

Tetracycline HCl

(Capsule)1

Vibramycin

Vibramycin (50mg/5ml

Syrup)1

Anticonvulsants

Anticonvulsants, OtherBRIVIACT

BRIVIACT (100mg

Tablet, 10mg Tablet,

25mg Tablet, 50mg

Tablet, 75mg Tablet,

10mg/ml Oral Solution)

1 QL

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

BRIVIACT

BRIVIACT (50mg/5ml

Injection)1 QL

Fycompa

Fycompa (Tablet, Oral

Suspension)1

Levetiracetam

Levetiracetam (1000mg

Tablet Immediate-

Release, 250mg Tablet

Immediate-Release,

500mg Tablet Immediate-

Release, 750mg Tablet

Immediate-Release,

100mg/ml Oral Solution)

1

Levetiracetam

Levetiracetam

(1000mg/100ml

Injection, 1500mg/

100ml Injection,

500mg/100ml

Injection)

1

Levetiracetam

Levetiracetam (500mg/

5ml Injection)1

Levetiracetam ER

Levetiracetam ER (Tablet

Extended-Release 24

Hour)

1

Potiga

Potiga (Tablet) 1 QL Roweepra

Roweepra (Tablet) 1

Spritam

Spritam (Tablet

Disintegrating Soluble)1

Calcium Channel Modifying AgentsCelontin

Celontin (Capsule) 1

Ethosuximide

Ethosuximide (250mg

Capsule, 250mg/5ml Oral

Solution)

1

Zonisamide

Zonisamide (Capsule) 1

Gamma-aminobutyric Acid (GABA)

Augmenting AgentsDiastat AcuDial

Diastat AcuDial (Gel) 1

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Bold type = Brand name drug Plain type = Generic drug

11

22

11tRACK

22 Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Diastat Pediatric

Diastat Pediatric (Gel) 1

Diazepam

Diazepam (10mg Gel,

2.5mg Gel, 20mg Gel)1

Divalproex Sodium

Divalproex Sodium

(Capsule Sprinkle

Delayed-Release)

1

Divalproex Sodium DR

Divalproex Sodium DR

(Tablet Delayed-Release)1

Divalproex Sodium ER

Divalproex Sodium ER

(Tablet Extended-Release

24 Hour)

1

Gabapentin

Gabapentin (100mg

Capsule, 300mg Capsule,

400mg Capsule, 600mg

Tablet, 800mg Tablet)

1

Gabapentin

Gabapentin (250mg/5ml

Oral Solution)1

Gabitril

Gabitril (12mg Tablet,

16mg Tablet)1 QL

Onfi

Onfi (10mg Tablet) 1 QL Onfi

Onfi (2.5mg/ml

Suspension)1

Onfi

Onfi (20mg Tablet) 1 QL Phenobarbital

Phenobarbital (100mg

Tablet, 15mg Tablet,

16.2mg Tablet, 30mg

Tablet, 32.4mg Tablet,

60mg Tablet, 64.8mg

Tablet, 97.2mg Tablet,

20mg/5ml Elixir)

1

Primidone

Primidone (Tablet) 1

Sabril

Sabril (500mg Packet,

500mg Tablet)1 PA, QL, LA

Tiagabine HCl

Tiagabine HCl (Tablet) 1

Valproate Sodium

Valproate Sodium

(100mg/ml Injection)1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Valproic Acid

Valproic Acid (250mg

Capsule, 250mg/5ml

Syrup)

1

Glutamate Reducing AgentsFelbamate

Felbamate (400mg

Tablet, 600mg Tablet)1

Felbamate

Felbamate (600mg/5ml

Suspension)1

Felbatol

Felbatol (600mg/5ml

Suspension)1

Lamotrigine

Lamotrigine (100mg

Tablet Immediate-

Release, 150mg Tablet

Immediate-Release,

200mg Tablet Immediate-

Release, 25mg Tablet

Immediate-Release)

1

Lamotrigine

Lamotrigine (25mg Tablet

Chewable, 5mg Tablet

Chewable)

1

Topiramate

Topiramate (100mg

Tablet Immediate-

Release, 200mg Tablet

Immediate-Release, 25mg

Tablet Immediate-

Release, 50mg Tablet

Immediate-Release, 15mg

Capsule Sprinkle

Immediate-Release, 25mg

Capsule Sprinkle

Immediate-Release)

1

Sodium Channel AgentsAptiom

Aptiom (200mg Tablet) 1 QL Aptiom

Aptiom (400mg Tablet,

600mg Tablet, 800mg

Tablet)

1 QL

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12

You can find information on what the symbols and abbreviations in this table mean by going to page 7.

12

23

12tRACK

23Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Banzel

Banzel (200mg Tablet,

400mg Tablet, 40mg/

ml Suspension)

1

Carbamazepine

Carbamazepine (100mg

Tablet Chewable,

100mg/5ml Suspension,

200mg Tablet Immediate-

Release)

1

Carbamazepine ER

Carbamazepine ER

(Capsule Extended-

Release 12 Hour, Tablet

Extended-Release 12

Hour)

1

Dilantin

Dilantin (Capsule) 1

Dilantin INFATABS

Dilantin INFATABS (Tablet

Chewable)1

Epitol

Epitol (Tablet) 1

Fosphenytoin Sodium

Fosphenytoin Sodium

(Injection)1

Oxcarbazepine

Oxcarbazepine (150mg

Tablet, 300mg Tablet,

600mg Tablet)

1

Oxcarbazepine

Oxcarbazepine (300mg/

5ml Suspension)1

Peganone

Peganone (Tablet) 1

Phenytek

Phenytek (Capsule) 1

Phenytoin

Phenytoin (125mg/5ml

Suspension, 50mg Tablet

Chewable)

1

Phenytoin Sodium

Phenytoin Sodium

(Injection)1

Phenytoin Sodium Extended

Phenytoin Sodium

Extended (Capsule)1

Tegretol-XR

Tegretol-XR (100mg

Tablet Extended-

Release 12 Hour)

1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Vimpat

Vimpat (100mg Tablet,

150mg Tablet, 200mg

Tablet, 50mg Tablet,

10mg/ml Oral Solution)

1 QL

Vimpat

Vimpat (200mg/20ml

Injection)1 PA

Antidementia Agents

Cholinesterase InhibitorsDonepezil HCl

Donepezil HCl (Tablet

Immediate-Release)1 QL

Donepezil HCl ODT

Donepezil HCl ODT

(Tablet Dispersible)1 QL

Exelon

Exelon (Patch 24 Hour) 1 QL, ST Galantamine HBr

Galantamine HBr (12mg

Tablet, 4mg Tablet, 8mg

Tablet, 16mg Capsule

Extended-Release 24

Hour, 24mg Capsule

Extended-Release 24

Hour, 8mg Capsule

Extended-Release 24

Hour, 4mg/ml Oral

Solution)

1 QL

Rivastigmine Tartrate

Rivastigmine Tartrate

(Capsule Immediate-

Release)

1 QL

Rivastigmine Transdermal System

Rivastigmine Transdermal

System (Patch 24 Hour)1 QL, ST

N-methyl-D-aspartate (NMDA) Receptor

AntagonistMemantine HCl

Memantine HCl (10mg

Tablet, 5mg Tablet, 2mg/

ml Oral Solution)

1 PA, QL

Memantine HCl Titration Pak

Memantine HCl

Titration Pak (Tablet)1 PA

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Bold type = Brand name drug Plain type = Generic drug

13

24

13tRACK

24 Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Namenda

Namenda (10mg Tablet

Immediate-Release,

5mg Tablet Immediate-

Release)

1 PA, QL

Namenda

Namenda (10mg/5ml

Oral Solution)1 PA, QL

Namenda Titration Pak

Namenda Titration Pak

(Tablet)1 PA

Namenda XR

Namenda XR (Capsule

Extended-Release 24

Hour)

1 PA, QL

Namenda XR Titration Pack

Namenda XR Titration

Pack (Capsule

Extended-Release 24

Hour)

1 PA, QL

Antidepressants

Antidepressants, OtherBupropion HCl

Bupropion HCl (Tablet

Immediate-Release)1

Bupropion HCl SR

Bupropion HCl SR (Tablet

Extended-Release 12

Hour)

1

Bupropion HCl XL

Bupropion HCl XL (Tablet

Extended-Release 24

Hour)

1

Mirtazapine

Mirtazapine (Tablet

Immediate-Release)1

Mirtazapine ODT

Mirtazapine ODT (Tablet

Dispersible)1

Monoamine Oxidase InhibitorsEmsam

Emsam (Patch 24 Hour) 1 QL Marplan

Marplan (Tablet) 1

Phenelzine Sulfate

Phenelzine Sulfate

(Tablet)1

Tranylcypromine Sulfate

Tranylcypromine Sulfate

(Tablet)1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

SSRI/SNRI (Selective Serotonin Reuptake

Inhibitors/Serotonin and Norepinephrine

Reuptake Inhibitors)Citalopram HBr

Citalopram HBr (10mg

Tablet, 20mg Tablet,

40mg Tablet)

1

Citalopram HBr

Citalopram HBr (10mg/

5ml Oral Solution)1

Escitalopram Oxalate

Escitalopram Oxalate

(10mg Tablet, 20mg

Tablet, 5mg Tablet)

1

Escitalopram Oxalate

Escitalopram Oxalate

(5mg/5ml Oral Solution)1

Fetzima

Fetzima (Capsule

Extended-Release 24

Hour)

1 QL, ST

Fetzima Titration Pack

Fetzima Titration Pack

(Capsule Extended-

Release 24 Hour

Therapy Pack)

1 ST

Fluoxetine DR

Fluoxetine DR (Capsule

Delayed-Release)1

Fluoxetine HCl

Fluoxetine HCl (10mg

Capsule Immediate-

Release, 20mg Capsule

Immediate-Release, 40mg

Capsule Immediate-

Release, 20mg/5ml Oral

Solution)

1

Fluvoxamine Maleate

Fluvoxamine Maleate

(Tablet)1

Maprotiline HCl

Maprotiline HCl (Tablet) 1

Nefazodone HCl

Nefazodone HCl (Tablet) 1

Paroxetine HCl

Paroxetine HCl (Tablet

Immediate-Release)1

Paxil

Paxil (10mg/5ml

Suspension)1

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14

You can find information on what the symbols and abbreviations in this table mean by going to page 7.

14

25

14tRACK

25Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Pristiq

Pristiq (Tablet

Extended-Release 24

Hour)

1 QL

Sertraline HCl

Sertraline HCl (100mg

Tablet, 25mg Tablet,

50mg Tablet)

1

Sertraline HCl

Sertraline HCl (20mg/ml

Concentrate)1

Trazodone HCl

Trazodone HCl (Tablet) 1

Trintellix

Trintellix (Tablet) 1 QL Venlafaxine HCl

Venlafaxine HCl (Tablet

Immediate-Release)1

Venlafaxine HCl ER

Venlafaxine HCl ER

(150mg Capsule

Extended-Release 24

Hour, 37.5mg Capsule

Extended-Release 24

Hour, 75mg Capsule

Extended-Release 24

Hour)

1

Viibryd

Viibryd (Tablet) 1 QL Viibryd Starter Pack

Viibryd Starter Pack

(Kit)1 QL

TricyclicsAmitriptyline HCl

Amitriptyline HCl (Tablet) 1

Amoxapine

Amoxapine (Tablet) 1

Clomipramine HCl

Clomipramine HCl

(Capsule)1

Desipramine HCl

Desipramine HCl (Tablet) 1

Doxepin HCl

Doxepin HCl (100mg

Capsule, 10mg Capsule,

150mg Capsule, 25mg

Capsule, 50mg Capsule,

75mg Capsule, 10mg/ml

Concentrate)

1

Imipramine HCl

Imipramine HCl (Tablet) 1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Imipramine Pamoate

Imipramine Pamoate

(Capsule)1

Nortriptyline HCl

Nortriptyline HCl (10mg

Capsule, 25mg Capsule,

50mg Capsule, 75mg

Capsule, 10mg/5ml Oral

Solution)

1

Protriptyline HCl

Protriptyline HCl (Tablet) 1

Surmontil

Surmontil (Capsule) 1

Trimipramine Maleate

Trimipramine Maleate

(Capsule)1

Antiemetics

Antiemetics, OtherCompro

Compro (Suppository) 1

Hydroxyzine Pamoate

Hydroxyzine Pamoate

(Capsule)1

Meclizine HCl

Meclizine HCl (Tablet) 1

Metoclopramide HCl

Metoclopramide HCl

(10mg Tablet, 5mg

Tablet)

1

Metoclopramide HCl

Metoclopramide HCl

(5mg/5ml Oral Solution)1

Metoclopramide HCl

Metoclopramide HCl

(5mg/ml Injection)1

Perphenazine

Perphenazine (Tablet) 1

Prochlorperazine

Prochlorperazine

(Suppository)1

Prochlorperazine Edisylate

Prochlorperazine

Edisylate (Injection)1

Prochlorperazine Maleate

Prochlorperazine Maleate

(Tablet)1

Transderm-Scop

Transderm-Scop (Patch

72 Hour)1

Emetogenic Therapy AdjunctsAloxi

Aloxi (Injection) 1

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Bold type = Brand name drug Plain type = Generic drug

15

26

15tRACK

26 Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Anzemet

Anzemet (100mg

Tablet, 50mg Tablet)1 B/D, PA

Cesamet

Cesamet (Capsule) 1 PA Dronabinol

Dronabinol (10mg

Capsule)1 PA, QL

Dronabinol

Dronabinol (2.5mg

Capsule, 5mg Capsule)1 PA, QL

Emend

Emend (Pack, 125mg

Capsule, 40mg

Capsule, 80mg

Capsule, 125mg

Suspension)

1 PA

Emend

Emend (150mg

Injection)1

Granisetron HCl

Granisetron HCl (0.1mg/

ml Injection, 1mg/ml

Injection)

1

Granisetron HCl

Granisetron HCl (1mg

Tablet)1 B/D, PA, QL

Ondansetron HCl

Ondansetron HCl (24mg

Tablet, 4mg Tablet, 8mg

Tablet)

1 B/D, PA

Ondansetron HCl

Ondansetron HCl (4mg/

2ml Injection)1

Ondansetron HCl

Ondansetron HCl (4mg/

5ml Oral Solution)1 B/D, PA

Ondansetron ODT

Ondansetron ODT (Tablet

Dispersible)1 B/D, PA

Sancuso

Sancuso (Patch) 1

Antifungals

AntifungalsAbelcet

Abelcet (Injection) 1 B/D, PA AmBisome

AmBisome (Injection) 1 B/D, PA Amphotericin B

Amphotericin B (Injection) 1 B/D, PA Ancobon

Ancobon (Capsule) 1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Cancidas

Cancidas (Injection) 1

Ciclopirox

Ciclopirox (0.77% Gel,

0.77% Suspension, 1%

Shampoo)

1

Ciclopirox Nail Lacquer

Ciclopirox Nail Lacquer

(External Solution)1

Ciclopirox Olamine

Ciclopirox Olamine

(Cream)1

Clotrimazole

Clotrimazole (1% Cream,

1% External Solution,

10mg Troche)

1

Econazole Nitrate

Econazole Nitrate (Cream) 1

Eraxis

Eraxis (Injection) 1

Exelderm

Exelderm (1% Cream,

1% External Solution)1

Fluconazole

Fluconazole (100mg

Tablet, 150mg Tablet,

200mg Tablet, 50mg

Tablet, 10mg/ml

Suspension, 40mg/ml

Suspension)

1

Fluconazole in Dextrose

Fluconazole in Dextrose

(Injection)1

Fluconazole in NaCl

Fluconazole in NaCl

(Injection)1

Flucytosine

Flucytosine (Capsule) 1

Griseofulvin Microsize

Griseofulvin Microsize

(125mg/5ml Suspension,

500mg Tablet)

1

Griseofulvin Ultramicrosize

Griseofulvin

Ultramicrosize (Tablet)1

Itraconazole

Itraconazole (Capsule) 1 PA, QL Jublia

Jublia (External

Solution)1

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16

You can find information on what the symbols and abbreviations in this table mean by going to page 7.

16

27

16tRACK

27Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Ketoconazole

Ketoconazole (2% Cream,

2% Shampoo, 200mg

Tablet)

1

Ketoconazole

Ketoconazole (2% Foam) 1

Mentax

Mentax (Cream) 1

Miconazole 3

Miconazole 3

(Suppository)1

Mycamine

Mycamine (Injection) 1

Naftifine HCl

Naftifine HCl (1%

Cream)1

Naftifine HCl

Naftifine HCl (2% Cream) 1

Naftin

Naftin (1% Gel, 2% Gel,

2% Cream)1

Natacyn

Natacyn (Suspension) 1

Noxafil

Noxafil (100mg Tablet

Delayed-Release)1 PA

Noxafil

Noxafil (40mg/ml

Suspension)1

Nyamyc

Nyamyc (Powder) 1

Nystatin

Nystatin (Cream,

Ointment, Powder,

Suspension, Tablet)

1

Nystop

Nystop (Powder) 1

ONMEL

ONMEL (Tablet) 1 PA Oxiconazole Nitrate

Oxiconazole Nitrate

(Cream)1

Oxistat

Oxistat (1% Cream, 1%

Lotion)1

Sporanox

Sporanox (10mg/ml

Oral Solution)1 PA

Terbinafine HCl

Terbinafine HCl (Tablet) 1

Terconazole

Terconazole (0.4%

Cream, 0.8% Cream,

80mg Suppository)

1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Vfend

Vfend (200mg Tablet,

50mg Tablet, 40mg/ml

Suspension)

1

Voriconazole

Voriconazole (200mg

Injection)1

Voriconazole

Voriconazole (200mg

Tablet, 50mg Tablet,

40mg/ml Suspension)

1

Zazole

Zazole (0.8% Cream) 1

Antigout Agents

Antigout AgentsAllopurinol

Allopurinol (Tablet) 1

Colchicine

Colchicine (0.6mg

Tablet) (Generic

Colcrys)

1 QL

Colcrys

Colcrys (Tablet) 1 QL Probenecid

Probenecid (Tablet) 1

Probenecid/Colchicine

Probenecid/Colchicine

(Tablet)1

Uloric

Uloric (Tablet) 1 ST

Antimigraine Agents

Ergot AlkaloidsDihydroergotamine Mesylate

Dihydroergotamine

Mesylate (1mg/ml

Injection)

1

Migergot

Migergot (Suppository) 1

Serotonin (5-HT) 1b/1d Receptor AgonistsNaratriptan HCl

Naratriptan HCl (Tablet) 1 QL Rizatriptan Benzoate

Rizatriptan Benzoate

(Tablet Immediate-

Release)

1 QL

Rizatriptan Benzoate ODT

Rizatriptan Benzoate ODT

(Tablet Dispersible)1 QL

Sumatriptan

Sumatriptan (Nasal

Solution)1 QL

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17

Bold type = Brand name drug Plain type = Generic drug

17

28

17tRACK

28 Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Sumatriptan Succinate

Sumatriptan Succinate

(100mg Tablet, 25mg

Tablet, 50mg Tablet)

1 QL

Sumatriptan Succinate

Sumatriptan Succinate

(4mg/0.5ml Solution

Auto injector)

1 QL

Sumatriptan Succinate

Sumatriptan Succinate

(6mg/0.5ml Injection)1 QL

Sumatriptan Succinate Refill

Sumatriptan Succinate

Refill (4mg/0.5ml

Injection)

1 QL

Sumatriptan Succinate Refill

Sumatriptan Succinate

Refill (6mg/0.5ml

Injection)

1 QL

Sumavel DosePro

Sumavel DosePro

(Injection)1

Antimyasthenic Agents

ParasympathomimeticsGuanidine HCl

Guanidine HCl (Tablet) 1

Mestinon

Mestinon (60mg/5ml

Syrup)1

Mestinon Timespan

Mestinon Timespan

(Tablet Extended-

Release)

1

Pyridostigmine Bromide

Pyridostigmine Bromide

(180mg Tablet Extended-

Release)

1

Pyridostigmine Bromide

Pyridostigmine Bromide

(60mg Tablet)1

Antimycobacterials

Antimycobacterials, OtherDapsone

Dapsone (Tablet) 1

Rifabutin

Rifabutin (Capsule) 1

AntitubercularsCapastat Sulfate

Capastat Sulfate

(Injection)1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Ethambutol HCl

Ethambutol HCl (Tablet) 1

Isoniazid

Isoniazid (100mg Tablet,

300mg Tablet, 50mg/5ml

Syrup)

1

Isoniazid

Isoniazid (100mg/ml

Injection)1

Paser

Paser (Packet) 1

Priftin

Priftin (Tablet) 1

Pyrazinamide

Pyrazinamide (Tablet) 1

Rifampin

Rifampin (150mg

Capsule, 300mg Capsule)1

Rifampin

Rifampin (600mg

Injection)1

Rifater

Rifater (Tablet) 1

Sirturo

Sirturo (Tablet) 1 PA Trecator

Trecator (Tablet) 1

Antineoplastics

Alkylating AgentsBiCNU

BiCNU (Injection) 1

Busulfex

Busulfex (Injection) 1

Cyclophosphamide

Cyclophosphamide

(Capsule)1 B/D, PA

Dacarbazine

Dacarbazine (Injection) 1

Gleostine

Gleostine (Capsule) 1

Hexalen

Hexalen (Capsule) 1 PA Ifosfamide

Ifosfamide (Injection) 1

Leukeran

Leukeran (Tablet) 1

Matulane

Matulane (Capsule) 1 LA Melphalan HCl

Melphalan HCl (Injection) 1

Mustargen

Mustargen (Injection) 1

Treanda

Treanda (Injection) 1 PA Valchlor

Valchlor (Gel) 1 PA, LA

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18

You can find information on what the symbols and abbreviations in this table mean by going to page 7.

18

29

18tRACK

29Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Yondelis

Yondelis (Injection) 1 PA Zanosar

Zanosar (Injection) 1

Antiandrogens Bicalutamide

Bicalutamide (Tablet) 1

Flutamide

Flutamide (Capsule) 1

Nilandron

Nilandron (Tablet) 1

Nilutamide

Nilutamide (Tablet) 1

Xtandi

Xtandi (Capsule) 1 PA, QL Zytiga

Zytiga (Tablet) 1 PA, QL

Antiangiogenic AgentsPomalyst

Pomalyst (Capsule) 1 PA Revlimid

Revlimid (Capsule) 1 PA, LA Thalomid

Thalomid (Capsule) 1 PA

Antiestrogens/ModifiersEmcyt

Emcyt (Capsule) 1

Fareston

Fareston (Tablet) 1

Faslodex

Faslodex (Injection) 1

Soltamox

Soltamox (Oral

Solution)1

Tamoxifen Citrate

Tamoxifen Citrate (Tablet) 1

AntimetabolitesAdrucil

Adrucil (Injection) 1 B/D, PA Alimta

Alimta (Injection) 1 PA Cladribine

Cladribine (Injection) 1 B/D, PA Clolar

Clolar (Injection) 1

Cytarabine Aqueous

Cytarabine Aqueous

(Injection)1 B/D, PA

Droxia

Droxia (Capsule) 1

Elitek

Elitek (Injection) 1

Fluorouracil

Fluorouracil (2.5gm/50ml

Injection)1 B/D, PA

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Folotyn

Folotyn (Injection) 1

Gemcitabine HCl

Gemcitabine HCl

(Injection)1

Gemzar

Gemzar (Injection) 1

Hydroxyurea

Hydroxyurea (Capsule) 1

Lonsurf

Lonsurf (Tablet) 1 PA, QL Mercaptopurine

Mercaptopurine (Tablet) 1

Nipent

Nipent (Injection) 1

Purixan

Purixan (Suspension) 1 PA Tabloid

Tabloid (Tablet) 1 PA

Antineoplastics, OtherAbraxane

Abraxane (Injection) 1 PA Alecensa

Alecensa (Capsule) 1 PA, QL Amifostine

Amifostine (Injection) 1

Arranon

Arranon (Injection) 1

Azacitidine

Azacitidine (Injection) 1 PA Beleodaq

Beleodaq (Injection) 1 PA Bleomycin Sulfate

Bleomycin Sulfate

(Injection)1 B/D, PA

Carboplatin

Carboplatin (Injection) 1

Cisplatin

Cisplatin (Injection) 1

Cosmegen

Cosmegen (Injection) 1

Dacogen

Dacogen (Injection) 1

Daunorubicin HCl

Daunorubicin HCl

(Injection)1

Decitabine

Decitabine (Injection) 1

Dexrazoxane

Dexrazoxane (Injection) 1 PA Docefrez

Docefrez (Injection) 1

Docetaxel

Docetaxel (80mg/4ml

Injection)1

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19

Bold type = Brand name drug Plain type = Generic drug

19

30

19tRACK

30 Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Docetaxel

Docetaxel (80mg/8ml

Injection)1

Doxil

Doxil (Injection) 1

Doxorubicin HCl

Doxorubicin HCl

(Injection)1 B/D, PA

Doxorubicin HCl Liposome

Doxorubicin HCl

Liposome (Injection)1

Ellence

Ellence (Injection) 1

Epirubicin HCl

Epirubicin HCl (Injection) 1

Erwinaze

Erwinaze (Injection) 1

Farydak

Farydak (Capsule) 1 PA Fludarabine Phosphate

Fludarabine Phosphate

(Injection)1

Fusilev

Fusilev (Injection) 1

Halaven

Halaven (Injection) 1 PA Ibrance

Ibrance (Capsule) 1 PA, QL Idamycin PFS

Idamycin PFS

(Injection)1

Idarubicin HCl

Idarubicin HCl (Injection) 1

Irinotecan

Irinotecan (Injection) 1

Istodax

Istodax (Injection) 1 PA Ixempra Kit

Ixempra Kit (Injection) 1

Jevtana

Jevtana (Injection) 1 PA Leucovorin Calcium

Leucovorin Calcium

(100mg Injection, 350mg

Injection)

1

Leucovorin Calcium

Leucovorin Calcium

(10mg Tablet, 15mg

Tablet, 25mg Tablet, 5mg

Tablet)

1

Levoleucovorin Calcium

Levoleucovorin Calcium

(Injection)1

Lynparza

Lynparza (Capsule) 1 PA, QL

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Mesna

Mesna (Injection) 1

Mesnex

Mesnex (400mg Tablet) 1

Mitomycin

Mitomycin (Injection) 1

Mitoxantrone HCl

Mitoxantrone HCl

(Injection)1

Ninlaro

Ninlaro (Capsule) 1 PA, QL Oncaspar

Oncaspar (Injection) 1

Oxaliplatin

Oxaliplatin (Injection) 1

Paclitaxel

Paclitaxel (Injection) 1

Proleukin

Proleukin (Injection) 1 PA Synribo

Synribo (Injection) 1 PA Taxotere

Taxotere (Injection) 1

Thiotepa

Thiotepa (Injection) 1

Trisenox

Trisenox (Injection) 1

Velcade

Velcade (Injection) 1 PA Venclexta

Venclexta (100mg

Tablet)1 PA, QL

Venclexta

Venclexta (10mg

Tablet, 50mg Tablet)1 PA, QL

Venclexta Starting Pack

Venclexta Starting Pack

(Tablet Therapy Pack)1 PA

Vidaza

Vidaza (Injection) 1 PA Vinblastine Sulfate

Vinblastine Sulfate

(Injection)1 B/D, PA

Vincasar PFS

Vincasar PFS (Injection) 1 B/D, PA Vincristine Sulfate

Vincristine Sulfate

(Injection)1 B/D, PA

Vinorelbine Tartrate

Vinorelbine Tartrate

(Injection)1

Zaltrap

Zaltrap (Injection) 1 PA Zinecard

Zinecard (Injection) 1 PA Zolinza

Zolinza (Capsule) 1 PA

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20

You can find information on what the symbols and abbreviations in this table mean by going to page 7.

20

31

20tRACK

31Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Zydelig

Zydelig (Tablet) 1 PA, QL Zykadia

Zykadia (Capsule) 1 PA, QL

Aromatase Inhibitors, 3rd GenerationAnastrozole

Anastrozole (Tablet) 1

Exemestane

Exemestane (Tablet) 1

Letrozole

Letrozole (Tablet) 1

Enzyme InhibitorsEtopophos

Etopophos (Injection) 1

Etoposide

Etoposide (Injection) 1

Hycamtin

Hycamtin (Injection) 1

Toposar

Toposar (Injection) 1

Topotecan HCl

Topotecan HCl (Injection) 1

Molecular Target InhibitorsAfinitor

Afinitor (Tablet) 1 PA Afinitor Disperz

Afinitor Disperz (Tablet

Soluble)1 PA

Bosulif

Bosulif (Tablet) 1 PA Cabometyx

Cabometyx (Tablet) 1 PA, QL Caprelsa

Caprelsa (Tablet) 1 PA, LA Cometriq

Cometriq (Kit) 1 PA Cotellic

Cotellic (Tablet) 1 PA, QL, LA Erivedge

Erivedge (Capsule) 1 PA Gilotrif

Gilotrif (Tablet) 1 PA Iclusig

Iclusig (15mg Tablet) 1 PA, LA Iclusig

Iclusig (45mg Tablet) 1 PA Imatinib Mesylate

Imatinib Mesylate (Tablet) 1 PA Imbruvica

Imbruvica (Capsule) 1 PA Inlyta

Inlyta (Tablet) 1 PA Iressa

Iressa (Tablet) 1 PA, QL Jakafi

Jakafi (Tablet) 1 PA, LA

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Lenvima

Lenvima (Capsule

Therapy Pack)1 PA

Mekinist

Mekinist (Tablet) 1 PA Nexavar

Nexavar (Tablet) 1 PA Odomzo

Odomzo (Capsule) 1 PA, QL, LA Sprycel

Sprycel (Tablet) 1 PA Stivarga

Stivarga (Tablet) 1 PA Sutent

Sutent (Capsule) 1 PA Tafinlar

Tafinlar (Capsule) 1 PA Tarceva

Tarceva (Tablet) 1 PA Tasigna

Tasigna (Capsule) 1 PA Tykerb

Tykerb (Tablet) 1 PA Votrient

Votrient (Tablet) 1 PA Xalkori

Xalkori (Capsule) 1 PA, LA Zelboraf

Zelboraf (Tablet) 1 PA

Monoclonal AntibodiesAvastin

Avastin (Injection) 1 PA Cyramza

Cyramza (Injection) 1 PA Darzalex

Darzalex (Injection) 1 PA, LA Empliciti

Empliciti (Injection) 1 PA Erbitux

Erbitux (Injection) 1 PA Herceptin

Herceptin (Injection) 1 PA Kadcyla

Kadcyla (Injection) 1 PA Keytruda

Keytruda (Injection) 1 PA Opdivo

Opdivo (Injection) 1 PA Perjeta

Perjeta (Injection) 1 PA Rituxan

Rituxan (Injection) 1 PA Sylvant

Sylvant (Injection) 1 PA Tagrisso

Tagrisso (Tablet) 1 PA, QL, LA Tecentriq

Tecentriq (Injection) 1 PA

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32

21tRACK

32 Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Vectibix

Vectibix (Injection) 1 PA Yervoy

Yervoy (Injection) 1 PA

RetinoidsBexarotene

Bexarotene (Capsule) 1 PA Panretin

Panretin (Gel) 1 PA Targretin

Targretin (1% Gel,

75mg Capsule)1 PA

Tretinoin

Tretinoin (10mg Capsule) 1

Antiparasitics

AnthelminticsAlbenza

Albenza (Tablet) 1

Biltricide

Biltricide (Tablet) 1

Ivermectin

Ivermectin (Tablet) 1

AntiprotozoalsAlinia

Alinia (100mg/5ml

Suspension, 500mg

Tablet)

1

Atovaquone

Atovaquone (Suspension) 1

Atovaquone/Proguanil HCl

Atovaquone/Proguanil

HCl (Tablet) (Generic

Malarone)

1

Chloroquine Phosphate

Chloroquine Phosphate

(Tablet)1

Coartem

Coartem (Tablet) 1

DARAPRIM

DARAPRIM (Tablet) 1

Hydroxychloroquine Sulfate

Hydroxychloroquine

Sulfate (Tablet)1

Mefloquine HCl

Mefloquine HCl (Tablet) 1

Mepron

Mepron (Suspension) 1

Nebupent

Nebupent (Inhalation

Solution)1 B/D, PA

Pentam 300

Pentam 300 (Injection) 1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Primaquine Phosphate

Primaquine Phosphate

(Tablet)1

Quinine Sulfate

Quinine Sulfate (Capsule) 1 PA

Pediculicides/ScabicidesEurax

Eurax (10% Cream, 10%

Lotion)1

Lindane

Lindane (Shampoo) 1

Malathion

Malathion (Lotion) 1

Permethrin

Permethrin (Cream) 1

Antiparkinson Agents

AnticholinergicsBenztropine Mesylate

Benztropine Mesylate

(0.5mg Tablet, 1mg

Tablet, 2mg Tablet)

1

Benztropine Mesylate

Benztropine Mesylate

(1mg/ml Injection)1

Trihexyphenidyl HCl

Trihexyphenidyl HCl

(0.4mg/ml Elixir, 2mg

Tablet, 5mg Tablet)

1

Antiparkinson Agents, OtherAmantadine HCl

Amantadine HCl (100mg

Capsule, 100mg Tablet,

50mg/5ml Syrup)

1

Entacapone

Entacapone (Tablet) 1

Tasmar

Tasmar (Tablet) 1

Tolcapone

Tolcapone (Tablet) 1

Dopamine AgonistsApokyn

Apokyn (Injection) 1 PA Bromocriptine Mesylate

Bromocriptine Mesylate

(2.5mg Tablet, 5mg

Capsule)

1

Pramipexole Dihydrochloride

Pramipexole

Dihydrochloride (Tablet

Immediate-Release)

1

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You can find information on what the symbols and abbreviations in this table mean by going to page 7.

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33

22tRACK

33Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Ropinirole HCl

Ropinirole HCl (Tablet

Immediate-Release)1

Dopamine Precursors/L-Amino Acid

Decarboxylase InhibitorsCarbidopa

Carbidopa (Tablet) 1

Carbidopa/Levodopa

Carbidopa/Levodopa

(Tablet Immediate-

Release)

1

Carbidopa/Levodopa ER

Carbidopa/Levodopa ER

(Tablet Extended-Release)1

Carbidopa/Levodopa ODT

Carbidopa/Levodopa

ODT (Tablet Dispersible)1

Carbidopa/Levodopa/Entacapone

Carbidopa/Levodopa/

Entacapone (Tablet)1

Monoamine Oxidase B (MAO-B) InhibitorsAzilect

Azilect (Tablet) 1

Selegiline HCl

Selegiline HCl (5mg

Capsule, 5mg Tablet)1

Zelapar

Zelapar (Tablet

Dispersible)1

Antipsychotics

1st Generation/TypicalChlorpromazine HCl

Chlorpromazine HCl

(100mg Tablet, 10mg

Tablet, 200mg Tablet,

25mg Tablet, 50mg

Tablet, 50mg/2ml

Injection)

1

Fluphenazine Decanoate

Fluphenazine Decanoate

(Injection)1

Fluphenazine HCl

Fluphenazine HCl (10mg

Tablet, 1mg Tablet, 2.5mg

Tablet, 5mg Tablet)

1

Fluphenazine HCl

Fluphenazine HCl

(2.5mg/5ml Elixir, 5mg/ml

Concentrate)

1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Fluphenazine HCl

Fluphenazine HCl

(2.5mg/ml Injection)1

Haloperidol

Haloperidol (0.5mg

Tablet, 10mg Tablet, 1mg

Tablet, 20mg Tablet, 2mg

Tablet, 5mg Tablet, 2mg/

ml Concentrate)

1

Haloperidol Decanoate

Haloperidol Decanoate

(Injection)1

Haloperidol Lactate

Haloperidol Lactate

(Injection)1

Loxapine Succinate

Loxapine Succinate

(10mg Capsule, 5mg

Capsule)

1 QL

Loxapine Succinate

Loxapine Succinate

(25mg Capsule, 50mg

Capsule)

1

Molindone HCl

Molindone HCl (Tablet) 1

Orap

Orap (Tablet) 1

Pimozide

Pimozide (Tablet) 1

Thioridazine HCl

Thioridazine HCl (Tablet) 1

Thiothixene

Thiothixene (Capsule) 1

Trifluoperazine HCl

Trifluoperazine HCl

(Tablet)1

2nd Generation/AtypicalAbilify Maintena

Abilify Maintena

(Injection)1

Aripiprazole

Aripiprazole (10mg Tablet,

15mg Tablet, 2mg Tablet,

5mg Tablet)

1 QL

Aripiprazole

Aripiprazole (20mg Tablet,

30mg Tablet)1 QL

Aripiprazole ODT

Aripiprazole ODT (Tablet

Dispersible)1 QL

Aristada

Aristada (Injection) 1

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34

23tRACK

34 Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Fanapt

Fanapt (10mg Tablet,

12mg Tablet, 6mg

Tablet, 8mg Tablet)

1 QL, ST

Fanapt

Fanapt (1mg Tablet,

2mg Tablet, 4mg

Tablet)

1 QL, ST

Fanapt Titration Pack

Fanapt Titration Pack

(Tablet)1 ST

Geodon

Geodon (20mg

Injection)1

Invega

Invega (Tablet

Extended-Release 24

Hour)

1 QL

Invega Sustenna

Invega Sustenna

(117mg/0.75ml

Injection, 156mg/ml

Injection, 234mg/1.5ml

Injection, 78mg/0.5ml

Injection)

1

Invega Sustenna

Invega Sustenna

(39mg/0.25ml

Injection)

1

Invega Trinza

Invega Trinza (Injection) 1 PA Latuda

Latuda (Tablet) 1 QL Nuplazid

Nuplazid (Tablet) 1 PA, QL Olanzapine

Olanzapine (10mg

Injection)1

Olanzapine

Olanzapine (10mg Tablet

Immediate-Release, 15mg

Tablet Immediate-

Release, 2.5mg Tablet

Immediate-Release, 20mg

Tablet Immediate-

Release, 5mg Tablet

Immediate-Release,

7.5mg Tablet Immediate-

Release)

1 QL

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Olanzapine ODT

Olanzapine ODT (Tablet

Dispersible)1 QL

Paliperidone ER

Paliperidone ER (Tablet

Extended-Release 24

Hour)

1 QL

Quetiapine Fumarate

Quetiapine Fumarate

(Tablet Immediate-

Release)

1 QL

Rexulti

Rexulti (Tablet) 1 QL Risperdal Consta

Risperdal Consta

(12.5mg Injection,

25mg Injection)

1

Risperdal Consta

Risperdal Consta

(37.5mg Injection,

50mg Injection)

1

Risperidone

Risperidone (Tablet

Immediate-Release)1

Risperidone

Risperidone (1mg/ml Oral

Solution)1

Risperidone ODT

Risperidone ODT (Tablet

Dispersible)1

Saphris

Saphris (Tablet

Sublingual)1 QL

Seroquel XR

Seroquel XR (Tablet

Extended-Release 24

Hour)

1 QL

Vraylar

Vraylar (1.5mg Capsule,

3mg Capsule, 4.5mg

Capsule, 6mg Capsule)

1 QL, ST

Vraylar

Vraylar (Capsule

Therapy Pack)1 ST

Ziprasidone HCl

Ziprasidone HCl

(Capsule)1 QL

Zyprexa Relprevv

Zyprexa Relprevv

(Injection)1

Treatment-Resistant

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You can find information on what the symbols and abbreviations in this table mean by going to page 7.

24

35

24tRACK

35Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Clozapine

Clozapine (Tablet

Immediate-Release)1

Clozapine ODT

Clozapine ODT (100mg

Tablet Dispersible,

12.5mg Tablet

Dispersible, 150mg

Tablet Dispersible,

25mg Tablet

Dispersible)

1 QL

Clozapine ODT

Clozapine ODT (200mg

Tablet Dispersible)1 QL

Fazaclo

Fazaclo (100mg Tablet

Dispersible, 150mg

Tablet Dispersible,

200mg Tablet

Dispersible)

1 QL

Versacloz

Versacloz (Suspension) 1

Antivirals

Anti-cytomegalovirus (CMV) AgentsCidofovir

Cidofovir (Injection) 1

Ganciclovir

Ganciclovir (Injection) 1 B/D, PA Valcyte

Valcyte (450mg Tablet,

50mg/ml Oral Solution)1

Valganciclovir

Valganciclovir (Tablet) 1

Zirgan

Zirgan (Gel) 1

Anti-hepatitis B (HBV) AgentsAdefovir Dipivoxil

Adefovir Dipivoxil (Tablet) 1

Baraclude

Baraclude (0.05mg/ml

Oral Solution, 0.5mg

Tablet, 1mg Tablet)

1

Entecavir

Entecavir (Tablet) 1

Epivir HBV

Epivir HBV (5mg/ml

Oral Solution)1

Hepsera

Hepsera (Tablet) 1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Lamivudine

Lamivudine (100mg

Tablet)1

Tyzeka

Tyzeka (Tablet) 1

Anti-hepatitis C (HCV) AgentsDaklinza

Daklinza (Tablet) 1 PA, QL Epclusa

Epclusa (Tablet) 1 PA, QL Harvoni

Harvoni (Tablet) 1 PA, QL Intron A

Intron A (Injection) 1 PA Intron A w/Diluent

Intron A w/Diluent

(Injection)1 PA

Olysio

Olysio (Capsule) 1 PA, QL Pegasys

Pegasys (Injection) 1 PA Pegasys ProClick

Pegasys ProClick

(Injection)1 PA

PegIntron

PegIntron (Injection) 1 PA PegIntron REDIPEN

PegIntron REDIPEN

(Injection)1 PA

Ribasphere

Ribasphere (200mg

Capsule)1

Ribasphere

Ribasphere (200mg

Tablet, 400mg Tablet)1

Ribasphere

Ribasphere (600mg

Tablet)1

Ribavirin

Ribavirin (200mg

Capsule)1

Ribavirin

Ribavirin (200mg Tablet) 1

Sovaldi

Sovaldi (Tablet) 1 PA, QL Sylatron

Sylatron (Injection) 1 PA Zepatier

Zepatier (Tablet) 1 PA, QL

Antiherpetic AgentsAcyclovir

Acyclovir (200mg

Capsule, 200mg/5ml

Suspension)

1

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36

25tRACK

36 Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Acyclovir

Acyclovir (400mg Tablet,

800mg Tablet)1

Acyclovir

Acyclovir (5% Ointment) 1 QL Acyclovir Sodium

Acyclovir Sodium

(Injection)1 B/D, PA

Denavir

Denavir (Cream) 1 QL Famciclovir

Famciclovir (Tablet) 1 QL Trifluridine

Trifluridine (Ophthalmic

Solution)1

Valacyclovir HCl

Valacyclovir HCl (Tablet) 1 QL Zovirax

Zovirax (5% Cream) 1 QL Zovirax

Zovirax (5% Ointment) 1 QL

Anti-HIV Agents, Integrase Inhibitors

(INSTI) Evotaz

Evotaz (Tablet) 1 QL Genvoya

Genvoya (Tablet) 1 QL Isentress

Isentress (100mg

Packet, 100mg Tablet

Chewable, 400mg

Tablet)

1 QL

Isentress

Isentress (25mg Tablet

Chewable)1 QL

Prezcobix

Prezcobix (Tablet) 1 QL Stribild

Stribild (Tablet) 1 QL Tivicay

Tivicay (25mg Tablet,

50mg Tablet)1 QL

Triumeq

Triumeq (Tablet) 1 QL Tybost

Tybost (Tablet) 1 QL Vitekta

Vitekta (Tablet) 1 QL

Anti-HIV Agents, Non-nucleoside Reverse

Transcriptase Inhibitors (NNRTI)Atripla

Atripla (Tablet) 1 QL Complera

Complera (Tablet) 1 QL

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Edurant

Edurant (Tablet) 1 QL Intelence

Intelence (100mg

Tablet, 200mg Tablet)1 QL

Intelence

Intelence (25mg Tablet) 1 QL Nevirapine

Nevirapine (200mg Tablet

Immediate-Release)1 QL

Nevirapine

Nevirapine (50mg/5ml

Suspension)1 QL

Nevirapine ER

Nevirapine ER (Tablet

Extended-Release 24

Hour)

1 QL

Odefsey

Odefsey (Tablet) 1 QL Rescriptor

Rescriptor (Tablet) 1 QL Sustiva

Sustiva (200mg

Capsule, 600mg Tablet)1 QL

Sustiva

Sustiva (50mg Capsule) 1 QL Viramune

Viramune (50mg/5ml

Suspension)1 QL

Viramune XR

Viramune XR (100mg

Tablet Extended-

Release 24 Hour)

1 QL

Viramune XR

Viramune XR (400mg

Tablet Extended-

Release 24 Hour)

1 QL

Anti-HIV Agents, Nucleoside and

Nucleotide Reverse Transcriptase

Inhibitors (NRTI)Abacavir

Abacavir (Tablet) 1 QL Abacavir Sulfate/Lamivudine/Zidovudine

Abacavir Sulfate/

Lamivudine/Zidovudine

(Tablet)

1 QL

Combivir

Combivir (Tablet) 1 QL Descovy

Descovy (Tablet) 1 QL Didanosine

Didanosine (Capsule

Delayed-Release)1 QL

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26

You can find information on what the symbols and abbreviations in this table mean by going to page 7.

26

37

26tRACK

37Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Emtriva

Emtriva (10mg/ml Oral

Solution, 200mg

Capsule)

1 QL

Epivir

Epivir (10mg/ml Oral

Solution)1 QL

Epzicom

Epzicom (Tablet) 1 QL Lamivudine

Lamivudine (10mg/ml

Oral Solution, 150mg

Tablet, 300mg Tablet)

1 QL

Lamivudine/Zidovudine

Lamivudine/Zidovudine

(Tablet)1 QL

Retrovir IV Infusion

Retrovir IV Infusion

(Injection)1

Stavudine

Stavudine (15mg

Capsule, 20mg Capsule,

30mg Capsule, 40mg

Capsule, 1mg/ml Oral

Solution)

1 QL

Trizivir

Trizivir (Tablet) 1 QL Truvada

Truvada (Tablet) 1 QL Videx Pediatric

Videx Pediatric (Oral

Solution)1 QL

Viread

Viread (150mg Tablet,

200mg Tablet, 250mg

Tablet, 300mg Tablet,

40mg/gm Powder)

1 QL

Ziagen

Ziagen (20mg/ml Oral

Solution)1 QL

Zidovudine

Zidovudine (100mg

Capsule, 300mg Tablet,

50mg/5ml Syrup)

1 QL

Anti-HIV Agents, OtherFuzeon

Fuzeon (Injection) 1 QL Selzentry

Selzentry (Tablet) 1 QL Tivicay

Tivicay (10mg Tablet) 1 QL

Anti-HIV Agents, Protease Inhibitors

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Aptivus

Aptivus (100mg/ml Oral

Solution, 250mg

Capsule)

1 QL

Crixivan

Crixivan (Capsule) 1 QL Invirase

Invirase (200mg

Capsule, 500mg Tablet)1 QL

Kaletra

Kaletra (100mg-25mg

Tablet)1 QL

Kaletra

Kaletra (200mg-50mg

Tablet, 400mg-100mg/

5ml Oral Solution)

1 QL

Lexiva

Lexiva (50mg/ml

Suspension)1 QL

Lexiva

Lexiva (700mg Tablet) 1 QL Norvir

Norvir (100mg Capsule,

100mg Tablet, 80mg/

ml Oral Solution)

1 QL

Prezista

Prezista (100mg/ml

Suspension, 150mg

Tablet, 600mg Tablet,

800mg Tablet)

1 QL

Prezista

Prezista (75mg Tablet) 1 QL Reyataz

Reyataz (150mg

Capsule, 200mg

Capsule, 300mg

Capsule, 50mg Packet)

1 QL

Viracept

Viracept (Tablet) 1 QL

Anti-influenza AgentsRelenza Diskhaler

Relenza Diskhaler

(Aerosol Powder)1 QL

Rimantadine HCl

Rimantadine HCl (Tablet) 1

Tamiflu

Tamiflu (30mg Capsule,

45mg Capsule, 75mg

Capsule, 6mg/ml

Suspension)

1 QL

Antivirals

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38

27tRACK

38 Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Virazole

Virazole (Inhalation

Solution)1

Anxiolytics

Anxiolytics, OtherBuspirone HCl

Buspirone HCl (Tablet) 1

Hydroxyzine HCl

Hydroxyzine HCl (10mg

Tablet, 25mg Tablet,

50mg Tablet, 10mg/5ml

Syrup)

1

Hydroxyzine HCl

Hydroxyzine HCl (25mg/

ml Injection, 50mg/ml

Injection)

1

Benzodiazepines Alprazolam

Alprazolam (Tablet

Immediate-Release)1 QL

Chlordiazepoxide HCl

Chlordiazepoxide HCl

(Capsule)1

Clonazepam

Clonazepam (Tablet

Immediate-Release)1 QL

Clonazepam ODT

Clonazepam ODT (Tablet

Dispersible)1 QL

Clorazepate Dipotassium

Clorazepate Dipotassium

(Tablet)1 QL

Diazepam

Diazepam (10mg Tablet,

2mg Tablet, 5mg Tablet)1 QL

Diazepam

Diazepam (1mg/ml Oral

Solution)1

Diazepam Intensol

Diazepam Intensol (5mg/

ml Concentrate)1 QL

Lorazepam

Lorazepam (Tablet) 1 QL Lorazepam Intensol

Lorazepam Intensol

(2mg/ml Concentrate)1 QL

Bipolar Agents

Mood Stabilizers

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Equetro

Equetro (Capsule

Extended-Release 12

Hour)

1

Lithium

Lithium (Oral Solution) 1

Lithium Carbonate

Lithium Carbonate

(150mg Capsule

Immediate-Release,

300mg Capsule

Immediate-Release,

600mg Capsule

Immediate-Release,

300mg Tablet Immediate-

Release)

1

Lithium Carbonate ER

Lithium Carbonate ER

(Tablet Extended-Release)1

Blood Glucose Regulators

Antidiabetic AgentsAcarbose

Acarbose (Tablet) 1 QL Avandia

Avandia (Tablet) 1 PA, QL Bydureon Vial

Bydureon Vial

(Injection)1 QL

Bydureon Pen

Bydureon Pen

(Injection)1 QL

Byetta

Byetta (Injection) 1 QL Cycloset

Cycloset (Tablet) 1 PA, QL Glimepiride

Glimepiride (Tablet) 1 QL Glipizide

Glipizide (Tablet

Immediate-Release)1 QL

Glipizide ER

Glipizide ER (Tablet

Extended-Release 24

Hour)

1 QL

Glipizide/Metformin HCl

Glipizide/Metformin HCl

(Tablet)1 QL

Glyset

Glyset (Tablet) 1 QL Invokamet

Invokamet (Tablet) 1 QL

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28

You can find information on what the symbols and abbreviations in this table mean by going to page 7.

28

39

28tRACK

39Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Invokana

Invokana (Tablet) 1 QL Janumet

Janumet (Tablet

Immediate-Release)1 QL

Janumet XR

Janumet XR (Tablet

Extended-Release 24

Hour)

1 QL

Januvia

Januvia (Tablet) 1 QL Jardiance

Jardiance (Tablet) 1 QL Jentadueto

Jentadueto (Tablet) 1 QL Jentadueto XR

Jentadueto XR (Tablet

Extended-Release 24

Hour)

1 QL

Kazano

Kazano (Tablet) 1 QL Kombiglyze XR

Kombiglyze XR (Tablet

Extended-Release 24

Hour)

1 QL

Metformin HCl

Metformin HCl (Tablet

Immediate-Release)1 QL

Metformin HCl ER

Metformin HCl ER

(1000mg Tablet

Extended-Release 24

Hour) (Generic Fortamet),

(500mg Tablet Extended-

Release 24 Hour, 750mg

Tablet Extended-Release

24 Hour) (Generic

Glucophage XR)

1 QL

Miglitol

Miglitol (Tablet) 1 QL Nateglinide

Nateglinide (Tablet) 1 QL Nesina

Nesina (Tablet) 1 QL Onglyza

Onglyza (Tablet) 1 QL Oseni

Oseni (Tablet) 1 QL Pioglitazone HCl

Pioglitazone HCl (Tablet) 1 QL Pioglitazone HCl/Glimepiride

Pioglitazone HCl/

Glimepiride (Tablet)1 QL

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Pioglitazone HCl/Metformin HCl

Pioglitazone HCl/

Metformin HCl (Tablet)1 QL

Repaglinide

Repaglinide (Tablet) 1 QL Repaglinide/Metformin HCl

Repaglinide/Metformin

HCl (Tablet)1 QL

Riomet

Riomet (Oral Solution) 1 QL SymlinPen 120

SymlinPen 120

(Injection)1 PA

SymlinPen 60

SymlinPen 60

(Injection)1 PA

Synjardy

Synjardy (Tablet) 1 QL Tradjenta

Tradjenta (Tablet) 1 QL Trulicity

Trulicity (Injection) 1 QL Victoza

Victoza (Injection) 1 QL

Glycemic AgentsGlucaGen HypoKit

GlucaGen HypoKit

(Injection)1

Glucagon Emergency Kit

Glucagon Emergency

Kit (Injection)1

Proglycem

Proglycem

(Suspension)1

InsulinsHumalog Cartridge

Humalog Cartridge

(Injection)1

Humalog KwikPen

Humalog KwikPen

(Injection)1

Humalog Mix 50/50 KwikPen

Humalog Mix 50/50

KwikPen (Injection)1

Humalog Mix 50/50 Vial

Humalog Mix 50/50 Vial

(Injection)1

Humalog Mix 75/25 KwikPen

Humalog Mix 75/25

KwikPen (Injection)1

Humalog Mix 75/25 Vial

Humalog Mix 75/25 Vial

(Injection)1

Humalog Vial

Humalog Vial (Injection) 1

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29tRACK

40 Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Humulin 70/30 KwikPen

Humulin 70/30

KwikPen (Injection)1

Humulin 70/30 Vial

Humulin 70/30 Vial

(Injection)1

Humulin N KwikPen

Humulin N KwikPen

(Injection)1

Humulin N Vial

Humulin N Vial

(Injection)1

Humulin R U-500 KwikPen

Humulin R U-500

KwikPen (Injection)1

Humulin R U-500 Vial

Humulin R U-500 Vial

(Concentrated)

(Injection)

1

Humulin R Vial

Humulin R Vial

(Injection)1

Lantus SoloStar

Lantus SoloStar

(Injection)1

Lantus Vial

Lantus Vial (Injection) 1

Levemir FlexTouch

Levemir FlexTouch

(Injection)1

Levemir Vial

Levemir Vial (Injection) 1

Toujeo SoloStar

Toujeo SoloStar

(Injection)1

Blood Products/Modifiers/Volume Expanders

AnticoagulantsCoumadin

Coumadin (Tablet) 1

Eliquis

Eliquis (Tablet) 1 PA, QL Enoxaparin Sodium

Enoxaparin Sodium

(100mg/ml Injection,

120mg/0.8ml Injection,

150mg/ml Injection)

1 QL

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Enoxaparin Sodium

Enoxaparin Sodium

(300mg/3ml Injection,

30mg/0.3ml Injection,

40mg/0.4ml Injection,

60mg/0.6ml Injection,

80mg/0.8ml Injection)

1 QL

Fondaparinux Sodium

Fondaparinux Sodium

(10mg/0.8ml Injection,

5mg/0.4ml Injection,

7.5mg/0.6ml Injection)

1

Fondaparinux Sodium

Fondaparinux Sodium

(2.5mg/0.5ml Injection)1

Heparin Sodium

Heparin Sodium

(10000unit/ml Injection,

20000unit/ml Injection,

5000unit/ml Injection)

1

Heparin Sodium

Heparin Sodium

(1000unit/ml Injection)1 B/D, PA

Heparin Sodium/D5W

Heparin Sodium/D5W

(Injection)1

Jantoven

Jantoven (Tablet) 1

Pradaxa

Pradaxa (Capsule) 1 PA, QL Warfarin Sodium

Warfarin Sodium (Tablet) 1

Xarelto

Xarelto (Tablet) 1 PA, QL Xarelto Starter Pack

Xarelto Starter Pack

(Tablet Therapy Pack)1 PA, QL

Blood Formation ModifiersAnagrelide HCl

Anagrelide HCl (Capsule) 1

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You can find information on what the symbols and abbreviations in this table mean by going to page 7.

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41

30tRACK

41Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Aranesp Albumin Free

Aranesp Albumin Free

(100mcg/0.5ml

Injection, 100mcg/ml

Injection, 150mcg/

0.3ml Injection,

200mcg/0.4ml

Injection, 200mcg/ml

Injection, 300mcg/

0.6ml Injection,

300mcg/ml Injection,

500mcg/ml Injection,

60mcg/0.3ml Injection,

60mcg/ml Injection)

1 PA

Aranesp Albumin Free

Aranesp Albumin Free

(10mcg/0.4ml Injection,

25mcg/0.42ml

Injection, 25mcg/ml

Injection, 40mcg/0.4ml

Injection, 40mcg/ml

Injection)

1 PA

Granix

Granix (Injection) 1 PA Leukine

Leukine (Injection) 1 PA Mozobil

Mozobil (Injection) 1 PA Neulasta

Neulasta (Injection) 1 PA Neupogen

Neupogen (Injection) 1 PA Procrit

Procrit (10000unit/ml

Injection, 2000unit/ml

Injection, 3000unit/ml

Injection, 4000unit/ml

Injection)

1 PA

Procrit

Procrit (20000unit/ml

Injection, 40000unit/ml

Injection)

1 PA

Promacta

Promacta (Tablet) 1 PA Zarxio

Zarxio (Injection) 1

Blood Products/Modifiers/Volume

Expanders

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Argatroban

Argatroban (Injection) 1 B/D, PA

CoagulantsTranexamic Acid

Tranexamic Acid

(1000mg/10ml Injection,

650mg Tablet)

1

Platelet Modifying AgentsAggrenox

Aggrenox (Capsule

Extended-Release 12

Hour)

1 QL

Aspirin/Dipyridamole

Aspirin/Dipyridamole

(Capsule Extended-

Release 12 Hour)

1 QL

Brilinta

Brilinta (Tablet) 1 QL Cilostazol

Cilostazol (Tablet) 1

Clopidogrel

Clopidogrel (75mg Tablet) 1 QL Effient

Effient (Tablet) 1 QL

Cardiovascular Agents

Alpha-adrenergic AgonistsClonidine HCl

Clonidine HCl (0.1mg

Tablet Immediate-

Release, 0.2mg Tablet

Immediate-Release,

0.3mg Tablet Immediate-

Release)

1

Clonidine HCl

Clonidine HCl (0.1mg/

24hr Patch Weekly,

0.2mg/24hr Patch

Weekly, 0.3mg/24hr

Patch Weekly)

1

Methyldopa

Methyldopa (Tablet) 1

Methyldopate HCl

Methyldopate HCl

(Injection)1

Midodrine HCl

Midodrine HCl (Tablet) 1

Alpha-adrenergic Blocking AgentsDibenzyline

Dibenzyline (Capsule) 1

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42

31tRACK

42 Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Doxazosin Mesylate

Doxazosin Mesylate

(Tablet)1

Phenoxybenzamine HCl

Phenoxybenzamine HCl

(Capsule)1

Prazosin HCl

Prazosin HCl (Capsule) 1

Angiotensin II Receptor AntagonistsBenicar

Benicar (Tablet) 1 QL Candesartan Cilexetil

Candesartan Cilexetil

(Tablet)1 QL

Edarbi

Edarbi (Tablet) 1 QL Eprosartan Mesylate

Eprosartan Mesylate

(Tablet)1 QL

Irbesartan

Irbesartan (Tablet) 1 QL Losartan Potassium

Losartan Potassium

(Tablet)1 QL

Telmisartan

Telmisartan (Tablet) 1 QL Valsartan

Valsartan (Tablet) 1 QL

Angiotensin-converting Enzyme (ACE)

InhibitorsBenazepril HCl

Benazepril HCl (Tablet) 1 QL Captopril

Captopril (Tablet) 1 QL Enalapril Maleate

Enalapril Maleate (Tablet) 1 QL Epaned

Epaned (Oral Solution) 1

Fosinopril Sodium

Fosinopril Sodium (Tablet) 1 QL Lisinopril

Lisinopril (Tablet) 1 QL Moexipril HCl

Moexipril HCl (Tablet) 1 QL Perindopril Erbumine

Perindopril Erbumine

(Tablet)1 QL

Quinapril HCl

Quinapril HCl (Tablet) 1 QL Ramipril

Ramipril (Capsule) 1 QL Trandolapril

Trandolapril (Tablet) 1 QL

Antiarrhythmics

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Amiodarone HCl

Amiodarone HCl (200mg

Tablet)1

Amiodarone HCl

Amiodarone HCl (50mg/

ml Injection)1

Dofetilide

Dofetilide (Capsule) 1

Flecainide Acetate

Flecainide Acetate

(Tablet)1

Mexiletine HCl

Mexiletine HCl (Capsule) 1

Multaq

Multaq (Tablet) 1 QL Pacerone

Pacerone (200mg Tablet) 1

Procainamide HCl

Procainamide HCl

(Injection)1

Propafenone HCl

Propafenone HCl (Tablet) 1

Propafenone HCl ER

Propafenone HCl ER

(Capsule Extended-

Release 12 Hour)

1

Quinidine Gluconate

Quinidine Gluconate

(Injection)1

Quinidine Gluconate CR

Quinidine Gluconate CR

(Tablet Extended-Release)1

Quinidine Sulfate

Quinidine Sulfate (Tablet) 1

Sotalol HCl

Sotalol HCl (AF) (Tablet) 1

Sotalol HCl

Sotalol HCl (Tablet) 1

Tikosyn

Tikosyn (Capsule) 1

Beta-adrenergic Blocking AgentsAcebutolol HCl

Acebutolol HCl (Capsule) 1

Atenolol

Atenolol (Tablet) 1

Betaxolol HCl

Betaxolol HCl (10mg

Tablet, 20mg Tablet)1

Bisoprolol Fumarate

Bisoprolol Fumarate

(Tablet)1

Bystolic

Bystolic (Tablet) 1 QL Carvedilol

Carvedilol (Tablet

Immediate-Release)1

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You can find information on what the symbols and abbreviations in this table mean by going to page 7.

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43

32tRACK

43Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Labetalol HCl

Labetalol HCl (100mg

Tablet, 200mg Tablet,

300mg Tablet)

1

Labetalol HCl

Labetalol HCl (5mg/ml

Injection)1

Metoprolol Succinate ER

Metoprolol Succinate ER

(Tablet Extended-Release

24 Hour)

1

Metoprolol Tartrate

Metoprolol Tartrate

(100mg Tablet

Immediate-Release, 25mg

Tablet Immediate-

Release, 50mg Tablet

Immediate-Release)

1

Metoprolol Tartrate

Metoprolol Tartrate (1mg/

ml Injection)1

Nadolol

Nadolol (Tablet) 1

Pindolol

Pindolol (Tablet) 1

Propranolol HCl

Propranolol HCl (10mg

Tablet Immediate-

Release, 20mg Tablet

Immediate-Release, 40mg

Tablet Immediate-

Release, 60mg Tablet

Immediate-Release, 80mg

Tablet Immediate-

Release, 20mg/5ml Oral

Solution, 40mg/5ml Oral

Solution)

1

Propranolol HCl

Propranolol HCl (1mg/ml

Injection)1

Propranolol HCl ER

Propranolol HCl ER

(Capsule Extended-

Release 24 Hour)

1

Timolol Maleate

Timolol Maleate (10mg

Tablet, 20mg Tablet, 5mg

Tablet)

1

Calcium Channel Blocking Agents

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Afeditab CR

Afeditab CR (Tablet

Extended-Release 24

Hour)

1 QL

Amlodipine Besylate

Amlodipine Besylate

(Tablet)1

Cardene IV

Cardene IV (Injection) 1

Cartia XT

Cartia XT (Capsule

Extended-Release 24

Hour)

1

Diltiazem CD

Diltiazem CD (Capsule

Extended-Release 24

Hour)

1

Diltiazem HCl

Diltiazem HCl (100mg

Injection, 50mg/10ml

Injection)

1

Diltiazem HCl

Diltiazem HCl (Tablet

Immediate-Release)1

Diltiazem HCl ER

Diltiazem HCl ER

(Capsule Extended-

Release)

1

Dilt-XR

Dilt-XR (Capsule

Extended-Release 24

Hour)

1

Felodipine ER

Felodipine ER (Tablet

Extended-Release 24

Hour)

1

Matzim LA

Matzim LA (180mg Tablet

Extended-Release 24

Hour, 240mg Tablet

Extended-Release 24

Hour, 300mg Tablet

Extended-Release 24

Hour)

1

Matzim LA

Matzim LA (360mg Tablet

Extended-Release 24

Hour, 420mg Tablet

Extended-Release 24

Hour)

1 QL

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44

33tRACK

44 Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Nicardipine HCl

Nicardipine HCl (2.5mg/

ml Injection)1

Nicardipine HCl

Nicardipine HCl (20mg

Capsule, 30mg Capsule)1

Nifedical XL

Nifedical XL (Tablet

Extended-Release 24

Hour)

1 QL

Nifedipine ER

Nifedipine ER (Tablet

Extended-Release 24

Hour)

1 QL

Nimodipine

Nimodipine (Capsule) 1

Taztia XT

Taztia XT (Capsule

Extended-Release 24

Hour)

1

Verapamil HCl

Verapamil HCl (120mg

Tablet Immediate-

Release, 40mg Tablet

Immediate-Release, 80mg

Tablet Immediate-

Release)

1

Verapamil HCl

Verapamil HCl (2.5mg/ml

Injection)1

Verapamil HCl ER

Verapamil HCl ER

(100mg Capsule

Extended-Release 24

Hour, 120mg Capsule

Extended-Release 24

Hour, 180mg Capsule

Extended-Release 24

Hour, 200mg Capsule

Extended-Release 24

Hour, 240mg Capsule

Extended-Release 24

Hour, 300mg Capsule

Extended-Release 24

Hour)

1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Verapamil HCl ER

Verapamil HCl ER

(120mg Tablet Extended-

Release, 180mg Tablet

Extended-Release,

240mg Tablet Extended-

Release)

1

Verapamil HCl SR

Verapamil HCl SR

(Capsule Extended-

Release 24 Hour)

1

Cardiovascular Agents, OtherAmiloride/Hydrochlorothiazide

Amiloride/

Hydrochlorothiazide

(Tablet)

1

Amlodipine Besylate/Atorvastatin Calcium

Amlodipine Besylate/

Atorvastatin Calcium

(Tablet)

1 QL

Amlodipine Besylate/Benazepril HCl

Amlodipine Besylate/

Benazepril HCl (Capsule)1 QL

Amlodipine Besylate/Valsartan

Amlodipine Besylate/

Valsartan (Tablet)1 QL

Amlodipine/Valsartan/Hydrochlorothiazide

Amlodipine/Valsartan/

Hydrochlorothiazide

(Tablet)

1 QL

Atenolol/Chlorthalidone

Atenolol/Chlorthalidone

(Tablet)1

Azor

Azor (Tablet) 1 QL Benazepril HCl/Hydrochlorothiazide

Benazepril HCl/

Hydrochlorothiazide

(Tablet)

1 QL

Benicar HCT

Benicar HCT (Tablet) 1 QL BiDil

BiDil (Tablet) 1 QL Bisoprolol Fumarate/Hydrochlorothiazide

Bisoprolol Fumarate/

Hydrochlorothiazide

(Tablet)

1 QL

Candesartan Cilexetil/Hydrochlorothiazide

Candesartan Cilexetil/

Hydrochlorothiazide

(Tablet)

1 QL

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You can find information on what the symbols and abbreviations in this table mean by going to page 7.

34

45

34tRACK

45Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Captopril/Hydrochlorothiazide

Captopril/

Hydrochlorothiazide

(Tablet)

1 QL

Clorpres

Clorpres (Tablet) 1

Demser

Demser (Capsule) 1

Digitek

Digitek (Tablet) 1

Digoxin

Digoxin (0.05mg/ml

Oral Solution)1

Digoxin

Digoxin (0.25mg/ml

Injection)1

Digoxin

Digoxin (125mcg Tablet,

250mcg Tablet)1

Edarbyclor

Edarbyclor (Tablet) 1 QL Enalapril Maleate/Hydrochlorothiazide

Enalapril Maleate/

Hydrochlorothiazide

(Tablet)

1 QL

Entresto

Entresto (Tablet) 1 PA, QL Fosinopril Sodium/Hydrochlorothiazide

Fosinopril Sodium/

Hydrochlorothiazide

(Tablet)

1 QL

Irbesartan/Hydrochlorothiazide

Irbesartan/

Hydrochlorothiazide

(Tablet)

1 QL

Lanoxin

Lanoxin (125mcg

Tablet, 187.5mcg

Tablet, 250mcg Tablet,

62.5mcg Tablet)

1

Lisinopril/Hydrochlorothiazide

Lisinopril/

Hydrochlorothiazide

(Tablet)

1 QL

Losartan Potassium/Hydrochlorothiazide

Losartan Potassium/

Hydrochlorothiazide

(Tablet)

1 QL

Methyldopa/Hydrochlorothiazide

Methyldopa/

Hydrochlorothiazide

(Tablet)

1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Metoprolol/Hydrochlorothiazide

Metoprolol/

Hydrochlorothiazide

(Tablet)

1

Moexipril/Hydrochlorothiazide

Moexipril/

Hydrochlorothiazide

(Tablet)

1 QL

Nadolol/Bendroflumethiazide

Nadolol/

Bendroflumethiazide

(40mg-5mg Tablet)

1 QL

Nadolol/Bendroflumethiazide

Nadolol/

Bendroflumethiazide

(80mg-5mg Tablet)

1

Northera

Northera (Capsule) 1 PA, QL Pentoxifylline ER

Pentoxifylline ER (Tablet

Extended-Release)1

Propranolol/Hydrochlorothiazide

Propranolol/

Hydrochlorothiazide

(Tablet)

1

Quinapril/Hydrochlorothiazide

Quinapril/

Hydrochlorothiazide

(Tablet)

1 QL

Ranexa

Ranexa (Tablet

Extended-Release 12

Hour)

1 QL

Spironolactone/Hydrochlorothiazide

Spironolactone/

Hydrochlorothiazide

(Tablet)

1

Telmisartan/Amlodipine

Telmisartan/Amlodipine

(Tablet)1 QL

Telmisartan/Hydrochlorothiazide

Telmisartan/

Hydrochlorothiazide

(Tablet)

1 QL

Triamterene/Hydrochlorothiazide

Triamterene/

Hydrochlorothiazide

(37.5mg-25mg Capsule,

50mg-25mg Capsule,

37.5mg-25mg Tablet,

75mg-50mg Tablet)

1

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35tRACK

46 Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Tribenzor

Tribenzor (Tablet) 1 QL Valsartan/Hydrochlorothiazide

Valsartan/

Hydrochlorothiazide

(Tablet)

1 QL

Diuretics, Carbonic Anhydrase InhibitorsAcetazolamide

Acetazolamide (Tablet

Immediate-Release)1

Acetazolamide ER

Acetazolamide ER

(Capsule Extended-

Release 12 Hour)

1

Acetazolamide Sodium

Acetazolamide Sodium

(Injection)1

Diuretics, LoopBumetanide

Bumetanide (0.25mg/ml

Injection)1

Bumetanide

Bumetanide (0.5mg

Tablet, 1mg Tablet, 2mg

Tablet)

1

Edecrin

Edecrin (Tablet) 1

Furosemide

Furosemide (10mg/ml

Injection)1 B/D, PA

Furosemide

Furosemide (10mg/ml

Oral Solution, 8mg/ml

Oral Solution)

1

Furosemide

Furosemide (20mg

Tablet, 40mg Tablet,

80mg Tablet)

1

Torsemide

Torsemide (Tablet) 1

Diuretics, Potassium-sparingAmiloride HCl

Amiloride HCl (Tablet) 1

Dyrenium

Dyrenium (Capsule) 1

Eplerenone

Eplerenone (Tablet) 1

Spironolactone

Spironolactone (Tablet) 1

Diuretics, ThiazideChlorothiazide

Chlorothiazide (Tablet) 1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Chlorothiazide Sodium

Chlorothiazide Sodium

(Injection)1 B/D, PA

Chlorthalidone

Chlorthalidone (Tablet) 1

Diuril

Diuril (Suspension) 1

Hydrochlorothiazide

Hydrochlorothiazide

(12.5mg Capsule, 12.5mg

Tablet, 25mg Tablet,

50mg Tablet)

1

Indapamide

Indapamide (Tablet) 1

Methyclothiazide

Methyclothiazide (Tablet) 1

Metolazone

Metolazone (Tablet) 1

Dyslipidemics, Fibric Acid DerivativesFenofibrate

Fenofibrate (145mg

Tablet, 48mg Tablet)

(Generic Tricor), (160mg

Tablet, 54mg Tablet)

(Generic Lofibra)

1

Fenofibrate Micronized

Fenofibrate Micronized

(134mg Capsule, 200mg

Capsule, 67mg Capsule)

(Generic Lofibra)

1

Fenofibric Acid

Fenofibric Acid (Tablet) 1

Fenofibric Acid DR

Fenofibric Acid DR

(Capsule Delayed-

Release)

1

Gemfibrozil

Gemfibrozil (Tablet) 1

Dyslipidemics, HMG CoA Reductase

InhibitorsAtorvastatin Calcium

Atorvastatin Calcium

(Tablet)1 QL

Crestor

Crestor (Tablet) 1 QL Fluvastatin

Fluvastatin (Capsule

Immediate-Release)1 QL

Lovastatin

Lovastatin (Tablet

Immediate-Release)1 QL

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You can find information on what the symbols and abbreviations in this table mean by going to page 7.

36

47

36tRACK

47Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Pravastatin Sodium

Pravastatin Sodium

(Tablet)1 QL

Rosuvastatin Calcium

Rosuvastatin Calcium

(Tablet)1 QL

Simvastatin

Simvastatin (Tablet) 1 QL

Dyslipidemics, OtherCholestyramine Light

Cholestyramine Light

(4gm Packet, 4gm/dose

Powder)

1

Colestipol HCl

Colestipol HCl (1gm

Tablet, 5gm Granules)1

Juxtapid

Juxtapid (Capsule) 1 PA Kynamro

Kynamro (Injection) 1 PA Niacin ER

Niacin ER (Tablet

Extended-Release)1

Niacor

Niacor (Tablet) 1

Omega-3-Acid Ethyl Esters

Omega-3-Acid Ethyl

Esters (Capsule) (Generic

Lovaza)

1 QL

Praluent

Praluent (Injection) 1 PA, QL, LA Prevalite

Prevalite (Powder) 1

Repatha

Repatha (Injection) 1 PA, QL Repatha Pushtronex System

Repatha Pushtronex

System (Solution

Cartridge)

1 PA, QL

Repatha SureClick

Repatha SureClick

(Injection)1 PA, QL

Vascepa

Vascepa (Capsule) 1

Vytorin

Vytorin (Tablet) 1 QL Welchol

Welchol (3.75gm

Packet, 625mg Tablet)1

Zetia

Zetia (Tablet) 1 QL

Vasodilators, Direct-acting Arterial

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Hydralazine HCl

Hydralazine HCl (100mg

Tablet, 10mg Tablet,

25mg Tablet, 50mg

Tablet)

1

Hydralazine HCl

Hydralazine HCl (20mg/

ml Injection)1

Minoxidil

Minoxidil (Tablet) 1

Vasodilators, Direct-acting Arterial/VenousIsosorbide Dinitrate

Isosorbide Dinitrate

(Tablet Immediate-

Release)

1

Isosorbide Dinitrate ER

Isosorbide Dinitrate ER

(Tablet Extended-Release)1

Isosorbide Mononitrate

Isosorbide Mononitrate

(Tablet Immediate-

Release)

1

Isosorbide Mononitrate ER

Isosorbide Mononitrate

ER (Tablet Extended-

Release 24 Hour)

1

Minitran

Minitran (Patch 24 Hour) 1

Nitro-Bid

Nitro-Bid (Ointment) 1

Nitroglycerin

Nitroglycerin (Injection) 1

Nitroglycerin Lingual

Nitroglycerin Lingual

(Translingual Solution)1

Nitroglycerin Transdermal

Nitroglycerin Transdermal

(Patch 24 Hour)1

Nitrostat

Nitrostat (Tablet

Sublingual)1

Central Nervous System Agents

Attention Deficit Hyperactivity Disorder

Agents, Amphetamines

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48

37tRACK

48 Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Amphetamine/Dextroamphetamine

Amphetamine/

Dextroamphetamine

(10mg Capsule Extended-

Release 24 Hour, 15mg

Capsule Extended-

Release 24 Hour, 20mg

Capsule Extended-

Release 24 Hour, 25mg

Capsule Extended-

Release 24 Hour, 30mg

Capsule Extended-

Release 24 Hour, 5mg

Capsule Extended-

Release 24 Hour)

1 QL

Amphetamine/Dextroamphetamine

Amphetamine/

Dextroamphetamine

(10mg Tablet Immediate-

Release, 12.5mg Tablet

Immediate-Release, 15mg

Tablet Immediate-

Release, 20mg Tablet

Immediate-Release, 30mg

Tablet Immediate-

Release, 5mg Tablet

Immediate-Release,

7.5mg Tablet Immediate-

Release)

1 QL

Dexedrine

Dexedrine (Tablet) 1 QL Dextroamphetamine Sulfate

Dextroamphetamine

Sulfate (10mg Tablet

Immediate-Release, 5mg

Tablet Immediate-

Release)

1 QL

Dextroamphetamine Sulfate ER

Dextroamphetamine

Sulfate ER (Capsule

Extended-Release 24

Hour)

1 QL

Vyvanse

Vyvanse (Capsule) 1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Attention Deficit Hyperactivity Disorder

Agents, Non-amphetaminesClonidine HCl ER

Clonidine HCl ER (Tablet

Extended-Release 12

Hour)

1

Dexmethylphenidate HCl

Dexmethylphenidate HCl

(Tablet Immediate-

Release)

1 QL

Dexmethylphenidate HCl ER

Dexmethylphenidate HCl

ER (Capsule Extended-

Release 24 Hour)

1

Guanfacine ER

Guanfacine ER (Tablet

Extended-Release 24

Hour)

1

Metadate ER

Metadate ER (Tablet

Extended-Release)1 QL

Methylphenidate HCl

Methylphenidate HCl

(10mg Tablet Immediate-

Release, 20mg Tablet

Immediate-Release, 5mg

Tablet Immediate-

Release) (Generic Ritalin),

(10mg/5ml Oral Solution,

5mg/5ml Oral Solution)

1 QL

Methylphenidate HCl ER

Methylphenidate HCl ER

(10mg Tablet Extended-

Release, 20mg Tablet

Extended-Release)

1 QL

Strattera

Strattera (Capsule) 1 QL, ST

Central Nervous System, OtherNamzaric

Namzaric (Capsule

Extended-Release 24

Hour)

1 PA, QL

Nuedexta

Nuedexta (Capsule) 1 PA Rilutek

Rilutek (Tablet) 1

Riluzole

Riluzole (Tablet) 1

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49

38tRACK

49Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Tetrabenazine

Tetrabenazine (Tablet) 1 PA, QL Xenazine

Xenazine (Tablet) 1 PA, QL, LA

Fibromyalgia AgentsDuloxetine HCl

Duloxetine HCl (20mg

Capsule Delayed-Release,

30mg Capsule Delayed-

Release, 60mg Capsule

Delayed-Release)

1 QL

Lyrica

Lyrica (100mg Capsule,

150mg Capsule, 200mg

Capsule, 225mg

Capsule, 25mg

Capsule, 300mg

Capsule, 50mg

Capsule, 75mg

Capsule, 20mg/ml Oral

Solution)

1 QL

Savella

Savella (Tablet) 1

Savella Titration Pack

Savella Titration Pack 1

Multiple Sclerosis AgentsAmpyra

Ampyra (Tablet

Extended-Release 12

Hour)

1 PA, QL

Aubagio

Aubagio (Tablet) 1 PA, QL Avonex

Avonex (Injection) 1 PA Avonex Pen

Avonex Pen (Injection) 1 PA Betaseron

Betaseron (Injection) 1 PA Copaxone

Copaxone (Injection) 1 PA Gilenya

Gilenya (Capsule) 1 PA, QL Glatopa

Glatopa (Injection) 1 PA Rebif

Rebif (Injection) 1 PA Rebif Rebidose

Rebif Rebidose

(Injection)1 PA

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Rebif Rebidose Titration Pack

Rebif Rebidose

Titration Pack

(Injection)

1 PA

Rebif Titration Pack

Rebif Titration Pack

(Injection)1 PA

Tecfidera

Tecfidera (Capsule

Delayed-Release)1 PA, QL

Tecfidera Starter Pack

Tecfidera Starter Pack 1 PA Tysabri

Tysabri (Injection) 1 PA

Dental and Oral Agents

Dental and Oral AgentsChlorhexidine Gluconate Oral Rinse

Chlorhexidine Gluconate

Oral Rinse (Solution)1

Kepivance

Kepivance (Injection) 1

Periogard

Periogard (Solution) 1

Pilocarpine HCl

Pilocarpine HCl (5mg

Tablet, 7.5mg Tablet)1

Triamcinolone in Orabase

Triamcinolone in Orabase

(Paste)1

Dermatological Agents

Dermatological Agents8-MOP

8-MOP (Capsule) 1

Acitretin

Acitretin (Capsule) 1

Adapalene

Adapalene (0.1% Cream,

0.1% Gel)1

Ammonium Lactate

Ammonium Lactate (12%

Cream, 12% Lotion)1

Avita

Avita (0.025% Cream,

0.025% Gel)1 PA

Calcipotriene

Calcipotriene (0.005%

Cream, 0.005% External

Solution)

1

Calcitriol

Calcitriol (3mcg/gm

Ointment)1

Carac

Carac (Cream) 1

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39tRACK

50 Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Claravis

Claravis (Capsule) 1 PA Clindamycin Phosphate

Clindamycin Phosphate

(1% External Solution, 1%

Gel, 1% Lotion, 1% Swab)

1

Clindamycin/Benzoyl Peroxide

Clindamycin/Benzoyl

Peroxide (1%-5% Gel)

(Generic BenzaClin)

1

Clotrimazole/Betamethasone Dipropionate

Clotrimazole/

Betamethasone

Dipropionate (1%-0.05%

Cream)

1

Clotrimazole/Betamethasone Dipropionate

Clotrimazole/

Betamethasone

Dipropionate (1%-0.05%

Lotion)

1

Cortisporin

Cortisporin (0.5%-0.5%

Cream, 1%-0.5%

Ointment)

1

Diclofenac Sodium

Diclofenac Sodium (3%

Gel)1 PA

Doxepin HCl

Doxepin HCl (Cream) 1

Elidel

Elidel (Cream) 1 ST Ery

Ery (2% Pad) 1

Erythromycin

Erythromycin (2% External

Solution)1

Erythromycin

Erythromycin (2% Gel) 1

Erythromycin/Benzoyl Peroxide

Erythromycin/Benzoyl

Peroxide (Gel)1

Fluorouracil

Fluorouracil (2% External

Solution, 5% External

Solution, 5% Cream)

1

Imiquimod

Imiquimod (Cream) 1

Methoxsalen

Methoxsalen (Capsule) 1

Mirvaso

Mirvaso (Gel) 1 PA

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Oxsoralen Ultra

Oxsoralen Ultra

(Capsule)1

Picato

Picato (Gel) 1

Podofilox

Podofilox (External

Solution)1

PRUDOXIN

PRUDOXIN (Cream) 1

Regranex

Regranex (Gel) 1 PA Santyl

Santyl (Ointment) 1

Selenium Sulfide

Selenium Sulfide (Lotion) 1

Solaraze

Solaraze (Gel) 1 PA Soriatane

Soriatane (Capsule) 1

Tacrolimus

Tacrolimus (0.03%

Ointment, 0.1% Ointment)1 ST

Tazorac

Tazorac (0.05% Cream,

0.1% Cream)1 PA

Tretinoin

Tretinoin (0.01% Gel,

0.025% Gel, 0.025%

Cream, 0.05% Cream,

0.1% Cream)

1 PA

Tretinoin Microsphere

Tretinoin Microsphere

(Gel)1 PA

Uvadex

Uvadex (Injection) 1

Zyclara

Zyclara (Cream) 1 PA Zyclara Pump

Zyclara Pump (Cream) 1 PA

Enzyme Replacement/Modifiers

Enzyme Replacement/ModifiersAdagen

Adagen (Injection) 1 LA Aldurazyme

Aldurazyme (Injection) 1

Buphenyl

Buphenyl (3gm/tsp

Powder, 500mg Tablet)1

Cerezyme

Cerezyme (Injection) 1 PA Creon

Creon (Capsule

Delayed-Release)1

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51

40tRACK

51Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Cystadane

Cystadane (Powder) 1

Cystagon

Cystagon (Capsule) 1 LA Elaprase

Elaprase (Injection) 1

Elelyso

Elelyso (Injection) 1 PA, LA Fabrazyme

Fabrazyme (Injection) 1

Kuvan

Kuvan (100mg Packet,

500mg Packet, 100mg

Tablet Soluble)

1

Lumizyme

Lumizyme (Injection) 1

Naglazyme

Naglazyme (Injection) 1

Orfadin

Orfadin (Capsule, Oral

Suspension)1 LA

Procysbi

Procysbi (Capsule

Delayed-Release)1

RAVICTI

RAVICTI (Liquid) 1

Sodium Phenylbutyrate

Sodium Phenylbutyrate

(Powder)1

Strensiq

Strensiq (Injection) 1 PA, LA Sucraid

Sucraid (Oral Solution) 1 LA VPRIV

VPRIV (Injection) 1 PA Zavesca

Zavesca (Capsule) 1 PA, LA Zenpep

Zenpep (Capsule

Delayed-Release)1

Gastrointestinal Agents

Antispasmodics, GastrointestinalAtropine Sulfate

Atropine Sulfate

(Injection)1

Cuvposa

Cuvposa (Oral Solution) 1

Dicyclomine HCl

Dicyclomine HCl (10mg

Capsule, 10mg/5ml Oral

Solution, 20mg Tablet)

1

Glycopyrrolate

Glycopyrrolate (4mg/

20ml Injection)1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Methscopolamine Bromide

Methscopolamine

Bromide (Tablet)1

Gastrointestinal Agents, OtherChenodal

Chenodal (Tablet) 1

Cholbam

Cholbam (Capsule) 1 PA Cromolyn Sodium

Cromolyn Sodium

(100mg/5ml

Concentrate)

1

Diphenoxylate/Atropine

Diphenoxylate/Atropine

(2.5mg-0.025mg Tablet,

2.5mg-0.025mg/5ml

Liquid)

1

Gattex

Gattex (Injection) 1 PA Loperamide HCl

Loperamide HCl

(Capsule)1

Ocaliva

Ocaliva (Tablet) 1 PA, QL Relistor

Relistor (Injection) 1 PA Serostim

Serostim (Injection) 1 PA Ursodiol

Ursodiol (250mg Tablet,

500mg Tablet, 300mg

Capsule)

1

Zorbtive

Zorbtive (Injection) 1 PA

Histamine2 (H2) Receptor AntagonistsCimetidine

Cimetidine (Tablet) 1

Cimetidine HCl

Cimetidine HCl (Oral

Solution)1

Famotidine

Famotidine (20mg Tablet,

40mg Tablet)1

Famotidine

Famotidine (20mg/2ml

Injection, 40mg/5ml

Suspension)

1

Famotidine Premixed

Famotidine Premixed

(Injection)1

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Bold type = Brand name drug Plain type = Generic drug

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52

41tRACK

52 Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Ranitidine HCl

Ranitidine HCl (150mg

Capsule, 300mg Capsule,

15mg/ml Syrup)

1

Ranitidine HCl

Ranitidine HCl (150mg

Tablet, 300mg Tablet)1

Irritable Bowel Syndrome AgentsAlosetron HCl

Alosetron HCl (Tablet) 1 PA Amitiza

Amitiza (Capsule) 1 QL Linzess

Linzess (Capsule) 1 QL Lotronex

Lotronex (Tablet) 1 PA

LaxativesConstulose

Constulose (Oral Solution) 1

Enulose

Enulose (Oral Solution) 1

GaviLyte-C

GaviLyte-C (Oral Solution) 1

GaviLyte-G

GaviLyte-G (Oral Solution) 1

GaviLyte-H

GaviLyte-H (Kit) 1

GaviLyte-N/Flavor Pack

GaviLyte-N/Flavor Pack

(Oral Solution)1

Generlac

Generlac (Oral Solution) 1

Lactulose

Lactulose (Oral Solution) 1

PEG-3350/Electrolytes

PEG-3350/Electrolytes

(Oral Solution) (Generic

GoLYTELY)

1

PEG-3350/NaCl/Na Bicarbonate/KCl

PEG-3350/NaCl/Na

Bicarbonate/KCl (Oral

Solution) (Generic

NuLYTELY)

1

Polyethylene Glycol 3350 Powder

Polyethylene Glycol 3350

Powder (Generic

MiraLAX)

1

Suprep Bowel Prep

Suprep Bowel Prep

(Oral Solution)1

TriLyte

TriLyte (Oral Solution) 1

Protectants

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Carafate

Carafate (1gm/10ml

Suspension)1

Misoprostol

Misoprostol (Tablet) 1

Sucralfate

Sucralfate (Tablet) 1

Proton Pump InhibitorsDexilant

Dexilant (Capsule

Delayed-Release)1 QL

Esomeprazole Magnesium

Esomeprazole

Magnesium (Capsule

Delayed-Release)

(Generic Nexium)

1 QL

Esomeprazole Sodium

Esomeprazole Sodium

(Injection)1

Nexium

Nexium (10mg Packet,

2.5mg Packet, 20mg

Packet, 40mg Packet,

5mg Packet)

1

Nexium

Nexium (20mg Capsule

Delayed-Release, 40mg

Capsule Delayed-

Release)

1 QL

Omeprazole

Omeprazole (10mg

Capsule Delayed-Release,

40mg Capsule Delayed-

Release)

1 QL

Omeprazole

Omeprazole (20mg

Capsule Delayed-Release)1

Pantoprazole Sodium

Pantoprazole Sodium

(Tablet Delayed-Release)1 QL

Pantoprazole Sodium

Pantoprazole Sodium

(40mg Injection)1

Genitourinary Agents

Antispasmodics, UrinaryMyrbetriq

Myrbetriq (Tablet

Extended-Release 24

Hour)

1

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42

53

42tRACK

53Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Oxybutynin Chloride

Oxybutynin Chloride (5mg

Tablet Immediate-

Release, 5mg/5ml Syrup)

1

Oxybutynin Chloride ER

Oxybutynin Chloride ER

(Tablet Extended-Release

24 Hour)

1 QL

Vesicare

Vesicare (Tablet) 1 QL

Benign Prostatic Hypertrophy AgentsAlfuzosin HCl ER

Alfuzosin HCl ER (Tablet

Extended-Release 24

Hour)

1

Finasteride

Finasteride (5mg Tablet)

(Generic Proscar)1

Rapaflo

Rapaflo (Capsule) 1 QL Tamsulosin HCl

Tamsulosin HCl (Capsule) 1

Terazosin HCl

Terazosin HCl (Capsule) 1

Genitourinary Agents, OtherBethanechol Chloride

Bethanechol Chloride

(Tablet)1

Cuprimine

Cuprimine (Capsule) 1 ST Depen Titratabs

Depen Titratabs

(Tablet)1

Elmiron

Elmiron (Capsule) 1

Lithostat

Lithostat (Tablet) 1

Phosphate BindersCalcium Acetate

Calcium Acetate

(Capsule)1

Eliphos

Eliphos (Tablet) 1

Fosrenol

Fosrenol (1000mg

Packet, 750mg Packet,

1000mg Tablet

Chewable, 500mg

Tablet Chewable,

750mg Tablet

Chewable)

1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

PhosLo

PhosLo (Capsule) 1

Phoslyra

Phoslyra (Oral Solution) 1

Renagel

Renagel (Tablet) 1 ST Renvela

Renvela (0.8gm Packet,

2.4gm Packet, 800mg

Tablet)

1

Velphoro

Velphoro (Tablet

Chewable)1

Hormonal Agents, Stimulant/Replacement/

Modifying (Adrenal)

Hormonal Agents, Stimulant/

Replacement/Modifying (Adrenal)A-Hydrocort

A-Hydrocort (Injection) 1

Ala Cort

Ala Cort (Cream) 1

Alclometasone Dipropionate

Alclometasone

Dipropionate (0.05%

Cream, 0.05% Ointment)

1

Augmented Betamethasone Dipropionate

Augmented

Betamethasone

Dipropionate (0.05%

Cream)

1

Augmented Betamethasone Dipropionate

Augmented

Betamethasone

Dipropionate (0.05% Gel,

0.05% Lotion, 0.05%

Ointment)

1

Betamethasone Dipropionate

Betamethasone

Dipropionate (0.05%

Cream, 0.05% Lotion,

0.05% Ointment)

1

Betamethasone Valerate

Betamethasone Valerate

(0.1% Cream, 0.1%

Lotion, 0.1% Ointment)

1

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43tRACK

54 Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Clobetasol Propionate

Clobetasol Propionate

(0.05% External Solution,

0.05% Gel, 0.05%

Ointment)

1

Clobetasol Propionate

Clobetasol Propionate

(0.05% Shampoo)1

Clobetasol Propionate E

Clobetasol Propionate E

(Cream)1

Cordran Tape

Cordran Tape (Tape) 1

Cormax Scalp Application

Cormax Scalp Application

(External Solution)1

Cortisone Acetate

Cortisone Acetate (Tablet) 1

Depo-Medrol

Depo-Medrol (20mg/ml

Injection)1

Desonide

Desonide (0.05%

Ointment)1

Desoximetasone

Desoximetasone (0.05%

Cream, 0.25% Cream)1

Dexamethasone

Dexamethasone (0.5mg

Tablet, 0.75mg Tablet,

1.5mg Tablet, 1mg Tablet,

2mg Tablet, 4mg Tablet,

6mg Tablet, 0.5mg/5ml

Elixir)

1

Dexamethasone Intensol

Dexamethasone Intensol

(1mg/ml Concentrate)1

Dexamethasone Sodium Phosphate

Dexamethasone Sodium

Phosphate (10mg/ml

Injection, 120mg/30ml

Injection)

1

Fludrocortisone Acetate

Fludrocortisone Acetate

(Tablet)1

Fluocinolone Acetonide

Fluocinolone Acetonide

(0.01% Cream, 0.025%

Cream, 0.01% External

Solution, 0.025%

Ointment)

1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Fluocinolone Acetonide Body

Fluocinolone Acetonide

Body (Oil)1

Fluocinonide

Fluocinonide (0.05%

Cream, 0.05% External

Solution, 0.05% Gel,

0.05% Ointment)

1

Fluocinonide

Fluocinonide (0.1%

Cream)1

Fluocinonide-E

Fluocinonide-E (Cream) 1

Fluticasone Propionate

Fluticasone Propionate

(0.005% Ointment, 0.05%

Cream)

1

Halobetasol Propionate

Halobetasol Propionate

(0.05% Cream, 0.05%

Ointment)

1

Hydrocortisone

Hydrocortisone (1%

Cream, 2.5% Cream, 1%

Ointment, 2.5% Ointment)

1

Hydrocortisone

Hydrocortisone (Tablet,

2.5% Lotion)1

Hydrocortisone Butyrate

Hydrocortisone Butyrate

(0.1% Ointment)1

Hydrocortisone Valerate

Hydrocortisone Valerate

(0.2% Cream, 0.2%

Ointment)

1

Kenalog-10

Kenalog-10 (Injection) 1

Kenalog-40

Kenalog-40 (Injection) 1

Methylprednisolone

Methylprednisolone

(Tablet)1

Methylprednisolone Acetate

Methylprednisolone

Acetate (Injection)1

Methylprednisolone Dose Pack

Methylprednisolone Dose

Pack (Tablet Therapy

Pack)

1

Methylprednisolone Sodium Succinate

Methylprednisolone

Sodium Succinate

(Injection)

1

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55

44tRACK

55Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Millipred

Millipred (5mg Tablet) 1

Mometasone Furoate

Mometasone Furoate

(0.1% Cream, 0.1%

External Solution, 0.1%

Ointment)

1

Prednicarbate

Prednicarbate (0.1%

Cream)1

Prednicarbate

Prednicarbate (0.1%

Ointment)1

Prednisolone Sodium Phosphate

Prednisolone Sodium

Phosphate (15mg/5ml

Oral Solution, 25mg/5ml

Oral Solution, 5mg/5ml

Oral Solution)

1

Prednisone

Prednisone (10mg Tablet

Therapy Pack, 5mg

Tablet Therapy Pack,

10mg Tablet, 1mg Tablet,

2.5mg Tablet, 20mg

Tablet, 50mg Tablet, 5mg

Tablet)

1

Prednisone

Prednisone (5mg/5ml

Oral Solution)1

Prednisone Intensol

Prednisone Intensol

(5mg/ml Concentrate)1

Solu-Cortef

Solu-Cortef (Injection) 1

Solu-Medrol

Solu-Medrol (2gm

Injection)1

Triamcinolone Acetonide

Triamcinolone Acetonide

(0.025% Cream, 0.1%

Cream, 0.5% Cream,

0.025% Ointment, 0.1%

Ointment, 0.5% Ointment)

1

Triamcinolone Acetonide

Triamcinolone Acetonide

(0.025% Lotion, 0.1%

Lotion)

1

Triderm

Triderm (Cream) 1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Hormonal Agents, Stimulant/Replacement/

Modifying (Pituitary)

Hormonal Agents, Stimulant/

Replacement/Modifying (Pituitary)Chorionic Gonadotropin

Chorionic Gonadotropin

(Injection)1 PA

Desmopressin Acetate

Desmopressin Acetate

(0.01% Nasal Rhinal

Tube Solution)

1

Desmopressin Acetate

Desmopressin Acetate

(0.01% Nasal Spray

Solution, 0.1mg Tablet,

0.2mg Tablet)

1

Desmopressin Acetate

Desmopressin Acetate

(4mcg/ml Injection)1

Genotropin

Genotropin (12mg

Injection, 5mg Injection)1 PA

Genotropin Miniquick

Genotropin Miniquick

(0.2mg Injection)1 PA

Genotropin Miniquick

Genotropin Miniquick

(0.4mg Injection, 0.6mg

Injection, 0.8mg

Injection, 1.2mg

Injection, 1.4mg

Injection, 1.6mg

Injection, 1.8mg

Injection, 1mg Injection,

2mg Injection)

1 PA

Humatrope

Humatrope (Injection) 1 PA Humatrope Combo Pack

Humatrope Combo

Pack (Injection)1 PA

Increlex

Increlex (Injection) 1 PA Norditropin FlexPro

Norditropin FlexPro

(Injection)1 PA

Novarel

Novarel (Injection) 1 PA Nutropin AQ

Nutropin AQ (Injection) 1 PA

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Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Omnitrope

Omnitrope (Injection) 1 PA Pregnyl w/Diluent Benzyl Alcohol/NaCl

Pregnyl w/Diluent

Benzyl Alcohol/NaCl

(Injection)

1 PA

Saizen

Saizen (Injection) 1 PA Zomacton

Zomacton (Injection) 1 PA

Hormonal Agents, Stimulant/Replacement/

Modifying (Prostaglandins)

Hormonal Agents, Stimulant/

Replacement/Modifying (Prostaglandins)Korlym

Korlym (Tablet) 1 PA, QL

Hormonal Agents, Stimulant/Replacement/

Modifying (Sex Hormones/Modifiers)

AndrogensAnadrol-50

Anadrol-50 (Tablet) 1 PA Androderm

Androderm (Patch 24

Hour)1 PA, QL

AndroGel

AndroGel (1.62%

Packet)1 PA

AndroGel Pump

AndroGel Pump (1.62%

Gel)1 PA

Danazol

Danazol (Capsule) 1

Oxandrolone

Oxandrolone (10mg

Tablet)1 PA, QL

Oxandrolone

Oxandrolone (2.5mg

Tablet)1 PA, QL

Testosterone Cypionate

Testosterone Cypionate

(Injection)1

Testosterone Enanthate

Testosterone Enanthate

(Injection)1

EstrogensAlora

Alora (Patch Twice

Weekly)1

Amethia

Amethia (Tablet) 1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Amethyst

Amethyst (Tablet) 1

Apri

Apri (Tablet) 1

Aranelle

Aranelle (Tablet) 1

Ashlyna

Ashlyna (Tablet) 1

Aubra

Aubra (Tablet) 1

Aviane

Aviane (Tablet) 1

Balziva

Balziva (Tablet) 1

Bekyree

Bekyree (Tablet) 1

Blisovi 24 Fe

Blisovi 24 Fe (Tablet) 1

Blisovi Fe 1.5/30

Blisovi Fe 1.5/30 (Tablet) 1

Blisovi Fe 1/20

Blisovi Fe 1/20 (Tablet) 1

Briellyn

Briellyn (Tablet) 1

Caziant

Caziant (Tablet) 1

Climara Pro

Climara Pro (Patch

Weekly)1

Cryselle-28

Cryselle-28 (Tablet) 1

Cyclafem

Cyclafem (Tablet) 1

Delyla

Delyla (Tablet) 1

Depo-Estradiol

Depo-Estradiol (Injection) 1

Desogestrel/Ethinyl Estradiol

Desogestrel/Ethinyl

Estradiol (Tablet)1

Drospirenone/Ethinyl Estradiol

Drospirenone/Ethinyl

Estradiol (Tablet)1

Duavee

Duavee (Tablet) 1

Elestrin

Elestrin (Gel) 1

Emoquette

Emoquette (Tablet) 1

Enpresse-28

Enpresse-28 (Tablet) 1

Estrace

Estrace (0.1mg/gm

Cream)1

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Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Estradiol

Estradiol (0.025mg/24hr

Patch Weekly, 0.05mg/

24hr Patch Weekly,

0.06mg/24hr Patch

Weekly, 0.075mg/24hr

Patch Weekly, 0.1mg/

24hr Patch Weekly,

37.5mcg/24hr Patch

Weekly, 0.5mg Tablet,

1mg Tablet, 2mg Tablet)

1

Estradiol Valerate

Estradiol Valerate

(Injection)1

Estring

Estring (Ring) 1

Falmina

Falmina (Tablet) 1

Femring

Femring (Ring) 1

Gianvi

Gianvi (Tablet) 1

Gildagia

Gildagia (Tablet) 1

Gildess 1.5/30

Gildess 1.5/30 (Tablet) 1

Gildess 24 Fe

Gildess 24 Fe (Tablet) 1

Introvale

Introvale (Tablet) 1

Jinteli

Jinteli (Tablet) 1

Juleber

Juleber (Tablet) 1

Junel 1.5/30

Junel 1.5/30 (Tablet) 1

Junel 1/20

Junel 1/20 (Tablet) 1

Junel Fe 1.5/30

Junel Fe 1.5/30 (Tablet) 1

Junel Fe 1/20

Junel Fe 1/20 (Tablet) 1

Junel Fe 24

Junel Fe 24 (Tablet) 1

Kaitlib Fe

Kaitlib Fe (Tablet

Chewable)1

Kariva

Kariva (Tablet) 1

Kelnor 1/35

Kelnor 1/35 (Tablet) 1

Kimidess

Kimidess (Tablet) 1

LARIN 1.5/30

LARIN 1.5/30 (Tablet) 1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

LARIN 1/20

LARIN 1/20 (Tablet) 1

LARIN Fe 1.5/30

LARIN Fe 1.5/30 (Tablet) 1

LARIN Fe 1/20

LARIN Fe 1/20 (Tablet) 1

Larissia

Larissia (Tablet) 1

Layolis Fe

Layolis Fe (Tablet

Chewable)1

Lessina

Lessina (Tablet) 1

Levonest

Levonest (Tablet) 1

Levonorgestrel and Ethinyl Estradiol

Levonorgestrel and

Ethinyl Estradiol (Tablet)1

Levonorgestrel/Ethinyl Estradiol

Levonorgestrel/Ethinyl

Estradiol (Tablet)1

Levora 0.15/30-28

Levora 0.15/30-28

(Tablet)1

Lomedia 24 Fe

Lomedia 24 Fe (Tablet) 1

Loryna

Loryna (Tablet) 1

Low-Ogestrel

Low-Ogestrel (Tablet) 1

Lutera

Lutera (Tablet) 1

Marlissa

Marlissa (Tablet) 1

Menest

Menest (Tablet) 1

Microgestin 1.5/30

Microgestin 1.5/30

(Tablet)1

Microgestin 1/20

Microgestin 1/20 (Tablet) 1

Microgestin Fe

Microgestin Fe (Tablet) 1

Microgestin Fe 1.5/30

Microgestin Fe 1.5/30

(Tablet)1

MonoNessa

MonoNessa (Tablet) 1

Necon 0.5/35-28

Necon 0.5/35-28 (Tablet) 1

Necon 1/35

Necon 1/35 (Tablet) 1

Necon 1/50-28

Necon 1/50-28 (Tablet) 1

Necon 10/11-28

Necon 10/11-28 (Tablet) 1

Necon 7/7/7

Necon 7/7/7 (Tablet) 1

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Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Nikki

Nikki (Tablet) 1

Norethindrone & Ethinyl Estradiol Ferrous Fumarate

Norethindrone & Ethinyl

Estradiol Ferrous

Fumarate (Tablet

Chewable)

1

Norethindrone Acetate/Ethinyl Estradiol/Ferrous Fumarate

Norethindrone Acetate/

Ethinyl Estradiol/Ferrous

Fumarate (Tablet)

1

Norgestimate/Ethinyl Estradiol

Norgestimate/Ethinyl

Estradiol (Tablet)1

Nortrel 0.5/35

Nortrel 0.5/35 (28)

(Tablet)1

Nortrel 1/35

Nortrel 1/35 (Tablet) 1

Nortrel 7/7/7

Nortrel 7/7/7 (Tablet) 1

NuvaRing

NuvaRing (Ring) 1

Ocella

Ocella (Tablet) 1

Ogestrel

Ogestrel (Tablet) 1

Orsythia

Orsythia (Tablet) 1

Pimtrea

Pimtrea (Tablet) 1

Pirmella 1/35

Pirmella 1/35 (Tablet) 1

Portia-28

Portia-28 (Tablet) 1

Premarin

Premarin (0.3mg

Tablet, 0.45mg Tablet,

0.625mg Tablet, 0.9mg

Tablet, 1.25mg Tablet)

1

Premarin

Premarin (Vaginal

Cream)1

Premphase

Premphase (Tablet) 1

Prempro

Prempro (Tablet) 1

Previfem

Previfem (Tablet) 1

Quasense

Quasense (Tablet) 1

Reclipsen

Reclipsen (Tablet) 1

Setlakin

Setlakin (Tablet) 1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Sprintec 28

Sprintec 28 (Tablet) 1

Sronyx

Sronyx (Tablet) 1

Tarina Fe 1/20

Tarina Fe 1/20 (Tablet) 1

Tri-Legest Fe

Tri-Legest Fe (Tablet) 1

Tri-Lo-Estarylla

Tri-Lo-Estarylla (Tablet) 1

Tri-Lo-Sprintec

Tri-Lo-Sprintec (Tablet) 1

Trinessa

Trinessa (Tablet) 1

Tri-Previfem

Tri-Previfem (Tablet) 1

Tri-Sprintec

Tri-Sprintec (Tablet) 1

Trivora-28

Trivora-28 (Tablet) 1

Vagifem

Vagifem (Tablet) 1 QL Velivet

Velivet (Tablet) 1

Vestura

Vestura (Tablet) 1

Vienva

Vienva (Tablet) 1

Vyfemla

Vyfemla (Tablet) 1

WYMZYA Fe

WYMZYA Fe (Tablet

Chewable)1

Xulane

Xulane (Patch Weekly) 1

Zenchent

Zenchent (Tablet) 1

Zenchent Fe

Zenchent Fe (Tablet

Chewable)1

Zovia 1/35E

Zovia 1/35E (Tablet) 1

Zovia 1/50E

Zovia 1/50E (Tablet) 1

ProgestinsCamila

Camila (Tablet) 1

Crinone

Crinone (Gel) 1

Deblitane

Deblitane (Tablet) 1

Depo-Provera

Depo-Provera

(Injection)1

Errin

Errin (Tablet) 1

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Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Hydroxyprogesterone Caproate

Hydroxyprogesterone

Caproate (Injection)1 PA

Jolivette

Jolivette (Tablet) 1

Lyza

Lyza (Tablet) 1

Makena

Makena (Injection) 1 PA Medroxyprogesterone Acetate

Medroxyprogesterone

Acetate (10mg Tablet,

2.5mg Tablet, 5mg

Tablet)

1

Medroxyprogesterone Acetate

Medroxyprogesterone

Acetate (150mg/ml

Injection)

1

Megace ES

Megace ES

(Suspension)1

Megestrol Acetate

Megestrol Acetate (20mg

Tablet, 40mg Tablet,

40mg/ml Suspension)

1

Megestrol Acetate

Megestrol Acetate

(625mg/5ml Suspension)1

Nora-BE

Nora-BE (Tablet) 1

Norethindrone

Norethindrone (Tablet) 1

Norethindrone Acetate

Norethindrone Acetate

(Tablet)1

Norlyroc

Norlyroc (Tablet) 1

Progesterone

Progesterone (Capsule) 1

Sharobel

Sharobel (Tablet) 1

Selective Estrogen Receptor Modifying

AgentsRaloxifene HCl

Raloxifene HCl (Tablet) 1 QL

Hormonal Agents, Stimulant/Replacement/

Modifying (Thyroid)

Hormonal Agents, Stimulant/

Replacement/Modifying (Thyroid)

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Levothyroxine Sodium

Levothyroxine Sodium

(100mcg Injection)1

Levothyroxine Sodium

Levothyroxine Sodium

(100mcg Tablet, 112mcg

Tablet, 125mcg Tablet,

137mcg Tablet, 150mcg

Tablet, 175mcg Tablet,

200mcg Tablet, 25mcg

Tablet, 300mcg Tablet,

50mcg Tablet, 75mcg

Tablet, 88mcg Tablet)

1

Levoxyl

Levoxyl (Tablet) 1

Liothyronine Sodium

Liothyronine Sodium

(10mcg/ml Injection)1

Liothyronine Sodium

Liothyronine Sodium

(25mcg Tablet, 50mcg

Tablet, 5mcg Tablet)

1

Synthroid

Synthroid (Tablet) 1

Thyrolar

Thyrolar (Tablet) 1

Unithroid

Unithroid (Tablet) 1

Hormonal Agents, Suppressant (Adrenal)

Hormonal Agents, Suppressant (Adrenal)Lysodren

Lysodren (Tablet) 1

Hormonal Agents, Suppressant (Parathyroid)

Hormonal Agents, Suppressant

(Parathyroid)Sensipar

Sensipar (30mg Tablet) 1 QL Sensipar

Sensipar (60mg Tablet,

90mg Tablet)1 QL

Hormonal Agents, Suppressant (Pituitary)

Hormonal Agents, Suppressant (Pituitary)Cabergoline

Cabergoline (Tablet) 1

Egrifta

Egrifta (Injection) 1 PA Firmagon

Firmagon (120mg

Injection)1 PA

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Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Firmagon

Firmagon (80mg

Injection)1 PA

Leuprolide Acetate

Leuprolide Acetate

(Injection)1 PA

Lupaneta Pack

Lupaneta Pack (Kit) 1 PA Lupron Depot

Lupron Depot

(Injection)1 PA

Lupron Depot-PED

Lupron Depot-PED

(Injection)1 PA

Octreotide Acetate

Octreotide Acetate

(1000mcg/ml Injection,

500mcg/ml Injection)

1 PA

Octreotide Acetate

Octreotide Acetate

(100mcg/ml Injection,

200mcg/ml Injection,

50mcg/ml Injection)

1 PA

Sandostatin LAR Depot

Sandostatin LAR Depot

(Injection)1 PA

Signifor

Signifor (Injection) 1 PA Somatuline Depot

Somatuline Depot

(Injection)1 PA

Somavert

Somavert (Injection) 1 PA Synarel

Synarel (Nasal Solution) 1

Trelstar Mixject

Trelstar Mixject

(Injection)1 PA

Hormonal Agents, Suppressant (Thyroid)

Antithyroid AgentsMethimazole

Methimazole (Tablet) 1

Propylthiouracil

Propylthiouracil (Tablet) 1

Immunological Agents

Angioedema (HAE) Agents Berinert

Berinert (Injection) 1 PA, LA Cinryze

Cinryze (Injection) 1 PA, LA Firazyr

Firazyr (Injection) 1 PA

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Ruconest

Ruconest (Injection) 1 PA

Immune SuppressantsAzathioprine

Azathioprine (100mg

Injection)1 B/D, PA

Azathioprine

Azathioprine (50mg

Tablet)1 B/D, PA

Cellcept

Cellcept (200mg/ml

Suspension, 250mg

Capsule, 500mg Tablet)

1 PA

Cellcept Intravenous

Cellcept Intravenous

(Injection)1 PA

Cimzia

Cimzia (Injection) 1 PA Cyclosporine

Cyclosporine (100mg

Capsule, 25mg Capsule)1 B/D, PA

Cyclosporine

Cyclosporine (50mg/ml

Injection)1

Cyclosporine Modified

Cyclosporine Modified

(100mg Capsule, 25mg

Capsule, 50mg Capsule,

100mg/ml Oral Solution)

1 B/D, PA

Enbrel

Enbrel (Injection) 1 PA Enbrel SureClick

Enbrel SureClick

(Injection)1 PA

Gengraf

Gengraf (100mg Capsule,

25mg Capsule, 100mg/

ml Oral Solution, 50mg

Capsule)

1 B/D, PA

Humira

Humira (Injection) 1 PA Humira Pediatric Crohns Disease Starter Pack

Humira Pediatric

Crohns Disease Starter

Pack (Injection)

1 PA

Humira Pen

Humira Pen (Injection) 1 PA Humira Pen Crohns Disease Starter Pack

Humira Pen Crohns

Disease Starter Pack

(Injection)

1 PA

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Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Humira Pen-Psoriasis Starter

Humira Pen-Psoriasis

Starter (Injection)1 PA

Kineret

Kineret (Injection) 1 PA Methotrexate

Methotrexate (Tablet) 1

Methotrexate Sodium

Methotrexate Sodium

(Injection)1

Mycophenolate Mofetil

Mycophenolate Mofetil

(200mg/ml Suspension)1 PA

Mycophenolate Mofetil

Mycophenolate Mofetil

(250mg Capsule, 500mg

Tablet)

1 PA

Mycophenolic Acid DR

Mycophenolic Acid DR

(Tablet Delayed-Release)1 B/D, PA

Nulojix

Nulojix (Injection) 1 PA Orencia

Orencia (125mg/ml

Injection, 250mg

Injection)

1 PA

Orencia Clickject

Orencia Clickject

(Solution Auto injector)1 PA

Prograf

Prograf (5mg/ml

Injection)1 PA

Rapamune

Rapamune (1mg Tablet,

2mg Tablet, 1mg/ml

Oral Solution)

1 B/D, PA

Remicade

Remicade (Injection) 1 PA Sandimmune

Sandimmune (100mg

Capsule)1 B/D, PA

Sandimmune

Sandimmune (100mg/

ml Oral Solution)1 B/D, PA

Simponi

Simponi (Injection) 1 PA Simponi Aria

Simponi Aria (Injection) 1 PA Sirolimus

Sirolimus (0.5mg Tablet) 1 B/D, PA Sirolimus

Sirolimus (1mg Tablet,

2mg Tablet)1 B/D, PA

Stelara

Stelara (Injection) 1 PA

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Tacrolimus

Tacrolimus (0.5mg

Capsule, 1mg Capsule,

5mg Capsule)

1 PA

Torisel

Torisel (Injection) 1

Trexall

Trexall (Tablet) 1

Xeljanz

Xeljanz (Tablet) 1 PA, QL Xeljanz XR

Xeljanz XR (Tablet

Extended-Release 24

Hour)

1 PA, QL

Zinbryta

Zinbryta (Solution

Prefilled Syringe)1 PA

Zortress

Zortress (Tablet) 1 PA

Immunizing Agents, PassiveAtgam

Atgam (Injection) 1

BIVIGAM

BIVIGAM (Injection) 1 PA Carimune Nanofiltered

Carimune Nanofiltered

(Injection)1 PA

Flebogamma DIF

Flebogamma DIF

(Injection)1 PA

Gamastan S/D

Gamastan S/D

(Injection)1 PA

Gammagard Liquid

Gammagard Liquid

(Injection)1 PA

Gammaked

Gammaked (Injection) 1 PA Gammaplex

Gammaplex (Injection) 1 PA Gamunex-C

Gamunex-C (Injection) 1 PA Octagam

Octagam (Injection) 1 PA Privigen

Privigen (Injection) 1 PA Thymoglobulin

Thymoglobulin

(Injection)1

Varizig

Varizig (Injection) 1

Immunomodulators

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Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Actemra

Actemra (162mg/0.9ml

Injection, 200mg/10ml

Injection, 400mg/20ml

Injection, 80mg/4ml

Injection)

1 PA

Actimmune

Actimmune (Injection) 1

Arcalyst

Arcalyst (Injection) 1 PA, LA Benlysta

Benlysta (Injection) 1 PA Ilaris

Ilaris (Injection) 1 PA, LA Leflunomide

Leflunomide (Tablet) 1

Otezla

Otezla (Tablet Therapy

Pack, 30mg Tablet)1 PA

Ridaura

Ridaura (Capsule) 1

Simulect

Simulect (Injection) 1

Synagis

Synagis (Injection) 1 PA

VaccinesActHIB

ActHIB (Injection) 1

Adacel

Adacel (Injection) 1

BCG Vaccine

BCG Vaccine (Injection) 1

Bexsero

Bexsero (Injection) 1

Boostrix

Boostrix (Injection) 1

Cervarix

Cervarix (Injection) 1

Daptacel

Daptacel (Injection) 1

Diphtheria/Tetanus Toxoids Adsorbed Pediatric

Diphtheria/Tetanus

Toxoids Adsorbed

Pediatric (Injection)

1

Engerix-B

Engerix-B (Injection) 1 B/D, PA Gardasil

Gardasil (Injection) 1

Gardasil 9

Gardasil 9 (Injection) 1

Havrix

Havrix (Injection) 1

Hiberix

Hiberix (Injection) 1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Imovax Rabies

Imovax Rabies

(H.D.C.V.) (Injection)1 B/D, PA

Infanrix

Infanrix (Injection) 1

IPOL Inactivated IPV

IPOL Inactivated IPV

(Injection)1

Ixiaro

Ixiaro (Injection) 1

Menactra

Menactra (Injection) 1

MENHIBRIX

MENHIBRIX (Injection) 1

Menomune-A/C/Y/W-135

Menomune-A/C/Y/

W-135 (Injection)1

Menveo

Menveo (Injection) 1

M-M-R II

M-M-R II (Injection) 1

Pedvax HIB

Pedvax HIB (Injection) 1

ProQuad

ProQuad (Injection) 1

Quadracel

Quadracel (Injection) 1

Rabavert

Rabavert (Injection) 1 B/D, PA Recombivax HB

Recombivax HB

(Injection)1 B/D, PA

Rotarix

Rotarix (Suspension) 1

RotaTeq

RotaTeq (Oral Solution) 1

Tenivac

Tenivac (Injection) 1

Tetanus/Diphtheria Toxoids-Adsorbed Adult

Tetanus/Diphtheria

Toxoids-Adsorbed Adult

(Injection)

1

Trumenba

Trumenba (Injection) 1

Twinrix

Twinrix (Injection) 1

Typhim Vi

Typhim Vi (Injection) 1

VAQTA

VAQTA (Injection) 1

Varivax

Varivax (Injection) 1

YF-Vax

YF-Vax (Injection) 1

Zostavax

Zostavax (Injection) 1 PA

Inflammatory Bowel Disease Agents

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Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

AminosalicylatesApriso

Apriso (Capsule

Extended-Release 24

Hour)

1 QL

Balsalazide Disodium

Balsalazide Disodium

(Capsule)1

Canasa

Canasa (Suppository) 1

Dipentum

Dipentum (Capsule) 1

Giazo

Giazo (Tablet) 1

Lialda

Lialda (Tablet Delayed-

Release)1 QL

Mesalamine

Mesalamine (Kit) 1

Pentasa

Pentasa (Capsule

Extended-Release)1 QL

sfRowasa

sfRowasa (Enema) 1 QL

GlucocorticoidsBudesonide

Budesonide (3mg

Capsule Delayed-Release)1

Colocort

Colocort (Enema) 1

Entocort EC

Entocort EC (Capsule

Delayed-Release)1

Hydrocortisone

Hydrocortisone

(100mg/60ml Enema)1

Procto-Med HC

Procto-Med HC (Cream) 1

Procto-Pak

Procto-Pak (Cream) 1

Proctosol HC

Proctosol HC (Cream) 1

Proctozone-HC

Proctozone-HC (Cream) 1

Uceris

Uceris (9mg Tablet

Extended-Release 24

Hour)

1 ST

Sulfonamides

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Sulfasalazine

Sulfasalazine (500mg

Tablet Delayed-Release,

500mg Tablet Immediate-

Release)

1

Metabolic Bone Disease Agents

Metabolic Bone Disease AgentsActonel

Actonel (150mg Tablet) 1 QL Alendronate Sodium

Alendronate Sodium

(10mg Tablet, 35mg

Tablet, 40mg Tablet, 5mg

Tablet, 70mg Tablet)

1 QL

Alendronate Sodium

Alendronate Sodium

(70mg/75ml Oral

Solution)

1

Binosto

Binosto (Tablet

Effervescent)1 QL

Boniva

Boniva (3mg/3ml

Injection)1 B/D, PA

Calcitonin-Salmon

Calcitonin-Salmon (Nasal

Solution)1

Calcitriol

Calcitriol (0.25mcg

Capsule, 0.5mcg

Capsule, 1mcg/ml Oral

Solution)

1 B/D, PA

Calcitriol

Calcitriol (1mcg/ml

Injection)1 B/D, PA

Doxercalciferol

Doxercalciferol (0.5mcg

Capsule, 1mcg Capsule,

2.5mcg Capsule)

1 B/D, PA, QL

Doxercalciferol

Doxercalciferol (4mcg/

2ml Injection)1 B/D, PA

Etidronate Disodium

Etidronate Disodium

(Tablet)1

Forteo

Forteo (Injection) 1 PA, QL Hectorol

Hectorol (1mcg

Capsule, 2.5mcg

Capsule)

1 B/D, PA, QL

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Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Ibandronate Sodium

Ibandronate Sodium

(150mg Tablet)1 QL

Ibandronate Sodium

Ibandronate Sodium

(3mg/3ml Injection)1 B/D, PA

Miacalcin

Miacalcin (200unit/ml

Injection)1 PA

Natpara

Natpara (Injection) 1 PA Pamidronate Disodium

Pamidronate Disodium

(Injection)1 B/D, PA

Paricalcitol

Paricalcitol (1mcg

Capsule, 2mcg Capsule)1 B/D, PA, QL

Paricalcitol

Paricalcitol (2mcg/ml

Injection, 5mcg/ml

Injection)

1 B/D, PA

Paricalcitol

Paricalcitol (4mcg

Capsule)1 B/D, PA

Prolia

Prolia (Injection) 1 PA Risedronate Sodium

Risedronate Sodium

(Tablet)1 QL

Xgeva

Xgeva (Injection) 1 PA Zemplar

Zemplar (2mcg/ml

Injection, 5mcg/ml

Injection)

1 B/D, PA

Zoledronic Acid

Zoledronic Acid (4mg/

5ml Injection)1 B/D, PA

Zoledronic Acid

Zoledronic Acid (5mg/

100ml Injection)1 PA

Zometa

Zometa (Injection) 1 B/D, PA

Miscellaneous Therapeutic Agents

Miscellaneous Therapeutic AgentsAlcohol Prep Pads

Alcohol Prep Pads 1

Botox

Botox (Injection) 1 PA, QL Fomepizole

Fomepizole (Injection) 1

Gauze

Gauze (Non-medicated

2X2)1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Insulin Syringes, Needles

Insulin Syringes, Needles 1

Kanuma

Kanuma (Injection) 1 PA Methylergonovine Maleate

Methylergonovine

Maleate (Tablet)1

Myalept

Myalept (Injection) 1 PA Sterile Water Irrigation

Sterile Water Irrigation

(Solution)1

Ophthalmic Agents

Ophthalmic Agents, OtherBacitracin/Polymyxin B

Bacitracin/Polymyxin B

(Ophthalmic Ointment)1

Blephamide

Blephamide

(Suspension)1

Blephamide S.O.P.

Blephamide S.O.P.

(Ointment)1

Cystaran

Cystaran (Ophthalmic

Solution)1

Lacrisert

Lacrisert (Insert) 1

Lastacaft

Lastacaft (Ophthalmic

Solution)1

Neomycin/Bacitracin/Polymyxin

Neomycin/Bacitracin/

Polymyxin (Ointment)1

Neomycin/Polymyxin/Bacitracin/Hydrocortisone

Neomycin/Polymyxin/

Bacitracin/Hydrocortisone

(Ophthalmic Ointment)

1

Neomycin/Polymyxin/Dexamethasone

Neomycin/Polymyxin/

Dexamethasone (0.1%

Ophthalmic Ointment,

0.1% Ophthalmic

Suspension)

1

Neomycin/Polymyxin/Gramicidin

Neomycin/Polymyxin/

Gramicidin (Ophthalmic

Solution)

1

Neomycin/Polymyxin/Hydrocortisone

Neomycin/Polymyxin/

Hydrocortisone (1%

Ophthalmic Suspension)

1

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Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Polymyxin B Sulfate/Trimethoprim Sulfate

Polymyxin B Sulfate/

Trimethoprim Sulfate

(Ophthalmic Solution)

1

Pred-G

Pred-G (Suspension) 1

Pred-G S.O.P.

Pred-G S.O.P.

(Ointment)1

Proparacaine HCl

Proparacaine HCl

(Ophthalmic Solution)1

Restasis

Restasis (Emulsion) 1

Sulfacetamide Sodium/Prednisolone Sodium Phosphate

Sulfacetamide Sodium/

Prednisolone Sodium

Phosphate (Ophthalmic

Solution)

1

Tobradex ST

Tobradex ST

(Ophthalmic

Suspension)

1

Tobramycin/Dexamethasone

Tobramycin/

Dexamethasone

(Ophthalmic Suspension)

1

Ophthalmic Anti-allergy AgentsAlocril

Alocril (Ophthalmic

Solution)1

Alomide

Alomide (Ophthalmic

Solution)1

Azelastine HCl

Azelastine HCl (0.05%

Ophthalmic Solution)1

Bepreve

Bepreve (Ophthalmic

Solution)1

Cromolyn Sodium

Cromolyn Sodium (4%

Ophthalmic Solution)1

Epinastine HCl

Epinastine HCl

(Ophthalmic Solution)1

Olopatadine HCl

Olopatadine HCl

(Ophthalmic Solution)1

Pataday

Pataday (Ophthalmic

Solution)1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Patanol

Patanol (Ophthalmic

Solution)1

Pazeo

Pazeo (Ophthalmic

Solution)1

Ophthalmic Antiglaucoma AgentsAlphagan P

Alphagan P (0.1%

Ophthalmic Solution)1

Apraclonidine

Apraclonidine

(Ophthalmic Solution)1

Azopt

Azopt (Suspension) 1

Betaxolol HCl

Betaxolol HCl (0.5%

Ophthalmic Solution)1

Betimol

Betimol (Ophthalmic

Solution)1

Brimonidine Tartrate

Brimonidine Tartrate

(0.15% Ophthalmic

Solution)

1

Brimonidine Tartrate

Brimonidine Tartrate

(0.2% Ophthalmic

Solution)

1

Carteolol HCl

Carteolol HCl (Ophthalmic

Solution)1

Combigan

Combigan (Ophthalmic

Solution)1

Dorzolamide HCl

Dorzolamide HCl

(Ophthalmic Solution)1

Dorzolamide HCl/Timolol Maleate

Dorzolamide HCl/Timolol

Maleate (Ophthalmic

Solution)

1

Levobunolol HCl

Levobunolol HCl

(Ophthalmic Solution)1

Methazolamide

Methazolamide (Tablet) 1

Metipranolol

Metipranolol (Ophthalmic

Solution)1

Phospholine Iodide

Phospholine Iodide

(Ophthalmic Solution)1

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Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Pilocarpine HCl

Pilocarpine HCl (1%

Ophthalmic Solution,

2% Ophthalmic

Solution, 4%

Ophthalmic Solution)

1

Simbrinza

Simbrinza (Suspension) 1

Timolol Maleate

Timolol Maleate (0.25%

Ophthalmic Solution,

0.5% Ophthalmic

Solution)

1

Timolol Maleate Ophthalmic Gel Forming

Timolol Maleate

Ophthalmic Gel

Forming (Solution)

1

Ophthalmic Anti-inflammatoriesDexamethasone Sodium Phosphate

Dexamethasone Sodium

Phosphate (0.1%

Ophthalmic Solution)

1

Diclofenac Sodium

Diclofenac Sodium (0.1%

Ophthalmic Solution)1

Durezol

Durezol (Emulsion) 1

Flarex

Flarex (Suspension) 1

Fluorometholone

Fluorometholone

(Ophthalmic

Suspension)

1

Flurbiprofen Sodium

Flurbiprofen Sodium

(Ophthalmic Solution)1

FML

FML (Ointment) 1

FML Forte

FML Forte (Suspension) 1

Ilevro

Ilevro (Suspension) 1

Ketorolac Tromethamine

Ketorolac Tromethamine

(0.4% Ophthalmic

Solution, 0.5%

Ophthalmic Solution)

1

Lotemax

Lotemax (0.5% Gel,

0.5% Ointment, 0.5%

Suspension)

1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Nevanac

Nevanac (Suspension) 1

Pred Mild

Pred Mild (Suspension) 1

Prednisolone Acetate

Prednisolone Acetate

(Ophthalmic

Suspension)

1

Prednisolone Sodium Phosphate

Prednisolone Sodium

Phosphate (1%

Ophthalmic Solution)

1

Prolensa

Prolensa (Ophthalmic

Solution)1

Vexol

Vexol (Suspension) 1

Ophthalmic Prostaglandin and Prostamide

AnalogsLatanoprost

Latanoprost (Ophthalmic

Solution)1

Lumigan

Lumigan (Ophthalmic

Solution)1

Travatan Z

Travatan Z (Ophthalmic

Solution)1

Travoprost

Travoprost (Ophthalmic

Solution)1

Otic Agents

Otic AgentsAcetic Acid

Acetic Acid (Otic Solution) 1

Cipro HC

Cipro HC (Suspension) 1

Ciprodex

Ciprodex (Otic

Suspension)1

Coly-Mycin S

Coly-Mycin S

(Suspension)1

Fluocinolone Acetonide

Fluocinolone Acetonide

(0.01% Otic Oil)1

Hydrocortisone/Acetic Acid

Hydrocortisone/Acetic

Acid (Otic Solution)1

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67Last updated November 1, 2016

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Neomycin/Polymyxin/Hydrocortisone

Neomycin/Polymyxin/

Hydrocortisone (1% Otic

Solution, 1% Otic

Suspension)

1

Respiratory Tract/Pulmonary Agents

AntihistaminesAzelastine HCl

Azelastine HCl (0.1%

Nasal Solution)1 QL

Azelastine HCl

Azelastine HCl (0.15%

Nasal Solution)1

Cetirizine HCl

Cetirizine HCl (Syrup) 1

Cyproheptadine HCl

Cyproheptadine HCl

(4mg Tablet)1

Diphenhydramine HCl

Diphenhydramine HCl

(50mg/ml Injection)1 B/D, PA

Levocetirizine Dihydrochloride

Levocetirizine

Dihydrochloride (5mg

Tablet)

1 QL

Phenadoz

Phenadoz (Suppository) 1

Phenergan

Phenergan (12.5mg

Suppository, 25mg

Suppository)

1

Promethazine HCl

Promethazine HCl

(12.5mg Suppository,

25mg Suppository,

25mg/ml Injection,

50mg/ml Injection)

1

Promethazine HCl

Promethazine HCl

(12.5mg Tablet, 25mg

Tablet, 50mg Tablet,

6.25mg/5ml Syrup)

1

Promethegan

Promethegan (25mg

Suppository)1

Anti-inflammatories, Inhaled

CorticosteroidsArnuity Ellipta

Arnuity Ellipta (Aerosol

Powder)1 QL

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Budesonide

Budesonide (0.25mg/2ml

Suspension, 0.5mg/2ml

Suspension, 1mg/2ml

Suspension)

1 B/D, PA

Flovent Diskus

Flovent Diskus (Aerosol

Powder)1 QL

Flovent HFA

Flovent HFA (Aerosol) 1

Flunisolide

Flunisolide (Nasal

Solution)1

Fluticasone Propionate

Fluticasone Propionate

(50mcg/ACT

Suspension)

1

Mometasone Furoate

Mometasone Furoate

(50mcg/ACT

Suspension)

1

Nasonex

Nasonex (Suspension) 1

Pulmicort

Pulmicort (1mg/2ml

Suspension)1 B/D, PA

AntileukotrienesMontelukast Sodium

Montelukast Sodium

(10mg Tablet)1 QL

Montelukast Sodium

Montelukast Sodium

(4mg Packet, 4mg Tablet

Chewable, 5mg Tablet

Chewable)

1 QL

Zafirlukast

Zafirlukast (Tablet) 1 QL Zyflo

Zyflo (Tablet) 1 ST Zyflo CR

Zyflo CR (Tablet

Extended-Release 12

Hour)

1 ST

Bronchodilators, AnticholinergicAtrovent HFA

Atrovent HFA (Aerosol

Solution)1

Ipratropium Bromide

Ipratropium Bromide

(0.02% Inhalation

Solution)

1 B/D, PA

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Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Ipratropium Bromide

Ipratropium Bromide

(0.03% Nasal Solution,

0.06% Nasal Solution)

1

Spiriva HandiHaler

Spiriva HandiHaler

(Capsule)1 QL

Spiriva Respimat

Spiriva Respimat

(Aerosol Solution)1 QL

Bronchodilators, SympathomimeticAlbuterol Sulfate

Albuterol Sulfate (0.083%

Nebulized Solution, 0.5%

Nebulized Solution,

0.63mg/3ml Nebulized

Solution, 1.25mg/3ml

Nebulized Solution)

1 B/D, PA

Albuterol Sulfate

Albuterol Sulfate (2mg

Tablet Immediate-

Release, 4mg Tablet

Immediate-Release)

1

Brovana

Brovana (Nebulized

Solution)1 B/D, PA

EpiPen

EpiPen (Injection) 1

Levalbuterol

Levalbuterol (Nebulized

Solution)1 B/D, PA

Metaproterenol Sulfate

Metaproterenol Sulfate

(10mg Tablet, 20mg

Tablet, 10mg/5ml Syrup)

1

Perforomist

Perforomist (Nebulized

Solution)1 B/D, PA, QL

ProAir HFA

ProAir HFA (Aerosol

Solution)1

ProAir RespiClick

ProAir RespiClick

(Aerosol Powder)1

Serevent Diskus

Serevent Diskus

(Aerosol Powder)1 QL

Terbutaline Sulfate

Terbutaline Sulfate (1mg/

ml Injection)1

Cystic Fibrosis Agents

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Cayston

Cayston (Inhalation

Solution)1 PA, LA

Kalydeco

Kalydeco (50mg

Packet, 75mg Packet)1 PA, QL

Orkambi

Orkambi (Tablet) 1 PA, QL, LA

Phosphodiesterase Inhibitors, Airways

DiseaseAminophylline

Aminophylline (Injection) 1

Daliresp

Daliresp (Tablet) 1 PA, QL Theophylline

Theophylline (Oral

Solution)1

Theophylline CR

Theophylline CR (Tablet

Extended-Release 12

Hour)

1

Theophylline ER

Theophylline ER (300mg

Tablet Extended-Release

12 Hour, 450mg Tablet

Extended-Release 12

Hour, 400mg Tablet

Extended-Release 24

Hour, 600mg Tablet

Extended-Release 24

Hour)

1

Pulmonary AntihypertensivesAdcirca

Adcirca (Tablet) 1 PA, QL Adempas

Adempas (Tablet) 1 PA Letairis

Letairis (Tablet) 1 PA, LA Opsumit

Opsumit (Tablet) 1 PA, LA Orenitram

Orenitram (0.125mg

Tablet Extended-

Release)

1 PA, QL

Orenitram

Orenitram (0.25mg

Tablet Extended-

Release, 1mg Tablet

Extended-Release)

1 PA, QL

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Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Orenitram

Orenitram (2.5mg

Tablet Extended-

Release)

1 PA

Remodulin

Remodulin (Injection) 1 PA, LA Revatio

Revatio (10mg/12.5ml

Injection)1 PA

Revatio

Revatio (20mg Tablet) 1 PA, QL Sildenafil

Sildenafil (10mg/12.5ml

Injection)1 PA

Sildenafil

Sildenafil (20mg Tablet)

(Generic Revatio)1 PA, QL

Tracleer

Tracleer (Tablet) 1 PA, QL Tyvaso

Tyvaso (Inhalation

Solution)1 PA

Ventavis

Ventavis (Inhalation

Solution)1 PA, LA

Respiratory Tract Agents, OtherAcetylcysteine

Acetylcysteine (Inhalation

Solution)1 B/D, PA

Advair Diskus

Advair Diskus (Aerosol

Powder)1 QL

Advair HFA

Advair HFA (Aerosol) 1

Anoro Ellipta

Anoro Ellipta (Aerosol

Powder)1 QL

Aralast NP

Aralast NP (Injection) 1 PA, LA Breo Ellipta

Breo Ellipta (Aerosol

Powder)1

Cromolyn Sodium

Cromolyn Sodium (20mg/

2ml Nebulized Solution)1 B/D, PA

Dulera

Dulera (Aerosol) 1 PA Esbriet

Esbriet (Capsule) 1 PA, QL, LA Glassia

Glassia (Injection) 1 PA, LA Kalydeco

Kalydeco (150mg

Tablet)1 PA, QL

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Ofev

Ofev (Capsule) 1 PA, QL, LA Prolastin-C

Prolastin-C (Injection) 1 PA, LA Pulmozyme

Pulmozyme (Inhalation

Solution)1 B/D, PA

Stiolto Respimat

Stiolto Respimat

(Aerosol Solution)1 QL

Symbicort

Symbicort (Aerosol) 1

Tyzine Pediatric Nasal Drops

Tyzine Pediatric Nasal

Drops (Nasal Solution)1

Zemaira

Zemaira (Injection) 1 PA, LA

Respiratory Tract/Pulmonary AgentsCombivent Respimat

Combivent Respimat

(Aerosol Solution)1

Dymista

Dymista (Suspension) 1

Ipratropium Bromide/Albuterol Sulfate

Ipratropium Bromide/

Albuterol Sulfate

(Inhalation Solution)

1 B/D, PA

Xolair

Xolair (Injection) 1 PA

Skeletal Muscle Relaxants

Skeletal Muscle RelaxantsBaclofen

Baclofen (Tablet) 1

Cyclobenzaprine HCl

Cyclobenzaprine HCl

(7.5mg Tablet)1 PA, HRM

Dantrolene Sodium

Dantrolene Sodium

(Capsule)1

Gablofen

Gablofen (10000mcg/

20ml Injection, 50mcg/

ml Injection)

1 B/D, PA

Gablofen

Gablofen (40000mcg/

20ml Injection)1 B/D, PA

Lioresal Intrathecal

Lioresal Intrathecal

(0.05mg/ml Injection,

10mg/20ml Injection)

1 B/D, PA

Lioresal Intrathecal

Lioresal Intrathecal

(10mg/5ml Injection)1 B/D, PA

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Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Orphenadrine Citrate

Orphenadrine Citrate

(Injection)1

Tizanidine HCl

Tizanidine HCl (2mg

Tablet, 4mg Tablet)1

Sleep Disorder Agents

GABA Receptor ModulatorsTemazepam

Temazepam (Capsule) 1 QL Zaleplon

Zaleplon (Capsule) 1 QL, HRM Zolpidem Tartrate

Zolpidem Tartrate (10mg

Tablet Immediate-

Release, 5mg Tablet

Immediate-Release)

1 QL, HRM

Sleep Disorders, OtherBelsomra

Belsomra (Tablet) 1 QL Hetlioz

Hetlioz (Capsule) 1 PA, QL Modafinil

Modafinil (Tablet) 1 PA, QL Rozerem

Rozerem (Tablet) 1 QL Xyrem

Xyrem (Oral Solution) 1 PA, QL, LA

Therapeutic Nutrients/Minerals/Electrolytes

Electrolyte/Mineral ModifiersChemet

Chemet (Capsule) 1

Exjade

Exjade (Tablet Soluble) 1 PA Ferriprox

Ferriprox (100mg/ml

Oral Solution, 500mg

Tablet)

1 PA

Jadenu

Jadenu (Tablet) 1 PA Kionex

Kionex (Powder) 1

Samsca

Samsca (Tablet) 1 PA, QL Sodium Polystyrene Sulfonate

Sodium Polystyrene

Sulfonate (Suspension)1

SPS

SPS (Suspension) 1

Syprine

Syprine (Capsule) 1 ST

Electrolyte/Mineral Replacement

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Ammonium Chloride

Ammonium Chloride

(Injection)1

Carbaglu

Carbaglu (Tablet) 1 LA Isolyte-S

Isolyte-S (Injection) 1

Klor-Con 10

Klor-Con 10 (Tablet

Extended-Release)1

Klor-Con 8

Klor-Con 8 (Tablet

Extended-Release)1

Klor-Con M15

Klor-Con M15 (Tablet

Extended-Release)1

Klor-Con M20

Klor-Con M20 (Tablet

Extended-Release)1

Klor-Con Sprinkle

Klor-Con Sprinkle

(Capsule Extended-

Release)

1

K-Tab

K-Tab (10meq Tablet

Extended-Release,

8meq Tablet Extended-

Release)

1

Magnesium Sulfate

Magnesium Sulfate

(1gm/2ml-50%

Injection)

1

Magnesium Sulfate

Magnesium Sulfate (5gm/

10ml-50% Injection)1

Normosol-R

Normosol-R (Injection) 1

Physiolyte

Physiolyte (Irrigation

Solution)1

Physiosol Irrigation

Physiosol Irrigation

(Solution)1

Plasma-Lyte A

Plasma-Lyte A

(Injection)1

Plasma-Lyte-148

Plasma-Lyte-148

(Injection)1

Potassium Chloride

Potassium Chloride

(10% Oral Solution,

20% Oral Solution)

1

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Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Potassium Chloride

Potassium Chloride

(10meq/100ml

Injection, 20meq/100ml

Injection, 40meq/100ml

Injection)

1 B/D, PA

Potassium Chloride

Potassium Chloride

(2meq/ml Injection)1 B/D, PA

Potassium Chloride 0.15% /NaCl 0.45% Viaflex

Potassium Chloride

0.15% /NaCl 0.45%

Viaflex (Injection)

1 B/D, PA

Potassium Chloride 0.15%/NaCl 0.9%

Potassium Chloride

0.15%/NaCl 0.9%

(Injection)

1 B/D, PA

Potassium Chloride 0.3%/ NaCl 0.9%

Potassium Chloride

0.3%/ NaCl 0.9%

(Injection)

1 B/D, PA

Potassium Chloride ER

Potassium Chloride ER

(10meq Capsule

Extended-Release, 8meq

Capsule Extended-

Release, 8meq Tablet

Extended-Release)

1

Potassium Chloride ER Microencapsulated

Potassium Chloride ER

Microencapsulated

(10meq Tablet Extended-

Release, 20meq Tablet

Extended-Release)

1

Potassium Citrate ER

Potassium Citrate ER

(Tablet Extended-Release)1

Sodium Chloride

Sodium Chloride (0.9%

Injection)1

Sodium Chloride

Sodium Chloride

(2.5meq/ml Injection,

3% Injection, 5%

Injection)

1

Sodium Chloride 0.45%

Sodium Chloride 0.45%

(Injection)1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Sodium Chloride 0.9%

Sodium Chloride 0.9%

(Irrigation Solution)1

Sodium Fluoride

Sodium Fluoride (Tablet) 1

Therapeutic Nutrients/Minerals/

ElectrolytesAminosyn 7%/Electrolytes

Aminosyn 7%/

Electrolytes (Injection)1 B/D, PA

Aminosyn 8.5%/Electrolytes

Aminosyn 8.5%/

Electrolytes (Injection)1 B/D, PA

Aminosyn II

Aminosyn II (Injection) 1 B/D, PA Aminosyn II 8.5%/Electrolytes

Aminosyn II 8.5%/

Electrolytes (Injection)1 B/D, PA

Aminosyn M

Aminosyn M (Injection) 1 B/D, PA Aminosyn-HBC

Aminosyn-HBC

(Injection)1 B/D, PA

Aminosyn-PF

Aminosyn-PF (Injection) 1 B/D, PA Aminosyn-RF

Aminosyn-RF (Injection) 1 B/D, PA Clinisol SF 15%

Clinisol SF 15% (Injection) 1 B/D, PA Dextrose 10%

Dextrose 10%

(Injection)1

Dextrose 10%/NaCl 0.2%

Dextrose 10%/NaCl

0.2% (Injection)1

Dextrose 10%/NaCl 0.45%

Dextrose 10%/NaCl

0.45% (Injection)1

Dextrose 2.5%/NaCl 0.45%

Dextrose 2.5%/NaCl

0.45% (Injection)1

Dextrose 5%

Dextrose 5% (Injection) 1

Dextrose 5%/Lactated Ringers

Dextrose 5%/Lactated

Ringers (Injection)1

Dextrose 5%/NaCl 0.2%

Dextrose 5%/NaCl 0.2%

(Injection)1

Dextrose 5%/NaCl 0.225%

Dextrose 5%/NaCl

0.225% (Injection)1

Dextrose 5%/NaCl 0.33%

Dextrose 5%/NaCl

0.33% (Injection)1

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Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Dextrose 5%/NaCl 0.45%

Dextrose 5%/NaCl

0.45% (Injection)1

Dextrose 5%/NaCl 0.9%

Dextrose 5%/NaCl 0.9%

(Injection)1

Dextrose 5%/Potassium Chloride 0.15%

Dextrose 5%/Potassium

Chloride 0.15%

(Injection)

1 B/D, PA

FreAmine HBC 6.9%

FreAmine HBC 6.9%

(Injection)1 B/D, PA

HepatAmine

HepatAmine (Injection) 1 B/D, PA Intralipid

Intralipid (Injection) 1 B/D, PA Ionosol-B/Dextrose 5%

Ionosol-B/Dextrose 5%

(Injection)1

Ionosol-MB/Dextrose 5%

Ionosol-MB/Dextrose

5% (Injection)1

Isolyte-P/Dextrose 5%

Isolyte-P/Dextrose 5%

(Injection)1

KCl 0.075%/D5W/NaCl 0.45%

KCl 0.075%/D5W/NaCl

0.45% (Injection)1

KCl 0.15%/D5W/LR

KCl 0.15%/D5W/LR

(Injection)1

KCl 0.15%/D5W/NaCl 0.2%

KCl 0.15%/D5W/NaCl

0.2% (Injection)1

KCl 0.15%/D5W/NaCl 0.225%

KCl 0.15%/D5W/NaCl

0.225% (Injection)1

KCl 0.15%/D5W/NaCl 0.9%

KCl 0.15%/D5W/NaCl

0.9% (Injection)1

KCl 0.3%/D5W/NaCl 0.45%

KCl 0.3%/D5W/NaCl

0.45% (Injection)1

KCl 0.3%/D5W/NaCl 0.9%

KCl 0.3%/D5W/NaCl

0.9% (Injection)1

Lactated Ringers Irrigation

Lactated Ringers

Irrigation (Solution)1

Lactated Ringers Viaflex

Lactated Ringers

Viaflex (Injection)1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Levocarnitine

Levocarnitine (1gm/10ml

Oral Solution, 330mg

Tablet)

1 B/D, PA

Levocarnitine

Levocarnitine (200mg/ml

Injection)1 B/D, PA

Nephramine

Nephramine (Injection) 1 B/D, PA Normosol-M in D5W

Normosol-M in D5W

(Injection)1

Normosol-R in D5W

Normosol-R in D5W

(Injection)1

NutreStore

NutreStore (Packet) 1

Nutrilipid

Nutrilipid (Injection) 1 B/D, PA Plasma-Lyte-56/D5W

Plasma-Lyte-56/D5W

(Injection)1

Plenamine

Plenamine (Injection) 1 B/D, PA Potassium Chloride 0.15% D5W/NaCl 0.33%

Potassium Chloride

0.15% D5W/NaCl

0.33% (Injection)

1

Potassium Chloride 0.15% D5W/NaCl 0.45%

Potassium Chloride

0.15% D5W/NaCl

0.45% (Injection)

1

Potassium Chloride 0.22% D5W/NaCl 0.45%

Potassium Chloride

0.22% D5W/NaCl

0.45% (Injection)

1

Potassium Chloride 0.3%/D5W

Potassium Chloride

0.3%/D5W (Injection)1 B/D, PA

Premasol

Premasol (Injection) 1 B/D, PA Procalamine

Procalamine (Injection) 1 B/D, PA Prosol

Prosol (Injection) 1 B/D, PA Ringers Injection

Ringers Injection

(Injection)1

Ringers Irrigation

Ringers Irrigation

(Solution)1

Sodium Lactate

Sodium Lactate

(Injection)1

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Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

TPN Electrolytes

TPN Electrolytes

(Injection)1

Travasol

Travasol (Injection) 1 B/D, PA

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Trophamine

Trophamine (Injection) 1 B/D, PA VP-PNV-DHA

VP-PNV-DHA (Capsule) 1

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Drugs with a quantity limit (QL)

This list shows drugs that have a quantity limit. Your plan will cover only a certain amount of

these drugs or will only cover these drugs for a certain number of days. These limits may be in

place to ensure your safety.

Drugs are listed in alphabetical order in the chart below. Some drugs come in many 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.

For more information about quantity limits, talk to your doctor or pharmacist. You can also

contact us. Our contact information, along with the date we last updated the drug list, appears on

the cover.

Drug Name Quantity Limit

Abacavir (Tablet) Maximum of 3 tablets per day

Abacavir Sulfate/Lamivudine/Zidovudine (Tablet) Maximum of 3 tablets per day

Abstral (Tablet Sublingual) Maximum of 4 tablets per day

Acarbose (100mg Tablet) Maximum of 3 tablets per day

Acarbose (25mg Tablet) Maximum of 12 tablets per day

Acarbose (50mg Tablet) Maximum of 6 tablets per day

Acetaminophen/Codeine (120mg-12mg/5ml Oral

Solution)Maximum of 140 ml per day

Acetaminophen/Codeine (300mg-15mg Tablet,

300mg-30mg Tablet, 300mg-60mg Tablet)Maximum of 13 tablets per day

Actonel (150mg Tablet) Maximum of 1 tablet per 30 days

Acyclovir (5% Ointment) Maximum of 1 tube (30 grams) per 30 days

Adcirca (Tablet) Maximum of 2 tablets per day

Advair Diskus (Aerosol Powder) Maximum of 1 inhaler (60 blisters) per 30 days

Afeditab CR (Tablet Extended-Release 24 Hour) Maximum of 2 tablets per day

Aggrenox (Capsule Extended-Release 12 Hour) Maximum of 2 capsules per day

Alecensa (Capsule) Maximum of 8 capsules per day

Alendronate Sodium (10mg Tablet, 40mg Tablet, 5mg

Tablet)Maximum of 1 tablet per day

Alendronate Sodium (35mg Tablet) Maximum of 8 tablets per 28 days

Alendronate Sodium (70mg Tablet) Maximum of 4 tablets per 28 days

Alprazolam (0.25mg Tablet Immediate-Release, 0.5mg

Tablet Immediate-Release, 1mg Tablet Immediate-

Release)

Maximum of 4 tablets per day

Alprazolam (2mg Tablet Immediate-Release) Maximum of 5 tablets per day

Amitiza (Capsule) Maximum of 2 capsules per day

Amlodipine Besylate/Atorvastatin Calcium (Tablet) Maximum of 1 tablet per day

Amlodipine Besylate/Benazepril HCl (Capsule) Maximum of 1 capsule per day

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Drug Name Quantity Limit

Amlodipine Besylate/Valsartan (Tablet) Maximum of 1 tablet per day

Amlodipine/Valsartan/Hydrochlorothiazide (Tablet) Maximum of 1 tablet per day

Amphetamine/Dextroamphetamine (10mg Capsule

Extended-Release 24 Hour, 15mg Capsule Extended-

Release 24 Hour, 20mg Capsule Extended-Release

24 Hour, 25mg Capsule Extended-Release 24 Hour,

30mg Capsule Extended-Release 24 Hour, 5mg

Capsule Extended-Release 24 Hour)

Maximum of 2 capsules per day

Amphetamine/Dextroamphetamine (10mg Tablet

Immediate-Release, 12.5mg Tablet Immediate-

Release, 15mg Tablet Immediate-Release, 30mg

Tablet Immediate-Release, 5mg Tablet Immediate-

Release, 7.5mg Tablet Immediate-Release)

Maximum of 2 tablets per day

Amphetamine/Dextroamphetamine (20mg Tablet

Immediate-Release)Maximum of 3 tablets per day

Ampyra (Tablet Extended-Release 12 Hour) Maximum of 2 tablets per day

Androderm (Patch 24 Hour) Maximum of 1 patch per day

Anoro Ellipta (Aerosol Powder) Maximum of 1 inhaler (60 blisters) per 30 days

Apriso (Capsule Extended-Release 24 Hour) Maximum of 4 capsules per day

Aptiom (200mg Tablet, 400mg Tablet, 800mg

Tablet)Maximum of 1 tablet per day

Aptiom (600mg Tablet) Maximum of 2 tablets per day

Aptivus (100mg/ml Oral Solution) Maximum of 15 ml per day

Aptivus (250mg Capsule) Maximum of 6 capsules per day

Aripiprazole (10mg Tablet, 15mg Tablet, 20mg Tablet,

2mg Tablet, 30mg Tablet, 5mg Tablet)Maximum of 1 tablet per day

Aripiprazole ODT (10mg Tablet Dispersible) Maximum of 3 tablets per day

Aripiprazole ODT (15mg Tablet Dispersible) Maximum of 2 tablets per day

Arnuity Ellipta (Aerosol Powder) Maximum of 1 inhaler (30 blisters) per 30 days

Aspirin/Dipyridamole (Capsule Extended-Release

12 Hour)Maximum of 2 capsules per day

Atorvastatin Calcium (Tablet) Maximum of 1 tablet per day

Atripla (Tablet) Maximum of 2 tablets per day

Aubagio (Tablet) Maximum of 1 tablet per day

Avandia (2mg Tablet) Maximum of 4 tablets per day

Avandia (4mg Tablet) Maximum of 2 tablets per day

Azelastine HCl (0.1% Nasal Solution) Maximum of 2 bottles (60 ml) per 30 days

Azor (Tablet) Maximum of 1 tablet per day

Belsomra (Tablet) Maximum of 1 tablet per day

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Drug Name Quantity Limit

Benazepril HCl (Tablet) Maximum of 2 tablets per day

Benazepril HCl/Hydrochlorothiazide (Tablet) Maximum of 1 tablet per day

Benicar (20mg Tablet, 40mg Tablet) Maximum of 1 tablet per day

Benicar (5mg Tablet) Maximum of 2 tablets per day

Benicar HCT (Tablet) Maximum of 1 tablet per day

BiDil (Tablet) Maximum of 6 tablets per day

Binosto (Tablet Effervescent) Maximum of 4 tablets per 28 days

Bisoprolol Fumarate/Hydrochlorothiazide (Tablet) Maximum of 2 tablets per day

Botox (Injection) Maximum of 9 vials per 30 days

Brilinta (Tablet) Maximum of 2 tablets per day

BRIVIACT (100mg Tablet, 10mg Tablet, 25mg

Tablet, 50mg Tablet, 75mg Tablet)Maximum of 2 tablets per day

BRIVIACT (10mg/ml Oral Solution) Maximum of 20 ml per day

BRIVIACT (50mg/5ml Intravenous Solution) Maximum of 4 vials (20 ml) per day

Buprenorphine HCl (2mg Tablet Sublingual, 8mg

Tablet Sublingual)Maximum of 3 tablets per day

Buprenorphine HCl/Naloxone HCl (Tablet Sublingual) Maximum of 3 tablets per day

Butorphanol Tartrate (10mg/ml Nasal Solution) Maximum of 2 bottles (5 ml) per 30 days

Bydureon Vial (Injection) Maximum of 4 vials per 28 days

Bydureon Pen (Injection) Maximum of 4 pens per 28 days

Byetta (10mcg/0.04ml Solution Pen injector) Maximum of 1 pen (2.4 ml) per 30 days

Byetta (5mcg/0.02ml Solution Pen injector) Maximum of 1 pen (1.2 ml) per 30 days

Bystolic (10mg Tablet, 2.5mg Tablet, 5mg Tablet) Maximum of 1 tablet per day

Bystolic (20mg Tablet) Maximum of 2 tablets per day

Cabometyx (20mg Tablet, 60mg Tablet) Maximum of 1 tablet per day

Cabometyx (40mg Tablet) Maximum of 2 tablets per day

Candesartan Cilexetil (16mg Tablet, 32mg Tablet,

4mg Tablet)Maximum of 1 tablet per day

Candesartan Cilexetil (8mg Tablet) Maximum of 3 tablets per day

Candesartan Cilexetil/Hydrochlorothiazide (Tablet) Maximum of 1 tablet per day

Captopril (100mg Tablet) Maximum of 4 tablets per day

Captopril (12.5mg Tablet, 25mg Tablet) Maximum of 3 tablets per day

Captopril (50mg Tablet) Maximum of 9 tablets per day

Captopril/Hydrochlorothiazide (25mg-15mg Tablet,

50mg-15mg Tablet)Maximum of 3 tablets per day

Captopril/Hydrochlorothiazide (25mg-25mg Tablet,

50mg-25mg Tablet)Maximum of 2 tablets per day

Celecoxib (Capsule) Maximum of 2 capsules per day

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Drug Name Quantity Limit

Clonazepam (0.5mg Tablet Immediate-Release, 1mg

Tablet Immediate-Release)Maximum of 4 tablets per day

Clonazepam (2mg Tablet Immediate-Release) Maximum of 10 tablets per day

Clonazepam ODT (0.125mg Tablet Dispersible,

0.25mg Tablet Dispersible, 0.5mg Tablet Dispersible,

1mg Tablet Dispersible)

Maximum of 4 tablets per day

Clonazepam ODT (2mg Tablet Dispersible) Maximum of 10 tablets per day

Clopidogrel (75mg Tablet) Maximum of 4 tablets per day

Clorazepate Dipotassium (15mg Tablet) Maximum of 6 tablets per day

Clorazepate Dipotassium (3.75mg Tablet) Maximum of 24 tablets per day

Clorazepate Dipotassium (7.5mg Tablet) Maximum of 12 tablets per day

Clozapine ODT (100mg Tablet Dispersible) Maximum of 9 tablets per day

Clozapine ODT (12.5mg Tablet Dispersible) Maximum of 2 tablets per day

Clozapine ODT (150mg Tablet Dispersible) Maximum of 6 tablets per day

Clozapine ODT (200mg Tablet Dispersible) Maximum of 4 tablets per day

Clozapine ODT (25mg Tablet Dispersible) Maximum of 3 tablets per day

Codeine Sulfate (Tablet) Maximum of 6 tablets per day

Colchicine (0.6mg Tablet) (Generic Colcrys) Maximum of 4 tablets per day

Colcrys (Tablet) Maximum of 4 tablets per day

Combivir (Tablet) Maximum of 3 tablets per day

Complera (Tablet) Maximum of 2 tablets per day

Cotellic (Tablet) Maximum of 3 tablets per day

Crestor (Tablet) Maximum of 1 tablet per day

Crixivan (Capsule) Maximum of 9 capsules per day

Cycloset (Tablet) Maximum of 6 tablets per day

Daklinza (Tablet) Maximum of 1 tablet per day

Daliresp (Tablet) Maximum of 1 tablet per day

Denavir (Cream) Maximum of 1 tube (5 grams) per 30 days

Descovy (Tablet) Maximum of 2 tablets per day

Dexedrine (Tablet) Maximum of 6 tablets per day

Dexilant (Capsule Delayed-Release) Maximum of 1 capsule per day

Dexmethylphenidate HCl (Tablet Immediate-Release) Maximum of 2 tablets per day

Dextroamphetamine Sulfate (10mg Tablet Immediate-

Release, 5mg Tablet Immediate-Release)Maximum of 6 tablets per day

Dextroamphetamine Sulfate ER (10mg Capsule

Extended-Release 24 Hour)Maximum of 6 capsules per day

Dextroamphetamine Sulfate ER (15mg Capsule

Extended-Release 24 Hour)Maximum of 4 capsules per day

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Drug Name Quantity Limit

Dextroamphetamine Sulfate ER (5mg Capsule

Extended-Release 24 Hour)Maximum of 3 capsules per day

Diazepam (10mg Tablet, 2mg Tablet, 5mg Tablet) Maximum of 4 tablets per day

Diazepam Intensol (5mg/ml Concentrate) Maximum of 8 ml per day

Didanosine (Capsule Delayed-Release) Maximum of 2 capsules per day

Donepezil HCl (10mg Tablet Immediate-Release) Maximum of 2 tablets per day

Donepezil HCl (23mg Tablet Immediate-Release, 5mg

Tablet Immediate-Release)Maximum of 1 tablet per day

Donepezil HCl ODT (10mg Tablet Dispersible) Maximum of 2 tablets per day

Donepezil HCl ODT (5mg Tablet Dispersible) Maximum of 1 tablet per day

Doxercalciferol (0.5mcg Capsule) Maximum of 3 capsules per day

Doxercalciferol (1mcg Capsule) Maximum of 8 capsules per day

Doxercalciferol (2.5mcg Capsule) Maximum of 4 capsules per day

Dronabinol (10mg Capsule, 2.5mg Capsule, 5mg

Capsule)Maximum of 4 capsules per day

Duloxetine HCl (20mg Capsule Delayed-Release,

30mg Capsule Delayed-Release, 60mg Capsule

Delayed-Release)

Maximum of 2 capsules per day

Edarbi (Tablet) Maximum of 1 tablet per day

Edarbyclor (Tablet) Maximum of 1 tablet per day

Edurant (Tablet) Maximum of 2 tablets per day

Effient (Tablet) Maximum of 1 tablet per day

Eliquis (Tablet) Maximum of 2 tablets per day

Embeda (100mg-4mg Capsule Extended-Release) Maximum of 3 capsules per day

Embeda (20mg-0.8mg Capsule Extended-

Release, 80mg-3.2mg Capsule Extended-

Release)

Maximum of 4 capsules per day

Embeda (30mg-1.2mg Capsule Extended-

Release, 50mg-2mg Capsule Extended-Release)Maximum of 2 capsules per day

Embeda (60mg-2.4mg Capsule Extended-

Release)Maximum of 6 capsules per day

Emsam (Patch 24 Hour) Maximum of 1 patch per day

Emtriva (10mg/ml Oral Solution) Maximum of 42.5 ml per day

Emtriva (200mg Capsule) Maximum of 2 capsules per day

Enalapril Maleate (Tablet) Maximum of 2 tablets per day

Enalapril Maleate/Hydrochlorothiazide (10mg-25mg

Tablet)Maximum of 2 tablets per day

Enalapril Maleate/Hydrochlorothiazide (5mg-12.5mg

Tablet)Maximum of 1 tablet per day

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Drug Name Quantity Limit

Endocet (Tablet) Maximum of 12 tablets per day

Enoxaparin Sodium (100mg/ml Subcutaneous

Solution, 150mg/ml Subcutaneous Solution)Maximum of 2 syringes (2 ml) per day

Enoxaparin Sodium (120mg/0.8ml Subcutaneous

Solution, 80mg/0.8ml Subcutaneous Solution)Maximum of 2 syringes (1.6 ml) per day

Enoxaparin Sodium (300mg/3ml Solution) Maximum of 1 vial (3 ml) per day

Enoxaparin Sodium (30mg/0.3ml Subcutaneous

Solution)Maximum of 2 syringes (0.6 ml) per day

Enoxaparin Sodium (40mg/0.4ml Subcutaneous

Solution)Maximum of 2 syringes (0.8 ml) per day

Enoxaparin Sodium (60mg/0.6ml Subcutaneous

Solution)Maximum of 2 syringes (1.2 ml) per day

Entresto (Tablet) Maximum of 2 tablets per day

Epclusa (Tablet) Maximum of 1 tablet per day

Epivir (Oral Solution) Maximum of 48 ml per day

Eprosartan Mesylate (Tablet) Maximum of 1 tablet per day

Epzicom (Tablet) Maximum of 2 tablets per day

Esbriet (Capsule) Maximum of 9 capsules per day

Esomeprazole Magnesium (20mg Capsule Delayed-

Release) (Generic Nexium)Maximum of 3 capsules per day

Esomeprazole Magnesium (40mg Capsule Delayed-

Release) (Generic Nexium)Maximum of 2 capsules per day

Evotaz (Tablet) Maximum of 2 tablets per day

Exelon (Patch 24 Hour) Maximum of 1 patch per day

Famciclovir (125mg Tablet, 250mg Tablet) Maximum of 2 tablets per day

Famciclovir (500mg Tablet) Maximum of 3 tablets per day

Fanapt (10mg Tablet, 12mg Tablet, 1mg Tablet,

2mg Tablet, 4mg Tablet, 6mg Tablet, 8mg Tablet)Maximum of 2 tablets per day

Fazaclo (100mg Tablet Dispersible) Maximum of 9 tablets per day

Fazaclo (150mg Tablet Dispersible) Maximum of 6 tablets per day

Fazaclo (200mg Tablet Dispersible) Maximum of 4 tablets per day

Fentanyl (100mcg/hr Patch 72 Hour, 12mcg/hr

Patch 72 Hour, 25mcg/hr Patch 72 Hour, 50mcg/hr

Patch 72 Hour, 75mcg/hr Patch 72 Hour)

Maximum of 15 patches per 30 days

Fetzima (Capsule Extended-Release 24 Hour) Maximum of 1 capsule per day

Flector (Patch) Maximum of 2 patches per day

Flovent Diskus (Aerosol Powder) Maximum of 2 inhalers (120 blisters) per 30 days

Fluvastatin (20mg Capsule Immediate-Release) Maximum of 1 capsule per day

Fluvastatin (40mg Capsule Immediate-Release) Maximum of 2 capsules per day

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Drug Name Quantity Limit

Forteo (Injection) Maximum of 1 pen (2.4 ml) per 28 days

Fosinopril Sodium (Tablet) Maximum of 2 tablets per day

Fosinopril Sodium/Hydrochlorothiazide (Tablet) Maximum of 4 tablets per day

Fuzeon (Injection) Maximum of 3 vials per day

Gabitril (12mg Tablet) Maximum of 4 tablets per day

Gabitril (16mg Tablet) Maximum of 3 tablets per day

Galantamine HBr (12mg Tablet, 4mg Tablet, 8mg

Tablet)Maximum of 2 tablets per day

Galantamine HBr (16mg Capsule Extended-Release

24 Hour, 24mg Capsule Extended-Release 24 Hour,

8mg Capsule Extended-Release 24 Hour)

Maximum of 1 capsule per day

Galantamine HBr (4mg/ml Oral Solution) Maximum of 2 bottles (200 ml) per 30 days

Genvoya (Tablet) Maximum of 2 tablets per day

Gilenya (Capsule) Maximum of 1 pack (30 capsules) per 30 days

Glimepiride (1mg Tablet) Maximum of 8 tablets per day

Glimepiride (2mg Tablet) Maximum of 4 tablets per day

Glimepiride (4mg Tablet) Maximum of 2 tablets per day

Glipizide (10mg Tablet Immediate-Release) Maximum of 4 tablets per day

Glipizide (5mg Tablet Immediate-Release) Maximum of 8 tablets per day

Glipizide ER (10mg Tablet Extended-Release 24

Hour)Maximum of 2 tablets per day

Glipizide ER (2.5mg Tablet Extended-Release 24

Hour)Maximum of 8 tablets per day

Glipizide ER (5mg Tablet Extended-Release 24 Hour) Maximum of 4 tablets per day

Glipizide/Metformin HCl (2.5mg-250mg Tablet) Maximum of 8 tablets per day

Glipizide/Metformin HCl (2.5mg-500mg Tablet,

5mg-500mg Tablet)Maximum of 4 tablets per day

Glyset (100mg Tablet) Maximum of 3 tablets per day

Glyset (25mg Tablet) Maximum of 12 tablets per day

Glyset (50mg Tablet) Maximum of 6 tablets per day

Granisetron HCl (1mg Tablet) Maximum of 2 tablets per day

Harvoni (Tablet) Maximum of 1 tablet per day

Hectorol (1mcg Capsule) Maximum of 8 capsules per day

Hectorol (2.5mcg Capsule) Maximum of 4 capsules per day

Hetlioz (Capsule) Maximum of 1 capsule per day

Hydrocodone Bitartrate/Acetaminophen

(7.5mg-325mg/15ml Oral Solution)Maximum of 180 ml per day

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Hydrocodone/Acetaminophen (10mg-325mg Tablet,

2.5mg-325mg Tablet, 5mg-325mg Tablet,

7.5mg-325mg Tablet)

Maximum of 12 tablets per day

Hydrocodone/Ibuprofen (7.5mg-200mg Tablet) Maximum of 5 tablets per day

Hydromorphone HCl (1mg/ml Liquid) Maximum of 90 ml per day

Hydromorphone HCl (2mg Tablet Immediate-Release,

4mg Tablet Immediate-Release)Maximum of 8 tablets per day

Hydromorphone HCl (8mg Tablet Immediate-Release) Maximum of 11 tablets per day

Hydromorphone HCl ER (12mg Tablet Extended-

Release 24 Hour Abuse-Deterrent, 16mg Tablet

Extended-Release 24 Hour Abuse-Deterrent, 8mg

Tablet Extended-Release 24 Hour Abuse-Deterrent)

Maximum of 2 tablets per day

Hydromorphone HCl ER (32mg Tablet Extended-

Release 24 Hour Abuse-Deterrent)Maximum of 2 tablets per day

Ibandronate Sodium (150mg Tablet) Maximum of 1 tablet per 28 days

Ibrance (Capsule) Maximum of 1 capsule per day

Intelence (100mg Tablet) Maximum of 2 tablets per day

Intelence (200mg Tablet) Maximum of 3 tablets per day

Intelence (25mg Tablet) Maximum of 6 tablets per day

Invega (1.5mg Tablet Extended-Release 24 Hour,

3mg Tablet Extended-Release 24 Hour, 9mg

Tablet Extended-Release 24 Hour)

Maximum of 1 tablet per day

Invega (6mg Tablet Extended-Release 24 Hour) Maximum of 2 tablets per day

Invirase (200mg Capsule) Maximum of 15 capsules per day

Invirase (500mg Tablet) Maximum of 6 tablets per day

Invokamet (Tablet) Maximum of 2 tablets per day

Invokana (Tablet) Maximum of 1 tablet per day

Irbesartan (150mg Tablet, 300mg Tablet) Maximum of 1 tablet per day

Irbesartan (75mg Tablet) Maximum of 3 tablets per day

Irbesartan/Hydrochlorothiazide (Tablet) Maximum of 1 tablet per day

Iressa (Tablet) Maximum of 2 tablets per day

Isentress (100mg Packet) Maximum of 4 packets per day

Isentress (100mg Tablet Chewable, 25mg Tablet

Chewable)Maximum of 9 tablets per day

Isentress (400mg Tablet) Maximum of 6 tablets per day

Itraconazole (Capsule) Maximum of 4 capsules per day

Janumet (Tablet Immediate-Release) Maximum of 2 tablets per day

Janumet XR (Tablet Extended-Release 24 Hour) Maximum of 2 tablets per day

Januvia (Tablet) Maximum of 1 tablet per day

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Drug Name Quantity Limit

Jardiance (Tablet) Maximum of 1 tablet per day

Jentadueto (Tablet) Maximum of 2 tablets per day

Jentadueto XR (2.5mg-1000mg Tablet Extended-

Release 24 Hour)Maximum of 2 tablets per day

Jentadueto XR (5mg-1000mg Tablet Extended-

Release 24 Hour)Maximum of 1 tablet per day

Kaletra (100mg-25mg Tablet) Maximum of 10 tablets per day

Kaletra (200mg-50mg Tablet) Maximum of 6 tablets per day

Kaletra (400mg-100mg/5ml Oral Solution) Maximum of 16 ml per day

Kalydeco (150mg Tablet) Maximum of 2 tablets per day

Kalydeco (50mg Packet, 75mg Packet) Maximum of 2 packets per day

Kazano (Tablet) Maximum of 2 tablets per day

Kombiglyze XR (2.5mg-1000mg Tablet Extended-

Release 24 Hour)Maximum of 2 tablets per day

Kombiglyze XR (5mg-1000mg Tablet Extended-

Release 24 Hour, 5mg-500mg Tablet Extended-

Release 24 Hour)

Maximum of 1 tablet per day

Korlym (Tablet) Maximum of 4 tablets per day

Lamivudine (10mg/ml Oral Solution) Maximum of 48 ml per day

Lamivudine (150mg Tablet) Maximum of 3 tablets per day

Lamivudine (300mg Tablet) Maximum of 2 tablets per day

Lamivudine/Zidovudine (Tablet) Maximum of 3 tablets per day

Latuda (120mg Tablet, 20mg Tablet, 40mg

Tablet, 60mg Tablet)Maximum of 1 tablet per day

Latuda (80mg Tablet) Maximum of 2 tablets per day

Levocetirizine Dihydrochloride (5mg Tablet) Maximum of 1 tablet per day

Levorphanol Tartrate (Tablet) Maximum of 6 tablets per day

Lexiva (50mg/ml Suspension) Maximum of 90 ml per day

Lexiva (700mg Tablet) Maximum of 6 tablets per day

Lialda (Tablet Delayed-Release) Maximum of 4 tablets per day

Lidocaine (5% Patch) Maximum of 3 patches per day

Linezolid (600mg Tablet) Maximum of 2 tablets per day

Linzess (Capsule) Maximum of 1 capsule per day

Lisinopril (Tablet) Maximum of 2 tablets per day

Lisinopril/Hydrochlorothiazide (10mg-12.5mg Tablet) Maximum of 1 tablet per day

Lisinopril/Hydrochlorothiazide (20mg-12.5mg Tablet) Maximum of 4 tablets per day

Lisinopril/Hydrochlorothiazide (20mg-25mg Tablet) Maximum of 2 tablets per day

Lonsurf (6.14mg-15mg Tablet) Maximum of 10 tablets per day

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Drug Name Quantity Limit

Lonsurf (8.19mg-20mg Tablet) Maximum of 8 tablets per day

Lorazepam (0.5mg Tablet, 1mg Tablet) Maximum of 4 tablets per day

Lorazepam (2mg Tablet) Maximum of 5 tablets per day

Lorazepam Intensol (2mg/ml Concentrate) Maximum of 5 ml per day

Lorcet (Tablet) Maximum of 12 tablets per day

Lorcet HD (Tablet) Maximum of 12 tablets per day

Lorcet Plus (Tablet) Maximum of 12 tablets per day

Lortab (Tablet) Maximum of 12 tablets per day

Losartan Potassium (100mg Tablet) Maximum of 1 tablet per day

Losartan Potassium (25mg Tablet, 50mg Tablet) Maximum of 2 tablets per day

Losartan Potassium/Hydrochlorothiazide

(100mg-12.5mg Tablet, 100mg-25mg Tablet)Maximum of 1 tablet per day

Losartan Potassium/Hydrochlorothiazide

(50mg-12.5mg Tablet)Maximum of 2 tablets per day

Lovastatin (10mg Tablet Immediate-Release, 20mg

Tablet Immediate-Release)Maximum of 1 tablet per day

Lovastatin (40mg Tablet Immediate-Release) Maximum of 2 tablets per day

Loxapine Succinate (10mg Capsule, 5mg Capsule) Maximum of 4 capsules per day

Lynparza (Capsule) Maximum of 16 capsules per day

Lyrica (100mg Capsule, 150mg Capsule, 200mg

Capsule, 25mg Capsule, 50mg Capsule, 75mg

Capsule)

Maximum of 3 capsules per day

Lyrica (20mg/ml Oral Solution) Maximum of 30 ml per day

Lyrica (225mg Capsule, 300mg Capsule) Maximum of 2 capsules per day

Matzim LA (360mg Tablet Extended-Release 24 Hour,

420mg Tablet Extended-Release 24 Hour)Maximum of 1 tablet per day

Memantine HCl (10mg Tablet) Maximum of 2 tablets per day

Memantine HCl (2mg/ml Oral Solution) Maximum of 10 ml per day

Memantine HCl (5mg Tablet) Maximum of 3 tablets per day

Metadate ER (Tablet Extended-Release) Maximum of 3 tablets per day

Metformin HCl (1000mg Tablet Immediate-Release) Maximum of 2.5 tablets per day

Metformin HCl (500mg Tablet Immediate-Release) Maximum of 5 tablets per day

Metformin HCl (850mg Tablet Immediate-Release) Maximum of 3 tablets per day

Metformin HCl ER (1000mg Tablet Extended-Release

24 Hour) (Generic Fortamet)Maximum of 2 tablets per day

Metformin HCl ER (500mg Tablet Extended-Release

24 Hour) (Generic Glucophage XR)Maximum of 4 tablets per day

Metformin HCl ER (750mg Tablet Extended-Release

24 Hour) (Generic Glucophage XR)Maximum of 2 tablets per day

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Drug Name Quantity Limit

Methadone HCl (10mg Tablet) Maximum of 12 tablets per day

Methadone HCl (10mg/5ml Oral Solution) Maximum of 60 ml per day

Methadone HCl (5mg Tablet) Maximum of 8 tablets per day

Methadone HCl (5mg/5ml Oral Solution) Maximum of 120 ml per day

Methylphenidate HCl (10mg Tablet Immediate-

Release, 20mg Tablet Immediate-Release, 5mg Tablet

Immediate-Release) (Generic Ritalin)

Maximum of 3 tablets per day

Methylphenidate HCl (10mg/5ml Oral Solution) Maximum of 30 ml per day

Methylphenidate HCl (5mg/5ml Oral Solution) Maximum of 60 ml per day

Methylphenidate HCl ER (10mg Tablet Extended-

Release)Maximum of 4 tablets per day

Methylphenidate HCl ER (20mg Tablet Extended-

Release)Maximum of 3 tablets per day

Miglitol (100mg Tablet) Maximum of 3 tablets per day

Miglitol (25mg Tablet) Maximum of 12 tablets per day

Miglitol (50mg Tablet) Maximum of 6 tablets per day

Modafinil (100mg Tablet) Maximum of 1 tablet per day

Modafinil (200mg Tablet) Maximum of 2 tablets per day

Moexipril HCl (Tablet) Maximum of 2 tablets per day

Moexipril/Hydrochlorothiazide (15mg-12.5mg Tablet,

15mg-25mg Tablet)Maximum of 2 tablets per day

Moexipril/Hydrochlorothiazide (7.5mg-12.5mg Tablet) Maximum of 1 tablet per day

Montelukast Sodium (10mg Tablet) Maximum of 1 tablet per day

Montelukast Sodium (4mg Packet) Maximum of 1 packet per day

Montelukast Sodium (4mg Tablet Chewable, 5mg

Tablet Chewable)Maximum of 1 tablet per day

Morphine Sulfate (100mg/5ml Oral Solution) Maximum of 18 ml per day

Morphine Sulfate (10mg/5ml Oral Solution) Maximum of 120 ml per day

Morphine Sulfate (15mg Tablet Immediate-

Release)Maximum of 8 tablets per day

Morphine Sulfate (20mg/5ml Oral Solution) Maximum of 90 ml per day

Morphine Sulfate (30mg Tablet Immediate-

Release)Maximum of 12 tablets per day

Morphine Sulfate ER (100mg Tablet Extended-

Release, 15mg Tablet Extended-Release) (Generic

MS Contin)

Maximum of 3 tablets per day

Morphine Sulfate ER (200mg Tablet Extended-

Release) (Generic MS Contin)Maximum of 2 tablets per day

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Morphine Sulfate ER (30mg Tablet Extended-Release,

60mg Tablet Extended-Release) (Generic MS Contin)Maximum of 4 tablets per day

Multaq (Tablet) Maximum of 2 tablets per day

Nadolol/Bendroflumethiazide (40mg-5mg Tablet) Maximum of 1 tablet per day

Namenda (10mg Tablet Immediate-Release) Maximum of 2 tablets per day

Namenda (10mg/5ml Oral Solution) Maximum of 10 ml per day

Namenda (5mg Tablet Immediate-Release) Maximum of 3 tablets per day

Namenda XR (Capsule Extended-Release 24

Hour)Maximum of 1 capsule per day

Namenda XR Titration Pack (Capsule Extended-

Release 24 Hour)Maximum of 1 capsule per day

Namzaric (Capsule Extended-Release 24 Hour) Maximum of 1 capsule per day

Naratriptan HCl (Tablet) Maximum of 9 tablets per 30 days

Nateglinide (120mg Tablet) Maximum of 3 tablets per day

Nateglinide (60mg Tablet) Maximum of 6 tablets per day

Nesina (Tablet) Maximum of 1 tablet per day

Nevirapine (200mg Tablet Immediate-Release) Maximum of 3 tablets per day

Nevirapine (50mg/5ml Suspension) Maximum of 60 ml per day

Nevirapine ER (100mg Tablet Extended-Release 24

Hour)Maximum of 3 tablets per day

Nevirapine ER (400mg Tablet Extended-Release 24

Hour)Maximum of 2 tablets per day

Nexium (20mg Capsule Delayed-Release) Maximum of 3 capsules per day

Nexium (40mg Capsule Delayed-Release) Maximum of 2 capsules per day

Nifedical XL (Tablet Extended-Release 24 Hour) Maximum of 2 tablets per day

Nifedipine ER (Tablet Extended-Release 24 Hour) Maximum of 2 tablets per day

Ninlaro (Capsule) Maximum of 3 capsules per 28 days

Northera (100mg Capsule) Maximum of 3 capsules per day

Northera (200mg Capsule, 300mg Capsule) Maximum of 6 capsules per day

Norvir (100mg Capsule) Maximum of 18 capsules per day

Norvir (100mg Tablet) Maximum of 18 tablets per day

Norvir (80mg/ml Oral Solution) Maximum of 24 ml per day

Nucynta ER (Tablet Extended-Release 12 Hour) Maximum of 2 tablets per day

Nuplazid (Tablet) Maximum of 2 tablets per day

Ocaliva (Tablet) Maximum of 1 tablet per day

Odefsey (Tablet) Maximum of 2 tablets per day

Odomzo (Capsule) Maximum of 1 capsule per day

Ofev (Capsule) Maximum of 2 capsules per day

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Drug Name Quantity Limit

Olanzapine (10mg Tablet Immediate-Release, 15mg

Tablet Immediate-Release, 2.5mg Tablet Immediate-

Release, 20mg Tablet Immediate-Release, 5mg Tablet

Immediate-Release, 7.5mg Tablet Immediate-Release)

Maximum of 1 tablet per day

Olanzapine ODT (Tablet Dispersible) Maximum of 1 tablet per day

Olysio (Capsule) Maximum of 1 capsule per day

Omega-3-Acid Ethyl Esters (Capsule) (Generic

Lovaza)Maximum of 4 capsules per day

Omeprazole (10mg Capsule Delayed-Release) Maximum of 3 capsules per day

Omeprazole (40mg Capsule Delayed-Release) Maximum of 2 capsules per day

Onfi (10mg Tablet, 20mg Tablet) Maximum of 2 tablets per day

Onglyza (Tablet) Maximum of 1 tablet per day

Opana ER (10mg Tablet Extended-Release 12

Hour Abuse-Deterrent, 15mg Tablet Extended-

Release 12 Hour Abuse-Deterrent, 20mg Tablet

Extended-Release 12 Hour Abuse-Deterrent, 5mg

Tablet Extended-Release 12 Hour Abuse-

Deterrent, 7.5mg Tablet Extended-Release 12

Hour Abuse-Deterrent)

Maximum of 2 tablets per day

Opana ER (30mg Tablet Extended-Release 12

Hour Abuse-Deterrent)Maximum of 4 tablets per day

Opana ER (40mg Tablet Extended-Release 12

Hour Abuse-Deterrent)Maximum of 3 tablets per day

Orenitram (0.125mg Tablet Extended-Release,

0.25mg Tablet Extended-Release, 1mg Tablet

Extended-Release)

Maximum of 6 tablets per day

Orkambi (Tablet) Maximum of 112 tablets per 28 days

Oseni (Tablet) Maximum of 1 tablet per day

Oxandrolone (10mg Tablet) Maximum of 2 tablets per day

Oxandrolone (2.5mg Tablet) Maximum of 4 tablets per day

Oxybutynin Chloride ER (10mg Tablet Extended-

Release 24 Hour, 15mg Tablet Extended-Release 24

Hour)

Maximum of 2 tablets per day

Oxybutynin Chloride ER (5mg Tablet Extended-

Release 24 Hour)Maximum of 1 tablet per day

Oxycodone HCl (100mg/5ml Concentrate) Maximum of 12 ml per day

Oxycodone HCl (10mg Tablet Immediate-Release,

20mg Tablet Immediate-Release, 5mg Tablet

Immediate-Release)

Maximum of 12 tablets per day

Oxycodone HCl (15mg Tablet Immediate-Release) Maximum of 16 tablets per day

Oxycodone HCl (30mg Tablet Immediate-Release) Maximum of 8 tablets per day

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Drug Name Quantity Limit

Oxycodone HCl (5mg/5ml Oral Solution) Maximum of 240 ml per day

Oxycodone/Acetaminophen (10mg-325mg Tablet,

2.5mg-325mg Tablet, 5mg-325mg Tablet,

7.5mg-325mg Tablet)

Maximum of 12 tablets per day

Oxycodone/Acetaminophen (325mg/5ml-5mg/5ml

Oral Solution)Maximum of 60 ml per day

Oxycodone/Aspirin (Tablet) Maximum of 12 tablets per day

Oxycodone/Ibuprofen (Tablet) Maximum of 4 tablets per day

Paliperidone ER (1.5mg Tablet Extended-Release 24

Hour, 3mg Tablet Extended-Release 24 Hour, 9mg

Tablet Extended-Release 24 Hour)

Maximum of 1 tablet per day

Paliperidone ER (6mg Tablet Extended-Release 24

Hour)Maximum of 2 tablets per day

Pantoprazole Sodium (20mg Tablet Delayed-Release) Maximum of 3 tablets per day

Pantoprazole Sodium (40mg Tablet Delayed-Release) Maximum of 2 tablets per day

Paricalcitol (1mcg Capsule) Maximum of 1 capsule per day

Paricalcitol (2mcg Capsule) Maximum of 2 capsules per day

Pentasa (250mg Capsule Extended-Release) Maximum of 12 capsules per day

Pentasa (500mg Capsule Extended-Release) Maximum of 8 capsules per day

Perforomist (Nebulized Solution) Maximum of 2 vials (4 ml) per day

Perindopril Erbumine (Tablet) Maximum of 2 tablets per day

Pioglitazone HCl (15mg Tablet) Maximum of 3 tablets per day

Pioglitazone HCl (30mg Tablet, 45mg Tablet) Maximum of 1 tablet per day

Pioglitazone HCl/Glimepiride (Tablet) Maximum of 1 tablet per day

Pioglitazone HCl/Metformin HCl (Tablet) Maximum of 3 tablets per day

Potiga (200mg Tablet, 300mg Tablet, 400mg

Tablet)Maximum of 3 tablets per day

Potiga (50mg Tablet) Maximum of 9 tablets per day

Pradaxa (Capsule) Maximum of 2 capsules per day

Praluent (150mg/ml Solution Pen injector, 75mg/

ml Solution Pen injector)Maximum of 2 pens (2 ml) per 28 days

Praluent (150mg/ml Solution Prefilled Syringe,

75mg/ml Solution Prefilled Syringe)Maximum of 2 syringes (2 ml) per 28 days

Pravastatin Sodium (Tablet) Maximum of 1 tablet per day

Prezcobix (Tablet) Maximum of 2 tablets per day

Prezista (100mg/ml Suspension) Maximum of 60 ml per day

Prezista (150mg Tablet) Maximum of 6 tablets per day

Prezista (600mg Tablet, 800mg Tablet) Maximum of 3 tablets per day

Prezista (75mg Tablet) Maximum of 7 tablets per day

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Pristiq (100mg Tablet Extended-Release 24 Hour) Maximum of 4 tablets per day

Pristiq (25mg Tablet Extended-Release 24 Hour,

50mg Tablet Extended-Release 24 Hour)Maximum of 1 tablet per day

Quetiapine Fumarate (100mg Tablet Immediate-

Release, 200mg Tablet Immediate-Release, 50mg

Tablet Immediate-Release)

Maximum of 3 tablets per day

Quetiapine Fumarate (25mg Tablet Immediate-

Release)Maximum of 4 tablets per day

Quetiapine Fumarate (300mg Tablet Immediate-

Release, 400mg Tablet Immediate-Release)Maximum of 2 tablets per day

Quinapril HCl (Tablet) Maximum of 2 tablets per day

Quinapril/Hydrochlorothiazide (10mg-12.5mg Tablet) Maximum of 1 tablet per day

Quinapril/Hydrochlorothiazide (20mg-12.5mg Tablet,

20mg-25mg Tablet)Maximum of 2 tablets per day

Raloxifene HCl (Tablet) Maximum of 1 tablet per day

Ramipril (Capsule) Maximum of 2 capsules per day

Ranexa (Tablet Extended-Release 12 Hour) Maximum of 2 tablets per day

Rapaflo (Capsule) Maximum of 1 capsule per day

Relenza Diskhaler (Aerosol Powder) Maximum of 3 inhalers (60 blisters) per 30 days

Repaglinide (0.5mg Tablet) Maximum of 32 tablets per day

Repaglinide (1mg Tablet) Maximum of 16 tablets per day

Repaglinide (2mg Tablet) Maximum of 8 tablets per day

Repaglinide/Metformin HCl (Tablet) Maximum of 5 tablets per day

Repatha (Injection) Maximum of 3 syringes (3 ml) per 28 days

Repatha Pushtronex System (Solution Cartridge) Maximum of 1 cartridge (3.5 ml) per 28 days

Repatha SureClick (Injection) Maximum of 3 pens (3 ml) per 28 days

Rescriptor (Tablet) Maximum of 9 tablets per day

Revatio (20mg Tablet) Maximum of 3 tablets per day

Rexulti (Tablet) Maximum of 1 tablet per day

Reyataz (150mg Capsule, 300mg Capsule) Maximum of 2 capsules per day

Reyataz (200mg Capsule) Maximum of 3 capsules per day

Reyataz (50mg Packet) Maximum of 8 packets per day

Riomet (Oral Solution) Maximum of 25.5 ml per day

Risedronate Sodium (150mg Tablet) Maximum of 1 tablet per 30 days

Risedronate Sodium (30mg Tablet, 5mg Tablet) Maximum of 1 tablet per day

Risedronate Sodium (35mg Tablet) Maximum of 4 tablets per 28 days

Rivastigmine Tartrate (Capsule Immediate-Release) Maximum of 2 capsules per day

Rivastigmine Transdermal System (Patch 24 Hour) Maximum of 1 patch per day

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Drug Name Quantity Limit

Rizatriptan Benzoate (Tablet Immediate-Release) Maximum of 12 tablets per 30 days

Rizatriptan Benzoate ODT (Tablet Dispersible) Maximum of 12 tablets per 30 days

Rosuvastatin Calcium (Tablet) Maximum of 1 tablet per day

Rozerem (Tablet) Maximum of 1 tablet per day

Sabril (500mg Packet) Maximum of 6 packets per day

Sabril (500mg Tablet) Maximum of 6 tablets per day

Samsca (Tablet) Maximum of 2 tablets per day

Saphris (Tablet Sublingual) Maximum of 2 tablets per day

Selzentry (150mg Tablet) Maximum of 3 tablets per day

Selzentry (300mg Tablet) Maximum of 6 tablets per day

Sensipar (30mg Tablet, 60mg Tablet) Maximum of 2 tablets per day

Sensipar (90mg Tablet) Maximum of 4 tablets per day

Serevent Diskus (Aerosol Powder) Maximum of 1 inhaler (60 inhalations) per 30 days

Seroquel XR (150mg Tablet Extended-Release 24

Hour, 200mg Tablet Extended-Release 24 Hour)Maximum of 1 tablet per day

Seroquel XR (300mg Tablet Extended-Release 24

Hour, 400mg Tablet Extended-Release 24 Hour,

50mg Tablet Extended-Release 24 Hour)

Maximum of 2 tablets per day

sfRowasa (Enema) Maximum of 1 bottle (60 ml) per day

Sildenafil (20mg Tablet) (Generic Revatio) Maximum of 3 tablets per day

Simvastatin (Tablet) Maximum of 1 tablet per day

Sovaldi (Tablet) Maximum of 1 tablet per day

Spiriva HandiHaler (Capsule) Maximum of 1 capsule per day

Spiriva Respimat (Aerosol Solution) Maximum of 1 inhaler (4 grams) per 30 days

Stavudine (15mg Capsule, 30mg Capsule, 40mg

Capsule)Maximum of 3 capsules per day

Stavudine (1mg/ml Oral Solution) Maximum of 120 ml per day

Stavudine (20mg Capsule) Maximum of 2 capsules per day

Stiolto Respimat (Aerosol Solution) Maximum of 1 inhaler (4 grams) per 30 days

Strattera (100mg Capsule, 60mg Capsule, 80mg

Capsule)Maximum of 1 capsule per day

Strattera (10mg Capsule, 18mg Capsule, 25mg

Capsule, 40mg Capsule)Maximum of 2 capsules per day

Stribild (Tablet) Maximum of 2 tablets per day

Suboxone (12mg-3mg Film, 4mg-1mg Film) Maximum of 2 sublingual films per day

Suboxone (2mg-0.5mg Film, 8mg-2mg Film) Maximum of 3 sublingual films per day

Sumatriptan (Nasal Solution) Maximum of 12 devices per 30 days

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Sumatriptan Succinate (100mg Tablet, 25mg Tablet,

50mg Tablet)Maximum of 9 tablets per 30 days

Sumatriptan Succinate (4mg/0.5ml Solution Auto

injector)Maximum of 12 injections (6 ml) per 30 days

Sumatriptan Succinate (6mg/0.5ml Solution Auto

injector)Maximum of 12 injections (6 ml) per 30 days

Sumatriptan Succinate (6mg/0.5ml Subcutaneous

Solution)Maximum of 12 injections (6 ml) per 30 days

Sumatriptan Succinate Refill (4mg/0.5ml Solution

Cartridge)Maximum of 12 injections (6 ml) per 30 days

Sumatriptan Succinate Refill (6mg/0.5ml Solution

Cartridge)Maximum of 12 injections (6 ml) per 30 days

Sustiva (200mg Capsule) Maximum of 3 capsules per day

Sustiva (50mg Capsule) Maximum of 9 capsules per day

Sustiva (600mg Tablet) Maximum of 2 tablets per day

Synjardy (Tablet) Maximum of 2 tablets per day

Tagrisso (Tablet) Maximum of 1 tablet per day

Tamiflu (30mg Capsule, 45mg Capsule, 75mg

Capsule)Maximum of 2 capsules per day

Tamiflu (6mg/ml Suspension) Maximum of 26 ml per day

Tecfidera (Capsule Delayed-Release) Maximum of 2 capsules per day

Telmisartan (Tablet) Maximum of 1 tablet per day

Telmisartan/Amlodipine (Tablet) Maximum of 1 tablet per day

Telmisartan/Hydrochlorothiazide (Tablet) Maximum of 1 tablet per day

Temazepam (Capsule) Maximum of 1 capsule per day

Tetrabenazine (12.5mg Tablet) Maximum of 3 tablets per day

Tetrabenazine (25mg Tablet) Maximum of 4 tablets per day

Tivicay (10mg Tablet) Maximum of 2 tablets per day

Tivicay (25mg Tablet) Maximum of 2 tablets per day

Tivicay (50mg Tablet) Maximum of 3 tablets per day

Tracleer (Tablet) Maximum of 2 tablets per day

Tradjenta (Tablet) Maximum of 1 tablet per day

Tramadol HCl (Tablet Immediate-Release) Maximum of 8 tablets per day

Tramadol HCl ER (100mg Tablet Extended-Release

24 Hour, 200mg Tablet Extended-Release 24 Hour)

(Generic Ultram ER)

Maximum of 1 tablet per day

Tramadol HCl ER (300mg Tablet Extended-Release

24 Hour) (Generic Ryzolt)Maximum of 1 tablet per day

Tramadol HCl/Acetaminophen (Tablet) Maximum of 12 tablets per day

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Trandolapril (1mg Tablet, 2mg Tablet) Maximum of 1 tablet per day

Trandolapril (4mg Tablet) Maximum of 2 tablets per day

Trezix (Capsule) Maximum of 10 capsules per day

Tribenzor (Tablet) Maximum of 1 tablet per day

Trintellix (Tablet) Maximum of 1 tablet per day

Triumeq (Tablet) Maximum of 2 tablets per day

Trizivir (Tablet) Maximum of 3 tablets per day

Trulicity (Injection) Maximum of 4 pens (2 ml) per 28 days

Truvada (Tablet) Maximum of 2 tablets per day

Tybost (Tablet) Maximum of 2 tablets per day

Vagifem (Tablet) Maximum of 1 tablet per day

Valacyclovir HCl (1000mg Tablet) Maximum of 4 tablets per day

Valacyclovir HCl (500mg Tablet) Maximum of 2 tablets per day

Valsartan (160mg Tablet, 40mg Tablet, 80mg Tablet) Maximum of 2 tablets per day

Valsartan (320mg Tablet) Maximum of 1 tablet per day

Valsartan/Hydrochlorothiazide (Tablet) Maximum of 1 tablet per day

Venclexta (100mg Tablet) Maximum of 4 tablets per day

Venclexta (10mg Tablet) Maximum of 2 tablets per day

Venclexta (50mg Tablet) Maximum of 1 tablet per day

Vesicare (Tablet) Maximum of 1 tablet per day

Victoza (Injection) Maximum of 3 pens (9 ml) per 30 days

Videx Pediatric (Oral Solution) Maximum of 30 ml per day

Viibryd (Tablet) Maximum of 1 tablet per day

Viibryd Starter Pack (Kit) Maximum of 1 tablet per day

Vimpat (100mg Tablet, 150mg Tablet, 200mg

Tablet, 50mg Tablet)Maximum of 2 tablets per day

Vimpat (10mg/ml Oral Solution) Maximum of 40 ml per day

Viracept (250mg Tablet) Maximum of 15 tablets per day

Viracept (625mg Tablet) Maximum of 6 tablets per day

Viramune (Suspension) Maximum of 60 ml per day

Viramune XR (100mg Tablet Extended-Release

24 Hour)Maximum of 3 tablets per day

Viramune XR (400mg Tablet Extended-Release

24 Hour)Maximum of 2 tablets per day

Viread (150mg Tablet) Maximum of 1 tablet per day

Viread (200mg Tablet, 250mg Tablet, 300mg

Tablet)Maximum of 2 tablets per day

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Viread (40mg/gm Powder) Maximum of 6 bottles (360 grams) per 30 days

Vitekta (Tablet) Maximum of 2 tablets per day

Vraylar (1.5mg Capsule, 3mg Capsule, 4.5mg

Capsule, 6mg Capsule)Maximum of 1 capsule per day

Vytorin (Tablet) Maximum of 1 tablet per day

Xarelto (10mg Tablet, 20mg Tablet) Maximum of 1 tablet per day

Xarelto (15mg Tablet) Maximum of 2 tablets per day

Xarelto Starter Pack (Tablet Therapy Pack) Maximum of 1 pack (51 tablets) per 30 days

Xeljanz (Tablet) Maximum of 2 tablets per day

Xeljanz XR (Tablet Extended-Release 24 Hour) Maximum of 1 tablet per day

Xenazine (12.5mg Tablet) Maximum of 3 tablets per day

Xenazine (25mg Tablet) Maximum of 4 tablets per day

Xtandi (Capsule) Maximum of 4 capsules per day

Xyrem (Oral Solution) Maximum of 18 ml per day

Zafirlukast (Tablet) Maximum of 2 tablets per day

Zaleplon (Capsule) Maximum of 90 days of use per year

Zepatier (Tablet) Maximum of 1 tablet per day

Zetia (Tablet) Maximum of 1 tablet per day

Ziagen (Oral Solution) Maximum of 48 ml per day

Zidovudine (100mg Capsule) Maximum of 8 capsules per day

Zidovudine (300mg Tablet) Maximum of 3 tablets per day

Zidovudine (50mg/5ml Syrup) Maximum of 96 ml per day

Ziprasidone HCl (Capsule) Maximum of 2 capsules per day

Zolpidem Tartrate (Tablet Immediate-Release) Maximum of 90 days of use per year

Zovirax (5% Cream) Maximum of 1 tube (5 grams) per 30 days

Zovirax (5% Ointment) Maximum of 1 tube (30 grams) per 30 days

Zydelig (Tablet) Maximum of 2 tablets per day

Zykadia (Capsule) Maximum of 5 capsules per day

Zytiga (Tablet) Maximum of 4 tablets per day

Zyvox (600mg Tablet) Maximum of 2 tablets per daytrack

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trackIndex of covered drugs

#

8-MOP................................ 49

A

A-Hydrocort....................... 53

Abacavir............................. 36

Abacavir Sulfate/

Lamivudine/Zidovudine

......................................... 36

Abelcet............................... 26

Abilify Maintena................ 33

Abraxane............................29

Abstral................................ 13

Acamprosate Calcium DR

.......................................... 15

Acarbose.............................38

Acebutolol HCl.................. 42

Acetaminophen/Codeine...13

Acetazolamide...................46

Acetazolamide ER............. 46

Acetazolamide Sodium..... 46

Acetic Acid.........................66

Acetylcysteine................... 69

Acitretin.............................49

Actemra..............................62

ActHIB................................62

Actimmune........................ 62

Actonel...............................63

Acyclovir.......................35, 36

Acyclovir Sodium.............. 36

Adacel................................ 62

Adagen............................... 50

Adapalene..........................49

Adcirca...............................68

Adefovir Dipivoxil..............35

Adempas............................ 68

Adrucil............................... 29

Advair Diskus.................... 69

Advair HFA........................ 69

Afeditab CR........................43

Afinitor............................... 31

Afinitor Disperz..................31

Aggrenox............................ 41

Ala Cort.............................. 53

Albenza.............................. 32

Albuterol Sulfate................68

Alclometasone Dipropionate

..........................................53

Alcohol Prep Pads..............64

Aldurazyme....................... 50

Alecensa............................. 29

Alendronate Sodium......... 63

Alfuzosin HCl ER............... 53

Alimta................................ 29

Alinia..................................32

Allopurinol......................... 27

Alocril.................................65

Alomide..............................65

Alora...................................56

Alosetron HCl.....................52

Aloxi................................... 25

Alphagan P.........................65

Alprazolam.........................38

Amantadine HCl................ 32

AmBisome..........................26

Amethia............................. 56

Amethyst............................56

Amifostine......................... 29

Amikacin Sulfate................ 15

Amiloride HCl....................46

Amiloride/

Hydrochlorothiazide...... 44

Aminophylline...................68

Aminosyn 7%/Electrolytes

.......................................... 71

Aminosyn 8.5%/Electrolytes

.......................................... 71

Aminosyn II........................71

Aminosyn II 8.5%/

Electrolytes...................... 71

Aminosyn M....................... 71

Aminosyn-HBC.................. 71

Aminosyn-PF......................71

Aminosyn-RF..................... 71

Amiodarone HCl................42

Amitiza............................... 52

Amitriptyline HCl.............. 25

Amlodipine Besylate......... 43

Amlodipine Besylate/

Atorvastatin Calcium......44

Amlodipine Besylate/

Benazepril HCl................ 44

Amlodipine Besylate/

Valsartan......................... 44

Amlodipine/Valsartan/

Hydrochlorothiazide...... 44

Ammonium Chloride........ 70

Ammonium Lactate.......... 49

Amoxapine......................... 25

Amoxicillin.........................18

Amoxicillin/Clavulanate

Potassium.........................18

Amoxicillin/Clavulanate

Potassium ER................... 18

Amphetamine/

Dextroamphetamine.......48

Amphotericin B................. 26

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Ampicillin........................... 18

Ampicillin Sodium............. 18

Ampicillin-Sulbactam........ 18

Ampyra...............................49

Anadrol-50..........................56

Anagrelide HCl.................. 40

Anastrozole......................... 31

Ancobon............................. 26

Androderm......................... 56

AndroGel............................ 56

AndroGel Pump..................56

Anoro Ellipta...................... 69

Anzemet............................. 26

Apokyn............................... 32

Apraclonidine.....................65

Apri..................................... 56

Apriso................................. 63

Aptiom................................ 22

Aptivus................................37

Aralast NP...........................69

Aranelle.............................. 56

Aranesp Albumin Free....... 41

Arcalyst...............................62

Argatroban..........................41

Aripiprazole........................33

Aripiprazole ODT............... 33

Aristada.............................. 33

Arnuity Ellipta....................67

Arranon.............................. 29

Ashlyna...............................56

Aspirin/Dipyridamole........ 41

Atenolol.............................. 42

Atenolol/Chlorthalidone... 44

Atgam..................................61

Atorvastatin Calcium.........46

Atovaquone........................ 32

Atovaquone/Proguanil HCl

.......................................... 32

Atripla.................................36

Atropine Sulfate..................51

Atrovent HFA..................... 67

Aubagio.............................. 49

Aubra.................................. 56

Augmented Betamethasone

Dipropionate.................... 53

Avandia.............................. 38

Avastin................................ 31

Avelox................................. 19

Aviane.................................56

Avita................................... 49

Avonex............................... 49

Avonex Pen........................ 49

Azacitidine......................... 29

Azactam in Iso-Osmotic

Dextrose............................18

Azasite.................................19

Azathioprine...................... 60

Azelastine HCl.............. 65, 67

Azilect................................. 33

Azithromycin......................19

Azopt...................................65

Azor.................................... 44

Aztreonam.......................... 18

B

BACiiM................................16

Bacitracin............................16

Bacitracin/Polymyxin B.....64

Baclofen..............................69

Bactocill in Dextrose...........19

Bactroban Nasal..................16

Balsalazide Disodium.........63

Balziva................................ 56

Banzel................................. 23

Baraclude............................35

BCG Vaccine....................... 62

Bekyree............................... 56

Beleodaq............................. 29

Belsomra.............................70

Benazepril HCl................... 42

Benazepril HCl/

Hydrochlorothiazide....... 44

Benicar................................42

Benicar HCT.......................44

Benlysta.............................. 62

Benztropine Mesylate.........32

Bepreve............................... 65

Berinert.............................. 60

Besivance............................ 19

Betamethasone Dipropionate

.......................................... 53

Betamethasone Valerate.... 53

Betaseron........................... 49

Betaxolol HCl................ 42, 65

Bethanechol Chloride.........53

Bethkis................................ 15

Betimol............................... 65

Bexarotene..........................32

Bexsero............................... 62

Bicalutamide...................... 29

Bicillin C-R..........................19

Bicillin L-A.......................... 19

BiCNU................................. 28

BiDil....................................44

Biltricide............................. 32

Binosto................................63

Bisoprolol Fumarate.......... 42

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Bisoprolol Fumarate/

Hydrochlorothiazide....... 44

BIVIGAM.............................61

Bleomycin Sulfate.............. 29

Blephamide........................ 64

Blephamide S.O.P.............. 64

Blisovi 24 Fe........................56

Blisovi Fe 1.5/30..................56

Blisovi Fe 1/20.....................56

Boniva.................................63

Boostrix...............................62

Bosulif................................. 31

Botox.................................. 64

Breo Ellipta.........................69

Briellyn............................... 56

Brilinta................................ 41

Brimonidine Tartrate......... 65

BRIVIACT............................21

Bromocriptine Mesylate.....32

Brovana.............................. 68

Budesonide................... 63, 67

Bumetanide........................46

Buphenyl............................ 50

Buprenorphine HCl............ 15

Buprenorphine HCl/

Naloxone HCl................... 15

Bupropion HCl................... 24

Bupropion HCl SR......... 15, 24

Bupropion HCl XL..............24

Buspirone HCl.................... 38

Busulfex.............................. 28

Butorphanol Tartrate..........13

Bydureon Pen..................... 38

Bydureon Vial.....................38

Byetta..................................38

Bystolic............................... 42

C

Cabergoline........................ 59

Cabometyx.......................... 31

Calcipotriene......................49

Calcitonin-Salmon............. 63

Calcitriol....................... 49, 63

Calcium Acetate................. 53

Camila.................................58

Canasa................................ 63

Cancidas............................. 26

Candesartan Cilexetil.........42

Candesartan Cilexetil/

Hydrochlorothiazide....... 44

Capastat Sulfate..................28

Caprelsa...............................31

Captopril.............................42

Captopril/

Hydrochlorothiazide....... 45

Carac...................................49

Carafate...............................52

Carbaglu............................. 70

Carbamazepine...................23

Carbamazepine ER............. 23

Carbidopa........................... 33

Carbidopa/Levodopa..........33

Carbidopa/Levodopa ER.... 33

Carbidopa/Levodopa ODT

.......................................... 33

Carbidopa/Levodopa/

Entacapone...................... 33

Carboplatin.........................29

Cardene IV..........................43

Carimune Nanofiltered...... 61

Carteolol HCl...................... 65

Cartia XT.............................43

Carvedilol........................... 42

Cayston...............................68

Caziant................................56

Cefaclor............................... 17

Cefadroxil............................17

Cefazolin Sodium................17

Cefdinir............................... 17

Cefepime............................. 17

Cefepime/Dextrose............. 17

Cefixime.............................. 17

Cefotaxime Sodium............ 17

Cefotetan.............................17

Cefoxitin Sodium................ 17

Cefpodoxime Proxetil......... 18

Cefprozil..............................18

Ceftazidime.........................18

Ceftazidime/Dextrose.........18

Ceftriaxone Sodium............18

Cefuroxime Axetil...............18

Cefuroxime Sodium............18

Celecoxib.............................12

Cellcept.............................. 60

Cellcept Intravenous..........60

Celontin...............................21

Cephalexin.......................... 18

Cerezyme............................50

Cervarix.............................. 62

Cesamet.............................. 26

Cetirizine HCl..................... 67

Chantix................................15

Chantix Continuing Month

Pak.................................... 15

Chantix Starting Month Pak

...........................................15

Chemet............................... 70

Chenodal............................. 51

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Chloramphenicol Sodium

Succinate.......................... 16

Chlordiazepoxide HCl........ 38

Chlorhexidine Gluconate

Oral Rinse.........................49

Chloroquine Phosphate......32

Chlorothiazide................... 46

Chlorothiazide Sodium......46

Chlorpromazine HCl.......... 33

Chlorthalidone...................46

Cholbam..............................51

Cholestyramine Light........ 47

Chorionic Gonadotropin.... 55

Ciclopirox........................... 26

Ciclopirox Nail Lacquer..... 26

Ciclopirox Olamine............ 26

Cidofovir............................. 35

Cilostazol............................ 41

Ciloxan............................... 20

Cimetidine.......................... 51

Cimetidine HCl................... 51

Cimzia................................ 60

Cinryze............................... 60

Cipro HC.............................66

Ciprodex............................. 66

Ciprofloxacin......................20

Ciprofloxacin ER................ 20

Ciprofloxacin HCl.............. 20

Ciprofloxacin I.V. in D5W

..........................................20

Cisplatin............................. 29

Citalopram HBr.................. 24

Cladribine...........................29

Claravis...............................50

Clarithromycin................... 19

Clarithromycin ER..............19

Climara Pro.........................56

Clindamycin HCl................ 16

Clindamycin Palmitate HCl

.......................................... 16

Clindamycin Phosphate.... 16,

50

Clindamycin Phosphate in

D5W.................................. 16

Clindamycin/Benzoyl

Peroxide........................... 50

Clinisol SF 15%.................... 71

Clobetasol Propionate........ 54

Clobetasol Propionate E.....54

Clolar.................................. 29

Clomipramine HCl............. 25

Clonazepam........................38

Clonazepam ODT............... 38

Clonidine HCl..................... 41

Clonidine HCl ER............... 48

Clopidogrel......................... 41

Clorazepate Dipotassium... 38

Clorpres.............................. 45

Clotrimazole....................... 26

Clotrimazole/Betamethasone

Dipropionate....................50

Clozapine............................ 35

Clozapine ODT....................35

Coartem.............................. 32

Codeine Sulfate...................13

Colchicine........................... 27

Colcrys................................ 27

Colestipol HCl.................... 47

Colistimethate Sodium.......16

Colocort.............................. 63

Coly-Mycin S...................... 66

Combigan........................... 65

Combivent Respimat......... 69

Combivir.............................36

Cometriq............................. 31

Complera............................ 36

Compro............................... 25

Constulose.......................... 52

Copaxone............................49

Cordran Tape......................54

Cormax Scalp Application

..........................................54

Cortisone Acetate............... 54

Cortisporin......................... 50

Cosmegen........................... 29

Cotellic................................ 31

Coumadin.......................... 40

Creon.................................. 50

Crestor................................ 46

Crinone............................... 58

Crixivan.............................. 37

Cromolyn Sodium... 51, 65, 69

Cryselle-28.......................... 56

Cubicin................................16

Cuprimine...........................53

Cuvposa...............................51

Cyclafem.............................56

Cyclobenzaprine HCl......... 69

Cyclophosphamide............ 28

Cycloset.............................. 38

Cyclosporine...................... 60

Cyclosporine Modified...... 60

Cyproheptadine HCl.......... 67

Cyramza.............................. 31

Cystadane............................51

Cystagon..............................51

Cystaran............................. 64

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Cytarabine Aqueous...........29

D

Dacarbazine........................28

Dacogen.............................. 29

Daklinza..............................35

Daliresp.............................. 68

Dalvance............................. 16

Danazol...............................56

Dantrolene Sodium............69

Dapsone.............................. 28

Daptacel..............................62

DARAPRIM......................... 32

Darzalex.............................. 31

Daunorubicin HCl.............. 29

Deblitane............................ 58

Decitabine.......................... 29

Delyla..................................56

Demeclocycline HCl.......... 20

Demser............................... 45

Denavir............................... 36

Depen Titratabs.................. 53

Depo-Estradiol................... 56

Depo-Medrol...................... 54

Depo-Provera......................58

Descovy.............................. 36

Desipramine HCl................ 25

Desmopressin Acetate........55

Desogestrel/Ethinyl

Estradiol........................... 56

Desonide.............................54

Desoximetasone................. 54

Dexamethasone..................54

Dexamethasone Intensol... 54

Dexamethasone Sodium

Phosphate...................54, 66

Dexedrine........................... 48

Dexilant.............................. 52

Dexmethylphenidate HCl

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

Dexmethylphenidate HCl ER

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

Dexrazoxane....................... 29

Dextroamphetamine Sulfate

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

Dextroamphetamine Sulfate

ER..................................... 48

Dextrose 10%.......................71

Dextrose 10%/NaCl 0.2%.... 71

Dextrose 10%/NaCl 0.45%

...........................................71

Dextrose 2.5%/NaCl 0.45%

...........................................71

Dextrose 5%.........................71

Dextrose 5%/Lactated

Ringers.............................. 71

Dextrose 5%/NaCl 0.2%...... 71

Dextrose 5%/NaCl 0.225%...71

Dextrose 5%/NaCl 0.33%.... 71

Dextrose 5%/NaCl 0.45%....72

Dextrose 5%/NaCl 0.9%......72

Dextrose 5%/Potassium

Chloride 0.15%..................72

Diastat AcuDial................... 21

Diastat Pediatric................. 22

Diazepam...................... 22, 38

Diazepam Intensol............. 38

Dibenzyline........................ 41

Diclofenac Potassium......... 12

Diclofenac Sodium.......12, 50,

66

Diclofenac Sodium DR........12

Diclofenac Sodium ER........ 12

Dicloxacillin Sodium.......... 19

Dicyclomine HCl.................51

Didanosine......................... 36

Dificid................................. 19

Diflunisal.............................12

Digitek................................ 45

Digoxin............................... 45

Dihydroergotamine Mesylate

.......................................... 27

Dilantin...............................23

Dilantin INFATABS............ 23

Dilt-XR................................43

Diltiazem CD...................... 43

Diltiazem HCl.....................43

Diltiazem HCl ER............... 43

Dipentum........................... 63

Diphenhydramine HCl.......67

Diphenoxylate/Atropine.... 51

Diphtheria/Tetanus Toxoids

Adsorbed Pediatric.......... 62

Disulfiram........................... 15

Diuril.................................. 46

Divalproex Sodium.............22

Divalproex Sodium DR....... 22

Divalproex Sodium ER....... 22

Docefrez..............................29

Docetaxel...................... 29, 30

Dofetilide............................42

Donepezil HCl.....................23

Donepezil HCl ODT............ 23

Doribax................................18

Dorzolamide HCl................65

Dorzolamide HCl/Timolol

Maleate.............................65

Doxazosin Mesylate........... 42

Doxepin HCl..................25, 50

Doxercalciferol................... 63

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Doxil................................... 30

Doxorubicin HCl................ 30

Doxorubicin HCl Liposome

..........................................30

Doxy 100.............................20

Doxycycline........................20

Doxycycline Hyclate...........21

Doxycycline Monohydrate

...........................................21

Dronabinol......................... 26

Drospirenone/Ethinyl

Estradiol........................... 56

Droxia................................. 29

Duavee................................ 56

Dulera................................. 69

Duloxetine HCl...................49

Duramorph......................... 14

Durezol............................... 66

Dymista.............................. 69

Dyrenium........................... 46

E

E.E.S. 400............................19

E.E.S. Granules................... 19

Econazole Nitrate...............26

Edarbi................................. 42

Edarbyclor.......................... 45

Edecrin............................... 46

Edurant...............................36

Effient................................. 41

Egrifta................................. 59

Elaprase...............................51

Elelyso.................................51

Elestrin............................... 56

Elidel.................................. 50

Eliphos................................53

Eliquis................................ 40

Elitek...................................29

Ellence................................30

Elmiron...............................53

Embeda............................... 13

Emcyt..................................29

Emend................................ 26

Emoquette.......................... 56

Empliciti............................. 31

Emsam................................24

Emtriva............................... 37

Enalapril Maleate............... 42

Enalapril Maleate/

Hydrochlorothiazide....... 45

Enbrel.................................60

Enbrel SureClick................ 60

Endocet...............................14

Engerix-B............................62

Enoxaparin Sodium...........40

Enpresse-28........................ 56

Entacapone.........................32

Entecavir.............................35

Entocort EC........................ 63

Entresto.............................. 45

Enulose............................... 52

Epaned................................42

Epclusa............................... 35

Epinastine HCl................... 65

EpiPen................................ 68

Epirubicin HCl................... 30

Epitol.................................. 23

Epivir.................................. 37

Epivir HBV..........................35

Eplerenone.........................46

Eprosartan Mesylate.......... 42

Epzicom.............................. 37

Equetro............................... 38

Eraxis.................................. 26

Erbitux................................ 31

Erivedge.............................. 31

Errin....................................58

Erwinaze.............................30

Ery...................................... 50

Ery-Tab............................... 19

EryPed 200..........................19

EryPed 400......................... 19

Erythrocin Lactobionate.... 19

Erythromycin................19, 50

Erythromycin Base............. 19

Erythromycin

Ethylsuccinate..................19

Erythromycin/Benzoyl

Peroxide........................... 50

Esbriet................................ 69

Escitalopram Oxalate......... 24

Esomeprazole Magnesium

.......................................... 52

Esomeprazole Sodium........52

Estrace................................ 56

Estradiol..............................57

Estradiol Valerate............... 57

Estring.................................57

Ethambutol HCl................. 28

Ethosuximide......................21

Etidronate Disodium..........63

Etodolac.............................. 12

Etodolac ER.........................12

Etopophos........................... 31

Etoposide............................ 31

Eurax...................................32

Evotaz................................. 36

Exelderm............................ 26

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Exelon................................. 23

Exemestane.........................31

Exjade................................. 70

F

Fabrazyme.......................... 51

Falmina...............................57

Famciclovir.........................36

Famotidine..........................51

Famotidine Premixed......... 51

Fanapt.................................34

Fanapt Titration Pack........ 34

Fareston..............................29

Farydak...............................30

Faslodex..............................29

Fazaclo................................ 35

Felbamate........................... 22

Felbatol............................... 22

Felodipine ER.....................43

Femring.............................. 57

Fenofibrate.........................46

Fenofibrate Micronized..... 46

Fenofibric Acid.................. 46

Fenofibric Acid DR.............46

Fentanyl.............................. 13

Ferriprox.............................70

Fetzima...............................24

Fetzima Titration Pack.......24

Finasteride..........................53

Firazyr................................ 60

Firmagon...................... 59, 60

Flarex..................................66

Flebogamma DIF................ 61

Flecainide Acetate..............42

Flector................................. 12

Flovent Diskus....................67

Flovent HFA....................... 67

Fluconazole........................ 26

Fluconazole in Dextrose.....26

Fluconazole in NaCl........... 26

Flucytosine......................... 26

Fludarabine Phosphate......30

Fludrocortisone Acetate.... 54

Flunisolide..........................67

Fluocinolone Acetonide....54,

66

Fluocinolone Acetonide

Body................................. 54

Fluocinonide...................... 54

Fluocinonide-E.................. 54

Fluorometholone............... 66

Fluorouracil.................. 29, 50

Fluoxetine DR.....................24

Fluoxetine HCl................... 24

Fluphenazine Decanoate... 33

Fluphenazine HCl.............. 33

Flurbiprofen........................12

Flurbiprofen Sodium......... 66

Flutamide........................... 29

Fluticasone Propionate..... 54,

67

Fluvastatin......................... 46

Fluvoxamine Maleate.........24

FML.................................... 66

FML Forte........................... 66

Folotyn............................... 29

Fomepizole.........................64

Fondaparinux Sodium.......40

Fortaz.................................. 18

Forteo................................. 63

Fosinopril Sodium..............42

Fosinopril Sodium/

Hydrochlorothiazide....... 45

Fosphenytoin Sodium........ 23

Fosrenol.............................. 53

FreAmine HBC 6.9%...........72

Furosemide........................ 46

Fusilev................................ 30

Fuzeon................................ 37

Fycompa..............................21

G

Gabapentin......................... 22

Gabitril................................22

Gablofen............................. 69

Galantamine HBr............... 23

Gamastan S/D..................... 61

Gammagard Liquid.............61

Gammaked..........................61

Gammaplex.........................61

Gamunex-C......................... 61

Ganciclovir......................... 35

Gardasil.............................. 62

Gardasil 9............................62

Gatifloxacin........................20

Gattex.................................. 51

Gauze..................................64

GaviLyte-C.......................... 52

GaviLyte-G..........................52

GaviLyte-H......................... 52

GaviLyte-N/Flavor Pack..... 52

Gemcitabine HCl................ 29

Gemfibrozil........................ 46

Gemzar............................... 29

Generlac..............................52

Gengraf...............................60

Genotropin......................... 55

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Genotropin Miniquick........55

Gentak................................. 15

Gentamicin Sulfate............. 15

Gentamicin Sulfate/0.9%

Sodium Chloride.............. 16

Genvoya..............................36

Geodon............................... 34

Gianvi..................................57

Giazo...................................63

Gildagia...............................57

Gildess 1.5/30...................... 57

Gildess 24 Fe....................... 57

Gilenya............................... 49

Gilotrif.................................31

Glassia................................ 69

Glatopa............................... 49

Gleostine.............................28

Glimepiride........................ 38

Glipizide............................. 38

Glipizide ER........................38

Glipizide/Metformin HCl...38

GlucaGen HypoKit............. 39

Glucagon Emergency Kit... 39

Glycopyrrolate.................... 51

Glyset.................................. 38

Granisetron HCl................. 26

Granix................................. 41

Griseofulvin Microsize....... 26

Griseofulvin Ultramicrosize

.......................................... 26

Guanfacine ER................... 48

Guanidine HCl....................28

H

Halaven.............................. 30

Halobetasol Propionate..... 54

Haloperidol.........................33

Haloperidol Decanoate...... 33

Haloperidol Lactate............33

Harvoni...............................35

Havrix................................. 62

Hectorol..............................63

Heparin Sodium.................40

Heparin Sodium/D5W....... 40

HepatAmine....................... 72

Hepsera...............................35

Herceptin............................ 31

Hetlioz................................ 70

Hexalen...............................28

Hiberix................................62

Humalog Cartridge.............39

Humalog KwikPen............. 39

Humalog Mix 50/50 KwikPen

.......................................... 39

Humalog Mix 50/50 Vial.... 39

Humalog Mix 75/25 KwikPen

.......................................... 39

Humalog Mix 75/25 Vial..... 39

Humalog Vial..................... 39

Humatrope......................... 55

Humatrope Combo Pack.... 55

Humira............................... 60

Humira Pediatric Crohns

Disease Starter Pack.........60

Humira Pen........................60

Humira Pen Crohns Disease

Starter Pack......................60

Humira Pen-Psoriasis Starter

.......................................... 61

Humulin 70/30 KwikPen...40

Humulin 70/30 Vial........... 40

Humulin N KwikPen......... 40

Humulin N Vial..................40

Humulin R U-500 KwikPen

......................................... 40

Humulin R U-500 Vial.......40

Humulin R Vial.................. 40

Hycamtin............................ 31

Hydralazine HCl.................47

Hydrochlorothiazide......... 46

Hydrocodone Bitartrate/

Acetaminophen................14

Hydrocodone/

Acetaminophen................14

Hydrocodone/Ibuprofen.... 14

Hydrocortisone.............54, 63

Hydrocortisone Butyrate... 54

Hydrocortisone Valerate....54

Hydrocortisone/Acetic Acid

..........................................66

Hydromorphone HCl......... 14

Hydromorphone HCl ER.... 13

Hydroxychloroquine Sulfate

.......................................... 32

Hydroxyprogesterone

Caproate........................... 59

Hydroxyurea...................... 29

Hydroxyzine HCl................38

Hydroxyzine Pamoate........ 25

I

Ibandronate Sodium.......... 64

Ibrance............................... 30

Ibuprofen............................ 12

Iclusig..................................31

Idamycin PFS..................... 30

Idarubicin HCl................... 30

Ifosfamide...........................28

Ilaris....................................62

Ilevro.................................. 66

Ilotycin................................19

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Imatinib Mesylate...............31

Imbruvica............................31

Imipenem/Cilastatin.......... 18

Imipramine HCl..................25

Imipramine Pamoate..........25

Imiquimod......................... 50

Imovax Rabies.................... 62

Increlex............................... 55

Indapamide........................46

Infanrix...............................62

Inlyta................................... 31

Insulin Syringes, Needles

..........................................64

Intelence.............................36

Intralipid.............................72

Intron A...............................35

Intron A w/Diluent............. 35

Introvale............................. 57

Invanz................................. 18

Invega................................. 34

Invega Sustenna................. 34

Invega Trinza..................... 34

Invirase............................... 37

Invokamet.......................... 38

Invokana.............................39

Ionosol-B/Dextrose 5%....... 72

Ionosol-MB/Dextrose 5%....72

IPOL Inactivated IPV..........62

Ipratropium Bromide... 67, 68

Ipratropium Bromide/

Albuterol Sulfate..............69

Irbesartan........................... 42

Irbesartan/

Hydrochlorothiazide....... 45

Iressa................................... 31

Irinotecan...........................30

Isentress............................. 36

Isolyte-P/Dextrose 5%........ 72

Isolyte-S..............................70

Isoniazid............................. 28

Isosorbide Dinitrate........... 47

Isosorbide Dinitrate ER......47

Isosorbide Mononitrate......47

Isosorbide Mononitrate ER

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

Isotonic Gentamicin........... 16

Istodax................................30

Itraconazole........................26

Ivermectin.......................... 32

Ixempra Kit........................ 30

Ixiaro...................................62

J

Jadenu................................ 70

Jakafi...................................31

Jantoven............................ 40

Janumet..............................39

Janumet XR........................39

Januvia............................... 39

Jardiance............................ 39

Jentadueto..........................39

Jentadueto XR....................39

Jevtana............................... 30

Jinteli.................................. 57

Jolivette.............................. 59

Jublia.................................. 26

Juleber................................ 57

Junel 1.5/30.........................57

Junel 1/20............................57

Junel Fe 1.5/30.................... 57

Junel Fe 1/20.......................57

Junel Fe 24..........................57

Juxtapid..............................47

K

K-Tab.................................. 70

Kadcyla............................... 31

Kaitlib Fe.............................57

Kaletra.................................37

Kalydeco....................... 68, 69

Kanuma..............................64

Kariva..................................57

Kazano................................ 39

KCl 0.075%/D5W/NaCl

0.45%................................ 72

KCl 0.15%/D5W/LR............. 72

KCl 0.15%/D5W/NaCl 0.2%

.......................................... 72

KCl 0.15%/D5W/NaCl 0.225%

.......................................... 72

KCl 0.15%/D5W/NaCl 0.9%

.......................................... 72

KCl 0.3%/D5W/NaCl 0.45%

.......................................... 72

KCl 0.3%/D5W/NaCl 0.9%

.......................................... 72

Kelnor 1/35.......................... 57

Kenalog-10..........................54

Kenalog-40......................... 54

Kepivance...........................49

Ketoconazole...................... 27

Ketoprofen.......................... 12

Ketorolac Tromethamine

.....................................12, 66

Keytruda............................. 31

Kimidess............................. 57

Kineret................................ 61

Kionex................................ 70

Klor-Con 10.........................70

Klor-Con 8.......................... 70

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Klor-Con M15......................70

Klor-Con M20..................... 70

Klor-Con Sprinkle.............. 70

Kombiglyze XR...................39

Korlym................................56

Kuvan.................................. 51

Kynamro.............................47

L

Labetalol HCl......................43

Lacrisert............................. 64

Lactated Ringers Irrigation

.......................................... 72

Lactated Ringers Viaflex.... 72

Lactulose.............................52

Lamivudine................... 35, 37

Lamivudine/Zidovudine.... 37

Lamotrigine........................ 22

Lanoxin...............................45

Lantus SoloStar.................. 40

Lantus Vial......................... 40

LARIN 1.5/30.......................57

LARIN 1/20..........................57

LARIN Fe 1.5/30.................. 57

LARIN Fe 1/20.....................57

Larissia................................57

Lastacaft............................. 64

Latanoprost........................ 66

Latuda.................................34

Layolis Fe............................ 57

Leflunomide....................... 62

Lenvima.............................. 31

Lessina................................ 57

Letairis................................68

Letrozole............................. 31

Leucovorin Calcium...........30

Leukeran.............................28

Leukine............................... 41

Leuprolide Acetate.............60

Levalbuterol....................... 68

Levemir FlexTouch............40

Levemir Vial.......................40

Levetiracetam..................... 21

Levetiracetam ER................21

Levobunolol HCl................ 65

Levocarnitine......................72

Levocetirizine

Dihydrochloride...............67

Levofloxacin.......................20

Levofloxacin in D5W.......... 20

Levoleucovorin Calcium....30

Levonest..............................57

Levonorgestrel and Ethinyl

Estradiol........................... 57

Levonorgestrel/Ethinyl

Estradiol........................... 57

Levora 0.15/30-28............... 57

Levorphanol Tartrate..........13

Levothyroxine Sodium.......59

Levoxyl............................... 59

Lexiva..................................37

Lialda.................................. 63

Lidocaine............................ 15

Lidocaine HCl..................... 15

Lidocaine Viscous............... 15

Lidocaine/Prilocaine.......... 15

Lincocin.............................. 16

Lincomycin HCl..................16

Lindane...............................32

Linezolid............................. 16

Linzess................................ 52

Lioresal Intrathecal............69

Liothyronine Sodium......... 59

Lisinopril............................ 42

Lisinopril/

Hydrochlorothiazide....... 45

Lithium...............................38

Lithium Carbonate............. 38

Lithium Carbonate ER....... 38

Lithostat..............................53

Lomedia 24 Fe.....................57

Lonsurf............................... 29

Loperamide HCl..................51

Lorazepam..........................38

Lorazepam Intensol........... 38

Lorcet.................................. 14

Lorcet HD............................14

Lorcet Plus.......................... 14

Lortab..................................14

Loryna.................................57

Losartan Potassium............42

Losartan Potassium/

Hydrochlorothiazide....... 45

Lotemax..............................66

Lotronex..............................52

Lovastatin...........................46

Low-Ogestrel.......................57

Loxapine Succinate............ 33

Lumigan............................. 66

Lumizyme........................... 51

Lupaneta Pack....................60

Lupron Depot.....................60

Lupron Depot-PED............ 60

Lutera..................................57

Lynparza.............................30

Lyrica..................................49

Lysodren.............................59

Lyza.....................................59

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M

M-M-R II............................. 62

Magnesium Sulfate............ 70

Makena............................... 59

Malathion........................... 32

Maprotiline HCl................. 24

Marlissa...............................57

Marplan.............................. 24

Matulane.............................28

Matzim LA.......................... 43

Meclizine HCl..................... 25

Medroxyprogesterone

Acetate..............................59

Mefloquine HCl.................. 32

Megace ES...........................59

Megestrol Acetate...............59

Mekinist.............................. 31

Meloxicam...........................12

Melphalan HCl................... 28

Memantine HCl.................. 23

Memantine HCl Titration

Pak.................................... 23

Menactra.............................62

Menest................................ 57

MENHIBRIX....................... 62

Menomune-A/C/Y/W-135...62

Mentax................................ 27

Menveo............................... 62

Mepron............................... 32

Mercaptopurine..................29

Meropenem.........................18

Mesalamine........................ 63

Mesna................................. 30

Mesnex............................... 30

Mestinon.............................28

Mestinon Timespan........... 28

Metadate ER....................... 48

Metaproterenol Sulfate...... 68

Metformin HCl................... 39

Metformin HCl ER..............39

Methadone HCl...................13

Methazolamide...................65

Methenamine Hippurate....16

Methimazole...................... 60

Methotrexate...................... 61

Methotrexate Sodium.........61

Methoxsalen.......................50

Methscopolamine Bromide

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

Methyclothiazide............... 46

Methyldopa.........................41

Methyldopa/

Hydrochlorothiazide....... 45

Methyldopate HCl.............. 41

Methylergonovine Maleate

..........................................64

Methylphenidate HCl........ 48

Methylphenidate HCl ER...48

Methylprednisolone...........54

Methylprednisolone Acetate

..........................................54

Methylprednisolone Dose

Pack.................................. 54

Methylprednisolone Sodium

Succinate..........................54

Metipranolol.......................65

Metoclopramide HCl.......... 25

Metolazone.........................46

Metoprolol Succinate ER... 43

Metoprolol Tartrate............43

Metoprolol/

Hydrochlorothiazide....... 45

Metronidazole.....................16

Metronidazole in NaCl 0.79%

.......................................... 16

Metronidazole Vaginal....... 17

Mexiletine HCl................... 42

Miacalcin............................64

Miconazole 3.......................27

Microgestin 1.5/30.............. 57

Microgestin 1/20................. 57

Microgestin Fe.................... 57

Microgestin Fe 1.5/30..........57

Midodrine HCl....................41

Migergot..............................27

Miglitol............................... 39

Millipred............................. 55

Minitran..............................47

Minocycline HCl................. 21

Minoxidil............................ 47

Mirtazapine........................ 24

Mirtazapine ODT................24

Mirvaso...............................50

Misoprostol......................... 52

Mitomycin..........................30

Mitoxantrone HCl.............. 30

Modafinil............................ 70

Moexipril HCl..................... 42

Moexipril/

Hydrochlorothiazide....... 45

Molindone HCl................... 33

Mometasone Furoate.... 55, 67

MonoNessa......................... 57

Montelukast Sodium.......... 67

Morphine Sulfate................14

Morphine Sulfate ER.......... 13

Moxeza............................... 20

Moxifloxacin HCl............... 20

Mozobil............................... 41

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Multaq................................ 42

Mupirocin............................17

Mustargen...........................28

Myalept.............................. 64

Mycamine........................... 27

Mycophenolate Mofetil...... 61

Mycophenolic Acid DR.......61

Myrbetriq............................ 52

N

Nabumetone....................... 12

Nadolol............................... 43

Nadolol/

Bendroflumethiazide.......45

Nafcillin in Dextrose...........19

Nafcillin Sodium.................19

Naftifine HCl...................... 27

Naftin..................................27

Naglazyme.......................... 51

Nalbuphine HCl..................14

Naloxone HCl......................15

Naltrexone HCl................... 15

Namenda............................ 24

Namenda Titration Pak......24

Namenda XR...................... 24

Namenda XR Titration Pack

..........................................24

Namzaric............................ 48

Naproxen............................ 12

Naproxen DR.......................13

Naproxen Sodium...............13

Naratriptan HCl..................27

Narcan.................................15

Nasonex.............................. 67

Natacyn...............................27

Nateglinide.........................39

Natpara...............................64

Nebupent............................ 32

Necon 0.5/35-28.................. 57

Necon 1/35...........................57

Necon 1/50-28..................... 57

Necon 10/11-28.................... 57

Necon 7/7/7......................... 57

Nefazodone HCl................. 24

Neomycin Sulfate............... 16

Neomycin/Bacitracin/

Polymyxin........................64

Neomycin/Polymyxin B

Sulfates............................. 17

Neomycin/Polymyxin/

Bacitracin/Hydrocortisone

..........................................64

Neomycin/Polymyxin/

Dexamethasone............... 64

Neomycin/Polymyxin/

Gramicidin.......................64

Neomycin/Polymyxin/

Hydrocortisone.......... 64, 67

Nephramine........................72

Nesina.................................39

Neulasta..............................41

Neupogen........................... 41

Nevanac..............................66

Nevirapine..........................36

Nevirapine ER.................... 36

Nexavar............................... 31

Nexium............................... 52

Niacin ER............................47

Niacor................................. 47

Nicardipine HCl................. 44

Nicotrol Inhaler.................. 15

Nifedical XL....................... 44

Nifedipine ER.....................44

Nikki................................... 58

Nilandron........................... 29

Nilutamide......................... 29

Nimodipine........................44

Ninlaro............................... 30

Nipent.................................29

Nitro-Bid.............................47

Nitrofurantoin.................... 17

Nitrofurantoin Macrocrystals

...........................................17

Nitrofurantoin Monohydrate

...........................................17

Nitroglycerin...................... 47

Nitroglycerin Lingual.........47

Nitroglycerin Transdermal

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

Nitrostat............................. 47

Nora-BE.............................. 59

Norditropin FlexPro........... 55

Norethindrone................... 59

Norethindrone & Ethinyl

Estradiol Ferrous Fumarate

.......................................... 58

Norethindrone Acetate...... 59

Norethindrone Acetate/

Ethinyl Estradiol/Ferrous

Fumarate.......................... 58

Norgestimate/Ethinyl

Estradiol........................... 58

Norlyroc..............................59

Normosol-M in D5W...........72

Normosol-R........................ 70

Normosol-R in D5W............72

Northera............................. 45

Nortrel 0.5/35..................... 58

Nortrel 1/35......................... 58

Nortrel 7/7/7........................58

Nortriptyline HCl............... 25

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Norvir..................................37

Novarel............................... 55

Noxafil................................ 27

Nucynta ER......................... 13

Nuedexta............................ 48

Nulojix................................ 61

Nuplazid............................. 34

NutreStore.......................... 72

Nutrilipid............................ 72

Nutropin AQ....................... 55

NuvaRing............................58

Nyamyc...............................27

Nystatin.............................. 27

Nystop.................................27

O

Ocaliva................................ 51

Ocella.................................. 58

Octagam.............................. 61

Octreotide Acetate............. 60

Odefsey............................... 36

Odomzo...............................31

Ofev.................................... 69

Ofloxacin............................ 20

Ogestrel...............................58

Olanzapine......................... 34

Olanzapine ODT.................34

Olopatadine HCl.................65

Olysio.................................. 35

Omega-3-Acid Ethyl Esters

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

Omeprazole.........................52

Omnitrope.......................... 56

Oncaspar............................ 30

Ondansetron HCl............... 26

Ondansetron ODT.............. 26

Onfi..................................... 22

Onglyza...............................39

ONMEL............................... 27

Opana ER............................ 13

Opdivo.................................31

Opsumit..............................68

Orap.................................... 33

Orencia................................61

Orencia Clickject.................61

Orenitram..................... 68, 69

Orfadin................................ 51

Orkambi..............................68

Orphenadrine Citrate.........70

Orsythia.............................. 58

Oseni...................................39

Otezla..................................62

Oxacillin Sodium................ 19

Oxaliplatin..........................30

Oxandrolone.......................56

Oxaprozin............................13

Oxcarbazepine....................23

Oxiconazole Nitrate............27

Oxistat.................................27

Oxsoralen Ultra.................. 50

Oxybutynin Chloride..........53

Oxybutynin Chloride ER.... 53

Oxycodone HCl...................14

Oxycodone/Acetaminophen

.......................................... 14

Oxycodone/Aspirin.............15

Oxycodone/Ibuprofen........ 15

P

Pacerone............................. 42

Paclitaxel............................ 30

Paliperidone ER................. 34

Pamidronate Disodium......64

Panretin.............................. 32

Pantoprazole Sodium......... 52

Paricalcitol......................... 64

Paromomycin Sulfate......... 16

Paroxetine HCl................... 24

Paser................................... 28

Pataday............................... 65

Patanol................................65

Paxil.................................... 24

Pazeo...................................65

Pedvax HIB......................... 62

PEG-3350/Electrolytes....... 52

PEG-3350/NaCl/Na

Bicarbonate/KCl...............52

Peganone............................ 23

Pegasys................................35

Pegasys ProClick.................35

PegIntron............................ 35

PegIntron REDIPEN........... 35

Penicillin G Potassium....... 19

Penicillin G Procaine.......... 19

Penicillin G Sodium............19

Penicillin V Potassium....... 19

Pentam 300.........................32

Pentasa............................... 63

Pentoxifylline ER............... 45

Perforomist.........................68

Perindopril Erbumine........42

Periogard............................ 49

Perjeta................................. 31

Permethrin......................... 32

Perphenazine......................25

Phenadoz............................ 67

Phenelzine Sulfate............. 24

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Phenergan...........................67

Phenobarbital..................... 22

Phenoxybenzamine HCl.... 42

Phenytek.............................23

Phenytoin........................... 23

Phenytoin Sodium..............23

Phenytoin Sodium Extended

.......................................... 23

PhosLo................................ 53

Phoslyra.............................. 53

Phospholine Iodide............ 65

Physiolyte...........................70

Physiosol Irrigation............70

Picato..................................50

Pilocarpine HCl............ 49, 66

Pimozide.............................33

Pimtrea............................... 58

Pindolol.............................. 43

Pioglitazone HCl.................39

Pioglitazone HCl/

Glimepiride...................... 39

Pioglitazone HCl/Metformin

HCl....................................39

Piperacillin/Tazobactam.... 19

Pirmella 1/35....................... 58

Piroxicam............................ 13

Plasma-Lyte A.................... 70

Plasma-Lyte-148.................70

Plasma-Lyte-56/D5W..........72

Plenamine...........................72

Podofilox............................ 50

Polyethylene Glycol 3350

Powder..............................52

Polymyxin B Sulfate............17

Polymyxin B Sulfate/

Trimethoprim Sulfate...... 65

Pomalyst............................. 29

Portia-28............................. 58

Potassium Chloride.......70, 71

Potassium Chloride 0.15% /

NaCl 0.45% Viaflex........... 71

Potassium Chloride 0.15%

D5W/NaCl 0.33%.............. 72

Potassium Chloride 0.15%

D5W/NaCl 0.45%..............72

Potassium Chloride 0.15%/

NaCl 0.9%......................... 71

Potassium Chloride 0.22%

D5W/NaCl 0.45%..............72

Potassium Chloride 0.3%/

NaCl 0.9%......................... 71

Potassium Chloride 0.3%/

D5W.................................. 72

Potassium Chloride ER....... 71

Potassium Chloride ER

Microencapsulated........... 71

Potassium Citrate ER.......... 71

Potiga.................................. 21

Pradaxa.............................. 40

Praluent.............................. 47

Pramipexole

Dihydrochloride...............32

Pravastatin Sodium............47

Prazosin HCl.......................42

Pred Mild............................ 66

Pred-G.................................65

Pred-G S.O.P....................... 65

Prednicarbate..................... 55

Prednisolone Acetate......... 66

Prednisolone Sodium

Phosphate................... 55, 66

Prednisone..........................55

Prednisone Intensol........... 55

Pregnyl w/Diluent Benzyl

Alcohol/NaCl....................56

Premarin.............................58

Premasol............................. 72

Premphase.......................... 58

Prempro.............................. 58

Prevalite..............................47

Previfem............................. 58

Prezcobix............................ 36

Prezista............................... 37

Priftin..................................28

Primaquine Phosphate.......32

Primidone........................... 22

Pristiq..................................25

Privigen...............................61

ProAir HFA......................... 68

ProAir RespiClick............... 68

Probenecid..........................27

Probenecid/Colchicine.......27

Procainamide HCl.............. 42

Procalamine........................72

Prochlorperazine................ 25

Prochlorperazine Edisylate

.......................................... 25

Prochlorperazine Maleate

.......................................... 25

Procrit................................. 41

Procto-Med HC...................63

Procto-Pak.......................... 63

Proctosol HC.......................63

Proctozone-HC................... 63

Procysbi...............................51

Progesterone.......................59

Proglycem...........................39

Prograf................................ 61

Prolastin-C..........................69

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Prolensa..............................66

Proleukin............................30

Prolia.................................. 64

Promacta.............................41

Promethazine HCl.............. 67

Promethegan...................... 67

Propafenone HCl................42

Propafenone HCl ER.......... 42

Proparacaine HCl............... 65

Propranolol HCl................. 43

Propranolol HCl ER............43

Propranolol/

Hydrochlorothiazide....... 45

Propylthiouracil.................60

ProQuad..............................62

Prosol.................................. 72

Protriptyline HCl................ 25

PRUDOXIN.........................50

Pulmicort............................67

Pulmozyme........................ 69

Purixan............................... 29

Pyrazinamide..................... 28

Pyridostigmine Bromide.... 28

Q

Quadracel........................... 62

Quasense.............................58

Quetiapine Fumarate......... 34

Quinapril HCl..................... 42

Quinapril/

Hydrochlorothiazide....... 45

Quinidine Gluconate..........42

Quinidine Gluconate CR.... 42

Quinidine Sulfate............... 42

Quinine Sulfate...................32

R

Rabavert............................. 62

Raloxifene HCl................... 59

Ramipril..............................42

Ranexa................................ 45

Ranitidine HCl....................52

Rapaflo................................53

Rapamune...........................61

RAVICTI.............................. 51

Rebif................................... 49

Rebif Rebidose................... 49

Rebif Rebidose Titration

Pack..................................49

Rebif Titration Pack........... 49

Reclipsen............................ 58

Recombivax HB..................62

Regranex.............................50

Relenza Diskhaler...............37

Relistor................................ 51

Remicade............................ 61

Remodulin..........................69

Renagel............................... 53

Renvela............................... 53

Repaglinide........................ 39

Repaglinide/Metformin HCl

.......................................... 39

Repatha.............................. 47

Repatha Pushtronex System

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

Repatha SureClick..............47

Rescriptor........................... 36

Restasis............................... 65

Retrovir IV Infusion............37

Revatio............................... 69

Revlimid............................. 29

Rexulti................................ 34

Reyataz............................... 37

Ribasphere..........................35

Ribavirin............................. 35

Ridaura............................... 62

Rifabutin.............................28

Rifampin.............................28

Rifater................................. 28

Rilutek................................ 48

Riluzole.............................. 48

Rimantadine HCl................37

Ringers Injection................ 72

Ringers Irrigation............... 72

Riomet................................ 39

Risedronate Sodium.......... 64

Risperdal Consta................ 34

Risperidone........................ 34

Risperidone ODT................34

Rituxan................................31

Rivastigmine Tartrate........ 23

Rivastigmine Transdermal

System.............................. 23

Rizatriptan Benzoate..........27

Rizatriptan Benzoate ODT

.......................................... 27

Ropinirole HCl....................33

Rosuvastatin Calcium........ 47

Rotarix................................ 62

RotaTeq.............................. 62

Roweepra............................ 21

Rozerem............................. 70

Ruconest............................ 60

S

Sabril................................... 22

Saizen................................. 56

Samsca................................70

Sancuso...............................26

Sandimmune...................... 61

Sandostatin LAR Depot..... 60

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Santyl..................................50

Saphris................................34

Savella................................ 49

Savella Titration Pack........ 49

Selegiline HCl..................... 33

Selenium Sulfide................ 50

Selzentry............................. 37

Sensipar.............................. 59

Serevent Diskus..................68

Seroquel XR........................ 34

Serostim.............................. 51

Sertraline HCl..................... 25

Setlakin...............................58

sfRowasa.............................63

Sharobel..............................59

Signifor...............................60

Sildenafil............................ 69

Silver Sulfadiazine............. 20

Simbrinza........................... 66

Simponi...............................61

Simponi Aria.......................61

Simulect..............................62

Simvastatin.........................47

Sirolimus.............................61

Sirturo.................................28

Sodium Chloride................. 71

Sodium Chloride 0.45%...... 71

Sodium Chloride 0.9%........ 71

Sodium Fluoride................. 71

Sodium Lactate...................72

Sodium Phenylbutyrate......51

Sodium Polystyrene

Sulfonate.......................... 70

Sodium Sulfacetamide.......20

Solaraze.............................. 50

Soltamox.............................29

Solu-Cortef..........................55

Solu-Medrol........................ 55

Somatuline Depot.............. 60

Somavert............................ 60

Soriatane............................ 50

Sotalol HCl..........................42

Sovaldi................................ 35

Spiriva HandiHaler............ 68

Spiriva Respimat................ 68

Spironolactone...................46

Spironolactone/

Hydrochlorothiazide....... 45

Sporanox............................. 27

Sprintec 28.......................... 58

Spritam................................21

Sprycel.................................31

SPS...................................... 70

Sronyx.................................58

SSD..................................... 20

Stavudine............................37

Stelara................................. 61

Sterile Water Irrigation...... 64

Stiolto Respimat.................69

Stivarga............................... 31

Strattera..............................48

Strensiq............................... 51

Streptomycin Sulfate..........16

Stribild................................ 36

Suboxone.............................15

Sucraid................................ 51

Sucralfate............................52

Sulfacetamide Sodium.......20

Sulfacetamide Sodium/

Prednisolone Sodium

Phosphate.........................65

Sulfadiazine....................... 20

Sulfamethoxazole/

Trimethoprim.................. 20

Sulfamethoxazole/

Trimethoprim DS.............20

Sulfamylon..........................17

Sulfasalazine...................... 63

Sulindac.............................. 13

Sumatriptan........................27

Sumatriptan Succinate.......28

Sumatriptan Succinate Refill

.......................................... 28

Sumavel DosePro................28

Suprax................................. 18

Suprep Bowel Prep..............52

Surmontil............................25

Sustiva................................ 36

Sutent.................................. 31

Sylatron.............................. 35

Sylvant................................ 31

Symbicort........................... 69

SymlinPen 120.................... 39

SymlinPen 60..................... 39

Synagis................................62

Synarel............................... 60

Synercid.............................. 17

Synjardy..............................39

Synribo............................... 30

Synthroid............................59

Syprine............................... 70

T

Tabloid................................29

Tacrolimus.................... 50, 61

Tafinlar............................... 31

Tagrisso............................... 31

Tamiflu............................... 37

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Tamoxifen Citrate.............. 29

Tamsulosin HCl..................53

Tarceva................................31

Targretin............................. 32

Tarina Fe 1/20..................... 58

Tasigna................................31

Tasmar................................ 32

Taxotere............................. 30

Tazicef.................................18

Tazorac............................... 50

Taztia XT............................ 44

Tecentriq.............................31

Tecfidera............................ 49

Tecfidera Starter Pack........49

Tegretol-XR........................ 23

Telmisartan........................ 42

Telmisartan/Amlodipine... 45

Telmisartan/

Hydrochlorothiazide....... 45

Temazepam........................70

Tenivac............................... 62

Terazosin HCl..................... 53

Terbinafine HCl.................. 27

Terbutaline Sulfate............ 68

Terconazole........................ 27

Testosterone Cypionate..... 56

Testosterone Enanthate.....56

Tetanus/Diphtheria Toxoids-

Adsorbed Adult................ 62

Tetrabenazine.................... 49

Tetracycline HCl................. 21

Thalomid............................ 29

Theophylline...................... 68

Theophylline CR................ 68

Theophylline ER................ 68

Thioridazine HCl................ 33

Thiotepa............................. 30

Thiothixene........................ 33

Thymoglobulin................... 61

Thyrolar..............................59

Tiagabine HCl.....................22

Tikosyn...............................42

Timolol Maleate........... 43, 66

Timolol Maleate Ophthalmic

Gel Forming..................... 66

Tinidazole........................... 17

Tivicay...........................36, 37

Tizanidine HCl................... 70

TOBI.................................... 16

TOBI Podhaler.................... 16

Tobradex............................. 16

Tobradex ST........................65

Tobramycin........................ 16

Tobramycin Sulfate............ 16

Tobramycin/Dexamethasone

.......................................... 65

Tobrex................................. 16

Tolcapone........................... 32

Topiramate......................... 22

Toposar............................... 31

Topotecan HCl.................... 31

Torisel................................. 61

Torsemide.......................... 46

Toujeo SoloStar.................. 40

TPN Electrolytes.................73

Tracleer.............................. 69

Tradjenta............................ 39

Tramadol HCl..................... 15

Tramadol HCl ER................13

Tramadol HCl/

Acetaminophen................ 15

Trandolapril....................... 42

Tranexamic Acid................ 41

Transderm-Scop................. 25

Tranylcypromine Sulfate... 24

Travasol.............................. 73

Travatan Z.......................... 66

Travoprost.......................... 66

Trazodone HCl....................25

Treanda...............................28

Trecator.............................. 28

Trelstar Mixject.................. 60

Tretinoin....................... 32, 50

Tretinoin Microsphere.......50

Trexall................................. 61

Trezix.................................. 15

Tri-Legest Fe.......................58

Tri-Lo-Estarylla.................. 58

Tri-Lo-Sprintec...................58

Tri-Previfem....................... 58

Tri-Sprintec........................ 58

Triamcinolone Acetonide

.......................................... 55

Triamcinolone in Orabase

..........................................49

Triamterene/

Hydrochlorothiazide....... 45

Tribenzor............................46

Triderm...............................55

Trifluoperazine HCl........... 33

Trifluridine.........................36

Trihexyphenidyl HCl..........32

TriLyte................................ 52

Trimethoprim..................... 17

Trimipramine Maleate....... 25

Trinessa.............................. 58

Trintellix............................. 25

Trisenox..............................30

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Triumeq..............................36

Trivora-28........................... 58

Trizivir................................ 37

Trophamine........................ 73

Trulicity..............................39

Trumenba...........................62

Truvada...............................37

Twinrix............................... 62

Tybost................................. 36

Tygacil.................................17

Tykerb................................. 31

Typhim Vi...........................62

Tysabri................................49

Tyvaso................................ 69

Tyzeka.................................35

Tyzine Pediatric Nasal Drops

..........................................69

U

Uceris..................................63

Uloric.................................. 27

Unithroid............................59

Ursodiol...............................51

Uvadex................................50

V

Vagifem.............................. 58

Valacyclovir HCl.................36

Valchlor.............................. 28

Valcyte................................ 35

Valganciclovir.....................35

Valproate Sodium...............22

Valproic Acid...................... 22

Valsartan............................ 42

Valsartan/

Hydrochlorothiazide....... 46

Vancocin HCl...................... 17

Vancomycin HCl.................17

Vandazole........................... 17

VAQTA................................62

Varivax................................62

Varizig.................................61

Vascepa...............................47

Vectibix...............................32

Velcade............................... 30

Velivet.................................58

Velphoro............................. 53

Venclexta............................30

Venclexta Starting Pack..... 30

Venlafaxine HCl................. 25

Venlafaxine HCl ER............25

Ventavis..............................69

Verapamil HCl................... 44

Verapamil HCl ER..............44

Verapamil HCl SR.............. 44

Versacloz.............................35

Vesicare.............................. 53

Vestura................................58

Vexol...................................66

Vfend.................................. 27

Vibramycin......................... 21

Victoza................................39

Vidaza.................................30

Videx Pediatric................... 37

Vienva.................................58

Vigamox............................. 20

Viibryd................................ 25

Viibryd Starter Pack........... 25

Vimpat................................ 23

Vinblastine Sulfate.............30

Vincasar PFS.......................30

Vincristine Sulfate............. 30

Vinorelbine Tartrate.......... 30

Viracept.............................. 37

Viramune............................36

Viramune XR......................36

Virazole...............................38

Viread..................................37

Vitekta................................ 36

Vivitrol................................ 15

Voltaren.............................. 13

Voriconazole.......................27

Votrient............................... 31

VP-PNV-DHA......................73

VPRIV.................................. 51

Vraylar................................34

Vyfemla.............................. 58

Vytorin................................47

Vyvanse.............................. 48

W

Warfarin Sodium............... 40

Welchol...............................47

WYMZYA Fe........................58

X

Xalkori.................................31

Xarelto................................40

Xarelto Starter Pack........... 40

Xeljanz................................ 61

Xeljanz XR...........................61

Xenazine.............................49

Xgeva.................................. 64

Xifaxan................................ 17

Xolair.................................. 69

Xtandi................................. 29

Xulane.................................58

Xyrem................................. 70

Y

Yervoy................................. 32

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YF-Vax................................ 62

Yondelis..............................29

Z

Zafirlukast.......................... 67

Zaleplon..............................70

Zaltrap................................ 30

Zanosar............................... 29

Zarxio.................................. 41

Zavesca................................51

Zazole..................................27

Zelapar................................ 33

Zelboraf............................... 31

Zemaira.............................. 69

Zemplar.............................. 64

Zenchent.............................58

Zenchent Fe........................ 58

Zenpep................................ 51

Zepatier...............................35

Zerbaxa............................... 18

Zetia.................................... 47

Ziagen................................. 37

Zidovudine......................... 37

Zinbryta.............................. 61

Zinecard............................. 30

Ziprasidone HCl................. 34

Zirgan..................................35

Zmax................................... 19

Zoledronic Acid..................64

Zolinza................................30

Zolpidem Tartrate.............. 70

Zomacton............................56

Zometa............................... 64

Zonisamide......................... 21

Zorbtive...............................51

Zortress............................... 61

Zostavax..............................62

Zovia 1/35E..........................58

Zovia 1/50E......................... 58

Zovirax................................36

Zyclara................................50

Zyclara Pump..................... 50

Zydelig................................ 31

Zyflo....................................67

Zyflo CR.............................. 67

Zykadia................................31

Zyprexa Relprevv............... 34

Zytiga.................................. 29

Zyvox................................... 17

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Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits,

formulary, pharmacy network, premium and/or co-payments/co-insurance may change on

January 1, 2016, and from time to time during the plan year.

This information is available for free in other languages. Please call our Customer Service number

listed above.

Esta información está disponible sin costo en otros idiomas. Llame a Servicio al Cliente al

número indicado arriba.

Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated

companies, a Medicare Advantage organization with a Medicare contract and a contract with the

State Medicaid Program. Enrollment in the plan depends on the plan’s contract renewal with

Medicare.

UHHI16RP3711973_011 Last updated November 1, 2016

For more recent information or if you have other questions, please

contact UnitedHealthcare Dual Complete Customer Service at:

Toll-Free 1-866-622-8054, TTY 711

8 a.m. to 8 p.m. local time, 7 days a week

www.UHCCommunityPlan.com


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