FORMULARY 2017 - · PDF file3 The COMPREHENSIVE FORMULARY UnitedHealthcare Dual Complete RP 3 (drug list) A formulary (drug list) is a list of covered drugs selected by your plan in

2017 Comprehensive

FORMULARY(Complete list of covered drugs)

UnitedHealthcare Dual Complete® RP (Regional PPO SNP)

Please read: This document contains information about the drugs we

cover in this plan.

For more recent information or if you have other questions, please call

UnitedHealthcare Dual Complete RP Customer Service at:

Toll-Free 1-866-818-4270, TTY 7118 a.m. - 8 p.m. local time, 7 days a week

www.UHCCommunityPlan.com

Formulary ID Number 00017009, Version 22

Y0066_160617_131835_FINAL_M42.09 Approved Last updated November 1, 2017

1

2

2

This Comprehensive Formulary is a complete list of the drugs covered by our plan. It is current as

of November 1, 2017.

For an up-to-date formulary (drug list), please call us. Our contact information, along with the date

we last updated the formulary, is on the cover.

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

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

This list of covered drugs is called a Formulary. We call it a “drug list” for short.

Note to existing members: This complete drug list has changed since last year. Please review

this document to make sure your drugs are still covered. In most cases, you must use network

pharmacies to have your prescriptions covered by the plan.

3

3

The UnitedHealthcare Dual Complete RP

COMPREHENSIVE FORMULARY (drug list)

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

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

a quality treatment program.

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

· Medically necessary

· The prescription is filled at a plan network pharmacy

· Other plan rules are followed

For more information on how to fill your prescriptions, please review your Evidence of Coverage.

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

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

To find out if your drug is covered:

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

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

a regular basis. The web address is on the cover.

3. Or call Customer Service. Our contact information is on the cover.

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

4

4

The drug list may changeWe try to make as few changes to the drug list as possible during the plan year.

· If there are changes to the drug list, such as regular or necessary updates, members may see

information in their Explanation of Benefits (EOB) statements.

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

receive a special mailing.

The drug list may change 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 requirements or limits for a drug.

Generally, if you are taking a drug on the 2017 drug list that was covered at the beginning of the

year, we will not discontinue or reduce coverage of the drug during the 2017 plan year except when

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

effectiveness of a drug is released.

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

are currently taking the drug. For those members it will remain available at the same cost for the

remainder of the plan year. We feel it is important for you to have access for the entire plan year to

the list of drugs that were available when you chose your plan, except when you can save additional

money or your safety is a concern.

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

restrictions on a drug during the plan year we must notify affected members at least 60 days before

the change becomes effective, or when the member requests a refill of the drug. At this time the

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

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

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

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

date printed on the cover. To get updated information about the drugs covered by your plan, please

call Customer Service or visit our website using the information provided on the cover of this drug

list.

5

5

Drug payment stages and drug tiers The amount you pay for a covered drug will depend on:

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

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

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

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

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

Evidence of Coverage.

Drug Tier Your Cost-Sharing Amount

Tier 1 “Covered Drugs” 25% co-insurance

If you qualify for Extra Help If you qualify for Extra Help for your prescription drugs, your co-pays and co-insurance may be

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

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

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

6

6

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

1. Medical condition: Turn to the “Covered drugs by medical condition” section, which

begins on page 12, to look for drugs based on your medical conditions. For example,

if you want to find drugs used to treat high cholesterol, go to the “Cardiovascular Agents”

category and look under “Dyslipidemics, HMG CoA Reductase Inhibitors.”

2. Alphabetical list (index): If you are not sure what category to look under, turn to the

“Index of covered drugs” section, which begins on page 112. Find the name of your

drug. The page number where you can find the drug will be next to it.

Generic drugsYour plan covers both brand name drugs and generic drugs.

Generic drugs:

· Are approved by the Food and Drug Administration (FDA) as having the same active ingredients

as brand name drugs.

· Usually cost less than brand name drugs.

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

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

plain type (for example, Simvastatin).

1

7

7Dummy

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

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

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

Utilization Management Restrictions

PA - Prior authorization

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

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

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

drug.

QL - Quantity limits

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

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

If your doctor prescribes more than this amount or thinks the limit is not right for your situation,

you or your doctor can ask the plan to cover the additional quantity.

ST - Step therapy

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

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

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

doctor can ask the plan to cover this drug.

Other Special Requirements for Coverage

B/D - Medicare Part B or Part D

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

outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide

the plan with more information about how this drug will be used to make sure it’s correctly

covered by Medicare.

HRM - High Risk Medication

This drug is known as a high risk medication (HRM) for Medicare members 65 and older. This

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

see if an alternative drug is available to treat your condition.

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.

MED - Morphine Equivalent Dose

Additional quantity limits may apply across all drugs in the opioid class used for the treatment of

pain. This additional edit is called a cumulative Morphine Equivalent Dose (MED). The MED is

calculated based on the number of opioid drugs prescribed for you over a period of time. This

cumulative limit is required for all plans and is designed to monitor safe dosing levels of opioids

for those individuals who may be taking more than one 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.

2

8

8

You can find out if your drug has any additional requirements, restrictions or limits by looking it up

in the “Covered drugs by medical condition” section that begins on page 12. You can also get

more information about the restrictions applied to specific covered drugs by visiting our website.

We have posted online documents that explain our prior authorization and step therapy

restrictions. You may ask us to send you a copy. Our contact information, along with the date we

last updated the drug list, is on the cover.

You and your doctor may ask the plan for an exception to these requirements, restrictions or limits,

or for a list of other, similar drugs that may treat your health condition. See the, “How to request an

exception to the UnitedHealthcare Dual Complete RP drug list” section on the next page or review

your Evidence of Coverage to learn more. If you do not get prior approval from the plan for a drug

with a requirement, restriction or limit, you may have to pay the full cost of the drug.

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

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

last updated the drug list, is on the cover.

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

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

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

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

how to request an exception.

9

9

How to request an exception to the

UnitedHealthcare Dual Complete RP drug list

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

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

determination).

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

exceptions that you can ask us to make.

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

If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not

be able to ask us to provide the drug at a lower cost-sharing level.

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

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

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

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

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

condition and/or would cause adverse medical effects.

Who can ask for a coverage decision

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

formulary exception or utilization restriction exception.

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

prescriber or physician should submit a statement supporting your request.

Receiving a coverage decision

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

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

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

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

statement.

10

10

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

or requesting an exception

New or continuing members

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

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

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

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

formulary exception so your plan will cover the drug you are currently taking. While you talk to your

doctor to decide what to do, your plan may cover your drug in certain cases during the first 90 days

you are a member of your plan.

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

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

days) from a network pharmacy. After you receive at least a 30-day supply, your plan will not pay for

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

Long-term care facility residents

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

until you have been provided with at least a 98-day transition supply of the drug consistent with

dispensing increment (unless your prescription is written for fewer days). Your plan will also cover

more than one refill of these drugs for the first 90 days you are a member of your plan. If you need

a drug that’s not on the drug list or if you have limited ability to get your drugs but you are past the

first 90 days of membership in the plan, your plan will cover at least a 31-day emergency supply of

the drug (unless your prescription is written for fewer days) while you request a formulary

exception.

Other transitions

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

this happens and your doctor prescribes a drug that is not on the drug list, or a drug that is on the

drug list but your ability to get it is limited, your plan may cover a one-time supply of at least 30-

days. You may also ask for a one-time emergency supply of at least 30-days to give you time to talk

to your doctor about other treatment options or to try to get a formulary exception.

11

11

Drugs with dosages other than a one-month supply

Drugs packaged in an extended day supply

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

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

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

cover.

Daily cost share for oral medications filled for less than a one-month supply

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

when dispensed for a supply of less than one month under applicable law. The daily cost share

requirements do not apply to either of the following:

1. Solid oral doses of antibiotics.

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

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

For more informationFor more information about your plan’s prescription drug coverage, please review your Evidence of

Coverage and other plan materials. If you have questions about your plan, please call us toll-free at

1-866-818-4270, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week. Or visit us online at

www.UHCCommunityPlan.com.

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

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

1

Bold type = Brand name drug Plain type = Generic drug

1

12

1tRACK

12

Covered drugs by medical condition

The Comprehensive Formulary (drug list) below provides coverage information about the drugs

covered by your plan. If you have trouble finding your drug in the list, turn to the “Index of covered

drugs,” which begins on page 112.

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

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

The “Required Actions, Restrictions or Limits” column shows you if your plan has any special

coverage requirements for the drug. If quantity limits (QL) apply to a drug, the restriction amounts

are shown in the chart on pages 88-111.tRACK

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Analgesics

AnalgesicsButalbital/Acetaminophen/Caffeine

Butalbital/

Acetaminophen/

Caffeine

(50mg-325mg-40mg

Tablet)

1 QL

Butalbital/Aspirin/Caffeine

Butalbital/Aspirin/

Caffeine

(50mg-325mg-40mg

Capsule)

1 QL

Nonsteroidal Anti-inflammatory DrugsCelecoxib

Celecoxib (Capsule) 1 QL Diclofenac Potassium

Diclofenac Potassium

(Tablet Immediate-

Release)

1

Diclofenac Sodium

Diclofenac Sodium

(1% Gel)1 PA

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsDiclofenac Sodium DR

Diclofenac Sodium DR

(Tablet Delayed-

Release)

1

Diclofenac Sodium ER

Diclofenac Sodium ER

(Tablet Extended-

Release 24 Hour)

1

Diflunisal

Diflunisal (Tablet) 1

Etodolac

Etodolac (200mg

Capsule, 300mg

Capsule, 400mg Tablet

Immediate-Release,

500mg Tablet

Immediate-Release)

1

Etodolac ER

Etodolac ER (Tablet

Extended-Release 24

Hour)

1

Flector

Flector (Patch) 1 PA, QL Flurbiprofen

Flurbiprofen (Tablet) 1

2

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

page 7.

2

13

2tRACK

13Last updated November 1, 2017

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsIbuprofen

Ibuprofen (100mg/5ml

Suspension, 400mg

Tablet, 600mg Tablet,

800mg Tablet)

1

Ketoprofen

Ketoprofen (Capsule

Immediate-Release)1

Ketorolac Tromethamine

Ketorolac

Tromethamine (15mg/

ml Injection, 30mg/ml

Injection, 60mg/2ml

Injection)

1

Meloxicam

Meloxicam (Tablet) 1

Nabumetone

Nabumetone (Tablet) 1

Naproxen

Naproxen (125mg/5ml

Suspension, 250mg

Tablet Immediate-

Release, 375mg Tablet

Immediate-Release,

500mg Tablet

Immediate-Release)

1

Naproxen DR

Naproxen DR (Tablet

Delayed-Release)

(Generic EC-Naprosyn)

1

Piroxicam

Piroxicam (Capsule) 1

Sulindac

Sulindac (Tablet) 1

Voltaren

Voltaren (Gel) 1 PA

Opioid Analgesics, Long-actingEmbeda

Embeda (Capsule

Extended-Release)1 QL, MED

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsFentanyl

Fentanyl (100mcg/hr

Patch 72 Hour,

12mcg/hr Patch 72

Hour, 25mcg/hr Patch

72 Hour, 50mcg/hr

Patch 72 Hour,

75mcg/hr Patch 72

Hour)

1 QL, MED

Hydromorphone HCl ER

Hydromorphone HCl

ER (12mg Tablet

Extended-Release 24

Hour Abuse-Deterrent,

8mg Tablet Extended-

Release 24 Hour

Abuse-Deterrent)

1 QL, MED


Hydromorphone HCl

ER (16mg Tablet

Extended-Release 24

Hour Abuse-Deterrent)

1 QL, MED


Hydromorphone HCl

ER (32mg Tablet

Extended-Release 24

Hour Abuse-

Deterrent)

1 QL, MED

Levorphanol Tartrate

Levorphanol Tartrate

(Tablet)1 QL, MED

Methadone HCl

Methadone HCl (10mg

Tablet, 5mg Tablet,

10mg/5ml Oral

Solution, 5mg/5ml Oral

Solution)

1 QL, MED

Methadone HCl

Methadone HCl

(10mg/ml Injection)1

3


3

14

3tRACK

14 Last updated November 1, 2017

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsMorphine Sulfate ER

Morphine Sulfate ER

(100mg Tablet

Extended-Release,



Extended-Release,



Extended-Release)

(Generic MS Contin)

1 QL, MED

Nucynta ER

Nucynta ER (Tablet

Extended-Release 12

Hour)

1 QL, MED

Opana ER

Opana ER (Tablet

Extended-Release 12

Hour Abuse-

Deterrent)

1 QL, MED

Tramadol HCl ER

Tramadol HCl ER

(100mg Tablet

Extended-Release 24

Hour, 200mg Tablet

Extended-Release 24

Hour, 300mg Tablet

Extended-Release 24

Hour)

1 QL, MED

Opioid Analgesics, Short-actingAbstral

Abstral (Tablet

Sublingual)1 PA, QL

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsAcetaminophen/Codeine

Acetaminophen/

Codeine

(120mg-12mg/5ml

Oral Solution,

300mg-15mg Tablet,

300mg-30mg Tablet,

300mg-60mg Tablet)

1 QL, MED

Butorphanol Tartrate


(10mg/ml Nasal

Solution)

1 QL, MED



(1mg/ml Injection,

2mg/ml Injection)

1

Codeine Sulfate

Codeine Sulfate

(Tablet)1 QL, MED

Duramorph

Duramorph (Injection) 1

Endocet

Endocet (Tablet) 1 QL, MED Fentanyl Citrate Oral Transmucosal

Fentanyl Citrate Oral

Transmucosal

(1200mcg Lollipop,

1600mcg Lollipop,

600mcg Lollipop,

800mcg Lollipop)

1 PA, QL

Fentanyl Citrate Oral Transmucosal


Transmucosal

(200mcg Lollipop,

400mcg Lollipop)

1 PA, QL

Hydrocodone Bitartrate/Acetaminophen

Hydrocodone

Bitartrate/

Acetaminophen

(7.5mg-325mg/15ml

Oral Solution)

1 QL, MED

4


page 7.

4

15

4tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsHydrocodone/Acetaminophen

Hydrocodone/

Acetaminophen

(10mg-325mg Tablet,

2.5mg-325mg Tablet,

5mg-325mg Tablet,

7.5mg-325mg Tablet)

1 QL, MED

Hydrocodone/Ibuprofen

Hydrocodone/

Ibuprofen

(7.5mg-200mg Tablet)

1 QL, MED

Hydromorphone HCl

Hydromorphone HCl

(10mg/ml Injection,

50mg/5ml Injection)

1

Hydromorphone HCl

Hydromorphone HCl

(1mg/ml Liquid)1 QL, MED

Hydromorphone HCl

Hydromorphone HCl

(2mg Tablet

Immediate-Release,

4mg Tablet Immediate-

Release, 8mg Tablet

Immediate-Release)

1 QL, MED

Hydromorphone HCl

Hydromorphone HCl

(2mg/ml Injection)1

Lorcet

Lorcet (Tablet) 1 QL, MED Lorcet HD

Lorcet HD (Tablet) 1 QL, MED Lorcet Plus

Lorcet Plus (Tablet) 1 QL, MED Morphine Sulfate

Morphine Sulfate

(100mg/5ml Oral

Solution, 10mg/5ml

Oral Solution, 20mg/

5ml Oral Solution)

1 QL, MED

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsMorphine Sulfate

Morphine Sulfate

(10mg/ml Injection,

4mg/ml Injection,

8mg/ml Injection)

1

Morphine Sulfate

Morphine Sulfate

(15mg Tablet

Immediate-Release,

30mg Tablet

Immediate-Release)

1 QL, MED

Morphine Sulfate

Morphine Sulfate

(2mg/ml Injection)1

Nalbuphine HCl

Nalbuphine HCl

(Injection)1

Oxycodone HCl

Oxycodone HCl

(100mg/5ml

Concentrate)

1 QL, MED

Oxycodone HCl

Oxycodone HCl (10mg

Tablet Immediate-


Immediate-Release,

20mg Tablet

Immediate-Release,

30mg Tablet

Immediate-Release,


Release)

1 QL, MED

Oxycodone HCl

Oxycodone HCl (5mg/

5ml Oral Solution)1 QL, MED

Oxycodone/Acetaminophen

Oxycodone/

Acetaminophen

(10mg-325mg Tablet,

2.5mg-325mg Tablet,

5mg-325mg Tablet,

7.5mg-325mg Tablet)

1 QL, MED

5


5

16

5tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsOxycodone/Acetaminophen

Oxycodone/

Acetaminophen

(325mg/5ml-5mg/5ml

Oral Solution)

1 QL, MED

Oxycodone/Aspirin

Oxycodone/Aspirin

(Tablet)1 QL, MED

Oxycodone/Ibuprofen

Oxycodone/Ibuprofen

(Tablet)1 QL, MED

Tramadol HCl

Tramadol HCl (Tablet

Immediate-Release)1 QL, MED

Tramadol HCl/Acetaminophen

Tramadol HCl/

Acetaminophen

(Tablet)

1 QL, MED

Trezix

Trezix (Capsule) 1 QL, MED

Anesthetics

Local AnestheticsLidocaine

Lidocaine (5%

Ointment)1

Lidocaine

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

Lidocaine HCl (0.5%

Injection, 1% Injection,

2% Injection)

1 B/D, PA

Lidocaine HCl

Lidocaine HCl (4%

External Solution)1

Lidocaine HCl

Lidocaine HCl (Gel) 1

Lidocaine Viscous

Lidocaine Viscous

(Solution)1

Lidocaine/Prilocaine

Lidocaine/Prilocaine

(2.5%-2.5% Cream)1

Anti-Addiction/Substance Abuse Treatment

Agents

Alcohol Deterrents/Anti-craving

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsAcamprosate Calcium DR

Acamprosate Calcium

DR (Tablet Delayed-

Release)

1

Disulfiram

Disulfiram (Tablet) 1

Naltrexone HCl

Naltrexone HCl

(Tablet)1

Vivitrol

Vivitrol (Injection) 1

Opioid Dependence TreatmentsBuprenorphine HCl

Buprenorphine HCl

(0.3mg/ml Injection)1

Buprenorphine HCl

Buprenorphine HCl

(2mg Tablet

Sublingual, 8mg Tablet

Sublingual)

1 QL

Buprenorphine HCl/Naloxone HCl

Buprenorphine HCl/

Naloxone HCl (Tablet

Sublingual)

1 QL

Naloxone HCl

Naloxone HCl

(Injection)1

Narcan

Narcan (Liquid) 1

Suboxone

Suboxone (Film) 1 QL

Smoking Cessation AgentsBupropion HCl SR

Bupropion HCl SR

(150mg Tablet

Extended-Release 12

Hour)

1

Chantix

Chantix (Tablet) 1

Chantix Continuing Month Pak

Chantix Continuing

Month Pak (Tablet)1

Chantix Starting Month Pak

Chantix Starting

Month Pak (Tablet)1

Nicotrol Inhaler

Nicotrol Inhaler 1

6


page 7.

6

17

6tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Antibacterials

AminoglycosidesAmikacin Sulfate

Amikacin Sulfate

(Injection)1

Bethkis

Bethkis (Nebulized

Solution)1 B/D, PA, QL

Gentak

Gentak (Ophthalmic

Ointment)1

Gentamicin Sulfate

Gentamicin Sulfate

(0.1% Cream, 0.1%

Ointment, 0.3%

Ophthalmic Solution)

1

Gentamicin Sulfate

Gentamicin Sulfate

(10mg/ml Injection,

40mg/ml Injection)

1

Gentamicin Sulfate/0.9% Sodium Chloride

Gentamicin Sulfate/

0.9% Sodium Chloride

(Injection)

1

Isotonic Gentamicin

Isotonic Gentamicin

(Injection)1

Neomycin Sulfate

Neomycin Sulfate

(Tablet)1

Paromomycin Sulfate

Paromomycin Sulfate

(Capsule)1

Streptomycin Sulfate

Streptomycin Sulfate

(Injection)1

TOBI

TOBI (Nebulized


TOBI Podhaler

TOBI Podhaler

(Capsule)1 PA, QL

Tobradex

Tobradex

(Ophthalmic

Ointment)

1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsTobramycin

Tobramycin (Nebulized


Tobramycin Sulfate

Tobramycin Sulfate

(0.3% Ophthalmic

Solution)

1

Tobramycin Sulfate

Tobramycin Sulfate

(10mg/ml Injection,

80mg/2ml Injection)

1

Tobrex

Tobrex (0.3%

Ophthalmic Ointment)1

Antibacterials, OtherBACiiM

BACiiM (Injection) 1

Bacitracin

Bacitracin (50000unit

Injection)1

Bacitracin

Bacitracin (500unit/gm


Bactroban Nasal

Bactroban Nasal

(Ointment)1 PA

Chloramphenicol Sodium Succinate

Chloramphenicol

Sodium Succinate

(Injection)

1

Clindamycin HCl

Clindamycin HCl

(Capsule Immediate-

Release)

1

Clindamycin Palmitate HCl

Clindamycin Palmitate

HCl (Oral Solution)1

Clindamycin Phosphate

Clindamycin

Phosphate (2% Cream)1

Clindamycin Phosphate

Clindamycin

Phosphate (300mg/

2ml Injection, 600mg/


6ml Injection)

1

7


7

18

7tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsClindamycin Phosphate in D5W

Clindamycin

Phosphate in D5W

(Injection)

1

Colistimethate Sodium

Colistimethate Sodium

(Injection)1

Cubicin

Cubicin (Injection) 1

Dalvance

Dalvance (Injection) 1 PA Daptomycin

Daptomycin (Injection) 1

Lincomycin HCl

Lincomycin HCl

(Injection)1

Linezolid

Linezolid (100mg/5ml

Suspension)1 PA

Linezolid

Linezolid (600mg

Tablet)1 PA, QL

Linezolid

Linezolid (600mg/

300ml Injection)1 PA

Methenamine Hippurate

Methenamine

Hippurate (Tablet)1

Metronidazole

Metronidazole (0.75%

Cream, 0.75% Gel, 1%

Gel, 0.75% Lotion)

1

Metronidazole

Metronidazole (250mg

Tablet Immediate-


Immediate-Release)

1

Metronidazole in NaCl 0.79%

Metronidazole in NaCl

0.79% (Injection)1

Metronidazole Vaginal

Metronidazole Vaginal

(Gel)1

Mupirocin

Mupirocin (2% Cream) 1

Mupirocin

Mupirocin (2%

Ointment)1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsNeomycin/Polymyxin B Sulfates

Neomycin/Polymyxin B

Sulfates (Irrigation

Solution)

1

Nitrofurantoin

Nitrofurantoin

(Suspension)1

Nitrofurantoin Macrocrystals

Nitrofurantoin

Macrocrystals (100mg

Capsule, 50mg

Capsule) (Generic

Macrodantin)

1

Nitrofurantoin Monohydrate

Nitrofurantoin

Monohydrate (100mg

Capsule) (Generic

Macrobid)

1

Polymyxin B Sulfate

Polymyxin B Sulfate

(Injection)1

Primsol

Primsol (Oral

Solution)1

Sulfamylon

Sulfamylon (85mg/

gm Cream)1

Synercid

Synercid (Injection) 1

Tigecycline

Tigecycline (Injection) 1

Tinidazole

Tinidazole (Tablet) 1

Trimethoprim

Trimethoprim (Tablet) 1

Tygacil

Tygacil (Injection) 1

Vancocin HCl

Vancocin HCl

(Capsule)1

Vancomycin HCl

Vancomycin HCl

(1000mg Injection,

10gm Injection, 500mg

Injection)

1

8


page 7.

8

19

8tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsVancomycin HCl

Vancomycin HCl

(125mg Capsule,

250mg Capsule)

1

Vandazole

Vandazole (Gel) 1

Xifaxan

Xifaxan (Tablet) 1 PA

Beta-lactam, CephalosporinsCefaclor

Cefaclor (250mg

Capsule Immediate-

Release, 500mg

Capsule Immediate-

Release)

1

Cefadroxil

Cefadroxil (250mg/5ml

Suspension, 500mg/

5ml Suspension,

500mg Capsule)

1

Cefazolin Sodium

Cefazolin Sodium

(Injection)1

Cefdinir

Cefdinir (125mg/5ml

Suspension, 250mg/

5ml Suspension,

300mg Capsule)

1

Cefepime

Cefepime (Injection) 1

Cefixime

Cefixime (Suspension) 1

Cefotaxime Sodium

Cefotaxime Sodium

(Injection)1

Cefotetan

Cefotetan (Injection) 1

Cefoxitin Sodium

Cefoxitin Sodium

(10gm Injection, 1gm

Injection, 2gm

Injection)

1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsCefpodoxime Proxetil

Cefpodoxime Proxetil

(100mg Tablet, 200mg

Tablet, 100mg/5ml

Suspension, 50mg/5ml

Suspension)

1

Cefprozil

Cefprozil (125mg/5ml

Suspension, 250mg/

5ml Suspension,

250mg Tablet, 500mg

Tablet)

1

Ceftazidime

Ceftazidime (Injection) 1

Ceftriaxone Sodium

Ceftriaxone Sodium

(10gm Injection, 1gm

Injection, 2gm

Injection, 250mg

Injection, 500mg

Injection)

1

Cefuroxime Axetil

Cefuroxime Axetil

(Tablet)1

Cefuroxime Sodium

Cefuroxime Sodium

(Injection)1

Cephalexin

Cephalexin (125mg/

5ml Suspension,

250mg/5ml

Suspension, 250mg

Capsule, 500mg

Capsule, 750mg

Capsule)

1

Suprax

Suprax (100mg Tablet

Chewable, 200mg

Tablet Chewable)

1

Suprax

Suprax (400mg

Capsule, 500mg/5ml

Suspension)

1

9


9

20

9tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Tazicef

Tazicef (Injection) 1

Zerbaxa

Zerbaxa (Injection) 1 PA

Beta-lactam, OtherAzactam in Iso-Osmotic Dextrose

Azactam in Iso-

Osmotic Dextrose

(Injection)

1

Aztreonam

Aztreonam (Injection) 1

Doribax

Doribax (Injection) 1

Imipenem/Cilastatin

Imipenem/Cilastatin

(Injection)1

Invanz

Invanz (Injection) 1

Meropenem

Meropenem (Injection) 1

Beta-lactam, PenicillinsAmoxicillin

Amoxicillin (125mg

Tablet Chewable,

250mg Tablet

Chewable, 125mg/5ml

Suspension, 200mg/

5ml Suspension,

250mg/5ml

Suspension, 400mg/

5ml Suspension,

250mg Capsule,

500mg Capsule,

500mg Tablet, 875mg

Tablet)

1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsAmoxicillin/Clavulanate Potassium

Amoxicillin/

Clavulanate Potassium

(200mg-28.5mg Tablet

Chewable,

400mg-57mg Tablet

Chewable, 200mg/

5ml-28.5mg/5ml

Suspension, 250mg/

5ml-62.5mg/5ml

Suspension, 400mg/

5ml-57mg/5ml

Suspension, 600mg/

5ml-42.9mg/5ml

Suspension,

250mg-125mg Tablet

Immediate-Release,

500mg-125mg Tablet

Immediate-Release,

875mg-125mg Tablet

Immediate-Release)

(Generic Augmentin)

1

Amoxicillin/Clavulanate Potassium ER

Amoxicillin/

Clavulanate Potassium

ER (Tablet Extended-

Release 12 Hour)

1

Ampicillin

Ampicillin (Capsule) 1

Ampicillin Sodium

Ampicillin Sodium

(10gm Injection,

125mg Injection, 1gm

Injection)

1

Ampicillin-Sulbactam

Ampicillin-Sulbactam

(10gm-5gm Injection,

1gm-0.5gm Injection,

2gm-1gm Injection)

1

10


page 7.

10

21

10tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsBactocill in Dextrose

Bactocill in Dextrose

(Injection)1

Bicillin C-R

Bicillin C-R (Injection) 1

Bicillin L-A

Bicillin L-A (Injection) 1

Dicloxacillin Sodium

Dicloxacillin Sodium

(Capsule)1

Nafcillin Sodium

Nafcillin Sodium

(10gm Injection)1

Nafcillin Sodium

Nafcillin Sodium (1gm

Injection)1

Oxacillin Sodium

Oxacillin Sodium

(10gm Injection)1

Penicillin G Potassium

Penicillin G Potassium

(Injection)1

Penicillin G Procaine

Penicillin G Procaine

(Injection)1

Penicillin G Sodium

Penicillin G Sodium

(Injection)1

Penicillin V Potassium

Penicillin V Potassium

(125mg/5ml Oral

Solution, 250mg/5ml

Oral Solution, 250mg

Tablet, 500mg Tablet)

1

Piperacillin/Tazobactam

Piperacillin/

Tazobactam (Injection)1

MacrolidesAzasite

Azasite (Ophthalmic

Solution)1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsAzithromycin

Azithromycin (100mg/

5ml Suspension,

200mg/5ml

Suspension, 250mg


600mg Tablet)

1

Azithromycin

Azithromycin (500mg

Injection)1

Clarithromycin

Clarithromycin

(125mg/5ml

Suspension, 250mg/

5ml Suspension)

1

Clarithromycin

Clarithromycin (250mg

Tablet, 500mg Tablet)1

Clarithromycin ER

Clarithromycin ER

(Tablet Extended-

Release 24 Hour)

1

Dificid

Dificid (Tablet) 1

E.E.S. Granules

E.E.S. Granules

(Suspension)1

Ery-Tab

Ery-Tab (Tablet

Delayed-Release)1

EryPed 200

EryPed 200

(Suspension)1

EryPed 400

EryPed 400

(Suspension)1

Erythrocin Lactobionate

Erythrocin

Lactobionate

(Injection)

1

Erythromycin

Erythromycin (250mg

Capsule Delayed-

Release)

1

11


11

22

11tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsErythromycin

Erythromycin (5mg/gm


Erythromycin Base

Erythromycin Base

(Tablet)1

Erythromycin Ethylsuccinate

Erythromycin

Ethylsuccinate

(200mg/5ml

Suspension, 400mg

Tablet)

1

Zmax

Zmax (Suspension) 1

QuinolonesAvelox

Avelox (400mg/

250ml-0.8% Injection)1

Besivance

Besivance

(Suspension)1

Ciloxan

Ciloxan (0.3%

Ointment)1

Ciprofloxacin

Ciprofloxacin (250mg/

5ml Suspension,

500mg/5ml

Suspension, 400mg/

40ml Injection)

1

Ciprofloxacin ER

Ciprofloxacin ER

(Tablet Extended-

Release 24 Hour)

1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsCiprofloxacin HCl

Ciprofloxacin HCl

(0.3% Ophthalmic

Solution, 100mg Tablet

Immediate-Release,

250mg Tablet

Immediate-Release,

500mg Tablet

Immediate-Release,

750mg Tablet

Immediate-Release)

1

Ciprofloxacin I.V. in D5W

Ciprofloxacin I.V. in

D5W (Injection)1

Gatifloxacin

Gatifloxacin

(Ophthalmic Solution)1

Levofloxacin

Levofloxacin (0.5%

Ophthalmic Solution)1

Levofloxacin

Levofloxacin (250mg


750mg Tablet)

1

Levofloxacin

Levofloxacin (25mg/ml

Injection, 25mg/ml

Oral Solution)

1

Levofloxacin in D5W

Levofloxacin in D5W

(Injection)1

Moxeza

Moxeza (Ophthalmic

Solution)1

Moxifloxacin HCl

Moxifloxacin HCl (0.5%


Moxifloxacin HCl

Moxifloxacin HCl

(400mg Tablet)1

Moxifloxacin HCl

Moxifloxacin HCl

(400mg/250ml

Injection)

1

12


page 7.

12

23

12tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsOfloxacin

Ofloxacin (0.3%


Ofloxacin

Ofloxacin (0.3% Otic

Solution, 300mg


1

Vigamox

Vigamox (Ophthalmic

Solution)1

SulfonamidesSilver Sulfadiazine

Silver Sulfadiazine

(Cream)1

Sodium Sulfacetamide

Sodium Sulfacetamide

(10% Ophthalmic

Solution)

1

SSD

SSD (Cream) 1

Sulfacetamide Sodium

Sulfacetamide Sodium

(Ophthalmic Ointment)1

Sulfadiazine

Sulfadiazine (Tablet) 1

Sulfamethoxazole/Trimethoprim

Sulfamethoxazole/

Trimethoprim

(200mg-40mg/5ml

Suspension,

400mg-80mg Tablet)

1

Sulfamethoxazole/Trimethoprim

Sulfamethoxazole/

Trimethoprim

(400mg-80mg/5ml

Injection)

1

Sulfamethoxazole/Trimethoprim DS

Sulfamethoxazole/

Trimethoprim DS

(Tablet)

1

TetracyclinesDemeclocycline HCl

Demeclocycline HCl

(Tablet)1

Doxy 100

Doxy 100 (Injection) 1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsDoxycycline

Doxycycline (25mg/

5ml Suspension)1

Doxycycline Hyclate

Doxycycline Hyclate

(100mg Capsule

Immediate-Release,

50mg Capsule

Immediate-Release,

100mg Tablet

Immediate-Release,

20mg Tablet

Immediate-Release)

1

Doxycycline Monohydrate

Doxycycline

Monohydrate (100mg

Capsule, 50mg

Capsule, 100mg


75mg Tablet)

1

Minocycline HCl

Minocycline HCl

(100mg Capsule

Immediate-Release,

50mg Capsule

Immediate-Release,

75mg Capsule

Immediate-Release)

1

Minocycline HCl

Minocycline HCl

(100mg Tablet

Immediate-Release,

50mg Tablet

Immediate-Release,

75mg Tablet

Immediate-Release)

1

Tetracycline HCl

Tetracycline HCl

(Capsule)1

13


13

24

13tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsVibramycin

Vibramycin (50mg/

5ml Syrup)1

Anticonvulsants

Anticonvulsants, OtherBRIVIACT

BRIVIACT (100mg


25mg Tablet, 50mg


10mg/ml Oral

Solution)

1 QL

BRIVIACT

BRIVIACT (50mg/5ml

Injection)1 QL

Fycompa

Fycompa (0.5mg/ml

Suspension, 10mg


2mg Tablet, 4mg

Tablet, 6mg Tablet,

8mg Tablet)

1

Levetiracetam

Levetiracetam

(1000mg Tablet

Immediate-Release,

250mg Tablet

Immediate-Release,

500mg Tablet

Immediate-Release,

750mg Tablet

Immediate-Release,

100mg/ml Oral

Solution)

1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsLevetiracetam

Levetiracetam

(1000mg/100ml

Injection, 1500mg/

100ml Injection,

500mg/100ml

Injection)

1

Levetiracetam

Levetiracetam (500mg/

5ml Injection)1

Levetiracetam ER

Levetiracetam ER

(Tablet Extended-

Release 24 Hour)

1

Roweepra

Roweepra (Tablet) 1

Spritam

Spritam (Tablet

Disintegrating

Soluble)

1

Calcium Channel Modifying AgentsCelontin

Celontin (Capsule) 1

Ethosuximide

Ethosuximide (250mg

Capsule, 250mg/5ml

Oral Solution)

1

Zonisamide

Zonisamide (Capsule) 1

Gamma-aminobutyric Acid (GABA)

Augmenting AgentsDiastat AcuDial

Diastat AcuDial (Gel) 1

Diastat Pediatric

Diastat Pediatric (Gel) 1

Diazepam Rectal Gel

Diazepam Rectal Gel

(Gel)1

Gabapentin

Gabapentin (100mg

Capsule, 300mg

Capsule, 400mg

Capsule, 600mg


1

14


page 7.

14

25

14tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsGabapentin

Gabapentin (250mg/

5ml Oral Solution)1

Gabitril

Gabitril (12mg Tablet,

16mg Tablet)1 QL

Onfi

Onfi (10mg Tablet,

20mg Tablet)1 QL

Onfi

Onfi (2.5mg/ml

Suspension)1

Phenobarbital

Phenobarbital (100mg


16.2mg Tablet, 30mg

Tablet, 32.4mg Tablet,

60mg Tablet, 64.8mg


20mg/5ml Elixir)

1

Primidone

Primidone (Tablet) 1

Sabril

Sabril (500mg Packet,

500mg Tablet)1 PA, QL, LA

Tiagabine HCl

Tiagabine HCl (Tablet) 1

Valproate Sodium

Valproate Sodium


Valproic Acid

Valproic Acid (250mg

Capsule, 250mg/5ml

Oral Solution)

1

Vigabatrin

Vigabatrin (Packet) 1 PA, QL

Glutamate Reducing AgentsFelbamate

Felbamate (400mg


Felbamate

Felbamate (600mg/

5ml Suspension)1

Felbatol

Felbatol (600mg/5ml

Suspension)1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsLamotrigine

Lamotrigine (100mg

Tablet Immediate-


Immediate-Release,

200mg Tablet

Immediate-Release,

25mg Tablet

Immediate-Release)

1

Lamotrigine

Lamotrigine (25mg

Tablet Chewable, 5mg

Tablet Chewable)

1

Topiramate

Topiramate (100mg

Tablet Immediate-


Immediate-Release,

25mg Tablet

Immediate-Release,

50mg Tablet

Immediate-Release,

15mg Capsule

Sprinkle Immediate-

Release, 25mg

Capsule Sprinkle

Immediate-Release)

1

Sodium Channel AgentsAptiom

Aptiom (200mg

Tablet)1 QL

Aptiom

Aptiom (400mg


800mg Tablet)

1 QL

Banzel

Banzel (200mg


40mg/ml Suspension)

1

15


15

26

15tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsCarbamazepine

Carbamazepine

(100mg Tablet

Chewable, 100mg/5ml

Suspension, 200mg

Tablet Immediate-

Release)

1

Carbamazepine ER

Carbamazepine ER

(100mg Capsule

Extended-Release 12

Hour, 200mg Capsule

Extended-Release 12

Hour, 300mg Capsule

Extended-Release 12

Hour, 100mg Tablet

Extended-Release 12

Hour, 200mg Tablet

Extended-Release 12

Hour, 400mg Tablet

Extended-Release 12

Hour)

1

Dilantin

Dilantin (Capsule) 1

Dilantin INFATABS

Dilantin INFATABS

(Tablet Chewable)1

Epitol

Epitol (Tablet) 1

Fosphenytoin Sodium

Fosphenytoin Sodium

(Injection)1

Oxcarbazepine

Oxcarbazepine

(150mg Tablet, 300mg


1

Oxcarbazepine

Oxcarbazepine

(300mg/5ml

Suspension)

1

Peganone

Peganone (Tablet) 1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Phenytek

Phenytek (Capsule) 1

Phenytoin

Phenytoin (125mg/5ml

Suspension, 50mg

Tablet Chewable)

1

Phenytoin Sodium

Phenytoin Sodium

(Injection)1

Phenytoin Sodium Extended

Phenytoin Sodium

Extended (Capsule)1

Vimpat

Vimpat (100mg


200mg Tablet, 50mg

Tablet, 10mg/ml Oral

Solution)

1 QL

Vimpat

Vimpat (200mg/20ml

Injection)1

Antidementia Agents

Cholinesterase InhibitorsDonepezil HCl

Donepezil HCl (Tablet

Immediate-Release)1 QL

Donepezil HCl ODT

Donepezil HCl ODT

(Tablet Dispersible)1 QL

Galantamine HBr

Galantamine HBr

(12mg Tablet, 4mg

Tablet, 8mg Tablet,

4mg/ml Oral Solution)

1 QL

Galantamine HBr ER

Galantamine HBr ER

(Capsule Extended-

Release 24 Hour)

1 QL

Rivastigmine Tartrate

Rivastigmine Tartrate

(Capsule Immediate-

Release)

1 QL

16


page 7.

16

27

16tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsRivastigmine Transdermal System

Rivastigmine

Transdermal System

(Patch 24 Hour)

1 QL, ST

N-methyl-D-aspartate (NMDA) Receptor

AntagonistMemantine HCl

Memantine HCl (10mg

Tablet, 5mg Tablet,


1 PA, QL

Memantine HCl Titration Pak

Memantine HCl

Titration Pak (Tablet)1 PA

Namenda XR

Namenda XR

(Capsule Extended-

Release 24 Hour)

1 PA, QL

Namenda XR Titration Pack

Namenda XR Titration

Pack (Capsule

Extended-Release 24

Hour)

1 PA, QL

Antidepressants

Antidepressants, OtherBupropion HCl

Bupropion HCl (Tablet

Immediate-Release)1

Bupropion HCl SR

Bupropion HCl SR

(100mg Tablet

Extended-Release 12

Hour, 150mg Tablet

Extended-Release 12

Hour, 200mg Tablet

Extended-Release 12

Hour)

1

Bupropion HCl XL

Bupropion HCl XL

(Tablet Extended-

Release 24 Hour)

1

Mirtazapine

Mirtazapine (Tablet

Immediate-Release)1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsMirtazapine ODT

Mirtazapine ODT

(Tablet Dispersible)1

Monoamine Oxidase InhibitorsEmsam

Emsam (Patch 24

Hour)1 QL

Marplan

Marplan (Tablet) 1

Phenelzine Sulfate

Phenelzine Sulfate

(Tablet)1

Tranylcypromine Sulfate

Tranylcypromine

Sulfate (Tablet)1

SSRI/SNRI (Selective Serotonin Reuptake

Inhibitors/Serotonin and Norepinephrine

Reuptake Inhibitors)Citalopram HBr

Citalopram HBr (10mg


40mg Tablet)

1

Citalopram HBr

Citalopram HBr

(10mg/5ml Oral

Solution)

1

Desvenlafaxine ER

Desvenlafaxine ER

(100mg Tablet

Extended-Release 24

Hour, 25mg Tablet

Extended-Release 24

Hour, 50mg Tablet

Extended-Release 24

Hour) (Generic Pristiq)

1 QL

Escitalopram Oxalate


(10mg Tablet, 20mg

Tablet, 5mg Tablet)

1



(5mg/5ml Oral

Solution)

1

17


17

28

17tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsFetzima

Fetzima (Capsule

Extended-Release 24

Hour)

1 QL, ST

Fetzima Titration Pack

Fetzima Titration

Pack (Capsule

Extended-Release 24

Hour Therapy Pack)

1 ST

Fluoxetine DR

Fluoxetine DR

(Capsule Delayed-

Release)

1

Fluoxetine HCl

Fluoxetine HCl (10mg

Capsule Immediate-

Release, 20mg

Capsule Immediate-

Release, 40mg

Capsule Immediate-

Release, 20mg/5ml

Oral Solution)

1

Fluvoxamine Maleate

Fluvoxamine Maleate

(Tablet)1

Maprotiline HCl

Maprotiline HCl

(Tablet)1

Nefazodone HCl

Nefazodone HCl

(Tablet)1

Paroxetine HCl

Paroxetine HCl (Tablet

Immediate-Release)1

Paxil

Paxil (10mg/5ml

Suspension)1

Pristiq

Pristiq (Tablet

Extended-Release 24

Hour)

1 QL

Sertraline HCl

Sertraline HCl (100mg


50mg Tablet)

1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsSertraline HCl

Sertraline HCl (20mg/

ml Concentrate)1

Trazodone HCl

Trazodone HCl (Tablet) 1

Trintellix

Trintellix (Tablet) 1 QL Venlafaxine HCl

Venlafaxine HCl

(Tablet Immediate-

Release)

1

Venlafaxine HCl ER

Venlafaxine HCl ER

(150mg Capsule

Extended-Release 24

Hour, 37.5mg Capsule

Extended-Release 24

Hour, 75mg Capsule

Extended-Release 24

Hour)

1

Viibryd

Viibryd (Tablet) 1 QL Viibryd Starter Pack

Viibryd Starter Pack

(Kit)1 QL

TricyclicsAmitriptyline HCl

Amitriptyline HCl

(Tablet)1

Amoxapine

Amoxapine (Tablet) 1

Clomipramine HCl

Clomipramine HCl

(Capsule)1

Desipramine HCl

Desipramine HCl

(Tablet)1

18


page 7.

18

29

18tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsDoxepin HCl

Doxepin HCl (100mg

Capsule, 10mg

Capsule, 150mg

Capsule, 25mg

Capsule, 50mg

Capsule, 75mg

Capsule, 10mg/ml

Concentrate)

1

Imipramine HCl

Imipramine HCl

(Tablet)1

Imipramine Pamoate

Imipramine Pamoate

(Capsule)1

Nortriptyline HCl

Nortriptyline HCl

(10mg Capsule, 25mg

Capsule, 50mg

Capsule, 75mg

Capsule, 10mg/5ml

Oral Solution)

1

Protriptyline HCl

Protriptyline HCl

(Tablet)1

Trimipramine Maleate

Trimipramine Maleate

(Capsule)1

Antiemetics

Antiemetics, OtherAkynzeo

Akynzeo (Capsule) 1 B/D, PA Compro

Compro (Suppository) 1

Hydroxyzine Pamoate

Hydroxyzine Pamoate

(Capsule)1

Meclizine HCl

Meclizine HCl (Tablet) 1

Metoclopramide HCl

Metoclopramide HCl

(10mg Tablet, 5mg

Tablet)

1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsMetoclopramide HCl

Metoclopramide HCl

(5mg/5ml Oral

Solution)

1

Metoclopramide HCl

Metoclopramide HCl

(5mg/ml Injection)1

Perphenazine

Perphenazine (Tablet) 1

Prochlorperazine

Prochlorperazine

(Suppository)1

Prochlorperazine Edisylate

Prochlorperazine

Edisylate (Injection)1

Prochlorperazine Maleate

Prochlorperazine

Maleate (Tablet)1

Transderm-Scop

Transderm-Scop

(Patch 72 Hour)1

Emetogenic Therapy AdjunctsAloxi

Aloxi (Injection) 1

Anzemet

Anzemet (100mg

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

Aprepitant

Aprepitant (Therapy

Pack, Capsule)1 PA

Cesamet

Cesamet (Capsule) 1 PA Dronabinol

Dronabinol (Capsule) 1 PA, QL Emend

Emend (125mg

Capsule, 40mg

Capsule, 80mg

Capsule, 125mg

Suspension)

1 PA

Emend

Emend (150mg

Injection)1

Emend Tripack

Emend Tripack

(Capsule)1 PA

19


19

30

19tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsGranisetron HCl

Granisetron HCl

(0.1mg/ml Injection,

1mg/ml Injection,

4mg/4ml Injection)

1

Granisetron HCl

Granisetron HCl (1mg

Tablet)1 B/D, PA, QL

Ondansetron HCl

Ondansetron HCl

(24mg Tablet, 4mg

Tablet, 8mg Tablet)

1 B/D, PA

Ondansetron HCl

Ondansetron HCl

(4mg/2ml Injection)1

Ondansetron HCl

Ondansetron HCl

(4mg/5ml Oral

Solution)

1 B/D, PA

Ondansetron ODT

Ondansetron ODT

(Tablet Dispersible)1 B/D, PA

Sancuso

Sancuso (Patch) 1

Antifungals

AntifungalsAbelcet

Abelcet (Injection) 1 B/D, PA AmBisome

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

Amphotericin B

(Injection)1 B/D, PA

Cancidas

Cancidas (Injection) 1

Caspofungin Acetate

Caspofungin Acetate

(Injection)1

Ciclopirox

Ciclopirox (0.77% Gel,

0.77% Suspension, 1%

Shampoo)

1

Ciclopirox Nail Lacquer

Ciclopirox Nail

Lacquer (External

Solution)

1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsCiclopirox Olamine

Ciclopirox Olamine

(Cream)1

Clotrimazole

Clotrimazole (1%

Cream, 1% External

Solution, 10mg

Troche)

1

Econazole Nitrate

Econazole Nitrate

(Cream)1

Eraxis

Eraxis (Injection) 1

Exelderm

Exelderm (1% Cream,

1% External Solution)1

Fluconazole

Fluconazole (100mg


200mg Tablet, 50mg

Tablet, 10mg/ml

Suspension, 40mg/ml

Suspension)

1

Fluconazole in NaCl

Fluconazole in NaCl

(Injection)1

Flucytosine

Flucytosine (Capsule) 1

Griseofulvin Microsize

Griseofulvin Microsize

(125mg/5ml

Suspension, 500mg

Tablet)

1

Griseofulvin Ultramicrosize

Griseofulvin

Ultramicrosize (Tablet)1

Itraconazole

Itraconazole (Capsule) 1 PA, QL Jublia

Jublia (External

Solution)1

Ketoconazole

Ketoconazole (2%

Cream, 2% Shampoo,

200mg Tablet)

1

20


page 7.

20

31

20tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsKetoconazole

Ketoconazole (2%

Foam)1

Mentax

Mentax (Cream) 1

Miconazole 3

Miconazole 3

(Suppository)1

Mycamine

Mycamine (100mg

Injection)1

Mycamine

Mycamine (50mg

Injection)1

Naftifine HCl

Naftifine HCl (1%

Cream)1

Naftifine HCl

Naftifine HCl (2%

Cream)1

Naftin

Naftin (1% Gel, 2%

Gel)1

Natacyn

Natacyn (Suspension) 1

Noxafil

Noxafil (100mg Tablet

Delayed-Release)1 PA, QL

Noxafil

Noxafil (40mg/ml

Suspension)1 QL

Nyamyc

Nyamyc (Powder) 1

Nyata

Nyata (100000unit/gm

Powder)1

Nystatin

Nystatin (Cream,

Ointment, Powder,

Suspension, Tablet)

1

Nystop

Nystop (Powder) 1

ONMEL

ONMEL (Tablet) 1 PA Oxiconazole Nitrate

Oxiconazole Nitrate

(Cream)1

Oxistat

Oxistat (1% Cream,

1% Lotion)1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsSporanox

Sporanox (10mg/ml

Oral Solution)1 PA

Terbinafine HCl

Terbinafine HCl

(Tablet)1

Terconazole

Terconazole (0.4%

Cream, 0.8% Cream,

80mg Suppository)

1

Vfend

Vfend (200mg Tablet,

50mg Tablet, 40mg/

ml Suspension)

1

Voriconazole

Voriconazole (200mg

Injection, 40mg/ml

Suspension)

1

Voriconazole

Voriconazole (200mg


Antigout Agents

Antigout AgentsAllopurinol

Allopurinol (Tablet) 1

Colchicine

Colchicine (0.6mg

Capsule, 0.6mg

Tablet)

1 QL

Colcrys

Colcrys (Tablet) 1 PA, QL Probenecid

Probenecid (Tablet) 1

Probenecid/Colchicine

Probenecid/Colchicine

(Tablet)1

Uloric

Uloric (Tablet) 1 ST

Antimigraine Agents

Ergot AlkaloidsCafergot

Cafergot (Tablet) 1

Dihydroergotamine Mesylate

Dihydroergotamine

Mesylate (1mg/ml

Injection)

1

21


21

32

21tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsErgotamine Tartrate/Caffeine

Ergotamine Tartrate/

Caffeine (Tablet)1

Migergot

Migergot (Suppository) 1

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

Naratriptan HCl

(Tablet)1 QL

Rizatriptan Benzoate


(Tablet Immediate-

Release)

1 QL

Rizatriptan Benzoate ODT


ODT (Tablet

Dispersible)

1 QL

Sumatriptan

Sumatriptan (Nasal

Solution)1 QL

Sumatriptan Succinate


(100mg Tablet, 25mg


1 QL



(4mg/0.5ml Injection,

6mg/0.5ml Injection)

1 QL

Sumatriptan Succinate Refill

Sumatriptan

Succinate Refill

(Injection)

1 QL

Sumavel DosePro

Sumavel DosePro

(Injection)1 QL

Antimyasthenic Agents

ParasympathomimeticsGuanidine HCl

Guanidine HCl

(Tablet)1

Mestinon

Mestinon (60mg/5ml

Syrup)1

Pyridostigmine Bromide

Pyridostigmine

Bromide (Tablet)1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsPyridostigmine Bromide ER

Pyridostigmine

Bromide ER (Tablet

Extended-Release)

1

Antimycobacterials

Antimycobacterials, OtherDapsone

Dapsone (Tablet) 1

Rifabutin

Rifabutin (Capsule) 1

AntitubercularsCapastat Sulfate

Capastat Sulfate

(Injection)1

Ethambutol HCl

Ethambutol HCl

(Tablet)1

Isoniazid

Isoniazid (100mg


Isoniazid

Isoniazid (100mg/ml

Injection, 50mg/5ml

Syrup)

1

Paser

Paser (Packet) 1

Priftin

Priftin (Tablet) 1

Pyrazinamide

Pyrazinamide (Tablet) 1

Rifampin

Rifampin (150mg

Capsule, 300mg

Capsule)

1

Rifampin

Rifampin (600mg

Injection)1

Rifater

Rifater (Tablet) 1

Sirturo

Sirturo (Tablet) 1 PA Trecator

Trecator (Tablet) 1

Antineoplastics

Alkylating AgentsBiCNU

BiCNU (Injection) 1

22


page 7.

22

33

22tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Busulfan

Busulfan (Injection) 1

Busulfex

Busulfex (Injection) 1

Cyclophosphamide

Cyclophosphamide

(Capsule)1 B/D, PA

Dacarbazine

Dacarbazine (Injection) 1

Gleostine

Gleostine (Capsule) 1

Hexalen

Hexalen (Capsule) 1 PA Ifosfamide

Ifosfamide (Injection) 1

Leukeran

Leukeran (Tablet) 1

Matulane

Matulane (Capsule) 1 LA Melphalan HCl

Melphalan HCl

(Injection)1

Mustargen

Mustargen (Injection) 1

Treanda

Treanda (Injection) 1 PA Valchlor

Valchlor (Gel) 1 PA, LA Yondelis

Yondelis (Injection) 1 PA Zanosar

Zanosar (Injection) 1

Antiandrogens Bicalutamide

Bicalutamide (Tablet) 1

Flutamide

Flutamide (Capsule) 1

Nilandron

Nilandron (Tablet) 1

Nilutamide

Nilutamide (Tablet) 1

Xtandi

Xtandi (Capsule) 1 PA, QL Zytiga

Zytiga (Tablet) 1 PA, QL

Antiangiogenic AgentsPomalyst

Pomalyst (Capsule) 1 PA, QL Revlimid

Revlimid (Capsule) 1 PA, QL, LA Thalomid

Thalomid (Capsule) 1 PA, QL

Antiestrogens/Modifiers

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Emcyt

Emcyt (Capsule) 1

Fareston

Fareston (Tablet) 1

Faslodex

Faslodex (Injection) 1

Soltamox

Soltamox (Oral

Solution)1

Tamoxifen Citrate

Tamoxifen Citrate

(Tablet)1

AntimetabolitesAdrucil

Adrucil (Injection) 1 B/D, PA Alimta

Alimta (Injection) 1 PA Cladribine

Cladribine (Injection) 1 B/D, PA Clofarabine

Clofarabine (Injection) 1

Clolar

Clolar (Injection) 1

Cytarabine Aqueous

Cytarabine Aqueous


Droxia

Droxia (Capsule) 1

Elitek

Elitek (Injection) 1

Fluorouracil

Fluorouracil (2.5gm/

50ml Injection)1 B/D, PA

Folotyn

Folotyn (Injection) 1

Gemcitabine HCl

Gemcitabine HCl

(Injection)1

Gemzar

Gemzar (Injection) 1

Hydroxyurea

Hydroxyurea (Capsule) 1

Lonsurf

Lonsurf (Tablet) 1 PA, QL Mercaptopurine

Mercaptopurine

(Tablet)1

Nipent

Nipent (Injection) 1

Purixan

Purixan (Suspension) 1 PA Tabloid

Tabloid (Tablet) 1 PA

23


23

34

23tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Antineoplastics, OtherAbraxane

Abraxane (Injection) 1 PA Adriamycin

Adriamycin (Injection) 1 B/D, PA Alecensa

Alecensa (Capsule) 1 PA, QL Arranon

Arranon (Injection) 1

Azacitidine

Azacitidine (Injection) 1 PA Beleodaq

Beleodaq (Injection) 1 PA Bleomycin Sulfate

Bleomycin Sulfate


Carboplatin

Carboplatin (Injection) 1

Cisplatin

Cisplatin (Injection) 1

Cosmegen

Cosmegen (Injection) 1

Dacogen

Dacogen (Injection) 1

Daunorubicin HCl

Daunorubicin HCl

(Injection)1

Decitabine

Decitabine (Injection) 1

Dexrazoxane

Dexrazoxane

(Injection)1 PA

Docetaxel

Docetaxel (80mg/4ml

Injection)1

Docetaxel

Docetaxel (80mg/8ml

Injection)1

Doxil

Doxil (Injection) 1

Doxorubicin HCl

Doxorubicin HCl


Doxorubicin HCl Liposome

Doxorubicin HCl

Liposome (Injection)1

Ellence

Ellence (Injection) 1

Epirubicin HCl

Epirubicin HCl

(Injection)1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Erwinaze

Erwinaze (Injection) 1

Farydak

Farydak (Capsule) 1 PA Fludarabine Phosphate

Fludarabine Phosphate

(Injection)1

Fusilev

Fusilev (Injection) 1

Halaven

Halaven (Injection) 1 PA Ibrance

Ibrance (Capsule) 1 PA, QL Idamycin PFS

Idamycin PFS

(Injection)1

Idarubicin HCl

Idarubicin HCl

(Injection)1

Irinotecan

Irinotecan (Injection) 1

Istodax

Istodax (Overfill)

(Injection)1 PA

Jevtana

Jevtana (Injection) 1 PA Kisqali

Kisqali (Tablet) 1 PA, QL Kisqali Femara 200 Dose

Kisqali Femara 200

Dose (Tablet Therapy

Pack)

1 PA, QL

Kisqali Femara 400 Dose

Kisqali Femara 400


Pack)

1 PA, QL

Kisqali Femara 600 Dose

Kisqali Femara 600


Pack)

1 PA, QL

Leucovorin Calcium

Leucovorin Calcium

(100mg Injection,

350mg Injection)

1

Leucovorin Calcium

Leucovorin Calcium

(10mg Tablet, 15mg


5mg Tablet)

1

24


page 7.

24

35

24tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsLevoleucovorin

Levoleucovorin

(Injection)1

Levoleucovorin Calcium

Levoleucovorin

Calcium (Injection)1

Lynparza

Lynparza (100mg


50mg Capsule)

1 PA, QL

Mesna

Mesna (Injection) 1

Mesnex

Mesnex (400mg

Tablet)1

Mitomycin

Mitomycin (Injection) 1

Mitoxantrone HCl

Mitoxantrone HCl

(Injection)1

Ninlaro

Ninlaro (Capsule) 1 PA, QL Oxaliplatin

Oxaliplatin (IV Solution

100mg/20ml)1

Paclitaxel

Paclitaxel (Injection) 1

Proleukin

Proleukin (Injection) 1 PA Synribo

Synribo (Injection) 1 PA Taxotere

Taxotere (Injection) 1

Thiotepa

Thiotepa (Injection) 1

Trisenox

Trisenox (Injection) 1

Velcade

Velcade (Injection) 1 PA Venclexta

Venclexta (100mg

Tablet)1 PA, QL

Venclexta

Venclexta (10mg

Tablet, 50mg Tablet)1 PA, QL

Venclexta Starting Pack

Venclexta Starting

Pack (Tablet Therapy

Pack)

1 PA

Vidaza

Vidaza (Injection) 1 PA

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsVinblastine Sulfate

Vinblastine Sulfate


Vincasar PFS

Vincasar PFS


Vincristine Sulfate

Vincristine Sulfate


Vinorelbine Tartrate

Vinorelbine Tartrate

(Injection)1

Vyxeos

Vyxeos (Injection) 1 PA Zaltrap

Zaltrap (Injection) 1 PA Zinecard

Zinecard (Injection) 1 PA Zolinza

Zolinza (Capsule) 1 PA Zydelig

Zydelig (Tablet) 1 PA, QL Zykadia

Zykadia (Capsule) 1 PA, QL

Aromatase Inhibitors, 3rd GenerationAnastrozole

Anastrozole (Tablet) 1

Exemestane

Exemestane (Tablet) 1

Letrozole

Letrozole (Tablet) 1

Enzyme InhibitorsEtopophos

Etopophos (Injection) 1

Etoposide

Etoposide (Injection) 1

Hycamtin

Hycamtin (Injection) 1

Kyprolis

Kyprolis (Injection) 1 PA Rubraca

Rubraca (Tablet) 1 PA, QL Toposar

Toposar (Injection) 1

Topotecan HCl

Topotecan HCl

(Injection)1

Zejula

Zejula (Capsule) 1 PA, QL

Molecular Target InhibitorsAfinitor

Afinitor (Tablet) 1 PA

25


25

36

25tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsAfinitor Disperz

Afinitor Disperz

(Tablet Soluble)1 PA

Alunbrig

Alunbrig (Tablet) 1 PA, QL Bosulif

Bosulif (Tablet) 1 PA, QL Cabometyx

Cabometyx (Tablet) 1 PA, QL Caprelsa

Caprelsa (Tablet) 1 PA, LA Cometriq

Cometriq (Kit) 1 PA Cotellic

Cotellic (Tablet) 1 PA, QL, LA Erivedge

Erivedge (Capsule) 1 PA, QL Gilotrif

Gilotrif (Tablet) 1 PA Iclusig

Iclusig (15mg Tablet) 1 PA, QL, LA Iclusig

Iclusig (45mg Tablet) 1 PA, QL Idhifa

Idhifa (Tablet) 1 PA, QL Imatinib Mesylate

Imatinib Mesylate

(Tablet)1 PA, QL

Imbruvica

Imbruvica (Capsule) 1 PA, QL Inlyta

Inlyta (Tablet) 1 PA, QL Iressa

Iressa (Tablet) 1 PA, QL Jakafi

Jakafi (Tablet) 1 PA, QL, LA Lenvima

Lenvima (Capsule

Therapy Pack)1 PA

Mekinist

Mekinist (Tablet) 1 PA Nerlynx

Nerlynx (Tablet) 1 PA, QL Nexavar

Nexavar (Tablet) 1 PA Odomzo

Odomzo (Capsule) 1 PA, QL, LA Rydapt

Rydapt (Capsule) 1 PA, QL Sprycel

Sprycel (Tablet) 1 PA, QL Stivarga

Stivarga (Tablet) 1 PA, QL Sutent

Sutent (Capsule) 1 PA, QL

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Tafinlar

Tafinlar (Capsule) 1 PA Tarceva

Tarceva (Tablet) 1 PA, QL Tasigna

Tasigna (Capsule) 1 PA, QL Tykerb

Tykerb (Tablet) 1 PA Votrient

Votrient (Tablet) 1 PA, QL Xalkori

Xalkori (Capsule) 1 PA, LA Zelboraf

Zelboraf (Tablet) 1 PA, QL

Monoclonal AntibodiesAvastin

Avastin (Injection) 1 PA Bavencio

Bavencio (Injection) 1 PA Cyramza

Cyramza (Injection) 1 PA Darzalex

Darzalex (Injection) 1 PA, LA Empliciti

Empliciti (Injection) 1 PA Erbitux

Erbitux (Injection) 1 PA Herceptin

Herceptin (Injection) 1 PA Imfinzi

Imfinzi (Injection) 1 PA Kadcyla

Kadcyla (Injection) 1 PA Keytruda

Keytruda (Injection) 1 PA Lartruvo

Lartruvo (Injection) 1 PA Opdivo

Opdivo (Injection) 1 PA Perjeta

Perjeta (Injection) 1 PA Rituxan

Rituxan (Injection) 1 PA Sylvant

Sylvant (Injection) 1 PA Tagrisso

Tagrisso (Tablet) 1 PA, QL, LA Tecentriq

Tecentriq (Injection) 1 PA Vectibix

Vectibix (Injection) 1 PA Yervoy

Yervoy (Injection) 1 PA

Retinoids

26


page 7.

26

37

26tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Bexarotene

Bexarotene (Capsule) 1 PA Panretin

Panretin (Gel) 1

Targretin

Targretin (1% Gel) 1 PA Tretinoin

Tretinoin (10mg

Capsule)1

Antiparasitics

AnthelminticsAlbenza

Albenza (Tablet) 1 QL Biltricide

Biltricide (Tablet) 1

Ivermectin

Ivermectin (Tablet) 1

AntiprotozoalsAlinia

Alinia (100mg/5ml

Suspension)1

Alinia

Alinia (500mg Tablet) 1

Atovaquone

Atovaquone

(Suspension)1

Atovaquone/Proguanil HCl

Atovaquone/Proguanil

HCl (Tablet) (Generic

Malarone)

1

Chloroquine Phosphate

Chloroquine

Phosphate (Tablet)1

Coartem

Coartem (Tablet) 1

DARAPRIM

DARAPRIM (Tablet) 1

Hydroxychloroquine Sulfate

Hydroxychloroquine

Sulfate (Tablet)1

Mefloquine HCl

Mefloquine HCl

(Tablet)1

Mepron

Mepron (Suspension) 1

Nebupent

Nebupent (Inhalation


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsPentam 300

Pentam 300

(Injection)1

Primaquine Phosphate

Primaquine Phosphate

(Tablet)1

Quinine Sulfate

Quinine Sulfate

(Capsule)1 PA

Pediculicides/ScabicidesEurax

Eurax (10% Cream,

10% Lotion)1

Lindane

Lindane (Shampoo) 1

Malathion

Malathion (Lotion) 1

Permethrin

Permethrin (Cream) 1

Antiparkinson Agents

AnticholinergicsBenztropine Mesylate

Benztropine Mesylate

(0.5mg Tablet, 1mg

Tablet, 2mg Tablet)

1



(1mg/ml Injection)1

Trihexyphenidyl HCl

Trihexyphenidyl HCl

(0.4mg/ml Elixir, 2mg

Tablet, 5mg Tablet)

1

Antiparkinson Agents, OtherAmantadine HCl

Amantadine HCl

(100mg Capsule,

100mg Tablet)

1

Amantadine HCl

Amantadine HCl

(50mg/5ml Syrup)1

Entacapone

Entacapone (Tablet) 1

Tolcapone

Tolcapone (Tablet) 1 QL

Dopamine AgonistsApokyn

Apokyn (Injection) 1 PA, QL

27


27

38

27tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsBromocriptine Mesylate

Bromocriptine

Mesylate (2.5mg

Tablet, 5mg Capsule)

1

Neupro

Neupro (Patch 24

Hour)1

Pramipexole Dihydrochloride

Pramipexole

Dihydrochloride

(Tablet Immediate-

Release)

1

Ropinirole HCl

Ropinirole HCl (Tablet

Immediate-Release)1

Dopamine Precursors/L-Amino Acid

Decarboxylase InhibitorsCarbidopa

Carbidopa (Tablet) 1

Carbidopa/Levodopa

Carbidopa/Levodopa

(Tablet Immediate-

Release)

1

Carbidopa/Levodopa ER

Carbidopa/Levodopa


Release)

1

Carbidopa/Levodopa ODT

Carbidopa/Levodopa

ODT (Tablet

Dispersible)

1

Carbidopa/Levodopa/Entacapone

Carbidopa/Levodopa/

Entacapone (Tablet)1

Stalevo 100

Stalevo 100 (Tablet) 1 PA Stalevo 125





Stalevo 75 (Tablet) 1 PA

Monoamine Oxidase B (MAO-B) Inhibitors

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Azilect

Azilect (Tablet) 1

Rasagiline Mesylate

Rasagiline Mesylate

(Tablet)1

Selegiline HCl

Selegiline HCl (5mg

Capsule, 5mg Tablet)1

Zelapar

Zelapar (Tablet

Dispersible)1

Antipsychotics

1st Generation/TypicalChlorpromazine HCl

Chlorpromazine HCl

(100mg Tablet, 10mg


25mg Tablet, 50mg

Tablet, 50mg/2ml

Injection)

1

Fluphenazine Decanoate

Fluphenazine

Decanoate (Injection)1

Fluphenazine HCl

Fluphenazine HCl

(10mg Tablet, 1mg


5mg Tablet)

1

Fluphenazine HCl

Fluphenazine HCl

(2.5mg/5ml Elixir,

2.5mg/ml Injection)

1

Fluphenazine HCl

Fluphenazine HCl

(5mg/ml Concentrate)1

Haloperidol

Haloperidol (0.5mg


1mg Tablet, 20mg

Tablet, 2mg Tablet,

5mg Tablet, 2mg/ml

Concentrate)

1

28


page 7.

28

39

28tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsHaloperidol Decanoate

Haloperidol Decanoate

(Injection)1

Haloperidol Lactate

Haloperidol Lactate

(Injection)1

Loxapine Succinate

Loxapine Succinate

(10mg Capsule, 5mg

Capsule)

1 QL

Loxapine Succinate

Loxapine Succinate

(25mg Capsule, 50mg

Capsule)

1

Pimozide

Pimozide (Tablet) 1

Thioridazine HCl

Thioridazine HCl

(Tablet)1

Thiothixene

Thiothixene (Capsule) 1

Trifluoperazine HCl

Trifluoperazine HCl

(Tablet)1

2nd Generation/AtypicalAbilify Maintena

Abilify Maintena

(Injection)1

Aripiprazole

Aripiprazole (Tablet) 1 QL Aripiprazole ODT

Aripiprazole ODT


Aristada

Aristada (Injection) 1

Fanapt

Fanapt (10mg Tablet,

12mg Tablet, 6mg

Tablet, 8mg Tablet)

1 QL, ST

Fanapt

Fanapt (1mg Tablet,

2mg Tablet, 4mg

Tablet)

1 QL, ST

Fanapt Titration Pack

Fanapt Titration Pack

(Tablet)1 ST

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsGeodon

Geodon (20mg

Injection)1

Invega Sustenna

Invega Sustenna

(117mg/0.75ml

Injection, 156mg/ml

Injection, 234mg/

1.5ml Injection,

78mg/0.5ml

Injection)

1

Invega Sustenna

Invega Sustenna

(39mg/0.25ml

Injection)

1

Invega Trinza

Invega Trinza

(Injection)1 PA

Latuda

Latuda (Tablet) 1 QL Nuplazid

Nuplazid (Tablet) 1 PA, QL Olanzapine

Olanzapine (10mg

Injection)1

Olanzapine

Olanzapine (10mg

Tablet Immediate-


Immediate-Release,

2.5mg Tablet

Immediate-Release,

20mg Tablet

Immediate-Release,


Release, 7.5mg Tablet

Immediate-Release)

1 QL

Olanzapine ODT

Olanzapine ODT


Paliperidone ER

Paliperidone ER

(Tablet Extended-

Release 24 Hour)

1 QL

29


29

40

29tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsQuetiapine Fumarate

Quetiapine Fumarate

(Tablet Immediate-

Release)

1 QL

Quetiapine Fumarate ER

Quetiapine Fumarate


Release 24 Hour)

1 QL

Rexulti

Rexulti (Tablet) 1 QL Risperdal Consta

Risperdal Consta

(12.5mg Injection,

25mg Injection)

1

Risperdal Consta

Risperdal Consta

(37.5mg Injection,

50mg Injection)

1

Risperidone

Risperidone (0.25mg

Tablet Immediate-


Immediate-Release,


Release, 2mg Tablet

Immediate-Release,


Release, 4mg Tablet

Immediate-Release)

1

Risperidone

Risperidone (1mg/ml

Oral Solution)1

Risperidone ODT

Risperidone ODT

(Tablet Dispersible)1

Saphris

Saphris (Tablet

Sublingual)1 QL

Seroquel XR

Seroquel XR (Tablet

Extended-Release 24

Hour)

1 QL

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsVraylar

Vraylar (1.5mg

Capsule, 3mg

Capsule, 4.5mg

Capsule, 6mg

Capsule)

1 QL, ST

Vraylar

Vraylar (Capsule

Therapy Pack)1 ST

Ziprasidone HCl

Ziprasidone HCl

(Capsule)1 QL

Zyprexa Relprevv

Zyprexa Relprevv

(Injection)1

Treatment-ResistantClozapine

Clozapine (Tablet

Immediate-Release)1

Clozapine ODT

Clozapine ODT

(100mg Tablet

Dispersible, 25mg

Tablet Dispersible)

1 QL

Clozapine ODT

Clozapine ODT

(12.5mg Tablet

Dispersible, 150mg

Tablet Dispersible)

1 QL

Clozapine ODT

Clozapine ODT

(200mg Tablet

Dispersible)

1 QL

Fazaclo

Fazaclo (100mg

Tablet Dispersible,

150mg Tablet

Dispersible, 200mg

Tablet Dispersible)

1 QL

Versacloz

Versacloz

(Suspension)1

Antivirals

30


page 7.

30

41

30tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Anti-cytomegalovirus (CMV) AgentsCidofovir

Cidofovir (Injection) 1

Ganciclovir

Ganciclovir (Injection) 1 B/D, PA Valcyte

Valcyte (450mg


Solution)

1

Valganciclovir

Valganciclovir (Tablet) 1

Valganciclovir Hydrochlorde

Valganciclovir

Hydrochlorde (Oral

Solution)

1

Zirgan

Zirgan (Gel) 1

Anti-hepatitis B (HBV) AgentsAdefovir Dipivoxil

Adefovir Dipivoxil

(Tablet)1

Baraclude

Baraclude (0.05mg/

ml Oral Solution,

0.5mg Tablet, 1mg

Tablet)

1

Entecavir

Entecavir (Tablet) 1

Epivir HBV

Epivir HBV (5mg/ml

Oral Solution)1

Hepsera

Hepsera (Tablet) 1

Lamivudine

Lamivudine (100mg

Tablet)1

Vemlidy

Vemlidy (Tablet) 1 QL

Anti-hepatitis C (HCV) AgentsDaklinza

Daklinza (Tablet) 1 PA, QL Epclusa

Epclusa (Tablet) 1 PA, QL Harvoni

Harvoni (Tablet) 1 PA, QL Intron A

Intron A (Injection) 1 PA Olysio

Olysio (Capsule) 1 PA, QL

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsPegIntron REDIPEN

PegIntron REDIPEN

(Injection)1 PA

Pegasys

Pegasys (Injection) 1 PA Pegasys ProClick

Pegasys ProClick

(Injection)1 PA

PegIntron

PegIntron (Injection) 1 PA Ribasphere

Ribasphere (200mg


600mg Tablet)

1

Ribavirin

Ribavirin (200mg

Tablet)1

Sovaldi

Sovaldi (Tablet) 1 PA, QL Sylatron

Sylatron (Injection) 1 PA Zepatier

Zepatier (Tablet) 1 PA, QL

Antiherpetic AgentsAcyclovir

Acyclovir (200mg

Capsule, 200mg/5ml

Suspension)

1

Acyclovir

Acyclovir (400mg


Acyclovir

Acyclovir (5%

Ointment)1 QL

Acyclovir Sodium

Acyclovir Sodium


Denavir

Denavir (Cream) 1 QL Famciclovir

Famciclovir (Tablet) 1 QL Trifluridine

Trifluridine


Valacyclovir HCl

Valacyclovir HCl

(Tablet)1 QL

Anti-HIV Agents, Integrase Inhibitors

(INSTI)

31


31

42

31tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Evotaz

Evotaz (Tablet) 1 QL Genvoya

Genvoya (Tablet) 1 QL Isentress

Isentress (100mg

Packet, 100mg Tablet

Chewable, 400mg

Tablet)

1 QL

Isentress

Isentress (25mg

Tablet Chewable)1 QL

Isentress HD

Isentress HD (Tablet) 1 QL Prezcobix

Prezcobix (Tablet) 1 QL Stribild

Stribild (Tablet) 1 QL Tivicay

Tivicay (10mg Tablet) 1 QL Tivicay

Tivicay (25mg Tablet,

50mg Tablet)1 QL

Triumeq

Triumeq (Tablet) 1 QL Tybost

Tybost (Tablet) 1 QL

Anti-HIV Agents, Non-nucleoside Reverse

Transcriptase Inhibitors (NNRTI)Atripla

Atripla (Tablet) 1 QL Complera

Complera (Tablet) 1 QL Edurant

Edurant (Tablet) 1 QL Intelence

Intelence (Tablet) 1 QL Nevirapine

Nevirapine (200mg

Tablet Immediate-

Release)

1 QL

Nevirapine

Nevirapine (50mg/

5ml Suspension)1 QL

Nevirapine ER

Nevirapine ER (Tablet

Extended-Release 24

Hour)

1 QL

Odefsey

Odefsey (Tablet) 1 QL

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Rescriptor

Rescriptor (Tablet) 1 QL Sustiva

Sustiva (200mg

Capsule, 600mg

Tablet)

1 QL

Sustiva

Sustiva (50mg

Capsule)1 QL

Anti-HIV Agents, Nucleoside and

Nucleotide Reverse Transcriptase

Inhibitors (NRTI)Abacavir

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

Abacavir Sulfate/

Lamivudine/

Zidovudine (Tablet)

1 QL

Abacavir/Lamivudine

Abacavir/Lamivudine

(Tablet)1 QL

Combivir

Combivir (Tablet) 1 QL Descovy

Descovy (Tablet) 1 QL Didanosine

Didanosine (Capsule

Delayed-Release)1 QL

Emtriva

Emtriva (10mg/ml


Capsule)

1 QL

Epzicom

Epzicom (Tablet) 1 QL Lamivudine

Lamivudine (10mg/ml



1 QL

Lamivudine/Zidovudine

Lamivudine/

Zidovudine (Tablet)1 QL

Retrovir IV Infusion

Retrovir IV Infusion

(Injection)1

Stavudine

Stavudine (Capsule) 1 QL Trizivir

Trizivir (Tablet) 1 QL

32


page 7.

32

43

32tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Truvada

Truvada (Tablet) 1 QL Videx Pediatric

Videx Pediatric (Oral

Solution)1 QL

Viread

Viread (150mg Tablet,

200mg Tablet, 250mg


40mg/gm Powder)

1 QL

Zerit

Zerit (1mg/ml Oral

Solution)1 QL

Ziagen

Ziagen (20mg/ml Oral

Solution)1 QL

Zidovudine

Zidovudine (100mg

Capsule, 300mg

Tablet, 50mg/5ml

Syrup)

1 QL

Anti-HIV Agents, OtherFuzeon

Fuzeon (Injection) 1 QL Selzentry

Selzentry (150mg


75mg Tablet)

1 QL

Selzentry

Selzentry (25mg

Tablet)1 QL

Anti-HIV Agents, Protease InhibitorsAptivus

Aptivus (100mg/ml


Capsule)

1 QL

Crixivan

Crixivan (Capsule) 1 QL Invirase

Invirase (200mg

Capsule, 500mg

Tablet)

1 QL

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsKaletra

Kaletra (100mg-25mg

Tablet,

400mg-100mg/5ml

Oral Solution)

1 QL

Kaletra

Kaletra (200mg-50mg

Tablet)1 QL

Lexiva

Lexiva (50mg/ml

Suspension)1 QL

Lexiva

Lexiva (700mg Tablet) 1 QL Lopinavir/Ritonavir

Lopinavir/Ritonavir

(Oral Solution)1 QL

Norvir

Norvir (100mg

Capsule, 100mg


Solution)

1 QL

Prezista

Prezista (100mg/ml

Suspension, 150mg


800mg Tablet)

1 QL

Prezista

Prezista (75mg

Tablet)1 QL

Reyataz

Reyataz (150mg

Capsule, 200mg

Capsule, 300mg

Capsule, 50mg

Packet)

1 QL

Viracept

Viracept (Tablet) 1 QL

Anti-influenza AgentsOseltamivir Phosphate

Oseltamivir Phosphate

(Capsule)1 QL

Relenza Diskhaler

Relenza Diskhaler

(Aerosol Powder)1 QL

33


33

44

33tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsRimantadine HCl

Rimantadine HCl

(Tablet)1

Tamiflu

Tamiflu (30mg

Capsule, 45mg

Capsule, 75mg

Capsule, 6mg/ml

Suspension)

1 QL

Anxiolytics

Anxiolytics, OtherBuspirone HCl

Buspirone HCl (Tablet) 1

Hydroxyzine HCl

Hydroxyzine HCl

(10mg Tablet, 25mg


10mg/5ml Syrup)

1

Hydroxyzine HCl

Hydroxyzine HCl

(25mg/ml Injection,

50mg/ml Injection)

1

Benzodiazepines Alprazolam

Alprazolam (Tablet


Chlordiazepoxide HCl

Chlordiazepoxide HCl

(Capsule)1

Clonazepam

Clonazepam (Tablet


Clonazepam ODT

Clonazepam ODT


Clorazepate Dipotassium

Clorazepate

Dipotassium (Tablet)1 QL

Diazepam

Diazepam (10mg

Tablet, 2mg Tablet,

5mg Tablet)

1 QL

Diazepam

Diazepam (1mg/ml

Oral Solution)1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsDiazepam Intensol

Diazepam Intensol

(5mg/ml Concentrate)1 QL

Lorazepam

Lorazepam (Tablet) 1 QL Lorazepam Intensol

Lorazepam Intensol

(2mg/ml Concentrate)1 QL

Bipolar Agents

Mood StabilizersDivalproex Sodium

Divalproex Sodium

(Capsule Sprinkle

Delayed-Release)

1

Divalproex Sodium DR

Divalproex Sodium DR

(Tablet Delayed-

Release)

1

Divalproex Sodium ER

Divalproex Sodium ER

(Tablet Extended-

Release 24 Hour)

1

Lithium

Lithium (Oral

Solution)1

Lithium Carbonate

Lithium Carbonate

(150mg Capsule

Immediate-Release,

300mg Capsule

Immediate-Release,

600mg Capsule

Immediate-Release,

300mg Tablet

Immediate-Release)

1

Lithium Carbonate ER

Lithium Carbonate ER

(Tablet Extended-

Release)

1

Blood Glucose Regulators

Antidiabetic AgentsAcarbose

Acarbose (Tablet) 1 QL

34


page 7.

34

45

34tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Avandia

Avandia (Tablet) 1 PA, QL Bydureon Pen

Bydureon Pen

(Injection)1 QL

Bydureon Vial

Bydureon Vial

(Injection)1 QL

Byetta

Byetta (Injection) 1 QL Cycloset

Cycloset (Tablet) 1 PA, QL Glimepiride

Glimepiride (Tablet) 1 QL Glipizide

Glipizide (Tablet


Glipizide ER

Glipizide ER (Tablet

Extended-Release 24

Hour)

1 QL

Glipizide/Metformin HCl

Glipizide/Metformin

HCl (Tablet)1 QL

Invokamet

Invokamet (Tablet) 1 QL Invokamet XR

Invokamet XR (Tablet

Extended-Release 24

Hour)

1 QL

Invokana

Invokana (Tablet) 1 QL Janumet

Janumet (Tablet


Janumet XR

Janumet XR (Tablet

Extended-Release 24

Hour)

1 QL

Januvia

Januvia (Tablet) 1 QL Jardiance

Jardiance (Tablet) 1 QL Jentadueto

Jentadueto (Tablet) 1 QL Jentadueto XR

Jentadueto XR

(Tablet Extended-

Release 24 Hour)

1 QL

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsKombiglyze XR

Kombiglyze XR

(Tablet Extended-

Release 24 Hour)

1 QL

Metformin HCl

Metformin HCl (Tablet


Metformin HCl ER

Metformin HCl ER

(500mg Tablet

Extended-Release 24

Hour, 750mg Tablet

Extended-Release 24

Hour) (Generic

Glucophage XR)

1 QL

Miglitol

Miglitol (Tablet) 1 QL Nateglinide

Nateglinide (Tablet) 1 QL Onglyza

Onglyza (Tablet) 1 QL Pioglitazone HCl

Pioglitazone HCl

(Tablet)1 QL

Pioglitazone HCl/Glimepiride

Pioglitazone HCl/

Glimepiride (Tablet)1 QL

Pioglitazone HCl/Metformin HCl

Pioglitazone HCl/

Metformin HCl (Tablet)1 QL

Repaglinide

Repaglinide (Tablet) 1 QL Repaglinide/Metformin HCl

Repaglinide/Metformin

HCl (Tablet)1 QL

Riomet

Riomet (Oral Solution) 1 QL Soliqua 100/33

Soliqua 100/33

(Injection)1 QL

SymlinPen 120

SymlinPen 120

(Injection)1 PA

SymlinPen 60

SymlinPen 60

(Injection)1 PA

Synjardy

Synjardy (Tablet) 1 QL

35


35

46

35tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Tradjenta

Tradjenta (Tablet) 1 QL Trulicity

Trulicity (Injection) 1 QL Victoza

Victoza (Injection) 1 QL

Glycemic AgentsGlucaGen HypoKit

GlucaGen HypoKit

(Injection)1

Glucagon Emergency Kit

Glucagon Emergency

Kit (Injection)1

Proglycem

Proglycem

(Suspension)1

InsulinsHumalog Cartridge

Humalog Cartridge

(Injection)1

Humalog KwikPen

Humalog KwikPen

(Injection)1

Humalog Mix 50/50 KwikPen

Humalog Mix 50/50

KwikPen (Injection)1

Humalog Mix 50/50 Vial

Humalog Mix 50/50

Vial (Injection)1


Humalog Mix 75/25


Humalog Mix 75/25 Vial

Humalog Mix 75/25

Vial (Injection)1

Humalog Vial

Humalog Vial

(Injection)1

Humulin 70/30 KwikPen

Humulin 70/30


Humulin 70/30 Vial

Humulin 70/30 Vial

(Injection)1

Humulin N KwikPen

Humulin N KwikPen

(Injection)1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsHumulin N Vial

Humulin N Vial

(Injection)1

Humulin R U-500 KwikPen

Humulin R U-500


Humulin R U-500 Vial

Humulin R U-500 Vial

(Concentrated)

(Injection)

1

Humulin R Vial

Humulin R Vial

(Injection)1

Lantus SoloStar

Lantus SoloStar

(Injection)1

Lantus Vial

Lantus Vial (Injection) 1

Levemir FlexTouch

Levemir FlexTouch

(Injection)1

Levemir Vial

Levemir Vial

(Injection)1

Toujeo SoloStar

Toujeo SoloStar

(Injection)1

Blood Products/Modifiers/Volume Expanders

AnticoagulantsCoumadin

Coumadin (Tablet) 1

Eliquis

Eliquis (Tablet) 1 PA, QL Enoxaparin Sodium

Enoxaparin Sodium

(100mg/ml Injection,

120mg/0.8ml Injection,

150mg/ml Injection,





300mg/3ml Injection)

1 QL

36


page 7.

36

47

36tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsFondaparinux Sodium

Fondaparinux Sodium

(10mg/0.8ml Injection,


7.5mg/0.6ml Injection)

1

Fondaparinux Sodium

Fondaparinux Sodium

(2.5mg/0.5ml Injection)1

Heparin Sodium

Heparin Sodium

(10000unit/ml

Injection, 20000unit/ml

Injection, 5000unit/ml

Injection)

1

Heparin Sodium

Heparin Sodium

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

Heparin Sodium/D5W

Heparin Sodium/D5W

(Injection)1

Jantoven

Jantoven (Tablet) 1

Pradaxa

Pradaxa (Capsule) 1 PA, QL Warfarin Sodium

Warfarin Sodium

(Tablet)1

Xarelto

Xarelto (Tablet) 1 PA, QL Xarelto Starter Pack

Xarelto Starter Pack

(Tablet Therapy Pack)1 PA, QL

Blood Formation ModifiersAnagrelide HCl

Anagrelide HCl

(Capsule)1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsAranesp Albumin Free

Aranesp Albumin

Free (100mcg/0.5ml

Injection, 100mcg/ml

Injection, 150mcg/

0.3ml Injection,

200mcg/0.4ml

Injection, 200mcg/ml

Injection, 300mcg/

0.6ml Injection,

300mcg/ml Injection,


60mcg/0.3ml

Injection, 60mcg/ml

Injection)

1 PA

Aranesp Albumin Free

Aranesp Albumin

Free (10mcg/0.4ml

Injection, 25mcg/

0.42ml Injection,

25mcg/ml Injection,

40mcg/0.4ml

Injection, 40mcg/ml

Injection)

1 PA

Granix

Granix (Injection) 1 PA Leukine

Leukine (Injection) 1 PA Mozobil

Mozobil (Injection) 1 PA Neulasta

Neulasta (Injection) 1 PA Neupogen

Neupogen (Injection) 1 PA Procrit

Procrit (10000unit/ml

Injection, 2000unit/

ml Injection,

3000unit/ml


ml Injection)

1 PA

37


37

48

37tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsProcrit

Procrit (20000unit/ml


ml Injection)

1 PA

Promacta

Promacta (Tablet) 1 PA, QL Zarxio

Zarxio (Injection) 1

Blood Products/Modifiers/Volume

ExpandersArgatroban

Argatroban (125mg/

125ml-0.9% Injection)1 B/D, PA

Argatroban

Argatroban (250mg/

2.5ml Injection)1 B/D, PA

CoagulantsTranexamic Acid

Tranexamic Acid

(1000mg/10ml

Injection)

1

Tranexamic Acid

Tranexamic Acid

(650mg Tablet)1

Platelet Modifying AgentsAggrenox

Aggrenox (Capsule

Extended-Release 12

Hour)

1 PA, QL

Aspirin/Dipyridamole

Aspirin/Dipyridamole

(Capsule Extended-

Release 12 Hour)

1 QL

Brilinta

Brilinta (Tablet) 1 QL Cilostazol

Cilostazol (Tablet) 1

Clopidogrel

Clopidogrel (75mg

Tablet)1 QL

Effient

Effient (Tablet) 1 QL Prasugrel

Prasugrel (Tablet) 1 QL

Cardiovascular Agents

Alpha-adrenergic Agonists

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsClonidine HCl

Clonidine HCl (0.1mg

Tablet Immediate-


Immediate-Release,

0.3mg Tablet

Immediate-Release)

1

Clonidine HCl

Clonidine HCl (0.1mg/

24hr Patch Weekly,

0.2mg/24hr Patch

Weekly, 0.3mg/24hr

Patch Weekly)

1

Methyldopa

Methyldopa (Tablet) 1

Methyldopate HCl

Methyldopate HCl

(Injection)1

Midodrine HCl

Midodrine HCl (Tablet) 1

Alpha-adrenergic Blocking AgentsDoxazosin Mesylate

Doxazosin Mesylate

(Tablet)1

Phenoxybenzamine HCl

Phenoxybenzamine

HCl (Capsule)1

Prazosin HCl

Prazosin HCl (Capsule) 1

Angiotensin II Receptor AntagonistsBenicar

Benicar (Tablet) 1 QL Candesartan Cilexetil

Candesartan Cilexetil

(Tablet)1 QL

Edarbi

Edarbi (Tablet) 1 QL Eprosartan Mesylate

Eprosartan Mesylate

(Tablet)1 QL

Irbesartan

Irbesartan (Tablet) 1 QL Losartan Potassium

Losartan Potassium

(Tablet)1 QL

38


page 7.

38

49

38tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsOlmesartan Medoxomil

Olmesartan Medoxomil

(Tablet)1 QL

Telmisartan

Telmisartan (Tablet) 1 QL Valsartan

Valsartan (Tablet) 1 QL

Angiotensin-converting Enzyme (ACE)

InhibitorsBenazepril HCl

Benazepril HCl (Tablet) 1 QL Captopril

Captopril (Tablet) 1 QL Enalapril Maleate

Enalapril Maleate

(Tablet)1 QL

Fosinopril Sodium

Fosinopril Sodium

(Tablet)1 QL

Lisinopril

Lisinopril (Tablet) 1 QL Moexipril HCl

Moexipril HCl (15mg

Tablet)1

Moexipril HCl

Moexipril HCl (7.5mg

Tablet)1 QL

Perindopril Erbumine

Perindopril Erbumine

(Tablet)1 QL

Quinapril HCl

Quinapril HCl (Tablet) 1 QL Ramipril

Ramipril (Capsule) 1 QL Trandolapril

Trandolapril (Tablet) 1 QL

AntiarrhythmicsAmiodarone HCl

Amiodarone HCl

(200mg Tablet)1

Amiodarone HCl

Amiodarone HCl


Dofetilide

Dofetilide (Capsule) 1

Flecainide Acetate

Flecainide Acetate

(Tablet)1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsMexiletine HCl

Mexiletine HCl

(Capsule)1

Multaq

Multaq (Tablet) 1 QL Pacerone

Pacerone (200mg

Tablet)1

Procainamide HCl

Procainamide HCl

(Injection)1

Propafenone HCl

Propafenone HCl

(Tablet)1

Propafenone HCl ER

Propafenone HCl ER

(Capsule Extended-

Release 12 Hour)

1

Quinidine Gluconate

Quinidine Gluconate

(Injection)1

Quinidine Gluconate CR

Quinidine Gluconate

CR (Tablet Extended-

Release)

1

Quinidine Sulfate

Quinidine Sulfate

(Tablet)1

Sotalol HCl

Sotalol HCl (AF)

(Tablet)1

Sotalol HCl

Sotalol HCl (Tablet) 1

Beta-adrenergic Blocking AgentsAcebutolol HCl

Acebutolol HCl

(Capsule)1

Atenolol

Atenolol (Tablet) 1

Betaxolol HCl

Betaxolol HCl (10mg


Bisoprolol Fumarate

Bisoprolol Fumarate

(Tablet)1

Bystolic

Bystolic (Tablet) 1 QL

39


39

50

39tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsCarvedilol

Carvedilol (Tablet

Immediate-Release)1

Labetalol HCl

Labetalol HCl (100mg


300mg Tablet)

1

Labetalol HCl

Labetalol HCl (5mg/ml

Injection)1

Metoprolol Succinate ER

Metoprolol Succinate


Release 24 Hour)

1

Metoprolol Tartrate

Metoprolol Tartrate

(100mg Tablet

Immediate-Release,

25mg Tablet

Immediate-Release,

50mg Tablet

Immediate-Release)

1

Metoprolol Tartrate

Metoprolol Tartrate

(5mg/5ml Injection)1

Nadolol

Nadolol (Tablet) 1

Pindolol

Pindolol (Tablet) 1

Propranolol HCl

Propranolol HCl (10mg

Tablet Immediate-


Immediate-Release,

40mg Tablet

Immediate-Release,

60mg Tablet

Immediate-Release,

80mg Tablet

Immediate-Release,

20mg/5ml Oral

Solution, 40mg/5ml

Oral Solution)

1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsPropranolol HCl

Propranolol HCl (1mg/

ml Injection)1

Propranolol HCl ER

Propranolol HCl ER

(Capsule Extended-

Release 24 Hour)

1

Timolol Maleate

Timolol Maleate (10mg


5mg Tablet)

1

Calcium Channel Blocking AgentsAfeditab CR

Afeditab CR (Tablet

Extended-Release 24

Hour)

1 QL

Amlodipine Besylate

Amlodipine Besylate

(Tablet)1

Cardene IV

Cardene IV (Injection) 1

Cartia XT

Cartia XT (Capsule

Extended-Release 24

Hour)

1

Dilt-XR

Dilt-XR (Capsule

Extended-Release 24

Hour)

1

Diltiazem CD

Diltiazem CD (Capsule

Extended-Release 24

Hour)

1

Diltiazem HCl

Diltiazem HCl (100mg

Injection, 50mg/10ml

Injection)

1

40


page 7.

40

51

40tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsDiltiazem HCl

Diltiazem HCl (120mg

Tablet Immediate-


Immediate-Release,

60mg Tablet

Immediate-Release,

90mg Tablet

Immediate-Release)

1

Diltiazem HCl ER

Diltiazem HCl ER

(Capsule Extended-

Release)

1

Felodipine ER

Felodipine ER (Tablet

Extended-Release 24

Hour)

1

Matzim LA

Matzim LA (180mg

Tablet Extended-

Release 24 Hour,

240mg Tablet

Extended-Release 24

Hour, 300mg Tablet

Extended-Release 24

Hour)

1

Matzim LA

Matzim LA (360mg

Tablet Extended-

Release 24 Hour,

420mg Tablet

Extended-Release 24

Hour)

1 QL

Nicardipine HCl

Nicardipine HCl

(2.5mg/ml Injection)1

Nicardipine HCl

Nicardipine HCl (20mg

Capsule, 30mg

Capsule)

1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsNifedipine ER

Nifedipine ER (Tablet

Extended-Release 24

Hour)

1 QL

Nimodipine

Nimodipine (Capsule) 1

Taztia XT

Taztia XT (Capsule

Extended-Release 24

Hour)

1

Verapamil HCl

Verapamil HCl (120mg

Tablet Immediate-


Immediate-Release,

80mg Tablet

Immediate-Release)

1

Verapamil HCl

Verapamil HCl (2.5mg/

ml Injection)1

Verapamil HCl ER

Verapamil HCl ER

(100mg Capsule

Extended-Release 24

Hour, 120mg Capsule

Extended-Release 24

Hour, 180mg Capsule

Extended-Release 24

Hour, 200mg Capsule

Extended-Release 24

Hour, 240mg Capsule

Extended-Release 24

Hour, 300mg Capsule

Extended-Release 24

Hour)

1

41


41

52

41tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsVerapamil HCl ER

Verapamil HCl ER

(120mg Tablet

Extended-Release,

180mg Tablet

Extended-Release,

240mg Tablet

Extended-Release)

1

Verapamil HCl SR

Verapamil HCl SR

(Capsule Extended-

Release 24 Hour)

1

Cardiovascular Agents, OtherAmiloride/Hydrochlorothiazide

Amiloride/

Hydrochlorothiazide

(Tablet)

1

Amlodipine Besylate/Atorvastatin Calcium

Amlodipine Besylate/

Atorvastatin Calcium

(Tablet)

1 QL

Amlodipine Besylate/Benazepril HCl


Benazepril HCl

(Capsule)

1 QL

Amlodipine Besylate/Valsartan


Valsartan (Tablet)1 QL

Amlodipine/Olmesartan Medoxomil

Amlodipine/

Olmesartan Medoxomil

(Tablet)

1 QL

Amlodipine/Valsartan/Hydrochlorothiazide

Amlodipine/Valsartan/

Hydrochlorothiazide

(Tablet)

1 QL

Atenolol/Chlorthalidone

Atenolol/

Chlorthalidone (Tablet)1

Azor

Azor (Tablet) 1 QL

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsBenazepril HCl/Hydrochlorothiazide

Benazepril HCl/

Hydrochlorothiazide

(Tablet)

1 QL

Benicar HCT

Benicar HCT (Tablet) 1 QL BiDil

BiDil (Tablet) 1 QL Bisoprolol Fumarate/Hydrochlorothiazide

Bisoprolol Fumarate/

Hydrochlorothiazide

(10mg-6.25mg Tablet)

1

Bisoprolol Fumarate/Hydrochlorothiazide


Hydrochlorothiazide

(2.5mg-6.25mg Tablet,

5mg-6.25mg Tablet)

1 QL

Candesartan Cilexetil/Hydrochlorothiazide

Candesartan Cilexetil/

Hydrochlorothiazide

(Tablet)

1 QL

Captopril/Hydrochlorothiazide

Captopril/

Hydrochlorothiazide

(Tablet)

1 QL

Clorpres

Clorpres (Tablet) 1

Corlanor

Corlanor (Tablet) 1 PA, QL Demser

Demser (Capsule) 1

Digitek

Digitek (Tablet) 1

Digoxin

Digoxin (0.05mg/ml

Oral Solution)1

Digoxin

Digoxin (0.25mg/ml

Injection)1

Digoxin

Digoxin (125mcg

Tablet, 250mcg Tablet)1

Edarbyclor

Edarbyclor (Tablet) 1 QL Enalapril Maleate/Hydrochlorothiazide

Enalapril Maleate/

Hydrochlorothiazide

(Tablet)

1 QL

42


page 7.

42

53

42tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Entresto

Entresto (Tablet) 1 QL Fosinopril Sodium/Hydrochlorothiazide

Fosinopril Sodium/

Hydrochlorothiazide

(Tablet)

1 QL

Irbesartan/Hydrochlorothiazide

Irbesartan/

Hydrochlorothiazide

(Tablet)

1 QL

Lanoxin

Lanoxin (125mcg

Tablet, 187.5mcg

Tablet, 250mcg

Tablet, 62.5mcg

Tablet)

1

Lisinopril/Hydrochlorothiazide

Lisinopril/

Hydrochlorothiazide

(Tablet)

1 QL

Losartan Potassium/Hydrochlorothiazide

Losartan Potassium/

Hydrochlorothiazide

(Tablet)

1 QL

Methyldopa/Hydrochlorothiazide

Methyldopa/

Hydrochlorothiazide

(Tablet)

1

Metoprolol/Hydrochlorothiazide

Metoprolol/

Hydrochlorothiazide

(Tablet)

1

Moexipril/Hydrochlorothiazide

Moexipril/

Hydrochlorothiazide

(Tablet)

1 QL

Nadolol/Bendroflumethiazide

Nadolol/

Bendroflumethiazide

(40mg-5mg Tablet)

1 QL


Nadolol/

Bendroflumethiazide

(80mg-5mg Tablet)

1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Northera

Northera (Capsule) 1 PA, QL Olmesartan Medoxomil/Amlodipine/Hydrochlorothiazide

Olmesartan

Medoxomil/

Amlodipine/

Hydrochlorothiazide

(Tablet)

1 QL

Olmesartan Medoxomil/Hydrochlorothiazide

Olmesartan

Medoxomil/

Hydrochlorothiazide

(Tablet)

1 QL

Pentoxifylline ER

Pentoxifylline ER

(Tablet Extended-

Release)

1

Propranolol/Hydrochlorothiazide

Propranolol/

Hydrochlorothiazide

(Tablet)

1

Quinapril/Hydrochlorothiazide

Quinapril/

Hydrochlorothiazide

(Tablet)

1 QL

Ranexa

Ranexa (Tablet

Extended-Release 12

Hour)

1 QL

Spironolactone/Hydrochlorothiazide

Spironolactone/

Hydrochlorothiazide

(Tablet)

1

Telmisartan/Amlodipine

Telmisartan/

Amlodipine (Tablet)1 QL

Telmisartan/Hydrochlorothiazide

Telmisartan/

Hydrochlorothiazide

(Tablet)

1 QL

43


43

54

43tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsTriamterene/Hydrochlorothiazide

Triamterene/

Hydrochlorothiazide

(37.5mg-25mg

Capsule, 50mg-25mg

Capsule, 37.5mg-25mg

Tablet, 75mg-50mg

Tablet)

1

Tribenzor

Tribenzor (Tablet) 1 QL Valsartan/Hydrochlorothiazide

Valsartan/

Hydrochlorothiazide

(Tablet)

1 QL

Diuretics, Carbonic Anhydrase InhibitorsAcetazolamide

Acetazolamide (Tablet

Immediate-Release)1

Acetazolamide ER

Acetazolamide ER

(Capsule Extended-

Release 12 Hour)

1

Acetazolamide Sodium

Acetazolamide Sodium

(Injection)1

Methazolamide

Methazolamide

(Tablet)1

Diuretics, LoopBumetanide

Bumetanide (0.25mg/

ml Injection)1

Bumetanide

Bumetanide (0.5mg

Tablet, 1mg Tablet,

2mg Tablet)

1

Edecrin

Edecrin (Tablet) 1

Ethacrynic Acid

Ethacrynic Acid

(Tablet)1

Furosemide

Furosemide (10mg/ml

Injection)1 B/D, PA

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsFurosemide

Furosemide (10mg/ml

Oral Solution, 8mg/ml

Oral Solution)

1

Furosemide

Furosemide (20mg


80mg Tablet)

1

Torsemide

Torsemide (Tablet) 1

Diuretics, Potassium-sparingAmiloride HCl

Amiloride HCl (Tablet) 1

Dyrenium

Dyrenium (Capsule) 1

Eplerenone

Eplerenone (Tablet) 1

Spironolactone

Spironolactone

(Tablet)1

Diuretics, ThiazideChlorothiazide

Chlorothiazide (Tablet) 1

Chlorothiazide Sodium

Chlorothiazide Sodium


Chlorthalidone

Chlorthalidone (Tablet) 1

Diuril

Diuril (Suspension) 1

Hydrochlorothiazide

Hydrochlorothiazide

(12.5mg Capsule,

12.5mg Tablet, 25mg


1

Indapamide

Indapamide (Tablet) 1

Methyclothiazide

Methyclothiazide

(Tablet)1

Metolazone

Metolazone (Tablet) 1

Dyslipidemics, Fibric Acid DerivativesFenofibrate

Fenofibrate (145mg


44


page 7.

44

55

44tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsFenofibrate

Fenofibrate (160mg


Fenofibrate Micronized

Fenofibrate Micronized

(Capsule)1

Fenofibric Acid

Fenofibric Acid

(Tablet)1

Fenofibric Acid DR

Fenofibric Acid DR

(Capsule Delayed-

Release)

1

Gemfibrozil

Gemfibrozil (Tablet) 1

Dyslipidemics, HMG CoA Reductase

InhibitorsAtorvastatin Calcium

Atorvastatin Calcium

(Tablet)1 QL

Crestor

Crestor (Tablet) 1 QL Fluvastatin

Fluvastatin (Capsule


Livalo

Livalo (Tablet) 1 QL Lovastatin

Lovastatin (Tablet


Pravastatin Sodium

Pravastatin Sodium

(Tablet)1 QL

Rosuvastatin Calcium

Rosuvastatin Calcium

(Tablet)1 QL

Simvastatin

Simvastatin (Tablet) 1 QL

Dyslipidemics, OtherCholestyramine Light

Cholestyramine Light

(4gm Packet, 4gm/

dose Powder)

1

Colestipol HCl

Colestipol HCl (1gm

Tablet)1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsColestipol HCl

Colestipol HCl (5gm

Granules)1

Ezetimibe

Ezetimibe (Tablet) 1 QL Ezetimibe/Simvastatin

Ezetimibe/Simvastatin

(Tablet)1 QL

Juxtapid

Juxtapid (Capsule) 1 PA Kynamro

Kynamro (Injection) 1 PA Niacin ER

Niacin ER (Tablet

Extended-Release)1

Niacor

Niacor (Tablet) 1

Omega-3-Acid Ethyl Esters

Omega-3-Acid Ethyl

Esters (Capsule)

(Generic Lovaza)

1 QL

Praluent

Praluent (Injection) 1 PA, QL Prevalite

Prevalite (Powder) 1

Repatha

Repatha (Injection) 1 PA, QL Repatha Pushtronex System

Repatha Pushtronex

System (Injection)1 PA, QL

Repatha SureClick

Repatha SureClick

(Injection)1 PA, QL

Vascepa

Vascepa (Capsule) 1

Vytorin

Vytorin (Tablet) 1 QL Welchol

Welchol (3.75gm

Packet, 625mg

Tablet)

1

Zetia

Zetia (Tablet) 1 QL

Vasodilators, Direct-acting ArterialHydralazine HCl

Hydralazine HCl

(100mg Tablet, 10mg


50mg Tablet)

1

45


45

56

45tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsHydralazine HCl

Hydralazine HCl


Minoxidil

Minoxidil (Tablet) 1

Vasodilators, Direct-acting Arterial/VenousIsosorbide Dinitrate

Isosorbide Dinitrate

(Tablet Immediate-

Release)

1

Isosorbide Dinitrate ER

Isosorbide Dinitrate ER

(Tablet Extended-

Release)

1

Isosorbide Mononitrate


(Tablet Immediate-

Release)

1

Isosorbide Mononitrate ER



Release 24 Hour)

1

Minitran

Minitran (Patch 24

Hour)1

Nitro-Bid

Nitro-Bid (Ointment) 1

Nitroglycerin

Nitroglycerin (0.3mg

Tablet Sublingual,

0.4mg Tablet

Sublingual, 0.6mg

Tablet Sublingual)

1

Nitroglycerin

Nitroglycerin (5mg/ml

Injection)1

Nitroglycerin Lingual

Nitroglycerin Lingual

(Translingual Solution)1

Nitroglycerin Transdermal

Nitroglycerin

Transdermal (Patch 24

Hour)

1

Nitrostat

Nitrostat (Tablet

Sublingual)1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Central Nervous System Agents

Attention Deficit Hyperactivity Disorder

Agents, AmphetaminesAmphetamine/Dextroamphetamine

Amphetamine/

Dextroamphetamine

(10mg Capsule

Extended-Release 24

Hour, 15mg Capsule

Extended-Release 24

Hour, 20mg Capsule

Extended-Release 24

Hour, 25mg Capsule

Extended-Release 24

Hour, 30mg Capsule

Extended-Release 24

Hour, 5mg Capsule

Extended-Release 24

Hour)

1 QL

Amphetamine/Dextroamphetamine

Amphetamine/

Dextroamphetamine

(10mg Tablet

Immediate-Release,

12.5mg Tablet

Immediate-Release,

15mg Tablet

Immediate-Release,

20mg Tablet

Immediate-Release,

30mg Tablet

Immediate-Release,



Immediate-Release)

1 QL

46


page 7.

46

57

46tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsDextroamphetamine Sulfate

Dextroamphetamine

Sulfate (10mg Tablet

Immediate-Release,


Release)

1 QL

Dextroamphetamine Sulfate ER

Dextroamphetamine

Sulfate ER (Capsule

Extended-Release 24

Hour)

1 QL

Vyvanse

Vyvanse (10mg

Capsule, 20mg

Capsule, 30mg

Capsule, 40mg

Capsule, 50mg

Capsule, 60mg

Capsule, 70mg

Capsule, 10mg Tablet

Chewable, 20mg

Tablet Chewable,

30mg Tablet

Chewable, 40mg

Tablet Chewable,

50mg Tablet

Chewable, 60mg

Tablet Chewable)

1

Attention Deficit Hyperactivity Disorder

Agents, Non-amphetaminesAtomoxetine

Atomoxetine (Capsule) 1 QL, ST Clonidine HCl ER

Clonidine HCl ER

(Tablet Extended-

Release 12 Hour)

1 PA

Dexmethylphenidate HCl

Dexmethylphenidate

HCl (Tablet Immediate-

Release)

1 QL

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsDexmethylphenidate HCl ER

Dexmethylphenidate

HCl ER (Capsule

Extended-Release 24

Hour)

1

Guanfacine ER

Guanfacine ER (Tablet

Extended-Release 24

Hour)

1

Metadate ER

Metadate ER (Tablet

Extended-Release)1 QL

Methylphenidate HCl

Methylphenidate HCl

(10mg Tablet

Immediate-Release,

20mg Tablet

Immediate-Release,


Release) (Generic

Ritalin)

1 QL

Methylphenidate HCl

Methylphenidate HCl

(10mg/5ml Oral

Solution, 5mg/5ml Oral

Solution)

1 QL

Methylphenidate HCl ER

Methylphenidate HCl

ER (10mg Tablet

Extended-Release,


Release)

1 QL

Strattera

Strattera (Capsule) 1 QL, ST

Central Nervous System, OtherNamzaric

Namzaric (Therapy

Pack, Capsule

Extended-Release 24

Hour)

1 PA, QL

Nuedexta

Nuedexta (Capsule) 1 PA

47


47

58

47tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Rilutek

Rilutek (Tablet) 1

Riluzole

Riluzole (Tablet) 1

Tetrabenazine

Tetrabenazine (Tablet) 1 PA, QL Xenazine

Xenazine (Tablet) 1 PA, QL, LA

Fibromyalgia AgentsDuloxetine HCl

Duloxetine HCl (20mg

Capsule Delayed-

Release, 30mg

Capsule Delayed-

Release, 60mg

Capsule Delayed-

Release)

1 QL

Lyrica

Lyrica (100mg

Capsule, 150mg

Capsule, 200mg

Capsule, 225mg

Capsule, 25mg

Capsule, 300mg

Capsule, 50mg

Capsule, 75mg

Capsule, 20mg/ml

Oral Solution)

1 QL

Savella

Savella (Tablet) 1

Savella Titration Pack

Savella Titration Pack 1

Multiple Sclerosis AgentsAmpyra

Ampyra (Tablet

Extended-Release 12

Hour)

1 QL

Aubagio

Aubagio (Tablet) 1 QL Avonex

Avonex (Injection) 1

Avonex Pen

Avonex Pen

(Injection)1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Betaseron

Betaseron (Injection) 1

Copaxone

Copaxone (Injection) 1

Gilenya

Gilenya (Capsule) 1 QL Glatopa

Glatopa (Injection) 1

Rebif

Rebif (Injection) 1

Rebif Rebidose

Rebif Rebidose

(Injection)1

Rebif Rebidose Titration Pack

Rebif Rebidose

Titration Pack

(Injection)

1

Rebif Titration Pack

Rebif Titration Pack

(Injection)1

Tecfidera

Tecfidera (Capsule


Tecfidera Starter Pack

Tecfidera Starter

Pack1

Tysabri

Tysabri (Injection) 1 PA Zinbryta

Zinbryta (Injection) 1 PA

Dental and Oral Agents

Dental and Oral AgentsChlorhexidine Gluconate

Chlorhexidine

Gluconate (Solution)1

Kepivance

Kepivance (Injection) 1

Periogard

Periogard (Solution) 1

Pilocarpine HCl

Pilocarpine HCl (5mg

Tablet, 7.5mg Tablet)1

Triamcinolone in Orabase

Triamcinolone in

Orabase (Paste)1

Dermatological Agents

Dermatological AgentsAcitretin

Acitretin (Capsule) 1

48


page 7.

48

59

48tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsAdapalene

Adapalene (0.1%

Cream, 0.1% Gel)1

Ammonium Lactate

Ammonium Lactate

(12% Cream, 12%

Lotion)

1

Calcipotriene

Calcipotriene (0.005%

Cream, 0.005%

External Solution)

1

Calcitriol

Calcitriol (3mcg/gm

Ointment)1

Carac

Carac (Cream) 1 PA Claravis

Claravis (Capsule) 1 PA Clindamycin Phosphate

Clindamycin

Phosphate (1%

External Solution, 1%

Gel, 1% Lotion, 1%

Swab)

1

Clindamycin/Benzoyl Peroxide

Clindamycin/Benzoyl

Peroxide (1%-5% Gel)

(Generic BenzaClin)

1

Clotrimazole/Betamethasone Dipropionate

Clotrimazole/

Betamethasone

Dipropionate

(1%-0.05% Cream)

1

Clotrimazole/Betamethasone Dipropionate

Clotrimazole/

Betamethasone

Dipropionate

(1%-0.05% Lotion)

1

Cortisporin

Cortisporin

(0.5%-0.5% Cream,

1%-0.5% Ointment)

1

Diclofenac Sodium

Diclofenac Sodium

(3% Gel)1 PA

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Doxepin HCl

Doxepin HCl (Cream) 1

Elidel

Elidel (Cream) 1 ST Ery

Ery (2% Pad) 1

Erythromycin

Erythromycin (2%

External Solution)1

Erythromycin

Erythromycin (2% Gel) 1

Erythromycin/Benzoyl Peroxide

Erythromycin/Benzoyl

Peroxide (Gel)1

Finacea

Finacea (15% Foam,

15% Gel)1

Fluorouracil

Fluorouracil (0.5%

Cream)1

Fluorouracil

Fluorouracil (2%

External Solution, 5%

External Solution)

1

Fluorouracil

Fluorouracil (5%

Cream)1

Imiquimod

Imiquimod (Cream) 1

Methoxsalen

Methoxsalen (Capsule) 1

Mirvaso

Mirvaso (Gel) 1

Oxsoralen Ultra

Oxsoralen Ultra

(Capsule)1

Picato

Picato (Gel) 1

Podofilox

Podofilox (External

Solution)1

PRUDOXIN

PRUDOXIN (Cream) 1

Regranex

Regranex (Gel) 1 PA Santyl

Santyl (Ointment) 1

Selenium Sulfide

Selenium Sulfide

(Lotion)1

Solaraze

Solaraze (Gel) 1 PA

49


49

60

49tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Soriatane

Soriatane (Capsule) 1

Tacrolimus

Tacrolimus (0.03%

Ointment, 0.1%

Ointment)

1 ST

Tazarotene

Tazarotene (Cream) 1 PA Tazorac

Tazorac (0.05%

Cream, 0.1% Cream)1 PA

Tretinoin

Tretinoin (0.01% Gel,

0.025% Gel, 0.025%

Cream, 0.05% Cream,

0.1% Cream)

1 PA

Tretinoin Microsphere

Tretinoin Microsphere

(Gel)1 PA

Zyclara

Zyclara (Cream) 1 PA Zyclara Pump

Zyclara Pump

(Cream)1 PA

Enzyme Replacement/Modifiers

Enzyme Replacement/ModifiersAdagen

Adagen (Injection) 1 LA Aldurazyme

Aldurazyme

(Injection)1

Buphenyl

Buphenyl (3gm/tsp

Powder, 500mg

Tablet)

1

Cerezyme

Cerezyme (Injection) 1 PA Creon

Creon (Capsule

Delayed-Release)1

Cystadane

Cystadane (Powder) 1

Cystagon

Cystagon (Capsule) 1 LA Elaprase

Elaprase (Injection) 1

Elelyso

Elelyso (Injection) 1 PA, LA

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Fabrazyme

Fabrazyme (Injection) 1

Kuvan

Kuvan (100mg

Packet, 500mg

Packet, 100mg Tablet

Soluble)

1

Lumizyme

Lumizyme (Injection) 1

Naglazyme

Naglazyme (Injection) 1

Orfadin

Orfadin (10mg

Capsule, 20mg

Capsule, 2mg

Capsule, 5mg

Capsule, 4mg/ml

Suspension)

1 LA

Procysbi

Procysbi (Capsule

Delayed-Release)1

RAVICTI

RAVICTI (Liquid) 1 QL Sodium Phenylbutyrate

Sodium Phenylbutyrate

(Powder)1

Strensiq

Strensiq (Injection) 1 PA, LA Sucraid

Sucraid (Oral

Solution)1 LA

VPRIV

VPRIV (Injection) 1 PA Zavesca

Zavesca (Capsule) 1 PA, LA Zenpep

Zenpep (Capsule

Delayed-Release)1

Gastrointestinal Agents

Antispasmodics, GastrointestinalAtropine Sulfate

Atropine Sulfate

(Injection)1

Cuvposa

Cuvposa (Oral

Solution)1

50


page 7.

50

61

50tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsDicyclomine HCl

Dicyclomine HCl

(10mg Capsule, 10mg/

5ml Oral Solution,

20mg Tablet)

1

Glycopyrrolate

Glycopyrrolate (4mg/

20ml Injection)1

Methscopolamine Bromide

Methscopolamine

Bromide (Tablet)1

Gastrointestinal Agents, OtherChenodal

Chenodal (Tablet) 1

Cholbam

Cholbam (Capsule) 1 PA Cromolyn Sodium

Cromolyn Sodium

(100mg/5ml

Concentrate)

1

Diphenoxylate/Atropine

Diphenoxylate/

Atropine

(2.5mg-0.025mg

Tablet,

2.5mg-0.025mg/5ml

Liquid)

1

Gattex

Gattex (Injection) 1 PA Loperamide HCl

Loperamide HCl

(Capsule)1

Ocaliva

Ocaliva (Tablet) 1 PA, QL Relistor

Relistor (12mg/0.6ml

Injection, 8mg/0.4ml

Injection)

1 PA

Serostim

Serostim (Injection) 1 PA Ursodiol

Ursodiol (250mg


300mg Capsule)

1

Zorbtive

Zorbtive (Injection) 1 PA

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Histamine2 (H2) Receptor AntagonistsCimetidine

Cimetidine (Tablet) 1

Cimetidine HCl

Cimetidine HCl (Oral

Solution)1

Famotidine

Famotidine (20mg


Famotidine

Famotidine (20mg/2ml

Injection, 40mg/5ml

Suspension)

1

Famotidine Premixed

Famotidine Premixed

(Injection)1

Ranitidine HCl

Ranitidine HCl (150mg


Ranitidine HCl

Ranitidine HCl (15mg/

ml Syrup, 50mg/2ml

Injection)

1

Irritable Bowel Syndrome AgentsAlosetron HCl

Alosetron HCl (Tablet) 1 PA Amitiza

Amitiza (Capsule) 1 QL Linzess

Linzess (Capsule) 1 QL Lotronex

Lotronex (Tablet) 1 PA

LaxativesConstulose

Constulose (Oral

Solution)1

Enulose

Enulose (Oral Solution) 1

GaviLyte-C

GaviLyte-C (Oral

Solution)1

GaviLyte-G

GaviLyte-G (Oral

Solution)1

GaviLyte-N/Flavor Pack

GaviLyte-N/Flavor

Pack (Oral Solution)1

51


51

62

51tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsGenerlac

Generlac (Oral

Solution)1

Lactulose

Lactulose (Oral

Solution)1

PEG-3350/Electrolytes

PEG-3350/

Electrolytes (Oral

Solution) (Generic

GoLYTELY)

1

PEG-3350/NaCl/Na Bicarbonate/KCl

PEG-3350/NaCl/Na

Bicarbonate/KCl (Oral

Solution) (Generic

NuLYTELY)

1

Polyethylene Glycol 3350 Powder

Polyethylene Glycol

3350 Powder (Generic

MiraLAX)

1

Suprep Bowel Prep Kit

Suprep Bowel Prep

Kit (Oral Solution)1

TriLyte

TriLyte (Oral Solution) 1

ProtectantsCarafate

Carafate (1gm/10ml

Suspension)1

Misoprostol

Misoprostol (Tablet) 1

Sucralfate

Sucralfate (Tablet) 1

Proton Pump InhibitorsDexilant

Dexilant (Capsule


Esomeprazole Magnesium

Esomeprazole

Magnesium (Capsule

Delayed-Release)

(Generic Nexium)

1 QL

Esomeprazole Sodium

Esomeprazole Sodium

(Injection)1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsNexium

Nexium (10mg

Packet, 2.5mg

Packet, 20mg Packet,

40mg Packet, 5mg

Packet)

1

Nexium

Nexium (20mg

Capsule Delayed-

Release, 40mg

Capsule Delayed-

Release)

1 QL

Omeprazole

Omeprazole (10mg

Capsule Delayed-

Release, 40mg

Capsule Delayed-

Release)

1 QL

Omeprazole

Omeprazole (20mg

Capsule Delayed-

Release)

1

Pantoprazole Sodium

Pantoprazole Sodium

(20mg Tablet Delayed-


Delayed-Release)

1 QL

Prilosec

Prilosec (10mg

Packet, 2.5mg

Packet)

1 PA

Genitourinary Agents

Antispasmodics, UrinaryMyrbetriq

Myrbetriq (Tablet

Extended-Release 24

Hour)

1

Oxybutynin Chloride

Oxybutynin Chloride

(5mg Tablet

Immediate-Release,

5mg/5ml Syrup)

1

52


page 7.

52

63

52tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsOxybutynin Chloride ER

Oxybutynin Chloride


Release 24 Hour)

1 QL

Vesicare

Vesicare (Tablet) 1 QL

Benign Prostatic Hypertrophy AgentsAlfuzosin HCl ER

Alfuzosin HCl ER

(Tablet Extended-

Release 24 Hour)

1

Finasteride

Finasteride (5mg

Tablet) (Generic

Proscar)

1

Rapaflo

Rapaflo (Capsule) 1 QL Tamsulosin HCl

Tamsulosin HCl

(Capsule)1

Terazosin HCl

Terazosin HCl

(Capsule)1

Genitourinary Agents, OtherBethanechol Chloride

Bethanechol Chloride

(Tablet)1

Cuprimine

Cuprimine (Capsule) 1 PA Depen Titratabs

Depen Titratabs

(Tablet)1

Elmiron

Elmiron (Capsule) 1

Lithostat

Lithostat (Tablet) 1

Phosphate BindersAuryxia

Auryxia (Tablet) 1

Calcium Acetate

Calcium Acetate

(667mg Capsule,

667mg Tablet)

1

Eliphos

Eliphos (Tablet) 1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsFosrenol

Fosrenol (1000mg

Packet, 750mg

Packet, 1000mg

Tablet Chewable,

500mg Tablet

Chewable, 750mg

Tablet Chewable)

1

Phoslyra

Phoslyra (Oral

Solution)1

Renagel

Renagel (Tablet) 1 ST Renvela

Renvela (0.8gm

Packet, 2.4gm

Packet, 800mg

Tablet)

1

Velphoro

Velphoro (Tablet

Chewable)1

Hormonal Agents, Stimulant/Replacement/

Modifying (Adrenal)


Modifying (Adrenal)Ala-Cort

Ala-Cort (Cream) 1

Alclometasone Dipropionate

Alclometasone

Dipropionate (0.05%

Cream, 0.05%

Ointment)

1

Augmented Betamethasone Dipropionate

Augmented

Betamethasone

Dipropionate (0.05%

Cream)

1

Augmented Betamethasone Dipropionate

Augmented

Betamethasone

Dipropionate (0.05%

Gel, 0.05% Lotion,

0.05% Ointment)

1

53


53

64

53tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsBetamethasone Dipropionate

Betamethasone

Dipropionate (0.05%

Cream, 0.05% Lotion,

0.05% Ointment)

1

Betamethasone Valerate

Betamethasone

Valerate (0.1% Cream,

0.1% Lotion, 0.1%

Ointment)

1

Clobetasol Propionate


(0.05% External

Solution)

1



(0.05% Gel, 0.05%

Ointment, 0.05%

Shampoo)

1

Clobetasol Propionate E


E (Cream)1

Cordran

Cordran (4mcg/sqcm

Tape)1

Cormax Scalp Application

Cormax Scalp

Application (External

Solution)

1

Cortisone Acetate

Cortisone Acetate

(Tablet)1

Depo-Medrol

Depo-Medrol (20mg/

ml Injection)1

Desonide

Desonide (0.05%

Ointment)1

Desoximetasone

Desoximetasone

(0.05% Cream, 0.25%

Cream)

1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsDexamethasone

Dexamethasone

(0.5mg Tablet, 0.75mg


1mg Tablet, 2mg

Tablet, 4mg Tablet,

6mg Tablet, 0.5mg/

5ml Elixir)

1

Dexamethasone Intensol

Dexamethasone

Intensol (1mg/ml

Concentrate)

1

Dexamethasone Sodium Phosphate

Dexamethasone

Sodium Phosphate

(10mg/ml Injection,

120mg/30ml Injection)

1

Fludrocortisone Acetate

Fludrocortisone

Acetate (Tablet)1

Fluocinolone Acetonide

Fluocinolone

Acetonide (0.01%

Cream, 0.025% Cream,

0.01% External

Solution, 0.025%

Ointment)

1

Fluocinolone Acetonide Body

Fluocinolone

Acetonide Body (Oil)1

Fluocinonide

Fluocinonide (0.05%

External Solution,

0.05% Gel, 0.05%

Ointment)

1

Fluocinonide Emulsified Base

Fluocinonide

Emulsified Base

(Cream)

1

Fluticasone Propionate


(0.005% Ointment,

0.05% Cream)

1

54


page 7.

54

65

54tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsHalobetasol Propionate

Halobetasol

Propionate (0.05%

Cream, 0.05%

Ointment)

1

Hydrocortisone

Hydrocortisone (1%

Cream, 2.5% Cream,

1% Ointment, 2.5%

Ointment)

1

Hydrocortisone

Hydrocortisone (10mg


5mg Tablet, 2.5%

Lotion)

1

Hydrocortisone Butyrate

Hydrocortisone

Butyrate (0.1%

Ointment)

1

Hydrocortisone Valerate

Hydrocortisone

Valerate (0.2% Cream,

0.2% Ointment)

1

Kenalog-10

Kenalog-10 (Injection) 1

Kenalog-40

Kenalog-40 (Injection) 1

Methylprednisolone

Methylprednisolone

(Tablet)1

Methylprednisolone Acetate

Methylprednisolone

Acetate (Injection)1

Methylprednisolone Dose Pack

Methylprednisolone

Dose Pack (Tablet

Therapy Pack)

1

Methylprednisolone Sodium Succinate

Methylprednisolone

Sodium Succinate

(Injection)

1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsMometasone Furoate

Mometasone Furoate

(0.1% Cream, 0.1%

External Solution, 0.1%

Ointment)

1

Prednicarbate

Prednicarbate (0.1%

Cream)1

Prednicarbate

Prednicarbate (0.1%

Ointment)1

Prednisolone Sodium Phosphate

Prednisolone Sodium

Phosphate (10mg/5ml

Oral Solution, 15mg/

5ml Oral Solution,

20mg/5ml Oral

Solution, 25mg/5ml

Oral Solution, 5mg/5ml

Oral Solution)

1

Prednisone

Prednisone (10mg

Tablet Therapy Pack,

5mg Tablet Therapy

Pack, 10mg Tablet,

1mg Tablet, 2.5mg


50mg Tablet, 5mg

Tablet)

1

Prednisone

Prednisone (5mg/5ml

Oral Solution)1

Prednisone Intensol

Prednisone Intensol

(5mg/ml Concentrate)1

Solu-Cortef

Solu-Cortef (Injection) 1

Solu-Medrol

Solu-Medrol (2gm

Injection)1

55


55

66

55tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsTriamcinolone Acetonide

Triamcinolone

Acetonide (0.025%

Cream, 0.1% Cream,

0.5% Cream, 0.025%

Ointment, 0.1%

Ointment, 0.5%

Ointment)

1

Triamcinolone Acetonide

Triamcinolone

Acetonide (0.025%

Lotion, 0.1% Lotion)

1

Triderm

Triderm (Cream) 1


Modifying (Pituitary)


Modifying (Pituitary)Chorionic Gonadotropin

Chorionic

Gonadotropin

(Injection)

1 PA

Desmopressin Acetate

Desmopressin

Acetate (0.01% Nasal

Rhinal Tube Solution)

1



(0.01% Nasal Spray

Solution, 4mcg/ml

Injection)

1



(0.1mg Tablet, 0.2mg

Tablet)

1

Genotropin

Genotropin (12mg

Injection, 5mg

Injection)

1 PA

Genotropin Miniquick


(0.2mg Injection)1 PA

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsGenotropin Miniquick


(0.4mg Injection,

0.6mg Injection,

0.8mg Injection,

1.2mg Injection,

1.4mg Injection,

1.6mg Injection,

1.8mg Injection, 1mg

Injection, 2mg

Injection)

1 PA

Humatrope

Humatrope (Injection) 1 PA Humatrope Combo Pack

Humatrope Combo

Pack (Injection)1 PA

Increlex

Increlex (Injection) 1 PA Norditropin FlexPro

Norditropin FlexPro

(Injection)1 PA

Novarel

Novarel (Injection) 1 PA Nutropin AQ

Nutropin AQ

(Injection)1 PA

Pregnyl w/Diluent Benzyl Alcohol/NaCl

Pregnyl w/Diluent

Benzyl Alcohol/NaCl

(Injection)

1 PA

Saizen

Saizen (Injection) 1 PA Zomacton

Zomacton (10mg

Injection)1 PA


Modifying (Prostaglandins)


Modifying (Prostaglandins)Korlym

Korlym (Tablet) 1 PA, QL


Modifying (Sex Hormones/Modifiers)

Androgens

56


page 7.

56

67

56tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Anadrol-50

Anadrol-50 (Tablet) 1 PA Androderm

Androderm (Patch 24

Hour)1 QL

AndroGel

AndroGel (1.62%

Packet Gel)1

AndroGel Pump

AndroGel Pump

(1.62% Gel)1

Danazol

Danazol (Capsule) 1

Oxandrolone

Oxandrolone (10mg

Tablet)1 PA, QL

Oxandrolone

Oxandrolone (2.5mg

Tablet)1 PA, QL

Testosterone Cypionate

Testosterone

Cypionate (Injection)1

Testosterone Enanthate

Testosterone

Enanthate (Injection)1

EstrogensAlyacen 1/35

Alyacen 1/35 (Tablet) 1

Amethia

Amethia (Tablet) 1

Amethia Lo

Amethia Lo (Tablet) 1

Apri

Apri (Tablet) 1

Aranelle

Aranelle (Tablet) 1

Ashlyna

Ashlyna (Tablet) 1

Aubra

Aubra (Tablet) 1

Aviane

Aviane (Tablet) 1

Balziva

Balziva (Tablet) 1

Bekyree

Bekyree (Tablet) 1

Blisovi 24 Fe

Blisovi 24 Fe (Tablet) 1

Blisovi Fe 1.5/30

Blisovi Fe 1.5/30

(Tablet)1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Blisovi Fe 1/20

Blisovi Fe 1/20 (Tablet) 1

Briellyn

Briellyn (Tablet) 1

Camrese Lo

Camrese Lo (Tablet) 1

Caziant

Caziant (Tablet) 1

Climara Pro

Climara Pro (Patch

Weekly)1

Cryselle-28

Cryselle-28 (Tablet) 1

Cyclafem

Cyclafem (Tablet) 1

Delyla

Delyla (Tablet) 1

Depo-Estradiol

Depo-Estradiol

(Injection)1

Desogestrel/Ethinyl Estradiol

Desogestrel/Ethinyl

Estradiol (Tablet)1

Drospirenone/Ethinyl Estradiol

Drospirenone/Ethinyl

Estradiol (Tablet)1

Duavee

Duavee (Tablet) 1

Elestrin

Elestrin (Gel) 1

Emoquette

Emoquette (Tablet) 1

Enpresse-28

Enpresse-28 (Tablet) 1

Estrace

Estrace (0.1mg/gm

Cream)1

Estradiol

Estradiol (0.025mg/

24hr Patch Weekly,

0.05mg/24hr Patch

Weekly, 0.06mg/24hr

Patch Weekly,

0.075mg/24hr Patch

Weekly, 0.1mg/24hr

Patch Weekly,

37.5mcg/24hr Patch

Weekly)

1 QL

57


57

68

57tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsEstradiol

Estradiol (0.5mg

Tablet, 1mg Tablet,

2mg Tablet) (Generic

Estrace)

1

Estradiol

Estradiol (10mcg

Tablet)1 QL

Estradiol Valerate

Estradiol Valerate

(Injection)1

Estring

Estring (Ring) 1

Ethynodiol Diacetate/Ethinyl Estradiol

Ethynodiol Diacetate/

Ethinyl Estradiol

(Tablet)

1

Falmina

Falmina (Tablet) 1

Femring

Femring (Ring) 1

Femynor

Femynor (Tablet) 1

Gianvi

Gianvi (Tablet) 1

Gildagia

Gildagia (Tablet) 1

Introvale

Introvale (Tablet) 1

Isibloom

Isibloom (Tablet) 1

Jinteli

Jinteli (Tablet) 1

Juleber

Juleber (Tablet) 1

Junel 1.5/30

Junel 1.5/30 (Tablet) 1

Junel 1/20

Junel 1/20 (Tablet) 1

Junel Fe 1.5/30

Junel Fe 1.5/30

(Tablet)1

Junel Fe 1/20

Junel Fe 1/20 (Tablet) 1

Junel Fe 24

Junel Fe 24 (Tablet) 1

Kaitlib Fe

Kaitlib Fe (Tablet

Chewable)1

Kariva

Kariva (Tablet) 1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Kelnor 1/35

Kelnor 1/35 (Tablet) 1

Kimidess

Kimidess (Tablet) 1

LARIN 1.5/30

LARIN 1.5/30 (Tablet) 1

LARIN 1/20

LARIN 1/20 (Tablet) 1

LARIN Fe 1.5/30

LARIN Fe 1.5/30

(Tablet)1

LARIN Fe 1/20

LARIN Fe 1/20 (Tablet) 1

Larissia

Larissia (Tablet) 1

Layolis Fe

Layolis Fe (Tablet

Chewable)1

Leena

Leena (Tablet) 1

Lessina

Lessina (Tablet) 1

Levonest

Levonest (Tablet) 1

Levonorgestrel and Ethinyl Estradiol

Levonorgestrel and

Ethinyl Estradiol

(Tablet)

1

Levonorgestrel/Ethinyl Estradiol

Levonorgestrel/Ethinyl

Estradiol (Tablet)1

Levora 0.15/30-28

Levora 0.15/30-28

(Tablet)1

Lomedia 24 Fe

Lomedia 24 Fe (Tablet) 1

Loryna

Loryna (Tablet) 1

Low-Ogestrel

Low-Ogestrel (Tablet) 1

Lutera

Lutera (Tablet) 1

Marlissa

Marlissa (Tablet) 1

Menest

Menest (Tablet) 1

Mibelas 24 Fe

Mibelas 24 Fe (Tablet

Chewable)1

Microgestin 1.5/30

Microgestin 1.5/30

(Tablet)1

58


page 7.

58

69

58tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsMicrogestin 1/20

Microgestin 1/20

(Tablet)1

Microgestin Fe

Microgestin Fe

(Tablet)1

Microgestin Fe 1.5/30

Microgestin Fe 1.5/30

(Tablet)1

MonoNessa

MonoNessa (Tablet) 1

Necon 0.5/35-28

Necon 0.5/35-28

(Tablet)1

Necon 1/50-28

Necon 1/50-28

(Tablet)1

Necon 7/7/7

Necon 7/7/7 (Tablet) 1

Nikki

Nikki (Tablet) 1

Norethindrone Acetate/Ethinyl Estradiol

Norethindrone

Acetate/Ethinyl

Estradiol (20mcg-1mg

Tablet)

1

Norethindrone Acetate/Ethinyl Estradiol/Ferrous Fumarate

Norethindrone

Acetate/Ethinyl

Estradiol/Ferrous

Fumarate

(20mcg-75mg-1mg

Tablet Chewable)

1

Norethindrone Acetate/Ethinyl Estradiol/Ferrous Fumarate

Norethindrone

Acetate/Ethinyl

Estradiol/Ferrous

Fumarate

(20mcg-75mg-1mg

Tablet)

1

Norethindrone/Ethinyl Estradiol/Ferrous Fumarate

Norethindrone/Ethinyl

Estradiol/Ferrous

Fumarate (Tablet

Chewable)

1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsNorgestimate/Ethinyl Estradiol

Norgestimate/Ethinyl

Estradiol (Tablet)1

Nortrel 0.5/35

Nortrel 0.5/35 (28)

(Tablet)1

Nortrel 1/35

Nortrel 1/35 (Tablet) 1

Nortrel 7/7/7

Nortrel 7/7/7 (Tablet) 1

NuvaRing

NuvaRing (Ring) 1

Ocella

Ocella (Tablet) 1

Ogestrel

Ogestrel (Tablet) 1

Orsythia

Orsythia (Tablet) 1

Pimtrea

Pimtrea (Tablet) 1

Pirmella 1/35

Pirmella 1/35 (Tablet) 1

Portia-28

Portia-28 (Tablet) 1

Premarin

Premarin (0.3mg

Tablet, 0.45mg

Tablet, 0.625mg


1.25mg Tablet)

1 QL

Premarin

Premarin (Vaginal

Cream)1

Premphase

Premphase (Tablet) 1

Prempro

Prempro (Tablet) 1 QL Previfem

Previfem (Tablet) 1

Quasense

Quasense (Tablet) 1

Reclipsen

Reclipsen (Tablet) 1

Setlakin

Setlakin (Tablet) 1

Sprintec 28

Sprintec 28 (Tablet) 1

Sronyx

Sronyx (Tablet) 1

Tarina Fe 1/20

Tarina Fe 1/20 (Tablet) 1

Tri-Legest Fe

Tri-Legest Fe (Tablet) 1

59


59

70

59tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Tri-Lo-Estarylla

Tri-Lo-Estarylla (Tablet) 1

Tri-Lo-Sprintec

Tri-Lo-Sprintec (Tablet) 1

Tri-Previfem

Tri-Previfem (Tablet) 1

Tri-Sprintec

Tri-Sprintec (Tablet) 1

Trinessa

Trinessa (Tablet) 1

Trivora-28

Trivora-28 (Tablet) 1

Vagifem

Vagifem (Tablet) 1 QL Velivet

Velivet (Tablet) 1

Vestura

Vestura (Tablet) 1

Vienva

Vienva (Tablet) 1

Vyfemla

Vyfemla (Tablet) 1

WYMZYA Fe

WYMZYA Fe (Tablet

Chewable)1

Xulane

Xulane (Patch Weekly) 1

Yuvafem

Yuvafem (Tablet) 1 QL Zarah

Zarah (Tablet) 1

Zenchent

Zenchent (Tablet) 1

Zenchent Fe

Zenchent Fe (Tablet

Chewable)1

Zovia 1/35E

Zovia 1/35E (Tablet) 1

Zovia 1/50E

Zovia 1/50E (Tablet) 1

ProgestinsCamila

Camila (Tablet) 1

Crinone

Crinone (Gel) 1 PA Deblitane

Deblitane (Tablet) 1

Depo-Provera

Depo-Provera

(Injection)1

Errin

Errin (Tablet) 1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsHydroxyprogesterone Caproate

Hydroxyprogesterone

Caproate (Injection)1 PA

Jolivette

Jolivette (Tablet) 1

Lyza

Lyza (Tablet) 1

Makena

Makena (Injection) 1 PA Medroxyprogesterone Acetate

Medroxyprogesterone

Acetate (10mg Tablet,

2.5mg Tablet, 5mg

Tablet)

1

Medroxyprogesterone Acetate

Medroxyprogesterone

Acetate (150mg/ml

Injection)

1

Megace ES

Megace ES

(Suspension)1

Megestrol Acetate

Megestrol Acetate

(20mg Tablet, 40mg

Tablet, 40mg/ml

Suspension)

1

Megestrol Acetate

Megestrol Acetate

(625mg/5ml

Suspension)

1

Nora-BE

Nora-BE (Tablet) 1

Norethindrone

Norethindrone

(0.35mg Tablet)1

Norethindrone Acetate

Norethindrone Acetate

(5mg Tablet)1

Norlyroc

Norlyroc (Tablet) 1

Progesterone

Progesterone

(Capsule)1

Sharobel

Sharobel (Tablet) 1

Selective Estrogen Receptor Modifying

Agents

60


page 7.

60

71

60tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Raloxifene HCl

Raloxifene HCl (Tablet) 1 QL


Modifying (Thyroid)


Modifying (Thyroid)Levothyroxine Sodium

Levothyroxine

Sodium (100mcg

Injection)

1

Levothyroxine Sodium

Levothyroxine Sodium

(100mcg Tablet,

112mcg Tablet,

125mcg Tablet,

137mcg Tablet,

150mcg Tablet,

175mcg Tablet,

200mcg Tablet, 25mcg

Tablet, 300mcg Tablet,

50mcg Tablet, 75mcg

Tablet, 88mcg Tablet)

1

Levoxyl

Levoxyl (Tablet) 1

Liothyronine Sodium

Liothyronine Sodium

(10mcg/ml Injection)1

Liothyronine Sodium

Liothyronine Sodium

(25mcg Tablet, 50mcg

Tablet, 5mcg Tablet)

1

Synthroid

Synthroid (Tablet) 1

Unithroid

Unithroid (Tablet) 1

Hormonal Agents, Suppressant (Adrenal)

Hormonal Agents, Suppressant (Adrenal)Lysodren

Lysodren (Tablet) 1

Hormonal Agents, Suppressant (Parathyroid)

Hormonal Agents, Suppressant

(Parathyroid)

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsSensipar

Sensipar (30mg

Tablet)1 QL

Sensipar

Sensipar (60mg

Tablet, 90mg Tablet)1 QL

Hormonal Agents, Suppressant (Pituitary)

Hormonal Agents, Suppressant (Pituitary)Cabergoline

Cabergoline (Tablet) 1

Egrifta

Egrifta (Injection) 1 PA Firmagon

Firmagon (120mg

Injection)1 PA

Firmagon

Firmagon (80mg

Injection)1 PA

Leuprolide Acetate

Leuprolide Acetate

(Injection)1 PA

Lupaneta Pack

Lupaneta Pack (Kit) 1 PA Lupron Depot

Lupron Depot (1-

Month) (Injection)1 PA

Lupron Depot

Lupron Depot (3-


Lupron Depot

Lupron Depot (4-


Lupron Depot

Lupron Depot (6-


Lupron Depot-Ped

Lupron Depot-Ped (1-


Octreotide Acetate

Octreotide Acetate

(1000mcg/ml Injection)1 PA

Octreotide Acetate

Octreotide Acetate

(100mcg/ml Injection,



50mcg/ml Injection)

1 PA

61


61

72

61tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsSandostatin LAR Depot

Sandostatin LAR

Depot (Injection)1 PA

Signifor

Signifor (Injection) 1 PA Somatuline Depot

Somatuline Depot

(Injection)1 PA

Somavert

Somavert (Injection) 1 PA, QL Synarel

Synarel (Nasal

Solution)1

Trelstar Mixject

Trelstar Mixject

(Injection)1 PA

Hormonal Agents, Suppressant (Thyroid)

Antithyroid AgentsMethimazole

Methimazole (Tablet) 1

Propylthiouracil

Propylthiouracil

(Tablet)1

Immunological Agents

Angioedema (HAE) Agents Berinert

Berinert (Injection) 1 PA, LA Cinryze

Cinryze (Injection) 1 PA, LA Firazyr

Firazyr (Injection) 1 PA, QL Ruconest

Ruconest (Injection) 1 PA

Immune SuppressantsAzathioprine

Azathioprine (100mg

Injection)1 B/D, PA

Azathioprine

Azathioprine (50mg

Tablet)1 B/D, PA

Cellcept

Cellcept (200mg/ml

Suspension, 250mg

Capsule, 500mg

Tablet)

1 PA

Cellcept Intravenous

Cellcept Intravenous

(Injection)1 PA

Drug NameDrug

Tier

Required

Actions,

Restrictions

or Limits

Cimzia

Cimzia (Injection) 1 PA Cosentyx

Cosentyx (Injection) 1 PA Cosentyx Sensoready Pen

Cosentyx Sensoready

Pen (Injection)1 PA

Cyclosporine

Cyclosporine (100mg

Capsule, 25mg

Capsule)

1 B/D, PA

Cyclosporine

Cyclosporine (50mg/

ml Injection)1

Cyclosporine Modified

Cyclosporine Modified

(100mg Capsule,

25mg Capsule, 50mg

Capsule, 100mg/ml

Oral Solution)

1 B/D, PA

Enbrel

Enbrel (Injection) 1 PA Enbrel SureClick

Enbrel SureClick

(Injection)1 PA

Gengraf

Gengraf (100mg

Capsule, 25mg

Capsule, 50mg

Capsule, 100mg/ml

Oral Solution)

1 B/D, PA

Humira

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

Humira Pediatric

Crohns Disease

Starter Pack

(Injection)

1 PA

Humira Pen

Humira Pen

(Injection)1 PA

Humira Pen Crohns Disease Starter Pack

Humira Pen Crohns

Disease Starter Pack

(Injection)

1 PA

62


page 7.

62

73

62tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsHumira Pen-Psoriasis Starter

Humira Pen-Psoriasis

Starter (Injection)1 PA

Kineret

Kineret (Injection) 1 PA Methotrexate

Methotrexate (Tablet) 1

Methotrexate Sodium

Methotrexate Sodium

(Injection)1

Mycophenolate Mofetil


(200mg/ml

Suspension)

1 PA



(250mg Capsule,

500mg Tablet)

1 PA



(500mg Injection)1 PA

Mycophenolic Acid DR

Mycophenolic Acid DR

(Tablet Delayed-

Release)

1 B/D, PA

Nulojix

Nulojix (Injection) 1 PA Orencia

Orencia (125mg/ml

Injection, 50mg/

0.4ml Injection,

87.5mg/0.7ml

Injection, 250mg

Injection)

1 PA

Orencia Clickject

Orencia Clickject

(Injection)1 PA

Prograf

Prograf (5mg/ml

Injection)1 PA

Rapamune

Rapamune (1mg

Tablet, 2mg Tablet,


1 B/D, PA

Remicade

Remicade (Injection) 1 PA

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsSandimmune

Sandimmune (100mg

Capsule)1 B/D, PA

Sandimmune

Sandimmune

(100mg/ml Oral

Solution)

1 B/D, PA

Simponi

Simponi (Injection) 1 PA Simponi Aria

Simponi Aria

(Injection)1 PA

Sirolimus

Sirolimus (0.5mg

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

Sirolimus

Sirolimus (2mg Tablet) 1 B/D, PA Stelara

Stelara (130mg/26ml

Injection, 45mg/

0.5ml Injection,

90mg/ml Injection)

1 PA

Tacrolimus

Tacrolimus (0.5mg

Capsule, 1mg Capsule,

5mg Capsule)

1 PA

Torisel

Torisel (Injection) 1

Trexall

Trexall (Tablet) 1

Xatmep

Xatmep (Oral

Solution)1 PA

Xeljanz

Xeljanz (Tablet) 1 PA, QL Xeljanz XR

Xeljanz XR (Tablet

Extended-Release 24

Hour)

1 PA, QL

Zortress

Zortress (Tablet) 1 PA

Immunizing Agents, PassiveAtgam

Atgam (Injection) 1

BIVIGAM

BIVIGAM (Injection) 1 PA

63


63

74

63tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsCarimune Nanofiltered

Carimune

Nanofiltered

(Injection)

1 PA

Flebogamma DIF

Flebogamma DIF

(Injection)1 PA

Gamastan S/D

Gamastan S/D

(Injection)1 PA

Gammagard Liquid

Gammagard Liquid

(Injection)1 PA

Gammagard S/D IGA Less Than 1 mcg/ml

Gammagard S/D IGA

Less Than 1 mcg/ml

(Injection)

1 PA

Gammaked

Gammaked (Injection) 1 PA Gammaplex

Gammaplex

(Injection)1 PA

Gamunex-C

Gamunex-C

(Injection)1 PA

Octagam

Octagam (Injection) 1 PA Privigen

Privigen (Injection) 1 PA Thymoglobulin

Thymoglobulin

(Injection)1

Varizig

Varizig (Injection) 1

ImmunomodulatorsActemra

Actemra (162mg/

0.9ml Injection,

200mg/10ml

Injection, 400mg/


4ml Injection)

1 PA

Actimmune

Actimmune (Injection) 1

Arcalyst

Arcalyst (Injection) 1 PA, LA

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsBenlysta

Benlysta (120mg

Injection, 400mg

Injection, 200mg/ml

Injection)

1 PA

Ilaris

Ilaris (Injection) 1 PA, QL, LA Leflunomide

Leflunomide (Tablet) 1

Otezla

Otezla (Tablet

Therapy Pack, 30mg

Tablet)

1 PA

Ridaura

Ridaura (Capsule) 1

Simulect

Simulect (Injection) 1

Synagis

Synagis (Injection) 1 PA

VaccinesActHIB

ActHIB (Injection) 1

Adacel

Adacel (Injection) 1

BCG Vaccine

BCG Vaccine

(Injection)1

Bexsero

Bexsero (Injection) 1

Boostrix

Boostrix (Injection) 1

Daptacel

Daptacel (Injection) 1

Diphtheria/Tetanus Toxoids Adsorbed Pediatric

Diphtheria/Tetanus

Toxoids Adsorbed

Pediatric (Injection)

1

Engerix-B

Engerix-B (Injection) 1 B/D, PA Gardasil 9

Gardasil 9 (Injection) 1

Havrix

Havrix (Injection) 1

Hiberix

Hiberix (Injection) 1

Imovax Rabies

Imovax Rabies

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

Infanrix

Infanrix (Injection) 1

64


page 7.

64

75

64tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsIPOL Inactivated IPV

IPOL Inactivated IPV

(Injection)1

Ixiaro

Ixiaro (Injection) 1

Kinrix

Kinrix (Injection) 1

M-M-R II

M-M-R II (Injection) 1

Menactra

Menactra (Injection) 1

Menveo

Menveo (Injection) 1

Pediarix

Pediarix (Injection) 1

Pedvax HIB

Pedvax HIB (Injection) 1

ProQuad

ProQuad (Injection) 1

Quadracel

Quadracel (Injection) 1

Rabavert

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

Recombivax HB


Rotarix

Rotarix (Suspension) 1

RotaTeq

RotaTeq (Oral

Solution)1

Tenivac

Tenivac (Injection) 1

Tetanus/Diphtheria Toxoids-Adsorbed Adult

Tetanus/Diphtheria

Toxoids-Adsorbed

Adult (Injection)

1

Trumenba

Trumenba (Injection) 1

Twinrix

Twinrix (Injection) 1

Typhim Vi

Typhim Vi (Injection) 1

VAQTA

VAQTA (Injection) 1

Varivax

Varivax (Injection) 1

YF-Vax

YF-Vax (Injection) 1

Zostavax

Zostavax (Injection) 1 PA

Inflammatory Bowel Disease Agents

Aminosalicylates

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsApriso

Apriso (Capsule

Extended-Release 24

Hour)

1 QL

Balsalazide Disodium

Balsalazide Disodium

(Capsule)1

Canasa

Canasa (Suppository) 1

Dipentum

Dipentum (Capsule) 1

Lialda

Lialda (Tablet


Mesalamine

Mesalamine (Kit) 1

Mesalamine DR

Mesalamine DR

(1.2gm Tablet Delayed-

Release)

1 QL

Pentasa

Pentasa (Capsule

Extended-Release)1 QL

sfRowasa

sfRowasa (Enema) 1 QL

GlucocorticoidsBudesonide

Budesonide (3mg

Capsule Delayed-

Release)

1

Colocort

Colocort (Enema) 1

Entocort EC

Entocort EC (Capsule

Delayed-Release)1

Hydrocortisone

Hydrocortisone

(100mg/60ml Enema)1

Procto-Med HC

Procto-Med HC

(Cream)1

Procto-Pak

Procto-Pak (Cream) 1

Proctosol HC

Proctosol HC (Cream) 1

Proctozone-HC

Proctozone-HC

(Cream)1

65


65

76

65tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsUceris

Uceris (9mg Tablet

Extended-Release 24

Hour)

1 ST

SulfonamidesSulfasalazine

Sulfasalazine (500mg

Tablet Delayed-


Immediate-Release)

1

Metabolic Bone Disease Agents

Metabolic Bone Disease AgentsAlendronate Sodium

Alendronate Sodium

(10mg Tablet, 35mg


5mg Tablet, 70mg

Tablet)

1 QL

Alendronate Sodium

Alendronate Sodium

(70mg/75ml Oral

Solution)

1

Binosto

Binosto (Tablet

Effervescent)1 QL

Calcitonin-Salmon

Calcitonin-Salmon

(Nasal Solution)1 QL

Calcitriol

Calcitriol (0.25mcg

Capsule, 0.5mcg

Capsule, 1mcg/ml Oral

Solution)

1 B/D, PA

Calcitriol

Calcitriol (1mcg/ml

Injection)1 B/D, PA

Doxercalciferol

Doxercalciferol

(0.5mcg Capsule,

1mcg Capsule, 2.5mcg

Capsule)

1 B/D, PA, QL

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsDoxercalciferol

Doxercalciferol (4mcg/


Etidronate Disodium

Etidronate Disodium

(Tablet)1

Forteo

Forteo (Injection) 1 PA, QL Hectorol

Hectorol (1mcg

Capsule, 2.5mcg

Capsule)

1 B/D, PA, QL

Ibandronate Sodium

Ibandronate Sodium

(150mg Tablet)1 QL

Ibandronate Sodium

Ibandronate Sodium

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

Miacalcin

Miacalcin (200unit/ml

Injection)1 PA

Natpara

Natpara (Injection) 1 PA Pamidronate Disodium

Pamidronate Disodium


Paricalcitol

Paricalcitol (1mcg

Capsule, 2mcg

Capsule)

1 B/D, PA, QL

Paricalcitol

Paricalcitol (2mcg/ml

Injection, 5mcg/ml

Injection, 4mcg

Capsule)

1 B/D, PA

Prolia

Prolia (Injection) 1

Rayaldee

Rayaldee (Capsule

Extended-Release)1 QL, ST

Risedronate Sodium

Risedronate Sodium

(Tablet)1 QL

Tymlos

Tymlos (Injection) 1 PA, QL Xgeva

Xgeva (Injection) 1 PA

66


page 7.

66

77

66tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsZemplar

Zemplar (2mcg/ml

Injection)1 B/D, PA

Zemplar

Zemplar (5mcg/ml

Injection)1 B/D, PA

Zoledronic Acid

Zoledronic Acid (4mg/


Zoledronic Acid

Zoledronic Acid (5mg/

100ml Injection)1 PA

Zometa

Zometa (Injection) 1 B/D, PA

Miscellaneous Therapeutic Agents

Miscellaneous Therapeutic AgentsAlcohol Prep Pads

Alcohol Prep Pads 1

Botox

Botox (Injection) 1 PA, QL Exondys 51

Exondys 51

(Injection)1 PA, LA

Fomepizole

Fomepizole (Injection) 1

Gauze

Gauze (Non-medicated

2X2)1

Insulin Syringes, Needles

Insulin Syringes,

Needles1

Kanuma

Kanuma (Injection) 1 PA Myalept

Myalept (Injection) 1 PA Sterile Water Irrigation

Sterile Water

Irrigation (Solution)1

Ophthalmic Agents

Ophthalmic Agents, OtherBacitracin/Polymyxin B

Bacitracin/Polymyxin B

(Ophthalmic Ointment)1

Blephamide

Blephamide

(Suspension)1

Blephamide S.O.P.

Blephamide S.O.P.

(Ointment)1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsCystaran

Cystaran (Ophthalmic

Solution)1

Lacrisert

Lacrisert (Insert) 1

Lastacaft

Lastacaft (Ophthalmic

Solution)1

Neomycin/Bacitracin/Polymyxin

Neomycin/Bacitracin/

Polymyxin (Ointment)1

Neomycin/Polymyxin/Bacitracin/Hydrocortisone

Neomycin/Polymyxin/

Bacitracin/

Hydrocortisone

(Ophthalmic Ointment)

1

Neomycin/Polymyxin/Dexamethasone

Neomycin/Polymyxin/

Dexamethasone (0.1%

Ophthalmic Ointment,

0.1% Ophthalmic

Suspension)

1

Neomycin/Polymyxin/Gramicidin

Neomycin/Polymyxin/

Gramicidin

(Ophthalmic Solution)

1

Neomycin/Polymyxin/Hydrocortisone

Neomycin/Polymyxin/

Hydrocortisone (1%

Ophthalmic

Suspension)

1

Polymyxin B Sulfate/Trimethoprim Sulfate

Polymyxin B Sulfate/

Trimethoprim Sulfate


1

Pred-G

Pred-G (Suspension) 1

Pred-G S.O.P.

Pred-G S.O.P.

(Ointment)1

Proparacaine HCl

Proparacaine HCl


Restasis

Restasis (Emulsion) 1 QL

67


67

78

67tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsSulfacetamide Sodium/Prednisolone Sodium Phosphate

Sulfacetamide

Sodium/Prednisolone

Sodium Phosphate


1

Tobradex ST

Tobradex ST

(Ophthalmic

Suspension)

1

Tobramycin/Dexamethasone

Tobramycin/

Dexamethasone

(Ophthalmic

Suspension)

1

Ophthalmic Anti-allergy AgentsAlocril

Alocril (Ophthalmic

Solution)1

Alomide

Alomide (Ophthalmic

Solution)1

Azelastine HCl

Azelastine HCl (0.05%


Bepreve

Bepreve (Ophthalmic

Solution)1

Cromolyn Sodium

Cromolyn Sodium (4%


Epinastine HCl

Epinastine HCl


Olopatadine HCl

Olopatadine HCl (0.1%


Olopatadine HCl

Olopatadine HCl (0.2%


Pataday

Pataday (Ophthalmic

Solution)1

Patanol

Patanol (Ophthalmic

Solution)1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsPazeo

Pazeo (Ophthalmic

Solution)1

Ophthalmic Antiglaucoma AgentsAlphagan P

Alphagan P (0.1%


Apraclonidine

Apraclonidine


Azopt

Azopt (Suspension) 1

Betaxolol HCl

Betaxolol HCl (0.5%


Betimol

Betimol (Ophthalmic

Solution)1

Brimonidine Tartrate

Brimonidine Tartrate

(0.2% Ophthalmic

Solution)

1

Carteolol HCl

Carteolol HCl


Combigan

Combigan


Cosopt PF

Cosopt PF


Dorzolamide HCl

Dorzolamide HCl


Dorzolamide HCl/Timolol Maleate

Dorzolamide HCl/

Timolol Maleate


1

Levobunolol HCl

Levobunolol HCl


Metipranolol

Metipranolol


Phospholine Iodide

Phospholine Iodide


68


page 7.

68

79

68tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsPilocarpine HCl

Pilocarpine HCl (1%

Ophthalmic Solution,

2% Ophthalmic

Solution, 4%


1

Simbrinza

Simbrinza

(Suspension)1

Timolol Maleate

Timolol Maleate

(0.25% Ophthalmic

Solution, 0.5%


1

Timolol Maleate Ophthalmic Gel Forming

Timolol Maleate

Ophthalmic Gel

Forming (Solution)

1

Ophthalmic Anti-inflammatoriesDexamethasone Sodium Phosphate

Dexamethasone

Sodium Phosphate

(0.1% Ophthalmic

Solution)

1

Diclofenac Sodium

Diclofenac Sodium

(0.1% Ophthalmic

Solution)

1

Durezol

Durezol (Emulsion) 1

Flarex

Flarex (Suspension) 1

Fluorometholone

Fluorometholone

(Ophthalmic

Suspension)

1

Flurbiprofen Sodium

Flurbiprofen Sodium


FML

FML (Ointment) 1

FML Forte

FML Forte

(Suspension)1

Ilevro

Ilevro (Suspension) 1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsKetorolac Tromethamine

Ketorolac

Tromethamine (0.4%

Ophthalmic Solution,

0.5% Ophthalmic

Solution)

1

Lotemax

Lotemax (0.5% Gel,

0.5% Ointment, 0.5%

Suspension)

1

Nevanac

Nevanac

(Suspension)1

Pred Mild

Pred Mild

(Suspension)1

Prednisolone Acetate

Prednisolone Acetate

(Ophthalmic

Suspension)

1

Prednisolone Sodium Phosphate

Prednisolone Sodium

Phosphate (1%


1

Prolensa

Prolensa (Ophthalmic

Solution)1

Ophthalmic Prostaglandin and Prostamide

AnalogsLatanoprost

Latanoprost


Lumigan

Lumigan (Ophthalmic

Solution)1

Travatan Z

Travatan Z


Otic Agents

Otic AgentsAcetic Acid

Acetic Acid (Otic

Solution)1

69


69

80

69tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsCipro HC

Cipro HC

(Suspension)1

Ciprodex

Ciprodex (Otic

Suspension)1

Coly-Mycin S

Coly-Mycin S

(Suspension)1

Fluocinolone Acetonide

Fluocinolone

Acetonide (0.01% Otic

Oil)

1

Hydrocortisone/Acetic Acid

Hydrocortisone/Acetic

Acid (Otic Solution)1

Neomycin/Polymyxin/Hydrocortisone

Neomycin/Polymyxin/

Hydrocortisone (1%

Otic Solution, 1% Otic

Suspension)

1

Respiratory Tract/Pulmonary Agents

AntihistaminesAzelastine HCl


Nasal Solution)1 QL

Azelastine HCl


Nasal Solution)1

Cetirizine HCl

Cetirizine HCl (Syrup) 1

Cyproheptadine HCl

Cyproheptadine HCl

(4mg Tablet)1

Diphenhydramine HCl

Diphenhydramine HCl

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

Levocetirizine Dihydrochloride

Levocetirizine

Dihydrochloride (5mg

Tablet)

1 QL

Phenadoz

Phenadoz

(Suppository)1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsPhenergan

Phenergan (12.5mg

Suppository, 25mg

Suppository)

1

Promethazine HCl

Promethazine HCl

(12.5mg Suppository,

25mg Suppository,

25mg/ml Injection,

50mg/ml Injection)

1

Promethazine HCl

Promethazine HCl

(12.5mg Tablet, 25mg


6.25mg/5ml Syrup)

1

Promethegan

Promethegan (25mg

Suppository)1

Anti-inflammatories, Inhaled

CorticosteroidsArnuity Ellipta

Arnuity Ellipta


Budesonide

Budesonide (0.25mg/

2ml Suspension,

0.5mg/2ml

Suspension, 1mg/2ml

Suspension)

1 B/D, PA

Flovent Diskus

Flovent Diskus


Flovent HFA

Flovent HFA (Aerosol) 1 QL Flunisolide

Flunisolide (Nasal

Solution)1



(50mcg/act

Suspension)

1

70


page 7.

70

81

70tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsMometasone Furoate

Mometasone Furoate

(50mcg/act

Suspension)

1

Nasonex

Nasonex

(Suspension)1 PA

Triamcinolone Acetonide

Triamcinolone

Acetonide (55mcg/act

Aerosol)

1

AntileukotrienesMontelukast Sodium

Montelukast Sodium

(10mg Tablet)1 QL

Montelukast Sodium

Montelukast Sodium

(4mg Packet, 4mg

Tablet Chewable, 5mg

Tablet Chewable)

1 QL

Zafirlukast

Zafirlukast (Tablet) 1 QL Zileuton ER

Zileuton ER (Tablet

Extended-Release 12

Hour)

1 ST

Zyflo

Zyflo (Tablet) 1 ST Zyflo CR

Zyflo CR (Tablet

Extended-Release 12

Hour)

1 ST

Bronchodilators, AnticholinergicAtrovent HFA

Atrovent HFA

(Aerosol Solution)1

Incruse Ellipta

Incruse Ellipta


Ipratropium Bromide

Ipratropium Bromide

(0.02% Inhalation

Solution)

1 B/D, PA

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsIpratropium Bromide

Ipratropium Bromide

(0.03% Nasal Solution,

0.06% Nasal Solution)

1

Spiriva HandiHaler

Spiriva HandiHaler

(Capsule)1 QL

Spiriva Respimat

Spiriva Respimat

(Aerosol Solution)1 QL

Bronchodilators, SympathomimeticAlbuterol Sulfate

Albuterol Sulfate

(0.083% Nebulized

Solution, 0.5%

Nebulized Solution,

0.63mg/3ml Nebulized

Solution, 1.25mg/3ml

Nebulized Solution)

1 B/D, PA

Albuterol Sulfate

Albuterol Sulfate (2mg

Tablet Immediate-

Release, 4mg Tablet

Immediate-Release)

1

Brovana

Brovana (Nebulized


Epinephrine

Epinephrine (0.15mg/

0.3ml Injection,

0.3mg/0.3ml

Injection) (Generic

EpiPen)

1

EpiPen

EpiPen (Injection) 1

Levalbuterol

Levalbuterol

(Nebulized Solution)1 B/D, PA

Metaproterenol Sulfate

Metaproterenol Sulfate

(10mg Tablet, 20mg

Tablet, 10mg/5ml

Syrup)

1

71


71

82

71tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsPerforomist

Perforomist

(Nebulized Solution)1 B/D, PA, QL

ProAir HFA

ProAir HFA (Aerosol

Solution)1

ProAir RespiClick

ProAir RespiClick

(Aerosol Powder)1

Serevent Diskus

Serevent Diskus


Terbutaline Sulfate

Terbutaline Sulfate

(1mg/ml Injection)1

Cystic Fibrosis AgentsCayston

Cayston (Inhalation

Solution)1 PA, LA

Kalydeco

Kalydeco (50mg

Packet, 75mg Packet)1 PA, QL

Orkambi

Orkambi (Tablet) 1 PA, QL, LA

Phosphodiesterase Inhibitors, Airways

DiseaseAminophylline

Aminophylline

(Injection)1

Daliresp

Daliresp (Tablet) 1 PA, QL Theophylline

Theophylline (Oral

Solution)1

Theophylline CR

Theophylline CR

(Tablet Extended-

Release 12 Hour)

1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsTheophylline ER

Theophylline ER

(300mg Tablet

Extended-Release 12

Hour, 450mg Tablet

Extended-Release 12

Hour, 400mg Tablet

Extended-Release 24

Hour, 600mg Tablet

Extended-Release 24

Hour)

1

Pulmonary AntihypertensivesAdcirca

Adcirca (Tablet) 1 PA, QL Adempas

Adempas (Tablet) 1 PA Letairis

Letairis (Tablet) 1 PA, QL, LA Opsumit

Opsumit (Tablet) 1 PA, LA Orenitram

Orenitram (0.125mg

Tablet Extended-

Release)

1 PA, QL

Orenitram

Orenitram (0.25mg

Tablet Extended-

Release, 1mg Tablet

Extended-Release)

1 PA, QL

Orenitram

Orenitram (2.5mg

Tablet Extended-

Release, 5mg Tablet

Extended-Release)

1 PA

Remodulin

Remodulin (Injection) 1 PA, LA Revatio

Revatio (10mg/

12.5ml Injection)1 PA

Revatio

Revatio (20mg Tablet) 1 PA, QL Sildenafil

Sildenafil (10mg/

12.5ml Injection)1 PA

72


page 7.

72

83

72tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsSildenafil

Sildenafil (20mg

Tablet) (Generic

Revatio)

1 PA, QL

Tracleer

Tracleer (Tablet) 1 PA, QL Ventavis

Ventavis (Inhalation

Solution)1 PA, QL, LA

Respiratory Tract Agents, OtherAcetylcysteine

Acetylcysteine

(Inhalation Solution)1 B/D, PA

Advair Diskus

Advair Diskus


Advair HFA

Advair HFA (Aerosol) 1 QL Anoro Ellipta

Anoro Ellipta (Aerosol

Powder)1 QL

Aralast NP

Aralast NP (Injection) 1 PA, LA Bevespi Aerosphere

Bevespi Aerosphere

(Aerosol)1 QL

Breo Ellipta

Breo Ellipta (Aerosol

Powder)1 QL

Cromolyn Sodium

Cromolyn Sodium

(20mg/2ml Nebulized

Solution)

1 B/D, PA

Dulera

Dulera (Aerosol) 1 PA, QL Esbriet

Esbriet (267mg

Capsule, 267mg


1 PA, QL, LA

Fluticasone Propionate/Salmeterol

Fluticasone

Propionate/

Salmeterol (Aerosol

Powder)

1 QL

Glassia

Glassia (Injection) 1 PA, LA

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsKalydeco

Kalydeco (150mg

Tablet)1 PA, QL

Ofev

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

Prolastin-C (Injection) 1 PA, LA Pulmozyme

Pulmozyme

(Inhalation Solution)1 B/D, PA, QL

Stiolto Respimat

Stiolto Respimat

(Aerosol Solution)1 QL

Symbicort

Symbicort (Aerosol) 1 QL Zemaira

Zemaira (Injection) 1 PA, LA

Respiratory Tract/Pulmonary AgentsCombivent Respimat

Combivent Respimat

(Aerosol Solution)1

Dymista

Dymista (Suspension) 1

Ipratropium Bromide/Albuterol Sulfate

Ipratropium Bromide/

Albuterol Sulfate

(Inhalation Solution)

1 B/D, PA

Xolair

Xolair (Injection) 1 PA

Skeletal Muscle Relaxants

Skeletal Muscle RelaxantsBaclofen

Baclofen (Tablet) 1

Cyclobenzaprine HCl

Cyclobenzaprine HCl

(10mg Tablet, 5mg

Tablet)

1

Cyclobenzaprine HCl

Cyclobenzaprine HCl

(7.5mg Tablet)1 PA

Dantrolene Sodium

Dantrolene Sodium

(Capsule)1

Gablofen

Gablofen (10000mcg/

20ml Injection,

50mcg/ml Injection)

1 B/D, PA

73


73

84

73tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsGablofen

Gablofen (40000mcg/


Lioresal Intrathecal


(10mg/20ml

Injection)

1 B/D, PA



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

Orphenadrine Citrate

Orphenadrine Citrate

(Injection)1

Tizanidine HCl

Tizanidine HCl (2mg


Sleep Disorder Agents

GABA Receptor ModulatorsTemazepam

Temazepam (15mg

Capsule, 30mg

Capsule)

1 QL

Zaleplon

Zaleplon (Capsule) 1 QL, HRM Zolpidem Tartrate

Zolpidem Tartrate

(10mg Tablet

Immediate-Release,


Release)

1 QL, HRM

Sleep Disorders, OtherBelsomra

Belsomra (Tablet) 1 QL Hetlioz

Hetlioz (Capsule) 1 PA, QL Modafinil

Modafinil (Tablet) 1 PA, QL Rozerem

Rozerem (Tablet) 1 QL Xyrem

Xyrem (Oral Solution) 1 PA, QL, LA

Therapeutic Nutrients/Minerals/Electrolytes

Electrolyte/Mineral ModifiersChemet

Chemet (Capsule) 1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsExjade

Exjade (Tablet

Soluble)1 PA

Ferriprox

Ferriprox (100mg/ml


Tablet)

1 PA

Jadenu

Jadenu (Tablet) 1 PA Jadenu Sprinkle

Jadenu Sprinkle

(Packet)1 PA

Kionex

Kionex (Powder) 1

Samsca

Samsca (Tablet) 1 PA, QL Sodium Polystyrene Sulfonate

Sodium Polystyrene

Sulfonate (Suspension)1

SPS

SPS (Suspension) 1

Syprine

Syprine (Capsule) 1 PA

Electrolyte/Mineral ReplacementCarbaglu

Carbaglu (Tablet) 1 LA Isolyte-S

Isolyte-S (Injection) 1

Klor-Con 10

Klor-Con 10 (Tablet

Extended-Release)1

Klor-Con 8

Klor-Con 8 (Tablet

Extended-Release)1

Klor-Con M10

Klor-Con M10 (Tablet

Extended-Release)1

Klor-Con M15


Extended-Release)1

Klor-Con M20


Extended-Release)1

Klor-Con Sprinkle

Klor-Con Sprinkle

(Capsule Extended-

Release)

1

74


page 7.

74

85

74tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsMagnesium Sulfate

Magnesium Sulfate

(1gm/2ml-50%

Injection)

1

Magnesium Sulfate

Magnesium Sulfate

(5gm/10ml-50%

Injection)

1

Normosol-R

Normosol-R

(Injection)1

Physiolyte

Physiolyte (Irrigation

Solution)1

Physiosol Irrigation

Physiosol Irrigation

(Solution)1

Plasma-Lyte A

Plasma-Lyte A

(Injection)1

Plasma-Lyte-148

Plasma-Lyte-148

(Injection)1

Potassium Chloride

Potassium Chloride

(10% Oral Solution,

20% Oral Solution)

1

Potassium Chloride

Potassium Chloride

(10meq/100ml

Injection, 20meq/

100ml Injection,

40meq/100ml

Injection)

1 B/D, PA

Potassium Chloride

Potassium Chloride

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

Potassium Chloride ER


(10meq Capsule

Extended-Release,

8meq Capsule

Extended-Release)

1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsPotassium Chloride ER


(10meq Tablet

Extended-Release,

20meq Tablet

Extended-Release,

8meq Tablet Extended-

Release)

1

Potassium Chloride/Sodium Chloride

Potassium Chloride/

Sodium Chloride

(20meq/L-0.45%

Injection)

1 B/D, PA

Potassium Chloride/Sodium Chloride

Potassium Chloride/

Sodium Chloride

(20meq/L-0.9%

Injection, 40meq/

L-0.9% Injection)

1 B/D, PA

Potassium Citrate ER

Potassium Citrate ER

(Tablet Extended-

Release)

1

Sodium Chloride

Sodium Chloride (0.9%

Injection)1

Sodium Chloride

Sodium Chloride

(2.5meq/ml Injection,

3% Injection, 5%

Injection)

1

Sodium Chloride 0.45%

Sodium Chloride

0.45% (Injection)1

Sodium Chloride 0.9%

Sodium Chloride

0.9% (Irrigation

Solution)

1

Sodium Fluoride

Sodium Fluoride

(Tablet)1

Therapeutic Nutrients/Minerals/

Electrolytes

75


75

86

75tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsAminosyn 7%/Electrolytes

Aminosyn 7%/

Electrolytes

(Injection)

1 B/D, PA

Aminosyn 8.5%/Electrolytes

Aminosyn 8.5%/

Electrolytes

(Injection)

1 B/D, PA

Aminosyn II

Aminosyn II (10%

Injection)1 B/D, PA

Aminosyn II 8.5%/Electrolytes

Aminosyn II 8.5%/

Electrolytes

(Injection)

1 B/D, PA

Aminosyn-HBC

Aminosyn-HBC


Aminosyn-PF

Aminosyn-PF


Aminosyn-RF

Aminosyn-RF


Dextrose 10%

Dextrose 10%

(Injection)1

Dextrose 10%/NaCl 0.2%

Dextrose 10%/NaCl

0.2% (Injection)1


Dextrose 10%/NaCl

0.45% (Injection)1

Dextrose 2.5%/NaCl 0.45%

Dextrose 2.5%/NaCl

0.45% (Injection)1

Dextrose 5%

Dextrose 5%

(Injection)1

Dextrose 5%/Lactated Ringers

Dextrose 5%/

Lactated Ringers

(Injection)

1


Dextrose 5%/NaCl

0.2% (Injection)1

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsDextrose 5%/NaCl 0.225%

Dextrose 5%/NaCl

0.225% (Injection)1


Dextrose 5%/NaCl

0.33% (Injection)1


Dextrose 5%/NaCl

0.45% (Injection)1


Dextrose 5%/NaCl

0.9% (Injection)1

FreAmine HBC 6.9%

FreAmine HBC 6.9%


HepatAmine

HepatAmine


Intralipid

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

Ionosol-B/Dextrose

5% (Injection)1

Ionosol-MB/Dextrose 5%

Ionosol-MB/Dextrose

5% (Injection)1

Isolyte-P/Dextrose 5%

Isolyte-P/Dextrose 5%

(Injection)1

KCl 0.075%/D5W/NaCl 0.45%

KCl 0.075%/D5W/

NaCl 0.45%

(Injection)

1

KCl 0.15%/D5W/NaCl 0.2%

KCl 0.15%/D5W/NaCl

0.2% (Injection)1

KCl 0.15%/D5W/NaCl 0.225%

KCl 0.15%/D5W/NaCl

0.225% (Injection)1

KCl 0.15%/D5W/NaCl 0.9%

KCl 0.15%/D5W/NaCl

0.9% (Injection)1

KCl 0.3%/D5W/NaCl 0.45%

KCl 0.3%/D5W/NaCl

0.45% (Injection)1

KCl 0.3%/D5W/NaCl 0.9%

KCl 0.3%/D5W/NaCl

0.9% (Injection)1

76


page 7.

76

87

76tRACK


Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsLactated Ringers Irrigation

Lactated Ringers

Irrigation (Solution)1

Lactated Ringers Viaflex

Lactated Ringers

Viaflex (Injection)1

Levocarnitine

Levocarnitine (1gm/

10ml Oral Solution,

330mg Tablet)

1

Nephramine

Nephramine


Normosol-M in D5W

Normosol-M in D5W

(Injection)1

Normosol-R in D5W

Normosol-R in D5W

(Injection)1

Nutrilipid

Nutrilipid (Injection) 1 B/D, PA Plenamine

Plenamine (Injection) 1 B/D, PA Potassium Chloride 0.15% D5W/NaCl 0.45%

Potassium Chloride

0.15% D5W/NaCl

0.45% (Injection)

1

Potassium Chloride 0.22% D5W/NaCl 0.45%

Potassium Chloride

0.22% D5W/NaCl

0.45% (Injection)

1

Potassium Chloride/Dextrose

Potassium Chloride/

Dextrose (Injection)1 B/D, PA

Drug NameDrug

Tier

Required

Actions,

Restrictions

or LimitsPotassium Chloride/Dextrose/Lactated Ringers

Potassium Chloride/

Dextrose/Lactated

Ringers (Injection)

1

Potassium Chloride 0.15% D5W/NaCl 0.33%

Potassium Chloride

0.15% D5W/NaCl

0.33% (Injection)

1

Premasol

Premasol (Injection) 1 B/D, PA Procalamine

Procalamine


Prosol

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

Ringers Injection 1

Ringers Irrigation

Ringers Irrigation

(Solution)1

Sodium Lactate

Sodium Lactate

(Injection)1

TPN Electrolytes

TPN Electrolytes

(Injection)1

Travasol

Travasol (Injection) 1 B/D, PA Trophamine

Trophamine (10%

Injection)1 B/D, PA

VP-PNV-DHA

VP-PNV-DHA (Capsule) 1

track


88

88

Drugs with a quantity limit (QL)

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

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

ensure your safety.

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

Each strength may have a different quantity limit. If quantity limits for a drug vary by strength, the

different strengths are listed on separate lines.

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

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

Drug Name Quantity Limit

Abacavir (Tablet) Maximum of 3 tablets per day

Abacavir Sulfate/Lamivudine/Zidovudine

(Tablet)Maximum of 3 tablets per day

Abacavir/Lamivudine (Tablet) Maximum of 2 tablets per day

Abstral (Tablet Sublingual) Maximum of 4 tablets per day

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



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

Oral Solution)Maximum of 140 ml per day

Acetaminophen/Codeine (300mg-15mg Tablet,

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

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

Adcirca (Tablet) Maximum of 2 tablets per day

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

Advair HFA (Aerosol) Maximum of 1 inhaler (12 grams) per 30 days

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

Aggrenox (Capsule Extended-Release 12

Hour)Maximum of 2 capsules per day

Albenza (Tablet) Maximum of 16 tablets per day

Alecensa (Capsule) Maximum of 8 capsules per day

Alendronate Sodium (10mg Tablet, 40mg

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

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

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

Alprazolam (0.25mg Tablet Immediate-Release,

0.5mg Tablet Immediate-Release, 1mg Tablet

Immediate-Release)

Maximum of 4 tablets per day


89

89


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

Alunbrig (Tablet) Maximum of 6 tablets per day

Amitiza (Capsule) Maximum of 2 capsules per day

Amlodipine Besylate/Atorvastatin Calcium

(Tablet)Maximum of 1 tablet per day

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

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

Amlodipine/Olmesartan Medoxomil (Tablet) Maximum of 1 tablet per day

Amlodipine/Valsartan/Hydrochlorothiazide


Amphetamine/Dextroamphetamine (10mg

Capsule Extended-Release 24 Hour, 15mg





Capsule Extended-Release 24 Hour)

Maximum of 2 capsules per day


Tablet Immediate-Release, 12.5mg Tablet

Immediate-Release, 15mg Tablet Immediate-

Release, 30mg Tablet Immediate-Release, 5mg

Tablet Immediate-Release, 7.5mg Tablet

Immediate-Release)



Tablet Immediate-Release)Maximum of 3 tablets per day

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

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

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

Apokyn (Injection) Maximum of 3 ml per day

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

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

Tablet)Maximum of 1 tablet per day

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

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

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

Aripiprazole (Tablet) Maximum of 1 tablet per day

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

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


90

90


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

Aspirin/Dipyridamole (Capsule Extended-

Release 12 Hour)Maximum of 2 capsules per day

Atomoxetine (100mg Capsule, 60mg Capsule,

80mg Capsule)Maximum of 1 capsule per day

Atomoxetine (10mg Capsule, 18mg Capsule,

25mg Capsule, 40mg Capsule)Maximum of 2 capsules per day

Atorvastatin Calcium (Tablet) Maximum of 1 tablet per day

Atripla (Tablet) Maximum of 2 tablets per day

Aubagio (Tablet) Maximum of 1 tablet per day

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

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

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

Azor (Tablet) Maximum of 1 tablet per day

Belsomra (Tablet) Maximum of 1 tablet per day

Benazepril HCl (Tablet) Maximum of 2 tablets per day

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

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

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

Benicar HCT (Tablet) Maximum of 1 tablet per day

Bethkis (Nebulized Solution) Maximum of 8 ml (2 ampules) per day

Bevespi Aerosphere (Aerosol) Maximum of 1 inhaler (10.7 grams) per 30 days

BiDil (Tablet) Maximum of 6 tablets per day

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

Bisoprolol Fumarate/Hydrochlorothiazide

(2.5mg-6.25mg Tablet, 5mg-6.25mg Tablet)Maximum of 2 tablets per day

Bosulif (100mg Tablet) Maximum of 6 tablets per day

Bosulif (500mg Tablet) Maximum of 1 tablet per day

Botox (Injection) Maximum of 9 vials per 30 days

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

Brilinta (Tablet) Maximum of 2 tablets per day

BRIVIACT (100mg Tablet, 10mg Tablet,

25mg Tablet, 50mg Tablet, 75mg Tablet)Maximum of 2 tablets per day

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

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

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


91

91


Buprenorphine HCl (2mg Tablet Sublingual,

8mg Tablet Sublingual)Maximum of 3 tablets per day

Buprenorphine HCl/Naloxone HCl (Tablet

Sublingual)Maximum of 3 tablets per day

Butalbital/Acetaminophen/Caffeine (Tablet) Maximum of 6 tablets per day

Butalbital/Aspirin/Caffeine (Capsule) Maximum of 6 capsules per day

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

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

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

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

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

Bystolic (10mg Tablet, 2.5mg Tablet, 5mg


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

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

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

Calcitonin-Salmon (Nasal Solution) Maximum of 1 bottle per 28 days

Candesartan Cilexetil (16mg Tablet, 32mg


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

Candesartan Cilexetil/Hydrochlorothiazide


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

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

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

Captopril/Hydrochlorothiazide (25mg-15mg

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

Captopril/Hydrochlorothiazide (25mg-25mg


Celecoxib (Capsule) Maximum of 2 capsules per day

Clonazepam (0.5mg Tablet Immediate-Release) Maximum of 4 tablets per day

Clonazepam (1mg Tablet Immediate-Release) Maximum of 4 tablets per day

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

Clonazepam ODT (0.125mg Tablet Dispersible,

0.25mg Tablet Dispersible, 0.5mg Tablet

Dispersible, 1mg Tablet Dispersible)


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

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


92

92


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

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

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

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

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




Codeine Sulfate (Tablet) Maximum of 6 tablets per day

Colchicine (0.6mg Capsule) (Generic

Mitigare)Maximum of 4 capsules per day

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

Colcrys (Tablet) Maximum of 4 tablets per day

Combivir (Tablet) Maximum of 3 tablets per day

Complera (Tablet) Maximum of 2 tablets per day

Corlanor (Tablet) Maximum of 2 tablets per day

Cotellic (Tablet) Maximum of 3 tablets per day

Crestor (Tablet) Maximum of 1 tablet per day

Crixivan (Capsule) Maximum of 9 capsules per day

Cycloset (Tablet) Maximum of 6 tablets per day

Daklinza (Tablet) Maximum of 1 tablet per day

Daliresp (Tablet) Maximum of 1 tablet per day

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

Descovy (Tablet) Maximum of 2 tablets per day

Desvenlafaxine ER (100mg Tablet Extended-

Release 24 Hour) (Generic Pristiq)Maximum of 4 tablets per day

Desvenlafaxine ER (25mg Tablet Extended-

Release 24 Hour, 50mg Tablet Extended-

Release 24 Hour) (Generic Pristiq)

Maximum of 1 tablet per day

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

Dexmethylphenidate HCl (Tablet Immediate-

Release)Maximum of 2 tablets per day

Dextroamphetamine Sulfate (10mg Tablet


Release)


Dextroamphetamine Sulfate ER (10mg Capsule

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


93

93






Diazepam (10mg Tablet, 2mg Tablet, 5mg

Tablet)Maximum of 4 tablets per day

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

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

Donepezil HCl (10mg Tablet Immediate-


Donepezil HCl (23mg Tablet Immediate-

Release)Maximum of 1 tablet per day

Donepezil HCl (5mg Tablet Immediate-Release) Maximum of 1 tablet per day

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

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

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

Doxercalciferol (1mcg Capsule, 2.5mcg

Capsule)Maximum of 4 capsules per day

Dronabinol (Capsule) Maximum of 4 capsules per day

Dulera (Aerosol) Maximum of 1 inhaler (13 grams) per 30 days

Duloxetine HCl (20mg Capsule Delayed-

Release, 30mg Capsule Delayed-Release, 60mg

Capsule Delayed-Release)


Edarbi (Tablet) Maximum of 1 tablet per day

Edarbyclor (Tablet) Maximum of 1 tablet per day

Edurant (Tablet) Maximum of 2 tablets per day

Effient (Tablet) Maximum of 1 tablet per day

Eliquis (Tablet) Maximum of 2 tablets per day

Embeda (100mg-4mg Capsule Extended-

Release)Maximum of 3 capsules per day

Embeda (20mg-0.8mg Capsule Extended-

Release, 80mg-3.2mg Capsule Extended-

Release)



Release, 50mg-2mg Capsule Extended-

Release)




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


94

94


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

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

Enalapril Maleate (Tablet) Maximum of 2 tablets per day

Enalapril Maleate/Hydrochlorothiazide

(10mg-25mg Tablet)Maximum of 2 tablets per day

Enalapril Maleate/Hydrochlorothiazide

(5mg-12.5mg Tablet)Maximum of 1 tablet per day

Endocet (Tablet) Maximum of 12 tablets per day

Enoxaparin Sodium (100mg/ml Subcutaneous

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

Enoxaparin Sodium (120mg/0.8ml

Subcutaneous Solution, 80mg/0.8ml

Subcutaneous Solution)

Maximum of 2 syringes (1.6 ml) per day

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


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





Entresto (Tablet) Maximum of 2 tablets per day

Epclusa (Tablet) Maximum of 1 tablet per day

Eprosartan Mesylate (Tablet) Maximum of 1 tablet per day

Epzicom (Tablet) Maximum of 2 tablets per day

Erivedge (Capsule) Maximum of 1 capsule per day

Esbriet (267mg Capsule) Maximum of 9 capsules per day

Esbriet (267mg Tablet) Maximum of 9 tablets per day

Esbriet (801mg Tablet) Maximum of 3 tablets per day

Esomeprazole Magnesium (20mg Capsule

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

Esomeprazole Magnesium (40mg Capsule

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

Estradiol (0.025mg/24hr Patch Weekly,

0.05mg/24hr Patch Weekly, 0.06mg/24hr Patch

Weekly, 0.075mg/24hr Patch Weekly, 0.1mg/

24hr Patch Weekly, 37.5mcg/24hr Patch

Weekly)

Maximum of 4 patches per 28 days

Estradiol (10mcg Tablet) Maximum of 1 tablet per day


95

95


Evotaz (Tablet) Maximum of 2 tablets per day

Ezetimibe (Tablet) Maximum of 1 tablet per day

Ezetimibe/Simvastatin (Tablet) Maximum of 1 tablet per day

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

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

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

Tablet, 2mg Tablet, 4mg Tablet, 6mg Tablet,

8mg Tablet)


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



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

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

50mcg/hr Patch 72 Hour, 75mcg/hr Patch 72

Hour)

Maximum of 15 patches per 30 days

Fentanyl Citrate Oral Transmucosal (1200mcg

Lollipop, 1600mcg Lollipop, 200mcg Lollipop,

400mcg Lollipop, 600mcg Lollipop, 800mcg

Lollipop)

Maximum of 4 lozenges per day

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

Firazyr (Injection) Maximum of 9 ml per day

Flector (Patch) Maximum of 2 patches per day

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

days

Flovent HFA (110mcg/act Aerosol) Maximum of 1 inhaler (12 grams) per 30 days

Flovent HFA (220mcg/act Aerosol) Maximum of 2 inhalers (24 grams) per 30 days

Flovent HFA (44mcg/act Aerosol) Maximum of 1 inhaler (10.6 grams) per 30 days

Fluticasone Propionate/Salmeterol (Aerosol

Powder)Maximum of 1 inhaler per 30 days

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

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

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

Fosinopril Sodium (Tablet) Maximum of 2 tablets per day

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

Fuzeon (Injection) Maximum of 3 vials per day

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

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


96

96


Galantamine HBr (12mg Tablet, 4mg Tablet,

8mg Tablet)Maximum of 2 tablets per day

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

Galantamine HBr ER (Capsule Extended-

Release 24 Hour)Maximum of 1 capsule per day

Genvoya (Tablet) Maximum of 2 tablets per day

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

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



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

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

Glipizide ER (10mg Tablet Extended-Release 24

Hour)Maximum of 2 tablets per day

Glipizide ER (2.5mg Tablet Extended-Release

24 Hour)Maximum of 8 tablets per day

Glipizide ER (5mg Tablet Extended-Release 24


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

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

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

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

Harvoni (Tablet) Maximum of 1 tablet per day

Hectorol (1mcg Capsule, 2.5mcg Capsule) Maximum of 4 capsules per day

Hetlioz (Capsule) Maximum of 1 capsule per day

Hydrocodone Bitartrate/Acetaminophen

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

Hydrocodone/Acetaminophen (10mg-325mg

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

Tablet, 7.5mg-325mg Tablet)


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

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

Hydromorphone HCl (2mg Tablet Immediate-

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

Hydromorphone HCl (8mg Tablet Immediate-



97

97


Hydromorphone HCl ER (12mg Tablet

Extended-Release 24 Hour Abuse-Deterrent,

16mg Tablet Extended-Release 24 Hour Abuse-

Deterrent, 8mg Tablet Extended-Release 24

Hour Abuse-Deterrent)


Hydromorphone HCl ER (32mg Tablet

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

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

Ibrance (Capsule) Maximum of 1 capsule per day

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

Iclusig (45mg Tablet) Maximum of 1 tablet per day

Idhifa (Tablet) Maximum of 1 tablet per day

Ilaris (Injection) Maximum of 2 vials per 28 days

Imatinib Mesylate (Tablet) Maximum of 3 tablets per day

Imbruvica (Capsule) Maximum of 4 capsules per day

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

Inlyta (Tablet) Maximum of 4 tablets per day

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



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

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

Invokamet (Tablet) Maximum of 2 tablets per day

Invokamet XR (Tablet Extended-Release 24


Invokana (Tablet) Maximum of 1 tablet per day

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

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

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

Iressa (Tablet) Maximum of 2 tablets per day

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

Isentress (100mg Tablet Chewable, 25mg

Tablet Chewable)Maximum of 9 tablets per day

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

Isentress HD (Tablet) Maximum of 3 tablets per day

Itraconazole (Capsule) Maximum of 4 capsules per day

Jakafi (Tablet) Maximum of 2 tablets per day


98

98


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

Janumet XR (Tablet Extended-Release 24


Januvia (Tablet) Maximum of 1 tablet per day

Jardiance (Tablet) Maximum of 1 tablet per day

Jentadueto (Tablet) Maximum of 2 tablets per day

Jentadueto XR (2.5mg-1000mg Tablet

Extended-Release 24 Hour)Maximum of 2 tablets per day

Jentadueto XR (5mg-1000mg Tablet

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

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

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

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

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

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

Kisqali (Tablet) Maximum of 3 tablets per day

Kisqali Femara 200 Dose (Tablet Therapy

Pack)Maximum of 91 tablets (1 pack) per 28 days





Kombiglyze XR (2.5mg-1000mg Tablet

Extended-Release 24 Hour)Maximum of 2 tablets per day

Kombiglyze XR (5mg-1000mg Tablet

Extended-Release 24 Hour, 5mg-500mg

Tablet Extended-Release 24 Hour)


Korlym (Tablet) Maximum of 4 tablets per day

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

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

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

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

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


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

Letairis (Tablet) Maximum of 1 tablet per day

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

Levorphanol Tartrate (Tablet) Maximum of 6 tablets per day


99

99


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

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

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

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

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

Linzess (Capsule) Maximum of 1 capsule per day

Lisinopril (Tablet) Maximum of 2 tablets per day

Lisinopril/Hydrochlorothiazide (10mg-12.5mg


Lisinopril/Hydrochlorothiazide (20mg-12.5mg


Lisinopril/Hydrochlorothiazide (20mg-25mg


Livalo (Tablet) Maximum of 1 tablet per day

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

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

Lopinavir/Ritonavir (Oral Solution) Maximum of 16 ml per day

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

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

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

Lorcet (Tablet) Maximum of 12 tablets per day

Lorcet HD (Tablet) Maximum of 12 tablets per day

Lorcet Plus (Tablet) Maximum of 12 tablets per day

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

Losartan Potassium (25mg Tablet, 50mg



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


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

Lovastatin (10mg Tablet Immediate-Release,

20mg Tablet Immediate-Release)Maximum of 1 tablet per day

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

Loxapine Succinate (10mg Capsule, 5mg

Capsule)Maximum of 4 capsules per day

Lynparza (100mg Tablet, 150mg Tablet) Maximum of 4 tablets per day

Lynparza (50mg Capsule) Maximum of 16 capsules per day


100

100


Lyrica (100mg Capsule, 150mg Capsule,

200mg Capsule, 25mg Capsule, 50mg

Capsule, 75mg Capsule)


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

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

Matzim LA (360mg Tablet Extended-Release 24

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

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

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

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

Mesalamine DR (1.2GM Tablet Delayed-


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

Metformin HCl (1000mg Tablet Immediate-

Release)Maximum of 2.5 tablets per day





Metformin HCl ER (500mg Tablet Extended-

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

Metformin HCl ER (750mg Tablet Extended-

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

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

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

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

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

Methylphenidate HCl (10mg Tablet Immediate-


Tablet Immediate-Release) (Generic Ritalin)


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

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

Methylphenidate HCl ER (10mg Tablet

Extended-Release)Maximum of 4 tablets per day

Methylphenidate HCl ER (20mg Tablet

Extended-Release)Maximum of 3 tablets per day

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



101

101



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

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

Moexipril HCl (7.5mg Tablet) Maximum of 2 tablets per day

Moexipril/Hydrochlorothiazide (15mg-12.5mg


Moexipril/Hydrochlorothiazide (7.5mg-12.5mg


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

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

Montelukast Sodium (4mg Tablet Chewable,

5mg Tablet Chewable)Maximum of 1 tablet per day

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


Morphine Sulfate (15mg Tablet Immediate-



Morphine Sulfate (30mg Tablet Immediate-


Morphine Sulfate ER (100mg Tablet Extended-

Release, 15mg Tablet Extended-Release)

(Generic MS Contin)



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


Release, 60mg Tablet Extended-Release)

(Generic MS Contin)


Multaq (Tablet) Maximum of 2 tablets per day

Nadolol/Bendroflumethiazide (40mg-5mg


Namenda XR (Capsule Extended-Release 24

Hour)Maximum of 1 capsule per day

Namenda XR Titration Pack (Capsule

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

Namzaric (Capsule Extended-Release 24

Hour)Maximum of 1 capsule per day

Namzaric (Therapy Pack) Maximum of 1 capsule per day

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

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


102

102


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

Nebupent (Inhalation Solution) Maximum of 300 mg (1 vial) in 28 days

Nerlynx (Tablet) Maximum of 6 tablets per day

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

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

Nevirapine ER (100mg Tablet Extended-Release


Nevirapine ER (400mg Tablet Extended-Release


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

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

Nifedipine ER (Tablet Extended-Release 24


Ninlaro (Capsule) Maximum of 3 capsules per 28 days

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

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

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

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

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

Noxafil (100mg Tablet Delayed-Release) Maximum of 8 tablets per day

Noxafil (40mg/ml Suspension) Maximum of 20 ml per day

Nucynta ER (Tablet Extended-Release 12


Nuplazid (Tablet) Maximum of 2 tablets per day

Ocaliva (Tablet) Maximum of 1 tablet per day

Odefsey (Tablet) Maximum of 2 tablets per day

Odomzo (Capsule) Maximum of 1 capsule per day

Ofev (Capsule) Maximum of 2 capsules per day

Olanzapine (10mg Tablet Immediate-Release,

15mg Tablet Immediate-Release, 20mg Tablet


Release, 7.5mg Tablet Immediate-Release)


Olanzapine (2.5mg Tablet Immediate-Release) Maximum of 1 tablet per day

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

Olmesartan Medoxomil (20mg Tablet, 40mg


Olmesartan Medoxomil (5mg Tablet) Maximum of 2 tablets per day


103

103


Olmesartan Medoxomil/Amlodipine/

Hydrochlorothiazide (Tablet)Maximum of 1 tablet per day

Olmesartan Medoxomil/Hydrochlorothiazide


Olysio (Capsule) Maximum of 1 capsule per day

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

Lovaza)Maximum of 4 capsules per day

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

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

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

Onglyza (Tablet) Maximum of 1 tablet per day

Opana ER (10mg Tablet Extended-Release 12

Hour Abuse-Deterrent, 15mg Tablet

Extended-Release 12 Hour Abuse-Deterrent,

20mg Tablet Extended-Release 12 Hour

Abuse-Deterrent, 5mg Tablet Extended-

Release 12 Hour Abuse-Deterrent, 7.5mg

Tablet Extended-Release 12 Hour Abuse-

Deterrent)



Hour Abuse-Deterrent)Maximum of 4 tablets per day


Hour Abuse-Deterrent)Maximum of 3 tablets per day

Orenitram (0.125mg Tablet Extended-

Release, 0.25mg Tablet Extended-Release,

1mg Tablet Extended-Release)


Orkambi (Tablet) Maximum of 112 tablets per 28 days

Oseltamivir Phosphate (Capsule) Maximum of 2 capsules per day

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

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

Oxybutynin Chloride ER (10mg Tablet

Extended-Release 24 Hour, 15mg Tablet

Extended-Release 24 Hour)


Oxybutynin Chloride ER (5mg Tablet Extended-

Release 24 Hour)Maximum of 1 tablet per day

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

Oxycodone HCl (10mg Tablet Immediate-


Tablet Immediate-Release)



104

104






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

Oxycodone/Acetaminophen (10mg-325mg

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

Tablet, 7.5mg-325mg Tablet)


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

5ml Oral Solution)Maximum of 60 ml per day

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

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

Paliperidone ER (1.5mg Tablet Extended-

Release 24 Hour, 3mg Tablet Extended-Release

24 Hour, 9mg Tablet Extended-Release 24

Hour)


Paliperidone ER (6mg Tablet Extended-Release


Pantoprazole Sodium (20mg Tablet Delayed-


Pantoprazole Sodium (40mg Tablet Delayed-


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

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

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

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

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

Perindopril Erbumine (Tablet) Maximum of 2 tablets per day

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

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

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

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

Pomalyst (Capsule) Maximum of 1 capsule per day

Pradaxa (Capsule) Maximum of 2 capsules per day

Praluent (Injection) Maximum of 2 pens (2 ml) per 28 days

Prasugrel (Tablet) Maximum of 1 tablet per day

Pravastatin Sodium (Tablet) Maximum of 1 tablet per day


105

105


Premarin (0.3mg Tablet, 0.45mg Tablet,

0.625mg Tablet, 0.9mg Tablet, 1.25mg

Tablet)


Prempro (Tablet) Maximum of 1 tablet per day

Prezcobix (Tablet) Maximum of 2 tablets per day

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

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

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

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

Pristiq (100mg Tablet Extended-Release 24


Pristiq (25mg Tablet Extended-Release 24

Hour, 50mg Tablet Extended-Release 24

Hour)


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

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

Pulmozyme (Inhalation Solution) Maximum of 5 ml (2 ampules) per day

Quetiapine Fumarate (100mg Tablet Immediate-

Release, 200mg Tablet Immediate-Release,

50mg Tablet Immediate-Release)





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

Quetiapine Fumarate ER (150mg Tablet




Quetiapine Fumarate ER (300mg Tablet





Quinapril HCl (Tablet) Maximum of 2 tablets per day

Quinapril/Hydrochlorothiazide (10mg-12.5mg


Quinapril/Hydrochlorothiazide (20mg-12.5mg


Raloxifene HCl (Tablet) Maximum of 1 tablet per day

Ramipril (Capsule) Maximum of 2 capsules per day

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


106

106


Rapaflo (Capsule) Maximum of 1 capsule per day

RAVICTI (Liquid) Maximum of 17.5 ml per day

Rayaldee (Capsule Extended-Release) Maximum of 2 capsules per day

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

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

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

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

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

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

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

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

Rescriptor (Tablet) Maximum of 9 tablets per day

Restasis (Emulsion) Maximum of 2 vials per day

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

Revlimid (Capsule) Maximum of 1 capsule per day

Rexulti (Tablet) Maximum of 1 tablet per day

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

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

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

Riomet (Oral Solution) Maximum of 25.5 ml per day

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

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

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

Rivastigmine Tartrate (Capsule Immediate-


Rivastigmine Transdermal System (Patch 24

Hour)Maximum of 1 patch per day

Rizatriptan Benzoate (Tablet Immediate-

Release)Maximum of 12 tablets per 30 days

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

Rosuvastatin Calcium (Tablet) Maximum of 1 tablet per day

Rozerem (Tablet) Maximum of 1 tablet per day

Rubraca (Tablet) Maximum of 4 tablets per day

Rydapt (Capsule) Maximum of 8 capsules per day

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

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

Samsca (Tablet) Maximum of 2 tablets per day


107

107


Saphris (Tablet Sublingual) Maximum of 2 tablets per day

Selzentry (150mg Tablet, 75mg Tablet) Maximum of 3 tablets per day

Selzentry (25mg Tablet, 300mg Tablet) Maximum of 6 tablets per day

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

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

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

days

Seroquel XR (150mg Tablet Extended-


Release 24 Hour)


Seroquel XR (300mg Tablet Extended-



Release 24 Hour)


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

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

Simvastatin (Tablet) Maximum of 1 tablet per day

Soliqua 100/33 (Injection) Maximum of 18 ml (6 pens) per 30 days

Somavert (Injection) Maximum of 1 vial per day

Sovaldi (Tablet) Maximum of 1 tablet per day

Spiriva HandiHaler (Capsule) Maximum of 1 capsule per day

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

Sprycel (100mg Tablet, 140mg Tablet, 70mg


Sprycel (20mg Tablet, 50mg Tablet) Maximum of 3 tablets per day

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

Stavudine (15mg Capsule, 30mg Capsule,

40mg Capsule)Maximum of 3 capsules per day

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

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

Stivarga (Tablet) Maximum of 4 tablets per day

Strattera (100mg Capsule, 60mg Capsule,


Strattera (10mg Capsule, 18mg Capsule,

25mg Capsule, 40mg Capsule)Maximum of 2 capsules per day

Stribild (Tablet) Maximum of 2 tablets per day

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

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


108

108


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

Sumatriptan Succinate (100mg Tablet, 25mg

Tablet, 50mg Tablet)Maximum of 9 tablets per 30 days

Sumatriptan Succinate (4mg/0.5ml Solution

Auto injector, 6mg/0.5ml Solution Auto injector)Maximum of 12 injections (6 ml) per 30 days

Sumatriptan Succinate (6mg/0.5ml Solution

Prefilled Syringe)Maximum of 12 injections (6 ml) per 30 days

Sumatriptan Succinate (6mg/0.5ml

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

Sumatriptan Succinate Refill (Injection) Maximum of 12 injections (6 ml) per 30 days

Sumavel DosePro (Injection) Maximum of 12 injections (6 ml) per 30 days

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

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

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

Sutent (12.5mg Capsule, 25mg Capsule,


Sutent (37.5mg Capsule) Maximum of 2 tablets per day

Symbicort (Aerosol) Maximum of 1 inhaler (10.2 grams) per 30 days

Synjardy (Tablet) Maximum of 2 tablets per day

Tagrisso (Tablet) Maximum of 1 tablet per day

Tamiflu (30mg Capsule, 45mg Capsule,

75mg Capsule)Maximum of 2 capsules per day

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

Tarceva (100mg Tablet, 150mg Tablet) Maximum of 1 tablet per day

Tarceva (25mg Tablet) Maximum of 3 tablets per day

Tasigna (150mg Capsule) Maximum of 5 capsules per day

Tasigna (200mg Capsule) Maximum of 4 capsules per day

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

Telmisartan (Tablet) Maximum of 1 tablet per day

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

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

Temazepam (15mg Capsule, 30mg Capsule) Maximum of 1 capsule per day

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

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

Thalomid (100mg Capsule, 50mg Capsule) Maximum of 1 capsule per day

Thalomid (150mg Capsule, 200mg Capsule) Maximum of 2 tablets per day

Tivicay (10mg Tablet, 25mg Tablet) Maximum of 2 tablets per day


109

109


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

TOBI (Nebulized Solution) Maximum of 10 ml (2 ampules) per day

TOBI Podhaler (Capsule) Maximum of 8 capsules per day

Tobramycin (Nebulized Solution) Maximum of 10 ml (2 ampules) per day

Tolcapone (Tablet) Maximum of 6 tablets per day

Tracleer (Tablet) Maximum of 2 tablets per day

Tradjenta (Tablet) Maximum of 1 tablet per day

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

Tramadol HCl ER (Tablet Extended-Release 24

Hour)Maximum of 1 tablet per day

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

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

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

Trezix (Capsule) Maximum of 10 capsules per day

Tribenzor (Tablet) Maximum of 1 tablet per day

Trintellix (Tablet) Maximum of 1 tablet per day

Triumeq (Tablet) Maximum of 2 tablets per day

Trizivir (Tablet) Maximum of 3 tablets per day

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

Truvada (Tablet) Maximum of 2 tablets per day

Tybost (Tablet) Maximum of 2 tablets per day

Tymlos (Injection) Maximum of 1.56 ml per 30 days

Vagifem (Tablet) Maximum of 1 tablet per day

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

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

Valsartan (160mg Tablet, 40mg Tablet, 80mg


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

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

Vemlidy (Tablet) Maximum of 1 tablet per day

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

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

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

Ventavis (10mcg/ml Inhalation Solution) Maximum of 7 ml per day

Ventavis (20mcg/ml Inhalation Solution) Maximum of 3 ml per day

Vesicare (Tablet) Maximum of 1 tablet per day


110

110


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

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

Vigabatrin (Packet) Maximum of 6 packets per day

Viibryd (Tablet) Maximum of 1 tablet per day

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

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

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

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

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

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

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

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


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

Votrient (Tablet) Maximum of 4 tablets per day

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

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

Vytorin (Tablet) Maximum of 1 tablet per day

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

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

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

Xeljanz (Tablet) Maximum of 2 tablets per day

Xeljanz XR (Tablet Extended-Release 24

Hour)Maximum of 1 tablet per day

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

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

Xtandi (Capsule) Maximum of 4 capsules per day

Xyrem (Oral Solution) Maximum of 18 ml per day

Yuvafem (Tablet) Maximum of 1 tablet per day

Zafirlukast (Tablet) Maximum of 2 tablets per day

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

Zejula (Capsule) Maximum of 3 capsules per day

Zelboraf (Tablet) Maximum of 8 tablets per day

Zepatier (Tablet) Maximum of 1 tablet per day

Zerit (Oral Solution) Maximum of 120 ml per day

Zetia (Tablet) Maximum of 1 tablet per day

Ziagen (Oral Solution) Maximum of 48 ml per day


111

111


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

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

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

Ziprasidone HCl (Capsule) Maximum of 2 capsules per day

Zolpidem Tartrate (10mg Tablet Immediate-

Release, 5mg Tablet Immediate-Release)Maximum of 90 days of use per year

Zydelig (Tablet) Maximum of 2 tablets per day

Zykadia (Capsule) Maximum of 5 capsules per day

Zytiga (250mg Tablet) Maximum of 4 tablets per day

Zytiga (500mg Tablet) Maximum of 2 tablets per daytrack

112

Tracked

112trackIndex of covered drugs

A

Abacavir................................42

Abacavir Sulfate/Lamivudine/

Zidovudine......................... 42

Abacavir/Lamivudine.......... 42

Abelcet..................................30

Abilify Maintena................... 39

Abraxane.............................. 34

Abstral...................................14

Acamprosate Calcium DR...16

Acarbose.............................. 44

Acebutolol HCl.....................49

Acetaminophen/Codeine....14

Acetazolamide..................... 54

Acetazolamide ER............... 54

Acetazolamide Sodium....... 54

Acetic Acid........................... 79

Acetylcysteine...................... 83

Acitretin.................................58

Actemra................................ 74

ActHIB...................................74

Actimmune........................... 74

Acyclovir............................... 41

Acyclovir Sodium................. 41

Adacel...................................74

Adagen................................. 60

Adapalene............................ 59

Adcirca..................................82

Adefovir Dipivoxil................. 41

Adempas.............................. 82

Adriamycin........................... 34

Adrucil...................................33

Advair Diskus....................... 83

Advair HFA........................... 83

Afeditab CR..........................50

Afinitor.................................. 35

Afinitor Disperz.....................36

Aggrenox.............................. 48

Akynzeo................................ 29

Ala-Cort.................................63

Albenza.................................37

Albuterol Sulfate.................. 81

Alclometasone Dipropionate

............................................ 63

Alcohol Prep Pads............... 77

Aldurazyme...........................60

Alecensa............................... 34

Alendronate Sodium............76

Alfuzosin HCl ER..................63

Alimta....................................33

Alinia..................................... 37

Allopurinol............................ 31

Alocril....................................78

Alomide.................................78

Alosetron HCl....................... 61

Aloxi...................................... 29

Alphagan P...........................78

Alprazolam........................... 44

Alunbrig................................ 36

Alyacen 1/35........................ 67

Amantadine HCl...................37

AmBisome............................ 30

Amethia.................................67

Amethia Lo........................... 67

Amikacin Sulfate.................. 17

Amiloride HCl....................... 54

Amiloride/

Hydrochlorothiazide..........52

Aminophylline...................... 82

Aminosyn 7%/Electrolytes

............................................ 86

Aminosyn 8.5%/Electrolytes

............................................ 86

Aminosyn II...........................86

Aminosyn II 8.5%/Electrolytes

............................................ 86

Aminosyn-HBC.....................86

Aminosyn-PF........................ 86

Aminosyn-RF........................ 86

Amiodarone HCl.................. 49

Amitiza.................................. 61

Amitriptyline HCl.................. 28

Amlodipine Besylate............50


Atorvastatin Calcium......... 52


Benazepril HCl...................52


Valsartan............................ 52

Amlodipine/Olmesartan

Medoxomil......................... 52

Amlodipine/Valsartan/

Hydrochlorothiazide..........52

Ammonium Lactate............. 59

Amoxapine........................... 28

Amoxicillin............................ 20

Amoxicillin/Clavulanate

Potassium.......................... 20

Amoxicillin/Clavulanate

Potassium ER.................... 20

Amphetamine/

Dextroamphetamine..........56

113

Tracked

113

Amphotericin B.....................30

Ampicillin...............................20

Ampicillin Sodium................ 20

Ampicillin-Sulbactam........... 20

Ampyra.................................. 58

Anadrol-50.............................67

Anagrelide HCl..................... 47

Anastrozole........................... 35

Androderm............................67

AndroGel...............................67

AndroGel Pump....................67

Anoro Ellipta......................... 83

Anzemet................................ 29

Apokyn.................................. 37

Apraclonidine........................78

Aprepitant............................. 29

Apri........................................ 67

Apriso.................................... 75

Aptiom...................................25

Aptivus...................................43

Aralast NP............................. 83

Aranelle................................. 67

Aranesp Albumin Free......... 47

Arcalyst..................................74

Argatroban............................ 48

Aripiprazole...........................39

Aripiprazole ODT..................39

Aristada................................. 39

Arnuity Ellipta........................80

Arranon..................................34

Ashlyna..................................67

Aspirin/Dipyridamole........... 48

Atenolol................................. 49

Atenolol/Chlorthalidone...... 52

Atgam.................................... 73

Atomoxetine..........................57

Atorvastatin Calcium............ 55

Atovaquone...........................37

Atovaquone/Proguanil HCl

.............................................37

Atripla.................................... 42

Atropine Sulfate....................60

Atrovent HFA........................ 81

Aubagio.................................58

Aubra.....................................67

Augmented Betamethasone

Dipropionate.......................63

Auryxia...................................63

Avandia..................................45

Avastin...................................36

Avelox....................................22

Aviane....................................67

Avonex...................................58

Avonex Pen...........................58

Azacitidine.............................34

Azactam in Iso-Osmotic

Dextrose..............................20

Azasite...................................21

Azathioprine..........................72

Azelastine HCl................ 78, 80

Azilect....................................38

Azithromycin......................... 21

Azopt..................................... 78

Azor....................................... 52

Aztreonam.............................20

B

BACiiM.................................. 17

Bacitracin.............................. 17

Bacitracin/Polymyxin B........77

Baclofen................................ 83

Bactocill in Dextrose............ 21

Bactroban Nasal...................17

Balsalazide Disodium...........75

Balziva................................... 67

Banzel....................................25

Baraclude..............................41

Bavencio............................... 36

BCG Vaccine........................ 74

Bekyree................................. 67

Beleodaq...............................34

Belsomra............................... 84

Benazepril HCl......................49

Benazepril HCl/

Hydrochlorothiazide...........52

Benicar.................................. 48

Benicar HCT......................... 52

Benlysta.................................74

Benztropine Mesylate.......... 37

Bepreve................................. 78

Berinert..................................72

Besivance..............................22

Betamethasone Dipropionate

.............................................64

Betamethasone Valerate..... 64

Betaseron..............................58

Betaxolol HCl..................49, 78

Bethanechol Chloride.......... 63

Bethkis...................................17

Betimol.................................. 78

Bevespi Aerosphere.............83

Bexarotene............................37

Bexsero................................. 74

Bicalutamide.........................33

114

Tracked

114

Bicillin C-R.............................21

Bicillin L-A............................. 21

BiCNU....................................32

BiDil....................................... 52

Biltricide................................ 37

Binosto.................................. 76

Bisoprolol Fumarate.............49



BIVIGAM................................73

Bleomycin Sulfate................ 34

Blephamide...........................77

Blephamide S.O.P................77

Blisovi 24 Fe..........................67

Blisovi Fe 1.5/30...................67

Blisovi Fe 1/20......................67

Boostrix................................. 74

Bosulif....................................36

Botox..................................... 77

Breo Ellipta............................83

Briellyn...................................67

Brilinta................................... 48

Brimonidine Tartrate............ 78

BRIVIACT.............................. 24

Bromocriptine Mesylate.......38

Brovana................................. 81

Budesonide.................... 75, 80

Bumetanide...........................54

Buphenyl............................... 60

Buprenorphine HCl.............. 16

Buprenorphine HCl/Naloxone

HCl...................................... 16

Bupropion HCl......................27

Bupropion HCl SR......... 16, 27

Bupropion HCl XL................ 27

Buspirone HCl...................... 44

Busulfan................................ 33

Busulfex................................ 33

Butalbital/Acetaminophen/

Caffeine...............................12

Butalbital/Aspirin/Caffeine

.............................................12

Butorphanol Tartrate............14

Bydureon Pen.......................45

Bydureon Vial....................... 45

Byetta.................................... 45

Bystolic..................................49

C

Cabergoline.......................... 71

Cabometyx............................36

Cafergot................................ 31

Calcipotriene.........................59

Calcitonin-Salmon................ 76

Calcitriol.......................... 59, 76

Calcium Acetate................... 63

Camila................................... 70

Camrese Lo...........................67

Canasa.................................. 75

Cancidas............................... 30

Candesartan Cilexetil........... 48

Candesartan Cilexetil/


Capastat Sulfate................... 32

Caprelsa................................ 36

Captopril................................49

Captopril/Hydrochlorothiazide

.............................................52

Carac..................................... 59

Carafate.................................62

Carbaglu................................84

Carbamazepine.................... 26

Carbamazepine ER.............. 26

Carbidopa............................. 38

Carbidopa/Levodopa...........38

Carbidopa/Levodopa ER.....38

Carbidopa/Levodopa ODT

.............................................38

Carbidopa/Levodopa/

Entacapone........................ 38

Carboplatin........................... 34

Cardene IV............................ 50

Carimune Nanofiltered.........74

Carteolol HCl........................ 78

Cartia XT................................50

Carvedilol.............................. 50

Caspofungin Acetate........... 30

Cayston................................. 82

Caziant.................................. 67

Cefaclor.................................19

Cefadroxil..............................19

Cefazolin Sodium................. 19

Cefdinir..................................19

Cefepime...............................19

Cefixime................................ 19

Cefotaxime Sodium..............19

Cefotetan...............................19

Cefoxitin Sodium.................. 19

Cefpodoxime Proxetil...........19

Cefprozil................................ 19

Ceftazidime...........................19

Ceftriaxone Sodium............. 19

Cefuroxime Axetil................. 19

Cefuroxime Sodium............. 19

115

Tracked

115

Celecoxib.............................. 12

Cellcept................................. 72

Cellcept Intravenous............ 72

Celontin................................. 24

Cephalexin............................ 19

Cerezyme.............................. 60

Cesamet................................ 29

Cetirizine HCl........................ 80

Chantix.................................. 16

Chantix Continuing Month

Pak...................................... 16

Chantix Starting Month Pak

.............................................16

Chemet..................................84

Chenodal...............................61

Chloramphenicol Sodium

Succinate............................17

Chlordiazepoxide HCl.......... 44

Chlorhexidine Gluconate..... 58

Chloroquine Phosphate.......37

Chlorothiazide.......................54

Chlorothiazide Sodium........ 54

Chlorpromazine HCl.............38

Chlorthalidone...................... 54

Cholbam................................61

Cholestyramine Light........... 55

Chorionic Gonadotropin...... 66

Ciclopirox.............................. 30

Ciclopirox Nail Lacquer....... 30

Ciclopirox Olamine...............30

Cidofovir................................41

Cilostazol...............................48

Ciloxan.................................. 22

Cimetidine.............................61

Cimetidine HCl......................61

Cimzia....................................72

Cinryze.................................. 72

Cipro HC............................... 80

Ciprodex................................80

Ciprofloxacin.........................22

Ciprofloxacin ER...................22

Ciprofloxacin HCl................. 22

Ciprofloxacin I.V. in D5W..... 22

Cisplatin................................ 34

Citalopram HBr.....................27

Cladribine..............................33

Claravis..................................59

Clarithromycin...................... 21

Clarithromycin ER................ 21

Climara Pro........................... 67

Clindamycin HCl...................17

Clindamycin Palmitate HCl

.............................................17

Clindamycin Phosphate......17,

59

Clindamycin Phosphate in

D5W.................................... 18

Clindamycin/Benzoyl

Peroxide..............................59

Clobetasol Propionate......... 64

Clobetasol Propionate E...... 64

Clofarabine............................33

Clolar..................................... 33

Clomipramine HCl................28

Clonazepam..........................44

Clonazepam ODT.................44

Clonidine HCl........................48

Clonidine HCl ER..................57

Clopidogrel........................... 48

Clorazepate Dipotassium.... 44

Clorpres.................................52

Clotrimazole..........................30

Clotrimazole/Betamethasone

Dipropionate.......................59

Clozapine.............................. 40

Clozapine ODT..................... 40

Coartem................................ 37

Codeine Sulfate.................... 14

Colchicine............................. 31

Colcrys.................................. 31

Colestipol HCl.......................55

Colistimethate Sodium.........18

Colocort.................................75

Coly-Mycin S......................... 80

Combigan............................. 78

Combivent Respimat............83

Combivir................................42

Cometriq............................... 36

Complera.............................. 42

Compro................................. 29

Constulose............................ 61

Copaxone..............................58

Cordran................................. 64

Corlanor................................ 52

Cormax Scalp Application...64

Cortisone Acetate.................64

Cortisporin............................ 59

Cosentyx............................... 72

Cosentyx Sensoready Pen...72

Cosmegen.............................34

Cosopt PF............................. 78

Cotellic.................................. 36

Coumadin..............................46

Creon.....................................60

116

Tracked

116

Crestor...................................55

Crinone..................................70

Crixivan..................................43

Cromolyn Sodium....61, 78, 83

Cryselle-28............................ 67

Cubicin.................................. 18

Cuprimine............................. 63

Cuvposa................................ 60

Cyclafem............................... 67

Cyclobenzaprine HCl........... 83

Cyclophosphamide.............. 33

Cycloset.................................45

Cyclosporine.........................72

Cyclosporine Modified.........72

Cyproheptadine HCl.............80

Cyramza................................ 36

Cystadane............................. 60

Cystagon............................... 60

Cystaran................................ 77

Cytarabine Aqueous.............33

D

Dacarbazine..........................33

Dacogen................................34

Daklinza.................................41

Daliresp................................. 82

Dalvance................................18

Danazol................................. 67

Dantrolene Sodium.............. 83

Dapsone................................32

Daptacel................................ 74

Daptomycin...........................18

DARAPRIM........................... 37

Darzalex.................................36

Daunorubicin HCl.................34

Deblitane............................... 70

Decitabine.............................34

Delyla.....................................67

Demeclocycline HCl.............23

Demser..................................52

Denavir.................................. 41

Depen Titratabs.................... 63

Depo-Estradiol...................... 67

Depo-Medrol......................... 64

Depo-Provera........................70

Descovy.................................42

Desipramine HCl.................. 28

Desmopressin Acetate.........66

Desogestrel/Ethinyl Estradiol

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

Desonide............................... 64

Desoximetasone...................64

Desvenlafaxine ER............... 27

Dexamethasone....................64

Dexamethasone Intensol..... 64

Dexamethasone Sodium

Phosphate.................... 64, 79

Dexilant................................. 62

Dexmethylphenidate HCl.....57

Dexmethylphenidate HCl ER

.............................................57

Dexrazoxane......................... 34

Dextroamphetamine Sulfate

.............................................57

Dextroamphetamine Sulfate

ER........................................57

Dextrose 10%........................86

Dextrose 10%/NaCl 0.2%.... 86


.............................................86

Dextrose 2.5%/NaCl 0.45%

.............................................86

Dextrose 5%..........................86

Dextrose 5%/Lactated

Ringers................................86

Dextrose 5%/NaCl 0.2%...... 86


.............................................86



Dextrose 5%/NaCl 0.9%...... 86

Diastat AcuDial..................... 24

Diastat Pediatric................... 24

Diazepam.............................. 44

Diazepam Intensol................44

Diazepam Rectal Gel........... 24

Diclofenac Potassium.......... 12

Diclofenac Sodium........12, 59,

79

Diclofenac Sodium DR.........12

Diclofenac Sodium ER.........12

Dicloxacillin Sodium.............21

Dicyclomine HCl...................61

Didanosine............................ 42

Dificid.................................... 21

Diflunisal................................12

Digitek................................... 52

Digoxin.................................. 52

Dihydroergotamine Mesylate

.............................................31

Dilantin.................................. 26

Dilantin INFATABS............... 26

Dilt-XR....................................50

Diltiazem CD......................... 50

Diltiazem HCl.................. 50, 51

117

Tracked

117

Diltiazem HCl ER.................. 51

Dipentum...............................75

Diphenhydramine HCl..........80

Diphenoxylate/Atropine.......61

Diphtheria/Tetanus Toxoids

Adsorbed Pediatric............ 74

Disulfiram.............................. 16

Diuril...................................... 54

Divalproex Sodium............... 44

Divalproex Sodium DR.........44

Divalproex Sodium ER......... 44

Docetaxel.............................. 34

Dofetilide............................... 49

Donepezil HCl.......................26

Donepezil HCl ODT.............. 26

Doribax.................................. 20

Dorzolamide HCl.................. 78

Dorzolamide HCl/Timolol

Maleate............................... 78

Doxazosin Mesylate............. 48

Doxepin HCl................... 29, 59

Doxercalciferol......................76

Doxil.......................................34

Doxorubicin HCl................... 34

Doxorubicin HCl Liposome

.............................................34

Doxy 100............................... 23

Doxycycline...........................23

Doxycycline Hyclate............. 23

Doxycycline Monohydrate... 23

Dronabinol............................ 29

Drospirenone/Ethinyl

Estradiol..............................67

Droxia.................................... 33

Duavee.................................. 67

Dulera.................................... 83

Duloxetine HCl......................58

Duramorph............................14

Durezol.................................. 79

Dymista..................................83

Dyrenium...............................54

E

E.E.S. Granules.....................21

Econazole Nitrate................. 30

Edarbi.................................... 48

Edarbyclor.............................52

Edecrin.................................. 54

Edurant..................................42

Effient.................................... 48

Egrifta.................................... 71

Elaprase................................ 60

Elelyso................................... 60

Elestrin...................................67

Elidel......................................59

Eliphos...................................63

Eliquis....................................46

Elitek......................................33

Ellence...................................34

Elmiron.................................. 63

Embeda.................................13

Emcyt.....................................33

Emend................................... 29

Emend Tripack..................... 29

Emoquette.............................67

Empliciti.................................36

Emsam.................................. 27

Emtriva.................................. 42

Enalapril Maleate..................49

Enalapril Maleate/


Enbrel.................................... 72

Enbrel SureClick...................72

Endocet................................. 14

Engerix-B...............................74

Enoxaparin Sodium..............46

Enpresse-28.......................... 67

Entacapone...........................37

Entecavir............................... 41

Entocort EC...........................75

Entresto................................. 53

Enulose..................................61

Epclusa..................................41

Epinastine HCl...................... 78

Epinephrine...........................81

EpiPen................................... 81

Epirubicin HCl.......................34

Epitol......................................26

Epivir HBV............................. 41

Eplerenone............................54

Eprosartan Mesylate............ 48

Epzicom................................ 42

Eraxis.....................................30

Erbitux................................... 36

Ergotamine Tartrate/Caffeine

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

Erivedge................................ 36

Errin....................................... 70

Erwinaze................................34

Ery..........................................59

Ery-Tab.................................. 21

EryPed 200............................21

EryPed 400............................21

118

Tracked

118

Erythrocin Lactobionate.......21

Erythromycin............ 21, 22, 59

Erythromycin Base............... 22

Erythromycin Ethylsuccinate

.............................................22

Erythromycin/Benzoyl

Peroxide..............................59

Esbriet................................... 83

Escitalopram Oxalate........... 27

Esomeprazole Magnesium

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

Esomeprazole Sodium.........62

Estrace.................................. 67

Estradiol.......................... 67, 68

Estradiol Valerate................. 68

Estring................................... 68

Ethacrynic Acid.....................54

Ethambutol HCl.................... 32

Ethosuximide........................ 24

Ethynodiol Diacetate/Ethinyl

Estradiol..............................68

Etidronate Disodium............ 76

Etodolac................................ 12

Etodolac ER.......................... 12

Etopophos.............................35

Etoposide.............................. 35

Eurax......................................37

Evotaz.................................... 42

Exelderm............................... 30

Exemestane.......................... 35

Exjade....................................84

Exondys 51........................... 77

Ezetimibe...............................55

Ezetimibe/Simvastatin......... 55

F

Fabrazyme............................ 60

Falmina..................................68

Famciclovir............................41

Famotidine............................ 61

Famotidine Premixed........... 61

Fanapt................................... 39

Fanapt Titration Pack...........39

Fareston................................ 33

Farydak..................................34

Faslodex................................33

Fazaclo.................................. 40

Felbamate............................. 25

Felbatol..................................25

Felodipine ER....................... 51

Femring................................. 68

Femynor................................ 68

Fenofibrate......................54, 55

Fenofibrate Micronized........55

Fenofibric Acid..................... 55

Fenofibric Acid DR............... 55

Fentanyl.................................13


Transmucosal.....................14

Ferriprox................................84

Fetzima..................................28

Fetzima Titration Pack......... 28

Finacea..................................59

Finasteride............................ 63

Firazyr....................................72

Firmagon............................... 71

Flarex.....................................79

Flebogamma DIF.................. 74

Flecainide Acetate................49

Flector................................... 12

Flovent Diskus...................... 80

Flovent HFA.......................... 80

Fluconazole...........................30

Fluconazole in NaCl............. 30

Flucytosine............................30

Fludarabine Phosphate........34

Fludrocortisone Acetate...... 64

Flunisolide.............................80

Fluocinolone Acetonide......64,

80

Fluocinolone Acetonide Body

.............................................64

Fluocinonide......................... 64

Fluocinonide Emulsified Base

.............................................64

Fluorometholone.................. 79

Fluorouracil.....................33, 59

Fluoxetine DR....................... 28

Fluoxetine HCl...................... 28

Fluphenazine Decanoate.....38

Fluphenazine HCl................. 38

Flurbiprofen.......................... 12

Flurbiprofen Sodium............ 79

Flutamide.............................. 33

Fluticasone Propionate....... 64,

80

Fluticasone Propionate/

Salmeterol...........................83

Fluvastatin............................. 55

Fluvoxamine Maleate........... 28

FML........................................79

FML Forte..............................79

Folotyn...................................33

Fomepizole........................... 77

119

Tracked

119

Fondaparinux Sodium..........47

Forteo.................................... 76

Fosinopril Sodium................ 49

Fosinopril Sodium/


Fosphenytoin Sodium..........26

Fosrenol................................ 63

FreAmine HBC 6.9%............ 86

Furosemide...........................54

Fusilev................................... 34

Fuzeon...................................43

Fycompa............................... 24

G

Gabapentin..................... 24, 25

Gabitril...................................25

Gablofen......................... 83, 84

Galantamine HBr.................. 26

Galantamine HBr ER............ 26

Gamastan S/D...................... 74

Gammagard Liquid.............. 74

Gammagard S/D IGA Less

Than 1 mcg/ml...................74

Gammaked........................... 74

Gammaplex...........................74

Gamunex-C........................... 74

Ganciclovir............................ 41

Gardasil 9..............................74

Gatifloxacin........................... 22

Gattex.................................... 61

Gauze.................................... 77

GaviLyte-C.............................61

GaviLyte-G.............................61

GaviLyte-N/Flavor Pack....... 61

Gemcitabine HCl.................. 33

Gemfibrozil............................55

Gemzar..................................33

Generlac................................62

Gengraf................................. 72

Genotropin............................66

Genotropin Miniquick.......... 66

Gentak...................................17

Gentamicin Sulfate...............17

Gentamicin Sulfate/0.9%

Sodium Chloride................ 17

Genvoya................................ 42

Geodon................................. 39

Gianvi.....................................68

Gildagia................................. 68

Gilenya.................................. 58

Gilotrif....................................36

Glassia...................................83

Glatopa..................................58

Gleostine............................... 33

Glimepiride............................45

Glipizide................................ 45

Glipizide ER.......................... 45

Glipizide/Metformin HCl...... 45

GlucaGen HypoKit................46

Glucagon Emergency Kit.....46

Glycopyrrolate...................... 61

Granisetron HCl....................30

Granix.................................... 47

Griseofulvin Microsize..........30

Griseofulvin Ultramicrosize

.............................................30

Guanfacine ER......................57

Guanidine HCl...................... 32

H

Halaven..................................34

Halobetasol Propionate....... 65

Haloperidol............................38

Haloperidol Decanoate........ 39

Haloperidol Lactate..............39

Harvoni.................................. 41

Havrix.....................................74

Hectorol.................................76

Heparin Sodium....................47

Heparin Sodium/D5W..........47

HepatAmine.......................... 86

Hepsera.................................41

Herceptin...............................36

Hetlioz....................................84

Hexalen................................. 33

Hiberix................................... 74

Humalog Cartridge...............46

Humalog KwikPen................46


.............................................46

Humalog Mix 50/50 Vial...... 46


.............................................46

Humalog Mix 75/25 Vial...... 46

Humalog Vial.........................46

Humatrope............................ 66

Humatrope Combo Pack.....66

Humira...................................72

Humira Pediatric Crohns

Disease Starter Pack......... 72

Humira Pen........................... 72

Humira Pen Crohns Disease

Starter Pack........................72

120

Tracked

120

Humira Pen-Psoriasis Starter

.............................................73

Humulin 70/30 KwikPen......46

Humulin 70/30 Vial...............46

Humulin N KwikPen............. 46

Humulin N Vial...................... 46

Humulin R U-500 KwikPen

.............................................46

Humulin R U-500 Vial........... 46

Humulin R Vial...................... 46

Hycamtin............................... 35

Hydralazine HCl..............55, 56

Hydrochlorothiazide.............54

Hydrocodone Bitartrate/

Acetaminophen..................14

Hydrocodone/Acetaminophen

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

Hydrocodone/Ibuprofen......15

Hydrocortisone...............65, 75

Hydrocortisone Butyrate......65

Hydrocortisone Valerate...... 65

Hydrocortisone/Acetic Acid

.............................................80

Hydromorphone HCl............15

Hydromorphone HCl ER......13

Hydroxychloroquine Sulfate

.............................................37

Hydroxyprogesterone

Caproate............................. 70

Hydroxyurea..........................33

Hydroxyzine HCl................... 44

Hydroxyzine Pamoate.......... 29

I

Ibandronate Sodium............ 76

Ibrance.................................. 34

Ibuprofen...............................13

Iclusig.................................... 36

Idamycin PFS........................34

Idarubicin HCl.......................34

Idhifa......................................36

Ifosfamide............................. 33

Ilaris....................................... 74

Ilevro...................................... 79

Imatinib Mesylate................. 36

Imbruvica...............................36

Imfinzi.................................... 36

Imipenem/Cilastatin.............20

Imipramine HCl.....................29

Imipramine Pamoate............29

Imiquimod............................. 59

Imovax Rabies...................... 74

Increlex..................................66

Incruse Ellipta....................... 81

Indapamide........................... 54

Infanrix...................................74

Inlyta...................................... 36

Insulin Syringes, Needles.... 77

Intelence................................42

Intralipid................................ 86

Intron A..................................41

Introvale.................................68

Invanz.................................... 20

Invega Sustenna...................39

Invega Trinza.........................39

Invirase.................................. 43

Invokamet..............................45

Invokamet XR........................45

Invokana................................45

Ionosol-B/Dextrose 5%........ 86

Ionosol-MB/Dextrose 5%.....86

IPOL Inactivated IPV............ 75

Ipratropium Bromide............81

Ipratropium Bromide/

Albuterol Sulfate.................83

Irbesartan.............................. 48

Irbesartan/


Iressa..................................... 36

Irinotecan.............................. 34

Isentress................................42

Isentress HD......................... 42

Isibloom.................................68

Isolyte-P/Dextrose 5%..........86

Isolyte-S................................. 84

Isoniazid................................ 32

Isosorbide Dinitrate.............. 56

Isosorbide Dinitrate ER........ 56

Isosorbide Mononitrate........56

Isosorbide Mononitrate ER

.............................................56

Isotonic Gentamicin............. 17

Istodax...................................34

Itraconazole.......................... 30

Ivermectin..............................37

Ixiaro...................................... 75

J

Jadenu...................................84

Jadenu Sprinkle....................84

Jakafi..................................... 36

Jantoven................................47

Janumet................................ 45

Janumet XR.......................... 45

Januvia.................................. 45

Jardiance...............................45

Jentadueto............................ 45

121

Tracked

121

Jentadueto XR...................... 45

Jevtana.................................. 34

Jinteli..................................... 68

Jolivette................................. 70

Jublia..................................... 30

Juleber...................................68

Junel 1.5/30..........................68

Junel 1/20............................. 68

Junel Fe 1.5/30.....................68

Junel Fe 1/20........................68

Junel Fe 24............................68

Juxtapid.................................55

K

Kadcyla..................................36

Kaitlib Fe............................... 68

Kaletra................................... 43

Kalydeco......................... 82, 83

Kanuma................................. 77

Kariva.....................................68

KCl 0.075%/D5W/NaCl 0.45%

.............................................86

KCl 0.15%/D5W/NaCl 0.2%

.............................................86

KCl 0.15%/D5W/NaCl 0.225%

.............................................86

KCl 0.15%/D5W/NaCl 0.9%

.............................................86

KCl 0.3%/D5W/NaCl 0.45%

.............................................86

KCl 0.3%/D5W/NaCl 0.9%

.............................................86

Kelnor 1/35........................... 68

Kenalog-10............................65

Kenalog-40............................65

Kepivance............................. 58

Ketoconazole..................30, 31

Ketoprofen............................ 13

Ketorolac Tromethamine.... 13,

79

Keytruda................................36

Kimidess................................68

Kineret................................... 73

Kinrix......................................75

Kionex....................................84

Kisqali....................................34

Kisqali Femara 200 Dose.....34



Klor-Con 10........................... 84

Klor-Con 8............................. 84

Klor-Con M10........................84

Klor-Con M15........................84

Klor-Con M20........................84

Klor-Con Sprinkle................. 84

Kombiglyze XR..................... 45

Korlym................................... 66

Kuvan.....................................60

Kynamro................................55

Kyprolis..................................35

L

Labetalol HCl........................ 50

Lacrisert................................ 77

Lactated Ringers Irrigation

.............................................87

Lactated Ringers Viaflex......87

Lactulose...............................62

Lamivudine..................... 41, 42

Lamivudine/Zidovudine.......42

Lamotrigine...........................25

Lanoxin..................................53

Lantus SoloStar.................... 46

Lantus Vial.............................46

LARIN 1.5/30........................68

LARIN 1/20........................... 68

LARIN Fe 1.5/30...................68

LARIN Fe 1/20......................68

Larissia.................................. 68

Lartruvo................................. 36

Lastacaft................................77

Latanoprost...........................79

Latuda................................... 39

Layolis Fe.............................. 68

Leena.....................................68

Leflunomide..........................74

Lenvima.................................36

Lessina.................................. 68

Letairis...................................82

Letrozole............................... 35

Leucovorin Calcium............. 34

Leukeran............................... 33

Leukine..................................47

Leuprolide Acetate...............71

Levalbuterol.......................... 81

Levemir FlexTouch...............46

Levemir Vial.......................... 46

Levetiracetam....................... 24

Levetiracetam ER................. 24

Levobunolol HCl...................78

Levocarnitine........................ 87

Levocetirizine Dihydrochloride

.............................................80

Levofloxacin..........................22

Levofloxacin in D5W............ 22

122

Tracked

122

Levoleucovorin..................... 35

Levoleucovorin Calcium...... 35

Levonest................................68

Levonorgestrel and Ethinyl

Estradiol..............................68

Levonorgestrel/Ethinyl

Estradiol..............................68

Levora 0.15/30-28................ 68

Levorphanol Tartrate............13

Levothyroxine Sodium......... 71

Levoxyl.................................. 71

Lexiva.................................... 43

Lialda.....................................75

Lidocaine...............................16

Lidocaine HCl....................... 16

Lidocaine Viscous................ 16

Lidocaine/Prilocaine............ 16

Lincomycin HCl.................... 18

Lindane................................. 37

Linezolid................................18

Linzess.................................. 61

Lioresal Intrathecal...............84

Liothyronine Sodium............71

Lisinopril................................49

Lisinopril/Hydrochlorothiazide

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

Lithium...................................44

Lithium Carbonate................44

Lithium Carbonate ER..........44

Lithostat.................................63

Livalo..................................... 55

Lomedia 24 Fe......................68

Lonsurf.................................. 33

Loperamide HCl................... 61

Lopinavir/Ritonavir...............43

Lorazepam............................ 44

Lorazepam Intensol..............44

Lorcet.................................... 15

Lorcet HD..............................15

Lorcet Plus............................ 15

Loryna....................................68

Losartan Potassium..............48

Losartan Potassium/


Lotemax................................ 79

Lotronex................................ 61

Lovastatin..............................55

Low-Ogestrel.........................68

Loxapine Succinate..............39

Lumigan................................ 79

Lumizyme..............................60

Lupaneta Pack......................71

Lupron Depot........................71

Lupron Depot-Ped................71

Lutera.................................... 68

Lynparza................................35

Lyrica..................................... 58

Lysodren............................... 71

Lyza....................................... 70

M

M-M-R II................................. 75

Magnesium Sulfate.............. 85

Makena..................................70

Malathion.............................. 37

Maprotiline HCl.....................28

Marlissa................................. 68

Marplan................................. 27

Matulane............................... 33

Matzim LA............................. 51

Meclizine HCl........................29

Medroxyprogesterone Acetate

.............................................70

Mefloquine HCl.....................37

Megace ES............................70

Megestrol Acetate................ 70

Mekinist.................................36

Meloxicam.............................13

Melphalan HCl...................... 33

Memantine HCl.....................27

Memantine HCl Titration Pak

.............................................27

Menactra............................... 75

Menest...................................68

Mentax...................................31

Menveo..................................75

Mepron..................................37

Mercaptopurine.................... 33

Meropenem.......................... 20

Mesalamine...........................75

Mesalamine DR.................... 75

Mesna....................................35

Mesnex..................................35

Mestinon............................... 32

Metadate ER......................... 57

Metaproterenol Sulfate........ 81

Metformin HCl...................... 45

Metformin HCl ER................ 45

Methadone HCl.................... 13

Methazolamide..................... 54

Methenamine Hippurate...... 18

Methimazole......................... 72

Methotrexate.........................73

Methotrexate Sodium...........73

123

Tracked

123

Methoxsalen......................... 59

Methscopolamine Bromide

.............................................61

Methyclothiazide.................. 54

Methyldopa........................... 48

Methyldopa/


Methyldopate HCl.................48

Methylphenidate HCl........... 57

Methylphenidate HCl ER..... 57

Methylprednisolone..............65

Methylprednisolone Acetate

.............................................65

Methylprednisolone Dose

Pack.................................... 65

Methylprednisolone Sodium

Succinate............................65

Metipranolol..........................78

Metoclopramide HCl............ 29

Metolazone........................... 54

Metoprolol Succinate ER.....50

Metoprolol Tartrate...............50

Metoprolol/


Metronidazole.......................18

Metronidazole in NaCl 0.79%

.............................................18

Metronidazole Vaginal......... 18

Mexiletine HCl.......................49

Miacalcin............................... 76

Mibelas 24 Fe....................... 68

Miconazole 3.........................31

Microgestin 1.5/30............... 68

Microgestin 1/20.................. 69

Microgestin Fe......................69

Microgestin Fe 1.5/30..........69

Midodrine HCl.......................48

Migergot................................32

Miglitol...................................45

Minitran................................. 56

Minocycline HCl................... 23

Minoxidil................................56

Mirtazapine........................... 27

Mirtazapine ODT.................. 27

Mirvaso..................................59

Misoprostol........................... 62

Mitomycin..............................35

Mitoxantrone HCl................. 35

Modafinil............................... 84

Moexipril HCl........................ 49

Moexipril/Hydrochlorothiazide

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

Mometasone Furoate.....65, 81

MonoNessa...........................69

Montelukast Sodium............ 81

Morphine Sulfate.................. 15

Morphine Sulfate ER............ 14

Moxeza.................................. 22

Moxifloxacin HCl.................. 22

Mozobil..................................47

Multaq................................... 49

Mupirocin.............................. 18

Mustargen.............................33

Myalept..................................77

Mycamine..............................31

Mycophenolate Mofetil........ 73

Mycophenolic Acid DR........ 73

Myrbetriq...............................62

N

Nabumetone......................... 13

Nadolol.................................. 50


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

Nafcillin Sodium................... 21

Naftifine HCl..........................31

Naftin..................................... 31

Naglazyme............................ 60

Nalbuphine HCl.................... 15

Naloxone HCl........................16

Naltrexone HCl..................... 16

Namenda XR.........................27

Namenda XR Titration Pack

.............................................27

Namzaric............................... 57

Naproxen...............................13

Naproxen DR........................ 13

Naratriptan HCl.....................32

Narcan...................................16

Nasonex................................ 81

Natacyn................................. 31

Nateglinide............................45

Natpara..................................76

Nebupent.............................. 37

Necon 0.5/35-28...................69

Necon 1/50-28......................69

Necon 7/7/7......................... 69

Nefazodone HCl................... 28

Neomycin Sulfate................. 17

Neomycin/Bacitracin/

Polymyxin........................... 77

Neomycin/Polymyxin B

Sulfates............................... 18

Neomycin/Polymyxin/

Bacitracin/Hydrocortisone

.............................................77

124

Tracked

124

Neomycin/Polymyxin/

Dexamethasone................. 77

Neomycin/Polymyxin/

Gramicidin.......................... 77

Neomycin/Polymyxin/

Hydrocortisone............ 77, 80

Nephramine.......................... 87

Nerlynx.................................. 36

Neulasta................................ 47

Neupogen............................. 47

Neupro.................................. 38

Nevanac................................ 79

Nevirapine............................. 42

Nevirapine ER.......................42

Nexavar................................. 36

Nexium.................................. 62

Niacin ER.............................. 55

Niacor.................................... 55

Nicardipine HCl.................... 51

Nicotrol Inhaler..................... 16

Nifedipine ER........................51

Nikki.......................................69

Nilandron...............................33

Nilutamide.............................33

Nimodipine............................51

Ninlaro................................... 35

Nipent....................................33

Nitro-Bid................................ 56

Nitrofurantoin........................18

Nitrofurantoin Macrocrystals

.............................................18

Nitrofurantoin Monohydrate

.............................................18

Nitroglycerin..........................56

Nitroglycerin Lingual............ 56

Nitroglycerin Transdermal... 56

Nitrostat.................................56

Nora-BE................................. 70

Norditropin FlexPro.............. 66

Norethindrone.......................70

Norethindrone Acetate........ 70

Norethindrone Acetate/Ethinyl

Estradiol..............................69

Norethindrone Acetate/Ethinyl

Estradiol/Ferrous Fumarate

.............................................69

Norethindrone/Ethinyl

Estradiol/Ferrous Fumarate

.............................................69

Norgestimate/Ethinyl Estradiol

.............................................69

Norlyroc.................................70

Normosol-M in D5W............. 87

Normosol-R........................... 85

Normosol-R in D5W..............87

Northera................................ 53

Nortrel 0.5/35....................... 69

Nortrel 1/35...........................69

Nortrel 7/7/7.........................69

Nortriptyline HCl................... 29

Norvir..................................... 43

Novarel.................................. 66

Noxafil................................... 31

Nucynta ER........................... 14

Nuedexta...............................57

Nulojix....................................73

Nuplazid................................ 39

Nutrilipid................................87

Nutropin AQ..........................66

NuvaRing...............................69

Nyamyc................................. 31

Nyata..................................... 31

Nystatin................................. 31

Nystop................................... 31

O

Ocaliva...................................61

Ocella.................................... 69

Octagam................................74

Octreotide Acetate............... 71

Odefsey................................. 42

Odomzo.................................36

Ofev....................................... 83

Ofloxacin............................... 23

Ogestrel.................................69

Olanzapine............................ 39

Olanzapine ODT................... 39

Olmesartan Medoxomil........49

Olmesartan Medoxomil/

Amlodipine/


Olmesartan Medoxomil/


Olopatadine HCl................... 78

Olysio.....................................41

Omega-3-Acid Ethyl Esters

.............................................55

Omeprazole.......................... 62

Ondansetron HCl..................30

Ondansetron ODT................ 30

Onfi........................................ 25

Onglyza................................. 45

ONMEL..................................31

Opana ER..............................14

Opdivo...................................36

Opsumit.................................82

125

Tracked

125

Orencia..................................73

Orencia Clickject.................. 73

Orenitram.............................. 82

Orfadin...................................60

Orkambi.................................82

Orphenadrine Citrate........... 84

Orsythia................................. 69

Oseltamivir Phosphate.........43

Otezla.................................... 74

Oxacillin Sodium.................. 21

Oxaliplatin............................. 35

Oxandrolone......................... 67

Oxcarbazepine......................26

Oxiconazole Nitrate..............31

Oxistat................................... 31

Oxsoralen Ultra.....................59

Oxybutynin Chloride.............62

Oxybutynin Chloride ER.......63

Oxycodone HCl.................... 15

Oxycodone/Acetaminophen

.......................................15, 16

Oxycodone/Aspirin.............. 16

Oxycodone/Ibuprofen..........16

P

Pacerone...............................49

Paclitaxel............................... 35

Paliperidone ER....................39

Pamidronate Disodium........ 76

Panretin................................. 37

Pantoprazole Sodium...........62

Paricalcitol.............................76

Paromomycin Sulfate...........17

Paroxetine HCl......................28

Paser......................................32

Pataday................................. 78

Patanol.................................. 78

Paxil....................................... 28

Pazeo.....................................78

Pediarix................................. 75

Pedvax HIB........................... 75

PEG-3350/Electrolytes.........62

PEG-3350/NaCl/Na

Bicarbonate/KCl................ 62

Peganone..............................26

Pegasys.................................41

Pegasys ProClick................. 41

PegIntron...............................41

PegIntron REDIPEN............. 41

Penicillin G Potassium......... 21

Penicillin G Procaine............21

Penicillin G Sodium..............21

Penicillin V Potassium..........21

Pentam 300...........................37

Pentasa................................. 75

Pentoxifylline ER...................53

Perforomist........................... 82

Perindopril Erbumine........... 49

Periogard...............................58

Perjeta................................... 36

Permethrin............................ 37

Perphenazine........................29

Phenadoz.............................. 80

Phenelzine Sulfate................27

Phenergan.............................80

Phenobarbital....................... 25

Phenoxybenzamine HCl...... 48

Phenytek............................... 26

Phenytoin.............................. 26

Phenytoin Sodium................ 26

Phenytoin Sodium Extended

.............................................26

Phoslyra.................................63

Phospholine Iodide.............. 78

Physiolyte..............................85

Physiosol Irrigation...............85

Picato.....................................59

Pilocarpine HCl.............. 58, 79

Pimozide............................... 39

Pimtrea.................................. 69

Pindolol................................. 50

Pioglitazone HCl................... 45

Pioglitazone HCl/Glimepiride

.............................................45

Pioglitazone HCl/Metformin

HCl...................................... 45

Piperacillin/Tazobactam......21

Pirmella 1/35........................ 69

Piroxicam.............................. 13

Plasma-Lyte A....................... 85

Plasma-Lyte-148................... 85

Plenamine............................. 87

Podofilox............................... 59

Polyethylene Glycol 3350

Powder................................62

Polymyxin B Sulfate............. 18

Polymyxin B Sulfate/

Trimethoprim Sulfate.........77

Pomalyst................................33

Portia-28................................ 69

Potassium Chloride..............85

Potassium Chloride 0.15%

D5W/NaCl 0.33%...............87


D5W/NaCl 0.45%...............87

126

Tracked

126


D5W/NaCl 0.45%...............87

Potassium Chloride ER........85

Potassium Chloride/Dextrose

.............................................87

Potassium Chloride/Dextrose/

Lactated Ringers................87

Potassium Chloride/Sodium

Chloride.............................. 85

Potassium Citrate ER........... 85

Pradaxa................................. 47

Praluent................................. 55

Pramipexole Dihydrochloride

.............................................38

Prasugrel...............................48

Pravastatin Sodium.............. 55

Prazosin HCl......................... 48

Pred Mild...............................79

Pred-G................................... 77

Pred-G S.O.P.........................77

Prednicarbate....................... 65

Prednisolone Acetate...........79

Prednisolone Sodium

Phosphate.................... 65, 79

Prednisone............................65

Prednisone Intensol............. 65

Pregnyl w/Diluent Benzyl

Alcohol/NaCl......................66

Premarin................................69

Premasol............................... 87

Premphase............................69

Prempro................................ 69

Prevalite.................................55

Previfem................................ 69

Prezcobix.............................. 42

Prezista..................................43

Priftin..................................... 32

Prilosec..................................62

Primaquine Phosphate........ 37

Primidone..............................25

Primsol.................................. 18

Pristiq.................................... 28

Privigen................................. 74

ProAir HFA............................ 82

ProAir RespiClick................. 82

Probenecid............................31

Probenecid/Colchicine........31

Procainamide HCl................ 49

Procalamine..........................87

Prochlorperazine.................. 29

Prochlorperazine Edisylate

.............................................29

Prochlorperazine Maleate....29

Procrit..............................47, 48

Procto-Med HC.....................75

Procto-Pak.............................75

Proctosol HC.........................75

Proctozone-HC..................... 75

Procysbi................................ 60

Progesterone........................ 70

Proglycem............................. 46

Prograf...................................73

Prolastin-C.............................83

Prolensa................................ 79

Proleukin............................... 35

Prolia......................................76

Promacta...............................48

Promethazine HCl................ 80

Promethegan........................ 80

Propafenone HCl..................49

Propafenone HCl ER............49

Proparacaine HCl................. 77

Propranolol HCl.................... 50

Propranolol HCl ER.............. 50

Propranolol/


Propylthiouracil.....................72

ProQuad................................75

Prosol.................................... 87

Protriptyline HCl................... 29

PRUDOXIN............................59

Pulmozyme........................... 83

Purixan.................................. 33

Pyrazinamide........................ 32

Pyridostigmine Bromide...... 32

Pyridostigmine Bromide ER

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

Q

Quadracel..............................75

Quasense.............................. 69

Quetiapine Fumarate........... 40

Quetiapine Fumarate ER..... 40

Quinapril HCl........................ 49

Quinapril/Hydrochlorothiazide

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

Quinidine Gluconate............ 49

Quinidine Gluconate CR......49

Quinidine Sulfate.................. 49

Quinine Sulfate..................... 37

R

Rabavert................................75

Raloxifene HCl......................71

Ramipril................................. 49

Ranexa.................................. 53

Ranitidine HCl.......................61

127

Tracked

127

Rapaflo.................................. 63

Rapamune.............................73

Rasagiline Mesylate............. 38

RAVICTI.................................60

Rayaldee............................... 76

Rebif...................................... 58

Rebif Rebidose.....................58

Rebif Rebidose Titration Pack

.............................................58

Rebif Titration Pack..............58

Reclipsen.............................. 69

Recombivax HB....................75

Regranex...............................59

Relenza Diskhaler.................43

Relistor.................................. 61

Remicade..............................73

Remodulin.............................82

Renagel................................. 63

Renvela..................................63

Repaglinide...........................45

Repaglinide/Metformin HCl

.............................................45

Repatha.................................55

Repatha Pushtronex System

.............................................55

Repatha SureClick............... 55

Rescriptor............................. 42

Restasis.................................77

Retrovir IV Infusion............... 42

Revatio.................................. 82

Revlimid................................ 33

Rexulti....................................40

Reyataz..................................43

Ribasphere............................41

Ribavirin................................ 41

Ridaura..................................74

Rifabutin................................32

Rifampin................................32

Rifater.................................... 32

Rilutek................................... 58

Riluzole..................................58

Rimantadine HCl.................. 44

Ringers Injection...................87

Ringers Irrigation..................87

Riomet................................... 45

Risedronate Sodium............ 76

Risperdal Consta..................40

Risperidone...........................40

Risperidone ODT..................40

Rituxan.................................. 36

Rivastigmine Tartrate........... 26

Rivastigmine Transdermal

System................................ 27

Rizatriptan Benzoate............32

Rizatriptan Benzoate ODT...32

Ropinirole HCl...................... 38

Rosuvastatin Calcium.......... 55

Rotarix................................... 75

RotaTeq.................................75

Roweepra..............................24

Rozerem................................84

Rubraca.................................35

Ruconest...............................72

Rydapt................................... 36

S

Sabril..................................... 25

Saizen....................................66

Samsca..................................84

Sancuso................................ 30

Sandimmune.........................73

Sandostatin LAR Depot....... 72

Santyl.....................................59

Saphris.................................. 40

Savella................................... 58

Savella Titration Pack...........58

Selegiline HCl....................... 38

Selenium Sulfide.................. 59

Selzentry................................43

Sensipar................................ 71

Serevent Diskus....................82

Seroquel XR..........................40

Serostim................................ 61

Sertraline HCl........................28

Setlakin..................................69

sfRowasa...............................75

Sharobel................................70

Signifor.................................. 72

Sildenafil......................... 82, 83

Silver Sulfadiazine................ 23

Simbrinza.............................. 79

Simponi................................. 73

Simponi Aria......................... 73

Simulect................................ 74

Simvastatin............................55

Sirolimus............................... 73

Sirturo....................................32

Sodium Chloride...................85

Sodium Chloride 0.45%....... 85

Sodium Chloride 0.9%......... 85

Sodium Fluoride................... 85

Sodium Lactate.................... 87

Sodium Phenylbutyrate........60

128

Tracked

128

Sodium Polystyrene Sulfonate

.............................................84

Sodium Sulfacetamide.........23

Solaraze.................................59

Soliqua 100/33..................... 45

Soltamox............................... 33

Solu-Cortef............................ 65

Solu-Medrol...........................65

Somatuline Depot.................72

Somavert............................... 72

Soriatane............................... 60

Sotalol HCl............................ 49

Sovaldi...................................41

Spiriva HandiHaler................81

Spiriva Respimat.................. 81

Spironolactone..................... 54

Spironolactone/


Sporanox...............................31

Sprintec 28............................69

Spritam..................................24

Sprycel.................................. 36

SPS........................................ 84

Sronyx................................... 69

SSD........................................23

Stalevo 100........................... 38

Stalevo 125........................... 38

Stalevo 150........................... 38

Stalevo 200........................... 38

Stalevo 50............................. 38

Stalevo 75............................. 38

Stavudine.............................. 42

Stelara................................... 73

Sterile Water Irrigation......... 77

Stiolto Respimat................... 83

Stivarga................................. 36

Strattera.................................57

Strensiq................................. 60

Streptomycin Sulfate............17

Stribild................................... 42

Suboxone..............................16

Sucraid.................................. 60

Sucralfate.............................. 62

Sulfacetamide Sodium.........23

Sulfacetamide Sodium/

Prednisolone Sodium

Phosphate.......................... 78

Sulfadiazine...........................23

Sulfamethoxazole/

Trimethoprim......................23

Sulfamethoxazole/

Trimethoprim DS................23

Sulfamylon............................ 18

Sulfasalazine.........................76

Sulindac................................ 13

Sumatriptan.......................... 32

Sumatriptan Succinate........ 32

Sumatriptan Succinate Refill

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

Sumavel DosePro.................32

Suprax................................... 19

Suprep Bowel Prep Kit.........62

Sustiva...................................42

Sutent.................................... 36

Sylatron................................. 41

Sylvant................................... 36

Symbicort..............................83

SymlinPen 120......................45

SymlinPen 60........................45

Synagis..................................74

Synarel...................................72

Synercid................................ 18

Synjardy.................................45

Synribo.................................. 35

Synthroid...............................71

Syprine.................................. 84

T

Tabloid.................................. 33

Tacrolimus...................... 60, 73

Tafinlar...................................36

Tagrisso.................................36

Tamiflu...................................44

Tamoxifen Citrate................. 33

Tamsulosin HCl.................... 63

Tarceva..................................36

Targretin................................37

Tarina Fe 1/20...................... 69

Tasigna..................................36

Taxotere................................ 35

Tazarotene............................ 60

Tazicef................................... 20

Tazorac..................................60

Taztia XT............................... 51

Tecentriq............................... 36

Tecfidera............................... 58

Tecfidera Starter Pack......... 58

Telmisartan........................... 49

Telmisartan/Amlodipine...... 53

Telmisartan/


Temazepam.......................... 84

Tenivac.................................. 75

Terazosin HCl....................... 63

129

Tracked

129

Terbinafine HCl.....................31

Terbutaline Sulfate............... 82

Terconazole.......................... 31

Testosterone Cypionate.......67

Testosterone Enanthate.......67

Tetanus/Diphtheria Toxoids-

Adsorbed Adult.................. 75

Tetrabenazine.......................58

Tetracycline HCl................... 23

Thalomid............................... 33

Theophylline......................... 82

Theophylline CR...................82

Theophylline ER................... 82

Thioridazine HCl................... 39

Thiotepa................................ 35

Thiothixene........................... 39

Thymoglobulin......................74

Tiagabine HCl....................... 25

Tigecycline............................18

Timolol Maleate..............50, 79

Timolol Maleate Ophthalmic

Gel Forming........................79

Tinidazole..............................18

Tivicay....................................42

Tizanidine HCl...................... 84

TOBI...................................... 17

TOBI Podhaler...................... 17

Tobradex...............................17

Tobradex ST......................... 78

Tobramycin........................... 17

Tobramycin Sulfate.............. 17

Tobramycin/Dexamethasone

.............................................78

Tobrex................................... 17

Tolcapone............................. 37

Topiramate............................25

Toposar................................. 35

Topotecan HCl......................35

Torisel....................................73

Torsemide............................. 54

Toujeo SoloStar....................46

TPN Electrolytes................... 87

Tracleer................................. 83

Tradjenta............................... 46

Tramadol HCl........................16

Tramadol HCl ER..................14

Tramadol HCl/

Acetaminophen..................16

Trandolapril...........................49

Tranexamic Acid...................48

Transderm-Scop...................29

Tranylcypromine Sulfate......27

Travasol.................................87

Travatan Z............................. 79

Trazodone HCl......................28

Treanda................................. 33

Trecator.................................32

Trelstar Mixject..................... 72

Tretinoin..........................37, 60

Tretinoin Microsphere..........60

Trexall....................................73

Trezix..................................... 16

Tri-Legest Fe......................... 69

Tri-Lo-Estarylla...................... 70

Tri-Lo-Sprintec...................... 70

Tri-Previfem...........................70

Tri-Sprintec............................70

Triamcinolone Acetonide... 66,

81

Triamcinolone in Orabase... 58

Triamterene/


Tribenzor............................... 54

Triderm..................................66

Trifluoperazine HCl.............. 39

Trifluridine............................. 41

Trihexyphenidyl HCl.............37

TriLyte....................................62

Trimethoprim........................ 18

Trimipramine Maleate.......... 29

Trinessa.................................70

Trintellix.................................28

Trisenox.................................35

Triumeq................................. 42

Trivora-28.............................. 70

Trizivir.................................... 42

Trophamine...........................87

Trulicity..................................46

Trumenba..............................75

Truvada................................. 43

Twinrix................................... 75

Tybost....................................42

Tygacil................................... 18

Tykerb................................... 36

Tymlos...................................76

Typhim Vi.............................. 75

Tysabri...................................58

U

Uceris.................................... 76

Uloric..................................... 31

Unithroid................................71

Ursodiol.................................61

130

Tracked

130

V

Vagifem................................. 70

Valacyclovir HCl....................41

Valchlor................................. 33

Valcyte...................................41

Valganciclovir........................41

Valganciclovir Hydrochlorde

.............................................41

Valproate Sodium.................25

Valproic Acid.........................25

Valsartan............................... 49

Valsartan/Hydrochlorothiazide

.............................................54

Vancocin HCl........................ 18

Vancomycin HCl.............18, 19

Vandazole............................. 19

VAQTA...................................75

Varivax...................................75

Varizig....................................74

Vascepa.................................55

Vectibix..................................36

Velcade................................. 35

Velivet.................................... 70

Velphoro................................63

Vemlidy..................................41

Venclexta...............................35

Venclexta Starting Pack.......35

Venlafaxine HCl.................... 28

Venlafaxine HCl ER.............. 28

Ventavis.................................83

Verapamil HCl.......................51

Verapamil HCl ER.......... 51, 52

Verapamil HCl SR.................52

Versacloz...............................40

Vesicare.................................63

Vestura.................................. 70

Vfend..................................... 31

Vibramycin............................ 24

Victoza...................................46

Vidaza....................................35

Videx Pediatric......................43

Vienva....................................70

Vigabatrin..............................25

Vigamox................................ 23

Viibryd................................... 28

Viibryd Starter Pack..............28

Vimpat................................... 26

Vinblastine Sulfate................35

Vincasar PFS.........................35

Vincristine Sulfate.................35

Vinorelbine Tartrate..............35

Viracept................................. 43

Viread.................................... 43

Vivitrol....................................16

Voltaren................................. 13

Voriconazole......................... 31

Votrient.................................. 36

VP-PNV-DHA......................... 87

VPRIV.................................... 60

Vraylar................................... 40

Vyfemla..................................70

Vytorin................................... 55

Vyvanse................................. 57

Vyxeos................................... 35

W

Warfarin Sodium...................47

Welchol..................................55

WYMZYA Fe..........................70

X

Xalkori....................................36

Xarelto................................... 47

Xarelto Starter Pack............. 47

Xatmep.................................. 73

Xeljanz................................... 73

Xeljanz XR............................. 73

Xenazine................................58

Xgeva.....................................76

Xifaxan...................................19

Xolair......................................83

Xtandi.................................... 33

Xulane....................................70

Xyrem.................................... 84

Y

Yervoy....................................36

YF-Vax....................................75

Yondelis.................................33

Yuvafem................................ 70

Z

Zafirlukast............................. 81

Zaleplon................................ 84

Zaltrap................................... 35

Zanosar................................. 33

Zarah..................................... 70

Zarxio.....................................48

Zavesca................................. 60

Zejula.....................................35

Zelapar.................................. 38

Zelboraf................................. 36

Zemaira................................. 83

Zemplar................................. 77

Zenchent............................... 70

Zenchent Fe..........................70

131

Tracked

131

Zenpep.................................. 60

Zepatier................................. 41

Zerbaxa................................. 20

Zerit....................................... 43

Zetia.......................................55

Ziagen................................... 43

Zidovudine............................ 43

Zileuton ER........................... 81

Zinbryta................................. 58

Zinecard................................ 35

Ziprasidone HCl....................40

Zirgan.................................... 41

Zmax......................................22

Zoledronic Acid.................... 77

Zolinza...................................35

Zolpidem Tartrate.................84

Zomacton..............................66

Zometa.................................. 77

Zonisamide........................... 24

Zorbtive................................. 61

Zortress................................. 73

Zostavax................................ 75

Zovia 1/35E...........................70

Zovia 1/50E...........................70

Zyclara...................................60

Zyclara Pump........................60

Zydelig...................................35

Zyflo.......................................81

Zyflo CR................................ 81

Zykadia..................................35

Zyprexa Relprevv..................40

Zytiga.....................................33

For more recent information or if you have other questions,

please call UnitedHealthcare Dual Complete RP Customer

Service at:

Toll-Free 1-866-818-4270, TTY 711

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

www.UHCCommunityPlan.com

Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits,

formulary, pharmacy network, and/or co-payments/co-insurance may change on January 1 of each

year, and from time to time during the plan year. You will receive notice when necessary.

This information is available for free in other languages. Please call our Customer Service number

listed above.

Esta información está disponible sin costo en otros idiomas. Llame a Servicio al Cliente al número

indicado arriba.

Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies,

a Medicare Advantage organization with a Medicare contract and a contract with the State

Medicaid Program. Enrollment in the plan depends on the plan’s contract renewal with Medicare.

UHFL17RP3881536_010 Last updated November 1, 2017

Documents

FORMULARY 2017 - · PDF file3 The COMPREHENSIVE FORMULARY UnitedHealthcare Dual Complete RP 3 (drug list) A formulary (drug list) is a list of covered drugs selected by your plan in