1

2020
COMPLETE DRUG LIST
(FORMULARY)
Prescription drug list information

UnitedHealthcare® Group Medicare Advantage (PPO)

North Carolina State Health Plan for Teachers and State Employees

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

Toll-free 1-866-747-1014, TTY 711

8 a.m. - 8 p.m. ET, Monday - Friday

www.UHCRetiree.com/ncshp

Formulary ID Number 00020062, Version 14

Y0066_190621_090130_C Last updated September 1, 2019
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TABLE OF CONTENTS
What is a drug list?......................................................................................................................................3
Note to existing members.......................................................................................................................... 3
How do I use the drug list?.........................................................................................................................4
What are generic drugs?............................................................................................................................ 4
Drug tiers..................................................................................................................................................... 5
Getting Extra Help.......................................................................................................................................5
Are there any rules or limits on my drug coverage?................................................................................ 6
What if my drug is not on this list?.............................................................................................................8
How can I get an exception?......................................................................................................................8
Can I get my drug while I wait for an exception?......................................................................................9
Can the drug list change?........................................................................................................................ 10
Drugs with dosages other than a 1-month supply..................................................................................11
Covered drugs by name (Drug index).................................................................................................... 12
Covered drugs by medical condition...................................................................................................... 39
Covered drugs with a quantity limit (QL).............................................................................................. 165
 2 3
What is a drug list?
A drug list, or formulary, is a list of prescription drugs covered by your plan. Your plan and a team
of health care providers work together in selecting drugs that are needed for well-rounded care
and treatment.
Your plan will generally cover the drugs listed in our drug list as long as:
· The drug is used for a medically accepted indication,
· The prescription is filled at a network pharmacy and
· Other plan rules are followed.
For more information about your drug coverage, please review your Evidence of Coverage.

Note to existing members:

This complete list of prescription drugs covered by your plan is current as of September 1, 2019.
For an up-to-date list of covered drugs or if you have questions, please call Customer Service. Our
contact information is on the cover.
This drug list has changed since last year. Please review this document to make sure your
prescription drugs are still covered. In most cases, you must use network pharmacies to have your
prescriptions covered by the plan.
When this drug list refers to “we,” “us,” or “our,” it means UnitedHealthcare. When it refers to
“plan,” “our plan,” or “your plan,” it means UnitedHealthcare Group Medicare Advantage.
4 3
How do I use the drug list?
There are 2 ways to find your prescription drugs in this drug list:
1. By name. Turn to section “Covered drugs by name (Drug index)” on pages 12–38 to see the
.......list of drug names in alphabetical order. Find the name of your drug. The page number where
.......you can find the drug will be next to it.
2. By medical condition. Turn to section “Covered drugs by medical condition” on pages
.......39–164 to look for drugs based on your medical conditions. For example, if you have a heart
.......condition, you should look in the category Cardiovascular Agents. This is where you will find
.......drugs that treat heart conditions.

What are generic drugs?

Generic drugs have the same active ingredients as brand name drugs. They usually cost less than
brand name drugs and are approved by the Food and Drug Administration (FDA). Our plan covers
both brand name and generic drugs.
Talk with your doctor to see if any of the brand name drugs you take have generic versions. Then
review the drug list to make sure you are getting the drug you need for the least amount of money.
The drug list shows brand name drugs in bold type (for example, Humalog) and generic drugs in
plain type (for example, Simvastatin).
 4 5
Drug tiers
The amount you pay for a covered prescription drug will depend on:
· Your drug’s tier. Each covered drug is in 1 of 4 drug tiers. Each tier has a copay or coinsurance
amount. The chart below shows the differences between the tiers.
If you need help or have any questions about your drug costs, please review your Evidence of
Coverage or call Customer Service. Our contact information is on the cover.

Drug Tier Includes

Tier 1: Most generic drugs.
Preferred generic
Tier 2: Many common brand name drugs, called preferred
Preferred brand brands.
Tier 3: Non-preferred generic and non-preferred brand name
Non-preferred drug drugs. In addition, Part D eligible compound medications
are covered in Tier 3.
Tier 4: Unique and/or very high-cost brand and generic drugs.
Specialty tier

Getting Extra Help

If you qualify for Extra Help paying for your prescription drugs, your copays and coinsurance may
be lower. Members who qualify for Extra Help will receive the “Evidence of Coverage Rider for
People Who Get Extra Help Paying for Prescription Drugs” (LIS Rider). Please read it to learn about
your costs. You can also call Customer Service. Our contact information is on the cover.
6
.. 5 1
Are there any rules or limits on my drug coverage?
Yes, some drugs may have coverage rules or have limits on the amount you can get. If your drug
has any coverage rules or limits, there will be a code(s) in the “Coverage Rules or Limits on use”
column of the “Covered drugs by medical condition” chart starting on page 39. The codes and
what they mean are shown below and on the next page.
You can also get more information about the coverage rules and/or limits applied to specific
covered drugs by visiting our website. We have posted online documents that explain our prior
authorization and step therapy restrictions. If you would like a copy sent to you, please call
Customer Service. Our contact information is on the cover.
Coverage Rules and Limits
PA - Prior authorization
The plan requires you or your doctor to get prior approval for certain drugs. This means the plan
needs more information from your doctor to make sure the drug is being used and covered
correctly by Medicare for your medical condition. Certain drugs may be covered by either Medicare
Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs) depending on
how it is used. If you don’t get prior approval, the plan may not cover the drug.
QL - Quantity limits
The plan will cover only a certain amount of this drug for 1 copay/coinsurance or over a certain
number of days. These limits may be in place to ensure safe and effective use of the drug. If your
doctor prescribes more than this amount or thinks the limit is not right for your situation, you or
your doctor can ask the plan to cover the additional quantity.
ST - Step therapy
There may be effective, lower-cost drugs that treat the same medical condition as this drug. You
may be required to try 1 or more of these other drugs before the plan will cover your drug. If you
have already tried other drugs or your doctor thinks they are not right for you, you or your doctor
can ask the plan to cover this drug.
 6 7
Other Special Coverage Rules
B/D - Medicare Part B or Part D
Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and
outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide
the plan with more information about how this drug will be used to make sure it’s correctly
covered by Medicare.
HRM - High-risk medication
This drug is known as a high-risk medication (HRM) for patients 65 years and older. This drug
may cause side effects if taken on a regular basis. We suggest you talk with your doctor to see if
an alternative drug is available to treat your condition.
LA - Limited access
Drugs are considered “limited access” if the FDA says the drug can be given out only by certain
facilities or doctors. These drugs may require extra handling, provider coordination or patient
education that can’t be done at a network pharmacy.

MME - Morphine milligram equivalent

Additional quantity limits may apply across all drugs in the opioid class used for the treatment of
pain. This additional limit is called a cumulative morphine milligram equivalent (MME), and is
designed to monitor safe dosing levels of opioids for individuals who may be taking more than 1
opioid drug for pain management. If your doctor prescribes more than this amount or thinks the
limit is not right for your situation, you or your doctor can ask the plan to cover the additional
quantity.
7D - 7-Day limit
An opioid drug used for the treatment of acute pain may be limited to a 7-day supply for members
with no recent history of opioid use. This limit is intended to minimize long-term opioid use. For
members who are new to the plan and have a recent history of using opioids, the limit may be
overridden by having the pharmacy contact the plan.
DL - Dispensing limit
Dispensing limits apply to this drug. This drug is limited to a 1 month supply per prescription.
For Track Refered Purpose

You and your doctor may ask the plan for an exception to the coverage rules and/or limits for your
drug. See section “How can I get an exception?" on page 8 or see your Evidence of Coverage to
learn more.
If you don’t get approval from the plan before you fill a prescription for a drug with coverage rules
or limits, you may have to pay the full cost of the drug.
8 7 Track
What if my drug is not on this list?
If your drug is not included in this drug list we may still cover it. Call Customer Service to ask if it’s
covered. Our contact information, along with the date we last updated the drug list is on the cover.
If you find out that your drug is not covered, you can do 1 of these things:
1. Ask Customer Service for a list of similar drugs that are covered by the plan. When you get
the list, show it to your doctor and ask him or her to prescribe a covered drug.
2. Ask the plan to make an exception and cover your drug. Review the next section for more
exception information.

How can I get an exception?

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

Types of exceptions you can ask for

· Drug list exception: Ask the plan to cover your drug even if it’s not on the drug list. If approved,
this drug will be covered at a pre-determined cost-sharing level. You will not be able to ask us to
provide the drug at a lower cost-sharing level.
· Utilization exception: Ask the plan to revise the coverage rules or limits on your drug. For
example, if your drug has a quantity limit, you can ask the plan to change the limit and cover
more.
· Tiering exception: Ask the plan to cover your drug on our list at a lower cost-sharing level if this
drug is not on the specialty tier.
The plan may approve your request for an exception if the covered alternative drugs wouldn’t be as
effective in treating your condition or would cause adverse medical effects.
Who can ask for an exception?
You, your authorized representative or your doctor can ask for an exception by calling Customer
Service. Your doctor must give us a supporting statement with the reason for the exception.
How long does it take to get an exception?
After we get the statement from your doctor supporting your request for an exception, we’ll give
you a decision within 72 hours. You can ask for an expedited (fast) decision if you or your doctor
believes that your health could be seriously harmed by waiting 72 hours. If your request for an
expedited review is approved, we’ll give you a decision within 24 hours after we get your doctor’s
supporting statement.
 8 9
Can I get my drug while I wait for an exception?
As a new or continuing member in our plan, we may cover a temporary supply of your drug if it’s
not on our drug list or if it has rules or limits. For example, you may need a prior authorization from
us before you can fill your prescription. During the time when you are getting a temporary supply,
you should talk with your doctor to decide if there is a similar drug on the drug list you can take
instead. If you and your doctor decide this is the only drug that will work for you, you will need to
ask for an exception. We may cover your drug in certain cases during the first 90 days of your
membership.
The following chart shows how much of your drug we may cover while you ask for an exception.

If you... And you are… We may cover…

are a new member in the first 90 days of not in a nursing home or at least a 30-day
your membership long-term care facility temporary supply
OR
in a nursing home or long- at least a 31-day
were a member last year and it’s the
term care facility temporary supply
first 90 days of your plan year
have been in the plan for more than 90 in a nursing home or long- at least a 31-day
days term care facility and emergency supply
need a supply right away
are going through a change in your level not in a nursing home or at least a 30-day
of care, such as being transferred from long-term care facility temporary supply
a hospital to a long-term care facility,
in a nursing home or long- at least a 31-day
any time during the year
term care facility temporary supply

The prescription must be filled at a network pharmacy. If your prescription is written for fewer days,
we’ll allow refills to provide at least the day supply listed in the chart above. (Please note that the
long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.)
We will not pay for more of your drug after you get this temporary or emergency supply unless you
receive authorization from the plan.
10 9
Can the drug list change?
Most changes in drug coverage happen on January 1. We may need to make changes during the
plan year for safety or other reasons that can affect you. We must follow Medicare rules in making
these changes.
The drug list may change during the year if your plan:
· Adds new drugs, including generic drugs, as they become available.
· Removes a drug that has been found to be ineffective or unsafe.
· Changes the coverage rules or limits for a drug.
· Moves a drug into a different cost-sharing tier.
If we add new generic drugs
We may immediately remove a brand name drug on our Drug List if we are replacing it with a new
generic drug that will appear on the same or lower cost-sharing tier and with the same or fewer
restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug
on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If
you are currently taking that brand name drug, we may not tell you in advance before we make that
change, but we will later provide you with information about the specific change(s) we have made.
If we make such a change, you or your prescriber can ask us to make an exception and continue to
cover the brand name drug for you. The notice we provide you will also include information on how
to request an exception, and you can also find information in the section “How can I get an
exception?” on page 8.
If we remove a drug from the list
Usually, if you’re taking a drug on this drug list that was covered at the beginning of the year, we will
not remove or reduce coverage during the year. If you are taking a drug that is removed because a
generic version becomes available, we will tell you. If the Food and Drug Administration (FDA) says
a drug you are taking is not effective or is unsafe, we will take it off the drug list right away.
If we change the coverage rules or limits
We’ll tell you if we add prior approval, quantity limits and/or step therapy restrictions on a drug. You
can find out if your drug has any rules or limits by looking in the chart on pages 165-202.
We’ll tell you about other changes
If a drug you are taking is removed from the drug list during the plan year, we’ll include an update
in your Part D Explanation of Benefits (Part D EOB) statement. We’ll tell you about other changes to
our drug list at least 30 days before they go into effect or when you request a refill of the drug. If
you find out when requesting a refill, you will receive at least a 30-day supply of the drug so you
have time to talk with your doctor. To get updated information about the drugs covered by your
plan, please call Customer Service. Our contact information is on the cover.
 10 11
Drugs with dosages other than a 1-month supply
Drugs packaged in an extended day supply
Some drugs are packaged from the manufacturer to provide more than a 1-month supply. When
you fill these drugs, you may have to pay more than 1 copay/coinsurance for a single prescription.
For more information, please call Customer Service. Our contact information is on the cover.
Daily cost-sharing for oral medications filled for less than a 1-month supply
A daily cost-sharing rate may apply when your doctor prescribes less than a full month’s supply of
certain drugs for you and you are required to pay a copayment. A daily cost-sharing rate is the
copayment divided by the number of days in a month’s supply.
Daily cost-sharing applies only if the drug is in the form of a solid oral dose (e.g., tablet or capsule)
when dispensed for a supply of less than 1 month under applicable law. The daily cost-sharing
requirements do not apply to either of the following:
1. Solid oral doses of antibiotics.
2. Solid oral doses that are dispensed in their original container or are usually dispensed in their
original packaging to help patients comply with usage and dosage directions.

For more information

For more detailed information about your plan’s prescription drug coverage, please review your
Evidence of Coverage and other plan materials.
If you have questions about your plan’s prescription drug coverage, please call Customer Service.
Our contact information, along with the date we last updated the drug list, is on the cover.
If you have general questions about Medicare prescription drug coverage, visit www.medicare.gov
or call Medicare at 1-800-633-4227, TTY 1-877-486-2048, 24 hours a day, 7 days a week.
12 12
Tracked 12
track
Covered drugs by name (Drug index)
A Actoplus Met.......................... 91 AirDuo RespiClick 55/14.... 162
Abacavir Sulfate..................... 88 Actos....................................... 91 Ajovy........................................72
Abacavir Sulfate-Lamivudine Acular....................................155 Aktipak..................................114
.............................................. 88 Acular LS.............................. 155 Ala Scalp...............................129
Abacavir-Lamivudine- Acuvail.................................. 155 Ala-Cort................................. 129
Zidovudine........................... 88
Acyclovir................................. 86 Albendazole............................78
Abelcet....................................68
Acyclovir Sodium................... 86 Albenza................................... 78
Abilify...................................... 82
Aczone..................................114 Albuterol Sulfate.................. 159
Abilify Maintena............... 81, 82
Adacel...................................148 Albuterol Sulfate ER............ 159
Abiraterone Acetate...............74
Adalat CC............................. 102 Albuterol Sulfate HFA.......... 159
Absorica................................114
Adapalene............................ 114 Alclometasone Dipropionate
Abstral.....................................44 ............................................ 129
Adapalene-Benzoyl Peroxide
Acamprosate Calcium........... 47 ............................................ 114 Alcohol Prep Pads............... 152
Acanya.................................. 114 Adcirca..................................161 Aldactazide...........................104
Acarbose................................ 91 Adderall................................ 110 Aldactone............................. 106
Accolate................................158 Adderall XR.......................... 110 Aldara....................................114
Accupril.................................100 Adefovir Dipivoxil................... 85 Alecensa................................. 76
Accuretic.............................. 104 Adempas.............................. 161 Alendronate Sodium............151
Acebutolol HCl..................... 101 Adlyxin.................................... 91 Alfuzosin HCl ER..................128
Acetaminophen-Codeine...... 44 Adlyxin Starter Pack.............. 91 Alinia....................................... 78
Acetazolamide..................... 106 Advair Diskus....................... 162 Aliskiren Fumarate...............104
Acetazolamide ER............... 106 Advair HFA........................... 162 Allopurinol.............................. 71
Acetic Acid........................... 156 Adzenys ER.......................... 110 Almotriptan Malate.................72
Acetylcysteine...................... 162 Adzenys XR-ODT................. 110 Alocril.................................... 153
Aciphex.................................125 Afinitor.....................................76 Alogliptin Benzoate................91
Acitretin................................ 114 Afinitor Disperz.......................76 Alogliptin-Metformin HCl....... 91
Actemra................................ 147 Afrezza.................................... 94 Alogliptin-Pioglitazone........... 91
Actemra ACTPen................. 147 Aggrenox................................ 99 Alomide.................................153
Acthar................................... 129 Agrylin..................................... 97 Alora......................................137
ActHIB...................................148 Aimovig................................... 72 Alosetron HCl....................... 124
Actigall.................................. 123 AirDuo RespiClick 113/14 Alphagan P...........................154
Actimmune........................... 147 ............................................ 162 Alprazolam..............................90
Actiq........................................ 44 AirDuo RespiClick 232/14 Alprazolam ER........................90
Actonel..................................151 ............................................ 162 Alprazolam Intensol............... 90
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Tracked 13 13

Alprazolam ODT..................... 90 Ammonium Lactate..............114 Apraclonidine HCl................ 154

Alrex.......................................155 Amnesteem...........................114 Aprepitant................................68
Altace.................................... 100 Amoxapine.............................. 67 Apri........................................ 137
Altavera................................. 137 Amoxicillin...............................54 Apriso.................................... 150
Altoprev................................. 108 Amoxicillin-Clarithromycin- Aptensio XR.......................... 110
Altreno...................................114 Lansoprazole......................123 Aptiom..................................... 62
Alunbrig...................................76 Amoxicillin-Potassium Aptivus.....................................89
Clavulanate........................... 54
Alvesco..................................157 Aralast NP............................. 126
Amoxicillin-Potassium
Alyacen 1/35.........................137 Aranelle................................. 137
Clavulanate ER..................... 54
Alyq........................................161 Aranesp.............................97, 98
Amphetamine Sulfate.......... 110
Amantadine HCl..................... 79 Arava..................................... 147
Amphetamine-
Amaryl..................................... 91 Dextroamphetamine.......... 110 Arcalyst..................................147
Ambien.................................. 164 Amphetamine- Arcapta Neohaler................. 159
AmBisome...............................69 Dextroamphetamine ER.... 110 Aricept..................................... 64
Ambrisentan......................... 161 Amphotericin B.......................69 Arikayce...................................48
Amcinonide...........................129 Ampicillin.................................54 Arimidex.................................. 76
Amerge....................................72 Ampicillin Sodium.................. 54 Aripiprazole.............................82
Amethia................................. 137 Ampicillin-Sulbactam Sodium Aripiprazole ODT.................... 82
............................................... 54
Amethia Lo............................137 Aristada................................... 82
Ampyra.................................. 112
Amikacin Sulfate.....................48 Aristada Initio.......................... 82
Anadrol-50.............................136
Amiloride HCl........................107 Arixtra...................................... 95
Anafranil.................................. 67
Amiloride-Hydrochlorothiazide Armodafinil............................164
.............................................104 Anagrelide HCl........................97 Arnuity Ellipta........................157
Aminosyn II........................... 118 Anastrozole............................. 76 Aromasin................................. 76
Aminosyn-PF.........................118 Ancobon..................................69 Arthrotec................................. 39
Amiodarone HCl................... 100 Androderm............................136 Asacol HD............................. 150
Amitiza...................................124 AndroGel...............................136 Ashlyna..................................137
Amitriptyline HCl.....................67 AndroGel Pump....................136 Asmanex............................... 157
Amlodipine Besylate............ 102 Anoro Ellipta......................... 162 Asmanex HFA....................... 157
Amlodipine-Atorvastatin.......104 Antabuse................................. 47 Aspirin-Dipyridamole ER........99
Amlodipine-Benazepril.........104 Antara.................................... 107 Astagraf XL........................... 144
Amlodipine-Olmesartan....... 104 Anusol-HC............................. 150 Astepro..................................156
Amlodipine-Valsartan........... 104 ApexiCon E........................... 129 Atacand................................. 100
Amlodipine-Valsartan-HCTZ Aplenzin...................................65
Atacand HCT........................ 104
.............................................104 Apokyn.................................... 79
14 14
Tracked 14

Atazanavir Sulfate...................89 Azasite..................................... 55 Benicar.................................. 100

Atelvia....................................151 Azathioprine..........................144 Benicar HCT......................... 104
Atenolol................................. 101 Azelaic Acid.......................... 115 Benlysta.................................148
Atenolol-Chlorthalidone....... 104 Azelastine HCl.............. 153, 157 BenzaClin with Pump...........115
Ativan.......................................90 Azelex.................................... 115 Benzamycin.......................... 115
Atomoxetine HCl.................. 111 Azilect...................................... 81 Benznidazole.......................... 78
Atorvastatin Calcium............ 108 Azithromycin........................... 55 Benzoyl Peroxide-Erythromycin
Atovaquone.............................78 Azopt..................................... 154 .............................................115
Atovaquone-Proguanil HCl.... 78 Azor....................................... 104 Benztropine Mesylate............ 79
Atralin.................................... 114 Aztreonam...............................53 Bepreve................................. 153
Atripla...................................... 87 Azulfidine.............................. 151 Berinert..................................144
Atropine Sulfate....................152 Azulfidine EN-tabs................ 151 Beser..................................... 129
Atrovent HFA........................ 158 B Besivance................................56
Aubagio.................................112 Bacitracin................................ 49 Betamethasone Dipropionate
.................................... 129, 130
Aubra.....................................137 Bacitracin-Polymyxin B........ 152
Betamethasone Dipropionate
Augmentin...............................54 Baclofen................................ 163
Aug......................................129
Auryxia...................................122 Bactocill in Dextrose.............. 54
Betamethasone Valerate..... 130
Austedo................................. 112 Bactrim.................................... 57
Betapace AF......................... 101
Avalide...................................104 Bactrim DS.............................. 57
Betaseron..............................113
Avandia....................................91 Bactroban................................49
Betaxolol HCl................101, 154
Avapro................................... 100 Balsalazide Disodium...........150
Bethanechol Chloride.......... 129
AVC Vaginal............................ 69 Balversa...................................76
Bethkis.................................. 160
Aveed.................................... 136 Balziva................................... 137
Betimol.................................. 154
Avelox...................................... 56 Banzel......................................63
Betoptic-S..............................154
Aviane....................................137 Baraclude................................ 85
Bevespi Aerosphere.............162
Avita.............................. 114, 115 Basaglar KwikPen...................94
Bevyxxa................................... 95
Avodart.................................. 128 Baxdela....................................56
Bexarotene..............................78
Avonex...................................112 BCG Vaccine........................ 148
Bexsero................................. 148
Avonex Pen...........................113 Beconase AQ........................157
Beyaz.....................................137
Avonex Prefilled....................113 Belbuca................................... 41
Bicalutamide........................... 74
Avycaz..................................... 51 Belsomra............................... 164
Bicillin C-R...............................54
Aygestin................................ 141 Benazepril HCl......................100
Bicillin C-R 900/300............... 54
Azactam.................................. 53 Benazepril-Hydrochlorothiazide
Bicillin L-A............................... 54
Azasan...................................144 .............................................104
BiDil....................................... 104
 15
Tracked 15 15

Biktarvy....................................88 Buprenorphine HCl................ 47 Candesartan Cilexetil........... 100

Biltricide.................................. 78 Buprenorphine HCl-Naloxone Candesartan Cilexetil-HCTZ
Bimatoprost.......................... 156 HCl.........................................47 .............................................104
Binosto.................................. 151 Bupropion HCl........................ 65 Capex.................................... 130
Bisoprolol Fumarate.............101 Bupropion HCl ER.................. 65 Caprelsa.................................. 76
Bisoprolol-Hydrochlorothiazide Bupropion HCl SR............48, 65 Captopril............................... 100
.............................................104 Bupropion HCl XL.................. 65 Captopril-Hydrochlorothiazide
BIVIGAM................................147 Buspirone HCl........................ 90 .............................................104
Bleph-10.................................. 57 Butorphanol Tartrate.............. 44 Carac..................................... 115
Blephamide...........................152 Butrans.................................... 41 Carafate.................................125
Blephamide S.O.P................152 Bydureon.................................91 Carbaglu................................118
Blisovi 24 Fe..........................137 Bydureon BCise......................91 Carbamazepine...................... 63
Blisovi Fe 1.5/30...................137 Byetta 10MCG Pen.................91 Carbamazepine ER................ 63
Boniva....................................151 Byetta 5MCG Pen...................91 Carbatrol................................. 63
Boostrix................................. 148 Bystolic..................................101 Carbidopa............................... 80
Bosentan............................... 161 C Carbidopa-Levodopa............. 80
Bosulif......................................76 Cabergoline.......................... 143 Carbidopa-Levodopa ER....... 80
Braftovi.................................... 76 Cablivi......................................99 Carbidopa-Levodopa ODT.....80
Breo Ellipta............................162 Cabometyx.............................. 76 Carbidopa-Levodopa-
Entacapone.......................... 80
Briellyn...................................137 Caduet...................................104
Cardizem...............................102
Brilinta..................................... 99 Cafergot...................................71
Cardizem CD........................ 102
Brimonidine Tartrate............ 154 Calan..................................... 102
Cardizem LA......................... 102
BRIVIACT................................ 59 Calan SR............................... 102
Cardura................................... 99
Bromfenac Sodium.............. 155 Calcipotriene.........................115
Cardura XL............................128
Bromocriptine Mesylate.........79 Calcipotriene-Betamethasone
Carnitor................................. 118
BromSite............................... 155 .............................................115
CaroSpir................................ 107
Brovana................................. 159 Calcitonin Salmon................ 151
Carteolol HCl........................ 154
Bryhali................................... 130 Calcitriol........................115, 151
Cartia XT............................... 102
Budesonide.................. 150, 157 Calcium Acetate................... 122
Carvedilol.............................. 101
Budesonide ER.....................150 Calquence...............................76
Carvedilol Phosphate ER.....101
Bumetanide.......................... 106 Cambia.................................... 39
Casodex.................................. 74
Bunavail...................................47 Camila................................... 141
Caspofungin Acetate............. 69
Buphenyl............................... 126 Camrese Lo.......................... 137
Catapres..................................99
Buprenorphine........................41 Canasa.................................. 150
Cancidas................................. 69 Catapres-TTS-1....................... 99
16 16
Tracked 16

Catapres-TTS-2....................... 99 Chemet..................................121 Clarithromycin ER...................55

Catapres-TTS-3....................... 99 Chenodal...............................123 Clenpiq.................................. 124
Cayston................................. 160 Chlordiazepoxide HCl............ 90 Cleocin.................................... 49
Caziant.................................. 137 Chlorhexidine Gluconate..... 114 Cleocin in D5W....................... 49
Cefaclor.............................51, 52 Chloroquine Phosphate......... 78 Cleocin Phosphate................. 49
Cefaclor ER............................. 51 Chlorothiazide.......................107 Cleocin-T............................... 115
Cefadroxil................................ 52 Chlorpromazine HCl...............81 Climara Pro........................... 137
Cefazolin Sodium................... 52 Chlorthalidone...................... 107 Clindacin-P............................115
Cefdinir....................................52 Cholbam................................126 Clindagel............................... 115
Cefepime HCl......................... 52 Cholestyramine.....................108 Clindamycin HCl.....................49
Cefixime.................................. 52 Cholestyramine Light........... 108 Clindamycin Palmitate HCl.... 49
Cefotetan Disodium............... 52 Cialis...................................... 128 Clindamycin Phosphate........49,
Cefoxitin Sodium.................... 52 Ciclopirox................................ 69 115
Cefpodoxime Proxetil.............52 Ciclopirox Olamine.................69 Clindamycin Phosphate in D5W
............................................... 49
Cefprozil.................................. 52 Cilostazol.................................99
Clindamycin Phosphate-
Ceftazidime............................. 52 Ciloxan.....................................56
Benzoyl Peroxide............... 115
Ceftriaxone Sodium................52 Cimduo....................................88
Clindamycin-Tretinoin.......... 115
Cefuroxime Axetil................... 52 Cimetidine.............................124
Clindesse.................................49
Cefuroxime Sodium............... 52 Cimetidine HCl..................... 124
Clinimix E/Dextrose..... 118, 119
Celebrex.................................. 39 Cimzia....................................144
Clinimix/Dextrose.................119
Celecoxib................................ 39 Cimzia Prefilled.....................144
Clinisol SF............................. 119
Celexa......................................65 Cinacalcet HCl......................151
Clobazam................................ 60
Cellcept................................. 144 Cinryze.................................. 144
Clobetasol Propionate......... 130
Celontin................................... 60 Cipro..................................56, 57
Clobetasol Propionate
Cephalexin.............................. 53 Cipro HC............................... 156 Emollient Base................... 130
Cerdelga................................126 Ciprodex................................156 Clobetasol Propionate
Cesamet.................................. 68 Ciprofloxacin...........................57 Emulsion............................. 130
Cetirizine HCl........................ 157 Ciprofloxacin HCl........... 57, 156 Clobex................................... 130
Cetraxal................................. 156 Ciprofloxacin in D5W............. 57 Clobex Spray........................ 130
Cevimeline HCl..................... 114 Citalopram Hydrobromide..... 65 Clodan................................... 130
Chantix.................................... 48 Claravis..................................115 Clomipramine HCl.................. 67
Chantix Continuing Month Pak Clarinex................................. 157 Clonazepam............................90
............................................... 48 Clarinex-D 12 Hour............... 162 Clonazepam ODT................... 90
Chantix Starting Month Pak...48 Clarithromycin.........................55 Clonidine................................. 99
 17
Tracked 17 17

Clonidine HCl..........................99 Cordran................................. 130 Cyclosporine Modified.........145

Clonidine HCl ER..................111 Coreg.....................................101 Cymbalta............................... 112
Clopidogrel Bisulfate..............99 Coreg CR.............................. 101 Cyproheptadine HCl............ 157
Clorazepate Dipotassium.......90 Corgard................................. 101 Cyred..................................... 137
Clotrimazole............................ 69 Corlanor................................ 104 Cystadane............................. 126
Clotrimazole-Betamethasone Cortef.....................................130 Cystagon............................... 126
.............................................115 Cortisone Acetate.................130 Cystaran................................ 152
Clozapine................................ 85 Cortisporin............................ 116 Cytomel................................. 142
Clozapine ODT....................... 85 Cosentyx............................... 116 Cytotec.................................. 125
Clozaril.....................................85 Cosentyx Sensoready.......... 116 D
Coartem...................................78 Cosopt...................................154 Daklinza...................................86
Codeine Sulfate...................... 44 Cosopt PF............................. 154 Dalfampridine ER................. 113
Colazal...................................150 Cotellic.....................................76 Daliresp................................. 161
Colchicine............................... 71 Cotempla XR-ODT................111 Dalvance..................................50
Colcrys.....................................71 Coumadin................................95 Danazol................................. 136
Colesevelam HCl.................. 108 Cozaar................................... 100 Dantrium................................163
Colestid................................. 108 Creon.....................................126 Dantrolene Sodium.............. 163
Colestipol HCl.......................108 Cresemba................................69 Dapsone..........................74, 116
Colistimethate Sodium...........49 Crestor...................................108 Daptacel................................ 148
Colocort.................................150 Crinone..................................141 Daptomycin.............................50
Colyte with Flavor Packs......124 Crixivan....................................89 DARAPRIM............................. 78
Combigan............................. 154 Cromolyn Sodium....... 123, 153, Darifenacin Hydrobromide ER
Combivent Respimat........... 162 161 .............................................127
Combivir.................................. 88 Cryselle-28............................ 137 Daurismo................................. 76
Cometriq................................. 76 Cubicin.................................... 49 Daypro..................................... 39
Complera.................................87 Cuprimine............................. 129 Daytrana................................ 111
Compro................................... 67 Cutivate................................. 130 DDAVP.................................. 134
Comtan....................................79 Cuvposa................................ 122 DDAVP Rhinal Tube.............134
Concerta................................111 Cyclafem 1/35...................... 137 Deblitane............................... 141
Condylox............................... 116 Cyclafem 7/7/7.....................137 Deferasirox............................121
Constulose............................ 124 Cyclobenzaprine HCl........... 163 Delestrogen.......................... 137
ConZip.....................................41 Cyclophosphamide................ 74 Delstrigo.................................. 87
Copaxone..............................113 Cycloset...................................91 Delyla.....................................137
Copiktra...................................75 Cyclosporine.........................145 Delzicol..................................150
18 18
Tracked 18

Demeclocycline HCl...............58 Dexedrine..............................110 Dihydroergotamine Mesylate

Demser..................................104 Dexilant................................. 125 ............................................... 72
Denavir.................................... 86 Dexmethylphenidate HCl.....111 Dilantin.................................... 63
Depakene................................ 60 Dexmethylphenidate HCl ER Dilantin INFATABS................. 63
Depakote.................................91 .............................................111 Dilaudid................................... 44
Depakote ER...........................91 DexPak 13 Day..................... 131 Dilt-XR....................................103
Depakote Sprinkles................ 91 Dextroamphetamine Sulfate Diltiazem HCl........................ 103
.............................................110 Diltiazem HCl ER.................. 103
Depen Titratabs.................... 129
Dextroamphetamine Sulfate ER Diltiazem HCl ER Beads...... 102
Depo-Estradiol...................... 138
.............................................110
Depo-Provera........................ 141 Diltiazem HCl ER Coated
Dextrose................................ 119 Beads.................................. 102
Depo-SubQ Provera 104......141
Dextrose-NaCl.......................119 Diovan................................... 100
Depo-Testosterone...............136
Diastat AcuDial....................... 60 Diovan HCT...........................105
Descovy...................................88
Diastat Pediatric......................60 Dipentum...............................150
Desipramine HCl.................... 67
Diazepam................................ 90 Diphenoxylate-Atropine....... 123
Desloratadine........................157
Diazepam Intensol..................90 Diphtheria-Tetanus Toxoids DT
Desloratadine ODT...............157
Dibenzyline........................... 100 .............................................148
Desmopressin Acetate.........134
Diclofenac Epolamine............ 39 Diprolene...............................131
Desmopressin Acetate Spray
Diclofenac Potassium............ 39 Disulfiram................................ 47
.............................................134
Diclofenac Sodium........39, 116, Ditropan XL........................... 128
Desogestrel-Ethinyl Estradiol
155 Diuril...................................... 107
.............................................138
Diclofenac Sodium ER........... 39 Divalproex Sodium................. 91
Desonate............................... 130
Diclofenac-Misoprostol.......... 39 Divalproex Sodium ER........... 91
Desonide............................... 130
Dicloxacillin Sodium...............54 Dofetilide............................... 101
DesOwen...............................130
Dicyclomine HCl................... 122 Dolophine................................41
Desoximetasone...................131
Didanosine.............................. 88 Donepezil HCl......................... 64
Desoxyn.................................110
Differin................................... 116 Donepezil HCl ODT................ 64
Desvenlafaxine ER..................65
Dificid.......................................55 Doptelet...................................98
Desvenlafaxine Succinate ER
............................................... 66 Diflorasone Diacetate...........131 Doryx....................................... 58
Detrol.....................................127 Diflucan................................... 69 Doryx MPC.............................. 58
Detrol LA............................... 127 Diflunisal..................................39 Dorzolamide HCl.................. 154
Dexamethasone....................131 Digitek................................... 104 Dorzolamide HCl-Timolol
Dexamethasone Intensol..... 131 Digox..................................... 104 Maleate............................... 154
Dexamethasone Sodium Digoxin..........................104, 105 Dorzolamide HCl-Timolol
Phosphate.......................... 155 Maleate Preservative Free
.............................................154
 19
Tracked 19 19

Dotti....................................... 138 Dyazide..................................105 Emverm................................... 78

Dovato..................................... 87 Dymista................................. 162 Enablex..................................128
Dovonex................................ 116 Dyrenium...............................107 Enalapril Maleate..................100
Doxazosin Mesylate............. 100 E Enalapril-Hydrochlorothiazide
Doxepin HCl................... 67, 116 E.E.S. 400................................55 .............................................105
Doxercalciferol......................151 E.E.S. Granules.......................56 Enbrel.................................... 145
Doxy 100................................. 58 Econazole Nitrate................... 69 Enbrel SureClick...................145
Doxycycline Hyclate............... 58 Edarbi.................................... 100 Endari.................................... 119
Doxycycline Monohydrate..... 58 Edarbyclor.............................105 Endocet................................... 44
Dronabinol...............................68 Edecrin.................................. 106 Engerix-B...............................148
Drospirenone-Ethinyl Estradiol Edurant.................................... 87 Enoxaparin Sodium................96
.............................................138 Efavirenz..................................87 Enpresse-28.......................... 138
Drospirenone-Ethinyl Estradiol- Effexor XR............................... 66 Enskyce.................................138
Levomefolate......................138 Enstilar...................................116
Effient...................................... 99
Droxia...................................... 75 Entacapone.............................79
Efudex................................... 116
Duac...................................... 116 Entecavir..................................85
Egrifta.................................... 143
Duetact.................................... 92 Entocort EC...........................150
Elestrin...................................138
Dulera.................................... 162 Entresto................................. 105
Eletriptan Hydrobromide........72
Duloxetine HCl......................112 Enulose................................. 124
Elidel......................................116
Duobrii...................................116 Envarsus XR..........................145
Eligard................................... 143
Duopa...................................... 80 Epclusa....................................86
Elimite......................................79
Dupixent........................116, 145 Epidiolex..................................59
Eliquis...................................... 95
Duragesic-100.........................41 Epiduo................................... 116
Eliquis Starter Pack................ 95
Duragesic-12...........................41 Epiduo Forte......................... 116
Elmiron.................................. 129
Duragesic-25...........................41 Epinastine HCl...................... 153
Elocon................................... 131
Duragesic-50...........................41 Epinephrine...........................159
Embeda................................... 41
Duragesic-75...........................41 EpiPen 2-Pak.........................159
Emcyt.......................................75
Duramorph.............................. 44 EpiPen Jr 2-Pak.................... 159
Emend..................................... 68
Durezol.................................. 155 Epitol........................................63
Emend Tri-Pack...................... 68
Dutasteride............................128 Epivir........................................88
Emflaza..................................131
Dutasteride-Tamsulosin HCl Epivir HBV............................... 85
Emgality...................................72
.............................................128
Emoquette.............................138 Eplerenone............................107
DUTOPROL.......................... 105
Emsam.....................................65 Epogen.................................... 98
Dvorah..................................... 44
Emtriva.....................................88 Eprosartan Mesylate............ 100
Dyanavel XR..........................110
20 20
Tracked 20

Epzicom...................................88 Ethynodiol Diacetate-Ethinyl Fayosim................................. 138

Equetro....................................91 Estradiol..............................138 FazaClo....................................85
Eraxis....................................... 69 Etodolac.................................. 39 Felbamate............................... 61
Ergotamine-Caffeine...............72 Etodolac ER............................ 39 Felbatol....................................61
Erivedge.................................. 76 Eucrisa...................................116 Feldene....................................39
Erleada.................................... 74 Eurax........................................79 Felodipine ER....................... 103
Erlotinib HCl............................ 76 Evekeo...................................110 Femara.................................... 76
Errin....................................... 141 Evista..................................... 142 Femring................................. 138
Ertaczo.....................................69 Evoclin................................... 116 Femynor................................ 138
Ertapenem Sodium................ 53 Evotaz...................................... 89 Fenofibrate............................107
Ery..........................................116 Evoxac................................... 114 Fenofibrate Micronized........107
Ery-Tab.................................... 56 Evzio........................................ 48 Fenofibric Acid..................... 107
Erygel.....................................116 Exelderm................................. 69 Fenoglide.............................. 107
EryPed 200..............................56 Exelon......................................64 Fenoprofen Calcium...............39
EryPed 400..............................56 Exemestane............................ 76 Fentanyl.............................41, 42
Erythrocin Lactobionate.........56 Exforge.................................. 105 Fentanyl Citrate.......................44
Erythrocin Stearate.................56 Exforge HCT......................... 105 Fentora.................................... 44
Erythromycin.................. 56, 116 Exjade....................................121 Ferriprox....................... 121, 122
Erythromycin Base................. 56 Extavia................................... 113 Fetzima.................................... 66
Erythromycin Ethylsuccinate Extina....................................... 69 Fetzima Titration..................... 66
............................................... 56 Ezallor Sprinkle.....................108 Fexmid...................................163
Esbriet................................... 162 Ezetimibe.............................. 108 Fibricor.................................. 107
Escitalopram Oxalate............. 66 Ezetimibe-Simvastatin.......... 108 Finacea..................................116
Esomeprazole Magnesium F Finasteride............................ 128
.............................................125 Fabior.................................... 116
Firazyr....................................144
Esomeprazole Strontium..... 125 Falmina..................................138
Firdapse................................ 152
Estarylla.................................138 Famciclovir..............................86
Firmagon............................... 143
Estrace.................................. 138 Famotidine............................ 124
Firvanq.....................................50
Estradiol................................ 138 Fanapt......................................82
Flac........................................ 156
Estradiol Valerate................. 138 Fanapt Titration Pack............. 82
Flagyl....................................... 50
Estring................................... 138 Fareston.................................. 75
Flarex.....................................155
Ethacrynic Acid.....................106 Farxiga.....................................92
Flavoxate HCl........................128
Ethambutol HCl...................... 74 Farydak....................................76
Flebogamma DIF.................. 147
Ethosuximide.......................... 60 Fasenra..................................162
Flecainide Acetate................101
 21
Tracked 21 21

Flector......................................39 FML........................................155 Gammagard S/D Less IgA

FloLipid................................. 108 FML Forte..............................155 .............................................147
Flomax...................................128 FML Liquifilm........................ 155 Gammaked........................... 147
Flovent Diskus...................... 157 Focalin...................................111 Gammaplex...........................147
Flovent HFA.......................... 157 Focalin XR.............................111 Gamunex-C........................... 147
Fluconazole.............................70 Fondaparinux Sodium............96 Gardasil 9..............................148
Fluconazole in Sodium Forfivo XL................................ 65 Gastrocrom........................... 123
Chloride................................ 69 Fortamet.................................. 92 Gatifloxacin............................. 57
Flucytosine.............................. 70 Forteo.................................... 151 Gattex.................................... 123
Fludrocortisone Acetate...... 131 Fortesta................................. 136 Gauze.................................... 152
Flumadine............................... 89 Fosamax................................151 GaviLyte-C.............................124
Flunisolide.............................157 Fosamax Plus D....................151 GaviLyte-G.............................124
Fluocinolone Acetonide......131, Fosamprenavir Calcium......... 89 GaviLyte-N with Flavor Pack
156 .............................................124
Fosinopril Sodium................ 100
Fluocinolone Acetonide Scalp Gelnique Pump.....................128
Fosinopril Sodium-HCTZ..... 105
.............................................131 Gemfibrozil............................107
Fosrenol................................ 122
Fluocinonide......................... 131 Generess Fe..........................138
Fragmin................................... 96
Fluocinonide Emulsified Base Generlac................................124
.............................................131 FreAmine HBC......................119
Gengraf................................. 145
Fluorometholone.................. 155 Frova........................................72
Genotropin............................ 135
Fluorouracil........................... 116 Frovatriptan Succinate........... 72
Genotropin MiniQuick.........134,
Fluoxetine HCl........................ 66 Fulphila....................................98 135
Fluphenazine Decanoate....... 81 Furadantin............................... 50 Gentak..................................... 48
Fluphenazine HCl................... 81 Furosemide........................... 106 Gentamicin Sulfate................. 48
Flurandrenolide.................... 131 Fuzeon.....................................89 Gentamicin Sulfate-0.9%
Flurbiprofen.............................39 Fyavolv...................................138 Sodium Chloride.................. 48
Flurbiprofen Sodium............ 155 Fycompa..................................61 Genvoya.................................. 87
Flutamide................................ 74 G Geodon....................................82
Fluticasone Propionate....... 131, Gabapentin............................. 60 Gianvi.....................................138
132, 157 Gabitril..................................... 60 Gilenya.................................. 113
Fluticasone-Salmeterol....... 162, Galafold.................................126 Gilotrif...................................... 76
163
Galantamine Hydrobromide Glassia...................................126
Fluvastatin Sodium...............108 ............................................... 64
Glatiramer Acetate............... 113
Fluvastatin Sodium ER.........108 Galantamine Hydrobromide ER
Glatopa..................................113
Fluvoxamine Maleate............. 66 ............................................... 64
Gleevec................................... 76
Fluvoxamine Maleate ER....... 66 Gammagard..........................147
22 22
Tracked 22

Gleostine................................. 74 Haloperidol Decanoate.......... 81 Humulin R U-500 KwikPen.....95

Glimepiride..............................92 Haloperidol Lactate................ 81 Hydralazine HCl....................109
Glipizide...................................92 Harvoni.................................... 86 Hydrea..................................... 75
Glipizide ER............................ 92 Havrix.....................................148 Hydrochlorothiazide.............107
Glipizide-Metformin HCl.........92 Heparin Sodium......................96 Hydrocodone-Acetaminophen
GlucaGen HypoKit..................94 HepatAmine.......................... 119 .........................................44, 45
Glucagon Emergency............ 94 Hepsera................................... 85 Hydrocodone-Ibuprofen.........45
Glucophage............................ 92 Hetlioz....................................164 Hydrocortisone.............132, 151
Glucophage XR...................... 92 Hiberix................................... 148 Hydrocortisone Acetate-
Pramoxine...........................150
Glucotrol..................................92 Hiprex...................................... 50
Hydrocortisone Butyrate......132
Glucotrol XL............................ 92 Horizant................................. 112
Hydrocortisone Valerate...... 132
Glumetza................................. 92 Humalog..................................94
Hydrocortisone-Acetic Acid
Glycopyrrolate...................... 123 Humalog Junior KwikPen...... 94
.............................................156
Glyset.......................................92 Humalog KwikPen.................. 94
Hydromorphone HCl.............. 45
Glyxambi................................. 92 Humalog Mix 50/50................94
Hydromorphone HCl ER........ 42
Gocovri.................................... 79 Humalog Mix 50/50 KwikPen
Hydromorphone HCl
GoLYTELY............................ 124 ............................................... 94 Preservative Free..................45
GoNitro..................................109 Humalog Mix 75/25................94 Hydroxychloroquine Sulfate
Gralise................................... 112 Humalog Mix 75/25 KwikPen ............................................... 78
............................................... 94
Gralise Starter.......................112 Hydroxyurea............................75
Humatrope............................ 135
Granisetron HCl...................... 68 Hydroxyzine HCl..................... 90
Humira...................................145
Granix...................................... 98 Hydroxyzine Pamoate............ 67
Humira Pediatric Crohns Start
Griseofulvin Microsize............70 Hysingla ER.............................42
.............................................145
Griseofulvin Ultramicrosize....70 Hyzaar................................... 105
Humira Pen........................... 145
Guanidine HCl........................ 73 I
Humira Pen Crohns Disease
Gynazole-1.............................. 70 Starter................................. 145 Ibandronate Sodium............ 151
H Humira Pen Psoriasis Starter Ibrance.................................... 76
Haegarda.............................. 144 .............................................145 Ibu............................................ 39
Hailey 24 Fe.......................... 138 Humulin 70/30........................95 Ibuprofen.................................40
Haldol...................................... 81 Humulin 70/30 KwikPen........ 95 Iclusig...................................... 76
Haldol Decanoate...................81 Humulin N............................... 95 IDHIFA..................................... 76
Halobetasol Propionate....... 132 Humulin N KwikPen............... 95 Ilevro...................................... 155
Halog..................................... 132 Humulin R............................... 95 Ilumya.................................... 116
Haloperidol..............................81 Humulin R U-500.................... 95 Imatinib Mesylate....................76
 23
Tracked 23 23

Imbruvica.................................77 Invega Sustenna..................... 82 J

Imipenem-Cilastatin................53 Invega Trinza...........................83 Jadenu...................................122
Imipramine HCl.......................67 Inveltys.................................. 155 Jadenu Sprinkle....................122
Imipramine Pamoate.............. 67 Invirase.................................... 89 Jakafi....................................... 77
Imiquimod............................. 117 Invokamet................................92 Jalyn...................................... 128
Imiquimod Pump..................117 Invokamet XR..........................92 Jantoven..................................96
Imitrex......................................72 Invokana.................................. 92 Janumet...................................92
Imitrex STATdose Refill......... 72 Ionosol-MB in D5W...............119 Janumet XR.............................92
Imitrex STATdose System..... 72 Iopidine................................. 154 Januvia.................................... 92
Imovax Rabies...................... 149 IPOL.......................................149 Jardiance.................................92
Impoyz...................................132 Ipratropium Bromide............158 Jasmiel.................................. 138
Imuran................................... 145 Ipratropium-Albuterol........... 163 Jentadueto.............................. 92
Imvexxy Maintenance Pack Irbesartan.............................. 100 Jentadueto XR........................ 92
.............................................138 Irbesartan-Hydrochlorothiazide Jinteli..................................... 138
Imvexxy Starter Pack............138 .............................................105 Jolivette................................. 141
Inbrija.......................................79 Iressa....................................... 77 Jublia....................................... 70
Incassia................................. 141 Isentress.................................. 87 Juleber...................................138
Increlex..................................135 Isentress HD............................87 Juluca...................................... 87
Incruse Ellipta....................... 158 Isibloom.................................138 Junel 1.5/30..........................138
Indapamide........................... 107 Isolyte-P in D5W....................119 Junel 1/20............................. 138
Inderal LA..............................101 Isolyte-S................................. 119 Junel Fe 1.5/30.....................138
Infanrix...................................149 Isoniazid.................................. 74 Junel Fe 1/20........................138
Ingrezza.................................112 Isopto Carpine...................... 154 Junel Fe 24........................... 138
Inlyta........................................ 77 Isordil Titradose....................109 Juxtapid.................................108
InnoPran XL.......................... 101 Isosorbide Dinitrate.............. 109 Jynarque............................... 122
Inspra.....................................107 Isosorbide Dinitrate ER........ 109 K
Insulin Syringes, Needles.... 152 Isosorbide Mononitrate........109 K-Tab..................................... 120
Intelence..................................87 Isosorbide Mononitrate ER Kadian..................................... 42
Intralipid................................ 119 .............................................109
Kaitlib Fe............................... 139
Intrarosa................................ 136 Isotretinoin............................ 117 Kaletra..................................... 89
Intron A....................................86 Isradipine.............................. 103 Kalydeco............................... 163
Introvale.................................138 Istalol..................................... 154 Kapvay...................................111
Invanz...................................... 53 Itraconazole.............................70 Kariva.....................................139
Invega...................................... 82 Ivermectin................................78 Kazano.....................................92
Ixiaro...................................... 149
24 24
Tracked 24

KCl in Dextrose-NaCl............119 Kurvelo.................................. 139 Latuda......................................83

KCl-Lactated Ringers-D5W Kuvan.....................................126 Layolis Fe.............................. 139
.............................................120 L Lazanda...................................45
Kelnor 1/35........................... 139 Labetalol HCl........................ 101 Ledipasvir-Sofosbuvir.............86
Kelnor 1/50........................... 139 Lacrisert................................ 152 Leena.....................................139
Kenalog................................. 132 Lactulose...............................124 Leflunomide..........................148
Keppra.....................................59 Lamictal...................................61 Lenvima 10MG Daily Dose.... 77
Keppra XR...............................59 Lamictal ODT.......................... 61 Lenvima 12MG Daily Dose.... 77
Kerydin.................................... 70 Lamictal Starter...................... 61 Lenvima 14MG Daily Dose.... 77
Ketoconazole.......................... 70 Lamictal XR.............................61 Lenvima 18MG Daily Dose.... 77
Ketoprofen.............................. 40 Lamivudine....................... 85, 88 Lenvima 20MG Daily Dose.... 77
Ketoprofen ER........................ 40 Lamivudine-Zidovudine..........88 Lenvima 24MG Daily Dose.... 77
Ketorolac Tromethamine..... 155 Lamotrigine............................. 62 Lenvima 4MG Daily Dose...... 77
Keveyis.................................. 106 Lamotrigine ER....................... 62 Lenvima 8MG Daily Dose...... 77
Kevzara..................................148 Lamotrigine ODT.................... 62 Lescol XL.............................. 108
Khedezla..................................66 Lamotrigine Starter Kit-Blue Lessina.................................. 139
Kineret................................... 145 ............................................... 62 Letairis...................................161
Kinrix......................................149 Lamotrigine Starter Kit-Green Letrozole..................................76
Kionex....................................122 ............................................... 62
Leucovorin Calcium............... 75
Kisqali...................................... 75 Lamotrigine Starter Kit-Orange
Leukeran................................. 74
............................................... 62
Kisqali Femara........................ 75 Leukine....................................98
Lanoxin..................................105
Klaron.................................... 117 Leuprolide Acetate...............143
Lansoprazole........................ 125
Klonopin.................................. 90 Levalbuterol HCl.......... 159, 160
Lansoprazole ODT............... 125
Klor-Con................................ 120 Levalbuterol Tartrate............ 160
Lanthanum Carbonate......... 122
Klor-Con 10........................... 120 Levemir....................................95
Lantus......................................95
Klor-Con 8............................. 120 Levemir FlexTouch................. 95
Lantus SoloStar...................... 95
Klor-Con M10........................120 Levetiracetam................... 59, 60
LARIN 1.5/30........................139
Klor-Con M15........................120 Levetiracetam ER................... 59
LARIN 1/20........................... 139
Klor-Con M20........................120 Levo-T....................................142
LARIN Fe 1.5/30...................139
Klor-Con Sprinkle................. 120 Levobunolol HCl...................154
LARIN Fe 1/20......................139
Kombiglyze XR....................... 92 Levocarnitine........................ 120
Larissia.................................. 139
Korlym................................... 136 Levocetirizine Dihydrochloride
Lasix...................................... 106
Krintafel................................... 78 .............................................157
Lastacaft................................152
Kristalose.............................. 124 Levofloxacin............................ 57
Latanoprost...........................156
 25
Tracked 25 25

Levofloxacin in D5W...............57 Livalo..................................... 108 Lotrisone............................... 117

Levonest................................139 Lo Loestrin Fe.......................139 Lotronex................................ 124
Levonorgestrel-Ethinyl Estradiol Locoid................................... 132 Lovastatin..............................108
.............................................139 Locoid Lipocream................ 132 Lovaza................................... 108
Levonorgestrel-Ethinyl Estradiol Lodine......................................40 Lovenox...................................97
& Ethinyl Estradiol.............. 139
Lodosyn...................................80 Low-Ogestrel.........................139
Levonorgestrel-Ethinyl Estradiol
Loestrin 1.5/30..................... 139 Loxapine Succinate................81
91-Day................................. 139
Loestrin 1/20........................ 139 Lucemyra.............................. 152
Levora 0.15/30..................... 139
Loestrin Fe 1.5/30................ 139 Luliconazole............................70
Levorphanol Tartrate..............42
Loestrin Fe 1/20................... 139 Lumigan................................ 156
Levothyroxine Sodium......... 142
Lokelma.................................122 Lupaneta Pack......................143
Levoxyl.................................. 142
Lomotil.................................. 123 Lupron Depot........................143
Lexapro................................... 66
Lonhala Magnair Refill Kit....158 Lutera.................................... 139
Lexette...................................132
Lonsurf.................................... 75 Luxiq......................................132
Lexiva.......................................89
Loperamide HCl................... 123 Luzu......................................... 70
Lialda..................................... 150
Lopid..................................... 107 Lynparza..................................77
Lidocaine.................................47
Lopinavir-Ritonavir..................89 Lyrica..................................... 112
Lidocaine HCl......................... 47
Lopressor.............................. 102 Lyrica CR...............................112
Lidocaine Viscous.................. 47
Lopressor HCT..................... 105 Lysodren............................... 143
Lidocaine-Prilocaine...............47
Loprox..................................... 70 Lysteda.................................... 99
Lidoderm.................................47
Lorazepam.............................. 90 Lyza....................................... 142
Lindane....................................79
Linezolid.................................. 50
Lorbrena..................................75 M
Lorcet...................................... 45 M-M-R II................................. 149
Linzess.................................. 124
Lorcet HD................................ 45 Macrobid................................. 50
Liothyronine Sodium............142
Lorcet Plus.............................. 45 Macrodantin............................50
Lipitor.................................... 108
Loryna................................... 139 Mafenide Acetate................... 50
Lipofen.................................. 107
Losartan Potassium............. 100 Magnesium Sulfate.............. 120
Lisinopril................................100
Losartan Potassium-HCTZ...105 Malarone................................. 78
Lisinopril-Hydrochlorothiazide
.............................................105 LoSeasonique.......................139 Malathion.................................79
Lithium.....................................91 Lotemax................................ 155 Maprotiline HCl.......................66
Lithium Carbonate..................91 Lotemax SM..........................155 Marinol.....................................68
Lithium Carbonate ER............91 Lotensin.................................100 Marlissa................................. 139
Lithobid................................... 91 Loteprednol Etabonate........ 156 Marplan................................... 65
Lithostat................................ 129 Lotrel..................................... 105 Matulane..................................74
26 26
Tracked 26

Matzim LA............................. 103 Mesalamine...........................150 Metoprolol-Hydrochlorothiazide

Mavenclad.............................113 Mesnex.................................... 78 .............................................105
Mavyret....................................86 Mestinon..................................73 MetroCream............................ 50
Maxalt...................................... 72 Metadate ER......................... 111 Metrogel.................................. 50
Maxalt-MLT............................. 72 Metaproterenol Sulfate........ 160 MetroGel-Vaginal.................... 50
Maxidex.................................156 Metformin HCl.........................93 MetroLotion.............................50
Maxipime.................................53 Metformin HCl ER............ 92, 93 Metronidazole......................... 50
Maxitrol..................................152 Methadone HCl.......................42 Metronidazole in NaCl 0.79%
............................................... 50
Maxzide................................. 105 Methamphetamine HCl........110
Mexiletine HCl.......................101
Maxzide-25............................105 Methazolamide..................... 106
Mibelas 24 Fe....................... 139
Mayzent.................................113 Methenamine Hippurate........ 50
Micardis.................................100
Meclizine HCl.......................... 67 Methimazole......................... 144
Micardis HCT........................105
Meclofenamate Sodium.........40 Methitest............................... 136
Miconazole 3...........................70
Medrol................................... 132 Methotrexate.........................145
MiCort-HC............................. 132
Medroxyprogesterone Acetate Methotrexate Sodium...........145
.............................................142 Methoxsalen Rapid.............. 117 Microgestin 1.5/30............... 139
Mefenamic Acid......................40 Methscopolamine Bromide Microgestin 1/20.................. 139
Mefloquine HCl.......................78 .............................................123 Microgestin Fe 1.5/30..........139
Megestrol Acetate................ 142 Methyclothiazide.................. 107 Microgestin Fe 1/20.............139
Mekinist................................... 77 Methyldopa............................. 99 Midodrine HCl.........................99
Mektovi.................................... 77 Methylin.................................111 Migergot.................................. 72
Melodetta 24 Fe....................139 Methylphenidate HCl........... 111 Miglitol..................................... 93
Meloxicam...............................40 Methylphenidate HCl CD..... 111 Miglustat................................126
Memantine HCl.......................64 Methylphenidate HCl ER..... 111 Migranal.................................. 72
Memantine HCl ER.................64 Methylphenidate HCl ER Mili......................................... 139
Memantine HCl Titration Pak Osmotic Release................111 Millipred................................ 133
............................................... 64 Methylphenidate HCl LA......111 Minastrin 24 Fe..................... 139
Menactra............................... 149 Methylprednisolone............. 132 Minipress...............................100
Menest...................................139 Methyltestosterone...............136 Minitran................................. 109
Mentax.....................................70 Metoclopramide HCl.............. 68 Minivelle................................ 139
Menveo..................................149 Metoclopramide HCl ODT..... 68 Minocin....................................59
Mepron.................................... 78 Metolazone........................... 107 Minocycline HCl......................59
Mercaptopurine...................... 75 Metoprolol Succinate ER.....102 Minocycline HCl ER................59
Meropenem.............................53 Metoprolol Tartrate.............. 102 Minoxidil................................109
Merrem.................................... 53 Mirapex....................................79
 27
Tracked 27 27

Mirapex ER..............................79 Mycamine................................70 Nasonex................................ 158

Mirtazapine............................. 65 Mycobutin............................... 74 Natacyn................................... 70
Mirtazapine ODT.....................65 Mycophenolate Mofetil........ 145 Natazia...................................140
Mirvaso..................................117 Mycophenolate Sodium.......146 Nateglinide.............................. 93
Misoprostol........................... 125 Mydayis................................. 110 Natpara..................................151
Mitigare................................... 71 Myfortic................................. 146 Natroba....................................79
Mobic.......................................40 Myorisan................................117 Nebupent................................ 78
Modafinil............................... 164 Myrbetriq...............................128 Necon 0.5/35........................140
Moexipril HCl........................ 100 Mysoline.................................. 60 Nefazodone HCl..................... 66
Molindone HCl........................81 Mytesi.................................... 123 Neo-Synalar...........................117
Mometasone Furoate..........133, N Neomycin Sulfate................... 48
157 Nabumetone........................... 40 Neomycin-Bacitracin-Polymyxin
Mondoxyne NL....................... 59 Nadolol.................................. 102 .............................................152
MonoNessa...........................140 Nadolol-Bendroflumethiazide Neomycin-Polymyxin-
Montelukast Sodium............ 158 .............................................105 Bacitracin-Hydrocortisone
.............................................152
Monurol................................... 50 Nafcillin Sodium..................... 54
Neomycin-Polymyxin-
Morgidox................................. 59 Naftifine HCl............................70
Dexamethasone................. 153
MorphaBond ER.....................42 Naftin....................................... 70
Neomycin-Polymyxin-
Morphine Sulfate.................... 45 Nalfon...................................... 40 Gramicidin.......................... 153
Morphine Sulfate ER........42, 43 Naloxone HCl..........................48 Neomycin-Polymyxin-HC.... 153,
Morphine Sulfate ER Beads Naltrexone HCl....................... 47 156
............................................... 42 Namenda.................................64 Neoral.................................... 146
Motegrity............................... 123 Namenda Titration Pak.......... 64 NephrAmine..........................120
Movantik................................123 Namenda XR...........................64 Nerlynx.................................... 77
MoviPrep............................... 124 Namenda XR Titration Pack Nesina......................................93
Moxeza.................................... 57
............................................... 64 Neuac.................................... 117
Moxifloxacin HCl.....................57 Namzaric............................... 112 Neulasta.................................. 98
Moxifloxacin HCl in NaCl....... 57 Naprelan..................................40 Neupogen............................... 98
MS Contin............................... 43 Naproxen.................................40 Neupro.....................................80
Mulpleta...................................98 Naproxen DR.......................... 40 Neurontin................................ 60
Multaq................................... 101 Naproxen Sodium.................. 40 Nevanac................................ 156
Mupirocin................................ 50 Naproxen Sodium ER............ 40 Nevirapine............................... 87
Mupirocin Calcium................. 50 Naratriptan HCl....................... 72 Nevirapine ER......................... 87
Myalept..................................123 Narcan..................................... 48 Nexavar................................... 77
Myambutol.............................. 74 Nardil....................................... 65 Nexium.................................. 125
28 28
Tracked 28

Niacin ER.............................. 108 Norethindrone Acetate-Ethinyl Nuzyra..................................... 59

Niacor.................................... 108 Estradiol..............................140 Nyamyc....................................70
Niaspan................................. 109 Norethindrone Acetate-Ethinyl Nymalize................................103
Estradiol-Fe.........................140
Nicardipine HCl.................... 103 Nystatin............................. 70, 71
Norgestimate-Ethinyl Estradiol
Nicotrol.................................... 48 Nystatin-Triamcinolone.......... 71
.............................................140
Nicotrol NS..............................48 Nystop..................................... 71
Norgestimate-Ethinyl Estradiol
Nifedipine ER........................103 Triphasic............................. 140 O
Nifedipine ER Osmotic Release Noritate....................................51 Ocaliva...................................126
.............................................103
Norlyroc.................................142 Ocella.................................... 140
Nikki.......................................140
Normosol-M in D5W............. 120 Octagam................................147
Nilandron.................................74
Normosol-R in D5W..............120 Octreotide Acetate............... 143
Nilutamide............................... 74
Normosol-R pH 7.4...............120 Ocuflox.................................... 57
Nimodipine............................103
Norpramin............................... 67 Odefsey................................... 87
Ninlaro..................................... 75
Northera.................................. 99 Odomzo...................................77
Nisoldipine ER...................... 103
Nortrel 0.5/35....................... 140 Ofev....................................... 162
Nitro-Bid................................ 109
Nortrel 1/35.......................... 140 Ofloxacin................................. 57
Nitro-Dur................................109
Nortrel 7/7/7.........................140 Ogestrel.................................140
Nitrofurantoin..........................51
Nortriptyline HCl..................... 67 Olanzapine.............................. 83
Nitrofurantoin Macrocrystal
Norvasc................................. 103 Olanzapine ODT..................... 83
.........................................50, 51
Norvir....................................... 89 Olanzapine-Fluoxetine HCl.... 65
Nitrofurantoin Monohydrate
Olmesartan Medoxomil........100
............................................... 51 Noxafil......................................70
Olmesartan Medoxomil-HCTZ
Nitroglycerin..........................109 Nucala................................... 163
.............................................105
Nitrostat.................................109 Nucynta............................. 45, 46
Olmesartan-Amlodipine-HCTZ
Nityr....................................... 126 Nucynta ER............................. 43 .............................................105
Nivestym..................................98 Nuedexta...............................112 Olopatadine HCl...........153, 157
Nizatidine.............................. 124 NuLYTELY with Flavor Packs Olumiant................................146
.............................................125
Nizoral..................................... 70 Olux....................................... 133
Nuplazid.................................. 83
Nocdurna.............................. 135 Olux-E.................................... 133
Nutrilipid................................120
Nolix.......................................133 Omeclamox-Pak................... 123
Nutropin AQ NuSpin 10....... 135
Nora-BE................................. 142 Omega-3-Acid Ethyl Esters
Nutropin AQ NuSpin 20....... 135
Norco.......................................45 .............................................109
Nutropin AQ NuSpin 5......... 135
Norditropin FlexPro.............. 135 Omeprazole.................. 125, 126
NuvaRing.............................. 140
Norethindrone...................... 142 Omnaris.................................158
Nuvigil....................................164
Norethindrone Acetate........ 142 Omnipred.............................. 156
 29
Tracked 29 29

Omnitrope............................. 135 Oxandrolone......................... 136 Parnate.................................... 65

Ondansetron HCl....................68 Oxaprozin................................ 40 Paromomycin Sulfate.............49
Ondansetron ODT.................. 68 Oxazepam............................... 90 Paroxetine HCl........................66
Onexton.................................117 Oxcarbazepine........................63 Paser........................................74
Onfi.......................................... 60 Oxervate................................ 153 Pataday................................. 153
Onglyza................................... 93 Oxiconazole Nitrate................ 71 Patanase............................... 157
Onzetra Xsail........................... 72 Oxistat......................................71 Patanol.................................. 154
Opana......................................46 Oxsoralen Ultra.....................117 Paxil......................................... 66
Opsumit.................................161 Oxtellar XR.............................. 63 Pazeo.....................................154
Oracea..................................... 59 Oxybutynin Chloride............ 128 Pediarix................................. 149
Oralair 300IR.........................163 Oxybutynin Chloride ER...... 128 Pedvax HIB........................... 149
Orapred ODT........................ 133 Oxycodone HCl...................... 46 PEG-3350-Electrolytes......... 125
Oravig...................................... 71 Oxycodone HCl ER................ 43 PEG-3350-NaCl-Na
Orencia..................................146 Oxycodone-Acetaminophen Bicarbonate-KCl................. 125
Orencia ClickJect................. 146 ............................................... 46 Peganone................................ 63
Orenitram.............................. 161 Oxycodone-Aspirin................. 46 Pegasys................................... 86
Orfadin.................................. 126 Oxycodone-Ibuprofen............ 46 Pegasys ProClick....................86
Orilissa...................................143 OxyContin............................... 43 Penicillamine.........................129
Orkambi................................ 160 Oxymorphone HCl..................46 Penicillin G Potassium........... 55
Orsythia................................. 140 Oxymorphone HCl ER............43 Penicillin G Potassium in
Dextrose................................55
Ortho Micronor..................... 142 Oxytrol................................... 128
Penicillin G Procaine.............. 55
Ortho Tri-Cyclen Lo.............. 140 Ozempic.................................. 93
P Penicillin G Sodium................ 55
Ortho-Novum 1/35............... 140
Penicillin V Potassium............55
Ortho-Novum 7/7/7..............140 Pacerone...............................101
Pennsaid................................. 40
Oseltamivir Phosphate........... 89 Paliperidone ER......................83
PENTAM 300.......................... 78
Oseni....................................... 93 Palynziq................................. 126
Pentasa................................. 150
Osmolex ER............................ 79 Pamelor................................... 67
Pentoxifylline ER...................105
OsmoPrep.............................125 Pancreaze............................. 127
Pepcid................................... 124
Osphena................................142 Pandel................................... 133
Percocet.................................. 46
Otezla.................................... 148 Panretin................................... 78
Perforomist........................... 160
Otovel.................................... 156 Pantoprazole Sodium...........126
Perindopril Erbumine........... 100
Otrexup................................. 146 Panzyga.................................147
Permethrin...............................79
Ovide....................................... 79 Paricalcitol.................... 151, 152
Perphenazine..........................68
Oxacillin Sodium.....................55 Parlodel................................... 80
Perseris....................................83
30 30
Tracked 30

Pertzye...................................127 Pliaglis..................................... 47 Prednisolone Acetate...........156

Phenadoz.............................. 157 Podofilox............................... 117 Prednisolone Sodium
Phenelzine Sulfate..................65 Polymyxin B Sulfate................51 Phosphate.................. 133, 156
Phenobarbital................... 60, 61 Polymyxin B-Trimethoprim Prednisolone Sodium
Phosphate ODT..................133
Phenoxybenzamine HCl...... 100 .............................................153
Prednisone............................133
Phenytek................................. 63 Polytrim................................. 153
Prednisone Intensol............. 133
Phenytoin................................ 63 Pomalyst..................................75
Phenytoin Sodium Extended Portia-28................................ 140 Premarin................................140
............................................... 63 Potassium Chloride..............121 Premasol............................... 121
Phoslyra................................ 122 Potassium Chloride CR....... 120 Prepopik................................125
Phospholine Iodide.............. 154 Potassium Chloride ER........120 Prevacid................................ 126
Picato.................................... 117 Potassium Chloride in Dextrose Prevacid SoluTab................. 126
Pifeltro..................................... 87 .............................................120 Prevalite.................................109
Pilocarpine HCl............ 114, 154 Potassium Chloride in NaCl Previfem................................ 140
.............................................120 Prevymis..................................85
Pimecrolimus........................ 117
Potassium Citrate ER........... 121 Prezcobix................................ 89
Pimozide..................................81
Pradaxa................................... 97 Prezista....................................89
Pimtrea.................................. 140
Praluent................................. 109 Priftin....................................... 74
Pindolol................................. 102
Pramipexole Dihydrochloride Prilosec..................................126
Pioglitazone HCl..................... 93
............................................... 80
Pioglitazone HCl-Glimepiride Primaquine Phosphate...........79
Pramipexole Dihydrochloride
............................................... 93 Primaxin IV.............................. 53
ER..........................................80
Pioglitazone HCl-Metformin HCl Primidone................................61
Prandin.................................... 93
............................................... 93 Primlev.....................................46
Prasugrel HCl..........................99
Piperacillin-Tazobactam.........55 Prinivil.................................... 100
Pravachol.............................. 108
Piqray................................ 75, 76 Pristiq.......................................66
Pravastatin Sodium.............. 108
Pirmella 1/35........................ 140 Privigen................................. 147
Praziquantel............................ 78
Piroxicam................................ 40 ProAir HFA............................ 160
Prazosin HCl......................... 100
Plaquenil..................................79 ProAir RespiClick................. 160
Precose................................... 93
Plasma-Lyte 148................... 120 Probenecid..............................71
Pred Forte............................. 156
Plasma-Lyte A....................... 120 Probenecid-Colchicine...........71
Pred Mild...............................156
Plavix....................................... 99 Procalamine..........................121
Pred-G................................... 153
Plegridy................................. 113 Procardia XL......................... 103
Pred-G S.O.P.........................153
Plegridy Starter Pack........... 113 ProCentra..............................110
Prednicarbate....................... 133
Plenamine............................. 120 Prochlorperazine.................... 68
Prednisolone.........................133
Plenvu....................................125 Prochlorperazine Maleate......68
 31
Tracked 31 31

Procrit...................................... 98 Pulmicort...............................158 Rabeprazole Sodium........... 126

Procto-Med HC..................... 151 Pulmicort Flexhaler.............. 158 Raloxifene HCl......................142
Procto-Pak.............................151 Pulmozyme........................... 163 Ramipril................................. 100
Proctosol HC.........................151 Purixan.................................... 75 Ranexa.................................. 105
Proctozone-HC..................... 151 Pylera.....................................123 Ranitidine HCl.......................124
Progesterone Micronized.... 142 Pyrazinamide.......................... 74 Ranolazine ER...................... 105
Proglycem............................... 94 Pyridostigmine Bromide....... 73, Rapaflo.................................. 128
Prograf...................................146 74 Rapamune............................ 146
Prolastin-C.............................127 Pyridostigmine Bromide ER Rasagiline Mesylate............... 81
............................................... 73
Prolensa................................ 156 Rasuvo.................................. 146
Q
Prolia..................................... 152 RAVICTI.................................127
Qbrelis................................... 100
Promacta.................................98 Rayaldee............................... 152
Qmiiz ODT...............................40
Promethazine HCl................ 157 Rayos.....................................133
Qnasl..................................... 158
Prometrium........................... 142 Razadyne................................ 64
Qnasl Childrens.................... 158
Propafenone HCl..................101 Razadyne ER.......................... 64
Qtern........................................93
Propafenone HCl ER............101 Rebetol.................................... 86
Quadracel............................. 149
Propantheline Bromide........123 Rebif...................................... 114
Qualaquin................................79
Proparacaine HCl................. 153 Rebif Rebidose.....................113
Quartette............................... 140
Propranolol HCl.................... 102 Rebif Rebidose Titration Pack
Qudexy XR.............................. 62 .............................................114
Propranolol HCl ER.............. 102
Questran................................109 Rebif Titration Pack..............114
Propranolol-HCTZ................ 105
Questran Light...................... 109 Reclipsen.............................. 140
Propylthiouracil.....................144
Quetiapine Fumarate..............83 Recombivax HB....................149
ProQuad................................ 149
Quetiapine Fumarate ER........83 Rectiv.....................................110
Proscar.................................. 128
QuilliChew ER.......................111 Reglan..................................... 68
Prosol.................................... 121
Quillivant XR......................... 112 Regranex...............................117
Protonix................................. 126
Quinapril HCl........................ 100 Relenza Diskhaler...................89
Protopic.................................117
Quinapril-Hydrochlorothiazide Relexxii.................................. 112
Protriptyline HCl......................67
.............................................105
Proventil HFA........................ 160 Relistor.................................. 123
Quinidine Gluconate ER...... 101
Provera.................................. 142 Relpax......................................72
Quinidine Sulfate.................. 101
Provigil...................................164 Remeron..................................65
Quinine Sulfate....................... 79
Prozac......................................66 Remeron SolTab.................... 65
QVAR RediHaler...................158
PRUDOXIN............................117 Renagel................................. 122
R
Psorcon................................. 133 Renvela................................. 122
RabAvert............................... 149
32 32
Tracked 32

Repaglinide.............................93 Risedronate Sodium............ 152 Saizenprep............................136

Repaglinide-Metformin HCl... 93 Risperdal................................. 83 Salagen................................. 114
Repatha.................................109 Risperdal Consta.................... 83 Samsca..................................122
Repatha Pushtronex System Risperidone.............................83 Sancuso.................................. 68
.............................................109 Risperidone ODT....................84 Sandimmune........................ 146
Repatha SureClick............... 109 Ritalin.....................................112 Sandostatin........................... 143
Requip XL............................... 80 Ritalin LA...............................112 Santyl.....................................117
Rescriptor................................87 Ritonavir.................................. 89 Saphris.................................... 84
Restasis.................................153 Rivastigmine........................... 64 Sarafem................................... 66
Restoril.................................. 164 Rivastigmine Tartrate............. 64 Savaysa................................... 97
Retacrit.................................... 99 Rivelsa................................... 140 Savella................................... 112
Retin-A...................................117 Rizatriptan Benzoate.............. 72 Savella Titration Pack...........112
Retin-A Micro........................ 117 Rizatriptan Benzoate ODT..... 73 Scopolamine........................... 68
Retin-A Micro Pump............. 117 Rocaltrol................................152 Seasonique........................... 140
Retrovir.................................... 88 Rocklatan.............................. 154 Seebri Neohaler....................158
Revatio.................................. 161 Ropinirole HCl........................ 80 Segluromet..............................93
Revlimid...................................75 Ropinirole HCl ER.................. 80 Selegiline HCl......................... 81
Rexulti......................................83 Rosuvastatin Calcium.......... 108 Selenium Sulfide.................. 117
Reyataz....................................89 Rotarix................................... 149 Selzentry..................................89
Rhofade.................................117 RotaTeq.................................149 Semprex-D............................ 163
Rhopressa.............................153 Rowasa..................................150 Sensipar................................ 152
Ribasphere..............................86 Roweepra................................ 60 Serevent Diskus....................160
Ribasphere RibaPak.............. 86 Roweepra XR..........................60 Seroquel.................................. 84
Ribavirin.................................. 86 Roxicodone.............................46 Seroquel XR............................ 84
Ridaura..................................148 Rozerem................................164 Serostim................................ 123
Rifabutin.................................. 74 Rubraca...................................76 Sertraline HCl..........................66
Rifadin..................................... 74 Ruconest...............................144 Setlakin..................................140
Rifamate.................................. 74 Rydapt..................................... 77 Sevelamer Carbonate.......... 122
Rifampin.................................. 74 Rytary.......................................80 Sevelamer HCl...................... 122
Rifater...................................... 74 Rythmol SR........................... 101 Sharobel................................142
Rilutek................................... 112 S Shingrix................................. 149
Riluzole..................................112 Sabril........................................61 Signifor.................................. 143
Rimantadine HCl.................... 90 Safyral....................................140 Sildenafil Citrate................... 161
Riomet..................................... 93 Saizen....................................135 Silenor................................... 164
 33
Tracked 33 33

Siliq........................................117 Sotylize.................................. 101 Subsys..................................... 46

Silodosin............................... 128 Sovaldi.....................................86 Sucraid.................................. 127
Silvadene.................................57 Spiriva HandiHaler............... 158 Sucralfate.............................. 125
Silver Sulfadiazine.................. 58 Spiriva Respimat.................. 158 Sular...................................... 103
Simbrinza.............................. 154 Spironolactone..................... 107 Sulfacetamide Sodium..........58,
Simponi................................. 146 Spironolactone-HCTZ.......... 106 117
Simvastatin............................108 Sporanox.................................71 Sulfacetamide-Prednisolone
.............................................153
Sinemet................................... 80 Sprintec 28............................141
Sulfadiazine.............................58
Sinemet CR.............................80 Spritam.................................... 60
Sulfamethoxazole-
Singulair................................ 158 Sprycel.....................................77
Trimethoprim........................58
Sirolimus............................... 146 SPS........................................ 122
Sulfamylon.............................. 51
Sirturo...................................... 74 Sronyx................................... 141
Sulfasalazine.........................151
Sivextro....................................51 SSD..........................................58
Sulindac.................................. 40
Sklice....................................... 78 Stalevo 100............................. 81
Sumatriptan.............................73
Sodium Chloride.................. 121 Stalevo 125............................. 81
Sumatriptan Succinate...........73
Sodium Fluoride................... 121 Stalevo 150............................. 81
Sumatriptan Succinate Refill
Sodium Lactate.................... 121 Stalevo 200............................. 81 ............................................... 73
Sodium Phenylbutyrate........127 Stalevo 50................................81 Suprax..................................... 53
Sodium Polystyrene Sulfonate Stalevo 75................................81 Suprep Bowel Prep Kit.........125
.............................................122 Starlix.......................................93
Surmontil................................. 67
Sofosbuvir-Velpatasvir............86 Stavudine................................ 88
Sustiva..................................... 87
Solifenacin Succinate.......... 128 Steglatro.................................. 93
Sutent...................................... 77
Soliqua.................................... 93 Steglujan................................. 93
Syeda.....................................141
Solodyn................................... 59 Stelara................................... 117
Sylatron................................... 86
Solosec....................................51 Stimate.................................. 136
Symbicort..............................163
Soloxide...................................59 Stiolto Respimat................... 163
Symbyax..................................65
Soltamox................................. 75 Stivarga....................................77
Symdeko............................... 160
Somatuline Depot.................144 Strattera.................................112
Symfi........................................88
Somavert............................... 144 Streptomycin Sulfate..............49
Symfi Lo.................................. 87
Soolantra...............................117 Striant.................................... 136
SymlinPen 120........................93
Soriatane............................... 117 Stribild..................................... 87
SymlinPen 60.......................... 93
Sorilux................................... 117 Striverdi Respimat................ 160
Sympazan................................61
Sorine.................................... 101 Stromectol...............................78
Symproic............................... 123
Sotalol HCl............................ 101 Suboxone................................ 47
Symtuza...................................89
34 34
Tracked 34

Synalar...................................133 Tazarotene............................ 118 Thalomid................................. 75

Synarel.................................. 144 Tazicef..................................... 53 Theo-24................................. 161
Syndros................................... 68 Tazorac..................................118 Theophylline......................... 161
Synjardy...................................93 Taztia XT............................... 103 Theophylline ER................... 161
Synjardy XR.............................93 TDVAX................................... 149 Thiola.....................................129
Synribo.................................... 76 Tecfidera............................... 114 Thioridazine HCl..................... 81
Synthroid...............................142 Tecfidera Starter Pack......... 114 Thiothixene............................. 81
Syprine.................................. 122 Teflaro..................................... 53 Thyrolar-1.............................. 142
T Tegretol................................... 63 Thyrolar-1/2.......................... 142
Tabloid.....................................75 Tegretol XR............................. 64 Thyrolar-1/4.......................... 142
Taclonex................................118 Tegsedi..................................127 Thyrolar-2.............................. 142
Tacrolimus....................118, 146 Tekturna................................ 106 Thyrolar-3.............................. 142
Tadalafil........................ 129, 161 Tekturna HCT....................... 106 Tiagabine HCl......................... 61
Tafinlar.....................................77 Telmisartan........................... 100 Tiazac.................................... 103
Tagrisso...................................77 Telmisartan-Amlodipine....... 106 Tibsovo....................................77
Takhzyro................................144 Telmisartan-HCTZ................ 106 Tigan........................................68
Taltz....................................... 118 Temazepam.......................... 164 Tigecycline.............................. 51
Talzenna.................................. 76 Tenivac.................................. 149 Tiglutik...................................112
Tamiflu.....................................90 Tenofovir Disoproxil Fumarate Tikosyn.................................. 101
Tamoxifen Citrate................... 75 ............................................... 88 Timolol Maleate..............72, 155
Tamsulosin HCl.................... 129 Tenoretic 100........................106 Timolol Maleate Ophthalmic
Tapazole................................144 Tenoretic 50..........................106 Gel Forming........................154
TaperDex 12-Day..................133 Tenormin...............................102 Timoptic Ocudose................155
TaperDex 6-Day.................... 133 Terazosin HCl....................... 129 Timoptic-XE...........................155
TaperDex 7-Day.................... 133 Terbinafine HCl.......................71 Tinidazole................................51
Tarceva....................................77 Terbutaline Sulfate............... 160 Tirosint.................................. 142
TARGADOX............................ 59 Terconazole............................ 71 Tirosint-SOL.......................... 142
Targretin.................................. 78 Testim....................................136 Tivicay......................................87
Tarina 24 Fe.......................... 141 Testosterone.........................137 Tizanidine HCl...................... 163
Tarina Fe 1/20...................... 141 Testosterone Cypionate.......137 TOBI...................................... 161
Tarka......................................106 Testosterone Enanthate.......137 TOBI Podhaler...................... 161
Tasigna....................................77 Tetrabenazine.......................112 TobraDex.............................. 153
Tasmar.....................................79 Tetracycline HCl..................... 59 TobraDex ST.........................153
Tavalisse..................................99 Texacort................................ 133 Tobramycin.....................49, 161
 35
Tracked 35 35

Tobramycin Sulfate................ 49 Transderm-Scop..................... 68 Trifluoperazine HCl.................81

Tobramycin-Dexamethasone Tranxene-T.............................. 90 Trifluridine............................... 86
.............................................153 Tranylcypromine Sulfate........ 65 Triglide.................................. 107
Tobrex..................................... 49 Travasol.................................121 Trihexyphenidyl HCl............... 79
Tofranil.................................... 67 Travatan Z............................. 156 Trileptal....................................64
Tolak......................................118 Trazodone HCl........................67 Trilipix.................................... 107
Tolazamide..............................93 Trecator................................... 74 TriLyte....................................125
Tolbutamide............................93 Trelegy Ellipta....................... 163 Trimethobenzamide HCl........68
Tolcapone............................... 79 Trelstar Mixject..................... 144 Trimethoprim.......................... 51
Tolmetin Sodium.................... 40 Tremfya................................. 118 Trimipramine Maleate............ 67
Tolsura.....................................71 Tresiba.....................................95 Trintellix................................... 67
Tolterodine Tartrate............. 128 Tresiba FlexTouch..................95 Triumeq................................... 87
Tolterodine Tartrate ER....... 128 Tretinoin..........................78, 118 Trivora................................... 141
Topamax................................. 62 Tretinoin Microsphere..........118 Trizivir...................................... 88
Topamax Sprinkle.................. 62 Trexall....................................146 Trokendi XR............................ 62
Topicort........................ 133, 134 Trezix....................................... 46 TrophAmine.......................... 121
Topicort Spray...................... 134 Tri-Estarylla............................141 Trospium Chloride............... 128
Topiramate..............................62 Tri-Legest Fe......................... 141 Trospium Chloride ER......... 128
Topiramate ER........................62 Tri-Lo-Estarylla...................... 141 Trulance................................ 123
Toprol XL...............................102 Tri-Lo-Sprintec...................... 141 Trulicity.................................... 94
Toremifene Citrate..................75 Tri-Mili....................................141 Trumenba..............................149
Torsemide............................. 106 Tri-Previfem...........................141 Trusopt.................................. 155
Toujeo Max SoloStar..............95 Tri-Sprintec............................141 Truvada................................... 88
Toujeo SoloStar...................... 95 Tri-VyLibra............................. 141 Tudorza Pressair.................. 159
Toviaz.................................... 128 Tri-VyLibra Lo........................141 Twinrix................................... 149
TPN Electrolytes................... 121 Triamcinolone Acetonide... 114, Twynsta................................. 106
Tracleer................................. 161 134 Tybost......................................87
Tradjenta................................. 94 Triamterene-HCTZ................106 Tydemy..................................141
Tramadol HCl..........................46 Trianex...................................134 Tygacil..................................... 51
Tramadol HCl ER............. 43, 44 Tribenzor............................... 106 Tykerb......................................77
Tramadol-Acetaminophen..... 46 Tricor..................................... 107 Tylenol with Codeine #3........ 46
Trandolapril...........................100 Triderm..................................134 Tylenol with Codeine #4........ 47
Trandolapril-Verapamil HCl ER Tridesilon.............................. 134 Tymlos...................................152
.............................................106 Trientine HCl.........................122
Typhim Vi.............................. 149
Tranexamic Acid.....................99
36 36
Tracked 36

U Vandazole................................51 Vicodin ES...............................47

Uceris.................................... 151 Vanos.....................................134 Vicodin HP.............................. 47
Udenyca.................................. 99 VAQTA...................................150 Victoza..................................... 94
Uloric....................................... 71 Varivax................................... 150 Videx........................................88
Ultracet.................................... 47 Varizig....................................147 Videx EC..................................88
Ultram...................................... 47 Varubi...................................... 68 Viekira Pak.............................. 86
Ultravate................................ 134 Vascepa................................ 109 Vienva....................................141
Unasyn.....................................55 Vaseretic............................... 106 Vigabatrin................................ 61
Unithroid............................... 143 Vasotec................................. 100 Vigadrone................................61
Uptravi...........................161, 162 Vecamyl.................................106 Vigamox.................................. 57
Urecholine.............................129 Vectical..................................118 Viibryd......................................67
Urocit-K 10............................ 121 Velivet.................................... 141 Viibryd Starter Pack................67
Urocit-K 15............................ 121 Velphoro................................122 Vimpat..................................... 64
Urocit-K 5.............................. 121 Veltassa................................. 122 Viokace..................................127
Uroxatral................................129 Vemlidy....................................85 Viracept................................... 89
Urso 250................................123 Venclexta.................................77 Viramune................................. 88
Urso Forte............................. 123 Venclexta Starting Pack......... 77 Viramune XR........................... 88
Ursodiol................................. 123 Venlafaxine HCl...................... 67 Viread...................................... 88
Utibron Neohaler.................. 163 Venlafaxine HCl ER................ 67 Vistaril...................................... 68
V Ventavis.................................162 Vitrakvi..................................... 77
Vabomere................................53 Ventolin HFA.........................160 Vivelle-Dot............................. 141
Vagifem................................. 141 Verapamil HCl.......................104 Vivitrol...................................... 47
Valacyclovir HCl......................86 Verapamil HCl ER.................103 Vivlodex................................... 40
Valchlor................................... 74 Veregen.................................118 Vizimpro.................................. 77
Valcyte..................................... 85 Verelan.................................. 104 Vogelxo................................. 137
Valganciclovir HCl.................. 85 Verelan PM............................104 Vogelxo Pump...................... 137
Valium......................................90 Versacloz.................................85 Voltaren................................... 40
Valproic Acid...........................61 Verzenio.................................. 76 Voriconazole........................... 71
Valsartan............................... 100 Vesicare.................................128 Vosevi...................................... 86
Valsartan-Hydrochlorothiazide Vfend....................................... 71 Votrient.................................... 77
.............................................106 Vfend IV................................... 71 VP-PNV-DHA......................... 122
Valtrex......................................86 Viberzi....................................124 Vraylar......................................84
Vancocin HCl.......................... 51 Vibramycin.............................. 59 Vyfemla..................................141
Vancomycin HCl..................... 51 Vicodin.....................................47 VyLibra.................................. 141
 37
Tracked 37 37

Vytorin................................... 109 Xopenex Concentrate.......... 160 Zenzedi..................................110

Vyvanse................................. 110 Xopenex HFA........................160 Zepatier................................... 86
Vyzulta................................... 156 Xospata................................... 77 Zerbaxa................................... 53
W Xtampza ER............................ 44 Zestoretic.............................. 106
Warfarin Sodium.....................97 Xtandi.......................................75 Zestril.....................................100
Welchol................................. 109 Xulane....................................141 Zetia.......................................109
Wellbutrin SR.......................... 65 Xultophy.................................. 94 Zetonna................................. 158
Wellbutrin XL...........................65 Xuriden.................................. 127 Ziac........................................106
Wixela Inhub......................... 163 Xyosted................................. 137 Ziagen......................................88
WYMZYA Fe..........................141 Xyrem.................................... 164 Ziana......................................118
X Y Zidovudine.............................. 88
Xalatan...................................156 Yasmin 28............................. 141 Zileuton ER........................... 158
Xalkori......................................77 YAZ........................................ 141 Zioptan.................................. 156
Xanax.......................................90 YF-Vax....................................150 Ziprasidone HCl......................84
Xanax XR.................................90 Yonsa.......................................75 Zipsor...................................... 40
Xarelto..................................... 97 Yosprala................................ 126 Zirgan...................................... 85
Xarelto Starter Pack............... 97 Yupelri................................... 159 Zithromax................................ 56
Xatmep.................................. 147 Yuvafem................................ 141 Zithromax Tri-Pak................... 56
Xeljanz................................... 147 Z Zithromax Z-Pak..................... 56
Xeljanz XR............................. 147 Zafirlukast............................. 158 Zocor..................................... 108
Xelpros.................................. 156 Zaleplon................................ 164 Zofran...................................... 68
Xenazine................................112 Zanaflex........................ 163, 164 Zohydro ER............................. 44
Xepi..........................................57 Zarah..................................... 141 Zolinza..................................... 76
Xerese......................................87 Zarontin................................... 60 Zolmitriptan.............................73
Xermelo................................. 123 Zarxio.......................................99 Zolmitriptan ODT.................... 73
Xgeva.....................................152 Zavesca................................. 127 Zoloft....................................... 67
Xhance.................................. 158 Zejula....................................... 76 Zolpidem Tartrate.................164
Xifaxan...................................124 Zelapar.................................... 81 Zomacton..............................136
Xigduo XR............................... 94 Zelboraf................................... 78 Zomig...................................... 73
Xiidra..................................... 153 Zemaira................................. 127 Zomig ZMT..............................73
Ximino......................................59 Zembrace SymTouch.............73 Zonalon................................. 118
Xofluza.....................................90 Zemplar................................. 152 Zonegran.................................60
Xolair......................................148 Zenatane............................... 118 Zonisamide............................. 60
Xopenex................................ 160 Zenpep.................................. 127 Zontivity................................... 97
38 38
Tracked 38

Zorbtive................................. 123 Zuplenz....................................68 Zymaxid...................................57

Zortress................................. 147 Zyban.......................................48 Zypitamag............................. 108
Zorvolex...................................41 Zyclara Pump........................118 Zyprexa....................................84
Zostavax................................ 150 Zydelig.....................................78 Zyprexa Relprevv....................84
Zosyn....................................... 55 Zyflo.......................................158 Zyprexa Zydis................... 84, 85
Zovia 1/35E...........................141 Zyflo CR................................ 158 Zytiga.......................................75
Zovirax..................................... 87 Zykadia.................................... 78 Zyvox....................................... 51
ZTlido...................................... 47 Zylet....................................... 153
Zubsolv....................................48 Zyloprim.................................. 71
 tRACK 39 39
38
1
Covered drugs by medical condition
The list below has information about the drugs covered by this plan. Find your medical condition to
see what drugs are covered. If you have trouble finding your drug, turn to the “Covered drugs by
name (Drug index)” on pages 12-38.
The first column lists the drug name, which may include the dosage form and strength. Brand
name drugs are listed in bold type (for example, Humalog) and generic drugs are listed in plain
type (for example, Simvastatin). The second column lists the drug tier or coverage level. The third
column lists any rules or limits for the drug. If quantity limits (QL) apply to a drug, the restriction
amounts are shown in the chart on pages 165-202.
tRACK

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1

Dicl
ofen

Analgesics Diclofenac-Misoprostol
A1 ac-
Mis
opr
osto
l

B1

Nonsteroidal Anti-inflammatory Drugs (Oral Tablet Delayed 1

C1

Arth
rote

Release)
Arthrotec (Oral Tablet
c

C1

3
Diflu
nisal

Delayed Release) C1
Diflunisal (Oral Tablet) 1
Eto
dola

Etodolac ER (Oral
C1 c
ER
Cam
bia

Cambia (Oral Packet) 3

C1

Cele
brex
Tablet Extended 1
Celebrex (Oral Release 24 Hour)
3 QL
Capsule) C1

Eto
dola

Etodolac (Oral
c

C1

1
Cele
coxi

Celecoxib (Oral
b

1 QL Capsule)
Capsule) C1

Eto
dola

Etodolac (Oral Tablet

c

C1

1
Day
pro

C1
Daypro (Oral Tablet) 3 Immediate Release)
Dicl
ofen

Diclofenac Epolamine
ac C1
Epol
ami Feld
ne ene

3 PA; QL Feldene (Oral

(Transdermal Patch) 3
C1

Dicl
ofen
Capsule)
Diclofenac Potassium
ac
Pota
C1
ssiu
m Fen
opr

Fenoprofen Calcium
ofen

1 Calc
ium

3
C1
(Oral Tablet) (400MG Oral Capsule)
Dicl
ofen

Diclofenac Sodium ER
ac
Sodi
C1
um
ER Fen
opr

Fenoprofen Calcium
ofen

Calc
ium

(Oral Tablet Extended 1 3

(Oral Tablet)
Release 24 Hour) C1

Flec
tor

C1

Dicl
ofen
Flector (Transdermal
Diclofenac Sodium 3 PA; QL
ac
Sodi
um

Patch)
(Oral Tablet Delayed 1 C1

Flur
bipr

Flurbiprofen (Oral
ofen

Release) 1
C1

Dicl
ofen

Tablet)
Diclofenac Sodium
ac
Sodi
um

C1

1 Ibu

Ibu (600MG Oral

(1% Transdermal Gel)
C1

Dicl
ofen

Tablet, 800MG Oral 1

Diclofenac Sodium
ac
Sodi
um

1 PA Tablet)
(Transdermal Solution)

Bold type = Brand name drug Plain type = Generic drug

 40 tRACK 40 Last updated September 1, 2019
39
2

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Ibup Nap
rofe roxe

Ibuprofen (Oral Naproxen Sodium ER

n n
Sodi
um
ER

1
C1
Suspension) (375MG Oral Tablet
Extended Release 24 4
Ibup
rofe

Ibuprofen (400MG
n

Oral Tablet, 600MG Hour) (Generic

1 Naprelan)
Oral Tablet, 800MG C1

Nap
roxe

Oral Tablet) Naproxen Sodium ER

n
Sodi
um
ER

C1

(500MG Oral Tablet

Ket
opr

Ketoprofen ER (Oral
ofen
ER

Capsule Extended 3 Extended Release 24 3

Release 24 Hour) Hour) (Generic
C1

Ket
opr

Naprelan)
Ketoprofen (Oral
ofen

C1

Nap
roxe

Naproxen Sodium
n
Sodi
um

Capsule Immediate 1
Release) (275MG Oral Tablet
C1

Lodi
ne

Immediate Release, 1
Lodine (Oral Tablet) 4
C1

Mec
lofe
550MG Oral Tablet
Meclofenamate
nam
ate
Sodi
um

3 Immediate Release)
Sodium (Oral Capsule) C1

Oxa
proz

Oxaprozin (Oral
in

C1

1
Mef
ena

Mefenamic Acid (Oral

mic
Acid

3 Tablet)
Capsule) C1

Pen
nsai

Pennsaid
d

C1

Mel
oxic

Meloxicam (Oral
am

1 (Transdermal 4 PA
Tablet)
C1

Mob
ic
Solution)
Mobic (Oral Tablet) 3 C1

Piro
xica

Piroxicam (Oral
m

C1

1
Nab
ume

Nabumetone (Oral
tone

1 Capsule)
Tablet) C1

Qmii
z

Qmiiz ODT (Oral

ODT

C1

3
Nalf
on

C1
Nalfon (Oral Tablet) 3 Tablet Dispersible)
Nap
rela

Naprelan (Oral Tablet

n C1

Suli
nda

Sulindac (Oral Tablet) 1

c

Extended Release 24 4 C1

Tol
meti

Tolmetin Sodium (Oral

n
Sodi
um

Hour) 3
C1

Nap
roxe
Capsule)
Naproxen DR (Oral
n
DR C1

Tol
meti

Tolmetin Sodium
n
Sodi
um

Tablet Delayed 3
1 (600MG Oral Tablet)
Release) (Generic EC- C1

Vivl
ode

Vivlodex (Oral
x

Naprosyn) 4 QL
C1

Nap
roxe
Capsule)
Naproxen (Oral
n

C1

3
Volt
aren

Suspension) Voltaren
3 PA
C1

Nap
roxe
n

Naproxen (Oral Tablet (Transdermal Gel)

1
C1

Zips
or

Immediate Release) Zipsor (Oral Capsule) 4 ST

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
tRACK 41 41
40
3

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Zorv Dur
olex age

Zorvolex (Oral Duragesic-100

sic-1
00

3 ST 7D; MME;
Capsule) (Transdermal Patch 4
DL; QL
B1

Opioid Analgesics, Long-acting C1

72 Hour)
C1 Dur
age

Duragesic-12
Belb sic-1
uca 2

Belbuca (150MCG 7D; MME;

Buccal Film, 300MCG (Transdermal Patch 3
PA; 7D; DL; DL; QL
Buccal Film, 450MCG 3 72 Hour)
QL C1

Dur
age

Buccal Film, 75MCG Duragesic-25

sic-2
5

7D; MME;
Buccal Film) (Transdermal Patch 3
C1

DL; QL
72 Hour)
Belb
uca

Belbuca (600MCG C1

Dur
age

Buccal Film, 750MCG PA; 7D; DL; Duragesic-50

sic-5
0

4 7D; MME;
Buccal Film, 900MCG QL (Transdermal Patch 4
DL; QL
C1
Buccal Film) C1
72 Hour)
Bup Dur
reno age

Buprenorphine Duragesic-75
rphi sic-7
ne 5

7D; MME;
(10MCG/HR (Transdermal Patch 4
Transdermal Patch DL; QL
72 Hour)
Weekly, 15MCG/HR C1

Emb
eda

Embeda (Oral
Transdermal Patch 7D; MME;
1 7D; DL; QL Capsule Extended 2
Weekly, 20MCG/HR DL; QL
Transdermal Patch C1
Release)
Fent
anyl

Weekly, 5MCG/HR Fentanyl (100MCG/HR

Transdermal Patch Transdermal Patch 72
Weekly) Hour, 12MCG/HR
Transdermal Patch 72
C1

Bup
reno

Buprenorphine
rphi
ne

(7.5MCG/HR Hour, 25MCG/HR 7D; MME;

2 7D; DL; QL Transdermal Patch 72 1
Transdermal Patch DL; QL
Weekly) Hour, 50MCG/HR
C1

Butr
ans Transdermal Patch 72
Butrans (Transdermal Hour, 75MCG/HR
2 7D; DL; QL
C1
Patch Weekly) Transdermal Patch 72
Con
Zip

ConZip (Oral Capsule Hour)

7D; MME; C1

Extended Release 24 3
Fent
anyl

DL; QL Fentanyl (37.5MCG/ 7D; MME;

Hour) HR Transdermal Patch 3
C1

DL; QL
72 Hour)
Dol
ophi

Dolophine (Oral 7D; MME;

ne

3
Tablet) DL; QL

Bold type = Brand name drug Plain type = Generic drug

 42 tRACK 42 Last updated September 1, 2019
41

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Fent Lev
anyl orph

Fentanyl (62.5MCG/ 7D; MME;

anol

Tartr
ate

Levorphanol Tartrate
4
HR Transdermal Patch (Oral Tablet) DL; QL
7D; MME;
72 Hour, 87.5MCG/HR 4
C1

Met
had

7D; MME;
one

Methadone HCl (Oral

HCl

DL; QL 1
Transdermal Patch 72 Solution) DL; QL
Hour) C1

Met
had

7D; MME;
one

Methadone HCl (Oral

HCl

C1

Hyd
rom

Hydromorphone HCl 1
orph
one
HCl
ER

7D; MME; Tablet) DL; QL

ER (Oral Tablet ER 24 3 C1

DL; QL
Mor
pha

MorphaBond ER
Bon
d
ER

Hour Abuse-Deterrent)
(100MG Oral Tablet
C1

Hysi
ngla

Hysingla ER (Oral
ER

7D; MME; ER 12 Hour Abuse-

Tablet ER 24 Hour 2
DL; QL Deterrent, 30MG Oral
Abuse-Deterrent) 7D; MME;
C1

Kadi
an
Tablet ER 12 Hour 4
Kadian (100MG Oral DL; QL
Abuse-Deterrent,
Capsule Extended
60MG Oral Tablet ER
Release 24 Hour,
12 Hour Abuse-
200MG Oral Capsule
Deterrent)
Extended Release 24 C1

Mor
pha

MorphaBond ER
Bon
d
ER

Hour, 40MG Oral

Capsule Extended (15MG Oral Tablet ER 7D; MME;
3
Release 24 Hour, 7D; MME; 12 Hour Abuse- DL; QL
4 Deterrent)
50MG Oral Capsule DL; QL C1

Mor
phin

Morphine Sulfate ER
e
Sulf
ate

Extended Release 24
ER
Bea
ds

Hour, 60MG Oral Beads (Oral Capsule 7D; MME;

3
Capsule Extended Extended Release 24 DL; QL
Hour) (Generic Avinza)
Release 24 Hour, C1

Mor
phin

Morphine Sulfate ER
e
Sulf
ate
ER

80MG Oral Capsule

(Oral Capsule 7D; MME;
Extended Release 24 3
Extended Release 24 DL; QL
C1
Hour) Hour) (Generic Kadian)
Kadi
an

Kadian (10MG Oral

Capsule Extended
Release 24 Hour,
20MG Oral Capsule 7D; MME;
3
Extended Release 24 DL; QL
Hour, 30MG Oral
Capsule Extended
Release 24 Hour)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
tRACK 43 43
42
5

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Mor Oxy
phin cod

Morphine Sulfate ER Oxycodone HCl ER

e one
Sulf HCl
ate ER
ER

(100MG Oral Tablet (10MG Oral Tablet ER

Extended Release, 12 Hour Abuse-
15MG Oral Tablet Deterrent, 15MG Oral
Extended Release, 7D; MME; Tablet ER 12 Hour
1
30MG Oral Tablet DL; QL Abuse-Deterrent,
Extended Release, 20MG Oral Tablet ER 7D; MME;
3
60MG Oral Tablet 12 Hour Abuse- DL; QL
Extended Release) Deterrent, 30MG Oral
C1
(Generic MS Contin) Tablet ER 12 Hour
Abuse-Deterrent,
Mor
phin

Morphine Sulfate ER
e
Sulf
ate
ER

(200MG Oral Tablet 7D; MME; 40MG Oral Tablet ER

3 12 Hour Abuse-
Extended Release) DL; QL
(Generic MS Contin) C1
Deterrent)
Oxy
C1 cod

Oxycodone HCl ER
one
MS HCl
Con ER

MS Contin (100MG
tin

Oral Tablet Extended (60MG Oral Tablet ER

12 Hour Abuse- 7D; MME;
Release, 200MG Oral 4
Deterrent, 80MG Oral DL; QL
Tablet Extended
7D; MME; Tablet ER 12 Hour
Release, 30MG Oral 4 Abuse-Deterrent)
DL; QL
Tablet Extended C1

Oxy
Con

OxyContin (Oral
tin

Release, 60MG Oral 7D; MME;

Tablet ER 12 Hour 2
Tablet Extended DL; QL
Abuse-Deterrent)
Release) C1

Oxy
mor

Oxymorphone HCl ER
pho
ne
HCl
C1 ER
MS

7D; MME;
Con

MS Contin (15MG
tin

7D; MME; (Oral Tablet Extended 3

Oral Tablet Extended 3 DL; QL
DL; QL Release 12 Hour)
Release) C1

Tra
mad

Tramadol HCl ER
ol
HCl
ER

C1

Nuc
ynta

Nucynta ER (Oral
ER

7D; MME; (Biphasic) (Oral Tablet 7D; MME;

Tablet Extended 2 1
DL; QL Extended Release 24 DL; QL
Release 12 Hour) Hour)

Bold type = Brand name drug Plain type = Generic drug

 44 tRACK 44 Last updated September 1, 2019
43
6

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Tra Acti
mad q

Tramadol HCl ER Actiq (Buccal

ol
HCl
ER

(100MG Oral Capsule Lozenge On A 4 PA; DL; QL

Extended Release 24 Handle)
Hour, 200MG Oral C1

But
orph
anol

7D; MME;
7D; MME; Tartr
ate

Butorphanol Tartrate
Capsule Extended 3 1
DL; QL (Nasal Solution) DL; QL
Release 24 Hour, C1

Cod
eine

Codeine Sulfate (Oral 7D; MME;

Sulf
ate

300MG Oral Capsule 1

Extended Release 24 C1
Tablet) DL; QL
Dila

Hour)
udid

7D; MME;
C1

Tra
Dilaudid (Oral Liquid) 3
DL; QL
mad

Tramadol HCl ER
ol
HCl
ER

C1

(100MG Oral Tablet

Dila
udid

Dilaudid (2MG Oral

Extended Release 24 7D; MME;
Tablet, 4MG Oral 3
Hour, 200MG Oral DL; QL
7D; MME; Tablet)
Tablet Extended 1 C1

Dila
udid

DL; QL Dilaudid (8MG Oral 7D; MME;

Release 24 Hour, 4
300MG Oral Tablet C1
Tablet) DL; QL
Dur
amo

Duramorph (Injection
rph

Extended Release 24 1 DL
C1
Hour) C1
Solution)
Xta Dvo
mpz rah

Xtampza ER (Oral ST; 7D; 7D; MME;

a
ER

Dvorah (Oral Tablet) 3

Capsule ER 12 Hour 3 MME; DL; C1
DL; QL
End

Abuse-Deterrent) QL
ocet

C1

Zoh
Endocet (10-325MG
Oral Tablet, 5-325MG
ydro

Zohydro ER (Oral PA; 7D;

ER

7D; MME;
Capsule ER 12 Hour 3 MME; DL; Oral Tablet, 1
DL; QL
Abuse-Deterrent) QL 7.5-325MG Oral
Tablet)
Opioid Analgesics, Short-acting
B1

C1

Fent
anyl

Fentanyl Citrate
Citra
te
C1

Abst
ral

Abstral (Tablet
4 PA; DL; QL (Buccal Lozenge On A 4 PA; DL; QL
C1
Sublingual) Handle)
Acet
ami

Acetaminophen-
nop
hen- C1
Cod
eine Fent
anyl

Fentanyl Citrate
Citra

7D; MME;
te

Codeine (120-12MG/ 1 4 PA; DL; QL

DL; QL (Buccal Tablet)
5ML Oral Solution) C1

Fent
ora

C1

Acet
Fentora (Buccal
4 PA; DL; QL
ami

Acetaminophen-
nop
hen-
Cod
eine

Tablet)
Codeine (300-15MG C1

7D; MME;
Hyd
roco

Hydrocodone-
don
e-
Acet
ami

Oral Tablet, 300-30MG 1

nop
hen

DL; QL Acetaminophen 7D; MME;

Oral Tablet, 300-60MG 1
Oral Tablet) (7.5-325MG/15ML DL; QL
Oral Solution)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
tRACK 45 45
44
7

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Hyd Lorc
roco et

Hydrocodone- 7D; MME;

don HD

Lorcet HD (Oral
e-
Acet
ami
nop
hen

1
Acetaminophen Tablet) DL; QL
(10-300MG Oral
C1

Lorc
et

7D; MME;
Tablet, 10-325MG Oral Lorcet (Oral Tablet) 1
DL; QL
Tablet, 5-300MG Oral 7D; MME; C1

1
Lorc
et

7D; MME;
Plus

Tablet, 5-325MG Oral DL; QL Lorcet Plus (Oral

1
Tablet, 7.5-300MG C1
Tablet) DL; QL
Mor
phin

Morphine Sulfate
e

Oral Tablet,
Sulf
ate

7D; MME;
7.5-325MG Oral (100MG/5ML Oral 1
DL; QL
C1
Tablet) C1
Solution)
Hyd Mor
roco phin

Morphine Sulfate
e

Hydrocodone-
don
e- Sulf
Ibup ate
rofe
n

7D; MME;
Ibuprofen (10-200MG 3 (8MG/ML Intravenous
DL; QL 1 DL
C1
Oral Tablet) Solution Prefilled
Hyd
roco
don
e-
Ibup
rofe
n

Hydrocodone- C1
Syringe)
Mor
phin

Morphine Sulfate
e

Ibuprofen (5-200MG
Sulf
ate

7D; MME;
Oral Tablet, 1 (10MG/ML Injection
DL; QL 1 DL
7.5-200MG Oral Solution, 4MG/ML
C1
Tablet) C1
Injection Solution)
Hyd Mor
rom phin

Morphine Sulfate
e

Hydromorphone HCl
orph
one Sulf
HCl ate

(2MG/ML Injection 3 DL (2MG/ML Injection

Solution) 1 DL
C1

Hyd
Solution, 5MG/ML
rom

7D; MME; Injection Solution)

orph

Hydromorphone HCl
one
HCl

1 C1

(1MG/ML Oral Liquid) DL; QL

Mor
phin

7D; MME;
e

Morphine Sulfate (Oral

Sulf
ate

C1

Hyd
rom
1
Hydromorphone HCl Solution) DL; QL
orph
one
HCl

C1

(2MG Oral Tablet

Mor
phin

Morphine Sulfate
e
Sulf
ate

Immediate Release, 7D; MME;

7D; MME; (Oral Tablet 1
4MG Oral Tablet 1 DL; QL
DL; QL Immediate Release)
Immediate Release, C1

Nor
co

8MG Oral Tablet 7D; MME;

Norco (Oral Tablet) 3
Immediate Release) C1
DL; QL
Nuc
C1 ynta

Nucynta (100MG Oral

Hyd
rom

Hydromorphone HCl
orph
one
HCl
Pres

7D; MME;
erva
tive
Free

Preservative Free Tablet Immediate 4

DL; QL
(10MG/ML Injection 3 DL Release)
Solution, 50MG/5ML
C1
Injection Solution)
Laza
nda

Lazanda (Nasal
4 PA; DL; QL
Solution)

Bold type = Brand name drug Plain type = Generic drug

 46 tRACK 46 Last updated September 1, 2019
45
8

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Nuc Oxy
ynta mor

Nucynta (50MG Oral Oxymorphone HCl

pho
ne
HCl

7D; MME;
Tablet Immediate (Oral Tablet Immediate 1
7D; MME; DL; QL
Release, 75MG Oral 3 Release)
DL; QL C1

Perc
ocet

Tablet Immediate Percocet (10-325MG

Release) Oral Tablet, 5-325MG
7D; MME;
Oral Tablet, 4
C1

Opa
na

Opana (10MG Oral DL; QL

7D; MME; 7.5-325MG Oral
Tablet Immediate 4
DL; QL Tablet)
Release) C1

Perc
ocet

C1

Opa
na
Percocet (2.5-325MG 7D; MME;
Opana (5MG Oral 3
7D; MME; Oral Tablet) DL; QL
Tablet Immediate 3 C1

DL; QL
Prim
lev

Release) 7D; MME;

Primlev (Oral Tablet) 4
C1

Oxy
cod
DL; QL
7D; MME;
one

Oxycodone HCl (5MG

HCl

C1

1
Roxi
cod

Roxicodone (15MG
one

Oral Capsule) DL; QL 7D; MME;

C1

Oxy
cod
Oral Tablet, 5MG Oral 3
Oxycodone HCl DL; QL
one
HCl

7D; MME; Tablet)

(100MG/5ML Oral 3 C1

DL; QL
Roxi
cod

Roxicodone (30MG 7D; MME;

one

Concentrate) 4
Oral Tablet) DL; QL
C1

Oxy
cod

7D; MME;
one

Oxycodone HCl (5MG/

HCl

1
C1

Sub
sys

5ML Oral Solution) DL; QL Subsys (100MCG

Sublingual Liquid,
C1

Oxy
cod

Oxycodone HCl
one
HCl

(10MG Oral Tablet 200MCG Sublingual

Immediate Release, Liquid, 400MCG
4 PA; DL; QL
15MG Oral Tablet Sublingual Liquid,
Immediate Release, 7D; MME; 600MCG Sublingual
20MG Oral Tablet 1 Liquid, 800MCG
DL; QL
Immediate Release, Sublingual Liquid)
30MG Oral Tablet C1

Tra
mad
ol
HCl

Tramadol HCl (Oral

Immediate Release, 7D; MME;
Tablet Immediate 1
5MG Oral Tablet DL; QL
Release)
Immediate Release) C1

Tra
mad

Tramadol-
ol-
Acet
ami
C1 nop
hen
Oxy

7D; MME;
cod

Oxycodone-
one-
Acet
ami
nop
hen

7D; MME; Acetaminophen (Oral 1

Acetaminophen (Oral 1 Tablet) DL; QL
Tablet) DL; QL C1

Trez
ix

C1

Oxy
cod
7D; MME;
7D; MME; Trezix (Oral Capsule) 3
one-

Oxycodone-Aspirin
Aspi
rin

1 DL; QL
(Oral Tablet) DL; QL C1

Tyle
nol

7D; MME;
with

Tylenol with Codeine

Cod
eine
C1 #3

Oxy
cod

7D; MME; 3
one-

Oxycodone-Ibuprofen
Ibup
rofe
n

1 #3 (Oral Tablet) DL; QL

(Oral Tablet) DL; QL

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
tRACK 47 47
46
9

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1

Tyle
nol

7D; MME; Anti-Addiction/Substance Abuse Treatment

with A1

Tylenol with Codeine

Cod
eine
#4

3
C1
#4 (Oral Tablet) DL; QL Agents
Ultra
cet

7D; MME; Alcohol Deterrents/Anti-craving

B1

Ultracet (Oral Tablet) 3 C1

DL; QL
Aca
mpr

Acamprosate Calcium
osat
e
Calc
ium

C1

Ultra

(Oral Tablet Delayed 1

m

7D; MME;
Ultram (Oral Tablet) 3 Release)
C1
DL; QL C1

Anta
bus

Antabuse (Oral Tablet) 3

Vico e
din

7D; MME;
ES

Vicodin ES (Oral
1 C1

Disu
lfira

Tablet) Disulfiram (Oral Tablet) 1

m

C1
DL; QL C1

Nalt
Vico
rexo
din

Naltrexone HCl (Oral

ne

7D; MME;
HP

Vicodin HP (Oral
HCl

1 1
Tablet) DL; QL C1
Tablet)
C1 Vivit
rol

Vivitrol
Vico
din

7D; MME;
Vicodin (Oral Tablet) 1 (Intramuscular
DL; QL 4
A1

Anesthetics Suspension
B1

Local Anesthetics Reconstituted)

Opioid Dependence Treatments
B1
C1

Lido
cain

Lidocaine (5% External

e

3 QL
C1

Bun
avail

Ointment) Bunavail (Buccal

3 ST; QL
Film)
C1

Lido
cain

Lidocaine (5% External

e

3 PA; QL C1

Bup
reno
rphi

Buprenorphine HCl
Patch)
ne
HCl

1 QL
(Tablet Sublingual)
C1

Lido
cain

Lidocaine HCl (4%

e
HCl

1 C1

Bup
reno
rphi

Buprenorphine HCl-
External Solution)
ne
HCl-
Nalo
xon
e
HCl

Naloxone HCl 3 QL
C1

Lido
cain

Lidocaine HCl
e
HCl

1 (Sublingual Film)
(External Gel) C1

Bup
reno

Buprenorphine HCl-
C1 rphi
ne
Lido HCl-
cain Nalo

Lidocaine Viscous (2%

e xon
Visc e
ous HCl

Mouth/Throat 1 Naloxone HCl (Tablet 1 QL

Solution) C1
Sublingual)
Sub
oxo

Suboxone (Sublingual
C1 ne

Lido
cain

Lidocaine-Prilocaine
e-
Prilo
cain

3 QL
e

1 Film)
C1
(External Cream)
Lido
der

Lidoderm (External
m

4 PA; QL
C1
Patch)
Plia
glis

Pliaglis (External
3
C1
Cream)
ZTli
do

ZTlido (External
3 PA; QL
Patch)

Bold type = Brand name drug Plain type = Generic drug

 48 tRACK 48 Last updated September 1, 2019
47
10

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Zub Cha
solv ntix

Zubsolv (1.4-0.36MG Chantix Starting

Start
ing
Mon
th
Pak

Tablet Sublingual, Month Pak (Oral 2

11.4-2.9MG Tablet C1
Tablet)
Sublingual,
Nico
trol

Nicotrol (Inhalation
2.9-0.71MG Tablet 3
3 QL Inhaler)
Sublingual,
C1

Nico
trol

Nicotrol NS (Nasal
NS

5.7-1.4MG Tablet 3
Solution)
Sublingual, C1

Zyb
an

Zyban (150MG Oral

8.6-2.1MG Tablet Tablet Extended 3
Sublingual) Release 12 Hour)
Opioid Reversal Agents
B1

Antibacterials
A1

C1

Evzi
o

Evzio (Injection B1

Aminoglycosides
Solution Auto- 4 ST C1

Ami
kaci

Amikacin Sulfate
n
Sulf
ate

Injector)
C1

Nalo
xon
(500MG/2ML Injection 1
Naloxone HCl (0.4MG/
e
HCl

1 Solution)
ML Injection Solution) C1

Arik
ayce

C1
Arikayce (Inhalation
4
Nalo
xon

Naloxone HCl
e
HCl

Suspension)
(Injection Solution 1 C1

Gen
tak

Cartridge) Gentak (Ophthalmic

1
C1

Nalo
xon
Ointment)
Naloxone HCl
e
HCl

C1

Gen
tami

Gentamicin
cin
Sulf
ate-
0.9
%

(Injection Solution 1
Sodi
um
Chlo
ride

Prefilled Syringe) Sulfate-0.9% Sodium

1
C1

Nar
can
Chloride (Intravenous
Narcan (Nasal Liquid) 2 Solution)
Smoking Cessation Agents
B1 C1

Gen
tami

Gentamicin Sulfate
cin
Sulf
ate

1
C1

Bup
ropi

Bupropion HCl SR
on

(External Cream)
HCl
SR

(150MG Oral Tablet

C1

Gen
tami

Gentamicin Sulfate
cin
Sulf
ate

Extended Release 12 1 1
(External Ointment)
Hour Smoking- C1

Gen
tami

Gentamicin Sulfate
cin
Sulf
ate

Deterrent)
C1

Cha
ntix
(40MG/ML Injection 1
Chantix Continuing
Con
tinui
ng
Mon

Solution)
th
Pak

Month Pak (Oral 2 C1

Gen
tami

Gentamicin Sulfate
cin
Sulf
ate

Tablet) 1
C1

Cha
ntix
(Ophthalmic Solution)
Chantix (Oral Tablet) 2
C1

Neo
myci

Neomycin Sulfate (Oral

n
Sulf
ate

1
Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
tRACK 49 49
48
11

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Paro Cleo
mo cin

Paromomycin Sulfate Cleocin (Oral Solution

myci
n
Sulf
ate

3 3
C1
(Oral Capsule) C1
Reconstituted)
Stre Cleo
pto cin

Streptomycin Sulfate Cleocin Phosphate

myci Pho
n sph
Sulf ate
ate

(Intramuscular (900MG/6ML Injection 3

4
Solution C1
Solution)
Reconstituted)
Cleo
cin

Cleocin (Vaginal
C1

Tob
ram

3
Tobramycin
ycin

1 Cream)
(Ophthalmic Solution)
C1

Cleo
cin

Cleocin (Vaginal
3
C1

Tob
ram

Tobramycin Sulfate
ycin
Sulf

Suppository)
ate

(10MG/ML Injection C1

Clin
dam
ycin

Clindamycin HCl (Oral

3
HCl

Solution, 80MG/2ML 1
Capsule)
Injection Solution) C1

Clin
dam

Clindamycin Palmitate
ycin
Pal
mita
C1 te
HCl
Tob
rex

Tobrex (Ophthalmic HCl (Oral Solution 1

2
C1
Ointment) Reconstituted)
Tob
rex

Tobrex (Ophthalmic
C1

Clin
dam

Clindamycin
ycin
Pho
sph

3
ate
in
D5
W

Solution) Phosphate in D5W 1

Antibacterials, Other (Intravenous Solution)
B1

C1 C1

Baci Clin
traci dam

Bacitracin (Ophthalmic Clindamycin

n ycin
Pho
sph
ate

1
C1
Ointment) Phosphate (300MG/
2ML Injection Solution,
Bact
roba

Bactroban (2%
n

3 1
External Cream) 600MG/4ML Injection
C1

Bact
roba
Solution, 900MG/6ML
Bactroban (2% Nasal
n

3 PA Injection Solution)
Ointment) C1

Clin
dam

Clindamycin
ycin
Pho
sph
ate
C1

Cleo
cin

Cleocin in D5W
in
D5
W

Phosphate (Vaginal 1
(300MG/50ML Cream)
Intravenous Solution,
C1

Clin
des

Clindesse (Vaginal
se

600MG/50ML 3 3
Cream)
Intravenous Solution, C1

Coli
stim

Colistimethate Sodium
etha
te
Sodi
um

900MG/50ML (CBA) (Injection

Intravenous Solution) 4
C1

Cleo
cin
Solution
Cleocin (150MG Oral Reconstituted)
C1

Capsule, 75MG Oral 3 Cubi

cin

Cubicin (Intravenous
C1
Capsule) Solution 4
Cleo
cin

Cleocin (300MG Oral Reconstituted)

4
Capsule)

Bold type = Brand name drug Plain type = Generic drug

 50 tRACK 50 Last updated September 1, 2019
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12

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Dalv Metr
anc oGe

Dalvance MetroGel-Vaginal
e l-
Vagi
nal

3
(Intravenous Solution 4 PA C1
(Vaginal Gel)
Reconstituted)
Metr
oLot

MetroLotion (External
ion

C1

Dap
tom
4
Daptomycin (350MG Lotion)
ycin

C1

Intravenous Solution 4
Metr
onid

Metronidazole (0.75%
azol
e

Reconstituted) 1
C1
C1
External Cream)
Dap
tom Metr
onid

Daptomycin (500MG
ycin

Metronidazole (0.75%
azol
e

Intravenous Solution 4 1
C1
External Gel)
Reconstituted) Metr
onid
azol
e

Metronidazole (1%
C1

Firv
anq

Firvanq (Oral Solution 3

External Gel)
3 C1

Reconstituted)
Metr
onid

Metronidazole (0.75%
azol
e

C1

Flag
yl
1
C1
Flagyl (Oral Capsule) 3 C1
External Lotion)
Metr
Flag
onid
yl

Flagyl (Oral Tablet) Metronidazole in NaCl

azol

3
e in
NaC
l
0.79
%

C1

Fura
dant
in

Furadantin (Oral 0.79% (Intravenous 1

4 HRM Solution)
Suspension) C1

Metr
onid

Metronidazole (375MG
azol
C1
e
Hipr
ex

Hiprex (Oral Tablet) 3 3

C1

Line
zoli Oral Capsule)
Linezolid (Intravenous
d

C1

Metr

3
onid

Metronidazole (250MG
azol
e

Solution)
C1

Line
zoli Oral Tablet, 500MG 1
Linezolid (Oral
d

Oral Tablet)
Suspension 4 C1

Metr
onid

Metronidazole (0.75%
azol
e

Reconstituted) 1
C1

Line
zoli Vaginal Gel)
Linezolid (Oral Tablet) 1
d

C1

Mon
urol

C1

Mac
robi Monurol (Oral Packet) 3
Macrobid (Oral
d

C1

Mup

3 HRM
iroci

Mupirocin Calcium
n
Calc
ium

Capsule) 3
C1
Mac
roda
(External Cream)
Macrodantin (Oral
ntin

C1

Mup
iroci

3 HRM Mupirocin (External

n

Capsule) 1
C1

Maf
enid
Ointment)
Mafenide Acetate
e
Acet
ate C1

Nitr
ofur

Nitrofurantoin
anto

3
in
Mac
rocr
ystal

(External Packet)
C1

Met
hen
Macrocrystal (100MG
Methenamine
ami
ne
Hip

Oral Capsule, 50MG 1 HRM

pura
te

1
C1
Hippurate (Oral Tablet) Oral Capsule) (Generic
Metr
oCr

MetroCream Macrodantin)
eam

3
C1
(External Cream)
Metr
ogel

Metrogel (External
3
Gel)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Nitr Van
ofur com

Nitrofurantoin Vancomycin HCl

anto ycin
in HCl
Mac
rocr
ystal

Macrocrystal (25MG (10GM Intravenous

3 HRM
Oral Capsule) (Generic Solution
C1
Macrodantin) Reconstituted, 1GM
Intravenous Solution
Nitr
ofur

Nitrofurantoin
anto
in
Mon

1
ohy
drat
e

Monohydrate (Generic 1 HRM Reconstituted, 500MG

Macrobid) Intravenous Solution
C1

Nitr
ofur

Reconstituted, 750MG
Nitrofurantoin (Oral
anto
in

3 HRM Intravenous Solution

Suspension)
C1

Nori
tate
Reconstituted)
Noritate (External C1

Van
com

4 Vancomycin HCl
ycin
HCl

Cream)
C1

(250MG Intravenous
1
Poly
myxi

Polymyxin B Sulfate
nB
Sulf
ate

Solution
(Injection Solution 1
Reconstituted)
Reconstituted) C1

Van
com

Vancomycin HCl (Oral

ycin
HCl
C1

Sive
xtro

Sivextro (Intravenous 3 QL
Capsule)
Solution 4 PA C1

Van
daz

Vandazole (Vaginal
ole

Reconstituted) 1
C1

Sive
xtro Gel)
Sivextro (Oral Tablet) 4 PA C1

Zyv
ox

C1

Solo
sec Zyvox (600MG/
Solosec (Oral Packet) 3
C1

Sulf
amyl
300ML Intravenous 4
Sulfamylon (External
on

3 Solution)
Cream) C1

Zyv
ox

C1

Sulf
amyl
Zyvox (Oral
Sulfamylon (External
on

4 Suspension 4
C1
Packet) Reconstituted)
Tige
cycli

Tigecycline
ne C1

Zyv
ox

Zyvox (Oral Tablet) 4

(Intravenous Solution 4
Beta-lactam, Cephalosporins
B1

Reconstituted) C1

Avy
caz

C1

Tini
daz
ole

Tinidazole (Oral Avycaz (Intravenous

1 Solution 4 PA
Tablet)
C1

Trim
etho
Reconstituted)
Trimethoprim (Oral
prim

C1

1 Cefa
clor
ER

Cefaclor ER (Oral
Tablet)
C1

Tyg
acil
Tablet Extended 1
Tygacil (Intravenous
Release 12 Hour)
Solution 4 C1

Cefa
clor

Reconstituted) Cefaclor (Oral

1
C1

Van
coci Capsule)
Vancocin HCl (Oral
n
HCl

4 QL
Capsule)

Bold type = Brand name drug Plain type = Generic drug

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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Cefa Cef
clor oxiti

Cefaclor (Oral Cefoxitin Sodium

n
Sodi
um

Suspension 3 (Intravenous Solution 1

C1
Reconstituted) C1
Reconstituted)
Cefa Cef
drox pod

Cefadroxil (Oral Cefpodoxime Proxetil

il oxi
me
Prox
etil

1
C1
Capsule) (Oral Suspension 3
Reconstituted)
Cefa
drox

Cefadroxil (Oral
il

C1

Cef
pod

Suspension 1 Cefpodoxime Proxetil

oxi
me
Prox
etil

1
C1
Reconstituted) C1
(Oral Tablet)
Cefa Cef
drox proz

Cefadroxil (Oral Cefprozil (Oral

il il

1
C1
Tablet) Suspension 1
Reconstituted)
Cefa
zolin

Cefazolin Sodium
Sodi
um

C1

Cef
proz

(10GM Injection Cefprozil (Oral Tablet) 1

il

C1

Solution
Ceft
azidi

Ceftazidime (Injection
me

Reconstituted, 1GM Solution 1

1
Injection Solution Reconstituted)
Reconstituted, 500MG C1

Ceft
riax

Ceftriaxone Sodium
one
Sodi
um

Injection Solution
(1GM Injection
Reconstituted)
C1

Cef
dinir
Solution
C1
Cefdinir (Oral Capsule) 1 Reconstituted, 250MG
Cef
dinir

Cefdinir (Oral Injection Solution

1
Suspension 1 Reconstituted, 2GM
C1
Reconstituted) Injection Solution
Reconstituted, 500MG
Cef
epi

Cefepime HCl
me
HCl

(Injection Solution 1 Injection Solution

Reconstituted) C1
Reconstituted)
Ceft
C1 riax

Ceftriaxone Sodium
one
Cefi Sodi
xim um

Cefixime (Oral
e

Suspension 3 (10GM Intravenous

1
Reconstituted) Solution
C1

Cef
otet

Reconstituted)
Cefotetan Disodium
an
Diso
diu
m

C1

Cef
urox

Cefuroxime Axetil (Oral

ime
Axet
il

(1GM Injection 1
Solution Tablet)
1 C1

Cef
urox

Reconstituted, 2GM Cefuroxime Sodium

ime
Sodi
um

Injection Solution (Injection Solution 1

C1
Reconstituted) C1
Reconstituted)
Cef Cef
oxiti urox

Cefoxitin Sodium Cefuroxime Sodium

n ime
Sodi Sodi
um um

(Injection Solution 1 (Intravenous Solution 1

Reconstituted) Reconstituted)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
tRACK 53 53
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15

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Cep Aza
hale cta

Cephalexin (Oral Azactam (Injection

xin m

1
C1
Capsule) Solution 3
Cep

Reconstituted)
hale

Cephalexin (Oral
xin

C1

Suspension 1
Aztr
eon

Aztreonam (1GM
am

C1
Reconstituted) Injection Solution 3
Cep
hale

Cephalexin (Oral Reconstituted)

xin

1 C1

Tablet)
Erta
pen

Ertapenem Sodium
em
Sodi
um

C1

Maxi
pim

Maxipime (1GM (Injection Solution 3

e

Injection Solution 3 C1
Reconstituted)
Imip
ene

Reconstituted) Imipenem-Cilastatin
m-
Cila
stati
n

C1

(250MG Intravenous
Maxi
pim

Maxipime (2GM
e

1
Intravenous Solution 3 Solution
Reconstituted) C1
Reconstituted)
Imip
ene

Imipenem-Cilastatin
m-
C1 Cila
stati
Sup n
rax

Suprax (Oral Capsule) 2

C1

(500MG Intravenous
3
Sup
rax

Suprax (100MG/5ML Solution

Oral Suspension Reconstituted)
Reconstituted, C1

Inva

3
nz

200MG/5ML Oral Invanz (Injection

Suspension Solution 4
Reconstituted) C1
Reconstituted)
Mer
C1 ope

Meropenem (1GM
nem
Sup
rax

Suprax (500MG/5ML
Oral Suspension 3 Intravenous Solution 3
Reconstituted) C1
Reconstituted)
Mer
ope

Meropenem (500MG
nem
C1

Sup
rax

Suprax (Oral Tablet

2 Intravenous Solution 1
Chewable)
C1

Tazi
cef Reconstituted)
Tazicef (Injection C1

Merr
em

Solution 1 Merrem (500MG

Reconstituted) Intravenous Solution 3
C1

Tefl
aro

Reconstituted)
Teflaro (Intravenous C1

Prim
axin

Primaxin IV
IV

Solution 4
Reconstituted) (Intravenous Solution 3
C1

Zer
bax

Reconstituted)
Zerbaxa (Intravenous
a

C1

Vab
ome

Vabomere
re

Solution 4 PA
Reconstituted) (Intravenous Solution 4
Reconstituted)
Beta-lactam, Other
B1

Bold type = Brand name drug Plain type = Generic drug

 54 tRACK 54 Last updated September 1, 2019
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16

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1

Am
picill

Beta-lactam, Penicillins Ampicillin Sodium

B1 in
Sodi
um

C1

(10GM Intravenous
Am
oxici

Amoxicillin (Oral
llin

1 1
Capsule) Solution
C1

Am
oxici

Reconstituted)
Amoxicillin (Oral
llin

C1

Am
picill

Ampicillin-Sulbactam
in-
Sulb
acta

Suspension 1
m
Sodi
um

Reconstituted) Sodium (Injection

1
C1

Am
oxici

Solution
Amoxicillin (Oral
llin

1 Reconstituted)
Tablet) C1

Aug
men

Augmentin
tin
C1

Am
oxici

Amoxicillin (Oral
llin

1 (125-31.25MG/5ML
Tablet Chewable) 4
C1

Am
oxici
Oral Suspension
Amoxicillin-Potassium
llin-
Pota
ssiu
m
Clav
ulan
ate

Reconstituted)
ER

Clavulanate ER (Oral
1
C1

Bact
ocill

Bactocill in Dextrose
in
Dext

Tablet Extended
rose

3
Release 12 Hour) C1
(Intravenous Solution)
C1
Bicill
Am in C-

Bicillin C-R 900/300

oxici R

Amoxicillin-Potassium
llin- 900/
Pota 300
ssiu
m
Clav
ulan
ate

Clavulanate (Oral (Intramuscular 3

1
Suspension Suspension)
Reconstituted)
C1

Bicill
in C-

Bicillin C-R
R

C1

Am
oxici

Amoxicillin-Potassium
llin-
Pota

(Intramuscular 3
ssiu
m
Clav
ulan
ate

Clavulanate (Oral Suspension)

1
Tablet Immediate C1

Bicill
in L-

Bicillin L-A
A

Release)
C1

Am
oxici (Intramuscular 3
Amoxicillin-Potassium
llin-
Pota
ssiu
m
Clav

Suspension)
ulan
ate

Clavulanate (Oral 1 C1

Dicl
oxa

Dicloxacillin Sodium
cillin

Sodi
um

Tablet Chewable) 1
C1

Am
picill
(Oral Capsule)
Ampicillin (Oral
in

C1

1
Nafc
illin

Nafcillin Sodium (1GM

Sodi
um

Capsule)
C1

Am
picill
Injection Solution
Ampicillin Sodium
in
Sodi
um

Reconstituted, 2GM 3
(125MG Injection Injection Solution
Solution Reconstituted)
1
Reconstituted, 1GM C1

Nafc
illin

Nafcillin Sodium
Sodi
um

Injection Solution
Reconstituted) (10GM Intravenous
3
Solution
Reconstituted)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
tRACK 55 55
54
17

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Oxa Zos
cillin yn

Oxacillin Sodium Zosyn (2-0.25GM/

Sodi
um

(Injection Solution 3 50ML Intravenous

C1
Reconstituted) Solution, 3-0.375GM/ 3
Peni
cillin

Penicillin G
G

50ML Intravenous
Pota
ssiu
m in
Dext
rose

Potassium in C1
Solution)
Dextrose
Zos
yn

Zosyn (40.5
(40000UNIT/ML 2 (36-4.5)GM
Intravenous Solution, 3
Intravenous Solution
60000UNIT/ML Reconstituted)
C1
Intravenous Solution) B1

Macrolides
Peni
cillin

Penicillin G Potassium
G C1
Pota
ssiu Aza
m site

Azasite (Ophthalmic
(20000000UNIT 3
3 Solution)
Injection Solution C1

Azit
hro

Azithromycin
myci
n

Reconstituted)
C1

Peni
cillin
(Intravenous Solution 1
Penicillin G Procaine
G
Proc
aine

Reconstituted)
(Intramuscular 3 C1

Azit
hro

Azithromycin (Oral
myci
n

Suspension) 1
C1

Peni
cillin
Packet)
Penicillin G Sodium
G
Sodi
um

C1

Azit
hro

Azithromycin (Oral
myci
n

(Injection Solution 4
Reconstituted) Suspension 1
C1

Peni
cillin
Reconstituted)
Penicillin V Potassium
V
Pota
ssiu
m

C1

Azit
hro

Azithromycin (Oral
myci
n

(Oral Solution 1 1
Reconstituted) C1
Tablet)
Clari
C1 thro

Clarithromycin ER
myci
Peni n
cillin ER

Penicillin V Potassium
V
Pota
ssiu
m

1 (Oral Tablet Extended 1

(Oral Tablet)
C1

Pipe
racill
Release 24 Hour)
Piperacillin-
in-
Taz
oba
cta
m
C1

Clari
thro

Clarithromycin (Oral
myci
n

Tazobactam
1 Suspension 3
(Intravenous Solution
Reconstituted) C1
Reconstituted)
Clari
C1 thro

Clarithromycin (Oral
myci
Una n
syn

Unasyn (15 (10-5)GM

Injection Solution Tablet Immediate 1
Reconstituted, 3 C1
Release)
3
Dific
id

(2-1)GM Injection C1
Dificid (Oral Tablet) 4
E.E.
S.

E.E.S. 400 (Oral

400

Solution 3
Reconstituted) Tablet)

Bold type = Brand name drug Plain type = Generic drug

 56 tRACK 56 Last updated September 1, 2019
55
18

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

E.E. Eryt
S. hro

E.E.S. Granules (Oral Erythromycin

Gra myci
nule n
s

1
Suspension 3 C1
(Ophthalmic Ointment)
Zithr

Reconstituted)
oma

Zithromax
x

C1

EryP

(Intravenous Solution 3
ed

EryPed 200 (Oral

200

Suspension 3 C1
Reconstituted)
Zithr

Reconstituted)
oma

Zithromax (Oral
x

C1

EryP
3
Packet)
ed

EryPed 400 (Oral

400

C1

Zithr

Suspension
oma

4 Zithromax (Oral
x

C1
Reconstituted) Suspension 3
Ery-

Reconstituted)
Tab

Ery-Tab (Oral Tablet

3 C1

Delayed Release)
Zithr
oma

Zithromax (250MG
x

C1

Eryt
hroc

Erythrocin Oral Tablet, 500MG 3

in
Lact
obio
nate

Lactobionate Oral Tablet)

3
(Intravenous Solution
C1

Zithr
oma

Zithromax Tri-Pak
x
Tri-
Pak

Reconstituted) 3
C1

Eryt
hroc
(Oral Tablet)
Erythrocin Stearate
in
Stea C1
rate
Zithr
oma

Zithromax Z-Pak (Oral

x Z-

3
Pak

(Oral Tablet) 3
C1

Eryt
hro
Tablet)
Erythromycin Base
myci
n
Bas
e

Quinolones
B1

(Oral Capsule Delayed 3 C1

Avel
ox

Release Particles) Avelox (400MG Oral

3
Tablet)
C1

Eryt
hro

Erythromycin Base
myci
n
Bas
e

C1

Bax
dela

(Oral Tablet Immediate 3 Baxdela (Intravenous

C1
Release) Solution 4
Reconstituted)
Eryt
hro

Erythromycin
myci
n
Ethy
lsuc
cina
te

C1

Bax
dela

Ethylsuccinate C1
Baxdela (Oral Tablet) 4
(200MG/5ML Oral 3
Besi
vanc

Besivance
e

Suspension (Ophthalmic 3
C1
Reconstituted) Suspension)
Eryt
hro

Erythromycin
myci
n C1
Ethy
lsuc Cilo
cina xan

Ciloxan (Ophthalmic
te

Ethylsuccinate 3
Ointment)
(400MG/5ML Oral 4 C1

Cilo
xan

Suspension Ciloxan (Ophthalmic

3
Reconstituted) C1
Solution)
C1 Cipr
o

Cipro (Oral
Eryt
hro

Erythromycin
myci
n
Ethy
lsuc
cina
te

Ethylsuccinate (Oral 3 Suspension 3

Tablet) Reconstituted)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
tRACK 57 57
56
19

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Cipr Lev
o oflo

Cipro (Oral Tablet) 3 Levofloxacin (250MG

xaci
n

C1

Oral Tablet, 500MG

Cipr
oflo

Ciprofloxacin HCl
xaci
n
HCl

1 1
(Ophthalmic Solution) Oral Tablet, 750MG
C1

Cipr
oflo

Oral Tablet)
Ciprofloxacin HCl
xaci
n
HCl

C1

Mox
eza

(100MG Oral Tablet 3 Moxeza (Ophthalmic

3
Immediate Release) C1
Solution)
C1 Mox
iflox

Moxifloxacin HCl in
Cipr acin
oflo HCl

Ciprofloxacin HCl
xaci in
n NaC
HCl l

(250MG Oral Tablet NaCl (Intravenous 3

Immediate Release, C1
Solution)
Mox

500MG Oral Tablet 1

iflox

Moxifloxacin HCl
acin
HCl

Immediate Release, 1
(Ophthalmic Solution)
750MG Oral Tablet
C1

Mox
iflox

Moxifloxacin HCl (Oral

acin
HCl

Immediate Release) 1
C1

Cipr
oflo
Tablet)
Ciprofloxacin in D5W
xaci C1
n in
D5 Ocu
W flox

Ocuflox (Ophthalmic
(200MG/100ML 1 3
Solution)
Intravenous Solution) C1

Oflo
xaci

Ofloxacin (Ophthalmic
n

C1

Cipr

1
oflo

Ciprofloxacin (Oral
xaci
n

Solution)
Suspension 1 C1

Oflo
xaci

Ofloxacin (Oral Tablet) 1

n

Reconstituted) C1

Oflo
xaci

Ofloxacin (Otic
C1 n

Gatif
loxa

Gatifloxacin
cin

1 1
(Ophthalmic Solution) C1
Solution)
Viga
mox

Vigamox (Ophthalmic
C1

Lev
oflo

Levofloxacin in D5W
xaci
n in

3
D5
W

(500MG/100ML C1
Solution)
Xepi

Intravenous Solution, 1 C1
Xepi (External Cream) 3
750MG/150ML
Zym
axid

Zymaxid (Ophthalmic
Intravenous Solution) 3
C1

Lev
oflo
Solution)
Levofloxacin (25MG/
xaci
n

Sulfonamides
B1

ML Intravenous 3 C1

Bact
rim

Bactrim DS (Oral
DS

Solution) 3
C1

Lev
oflo Tablet)
Levofloxacin (0.5%
xaci
n

C1

Bact

1
rim

Ophthalmic Solution) C1
Bactrim (Oral Tablet) 3
Blep
h-10

Bleph-10 (Ophthalmic
C1

Lev
oflo

Levofloxacin (25MG/
xaci
n

1 3
ML Oral Solution) C1
Solution)
Silva
den

Silvadene (External
e

3
Cream)

Bold type = Brand name drug Plain type = Generic drug

 58 tRACK 58 Last updated September 1, 2019
57
20

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Silv Dox
er ycyc

Silver Sulfadiazine Doxycycline Hyclate

Sulf line
adia Hycl
zine ate

1
C1
(External Cream) (100MG Oral Tablet
Immediate Release, 1
SSD

SSD (External Cream) 1

C1

Sulf
acet

20MG Oral Tablet

Sulfacetamide Sodium
ami
de
Sodi
um

1 Immediate Release)
(Ophthalmic Ointment) C1

Dox
ycyc

Doxycycline Hyclate
line
Hycl
C1 ate
Sulf
acet

Sulfacetamide Sodium
ami
de
Sodi
um

1 (150MG Oral Tablet

(Ophthalmic Solution)
C1

Sulf
adia
Immediate Release, 3
Sulfadiazine (Oral
zine

3 75MG Oral Tablet

C1
Tablet) Immediate Release)
Sulf
ame

Sulfamethoxazole-
thox C1
azol
e- Dox
Trim ycyc

Doxycycline Hyclate
etho line
prim Hycl
ate

Trimethoprim (Oral 1 (100MG Oral Tablet

C1
Suspension) Delayed Release,
Sulf
ame

Sulfamethoxazole-
thox

150MG Oral Tablet

azol
e-
Trim
etho
prim

Trimethoprim (Oral 1 Delayed Release,

Tablet) 200MG Oral Tablet 3
B1

Tetracyclines Delayed Release,

50MG Oral Tablet
C1

De
mec

Demeclocycline HCl
locy
cline
HCl

3 Delayed Release,
(Oral Tablet)
C1

Dor
yx 75MG Oral Tablet
Doryx MPC (Oral
MP
C

Delayed Release)
Tablet Delayed 3 C1

Dox
ycyc

Doxycycline
line
Mon
ohy
drat
e

C1
Release) Monohydrate (100MG
Dor
yx

Doryx (200MG Oral Oral Capsule, 150MG 1

Tablet Delayed 4 Oral Capsule, 50MG
C1
Release) C1
Oral Capsule)
Dor Dox
yx ycyc

Doryx (50MG Oral Doxycycline

line
Mon
ohy
drat
e

Tablet Delayed 3 Monohydrate (75MG 3

Release) C1
Oral Capsule)
C1 Dox
ycyc

Doxycycline
Dox line
y Mon

Doxy 100 (Intravenous

100 ohy
drat
e

Solution 3 Monohydrate (Oral

1
Reconstituted) Suspension
Reconstituted)
C1

Dox
ycyc

Doxycycline Hyclate
line
Hycl
ate

1
C1

Dox
ycyc

Doxycycline
line
Mon

(Oral Capsule)
ohy
drat
e

Monohydrate (Oral 1
Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
tRACK 59 59
58
21

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Min Vibr
ocin amy

Minocin (50MG Oral Vibramycin (50MG/

cin

3 3
C1
Capsule) C1
5ML Oral Syrup)
Min Ximi
ocy no

Minocycline HCl ER Ximino (Oral Capsule

cline
HCl
ER

(Oral Tablet Extended 3 QL Extended Release 24 4 QL

C1
Release 24 Hour) Hour)
Min
ocy

Minocycline HCl (Oral

cline
HCl

Anticonvulsants
A1

1
C1
Capsule) B1

Anticonvulsants, Other
Min
ocy

Minocycline HCl (Oral

cline
HCl C1

BRI
VIA

BRIVIACT (Oral
CT

Tablet Immediate 1 4 PA; QL

Solution)
Release) C1

BRI
VIA

BRIVIACT (Oral
CT

C1

Mon
dox

Mondoxyne NL
yne

4 PA; QL
NL

(100MG Oral Capsule, 1 C1

Tablet)
Epid
iolex

75MG Oral Capsule) Epidiolex (Oral

4 PA
Solution)
C1

Mor
gido

Morgidox (50MG Oral

x

1 C1

Kep
pra

Keppra (Oral
Capsule)
C1
4
Solution)
Nuz
yra

Nuzyra (Intravenous C1

Kep
pra

Solution 4 PA Keppra (1000MG Oral

C1
Reconstituted) Tablet Immediate
Release, 500MG Oral
Nuz
yra

Nuzyra (Oral Tablet) 4 PA; QL

Tablet Immediate 4
C1

Ora
cea

Oracea (Oral Capsule

3 Release, 750MG Oral
Delayed Release)
C1

Solo
dyn
Tablet Immediate
Solodyn (Oral Tablet
Release)
Extended Release 24 4 QL C1

Kep
pra

Hour) Keppra (250MG Oral

C1

Solo
xide
Tablet Immediate 3
Soloxide (Oral Tablet
3 Release)
Delayed Release) C1

Kep
pra

Keppra XR (Oral
XR
C1

TAR
GA

TARGADOX (Oral
DOX

3 Tablet Extended 4
Tablet)
C1

Tetr
acyc

Release 24 Hour)
Tetracycline HCl (Oral
line
HCl

C1

3 Lev
etira
ceta
m
ER

Levetiracetam ER (Oral
Capsule)
C1

Vibr
amy

Tablet Extended 1
Vibramycin (Oral
cin

3 Release 24 Hour)
Capsule) C1

Lev
etira

Levetiracetam (Oral
ceta
m

C1

Vibr
amy

Vibramycin (Oral 1
cin

Solution)
Suspension 3
Reconstituted)

Bold type = Brand name drug Plain type = Generic drug

 60 tRACK 60 Last updated September 1, 2019
59
22

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Lev Clo
etira baz

Levetiracetam (Oral Clobazam (2.5MG/ML

ceta am
m

4 PA; QL
Tablet Immediate 1 C1
Oral Suspension)
Release)
Clo
baz

Clobazam (10MG Oral

am

C1

Row
eepr
3 PA; QL
Roweepra (Oral Tablet Tablet)
a

1 C1

Immediate Release)
Clo
baz

Clobazam (20MG Oral

am

C1

Row
eepr
4 PA; QL
Roweepra XR (Oral Tablet)
a XR

C1

Tablet Extended 1
Dep
ake

Depakene (Oral
ne

Release 24 Hour) 3
C1

Sprit
am
Capsule)
Spritam (1000MG
C1

Dias
tat

Diastat AcuDial
Acu
Dial

Oral Tablet 3
(Rectal Gel)
Disintegrating C1

Dias
tat

Diastat Pediatric
Pedi
atric

Soluble, 250MG Oral 3

(Rectal Gel)
Tablet Disintegrating C1

Gab

3
ape

Gabapentin (Oral
ntin

Soluble, 500MG Oral 1

Capsule)
Tablet Disintegrating C1

Gab
ape

Gabapentin (250MG/
ntin

Soluble, 750MG Oral 1

5ML Oral Solution)
Tablet Disintegrating C1

Gab
ape

Gabapentin (Oral
ntin

Soluble) 1
Tablet)
Calcium Channel Modifying Agents
B1

C1

Gabi
tril

C1

Celo
ntin Gabitril (Oral Tablet) 4
Celontin (Oral C1

Mys

3
olin

Mysoline (Oral Tablet) 4

e

Capsule) C1

Neu
ronti

Neurontin (100MG
n

C1

Etho
suxi

Ethosuximide (Oral
mid

3
e

1 Oral Capsule)
Capsule) C1

Neu
ronti

Neurontin (300MG
n
C1

Etho
suxi

Ethosuximide (Oral
mid
e

1 Oral Capsule, 400MG 4

Solution)
C1

Zaro
ntin

Zarontin (Oral C1
Oral Capsule)
3
Neu
ronti

Neurontin (Oral
n

Capsule) 3
C1

Zaro
ntin

Zarontin (Oral Solution)

3
C1

Neu
ronti

Neurontin (Oral
n

Solution) 4
Tablet)
C1

Zon
egra

Zonegran (Oral
n

4
C1

Onfi

Capsule) Onfi (Oral

4 PA; QL
Suspension)
C1

Zoni
sami

Zonisamide (Oral
de

1
C1

Onfi

Capsule) C1
Onfi (Oral Tablet) 4 PA; QL
Phe
nob

Phenobarbital (Oral
arbit
al

Gamma-aminobutyric Acid (GABA)

B1

1 PA; HRM
Augmenting Agents Elixir)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
tRACK 61 61
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Phe Lam
nob ictal

Phenobarbital (Oral Lamictal (100MG Oral

arbit
al

1 PA; HRM
C1
Tablet) Tablet Immediate
Prim

Release, 150MG Oral

idon

Primidone (Oral
e

1
C1
Tablet) Tablet Immediate
Sabr

Release, 200MG Oral 4

il

C1
Sabril (Oral Packet) 4 PA; LA; QL
Tablet Immediate
Sabr
il

Sabril (Oral Tablet) 4 PA; LA; QL

Release, 25MG Oral
C1

Sym
paz

Sympazan (Oral Film) 4 PA; QL

an

C1

Tiag
abin
Tablet Immediate
Tiagabine HCl (Oral
e
HCl

3 Release)
Tablet) C1

Lam
ictal

C1

Valp
roic
Acid

Valproic Acid (Oral Lamictal (25MG Oral

1 4
Capsule) C1
Tablet Chewable)
Lam
ictal

Lamictal (5MG Oral

C1

Valp
roic

Valproic Acid (Oral

Acid

1 3
Solution) C1
Tablet Chewable)
Lam
C1 ictal

Lamictal Starter (35

Start
Viga er
batri

Vigabatrin (Oral
n

4 PA; LA; QL Tablets Oral Kit, 49 3

Packet)
Tablets Oral Kit)
C1

Viga
batri

Vigabatrin (Oral
n

4 PA; LA; QL C1

Lam
ictal
Start

Lamictal Starter (98

Tablet)
er

C1
4
Tablets Oral Kit)
Viga
dron

Vigadrone (Oral
e

4 PA; LA; QL C1

Lam
ictal

Packet) Lamictal XR (Oral Kit) 3

XR

C1

Lam
ictal

Glutamate Reducing Agents Lamictal XR (100MG

B1 XR

C1

Felb

Oral Tablet Extended

ama

Felbamate (Oral
te

4
C1
Suspension) Release 24 Hour,
200MG Oral Tablet
Felb
ama

Felbamate (Oral
te

3 Extended Release 24
C1
Tablet)
Hour, 250MG Oral
Felb
atol

Felbatol (Oral
4 Tablet Extended
Suspension)
Release 24 Hour,
C1

Felb
atol

Felbatol (Oral Tablet) 4 4

C1

Fyc
omp
25MG Oral Tablet
Fycompa (Oral
a

4 Extended Release 24
Suspension)
C1

Fyc
omp Hour, 300MG Oral
Fycompa (Oral
a

4 Tablet Extended
C1
Tablet) Release 24 Hour,
Lam
ictal

Lamictal ODT (Oral

ODT

4 50MG Oral Tablet

Tablet Dispersible) Extended Release 24
Hour)

Bold type = Brand name drug Plain type = Generic drug

 62 tRACK 62 Last updated September 1, 2019
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Lam Top
otrig ama

Lamotrigine ER (Oral Topamax (100MG

ine x
ER

Tablet Extended 3 Oral Tablet, 200MG

Release 24 Hour) 4
C1

Lam
otrig
Oral Tablet, 50MG
Lamotrigine (100MG
ine

C1
Oral Tablet)
Oral Tablet Immediate Top
ama
x

Topamax (25MG Oral

Release, 150MG Oral 3
Tablet)
Tablet Immediate C1

Top
ama

Topamax Sprinkle
x
Spri
nkle

Release, 200MG Oral 1

Tablet Immediate (15MG Oral Capsule 3
Release, 25MG Oral C1
Sprinkle)
Top
ama

Tablet Immediate Topamax Sprinkle

x
Spri
nkle

C1
Release) (25MG Oral Capsule 4
Lam
otrig

Lamotrigine (25MG Sprinkle)

ine

C1

Oral Tablet Chewable,

Topi
ram

Topiramate ER (Oral
ate
ER

1
5MG Oral Tablet Capsule ER 24 Hour 3 PA
C1
Chewable) Sprinkle)
Lam
C1
otrig

Lamotrigine ODT (Oral

ine Topi
ODT ram

Topiramate (Oral
ate

3
C1
Tablet Dispersible) Capsule Sprinkle 1
Lam
otrig

Lamotrigine Starter Kit- Immediate Release)

ine
Start
er
Kit-
Blue

3 C1

Blue (Oral Kit)

Topi
ram

Topiramate (Oral
ate

C1

Lam
otrig
1
Lamotrigine Starter Kit- Tablet)
ine
Start
er
Kit-
Gre
en

4 C1

Green (Oral Kit)

Trok
endi

Trokendi XR (100MG
XR

C1

Lam
otrig

Lamotrigine Starter Kit-

ine

Oral Capsule
Start
er
Kit-
Ora
nge

3
Orange (Oral Kit) Extended Release 24
C1

Qud
exy
4 PA
Qudexy XR (100MG Hour, 200MG Oral
XR

Oral Capsule ER 24 Capsule Extended

Hour Sprinkle, 25MG C1
Release 24 Hour)
Oral Capsule ER 24 3 PA
Trok
endi

Trokendi XR (25MG
XR

Hour Sprinkle, 50MG Oral Capsule

Oral Capsule ER 24 Extended Release 24
Hour Sprinkle) 3 PA
C1

Qud
Hour, 50MG Oral
exy

Qudexy XR (150MG Capsule Extended

XR

Oral Capsule ER 24 Release 24 Hour)

Hour Sprinkle, 4 PA B1

Sodium Channel Agents

200MG Oral Capsule
C1

Apti
om

Aptiom (Oral Tablet) 4 QL

ER 24 Hour Sprinkle)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Ban Dila
zel ntin

Banzel (Oral Dilantin (Oral

4 3
C1
Suspension) C1
Suspension)
Ban Epit
zel ol

C1
Banzel (Oral Tablet) 4 C1
Epitol (Oral Tablet) 1
Car Oxc
bam arba

Carbamazepine ER Oxcarbazepine
aze zepi
pine ne
ER

(100MG Oral Capsule (300MG/5ML Oral 3

Extended Release 12 C1
Suspension)
Hour, 200MG Oral
Oxc
arba

Oxcarbazepine
zepi
ne

Capsule Extended 1 (150MG Oral Tablet,

Release 12 Hour, 1
300MG Oral Tablet,
300MG Oral Capsule 600MG Oral Tablet)
Extended Release 12 C1

Oxt
ellar

Oxtellar XR (150MG
XR

Hour)
C1

Car
bam
Oral Tablet Extended
Carbamazepine ER
aze
pine
ER

Release 24 Hour,
(100MG Oral Tablet 3 PA
300MG Oral Tablet
Extended Release 12
1 Extended Release 24
Hour, 200MG Oral
Tablet Extended C1
Hour)
Oxt
ellar

Oxtellar XR (600MG
XR

C1
Release 12 Hour)
Oral Tablet Extended 4 PA
Car
bam

Carbamazepine ER
aze
pine
ER

(400MG Oral Tablet Release 24 Hour)

3 C1

Peg

Extended Release 12
ano

Peganone (Oral
ne

Hour) 3
C1

Car
bam
C1
Tablet)
Carbamazepine (Oral
aze Phe
pine nyte

Phenytek (Oral
k

1 1
C1
Suspension) Capsule)
Car
C1
bam

Carbamazepine (Oral
aze Phe
pine nyto

Phenytoin (Oral
in

Tablet Immediate 1 1
Suspension)
Release) C1

Phe
nyto
in

Phenytoin (Oral Tablet

1
C1

Car
bam

Carbamazepine (Oral
aze
pine

1 Chewable)
C1
Tablet Chewable) C1

Phe
nyto
in
Sodi
um
Exte
nde
d
Phenytoin Sodium
Car
batr

Carbatrol (Oral
ol

Extended (Oral 1
Capsule Extended 3 Capsule)
C1

Release 12 Hour)
Tegr
etol

Tegretol (Oral
C1

Dila
ntin
INF

Dilantin INFATABS 3
Suspension)
ATA
BS

2
(Oral Tablet Chewable)
C1

Tegr
etol

Tegretol (Oral Tablet

3
C1

Dila
ntin

Dilantin (Oral Capsule) 2 Immediate Release)

Bold type = Brand name drug Plain type = Generic drug

 64 tRACK 64 Last updated September 1, 2019
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Tegr Raz
etol ady

Tegretol XR (Oral Razadyne ER (Oral

XR ne
ER

Tablet Extended 3 Capsule Extended 3

C1
Release 12 Hour) C1
Release 24 Hour)
Trile Raz
ptal ady

Trileptal (Oral Razadyne (Oral

ne

4 3
C1
Suspension) C1
Tablet)
Trile Riva
ptal stig

Trileptal (150MG Oral Rivastigmine Tartrate

min
e
Tartr
ate

3 1
Tablet) C1
(Oral Capsule)
C1
Riva
Trile stig

Rivastigmine
ptal min

Trileptal (300MG Oral

e

Tablet, 600MG Oral 4 (Transdermal Patch 24 3 ST; QL

Tablet) Hour)
C1

N-methyl-D-aspartate (NMDA) Receptor

B1
Vim
pat

Vimpat (Oral Solution) 3 QL

C1

Vim
pat

Vimpat (Oral Tablet) 3 QL C1

Antagonist
Me
man

Memantine HCl ER
tine
HCl
ER

Antidementia Agents
A1

(Oral Capsule
B1

Cholinesterase Inhibitors 3 PA; QL

C1

Aric
ept
Extended Release 24
C1
Aricept (Oral Tablet) 3 QL Hour)
Don C1
epe
Me

Donepezil HCl (Oral

zil
man
HCl

Memantine HCl (Oral

tine
HCl

1 QL 3 PA; QL
C1
Tablet) Solution)
Don C1
epe
Me

Donepezil HCl ODT

zil
man
HCl

Memantine HCl (10MG

tine
ODT
HCl

(Oral Tablet 1 QL Oral Tablet, 5MG Oral 1 PA; QL

C1
Dispersible) Tablet)
Exel C1
on
Me

Exelon (Transdermal
man

Memantine HCl
tine
HCl
Titra
tion
Pak

3 ST; QL
C1
Patch 24 Hour) Titration Pak (Oral 1 PA
Gala
nta

Galantamine Tablet)
min
e
Hyd
robr
omi
de
ER

C1

Hydrobromide ER
Na
men

Namenda (Oral
da

(Oral Capsule 1 3 PA; QL

Tablet)
Extended Release 24 C1

Na
men

Namenda Titration
da
Titra
tion
Pak

Hour) 3 PA
C1

Gala
nta Pak (Oral Tablet)
Galantamine
min
e
Hyd
robr
omi C1
de
Na
men

Namenda XR (Oral
da
XR

Hydrobromide (Oral 3
Solution) Capsule Extended 3 PA; QL
C1

Gala
nta
min
e
Hyd
robr
omi
de
Galantamine C1
Release 24 Hour)
Na
men

Namenda XR
da
XR

Hydrobromide (Oral 1
Titra
tion
Pac
k

Tablet) Titration Pack (Oral

3 PA; QL
Capsule Extended
Release 24 Hour)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
tRACK 65 65
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1

Sym
byax

Antidepressants Symbyax (Oral

A1

3
B1

Antidepressants, Other C1
Capsule)
C1 Well
butri

Wellbutrin SR (Oral
Aple n
nzin SR

Aplenzin (Oral Tablet

Extended Release 24 4 Tablet Extended 3
Hour) C1
Release 12 Hour)
C1 Well
butri

Wellbutrin XL (Oral
Bup n XL
ropi

Bupropion HCl SR
on
HCl
SR

(Oral Tablet Extended 1 Tablet Extended 4

C1
Release 12 Hour) Release 24 Hour)
Bup
ropi

Bupropion HCl XL
on

Monoamine Oxidase Inhibitors

B1
HCl
XL

C1

(150MG Oral Tablet Ems

am

Emsam (Transdermal
Extended Release 24 4
1 Patch 24 Hour)
Hour, 300MG Oral C1

Mar
plan

Tablet Extended C1
Marplan (Oral Tablet) 3
Nar
dil

Release 24 Hour) C1
Nardil (Oral Tablet) 3
C1 Parn
ate

Parnate (Oral Tablet) 4

Bup
ropi

Bupropion HCl ER (XL)

on
HCl
ER

C1

Phe

(450MG Oral Tablet

nelzi

Phenelzine Sulfate
ne
Sulf
ate

3 1
Extended Release 24 (Oral Tablet)
Hour)
C1

Tran
ylcy

Tranylcypromine
pro
min
e
Sulf
ate

C1

Bup
ropi
on

Bupropion HCl (Oral 3

Sulfate (Oral Tablet)
HCl

Tablet Immediate 1 B1

SSRI/SNRI (Selective Serotonin Reuptake

C1
Release) Inhibitors/Serotonin and Norepinephrine
Forfi
vo

Forfivo XL (Oral
XL

Reuptake Inhibitors)
Tablet Extended 3
C1

Cele
xa

Celexa (Oral Tablet) 3

Release 24 Hour) C1

Cital
opra

Citalopram
m
Hyd
robr
omi
de
C1

Mirt
aza

Mirtazapine (Oral
pine

1 Hydrobromide (Oral 1
C1
Tablet) Solution)
Mirt
aza

Mirtazapine ODT (Oral

pine C1

Cital
ODT
opra

Citalopram
m
Hyd
robr

1
omi
de

C1
Tablet Dispersible) Hydrobromide (Oral 1
Olan
zapi

Olanzapine-Fluoxetine
ne-

Tablet)
Fluo
xeti
ne
HCl

3
HCl (Oral Capsule)
C1

Des
venl

Desvenlafaxine ER
afaxi
ne
ER

C1

Re
mer

Remeron (Oral
on

(Oral Tablet Extended

3
C1
Tablet) Release 24 Hour) 3
Re
mer
on
SolT
ab

Remeron SolTab (Brand Equivalent

(Oral Tablet 3 Khedezla)
Dispersible)

Bold type = Brand name drug Plain type = Generic drug

 66 tRACK 66 Last updated September 1, 2019
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Des Fluv
venl oxa

Desvenlafaxine Fluvoxamine Maleate

afaxi min
ne e
Suc Mal
cina eate
te ER
ER

Succinate ER (Oral ER (Oral Capsule

3
Tablet Extended 1 Extended Release 24
Release 24 Hour) C1
Hour)
(Generic Pristiq)
Fluv
oxa

Fluvoxamine Maleate
min
e
Mal
eate

C1

Effe
xor
1
Effexor XR (Oral (Oral Tablet)
XR

C1

Capsule Extended 3
Khe
dezl

Khedezla (Oral Tablet

a

C1
Release 24 Hour) Extended Release 24 3
Esci
talo

Escitalopram Oxalate Hour)

pra
m
Oxal
ate

1 C1

(Oral Solution)
Lex
apro

C1

Esci
talo C1
Lexapro (Oral Tablet) 3
Escitalopram Oxalate
pra
m Map
Oxal rotili

Maprotiline HCl (Oral

ate ne
HCl

1 1
C1
(Oral Tablet) Tablet)
Fetz
ima C1

Fetzima (Oral
Nef
azo

Nefazodone HCl (Oral

don
e
HCl

Capsule Extended 3 ST 1
Tablet)
Release 24 Hour)
C1

Paro
xeti

Paroxetine HCl (Oral

ne
HCl

C1

Fetz
ima

Fetzima Titration
Titra

Tablet Immediate 1 PA; HRM

tion

(Oral Capsule ER 24 3 ST C1
Release)
Paxil

Hour Therapy Pack) Paxil (Oral

C1

Fluo
xeti
3 PA; HRM
Fluoxetine HCl (10MG Suspension)
ne
HCl

C1

Oral Capsule
Paxil

Paxil (Oral Tablet

Immediate Release, 3 PA; HRM
Immediate Release)
20MG Oral Capsule 1 C1

Prist
iq

Pristiq (Oral Tablet

Immediate Release,
40MG Oral Capsule Extended Release 24 3
Immediate Release) C1
Hour)
Proz
ac

Prozac (10MG Oral

C1

Fluo
xeti

Fluoxetine HCl (90MG

ne
HCl

3
Oral Capsule Delayed 1 C1
Capsule)
Proz
ac

C1
Release) Prozac (20MG Oral
Fluo

Capsule, 40MG Oral 4

xeti

Fluoxetine HCl (20MG/

ne
HCl

1
C1
5ML Oral Solution) C1
Capsule)
Fluo Sara
xeti fem

Fluoxetine HCl (10MG Sarafem (Oral Tablet) 3

ne
HCl

C1

Oral Tablet, 20MG Oral 1

Sert
ralin

Sertraline HCl (Oral

e
HCl

Tablet) 1
C1

Fluo
xeti C1
Concentrate)
Fluoxetine HCl (60MG
ne Sert
HCl ralin

Sertraline HCl (Oral

e
HCl

3 1
Oral Tablet) Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
tRACK 67 67
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Traz Dox
odo epin

Trazodone HCl (Oral Doxepin HCl (Oral

ne HCl
HCl

1 1 PA; HRM
C1
Tablet) C1
Capsule)
Trint Dox
ellix epin

Trintellix (Oral Tablet) 3 Doxepin HCl (Oral

HCl

C1
1 PA; HRM
Concentrate)
Venl
afaxi

Venlafaxine HCl ER
ne
HCl
ER

C1

Imip
rami

(Oral Capsule Imipramine HCl (Oral

ne
HCl

1 1 PA; HRM
Extended Release 24 C1
Tablet)
Hour)
Imip
rami

Imipramine Pamoate
ne
Pam
oate

C1

Venl
afaxi
3 PA; HRM
Venlafaxine HCl ER (Oral Capsule)
ne
HCl
ER

C1

(Oral Tablet Extended 3

Nor
pra

Norpramin (Oral
min

Release 24 Hour) 3 PA; HRM

C1

Venl
afaxi
Tablet)
Venlafaxine HCl (Oral
ne C1
HCl
Nort
ripty

Nortriptyline HCl (Oral

line
HCl

Tablet Immediate 1 1 PA; HRM

Capsule)
Release) C1

Nort
ripty

Nortriptyline HCl (Oral

line
HCl

C1

1 PA; HRM
Viibr
yd

C1
Viibryd (Oral Tablet) 3 Solution)
Viibr
yd

Viibryd Starter Pack

Start C1
er
Pac Pam
k elor

3 Pamelor (Oral
(Oral Kit) 4 PA; HRM
C1

Zolo
ft
Capsule)
Zoloft (Oral Tablet) 3
C1

Prot
ripty

Protriptyline HCl (Oral

line
HCl

B1

Tricyclics 1 PA; HRM

C1

Amit
C1
Tablet)
ripty Sur

Amitriptyline HCl (Oral

line mon

Surmontil (100MG
HCl til

1 HRM
Tablet) Oral Capsule, 25MG
C1

Am
oxa
3 PA; HRM
Amoxapine (Oral
pine

Oral Capsule, 50MG

1 PA; HRM
C1
Tablet) Oral Capsule)
Anaf C1
ranil

Anafranil (Oral
Tofr
anil

4 PA; HRM C1
Tofranil (Oral Tablet) 4 PA; HRM
Capsule) Trim
ipra
min
e
Mal
eate

Trimipramine Maleate
C1

Clo
mipr

3 PA; HRM
Clomipramine HCl
ami

(Oral Capsule)
ne
HCl

3 PA; HRM
C1
(Oral Capsule) A1

Antiemetics
Desi
pra

Desipramine HCl
min
e
HCl

Antiemetics, Other
B1

(100MG Oral Tablet, 3 PA; HRM C1

Co
mpr

Compro (Rectal
o

150MG Oral Tablet) 1

C1

Desi
pra
Suppository)
Desipramine HCl
min
e
HCl C1

Hyd
roxy

Hydroxyzine Pamoate
zine
Pam
oate

(10MG Oral Tablet, 1 PA; HRM

(Oral Capsule)
25MG Oral Tablet, 1 PA; HRM C1

Mec
lizin

Meclizine HCl (12.5MG

e
HCl

50MG Oral Tablet, 1 HRM

75MG Oral Tablet) Oral Tablet)

Bold type = Brand name drug Plain type = Generic drug

 68 tRACK 68 Last updated September 1, 2019
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Met Eme
oclo nd

Metoclopramide HCl Emend (Oral

pra
mid
e
HCl

(5MG/5ML Oral 1 Suspension 3 PA

C1
Solution) Reconstituted)
Met C1
oclo

Metoclopramide HCl
pra Eme
mid nd

Emend Tri-Pack (Oral

e Tri-
HCl Pac
k

1 4 PA
C1
(Oral Tablet) Capsule)
Met
oclo C1

Metoclopramide HCl
pra
mid Gra
e nise

Granisetron HCl (Oral

HCl tron
ODT HCl

ODT (Oral Tablet 3 1 B/D, PA

Tablet)
Dispersible) C1

Mari
nol

C1

Per
phe
Marinol (10MG Oral
Perphenazine (Oral
nazi
ne

1 Capsule, 5MG Oral 4 PA

C1
Tablet) Capsule)
Proc
hlor

Prochlorperazine
pera
zine
Mal C1
eate Mari
nol

1 Marinol (2.5MG Oral

Maleate (Oral Tablet) 3 PA
C1

Proc
hlor
Capsule)
Prochlorperazine
pera
zine
C1

Ond
ans

1 Ondansetron HCl (Oral

etro
n
HCl

(Rectal Suppository) 1 B/D, PA

C1

Regl
an
Solution)
Reglan (Oral Tablet) 3 C1

Ond
ans

Ondansetron HCl (Oral

etro
n
HCl

C1

1 B/D, PA
Sco
pola

Scopolamine
min
e

Tablet)
(Transdermal Patch 72 1 PA; HRM C1

Ond
ans

Ondansetron ODT
etro
n
ODT

Hour)
C1

Tiga
n
(Oral Tablet 1 B/D, PA
C1
Tigan (Oral Capsule) 3 B/D, PA Dispersible)
Tran
sder

Transderm-Scop
m- C1
Sco
p San
cus

Sancuso
o

(1.5MG) 4
3 PA; HRM (Transdermal Patch)
(Transdermal Patch C1

Syn
dros

Syndros (Oral
72 Hour) 4 PA
C1

Trim
etho
Solution)
Trimethobenzamide
ben
zami
de C1
HCl Varu
bi

1 B/D, PA Varubi (Oral Tablet) 3 B/D, PA

HCl (Oral Capsule) C1

Zofr
an

C1

Vist
aril
Zofran (8MG Oral
Vistaril (Oral Capsule) 3 PA; HRM 4 B/D, PA
Tablet)
Emetogenic Therapy Adjuncts
B1

C1

Zupl
enz

C1

Apr
epit
Zuplenz (Oral Film) 4 B/D, PA
Aprepitant (Oral
ant

Antifungals
A1

Therapy Pack, Oral 3 PA

Antifungals
B1

C1
Capsule) C1

Abel
cet

Abelcet (Intravenous
Ces
ame

Cesamet (Oral
t

4 PA 3 B/D, PA
Capsule) Suspension)
C1

Dro
nabi

Dronabinol (Oral
nol

3 PA
C1
Capsule)
Eme
nd

Emend (Oral Capsule) 3 PA

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Am Clot
Biso rima

AmBisome Clotrimazole (External

me zole

1
(Intravenous Solution)
4 B/D, PA C1

Clot

Suspension
rima

Clotrimazole (Mouth/
zole

1
C1
Reconstituted) C1
Throat Lozenge)
Cres
Am
emb
phot

Cresemba (Oral
a

Amphotericin B
erici
nB

4 PA
(Intravenous Solution 3 B/D, PA C1
Capsule)
C1
Reconstituted) Diflu
can

Diflucan (Oral
Anc
obo

Ancobon (Oral
n

4 Suspension 3
C1
Capsule) Reconstituted)
AVC C1
Vagi

AVC Vaginal (Vaginal

nal Diflu
can

3 Diflucan (100MG Oral

Cream) Tablet, 150MG Oral
C1

Can
cida
3
Cancidas Tablet, 50MG Oral
s

(Intravenous Solution 4 C1
Tablet)
Reconstituted)
Diflu
can

Diflucan (200MG Oral

C1

Cas
pofu
4
Caspofungin Acetate Tablet)
ngin

Acet
ate

C1

(50MG Intravenous
Eco
naz

Econazole Nitrate
ole
Nitr
ate

4 1 QL
Solution (External Cream)
Reconstituted) C1

Erax
is

C1

Cas
pofu
Eraxis (100MG
Caspofungin Acetate
ngin

Acet
ate

Intravenous Solution 4
(70MG Intravenous Reconstituted)
3
Solution C1

Erax
is

Reconstituted) Eraxis (50MG

C1

Cicl
opir
Intravenous Solution 3
Ciclopirox (External
ox

1 Reconstituted)
Gel) C1

Erta
czo

Ertaczo (External
C1

Cicl
opir

Ciclopirox (External
ox

1 4
Shampoo) C1
Cream)
Exel
der

Exelderm (External
C1 m
Cicl
opir

Ciclopirox (External
ox

1 3
Solution) C1
Cream)
Exel
C1 der

Exelderm (External
m
Cicl
opir

Ciclopirox Olamine
ox
Ola
min
e

1 3
(External Cream) C1
Solution)
C1 Exti
na

Extina (External
Cicl
opir

Ciclopirox Olamine
ox
Ola
min
e

1 4 QL
C1
(External Suspension) C1
Foam)
Fluc
Clot
ona
rima

Fluconazole in Sodium
zole

Clotrimazole (External
zole
in
Sodi
um
Chlo
ride

1
Cream) Chloride (Intravenous 1
Solution)

Bold type = Brand name drug Plain type = Generic drug

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32

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Fluc Lopr
ona ox

Fluconazole (Oral Loprox (External

zole

4
Suspension 1 Shampoo)
Reconstituted)
C1

Lulic
ona

Luliconazole
zole

3 QL
C1

Fluc
ona

Fluconazole (Oral
zole

1 (External Cream)
C1
Tablet) C1

Luz
u

Luzu (External
Fluc
ytosi
ne

Flucytosine (Oral 3 QL
4 Cream)
Capsule) C1

Men
tax

C1
Mentax (External
3
Gris
eofu

Griseofulvin Microsize
lvin
Micr
osiz
e

1 Cream)
(Oral Suspension) C1

Mic
ona

Miconazole 3 (Vaginal
zole
3

C1

Gris

1
eofu

Griseofulvin Microsize
lvin
Micr
osiz
e

3 Suppository)
(Oral Tablet) C1

Myc
ami

Mycamine
ne

C1

Gris
eofu

Griseofulvin
lvin
Ultra
micr
osiz
e

(Intravenous Solution 4
Ultramicrosize (Oral 3
Reconstituted)
Tablet) C1

Nafti
fine

Naftifine HCl (External

HCl
C1

Gyn
azol

Gynazole-1 (Vaginal
e-1

3
3 Cream)
Cream) C1

Nafti
n

C1

Itrac
ona

Naftin (External
Itraconazole (Oral
zole

3 PA 3
Capsule) C1
Cream)
Nafti
n

Naftin (External Gel) 3

C1

Itrac
ona

Itraconazole (Oral
zole

4 PA
C1

Nata
cyn

Solution) Natacyn (Ophthalmic

C1
3
Jubli
a

Jublia (External Suspension)

3 C1

Nizo
ral

Nizoral (External
C1
Solution) 3
Kery
din

Kerydin (External Shampoo)

4 ST C1

Nox
afil

Noxafil (Oral
C1
Solution) 4 QL
Ket
oco
naz
ole

Ketoconazole (External Suspension)

1 QL C1

Nox
afil

Cream) Noxafil (Oral Tablet

C1
4 PA; QL
Delayed Release)
Ket
oco

Ketoconazole (External
naz
ole

3 QL C1

Nya
myc

Foam) Nyamyc (External

C1

1
Powder)
Ket
oco

Ketoconazole (External
naz
ole

1 C1

Nyst
atin

Shampoo) Nystatin (External

C1

1
Cream)
Ket
oco

Ketoconazole (Oral
naz
ole

1 C1

Nyst
atin

Tablet) Nystatin (External

C1

1
Ointment)
Lopr
ox

Loprox (External
3 C1

Nyst
atin

Cream) Nystatin (External

1
Powder)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Nyst Vfen
atin d

Nystatin (Mouth/ Vfend (Oral

1
C1
Throat Suspension) Suspension 4
Nyst

Reconstituted)
atin

C1
Nystatin (Oral Tablet) 1 C1

Vfen
Nyst d

Vfend (Oral Tablet)

atin-

Nystatin-Triamcinolone 4
Tria
mci
nolo
ne

1 C1

(External Cream)
Vori
con

Voriconazole
azol
e

C1

Nyst
atin-

Nystatin-Triamcinolone (Intravenous Solution 4

Tria
mci
nolo
ne

1 Reconstituted)
C1
(External Ointment) C1

Vori
Nyst con
op

Voriconazole (Oral
azol

Nystop (External
e

1 Suspension 4
C1
Powder)
Ora
vig

Oravig (Buccal Reconstituted)

4
C1

Vori
con

Voriconazole (Oral
azol
e

Tablet) 3
Tablet)
C1

Oxic
ona

Oxiconazole Nitrate
zole

Nitr
ate

3 QL A1

Antigout Agents
C1
(External Cream)
Antigout Agents
Oxis B1
tat

Oxistat (External
4 QL C1

Allo
puri

Cream) Allopurinol (Oral

nol

C1
1
Tablet)
Oxis
tat

Oxistat (External
4 QL C1

Colc
hicin
e

Colchicine (0.6MG
C1
Lotion)
Oral Capsule) (Brand 2 QL
Spo
rano

Sporanox (Oral
x

4 PA Equivalent Mitigare)
C1
Capsule) C1

Colc
hicin

Colchicine (0.6MG
e
Spo
rano

Sporanox (Oral
x

4 PA Oral Tablet) (Brand 2 QL

Solution)
C1

Terb
inafi
Equivalent Colcrys)
Terbinafine HCl (Oral
ne
HCl

C1

1
Colc
rys

Tablet) C1
Colcrys (Oral Tablet) 3 PA; QL
Miti
gare

Mitigare (Oral
C1

Terc
ona

Terconazole (Vaginal
zole

1 3 QL
Cream) C1
Capsule)
Pro
C1 ben

Probenecid (Oral
ecid
Terc
ona

Terconazole (Vaginal
zole

1 1
Suppository) C1
Tablet)
Pro
C1 ben

Probenecid-Colchicine
ecid
Tols -
ura Colc

Tolsura (Oral
hicin
e

4 PA 1
Capsule) C1
(Oral Tablet)
Ulori
c

Uloric (Oral Tablet) 3 ST

C1

Vfen
d IV

Vfend IV (Intravenous C1

Zylo
prim

Solution 4 Zyloprim (Oral Tablet) 3

Antimigraine Agents
A1

Reconstituted)
Ergot Alkaloids
B1

C1

Cafe
rgot

Cafergot (Oral Tablet) 3

Bold type = Brand name drug Plain type = Generic drug

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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Dihy Ame
droe rge

Dihydroergotamine Amerge (Oral Tablet) 3 QL

rgot
ami
ne
Mes
ylate

C1

Mesylate (Nasal 4
Eletr
ipta

Eletriptan
n
Hyd
robr
omi
de

C1
Solution) Hydrobromide (Oral 3 ST; QL
Erg
ota

Ergotamine-Caffeine Tablet)
min
e-
Caff
eine

1 C1

(Oral Tablet)
Frov
a

C1

Mig
ergo C1
Frova (Oral Tablet) 4 ST; QL
Migergot (Rectal
t
Frov
atrip

Frovatriptan Succinate
tan
Suc
cina

4
te

Suppository) 3 ST; QL
C1

Migr
anal C1
(Oral Tablet)
Migranal (Nasal
Imitr
ex

4 Imitrex (Nasal
Solution) 3 QL
C1
Solution)
Prophylactic
B1
Imitr
ex

C1

Aim
ovig C1
Imitrex (Oral Tablet) 3 QL
Aimovig
Imitr
ex

Imitrex STATdose
STA
Tdo
se
Refil
l

(Subcutaneous Refill (6MG/0.5ML

3 PA; QL 4 QL
Solution Auto- Subcutaneous
C1
Injector) Solution Cartridge)
Ajov
y C1

Ajovy (Subcutaneous
Imitr
ex

Imitrex STATdose
STA
Tdo
se
Syst
em

Solution Prefilled 3 PA; QL System (4MG/0.5ML

C1
Syringe) Subcutaneous 4 QL
Emg
ality

Emgality (300 MG Solution Auto-

Dose) (Subcutaneous Injector)
3 PA; QL C1

Solution Prefilled
Imitr
ex

Imitrex
C1
Syringe) (Subcutaneous 4 QL
Emg
ality

Emgality Solution)
C1

(Subcutaneous
Max
alt

3 PA; QL Maxalt (Oral Tablet) 3 QL

Solution Auto-
C1

Max
alt-

Maxalt-MLT (Oral
MLT

Injector) 3 QL
C1

Emg
ality
Tablet Dispersible)
Emgality
C1

Nar
atrip

Naratriptan HCl (Oral

tan
HCl

(Subcutaneous 1 QL
3 PA; QL Tablet)
Solution Prefilled C1

Onz
etra
Xsail

Onzetra Xsail (Nasal

Syringe) 4 QL
C1

Tim
olol
Exhaler Powder)
Timolol Maleate (Oral
Mal
eate C1

Relp
ax

1 Relpax (Oral Tablet) 3 ST; QL

Tablet) C1

Riza
tript

Rizatriptan Benzoate
an
Ben
zoat
e

Serotonin (5-HT) 1b/1d Receptor Agonists 1 QL

B1

C1

Alm
otrip
(Oral Tablet)
Almotriptan Malate
tan
Mal
ate

3 ST; QL
(Oral Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Riza Sum
tript atrip

Rizatriptan Benzoate Sumatriptan Succinate

an tan
Ben Suc
zoat cina
e te
ODT

ODT (Oral Tablet 1 QL (6MG/0.5ML

C1
Dispersible) Subcutaneous 3 QL
Solution Prefilled
Sum
atrip

Sumatriptan (Nasal
tan

3 QL Syringe)
C1
Solution) C1

Zem
brac

Zembrace SymTouch
e
Sum Sym
atrip Tou

Sumatriptan Succinate
tan ch
Suc
cina
te

(100MG Oral Tablet, (Subcutaneous

1 QL 4 QL
25MG Oral Tablet, Solution Auto-
C1
50MG Oral Tablet) C1
Injector)
Sum
Zol
atrip
mitri

Sumatriptan
tan

Zolmitriptan (Oral
ptan
Suc
cina
te
Refil
l

1 QL
Succinate Refill Tablet)
3 QL C1

Zol

(Subcutaneous
mitri

Zolmitriptan ODT (Oral

ptan

ODT

1 QL
C1
Solution Cartridge) C1
Tablet Dispersible)
Sum Zom
atrip ig

Sumatriptan Succinate Zomig (Nasal

tan
Suc
cina
te

3 QL
(6MG/0.5ML Solution)
3 QL
Subcutaneous
C1

Zom
ig

Zomig (Oral Tablet) 4 QL

Solution) C1

Zom
ig

Zomig ZMT (Oral

ZMT

C1

Sum

4 QL
atrip

Sumatriptan Succinate
tan
Suc
cina
te

Tablet Dispersible)
(4MG/0.5ML
3 QL A1

Antimyasthenic Agents
Subcutaneous
Parasympathomimetics
B1

C1
Solution Auto-Injector) C1

Gua
nidi
Sum

Guanidine HCl (Oral

ne
atrip
HCl

Sumatriptan Succinate
tan
Suc
cina
te

3
(6MG/0.5ML C1
Tablet)
Subcutaneous 3 QL
Mes
tino

Mestinon (Oral Syrup) 4

n

Solution Auto-Injector) C1

Mes
tino
n

Mestinon (Oral Tablet

(Generic Imitrex) 4
C1

Sum
atrip
Immediate Release)
Sumatriptan
tan
Suc
cina
C1
te
Mes
tino

Mestinon (Oral Tablet

n

Succinate (6MG/ 4
Extended Release)
0.5ML Subcutaneous C1

Pyri

3 QL
dost

Pyridostigmine
igmi
ne
Bro
mid
e

Solution Auto-
ER

Bromide ER (Oral
Injector) (Generic 3
Tablet Extended
Imitrex STATdose) Release)
C1

Pyri
dost

Pyridostigmine
igmi
ne
Bro
mid
e

Bromide (Oral 4
Solution)

Bold type = Brand name drug Plain type = Generic drug

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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Pyri Rifa
dost mpi

Pyridostigmine Rifampin (Oral

igmi n
ne
Bro
mid
e

1
Bromide (30MG Oral Capsule)
4 C1

Tablet Immediate
Rifat
er

Rifater (Oral Tablet) 4

Release) C1

Sirtu
ro

C1

Pyri
dost
Sirturo (Oral Tablet) 4 PA; LA
Pyridostigmine
igmi
ne
Bro C1
mid
e Trec
ator

Trecator (Oral Tablet) 3

Bromide (60MG Oral
1 A1

Antineoplastics
Tablet Immediate
Alkylating Agents
B1

Release) C1

Cycl
oph

Cyclophosphamide
osp

Antimycobacterials
A1 ham
ide

1 B/D, PA
B1

Antimycobacterials, Other C1
(Oral Capsule)
Gle
osti

Gleostine (100MG
C1 ne
Dap
son

Dapsone (Oral Tablet) 1

e

4
C1

Myc
obut
in

Mycobutin (Oral C1
Oral Capsule)
4
Gle
osti

Gleostine (10MG Oral

ne

Capsule) 2
C1

Rifa
buti
n

Rifabutin (Oral C1
Capsule)
3 Gle
osti
ne

Gleostine (40MG Oral

Capsule) 3
B1

Antituberculars C1
Capsule)
Leu
kera

Leukeran (Oral
C1 n

Etha
mbu

Ethambutol HCl (Oral

tol
HCl

1 4
Tablet) C1
Tablet)
Mat
C1 ulan

Matulane (Oral
e
Ison
iazid

Isoniazid (Oral Syrup) 3 4 LA

Capsule)
C1

Ison
iazid

Isoniazid (Oral Tablet) 1 C1

Valc
hlor

Valchlor (External
C1

Mya
mbu

Myambutol (400MG
tol

3 4 PA; LA
Oral Tablet) Gel)
Antiandrogens
B1
C1

Pas
er

Paser (Oral Packet) 3 C1

Abir
ater

Abiraterone Acetate
one
C1 Acet
ate
Prifti
n

Priftin (Oral Tablet) 3 4 PA

C1

Pyra
zina (Oral Tablet)
Pyrazinamide (Oral
mid
e

C1

Bica

1
luta

Bicalutamide (Oral
mid
e

Tablet) 1
C1

Rifa
din Tablet)
Rifadin (150MG Oral C1

Cas
ode

3 Casodex (Oral Tablet) 4

x

Capsule) C1

Erle
ada

C1

Rifa
mat
Erleada (Oral Tablet) 4 PA; QL
Rifamate (Oral
e

C1

3
Flut
ami

Flutamide (Oral
de

Capsule) 3
C1

Rifa
mpi
Capsule)
Rifampin (Intravenous
n

C1

Nila
ndro

Nilandron (Oral
n

Solution 3 4
Reconstituted) C1
Tablet)
Nilut
ami

Nilutamide (Oral
de

4
Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Xtan Kisq
di ali

Xtandi (Oral Capsule) 4 PA; LA Kisqali (200MG Dose)

C1

4 PA
(Oral Tablet)
Yon
sa

C1
Yonsa (Oral Tablet) 4 PA C1

Kisq
ali

Kisqali (400MG Dose)

Zyti
ga

Zytiga (Oral Tablet) 4 PA 4 PA

B1

Antiangiogenic Agents C1
(Oral Tablet)
Kisq
ali

Kisqali (600MG Dose)

C1

Pom
alyst

Pomalyst (Oral 4 PA
4 PA (Oral Tablet)
Capsule) C1

Kisq
ali

Kisqali Femara
C1 Fem
Revl ara
imid

Revlimid (Oral
4 PA; LA (400MG Dose) (Oral 4 PA
Capsule)
C1

Thal
omi
d

Thalomid (Oral C1
Tablet Therapy Pack)
4 PA; QL Kisq
ali
Fem
ara

Kisqali Femara
Capsule)
B1

Antiestrogens/Modifiers (600MG Dose) (Oral 4 PA

C1

Emc
yt
Tablet Therapy Pack)
Emcyt (Oral Capsule) 4 C1

Kisq
ali

Kisqali Femara
Fem
ara

C1

Fare
ston

Fareston (Oral Tablet) 4

C1

Solt
amo
(200MG Dose) (Oral 4 PA
Soltamox (Oral
x

4 Tablet Therapy Pack)

Solution) C1

Leu
cov

Leucovorin Calcium
orin
Calc
ium

C1

Tam
oxif

Tamoxifen Citrate
en
Citra
te

1 (10MG Oral Tablet,

(Oral Tablet) 1
C1

Tore
mife
15MG Oral Tablet,
Toremifene Citrate
ne

5MG Oral Tablet)

Citra
te

4
(Oral Tablet)
C1

Leu
cov

Leucovorin Calcium
orin
Calc
ium

B1

Antimetabolites 3
C1
C1
(25MG Oral Tablet)
Dro
xia Lon

Droxia (Oral Capsule) 3

surf

C1
C1
Lonsurf (Oral Tablet) 4 PA; LA
Hyd
rea Lorb

Hydrea (Oral
rena

Lorbrena (Oral
3 4 PA; QL
C1
Capsule) C1
Tablet)
Hyd
roxy Ninl

Hydroxyurea (Oral
urea aro

1 Ninlaro (Oral
Capsule) 4 PA; QL
C1

Mer C1
Capsule)
capt

Mercaptopurine (Oral
opur Piqr
ine ay

1 Piqray (200 MG Daily

C1
Tablet) Dose) (Oral Tablet 4 PA; QL
Puri
xan

Purixan (Oral Therapy Pack)

4 PA C1

Suspension)
Piqr
ay

C1

Tabl
oid
Piqray (250 MG Daily
Tabloid (Oral Tablet) 3 PA Dose) (Oral Tablet 4 PA; QL
Antineoplastics, Other Therapy Pack)
B1

C1

Cop
iktra

Copiktra (Oral
4 PA; QL
Capsule)

Bold type = Brand name drug Plain type = Generic drug

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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Piqr Alun
ay brig

Piqray (300 MG Daily Alunbrig (Oral Tablet

4 PA; LA; QL
Dose) (Oral Tablet 4 PA; QL C1
Therapy Pack)
Therapy Pack)
Bos
ulif

C1

Synr C1
Bosulif (Oral Tablet) 4 PA
ibo

Synribo
Braf
tovi

Braftovi (Oral
(Subcutaneous 4 PA
4 PA Capsule)
Solution
C1

Cab
ome

Cabometyx (Oral
tyx

Reconstituted) 4 PA; LA; QL

C1

Verz
enio
Tablet)
Verzenio (Oral Tablet) 4
C1

PA; LA Calq
uen
ce

Calquence (Oral
4 PA; QL
C1

Zoli
nza

Zolinza (Oral Capsule)

4 PA
Capsule)
C1

Cap
rels

Caprelsa (Oral Tablet) 4 PA; LA

a

C1

Aromatase Inhibitors, 3rd Generation

B1
Co
metr

Cometriq (100MG
iq

4 PA; LA
C1

Ana
stro

Anastrozole (Oral
zole

1 Daily Dose) (Oral Kit)

Tablet)
C1

Co
metr

Cometriq (140MG
iq

4 PA; LA
C1

Arim
idex

C1
Arimidex (Oral Tablet) 4 Daily Dose) (Oral Kit)
Aro
masi C1

Aromasin (Oral
n
Co
metr

Cometriq (60MG
iq

4 4 PA; LA
C1
Tablet) Daily Dose) (Oral Kit)
Exe
mes C1

Exemestane (Oral
tane
Cot
ellic

3 Cotellic (Oral Tablet) 4 PA; LA

Tablet) C1

Dau
rism

Daurismo (Oral
o

C1

4 PA; LA; QL
Fem
ara

C1
Femara (Oral Tablet) 4 Tablet)
Letr
ozol

Letrozole (Oral Tablet) 1

e C1

Eriv
edg

Erivedge (Oral
e

B1

Enzyme Inhibitors 4 PA; LA; QL

C1

Balv
ersa
C1
Capsule)
Balversa (Oral Tablet) 4 PA; QL
Erlot
inib

Erlotinib HCl (Oral

HCl

C1

Rub
raca
4 PA; QL
C1
Rubraca (Oral Tablet) 4 PA; LA C1
Tablet)
Fary
Talz dak

Farydak (Oral
enn

Talzenna (Oral
a

4 PA; LA; QL 4 PA
C1
Capsule) C1
Capsule)
Gilot
Zeju rif

Gilotrif (Oral Tablet)

la

Zejula (Oral Capsule) 4 PA; LA; QL C1

4 PA; LA
Glee
vec

Molecular Target Inhibitors Gleevec (Oral Tablet) 4 PA; QL

B1

C1
C1
Ibra
Afini nce

Ibrance (Oral
tor

Afinitor Disperz (Oral

Disp
erz

4 PA 4 PA; LA
C1
Tablet Soluble) C1
Capsule)
Iclus
Afini ig

Iclusig (Oral Tablet)

tor

C1
Afinitor (Oral Tablet) 4 PA C1
4 PA; LA
IDHI
Alec FA

IDHIFA (Oral Tablet)

ens

Alecensa (Oral 4 PA; LA

a

4 PA; LA C1

Imat

Capsule)
inib

Imatinib Mesylate (Oral

Mes
ylate

C1

4 PA; QL
Tablet)
Alun
brig

Alunbrig (Oral Tablet) 4 PA; LA; QL

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
tRACK 77 77
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39

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Imbr Mek
uvic tovi

Imbruvica (Oral Mektovi (Oral Tablet) 4 PA

a

4 PA; LA; QL C1

Capsule)
Nerl
ynx

C1

Imbr C1
Nerlynx (Oral Tablet) 4 PA; LA; QL
uvic

Imbruvica (Oral
a Nex
avar

4 PA; QL Nexavar (Oral Tablet) 4 PA; LA

Tablet)
C1

Odo
mzo

Odomzo (Oral
4 PA; LA; QL
C1

Inlyt
a

C1
Inlyta (Oral Tablet) 4 PA; LA; QL Capsule)
Ires C1
sa

Iressa (Oral Tablet) 4 PA; LA; QL

Ryd
apt

C1

Jaka C1
Rydapt (Oral Capsule) 4 PA; QL
fi

Jakafi (Oral Tablet) 4 PA; LA; QL

Spry
cel

C1

Len C1
Sprycel (Oral Tablet) 4 PA
vima

Lenvima 10MG Daily

Stiv
10M arga

Stivarga (Oral Tablet) 4 PA; LA; QL

G
Dail
y
Dos
e

Dose (Oral Capsule

C1

4 PA; LA Sute
nt

Sutent (Oral Capsule) 4 PA

C1
Therapy Pack) C1

Tafi
nlar

Tafinlar (Oral
Len
vima

12M
G

Lenvima 12MG Daily 4 PA; LA

Capsule)
Dail
y
Dos
e

Dose (Oral Capsule 4 PA; LA C1

Tagr
isso

Tagrisso (Oral Tablet) 4 PA; LA

Therapy Pack) C1

Tarc
eva

C1

Len
vima
Tarceva (Oral Tablet) 4 PA; LA; QL
Lenvima 14MG Daily
14M
G
Dail C1
y
Dos Tasi
e gna

Tasigna (Oral
Dose (Oral Capsule 4 PA; LA 4 PA
Capsule)
Therapy Pack) C1

Tibs
ovo

C1

Len
vima
Tibsovo (Oral Tablet) 4 PA; QL
Lenvima 18MG Daily
18M
G
Dail
y
Dos C1
e
Tyk
erb

Dose (Oral Capsule 4 PA; LA C1

Tykerb (Oral Tablet) 4 PA; LA
Ven
clext

Venclexta (100MG
a

Therapy Pack)
Oral Tablet, 50MG 4 PA; LA
C1

Len
vima

Lenvima 20MG Daily

20M
G
Dail
y
Dos
e

Dose (Oral Capsule 4 PA; LA C1

Oral Tablet)
Ven
clext

Venclexta (10MG Oral

a

Therapy Pack) 2 PA; LA

Tablet)
C1

Len
vima

Lenvima 24MG Daily

24M
G
Dail
y
Dos
e C1

Ven
clext

Venclexta Starting
a
Start
ing

Dose (Oral Capsule 4 PA; LA

Pac
k

Therapy Pack) Pack (Oral Tablet 4 PA; LA

Therapy Pack)
C1

Len
vima

Lenvima 4MG Daily

4M
G
Dail
y
Dos
e C1

Vitra
kvi

Dose (Oral Capsule 4 PA; LA Vitrakvi (Oral

4 PA; LA; QL
Therapy Pack) C1
Capsule)
Vitra
C1 kvi

Vitrakvi (Oral
Len
vima

Lenvima 8MG Daily

8M
G
Dail

4 PA; LA; QL
y
Dos
e

Dose (Oral Capsule 4 PA; LA C1

Solution)
Vizi
mpr

Vizimpro (Oral Tablet) 4 PA; LA

o

C1
Therapy Pack) C1

Votri
Lyn ent

Votrient (Oral Tablet) 4 PA; LA; QL

parz

Lynparza (Oral
a

4 PA; LA C1

Xalk
ori

C1
Tablet) C1
Xalkori (Oral Capsule) 4 PA; LA
Mek
Xos
inist
pata

Mekinist (Oral Tablet) 4 PA; LA Xospata (Oral Tablet) 4 PA; QL

Bold type = Brand name drug Plain type = Generic drug

 78 tRACK 78 Last updated September 1, 2019
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40

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Zelb Stro
oraf mec

Zelboraf (Oral Tablet) 4 PA; LA; QL Stromectol (Oral

tol

C1

3
Tablet)
Zyd
elig

C1
Zydelig (Oral Tablet) 4 PA; LA
Antiprotozoals
Zyk B1
adia

Zykadia (Oral
4 PA C1

Alini
a

C1
Capsule) Alinia (Oral
Suspension 4
Zyk
adia

Zykadia (Oral Tablet) 4 PA

B1

Retinoids C1
Reconstituted)
Alini
a

Alinia (Oral Tablet)

C1

Bex
arot
ene

Bexarotene (Oral 4
4 PA C1

Atov
aqu
one

Atovaquone (Oral
C1
Capsule) 4
Panr
etin

Panretin (External Suspension)

4
C1

Atov
aqu

Atovaquone-Proguanil
one-
Pro

Gel)
gua
nil
HCl

1
HCl (Oral Tablet)
C1

Targ
retin

Targretin (External
4 PA
C1

Ben
znid

Benznidazole (Oral
azol
e

Gel) 3
Tablet)
C1

Targ
retin

Targretin (Oral
4 PA
C1

Chlo
roqu

Chloroquine
ine
Pho
sph

Capsule)
ate

C1

Treti
noin

Phosphate (Oral 1
Tretinoin (Oral
4 Tablet)
Capsule) C1

Coa
rtem

Coartem (Oral Tablet) 3

Treatment Adjuncts
B1

C1

DAR
APR

DARAPRIM (Oral
IM
C1

Mes
nex

Mesnex (Oral Tablet) 4 4

Tablet)
Antiparasitics
A1

C1

Hyd
roxy

Hydroxychloroquine
chlo
roqu
ine
Sulf
ate

B1

Anthelmintics 1
C1

Albe
nda
Sulfate (Oral Tablet)
Albendazole (Oral
zole
C1

Krint
afel

4 QL Krintafel (Oral Tablet) 3

Tablet) C1

Mal
aron

Malarone (Oral
e

C1

Albe

3
nza

Albenza (Oral Tablet) 4 QL

C1

Biltri
cide
Tablet)
Biltricide (Oral Tablet) 3 C1

Mefl
oqui

Mefloquine HCl (Oral

ne
HCl

C1

1
Emv
erm

Emverm (Oral Tablet Tablet)

4
Chewable) C1

Mep
ron

C1
Mepron (Oral
4
Iver
mec

Ivermectin (Oral
tin

1 Suspension)
Tablet) C1

Neb
upe

Nebupent (Inhalation
nt

C1

Praz
iqua

Praziquantel (Oral
ntel

3 Solution 3 B/D, PA; QL

Tablet)
C1

Skli
ce
Reconstituted)
Sklice (External C1

PEN
TA

3 PENTAM 300
M
300

Lotion)
(Injection Solution 3
Reconstituted)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
tRACK 79 79
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Plaq Ama
ueni ntad

Plaquenil (Oral Amantadine HCl (Oral

l ine
HCl

3 1
Tablet) C1
Capsule)
C1
Ama
Prim ntad

Amantadine HCl (Oral

aqui ine

Primaquine Phosphate
ne HCl
Pho
sph
ate

1 1
(Oral Tablet) C1
Syrup)
C1
Ama
Qual ntad

Amantadine HCl (Oral

aqui ine

Qualaquin (Oral
n HCl

3 PA 1
Capsule) C1
Tablet)
C1 Co
mta

Comtan (Oral Tablet) 4

Quin n
ine

Quinine Sulfate (Oral

Sulf
ate

1 PA C1

Enta
cap

Capsule) Entacapone (Oral

one

3
B1

Pediculicides/Scabicides C1
Tablet)
C1 Goc
ovri

Gocovri (Oral Capsule

Elim
ite

Elimite (External
3 Extended Release 24 4 PA
Cream)
Hour)
C1

Eura
x

Eurax (External
3
C1

Os
mol

Osmolex ER (Oral
ex
ER

Cream)
Tablet Extended 3 PA
C1

Eura
x

Eurax (External
3 Release 24 Hour)
Lotion) C1

Tas
mar

Tasmar (Oral Tablet) 4 QL

C1

Lind
ane

Lindane (External
1 C1

Tolc
apo
ne

Tolcapone (Oral
Shampoo) 4 QL
Tablet)
C1

Mal
athi

Malathion (External
on

3 B1

Dopamine Agonists
C1
Lotion) C1

Apo
Natr kyn

Apokyn
oba

Natroba (External
3 (Subcutaneous 4 PA; LA; QL
C1
Suspension)
Solution Cartridge)
Ovid
e

C1
Ovide (External Lotion) 3 C1

Bro
moc

Bromocriptine
ripti
Per ne
met Mes

Permethrin (External
hrin ylate

1 Mesylate (Oral 3
Cream)
Capsule)
Antiparkinson Agents
A1

C1

Bro
moc

Bromocriptine
ripti
ne
Mes
ylate

Anticholinergics
B1

1
C1

Ben
ztro
Mesylate (Oral Tablet)
Benztropine Mesylate
pine

Mes
ylate C1

Inbri
ja

1 PA; HRM Inbrija (Inhalation

(Oral Tablet) 4 PA
C1

Trih
exy Capsule)
Trihexyphenidyl HCl
phe
nidyl
HCl
C1

Mira

1 PA; HRM
pex

Mirapex ER (Oral
ER

(Oral Elixir)
C1

Trih
exy
Tablet Extended 3
Trihexyphenidyl HCl
phe
nidyl
HCl

1 PA; HRM Release 24 Hour)

(Oral Tablet) C1

Mira
pex

B1

Antiparkinson Agents, Other Mirapex (Oral Tablet

3
Immediate Release)

Bold type = Brand name drug Plain type = Generic drug

 80 tRACK 80 Last updated September 1, 2019
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42

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Neu Rop
pro iniro

Neupro (Transdermal Ropinirole HCl ER

le
HCl
ER

3
Patch 24 Hour) (2MG Oral Tablet
Extended Release 24
C1

Parl
odel

Parlodel (Oral 1
3 Hour, 4MG Oral Tablet
Capsule)
C1

Parl
odel Extended Release 24
C1
Parlodel (Oral Tablet) 3 Hour)
Pra
mip

Pramipexole
exol C1
e
Dihy Rop
droc iniro

Ropinirole HCl (Oral

hlori le
de HCl
ER

Dihydrochloride ER Tablet Immediate 1

3
(Oral Tablet Extended Release)
Release 24 Hour)
Dopamine Precursors/L-Amino Acid
B1

C1

Pra
mip

Pramipexole
exol
e
Dihy
droc
hlori
de

Decarboxylase Inhibitors
Dihydrochloride (Oral C1

1
Car
bido

Carbidopa (Oral
pa

Tablet Immediate 3
Release) C1
Tablet)
Car
bido

Carbidopa-Levodopa
C1 pa-
Lev
Req odo
uip pa

Requip XL (12MG
XL ER

Oral Tablet Extended ER (Oral Tablet 1

Extended Release)
Release 24 Hour, C1

4
Car
bido

Carbidopa-Levodopa
pa-
Lev
odo
pa

8MG Oral Tablet

Extended Release 24 (Oral Tablet Immediate 1
Release)
Hour) C1

Car
bido

Carbidopa-Levodopa
pa-
Lev
odo
C1 pa
ODT
Req
uip

Requip XL (4MG Oral

XL

ODT (Oral Tablet 1

Tablet Extended Dispersible)
Release 24 Hour, C1

Car
bido

Carbidopa-Levodopa-
pa-

3
Lev
odo
pa-
Enta
cap
one

6MG Oral Tablet Entacapone (Oral 3

Extended Release 24 Tablet)
Hour) C1

Duo
pa

C1
Duopa (Enteral
4 PA
Rop
iniro

Ropinirole HCl ER
le
HCl
ER

Suspension)
(12MG Oral Tablet C1

Lod
osy

Lodosyn (Oral Tablet) 4

n

Extended Release 24 C1

Ryta
ry

Hour, 6MG Oral Tablet Rytary (Oral Capsule

3 3
Extended Release 24 C1
Extended Release)
Sine

Hour, 8MG Oral Tablet

met

Sinemet CR (Oral
CR

Extended Release 24 Tablet Extended 3

Hour) Release)
C1

Sine
met

Sinemet (Oral Tablet

3
Immediate Release)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Stal Flup
evo hen

Stalevo 100 (Oral Fluphenazine HCl

100 azin
e
HCl

4 1
Tablet) C1
(Oral Elixir)
C1
Flup
Stal hen

Fluphenazine HCl
evo azin

Stalevo 125 (Oral

125 e
HCl

4 1
Tablet) C1
(Oral Tablet)
C1 Hald
ol

Haldol Decanoate
Stal Dec
evo ano

Stalevo 150 (Oral

150 ate

4 (Intramuscular 3
Tablet)
Solution)
C1

Stal
evo

Stalevo 200 (Oral

200

4
C1

Hald
ol

Tablet) Haldol (Injection

3
Solution)
C1

Stal
evo

Stalevo 50 (Oral
50

4
C1

Halo
peri

Haloperidol Decanoate
dol
Dec

Tablet)
ano
ate

C1

Stal
evo
75

Stalevo 75 (Oral (Intramuscular 1

4 Solution)
Tablet) C1

Halo
peri

Haloperidol Lactate
dol
Lact
ate

Monoamine Oxidase B (MAO-B) Inhibitors 1

B1

C1

Azil
ect
(Injection Solution)
Azilect (Oral Tablet) 3 C1

Halo
peri

Haloperidol Lactate
dol
Lact
ate

C1

1
Ras
agili

Rasagiline Mesylate
ne
Mes
ylate

3 (Oral Concentrate)
(Oral Tablet) C1

Halo
peri

Haloperidol (Oral
dol

C1

1
Sele
gilin

Selegiline HCl (Oral

e
HCl

1 Tablet)
Capsule) C1

Lox
apin

Loxapine Succinate
e
Suc
cina
te

C1

1
Sele
gilin

Selegiline HCl (Oral

e
HCl

1 (Oral Capsule)
Tablet) C1

Moli
ndo

Molindone HCl (Oral

ne
HCl

C1

3
Zela
par

Zelapar (Oral Tablet Tablet)

4
Dispersible)
C1

Pim
ozid

Pimozide (Oral Tablet) 1

e

Antipsychotics
A1
C1

Thio
rida

Thioridazine HCl (Oral

zine
HCl

B1

1st Generation/Typical 1
C1

Chlo
rpro
C1
Tablet)
Chlorpromazine HCl
mazi Thio
ne thix

Thiothixene (Oral
HCl ene

3 1
C1
(Oral Tablet) Capsule)
Flup C1
hen

Fluphenazine
azin Trifl
e uop

Trifluoperazine HCl
Dec eraz
ano ine
ate HCl

Decanoate (Injection 1 1
(Oral Tablet)
C1
Solution) B1

2nd Generation/Atypical
Flup
hen

Fluphenazine HCl
azin
e C1
HCl
Abili
fy

Abilify Maintena
Mai

1
nten
a

(Injection Solution)
C1

Flup
hen
(Intramuscular 4
Fluphenazine HCl
azin
e
HCl

1 Prefilled Syringe)
(Oral Concentrate)

Bold type = Brand name drug Plain type = Generic drug

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44

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Abili Fan
fy apt

Abilify Maintena Fanapt Titration Pack

Mai Titra
nten tion
a Pac
k

3 ST
(Intramuscular (Oral Tablet)
4 C1

Suspension
Geo
don

Geodon
Reconstituted ER) (Intramuscular
C1

Abili
fy
3
C1
Abilify (Oral Tablet) 4 QL Solution
Reconstituted)
Aripi
praz

Aripiprazole (1MG/ML
ole

3 QL C1

Geo

Oral Solution)
don

Geodon (Oral
C1

Aripi
4 QL
Capsule)
praz

Aripiprazole (10MG
ole

C1

Oral Tablet, 15MG Oral

Inve
ga

Invega (3MG Oral

Tablet, 20MG Oral Tablet Extended
Tablet, 2MG Oral 1 QL Release 24 Hour,
Tablet, 30MG Oral 6MG Oral Tablet
Tablet, 5MG Oral 4 PA; QL
Extended Release 24
Tablet)
C1

Aripi
praz Hour, 9MG Oral
Aripiprazole ODT
ole
ODT

Tablet Extended
(10MG Oral Tablet
Dispersible, 15MG 4 QL C1
Release 24 Hour)
Inve
ga

Invega Sustenna
Sust
enn

Oral Tablet
a

Dispersible) (117MG/0.75ML
C1

Intramuscular
Arist
ada

Aristada Initio
Initi
o

(Intramuscular 4 Suspension Prefilled

Prefilled Syringe) Syringe, 156MG/ML
Intramuscular
C1

Arist
ada

Aristada
(Intramuscular 4 Suspension Prefilled
4
Prefilled Syringe) Syringe, 234MG/
C1

Fan
apt
1.5ML Intramuscular
Fanapt (10MG Oral
Suspension Prefilled
Tablet, 12MG Oral
Syringe, 78MG/
Tablet, 4MG Oral
4 ST; QL 0.5ML Intramuscular
Tablet, 6MG Oral
Suspension Prefilled
Tablet, 8MG Oral
Syringe)
Tablet) C1

Inve
ga

Invega Sustenna
Sust
enn
C1 a

Fan
apt

Fanapt (1MG Oral

(39MG/0.25ML
Tablet, 2MG Oral 3 ST; QL
Intramuscular 3
Tablet)
Suspension Prefilled
Syringe)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Inve Que
ga tiapi

Invega Trinza Quetiapine Fumarate

Trin ne
za Fum
arat
e

(Intramuscular (Oral Tablet Immediate 1 QL

4 Release)
Suspension Prefilled C1

Rex
ulti

C1
Syringe) C1
Rexulti (Oral Tablet) 4 QL
Risp
Latu
erda
da

Latuda (Oral Tablet) Risperdal Consta

l

4 QL
Con
sta

C1

(12.5MG
Nup
lazid

Nuplazid (Oral
4 PA; QL Intramuscular 3
Capsule)
Suspension
C1

Nup
lazid

Nuplazid (Oral Tablet) 4 PA; QL

C1

Olan
zapi

Reconstituted)
Olanzapine (10MG
ne

C1

Risp
erda

Risperdal Consta
l
Con
sta

Intramuscular Solution 3
Reconstituted) (25MG Intramuscular
Suspension
C1

Olan
zapi

Olanzapine (10MG
ne

Oral Tablet, 15MG Oral Reconstituted,

Tablet, 2.5MG Oral 37.5MG
Tablet, 20MG Oral 1 QL Intramuscular 4
Tablet, 5MG Oral Suspension
Tablet, 7.5MG Oral Reconstituted, 50MG
C1
Tablet) Intramuscular
Olan
zapi

Olanzapine ODT
ne

Suspension
ODT

(10MG Oral Tablet Reconstituted)

Dispersible, 15MG C1

Risp
erda
l

Risperdal (1MG/ML
Oral Tablet 4
1 QL Oral Solution)
Dispersible, 20MG C1

Risp
erda

Risperdal (0.25MG
l

Oral Tablet
Dispersible, 5MG Oral Oral Tablet, 0.5MG 3
C1
Tablet Dispersible) C1
Oral Tablet)
Risp
Pali erda

Risperdal (1MG Oral

peri l

Paliperidone ER (Oral
don
e
ER

Tablet Extended 3 QL Tablet, 2MG Oral

C1
Release 24 Hour) Tablet, 3MG Oral 4
Pers
eris

Perseris Tablet, 4MG Oral

(Subcutaneous 4 C1
Tablet)
Prefilled Syringe)
Risp
erid

Risperidone (Oral
one

C1

Que
1
Solution)
tiapi

Quetiapine Fumarate
ne
Fum
arat
e
ER

C1

Risp

ER (Oral Tablet
erid

Risperidone (Oral
one

1 QL 1
Extended Release 24 Tablet)
Hour)

Bold type = Brand name drug Plain type = Generic drug

 84 tRACK 84 Last updated September 1, 2019
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46

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Risp Vray
erid lar

Risperidone ODT (Oral Vraylar (1.5MG Oral

one
ODT

1
C1
Tablet Dispersible) Capsule, 3MG Oral
Sap

Capsule, 4.5MG Oral

hris

Saphris (Tablet 4 ST; QL

4
C1
Sublingual) Capsule, 6MG Oral
Capsule)
Ser
oqu

Seroquel (100MG
el

C1

Vray
lar

Oral Tablet Vraylar (Oral Capsule

3 ST
Immediate Release, C1
Therapy Pack)
Zipr

200MG Oral Tablet

asid

Ziprasidone HCl (Oral

one
HCl

1 QL
Immediate Release, 3 QL C1
Capsule)
25MG Oral Tablet
Zypr
exa

Zyprexa (10MG
Immediate Release, Intramuscular
50MG Oral Tablet 3
Solution
C1
Immediate Release) Reconstituted)
Ser C1
oqu

Seroquel (300MG
el Zypr
exa

Zyprexa (10MG Oral

Oral Tablet Tablet, 2.5MG Oral
Immediate Release, 4 QL Tablet, 5MG Oral 3 QL
400MG Oral Tablet Tablet, 7.5MG Oral
C1
Immediate Release) Tablet)
Ser C1
oqu

Seroquel XR (150MG
el Zypr
XR exa

Zyprexa (15MG Oral

Oral Tablet Extended Tablet, 20MG Oral 4 QL
Release 24 Hour, Tablet)
200MG Oral Tablet
C1

Zypr
exa

Zyprexa Relprevv
Relp
revv

Extended Release 24 (210MG

Hour, 300MG Oral 3 QL Intramuscular 3
Tablet Extended Suspension
Release 24 Hour, Reconstituted)
50MG Oral Tablet C1

Zypr
exa
Zydi
s

Zyprexa Zydis (10MG

Extended Release 24 Oral Tablet
C1
Hour) Dispersible, 15MG
Ser
oqu

Seroquel XR (400MG
el
XR

Oral Tablet 4 QL
Oral Tablet Extended 4 QL Dispersible, 20MG
Release 24 Hour) Oral Tablet
Dispersible)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
tRACK 85 85
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47

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Zypr Vers
exa aclo

Zyprexa Zydis (5MG Versacloz (Oral

Zydi z
s

4
Oral Tablet 3 QL Suspension)
Dispersible) A1

Antivirals
Treatment-Resistant
B1

Anti-cytomegalovirus (CMV) Agents

B1

C1

Cloz C1
apin

Clozapine (100MG
e Prev
ymis

Prevymis (Oral
Oral Tablet, 200MG 4 PA; QL
Tablet)
Oral Tablet, 25MG Oral 1 C1

Valc
yte

Valcyte (Oral Solution

Tablet, 50MG Oral 4 QL
Tablet) C1
Reconstituted)
Valc
yte

C1

Cloz
apin
e
ODT

Clozapine ODT C1
Valcyte (Oral Tablet) 4 QL
Valg
anci

Valganciclovir HCl
clovi
r
HCl

(100MG Oral Tablet

Dispersible, 150MG 3 (Oral Solution 4 QL
Oral Tablet C1
Reconstituted)
Valg
anci

Dispersible) Valganciclovir HCl

clovi
r
HCl

C1
4 QL
(Oral Tablet)
Cloz
apin

Clozapine ODT
e
ODT

C1

Zirg
an

(12.5MG Oral Tablet Zirgan (Ophthalmic

Dispersible, 25MG 1 3
Gel)
Oral Tablet B1

Anti-hepatitis B (HBV) Agents

Dispersible) C1

Ade
fovir

Adefovir Dipivoxil (Oral

Dipi
voxil

C1

4
Cloz
apin

Clozapine ODT
e
ODT

Tablet)
(200MG Oral Tablet 4 C1

Bara
clud

Baraclude (Oral
e

Dispersible) 3
C1

Cloz
aril
Solution)
Clozaril (100MG Oral C1

Bara

4
clud

Baraclude (Oral
e

Tablet) 4
C1

Cloz
aril
Tablet)
Clozaril (25MG Oral C1

Ente

3
cavir

Tablet) C1
Entecavir (Oral Tablet) 3
Epiv
ir

Epivir HBV (Oral

HBV
C1

Faza
Clo

FazaClo (100MG Oral 3

Tablet Dispersible, C1
Solution)
Epiv
ir

Epivir HBV (Oral

HBV

150MG Oral Tablet 3

4 Tablet)
Dispersible, 200MG C1

Hep
sera

Oral Tablet C1
Hepsera (Oral Tablet) 4
Lam
ivudi

Dispersible) Lamivudine (100MG

ne

C1
1
Oral Tablet)
Faza
Clo

FazaClo (12.5MG Oral C1

Vem
lidy

Tablet Dispersible, Vemlidy (Oral Tablet) 4 QL

3
25MG Oral Tablet Anti-hepatitis C (HCV) Agents, Other
B1

Dispersible)

Bold type = Brand name drug Plain type = Generic drug

 86 tRACK 86 Last updated September 1, 2019
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48

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Intro Ledi
nA pasv

Intron A (Injection Ledipasvir-Sofosbuvir

ir-
Sof
osb
uvir

4 PA; LA 4 PA; QL
Solution) C1
(Oral Tablet)
C1
Mav
Intro yret

Mavyret (Oral Tablet) 4 PA; QL

nA

Intron A (Injection C1

Sof

Solution
osb

4 PA; LA Sofosbuvir-Velpatasvir
uvir-
Velp
atas
vir

4 PA; QL
C1
Reconstituted) C1
(Oral Tablet)
Sov
Peg
aldi
asys

Pro
Clic
k

Pegasys ProClick C1
Sovaldi (Oral Tablet) 4 PA; QL
Viek

(Subcutaneous 4 PA
ira

Viekira Pak (Oral

Pak

Solution) 4 PA; QL
C1

Peg
C1
Tablet Therapy Pack)
asys Vos

Pegasys
evi

C1
Vosevi (Oral Tablet) 4 PA; QL
(Subcutaneous 4 PA
Zep
atier

Zepatier (Oral Tablet) 4 PA; QL

C1
Solution) B1

Antiherpetic Agents
Reb
etol

Rebetol (Oral
C1

Acy
clovi

Acyclovir (External
r

3 3
C1
Solution) Cream)
Riba
sph

Ribasphere (Oral
ere C1

Acy
clovi

Acyclovir (External
r

1 1
C1
Capsule) Ointment)
Riba
sph

Ribasphere (600MG
ere C1

Acy
clovi

Acyclovir (Oral
r

4 1
C1
Oral Tablet) Capsule)
Riba
sph

Ribasphere RibaPak
ere C1
Riba
Acy
Pak
clovi

Acyclovir (Oral
r

4 3
C1
(600MG Oral Tablet) Suspension)
Riba
sph

Ribasphere RibaPak
ere C1
Riba
Acy
Pak
clovi

Acyclovir (Oral Tablet) 1

r

(400 & 600MG Oral 4 C1

Acy
clovi

Acyclovir Sodium
r
Sodi
um

Tablet Therapy Pack) 3 B/D, PA

C1

Riba
virin
(Intravenous Solution)
Ribavirin (Oral C1

Den
avir

1 Denavir (External
Capsule) 4
C1

Riba
virin Cream)
Ribavirin (Oral Tablet) 1 C1

Fam
ciclo

Famciclovir (Oral
vir

C1

Syla

1
tron

Sylatron Tablet)
4 PA
(Subcutaneous Kit) C1

Trifl
uridi

Trifluridine
ne

B1

Anti-hepatitis C (HCV) Direct Acting Agents 1

C1

Dakl
inza
(Ophthalmic Solution)
Daklinza (30MG Oral
C1

Vala
cycl

Valacyclovir HCl (Oral

ovir
HCl

Tablet, 60MG Oral 4 PA; QL 1 QL

Tablet)
Tablet)
C1

Valtr
ex

Valtrex (1GM Oral

4 QL
C1

Epcl
usa

C1
Epclusa (Oral Tablet) 4 PA; QL Tablet)
Harv
oni C1

Harvoni (Oral Tablet) 4 PA; QL

Valtr
ex

Valtrex (500MG Oral

3 QL
Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
tRACK 87 87
86
49

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Xere Tyb
se ost

Xerese (External Tybost (Oral Tablet) 3 QL

4 PA
C1
Cream) B1

Anti-HIV Agents, Non-nucleoside Reverse

Zovi
rax

Zovirax (External Transcriptase Inhibitors (NNRTI)

4 C1

Cream)
Atri
pla

C1

Zovi C1
Atripla (Oral Tablet) 4 QL
rax

Zovirax (External
Co
mpl

Complera (Oral
era

4 4 QL
C1
Ointment) Tablet)
Zovi C1
rax

Zovirax (Oral
Dels
trigo

3 Delstrigo (Oral
Capsule) 4 QL
C1

Zovi C1
Tablet)
rax

Zovirax (Oral
Edu
rant

3 Edurant (Oral Tablet) 4 QL

Suspension)
C1

Efav
iren

Efavirenz (Oral
z

C1

Zovi
rax

Zovirax (800MG Oral 3 QL

Capsule)
3 C1

Tablet)
Efav
iren

Efavirenz (Oral Tablet) 4 QL

z

C1

Anti-HIV Agents, Integrase Inhibitors (INSTI)

B1
Intel
enc

Intelence (100MG
e

C1

Dov
ato

C1
Dovato (Oral Tablet) 4 QL Oral Tablet, 200MG 4 QL
Gen

Oral Tablet)
voya

C1
Genvoya (Oral Tablet) 4 QL C1

Intel
Isen enc

Intelence (25MG Oral

tres e

Isentress HD (Oral
s
HD

4 QL 3 QL
Tablet) C1
Tablet)
C1
Julu
Isen ca

Juluca (Oral Tablet) 4 QL

tres

Isentress (Oral
s

3 QL C1

Nevi

Packet)
rapi

Nevirapine ER (Oral
ne
ER

C1

Tablet Extended 3 QL
Isen
tres

Isentress (Oral
s

4 QL Release 24 Hour)
C1
Tablet) C1

Nevi
rapi

Nevirapine (Oral
ne
Isen
tres

Isentress (100MG
s

3 QL
Oral Tablet 4 QL C1
Suspension)
Nevi
rapi

Nevirapine (Oral Tablet

ne

Chewable) 1 QL
C1

Isen
tres
s

Isentress (25MG Oral C1

Immediate Release)
2 QL
Ode
fsey

Tablet Chewable) C1
Odefsey (Oral Tablet) 4 QL
Pifel
tro

Pifeltro (Oral Tablet) 4 QL

C1

Strib
ild

Stribild (Oral Tablet) 4 QL C1

Res
cript

Rescriptor (Oral
C1 or
Tivic
ay

Tivicay (10MG Oral 3 QL

3 QL Tablet)
Tablet) C1

Sust
iva

Sustiva (Oral
C1

Tivic
ay

Tivicay (25MG Oral 3 QL

Tablet, 50MG Oral 4 QL C1
Capsule)
Sust
iva

Tablet) C1
Sustiva (Oral Tablet) 4 QL
C1 Sym
fi Lo

Symfi Lo (Oral Tablet) 4 QL

Triu
meq

Triumeq (Oral Tablet) 4 QL

Bold type = Brand name drug Plain type = Generic drug

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50

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Sym Lam
fi ivudi

Symfi (Oral Tablet) 4 QL Lamivudine (10MG/ML

ne

C1
1 QL
Oral Solution)
Vira
mun

Viramune (Oral
e

4 QL C1

Lam
ivudi

Lamivudine (150MG
ne

Suspension)
Oral Tablet, 300MG 1 QL
C1

Vira
mun

Viramune (Oral Tablet

e

4 QL Oral Tablet)
Immediate Release) C1

Lam
ivudi

Lamivudine-
ne-
C1 Zido
vudi
Vira ne
mun

Viramune XR (Oral
e
XR

Zidovudine (Oral 1 QL
Tablet Extended 4 QL
Tablet)
Release 24 Hour) C1

Retr
ovir

Retrovir (Oral
Anti-HIV Agents, Nucleoside and Nucleotide 3 QL
B1

Capsule)
Reverse Transcriptase Inhibitors (NRTI) C1

Retr
ovir

C1

Aba
cavir Retrovir (Oral Syrup) 3 QL
Abacavir Sulfate (Oral
Sulf
ate

C1

Stav

3 QL
udin

Stavudine (Oral
e

Solution) 1 QL
C1

Aba
cavir Capsule)
Abacavir Sulfate (Oral
Sulf
ate

C1

Ten

1 QL
ofov

Tenofovir Disoproxil
ir
Diso
prox
il
Fum

Tablet)
arat

3 QL
e

C1

Aba
cavir Fumarate (Oral Tablet)
Abacavir Sulfate-
Sulf
ate-
Lam
ivudi C1
ne
Trizi
vir

Lamivudine (Oral 3 QL C1
Trizivir (Oral Tablet) 4 QL
Truv
ada

Tablet) C1
Truvada (Oral Tablet) 4 QL
C1 Vide
x EC

Videx EC (Oral
Aba
cavir

Abacavir-Lamivudine-
-
Lam
ivudi
ne-
Zido
vudi
ne

Zidovudine (Oral 4 QL Capsule Delayed 3 QL

C1
Tablet) C1
Release)
Bikt
arvy Vide

Biktarvy (Oral Tablet)

x

C1
4 QL Videx (4GM Oral
Cim

Solution 3 QL
duo

C1
Cimduo (Oral Tablet) 4 QL
Reconstituted)
Co
mbi

Combivir (Oral Tablet) 4 QL

vir

C1

Vire
C1 ad

Viread (Oral Powder) 4 QL

Des
covy

C1
Descovy (Oral Tablet) 4 QL C1

Vire
ad

Viread (Oral Tablet) 4 QL

Dida
nosi

Didanosine (Oral
ne

C1

Ziag
en

Capsule Delayed 1 QL C1
Ziagen (Oral Solution) 3 QL
Release)
Ziag
en

C1

Emt
riva C1
Ziagen (Oral Tablet) 3 QL
Emtriva (Oral
Zido
vudi

Zidovudine (Oral
ne

3 QL 1 QL
C1
Capsule) Capsule)
Emt C1
riva

Emtriva (Oral
Zido
vudi

Zidovudine (Oral
ne

3 QL 1 QL
C1
Solution) C1
Syrup)
Epiv
ir Zido

Epivir (Oral Solution)

vudi

3 QL Zidovudine (Oral
ne

C1

1 QL
Tablet)
Epiv
ir

C1
Epivir (Oral Tablet) 3 QL
Anti-HIV Agents, Other
Epzi B1
com

Epzicom (Oral Tablet) 4 QL

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
tRACK 89 89
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51

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Fuz Lopi
eon navi

Fuzeon Lopinavir-Ritonavir
r-
Rito
navi
r

3 QL
(Subcutaneous (Oral Solution)
4 QL C1

Nor

Solution
vir

C1
Norvir (Oral Packet) 3 QL
Reconstituted)
Nor
vir

C1

Selz
entr
C1
Norvir (Oral Solution) 3 QL
Selzentry (Oral
y Nor
vir

4 QL Norvir (Oral Tablet) 3 QL

Solution)
C1

Prez
cobi

Prezcobix (Oral
x

4 QL
C1

Selz
entr

Selzentry (150MG
y

Tablet)
Oral Tablet, 300MG
C1

Prez
ista

4 QL Prezista (Oral
Oral Tablet, 75MG 4 QL
Suspension)
Oral Tablet) C1

Prez
ista

C1
Selz
entr
Prezista (150MG Oral
Selzentry (25MG Oral
y

2 QL Tablet, 75MG Oral 3 QL

Tablet) Tablet)
Anti-HIV Agents, Protease Inhibitors
B1 C1

Prez
ista

C1

Apti
vus
Prezista (600MG Oral
Aptivus (Oral Tablet, 800MG Oral 4 QL
4 QL
C1
Capsule) Tablet)
Apti
C1
vus

Aptivus (Oral
Rey
ataz

4 QL Reyataz (Oral
Solution) 4 QL
C1

Ataz
anav
C1
Capsule)
Atazanavir Sulfate
ir Rey
Sulf ataz

Reyataz (Oral Packet) 4 QL

ate

4 QL
C1
(Oral Capsule) C1

Rito
navi
r

Ritonavir (Oral Tablet) 1 QL

Crixi
van

Crixivan (Oral C1

Sym
tuza

Symtuza (Oral Tablet) 4 QL

2 QL
Capsule) C1

Vira
cept

C1

Evot
az
Viracept (Oral Tablet) 4 QL
Evotaz (Oral Tablet) 4 QL
Anti-influenza Agents
B1

C1

Fos
amp

Fosamprenavir
rena
vir
Calc
ium C1

Flu

4 QL
mad

Flumadine (Oral
ine

Calcium (Oral Tablet) 3

C1

Invir
ase
Tablet)
Invirase (Oral Tablet) 4 QL C1

Osel
tami

Oseltamivir Phosphate
vir
Pho
sph
C1 ate

Kale

1
tra

Kaletra (Oral (Oral Capsule)

3 QL
Solution) C1

Osel
tami

Oseltamivir Phosphate
vir
Pho
sph
ate
C1

Kale
tra

Kaletra (100-25MG (Oral Suspension 1

3 QL
C1
Oral Tablet) Reconstituted)
Kale
tra C1

Kaletra (200-50MG
Rele
nza

Relenza Diskhaler
Disk
hale
r

4 QL
Oral Tablet) (Inhalation Aerosol
C1

Lexi
va

Lexiva (Oral 2
3 QL Powder Breath
C1
Suspension) Activated)
Lexi
va

Lexiva (Oral Tablet) 4 QL

Bold type = Brand name drug Plain type = Generic drug

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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Rim Clor
anta aze

Rimantadine HCl (Oral Clorazepate

dine pate
HCl
Dip
otas
siu
m

1
C1
Tablet) Dipotassium (Oral 1 QL
Tablet)
Tam
iflu

Tamiflu (Oral
3 C1

Diaz
epa

Diazepam Intensol
m

Capsule)
Inte
nsol

(5MG/ML Oral 1 QL
C1

Tam
iflu

Tamiflu (Oral
Suspension 3 C1
Concentrate)
Diaz
epa

Diazepam (5MG/5ML
m

Reconstituted) 1
C1

Xofl
uza
Oral Solution)
Xofluza (Oral Tablet C1

2 QL
Diaz
epa

Diazepam (10MG Oral

m

Therapy Pack)
Tablet, 2MG Oral
Anxiolytics 1 QL
A1

Tablet, 5MG Oral

Anxiolytics, Other
B1

C1

Bus
piro
C1
Tablet)
Buspirone HCl (Oral
ne Klon
HCl opin

1 Klonopin (Oral Tablet) 3 QL

Tablet)
C1

Lora
zep

Lorazepam (2MG/ML
am

1 QL
C1

Hyd
roxy

Hydroxyzine HCl (Oral

zine
HCl

1 PA; HRM Oral Concentrate)

Syrup)
C1

Lora
zep

Lorazepam (Oral
am

B1

Benzodiazepines 1 QL
C1

Alpr
azol
C1
Tablet)
Alprazolam ER (Oral
am Oxa
ER zep

Oxazepam (Oral
am

Tablet Extended 1 PA; QL 1

Capsule)
Release 24 Hour)
C1

Tran
xen

Tranxene-T (Oral
e-T

C1

Alpr
azol
am
Inte
nsol

Alprazolam Intensol 3 QL
1 QL Tablet)
(Oral Concentrate) C1

Vali
um

C1

Alpr
azol
Valium (Oral Tablet) 3 QL
Alprazolam (Oral
am

C1

Xan
ax

Xanax (0.25MG Oral

Tablet Immediate 1 QL
Release) Tablet Immediate
C1

Alpr
azol
Release, 0.5MG Oral
Alprazolam ODT (Oral
am
ODT

1 QL Tablet Immediate 3 QL
Tablet Dispersible)
C1

Ativ
an Release, 1MG Oral
Ativan (Oral Tablet) 4 QL
C1

Chlo
rdia
Tablet Immediate
Chlordiazepoxide HCl
zep
oxid
e
HCl

1 Release)
(Oral Capsule) C1

Xan
ax

C1

Clon
aze Xanax (2MG Oral
Clonazepam (Oral
pam

1 QL Tablet Immediate 4 QL
Tablet)
C1

Clon
aze
Release)
Clonazepam ODT
pam

ODT
C1

Xan
ax

Xanax XR (Oral Tablet

XR

(Oral Tablet 1 QL
Dispersible) Extended Release 24 3 PA; QL
Hour)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Bipolar Agents Blood Glucose Regulators
A1 A1

Mood Stabilizers Antidiabetic Agents

B1 B1

C1 C1

Dep Acar
akot bos

Depakote ER (Oral Acarbose (Oral Tablet) 1

e e
ER

C1

Tablet Extended 3
Acto
plus

Actoplus Met (Oral

Met

C1
Release 24 Hour) Tablet Immediate 3 QL
Dep
akot

Depakote (Oral Tablet Release)

e

3 C1

Delayed Release)
Acto
s

C1

Dep C1
Actos (Oral Tablet) 3 QL
akot

Depakote Sprinkles
e Adly
Spri xin

Adlyxin Starter Pack

nkle Start
s er
Pac
k

(Oral Capsule (Subcutaneous Pen- 3 ST; QL

3
Delayed Release Injector Kit)
Sprinkle)
C1

Adly
xin

C1

Diva
lpro
Adlyxin
Divalproex Sodium ER
ex
Sodi

(Subcutaneous 3 ST; QL
um
ER

(Oral Tablet Extended 1 Solution Pen-Injector)

Release 24 Hour) C1

Alog
lipti

Alogliptin Benzoate
n
Ben
zoat
e

C1

Diva
lpro
ex
Sodi
um

Divalproex Sodium 3 ST; QL

(Oral Tablet)
(Oral Capsule Delayed 1 C1

Alog
lipti

Alogliptin-Metformin
n-
Metf
ormi
n
HCl

Release Sprinkle) 3 ST; QL

C1

Diva
lpro
HCl (Oral Tablet)
Divalproex Sodium
ex
Sodi
um
C1

Alog
lipti

Alogliptin-Pioglitazone
n-
Piog
litaz
one

(Oral Tablet Delayed 1 3 ST; QL

Release) C1
(Oral Tablet)
Ama
ryl

C1

Equ
etro

Equetro (Oral C1
Amaryl (Oral Tablet) 3 QL
Ava
ndia

Capsule Extended 3 C1
Avandia (Oral Tablet) 3 PA; QL
Byd
ureo

Bydureon BCise
n
BCis

Release 12 Hour)
e

(Subcutaneous Auto- 3 QL
C1

Lithi
um

Lithium Carbonate ER
Car
bon
ate
ER

(Oral Tablet Extended 1 C1

Injector)
Byd
ureo

Release) Bydureon
n

C1

Lithi

(Subcutaneous Pen- 3 QL
um

Lithium Carbonate
Car
bon
ate

1
C1
(Oral Capsule) C1
Injector)
Lithi Byet
um ta

Byetta 10MCG Pen

10M

Lithium Carbonate
Car
bon CG
ate Pen

(Oral Tablet Immediate 1 (Subcutaneous 3 ST; QL

C1
Release) Solution Pen-Injector)
Lithi C1
um

Lithium (Oral
Byet
ta

Byetta 5MCG Pen

5M
CG
Pen

1
C1
Solution) (Subcutaneous 3 ST; QL
Lith
obid

Lithobid (Oral Tablet Solution Pen-Injector)

4 C1

Extended Release)
Cycl
oset

Cycloset (Oral Tablet) 3 PA

Bold type = Brand name drug Plain type = Generic drug

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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Due Invo
tact kam

Duetact (Oral Tablet) 3 QL Invokamet XR (Oral

et
XR

C1

Tablet Extended 2 QL
Farx
iga

Farxiga (Oral Tablet) 3 ST; QL

Release 24 Hour)
C1

Fort
ame

Fortamet (Oral Tablet

t

C1

Invo
kan

Invokana (Oral Tablet) 2 QL

a

Extended Release 24 4 PA; QL C1

Jan
ume

Hour) Janumet (Oral Tablet

t

C1

2 QL
Immediate Release)
Glim
epiri

Glimepiride (Oral
de

1 QL C1

Jan

Tablet)
ume

Janumet XR (Oral
t XR

C1

Glipi

Tablet Extended
zide

Glipizide ER (Oral 2 QL
ER

Tablet Extended 1 QL C1
Release 24 Hour)
C1
Release 24 Hour) Jan
uvia

Januvia (Oral Tablet) 2 QL

Glipi
zide
C1

Glipizide (Oral Tablet Jard

ianc
e

Jardiance (Oral
1 QL 2 QL
C1
Immediate Release) Tablet)
Glipi
zide-

Glipizide-Metformin
Metf
ormi C1
n Jent
HCl adu

Jentadueto (Oral
eto

1 QL
HCl (Oral Tablet)
C1

Gluc
oph
Tablet Immediate 2 QL
Glucophage (Oral
age

Release)
Tablet Immediate 3 QL C1

Jent
adu

Jentadueto XR (Oral
eto
XR

Release)
C1

Gluc
oph
Tablet Extended 2 QL
Glucophage XR (Oral
age
XR

Release 24 Hour)
Tablet Extended 3 QL C1

Kaz
ano

Kazano (Oral Tablet) 3 ST; QL

Release 24 Hour) C1

Ko
mbi

Kombiglyze XR (Oral
glyz
e
XR
C1

Gluc
otrol

Glucotrol (Oral Tablet

3 QL Tablet Extended 3 QL
Immediate Release)
C1

Gluc
otrol
Release 24 Hour)
Glucotrol XL (Oral
XL
C1

Metf
ormi

Metformin HCl ER
n
HCl
ER

Tablet Extended 3 QL (1000MG Oral Tablet

C1
Release 24 Hour) Extended Release 24
Glu
met

Glumetza (Oral Tablet

za

Hour, 500MG Oral 4 PA; QL

Extended Release 24 4 PA; QL Tablet Extended
Hour) Release 24 Hour)
(Generic Glumetza)
C1

Glys
et

Glyset (Oral Tablet) 3 C1

Metf
ormi

Metformin HCl ER
n
C1 HCl
ER
Glyx
amb

Glyxambi (Oral
i

2 QL (1000MG Oral Tablet

Tablet)
C1

Invo
kam
Extended Release 24 4 PA; QL
Invokamet (Oral
et

Hour) (Generic
Tablet Immediate 2 QL Fortamet)
Release)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Metf Qter
ormi n

Metformin HCl ER Qtern (Oral Tablet) 3 ST; QL

n
HCl
ER

C1

(500MG Oral Tablet

Rep
agli

Repaglinide (Oral
nide

Extended Release 24 3 PA; QL 1 QL

Tablet)
Hour) (Generic C1

Rep
agli

Repaglinide-Metformin
nide
-
Metf
ormi
n
HCl

Fortamet) 3 QL
C1

Metf
ormi
HCl (Oral Tablet)
Metformin HCl ER
n
HCl
ER C1

Rio
met

Riomet (Oral
(Oral Tablet Extended 3 QL
Release 24 Hour) 1 QL C1
Solution)
Segl
uro

Segluromet (Oral
met

(Generic Glucophage 3 ST; QL

XR) C1
Tablet)
C1 Soli
qua
Metf

Soliqua
ormi

Metformin HCl (Oral

n
HCl

Tablet Immediate 1 QL (Subcutaneous 2 QL

C1
Release) C1
Solution Pen-Injector)
Migl
itol Starl

Miglitol (Oral Tablet) 1

ix

C1
C1
Starlix (Oral Tablet) 3 QL
Nat
egli Steg

Nateglinide (Oral
nide latro

1 QL Steglatro (Oral
Tablet) 3 ST; QL
C1

Nesi C1
Tablet)
na

Nesina (Oral Tablet) 3 ST; QL

Steg
lujan

Steglujan (Oral
C1

Ong
lyza
3 ST; QL
C1
Onglyza (Oral Tablet) 3 QL C1
Tablet)
Ose Sym
ni linP

Oseni (Oral Tablet) 3 ST; QL SymlinPen 120

en
120

C1

(Subcutaneous
Oze

4 PA
mpi

Ozempic
c

(Subcutaneous 2 QL C1
Solution Pen-Injector)
Sym
linP

Solution Pen-Injector) SymlinPen 60

en
60

C1

(Subcutaneous
Piog

4 PA
litaz

Pioglitazone HCl (Oral

one
HCl

1 QL
C1
Tablet) C1
Solution Pen-Injector)
Synj
Piog
ardy
litaz

Pioglitazone HCl- Synjardy (Oral Tablet

one
HCl-
Glim
epiri
de

2 QL
Glimepiride (Oral 3 QL C1
Immediate Release)
C1
Tablet) Synj
ardy
XR

Synjardy XR (Oral
Piog
litaz

Pioglitazone HCl-
one
HCl-

Tablet Extended 2 QL
Metf
ormi
n
HCl

Metformin HCl (Oral 1 QL Release 24 Hour)

Tablet) C1

Tola
zami

Tolazamide (250MG
de

C1

Pran
din

Prandin (1MG Oral Oral Tablet, 500MG 1 QL

3 QL
C1
Tablet) Oral Tablet)
Pran
din C1

Prandin (2MG Oral

Tolb
uta

Tolbutamide (Oral
mid
e

4 QL 1 QL
C1
Tablet) Tablet)
Prec
ose

Precose (Oral Tablet) 3

Bold type = Brand name drug Plain type = Generic drug

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56

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Trad Bas
jent agla

Tradjenta (Oral Basaglar KwikPen

a r
Kwi
kPe
n

2 QL
C1
Tablet) (Subcutaneous 3 ST
Solution Pen-Injector)
Truli
city

Trulicity C1

Hu
mal

(Subcutaneous 2 QL Humalog Junior

og
Juni
or
Kwi
kPe
n

Solution Pen-Injector) KwikPen

C1

2
(Subcutaneous
Vict
oza

Victoza
(Subcutaneous 2 QL C1
Solution Pen-Injector)
Hu
mal

Solution Pen-Injector) Humalog KwikPen

og
Kwi
kPe
n

C1

(Subcutaneous 2
Xigd
uo

Xigduo XR (Oral
XR

Tablet Extended 3 ST; QL C1

Solution Pen-Injector)
Hu
mal

Release 24 Hour) Humalog Mix 50/50

og
Mix
50/5
0
Kwi
kPe
n

C1

KwikPen
Xult
oph

Xultophy
y

(Subcutaneous 3 ST; QL (Subcutaneous 2

Solution Pen-Injector) Suspension Pen-
B1

Glycemic Agents C1
Injector)
Hu
mal

Humalog Mix 50/50

C1 og
Gluc Mix
aGe 50/5

GlucaGen HypoKit
n 0
Hyp
oKit

(Injection Solution 3 (Subcutaneous 2

Reconstituted) C1
Suspension)
Hu
mal

Humalog Mix 75/25

C1 og
Gluc Mix
ago 75/2

Glucagon Emergency
n 5
Eme Kwi
rgen kPe
cy n

2 KwikPen
(Injection Kit)
C1

Pro
glyc
em

Proglycem (Oral (Subcutaneous 2

4 Suspension Pen-
Suspension)
Injector)
Insulins
B1

C1

Hu
mal

Humalog Mix 75/25

og
Mix
75/2
C1 5
Afre
zza

Afrezza (12UNIT
(Subcutaneous 2
Inhalation Powder, 4
Suspension)
& 8 & 12UNIT C1

Hu
mal

Humalog
og

Inhalation Powder, 4 4 PA
& 8UNIT Inhalation (Subcutaneous 2
Powder, 8 & 12UNIT C1
Solution)
Hu
mal

Humalog
og

Inhalation Powder)
C1

Afre
zza

Afrezza (4UNIT (Subcutaneous 2

Inhalation Powder, Solution Cartridge)
3 PA
8UNIT Inhalation
Powder)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
tRACK 95 95
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57

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Hu Lev
muli emir

Humulin 70/30 Levemir

n
70/3
0
Kwi
kPe
n

KwikPen (Subcutaneous 2
(Subcutaneous 2 C1
Solution)
Suspension Pen-
Touj
eo

Toujeo Max SoloStar

Max
Solo
Star

C1
Injector) (Subcutaneous 2
Hu
muli

Humulin 70/30 Solution Pen-Injector)

n
70/3
0

C1

(Subcutaneous 2
Touj
eo

Toujeo SoloStar
Solo
Star

C1
Suspension) (Subcutaneous 2
Hu
muli

Humulin N KwikPen Solution Pen-Injector)

nN
Kwi
kPe
n

C1

(Subcutaneous
Tres
iba

Tresiba FlexTouch
Flex
Tou
ch

2
Suspension Pen- (Subcutaneous 2
C1
Injector) Solution Pen-Injector)
Hu C1
muli

Humulin N
nN Tres
iba

Tresiba
(Subcutaneous 2 (Subcutaneous 2
C1
Suspension) Solution)
Hu
muli

Humulin R (Injection
nR

Blood Products/Modifiers/Volume Expanders

A1

2
C1
Solution) B1

Anticoagulants
Hu
muli

Humulin R U-500
nR C1
U-50 Arixt
0 ra

Arixtra
(Concentrated) (Subcutaneous 4
2
(Subcutaneous Solution)
C1
Solution) C1

Bev
yxxa

Bevyxxa (Oral
Hu
muli
nR
U-50
0

Humulin R U-500 3 QL
Capsule)
Kwi
kPe
n

KwikPen C1

Cou
mad
in

Coumadin (Oral
2 2
(Subcutaneous Tablet)
Solution Pen-Injector) C1

Eliq
uis

C1

Lant
us
Eliquis (Oral Tablet) 2 QL
Lantus SoloStar
Solo
Star

C1

Eliq
uis

Eliquis Starter Pack

Start
er
Pac
k

(Subcutaneous 2 2 QL
(Oral Tablet)
C1
Solution Pen-Injector)
Lant
us

Lantus
(Subcutaneous 2
C1
Solution)
Lev
emir

Levemir FlexTouch
Flex
Tou
ch

(Subcutaneous 2
Solution Pen-Injector)

Bold type = Brand name drug Plain type = Generic drug

 96 tRACK 96 Last updated September 1, 2019
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Eno Frag
xap min

Enoxaparin Sodium Fragmin (10000UNIT/

arin
Sodi
um

(100MG/ML ML Subcutaneous
Subcutaneous Solution, 12500UNIT/
Solution, 120MG/ 0.5ML Subcutaneous
0.8ML Subcutaneous Solution, 15000UNIT/
Solution, 150MG/ML 0.6ML Subcutaneous
3 QL
Subcutaneous
Solution, 18000UNT/
Solution, 60MG/0.6ML
Subcutaneous 0.72ML
4
Solution, 80MG/0.8ML Subcutaneous
Subcutaneous Solution, 5000UNIT/
Solution) 0.2ML Subcutaneous
C1

Solution, 7500UNIT/
Eno
xap

Enoxaparin Sodium
arin
Sodi
um

(30MG/0.3ML 0.3ML Subcutaneous

Subcutaneous Solution, 95000UNIT/
1 QL
Solution, 40MG/0.4ML 3.8ML Subcutaneous
Subcutaneous Solution)
Solution)
C1

Frag
min

C1

Fon
dap
Fragmin (2500UNIT/
Fondaparinux Sodium
arin
ux
Sodi

0.2ML Subcutaneous 3
um

(10MG/0.8ML Solution)
Subcutaneous C1

Hep
arin

Heparin Sodium
Sodi
um

Solution, 5MG/0.4ML
4 (10000UNIT/ML
Subcutaneous
Solution, 7.5MG/ Injection Solution,
20000UNIT/ML 1
0.6ML Subcutaneous
Solution) Injection Solution,
C1

Fon
dap
5000UNIT/ML
Fondaparinux Sodium
arin
ux
Sodi
um

Injection Solution)
(2.5MG/0.5ML C1

Hep
arin

3 Heparin Sodium
Sodi
um

Subcutaneous
(1000UNIT/ML 1 B/D, PA
Solution)
C1
Injection Solution)
Jant
ove

Jantoven (Oral Tablet) 1

n

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
tRACK 97 97
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Lov Aran
eno esp

Lovenox (100MG/ML Aranesp (Albumin

x

Subcutaneous Free) (100MCG/ML

Solution, 120MG/ Injection Solution,
0.8ML Subcutaneous 200MCG/ML
Solution, 60MG/ 4 QL Injection Solution, 4 PA
0.6ML Subcutaneous 300MCG/ML
Solution, 80MG/ Injection Solution,
0.8ML Subcutaneous 60MCG/ML Injection
C1
Solution) C1
Solution)
Lov Aran
eno esp

Lovenox (150MG/ML Aranesp (Albumin

x

Subcutaneous Free) (25MCG/ML

Solution, 30MG/ Injection Solution, 3 PA
0.3ML Subcutaneous 3 QL 40MCG/ML Injection
Solution, 40MG/ C1
Solution)
0.4ML Subcutaneous
Aran
esp

Aranesp (Albumin
C1
Solution) Free) (100MCG/
Prad
axa

Pradaxa (Oral 0.5ML Injection

3 ST; QL
C1
Capsule) Solution Prefilled
Syringe, 150MCG/
Sav
aysa

Savaysa (Oral Tablet) 3 ST; QL

0.3ML Injection
C1

Warf
arin

Warfarin Sodium (Oral

Sodi
um

1 Solution Prefilled
Tablet)
Syringe, 200MCG/
C1

Xare
lto

Xarelto (Oral Tablet) 2 QL

C1

Xare
lto
0.4ML Injection
Xarelto Starter Pack
Start
er
Pac
k

Solution Prefilled 4 PA
(Oral Tablet Therapy 2 QL
Syringe, 300MCG/
Pack)
C1

Zont
ivity 0.6ML Injection
Zontivity (Oral Tablet) 3 PA
Solution Prefilled
Blood Formation Modifiers
B1

C1

Agry
lin
Syringe, 500MCG/ML
C1
Agrylin (Oral Capsule) 3 Injection Solution
Ana
greli

Anagrelide HCl
de

Prefilled Syringe,
HCl

3
C1
(0.5MG Oral Capsule) 60MCG/0.3ML
Ana
greli

Anagrelide HCl (1MG Injection Solution

de
HCl

1
Oral Capsule) Prefilled Syringe)

Bold type = Brand name drug Plain type = Generic drug

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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Aran Mul
esp plet

Aranesp (Albumin Mulpleta (Oral Tablet) 4 PA

a

C1

Free) (10MCG/0.4ML
Neul
asta

Neulasta
Injection Solution (Subcutaneous
Prefilled Syringe, 4 PA
Solution Prefilled
25MCG/0.42ML Syringe)
3 PA
Injection Solution
C1

Neu
pog

Neupogen (Injection
en

Prefilled Syringe, 4 ST
Solution)
40MCG/0.4ML C1

Neu
pog
en

Neupogen (Injection
Injection Solution Solution Prefilled 4 ST
C1
Prefilled Syringe) Syringe)
Dop
telet

C1
Doptelet (Oral Tablet) 4 PA C1

Nive
sty
m

Nivestym (Injection
Epo
gen

Epogen (10000UNIT/ 4 ST
Solution)
ML Injection Solution, C1

Nive
sty
m

Nivestym (Injection
2000UNIT/ML Solution Prefilled 4 ST
Injection Solution, Syringe)
3 PA
3000UNIT/ML C1

Proc
rit

Procrit (10000UNIT/
Injection Solution,
ML Injection Solution,
4000UNIT/ML
2000UNIT/ML
Injection Solution)
C1

Epo
Injection Solution,
3 PA
gen

Epogen (20000UNIT/ 3000UNIT/ML

4 PA
C1
ML Injection Solution) Injection Solution,
Fulp
hila

Fulphila 4000UNIT/ML
(Subcutaneous Injection Solution)
4 PA
Solution Prefilled C1

Proc
rit

Procrit (20000UNIT/
C1
Syringe) ML Injection Solution,
Gra
nix

Granix 4 PA
40000UNIT/ML
(Subcutaneous 4 ST Injection Solution)
C1
Solution) C1

Pro
mac
ta

Promacta (Oral
Gra
nix

Granix 4 PA; LA; QL

Packet)
(Subcutaneous C1

Pro
mac
ta

Promacta (Oral
4 ST 4 PA; LA; QL
Solution Prefilled Tablet)
C1
Syringe)
Leu
kine

Leukine (Injection
Solution 4 PA
Reconstituted)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
tRACK 99 99
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Reta Clo
crit pido

Retacrit (10000UNIT/ Clopidogrel Bisulfate

grel
Bisu
lfate

1 QL
ML Injection Solution, C1
(75MG Oral Tablet)
Effie

2000UNIT/ML
nt

C1
Effient (Oral Tablet) 3
Injection Solution,
Plavi
x

3 PA Plavix (Oral Tablet) 3 QL

3000UNIT/ML
C1

Pras
ugre

Prasugrel HCl (Oral

l
HCl

Injection Solution, 1
Tablet)
4000UNIT/ML A1

Cardiovascular Agents
Injection Solution)
Alpha-adrenergic Agonists
B1

C1

Reta
crit

Retacrit (40000UNIT/ C1

Cata
pres

4 PA Catapres (Oral
ML Injection Solution) 3
C1

Ude
nyca
Tablet)
Udenyca C1

Cata
pres

Catapres-TTS-1
-
TTS-
1

(Subcutaneous
4 PA (Transdermal Patch 3
Solution Prefilled
Weekly)
Syringe) C1

Cata
pres

Catapres-TTS-2
-
TTS-
2
C1

Zarx
io

Zarxio (Injection
(Transdermal Patch 3
Solution Prefilled 4
Weekly)
Syringe) C1

Cata
pres

Catapres-TTS-3
-
TTS-
3

Hemostasis Agents
B1

C1

Lyst
eda
(Transdermal Patch 3
C1
Lysteda (Oral Tablet) 3 Weekly)
Tav
aliss

Tavalisse (Oral
e
C1

Clon
idin

Clonidine HCl (Oral

e
HCl

4 PA; QL
C1
Tablet) Tablet Immediate 1
Tran
exa

Tranexamic Acid (Oral

mic

Release)
Acid

1
Tablet)
C1

Clon
idin

Clonidine
e

Platelet Modifying Agents

B1

C1
(Transdermal Patch 1
Weekly)
Agg
reno

Aggrenox (Oral
x

C1

Met
hyld

Capsule Extended Methyldopa (Oral

opa

3 QL
1 PA; HRM
Release 12 Hour) C1
Tablet)
C1 Mid
odri
Aspi

Midodrine HCl (Oral

ne
rin-
HCl

Aspirin-Dipyridamole
Dipy
rida
mol
e
ER

1
ER (Oral Capsule Tablet)
3 QL C1

Nort

Extended Release 12
hera

Northera (Oral
Hour) 4 PA; LA; QL
C1

Brili
nta
Capsule)
C1
Brilinta (Oral Tablet) 2 QL B1

Alpha-adrenergic Blocking Agents

Cabl
ivi C1

Cablivi (Injection Kit) 4 PA; QL

Car
dura

Cardura (Oral Tablet

C1

Cilo
staz
3
Cilostazol (Oral Tablet) 1
ol

Immediate Release)

Bold type = Brand name drug Plain type = Generic drug

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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Dibe Alta
nzyli ce

Dibenzyline (Oral Altace (Oral Capsule) 3 QL

ne

4 C1

Capsule)
Ben
aze

Benazepril HCl (Oral

pril
HCl

C1

Dox
1 QL
Tablet)
azos

Doxazosin Mesylate
in
Mes
ylate

1 C1

(Oral Tablet)
Cap
topri

Captopril (Oral Tablet) 1 QL

l

C1

Mini C1
pres

Minipress (Oral
s Enal
april

Enalapril Maleate (Oral

Mal
eate

3 1 QL
C1
Capsule) C1
Tablet)
Phe
nox Fosi
nopr

Phenoxybenzamine
ybe

Fosinopril Sodium
nza il
min Sodi
e um
HCl

4 1 QL
C1
HCl (Oral Capsule) C1
(Oral Tablet)
Praz
osin Lisin
opril

Prazosin HCl (Oral

HCl

1 C1
Lisinopril (Oral Tablet) 1 QL
Capsule) Lote
nsin

Lotensin (Oral Tablet) 3 QL

C1

Angiotensin II Receptor Antagonists

B1
Moe
xipril

Moexipril HCl (Oral

HCl

C1

Atac
and

Atacand (Oral Tablet) 3 QL 1 QL

C1
C1
Tablet)
Ava
pro Peri

Avapro (Oral Tablet)

ndo

3 QL Perindopril Erbumine
pril
Erb
umi
ne

C1

1 QL
(Oral Tablet)
Beni
car

C1
Benicar (Oral Tablet) 3 QL C1

Prini
vil

Prinivil (Oral Tablet) 3 QL

Can
des

Candesartan Cilexetil
arta
n
Cile
xetil

1 QL C1

Qbr
elis

(Oral Tablet) Qbrelis (Oral

C1

Coz
4 QL
Solution)
aar

C1
Cozaar (Oral Tablet) 3 QL C1

Quin
Diov april

Quinapril HCl (Oral

an HCl

Diovan (Oral Tablet) 3 QL 1 QL

Tablet)
C1

Edar
bi

Edarbi (Oral Tablet) 3 QL C1

Ram
ipril

Ramipril (Oral
C1

Epr
osar

Eprosartan Mesylate
tan
Mes

1 QL
ylate

1 QL Capsule)
(Oral Tablet) C1

Tran
dola

Trandolapril (Oral
C1 pril

Irbe
sart

Irbesartan (Oral Tablet) 1 QL

an

1 QL
C1

Los
arta
Tablet)
Losartan Potassium
n
Pota
ssiu
m
C1

1 QL
Vas
otec

(Oral Tablet) Vasotec (10MG Oral

C1

Mic
ardi

Tablet, 20MG Oral 4 QL

Micardis (Oral Tablet) 3 QL
s

C1

Olm
esar Tablet)
Olmesartan
tan
Med
oxo
mil
C1

Vas
otec

Medoxomil (Oral 1 QL Vasotec (2.5MG Oral

Tablet) Tablet, 5MG Oral 3 QL
C1

Tel
misa
rtan

Telmisartan (Oral Tablet)

1 QL
C1

Zest
ril

Tablet) Zestril (Oral Tablet) 3 QL

C1

Antiarrhythmics
B1
Vals
arta

Valsartan (Oral Tablet) 1 QL

n

C1

Ami
odar

Amiodarone HCl (Oral

one
HCl

Angiotensin-converting Enzyme (ACE)

B1

1
Inhibitors Tablet)
C1

Acc
upril

Accupril (Oral Tablet) 3 QL

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Beta Sota
pac lol

Betapace AF (120MG Sotalol HCl (Oral

e AF HCl

1
Oral Tablet, 160MG 4 C1
Tablet)
Soty

Oral Tablet)
lize

Sotylize (Oral
C1

Beta
3 PA
Solution)
pac

Betapace AF (80MG
e AF

3 C1

Tiko

Oral Tablet)
syn

Tikosyn (Oral
C1

Dof
3
Capsule)
etili

Dofetilide (Oral
de

3
C1
Capsule) B1

Beta-adrenergic Blocking Agents

Flec C1
aini

Flecainide Acetate
de Ace
Acet buto

Acebutolol HCl (Oral

ate lol
HCl

1 1
C1
(Oral Tablet) Capsule)
Mex C1
iletin

Mexiletine HCl (Oral

e Aten
HCl olol

1 Atenolol (Oral Tablet) 1

Capsule)
C1

Beta
xolo

Betaxolol HCl (Oral

l
HCl

1
C1

Mult
aq

C1
Multaq (Oral Tablet) 2 Tablet)
Pac C1
eron

Pacerone (100MG Oral

e Biso
prol

Bisoprolol Fumarate
ol
Fum
arat
e

Tablet, 400MG Oral 3 1

(Oral Tablet)
Tablet)
C1

Byst
olic

C1

Pac
eron
Bystolic (Oral Tablet) 2 QL
Pacerone (200MG Oral
e
C1

Carv
edil

Carvedilol (Oral Tablet) 1

ol

1
Tablet) C1

Carv
edil

Carvedilol Phosphate
ol
Pho
sph
ate
C1 ER
Pro
pafe

Propafenone HCl ER
non
e
HCl
ER

ER (Oral Capsule
(Oral Capsule 3
3 Extended Release 24
Extended Release 12 Hour)
Hour) C1

Cor
eg

Coreg CR (Oral
CR

C1

Pro
pafe

Propafenone HCl (Oral

non
e
HCl

1 Capsule Extended 3
Tablet)
C1

Quin
idin
Release 24 Hour)
Quinidine Gluconate
e
Gluc
onat
e C1
ER
Cor
eg

ER (Oral Tablet 3 C1
Coreg (Oral Tablet) 3
Cor
gard

Extended Release) C1
Corgard (Oral Tablet) 3
Inde
C1 ral

Inderal LA (Oral
LA
Quin
idin

Quinidine Sulfate (Oral

e
Sulf
ate

1 Capsule Extended 4
C1
Tablet)
Ryth
mol
SR

Rythmol SR (Oral C1
Release 24 Hour)
Inno
Pran

InnoPran XL (Oral
XL

Capsule Extended 4
Release 12 Hour) Capsule Extended 4
C1

Sori
ne

Sorine (Oral Tablet) 1 C1

Release 24 Hour)
Lab
C1 etal

Labetalol HCl (Oral

ol
Sota HCl
lol

Sotalol HCl (AF)

HCl

1 1
(120MG Oral Tablet) Tablet)

Bold type = Brand name drug Plain type = Generic drug

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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Lopr Cala
ess n

Lopressor (100MG Calan SR (120MG

or SR

3
C1
Oral Tablet) Oral Tablet Extended
Release, 240MG Oral 3
Met
opr

Metoprolol Succinate
olol
Suc
cina
te
ER

ER (Oral Tablet Tablet Extended

1
Extended Release 24 C1
Release)
C1
Hour) Car
dize
m
CD

Cardizem CD (Oral
Met
opr

Metoprolol Tartrate
olol
Tartr

Capsule Extended 4
ate

(100MG Oral Tablet, Release 24 Hour)

1
25MG Oral Tablet, C1

Car
dize
m
LA

Cardizem LA (Oral
50MG Oral Tablet)
C1

Nad
olol
Tablet Extended 3
C1
Nadolol (Oral Tablet) 1 Release 24 Hour)
Pind
olol

Pindolol (Oral Tablet) 1

C1

Car
dize

Cardizem (Oral Tablet

m

C1

Pro
pran
olol
HCl
ER

Propranolol HCl ER 4
Immediate Release)
(Oral Capsule C1

Carti
a XT

1 Cartia XT (Oral
Extended Release 24
Capsule Extended 1
Hour)
C1

Pro
pran
Release 24 Hour)
Propranolol HCl (Oral
olol
HCl
C1

Dilti
aze

1 Diltiazem HCl ER
m
HCl
ER
Bea
ds

Solution)
C1

Pro
pran
Beads (360MG Oral
Propranolol HCl (Oral
olol
HCl

1 Capsule Extended
C1
Tablet) Release 24 Hour, 1
Ten
ormi

Tenormin (Oral
n

420MG Oral Capsule

3
Tablet) Extended Release 24
Hour)
C1

Top
rol

Toprol XL (Oral Tablet

XL

C1

Dilti
aze

Diltiazem HCl ER
m
HCl

Extended Release 24 3
ER
Coa
ted
Bea
ds

Hour) Coated Beads (120MG

Oral Capsule Extended
Calcium Channel Blocking Agents
B1

C1

Adal
at
Release 24 Hour,
Adalat CC (Oral
CC

180MG Oral Capsule

Tablet Extended 3 Extended Release 24
Release 24 Hour) 1
C1

Aml
Hour, 240MG Oral
Capsule Extended
odip

Amlodipine Besylate
ine
Bes
ylate

1 Release 24 Hour,
(Oral Tablet)
300MG Oral Capsule
C1

Cala
n

Calan (Oral Tablet

3 Extended Release 24
Immediate Release)
Hour)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Dilti Proc
aze ardi

Diltiazem HCl ER (Oral Procardia XL (Oral

m a XL
HCl
ER

Capsule Extended 1 Tablet Extended 3

C1
Release 12 Hour) Release 24 Hour)
Dilti C1
aze

Diltiazem HCl (Oral

m Sula
HCl r

Sular (Oral Tablet

Tablet Immediate 1 Extended Release 24 3
C1
Release) Hour)
Dilt-
XR

Dilt-XR (Oral Capsule

C1

Tazt
ia

Taztia XT (Oral
XT

Extended Release 24 1 Capsule Extended 1

C1
Hour) Release 24 Hour)
Felo
dipi

Felodipine ER (Oral
ne
C1
ER
Tiaz
ac

Tiazac (Oral Capsule

Tablet Extended 1 Extended Release 24 3
Release 24 Hour)
C1

Isra
dipi
Hour)
Isradipine (Oral
ne

C1

Vera
pam

1 Verapamil HCl ER
il
HCl
ER

Capsule)
C1

Mat
zim
(100MG Oral Capsule
Matzim LA (Oral Tablet
LA

Extended Release 24
Extended Release 24 1 Hour, 120MG Oral
C1
Hour) Capsule Extended
Nica
rdipi

Nicardipine HCl (Oral

ne

Release 24 Hour,
HCl

1
C1
Capsule) 180MG Oral Capsule
Extended Release 24
Nife
dipi

Nifedipine ER (Oral
ne
ER

1
Tablet Extended 1 Hour, 200MG Oral
Release 24 Hour) Capsule Extended
Release 24 Hour,
C1

Nife
dipi

Nifedipine ER Osmotic
ne
ER
Os
moti
c
Rele
ase

Release (Oral Tablet 240MG Oral Capsule

1 Extended Release 24
Extended Release 24
Hour) Hour, 300MG Oral
C1

Nim
odip Capsule Extended
Nimodipine (Oral
ine

3 Release 24 Hour)
Capsule) C1

Vera
pam

Verapamil HCl ER
il
HCl
ER
C1

Niso
ldipi

Nisoldipine ER (Oral
ne
ER

(360MG Oral Capsule

Tablet Extended 3 1
Release 24 Hour) Extended Release 24
C1

Nor
vasc
Hour)
Norvasc (Oral Tablet) 3 C1

Vera
pam

Verapamil HCl ER
il
HCl
ER
C1

Nym
alize

Nymalize (60MG/ (Oral Tablet Extended 1

4
20ML Oral Solution) Release)

Bold type = Brand name drug Plain type = Generic drug

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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Vera Aten
pam olol-

Verapamil HCl (Oral Atenolol-

il Chlo
HCl rthal
idon
e

Tablet Immediate 1 Chlorthalidone (Oral 1

C1
Release) C1
Tablet)
Vere Aval
lan ide

Verelan (Oral Capsule C1

Avalide (Oral Tablet) 3 QL
Extended Release 24 3
Azor

Azor (Oral Tablet) 3 QL

Hour)
C1

Ben
aze

Benazepril-
pril-
Hyd
roch
lorot
hiazi
de

C1

Vere
lan

Verelan PM (Oral
PM

Hydrochlorothiazide 1 QL
Capsule Extended 3 C1
(Oral Tablet)
Beni

Release 24 Hour)
car

Benicar HCT (Oral

HCT

3 QL
Cardiovascular Agents, Other Tablet)
B1

C1
C1
BiDil
Acc
ureti

Accuretic (Oral BiDil (Oral Tablet) 2

c

3 QL C1

Biso

Tablet)
prol

Bisoprolol-
ol-
Hyd
roch
lorot
hiazi
de

C1

Alda

Hydrochlorothiazide 1 QL
ctazi

Aldactazide (Oral
de

3 (Oral Tablet)
C1
Tablet) C1

Cad
uet

Caduet (Oral Tablet) 3 QL

Alis
kire

Aliskiren Fumarate
n
Fum
arat
e

3 QL C1

Can
des

(Oral Tablet) Candesartan Cilexetil-

arta
n
Cile
xetil-
HCT
Z

C1
1 QL
HCTZ (Oral Tablet)
Amil
orid

Amiloride-
e-
Hyd
roch
lorot
hiazi
de

C1

Cap
topri

Hydrochlorothiazide 1 Captopril-
l-
Hyd
roch
lorot
hiazi
de

C1
(Oral Tablet) Hydrochlorothiazide 1 QL
(Oral Tablet)
Aml
odip

Amlodipine-
ine-
Ator
vast
atin

C1

Corl
anor

Atorvastatin (Oral 3 QL C1
Corlanor (Oral Tablet) 3 PA; QL
Tablet)
De
mse

Demser (Oral
r

C1

Aml
odip
ine-

Amlodipine-Benazepril 4
Capsule)
Ben
aze
pril

1 QL
(Oral Capsule)
C1

Digit
ek

Digitek (125MCG Oral

1 HRM; QL
C1

Aml
odip

Amlodipine-
ine-

Tablet)
Olm
esar
tan

Olmesartan (Oral 1 QL
C1

Digit
ek

Digitek (250MCG Oral

Tablet) 1 PA; HRM
C1

Aml
odip
Tablet)
Amlodipine-Valsartan
ine- C1
Vals
arta Dig
n ox

1 QL Digox (125MCG Oral

(Oral Tablet) 1 HRM; QL
C1

Aml
odip
Tablet)
Amlodipine-Valsartan-
ine- C1
Vals
arta Dig
n- ox

Digox (250MCG Oral

HCT
Z

1 1 PA; HRM
C1
HCTZ (Oral Tablet) Tablet)
Atac
and

Atacand HCT (Oral

HCT C1

Dig
oxin

3 QL Digoxin (Oral PA; HRM;

Tablet) 1
C1
Solution) QL
Dig
oxin

Digoxin (125MCG Oral

1 HRM; QL
Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
tRACK 105 105
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Dig Los
oxin arta

Digoxin (250MCG Oral Losartan Potassium-

n
Pota
ssiu
m-
HCT
Z

1 PA; HRM 1 QL
C1
Tablet) C1
HCTZ (Oral Tablet)
Diov Lotr
an el

Diovan HCT (Oral Lotrel (Oral Capsule) 3 QL

HCT

3 QL C1

Tablet)
Max
zide

C1

DUT C1
Maxzide (Oral Tablet) 3
OP

DUTOPROL (Oral
ROL Max
zide-

Maxzide-25 (Oral
25

Tablet Extended 3 3
Tablet)
Release 24 Hour)
C1

Met
opr

Metoprolol-
olol-
Hyd
roch
lorot
hiazi
de

C1

Dya
zide

Dyazide (Oral Hydrochlorothiazide 1

3
C1
Capsule) C1
(Oral Tablet)
Mic
Edar
ardi
bycl

Edarbyclor (Oral Micardis HCT (Oral

s
or
HCT

3 QL 3 QL
C1
Tablet) C1
Tablet)
Nad
Enal
olol-
april

Nadolol-
Ben

Enalapril-
-
drofl
Hyd
ume
roch
thiaz
lorot
ide
hiazi
de

Hydrochlorothiazide 1 QL Bendroflumethiazide 1
C1
(Oral Tablet) C1
(40-5MG Oral Tablet)
Olm
Entr
esar
esto

Entresto (Oral Tablet) Olmesartan

tan

2 QL
Med
oxo
mil-
HCT
Z

C1

Exfo
rge
HCT

Exforge HCT (Oral Medoxomil-HCTZ (Oral 1 QL

3 Tablet)
Tablet) C1

Olm
esar

Olmesartan-
tan-
C1
Aml
Exfo odip
rge ine-

Exforge (Oral Tablet)

HCT

3 QL
Z

C1

Fosi
nopr Amlodipine-HCTZ 1 QL
Fosinopril Sodium-
il
Sodi
um-
HCT
Z

1 QL (Oral Tablet)
HCTZ (Oral Tablet) C1

Pent
oxify

Pentoxifylline ER (Oral
lline
ER

C1

Hyz
aar

C1
Hyzaar (Oral Tablet) 3 QL Tablet Extended 1
Irbe
sart

Irbesartan-
an-
Hyd

Release)
roch
lorot
hiazi
de

Hydrochlorothiazide 1 QL
C1

Pro
pran

Propranolol-HCTZ
olol-
HCT
Z

(Oral Tablet) 1
C1

Lan
oxin
(Oral Tablet)
Lanoxin (125MCG
C1

Quin
april

Quinapril-
-
Hyd
roch
lorot
hiazi
de

Oral Tablet, 62.5MCG 3 HRM; QL Hydrochlorothiazide 1 QL

C1
Oral Tablet) (Oral Tablet)
Lan
oxin C1

Lanoxin (250MCG
Ran
exa

3 PA; HRM Ranexa (Oral Tablet

C1
Oral Tablet) Extended Release 12 3
Lisin
opril

Lisinopril-
-

Hour)
Hyd
roch
lorot
hiazi
de

Hydrochlorothiazide 1 QL
C1

Ran
olazi

Ranolazine ER (Oral
ne
ER

C1
(Oral Tablet) Tablet Extended 1
Lopr
ess

Lopressor HCT (Oral

or

Release 12 Hour)
HCT

3
Tablet)

Bold type = Brand name drug Plain type = Generic drug

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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Spir Zest
onol oreti

Spironolactone-HCTZ Zestoretic (Oral

acto c
ne-
HCT
Z

1 3 QL
C1
(Oral Tablet) Tablet)
C1
Tark
a Ziac

Tarka (Oral Tablet Ziac (2.5-6.25MG

3 QL 3 QL
C1
Extended Release) Oral Tablet)
Tekt
urna

Tekturna HCT (Oral Diuretics, Carbonic Anhydrase Inhibitors

HCT B1

3 QL C1

Tablet)
Acet
azol

Acetazolamide ER
ami
de
ER

C1

Tekt
urna

Tekturna (Oral Tablet) 3 QL (Oral Capsule

C1
1
Extended Release 12
Tel
misa

Telmisartan-
rtan-
Aml
odip
ine

Amlodipine (Oral 1 QL C1
Hour)
Acet
azol

Tablet) Acetazolamide (Oral

ami
de

C1
1
Tablet)
Tel
misa

Telmisartan-HCTZ
rtan-
HCT
Z

1 QL C1

Kev
eyis

C1
(Oral Tablet) C1
Keveyis (Oral Tablet) 4 PA; QL
Ten Met
oreti haz

Tenoretic 100 (Oral Methazolamide (Oral

c ola
100 mid
e

3 3
Tablet) Tablet)
C1

Ten

Diuretics, Loop
oreti B1

Tenoretic 50 (Oral
c 50

3 C1

Bum

Tablet)
etan

Bumetanide (Injection
ide

C1

1
Solution)
Tran
dola

Trandolapril-Verapamil
pril-
Vera
pam
il
HCl
ER

C1

Bum
etan

HCl ER (Oral Tablet 1 QL Bumetanide (Oral

ide

Extended Release) 1
C1
C1
Tablet)
Tria
mter Ede
crin

Triamterene-HCTZ
ene-

Edecrin (Oral Tablet) 4

HCT
Z

1 C1

(Oral Capsule) Etha

cryn
ic
Acid

Ethacrynic Acid (Oral

C1

Tria
mter
ene-

Triamterene-HCTZ 3
Tablet)
HCT
Z

1 C1

(Oral Tablet) Furo

sem
ide

Furosemide (Injection
C1

Trib
enz
or

Tribenzor (Oral 1 B/D, PA

Solution)
3 QL C1

Tablet)
Furo
sem

Furosemide (Oral
ide

C1

Twy
nsta
1
Twynsta (40-10MG C1
Solution)
Furo

Oral Tablet, 40-5MG

sem

Furosemide (Oral
ide

3 QL 1
Oral Tablet, 80-5MG C1
Tablet)
Oral Tablet)
Lasi
x

C1

Vals C1
Lasix (Oral Tablet) 3
arta

Valsartan-
n- Tors
Hyd emi

Torsemide (Oral
roch de
lorot
hiazi
de

Hydrochlorothiazide 1 QL 1
Tablet)
C1
(Oral Tablet) B1

Diuretics, Potassium-sparing
Vas
ereti

Vaseretic (Oral
c
C1

Alda
cton

Aldactone (Oral
e

3 QL 3
C1
Tablet) Tablet)
Vec
amyl

Vecamyl (Oral Tablet) 4 PA

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Amil Fen
orid ofibr

Amiloride HCl (Oral Fenofibrate (150MG

e ate
HCl

1
C1
Tablet) Oral Capsule, 50MG 1
Oral Capsule)
Car
oSpi

CaroSpir (Oral
r

3 C1

Fen
ofibr

Fenofibrate (120MG
ate

Suspension)
Oral Tablet, 40MG Oral 3
C1

Dyre
niu

Dyrenium (Oral
m

3 Tablet)
Capsule) C1

Fen
ofibr

Fenofibrate (145MG
ate
C1

Eple
reno

Eplerenone (Oral
ne

1 Oral Tablet, 160MG

Tablet)
C1

Insp
ra Oral Tablet, 48MG Oral 1
C1
Inspra (Oral Tablet) 3 Tablet, 54MG Oral
Spir
onol

Spironolactone (Oral
acto
ne

1 Tablet)
Tablet)
C1

Fen
ofibr

Fenofibric Acid (Oral

ic
Acid

Diuretics, Thiazide
B1

C1

Chlo
Capsule Delayed 1
Release)
rothi

Chlorothiazide (Oral
azid
e

1 C1

Fen

Tablet)
ofibr

Fenofibric Acid
ic
Acid

C1

Chlo
rthal
1
Chlorthalidone (Oral (105MG Oral Tablet)
idon
e

1 C1

Tablet)
Fen
ofibr

Fenofibric Acid (35MG

ic
Acid

C1

Diuri
l
1
Diuril (Oral Oral Tablet)
3 C1

Fen

Suspension)
ogli

Fenoglide (120MG
de

C1

Hyd
roch
4
Hydrochlorothiazide Oral Tablet)
lorot
hiazi
de

1 C1

(Oral Capsule)
Fen
ogli

Fenoglide (40MG Oral

de

C1

Hyd
roch
3
Hydrochlorothiazide
lorot

Tablet)
hiazi
de

1
(Oral Tablet)
C1

Fibri
cor

C1

Inda
pam
Fibricor (Oral Tablet) 3
Indapamide (Oral
ide C1

Ge
mfib

Gemfibrozil (Oral
rozil

1 1
C1
Tablet) Tablet)
Met
hycl

Methyclothiazide (5MG
othi C1
azid
e Lipo
fen

1 Lipofen (Oral
Oral Tablet) 3
C1

Met
olaz
Capsule)
Metolazone (Oral
one
C1

Lopi
d

1 Lopid (Oral Tablet) 3

Tablet) C1

Tric
or

Tricor (Oral Tablet) 3

Dyslipidemics, Fibric Acid Derivatives
B1

C1

Trigl
ide

C1

Anta
ra Triglide (Oral Tablet) 3
Antara (Oral Capsule) 2 C1

Trili
pix

C1

Fen
Trilipix (Oral Capsule
3
ofibr

Fenofibrate Micronized
ate
Micr
oniz
ed

1 Delayed Release)
(Oral Capsule)
Dyslipidemics, HMG CoA Reductase
B1

Inhibitors

Bold type = Brand name drug Plain type = Generic drug

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70

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Alto Zoc
prev or

Altoprev (Oral Tablet Zocor (10MG Oral

Extended Release 24 4 QL Tablet, 20MG Oral
C1
Hour) Tablet, 40MG Oral 3 QL
Tablet, 80MG Oral
Ator
vast

Atorvastatin Calcium
atin
Calc
ium

1 QL Tablet)
C1
(Oral Tablet) C1

Zypi
Cres tam

Zypitamag (Oral
tor ag

Crestor (Oral Tablet) 3 QL

C1
3 ST; QL
Tablet)
Ezall
or

Ezallor Sprinkle (Oral

Spri
nkle

3 QL
Dyslipidemics, Other
B1

C1
Capsule Sprinkle) C1

Chol
FloL esty
ipid

Cholestyramine Light
rami

FloLipid (Oral
ne
Ligh
t

3 QL 1
Suspension) C1
(Oral Powder)
C1 Chol
esty

Cholestyramine (Oral
Fluv rami
asta ne

Fluvastatin Sodium ER
tin
Sodi
um
ER

1
(Oral Tablet Extended 3 QL C1
Packet)
Cole

Release 24 Hour)
seve

Colesevelam HCl (Oral

lam
HCl

C1

3
Packet)
Fluv
asta

Fluvastatin Sodium
tin
Sodi
um

1 QL C1

Cole

(Oral Capsule)
seve

Colesevelam HCl (Oral

lam
HCl

C1

3
Tablet)
Les
col

Lescol XL (Oral
XL

C1

Cole
stid

Tablet Extended 3 QL C1
Colestid (Oral Packet) 3
Release 24 Hour)
Cole
stid

C1

Lipit C1
Colestid (Oral Tablet) 3
or

Lipitor (Oral Tablet) 3 QL

Cole
stip

Colestipol HCl (Oral

ol
HCl

C1

Lival
1
Packet)
o

C1
Livalo (Oral Tablet) 2 QL C1

Cole
Lov stip

Colestipol HCl (Oral

asta ol

Lovastatin (Oral
tin HCl

1 QL 1
Tablet) C1
Tablet)
C1
Ezet
Prav imib

Ezetimibe (Oral Tablet) 1

ach e

Pravachol (Oral
ol

3 QL C1

Ezet

Tablet)
imib

Ezetimibe-Simvastatin
e-
Sim
vast
atin

C1

1 QL
(Oral Tablet)
Prav
asta

Pravastatin Sodium
tin
Sodi
um

1 QL C1

Juxt
apid

(Oral Tablet) Juxtapid (Oral

C1

Ros
4 PA; LA
Capsule)
uvas

Rosuvastatin Calcium
tatin

Calc
ium

1 QL C1

(Oral Tablet)
Lov
aza

C1

Sim C1
Lovaza (Oral Capsule) 3
vast

Simvastatin (Oral
atin Niac
in

Niacin ER
ER

1 QL
Tablet) (Antihyperlipidemic)
1
(Oral Tablet Extended
C1
Release)
Niac
or

Niacor (Oral Tablet) 1

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1

Nias
pan

Niaspan (Oral Tablet Vasodilators, Direct-acting Arterial/Venous

B1

3 C1

Extended Release)
GoN
itro

GoNitro (Sublingual
C1

Om
ega-
3
Omega-3-Acid Ethyl Packet)
3-
Acid
Ethy
l
Este
rs

C1

Esters (Oral Capsule) 1

Isor
dil

Isordil Titradose (Oral

Titra
dos
e

(Generic Lovaza) 4
C1

Pral
uent
Tablet)
Praluent
C1

Isos
orbi

Isosorbide Dinitrate ER
de
Dinit
rate
ER

(Subcutaneous 3 PA; LA; QL (Oral Tablet Extended 1

C1
Solution Pen-Injector) Release)
Prev C1
alite

Prevalite (Oral Packet) 1

Isos
orbi

Isosorbide Dinitrate
de
Dinit
rate

C1

Que

(Oral Tablet Immediate 1

stra

Questran Light (Oral

n
Ligh
t

3 Release)
C1
Powder) C1

Isos
Que orbi

Isosorbide
stra de

Questran (Oral Packet) 3

n Mon
onitr
ate
ER

Mononitrate ER (Oral
C1

Rep
atha

Repatha Pushtronex
Pus

1
htro
nex
Syst
em

System Tablet Extended

3 PA; QL Release 24 Hour)
(Subcutaneous C1

Isos
orbi

Isosorbide
de
Mon
onitr
ate

Solution Cartridge)
C1

Rep
Mononitrate (Oral
1
atha

Repatha Tablet Immediate

(Subcutaneous Release)
3 PA; QL
Solution Prefilled C1

Mini
tran

Minitran (Transdermal
Syringe) 1
C1

Rep
atha
Patch 24 Hour)
Repatha SureClick
C1
Sure
Clic Nitr
k o-

Nitro-Bid (Transdermal
Bid

(Subcutaneous 2
3 PA; QL Ointment)
Solution Auto- C1

Nitr
o-
Dur

Nitro-Dur
C1
Injector) (Transdermal Patch 3
Vas
cep

Vascepa (Oral
a

3 24 Hour)
Capsule) C1

Nitr
ogly
ceri
n

Nitroglycerin (Tablet
1
C1

Vyto
rin

C1
Vytorin (Oral Tablet) 3 QL Sublingual)
Wel C1
chol

Welchol (Oral Packet) 3

Nitr
ogly

Nitroglycerin
ceri
n

C1

Wel
chol

C1
Welchol (Oral Tablet) 3 (Transdermal Patch 24 1
Zeti
a

Zetia (Oral Tablet) 3 C1

Hour)
Nitr
ogly

Nitroglycerin
ceri
n

Vasodilators, Direct-acting Arterial

B1

1
C1

Hyd
ralaz
(Translingual Solution)
Hydralazine HCl (Oral
ine
HCl

C1

1
Nitr
osta

Nitrostat (Tablet
t

Tablet) 3
C1

Min
oxid
il

Minoxidil (Oral Tablet) 1 Sublingual)

Bold type = Brand name drug Plain type = Generic drug

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72

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Rect Dext
iv roa

Rectiv (Rectal Dextroamphetamine

mph
eta
min
e
Sulf
ate
ER

3
Ointment) Sulfate ER (10MG Oral
A1

Central Nervous System Agents Capsule Extended

Release 24 Hour, 3 QL
Attention Deficit Hyperactivity Disorder
B1

15MG Oral Capsule

C1
Agents, Amphetamines Extended Release 24
Add
erall

Adderall (20MG Oral Hour)

Tablet, 5MG Oral
C1

Dext
roa

Dextroamphetamine
mph
eta

3 QL
min
e
Sulf
ate
ER

Tablet, 7.5MG Oral Sulfate ER (5MG Oral

Tablet) 1 QL
C1

Add
erall
Capsule Extended
Adderall XR (Oral
XR

C1
Release 24 Hour)
Capsule Extended 3 QL Dext
roa
mph
eta
min
e
Sulf
ate
Dextroamphetamine
Release 24 Hour) 1 QL
C1

Adz
enys
C1
Sulfate (Oral Tablet)
Adzenys ER (Oral
ER Dya
nav

Dyanavel XR (Oral
el
XR

Suspension Extended 3 QL Suspension Extended 3 QL

C1
Release) Release)
Adz C1
enys

Adzenys XR-ODT
XR- Eve
ODT keo

Evekeo (Oral Tablet) 3

(Oral Tablet Extended 3 QL
C1

Met
ham

Methamphetamine HCl
phet
ami
ne
HCl

Release Dispersible) 3 PA
C1

Am
phet C1
(Oral Tablet)
Amphetamine Sulfate
ami
ne Myd
Sulf ayis

Mydayis (Oral
ate

3
C1
(Oral Tablet) Capsule Extended 3 QL
Am
phet

Amphetamine-
ami
ne-

Release 24 Hour)
Dext
roa
mph
eta
min
e
ER

Dextroamphetamine
C1

Pro
Cen

ProCentra (Oral
tra

ER (Oral Capsule 1 QL 3
Solution)
Extended Release 24 C1

Vyv
ans

Vyvanse (Oral
e

Hour) 3
C1

Am
phet
Capsule)
Amphetamine-
ami
ne-
Dext
roa
mph
eta C1
min
e Vyv
ans

Vyvanse (Oral Tablet

e

Dextroamphetamine 1 QL 3
(Oral Tablet) C1
Chewable)
C1 Zen
zedi

Zenzedi (Oral Tablet) 3 QL

Des
oxy

Desoxyn (Oral Tablet) 4 PA

n

C1

Attention Deficit Hyperactivity Disorder

Dex B1
edri

Dexedrine (Oral
ne

Capsule Extended 4 QL C1
Agents, Non-amphetamines
Apt
ensi

Release 24 Hour) Aptensio XR (Oral

o
XR

Capsule Extended 3 QL
Release 24 Hour)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
tRACK 111 111
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Ato Met
mox hylp

Atomoxetine HCl (Oral Methylphenidate HCl

etin heni
e date
HCl HCl
LA

1
Capsule) LA (Oral Capsule
C1
3
Extended Release 24
Clon
idin

Clonidine HCl ER (Oral

e
HCl
ER

Tablet Extended 3 PA C1
Hour)
Met
hylp

Release 12 Hour) Methylphenidate HCl

heni
date
HCl
ER

C1

ER (10MG Oral Tablet

Con
cert

Concerta (Oral Tablet

a

3 QL Extended Release, 1 QL
Extended Release)
C1

Cot
emp
20MG Oral Tablet
Cotempla XR-ODT
la
XR-
ODT

Extended Release)
(Oral Tablet Extended 3 QL C1

Met
hylp

Methylphenidate HCl
heni
date
HCl
ER
Os
moti

Release Dispersible)
c
Rele
ase

C1

Dayt
rana
ER Osmotic Release
Daytrana (18MG Oral Tablet
3 QL
C1
(Transdermal Patch) Extended Release,
Dex

27MG Oral Tablet

met

Dexmethylphenidate
hylp
heni
date
HCl
ER

HCl ER (Oral Capsule Extended Release,

3 3 QL
Extended Release 24 36MG Oral Tablet
Hour) Extended Release,
54MG Oral Tablet
C1

Dex
met

Dexmethylphenidate
hylp
heni
date
HCl

1 QL Extended Release,
HCl (Oral Tablet)
C1

Foc
alin
72MG Oral Tablet
Focalin (Oral Tablet) 3 QL
C1

Foc
alin
Extended Release)
Focalin XR (Oral
XR

C1

Met
hylp

Methylphenidate HCl
heni
date
HCl
ER

Capsule Extended 3 ER (Oral Tablet

Release 24 Hour) 3 QL
C1

Kap
vay
Extended Release 24
Kapvay (Oral Tablet C1
Hour)
Extended Release 12 3 PA
Met
hylp

Methylphenidate HCl
heni
date
HCl

Hour) 1 QL
C1

Met
C1
(Oral Solution)
adat Met

Metadate ER (Oral
e hylp
ER

Methylphenidate HCl
heni
date
HCl

Tablet Extended 1 QL (Oral Tablet Immediate

Release) 1 QL
C1

Met
Release) (Generic
Ritalin)
hylin

Methylin (Oral
3 QL C1

Met
hylp

Solution) Methylphenidate HCl

heni
date
HCl

C1
3 QL
(Oral Tablet Chewable)
Met
hylp

Methylphenidate HCl
heni
date
HCl
CD

C1

Quill
iChe

CD (Oral Capsule 1 QuilliChew ER (Oral

w
ER

Extended Release) Tablet Chewable 3 QL

Extended Release)

Bold type = Brand name drug Plain type = Generic drug

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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Quill Tigl
ivant utik

Quillivant XR (Oral Tiglutik (Oral

XR

4 PA
Suspension 3 C1
Suspension)
Reconstituted)
Xen
azin

Xenazine (Oral
e

C1

Rele
xxii
4 PA; LA
Relexxii (Oral Tablet Tablet)
3 QL
C1
Extended Release) B1

Fibromyalgia Agents
Rital
in C1

Ritalin LA (Oral
LA
Cym
balt

Cymbalta (Oral
a

Capsule Extended 3 Capsule Delayed 3 QL

C1
Release 24 Hour) Release Particles)
Rital
in C1

Ritalin (Oral Tablet) 3 QL

Dulo
xeti

Duloxetine HCl (20MG

ne
HCl

C1

Strat
tera

Strattera (Oral Oral Capsule Delayed

3
Capsule) Release Particles,
B1

Central Nervous System, Other 30MG Oral Capsule

1 QL
C1

Aust
edo
Delayed Release
C1
Austedo (Oral Tablet) 4 PA; LA; QL Particles, 60MG Oral
Grali
se

C1
Gralise (Oral Tablet) 3 PA Capsule Delayed
Grali
se

Gralise Starter (Oral) 3 PA Release Particles)

Start
er

C1 C1

Hori Dulo
zant xeti

Horizant (Oral Tablet Duloxetine HCl (40MG

ne
HCl

3 PA Oral Capsule Delayed 3 QL

Extended Release)
Release Particles)
C1

Ingr
ezza

Ingrezza (Oral
4 PA; QL
C1

Lyri
ca

Lyrica CR (Oral Tablet

CR

Capsule)
Extended Release 24 3 PA; QL
C1

Ingr
ezza

Ingrezza (Oral
Capsule Therapy 4 PA; QL C1
Hour)
Lyri
ca

Pack) C1
Lyrica (Oral Capsule) 2 QL
Lyri
C1 ca

Lyrica (Oral Solution) 2 QL

Na
mza

Namzaric (Oral
ric

C1

Sav
ella

Capsule ER 24 Hour 2 PA; QL C1

Savella (Oral Tablet) 2
Sav

Therapy Pack)
ella

Savella Titration Pack

Titra
tion
Pac
k

C1

Na
2
(Oral Tablet)
mza

Namzaric (Oral
ric

Capsule Extended 2 PA; QL Multiple Sclerosis Agents

B1

C1

Release 24 Hour)
Am
pyra

C1

Nue
dext
Ampyra (Oral Tablet
Nuedexta (Oral
a

Extended Release 12 4 QL
3 PA
C1
Capsule) C1
Hour)
Rilut
ek Aub

Rilutek (Oral Tablet) 4

agio

C1

Rilu
C1
Aubagio (Oral Tablet) 4 LA; QL
zole Avo

Riluzole (Oral Tablet) 1

nex

Avonex (30MCG
C1

Tetr
4
Intramuscular Kit)
abe

Tetrabenazine (Oral
nazi
ne

4 PA; LA
Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
tRACK 113 113
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Avo Mav
nex encl

Avonex Pen Mavenclad (5 Tabs)

Pen ad

(Intramuscular Auto- 4 (Oral Tablet Therapy 4 PA

C1
Injector Kit) C1
Pack)
Avo Mav
nex encl

Avonex Prefilled Mavenclad (6 Tabs)

Prefi ad
lled

(Intramuscular 4 (Oral Tablet Therapy 4 PA

C1
Prefilled Syringe Kit) C1
Pack)
Beta Mav
sero encl

Betaseron Mavenclad (7 Tabs)

n ad

4
C1
(Subcutaneous Kit) (Oral Tablet Therapy 4 PA
Pack)
Cop
axo

Copaxone
ne

C1

Mav
encl

(Subcutaneous Mavenclad (8 Tabs)

ad

4
Solution Prefilled (Oral Tablet Therapy 4 PA
C1
Syringe) C1
Pack)
Dalf Mav
amp encl

Dalfampridine ER (Oral Mavenclad (9 Tabs)

ridin ad
e
ER

Tablet Extended 4 QL (Oral Tablet Therapy 4 PA

C1
Release 12 Hour) Pack)
Exta C1
via

Extavia
May
zent

4 Mayzent (Oral Tablet) 4 QL

(Subcutaneous Kit)
C1

Pleg
ridy

Plegridy Starter Pack

Start
er
Pac
k

C1

Gile
nya

Gilenya (0.5MG Oral (Subcutaneous 4

4 QL
C1
Capsule) Solution Pen-Injector)
Glati C1
ram

Glatiramer Acetate
er Pleg
Acet ridy

Plegridy Starter Pack

ate Start
er
Pac
k

(Subcutaneous (Subcutaneous
4 4
Solution Prefilled Solution Prefilled
Syringe)
C1

Glat
opa
Syringe)
Glatopa C1

Pleg
ridy

Plegridy
(Subcutaneous
4 (Subcutaneous 4
Solution Prefilled
Syringe) C1
Solution Pen-Injector)
Pleg
ridy

Plegridy
C1

Mav
encl

Mavenclad (10 Tabs)

ad

(Oral Tablet Therapy 4 PA (Subcutaneous

4
Pack) Solution Prefilled
C1

Mav
encl
Syringe)
Mavenclad (4 Tabs)
ad

C1

Rebi
f

Rebif Rebidose
Rebi
dos
e

(Oral Tablet Therapy 4 PA

Pack) (Subcutaneous
4
Solution Auto-
Injector)

Bold type = Brand name drug Plain type = Generic drug

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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Rebi Abs
f oric

Rebif Rebidose Absorica (Oral

Rebi a
dos
e
Titra
tion
Pac
k

4 PA
Titration Pack C1
Capsule)
(Subcutaneous 4
Aca
nya

Acanya (External Gel) 3 ST

Solution Auto-
C1

Acitr
etin

Acitretin (Oral
Injector) 3
C1

Rebi
f
C1
Capsule)
Rebif (Subcutaneous
Acz
one

Aczone (5% External

Solution Prefilled 4 3
Gel)
Syringe)
C1

Ada
pale

Adapalene (External
ne

3
C1

Rebi
f

Rebif Titration Pack

Titra

Cream)
tion
Pac
k

C1

(Subcutaneous
Ada
pale

Adapalene (0.1%
ne

4 1
Solution Prefilled External Gel)
Syringe)
C1

Ada
pale

Adapalene (0.3%
ne

C1

Tecf
ider
a

Tecfidera Starter 3
External Gel)
Start
er
Pac
k

4 LA C1

Pack (Oral)
Ada
pale

Adapalene (External
ne

C1

Tecf
ider
3
Tecfidera (Oral Pad)
a

C1

Ada

Capsule Delayed 4 LA; QL

pale

Adapalene (External
ne

4
Release) C1
Solution)
Ada
pale

Dental and Oral Agents

A1

Adapalene-Benzoyl
ne-
Ben
zoyl
Per
oxid
e

3 ST
B1

Dental and Oral Agents C1

Peroxide (External Gel)
Akti
C1 pak

Aktipak (External
Cevi
meli

Cevimeline HCl (Oral

ne
HCl

3 ST 3 ST
Capsule) C1
Packet)
C1 Alda
ra
Chlo

Aldara (External
rhex

Chlorhexidine
idin
e
Gluc
onat
e

3
Gluconate (Mouth 1 C1
Cream)
Solution)
Altre
no

Altreno (External
C1

Evo
xac
3 PA
C1
Evoxac (Oral Capsule) 3 ST C1
Lotion)
Pilo
carp Am

Pilocarpine HCl (Oral

ine mon

Ammonium Lactate
HCl ium
Lact
ate

1 1
C1
Tablet) C1
(External Cream)
Sala
gen Am

Salagen (Oral Tablet) 3

mon

Ammonium Lactate
ium
Lact
ate

C1

1
(External Lotion)
Tria
mci

Triamcinolone
nolo
ne
Acet
onid
e

C1

Amn

Acetonide (Dental 1
este

Amnesteem (Oral
em

Paste) 3 PA
C1
Capsule)
Atral

Dermatological Agents
A1 in

C1
Atralin (External Gel) 3 PA
Avit

Dermatological Agents
B1 a

Avita (External
1 PA
Cream)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Avit Clin
a daci

Avita (External Gel) 1 PA Clindacin-P (External

n-P

C1
1
Swab)
Azel
aic

Azelaic Acid (External

Acid

3 C1

Clin
dag

Gel) Clindagel (External

el

C1

4
Gel)
Azel
ex

Azelex (External
3 C1

Clin
dam

Cream) Clindamycin
ycin
Pho
sph
ate

C1

Phosphate (External 3
Ben
zaCl

BenzaClin with Pump

in
with
Pum
p

3 Foam)
(External Gel) C1

Clin
dam

Clindamycin
C1 ycin
Pho
Ben sph
zam ate

Benzamycin (External
ycin

3 Phosphate (External 1
Gel)
C1

Ben
zoyl Gel)
Benzoyl Peroxide-
Per
oxid
e-
Eryt C1
hro
myci Clin
n dam

Clindamycin
ycin
Pho
sph
ate

Erythromycin (External 3
Gel) Phosphate (External 1
C1

Calc
ipotr Lotion)
Calcipotriene (External
iene

C1

Clin

3
dam

Clindamycin
ycin
Pho
sph
ate

Cream)
C1

Calc
ipotr Phosphate (External 1
Calcipotriene (External
iene

3 Solution)
Ointment) C1

Clin
dam

Clindamycin
ycin
Pho
sph
ate
C1

Calc
ipotr

Calcipotriene (External
iene

1 Phosphate (External 1
C1
Solution) Swab)
Calc
ipotr

Calcipotriene-
iene C1
-
Beta Clin
met dam

Clindamycin
has ycin
one Pho
sph
ate-
Ben
zoyl
Per
oxid

Betamethasone 3
e

Phosphate-Benzoyl
(External Ointment) 3 ST
C1

Calc
itriol
Peroxide (1.2-2.5%
Calcitriol (External External Gel)
3 C1

C1
Ointment) Clin
dam
ycin
Pho
sph
ate-
Ben
zoyl
Per
oxid
e
Clindamycin
Cara
c

Carac (External Phosphate-Benzoyl

4
Cream) Peroxide (1-5% 1
External Gel, 1.2-5%
C1

Clar
avis

Claravis (10MG Oral

Capsule, 20MG Oral External Gel)
3 PA C1

Clin
dam
ycin-

Clindamycin-Tretinoin
Capsule, 40MG Oral
Treti
noin

3 PA
C1
Capsule) C1
(External Gel)
Clot
Cleo rima

Clotrimazole-
cin- zole-

Cleocin-T (External
T Beta
met
has
one

3 Betamethasone 1
Gel)
(External Cream)
C1

Cleo
cin-

Cleocin-T (External
T

3
C1

Clot
rima

Clotrimazole-
zole-
Beta
met

Lotion)
has
one

C1

Cleo
cin-
Betamethasone 1
Cleocin-T (External
T

3 (External Lotion)
Swab)

Bold type = Brand name drug Plain type = Generic drug

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78

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Con Efud
dylo ex

Condylox (External Efudex (External

x

3 3
C1
Gel) C1
Cream)
Cort Elid
ispo el

Cortisporin (External Elidel (External

rin

3 3 ST
C1
Cream) C1
Cream)
Cort Enst
ispo ilar

Cortisporin (External Enstilar (External

rin

3 4 PA
C1
Ointment) C1
Foam)
Cos Epid
enty uo

Cosentyx (300 MG Epiduo (External Gel) 3 ST

x

C1

Dose) (Subcutaneous
Epid
uo

Epiduo Forte
Fort
e

4 PA; LA 3 ST
Solution Prefilled (External Gel)
Syringe)
C1

Ery

C1

Cos
enty
Ery (External Pad) 1
Cosentyx Sensoready
x C1
Sen Eryg
sore el

Erygel (External Gel)

ady

3
(300 MG) C1

Eryt
hro
myci
n

Erythromycin (External
(Subcutaneous 4 PA; LA 1
Gel)
Solution Auto- C1

Eryt
hro

Erythromycin (External
myci
n

Injector) 1
C1

Dap
son
Solution)
Dapsone (External Gel) 3
e
C1

Eucr
isa

Eucrisa (External
3 PA; QL
C1

Dicl
ofen

Diclofenac Sodium
ac
Sodi
um

3 PA Ointment)
(3% Transdermal Gel) C1

Evo
clin

C1
Evoclin (External
4
Diffe
rin

Differin (External Foam)

3
Cream) C1

Fabi
or

C1
Fabior (External
3 PA
Diffe
rin

C1
Differin (External Gel) 3 Foam)
Diffe
rin

Differin (External
C1

Fina
cea

3 Finacea (External
Lotion) 3
C1

Dov
one
Foam)
Dovonex (External
x C1

Fina
cea

4 Finacea (External Gel) 3

Cream) C1

Fluo
rour

Fluorouracil (0.5%
acil

C1

Dox
epin
HCl

Doxepin HCl (External 4

3 PA; QL External Cream)
Cream) C1

Fluo
rour

Fluorouracil (5%
acil

C1

Dua
c

Duac (External Gel) 3 1

C1

Duo
brii C1
External Cream)
Duobrii (External
Fluo
rour

Fluorouracil (External
acil

4 PA 1
C1
Lotion) Solution)
Dupi C1
xent

Dupixent (300MG/
Ilum
ya

Ilumya
2ML Subcutaneous (Subcutaneous
4 PA 4 PA
Solution Prefilled Solution Prefilled
Syringe) Syringe)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Imiq Reti
uim n-A

Imiquimod (5% Retin-A (External

od

1 3 PA
C1
External Cream) Cream)
C1
Imiq
uim Reti

Imiquimod Pump
od n-A

Retin-A (External Gel) 3 PA

Pum
p

(3.75% External 4 PA
C1

Reti
n-A

Retin-A Micro
Micr
o

Cream) 4 PA
C1

Isotr
etin
(External Gel)
Isotretinoin (Oral
oin
C1

Reti
n-A

Retin-A Micro Pump

Micr

3 PA
o
Pum
p

Capsule)
C1

Klar
on
(0.06% External Gel, 4 PA
Klaron (External 0.08% External Gel)
3 PA
Lotion) C1

Rho
fade

C1
Rhofade (External
3 PA
Lotri
son

Lotrisone (External
e

3 Cream)
Cream) C1

Sant
yl

C1
Santyl (External
3
Met
hox

Methoxsalen Rapid
sale
n
Rapi
d

4 Ointment)
(Oral Capsule) C1

Sele
niu

Selenium Sulfide
m
Sulfi
de
C1

Mirv

1
aso

C1
Mirvaso (External Gel) 3 (External Lotion)
Myo
risa

Myorisan (Oral
n
C1

Siliq

3 PA Siliq (Subcutaneous
C1
Capsule) Solution Prefilled 4 PA
Neo
-

Neo-Synalar (External
Syn
alar

4 Syringe)
Cream) C1

Sool
antr

Soolantra (External
a

C1

3
Neu
ac

C1
Neuac (External Gel) 1 Cream)
One
xton

Onexton (External
C1

Sori
atan

Soriatane (Oral
e

3 4
C1
Gel) Capsule)
Oxs
oral

Oxsoralen Ultra (Oral

en
Ultra C1

Soril
ux

4 Sorilux (External
Capsule) 4
C1

Pica
to
Foam)
Picato (External Gel) 2
C1

Stel
ara

C1

Pim
ecro
Stelara
Pimecrolimus (External
limu
s

3 ST (Subcutaneous 4 PA
C1
Cream) Solution)
Pod
ofilo

Podofilox (External
x C1

Stel
ara

1 Stelara
C1
Solution) (Subcutaneous
4 PA
Prot
opic

Protopic (External Solution Prefilled

3 ST
C1
Ointment) Syringe)
PRU
DOX

PRUDOXIN (External
IN C1

Sulf
acet

Sulfacetamide Sodium
ami
de
Sodi

3 PA; QL
um

C1
Cream) (Acne) (External 1 PA
Reg
rane

Regranex (External Lotion)

x

4 PA
Gel)

Bold type = Brand name drug Plain type = Generic drug

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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Tacl Treti
one noin

Taclonex (External Tretinoin (0.05%

x

4 3 PA
Ointment) C1
External Gel)
C1
Treti
Tacl noin

Tretinoin Microsphere
one

Taclonex (External
x Micr
osp
here

4 3 PA
Suspension) C1
(External Gel)
C1 Vect
ical

Vectical (External
Tacr
olim

Tacrolimus (External
us

3 ST 4
Ointment) C1
Ointment)
C1
Vere
Talt gen

Veregen (External
z

Taltz (Subcutaneous 4
Solution Auto- 4 PA; LA C1
Ointment)
Zen

Injector)
atan

Zenatane (Oral
e

C1

3 PA
Capsule)
Talt
z

Taltz (Subcutaneous C1

Zian
a

Solution Prefilled 4 PA; LA C1

Ziana (External Gel) 4 PA
Zon

Syringe)
alon

Zonalon (External
C1

Taz
arot
3 PA; QL
Tazarotene (External Cream)
ene

3 PA C1

Cream)
Zycl
ara

Zyclara Pump
Pum
p

C1

Taz
orac
4 PA
Tazorac (External (External Cream)
3 PA
C1
Cream) A1

Electrolytes/Minerals/Metals/Vitamins
Taz
orac

Tazorac (0.05% B1

Electrolyte/Mineral Replacement
4 PA
External Gel)
C1

Ami
nos

Aminosyn II
yn II

3 B/D, PA
C1

Taz
orac

Tazorac (0.1% (Intravenous Solution)

3 PA
External Gel)
C1

Ami
nos

Aminosyn-PF
yn-
PF

3 B/D, PA
C1

Tola
k

Tolak (External (Intravenous Solution)

3
Cream)
C1

Car
bagl

Carbaglu (Oral
u

4 LA
C1

Tre
mfy

Tremfya
a

Tablet)
(Subcutaneous 4 PA
C1

Car
nitor

Carnitor (Oral
Solution Pen-Injector) 3
C1

Tre
mfy
Solution)
Tremfya
a C1

Car
nitor

Carnitor (Oral Tablet) 3

(Subcutaneous C1

Clini
mix

Clinimix E/Dextrose
E/

4 PA
Dext
rose

Solution Prefilled
(2.75/5) (Intravenous 3 B/D, PA
Syringe)
C1

Treti
noin
Solution)
Tretinoin (External C1

Clini
mix

1 PA Clinimix E/Dextrose
E/
Dext
rose

Cream)
C1

Treti
noin
(4.25/10) 3 B/D, PA
Tretinoin (0.01% (Intravenous Solution)
External Gel, 0.025% 1 PA
External Gel)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Clini Dext
mix rose

Clinimix E/Dextrose Dextrose-NaCl

E/ -
Dext NaC
rose l

(4.25/5) (Intravenous 3 B/D, PA (10-0.2% Intravenous

C1
Solution) Solution, 10-0.45%
Intravenous Solution,
Clini
mix

Clinimix E/Dextrose
E/
Dext
rose

(5/15) (Intravenous 3 B/D, PA 2.5-0.45%

Solution) Intravenous Solution,
1
5-0.2% Intravenous
C1

Clini
mix

Clinimix E/Dextrose
E/
Dext
rose

(5/20) (Intravenous 3 B/D, PA Solution, 5-0.225%

Solution) Intravenous Solution,
C1

Clini
mix/
Dext
rose

Clinimix/Dextrose 5-0.33% Intravenous

(4.25/10) 3 B/D, PA Solution, 5-0.45%
(Intravenous Solution) C1
Intravenous Solution)
Dext
rose

Dextrose-NaCl
-
C1 NaC
l
Clini
mix/

Clinimix/Dextrose
Dext
rose

(4.25/5) (Intravenous 3 B/D, PA (5-0.9% Intravenous 1 B/D, PA

Solution) C1
Solution)
End
ari

C1

Clini
mix/
Dext
rose

Clinimix/Dextrose C1
Endari (Oral Packet) 4 PA
Fre
Ami

FreAmine HBC
ne
HBC

(5/15) (Intravenous 3 B/D, PA 3 B/D, PA

Solution) C1
(Intravenous Solution)
Hep
atA

HepatAmine
C1 min
Clini e
mix/

Clinimix/Dextrose
Dext
rose

1 B/D, PA
(5/20) (Intravenous 3 B/D, PA C1
(Intravenous Solution)
Intra
lipid

Solution) Intralipid (20%

Intravenous
C1

Clini
sol
SF

Clinisol SF 1 B/D, PA
3 B/D, PA Emulsion)
C1
(Intravenous Solution) C1

Intra
lipid

Intralipid (30%
Dext
rose

Dextrose (10%
1 Intravenous 3 B/D, PA
Intravenous Solution)
Emulsion)
C1

Dext
rose

Dextrose (5%
1 B/D, PA
C1

Iono
sol-

Ionosol-MB in D5W
MB

Intravenous Solution)
in
D5
W

3
C1
(Intravenous Solution)
Isoly
te-P

Isolyte-P in D5W
in
D5
W

3
C1
(Intravenous Solution)
Isoly
te-S

Isolyte-S (Intravenous
3
C1
Solution)
KCl
in

KCl in Dextrose-NaCl
Dext
rose
-
NaC
l

1
(Injection)

Bold type = Brand name drug Plain type = Generic drug

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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

KCl- Nep
Lact hrA

KCl-Lactated Ringers- NephrAmine

ated min
e
Ring
ers-
D5
W

3 B/D, PA
D5W (Intravenous 1 C1
(Intravenous Solution)
Solution)
Nor
mos

Normosol-M in D5W
ol-M
in
D5
W

C1

Klor-
Con
1
Klor-Con 10 (Oral (Intravenous Solution)
10

C1

Tablet Extended 1
Nor
mos

Normosol-R in D5W
ol-R
in
D5
W

Release) 1
C1

Klor- C1
(Intravenous Solution)
Con

Klor-Con M10 (Oral

M10 Nor
mos

Normosol-R pH 7.4
ol-R
pH
7.4

Tablet Extended 1 1
(Intravenous Solution)
Release) C1

Nutr
ilipid

C1

Klor-
Con
Nutrilipid
Klor-Con M15 (Oral
M15

(Intravenous 1 B/D, PA
Tablet Extended 1 Emulsion)
Release) C1

Plas
ma-

Plasma-Lyte 148
Lyte
148

C1

Klor-
Con

Klor-Con M20 (Oral 3

M20

(Intravenous Solution)
Tablet Extended 1 C1

Plas
ma-

Plasma-Lyte A
Lyte
A

Release) 3
(Intravenous Solution)
C1

Klor-
Con

Klor-Con (Oral Packet) 3 C1

Plen
ami

Plenamine
ne
C1

Klor-
Con

Klor-Con 8 (Oral
8

1 B/D, PA
(Intravenous Solution)
Tablet Extended 1 C1

Pota
ssiu

Potassium Chloride
m
Chlo
ride
CR

Release)
C1

Klor-
Con
CR (Oral Tablet 1
Klor-Con Sprinkle
Spri
nkle

Extended Release)
(8MEQ Oral Capsule 1 C1

Pota
ssiu

Potassium Chloride ER
m
Chlo
ride
ER

Extended Release)
C1

K-
Tab
(Oral Capsule 1
K-Tab (Oral Tablet Extended Release)
3
Extended Release) C1

Pota
ssiu

Potassium Chloride in
m
Chlo
ride
in
C1 Dext
rose
Lev
ocar

Levocarnitine (1GM/
nitin
e

1 Dextrose (Intravenous 1 B/D, PA

10ML Oral Solution)
C1

Lev
ocar
Solution)
Levocarnitine
nitin
e
C1

Pota
ssiu

Potassium Chloride in
m

1
Chlo
ride
in
NaC
l

(330MG Oral Tablet) NaCl (20-0.45MEQ/L-

1 B/D, PA
C1

Mag
nesi

Magnesium Sulfate
um
Sulf

% Intravenous
ate

(50% Injection 1 Solution)

C1

Solution)
Pota
ssiu

Potassium Chloride in
m
Chlo
ride
in
NaC
l

C1

Mag
nesi

Magnesium Sulfate
um

NaCl (20-0.9MEQ/L-%
Sulf
ate

(50% (10ML Syringe) 1 Intravenous Solution, 1 B/D, PA

Injection Solution) 40-0.9MEQ/L-%
Intravenous Solution)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Pota Sodi
ssiu um

Potassium Chloride Sodium Chloride (3%

m Chlo
Chlo ride
ride

(10MEQ/100ML Intravenous Solution,

1 B/D, PA
Intravenous Solution, 5% Intravenous
20MEQ/100ML 1 B/D, PA C1
Solution)
Intravenous Solution,
Sodi
um

Sodium Chloride
Chlo
ride

40MEQ/100ML 1
(Irrigation Solution)
Intravenous Solution)
C1

Sodi
um

Sodium Fluoride (Oral

Fluo
ride

C1

Pota
ssiu
m

Potassium Chloride 1
Tablet)
Chlo
ride

C1

(2MEQ/ML Sodi
um
Lact
ate

Sodium Lactate
Intravenous Solution, 1 B/D, PA 1
(Intravenous Solution)
2MEQ/ML (20ML) C1

TPN
Elec

TPN Electrolytes
troly
tes

Intravenous Solution) 1
C1

Pota
ssiu
(Intravenous Solution)
Potassium Chloride
m
Chlo
ride

C1

3
Trav
asol

(Oral Packet) Travasol (Intravenous

3 B/D, PA
C1

Pota
ssiu
m
Chlo
ride

Potassium Chloride C1
Solution)
3 Tro
phA
min
e

TrophAmine
(Oral Solution) 3 B/D, PA
(Intravenous Solution)
C1

Pota
ssiu

Potassium Citrate ER
m
Citra
te
ER

C1

Uro
cit-K

Urocit-K 10 (Oral
10

(Oral Tablet Extended 1

C1
Release) Tablet Extended 3
Release)
Pre
mas

Premasol (10%
ol

3 B/D, PA C1

Uro

Intravenous Solution)
cit-K

Urocit-K 15 (Oral
15

C1

Pre

Tablet Extended 3
mas

Premasol (6%
ol

1 B/D, PA
C1
Intravenous Solution) C1
Release)
Proc Uro
ala cit-K

Procalamine Urocit-K 5 (Oral

min 5
e

3 B/D, PA
C1
(Intravenous Solution) Tablet Extended 3
Release)
Pros
ol

Prosol (Intravenous
3 B/D, PA
Solution) Electrolyte/Mineral/Metal Modifiers
B1

C1 C1
Sodi Che
um met

Sodium Chloride Chemet (Oral

Chlo
ride

4
(0.45% Intravenous 1 C1
Capsule)
Solution)
Def
eras

Deferasirox (Oral
irox

C1

Sodi
4 PA
Tablet Soluble)
um

Sodium Chloride (0.9%

Chlo
ride

1 B/D, PA C1

Intravenous Solution)
Exja
de

Exjade (Oral Tablet

4 PA
C1
Soluble)
Ferri
prox

Ferriprox (Oral
4 PA
Solution)

Bold type = Brand name drug Plain type = Generic drug

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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Ferri Fosr
prox enol

Ferriprox (Oral Fosrenol (Oral

4 PA 4
C1
Tablet) C1
Packet)
Jad Fosr
enu enol

Jadenu (Oral Tablet) 4 PA Fosrenol (Oral Tablet

C1

4
Chewable)
Jad
enu

Jadenu Sprinkle (Oral

Spri
nkle

4 PA C1

Lant
han

Packet) Lanthanum Carbonate

um
Car
bon
ate

C1
4
(Oral Tablet Chewable)
Jyna
rque

Jynarque (Oral
4 PA C1

Pho
slyra

Tablet) Phoslyra (Oral

C1
2
Solution)
Jyna
rque

Jynarque (Oral Tablet

4 PA; QL C1

Ren
agel

Therapy Pack) C1
Renagel (Oral Tablet) 4
C1
Ren
Kion vela

Renvela (Oral Packet) 4

ex

Kionex (Oral
1 C1

Suspension)
Ren
vela

C1

Lok C1
Renvela (Oral Tablet) 4
elm

Lokelma (Oral
a Sev
ela

Sevelamer Carbonate
mer
Car
bon
ate

3 QL 4
C1
Packet) C1
(Oral Packet)
Sam
sca Sev

Samsca (Oral Tablet)

ela

4 PA Sevelamer Carbonate
mer
Car
bon
ate

C1

(Oral Tablet) (Generic 3

Sodi
um

Sodium Polystyrene
Poly
styr
ene
Sulf
onat
e

Sulfonate (Oral 1 C1
Renvela)
Sev
ela

Powder) Sevelamer HCl (Oral

mer
HCl

C1

3
Tablet)
Sodi
um

Sodium Polystyrene
Poly
styr
ene
Sulf
onat
e

C1

Velp
horo

Sulfonate (Oral 1 Velphoro (Oral Tablet

Suspension) 4
C1

SPS
Chewable)
C1
SPS (Oral Suspension) 1 B1

Vitamins
Sypr C1
ine

Syprine (Oral
VP-
PNV

VP-PNV-DHA (Oral
-
DHA

4 PA; QL 1
C1
Capsule) Capsule)
Trie
ntin

Trientine HCl (Oral

e

Gastrointestinal Agents
A1
HCl

4 PA; QL
C1
Capsule) B1

Antispasmodics, Gastrointestinal
Velt
assa

Veltassa (Oral Packet)

C1

4 QL Cuv
pos
a

Cuvposa (Oral
B1

Phosphate Binders 3 PA
C1

Aury C1
Solution)
xia

Auryxia (Oral Tablet) 4 PA

Dicy
clo

Dicyclomine HCl (Oral

min
e
HCl

C1

Calc
1 HRM
Capsule)
ium

Calcium Acetate
Acet
ate

C1

(Phosphate Binder) 1
Dicy
clo

Dicyclomine HCl (Oral

min
e
HCl

(Oral Capsule) 1 HRM

C1

Calc C1
Solution)
ium

Calcium Acetate
Acet Dicy
ate clo

Dicyclomine HCl (Oral

min
e
HCl

(Phosphate Binder) 1 1 HRM

Tablet)
(Oral Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
tRACK 123 123
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Glyc Myal
opyr ept

Glycopyrrolate (1MG Myalept

rolat
e

Oral Tablet, 2MG Oral 1 PA (Subcutaneous

Tablet) 4 PA; LA
C1

Met
hsc
Solution
Methscopolamine
opol

Reconstituted)
ami
ne
Bro
mid
e

1 C1

Bromide (Oral Tablet) Myt

esi

Mytesi (Oral Tablet

C1

Pro
pant
heli
ne

Propantheline Bromide 4 PA
Delayed Release)
Bro
mid
e

1 PA; HRM
(Oral Tablet)
C1

Om
ecla

Omeclamox-Pak
mox
-Pak

B1

Gastrointestinal Agents, Other 4

C1

Acti
gall C1
(Oral)
Actigall (Oral
Pyle
ra

4 Pylera (Oral Capsule) 4

Capsule)
C1

Reli
stor

C1

Am
oxici
Relistor (Oral Tablet) 4 PA
Amoxicillin-
llin-
C1
Clari
thro Reli
myci stor

Relistor
n-
Lan
sopr
azol
e

Clarithromycin- 3 (Subcutaneous 4 PA
Lansoprazole (Oral)
C1

Che
nod
Solution)
Chenodal (Oral Tablet) 4
al

C1

Ser
osti

Serostim
m

C1

Cro
mol

Cromolyn Sodium
yn
Sodi
um

1 (Subcutaneous
(Oral Concentrate) 4 PA; LA
C1

Diph
eno
Solution
Diphenoxylate-
xylat
e-
Atro
pine

1 PA; HRM Reconstituted)

Atropine (Oral Liquid) C1

Sym
proi

Symproic (Oral
c

C1

Diph

3 PA; QL
eno

Diphenoxylate-
xylat
e-
Atro
pine

1 PA; HRM Tablet)

Atropine (Oral Tablet) C1

Trul
anc

Trulance (Oral Tablet) 3 ST

e

C1

Gast
rocr

Gastrocrom (Oral
om

C1

Urs

4
o

Urso 250 (Oral

250

Concentrate) 3
C1

Gatt
ex
Tablet)
Gattex C1

Urs

4 PA; LA
o

Urso Forte (Oral

Fort
e

(Subcutaneous Kit) 3
C1

Lom
otil
Tablet)
Lomotil (Oral Tablet) 3 PA; HRM C1

Urs
odio

Ursodiol (Oral
l

C1

Lop
era

Loperamide HCl (Oral 1

mid
e
HCl

1 Capsule)
Capsule) C1

Urs
odio

Ursodiol (Oral Tablet) 3

l

C1

Mot
egrit

Motegrity (Oral
y

C1

Xer

3 ST; QL
mel

Xermelo (Oral Tablet) 4 PA; LA; QL

o

Tablet) C1

Zor
btiv

Zorbtive
e
C1

Mov
anti

Movantik (Oral
k

3 PA; QL (Subcutaneous
Tablet) 4 PA; LA
Solution
Reconstituted)
Histamine2 (H2) Receptor Antagonists
B1

Bold type = Brand name drug Plain type = Generic drug

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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1

Cim
etidi

Cimetidine HCl (Oral Laxatives

ne B1
HCl

1 C1

Solution)
Clen
piq

Clenpiq (Oral
C1

Cim
etidi

2
Cimetidine (Oral
ne

1 Solution)
Tablet)
C1

Coly
te

Colyte with Flavor

with
Flav
or
Pac
ks

C1

Fam
otidi

Famotidine (Oral
ne

Packs (Oral Solution 3

Suspension 1 Reconstituted)
Reconstituted) C1

Con
stul

Constulose (Oral
ose

C1

1
Fam
otidi

Famotidine (20MG
ne

Solution)
Oral Tablet, 40MG Oral 1 C1

Enul
ose

Enulose (Oral Solution) 1

Tablet) C1

Gavi
Lyte

GaviLyte-C (Oral
-C

C1

Niza
tidin

Nizatidine (Oral
e

1 Solution 1
Capsule)
C1

Niza
tidin
Reconstituted)
Nizatidine (Oral
e

C1

Gavi
Lyte

3 GaviLyte-G (Oral
-G

Solution)
C1

Pep
cid
Solution 1
Pepcid (20MG Oral Reconstituted)
3
Tablet) C1

Gavi
Lyte

GaviLyte-N with Flavor

-N
with
Flav
or
Pac
C1 k
Pep
cid

Pepcid (40MG Oral Pack (Oral Solution 1

4
C1
Tablet) Reconstituted)
Rani
tidin C1

Ranitidine HCl (Oral

e
HCl Gen
erla

Generlac (Oral
c

1 1
C1
Capsule) Solution)
Rani
tidin C1

Ranitidine HCl (75MG/

e
HCl GoL
YTE

GoLYTELY (Oral
LY

1
C1
5ML Oral Syrup) Solution 3
Rani
tidin

Ranitidine HCl (150MG

e
HCl

Reconstituted)
Oral Tablet, 300MG 1 C1

Krist
alos

Kristalose (Oral
e

Oral Tablet) 3
Packet)
Irritable Bowel Syndrome Agents
B1

C1

Lact
ulos

Lactulose (Oral
e

C1

Alos
etro
n
HCl

Alosetron HCl (Oral 3

4 PA Packet)
C1
Tablet) C1

Lact
ulos
e

Lactulose (10GM/
Amit
iza

Amitiza (Oral 1
2 QL 15ML Oral Solution)
Capsule)
C1

Mov
iPre

MoviPrep (Oral
p

C1

Linz
ess

Linzess (Oral Solution 3

2 QL
C1
Capsule) Reconstituted)
Lotr
one

Lotronex (Oral Tablet) 4 PA

x

C1

Vibe
rzi

C1
Viberzi (Oral Tablet) 4 PA; QL
Xifa
xan

Xifaxan (Oral Tablet) 4 PA

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

NuL Acip
YTE hex

NuLYTELY with Aciphex (Oral Tablet

LY
with
Flav
or
Pac
ks

3
Flavor Packs (Oral Delayed Release)
3 C1

Solution
Dexi
lant

Dexilant (Oral
C1
Reconstituted) Capsule Delayed 3 QL
Os
moP

OsmoPrep (Oral Release)

rep

3 C1

Tablet)
Eso
mep

Esomeprazole
razo
le
Mag
nesi
um

C1

PEG

Magnesium (Oral
-335

PEG-3350-Electrolytes
0-
Elec
troly
tes

(Oral Solution Capsule Delayed 1 QL

1 Release) (Generic
Reconstituted)
(Generic Colyte) C1
Nexium)
C1
Eso
PEG mep

Esomeprazole
-335 razo

PEG-3350-NaCl-Na
0- le
NaC Stro
l-Na ntiu
Bica m
rbon
ate-
KCl

Bicarbonate-KCl (Oral Strontium (Oral

1 3 QL
Solution) (Generic Capsule Delayed
C1
NuLYTELY) Release)
PEG C1
-335

PEG-3350-Electrolytes
0- Lan
Elec sopr

Lansoprazole (Oral
troly azol
tes e

(Oral Solution) 1 Capsule Delayed 1 QL

C1
(Generic GoLYTELY) Release)
Plen C1
vu

Plenvu (Oral Solution

Lan
sopr

Lansoprazole ODT
azol
e
ODT

3
C1
Reconstituted) (Oral Tablet 3
Dispersible)
Pre
popi

Prepopik (Oral
k

3 C1

Nexi
um

C1
Packet) Nexium (20MG Oral
Capsule Delayed
Sup
rep

Suprep Bowel Prep

Bow
el
Pre
p Kit

2 Release, 40MG Oral 2 QL

Kit (Oral Solution)
Capsule Delayed
C1

TriL
yte

TriLyte (Oral Solution

1 Release)
Reconstituted) C1
Nexi
um

B1

Protectants Nexium (10MG Oral

Packet, 2.5MG Oral
C1

Cara
fate

Carafate (Oral
3 Packet, 20MG Oral
Suspension) 2
C1

Cara
fate
Packet, 40MG Oral
Carafate (Oral Tablet) 3
C1

Cyto
tec Packet, 5MG Oral
Cytotec (Oral Tablet) 3
C1

Mis
opr
Packet)
Misoprostol (Oral
osto
l
C1

Om
epra

1 Omeprazole (10MG
zole

Tablet)
C1

Sucr
alfat
Oral Capsule Delayed 1 QL
Sucralfate (Oral Tablet) 1
e

Release)
Proton Pump Inhibitors
B1

Bold type = Brand name drug Plain type = Generic drug

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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Om Cer
epra delg

Omeprazole (20MG Cerdelga (Oral

zole a

4 PA
Oral Capsule Delayed Capsule)
Release, 40MG Oral 1
C1

Chol
bam

Cholbam (Oral
Capsule Delayed 4 PA
Capsule)
Release) C1

Cre
on

C1

Pant
opra
Creon (Oral Capsule
Pantoprazole Sodium
zole

Sodi
um

Delayed Release 2
(Oral Tablet Delayed 1 QL
Release) C1
Particles)
Cyst
ada

Cystadane (Oral
ne
C1

Prev
acid

Prevacid (Oral 4
Capsule Delayed 3 QL C1
Powder)
Cyst
ago

Cystagon (Oral
n

Release) 3 LA
Capsule)
C1

Prev
acid

Prevacid SoluTab
Solu
Tab

C1

Gala
fold

(Oral Tablet 3 Galafold (Oral

4 LA
Dispersible) C1
Capsule)
Glas
C1 sia

Prilo
sec

Prilosec (Oral Packet) 3 PA Glassia (Intravenous

4 PA; LA
Solution)
C1

Prot
onix

Protonix (Oral Packet) 3 ST C1

Kuv
an

Kuvan (Oral Packet) 4 LA

C1

Prot
onix

Protonix (Oral Tablet C1

3 QL Kuv
an

Kuvan (Oral Tablet

Delayed Release) 4 LA
Soluble)
C1

Rab
epra

Rabeprazole Sodium
zole

Sodi
um

C1

Migl
usta

Miglustat (Oral
t

(Oral Tablet Delayed 1 4 PA; LA

Release) C1
Capsule)
C1 Nityr

Nityr (Oral Tablet) 4 LA

Yos
pral

Yosprala (Oral Tablet

a

3 C1

Ocal
iva

Delayed Release) C1
Ocaliva (Oral Tablet) 4 PA; QL
Orfa
din

Genetic or Enzyme Disorder: Replacement, Orfadin (Oral

A1

4 LA
Modifiers, Treatment C1
Capsule)
Orfa
din

Genetic or Enzyme Disorder: Replacement, Orfadin (Oral

B1

4 LA
C1
Modifiers, Treatment C1
Suspension)
Aral Paly
ast nziq

Aralast NP (1000MG Palynziq

NP

Intravenous Solution 4 PA; LA (Subcutaneous

4 PA; QL
C1
Reconstituted) Solution Prefilled
Syringe)
Bup
hen

Buphenyl (Oral
yl

4
C1
Powder)
Bup
hen

Buphenyl (Oral
yl

4
Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Pan Sodi
crea um

Pancreaze Sodium
ze Phe
nylb
utyr
ate

(10500UNIT Oral Phenylbutyrate (Oral 4

Capsule Delayed C1
Tablet)
Sucr
aid

Release Particles, Sucraid (Oral

4 LA
16800UNIT Oral C1
Solution)
Teg

Capsule Delayed
sedi

Tegsedi
Release Particles, 3 ST (Subcutaneous
2600UNIT Oral 4 PA; LA
Solution Prefilled
Capsule Delayed Syringe)
C1

Release Particles,
Viok
ace

Viokace (10440UNIT
4200UNIT Oral 3 ST
Oral Tablet)
Capsule Delayed
C1

Viok
ace

Viokace (20880UNIT
Release Particles) 4 ST
C1

Pan
crea
Oral Tablet)
Pancreaze
ze
C1

Xuri
den

Xuriden (Oral Packet) 4 PA; LA

(21000UNIT Oral C1

Zav
esca

4 ST Zavesca (Oral
Capsule Delayed 4 PA; LA
Capsule)
Release Particles) C1

Zem
aira

C1

Pert
zye
Zemaira (Intravenous
Pertzye (16000UNIT
Solution 4 PA; LA
Oral Capsule Delayed 4 ST
Reconstituted)
Release Particles) C1

Zen
pep

C1

Pert
zye
Zenpep (Oral Capsule
Pertzye (4000UNIT
Delayed Release 2
Oral Capsule Delayed
Particles)
Release Particles,
3 ST A1

Genitourinary Agents
8000UNIT Oral
Antispasmodics, Urinary
B1

Capsule Delayed C1
Darif
ena

Darifenacin
cin
Hyd

Release Particles)
robr
omi
de
ER

Hydrobromide ER
C1

Prol
astin

Prolastin-C
-C

3 ST; QL
(Oral Tablet Extended
(Intravenous Solution 4 PA; LA
Release 24 Hour)
Reconstituted) C1

Detr
ol

Detrol LA (Oral
LA

C1

RAV
ICTI

RAVICTI (Oral Liquid) 4 LA

C1

Sodi
um
Capsule Extended 3
Sodium
Phe
nylb
utyr
ate

Release 24 Hour)
Phenylbutyrate (Oral 4 C1

Detr
ol

Powder) Detrol (Oral Tablet) 3

Bold type = Brand name drug Plain type = Generic drug

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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Ditr Tros
opa piu

Ditropan XL (Oral Trospium Chloride ER

n XL m
Chlo
ride
ER

Tablet Extended 3 (Oral Capsule

1
Release 24 Hour) Extended Release 24
C1

Ena
blex

Enablex (Oral Tablet C1

Hour)
Tros
piu

Trospium Chloride
m
Chlo
ride

Extended Release 24 3 ST; QL 1

Hour) C1
(Oral Tablet)
Vesi
care

Vesicare (Oral Tablet) 3 ST; QL

C1

Flav
oxat

Flavoxate HCl (Oral

e
HCl

1 B1

Benign Prostatic Hypertrophy Agents

C1
Tablet) C1

Alfu
zosi
Geln

Alfuzosin HCl ER (Oral

n
ique HCl

Gelnique Pump
ER
Pum
p

3 Tablet Extended 1
(Transdermal Gel)
C1

Myr
betri

Release 24 Hour)
Myrbetriq (Oral
q

C1

Avo
dart

Tablet Extended 2 Avodart (Oral

3
Release 24 Hour) C1
Capsule)
Car
dura

Cardura XL (Oral
C1 XL
Oxy
buty

Oxybutynin Chloride
nin
Chlo
ride
ER

ER (Oral Tablet Tablet Extended 3 QL

1 Release 24 Hour)
Extended Release 24 C1

Ciali

Hour)
s

C1

Oxy
Cialis (2.5MG Oral
buty

Oxybutynin Chloride Tablet, 5MG Oral 3 PA; QL

nin
Chlo
ride

1
C1
(Oral Syrup) C1
Tablet)
Oxy
buty Duta
steri

Oxybutynin Chloride
nin

Dutasteride (Oral
Chlo de
ride

(Oral Tablet Immediate 1 1

C1
Capsule)
C1
Release) Duta
steri
de-
Tam
sulo
sin
HCl

Dutasteride-
Oxyt
rol

Oxytrol (Transdermal Tamsulosin HCl (Oral 1

4
C1
Patch Twice Weekly) C1
Capsule)
Fina
Solif
steri
ena

Finasteride (5MG Oral

de

Solifenacin Succinate
cin
Suc
cina
te

1 QL
C1
(Oral Tablet) Tablet) (Generic 1
Tolt
erod
ine
Tartr
ate
ER

Tolterodine Tartrate C1
Proscar)
Flo
max

ER (Oral Capsule Flomax (Oral

1 3
Extended Release 24 C1
Capsule)
C1
Hour) Jaly
n

Jalyn (Oral Capsule) 3

Tolt
erod
C1

Tolterodine Tartrate
ine
Tartr Pros
ate car

1 Proscar (Oral Tablet) 3

(Oral Tablet) C1

Rap
aflo

C1
Rapaflo (Oral
3 QL
Tovi
az

Toviaz (Oral Tablet Capsule)

Extended Release 24 3 ST; QL C1

Silo
dosi

Silodosin (Oral
n

Hour) 1 QL
Capsule)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Tad Ala-
alafil Cort

Tadalafil (2.5MG Oral Ala-Cort (External

1
Tablet, 5MG Oral 3 PA; QL C1
Cream)
Tablet)
Alcl
ome

Alclometasone
taso
ne
Dipr
opio
nate

C1

Tam
sulo

Tamsulosin HCl (Oral Dipropionate (External 1

sin
HCl

1
C1
Capsule) C1
Cream)
Tera Alcl
zosi ome

Terazosin HCl (Oral Alclometasone

n taso
HCl ne
Dipr
opio
nate

1
C1
Capsule) Dipropionate (External 1
Ointment)
Uro
xatr

Uroxatral (Oral Tablet

al

C1

Amc
inon

Amcinonide (External
ide

Extended Release 24 3 3
Hour) C1
Cream)
Amc
inon

Amcinonide (External
ide

Genitourinary Agents, Other

B1

3
C1

Beth
ane
chol

Chlo
ride

Bethanechol Chloride Lotion)

1
C1

Amc
inon

Amcinonide (External
ide

(Oral Tablet) 3
C1

Cup
rimi
ne

Cuprimine (Oral C1
Ointment)
4 PA Ape
xiCo
nE

ApexiCon E (External
Capsule) 4
C1

Dep
en
Cream)
Depen Titratabs (Oral
Titra
tabs

C1

4
Bes
er

Tablet) C1
Beser (External Lotion) 3
Beta
met

Betamethasone
has
C1
one
Elmi Dipr
ron opio

Elmiron (Oral
nate
Aug

4 Dipropionate Aug 1
Capsule)
C1

Lith
osta
(External Cream)
Lithostat (Oral Tablet) 4
t

C1

Beta
met

Betamethasone
has
one
Dipr
opio
C1 nate
Aug
Peni
cilla

Penicillamine (Oral
min
e

4 PA Dipropionate Aug 1
C1
Capsule) (External Gel)
Thio
la

Thiola (Oral Tablet

C1

Beta
met

Betamethasone
has
one
Dipr

4 LA
opio
nate
Aug

C1
Immediate Release) Dipropionate Aug 1
Ure
chol

Urecholine (Oral (External Lotion)

ine

3 C1

Tablet)
Beta
met

Betamethasone
has
one
Dipr
opio
nate
Aug

Hormonal Agents, Stimulant/Replacement/ Dipropionate Aug 1

A1

Modifying (Adrenal) C1
(External Ointment)
Beta
met

Betamethasone
has

Hormonal Agents, Stimulant/Replacement/

B1 one
Dipr
opio
nate

Modifying (Adrenal) Dipropionate (External 1

C1

Acth
ar

Acthar (Injection Gel) 4 PA; LA C1

Cream)
Beta
met

Betamethasone
has
C1 one
Dipr
Ala opio
Scal nate

Ala Scalp (External

p

3 Dipropionate (External 1
Lotion)
Lotion)

Bold type = Brand name drug Plain type = Generic drug

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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Beta Clo
met beta

Betamethasone Clobetasol Propionate

has sol
one Pro
Dipr pion
opio ate
nate

1
Dipropionate (External 1 C1
(External Ointment)
Ointment)
Clo
beta

Clobetasol Propionate
sol
Pro
pion
ate

C1

Beta
met
3
Betamethasone (External Shampoo)
has
one
Vale
rate

C1

Valerate (External 1
Clo
beta

Clobetasol Propionate
sol
Pro
pion
ate

Cream) 1
C1

Beta
met C1
(External Solution)
Betamethasone
has
one Clo
Vale bex

Clobex (External
rate

Valerate (External 3 3
Lotion)
Foam) C1

Clo
bex

C1

Beta Clobex (External

4
met

Betamethasone
has
one
Vale
rate

Shampoo)
Valerate (External 1 C1

Clo
bex

Clobex Spray
Spra
y

Lotion) 4
C1

Beta
met
(External Liquid)
Betamethasone
has
one
Vale
rate

C1

Clo
dan

Valerate (External 1 Clodan (External

3
Ointment) C1
Shampoo)
Cor
C1 dran

Bryh
ali

Bryhali (External Cordran (External

3 4
Lotion) C1
Tape)
Cort
C1 ef

Cap
ex

Capex (External Cortef (Oral Tablet) 3

3 C1

Cort
ison
e

Cortisone Acetate
Shampoo)
Acet
ate

1
(Oral Tablet)
C1

Clo
beta

Clobetasol Propionate
sol
Pro
pion
ate
Emo
llient

Bas C1
e
Cuti
vate

Emollient Base 1 Cutivate (External

4
C1
(External Cream) C1
Lotion)
Clo Des
beta onat

Desonate (External
e

Clobetasol Propionate
sol
Pro
pion
ate
Emu
lsion

3
Emulsion (External 3 Gel)
Foam)
C1

Des
onid

Desonide (External
e

C1

Clo
beta
sol

Clobetasol Propionate 1
Cream)
Pro
pion
ate

1
(External Cream)
C1

Des
onid

Desonide (External
e

C1

Clo
beta
sol

Clobetasol Propionate 3
Lotion)
Pro
pion
ate

3
(External Foam)
C1

Des
onid

Desonide (External
e

C1

Clo
beta
sol

Clobetasol Propionate 1
Ointment)
Pro
pion
ate

1
(External Gel)
C1

Des
Owe

DesOwen (External
n

3
C1

Clo
beta

Clobetasol Propionate
sol
Pro

Cream)
pion
ate

3
(External Liquid)
C1

Des
Owe

DesOwen (0.05%
n

3
C1

Clo
beta

Clobetasol Propionate
sol
Pro

External Lotion)
pion
ate

3
(External Lotion)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Des Emfl
oxi aza

Desoximetasone Emflaza (Oral Tablet) 4 PA; LA

met
aso
ne

C1

(0.05% External 3
Flud
roco

Fludrocortisone
rtiso
ne
Acet
ate

Cream) 1
C1

Des
oxi C1
Acetate (Oral Tablet)
Desoximetasone
met
aso Fluo
ne cino

Fluocinolone
lone

Acet
onid
e

(0.25% External 1 Acetonide (External 1

C1
Cream) Cream)
Des
oxi C1

Desoximetasone
met
aso Fluo
ne cino

Fluocinolone
lone

Acet

3
onid
e

C1
(External Gel) Acetonide (External 1
Des
oxi

Desoximetasone Ointment)
met
aso
ne

3 C1

(External Liquid)
Fluo
cino

Fluocinolone
lone

Acet
onid
e

C1

Des
oxi

Desoximetasone Acetonide (External 1

met
aso
ne

3
C1
(External Ointment) C1
Solution)
Dex Fluo
ame cino

Dexamethasone Fluocinolone
thas lone
one
Inte Acet
nsol onid
e
Scal
p

Intensol (Oral 1 Acetonide Scalp 1

C1
Concentrate) C1
(External Oil)
Dex Fluo
ame cino

Dexamethasone (Oral Fluocinonide

thas nide
one
Emu
lsifie
d
Bas

1
e

C1
Elixir) Emulsified Base 1
(External Cream)
Dex
ame

Dexamethasone (Oral
thas
one

1 C1

Fluo
cino

Tablet) Fluocinonide (0.1%

nide

C1
3
External Cream)
Dex
ame

Dexamethasone (Oral
thas
one

3 C1

Fluo
cino

Tablet Therapy Pack) Fluocinonide (External

nide

C1
1
Gel)
Dex
Pak

DexPak 13 Day (Oral

13
Day

3 C1

Fluo
cino

Tablet Therapy Pack) Fluocinonide (External

nide

C1
1
Ointment)
Diflo
raso

Diflorasone Diacetate
ne
Diac
etat
e

3 C1

Fluo
cino

(External Cream) Fluocinonide (External

nide

C1
1
Solution)
Diflo
raso

Diflorasone Diacetate
ne
Diac
etat
e

3 C1

Flur
andr

(External Ointment) Flurandrenolide

enol
ide

C1
3
(External Cream)
Dipr
olen

Diprolene (External
e

3 C1

Flur
andr

Flurandrenolide
enol

Ointment)
ide

3
(External Lotion)
C1

Eloc
on

Elocon (External
3
C1

Flur
andr

Flurandrenolide
enol
ide

Cream) 3
C1

Eloc
on

Elocon (0.1% External C1

(External Ointment)
3 Fluti
cas
one
Pro
pion

Fluticasone Propionate
Ointment)
ate

1
C1

Emfl
aza
(External Cream)
Emflaza (Oral
4 PA; LA
Suspension)

Bold type = Brand name drug Plain type = Generic drug

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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Fluti Hyd
cas roco

Fluticasone Propionate Hydrocortisone (1%

one rtiso
Pro ne
pion
ate

3
(External Lotion) External Ointment,
C1
1
2.5% External
Fluti
cas

Fluticasone Propionate
one
Pro
pion
ate

1 Ointment)
C1
(External Ointment) C1

Hyd
roco

Hydrocortisone (Oral
rtiso
Halo ne
beta

Halobetasol
sol
Pro
pion

1
ate

Propionate (External 1 C1
Tablet)
Hyd
roco

Cream) Hydrocortisone
rtiso
ne
Vale
rate

C1

Valerate (External 1
Halo
beta

Halobetasol
sol
Pro
pion
ate

Propionate (External 4 C1
Cream)
Hyd
roco

Hydrocortisone
rtiso
ne

Foam)
Vale
rate

C1

Halo
beta
sol
Pro
pion
ate

Halobetasol Valerate (External 1

Propionate (External 1 C1
Ointment)
Imp
oyz

Ointment) Impoyz (External

3
Cream)
C1

Halo
g

Halog (External
4
C1

Ken
alog

Cream) Kenalog (External

4
Aerosol Solution)
C1

Halo
g

Halog (External
4
C1

Lex
ette

Ointment) Lexette (External

4
Foam)
C1

Hyd
roco

Hydrocortisone
rtiso
ne
Buty
rate

C1

Loc
oid

Butyrate (External 3 Locoid (External

4
C1
Cream) C1
Lotion)
Hyd Loc
roco oid

Hydrocortisone Locoid (External

rtiso
ne
Buty
rate

3
Butyrate (External 3 Solution)
Lotion)
C1

Loc
oid

Locoid Lipocream
Lipo
crea
m

3
C1

Hyd
roco

Hydrocortisone
rtiso
ne

(External Cream)
Buty
rate

Butyrate (External 1 C1

Luxi
q

Luxiq (External Foam) 3

Ointment) C1

Med
rol

C1

Hyd
roco
Medrol (Oral Tablet) 3
Hydrocortisone
rtiso
ne
Buty
rate
C1

Med
rol

Butyrate (External 1 Medrol (Oral Tablet

3
Solution) C1
Therapy Pack)
Met
C1 hylp

Methylprednisolone
redn
Hyd isol
roco one

Hydrocortisone (1%
rtiso
ne

1
External Cream, 2.5% 1 C1
(Oral Tablet)
Met
hylp

Methylprednisolone
redn

External Cream)
isol
one

C1

Hyd
roco
rtiso
ne

Hydrocortisone (2.5% (Oral Tablet Therapy 1

1 Pack)
External Lotion) C1

MiC
ort-

MiCort-HC (External
HC

3
Cream)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Milli Pre
pred dnis

Millipred (Oral Tablet) 3 Prednisolone Sodium

olon
e
Sodi
um
Pho
sph
ate
ODT

C1

Phosphate ODT
Mo
met

Mometasone Furoate
aso
ne
Furo
ate

1 (10MG Oral Tablet

(External Cream)
C1

Mo
met

Dispersible, 15MG
Mometasone Furoate
aso

3
ne
Furo
ate

1 Oral Tablet
(External Ointment)
C1

Mo
met
Dispersible, 30MG
Mometasone Furoate
aso
ne
Furo
ate

1 Oral Tablet
C1
(External Solution) Dispersible)
Noli
x

Nolix (External Cream) 3

C1

Pre
dnis

Prednisone Intensol
one
Inte
nsol

C1

Noli
x

Nolix (External Lotion) 3 3

C1

Olux
C1
(Oral Concentrate)
Pre

Olux (External Foam) 4

dnis

Prednisone (5MG/5ML
one

C1

1
Oral Solution)
Olux
-E

Olux-E (External
4 C1

Pre
dnis

Foam) Prednisone (Oral

one

C1
1
Tablet)
Ora
pred

Orapred ODT (Oral

ODT

3 C1

Pre
dnis
one

Prednisone (Oral
Tablet Dispersible) 1
Tablet Therapy Pack)
C1

Pan
del

Pandel (External
4
C1

Psor
con

Cream) Psorcon (External

3
C1

Pre
dnic
arba
te

Prednicarbate Cream)
1
C1

Ray
os

(External Cream) Rayos (Oral Tablet

4 PA
Delayed Release)
C1

Pre
dnic

Prednicarbate
arba
te

1
C1

Syn
alar

(External Ointment) Synalar (External

C1
3
Cream)
Pre
dnis

Prednisolone (Oral
olon
e

1 C1

Tap
erD

Solution) TaperDex 12-Day (Oral

ex
12-
Day

C1
3
Tablet Therapy Pack)
Pre
dnis

Prednisolone Sodium
olon
e
Sodi
um
Pho
sph
ate

C1

Tap
erD

Phosphate (10MG/ TaperDex 6-Day (Oral

ex 6-
Day

3
5ML Oral Solution, 3 C1
Tablet Therapy Pack)
20MG/5ML Oral
Tap
erD

TaperDex 7-Day (Oral

ex 7-
Day

Solution) 3
C1

Pre
dnis C1
Tablet Therapy Pack)
Prednisolone Sodium
olon
e Tex
Sodi acor

Texacort (External
um t
Pho
sph
ate

Phosphate (25MG/ 3
Solution)
5ML Oral Solution, 1 C1

Topi
cort

Topicort (External
6.7MG/5ML Oral 3
Cream)
Solution) C1

Topi
cort

C1
Topicort (External Gel) 3
Topi
cort

Topicort (0.05%
3
External Ointment)

Bold type = Brand name drug Plain type = Generic drug

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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Topi DDA
cort VP

Topicort (0.25% DDAVP (Nasal

3 4
C1
External Ointment) Solution)
C1
Topi
cort DDA

Topicort Spray
Spra VP

DDAVP (0.1MG Oral

y

3 3
C1
(External Liquid) Tablet)
C1
Tria
mci DDA

Triamcinolone
nolo VP

DDAVP (0.2MG Oral

ne
Acet
onid
e

Acetonide (External 4
3 Tablet)
Aerosol Solution) C1

DDA
VP
Rhin
al
Tub
e

DDAVP Rhinal Tube

(Generic Kenalog) 3
C1

Tria
mci
(Nasal Solution)
Triamcinolone
nolo
ne
Acet C1
onid
e Des
mop

Desmopressin Acetate
ressi
n
Acet
ate

Acetonide (External 1 1
(Oral Tablet)
Cream) C1

Des
mop

Desmopressin Acetate
ressi
n
C1 Acet
ate
Tria Spra
mci y

Triamcinolone 3
nolo
ne
Acet
onid
e

Spray (Nasal Solution)

Acetonide (External 1 C1

Gen
otro

Genotropin MiniQuick
pin
Mini
Quic

Lotion)
k

(0.2MG
C1

Tria
mci

Triamcinolone
nolo
ne
Acet
onid
e

Acetonide (External 1 Subcutaneous 3 PA

Ointment) Solution
Reconstituted)
C1

Tria
nex

Trianex (External
4
C1
Ointment)
Trid
erm

Triderm (0.1% External

1
C1
Cream)
Trid
esilo

Tridesilon (External
n

1
C1
Cream)
Ultra
vate

Ultravate (External
3
C1
Cream)
Ultra
vate

Ultravate (External
4
C1
Lotion)
Ultra
vate

Ultravate (External
3
C1
Ointment)
Van
os

Vanos (External
4
Cream)
Hormonal Agents, Stimulant/Replacement/
A1

Modifying (Pituitary)
Hormonal Agents, Stimulant/Replacement/
B1

Modifying (Pituitary)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Gen Hu
otro matr

Genotropin MiniQuick Humatrope (Injection

pin ope
Mini
Quic
k

(0.4MG Solution
Subcutaneous Renconstituted), 4 PA
Solution Humatrope Combo
Reconstituted, 0.6MG C1
Pack (Injection)
Subcutaneous
Incr
elex

Increlex
Solution (Subcutaneous 4 PA; LA
Reconstituted, 0.8MG Solution)
Subcutaneous
C1

Noc
durn

Nocdurna (Tablet
a

Solution 3 PA
Sublingual)
Reconstituted, 1.2MG C1
Nor
ditro
pin
Flex
Pro

Norditropin FlexPro
Subcutaneous (Subcutaneous 4 PA
Solution Solution)
Reconstituted, 1.4MG C1

Nutr
opin

Nutropin AQ NuSpin
AQ
NuS
pin
10

Subcutaneous 4 PA
10 (Subcutaneous 4 PA
Solution
Solution)
Reconstituted, 1.6MG C1

Nutr
opin

Nutropin AQ NuSpin
AQ
NuS
pin
20

Subcutaneous
Solution 20 (Subcutaneous 4 PA
Reconstituted, 1.8MG C1
Solution)
Nutr
opin

Nutropin AQ NuSpin
AQ
NuS
pin

Subcutaneous
5

Solution 5 (Subcutaneous 4 PA
Reconstituted, 1MG C1
Solution)
Om
nitro

Omnitrope
pe

Subcutaneous
Solution (Subcutaneous 4 PA
Reconstituted, 2MG C1
Solution)
Om
nitro

Subcutaneous Omnitrope
pe

Solution (Subcutaneous
4 PA
C1
Reconstituted) Solution
Gen

Reconstituted)
otro

Genotropin
pin

C1

Saiz
en

(Subcutaneous Saizen (Injection

4 PA
Solution Solution 4 PA; LA
Reconstituted) Reconstituted)

Bold type = Brand name drug Plain type = Generic drug

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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Saiz And
enpr roG

Saizenprep (Injection AndroGel (20.25 MG/

ep el

Solution 4 PA; LA 1.25GM 1.62%

C1
Reconstituted) Transdermal Gel,
40.5 MG/2.5GM 3
Stim
ate

Stimate (Nasal
4 1.62% Transdermal
Solution)
Gel, 50 MG/5GM 1%
C1

Zom
acto

Zomacton (10MG
n

Subcutaneous Transdermal Gel)

4 PA
C1

And
roG

AndroGel (25 MG/

el

Solution
Reconstituted) 2.5GM 1% 4
Transdermal Gel)
C1

Zom
acto

Zomacton (5MG
n

C1

Ave
ed

Subcutaneous Aveed (Intramuscular

3 PA 3 PA
Solution C1
Solution)
Dan
azol

Reconstituted) Danazol (100MG Oral

A1

Hormonal Agents, Stimulant/Replacement/ Capsule, 200MG Oral 3

Modifying (Prostaglandins) C1
Capsule)
Dan
azol

B1

Hormonal Agents, Stimulant/Replacement/ Danazol (50MG Oral

1
Modifying (Prostaglandins) C1
Capsule)
Dep
o-

Depo-Testosterone
Test
C1 oste
rone
Korl
ym

Korlym (Oral Tablet) 4 PA; LA

(Intramuscular 3
Hormonal Agents, Stimulant/Replacement/
A1

Solution)
Modifying (Sex Hormones/Modifiers) C1

Fort
esta

Fortesta
B1

Androgens 3
C1

Ana
drol-
(Transdermal Gel)
Anadrol-50 (Oral
50 C1

Intra
rosa

4 PA Intrarosa (Vaginal
Tablet) 3 PA; QL
C1

And
rode
Insert)
Androderm
rm C1

Met
hite

Methitest (Oral Tablet) 4 PA

st

(Transdermal Patch 2 C1

Met
hylt

Methyltestosterone
esto
ster
one

24 Hour) 4 PA
C1

And
roG
(Oral Capsule)
AndroGel Pump
el
Pum C1
p
Oxa
ndro

Oxandrolone (10MG
lone

3 3 PA
(Transdermal Gel) Oral Tablet)
C1

Oxa
ndro

Oxandrolone (2.5MG
lone

1 PA
C1
Oral Tablet)
Stria
nt

C1
Striant (Buccal) 4 PA
Test
im

Testim (Transdermal
3
Gel)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Test Alya
oste cen

Testosterone Alyacen 1/35 (Oral

rone 1/35

Cypi
onat
e

1
Cypionate Tablet)
1 C1

(Intramuscular
Ame
thia

Amethia Lo (Oral
Lo

Solution) 1
C1

Test
oste C1
Tablet)
Testosterone
rone
Ame
Ena thia

Amethia (Oral Tablet) 1

ntha
te

Enanthate C1

Apri

1 Apri (Oral Tablet) 1

(Intramuscular C1

Aran
elle

Solution) C1
Aranelle (Oral Tablet) 1
Ashl
yna

Ashlyna (Oral Tablet) 1

C1

Test
oste

Testosterone (20.25
rone

C1

Aub
ra

MG/1.25GM 1.62% C1
Aubra (Oral Tablet) 1
Transdermal Gel, 25
Avia
ne

Aviane (Oral Tablet) 1

MG/2.5GM 1%
C1

Balz
iva

Balziva (Oral Tablet) 1

Transdermal Gel, 40.5 C1

Bey
az

MG/2.5GM 1.62% C1
Beyaz (Oral Tablet) 3
Blis
ovi

Blisovi 24 Fe (Oral
24
Fe

Transdermal Gel, 50 1
3 Tablet)
MG/5GM 1% C1

Blis

Transdermal Gel),
ovi

Blisovi Fe 1.5/30 (Oral

Fe
1.5/
30

Testosterone Pump 1
Tablet)
(2% Transdermal Gel,
C1

Briel
lyn

Briellyn (Oral Tablet) 1

1% Transdermal Gel, C1

Cam
rese

Camrese Lo (Oral
Lo

1.62% Transdermal 1
Gel) C1
Tablet)
Cazi
ant

C1

Test
oste
rone

Testosterone C1
Caziant (Oral Tablet) 1
3 Clim
ara
Pro

Climara Pro
(Transdermal Solution)
(Transdermal Patch 3 PA; HRM
C1

Vog
elxo

Vogelxo Pump
Pum
p

3 Weekly)
(Transdermal Gel) C1

Crys
elle-

Cryselle-28 (Oral
C1 28

Vog
elxo

Vogelxo (Transdermal 1
3 Tablet)
Gel) C1

Cycl
afe

Cyclafem 1/35 (Oral

m
1/35
C1

Xyo
sted

Xyosted 1
Tablet)
(Subcutaneous C1

3 PA
Cycl
afe

Cyclafem 7/7/7 (Oral

m
7/7/
7

Solution Auto- 1
Tablet)
Injector) C1

Cyre
d

Cyred (Oral Tablet) 1

Estrogens
B1

C1

Dele
stro

Delestrogen
gen

C1

Alor
a

Alora (Transdermal PA; HRM; 3

3 (Intramuscular Oil)
Patch Twice Weekly) QL C1

Dely
la

C1

Alta
vera
Delyla (Oral Tablet) 1
Altavera (Oral Tablet) 1

Bold type = Brand name drug Plain type = Generic drug

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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Dep Ethy
o- nodi

Depo-Estradiol Ethynodiol Diacetate-

Estr ol
adio Diac
l etat
e-
Ethi
nyl

3
Estr
adio
l

C1
(Intramuscular Oil) Ethinyl Estradiol (Oral 1
Tablet)
Des
oge

Desogestrel-Ethinyl
strel
-
Ethi
nyl
Estr
adio

1
l

C1

Fal
min

Estradiol (Oral Tablet) Falmina (Oral Tablet) 1

a

C1 C1

Dott Fay
i osi

PA; HRM; Fayosim (Oral Tablet) 1

m

Dotti (Transdermal
1 C1

Patch Twice Weekly) QL

Fem
ring

Femring (Vaginal
C1

Dro
spir
3
Drospirenone-Ethinyl Ring)
eno
ne-
Ethi
nyl
Estr
adio

1
l

C1

Estradiol (Oral Tablet)

Fem
ynor

C1

Dro
spir C1
Femynor (Oral Tablet) 1
Drospirenone-Ethinyl
eno
ne- Fyav
Ethi olv

Fyavolv (Oral Tablet) 1 PA; HRM

nyl
Estr
adio
l-
Lev
ome
folat
e

Estradiol-Levomefolate C1

Gen
eres

Generess Fe (Oral
s Fe

1
(3-0.02-0.451MG Oral 3
Tablet) C1
Tablet Chewable)
Gian
vi

C1

Eles
trin

Elestrin (Transdermal C1
Gianvi (Oral Tablet) 1
3 PA; HRM
Hail
ey

Hailey 24 Fe (Oral
24
Fe

Gel) 1
C1

Emo
quet
Tablet)
Emoquette (Oral
te

C1

1
Imv
exxy

Imvexxy Maintenance
Mai
nten
anc

Tablet)
e
Pac
k

2 PA; QL
C1

Enp
ress
e-28

Enpresse-28 (Oral C1
Pack (Vaginal Insert)
1 Imv
exxy

Start
er

Imvexxy Starter Pack

Tablet)
Pac
k

2 PA; QL
(Vaginal Insert)
C1

Ens
kyce

Enskyce (Oral Tablet) 1 C1

Intro
vale

Introvale (Oral Tablet) 1

C1

Esta
rylla

Estarylla (Oral Tablet) 1 C1

Isibl
oom

Isibloom (Oral Tablet) 1

C1

Estr
ace

Estrace (Oral Tablet) 3 PA; HRM C1

Jas
miel

Jasmiel (Oral Tablet) 1

C1

Estr
ace

Estrace (Vaginal
3
C1

Jint
eli

Cream) C1
Jinteli (Oral Tablet) 1 PA; HRM
C1 Jule
ber
Estr

Juleber (Oral Tablet) 1

adio

Estradiol (Oral Tablet) 1 PA; HRM

l

C1
C1 Jun
el
Estr

Junel 1.5/30 (Oral

1.5/
adio
30

PA; HRM;
l

Estradiol (Transdermal 1
1 Tablet)
C1
Patch Twice Weekly) QL C1

Jun
el

Junel 1/20 (Oral

1/20
Estr
adio

Estradiol (Vaginal
l

1 1
Cream) C1
Tablet)
Jun
C1 el

Junel Fe 1.5/30 (Oral

Fe
Estr 1.5/
adio 30

Estradiol (Vaginal
l

3 1
Tablet) C1
Tablet)
Jun
C1 el

Junel Fe 1/20 (Oral

Fe
Estr 1/20
adio

Estradiol Valerate
l
Vale
rate

1 1
(Intramuscular Oil) C1
Tablet)
Jun
C1 el

Junel Fe 24 (Oral
Fe
Estri 24
ng

Estring (Vaginal Ring) 3 1

Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Kaitl Loe
ib strin

Kaitlib Fe (Oral Tablet Loestrin 1.5/30 (21)

Fe
1.5/
30

1 3
C1
Chewable) C1
(Oral Tablet)
Kari Loe
va strin

Kariva (Oral Tablet) 1 Loestrin 1/20 (21)

1/20

C1
3
(Oral Tablet)
Keln
or

Kelnor 1/35 (Oral

1/35

1 C1

Loe
strin

Tablet) Loestrin Fe 1.5/30

Fe
1.5/
30

C1
3
(Oral Tablet)
Keln
or

Kelnor 1/50 (Oral

1/50

1 C1

Loe
strin

Tablet) Loestrin Fe 1/20 (Oral

Fe
1/20

C1
3
Tablet)
Kurv
elo

C1
Kurvelo (Oral Tablet) 1 C1

Lory
na

Loryna (Oral Tablet) 1

LAR
IN

LARIN 1.5/30 (Oral

1.5/
30

1 C1

LoS
eas

Tablet) LoSeasonique (Oral

oniq
ue

C1

3
Tablet)
LAR
IN

LARIN 1/20 (Oral

1/20

1 C1

Low

Tablet)
-

Low-Ogestrel (Oral
Oge
strel

C1

1
Tablet)
LAR
IN

LARIN Fe 1.5/30 (Oral

Fe
1.5/
30

1 C1

Lute

Tablet)
ra

C1

LAR
C1
Lutera (Oral Tablet) 1
IN Marl

LARIN Fe 1/20 (Oral

Fe issa

Marlissa (Oral Tablet) 1

1/20

1
Tablet)
C1

Mel
odet

Melodetta 24 Fe (Oral
ta
24
Fe

C1

Lari
ssia

Larissia (Oral Tablet) 1 1

C1

Lay
C1
Tablet Chewable)
olis Men

Layolis Fe (Oral
Fe est

Menest (Oral Tablet) 3 PA; HRM

1 C1

Tablet Chewable)
Mib
elas

Mibelas 24 Fe (Oral
24
Fe

C1

Lee
na
1
C1
Leena (Oral Tablet) 1 C1
Tablet Chewable)
Less Micr
ina oge

Lessina (Oral Tablet) 1 Microgestin 1.5/30

stin
1.5/
30

C1
1
(Oral Tablet)
Lev
one

Levonest (Oral Tablet) 1

st

C1

Micr
C1 oge

Microgestin 1/20 (Oral

stin
Lev 1/20
onor

Levonorgestrel-Ethinyl
gest
rel-
Ethi

1
nyl
Estr
adio
l&
Ethi
nyl

Tablet)
Estr
adio
l

Estradiol & Ethinyl 1 C1

Micr
oge

Estradiol (Oral Tablet) Microgestin Fe 1.5/30

stin
Fe
1.5/
30

C1
1
(Oral Tablet)
Lev
onor

Levonorgestrel-Ethinyl
gest
rel-
Ethi
nyl
Estr
adio
l 91-
Day
C1

Micr
oge

Estradiol 91-Day (Oral 1 Microgestin Fe 1/20

stin
Fe
1/20

1
C1
Tablet) C1
(Oral Tablet)
Lev Mili
onor

Levonorgestrel-Ethinyl Mili (Oral Tablet) 1

gest
rel-
Ethi
nyl
Estr
adio

1
l

C1

Estradiol (Oral Tablet)

Min
astri

Minastrin 24 Fe (Oral
n 24
Fe

C1

Lev
ora
0.15

Levora 0.15/30 (28) 3

Tablet Chewable)
/30

1
(Oral Tablet)
C1

Mini
velle

Minivelle
PA; HRM;
C1

Lo
Loe

Lo Loestrin Fe (Oral
strin
Fe

3 (Transdermal Patch 3
Tablet) QL
Twice Weekly)

Bold type = Brand name drug Plain type = Generic drug

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102

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Mon Nort
oNe rel

MonoNessa (Oral Nortrel 1/35 (21) (Oral

ssa 1/35

1 1
Tablet) C1
Tablet)
C1
Nort
Nata rel

Nortrel 1/35 (28) (Oral

zia 1/35

Natazia (Oral Tablet) 3 1

Tablet)
C1

Nec
on

Necon 0.5/35 (28)

0.5/
35

1 C1

Nort
rel
7/7/

Nortrel 7/7/7 (Oral

(Oral Tablet)
7

1
Tablet)
C1

Nikk
i

Nikki (Oral Tablet) 1 C1

Nuv
aRin

NuvaRing (Vaginal
C1 g

Nor
ethi

Norethindrone
ndro
ne
Acet

3
ate-
Ethi
nyl
Estr
adio
l

Acetate-Ethinyl C1
Ring)
Ocel
la

Estradiol (0.5-2.5MG- Ocella (Oral Tablet) 1

1 PA; HRM C1

MCG Oral Tablet,

Oge
strel

Ogestrel (Oral Tablet) 1

1-5MG-MCG Oral C1

Orsy
thia

Orsythia (Oral Tablet) 1

Tablet) C1

Orth
o

Ortho Tri-Cyclen Lo
Tri-
Cycl
en
C1 Lo
Nor
ethi

Norethindrone 3
ndro
ne
Acet
ate-
Ethi
nyl
Estr

(Oral Tablet)
adio
l

Acetate-Ethinyl C1

1 Orth
o-
Nov
um
1/35

Ortho-Novum 1/35
Estradiol (1-20MG- 3
MCG Oral Tablet) C1
(28) (Oral Tablet)
C1 Orth
o-
Nor

Ortho-Novum 7/7/7
Nov
ethi
um

Norethindrone
ndro
7/7/
ne
7
Acet
ate-
Ethi

3
nyl
Estr
adio
l-Fe

Acetate-Ethinyl (28) (Oral Tablet)

1 C1

Estradiol-Fe (1-20MG-
Pimt
rea

Pimtrea (Oral Tablet) 1

MCG(24) Oral Tablet) C1

Pirm
ella
1/35

Pirmella 1/35 (Oral

1
C1

Nor
ethi

Norethindrone
ndro
ne
Acet

Tablet)
ate-
Ethi
nyl
Estr
adio
l-Fe

Acetate-Ethinyl C1

Porti
a-28

Portia-28 (Oral Tablet) 1

Estradiol-Fe C1

Pre
mari

Premarin (Vaginal
n

(0.4-35MG-MCG Oral 2
Tablet Chewable, 1 C1
Cream)
Prev
ifem

0.8-25MG-MCG Oral C1
Previfem (Oral Tablet) 1
Tablet Chewable,
Qua
rtett

Quartette (Oral
e

1-20MG-MCG(24) Oral 3
Tablet)
Tablet Chewable) C1

Recl
ipse

Reclipsen (Oral Tablet) 1

n

C1

Nor
gest

Norgestimate-Ethinyl
imat
e-
Ethi
nyl C1
Estr
Rive
adio
lsa

1
l

Rivelsa (Oral Tablet) 1

Estradiol (Oral Tablet) C1

Safy
ral

C1

Nor
gest

Safyral (Oral Tablet) 3

Norgestimate-Ethinyl
imat
e-
Ethi
nyl
Estr
adio
C1
l
Trip Sea
hasi soni

Seasonique (Oral
c que

Estradiol Triphasic 1 3
(Oral Tablet) C1
Tablet)
C1 Setl
akin
Nort

Setlakin (Oral Tablet) 1

rel

Nortrel 0.5/35 (28)

0.5/
35

1
(Oral Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
tRACK 141 141
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Spri Vive
ntec lle-

Sprintec 28 (Oral Vivelle-Dot

28 Dot

1 PA; HRM;
Tablet) (Transdermal Patch 3
C1

Sro
QL
Twice Weekly)
nyx

C1
Sronyx (Oral Tablet) 1 C1

Vyfe
Sye mla
da

C1
Syeda (Oral Tablet) 1 C1
Vyfemla (Oral Tablet) 1
VyLi
Tari bra
na

Tarina 24 Fe (Oral VyLibra (Oral Tablet) 1

24
Fe

1 C1

Tablet)
WY
MZ

WYMZYA Fe (Oral
YA
Fe

C1

Tari
na
1
Tarina Fe 1/20 (Oral Tablet Chewable)
Fe
1/20

1 C1

Tablet)
Xula
ne

Xulane (Transdermal
C1

Tri-
Esta
1
Tri-Estarylla (Oral Patch Weekly)
rylla

1 C1

Tablet)
Yas
min

Yasmin 28 (Oral
28

C1

Tri-
Leg
3
Tri-Legest Fe (Oral
est

Tablet)
Fe

1 C1

C1
Tablet) YAZ

YAZ (Oral Tablet) 3

Tri-
Lo-
C1

Tri-Lo-Estarylla (Oral
Esta
rylla Yuv
afe

Yuvafem (Vaginal
m

1 3
C1
Tablet) Tablet)
Tri-
Lo- C1

Tri-Lo-Sprintec (Oral
Spri
ntec Zara
h

1 Zarah (Oral Tablet) 1

Tablet) C1

Zovi
a

Zovia 1/35E (28) (Oral

1/35
E

C1

1
Tri-
Mili

C1
Tri-Mili (Oral Tablet) 1 Tablet)
Tri-
Prev

Tri-Previfem (Oral
ifem

Progestins
B1

1
Tablet) C1

Ayg
esti

Aygestin (Oral Tablet) 3

n

C1

Tri-
Spri

Tri-Sprintec (Oral
ntec

C1

Cam
ila

1 Camila (Oral Tablet) 1

Tablet) C1

Crin
one

C1

Triv
ora
Crinone (Vaginal Gel) 3 PA
Trivora (28) (Oral C1

1
Debl
itan

Deblitane (Oral Tablet) 1

e

C1
Tablet) C1

Dep
o-

Depo-Provera
Prov
Tri- era
VyLi

Tri-VyLibra Lo (Oral
bra
Lo

1 (Intramuscular 3
Tablet)
Suspension)
C1

Tri-
VyLi

Tri-VyLibra (Oral
bra

1 C1

Dep
o-
Sub

Depo-SubQ Provera
Tablet)
Q
Prov
era
104

C1

104 (Subcutaneous
Tyd
emy

Tydemy (Oral Tablet) 1 3

Suspension Prefilled
C1

Vagi
fem

Vagifem (Vaginal
3 Syringe)
Tablet) C1

Errin

Errin (Oral Tablet) 1

C1

Veli
vet

Velivet (Oral Tablet) 1 C1

Inca
ssia

Incassia (Oral Tablet) 1

C1

Vien
va

Vienva (Oral Tablet) 1 C1

Joliv
ette

Jolivette (0.35MG
1
Oral Tablet)

Bold type = Brand name drug Plain type = Generic drug

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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Lyza Evis
ta

C1
Lyza (Oral Tablet) 1 C1
Evista (Oral Tablet) 3
Med Osp
roxy hen

Medroxyprogesterone Osphena (Oral Tablet) 2 PA; QL

pro a
gest
eron
e
Acet
ate

C1

Acetate (Intramuscular 1
Ralo
xife

Raloxifene HCl (Oral

ne
HCl

Suspension) 1
C1

Med
roxy
Tablet)
Medroxyprogesterone
pro
gest
eron

Hormonal Agents, Stimulant/Replacement/

e A1
Acet
ate

Acetate (Intramuscular Modifying (Thyroid)

1
Suspension Prefilled
Hormonal Agents, Stimulant/Replacement/
B1

Syringe)
C1

Med
roxy
Modifying (Thyroid)
Medroxyprogesterone
pro
gest
eron
e
Acet C1
ate

1
Cyto
mel

Acetate (Oral Tablet) C1

Cytomel (Oral Tablet) 3
Lev
o-T

Levo-T (Oral Tablet) 1

C1

Meg
estr

Megestrol Acetate
ol
Acet
ate

C1

Lev
othy

Levothyroxine Sodium
roxi
ne

(40MG/ML Oral 1 PA; HRM

Sodi
um

1
Suspension) C1
(Oral Tablet)
C1 Lev
oxyl
Meg

Levoxyl (Oral Tablet) 1

estr

Megestrol Acetate
ol
Acet
ate

C1

Liot

(625MG/5ML Oral 3 PA; HRM

hyro

Liothyronine Sodium
nine

Sodi
um

Suspension) 1
C1

Meg
C1
(Oral Tablet)
estr Synt

Megestrol Acetate
ol hroi

Synthroid (Oral
Acet d
ate

1 PA; HRM 2
C1
(Oral Tablet) Tablet)
Nor
a-BE C1

Nora-BE (Oral Tablet) 1

Thyr
olar-

Thyrolar-1 (Oral
1

C1

Nor
ethi
2
Norethindrone Acetate
ndro

Tablet)
ne
Acet
ate

1
(5MG Oral Tablet)
C1

Thyr
olar-

Thyrolar-1/2 (Oral
1/2

2
C1

Nor
ethi

Norethindrone
ndro
ne

1 Tablet)
(0.35MG Oral Tablet)
C1

Thyr
olar-

Thyrolar-1/4 (Oral
1/4

2
C1

Norl
yroc

C1
Norlyroc (Oral Tablet) 1 Tablet)
Orth
o C1

Ortho Micronor (Oral

Micr
onor Thyr
olar-

Thyrolar-2 (Oral
2

3 2
C1
Tablet) Tablet)
Pro
gest C1

Progesterone
eron
e Thyr
Micr olar-

Thyrolar-3 (Oral
oniz 3
ed

Micronized (Oral 1 2
Tablet)
Capsule) C1

Tiro
sint

C1

Pro
Tirosint (Oral
3
metr

Prometrium (Oral
ium

3 Capsule)
Capsule) C1

Tiro
sint-

Tirosint-SOL (Oral
SOL

C1

Prov

3
era

C1
Provera (Oral Tablet) 3 Solution)
Shar
obel

Sharobel (Oral Tablet) 1

Selective Estrogen Receptor Modifying
B1

Agents

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Unit Leu
hroi proli

Unithroid (100MCG Leuprolide Acetate

d de
Acet
ate

3 PA
Oral Tablet, 112MCG C1
(Injection Kit)
Lup

Oral Tablet, 125MCG

anet

Lupaneta Pack
a
Pac
k

4 PA
Oral Tablet, 150MCG C1
(Combination Kit)
Oral Tablet, 175MCG
Lupr
on

Lupron Depot (1-

Dep
ot

Oral Tablet, 200MCG Month) 4 PA

1
Oral Tablet, 25MCG (Intramuscular Kit)
Oral Tablet, 300MCG
C1

Lupr
on

Lupron Depot (3-

Dep
ot

Oral Tablet, 50MCG Month) 4 PA

Oral Tablet, 75MCG (Intramuscular Kit)
Oral Tablet, 88MCG C1

Lupr
on

Lupron Depot (4-

Dep
ot

Oral Tablet)
Month) 4 PA
Hormonal Agents, Suppressant (Adrenal)
A1

(Intramuscular Kit)
Hormonal Agents, Suppressant (Adrenal)
B1 C1

Lupr
on

Lupron Depot (6-

Dep
ot

C1

Lys
odre

Lysodren (Oral
n

4 Month) 4 PA
Tablet) (Intramuscular Kit)
C1

Hormonal Agents, Suppressant (Pituitary)

A1
Octr
eoti

Octreotide Acetate
de
Acet
ate

Hormonal Agents, Suppressant (Pituitary) (1000MCG/ML

B1

C1

Cab
ergo
line

Cabergoline (Oral Injection Solution, 4 PA

1 500MCG/ML Injection
Tablet)
C1

Egrif
ta
Solution)
Egrifta C1

Octr
eoti

Octreotide Acetate
de
Acet
ate

(Subcutaneous
4 PA; LA (100MCG/ML Injection
Solution
Solution, 200MCG/ML
Reconstituted) 3 PA
C1

Elig
ard
Injection Solution,
Eligard 50MCG/ML Injection
3 PA
C1
(Subcutaneous Kit) Solution)
Firm C1
ago

Firmagon (120MG
n Orili
ssa

C1
Orilissa (Oral Tablet) 4 PA; QL
Subcutaneous San
dost
atin

Sandostatin (Injection
4 PA 4 PA
Solution Solution)
C1
Reconstituted) C1

Sign
ifor

Signifor
Firm
ago

Firmagon (80MG
n

(Subcutaneous 4 PA; LA
Subcutaneous Solution)
3 PA
Solution
Reconstituted)

Bold type = Brand name drug Plain type = Generic drug

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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Som Ruc
atuli one

Somatuline Depot Ruconest

ne st
Dep
ot

(Subcutaneous 4 (Intravenous Solution 4 PA; LA

C1
Solution) C1
Reconstituted)
Som Tak
aver hzyr

Somavert Takhzyro
t o

(Subcutaneous (Subcutaneous 4 PA
4 PA; LA; QL
Solution Solution)
C1
Reconstituted) B1

Immune Suppressants
Syn C1
arel

Synarel (Nasal
Asta
graf

Astagraf XL (0.5MG
XL

4
C1
Solution) Oral Capsule
Trel
star

Trelstar Mixject Extended Release 24

Mixj
ect

3 B/D, PA
(Intramuscular Hour, 1MG Oral
4 PA
Suspension Capsule Extended
Reconstituted) C1
Release 24 Hour)
Asta
graf

Hormonal Agents, Suppressant (Thyroid) Astagraf XL (5MG

A1 XL

B1

Antithyroid Agents Oral Capsule

4 B/D, PA
Extended Release 24
C1

Met
him

Methimazole (Oral
azol
e

1 Hour)
C1
Tablet) C1

Aza
san

Azasan (100MG Oral

Pro
pylt

Propylthiouracil (Oral
hiou
racil

1 3 B/D, PA
Tablet) C1
Tablet)
Aza
C1
san

Azasan (75MG Oral

Tap
azol

Tapazole (Oral Tablet) 3

e

4 B/D, PA
A1

Immunological Agents C1
Tablet)
Azat
hiop

Azathioprine (Oral
rine

Angioedema Agents
B1

1 B/D, PA
C1

Beri
nert Tablet)
Berinert (Intravenous C1

Cell
cept

4 PA; LA Cellcept (Oral

Kit) 4 B/D, PA
C1

Cinr
yze Capsule)
Cinryze (Intravenous C1

Cell
cept

Cellcept (Oral
Solution 4 PA; LA
Suspension 4 B/D, PA
Reconstituted)
C1

Fira
zyr Reconstituted)
Firazyr C1

Cell
cept

Cellcept (Oral Tablet) 4 B/D, PA

(Subcutaneous 4 PA; LA; QL C1

Cim
zia

Cimzia Prefilled
Prefi
lled

Solution) 4 PA
C1

Hae
gard
(Subcutaneous Kit)
Haegarda
a

C1

Cim
zia

(Subcutaneous Cimzia
4 PA; LA 4 PA
Solution (Subcutaneous Kit)
Reconstituted)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
tRACK 145 145
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Cycl Hu
osp mira

Cyclosporine Modified Humira Pen

orin Pen
e
Mod
ified

1 B/D, PA
C1
(Oral Capsule) (Subcutaneous Pen- 4 PA
Cycl

Injector Kit)
osp

Cyclosporine Modified
orin
e
Mod
ified

1 B/D, PA C1

(Oral Solution)
Hu
mira

Humira Pen Crohns

Pen
Cro
hns
Dise
ase
Start
er

C1

Cycl
osp

Cyclosporine (Oral
orin

Disease Starter
e

3 B/D, PA 4 PA
C1
Capsule) (Subcutaneous Pen-
Dupi
xent

Dupixent (200MG/ C1
Injector Kit)
1.14ML
Hu
mira

Humira Pen Psoriasis

Pen
Psor
iasis

Start
er

Subcutaneous 4 PA Starter
Solution Prefilled 4 PA
(Subcutaneous Pen-
C1
Syringe) Injector Kit)
Enb C1
rel

Enbrel
Hu
mira

Humira
(Subcutaneous (Subcutaneous 4 PA
4 PA
Solution Prefilled Prefilled Syringe Kit)
C1

C1
Syringe) Imur
an

Imuran (Oral Tablet) 3 B/D, PA

Enb
rel C1

Enbrel Kine
ret

Kineret
(Subcutaneous (Subcutaneous
4 PA 4 PA
Solution Solution Prefilled
C1
Reconstituted) Syringe)
Enb
rel C1

Enbrel SureClick
Sure
Clic Met
k hotr

Methotrexate (Oral
exat
e

(Subcutaneous 1
4 PA Tablet)
Solution Auto-
C1

Met
hotr

Methotrexate Sodium
exat
e
Sodi
um

Injector) (50MG/2ML Injection

C1

Env
arsu
1
Envarsus XR (Oral Solution Prefilled
s XR

Tablet Extended 3 B/D, PA C1

Syringe)
Met

Release 24 Hour)
hotr

Methotrexate Sodium
exat
e
Sodi
um

C1

(50MG/2ML Injection 1
Gen
graf

Gengraf (Oral Capsule) 1 B/D, PA

C1

Gen
graf

Gengraf (Oral Solution) 1 B/D, PA C1

Solution)
Myc
oph

Mycophenolate Mofetil
enol
C1 ate
Mof
Hu etil
mira

Humira Pediatric 1 B/D, PA

Pedi
atric

Cro
hns
Start

(Oral Capsule)
Crohns Start C1

4 PA
Myc
oph

Mycophenolate Mofetil
enol
ate
Mof
etil

(Subcutaneous
Prefilled Syringe Kit) (Oral Suspension 4 B/D, PA
C1
Reconstituted)
Myc
oph

Mycophenolate Mofetil
enol
ate
Mof
etil

1 B/D, PA
(Oral Tablet)

Bold type = Brand name drug Plain type = Generic drug

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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Myc Rap
oph amu

Mycophenolate Rapamune (0.5MG

enol ne
ate
Sodi
um

3 B/D, PA
Sodium (Oral Tablet 3 B/D, PA Oral Tablet)
Delayed Release)
C1

Rap
amu

Rapamune (1MG Oral

ne

C1

Myf
ortic

Myfortic (180MG Oral Tablet, 2MG Oral 4 B/D, PA

Tablet Delayed 3 B/D, PA Tablet)
Release)
C1

Ras
uvo

C1

Myf
ortic
Rasuvo
Myfortic (360MG Oral (Subcutaneous
Tablet Delayed 4 B/D, PA 3 PA
Solution Auto-
C1
Release) Injector)
Neo C1
ral

Neoral (Oral Capsule) 3 B/D, PA

San
dim

Sandimmune (100MG
mun
e

C1

Neo
ral
4 B/D, PA
C1
Neoral (Oral Solution) 3 B/D, PA C1
Oral Capsule)
Olu
San
mia
dim

Olumiant (Oral
nt

Sandimmune (25MG
mun
e

4 PA; QL 3 B/D, PA
C1
Tablet) C1
Oral Capsule)
Ore
San
ncia
dim

Orencia ClickJect
Clic

Sandimmune
mun
kJec
e
t

(Subcutaneous (100MG/ML Oral 4 B/D, PA

4 PA
Solution Auto- C1
Solution)
Injector)
Sim
poni

C1

Ore
ncia
Simponi
Orencia (Subcutaneous
4 PA
(Subcutaneous Solution Auto-
4 PA
Solution Prefilled C1
Injector)
Syringe)
Sim
poni

C1

Otre
xup
Simponi
Otrexup (Subcutaneous
4 PA
(Subcutaneous Solution Prefilled
3 PA
Solution Auto- C1
Syringe)
Injector)
Sirol
imu

Sirolimus (Oral
s

C1

Pro
graf
4 B/D, PA
Prograf (0.5MG Oral Solution)
3 B/D, PA C1

Sirol

Capsule)
imu

Sirolimus (0.5MG Oral

s

C1

Tablet, 1MG Oral 3 B/D, PA

Pro
graf

Prograf (1MG Oral

Capsule, 5MG Oral 4 B/D, PA C1
Tablet)
Sirol
imu

Sirolimus (2MG Oral

s

Capsule) 4 B/D, PA
Tablet)
C1

Pro
graf

Prograf (Oral Packet) 4 B/D, PA C1

Tacr
olim

Tacrolimus (Oral
C1 us

Rap
amu

Rapamune (Oral
ne

4 B/D, PA 1 B/D, PA
Solution) C1
Capsule)
Trex
all

Trexall (Oral Tablet) 3

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
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109

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Xat Ga
mep mun

Xatmep (Oral Gamunex-C (1GM/

ex-C

3 PA
C1
Solution) 10ML Injection 4 PA
Solution)
Xelj
anz

Xeljanz (Oral Tablet

4 PA; QL C1

Oct
aga

Immediate Release) Octagam (1GM/20ML

m

C1

Intravenous Solution,
Xelj
anz

Xeljanz XR (Oral
XR

4 PA
Tablet Extended 4 PA; QL 2GM/20ML
Release 24 Hour) C1
Intravenous Solution)
C1 Pan
zyga

Panzyga (Intravenous
Zort
ress

Zortress (Oral Tablet) 4 B/D, PA 4 PA

B1

Immunizing Agents, Passive C1

Solution)
Privi
gen

Privigen (20GM/
C1

BIVI
GA

BIVIGAM (10GM/
M

100ML Intravenous 4 PA 200ML Intravenous 4 PA

Solution) C1
Solution)
Vari
zig

Varizig (Intramuscular
C1

Fleb
oga

Flebogamma DIF
mm
a
DIF

4
(5GM/50ML 4 PA Solution)
Immunomodulators
B1

C1
Intravenous Solution) C1

Acte
mra

Actemra ACTPen
Ga ACT
mm Pen

Gammagard (2.5GM/
agar
d

25ML Injection 4 PA (Subcutaneous

4 PA
Solution) Solution Auto-
Injector)
C1

Ga
mm

Gammagard S/D
agar
d S/
D
Less
IgA

C1

Acte
mra

Less IgA (Intravenous Actemra

4 PA (Subcutaneous
Solution 4 PA
Reconstituted) Solution Prefilled
Syringe)
C1

Ga
mm

Gammaked (1GM/
ake
d

C1

Acti
mm

Actimmune
une

10ML Injection 4 PA
Solution) (Subcutaneous 4 LA
Solution)
C1

Ga
mm

Gammaplex (10GM/
aple
x

C1

Arav
a

100ML Intravenous C1
Arava (Oral Tablet) 4
Arca
lyst

Solution, 10GM/ Arcalyst

200ML Intravenous (Subcutaneous
4 PA 4 PA; LA
Solution, 20GM/ Solution
200ML Intravenous Reconstituted)
Solution, 5GM/50ML
Intravenous Solution)

Bold type = Brand name drug Plain type = Generic drug

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110

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Benl BC
ysta G

Benlysta BCG Vaccine

Vac
cine

1
(Subcutaneous (Injection)
4 PA C1

Solution Auto-
Bex
sero

Bexsero
Injector) (Intramuscular
C1

Benl
ysta
1
Benlysta Suspension Prefilled
(Subcutaneous Syringe)
4 PA C1

Solution Prefilled
Boo
strix

Boostrix (5-2.5-18.5
C1
Syringe) Intramuscular
Kev
zara

Kevzara Suspension,
(Subcutaneous 5-2.5-18.5 (0.5ML 1
4 PA
Solution Prefilled Syringe)
C1
Syringe) Intramuscular
Suspension)
Lefl
uno

Leflunomide (Oral
mid
e

1 C1

Dap

Tablet)
tace

Daptacel
l

C1

Ote

(Intramuscular
zla

C1
Otezla (Oral Tablet) 4 PA; LA 1
Suspension)
Ote
zla

Otezla (Oral Tablet

4 PA; LA C1

Diph
theri

Diphtheria-Tetanus
a-

Therapy Pack)
Teta
nus
Tox
oids
DT

C1

Toxoids DT
Rida
ura

Ridaura (Oral 1
4 (Intramuscular
Capsule)
Suspension)
C1

Xola
ir

Xolair (Subcutaneous C1

Eng
erix-

Engerix-B (Injection
B

Solution Prefilled 4 PA; LA 1 B/D, PA

Syringe) C1
Suspension)
Gar
C1
dasil

Gardasil 9
Xola 9
ir

Xolair (Subcutaneous
Solution 4 PA; LA (Intramuscular 1
Reconstituted) C1
Suspension)
Gar
dasil

Gardasil 9
9

Vaccines
B1

(Intramuscular
C1

Act
HIB

ActHIB 1
(Intramuscular Suspension Prefilled
1 Syringe)
Solution C1

Havr
ix

Reconstituted) Havrix (Intramuscular

1 PA
Suspension)
C1

Ada
cel

Adacel C1

Hibe
rix

(Intramuscular 1 Hiberix (Injection

Suspension) Solution 1
Reconstituted)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
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111

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Imo Rab
vax Aver

Imovax Rabies RabAvert

Rabi t
es

(Intramuscular 1 B/D, PA (Intramuscular

1 B/D, PA
C1
Injectable) Suspension
Reconstituted)
Infa
nrix

Infanrix C1

Rec
omb

(Intramuscular 1 Recombivax HB
ivax
HB

C1
Suspension) (Injection 1 B/D, PA
Suspension)
IPO
L

C1
IPOL (Injection) 1 C1

Rot
arix

Rotarix (Oral
Ixiar
o

Ixiaro (Intramuscular
2 Suspension 1
Suspension)
Reconstituted)
C1

Kinri
x

Kinrix (Intramuscular
1
C1
Rot
aTe

RotaTeq (Oral
q

Suspension) 1
Solution)
C1

Men
actr

Menactra
a

C1

Shin
grix

(Intramuscular 1 Shingrix
Injectable) (Intramuscular
1 PA
Suspension
C1

Men
veo

Menveo
(Intramuscular Reconstituted)
1
C1

TDV
AX

Solution TDVAX
Reconstituted) (Intramuscular 1
Suspension)
C1

M-
M-R

M-M-R II
II

C1

Teni
vac

(Subcutaneous 1 Tenivac
Injectable) (Intramuscular 1
Injectable)
C1

Pedi
arix

Pediarix C1

Tru
men

Trumenba
ba

(Intramuscular 1
Suspension) (Intramuscular
1
Suspension Prefilled
C1

Ped
vax

Pedvax HIB
HIB

(Intramuscular 1 C1
Syringe)
Twi
nrix

Suspension) Twinrix
(Intramuscular
C1

Pro
Qua

ProQuad
d

1
(Subcutaneous Suspension Prefilled
1 Syringe)
Suspension C1

Typ
him

Typhim Vi
Vi

Reconstituted)
(Intramuscular
C1

Qua
drac
el

Quadracel 2
(Intramuscular 1 Solution)
Suspension)

Bold type = Brand name drug Plain type = Generic drug

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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

VAQ Mes
TA ala

VAQTA Mesalamine (Oral

min
e

(Intramuscular 1 PA Capsule Delayed 3 ST

Suspension) C1
Release)
C1 Mes
ala

Mesalamine (1.2GM
Vari min
vax e

Varivax
(Subcutaneous 1 Oral Tablet Delayed
3 QL
Injectable) Release) (Generic
C1

YF-
Vax Lialda)
YF-Vax C1

Mes
ala

Mesalamine (800MG
min
e

(Subcutaneous 2
Oral Tablet Delayed 3 ST; QL
Injectable)
C1

Zost
avax
Release)
Zostavax C1

Mes
ala

Mesalamine (Rectal
min
e

(Subcutaneous 3
3 PA Enema)
Suspension C1

Mes
ala

Mesalamine (Rectal
min
e

Reconstituted) 4
Suppository)
Inflammatory Bowel Disease Agents
A1
C1

Pent
asa

Pentasa (Oral
Aminosalicylates
B1

C1

Apri
so
Capsule Extended 3 QL
Apriso (Oral Capsule Release)
C1

Extended Release 24 2 QL Row

asa

Rowasa (Rectal Kit) 4

C1
Hour) B1

Glucocorticoids
Asa
col

Asacol HD (Oral
HD
C1

Anu
sol-

Anusol-HC (Rectal
HC

Tablet Delayed 4 ST; QL 3

Cream)
Release) C1

Bud
eso

Budesonide ER (Oral
nide
ER

C1

Bals
alazi

Balsalazide Disodium
de
Diso
diu

Tablet Extended 4 ST
m

3
C1
(Oral Capsule) Release 24 Hour)
Can
asa C1

Canasa (Rectal
Bud
eso

Budesonide (Oral
nide

4
C1
Suppository) Capsule Delayed 3
Cola

Release Particles)
zal

C1
Colazal (Oral Capsule) 4 C1

Col
Delz ocor

Colocort (Rectal
icol t

Delzicol (Oral 1
Capsule Delayed 3 ST C1
Enema)
Ento
cort

Release) Entocort EC (Oral

EC

C1

Capsule Delayed 4
Dipe
ntu

Dipentum (Oral
m

4 Release Particles)
C1
Capsule) C1

Hyd
roco

Hydrocortisone
Lial rtiso
da ne

Lialda (Oral Tablet

Acet
ate-
Pra
mox
ine

4 QL Acetate-Pramoxine 1
Delayed Release)
(1-1% Rectal Cream)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Hyd Alen
roco dron

Hydrocortisone (Rectal Alendronate Sodium

rtiso ate
ne Sodi
um

1 1
C1
Enema) C1
(Oral Tablet)
Proc Atel
to- via

Procto-Med HC (Rectal Atelvia (Oral Tablet

Med
HC

1 3
C1
Cream) Delayed Release)
C1
Proc
to- Bino

Procto-Pak (Rectal
Pak sto

1 Binosto (Oral Tablet

Cream) 3
C1

Proc
toso
C1
Effervescent)
Proctosol HC (Rectal
l HC Boni
va

1 Boniva (Oral Tablet) 3

Cream) C1

Calc
itoni
n
Sal
mon

Calcitonin Salmon
1
C1

Proc
tozo

Proctozone-HC (Rectal
ne-
HC

1 (Nasal Solution)
Cream) C1

Calc
itriol

Calcitriol (Oral
1 B/D, PA
C1

Uce
ris

Uceris (Oral Tablet Capsule)

Extended Release 24 4 ST
C1

Calc
itriol

Calcitriol (Oral
Hour) 1 B/D, PA
C1

Uce
ris C1
Solution)
Uceris (Rectal Foam) 3
Cina
calc

Cinacalcet HCl (30MG

et
HCl

3 B/D, PA; QL
Sulfonamides Oral Tablet)
B1

C1 C1

Azul Cina
fidin calc

Azulfidine EN-tabs Cinacalcet HCl (60MG

e et
EN- HCl
tabs

(Oral Tablet Delayed 3 Oral Tablet, 90MG Oral 4 B/D, PA; QL

Release) C1
Tablet)
C1 Dox
erca

Doxercalciferol (Oral
Azul lcife
fidin rol

Azulfidine (Oral
e

3 B/D, PA
Tablet Immediate 3 C1
Capsule)
Fort
eo

Release) Forteo
C1

Sulf
asal
azin
e

Sulfasalazine (Oral (Subcutaneous 4 PA

Tablet Immediate 1 C1
Solution)
Fos
ama

Release) Fosamax (Oral Tablet) 3

x

C1
C1
Sulf
asal Fos
ama

Sulfasalazine (Oral
azin

Fosamax Plus D (Oral

e x
Plus
D

Tablet Delayed 1 3
Tablet)
Release)
C1

Iban
dron

Ibandronate Sodium
ate
Sodi
um

A1

Metabolic Bone Disease Agents 1

C1
(Oral Tablet)
Metabolic Bone Disease Agents
B1 Nat
para

C1

Acto
Natpara
nel

Actonel (150MG Oral (Subcutaneous 4 PA; LA

Tablet, 35MG Oral Cartridge)
3 C1

Tablet, 5MG Oral

Pari
calci

Paricalcitol (1MCG
tol

Tablet) 1 B/D, PA
C1
Oral Capsule)
Alen
dron

Alendronate Sodium
ate
Sodi
um

1
(Oral Solution)

Bold type = Brand name drug Plain type = Generic drug

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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Pari Gau
calci ze

Paricalcitol (2MCG Gauze (Non-medicated

tol

1
Oral Capsule, 4MCG 3 B/D, PA C1
2X2 Pad)
Oral Capsule)
Insul
in

Insulin Syringes,
Syri
nge
s,
Nee
dles

C1

Proli
a
1
Prolia (Subcutaneous C1
Needles
Solution Prefilled 3 QL
Luc
emy

Lucemyra (Oral
ra

Syringe) 4 QL
C1

Ray
Tablet)
alde

Rayaldee (Oral
e

Ophthalmic Agents
A1

Capsule Extended 4 QL B1

Ophthalmic Agents, Other

C1
Release) C1

Atro
pine

Sulf
ate

Atropine Sulfate
Rise
dron
ate
Sodi
um

Risedronate Sodium 1
(Ophthalmic Solution)
(Oral Tablet Immediate 1 C1

Baci
traci

Bacitracin-Polymyxin B
n-
Poly
myxi
nB

Release) 1
C1

Rise
dron
(Ophthalmic Ointment)
Risedronate Sodium
ate
Sodi
um C1

Neo
myci

Neomycin-Polymyxin-
n-
Poly
myxi
n-
Baci
traci
n-

(Oral Tablet Delayed 1

Hyd
roco
rtiso
ne

Bacitracin-
Release) 1
C1

Roc
altro
Hydrocortisone
Rocaltrol (Oral
l

3 B/D, PA C1
(Ophthalmic Ointment)
Capsule)
Blep
ham

Blephamide
ide

C1

Roc
altro

Rocaltrol (Oral
l

3 B/D, PA (Ophthalmic 3
C1
Solution) Suspension)
C1
Sen
sipa Blep

Sensipar (Oral Tablet) 4 B/D, PA; QL

r ham

Blephamide S.O.P.
ide
S.O.
P.

C1

Tym
3
(Ophthalmic Ointment)
los

Tymlos C1

Cyst
aran

(Subcutaneous 4 PA; QL Cystaran (Ophthalmic

4 LA
C1
Solution Pen-Injector) C1
Solution)
Xge Lacr
va isert

Xgeva (Subcutaneous Lacrisert (Ophthalmic

4 PA 3
C1
Solution) C1
Insert)
Zem Last
plar acaf

Zemplar (1MCG Oral Lastacaft

t

3 B/D, PA 2
C1
Capsule) C1
(Ophthalmic Solution)
Zem Maxi
plar trol

Zemplar (2MCG Oral Maxitrol (Ophthalmic

4 B/D, PA 3
Capsule) C1
Ointment)
Maxi
trol

Miscellaneous Therapeutic Agents Maxitrol (Ophthalmic

A1

3
B1

Miscellaneous Therapeutic Agents C1

Suspension)
C1 Neo
myci
Alco

Neomycin-Bacitracin-
n-
hol Baci

Alcohol Prep Pads 1

Pre traci
p n-
Pad Poly
s myxi
n

Polymyxin
C1

Fird
aps

Firdapse (Oral Tablet) 4 PA; LA; QL

e

1
(5-400-10000
Ophthalmic Ointment)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Neo Tob
myci raD

Neomycin-Polymyxin- TobraDex
n- ex
Poly
myxi
n-
Dex
ame
thas
one

Dexamethasone 1 (Ophthalmic 2
C1
(Ophthalmic Ointment) Ointment)
Neo C1
myci

Neomycin-Polymyxin-
n- Tob
Poly raD

TobraDex
myxi ex
n-
Dex
ame
thas
one

Dexamethasone (Ophthalmic 3
(3.5-10000-0.1 1 Suspension)
Ophthalmic C1

Tob
raD

TobraDex ST
ex
ST

Suspension)
C1

Neo
myci
(Ophthalmic 3
Neomycin-Polymyxin-
n-
Poly
myxi
n-
Gra
mici
din

Gramicidin 1 C1
Suspension)
Tob
ram

Tobramycin-
ycin-
Dex
ame

(Ophthalmic Solution)
thas
one

C1

Neo
myci
n-

Neomycin-Polymyxin- Dexamethasone
1
Poly
myxi
n-
HC

HC (Ophthalmic 1 (Ophthalmic
Suspension)
Suspension) C1

Xiidr
a

C1

Oxe
rvat

Xiidra (Ophthalmic
Oxervate (Ophthalmic
e

3 QL
4 PA; LA; QL Solution)
Solution) C1

Zyle
t

C1

Poly
myxi
n B-

Polymyxin B- Zylet (Ophthalmic

3
Trim
etho
prim

Trimethoprim 1 Suspension)
Ophthalmic Anti-allergy Agents
B1

C1
(Ophthalmic Solution) C1

Aloc
ril

Alocril (Ophthalmic
Poly
trim

Polytrim (Ophthalmic 3
3 Solution)
C1
Solution) C1

Alo
mid

Alomide (Ophthalmic
Pre e
d-G

Pred-G (Ophthalmic 3
3 Solution)
C1
Suspension) C1

Azel
astin
Pre

Azelastine HCl
e
d-G HCl

Pred-G S.O.P.
S.O.
P.

1
(Ophthalmic 3 C1
(Ophthalmic Solution)
Bep
reve

Ointment) Bepreve (Ophthalmic

C1
3
Solution)
Pro
para

Proparacaine HCl
cain
e
HCl

1 C1

Cro
mol

(Ophthalmic Solution) Cromolyn Sodium

yn
Sodi
um

C1
1
(Ophthalmic Solution)
Rest
asis

Restasis (Ophthalmic
2 QL C1

Epin
astin

Epinastine HCl
e

Emulsion)
HCl

1
(Ophthalmic Solution)
C1

Rho
pres

Rhopressa
sa

2 ST
C1

Olo
pata

Olopatadine HCl
dine
HCl

(Ophthalmic Solution) 1
(Ophthalmic Solution)
C1

Sulf
acet

Sulfacetamide-
ami
de-
Pre
dnis
olon
e
C1

Pata
day

Prednisolone 1 Pataday (Ophthalmic

3
(Ophthalmic Solution) Solution)

Bold type = Brand name drug Plain type = Generic drug

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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Pata Dor
nol zola

Patanol (Ophthalmic Dorzolamide HCl

mid
e
HCl

2 1
Solution) C1
(Ophthalmic Solution)
C1
Dor
Paz zola

Dorzolamide HCl-
eo mid

Pazeo (Ophthalmic
e
HCl-
Tim
olol
Mal
eate

2 Timolol Maleate 1
Solution)
B1

Ophthalmic Antiglaucoma Agents C1

(Ophthalmic Solution)
Dor
zola

Dorzolamide HCl-
mid
C1 e
HCl-
Alph Tim
aga olol

Alphagan P (0.1%
nP Mal
eate

Pres
erva
tive
Free

2 Timolol Maleate
Ophthalmic Solution) 1
C1

Alph
aga
Preservative Free
Alphagan P (0.15%
nP

3 (Ophthalmic Solution)
Ophthalmic Solution)
C1

Iopi
dine

C1 Iopidine (1%
Apr
aclo
nidi
ne
HCl

Apraclonidine HCl 4
1 Ophthalmic Solution)
(Ophthalmic Solution) C1

Isop
to

Isopto Carpine
Car
pine

C1

3
Azo
pt

Azopt (Ophthalmic (Ophthalmic Solution)

2
Suspension) C1

Istal
ol

C1
Istalol (Ophthalmic
3
Beta
xolo

Betaxolol HCl
l
HCl

1 Solution)
(Ophthalmic Solution) C1

Lev
obu

Levobunolol HCl
nolo
l
HCl

C1

1
Beti
mol

Betimol (Ophthalmic (Ophthalmic Solution)

3
Solution) C1

Pho
sph

Phospholine Iodide
olin
e
Iodi
de

C1

Bet
opti

Betoptic-S
c-S

(Ophthalmic Solution 3
(Ophthalmic 3 Reconstituted)
Suspension) C1

Pilo
carp

Pilocarpine HCl
ine
HCl

C1

1
Brim
onid

Brimonidine Tartrate
ine
Tartr
ate

(Ophthalmic Solution)
(0.15% Ophthalmic 1
C1

Roc
klata

Rocklatan
n

Solution) 3 ST
C1

Brim
onid
(Ophthalmic Solution)
Brimonidine Tartrate
ine
Tartr C1
ate
Sim
brin

Simbrinza
za

(0.2% Ophthalmic 1
(Ophthalmic 2
Solution)
C1

Cart
eolo Suspension)
Carteolol HCl
l
HCl

C1

Tim

1
olol

Timolol Maleate
Mal
eate

Oph
thal

(Ophthalmic Solution)
mic
Gel
For
min
g

C1

Co
mbi Ophthalmic Gel
Combigan
gan

2 Forming (Ophthalmic 1
C1
(Ophthalmic Solution) Solution) (Generic
Cos
opt

Cosopt (Ophthalmic Timoptic-XE)

3
C1
Solution)
Cos
opt

Cosopt PF
PF

3
(Ophthalmic Solution)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Tim Dur
olol ezol

Timolol Maleate Durezol (Ophthalmic

Mal
eate

2
(0.25% Ophthalmic Emulsion)
Solution, 0.5% 1
C1

Flar
ex

Flarex (Ophthalmic
Ophthalmic Solution) 3
Suspension)
(Generic Timoptic) C1

Fluo
rom

Fluorometholone
etho
lone

C1

Tim
olol

Timolol Maleate (0.5%

Mal
eate

(Ophthalmic 1
(DAILY) Ophthalmic 3 Suspension)
Solution) C1

Flur
bipr

Flurbiprofen Sodium
ofen

Sodi
C1 um

Tim

1
opti

Timoptic Ocudose
c
Ocu
dos
e

3 (Ophthalmic Solution)
(Ophthalmic Solution) C1

FML
Fort

FML Forte
e

C1

Tim
opti

Timoptic-XE
c-XE

(Ophthalmic 3
(Ophthalmic Gel 3 Suspension)
Forming Solution) C1

FML
Liqu

FML Liquifilm
ifilm

C1

Trus
opt

Trusopt (Ophthalmic (Ophthalmic 3

3
Solution) Suspension)
Ophthalmic Anti-inflammatories
B1
C1

FML

C1
FML (Ophthalmic
Acul
ar
LS

Acular LS 3
3 Ointment)
C1
(Ophthalmic Solution) C1

Ilevr
o

Ilevro (Ophthalmic
Acul
ar

Acular (Ophthalmic 2
3 Suspension)
C1
Solution) C1

Invel
tys

Inveltys (Ophthalmic
Acu
vail

Acuvail (Ophthalmic 3 ST
3 ST Suspension)
C1
Solution) C1

Ket
orol
ac
Tro
met
ham
ine

Ketorolac
Alre
x

Alrex (Ophthalmic Tromethamine 1

3
C1
Suspension) (Ophthalmic Solution)
C1
Bro
mfe Lote

Bromfenac Sodium
nac max

Lotemax (Ophthalmic
Sodi
um

(Once-Daily) 1 3
Gel)
C1
(Ophthalmic Solution) C1

Lote
max

Lotemax (Ophthalmic
Bro
mSit
e

BromSite 3
3 ST Ointment)
C1
(Ophthalmic Solution) C1

Lote
max

Lotemax (Ophthalmic
Dex
ame
thas
one
Sodi

Dexamethasone 3
Suspension)
um
Pho
sph
ate

Sodium Phosphate 1 C1

Lote
max

Lotemax SM
SM

(Ophthalmic Solution) 3
C1

Dicl
ofen (Ophthalmic Gel)
Diclofenac Sodium
ac
Sodi
um

1
(Ophthalmic Solution)

Bold type = Brand name drug Plain type = Generic drug

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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Lote Vyz
pred ulta

Loteprednol Etabonate Vyzulta (Ophthalmic

nol
Etab
onat
e

3
(Ophthalmic 3 Solution)
Suspension)
C1

Xala
tan

Xalatan (Ophthalmic
3
C1

Maxi
dex

Maxidex (Ophthalmic Solution)

3
Suspension)
C1

Xelp
ros

Xelpros (Ophthalmic
3 ST
C1

Nev
ana

Nevanac (Ophthalmic
c

3 Emulsion)
Suspension)
C1

Ziop
tan

Zioptan (Ophthalmic
3
C1

Om
nipr

Omnipred (1%
ed

Solution)
Ophthalmic 3 A1

Otic Agents
Suspension)
Otic Agents
B1

C1

Pre
d

Pred Forte
Fort
e
C1

Acet
ic

Acetic Acid (Otic

Acid

(Ophthalmic 3 1
Solution)
Suspension) C1

Cetr
axal

C1
Cetraxal (Otic
3
Pre
d

Pred Mild
Mild

Solution)
(Ophthalmic 3 C1

Cipr
o

Cipro HC (Otic
HC

Suspension) 3
C1

Pre
dnis
Suspension)
Prednisolone Acetate
olon
e
Acet C1
ate
Cipr
ode

Ciprodex (Otic
x

(Ophthalmic 1 2
Suspension) C1
Suspension)
Cipr
oflo

Ciprofloxacin HCl
xaci
C1 n
HCl
Pre
dnis

Prednisolone Sodium
olon
e

1
Sodi
um
Pho
sph
ate

Phosphate (1% 1 C1
(Otic Solution)
Flac

C1
Ophthalmic Solution) C1
Flac (Otic Oil) 1
Fluo
Prol cino

Fluocinolone
ens lone

Prolensa (Ophthalmic
a
Acet
onid
e

3 1
Solution) C1
Acetonide (Otic Oil)
Hyd
roco

Hydrocortisone-Acetic
rtiso
ne-

Ophthalmic Prostaglandin and Prostamide

B1 Acet
ic
Acid

1
Analogs C1
Acid (Otic Solution)
Neo
C1 myci

Neomycin-Polymyxin-
n-
Bim Poly
atop myxi

Bimatoprost
rost n-
HC

1 1
(Ophthalmic Solution) C1
HC (1% Otic Solution)
Neo
C1 myci

Neomycin-Polymyxin-
n-
Lata Poly
nopr myxi

Latanoprost
ost n-
HC

1 1
(Ophthalmic Solution) C1
HC (Otic Suspension)
Oto
C1 vel

Otovel (Otic Solution) 3 ST

Lum
igan

Lumigan (Ophthalmic
2 A1

Respiratory Tract/Pulmonary Agents

C1
Solution)
Trav

Antihistamines
B1
atan

Travatan Z
Z

3 C1

Aste
pro

(Ophthalmic Solution) Astepro (Nasal

3
Solution)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Azel Arn
astin uity

Azelastine HCl (0.1% Arnuity Ellipta

e Ellip
HCl ta

Nasal Solution, 0.15% 1 (Inhalation Aerosol

Nasal Solution) 2 QL
C1

Ceti
rizin
Powder Breath
Cetirizine HCl (1MG/
e

Activated)
HCl

1 C1

C1
ML Oral Solution) Asm
ane
x

Asmanex (120
Clari
nex

C1
Clarinex (Oral Syrup) 3 Metered Doses)
Clari
nex

C1
Clarinex (Oral Tablet) 3 (Inhalation Aerosol 3 ST; QL
Powder Breath
Cyp
rohe

Cyproheptadine HCl
ptad
ine
HCl

1 PA; HRM Activated)

C1
(Oral Tablet) C1

Asm
Desl ane

Asmanex (30 Metered

orat x

Desloratadine (Oral
adin
e

1
Tablet) Doses) (Inhalation
C1

Desl
3 ST; QL
Aerosol Powder
orat

Desloratadine ODT
adin
e
ODT

(Oral Tablet 1 C1
Breath Activated)
Dispersible)
Asm
ane

Asmanex (60 Metered

x

C1

Lev
ocet

Levocetirizine
irizin

Doses) (Inhalation
e
Dihy
droc
hlori
de

Dihydrochloride (Oral 1 3 ST; QL

Aerosol Powder
C1
Solution) Breath Activated)
Lev
ocet C1

Levocetirizine
irizin
e Asm
Dihy ane

Asmanex HFA
droc x
hlori HFA
de

Dihydrochloride (Oral 1 3 ST; QL

(Inhalation Aerosol)
Tablet) C1

Bec
ona

Beconase AQ (Nasal
se
AQ

C1

Olo

3 ST
pata

Olopatadine HCl
dine
HCl

3 Suspension)
(Nasal Solution) C1

Bud
eso

Budesonide (Inhalation
nide

C1

Pata

3 B/D, PA
nas

Patanase (Nasal
e

3 Suspension)
Solution) C1

Flov
ent

Flovent Diskus
Disk
us

C1

Phe
nad

Phenadoz (12.5MG
oz

1 PA; HRM (Inhalation Aerosol

Rectal Suppository) 2
C1

Pro
met
Powder Breath
Promethazine HCl
hazi
ne
HCl

1 PA; HRM Activated)

(Oral Tablet) C1

Flov
ent

Flovent HFA
HFA

C1

Pro

2 QL
met

Promethazine HCl
hazi
ne
HCl

(Inhalation Aerosol)
(12.5MG Rectal 1 PA; HRM C1

Flun
isoli

Flunisolide (Nasal
de

Suppository) 1
Solution)
Anti-inflammatories, Inhaled Corticosteroids
B1

C1

Fluti
cas

Fluticasone Propionate
one
Pro
pion
C1
ate
Alve
sco

Alvesco (Inhalation 1
3 ST; QL (Nasal Suspension)
Aerosol Solution) C1

Mo
met

Mometasone Furoate
aso
ne
Furo
ate

1
(Nasal Suspension)

Bold type = Brand name drug Plain type = Generic drug

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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Nas Sing
one ulair

Nasonex (Nasal Singulair (Oral Tablet

x

3 3 QL
C1
Suspension) C1
Chewable)
Om Zafir
nari luka

Omnaris (Nasal Zafirlukast (Oral

s st

3 ST 1
Suspension) C1
Tablet)
C1
Zile
Pul uton

Zileuton ER (Oral
mic ER

Pulmicort Flexhaler
ort
Flex
hale
r

(Inhalation Aerosol Tablet Extended 4 ST

3 ST Release 12 Hour)
Powder Breath C1

Zyfl
o

Zyflo CR (600MG Oral

CR

C1
Activated)
Pul
mic
ort

Pulmicort (Inhalation Tablet Extended 4 ST

3 B/D, PA Release 12 Hour)
C1
Suspension) C1

Zyfl
o

Qna
sl
Chil
dren
s

Qnasl Childrens Zyflo (Oral Tablet

4 ST
(Nasal Aerosol 3 ST Immediate Release)
Bronchodilators, Anticholinergic
B1

C1
Solution) C1

Atro
vent

Atrovent HFA
Qna
sl HFA

Qnasl (Nasal Aerosol

3 ST (Inhalation Aerosol 3
C1
Solution)
QVA
R
Redi
Hale
r

QVAR RediHaler C1
Solution)
Incr
use

Incruse Ellipta
Ellip
ta

(Inhalation Aerosol 3 ST; QL

Breath Activated) (Inhalation Aerosol
C1
2 QL
Xha
nce

Xhance (Nasal Powder Breath

3 Activated)
C1
Exhaler Suspension) C1

Iprat
ropi

Ipratropium Bromide
um
Zeto Bro
nna mid

Zetonna (Nasal
e

3 ST 1 B/D, PA
Aerosol Solution) C1
(Inhalation Solution)
Iprat
ropi

Ipratropium Bromide
um
Bro
mid
e

Antileukotrienes
B1

1
C1

Acc
olat (Nasal Solution)
Accolate (Oral Tablet) 3
e

C1

Lon
hala

Lonhala Magnair
Mag
nair
Refil
C1 l Kit

Mon
telu

Montelukast Sodium
kast
Sodi
um

1 QL Refill Kit (Inhalation 4 QL

(Oral Packet)
C1

Mon
telu Solution)
Montelukast Sodium
kast
Sodi
um
C1

See

1 QL
bri

Seebri Neohaler
Neo
hale
r

(Oral Tablet) 3 ST
C1

Mon
telu
(Inhalation Capsule)
Montelukast Sodium
kast
Sodi
um

C1

1 QL
Spiri
va

Spiriva HandiHaler
Han
diHa
ler

(Oral Tablet Chewable) 2 QL

C1

Sing
ulair

(Inhalation Capsule)
Singulair (Oral C1

3 QL
Spiri
va

Spiriva Respimat
Res
pim
at

Packet)
C1

Sing
ulair

(Inhalation Aerosol 2 QL
Singulair (Oral Tablet) 3 QL
Solution)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Tud Brov
orza ana

Tudorza Pressair Brovana (Inhalation

Pres
sair

(Inhalation Aerosol Nebulization 4 PA; QL

3 ST
Powder Breath C1
Solution)
Activated)
Epin
ephr

Epinephrine (0.3MG/
ine

C1

Yup

0.3ML Injection
elri

Yupelri (Inhalation
4 B/D, PA; QL Solution Auto-Injector) 3 ST; QL
Solution)
B1

Bronchodilators, Sympathomimetic (Brand Equivalent

C1

Albu
terol Adrenaclick)
Albuterol Sulfate ER
Sulf
ate
ER C1

Epin
ephr

Epinephrine (0.15MG/
ine

(Oral Tablet Extended 1

Release 12 Hour) 0.15ML Injection
C1

Albu
terol Solution Auto-Injector) 3 ST; QL
Albuterol Sulfate HFA
Sulf
ate
HFA

(Brand Equivalent
(108 (90 Base)MCG/ Adrenaclick)
ACT Inhalation
C1

Epin
ephr

Epinephrine (0.15MG/
ine

3 ST
Aerosol Solution) 0.3ML Injection
(Brand Equivalent Solution Auto-Injector,
C1
Proair) 0.3MG/0.3ML Injection 2 QL
Albu

Solution Auto-Injector)
terol

Albuterol Sulfate HFA

Sulf
ate
HFA

(108 (90 Base)MCG/ (Brand Equivalent

ACT Inhalation Aerosol C1
Epipen)
EpiP

Solution) (Brand
en

EpiPen 2-Pak
2-
Pak

Equivalent Proventil), (Injection Solution 3 ST; QL

3 ST
Albuterol Sulfate HFA Auto-Injector)
(108 (90 Base)MCG/ C1

EpiP
en

EpiPen Jr 2-Pak
Jr 2-
Pak

ACT Inhalation Aerosol

Solution) (Brand (Injection Solution 3 ST; QL
Equivalent Ventolin) C1
Auto-Injector)
Lev
albu
C1

Levalbuterol HCl
terol
Albu HCl
terol

Albuterol Sulfate
Sulf
ate

(Inhalation 1 B/D, PA (0.31MG/3ML

Nebulization Solution) Inhalation Nebulization
C1

Albu
terol
Solution, 0.63MG/3ML
Sulf
ate

Albuterol Sulfate (Oral 1 B/D, PA

1 Inhalation Nebulization
Syrup)
C1

Albu
terol
Solution, 1.25MG/3ML
Albuterol Sulfate (Oral
Sulf
ate

Inhalation Nebulization
Tablet Immediate 3 Solution)
C1
Release)
Arca
pta

Arcapta Neohaler
Neo
hale
r

3 ST
(Inhalation Capsule)

Bold type = Brand name drug Plain type = Generic drug

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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Lev Vent
albu olin

Levalbuterol HCl Ventolin HFA

terol HFA
HCl

(1.25MG/0.5ML (Inhalation Aerosol 3 ST

3 B/D, PA
Inhalation Nebulization Solution)
C1
Solution) C1

Xop
ene
x
Con
cent
rate

Xopenex Concentrate
Lev
albu

Levalbuterol Tartrate
terol

Tartr

(Inhalation
ate

3 ST 3 B/D, PA
C1
(Inhalation Aerosol) Nebulization
Met
apro

Metaproterenol Sulfate
tere
nol
Sulf

Solution)
ate

1
(Oral Syrup) C1

Xop
ene

Xopenex HFA
x
HFA

C1

3 ST
Met
apro

Metaproterenol Sulfate
tere
nol
Sulf
ate

(Inhalation Aerosol)
(10MG Oral Tablet, 1 C1

Xop
ene

Xopenex (0.31MG/
x

20MG Oral Tablet)

C1

Perf
oro 3ML Inhalation
Perforomist
mist

Nebulization Solution,
(Inhalation
3 B/D, PA; QL 0.63MG/3ML 3 B/D, PA
Nebulization
Inhalation
Solution)
C1

Pro
Air
Nebulization
ProAir HFA
HFA

Solution)
(Inhalation Aerosol 2 C1

Xop
ene

Xopenex (1.25MG/
x

Solution)
C1
3ML Inhalation
4 B/D, PA
Pro
Air

ProAir RespiClick
Res
piCli
ck

Nebulization
(Inhalation Aerosol Solution)
2
Powder Breath
Cystic Fibrosis Agents
B1

Activated) C1

Beth
kis

C1

Prov
entil Bethkis (Inhalation
Proventil HFA
HFA

Nebulization 4 B/D, PA; QL

(Inhalation Aerosol 3 ST
Solution)
Solution) C1

Cay
ston

C1

Sere
vent Cayston (Inhalation
Serevent Diskus
Disk
us

Solution 4 PA; LA
(Inhalation Aerosol
2 QL Reconstituted)
Powder Breath C1

Ork
amb

Orkambi (Oral
i

Activated) 4 PA; LA; QL

C1

Striv
erdi Packet)
Striverdi Respimat
Res
pim
at
C1

Ork
amb

Orkambi (Oral Tablet) 4 PA; LA; QL

i

(Inhalation Aerosol 3 ST C1

Sym
dek

Symdeko (Oral Tablet

o

Solution) 4 PA; QL
C1

Terb
utali

Therapy Pack)
Terbutaline Sulfate
ne
Sulf
ate

3
(Oral Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
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Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

TOB Alyq
I

TOBI (Inhalation C1
Alyq (Oral Tablet) 4 PA
Nebulization 4 B/D, PA; QL
Am
bris

Ambrisentan (Oral
enta
n

Solution) 4 PA; LA; QL

C1
C1
Tablet)
TOB
I Bos

TOBI Podhaler
Pod enta

Bosentan (Oral Tablet) 4 PA; LA; QL

hale n
r

4 PA; QL C1

(Inhalation Capsule)
Leta
iris

C1

Tob
ram
C1
Letairis (Oral Tablet) 4 PA; LA; QL
Tobramycin (Inhalation
ycin Ops
umit

4 B/D, PA; QL Opsumit (Oral Tablet) 4 PA; LA

Nebulization Solution) C1

Ore
nitra
m

Orenitram (0.125MG
Mast Cell Stabilizers
B1

C1

Cro
mol
Oral Tablet Extended 3 PA; LA
Cromolyn Sodium
yn
Sodi

Release)
um

(Inhalation 1 B/D, PA
C1

Ore
nitra

Orenitram (0.25MG
m

Nebulization Solution)
Oral Tablet Extended
Phosphodiesterase Inhibitors, Airways
B1

Release, 1MG Oral

C1
Disease Tablet Extended
Dalir
esp

C1
Daliresp (Oral Tablet) 3 PA Release, 2.5MG Oral 4 PA; LA
The
o-24

Theo-24 (Oral Capsule Tablet Extended

Extended Release 24 3 Release, 5MG Oral
C1
Hour) Tablet Extended
The
oph

Theophylline ER
yllin

Release)
e
ER

(100MG Oral Tablet

C1

Rev
atio

Revatio (Oral
Extended Release 12 Suspension 4 PA
Hour, 200MG Oral
Reconstituted)
Tablet Extended 1 C1

Rev
atio

Release 12 Hour, C1
Revatio (Oral Tablet) 4 PA
Sild
enaf

Sildenafil Citrate (Oral

il

300MG Oral Tablet

Citra
te

Extended Release 12 Suspension 4 PA

C1
Hour) C1
Reconstituted)
Sild
The
enaf
oph

Sildenafil Citrate
il

Theophylline ER (Oral
yllin
Citra
e
te
ER

Tablet Extended 1 (20MG Oral Tablet) 1 PA

C1
Release 24 Hour) C1
(Generic Revatio)
Tad
The
alafil
oph

Theophylline (Oral Tadalafil (PAH) (20MG

yllin
e

1 4 PA
Solution) C1
Oral Tablet)
Trac
leer

Pulmonary Antihypertensives Tracleer (Oral Tablet) 4 PA; LA; QL

B1

C1
C1
Trac
Adci
leer
rca

Adcirca (Oral Tablet) 4 PA Tracleer (Oral Tablet

C1
4 PA; LA; QL
Soluble)
Ade
mpa

Adempas (Oral
s

4 PA; LA C1

Uptr
avi

Tablet) Uptravi (Oral Tablet) 4 PA; LA; QL

Bold type = Brand name drug Plain type = Generic drug

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Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Uptr Bev
avi espi

Uptravi (Oral Tablet Bevespi Aerosphere

Aer
osp
here

4 PA; LA 3 ST
C1
Therapy Pack) C1
(Inhalation Aerosol)
Vent Bre
avis o

Ventavis (Inhalation Breo Ellipta

Ellip
ta

4 PA; LA
Solution) (Inhalation Aerosol
2 QL
B1

Pulmonary Fibrosis Agents Powder Breath

Activated)
C1

Esbr
iet

Esbriet (Oral Capsule) 4 PA; LA; QL C1

Clari
nex-

Clarinex-D 12 Hour
C1 D 12
Esbr Hou
iet r

Esbriet (Oral Tablet) 4 PA; LA; QL

C1

Ofe
v

Ofev (Oral Capsule) 4 PA; LA; QL (Oral Tablet Extended 3

Release 12 Hour)
Respiratory Tract Agents, Other
B1

C1

Co
mbi

Combivent Respimat
vent

Res
C1 pim
at
Acet
ylcy

Acetylcysteine
stei
ne

1 B/D, PA (Inhalation Aerosol 2 QL

(Inhalation Solution)
C1

Adv
air Solution)
Advair Diskus
Disk
us

C1

Dule
ra

Dulera (Inhalation
(Inhalation Aerosol 3 QL
1 QL Aerosol)
Powder Breath C1

Dym
ista

Activated) Dymista (Nasal

3
C1

Adv
air
Suspension)
Advair HFA
HFA

C1

2 QL
Fas
enra

(Inhalation Aerosol) Fasenra

C1

AirD
uo
(Subcutaneous
AirDuo RespiClick
Res

4 PA; LA
piCli
ck
113/
14

Solution Prefilled
113/14 (Inhalation
3 ST; QL Syringe)
Aerosol Powder C1

Fluti
cas

Fluticasone-Salmeterol
one-
Sal
met
erol

Breath Activated)
C1

AirD
uo
(100-50MCG/DOSE
AirDuo RespiClick
Res
piCli
ck
232/
14

Inhalation Aerosol
232/14 (Inhalation Powder Breath
3 ST; QL
Aerosol Powder Activated,
C1
Breath Activated) 250-50MCG/DOSE
AirD

Inhalation Aerosol
uo

AirDuo RespiClick
Res
piCli
ck
55/1
4

1 QL
55/14 (Inhalation Powder Breath
3 ST; QL Activated,
Aerosol Powder
Breath Activated) 500-50MCG/DOSE
C1

Ano
ro
Inhalation Aerosol
Anoro Ellipta
Ellip
ta

Powder Breath
(Inhalation Aerosol Activated) (Generic
2 QL
Powder Breath Advair)
Activated)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 Last updated September 1, 2019
tRACK 163 163
162
125

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1 C1

Fluti Sem
cas prex

Fluticasone-Salmeterol Semprex-D (Oral

one- -D
Sal
met
erol

3
(113-14MCG/ACT Capsule)
Inhalation Aerosol
C1

Stiol
to

Stiolto Respimat
Res
pim
at

Powder Breath (Inhalation Aerosol 2

Activated,
Solution)
232-14MCG/ACT C1

Sym
bico

Symbicort (Inhalation
rt

Inhalation Aerosol 2 QL 2 QL
Powder Breath C1
Aerosol)
Trel

Activated, 55-14MCG/
egy

Trelegy Ellipta
Ellip
ta

ACT Inhalation Aerosol (Inhalation Aerosol

Powder Breath 2 QL
Powder Breath
Activated) (Brand Activated)
Equivalent AirDuo) C1

Utib
ron

Utibron Neohaler
Neo
hale
r

C1

Iprat

3 ST
ropi

Ipratropium-Albuterol
um-
Albu
terol

1 B/D, PA (Inhalation Capsule)

(Inhalation Solution) C1

Wix
ela

Wixela Inhub
Inhu
b

C1

Kaly
dec

Kalydeco (Oral
o

4 PA; LA (Inhalation Aerosol

C1
Packet) Powder Breath 1 QL
Kaly
dec

Kalydeco (Oral
o

4 PA; LA Activated) (Generic

C1
Tablet) Advair)
Nuc
ala

Nucala Skeletal Muscle Relaxants

A1

(Subcutaneous B1

Skeletal Muscle Relaxants

4 PA; LA; QL
Solution Auto-
C1

Bacl
ofen

Baclofen (Oral Tablet) 1

Injector) C1

Cycl
obe
nza
prin
e
HCl

Cyclobenzaprine HCl
3 PA; HRM
C1

Nuc
ala

Nucala (7.5MG Oral Tablet)

(Subcutaneous
C1

Dant
rium

4 PA; LA; QL Dantrium (Oral

Solution Prefilled 3
Capsule)
Syringe) C1

Dant
role

Dantrolene Sodium
ne
Sodi
um

C1

1
Nuc
ala

Nucala (Oral Capsule)

(Subcutaneous
C1

Fex
mid

4 PA; LA; QL Fexmid (Oral Tablet) 3 PA; HRM

Solution C1

Tiza
nidi

Tizanidine HCl (Oral

ne
HCl

Reconstituted) 1
C1

Oral
air
Capsule)
Oralair 300IR (Tablet
300I
R
C1

Tiza
nidi

Tizanidine HCl (Oral

ne

3 PA
HCl

Sublingual) 1
C1

Pul
moz
Tablet)
Pulmozyme
yme C1

Zan
aflex

4 B/D, PA; QL Zanaflex (Oral

(Inhalation Solution) 3
Capsule)

Bold type = Brand name drug Plain type = Generic drug

 164 tRACK 164 Last updated September 1, 2019
163
126

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
C1

Zan
aflex

Zanaflex (Oral Tablet) 3 Sleep Disorders, Other

B1

C1

Arm
odaf

Sleep Disorder Agents Armodafinil (Oral

A1 inil

1 PA; QL
B1

GABA Receptor Modulators C1

Tablet)
Bels
C1 omr

Belsomra (Oral
a
Am
bien

Ambien (Oral Tablet PA; HRM; 2 QL

3 Tablet)
C1
Immediate Release) QL C1

Hetli
oz

Hetlioz (Oral Capsule) 4 PA; LA; QL

Rest
oril

Restoril (22.5MG Oral

4 HRM; QL C1

Mod
afinil

Capsule) C1
Modafinil (Oral Tablet) 1 PA; QL
C1
Nuvi
Tem gil

Nuvigil (150MG Oral

aze

Temazepam (15MG
pam

Oral Capsule, 30MG Tablet, 200MG Oral

1 HRM; QL 4 PA; QL
Oral Capsule, 7.5MG Tablet, 250MG Oral
C1
Oral Capsule) Tablet)
Tem C1
aze

Temazepam (22.5MG
pam Nuvi
gil

3 HRM; QL Nuvigil (50MG Oral

Oral Capsule) 3 PA; QL
C1

Zale
plon C1
Tablet)
Zaleplon (Oral Prov
igil

Provigil (Oral Tablet) 4 PA; QL

1 HRM; QL
Capsule) C1

Roz
ere

Rozerem (Oral Tablet) 3

m

C1

Zolp
ide

Zolpidem Tartrate
m
Tartr
ate C1

Sile
nor

PA; HRM; Silenor (Oral Tablet) 3

(Oral Tablet Immediate 1 C1

QL
Xyre
m

Release) Xyrem (Oral Solution) 4 PA; LA; QL

You can find information on what the abbreviations in this table mean on pages 6 - 7.
 165 1 1 track 165
Covered drugs with a quantity limit (QL)
This list shows drugs that have a quantity limit. Some drugs come in several strengths. Each
strength may have a different quantity limit. If quantity limits for a drug vary by strength, the
different strengths are listed on separate lines. These limits may be in place to ensure your safety.
Your plan will cover only a certain amount of these drugs or will only cover these drugs for a certain
number of days. For more information about quantity limits, talk with your doctor or pharmacist.
You can also call Customer Service. Our contact information is on the cover.
Drugs are listed in alphabetical order in the chart below.
track

Drug Name Quantity Limit

Abacavir Sulfate (Oral Solution)
Abacavir Sulfate (Oral Tablet)
Abacavir Sulfate-Lamivudine (Oral Tablet)
Abacavir-Lamivudine-Zidovudine (Oral Tablet)
Abilify (Oral Tablet)
Abstral (Tablet Sublingual)
Accupril (Oral Tablet)
Accuretic (10-12.5MG Oral Tablet)
Accuretic (20-12.5MG Oral Tablet, 20-25MG
Oral Tablet)
Acetaminophen-Codeine (120-12MG/5ML Oral
Solution)
Acetaminophen-Codeine (300-15MG Oral
Tablet, 300-30MG Oral Tablet, 300-60MG Oral
Tablet)
Actiq (Buccal Lozenge On A Handle)
Actoplus Met (Oral Tablet Immediate
Release)
Actos (15MG Oral Tablet)
Actos (30MG Oral Tablet, 45MG Oral Tablet)
Adderall (20MG Oral Tablet)
Adderall (5MG Oral Tablet, 7.5MG Oral Tablet)
Adderall XR (Oral Capsule Extended Release
24 Hour)
Adlyxin Starter Pack (Subcutaneous Pen-
Injector Kit)
Adlyxin (Subcutaneous Solution Pen-Injector)
Advair Diskus (Inhalation Aerosol Powder
Breath Activated)
Maximum of 32 ml per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 4 tablets per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 150 ml per day
Maximum of 13 tablets per day
Maximum of 4 lozenges per day
Maximum of 3 tablets per day
Maximum of 3 tablets per day
Maximum of 1 tablet per day
Maximum of 3 tablets per day
Maximum of 2 tablets per day
Maximum of 2 capsules per day
Maximum of 6 ml (1 kit) per 28 days
Maximum of 6 ml (2 pens) per 28 days
Maximum of 1 inhaler (60 blisters) per 30 days

Bold type = Brand name drug Plain type = Generic drug

166166 2 2 Last updated September 1, 2019

Drug Name Quantity Limit

Advair HFA (Inhalation Aerosol) Maximum of 1 inhaler (12 grams) per 30 days
Adzenys ER (Oral Suspension Extended
Maximum of 15 ml per day
Release)
Adzenys XR-ODT (Oral Tablet Extended
Maximum of 1 tablet per day
Release Dispersible)
Aggrenox (Oral Capsule Extended Release 12
Maximum of 2 capsules per day
Hour)
Aimovig (140MG/ML Subcutaneous Solution
Maximum of 1 ml (1 pen) per 30 days
Auto-Injector)
Aimovig (70MG/ML Subcutaneous Solution
Maximum of 2 ml per 30 days
Auto-Injector)
AirDuo RespiClick 113/14 (Inhalation Aerosol
Maximum of 1 inhaler per 30 days
Powder Breath Activated)
AirDuo RespiClick 232/14 (Inhalation Aerosol
Maximum of 1 inhaler per 30 days
Powder Breath Activated)
AirDuo RespiClick 55/14 (Inhalation Aerosol
Maximum of 1 inhaler per 30 days
Powder Breath Activated)
Ajovy (Subcutaneous Solution Prefilled
Maximum of 1.5 ml (1 syringe) per 30 days
Syringe)
Albendazole (Oral Tablet) Maximum of 16 tablets per day
Albenza (Oral Tablet) Maximum of 16 tablets per day
Aliskiren Fumarate (Oral Tablet) Maximum of 1 tablet per day
Almotriptan Malate (Oral Tablet) Maximum of 12 tablets per 30 days
Alogliptin Benzoate (Oral Tablet) Maximum of 1 tablet per day
Alogliptin-Metformin HCl (Oral Tablet) Maximum of 2 tablets per day
Alogliptin-Pioglitazone (Oral Tablet) Maximum of 1 tablet per day
Alora (Transdermal Patch Twice Weekly) Maximum of 8 patches per 28 days
Alprazolam ER (0.5MG Oral Tablet Extended
Release 24 Hour, 1MG Oral Tablet Extended Maximum of 1 tablet per day
Release 24 Hour)
Alprazolam ER (2MG Oral Tablet Extended
Maximum of 5 tablets per day
Release 24 Hour)
Alprazolam ER (3MG Oral Tablet Extended
Maximum of 3 tablets per day
Release 24 Hour)
Alprazolam Intensol (Oral Concentrate) Maximum of 10 ml per day
Alprazolam (0.25MG Oral Tablet Immediate
Release, 0.5MG Oral Tablet Immediate Release, Maximum of 4 tablets per day
1MG Oral Tablet Immediate Release)
Alprazolam (2MG Oral Tablet Immediate
Maximum of 5 tablets per day
Release)

Bold type = Brand name drug Plain type = Generic drug

Last167
updated September 1, 2019 3 3 167

Drug Name Quantity Limit

Alprazolam ODT (0.25MG Oral Tablet
Dispersible, 0.5MG Oral Tablet Dispersible, Maximum of 4 tablets per day
1MG Oral Tablet Dispersible)
Alprazolam ODT (2MG Oral Tablet Dispersible) Maximum of 5 tablets per day
Altace (Oral Capsule) Maximum of 2 capsules per day
Altoprev (Oral Tablet Extended Release 24
Maximum of 1 tablet per day
Hour)
Alunbrig (180MG Oral Tablet, 90MG Oral
Maximum of 1 tablet per day
Tablet)
Alunbrig (30MG Oral Tablet) Maximum of 4 tablets per day
Alunbrig (Oral Tablet Therapy Pack) Maximum of 1 pack (30 tablets) per 30 days
Alvesco (160MCG/ACT Inhalation Aerosol Maximum of 2 inhalers (12.2 grams) per 30
Solution) days
Alvesco (80MCG/ACT Inhalation Aerosol
Maximum of 1 inhaler (6.1 grams) per 30 days
Solution)
Amaryl (1MG Oral Tablet) Maximum of 8 tablets per day
Amaryl (2MG Oral Tablet) Maximum of 4 tablets per day
Amaryl (4MG Oral Tablet) Maximum of 2 tablets per day
Ambien (Oral Tablet Immediate Release) Maximum of 90 tablets per year
Ambrisentan (Oral Tablet) Maximum of 1 tablet per day
Amerge (Oral Tablet) Maximum of 12 tablets per 30 days
Amitiza (Oral Capsule) Maximum of 2 capsules per day
Amlodipine-Atorvastatin (Oral Tablet) Maximum of 1 tablet per day
Amlodipine-Benazepril (Oral Capsule) Maximum of 1 capsule per day
Amlodipine-Olmesartan (Oral Tablet) Maximum of 1 tablet per day
Amlodipine-Valsartan (Oral Tablet) Maximum of 1 tablet per day
Amphetamine-Dextroamphetamine ER (Oral
Maximum of 2 capsules per day
Capsule Extended Release 24 Hour)
Amphetamine-Dextroamphetamine (10MG Oral
Tablet, 12.5MG Oral Tablet, 15MG Oral Tablet,
Maximum of 2 tablets per day
30MG Oral Tablet, 5MG Oral Tablet, 7.5MG
Oral Tablet)
Amphetamine-Dextroamphetamine (20MG Oral
Maximum of 3 tablets per day
Tablet)
Ampyra (Oral Tablet Extended Release 12
Maximum of 2 tablets per day
Hour)
Anoro Ellipta (Inhalation Aerosol Powder
Maximum of 1 inhaler (60 blisters) per 30 days
Breath Activated)
Apokyn (Subcutaneous Solution Cartridge) Maximum of 3 ml per day

Bold type = Brand name drug Plain type = Generic drug

168168 4 4 Last updated September 1, 2019

Drug Name Quantity Limit

Apriso (Oral Capsule Extended Release 24
Maximum of 4 capsules per day
Hour)
Aptensio XR (Oral Capsule Extended Release
Maximum of 1 capsule per day
24 Hour)
Aptiom (200MG Oral Tablet, 400MG Oral
Maximum of 1 tablet per day
Tablet)
Aptiom (600MG Oral Tablet, 800MG Oral
Maximum of 2 tablets per day
Tablet)
Aptivus (Oral Capsule) Maximum of 4 capsules per day
Aptivus (Oral Solution) Maximum of 4 bottles (380 ml) per 30 days
Aricept (10MG Oral Tablet) Maximum of 2 tablets per day
Aricept (23MG Oral Tablet, 5MG Oral Tablet) Maximum of 1 tablet per day
Aripiprazole (1MG/ML Oral Solution) Maximum of 25 ml per day
Aripiprazole (10MG Oral Tablet, 15MG Oral
Tablet, 20MG Oral Tablet, 2MG Oral Tablet, Maximum of 1 tablet per day
30MG Oral Tablet, 5MG Oral Tablet)
Aripiprazole ODT (10MG Oral Tablet
Maximum of 3 tablets per day
Dispersible)
Aripiprazole ODT (15MG Oral Tablet
Maximum of 2 tablets per day
Dispersible)
Armodafinil (150MG Oral Tablet, 200MG Oral
Maximum of 1 tablet per day
Tablet, 250MG Oral Tablet)
Armodafinil (50MG Oral Tablet) Maximum of 2 tablets per day
Arnuity Ellipta (Inhalation Aerosol Powder
Maximum of 1 inhaler (30 blisters) per 30 days
Breath Activated)
Asacol HD (Oral Tablet Delayed Release) Maximum of 6 tablets per day
Asmanex (120 Metered Doses) (Inhalation
Maximum of 1 inhaler per 30 days
Aerosol Powder Breath Activated)
Asmanex (30 Metered Doses) (110MCG/INH
Maximum of 2 inhalers per 30 days
Inhalation Aerosol Powder Breath Activated)
Asmanex (30 Metered Doses) (220MCG/INH
Maximum of 1 inhaler per 30 days
Inhalation Aerosol Powder Breath Activated)
Asmanex (60 Metered Doses) (Inhalation
Maximum of 1 inhaler per 30 days
Aerosol Powder Breath Activated)
Asmanex HFA (Inhalation Aerosol) Maximum of 1 inhaler (13 grams) per 30 days
Aspirin-Dipyridamole ER (Oral Capsule
Maximum of 2 capsules per day
Extended Release 12 Hour)
Atacand HCT (Oral Tablet) Maximum of 1 tablet per day
Atacand (16MG Oral Tablet, 32MG Oral
Maximum of 1 tablet per day
Tablet, 4MG Oral Tablet)

Bold type = Brand name drug Plain type = Generic drug

Last169
updated September 1, 2019 5 5 169

Drug Name Quantity Limit

Atacand (8MG Oral Tablet) Maximum of 3 tablets per day
Atazanavir Sulfate (150MG Oral Capsule,
Maximum of 1 capsule per day
300MG Oral Capsule)
Atazanavir Sulfate (200MG Oral Capsule) Maximum of 2 capsules per day
Ativan (0.5MG Oral Tablet, 1MG Oral Tablet) Maximum of 4 tablets per day
Ativan (2MG Oral Tablet) Maximum of 5 tablets per day
Atorvastatin Calcium (Oral Tablet) Maximum of 1 tablet per day
Atripla (Oral Tablet) Maximum of 1 tablet per day
Aubagio (Oral Tablet) Maximum of 1 tablet per day
Austedo (Oral Tablet) Maximum of 4 tablets per day
Avalide (Oral Tablet) Maximum of 1 tablet per day
Avandia (2MG Oral Tablet) Maximum of 4 tablets per day
Avandia (4MG Oral Tablet) Maximum of 2 tablets per day
Avapro (150MG Oral Tablet, 300MG Oral
Maximum of 1 tablet per day
Tablet)
Avapro (75MG Oral Tablet) Maximum of 3 tablets per day
Azor (Oral Tablet) Maximum of 1 tablet per day
Balversa (3MG Oral Tablet) Maximum of 3 tablets per day
Balversa (4MG Oral Tablet) Maximum of 2 tablets per day
Balversa (5MG Oral Tablet) Maximum of 1 tablet per day
Belbuca (Buccal Film) Maximum of 2 films per day
Belsomra (Oral Tablet) Maximum of 1 tablet per day
Benazepril HCl (Oral Tablet) Maximum of 2 tablets per day
Benazepril-Hydrochlorothiazide (Oral Tablet) Maximum of 1 tablet per day
Benicar HCT (Oral Tablet) Maximum of 1 tablet per day
Benicar (20MG Oral Tablet, 40MG Oral
Maximum of 1 tablet per day
Tablet)
Benicar (5MG Oral Tablet) Maximum of 2 tablets per day
Bethkis (Inhalation Nebulization Solution) Maximum of 8 ml (2 ampules) per day
Bevyxxa (Oral Capsule) Maximum of 31 capsules per 30 days
Biktarvy (Oral Tablet) Maximum of 1 tablet per day
Bisoprolol-Hydrochlorothiazide (Oral Tablet) Maximum of 2 tablets per day
Bosentan (Oral Tablet) Maximum of 2 tablets per day
Breo Ellipta (Inhalation Aerosol Powder
Maximum of 1 inhaler (60 blisters) per 30 days
Breath Activated)
Brilinta (Oral Tablet) Maximum of 2 tablets per day
BRIVIACT (10MG/ML Oral Solution) Maximum of 20 ml per day

Bold type = Brand name drug Plain type = Generic drug

170170 6 6 Last updated September 1, 2019

Drug Name Quantity Limit

BRIVIACT (100MG Oral Tablet, 10MG Oral
Tablet, 25MG Oral Tablet, 50MG Oral Tablet, Maximum of 2 tablets per day
75MG Oral Tablet)
Brovana (Inhalation Nebulization Solution) Maximum of 2 vials (4 ml) per day
Bunavail (Buccal Film) Maximum of 2 films per day
Buprenorphine HCl (Tablet Sublingual) Maximum of 3 tablets per day
Buprenorphine HCl-Naloxone HCl (12-3MG
Maximum of 2 films per day
Sublingual Film, 4-1MG Sublingual Film)
Buprenorphine HCl-Naloxone HCl (2-0.5MG
Maximum of 3 films per day
Sublingual Film, 8-2MG Sublingual Film)
Buprenorphine HCl-Naloxone HCl (Tablet
Maximum of 3 tablets per day
Sublingual)
Buprenorphine (Transdermal Patch Weekly) Maximum of 4 patches per 28 days
Butorphanol Tartrate (Nasal Solution) Maximum of 2 bottles (5 ml) per 30 days
Butrans (Transdermal Patch Weekly) Maximum of 4 patches per 28 days
Bydureon BCise (Subcutaneous Auto-
Maximum of 4 pens (3.4 ml) per 28 days
Injector)
Bydureon (Subcutaneous Pen-Injector) Maximum of 4 pens per 28 days
Byetta 10MCG Pen (Subcutaneous Solution
Maximum of 1 pen (2.4 ml) per 30 days
Pen-Injector)
Byetta 5MCG Pen (Subcutaneous Solution
Maximum of 1 pen (1.2 ml) per 30 days
Pen-Injector)
Bystolic (10MG Oral Tablet, 2.5MG Oral
Maximum of 1 tablet per day
Tablet, 5MG Oral Tablet)
Bystolic (20MG Oral Tablet) Maximum of 2 tablets per day
Cablivi (Injection Kit) Maximum of 1 kit per day
Cabometyx (20MG Oral Tablet, 60MG Oral
Maximum of 1 tablet per day
Tablet)
Cabometyx (40MG Oral Tablet) Maximum of 2 tablets per day
Caduet (Oral Tablet) Maximum of 1 tablet per day
Calquence (Oral Capsule) Maximum of 2 capsules per day
Candesartan Cilexetil (16MG Oral Tablet, 32MG
Maximum of 1 tablet per day
Oral Tablet, 4MG Oral Tablet)
Candesartan Cilexetil (8MG Oral Tablet) Maximum of 3 tablets per day
Candesartan Cilexetil-HCTZ (Oral Tablet) Maximum of 1 tablet per day
Captopril (100MG Oral Tablet) Maximum of 4 tablets per day
Captopril (12.5MG Oral Tablet, 25MG Oral
Maximum of 3 tablets per day
Tablet)
Captopril (50MG Oral Tablet) Maximum of 9 tablets per day

Bold type = Brand name drug Plain type = Generic drug

Last171
updated September 1, 2019 7 7 171

Drug Name Quantity Limit

Captopril-Hydrochlorothiazide (25-15MG Oral
Maximum of 3 tablets per day
Tablet, 50-15MG Oral Tablet)
Captopril-Hydrochlorothiazide (25-25MG Oral
Maximum of 2 tablets per day
Tablet, 50-25MG Oral Tablet)
Cardura XL (Oral Tablet Extended Release 24
Maximum of 1 tablet per day
Hour)
Celebrex (Oral Capsule) Maximum of 2 capsules per day
Celecoxib (Oral Capsule) Maximum of 2 capsules per day
Cialis (2.5MG Oral Tablet, 5MG Oral Tablet) Maximum of 1 tablet per day
Cimduo (Oral Tablet) Maximum of 1 tablet per day
Cinacalcet HCl (30MG Oral Tablet, 60MG Oral
Maximum of 2 tablets per day
Tablet)
Cinacalcet HCl (90MG Oral Tablet) Maximum of 4 tablets per day
Clobazam (2.5MG/ML Oral Suspension) Maximum of 16 ml per day
Clobazam (10MG Oral Tablet, 20MG Oral
Maximum of 2 tablets per day
Tablet)
Clonazepam (0.5MG Oral Tablet, 1MG Oral
Maximum of 4 tablets per day
Tablet)
Clonazepam (2MG Oral Tablet) Maximum of 10 tablets per day
Clonazepam ODT (0.125MG Oral Tablet
Dispersible, 0.25MG Oral Tablet Dispersible,
Maximum of 4 tablets per day
0.5MG Oral Tablet Dispersible, 1MG Oral Tablet
Dispersible)
Clonazepam ODT (2MG Oral Tablet Dispersible) Maximum of 10 tablets per day
Clopidogrel Bisulfate (75MG Oral Tablet) Maximum of 4 tablets per day
Clorazepate Dipotassium (15MG Oral Tablet) Maximum of 6 tablets per day
Clorazepate Dipotassium (3.75MG Oral Tablet) Maximum of 24 tablets per day
Clorazepate Dipotassium (7.5MG Oral Tablet) Maximum of 12 tablets per day
Codeine Sulfate (Oral Tablet) Maximum of 6 tablets per day
Colchicine (0.6MG Oral Capsule) (Brand
Maximum of 4 capsules per day
Equivalent Mitigare)
Colchicine (0.6MG Oral Tablet) (Brand
Maximum of 4 tablets per day
Equivalent Colcrys)
Colcrys (Oral Tablet) Maximum of 4 tablets per day
Combivent Respimat (Inhalation Aerosol
Maximum of 1 inhaler (4 grams) per 20 days
Solution)
Combivir (Oral Tablet) Maximum of 2 tablets per day
Complera (Oral Tablet) Maximum of 1 tablet per day

Bold type = Brand name drug Plain type = Generic drug

172172 8 8 Last updated September 1, 2019

Drug Name Quantity Limit

Concerta (18MG Oral Tablet Extended
Maximum of 3 tablets per day
Release)
Concerta (27MG Oral Tablet Extended
Release, 36MG Oral Tablet Extended Maximum of 2 tablets per day
Release)
Concerta (54MG Oral Tablet Extended
Maximum of 1 tablet per day
Release)
ConZip (Oral Capsule Extended Release 24
Maximum of 1 capsule per day
Hour)
Copiktra (Oral Capsule) Maximum of 2 capsules per day
Corlanor (Oral Tablet) Maximum of 2 tablets per day
Cotempla XR-ODT (Oral Tablet Extended
Maximum of 2 tablets per day
Release Dispersible)
Cozaar (100MG Oral Tablet) Maximum of 1 tablet per day
Cozaar (25MG Oral Tablet, 50MG Oral Tablet) Maximum of 2 tablets per day
Crestor (Oral Tablet) Maximum of 1 tablet per day
Crixivan (200MG Oral Capsule) Maximum of 9 capsules per day
Crixivan (400MG Oral Capsule) Maximum of 6 capsules per day
Cymbalta (Oral Capsule Delayed Release
Maximum of 2 capsules per day
Particles)
Daklinza (30MG Oral Tablet, 60MG Oral
Maximum of 1 tablet per day
Tablet)
Dalfampridine ER (Oral Tablet Extended
Maximum of 2 tablets per day
Release 12 Hour)
Darifenacin Hydrobromide ER (Oral Tablet
Maximum of 1 tablet per day
Extended Release 24 Hour)
Daurismo (100MG Oral Tablet) Maximum of 1 tablet per day
Daurismo (25MG Oral Tablet) Maximum of 2 tablets per day
Daytrana (Transdermal Patch) Maximum of 1 patch per day
Delstrigo (Oral Tablet) Maximum of 1 tablet per day
Descovy (Oral Tablet) Maximum of 1 tablet per day
Dexedrine (10MG Oral Capsule Extended
Maximum of 6 capsules per day
Release 24 Hour)
Dexedrine (15MG Oral Capsule Extended
Maximum of 4 capsules per day
Release 24 Hour)
Dexedrine (5MG Oral Capsule Extended
Maximum of 3 capsules per day
Release 24 Hour)
Dexilant (Oral Capsule Delayed Release) Maximum of 1 capsule per day
Dexmethylphenidate HCl (Oral Tablet) Maximum of 2 tablets per day

Bold type = Brand name drug Plain type = Generic drug

Last173
updated September 1, 2019 9 9 173

Drug Name Quantity Limit

Dextroamphetamine Sulfate ER (10MG Oral
Maximum of 6 capsules per day
Capsule Extended Release 24 Hour)
Dextroamphetamine Sulfate ER (15MG Oral
Maximum of 4 capsules per day
Capsule Extended Release 24 Hour)
Dextroamphetamine Sulfate ER (5MG Oral
Maximum of 3 capsules per day
Capsule Extended Release 24 Hour)
Dextroamphetamine Sulfate (Oral Tablet) Maximum of 6 tablets per day
Diazepam Intensol (5MG/ML Oral Concentrate) Maximum of 8 ml per day
Diazepam (10MG Oral Tablet, 2MG Oral Tablet,
Maximum of 4 tablets per day
5MG Oral Tablet)
Diclofenac Epolamine (Transdermal Patch) Maximum of 2 patches per day
Didanosine (200MG Oral Capsule Delayed
Maximum of 2 capsules per day
Release)
Didanosine (250MG Oral Capsule Delayed
Release, 400MG Oral Capsule Delayed Maximum of 1 capsule per day
Release)
Digitek (125MCG Oral Tablet) Maximum of 1 tablet per day
Digox (125MCG Oral Tablet) Maximum of 1 tablet per day
Digoxin (Oral Solution) Maximum of 5 ml per day
Digoxin (125MCG Oral Tablet) Maximum of 1 tablet per day
Dilaudid (Oral Liquid) Maximum of 50 ml per day
Dilaudid (2MG Oral Tablet, 4MG Oral Tablet) Maximum of 8 tablets per day
Dilaudid (8MG Oral Tablet) Maximum of 6 tablets per day
Diovan HCT (Oral Tablet) Maximum of 1 tablet per day
Diovan (160MG Oral Tablet, 40MG Oral
Maximum of 2 tablets per day
Tablet, 80MG Oral Tablet)
Diovan (320MG Oral Tablet) Maximum of 1 tablet per day
Dolophine (10MG Oral Tablet) Maximum of 12 tablets per day
Dolophine (5MG Oral Tablet) Maximum of 8 tablets per day
Donepezil HCl (10MG Oral Tablet) Maximum of 2 tablets per day
Donepezil HCl (23MG Oral Tablet, 5MG Oral
Maximum of 1 tablet per day
Tablet)
Donepezil HCl ODT (10MG Oral Tablet
Maximum of 2 tablets per day
Dispersible)
Donepezil HCl ODT (5MG Oral Tablet
Maximum of 1 tablet per day
Dispersible)
Dotti (Transdermal Patch Twice Weekly) Maximum of 8 patches per 28 days
Dovato (Oral Tablet) Maximum of 1 tablet per day
Doxepin HCl (External Cream) Maximum of 90 grams per 30 days

Bold type = Brand name drug Plain type = Generic drug

174174 10
Drug Name
Duetact (Oral Tablet)
Dulera (Inhalation Aerosol)
Duloxetine HCl (20MG Oral Capsule Delayed
Release Particles, 30MG Oral Capsule Delayed
Release Particles, 60MG Oral Capsule Delayed
Release Particles)
Duloxetine HCl (40MG Oral Capsule Delayed
Release Particles)
Duragesic-100 (Transdermal Patch 72 Hour)
Duragesic-12 (Transdermal Patch 72 Hour)
Duragesic-25 (Transdermal Patch 72 Hour)
Duragesic-50 (Transdermal Patch 72 Hour)
Duragesic-75 (Transdermal Patch 72 Hour)
Dvorah (Oral Tablet)
Dyanavel XR (Oral Suspension Extended
Release)
Econazole Nitrate (External Cream)
Edarbi (Oral Tablet)
Edarbyclor (Oral Tablet)
Edurant (Oral Tablet)
Efavirenz (Oral Capsule)
Efavirenz (Oral Tablet)
Eletriptan Hydrobromide (Oral Tablet)
Eliquis (Oral Tablet)
Eliquis Starter Pack (Oral Tablet)
Embeda (100-4MG Oral Capsule Extended
Release)
Embeda (20-0.8MG Oral Capsule Extended
Release, 80-3.2MG Oral Capsule Extended
Release)
Embeda (30-1.2MG Oral Capsule Extended
Release, 50-2MG Oral Capsule Extended
Release)
Embeda (60-2.4MG Oral Capsule Extended
Release)
Emgality (300 MG Dose) (Subcutaneous
Solution Prefilled Syringe)
Emgality (Subcutaneous Solution Auto-
Injector)
Bold type = Brand name drug Plain type = Generic drug
10 Last updated September 1, 2019
Quantity Limit
Maximum of 1 tablet per day
Maximum of 1 inhaler (13 grams) per 30 days
Maximum of 2 capsules per day
Maximum of 3 capsules per day
Maximum of 15 patches per 30 days
Maximum of 15 patches per 30 days
Maximum of 15 patches per 30 days
Maximum of 15 patches per 30 days
Maximum of 15 patches per 30 days
Maximum of 10 tablets per day
Maximum of 8 ml per day
Maximum of 90 grams per 30 days
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 3 capsules per day
Maximum of 1 tablet per day
Maximum of 12 tablets per 30 days
Maximum of 2 tablets per day
Maximum of 1 pack (74 tablets) per 30 days
Maximum of 3 capsules per day
Maximum of 4 capsules per day
Maximum of 2 capsules per day
Maximum of 6 capsules per day
Maximum of 3 ml (3 syringes or pens) per 30
days
Maximum of 2 ml (2 syringes or pens) per 30
days
Last175
updated September 1, 2019 11 11 175

Drug Name Quantity Limit

Emgality (120 MG Dose) (Subcutaneous Maximum of 2 ml (2 syringes or pens) per 30
Solution Prefilled Syringe) days
Emtriva (Oral Capsule) Maximum of 1 capsule per day
Emtriva (Oral Solution) Maximum of 5 bottles (850 ml) per 30 days
Enablex (Oral Tablet Extended Release 24
Maximum of 1 tablet per day
Hour)
Enalapril Maleate (Oral Tablet) Maximum of 2 tablets per day
Enalapril-Hydrochlorothiazide (10-25MG Oral
Maximum of 2 tablets per day
Tablet)
Enalapril-Hydrochlorothiazide (5-12.5MG Oral
Maximum of 1 tablet per day
Tablet)
Endocet (10-325MG Oral Tablet, 5-325MG Oral
Maximum of 12 tablets per day
Tablet, 7.5-325MG Oral Tablet)
Enoxaparin Sodium (100MG/ML Subcutaneous
Maximum of 2 syringes (2 ml) per day
Solution, 150MG/ML Subcutaneous Solution)
Enoxaparin Sodium (120MG/0.8ML
Subcutaneous Solution, 80MG/0.8ML Maximum of 2 syringes (1.6 ml) per day
Subcutaneous Solution)
Enoxaparin Sodium (30MG/0.3ML
Maximum of 2 syringes (0.6 ml) per day
Subcutaneous Solution)
Enoxaparin Sodium (40MG/0.4ML
Maximum of 2 syringes (0.8 ml) per day
Subcutaneous Solution)
Enoxaparin Sodium (60MG/0.6ML
Maximum of 2 syringes (1.2 ml) per day
Subcutaneous Solution)
Entresto (Oral Tablet) Maximum of 2 tablets per day
Epclusa (Oral Tablet) Maximum of 1 tablet per day
Epinephrine (Injection Solution) Maximum of 4 pens (2 boxes) per 30 days
Epinephrine (Injection Solution Auto-Injector) Maximum of 4 pens (2 boxes) per 30 days
EpiPen 2-Pak (Injection Solution Auto-
Maximum of 4 pens (2 boxes) per 30 days
Injector)
EpiPen Jr 2-Pak (Injection Solution Auto-
Maximum of 4 pens (2 boxes) per 30 days
Injector)
Epivir (Oral Solution) Maximum of 32 ml per day
Epivir (150MG Oral Tablet) Maximum of 2 tablets per day
Epivir (300MG Oral Tablet) Maximum of 1 tablet per day
Eprosartan Mesylate (Oral Tablet) Maximum of 1 tablet per day
Epzicom (Oral Tablet) Maximum of 1 tablet per day
Erivedge (Oral Capsule) Maximum of 1 capsule per day
Erleada (Oral Tablet) Maximum of 4 tablets per day

Bold type = Brand name drug Plain type = Generic drug

176176 12 12 Last updated September 1, 2019

Drug Name Quantity Limit

Erlotinib HCl (100MG Oral Tablet, 150MG Oral
Maximum of 1 tablet per day
Tablet)
Erlotinib HCl (25MG Oral Tablet) Maximum of 3 tablets per day
Esbriet (Oral Capsule) Maximum of 9 capsules per day
Esbriet (267MG Oral Tablet) Maximum of 9 tablets per day
Esbriet (801MG Oral Tablet) Maximum of 3 tablets per day
Esomeprazole Magnesium (20MG Oral Capsule
Maximum of 3 capsules per day
Delayed Release) (Generic Nexium)
Esomeprazole Magnesium (40MG Oral Capsule
Maximum of 2 capsules per day
Delayed Release) (Generic Nexium)
Esomeprazole Strontium (Oral Capsule
Maximum of 2 capsules per day
Delayed Release)
Estradiol (Transdermal Patch Twice Weekly) Maximum of 8 patches per 28 days
Eucrisa (External Ointment) Maximum of 60 grams per 30 days
Evotaz (Oral Tablet) Maximum of 1 tablet per day
Exelon (Transdermal Patch 24 Hour) Maximum of 1 patch per day
Exforge (Oral Tablet) Maximum of 1 tablet per day
Extina (External Foam) Maximum of 100 grams per 28 days
Ezallor Sprinkle (Oral Capsule Sprinkle) Maximum of 1 capsule per day
Ezetimibe-Simvastatin (Oral Tablet) Maximum of 1 tablet per day
Fanapt (10MG Oral Tablet, 12MG Oral Tablet,
1MG Oral Tablet, 2MG Oral Tablet, 4MG Oral Maximum of 2 tablets per day
Tablet, 6MG Oral Tablet, 8MG Oral Tablet)
Farxiga (Oral Tablet) Maximum of 1 tablet per day
Fentanyl Citrate (1200MCG Buccal Lozenge On
A Handle, 1600MCG Buccal Lozenge On A
Handle, 200MCG Buccal Lozenge On A Handle,
Maximum of 4 lozenges per day
400MCG Buccal Lozenge On A Handle,
600MCG Buccal Lozenge On A Handle,
800MCG Buccal Lozenge On A Handle)
Fentanyl Citrate (100MCG Buccal Tablet,
200MCG Buccal Tablet, 400MCG Buccal
Maximum of 4 tablets per day
Tablet, 600MCG Buccal Tablet, 800MCG
Buccal Tablet)
Fentanyl (Transdermal Patch 72 Hour) Maximum of 15 patches per 30 days
Fentora (Buccal Tablet) Maximum of 4 tablets per day
Firazyr (Subcutaneous Solution) Maximum of 9 ml per day
Firdapse (Oral Tablet) Maximum of 8 tablets per day
Flector (Transdermal Patch) Maximum of 2 patches per day

Bold type = Brand name drug Plain type = Generic drug

Last177
updated September 1, 2019 13 13 177

Drug Name Quantity Limit

FloLipid (20MG/5ML Oral Suspension) Maximum of 5 ml per day
FloLipid (40MG/5ML Oral Suspension) Maximum of 10 ml per day
Flovent HFA (110MCG/ACT Inhalation
Maximum of 1 inhaler (12 grams) per 30 days
Aerosol)
Flovent HFA (220MCG/ACT Inhalation
Maximum of 2 inhalers (24 grams) per 30 days
Aerosol)
Flovent HFA (44MCG/ACT Inhalation Aerosol) Maximum of 1 inhaler (10.6 grams) per 30 days
Fluticasone-Salmeterol (100-50MCG/DOSE
Inhalation Aerosol Powder Breath Activated,
250-50MCG/DOSE Inhalation Aerosol Powder
Maximum of 1 inhaler (60 blisters) per 30 days
Breath Activated, 500-50MCG/DOSE Inhalation
Aerosol Powder Breath Activated) (Generic
Advair)
Fluticasone-Salmeterol (113-14MCG/ACT
Inhalation Aerosol Powder Breath Activated,
232-14MCG/ACT Inhalation Aerosol Powder
Maximum of 1 inhaler per 30 days
Breath Activated, 55-14MCG/ACT Inhalation
Aerosol Powder Breath Activated) (Brand
Equivalent AirDuo)
Fluvastatin Sodium ER (Oral Tablet Extended
Maximum of 1 tablet per day
Release 24 Hour)
Fluvastatin Sodium (20MG Oral Capsule) Maximum of 1 capsule per day
Fluvastatin Sodium (40MG Oral Capsule) Maximum of 2 capsules per day
Focalin (Oral Tablet) Maximum of 2 tablets per day
Fortamet (1000MG Oral Tablet Extended
Maximum of 2 tablets per day
Release 24 Hour)
Fortamet (500MG Oral Tablet Extended
Maximum of 5 tablets per day
Release 24 Hour)
Fosamprenavir Calcium (Oral Tablet) Maximum of 4 tablets per day
Fosinopril Sodium (Oral Tablet) Maximum of 2 tablets per day
Fosinopril Sodium-HCTZ (Oral Tablet) Maximum of 4 tablets per day
Frova (Oral Tablet) Maximum of 12 tablets per 30 days
Frovatriptan Succinate (Oral Tablet) Maximum of 12 tablets per 30 days
Fuzeon (Subcutaneous Solution
Maximum of 2 vials per day
Reconstituted)
Genvoya (Oral Tablet) Maximum of 1 tablet per day
Geodon (Oral Capsule) Maximum of 2 capsules per day
Gilenya (0.5MG Oral Capsule) Maximum of 1 pack (30 capsules) per 30 days
Gleevec (Oral Tablet) Maximum of 3 tablets per day

Bold type = Brand name drug Plain type = Generic drug

178178 14 14 Last updated September 1, 2019

Drug Name Quantity Limit

Glimepiride (1MG Oral Tablet) Maximum of 8 tablets per day
Glimepiride (2MG Oral Tablet) Maximum of 4 tablets per day
Glimepiride (4MG Oral Tablet) Maximum of 2 tablets per day
Glipizide ER (10MG Oral Tablet Extended
Maximum of 2 tablets per day
Release 24 Hour)
Glipizide ER (2.5MG Oral Tablet Extended
Maximum of 8 tablets per day
Release 24 Hour)
Glipizide ER (5MG Oral Tablet Extended
Maximum of 4 tablets per day
Release 24 Hour)
Glipizide (10MG Oral Tablet Immediate
Maximum of 4 tablets per day
Release)
Glipizide (5MG Oral Tablet Immediate Release) Maximum of 8 tablets per day
Glipizide-Metformin HCl (2.5-250MG Oral
Maximum of 8 tablets per day
Tablet)
Glipizide-Metformin HCl (2.5-500MG Oral
Maximum of 4 tablets per day
Tablet, 5-500MG Oral Tablet)
Glucophage (1000MG Oral Tablet Immediate
Maximum of 2.5 tablets per day
Release)
Glucophage (500MG Oral Tablet Immediate
Maximum of 5 tablets per day
Release)
Glucophage (850MG Oral Tablet Immediate
Maximum of 3 tablets per day
Release)
Glucophage XR (500MG Oral Tablet
Maximum of 4 tablets per day
Extended Release 24 Hour)
Glucophage XR (750MG Oral Tablet
Maximum of 2 tablets per day
Extended Release 24 Hour)
Glucotrol (10MG Oral Tablet Immediate
Maximum of 4 tablets per day
Release)
Glucotrol (5MG Oral Tablet Immediate
Maximum of 8 tablets per day
Release)
Glucotrol XL (10MG Oral Tablet Extended
Maximum of 2 tablets per day
Release 24 Hour)
Glucotrol XL (2.5MG Oral Tablet Extended
Maximum of 8 tablets per day
Release 24 Hour)
Glucotrol XL (5MG Oral Tablet Extended
Maximum of 4 tablets per day
Release 24 Hour)
Glumetza (1000MG Oral Tablet Extended
Maximum of 2 tablets per day
Release 24 Hour)
Glumetza (500MG Oral Tablet Extended
Maximum of 4 tablets per day
Release 24 Hour)

Bold type = Brand name drug Plain type = Generic drug

Last179
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Drug Name Quantity Limit

Glyxambi (Oral Tablet) Maximum of 1 tablet per day
Harvoni (Oral Tablet) Maximum of 1 tablet per day
Hetlioz (Oral Capsule) Maximum of 1 capsule per day
Hydrocodone-Acetaminophen (7.5-325MG/
Maximum of 180 ml per day
15ML Oral Solution)
Hydrocodone-Acetaminophen (10-300MG Oral
Tablet, 5-300MG Oral Tablet, 7.5-300MG Oral Maximum of 13 tablets per day
Tablet)
Hydrocodone-Acetaminophen (10-325MG Oral
Tablet, 5-325MG Oral Tablet, 7.5-325MG Oral Maximum of 12 tablets per day
Tablet)
Hydrocodone-Ibuprofen (Oral Tablet) Maximum of 5 tablets per day
Hydromorphone HCl ER (Oral Tablet ER 24
Maximum of 2 tablets per day
Hour Abuse-Deterrent)
Hydromorphone HCl (1MG/ML Oral Liquid) Maximum of 50 ml per day
Hydromorphone HCl (2MG Oral Tablet
Immediate Release, 4MG Oral Tablet Immediate Maximum of 8 tablets per day
Release)
Hydromorphone HCl (8MG Oral Tablet
Maximum of 6 tablets per day
Immediate Release)
Hysingla ER (Oral Tablet ER 24 Hour Abuse-
Maximum of 1 tablet per day
Deterrent)
Hyzaar (100-12.5MG Oral Tablet, 100-25MG
Maximum of 1 tablet per day
Oral Tablet)
Hyzaar (50-12.5MG Oral Tablet) Maximum of 2 tablets per day
Imatinib Mesylate (Oral Tablet) Maximum of 3 tablets per day
Imbruvica (140MG Oral Capsule) Maximum of 4 capsules per day
Imbruvica (70MG Oral Capsule) Maximum of 1 capsule per day
Imbruvica (Oral Tablet) Maximum of 1 tablet per day
Imitrex (Nasal Solution) Maximum of 12 devices per 30 days
Imitrex (Oral Tablet) Maximum of 12 tablets per 30 days
Imitrex STATdose Refill (6MG/0.5ML
Maximum of 12 injections (6 ml) per 30 days
Subcutaneous Solution Cartridge)
Imitrex STATdose System (4MG/0.5ML
Maximum of 12 injections (6 ml) per 30 days
Subcutaneous Solution Auto-Injector)
Imitrex (Subcutaneous Solution) Maximum of 12 injections (6 ml) per 30 days
Imvexxy Maintenance Pack (Vaginal Insert) Maximum of 1 vaginal insert per day
Imvexxy Starter Pack (Vaginal Insert) Maximum of 1 vaginal insert per day

Bold type = Brand name drug Plain type = Generic drug

180180 16
Drug Name
Incruse Ellipta (Inhalation Aerosol Powder
Breath Activated)
Ingrezza (Oral Capsule)
Ingrezza (Oral Capsule Therapy Pack)
Inlyta (Oral Tablet)
Intelence (100MG Oral Tablet, 200MG Oral
Tablet)
Intelence (25MG Oral Tablet)
Intrarosa (Vaginal Insert)
Invega (3MG Oral Tablet Extended Release
24 Hour, 9MG Oral Tablet Extended Release
24 Hour)
Invega (6MG Oral Tablet Extended Release
24 Hour)
Invirase (Oral Tablet)
Invokamet (Oral Tablet Immediate Release)
Invokamet XR (Oral Tablet Extended Release
24 Hour)
Invokana (Oral Tablet)
Irbesartan (150MG Oral Tablet, 300MG Oral
Tablet)
Irbesartan (75MG Oral Tablet)
Irbesartan-Hydrochlorothiazide (Oral Tablet)
Iressa (Oral Tablet)
Isentress HD (Oral Tablet)
Isentress (Oral Packet)
Isentress (Oral Tablet)
Isentress (Oral Tablet Chewable)
Jakafi (Oral Tablet)
Janumet (Oral Tablet Immediate Release)
Janumet XR (100-1000MG Oral Tablet
Extended Release 24 Hour)
Janumet XR (50-1000MG Oral Tablet
Extended Release 24 Hour, 50-500MG Oral
Tablet Extended Release 24 Hour)
Januvia (Oral Tablet)
Jardiance (Oral Tablet)
Jentadueto (Oral Tablet Immediate Release)
Bold type = Brand name drug Plain type = Generic drug
16 Last updated September 1, 2019
Quantity Limit
Maximum of 1 inhaler (30 blisters) per 30 days
Maximum of 1 capsule per day
Maximum of 28 capsules (1 pack) per 28 days
Maximum of 4 tablets per day
Maximum of 2 tablets per day
Maximum of 4 tablets per day
Maximum of 1 vaginal insert per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 4 tablets per day
Maximum of 2 tablets per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 3 tablets per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 2 tablets per day
Maximum of 2 packets per day
Maximum of 2 tablets per day
Maximum of 6 tablets per day
Maximum of 2 tablets per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Last181
updated September 1, 2019 17 17 181

Drug Name Quantity Limit

Jentadueto XR (2.5-1000MG Oral Tablet
Maximum of 2 tablets per day
Extended Release 24 Hour)
Jentadueto XR (5-1000MG Oral Tablet
Maximum of 1 tablet per day
Extended Release 24 Hour)
Juluca (Oral Tablet) Maximum of 1 tablet per day
Jynarque (Oral Tablet Therapy Pack) Maximum of 2 tablets per day
Kadian (100MG Oral Capsule Extended
Release 24 Hour, 60MG Oral Capsule
Maximum of 3 capsules per day
Extended Release 24 Hour, 80MG Oral
Capsule Extended Release 24 Hour)
Kadian (10MG Oral Capsule Extended
Release 24 Hour, 20MG Oral Capsule
Extended Release 24 Hour, 30MG Oral
Capsule Extended Release 24 Hour, 40MG Maximum of 2 capsules per day
Oral Capsule Extended Release 24 Hour,
50MG Oral Capsule Extended Release 24
Hour)
Kadian (200MG Oral Capsule Extended
Maximum of 1 capsule per day
Release 24 Hour)
Kaletra (Oral Solution) Maximum of 2 bottles (320 ml) per 30 days
Kaletra (100-25MG Oral Tablet) Maximum of 2 tablets per day
Kaletra (200-50MG Oral Tablet) Maximum of 4 tablets per day
Kazano (Oral Tablet) Maximum of 2 tablets per day
Ketoconazole (External Cream) Maximum of 90 grams per 30 days
Ketoconazole (External Foam) Maximum of 100 grams per 28 days
Keveyis (Oral Tablet) Maximum of 4 tablets per day
Klonopin (0.5MG Oral Tablet, 1MG Oral
Maximum of 4 tablets per day
Tablet)
Klonopin (2MG Oral Tablet) Maximum of 10 tablets per day
Kombiglyze XR (2.5-1000MG Oral Tablet
Maximum of 2 tablets per day
Extended Release 24 Hour)
Kombiglyze XR (5-1000MG Oral Tablet
Extended Release 24 Hour, 5-500MG Oral Maximum of 1 tablet per day
Tablet Extended Release 24 Hour)
Lamivudine (10MG/ML Oral Solution) Maximum of 32 ml per day
Lamivudine (150MG Oral Tablet) Maximum of 2 tablets per day
Lamivudine (300MG Oral Tablet) Maximum of 1 tablet per day
Lamivudine-Zidovudine (Oral Tablet) Maximum of 2 tablets per day
Lanoxin (125MCG Oral Tablet) Maximum of 1 tablet per day

Bold type = Brand name drug Plain type = Generic drug

182182 18
Drug Name
Lanoxin (62.5MCG Oral Tablet)
Lansoprazole (Oral Capsule Delayed Release)
Latuda (120MG Oral Tablet, 20MG Oral
Tablet, 40MG Oral Tablet, 60MG Oral Tablet)
Latuda (80MG Oral Tablet)
Lazanda (Nasal Solution)
Ledipasvir-Sofosbuvir (Oral Tablet)
Lescol XL (Oral Tablet Extended Release 24
Hour)
Letairis (Oral Tablet)
Levorphanol Tartrate (Oral Tablet)
Lexiva (Oral Suspension)
Lexiva (Oral Tablet)
Lialda (Oral Tablet Delayed Release)
Lidocaine (5% External Ointment)
Lidocaine (5% External Patch)
Lidoderm (External Patch)
Linzess (Oral Capsule)
Lipitor (Oral Tablet)
Lisinopril (Oral Tablet)
Lisinopril-Hydrochlorothiazide (10-12.5MG Oral
Tablet)
Lisinopril-Hydrochlorothiazide (20-12.5MG Oral
Tablet)
Lisinopril-Hydrochlorothiazide (20-25MG Oral
Tablet)
Livalo (Oral Tablet)
Lokelma (Oral Packet)
Lonhala Magnair Refill Kit (Inhalation
Solution)
Lopinavir-Ritonavir (Oral Solution)
Lorazepam (2MG/ML Oral Concentrate)
Lorazepam (0.5MG Oral Tablet, 1MG Oral
Tablet)
Lorazepam (2MG Oral Tablet)
Lorbrena (100MG Oral Tablet)
Lorbrena (25MG Oral Tablet)
Lorcet HD (Oral Tablet)
Bold type = Brand name drug Plain type = Generic drug
18 Last updated September 1, 2019
Quantity Limit
Maximum of 2 tablets per day
Maximum of 2 capsules per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 15 bottles (79.5 ml) per 30 days
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 6 tablets per day
Maximum of 60 ml per day
Maximum of 4 tablets per day
Maximum of 4 tablets per day
Maximum of 152 grams per 30 days
Maximum of 3 patches per day
Maximum of 3 patches per day
Maximum of 1 capsule per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 4 tablets per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 90 packets per 30 days
Maximum of 2 vials (2 ml) per day
Maximum of 2 bottles (320 ml) per 30 days
Maximum of 5 ml per day
Maximum of 4 tablets per day
Maximum of 5 tablets per day
Maximum of 1 tablet per day
Maximum of 3 tablets per day
Maximum of 12 tablets per day
Last183
updated September 1, 2019 19 19 183

Drug Name Quantity Limit

Lorcet (Oral Tablet) Maximum of 12 tablets per day
Lorcet Plus (Oral Tablet) Maximum of 12 tablets per day
Losartan Potassium (100MG Oral Tablet) Maximum of 1 tablet per day
Losartan Potassium (25MG Oral Tablet, 50MG
Maximum of 2 tablets per day
Oral Tablet)
Losartan Potassium-HCTZ (100-12.5MG Oral
Maximum of 1 tablet per day
Tablet, 100-25MG Oral Tablet)
Losartan Potassium-HCTZ (50-12.5MG Oral
Maximum of 2 tablets per day
Tablet)
Lotensin (Oral Tablet) Maximum of 2 tablets per day
Lotrel (Oral Capsule) Maximum of 1 capsule per day
Lovastatin (10MG Oral Tablet, 20MG Oral
Maximum of 1 tablet per day
Tablet)
Lovastatin (40MG Oral Tablet) Maximum of 2 tablets per day
Lovenox (100MG/ML Subcutaneous Solution,
Maximum of 2 syringes (2 ml) per day
150MG/ML Subcutaneous Solution)
Lovenox (120MG/0.8ML Subcutaneous
Solution, 80MG/0.8ML Subcutaneous Maximum of 2 syringes (1.6 ml) per day
Solution)
Lovenox (30MG/0.3ML Subcutaneous
Maximum of 2 syringes (0.6 ml) per day
Solution)
Lovenox (40MG/0.4ML Subcutaneous
Maximum of 2 syringes (0.8 ml) per day
Solution)
Lovenox (60MG/0.6ML Subcutaneous
Maximum of 2 syringes (1.2 ml) per day
Solution)
Lucemyra (Oral Tablet) Maximum of 16 tablets per day
Luliconazole (External Cream) Maximum of 60 grams per 28 days
Luzu (External Cream) Maximum of 60 grams per 28 days
Lyrica CR (165MG Oral Tablet Extended
Release 24 Hour, 82.5MG Oral Tablet Maximum of 3 tablets per day
Extended Release 24 Hour)
Lyrica CR (330MG Oral Tablet Extended
Maximum of 2 tablets per day
Release 24 Hour)
Lyrica (100MG Oral Capsule, 150MG Oral
Capsule, 200MG Oral Capsule, 25MG Oral
Maximum of 3 capsules per day
Capsule, 50MG Oral Capsule, 75MG Oral
Capsule)
Lyrica (225MG Oral Capsule, 300MG Oral
Maximum of 2 capsules per day
Capsule)
Lyrica (Oral Solution) Maximum of 30 ml per day

Bold type = Brand name drug Plain type = Generic drug

184184 20 20 Last updated September 1, 2019

Drug Name Quantity Limit

Mavyret (Oral Tablet) Maximum of 3 tablets per day
Maxalt (Oral Tablet) Maximum of 12 tablets per 30 days
Maxalt-MLT (Oral Tablet Dispersible) Maximum of 12 tablets per 30 days
Mayzent (0.25MG Oral Tablet) Maximum of 8 tablets per day
Mayzent (2MG Oral Tablet) Maximum of 1 tablet per day
Memantine HCl ER (Oral Capsule Extended
Maximum of 1 capsule per day
Release 24 Hour)
Memantine HCl (Oral Solution) Maximum of 10 ml per day
Memantine HCl (10MG Oral Tablet) Maximum of 2 tablets per day
Memantine HCl (5MG Oral Tablet) Maximum of 3 tablets per day
Mesalamine (1.2GM Oral Tablet Delayed
Maximum of 4 tablets per day
Release) (Generic Lialda)
Mesalamine (800MG Oral Tablet Delayed
Maximum of 6 tablets per day
Release)
Metadate ER (Oral Tablet Extended Release) Maximum of 3 tablets per day
Metformin HCl ER (1000MG Oral Tablet
Maximum of 2 tablets per day
Extended Release 24 Hour) (Generic Glumetza)
Metformin HCl ER (500MG Oral Tablet
Maximum of 4 tablets per day
Extended Release 24 Hour) (Generic Glumetza)
Metformin HCl ER (1000MG Oral Tablet
Maximum of 2 tablets per day
Extended Release 24 Hour) (Generic Fortamet)
Metformin HCl ER (500MG Oral Tablet
Maximum of 5 tablets per day
Extended Release 24 Hour) (Generic Fortamet)
Metformin HCl ER (500MG Oral Tablet
Extended Release 24 Hour) (Generic Maximum of 4 tablets per day
Glucophage XR)
Metformin HCl ER (750MG Oral Tablet
Extended Release 24 Hour) (Generic Maximum of 2 tablets per day
Glucophage XR)
Metformin HCl (1000MG Oral Tablet Immediate
Maximum of 2.5 tablets per day
Release)
Metformin HCl (500MG Oral Tablet Immediate
Maximum of 5 tablets per day
Release)
Metformin HCl (850MG Oral Tablet Immediate
Maximum of 3 tablets per day
Release)
Methadone HCl (10MG/5ML Oral Solution) Maximum of 60 ml per day
Methadone HCl (5MG/5ML Oral Solution) Maximum of 120 ml per day
Methadone HCl (10MG Oral Tablet) Maximum of 12 tablets per day
Methadone HCl (5MG Oral Tablet) Maximum of 8 tablets per day

Bold type = Brand name drug Plain type = Generic drug

Last185
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Drug Name Quantity Limit

Methylin (10MG/5ML Oral Solution) Maximum of 30 ml per day
Methylin (5MG/5ML Oral Solution) Maximum of 60 ml per day
Methylphenidate HCl ER Osmotic Release
Maximum of 4 tablets per day
(10MG Oral Tablet Extended Release)
Methylphenidate HCl ER Osmotic Release
(18MG Oral Tablet Extended Release, 20MG Maximum of 3 tablets per day
Oral Tablet Extended Release)
Methylphenidate HCl ER (18MG Oral Tablet
Maximum of 3 tablets per day
Extended Release 24 Hour)
Methylphenidate HCl ER (27MG Oral Tablet
Extended Release 24 Hour, 36MG Oral Tablet Maximum of 2 tablets per day
Extended Release 24 Hour)
Methylphenidate HCl ER (54MG Oral Tablet
Maximum of 1 tablet per day
Extended Release 24 Hour)
Methylphenidate HCl ER Osmotic Release
(27MG Oral Tablet Extended Release, 36MG Maximum of 2 tablets per day
Oral Tablet Extended Release)
Methylphenidate HCl ER Osmotic Release
(54MG Oral Tablet Extended Release, 72MG Maximum of 1 tablet per day
Oral Tablet Extended Release)
Methylphenidate HCl (10MG/5ML Oral
Maximum of 30 ml per day
Solution)
Methylphenidate HCl (5MG/5ML Oral Solution) Maximum of 60 ml per day
Methylphenidate HCl (Oral Tablet Immediate
Maximum of 3 tablets per day
Release) (Generic Ritalin)
Methylphenidate HCl (10MG Oral Tablet
Maximum of 6 tablets per day
Chewable)
Methylphenidate HCl (2.5MG Oral Tablet
Maximum of 3 tablets per day
Chewable, 5MG Oral Tablet Chewable)
Micardis HCT (40-12.5MG Oral Tablet,
Maximum of 1 tablet per day
80-25MG Oral Tablet)
Micardis HCT (80-12.5MG Oral Tablet) Maximum of 2 tablets per day
Micardis (Oral Tablet) Maximum of 1 tablet per day
Minivelle (Transdermal Patch Twice Weekly) Maximum of 8 patches per 28 days
Minocycline HCl ER (Oral Tablet Extended
Maximum of 1 tablet per day
Release 24 Hour)
Mitigare (Oral Capsule) Maximum of 4 capsules per day
Modafinil (100MG Oral Tablet) Maximum of 1 tablet per day
Modafinil (200MG Oral Tablet) Maximum of 2 tablets per day
Moexipril HCl (Oral Tablet) Maximum of 2 tablets per day

Bold type = Brand name drug Plain type = Generic drug

186186 22 22 Last updated September 1, 2019

Drug Name Quantity Limit

Montelukast Sodium (Oral Packet) Maximum of 1 packet per day
Montelukast Sodium (Oral Tablet) Maximum of 1 tablet per day
Montelukast Sodium (Oral Tablet Chewable) Maximum of 1 tablet per day
MorphaBond ER (100MG Oral Tablet ER 12
Hour Abuse-Deterrent, 60MG Oral Tablet ER Maximum of 3 tablets per day
12 Hour Abuse-Deterrent)
MorphaBond ER (15MG Oral Tablet ER 12
Hour Abuse-Deterrent, 30MG Oral Tablet ER Maximum of 2 tablets per day
12 Hour Abuse-Deterrent)
Morphine Sulfate (100MG/5ML Oral Solution) Maximum of 10 ml per day
Morphine Sulfate ER Beads (120MG Oral
Capsule Extended Release 24 Hour) (Generic Maximum of 3 capsules per day
Avinza)
Morphine Sulfate ER Beads (30MG Oral
Capsule Extended Release 24 Hour, 45MG Oral
Capsule Extended Release 24 Hour, 60MG Oral Maximum of 2 capsules per day
Capsule Extended Release 24 Hour) (Generic
Avinza)
Morphine Sulfate ER Beads (75MG Oral
Capsule Extended Release 24 Hour, 90MG Oral
Maximum of 4 capsules per day
Capsule Extended Release 24 Hour) (Generic
Avinza)
Morphine Sulfate ER (100MG Oral Capsule
Extended Release 24 Hour, 60MG Oral Capsule
Maximum of 3 capsules per day
Extended Release 24 Hour, 80MG Oral Capsule
Extended Release 24 Hour) (Generic Kadian)
Morphine Sulfate ER (10MG Oral Capsule
Extended Release 24 Hour, 20MG Oral Capsule
Extended Release 24 Hour, 30MG Oral Capsule
Maximum of 2 capsules per day
Extended Release 24 Hour, 40MG Oral Capsule
Extended Release 24 Hour, 50MG Oral Capsule
Extended Release 24 Hour) (Generic Kadian)
Morphine Sulfate ER (100MG Oral Tablet
Extended Release, 15MG Oral Tablet Extended Maximum of 3 tablets per day
Release) (Generic MS Contin)
Morphine Sulfate ER (200MG Oral Tablet
Maximum of 2 tablets per day
Extended Release) (Generic MS Contin)
Morphine Sulfate ER (30MG Oral Tablet
Extended Release, 60MG Oral Tablet Extended Maximum of 4 tablets per day
Release) (Generic MS Contin)
Morphine Sulfate (10MG/5ML Oral Solution) Maximum of 100 ml per day

Bold type = Brand name drug Plain type = Generic drug

Last187
updated September 1, 2019 23 23 187

Drug Name Quantity Limit

Morphine Sulfate (20MG/5ML Oral Solution) Maximum of 50 ml per day
Morphine Sulfate (15MG Oral Tablet
Maximum of 8 tablets per day
Immediate Release)
Morphine Sulfate (30MG Oral Tablet
Maximum of 6 tablets per day
Immediate Release)
Motegrity (Oral Tablet) Maximum of 1 tablet per day
Movantik (Oral Tablet) Maximum of 1 tablet per day
MS Contin (100MG Oral Tablet Extended
Release, 15MG Oral Tablet Extended Maximum of 3 tablets per day
Release)
MS Contin (200MG Oral Tablet Extended
Maximum of 2 tablets per day
Release)
MS Contin (30MG Oral Tablet Extended
Release, 60MG Oral Tablet Extended Maximum of 4 tablets per day
Release)
Mydayis (12.5MG Oral Capsule Extended
Release 24 Hour, 25MG Oral Capsule Maximum of 2 capsules per day
Extended Release 24 Hour)
Mydayis (37.5MG Oral Capsule Extended
Release 24 Hour, 50MG Oral Capsule Maximum of 1 capsule per day
Extended Release 24 Hour)
Namenda (10MG Oral Tablet) Maximum of 2 tablets per day
Namenda (5MG Oral Tablet) Maximum of 3 tablets per day
Namenda XR (Oral Capsule Extended
Maximum of 1 capsule per day
Release 24 Hour)
Namenda XR Titration Pack (Oral Capsule
Maximum of 1 capsule per day
Extended Release 24 Hour)
Namzaric (Oral Capsule ER 24 Hour Therapy
Maximum of 1 capsule per day
Pack)
Namzaric (Oral Capsule Extended Release 24
Maximum of 1 capsule per day
Hour)
Naratriptan HCl (Oral Tablet) Maximum of 12 tablets per 30 days
Nateglinide (120MG Oral Tablet) Maximum of 3 tablets per day
Nateglinide (60MG Oral Tablet) Maximum of 6 tablets per day
Nebupent (Inhalation Solution Reconstituted) Maximum of 300 mg (1 vial) per 28 days
Nerlynx (Oral Tablet) Maximum of 6 tablets per day
Nesina (Oral Tablet) Maximum of 1 tablet per day
Nevirapine ER (100MG Oral Tablet Extended
Maximum of 2 tablets per day
Release 24 Hour)

Bold type = Brand name drug Plain type = Generic drug

188188 24 24
Drug Name
Nevirapine ER (400MG Oral Tablet Extended
Release 24 Hour)
Nevirapine (Oral Suspension)
Nevirapine (Oral Tablet Immediate Release)
Nexium (20MG Oral Capsule Delayed
Release)
Nexium (40MG Oral Capsule Delayed
Release)
Ninlaro (Oral Capsule)
Norco (Oral Tablet)
Northera (100MG Oral Capsule)
Northera (200MG Oral Capsule, 300MG Oral
Capsule)
Norvir (Oral Packet)
Norvir (Oral Solution)
Norvir (Oral Tablet)
Noxafil (Oral Suspension)
Noxafil (Oral Tablet Delayed Release)
Nucala (Subcutaneous Solution Auto-Injector)
Nucala (Subcutaneous Solution Prefilled
Syringe)
Nucala (Subcutaneous Solution
Reconstituted)
Nucynta ER (Oral Tablet Extended Release
12 Hour)
Nucynta (Oral Tablet Immediate Release)
Nuplazid (Oral Capsule)
Nuplazid (10MG Oral Tablet)
Nuvigil (150MG Oral Tablet, 200MG Oral
Tablet, 250MG Oral Tablet)
Nuvigil (50MG Oral Tablet)
Nuzyra (Oral Tablet)
Ocaliva (Oral Tablet)
Odefsey (Oral Tablet)
Odomzo (Oral Capsule)
Ofev (Oral Capsule)
Olanzapine (10MG Oral Tablet, 15MG Oral
Tablet, 2.5MG Oral Tablet, 20MG Oral Tablet,
5MG Oral Tablet, 7.5MG Oral Tablet)
Bold type = Brand name drug Plain type = Generic drug
Last updated September 1, 2019
Quantity Limit
Maximum of 1 tablet per day
Maximum of 40 ml per day
Maximum of 2 tablets per day
Maximum of 3 capsules per day
Maximum of 2 capsules per day
Maximum of 3 capsules per 28 days
Maximum of 12 tablets per day
Maximum of 3 capsules per day
Maximum of 6 capsules per day
Maximum of 12 packets per day
Maximum of 16 ml per day
Maximum of 12 tablets per day
Maximum of 20 ml per day
Maximum of 6 tablets per day
Maximum of 3 ml per 28 days
Maximum of 3 ml per 28 days
Maximum of 3 vials per 28 days
Maximum of 2 tablets per day
Maximum of 6 tablets per day
Maximum of 1 capsule per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 1 capsule per day
Maximum of 2 capsules per day
Maximum of 1 tablet per day
Last189
updated September 1, 2019 25
Drug Name
Olanzapine ODT (10MG Oral Tablet Dispersible,
15MG Oral Tablet Dispersible, 20MG Oral
Tablet Dispersible, 5MG Oral Tablet
Dispersible)
Olmesartan Medoxomil (20MG Oral Tablet,
40MG Oral Tablet)
Olmesartan Medoxomil (5MG Oral Tablet)
Olmesartan Medoxomil-HCTZ (Oral Tablet)
Olmesartan-Amlodipine-HCTZ (Oral Tablet)
Olumiant (Oral Tablet)
Omeprazole (10MG Oral Capsule Delayed
Release)
Onfi (Oral Suspension)
Onfi (Oral Tablet)
Onglyza (Oral Tablet)
Onzetra Xsail (Nasal Exhaler Powder)
Opana (Oral Tablet Immediate Release)
Orilissa (150MG Oral Tablet)
Orilissa (200MG Oral Tablet)
Orkambi (Oral Packet)
Orkambi (Oral Tablet)
Oseni (Oral Tablet)
Osphena (Oral Tablet)
Oxervate (Ophthalmic Solution)
Oxiconazole Nitrate (External Cream)
Oxistat (External Cream)
Oxistat (External Lotion)
Oxycodone HCl ER (Oral Tablet ER 12 Hour
Abuse-Deterrent)
Oxycodone HCl (5MG Oral Capsule)
Oxycodone HCl (100MG/5ML Oral
Concentrate)
Oxycodone HCl (5MG/5ML Oral Solution)
Oxycodone HCl (10MG Oral Tablet Immediate
Release, 5MG Oral Tablet Immediate Release)
Oxycodone HCl (15MG Oral Tablet Immediate
Release)
Bold type = Brand name drug Plain type = Generic drug
25 189
Quantity Limit
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 3 capsules per day
Maximum of 16 ml per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 1 kit (16 exhalers) per 30 days
Maximum of 6 tablets per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 56 packets per 28 days
Maximum of 112 tablets per 28 days
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 2 ml (2 vials) per day
Maximum of 90 grams per 30 days
Maximum of 90 grams per 30 days
Maximum of 60 ml per 30 days
Maximum of 3 tablets per day
Maximum of 12 capsules per day
Maximum of 6 ml per day
Maximum of 130 ml per day
Maximum of 12 tablets per day
Maximum of 8 tablets per day
190190 26 26 Last updated September 1, 2019

Drug Name Quantity Limit

Oxycodone HCl (20MG Oral Tablet Immediate
Maximum of 6 tablets per day
Release, 30MG Oral Tablet Immediate Release)
Oxycodone-Acetaminophen (Oral Tablet) Maximum of 12 tablets per day
Oxycodone-Aspirin (Oral Tablet) Maximum of 12 tablets per day
Oxycodone-Ibuprofen (Oral Tablet) Maximum of 4 tablets per day
OxyContin (Oral Tablet ER 12 Hour Abuse-
Maximum of 3 tablets per day
Deterrent)
Oxymorphone HCl ER (10MG Oral Tablet
Extended Release 12 Hour, 15MG Oral Tablet
Extended Release 12 Hour, 20MG Oral Tablet
Maximum of 2 tablets per day
Extended Release 12 Hour, 5MG Oral Tablet
Extended Release 12 Hour, 7.5MG Oral Tablet
Extended Release 12 Hour)
Oxymorphone HCl ER (30MG Oral Tablet
Maximum of 4 tablets per day
Extended Release 12 Hour)
Oxymorphone HCl ER (40MG Oral Tablet
Maximum of 3 tablets per day
Extended Release 12 Hour)
Oxymorphone HCl (Oral Tablet Immediate
Maximum of 6 tablets per day
Release)
Ozempic (0.25 or 0.5MG/DOSE
Maximum of 1 pen (1.5 ml) per 28 days
Subcutaneous Solution Pen-Injector)
Ozempic (1MG/DOSE Subcutaneous Solution
Maximum of 2 pens (3 ml) per 28 days
Pen-Injector)
Paliperidone ER (1.5MG Oral Tablet Extended
Release 24 Hour, 3MG Oral Tablet Extended
Maximum of 1 tablet per day
Release 24 Hour, 9MG Oral Tablet Extended
Release 24 Hour)
Paliperidone ER (6MG Oral Tablet Extended
Maximum of 2 tablets per day
Release 24 Hour)
Palynziq (10MG/0.5ML Subcutaneous
Maximum of 28 syringes per 28 days
Solution Prefilled Syringe)
Palynziq (2.5MG/0.5ML Subcutaneous
Maximum of 8 syringes per 28 days
Solution Prefilled Syringe)
Palynziq (20MG/ML Subcutaneous Solution
Maximum of 56 syringes per 28 days
Prefilled Syringe)
Pantoprazole Sodium (20MG Oral Tablet
Maximum of 3 tablets per day
Delayed Release)
Pantoprazole Sodium (40MG Oral Tablet
Maximum of 2 tablets per day
Delayed Release)
Pentasa (250MG Oral Capsule Extended
Maximum of 12 capsules per day
Release)

Bold type = Brand name drug Plain type = Generic drug

Last191
updated September 1, 2019 27
Drug Name
Pentasa (500MG Oral Capsule Extended
Release)
Percocet (Oral Tablet)
Perforomist (Inhalation Nebulization Solution)
Perindopril Erbumine (Oral Tablet)
Pifeltro (Oral Tablet)
Pioglitazone HCl (15MG Oral Tablet)
Pioglitazone HCl (30MG Oral Tablet, 45MG Oral
Tablet)
Pioglitazone HCl-Glimepiride (Oral Tablet)
Pioglitazone HCl-Metformin HCl (Oral Tablet)
Piqray (200 MG Daily Dose) (Oral Tablet
Therapy Pack)
Piqray (250 MG Daily Dose) (Oral Tablet
Therapy Pack)
Piqray (300 MG Daily Dose) (Oral Tablet
Therapy Pack)
Plavix (Oral Tablet)
Pradaxa (Oral Capsule)
Praluent (Subcutaneous Solution Pen-
Injector)
Prandin (1MG Oral Tablet)
Prandin (2MG Oral Tablet)
Pravachol (Oral Tablet)
Pravastatin Sodium (Oral Tablet)
Prevacid (Oral Capsule Delayed Release)
Prevymis (Oral Tablet)
Prezcobix (Oral Tablet)
Prezista (Oral Suspension)
Prezista (150MG Oral Tablet)
Prezista (600MG Oral Tablet, 75MG Oral
Tablet)
Prezista (800MG Oral Tablet)
Primlev (Oral Tablet)
Prinivil (Oral Tablet)
Prolia (Subcutaneous Solution Prefilled
Syringe)
Promacta (Oral Packet)
Bold type = Brand name drug Plain type = Generic drug
27 191
Quantity Limit
Maximum of 8 capsules per day
Maximum of 12 tablets per day
Maximum of 2 vials (4 ml) per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 3 tablets per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 3 tablets per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 2 tablets per day
Maximum of 4 tablets per day
Maximum of 2 capsules per day
Maximum of 2 pens (2 ml) per 28 days
Maximum of 16 tablets per day
Maximum of 8 tablets per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 2 capsules per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 2 bottles (400 ml) per 30 days
Maximum of 6 tablets per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 13 tablets per day
Maximum of 2 tablets per day
Maximum of 1 syringe per 180 days
Maximum of 6 packets per day
192192 28 28 Last updated September 1, 2019

Drug Name Quantity Limit

Promacta (12.5MG Oral Tablet, 25MG Oral
Maximum of 1 tablet per day
Tablet)
Promacta (50MG Oral Tablet, 75MG Oral
Maximum of 2 tablets per day
Tablet)
Protonix (20MG Oral Tablet Delayed Release) Maximum of 3 tablets per day
Protonix (40MG Oral Tablet Delayed Release) Maximum of 2 tablets per day
Provigil (100MG Oral Tablet) Maximum of 1 tablet per day
Provigil (200MG Oral Tablet) Maximum of 2 tablets per day
PRUDOXIN (External Cream) Maximum of 90 grams per 30 days
Pulmozyme (Inhalation Solution) Maximum of 5 ml (2 ampules) per day
Qbrelis (Oral Solution) Maximum of 80 ml per day
Qtern (Oral Tablet) Maximum of 1 tablet per day
Quetiapine Fumarate ER (150MG Oral Tablet
Extended Release 24 Hour, 200MG Oral Tablet Maximum of 1 tablet per day
Extended Release 24 Hour)
Quetiapine Fumarate ER (300MG Oral Tablet
Extended Release 24 Hour, 400MG Oral Tablet
Maximum of 2 tablets per day
Extended Release 24 Hour, 50MG Oral Tablet
Extended Release 24 Hour)
Quetiapine Fumarate (100MG Oral Tablet
Immediate Release, 200MG Oral Tablet
Maximum of 3 tablets per day
Immediate Release, 50MG Oral Tablet
Immediate Release)
Quetiapine Fumarate (25MG Oral Tablet
Maximum of 4 tablets per day
Immediate Release)
Quetiapine Fumarate (300MG Oral Tablet
Immediate Release, 400MG Oral Tablet Maximum of 2 tablets per day
Immediate Release)
QuilliChew ER (20MG Oral Tablet Chewable
Extended Release, 40MG Oral Tablet Maximum of 1 tablet per day
Chewable Extended Release)
QuilliChew ER (30MG Oral Tablet Chewable
Maximum of 2 tablets per day
Extended Release)
Quinapril HCl (Oral Tablet) Maximum of 2 tablets per day
Quinapril-Hydrochlorothiazide (10-12.5MG Oral
Maximum of 1 tablet per day
Tablet)
Quinapril-Hydrochlorothiazide (20-12.5MG Oral
Maximum of 2 tablets per day
Tablet, 20-25MG Oral Tablet)
QVAR RediHaler (Inhalation Aerosol Breath Maximum of 2 inhalers (21.2 grams) per 30
Activated) days

Bold type = Brand name drug Plain type = Generic drug

Last193
updated September 1, 2019 29
Drug Name
Ramipril (Oral Capsule)
Rapaflo (Oral Capsule)
Rayaldee (Oral Capsule Extended Release)
Relexxii (Oral Tablet Extended Release)
Relpax (Oral Tablet)
Repaglinide (0.5MG Oral Tablet)
Repaglinide (1MG Oral Tablet)
Repaglinide (2MG Oral Tablet)
Repaglinide-Metformin HCl (Oral Tablet)
Repatha Pushtronex System (Subcutaneous
Solution Cartridge)
Repatha (Subcutaneous Solution Prefilled
Syringe)
Repatha SureClick (Subcutaneous Solution
Auto-Injector)
Rescriptor (Oral Tablet)
Restasis (Ophthalmic Emulsion)
Restoril (22.5MG Oral Capsule)
Retrovir (Oral Capsule)
Retrovir (Oral Syrup)
Rexulti (Oral Tablet)
Reyataz (150MG Oral Capsule, 300MG Oral
Capsule)
Reyataz (200MG Oral Capsule)
Reyataz (Oral Packet)
Riomet (Oral Solution)
Ritalin (Oral Tablet)
Ritonavir (Oral Tablet)
Rivastigmine (Transdermal Patch 24 Hour)
Rizatriptan Benzoate (Oral Tablet)
Rizatriptan Benzoate ODT (Oral Tablet
Dispersible)
Rosuvastatin Calcium (Oral Tablet)
Roxicodone (15MG Oral Tablet)
Roxicodone (30MG Oral Tablet)
Roxicodone (5MG Oral Tablet)
Rydapt (Oral Capsule)
Sabril (Oral Packet)
Bold type = Brand name drug Plain type = Generic drug
29 193
Quantity Limit
Maximum of 2 capsules per day
Maximum of 1 capsule per day
Maximum of 2 capsules per day
Maximum of 1 tablet per day
Maximum of 12 tablets per 30 days
Maximum of 32 tablets per day
Maximum of 16 tablets per day
Maximum of 8 tablets per day
Maximum of 5 tablets per day
Maximum of 1 cartridge (3.5 ml) per 28 days
Maximum of 3 syringes (3 ml) per 28 days
Maximum of 3 pens (3 ml) per 28 days
Maximum of 6 tablets per day
Maximum of 2 vials per day
Maximum of 1 capsule per day
Maximum of 6 capsules per day
Maximum of 64 ml per day
Maximum of 1 tablet per day
Maximum of 1 capsule per day
Maximum of 2 capsules per day
Maximum of 6 packets per day
Maximum of 25.5 ml per day
Maximum of 3 tablets per day
Maximum of 12 tablets per day
Maximum of 1 patch per day
Maximum of 12 tablets per 30 days
Maximum of 12 tablets per 30 days
Maximum of 1 tablet per day
Maximum of 8 tablets per day
Maximum of 6 tablets per day
Maximum of 12 tablets per day
Maximum of 8 capsules per day
Maximum of 6 packets per day
194194 30 30 Last updated September 1, 2019

Drug Name Quantity Limit

Sabril (Oral Tablet) Maximum of 6 tablets per day
Savaysa (Oral Tablet) Maximum of 1 tablet per day
Segluromet (2.5-1000MG Oral Tablet,
7.5-1000MG Oral Tablet, 7.5-500MG Oral Maximum of 2 tablets per day
Tablet)
Segluromet (2.5-500MG Oral Tablet) Maximum of 4 tablets per day
Selzentry (Oral Solution) Maximum of 8 bottles (1840 ml) per 30 days
Selzentry (150MG Oral Tablet, 75MG Oral
Maximum of 2 tablets per day
Tablet)
Selzentry (25MG Oral Tablet, 300MG Oral
Maximum of 4 tablets per day
Tablet)
Sensipar (30MG Oral Tablet, 60MG Oral
Maximum of 2 tablets per day
Tablet)
Sensipar (90MG Oral Tablet) Maximum of 4 tablets per day
Serevent Diskus (Inhalation Aerosol Powder Maximum of 1 inhaler (60 inhalations) per 30
Breath Activated) days
Seroquel (100MG Oral Tablet Immediate
Release, 200MG Oral Tablet Immediate
Maximum of 3 tablets per day
Release, 50MG Oral Tablet Immediate
Release)
Seroquel (25MG Oral Tablet Immediate
Maximum of 4 tablets per day
Release)
Seroquel (300MG Oral Tablet Immediate
Release, 400MG Oral Tablet Immediate Maximum of 2 tablets per day
Release)
Seroquel XR (150MG Oral Tablet Extended
Release 24 Hour, 200MG Oral Tablet Maximum of 1 tablet per day
Extended Release 24 Hour)
Seroquel XR (300MG Oral Tablet Extended
Release 24 Hour, 400MG Oral Tablet
Maximum of 2 tablets per day
Extended Release 24 Hour, 50MG Oral Tablet
Extended Release 24 Hour)
Silodosin (Oral Capsule) Maximum of 1 capsule per day
Simvastatin (Oral Tablet) Maximum of 1 tablet per day
Singulair (Oral Packet) Maximum of 1 packet per day
Singulair (Oral Tablet) Maximum of 1 tablet per day
Singulair (Oral Tablet Chewable) Maximum of 1 tablet per day
Sofosbuvir-Velpatasvir (Oral Tablet) Maximum of 1 tablet per day
Solifenacin Succinate (Oral Tablet) Maximum of 1 tablet per day
Soliqua (Subcutaneous Solution Pen-Injector) Maximum of 18 ml (6 pens) per 30 days

Bold type = Brand name drug Plain type = Generic drug

Last195
updated September 1, 2019 31 31 195

Drug Name Quantity Limit

Solodyn (Oral Tablet Extended Release 24
Maximum of 1 tablet per day
Hour)
Somavert (Subcutaneous Solution
Maximum of 1 vial per day
Reconstituted)
Sovaldi (Oral Tablet) Maximum of 1 tablet per day
Spiriva HandiHaler (Inhalation Capsule) Maximum of 1 capsule per day
Spiriva Respimat (Inhalation Aerosol
Maximum of 1 inhaler (4 grams) per 30 days
Solution)
Starlix (120MG Oral Tablet) Maximum of 3 tablets per day
Starlix (60MG Oral Tablet) Maximum of 6 tablets per day
Stavudine (Oral Capsule) Maximum of 2 capsules per day
Steglatro (15MG Oral Tablet) Maximum of 1 tablet per day
Steglatro (5MG Oral Tablet) Maximum of 2 tablets per day
Steglujan (Oral Tablet) Maximum of 1 tablet per day
Stivarga (Oral Tablet) Maximum of 4 tablets per day
Stribild (Oral Tablet) Maximum of 1 tablet per day
Suboxone (12-3MG Sublingual Film, 4-1MG
Maximum of 2 films per day
Sublingual Film)
Suboxone (2-0.5MG Sublingual Film, 8-2MG
Maximum of 3 films per day
Sublingual Film)
Subsys (100MCG Sublingual Liquid, 200MCG
Sublingual Liquid, 400MCG Sublingual
Maximum of 4 sprays per day
Liquid, 600MCG Sublingual Liquid, 800MCG
Sublingual Liquid)
Sumatriptan (Nasal Solution) Maximum of 12 devices per 30 days
Sumatriptan Succinate (100MG Oral Tablet,
Maximum of 12 tablets per 30 days
25MG Oral Tablet, 50MG Oral Tablet)
Sumatriptan Succinate Refill (Subcutaneous
Maximum of 12 injections (6 ml) per 30 days
Solution Cartridge)
Sumatriptan Succinate (6MG/0.5ML
Maximum of 12 injections (6 ml) per 30 days
Subcutaneous Solution)
Sumatriptan Succinate (4MG/0.5ML
Maximum of 12 injections (6 ml) per 30 days
Subcutaneous Solution Auto-Injector)
Sumatriptan Succinate (6MG/0.5ML
Subcutaneous Solution Auto-Injector) (Generic Maximum of 12 injections (6 ml) per 30 days
Imitrex)
Sumatriptan Succinate (6MG/0.5ML
Subcutaneous Solution Auto-Injector) Maximum of 12 injections (6 ml) per 30 days
(Generic Imitrex STATdose)

Bold type = Brand name drug Plain type = Generic drug

196196 32
Drug Name
Sumatriptan Succinate (6MG/0.5ML
Subcutaneous Solution Prefilled Syringe)
Sustiva (Oral Capsule)
Sustiva (Oral Tablet)
Symbicort (Inhalation Aerosol)
Symdeko (Oral Tablet Therapy Pack)
Symfi Lo (Oral Tablet)
Symfi (Oral Tablet)
Sympazan (Oral Film)
Symproic (Oral Tablet)
Symtuza (Oral Tablet)
Synjardy (Oral Tablet Immediate Release)
Synjardy XR (10-1000MG Oral Tablet
Extended Release 24 Hour, 25-1000MG Oral
Tablet Extended Release 24 Hour)
Synjardy XR (12.5-1000MG Oral Tablet
Extended Release 24 Hour, 5-1000MG Oral
Tablet Extended Release 24 Hour)
Syprine (Oral Capsule)
Tadalafil (2.5MG Oral Tablet, 5MG Oral Tablet)
Talzenna (0.25MG Oral Capsule)
Talzenna (1MG Oral Capsule)
Tarceva (100MG Oral Tablet, 150MG Oral
Tablet)
Tarceva (25MG Oral Tablet)
Tarka (Oral Tablet Extended Release)
Tasmar (Oral Tablet)
Tavalisse (Oral Tablet)
Tecfidera (Oral Capsule Delayed Release)
Tekturna HCT (Oral Tablet)
Tekturna (Oral Tablet)
Telmisartan (Oral Tablet)
Telmisartan-Amlodipine (Oral Tablet)
Telmisartan-HCTZ (40-12.5MG Oral Tablet,
80-25MG Oral Tablet)
Telmisartan-HCTZ (80-12.5MG Oral Tablet)
Temazepam (Oral Capsule)
Tenofovir Disoproxil Fumarate (Oral Tablet)
Bold type = Brand name drug Plain type = Generic drug
32 Last updated September 1, 2019
Quantity Limit
Maximum of 12 injections (6 ml) per 30 days
Maximum of 3 capsules per day
Maximum of 1 tablet per day
Maximum of 1 inhaler (10.2 grams) per 30 days
Maximum of 1 pack (56 tablets) per 28 days
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 2 films per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 8 capsules per day
Maximum of 1 tablet per day
Maximum of 3 capsules per day
Maximum of 1 capsule per day
Maximum of 1 tablet per day
Maximum of 3 tablets per day
Maximum of 1 tablet per day
Maximum of 6 tablets per day
Maximum of 2 tablets per day
Maximum of 2 capsules per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 1 capsule per day
Maximum of 1 tablet per day
Last197
updated September 1, 2019 33 33 197

Drug Name Quantity Limit

Thalomid (100MG Oral Capsule, 50MG Oral
Maximum of 1 capsule per day
Capsule)
Thalomid (150MG Oral Capsule, 200MG Oral
Maximum of 2 capsules per day
Capsule)
Tibsovo (Oral Tablet) Maximum of 2 tablets per day
Tivicay (10MG Oral Tablet, 25MG Oral Tablet) Maximum of 1 tablet per day
Tivicay (50MG Oral Tablet) Maximum of 2 tablets per day
TOBI (Inhalation Nebulization Solution) Maximum of 10 ml (2 ampules) per day
TOBI Podhaler (Inhalation Capsule) Maximum of 8 capsules per day
Tobramycin (Inhalation Nebulization Solution) Maximum of 10 ml (2 ampules) per day
Tolazamide (250MG Oral Tablet) Maximum of 4 tablets per day
Tolazamide (500MG Oral Tablet) Maximum of 2 tablets per day
Tolbutamide (Oral Tablet) Maximum of 6 tablets per day
Tolcapone (Oral Tablet) Maximum of 6 tablets per day
Toviaz (Oral Tablet Extended Release 24
Maximum of 1 tablet per day
Hour)
Tracleer (Oral Tablet) Maximum of 2 tablets per day
Tracleer (Oral Tablet Soluble) Maximum of 8 tablets per day
Tradjenta (Oral Tablet) Maximum of 1 tablet per day
Tramadol HCl ER (Biphasic) (Oral Tablet
Maximum of 1 tablet per day
Extended Release 24 Hour)
Tramadol HCl ER (100MG Oral Capsule
Extended Release 24 Hour, 200MG Oral
Maximum of 1 capsule per day
Capsule Extended Release 24 Hour, 300MG
Oral Capsule Extended Release 24 Hour)
Tramadol HCl ER (100MG Oral Tablet Extended
Release 24 Hour, 200MG Oral Tablet Extended
Maximum of 1 tablet per day
Release 24 Hour, 300MG Oral Tablet Extended
Release 24 Hour)
Tramadol HCl (Oral Tablet Immediate Release) Maximum of 8 tablets per day
Tramadol-Acetaminophen (Oral Tablet) Maximum of 8 tablets per day
Trandolapril (1MG Oral Tablet, 2MG Oral
Maximum of 1 tablet per day
Tablet)
Trandolapril (4MG Oral Tablet) Maximum of 2 tablets per day
Trandolapril-Verapamil HCl ER (Oral Tablet
Maximum of 1 tablet per day
Extended Release)
Tranxene-T (Oral Tablet) Maximum of 12 tablets per day
Trelegy Ellipta (Inhalation Aerosol Powder
Maximum of 1 inhaler (60 blisters) per 30 days
Breath Activated)

Bold type = Brand name drug Plain type = Generic drug

198198 34
Drug Name
Trezix (Oral Capsule)
Tribenzor (Oral Tablet)
Trientine HCl (Oral Capsule)
Triumeq (Oral Tablet)
Trizivir (Oral Tablet)
Trulicity (Subcutaneous Solution Pen-
Injector)
Truvada (Oral Tablet)
Twynsta (40-10MG Oral Tablet, 40-5MG Oral
Tablet, 80-5MG Oral Tablet)
Tybost (Oral Tablet)
Tylenol with Codeine #3 (Oral Tablet)
Tylenol with Codeine #4 (Oral Tablet)
Tymlos (Subcutaneous Solution Pen-Injector)
Ultracet (Oral Tablet)
Ultram (Oral Tablet)
Uptravi (1000MCG Oral Tablet, 1200MCG
Oral Tablet, 1400MCG Oral Tablet, 1600MCG
Oral Tablet, 400MCG Oral Tablet, 600MCG
Oral Tablet, 800MCG Oral Tablet)
Uptravi (200MCG Oral Tablet)
Valacyclovir HCl (1GM Oral Tablet)
Valacyclovir HCl (500MG Oral Tablet)
Valcyte (Oral Solution Reconstituted)
Valcyte (Oral Tablet)
Valganciclovir HCl (50MG/ML Oral Solution
Reconstituted)
Valganciclovir HCl (450MG Oral Tablet)
Valium (Oral Tablet)
Valsartan (160MG Oral Tablet, 40MG Oral
Tablet, 80MG Oral Tablet)
Valsartan (320MG Oral Tablet)
Valsartan-Hydrochlorothiazide (Oral Tablet)
Valtrex (1GM Oral Tablet)
Valtrex (500MG Oral Tablet)
Vancocin HCl (125MG Oral Capsule)
Vancocin HCl (250MG Oral Capsule)
Vancomycin HCl (125MG Oral Capsule)
Bold type = Brand name drug Plain type = Generic drug
34 Last updated September 1, 2019
Quantity Limit
Maximum of 10 capsules per day
Maximum of 1 tablet per day
Maximum of 8 capsules per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 4 pens (2 ml) per 28 days
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 13 tablets per day
Maximum of 13 tablets per day
Maximum of 1.56 ml per 30 days
Maximum of 8 tablets per day
Maximum of 8 tablets per day
Maximum of 2 tablets per day
Maximum of 5 tablets per day
Maximum of 4 tablets per day
Maximum of 2 tablets per day
Maximum of 36 ml per day
Maximum of 4 tablets per day
Maximum of 36 ml per day
Maximum of 4 tablets per day
Maximum of 4 tablets per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 4 tablets per day
Maximum of 2 tablets per day
Maximum of 4 capsules per day
Maximum of 8 capsules per day
Maximum of 4 capsules per day
Last199
updated September 1, 2019 35
Drug Name
Vancomycin HCl (250MG Oral Capsule)
Vaseretic (Oral Tablet)
Vasotec (Oral Tablet)
Veltassa (Oral Packet)
Vemlidy (Oral Tablet)
Vesicare (Oral Tablet)
Viberzi (Oral Tablet)
Vicodin ES (Oral Tablet)
Vicodin HP (Oral Tablet)
Vicodin (Oral Tablet)
Victoza (Subcutaneous Solution Pen-Injector)
Videx EC (125MG Oral Capsule Delayed
Release, 250MG Oral Capsule Delayed
Release, 400MG Oral Capsule Delayed
Release)
Videx EC (200MG Oral Capsule Delayed
Release)
Videx (4GM Oral Solution Reconstituted)
Viekira Pak (Oral Tablet Therapy Pack)
Vigabatrin (Oral Packet)
Vigabatrin (Oral Tablet)
Vigadrone (Oral Packet)
Vimpat (Oral Solution)
Vimpat (Oral Tablet)
Viracept (250MG Oral Tablet)
Viracept (625MG Oral Tablet)
Viramune (Oral Suspension)
Viramune (Oral Tablet Immediate Release)
Viramune XR (Oral Tablet Extended Release
24 Hour)
Viread (Oral Powder)
Viread (Oral Tablet)
Vitrakvi (100MG Oral Capsule)
Vitrakvi (25MG Oral Capsule)
Vitrakvi (Oral Solution)
Vivelle-Dot (Transdermal Patch Twice
Weekly)
Vivlodex (Oral Capsule)
Bold type = Brand name drug Plain type = Generic drug
35 199
Quantity Limit
Maximum of 8 capsules per day
Maximum of 2 tablets per day
Maximum of 2 tablets per day
Maximum of 1 packet per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 13 tablets per day
Maximum of 13 tablets per day
Maximum of 13 tablets per day
Maximum of 3 pens (9 ml) per 30 days
Maximum of 1 capsule per day
Maximum of 2 capsules per day
Maximum of 40 ml per day
Maximum of 1 pack (112 tablets) per 28 days
Maximum of 6 packets per day
Maximum of 6 tablets per day
Maximum of 6 packets per day
Maximum of 40 ml per day
Maximum of 2 tablets per day
Maximum of 10 tablets per day
Maximum of 4 tablets per day
Maximum of 40 ml per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 4 bottles (240 grams) per 30 days
Maximum of 1 tablet per day
Maximum of 4 capsules per day
Maximum of 6 capsules per day
Maximum of 20 ml per day
Maximum of 8 patches per 28 days
Maximum of 1 capsule per day
200200 36 36 Last updated September 1, 2019

Drug Name Quantity Limit

Vosevi (Oral Tablet) Maximum of 1 tablet per day
Votrient (Oral Tablet) Maximum of 4 tablets per day
Vraylar (1.5MG Oral Capsule, 3MG Oral
Capsule, 4.5MG Oral Capsule, 6MG Oral Maximum of 1 capsule per day
Capsule)
Vytorin (Oral Tablet) Maximum of 1 tablet per day
Wixela Inhub (Inhalation Aerosol Powder Breath
Maximum of 1 inhaler (60 blisters) per 30 days
Activated) (Generic Advair)
Xanax (0.25MG Oral Tablet Immediate
Release, 0.5MG Oral Tablet Immediate
Maximum of 4 tablets per day
Release, 1MG Oral Tablet Immediate
Release)
Xanax (2MG Oral Tablet Immediate Release) Maximum of 5 tablets per day
Xanax XR (0.5MG Oral Tablet Extended
Release 24 Hour, 1MG Oral Tablet Extended Maximum of 1 tablet per day
Release 24 Hour)
Xanax XR (2MG Oral Tablet Extended
Maximum of 5 tablets per day
Release 24 Hour)
Xanax XR (3MG Oral Tablet Extended
Maximum of 3 tablets per day
Release 24 Hour)
Xarelto (10MG Oral Tablet, 20MG Oral Tablet) Maximum of 1 tablet per day
Xarelto (15MG Oral Tablet, 2.5MG Oral
Maximum of 2 tablets per day
Tablet)
Xarelto Starter Pack (Oral Tablet Therapy
Maximum of 1 pack (51 tablets) per 30 days
Pack)
Xeljanz (Oral Tablet Immediate Release) Maximum of 2 tablets per day
Xeljanz XR (Oral Tablet Extended Release 24
Maximum of 1 tablet per day
Hour)
Xermelo (Oral Tablet) Maximum of 3 tablets per day
Xigduo XR (10-1000MG Oral Tablet Extended
Release 24 Hour, 10-500MG Oral Tablet
Maximum of 1 tablet per day
Extended Release 24 Hour, 5-500MG Oral
Tablet Extended Release 24 Hour)
Xigduo XR (2.5-1000MG Oral Tablet
Extended Release 24 Hour, 5-1000MG Oral Maximum of 2 tablets per day
Tablet Extended Release 24 Hour)
Xiidra (Ophthalmic Solution) Maximum of 2 vials per day
Ximino (Oral Capsule Extended Release 24
Maximum of 1 capsule per day
Hour)
Xofluza (Oral Tablet Therapy Pack) Maximum of 2 tablets per 30 days

Bold type = Brand name drug Plain type = Generic drug

Last201
updated September 1, 2019 37 37
Drug Name
Xospata (Oral Tablet)
Xtampza ER (13.5MG Oral Capsule ER 12
Hour Abuse-Deterrent, 18MG Oral Capsule
ER 12 Hour Abuse-Deterrent, 9MG Oral
Capsule ER 12 Hour Abuse-Deterrent)
Xtampza ER (27MG Oral Capsule ER 12 Hour
Abuse-Deterrent, 36MG Oral Capsule ER 12
Hour Abuse-Deterrent)
Xultophy (Subcutaneous Solution Pen-
Injector)
Xyrem (Oral Solution)
Yupelri (Inhalation Solution)
Zaleplon (Oral Capsule)
Zejula (Oral Capsule)
Zelboraf (Oral Tablet)
Zembrace SymTouch (Subcutaneous
Solution Auto-Injector)
Zenzedi (10MG Oral Tablet, 2.5MG Oral Tablet,
5MG Oral Tablet, 7.5MG Oral Tablet)
Zenzedi (15MG Oral Tablet, 20MG Oral Tablet)
Zenzedi (30MG Oral Tablet)
Zepatier (Oral Tablet)
Zestoretic (10-12.5MG Oral Tablet)
Zestoretic (20-12.5MG Oral Tablet)
Zestoretic (20-25MG Oral Tablet)
Zestril (Oral Tablet)
Ziac (2.5-6.25MG Oral Tablet)
Ziagen (Oral Solution)
Ziagen (Oral Tablet)
Zidovudine (Oral Capsule)
Zidovudine (Oral Syrup)
Zidovudine (Oral Tablet)
Ziprasidone HCl (Oral Capsule)
Zocor (10MG Oral Tablet, 20MG Oral Tablet,
40MG Oral Tablet, 80MG Oral Tablet)
Zohydro ER (Oral Capsule ER 12 Hour Abuse-
Deterrent)
Zolmitriptan (Oral Tablet)
Bold type = Brand name drug Plain type = Generic drug
201
Quantity Limit
Maximum of 3 tablets per day
Maximum of 3 capsules per day
Maximum of 6 capsules per day
Maximum of 5 pens (15 ml) per 30 days
Maximum of 18 ml per day
Maximum of 1 vial (3 ml) per day
Maximum of 90 capsules per year
Maximum of 3 capsules per day
Maximum of 8 tablets per day
Maximum of 8 ml (16 syringes) per 30 days
Maximum of 6 tablets per day
Maximum of 3 tablets per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 4 tablets per day
Maximum of 2 tablets per day
Maximum of 2 tablets per day
Maximum of 2 tablets per day
Maximum of 32 ml per day
Maximum of 2 tablets per day
Maximum of 6 capsules per day
Maximum of 64 ml per day
Maximum of 2 tablets per day
Maximum of 2 capsules per day
Maximum of 1 tablet per day
Maximum of 2 capsules per day
Maximum of 12 tablets per 30 days
202202 38
Drug Name
Zolmitriptan ODT (Oral Tablet Dispersible)
Zolpidem Tartrate (Oral Tablet Immediate
Release)
Zomig (2.5MG Nasal Solution)
Zomig (5MG Nasal Solution)
Zomig (Oral Tablet)
Zomig ZMT (Oral Tablet Dispersible)
Zonalon (External Cream)
ZTlido (External Patch)
Zubsolv (1.4-0.36MG Tablet Sublingual,
5.7-1.4MG Tablet Sublingual)
Zubsolv (11.4-2.9MG Tablet Sublingual)
Zubsolv (2.9-0.71MG Tablet Sublingual)
Zubsolv (8.6-2.1MG Tablet Sublingual)
Zypitamag (Oral Tablet)
Zyprexa (10MG Oral Tablet, 15MG Oral
Tablet, 2.5MG Oral Tablet, 20MG Oral Tablet,
5MG Oral Tablet, 7.5MG Oral Tablet)
Zyprexa Zydis (Oral Tablet Dispersible)
track
Bold type = Brand name drug Plain type = Generic drug
38 Last updated September 1, 2019
Quantity Limit
Maximum of 12 tablets per 30 days
Maximum of 90 tablets per year
Maximum of 18 devices per 30 days
Maximum of 12 devices per 30 days
Maximum of 12 tablets per 30 days
Maximum of 12 tablets per 30 days
Maximum of 90 grams per 30 days
Maximum of 3 patches per day
Maximum of 3 tablets per day
Maximum of 1 tablet per day
Maximum of 5 tablets per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
 203 0 203
Required information
Benefits, drug list (formulary), pharmacy network and/or copayments/coinsurance may change
from time to time during each plan year. You will receive notice when necessary.
ATTENTION: If you speak a language other than English, language assistance services, free of
charge, are available to you. Please call Customer Service. Our contact information is on the cover.
Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies,
a Medicare Advantage organization with a Medicare contract. Enrollment in the plan depends on
the plan’s contract renewal with Medicare.
 For more up-to-date information or if you have other questions,
please call Customer Service at:

Toll-free 1-866-747-1014, TTY 711

8 a.m. - 8 p.m. ET, Monday - Friday

www.UHCRetiree.com/ncshp

OVEX20PP4480423_000 Last updated September 1, 2019