2020 - Ohio Insurance Resource€¦ · Y0066_190628_124536_C v01.00 Last updated September 1, 2019. TABLE OF CONTENTS211 What is a drug list? ... Our contact information, along with

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2020COMPLETE DRUG LIST(FORMULARY)

Prescription drug list information

AARP® Medicare Advantage (HMO)

AARP® Medicare Advantage Plan 1 (HMO)







Important Notes: This document has information about the drugs covered by this plan. For more up-to-date information or if you have any questions, please call UnitedHealthcare Customer Service at:

Toll-free 1-800-643-4845, TTY 7118 a.m. - 8 p.m. local time, 7 days a week

www.myAARPMedicare.com

Formulary ID Number 00020047, Version 8Y0066_190628_124536_C v01.00 Last updated September 1, 2019

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TABLE OF CONTENTS2

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Covered drugs by medical condition...................................................................................................... 29

Covered drugs with a quantity limit (QL).............................................................................................. 107

Questions?

If you have questions, we’re here to help. Call UnitedHealthcare Customer Service at:

Toll-free 1-800-643-4845, TTY 711

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

2 3What is a drug list?A drug list, or formulary, is a list of prescription drugs covered by your plan. Your plan and a team of health care providers work together in selecting drugs that are needed for well-rounded care and treatment.

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

· The drug is used for a medically accepted indication,

· The prescription is filled at a network pharmacy and

· Other plan rules are followed.

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

Note to existing members: This complete list of prescription drugs covered by your plan is current as of September 1, 2019.

For an up-to-date list of covered drugs or if you have questions, please call UnitedHealthcare Customer Service. Our contact information is on the cover.

This drug list has changed since last year. Please review this document to make sure your prescription drugs are still covered. In most cases, you must use network pharmacies to have your prescriptions covered by the plan.

When this drug list refers to “we,” “us,” or “our,” it means UnitedHealthcare. When it refers to “plan,” “our plan,” or “your plan,” it means AARP Medicare Advantage Plans.

34How do I use the drug list?There are 2 ways to find your prescription drugs in this drug list:

1. By name. Turn to section “Covered drugs by name (Drug index)” on pages 12–28 to see the .......list of drug names in alphabetical order. Find the name of your drug. The page number where .......you can find the drug will be next to it.

2. By medical condition. Turn to section “Covered drugs by medical condition” on pages .......29–106 to look for drugs based on your medical conditions. For example, if you have a heart .......condition, you should look in the category Cardiovascular Agents. This is where you will find .......drugs that treat heart conditions.

Can’t find your drug?

Check the complete drug list by visiting our plan website at www.myAARPMedicare.com. You can use online tools to look up your drugs. This information is updated on a regular basis.

What are generic drugs?Generic drugs have the same active ingredients as brand name drugs. They usually cost less than brand name drugs and are approved by the Food and Drug Administration (FDA). Our plan covers both brand name and generic drugs.

Talk with your doctor to see if any of the brand name drugs you take have generic versions. Then review the drug list to make sure you are getting the drug you need for the least amount of money.

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

What is a compounded drug?A compounded drug is created by a pharmacist by combining or mixing ingredients to create a prescription medication customized to the needs of an individual patient. Generally compounded drugs are non-formulary drugs (not covered) by your plan. You may need to ask for and receive an approved coverage determination from us to have your compounded drug covered. Compounded drugs may be Part D eligible. For more information about compounded drugs, please review your Evidence of Coverage.

4 5Drug payment stage and drug tiersThe amount you pay for a covered prescription drug will depend on:

· Your drug payment stage. Your plan has different stages of drug coverage. When you fill a prescription, the amount you pay depends on the coverage stage you’re in.

· Your drug’s tier. Each covered drug is in 1 of 5 drug tiers. Each tier has a copay or coinsurance amount. The chart below shows the differences between the tiers.

If you need help or have any questions about your drug costs, please review your Evidence of Coverage or call UnitedHealthcare Customer Service. Our contact information is on the cover.

Drug Tier Includes

Tier 1:

Preferred generic

Lower-cost, commonly used generic drugs.

Tier 2:

Generic

Many generic drugs.

Tier 3:

Preferred brand

Many common brand name drugs, called preferred brands and some higher-cost generic drugs.

Tier 4:

Non-preferred drug

Non-preferred generic and non-preferred brand name drugs.

Tier 5:

Specialty tier

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

Getting Extra HelpIf you qualify for Extra Help paying for your prescription drugs, your copays and coinsurance may be lower. Members who qualify for Extra Help will receive the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (LIS Rider). Please read it to learn about your costs. You can also call UnitedHealthcare Customer Service. Our contact information is on the cover.

5 16..

Are there any rules or limits on my drug coverage?Yes, some drugs may have coverage rules or have limits on the amount you can get. If your drug has any coverage rules or limits, there will be a code(s) in the “Coverage Rules or Limits on use” column of the “Covered drugs by medical condition” chart starting on page 29. The codes and what they mean are shown below and on the next page.

You can also get more information about the coverage rules and/or limits applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. If you would like a copy sent to you, please call UnitedHealthcare Customer Service. Our contact information is on the cover.

Coverage Rules and Limits

PA - Prior authorization

The plan requires you or your doctor to get prior approval for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used 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 1 copay or over a certain number of days. These limits may be in place to ensure safe and effective use of the drug. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you or your doctor can ask the plan to cover the additional quantity.

ST - Step therapy

There may be effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try 1 or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you or your doctor can ask the plan to cover this drug.

6 7

Other Special Coverage Rules

B/D - Medicare Part B or Part D

Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it’s correctly covered by Medicare.

LA - Limited access

Drugs are considered “limited access” if the FDA says the drug can be given out only by certain facilities or doctors. These drugs may require extra handling, provider coordination or patient education that can’t be done at a network pharmacy.

MME - Morphine milligram equivalent

Additional quantity limits may apply across all drugs in the opioid class used for the treatment of pain. This additional limit is called a cumulative morphine milligram equivalent (MME), and is designed to monitor safe dosing levels of opioids for individuals who may be taking more than 1 opioid drug for pain management. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you or your doctor can ask the plan to cover the additional quantity.

7D - 7-Day limit

An opioid drug used for the treatment of acute pain may be limited to a 7-day supply for members with no recent history of opioid use. This limit is intended to minimize long-term opioid use. For members who are new to the plan and have a recent history of using opioids, the limit may be overridden by having the pharmacy contact the plan.

DL - Dispensing limit

Dispensing limits apply to this drug. This drug is limited to a 1 month supply per prescription.For Track Refered Purpose

You and your doctor may ask the plan for an exception to the coverage rules and/or limits for your drug. See section “How can I get an exception?" on page 8 or see your Evidence of Coverage to learn more.

If you don’t get approval from the plan before you fill a prescription for a drug with coverage rules or limits, you may have to pay the full cost of the drug.

78Track

What if my drug is not on this list?If your drug is not included in this drug list we may still cover it. Call UnitedHealthcare Customer Service to ask if it’s covered. Our contact information, along with the date we last updated the drug list is on the cover.

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

1. Ask UnitedHealthcare Customer Service for a list of similar drugs that are covered by the plan. When you get the list, show it to your doctor and ask him or her to prescribe a covered drug.

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

How can I get an exception?Sometimes you may need to ask for drug coverage that’s not normally provided by your plan. This is called asking for an exception. When you do, the plan will review your request and give you a coverage decision known as a coverage determination.

Types of exceptions you can ask for

· Drug list exception: Ask the plan to cover your drug even if it’s not on the drug list. If approved, this drug will be covered at a pre-determined cost-sharing level. You will not be able to ask us to provide the drug at a lower cost-sharing level.

· Utilization exception: Ask the plan to revise the coverage rules or limits on your drug. For example, if your drug has a quantity limit, you can ask the plan to change the limit and cover more.

· Tiering exception: Ask the plan to cover your drug on our list at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you pay out-of-pocket for your drug.

The plan may approve your request for an exception if the covered alternative drugs wouldn’t be as effective in treating your condition or would cause adverse medical effects.

Who can ask for an exception?

You, your authorized representative or your doctor can ask for an exception by calling UnitedHealthcare Customer Service. Your doctor must give us a supporting statement with the reason for the exception.

How long does it take to get an exception?

After we get the statement from your doctor supporting your request for an exception, we’ll give you a decision within 72 hours. You can ask for an expedited (fast) decision if you or your doctor believes that your health could be seriously harmed by waiting 72 hours. If your request for an expedited review is approved, we’ll give you a decision within 24 hours after we get your doctor’s supporting statement.

8 9Can I get my drug while I wait for an exception?As a new or continuing member in our plan, we may cover a temporary supply of your drug if it’s not on our drug list or if it has rules or limits. For example, you may need a prior authorization from us before you can fill your prescription. During the time when you are getting a temporary supply, you should talk with your doctor to decide if there is a similar drug on the drug list you can take instead. If you and your doctor decide this is the only drug that will work for you, you will need to ask for an exception. We may cover your drug in certain cases during the first 90 days of your membership.

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

If you... And you are… We may cover…

are a new member in the first 90 days of your membershipOR

were a member last year and it’s the first 90 days of your plan year

not in a nursing home or long-term care facility

at least a 30-day temporary supply

in a nursing home or long-term care facility


have been in the plan for more than 90 days

in a nursing home or long-term care facility and need a supply right away

at least a 31-day emergency supply

are going through a change in your level of care, such as being transferred from a hospital to a long-term care facility, any time during the year

not in a nursing home or long-term care facility


in a nursing home or long-term care facility


The prescription must be filled at a network pharmacy. If your prescription is written for fewer days, we’ll allow refills to provide at least the day supply listed in the chart above. (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.)

We will not pay for more of your drug after you get this temporary or emergency supply unless you receive authorization from the plan.

910Can the drug list change?Most changes in drug coverage happen on January 1. We may need to make changes during the plan year for safety or other reasons that can affect you. We must follow Medicare rules in making these changes.

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

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

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

· Changes the coverage rules or limits for a drug.

· Moves a drug into a different cost-sharing tier.

If we add new generic drugs

We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost-sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made.

If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section “How can I get an exception?” on page 8.

If we remove a drug from the list

Usually, if you’re taking a drug on this drug list that was covered at the beginning of the year, we will not remove or reduce coverage during the year. If you are taking a drug that is removed because a generic version becomes available, we will tell you. If the Food and Drug Administration (FDA) says a drug you are taking is not effective or is unsafe, we will take it off the drug list right away.

If we change the coverage rules or limits

We’ll tell you if we add prior approval, quantity limits and/or step therapy restrictions on a drug. You can find out if your drug has any rules or limits by looking in the chart on pages 107-133.

We’ll tell you about other changes

If a drug you are taking is removed from the drug list during the plan year, we’ll include an update in your Part D Explanation of Benefits (Part D EOB) statement. We’ll tell you about other changes to our drug list at least 30 days before they go into effect or when you request a refill of the drug. If you find out when requesting a refill, you will receive at least a 30-day supply of the drug so you have time to talk with your doctor. To get updated information about the drugs covered by your plan, please call UnitedHealthcare Customer Service. Our contact information is on the cover.

10 11Drugs with dosages other than a 1-month supply

Drugs packaged in an extended day supply

Some drugs are packaged from the manufacturer to provide more than a 1-month supply. When you fill these drugs, you may have to pay more than 1 copay/coinsurance for a single prescription. For more information, please call Customer Service. Our contact information is on the cover.

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

A daily cost-sharing rate may apply when your doctor prescribes less than a full month’s supply of certain drugs for you and you are required to pay a copayment. A daily cost-sharing rate is the copayment divided by the number of days in a month’s supply.

Daily cost-sharing applies only if the drug is in the form of a solid oral dose (e.g., tablet or capsule) when dispensed for a supply of less than 1 month under applicable law. The daily cost-sharing requirements do not apply to either of the following:

1. Solid oral doses of antibiotics.

2. Solid oral doses that are dispensed in their original container or are usually dispensed in their original packaging to help patients comply with usage and dosage directions.

For more informationFor more detailed information about your plan’s prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about your plan’s prescription drug coverage, please call UnitedHealthcare Customer Service. Our contact information, along with the date we last updated the drug list, is on the cover.

If you have general questions about Medicare prescription drug coverage, visit www.medicare.gov or call Medicare at 1-800-633-4227, TTY 1-877-486-2048, 24 hours a day, 7 days a week.

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Covered drugs by name (Drug index)

A

Abacavir Sulfate..................... 58

Abacavir Sulfate-Lamivudine.............................................. 58

Abacavir-Lamivudine-Zidovudine........................... 58

Abelcet....................................45

Abilify Maintena......................54

Abiraterone Acetate...............48

Acamprosate Calcium........... 32

Acarbose................................ 61

Acebutolol HCl....................... 67

Acetaminophen-Codeine...... 31

Acetazolamide........................70

Acetazolamide ER..................70

Acetic Acid........................... 102

Acetylcysteine...................... 105

Acitretin...................................75

Actemra.................................. 95

Actemra ACTPen................... 95

ActHIB.....................................96

Actimmune............................. 95

Acyclovir................................. 57

Acyclovir Sodium................... 57

Adacel.....................................96

Adapalene.............................. 75

Adefovir Dipivoxil................... 57

Adempas.............................. 104

Advair Diskus....................... 105

Advair HFA........................... 105

Afinitor.....................................50

Afinitor Disperz.......................50

Aimovig................................... 47

Ala-Cort................................... 83

Albendazole............................52

Albuterol Sulfate.................. 103

Alclometasone Dipropionate.............................................. 83

Alcohol Prep Pads................. 99

Alecensa................................. 50

Alendronate Sodium..............98

Alfuzosin HCl ER....................83

Alinia....................................... 52

Aliskiren Fumarate................. 69

Allopurinol.............................. 47

Alocril....................................100

Alomide.................................100

Alosetron HCl......................... 81

Alphagan P...........................100

Alprazolam..............................60

Altavera................................... 87

Alunbrig.................................. 50

Alyacen 1/35.......................... 87

Alyq....................................... 104

Amantadine HCl.....................53

AmBisome.............................. 45

Ambrisentan.........................104

Amethia...................................87

Amethia Lo............................. 87

Amikacin Sulfate.................... 33

Amiloride HCl......................... 71

Amiloride-Hydrochlorothiazide.............................................. 69

Aminosyn II.............................77

Aminosyn-PF.......................... 77

Amiodarone HCl.....................67

Amitiza.................................... 81

Amitriptyline HCl.................... 44

Amlodipine Besylate..............68

Amlodipine-Atorvastatin........ 69

Amlodipine-Benazepril.......... 69

Amlodipine-Olmesartan.........69

Amlodipine-Valsartan.............69

Amlodipine-Valsartan-HCTZ.............................................. 69

Ammonium Lactate............... 75

Amoxapine............................. 44

Amoxicillin.............................. 37

Amoxicillin-Potassium Clavulanate.......................... 37

Amoxicillin-Potassium Clavulanate ER.................... 37

Amphetamine-Dextroamphetamine............73

Amphetamine-Dextroamphetamine ER......73

Amphotericin B...................... 45

Ampicillin................................ 37

Ampicillin Sodium..................37

Ampicillin-Sulbactam Sodium.............................................. 37

Ampyra....................................74

Anadrol-50.............................. 86

Anagrelide HCl.......................64

Anastrozole.............................50

Androderm............................. 86

Anoro Ellipta.........................105

Apokyn....................................53

Apraclonidine HCl................100

Aprepitant...............................45

Apri..........................................87

Apriso......................................97

Aptiom.................................... 41

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Aptivus.....................................59

Aralast NP............................... 82

Aranelle................................... 87

Aranesp.............................64, 65

Arcalyst....................................95

Aripiprazole.............................54

Aripiprazole ODT.................... 54

Aristada................................... 54

Aristada Initio.......................... 54

Arnuity Ellipta........................102

Ashlyna....................................87

Aspirin-Dipyridamole ER........66

Atazanavir Sulfate...................59

Atenolol................................... 67

Atenolol-Chlorthalidone......... 69

Atomoxetine HCl.................... 73

Atorvastatin Calcium.............. 71

Atovaquone.............................52

Atovaquone-Proguanil HCl.... 52

Atripla...................................... 58

Atropine Sulfate......................99

Atrovent HFA........................ 103

Aubagio................................... 74

Aubra....................................... 87

Auryxia.....................................79

Austedo................................... 73

Aviane......................................87

Avonex.....................................74

Avonex Pen............................. 74

Avonex Prefilled......................74

Azasite..................................... 38

Azathioprine............................93

Azelaic Acid............................ 75

Azelastine HCl.............. 100, 102

Azithromycin........................... 38

Azopt..................................... 100

Aztreonam...............................36

B

Bacitracin................................ 34

Bacitracin-Polymyxin B.......... 99

Baclofen................................ 106

Bactocill in Dextrose.............. 37

Bactroban................................34

Balsalazide Disodium.............97

Balversa...................................50

Balziva..................................... 87

Banzel............................... 41, 42

Baraclude................................57

BCG Vaccine...........................96

Belsomra...............................106

Benazepril HCl........................67

Benazepril-Hydrochlorothiazide...............................................69

Benlysta...................................95

Benznidazole.......................... 52

Benzoyl Peroxide-Erythromycin...............................................75

Benztropine Mesylate............ 52

Bepreve................................. 100

Berinert....................................92

Besivance................................38

Betamethasone Dipropionate...............................................83

Betamethasone Dipropionate Aug........................................ 83

Betamethasone Valerate........84

Betaseron................................74

Betaxolol HCl..................67, 100

Bethanechol Chloride............ 83

Bethkis.................................. 104

Betimol.................................. 100

Bevespi Aerosphere.............105

Bexarotene..............................51

Bexsero................................... 96

Bicalutamide........................... 48

Bicillin C-R...............................37

Bicillin C-R 900/300............... 37

Bicillin L-A............................... 37

BiDil......................................... 69

Biktarvy....................................58

Binosto.................................... 98

Bisoprolol Fumarate...............67

Bisoprolol-Hydrochlorothiazide...............................................69

BIVIGAM..................................94

Blephamide.............................99

Blephamide S.O.P.................. 99

Blisovi 24 Fe............................87

Blisovi Fe 1.5/30.....................87

Boostrix................................... 96

Bosentan...............................104

Bosulif......................................50

Braftovi.................................... 50

Breo Ellipta............................105

Briellyn.....................................87

Brilinta..................................... 66

Brimonidine Tartrate............ 100

BRIVIACT................................ 40

Bromocriptine Mesylate.........53

Budesonide.................... 98, 102

Budesonide ER.......................98

Bumetanide.............................70

Buprenorphine........................30

14Tracked14 14

Buprenorphine HCl................ 33

Buprenorphine HCl-Naloxone HCl.........................................33

Bupropion HCl........................43

Bupropion HCl SR............33, 43

Bupropion HCl XL.................. 43

Buspirone HCl........................ 60

Butalbital-Acetaminophen-Caffeine.................................29

Butalbital-Aspirin-Caffeine..... 29

Butorphanol Tartrate..............31

Bydureon.................................61

Bydureon BCise......................61

Byetta 10MCG Pen.................61

Byetta 5MCG Pen...................61

Bystolic....................................67

C

Cabergoline............................ 91

Cablivi......................................66

Cabometyx..............................50

Calcipotriene...........................75

Calcitonin Salmon.................. 98

Calcitriol............................ 75, 98

Calcium Acetate..................... 79

Calquence...............................50

Camila..................................... 90

Camrese Lo.............................87

Canasa.................................... 97

Candesartan Cilexetil............. 66

Candesartan Cilexetil-HCTZ...............................................69

Caprelsa.................................. 50

Captopril..................................67

Captopril-Hydrochlorothiazide...............................................69

Carac....................................... 75

Carafate...................................81

Carbaglu..................................77

Carbamazepine...................... 42

Carbamazepine ER................ 42

Carbidopa............................... 53

Carbidopa-Levodopa............. 53

Carbidopa-Levodopa ER....... 53

Carbidopa-Levodopa ODT.....53

Carbidopa-Levodopa-Entacapone.......................... 53

Carteolol HCl........................ 100

Cartia XT..................................68

Carvedilol................................ 67

Cayston................................. 104

Caziant.....................................87

Cefaclor...................................35

Cefadroxil................................35

Cefazolin Sodium................... 35

Cefdinir....................................35

Cefepime HCl......................... 35

Cefixime.................................. 35

Cefotetan Disodium............... 36

Cefoxitin Sodium.................... 36

Cefpodoxime Proxetil.............36

Cefprozil.................................. 36

Ceftazidime............................. 36

Ceftriaxone Sodium................36

Cefuroxime Axetil................... 36

Cefuroxime Sodium............... 36

Celecoxib................................ 29

Celontin................................... 40

Cephalexin.............................. 36

Cesamet.................................. 45

Cetirizine HCl........................102

Chantix.................................... 33

Chantix Continuing Month Pak...............................................33

Chantix Starting Month Pak...33

Chemet....................................79

Chenodal.................................80

Chlordiazepoxide HCl............ 60

Chlorhexidine Gluconate....... 75

Chloroquine Phosphate......... 52

Chlorothiazide.........................71

Chlorpromazine HCl...............53

Chlorthalidone........................ 71

Chlorzoxazone......................106

Cholbam..................................82

Cholestyramine.......................72

Cholestyramine Light............. 72

Ciclopirox................................ 45

Ciclopirox Olamine.................45

Cilostazol.................................66

Ciloxan.....................................39

Cimduo....................................58

Cimetidine...............................80

Cimetidine HCl........................80

Cimzia......................................93

Cimzia Prefilled.......................93

Cinacalcet HCl........................ 98

Cinryze.....................................92

Cipro HC............................... 102

Ciprodex................................102

Ciprofloxacin...........................39

Ciprofloxacin HCl................... 39

Ciprofloxacin in D5W............. 39

Citalopram Hydrobromide..... 43

15Tracked 1515

Claravis....................................75

Clarithromycin.........................38

Clarithromycin ER...................38

Clenpiq.................................... 81

Climara Pro............................. 87

Clindamycin HCl.....................34

Clindamycin Palmitate HCl.... 34

Clindamycin Phosphate...34, 75

Clindamycin Phosphate in D5W...............................................34

Clindamycin Phosphate-Benzoyl Peroxide................. 75

Clobazam................................ 41

Clobetasol Propionate........... 84

Clobetasol Propionate Emollient Base......................84

Clomipramine HCl.................. 44

Clonazepam............................60

Clonazepam ODT................... 60

Clonidine................................. 66

Clonidine HCl..........................66

Clonidine HCl ER....................73

Clopidogrel Bisulfate..............66

Clorazepate Dipotassium.......60

Clotrimazole............................ 45

Clotrimazole-Betamethasone...............................................75

Clozapine................................ 56

Clozapine ODT....................... 56

Coartem...................................52

Codeine Sulfate...................... 31

Colchicine............................... 47

Colcrys.....................................47

Colesevelam HCl.................... 72

Colestipol HCl.........................72

Colistimethate Sodium...........34

Colocort...................................98

Combigan............................. 100

Combivent Respimat........... 105

Cometriq................................. 50

Complera.................................58

Compro................................... 44

Constulose.............................. 81

Copiktra...................................49

Cordran................................... 84

Corlanor...................................69

Cortisone Acetate...................84

Cortisporin........................ 75, 76

Cosentyx................................. 76

Cosentyx Sensoready............ 76

Cosopt PF............................. 100

Cotellic.....................................50

Coumadin................................64

Creon.......................................82

Crinone....................................90

Crixivan....................................59

Cromolyn Sodium......... 80, 100, 104

Cryselle-28.............................. 87

Cuvposa.................................. 80

Cyclafem 1/35........................ 87

Cyclafem 7/7/7.......................87

Cyclobenzaprine HCl........... 106

Cyclophosphamide................ 48

Cycloset...................................61

Cyclosporine...........................93

Cyclosporine Modified...........93

Cyproheptadine HCl............ 102

Cyred....................................... 87

Cystadane............................... 82

Cystagon................................. 82

Cystaran.................................. 99

D

Daklinza...................................57

Dalfampridine ER................... 74

Daliresp................................. 104

Dalvance..................................34

Danazol....................................86

Dantrolene Sodium.............. 106

Dapsone.................................. 48

Daptacel.................................. 96

Daptomycin.............................34

DARAPRIM............................. 52

Daurismo.................................50

Deblitane................................. 90

Deferasirox..............................79

Delstrigo.................................. 58

Delyla.......................................87

Demeclocycline HCl...............39

Demser.................................... 69

Denavir.................................... 57

Depen Titratabs...................... 83

Depo-Estradiol........................ 87

Depo-Provera.......................... 90

Descovy...................................58

Desipramine HCl.................... 44

Desmopressin Acetate...........86

Desmopressin Acetate Spray...............................................86

Desogestrel-Ethinyl Estradiol...............................................87

Desonide................................. 84

Desoximetasone.....................84

16Tracked16 16

Desvenlafaxine Succinate ER...............................................43

Dexamethasone......................84

Dexamethasone Intensol....... 84

Dexamethasone Sodium Phosphate.......................... 101

Dexilant....................................81

Dexmethylphenidate HCl.......73

Dexmethylphenidate HCl ER...............................................73

Dextroamphetamine Sulfate...............................................73

Dextroamphetamine Sulfate ER...............................................73

Dextrose.................................. 77

Dextrose-NaCl.........................77

Diastat AcuDial....................... 41

Diastat Pediatric......................41

Diazepam................................ 60

Diazepam Intensol..................60

Diclofenac Epolamine............ 29

Diclofenac Potassium............ 29

Diclofenac Sodium..........29, 76, 101

Diclofenac Sodium ER........... 29

Dicloxacillin Sodium...............37

Dicyclomine HCl..................... 80

Didanosine.............................. 58

Dificid.......................................38

Diflunisal..................................29

Digitek..................................... 69

Digox....................................... 69

Digoxin.................................... 69

Dihydroergotamine Mesylate...............................................47

Dilantin.................................... 42

Dilantin INFATABS................. 42

Dilt-XR......................................68

Diltiazem HCl.......................... 68

Diltiazem HCl ER.................... 68

Diltiazem HCl ER Beads........ 68

Diltiazem HCl ER Coated Beads.................................... 68

Dipentum.................................98

Diphenoxylate-Atropine..........80

Diphtheria-Tetanus Toxoids DT...............................................96

Disulfiram................................ 32

Diuril.........................................71

Divalproex Sodium................. 61

Divalproex Sodium ER........... 61

Dofetilide................................. 67

Donepezil HCl.........................42

Donepezil HCl ODT................ 42

Dorzolamide HCl.................. 100

Dorzolamide HCl-Timolol Maleate............................... 100

Dorzolamide HCl-Timolol Maleate Preservative Free.............................................101

Dovato..................................... 57

Doxazosin Mesylate............... 66

Doxepin HCl......................44, 76

Doxercalciferol........................98

Doxy 100................................. 40

Doxycycline Hyclate............... 40

Doxycycline Monohydrate..... 40

Dronabinol...............................45

Drospirenone-Ethinyl Estradiol...............................................87

Droxia...................................... 49

Duavee.................................... 87

Dulera.................................... 105

Duloxetine HCl........................74

Duramorph..............................31

Durezol.................................. 101

Dutasteride..............................83

Dymista................................. 105

Dyrenium.................................71

E

E.E.S. Granules.......................38

Econazole Nitrate................... 45

Edarbi...................................... 66

Edarbyclor...............................69

Edurant....................................58

Efavirenz..................................58

Egrifta...................................... 92

Elestrin.....................................87

Eliquis...................................... 64

Eliquis Starter Pack................ 64

Elmiron.................................... 83

Embeda................................... 30

Emcyt.......................................49

Emoquette...............................87

Emsam.....................................43

Emtriva.....................................59

Enalapril Maleate.................... 67

Enalapril-Hydrochlorothiazide...............................................69

Enbrel...................................... 93

Enbrel SureClick.....................93

Endocet................................... 31

Engerix-B.................................96

Enoxaparin Sodium................64

Enpresse-28............................ 87

Enskyce................................... 87

17Tracked 1717

Entacapone.............................53

Entecavir..................................57

Entresto................................... 70

Enulose....................................81

Envarsus XR............................93

Epclusa....................................57

Epidiolex..................................40

Epinastine HCl...................... 100

Epinephrine...........................103

EpiPen 2-Pak.........................103

EpiPen Jr 2-Pak.................... 103

Epitol........................................42

Epivir HBV............................... 57

Eplerenone..............................71

Eprosartan Mesylate.............. 66

Eraxis....................................... 45

Ergotamine-Caffeine...............47

Erivedge.................................. 50

Erleada.................................... 48

Erlotinib HCl............................50

Errin......................................... 90

Ertapenem Sodium................ 37

Ery............................................76

Ery-Tab.................................... 38

Erythrocin Lactobionate.........38

Erythromycin.....................38, 76

Erythromycin Base................. 38

Erythromycin Ethylsuccinate...............................................38

Esbriet................................... 105

Escitalopram Oxalate............. 43

Esomeprazole Magnesium.... 81

Estarylla................................... 87

Estradiol............................ 87, 88

Estradiol Valerate....................88

Estring..................................... 88

Ethacrynic Acid.......................70

Ethambutol HCl...................... 48

Ethosuximide.......................... 40

Ethynodiol Diacetate-Ethinyl Estradiol................................ 88

Etodolac.................................. 29

Etodolac ER............................ 29

Eurax........................................52

Evotaz...................................... 59

Exelderm................................. 45

Exemestane............................ 50

Ezetimibe.................................72

Ezetimibe-Simvastatin............ 72

F

Falmina....................................88

Famciclovir..............................57

Famotidine.............................. 80

Fanapt......................................54

Fanapt Titration Pack............. 54

Farydak....................................50

Fayosim................................... 88

Felbamate............................... 41

Felodipine ER......................... 68

Femring................................... 88

Femynor.................................. 88

Fenofibrate..............................71

Fenofibrate Micronized.......... 71

Fenofibric Acid....................... 71

Fentanyl...................................30

Fentanyl Citrate.......................31

Ferriprox..................................79

Fetzima.................................... 43

Fetzima Titration..................... 43

Finacea....................................76

Finasteride.............................. 83

Firazyr...................................... 93

Firmagon................................. 92

Flac........................................ 102

Flarex.....................................101

Flebogamma DIF.................... 94

Flecainide Acetate..................67

Flector......................................29

Flovent Diskus...................... 102

Flovent HFA.......................... 102

Fluconazole.............................46

Fluconazole in Sodium Chloride................................ 46

Flucytosine..............................46

Fludrocortisone Acetate........ 84

Flunisolide.............................103

Fluocinolone Acetonide........84, 102

Fluocinolone Acetonide Scalp...............................................84

Fluocinonide........................... 84

Fluocinonide Emulsified Base...............................................84

Fluorometholone.................. 101

Fluorouracil............................. 76

Fluoxetine HCl........................ 43

Fluphenazine Decanoate....... 53

Fluphenazine HCl.............53, 54

Flurbiprofen.............................29

Flurbiprofen Sodium............ 101

Flutamide................................ 49

Fluticasone Propionate......... 84, 103

18Tracked18 18

Fluticasone-Salmeterol........ 105

Fluvastatin Sodium.................71

Fluvoxamine Maleate............. 43

FML........................................101

FML Forte..............................101

Fondaparinux Sodium............64

Forteo...................................... 98

Fosamprenavir Calcium......... 59

Fosinopril Sodium.................. 67

Fosinopril Sodium-HCTZ....... 70

FreAmine HBC........................77

Furosemide.......................70, 71

Fuzeon.....................................59

Fyavolv.....................................88

Fycompa..................................41

G

Gabapentin............................. 41

Galantamine Hydrobromide...............................................42

Galantamine Hydrobromide ER...............................................42

Gammagard............................ 94

Gammagard S/D Less IgA.....95

Gammaked............................. 95

Gammaplex.............................95

Gamunex-C............................. 95

Gardasil 9................................ 96

Gatifloxacin............................. 39

Gattex...................................... 80

Gauze...................................... 99

GaviLyte-C...............................81

GaviLyte-G...............................81

GaviLyte-N with Flavor Pack...............................................81

Gemfibrozil..............................71

Generlac..................................81

Gengraf................................... 93

Genotropin.............................. 86

Genotropin MiniQuick............86

Gentak..................................... 33

Gentamicin Sulfate.................33

Gentamicin Sulfate-0.9% Sodium Chloride.................. 33

Genvoya.................................. 57

Geodon....................................55

Gianvi.......................................88

Gilenya.....................................74

Gilotrif...................................... 50

Glassia.....................................82

Glatiramer Acetate................. 74

Glatopa....................................74

Gleostine................................. 48

Glimepiride..............................61

Glipizide...................................61

Glipizide ER............................ 61

Glipizide-Metformin HCl.........61

GlucaGen HypoKit..................62

Glucagon Emergency............ 62

Glyxambi................................. 61

Granisetron HCl...................... 45

Granix...................................... 65

Griseofulvin Microsize............46

Griseofulvin Ultramicrosize....46

Guanfacine HCl ER................ 73

Guanidine HCl........................ 48

H

Haegarda.................................93

Hailey 24 Fe............................ 88

Halobetasol Propionate......... 84

Haloperidol..............................54

Haloperidol Decanoate.......... 54

Haloperidol Lactate................ 54

Havrix.......................................96

Heparin Sodium......................64

HepatAmine............................ 77

Hetlioz....................................106

Hiberix..................................... 96

Humalog..................................63

Humalog Junior KwikPen...... 63

Humalog KwikPen.................. 63

Humalog Mix 50/50................63

Humalog Mix 50/50 KwikPen...............................................63

Humalog Mix 75/25................63

Humalog Mix 75/25 KwikPen...............................................63

Humatrope.............................. 86

Humira.....................................93

Humira Pediatric Crohns Start...............................................93

Humira Pen............................. 93

Humira Pen Crohns Disease Starter....................................93

Humira Pen Psoriasis Starter...............................................93

Humulin 70/30........................63

Humulin 70/30 KwikPen........ 63

Humulin N............................... 63

Humulin N KwikPen............... 63

Humulin R............................... 63

Humulin R U-500.................... 63

Humulin R U-500 KwikPen.....63

Hydralazine HCl...................... 72

Hydrochlorothiazide............... 71

19Tracked 1919

Hydrocodone-Acetaminophen...............................................31

Hydrocodone-Ibuprofen.........31

Hydrocortisone.................85, 98

Hydrocortisone Butyrate........85

Hydrocortisone Valerate........ 85

Hydrocortisone-Acetic Acid.............................................102

Hydromorphone HCl.............. 31

Hydromorphone HCl ER........ 30

Hydromorphone HCl PF........ 31

Hydroxychloroquine Sulfate...............................................52

Hydroxyurea............................49

Hydroxyzine HCl..................... 60

Hydroxyzine Pamoate............ 44

Hysingla ER.............................30

I

Ibandronate Sodium...............98

Ibrance.................................... 50

Ibu............................................29

Ibuprofen.................................29

Iclusig...................................... 50

IDHIFA..................................... 50

Ilevro...................................... 101

Imatinib Mesylate....................50

Imbruvica.................................50

Imipenem-Cilastatin................37

Imipramine HCl.......................44

Imipramine Pamoate.............. 44

Imiquimod............................... 76

Imiquimod Pump.................... 76

Imovax Rabies........................ 96

Imvexxy Maintenance Pack... 88

Imvexxy Starter Pack..............88

Incassia................................... 90

Increlex....................................86

Incruse Ellipta....................... 103

Indapamide............................. 71

Indomethacin..........................29

Infanrix.....................................96

Ingrezza................................... 73

Inlyta........................................ 50

Insulin Lispro...........................63

Insulin Syringes, Needles...... 99

Intelence..................................58

Intralipid...................................77

Intron A....................................57

Introvale...................................88

Invega Sustenna..................... 55

Invega Trinza...........................55

Invirase.................................... 59

Invokamet................................61

Invokamet XR..........................61

Invokana.................................. 61

Ionosol-MB in D5W.................77

IPOL.........................................96

Ipratropium Bromide............103

Ipratropium-Albuterol........... 105

Irbesartan................................ 66

Irbesartan-Hydrochlorothiazide...............................................70

Iressa....................................... 50

Isentress.................................. 58

Isentress HD............................58

Isibloom...................................88

Isolyte-P in D5W......................77

Isolyte-S................................... 77

Isoniazid.................................. 48

Isosorbide Dinitrate................ 72

Isosorbide Dinitrate ER.......... 72

Isosorbide Mononitrate..........72

Isosorbide Mononitrate ER....72

Isotretinoin.............................. 76

Itraconazole.............................46

Ivermectin................................52

Ixiaro........................................ 96

J

Jadenu.....................................79

Jadenu Sprinkle......................79

Jakafi....................................... 50

Jantoven..................................64

Janumet...................................61

Janumet XR.............................61

Januvia.................................... 61

Jardiance.................................62

Jasmiel.................................... 88

Jentadueto.............................. 62

Jentadueto XR........................ 62

Jinteli....................................... 88

Jolivette................................... 90

Jublia....................................... 46

Juleber.....................................88

Juluca...................................... 58

Junel 1.5/30............................88

Junel 1/20............................... 88

Junel Fe 1.5/30.......................88

Junel Fe 1/20..........................88

Junel Fe 24..............................88

Juxtapid...................................72

K

Kaitlib Fe..................................88

Kaletra..................................... 59

20Tracked20 20

Kalydeco............................... 105

Kariva.......................................88

KCl in Dextrose-NaCl..............77

KCl-Lactated Ringers-D5W.... 77

Kelnor 1/35............................. 88

Kelnor 1/50............................. 88

Ketoconazole.......................... 46

Ketoprofen.............................. 30

Ketorolac Tromethamine..... 101

Kineret..................................... 93

Kinrix........................................96

Kionex......................................79

Kisqali...................................... 49

Kisqali Femara........................ 49

Klor-Con.................................. 77

Klor-Con 10............................. 77

Klor-Con 8............................... 78

Klor-Con M10..........................77

Klor-Con M15..........................77

Klor-Con M20..........................77

Klor-Con Sprinkle................... 78

Korlym..................................... 86

Kurvelo.................................... 88

Kuvan.......................................82

L

Labetalol HCl.......................... 67

Lacrisert...................................99

Lactulose.................................81

Lamivudine....................... 57, 59

Lamivudine-Zidovudine..........59

Lamotrigine............................. 41

Lanoxin....................................70

Lansoprazole.......................... 81

Lanthanum Carbonate........... 79

Lantus......................................63

Lantus SoloStar...................... 63

LARIN 1.5/30.......................... 88

LARIN 1/20............................. 88

LARIN Fe 1.5/30.....................88

LARIN Fe 1/20........................88

Larissia.................................... 88

Lastacaft..................................99

Latanoprost...........................102

Latuda......................................55

Layolis Fe................................ 88

Leena.......................................88

Leflunomide............................ 95

Lenvima 10MG Daily Dose.... 51






Lenvima 4MG Daily Dose...... 51

Lenvima 8MG Daily Dose...... 51

Lessina.................................... 88

Letrozole..................................50

Leucovorin Calcium............... 49

Leukeran................................. 48

Leukine....................................65

Leuprolide Acetate................. 92

Levalbuterol HCl...................103

Levemir....................................64

Levemir FlexTouch.................63

Levetiracetam......................... 40

Levetiracetam ER................... 40

Levo-T......................................91

Levobunolol HCl...................101

Levocarnitine.......................... 78

Levocetirizine Dihydrochloride.............................................102

Levofloxacin............................39

Levofloxacin in D5W...............39

Levonest..................................88

Levonorgestrel-Ethinyl Estradiol...............................................89

Levonorgestrel-Ethinyl Estradiol & Ethinyl Estradiol................ 88

Levonorgestrel-Ethinyl Estradiol 91-Day................................... 88

Levora 0.15/30....................... 89

Levorphanol Tartrate..............30

Levothyroxine Sodium........... 91

Levoxyl.....................................91

Lexiva.......................................59

Lidocaine.................................32

Lidocaine HCl......................... 32

Lidocaine Viscous.................. 32

Lidocaine-Prilocaine...............32

Lindane....................................52

Linezolid.................................. 34

Linzess.....................................81

Liothyronine Sodium.............. 91

Lisinopril..................................67

Lisinopril-Hydrochlorothiazide...............................................70

Lithium.....................................61

Lithium Carbonate..................61

Lithium Carbonate ER............61

Lithostat...................................83

Livalo....................................... 71

Lokelma...................................79

Lonhala Magnair Refill Kit....103

21Tracked 2121

Lonsurf.................................... 49

Loperamide HCl..................... 80

Lopinavir-Ritonavir..................59

Lorazepam.............................. 61

Lorbrena..................................49

Lorcet...................................... 31

Lorcet HD................................ 31

Lorcet Plus.............................. 31

Loryna......................................89

Losartan Potassium................66

Losartan Potassium-HCTZ.....70

Lotemax................................ 101

Lotemax SM..........................101

Loteprednol Etabonate........ 101

Lovastatin................................71

Low-Ogestrel...........................89

Loxapine Succinate................54

Lumigan................................ 102

Lupaneta Pack........................92

Lupron Depot..........................92

Lutera...................................... 89

Lynparza..................................51

Lyrica....................................... 74

Lysodren................................. 91

Lyza..........................................90

M

M-M-R II................................... 96

Magnesium Sulfate.................78

Malathion.................................52

Maprotiline HCl.......................44

Marlissa................................... 89

Marplan................................... 43

Matulane..................................48

Matzim LA............................... 68

Mavyret....................................57

Mayzent................................... 74

Meclizine HCl..........................44

Medroxyprogesterone Acetate...............................................91

Mefloquine HCl.......................52

Megestrol Acetate.................. 91

Mekinist................................... 51

Mektovi....................................51

Melodetta 24 Fe......................89

Meloxicam...............................30

Memantine HCl.................42, 43

Memantine HCl ER.................42

Memantine HCl Titration Pak...............................................43

Menactra................................. 96

Menest.....................................89

Mentax.....................................46

Menveo....................................96

Mercaptopurine...................... 49

Meropenem.............................37

Mesalamine.............................98

Mesnex.................................... 52

Metadate ER........................... 73

Metaproterenol Sulfate....... 103, 104

Metformin HCl.........................62

Metformin HCl ER...................62

Methadone HCl.......................30

Methazolamide....................... 70

Methenamine Hippurate........ 34

Methimazole............................92

Methotrexate...........................93

Methotrexate Sodium.............94

Methoxsalen Rapid................ 76

Methscopolamine Bromide... 80

Methyclothiazide.................... 71

Methyldopa............................. 66

Methyldopa-Hydrochlorothiazide.............70

Methylphenidate HCl..............73

Methylphenidate HCl ER........73

Methylprednisolone................85

Metoclopramide HCl.............. 44

Metolazone............................. 71

Metoprolol Succinate ER.......67

Metoprolol Tartrate.................67

Metoprolol-Hydrochlorothiazide...............................................70

Metronidazole......................... 34

Metronidazole in NaCl 0.79%...............................................34

Mexiletine HCl.........................67

Mibelas 24 Fe......................... 89

Miconazole 3...........................46

Microgestin 1.5/30................. 89

Microgestin 1/20.................... 89

Microgestin Fe 1.5/30............89

Microgestin Fe 1/20............... 89

Midodrine HCl.........................66

Migergot.................................. 47

Miglitol.....................................62

Miglustat..................................82

Mili........................................... 89

Minitran................................... 72

Minocycline HCl......................40

Minoxidil.................................. 72

Mirtazapine............................. 43

Mirtazapine ODT.....................43

Mirvaso.................................... 76

22Tracked22 22

Misoprostol............................. 81

Modafinil............................... 106

Moexipril HCl.......................... 67

Molindone HCl........................54

Mometasone Furoate.....85, 103

MonoNessa.............................89

Montelukast Sodium............ 103

Morphine Sulfate..............31, 32

Morphine Sulfate ER.............. 30

Moxifloxacin HCl.....................39

Moxifloxacin HCl in NaCl....... 39

Multaq......................................67

Mupirocin................................ 35

Mupirocin Calcium................. 34

Myalept....................................80

Mycamine................................46

Mycophenolate Mofetil.......... 94

Mycophenolate Sodium.........94

Myrbetriq.................................82

N

Nabumetone........................... 30

Nadolol.................................... 68

Nadolol-Bendroflumethiazide...............................................70

Nafcillin Sodium..................... 37

Naftifine HCl............................46

Naftin....................................... 46

Naloxone HCl..........................33

Naltrexone HCl....................... 32

Namzaric...........................73, 74

Naproxen.................................30

Naproxen DR.......................... 30

Naratriptan HCl.......................47

Narcan..................................... 33

Natacyn................................... 46

Nateglinide..............................62

Natpara....................................98

Nebupent................................ 52

Necon 0.5/35..........................89

Nefazodone HCl..................... 44

Neomycin Sulfate................... 33

Neomycin-Bacitracin-Polymyxin...............................................99

Neomycin-Polymyxin-Bacitracin-Hydrocortisone...99

Neomycin-Polymyxin-Dexamethasone................... 99

Neomycin-Polymyxin-Gramicidin............................ 99

Neomycin-Polymyxin-HC.......99, 102

NephrAmine............................78

Nerlynx.................................... 51

Neulasta.................................. 65

Neupogen............................... 65

Neupro.....................................53

Nevirapine............................... 58

Nevirapine ER......................... 58

Nexavar................................... 51

Niacin ER.................................72

Niacor...................................... 72

Nicardipine HCl...................... 68

Nicotrol....................................33

Nicotrol NS..............................33

Nifedipine ER..........................68

Nifedipine ER Osmotic Release...............................................68

Nikki.........................................89

Nilutamide...............................49

Nimodipine..............................68

Ninlaro..................................... 49

Nitro-Bid.................................. 72

Nitrofurantoin..........................35

Nitrofurantoin Macrocrystal...35

Nitrofurantoin Monohydrate...............................................35

Nitroglycerin..................... 72, 73

Nitrostat...................................73

Nora-BE................................... 91

Norditropin FlexPro................ 86

Norethindrone.........................91

Norethindrone Acetate...........91

Norethindrone Acetate-Ethinyl Estradiol................................ 89

Norethindrone Acetate-Ethinyl Estradiol-Fe...........................89

Norgestimate-Ethinyl Estradiol...............................................89

Norgestimate-Ethinyl Estradiol Triphasic............................... 89

Norlyroc...................................91

Normosol-M in D5W............... 78

Normosol-R in D5W................78

Normosol-R pH 7.4.................78

Northera.................................. 66

Nortrel 0.5/35......................... 89

Nortrel 1/35.............................89

Nortrel 7/7/7........................... 89

Nortriptyline HCl..................... 44

Norvir.................................59, 60

Noxafil......................................46

Nucala...........................105, 106

Nucynta ER............................. 30

Nuedexta.................................74

Nuplazid.................................. 55

23Tracked 2323

Nutrilipid..................................78

Nutropin AQ NuSpin 10......... 86

Nutropin AQ NuSpin 20......... 86

Nutropin AQ NuSpin 5........... 86

Nyamyc....................................46

Nymalize..................................68

Nystatin....................................46

Nystop..................................... 46

O

Ocaliva.....................................82

Ocella...................................... 89

Octagam..................................95

Octreotide Acetate................. 92

Odefsey................................... 58

Odomzo...................................51

Ofev....................................... 105

Ofloxacin................................. 39

Ogestrel...................................89

Olanzapine.............................. 55

Olanzapine ODT..................... 55

Olmesartan Medoxomil..........66

Olmesartan Medoxomil-HCTZ...............................................70

Olmesartan-Amlodipine-HCTZ...............................................70

Olopatadine HCl................... 100

Omega-3-Acid Ethyl Esters.... 72

Omeprazole...................... 81, 82

Ondansetron HCl....................45

Ondansetron ODT.................. 45

Opsumit.................................104

Orencia....................................94

Orencia ClickJect................... 94

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

Orfadin.....................................82

Orkambi................................ 104

Orsythia................................... 89

Oseltamivir Phosphate........... 60

Osphena..................................91

Otezla...................................... 95

Oxacillin Sodium.....................38

Oxandrolone........................... 86

Oxcarbazepine........................42

Oxsoralen Ultra....................... 76

Oxybutynin Chloride...............83

Oxybutynin Chloride ER.........83

Oxycodone HCl...................... 32

Oxycodone-Acetaminophen...............................................32

Oxycodone-Aspirin................. 32

Oxycodone-Ibuprofen............ 32

Ozempic.................................. 62

P

Pacerone................................. 67

Paliperidone ER......................55

Panretin................................... 52

Pantoprazole Sodium.............82

Panzyga...................................95

Paricalcitol...............................99

Paromomycin Sulfate.............33

Paroxetine HCl........................44

Paser........................................48

Paxil......................................... 44

Pazeo.....................................100

Pediarix....................................96

Pedvax HIB..............................97

PEG-3350-Electrolytes............81

PEG-3350-NaCl-Na Bicarbonate-KCl................... 81

Peganone................................42

Pegasys................................... 57

Pegasys ProClick....................57

Penicillamine...........................83

Penicillin G Potassium........... 38

Penicillin G Procaine.............. 38

Penicillin G Sodium................38

Penicillin V Potassium............38

PENTAM 300.......................... 52

Pentasa....................................98

Pentoxifylline ER.....................70

Perforomist........................... 104

Perindopril Erbumine............. 67

Permethrin...............................52

Perphenazine..........................44

Perseris....................................55

Phenadoz.............................. 102

Phenelzine Sulfate..................43

Phenobarbital......................... 41

Phenoxybenzamine HCl.........66

Phenytek................................. 42

Phenytoin................................ 42

Phenytoin Sodium Extended...............................................42

Phoslyra...................................80

Phospholine Iodide.............. 101

Picato.......................................76

Pifeltro..................................... 58

Pilocarpine HCl.............. 75, 101

Pimecrolimus.......................... 76

Pimozide..................................54

Pimtrea.................................... 89

Pindolol................................... 68

Pioglitazone HCl..................... 62

Pioglitazone HCl-Glimepiride...............................................62

24Tracked24 24

Pioglitazone HCl-Metformin HCl...............................................62

Piperacillin-Tazobactam.........38

Piqray.......................................49

Pirmella 1/35...........................89

Piroxicam................................ 30

Plasma-Lyte 148..................... 78

Plasma-Lyte A......................... 78

Plenamine............................... 78

Podofilox................................. 76

Polymyxin B Sulfate................35

Polymyxin B-Trimethoprim.... 99

Pomalyst..................................49

Portia-28.................................. 90

Potassium Chloride................ 78

Potassium Chloride CR..........78

Potassium Chloride ER.......... 78

Potassium Chloride in Dextrose...............................................78

Potassium Chloride in NaCl...78

Potassium Citrate ER............. 79

Praluent................................... 72

Pramipexole Dihydrochloride...............................................53

Prasugrel HCl..........................66

Pravastatin Sodium................ 71

Praziquantel............................ 52

Prazosin HCl........................... 66

Pred Mild...............................101

Pred-G..................................... 99

Pred-G S.O.P.........................100

Prednicarbate......................... 85

Prednisolone...........................85

Prednisolone Acetate...........101

Prednisolone Sodium Phosphate.................... 85, 101

Prednisone..............................85

Prednisone Intensol............... 85

Premarin..................................90

Premasol................................. 79

Premphase..............................90

Prempro.................................. 90

Prevalite...................................72

Previfem.................................. 90

Prezcobix................................ 60

Prezista....................................60

Priftin....................................... 48

Prilosec....................................82

Primaquine Phosphate...........52

Primidone................................41

Privigen....................................95

ProAir HFA............................ 104

ProAir RespiClick................. 104

Probenecid..............................47

Probenecid-Colchicine...........47

Procalamine............................ 79

Prochlorperazine.................... 45

Prochlorperazine Maleate......45

Procrit...................................... 65

Procto-Med HC....................... 98

Procto-Pak...............................98

Proctosol HC...........................98

Proctozone-HC....................... 98

Progesterone Micronized...... 91

Proglycem............................... 62

Prograf.....................................94

Prolastin-C...............................82

Prolensa................................ 102

Prolia........................................99

Promacta...........................65, 66

Promethazine HCl................ 102

Promethegan........................ 102

Propafenone HCl....................67

Propafenone HCl ER..............67

Proparacaine HCl................. 100

Propranolol HCl...................... 68

Propranolol HCl ER................ 68

Propranolol-HCTZ...................70

Propylthiouracil.......................92

ProQuad.................................. 97

Prosol...................................... 79

Protriptyline HCl......................44

Pulmozyme........................... 106

Purixan.................................... 49

Pyrazinamide.......................... 48

Pyridostigmine Bromide........ 48

Pyridostigmine Bromide ER...............................................48

Q

Quadracel................................97

Quetiapine Fumarate..............55

Quetiapine Fumarate ER........55

Quinapril HCl...........................67

Quinapril-Hydrochlorothiazide...............................................70

Quinidine Gluconate ER........ 67

Quinidine Sulfate.................... 67

Quinine Sulfate....................... 52

R

RabAvert................................. 97

Rabeprazole Sodium..............82

Raloxifene HCl........................ 91

Ramipril................................... 67

25Tracked 2525

Ranitidine HCl...................80, 81

Ranolazine ER........................ 70

Rasagiline Mesylate............... 53

Rasuvo.....................................94

RAVICTI...................................82

Rayaldee................................. 99

Rebif........................................ 74

Rebif Rebidose.......................74

Rebif Rebidose Titration Pack...............................................74

Rebif Titration Pack................74

Reclipsen................................ 90

Recombivax HB......................97

Rectiv.......................................73

Regranex.................................76

Relenza Diskhaler...................60

Relistor.................................... 80

Repaglinide.............................62

Repaglinide-Metformin HCl... 62

Repatha...................................72

Repatha Pushtronex System...............................................72

Repatha SureClick................. 72

Rescriptor................................58

Restasis.................................100

Retacrit.................................... 66

Revlimid...................................49

Rexulti......................................55

Reyataz....................................60

Rhopressa.............................100

Ribasphere..............................57

Ribavirin.................................. 57

Ridaura....................................95

Rifabutin.................................. 48

Rifampin.................................. 48

Rifater...................................... 48

Riluzole....................................74

Rimantadine HCl.................... 60

Riomet..................................... 62

Risedronate Sodium.............. 99

Risperdal Consta....................56

Risperidone.............................56

Risperidone ODT....................56

Ritonavir.................................. 60

Rivastigmine........................... 42

Rivastigmine Tartrate............. 42

Rivelsa..................................... 90

Rizatriptan Benzoate..............47

Rizatriptan Benzoate ODT..... 47

Ropinirole HCl........................ 53

Rosuvastatin Calcium............ 71

Rotarix..................................... 97

RotaTeq...................................97

Roweepra................................40

Roweepra XR..........................40

Rubraca...................................50

Ruconest................................. 93

Rydapt..................................... 51

Rytary.......................................53

S

Saizen......................................86

Saizenprep.............................. 86

Sancuso.................................. 45

Sandimmune...........................94

Santyl.......................................76

Saphris.................................... 56

Savella..................................... 74

Savella Titration Pack.............74

Scopolamine...........................45

Selegiline HCl......................... 53

Selenium Sulfide.....................76

Selzentry..................................59

Serevent Diskus....................104

Serostim.................................. 80

Sertraline HCl..........................44

Setlakin....................................90

Sevelamer Carbonate............ 80

Sharobel.................................. 91

Shingrix................................... 97

Signifor.................................... 92

Sildenafil Citrate................... 105

Silodosin..................................83

Silver Sulfadiazine.................. 39

Simbrinza.............................. 101

Simponi................................... 94

Simvastatin..............................71

Sirolimus................................. 94

Sirturo......................................48

Sodium Chloride.....................79

Sodium Fluoride..................... 79

Sodium Lactate.......................79

Sodium Phenylbutyrate..........82

Sodium Polystyrene Sulfonate...............................................79

Sofosbuvir-Velpatasvir............57

Solifenacin Succinate.............83

Soliqua.................................... 62

Soltamox................................. 49

Somatuline Depot...................92

Somavert................................. 92

Sotalol HCl.............................. 67

Sovaldi.....................................57

Spiriva HandiHaler............... 103

26Tracked26 26

Spiriva Respimat.................. 103

Spironolactone....................... 71

Spironolactone-HCTZ............ 70

Sprintec 28..............................90

Spritam.................................... 40

Sprycel.....................................51

SPS.......................................... 79

Sronyx......................................90

SSD..........................................39

Stavudine................................ 59

Stelara..................................... 76

Stiolto Respimat................... 106

Stivarga....................................51

Streptomycin Sulfate..............33

Stribild..................................... 58

Suboxone................................ 33

Sucraid.................................... 82

Sucralfate................................ 81

Sulfacetamide Sodium...........39

Sulfacetamide-Prednisolone.............................................100

Sulfadiazine.............................39

Sulfamethoxazole-Trimethoprim........................39

Sulfamylon.............................. 35

Sulfasalazine........................... 98

Sulindac.................................. 30

Sumatriptan.............................47

Sumatriptan Succinate.... 47, 48

Sumatriptan Succinate Refill...............................................47

Suprax..................................... 36

Suprep Bowel Prep Kit...........81

Sutent...................................... 51

Syeda.......................................90

Sylatron................................... 57

Symbicort..............................106

Symfi........................................58

Symfi Lo.................................. 58

SymlinPen 120........................62

SymlinPen 60..........................62

Sympazan................................41

Symtuza...................................60

Synarel.....................................92

Synjardy...................................62

Synjardy XR.............................62

Synribo.................................... 50

Synthroid................................. 91

T

Tabloid.....................................49

Tacrolimus........................ 76, 94

Tadalafil.................................105

Tafinlar.....................................51

Tagrisso...................................51

Talzenna..................................50

Tamoxifen Citrate................... 49

Tamsulosin HCl...................... 83

Targretin..................................52

Tarina 24 Fe............................ 90

Tarina Fe 1/20........................ 90

Tasigna....................................51

Tazarotene.............................. 76

Tazicef..................................... 36

Tazorac....................................76

Taztia XT..................................68

TDVAX..................................... 97

Tecfidera................................. 75

Tecfidera Starter Pack........... 75

Tegsedi....................................82

Telmisartan............................. 66

Telmisartan-Amlodipine......... 70

Telmisartan-HCTZ.................. 70

Temazepam.......................... 106

Tenivac.................................... 97

Tenofovir Disoproxil Fumarate...............................................59

Terazosin HCl......................... 83

Terbinafine HCl.......................46

Terconazole............................ 46

Testosterone........................... 87

Testosterone Cypionate.........86

Testosterone Enanthate.........87

Tetrabenazine......................... 74

Tetracycline HCl..................... 40

Thalomid................................. 49

Theophylline......................... 104

Theophylline ER................... 104

Thioridazine HCl..................... 54

Thiothixene............................. 54

Tiagabine HCl......................... 41

Tibsovo....................................51

Tigecycline..............................35

Timolol Maleate..............47, 101

Timolol Maleate Ophthalmic Gel Forming........................101

Tinidazole................................35

Tivicay......................................58

Tizanidine HCl...................... 106

TOBI Podhaler...................... 104

TobraDex.............................. 100

TobraDex ST.........................100

Tobramycin.....................34, 104

Tobramycin Sulfate................ 34

27Tracked 2727

Tobramycin-Dexamethasone.............................................100

Tobrex..................................... 34

Tolak........................................77

Tolcapone............................... 53

Topiramate..............................41

Toremifene Citrate..................49

Torsemide............................... 71

Toujeo Max SoloStar..............64

Toujeo SoloStar...................... 64

TPN Electrolytes..................... 79

Tracleer................................. 105

Tradjenta................................. 62

Tramadol HCl..........................32

Tramadol HCl ER....................30

Tramadol-Acetaminophen..... 32

Trandolapril.............................67

Tranexamic Acid.....................66

Transderm-Scop.....................45

Tranylcypromine Sulfate........ 43

Travasol...................................79

Trazodone HCl........................44

Trecator...................................48

Trelegy Ellipta....................... 106

Trelstar Mixject....................... 92

Tresiba.....................................64

Tresiba FlexTouch..................64

Tretinoin............................52, 77

Tretinoin Microsphere............77

Trexall...................................... 94

Trezix....................................... 32

Tri-Estarylla..............................90

Tri-Legest Fe........................... 90

Tri-Lo-Estarylla........................ 90

Tri-Lo-Sprintec........................ 90

Tri-Mili...................................... 90

Tri-Previfem............................. 90

Tri-Sprintec..............................90

Tri-VyLibra............................... 90

Tri-VyLibra Lo..........................90

Triamcinolone Acetonide......75, 85

Triamterene-HCTZ..................70

Triderm....................................86

Trientine HCl........................... 79

Trifluoperazine HCl.................54

Trifluridine............................... 57

Trihexyphenidyl HCl............... 52

TriLyte......................................81

Trimethoprim.......................... 35

Trimipramine Maleate............ 44

Trintellix................................... 44

Triumeq................................... 58

Trivora......................................90

TrophAmine............................ 79

Trulicity....................................62

Trumenba................................97

Truvada................................... 59

Twinrix..................................... 97

Tybost......................................58

Tykerb......................................51

Tymlos..................................... 99

Typhim Vi................................ 97

U

Udenyca.................................. 66

Unithroid..................................91

Ursodiol................................... 80

V

Valacyclovir HCl......................57

Valchlor................................... 48

Valganciclovir HCl.................. 57

Valproic Acid...........................41

Valsartan..................................67

Valsartan-Hydrochlorothiazide...............................................70

Vancomycin HCl..................... 35

Vandazole................................35

VAQTA.....................................97

Varivax..................................... 97

Varizig......................................95

Vascepa...................................72

Velivet...................................... 90

Velphoro..................................80

Veltassa................................... 79

Vemlidy....................................57

Venclexta.................................51

Venclexta Starting Pack.........51

Venlafaxine HCl...................... 44

Venlafaxine HCl ER................ 44

Ventavis.................................105

Verapamil HCl.........................69

Verapamil HCl ER...................69

Versacloz.................................56

Verzenio.................................. 50

Vibramycin.............................. 40

Victoza.....................................62

Videx........................................59

Videx EC..................................59

Vienva...................................... 90

Vigabatrin................................ 41

Vigadrone................................41

28Tracked28 28

Viibryd......................................44

Viibryd Starter Pack................44

Vimpat..................................... 42

Viracept................................... 60

Viread...................................... 59

Vitrakvi.....................................51

Vivitrol......................................33

Vizimpro.................................. 51

Voriconazole.....................46, 47

Vosevi...................................... 57

Votrient.................................... 51

VP-PNV-DHA........................... 80

Vraylar......................................56

Vyfemla....................................90

VyLibra.................................... 90

Vyvanse................................... 73

Vyzulta................................... 102

W

Warfarin Sodium.....................64

Wixela Inhub......................... 106

WYMZYA Fe............................90

X

Xalkori......................................51

Xarelto..................................... 64

Xarelto Starter Pack............... 64

Xatmep.................................... 94

Xeljanz..................................... 94

Xeljanz XR............................... 94

Xgeva.......................................99

Xifaxan.....................................81

Xiidra..................................... 100

Xofluza.....................................60

Xolair........................................95

Xospata................................... 51

Xtampza ER............................ 31

Xtandi.......................................49

Xulane......................................90

Xyrem.................................... 106

Y

YF-Vax......................................97

Yuvafem...................................90

Z

Zafirlukast............................. 103

Zaleplon................................ 106

Zarah....................................... 90

Zarxio.......................................66

Zejula.......................................50

Zelapar.................................... 53

Zelboraf................................... 51

Zemaira................................... 82

Zenpep.................................... 82

Zerbaxa................................... 36

Zidovudine.............................. 59

Zileuton ER........................... 103

Zioptan.................................. 102

Ziprasidone HCl......................56

Zirgan...................................... 57

Zolinza..................................... 50

Zolpidem Tartrate.................106

Zonisamide............................. 41

Zorbtive................................... 80

Zortress................................... 94

Zostavax.................................. 97

Zovia 1/35E.............................90

Zyclara Pump..........................77

Zydelig.....................................51

Zyflo.......................................103

Zykadia....................................51

Zyprexa Relprevv....................56

12829 29

Bold type = Brand name drug Plain type = Generic drug

tRACK

Covered drugs by medical condition

The list below has information about the drugs covered by this plan. Find your medical condition to see what drugs are covered. If you have trouble finding your drug, turn to the “Covered drugs by name (Drug index)” on pages 12-28.

The first column lists the drug name, which may include the dosage form and strength. Brand

name drugs are listed in bold type (for example, Humalog) and generic drugs are listed in plain type (for example, Simvastatin). The second column lists the drug tier or coverage level. The third column lists any rules or limits for the drug. If quantity limits (QL) apply to a drug, the restriction amounts are shown in the chart on pages 107-133.tRACK

Drug NameDrug

Tier

Coverage

Rules or

Limits on

use

A1

AnalgesicsB1

AnalgesicsC1

Butalbital-Acetaminophen-Caffeine Butalbital-

Acetaminophen-Caffeine (Oral Tablet)

3 QL

C1

Butalbital-Aspirin-Caffeine Butalbital-Aspirin-

Caffeine (Oral Capsule)

3 QL

B1

Nonsteroidal Anti-inflammatory DrugsC1

Celecoxib

Celecoxib (Oral Capsule)

3 QL C1

Diclofenac Epolamine Diclofenac Epolamine

(Transdermal Patch)4 PA; QL

C1

Diclofenac Potassium Diclofenac Potassium

(Oral Tablet)2

C1

Diclofenac Sodium ER Diclofenac Sodium ER

(Oral Tablet Extended Release 24 Hour)

2

C1

Diclofenac Sodium Diclofenac Sodium

(Oral Tablet Delayed Release)

2

C1


(1% Transdermal Gel)3

C1

Diflunisal

Diflunisal (Oral Tablet) 3

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Etodolac ER Etodolac ER (Oral

Tablet Extended Release 24 Hour)

4

C1

Etodolac

Etodolac (Oral Capsule)

3

C1

Etodolac

Etodolac (Oral Tablet Immediate Release)

3

C1

Flector

Flector (Transdermal

Patch)4 PA; QL

C1

Flurbiprofen

Flurbiprofen (Oral Tablet)

2

C1

Ibu

Ibu (600MG Oral Tablet, 800MG Oral Tablet)

2

C1

Ibuprofen

Ibuprofen (Oral Suspension)

2

C1

Ibuprofen

Ibuprofen (400MG Oral Tablet, 600MG Oral Tablet, 800MG Oral Tablet)

2

C1

Indomethacin Indomethacin (Oral

Capsule Immediate Release)

2

2293030

You can find information on what the abbreviations in this table mean on pages 6 - 7.

tRACK Last updated September 1, 2019

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Ketoprofen

Ketoprofen (Oral Capsule Immediate Release)

3

C1

Meloxicam

Meloxicam (Oral Tablet)

1

C1

Nabumetone

Nabumetone (Oral Tablet)

2

C1

Naproxen DR Naproxen DR (Oral

Tablet Delayed Release) (Generic EC-Naprosyn)

2

C1

Naproxen

Naproxen (Oral Suspension)

4

C1

Naproxen

Naproxen (Oral Tablet Immediate Release)

2

C1

Piroxicam

Piroxicam (Oral Capsule)

3

C1

Sulindac

Sulindac (Oral Tablet) 2

B1

Opioid Analgesics, Long-actingC1

Buprenorphine Buprenorphine

(Transdermal Patch Weekly)

4 7D; DL; QL

C1

Embeda

Embeda (Oral

Capsule Extended

Release)

37D; MME;

DL; QL C1

Fentanyl

Fentanyl (100MCG/HR Transdermal Patch 72 Hour, 12MCG/HR Transdermal Patch 72 Hour, 25MCG/HR Transdermal Patch 72 Hour, 50MCG/HR Transdermal Patch 72 Hour, 75MCG/HR Transdermal Patch 72 Hour)

47D; MME;

DL; QL

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Hydromorphone HCl ER Hydromorphone HCl

ER (Oral Tablet ER 24 Hour Abuse-Deterrent)

47D; MME;

DL; QL C1

Hysingla ER

Hysingla ER (Oral

Tablet ER 24 Hour

Abuse-Deterrent)

37D; MME;

DL; QL C1

Levorphanol Tartrate Levorphanol Tartrate

(Oral Tablet)5

7D; MME; DL; QL

C1

Methadone HCl

Methadone HCl (Oral Solution)

37D; MME;

DL; QL C1

Methadone HCl

Methadone HCl (Oral Tablet)

37D; MME;

DL; QL C1

Morphine Sulfate ER Morphine Sulfate ER

(100MG Oral Tablet Extended Release, 15MG Oral Tablet Extended Release, 30MG Oral Tablet Extended Release, 60MG Oral Tablet Extended Release) (Generic MS Contin)

37D; MME;

DL; QL

C1

Morphine Sulfate ER Morphine Sulfate ER

(200MG Oral Tablet Extended Release) (Generic MS Contin)

47D; MME;

DL; QL

C1

Nucynta ER

Nucynta ER (Oral

Tablet Extended

Release 12 Hour)

37D; MME;

DL; QL C1

Tramadol HCl ER Tramadol HCl ER

(Biphasic) (Oral Tablet Extended Release 24 Hour)

37D; MME;

DL; QL

C1

Tramadol HCl ER Tramadol HCl ER (Oral


37D; MME;

DL; QL

33031 31


tRACKLast updated September 1, 2019

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Xtampza ER

Xtampza ER (Oral

Capsule ER 12 Hour

Abuse-Deterrent)

37D; MME;

DL; QL

B1

Opioid Analgesics, Short-actingC1

Acetaminophen-Codeine Acetaminophen-

Codeine (120-12MG/5ML Oral Solution)

27D; MME;

DL; QL C1

Acetaminophen-Codeine Acetaminophen-

Codeine (300-15MG Oral Tablet, 300-30MG Oral Tablet, 300-60MG Oral Tablet)

27D; MME;

DL; QL

C1

Butorphanol Tartrate Butorphanol Tartrate

(Nasal Solution)3

7D; MME; DL; QL

C1

Codeine Sulfate Codeine Sulfate (Oral

Tablet)3

7D; MME; DL; QL

C1

Duramorph

Duramorph (Injection

Solution)4 DL

C1

Endocet

Endocet (10-325MG Oral Tablet, 5-325MG Oral Tablet, 7.5-325MG Oral Tablet)

37D; MME;

DL; QL

C1

Fentanyl Citrate Fentanyl Citrate

(Buccal Lozenge On A Handle)

5 PA; DL; QL

C1

Hydrocodone-Acetaminophen Hydrocodone-

Acetaminophen (7.5-325MG/15ML Oral Solution)

37D; MME;

DL; QL

C1

Hydrocodone-Acetaminophen Hydrocodone-

Acetaminophen (10-325MG Oral Tablet, 5-325MG Oral Tablet, 7.5-325MG Oral Tablet)

37D; MME;

DL; QL

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Hydrocodone-Ibuprofen Hydrocodone-

Ibuprofen (7.5-200MG Oral Tablet)

37D; MME;

DL; QL C1

Hydromorphone HCl Hydromorphone HCl

(2MG/ML Injection Solution)

4 DL

C1


(1MG/ML Oral Liquid)4

7D; MME; DL; QL

C1


(2MG Oral Tablet Immediate Release, 4MG Oral Tablet Immediate Release, 8MG Oral Tablet Immediate Release)

27D; MME;

DL; QL

C1

Hydromorphone HCl PF Hydromorphone HCl

PF (10MG/ML Injection Solution, 50MG/5ML Injection Solution)

4 DL

C1

Lorcet HD

Lorcet HD (Oral Tablet)

37D; MME;

DL; QL C1

Lorcet

Lorcet (Oral Tablet) 37D; MME;

DL; QL C1

Lorcet Plus

Lorcet Plus (Oral Tablet)

37D; MME;

DL; QL C1

Morphine Sulfate Morphine Sulfate

(100MG/5ML Oral Solution)

37D; MME;

DL; QL C1


(8MG/ML Intravenous Solution Prefilled Syringe)

4 DL

4313232



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1


(10MG/ML Injection Solution, 4MG/ML Injection Solution)

4 DL

C1


(2MG/ML Injection

Solution, 5MG/ML

Injection Solution)

4 DL

C1

Morphine Sulfate Morphine Sulfate (Oral

Solution)3

7D; MME; DL; QL

C1


(Oral Tablet

Immediate Release)

37D; MME;

DL; QL C1

Oxycodone HCl Oxycodone HCl

(100MG/5ML Oral Concentrate)

47D; MME;

DL; QL C1

Oxycodone HCl

Oxycodone HCl (5MG/5ML Oral Solution)

37D; MME;

DL; QL C1

Oxycodone HCl Oxycodone HCl

(10MG Oral Tablet Immediate Release, 15MG Oral Tablet Immediate Release, 20MG Oral Tablet Immediate Release, 30MG Oral Tablet Immediate Release, 5MG Oral Tablet Immediate Release)

27D; MME;

DL; QL

C1

Oxycodone-Acetaminophen Oxycodone-

Acetaminophen (Oral Tablet)

37D; MME;

DL; QL C1

Oxycodone-Aspirin Oxycodone-Aspirin

(Oral Tablet)3

7D; MME; DL; QL

C1

Oxycodone-Ibuprofen Oxycodone-Ibuprofen

(Oral Tablet)3

7D; MME; DL; QL

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Tramadol HCl Tramadol HCl (Oral

Tablet Immediate Release)

27D; MME;

DL; QL C1

Tramadol-Acetaminophen Tramadol-

Acetaminophen (Oral Tablet)

27D; MME;

DL; QL C1

Trezix

Trezix (Oral Capsule) 47D; MME;

DL; QL A1

AnestheticsB1

Local AnestheticsC1

Lidocaine

Lidocaine (5% External Ointment)

4 QL C1

Lidocaine

Lidocaine (5% External Patch)

4 PA; QL C1

Lidocaine HCl Lidocaine HCl (4%

External Solution)2

C1

Lidocaine HCl Lidocaine HCl

(External Gel)2

C1

Lidocaine Viscous Lidocaine Viscous (2%

Mouth/Throat Solution)

2

C1

Lidocaine-Prilocaine Lidocaine-Prilocaine

(External Cream)3

A1

Anti-Addiction/Substance Abuse Treatment Agents

B1

Alcohol Deterrents/Anti-cravingC1

Acamprosate Calcium Acamprosate Calcium


4

C1

Disulfiram

Disulfiram (Oral Tablet) 3

C1

Naltrexone HCl Naltrexone HCl (Oral

Tablet)3

53233 33



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Vivitrol

Vivitrol

(Intramuscular

Suspension

Reconstituted)

5

B1

Opioid Dependence TreatmentsC1

Buprenorphine HCl Buprenorphine HCl

(Tablet Sublingual)2 QL

C1

Buprenorphine HCl-Naloxone HCl Buprenorphine HCl-

Naloxone HCl (Sublingual Film)

4 QL

C1

Buprenorphine HCl-Naloxone HCl Buprenorphine HCl-

Naloxone HCl (Tablet Sublingual)

2 QL

C1

Suboxone

Suboxone (Sublingual

Film)4 QL

B1

Opioid Reversal AgentsC1

Naloxone HCl Naloxone HCl (0.4MG/

ML Injection Solution)2

C1

Naloxone HCl Naloxone HCl

(Injection Solution Cartridge)

2

C1

Naloxone HCl Naloxone HCl

(Injection Solution Prefilled Syringe)

2

C1

Narcan

Narcan (Nasal Liquid) 3

B1

Smoking Cessation AgentsC1

Bupropion HCl SR Bupropion HCl SR

(150MG Oral Tablet Extended Release 12 Hour Smoking-Deterrent)

2

C1

Chantix Continuing Month Pak Chantix Continuing

Month Pak (Oral

Tablet)

3

C1

Chantix

Chantix (Oral Tablet) 3

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Chantix Starting Month Pak Chantix Starting

Month Pak (Oral

Tablet)

3

C1

Nicotrol

Nicotrol (Inhalation

Inhaler)4

C1

Nicotrol NS

Nicotrol NS (Nasal

Solution)4

A1

AntibacterialsB1

AminoglycosidesC1

Amikacin Sulfate Amikacin Sulfate

(500MG/2ML Injection Solution)

4

C1

Gentak

Gentak (Ophthalmic Ointment)

2

C1

Gentamicin Sulfate-0.9% Sodium Chloride

Gentamicin Sulfate-0.9% Sodium Chloride (Intravenous Solution)

4

C1

Gentamicin Sulfate Gentamicin Sulfate

(External Cream)2

C1


(External Ointment)2

C1


(40MG/ML Injection Solution)

4

C1


(Ophthalmic Solution)2

C1

Neomycin Sulfate Neomycin Sulfate (Oral

Tablet)2

C1

Paromomycin Sulfate Paromomycin Sulfate

(Oral Capsule)4

C1

Streptomycin Sulfate Streptomycin Sulfate

(Intramuscular Solution Reconstituted)

5

6333434



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Tobramycin

Tobramycin (Ophthalmic Solution)

2

C1

Tobramycin Sulfate Tobramycin Sulfate

(10MG/ML Injection Solution, 80MG/2ML Injection Solution)

4

C1

Tobrex

Tobrex (Ophthalmic

Ointment)4

B1

Antibacterials, OtherC1

Bacitracin

Bacitracin (Ophthalmic Ointment)

2

C1

Bactroban

Bactroban (2% Nasal

Ointment)4 PA

C1

Clindamycin HCl Clindamycin HCl (Oral

Capsule)2

C1

Clindamycin Palmitate HCl Clindamycin Palmitate

HCl (Oral Solution Reconstituted)

2

C1

Clindamycin Phosphate in D5W Clindamycin

Phosphate in D5W (Intravenous Solution)

4

C1

Clindamycin Phosphate Clindamycin

Phosphate (300MG/2ML Injection Solution, 600MG/4ML Injection Solution, 900MG/6ML Injection Solution)

4

C1


Phosphate (Vaginal Cream)

3

C1

Colistimethate Sodium Colistimethate Sodium

(CBA) (Injection Solution Reconstituted)

5

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Dalvance

Dalvance

(Intravenous Solution

Reconstituted)

5 PA

C1

Daptomycin

Daptomycin (350MG

Intravenous Solution

Reconstituted)

5

C1

Daptomycin

Daptomycin (500MG Intravenous Solution Reconstituted)

5

C1

Linezolid

Linezolid (Intravenous Solution)

4

C1

Linezolid

Linezolid (Oral Suspension Reconstituted)

5

C1

Linezolid

Linezolid (Oral Tablet) 4 QL C1

Methenamine Hippurate Methenamine

Hippurate (Oral Tablet)4

C1

Metronidazole Metronidazole (0.75%

External Cream)4

C1


External Gel, 1% External Gel)

4

C1


External Lotion)4

C1

Metronidazole in NaCl 0.79% Metronidazole in NaCl

0.79% (Intravenous Solution)

4

C1

Metronidazole Metronidazole (250MG

Oral Tablet, 500MG Oral Tablet)

2

C1


Vaginal Gel)3

C1

Mupirocin Calcium Mupirocin Calcium

(External Cream)4

73435 35



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Mupirocin

Mupirocin (External Ointment)

2

C1

Nitrofurantoin Macrocrystal Nitrofurantoin

Macrocrystal (100MG Oral Capsule, 50MG Oral Capsule) (Generic Macrodantin)

3

C1

Nitrofurantoin Monohydrate Nitrofurantoin

Monohydrate (Generic Macrobid)

3

C1

Nitrofurantoin Nitrofurantoin (Oral

Suspension)4

C1

Polymyxin B Sulfate Polymyxin B Sulfate

(Injection Solution Reconstituted)

4

C1

Sulfamylon

Sulfamylon (External

Cream)4

C1

Tigecycline

Tigecycline (Intravenous Solution Reconstituted)

5

C1

Tinidazole

Tinidazole (Oral Tablet)

4

C1

Trimethoprim

Trimethoprim (Oral Tablet)

2

C1

Vancomycin HCl Vancomycin HCl

(10GM Intravenous Solution Reconstituted, 1GM Intravenous Solution Reconstituted, 500MG Intravenous Solution Reconstituted, 750MG Intravenous Solution Reconstituted)

4

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Vancomycin HCl

Vancomycin HCl

(250MG Intravenous

Solution

Reconstituted)

4

C1

Vancomycin HCl Vancomycin HCl (Oral

Capsule)4 QL

C1

Vandazole

Vandazole (Vaginal

Gel)3

B1

Beta-lactam, CephalosporinsC1

Cefaclor

Cefaclor (Oral Capsule)

2

C1

Cefadroxil

Cefadroxil (Oral Capsule)

2

C1

Cefadroxil

Cefadroxil (Oral Suspension Reconstituted)

2

C1

Cefazolin Sodium Cefazolin Sodium

(10GM Injection Solution Reconstituted, 1GM Injection Solution Reconstituted, 500MG Injection Solution Reconstituted)

4

C1

Cefdinir

Cefdinir (Oral Capsule) 3

C1

Cefdinir

Cefdinir (Oral Suspension Reconstituted)

3

C1

Cefepime HCl Cefepime HCl


4

C1

Cefixime

Cefixime (Oral Suspension Reconstituted)

4

8353636



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Cefotetan Disodium Cefotetan Disodium

(1GM Injection Solution Reconstituted, 2GM Injection Solution Reconstituted)

4

C1

Cefoxitin Sodium Cefoxitin Sodium


4

C1

Cefoxitin Sodium Cefoxitin Sodium

(Intravenous Solution Reconstituted)

4

C1

Cefpodoxime Proxetil Cefpodoxime Proxetil

(Oral Suspension Reconstituted)

4

C1

Cefpodoxime Proxetil Cefpodoxime Proxetil

(Oral Tablet)4

C1

Cefprozil

Cefprozil (Oral Suspension Reconstituted)

3

C1

Cefprozil

Cefprozil (Oral Tablet) 3

C1

Ceftazidime

Ceftazidime (Injection Solution Reconstituted)

4

C1

Ceftriaxone Sodium Ceftriaxone Sodium

(1GM Injection Solution Reconstituted, 250MG Injection Solution Reconstituted, 2GM Injection Solution Reconstituted, 500MG Injection Solution Reconstituted)

4

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Ceftriaxone Sodium Ceftriaxone Sodium

(10GM Intravenous Solution Reconstituted)

4

C1

Cefuroxime Axetil Cefuroxime Axetil (Oral

Tablet)2

C1

Cefuroxime Sodium Cefuroxime Sodium


4

C1

Cefuroxime Sodium Cefuroxime Sodium


4

C1

Cephalexin

Cephalexin (Oral Capsule)

2

C1

Cephalexin

Cephalexin (Oral Suspension Reconstituted)

2

C1

Suprax

Suprax (Oral Capsule) 3

C1

Suprax

Suprax (500MG/5ML

Oral Suspension

Reconstituted)

3

C1

Suprax

Suprax (Oral Tablet Chewable)

3

C1

Tazicef

Tazicef (Injection Solution Reconstituted)

4

C1

Zerbaxa

Zerbaxa (Intravenous

Solution

Reconstituted)

5 PA

B1

Beta-lactam, OtherC1

Aztreonam

Aztreonam (1GM Injection Solution Reconstituted)

4

93637 37



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Ertapenem Sodium Ertapenem Sodium


4

C1

Imipenem-Cilastatin Imipenem-Cilastatin


4

C1

Meropenem

Meropenem (Intravenous Solution Reconstituted)

4

B1

Beta-lactam, PenicillinsC1

Amoxicillin

Amoxicillin (Oral Capsule)

1

C1

Amoxicillin

Amoxicillin (Oral Suspension Reconstituted)

1

C1

Amoxicillin

Amoxicillin (Oral Tablet)

1

C1

Amoxicillin

Amoxicillin (Oral Tablet Chewable)

1

C1

Amoxicillin-Potassium Clavulanate ER

Amoxicillin-Potassium Clavulanate ER (Oral Tablet Extended Release 12 Hour)

4

C1

Amoxicillin-Potassium Clavulanate Amoxicillin-Potassium

Clavulanate (Oral Suspension Reconstituted)

2

C1


Clavulanate (Oral Tablet Immediate Release)

2

C1


Clavulanate (Oral Tablet Chewable)

2

C1

Ampicillin

Ampicillin (Oral Capsule)

2

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Ampicillin Sodium Ampicillin Sodium

(125MG Injection Solution Reconstituted, 1GM Injection Solution Reconstituted)

4

C1

Ampicillin Sodium Ampicillin Sodium


4

C1

Ampicillin-Sulbactam Sodium Ampicillin-Sulbactam

Sodium (Injection Solution Reconstituted)

4

C1

Bactocill in Dextrose Bactocill in Dextrose

(Intravenous Solution)4

C1

Bicillin C-R 900/300 Bicillin C-R 900/300

(Intramuscular

Suspension)

4

C1

Bicillin C-R

Bicillin C-R

(Intramuscular

Suspension)

4

C1

Bicillin L-A

Bicillin L-A

(Intramuscular

Suspension)

4

C1

Dicloxacillin Sodium Dicloxacillin Sodium

(Oral Capsule)2

C1

Nafcillin Sodium Nafcillin Sodium (1GM

Injection Solution Reconstituted, 2GM Injection Solution Reconstituted)

4

C1

Nafcillin Sodium Nafcillin Sodium


4

10373838



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Oxacillin Sodium Oxacillin Sodium


4

C1

Penicillin G Potassium Penicillin G Potassium

(20000000UNIT Injection Solution Reconstituted)

4

C1

Penicillin G Procaine Penicillin G Procaine

(Intramuscular Suspension)

4

C1

Penicillin G Sodium Penicillin G Sodium


5

C1

Penicillin V Potassium Penicillin V Potassium

(Oral Solution Reconstituted)

2

C1

Penicillin V Potassium Penicillin V Potassium

(Oral Tablet)2

C1

Piperacillin-Tazobactam Piperacillin-

Tazobactam (Intravenous Solution Reconstituted)

4

B1

MacrolidesC1

Azasite

Azasite (Ophthalmic

Solution)4

C1

Azithromycin Azithromycin


4

C1

Azithromycin Azithromycin (Oral

Suspension Reconstituted)

1

C1

Azithromycin Azithromycin (Oral

Tablet)1

C1

Clarithromycin ER Clarithromycin ER


3

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Clarithromycin Clarithromycin (Oral


4

C1

Clarithromycin Clarithromycin (Oral


3

C1

Dificid

Dificid (Oral Tablet) 5

C1

E.E.S. Granules E.E.S. Granules (Oral

Suspension

Reconstituted)

4

C1

Ery-Tab

Ery-Tab (Oral Tablet Delayed Release)

4

C1

Erythrocin Lactobionate Erythrocin

Lactobionate (Intravenous Solution Reconstituted)

4

C1

Erythromycin Base Erythromycin Base

(Oral Capsule Delayed Release Particles)

4

C1

Erythromycin Base Erythromycin Base

(Oral Tablet Immediate Release)

4

C1

Erythromycin Ethylsuccinate Erythromycin

Ethylsuccinate (200MG/5ML Oral Suspension Reconstituted)

4

C1

Erythromycin Ethylsuccinate Erythromycin

Ethylsuccinate (Oral Tablet)

4

C1

Erythromycin Erythromycin

(Ophthalmic Ointment)2

B1

QuinolonesC1

Besivance

Besivance

(Ophthalmic

Suspension)

4

113839 39



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Ciloxan

Ciloxan (Ophthalmic

Ointment)4

C1

Ciprofloxacin HCl Ciprofloxacin HCl


C1


(100MG Oral Tablet Immediate Release)

3

C1


(250MG Oral Tablet Immediate Release, 500MG Oral Tablet Immediate Release, 750MG Oral Tablet Immediate Release)

2

C1

Ciprofloxacin in D5W Ciprofloxacin in D5W

(200MG/100ML Intravenous Solution)

4

C1

Ciprofloxacin Ciprofloxacin (Oral


4

C1

Gatifloxacin

Gatifloxacin (Ophthalmic Solution)

3

C1

Levofloxacin in D5W Levofloxacin in D5W

(500MG/100ML Intravenous Solution, 750MG/150ML Intravenous Solution)

4

C1

Levofloxacin Levofloxacin (25MG/

ML Intravenous Solution)

4

C1

Levofloxacin Levofloxacin (0.5%

Ophthalmic Solution)3

C1

Levofloxacin Levofloxacin (25MG/

ML Oral Solution)4

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Levofloxacin Levofloxacin (250MG

Oral Tablet, 500MG Oral Tablet, 750MG Oral Tablet)

1

C1

Moxifloxacin HCl in NaCl Moxifloxacin HCl in

NaCl (Intravenous Solution)

4

C1

Moxifloxacin HCl Moxifloxacin HCl


C1

Moxifloxacin HCl Moxifloxacin HCl (Oral

Tablet)3

C1

Ofloxacin

Ofloxacin (Ophthalmic Solution)

2

C1

Ofloxacin

Ofloxacin (Oral Tablet) 3

C1

Ofloxacin

Ofloxacin (Otic Solution)

3

B1

SulfonamidesC1

Silver Sulfadiazine Silver Sulfadiazine

(External Cream)3

C1

SSD

SSD (External Cream) 3

C1

Sulfacetamide Sodium Sulfacetamide Sodium


C1

Sulfacetamide Sodium Sulfacetamide Sodium


C1

Sulfadiazine

Sulfadiazine (Oral Tablet)

4

C1

Sulfamethoxazole-Trimethoprim Sulfamethoxazole-

Trimethoprim (Oral Suspension)

2

C1

Sulfamethoxazole-Trimethoprim Sulfamethoxazole-

Trimethoprim (Oral Tablet)

2

B1

TetracyclinesC1

Demeclocycline HCl Demeclocycline HCl

(Oral Tablet)4

12394040



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Doxy 100

Doxy 100 (Intravenous Solution Reconstituted)

4

C1

Doxycycline Hyclate Doxycycline Hyclate

(Oral Capsule)3

C1

Doxycycline Hyclate Doxycycline Hyclate

(100MG Oral Tablet Immediate Release, 20MG Oral Tablet Immediate Release)

3

C1

Doxycycline Monohydrate Doxycycline

Monohydrate (100MG Oral Capsule, 50MG Oral Capsule)

3

C1


Monohydrate (Oral Suspension Reconstituted)

4

C1


Monohydrate (100MG Oral Tablet, 50MG Oral Tablet, 75MG Oral Tablet)

3

C1

Minocycline HCl Minocycline HCl (Oral

Capsule)2

C1

Minocycline HCl Minocycline HCl (Oral


4

C1

Tetracycline HCl Tetracycline HCl (Oral

Capsule)4

C1

Vibramycin

Vibramycin (50MG/

5ML Oral Syrup)4

A1

AnticonvulsantsB1

Anticonvulsants, OtherC1

BRIVIACT

BRIVIACT (Oral

Solution)5 PA; QL

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

BRIVIACT

BRIVIACT (Oral

Tablet)5 PA; QL

C1

Epidiolex

Epidiolex (Oral

Solution)5 PA

C1

Levetiracetam ER Levetiracetam ER (Oral


3

C1

Levetiracetam Levetiracetam (Oral

Solution)2

C1

Levetiracetam Levetiracetam (Oral


2

C1

Roweepra

Roweepra (Oral Tablet Immediate Release)

2

C1

Roweepra XR

Roweepra XR (Oral Tablet Extended Release 24 Hour)

3

C1

Spritam

Spritam (1000MG

Oral Tablet

Disintegrating

Soluble, 250MG Oral

Tablet Disintegrating

Soluble, 500MG Oral


Soluble, 750MG Oral


Soluble)

4

B1

Calcium Channel Modifying AgentsC1

Celontin

Celontin (Oral

Capsule)4

C1

Ethosuximide Ethosuximide (Oral

Capsule)3

C1

Ethosuximide Ethosuximide (Oral

Solution)3

134041 41



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Zonisamide

Zonisamide (Oral Capsule)

2

B1

Gamma-aminobutyric Acid (GABA) Augmenting Agents

C1

Clobazam

Clobazam (2.5MG/ML Oral Suspension)

5 PA; QL C1

Clobazam

Clobazam (10MG Oral Tablet)

4 PA; QL C1

Clobazam

Clobazam (20MG Oral Tablet)

5 PA; QL C1

Diastat AcuDial

Diastat AcuDial

(Rectal Gel)4

C1

Diastat Pediatric

Diastat Pediatric

(Rectal Gel)4

C1

Gabapentin

Gabapentin (Oral Capsule)

2

C1

Gabapentin

Gabapentin (250MG/5ML Oral Solution)

3

C1

Gabapentin

Gabapentin (Oral Tablet)

2

C1

Phenobarbital Phenobarbital (Oral

Elixir)2

C1

Phenobarbital Phenobarbital (Oral

Tablet)2

C1

Primidone

Primidone (Oral Tablet)

2

C1

Sympazan

Sympazan (Oral Film) 5 PA; QL C1

Tiagabine HCl Tiagabine HCl (Oral

Tablet)4

C1

Valproic Acid

Valproic Acid (Oral Capsule)

2

C1

Valproic Acid

Valproic Acid (Oral Solution)

2

C1

Vigabatrin

Vigabatrin (Oral Packet)

5 PA; LA; QL

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Vigabatrin

Vigabatrin (Oral Tablet)

5 PA; LA; QL C1

Vigadrone

Vigadrone (Oral Packet)

5 PA; LA; QL B1

Glutamate Reducing AgentsC1

Felbamate

Felbamate (Oral Suspension)

5

C1

Felbamate

Felbamate (Oral Tablet)

4

C1

Fycompa

Fycompa (Oral

Suspension)5

C1

Fycompa

Fycompa (Oral

Tablet)5

C1

Lamotrigine

Lamotrigine (100MG Oral Tablet Immediate Release, 150MG Oral Tablet Immediate Release, 200MG Oral Tablet Immediate Release, 25MG Oral Tablet Immediate Release)

2

C1

Lamotrigine

Lamotrigine (25MG Oral Tablet Chewable, 5MG Oral Tablet Chewable)

3

C1

Topiramate

Topiramate (Oral Capsule Sprinkle Immediate Release)

2

C1

Topiramate

Topiramate (Oral Tablet)

2

B1

Sodium Channel AgentsC1

Aptiom

Aptiom (Oral Tablet) 5 QL C1

Banzel

Banzel (Oral

Suspension)5

14414242



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Banzel

Banzel (Oral Tablet) 5

C1

Carbamazepine ER Carbamazepine ER

(Oral Capsule Extended Release 12 Hour)

3

C1

Carbamazepine ER Carbamazepine ER


3

C1

Carbamazepine Carbamazepine (Oral

Suspension)3

C1



3

C1


Tablet Chewable)3

C1

Dilantin INFATABS Dilantin INFATABS

(Oral Tablet Chewable)3

C1

Dilantin

Dilantin (Oral Capsule) 3

C1

Epitol

Epitol (Oral Tablet) 3

C1

Oxcarbazepine Oxcarbazepine

(300MG/5ML Oral Suspension)

4

C1

Oxcarbazepine Oxcarbazepine

(150MG Oral Tablet, 300MG Oral Tablet, 600MG Oral Tablet)

3

C1

Peganone

Peganone (Oral

Tablet)4

C1

Phenytek

Phenytek (Oral Capsule)

2

C1

Phenytoin

Phenytoin (Oral Suspension)

2

C1

Phenytoin

Phenytoin (Oral Tablet Chewable)

2

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Phenytoin Sodium Extended Phenytoin Sodium

Extended (Oral Capsule)

2

C1

Vimpat

Vimpat (Oral Solution) 4 QL C1

Vimpat

Vimpat (Oral Tablet) 4 QL A1

Antidementia AgentsB1

Cholinesterase InhibitorsC1

Donepezil HCl Donepezil HCl (Oral

Tablet)1 QL

C1

Donepezil HCl ODT Donepezil HCl ODT

(Oral Tablet Dispersible)

2 QL

C1

Galantamine Hydrobromide ER Galantamine

Hydrobromide ER (Oral Capsule Extended Release 24 Hour)

4 QL

C1

Galantamine Hydrobromide Galantamine

Hydrobromide (Oral Solution)

4 QL

C1

Galantamine Hydrobromide Galantamine

Hydrobromide (Oral Tablet)

4 QL

C1

Rivastigmine Tartrate Rivastigmine Tartrate

(Oral Capsule)3 QL

C1

Rivastigmine Rivastigmine

(Transdermal Patch 24 Hour)

4 ST; QL

B1

N-methyl-D-aspartate (NMDA) Receptor Antagonist

C1

Memantine HCl ER Memantine HCl ER


3 PA; QL

C1

Memantine HCl Memantine HCl (Oral

Solution)4 PA; QL

154243 43



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Memantine HCl Memantine HCl (10MG


2 PA; QL

C1

Memantine HCl Titration Pak Memantine HCl

Titration Pak (Oral

Tablet)

3 PA

A1

AntidepressantsB1

Antidepressants, OtherC1

Bupropion HCl SR Bupropion HCl SR


2

C1

Bupropion HCl XL Bupropion HCl XL

(150MG Oral Tablet Extended Release 24 Hour, 300MG Oral Tablet Extended Release 24 Hour)

2

C1

Bupropion HCl Bupropion HCl (Oral


2

C1

Mirtazapine

Mirtazapine (Oral Tablet)

2

C1

Mirtazapine ODT Mirtazapine ODT (Oral

Tablet Dispersible)2

B1

Monoamine Oxidase InhibitorsC1

Emsam

Emsam (Transdermal

Patch 24 Hour)5 QL

C1

Marplan

Marplan (Oral Tablet) 4

C1

Phenelzine Sulfate Phenelzine Sulfate

(Oral Tablet)3

C1

Tranylcypromine Sulfate Tranylcypromine

Sulfate (Oral Tablet)4

B1

SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors)

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Citalopram Hydrobromide Citalopram

Hydrobromide (Oral Solution)

3

C1

Citalopram Hydrobromide Citalopram

Hydrobromide (Oral Tablet)

1

C1

Desvenlafaxine Succinate ER Desvenlafaxine

Succinate ER (Oral Tablet Extended Release 24 Hour) (Generic Pristiq)

3 QL

C1

Escitalopram Oxalate Escitalopram Oxalate

(Oral Solution)2

C1

Escitalopram Oxalate Escitalopram Oxalate

(Oral Tablet)1

C1

Fetzima

Fetzima (Oral

Capsule Extended

Release 24 Hour)

4 ST; QL

C1

Fetzima Titration

Fetzima Titration

(Oral Capsule ER 24

Hour Therapy Pack)

4 ST

C1

Fluoxetine HCl Fluoxetine HCl (10MG

Oral Capsule Immediate Release, 20MG Oral Capsule Immediate Release, 40MG Oral Capsule Immediate Release)

2

C1

Fluoxetine HCl Fluoxetine HCl (90MG

Oral Capsule Delayed Release)

4

C1

Fluoxetine HCl Fluoxetine HCl (20MG/

5ML Oral Solution)2

C1

Fluvoxamine Maleate Fluvoxamine Maleate

(Oral Tablet)3

16434444



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Maprotiline HCl Maprotiline HCl (Oral

Tablet)4

C1

Nefazodone HCl Nefazodone HCl (Oral

Tablet)4

C1

Paroxetine HCl Paroxetine HCl (Oral


2

C1

Paxil

Paxil (Oral

Suspension)4

C1

Sertraline HCl Sertraline HCl (Oral

Concentrate)4

C1

Sertraline HCl Sertraline HCl (Oral

Tablet)1

C1

Trazodone HCl Trazodone HCl


1

C1

Trazodone HCl Trazodone HCl

(300MG Oral Tablet)2

C1

Trintellix

Trintellix (Oral Tablet) 4 QL C1

Venlafaxine HCl ER Venlafaxine HCl ER


2

C1

Venlafaxine HCl Venlafaxine HCl (Oral


3

C1

Viibryd

Viibryd (Oral Tablet) 4 QL C1

Viibryd Starter Pack Viibryd Starter Pack

(Oral Kit)4 QL

B1

TricyclicsC1

Amitriptyline HCl Amitriptyline HCl (Oral

Tablet)4

C1

Amoxapine

Amoxapine (Oral Tablet)

3

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Clomipramine HCl Clomipramine HCl

(Oral Capsule)4

C1

Desipramine HCl Desipramine HCl (Oral

Tablet)3

C1

Doxepin HCl

Doxepin HCl (Oral Capsule)

3

C1

Doxepin HCl

Doxepin HCl (Oral Concentrate)

3

C1

Imipramine HCl Imipramine HCl (Oral

Tablet)4

C1

Imipramine Pamoate Imipramine Pamoate

(Oral Capsule)4

C1

Nortriptyline HCl Nortriptyline HCl (Oral

Capsule)2

C1

Nortriptyline HCl Nortriptyline HCl (Oral

Solution)2

C1

Protriptyline HCl Protriptyline HCl (Oral

Tablet)4

C1

Trimipramine Maleate Trimipramine Maleate

(Oral Capsule)4

A1

AntiemeticsB1

Antiemetics, OtherC1

Compro

Compro (Rectal Suppository)

4

C1

Hydroxyzine Pamoate Hydroxyzine Pamoate

(Oral Capsule)3

C1

Meclizine HCl Meclizine HCl (Oral

Tablet)2

C1

Metoclopramide HCl Metoclopramide HCl

(5MG/5ML Oral Solution)

2

C1

Metoclopramide HCl Metoclopramide HCl

(Oral Tablet)1

C1

Perphenazine Perphenazine (Oral

Tablet)4

174445 45



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Prochlorperazine Maleate Prochlorperazine

Maleate (Oral Tablet)2

C1

Prochlorperazine Prochlorperazine

(Rectal Suppository)4

C1

Scopolamine Scopolamine


4

C1

Transderm-Scop Transderm-Scop

(1.5MG)

(Transdermal Patch

72 Hour)

4

B1

Emetogenic Therapy AdjunctsC1

Aprepitant

Aprepitant (Oral Therapy Pack, Oral Capsule)

4 PA

C1

Cesamet

Cesamet (Oral

Capsule)5 PA

C1

Dronabinol

Dronabinol (Oral Capsule)

4 PA C1

Granisetron HCl Granisetron HCl (Oral

Tablet)4 B/D, PA; QL

C1

Ondansetron HCl Ondansetron HCl (Oral

Solution)4 B/D, PA

C1

Ondansetron HCl Ondansetron HCl (Oral

Tablet)2 B/D, PA

C1

Ondansetron ODT Ondansetron ODT

(Oral Tablet Dispersible)

2 B/D, PA

C1

Sancuso

Sancuso

(Transdermal Patch)5

A1

AntifungalsB1

AntifungalsC1

Abelcet

Abelcet (Intravenous

Suspension)4 B/D, PA

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

AmBisome

AmBisome

(Intravenous

Suspension

Reconstituted)

5 B/D, PA

C1

Amphotericin B Amphotericin B


4 B/D, PA

C1

Ciclopirox

Ciclopirox (External Gel)

3

C1

Ciclopirox

Ciclopirox (External Shampoo)

3

C1

Ciclopirox

Ciclopirox (External Solution)

3

C1

Ciclopirox Olamine Ciclopirox Olamine

(External Cream)3

C1

Ciclopirox Olamine Ciclopirox Olamine

(External Suspension)3

C1

Clotrimazole

Clotrimazole (External Cream)

2

C1

Clotrimazole

Clotrimazole (External Solution)

2

C1

Clotrimazole

Clotrimazole (Mouth/Throat Lozenge)

2

C1

Econazole Nitrate Econazole Nitrate

(External Cream)4 QL

C1

Eraxis

Eraxis (100MG


Reconstituted)

5

C1

Eraxis

Eraxis (50MG


Reconstituted)

4

C1

Exelderm

Exelderm (External

Cream)4

C1

Exelderm

Exelderm (External

Solution)4

18454646



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Fluconazole in Sodium Chloride Fluconazole in Sodium

Chloride (Intravenous Solution)

4

C1

Fluconazole

Fluconazole (Oral Suspension Reconstituted)

2

C1

Fluconazole

Fluconazole (Oral Tablet)

2

C1

Flucytosine

Flucytosine (Oral Capsule)

5

C1

Griseofulvin Microsize Griseofulvin Microsize

(Oral Suspension)4

C1

Griseofulvin Microsize Griseofulvin Microsize

(Oral Tablet)4

C1

Griseofulvin Ultramicrosize Griseofulvin

Ultramicrosize (Oral Tablet)

4

C1

Itraconazole

Itraconazole (Oral Capsule)

4 PA; QL C1

Itraconazole

Itraconazole (Oral Solution)

5 PA C1

Jublia

Jublia (External

Solution)4

C1

Ketoconazole Ketoconazole (External

Cream)2 QL

C1

Ketoconazole Ketoconazole (External

Shampoo)2

C1

Ketoconazole Ketoconazole (Oral

Tablet)2

C1

Mentax

Mentax (External

Cream)4

C1

Miconazole 3 Miconazole 3 (Vaginal

Suppository)3

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Mycamine

Mycamine


Reconstituted)

5

C1

Naftifine HCl

Naftifine HCl (External Cream)

4

C1

Naftin

Naftin (External Gel) 4

C1

Natacyn

Natacyn (Ophthalmic

Suspension)4

C1

Noxafil

Noxafil (Oral

Suspension)5 QL

C1

Noxafil

Noxafil (Oral Tablet

Delayed Release)5 PA; QL

C1

Nyamyc

Nyamyc (External Powder)

2

C1

Nystatin

Nystatin (External Cream)

2

C1

Nystatin

Nystatin (External Ointment)

2

C1

Nystatin

Nystatin (External Powder)

2

C1

Nystatin

Nystatin (Mouth/Throat Suspension)

2

C1

Nystatin

Nystatin (Oral Tablet) 2

C1

Nystop

Nystop (External Powder)

2

C1

Terbinafine HCl Terbinafine HCl (Oral

Tablet)2

C1

Terconazole

Terconazole (Vaginal Cream)

3

C1

Terconazole

Terconazole (Vaginal Suppository)

3

C1

Voriconazole Voriconazole


5

194647 47



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Voriconazole Voriconazole (Oral


5

C1

Voriconazole Voriconazole (Oral

Tablet)4

A1

Antigout AgentsB1

Antigout AgentsC1

Allopurinol

Allopurinol (Oral Tablet)

1

C1

Colchicine

Colchicine (0.6MG

Oral Capsule) (Brand

Equivalent Mitigare)

3 QL

C1

Colchicine

Colchicine (0.6MG Oral Tablet) (Brand Equivalent Colcrys)

3 QL

C1

Colcrys

Colcrys (Oral Tablet) 3 QL C1

Probenecid

Probenecid (Oral Tablet)

2

C1

Probenecid-Colchicine Probenecid-Colchicine

(Oral Tablet)2

A1

Antimigraine AgentsB1

Ergot AlkaloidsC1

Dihydroergotamine Mesylate Dihydroergotamine

Mesylate (Nasal Solution)

5

C1

Ergotamine-Caffeine Ergotamine-Caffeine

(Oral Tablet)3

C1

Migergot

Migergot (Rectal Suppository)

5

B1

ProphylacticC1

Aimovig

Aimovig

(Subcutaneous

Solution Auto-

Injector)

4 PA; QL

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Timolol Maleate Timolol Maleate (Oral

Tablet)3

B1

Serotonin (5-HT) 1b/1d Receptor AgonistsC1

Naratriptan HCl Naratriptan HCl (Oral

Tablet)3 QL

C1

Rizatriptan Benzoate Rizatriptan Benzoate

(Oral Tablet)3 QL

C1

Rizatriptan Benzoate ODT Rizatriptan Benzoate

ODT (Oral Tablet Dispersible)

3 QL

C1

Sumatriptan

Sumatriptan (Nasal Solution)

4 QL C1

Sumatriptan Succinate Sumatriptan Succinate


2 QL

C1

Sumatriptan Succinate Refill Sumatriptan

Succinate Refill

(Subcutaneous

Solution Cartridge)

4 QL

C1


(6MG/0.5ML Subcutaneous Solution)

4 QL

C1


(4MG/0.5ML Subcutaneous Solution Auto-Injector)

4 QL

C1


(6MG/0.5ML Subcutaneous Solution Auto-Injector) (Generic Imitrex)

4 QL

20474848



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Sumatriptan Succinate Sumatriptan

Succinate (6MG/

0.5ML Subcutaneous

Solution Auto-

Injector) (Generic

Imitrex STATdose)

4 QL

C1


(6MG/0.5ML Subcutaneous Solution Prefilled Syringe)

4 QL

A1

Antimyasthenic AgentsB1

ParasympathomimeticsC1

Guanidine HCl

Guanidine HCl (Oral

Tablet)3

C1

Pyridostigmine Bromide ER Pyridostigmine

Bromide ER (Oral Tablet Extended Release)

4

C1

Pyridostigmine Bromide Pyridostigmine

Bromide (Oral Solution)

5

C1

Pyridostigmine Bromide Pyridostigmine

Bromide (60MG Oral Tablet Immediate Release)

3

A1

AntimycobacterialsB1

Antimycobacterials, OtherC1

Dapsone

Dapsone (Oral Tablet) 3

C1

Rifabutin

Rifabutin (Oral Capsule)

4

B1

AntitubercularsC1

Ethambutol HCl Ethambutol HCl (Oral

Tablet)3

C1

Isoniazid

Isoniazid (Oral Syrup) 4

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Isoniazid

Isoniazid (Oral Tablet) 2

C1

Paser

Paser (Oral Packet) 4

C1

Priftin

Priftin (Oral Tablet) 4

C1

Pyrazinamide Pyrazinamide (Oral

Tablet)4

C1

Rifampin

Rifampin (Intravenous Solution Reconstituted)

4

C1

Rifampin

Rifampin (Oral Capsule)

3

C1

Rifater

Rifater (Oral Tablet) 5

C1

Sirturo

Sirturo (Oral Tablet) 5 PA; LA C1

Trecator

Trecator (Oral Tablet) 4

A1

AntineoplasticsB1

Alkylating AgentsC1

Cyclophosphamide Cyclophosphamide

(Oral Capsule)4 B/D, PA

C1

Gleostine

Gleostine (100MG

Oral Capsule)5

C1

Gleostine

Gleostine (10MG Oral

Capsule, 40MG Oral

Capsule)

3

C1

Leukeran

Leukeran (Oral

Tablet)5

C1

Matulane

Matulane (Oral

Capsule)5 LA

C1

Valchlor

Valchlor (External

Gel)5 PA; LA

B1

AntiandrogensC1

Abiraterone Acetate Abiraterone Acetate

(Oral Tablet)5 PA; QL

C1

Bicalutamide Bicalutamide (Oral

Tablet)2

C1

Erleada

Erleada (Oral Tablet) 5 PA; QL

214849 49



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Flutamide

Flutamide (Oral Capsule)

3

C1

Nilutamide

Nilutamide (Oral Tablet)

5

C1

Xtandi

Xtandi (Oral Capsule) 5 PA; LA; QL B1

Antiangiogenic AgentsC1

Pomalyst

Pomalyst (Oral

Capsule)5 PA; QL

C1

Revlimid

Revlimid (Oral

Capsule)5 PA; LA; QL

C1

Thalomid

Thalomid (Oral

Capsule)5 PA; QL

B1

Antiestrogens/ModifiersC1

Emcyt

Emcyt (Oral Capsule) 5

C1

Soltamox

Soltamox (Oral

Solution)5

C1

Tamoxifen Citrate Tamoxifen Citrate

(Oral Tablet)2

C1

Toremifene Citrate Toremifene Citrate

(Oral Tablet)5

B1

AntimetabolitesC1

Droxia

Droxia (Oral Capsule) 4

C1

Hydroxyurea

Hydroxyurea (Oral Capsule)

2

C1

Mercaptopurine Mercaptopurine (Oral

Tablet)3

C1

Purixan

Purixan (Oral

Suspension)5 PA

C1

Tabloid

Tabloid (Oral Tablet) 4 PA B1

Antineoplastics, OtherC1

Copiktra

Copiktra (Oral

Capsule)5 PA; QL

C1

Kisqali

Kisqali (200MG Dose)


Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Kisqali



C1

Kisqali



C1

Kisqali Femara

Kisqali Femara

(400MG Dose) (Oral

Tablet Therapy Pack)

5 PA; QL

C1

Kisqali Femara

Kisqali Femara

(600MG Dose) (Oral


5 PA; QL

C1

Kisqali Femara

Kisqali Femara

(200MG Dose) (Oral


5 PA; QL

C1

Leucovorin Calcium Leucovorin Calcium


3

C1

Leucovorin Calcium Leucovorin Calcium

(25MG Oral Tablet)4

C1

Lonsurf

Lonsurf (Oral Tablet) 5 PA; LA; QL C1

Lorbrena

Lorbrena (Oral

Tablet)5 PA; QL

C1

Ninlaro

Ninlaro (Oral

Capsule)5 PA; QL

C1

Piqray

Piqray (200 MG Daily

Dose) (Oral Tablet

Therapy Pack)

5 PA; QL

C1

Piqray


Dose) (Oral Tablet

Therapy Pack)

5 PA; QL

C1

Piqray


Dose) (Oral Tablet

Therapy Pack)

5 PA; QL

22495050



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Synribo

Synribo

(Subcutaneous

Solution

Reconstituted)

5 PA

C1

Verzenio

Verzenio (Oral Tablet) 5 PA; LA; QL C1

Zolinza

Zolinza (Oral

Capsule)5 PA

B1

Aromatase Inhibitors, 3rd GenerationC1

Anastrozole

Anastrozole (Oral Tablet)

1

C1

Exemestane

Exemestane (Oral Tablet)

4

C1

Letrozole

Letrozole (Oral Tablet) 2

B1

Enzyme InhibitorsC1

Balversa

Balversa (Oral Tablet) 5 PA; QL C1

Rubraca

Rubraca (Oral Tablet) 5 PA; LA; QL C1

Talzenna

Talzenna (Oral


C1

Zejula

Zejula (Oral Capsule) 5 PA; LA; QL B1

Molecular Target InhibitorsC1

Afinitor Disperz

Afinitor Disperz (Oral

Tablet Soluble)5 PA

C1

Afinitor

Afinitor (Oral Tablet) 5 PA C1

Alecensa

Alecensa (Oral


C1

Alunbrig

Alunbrig (Oral Tablet) 5 PA; LA; QL C1

Alunbrig

Alunbrig (Oral Tablet

Therapy Pack)5 PA; LA; QL

C1

Bosulif

Bosulif (Oral Tablet) 5 PA; QL C1

Braftovi

Braftovi (Oral

Capsule)5 PA

C1

Cabometyx

Cabometyx (Oral

Tablet)5 PA; LA; QL

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Calquence

Calquence (Oral

Capsule)5 PA; QL

C1

Caprelsa

Caprelsa (Oral Tablet) 5 PA; LA C1

Cometriq

Cometriq (100MG

Daily Dose) (Oral Kit)5 PA; LA

C1

Cometriq

Cometriq (140MG


C1

Cometriq

Cometriq (60MG


C1

Cotellic

Cotellic (Oral Tablet) 5 PA; LA; QL C1

Daurismo

Daurismo (Oral

Tablet)5 PA; LA; QL

C1

Erivedge

Erivedge (Oral


C1

Erlotinib HCl

Erlotinib HCl (Oral Tablet)

5 PA; QL C1

Farydak

Farydak (Oral

Capsule)5 PA

C1

Gilotrif

Gilotrif (Oral Tablet) 5 PA; LA C1

Ibrance

Ibrance (Oral


C1

Iclusig

Iclusig (Oral Tablet) 5 PA; LA; QL C1

IDHIFA

IDHIFA (Oral Tablet) 5 PA; LA; QL C1

Imatinib Mesylate Imatinib Mesylate (Oral

Tablet)5 PA; QL

C1

Imbruvica

Imbruvica (Oral


C1

Imbruvica

Imbruvica (Oral

Tablet)5 PA; QL

C1

Inlyta

Inlyta (Oral Tablet) 5 PA; LA; QL C1

Iressa

Iressa (Oral Tablet) 5 PA; LA; QL C1

Jakafi

Jakafi (Oral Tablet) 5 PA; LA; QL

235051 51



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Lenvima 10MG Daily Dose Lenvima 10MG Daily

Dose (Oral Capsule

Therapy Pack)

5 PA; LA

C1


Dose (Oral Capsule

Therapy Pack)

5 PA; LA

C1


Dose (Oral Capsule

Therapy Pack)

5 PA; LA

C1


Dose (Oral Capsule

Therapy Pack)

5 PA; LA

C1


Dose (Oral Capsule

Therapy Pack)

5 PA; LA

C1


Dose (Oral Capsule

Therapy Pack)

5 PA; LA

C1


Dose (Oral Capsule

Therapy Pack)

5 PA; LA

C1


Dose (Oral Capsule

Therapy Pack)

5 PA; LA

C1

Lynparza

Lynparza (Oral

Tablet)5 PA; LA; QL

C1

Mekinist

Mekinist (Oral Tablet) 5 PA; LA C1

Mektovi

Mektovi (Oral Tablet) 5 PA C1

Nerlynx

Nerlynx (Oral Tablet) 5 PA; LA; QL C1

Nexavar

Nexavar (Oral Tablet) 5 PA; LA C1

Odomzo

Odomzo (Oral


C1

Rydapt

Rydapt (Oral Capsule) 5 PA; QL C1

Sprycel

Sprycel (Oral Tablet) 5 PA; QL

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Stivarga

Stivarga (Oral Tablet) 5 PA; LA; QL C1

Sutent

Sutent (Oral Capsule) 5 PA; QL C1

Tafinlar

Tafinlar (Oral

Capsule)5 PA; LA

C1

Tagrisso

Tagrisso (Oral Tablet) 5 PA; LA; QL C1

Tasigna

Tasigna (Oral

Capsule)5 PA; QL

C1

Tibsovo

Tibsovo (Oral Tablet) 5 PA; QL C1

Tykerb

Tykerb (Oral Tablet) 5 PA; LA C1

Venclexta

Venclexta (100MG

Oral Tablet, 50MG

Oral Tablet)

5 PA; LA; QL

C1

Venclexta

Venclexta (10MG Oral

Tablet)3 PA; LA; QL

C1

Venclexta Starting Pack Venclexta Starting

Pack (Oral Tablet

Therapy Pack)

5 PA; LA

C1

Vitrakvi

Vitrakvi (Oral


C1

Vitrakvi

Vitrakvi (Oral

Solution)5 PA; LA; QL

C1

Vizimpro

Vizimpro (Oral Tablet) 5 PA; LA; QL C1

Votrient

Votrient (Oral Tablet) 5 PA; LA; QL C1

Xalkori

Xalkori (Oral Capsule) 5 PA; LA C1

Xospata

Xospata (Oral Tablet) 5 PA; QL C1

Zelboraf

Zelboraf (Oral Tablet) 5 PA; LA; QL C1

Zydelig

Zydelig (Oral Tablet) 5 PA; LA; QL C1

Zykadia

Zykadia (Oral

Capsule)5 PA; QL

C1

Zykadia

Zykadia (Oral Tablet) 5 PA; QL B1

RetinoidsC1

Bexarotene

Bexarotene (Oral Capsule)

5 PA

24515252



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Panretin

Panretin (External

Gel)5

C1

Targretin

Targretin (External

Gel)5 PA

C1

Tretinoin

Tretinoin (Oral Capsule)

5

B1

Treatment AdjunctsC1

Mesnex

Mesnex (Oral Tablet) 5

A1

AntiparasiticsB1

AnthelminticsC1

Albendazole

Albendazole (Oral Tablet)

5 QL C1

Ivermectin

Ivermectin (Oral Tablet)

3

C1

Praziquantel

Praziquantel (Oral Tablet)

4

B1

AntiprotozoalsC1

Alinia

Alinia (Oral

Suspension

Reconstituted)

5

C1

Alinia

Alinia (Oral Tablet) 5

C1

Atovaquone

Atovaquone (Oral Suspension)

5

C1

Atovaquone-Proguanil HCl Atovaquone-Proguanil

HCl (Oral Tablet)3

C1

Benznidazole

Benznidazole (Oral

Tablet)4

C1

Chloroquine Phosphate Chloroquine

Phosphate (Oral Tablet)

2

C1

Coartem

Coartem (Oral Tablet) 4

C1

DARAPRIM

DARAPRIM (Oral

Tablet)5

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Hydroxychloroquine Sulfate Hydroxychloroquine

Sulfate (Oral Tablet)2

C1

Mefloquine HCl Mefloquine HCl (Oral

Tablet)2

C1

Nebupent

Nebupent (Inhalation

Solution

Reconstituted)

4 B/D, PA; QL

C1

PENTAM 300

PENTAM 300

(Injection Solution

Reconstituted)

4

C1

Primaquine Phosphate Primaquine Phosphate

(Oral Tablet)4

C1

Quinine Sulfate Quinine Sulfate (Oral

Capsule)4 PA

B1

Pediculicides/ScabicidesC1

Eurax

Eurax (External

Cream)4

C1

Eurax

Eurax (External

Lotion)4

C1

Lindane

Lindane (External Shampoo)

4

C1

Malathion

Malathion (External Lotion)

4

C1

Permethrin

Permethrin (External Cream)

3

A1

Antiparkinson AgentsB1

AnticholinergicsC1

Benztropine Mesylate Benztropine Mesylate

(Oral Tablet)2

C1

Trihexyphenidyl HCl Trihexyphenidyl HCl

(Oral Elixir)2

C1

Trihexyphenidyl HCl Trihexyphenidyl HCl

(Oral Tablet)2

B1

Antiparkinson Agents, Other

255253 53



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Amantadine HCl Amantadine HCl (Oral

Capsule)3

C1


Syrup)2

C1


Tablet)3

C1

Entacapone

Entacapone (Oral Tablet)

4

C1

Tolcapone

Tolcapone (Oral Tablet)

5 QL B1

Dopamine AgonistsC1

Apokyn

Apokyn

(Subcutaneous

Solution Cartridge)

5 PA; LA; QL

C1

Bromocriptine Mesylate Bromocriptine

Mesylate (Oral Capsule)

3

C1

Bromocriptine Mesylate Bromocriptine

Mesylate (Oral Tablet)3

C1

Neupro

Neupro (Transdermal

Patch 24 Hour)4

C1

Pramipexole Dihydrochloride Pramipexole

Dihydrochloride (Oral Tablet Immediate Release)

2

C1

Ropinirole HCl Ropinirole HCl (Oral


2

B1

Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors

C1

Carbidopa

Carbidopa (Oral Tablet)

4

C1

Carbidopa-Levodopa ER Carbidopa-Levodopa

ER (Oral Tablet Extended Release)

1

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Carbidopa-Levodopa Carbidopa-Levodopa


1

C1

Carbidopa-Levodopa ODT Carbidopa-Levodopa

ODT (Oral Tablet Dispersible)

2

C1

Carbidopa-Levodopa-Entacapone Carbidopa-Levodopa-

Entacapone (Oral Tablet)

4

C1

Rytary

Rytary (Oral Capsule

Extended Release)4 ST

B1

Monoamine Oxidase B (MAO-B) InhibitorsC1

Rasagiline Mesylate Rasagiline Mesylate

(Oral Tablet)4

C1

Selegiline HCl Selegiline HCl (Oral

Capsule)3

C1

Selegiline HCl Selegiline HCl (Oral

Tablet)3

C1

Zelapar

Zelapar (Oral Tablet

Dispersible)5

A1

AntipsychoticsB1

1st Generation/TypicalC1

Chlorpromazine HCl Chlorpromazine HCl

(Oral Tablet)4

C1

Fluphenazine Decanoate Fluphenazine

Decanoate (Injection Solution)

4

C1

Fluphenazine HCl Fluphenazine HCl

(2.5MG/ML Injection Solution)

4

C1


(5MG/ML Oral Concentrate)

3

26535454



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1


(2.5MG/5ML Oral Elixir)

4

C1


(10MG Oral Tablet, 1MG Oral Tablet, 2.5MG Oral Tablet, 5MG Oral Tablet)

2

C1

Haloperidol Decanoate Haloperidol Decanoate

(Intramuscular Solution)

4

C1

Haloperidol Lactate Haloperidol Lactate

(Injection Solution)4

C1

Haloperidol Lactate Haloperidol Lactate

(Oral Concentrate)2

C1

Haloperidol

Haloperidol (Oral Tablet)

2

C1

Loxapine Succinate Loxapine Succinate

(Oral Capsule)2

C1

Molindone HCl Molindone HCl (Oral

Tablet)4

C1

Pimozide

Pimozide (Oral Tablet) 4

C1

Thioridazine HCl Thioridazine HCl (Oral

Tablet)3

C1

Thiothixene

Thiothixene (Oral Capsule)

3

C1

Trifluoperazine HCl Trifluoperazine HCl

(Oral Tablet)3

B1

2nd Generation/AtypicalC1

Abilify Maintena Abilify Maintena

(Intramuscular

Prefilled Syringe)

5

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Abilify Maintena Abilify Maintena

(Intramuscular

Suspension

Reconstituted ER)

5

C1

Aripiprazole

Aripiprazole (1MG/ML Oral Solution)

4 QL C1

Aripiprazole

Aripiprazole (10MG Oral Tablet, 15MG Oral Tablet, 20MG Oral Tablet, 2MG Oral Tablet, 30MG Oral Tablet, 5MG Oral Tablet)

3 QL

C1

Aripiprazole ODT Aripiprazole ODT

(10MG Oral Tablet Dispersible, 15MG Oral Tablet Dispersible)

5 QL

C1

Aristada Initio

Aristada Initio

(Intramuscular

Prefilled Syringe)

5

C1

Aristada

Aristada

(Intramuscular

Prefilled Syringe)

5

C1

Fanapt

Fanapt (10MG Oral

Tablet, 12MG Oral

Tablet, 4MG Oral

Tablet, 6MG Oral

Tablet, 8MG Oral

Tablet)

5 ST; QL

C1

Fanapt

Fanapt (1MG Oral

Tablet, 2MG Oral

Tablet)

4 ST; QL

C1

Fanapt Titration Pack Fanapt Titration Pack

(Oral Tablet)4 ST

275455 55



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Geodon

Geodon

(Intramuscular

Solution

Reconstituted)

4

C1

Invega Sustenna Invega Sustenna

(117MG/0.75ML

Intramuscular

Suspension Prefilled

Syringe, 156MG/ML

Intramuscular


Syringe, 234MG/

1.5ML Intramuscular


Syringe, 78MG/

0.5ML Intramuscular


Syringe)

5

C1

Invega Sustenna Invega Sustenna

(39MG/0.25ML

Intramuscular


Syringe)

4

C1

Invega Trinza

Invega Trinza

(Intramuscular


Syringe)

5

C1

Latuda

Latuda (Oral Tablet) 5 QL C1

Nuplazid

Nuplazid (Oral

Capsule)5 PA; QL

C1

Nuplazid

Nuplazid (Oral Tablet) 5 PA; QL C1

Olanzapine

Olanzapine (10MG Intramuscular Solution Reconstituted)

4

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Olanzapine

Olanzapine (10MG Oral Tablet, 15MG Oral Tablet, 2.5MG Oral Tablet, 20MG Oral Tablet, 5MG Oral Tablet, 7.5MG Oral Tablet)

2 QL

C1

Olanzapine ODT Olanzapine ODT

(10MG Oral Tablet Dispersible, 15MG Oral Tablet Dispersible, 20MG Oral Tablet Dispersible, 5MG Oral Tablet Dispersible)

4 QL

C1

Paliperidone ER Paliperidone ER (Oral


4 QL

C1

Perseris

Perseris

(Subcutaneous

Prefilled Syringe)

5

C1

Quetiapine Fumarate ER Quetiapine Fumarate

ER (Oral Tablet Extended Release 24 Hour)

3 QL

C1

Quetiapine Fumarate Quetiapine Fumarate


2 QL

C1

Rexulti

Rexulti (Oral Tablet) 5 QL

28555656



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Risperdal Consta Risperdal Consta

(12.5MG

Intramuscular

Suspension

Reconstituted, 25MG

Intramuscular

Suspension

Reconstituted)

4

C1

Risperdal Consta Risperdal Consta

(37.5MG

Intramuscular

Suspension

Reconstituted, 50MG

Intramuscular

Suspension

Reconstituted)

5

C1

Risperidone

Risperidone (1MG/ML Oral Solution)

4

C1

Risperidone

Risperidone (0.25MG Oral Tablet, 0.5MG Oral Tablet, 1MG Oral Tablet, 2MG Oral Tablet, 3MG Oral Tablet, 4MG Oral Tablet)

2

C1

Risperidone ODT Risperidone ODT

(0.25MG Oral Tablet Dispersible, 0.5MG Oral Tablet Dispersible, 1MG Oral Tablet Dispersible, 2MG Oral Tablet Dispersible, 3MG Oral Tablet Dispersible, 4MG Oral Tablet Dispersible)

4

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Saphris

Saphris (Tablet

Sublingual)5 QL

C1

Vraylar

Vraylar (1.5MG Oral

Capsule, 3MG Oral

Capsule, 4.5MG Oral

Capsule, 6MG Oral

Capsule)

5 ST; QL

C1

Vraylar

Vraylar (Oral Capsule

Therapy Pack)4 ST

C1

Ziprasidone HCl Ziprasidone HCl (Oral

Capsule)3 QL

C1

Zyprexa Relprevv

Zyprexa Relprevv

(210MG

Intramuscular

Suspension

Reconstituted)

4

B1

Treatment-ResistantC1

Clozapine

Clozapine (100MG Oral Tablet, 200MG Oral Tablet, 25MG Oral Tablet, 50MG Oral Tablet)

3

C1

Clozapine ODT Clozapine ODT

(100MG Oral Tablet Dispersible, 12.5MG Oral Tablet Dispersible, 150MG Oral Tablet Dispersible, 200MG Oral Tablet Dispersible, 25MG Oral Tablet Dispersible)

4 QL

C1

Versacloz

Versacloz (Oral

Suspension)5

A1

Antivirals

295657 57



Drug NameDrug

Tier

Coverage

Rules or

Limits on

use

B1

Anti-cytomegalovirus (CMV) AgentsC1

Valganciclovir HCl Valganciclovir HCl

(Oral Solution Reconstituted)

5 QL

C1

Valganciclovir HCl Valganciclovir HCl

(Oral Tablet)5 QL

C1

Zirgan

Zirgan (Ophthalmic

Gel)4

B1

Anti-hepatitis B (HBV) AgentsC1

Adefovir Dipivoxil Adefovir Dipivoxil (Oral

Tablet)5

C1

Baraclude

Baraclude (Oral

Solution)4

C1

Entecavir

Entecavir (Oral Tablet) 4

C1

Epivir HBV

Epivir HBV (Oral

Solution)4

C1

Lamivudine

Lamivudine (100MG Oral Tablet)

3

C1

Vemlidy

Vemlidy (Oral Tablet) 5 QL B1

Anti-hepatitis C (HCV) Agents, OtherC1

Intron A

Intron A (Injection

Solution)5 PA; LA

C1

Intron A

Intron A (Injection

Solution

Reconstituted)

5 PA; LA

C1

Pegasys ProClick Pegasys ProClick

(Subcutaneous

Solution)

5 PA

C1

Pegasys

Pegasys

(Subcutaneous

Solution)

5 PA

C1

Ribasphere

Ribasphere (600MG Oral Tablet)

3

C1

Ribavirin

Ribavirin (Oral Tablet) 3

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Sylatron

Sylatron

(Subcutaneous Kit)5 PA

B1

Anti-hepatitis C (HCV) Direct Acting AgentsC1

Daklinza

Daklinza (30MG Oral

Tablet, 60MG Oral

Tablet)

5 PA; QL

C1

Epclusa

Epclusa (Oral Tablet) 5 PA; QL C1

Mavyret

Mavyret (Oral Tablet) 5 PA; QL C1

Sofosbuvir-Velpatasvir Sofosbuvir-Velpatasvir


C1

Sovaldi

Sovaldi (Oral Tablet) 5 PA; QL C1

Vosevi

Vosevi (Oral Tablet) 5 PA; QL B1

Antiherpetic AgentsC1

Acyclovir

Acyclovir (External Ointment)

4 QL C1

Acyclovir

Acyclovir (Oral Capsule)

2

C1

Acyclovir

Acyclovir (Oral Suspension)

3

C1

Acyclovir

Acyclovir (Oral Tablet) 1

C1

Acyclovir Sodium Acyclovir Sodium

(Intravenous Solution)4 B/D, PA

C1

Denavir

Denavir (External

Cream)5 QL

C1

Famciclovir

Famciclovir (Oral Tablet)

3 QL C1

Trifluridine

Trifluridine (Ophthalmic Solution)

3

C1

Valacyclovir HCl Valacyclovir HCl (Oral

Tablet)3 QL

B1

Anti-HIV Agents, Integrase Inhibitors (INSTI)C1

Dovato

Dovato (Oral Tablet) 5 QL C1

Genvoya

Genvoya (Oral Tablet) 5 QL

30575858



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Isentress HD

Isentress HD (Oral

Tablet)5 QL

C1

Isentress

Isentress (Oral

Packet)4 QL

C1

Isentress

Isentress (Oral

Tablet)5 QL

C1

Isentress

Isentress (100MG

Oral Tablet

Chewable)

5 QL

C1

Isentress

Isentress (25MG Oral

Tablet Chewable)3 QL

C1

Stribild

Stribild (Oral Tablet) 5 QL C1

Tivicay

Tivicay (10MG Oral

Tablet)4 QL

C1

Tivicay

Tivicay (25MG Oral

Tablet, 50MG Oral

Tablet)

5 QL

C1

Triumeq

Triumeq (Oral Tablet) 5 QL C1

Tybost

Tybost (Oral Tablet) 4 QL B1

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)

C1

Atripla

Atripla (Oral Tablet) 5 QL C1

Complera

Complera (Oral

Tablet)5 QL

C1

Delstrigo

Delstrigo (Oral

Tablet)5 QL

C1

Edurant

Edurant (Oral Tablet) 5 QL C1

Efavirenz

Efavirenz (Oral Capsule)

4 QL C1

Efavirenz

Efavirenz (Oral Tablet) 5 QL C1

Intelence

Intelence (100MG

Oral Tablet, 200MG

Oral Tablet)

5 QL

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Intelence

Intelence (25MG Oral

Tablet)4 QL

C1

Juluca

Juluca (Oral Tablet) 5 QL C1

Nevirapine ER Nevirapine ER (Oral


4 QL

C1

Nevirapine

Nevirapine (Oral Suspension)

4 QL C1

Nevirapine

Nevirapine (Oral Tablet Immediate Release)

3 QL C1

Odefsey

Odefsey (Oral Tablet) 5 QL C1

Pifeltro

Pifeltro (Oral Tablet) 5 QL C1

Rescriptor

Rescriptor (Oral

Tablet)4 QL

C1

Symfi Lo

Symfi Lo (Oral Tablet) 5 QL C1

Symfi

Symfi (Oral Tablet) 5 QL B1

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)

C1

Abacavir Sulfate Abacavir Sulfate (Oral

Solution)4 QL

C1

Abacavir Sulfate Abacavir Sulfate (Oral

Tablet)4 QL

C1

Abacavir Sulfate-Lamivudine Abacavir Sulfate-

Lamivudine (Oral Tablet)

4 QL

C1

Abacavir-Lamivudine-Zidovudine Abacavir-Lamivudine-

Zidovudine (Oral Tablet)

5 QL

C1

Biktarvy

Biktarvy (Oral Tablet) 5 QL C1

Cimduo

Cimduo (Oral Tablet) 5 QL C1

Descovy

Descovy (Oral Tablet) 5 QL C1

Didanosine

Didanosine (Oral Capsule Delayed Release)

3 QL

315859 59



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Emtriva

Emtriva (Oral

Capsule)4 QL

C1

Emtriva

Emtriva (Oral

Solution)4 QL

C1

Lamivudine

Lamivudine (10MG/ML Oral Solution)

3 QL C1

Lamivudine

Lamivudine (150MG Oral Tablet, 300MG Oral Tablet)

3 QL

C1

Lamivudine-Zidovudine Lamivudine-


4 QL

C1

Stavudine

Stavudine (Oral Capsule)

3 QL C1

Tenofovir Disoproxil Fumarate Tenofovir Disoproxil

Fumarate (Oral Tablet)4 QL

C1

Truvada

Truvada (Oral Tablet) 5 QL C1

Videx EC

Videx EC (125MG

Oral Capsule Delayed

Release)

4 QL

C1

Videx

Videx (4GM Oral

Solution

Reconstituted)

4 QL

C1

Viread

Viread (Oral Powder) 5 QL C1

Viread

Viread (150MG Oral

Tablet, 200MG Oral

Tablet, 250MG Oral

Tablet)

5 QL

C1

Zidovudine

Zidovudine (Oral Capsule)

3 QL C1

Zidovudine

Zidovudine (Oral Syrup)

3 QL C1

Zidovudine


3 QL B1

Anti-HIV Agents, Other

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Fuzeon

Fuzeon

(Subcutaneous

Solution

Reconstituted)

5 QL

C1

Selzentry

Selzentry (Oral

Solution)5 QL

C1

Selzentry

Selzentry (150MG

Oral Tablet, 300MG

Oral Tablet, 75MG

Oral Tablet)

5 QL

C1

Selzentry

Selzentry (25MG Oral

Tablet)3 QL

B1

Anti-HIV Agents, Protease InhibitorsC1

Aptivus

Aptivus (Oral

Capsule)5 QL

C1

Aptivus

Aptivus (Oral

Solution)5 QL

C1

Atazanavir Sulfate Atazanavir Sulfate

(Oral Capsule)5 QL

C1

Crixivan

Crixivan (Oral

Capsule)3 QL

C1

Evotaz

Evotaz (Oral Tablet) 5 QL C1

Fosamprenavir Calcium Fosamprenavir

Calcium (Oral Tablet)5 QL

C1

Invirase

Invirase (Oral Tablet) 5 QL C1

Kaletra

Kaletra (100-25MG

Oral Tablet)4 QL

C1

Kaletra

Kaletra (200-50MG

Oral Tablet)5 QL

C1

Lexiva

Lexiva (Oral

Suspension)4 QL

C1

Lopinavir-Ritonavir Lopinavir-Ritonavir

(Oral Solution)4 QL

C1

Norvir

Norvir (Oral Packet) 4 QL

32596060



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Norvir

Norvir (Oral Solution) 4 QL C1

Prezcobix

Prezcobix (Oral

Tablet)5 QL

C1

Prezista

Prezista (Oral

Suspension)5 QL

C1

Prezista

Prezista (150MG Oral

Tablet, 75MG Oral

Tablet)

4 QL

C1

Prezista

Prezista (600MG Oral

Tablet, 800MG Oral

Tablet)

5 QL

C1

Reyataz

Reyataz (Oral Packet) 5 QL C1

Ritonavir

Ritonavir (Oral Tablet) 3 QL C1

Symtuza

Symtuza (Oral Tablet) 5 QL C1

Viracept

Viracept (Oral Tablet) 5 QL B1

Anti-influenza AgentsC1

Oseltamivir Phosphate Oseltamivir Phosphate

(Oral Capsule)3 QL

C1

Oseltamivir Phosphate Oseltamivir Phosphate


3 QL

C1

Relenza Diskhaler Relenza Diskhaler

(Inhalation Aerosol

Powder Breath

Activated)

3 QL

C1

Rimantadine HCl Rimantadine HCl (Oral

Tablet)4

C1

Xofluza

Xofluza (Oral Tablet

Therapy Pack)3 QL

A1

AnxiolyticsB1

Anxiolytics, OtherC1

Buspirone HCl Buspirone HCl (Oral

Tablet)2

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Hydroxyzine HCl Hydroxyzine HCl (Oral

Syrup)3

C1

Hydroxyzine HCl Hydroxyzine HCl (Oral

Tablet)3

B1

BenzodiazepinesC1

Alprazolam

Alprazolam (Oral Tablet Immediate Release)

1 QL

C1

Chlordiazepoxide HCl Chlordiazepoxide HCl

(Oral Capsule)2

C1

Clonazepam

Clonazepam (0.5MG Oral Tablet, 1MG Oral Tablet, 2MG Oral Tablet)

2 QL

C1

Clonazepam ODT Clonazepam ODT

(0.125MG Oral Tablet Dispersible, 0.25MG Oral Tablet Dispersible, 0.5MG Oral Tablet Dispersible, 1MG Oral Tablet Dispersible, 2MG Oral Tablet Dispersible)

4 QL

C1

Clorazepate Dipotassium Clorazepate

Dipotassium (Oral Tablet)

3 QL

C1

Diazepam Intensol Diazepam Intensol

(5MG/ML Oral Concentrate)

2 QL

C1

Diazepam

Diazepam (5MG/5ML Oral Solution)

2

C1

Diazepam

Diazepam (10MG Oral Tablet, 2MG Oral Tablet, 5MG Oral Tablet)

2 QL

336061 61



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Lorazepam

Lorazepam (2MG/ML Oral Concentrate)

2 QL C1

Lorazepam

Lorazepam (0.5MG Oral Tablet, 1MG Oral Tablet, 2MG Oral Tablet)

1 QL

A1

Bipolar AgentsB1

Mood StabilizersC1

Divalproex Sodium ER Divalproex Sodium ER


2

C1

Divalproex Sodium Divalproex Sodium

(Oral Capsule Delayed Release Sprinkle)

2

C1

Divalproex Sodium Divalproex Sodium


2

C1

Lithium Carbonate ER Lithium Carbonate ER

(Oral Tablet Extended Release)

2

C1

Lithium Carbonate Lithium Carbonate

(Oral Capsule)2

C1

Lithium Carbonate Lithium Carbonate


2

C1

Lithium

Lithium (Oral

Solution)3

A1

Blood Glucose RegulatorsB1

Antidiabetic AgentsC1

Acarbose

Acarbose (Oral Tablet) 1 QL C1

Bydureon BCise Bydureon BCise

(Subcutaneous Auto-

Injector)

3 QL

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Bydureon

Bydureon

(Subcutaneous Pen-

Injector)

3 QL

C1

Byetta 10MCG Pen Byetta 10MCG Pen

(Subcutaneous

Solution Pen-Injector)

4 QL

C1

Byetta 5MCG Pen Byetta 5MCG Pen

(Subcutaneous


4 QL

C1

Cycloset

Cycloset (Oral Tablet) 4 PA; QL C1

Glimepiride

Glimepiride (Oral Tablet)

1 QL C1

Glipizide ER

Glipizide ER (Oral Tablet Extended Release 24 Hour)

1 QL

C1

Glipizide

Glipizide (Oral Tablet Immediate Release)

1 QL C1

Glipizide-Metformin HCl Glipizide-Metformin

HCl (Oral Tablet)1 QL

C1

Glyxambi

Glyxambi (Oral

Tablet)3 QL

C1

Invokamet

Invokamet (Oral

Tablet Immediate

Release)

3 QL

C1

Invokamet XR

Invokamet XR (Oral

Tablet Extended

Release 24 Hour)

3 QL

C1

Invokana

Invokana (Oral Tablet) 3 QL C1

Janumet

Janumet (Oral Tablet

Immediate Release)3 QL

C1

Janumet XR

Janumet XR (Oral

Tablet Extended

Release 24 Hour)

3 QL

C1

Januvia

Januvia (Oral Tablet) 3 QL

34616262



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Jardiance

Jardiance (Oral

Tablet)3 QL

C1

Jentadueto

Jentadueto (Oral

Tablet Immediate

Release)

3 QL

C1

Jentadueto XR

Jentadueto XR (Oral

Tablet Extended

Release 24 Hour)

3 QL

C1

Metformin HCl ER Metformin HCl ER

(Oral Tablet Extended Release 24 Hour) (Generic Glucophage XR)

1 QL

C1

Metformin HCl Metformin HCl (Oral


1 QL

C1

Miglitol

Miglitol (Oral Tablet) 4 QL C1

Nateglinide

Nateglinide (Oral Tablet)

1 QL C1

Ozempic

Ozempic

(Subcutaneous


3 QL

C1

Pioglitazone HCl Pioglitazone HCl (Oral

Tablet)1 QL

C1

Pioglitazone HCl-Glimepiride Pioglitazone HCl-

Glimepiride (Oral Tablet)

1 QL

C1

Pioglitazone HCl-Metformin HCl Pioglitazone HCl-

Metformin HCl (Oral Tablet)

1 QL

C1

Repaglinide

Repaglinide (Oral Tablet)

1 QL C1

Repaglinide-Metformin HCl Repaglinide-Metformin


Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Riomet

Riomet (Oral

Solution)4 QL

C1

Soliqua

Soliqua

(Subcutaneous


3 QL

C1

SymlinPen 120

SymlinPen 120

(Subcutaneous


5 PA

C1

SymlinPen 60

SymlinPen 60

(Subcutaneous


5 PA

C1

Synjardy

Synjardy (Oral Tablet

Immediate Release)3 QL

C1

Synjardy XR

Synjardy XR (Oral

Tablet Extended

Release 24 Hour)

3 QL

C1

Tradjenta

Tradjenta (Oral

Tablet)3 QL

C1

Trulicity

Trulicity

(Subcutaneous


3 QL

C1

Victoza

Victoza

(Subcutaneous


3 QL

B1

Glycemic AgentsC1

GlucaGen HypoKit GlucaGen HypoKit

(Injection Solution

Reconstituted)

4

C1

Glucagon Emergency Glucagon Emergency

(Injection Kit)3

C1

Proglycem

Proglycem (Oral

Suspension)5

B1

Insulins

356263 63



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Humalog Junior KwikPen Humalog Junior

KwikPen

(Subcutaneous


3

C1

Humalog KwikPen Humalog KwikPen

(Subcutaneous


3

C1

Humalog Mix 50/50 KwikPen Humalog Mix 50/50

KwikPen

(Subcutaneous

Suspension Pen-

Injector)

3

C1

Humalog Mix 50/50 Humalog Mix 50/50

(Subcutaneous

Suspension)

3

C1

Humalog Mix 75/25 KwikPen Humalog Mix 75/25

KwikPen

(Subcutaneous

Suspension Pen-

Injector)

3

C1

Humalog Mix 75/25 Humalog Mix 75/25

(Subcutaneous

Suspension)

3

C1

Humalog

Humalog

(Subcutaneous

Solution)

3

C1

Humalog

Humalog

(Subcutaneous

Solution Cartridge)

3

C1

Humulin 70/30 KwikPen Humulin 70/30

KwikPen

(Subcutaneous

Suspension Pen-

Injector)

3

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Humulin 70/30 Humulin 70/30

(Subcutaneous

Suspension)

3

C1

Humulin N KwikPen Humulin N KwikPen

(Subcutaneous

Suspension Pen-

Injector)

3

C1

Humulin N

Humulin N

(Subcutaneous

Suspension)

3

C1

Humulin R

Humulin R (Injection

Solution)3

C1

Humulin R U-500 Humulin R U-500

(Concentrated)

(Subcutaneous

Solution)

3

C1

Humulin R U-500 KwikPen Humulin R U-500

KwikPen

(Subcutaneous


3

C1

Insulin Lispro Insulin Lispro

(Subcutaneous Solution)

3

C1

Insulin Lispro Insulin Lispro

(Subcutaneous Solution Pen-Injector)

3

C1

Lantus SoloStar

Lantus SoloStar

(Subcutaneous


3

C1

Lantus

Lantus

(Subcutaneous

Solution)

3

C1

Levemir FlexTouch Levemir FlexTouch

(Subcutaneous


3

36636464



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Levemir

Levemir

(Subcutaneous

Solution)

3

C1

Toujeo Max SoloStar Toujeo Max SoloStar

(Subcutaneous


3

C1

Toujeo SoloStar

Toujeo SoloStar

(Subcutaneous


3

C1

Tresiba FlexTouch Tresiba FlexTouch

(Subcutaneous


3

C1

Tresiba

Tresiba

(Subcutaneous

Solution)

3

A1

Blood Products/Modifiers/Volume ExpandersB1

AnticoagulantsC1

Coumadin

Coumadin (Oral

Tablet)4

C1

Eliquis

Eliquis (Oral Tablet) 3 QL C1

Eliquis Starter Pack Eliquis Starter Pack

(Oral Tablet)3 QL

C1

Enoxaparin Sodium Enoxaparin Sodium

(Subcutaneous Solution)

4 QL

C1

Fondaparinux Sodium Fondaparinux Sodium

(10MG/0.8ML Subcutaneous Solution, 5MG/0.4ML Subcutaneous Solution, 7.5MG/0.6ML Subcutaneous Solution)

5

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Fondaparinux Sodium Fondaparinux Sodium

(2.5MG/0.5ML Subcutaneous Solution)

4

C1

Heparin Sodium Heparin Sodium

(10000UNIT/ML Injection Solution, 20000UNIT/ML Injection Solution, 5000UNIT/ML Injection Solution)

3

C1

Heparin Sodium Heparin Sodium

(1000UNIT/ML Injection Solution)

3 B/D, PA

C1

Jantoven

Jantoven (Oral Tablet) 1

C1

Warfarin Sodium Warfarin Sodium (Oral

Tablet)1

C1

Xarelto

Xarelto (Oral Tablet) 3 QL C1

Xarelto Starter Pack Xarelto Starter Pack

(Oral Tablet Therapy

Pack)

3 QL

B1

Blood Formation ModifiersC1

Anagrelide HCl Anagrelide HCl (Oral

Capsule)3

C1

Aranesp

Aranesp (Albumin

Free) (100MCG/ML

Injection Solution,

200MCG/ML

Injection Solution,

300MCG/ML

Injection Solution,

60MCG/ML Injection

Solution)

5 PA

376465 65



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Aranesp

Aranesp (Albumin

Free) (25MCG/ML

Injection Solution,

40MCG/ML Injection

Solution)

4 PA

C1

Aranesp

Aranesp (Albumin

Free) (100MCG/

0.5ML Injection

Solution Prefilled

Syringe, 150MCG/

0.3ML Injection

Solution Prefilled

Syringe, 200MCG/

0.4ML Injection

Solution Prefilled

Syringe, 300MCG/

0.6ML Injection

Solution Prefilled

Syringe, 500MCG/ML

Injection Solution

Prefilled Syringe,

60MCG/0.3ML

Injection Solution

Prefilled Syringe)

5 PA

C1

Aranesp

Aranesp (Albumin

Free) (10MCG/0.4ML

Injection Solution

Prefilled Syringe,

25MCG/0.42ML

Injection Solution

Prefilled Syringe,

40MCG/0.4ML

Injection Solution

Prefilled Syringe)

4 PA

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Granix

Granix

(Subcutaneous

Solution)

5 ST

C1

Granix

Granix

(Subcutaneous

Solution Prefilled

Syringe)

5 ST

C1

Leukine

Leukine (Injection

Solution

Reconstituted)

5 PA

C1

Neulasta

Neulasta

(Subcutaneous

Solution Prefilled

Syringe)

5 PA

C1

Neupogen

Neupogen (Injection

Solution)5 ST

C1

Neupogen

Neupogen (Injection

Solution Prefilled

Syringe)

5 ST

C1

Procrit

Procrit (10000UNIT/

ML Injection Solution,

2000UNIT/ML

Injection Solution,

3000UNIT/ML

Injection Solution,

4000UNIT/ML

Injection Solution)

4 PA

C1

Procrit

Procrit (20000UNIT/


40000UNIT/ML

Injection Solution)

5 PA

C1

Promacta

Promacta (Oral

Packet)5 PA; LA; QL

38656666



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Promacta

Promacta (Oral

Tablet)5 PA; LA; QL

C1

Retacrit

Retacrit (10000UNIT/


2000UNIT/ML

Injection Solution,

3000UNIT/ML

Injection Solution,

4000UNIT/ML

Injection Solution)

4 PA

C1

Retacrit

Retacrit (40000UNIT/

ML Injection Solution)5 PA

C1

Udenyca

Udenyca

(Subcutaneous

Solution Prefilled

Syringe)

5 PA

C1

Zarxio

Zarxio (Injection

Solution Prefilled

Syringe)

5

B1

Hemostasis AgentsC1

Tranexamic Acid Tranexamic Acid (Oral

Tablet)3

B1

Platelet Modifying AgentsC1

Aspirin-Dipyridamole ER Aspirin-Dipyridamole

ER (Oral Capsule Extended Release 12 Hour)

3 QL

C1

Brilinta

Brilinta (Oral Tablet) 3 QL C1

Cablivi

Cablivi (Injection Kit) 5 PA; QL C1

Cilostazol

Cilostazol (Oral Tablet) 2

C1

Clopidogrel Bisulfate Clopidogrel Bisulfate

(75MG Oral Tablet)2 QL

C1

Prasugrel HCl Prasugrel HCl (Oral

Tablet)3 QL

Drug NameDrug

Tier

Coverage

Rules or

Limits on

use

A1

Cardiovascular AgentsB1

Alpha-adrenergic AgonistsC1

Clonidine HCl Clonidine HCl (Oral


1

C1

Clonidine

Clonidine (Transdermal Patch Weekly)

4

C1

Methyldopa

Methyldopa (Oral Tablet)

3

C1

Midodrine HCl Midodrine HCl (Oral

Tablet)3

C1

Northera

Northera (Oral


B1

Alpha-adrenergic Blocking AgentsC1

Doxazosin Mesylate Doxazosin Mesylate

(Oral Tablet)2

C1

Phenoxybenzamine HCl Phenoxybenzamine

HCl (Oral Capsule)5

C1

Prazosin HCl

Prazosin HCl (Oral Capsule)

2

B1

Angiotensin II Receptor AntagonistsC1

Candesartan Cilexetil Candesartan Cilexetil

(Oral Tablet)1 QL

C1

Edarbi

Edarbi (Oral Tablet) 4 QL C1

Eprosartan Mesylate Eprosartan Mesylate

(Oral Tablet)1 QL

C1

Irbesartan

Irbesartan (Oral Tablet) 1 QL C1

Losartan Potassium Losartan Potassium

(Oral Tablet)1 QL

C1

Olmesartan Medoxomil Olmesartan

Medoxomil (Oral Tablet)

1 QL

C1

Telmisartan

Telmisartan (Oral Tablet)

1 QL

396667 67



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Valsartan

Valsartan (Oral Tablet) 1 QL B1

Angiotensin-converting Enzyme (ACE) Inhibitors

C1

Benazepril HCl Benazepril HCl (Oral

Tablet)1 QL

C1

Captopril

Captopril (Oral Tablet) 1 QL C1

Enalapril Maleate Enalapril Maleate (Oral

Tablet)1 QL

C1

Fosinopril Sodium Fosinopril Sodium

(Oral Tablet)1 QL

C1

Lisinopril

Lisinopril (Oral Tablet) 1 QL C1

Moexipril HCl

Moexipril HCl (Oral Tablet)

1 QL C1

Perindopril Erbumine Perindopril Erbumine

(Oral Tablet)1 QL

C1

Quinapril HCl

Quinapril HCl (Oral Tablet)

1 QL C1

Ramipril

Ramipril (Oral Capsule)

1 QL C1

Trandolapril

Trandolapril (Oral Tablet)

1 QL B1

AntiarrhythmicsC1

Amiodarone HCl Amiodarone HCl


C1

Dofetilide

Dofetilide (Oral Capsule)

4

C1

Flecainide Acetate Flecainide Acetate

(Oral Tablet)2

C1

Mexiletine HCl Mexiletine HCl (Oral

Capsule)3

C1

Multaq

Multaq (Oral Tablet) 3 QL C1

Pacerone

Pacerone (200MG Oral Tablet)

1

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Propafenone HCl ER Propafenone HCl ER


4

C1

Propafenone HCl Propafenone HCl (Oral

Tablet)2

C1

Quinidine Gluconate ER Quinidine Gluconate

ER (Oral Tablet Extended Release)

4

C1

Quinidine Sulfate Quinidine Sulfate (Oral

Tablet)2

C1

Sotalol HCl

Sotalol HCl (AF) (120MG Oral Tablet)

2

C1

Sotalol HCl

Sotalol HCl (Oral Tablet)

2

B1

Beta-adrenergic Blocking AgentsC1

Acebutolol HCl Acebutolol HCl (Oral

Capsule)2

C1

Atenolol

Atenolol (Oral Tablet) 1

C1

Betaxolol HCl Betaxolol HCl (Oral

Tablet)3

C1

Bisoprolol Fumarate Bisoprolol Fumarate

(Oral Tablet)2

C1

Bystolic

Bystolic (Oral Tablet) 3 QL C1

Carvedilol

Carvedilol (Oral Tablet) 1

C1

Labetalol HCl Labetalol HCl (Oral

Tablet)2

C1

Metoprolol Succinate ER Metoprolol Succinate


1

C1

Metoprolol Tartrate Metoprolol Tartrate


1

40676868



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Nadolol

Nadolol (Oral Tablet) 4

C1

Pindolol

Pindolol (Oral Tablet) 3

C1

Propranolol HCl ER Propranolol HCl ER


2

C1

Propranolol HCl Propranolol HCl (Oral

Solution)2

C1

Propranolol HCl Propranolol HCl (Oral

Tablet)2

B1

Calcium Channel Blocking AgentsC1

Amlodipine Besylate Amlodipine Besylate

(Oral Tablet)1

C1

Cartia XT

Cartia XT (Oral Capsule Extended Release 24 Hour)

2

C1

Diltiazem HCl ER Beads Diltiazem HCl ER

Beads (360MG Oral Capsule Extended Release 24 Hour, 420MG Oral Capsule Extended Release 24 Hour)

2

C1

Diltiazem HCl ER Coated Beads Diltiazem HCl ER

Coated Beads (120MG Oral Capsule Extended Release 24 Hour, 180MG Oral Capsule Extended Release 24 Hour, 240MG Oral Capsule Extended Release 24 Hour, 300MG Oral Capsule Extended Release 24 Hour)

2

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Diltiazem HCl ER Diltiazem HCl ER (Oral

Capsule Extended Release 12 Hour)

2

C1

Diltiazem HCl Diltiazem HCl (Oral


2

C1

Dilt-XR

Dilt-XR (Oral Capsule Extended Release 24 Hour)

2

C1

Felodipine ER Felodipine ER (Oral


2

C1

Matzim LA

Matzim LA (Oral Tablet Extended Release 24 Hour)

2

C1

Nicardipine HCl Nicardipine HCl (Oral

Capsule)3

C1

Nifedipine ER Nifedipine ER (Oral


2 QL

C1

Nifedipine ER Osmotic Release Nifedipine ER Osmotic

Release (Oral Tablet Extended Release 24 Hour)

2 QL

C1

Nimodipine

Nimodipine (Oral Capsule)

4

C1

Nymalize

Nymalize (60MG/

20ML Oral Solution)5

C1

Taztia XT

Taztia XT (Oral Capsule Extended Release 24 Hour)

2

416869 69



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Verapamil HCl ER Verapamil HCl ER

(100MG Oral Capsule Extended Release 24 Hour, 120MG Oral Capsule Extended Release 24 Hour, 180MG Oral Capsule Extended Release 24 Hour, 200MG Oral Capsule Extended Release 24 Hour, 240MG Oral Capsule Extended Release 24 Hour, 300MG Oral Capsule Extended Release 24 Hour)

3

C1


(360MG Oral Capsule

Extended Release 24

Hour)

3

C1



2

C1

Verapamil HCl Verapamil HCl (Oral


2

B1

Cardiovascular Agents, OtherC1

Aliskiren Fumarate Aliskiren Fumarate

(Oral Tablet)4 QL

C1

Amiloride-Hydrochlorothiazide Amiloride-

Hydrochlorothiazide (Oral Tablet)

2

C1

Amlodipine-Atorvastatin Amlodipine-

Atorvastatin (Oral Tablet)

2 QL

C1

Amlodipine-Benazepril Amlodipine-Benazepril

(Oral Capsule)1 QL

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Amlodipine-Olmesartan Amlodipine-

Olmesartan (Oral Tablet)

2 QL

C1

Amlodipine-Valsartan Amlodipine-Valsartan

(Oral Tablet)2 QL

C1

Amlodipine-Valsartan-HCTZ Amlodipine-Valsartan-

HCTZ (Oral Tablet)2 QL

C1

Atenolol-Chlorthalidone Atenolol-

Chlorthalidone (Oral Tablet)

1

C1

Benazepril-Hydrochlorothiazide Benazepril-


1 QL

C1

BiDil

BiDil (Oral Tablet) 3 QL C1

Bisoprolol-Hydrochlorothiazide Bisoprolol-


2 QL

C1

Candesartan Cilexetil-HCTZ Candesartan Cilexetil-


C1

Captopril-Hydrochlorothiazide Captopril-


1 QL

C1

Corlanor

Corlanor (Oral Tablet) 4 PA; QL C1

Demser

Demser (Oral

Capsule)5

C1

Digitek

Digitek (Oral Tablet) 2

C1

Digox

Digox (Oral Tablet) 2

C1

Digoxin

Digoxin (Oral

Solution)3

C1

Digoxin

Digoxin (Oral Tablet) 2

C1

Edarbyclor

Edarbyclor (Oral

Tablet)4 QL

C1

Enalapril-Hydrochlorothiazide Enalapril-


1 QL

42697070



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Entresto

Entresto (Oral Tablet) 3 QL C1

Fosinopril Sodium-HCTZ Fosinopril Sodium-


C1

Irbesartan-Hydrochlorothiazide Irbesartan-


1 QL

C1

Lanoxin

Lanoxin (Oral Tablet) 4

C1

Lisinopril-Hydrochlorothiazide Lisinopril-


1 QL

C1

Losartan Potassium-HCTZ Losartan Potassium-


C1

Methyldopa-Hydrochlorothiazide Methyldopa-


3

C1

Metoprolol-Hydrochlorothiazide Metoprolol-


2

C1

Nadolol-Bendroflumethiazide Nadolol-

Bendroflumethiazide (40-5MG Oral Tablet)

3

C1

Olmesartan Medoxomil-HCTZ Olmesartan

Medoxomil-HCTZ (Oral Tablet)

1 QL

C1

Olmesartan-Amlodipine-HCTZ Olmesartan-

Amlodipine-HCTZ (Oral Tablet)

2 QL

C1

Pentoxifylline ER Pentoxifylline ER (Oral

Tablet Extended Release)

2

C1

Propranolol-HCTZ Propranolol-HCTZ

(Oral Tablet)2

C1

Quinapril-Hydrochlorothiazide Quinapril-


1 QL

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Ranolazine ER Ranolazine ER (Oral


3 QL

C1

Spironolactone-HCTZ Spironolactone-HCTZ

(Oral Tablet)2

C1

Telmisartan-Amlodipine Telmisartan-

Amlodipine (Oral Tablet)

1 QL

C1

Telmisartan-HCTZ Telmisartan-HCTZ

(Oral Tablet)1 QL

C1

Triamterene-HCTZ Triamterene-HCTZ

(Oral Capsule)2

C1

Triamterene-HCTZ Triamterene-HCTZ

(Oral Tablet)2

C1

Valsartan-Hydrochlorothiazide Valsartan-


1 QL

B1

Diuretics, Carbonic Anhydrase InhibitorsC1

Acetazolamide ER Acetazolamide ER


4

C1

Acetazolamide Acetazolamide (Oral

Tablet)3

C1

Methazolamide Methazolamide (Oral

Tablet)4

B1

Diuretics, LoopC1

Bumetanide

Bumetanide (Injection Solution)

4

C1

Bumetanide

Bumetanide (Oral Tablet)

1

C1

Ethacrynic Acid Ethacrynic Acid (Oral

Tablet)4

C1

Furosemide

Furosemide (Injection Solution)

4 B/D, PA

437071 71



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Furosemide

Furosemide (Oral Solution)

2

C1

Furosemide

Furosemide (Oral Tablet)

1

C1

Torsemide

Torsemide (Oral Tablet)

2

B1

Diuretics, Potassium-sparingC1

Amiloride HCl Amiloride HCl (Oral

Tablet)2

C1

Dyrenium

Dyrenium (Oral

Capsule)4

C1

Eplerenone

Eplerenone (Oral Tablet)

3

C1

Spironolactone Spironolactone (Oral

Tablet)2

B1

Diuretics, ThiazideC1

Chlorothiazide Chlorothiazide (Oral

Tablet)2

C1

Chlorthalidone Chlorthalidone (Oral

Tablet)2

C1

Diuril

Diuril (Oral

Suspension)4

C1

Hydrochlorothiazide Hydrochlorothiazide

(Oral Capsule)1

C1

Hydrochlorothiazide Hydrochlorothiazide

(Oral Tablet)1

C1

Indapamide

Indapamide (Oral Tablet)

2

C1

Methyclothiazide Methyclothiazide (5MG

Oral Tablet)3

C1

Metolazone

Metolazone (Oral Tablet)

3

B1

Dyslipidemics, Fibric Acid Derivatives

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Fenofibrate Micronized Fenofibrate Micronized

(134MG Oral Capsule, 200MG Oral Capsule, 67MG Oral Capsule)

2

C1

Fenofibrate

Fenofibrate (145MG Oral Tablet, 48MG Oral Tablet)

2

C1

Fenofibrate

Fenofibrate (160MG Oral Tablet, 54MG Oral Tablet)

1

C1

Fenofibric Acid Fenofibric Acid (Oral

Capsule Delayed Release)

3

C1

Fenofibric Acid

Fenofibric Acid


C1

Fenofibric Acid Fenofibric Acid (35MG

Oral Tablet)3

C1

Gemfibrozil

Gemfibrozil (Oral Tablet)

2

B1

Dyslipidemics, HMG CoA Reductase Inhibitors

C1

Atorvastatin Calcium Atorvastatin Calcium

(Oral Tablet)1 QL

C1

Fluvastatin Sodium Fluvastatin Sodium

(Oral Capsule)2 QL

C1

Livalo

Livalo (Oral Tablet) 3 QL C1

Lovastatin

Lovastatin (Oral Tablet)

1 QL C1

Pravastatin Sodium Pravastatin Sodium

(Oral Tablet)1 QL

C1

Rosuvastatin Calcium Rosuvastatin Calcium

(Oral Tablet)1 QL

C1

Simvastatin

Simvastatin (Oral Tablet)

1 QL B1

Dyslipidemics, Other

44717272



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Cholestyramine Light Cholestyramine Light

(Oral Powder)4

C1

Cholestyramine Cholestyramine (Oral

Packet)4

C1

Colesevelam HCl Colesevelam HCl (Oral

Packet)3

C1

Colesevelam HCl Colesevelam HCl (Oral

Tablet)3

C1

Colestipol HCl Colestipol HCl (Oral

Packet)4

C1

Colestipol HCl Colestipol HCl (Oral

Tablet)3

C1

Ezetimibe

Ezetimibe (Oral Tablet) 2 QL C1

Ezetimibe-Simvastatin Ezetimibe-Simvastatin

(Oral Tablet)3 QL

C1

Juxtapid

Juxtapid (Oral

Capsule)5 PA; LA

C1

Niacin ER

Niacin ER (Antihyperlipidemic) (Oral Tablet Extended Release)

4

C1

Niacor

Niacor (Oral Tablet) 2

C1

Omega-3-Acid Ethyl Esters Omega-3-Acid Ethyl

Esters (Oral Capsule) (Generic Lovaza)

4 QL

C1

Praluent

Praluent

(Subcutaneous


4 PA; LA; QL

C1

Prevalite

Prevalite (Oral Packet) 4

C1

Repatha Pushtronex System Repatha Pushtronex

System

(Subcutaneous

Solution Cartridge)

4 PA; QL

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Repatha

Repatha

(Subcutaneous

Solution Prefilled

Syringe)

4 PA; QL

C1

Repatha SureClick Repatha SureClick

(Subcutaneous

Solution Auto-

Injector)

4 PA; QL

C1

Vascepa

Vascepa (Oral

Capsule)4

B1

Vasodilators, Direct-acting ArterialC1

Hydralazine HCl Hydralazine HCl (Oral

Tablet)2

C1

Minoxidil

Minoxidil (Oral Tablet) 2

B1

Vasodilators, Direct-acting Arterial/VenousC1

Isosorbide Dinitrate ER Isosorbide Dinitrate ER


2

C1

Isosorbide Dinitrate Isosorbide Dinitrate


2

C1

Isosorbide Mononitrate ER Isosorbide

Mononitrate ER (Oral Tablet Extended Release 24 Hour)

2

C1

Isosorbide Mononitrate Isosorbide

Mononitrate (Oral Tablet Immediate Release)

2

C1

Minitran

Minitran (Transdermal Patch 24 Hour)

2

C1

Nitro-Bid

Nitro-Bid (Transdermal Ointment)

4

C1

Nitroglycerin Nitroglycerin (Tablet

Sublingual)2

457273 73



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Nitroglycerin Nitroglycerin


2

C1

Nitroglycerin Nitroglycerin

(Translingual Solution)3

C1

Nitrostat

Nitrostat (Tablet

Sublingual)3

C1

Rectiv

Rectiv (Rectal

Ointment)4

A1

Central Nervous System AgentsB1

Attention Deficit Hyperactivity Disorder Agents, Amphetamines

C1

Amphetamine-Dextroamphetamine ER

Amphetamine-Dextroamphetamine ER (Oral Capsule Extended Release 24 Hour)

4 QL

C1

Amphetamine-Dextroamphetamine

Amphetamine-Dextroamphetamine (Oral Tablet)

3 QL

C1

Dextroamphetamine Sulfate ER Dextroamphetamine

Sulfate ER (Oral Capsule Extended Release 24 Hour)

4 QL

C1

Dextroamphetamine Sulfate Dextroamphetamine

Sulfate (Oral Tablet)4 QL

C1

Vyvanse

Vyvanse (Oral

Capsule)4

C1

Vyvanse

Vyvanse (Oral Tablet

Chewable)4

B1

Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines

C1

Atomoxetine HCl Atomoxetine HCl (Oral

Capsule)4 QL

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Clonidine HCl ER Clonidine HCl ER (Oral


4 PA

C1

Dexmethylphenidate HCl ER Dexmethylphenidate

HCl ER (Oral Capsule Extended Release 24 Hour)

4

C1

Dexmethylphenidate HCl Dexmethylphenidate


C1

Guanfacine HCl ER Guanfacine HCl ER


4

C1

Metadate ER Metadate ER (Oral

Tablet Extended Release)

4 QL

C1

Methylphenidate HCl ER Methylphenidate HCl

ER (10MG Oral Tablet Extended Release, 20MG Oral Tablet Extended Release)

4 QL

C1

Methylphenidate HCl Methylphenidate HCl

(Oral Solution)4 QL

C1

Methylphenidate HCl Methylphenidate HCl

(Oral Tablet Immediate Release) (Generic Ritalin)

3 QL

B1

Central Nervous System, OtherC1

Austedo

Austedo (Oral Tablet) 5 PA; LA; QL C1

Ingrezza

Ingrezza (Oral

Capsule)5 PA; QL

C1

Ingrezza

Ingrezza (Oral

Capsule Therapy

Pack)

5 PA; QL

C1

Namzaric

Namzaric (Oral

Capsule ER 24 Hour

Therapy Pack)

3 PA; QL

46737474



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Namzaric

Namzaric (Oral

Capsule Extended

Release 24 Hour)

3 PA; QL

C1

Nuedexta

Nuedexta (Oral

Capsule)4 PA

C1

Riluzole

Riluzole (Oral Tablet) 3

C1

Tetrabenazine Tetrabenazine (Oral

Tablet)5 PA; LA; QL

B1

Fibromyalgia AgentsC1

Duloxetine HCl Duloxetine HCl (20MG

Oral Capsule Delayed Release Particles, 30MG Oral Capsule Delayed Release Particles, 60MG Oral Capsule Delayed Release Particles)

2 QL

C1

Lyrica

Lyrica (Oral Capsule) 3 QL C1

Lyrica

Lyrica (Oral Solution) 3 QL C1

Savella

Savella (Oral Tablet) 3

C1

Savella Titration Pack Savella Titration Pack

(Oral Tablet)3

B1

Multiple Sclerosis AgentsC1

Ampyra

Ampyra (Oral Tablet

Extended Release 12

Hour)

5 QL

C1

Aubagio

Aubagio (Oral Tablet) 5 LA; QL C1

Avonex

Avonex (30MCG

Intramuscular Kit)5 QL

C1

Avonex Pen

Avonex Pen

(Intramuscular Auto-

Injector Kit)

5 QL

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Avonex Prefilled

Avonex Prefilled

(Intramuscular

Prefilled Syringe Kit)

5 QL

C1

Betaseron

Betaseron

(Subcutaneous Kit)5 QL

C1

Dalfampridine ER Dalfampridine ER (Oral


5 QL

C1

Gilenya

Gilenya (0.5MG Oral

Capsule)5 QL

C1

Glatiramer Acetate Glatiramer Acetate

(Subcutaneous Solution Prefilled Syringe)

5 QL

C1

Glatopa

Glatopa (Subcutaneous Solution Prefilled Syringe)

5 QL

C1

Mayzent

Mayzent (Oral Tablet) 5 QL C1

Rebif Rebidose Rebif Rebidose

(Subcutaneous

Solution Auto-

Injector)

5 QL

C1

Rebif Rebidose Titration Pack Rebif Rebidose

Titration Pack

(Subcutaneous

Solution Auto-

Injector)

5 QL

C1

Rebif

Rebif (Subcutaneous

Solution Prefilled

Syringe)

5 QL

C1

Rebif Titration Pack Rebif Titration Pack

(Subcutaneous

Solution Prefilled

Syringe)

5 QL

477475 75



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Tecfidera Starter Pack Tecfidera Starter

Pack (Oral)5 LA

C1

Tecfidera

Tecfidera (Oral

Capsule Delayed

Release)

5 LA; QL

A1

Dental and Oral AgentsB1

Dental and Oral AgentsC1

Chlorhexidine Gluconate Chlorhexidine

Gluconate (Mouth Solution)

2

C1

Pilocarpine HCl Pilocarpine HCl (Oral

Tablet)4

C1

Triamcinolone Acetonide Triamcinolone

Acetonide (Dental Paste)

3

A1

Dermatological AgentsB1

Dermatological AgentsC1

Acitretin

Acitretin (Oral Capsule)

4

C1

Adapalene

Adapalene (External Cream)

4

C1

Adapalene

Adapalene (0.1% External Gel)

3

C1

Ammonium Lactate Ammonium Lactate

(External Cream)3

C1

Ammonium Lactate Ammonium Lactate

(External Lotion)3

C1

Azelaic Acid

Azelaic Acid (External Gel)

4

C1

Benzoyl Peroxide-Erythromycin Benzoyl Peroxide-

Erythromycin (External Gel)

4

C1

Calcipotriene

Calcipotriene (External Cream)

4

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Calcipotriene

Calcipotriene (External Ointment)

4

C1

Calcipotriene

Calcipotriene (External Solution)

3

C1

Calcitriol

Calcitriol (External

Ointment)4

C1

Carac

Carac (External

Cream)5 PA

C1

Claravis

Claravis (10MG Oral Capsule, 20MG Oral Capsule, 40MG Oral Capsule)

4 PA

C1


Phosphate (External Gel)

3

C1


Phosphate (External Lotion)

3

C1


Phosphate (External Solution)

3

C1


Phosphate (External Swab)

3

C1

Clindamycin Phosphate-Benzoyl Peroxide

Clindamycin Phosphate-Benzoyl Peroxide (1-5% External Gel)

4

C1

Clotrimazole-Betamethasone Clotrimazole-

Betamethasone (External Cream)

3

C1

Clotrimazole-Betamethasone Clotrimazole-

Betamethasone (External Lotion)

4

C1

Cortisporin

Cortisporin (External

Cream)4

48757676



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Cortisporin

Cortisporin (External

Ointment)4

C1

Cosentyx

Cosentyx (300 MG

Dose) (Subcutaneous

Solution Prefilled

Syringe)

5 PA; LA

C1

Cosentyx Sensoready Cosentyx Sensoready

(300 MG)

(Subcutaneous

Solution Auto-

Injector)

5 PA; LA

C1


(3% Transdermal Gel)4 PA

C1

Doxepin HCl

Doxepin HCl (External Cream)

5 PA; QL C1

Ery

Ery (External Pad) 3

C1

Erythromycin Erythromycin (External

Gel)4

C1

Erythromycin Erythromycin (External

Solution)2

C1

Finacea

Finacea (External

Foam)4

C1

Fluorouracil

Fluorouracil (0.5% External Cream)

5

C1

Fluorouracil

Fluorouracil (5% External Cream)

4

C1

Fluorouracil

Fluorouracil (External Solution)

3

C1

Imiquimod

Imiquimod (5% External Cream)

4

C1

Imiquimod Pump Imiquimod Pump

(3.75% External Cream)

5 PA

C1

Isotretinoin

Isotretinoin (Oral Capsule)

4 PA

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Methoxsalen Rapid Methoxsalen Rapid

(Oral Capsule)5

C1

Mirvaso

Mirvaso (External Gel) 4

C1

Oxsoralen Ultra

Oxsoralen Ultra (Oral

Capsule)5

C1

Picato

Picato (External Gel) 3

C1

Pimecrolimus Pimecrolimus (External

Cream)4 ST

C1

Podofilox

Podofilox (External Solution)

3

C1

Regranex

Regranex (External

Gel)5 PA

C1

Santyl

Santyl (External

Ointment)4

C1

Selenium Sulfide Selenium Sulfide

(External Lotion)2

C1

Stelara

Stelara

(Subcutaneous

Solution)

5 PA

C1

Stelara

Stelara

(Subcutaneous

Solution Prefilled

Syringe)

5 PA

C1

Tacrolimus

Tacrolimus (External Ointment)

4 ST C1

Tazarotene

Tazarotene (External Cream)

4 PA C1

Tazorac

Tazorac (0.05%

External Cream)4 PA

C1

Tazorac

Tazorac (0.05%

External Gel)5 PA

C1

Tazorac

Tazorac (0.1%

External Gel)4 PA

497677 77



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Tolak

Tolak (External

Cream)4

C1

Tretinoin

Tretinoin (External Cream)

4 PA C1

Tretinoin

Tretinoin (0.01% External Gel, 0.025% External Gel)

4 PA

C1

Tretinoin Microsphere Tretinoin Microsphere

(External Gel)4 PA

C1

Zyclara Pump

Zyclara Pump

(External Cream)5 PA

A1

Electrolytes/Minerals/Metals/VitaminsB1

Electrolyte/Mineral ReplacementC1

Aminosyn II

Aminosyn II


C1

Aminosyn-PF

Aminosyn-PF


C1

Carbaglu

Carbaglu (Oral

Tablet)5 LA

C1

Dextrose

Dextrose (10%

Intravenous Solution)4

C1

Dextrose

Dextrose (5% Intravenous Solution)

4 B/D, PA C1

Dextrose-NaCl Dextrose-NaCl

(10-0.2% Intravenous

Solution, 10-0.45%

Intravenous Solution,

2.5-0.45%


5-0.2% Intravenous

Solution, 5-0.225%


5-0.33% Intravenous

Solution, 5-0.45%

Intravenous Solution)

4

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Dextrose-NaCl Dextrose-NaCl

(5-0.9% Intravenous

Solution)

4 B/D, PA

C1

FreAmine HBC

FreAmine HBC


C1

HepatAmine

HepatAmine


C1

Intralipid

Intralipid (Intravenous

Emulsion)4 B/D, PA

C1

Ionosol-MB in D5W Ionosol-MB in D5W


C1

Isolyte-P in D5W Isolyte-P in D5W


C1

Isolyte-S

Isolyte-S (Intravenous

Solution)4

C1

KCl in Dextrose-NaCl KCl in Dextrose-NaCl

(Injection)4

C1

KCl-Lactated Ringers-D5W KCl-Lactated Ringers-

D5W (Intravenous

Solution)

4

C1

Klor-Con 10

Klor-Con 10 (Oral

Tablet Extended

Release)

3

C1

Klor-Con M10

Klor-Con M10 (Oral Tablet Extended Release)

2

C1

Klor-Con M15


2

C1

Klor-Con M20


2

C1

Klor-Con

Klor-Con (Oral Packet) 3

50777878



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Klor-Con 8

Klor-Con 8 (Oral

Tablet Extended

Release)

3

C1

Klor-Con Sprinkle Klor-Con Sprinkle

(8MEQ Oral Capsule Extended Release)

3

C1

Levocarnitine Levocarnitine (1GM/

10ML Oral Solution)3

C1

Levocarnitine

Levocarnitine


C1

Magnesium Sulfate Magnesium Sulfate

(50% Injection

Solution)

4

C1

Magnesium Sulfate Magnesium Sulfate

(50% (10ML Syringe) Injection Solution)

4

C1

NephrAmine

NephrAmine


C1

Normosol-M in D5W Normosol-M in D5W


C1

Normosol-R in D5W Normosol-R in D5W


C1

Normosol-R pH 7.4 Normosol-R pH 7.4


C1

Nutrilipid

Nutrilipid

(Intravenous

Emulsion)

4 B/D, PA

C1

Plasma-Lyte 148

Plasma-Lyte 148


C1

Plasma-Lyte A

Plasma-Lyte A


C1

Plenamine

Plenamine (Intravenous Solution)

4 B/D, PA

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Potassium Chloride CR Potassium Chloride

CR (Oral Tablet Extended Release)

2

C1

Potassium Chloride ER Potassium Chloride ER

(Oral Capsule Extended Release)

2

C1

Potassium Chloride in Dextrose Potassium Chloride in

Dextrose (Intravenous

Solution)

4 B/D, PA

C1

Potassium Chloride in NaCl Potassium Chloride in

NaCl (20-0.45MEQ/L-% Intravenous Solution)

4 B/D, PA

C1

Potassium Chloride in NaCl Potassium Chloride in

NaCl (20-0.9MEQ/L-%


40-0.9MEQ/L-%


4 B/D, PA

C1

Potassium Chloride Potassium Chloride

(10MEQ/100ML


20MEQ/100ML


40MEQ/100ML


4 B/D, PA

C1


(2MEQ/ML Intravenous Solution, 2MEQ/ML (20ML) Intravenous Solution)

4 B/D, PA

C1


(Oral Packet)3

C1


(Oral Solution)3

517879 79



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Potassium Citrate ER Potassium Citrate ER


3

C1

Premasol

Premasol (Intravenous Solution)

4 B/D, PA C1

Procalamine

Procalamine


C1

Prosol

Prosol (Intravenous

Solution)4 B/D, PA

C1

Sodium Chloride

Sodium Chloride

(0.45% Intravenous

Solution)

4

C1

Sodium Chloride Sodium Chloride (0.9%

Intravenous Solution)4 B/D, PA

C1

Sodium Chloride

Sodium Chloride (3%


5% Intravenous

Solution)

4 B/D, PA

C1

Sodium Chloride

Sodium Chloride

(Irrigation Solution)3

C1

Sodium Fluoride Sodium Fluoride (Oral

Tablet)2

C1

Sodium Lactate

Sodium Lactate


C1

TPN Electrolytes

TPN Electrolytes


C1

Travasol

Travasol (Intravenous

Solution)4 B/D, PA

C1

TrophAmine

TrophAmine (10%

Intravenous Solution)4 B/D, PA

B1

Electrolyte/Mineral/Metal ModifiersC1

Chemet

Chemet (Oral

Capsule)5

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Deferasirox

Deferasirox (Oral Tablet Soluble)

5 PA C1

Ferriprox

Ferriprox (Oral

Solution)5 PA

C1

Ferriprox

Ferriprox (Oral

Tablet)5 PA

C1

Jadenu

Jadenu (Oral Tablet) 5 PA C1

Jadenu Sprinkle

Jadenu Sprinkle (Oral

Packet)5 PA

C1

Kionex

Kionex (Oral Suspension)

3

C1

Lokelma

Lokelma (Oral

Packet)4 QL

C1

Sodium Polystyrene Sulfonate Sodium Polystyrene

Sulfonate (Oral Powder)

3

C1

Sodium Polystyrene Sulfonate Sodium Polystyrene

Sulfonate (Oral Suspension)

3

C1

SPS

SPS (Oral Suspension) 3

C1

Trientine HCl Trientine HCl (Oral

Capsule)5 PA; QL

C1

Veltassa

Veltassa (Oral Packet) 5 QL B1

Phosphate BindersC1

Auryxia

Auryxia (Oral Tablet) 5 PA C1

Calcium Acetate Calcium Acetate

(Phosphate Binder) (Oral Capsule)

3

C1

Calcium Acetate Calcium Acetate

(Phosphate Binder) (Oral Tablet)

3

C1

Lanthanum Carbonate Lanthanum Carbonate

(Oral Tablet Chewable)5

52798080



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Phoslyra

Phoslyra (Oral

Solution)3

C1

Sevelamer Carbonate Sevelamer Carbonate

(Oral Packet)5

C1

Sevelamer Carbonate Sevelamer Carbonate

(Oral Tablet) (Generic Renvela)

4

C1

Velphoro

Velphoro (Oral Tablet

Chewable)5

B1

VitaminsC1

VP-PNV-DHA VP-PNV-DHA (Oral

Capsule)2

A1

Gastrointestinal AgentsB1

Antispasmodics, GastrointestinalC1

Cuvposa

Cuvposa (Oral

Solution)4 PA

C1

Dicyclomine HCl Dicyclomine HCl (Oral

Capsule)2

C1


Solution)2

C1


Tablet)2

C1

Methscopolamine Bromide Methscopolamine

Bromide (Oral Tablet)4

B1

Gastrointestinal Agents, OtherC1

Chenodal

Chenodal (Oral Tablet) 5

C1

Cromolyn Sodium Cromolyn Sodium

(Oral Concentrate)3

C1

Diphenoxylate-Atropine Diphenoxylate-

Atropine (Oral Liquid)4

C1

Diphenoxylate-Atropine Diphenoxylate-

Atropine (Oral Tablet)4

C1

Gattex

Gattex

(Subcutaneous Kit)5 PA; LA

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Loperamide HCl Loperamide HCl (Oral

Capsule)2

C1

Myalept

Myalept

(Subcutaneous

Solution

Reconstituted)

5 PA; LA

C1

Relistor

Relistor (Oral Tablet) 5 PA; QL C1

Relistor

Relistor

(Subcutaneous

Solution)

5 PA

C1

Serostim

Serostim

(Subcutaneous

Solution

Reconstituted)

5 PA; LA

C1

Ursodiol

Ursodiol (Oral Capsule)

3

C1

Ursodiol

Ursodiol (Oral Tablet) 4

C1

Zorbtive

Zorbtive

(Subcutaneous

Solution

Reconstituted)

5 PA; LA

B1

Histamine2 (H2) Receptor AntagonistsC1

Cimetidine HCl Cimetidine HCl (Oral

Solution)2

C1

Cimetidine

Cimetidine (Oral Tablet)

2

C1

Famotidine

Famotidine (Oral Suspension Reconstituted)

4

C1

Famotidine

Famotidine (20MG Oral Tablet, 40MG Oral Tablet)

2

C1

Ranitidine HCl Ranitidine HCl (75MG/

5ML Oral Syrup)2

538081 81



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Ranitidine HCl Ranitidine HCl (150MG


2

B1

Irritable Bowel Syndrome AgentsC1

Alosetron HCl Alosetron HCl (Oral

Tablet)5 PA

C1

Amitiza

Amitiza (Oral

Capsule)3 QL

C1

Linzess

Linzess (Oral

Capsule)3 QL

C1

Xifaxan

Xifaxan (Oral Tablet) 5 PA B1

LaxativesC1

Clenpiq

Clenpiq (Oral

Solution)3

C1

Constulose

Constulose (Oral Solution)

2

C1

Enulose

Enulose (Oral Solution) 2

C1

GaviLyte-C

GaviLyte-C (Oral Solution Reconstituted)

2

C1

GaviLyte-G

GaviLyte-G (Oral Solution Reconstituted)

2

C1

GaviLyte-N with Flavor Pack GaviLyte-N with Flavor

Pack (Oral Solution Reconstituted)

2

C1

Generlac

Generlac (Oral Solution)

2

C1

Lactulose

Lactulose (10GM/15ML Oral Solution)

2

C1

PEG-3350-Electrolytes PEG-3350-Electrolytes

(Oral Solution Reconstituted) (Generic Colyte)

2

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

PEG-3350-NaCl-Na Bicarbonate-KCl PEG-3350-NaCl-Na

Bicarbonate-KCl (Oral Solution) (Generic NuLYTELY)

2

C1

PEG-3350-Electrolytes PEG-3350-Electrolytes

(Oral Solution) (Generic GoLYTELY)

2

C1

Suprep Bowel Prep Kit Suprep Bowel Prep

Kit (Oral Solution)3

C1

TriLyte

TriLyte (Oral Solution Reconstituted)

2

B1

ProtectantsC1

Carafate

Carafate (Oral

Suspension)4

C1

Misoprostol Misoprostol (Oral

Tablet)3

C1

Sucralfate

Sucralfate (Oral Tablet) 2

B1

Proton Pump InhibitorsC1

Dexilant

Dexilant (Oral

Capsule Delayed

Release)

4 QL

C1

Esomeprazole Magnesium Esomeprazole

Magnesium (Oral Capsule Delayed Release) (Generic Nexium)

3 QL

C1

Lansoprazole Lansoprazole (Oral

Capsule Delayed Release)

2 QL

C1

Omeprazole

Omeprazole (10MG Oral Capsule Delayed Release)

2 QL

54818282



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Omeprazole

Omeprazole (20MG Oral Capsule Delayed Release, 40MG Oral Capsule Delayed Release)

2

C1

Pantoprazole Sodium Pantoprazole Sodium


1 QL

C1

Prilosec

Prilosec (Oral Packet) 4 PA C1

Rabeprazole Sodium Rabeprazole Sodium


3

A1

Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment

B1

Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment

C1

Aralast NP

Aralast NP (1000MG


Reconstituted)

5 PA; LA

C1

Cholbam

Cholbam (Oral

Capsule)5 PA

C1

Creon

Creon (Oral Capsule

Delayed Release

Particles)

3

C1

Cystadane

Cystadane (Oral

Powder)5

C1

Cystagon

Cystagon (Oral

Capsule)4 LA

C1

Glassia

Glassia (Intravenous

Solution)5 PA; LA

C1

Kuvan

Kuvan (Oral Packet) 5 LA C1

Kuvan

Kuvan (Oral Tablet

Soluble)5 LA

C1

Miglustat

Miglustat (Oral Capsule)

5 PA; LA

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Ocaliva

Ocaliva (Oral Tablet) 5 PA; QL C1

Orfadin

Orfadin (Oral

Capsule)5 LA

C1

Orfadin

Orfadin (Oral

Suspension)5 LA

C1

Prolastin-C

Prolastin-C


Reconstituted)

5 PA; LA

C1

RAVICTI

RAVICTI (Oral Liquid) 5 LA; QL C1

Sodium Phenylbutyrate Sodium

Phenylbutyrate (Oral Powder)

5

C1

Sodium Phenylbutyrate Sodium

Phenylbutyrate (Oral Tablet)

5

C1

Sucraid

Sucraid (Oral

Solution)5 LA

C1

Tegsedi

Tegsedi

(Subcutaneous

Solution Prefilled

Syringe)

5 PA; LA

C1

Zemaira

Zemaira (Intravenous

Solution

Reconstituted)

5 PA; LA

C1

Zenpep

Zenpep (Oral Capsule

Delayed Release

Particles)

3

A1

Genitourinary AgentsB1

Antispasmodics, UrinaryC1

Myrbetriq

Myrbetriq (Oral

Tablet Extended

Release 24 Hour)

3

558283 83



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Oxybutynin Chloride ER Oxybutynin Chloride


2 QL

C1

Oxybutynin Chloride Oxybutynin Chloride

(Oral Syrup)2

C1

Oxybutynin Chloride Oxybutynin Chloride


2

C1

Solifenacin Succinate Solifenacin Succinate

(Oral Tablet)3 QL

B1

Benign Prostatic Hypertrophy AgentsC1

Alfuzosin HCl ER Alfuzosin HCl ER (Oral


2

C1

Dutasteride

Dutasteride (Oral Capsule)

3 QL C1

Finasteride

Finasteride (5MG Oral Tablet) (Generic Proscar)

1

C1

Silodosin

Silodosin (Oral Capsule)

3 QL C1

Tamsulosin HCl Tamsulosin HCl (Oral

Capsule)1

C1

Terazosin HCl Terazosin HCl (Oral

Capsule)2

B1

Genitourinary Agents, OtherC1

Bethanechol Chloride Bethanechol Chloride

(Oral Tablet)2

C1

Depen Titratabs

Depen Titratabs (Oral

Tablet)5

C1

Elmiron

Elmiron (Oral

Capsule)5

C1

Lithostat

Lithostat (Oral Tablet) 5

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Penicillamine Penicillamine (Oral

Capsule)5 PA

A1

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

B1

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

C1

Ala-Cort

Ala-Cort (External Cream)

2

C1

Alclometasone Dipropionate Alclometasone

Dipropionate (External Cream)

3

C1

Alclometasone Dipropionate Alclometasone

Dipropionate (External Ointment)

3

C1

Betamethasone Dipropionate Aug Betamethasone

Dipropionate Aug (External Cream)

3

C1


Dipropionate Aug (External Gel)

3

C1


Dipropionate Aug (External Lotion)

3

C1


Dipropionate Aug (External Ointment)

3

C1

Betamethasone Dipropionate Betamethasone

Dipropionate (External Cream)

3

C1


Dipropionate (External Lotion)

3

C1


Dipropionate (External Ointment)

3

56838484



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Betamethasone Valerate Betamethasone

Valerate (External Cream)

3

C1


Valerate (External Lotion)

3

C1


Valerate (External Ointment)

3

C1

Clobetasol Propionate Emollient Base

Clobetasol Propionate Emollient Base (External Cream)

4

C1

Clobetasol Propionate Clobetasol Propionate

(External Cream)4

C1


(External Gel)4

C1



C1


(External Shampoo)4

C1


(External Solution)3

C1

Cordran

Cordran (External

Tape)4

C1

Cortisone Acetate Cortisone Acetate

(Oral Tablet)4

C1

Desonide

Desonide (External Ointment)

4

C1

Desoximetasone Desoximetasone

(External Cream)4

C1

Dexamethasone Intensol Dexamethasone

Intensol (Oral Concentrate)

2

C1

Dexamethasone Dexamethasone (Oral

Elixir)2

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Dexamethasone Dexamethasone (Oral

Tablet)2

C1

Fludrocortisone Acetate Fludrocortisone

Acetate (Oral Tablet)2

C1

Fluocinolone Acetonide Fluocinolone

Acetonide (External Cream)

3

C1


Acetonide (External Ointment)

3

C1


Acetonide (External Solution)

3

C1

Fluocinolone Acetonide Scalp Fluocinolone

Acetonide Scalp (External Oil)

4

C1

Fluocinonide Emulsified Base Fluocinonide

Emulsified Base (External Cream)

3

C1

Fluocinonide

Fluocinonide (External Gel)

3

C1

Fluocinonide

Fluocinonide (External Ointment)

3

C1

Fluocinonide

Fluocinonide (External Solution)

3

C1

Fluticasone Propionate Fluticasone Propionate

(External Cream)3

C1



C1

Halobetasol Propionate Halobetasol

Propionate (External Cream)

4

C1

Halobetasol Propionate Halobetasol

Propionate (External Ointment)

4

578485 85



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Hydrocortisone Butyrate Hydrocortisone

Butyrate (External Ointment)

3

C1

Hydrocortisone Hydrocortisone (1%

External Cream, 2.5% External Cream)

2

C1

Hydrocortisone Hydrocortisone (2.5%

External Lotion)3

C1

Hydrocortisone Hydrocortisone (1%

External Ointment, 2.5% External Ointment)

2

C1

Hydrocortisone Hydrocortisone (Oral

Tablet)3

C1

Hydrocortisone Valerate Hydrocortisone

Valerate (External Cream)

4

C1

Hydrocortisone Valerate Hydrocortisone

Valerate (External Ointment)

4

C1

Methylprednisolone Methylprednisolone

(Oral Tablet)2

C1

Methylprednisolone Methylprednisolone

(Oral Tablet Therapy Pack)

2

C1

Mometasone Furoate Mometasone Furoate

(External Cream)2

C1



C1


(External Solution)2

C1

Prednicarbate Prednicarbate

(External Cream)4

C1

Prednicarbate Prednicarbate


Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Prednisolone Prednisolone (Oral

Solution)2

C1

Prednisolone Sodium Phosphate Prednisolone Sodium

Phosphate (25MG/5ML Oral Solution, 6.7MG/5ML Oral Solution)

2

C1

Prednisone Intensol Prednisone Intensol

(Oral Concentrate)2

C1

Prednisone

Prednisone (5MG/5ML Oral Solution)

2

C1

Prednisone

Prednisone (10MG Oral Tablet, 1MG Oral Tablet, 2.5MG Oral Tablet, 20MG Oral Tablet, 50MG Oral Tablet, 5MG Oral Tablet)

1

C1

Prednisone

Prednisone (10MG (21) Oral Tablet Therapy Pack, 10MG (48) Oral Tablet Therapy Pack, 5MG (21) Oral Tablet Therapy Pack, 5MG (48) Oral Tablet Therapy Pack)

1

C1


Acetonide (External Cream)

2

C1


Acetonide (External Lotion)

2

C1


Acetonide (External Ointment)

2

58858686



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Triderm

Triderm (0.1% External Cream)

2

A1

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

B1

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

C1

Desmopressin Acetate Desmopressin Acetate

(Oral Tablet)3

C1

Desmopressin Acetate Spray Desmopressin Acetate

Spray (Nasal Solution)4

C1

Genotropin MiniQuick Genotropin MiniQuick

(Subcutaneous

Solution

Reconstituted)

5 PA

C1

Genotropin

Genotropin

(Subcutaneous

Solution

Reconstituted)

5 PA

C1

Humatrope

Humatrope (Injection

Solution

Renconstituted),

Humatrope Combo

Pack (Injection)

5 PA

C1

Increlex

Increlex

(Subcutaneous

Solution)

5 PA; LA

C1

Norditropin FlexPro Norditropin FlexPro

(Subcutaneous

Solution)

5 PA

C1

Nutropin AQ NuSpin 10 Nutropin AQ NuSpin

10 (Subcutaneous

Solution)

5 PA

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1


20 (Subcutaneous

Solution)

5 PA

C1


5 (Subcutaneous

Solution)

5 PA

C1

Saizen

Saizen (Injection

Solution

Reconstituted)

5 PA; LA

C1

Saizenprep

Saizenprep (Injection

Solution

Reconstituted)

5 PA; LA

A1

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)

B1

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)

C1

Korlym

Korlym (Oral Tablet) 5 PA; LA; QL A1

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)

B1

AndrogensC1

Anadrol-50

Anadrol-50 (Oral

Tablet)5 PA

C1

Androderm

Androderm

(Transdermal Patch

24 Hour)

3 QL

C1

Danazol

Danazol (Oral Capsule) 4

C1

Oxandrolone

Oxandrolone (10MG Oral Tablet)

4 PA; QL C1

Oxandrolone

Oxandrolone (2.5MG Oral Tablet)

3 PA; QL C1

Testosterone Cypionate Testosterone

Cypionate (Intramuscular Solution)

2

598687 87



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Testosterone Enanthate Testosterone

Enanthate (Intramuscular Solution)

3

C1

Testosterone

Testosterone (25MG/2.5GM 1% Transdermal Gel, 50MG/5GM 1% Transdermal Gel), Testosterone Pump (1% Transdermal Gel)

3

C1

Testosterone

Testosterone (20.25MG/1.25GM 1.62% Transdermal Gel, 40.5MG/2.5GM 1.62% Transdermal Gel), Testosterone Pump (1.62% Transdermal Gel)

4

B1

EstrogensC1

Altavera

Altavera (Oral Tablet) 4

C1

Alyacen 1/35

Alyacen 1/35 (Oral Tablet)

4

C1

Amethia Lo

Amethia Lo (Oral Tablet)

4

C1

Amethia

Amethia (Oral Tablet) 4

C1

Apri

Apri (Oral Tablet) 4

C1

Aranelle

Aranelle (Oral Tablet) 4

C1

Ashlyna

Ashlyna (Oral Tablet) 4

C1

Aubra

Aubra (Oral Tablet) 4

C1

Aviane

Aviane (Oral Tablet) 4

C1

Balziva

Balziva (Oral Tablet) 4

C1

Blisovi 24 Fe Blisovi 24 Fe (Oral

Tablet)4

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Blisovi Fe 1.5/30 Blisovi Fe 1.5/30 (Oral

Tablet)4

C1

Briellyn

Briellyn (Oral Tablet) 4

C1

Camrese Lo

Camrese Lo (Oral Tablet)

4

C1

Caziant

Caziant (Oral Tablet) 4

C1

Climara Pro

Climara Pro

(Transdermal Patch

Weekly)

4

C1

Cryselle-28

Cryselle-28 (Oral Tablet)

4

C1

Cyclafem 1/35 Cyclafem 1/35 (Oral

Tablet)4

C1

Cyclafem 7/7/7 Cyclafem 7/7/7 (Oral

Tablet)4

C1

Cyred

Cyred (Oral Tablet) 4

C1

Delyla

Delyla (Oral Tablet) 4

C1

Depo-Estradiol Depo-Estradiol

(Intramuscular Oil)4

C1

Desogestrel-Ethinyl Estradiol Desogestrel-Ethinyl

Estradiol (Oral Tablet)4

C1

Drospirenone-Ethinyl Estradiol Drospirenone-Ethinyl


C1

Duavee

Duavee (Oral Tablet) 4

C1

Elestrin

Elestrin (Transdermal

Gel)4

C1

Emoquette

Emoquette (Oral Tablet)

4

C1

Enpresse-28

Enpresse-28 (Oral Tablet)

4

C1

Enskyce

Enskyce (Oral Tablet) 4

C1

Estarylla

Estarylla (Oral Tablet) 4

C1

Estradiol

Estradiol (Oral Tablet) 3

60878888



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Estradiol

Estradiol (Transdermal Patch Weekly)

3 QL C1

Estradiol

Estradiol (Vaginal Cream)

4

C1

Estradiol

Estradiol (Vaginal Tablet)

4 QL C1

Estradiol Valerate Estradiol Valerate

(Intramuscular Oil)4

C1

Estring

Estring (Vaginal Ring) 4

C1

Ethynodiol Diacetate-Ethinyl Estradiol

Ethynodiol Diacetate-Ethinyl Estradiol (Oral Tablet)

4

C1

Falmina

Falmina (Oral Tablet) 4

C1

Fayosim

Fayosim (Oral Tablet) 4

C1

Femring

Femring (Vaginal

Ring)4

C1

Femynor

Femynor (Oral Tablet) 4

C1

Fyavolv

Fyavolv (Oral Tablet) 4

C1

Gianvi

Gianvi (Oral Tablet) 4

C1

Hailey 24 Fe Hailey 24 Fe (Oral

Tablet)4

C1

Imvexxy Maintenance Pack Imvexxy Maintenance

Pack (Vaginal Insert)3 PA; QL

C1

Imvexxy Starter Pack Imvexxy Starter Pack

(Vaginal Insert)3 PA; QL

C1

Introvale

Introvale (Oral Tablet) 4

C1

Isibloom

Isibloom (Oral Tablet) 4

C1

Jasmiel

Jasmiel (Oral Tablet) 4

C1

Jinteli

Jinteli (Oral Tablet) 4

C1

Juleber

Juleber (Oral Tablet) 4

C1

Junel 1.5/30 Junel 1.5/30 (Oral

Tablet)4

C1

Junel 1/20

Junel 1/20 (Oral Tablet)

4

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Junel Fe 1.5/30 Junel Fe 1.5/30 (Oral

Tablet)4

C1

Junel Fe 1/20 Junel Fe 1/20 (Oral

Tablet)4

C1

Junel Fe 24 Junel Fe 24 (Oral

Tablet)4

C1

Kaitlib Fe

Kaitlib Fe (Oral Tablet Chewable)

4

C1

Kariva

Kariva (Oral Tablet) 4

C1

Kelnor 1/35

Kelnor 1/35 (Oral Tablet)

4

C1

Kelnor 1/50

Kelnor 1/50 (Oral Tablet)

4

C1

Kurvelo

Kurvelo (Oral Tablet) 4

C1

LARIN 1.5/30 LARIN 1.5/30 (Oral

Tablet)4

C1

LARIN 1/20

LARIN 1/20 (Oral Tablet)

4

C1

LARIN Fe 1.5/30 LARIN Fe 1.5/30 (Oral

Tablet)4

C1

LARIN Fe 1/20 LARIN Fe 1/20 (Oral

Tablet)4

C1

Larissia

Larissia (Oral Tablet) 4

C1

Layolis Fe

Layolis Fe (Oral

Tablet Chewable)4

C1

Leena

Leena (Oral Tablet) 4

C1

Lessina

Lessina (Oral Tablet) 4

C1

Levonest

Levonest (Oral Tablet) 4

C1

Levonorgestrel-Ethinyl Estradiol & Ethinyl Estradiol

Levonorgestrel-Ethinyl Estradiol & Ethinyl Estradiol (Oral Tablet)

4

C1

Levonorgestrel-Ethinyl Estradiol 91-Day

Levonorgestrel-Ethinyl Estradiol 91-Day (Oral Tablet)

4

618889 89



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Levonorgestrel-Ethinyl Estradiol Levonorgestrel-Ethinyl


C1

Levora 0.15/30 Levora 0.15/30 (28)

(Oral Tablet)4

C1

Loryna

Loryna (Oral Tablet) 4

C1

Low-Ogestrel Low-Ogestrel (Oral

Tablet)4

C1

Lutera

Lutera (Oral Tablet) 4

C1

Marlissa

Marlissa (Oral Tablet) 4

C1

Melodetta 24 Fe Melodetta 24 Fe (Oral

Tablet Chewable)4

C1

Menest

Menest (Oral Tablet) 3

C1

Mibelas 24 Fe Mibelas 24 Fe (Oral

Tablet Chewable)4

C1

Microgestin 1.5/30 Microgestin 1.5/30

(Oral Tablet)4

C1

Microgestin 1/20 Microgestin 1/20 (Oral

Tablet)4

C1

Microgestin Fe 1.5/30 Microgestin Fe 1.5/30

(Oral Tablet)4

C1

Microgestin Fe 1/20 Microgestin Fe 1/20

(Oral Tablet)4

C1

Mili

Mili (Oral Tablet) 4

C1

MonoNessa

MonoNessa (Oral

Tablet)4

C1

Necon 0.5/35 Necon 0.5/35 (28)

(Oral Tablet)4

C1

Nikki

Nikki (Oral Tablet) 4

C1

Norethindrone Acetate-Ethinyl Estradiol

Norethindrone Acetate-Ethinyl Estradiol (0.5-2.5MG-MCG Oral Tablet, 1-5MG-MCG Oral Tablet)

4

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Norethindrone Acetate-Ethinyl Estradiol

Norethindrone Acetate-Ethinyl Estradiol (1-20MG-MCG Oral Tablet)

4

C1

Norethindrone Acetate-Ethinyl Estradiol-Fe

Norethindrone Acetate-Ethinyl Estradiol-Fe (1-20MG-MCG(24) Oral Tablet)

4

C1

Norethindrone Acetate-Ethinyl Estradiol-Fe

Norethindrone Acetate-Ethinyl Estradiol-Fe (0.4-35MG-MCG Oral Tablet Chewable, 0.8-25MG-MCG Oral Tablet Chewable, 1-20MG-MCG(24) Oral Tablet Chewable)

4

C1

Norgestimate-Ethinyl Estradiol Norgestimate-Ethinyl


C1

Norgestimate-Ethinyl Estradiol Triphasic

Norgestimate-Ethinyl Estradiol Triphasic (Oral Tablet)

4

C1

Nortrel 0.5/35 Nortrel 0.5/35 (28)

(Oral Tablet)4

C1

Nortrel 1/35

Nortrel 1/35 (21) (Oral Tablet)

4

C1

Nortrel 1/35

Nortrel 1/35 (28) (Oral Tablet)

4

C1

Nortrel 7/7/7 Nortrel 7/7/7 (Oral

Tablet)4

C1

Ocella

Ocella (Oral Tablet) 4

C1

Ogestrel

Ogestrel (Oral Tablet) 4

C1

Orsythia

Orsythia (Oral Tablet) 4

C1

Pimtrea

Pimtrea (Oral Tablet) 4

C1

Pirmella 1/35

Pirmella 1/35 (Oral Tablet)

4

62899090



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Portia-28

Portia-28 (Oral Tablet) 4

C1

Premarin

Premarin (Oral

Tablet)4 QL

C1

Premarin

Premarin (Vaginal

Cream)3

C1

Premphase

Premphase (Oral

Tablet)4 QL

C1

Prempro

Prempro (Oral Tablet) 4 QL C1

Previfem

Previfem (Oral Tablet) 4

C1

Reclipsen

Reclipsen (Oral Tablet) 4

C1

Rivelsa

Rivelsa (Oral Tablet) 4

C1

Setlakin

Setlakin (Oral Tablet) 4

C1

Sprintec 28

Sprintec 28 (Oral Tablet)

4

C1

Sronyx

Sronyx (Oral Tablet) 4

C1

Syeda

Syeda (Oral Tablet) 4

C1

Tarina 24 Fe Tarina 24 Fe (Oral

Tablet)4

C1

Tarina Fe 1/20 Tarina Fe 1/20 (Oral

Tablet)4

C1

Tri-Estarylla

Tri-Estarylla (Oral Tablet)

4

C1

Tri-Legest Fe Tri-Legest Fe (Oral

Tablet)4

C1

Tri-Lo-Estarylla Tri-Lo-Estarylla (Oral

Tablet)4

C1

Tri-Lo-Sprintec Tri-Lo-Sprintec (Oral

Tablet)4

C1

Tri-Mili

Tri-Mili (Oral Tablet) 4

C1

Tri-Previfem

Tri-Previfem (Oral Tablet)

4

C1

Tri-Sprintec

Tri-Sprintec (Oral Tablet)

4

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Trivora

Trivora (28) (Oral Tablet)

4

C1

Tri-VyLibra Lo Tri-VyLibra Lo (Oral

Tablet)4

C1

Tri-VyLibra

Tri-VyLibra (Oral Tablet)

4

C1

Velivet

Velivet (Oral Tablet) 4

C1

Vienva

Vienva (Oral Tablet) 4

C1

Vyfemla

Vyfemla (Oral Tablet) 4

C1

VyLibra

VyLibra (Oral Tablet) 4

C1

WYMZYA Fe WYMZYA Fe (Oral

Tablet Chewable)4

C1

Xulane

Xulane (Transdermal Patch Weekly)

4

C1

Yuvafem

Yuvafem (Vaginal Tablet)

4 QL C1

Zarah

Zarah (Oral Tablet) 4

C1

Zovia 1/35E Zovia 1/35E (28) (Oral

Tablet)4

B1

ProgestinsC1

Camila

Camila (Oral Tablet) 3

C1

Crinone

Crinone (Vaginal Gel) 4 PA C1

Deblitane

Deblitane (Oral Tablet) 3

C1

Depo-Provera

Depo-Provera

(400MG/ML

Intramuscular

Suspension)

4

C1

Errin

Errin (Oral Tablet) 3

C1

Incassia

Incassia (Oral Tablet) 3

C1

Jolivette

Jolivette (0.35MG

Oral Tablet)3

C1

Lyza

Lyza (Oral Tablet) 3

639091 91



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Medroxyprogesterone Acetate Medroxyprogesterone

Acetate (150MG/ML Intramuscular Suspension)

4

C1


Acetate (150MG/ML Intramuscular Suspension Prefilled Syringe)

4

C1


Acetate (10MG Oral Tablet, 2.5MG Oral Tablet, 5MG Oral Tablet)

2

C1

Megestrol Acetate Megestrol Acetate

(40MG/ML Oral Suspension)

3

C1


(625MG/5ML Oral Suspension)

4

C1


(Oral Tablet)3

C1

Nora-BE

Nora-BE (Oral Tablet) 3

C1

Norethindrone Acetate Norethindrone Acetate

(5MG Oral Tablet)2

C1

Norethindrone Norethindrone

(0.35MG Oral Tablet)3

C1

Norlyroc

Norlyroc (Oral Tablet) 3

C1

Progesterone Micronized Progesterone

Micronized (Oral Capsule)

2

C1

Sharobel

Sharobel (Oral Tablet) 3

B1

Selective Estrogen Receptor Modifying Agents

C1

Osphena

Osphena (Oral Tablet) 3 PA; QL

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Raloxifene HCl Raloxifene HCl (Oral

Tablet)3 QL

A1

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

B1

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

C1

Levo-T

Levo-T (Oral Tablet) 3

C1

Levothyroxine Sodium Levothyroxine Sodium

(Oral Tablet)1

C1

Levoxyl

Levoxyl (Oral Tablet) 3

C1

Liothyronine Sodium Liothyronine Sodium

(Oral Tablet)2

C1

Synthroid

Synthroid (Oral

Tablet)3

C1

Unithroid

Unithroid (100MCG

Oral Tablet, 112MCG

Oral Tablet, 125MCG

Oral Tablet, 150MCG

Oral Tablet, 175MCG

Oral Tablet, 200MCG

Oral Tablet, 25MCG

Oral Tablet, 300MCG

Oral Tablet, 50MCG

Oral Tablet, 75MCG

Oral Tablet, 88MCG

Oral Tablet)

3

A1

Hormonal Agents, Suppressant (Adrenal)B1

Hormonal Agents, Suppressant (Adrenal)C1

Lysodren

Lysodren (Oral

Tablet)5

A1

Hormonal Agents, Suppressant (Pituitary)B1

Hormonal Agents, Suppressant (Pituitary)C1

Cabergoline

Cabergoline (Oral Tablet)

3

64919292



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Egrifta

Egrifta

(Subcutaneous

Solution

Reconstituted)

5 PA; LA

C1

Firmagon

Firmagon (120MG

Subcutaneous

Solution

Reconstituted)

5 PA

C1

Firmagon

Firmagon (80MG

Subcutaneous

Solution

Reconstituted)

4 PA

C1

Leuprolide Acetate Leuprolide Acetate

(Injection Kit)4 PA

C1

Lupaneta Pack Lupaneta Pack

(Combination Kit)5 PA

C1

Lupron Depot

Lupron Depot (1-

Month)

(Intramuscular Kit)

5 PA

C1

Lupron Depot

Lupron Depot (3-

Month)

(Intramuscular Kit)

5 PA

C1

Lupron Depot

Lupron Depot (4-

Month)

(Intramuscular Kit)

5 PA

C1

Lupron Depot

Lupron Depot (6-

Month)

(Intramuscular Kit)

5 PA

C1

Octreotide Acetate Octreotide Acetate

(1000MCG/ML Injection Solution, 500MCG/ML Injection Solution)

5 PA

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Octreotide Acetate Octreotide Acetate

(100MCG/ML Injection Solution, 200MCG/ML Injection Solution, 50MCG/ML Injection Solution)

4 PA

C1

Signifor

Signifor

(Subcutaneous

Solution)

5 PA; LA

C1

Somatuline Depot Somatuline Depot

(Subcutaneous

Solution)

5

C1

Somavert

Somavert

(Subcutaneous

Solution

Reconstituted)

5 PA; LA; QL

C1

Synarel

Synarel (Nasal

Solution)5

C1

Trelstar Mixject

Trelstar Mixject

(Intramuscular

Suspension

Reconstituted)

5 PA

A1

Hormonal Agents, Suppressant (Thyroid)B1

Antithyroid AgentsC1

Methimazole Methimazole (Oral

Tablet)2

C1

Propylthiouracil Propylthiouracil (Oral

Tablet)2

A1

Immunological AgentsB1

Angioedema AgentsC1

Berinert

Berinert (Intravenous

Kit)5 PA; LA

C1

Cinryze

Cinryze (Intravenous

Solution

Reconstituted)

5 PA; LA

659293 93



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Firazyr

Firazyr

(Subcutaneous

Solution)

5 PA; LA; QL

C1

Haegarda

Haegarda

(Subcutaneous

Solution

Reconstituted)

5 PA; LA

C1

Ruconest

Ruconest


Reconstituted)

5 PA; LA

B1

Immune SuppressantsC1

Azathioprine

Azathioprine (Oral Tablet)

2 B/D, PA C1

Cimzia Prefilled

Cimzia Prefilled


C1

Cimzia

Cimzia


C1

Cyclosporine Modified Cyclosporine Modified


C1

Cyclosporine Modified Cyclosporine Modified

(Oral Solution)3 B/D, PA

C1

Cyclosporine Cyclosporine (Oral

Capsule)3 B/D, PA

C1

Enbrel

Enbrel

(Subcutaneous

Solution Prefilled

Syringe)

5 PA

C1

Enbrel

Enbrel

(Subcutaneous

Solution

Reconstituted)

5 PA

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Enbrel SureClick Enbrel SureClick

(Subcutaneous

Solution Auto-

Injector)

5 PA

C1

Envarsus XR

Envarsus XR (Oral

Tablet Extended

Release 24 Hour)

4 B/D, PA

C1

Gengraf

Gengraf (Oral Capsule) 3 B/D, PA C1

Gengraf

Gengraf (Oral Solution) 3 B/D, PA C1

Humira Pediatric Crohns Start Humira Pediatric

Crohns Start

(Subcutaneous


5 PA

C1

Humira Pen

Humira Pen

(Subcutaneous Pen-

Injector Kit)

5 PA

C1

Humira Pen Crohns Disease Starter Humira Pen Crohns

Disease Starter

(Subcutaneous Pen-

Injector Kit)

5 PA

C1

Humira Pen Psoriasis Starter Humira Pen Psoriasis

Starter

(Subcutaneous Pen-

Injector Kit)

5 PA

C1

Humira

Humira

(Subcutaneous


5 PA

C1

Kineret

Kineret

(Subcutaneous

Solution Prefilled

Syringe)

5 PA

C1

Methotrexate Methotrexate (Oral

Tablet)2

66939494



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Methotrexate Sodium Methotrexate Sodium

(50MG/2ML Injection Solution Prefilled Syringe)

2

C1

Methotrexate Sodium Methotrexate Sodium

(50MG/2ML Injection Solution)

2

C1

Mycophenolate Mofetil Mycophenolate Mofetil


C1



5 B/D, PA

C1


(Oral Tablet)3 B/D, PA

C1

Mycophenolate Sodium Mycophenolate

Sodium (Oral Tablet Delayed Release)

4 B/D, PA

C1

Orencia ClickJect Orencia ClickJect

(Subcutaneous

Solution Auto-

Injector)

5 PA

C1

Orencia

Orencia

(Subcutaneous

Solution Prefilled

Syringe)

5 PA

C1

Prograf

Prograf (Oral Packet) 5 B/D, PA C1

Rasuvo

Rasuvo

(Subcutaneous

Solution Auto-

Injector)

4 PA

C1

Sandimmune

Sandimmune (Oral

Solution)4 B/D, PA

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Simponi

Simponi

(Subcutaneous

Solution Auto-

Injector)

5 PA

C1

Simponi

Simponi

(Subcutaneous

Solution Prefilled

Syringe)

5 PA

C1

Sirolimus

Sirolimus (Oral Solution)

5 B/D, PA C1

Sirolimus

Sirolimus (Oral Tablet) 4 B/D, PA C1

Tacrolimus

Tacrolimus (Oral Capsule)

3 B/D, PA C1

Trexall

Trexall (Oral Tablet) 4

C1

Xatmep

Xatmep (Oral

Solution)4 PA

C1

Xeljanz

Xeljanz (Oral Tablet

Immediate Release)5 PA; QL

C1

Xeljanz XR

Xeljanz XR (Oral

Tablet Extended

Release 24 Hour)

5 PA; QL

C1

Zortress

Zortress (Oral Tablet) 5 B/D, PA B1

Immunizing Agents, PassiveC1

BIVIGAM

BIVIGAM (10GM/

100ML Intravenous

Solution)

5 PA

C1

Flebogamma DIF Flebogamma DIF

(5GM/50ML


5 PA

C1

Gammagard

Gammagard (2.5GM/

25ML Injection

Solution)

5 PA

679495 95



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Gammagard S/D Less IgA Gammagard S/D

Less IgA (Intravenous

Solution

Reconstituted)

5 PA

C1

Gammaked

Gammaked (1GM/

10ML Injection

Solution)

5 PA

C1

Gammaplex

Gammaplex (10GM/

100ML Intravenous

Solution, 10GM/

200ML Intravenous

Solution, 20GM/

200ML Intravenous

Solution, 5GM/50ML


5 PA

C1

Gamunex-C

Gamunex-C (1GM/

10ML Injection

Solution)

5 PA

C1

Octagam

Octagam (1GM/20ML


2GM/20ML


5 PA

C1

Panzyga

Panzyga (Intravenous

Solution)5 PA

C1

Privigen

Privigen (20GM/

200ML Intravenous

Solution)

5 PA

C1

Varizig

Varizig (Intramuscular

Solution)5

B1

ImmunomodulatorsC1

Actemra ACTPen

Actemra ACTPen

(Subcutaneous

Solution Auto-

Injector)

5 PA

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Actemra

Actemra

(Subcutaneous

Solution Prefilled

Syringe)

5 PA

C1

Actimmune

Actimmune

(Subcutaneous

Solution)

5 LA

C1

Arcalyst

Arcalyst

(Subcutaneous

Solution

Reconstituted)

5 PA; LA

C1

Benlysta

Benlysta

(Subcutaneous

Solution Auto-

Injector)

5 PA

C1

Benlysta

Benlysta

(Subcutaneous

Solution Prefilled

Syringe)

5 PA

C1

Leflunomide Leflunomide (Oral

Tablet)2

C1

Otezla

Otezla (Oral Tablet) 5 PA; LA C1

Otezla

Otezla (Oral Tablet

Therapy Pack)5 PA; LA

C1

Ridaura

Ridaura (Oral

Capsule)5

C1

Xolair

Xolair (Subcutaneous

Solution Prefilled

Syringe)

5 PA; LA

C1

Xolair

Xolair (Subcutaneous

Solution

Reconstituted)

5 PA; LA

B1

Vaccines

68959696



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

ActHIB

ActHIB

(Intramuscular

Solution

Reconstituted)

3

C1

Adacel

Adacel

(Intramuscular

Suspension)

3

C1

BCG Vaccine

BCG Vaccine

(Injection)3

C1

Bexsero

Bexsero

(Intramuscular


Syringe)

3

C1

Boostrix

Boostrix (5-2.5-18.5

Intramuscular

Suspension,

5-2.5-18.5 (0.5ML

Syringe)

Intramuscular

Suspension)

3

C1

Daptacel

Daptacel

(Intramuscular

Suspension)

3

C1

Diphtheria-Tetanus Toxoids DT Diphtheria-Tetanus

Toxoids DT

(Intramuscular

Suspension)

3

C1

Engerix-B

Engerix-B (Injection

Suspension)3 B/D, PA

C1

Gardasil 9

Gardasil 9

(Intramuscular

Suspension)

3

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Gardasil 9

Gardasil 9

(Intramuscular


Syringe)

3

C1

Havrix

Havrix (Intramuscular

Suspension)3 PA

C1

Hiberix

Hiberix (Injection

Solution

Reconstituted)

3

C1

Imovax Rabies

Imovax Rabies

(Intramuscular

Injectable)

3 B/D, PA

C1

Infanrix

Infanrix

(Intramuscular

Suspension)

3

C1

IPOL

IPOL (Injection) 3

C1

Ixiaro

Ixiaro (Intramuscular

Suspension)3

C1

Kinrix

Kinrix (Intramuscular

Suspension)3

C1

Menactra

Menactra

(Intramuscular

Injectable)

3

C1

Menveo

Menveo

(Intramuscular

Solution

Reconstituted)

3

C1

M-M-R II

M-M-R II

(Subcutaneous

Injectable)

3

C1

Pediarix

Pediarix

(Intramuscular

Suspension)

3

699697 97



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Pedvax HIB

Pedvax HIB

(Intramuscular

Suspension)

3

C1

ProQuad

ProQuad

(Subcutaneous

Suspension

Reconstituted)

3

C1

Quadracel

Quadracel

(Intramuscular

Suspension)

3

C1

RabAvert

RabAvert

(Intramuscular

Suspension

Reconstituted)

3 B/D, PA

C1

Recombivax HB

Recombivax HB

(Injection

Suspension)

3 B/D, PA

C1

Rotarix

Rotarix (Oral

Suspension

Reconstituted)

3

C1

RotaTeq

RotaTeq (Oral

Solution)3

C1

Shingrix

Shingrix

(Intramuscular

Suspension

Reconstituted)

3 PA

C1

TDVAX

TDVAX

(Intramuscular

Suspension)

3

C1

Tenivac

Tenivac

(Intramuscular

Injectable)

3

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Trumenba

Trumenba

(Intramuscular


Syringe)

3

C1

Twinrix

Twinrix

(Intramuscular


Syringe)

3

C1

Typhim Vi

Typhim Vi

(Intramuscular

Solution)

3

C1

VAQTA

VAQTA

(Intramuscular

Suspension)

3 PA

C1

Varivax

Varivax

(Subcutaneous

Injectable)

3

C1

YF-Vax

YF-Vax

(Subcutaneous

Injectable)

3

C1

Zostavax

Zostavax

(Subcutaneous

Suspension

Reconstituted)

4 PA

A1

Inflammatory Bowel Disease AgentsB1

AminosalicylatesC1

Apriso

Apriso (Oral Capsule

Extended Release 24

Hour)

3 QL

C1

Balsalazide Disodium Balsalazide Disodium

(Oral Capsule)4

C1

Canasa

Canasa (Rectal

Suppository)5

70979898



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Dipentum

Dipentum (Oral

Capsule)5

C1

Mesalamine Mesalamine (1.2GM

Oral Tablet Delayed Release) (Generic Lialda)

3 QL

C1

Mesalamine Mesalamine (Rectal

Enema)4 QL

C1

Mesalamine Mesalamine (Rectal

Suppository)5

C1

Pentasa

Pentasa (Oral

Capsule Extended

Release)

4 QL

B1

GlucocorticoidsC1

Budesonide ER Budesonide ER (Oral


5 ST

C1

Budesonide

Budesonide (Oral Capsule Delayed Release Particles)

4

C1

Colocort

Colocort (Rectal Enema)

4

C1

Hydrocortisone Hydrocortisone (Rectal

Enema)4

C1

Procto-Med HC Procto-Med HC (Rectal

Cream)2

C1

Procto-Pak

Procto-Pak (Rectal Cream)

2

C1

Proctosol HC

Proctosol HC (Rectal Cream)

2

C1

Proctozone-HC Proctozone-HC (Rectal

Cream)2

B1

Sulfonamides

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Sulfasalazine Sulfasalazine (Oral


2

C1

Sulfasalazine Sulfasalazine (Oral

Tablet Delayed Release)

2

A1

Metabolic Bone Disease AgentsB1

Metabolic Bone Disease AgentsC1

Alendronate Sodium Alendronate Sodium

(Oral Solution)4

C1

Alendronate Sodium Alendronate Sodium

(Oral Tablet)1 QL

C1

Binosto

Binosto (Oral Tablet

Effervescent)4 QL

C1

Calcitonin Salmon Calcitonin Salmon

(Nasal Solution)3 QL

C1

Calcitriol

Calcitriol (Oral Capsule)

2 B/D, PA C1

Calcitriol

Calcitriol (Oral Solution)

2 B/D, PA C1

Cinacalcet HCl Cinacalcet HCl (30MG

Oral Tablet)4 B/D, PA; QL

C1

Cinacalcet HCl Cinacalcet HCl (60MG


5 B/D, PA; QL

C1

Doxercalciferol Doxercalciferol (Oral

Capsule)4 B/D, PA; QL

C1

Forteo

Forteo

(Subcutaneous

Solution)

5 PA; QL

C1

Ibandronate Sodium Ibandronate Sodium

(Oral Tablet)2 QL

C1

Natpara

Natpara

(Subcutaneous

Cartridge)

5 PA; LA

719899 99



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Paricalcitol

Paricalcitol (Oral Capsule)

4 B/D, PA C1

Prolia

Prolia (Subcutaneous

Solution Prefilled

Syringe)

4 QL

C1

Rayaldee

Rayaldee (Oral

Capsule Extended

Release)

5 QL

C1

Risedronate Sodium Risedronate Sodium


3 QL

C1

Tymlos

Tymlos

(Subcutaneous


5 PA; QL

C1

Xgeva

Xgeva (Subcutaneous

Solution)5 PA

A1

Miscellaneous Therapeutic AgentsB1

Miscellaneous Therapeutic AgentsC1

Alcohol Prep Pads Alcohol Prep Pads 3

C1

Gauze

Gauze (Non-medicated 2X2 Pad)

3

C1

Insulin Syringes, Needles Insulin Syringes,

Needles3

A1

Ophthalmic AgentsB1

Ophthalmic Agents, OtherC1

Atropine Sulfate Atropine Sulfate


C1

Bacitracin-Polymyxin B Bacitracin-Polymyxin B


C1

Neomycin-Polymyxin-Bacitracin-Hydrocortisone

Neomycin-Polymyxin-Bacitracin-Hydrocortisone (Ophthalmic Ointment)

3

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Blephamide

Blephamide

(Ophthalmic

Suspension)

4

C1

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


C1

Cystaran

Cystaran (Ophthalmic

Solution)5 LA

C1

Lacrisert

Lacrisert (Ophthalmic

Insert)4

C1

Lastacaft

Lastacaft


C1

Neomycin-Bacitracin-Polymyxin Neomycin-Bacitracin-

Polymyxin (5-400-10000 Ophthalmic Ointment)

3

C1

Neomycin-Polymyxin-Dexamethasone

Neomycin-Polymyxin-Dexamethasone (Ophthalmic Ointment)

2

C1

Neomycin-Polymyxin-Dexamethasone

Neomycin-Polymyxin-Dexamethasone (3.5-10000-0.1 Ophthalmic Suspension)

2

C1

Neomycin-Polymyxin-Gramicidin Neomycin-Polymyxin-

Gramicidin (Ophthalmic Solution)

3

C1

Neomycin-Polymyxin-HC Neomycin-Polymyxin-

HC (Ophthalmic Suspension)

4

C1

Polymyxin B-Trimethoprim Polymyxin B-

Trimethoprim (Ophthalmic Solution)

2

C1

Pred-G

Pred-G (Ophthalmic

Suspension)4

7299100100



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Pred-G S.O.P.

Pred-G S.O.P.

(Ophthalmic

Ointment)

4

C1

Proparacaine HCl Proparacaine HCl


C1

Restasis

Restasis (Ophthalmic

Emulsion)3 QL

C1

Rhopressa

Rhopressa

(Ophthalmic Solution)3 ST

C1

Sulfacetamide-Prednisolone Sulfacetamide-

Prednisolone (Ophthalmic Solution)

2

C1

TobraDex

TobraDex

(Ophthalmic

Ointment)

3

C1

TobraDex ST

TobraDex ST

(Ophthalmic

Suspension)

4

C1

Tobramycin-Dexamethasone Tobramycin-

Dexamethasone (Ophthalmic Suspension)

3

C1

Xiidra

Xiidra (Ophthalmic

Solution)4 QL

B1

Ophthalmic Anti-allergy AgentsC1

Alocril

Alocril (Ophthalmic

Solution)4

C1

Alomide

Alomide (Ophthalmic

Solution)4

C1

Azelastine HCl Azelastine HCl


C1

Bepreve

Bepreve (Ophthalmic

Solution)4

C1



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Epinastine HCl Epinastine HCl


C1

Olopatadine HCl Olopatadine HCl


C1

Pazeo

Pazeo (Ophthalmic

Solution)3

B1

Ophthalmic Antiglaucoma AgentsC1

Alphagan P

Alphagan P (0.1%

Ophthalmic Solution)3

C1

Apraclonidine HCl Apraclonidine HCl


C1

Azopt

Azopt (Ophthalmic

Suspension)3

C1

Betaxolol HCl Betaxolol HCl


C1

Betimol

Betimol (Ophthalmic

Solution)4

C1

Brimonidine Tartrate Brimonidine Tartrate

(0.15% Ophthalmic

Solution)

4

C1

Brimonidine Tartrate Brimonidine Tartrate

(0.2% Ophthalmic Solution)

2

C1

Carteolol HCl Carteolol HCl


C1

Combigan

Combigan


C1

Cosopt PF

Cosopt PF


C1

Dorzolamide HCl Dorzolamide HCl


C1

Dorzolamide HCl-Timolol Maleate Dorzolamide HCl-

Timolol Maleate (Ophthalmic Solution)

2

73100101 101



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Dorzolamide HCl-Timolol Maleate Preservative Free

Dorzolamide HCl-Timolol Maleate Preservative Free (Ophthalmic Solution)

4

C1

Levobunolol HCl Levobunolol HCl


C1

Phospholine Iodide Phospholine Iodide

(Ophthalmic Solution

Reconstituted)

4

C1

Pilocarpine HCl Pilocarpine HCl


C1

Simbrinza

Simbrinza

(Ophthalmic

Suspension)

3

C1

Timolol Maleate Ophthalmic Gel Forming

Timolol Maleate Ophthalmic Gel Forming (Ophthalmic Solution) (Generic Timoptic-XE)

3

C1

Timolol Maleate Timolol Maleate

(0.25% Ophthalmic Solution, 0.5% Ophthalmic Solution) (Generic Timoptic)

2

B1

Ophthalmic Anti-inflammatoriesC1

Dexamethasone Sodium Phosphate Dexamethasone

Sodium Phosphate (Ophthalmic Solution)

2

C1



C1

Durezol

Durezol (Ophthalmic

Emulsion)3

C1

Flarex

Flarex (Ophthalmic

Suspension)4

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Fluorometholone Fluorometholone

(Ophthalmic Suspension)

3

C1

Flurbiprofen Sodium Flurbiprofen Sodium


C1

FML Forte

FML Forte

(Ophthalmic

Suspension)

4

C1

FML

FML (Ophthalmic

Ointment)4

C1

Ilevro

Ilevro (Ophthalmic

Suspension)3

C1

Ketorolac Tromethamine Ketorolac

Tromethamine (Ophthalmic Solution)

3

C1

Lotemax

Lotemax (Ophthalmic

Gel)4

C1

Lotemax

Lotemax (Ophthalmic

Ointment)4

C1

Lotemax

Lotemax (Ophthalmic

Suspension)4

C1

Lotemax SM

Lotemax SM

(Ophthalmic Gel)4

C1

Loteprednol Etabonate Loteprednol Etabonate


4

C1

Pred Mild

Pred Mild

(Ophthalmic

Suspension)

4

C1

Prednisolone Acetate Prednisolone Acetate


3

C1

Prednisolone Sodium Phosphate Prednisolone Sodium

Phosphate (1% Ophthalmic Solution)

2

74101102102



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Prolensa

Prolensa (Ophthalmic

Solution)4

B1

Ophthalmic Prostaglandin and Prostamide Analogs

C1

Latanoprost

Latanoprost (Ophthalmic Solution)

1

C1

Lumigan

Lumigan (Ophthalmic

Solution)3

C1

Vyzulta

Vyzulta (Ophthalmic

Solution)4

C1

Zioptan

Zioptan (Ophthalmic

Solution)4

A1

Otic AgentsB1

Otic AgentsC1

Acetic Acid

Acetic Acid (Otic Solution)

2

C1

Cipro HC

Cipro HC (Otic

Suspension)4

C1

Ciprodex

Ciprodex (Otic

Suspension)3

C1

Flac

Flac (Otic Oil) 4

C1


Acetonide (Otic Oil)4

C1

Hydrocortisone-Acetic Acid Hydrocortisone-Acetic

Acid (Otic Solution)3

C1


HC (1% Otic Solution)3

C1


HC (Otic Suspension)3

A1

Respiratory Tract/Pulmonary AgentsB1

AntihistaminesC1

Azelastine HCl Azelastine HCl (0.1%

Nasal Solution, 0.15% Nasal Solution)

3

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Cetirizine HCl Cetirizine HCl (1MG/

ML Oral Solution)2

C1

Cyproheptadine HCl Cyproheptadine HCl

(Oral Syrup)4

C1

Cyproheptadine HCl Cyproheptadine HCl

(Oral Tablet)4

C1

Levocetirizine Dihydrochloride Levocetirizine

Dihydrochloride (Oral Tablet)

1 QL

C1

Phenadoz

Phenadoz (12.5MG Rectal Suppository)

4

C1

Promethazine HCl Promethazine HCl

(Oral Syrup)3

C1


(Oral Tablet)3

C1


(12.5MG Rectal Suppository, 25MG Rectal Suppository)

4

C1

Promethegan Promethegan (25MG

Rectal Suppository)4

B1

Anti-inflammatories, Inhaled CorticosteroidsC1

Arnuity Ellipta

Arnuity Ellipta

(Inhalation Aerosol

Powder Breath

Activated)

3 QL

C1

Budesonide

Budesonide (Inhalation Suspension)

4 B/D, PA C1

Flovent Diskus

Flovent Diskus

(Inhalation Aerosol

Powder Breath

Activated)

3 QL

C1

Flovent HFA

Flovent HFA

(Inhalation Aerosol)3 QL

75102103 103



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Flunisolide

Flunisolide (Nasal Solution)

1

C1


(Nasal Suspension)2

C1


(Nasal Suspension)4

B1

AntileukotrienesC1

Montelukast Sodium Montelukast Sodium

(Oral Packet)2 QL

C1


(Oral Tablet)1 QL

C1


(Oral Tablet Chewable)2 QL

C1

Zafirlukast

Zafirlukast (Oral Tablet)

3 QL C1

Zileuton ER

Zileuton ER (Oral Tablet Extended Release 12 Hour)

5 ST

C1

Zyflo

Zyflo (Oral Tablet

Immediate Release)5 ST

B1

Bronchodilators, AnticholinergicC1

Atrovent HFA

Atrovent HFA

(Inhalation Aerosol

Solution)

4

C1

Incruse Ellipta

Incruse Ellipta

(Inhalation Aerosol

Powder Breath

Activated)

3 QL

C1

Ipratropium Bromide Ipratropium Bromide

(Inhalation Solution)2 B/D, PA

C1

Ipratropium Bromide Ipratropium Bromide

(Nasal Solution)2

C1

Lonhala Magnair Refill Kit Lonhala Magnair

Refill Kit (Inhalation

Solution)

5 QL

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Spiriva HandiHaler Spiriva HandiHaler

(Inhalation Capsule)3 QL

C1

Spiriva Respimat Spiriva Respimat

(Inhalation Aerosol

Solution)

3 QL

B1

Bronchodilators, SympathomimeticC1

Albuterol Sulfate Albuterol Sulfate

(Inhalation Nebulization Solution)

2 B/D, PA

C1

Albuterol Sulfate Albuterol Sulfate (Oral

Syrup)4

C1

Albuterol Sulfate Albuterol Sulfate (Oral


4

C1

Epinephrine

Epinephrine (0.15MG/0.3ML Injection Solution Auto-Injector) (Brand Equivalent Epipen-JR), Epinephrine (0.3MG/0.3ML Injection Solution Auto-Injector) (Brand Equivalent Epipen)

3 QL

C1

EpiPen 2-Pak

EpiPen 2-Pak

(Injection Solution

Auto-Injector)

3 QL

C1

EpiPen Jr 2-Pak

EpiPen Jr 2-Pak

(Injection Solution

Auto-Injector)

3 QL

C1

Levalbuterol HCl Levalbuterol HCl


4 B/D, PA

C1

Metaproterenol Sulfate Metaproterenol Sulfate

(Oral Syrup)4

76103104104



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Metaproterenol Sulfate Metaproterenol Sulfate

(10MG Oral Tablet, 20MG Oral Tablet)

4

C1

Perforomist

Perforomist

(Inhalation

Nebulization

Solution)

4 B/D, PA; QL

C1

ProAir HFA

ProAir HFA

(Inhalation Aerosol

Solution)

3

C1

ProAir RespiClick ProAir RespiClick

(Inhalation Aerosol

Powder Breath

Activated)

3

C1

Serevent Diskus Serevent Diskus

(Inhalation Aerosol

Powder Breath

Activated)

3 QL

B1

Cystic Fibrosis AgentsC1

Bethkis

Bethkis (Inhalation

Nebulization

Solution)

5 B/D, PA; QL

C1

Cayston

Cayston (Inhalation

Solution

Reconstituted)

5 PA; LA

C1

Orkambi

Orkambi (Oral

Packet)5 PA; LA; QL

C1

Orkambi

Orkambi (Oral Tablet) 5 PA; LA; QL C1

TOBI Podhaler TOBI Podhaler

(Inhalation Capsule)5 PA; QL

C1

Tobramycin

Tobramycin (Inhalation Nebulization Solution)

5 B/D, PA; QL B1

Mast Cell Stabilizers

Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1



3 B/D, PA

B1

Phosphodiesterase Inhibitors, Airways Disease

C1

Daliresp

Daliresp (Oral Tablet) 4 PA; QL C1

Theophylline ER Theophylline ER

(100MG Oral Tablet Extended Release 12 Hour, 200MG Oral Tablet Extended Release 12 Hour, 300MG Oral Tablet Extended Release 12 Hour)

2

C1

Theophylline ER Theophylline ER (Oral


2

C1

Theophylline Theophylline (Oral

Solution)2

B1

Pulmonary AntihypertensivesC1

Adempas

Adempas (Oral

Tablet)5 PA; LA

C1

Alyq

Alyq (Oral Tablet) 5 PA; QL C1

Ambrisentan Ambrisentan (Oral

Tablet)5 PA; LA; QL

C1

Bosentan

Bosentan (Oral Tablet) 5 PA; LA; QL C1

Opsumit

Opsumit (Oral Tablet) 5 PA; LA C1

Orenitram

Orenitram (0.125MG

Oral Tablet Extended

Release)

4 PA; LA

77104105 105



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Orenitram

Orenitram (0.25MG

Oral Tablet Extended

Release, 1MG Oral

Tablet Extended

Release, 2.5MG Oral

Tablet Extended

Release, 5MG Oral

Tablet Extended

Release)

5 PA; LA

C1

Sildenafil Citrate Sildenafil Citrate

(20MG Oral Tablet) (Generic Revatio)

3 PA; QL

C1

Tadalafil

Tadalafil (PAH) (20MG Oral Tablet)

5 PA; QL C1

Tracleer

Tracleer (Oral Tablet

Soluble)5 PA; LA; QL

C1

Ventavis

Ventavis (Inhalation

Solution)5 PA; LA; QL

B1

Pulmonary Fibrosis AgentsC1

Esbriet

Esbriet (Oral Capsule) 5 PA; LA; QL C1

Esbriet

Esbriet (Oral Tablet) 5 PA; LA; QL C1

Ofev

Ofev (Oral Capsule) 5 PA; LA; QL B1

Respiratory Tract Agents, OtherC1

Acetylcysteine Acetylcysteine


C1

Advair Diskus

Advair Diskus

(Inhalation Aerosol

Powder Breath

Activated)

3 QL

C1

Advair HFA

Advair HFA


Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Anoro Ellipta

Anoro Ellipta

(Inhalation Aerosol

Powder Breath

Activated)

3 QL

C1

Bevespi Aerosphere Bevespi Aerosphere


C1

Breo Ellipta

Breo Ellipta

(Inhalation Aerosol

Powder Breath

Activated)

3 QL

C1

Combivent Respimat Combivent Respimat

(Inhalation Aerosol

Solution)

3 QL

C1

Dulera

Dulera (Inhalation

Aerosol)4 QL

C1

Dymista

Dymista (Nasal

Suspension)4

C1

Fluticasone-Salmeterol Fluticasone-Salmeterol

(Inhalation Aerosol Powder Breath Activated)

3 QL

C1

Ipratropium-Albuterol Ipratropium-Albuterol


C1

Kalydeco

Kalydeco (Oral

Packet)5 PA; LA; QL

C1

Kalydeco

Kalydeco (Oral

Tablet)5 PA; LA; QL

C1

Nucala

Nucala

(Subcutaneous

Solution Auto-

Injector)

5 PA; LA; QL

C1

Nucala

Nucala

(Subcutaneous

Solution Prefilled

Syringe)

5 PA; LA; QL

78105106106



Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Nucala

Nucala

(Subcutaneous

Solution

Reconstituted)

5 PA; LA; QL

C1

Pulmozyme

Pulmozyme

(Inhalation Solution)5 B/D, PA; QL

C1

Stiolto Respimat Stiolto Respimat

(Inhalation Aerosol

Solution)

3 QL

C1

Symbicort

Symbicort (Inhalation

Aerosol)3 QL

C1

Trelegy Ellipta

Trelegy Ellipta

(Inhalation Aerosol

Powder Breath

Activated)

3 QL

C1

Wixela Inhub Wixela Inhub

(Inhalation Aerosol Powder Breath Activated) (Generic Advair)

3 QL

A1

Skeletal Muscle RelaxantsB1

Skeletal Muscle RelaxantsC1

Baclofen

Baclofen (Oral Tablet) 2

C1

Chlorzoxazone Chlorzoxazone


Drug NameDrug

Tier

Coverage

Rules or

Limits on

useC1

Cyclobenzaprine HCl Cyclobenzaprine HCl

(10MG Oral Tablet, 5MG Oral Tablet)

2

C1

Cyclobenzaprine HCl Cyclobenzaprine HCl

(7.5MG Oral Tablet)4

C1

Dantrolene Sodium Dantrolene Sodium

(Oral Capsule)4

C1

Tizanidine HCl Tizanidine HCl (Oral

Tablet)2

A1

Sleep Disorder AgentsB1

GABA Receptor ModulatorsC1

Temazepam

Temazepam (15MG Oral Capsule, 30MG Oral Capsule)

2 QL

C1

Zaleplon

Zaleplon (Oral Capsule)

3 QL C1

Zolpidem Tartrate Zolpidem Tartrate


2 QL

B1

Sleep Disorders, OtherC1

Belsomra

Belsomra (Oral

Tablet)3 QL

C1

Hetlioz

Hetlioz (Oral Capsule) 5 PA; LA; QL C1

Modafinil

Modafinil (Oral Tablet) 4 PA; QL C1

Xyrem

Xyrem (Oral Solution) 5 PA; LA; QL

11107 track


107Covered drugs with a quantity limit (QL)This list shows drugs that have a quantity limit. Some drugs come in several strengths. Each strength may have a different quantity limit. If quantity limits for a drug vary by strength, the different strengths are listed on separate lines. These limits may be in place to ensure your safety.

Your plan will cover only a certain amount of these drugs or will only cover these drugs for a certain number of days. For more information about quantity limits, talk with your doctor or pharmacist. You can also call UnitedHealthcare Customer Service. Our contact information is on the cover.

Drugs are listed in alphabetical order in the chart below.track

Drug Name Quantity Limit

Abacavir Sulfate (Oral Solution) Maximum of 32 ml per day

Abacavir Sulfate (Oral Tablet) Maximum of 2 tablets per day

Abacavir Sulfate-Lamivudine (Oral Tablet) Maximum of 1 tablet per day

Abacavir-Lamivudine-Zidovudine (Oral Tablet) Maximum of 2 tablets per day

Abiraterone Acetate (Oral Tablet) Maximum of 4 tablets per day

Acarbose (100MG Oral Tablet) Maximum of 3 tablets per day



Acetaminophen-Codeine (120-12MG/5ML Oral Solution)

Maximum of 150 ml per day

Acetaminophen-Codeine (300-15MG Oral Tablet, 300-30MG Oral Tablet, 300-60MG Oral Tablet)

Maximum of 13 tablets per day

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

Advair Diskus (Inhalation Aerosol Powder

Breath Activated)Maximum of 1 inhaler (60 blisters) per 30 days

Advair HFA (Inhalation Aerosol) Maximum of 1 inhaler (12 grams) per 30 days

Aimovig (140MG/ML Subcutaneous Solution

Auto-Injector)Maximum of 1 ml (1 pen) per 30 days

Aimovig (70MG/ML Subcutaneous Solution

Auto-Injector)Maximum of 2 ml per 30 days

Albendazole (Oral Tablet) Maximum of 16 tablets per day

Alecensa (Oral Capsule) Maximum of 8 capsules per day

Alendronate Sodium (10MG Oral Tablet, 40MG Oral Tablet, 5MG Oral Tablet)

Maximum of 1 tablet per day

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

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

Aliskiren Fumarate (Oral Tablet) Maximum of 1 tablet per day

22108


108 Last updated September 1, 2019


Alprazolam (0.25MG Oral Tablet Immediate Release, 0.5MG Oral Tablet Immediate Release, 1MG Oral Tablet Immediate Release)


Alprazolam (2MG Oral Tablet Immediate Release)


Alunbrig (180MG Oral Tablet, 90MG Oral

Tablet)Maximum of 1 tablet per day

Alunbrig (30MG Oral Tablet) Maximum of 4 tablets per day

Alunbrig (Oral Tablet Therapy Pack) Maximum of 1 pack (30 tablets) per 30 days

Alyq (Oral Tablet) Maximum of 2 tablets per day

Ambrisentan (Oral Tablet) Maximum of 1 tablet per day

Amitiza (Oral Capsule) Maximum of 2 capsules per day

Amlodipine-Atorvastatin (Oral Tablet) Maximum of 1 tablet per day

Amlodipine-Benazepril (Oral Capsule) Maximum of 1 capsule per day

Amlodipine-Olmesartan (Oral Tablet) Maximum of 1 tablet per day

Amlodipine-Valsartan (Oral Tablet) Maximum of 1 tablet per day

Amlodipine-Valsartan-HCTZ (Oral Tablet) Maximum of 1 tablet per day

Amphetamine-Dextroamphetamine ER (Oral Capsule Extended Release 24 Hour)

Maximum of 2 capsules per day

Amphetamine-Dextroamphetamine (10MG Oral Tablet, 12.5MG Oral Tablet, 15MG Oral Tablet, 30MG Oral Tablet, 5MG Oral Tablet, 7.5MG Oral Tablet)


Amphetamine-Dextroamphetamine (20MG Oral Tablet)


Ampyra (Oral Tablet Extended Release 12

Hour)Maximum of 2 tablets per day

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

Anoro Ellipta (Inhalation Aerosol Powder


Apokyn (Subcutaneous Solution Cartridge) Maximum of 3 ml per day

Apriso (Oral Capsule Extended Release 24

Hour)Maximum of 4 capsules per day

Aptiom (200MG Oral Tablet, 400MG Oral


Aptiom (600MG Oral Tablet, 800MG Oral

Tablet)Maximum of 2 tablets per day

Aptivus (Oral Capsule) Maximum of 4 capsules per day

Aptivus (Oral Solution) Maximum of 4 bottles (380 ml) per 30 days

33109


109Last updated September 1, 2019


Aripiprazole (1MG/ML Oral Solution) Maximum of 25 ml per day

Aripiprazole (10MG Oral Tablet, 15MG Oral Tablet, 20MG Oral Tablet, 2MG Oral Tablet, 30MG Oral Tablet, 5MG Oral Tablet)


Aripiprazole ODT (10MG Oral Tablet Dispersible)


Aripiprazole ODT (15MG Oral Tablet Dispersible)


Arnuity Ellipta (Inhalation Aerosol Powder


Aspirin-Dipyridamole ER (Oral Capsule Extended Release 12 Hour)


Atazanavir Sulfate (150MG Oral Capsule, 300MG Oral Capsule)

Maximum of 1 capsule per day

Atazanavir Sulfate (200MG Oral Capsule) Maximum of 2 capsules per day

Atomoxetine HCl (100MG Oral Capsule, 60MG Oral Capsule, 80MG Oral Capsule)


Atomoxetine HCl (10MG Oral Capsule, 18MG Oral Capsule, 25MG Oral Capsule, 40MG Oral Capsule)


Atorvastatin Calcium (Oral Tablet) Maximum of 1 tablet per day

Atripla (Oral Tablet) Maximum of 1 tablet per day

Aubagio (Oral Tablet) Maximum of 1 tablet per day

Austedo (Oral Tablet) Maximum of 4 tablets per day

Avonex (30MCG Intramuscular Kit) Maximum of 1 kit (4 vials) per 28 days

Avonex Pen (Intramuscular Auto-Injector Kit) Maximum of 1 kit per 28 days

Avonex Prefilled (Intramuscular Prefilled

Syringe Kit)Maximum of 1 kit per 28 days

Balversa (3MG Oral Tablet) Maximum of 3 tablets per day

Balversa (4MG Oral Tablet) Maximum of 2 tablets per day

Balversa (5MG Oral Tablet) Maximum of 1 tablet per day

Belsomra (Oral Tablet) Maximum of 1 tablet per day

Benazepril HCl (Oral Tablet) Maximum of 2 tablets per day

Benazepril-Hydrochlorothiazide (Oral Tablet) Maximum of 1 tablet per day

Betaseron (Subcutaneous Kit) Maximum of 1 kit (15 vials) per 30 days

Bethkis (Inhalation Nebulization Solution) Maximum of 8 ml (2 ampules) per day

Bevespi Aerosphere (Inhalation Aerosol) Maximum of 1 inhaler (10.7 grams) per 30 days

BiDil (Oral Tablet) Maximum of 6 tablets per day

Biktarvy (Oral Tablet) Maximum of 1 tablet per day

44110




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

Bisoprolol-Hydrochlorothiazide (Oral Tablet) Maximum of 2 tablets per day

Bosentan (Oral Tablet) Maximum of 2 tablets per day

Bosulif (100MG Oral Tablet) Maximum of 6 tablets per day

Bosulif (400MG Oral Tablet, 500MG Oral


Breo Ellipta (Inhalation Aerosol Powder


Brilinta (Oral Tablet) Maximum of 2 tablets per day

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

BRIVIACT (100MG Oral Tablet, 10MG Oral

Tablet, 25MG Oral Tablet, 50MG Oral Tablet,

75MG Oral Tablet)


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

Buprenorphine HCl-Naloxone HCl (12-3MG Sublingual Film, 4-1MG Sublingual Film)

Maximum of 2 films per day

Buprenorphine HCl-Naloxone HCl (2-0.5MG Sublingual Film, 8-2MG Sublingual Film)

Maximum of 3 films per day

Buprenorphine HCl-Naloxone HCl (Tablet Sublingual)


Buprenorphine (Transdermal Patch Weekly) Maximum of 4 patches per 28 days

Butalbital-Acetaminophen-Caffeine (Oral Tablet) Maximum of 6 tablets per day

Butalbital-Aspirin-Caffeine (Oral Capsule) Maximum of 6 capsules per day

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

Bydureon BCise (Subcutaneous Auto-

Injector)Maximum of 4 pens (3.4 ml) per 28 days

Bydureon (Subcutaneous Pen-Injector) Maximum of 4 pens per 28 days

Byetta 10MCG Pen (Subcutaneous Solution

Pen-Injector)Maximum of 1 pen (2.4 ml) per 30 days

Byetta 5MCG Pen (Subcutaneous Solution

Pen-Injector)Maximum of 1 pen (1.2 ml) per 30 days

Bystolic (10MG Oral Tablet, 2.5MG Oral

Tablet, 5MG Oral Tablet)Maximum of 1 tablet per day

Bystolic (20MG Oral Tablet) Maximum of 2 tablets per day

Cablivi (Injection Kit) Maximum of 1 kit per day

Cabometyx (20MG Oral Tablet, 60MG Oral


Cabometyx (40MG Oral Tablet) Maximum of 2 tablets per day

Calcitonin Salmon (Nasal Solution) Maximum of 1 bottle per 28 days

55111




Calquence (Oral Capsule) Maximum of 2 capsules per day

Candesartan Cilexetil (16MG Oral Tablet, 32MG Oral Tablet, 4MG Oral Tablet)


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

Candesartan Cilexetil-HCTZ (Oral Tablet) Maximum of 1 tablet per day

Captopril (100MG Oral Tablet) Maximum of 4 tablets per day

Captopril (12.5MG Oral Tablet, 25MG Oral Tablet)


Captopril (50MG Oral Tablet) Maximum of 9 tablets per day

Captopril-Hydrochlorothiazide (25-15MG Oral Tablet, 50-15MG Oral Tablet)


Captopril-Hydrochlorothiazide (25-25MG Oral Tablet, 50-25MG Oral Tablet)


Celecoxib (Oral Capsule) Maximum of 2 capsules per day

Cimduo (Oral Tablet) Maximum of 1 tablet per day

Cinacalcet HCl (30MG Oral Tablet, 60MG Oral Tablet)


Cinacalcet HCl (90MG Oral Tablet) Maximum of 4 tablets per day

Clobazam (2.5MG/ML Oral Suspension) Maximum of 16 ml per day

Clobazam (10MG Oral Tablet, 20MG Oral Tablet)


Clonazepam (0.5MG Oral Tablet, 1MG Oral Tablet)


Clonazepam (2MG Oral Tablet) Maximum of 10 tablets per day

Clonazepam ODT (0.125MG Oral Tablet Dispersible, 0.25MG Oral Tablet Dispersible, 0.5MG Oral Tablet Dispersible, 1MG Oral Tablet Dispersible)


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

Clopidogrel Bisulfate (75MG Oral Tablet) Maximum of 4 tablets per day

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

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

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

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

Clozapine ODT (12.5MG Oral Tablet Dispersible)





66112




Codeine Sulfate (Oral Tablet) Maximum of 6 tablets per day

Colchicine (0.6MG Oral Capsule) (Brand

Equivalent Mitigare)Maximum of 4 capsules per day

Colchicine (0.6MG Oral Tablet) (Brand Equivalent Colcrys)


Colcrys (Oral Tablet) Maximum of 4 tablets per day

Combivent Respimat (Inhalation Aerosol

Solution)Maximum of 1 inhaler (4 grams) per 20 days

Complera (Oral Tablet) Maximum of 1 tablet per day

Copiktra (Oral Capsule) Maximum of 2 capsules per day

Corlanor (Oral Tablet) Maximum of 2 tablets per day

Cotellic (Oral Tablet) Maximum of 3 tablets per day

Crixivan (200MG Oral Capsule) Maximum of 9 capsules per day

Crixivan (400MG Oral Capsule) Maximum of 6 capsules per day

Cycloset (Oral Tablet) Maximum of 6 tablets per day

Daklinza (30MG Oral Tablet, 60MG Oral


Dalfampridine ER (Oral Tablet Extended Release 12 Hour)


Daliresp (Oral Tablet) Maximum of 1 tablet per day

Daurismo (100MG Oral Tablet) Maximum of 1 tablet per day

Daurismo (25MG Oral Tablet) Maximum of 2 tablets per day

Delstrigo (Oral Tablet) Maximum of 1 tablet per day

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

Descovy (Oral Tablet) Maximum of 1 tablet per day

Desvenlafaxine Succinate ER (100MG Oral Tablet Extended Release 24 Hour) (Generic Pristiq)


Desvenlafaxine Succinate ER (25MG Oral Tablet Extended Release 24 Hour, 50MG Oral Tablet Extended Release 24 Hour) (Generic Pristiq)


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

Dexmethylphenidate HCl (Oral Tablet) Maximum of 2 tablets per day

Dextroamphetamine Sulfate ER (10MG Oral Capsule Extended Release 24 Hour)




77113






Dextroamphetamine Sulfate (Oral Tablet) Maximum of 6 tablets per day

Diazepam Intensol (5MG/ML Oral Concentrate) Maximum of 8 ml per day

Diazepam (10MG Oral Tablet, 2MG Oral Tablet, 5MG Oral Tablet)


Diclofenac Epolamine (Transdermal Patch) Maximum of 2 patches per day

Didanosine (200MG Oral Capsule Delayed Release)


Didanosine (250MG Oral Capsule Delayed Release, 400MG Oral Capsule Delayed Release)


Donepezil HCl (10MG Oral Tablet) Maximum of 2 tablets per day

Donepezil HCl (23MG Oral Tablet, 5MG Oral Tablet)


Donepezil HCl ODT (10MG Oral Tablet Dispersible)


Donepezil HCl ODT (5MG Oral Tablet Dispersible)


Dovato (Oral Tablet) Maximum of 1 tablet per day

Doxepin HCl (External Cream) Maximum of 90 grams per 30 days

Doxercalciferol (0.5MCG Oral Capsule) Maximum of 3 capsules per day

Doxercalciferol (1MCG Oral Capsule, 2.5MCG Oral Capsule)


Dulera (Inhalation Aerosol) Maximum of 1 inhaler (13 grams) per 30 days

Duloxetine HCl (20MG Oral Capsule Delayed Release Particles, 30MG Oral Capsule Delayed Release Particles, 60MG Oral Capsule Delayed Release Particles)


Dutasteride (Oral Capsule) Maximum of 1 capsule per day

Econazole Nitrate (External Cream) Maximum of 90 grams per 30 days

Edarbi (Oral Tablet) Maximum of 1 tablet per day

Edarbyclor (Oral Tablet) Maximum of 1 tablet per day

Edurant (Oral Tablet) Maximum of 1 tablet per day

Efavirenz (Oral Capsule) Maximum of 3 capsules per day

Efavirenz (Oral Tablet) Maximum of 1 tablet per day

Eliquis (Oral Tablet) Maximum of 2 tablets per day

Eliquis Starter Pack (Oral Tablet) Maximum of 1 pack (74 tablets) per 30 days

88114




Embeda (100-4MG Oral Capsule Extended

Release)Maximum of 3 capsules per day

Embeda (20-0.8MG Oral Capsule Extended

Release, 80-3.2MG Oral Capsule Extended

Release)



Release, 50-2MG Oral Capsule Extended

Release)




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

Emtriva (Oral Capsule) Maximum of 1 capsule per day

Emtriva (Oral Solution) Maximum of 5 bottles (850 ml) per 30 days

Enalapril Maleate (Oral Tablet) Maximum of 2 tablets per day

Enalapril-Hydrochlorothiazide (10-25MG Oral Tablet)


Enalapril-Hydrochlorothiazide (5-12.5MG Oral Tablet)


Endocet (10-325MG Oral Tablet, 5-325MG Oral Tablet, 7.5-325MG Oral Tablet)


Enoxaparin Sodium (100MG/ML Subcutaneous Solution, 150MG/ML Subcutaneous Solution)

Maximum of 2 syringes (2 ml) per day

Enoxaparin Sodium (120MG/0.8ML Subcutaneous Solution, 80MG/0.8ML Subcutaneous Solution)

Maximum of 2 syringes (1.6 ml) per day

Enoxaparin Sodium (30MG/0.3ML Subcutaneous Solution)






Entresto (Oral Tablet) Maximum of 2 tablets per day

Epclusa (Oral Tablet) Maximum of 1 tablet per day

Epinephrine (0.15MG/0.3ML Injection Solution Auto-Injector) (Brand Equivalent Epipen-JR), Epinephrine (0.3MG/0.3ML Injection Solution Auto-Injector) (Brand Equivalent Epipen)

Maximum of 4 pens (2 boxes) per 30 days

EpiPen 2-Pak (Injection Solution Auto-

Injector)Maximum of 4 pens (2 boxes) per 30 days

99115




EpiPen Jr 2-Pak (Injection Solution Auto-

Injector)Maximum of 4 pens (2 boxes) per 30 days

Eprosartan Mesylate (Oral Tablet) Maximum of 1 tablet per day

Erivedge (Oral Capsule) Maximum of 1 capsule per day

Erleada (Oral Tablet) Maximum of 4 tablets per day

Erlotinib HCl (100MG Oral Tablet, 150MG Oral Tablet)


Erlotinib HCl (25MG Oral Tablet) Maximum of 3 tablets per day

Esbriet (Oral Capsule) Maximum of 9 capsules per day

Esbriet (267MG Oral Tablet) Maximum of 9 tablets per day

Esbriet (801MG Oral Tablet) Maximum of 3 tablets per day

Esomeprazole Magnesium (20MG Oral Capsule Delayed Release) (Generic Nexium)


Esomeprazole Magnesium (40MG Oral Capsule Delayed Release) (Generic Nexium)


Estradiol (Transdermal Patch Weekly) Maximum of 4 patches per 28 days

Estradiol (Vaginal Tablet) Maximum of 1 tablet per day

Evotaz (Oral Tablet) Maximum of 1 tablet per day

Ezetimibe (Oral Tablet) Maximum of 1 tablet per day

Ezetimibe-Simvastatin (Oral Tablet) Maximum of 1 tablet per day

Famciclovir (125MG Oral Tablet, 250MG Oral Tablet)


Famciclovir (500MG Oral Tablet) Maximum of 3 tablets per day

Fanapt (10MG Oral Tablet, 12MG Oral Tablet,

1MG Oral Tablet, 2MG Oral Tablet, 4MG Oral

Tablet, 6MG Oral Tablet, 8MG Oral Tablet)


Fentanyl Citrate (Buccal Lozenge On A Handle) Maximum of 4 lozenges per day

Fentanyl (100MCG/HR Transdermal Patch 72 Hour, 12MCG/HR Transdermal Patch 72 Hour, 25MCG/HR Transdermal Patch 72 Hour, 50MCG/HR Transdermal Patch 72 Hour, 75MCG/HR Transdermal Patch 72 Hour)

Maximum of 15 patches per 30 days

Fetzima (Oral Capsule Extended Release 24

Hour)Maximum of 1 capsule per day

Firazyr (Subcutaneous Solution) Maximum of 9 ml per day

Flector (Transdermal Patch) Maximum of 2 patches per day

Flovent Diskus (Inhalation Aerosol Powder

Breath Activated)

Maximum of 2 inhalers (120 blisters) per 30 days

1010116




Flovent HFA (110MCG/ACT Inhalation

Aerosol)Maximum of 1 inhaler (12 grams) per 30 days

Flovent HFA (220MCG/ACT Inhalation

Aerosol)Maximum of 2 inhalers (24 grams) per 30 days

Flovent HFA (44MCG/ACT Inhalation Aerosol) Maximum of 1 inhaler (10.6 grams) per 30 days

Fluticasone-Salmeterol (100-50MCG/DOSE Inhalation Aerosol Powder Breath Activated, 250-50MCG/DOSE Inhalation Aerosol Powder Breath Activated, 500-50MCG/DOSE Inhalation Aerosol Powder Breath Activated) (Generic Advair)

Maximum of 1 inhaler (60 blisters) per 30 days

Fluticasone-Salmeterol (113-14MCG/ACT Inhalation Aerosol Powder Breath Activated, 232-14MCG/ACT Inhalation Aerosol Powder Breath Activated, 55-14MCG/ACT Inhalation Aerosol Powder Breath Activated) (Brand Equivalent AirDuo)

Maximum of 1 inhaler per 30 days

Fluvastatin Sodium (20MG Oral Capsule) Maximum of 1 capsule per day

Fluvastatin Sodium (40MG Oral Capsule) Maximum of 2 capsules per day

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

Fosamprenavir Calcium (Oral Tablet) Maximum of 4 tablets per day

Fosinopril Sodium (Oral Tablet) Maximum of 2 tablets per day

Fosinopril Sodium-HCTZ (Oral Tablet) Maximum of 4 tablets per day

Fuzeon (Subcutaneous Solution

Reconstituted)Maximum of 2 vials per day

Galantamine Hydrobromide ER (Oral Capsule Extended Release 24 Hour)


Galantamine Hydrobromide (Oral Solution) Maximum of 2 bottles (200 ml) per 30 days

Galantamine Hydrobromide (Oral Tablet) Maximum of 2 tablets per day

Genvoya (Oral Tablet) Maximum of 1 tablet per day

Gilenya (0.5MG Oral Capsule) Maximum of 1 pack (30 capsules) per 30 days

Glatiramer Acetate (20MG/ML Subcutaneous Solution Prefilled Syringe)

Maximum of 1 syringe (1 ml) per day

Glatiramer Acetate (40MG/ML Subcutaneous Solution Prefilled Syringe)

Maximum of 12 syringes (12 ml) per 28 days

Glatopa (20MG/ML Subcutaneous Solution Prefilled Syringe)

Maximum of 1 syringe (1 ml) per day

Glatopa (40MG/ML Subcutaneous Solution Prefilled Syringe)

Maximum of 12 syringes (12 ml) per 28 days

Glimepiride (1MG Oral Tablet) Maximum of 8 tablets per day

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Glipizide ER (10MG Oral Tablet Extended Release 24 Hour)


Glipizide ER (2.5MG Oral Tablet Extended Release 24 Hour)


Glipizide ER (5MG Oral Tablet Extended Release 24 Hour)


Glipizide (10MG Oral Tablet Immediate Release)


Glipizide (5MG Oral Tablet Immediate Release) Maximum of 8 tablets per day

Glipizide-Metformin HCl (2.5-250MG Oral Tablet)


Glipizide-Metformin HCl (2.5-500MG Oral Tablet, 5-500MG Oral Tablet)


Glyxambi (Oral Tablet) Maximum of 1 tablet per day

Granisetron HCl (Oral Tablet) Maximum of 2 tablets per day

Hetlioz (Oral Capsule) Maximum of 1 capsule per day

Hydrocodone-Acetaminophen (7.5-325MG/15ML Oral Solution)


Hydrocodone-Acetaminophen (10-325MG Oral Tablet, 5-325MG Oral Tablet, 7.5-325MG Oral Tablet)


Hydrocodone-Ibuprofen (7.5-200MG Oral Tablet)


Hydromorphone HCl ER (Oral Tablet ER 24 Hour Abuse-Deterrent)


Hydromorphone HCl (1MG/ML Oral Liquid) Maximum of 50 ml per day

Hydromorphone HCl (2MG Oral Tablet Immediate Release, 4MG Oral Tablet Immediate Release)


Hydromorphone HCl (8MG Oral Tablet Immediate Release)


Hysingla ER (Oral Tablet ER 24 Hour Abuse-

Deterrent)Maximum of 1 tablet per day

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

Ibrance (Oral Capsule) Maximum of 1 capsule per day

Iclusig (15MG Oral Tablet) Maximum of 2 tablets per day

Iclusig (45MG Oral Tablet) Maximum of 1 tablet per day

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IDHIFA (Oral Tablet) Maximum of 1 tablet per day

Imatinib Mesylate (Oral Tablet) Maximum of 3 tablets per day

Imbruvica (140MG Oral Capsule) Maximum of 4 capsules per day

Imbruvica (70MG Oral Capsule) Maximum of 1 capsule per day

Imbruvica (Oral Tablet) Maximum of 1 tablet per day

Imvexxy Maintenance Pack (Vaginal Insert) Maximum of 1 vaginal insert per day

Imvexxy Starter Pack (Vaginal Insert) Maximum of 1 vaginal insert per day

Incruse Ellipta (Inhalation Aerosol Powder


Ingrezza (Oral Capsule) Maximum of 1 capsule per day

Ingrezza (Oral Capsule Therapy Pack) Maximum of 28 capsules (1 pack) per 28 days

Inlyta (Oral Tablet) Maximum of 4 tablets per day

Intelence (100MG Oral Tablet, 200MG Oral


Intelence (25MG Oral Tablet) Maximum of 4 tablets per day

Invirase (Oral Tablet) Maximum of 4 tablets per day

Invokamet (Oral Tablet Immediate Release) Maximum of 2 tablets per day

Invokamet XR (Oral Tablet Extended Release

24 Hour)Maximum of 2 tablets per day

Invokana (Oral Tablet) Maximum of 1 tablet per day

Irbesartan (150MG Oral Tablet, 300MG Oral Tablet)


Irbesartan (75MG Oral Tablet) Maximum of 3 tablets per day

Irbesartan-Hydrochlorothiazide (Oral Tablet) Maximum of 1 tablet per day

Iressa (Oral Tablet) Maximum of 2 tablets per day

Isentress HD (Oral Tablet) Maximum of 2 tablets per day

Isentress (Oral Packet) Maximum of 2 packets per day

Isentress (Oral Tablet) Maximum of 2 tablets per day

Isentress (Oral Tablet Chewable) Maximum of 6 tablets per day

Itraconazole (Oral Capsule) Maximum of 4 capsules per day

Jakafi (Oral Tablet) Maximum of 2 tablets per day

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

Janumet XR (100-1000MG Oral Tablet

Extended Release 24 Hour)Maximum of 1 tablet per day

Janumet XR (50-1000MG Oral Tablet

Extended Release 24 Hour, 50-500MG Oral



Januvia (Oral Tablet) Maximum of 1 tablet per day

1313119




Jardiance (Oral Tablet) Maximum of 1 tablet per day

Jentadueto (Oral Tablet Immediate Release) Maximum of 2 tablets per day

Jentadueto XR (2.5-1000MG Oral Tablet

Extended Release 24 Hour)Maximum of 2 tablets per day

Jentadueto XR (5-1000MG Oral Tablet

Extended Release 24 Hour)Maximum of 1 tablet per day

Juluca (Oral Tablet) Maximum of 1 tablet per day

Kaletra (100-25MG Oral Tablet) Maximum of 2 tablets per day

Kaletra (200-50MG Oral Tablet) Maximum of 4 tablets per day

Kalydeco (Oral Packet) Maximum of 2 packets per day

Kalydeco (Oral Tablet) Maximum of 2 tablets per day

Ketoconazole (External Cream) Maximum of 90 grams per 30 days

Kisqali (200MG Dose) (Oral Tablet) Maximum of 3 tablets per day



Kisqali Femara (400MG Dose) (Oral Tablet

Therapy Pack)Maximum of 1 pack (91 tablets) per 28 days





Korlym (Oral Tablet) Maximum of 4 tablets per day

Lamivudine (10MG/ML Oral Solution) Maximum of 32 ml per day

Lamivudine (150MG Oral Tablet) Maximum of 2 tablets per day

Lamivudine (300MG Oral Tablet) Maximum of 1 tablet per day

Lamivudine-Zidovudine (Oral Tablet) Maximum of 2 tablets per day

Lansoprazole (Oral Capsule Delayed Release) Maximum of 2 capsules per day

Latuda (120MG Oral Tablet, 20MG Oral

Tablet, 40MG Oral Tablet, 60MG Oral Tablet)Maximum of 1 tablet per day

Latuda (80MG Oral Tablet) Maximum of 2 tablets per day

Levocetirizine Dihydrochloride (Oral Tablet) Maximum of 1 tablet per day

Levorphanol Tartrate (Oral Tablet) Maximum of 6 tablets per day

Lexiva (Oral Suspension) Maximum of 60 ml per day

Lidocaine (5% External Ointment) Maximum of 152 grams per 30 days

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

Linezolid (Oral Tablet) Maximum of 2 tablets per day

Linzess (Oral Capsule) Maximum of 1 capsule per day

Lisinopril (Oral Tablet) Maximum of 2 tablets per day

1414120




Lisinopril-Hydrochlorothiazide (10-12.5MG Oral Tablet)


Lisinopril-Hydrochlorothiazide (20-12.5MG Oral Tablet)


Lisinopril-Hydrochlorothiazide (20-25MG Oral Tablet)


Livalo (Oral Tablet) Maximum of 1 tablet per day

Lokelma (Oral Packet) Maximum of 90 packets per 30 days

Lonhala Magnair Refill Kit (Inhalation

Solution)Maximum of 2 vials (2 ml) per day

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

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

Lopinavir-Ritonavir (Oral Solution) Maximum of 2 bottles (320 ml) per 30 days

Lorazepam (2MG/ML Oral Concentrate) Maximum of 5 ml per day

Lorazepam (0.5MG Oral Tablet, 1MG Oral Tablet)


Lorazepam (2MG Oral Tablet) Maximum of 5 tablets per day

Lorbrena (100MG Oral Tablet) Maximum of 1 tablet per day

Lorbrena (25MG Oral Tablet) Maximum of 3 tablets per day

Lorcet HD (Oral Tablet) Maximum of 12 tablets per day

Lorcet (Oral Tablet) Maximum of 12 tablets per day

Lorcet Plus (Oral Tablet) Maximum of 12 tablets per day

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

Losartan Potassium (25MG Oral Tablet, 50MG Oral Tablet)


Losartan Potassium-HCTZ (100-12.5MG Oral Tablet, 100-25MG Oral Tablet)


Losartan Potassium-HCTZ (50-12.5MG Oral Tablet)


Lovastatin (10MG Oral Tablet, 20MG Oral Tablet)


Lovastatin (40MG Oral Tablet) Maximum of 2 tablets per day

Lynparza (Oral Tablet) Maximum of 4 tablets per day

Lyrica (100MG Oral Capsule, 150MG Oral

Capsule, 200MG Oral Capsule, 25MG Oral

Capsule, 50MG Oral Capsule, 75MG Oral

Capsule)


Lyrica (225MG Oral Capsule, 300MG Oral

Capsule)Maximum of 2 capsules per day

1515121




Lyrica (Oral Solution) Maximum of 30 ml per day

Mavyret (Oral Tablet) Maximum of 3 tablets per day

Mayzent (0.25MG Oral Tablet) Maximum of 8 tablets per day

Mayzent (2MG Oral Tablet) Maximum of 1 tablet per day

Memantine HCl ER (Oral Capsule Extended Release 24 Hour)


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

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

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

Mesalamine (1.2GM Oral Tablet Delayed Release) (Generic Lialda)


Mesalamine (Rectal Enema) Maximum of 1 bottle (60 ml) per day

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

Metformin HCl ER (500MG Oral Tablet Extended Release 24 Hour) (Generic Glucophage XR)


Metformin HCl ER (750MG Oral Tablet Extended Release 24 Hour) (Generic Glucophage XR)


Metformin HCl (1000MG Oral Tablet Immediate Release)

Maximum of 2.5 tablets per day





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

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

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

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

Methylphenidate HCl ER (10MG Oral Tablet Extended Release)


Methylphenidate HCl ER (20MG Oral Tablet Extended Release)


Methylphenidate HCl (10MG/5ML Oral Solution)


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

Methylphenidate HCl (Oral Tablet Immediate Release) (Generic Ritalin)


Miglitol (100MG Oral Tablet) Maximum of 3 tablets per day

1616122






Modafinil (100MG Oral Tablet) Maximum of 1 tablet per day

Modafinil (200MG Oral Tablet) Maximum of 2 tablets per day

Moexipril HCl (Oral Tablet) Maximum of 2 tablets per day

Montelukast Sodium (Oral Packet) Maximum of 1 packet per day

Montelukast Sodium (Oral Tablet) Maximum of 1 tablet per day

Montelukast Sodium (Oral Tablet Chewable) Maximum of 1 tablet per day

Morphine Sulfate (100MG/5ML Oral Solution) Maximum of 10 ml per day

Morphine Sulfate ER (100MG Oral Tablet Extended Release, 15MG Oral Tablet Extended Release) (Generic MS Contin)


Morphine Sulfate ER (200MG Oral Tablet Extended Release) (Generic MS Contin)


Morphine Sulfate ER (30MG Oral Tablet Extended Release, 60MG Oral Tablet Extended Release) (Generic MS Contin)




Morphine Sulfate (15MG Oral Tablet

Immediate Release)Maximum of 8 tablets per day

Morphine Sulfate (30MG Oral Tablet

Immediate Release)Maximum of 6 tablets per day

Multaq (Oral Tablet) Maximum of 2 tablets per day

Namzaric (Oral Capsule ER 24 Hour Therapy

Pack)Maximum of 1 capsule per day

Namzaric (Oral Capsule Extended Release 24

Hour)Maximum of 1 capsule per day

Naratriptan HCl (Oral Tablet) Maximum of 12 tablets per 30 days

Nateglinide (120MG Oral Tablet) Maximum of 3 tablets per day

Nateglinide (60MG Oral Tablet) Maximum of 6 tablets per day

Nebupent (Inhalation Solution Reconstituted) Maximum of 300 mg (1 vial) per 28 days

Nerlynx (Oral Tablet) Maximum of 6 tablets per day

Nevirapine ER (100MG Oral Tablet Extended Release 24 Hour)


Nevirapine ER (400MG Oral Tablet Extended Release 24 Hour)


Nevirapine (Oral Suspension) Maximum of 40 ml per day

Nevirapine (Oral Tablet Immediate Release) Maximum of 2 tablets per day

1717123




Nifedipine ER (Oral Tablet Extended Release 24 Hour)


Nifedipine ER Osmotic Release (Oral Tablet Extended Release 24 Hour)


Ninlaro (Oral Capsule) Maximum of 3 capsules per 28 days

Northera (100MG Oral Capsule) Maximum of 3 capsules per day

Northera (200MG Oral Capsule, 300MG Oral


Norvir (Oral Packet) Maximum of 12 packets per day

Norvir (Oral Solution) Maximum of 16 ml per day

Noxafil (Oral Suspension) Maximum of 20 ml per day

Noxafil (Oral Tablet Delayed Release) Maximum of 6 tablets per day

Nucala (Subcutaneous Solution Auto-Injector) Maximum of 3 ml per 28 days

Nucala (Subcutaneous Solution Prefilled

Syringe)Maximum of 3 ml per 28 days

Nucala (Subcutaneous Solution

Reconstituted)Maximum of 3 vials per 28 days

Nucynta ER (Oral Tablet Extended Release

12 Hour)Maximum of 2 tablets per day

Nuplazid (Oral Capsule) Maximum of 1 capsule per day

Nuplazid (10MG Oral Tablet) Maximum of 1 tablet per day

Ocaliva (Oral Tablet) Maximum of 1 tablet per day

Odefsey (Oral Tablet) Maximum of 1 tablet per day

Odomzo (Oral Capsule) Maximum of 1 capsule per day

Ofev (Oral Capsule) Maximum of 2 capsules per day

Olanzapine (10MG Oral Tablet, 15MG Oral Tablet, 2.5MG Oral Tablet, 20MG Oral Tablet, 5MG Oral Tablet, 7.5MG Oral Tablet)


Olanzapine ODT (10MG Oral Tablet Dispersible, 15MG Oral Tablet Dispersible, 20MG Oral Tablet Dispersible, 5MG Oral Tablet Dispersible)


Olmesartan Medoxomil (20MG Oral Tablet, 40MG Oral Tablet)


Olmesartan Medoxomil (5MG Oral Tablet) Maximum of 2 tablets per day

Olmesartan Medoxomil-HCTZ (Oral Tablet) Maximum of 1 tablet per day

Olmesartan-Amlodipine-HCTZ (Oral Tablet) Maximum of 1 tablet per day

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


1818124




Omeprazole (10MG Oral Capsule Delayed Release)


Orkambi (Oral Packet) Maximum of 56 packets per 28 days

Orkambi (Oral Tablet) Maximum of 112 tablets per 28 days

Oseltamivir Phosphate (Oral Capsule) Maximum of 2 capsules per day

Oseltamivir Phosphate (Oral Suspension Reconstituted)


Osphena (Oral Tablet) Maximum of 1 tablet per day

Oxandrolone (10MG Oral Tablet) Maximum of 2 tablets per day

Oxandrolone (2.5MG Oral Tablet) Maximum of 4 tablets per day

Oxybutynin Chloride ER (10MG Oral Tablet Extended Release 24 Hour)






Oxycodone HCl (100MG/5ML Oral Concentrate)


Oxycodone HCl (5MG/5ML Oral Solution) Maximum of 130 ml per day

Oxycodone HCl (10MG Oral Tablet Immediate Release, 5MG Oral Tablet Immediate Release)


Oxycodone HCl (15MG Oral Tablet Immediate Release)


Oxycodone HCl (20MG Oral Tablet Immediate Release, 30MG Oral Tablet Immediate Release)


Oxycodone-Acetaminophen (Oral Tablet) Maximum of 12 tablets per day

Oxycodone-Aspirin (Oral Tablet) Maximum of 12 tablets per day

Oxycodone-Ibuprofen (Oral Tablet) Maximum of 4 tablets per day

Ozempic (0.25 or 0.5MG/DOSE

Subcutaneous Solution Pen-Injector)Maximum of 1 pen (1.5 ml) per 28 days

Ozempic (1MG/DOSE Subcutaneous Solution

Pen-Injector)Maximum of 2 pens (3 ml) per 28 days

Paliperidone ER (1.5MG Oral Tablet Extended Release 24 Hour, 3MG Oral Tablet Extended Release 24 Hour, 9MG Oral Tablet Extended Release 24 Hour)


Paliperidone ER (6MG Oral Tablet Extended Release 24 Hour)


Pantoprazole Sodium (20MG Oral Tablet Delayed Release)


1919125




Pantoprazole Sodium (40MG Oral Tablet Delayed Release)


Pentasa (250MG Oral Capsule Extended


Pentasa (500MG Oral Capsule Extended


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

Perindopril Erbumine (Oral Tablet) Maximum of 2 tablets per day

Pifeltro (Oral Tablet) Maximum of 1 tablet per day

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

Pioglitazone HCl (30MG Oral Tablet, 45MG Oral Tablet)


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

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

Piqray (200 MG Daily Dose) (Oral Tablet

Therapy Pack)Maximum of 1 tablet per day


Therapy Pack)Maximum of 2 tablets per day


Therapy Pack)Maximum of 2 tablets per day

Pomalyst (Oral Capsule) Maximum of 1 capsule per day

Praluent (Subcutaneous Solution Pen-

Injector)Maximum of 2 pens (2 ml) per 28 days

Prasugrel HCl (Oral Tablet) Maximum of 1 tablet per day

Pravastatin Sodium (Oral Tablet) Maximum of 1 tablet per day

Premarin (Oral Tablet) Maximum of 1 tablet per day

Premphase (Oral Tablet) Maximum of 1 tablet per day

Prempro (Oral Tablet) Maximum of 1 tablet per day

Prezcobix (Oral Tablet) Maximum of 1 tablet per day

Prezista (Oral Suspension) Maximum of 2 bottles (400 ml) per 30 days

Prezista (150MG Oral Tablet) Maximum of 6 tablets per day

Prezista (600MG Oral Tablet, 75MG Oral


Prezista (800MG Oral Tablet) Maximum of 1 tablet per day

Prolia (Subcutaneous Solution Prefilled

Syringe)Maximum of 1 syringe per 180 days

Promacta (Oral Packet) Maximum of 6 packets per day

Promacta (12.5MG Oral Tablet, 25MG Oral


2020126




Promacta (50MG Oral Tablet, 75MG Oral


Pulmozyme (Inhalation Solution) Maximum of 5 ml (2 ampules) per day

Quetiapine Fumarate ER (150MG Oral Tablet Extended Release 24 Hour, 200MG Oral Tablet Extended Release 24 Hour)


Quetiapine Fumarate ER (300MG Oral Tablet Extended Release 24 Hour, 400MG Oral Tablet Extended Release 24 Hour, 50MG Oral Tablet Extended Release 24 Hour)


Quetiapine Fumarate (100MG Oral Tablet Immediate Release, 200MG Oral Tablet Immediate Release, 50MG Oral Tablet Immediate Release)


Quetiapine Fumarate (25MG Oral Tablet Immediate Release)


Quetiapine Fumarate (300MG Oral Tablet Immediate Release, 400MG Oral Tablet Immediate Release)


Quinapril HCl (Oral Tablet) Maximum of 2 tablets per day

Quinapril-Hydrochlorothiazide (10-12.5MG Oral Tablet)


Quinapril-Hydrochlorothiazide (20-12.5MG Oral Tablet, 20-25MG Oral Tablet)


Raloxifene HCl (Oral Tablet) Maximum of 1 tablet per day

Ramipril (Oral Capsule) Maximum of 2 capsules per day

Ranolazine ER (Oral Tablet Extended Release 12 Hour)


RAVICTI (Oral Liquid) Maximum of 17.5 ml per day

Rayaldee (Oral Capsule Extended Release) Maximum of 2 capsules per day

Rebif Rebidose (Subcutaneous Solution Auto-


Rebif Rebidose Titration Pack (Subcutaneous

Solution Auto-Injector)Maximum of 1 pack (4.2 ml) per 28 days

Rebif (Subcutaneous Solution Prefilled

Syringe)Maximum of 12 syringes (6 ml) per 28 days

Rebif Titration Pack (Subcutaneous Solution

Prefilled Syringe)Maximum of 1 pack (4.2 ml) per 28 days

Relenza Diskhaler (Inhalation Aerosol Powder

Breath Activated)Maximum of 3 inhalers (60 blisters) per 30 days

2121127




Relistor (Oral Tablet) Maximum of 3 tablets per day

Repaglinide (0.5MG Oral Tablet) Maximum of 32 tablets per day

Repaglinide (1MG Oral Tablet) Maximum of 16 tablets per day

Repaglinide (2MG Oral Tablet) Maximum of 8 tablets per day

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

Repatha Pushtronex System (Subcutaneous

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

Repatha (Subcutaneous Solution Prefilled

Syringe)Maximum of 3 syringes (3 ml) per 28 days

Repatha SureClick (Subcutaneous Solution

Auto-Injector)Maximum of 3 pens (3 ml) per 28 days

Rescriptor (Oral Tablet) Maximum of 6 tablets per day

Restasis (Ophthalmic Emulsion) Maximum of 2 vials per day

Revlimid (Oral Capsule) Maximum of 1 capsule per day

Rexulti (Oral Tablet) Maximum of 1 tablet per day

Reyataz (Oral Packet) Maximum of 6 packets per day

Riomet (Oral Solution) Maximum of 25.5 ml per day

Risedronate Sodium (150MG Oral Tablet Immediate Release)

Maximum of 1 tablet per 30 days

Risedronate Sodium (30MG Oral Tablet Immediate Release, 5MG Oral Tablet Immediate Release)


Risedronate Sodium (35MG Oral Tablet Immediate Release, 35MG (12 PACK) Oral Tablet Immediate Release, 35MG (4 PACK) Oral Tablet Immediate Release)

Maximum of 4 tablets per 28 days

Ritonavir (Oral Tablet) Maximum of 12 tablets per day

Rivastigmine Tartrate (Oral Capsule) Maximum of 2 capsules per day

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

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

Rizatriptan Benzoate ODT (Oral Tablet Dispersible)


Rosuvastatin Calcium (Oral Tablet) Maximum of 1 tablet per day

Rubraca (Oral Tablet) Maximum of 4 tablets per day

Rydapt (Oral Capsule) Maximum of 8 capsules per day

Saphris (Tablet Sublingual) Maximum of 2 tablets per day

Selzentry (Oral Solution) Maximum of 8 bottles (1840 ml) per 30 days

Selzentry (150MG Oral Tablet, 75MG Oral


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Selzentry (25MG Oral Tablet, 300MG Oral


Serevent Diskus (Inhalation Aerosol Powder

Breath Activated)

Maximum of 1 inhaler (60 inhalations) per 30 days

Sildenafil Citrate (20MG Oral Tablet) (Generic Revatio)


Silodosin (Oral Capsule) Maximum of 1 capsule per day

Simvastatin (Oral Tablet) Maximum of 1 tablet per day

Sofosbuvir-Velpatasvir (Oral Tablet) Maximum of 1 tablet per day

Solifenacin Succinate (Oral Tablet) Maximum of 1 tablet per day

Soliqua (Subcutaneous Solution Pen-Injector) Maximum of 18 ml (6 pens) per 30 days

Somavert (Subcutaneous Solution

Reconstituted)Maximum of 1 vial per day

Sovaldi (Oral Tablet) Maximum of 1 tablet per day

Spiriva HandiHaler (Inhalation Capsule) Maximum of 1 capsule per day

Spiriva Respimat (Inhalation Aerosol

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

Sprycel (100MG Oral Tablet, 140MG Oral


Sprycel (20MG Oral Tablet, 50MG Oral


Sprycel (80MG Oral Tablet) Maximum of 2 tablets per day

Stavudine (Oral Capsule) Maximum of 2 capsules per day

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

Stivarga (Oral Tablet) Maximum of 4 tablets per day

Stribild (Oral Tablet) Maximum of 1 tablet per day

Suboxone (12-3MG Sublingual Film, 4-1MG

Sublingual Film)Maximum of 2 films per day

Suboxone (2-0.5MG Sublingual Film, 8-2MG

Sublingual Film)Maximum of 3 films per day

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

Sumatriptan Succinate (100MG Oral Tablet, 25MG Oral Tablet, 50MG Oral Tablet)


Sumatriptan Succinate Refill (Subcutaneous

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

Sumatriptan Succinate (6MG/0.5ML Subcutaneous Solution)

Maximum of 12 injections (6 ml) per 30 days

Sumatriptan Succinate (4MG/0.5ML Subcutaneous Solution Auto-Injector)


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Sumatriptan Succinate (6MG/0.5ML Subcutaneous Solution Auto-Injector) (Generic Imitrex)


Sumatriptan Succinate (6MG/0.5ML

Subcutaneous Solution Auto-Injector)

(Generic Imitrex STATdose)


Sumatriptan Succinate (6MG/0.5ML Subcutaneous Solution Prefilled Syringe)


Sutent (12.5MG Oral Capsule, 25MG Oral

Capsule, 50MG Oral Capsule)Maximum of 1 capsule per day

Sutent (37.5MG Oral Capsule) Maximum of 2 capsules per day

Symbicort (Inhalation Aerosol) Maximum of 1 inhaler (10.2 grams) per 30 days

Symfi Lo (Oral Tablet) Maximum of 1 tablet per day

Symfi (Oral Tablet) Maximum of 1 tablet per day

Sympazan (Oral Film) Maximum of 2 films per day

Symtuza (Oral Tablet) Maximum of 1 tablet per day

Synjardy (Oral Tablet Immediate Release) Maximum of 2 tablets per day

Synjardy XR (10-1000MG Oral Tablet




Synjardy XR (12.5-1000MG Oral Tablet




Tadalafil (PAH) (20MG Oral Tablet) Maximum of 2 tablets per day

Tagrisso (Oral Tablet) Maximum of 1 tablet per day

Talzenna (0.25MG Oral Capsule) Maximum of 3 capsules per day

Talzenna (1MG Oral Capsule) Maximum of 1 capsule per day

Tasigna (150MG Oral Capsule) Maximum of 5 capsules per day



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

Telmisartan (Oral Tablet) Maximum of 1 tablet per day

Telmisartan-Amlodipine (Oral Tablet) Maximum of 1 tablet per day

Telmisartan-HCTZ (40-12.5MG Oral Tablet, 80-25MG Oral Tablet)


Telmisartan-HCTZ (80-12.5MG Oral Tablet) Maximum of 2 tablets per day

Temazepam (15MG Oral Capsule, 30MG Oral Capsule)


Tenofovir Disoproxil Fumarate (Oral Tablet) Maximum of 1 tablet per day

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Tetrabenazine (12.5MG Oral Tablet) Maximum of 3 tablets per day

Tetrabenazine (25MG Oral Tablet) Maximum of 4 tablets per day

Thalomid (100MG Oral Capsule, 50MG Oral

Capsule)Maximum of 1 capsule per day

Thalomid (150MG Oral Capsule, 200MG Oral


Tibsovo (Oral Tablet) Maximum of 2 tablets per day

Tivicay (10MG Oral Tablet, 25MG Oral Tablet) Maximum of 1 tablet per day

Tivicay (50MG Oral Tablet) Maximum of 2 tablets per day

TOBI Podhaler (Inhalation Capsule) Maximum of 8 capsules per day

Tobramycin (Inhalation Nebulization Solution) Maximum of 10 ml (2 ampules) per day

Tolcapone (Oral Tablet) Maximum of 6 tablets per day

Tracleer (Oral Tablet Soluble) Maximum of 8 tablets per day

Tradjenta (Oral Tablet) Maximum of 1 tablet per day

Tramadol HCl ER (Biphasic) (Oral Tablet Extended Release 24 Hour)


Tramadol HCl ER (Oral Tablet Extended Release 24 Hour)


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

Tramadol-Acetaminophen (Oral Tablet) Maximum of 8 tablets per day

Trandolapril (1MG Oral Tablet, 2MG Oral Tablet)


Trandolapril (4MG Oral Tablet) Maximum of 2 tablets per day

Trelegy Ellipta (Inhalation Aerosol Powder


Trezix (Oral Capsule) Maximum of 10 capsules per day

Trientine HCl (Oral Capsule) Maximum of 8 capsules per day

Trintellix (Oral Tablet) Maximum of 1 tablet per day

Triumeq (Oral Tablet) Maximum of 1 tablet per day

Trulicity (Subcutaneous Solution Pen-


Truvada (Oral Tablet) Maximum of 1 tablet per day

Tybost (Oral Tablet) Maximum of 1 tablet per day

Tymlos (Subcutaneous Solution Pen-Injector) Maximum of 1.56 ml per 30 days

Valacyclovir HCl (1GM Oral Tablet) Maximum of 4 tablets per day

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

Valganciclovir HCl (50MG/ML Oral Solution Reconstituted)


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Valganciclovir HCl (450MG Oral Tablet) Maximum of 4 tablets per day

Valsartan (160MG Oral Tablet, 40MG Oral Tablet, 80MG Oral Tablet)


Valsartan (320MG Oral Tablet) Maximum of 1 tablet per day

Valsartan-Hydrochlorothiazide (Oral Tablet) Maximum of 1 tablet per day

Vancomycin HCl (125MG Oral Capsule) Maximum of 4 capsules per day

Vancomycin HCl (250MG Oral Capsule) Maximum of 8 capsules per day

Veltassa (Oral Packet) Maximum of 1 packet per day

Vemlidy (Oral Tablet) Maximum of 1 tablet per day

Venclexta (100MG Oral Tablet) Maximum of 6 tablets per day

Venclexta (10MG Oral Tablet) Maximum of 2 tablets per day

Venclexta (50MG Oral Tablet) Maximum of 1 tablet per day

Ventavis (10MCG/ML Inhalation Solution) Maximum of 7 ml per day

Ventavis (20MCG/ML Inhalation Solution) Maximum of 3 ml per day

Verzenio (Oral Tablet) Maximum of 2 tablets per day

Victoza (Subcutaneous Solution Pen-Injector) Maximum of 3 pens (9 ml) per 30 days

Videx EC (125MG Oral Capsule Delayed


Videx (4GM Oral Solution Reconstituted) Maximum of 40 ml per day

Vigabatrin (Oral Packet) Maximum of 6 packets per day

Vigabatrin (Oral Tablet) Maximum of 6 tablets per day

Vigadrone (Oral Packet) Maximum of 6 packets per day

Viibryd (Oral Tablet) Maximum of 1 tablet per day

Viibryd Starter Pack (Oral Kit) Maximum of 1 pack (30 tablets) per 30 days

Vimpat (Oral Solution) Maximum of 40 ml per day

Vimpat (Oral Tablet) Maximum of 2 tablets per day

Viracept (250MG Oral Tablet) Maximum of 10 tablets per day

Viracept (625MG Oral Tablet) Maximum of 4 tablets per day

Viread (Oral Powder) Maximum of 4 bottles (240 grams) per 30 days

Viread (150MG Oral Tablet, 200MG Oral


Vitrakvi (100MG Oral Capsule) Maximum of 4 capsules per day

Vitrakvi (25MG Oral Capsule) Maximum of 6 capsules per day

Vitrakvi (Oral Solution) Maximum of 20 ml per day

Vizimpro (Oral Tablet) Maximum of 1 tablet per day

Vosevi (Oral Tablet) Maximum of 1 tablet per day

Votrient (Oral Tablet) Maximum of 4 tablets per day

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Vraylar (1.5MG Oral Capsule, 3MG Oral

Capsule, 4.5MG Oral Capsule, 6MG Oral

Capsule)


Wixela Inhub (Inhalation Aerosol Powder Breath Activated) (Generic Advair)

Maximum of 1 inhaler (60 blisters) per 30 days

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

Xarelto (15MG Oral Tablet, 2.5MG Oral


Xarelto Starter Pack (Oral Tablet Therapy

Pack)Maximum of 1 pack (51 tablets) per 30 days

Xeljanz (Oral Tablet Immediate Release) Maximum of 2 tablets per day

Xeljanz XR (Oral Tablet Extended Release 24

Hour)Maximum of 1 tablet per day

Xiidra (Ophthalmic Solution) Maximum of 2 vials per day

Xofluza (Oral Tablet Therapy Pack) Maximum of 2 tablets per 30 days

Xospata (Oral Tablet) Maximum of 3 tablets per day

Xtampza ER (13.5MG Oral Capsule ER 12

Hour Abuse-Deterrent, 18MG Oral Capsule

ER 12 Hour Abuse-Deterrent, 9MG Oral

Capsule ER 12 Hour Abuse-Deterrent)


Xtampza ER (27MG Oral Capsule ER 12 Hour

Abuse-Deterrent, 36MG Oral Capsule ER 12

Hour Abuse-Deterrent)


Xtandi (Oral Capsule) Maximum of 4 capsules per day

Xyrem (Oral Solution) Maximum of 18 ml per day

Yuvafem (Vaginal Tablet) Maximum of 1 tablet per day

Zafirlukast (Oral Tablet) Maximum of 2 tablets per day

Zaleplon (10MG Oral Capsule) Maximum of 2 capsules per day

Zaleplon (5MG Oral Capsule) Maximum of 1 capsule per day

Zejula (Oral Capsule) Maximum of 3 capsules per day

Zelboraf (Oral Tablet) Maximum of 8 tablets per day

Zidovudine (Oral Capsule) Maximum of 6 capsules per day

Zidovudine (Oral Syrup) Maximum of 64 ml per day

Zidovudine (Oral Tablet) Maximum of 2 tablets per day

Ziprasidone HCl (Oral Capsule) Maximum of 2 capsules per day

Zolpidem Tartrate (Oral Tablet Immediate Release)


Zydelig (Oral Tablet) Maximum of 2 tablets per day

Zykadia (Oral Capsule) Maximum of 3 capsules per day

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Zykadia (Oral Tablet) Maximum of 3 tablets per daytrack

0134Required informationBenefits, drug list (formulary), pharmacy network and/or copayments/coinsurance may change on January 1 of each year, and from time to time during the plan year. You will receive notice when necessary.

ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Please call UnitedHealthcare Customer Service. Our contact information is on the cover.

ATENCIÓN: Si habla español, hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame a Servicio al Cliente de UnitedHealthcare. Nuestra información de contacto se encuentra en la portada.

This document is available for free in other languages. Please call UnitedHealthcare Customer Service. Our contact information is on the cover.

Este documento está disponible sin costo en otros idiomas. Llame a Servicio al Cliente de UnitedHealthcare. Nuestra información de contacto se encuentra en la portada.

Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract. Enrollment in the plan depends on the plan’s contract renewal with Medicare. The AARP® MedicareComplete® Plans carry the AARP name, and UnitedHealthcare Insurance Company pays royalty fees to AARP for the use of its intellectual property. These fees are used for the general purposes of AARP.

134

For more up-to-date information or if you have other questions, please call UnitedHealthcare Customer Service at:

Toll-free 1-800-643-4845, TTY 711

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

www.myAARPMedicare.com

AAEX20HM4540530_000 Last updated September 1, 2019

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2020 - Ohio Insurance Resource€¦ · Y0066_190628_124536_C v01.00 Last updated September 1, 2019. TABLE OF CONTENTS211 What is a drug list? ... Our contact information, along with