20191 COMPLETE DRUG LIST (FORMULARY)

Prescription drug list information

UnitedHealthcare® Group Medicare Advantage

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 1-800-457-8506, TTY 711 8 a.m. - 8 p.m. local time, Monday - Friday

www.UHCRetiree.com

Formulary ID Number 00019090, Version 9 Y0066_180629_042324 Last updated October 1, 2018 TABLE2 11 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 payment stage and drug tiers...... 5 Getting Extra Help...... 5 Are there any rules or limits on my drug coverage?...... 6 What if my drug is not on this list?...... 8 How can I get an exception?...... 8 Can I get my drug while I wait for an exception?...... 9 Can the drug list change?...... 10 Drugs with dosages other than a 1-month supply...... 11 Covered drugs by name (Drug index)...... 12 Covered drugs by medical condition...... 39 Covered drugs with a quantity limit (QL)...... 132

Questions?

If you have questions, we’re here to help. Call Customer Service at: Toll-free 1-800-457-8506, TTY 711 8 a.m. - 8 p.m. local time, Monday - Friday 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 October 1, 2018. 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 ...... 39–131 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 payment stage and drug tiers The amount you pay for a covered prescription drug will depend on: · Your drug payment stage. Your plan has different stages of drug coverage. When you fill a prescription, the amount you pay depends on the coverage stage you’re in.

· Your drug’s tier. Each covered drug is in 1 of 4 drug tiers. Each tier has a copay or coinsurance amount. The chart below shows the differences between the tiers. If you need help or have any questions about your drug costs, please review your Evidence of Coverage or call Customer Service. Our contact information is on the cover.

Drug Tier Includes Tier 1: All covered generic drugs. Preferred generic Tier 2: Many common brand name drugs, called preferred Preferred brand brands. Tier 3: Non-preferred brand name drugs. In addition, Part D Non-preferred drug eligible compound are covered in Tier 3. Tier 4: Unique and/or very high-cost brand 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 This drug is known as a high-risk medication (HRM) for Medicare members 65 and older. This drug may cause side effects if taken on a regular basis. We suggest you talk with your doctor to see if an alternative drug is available to treat your condition. LA - Limited access Drugs are considered “limited access” if the FDA says the drug can be given out only by certain facilities or doctors. These drugs may require extra handling, provider coordination or patient education that can’t be done at a network pharmacy. 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. Or go to www.UHCRetiree.com to look it up online. The information is updated on a regular basis. 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 expedited request 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, at least a 31-day any time during the year in a nursing home or long- 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? We try to change the drug list as little as possible during the plan year. Occasionally we may need to make changes for safety or other reasons. 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 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 the steps you may take 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 132-165. We’ll tell you about any 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 any 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 or go to www.UHCRetiree.com to look it up online. 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, we’re here to help. Call Customer Service toll-free at 1-800-457-8506, TTY 711, 8 a.m. - 8 p.m. local time, Monday - Friday. Or visit us online at www.UHCRetiree.com. If you have general questions about Medicare prescription drug coverage, visit www.medicare.gov or call Medicare at 1-800-633-4227, TTY 1-877-486-2048, 24 hours a day, 7 days a week. 12 12Tracked 12 Covered drugs by name (Drug index) track

A Acular LS...... 124 Ala-Cort...... 107 Abacavir...... 75 Acuvail...... 124 Albenza...... 68 Abacavir Sulfate/Lamivudine/ Acyclovir...... 73 Albuterol Sulfate...... 127, 128 Zidovudine...... 75 Acyclovir Sodium...... 73 Albuterol Sulfate ER...... 128 Abacavir/Lamivudine...... 75 Aczone...... 95 Alclometasone Dipropionate Abelcet...... 62 Adacel...... 119 ...... 107 Abilify...... 70 Adalat CC...... 85 Alcohol Prep Pads...... 121 Abilify Maintena...... 70 Adapalene...... 95 Aldactazide...... 87 Absorica...... 95 Adapalene and Benzoyl Aldactone...... 89 Abstral...... 43 Peroxide...... 95 Aldara...... 95 Acamprosate Calcium DR.....45 Adcirca...... 129 Alecensa...... 66 Acanya...... 95 Adderall...... 92 Alendronate Sodium...... 121 Acarbose...... 78 Adderall XR...... 92 Alfuzosin HCl ER...... 107 Accolate...... 127 Adefovir Dipivoxil...... 73 Alinia...... 68 Accupril...... 83 Adempas...... 129 Allopurinol...... 63 Accuretic...... 87 Adlyxin...... 78 Almotriptan Malate...... 64 Acebutolol HCl...... 84 Adlyxin Starter Pack...... 78 Alocril...... 123 Acetaminophen/Codeine...... 43 Admelog...... 80 Alogliptin...... 78 Acetazolamide...... 89 Admelog Solostar...... 80 Alogliptin/Metformin HCl...... 78 Acetazolamide ER...... 89 Advair Diskus...... 130 Alogliptin/Pioglitazone...... 78 Acetic Acid...... 125 Advair HFA...... 130 Alomide...... 123 Acetylcysteine...... 130 Adzenys ER...... 92 Alora...... 112 Aciphex...... 104 Adzenys XR-ODT...... 92 Alosetron HCl...... 103 Acitretin...... 95 Afeditab CR...... 85 Alphagan P...... 123 Actemra...... 119 Afinitor...... 66 Alprazolam...... 76 ActHIB...... 119 Afinitor Disperz...... 66 Alprazolam ER...... 76 Actigall...... 102 Afrezza...... 80 Alprazolam Intensol...... 76 Actimmune...... 119 Aggrenox...... 82 Alprazolam ODT...... 76 Actiq...... 43 Agrylin...... 82 Alrex...... 124 Actonel...... 121 Airduo Respiclick 113/14... 130 Altace...... 83 Actoplus Met...... 78 Airduo Respiclick 232/14... 130 Altavera...... 112 Actoplus Met XR...... 78 Airduo Respiclick 55/14..... 130 Altoprev...... 90 Actos...... 78 Aktipak...... 95 Alunbrig...... 67 Acular...... 124 Ala Scalp...... 107 Alvesco...... 126 13Tracked 13 13 Alyacen 1/35...... 112 Ammonium Lactate...... 95 Apriso...... 120 Amantadine HCl...... 68 Amnesteem...... 95 Aptensio XR...... 93 Amaryl...... 78 Amoxapine...... 60 Aptiom...... 56 Ambien...... 131 Amoxicillin...... 49 Aptivus...... 75 AmBisome...... 62 Amoxicillin/Clavulanate Aralast NP...... 105 Amcinonide...... 107 Potassium...... 49 Aranelle...... 112 Amerge...... 64 Amoxicillin/Clavulanate Aranesp Albumin Free...... 82 Potassium ER...... 49 Amethia...... 112 Arava...... 119 Amphetamine/ Amethia Lo...... 112 Arcalyst...... 119 Dextroamphetamine...... 92 Amikacin Sulfate...... 46 Arcapta Neohaler...... 128 Amphotericin B...... 62 Amiloride HCl...... 89 Aricept...... 57 Ampicillin...... 49 Amiloride/Hydrochlorothiazide Arimidex...... 66 Ampicillin Sodium...... 49 ...... 87 Aripiprazole...... 70 Ampicillin-Sulbactam...... 49 Aminosyn 7%/Electrolytes.....98 Aripiprazole ODT...... 70 Ampyra...... 94 Aminosyn 8.5%/Electrolytes Aristada...... 70 ...... 98 Anadrol-50...... 111 Arixtra...... 81 Aminosyn II...... 98 Anafranil...... 60 Armodafinil...... 131 Aminosyn II 8.5%/Electrolytes Anagrelide HCl...... 82 Armonair Respiclick...... 126 ...... 98 Anastrozole...... 66 Armonair Respiclick 232..... 126 Aminosyn-HBC...... 98 Ancobon...... 62 Armonair Respiclick 55...... 126 Aminosyn-PF...... 98 Androderm...... 111 Arnuity Ellipta...... 126 Aminosyn-RF...... 98 AndroGel...... 111 Aromasin...... 66 Amiodarone HCl...... 84 AndroGel Pump...... 111 Arthrotec 50...... 39 Amitiza...... 103 Anoro Ellipta...... 130 Arthrotec 75...... 39 Amitriptyline HCl...... 60 Antabuse...... 45 Asacol HD...... 120 Amlodipine Besylate...... 85 Antara...... 90 Ashlyna...... 112 Amlodipine Besylate/ Anusol-HC...... 120 Asmanex HFA...... 126 Atorvastatin Calcium...... 87 ApexiCon E...... 107 Asmanex Twisthaler 120 Amlodipine Besylate/ Apidra SoloStar...... 80 Benazepril HCl...... 87 Metered Doses...... 126 Apidra Vial...... 80 Amlodipine Besylate/Valsartan Asmanex Twisthaler 30 Aplenzin...... 58 ...... 87 Metered Doses...... 126 Apokyn...... 69 Amlodipine/Olmesartan Asmanex Twisthaler 60 Medoxomil...... 87 Apraclonidine...... 123 Metered Doses...... 126 Amlodipine/Valsartan/ Aprepitant...... 61 Aspirin/Dipyridamole...... 83 Hydrochlorothiazide...... 87 Apri...... 112 Astagraf XL...... 117 14 14Tracked 14 Astepro...... 125 Avycaz...... 48 Benazepril HCl...... 83 Atacand...... 83 Aygestin...... 115 Benazepril HCl/ Atacand HCT...... 87 Azactam...... 49 Hydrochlorothiazide...... 87 Atazanavir Sulfate...... 75 Azasan...... 117 Benicar...... 83 Atelvia...... 121 Azasite...... 50 Benicar HCT...... 87 Atenolol...... 84 Azathioprine...... 117 Benlysta...... 119 Atenolol/Chlorthalidone...... 87 Azelastine HCl...... 123, 125 BenzaClin with Pump...... 95 Ativan...... 76 Azelex...... 95 Benzamycin...... 95 Atomoxetine...... 93 Azilect...... 70 Benznidazole...... 68 Atorvastatin Calcium...... 90 Azithromycin...... 50 Benztropine Mesylate...... 68 Atovaquone...... 68 Azopt...... 123 Bepreve...... 123 Atovaquone/Proguanil HCl....68 Azor...... 87 Berinert...... 117 Atralin...... 95 Aztreonam...... 49 Besivance...... 51 Atripla...... 74 Azulfidine...... 121 Betagan...... 123 Atropine Sulfate...... 122 Azulfidine EN-Tabs...... 121 Betamethasone Dipropionate ...... 107 Atrovent HFA...... 127 B Betamethasone Valerate..... 108 Aubagio...... 95 Bacitracin...... 46 Betapace AF...... 84 Aubra...... 112 Bacitracin/Polymyxin B...... 122 Betaseron...... 95 Augmented Betamethasone Baclofen...... 130 Betaxolol HCl...... 84, 123 Dipropionate...... 107 Bactocill in Dextrose...... 50 Bethanechol Chloride...... 107 Augmentin...... 50 Bactrim...... 52 Bethkis...... 128 Auryxia...... 101 Bactrim DS...... 52 Betimol...... 123 Austedo...... 94 Bactroban...... 46 Betoptic-S...... 123 Avalide...... 87 Bactroban Nasal...... 46 Bevespi Aerosphere...... 130 Avandia...... 78 Balsalazide Disodium...... 120 Bevyxxa...... 81 Avapro...... 83 Balziva...... 112 Bexarotene...... 67 AVC...... 62 Banzel...... 56 Bexsero...... 119 Aveed...... 111 Baraclude...... 73 Beyaz...... 112 Avelox...... 51 Basaglar KwikPen...... 80 Bicalutamide...... 66 Aviane...... 112 Baxdela...... 51 Bicillin C-R...... 50 Avita...... 95 BCG Vaccine...... 119 Bicillin L-A...... 50 Avodart...... 107 Beconase AQ...... 126 BiDil...... 87 Avonex...... 95 Belbuca...... 40 Biktarvy...... 75 Avonex Pen...... 95 Belsomra...... 131 Biltricide...... 68 15Tracked 15 15 Bimatoprost...... 125 Buspirone HCl...... 76 Captopril/Hydrochlorothiazide Binosto...... 121 Butorphanol Tartrate...... 43 ...... 87 Bisoprolol Fumarate...... 84 Butrans...... 40 Carac...... 96 Bisoprolol Fumarate/ Bydureon Bcise...... 78 Carafate...... 104 Hydrochlorothiazide...... 87 Bydureon Injection...... 78 Carbaglu...... 98 BIVIGAM...... 118 Bydureon Vial...... 78 Carbamazepine...... 56 Bleph-10...... 52 Byetta...... 78 Carbamazepine ER...... 57 Blephamide...... 122 Bystolic...... 84 Carbatrol...... 57 Blephamide S.O.P...... 122 Byvalson...... 87 Carbidopa...... 69 Blisovi 24 Fe...... 112 C Carbidopa/Levodopa...... 69 Blisovi Fe 1.5/30...... 112 Cabergoline...... 116 Carbidopa/Levodopa ER...... 69 Blisovi Fe 1/20...... 112 Cabometyx...... 67 Carbidopa/Levodopa ODT....69 Boniva...... 121 Caduet...... 87 Carbidopa/Levodopa/ Entacapone...... 69 Boostrix...... 119 Cafergot...... 64 Cardizem...... 85 Bosulif...... 67 Calan...... 85 Cardizem CD...... 85 Breo Ellipta...... 130 Calan SR...... 85 Cardizem LA...... 85 Briellyn...... 112 Calcipotriene...... 96 Cardura...... 83 Brilinta...... 83 Calcipotriene/Betamethasone Brimonidine Tartrate...... 123 Dipropionate...... 96 Cardura XL...... 107 Brisdelle...... 59 Calcitonin-Salmon...... 121 Carimune Nanofiltered...... 119 Briviact...... 53 Calcitriol...... 96, 121 Carnitor...... 98 Bromocriptine Mesylate...... 69 Calcium Acetate...... 101 Carospir...... 89 Bromsite...... 124 Calquence...... 67 Carteolol HCl...... 123 Brovana...... 128 Cambia...... 39 Cartia XT...... 85 Budesonide...... 120, 126 Camila...... 115 Carvedilol...... 84 Budesonide ER...... 120 Camrese Lo...... 112 Carvedilol Phosphate...... 84 Bumetanide...... 89 Canasa...... 120 Casodex...... 66 Bunavail...... 45 Cancidas...... 62 Caspofungin Acetate...... 62 Buphenyl...... 105 Candesartan Cilexetil...... 83 Catapres...... 83 Buprenorphine...... 40 Candesartan Cilexetil/ Catapres-TTS-1...... 83 Buprenorphine HCl...... 45 Hydrochlorothiazide...... 87 Catapres-TTS-2...... 83 Buprenorphine HCl/Naloxone Capex...... 108 Catapres-TTS-3...... 83 HCl...... 45 Caprelsa...... 67 Cayston...... 128 Bupropion HCl...... 58 Captopril...... 83 Caziant...... 112 Bupropion HCl SR...... 46 Cefaclor...... 48 16 16Tracked 16 Cefaclor ER...... 48 Chloroquine Phosphate...... 68 Cleocin Pediatric Granules....46 Cefadroxil...... 48 Chlorothiazide...... 89 Cleocin Phosphate...... 46 Cefazolin Sodium...... 48 Chlorpromazine HCl...... 70 Cleocin-T...... 96 Cefdinir...... 48 Chlorthalidone...... 89 Climara Pro...... 112 Cefepime...... 48 Cholbam...... 105 Clindacin-P...... 96 Cefixime...... 48 Cholestyramine...... 90 Clindagel...... 96 Cefotaxime Sodium...... 48 Cholestyramine Light...... 90 Clindamycin HCl...... 46 Cefotetan...... 48 Cialis...... 107 Clindamycin Palmitate HCl....47 Cefoxitin Sodium...... 48 Ciclopirox...... 62 Clindamycin Phosphate...47, 96 Cefpodoxime Proxetil...... 48 Ciclopirox Nail Lacquer...... 62 Clindamycin Phosphate in D5W Cefprozil...... 48 Ciclopirox Olamine...... 62 ...... 47 Ceftazidime...... 48 Cilostazol...... 83 Clindamycin Phosphate/ Tretinoin...... 96 Ceftriaxone Sodium...... 48 Ciloxan...... 51 Clindamycin/Benzoyl Peroxide Cefuroxime Axetil...... 49 Cimduo...... 75 ...... 96 Cefuroxime Sodium...... 49 Cimetidine...... 103 Clindesse...... 47 Celebrex...... 39 Cimetidine HCl...... 103 Clinimix 2.75%/Dextrose 5% Celecoxib...... 39 Cimzia...... 117 ...... 98 Celexa...... 59 Cinryze...... 117 Clinimix 4.25%/Dextrose 10% Cellcept...... 117 Cipro...... 51 ...... 98 Celontin...... 53 Cipro HC...... 125 Clinimix 4.25%/Dextrose 20% ...... 98 Cephalexin...... 49 Ciprodex...... 125 Clinimix 4.25%/Dextrose 25% Cerdelga...... 105 Ciprofloxacin...... 51, 125 ...... 98 Cesamet...... 61 Ciprofloxacin ER...... 51 Clinimix 4.25%/Dextrose 5% Cetirizine HCl...... 126 Ciprofloxacin HCl...... 51 ...... 98 Cetraxal...... 125 Ciprofloxacin I.V. in D5W...... 51 Clinimix 5%/Dextrose 15%.... 98 Cevimeline HCl...... 95 Citalopram HBr...... 59 Clinimix 5%/Dextrose 20%.... 98 Chantix...... 46 Claravis...... 96 Clinimix 5%/Dextrose 25%.... 98 Chantix Continuing Month Pak Clarinex...... 126 Clinimix E 2.75%/Dextrose 10% ...... 46 Clarinex-D 12 Hour...... 130 ...... 98 Chantix Starting Month Pak...46 Clarithromycin...... 50 Clinimix E 2.75%/Dextrose 5% Chemet...... 101 Clarithromycin ER...... 50 ...... 98 Chenodal...... 102 Clenpiq...... 103 Clinimix E 4.25%/Dextrose 10% ...... 98 Chlordiazepoxide HCl...... 76 Cleocin...... 46 Clinimix E 4.25%/Dextrose 25% Chlorhexidine Gluconate...... 95 Cleocin in D5W...... 46 ...... 98 17Tracked 17 17 Clinimix E 4.25%/Dextrose 5% Colistimethate Sodium...... 47 Crestor...... 90 ...... 99 Colocort...... 120 Crinone...... 115 Clinimix E 5%/Dextrose 15% Coly-Mycin S...... 125 Crixivan...... 76 ...... 99 CoLyte-Flavor Packs...... 103 Cromolyn Sodium...... 102, 123, Clinimix E 5%/Dextrose 20% Combigan...... 123 129 ...... 99 Combivent Respimat...... 130 Cryselle-28...... 112 Clinimix E 5%/Dextrose 25% Cubicin...... 47 ...... 99 Combivir...... 75 Cuprimine...... 107 Clinisol SF 15%...... 99 Cometriq...... 67 Cutivate...... 108 Clobetasol Propionate...... 108 Complera...... 74 Cuvposa...... 102 Clobetasol Propionate E...... 108 Compro...... 61 Cyclafem...... 112 Clobex...... 108 Comtan...... 68 Cyclobenzaprine HCl...... 130 Clodan...... 108 Concerta...... 93 Cyclophosphamide...... 65 Cloderm...... 108 Condylox...... 96 Cycloset...... 78 Clomipramine HCl...... 60 Constulose...... 103 Cyclosporine...... 117 Clonazepam...... 77 Conzip...... 40 Cyclosporine Modified...... 117 Clonazepam ODT...... 77 Copaxone...... 95 Cymbalta...... 94 Clonidine HCl...... 83 Cordran...... 108 Cyproheptadine HCl...... 126 Clonidine HCl ER...... 93 Coreg...... 84 Cystadane...... 105 Clopidogrel...... 83 Coreg CR...... 84 Cystagon...... 105 Clorazepate Dipotassium...... 77 Corgard...... 84 Cystaran...... 122 Clotrimazole...... 62 Corlanor...... 87 Cytomel...... 116 Clotrimazole/Betamethasone Cortef...... 108 Dipropionate...... 96 Cortisone Acetate...... 108 Cytotec...... 104 Clozapine...... 72 Cortisporin...... 96 D Clozapine ODT...... 72 Corzide...... 87 Daklinza...... 73 Clozaril...... 72 Cosentyx...... 96 Daliresp...... 129 Coartem...... 68 Cosentyx Sensoready Pen.....96 Dalvance...... 47 Codeine Sulfate...... 43 Cosopt...... 123 ...... 111 Colazal...... 120 Cosopt PF...... 123 Dantrium...... 130 Colchicine...... 63 Cotellic...... 67 Dantrolene Sodium...... 130 Colcrys...... 63 Coumadin...... 81 Dapsone...... 65, 96 Colesevelam HCl...... 90 Cozaar...... 83 Daptacel...... 119 Colestid...... 91 Creon...... 105 Daptomycin...... 47 Colestipol HCl...... 91 Cresemba...... 62 DARAPRIM...... 68 18 18Tracked 18 Darifenacin HBr ER...... 106 Detrol...... 106 Diclofenac Sodium ER...... 39 Daypro...... 39 Detrol LA...... 106 Diclofenac Sodium/Misoprostol Daytrana...... 93 Dexamethasone...... 108 ...... 39 DDAVP...... 111 Dexamethasone Intensol..... 108 Dicloxacillin Sodium...... 50 Deblitane...... 115 Dexamethasone Sodium Dicyclomine HCl...... 102 Delestrogen...... 112 Phosphate...... 124 Didanosine...... 75 Delyla...... 112 Dexedrine...... 92 Differin...... 96 Delzicol...... 120 Dexilant...... 104 Dificid...... 50 Demeclocycline HCl...... 52 Dexmethylphenidate HCl...... 93 Diflorasone Diacetate...... 108 Demser...... 87 Dexmethylphenidate HCl ER Diflucan...... 62 ...... 93 Denavir...... 73 Diflunisal...... 39 DexPak 13 Day...... 108 Depakene...... 54 Digitek...... 87 Dextroamphetamine Sulfate Depakote...... 77 Digox...... 87 ...... 92 Depakote ER...... 77 Digoxin...... 87 Dextroamphetamine Sulfate ER Dihydroergotamine Mesylate Depakote Sprinkles...... 77 ...... 92 ...... 64 Depen Titratabs...... 107 Dextrose 10%...... 99 Dilantin...... 57 Depo-...... 112 Dextrose 10%/NaCl 0.2%...... 99 Dilantin INFATABS...... 57 Depo-Provera...... 115 Dextrose 10%/NaCl 0.45%.... 99 Dilantin-125...... 57 Depo-Provera Contraceptive Dextrose 2.5%/NaCl 0.45%... 99 ...... 115 Dilaudid...... 43 Dextrose 5%...... 99 Depo-SubQ Provera104...... 116 Dilt-XR...... 86 Dextrose 5%/NaCl 0.2%...... 99 Depo-...... 112 Diltiazem HCl...... 85 Dextrose 5%/NaCl 0.225%.... 99 Descovy...... 75 Diltiazem HCl ER...... 86 Dextrose 5%/NaCl 0.33%...... 99 Desipramine HCl...... 60 Diovan...... 83 Dextrose 5%/NaCl 0.45%...... 99 Desloratadine...... 126 Diovan HCT...... 87 Dextrose 5%/NaCl 0.9%...... 99 Desloratadine ODT...... 126 Dipentum...... 120 Diastat AcuDial...... 54 Desmopressin Acetate...... 111 Diphenoxylate/Atropine...... 102 Diastat Pediatric...... 54 Desogestrel/Ethinyl Estradiol Diphtheria/Tetanus Toxoids Diazepam...... 77 ...... 112 Adsorbed Pediatric...... 119 Diazepam Intensol...... 77 Desonate...... 108 Diprolene...... 108 Dibenzyline...... 83 Desonide...... 108 Disulfiram...... 45 Diclofenac Potassium...... 39 DesOwen...... 108 Ditropan XL...... 106 Diclofenac Sodium...... 39, 96, Desoximetasone...... 108 Diuril...... 89 124 Desoxyn...... 92 Divalproex Sodium...... 77 Diclofenac Sodium DR...... 39 Desvenlafaxine ER...... 59 Divalproex Sodium DR...... 77 19Tracked 19 19 Divalproex Sodium ER...... 77 Duramorph...... 43 Elocon...... 108 Dofetilide...... 84 Durezol...... 124 Emadine...... 123 Dolophine...... 40 Dutasteride...... 107 Embeda...... 41 Donepezil HCl...... 57 Dutasteride/Tamsulosin HCl Emcyt...... 66 Donepezil HCl ODT...... 57 ...... 107 Emend...... 61 Doptelet...... 82 DUTOPROL...... 87 Emend Tripack...... 61 Doripenem...... 49 Duzallo...... 63 Emflaza...... 108 Doryx...... 52 Dyanavel XR...... 93 Emoquette...... 112 Doryx MPC...... 52 Dyazide...... 87 Emsam...... 59 Dorzolamide HCl...... 123 Dymista...... 130 Emtriva...... 75 Dorzolamide HCl/Timolol Dyrenium...... 89 Emverm...... 68 Maleate...... 124 E Enablex...... 106 Dovonex...... 96 E.E.S. 400...... 50 Enalapril Maleate...... 83 Doxazosin Mesylate...... 83 E.E.S. Granules...... 50 Enalapril Maleate/ Doxepin HCl...... 60, 96 Econazole Nitrate...... 62 Hydrochlorothiazide...... 88 Doxercalciferol...... 121 Edarbi...... 83 Enbrel...... 117 Doxy 100...... 52 Edarbyclor...... 87 Enbrel SureClick...... 117 Doxycycline...... 52 Edecrin...... 89 Endari...... 99 Doxycycline Hyclate...... 52 Edurant...... 74 Endocet...... 43 Doxycycline Hyclate DR...... 52 ...... 74 Engerix-B...... 119 Doxycycline Monohydrate..... 53 Effexor XR...... 59 Enoxaparin Sodium...... 81 Dronabinol...... 61 Effient...... 83 Enpresse-28...... 112 Drospirenone/Ethinyl Estradiol Efudex...... 96 Enskyce...... 112 ...... 112 Egrifta...... 116 Enstilar...... 96 Drospirenone/Ethinyl Estradiol/ Eldepryl...... 70 Entacapone...... 68 Levomefolate Calcium...... 112 Elestat...... 123 Entecavir...... 73 Droxia...... 66 Elestrin...... 112 Entocort EC...... 120 Duac...... 96 Eletriptan HBr...... 64 Entresto...... 88 Duetact...... 78 Elidel...... 96 Enulose...... 103 Duexis...... 39 Eligard...... 116 Envarsus XR...... 117 Dulera...... 130 Elimite...... 68 Epclusa...... 73 Duloxetine HCl...... 94 Eliquis...... 81 Epiduo...... 96 Duopa...... 69 Eliquis Starter Pack...... 81 Epiduo Forte...... 96 Dupixent...... 96 Elmiron...... 107 Epinastine HCl...... 123 Duragesic...... 40, 41 20 20Tracked 20 Epinephrine...... 128 Estarylla...... 112 Famciclovir...... 73 EpiPen...... 128 Estrace...... 113 Famotidine...... 103 Epitol...... 57 Estradiol...... 113 Fanapt...... 70 Epivir...... 75 ...... 113 Fanapt Titration Pack...... 71 Epivir HBV...... 73 Estring...... 113 Fareston...... 66 Eplerenone...... 89 Ethacrynic Acid...... 89 Farxiga...... 78 Epogen...... 82 Ethambutol HCl...... 65 Farydak...... 67 Eprosartan Mesylate...... 83 Ethosuximide...... 54 Fasenra...... 130 Epzicom...... 75 Ethynodiol Diacetate/Ethinyl Fayosim...... 113 Equetro...... 77 Estradiol...... 113 Fazaclo...... 72 Eraxis...... 62 Etidronate Disodium...... 121 Felbamate...... 54 Ergotamine Tartrate/Caffeine Etodolac...... 39 Felbatol...... 54 ...... 64 Etodolac ER...... 39 Feldene...... 39 Erivedge...... 67 Eucrisa...... 96 Felodipine ER...... 86 Erleada...... 66 Eurax...... 68 Femara...... 66 Errin...... 116 Evista...... 116 Femring...... 113 Ertaczo...... 62 Evoclin...... 96 Femynor...... 113 Ery...... 96 Evotaz...... 76 Fenofibrate...... 90 Ery-Tab...... 50 Evoxac...... 95 Fenofibrate Micronized...... 90 Erygel...... 96 Evzio...... 45 Fenofibric Acid...... 90 EryPed 200...... 50 Exalgo...... 41 Fenofibric Acid DR...... 90 EryPed 400...... 50 Exelderm...... 62 Fenoglide...... 90 Erythrocin Lactobionate...... 50 Exelon...... 58 Fenoprofen Calcium...... 39 Erythrocin Stearate...... 50 Exemestane...... 66 Fentanyl...... 41 Erythromycin...... 51, 96 Exforge...... 88 Fentanyl Citrate Oral Erythromycin Base...... 51 Exforge HCT...... 88 Transmucosal...... 43 Erythromycin Ethylsuccinate Exjade...... 101 Fentora...... 43 ...... 51 Extavia...... 95 Ferriprox...... 101 Erythromycin/Benzoyl Peroxide Extina...... 62 Fetzima...... 59 ...... 96 Ezetimibe...... 91 Fetzima Titration Pack...... 59 Esbriet...... 130 Ezetimibe/Simvastatin...... 91 Fexmid...... 130 Escitalopram Oxalate...... 59 F Fiasp...... 80 Esomeprazole Magnesium Fabior...... 96 Fiasp Flextouch...... 80 ...... 104 Falmina...... 113 Fibricor...... 90 Esomeprazole Strontium..... 104 21Tracked 21 21 Finacea...... 96 Flurbiprofen Sodium...... 124 Fycompa...... 55 Finasteride...... 107 Flutamide...... 66 G Firazyr...... 117 Fluticasone Propionate...... 109, Gabapentin...... 54 Firmagon...... 116 126 Gabitril...... 54 Flagyl...... 47 Fluticasone Propionate/ Galantamine HBr...... 58 Salmeterol...... 130 Flarex...... 124 Galantamine HBr ER...... 58 Fluvastatin...... 90 Flavoxate HCl...... 106 Gammagard Liquid...... 119 Fluvastatin Sodium ER...... 90 Flebogamma DIF...... 119 Gammagard S/D IGA Less Fluvoxamine Maleate...... 59 Flecainide Acetate...... 84 Than 1 mcg/ml...... 119 Fluvoxamine Maleate ER...... 59 Flector...... 39 Gammaked...... 119 FML...... 124 Flolipid...... 90 Gammaplex...... 119 FML Forte...... 124 Flomax...... 107 Gamunex-C...... 119 FML Liquifilm...... 124 Flovent Diskus...... 126 Gardasil 9...... 119 Focalin...... 93 Flovent HFA...... 126 Gastrocrom...... 102 Focalin XR...... 93 Fluconazole...... 62 Gatifloxacin...... 51 Fondaparinux Sodium...... 81 Fluconazole in NaCl...... 62 Gattex...... 102 Forfivo XL...... 58 Flucytosine...... 62 Gauze...... 122 Fortamet...... 78 Fludrocortisone Acetate...... 108 GaviLyte-C...... 103 Forteo...... 121 Flumadine...... 76 GaviLyte-G...... 103 Fortesta...... 112 Flunisolide...... 126 GaviLyte-N/Flavor Pack...... 103 Fosamax...... 121 Fluocinolone Acetonide...... 108, Gelnique...... 106 125 Fosamax Plus D...... 121 Gemfibrozil...... 90 Fluocinolone Acetonide Scalp Fosamprenavir Calcium...... 76 Generess Fe...... 113 ...... 109 Fosinopril Sodium...... 83 Generlac...... 103 Fluocinonide...... 109 Fosinopril Sodium/ Gengraf...... 117 Hydrochlorothiazide...... 88 Fluocinonide Emulsified Base Genotropin...... 111 ...... 109 Fosrenol...... 102 Genotropin Miniquick...... 111 Fluorometholone...... 124 Fragmin...... 81 Gentak...... 46 Fluorouracil...... 97 FreAmine HBC 6.9%...... 99 Gentamicin Sulfate...... 46 Fluoxetine DR...... 59 Frova...... 64 Gentamicin Sulfate/0.9% Fluoxetine HCl...... 59 Frovatriptan Succinate...... 64 Sodium Chloride...... 46 Fluphenazine Decanoate...... 70 Furadantin...... 47 Genvoya...... 74 Fluphenazine HCl...... 70 Furosemide...... 89 Geodon...... 71 Flurandrenolide...... 109 Fuzeon...... 75 Gianvi...... 113 Flurbiprofen...... 39 Fyavolv...... 113 Giazo...... 120 22 22Tracked 22 Gilenya...... 95 Haegarda...... 117 Humira Pen Crohns Disease Gilotrif...... 67 Haldol...... 70 Starter Pack...... 118 Glassia...... 105 Haldol Decanoate 100...... 70 Humira Pen-Psoriasis Starter ...... 118 Glatiramer Acetate...... 95 Haldol Decanoate 50...... 70 Humulin 70/30 KwikPen...... 80 Glatopa...... 95 Halobetasol Propionate...... 109 Humulin 70/30 Vial...... 80 Gleevec...... 67 Halog...... 109 Humulin N KwikPen...... 80 Gleostine...... 65 Haloperidol...... 70 Humulin N Vial...... 80 Glimepiride...... 78 Haloperidol Decanoate...... 70 Humulin R U-500 KwikPen.....80 Glipizide...... 78 Haloperidol Lactate...... 70 Humulin R U-500 Vial...... 80 Glipizide ER...... 78 Harvoni...... 73 Humulin R Vial...... 80 Glipizide/Metformin HCl...... 78 Havrix...... 119 Hydralazine HCl...... 91 GlucaGen HypoKit...... 80 Heparin Sodium...... 81 Hydrea...... 66 Glucagon Emergency Kit...... 80 HepatAmine...... 99 Hydrochlorothiazide...... 89 Glucophage...... 78 Hepsera...... 73 Hydrocodone Bitartrate/ Glucophage XR...... 78 Hetlioz...... 131 Acetaminophen...... 43 Glucotrol...... 78 Hexalen...... 65 Hydrocodone/Acetaminophen Glucotrol XL...... 78 Hiberix...... 119 ...... 43 Glumetza...... 78 Hiprex...... 47 Hydrocodone/Ibuprofen...... 43 Glycopyrrolate...... 102 Horizant...... 94 Hydrocortisone...... 109, 120 Glyset...... 78 Humalog Cartridge...... 80 Hydrocortisone Acetate/ Glyxambi...... 78 Humalog Junior KwikPen...... 80 Pramoxine...... 120 Gocovri...... 69 Humalog KwikPen...... 80 Hydrocortisone Butyrate...... 109 GoLYTELY...... 103 Humalog Mix 50/50 KwikPen Hydrocortisone Valerate...... 109 Gonitro...... 91 ...... 80 Hydrocortisone/Acetic Acid ...... 125 Gralise...... 94 Humalog Mix 50/50 Vial...... 80 Hydromorphone HCl...... 43 Gralise Starter Pack...... 94 Humalog Mix 75/25 KwikPen ...... 80 Hydromorphone HCl ER...... 41 Granisetron HCl...... 61 Humalog Mix 75/25 Vial...... 80 Hydroxychloroquine Sulfate Granix...... 82 Humalog Vial...... 80 ...... 68 Griseofulvin Microsize...... 62 Humatrope...... 111 Hydroxyurea...... 66 Griseofulvin Ultramicrosize....62 Humatrope Combo Pack.....111 Hydroxyzine HCl...... 76 Guanidine HCl...... 65 Humira...... 117 Hydroxyzine Pamoate...... 61 Gynazole-1...... 62 Humira Pediatric Crohns Hysingla ER...... 41 H Disease Starter Pack...... 117 Hyzaar...... 88 H.P. Acthar...... 109 Humira Pen...... 118 23Tracked 23 23 I Intralipid...... 99 Isotretinoin...... 97 Ibandronate Sodium...... 121 Intrarosa...... 112 Isradipine...... 86 Ibrance...... 67 Intron A...... 73 Istalol...... 124 Ibu...... 39 Introvale...... 113 Itraconazole...... 62 Ibudone...... 43 Invanz...... 49 Ivermectin...... 68 Ibuprofen...... 39 Invega...... 71 Ixiaro...... 119 Iclusig...... 67 Invega Sustenna...... 71 J Idhifa...... 67 Invega Trinza...... 71 Jadenu...... 101 Ilevro...... 124 Invirase...... 76 Jadenu Sprinkle...... 101 Imatinib Mesylate...... 67 Invokamet...... 78 Jakafi...... 67 Imbruvica...... 67 Invokamet XR...... 78 Jalyn...... 107 Imipenem/Cilastatin...... 49 Invokana...... 78 Jantoven...... 81 Imipramine HCl...... 60 Ionosol-MB/Dextrose 5%...... 99 Janumet...... 78 Imipramine Pamoate...... 60 Iopidine...... 124 Janumet XR...... 78 Imiquimod...... 97 IPOL Inactivated IPV...... 119 Januvia...... 78 Imitrex...... 64 Ipratropium Bromide...... 127 Jardiance...... 78 Imitrex Statdose Refill...... 64 Ipratropium Bromide/Albuterol Jentadueto...... 78 Imitrex Statdose System...... 64 Sulfate...... 130 Jentadueto XR...... 78 Imovax Rabies...... 119 Irbesartan...... 83 Jinteli...... 113 Impoyz...... 109 Irbesartan/Hydrochlorothiazide Jolivette...... 116 ...... 88 Imuran...... 118 Jublia...... 63 Iressa...... 67 Imvexxy...... 113 Juleber...... 113 Isentress...... 74 Incassia...... 116 Juluca...... 74 Isentress HD...... 74 Increlex...... 111 Junel 1.5/30...... 113 Isibloom...... 113 Incruse Ellipta...... 127 Junel 1/20...... 113 Isolyte-P/Dextrose 5%...... 99 Indapamide...... 89 Junel Fe 1.5/30...... 113 Isolyte-S...... 99 Inderal LA...... 85 Junel Fe 1/20...... 113 Isoniazid...... 65 Infanrix...... 119 Junel Fe 24...... 113 Isopto Carpine...... 124 Ingrezza...... 94 Juxtapid...... 91 Isordil Titradose...... 91 Inlyta...... 67 Jynarque...... 101 Isosorbide Dinitrate...... 91 Innopran XL...... 85 K Isosorbide Dinitrate ER...... 91 Inspra...... 89 K-Tab...... 100 Isosorbide Mononitrate...... 91 Insulin Syringes, Needles.... 122 Kadian...... 41 Isosorbide Mononitrate ER....91 Intelence...... 74 Kaitlib Fe...... 113 Isotonic Gentamicin...... 46 24 24Tracked 24 Kaletra...... 76 Kisqali Femara 600 Dose...... 66 Lamotrigine Starter Kit/Orange Kalydeco...... 128 Klaron...... 97 ...... 55 Kapvay...... 93 Klonopin...... 77 Lanoxin...... 88 Kariva...... 113 Klor-Con...... 99 Lansoprazole...... 104 Kazano...... 79 Klor-Con 10...... 99 Lansoprazole/Amoxicillin/ Clarithromycin...... 102 KCl 0.075%/D5W/NaCl 0.45% Klor-Con 8...... 99 Lanthanum Carbonate...... 102 ...... 99 Klor-Con M10...... 99 Lantus SoloStar...... 80 KCl 0.15%/D5W/NaCl 0.2% Klor-Con M15...... 100 ...... 99 Lantus Vial...... 80 Klor-Con M20...... 100 KCl 0.15%/D5W/NaCl 0.45% LARIN 1.5/30...... 113 Klor-Con Sprinkle...... 100 ...... 99 LARIN 1/20...... 113 Kombiglyze XR...... 79 KCl 0.15%/D5W/NaCl 0.9% LARIN Fe 1.5/30...... 113 ...... 99 Korlym...... 111 LARIN Fe 1/20...... 113 KCl 0.3%/D5W/NaCl 0.45% Kristalose...... 103 Larissia...... 113 ...... 99 Kurvelo...... 113 Lasix...... 89 KCl 0.3%/D5W/NaCl 0.9%.... 99 Kuvan...... 105 Lastacaft...... 122 Kelnor 1/35...... 113 Kynamro...... 91 Latanoprost...... 125 Kelnor 1/50...... 113 L Latuda...... 71 Kenalog...... 109 Labetalol HCl...... 85 Layolis Fe...... 113 Keppra...... 53 Lacrisert...... 122 Lazanda...... 43 Keppra XR...... 53 Lactulose...... 103 Leena...... 113 Kerydin...... 63 Lamictal...... 55 Leflunomide...... 119 Ketoconazole...... 63 Lamictal Chewable Dispersible Lenvima...... 67 Ketoprofen ER...... 39 ...... 55 Lescol XL...... 90 Ketorolac Tromethamine.....124 Lamictal ODT...... 55 Lessina...... 113 Keveyis...... 89 Lamictal Starter...... 55 Letairis...... 129 Kevzara...... 119 Lamictal XR...... 55 Letrozole...... 66 Khedezla...... 60 Lamivudine...... 73, 75 Leucovorin Calcium...... 66 Kimidess...... 113 Lamivudine/Zidovudine...... 75 Leukeran...... 65 Kineret...... 118 Lamotrigine...... 55 Leukine...... 82 Kinrix...... 119 Lamotrigine ER...... 55 Leuprolide Acetate...... 116 Kionex...... 101 Lamotrigine ODT...... 55 Levalbuterol...... 128 Kisqali...... 66 Lamotrigine Starter Kit/Blue ...... 55 Levalbuterol Tartrate HFA... 128 Kisqali Femara 200 Dose...... 66 Lamotrigine Starter Kit/Green Levaquin...... 51 Kisqali Femara 400 Dose...... 66 ...... 55 Levemir FlexTouch...... 80 25Tracked 25 25 Levemir Vial...... 80 Lithium Carbonate...... 77 Lotensin...... 83 Levetiracetam...... 53 Lithium Carbonate ER...... 77 Lotrel...... 88 Levetiracetam ER...... 53 Lithobid...... 77 Lotrisone...... 97 Levo-T...... 116 Lithostat...... 107 Lotronex...... 103 Levobunolol HCl...... 124 Livalo...... 90 Lovastatin...... 90 Levocarnitine...... 100 Lo Loestrin Fe...... 114 Lovaza...... 91 Levocetirizine Dihydrochloride Locoid...... 109 Lovenox...... 81 ...... 126 Locoid Lipocream...... 109 Low-Ogestrel...... 114 Levofloxacin...... 51 Lodine...... 40 Loxapine Succinate...... 70 Levofloxacin in D5W...... 51 Lodosyn...... 70 Lucemyra...... 122 Levonest...... 113 Loestrin 1.5/30-21...... 114 Lumigan...... 125 Levonorgestrel/Ethinyl Loestrin 1/20-21...... 114 Lupaneta Pack...... 116 Estradiol...... 113 Loestrin Fe 1.5/30...... 114 Lupron Depot...... 117 Levora 0.15/30-28...... 114 Loestrin Fe 1/20...... 114 Lutera...... 114 Levorphanol Tartrate...... 41 Lomotil...... 102 Luzu...... 63 Levothyroxine Sodium...... 116 Lonhala Magnair Starter Kit Lynparza...... 67 Levoxyl...... 116 ...... 127 Lyrica...... 94 Lexapro...... 60 Lonsurf...... 66 Lyrica CR...... 94 Lexiva...... 76 Loperamide HCl...... 102 Lysodren...... 116 Lialda...... 120 Lopid...... 90 Lysteda...... 82 Lidocaine...... 45 Lopinavir/Ritonavir...... 76 Lyza...... 116 Lidocaine HCl...... 45 Lopressor...... 85 M Lidocaine Viscous...... 45 Lopressor HCT...... 88 M-M-R II...... 119 Lidocaine/Prilocaine...... 45 Loprox...... 63 Macrobid...... 47 Lidoderm...... 45 Loprox Shampoo...... 63 Macrodantin...... 47 Lindane...... 68 Lorazepam...... 77 Magnesium Sulfate...... 100 Linezolid...... 47 Lorcet...... 43 Malarone...... 68 Linzess...... 103 Lorcet HD...... 43 Malathion...... 68 Liothyronine Sodium...... 116 Lorcet Plus...... 44 Maprotiline HCl...... 60 Lipitor...... 90 Loryna...... 114 Marinol...... 61 Lipofen...... 90 Losartan Potassium...... 83 Marlissa...... 114 Lisinopril...... 83 Losartan Potassium/ Marplan...... 59 Lisinopril/Hydrochlorothiazide Hydrochlorothiazide...... 88 Matulane...... 65 ...... 88 LoSeasonique...... 114 Matzim LA...... 86 Lithium...... 77 Lotemax...... 125 26 26Tracked 26 Mavyret...... 73 Mestinon...... 65 Metoprolol/ Maxalt...... 64 Mestinon Timespan...... 65 Hydrochlorothiazide...... 88 Maxalt-MLT...... 64 Metadate ER...... 93 MetroCream...... 47 Maxidex...... 125 Metaproterenol Sulfate...... 128 MetroGel...... 47 Maxipime...... 49 Metformin HCl...... 79 MetroGel-Vaginal...... 47 Maxitrol...... 122 Metformin HCl ER...... 79 MetroLotion...... 47 Maxzide...... 88 Methadone HCl...... 41 Metronidazole...... 47 Meclizine HCl...... 61 Methamphetamine HCl...... 93 Metronidazole in NaCl 0.79% ...... 47 Meclofenamate Sodium...... 40 Methazolamide...... 89 Metronidazole Vaginal...... 47 Medrol...... 109 Methenamine Hippurate...... 47 Mexiletine HCl...... 84 Medrol Dosepak...... 109 Methimazole...... 117 Mibelas 24 Fe...... 114 Medroxyprogesterone Acetate Methitest...... 112 Micardis...... 83 ...... 116 Methotrexate...... 118 Micardis HCT...... 88 Mefenamic Acid...... 40 Methotrexate Sodium...... 118 Miconazole 3...... 63 Mefloquine HCl...... 68 Methoxsalen...... 97 Micort-HC...... 109 Megace ES...... 116 Methscopolamine Bromide Megestrol Acetate...... 116 ...... 102 Microgestin 1.5/30...... 114 Mekinist...... 67 Methyclothiazide...... 89 Microgestin 1/20...... 114 Melodetta 24 Fe...... 114 Methyldopa...... 83 Microgestin Fe...... 114 Meloxicam...... 40 Methylin...... 93 Microgestin Fe 1.5/30...... 114 Memantine HCl...... 58 Methylphenidate HCl...... 93 Microzide...... 89 Memantine HCl ER...... 58 Methylphenidate HCl CD...... 93 Midodrine HCl...... 83 Memantine HCl Titration Pak Methylphenidate HCl ER...... 93, Migergot...... 64 ...... 58 94 Miglitol...... 79 Menactra...... 119 Methylprednisolone...... 109 Miglustat...... 105 Menest...... 114 Methylprednisolone Dose Pack Migranal...... 64 Mentax...... 63 ...... 109 Mili...... 114 Menveo...... 119 ...... 112 Millipred...... 109 Mepron...... 68 Metipranolol...... 124 Minastrin 24 Fe...... 114 Mercaptopurine...... 66 Metoclopramide HCl...... 61 Minipress...... 83 Meropenem...... 49 Metoclopramide ODT...... 61 Minitran...... 91 Merrem...... 49 Metolazone...... 89 Minivelle...... 114 Mesalamine...... 120 Metoprolol Succinate ER...... 85 Minocin...... 53 Mesalamine DR...... 120 Metoprolol Tartrate...... 85 Minocycline HCl...... 53 Mesnex...... 68 Minocycline HCl ER...... 53 27Tracked 27 27 Minoxidil...... 92 Myambutol...... 65 Nasonex...... 127 Mirapex...... 69 Mycamine...... 63 Natacyn...... 63 Mirapex ER...... 69 Mycobutin...... 65 Natazia...... 114 Mircera...... 82 Mycophenolate Mofetil...... 118 Nateglinide...... 79 Mirtazapine...... 58 Mycophenolic Acid DR...... 118 Natpara...... 121 Mirtazapine ODT...... 58 Mydayis...... 93 Natroba...... 68 Mirvaso...... 97 Myfortic...... 118 Nebupent...... 68 Misoprostol...... 104 Myorisan...... 97 Necon 0.5/35-28...... 114 Mitigare...... 63 Myrbetriq...... 106 Necon 7/7/7...... 114 Mobic...... 40 Mysoline...... 54 Nefazodone HCl...... 60 Modafinil...... 131 Mytesi...... 102 Neo-Synalar...... 97 Moderiba...... 73 N Neomycin Sulfate...... 46 Moderiba 1200 Dose Pack.... 73 Nabumetone...... 40 Neomycin/Bacitracin/ Moderiba 800 Dose Pack...... 73 Nadolol...... 85 Polymyxin...... 122 Moexipril HCl...... 83 Nadolol/Bendroflumethiazide Neomycin/Polymyxin/ Bacitracin/Hydrocortisone Moexipril/Hydrochlorothiazide ...... 88 ...... 122 ...... 88 Nafcillin Sodium...... 50 Neomycin/Polymyxin/ Mometasone Furoate...... 109, Naftifine HCl...... 63 Dexamethasone...... 122 126 Naftin...... 63 Neomycin/Polymyxin/ MonoNessa...... 114 Naloxone HCl...... 45 Gramicidin...... 122 Montelukast Sodium...... 127 Naltrexone HCl...... 45 Neomycin/Polymyxin/ Monurol...... 47 Namenda...... 58 Hydrocortisone...... 122, 125 Morgidox 1x50mg...... 53 Namenda Titration Pak...... 58 Neoral...... 118 Morphine Sulfate...... 44 Namenda XR...... 58 Nephramine...... 100 Morphine Sulfate ER...... 42 Namenda XR Titration Pack Nerlynx...... 67 Movantik...... 102 ...... 58 Nesina...... 79 MoviPrep...... 103 Namzaric...... 94 Neuac...... 97 Moxeza...... 51 Naprelan...... 40 Neulasta...... 82 Moxifloxacin HCl/Sodium HCl Naproxen...... 40 Neupogen...... 82 ...... 52 Naproxen DR...... 40 Neupro...... 69 Moxifloxacin HCl...... 52 Naproxen Sodium...... 40 Neurontin...... 54 MS Contin...... 42 Naproxen Sodium ER...... 40 Nevanac...... 125 Multaq...... 84 Naratriptan HCl...... 64 Nevirapine...... 74 Mupirocin...... 47 Narcan...... 45 Nevirapine ER...... 74 Myalept...... 102 Nardil...... 59 Nexavar...... 67 28 28Tracked 28 Nexium...... 104 Norethindrone Acetate/Ethinyl Nuplazid...... 71 ER...... 91 Estradiol...... 114 NutreStore...... 100 Niacor...... 91 Norethindrone Acetate/Ethinyl Nutrilipid...... 100 Estradiol/Ferrous Fumarate Niaspan...... 91 Nutropin AQ...... 111 ...... 114 Nicardipine HCl...... 86 NuvaRing...... 114 Norgestimate/Ethinyl Estradiol Nicotrol Inhaler...... 46 ...... 114 Nuvigil...... 131 Nicotrol NS...... 46 Noritate...... 47 Nyamyc...... 63 Nifedipine ER...... 86 Norlyroc...... 116 Nymalize...... 86 Nikki...... 114 Normosol-M in D5W...... 100 Nystatin...... 63 Nilandron...... 66 Normosol-R...... 100 Nystatin/Triamcinolone...... 63 Nilutamide...... 66 Normosol-R in D5W...... 100 Nystop...... 63 Nimodipine...... 86 Norpramin...... 60 O Ninlaro...... 66 Northera...... 83 Ocaliva...... 105 Nisoldipine ER...... 86 Nortrel 0.5/35...... 114 Ocella...... 114 Nitro-Bid...... 91 Nortrel 1/35...... 114 Octagam...... 119 Nitro-Dur...... 91 Nortrel 7/7/7...... 114 Octreotide Acetate...... 117 Nitrofurantoin...... 47 Nortriptyline HCl...... 61 Ocuflox...... 52 Nitrofurantoin Macrocrystals Norvasc...... 86 Odefsey...... 74 ...... 47 Norvir...... 76 Odomzo...... 67 Nitrofurantoin Monohydrate Novolin 70/30 Vial...... 81 Ofev...... 130 ...... 47 Novolin N Vial...... 81 Ofloxacin...... 52 Nitroglycerin...... 91 Novolin R Vial...... 81 Ogestrel...... 114 Nitroglycerin Lingual...... 91 NovoLog FlexPen...... 81 Olanzapine...... 71 Nitroglycerin Transdermal..... 91 NovoLog Mix 70/30 Prefilled Olanzapine ODT...... 71 Nitrostat...... 91 FlexPen...... 81 Olanzapine/Fluoxetine...... 58 Nizatidine...... 103 NovoLog Mix 70/30 Vial...... 81 Olmesartan Medoxomil...... 83 Nizoral...... 63 NovoLog PenFill...... 81 Olmesartan Medoxomil/ Noctiva...... 111 NovoLog Vial...... 81 Amlodipine/ Nolix...... 109 Hydrochlorothiazide...... 88 Noxafil...... 63 Nora-BE...... 116 Olmesartan Medoxomil/ Nucala...... 130 Norco...... 44 Hydrochlorothiazide...... 88 Nucynta...... 44 Norditropin FlexPro...... 111 Olopatadine HCl...... 123, 126 Nucynta ER...... 42 Norethindrone...... 116 Olumiant...... 118 Nuedexta...... 94 Norethindrone Acetate...... 116 Olux...... 109 NuLYTELY/Flavor Packs..... 103 Omeclamox-Pak...... 102 29Tracked 29 29 Omega-3-Acid Ethyl Esters.... 91 OsmoPrep...... 104 Pandel...... 109 Omeprazole...... 104 Osphena...... 116 Panlor...... 44 Omeprazole/Sodium Otezla...... 119 Panretin...... 67 Bicarbonate...... 104 Otovel...... 125 Pantoprazole Sodium...... 104 Omnaris...... 127 Otrexup...... 118 Paricalcitol...... 121 Omnipred...... 125 Ovide...... 68 Parlodel...... 69 Omnitrope...... 111 Oxacillin Sodium...... 50 Parnate...... 59 Ondansetron HCl...... 61 Oxandrolone...... 112 Paromomycin Sulfate...... 46 Ondansetron ODT...... 61 Oxaprozin...... 40 Paroxetine...... 60 Onexton...... 97 Oxazepam...... 77 Paroxetine HCl...... 60 Onfi...... 54 Oxcarbazepine...... 57 Paser...... 65 Onglyza...... 79 Oxiconazole Nitrate...... 63 Pataday...... 123 Onzetra Xsail...... 64 Oxistat...... 63 Patanase...... 126 Opana...... 44 Oxsoralen Ultra...... 97 Patanol...... 123 Opsumit...... 129 Oxtellar XR...... 57 Paxil...... 60 Oracea...... 53 Oxybutynin Chloride...... 106 Pazeo...... 123 Oralair...... 130 Oxybutynin Chloride ER...... 106 Pediarix...... 119 Orap...... 70 Oxycodone HCl...... 44 Pedvax HIB...... 119 Orapred ODT...... 109 Oxycodone HCl ER...... 42 PEG 3350/Electrolytes...... 104 Oravig...... 63 Oxycodone/Acetaminophen PEG-3350/Electrolytes...... 104 Orencia...... 118 ...... 44 PEG-3350/NaCl/Na Orencia Clickject...... 118 Oxycodone/Aspirin...... 44 Bicarbonate/KCl...... 104 Orenitram...... 129 Oxycodone/Ibuprofen...... 44 Peganone...... 57 Orfadin...... 105 OxyContin...... 42 Pegasys...... 73 Orkambi...... 128 Oxymorphone HCl...... 44 Pegasys ProClick...... 73 Orsythia...... 114 Oxymorphone HCl ER...... 42 Penicillin G Potassium...... 50 Ortho Micronor...... 116 Oxytrol...... 106 Penicillin G Potassium in Iso- Ortho Tri-Cyclen...... 115 Ozempic...... 79 Osmotic Dextrose...... 50 Ortho Tri-Cyclen Lo...... 115 P Penicillin G Procaine...... 50 Ortho-Cyclen...... 115 Pacerone...... 84 Penicillin G Sodium...... 50 Ortho-Novum 1/35...... 115 Paliperidone ER...... 71 Penicillin V Potassium...... 50 Ortho-Novum 7/7/7...... 115 Palynziq...... 105 Pennsaid...... 40 Oseltamivir Phosphate...... 76 Pamelor...... 61 Pentam 300...... 68 Oseni...... 79 Pancreaze...... 105 Pentasa...... 120 Pentoxifylline ER...... 88 30 30Tracked 30 Pepcid...... 103 Plegridy...... 95 Prazosin HCl...... 83 Percocet...... 44 Plegridy Starter Pack...... 95 Precose...... 79 Perforomist...... 128 Plenamine...... 100 Pred Forte...... 125 Perindopril Erbumine...... 84 Plenvu...... 104 Pred Mild...... 125 Periogard...... 95 Pliaglis...... 45 Pred-G...... 122 Permethrin...... 68 Podofilox...... 97 Pred-G S.O.P...... 122 Perphenazine...... 61 Polyethylene Glycol 3350 Prednicarbate...... 110 Pertzye...... 106 Powder...... 104 Prednisolone...... 110 Phenadoz...... 126 Polymyxin B Sulfate...... 47 Prednisolone Acetate...... 125 Phenelzine Sulfate...... 59 Polymyxin B Sulfate/ Prednisolone Sodium Trimethoprim Sulfate...... 122 Phenobarbital...... 54 Phosphate...... 110, 125 Polytrim...... 122 Phenoxybenzamine HCl...... 83 Prednisolone Sodium Pomalyst...... 66 Phosphate ODT...... 110 Phenytek...... 57 Portia-28...... 115 Prednisone...... 110 ...... 57 Potassium Chloride...... 100 Prednisone Intensol...... 110 Phenytoin Sodium Extended ...... 57 Potassium Chloride CR...... 100 Premarin...... 115 Phoslyra...... 102 Potassium Chloride ER...... 100 Premasol...... 101 Phospholine Iodide...... 124 Potassium Chloride/Dextrose Prepopik...... 104 ...... 100 Picato...... 97 Prevacid...... 104 Potassium Chloride/Dextrose/ Pilocarpine HCl...... 95, 124 Prevacid SoluTab...... 105 Lactated Ringers...... 100 Pimozide...... 70 Prevalite...... 91 Potassium Chloride/Dextrose/ Previfem...... 115 Pimtrea...... 115 Sodium Chloride...... 100 Prevymis...... 72 Pindolol...... 85 Potassium Chloride/Sodium Pioglitazone HCl...... 79 Chloride...... 101 Prezcobix...... 76 Pioglitazone HCl/Glimepiride Potassium Citrate ER...... 101 Prezista...... 76 ...... 79 Pradaxa...... 81 Priftin...... 65 Pioglitazone HCl/Metformin Praluent...... 91 Prilosec...... 105 HCl...... 79 Pramipexole Dihydrochloride Primaquine Phosphate...... 68 Piperacillin/Tazobactam...... 50 ...... 69 Primaxin IV...... 49 Pirmella 1/35...... 115 Pramipexole Dihydrochloride Primidone...... 54 ER...... 69 Piroxicam...... 40 Primlev...... 44 Prandin...... 79 Plaquenil...... 68 Prinivil...... 84 Prasugrel...... 83 Plasma-Lyte A...... 100 Pristiq...... 60 Pravachol...... 90 Plasma-Lyte-148...... 100 Privigen...... 119 Pravastatin Sodium...... 90 Plavix...... 83 ProAir HFA...... 128 31Tracked 31 31 ProAir RespiClick...... 128 Prosol...... 101 Quillivant XR...... 94 Probenecid...... 64 Protonix...... 105 Quinapril HCl...... 84 Probenecid/Colchicine...... 64 Protopic...... 97 Quinapril/Hydrochlorothiazide Procalamine...... 101 Protriptyline HCl...... 61 ...... 88 Procardia XL...... 86 Proventil HFA...... 128 Quinidine Gluconate CR...... 84 ProCentra...... 93 Provera...... 116 Quinidine Sulfate...... 84 Prochlorperazine...... 61 Provigil...... 131 Quinine Sulfate...... 68 Prochlorperazine Maleate...... 61 Prozac...... 60 Qvar Redihaler...... 127 Procrit...... 82 Prudoxin...... 97 R Procto-Med HC...... 120 Psorcon...... 110 Rabavert...... 119 Procto-Pak...... 120 Pulmicort...... 127 Rabeprazole Sodium...... 105 Proctosol HC...... 120 Pulmicort Flexhaler...... 127 HCl...... 116 Proctozone-HC...... 120 Pulmozyme...... 130 Ramipril...... 84 Profeno...... 40 Purixan...... 66 Ranexa...... 88 Progesterone...... 116 Pylera...... 103 Ranitidine HCl...... 103 Proglycem...... 80 Pyrazinamide...... 65 Rapaflo...... 107 Prograf...... 118 Pyridostigmine Bromide...... 65 Rapamune...... 118 Prolastin-C...... 106 Pyridostigmine Bromide ER Rasagiline Mesylate...... 70 Prolensa...... 125 ...... 65 Rasuvo...... 118 Prolia...... 121 Q Ravicti...... 106 Promacta...... 82 Qbrelis...... 84 Rayaldee...... 121 Promethazine HCl...... 126 Qnasl...... 127 Rayos...... 110 Prometrium...... 116 Qnasl Childrens...... 127 Razadyne...... 58 Propafenone HCl...... 84 Qtern...... 79 Razadyne ER...... 58 Propafenone HCl ER...... 84 Quadracel...... 119 Rebetol...... 73 Propantheline Bromide...... 102 Qualaquin...... 68 Rebif...... 95 Proparacaine HCl...... 122 Quartette...... 115 Rebif Rebidose...... 95 Propranolol HCl...... 85 Quasense...... 115 Rebif Rebidose Titration Pack ...... 95 Propranolol HCl ER...... 85 Qudexy XR...... 55, 56 Rebif Titration Pack...... 95 Propranolol/ Questran...... 91 Hydrochlorothiazide...... 88 Questran Light...... 91 Reclipsen...... 115 Propylthiouracil...... 117 Quetiapine Fumarate...... 71 Recombivax HB...... 119 ProQuad...... 119 Quetiapine Fumarate ER...... 71 Rectiv...... 91 Proscar...... 107 QuilliChew ER...... 94 Reglan...... 61 Regranex...... 97 32 32Tracked 32 Relenza Diskhaler...... 76 Rifater...... 65 Ruconest...... 117 Relistor...... 103 Rilutek...... 94 Rydapt...... 67 Relpax...... 64 Riluzole...... 94 Rytary...... 70 Remeron...... 58 Rimantadine HCl...... 76 Rythmol SR...... 84 Remeron Soltab...... 58 Riomet...... 79 S Renagel...... 102 Risedronate Sodium...... 121 Sabril...... 54 Renvela...... 102 Risedronate Sodium DR...... 121 Safyral...... 115 Repaglinide...... 79 Risperdal...... 71 Saizen...... 111 Repaglinide/Metformin HCl Risperdal Consta...... 71 Saizenprep Reconstitution Kit ...... 79 Risperidone...... 71 ...... 111 Repatha...... 91 Risperidone ODT...... 71 Salagen...... 95 Repatha Pushtronex System Ritalin...... 94 Samsca...... 101 ...... 91 Ritalin LA...... 94 Sancuso...... 61 Repatha SureClick...... 91 Ritonavir...... 76 Sandimmune...... 118 Requip XL...... 69 Rivastigmine Tartrate...... 58 Sandostatin...... 117 Rescriptor...... 74 Rivastigmine Transdermal Santyl...... 97 Restasis...... 122 System...... 58 Saphris...... 71 Restoril...... 131 Rivelsa...... 115 Sarafem...... 60 Retin-A...... 97 Rizatriptan Benzoate...... 64 Savaysa...... 81 Retin-A Micro...... 97 Rizatriptan Benzoate ODT..... 64 Savella...... 94 Retin-A Micro Pump...... 97 Robinul...... 102 Savella Titration Pack...... 94 Retrovir...... 75 Robinul Forte...... 102 Scopolamine...... 61 Revatio...... 129 Rocaltrol...... 121 Seasonique...... 115 Revlimid...... 66 Ropinirole ER...... 69 Segluromet...... 79 Rexulti...... 71 Ropinirole HCl...... 69 Selegiline HCl...... 70 Reyataz...... 76 Rosuvastatin Calcium...... 90 Selenium Sulfide...... 97 Rhopressa...... 122 Rotarix...... 119 Selzentry...... 75 Ribasphere...... 73 RotaTeq...... 120 Semprex-D...... 130 Ribasphere Ribapak...... 73 Rowasa...... 120 Sensipar...... 121 Ribavirin...... 73 Roweepra...... 53 Serevent Diskus...... 128 Ridaura...... 119 Roweepra XR...... 53 Seroquel...... 71 Rifabutin...... 65 Roxicodone...... 45 Seroquel XR...... 72 Rifadin...... 65 Rozerem...... 131 Serostim...... 103 Rifamate...... 65 Rubraca...... 66 Sertraline HCl...... 60 Rifampin...... 65 33Tracked 33 33 Setlakin...... 115 Somatuline Depot...... 117 Stribild...... 74 Sevelamer Carbonate...... 102 Somavert...... 117 Striverdi Respimat...... 128 Sharobel...... 116 Sonata...... 131 Stromectol...... 68 Shingrix...... 120 Soolantra...... 97 Suboxone...... 45 Signifor...... 117 Soriatane...... 97 Subsys...... 45 Sildenafil...... 129 Sorilux...... 97 Sucraid...... 106 Silenor...... 131 Sorine...... 84 Sucralfate...... 104 Siliq...... 97 Sotalol HCl...... 84 Sular...... 86 Silvadene...... 52 Sotylize...... 84 Sulfacetamide Sodium.... 52, 97 Silver Sulfadiazine...... 52 Sovaldi...... 73 Sulfacetamide Sodium/ Simbrinza...... 124 Spiriva HandiHaler...... 127 Prednisolone Sodium Phosphate...... 122 Simponi...... 118 Spiriva Respimat...... 127 Sulfadiazine...... 52 Simvastatin...... 90 ...... 89 Sulfamethoxazole/ Sinemet...... 70 Spironolactone/ Trimethoprim...... 52 Sinemet CR...... 70 Hydrochlorothiazide...... 88 Sulfamethoxazole/ Sporanox...... 63 Singulair...... 127 Trimethoprim DS...... 52 Sprintec 28...... 115 Sirolimus...... 118 Sulfamylon...... 48 Spritam...... 53 Sirturo...... 65 Sulfasalazine...... 121 Sprycel...... 67 Sivextro...... 47 Sulindac...... 40 SPS...... 101 Sklice...... 68 Sumatriptan...... 64 Sronyx...... 115 Sodium Chloride...... 101 Sumatriptan Succinate...... 64 SSD...... 52 Sodium Chloride 0.45%...... 101 Sumatriptan Succinate Refill Sodium Chloride 0.9%...... 101 Stalevo...... 70 ...... 64 Sodium Fluoride...... 101 Starlix...... 79 Sumatriptan/Naproxen Sodium ...... 64 Sodium Lactate...... 101 Stavudine...... 75 Suprax...... 49 Sodium Phenylbutyrate...... 106 Steglatro...... 79 Suprep Bowel Prep Kit...... 104 Sodium Polystyrene Sulfonate Steglujan...... 79 ...... 101 Stelara...... 97 Surmontil...... 61 Sodium Sulfacetamide...... 52 Stimate...... 111 Sustiva...... 74 Soliqua 100/33...... 79 Stiolto Respimat...... 130 Sutent...... 67 Solodyn...... 53 Stivarga...... 67 Syeda...... 115 Solosec...... 47 Strattera...... 94 Sylatron...... 73 Soloxide...... 53 Streptomycin Sulfate...... 46 Symbicort...... 130 Soltamox...... 66 Striant...... 112 Symbyax...... 58 Symdeko...... 128 34 34Tracked 34 Symfi...... 74 Tavalisse...... 82 Tetrabenazine...... 94 Symfi Lo...... 74 Tazarotene...... 97 Tetracycline HCl...... 53 SymlinPen 120...... 79 Tazicef...... 49 Texacort...... 110 SymlinPen 60...... 79 Tazorac...... 97 Thalomid...... 66 Symproic...... 103 Taztia XT...... 86 Theo-24...... 129 Synalar...... 110 Tecfidera...... 95 Theophylline...... 129 Synarel...... 117 Tecfidera Starter Pack...... 95 Theophylline CR...... 129 Syndros...... 62 Technivie...... 73 Theophylline ER...... 129 Synjardy...... 79 Teflaro...... 49 Thiola...... 107 Synjardy XR...... 79 Tegretol...... 57 Thioridazine HCl...... 70 Synribo...... 66 Tegretol-XR...... 57 Thiothixene...... 70 Synthroid...... 116 Tekturna...... 88 Thyrolar...... 116 Syprine...... 101 Tekturna HCT...... 88 Tiagabine HCl...... 54 T Telmisartan...... 83 Tiazac...... 86 Tabloid...... 66 Telmisartan/Amlodipine...... 88 Tigan...... 61 Taclonex...... 97 Telmisartan/ Tigecycline...... 48 Tacrolimus...... 97, 118 Hydrochlorothiazide...... 88 Tikosyn...... 84 Tafinlar...... 67 Temazepam...... 131 Timolol Maleate...... 85, 124 Tagrisso...... 67 Tenivac...... 120 Timolol Maleate Ophthalmic Taltz...... 97 Tenofovir Disoproxil Fumarate Gel Forming...... 124 ...... 75 Tamiflu...... 76 Timoptic Ocudose...... 124 Tenoretic 100...... 89 Citrate...... 66 Timoptic-XE...... 124 Tenoretic 50...... 89 Tamsulosin HCl...... 107 Tindamax...... 48 Tenormin...... 85 Tanzeum...... 79 Tinidazole...... 48 Terazosin HCl...... 107 Tapazole...... 117 Tirosint...... 116 Terbinafine HCl...... 63 Taperdex 12-Day...... 110 Tivicay...... 74 Terbutaline Sulfate...... 128 Taperdex 6-Day...... 110 Tizanidine HCl...... 130 Terconazole...... 63 Tarceva...... 67 TOBI...... 128 Testim...... 112 Targadox...... 53 TOBI Podhaler...... 128 Testosterone...... 112 Targretin...... 67 Tobradex...... 122 ...... 112 Tarina Fe 1/20...... 115 Tobradex ST...... 122 ...... 112 Tarka...... 88 Tobramycin...... 128 Testosterone Pump...... 112 Tasigna...... 67 Tobramycin Sulfate...... 46 Tetanus/Diphtheria Toxoids- Tasmar...... 69 Tobramycin/Dexamethasone Adsorbed Adult...... 120 ...... 123 35Tracked 35 35 Tobrex...... 46 Trazodone HCl...... 60 Trilipix...... 90 Tofranil...... 61 Trecator...... 65 TriLyte...... 104 Tolak...... 97 Trelegy Ellipta...... 130 Trimethobenzamide HCl...... 61 Tolazamide...... 79 Trelstar Mixject...... 117 Trimethoprim...... 48 Tolbutamide...... 79 Tremfya...... 97 Trimipramine Maleate...... 61 Tolcapone...... 69 Tresiba FlexTouch...... 81 Trinessa...... 115 Tolmetin Sodium...... 40 Tretinoin...... 68, 97 Trintellix...... 60 Tolterodine Tartrate...... 106 Tretinoin Microsphere...... 98 Triumeq...... 74 Tolterodine Tartrate ER...... 106 Trexall...... 118 Trivora-28...... 115 Topamax...... 56 Treximet...... 64 Trizivir...... 75 Topamax Sprinkle...... 56 Trezix...... 45 Trokendi XR...... 56 Topicort...... 110 Tri-Legest Fe...... 115 Trophamine...... 101 Topiramate...... 56 Tri-Lo-Estarylla...... 115 Trospium Chloride...... 106 Topiramate ER...... 56 Tri-Lo-Sprintec...... 115 Trospium Chloride ER...... 107 Toprol XL...... 85 Tri-Mili...... 115 Trulance...... 103 Torsemide...... 89 Tri-Norinyl 28...... 115 Trulicity...... 79 Toujeo Max Solostar...... 81 Tri-Previfem...... 115 Trumenba...... 120 Toujeo SoloStar...... 81 Tri-Sprintec...... 115 Trusopt...... 124 Toviaz...... 106 Tri-Vylibra...... 115 Truvada...... 75 TPN Electrolytes...... 101 Triamcinolone Acetonide... 110, Tudorza Pressair...... 127 Tracleer...... 129 127 Twinrix...... 120 Tradjenta...... 79 Triamcinolone in Orabase..... 95 Twynsta...... 89 Tramadol HCl...... 45 Triamterene/ Tybost...... 74 Hydrochlorothiazide...... 89 Tramadol HCl ER...... 42 Tydemy...... 115 Trianex...... 110 Tramadol HCl/Acetaminophen Tygacil...... 48 Tribenzor...... 89 ...... 45 Tykerb...... 67 Tricor...... 90 Trandolapril...... 84 Tylenol/Codeine #3...... 45 Triderm...... 110 Trandolapril/Verapamil HCl ER Tylenol/Codeine #4...... 45 ...... 89 Tridesilon...... 110 Tymlos...... 121 Tranexamic Acid...... 82 Trientine HCl...... 101 Typhim Vi...... 120 Transderm-Scop...... 61 Trifluoperazine HCl...... 70 U Tranxene T...... 77 Trifluridine...... 74 Uceris...... 120, 121 Tranylcypromine Sulfate...... 59 Triglide...... 90 Uloric...... 64 Travasol...... 101 Trihexyphenidyl HCl...... 68 Ultracet...... 45 Travatan Z...... 125 Trileptal...... 57 36 36Tracked 36 Ultram...... 45 Vaseretic...... 89 Viekira Pak...... 73 Ultravate...... 110 Vasotec...... 84 Viekira XR...... 73 Unasyn...... 50 Vecamyl...... 89 Vienva...... 115 Unasyn Bulk Pack...... 50 Vectical...... 98 Vigabatrin...... 54 Unithroid...... 116 Velivet...... 115 Vigamox...... 52 Uptravi...... 129 Velphoro...... 102 Viibryd...... 60 Urecholine...... 107 Veltassa...... 101 Viibryd Starter Pack...... 60 Urocit-K...... 101 Vemlidy...... 73 Vimovo...... 40 Uroxatral...... 107 Venclexta...... 67 Vimpat...... 57 Urso...... 103 Venclexta Starting Pack...... 67 Viokace...... 106 Ursodiol...... 103 Venlafaxine HCl...... 60 Viracept...... 76 V Venlafaxine HCl ER...... 60 Viramune...... 74 Vabomere...... 49 Ventavis...... 129 Viramune XR...... 74 Vagifem...... 115 Ventolin HFA...... 128 Viread...... 75 Valacyclovir HCl...... 74 Verapamil HCl...... 86 Viroptic...... 74 Valchlor...... 65 Verapamil HCl ER...... 86 Vistaril...... 61 Valcyte...... 72 Verapamil HCl SR...... 86 Vivelle-Dot...... 115 Valganciclovir...... 72 Veregen...... 98 Vivitrol...... 45 Valganciclovir Hydrochlorde Verelan...... 86 Vivlodex...... 40 ...... 73 Verelan PM...... 87 Vogelxo...... 112 Valium...... 77 Veripred 20...... 110 Vogelxo Pump...... 112 Valproic Acid...... 54 Versacloz...... 72 Voltaren...... 40 Valsartan...... 83 Verzenio...... 66 Voriconazole...... 63 Valsartan/Hydrochlorothiazide Vesicare...... 107 Vosevi...... 73 ...... 89 Vfend...... 63 Votrient...... 67 Valtrex...... 74 Vfend IV...... 63 VP-PNV-DHA...... 102 Vancocin HCl...... 48 Viberzi...... 103 Vraylar...... 72 Vancomycin HCl...... 48 Vibramycin...... 53 Vyfemla...... 115 Vandazole...... 48 Vicodin...... 45 Vylibra...... 115 Vanos...... 110 Vicodin ES...... 45 Vytorin...... 91 VAQTA...... 120 Vicodin HP...... 45 Vyvanse...... 93 Varivax...... 120 Victoza...... 79 Vyzulta...... 125 Varizig...... 119 Videx EC...... 75 W Varubi...... 62 Videx Pediatric...... 75 Warfarin Sodium...... 82 Vascepa...... 91 37Tracked 37 37 Welchol...... 91 Y Ziagen...... 75 Wellbutrin SR...... 59 Yasmin 28...... 115 Ziana...... 98 Wellbutrin XL...... 59 Yaz...... 115 Zidovudine...... 75 WYMZYA Fe...... 115 YF-Vax...... 120 Zileuton ER...... 127 X Yosprala...... 105 Zioptan...... 125 Xalatan...... 125 Yuvafem...... 115 Ziprasidone HCl...... 72 Xalkori...... 67 Z Zipsor...... 40 Xanax...... 77 Zafirlukast...... 127 Zirgan...... 73 Xanax XR...... 77 Zaleplon...... 131 Zithromax...... 51 Xarelto...... 82 Zanaflex...... 131 Zithromax Tri-Pak...... 51 Xarelto Starter Pack...... 82 Zantac...... 103 Zithromax Z-Pak...... 51 Xatmep...... 118 Zarah...... 115 Zocor...... 90 Xeljanz...... 118 Zarontin...... 54 Zofran...... 62 Xeljanz XR...... 118 Zarxio...... 82 Zofran ODT...... 62 Xenazine...... 94 Zavesca...... 106 Zohydro ER...... 43 Xerese...... 74 Zegerid...... 105 Zolinza...... 66 Xermelo...... 103 Zejula...... 66 Zolmitriptan...... 65 Xgeva...... 121 Zelapar...... 70 Zolmitriptan ODT...... 65 Xhance...... 127 Zelboraf...... 67 Zoloft...... 60 Xifaxan...... 103 Zemaira...... 106 Zolpidem Tartrate...... 131 Xigduo XR...... 79 Zembrace Symtouch...... 65 Zomacton...... 111 Xiidra...... 123 Zemplar...... 121 Zomig...... 65 Ximino...... 53 Zenatane...... 98 Zomig ZMT...... 65 Xolair...... 119 Zenchent...... 115 Zonalon...... 98 Xopenex...... 128 Zenpep...... 106 Zonegran...... 54 Xopenex Concentrate...... 128 Zenzedi...... 93 Zonisamide...... 54 Xopenex HFA...... 128 Zepatier...... 73 Zontivity...... 82 Xtampza ER...... 43 Zerbaxa...... 49 Zorbtive...... 103 Xtandi...... 66 Zerit...... 75 Zortress...... 118 Xulane...... 115 Zestoretic...... 89 Zorvolex...... 40 Xultophy 100/3.6...... 80 Zestril...... 84 Zostavax...... 120 Xuriden...... 106 Zetia...... 91 Zosyn...... 50 Xyrem...... 131 Zetonna...... 127 Zovia 1/35E...... 115 Ziac...... 89 Zovirax...... 74 38 38Tracked 38 Zubsolv...... 45 Zyflo...... 127 Zypitamag...... 90 Zuplenz...... 62 Zyflo CR...... 127 Zyprexa...... 72 Zurampic...... 64 Zykadia...... 67 Zyprexa Relprevv...... 72 Zyban...... 46 Zylet...... 123 Zyprexa Zydis...... 72 Zyclara Pump...... 98 Zyloprim...... 64 Zytiga...... 66 Zydelig...... 67 Zymaxid...... 52 Zyvox...... 48 tRACK 39 39 Covered drugs by medical condition 138 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 132-165. tRACK

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

A1 DifluC1 Analgesics Diflunisalnisal (Tablet) 1

B1 DuexC1 Anti-inflammatory Drugs Duexisis (Tablet) 4 ST

ArthrC1 EtodC1 otec olac Arthrotec50 50 (Tablet Etodolac (200mg 3 Delayed-Release) Capsule, 300mg

ArthrC1 otec Capsule, 400mg Tablet Arthrotec75 75 (Tablet 3 1 Delayed-Release) Immediate-Release,

CamC1 500mg Tablet bia Cambia (Packet) 3 Immediate-Release) CeleC1 brex EtodC1 Celebrex (Capsule) 3 QL olac EtodolacER ER (Tablet CeleC1 coxi Celecoxibb (Capsule) 1 QL Extended-Release 24 1

DaypC1 Dayproro (Tablet) 3 Hour)

FeldC1 C1 Diclo ene fena c DiclofenacPota Potassium Feldene (Capsule) 3 ssiu m FenoC1 prof en (Tablet Immediate- 1 FenoprofenCalci Calcium um Release) (400mg Capsule, 1

DicloC1 fena c DiclofenacSodi Sodium 600mg Tablet) um

FlectC1 (1% Gel, 1.5% 1 PA Flectoror (Patch) 3 PA, QL

FlurbC1 Transdermal Solution) iprof Flurbiprofenen (Tablet) 1 DicloC1 fena c IbuC1 DiclofenacSodi Sodium DR um DR Ibu (Tablet) 1

(Tablet Delayed- 1 IbupC1 rofe Release) Ibuprofenn (100mg/5ml

DicloC1 Suspension, 400mg fena c DiclofenacSodi Sodium ER 1 um ER Tablet, 600mg Tablet, (Tablet Extended- 1 800mg Tablet)

Release 24 Hour) KetoC1 prof en ER DicloC1 Ketoprofen ER fena c DiclofenacSodi Sodium/ um/ Miso prost (Capsule Extended- 1 ol Misoprostol (Tablet 1 Release 24 Hour) Delayed-Release)

Bold type = Brand name drug Plain type = Generic drug 40 tRACK 40 Last updated October 1, 2018 239 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

LodiC1 SulinC1 Lodinene (Tablet) 4 Sulindacdac (Tablet) 1

MeclC1 TolmC1 ofen etin amat Sodi Meclofenamatee Tolmetinum Sodium Sodi um 1 Sodium (Capsule) (400mg Capsule, 1

MefeC1 nami c 600mg Tablet) MefenamicAcid Acid 1 VimoC1 (Capsule) Vimovovo (Tablet

C1 4 ST Melo xica Meloxicamm (Tablet) 1 Delayed-Release)

VivloC1 MobiC1 dex Mobicc (Tablet) 3 Vivlodex (Capsule) 3 QL

VoltaC1 NabC1 ren umet Nabumetoneone (Tablet) 1 Voltaren (Gel) 3 PA

ZipsC1 NaprC1 or Naprelanelan (Tablet Zipsor (Capsule) 4 ST

ZorvC1 Extended-Release 24 4 Zorvolexolex (Capsule) 3 ST Hour) OpioidB1 Analgesics, Long-acting

NaprC1 oxen BelbC1 Naproxen (125mg/5ml Belbucauca (150mcg Suspension, 250mg Film, 300mcg Film, Tablet Immediate- 450mcg Film, 7D, DL, PA, 3 Release, 375mg Tablet 1 600mcg Film, QL Immediate-Release, 750mcg Film, 75mcg 500mg Tablet Immediate-Release) Film) BelbC1 uca NaprC1 oxen Belbuca (900mcg 7D, DL, PA, Naproxen DR DR (Tablet 4 Delayed-Release) 1 Film) QL BuprC1 enor phin Buprenorphinee (Patch (Generic EC-Naprosyn) 3 7D, DL, QL NaprC1 oxen Weekly) NaproxenSodi Sodium um ButrC1 (Tablet Immediate- ansButrans (Patch 1 2 7D, DL, QL Release) (Generic Weekly)

ConzC1 Anaprox DS) ipConzip (Capsule

NaprC1 oxen 7D, DL, QL,

NaproxenSodi Sodium ER um Extended-Release 24 3 (TabletER Extended- MME 1 Hour) Release 24 Hour) DoloC1 7D, DL, QL, phin (Generic Naprelan) Dolophinee (Tablet) 3

C1 MME Oxa prozi n Oxaprozin (Tablet) 1 DuraC1 gesi Duragesicc (100mcg/ PenC1 nsai Pennsaidd hr Patch 72 Hour, 7D, DL, QL, (Transdermal 4 PA 50mcg/hr Patch 72 4 MME Solution) Hour, 75mcg/hr PiroxC1 Piroxicamicam (Capsule) 1 Patch 72 Hour)

ProfC1 Profenoeno (Tablet) 1

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 41 41 340 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

DuraC1 KadiC1 gesi an Duragesicc (12mcg/hr Kadian (100mg Patch 72 Hour, 7D, DL, QL, Capsule Extended- 3 25mcg/hr Patch 72 MME Release 24 Hour, Hour) 200mg Capsule

EmbC1 Embedaeda (Capsule 7D, DL, QL, Extended-Release 24 2 Extended-Release) MME Hour, 40mg Capsule

ExalC1 go Extended-Release 24 7D, DL, QL, Exalgo (12mg Tablet 4 Extended-Release 24 Hour, 60mg Capsule MME Hour Abuse- Extended-Release 24 Deterrent, 16mg Hour, 80mg Capsule Tablet Extended- Extended-Release 24 7D, DL, QL, Release 24 Hour 4 Hour, 50mg Capsule MME Abuse-Deterrent, Extended-Release 24 32mg Tablet Hour)

KadiC1 Extended-Release 24 Kadianan (10mg Hour Abuse- Capsule Extended- Deterrent) Release 24 Hour,

ExalC1 go 20mg Capsule 7D, DL, QL, Exalgo (8mg Tablet 3 Extended-Release 24 7D, DL, QL, Extended-Release 24 MME 3 Hour Abuse- MME Hour, 30mg Capsule Deterrent) Extended-Release 24

FentC1 anyl Hour) Fentanyl (Patch 72 7D, DL, QL, LevoC1 rpha 1 nol LevorphanolTartr Tartrate 7D, DL, QL, Hour) MME ate 1

HydrC1 omo (Tablet) MME rpho Hydromorphonene HCl HCl ER MethC1 adon e ER (Tablet Extended- 7D, DL, QL, MethadoneHCl HCl (10mg 1 Release 24 Hour MME Tablet, 5mg Tablet, 7D, DL, QL, 10mg/5ml Oral 1 Abuse-Deterrent) MME HysiC1 ngla Solution, 5mg/5ml Oral HysinglaER ER (Tablet Solution) Extended-Release 24 7D, DL, QL, 2 Hour Abuse- MME Deterrent)

Bold type = Brand name drug Plain type = Generic drug 42 tRACK 42 Last updated October 1, 2018 441 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

MorC1 OxycC1 phin odon e e MorphineSulfa Sulfate ER OxycodoneHCl HCl ER te ER (CapsuleER Extended- (10mg Tablet Release 24 Hour) Extended-Release 12 (Generic Kadian), 7D, DL, QL, Hour Abuse-Deterrent, (Tablet Extended- 1 15mg Tablet Extended- Release) (Generic MS MME Release 12 Hour Contin), (Capsule Abuse-Deterrent, 20mg Extended-Release 24 Tablet Extended- 7D, DL, QL, 3 Hour) (Generic Avinza) Release 12 Hour MME

MSC1 Cont MSin Contin (100mg Abuse-Deterrent, 30mg Tablet Extended- Tablet Extended- Release, 200mg Release 12 Hour Abuse-Deterrent, 40mg Tablet Extended- 7D, DL, QL, 4 Tablet Extended- Release, 30mg Tablet MME Release 12 Hour Extended-Release, Abuse-Deterrent)

OxycC1 60mg Tablet odon e OxycodoneHCl HCl ER ER Extended-Release) (60mg Tablet MSC1 Cont MSin Contin (15mg 7D, DL, QL, Extended-Release 12 7D, DL, QL, Tablet Extended- 3 Hour Abuse-Deterrent, 4 MME MME Release) 80mg Tablet Extended-

NucyC1 nta NucyntaER ER (Tablet Release 12 Hour 7D, DL, QL, Extended-Release 12 2 Abuse-Deterrent) OxyC1 Cont MME in Hour) OxyContin (Tablet Extended-Release 12 7D, DL, QL, 2 Hour Abuse- MME Deterrent)

OxyC1 mor phon Oxymorphonee HCl ER HCl ER 7D, DL, QL, (Tablet Extended- 1 MME Release 12 Hour)

TramC1 adol HCl TramadolER HCl ER 7D, DL, QL, (Capsule Extended- 3 Release 24 Hour) MME

TramC1 adol HCl TramadolER HCl ER 7D, DL, QL, (Tablet Extended- 1 Release 24 Hour) MME

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 43 43 542 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

XtamC1 FentC1 pza ora XtampzaER ER (Capsule Fentora (Tablet) 4 DL, PA, QL

HydrC1 ocod Extended-Release 12 one 7D, DL, QL, HydrocodoneBitar trate / 3 Acet amin ophe Hour Abuse- ST, MME Bitartrate/n Deterrent) Acetaminophen

ZohyC1 dro ZohydroER ER (Capsule (10mg-300mg Tablet, 7D, DL, QL, Extended-Release 12 7D, DL, PA, 325mg-2.5mg Tablet, 1 3 5mg-300mg Tablet, MME Hour Abuse- QL, MME 7.5mg-300mg Tablet, Deterrent) 7.5mg-325mg/15ml B1 Opioid Analgesics, Short-acting Oral Solution)

AbstC1 ral HydrC1 ocod Abstral (Tablet one/ Hydrocodone/Acet amin 4 DL, PA, QL ophe n 7D, DL, QL, Sublingual) Acetaminophen 1

AcetC1 MME amin ophe Acetaminophen/n/ (Tablet) Cod eine

HydrC1 ocod Codeine one/ Hydrocodone/Ibup 7D, DL, QL, rofe n 1 (120mg-12mg/5ml 7D, DL, QL, Ibuprofen (Tablet) MME

HydrC1 Oral Solution, 1 omo rpho Hydromorphonene HCl MME HCl 300mg-15mg Tablet, (10mg/ml Injection, 1 7D, DL 300mg-30mg Tablet, 50mg/5ml Injection)

300mg-60mg Tablet) C1 Hydr omo rpho ActiqC1 Hydromorphonene HCl Actiq (Lozenge on a HCl 4 DL, PA, QL (1mg/ml Liquid, 2mg Handle) Tablet Immediate- ButoC1 rpha 7D, DL, QL, nol ButorphanolTartr Tartrate 7D, DL, QL, ate Release, 4mg Tablet 1 1 MME (Nasal Solution) MME Immediate-Release,

CodC1 eine Sulfa 8mg Tablet Immediate- Codeinete Sulfate 7D, DL, QL, 1 (Tablet) MME Release)

HydrC1 omo C1 Dilau rpho did Hydromorphonene HCl Dilaudid (1mg/ml HCl 7D, DL, QL, 1 7D, DL Liquid, 2mg Tablet, 3 (2mg/ml Injection) MME IbudC1 7D, DL, QL, 4mg Tablet) Ibudoneone (Tablet) 1 MME DilauC1 7D, DL, QL, did LazaC1 Dilaudid (8mg Tablet) 4 Lazandanda (Nasal MME 4 DL, PA, QL DuraC1 mor Duramorphph (Injection) 1 7D, DL Solution)

LorcC1 7D, DL, QL, et EndC1 7D, DL, QL, ocetEndocet (Tablet) 1 Lorcet (Tablet) 1 MME MME

FentC1

anyl C1 Citra Lorc 7D, DL, QL, te et Fentanyl Citrate Oral HD Oral Tran Lorcet HD (Tablet) 1 smu cosa Transmucosall 1 DL, PA, QL MME (Lozenge on a Handle)

Bold type = Brand name drug Plain type = Generic drug 44 tRACK 44 Last updated October 1, 2018 643 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

OxycC1 odon e LorcC1 7D, DL, QL, OxycodoneHCl HCl et LorcetPlus Plus (Tablet) 1 MME (100mg/5ml

MorC1 phin Concentrate, 10mg e MorphineSulfa Sulfate te Tablet Immediate- (100mg/5ml Oral 7D, DL, QL, Solution, 10mg/5ml 1 Release, 15mg Tablet Oral Solution, 20mg/ MME Immediate-Release, 5ml Oral Solution) 20mg Tablet 7D, DL, QL,

MorC1 Immediate-Release, 1 phin e MorphineSulfa Sulfate MME te 30mg Tablet (10mg/ml Injection, 1 7D, DL Immediate-Release, 4mg/ml Injection, 5mg Tablet Immediate- 8mg/ml Injection) Release, 5mg Capsule MorC1 phin e SulfaMorphine Sulfate te Immediate-Release, (15mg Tablet 7D, DL, QL, 5mg/5ml Oral Immediate-Release, 1 Solution)

MME C1 Oxyc odon 30mg Tablet e/ Oxycodone/Acet amin ophe n 7D, DL, QL, Immediate-Release) Acetaminophen 1

MorC1 MME phin e MorphineSulfa Sulfate (Tablet) te

OxycC1 odon e/ (2mg/ml Injection, 1 7D, DL Oxycodone/AspirinAspir 7D, DL, QL, in 1 5mg/ml Injection) (Tablet) MME

OxycC1 odon e/ NorcC1 7D, DL, QL, Oxycodone/IbuprofenIbup 7D, DL, QL, o rofe Norco (Tablet) 3 n 1 MME (Tablet) MME

NucyC1 OxyC1 nta mor phon Nucynta (100mg 7D, DL, QL, Oxymorphonee HCl 4 HCl 7D, DL, QL, Tablet) (Tablet Immediate- 1 MME MME NucyC1 Nucyntanta (50mg 7D, DL, QL, Release) 3 PanlC1 7D, DL, QL, Tablet, 75mg Tablet) MME Panloror (Tablet) 1 OpaC1 Opanana (10mg Tablet 7D, DL, QL, MME PercC1 4 ocet Immediate-Release) MME Percocet

OpaC1 na (10mg-325mg Tablet, 7D, DL, QL, Opana (5mg Tablet 7D, DL, QL, 4 3 5mg-325mg Tablet, MME Immediate-Release) MME 7.5mg-325mg Tablet)

PercC1 Percocetocet 7D, DL, QL, 3 (2.5mg-325mg Tablet) MME

PrimlC1 7D, DL, QL, Primlevev (Tablet) 4 MME

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 45 45 744 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

RoxiC1 LidoC1 codo cain ne e Roxicodone (15mg 7D, DL, QL, LidocaineVisc Viscous 3 ous 1 Tablet, 5mg Tablet) MME (Solution)

C1 C1 Lido Roxi cain codo e/ ne Lidocaine/PrilocainePrilo Roxicodone (30mg 7D, DL, QL, cain 4 e 1 Tablet) MME (Cream)

LidoC1 SubsC1 der Subsysys (Liquid) 4 DL, PA, QL Lidodermm (Patch) 4 PA, QL

PliagC1 TramC1 lis adol TramadolHCl HCl (Tablet 7D, DL, QL, Pliaglis (Cream) 3 1 A1 Immediate-Release) MME Anti-Addiction/Substance Abuse Treatment

TramC1 adol HCl/ Agents TramadolAcet HCl/ amin ophe n 7D, DL, QL, B1 Acetaminophen 1 Alcohol Deterrents/Anti-craving MME AcaC1 mpr (Tablet) osat Acamprosatee Calcium Calci um DR

TreziC1 7D, DL, QL, DR (Tablet Delayed- 1 Trezixx (Capsule) 1 MME Release)

C1 C1 Anta Tyle buse nol/ Cod Tylenol/Codeineeine #3 7D, DL, QL, Antabuse (Tablet) 3 #3

3 DisulC1 (Tablet) MME Disulfiramfiram (Tablet) 1

C1 Tyle NaltrC1 nol/ exon Cod e Tylenol/Codeineeine #4 7D, DL, QL, HCl #4 Naltrexone HCl 3 1 (Tablet) MME (Tablet)

VivitrC1 ol UltraC1 7D, DL, QL, Vivitrol (Injection) 4 cet

Ultracet (Tablet) 3 B1 MME Opioid Dependence Treatments

BunC1 avail UltraC1 7D, DL, QL, Ultramm (Tablet) 3 Bunavail (Film) 3 QL, ST BuprC1 enor MME phin Buprenorphinee HCl HCl 1 QL VicoC1 7D, DL, QL, din (Tablet Sublingual) Vicodin (Tablet) 1 BuprC1 enor MME phin Buprenorphinee HCl/ HCl/ Nalo xone HCl

VicoC1 7D, DL, QL, Naloxone HCl (Tablet 1 QL din VicodinES ES (Tablet) 1 MME Sublingual)

SubC1 oxon e

C1 Suboxone (Film) 3 QL Vico 7D, DL, QL, din HP Vicodin HP (Tablet) 1 ZubsC1 MME Zubsolvolv (Tablet

A1 3 QL, ST Anesthetics Sublingual)

B1 LocalB1 Anesthetics Opioid Reversal Agents

EvziC1 LidoC1 o cain Lidocainee (5% Evzio (Injection) 4 ST

1 QL NaloC1 xone Ointment) Naloxone HCl HCl

LidoC1 1 cain Lidocainee (5% Patch) 1 PA, QL (Injection)

NarcC1 LidoC1 an cain e HClLidocaine HCl (4% Narcan (Liquid) 2

1 B1 External Solution) Smoking Cessation Agents

LidoC1 cain e LidocaineHCl HCl (Gel) 1

Bold type = Brand name drug Plain type = Generic drug 46 tRACK 46 Last updated October 1, 2018 845 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

BuprC1 ParoC1 opio mom n ycin BupropionHCl HCl SR ParomomycinSulfa Sulfate SR te 1 (150mg Tablet (Capsule) StreC1 ptom Extended-Release 12 1 ycin StreptomycinSulfa Sulfate te 4 Hour Smoking- (Injection)

TobrC1 Deterrent) amy cin TobramycinSulfa Sulfate te ChaC1 Chantixntix (Tablet) 2 (0.3% Ophthalmic

ChaC1 ntix Cont Chantixinuin Continuing Solution, 10mg/ml 1 g Mont h Pak 2 Month Pak (Tablet) Injection, 80mg/2ml

ChaC1 ntix Injection) Starti Chantixng Starting Mont h TobrC1 Pak 2 Tobrexex (0.3% Month Pak (Tablet) 2 NicoC1 trol Ophthalmic Ointment) Inhal Nicotroler Inhaler TobrC1 3 Tobrexex (0.3% (Inhaler) 3 NicoC1 trol Ophthalmic Solution) NicotrolNS NS (Nasal 3 B1 Solution) Antibacterials, Other

BacitC1 ZybaC1 racin Zybann (Tablet Bacitracin (Ophthalmic 1 Extended-Release 12 3 Ointment) BactC1 roba Hour) Bactrobann (Cream) 3

BactC1 A1 roba n BactrobanNasa Nasal Antibacterials l 3 PA AminoglycosidesB1 (Ointment)

CleoC1 cin AmikC1 acin Sulfa Cleocin (100mg Amikacinte Sulfate 1 Suppository, 150mg (Injection) GentC1 Gentakak (Ophthalmic Capsule, 300mg 3 1 Ointment) Capsule, 75mg

GentC1 amic Capsule, 2% Cream) in GentamicinSulfa Sulfate te CleoC1 cin in CleocinD5W in D5W (0.1% Cream, 0.1% 3 Ointment, 0.3% 1 (Injection)

CleoC1 cin Ophthalmic Solution, Pedi Cleocinatric Pediatric Gran ules 40mg/ml Injection) Granules (Oral 3

GentC1 amic in GentamicinSulfa Sulfate/ Solution) te/ 0.9% Sodi um CleoC1 Chlo cin 0.9%ride Sodium Chloride 1 Phos Cleocinphat Phosphate e 3 (Injection) (Injection)

IsotoC1 nic ClindC1 Gent amy Isotonicamic Gentamicin cin in 1 ClindamycinHCl HCl (Injection) (Capsule Immediate- 1

NeoC1 myci n NeomycinSulfa Sulfate Release) te 1 (Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 47 47 946 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

ClindC1 MetrC1 amy oGel cin - ClindamycinPalm Palmitate MetroGel-VaginalVagi itate nal HCl 1 3 HCl (Oral Solution) (Gel)

ClindC1 MetrC1 amy cin oLoti ClindamycinPhos on phat MetroLotion (Lotion) 4 e

MetrC1 Phosphate (2% Cream, onid azol Metronidazolee (0.75% 300mg/2ml Injection, 1 Cream, 0.75% Gel, 1% 600mg/4ml Injection, Gel, 0.75% Lotion, 900mg/6ml Injection) 250mg Tablet ClindC1 amy cin ClindamycinPhos phat Immediate-Release, 1 e in D5W Phosphate in D5W 1 500mg Tablet (Injection) Immediate-Release,

ClindC1 Clindesseesse (Cream) 3 375mg Capsule

ColisC1 timet Immediate-Release) hate ColistimethateSodi Sodium um MetrC1 1 onid azol Metronidazolee in in NaCl (Injection) NaCl 0.79 % 1 CubiC1 Cubicincin (Injection) 4 0.79% (Injection) MetrC1 onid DalvC1 azol ance Metronidazolee Vaginal Vagi Dalvance (Injection) 4 PA nal 1

DaptC1 (Gel) omy cin Daptomycin (Injection) 1 MonC1 urol

FlagC1 Monurol (Packet) 3 yl

Flagyl (250mg Tablet, MupiC1 Mupirocinrocin (2% Cream, 500mg Tablet, 375mg 3 1 2% Ointment)

Capsule) C1 Nitro furan toin FuraC1 Nitrofurantoin danti Furadantinn 1 HRM 4 HRM (Suspension)

(Suspension) NitroC1 furan toin Macr HiprC1 Nitrofurantoin ocry ex Hiprex (Tablet) 3 Macrocrystalsstals LineC1 zolid 1 HRM Linezolid (100mg/5ml (Capsule) (Generic Suspension, 600mg 1 PA Macrodantin) NitroC1 Tablet, 600mg/300ml furan toin NitrofurantoinMon ohyd Injection) Monohydraterate (100mg MacrC1 obid 1 HRM Macrobid (Capsule) 3 HRM Capsule) (Generic

MacrC1 odan Macrodantintin Macrobid)

3 HRM NoritC1 (Capsule) Noritateate (Cream) 4

MethC1 PolyC1 ena myxi mine n B Methenamine Sulfa Hipp Polymyxin B Sulfate te urate 1 1 Hippurate (Tablet) (Injection)

MetrC1 SiveC1 oCre xtro MetroCreamam (Cream) 3 Sivextro (200mg

MetrC1 MetroGeloGel (Gel) 3 Injection, 200mg 4 PA Tablet)

SoloC1 Solosecsec (Packet) 3

Bold type = Brand name drug Plain type = Generic drug 48 tRACK 48 Last updated October 1, 2018 1047 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

SulfaC1 CefaC1 mylo clor Sulfamylonn (5% CefaclorER ER (Tablet 4 Packet) Extended-Release 12 1

SulfaC1 mylo Hour) Sulfamylonn (85mg/ CefaC1 3 droxi gm Cream) Cefadroxill (1gm

TigeC1 cycli Tablet, 250mg/5ml Tigecyclinene (Injection) 1

TindC1 Suspension, 500mg/ 1 ama Tindamaxx (Tablet) 3 5ml Suspension, TinidC1 azol Tinidazolee (Tablet) 1 500mg Capsule)

TrimC1 etho CefaC1 prim zolin Sodi Trimethoprim (Tablet) 1 Cefazolinum Sodium

TygaC1 1 Tygacilcil (Injection) 4 (Injection)

CefdC1 C1 Vanc inir ocin VancocinHCl HCl Cefdinir (125mg/5ml 4 Suspension, 250mg/ (Capsule) 1 VancC1 omy 5ml Suspension, cin VancomycinHCl HCl (1000mg Injection, 300mg Capsule) CefeC1 10gm Injection, 500mg Cefepimepime (Injection) 1 1 CefixC1 Injection, 125mg Cefiximeime (Suspension) 1

CefoC1 taxi Capsule, 250mg me CefotaximeSodi Sodium um 1 Capsule) (Injection) VanC1 dazo CefoC1 le Vandazole (Gel) 1 Cefotetantetan (Injection) 1

ZyvoC1 x CefoC1 xitin Zyvox (100mg/5ml Sodi Cefoxitinum Sodium Suspension, 600mg (10gm Injection, 1gm 4 PA 1 Tablet, 600mg/300ml Injection, 2gm Injection) Injection)

B1 CefpC1 odox ime Beta-lactam, Cephalosporins CefpodoximeProx Proxetil etil

AvycC1 Avycazaz (Injection) 4 PA (100mg Tablet, 200mg

CefaC1 clor Tablet, 100mg/5ml 1 Cefaclor (125mg/5ml Suspension, 50mg/5ml Suspension, 375mg/ 3 Suspension) 5ml Suspension) CefpC1 rozil

CefaC1 clor Cefprozil (125mg/5ml Cefaclor (250mg Suspension, 250mg/ Capsule Immediate- 5ml Suspension, 1 Release, 500mg 1 250mg Tablet, 500mg Capsule Immediate- Tablet) Release, 250mg/5ml CeftC1 azidi Suspension) Ceftazidimeme (Injection) 1

CeftrC1 iaxo ne CeftriaxoneSodi Sodium um 1 (Injection)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 49 49 1148 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

CefuC1 MerrC1 roxi em me CefuroximeAxeti Axetil Merrem (Injection) 3 l 1 PrimC1 axin (Tablet) PrimaxinIV IV (Injection) 3

CefuC1 roxi VabC1 me omer Sodi Cefuroxime Sodium e um 1 Vabomere (Injection) 4 (Injection) B1 Beta-lactam, Penicillins CepC1 hale xin AmoC1 Cephalexin (125mg/ xicilli Amoxicillinn (125mg 5ml Suspension, Tablet Chewable, 250mg/5ml 250mg Tablet Suspension, 250mg 1 Chewable, 125mg/5ml Capsule, 500mg Suspension, 200mg/ Capsule, 750mg 5ml Suspension, Capsule, 250mg 250mg/5ml 1 Tablet, 500mg Tablet) Suspension, 400mg/ MaxiC1 Maxipimepime (Injection) 3 5ml Suspension,

SuprC1 ax Suprax (100mg Tablet 250mg Capsule, Chewable, 200mg 2 500mg Capsule, Tablet Chewable) 500mg Tablet, 875mg

SuprC1 Supraxax (100mg/5ml Tablet)

AmoC1 xicilli n/ Suspension, 200mg/ 3 Amoxicillin/Clav ulan ate Pota ssiu 5ml Suspension) Clavulanatem Potassium

SuprC1 Supraxax (400mg (Tablet Chewable, 2 1 Capsule) Suspension, Tablet

SuprC1 Immediate-Release) Supraxax (500mg/5ml 3 (Generic Augmentin)

Suspension) AmoC1 xicilli n/ Clav TaziC1 Amoxicillin/ ulan cef ate Pota Tazicef (Injection) 1 ssiu m ClavulanateER Potassium TeflaC1 ro 1 Teflaro (Injection) 4 ER (Tablet Extended-

ZerbC1 Zerbaxaaxa (Injection) 3 PA Release 12 Hour)

AmpC1 B1 Beta-lactam, Other Ampicillinicillin (Capsule) 1

AmpC1 AzacC1 icillin tam AmpicillinSodi Sodium Azactam (Injection) 3 um

AztreC1 ona (10gm Injection, Aztreonamm (Injection) 1 1

DoriC1 125mg Injection, 1gm pene Doripenemm (Injection) 3 Injection) ImipC1 ene

m/ C1 Cilas Amp Imipenem/Cilastatin icillin tatin - Ampicillin-SulbactamSulb 1 acta (Injection) (10gm-5gmm Injection, InvaC1 nz 1 Invanz (Injection) 4 1gm-0.5gm Injection,

MerC1 open Meropenemem (Injection) 1 2gm-1gm Injection)

Bold type = Brand name drug Plain type = Generic drug 50 tRACK 50 Last updated October 1, 2018 1249 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

AugC1 AzasC1 ment ite Augmentinin Azasite (Ophthalmic 4 3 (Suspension) Solution)

BactC1 AzithC1 ocill romy in cin BactocillDext in Dextrose Azithromycin (100mg/ rose 3 (Injection) 5ml Suspension,

BicillC1 in C- 200mg/5ml BicillinR C-R (Injection) 3

BicillC1 Suspension, 250mg 1 in L- BicillinA L-A (Injection) 3 Tablet, 500mg Tablet, DicloC1 xacill in DicloxacillinSodi Sodium um 1 600mg Tablet, 500mg (Capsule) Injection)

NafciC1 llin AzithC1 Sodi romy Nafcillinum Sodium Azithromycincin (1gm 1 (10gm Injection, 1gm 1 Packet)

Injection) ClaritC1 hro myci n C1 Clarithromycin Oxac illin Sodi Oxacillinum Sodium 1 (125mg/5ml (Injection) Suspension, 250mg/ PeniC1 cillin 1 G PenicillinPota G Potassium ssiu 5ml Suspension, m 1 (Injection) 250mg Tablet, 500mg

PeniC1 cillin G Tablet) PenicillinPota G ssiu m in Iso- ClaritC1 Osm hro otic myci Dext n ER Potassiumrose in Iso- Clarithromycin ER 2 Osmotic Dextrose (Tablet Extended- 1 (Injection) Release 24 Hour)

DificiC1 PeniC1 d cillin G Dificid (Tablet) 4 PenicillinProc G Procaine aine 1 E.E.C1 S. (Injection) E.E.S.400 400 (Tablet) 3

PeniC1 E.E.C1 cillin S. G Gran PenicillinSodi G Sodium ules um E.E.S. Granules 1 3 (Injection) (Suspension)

PeniC1 cillin EryPC1 V ed PenicillinPota V Potassium 200 ssiu EryPed 200 m 3 (125mg/5ml Oral (Suspension)

EryPC1 Solution, 250mg/5ml 1 ed EryPed400 400 Oral Solution, 250mg 4 (Suspension) Tablet, 500mg Tablet) Ery-C1 Tab PipeC1 racilli Ery-Tab (Tablet n/ Piperacillin/Tazo bact 3 am 1 Delayed-Release) Tazobactam (Injection) ErythC1 rocin

UnasC1 Lact yn Erythrocin obio Unasyn (Injection) 3 nate

C1 Lactobionate 3 Unas yn Bulk UnasynPack Bulk Pack 3 (Injection)

ErythC1 (Injection) rocin

ErythrocinStea Stearate rate ZosyC1 n 3 Zosyn (Injection) 3 (Tablet) MacrolidesB1

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 51 51 1350 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

ErythC1 CiprC1 romy o Erythromycincin (250mg Cipro (250mg Tablet, Capsule Delayed- 500mg Tablet, 1 Release, 5mg/gm 500mg/5ml 3 Ophthalmic Ointment) Suspension, 5gm/

ErythC1 romy cin ErythromycinBase Base 1 100ml Suspension) CiprC1 (Tablet) oflox Ciprofloxacinacin (250mg/ ErythC1 romy cin ErythromycinEthyl succ 5ml Suspension, inate 1 Ethylsuccinate 500mg/5ml (200mg/5ml 1 Suspension)

CiprC1 Suspension, 400mg oflox acin CiprofloxacinER ER Tablet) (Tablet Extended- 1 ZithrC1 oma Zithromaxx (100mg/ Release 24 Hour)

CiprC1 oflox 5ml Suspension, acin CiprofloxacinHCl HCl 200mg/5ml (0.3% Ophthalmic Suspension, 1gm 3 Solution, 100mg Tablet Packet, 250mg Immediate-Release, 1 Tablet, 500mg Tablet, 250mg Tablet 600mg Tablet, 500mg Immediate-Release, Injection) 750mg Tablet

ZithrC1 Immediate-Release) oma x Tri- ZithromaxPak Tri-Pak CiprC1 oflox 3 acin CiprofloxacinI.V. I.V. in in (Tablet) D5W 1

ZithrC1 D5W (Injection) oma x Z- Pak C1 Zithromax Z-Pak Gatif loxa 3 Gatifloxacincin (Tablet) 1

B1 (Ophthalmic Solution)

Quinolones LevaC1 quin

C1 Levaquin (Tablet) 3 Avel ox

Avelox (400mg LevoC1 floxa 3 Levofloxacincin (0.5% Tablet) Ophthalmic Solution, BaxdC1 Baxdelaela (300mg 250mg Tablet, 500mg Injection, 450mg 4 Tablet, 750mg Tablet, 1 Tablet) 25mg/ml Injection,

BesiC1 vanc Besivancee 25mg/ml Oral 3 (Suspension) Solution)

LevoC1 floxa C1 Cilox cin an Levofloxacinin in D5W Ciloxan (0.3% D5W 1 Ointment, 0.3% 3 (Injection) MoxC1 Moxezaeza (Ophthalmic Ophthalmic Solution) 3 Solution)

Bold type = Brand name drug Plain type = Generic drug 52 tRACK 52 Last updated October 1, 2018 1451 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

MoxiC1 SulfaC1 floxa meth cin oxaz MoxifloxacinHCl/ HCl/ Sulfamethoxazole/ole/ Sodi Trim um etho HCl 1 prim Sodium HCl (Injection) Trimethoprim MoxiC1 floxa cin (200mg-40mg/5ml 1 MoxifloxacinHCl HCl (Ophthalmic Solution, 1 Suspension, Tablet) 400mg-80mg Tablet)

SulfaC1 OcufC1 meth lox oxaz Sulfamethoxazole/ole/ Trim Ocuflox (Ophthalmic etho prim 3 DS Solution) Trimethoprim DS 1

OfloC1 (Tablet) xaci n

Ofloxacin (0.3% B1 Ophthalmic Solution, Tetracyclines DemC1 eclo cycli Demeclocyclinene HCl 0.3% Otic Solution, 1 HCl 1 300mg Tablet, 400mg (Tablet)

DoryC1 Tablet) Doryxx (Tablet

VigaC1 4 Vigamoxmox (Ophthalmic Delayed-Release)

3 C1 Dory x Solution) DoryxMPC MPC (Tablet

ZymC1 3 Zymaxidaxid (Ophthalmic Delayed-Release)

3 C1 Doxy Solution) Doxy100 100 (Injection) 1

B1 DoxyC1 cycli Sulfonamides Doxycyclinene

BactC1 1 Bactrimrim (Tablet) 3 (Suspension)

DoxyC1 BactC1 cycli rim ne DS DoxycyclineHycl Hyclate Bactrim DS (Tablet) 3 ate

BlepC1 Bleph-10h-10 (Ophthalmic (100mg Capsule, 3 Solution) 50mg Capsule, 100mg

SilvaC1 Tablet, 150mg Tablet, 1 Silvadenedene (Cream) 3 75mg Tablet, 20mg SilveC1 r Sulfa Silverdiazi Sulfadiazine ne 1 Tablet Immediate- (Cream) Release)

SodiC1 um DoxyC1 Sulfa cycli Sodiumceta Sulfacetamide ne mide DoxycyclineHycl Hyclate ate 1 DR (Ophthalmic Solution) DR (Tablet Delayed- 1

SSDC1 SSD (Cream) 1 Release)

SulfaC1 ceta mide Sulfacetamide Sodium Sodi um (10% Ophthalmic 1 Ointment)

SulfaC1 diazi Sulfadiazinene (Tablet) 1

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 53 53 1552 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

DoxyC1 A1 cycli ne DoxycyclineMon Anticonvulsants ohyd rate Monohydrate (100mg Anticonvulsants,B1 Other

BriviC1 Capsule, 150mg Briviactact (100mg Capsule, 50mg Tablet, 10mg Tablet, Capsule, 75mg 1 25mg Tablet, 50mg Capsule, 100mg 4 QL Tablet, 150mg Tablet, Tablet, 75mg Tablet, 50mg Tablet, 75mg 10mg/ml Oral Tablet) Solution)

KepC1 MinoC1 pra Minocincin (Capsule) 4 Keppra (1000mg

MinoC1 cycli ne Tablet, 500mg Tablet, MinocyclineHCl HCl (Capsule Immediate- 750mg Tablet, 4 1 Release, Tablet 100mg/ml Oral Immediate-Release) Solution)

C1 Mino KepC1 cycli pra ne MinocyclineHCl HCl ER ER Keppra (250mg 3 (Tablet Extended- 1 Tablet)

KepC1 Release 24 Hour) pra KeppraXR XR (Tablet MorC1 gido x Morgidox1x50 1x50mg mg 1 Extended-Release 24 4 (Capsule) Hour) OracC1 ea LeveC1 Oracea (Capsule tirac 3 Levetiracetametam (Tablet, Delayed-Release) 100mg/ml Oral 1

SoloC1 Solodyndyn (Tablet Solution)

LeveC1 tirac Extended-Release 24 etam 4 QL ER Levetiracetam ER Hour) (Tablet Extended- 1

SoloC1 Soloxidexide (Tablet Release 24 Hour)

1 RowC1 eepr Delayed-Release) Roweepraa (Tablet) 1

C1 Targ C1 Row adox eepr Targadox (Tablet) 3 Roweepraa XR XR (Tablet TetraC1 cycli ne Extended-Release 24 1 TetracyclineHCl HCl 1 (Capsule) Hour)

SpritC1 VibraC1 am myci n Spritam (Tablet Vibramycin (100mg Capsule, 25mg/5ml Disintegrating 3 3 Suspension, 50mg/ Soluble) 5ml Syrup) CalciumB1 Channel Modifying Agents

C1 XimiC1 Celo Ximinono (Capsule Celontinntin (Capsule) 3 Extended-Release 24 3 QL Hour)

Bold type = Brand name drug Plain type = Generic drug 54 tRACK 54 Last updated October 1, 2018 1653 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

EthoC1 NeurC1 suxi ontin Ethosuximidemide (250mg Neurontin (300mg Capsule, 250mg/5ml 1 Capsule, 400mg 4 Oral Solution) Capsule, 600mg

ZaroC1 Zarontinntin (250mg Tablet, 800mg Tablet) 3 Capsule) OnfiC1 (10mg Tablet,

ZaroC1 Zarontinntin (250mg/5ml 20mg Tablet, 2.5mg/ 4 PA 3 Oral Solution) ml Suspension)

ZoneC1 gran PheC1 noba Zonegran (Capsule) 4 Phenobarbitalrbital (100mg

ZoniC1 sami Zonisamidede (Capsule) 1 Tablet, 15mg Tablet, Gamma-aminobutyricB1 Acid (GABA) 16.2mg Tablet, 30mg Augmenting Agents Tablet, 32.4mg Tablet, 1 PA, HRM

C1 60mg Tablet, 64.8mg Dep aken Depakenee (250mg 3 Tablet, 97.2mg Tablet, Capsule) 20mg/5ml Elixir)

DepC1 aken PrimiC1 e Depakene (250mg/ done 4 Primidone (Tablet) 1

SabriC1 5ml Oral Solution) Sabrill (500mg Packet, DiastC1 at Acu 4 PA, QL, LA DiastatDial AcuDial (Gel) 3 500mg Tablet)

DiastC1 at TiagC1 Pedi abin atric Diastat Pediatric (Gel) 3 e HClTiagabine HCl (Tablet) 1

GabC1 apen ValprC1 tin oic Gabapentin (100mg Acid Valproic Acid (250mg Capsule, 300mg Capsule, 250mg/5ml 1 Capsule, 400mg 1 Oral Solution)

VigaC1 Capsule, 250mg/5ml batri Vigabatrinn (Packet) 1 PA, QL, LA

Oral Solution, 600mg B1 Tablet, 800mg Tablet) Glutamate Reducing Agents

FelbC1 amat C1 Gabi e Gabitriltril (12mg Tablet, Felbamate (400mg Tablet, 600mg Tablet, 2mg Tablet, 4mg 3 1 Tablet) 600mg/5ml

C1 Suspension) Gabi tril Gabitril (16mg Tablet) 4 FelbC1 atol

C1 Felbatol (400mg Mys oline Mysoline (Tablet) 4 Tablet, 600mg Tablet, NeurC1 Neurontinontin (100mg 4 600mg/5ml Capsule, 250mg/5ml 3 Suspension) Oral Solution)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 55 55 1754 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

FycoC1 LamiC1 mpa ctal Fycompa (0.5mg/ml LamictalXR XR (Kit) 3

LamC1 otrigi Suspension, 10mg Lamotriginene (100mg Tablet, 12mg Tablet, Tablet Immediate- 3 2mg Tablet, 4mg Release, 150mg Tablet Tablet, 6mg Tablet, Immediate-Release, 8mg Tablet) 200mg Tablet

LamiC1 Lamictalctal (Tablet) 4 Immediate-Release, 1

C1 25mg Tablet Lami ctal Che Lamictalwabl Chewable e Disp Immediate-Release, ersib Dispersiblele (25mg 4 25mg Tablet Tablet Chewable) Chewable, 5mg Tablet

LamiC1 ctal Che Lamictalwabl Chewable Chewable) e Disp ersib LamC1 le otrigi ne Dispersible (5mg 3 LamotrigineER ER (Tablet Tablet Chewable) Extended-Release 24 1

LamiC1 ctal LamictalODT ODT (Tablet Hour)

LamC1 4 otrigi ne LamotrigineODT ODT Dispersible) 1 LamiC1 ctal (Tablet Dispersible) Start Lamictaler Starter (Blue LamC1 otrigi 3 ne LamotrigineStart Starter er Kit) Kit/ Blue 1

LamiC1 ctal Kit/Blue (Kit) Start Lamictaler Starter LamC1 otrigi 4 ne LamotrigineStart Starter er (Green Kit) Kit/ Gree 1 n

LamiC1 Kit/Green (Kit) ctal Start er Lamictal Starter C1 Lam otrigi ne 3 LamotrigineStart Starter er Kit/ (Orange Kit) Oran 1 ge

LamiC1 Kit/Orange (Kit) ctal XR Lamictal XR (100mg QudC1 exy QudexyXR XR (100mg Tablet Extended- Capsule Extended- Release 24 Hour, Release 24 Hour 200mg Tablet Sprinkle, 150mg Extended-Release 24 Capsule Extended- Hour, 250mg Tablet 4 PA Release 24 Hour Extended-Release 24 4 Sprinkle, 200mg Hour, 25mg Tablet Capsule Extended- Extended-Release 24 Release 24 Hour Hour, 300mg Tablet Sprinkle) Extended-Release 24 Hour, 50mg Tablet Extended-Release 24 Hour)

Bold type = Brand name drug Plain type = Generic drug 56 tRACK 56 Last updated October 1, 2018 1855 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

QudC1 TrokC1 exy endi QudexyXR XR (25mg TrokendiXR XR (100mg Capsule Extended- Capsule Extended- Release 24 Hour Release 24 Hour, 4 PA Sprinkle, 50mg 3 PA 200mg Capsule Capsule Extended- Extended-Release 24 Release 24 Hour Hour)

TrokC1 endi Sprinkle) TrokendiXR XR (25mg

TopaC1 Topamaxmax (100mg Capsule Extended-

Tablet, 200mg Tablet, 4 Release 24 Hour, 3 PA 50mg Tablet) 50mg Capsule

TopaC1 Topamaxmax (25mg Extended-Release 24 3 Tablet) Hour)

B1 TopaC1 max Spri Topamaxnkle Sprinkle Sodium Channel Agents

AptiC1 (15mg Capsule 3 Aptiomom (Tablet) 4 QL

BanzC1 Sprinkle) Banzelel (200mg

TopaC1 max Spri Topamaxnkle Sprinkle Tablet, 400mg Tablet, 4

(25mg Capsule 4 40mg/ml Suspension)

CarbC1 ama Sprinkle) zepi Carbamazepinene

TopirC1 amat Topiramatee (100mg (100mg Tablet Chewable, 100mg/5ml Tablet Immediate- 1 Release, 200mg Tablet Suspension, 200mg Immediate-Release, Tablet Immediate- 25mg Tablet Release) Immediate-Release, 50mg Tablet 1 Immediate-Release, 15mg Capsule Sprinkle Immediate- Release, 25mg Capsule Sprinkle Immediate-Release)

TopirC1 amat Topiramatee ER ER (Capsule Extended- 1 PA Release 24 Hour Sprinkle)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 57 57 1956 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

CarbC1 OxtelC1 ama lar zepi XR Carbamazepinene ER Oxtellar XR (600mg ER (100mg Capsule Tablet Extended- 4 PA Extended-Release 12 Release 24 Hour)

PegaC1 Hour, 200mg Capsule Peganonenone (Tablet) 3

Extended-Release 12 PheC1 nyte Hour, 300mg Capsule Phenytekk (Capsule) 1 PheC1 nytoi Extended-Release 12 Phenytoinn (125mg/5ml 1 Hour, 100mg Tablet Suspension, 50mg 1 Extended-Release 12 Tablet Chewable)

PheC1 nytoi n Hour, 200mg Tablet PhenytoinSodi Sodium um Exte nded 1 Extended-Release 12 Extended (Capsule)

TegrC1 Hour, 400mg Tablet Tegretoletol (100mg/5ml

Extended-Release 12 Suspension, 200mg 3 Hour) Tablet) CarbC1 atrol Carbatrol (Capsule TegrC1 etol- Tegretol-XRXR (Tablet Extended-Release 12 3 Extended-Release 12 3 Hour) Hour) DilanC1 tin Dilantin (Capsule) 2 TrileC1 Trileptalptal (150mg DilanC1 tin INFA 3 DilantinTAB INFATABS S 2 Tablet)

(Tablet Chewable) TrileC1 ptal

DilanC1 Trileptal (300mg tin-1 Dilantin-12525 3 Tablet, 600mg Tablet, (Suspension) 4 300mg/5ml EpitoC1 Epitoll (Tablet) 1 Suspension) OxcaC1 rbaz epin VimpC1 Oxcarbazepinee Vimpatat (100mg (150mg Tablet, 300mg Tablet, 150mg Tablet, Tablet, 600mg Tablet, 1 200mg Tablet, 50mg 3 QL 300mg/5ml Suspension) Tablet, 10mg/ml Oral

OxtelC1 Solution) lar XR

Oxtellar XR (150mg A1 Tablet Extended- Antidementia Agents B1 Release 24 Hour, Cholinesterase Inhibitors

AriceC1 3 PA pt 300mg Tablet Aricept (Tablet) 3 QL

DonC1 epez il Extended-Release 24 DonepezilHCl HCl (Tablet 1 QL Hour) Immediate-Release)

DonC1 epez il DonepezilHCl HCl ODT ODT 1 QL (Tablet Dispersible)

Bold type = Brand name drug Plain type = Generic drug 58 tRACK 58 Last updated October 1, 2018 2057 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

ExelC1 NamC1 on enda Exelon (Patch 24 Namenda XR XR 3 QL Hour) (Capsule Extended- 3 PA, QL

GalaC1 ntam ine Release 24 Hour) GalantamineHBr HBr

NamC1 enda XR (12mg Tablet, 4mg NamendaTitrat XR Titration ion 1 QL Pack Tablet, 8mg Tablet, Pack (Capsule 3 PA, QL 4mg/ml Oral Solution) Extended-Release 24

GalaC1 ntam ine GalantamineHBr HBr ER ER Hour) (Capsule Extended- 1 QL AntidepressantsA1

Release 24 Hour) B1

RazaC1 Antidepressants, Other dyne

Razadyne (Tablet) 3 QL ApleC1 nzin

RazaC1 Aplenzin (Tablet dyne Razadyne ER ER Extended-Release 24 4 (Capsule Extended- 3 QL Hour)

Release 24 Hour) BuprC1 opio n HCl RivaC1 Bupropion HCl (Tablet stig mine Rivastigmine Tartrate Tartr ate Immediate-Release), (Capsule Immediate- 1 QL Bupropion HCl SR Release) (Tablet Extended- RivaC1 stig 1 mine Rivastigmine Tran Release 12 Hour), sder mal Syst Transdermalem System 1 QL Bupropion HCl XL (Patch 24 Hour) (Tablet Extended- N-methyl-D-aspartateB1 (NMDA) Receptor Release 24 Hour)

ForfiC1 vo Antagonist ForfivoXL XL (Tablet

C1 Mem antin e MemantineHCl HCl (10mg Extended-Release 24 3 Tablet, 5mg Tablet, 1 PA, QL Hour)

MirtaC1 zapi 2mg/ml Oral Solution) Mirtazapinene (Tablet MemC1 1 antin e HClMemantine HCl ER Immediate-Release) ER

MirtaC1 zapi (Capsule Extended- 1 PA, QL ne MirtazapineODT ODT 1 Release 24 Hour) (Tablet Dispersible)

MemC1 antin OlanC1 e zapi HClMemantine HCl ne/ Titrat Fluo ion Olanzapine/Fluoxetine xetin Pak 1 PA e 1 Titration Pak (Tablet) (Capsule)

NamC1 enda RemC1 Namenda (Tablet eron 3 PA, QL Remeron (Tablet) 3 RemC1 eron Immediate-Release) Solta Remeronb Soltab

NamC1 enda 3

TitratNamenda Titration ion (Tablet Dispersible) Pak 3 PA SymC1 Pak (Tablet) Symbyaxbyax (Capsule) 3

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 59 59 2158 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

WellC1 DesvC1 butri enlaf n SR axin Wellbutrin SR (Tablet Desvenlafaxinee ER ER

Extended-Release 12 3 (100mg Tablet Extended-Release 24 Hour) 3 WellC1 butri Hour, 50mg Tablet Wellbutrinn XL XL (Tablet Extended-Release 24 Extended-Release 24 4 Hour)

Hour) EffexC1 or XR B1 Effexor XR (Capsule Monoamine Oxidase Inhibitors Extended-Release 24 3 EmsC1 Emsamam (Patch 24 4 Hour) Hour) EscitC1 alopr am EscitalopramOxal Oxalate ate MarC1 Marplanplan (Tablet) 3 (10mg Tablet, 20mg NardC1 Nardilil (Tablet) 3 Tablet, 5mg Tablet, 1

ParnC1 Parnateate (Tablet) 4 5mg/5ml Oral

PheC1 nelzi Solution) ne PhenelzineSulfa Sulfate te FetziC1 1 ma (Tablet) Fetzima (Capsule

TranC1 ylcyp Extended-Release 24 3 ST romi Tranylcyprominene Sulfa te 1 Sulfate (Tablet) Hour)

FetziC1

B1 ma Titrat Fetzimaion Titration SSRI/SNRI (Selective Serotonin Reuptake Pack Pack (Capsule Inhibitors/Serotonin and Norepinephrine 3 ST Reuptake Inhibitors) Extended-Release 24

BrisdC1 Brisdelleelle (Capsule) 3 HRM Hour Therapy Pack) FluoC1 xetin CeleC1 e DR Celexaxa (Tablet) 3 Fluoxetine DR

CitalC1 (Capsule Delayed- 1 opra m CitalopramHBr HBr (10mg Release)

C1 Tablet, 20mg Tablet, Fluo xetin e 1 HCl 40mg Tablet, 10mg/ Fluoxetine HCl (10mg 5ml Oral Solution) Capsule Immediate-

DesvC1 Release, 20mg enlaf axin e ER 1 Desvenlafaxine ER Capsule, 40mg (100mg Tablet Capsule, 20mg/5ml Extended-Release 24 Oral Solution, Tablet)

Hour, 25mg Tablet FluvC1 oxa mine 1 QL Fluvoxamine Maleate Male Extended-Release 24 ate 1 Hour, 50mg Tablet (Tablet) FluvC1 oxa mine Fluvoxamine Maleate Extended-Release 24 Male ate ER Hour) ER (Capsule Extended- 1 Release 24 Hour)

Bold type = Brand name drug Plain type = Generic drug 60 tRACK 60 Last updated October 1, 2018 2259 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

KheC1 VenlC1 dezl afaxi a ne Khedezla (Tablet VenlafaxineHCl HCl ER ER Extended-Release 24 3 (Capsule Extended- Hour) Release 24 Hour, 1

LexaC1 Lexapropro (Tablet) 3 Tablet Extended-

MapC1 Release 24 Hour) rotili ne

HCl C1 Maprotiline HCl Viibr 1 yd (Tablet) Viibryd (Tablet) 3 QL ViibrC1 yd Start NefaC1 er zodo Viibryd Starter Pack Pack ne NefazodoneHCl HCl 1 3 QL (Tablet) (Kit) ZolofC1 t ParoC1 xetin Zoloft (Tablet) 3 Paroxetinee (Capsule) 1 HRM

B1

ParoC1 xetin Tricyclics e ParoxetineHCl HCl (Tablet AmitC1 1 PA, HRM riptyl ine AmitriptylineHCl HCl Immediate-Release) 1 PA, HRM PaxilC1 (10mg Tablet, (Tablet) AmoC1 xapi 20mg Tablet, 30mg Amoxapinene (Tablet) 1 PA, HRM

AnafC1 Tablet, 40mg Tablet, 3 PA, HRM Anafranilranil (Capsule) 4 PA, HRM

CloC1 mipr amin 10mg/5ml Clomipraminee HCl HCl 1 PA, HRM Suspension) (Capsule)

PristiC1 DesiC1 q pram ine Pristiq (Tablet DesipramineHCl HCl 1 PA, HRM Extended-Release 24 3 QL (Tablet)

DoxeC1 pin Hour) DoxepinHCl HCl (100mg

ProzC1 Prozacac (10mg Capsule, 10mg

Capsule, 20mg 3 Capsule, 150mg Capsule, 25mg Capsule) 1 PA, HRM

ProzC1 Capsule, 50mg Prozacac (40mg 4 Capsule, 75mg Capsule) Capsule, 10mg/ml SaraC1 Sarafemfem (Tablet) 3 Concentrate)

C1 Sertr C1 aline Imipr HCl amin e Sertraline HCl (100mg ImipramineHCl HCl Tablet, 25mg Tablet, 1 PA, HRM 1 (Tablet) ImiprC1 50mg Tablet, 20mg/ml amin e ImipraminePam Pamoate oate 1 PA, HRM Concentrate) (Capsule) TrazC1 odon e NorpC1 TrazodoneHCl HCl (Tablet) 1 rami Norpraminn (Tablet) 3 PA, HRM TrintC1 Trintellixellix (Tablet) 3 QL

VenlC1 afaxi ne VenlafaxineHCl HCl (Tablet Immediate- 1 Release)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 61 61 2360 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

NortrC1 TranC1 iptyli sder ne m- NortriptylineHCl HCl Transderm-ScopSco p 3 PA, HRM (10mg Capsule, 25mg (Patch 72 Hour)

TrimC1 Capsule, 50mg etho benz Trimethobenzamideamid 1 PA, HRM e HCl 1 B/D, PA Capsule, 75mg HCl (Capsule)

Capsule, 10mg/5ml VistaC1 Vistarilril (Capsule) Oral Solution) 3 PA, HRM B1

PamC1 elorPamelor (Capsule) 4 PA, HRM Emetogenic Therapy Adjuncts ApreC1 pitan t ProtrC1 iptyli Aprepitant (Therapy ne HClProtriptyline HCl 1 PA, HRM 1 PA (Tablet) Pack, Capsule) CesaC1 met SurC1 mont Cesamet (Capsule) 4 PA ilSurmontil (Capsule) 3 PA, HRM DronC1 abin ol TofrC1 anilTofranil (Tablet) 4 PA, HRM Dronabinol (Capsule) 1 PA EmeC1 nd TrimiC1 pram Emend (125mg ine MaleTrimipramine Maleate ate 1 PA, HRM 4 PA (Capsule) Capsule) EmeC1 nd AntiemeticsA1 Emend (125mg

B1 Suspension, 40mg Antiemetics, Other 3 PA

ComC1 Capsule, 80mg pro Compro (Suppository) 1 Capsule) HydrC1 oxyzi ne Pam EmeC1 Hydroxyzine Pamoate nd oate Tripa 1 PA, HRM Emendck Tripack (Capsule) 4 PA

C1 (Capsule) Mecl izine HCl Meclizine HCl (12.5mg GranC1 isetr on 1 PA, HRM GranisetronHCl HCl Tablet) 1 B/D, PA

C1 (Tablet) Meto clopr amid eMetoclopramide HCl MariC1 HCl Marinolnol (10mg (10mg Tablet, 5mg 1 Tablet, 5mg/5ml Oral Capsule, 5mg 4 PA Solution) Capsule)

MariC1 nol MetoC1 clopr amid Marinol (2.5mg Metoclopramidee ODT ODT 1 3 PA (Tablet Dispersible) Capsule)

OndC1 PerpC1 anse hena tron Perphenazinezine (Tablet) 1 OndansetronHCl HCl

ProcC1 hlorp (24mg Tablet, 4mg erazi Prochlorperazinene 1 (Suppository) Tablet, 8mg Tablet, 1 B/D, PA

ProcC1 4mg/5ml Oral hlorp erazi Prochlorperazinene Male ate 1 Solution)

Maleate (Tablet) OndC1 anse tron ODT ReglC1 Ondansetron ODT an 1 B/D, PA Reglan (Tablet) 3 (Tablet Dispersible) ScoC1 pola mine SancC1 Scopolamine (Patch 72 uso 1 PA, HRM Sancuso (Patch) 4 Hour)

TigaC1 nTigan (Capsule) 3 B/D, PA

Bold type = Brand name drug Plain type = Generic drug 62 tRACK 62 Last updated October 1, 2018 2461 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

SyndC1 DifluC1 Syndrosros (Oral Diflucancan (100mg 4 PA Solution) Tablet, 150mg Tablet,

VaruC1 Varubibi (Tablet) 3 B/D, PA 50mg Tablet, 10mg/ 3

ZofrC1 anZofran (Tablet) 4 B/D, PA ml Suspension,

ZofrC1 an 40mg/ml Suspension) ODTZofran ODT (4mg DifluC1 3 B/D, PA Diflucancan (200mg Tablet Dispersible) 4

ZofrC1 an Tablet) ODTZofran ODT (8mg EconC1 azol 4 B/D, PA e EconazoleNitra Nitrate Tablet Dispersible) te 1 ZuplC1 (Cream) enzZuplenz (Film) 4 B/D, PA C1 Eraxi s A1 Eraxis (100mg Antifungals 4

B1 Injection)

Antifungals EraxiC1 s

C1 Eraxis (50mg Abel cet 3 Abelcet (Injection) 4 B/D, PA Injection) AmBC1 isom e ErtacC1 AmBisome (Injection) 4 B/D, PA Ertaczozo (Cream) 4 AmpC1 hote

ricin C1 B Exel Amphotericin B der 1 B/D, PA Exeldermm (1% Cream, (Injection) 3 1% External Solution) AncC1 obon Ancobon (Capsule) 4 ExtinC1 Extinaa (Foam) C1 4 AVC

AVC (Cream) 3 FlucC1 onaz ole

C1 Fluconazole (100mg Can cida Cancidass (Injection) 4 Tablet, 150mg Tablet,

CaspC1 ofun gin CaspofunginAcet Acetate ate 200mg Tablet, 50mg 1 1 (Injection) Tablet, 10mg/ml

CicloC1 pirox Suspension, 40mg/ml Ciclopirox (0.77% Gel, 0.77% Suspension, 1% 1 Suspension)

FlucC1 onaz ole Shampoo) Fluconazolein in NaCl NaCl

C1 1 Ciclo pirox Nail (Injection) CiclopiroxLacq Nail uer

C1 Fluc ytosi Lacquer (External 1 Flucytosinene (Capsule) 1

GrisC1 eoful Solution) vin GriseofulvinMicr Microsize osize CicloC1 pirox

CiclopiroxOla Olamine mine (125mg/5ml 1 1 (Cream) Suspension, 500mg

ClotrC1 imaz Clotrimazoleole (1% Tablet)

GrisC1 eoful vin Cream, 1% External GriseofulvinUltra micr 1 osize 1 Solution, 10mg Ultramicrosize (Tablet)

GynC1 azol Lozenge) Gynazole-1e-1 (Cream) 3

CresC1 emb a ItracC1 onaz Cresemba (Capsule) 4 PA Itraconazoleole (Capsule) 1 PA

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 63 63 2562 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

JubliC1 NystC1 Jubliaa (External Nystopop (Powder) 1

3 C1 Oravi Solution) Oravigg (Tablet) 4

KeryC1 din OxicC1 onaz Kerydin (External ole OxiconazoleNitra Nitrate 4 ST te 1 Solution) (Cream)

C1 Keto OxistC1 cona at Ketoconazolezole (2% Oxistat (1% Cream, Cream, 2% Foam, 2% 3 1 1% Lotion) SporC1 Shampoo, 200mg Sporanoxanox (100mg Tablet) Capsule, 10mg/ml 4 PA LoprC1 Loproxox (Cream) 3 Oral Solution) LoprC1 ox Sha TerbiC1 Loproxmpo Shampoo nafin o 4 e TerbinafineHCl HCl

LuzuC1 1 Luzu (Cream) 3 (Tablet)

TercC1 MentC1 ax onaz Mentax (Cream) 3 Terconazoleole (0.4% MicoC1 nazo Miconazolele 3 3 Cream, 0.8% Cream, 1 1 (Suppository) 80mg Suppository) VfenC1 d MycC1 amin e Vfend (200mg Tablet, Mycamine (Injection) 4

NaftiC1 fine 50mg Tablet, 40mg/ 4 NaftifineHCl HCl (1% 1 Cream) ml Suspension) VfenC1 d IV NaftiC1 fine Vfend IV (Injection) 4 NaftifineHCl HCl (2% VoricC1 1 onaz Cream) Voriconazoleole (200mg

NaftiC1 Naftinn (1% Gel, 2% Injection, 200mg 3 1 Gel, 2% Cream) Tablet, 50mg Tablet,

C1 40mg/ml Suspension) Nata cyn

Natacyn (Suspension) 3 A1

C1 Antigout Agents Nizor al

Nizoral (Shampoo) 3 B1

C1 Antigout Agents Noxa fil

Noxafil (100mg Tablet AllopC1 urino 4 PA, QL Allopurinoll (Tablet) 1

Delayed-Release) C1 Colc hicin e NoxaC1 Colchicine (0.6mg filNoxafil (40mg/ml 4 QL Capsule) (Generic 2 QL Suspension)

C1 Mitigare) Nya myc

Nyamyc (Powder) 1 ColcC1 hicin e

C1 Colchicine (0.6mg Nyst atin Nystatin (Cream, Tablet) (Generic 2 QL Ointment, Powder, 1 Colcrys)

Suspension, Tablet) ColcC1 rys

C1 Colcrys (Tablet) 3 PA, QL Nyst atin/ Tria Nystatin/mcin DuzaC1 olon llo e Duzallo (Tablet) Triamcinolone (0.1% 1 3 PA MitigC1 Cream, 0.1% Ointment) Mitigareare (Capsule) 3 QL

Bold type = Brand name drug Plain type = Generic drug 64 tRACK 64 Last updated October 1, 2018 2663 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

ProbC1 ImitrC1 enec ex id Stat Probenecid (Tablet) 1 Imitrexdose Statdose Refill

Refill

C1 4 QL Prob enec id/ (Injection) Probenecid/ColchicineColc hicin e 1 ImitrC1 ex Stat (Tablet) Imitrexdose Statdose

Syst em UloriC1 3 QL Uloricc (Tablet) 2 ST System (Injection)

C1 ZuraC1 Max Zurampicmpic (Tablet) 3 PA Maxaltalt (Tablet) 3 QL

C1 ZyloC1 Max prim alt- Zyloprim (Tablet) 3 Maxalt-MLTMLT (Tablet 3 QL AntimigraineA1 Agents Dispersible)

NaraC1 B1 tripta n NaratriptanHCl HCl Ergot Alkaloids 1 QL CafeC1 Cafergotrgot (Tablet) 3 (Tablet) OnzC1 etra Xsail DihyC1 droe Onzetra Xsail (Exhaler rgota Dihydroergotaminemine 3 QL Mes ylate Mesylate (Nasal 1 Powder) RelpC1 Solution) Relpaxax (Tablet) 3 QL

C1 C1 Rizat Ergo ripta tami n ne Benz Tartr Rizatriptan Benzoate Ergotamine Tartrate/ oate ate/ Caff eine 1 Caffeine (Tablet) (Tablet Immediate- 1 QL

MigeC1 Migergotrgot (Suppository) 4 Release) RizatC1 ripta MigrC1 n anal RizatriptanBenz Benzoate oate Migranal (Nasal ODT 4 Solution) ODT (Tablet 1 QL

B1 Dispersible)

Serotonin (5-HT) 1b/1d Receptor Agonists SumC1 atript an

C1 Sumatriptan (Nasal Almo tripta n 1 QL AlmotriptanMala Malate te 1 QL Solution)

(Tablet) SumC1 atript an Succ C1 Sumatriptan Succinate Ame inate Amergerge (Tablet) 3 QL (100mg Tablet, 25mg EletriC1 ptan EletriptanHBr HBr (Tablet) 1 QL Tablet, 50mg Tablet, 1 QL

FrovC1 Frovaa (Tablet) 3 QL 4mg/0.5ml Injection,

FrovC1 atript 6mg/0.5ml Injection) an FrovatriptanSucc Succinate inate SumC1 1 QL atript an SumatriptanSucc (Tablet) inate

ImitrC1 Imitrexex (100mg Succinate (6mg/ 1 QL Tablet, 25mg Tablet, 0.5ml Injection)

SumC1 atript an SumatriptanSucc 50mg Tablet, 20mg/ inate

3 QL Refill act Nasal Solution, Succinate Refill 1 QL 5mg/act Nasal (Injection)

SumC1 atript an/ Solution) Sumatriptan/NaproxenNapr oxen

Sodi C1 1 QL Imitr um Imitrexex (6mg/0.5ml Sodium (Tablet)

TrexiC1 4 QL met Injection) Treximet (Tablet) 4 QL

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 65 65 2764 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

ZemC1 EthaC1 brac mbut e ol ZembraceSymt Symtouch EthambutolHCl HCl ouch 4 QL 1 (Injection) (Tablet)

C1 C1 Isoni Zolm azid itript Zolmitriptanan (Tablet) 1 QL Isoniazid (100mg ZolmC1 itript Tablet, 300mg Tablet, 1 an ZolmitriptanODT ODT 1 QL (Tablet Dispersible) 50mg/5ml Syrup) MyaC1 mbut ZomiC1 ol Zomigg (2.5mg Nasal Myambutol (Tablet) 3 PaseC1 Solution, 5mg Nasal 3 QL Paserr (Packet) 3

PriftiC1 Solution) Priftinn (Tablet) 3

C1 ZomiC1 Pyra g zina Zomig (2.5mg Tablet, Pyrazinamidemide (Tablet) 1

4 QL RifaC1 5mg Tablet) Rifadindin (150mg

ZomiC1 3 g ZomigZMT ZMT (Tablet Capsule)

4 QL RifaC1 Dispersible) Rifamatemate (Capsule) 3

A1 RifaC1 Antimyasthenic Agents Rifampinmpin (150mg B1 Capsule, 300mg Parasympathomimetics 1 GuaC1 nidin Capsule, 600mg e GuanidineHCl HCl 2 (Tablet) Injection) RifatC1 er

MestC1 Mestinoninon (60mg Rifater (Tablet) 3 SirtuC1 ro Tablet, 60mg/5ml 4 Sirturo (Tablet) 4 PA, LA TrecC1 Syrup) atorTrecator (Tablet) 3

A1 MestC1 inon Time Antineoplastics Mestinonspan Timespan

B1 (Tablet Extended- 4 Alkylating Agents

CyclC1 opho spha Release) Cyclophosphamidemide

PyridC1 1 B/D, PA ostig mine Pyridostigmine (Capsule) Bro mide 1 GleoC1 Bromide (Tablet) Gleostinestine (100mg

PyridC1 4 ostig mine Pyridostigmine Capsule) Bro mide ER GleoC1 Bromide ER (Tablet 1 Gleostinestine (10mg 2 Extended-Release) Capsule)

A1

GleoC1 Antimycobacterials Gleostinestine (40mg B1 3 Antimycobacterials, Other Capsule)

DapsC1 one HexaC1 Dapsone (Tablet) 1 Hexalenlen (Capsule) 4 PA

MycC1 obuti LeukC1 Mycobutinn (Capsule) 3 Leukeraneran (Tablet) 4

RifaC1 butin MatuC1 Rifabutin (Capsule) 1 Matulanelane (Capsule) 4 LA

B1 ValcC1 Antituberculars hlorValchlor (Gel) 4 PA, LA

Bold type = Brand name drug Plain type = Generic drug 66 tRACK 66 Last updated October 1, 2018 2865 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

B1 KisqC1 ali Fem Antiandrogens Kisqaliara Femara 200 200 Dose

BicalC1 utam Bicalutamideide (Tablet) 1 Dose (Tablet Therapy 4 PA, QL

CasoC1 Casodexdex (Tablet) 3 Pack)

KisqC1 ali C1 Erlea Fem da Kisqaliara Femara 400 400 Erleada (Tablet) 4 PA, QL Dose

FlutaC1 mideFlutamide (Capsule) 1 Dose (Tablet Therapy 4 PA, QL

NilanC1 Pack) dron

Nilandron (Tablet) 4 C1 Kisq ali Fem NilutC1 Kisqaliara Femara 600 amid 600 Nilutamidee (Tablet) 1 Dose Dose (Tablet Therapy C1 4 PA, QL Xtan di Xtandi (Capsule) 4 PA, LA Pack) ZytigC1 a LeucC1 Zytiga (Tablet) 4 PA, LA ovori n LeucovorinCalci Calcium um B1 1 Antiangiogenic Agents (Tablet)

PomC1 alyst LonsC1 Pomalyst (Capsule) 4 PA, QL Lonsurfurf (Tablet) 4 PA, QL, LA

RevliC1 mid NinlaC1 Revlimid (Capsule) 4 PA, QL, LA roNinlaro (Capsule) 4 PA, QL

ThalC1 omid SynriC1 Thalomid (Capsule) 4 PA, QL Synribobo (Injection) 4 PA

B1 VerzC1 /Modifiers Verzenioenio (Tablet) 4 PA, QL, LA

EmcC1 yt ZolinC1 Emcyt (Capsule) 4 zaZolinza (Capsule) 4 PA

FareC1 Farestonston (Tablet) 4 AromataseB1 Inhibitors, 3rd Generation

SoltaC1 mox AnasC1 trozo Soltamox (Oral le 4 Anastrozole (Tablet) 1 ArimiC1 Solution) Arimidexdex (Tablet) 3

TamC1 oxife n AroC1 Citra masi Tamoxifen Citrate n te 1 Aromasin (Tablet) 4 (Tablet) ExeC1 mest ane

B1 Exemestane (Tablet) 1

Antimetabolites FemC1 Femaraara (Tablet) C1 4 Droxi a Droxia (Capsule) 3 LetrC1 ozol e

C1 Letrozole (Tablet) 1 Hydr ea Hydrea (Capsule) 3 B1

C1 Enzyme Inhibitors Hydr oxyu rea Hydroxyurea (Capsule) 1 RubrC1 Rubracaaca (Tablet) C1 4 PA, QL, LA Merc apto purin Mercaptopurinee ZejulC1 1 aZejula (Capsule) 4 PA, QL, LA (Tablet) B1

PurixC1 an Molecular Target Inhibitors Purixan (Suspension) 4 PA AfinitC1 or TablC1 Afinitor (Tablet) oid 4 PA Tabloid (Tablet) 3 PA AfinitC1 or Disp B1 Afinitorerz Disperz Antineoplastics, Other 4 PA

KisqC1 (Tablet Soluble) ali

Kisqali (Tablet) 4 PA, QL AlecC1 Alecensaensa (Capsule) 4 PA, LA

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 67 67 2966 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

AlunC1 LynpC1 Alunbrigbrig (Tablet Lynparzaarza (50mg 4 PA, LA Therapy Pack, 180mg Capsule)

4 PA, QL, LA C1 Meki Tablet, 30mg Tablet, nistMekinist (Tablet) 4 PA, LA

NerlyC1 90mg Tablet) nxNerlynx (Tablet) 4 PA, QL, LA

BosuC1 lif NexaC1 Bosulif (Tablet) 4 PA, QL varNexavar (Tablet) 4 PA, LA

CabC1 omet C1 yx Odo Cabometyx (Tablet) 4 PA, QL, LA mzoOdomzo (Capsule) 4 PA, QL, LA

CalqC1 uenc C1 e Ryda Calquence (Capsule) 4 PA, QL ptRydapt (Capsule) 4 PA, QL

CaprC1 elsa SpryC1 Caprelsa (Tablet) 4 PA, LA Sprycelcel (Tablet) 4 PA

ComC1 etriq StivaC1 Cometriq (Kit) 4 PA, LA Stivargarga (Tablet) 4 PA, QL, LA

CoteC1 llic SuteC1 Cotellic (Tablet) 4 PA, LA ntSutent (Capsule) 4 PA

EriveC1 dge TafinC1 Erivedge (Capsule) 4 PA, QL, LA Tafinlarlar (Capsule) 4 PA, LA

FaryC1 dak TagriC1 Farydak (Capsule) 4 PA ssoTagrisso (Tablet) 4 PA, QL, LA

GilotC1 rif TarcC1 Gilotrif (Tablet) 4 PA, LA evaTarceva (Tablet) 4 PA, QL, LA

GleeC1 vec TasiC1 Gleevec (Tablet) 4 PA, QL gnaTasigna (Capsule) 4 PA, QL

IbranC1 ce TykeC1 Ibrance (Capsule) 4 PA, QL, LA Tykerbrb (Tablet) 4 PA, LA

IclusiC1 g VencC1 Iclusig (Tablet) 4 PA, QL, LA lextaVenclexta (100mg

IdhifC1 a 4 PA, QL, LA Idhifa (Tablet) 4 PA, QL, LA Tablet, 50mg Tablet)

ImatiC1 nib VencC1 Mes lexta Imatinibylate Mesylate Venclexta (10mg 1 PA, QL 2 PA, QL, LA (Tablet) Tablet)

ImbrC1 uvic VencC1 a lexta Imbruvica (140mg StartiVenclexta Starting ng Pack Capsule, 70mg 4 PA, QL, LA Pack (Tablet Therapy 4 PA, LA Capsule) Pack)

ImbrC1 uvic VotriC1 Imbruvicaa (140mg entVotrient (Tablet) 4 PA, QL, LA

XalkC1 Tablet, 280mg Tablet, ori 4 PA, QL Xalkori (Capsule) 4 PA, LA 420mg Tablet, 560mg ZelbC1 orafZelboraf (Tablet) 4 PA, QL, LA

Tablet) C1 Zyde lig

InlytC1 Zydelig (Tablet) 4 PA, QL, LA a

Inlyta (Tablet) 4 PA, QL, LA C1 Zyka dia

IressC1 Zykadia (Capsule) 4 PA a

Iressa (Tablet) 4 PA, QL, LA B1

JakaC1 Retinoids fi

Jakafi (Tablet) 4 PA, QL, LA C1 Bexa rote ne LenvC1 Bexarotene (Capsule) 1 PA ima

Lenvima (Capsule C1 Panr 4 PA, LA etin Therapy Pack) Panretin (Gel) 4 TargC1 retin LynpC1 Lynparzaarza (100mg Targretin (1% Gel, 4 PA, QL, LA 4 PA Tablet, 150mg Tablet) 75mg Capsule)

Bold type = Brand name drug Plain type = Generic drug 68 tRACK 68 Last updated October 1, 2018 3067 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

TretiC1 NebC1 noin upen Tretinoin (10mg Nebupentt (Inhalation 1 3 B/D, PA, QL Capsule) Solution)

B1 PentC1 am Treatment Adjuncts Pentam300 300

MesC1 3 Mesnexnex (Tablet) 4 (Injection)

C1 A1 Plaq Antiparasitics Plaqueniluenil (Tablet) 3

C1 B1 Prim aqui ne PrimaquinePhos Phosphate Anthelmintics phat e 1 AlbeC1 Albenzanza (Tablet) 4 QL (Tablet)

QualC1 aqui BiltriC1 n Biltricidecide (Tablet) 4 Qualaquin (Capsule) 3 PA

QuinC1 ine C1 Emv Sulfa Emvermerm (Tablet Quininete Sulfate 4 1 PA Chewable) (Capsule)

B1

IverC1 mect Ivermectinin (Tablet) 1 Pediculicides/Scabicides ElimiC1 te SklicC1 Sklicee (Lotion) 3 Elimite (Cream) 3

EuraC1 x StroC1 mect ol Eurax (10% Cream, Stromectol (Tablet) 3 3 AntiprotozoalsB1 10% Lotion) LindC1 ane AliniC1 Aliniaa (100mg/5ml Lindane (Shampoo) 1 MalaC1 thion Suspension, 500mg 4 Malathion (Lotion) 1 NatrC1 Tablet) Natrobaoba (Suspension) 3

OvidC1 AtovC1 e aquo Atovaquonene Ovide (Lotion) 3

1 PerC1 meth (Suspension) Permethrinrin (Cream) 1

C1 Atov A1 aquo ne/ Atovaquone/ProguanilProg uanil Antiparkinson Agents HCl HCl (Tablet) (Generic 1 AnticholinergicsB1

Malarone) BenzC1 tropi ne Mes C1 Benztropine Mesylate Benz ylate nida zole 1 PA, HRM Benznidazole (Tablet) 3 (Tablet) ChloC1 roqui ne TriheC1 ChloroquinePhos xyph phat enid e Trihexyphenidylyl HCl 1 HCl Phosphate (Tablet) (0.4mg/ml Elixir, 2mg 1 PA, HRM CoarC1 Coartemtem (Tablet) 3 Tablet, 5mg Tablet)

C1 DAR B1 APRI DARAPRIMM (Tablet) 4 Antiparkinson Agents, Other

C1 Hydr C1 oxyc Ama hloro ntadi quin ne Hydroxychloroquine HCl e Amantadine HCl Sulfa te 1 Sulfate (Tablet) (100mg Capsule,

MalaC1 1 Malaronerone (Tablet) 3 100mg Tablet, 50mg/

MeflC1 oqui 5ml Syrup) ne MefloquineHCl HCl ComC1 1 tan (Tablet) Comtan (Tablet) 4

EntaC1 MepC1 capo Mepronron (Suspension) 4 Entacaponene (Tablet) 1

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 69 69 3168 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

GocC1 PraC1 ovri mipe xole Gocovri (Capsule PramipexoleDihy droc hlori Dihydrochloridede Extended-Release 24 4 PA 1 Hour) (Tablet Immediate-

TasC1 Tasmarmar (Tablet) 4 QL Release) PraC1 mipe xole TolcC1 Dihy apon Pramipexole droc e hlori Tolcapone (Tablet) 1 QL de ER B1 Dihydrochloride ER 1 Dopamine Agonists (Tablet Extended- ApoC1 Apokynkyn (Injection) 4 PA, QL, LA Release 24 Hour)

BroC1 mocr ReqC1 iptin uip Bromocriptinee XL Mes Requip XL (4mg ylate Mesylate (2.5mg 1 Tablet Extended- Tablet, 5mg Capsule) Release 24 Hour, MiraC1 pex Mirapex (Tablet) 3 6mg Tablet Extended- 3

MiraC1 pex MirapexER ER (0.375mg Release 24 Hour, Tablet Extended- 8mg Tablet Extended- Release 24 Hour, Release 24 Hour)

RopiC1 nirol 0.75mg Tablet e ER 4 Ropinirole ER (Tablet Extended-Release 24 Extended-Release 24 1 Hour, 1.5mg Tablet Hour)

RopiC1 nirol e Extended-Release 24 RopiniroleHCl HCl (Tablet 1 Hour) Immediate-Release)

MiraC1 B1 pex MirapexER ER (2.25mg Dopamine Precursors/L-Amino Acid Tablet Extended- Decarboxylase Inhibitors

CarbC1 idop Release 24 Hour, Carbidopaa (Tablet) 1

CarbC1 3.75mg Tablet idop a/ Carbidopa/LevodopaLevo Extended-Release 24 dopa 3 (Tablet Immediate- 1 Hour, 3mg Tablet Release)

CarbC1 idop Extended-Release 24 a/ Carbidopa/LevodopaLevo dopa ER Hour, 4.5mg Tablet ER (Tablet Extended- 1 Extended-Release 24 Release)

CarbC1 idop Hour) a/ Carbidopa/LevodopaLevo dopa ODT NeuC1 Neupropro (Patch 24 ODT (Tablet 1 3 Hour) Dispersible)

C1 C1 Carb Parlo idop del a/ Carbidopa/Levodopa/Levo Parlodel (2.5mg dopa / Enta 1 3 capo Tablet, 5mg Capsule) Entacaponene (Tablet)

DuoC1 Duopapa (Suspension) 4 PA

Bold type = Brand name drug Plain type = Generic drug 70 tRACK 70 Last updated October 1, 2018 3269 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

LodoC1 HaloC1 syn perid Lodosyn (Tablet) 4 Haloperidolol (0.5mg

RytaC1 Rytaryry (Capsule Tablet, 10mg Tablet, 3 ST 1mg Tablet, 20mg Extended-Release) 1

SineC1 Tablet, 2mg Tablet, Sinemetmet (Tablet) 3 5mg Tablet, 2mg/ml SineC1 met SinemetCR CR (Tablet 3 Concentrate) HaloC1 Extended-Release) perid ol HaloperidolDec Decanoate anoa StaleC1 te vo 1 Stalevo (Tablet) 4 (Injection)

B1 HaloC1 perid ol Monoamine Oxidase B (MAO-B) Inhibitors HaloperidolLact Lactate ate

AzileC1 1 Azilectct (Tablet) 3 (Injection)

LoxaC1 EldeC1 pine pryl Succ Loxapineinate Succinate Eldepryl (Capsule) 3 1 RasaC1 gilin (Capsule) e RasagilineMes Mesylate ylate 1 OrapC1 (Tablet) Orap (Tablet) 3

PimoC1 C1 Sele zide gilin e SelegilineHCl HCl (5mg Pimozide (Tablet) 1

1 ThiorC1 idazi ne Capsule, 5mg Tablet) ThioridazineHCl HCl

ZelaC1 1 Zelaparpar (Tablet (Tablet)

4 ThiotC1 hixe Dispersible) Thiothixenene (Capsule) 1

A1 TrifluC1 oper azin Antipsychotics Trifluoperazinee HCl HCl

B1 1 1st Generation/Typical (Tablet)

B1 ChloC1 rpro mazi 2nd Generation/Atypical Chlorpromazinene HCl HCl 1 AbilifC1 (Tablet) Abilifyy (Tablet) 4 QL

FlupC1 AbilifC1 hena y zine Main FluphenazineDec tena anoa Abilify Maintena te 1 4 Decanoate (Injection) (Injection)

FlupC1 hena AripiC1 zine praz FluphenazineHCl HCl Aripiprazoleole (Tablet, 1 QL (10mg Tablet, 1mg Oral Solution)

AripiC1 Tablet, 2.5mg Tablet, praz ole AripiprazoleODT ODT 1 QL 5mg Tablet, 2.5mg/ 1 (Tablet Dispersible)

5ml Elixir, 2.5mg/ml AristC1 ada Injection, 5mg/ml Aristada (Injection) 4 FanaC1 Concentrate) Fanaptpt (10mg Tablet,

HaldC1 Haldolol (Injection) 3 12mg Tablet, 6mg 4 QL, ST

HaldC1 ol Tablet, 8mg Tablet) Dec Haldolanoa Decanoate 100 te C1 100 Fana 3 pt (Injection) Fanapt (1mg Tablet,

HaldC1 ol 2mg Tablet, 4mg 3 QL, ST Dec Haldolanoa Decanoate 50 te 50 3 Tablet) (Injection)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 71 71 3370 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

FanaC1 QuetC1 pt iapin Titrat e Fanaption Titration Pack QuetiapineFum Fumarate Pack 3 ST arate (Tablet) (Tablet Immediate- 1 QL

GeoC1 Geodondon (20mg Release) QuetC1 iapin e QuetiapineFum Fumarate Capsule, 40mg arate ER Capsule, 60mg 4 QL ER (Tablet Extended- 1 QL Capsule, 80mg Release 24 Hour) RexuC1 Capsule) Rexultilti (Tablet) 4 QL

RispC1 GeoC1 erdal Geodondon (20mg Risperdal (0.25mg 3 Injection) Tablet, 0.5mg Tablet, 3

InveC1 Invegaga (Tablet 1mg Tablet) RispC1 Extended-Release 24 4 PA, QL Risperdalerdal (1mg/ml Oral Solution, 2mg Hour) 4 InveC1 ga Tablet, 3mg Tablet, Sust ennaInvega Sustenna (117mg/0.75ml 4mg Tablet) RispC1 erdal

RisperdalCon Consta Injection, 156mg/ml sta 3 Injection, 234mg/ 4 (12.5mg Injection)

RispC1 erdal

RisperdalCon Consta 1.5ml Injection, sta 78mg/0.5ml (25mg Injection, 4 Injection) 37.5mg Injection,

InveC1 ga Sust 50mg Injection) Invegaenna Sustenna RispC1 erido (39mg/0.25ml 3 Risperidonene (Tablet Injection) Immediate-Release, 1

InveC1 ga 1mg/ml Oral Solution) Trinz Invegaa Trinza RispC1 erido 4 ne RisperidoneODT ODT (Injection) 1 LatuC1 (Tablet Dispersible) Latudada (Tablet) 4 QL SapC1 hris NuplC1 Saphris (Tablet Nuplazidazid (Tablet) 4 PA 4 QL

OlanC1 Sublingual) zapi ne

C1 Olanzapine (10mg Sero 1 quel Injection) Seroquel (100mg

OlanC1 Tablet, 200mg Tablet, zapi Olanzapinene (Tablet 3 QL 1 QL 25mg Tablet, 50mg Immediate-Release)

OlanC1 Tablet) zapi ne ODT Olanzapine ODT SeroC1 1 QL Seroquelquel (300mg (Tablet Dispersible) 4 QL PalipC1 Tablet, 400mg Tablet) erido ne PaliperidoneER ER (Tablet Extended- 1 QL Release 24 Hour)

Bold type = Brand name drug Plain type = Generic drug 72 tRACK 72 Last updated October 1, 2018 3471 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

SeroC1 ZyprC1 quel exa XR Zydi Seroquel XR (150mg Zyprexas Zydis (10mg Tablet Extended- Tablet Dispersible, 3 QL Release 24 Hour, 5mg Tablet 200mg Tablet Dispersible)

3 QL C1 Zypr exa Extended-Release 24 Zydi Zyprexas Zydis (15mg Hour, 50mg Tablet Tablet Dispersible, 4 QL Extended-Release 24 20mg Tablet Hour) Dispersible)

SeroC1 quel B1 SeroquelXR XR (300mg Treatment-Resistant

ClozC1 apin Tablet Extended- Clozapinee (Tablet Release 24 Hour, 1 4 QL Immediate-Release) ClozC1 400mg Tablet apin e ClozapineODT ODT (Tablet 1 Extended-Release 24 Dispersible)

ClozC1 Hour) Clozarilaril (100mg VraylC1 ar 4 Vraylar (1.5mg Tablet)

ClozC1 Capsule, 3mg Clozarilaril (25mg Tablet) 3

Capsule, 4.5mg 4 QL, ST FazaC1 Fazacloclo (100mg Capsule, 6mg Tablet Dispersible, Capsule) 150mg Tablet C1 4 Vrayl arVraylar (Capsule 3 ST Dispersible, 200mg Therapy Pack) Tablet Dispersible) ZipraC1 sido ne FazaC1 ZiprasidoneHCl HCl clo 1 QL Fazaclo (12.5mg (Capsule) Tablet Dispersible, ZyprC1 Zyprexaexa (10mg 3 3 25mg Tablet Injection) Dispersible) ZyprC1 exa VersC1 Zyprexa (10mg aclo Versaclozz Tablet, 2.5mg Tablet, 4 3 QL (Suspension) 5mg Tablet, 7.5mg A1 Antivirals

Tablet) B1

ZyprC1 Anti-cytomegalovirus (CMV) Agents exa

Zyprexa (15mg PrevC1 4 QL Prevymisymis (Tablet) 4 PA, QL Tablet, 20mg Tablet) ValcC1 yte ZyprC1 Valcyte (450mg exa Relp Zyprexarevv Relprevv 3 Tablet, 50mg/ml Oral 4 QL (Injection) Solution)

ValgC1 anci clovi Valganciclovirr (Tablet) 1 QL

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 73 73 3572 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

ValgC1 RibaC1 anci sphe clovi re Valganciclovirr Ribasphere (200mg Hydr ochl Hydrochlordeorde (Oral 1 QL Capsule, 200mg 1 Solution) Tablet, 400mg Tablet,

ZirgaC1 Zirgann (Gel) 3 600mg Tablet)

RibaC1

B1 sphe re RibasphereRiba Ribapak Anti-hepatitis B (HBV) Agents pak 1

AdefC1 ovir (Tablet) Dipiv Adefoviroxil Dipivoxil RibaC1 1 virin (Tablet) Ribavirin (200mg

BaraC1 clud Capsule, 200mg 1 Baracludee (0.05mg/ 3 Tablet)

ml Oral Solution) C1 Sylat ron

BaraC1 Sylatron (Injection) 4 PA clud e Baraclude (0.5mg B1 4 Tablet, 1mg Tablet) Anti-hepatitis C (HCV) Direct Acting Agents DakliC1 nza EnteC1 Entecavircavir (Tablet) 1 Daklinza (Tablet) 4 PA, QL EpclC1 usa EpiviC1 r Epclusa (Tablet) 4 PA, QL EpivirHBV HBV (100mg HarvC1 oni Tablet, 5mg/ml Oral 3 Harvoni (Tablet) 4 PA, QL

MavC1 Solution) Mavyretyret (Tablet) 4 PA, QL

SovaC1 HepC1 ldi Hepserasera (Tablet) 4 Sovaldi (Tablet) 4 PA, QL

TechC1 LamiC1 nivie vudi Lamivudinene (100mg Technivie (Tablet) 4 PA, QL

1 ViekiC1 ra Tablet) ViekiraPak Pak (Tablet

VemlC1 4 PA, QL Vemlidyidy (Tablet) 4 QL Therapy Pack)

C1 B1 Vieki ra Anti-hepatitis C (HCV) Agents, Other ViekiraXR XR (Tablet

IntroC1 Intronn A A (Injection) 4 PA, LA Extended-Release 24 4 PA, QL

ModC1 Moderibaeriba (200mg Hour) VoseC1 1 vi Tablet) Vosevi (Tablet) 4 PA, QL

ZepaC1 ModC1 tier eriba

Moderiba1200 1200 Dose Zepatier (Tablet) 4 PA, QL Dose Pack

1 B1 Pack (Tablet) Antiherpetic Agents

ModC1 eriba AcycC1 800 lovir ModeribaDose 800 Dose Pack 1 Acyclovir (200mg Pack (Tablet) Capsule, 200mg/5ml

C1 Pega Pegasyssys (Injection) 4 PA Suspension, 400mg 1

PegaC1 sys Tablet, 800mg Tablet, ProC Pegasyslick ProClick 4 PA (Injection) 5% Ointment) AcycC1 lovir Sodi RebC1 um etol Acyclovir Sodium Rebetol (Oral 1 B/D, PA 3 (Injection) Solution) DenC1 Denaviravir (Cream) 4

FamC1 ciclo Famciclovirvir (Tablet) 1

Bold type = Brand name drug Plain type = Generic drug 74 tRACK 74 Last updated October 1, 2018 3673 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

TrifluC1 EdurC1 ridin ant Trifluridinee Edurant (Tablet) 4 QL 1 EfaviC1 (Ophthalmic Solution) Efavirenzrenz (200mg

ValaC1 cycl ovir ValacyclovirHCl HCl Capsule, 50mg 1 QL 1 QL (Tablet) Capsule, 600mg

ValtrC1 Valtrexex (Tablet) 3 QL Tablet)

IntelC1 ViroC1 ence Viropticptic (Ophthalmic Intelence (100mg 3 4 QL Solution) Tablet, 200mg Tablet)

IntelC1 XereC1 ence se Intelence (25mg Xerese (Cream) 4 PA 3 QL ZovirC1 Zoviraxax (200mg Tablet) JuluC1 ca Capsule, 200mg/5ml 3 Juluca (Tablet) 4 QL

NevirC1 apin Suspension) Nevirapinee (Tablet) 1 QL

NevirC1 ZovirC1 apin ax Zovirax (5% Cream, Nevirapinee ER ER (Tablet

5% Ointment, 800mg 4 Extended-Release 24 1 QL Tablet) Hour)

OdefC1 sey Anti-HIVB1 Agents, Integrase Inhibitors (INSTI) Odefsey (Tablet) 4 QL

RescC1 ripto C1 Gen r Genvoyavoya (Tablet) 4 QL Rescriptor (Tablet) 3 QL

SustiC1 va IsentC1 Isentressress (100mg Sustiva (200mg Packet, 25mg Tablet 2 QL Capsule, 600mg 4 QL Chewable) Tablet)

SustiC1 va IsentC1 ress Sustiva (50mg Isentress (100mg 3 QL Tablet Chewable, 4 QL Capsule)

SymfC1 400mg Tablet) Symfii (Tablet) 4 QL

SymfC1 IsentC1 i Lo ress IsentressHD HD (Tablet) 4 QL Symfi Lo (Tablet) 4 QL

ViraC1 StribiC1 mun Stribildld (Tablet) 4 QL Viramunee (200mg

TivicC1 Tivicayay (10mg Tablet) 3 QL Tablet, 50mg/5ml 4 QL

TivicC1 Tivicayay (25mg Tablet, Suspension) ViraC1 mun 4 QL e XR 50mg Tablet) Viramune XR (100mg

TriuC1 Triumeqmeq (Tablet) 4 QL Tablet Extended- 3 QL

TyboC1 Release 24 Hour) st

Tybost (Tablet) 3 QL C1 Vira mun e XR B1 Viramune XR (400mg Anti-HIV Agents, Non-nucleoside Reverse Tablet Extended- 4 QL Transcriptase Inhibitors (NNRTI)

C1 Release 24 Hour) Atrip la Atripla (Tablet) 4 QL B1

C1 Anti-HIV Agents, Nucleoside and Nucleotide Com plera Complera (Tablet) 4 QL Reverse Transcriptase Inhibitors (NRTI)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 75 75 3774 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

AbaC1 VideC1 Abacavircavir (20mg/ml Videxx EC EC (Capsule 3 QL Oral Solution, 300mg 1 QL Delayed-Release)

VideC1 Tablet) x Pedi Videxatric Pediatric (Oral AbaC1 cavir 3 QL

AbacavirSulfa Sulfate/ te/ Solution) Lami vudi ne/ Zido VireaC1 vudi Lamivudine/ 1 QL d ne Viread (150mg Tablet, Zidovudine (Tablet) 200mg Tablet, 250mg AbaC1 cavir / 4 QL Abacavir/LamivudineLami vudi ne 1 QL Tablet, 300mg Tablet, (Tablet) 40mg/gm Powder) BiktaC1 rvy Biktarvy (Tablet) 4 QL ZeritC1 (15mg Capsule, CimC1 Cimduoduo (Tablet) 4 QL 20mg Capsule, 30mg ComC1 Combivirbivir (Tablet) 4 QL Capsule, 40mg 3 QL

DescC1 Descovyovy (Tablet) 4 QL Capsule, 1mg/ml Oral

DidaC1 nosi Didanosinene (Capsule Solution)

1 QL ZiagC1 Delayed-Release) Ziagenen (20mg/ml Oral

EmtriC1 Emtrivava (10mg/ml Solution, 300mg 3 QL Oral Solution, 200mg 3 QL Tablet)

ZidoC1 vudi Capsule) Zidovudinene (100mg

EpiviC1 r Capsule, 300mg Epivir (10mg/ml Oral 1 QL Solution, 150mg 3 QL Tablet, 50mg/5ml Tablet, 300mg Tablet) Syrup)

B1

EpziC1 Epzicomcom (Tablet) 4 QL Anti-HIV Agents, Other

FuzeC1 on LamiC1 vudi Lamivudinene (10mg/ml Fuzeon (Injection) 4 QL

SelzC1 Oral Solution, 150mg 1 QL Selzentryentry (150mg Tablet, 300mg Tablet) Tablet, 300mg Tablet,

C1 4 QL Lami vudi ne/ Lamivudine/Zido 75mg Tablet, 20mg/ vudi ne 1 QL Zidovudine (Tablet) ml Oral Solution)

RetrC1 SelzC1 Retrovirovir (100mg Selzentryentry (25mg 2 QL Capsule, 50mg/5ml 3 QL Tablet) Syrup) Anti-HIVB1 Agents, Protease Inhibitors

StavC1 udin AptivC1 Stavudinee (Capsule) 1 QL Aptivusus (100mg/ml

TenoC1 fovir Diso Tenofovirproxi Disoproxil Oral Solution, 250mg 4 QL l Fum arate 1 QL Fumarate (Tablet) Capsule)

TrizivC1 AtazC1 ir anav ir Trizivir (Tablet) 4 QL AtazanavirSulfa Sulfate te

C1 1 QL Truv Truvadaada (Tablet) 4 QL (Capsule)

Bold type = Brand name drug Plain type = Generic drug 76 tRACK 76 Last updated October 1, 2018 3875 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

CrixiC1 RitoC1 Crixivanvan (Capsule) 2 QL Ritonavirnavir (Tablet) 1 QL

EvotC1 ViracC1 Evotazaz (Tablet) 4 QL Viraceptept (Tablet) 4 QL

FosaC1 B1 mpr enav Fosamprenavirir Anti-influenza Agents Calci um 1 QL FlumC1 adin Calcium (Tablet) Flumadinee (Tablet) 3

InvirC1 ase OseltC1 amivi Invirase (200mg r OseltamivirPhos Phosphate phat Capsule, 500mg 4 QL (Capsule,e 6mg/ml 1 QL Tablet) Suspension)

C1 Kalet ReleC1 ra nza Disk Kaletra (100mg-25mg Relenzahaler Diskhaler 2 Tablet, (Aerosol Powder) 3 QL RimaC1 ntadi 400mg-100mg/5ml ne RimantadineHCl HCl 1 Oral Solution) (Tablet)

C1 Kalet C1 ra Tami Kaletra (200mg-50mg Tamifluflu (30mg 4 QL Tablet) Capsule, 45mg

LexivC1 Lexivaa (50mg/ml Capsule, 75mg 3 QL 3 QL Suspension) Capsule, 6mg/ml

LexivC1 Lexivaa (700mg Tablet) 4 QL Suspension)

A1 LopiC1 navir / Anxiolytics Lopinavir/RitonavirRito navir 1 QL B1 (Oral Solution) Anxiolytics, Other

C1 Norvi BusC1 r piron e Norvir (100mg BuspironeHCl HCl (Tablet) 1

HydrC1 oxyzi Capsule, 100mg ne HydroxyzineHCl HCl 1 PA, HRM Packet, 100mg 3 QL (10mg/5ml Syrup) Tablet, 80mg/ml Oral BenzodiazepinesB1

AlprC1 Solution) azol Alprazolamam (Tablet PrezC1 cobi 1 QL Prezcobixx (Tablet) 4 QL Immediate-Release)

PreziC1 sta AlprC1 azol Prezista (100mg/ml am AlprazolamER ER (Tablet Suspension, 600mg 4 QL Extended-Release 24 1 PA, QL Tablet, 800mg Tablet) Hour)

PreziC1 AlprC1 sta azol am AlprazolamInten Intensol Prezista (150mg sol 3 QL 1 QL Tablet, 75mg Tablet) (1mg/ml Concentrate)

AlprC1 ReyaC1 azol taz am AlprazolamODT ODT Reyataz (150mg 1 QL Capsule, 200mg (Tablet Dispersible)

AtivaC1 Capsule, 300mg 4 QL Ativann (Tablet) 4 QL

ChloC1 rdiaz epox Capsule, 50mg Chlordiazepoxideide HCl HCl 1 Packet) (Capsule)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 77 77 3976 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

ClonC1 A1 azep Clonazepamam (Tablet Bipolar Agents 1 QL Immediate-Release) MoodB1 Stabilizers

ClonC1 azep DepC1 am akot ClonazepamODT ODT Depakotee (Tablet 1 QL 3 (Tablet Dispersible) Delayed-Release) ClorC1 azep ate DepC1 ClorazepateDipo akot tassi e ER um Depakote ER (Tablet 1 QL Dipotassium (Tablet) Extended-Release 24 3 DiazC1 epa Diazepamm (10mg Hour)

Tablet, 2mg Tablet, 1 QL DepC1 akot e DepakoteSpri Sprinkles nkle 5mg Tablet) s

DiazC1 (Capsule Sprinkle 3 epa Diazepamm (1mg/ml 1 Delayed-Release)

Oral Solution) C1 Dival proe x DiazC1 DivalproexSodi Sodium epa um m DiazepamInten Intensol sol 1 QL (Capsule Sprinkle 1 (5mg/ml Concentrate) Delayed-Release) KlonC1 opin

DivalC1 Klonopin (Tablet) 3 QL proe x DivalproexSodi Sodium DR um C1 Lora DR zepa Lorazepamm (0.5mg (Tablet Delayed- 1 Tablet, 1mg Tablet, 1 QL Release)

DivalC1 2mg Tablet, 2mg/ml proe x DivalproexSodi Sodium ER um ER Concentrate) (Tablet Extended- 1 OxazC1 epa Oxazepamm (Capsule) 1 Release 24 Hour)

TranC1 xene EquC1 Tranxene T T (Tablet) 3 QL Equetroetro (Capsule ValiuC1 Valiumm (Tablet) 3 QL Extended-Release 12 3

XanaC1 Xanaxx (0.25mg Hour)

LithiC1 Tablet, 0.5mg Tablet, 3 QL Lithiumum (Oral 1 1mg Tablet) Solution)

XanaC1 LithiC1 x um Carb Xanax (2mg Tablet) 4 QL Lithiumonat Carbonate e

XanaC1 x XR (Capsule Immediate- Xanax XR (0.5mg 1 Tablet Extended- Release, Tablet Release 24 Hour, Immediate-Release) LithiC1 um Carb Lithiumonat Carbonate ER 1mg Tablet Extended- 3 PA, QL e ER Release 24 Hour, (Tablet Extended- 1 3mg Tablet Extended- Release) LithoC1 Lithobidbid (Tablet Release 24 Hour) 3 XanaC1 xXanax XR XR (2mg Tablet Extended-Release)

A1 Extended-Release 24 4 PA, QL Blood Glucose Regulators Hour) AntidiabeticB1 Agents

Bold type = Brand name drug Plain type = Generic drug 78 tRACK 78 Last updated October 1, 2018 4077 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

AcarC1 GlipiC1 bose zide Acarbose (Tablet) 1 GlipizideER ER (Tablet

ActoC1 plus ActoplusMet Met (Tablet) 3 QL Extended-Release 24 1 QL

ActoC1 plus Hour) Met ActoplusXR Met XR GlipiC1 zide/ Metf Glipizide/Metforminormi n (Tablet Extended- 3 QL HCl 1 QL Release 24 Hour) HCl (Tablet) GlucC1 opha ge ActoC1 Actoss (Tablet) 3 QL Glucophage (Tablet) 3 QL GlucC1 opha ge AdlyC1 XR Adlyxinxin (Injection) 3 QL, ST Glucophage XR

AdlyC1 (Tablet Extended- 3 QL xin Start erAdlyxin Starter Pack Pack 3 QL, ST Release 24 Hour)

(Injection) C1 Gluc otrol

AloglC1 Glucotrol (Tablet) 3 QL iptin

Alogliptin (Tablet) 3 QL, ST C1 Gluc otrol XL AloglC1 Glucotrol XL (Tablet iptin / MetfAlogliptin/Metformin ormi n HCl 3 QL, ST Extended-Release 24 3 QL HCl (Tablet)

C1 Hour) Alogl iptin / PioglAlogliptin/Pioglitazone GluC1 itazo metz ne 3 QL, ST Glumetzaa (Tablet (Tablet)

AmaC1 Extended-Release 24 4 PA, QL rylAmaryl (Tablet) 3 QL Hour) AvanC1 dia Avandia (Tablet) GlysC1 3 PA, QL et Glyset (Tablet) 3 BydC1 ureo n BcisBydureon Bcise (Auto GlyxC1 e 2 QL Glyxambiambi (Tablet) 2 QL

injector) InvoC1 kam et BydC1 Invokamet (Tablet) 2 QL ureo n Injec Bydureon Injection InvoC1 tion kam et 2 QL InvokametXR XR (Tablet (Pen, Vial)

BydC1 Extended-Release 24 2 QL ureo n BydureonVial Vial 2 QL Hour)

(Injection) InvoC1 kana

ByettC1 Invokana (Tablet) 2 QL a

Byetta (Injection) 3 QL JanuC1 met

CyclC1 Janumet (Tablet Cyclosetoset (Tablet) 3 PA 2 QL Immediate-Release) DuetC1 act Duetact (Tablet) JanuC1 3 QL met JanumetXR XR (Tablet FarxiC1 Farxigaga (Tablet) 3 QL, ST Extended-Release 24 2 QL FortaC1 metFortamet (Tablet Hour)

JanuC1 Extended-Release 24 4 PA, QL Januviavia (Tablet) 2 QL

Hour) JardiC1 Jardianceance (Tablet) 2 QL GlimC1 epiri de JentC1 Glimepiride (Tablet) 1 QL adue Jentaduetoto (Tablet) 3 QL GlipiC1 zide

JentC1 Glipizide (Tablet adue to 1 QL JentaduetoXR XR Immediate-Release) (Tablet Extended- 3 QL Release 24 Hour)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 79 79 4178 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

KazaC1 PioglC1 no itazo ne Kazano (Tablet) 3 QL, ST PioglitazoneHCl/ HCl/ Metf ormi n 1 QL KomC1 HCl bigly ze Metformin HCl (Tablet) XRKombiglyze XR

PranC1 (Tablet Extended- 2 QL Prandindin (1mg Tablet) 3 QL

PranC1 Release 24 Hour) Prandindin (2mg Tablet) 4 QL

C1 Metf PrecC1 ormi ose n MetforminHCl HCl (Tablet Precose (Tablet) 1 QL 3 QterC1 Immediate-Release) Qternn (Tablet) 3 QL, ST

MetfC1 ormi C1 n Rep HCl aglin Metformin HCl (Tablet ide 1 QL Repaglinide (Tablet) 1 QL Immediate-Release) RepC1 aglin ide/ Metf C1 Repaglinide/Metformin Metf ormi ormi n n HCl 1 QL MetforminHCl HCl ER ER HCl (Tablet)

(1000mg Tablet RioC1 Riometmet (Oral Solution) 3 QL Extended-Release 24 SeglC1 uro Hour Generic Seglurometmet (Tablet) 3 QL, ST

SoliqC1 ua 100/ Fortamet, 1000mg Soliqua33 100/33 1 PA, QL 2 QL Tablet Extended- (Injection)

StarliC1 Release 24 Hour, Starlixx (Tablet) 3 QL

500mg Tablet SteglC1 Steglatroatro (Tablet) 3 QL, ST Extended-Release 24 SteglC1 Hour) Steglujanujan (Tablet) 3 QL, ST

SymlC1 MetfC1 inPe ormi n n SymlinPen120 120 HClMetformin HCl ER ER 4 PA (500mg Tablet (Injection)

SymlC1 inPe Extended-Release 24 SymlinPenn 60 60 4 PA Hour, 750mg Tablet 1 QL (Injection)

SynjC1 Extended-Release 24 Synjardyardy (Tablet) 2 QL

Hour) (Generic SynjC1 ardy Glucophage XR) SynjardyXR XR (Tablet

MigliC1 Extended-Release 24 2 QL Miglitoltol (Tablet) 1

NateC1 Hour) glini de Nateglinide (Tablet) 1 QL TanzC1 eum

NesiC1 Tanzeum (Injection) 3 QL, ST na

Nesina (Tablet) 3 QL, ST TolaC1 zami de

OnglC1 Tolazamide (Tablet) 1 QL yza

Onglyza (Tablet) 2 QL TolbC1 utam ide

OseC1 Tolbutamide (Tablet) 1 QL ni

Oseni (Tablet) 3 QL, ST TradjC1 enta

OzeC1 Tradjenta (Tablet) 3 QL mpic

Ozempic (Injection) 3 QL, ST TruliC1 city

PioglC1 Trulicity (Injection) 2 QL itazo ne HCl Pioglitazone HCl VictoC1 1 QL za (Tablet) Victoza (Injection) 2 QL XigdC1 uo XR PioglC1 itazo Xigduo XR (Tablet ne PioglitazoneHCl/ HCl/ Glim epiri de 1 QL Glimepiride (Tablet) Extended-Release 24 3 QL, ST Hour)

Bold type = Brand name drug Plain type = Generic drug 80 tRACK 80 Last updated October 1, 2018 4279 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

XultoC1 HumC1 phy alog 100/ Kwik Xultophy3.6 100/3.6 HumalogPen KwikPen 3 QL, ST 2 (Injection) (Injection)

B1 HumC1 alog Mix Glycemic Agents Humalog50/5 Mix 50/50 0 Kwik Pen C1 2 Gluc aGe n KwikPen (Injection) GlucaGenHyp HypoKit oKit

3 HumC1 alog Mix (Injection) Humalog50/5 Mix 50/50 0 Vial

C1 2 Gluc agon Vial (Injection) GlucagonEme Emergency rgen cy Kit 2 HumC1 alog Mix Kit (Injection) Humalog75/2 Mix 75/25 5 Kwik Pen C1 2 Prog lyce Proglycemm KwikPen (Injection)

4 HumC1 alog Mix (Suspension) Humalog75/2 Mix 75/25 5 Vial

B1 2 Insulins Vial (Injection)

HumC1 AdmC1 alog elog HumalogVial Vial Admelog (Injection) 3 PA 2 AdmC1 elog Solo (Injection) Admelogstar Solostar

HumC1 3 PA ulin 70/3 Humulin0 70/30 (Injection) Kwik Pen 2 AfrezC1 Afrezzaza (4unit KwikPen (Injection)

HumC1 ulin 70/3 Humulin0 70/30 Vial Powder, 8unit 3 PA Vial 2 Powder) (Injection)

HumC1 AfrezC1 ulin za N HumulinKwik N KwikPen Afrezza (12unit Pen 2 Powder, 4&8unit (Injection)

4 PA HumC1 ulin N Powder, 4&8&12unit HumulinVial N Vial 2 Powder) (Injection)

ApidC1 HumC1 ra ulin Solo R ApidraStar SoloStar HumulinU-50 R U-500 0 Kwik 3 PA Pen 2 (Injection) KwikPen (Injection)

ApidC1 HumC1 ra ulin Vial R Apidra Vial (Injection) 3 PA HumulinU-50 R U-500 Vial 0 Vial BasaC1 glar Kwik (Concentrated) BasaglarPen KwikPen 2 3 ST (Injection) (Injection)

HumC1 FiasC1 ulin p R HumulinVial R Vial Fiasp (Injection) 3 PA 2 FiasC1 p Flext (Injection) Fiaspouch Flextouch

LantC1 3 PA us Solo LantusStar SoloStar (Injection) 2 HumC1 alog Cartr (Injection) Humalogidge Cartridge LantC1 2 us (Injection) LantusVial Vial (Injection) 2

LeveC1 HumC1 mir alog Flex Juni LevemirTouc FlexTouch Humalogor Junior h Kwik Pen 2 2 KwikPen (Injection) (Injection)

LeveC1 mir LevemirVial Vial 2 (Injection)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 81 81 4380 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

NovC1 FondC1 olin apari 70/3 nux Novolin0 70/30 Vial FondaparinuxSodi Sodium Vial 3 PA um 1 (Injection) (Injection)

C1 C1 Frag Nov min olin N NovolinVial N Vial Fragmin (10000unit/ 3 PA (Injection) ml Injection,

NovC1 olin R 12500unit/0.5ml NovolinVial R Vial 3 PA (Injection) Injection, 15000unit/

NovC1 oLog 0.6ml Injection,

NovoLogFlex FlexPen Pen 3 PA (Injection) 18000unit/0.72ml 4

NovC1 Injection, 5000unit/ oLog Mix NovoLog70/3 Mix 70/30 0 Prefil led Flex 0.2ml Injection, PrefilledPen FlexPen 3 PA 7500unit/0.3ml (Injection)

C1 Injection, 95000unit/ Nov oLog Mix NovoLog70/3 Mix 70/30 0 Vial 3 PA 3.8ml Injection)

Vial (Injection) FragC1 min

C1 Fragmin (2500unit/ Nov oLog

NovoLogPen PenFill 3 Fill 3 PA 0.2ml Injection)

(Injection) HepC1 arin Sodi um C1 Heparin Sodium Nov oLog NovoLog Vial Vial 3 PA (10000unit/ml (Injection) Injection, 20000unit/ml 1

ToujC1 eo Max ToujeoSolo Max Solostar star Injection, 5000unit/ml 2 (Injection) Injection)

C1 ToujC1 Hep eo arin Solo Sodi ToujeoStar SoloStar Heparinum Sodium 2 1 B/D, PA (Injection) (1000unit/ml Injection)

JantC1 TresiC1 oven ba Flex Jantoven (Tablet) 1 TresibaTouc FlexTouch h 2 LoveC1 (Injection) Lovenoxnox (100mg/ml BloodA1 Products/Modifiers/Volume Expanders Injection, 120mg/ AnticoagulantsB1 0.8ml Injection,

ArixtC1 ra 150mg/ml Injection, Arixtra (Injection) 4 4 QL

BevyC1 60mg/0.6ml Bevyxxaxxa (Capsule) 3 QL Injection, 80mg/ CouC1 madi Coumadinn (Tablet) 2 0.8ml Injection) EliquC1 is LoveC1 Eliquis (Tablet) 2 QL Lovenoxnox (30mg/0.3ml EliquC1 is Start Eliquiser Starter Pack Pack 2 QL Injection, 40mg/ 3 QL (Tablet) 0.4ml Injection)

EnoxC1 apari PradC1 n axa EnoxaparinSodi Sodium um 1 QL Pradaxa (Capsule) 3 QL

SavaC1 (Injection) ysa Savaysa (Tablet) 3 PA, QL

Bold type = Brand name drug Plain type = Generic drug 82 tRACK 82 Last updated October 1, 2018 4481 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

WarfC1 EpoC1 arin gen Sodi Warfarinum Sodium Epogen (10000unit/ 1 (Tablet) ml Injection,

XarelC1 Xareltoto (Tablet) 2 QL 2000unit/ml

XarelC1 to Start Injection, 3000unit/ 3 PA Xareltoer Starter Pack Pack 2 QL (Tablet Therapy Pack) ml Injection,

ZontiC1 Zontivityvity (Tablet) 3 PA 4000unit/ml

B1 Injection) Blood Formation Modifiers EpoC1 gen AgrylC1 Epogen (20000unit/ Agrylinin (Capsule) 3 4 PA

AnaC1 ml Injection) greli de HCl Anagrelide HCl GranC1 1 ix (Capsule) Granix (Injection) 4 ST LeukC1 ine AranC1 esp Leukine (Injection) 4 PA Albu Aranespmin Albumin Free MircC1 Free (100mcg/0.5ml Mirceraera (Injection) 3 PA, LA

NeulC1 Injection, 100mcg/ml astaNeulasta (Injection) 4 PA

NeuC1 poge Injection, 150mcg/ Neupogenn (Injection) 4 ST

ProcC1 0.3ml Injection, Procritrit (10000unit/ml 200mcg/0.4ml Injection, 2000unit/ Injection, 200mcg/ml ml Injection, 4 PA 3 PA Injection, 300mcg/ 3000unit/ml 0.6ml Injection, Injection, 4000unit/ 300mcg/ml Injection, ml Injection)

ProcC1 500mcg/ml Injection, Procritrit (20000unit/ml 60mcg/0.3ml Injection, 40000unit/ 4 PA Injection, 60mcg/ml ml Injection)

ProC1 Injection) mact Promactaa (Tablet) 4 PA, QL, LA AranC1 esp Albu min ZarxiC1 Aranesp Albumin o Free Zarxio (Injection) 4

Free (10mcg/0.4ml B1 Hemostasis Agents Injection, 25mcg/ LystC1 0.42ml Injection, Lystedaeda (Tablet) 4 TavaC1 3 PA lisse 25mcg/ml Injection, Tavalisse (Tablet) 4 PA, QL

TranC1 exa mic TranexamicAcid Acid 40mcg/0.4ml 1 Injection, 40mcg/ml (Tablet) Injection) PlateletB1 Modifying Agents

DoptC1 AggrC1 Dopteletelet (Tablet) 4 PA Aggrenoxenox (Capsule Extended-Release 12 3 QL Hour)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 83 83 4582 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

AspirC1 B1 in/ Dipy Aspirin/Dipyridamolerida Angiotensin II Receptor Antagonists mole

AtacC1 (Capsule Extended- 1 QL Atacandand (Tablet) 3 QL

AvapC1 Release 12 Hour) ro Avapro (Tablet) 3 QL BrilinC1 ta

BeniC1 Brilinta (Tablet) 2 QL car Benicar (Tablet) 3 QL CilosC1 tazol

CanC1 Cilostazol (Tablet) 1 desa rtan CandesartanCilex Cilexetil etil ClopiC1 dogr el 1 QL Clopidogrel (Tablet) 1 QL (Tablet)

EffieC1 nt CozaC1 Effient (Tablet) 3 QL Cozaarar (Tablet) 3 QL

PlaviC1 x DiovC1 Plavix (Tablet) 3 QL Diovanan (Tablet) 3 QL

PrasC1 ugrel EdarC1 Prasugrel (Tablet) 1 QL Edarbibi (Tablet) 3 QL

A1

EproC1 sarta Cardiovascular Agents n EprosartanMes Mesylate ylate B1 1 QL Alpha-adrenergic Agonists (Tablet)

CataC1 IrbesC1 Cataprespres (Tablet) 3 Irbesartanartan (Tablet) 1 QL

CataC1 LosaC1 pres- rtan TTS- Pota Catapres-TTS-11 Losartanssiu Potassium 3 m 1 QL (Patch Weekly) (Tablet)

C1 C1 Mica Cata rdis pres- TTS- Catapres-TTS-22 Micardis (Tablet) 3 QL

3 OlmC1 esart an (Patch Weekly) OlmesartanMed Medoxomil oxo mil

C1 1 QL Cata pres- TTS- (Tablet) Catapres-TTS-33 3 TelmC1 isart (Patch Weekly) Telmisartanan (Tablet) 1 QL

C1 CloniC1 Vals dine artan ClonidineHCl HCl (Tablet Valsartan (Tablet) 1 QL Immediate-Release, 1 Angiotensin-convertingB1 Enzyme (ACE) Patch Weekly) Inhibitors

MethC1 yldo C1 pa Accu Methyldopa (Tablet) 1 PA, HRM Accuprilpril (Tablet) 3 QL MidoC1 drine C1 HCl Altac Midodrine HCl (Tablet) 1 Altacee (Capsule) 3 QL

NortC1 hera BenC1 azep Northera (Capsule) 4 PA, QL, LA ril BenazeprilHCl HCl (Tablet) 1 QL

B1

CaptC1 Alpha-adrenergic Blocking Agents Captoprilopril (Tablet) 1 QL CardC1 ura EnalC1 april Cardura (Tablet) 3 Male Enalaprilate Maleate DibeC1 nzyli 1 QL Dibenzylinene (Capsule) 4 (Tablet)

C1 Doxa FosiC1 zosin nopri l Mes Doxazosin Mesylate Sodi ylate Fosinopril Sodium 1 um 1 QL (Tablet) (Tablet)

C1 Mini C1 Lisin pres opril Minipresss (Capsule) 3 Lisinopril (Tablet) 1 QL

C1 Phe LoteC1 noxy nsin benz Phenoxybenzamineamin e Lotensin (Tablet) 3 QL HCl 1 MoeC1 xipril HCl (Capsule) Moexipril HCl HCl (Tablet) 1 QL PrazC1 osin PrazosinHCl HCl (Capsule) 1

Bold type = Brand name drug Plain type = Generic drug 84 tRACK 84 Last updated October 1, 2018 4683 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

PerinC1 QuinC1 dopri idine l PerindoprilErbu Erbumine QuinidineGluc Gluconate mine onat 1 QL e CR (Tablet) CR (Tablet Extended- 1

PriniC1 Prinivilvil (Tablet) 3 QL Release)

QuinC1 QbreC1 idine lis QuinidineSulfa Sulfate Qbrelis (Oral Solution) 4 QL te 1

QuinC1 april (Tablet) QuinaprilHCl HCl (Tablet) 1 QL RythC1 mol SR RamiC1 pril Rythmol SR (Capsule Ramipril (Capsule) 1 QL

TranC1 Extended-Release 12 4 dola Trandolaprilpril (Tablet) 1 QL Hour) VasoC1 tec Vasotec (10mg SoriC1 4 QL Sorinene (Tablet) 1

Tablet, 20mg Tablet) SotalC1 ol HCl

C1 Vaso Sotalol HCl (AF) Vasotectec (2.5mg 1 3 QL (Tablet)

Tablet, 5mg Tablet) SotalC1 ol HCl

C1 Sotalol HCl (Tablet) 1 Zestr il Zestril (Tablet) 3 QL SotylC1 ize

B1 Sotylize (Oral 3 PA Antiarrhythmics Solution) AmioC1 daro ne TikoC1 HCl Amiodarone HCl syn 1 Tikosyn (Capsule) 3

(Tablet) B1

BetaC1 Beta-adrenergic Blocking Agents pace AF

C1 Betapace AF (120mg Ace butol ol 4 AcebutololHCl HCl Tablet, 160mg Tablet) 1

C1 (Capsule) Beta pace AF Betapace AF (80mg AtenC1 3 Atenolololol (Tablet) 1

Tablet) C1 Beta xolol HCl C1 Dofe Betaxolol HCl (10mg tilide 1 Dofetilide (Capsule) 1 Tablet, 20mg Tablet) FlecC1 ainid e C1 Acet Biso Flecainide Acetate prolo ate l BisoprololFum Fumarate 1 arate 1 (Tablet) (Tablet) MexiC1 letin e C1 HCl Byst Mexiletine HCl olic 1 Bystolic (Tablet) 2 QL

(Capsule) C1 Carv edilo l C1 Mult Carvedilol (Tablet Multaqaq (Tablet) 1 2 Immediate-Release) PaceC1 rone CarvC1 Pacerone (100mg edilo l CarvedilolPhos Phosphate 3 phat e Tablet, 400mg Tablet) (Capsule Extended- 1 PaceC1 Paceronerone (200mg 1 Release 24 Hour) CoreC1 Tablet) Coregg (Tablet) 3 PropC1 afen one C1 HCl Core Propafenone HCl g CR 1 Coreg CR (Capsule (Tablet)

C1 Extended-Release 24 3 Prop afen one PropafenoneHCl HCl ER ER Hour)

(Capsule Extended- 1 CorgC1 ard Release 12 Hour) Corgard (Tablet) 3

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 85 85 4784 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

InderC1 AfedC1 al LA itab Inderal LA (Capsule AfeditabCR CR (Tablet

Extended-Release 24 4 Extended-Release 24 1 Hour) Hour)

AmloC1 InnoC1 dipin pran e XL AmlodipineBesy Besylate Innopran XL (Capsule late 1 Extended-Release 24 4 (Tablet) CalaC1 Hour) Calann (Tablet) 3

CalaC1 LabeC1 n SR talol HCl Calan SR (Tablet Labetalol HCl (Tablet) 1 3 LoprC1 esso Lopressorr (Tablet) 3 Extended-Release) CardC1 izem MetoC1 prolo l Cardizem (Tablet) 4 MetoprololSucc Succinate inate ER CardC1 izem Cardizem CD CD ER (Tablet Extended- 1 Release 24 Hour) (Capsule Extended- 4

MetoC1 prolo l MetoprololTartr Tartrate Release 24 Hour) ate CardC1 izem (Tablet Immediate- 1 Cardizem LA LA (Tablet

Release) Extended-Release 24 3

NadC1 Nadolololol (Tablet) 1 Hour)

C1 Pind C1 olol Carti Pindolol (Tablet) 1 a XT Cartia XT (Capsule PropC1 ranol ol HCl Extended-Release 24 1 Propranolol HCl (Tablet Immediate- 1 Hour)

DiltiaC1 zem Release, Oral Solution) DiltiazemHCl HCl (Tablet

PropC1 1 ranol ol PropranololHCl HCl ER Immediate-Release) ER (Capsule Extended- 1 Release 24 Hour)

TenoC1 Tenorminrmin (Tablet) 3

TimoC1 lol Male Timololate Maleate (10mg Tablet, 20mg Tablet, 1 5mg Tablet)

ToprC1 Toprolol XL XL (Tablet

Extended-Release 24 3 Hour) CalciumB1 Channel Blocking Agents

AdalC1 at AdalatCC CC (Tablet

Extended-Release 24 3 Hour)

Bold type = Brand name drug Plain type = Generic drug 86 tRACK 86 Last updated October 1, 2018 4885 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

DiltiaC1 NifeC1 zem dipin HCl e ER DiltiazemER HCl ER Nifedipine ER (Tablet (120mg Capsule Extended-Release 24 1 Extended-Release 12 Hour)

NimC1 odipi Hour, 60mg Capsule Nimodipinene (Capsule) 1

NisolC1 Extended-Release 12 dipin Nisoldipinee ER ER (Tablet Hour, 90mg Capsule Extended-Release 24 1 Extended-Release 12 Hour)

Hour)(Generic C1 Norv Cardizem SR), (120mg Norvascasc (Tablet) 3 NymC1 Capsule Extended- Nymalizealize (Oral 4 Release 24 Hour, Solution)

ProcC1 ardia 180mg Capsule Procardia XL XL (Tablet 1 Extended-Release 24 Extended-Release 24 3 Hour, 240mg Capsule Hour)

Extended-Release 24 C1 Sular (Tablet Hour, 300mg Capsule Extended-Release 24 Extended-Release 24 3 Hour)( Generic Hour)

TaztiC1 Cardizem CD), (360mg a XT Taztia XT (Capsule Capsule Extended- Extended-Release 24 1 Release 24 Hour, Hour)

TiazC1 420mg Capsule Tiazacac (Capsule

Extended-Release 24 Extended-Release 24 3 Hour)( Generic Tiazac) Hour) Dilt-C1 XR Dilt-XR (Capsule VeraC1 pami Verapamill HCl HCl (Tablet Extended-Release 24 1 1 Immediate-Release) Hour) VeraC1 pami l HCl FeloC1 VerapamilER HCl ER dipin Felodipinee ER ER (Tablet (Capsule Extended- Extended-Release 24 1 Release 24 Hour, 1 Hour) Tablet Extended- IsradC1 Isradipineipine (Capsule) 1 Release)

MatzC1

im C1 LA Vera pami Matzim LA (Tablet l HCl VerapamilSR HCl SR

Extended-Release 24 1 (Capsule Extended- 1 Hour) Release 24 Hour) NicaC1 rdipi ne C1 HCl Verel Nicardipine HCl an 1 Verelan (Capsule (Capsule) Extended-Release 24 3 Hour)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 87 87 4986 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

VerelC1 BisoC1 an prolo PM l Verelan PM (Capsule BisoprololFum Fumarate/ arate / Hydr ochl orot Hydrochlorothiazidehiazi 1 QL Extended-Release 24 3 de Hour) (Tablet)

ByvaC1 CardiovascularB1 Agents, Other Byvalsonlson (Tablet) 3 QL, ST

CadC1 AccuC1 uet Accureticretic (Tablet) 3 QL Caduet (Tablet) 3 QL

CanC1 AldaC1 desa ctazi rtan de CandesartanCilex Cilexetil/ Aldactazide (Tablet) etil/ 3 Hydr ochl orot hiazi AmilC1 de oride Hydrochlorothiazide 1 QL / Amiloride/Hydr ochl orot hiazi Hydrochlorothiazidede 1 (Tablet) CaptC1 opril / Captopril/Hydr ochl (Tablet) orot hiazi de AmloC1 dipin Hydrochlorothiazide 1 QL e AmlodipineBesy Besylate/ late/ Ator vasta tin (Tablet) Calci Atorvastatinum Calcium 1 QL CorlC1 (Tablet) Corlanoranor (Tablet) 3 PA, QL

CorziC1 AmloC1 de dipin e Corzide (Tablet) 3 AmlodipineBesy Besylate/ late/ Ben azep DemC1 ril ser BenazeprilHCl HCl 1 QL Demser (Capsule) 4

DigitC1 (Capsule) Digitekek (0.125mg

AmloC1 dipin 1 QL, HRM e AmlodipineBesy Besylate/ late/ Tablet) Vals artan 1 QL DigitC1 Valsartan (Tablet) Digitekek (0.25mg

AmloC1 dipin 1 PA, HRM e/ Amlodipine/Olm esart Tablet) an Med oxo C1 mil Digo Olmesartan Medoxomil 1 QL Digoxx (125mcg Tablet) 1 QL, HRM

(Tablet) DigoC1 x

C1 Digox (250mcg Tablet) 1 PA, HRM Amlo dipin e/ Amlodipine/Valsartan/Vals DigoC1 artan xin / Hydr Digoxin (0.05mg/ml ochl PA, QL, orot Hydrochlorothiazidehiazi 1 de 1 (Tablet) Oral Solution) HRM DigoC1 xin AtacC1 and Digoxin (125mcg AtacandHCT HCT (Tablet) 3 QL 1 QL, HRM

AtenC1 Tablet) olol/ Chlo rthali C1 Atenolol/ Digo done 1 Digoxinxin (250mcg Chlorthalidone (Tablet) 1 PA, HRM

AvaliC1 Tablet) de

Avalide (Tablet) 3 QL DiovC1 an HCT AzorC1 Diovan HCT (Tablet) 3 QL

Azor (Tablet) 3 QL DUTC1 OPR OL BenC1 DUTOPROL (Tablet azep ril BenazeprilHCl/ HCl/ Hydr ochl orot Extended-Release 24 3 hiazi Hydrochlorothiazidede 1 QL Hour) (Tablet) DyazC1 ide BeniC1 car Dyazide (Capsule) 3 BenicarHCT HCT (Tablet) 3 QL EdarC1 bycl or BiDilC1 Edarbyclor (Tablet) BiDil (Tablet) 2 3 QL

Bold type = Brand name drug Plain type = Generic drug 88 tRACK 88 Last updated October 1, 2018 5087 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

EnalC1 NadC1 april olol/ Male Ben Enalaprilate/ Maleate/ Nadolol/drofl Hydr umet ochl hiazi orot de hiazi Hydrochlorothiazidede 1 QL Bendroflumethiazide 1 (Tablet) (Tablet)

EntrC1 OlmC1 esto esart an Entresto (Tablet) 2 QL OlmesartanMed oxo mil/ Amlo ExforC1 dipin ge e/ Medoxomil/Hydr ochl Exforge (Tablet) 3 QL orot hiazi de ExforC1 ge Amlodipine/ 1 QL ExforgeHCT HCT (Tablet) 3

C1 Hydrochlorothiazide Fosi nopri l FosinoprilSodi Sodium/ um/ Hydr (Tablet) ochl orot hiazi Hydrochlorothiazidede 1 QL OlmC1 esart an OlmesartanMed oxo mil/ (Tablet) Hydr ochl orot hiazi C1 Medoxomil/ Hyza de ar 1 QL Hyzaar (Tablet) 3 QL Hydrochlorothiazide IrbesC1 artan / Irbesartan/Hydr ochl (Tablet) orot hiazi de PentC1 oxifyl Hydrochlorothiazide 1 QL line PentoxifyllineER ER (Tablet) (Tablet Extended- 1 LanoC1 Lanoxinxin (125mcg Release)

PropC1 ranol Tablet, 62.5mcg 3 QL, HRM ol/ Propranolol/Hydr ochl orot hiazi Tablet) Hydrochlorothiazidede 1

LanoC1 xinLanoxin (250mcg (Tablet)

3 PA, HRM QuinC1 april / Tablet) Quinapril/Hydr ochl orot hiazi LisinC1 de opril / Hydrochlorothiazide 1 QL HydrLisinopril/ ochl orot hiazi deHydrochlorothiazide 1 QL (Tablet)

RanC1 (Tablet) Ranexaexa (Tablet

C1 Lopr esso r LopressorHCT HCT Extended-Release 12 2 3 (Tablet) Hour)

SpirC1 C1 Losa onol rtan acto Pota ne/ ssiu Spironolactone/ Losartan Potassium/ Hydr m/ ochl Hydr orot ochl hiazi orot de hiazi Hydrochlorothiazidede 1 QL Hydrochlorothiazide 1 (Tablet) (Tablet)

TarkC1 C1 Lotr a el Tarka (Tablet Lotrel (Capsule) 3 QL 3 QL MaxC1 Maxzidezide (Tablet) 3 Extended-Release)

TektC1 urna MetoC1 prolo l/ Tekturna (Tablet) 3 QL Metoprolol/Hydr ochl orot hiazi TektC1 de urna Hydrochlorothiazide 1 TekturnaHCT HCT (Tablet) 3 QL

TelmC1 isart (Tablet) an/ Telmisartan/Amlo dipin e MicaC1 1 QL rdis MicardisHCT HCT (Tablet) 3 QL Amlodipine (Tablet)

MoeC1 TelmC1 xipril isart / an/ Hydr Telmisartan/Hydr Moexipril/ ochl ochl orot orot hiazi hiazi Hydrochlorothiazidede 1 QL Hydrochlorothiazidede 1 QL (Tablet) (Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 89 89 5188 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

TenoC1 EthaC1 retic cryni 100 c Tenoretic 100 (Tablet) 3 EthacrynicAcid Acid 1 TenoC1 retic Tenoretic50 50 (Tablet) 3 (Tablet)

FuroC1 TranC1 semi dola de pril/ Furosemide (10mg/ml Trandolapril/VerapamilVera pami l HCl 1 B/D, PA HClER ER (Tablet 1 QL Injection)

FuroC1 semi Extended-Release) Furosemidede (10mg/ml

TriaC1 mter ene/ Oral Solution, 8mg/ml Triamterene/Hydr ochl orot hiazi Hydrochlorothiazidede Oral Solution, 20mg 1 (25mg-37.5mg Tablet, Tablet, 40mg Tablet, 1 50mg-75mg Tablet, 80mg Tablet)

LasixC1 37.5mg-25mg Lasix (Tablet) 3

TorsC1 emid Capsule) Torsemidee (Tablet) 1

TribeC1 nzor Tribenzor (Tablet) 3 QL Diuretics,B1 Potassium-sparing

TwyC1 nsta AldaC1 cton Twynsta (Tablet) 3 QL Aldactonee (Tablet) 3

ValsC1 artan AmilC1 / oride Valsartan/Hydr HCl ochl orot Amiloride HCl (Tablet) 1 hiazi de

CaroC1 Hydrochlorothiazide 1 QL Carospirspir (Tablet) 4

C1 (Suspension) Vase retic

Vaseretic (Tablet) 3 QL DyreC1 nium

C1 Dyrenium (Capsule) 3 Veca myl

Vecamyl (Tablet) 4 PA EplerC1 enon e

C1 Eplerenone (Tablet) 1 Zest oreti c Zestoretic (Tablet) 3 QL InsprC1 a

C1 Inspra (Tablet) 3 Ziac

Ziac (Tablet) 3 QL SpirC1 onol acto ne B1 Spironolactone 1 Diuretics, Carbonic Anhydrase Inhibitors (Tablet) AcetC1 azol amid B1 Acetazolamidee (Tablet 1 Diuretics, Thiazide

Immediate-Release) ChloC1 rothi azid e C1 Chlorothiazide (Tablet) 1 Acet azol amid Acetazolamidee ER ER ChloC1 rthali done (Capsule Extended- 1 Chlorthalidone (Tablet) 1 DiurilC1 Release 12 Hour) Diuril (Suspension) 3

HydrC1 KeveC1 ochl yis orot Hydrochlorothiazidehiazi Keveyis (Tablet) 4 PA, QL de

MethC1 azol (12.5mg Capsule, amid eMethazolamide 1 1 (Tablet) 12.5mg Tablet, 25mg

B1 Tablet, 50mg Tablet)

Diuretics, Loop IndaC1 pami de

C1 Indapamide (Tablet) 1 Bum etani de Bumetanide (0.25mg/ MethC1 yclot hiazi de ml Injection, 0.5mg Methyclothiazide 1 1 Tablet, 1mg Tablet, (Tablet) MetoC1 lazo 2mg Tablet) Metolazonene (Tablet) 1

MicrC1 EdecC1 ozid Edecrinrin (Tablet) 4 Microzidee (Capsule) 3

Bold type = Brand name drug Plain type = Generic drug 90 tRACK 90 Last updated October 1, 2018 5289 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

B1 AltoC1 Dyslipidemics, Fibric Acid Derivatives Altoprevprev (Tablet

AntaC1 Antarara (Capsule) 2 Extended-Release 24 4 QL

FenoC1 fibrat Fenofibratee (120mg Hour)

AtorC1 vasta tin AtorvastatinCalci Calcium Tablet, 145mg Tablet, um 1 QL 160mg Tablet, 40mg (Tablet)

CresC1 Tablet, 48mg Tablet, Crestortor (Tablet) 3 QL

FloliC1 54mg Tablet, 130mg 1 Flolipidpid (Suspension) 3 QL

Capsule, 150mg FluvC1 astat Fluvastatinin (Capsule Capsule, 43mg 1 QL Capsule, 50mg Immediate-Release) FluvC1 astat in FluvastatinSodi Sodium ER Capsule) um ER

FenoC1 fibrat (Tablet Extended- 1 QL e FenofibrateMicr Micronized oniz ed 1 (Capsule) Release 24 Hour) LescC1 ol XL FenoC1 fibric Lescol XL (Tablet Fenofibric Acid Acid 1 (105mg Tablet) Extended-Release 24 3 QL

FenoC1 Hour) fibric Fenofibric Acid Acid (35mg LipitC1 1 or Tablet) Lipitor (Tablet) 3 QL

LivalC1 o FenoC1 fibric Acid Livalo (Tablet) 2 QL FenofibricDR Acid DR LovaC1 stati (Capsule Delayed- 1 Lovastatinn (Tablet 1 QL Release) Immediate-Release)

FenoC1 PravC1 glide acho Fenoglide (120mg Pravacholl (Tablet) 3 QL

4 C1 Prav astat in Tablet) PravastatinSodi Sodium um

FenoC1 1 QL Fenoglideglide (40mg (Tablet)

3 RosC1 uvas tatin Tablet) RosuvastatinCalci Calcium um

C1 1 QL Fibri Fibricorcor (Tablet) 3 (Tablet)

SimvC1 GemC1 astat fibro in Gemfibrozilzil (Tablet) 1 Simvastatin (Tablet) 1 QL

ZocoC1 LipofC1 r Lipofenen (Capsule) 3 Zocor (Tablet) 3 QL

ZypitC1 LopiC1 ama Lopidd (Tablet) 3 Zypitamagg (Tablet) 3 QL, ST

B1 TricoC1 Tricorr (Tablet) 3 Dyslipidemics, Other

CholC1 TrigliC1 estyr de amin Cholestyraminee Triglide (Tablet) 3 1

TrilipC1 Trilipixix (Capsule (Packet) CholC1 estyr 3 amin Cholestyraminee Light Delayed-Release) Light 1 B1 (Powder)

Dyslipidemics, HMG CoA Reductase C1 Cole sevel am ColesevelamHCl HCl Inhibitors 1 (Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 91 91 5390 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

ColeC1 ZetiaC1 Colestidstid (1gm Tablet, Zetia (Tablet) 3

3 B1 5gm Packet) Vasodilators, Direct-acting Arterial

ColeC1 stipo B1 Colestipoll HCl HCl (1gm 1 Vasodilators, Direct-acting Arterial/Venous GoniC1 Tablet, 5gm Packet) Gonitrotro (Packet) 3 EzetiC1 mibe IsordC1 Ezetimibe (Tablet) 1 il Titra Isordildose Titradose EzetiC1 mibe / 4 Ezetimibe/SimvastatinSimv astat in 1 QL (Tablet)

IsosC1 (Tablet) orbid e IsosorbideDinit Dinitrate rate JuxtC1 apid Juxtapid (Capsule) 4 PA, LA (Tablet Immediate- 1

KynaC1 Kynamromro (Injection) 4 PA, LA Release)

LovaC1 IsosC1 za orbid e Lovaza (Capsule) 3 IsosorbideDinit Dinitrate ER rate ER NiaciC1 Niacinn ER ER (Tablet (Tablet Extended- 1 1 Extended-Release) Release)

IsosC1 orbid NiacC1 or e IsosorbideMon Mononitrate onitr Niacor (Tablet) 1 ate

NiasC1 Niaspanpan (Tablet (Tablet Immediate- 1 3 Release)

Extended-Release) C1 Isos orbid e OmeC1 IsosorbideMon Mononitrate ga-3- onitr Acid ate ER Omega-3-AcidEthyl Ethyl Ester s ER (Tablet Extended- 1 Esters (Capsule) 1 Release 24 Hour)

(Generic Lovaza) C1 Minit ran

C1 Pralu Minitran (Patch 24 Praluentent (Injection) 1 4 PA, QL, LA Hour) PrevC1 alite NitroC1 Prevalite (Packet) 1 Nitro-Bid-Bid (Ointment) 3 QueC1 stran NitroC1 Questran (Packet) 3 Nitro-Dur-Dur (Patch 24 QueC1 stran 3 QuestranLight Light 3 Hour) (Powder) NitroC1 glyc erin C1 Nitroglycerin (Tablet Rep atha 1 Repatha (Injection) 4 PA, QL Sublingual) RepC1 atha Push NitroC1 tron glyc Repatha Pushtronex erin ex Syst NitroglycerinLing Lingual em 4 PA, QL ual 1 System (Injection) (Translingual Solution)

RepC1 atha NitroC1 Sure glyc ClickRepatha SureClick erin NitroglycerinTran sder 4 PA, QL mal (Injection) Transdermal (Patch 24 1

VascC1 epaVascepa (Capsule) 3 Hour)

NitroC1 C1 Vytor stat in Nitrostat (Tablet Vytorin (Tablet) 3 QL 3 WelcC1 Welcholhol (3.75gm Sublingual) RectiC1 Packet, 625mg 3 Rectivv (Ointment) 3

HydrC1 alazi ne Tablet) HydralazineHCl HCl 1 (Tablet)

Bold type = Brand name drug Plain type = Generic drug 92 tRACK 92 Last updated October 1, 2018 5491 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

MinoC1 AmpC1 xidil heta mine Minoxidil (Tablet) 1 Amphetamine// Dext roam phet

A1 amin Central Nervous System Agents Dextroamphetaminee

B1 (10mg Capsule Attention Deficit Hyperactivity Disorder Extended-Release 24 Agents, Amphetamines Hour, 15mg Capsule AddC1 Adderallerall (Tablet) 3 QL Extended-Release 24

AddC1 erall AdderallXR XR (Capsule Hour, 20mg Capsule Extended-Release 24 3 QL Extended-Release 24 Hour) Hour, 25mg Capsule

AdzeC1 nys Extended-Release 24 AdzenysER ER Hour, 30mg Capsule (Suspension 3 QL Extended-Release 24 Extended-Release) Hour, 5mg Capsule AdzeC1 nys XR- AdzenysODT XR-ODT Extended-Release 24 1 QL (Tablet Extended- 3 QL Hour, 10mg Tablet Release Dispersible) Immediate-Release, 12.5mg Tablet Immediate-Release, 15mg Tablet Immediate-Release, 20mg Tablet Immediate-Release, 30mg Tablet Immediate-Release, 5mg Tablet Immediate- Release, 7.5mg Tablet Immediate-Release)

DesoC1 Desoxynxyn (Tablet) 4 PA

DexeC1 Dexedrinedrine (Capsule Extended-Release 24 4 QL Hour)

DextC1 roam phet Dextroamphetamineamin e Sulfa Sulfatete (Tablet 1 QL Immediate-Release)

DextC1 roam phet Dextroamphetamineamin e Sulfa te SulfateER ER (Capsule 1 QL Extended-Release 24 Hour)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 93 93 5592 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

DyanC1 FocaC1 avel lin DyanavelXR XR FocalinXR XR (Capsule

(Suspension 3 QL Extended-Release 24 3 Extended-Release) Hour)

MethC1 KapvC1 amp ay heta Methamphetaminemine HCl Kapvay (Tablet HCl 1 PA (Tablet) Extended-Release 12 3 PA

MydC1 Mydayisayis (Capsule Hour)

MetaC1 date Extended-Release 24 3 QL MetadateER ER (Tablet 1 QL Hour) Extended-Release)

ProCC1 MethC1 ProCentraentra (Oral Methylinylin (Oral 3 3 QL Solution) Solution)

C1 Vyva C1 nse Meth ylph enid Vyvanse (Capsule, Methylphenidateate HCl 3 HCl Tablet Chewable) (Tablet Chewable, 1 QL ZenzC1 Zenzediedi (Tablet) 3 QL Oral Solution, Tablet

B1 Immediate-Release) Attention Deficit Hyperactivity Disorder MethC1 ylph enid Methylphenidateate HCl HCl Agents, Non-amphetamines CD

ApteC1 CD (Capsule Extended- 1 nsio AptensioXR XR (Capsule Release)

Extended-Release 24 3 QL MethC1 ylph enid Methylphenidateate HCl HCl Hour) ER ER (10mg Capsule AtoC1 mox Atomoxetineetine (Capsule) 1 Extended-Release 24

CloniC1 dine HCl ClonidineER HCl ER Hour, 20mg Capsule (Tablet Extended- 1 PA Extended-Release 24 1 Release 12 Hour) Hour, 30mg Capsule

ConC1 Concertacerta (Tablet Extended-Release 24 3 QL Extended-Release) Hour, 40mg Capsule

DaytC1 Extended-Release 24 Daytranarana (Patch) 3 QL Hour) DexC1 meth ylph Dexmethylphenidateenid ate HCl (Tablet Immediate- 1 QL Release)

DexC1 meth ylph Dexmethylphenidateenid ate HCl HClER ER (Capsule 1 Extended-Release 24 Hour)

FocaC1 Focalinlin (Tablet) 3 QL

Bold type = Brand name drug Plain type = Generic drug 94 tRACK 94 Last updated October 1, 2018 5693 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

MethC1 NamC1 ylph zaric enid Methylphenidateate HCl Namzaric (Therapy HCl ER ER (10mg Tablet Pack, Capsule 2 PA, QL Extended-Release, Extended-Release 24 20mg Tablet Extended- Hour)

Release, 72mg Tablet NueC1 dext Nuedextaa (Capsule) 3 PA Extended-Release, RilutC1 18mg Tablet Extended- Rilutekek (Tablet) 4 RiluzC1 1 QL ole Release 24 Hour, Riluzole (Tablet) 1

TetraC1 bena 27mg Tablet Extended- Tetrabenazinezine (Tablet) 1 PA, LA

XenaC1 Release 24 Hour, zineXenazine (Tablet) 4 PA, LA

36mg Tablet Extended- B1 Release 24 Hour, Fibromyalgia Agents CymC1 Cymbaltabalta (Capsule 54mg Tablet Extended- 3 QL Release 24 Hour) Delayed-Release)

MethC1 DuloC1 ylph xetin enid e Methylphenidateate HCl DuloxetineHCl HCl HCl ER (LA) (Capsule (Capsule Delayed- 1 QL 1 Extended-Release 24 Release)

LyricC1 Hour) Lyricaa (100mg

QuilliC1 Che QuilliCheww ER ER (Tablet Capsule, 150mg Chewable Extended- 3 QL Capsule, 200mg Release) Capsule, 225mg

QuilliC1 vant QuillivantXR XR Capsule, 25mg 3 2 QL (Suspension) Capsule, 300mg

RitaliC1 Ritalinn (Tablet) 3 QL Capsule, 50mg

RitaliC1 Ritalinn LA LA (Capsule Capsule, 75mg

Extended-Release 24 3 Capsule, 20mg/ml Hour) Oral Solution) LyricC1 a CR StratC1 Stratteratera (Capsule) 3 Lyrica CR (Tablet

B1 Extended-Release 24 3 PA, QL Central Nervous System, Other

AustC1 Hour) edo

Austedo (Tablet) 4 PA, QL, LA SaveC1 lla

GraliC1 Savella (Tablet) 2 se

Gralise (Tablet) 3 PA SaveC1 lla Titrat ion GraliC1 Savella Titration Pack Pack 2 se Start Graliseer Starter Pack Pack 3 PA B1

HorizC1 Multiple Sclerosis Agents ant

Horizant (Tablet AmpC1 3 PA Ampyrayra (Tablet Extended-Release)

IngreC1 Extended-Release 12 4 QL, LA Ingrezzazza (Capsule) 4 PA, QL Hour)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 95 95 5794 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

AubC1 EvoxC1 Aubagioagio (Tablet) 4 QL, LA Evoxacac (Capsule) 3 ST

AvonC1 PerioC1 Avonexex (Injection) 4 Periogardgard (Solution) 1

AvonC1 PilocC1 ex arpin Pen e Avonex Pen PilocarpineHCl HCl (5mg 4 1 (Injection) Tablet, 7.5mg Tablet)

C1 C1 Sala Beta gen sero Betaseronn (Injection) 4 Salagen (Tablet) 3

TriaC1 CopC1 mcin axon olon e Triamcinolonee in in Copaxone (Injection) 4 Orab ase 1 ExtaC1 Extaviavia (Injection) 4 Orabase (Paste)

A1

GileC1 Gilenyanya (Capsule) 4 QL Dermatological Agents

B1

GlatiC1 rame Dermatological Agents r GlatiramerAcet Acetate ate AbsoC1 (Solution Prefilled 1 Absoricarica (Capsule) 4 PA

AcanC1 Syringe) Acanyaya (Gel) 3 ST

GlatC1 opa AcitrC1 Glatopa (Injection) 1 Acitretinetin (Capsule) 1

PlegrC1 idy AczoC1 Plegridy (Injection) 4 Aczonene (Gel) 3

PlegrC1 idy AdaC1 Start pale Plegridyer Starter Pack ne Pack 4 Adapalene (0.1% (Injection) Cream, 0.1% Gel, 0.3% 1

RebiC1 Rebiff (Injection) 4 Gel)

AdaC1 RebiC1 pale f ne Rebi Adapaleneand and Rebifdose Rebidose Benz oyl Pero 1 4 xide (Injection) Benzoyl Peroxide (Gel)

AktipC1 ak RebiC1 f Rebi Aktipak (Packet) 3 ST Rebifdose Rebidose

Titrat ion AldaC1 ra TitrationPack Pack 4 Aldara (Cream) 4

AmC1 moni um (Injection) AmmoniumLact Lactate ate RebiC1 f Titrat (12% Cream, 12% 1 Rebifion Titration Pack Pack 4 (Injection) Lotion) AmnC1 este TecfiC1 em Tecfideradera (Capsule Amnesteem (Capsule) 1 PA AtraliC1 4 QL, LA n Delayed-Release) Atralin (Gel) 3 PA

AvitaC1 TecfiC1 dera Start Avita (0.025% Cream, Tecfideraer Starter Pack 4 LA 1 PA Pack 0.025% Gel)

AzelC1 DentalA1 and Oral Agents Azelexex (Cream) 3

BenzC1 B1 aClin with BenzaClinPum with Pump Dental and Oral Agents p 3 CeviC1 meli (Gel) ne CevimelineHCl HCl BenzC1 1 ST amy (Capsule) Benzamycincin (Gel) 3

ChloC1 rhexi dine ChlorhexidineGluc onat e 1 Gluconate (Solution)

Bold type = Brand name drug Plain type = Generic drug 96 tRACK 96 Last updated October 1, 2018 5895 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

CalciC1 CortiC1 potri spori Calcipotrieneene (0.005% Cortisporinn

Cream, 0.005% 1 (0.5%-0.5% Cream, 3 External Solution, 1%-0.5% Ointment)

CoseC1 0.005% Ointment) Cosentyxntyx (Injection) 4 PA, LA CalciC1 potri ene/ CoseC1 Beta Calcipotriene/ ntyx meth Sens ason orea e Cosentyx Sensoready dy Dipr Pen opio Betamethasonenate 4 PA, LA 1 Pen (Injection) Dipropionate DapsC1 (Ointment) oneDapsone (5% Gel) 1

DicloC1

C1 fena Calci c triol DiclofenacSodi Sodium Calcitriol (3mcg/gm um 1 1 PA Ointment) (3% Gel) DiffeC1 rin CaraC1 c Differin (0.1% Cream, Carac (Cream) 4

ClarC1 0.1% Gel, 0.3% Gel, 3 Claravisavis (Capsule) 1 PA

CleoC1 0.1% Lotion) cin-T

Cleocin-T (1% DovoC1 Dovonexnex (Cream) 4 External Solution, 1% DoxeC1 pin 3 HCl Gel, 1% Lotion, 1% Doxepin HCl (Cream) 1 PA, QL DuaC1 Swab) Duacc (Gel) 3

DupiC1 ClindC1 xent acin- Clindacin-PP (Swab) 1 Dupixent (Injection) 4 PA

EfudC1 ClindC1 ex Clindagelagel (Gel) 4 Efudex (Cream) 3

ElideC1 ClindC1 l amy cin Elidel (Cream) 3 ST ClindamycinPhos phat e EnstiC1 lar Phosphate (1% Enstilar (Foam) 4 PA EpidC1 External Solution, 1% 1 Epiduouo (Gel) 3

EpidC1 Foam, 1% Gel, 1% uo Fort Epiduoe Forte (Gel) 3 ST

Lotion, 1% Swab) C1 Ery

ClindC1 Ery (2% Pad) 1 amy cin Phos Clindamycin C1 phat Eryg e/ el Treti Phosphate/Tretinoinnoin 1 PA Erygel (Gel) 3

ErythC1 romy (Gel) Erythromycincin (2% ClindC1 amy cin/ External Solution, 2% 1 Clindamycin/BenzoylBenz oyl Pero xide Peroxide (Gel) 1 Gel)

ErythC1 romy cin/ Erythromycin/BenzoylBenz (Generic BenzaClin) oyl Pero xide 1 ClotrC1 imaz ole/ Peroxide (Gel) Clotrimazole/Beta meth ason C1 e Eucri Dipr sa opio nate Eucrisa (Ointment) Betamethasone 3 PA EvocC1 Dipropionate 1 Evoclinlin (Foam) 4

FabiC1 (1%-0.05% Cream, Fabioror (Foam) 3 PA

1%-0.05% Lotion) FinaC1 cea

ConC1 Finacea (15% Foam, dylo Condyloxx (Gel) 3 2 15% Gel)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 97 97 5996 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

FluorC1 RetiC1 oura n-A cil Micr Fluorouracil (0.5% Retin-Ao Micro Pump Pum 4 p 4 PA Cream) (Gel)

FluorC1 SantC1 oura Fluorouracilcil (2% Santylyl (Ointment) 3

SeleC1 External Solution, 5% nium

SeleniumSulfi Sulfide 1 de 1 External Solution, 5% (Lotion)

Cream) SiliqC1

C1 Siliq (Injection) 4 PA Imiq uimo d Imiquimod (Cream) 1 SoolC1 antra

C1 Soolantra (Cream) 3 Isotr etino in Isotretinoin (Capsule) 1 PA SoriaC1 tane

C1 Soriatane (Capsule) 4 Klaro n

Klaron (Lotion) 3 PA SorilC1 ux

C1 Sorilux (Foam) 4 Lotri sone

Lotrisone (Cream) 3 StelaC1 ra

C1 Stelara (Injection) 4 PA Meth oxsal en Methoxsalen (Capsule) 1 SulfaC1 ceta mide

C1 Sulfacetamide Sodium Mirv Sodi aso um 1 PA Mirvaso (Gel) 3 (10% Lotion) MyorC1 isan TaclC1 Myorisan (Capsule) 1 PA Taclonexonex Neo-C1 Syna Neo-Synalarlar (Cream) 3 (0.064%-0.005%

NeuC1 Neuacac (Gel) 1 Ointment, 4

OneC1 Onextonxton (Gel) 3 0.064%-0.005%

OxsoC1 ralen Suspension) OxsoralenUltra Ultra

TacrC1 4 olim (Capsule) Tacrolimusus (0.03% PicatC1 Picatoo (Gel) 2 Ointment, 0.1% 1

PodC1 Ointment) ofilo x Podofilox (External C1 1 Taltz Solution) Taltz (Injection) 4 PA, LA TazaC1 rote ProtC1 ne Protopicopic (Ointment) 3 Tazarotene (Cream) 1 PA TazoC1 rac PrudC1 Prudoxinoxin (Cream) 1 PA, QL Tazorac (0.05%

RegrC1 Cream, 0.1% Cream, anex 3 PA Regranex (Gel) 4 PA

RetiC1 0.1% Gel) n-A

Retin-A (0.01% Gel, TazoC1 Tazoracrac (0.05% Gel) 4 PA 0.025% Gel, 0.025% TolaC1 3 PA k Cream, 0.05% Cream, Tolak (Cream) 3 TreC1 0.1% Cream) Tremfyamfya (Injection) 4 PA

TretiC1 RetiC1 noin n-A Micr Tretinoin (0.01% Gel, Retin-Ao Micro (0.04% 3 PA Gel, 0.1% Gel) 0.025% Gel, 0.05%

RetiC1 Gel, 0.025% Cream, 1 PA n-A Micr Retin-Ao Micro (0.06% 4 PA 0.05% Cream, 0.1% Gel) Cream)

Bold type = Brand name drug Plain type = Generic drug 98 tRACK 98 Last updated October 1, 2018 6097 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

TretiC1 CliniC1 noin mix Micr 2.75 Tretinoinosph Microsphere Clinimix%/ 2.75%/ ere Dext rose 1 PA 5% (Gel) Dextrose 5% 3 B/D, PA

VectiC1 Vecticalcal (Ointment) 4 (Injection)

C1 VereC1 Clini gen mix 4.25 Clinimix%/ 4.25%/ Veregen (Ointment) 4 Dext rose 10%

ZenaC1 Zenatanetane (Capsule) 1 PA Dextrose 10% 3 B/D, PA

ZianC1 Zianaa (Gel) 4 PA (Injection) CliniC1 mix ZonaC1 4.25 lon Clinimix%/ 4.25%/ Dext Zonalon (Cream) 3 PA, QL rose 20%

ZyclC1 Dextrose 20% ara 3 B/D, PA Pum pZyclara Pump 4 PA (Injection) (Cream) CliniC1 mix 4.25 A1 Clinimix%/ 4.25%/ Dext rose Electrolytes/Minerals/Metals/Vitamins 25%

B1 Dextrose 25% 3 B/D, PA Electrolyte/Mineral Replacement (Injection) AminC1 osyn 7%/ AminosynElect 7%/ CliniC1 rolyt mix es 4.25 Clinimix%/ 4.25%/ Dext rose Electrolytes 3 B/D, PA 5% Dextrose 5% 3 B/D, PA (Injection) (Injection) AminC1 osyn

8.5%Aminosyn 8.5%/ CliniC1 / mix Elect 5%/ rolyt ClinimixDext 5%/Dextrose es rose Electrolytes 1 B/D, PA 15% 3 B/D, PA 15% (Injection)

(Injection) CliniC1 mix 5%/ Dext AminC1 Clinimix 5%/Dextrose rose osyn 20% AminosynII II 3 B/D, PA 3 B/D, PA 20% (Injection)

(Injection) CliniC1 mix 5%/ Dext AminC1 Clinimix 5%/Dextrose rose osyn 25% II 8.5%Aminosyn II 8.5%/ 3 B/D, PA / Elect rolyt 25% (Injection) es

Electrolytes 1 B/D, PA CliniC1 mix E Clinimix2.75 E 2.75%/ %/ Dext (Injection) rose 10%

AminC1 Dextrose 10% 3 B/D, PA osyn - HBCAminosyn-HBC 3 B/D, PA (Injection)

(Injection) CliniC1 mix E 2.75 AminC1 Clinimix E 2.75%/ %/ osyn Dext -PF rose Aminosyn-PF 5% 3 B/D, PA Dextrose 5% 3 B/D, PA (Injection) (Injection) AminC1 osyn -RF Aminosyn-RF CliniC1 mix E Clinimix4.25 E 4.25%/ 3 B/D, PA %/ Dext rose (Injection) 10% Dextrose 10% 3 B/D, PA CarbC1 agluCarbaglu (Tablet) 4 LA (Injection) CarnC1 itor CliniC1 Carnitor (1gm/10ml mix E Clinimix4.25 E 4.25%/ %/ Dext rose Oral Solution, 330mg 3 Dextrose25% 25% 3 B/D, PA Tablet) (Injection)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 99 99 6198 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

CliniC1 FreAC1 mix mine E Clinimix4.25 E 4.25%/ FreAmineHBC HBC 6.9% %/ 6.9% Dext rose 5% 3 B/D, PA Dextrose 5% 3 B/D, PA (Injection)

HepC1 atA (Injection) HepatAminemine

CliniC1 1 B/D, PA mix E 5%/Clinimix E 5%/ (Injection) Dext rose 15% IntralC1 Dextrose 15% 3 B/D, PA Intralipidipid (20gm/ 1 B/D, PA (Injection) 100ml Injection)

CliniC1 mix IntralC1 E ipid 5%/Clinimix E 5%/ Dext Intralipid (30gm/ rose 20% 3 B/D, PA Dextrose 20% 3 B/D, PA 100ml Injection)

IonoC1 sol- (Injection) MB/ Ionosol-MB/DextroseDext rose 5% CliniC1 mix 3 E 5%/Clinimix E 5%/ Dext 5% (Injection) rose 25%

IsolytC1 e-P/ Dextrose 25% 3 B/D, PA Dext Isolyte-P/Dextroserose 5% 5% 3 (Injection) (Injection)

CliniC1 sol IsolytC1 SF 15%Clinisol SF 15% e-S 3 B/D, PA Isolyte-S (Injection) 3 (Injection) KClC1 0.07 5%/ KClD5W 0.075%/D5W/ DextC1 / rose NaCl 10% 0.45 Dextrose 10% % 1 NaCl 0.45% 1 (Injection) (Injection) DextC1 rose 10% KClC1 Dextrose/ 10%/NaCl 0.15 NaCl %/ 0.2% KClD5W 0.15%/D5W/NaCl 1 / NaCl 0.2% 1 0.2% (Injection) 0.2% (Injection) DextC1 rose 10% KClC1 Dextrose/ 10%/NaCl 0.15 NaCl %/ 0.45 D5W % KCl 0.15%/D5W/NaCl 1 / NaCl 0.45 % 1 0.45% (Injection) 0.45% (Injection) DextC1 rose 2.5% KClC1 Dextrose/ 2.5%/NaCl 0.15 NaCl %/ 0.45 D5W % KCl 0.15%/D5W/NaCl 1 / NaCl 0.9% 1 0.45% (Injection) 0.9% (Injection) DextC1 rose 5% KClC1 Dextrose 5% (Injection) 1 B/D, PA 0.3% / KClD5W 0.3%/D5W/NaCl / DextC1 NaCl rose 0.45 5%/ % 1 NaClDextrose 5%/NaCl 0.2% 1 0.45% (Injection) KClC1 0.2% (Injection) 0.3% / KClD5W 0.3%/D5W/NaCl / DextC1 NaCl rose 0.9% 5%/ 1 DextroseNaCl 5%/NaCl 0.22 5% 1 0.9% (Injection) Klor-C1 0.225% (Injection) Klor-ConCon (Packet) 1 DextC1 rose 5%/ Klor-C1 DextroseNaCl 5%/NaCl Con 0.33 10 % Klor-Con 10 (Tablet 1 1 0.33% (Injection) Extended-Release) DextC1 rose 5%/ Klor-C1 DextroseNaCl 5%/NaCl Con 0.45 8 % Klor-Con 8 (Tablet 1 1 0.45% (Injection) Extended-Release) DextC1 rose 5%/ Klor-C1 DextroseNaCl 5%/NaCl Con 0.9% Klor-ConM10 M10 (Tablet 1 B/D, PA 1 0.9% (Injection) Extended-Release)

EndaC1 riEndari (Packet) 4 PA

Bold type = Brand name drug Plain type = Generic drug 100 tRACK 100 Last updated October 1, 2018 6299 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

Klor-C1 PotaC1 Con ssiu M15 m Klor-Con M15 (Tablet PotassiumChlo Chloride 1 ride Extended-Release) (10% Oral Solution, 1

Klor-C1 Con Klor-ConM20 M20 (Tablet 20% Oral Solution)

1 C1 Pota ssiu Extended-Release) m PotassiumChlo Chloride ride

Klor-C1 Con Spri Klor-Connkle Sprinkle (10meq/100ml (Capsule Extended- 1 Injection, 20meq/ 1 B/D, PA Release) 100ml Injection,

K-C1 K-TabTab (Tablet 40meq/100ml 3 Extended-Release) Injection)

LevoC1 PotaC1 carni ssiu tine m Levocarnitine (1gm/ PotassiumChlo Chloride 1 ride 1 B/D, PA 10ml Oral Solution) (2meq/ml Injection)

LevoC1 PotaC1 carni ssiu tine m Levocarnitine (330mg PotassiumChlo Chloride CR ride 1 CR Tablet) (Tablet Extended- 1

MagC1 nesi um Release) MagnesiumSulfa Sulfate te PotaC1 ssiu m PotassiumChlo Chloride ER (1gm/2ml-50% 1 ride ER Injection) (10meq Capsule

MagC1 nesi Extended-Release, um MagnesiumSulfa Sulfate te (5gm/10ml-50% 1 8meq Capsule Injection) Extended-Release,

C1 10meq Tablet 1 Nep hram Nephramineine 3 B/D, PA Extended-Release, (Injection) 20meq Tablet

NorC1 mos ol-M inNormosol-M in D5W D5W Extended-Release, 1 (Injection) 8meq Tablet Extended-

NorC1 mos Normosol-Rol-R Release)

PotaC1 1 ssiu m PotassiumChlo Chloride/ (Injection) ride/ Dext rose 1 B/D, PA NorC1 mos ol-R Dextrose (Injection) Normosol-Rin in D5W D5W PotaC1 1 ssiu m PotassiumChlo Chloride/ (Injection) ride/ Dext rose / NutrC1 Lact eSto ated re Dextrose/LactatedRing 1 NutreStore (Packet) 3 ers

NutriC1 lipid Ringers (Injection) Nutrilipid (Injection) 1 B/D, PA PotaC1 ssiu m C1 Plas Chlo ma- Potassium Chloride/ ride/ Lyte Dext APlasma-Lyte A rose / Sodi 3 um Dextrose/SodiumChlo 1 (Injection) ride

PlasC1 Chloride (Injection) ma- Lyte- Plasma-Lyte-148148 3 (Injection)

PlenC1 amin Plenaminee (Injection) 1 B/D, PA

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 101 101 63100 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

PotaC1 TPNC1 ssiu Elect m rolyt PotassiumChlo Chloride/ TPNes Electrolytes ride/ Sodi um Chlo 1 Sodiumride Chloride 1 B/D, PA (Injection) TravC1 (20meq/L-0.45% Travasolasol (Injection) 3 B/D, PA

Injection) TropC1 hami ne

C1 Trophamine Pota ssiu m ChloPotassium Chloride/ 3 B/D, PA ride/ Sodi um (Injection) Chlo ride Sodium Chloride UrocC1 Urocit-Kit-K (Tablet (20meq/L-0.9% 1 B/D, PA 3 Extended-Release)

Injection, 40meq/ B1 L-0.9% Injection) Electrolyte/Mineral/Metal Modifiers CheC1 met PotaC1 ssiu Chemet (Capsule) 3 m CitraPotassium Citrate ER te ER ExjaC1 Exjadede (Tablet (Tablet Extended- 1 4 PA Release) Soluble)

FerriC1 PreC1 mas prox Premasolol (10% Ferriprox (100mg/ml 3 B/D, PA Injection) Oral Solution, 500mg 4 PA

PreC1 mas olPremasol (6% Tablet)

1 B/D, PA JadeC1 Injection) Jadenunu (Tablet) 4 PA

ProcC1 C1 alam Jade ine nu Spri Procalamine Jadenunkle Sprinkle 3 B/D, PA 4 PA (Injection) (Packet)

ProsC1 C1 ol Jyna Prosol (Injection) 3 B/D, PA Jynarquerque (Tablet

SodiC1 4 PA, QL um Chlo rideSodium Chloride (0.9% Therapy Pack)

1 B/D, PA C1 Kion Injection) Kionexex (Suspension) 1

SodiC1 um SamC1 Chlo sca rideSodium Chloride 1 Samsca (Tablet) 4 PA SodiC1 (2.5meq/ml Injection) um Poly Sodiumstyre Polystyrene ne SodiC1 Sulfo um nate 1 Chlo Sodiumride Chloride (3% Sulfonate (Powder)

SPSC1 Injection, 5% 1 B/D, PA SPS (Suspension) 1

SypriC1 Injection) Syprinene (Capsule) 4 PA, QL SodiC1 um Chlo TrienC1 rideSodium Chloride tine 0.45 HCl % 1 Trientine HCl (Capsule) 1 PA, QL

0.45% (Injection) VeltaC1 ssa

C1 Veltassa (Packet) 4 QL Sodi um Chlo Sodiumride Chloride B1 0.9% Phosphate Binders

0.9% (Irrigation 1 C1 Aury xia Solution) Auryxia (Tablet) 4 PA CalciC1 um Acet SodiC1 ate um Calcium Acetate Fluor Sodiumide Fluoride 1 (Tablet) (667mg Capsule, 1

SodiC1 667mg Tablet) um Lact Sodiumate Lactate 1 (Injection)

Bold type = Brand name drug Plain type = Generic drug 102 tRACK 102 Last updated October 1, 2018 64101 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

FosrC1 MethC1 enol scop olam Fosrenol (1000mg Methscopolamineine Bro mide 1 Packet, 750mg Bromide (Tablet)

PropC1 anth eline Packet, 1000mg Propantheline Bromide Bro mide 1 PA, HRM Tablet Chewable, 4 (Tablet)

RobiC1 500mg Tablet Robinulnul (Tablet) 3

RobiC1 nul Chewable, 750mg Fort Robinule Forte (Tablet) 3 Tablet Chewable) GastrointestinalB1 Agents, Other LantC1 hanu m ActigC1 Carb Lanthanum Carbonate all onat e 1 Actigall (Capsule) 4

(Tablet Chewable) CheC1 noda l PhosC1 Chenodal (Tablet) 4 lyra

C1 Phoslyra (Oral Cro moly n 2 CromolynSodi Sodium Solution) um

C1 (100mg/5ml 1 Ren Renagelagel (Tablet) 4 Concentrate)

RenvC1 ela DiphC1 enox Renvela (0.8gm ylate Diphenoxylate// Atro Packet, 2.4gm pine 4 Atropine Packet, 800mg (2.5mg-0.025mg 1 PA, HRM Tablet) Tablet,

SeveC1 lame r 2.5mg-0.025mg/5ml SevelamerCarb Carbonate onat e (0.8gm Packet, 2.4gm 1 Liquid)

GastC1 rocr Packet, 800mg Tablet) Gastrocromom

C1 4 Velp Velphorohoro (Tablet (Concentrate)

4 GattC1 Chewable) Gattexex (Injection) 4 PA, LA

B1 LansC1 opra zole/ Vitamins AmoLansoprazole/ xicilli n/ Clarit VP-C1 hro PNV- myci DHA nAmoxicillin/ VP-PNV-DHA (Capsule) 1 1 GastrointestinalA1 Agents Clarithromycin

B1 (Therapy Pack)

Antispasmodics, Gastrointestinal LomC1 otil

C1 Lomotil (Tablet) 3 PA, HRM Cuv posa

Cuvposa (Oral LopeC1 rami de 3 LoperamideHCl HCl Solution) 1 (Capsule) DicyC1 clom ine HCl MovC1 Dicyclomine HCl antik Movantik (Tablet) 3 PA, QL

(10mg Capsule, 10mg/ 1 HRM C1 Myal 5ml Oral Solution) Myaleptept (Injection) 4 PA, LA MyteC1 si DicyC1 clom ine Mytesi (Tablet DicyclomineHCl HCl 1 HRM 3 PA (Tablet) Delayed-Release)

OmeC1 GlycC1 clam opyrr ox- olate Omeclamox-PakPak Glycopyrrolate (Tablet) 1 3 (Therapy Pack)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 103 103 65102 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

PylerC1 ZantC1 Pyleraa (Capsule) 4 Zantacac (Tablet) 3

RelisC1 B1 Relistortor (12mg/0.6ml Irritable Bowel Syndrome Agents

AlosC1 etro Injection, 8mg/0.4ml n 4 PA AlosetronHCl HCl (Tablet) 1 PA AmitiC1 Injection, 150mg Amitizaza (Capsule) 2 QL

LinzC1 Tablet) Linzessess (Capsule) 2 QL SeroC1 stim LotrC1 Serostim (Injection) 4 PA, LA Lotronexonex (Tablet) 4 PA SymC1 proic VibeC1 Symproic (Tablet) 3 PA, QL Viberzirzi (Tablet) 4 PA, QL TrulaC1 nce XifaxC1 Trulance (Tablet) 3 ST Xifaxanan (Tablet) 4 PA UrsoC1 Urso (Tablet) 3 LaxativesB1 UrsoC1 diol ClenC1 Ursodiol (250mg Clenpiqpiq (Oral Tablet, 500mg Tablet, 1 3 Solution) 300mg Capsule) CoLC1 yte- Flav XerC1 CoLyte-Flavoror Packs melo Pack Xermelo (Tablet) 4 PA, QL, LA s 3

ZorbC1 (Oral Solution) tive

Zorbtive (Injection) 4 PA, LA ConC1 stulo se B1 Constulose (Oral 1 Histamine2 (H2) Receptor Antagonists Solution) CimC1 etidi ne EnulC1 Cimetidine (Tablet) 1 Enuloseose (Oral Solution) 1 CimC1 etidi ne GaviC1 CimetidineHCl HCl (Oral Lyte- GaviLyte-CC (Oral 1 1 Solution) Solution) FamC1 otidi ne GaviC1 Famotidine (20mg Lyte- GaviLyte-GG (Oral Tablet, 40mg Tablet, 1 1 Solution)

40mg/5ml GaviC1 Lyte- N/ GaviLyte-N/FlavorFlav or Suspension) Pack 1

NizatC1 Pack (Oral Solution) idine

Nizatidine (150mg GenC1 erlac Capsule, 300mg Generlac (Oral 1 1 Capsule, 15mg/ml Oral Solution) GoLC1 YTE GoLYTELYLY (Oral Solution) 3 PepcC1 Pepcidid (20mg Tablet) 3 Solution) KristC1 alos PepcC1 e Pepcidid (40mg Tablet) 4 Kristalose (Packet) 3 LactC1 ulos PepcC1 e Pepcidid (40mg/5ml Lactulose (Oral 3 1 Suspension) Solution) MoviC1 Prep RaniC1 tidin MoviPrep (Oral e RanitidineHCl HCl (150mg 3 Capsule, 300mg Solution) NuLC1 YTE LY/ NuLYTELY/FlavorFlav Capsule, 150mg 1 or Pack s 3 Tablet, 300mg Tablet, Packs (Oral Solution) 75mg/5ml Syrup)

Bold type = Brand name drug Plain type = Generic drug 104 tRACK 104 Last updated October 1, 2018 66103 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

OsmC1 EsoC1 oPre mep p razol OsmoPrep (Tablet) 3 Esomeprazolee Stro ntiu m PEGC1 3350 / Strontium (Capsule PEGElect 3350/Electrolytes 3 QL rolyt es 1 (Oral Solution) Delayed-Release)

C1 PEG-C1 Lans 3350 opra / zole PEG-3350/ElectrolytesElect Lansoprazole (15mg rolyt es Tablet Dispersible, (Oral Solution) 1 1 (Generic GoLYTELY) 30mg Tablet

PEG-C1 3350 / Dispersible) PEG-3350/NaCl/NaNaCl /Na Bicar C1 bona Lans te/ opra Bicarbonate/KClKCl (Oral Lansoprazolezole (Capsule 1 1 QL Solution) (Generic Delayed-Release)

NexiC1 NuLYTELY) Nexiumum (10mg

PlenC1 Plenvuvu (Oral Solution) 3 Packet, 2.5mg

C1 Poly ethyl ene PolyethyleneGlyc Glycol Packet, 20mg Packet, 2 ol 3350 Pow 3350der Powder (Generic 1 40mg Packet, 5mg MiraLAX) Packet)

C1 Prep C1 Nexi opik Prepopik (Packet) 3 Nexiumum (20mg

SuprC1 ep Bow Suprepel Bowel Prep Capsule Delayed- Prep Kit 2 Kit (Oral Solution) Release, 40mg 2 QL

TriLyC1 TriLytete (Oral Solution) 1 Capsule Delayed- ProtectantsB1 Release) OmeC1 praz CaraC1 ole Carafatefate (1gm Tablet, Omeprazole (10mg

1gm/10ml 3 Capsule Delayed- Release, 40mg 1 QL Suspension) Capsule Delayed- CytoC1 Cytotectec (Tablet) 3 Release)

MisoC1 prost OmeC1 ol praz Misoprostol (Tablet) 1 Omeprazoleole (20mg SucrC1 alfat Sucralfatee (Tablet) 1 Capsule Delayed- 1 ProtonB1 Pump Inhibitors Release)

OmeC1 AcipC1 praz hex ole/ Omeprazole/SodiumSodi um Aciphex (Tablet Bicar bona 3 te Delayed-Release) Bicarbonate (Capsule, 1 PA

DexilC1 Packet) ant

Dexilant (Capsule C1 Pant opra zole 3 QL PantoprazoleSodi Sodium Delayed-Release) um

EsoC1 (Tablet Delayed- 1 QL mep razol Esomeprazolee Mag nesi um Release)

Magnesium (Capsule PrevC1 1 QL Prevacidacid (Capsule Delayed-Release) 3 QL (Generic Nexium) Delayed-Release)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 105 105 67104 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

PrevC1 KuvaC1 acid n Solu PrevacidTab SoluTab Kuvan (100mg 3 (Tablet Dispersible) Packet, 500mg

C1 4 LA Prilo Prilosecsec (Packet) 3 PA Packet, 100mg Tablet

ProtC1 Protonixonix (20mg Soluble)

MiglC1 Tablet Delayed- ustatMiglustat (Capsule) 1 PA, LA

3 QL OcaliC1 Release, 40mg Tablet vaOcaliva (Tablet) 4 PA, QL

OrfaC1 Delayed-Release) Orfadindin (10mg

ProtC1 Protonixonix (40mg Capsule, 20mg 3 ST Packet) Capsule, 2mg

C1 4 LA Rab epra zole Capsule, 5mg RabeprazoleSodi Sodium um (Tablet Delayed- 1 Capsule, 4mg/ml Release) Suspension)

C1 Yosp PalyC1 Yospralarala (Tablet nziqPalynziq (Injection) 4 PA, QL 3 PancC1 reaz Delayed-Release) Pancreazee

ZegeC1 Zegeridrid (Capsule, (10850unit-2600unit- 4 PA Packet) 6200unit Capsule GeneticA1 or Enzyme Disorder: Replacement, Delayed-Release, Modifiers, Treatment 24600unit-4200unit-1 GeneticB1 or Enzyme Disorder: Replacement, 4200unit Capsule Modifiers, Treatment Delayed-Release, 3 ST

AralaC1 st 61500unit-10500unit- AralastNP NP (Injection) 4 PA, LA

BupC1 35500unit Capsule heny Buphenyll (3gm/tsp Delayed-Release, Powder, 500mg 4 98400unit-16800unit- Tablet)

C1 56800unit Capsule Cerd elga Cerdelga (Capsule) 4 PA Delayed-Release) CholC1 bam PancC1 Cholbam (Capsule) 4 PA reaz Pancreazee CreoC1 Creonn (Capsule (83900unit-21000unit 2 4 ST Delayed-Release) -54700unit Capsule CystC1 adan Cystadanee (Powder) 4 Delayed-Release)

CystC1 Cystagonagon (Capsule) 3 LA

GlasC1 Glassiasia (Injection) 4 PA, LA

Bold type = Brand name drug Plain type = Generic drug 106 tRACK 106 Last updated October 1, 2018 68105 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

PertzC1 DetrC1 Pertzyeye Detrolol (Tablet) 3

DetrC1 (15125unit-4000unit- Detrolol LA LA (Capsule

14375unit Capsule Extended-Release 24 3 Delayed-Release, 3 ST Hour)

DitroC1 pan 30250unit-8000unit-2 DitropanXL XL (Tablet 8750unit Capsule Extended-Release 24 3 QL Delayed-Release) Hour)

PertzC1 ye EnabC1 Pertzye Enablexlex (Tablet (60500unit-16000unit 4 ST Extended-Release 24 3 QL -57500unit Capsule Hour)

FlavC1 Delayed-Release) oxat e FlavoxateHCl HCl (Tablet) 1 ProlaC1 stin- C GelnC1 Prolastin-C (Injection) 4 PA, LA Gelniqueique (10% Gel) 3 RaviC1 cti MyrbC1 Ravicti (Liquid) 4 LA Myrbetriqetriq (Tablet SodiC1 um Phe Sodiumnylb Phenylbutyrate utyra te Extended-Release 24 2 (3gm/TSP Powder, 1 Hour)

500mg Tablet) OxybC1 utyni n Chlo SucrC1 Oxybutynin Chloride ride aid Sucraid (Oral (5mg Tablet 4 LA 1 Solution) Immediate-Release,

ViokC1 Viokaceace 5mg/5ml Syrup)

OxybC1 utyni (39150unit-10440unit 3 ST n OxybutyninChlo Chloride ride -39150unit Tablet) ER (Tablet Extended- 1 QL

ViokC1 Viokaceace Release 24 Hour)

OxytC1 (78300unit-20880unit 4 ST Oxytrolrol (Patch Twice 3 -78300unit Tablet) Weekly)

XuriC1 TolteC1 den rodin e Xuriden (Packet) 4 PA, LA TolterodineTartr Tartrate ate 1 ZaveC1 Zavescasca (Capsule) 4 PA, LA (Tablet)

TolteC1 ZemC1 rodin aira e TolterodineTartr Tartrate ate Zemaira (Injection) 4 PA, LA ER

ZenC1 Zenpeppep (Capsule ER (Capsule Extended- 1 2 Release 24 Hour)

Delayed-Release) C1 Tovi az

A1 Toviaz (Tablet Genitourinary Agents

B1 Extended-Release 24 3 QL, ST Antispasmodics, Urinary Hour) DarifC1 enac in TrosC1 DarifenacinHBr HBr ER pium ER TrospiumChlo Chloride ride 1 (Tablet Extended- 1 QL (Tablet) Release 24 Hour)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 107 107 69106 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

TrosC1 BethC1 pium anec hol TrospiumChlo Chloride ER BethanecholChlo Chloride ride ride ER 1 (Capsule Extended- 1 (Tablet)

CuprC1 imin Release 24 Hour) Cupriminee (Capsule) 4 PA

VesiC1 care DepC1 en Vesicare (Tablet) 2 QL Titrat Depenabs Titratabs B1 4 Benign Prostatic Hypertrophy Agents (Tablet)

AlfuzC1 ElmirC1 osin HCl on AlfuzosinER HCl ER Elmiron (Capsule) 4 LithoC1 (Tablet Extended- 1 Lithostatstat (Tablet) 4

Release 24 Hour) ThiolC1 a

C1 Thiola (Tablet) 4 LA Avod art

Avodart (Capsule) 3 QL UrecC1 holin e

C1 Urecholine (Tablet) 3 Card ura XL Cardura XL (Tablet A1 Hormonal Agents, Stimulant/Replacement/ Extended-Release 24 3 QL Modifying (Adrenal)

Hour) B1

CialiC1 Hormonal Agents, Stimulant/Replacement/ Cialiss (2.5mg Tablet, 3 PA, QL Modifying (Adrenal)

5mg Tablet) C1 Ala Scal p DutaC1 Ala Scalp (Lotion) 3 steri de

Dutasteride (Capsule) 1 QL C1 Ala- Cort DutaC1 Ala-Cort (Cream) 1 steri de/ Tam Dutasteride/ C1 sulo Alclo sin meta HCl sone Alclometasone Dipr Tamsulosin HCl 1 opio Dipropionatenate (0.05% (Capsule) 1 FinaC1 Cream, 0.05% steri Finasteridede (5mg Ointment)

Tablet) (Generic 1 C1 Amci noni Proscar) Amcinonidede (0.1%

FlomC1 Cream, 0.1% Lotion, 1 Flomaxax (Capsule) 3 0.1% Ointment) JalynC1

ApexC1 Jalyn (Capsule) 3 iCon ApexiCon E E (Cream) 4 ProsC1 car

AugC1 Proscar (Tablet) 3 ment ed AugmentedBeta C1 meth Rap ason aflo e Dipr Rapaflo (Capsule) 2 QL opio Betamethasonenate

TamC1 sulo sin TamsulosinHCl HCl Dipropionate (0.05% 1 1 (Capsule) Cream, 0.05% Gel,

TeraC1 zosin Terazosin HCl HCl 0.05% Lotion, 0.05% 1 (Capsule) Ointment)

BetaC1 UroxC1 meth atral ason Betamethasonee Dipr Uroxatral (Tablet opio Dipropionatenate (0.05% Extended-Release 24 3 1 Hour) Cream, 0.05% Lotion,

B1 0.05% Ointment) Genitourinary Agents, Other

Bold type = Brand name drug Plain type = Generic drug 108 tRACK 108 Last updated October 1, 2018 70107 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

BetaC1 DesoC1 meth xime ason taso Betamethasonee Desoximetasonene Valer ate Valerate (0.1% Cream, (0.05% Cream, 0.25% 0.1% Lotion, 0.1% 1 Cream, 0.05% Gel, 1 Ointment, 0.12% 0.05% Ointment, Foam) 0.25% Ointment)

CapC1 DexaC1 ex meth ason Capex (Shampoo) 3 Dexamethasonee

ClobC1 etas ol (0.5mg Tablet, 0.75mg ClobetasolProp Propionate ionat e (0.05% Cream, 0.05% Tablet, 1.5mg Tablet, External Solution, 1mg Tablet, 2mg 1 0.05% Foam, 0.05% Tablet, 4mg Tablet, 1 Gel, 0.05% Liquid, 6mg Tablet, 0.5mg/ 0.05% Lotion, 0.05% 5ml Elixir)

DexaC1 meth ason Ointment, 0.05% Dexamethasonee Inten sol Shampoo) Intensol (1mg/ml 1

ClobC1 etas ol Concentrate) ClobetasolProp Propionate ionat e E 1 DexC1 Pak 13 E (Cream) DexPakDay 13 Day (Tablet 3 ClobC1 Clobexex (0.05% Liquid, Therapy Pack) DifloC1 raso ne DiflorasoneDiac Diacetate 0.05% Lotion, 0.05% 4 etate Shampoo) (0.05% Cream, 0.05% 1

ClodC1 Clodanan (Shampoo) 1 Ointment) DiprC1 olen e ClodC1 Clodermerm (Cream) 3 Diprolene (Ointment) 3 ElocC1 on CordC1 ran Elocon (0.1% Cream, Cordran (Tape) 3 3

CortC1 0.1% Ointment) ef

Cortef (Tablet) 3 C1 Emfl aza

CortiC1 Emflaza (18mg sone

CortisoneAcet Acetate ate 1 Tablet, 30mg Tablet, (Tablet)

CutivC1 36mg Tablet, 6mg 4 PA, LA Cutivateate (Lotion) 4 Tablet, 22.75mg/ml DesoC1 Desonatenate (Gel) 3 Suspension) DesoC1 nide FludrC1 Desonide (0.05% ocort ison eFludrocortisone Acet ate 1 Cream, 0.05% Lotion, 1 Acetate (Tablet)

0.05% Ointment) FluoC1 cinol one Acet C1 Fluocinolone Des onid Owe e DesOwenn (0.05% 3 Acetonide (0.01% Cream) Cream, 0.025% Cream,

DesC1 Owe 1 DesOwenn (0.05% 0.01% External 3 Lotion) Solution, 0.025% Ointment)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 109 109 71108 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

FluoC1 HydrC1 cinol ocort one ison FluocinoloneAcet Hydrocortisonee onid Valer e ate Scal 1 Acetonidep Scalp (Oil) Valerate (0.2% Cream, 1

FluoC1 cino Fluocinonidenide (0.05% 0.2% Ointment)

ImpoC1 External Solution, Impoyzyz (Cream) 3 1 KenaC1 0.05% Gel, 0.05% Kenaloglog (Aerosol 4 Ointment, 0.1% Cream) Solution) FluoC1 cino nide LocoC1 FluocinonideEmul id sifie d Locoid (0.1% External Base 3 Emulsified Base 1 Solution)

(Cream) LocoC1 id

FluraC1 Locoid (0.1% Lotion) 4 ndre nolid e Flurandrenolide (0.05% LocoC1 id Lipo Locoidcrea Lipocream Cream, 0.05% Lotion, 1 m 3 0.05% Ointment) (Cream) MedC1 rol FlutiC1 caso ne Medrol (Tablet) 3 FluticasoneProp Propionate ionat e MedC1 rol Dose (0.005% Ointment, Medrolpak Dosepak 1 3 0.05% Cream, 0.05% (Tablet Therapy Pack)

MethC1 ylpre Lotion) dnis Methylprednisoloneolon e H.P.C1 Acth 1 H.P.ar Acthar (Injection) 4 PA, LA (Tablet)

C1 Halo MethC1 beta ylpre sol dnis HalobetasolProp olon ionat Methylprednisolone e e Dose Pack Propionate (0.05% 1 Dose Pack (Tablet 1 Cream, 0.05% Therapy Pack)

MicoC1 Ointment) Micort-HCrt-HC (Cream) 3

HaloC1 g MilliC1 Halog (0.1% Cream, pred 4 Millipred (10mg/5ml 0.1% Ointment) Oral Solution, 5mg 3

HydrC1 ocort ison Hydrocortisonee (1% Tablet)

MomC1 etas Cream, 2.5% Cream, one MometasoneFuro Furoate ate 1% Ointment, 2.5% (0.1% Cream, 0.1% 1 Ointment, 10mg 1 External Solution, 0.1% Tablet, 20mg Tablet, Ointment) 5mg Tablet, 2.5% NolixC1 (0.05% Cream, 1 Lotion) 0.05% Lotion) HydrC1 ocort ison OluxC1 Hydrocortisonee Buty rate Olux (Foam) 4

Butyrate (0.1% Cream, C1 Orap red 1 OrapredODT ODT (Tablet 0.1% External Solution, 3 0.1% Ointment) Dispersible)

PanC1 Pandeldel (Cream) 4

Bold type = Brand name drug Plain type = Generic drug 110 tRACK 110 Last updated October 1, 2018 72109 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

PredC1 TopiC1 nicar cort Prednicarbatebate (0.1% Topicort (0.05% 1 Cream, 0.1% Ointment) Cream, 0.25% Cream, 3 PredC1 nisol Prednisoloneone (15mg/ 0.05% Gel, 0.25% 1 5ml Oral Solution) Ointment)

TopiC1 PredC1 cort nisol one Topicort (0.05% PrednisoloneSodi Sodium um Phos phat Phosphatee (10mg/5ml Ointment, 0.25% 3 Liquid) Oral Solution, 20mg/ TriaC1 mcin 5ml Oral Solution, 1 olon Triamcinolonee Acet onid 25mg/5ml Oral Acetonidee (0.025% Solution, 5mg/5ml Oral Cream, 0.1% Cream, Solution) 0.5% Cream, 0.025%

PredC1 nisol one PrednisoloneSodi Sodium Lotion, 0.1% Lotion, um Phos phat e PhosphateODT ODT 1 0.025% Ointment, 1 (Tablet Dispersible) 0.1% Ointment, 0.5%

PredC1 niso Prednisonene (10mg Ointment, 0.147mg/ Tablet Therapy Pack, gm Aerosol Solution 5mg Tablet Therapy Generic Kenalog Pack, 10mg Tablet, Spray) TrianC1 1mg Tablet, 2.5mg 1 Trianexex (Ointment) 4

TrideC1 Tablet, 20mg Tablet, Tridermrm (Cream) 1

TrideC1 50mg Tablet, 5mg Tridesilonsilon (Cream) 1

Tablet, 5mg/5ml Oral UltraC1 Ultravatevate (0.05% Solution)

PredC1 Cream, 0.05% 3 niso ne PrednisoneInten Intensol sol 1 (5mg/ml Concentrate) Ointment) UltraC1 vate PsorC1 con Ultravate (0.05% Psorcon (Cream) 1 4

RayoC1 Lotion) s

Rayos (Tablet C1 Vano 4 PA s Delayed-Release) Vanos (Cream) 4 VeriC1 pred 20 SynaC1 lar Veripred 20 (Oral Synalar (Cream) 3 3

TapeC1 Solution) rdex 12- Day Taperdex 12-Day A1 3 (Tablet Therapy Pack) Hormonal Agents, Stimulant/Replacement/

TapeC1 Modifying (Pituitary) rdex 6- Day Taperdex 6-Day (Tablet B1 3 Therapy Pack) Hormonal Agents, Stimulant/Replacement/

TexaC1 Texacortcort (External Modifying (Pituitary) 3 Solution)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 111 111 73110 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

DDAC1 NutrC1 VP opin DDAVP (0.01% Nasal NutropinAQ AQ 4 PA Rhinal Tube Solution, (Injection)

OmnC1 itrop 0.01% Nasal Spray 4 Omnitropee (Injection) 4 PA

SaizC1 Solution, 0.2mg Saizenen (Injection) 4 PA, LA

SaizC1 Tablet) enpr ep RecSaizenprep onsti DDAC1 tutio DDAVPVP (0.1mg n Kit 3 Reconstitution Kit 4 PA, LA Tablet) (Injection)

DesC1 mop C1 ressi Stim Desmopressinn Acetate ate Acet ate Stimate (Nasal (0.01% Nasal Spray 4 1 Solution)

Solution, 0.1mg Tablet, ZomC1 acto Zomactonn (10mg 0.2mg Tablet) 4 PA

GenC1 Injection) otro pin

Genotropin (12mg C1 Zom acto Zomactonn (5mg Injection, 5mg 4 PA 3 PA Injection) Injection) A1

GenC1 otro Hormonal Agents, Stimulant/Replacement/ pin GenotropinMini Miniquick quic k 3 PA (0.2mg Injection) Modifying (Prostaglandins) B1

GenC1 otro Hormonal Agents, Stimulant/Replacement/ pin GenotropinMini Miniquick quic k (0.4mg Injection, Modifying (Prostaglandins) KorlyC1 0.6mg Injection, Korlymm (Tablet) 4 PA, LA 0.8mg Injection, HormonalA1 Agents, Stimulant/Replacement/ 1.2mg Injection, Modifying (Sex Hormones/Modifiers)

4 PA B1 1.4mg Injection, Androgens

AnaC1 drol- 1.6mg Injection, Anadrol-5050 (Tablet) 4 PA

AndrC1 1.8mg Injection, 1mg oder Androdermm (Patch 24 2 Injection, 2mg Hour)

AndrC1 Injection) AndroGeloGel (1% Packet HumC1 atro pe 4 Humatrope (Injection) 4 PA Gel) HumC1 atro pe AndrC1 HumatropeCom Combo oGel bo Pack AndroGel (1.62% 4 PA 3 Pack (Injection) Packet Gel) IncreC1 lex AndrC1 Increlex (Injection) oGel 4 PA, LA AndroGelPum Pump p NoctC1 iva 3 Noctiva (Emulsion) 3 PA (1.62% Gel)

NordC1 itropi AveeC1 n d NorditropinFlex FlexPro Pro 4 PA Aveed (Injection) 3 DanC1 (Injection) Danazolazol (Capsule) 1

Bold type = Brand name drug Plain type = Generic drug 112 tRACK 112 Last updated October 1, 2018 74111 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

DepC1 AshlC1 o- yna Test Depo-Testosteroneoster Ashlyna (Tablet) 1 one 3 AubrC1 (Injection) Aubraa (Tablet) 1

FortC1 esta AviaC1 Fortesta (Gel) 3 PA Avianene (Tablet) 1

IntraC1 rosa BalziC1 Intrarosa (Insert) 3 PA, QL Balzivava (Tablet) 1

MethC1 itest BeyaC1 Methitest (Tablet) 4 PA Beyazz (Tablet) 3

MethC1 yltes BlisoC1 toste vi 24 Methyltestosteronerone Fe 1 PA Blisovi 24 Fe (Tablet) 1

BlisoC1 (Capsule) vi Fe 1.5/ Blisovi30 Fe 1.5/30 OxaC1 ndrol one 1 Oxandrolone (Tablet) 1 PA (Tablet)

StriaC1 nt BlisoC1 vi Fe Striant 3 PA Blisovi1/20 Fe 1/20 (Tablet) 1

TestiC1 m BriellC1 Testim (Gel) 3 PA Briellynyn (Tablet) 1

TestC1 oster CamC1 one rese Testosterone (10mg/ Lo 3 PA Camrese Lo (Tablet) 1 CaziC1 act Gel) ant Caziant (Tablet) 1 TestC1 oster one ClimC1 Testosterone (25mg/ ara ClimaraPro Pro (Patch 2.5gm 1% Gel, 50mg/ 3 PA, HRM 1 Weekly) 5gm 1% Gel, 30mg/act CrysC1 elle- Transdermal Solution) Cryselle-2828 (Tablet) 1

CyclC1 TestC1 afem oster one Cyclafem (Tablet) 1 TestosteroneCypi onat e 1 DeleC1 strog Cypionate (Injection) Delestrogenen

C1 3 Test oster one TestosteroneEnan (Injection) thate

1 DelylC1 Enanthate (Injection) Delylaa (Tablet) 1

TestC1 C1 oster Dep one o- Pum Estra Testosterone Pump diol p Depo-Estradiol 1 3 (1% Gel) (Injection)

VogC1 C1 elxo Deso gestr el/ Vogelxo (Gel) 3 PA Desogestrel/EthinylEthin yl Estra diol VogC1 1 elxo Pum Vogelxop Pump (Gel) 3 PA Estradiol (Tablet)

DrosC1 B1 piren one/ Drospirenone/EthinylEthin yl Estra diol 1 AlorC1 Aloraa (Patch Twice PA, QL, Estradiol (Tablet) DrosC1 3 piren one/ Drospirenone/EthinylEthin yl Weekly) HRM Estra diol/ Levo mefo AltavC1 late era Estradiol/Levomefolate 1 Calci Altavera (Tablet) 1 um

C1 Calcium (Tablet) Alya cen 1/35 Alyacen 1/35 (Tablet) 1 ElestC1 rin

C1 Elestrin (Gel) 3 PA, HRM Ame thia

Amethia (Tablet) 1 EmoC1 quett e

C1 Emoquette (Tablet) 1 Ame thia Lo Amethia Lo (Tablet) 1 EnprC1 esse- 28

C1 Enpresse-28 (Tablet) 1 Apri

Apri (Tablet) 1 EnskC1 yce

C1 Enskyce (Tablet) 1 Aran elle

Aranelle (Tablet) 1 EstarC1 Estaryllaylla (Tablet) 1

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 113 113 75112 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

EstraC1 ImveC1 Estracece (0.1mg/gm Imvexxyxxy (10mcg 3 Cream) Maintenance Vaginal 3 PA, QL

EstraC1 Estracece (0.5mg Tablet, Suppository)

IntroC1 1mg Tablet, 2mg 3 PA, HRM Introvalevale (Tablet) 1

IsiblC1 Tablet) Isibloomoom (Tablet) 1 EstraC1 diol JinteC1 Estradiol (0.025mg/ Jintelili (Tablet) 1 PA, HRM

24hr Patch Twice JuleC1 ber Weekly, 0.0375mg/ Juleber (Tablet) 1 JuneC1 l 1.5/ 24hr Patch Twice Junel30 1.5/30 (Tablet) 1

JuneC1 l Weekly, 0.05mg/24hr PA, QL, 1/20 1 Junel 1/20 (Tablet) 1 JuneC1 Patch Twice Weekly, l Fe HRM 1.5/ Junel30 Fe 1.5/30 1 0.075mg/24hr Patch (Tablet)

Twice Weekly, 0.1mg/ JuneC1 l Fe 24hr Patch Twice Junel1/20 Fe 1/20 (Tablet) 1 JuneC1 l Fe Weekly) Junel24 Fe 24 (Tablet) 1

KaitliC1 EstraC1 b Fe Estradioldiol (0.1mg/gm Kaitlib Fe (Tablet 1 1 Cream, 10mcg Tablet) Chewable)

KarivC1 EstraC1 a Estradioldiol (0.5mg Kariva (Tablet) 1

KelnC1 or Tablet, 1mg Tablet, Kelnor1/35 1/35 (Tablet) 1 1 PA, HRM KelnC1 or 2mg Tablet) (Generic Kelnor1/50 1/50 (Tablet) 1

Estrace) KimiC1 Kimidessdess (Tablet) 1 EstraC1 diol Valer ateEstradiol Valerate KurvC1 1 Kurveloelo (Tablet) 1 (Injection) LARIC1 N 1.5/ EstriC1 LARIN30 1.5/30 (Tablet) 1 Estringng (Ring) 3 LARIC1 N 1/20 EthyC1 LARIN 1/20 (Tablet) 1 nodi ol EthynodiolDiac Diacetate/ etate LARIC1 / N Fe Ethin 1.5/ yl 30 Estra LARIN Fe 1.5/30 Ethinyldiol Estradiol 1 1 (Tablet) (Tablet) LARIC1 N Fe FalmC1 1/20 Falminaina (Tablet) 1 LARIN Fe 1/20 (Tablet) 1 LarisC1 sia FayoC1 Fayosimsim (Tablet) 1 Larissia (Tablet) 1

LayoC1 lis Fe FemrC1 ing Layolis Fe (Tablet Femring (Ring) 3 1 FemC1 Femynorynor (Tablet) 1 Chewable) LeenC1 a FyavC1 Fyavolvolv (Tablet) 1 PA, HRM Leena (Tablet) 1 LessiC1 na GenC1 eres Lessina (Tablet) 1 sGeneress Fe Fe (Tablet LevoC1 3 nest Chewable) Levonest (Tablet) 1

LevoC1 norg GianC1 estre vi Levonorgestrel/Ethinyll/ Ethin Gianvi (Tablet) 1 yl Estra 1 Estradioldiol (Tablet)

Bold type = Brand name drug Plain type = Generic drug 114 tRACK 114 Last updated October 1, 2018 76113 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

LevoC1 MiniC1 ra velle 0.15 Levora/30- 0.15/30-28 Minivelle (Patch PA, QL, 28 1 3 (Tablet) Twice Weekly) HRM

LoC1 MonC1 Loes trin oNe LoFe Loestrin Fe MonoNessassa (Tablet) 3 1 NataC1 (Tablet) Nataziazia (Tablet) 3

LoesC1 trin NecC1 1.5/ on 30-2 Loestrin 1.5/30-21 0.5/ 1 Necon35-2 0.5/35-28 3 8 1 (Tablet) (Tablet)

LoesC1 trin NecC1 1/20 on -21 Loestrin 1/20-21 7/7/ 3 Necon7 7/7/7 (Tablet) 1 (Tablet) NikkiC1 Nikki (Tablet) 1 LoesC1 trin Fe 1.5/ NoreC1 Loestrin Fe 1.5/30 thind 30 rone NorethindroneAcet 3 ate/ Ethin yl (Tablet) Estra Acetate/Ethinyldiol LoesC1 trin Fe Loestrin1/20 Fe 1/20 3 Estradiol 1 PA, HRM (Tablet) (2.5mcg-0.5mg Tablet,

LoryC1 Lorynana (Tablet) 1 5mcg-1mg Tablet)

LoSC1 NoreC1 easo thind niqu rone LoSeasoniquee NorethindroneAcet ate/ Ethin yl 3 Estra (Tablet) Acetate/Ethinyldiol

Low-C1 Oge Estradiol (20mcg-1mg Low-Ogestrelstrel (Tablet) 1 1

LuteC1 Tablet, ra Lutera (Tablet) 1 20mcg-75mg-1mg MarliC1 Marlissassa (Tablet) 1 Tablet Chewable)

MeloC1 detta NoreC1 24 thind MelodettaFe 24 Fe rone NorethindroneAcet ate/ 1 Ethin yl Estra (Tablet Chewable) diol/ Acetate/EthinylFerr ous Fum MenC1 arate Menestest (Tablet) 3 PA, HRM Estradiol/Ferrous 1

MibeC1 las 24 Fumarate (Tablet, FeMibelas 24 Fe (Tablet 1 Chewable) Tablet Chewable)

NorgC1 esti MicrC1 mate oges / tin Norgestimate/Ethinyl Ethin 1.5/ Microgestin 1.5/30 yl 30 Estra 1 1 diol (Tablet) Estradiol (Tablet)

NortrC1 el MicrC1 0.5/ oges 35 tin Nortrel 0.5/35 (28) Microgestin1/20 1/20 1 1 (Tablet) (Tablet) NortrC1 el MicrC1 1/35 oges tin Nortrel 1/35 (Tablet) 1 MicrogestinFe Fe (Tablet) 1 NortrC1 el MicrC1 7/7/ oges 7 tin Nortrel 7/7/7 (Tablet) 1 MicrogestinFe Fe 1.5/30 1.5/ 30 NuvaC1 1 Ring (Tablet) NuvaRing (Ring) 3

MiliC1 OcellC1 Mili (Tablet) 1 Ocellaa (Tablet) 1

MinaC1 OgeC1 strin strel 24 MinastrinFe 24 Fe Ogestrel (Tablet) 1

3 C1 Orsy (Tablet Chewable) Orsythiathia (Tablet) 1

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 115 115 77114 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

OrthC1 Tri-C1 o Tri- Previ Cycl fem Orthoen Tri-Cyclen Tri-Previfem (Tablet) 1

3 C1 Tri- Spri (Tablet) Tri-Sprintecntec (Tablet) 1

OrthC1 o Tri- TrivoC1 Cycl ra-28 Orthoen Tri-Cyclen Lo Lo 3 Trivora-28 (Tablet) 1 Tri-C1 Vylib (Tablet) Tri-Vylibrara (Tablet) 1 OrthC1 o- TydeC1 Cycl Ortho-Cyclenen (Tablet) 3 Tydemymy (Tablet) 1

OrthC1 o- VagifC1 Nov Ortho-Novumum 1/35 em 1/35 3 Vagifem (Tablet) 3 VelivC1 (Tablet) Velivetet (Tablet) 1 OrthC1 o- Nov VienC1 um Ortho-Novum 7/7/7 va 7/7/ 7 3 Vienva (Tablet) 1

(Tablet) VivellC1 e- Dot

C1 Vivelle-Dot (Patch PA, QL, Pimt rea 3 Pimtrea (Tablet) 1 Twice Weekly) HRM PirmC1 ella 1/35 VyfeC1 Pirmella 1/35 (Tablet) 1 Vyfemlamla (Tablet) 1 PortiC1 a-28 VylibC1 Portia-28 (Tablet) 1 Vylibrara (Tablet) 1 PreC1 mari n WYC1 Premarin (Vaginal MZY WYMZYAA Fe Fe (Tablet 2 1 Cream) Chewable) PreviC1 fem XulaC1 Previfem (Tablet) 1 Xulanene (Patch Weekly) 1 QuarC1 tette YasC1 Quartette (Tablet) 3 min Yasmin28 28 (Tablet) 3 QuaC1 sens e YazC1 Quasense (Tablet) 1 Yaz (Tablet) 3 RecliC1 psen YuvaC1 Reclipsen (Tablet) 1 Yuvafemfem (Tablet) 1 RivelC1 sa ZaraC1 Rivelsa (Tablet) 1 Zarahh (Tablet) 1 SafyrC1 al ZencC1 Safyral (Tablet) 3 Zenchenthent (Tablet) 1 SeasC1 oniq ue ZoviC1 Seasonique (Tablet) 3 a 1/35 ZoviaE 1/35E (Tablet) 1 SetlaC1 kin Setlakin (Tablet) 1 ProgestinsB1 SpriC1 ntec 28 AygeC1 Sprintec 28 (Tablet) 1 Aygestinstin (Tablet) 3 SronC1 yx CamiC1 Sronyx (Tablet) 1 Camilala (Tablet) 1 SyedC1 a CrinC1 Syeda (Tablet) 1 Crinoneone (Gel) 3 PA TarinC1 a Fe 1/20 DebliC1 Tarina Fe 1/20 (Tablet) 1 Deblitanetane (Tablet) 1 Tri-C1 Lege st Fe DepC1 Tri-Legest Fe (Tablet) 1 o- Prov Depo-Proveraera Tri-C1 Lo- 3 Estar Tri-Lo-Estaryllaylla (Tablet) 1 (Injection)

Tri-C1 Lo- DepC1 Spri o- Tri-Lo-Sprintecntec (Tablet) 1 Prov Depo-Proveraera Cont race Tri-C1 ptive Tri-MiliMili (Tablet) 1 Contraceptive 3

TrineC1 Trinessassa (Tablet) 1 (Injection)

Tri-C1 Nori nyl Tri-Norinyl28 28 (Tablet) 3

Bold type = Brand name drug Plain type = Generic drug 116 tRACK 116 Last updated October 1, 2018 78115 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

DepC1 EvistC1 o- a Sub Depo-SubQQ Evista (Tablet) 3 Prov era1 04 OspC1 Provera104 3 Osphenahena (Tablet) 2 PA, QL

RaloC1 xifen (Injection) e RaloxifeneHCl HCl (Tablet) 1 ErrinC1 Errin (Tablet) 1 HormonalA1 Agents, Stimulant/Replacement/ IncaC1 Incassiassia (Tablet) 1 Modifying (Thyroid)

JolivC1 Jolivetteette (Tablet) 1 HormonalB1 Agents, Stimulant/Replacement/

LyzaC1 Lyza (Tablet) 1 Modifying (Thyroid)

MedC1 CytoC1 roxy mel prog Medroxyprogesteroneester Cytomel (Tablet) 3 one Acet ate LevoC1 Acetate (10mg Tablet, Levo-T-T (Tablet) 1

LevoC1 2.5mg Tablet, 5mg 1 thyro xine LevothyroxineSodi Sodium Tablet, 150mg/ml um 1 (Tablet)

Injection) C1 Levo xyl MegC1 Levoxyl (Tablet) 1 ace ES

Megace ES C1 Lioth yroni ne 4 PA, HRM LiothyronineSodi Sodium (Suspension) um 1

MegC1 (Tablet) estro l Acet Megestrol Acetate SyntC1 ate hroid (20mg Tablet, 40mg Synthroid (Tablet) 2 ThyrC1 Tablet, 40mg/ml 1 PA, HRM Thyrolarolar (Tablet) 2

TirosC1 Suspension, 625mg/ Tirosintint (Capsule) 3

UnitC1 5ml Suspension) Unithroidhroid (Tablet) 1 NoraC1 -BE Nora-BE (Tablet) 1 HormonalA1 Agents, Suppressant (Adrenal) NoreC1 thind Norethindronerone B1 1 Hormonal Agents, Suppressant (Adrenal) (0.35mg Tablet) LysoC1 dren

C1 Lysodren (Tablet) 4 Nore thind rone NorethindroneAcet Acetate A1 ate 1 Hormonal Agents, Suppressant (Pituitary) (5mg Tablet) B1

NorlC1 yroc Hormonal Agents, Suppressant (Pituitary) Norlyroc (Tablet) 1 CabC1 ergol ine OrthC1 o Cabergoline (Tablet) 1 Micr Orthoonor Micronor EgrifC1 3 ta (Tablet) Egrifta (Injection) 4 PA, LA EligaC1 rd ProgC1 ester Eligard (Injection) 3 PA Progesteroneone FirmC1 1 Firmagonagon (120mg (Capsule) 4 PA ProC1 metri Prometriumum (Capsule) 3 Injection)

FirmC1 agon ProvC1 era Firmagon (80mg Provera (Tablet) 3 3 PA SharC1 Sharobelobel (Tablet) 1 Injection) LeupC1 rolid B1 e LeuprolideAcet Acetate Selective Receptor Modifying ate 1 PA (Injection) Agents LupaC1 neta LupanetaPack Pack (Kit) 4 PA

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 117 117 79116 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

LuprC1 B1 on Dep Lupronot Depot (1- Immune Suppressants

4 PA C1 Asta graf Month) (Injection) AstagrafXL XL (Capsule

LuprC1 on Dep Lupronot Depot (3- Extended-Release 24 3 B/D, PA 4 PA Month) (Injection) Hour)

LuprC1 AzasC1 on an Dep Lupronot Depot (4- Azasan (100mg Tablet) 3 B/D, PA

4 PA C1 Azas Month) (Injection) Azasanan (75mg Tablet) 4 B/D, PA

LuprC1 on AzatC1 Dep hiopr Lupronot Depot (6- ine 4 PA Azathioprine (Tablet) 1 B/D, PA CellcC1 Month) (Injection) Cellceptept (200mg/ml

OctrC1 eotid e OctreotideAcet Acetate ate Suspension, 250mg 1 PA 4 B/D, PA (Injection) Capsule, 500mg

SanC1 dost Sandostatinatin Tablet) 4 PA CimzC1 (Injection) Cimziaia (Injection) 4 PA

SigniC1 for CyclC1 ospo Signifor (Injection) 4 PA, LA Cyclosporinerine SomC1 1 B/D, PA atuli ne SomatulineDep Depot (Capsule) ot

4 C1 Cycl ospo (Injection) rine CyclosporineModi Modified fied

SomC1 Somavertavert (Injection) 4 PA, QL, LA (100mg Capsule,

SynaC1 Synarelrel (Nasal 25mg Capsule, 50mg 1 B/D, PA 4 Solution) Capsule, 100mg/ml

TrelsC1 Oral Solution) tar Mixj ect Trelstar Mixject EnbrC1 4 PA Enbrelel (Injection) 4 PA (Injection) EnbrC1 el Sure A1 EnbrelClick SureClick Hormonal Agents, Suppressant (Thyroid) 4 PA

B1 (Injection)

Antithyroid Agents EnvaC1 rsus XR

C1 Envarsus XR (Tablet Meth imaz Methimazoleole (Tablet) 1 Extended-Release 24 3 B/D, PA PropC1 ylthi oura Propylthiouracilcil 1 Hour) (Tablet) GenC1 graf

C1 Gengraf (100mg Tapa Tapazolezole (Tablet) 3 Capsule, 25mg A1 1 B/D, PA Immunological Agents Capsule, 100mg/ml AngioedemaB1 Agents Oral Solution)

HumC1 BeriC1 ira Berinertnert (Injection) 4 PA, LA Humira (Injection) 4 PA

HumC1 CinryC1 ira ze Pedi Humiraatric Pediatric Cinryze (Injection) 4 PA, LA Croh ns Dise ase FirazC1 Start yr er CrohnsPack Disease Firazyr (Injection) 4 PA, QL, LA 4 PA

HaeC1 gard Starter Pack Haegardaa (Injection) 4 PA, LA

RucC1 (Injection) ones Ruconestt (Injection) 4 PA, LA

Bold type = Brand name drug Plain type = Generic drug 118 tRACK 118 Last updated October 1, 2018 80117 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

HumC1 OtreC1 ira xup HumiraPen Pen Otrexup (Injection) 3 PA

4 PA C1 Prog (Injection) Prografraf (0.5mg

HumC1 ira Pen HumiraCroh Pen Crohns Capsule, 1mg 3 B/D, PA ns Dise ase Start er DiseasePack Starter Pack 4 PA Capsule)

ProgC1 (Injection) Prografraf (5mg

HumC1 4 B/D, PA ira Pen- HumiraPsori Pen-Psoriasis Capsule) asis Start er 4 PA C1 Rap amu Starter (Injection) Rapamunene (0.5mg

ImurC1 3 B/D, PA Imuranan (Tablet) 3 B/D, PA Tablet)

KineC1 RapC1 ret amu Kineret (Injection) 4 PA Rapamunene (1mg

MethC1 otrex Methotrexateate (Tablet) 1 Tablet, 2mg Tablet, 4 B/D, PA

MethC1 otrex ate 1mg/ml Oral Solution) MethotrexateSodi Sodium um

RasuC1 1 vo (Injection) Rasuvo (Injection) 3 PA

C1 MycC1 San ophe dim nolat mun Mycophenolatee Mofetil Sandimmunee (100mg Mofe til (200mg/ml Capsule, 100mg/ml 4 B/D, PA Suspension, 250mg 1 B/D, PA Oral Solution)

SanC1 Capsule, 500mg dim mun Sandimmunee (25mg 3 B/D, PA Tablet) Capsule) MycC1 ophe nolic Acid SimpC1 Mycophenolic Acid DR oni DR Simponi (Injection) 4 PA

(Tablet Delayed- 1 B/D, PA C1 Siroli Release) Sirolimusmus (Tablet) 1 B/D, PA TacrC1 olim MyfoC1 us rticMyfortic (180mg Tacrolimus (0.5mg Tablet Delayed- 3 B/D, PA Capsule, 1mg Capsule, 1 B/D, PA 5mg Capsule) Release) TrexC1 all MyfoC1 Trexall (Tablet) 3 rticMyfortic (360mg XatmC1 Xatmepep (Oral Tablet Delayed- 4 B/D, PA 3 PA Release) Solution) XeljaC1 nz NeorC1 alNeoral (100mg Xeljanz (Tablet) 4 PA, QL XeljaC1 nz Capsule, 25mg XeljanzXR XR (Tablet 3 B/D, PA Capsule, 100mg/ml Extended-Release 24 4 PA, QL Oral Solution) Hour)

ZortrC1 OluC1 ess mian tOlumiant (Tablet) 4 PA, QL Zortress (Tablet) 4 B/D, PA

B1 OrenC1 ciaOrencia (Injection) 4 PA Immunizing Agents, Passive

BIVIC1 OrenC1 GAM cia Click BIVIGAM (Injection) 4 PA Orenciaject Clickject 4 PA (Injection)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 119 119 81118 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

CariC1 AdaC1 mun cel e CarimuneNan Adacel (Injection) 2 ofilte red

BCGC1 Vacc Nanofiltered 4 PA BCGine Vaccine 2 (Injection) (Injection)

FlebC1 oga BexsC1 mma ero Flebogamma DIF DIF 4 PA Bexsero (Injection) 2 BoosC1 (Injection) Boostrixtrix (Injection) 2

GamC1 mag DaptC1 ard GammagardLiqui Liquid acel d 4 PA Daptacel (Injection) 2

DiphC1 (Injection) theri a/ Diphtheria/TetanusTeta nus GamC1 Toxo mag ids ard Adso GammagardS/D S/D IGA rbed IGA Less ToxoidsPedi Adsorbed 1 Than atric 1 mcg Less/ml Than 1 mcg/ml 4 PA Pediatric (Injection)

EngeC1 (Injection) Engerix-Brix-B (Injection) 2 B/D, PA GamC1 mak ed GardC1 Gammaked (Injection) 4 PA Gardasilasil 9 9 (Injection) 2 GamC1 mapl ex HavriC1 Gammaplex x 4 PA Havrix (Injection) 2

(Injection) HibeC1 rix

C1 Hiberix (Injection) 2 Gam unex -C Gamunex-C ImovC1 ax Rabi 4 PA Imovaxes Rabies (Injection) 2 B/D, PA

C1 (H.D.C.V.) (Injection) Octa gam

Octagam (Injection) 4 PA InfanC1 rix

C1 Infanrix (Injection) 2 Privi gen

Privigen (Injection) 4 PA IPOLC1 Inact ivate d C1 IPOL Inactivated IPV Variz IPV ig 2 Varizig (Injection) 2 (Injection) B1

IxiarC1 Immunomodulators Ixiaroo (Injection) 2 ActeC1 mra KinriC1 Actemra (Injection) 4 PA Kinrixx (Injection) 2 ActiC1 mmu ne MenC1 Actimmune (Injection) 4 LA Menactraactra (Injection) 2 AravC1 a MenC1 Arava (Tablet) 4 Menveoveo (Injection) 2 ArcalC1 yst M-M-C1 Arcalyst (Injection) 4 PA, LA M-M-RR II II (Injection) 2 BenlC1 ysta PediC1 Benlysta (Injection) 4 PA Pediarixarix (Injection) 2 KevzC1 ara PedvC1 Kevzara (Injection) 4 PA ax PedvaxHIB HIB (Injection) 2 LefluC1 nomi de ProQC1 Leflunomide (Tablet) 1 ProQuaduad (Injection) 2 OtezlC1 a QuaC1 Otezla (Tablet drac Quadracelel (Injection) 2

Therapy Pack, 30mg 4 PA, LA RabC1 Rabavertavert (Injection) 2 B/D, PA Tablet) RecC1 ombi vax RidaC1 RecombivaxHB HB Ridauraura (Capsule) 4 2 B/D, PA

C1 (Injection) Xolai r

Xolair (Injection) 4 PA, LA RotaC1 rix

B1 Rotarix (Suspension) 2 Vaccines

ActHC1 ActHIBIB (Injection) 2

Bold type = Brand name drug Plain type = Generic drug 120 tRACK 120 Last updated October 1, 2018 82119 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

RotaC1 MesC1 Teq alam ine RotaTeq (Oral MesalamineDR DR 2 Solution) (1.2gm Tablet Delayed- 1 QL

ShinC1 Shingrixgrix (Injection) 2 PA Release) MesC1 alam TeniC1 ine Tenivacvac (Injection) 2 MesalamineDR DR

TetaC1 (800mg Tablet 1 QL nus/ Diph Tetanus/Diphtheriatheri a Toxo ids- Delayed-Release) Adso rbed

Toxoids-AdsorbedAdul 1 PentC1 t Pentasaasa (Capsule Adult (Injection) 3 QL

C1 Extended-Release) Tru men ba Trumenba (Injection) 2 RowC1 asa

C1 Rowasa (Kit) Twin 4 rix

Twinrix (Injection) 2 B1

TyphC1 Glucocorticoids im Vi

Typhim Vi (Injection) 2 AnusC1 ol- HC VAQC1 Anusol-HC (Cream) 3 TA

VAQTA (Injection) 2 BudC1 eson ide VarivC1 Budesonide (3mg ax Varivax (Injection) 2 Capsule Delayed- 1 YF-C1 YF-VaxVax (Injection) 2 Release)

ZostC1 avax BudC1 eson ide Zostavax (Injection) 3 PA BudesonideER ER (Tablet

A1 Inflammatory Bowel Disease Agents Extended-Release 24 1 AminosalicylatesB1 Hour) ColoC1 cort AprisC1 Aprisoo (Capsule Colocort (Enema) 1 EntoC1 cort EntocortEC EC (Capsule Extended-Release 24 2 QL 4 Hour) Delayed-Release)

HydrC1 AsacC1 ocort ol ison AsacolHD HD (Tablet Hydrocortisonee 4 QL 1 Delayed-Release) (100mg/60ml Enema)

HydrC1 ocort BalsC1 ison alazi e de Hydrocortisone Acet BalsalazideDiso Disodium ate/ dium Pra moxi 1 ne (Capsule) Acetate/Pramoxine 1

CanC1 (Cream) Canasaasa (Suppository) 4 C1 Proc to- Med ColaC1 Procto-MedHC HC Colazalzal (Capsule) 4 1 (Cream) DelziC1 col Delzicol (Capsule ProcC1 to- 3 ST Procto-PakPak (Cream) 1

Delayed-Release) ProcC1 tosol HC DipeC1 Proctosol HC (Cream) 1 ntum

Dipentum (Capsule) 4 ProcC1 tozo ne- HC GiazC1 Proctozone-HC o 1 Giazo (Tablet) 3 (Cream) LialdC1 a UcerC1 Lialda (Tablet Ucerisis (2mg/act 2 QL 3 Delayed-Release) Foam) MesC1 alam Mesalamineine (Enema) 1

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 121 121 83120 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

UcerC1 EtidrC1 is onat e Uceris (9mg Tablet EtidronateDiso Disodium dium 1 Extended-Release 24 4 (Tablet)

FortC1 Hour) Forteoeo (Injection) 4 PA

B1 FosaC1 Sulfonamides Fosamaxmax (Tablet) 3

C1 Azulf C1 Fosa idine max Plus Azulfidine (Tablet) 3 FosamaxD Plus D

AzulfC1 3 idine EN- AzulfidineTabs EN-Tabs (Tablet)

C1 Iban dron ate (Tablet Delayed- 3 IbandronateSodi Sodium um 1 Release) (Tablet)

C1 SulfaC1 Natp salaz ara Sulfasalazineine (500mg Natpara (Injection) 4 PA, LA

ParicC1 alcit Tablet Delayed- ol 1 Paricalcitol (Capsule) 1 B/D, PA ProliC1 Release, 500mg Tablet Proliaa (Injection) 3 QL

Immediate-Release) C1 Raya ldee

A1 Rayaldee (Capsule Metabolic Bone Disease Agents 4 QL Extended-Release) B1

Metabolic Bone Disease Agents RiseC1 dron ate Sodi C1 Risedronate Sodium Acto um Actonelnel (150mg (Tablet Immediate- 1 Tablet, 35mg Tablet, 3 Release)

RiseC1 5mg Tablet) dron ate RisedronateSodi Sodium um DR ActoC1 Actonelnel (30mg 4 DR (Tablet Delayed- 1 Tablet) Release)

AlenC1 RocC1 dron altrol ate AlendronateSodi Sodium Rocaltrol (0.25mcg um 1 ( Tablet, Oral Solution) Capsule, 0.5mcg

AtelvC1 3 B/D, PA Atelviaia (Tablet Capsule, 1mcg/ml 3 Delayed-Release) Oral Solution)

C1 BinoC1 Sens Binostosto (Tablet Sensiparipar (Tablet) 4 B/D, PA, QL

3 TymlC1 Effervescent) Tymlosos (Injection) 4 PA, QL

BoniC1 C1 va Xgev Boniva (Tablet) 3 Xgevaa (Injection) 4 PA

C1 Calci C1 tonin Zem - plar Calcitonin-SalmonSalm on Zemplar (1mcg 1 3 B/D, PA (Nasal Solution) Capsule)

CalciC1 triol ZemC1 Calcitriol (0.25mcg Zemplarplar (2mcg Capsule, 0.5mcg 4 B/D, PA 1 B/D, PA Capsule) Capsule, 1mcg/ml Oral A1 Miscellaneous Therapeutic Agents Solution) B1

DoxeC1 rcalc Miscellaneous Therapeutic Agents iferolDoxercalciferol AlcoC1 hol 1 B/D, PA Prep (Capsule) AlcoholPads Prep Pads 2

Bold type = Brand name drug Plain type = Generic drug 122 tRACK 122 Last updated October 1, 2018 84121 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

GauC1 NeoC1 ze myci n/ Gauze (Non-medicated Neomycin/Polymyxin/Poly myxi n/ 2 Gra mici 2X2) Gramicidindin 1

InsulC1 in Syrin (Ophthalmic Solution) Insulinges, Syringes, Nee dles 2 NeoC1 myci n/ Needles Neomycin/Polymyxin/Poly myxi n/ Hydr LuceC1 ocort myra ison Hydrocortisonee (1% Lucemyra (Tablet) 4 QL 1 A1 Ophthalmic Ophthalmic Agents

B1 Suspension)

Ophthalmic Agents, Other PolyC1 myxi n B Sulfa C1 Polymyxin B Sulfate/ Atro te/ pine Trim Sulfa etho te prim Atropine Sulfate Sulfa 1 Trimethoprimte Sulfate 1 (Ophthalmic Solution) (Ophthalmic Solution)

BacitC1 racin PolytC1 / rim Bacitracin/PolymyxinPoly B myxi n B Polytrim (Ophthalmic 1 3 (Ophthalmic Ointment) Solution)

BlepC1 hami de PredC1 Blephamide -G 3 Pred-G (Suspension) 3

PredC1 (Suspension) -G S.O. Pred-GP. S.O.P. BlepC1 hami de 3 BlephamideS.O. S.O.P. P. 3 (Ointment) (Ointment) PropC1 arac aine HCl C1 Proparacaine HCl Cyst Cystaranaran (Ophthalmic 1 4 LA (Ophthalmic Solution)

RestC1 Solution) asis Restasis (Emulsion) 2 QL LacriC1 sert RhoC1 Lacrisert (Insert) 3 pres Rhopressasa LastC1 Lastacaftacaft (Ophthalmic 2 ST 2 (Ophthalmic Solution)

SulfaC1 Solution) ceta mide Sulfacetamide Sodi MaxiC1 um/ trol Pred nisol Maxitrol (0.1% one Sodium/PrednisoloneSodi um Phos phat 1 Ointment, 0.1% 3 Sodiume Phosphate Suspension) (Ophthalmic Solution)

NeoC1 TobrC1 myci adex n/ Neomycin/Bacitracin/Bacit racin Tobradex (0.3%-0.1% / Poly 1 myxi 2 Polymyxinn (Ointment) Ophthalmic Ointment)

NeoC1 myci TobrC1 n/ adex Neomycin/Polymyxin/Poly myxi Tobradex (0.3%-0.1% n/ Bacit racin / Bacitracin/Hydr ocort ison Ophthalmic 3 e 1 Hydrocortisone Suspension)

(Ophthalmic Ointment) TobrC1 adex ST

C1 Tobradex ST Neo myci n/ Neomycin/Polymyxin/Poly myxi n/ Dexa (Ophthalmic 3 meth ason Dexamethasonee (0.1% Suspension) Ophthalmic Ointment, 1 0.1% Ophthalmic Suspension)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 123 123 85122 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

TobrC1 B1 amy cin/ Tobramycin/Dexa Ophthalmic Antiglaucoma Agents meth ason e AlphC1 agan Dexamethasone Alphagan P P (0.1% 1 2 (Ophthalmic Ophthalmic Solution)

Suspension) AlphC1 agan P C1 Alphagan P (0.15% Xiidr Xiidraa (Ophthalmic 3 3 QL Ophthalmic Solution)

Solution) ApraC1 cloni dine C1 Apraclonidine Zylet 1 Zylet (Suspension) 3 (Ophthalmic Solution)

B1

AzopC1 Ophthalmic Anti-allergy Agents Azoptt (Suspension) 2 AlocC1 ril BetaC1 Alocril (Ophthalmic Betagangan (Ophthalmic 3 3 Solution) Solution) AlomC1 ide BetaC1 Alomide (Ophthalmic xolol Betaxolol HCl HCl (0.5% 3 1 Solution) Ophthalmic Solution)

AzelC1 astin BetiC1 e mol AzelastineHCl HCl (0.05% Betimol (Ophthalmic 1 3 Ophthalmic Solution) Solution) BeprC1 eve BetoC1 Bepreve (Ophthalmic ptic- Betoptic-SS 3 3 Solution) (Suspension) CroC1 moly n BrimC1 CromolynSodi Sodium (4% onidi um ne BrimonidineTartr Tartrate 1 ate Ophthalmic Solution) (0.15% Ophthalmic 1 ElestC1 Elestatat (Ophthalmic 3 Solution)

BrimC1 Solution) onidi ne BrimonidineTartr Tartrate ate EmaC1 Emadinedine (Ophthalmic 3 (0.2% Ophthalmic 1 Solution) Solution)

C1 Epin C1 astin Cart e eolol EpinastineHCl HCl Carteolol HCl HCl 1 1 (Ophthalmic Solution) (Ophthalmic Solution)

C1 Olop C1 atadi Com ne biga OlopatadineHCl HCl (0.1% Combigann 1 2 Ophthalmic Solution) (Ophthalmic Solution)

OlopC1 atadi CosC1 ne opt OlopatadineHCl HCl Cosopt (Ophthalmic 1 3 (Ophthalmic Solution) Solution)

PataC1 day CosC1 opt Pataday (Ophthalmic CosoptPF PF 3 3 Solution) (Ophthalmic Solution)

PataC1 nol DorzC1 olam Patanol (Ophthalmic ide DorzolamideHCl HCl 2 1 Solution) (Ophthalmic Solution)

PazeC1 Pazeoo (Ophthalmic 2 Solution)

Bold type = Brand name drug Plain type = Generic drug 124 tRACK 124 Last updated October 1, 2018 86123 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

DorzC1 B1 olam ide DorzolamideHCl/ HCl/ Ophthalmic Anti-inflammatories Timo lol Male ate AculC1 Timolol Maleate 1 Acularar (Ophthalmic 3 (Ophthalmic Solution) Solution) IopidC1 ine AculC1 Iopidine (0.5% ar AcularLS LS 3 3 Ophthalmic Solution) (Ophthalmic Solution) IopidC1 ine AcuvC1 Iopidine (1% Acuvailail (Ophthalmic 4 3 ST Ophthalmic Solution) Solution) IsoptC1 o Carp AlrexC1 Isoptoine Carpine 3 Alrex (Suspension) 3

BroC1 (Ophthalmic Solution) msit Bromsitee (Ophthalmic IstalC1 Istalolol (Ophthalmic 3 ST 3 Solution)

DexaC1 Solution) meth ason Dexamethasonee C1 Sodi Levo um buno Phos lol phat HCl Levobunolol HCl e 1 Sodium Phosphate 1 (Ophthalmic Solution) (Ophthalmic Solution)

MetiC1 pran DicloC1 olol fena Metipranolol c DiclofenacSodi Sodium 1 um (Ophthalmic Solution) (0.1% Ophthalmic 1

PhosC1 pholi ne PhospholineIodid Iodide Solution) e

3 C1 Dure (Ophthalmic Solution) Durezolzol (Emulsion) 2

PilocC1 arpin FlareC1 e x PilocarpineHCl HCl 1 Flarex (Suspension) 3 FluorC1 (Ophthalmic Solution) omet holo Fluorometholonene SimbC1 Simbrinzarinza 2 (Ophthalmic 1 (Suspension) Suspension)

C1 Timo FlurbC1 lol iprof Male en Timololate Maleate FlurbiprofenSodi Sodium um 1 (0.25% Ophthalmic (Ophthalmic Solution) FMLC1 Solution, 0.5% 1 FML (Ointment) 3

Ophthalmic Solution) FMLC1 Fort FMLe Forte (Generic Timoptic) 3

TimoC1 (Suspension) lol Male ate Timolol Maleate FMLC1 Opht halm Liqui ic film Gel FML Liquifilm For Ophthalmicming Gel 1 3 Forming (Solution) (Suspension) IlevrC1 o TimoC1 ptic Ocu Ilevro (Suspension) 2 Timopticdose Ocudose

KetoC1 3 rolac

KetorolacTro (Ophthalmic Solution) meth amin e

TimoC1 ptic- Tromethamine 1 Timoptic-XEXE (Gel 3 (Ophthalmic Solution) Form Solution)

TrusC1 Trusoptopt (Ophthalmic 3 Solution)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 125 125 87124 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

LoteC1 ZioptC1 Lotemaxmax (0.5% Gel, Zioptanan (Ophthalmic 3 0.5% Ointment, 0.5% 3 Solution) Suspension) OticA1 Agents

MaxiC1 Maxidexdex (Suspension) 3 OticB1 Agents

NevaC1 nac AcetiC1 c Nevanac AceticAcid Acid (Otic 2 1 (Suspension) Solution)

C1 Omn CetrC1 Omnipredipred Cetraxalaxal (Otic 3 3 (Suspension) Solution)

C1 Pred CiprC1 Fort o HC Prede Forte Cipro HC 3 3 (Suspension) (Suspension)

C1 Pred CiprC1 PredMild Mild Ciprodexodex (Otic 3 2 (Suspension) Suspension)

C1 Pred CiprC1 nisol oflox one acin PrednisoloneAcet Acetate ate Ciprofloxacin (0.2% 1 1 (Suspension) Otic Solution)

PredC1 nisol Coly-C1 one Myci PrednisoloneSodi Sodium n S um Coly-Mycin S Phos phat e 3 Phosphate (1% 1 (Suspension)

FluoC1 Ophthalmic Solution) cinol one FluocinoloneAcet C1 onid Prole e Prolensansa (Ophthalmic 3 Acetonide (0.01% Otic 1 Solution) Oil)

B1 HydrC1 ocort ison Ophthalmic Prostaglandin and Prostamide Hydrocortisone/Acetice/ Aceti c Acid 1 Analogs Acid (Otic Solution)

C1 Bima NeoC1 topr myci ost n/ Bimatoprost Neomycin/Polymyxin/Poly myxi n/ 1 Hydr ocort ison (Ophthalmic Solution) Hydrocortisonee (1%

C1 1 Lata nopr Latanoprostost Otic Solution, 1% Otic 1 (Ophthalmic Solution) Suspension)

OtovC1 LumiC1 el Lumigangan (Ophthalmic Otovel (Otic Solution) 3 ST 2 A1 Solution) Respiratory Tract/Pulmonary Agents

B1 TravC1 atan TravatanZ Z Antihistamines

2 AsteC1 (Ophthalmic Solution) Astepropro (Nasal

VyzuC1 3 Vyzultalta (Ophthalmic Solution)

3 AzelC1 astin e Solution) HCl Azelastine HCl (0.1% XalatC1 Xalatanan (Ophthalmic Nasal Solution, 0.15% 1 3 Solution) Nasal Solution)

Bold type = Brand name drug Plain type = Generic drug 126 tRACK 126 Last updated October 1, 2018 88125 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

CetirC1 ArnuC1 izine ity HCl Ellipt Cetirizine HCl (Oral Arnuitya Ellipta 1 Solution) (100mcg/act Aerosol

ClariC1 Clarinexnex (0.5mg/ml Powder, 200mcg/act 3 2 QL Syrup, 5mg Tablet) Aerosol Powder,

CyprC1 ohep tadin 50mcg/act Aerosol Cyproheptadinee HCl HCl 1 PA, HRM (4mg Tablet) Powder)

AsmC1 DeslC1 anex orata HFA dine Asmanex HFA Desloratadine (Tablet) 1 3 QL, ST DeslC1 orata dine (Aerosol) DesloratadineODT ODT 1 AsmC1 anex

(Tablet Dispersible) AsmanexTwist Twisthaler haler 120 Mete red LevoC1 cetiri Dose zine 120s Metered Doses LevocetirizineDihy 3 QL, ST droc hlori Dihydrochloridede (Aerosol Powder)

1 C1 Asm anex (2.5mg/5ml Oral AsmanexTwist Twisthaler haler 30 Mete red Solution, 5mg Tablet) Dose 30s Metered Doses 3 QL, ST

OlopC1 atadi ne OlopatadineHCl HCl (0.6% 1 (Aerosol Powder) AsmC1 Nasal Solution) anex

AsmanexTwist Twisthaler haler PataC1 60 nase Mete red Dose Patanase (Nasal s 3 60 Metered Doses 3 QL, ST Solution) (Aerosol Powder)

PheC1 nado BecC1 z onas Phenadoz (12.5mg Beconasee AQ AQ 1 PA, HRM 3 ST Suppository) (Suspension)

ProC1 meth azin BudC1 e eson Promethazine HCl ide HCl Budesonide (0.25mg/ (12.5mg Suppository, 1 PA, HRM 2ml Suspension, 12.5mg Tablet, 25mg 0.5mg/2ml 1 B/D, PA Tablet, 50mg Tablet) Suspension, 1mg/2ml Anti-inflammatories,B1 Inhaled Corticosteroids Suspension)

AlveC1 FlovC1 sco ent Disk Alvesco (Aerosol Floventus Diskus 3 QL, ST 2 Solution) (Aerosol Powder)

ArmC1 FlovC1 onair ent HFA ResArmonair Respiclick picli Flovent HFA (Aerosol) 2 QL ck 3 QL, ST FluniC1 solid (Aerosol Powder) Flunisolidee (Nasal ArmC1 1 onair

ResArmonair Respiclick Solution) picli ck 232 3 QL, ST C1 Fluti caso ne 232 (Aerosol Powder) FluticasoneProp Propionate ionat e

C1 Arm onair

ResArmonair Respiclick (50mcg/act 1 picli ck 55 3 QL, ST 55 (Aerosol Powder) Suspension)

MomC1 etas one MometasoneFuro Furoate ate (50mcg/act 1 Suspension)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 127 127 89126 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

NasoC1 ZileuC1 nex ton Nasonex ZileutonER ER (Tablet 3 (Suspension) Extended-Release 12 1 ST

OmnC1 Omnarisaris (Suspension) 3 ST Hour) ZyfloC1

PulmC1 Pulmicorticort Zyflo (Tablet) 4 ST ZyfloC1 3 B/D, PA CR (Suspension) Zyflo CR (Tablet

PulmC1 icort Extended-Release 12 4 ST Flex halerPulmicort Flexhaler 3 ST (Aerosol Powder) Hour)

B1

QnaC1 Qnaslsl (Aerosol Bronchodilators, Anticholinergic AtroC1 3 ST vent AtroventHFA HFA Solution) 3 QnaC1 sl (Aerosol Solution) Child Qnaslrens Childrens IncruC1 3 ST se Ellipt Incrusea Ellipta (Aerosol Solution) 2 QL QvarC1 Redi (Aerosol Powder) Qvarhaler Redihaler IpratC1 3 QL, ST ropiu m IpratropiumBro Bromide (Aerosol Powder) mide

TriaC1 mcin (0.02% Inhalation 1 B/D, PA olon eTriamcinolone Acet onid e Acetonide (55mcg/act 1 Solution) IpratC1 ropiu m IpratropiumBro Bromide Aerosol) mide

XhanC1 Xhancece (EXHU) 3 (0.03% Nasal Solution, 1

ZetoC1 0.06% Nasal Solution) nna

Zetonna (Aerosol LonhC1 ala Mag 3 ST Lonhalanair Magnair Start Solution) er Kit

B1 Starter Kit (Inhalation 4 QL Antileukotrienes Solution) AccoC1 late SpiriC1 Accolate (Tablet) 3 va Han SpirivadiHal HandiHaler er MontC1 eluk ast 2 QL MontelukastSodi Sodium um (Capsule)

(10mg Tablet, 4mg SpiriC1 va Res Spirivapima Respimat Packet, 4mg Tablet 1 QL t 2 QL Chewable, 5mg Tablet (Aerosol Solution) TudC1 orza Pres Tudorzasair Pressair Chewable) 3 ST SingC1 Singulairulair (10mg (Aerosol Powder) Tablet, 4mg Packet, Bronchodilators,B1 Sympathomimetic

AlbuC1 terol Sulfa 4mg Tablet 3 QL Albuterolte Sulfate Chewable, 5mg (0.083% Nebulized Tablet Chewable) Solution, 0.5%

ZafirlC1 ukas Nebulized Solution, 1 B/D, PA Zafirlukastt (Tablet) 1 0.63mg/3ml Nebulized Solution, 1.25mg/3ml Nebulized Solution)

Bold type = Brand name drug Plain type = Generic drug 128 tRACK 128 Last updated October 1, 2018 90127 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

AlbuC1 ProvC1 terol entil Sulfa HFA Albuterolte Sulfate (2mg Proventil HFA 3 ST Tablet Immediate- (Aerosol Solution) SereC1 Release, 4mg Tablet 1 vent Disk Sereventus Diskus 2 QL Immediate-Release, (Aerosol Powder)

2mg/5ml Syrup) StrivC1 erdi Res pima AlbuC1 Striverdi Respimat t terol Sulfa Albuterolte Sulfate ER 3 ST ER (Aerosol Solution) (Tablet Extended- 1 TerbC1 utali ne TerbutalineSulfa Sulfate Release 12 Hour) te 1 ArcaC1 (Tablet) pta Neo Arcaptahaler Neohaler VentC1 olin 3 ST VentolinHFA HFA (Aerosol (Capsule) 3 ST BrovC1 Solution) Brovanaana (Nebulized XopC1 4 PA, QL Xopenexenex (Nebulized Solution) 3 B/D, PA EpinC1 Solution) ephri neEpinephrine (0.15mg/ XopC1 enex

XopenexCon Concentrate centr 0.15ml Injection, ate 3 QL, ST 3 B/D, PA 0.3mg/0.3ml Injection) (Nebulized Solution)

XopC1 enex (Generic Adrenaclick) Xopenex HFA HFA

EpinC1 3 ST ephri neEpinephrine (0.15mg/ (Aerosol) 0.3ml Injection, 0.3mg/ B1 2 QL Cystic Fibrosis Agents BethC1 0.3ml Injection) Bethkiskis (Nebulized (Generic EpiPen) 4 B/D, PA, QL Solution) EpiPC1 en EpiPen (Injection) CaysC1 3 QL, ST ton Cayston (Inhalation LevaC1 lbute rolLevalbuterol 4 PA, LA 1 B/D, PA Solution)

(Nebulized Solution) KalyC1 deco

C1 Kalydeco (150mg Leva lbute rol TartrLevalbuterol Tartrate ate HFA 3 ST Tablet, 50mg Packet, 4 PA, LA HFA (Aerosol) 75mg Packet) MetaC1 prot eren Metaproterenolol Sulfate OrkaC1 Sulfa mbi te Orkambi (Tablet) 4 PA, QL, LA (10mg Tablet, 20mg SymC1 1 dekoSymdeko (Tablet Tablet, 10mg/5ml 4 PA, QL Syrup) Therapy Pack)

TOBIC1 PerfC1 oro Perforomistmist TOBI (Nebulized 3 B/D, PA, QL 4 B/D, PA, QL (Nebulized Solution) Solution)

TOBIC1 ProAC1 Pod ir haler HFAProAir HFA (Aerosol TOBI Podhaler 2 4 PA, QL Solution) (Capsule)

TobrC1 ProAC1 amy ir cin Res Tobramycin (Nebulized ProAirpiCli RespiClick ck 2 1 B/D, PA, QL (Aerosol Powder) Solution) MastB1 Cell Stabilizers

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 129 129 91128 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

CroC1 OrenC1 moly itram n CromolynSodi Sodium Orenitram (0.25mg um (20mg/2ml Nebulized 1 B/D, PA Tablet Extended- Solution) Release, 1mg Tablet PhosphodiesteraseB1 Inhibitors, Airways Extended-Release, 4 PA, LA Disease 2.5mg Tablet

DalirC1 Dalirespesp (Tablet) 3 PA Extended-Release,

TheoC1 -24 5mg Tablet Extended- Theo-24 (Capsule Extended-Release 24 3 Release)

RevaC1 Hour) tioRevatio (10mg/ml

TheoC1 phylli Theophyllinene (Oral Suspension, 20mg 4 PA 1 Solution) Tablet)

TheoC1 SildeC1 phylli nafil ne TheophyllineCR CR Sildenafil (20mg (Tablet Extended- 1 Tablet) (Generic 1 PA Release 12 Hour) Revatio)

TheoC1 TraclC1 phylli eer ne TheophyllineER ER Tracleer (125mg (300mg Tablet Tablet, 62.5mg 4 PA, QL, LA Extended-Release 12 Tablet, 32mg Tablet Hour, 400mg Tablet 1 Soluble) Extended-Release 24 UptrC1 aviUptravi (1000mcg Hour, 600mg Tablet Extended-Release 24 Tablet, 1200mcg Hour) Tablet, 1400mcg PulmonaryB1 Antihypertensives Tablet, 1600mcg

AdciC1 Tablet, 200mcg 4 PA, QL, LA Adcircarca (Tablet) 4 PA Tablet, 400mcg AdeC1 mpa Adempass (Tablet) 4 PA, LA Tablet, 600mcg LetaiC1 Letairisris (Tablet) 4 PA, QL, LA Tablet, 800mcg

OpsC1 Opsumitumit (Tablet) 4 PA, LA Tablet)

C1 Oren C1 itram Uptr Orenitram (0.125mg aviUptravi (Tablet 4 PA, LA Tablet Extended- 3 PA, LA Therapy Pack)

VentC1 Release) avisVentavis (10mcg/ml Solution, 20mcg/ml 4 PA, LA Solution) PulmonaryB1 Fibrosis Agents

Bold type = Brand name drug Plain type = Generic drug 130 tRACK 130 Last updated October 1, 2018 92129 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

EsbriC1 FlutiC1 et caso ne Esbriet (267mg FluticasoneProp ionat e/ Salm etero Capsule, 267mg 4 PA, QL, LA Propionate/Salmeteroll 2 QL Tablet, 801mg Tablet) (Aerosol Powder)

IpratC1 OfevC1 ropiu m IpratropiumBro Bromide/ Ofev (Capsule) mide 4 PA, QL, LA / Albu terol

B1 Sulfa Respiratory Tract Agents, Other Albuterolte Sulfate 1 B/D, PA

AcetC1 (Inhalation Solution) ylcys teine Acetylcysteine NucC1 1 B/D, PA ala (Inhalation Solution) Nucala (Injection) 4 PA, QL, LA OralC1 air AdvaC1 ir Oralair (Tablet Disk usAdvair Diskus 2 QL 3 PA (Aerosol Powder) Sublingual) PulmC1 ozy me AdvaC1 ir Pulmozyme AdvairHFA HFA (Aerosol) 2 QL 4 B/D, PA, QL

AirdC1 (Inhalation Solution) uo Res picli Airduo Respiclick C1 ck Sem 113/ prex- 113/1414 (Aerosol 3 QL, ST Semprex-DD (Capsule) 3 StioltC1 o Res Stioltopima Respimat Powder) t 2

AirdC1 uo (Aerosol Solution) Res picliAirduo Respiclick ck 232/ SymC1 14 bicor 232/14 (Aerosol 3 QL, ST Symbicortt (Aerosol) 2 QL

TreleC1 gy Ellipt Trelegya Ellipta Powder) 2 QL AirdC1 uo Res (Aerosol Powder) picliAirduo Respiclick ck 55/1 455/14 (Aerosol 3 QL, ST SkeletalA1 Muscle Relaxants Powder) SkeletalB1 Muscle Relaxants

AnorC1 BaclC1 o ofen Ellipt aAnoro Ellipta (Aerosol Baclofen (10mg Tablet, 2 QL Powder) 20mg Tablet, 5mg 1

BeveC1 spi Aero Tablet) Bevespisphe Aerosphere re CyclC1 2 oben zapri Cyclobenzaprinene HCl (Aerosol) HCl 1 PA, HRM BreoC1 Ellipt (7.5mg Tablet) Breoa Ellipta (Aerosol DantC1 2 QL rium Powder) Dantrium (Capsule) 3

DantC1

C1 rolen Clari e nex- Sodi D 12 Dantrolene Sodium um Clarinex-DHour 12 Hour 1 (Tablet Extended- 3 (Capsule) FexC1 Release) Fexmidmid (Tablet) 3 PA, HRM

TizaC1 ComC1 nidin bive e nt TizanidineHCl HCl (2mg CombiventRes Respimat pima t 2 Capsule, 4mg Capsule, (Aerosol Solution) 1 DuleC1 6mg Capsule, 2mg Dulerara (Aerosol) 3 QL Tablet, 4mg Tablet) DymiC1 Dymistasta (Suspension) 3

FaseC1 Fasenranra (Injection) 4 PA, LA

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 131 131 93130 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

ZanaC1 ZolpiC1 flex dem Tartr Zanaflex (2mg Zolpidemate Tartrate Capsule, 4mg (10mg Tablet PA, QL, 3 Immediate-Release, 1 Capsule, 6mg HRM Capsule, 4mg Tablet) 5mg Tablet Immediate-

A1 Release) Sleep Disorder Agents B1

B1 Sleep Disorders, Other GABA Receptor Modulators ArmC1 odafi Armodafinilnil (Tablet) 1 PA, QL

AmbC1 PA, QL, ien BelsC1 Ambien (Tablet) 3 omra HRM Belsomra (Tablet) 2 QL HetliC1 oz RestC1 Restoriloril (22.5mg Hetlioz (Capsule) 4 PA, QL, LA ModC1 4 QL, HRM afinil Capsule) Modafinil (Tablet) 1 PA, QL

NuviC1 Nuvigilgil (Tablet) 3 PA, QL SonaC1 PA, QL, ta

ProviC1 Sonata (Capsule) 3 gil HRM Provigil (Tablet) 4 PA, QL

C1 C1 Roze Tem rem azep Temazepamam (22.5mg Rozerem (Tablet) 3

1 QL, HRM SilenC1 Capsule) Silenoror (Tablet) 3

XyreC1 m ZaleC1 PA, QL, plonZaleplon (Capsule) 1 Xyrem (Oral Solution) 4 PA, QL, LA HRM

Bold type = Brand name drug Plain type = Generic drug 132132 1 1 track 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 (20mg/ml Oral Solution) Maximum of 48 ml per day Abacavir (300mg Tablet) Maximum of 3 tablets per day Abacavir Sulfate/Lamivudine/Zidovudine Maximum of 3 tablets per day (Tablet) Abacavir/Lamivudine (Tablet) Maximum of 2 tablets per day Abilify (Tablet) Maximum of 1 tablet per day Abstral (Tablet Sublingual) Maximum of 4 tablets per day Accupril (Tablet) Maximum of 2 tablets per day Accuretic (10mg-12.5mg Tablet) Maximum of 1 tablet per day Accuretic (20mg-12.5mg Tablet, 20mg-25mg Maximum of 2 tablets per day Tablet) Acetaminophen/Codeine (120mg/5ml-12mg/ Maximum of 150 ml per day 5ml Oral Solution) Acetaminophen/Codeine (300mg-15mg Tablet, Maximum of 13 tablets per day 300mg-30mg Tablet, 300mg-60mg Tablet) Actiq (Lozenge on a Handle) Maximum of 4 lozenges per day Actoplus Met (Tablet) Maximum of 3 tablets per day Actoplus Met XR (15mg-1000mg Tablet Maximum of 2 tablets per day Extended-Release 24 Hour) Actoplus Met XR (30mg-1000mg Tablet Maximum of 1 tablet per day Extended-Release 24 Hour) Actos (15mg Tablet) Maximum of 3 tablets per day Actos (30mg Tablet, 45mg Tablet) Maximum of 1 tablet per day Adderall (20mg Tablet) Maximum of 3 tablets per day Adderall (5mg Tablet, 7.5mg Tablet) Maximum of 2 tablets per day Adderall XR (Capsule Extended-Release 24 Maximum of 2 capsules per day Hour) Adlyxin (Injection) Maximum of 6 ml (2 pens) per 28 days Adlyxin Starter Pack (Injection) Maximum of 6 ml (1 kit) per 28 days

Bold type = Brand name drug Plain type = Generic drug Last133 updated October 1, 2018 2 2 133 Drug Name Quantity Limit Advair Diskus (Aerosol Powder) Maximum of 1 inhaler (60 blisters) per 30 days Advair HFA (Aerosol) Maximum of 1 inhaler (12 grams) per 30 days Adzenys ER (Suspension Extended-Release) Maximum of 15 ml per day Adzenys XR-ODT (Tablet Extended-Release Maximum of 1 tablet per day Dispersible) Aggrenox (Capsule Extended-Release 12 Maximum of 2 capsules per day Hour) Airduo Respiclick 113/14 (Aerosol Powder) Maximum of 1 inhaler per 30 days Airduo Respiclick 232/14 (Aerosol Powder) Maximum of 1 inhaler per 30 days Airduo Respiclick 55/14 (Aerosol Powder) Maximum of 1 inhaler per 30 days Albenza (Tablet) Maximum of 16 tablets per day Almotriptan Malate (Tablet) Maximum of 12 tablets per 30 days Alogliptin (Tablet) Maximum of 1 tablet per day Alogliptin/Metformin HCl (Tablet) Maximum of 2 tablets per day Alogliptin/Pioglitazone (Tablet) Maximum of 1 tablet per day Alora (Patch Twice Weekly) Maximum of 8 patches per 28 days Alprazolam (0.25mg Tablet Immediate-Release, 0.5mg Tablet Immediate-Release, 1mg Tablet Maximum of 4 tablets per day Immediate-Release) Alprazolam (2mg Tablet Immediate-Release) Maximum of 5 tablets per day Alprazolam ER (0.5mg Tablet Extended-Release 24 Hour, 1mg Tablet Extended-Release 24 Maximum of 1 tablet per day Hour) Alprazolam ER (2mg Tablet Extended-Release Maximum of 5 tablets per day 24 Hour) Alprazolam ER (3mg Tablet Extended-Release Maximum of 3 tablets per day 24 Hour) Alprazolam Intensol (1mg/ml Concentrate) Maximum of 10 ml per day Alprazolam ODT (0.25mg Tablet Dispersible, 0.5mg Tablet Dispersible, 1mg Tablet Maximum of 4 tablets per day Dispersible) Alprazolam ODT (2mg Tablet Dispersible) Maximum of 5 tablets per day Altace (Capsule) Maximum of 2 capsules per day Altoprev (Tablet Extended-Release 24 Hour) Maximum of 1 tablet per day Alunbrig (180mg Tablet, 90mg Tablet) Maximum of 1 tablet per day Alunbrig (30mg Tablet) Maximum of 4 tablets per day Alunbrig (Tablet Therapy Pack) Maximum of 1 pack (30 tablets) per 30 days Maximum of 2 inhalers (12.2 grams) per 30 Alvesco (160mcg/act Aerosol Solution) days

Bold type = Brand name drug Plain type = Generic drug 134134 3 3 Last updated October 1, 2018 Drug Name Quantity Limit Alvesco (80mcg/act Aerosol Solution) Maximum of 1 inhaler (6.1 grams) per 30 days Amaryl (1mg Tablet) Maximum of 8 tablets per day Amaryl (2mg Tablet) Maximum of 4 tablets per day Amaryl (4mg Tablet) Maximum of 2 tablets per day Ambien (Tablet) Maximum of 90 days of use per year Amerge (Tablet) Maximum of 12 tablets per 30 days Amitiza (Capsule) Maximum of 2 capsules per day Amlodipine Besylate/Atorvastatin Calcium Maximum of 1 tablet per day (Tablet) Amlodipine Besylate/Benazepril HCl (Capsule) Maximum of 1 capsule per day Amlodipine Besylate/Valsartan (Tablet) Maximum of 1 tablet per day Amlodipine/Olmesartan Medoxomil (Tablet) Maximum of 1 tablet per day Amphetamine/Dextroamphetamine (10mg Capsule Extended-Release 24 Hour, 15mg Capsule Extended-Release 24 Hour, 20mg Capsule Extended-Release 24 Hour, 25mg Maximum of 2 capsules per day Capsule Extended-Release 24 Hour, 30mg Capsule Extended-Release 24 Hour, 5mg Capsule Extended-Release 24 Hour) Amphetamine/Dextroamphetamine (10mg Tablet Immediate-Release, 12.5mg Tablet Immediate-Release, 15mg Tablet Immediate- Maximum of 2 tablets per day Release, 30mg Tablet Immediate-Release, 5mg Tablet Immediate-Release, 7.5mg Tablet Immediate-Release) Amphetamine/Dextroamphetamine (20mg Maximum of 3 tablets per day Tablet Immediate-Release) Ampyra (Tablet Extended-Release 12 Hour) Maximum of 2 tablets per day Anoro Ellipta (Aerosol Powder) Maximum of 1 inhaler (60 blisters) per 30 days Apokyn (Injection) Maximum of 3 ml per day Apriso (Capsule Extended-Release 24 Hour) Maximum of 4 capsules per day Aptensio XR (Capsule Extended-Release 24 Maximum of 1 capsule per day Hour) Aptiom (200mg Tablet, 400mg Tablet) Maximum of 1 tablet per day Aptiom (600mg Tablet, 800mg Tablet) Maximum of 2 tablets per day Aptivus (100mg/ml Oral Solution) Maximum of 15 ml per day Aptivus (250mg Capsule) Maximum of 6 capsules per day Aricept (10mg Tablet) Maximum of 2 tablets per day Aricept (23mg Tablet, 5mg Tablet) Maximum of 1 tablet per day

Bold type = Brand name drug Plain type = Generic drug Last135 updated October 1, 2018 4 4 135 Drug Name Quantity Limit Aripiprazole (Tablet) Maximum of 1 tablet per day Aripiprazole (1mg/ml Oral Solution) Maximum of 25 ml per day Aripiprazole ODT (10mg Tablet Dispersible) Maximum of 3 tablets per day Aripiprazole ODT (15mg Tablet Dispersible) Maximum of 2 tablets per day Armodafinil (150mg Tablet, 200mg Tablet, Maximum of 1 tablet per day 250mg Tablet) Armodafinil (50mg Tablet) Maximum of 2 tablets per day Armonair Respiclick (Aerosol Powder) Maximum of 1 inhaler per 30 days Arnuity Ellipta (Aerosol Powder) Maximum of 1 inhaler (30 blisters) per 30 days Asacol HD (Tablet Delayed-Release) Maximum of 6 tablets per day Asmanex HFA (Aerosol) Maximum of 1 inhaler (13 grams) per 30 days Asmanex Twisthaler 120 Metered Doses Maximum of 1 inhaler per 30 days (Aerosol Powder) Asmanex Twisthaler 30 Metered Doses Maximum of 2 inhalers per 30 days (110mcg/INH Aerosol Powder) Asmanex Twisthaler 30 Metered Doses Maximum of 1 inhaler per 30 days (220mcg/INH Aerosol Powder) Asmanex Twisthaler 60 Metered Doses Maximum of 1 inhaler per 30 days (Aerosol Powder) Aspirin/Dipyridamole (Capsule Extended- Maximum of 2 capsules per day Release 12 Hour) Atacand (16mg Tablet, 32mg Tablet, 4mg Maximum of 1 tablet per day Tablet) Atacand (8mg Tablet) Maximum of 3 tablets per day Atacand HCT (Tablet) Maximum of 1 tablet per day Atazanavir Sulfate (150mg Capsule, 300mg Maximum of 2 capsules per day Capsule) Atazanavir Sulfate (200mg Capsule) Maximum of 3 capsules per day Ativan (0.5mg Tablet, 1mg Tablet) Maximum of 4 tablets per day Ativan (2mg Tablet) Maximum of 5 tablets per day Atorvastatin Calcium (Tablet) Maximum of 1 tablet per day Atripla (Tablet) Maximum of 2 tablets per day Aubagio (Tablet) Maximum of 1 tablet per day Austedo (Tablet) Maximum of 4 tablets per day Avalide (Tablet) Maximum of 1 tablet per day Avandia (2mg Tablet) Maximum of 4 tablets per day Avandia (4mg Tablet) Maximum of 2 tablets per day Avapro (150mg Tablet, 300mg Tablet) Maximum of 1 tablet per day

Bold type = Brand name drug Plain type = Generic drug 136136 5 5 Last updated October 1, 2018 Drug Name Quantity Limit Avapro (75mg Tablet) Maximum of 3 tablets per day Avodart (Capsule) Maximum of 1 capsule per day Azor (Tablet) Maximum of 1 tablet per day Belbuca (Film) Maximum of 2 films per day Belsomra (Tablet) Maximum of 1 tablet per day Benazepril HCl (Tablet) Maximum of 2 tablets per day Benazepril HCl/Hydrochlorothiazide (Tablet) Maximum of 1 tablet per day Benicar (20mg Tablet, 40mg Tablet) Maximum of 1 tablet per day Benicar (5mg Tablet) Maximum of 2 tablets per day Benicar HCT (Tablet) Maximum of 1 tablet per day Bethkis (Nebulized Solution) Maximum of 8 ml (2 ampules) per day Bevyxxa (Capsule) Maximum of 31 capsules per 30 days Biktarvy (Tablet) Maximum of 2 tablets per day Bisoprolol Fumarate/Hydrochlorothiazide Maximum of 2 tablets per day (Tablet) Bosulif (100mg Tablet) Maximum of 6 tablets per day Bosulif (400mg Tablet, 500mg Tablet) Maximum of 1 tablet per day Breo Ellipta (Aerosol Powder) Maximum of 1 inhaler (60 blisters) per 30 days Brilinta (Tablet) Maximum of 2 tablets per day BRIVIACT (100mg Tablet, 10mg Tablet, Maximum of 2 tablets per day 25mg Tablet, 50mg Tablet, 75mg Tablet) BRIVIACT (10mg/ml Oral Solution) Maximum of 20 ml per day Brovana (Nebulized Solution) Maximum of 2 vials (4 ml) per day Bunavail (Film) Maximum of 2 films per day Buprenorphine (Patch Weekly) Maximum of 4 patches per 28 days Buprenorphine HCl (Tablet Sublingual) Maximum of 3 tablets per day Buprenorphine HCl/Naloxone HCl (Tablet Maximum of 3 tablets per day Sublingual) Butorphanol Tartrate (Nasal Solution) Maximum of 2 bottles (5 ml) per 30 days Butrans (Patch Weekly) Maximum of 4 patches per 28 days Bydureon Bcise (Auto injector) Maximum of 4 pens (3.4 ml) per 28 days Bydureon Pen (Injection) Maximum of 4 pens per 28 days Bydureon Vial (Injection) Maximum of 4 vials per 28 days Byetta (10mcg/0.04ml Solution Pen injector) Maximum of 1 pen (2.4 ml) per 30 days Byetta (5mcg/0.02ml Solution Pen injector) Maximum of 1 pen (1.2 ml) per 30 days Bystolic (10mg Tablet, 2.5mg Tablet, 5mg Maximum of 1 tablet per day Tablet)

Bold type = Brand name drug Plain type = Generic drug Last137 updated October 1, 2018 6 6 137 Drug Name Quantity Limit Bystolic (20mg Tablet) Maximum of 2 tablets per day Byvalson (Tablet) Maximum of 1 tablet per day Cabometyx (20mg Tablet, 60mg Tablet) Maximum of 1 tablet per day Cabometyx (40mg Tablet) Maximum of 2 tablets per day Caduet (Tablet) Maximum of 1 tablet per day Calquence (Capsule) Maximum of 2 capsules per day Candesartan Cilexetil (16mg Tablet, 32mg Maximum of 1 tablet per day Tablet, 4mg Tablet) Candesartan Cilexetil (8mg Tablet) Maximum of 3 tablets per day Candesartan Cilexetil/Hydrochlorothiazide Maximum of 1 tablet per day (Tablet) Captopril (100mg Tablet) Maximum of 4 tablets per day Captopril (12.5mg Tablet, 25mg Tablet) Maximum of 3 tablets per day Captopril (50mg Tablet) Maximum of 9 tablets per day Captopril/Hydrochlorothiazide (25mg-15mg Maximum of 3 tablets per day Tablet, 50mg-15mg Tablet) Captopril/Hydrochlorothiazide (25mg-25mg Maximum of 2 tablets per day Tablet, 50mg-25mg Tablet) Cardura XL (Tablet Extended-Release 24 Maximum of 1 tablet per day Hour) Celebrex (Capsule) Maximum of 2 capsules per day Celecoxib (Capsule) Maximum of 2 capsules per day Cialis (2.5mg Tablet, 5mg Tablet) Maximum of 1 tablet per day Cimduo (Tablet) Maximum of 2 tablets per day Clonazepam (0.5mg Tablet Immediate-Release, Maximum of 4 tablets per day 1mg Tablet Immediate-Release) Clonazepam (2mg Tablet Immediate-Release) Maximum of 10 tablets per day Clonazepam ODT (0.125mg Tablet Dispersible, 0.25mg Tablet Dispersible, 0.5mg Tablet Maximum of 4 tablets per day Dispersible, 1mg Tablet Dispersible) Clonazepam ODT (2mg Tablet Dispersible) Maximum of 10 tablets per day Clopidogrel (75mg Tablet) Maximum of 4 tablets per day Clorazepate Dipotassium (15mg Tablet) Maximum of 6 tablets per day Clorazepate Dipotassium (3.75mg Tablet) Maximum of 24 tablets per day Clorazepate Dipotassium (7.5mg Tablet) Maximum of 12 tablets per day Codeine Sulfate (Tablet) Maximum of 6 tablets per day Colchicine (0.6mg Capsule) (Generic Maximum of 4 capsules per day Mitigare)

Bold type = Brand name drug Plain type = Generic drug 138138 7 7 Last updated October 1, 2018 Drug Name Quantity Limit Colchicine (0.6mg Tablet) (Generic Colcrys) Maximum of 4 tablets per day Colcrys (Tablet) Maximum of 4 tablets per day Combivir (Tablet) Maximum of 3 tablets per day Complera (Tablet) Maximum of 2 tablets per day Concerta (18mg Tablet Extended-Release) Maximum of 3 tablets per day Concerta (27mg Tablet Extended-Release, Maximum of 2 tablets per day 36mg Tablet Extended-Release) Concerta (54mg Tablet Extended-Release) Maximum of 1 tablet per day Conzip (Capsule Extended-Release 24 Hour) Maximum of 1 capsule per day Corlanor (Tablet) Maximum of 2 tablets per day Cozaar (100mg Tablet) Maximum of 1 tablet per day Cozaar (25mg Tablet, 50mg Tablet) Maximum of 2 tablets per day Crestor (Tablet) Maximum of 1 tablet per day Crixivan (Capsule) Maximum of 9 capsules per day Cymbalta (Capsule Delayed-Release) Maximum of 2 capsules per day Daklinza (Tablet) Maximum of 1 tablet per day Darifenacin HBr ER (Tablet Extended-Release Maximum of 1 tablet per day 24 Hour) Daytrana (Patch) Maximum of 1 patch per day Descovy (Tablet) Maximum of 2 tablets per day Desvenlafaxine ER (100mg Tablet Extended- Maximum of 4 tablets per day Release 24 Hour) Desvenlafaxine ER (25mg Tablet Extended- Release 24 Hour, 50mg Tablet Extended- Maximum of 1 tablet per day Release 24 Hour) Dexedrine (10mg Capsule Extended-Release Maximum of 6 capsules per day 24 Hour) Dexedrine (15mg Capsule Extended-Release Maximum of 4 capsules per day 24 Hour) Dexedrine (5mg Capsule Extended-Release Maximum of 3 capsules per day 24 Hour) Dexilant (Capsule Delayed-Release) Maximum of 1 capsule per day Dexmethylphenidate HCl (Tablet Immediate- Maximum of 2 tablets per day Release) Dextroamphetamine Sulfate (Tablet) Maximum of 6 tablets per day Dextroamphetamine Sulfate ER (10mg Capsule Maximum of 6 capsules per day Extended-Release 24 Hour) Dextroamphetamine Sulfate ER (15mg Capsule Maximum of 4 capsules per day Extended-Release 24 Hour)

Bold type = Brand name drug Plain type = Generic drug Last139 updated October 1, 2018 8 8 139 Drug Name Quantity Limit Dextroamphetamine Sulfate ER (5mg Capsule Maximum of 3 capsules per day Extended-Release 24 Hour) Diazepam (10mg Tablet, 2mg Tablet, 5mg Maximum of 4 tablets per day Tablet) Diazepam Intensol (5mg/ml Concentrate) Maximum of 8 ml per day Didanosine (Capsule Delayed-Release) Maximum of 2 capsules per day Digitek (0.125mg Tablet) Maximum of 1 tablet per day Digox (125mcg Tablet) Maximum of 1 tablet per day Digoxin (0.05mg/ml Oral Solution) Maximum of 5 ml per day Digoxin (125mcg Tablet) Maximum of 1 tablet per day Dilaudid (1mg/ml Liquid) Maximum of 50 ml per day Dilaudid (2mg Tablet, 4mg Tablet) Maximum of 8 tablets per day Dilaudid (8mg Tablet) Maximum of 6 tablets per day Diovan (160mg Tablet, 40mg Tablet, 80mg Maximum of 2 tablets per day Tablet) Diovan (320mg Tablet) Maximum of 1 tablet per day Diovan HCT (Tablet) Maximum of 1 tablet per day Ditropan XL (10mg Tablet Extended-Release Maximum of 3 tablets per day 24 Hour) Ditropan XL (5mg Tablet Extended-Release Maximum of 1 tablet per day 24 Hour) Dolophine (10mg Tablet) Maximum of 12 tablets per day Dolophine (5mg Tablet) Maximum of 8 tablets per day Donepezil HCl (10mg Tablet Immediate- Maximum of 2 tablets per day Release) Donepezil HCl (23mg Tablet Immediate- Maximum of 1 tablet per day Release, 5mg Tablet Immediate-Release) Donepezil HCl ODT (10mg Tablet Dispersible) Maximum of 2 tablets per day Donepezil HCl ODT (5mg Tablet Dispersible) Maximum of 1 tablet per day Doxepin HCl (Cream) Maximum of 90 grams per 30 days Duetact (Tablet) Maximum of 1 tablet per day Dulera (Aerosol) Maximum of 1 inhaler (13 grams) per 30 days Duloxetine HCl (20mg Capsule Delayed- Release, 30mg Capsule Delayed-Release, 60mg Maximum of 2 capsules per day Capsule Delayed-Release) Duloxetine HCl (40mg Capsule Delayed- Maximum of 3 capsules per day Release)

Bold type = Brand name drug Plain type = Generic drug 140140 9 9 Last updated October 1, 2018 Drug Name Quantity Limit Duragesic (100mcg/hr Patch 72 Hour, 12mcg/hr Patch 72 Hour, 25mcg/hr Patch 72 Maximum of 15 patches per 30 days Hour, 50mcg/hr Patch 72 Hour, 75mcg/hr Patch 72 Hour) Dutasteride (Capsule) Maximum of 1 capsule per day Dyanavel XR (Suspension Extended-Release) Maximum of 8 ml per day Edarbi (Tablet) Maximum of 1 tablet per day Edarbyclor (Tablet) Maximum of 1 tablet per day Edurant (Tablet) Maximum of 2 tablets per day Efavirenz (200mg Capsule) Maximum of 3 capsules per day Efavirenz (50mg Capsule) Maximum of 9 capsules per day Efavirenz (600mg Tablet) Maximum of 2 tablets per day Effient (Tablet) Maximum of 1 tablet per day Eletriptan HBr (Tablet) Maximum of 12 tablets per 30 days Eliquis (Tablet) Maximum of 2 tablets per day Eliquis Starter Pack (Tablet) Maximum of 1 pack (74 tablets) per 30 days Embeda (100mg-4mg Capsule Extended- Maximum of 3 capsules per day Release) Embeda (20mg-0.8mg Capsule Extended- Release, 80mg-3.2mg Capsule Extended- Maximum of 4 capsules per day Release) Embeda (30mg-1.2mg Capsule Extended- Release, 50mg-2mg Capsule Extended- Maximum of 2 capsules per day Release) Embeda (60mg-2.4mg Capsule Extended- Maximum of 6 capsules per day Release) Emtriva (10mg/ml Oral Solution) Maximum of 42.5 ml per day Emtriva (200mg Capsule) Maximum of 2 capsules per day Enablex (Tablet Extended-Release 24 Hour) Maximum of 1 tablet per day Enalapril Maleate (Tablet) Maximum of 2 tablets per day Enalapril Maleate/Hydrochlorothiazide Maximum of 2 tablets per day (10mg-25mg Tablet) Enalapril Maleate/Hydrochlorothiazide Maximum of 1 tablet per day (5mg-12.5mg Tablet) Endocet (Tablet) Maximum of 12 tablets per day Enoxaparin Sodium (100mg/ml Subcutaneous Maximum of 2 syringes (2 ml) per day Solution, 150mg/ml Subcutaneous Solution)

Bold type = Brand name drug Plain type = Generic drug Last141 updated October 1, 2018 10 10 141 Drug Name Quantity Limit 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 (Tablet) Maximum of 2 tablets per day Epclusa (Tablet) Maximum of 1 tablet per day Epinephrine (Injection) (Generic EpiPen) Maximum of 4 pens (2 boxes) per 30 days EpiPen (Injection) Maximum of 4 pens (2 boxes) per 30 days Epivir (10mg/ml Oral Solution) Maximum of 48 ml per day Epivir (150mg Tablet) Maximum of 3 tablets per day Epivir (300mg Tablet) Maximum of 2 tablets per day Eprosartan Mesylate (Tablet) Maximum of 1 tablet per day Epzicom (Tablet) Maximum of 2 tablets per day Erivedge (Capsule) Maximum of 1 capsule per day Erleada (Tablet) Maximum of 4 tablets per day Esbriet (267mg Capsule) Maximum of 9 capsules per day Esbriet (267mg Tablet) Maximum of 9 tablets per day Esbriet (801mg Tablet) Maximum of 3 tablets per day Esomeprazole Magnesium (20mg Capsule Maximum of 3 capsules per day Delayed-Release) (Generic Nexium) Esomeprazole Magnesium (40mg Capsule Maximum of 2 capsules per day Delayed-Release) (Generic Nexium) Esomeprazole Strontium (Capsule Delayed- Maximum of 2 capsules per day Release) Estradiol (0.025mg/24hr Patch Twice Weekly, 0.0375mg/24hr Patch Twice Weekly, 0.05mg/ Maximum of 8 patches per 28 days 24hr Patch Twice Weekly, 0.075mg/24hr Patch Twice Weekly, 0.1mg/24hr Patch Twice Weekly) Evotaz (Tablet) Maximum of 2 tablets per day

Bold type = Brand name drug Plain type = Generic drug 142142 11 11 Last updated October 1, 2018 Drug Name Quantity Limit Exalgo (12mg Tablet Extended-Release 24 Hour Abuse-Deterrent, 16mg Tablet Extended-Release 24 Hour Abuse-Deterrent, Maximum of 2 tablets per day 32mg Tablet Extended-Release 24 Hour Abuse-Deterrent, 8mg Tablet Extended- Release 24 Hour Abuse-Deterrent) Exelon (Patch 24 Hour) Maximum of 1 patch per day Exforge (Tablet) Maximum of 1 tablet per day Ezetimibe/Simvastatin (Tablet) Maximum of 1 tablet per day Fanapt (10mg Tablet, 12mg Tablet, 1mg Tablet, 2mg Tablet, 4mg Tablet, 6mg Tablet, Maximum of 2 tablets per day 8mg Tablet) Farxiga (Tablet) Maximum of 1 tablet per day Fentanyl (Patch 72 Hour) Maximum of 15 patches per 30 days Fentanyl Citrate Oral Transmucosal (Lozenge Maximum of 4 lozenges per day on a Handle) Fentora (Tablet) Maximum of 4 tablets per day Firazyr (Injection) Maximum of 9 ml per day Flector (Patch) Maximum of 2 patches per day Flolipid (20mg/5ml Suspension) Maximum of 5 ml per day Flolipid (40mg/5ml Suspension) Maximum of 10 ml per day Flovent HFA (110mcg/act Aerosol) Maximum of 1 inhaler (12 grams) per 30 days Flovent HFA (220mcg/act Aerosol) Maximum of 2 inhalers (24 grams) per 30 days Flovent HFA (44mcg/act Aerosol) Maximum of 1 inhaler (10.6 grams) per 30 days Fluticasone Propionate/Salmeterol (Aerosol Maximum of 1 inhaler per 30 days Powder) Fluvastatin (20mg Capsule Immediate-Release) Maximum of 1 capsule per day Fluvastatin (40mg Capsule Immediate-Release) Maximum of 2 capsules per day Fluvastatin Sodium ER (Tablet Extended- Maximum of 1 tablet per day Release 24 Hour) Focalin (Tablet) Maximum of 2 tablets per day Fortamet (1000mg Tablet Extended-Release Maximum of 2 tablets per day 24 Hour) Fortamet (500mg Tablet Extended-Release Maximum of 5 tablets per day 24 Hour) Fosamprenavir Calcium (Tablet) Maximum of 6 tablets per day Fosinopril Sodium (Tablet) Maximum of 2 tablets per day Fosinopril Sodium/Hydrochlorothiazide (Tablet) Maximum of 4 tablets per day Frova (Tablet) Maximum of 12 tablets per 30 days

Bold type = Brand name drug Plain type = Generic drug Last143 updated October 1, 2018 12 12 143 Drug Name Quantity Limit Frovatriptan Succinate (Tablet) Maximum of 12 tablets per 30 days Fuzeon (Injection) Maximum of 3 vials per day Galantamine HBr (12mg Tablet, 4mg Tablet, Maximum of 2 tablets per day 8mg Tablet) Galantamine HBr (4mg/ml Oral Solution) Maximum of 2 bottles (200 ml) per 30 days Galantamine HBr ER (Capsule Extended- Maximum of 1 capsule per day Release 24 Hour) Genvoya (Tablet) Maximum of 2 tablets per day Geodon (20mg Capsule, 40mg Capsule, Maximum of 2 capsules per day 60mg Capsule, 80mg Capsule) Gilenya (Capsule) Maximum of 1 pack (30 capsules) per 30 days Gleevec (Tablet) Maximum of 3 tablets per day Glimepiride (1mg Tablet) Maximum of 8 tablets per day Glimepiride (2mg Tablet) Maximum of 4 tablets per day Glimepiride (4mg Tablet) Maximum of 2 tablets per day Glipizide (10mg Tablet Immediate-Release) Maximum of 4 tablets per day Glipizide (5mg Tablet Immediate-Release) Maximum of 8 tablets per day Glipizide ER (10mg Tablet Extended-Release 24 Maximum of 2 tablets per day Hour) Glipizide ER (2.5mg Tablet Extended-Release Maximum of 8 tablets per day 24 Hour) Glipizide ER (5mg Tablet Extended-Release 24 Maximum of 4 tablets per day Hour) Glipizide/Metformin HCl (2.5mg-250mg Tablet) Maximum of 8 tablets per day Glipizide/Metformin HCl (2.5mg-500mg Tablet, Maximum of 4 tablets per day 5mg-500mg Tablet) Glucophage (1000mg Tablet) Maximum of 2.5 tablets per day Glucophage (500mg Tablet) Maximum of 5 tablets per day Glucophage (850mg Tablet) Maximum of 3 tablets per day Glucophage XR (500mg Tablet Extended- Maximum of 4 tablets per day Release 24 Hour) Glucophage XR (750mg Tablet Extended- Maximum of 2 tablets per day Release 24 Hour) Glucotrol (10mg Tablet) Maximum of 4 tablets per day Glucotrol (5mg Tablet) Maximum of 8 tablets per day Glucotrol XL (10mg Tablet Extended-Release Maximum of 2 tablets per day 24 Hour) Glucotrol XL (2.5mg Tablet Extended-Release Maximum of 8 tablets per day 24 Hour)

Bold type = Brand name drug Plain type = Generic drug 144144 13 13 Last updated October 1, 2018 Drug Name Quantity Limit Glucotrol XL (5mg Tablet Extended-Release Maximum of 4 tablets per day 24 Hour) Glumetza (500mg Tablet Extended-Release Maximum of 4 tablets per day 24 Hour) Glyxambi (Tablet) Maximum of 1 tablet per day Harvoni (Tablet) Maximum of 1 tablet per day Hetlioz (Capsule) Maximum of 1 capsule per day Hydrocodone Bitartrate/Acetaminophen (10mg-300mg Tablet, 5mg-300mg Tablet, Maximum of 13 tablets per day 7.5mg-300mg Tablet) Hydrocodone Bitartrate/Acetaminophen Maximum of 180 ml per day (7.5mg-325mg/15ml Oral Solution) Hydrocodone/Acetaminophen (Tablet) Maximum of 12 tablets per day Hydrocodone/Ibuprofen (Tablet) Maximum of 5 tablets per day Hydromorphone HCl (1mg/ml Liquid) Maximum of 50 ml per day Hydromorphone HCl (2mg Tablet Immediate- Maximum of 8 tablets per day Release, 4mg Tablet Immediate-Release) Hydromorphone HCl (8mg Tablet Immediate- Maximum of 6 tablets per day Release) Hydromorphone HCl ER (Tablet Extended- Maximum of 2 tablets per day Release 24 Hour Abuse-Deterrent) Hysingla ER (Tablet Extended-Release 24 Maximum of 1 tablet per day Hour Abuse-Deterrent) Hyzaar (100mg-12.5mg Tablet, 100mg-25mg Maximum of 1 tablet per day Tablet) Hyzaar (50mg-12.5mg Tablet) Maximum of 2 tablets per day Ibrance (Capsule) Maximum of 1 capsule per day Ibudone (Tablet) Maximum of 5 tablets per day Iclusig (15mg Tablet) Maximum of 2 tablets per day Iclusig (45mg Tablet) Maximum of 1 tablet per day Idhifa (Tablet) Maximum of 1 tablet per day Imatinib Mesylate (Tablet) Maximum of 3 tablets per day Imbruvica (140mg Capsule) Maximum of 4 capsules per day Imbruvica (Tablet) Maximum of 1 tablet per day Imbruvica (70mg Capsule) Maximum of 1 capsule per day Imitrex (100mg Tablet, 25mg Tablet, 50mg Maximum of 12 tablets per 30 days Tablet) Imitrex (20mg/act Nasal Solution, 5mg/act Maximum of 12 devices per 30 days Nasal Solution)

Bold type = Brand name drug Plain type = Generic drug Last145 updated October 1, 2018 14 14 145 Drug Name Quantity Limit Imitrex (6mg/0.5ml Subcutaneous Solution) Maximum of 12 injections (6 ml) per 30 days Imitrex Statdose Refill (Injection) Maximum of 12 injections (6 ml) per 30 days Imitrex Statdose System (4mg/0.5ml Maximum of 12 injections (6 ml) per 30 days Injection) Imvexxy (10mcg Maintenance Vaginal Maximum of 1 vaginal insert per day Suppository) Incruse Ellipta (Aerosol Powder) Maximum of 1 inhaler (30 blisters) per 30 days Ingrezza (Capsule) Maximum of 1 capsule per day Inlyta (Tablet) Maximum of 4 tablets per day Intelence (100mg Tablet) Maximum of 2 tablets per day Intelence (200mg Tablet) Maximum of 3 tablets per day Intelence (25mg Tablet) Maximum of 6 tablets per day Intrarosa (Insert) Maximum of 1 vaginal insert per day Invega (1.5mg Tablet Extended-Release 24 Hour, 3mg Tablet Extended-Release 24 Hour, Maximum of 1 tablet per day 9mg Tablet Extended-Release 24 Hour) Invega (6mg Tablet Extended-Release 24 Maximum of 2 tablets per day Hour) Invirase (200mg Capsule) Maximum of 15 capsules per day Invirase (500mg Tablet) Maximum of 6 tablets per day Invokamet (Tablet) Maximum of 2 tablets per day Invokamet XR (Tablet Extended-Release 24 Maximum of 2 tablets per day Hour) Invokana (Tablet) Maximum of 1 tablet per day Irbesartan (150mg Tablet, 300mg Tablet) Maximum of 1 tablet per day Irbesartan (75mg Tablet) Maximum of 3 tablets per day Irbesartan/Hydrochlorothiazide (Tablet) Maximum of 1 tablet per day Iressa (Tablet) Maximum of 2 tablets per day Isentress (100mg Packet) Maximum of 4 packets per day Isentress (100mg Tablet Chewable, 25mg Maximum of 9 tablets per day Tablet Chewable) Isentress (400mg Tablet) Maximum of 6 tablets per day Isentress HD (Tablet) Maximum of 3 tablets per day Jakafi (Tablet) Maximum of 2 tablets per day Janumet (Tablet Immediate-Release) Maximum of 2 tablets per day Janumet XR (Tablet Extended-Release 24 Maximum of 2 tablets per day Hour) Januvia (Tablet) Maximum of 1 tablet per day

Bold type = Brand name drug Plain type = Generic drug 146146 15 15 Last updated October 1, 2018 Drug Name Quantity Limit Jardiance (Tablet) Maximum of 1 tablet per day Jentadueto (Tablet) Maximum of 2 tablets per day Jentadueto XR (2.5mg-1000mg Tablet Maximum of 2 tablets per day Extended-Release 24 Hour) Jentadueto XR (5mg-1000mg Tablet Maximum of 1 tablet per day Extended-Release 24 Hour) Juluca (Tablet) Maximum of 2 tablets per day Jynarque (Tablet Therapy Pack) Maximum of 2 tablets per day Kadian (100mg Capsule Extended-Release 24 Hour, 60mg Capsule Extended-Release 24 Maximum of 3 capsules per day Hour, 80mg Capsule Extended-Release 24 Hour) Kadian (10mg Capsule Extended-Release 24 Hour, 20mg Capsule Extended-Release 24 Hour, 30mg Capsule Extended-Release 24 Maximum of 2 capsules per day Hour, 40mg Capsule Extended-Release 24 Hour, 50mg Capsule Extended-Release 24 Hour) Kadian (200mg Capsule Extended-Release 24 Maximum of 1 capsule per day Hour) Kaletra (100mg-25mg Tablet) Maximum of 10 tablets per day Kaletra (200mg-50mg Tablet) Maximum of 6 tablets per day Kaletra (400mg-100mg/5ml Oral Solution) Maximum of 16 ml per day Kazano (Tablet) Maximum of 2 tablets per day Keveyis (Tablet) Maximum of 4 tablets per day Kisqali (Tablet) Maximum of 3 tablets per day Kisqali Femara (Tablet Therapy Pack) Maximum of 1 pack (91 tablets) per 28 days Klonopin (0.5mg Tablet, 1mg Tablet) Maximum of 4 tablets per day Klonopin (2mg Tablet) Maximum of 10 tablets per day Kombiglyze XR (2.5mg-1000mg Tablet Maximum of 2 tablets per day Extended-Release 24 Hour) Kombiglyze XR (5mg-1000mg Tablet Extended-Release 24 Hour, 5mg-500mg Maximum of 1 tablet per day Tablet Extended-Release 24 Hour) Lamivudine (10mg/ml Oral Solution) Maximum of 48 ml per day Lamivudine (150mg Tablet) Maximum of 3 tablets per day Lamivudine (300mg Tablet) Maximum of 2 tablets per day Lamivudine/Zidovudine (Tablet) Maximum of 3 tablets per day Lanoxin (125mcg Tablet) Maximum of 1 tablet per day

Bold type = Brand name drug Plain type = Generic drug Last147 updated October 1, 2018 16 16 147 Drug Name Quantity Limit Lanoxin (62.5mcg Tablet) Maximum of 2 tablets per day Lansoprazole (Capsule Delayed-Release) Maximum of 2 capsules per day Latuda (120mg Tablet, 20mg Tablet, 40mg Maximum of 1 tablet per day Tablet, 60mg Tablet) Latuda (80mg Tablet) Maximum of 2 tablets per day Lazanda (Nasal Solution) Maximum of 15 bottles (79.5 ml) per 30 days Lescol XL (Tablet Extended-Release 24 Hour) Maximum of 1 tablet per day Letairis (Tablet) Maximum of 1 tablet per day Levorphanol Tartrate (Tablet) Maximum of 6 tablets per day Lexiva (50mg/ml Suspension) Maximum of 90 ml per day Lexiva (700mg Tablet) Maximum of 6 tablets per day Lialda (Tablet Delayed-Release) Maximum of 4 tablets per day Lidocaine (5% Ointment) Maximum of 150 grams per 30 days Lidocaine (5% Patch) Maximum of 3 patches per day Lidoderm (Patch) Maximum of 3 patches per day Linzess (Capsule) Maximum of 1 capsule per day Lipitor (Tablet) Maximum of 1 tablet per day Lisinopril (Tablet) Maximum of 2 tablets per day Lisinopril/Hydrochlorothiazide (10mg-12.5mg Maximum of 1 tablet per day Tablet) Lisinopril/Hydrochlorothiazide (20mg-12.5mg Maximum of 4 tablets per day Tablet) Lisinopril/Hydrochlorothiazide (20mg-25mg Maximum of 2 tablets per day Tablet) Livalo (Tablet) Maximum of 1 tablet per day Lonhala Magnair Starter Kit (Inhalation Maximum of 2 vials (2 ml) per day Solution) Lonsurf (6.14mg-15mg Tablet) Maximum of 10 tablets per day Lonsurf (8.19mg-20mg Tablet) Maximum of 8 tablets per day Lopinavir/Ritonavir (Oral Solution) Maximum of 16 ml per day Lorazepam (0.5mg Tablet, 1mg Tablet) Maximum of 4 tablets per day Lorazepam (2mg Tablet) Maximum of 5 tablets per day Lorazepam Intensol (2mg/ml Concentrate) Maximum of 5 ml per day Lorcet (Tablet) Maximum of 12 tablets per day Lorcet HD (Tablet) Maximum of 12 tablets per day Lorcet Plus (Tablet) Maximum of 12 tablets per day Losartan Potassium (100mg Tablet) Maximum of 1 tablet per day

Bold type = Brand name drug Plain type = Generic drug 148148 17 17 Last updated October 1, 2018 Drug Name Quantity Limit Losartan Potassium (25mg Tablet, 50mg Maximum of 2 tablets per day Tablet) Losartan Potassium/Hydrochlorothiazide Maximum of 1 tablet per day (100mg-12.5mg Tablet, 100mg-25mg Tablet) Losartan Potassium/Hydrochlorothiazide Maximum of 2 tablets per day (50mg-12.5mg Tablet) Lotensin (Tablet) Maximum of 2 tablets per day Lotrel (Capsule) Maximum of 1 capsule per day Lovastatin (10mg Tablet Immediate-Release, Maximum of 1 tablet per day 20mg Tablet Immediate-Release) Lovastatin (40mg Tablet Immediate-Release) 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 (Tablet) Maximum of 16 tablets per day Lynparza (100mg Tablet, 150mg Tablet) Maximum of 4 tablets per day Lyrica (100mg Capsule, 150mg Capsule, 200mg Capsule, 25mg Capsule, 50mg Maximum of 3 capsules per day Capsule, 75mg Capsule) Lyrica (20mg/ml Oral Solution) Maximum of 30 ml per day Lyrica (225mg Capsule, 300mg Capsule) Maximum of 2 capsules per day Lyrica CR (165mg Tablet Extended-Release 24 Hour, 82.5mg Tablet Extended-Release 24 Maximum of 3 tablets per day Hour) Lyrica CR (330mg Tablet Extended-Release Maximum of 2 tablets per day 24 Hour) Mavyret (Tablet) Maximum of 3 tablets per day Maxalt (Tablet) Maximum of 12 tablets per 30 days Maxalt-MLT (Tablet Dispersible) Maximum of 12 tablets per 30 days Memantine HCl (10mg Tablet) Maximum of 2 tablets per day Memantine HCl (2mg/ml Oral Solution) Maximum of 10 ml per day

Bold type = Brand name drug Plain type = Generic drug Last149 updated October 1, 2018 18 18 149 Drug Name Quantity Limit Memantine HCl (5mg Tablet) Maximum of 3 tablets per day Memantine HCl ER (Capsule Extended-Release Maximum of 1 capsule per day 24 Hour) Mesalamine DR (1.2gm Tablet Delayed- Maximum of 4 tablets per day Release) Mesalamine DR (800mg Tablet Delayed- Maximum of 6 tablets per day Release) Metadate ER (Tablet Extended-Release) Maximum of 3 tablets per day Metformin HCl (1000mg Tablet Immediate- Maximum of 2.5 tablets per day Release) Metformin HCl (850mg Tablet Immediate- Maximum of 3 tablets per day Release) Metformin HCl (500mg Tablet Immediate- Maximum of 5 tablets per day Release) Metformin HCl ER (1000mg Tablet Extended- Maximum of 2 tablets per day Release 24 Hour) Metformin HCl ER (1000mg Tablet Extended- Maximum of 2 tablets per day Release 24 Hour) (Generic Fortamet) Metformin HCl ER (500mg Tablet Extended- Maximum of 4 tablets per day Release 24 Hour) (Generic Fortamet) Metformin HCl ER (500mg Tablet Extended- Maximum of 5 tablets per day Release 24 Hour) (Generic Glumetza) Metformin HCl ER (500mg Tablet Extended- Maximum of 4 tablets per day Release 24 Hour) (Generic Glucophage XR) Metformin HCl ER (750mg Tablet Extended- Maximum of 2 tablets per day Release 24 Hour) (Generic Glucophage XR) Methadone HCl (10mg Tablet) Maximum of 12 tablets per day Methadone HCl (10mg/5ml Oral Solution) Maximum of 60 ml per day Methadone HCl (5mg Tablet) Maximum of 8 tablets per day Methadone HCl (5mg/5ml Oral Solution) Maximum of 120 ml per day Methylin (10mg/5ml Oral Solution) Maximum of 30 ml per day Methylin (5mg/5ml Oral Solution) Maximum of 60 ml per day Methylphenidate HCl (10mg Tablet Chewable) Maximum of 6 tablets per day Methylphenidate HCl (10mg/5ml Oral Solution) Maximum of 30 ml per day Methylphenidate HCl (2.5mg Tablet Chewable, Maximum of 3 tablets per day 5mg Tablet Chewable) Methylphenidate HCl (10mg Tablet Immediate- Release, 20mg Tablet Immediate-Release, 5mg Maximum of 3 tablets per day Tablet Immediate-Release) (Generic Ritalin) Methylphenidate HCl (5mg/5ml Oral Solution) Maximum of 60 ml per day

Bold type = Brand name drug Plain type = Generic drug 150150 19 19 Last updated October 1, 2018 Drug Name Quantity Limit Methylphenidate HCl ER (10mg Tablet Maximum of 4 tablets per day Extended-Release) Methylphenidate HCl ER (18mg Tablet Maximum of 3 tablets per day Extended-Release 24 Hour) Methylphenidate HCl ER (20mg Tablet Maximum of 3 tablets per day Extended-Release) Methylphenidate HCl ER (27mg Tablet Extended-Release 24 Hour, 36mg Tablet Maximum of 2 tablets per day Extended-Release 24 Hour) Methylphenidate HCl ER (54mg Tablet Maximum of 1 tablet per day Extended-Release 24 Hour) Methylphenidate HCl ER (72mg Tablet Maximum of 1 tablet per day Extended-Release) Micardis (Tablet) Maximum of 1 tablet per day Micardis HCT (12.5mg-40mg Tablet, Maximum of 1 tablet per day 25mg-80mg Tablet) Micardis HCT (12.5mg-80mg Tablet) Maximum of 2 tablets per day Minivelle (Patch Twice Weekly) Maximum of 8 patches per 28 days Mitigare (Capsule) Maximum of 4 capsules per day Modafinil (100mg Tablet) Maximum of 1 tablet per day Modafinil (200mg Tablet) Maximum of 2 tablets per day Moexipril HCl (Tablet) Maximum of 2 tablets per day Moexipril/Hydrochlorothiazide (15mg-12.5mg Maximum of 2 tablets per day Tablet, 15mg-25mg Tablet) Moexipril/Hydrochlorothiazide (7.5mg-12.5mg Maximum of 1 tablet per day Tablet) Montelukast Sodium (10mg Tablet) Maximum of 1 tablet per day Montelukast Sodium (4mg Packet) Maximum of 1 packet per day Montelukast Sodium (4mg Tablet Chewable, Maximum of 1 tablet per day 5mg Tablet Chewable) Morphine Sulfate (100mg/5ml Oral Solution) Maximum of 10 ml per day Morphine Sulfate (10mg/5ml Oral Solution) Maximum of 100 ml per day Morphine Sulfate (15mg Tablet Immediate- Maximum of 8 tablets per day Release) Morphine Sulfate (20mg/5ml Oral Solution) Maximum of 50 ml per day Morphine Sulfate (30mg Tablet Immediate- Maximum of 6 tablets per day Release)

Bold type = Brand name drug Plain type = Generic drug Last151 updated October 1, 2018 20 20 151 Drug Name Quantity Limit Morphine Sulfate ER (100mg Capsule Extended-Release 24 Hour, 60mg Capsule Maximum of 3 capsules per day Extended-Release 24 Hour, 80mg Capsule Extended-Release 24 Hour) (Generic Kadian) Morphine Sulfate ER (100mg Tablet Extended- Release, 15mg Tablet Extended-Release) Maximum of 3 tablets per day (Generic MS Contin) Morphine Sulfate ER (10mg Capsule Extended- Release 24 Hour, 20mg Capsule Extended- Release 24 Hour, 30mg Capsule Extended- Maximum of 2 capsules per day Release 24 Hour, 50mg Capsule Extended- Release 24 Hour) (Generic Kadian) Morphine Sulfate ER (120mg Capsule Maximum of 3 capsules per day Extended-Release 24 Hour) (Generic Avinza) Morphine Sulfate ER (200mg Tablet Extended- Maximum of 2 tablets per day Release) (Generic MS Contin) Morphine Sulfate ER (30mg Capsule Extended- Release 24 Hour, 45mg Capsule Extended- Maximum of 2 capsules per day Release 24 Hour, 60mg Capsule Extended- Release 24 Hour) (Generic Avinza) Morphine Sulfate ER (30mg Tablet Extended- Release, 60mg Tablet Extended-Release) Maximum of 4 tablets per day (Generic MS Contin) Morphine Sulfate ER (75mg Capsule Extended- Release 24 Hour, 90mg Capsule Extended- Maximum of 4 capsules per day Release 24 Hour) (Generic Avinza) Movantik (Tablet) Maximum of 1 tablet per day MS Contin (100mg Tablet Extended-Release, Maximum of 3 tablets per day 15mg Tablet Extended-Release) MS Contin (200mg Tablet Extended-Release) Maximum of 2 tablets per day MS Contin (30mg Tablet Extended-Release, Maximum of 4 tablets per day 60mg Tablet Extended-Release) Mydayis (12.5mg Capsule Extended-Release 24 Hour, 25mg Capsule Extended-Release 24 Maximum of 2 capsules per day Hour) Mydayis (12.5mg-12.5mg-12.5mg-12.5mg Capsule Extended-Release 24 Hour, Maximum of 1 capsule per day 9.375mg-9.375mg-9.375mg-9.375mg Capsule Extended-Release 24 Hour) Namenda (10mg Tablet Immediate-Release) Maximum of 2 tablets per day Namenda (5mg Tablet Immediate-Release) Maximum of 3 tablets per day

Bold type = Brand name drug Plain type = Generic drug 152152 21 21 Last updated October 1, 2018 Drug Name Quantity Limit Namenda XR (Capsule Extended-Release 24 Maximum of 1 capsule per day Hour) Namenda XR Titration Pack (Capsule Maximum of 1 capsule per day Extended-Release 24 Hour) Namzaric (Capsule Extended-Release 24 Maximum of 1 capsule per day Hour) Namzaric (Therapy Pack, Capsule Extended- Maximum of 1 capsule per day Release 24 Hour) Naratriptan HCl (Tablet) Maximum of 12 tablets per 30 days Nateglinide (120mg Tablet) Maximum of 3 tablets per day Nateglinide (60mg Tablet) Maximum of 6 tablets per day Nebupent (Inhalation Solution) Maximum of 300 mg (1 vial) in 28 days Nerlynx (Tablet) Maximum of 6 tablets per day Nesina (Tablet) Maximum of 1 tablet per day Nevirapine (200mg Tablet Immediate-Release) Maximum of 3 tablets per day Nevirapine ER (100mg Tablet Extended-Release Maximum of 3 tablets per day 24 Hour) Nevirapine ER (400mg Tablet Extended-Release Maximum of 2 tablets per day 24 Hour) Nexium (20mg Capsule Delayed-Release) Maximum of 3 capsules per day Nexium (40mg Capsule Delayed-Release) Maximum of 2 capsules per day Ninlaro (Capsule) Maximum of 3 capsules per 28 days Norco (Tablet) Maximum of 12 tablets per day Northera (100mg Capsule) Maximum of 3 capsules per day Northera (200mg Capsule, 300mg Capsule) Maximum of 6 capsules per day Norvir (100mg Capsule) Maximum of 18 capsules per day Norvir (100mg Packet) Maximum of 18 packets per day Norvir (100mg Tablet) Maximum of 18 tablets per day Norvir (80mg/ml Oral Solution) Maximum of 24 ml per day Noxafil (100mg Tablet Delayed-Release) Maximum of 8 tablets per day Noxafil (40mg/ml Suspension) Maximum of 20 ml per day Nucala (Injection) Maximum of 3 vials per 28 days Nucynta (100mg Tablet, 50mg Tablet, 75mg Maximum of 6 tablets per day Tablet) Nucynta ER (Tablet Extended-Release 12 Maximum of 2 tablets per day Hour) Nuvigil (150mg Tablet, 200mg Tablet, 250mg Maximum of 1 tablet per day Tablet)

Bold type = Brand name drug Plain type = Generic drug Last153 updated October 1, 2018 22 22 153 Drug Name Quantity Limit Nuvigil (50mg Tablet) Maximum of 2 tablets per day Ocaliva (Tablet) Maximum of 1 tablet per day Odefsey (Tablet) Maximum of 2 tablets per day Odomzo (Capsule) Maximum of 1 capsule per day Ofev (Capsule) Maximum of 2 capsules per day Olanzapine (10mg Tablet Immediate-Release, 15mg Tablet Immediate-Release, 2.5mg Tablet Immediate-Release, 20mg Tablet Immediate- Maximum of 1 tablet per day Release, 5mg Tablet Immediate-Release, 7.5mg Tablet Immediate-Release) Olanzapine ODT (Tablet Dispersible) Maximum of 1 tablet per day Olmesartan Medoxomil (20mg Tablet, 40mg Maximum of 1 tablet per day Tablet) Olmesartan Medoxomil (5mg Tablet) Maximum of 2 tablets per day Olmesartan Medoxomil/Amlodipine/ Maximum of 1 tablet per day Hydrochlorothiazide (Tablet) Olmesartan Medoxomil/Hydrochlorothiazide Maximum of 1 tablet per day (Tablet) Olumiant (Tablet) Maximum of 1 tablet per day Omeprazole (10mg Capsule Delayed-Release) Maximum of 3 capsules per day Omeprazole (40mg Capsule Delayed-Release) Maximum of 2 capsules per day Onglyza (Tablet) Maximum of 1 tablet per day Onzetra Xsail (Exhaler Powder) Maximum of 1 kit (16 exhalers) per 30 days Opana (10mg Tablet Immediate-Release, Maximum of 6 tablets per day 5mg Tablet Immediate-Release) Orkambi (Tablet) Maximum of 112 tablets per 28 days Oseltamivir Phosphate (Capsule) Maximum of 2 capsules per day Oseltamivir Phosphate (6mg/ml Suspension) Maximum of 26 ml per day Oseni (Tablet) Maximum of 1 tablet per day Osphena (Tablet) Maximum of 1 tablet per day Oxybutynin Chloride ER (10mg Tablet Maximum of 3 tablets per day Extended-Release 24 Hour) Oxybutynin Chloride ER (15mg Tablet Maximum of 2 tablets per day Extended-Release 24 Hour) Oxybutynin Chloride ER (5mg Tablet Extended- Maximum of 1 tablet per day Release 24 Hour) Oxycodone HCl (100mg/5ml Concentrate) Maximum of 6 ml per day

Bold type = Brand name drug Plain type = Generic drug 154154 23 23 Last updated October 1, 2018 Drug Name Quantity Limit Oxycodone HCl (10mg Tablet Immediate- Release, 5mg Tablet Immediate-Release, 5mg Maximum of 12 tablets per day capsule Immediate-Release) Oxycodone HCl (15mg Tablet Immediate- Maximum of 8 tablets per day Release) Oxycodone HCl (20mg Tablet Immediate- Maximum of 6 tablets per day Release, 30mg Tablet Immediate-Release) Oxycodone HCl (5mg/5ml Oral Solution) Maximum of 130 ml per day Oxycodone HCl ER (Tablet Extended-Release Maximum of 3 tablets per day 12 Hour Abuse-Deterrent) Oxycodone/Acetaminophen (10mg-325mg Tablet, 2.5mg-325mg Tablet, 5mg-325mg Maximum of 12 tablets per day Tablet, 7.5mg-325mg Tablet) Oxycodone/Aspirin (Tablet) Maximum of 12 tablets per day Oxycodone/Ibuprofen (Tablet) Maximum of 4 tablets per day OxyContin (Tablet Extended-Release 12 Hour Maximum of 3 tablets per day Abuse-Deterrent) Oxymorphone HCl (Tablet Immediate-Release) Maximum of 6 tablets per day Oxymorphone HCl ER (10mg Tablet Extended- Release 12 Hour, 15mg Tablet Extended- Release 12 Hour, 20mg Tablet Extended- Maximum of 2 tablets per day Release 12 Hour, 5mg Tablet Extended-Release 12 Hour, 7.5mg Tablet Extended-Release 12 Hour) Oxymorphone HCl ER (30mg Tablet Extended- Maximum of 4 tablets per day Release 12 Hour) Oxymorphone HCl ER (40mg Tablet Extended- Maximum of 3 tablets per day Release 12 Hour) Ozempic (2mg/1.5ml Solution Pen injector) Maximum of 1 pen (1.5 ml) per 28 days Ozempic (2mg/1.5ml Solution Pen injector) Maximum of 2 pens (3 ml) per 28 days Paliperidone ER (1.5mg Tablet Extended- Release 24 Hour, 3mg Tablet Extended-Release Maximum of 1 tablet per day 24 Hour, 9mg Tablet Extended-Release 24 Hour) Paliperidone ER (6mg Tablet Extended-Release Maximum of 2 tablets per day 24 Hour) Palynziq (2.5mg/0.5ml Injection) Maximum 8 syringes per 28 days Palynziq (10mg/0.5ml Injection) Maximum 28 syringes per 28 days Palynziq (20mg/ml Injection) Maximum 56 syringes per 28 days Panlor (Tablet) Maximum of 10 tablets per day

Bold type = Brand name drug Plain type = Generic drug Last155 updated October 1, 2018 24 24 155 Drug Name Quantity Limit Pantoprazole Sodium (20mg Tablet Delayed- Maximum of 3 tablets per day Release) Pantoprazole Sodium (40mg Tablet Delayed- Maximum of 2 tablets per day Release) Pentasa (250mg Capsule Extended-Release) Maximum of 12 capsules per day Pentasa (500mg Capsule Extended-Release) Maximum of 8 capsules per day Percocet (10mg-325mg Tablet, 2.5mg-325mg Tablet, 5mg-325mg Tablet, 7.5mg-325mg Maximum of 12 tablets per day Tablet) Perforomist (Nebulized Solution) Maximum of 2 vials (4 ml) per day Perindopril Erbumine (Tablet) Maximum of 2 tablets per day Pioglitazone HCl (15mg Tablet) Maximum of 3 tablets per day Pioglitazone HCl (30mg Tablet, 45mg Tablet) Maximum of 1 tablet per day Pioglitazone HCl/Glimepiride (Tablet) Maximum of 1 tablet per day Pioglitazone HCl/Metformin HCl (Tablet) Maximum of 3 tablets per day Plavix (75mg Tablet) Maximum of 4 tablets per day Pomalyst (Capsule) Maximum of 1 capsule per day Pradaxa (Capsule) Maximum of 2 capsules per day Praluent (150mg/ml Solution Pen injector, Maximum of 2 pens (2 ml) per 28 days 75mg/ml Solution Pen injector) Prandin (1mg Tablet) Maximum of 16 tablets per day Prandin (2mg Tablet) Maximum of 8 tablets per day Prasugrel (Tablet) Maximum of 1 tablet per day Pravachol (Tablet) Maximum of 1 tablet per day Pravastatin Sodium (Tablet) Maximum of 1 tablet per day Prevacid (Capsule Delayed-Release) Maximum of 2 capsules per day Prevymis (Tablet) Maximum of 1 tablet per day Prezcobix (Tablet) Maximum of 2 tablets per day Prezista (100mg/ml Suspension) Maximum of 60 ml per day Prezista (150mg Tablet) Maximum of 6 tablets per day Prezista (600mg Tablet, 800mg Tablet) Maximum of 3 tablets per day Prezista (75mg Tablet) Maximum of 7 tablets per day Primlev (10mg-300mg Tablet, 5mg-300mg Maximum of 13 tablets per day Tablet, 7.5mg-300mg Tablet) Prinivil (Tablet) Maximum of 2 tablets per day Pristiq (100mg Tablet Extended-Release 24 Maximum of 4 tablets per day Hour)

Bold type = Brand name drug Plain type = Generic drug 156156 25 25 Last updated October 1, 2018 Drug Name Quantity Limit Pristiq (25mg Tablet Extended-Release 24 Hour, 50mg Tablet Extended-Release 24 Maximum of 1 tablet per day Hour) Prolia (Injection) Maximum of 1 syringe every 180 days Promacta (12.5mg Tablet, 25mg Tablet) Maximum of 1 tablet per day Promacta (50mg Tablet, 75mg Tablet) Maximum of 2 tablets per day Protonix (20mg Tablet Delayed-Release) Maximum of 3 tablets per day Protonix (40mg Tablet Delayed-Release) Maximum of 2 tablets per day Provigil (100mg Tablet) Maximum of 1 tablet per day Provigil (200mg Tablet) Maximum of 2 tablets per day PRUDOXIN (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 (Tablet) Maximum of 1 tablet per day Quetiapine Fumarate (100mg Tablet Immediate- Release, 200mg Tablet Immediate-Release, Maximum of 3 tablets per day 50mg Tablet Immediate-Release) Quetiapine Fumarate (25mg Tablet Immediate- Maximum of 4 tablets per day Release) Quetiapine Fumarate (300mg Tablet Immediate- Maximum of 2 tablets per day Release, 400mg Tablet Immediate-Release) Quetiapine Fumarate ER (150mg Tablet Extended-Release 24 Hour, 200mg Tablet Maximum of 1 tablet per day Extended-Release 24 Hour) Quetiapine Fumarate ER (300mg Tablet Extended-Release 24 Hour, 400mg Tablet Maximum of 2 tablets per day Extended-Release 24 Hour, 50mg Tablet Extended-Release 24 Hour) QuilliChew ER (20mg Tablet Chewable Extended-Release, 40mg Tablet Chewable Maximum of 1 tablet per day Extended-Release) QuilliChew ER (30mg Tablet Chewable Maximum of 2 tablets per day Extended-Release) Quinapril HCl (Tablet) Maximum of 2 tablets per day Quinapril/Hydrochlorothiazide (10mg-12.5mg Maximum of 1 tablet per day Tablet) Quinapril/Hydrochlorothiazide (20mg-12.5mg Maximum of 2 tablets per day Tablet, 20mg-25mg Tablet) Maximum of 2 inhalers (21.2 grams) per 30 Qvar Redihaler (Aerosol Powder) days

Bold type = Brand name drug Plain type = Generic drug Last157 updated October 1, 2018 26 26 157 Drug Name Quantity Limit Ramipril (Capsule) Maximum of 2 capsules per day Rapaflo (Capsule) Maximum of 1 capsule per day Rayaldee (Capsule Extended-Release) Maximum of 2 capsules per day Razadyne (Tablet) Maximum of 2 tablets per day Razadyne ER (Capsule Extended-Release 24 Maximum of 1 capsule per day Hour) Relpax (Tablet) Maximum of 12 tablets per 30 days Repaglinide (0.5mg Tablet) Maximum of 32 tablets per day Repaglinide (1mg Tablet) Maximum of 16 tablets per day Repaglinide (2mg Tablet) Maximum of 8 tablets per day Repaglinide/Metformin HCl (Tablet) Maximum of 5 tablets per day Repatha (Injection) Maximum of 3 syringes (3 ml) per 28 days Repatha Pushtronex System (Injection) Maximum of 1 cartridge (3.5 ml) per 28 days Repatha SureClick (Injection) Maximum of 3 pens (3 ml) per 28 days Rescriptor (Tablet) Maximum of 9 tablets per day Restasis (Emulsion) Maximum of 2 vials per day Restoril (22.5mg Capsule) Maximum of 1 capsule per day Retrovir (100mg Capsule) Maximum of 8 capsules per day Retrovir (50mg/5ml Syrup) Maximum of 96 ml per day Revlimid (Capsule) Maximum of 1 capsule per day Rexulti (Tablet) Maximum of 1 tablet per day Reyataz (150mg Capsule, 300mg Capsule) Maximum of 2 capsules per day Reyataz (200mg Capsule) Maximum of 3 capsules per day Reyataz (50mg Packet) Maximum of 8 packets per day Riomet (Oral Solution) Maximum of 25.5 ml per day Ritalin (Tablet) Maximum of 3 tablets per day Ritonavir (Tablet) Maximum of 18 tablets per day Rivastigmine Tartrate (Capsule Immediate- Maximum of 2 capsules per day Release) Rivastigmine Transdermal System (Patch 24 Maximum of 1 patch per day Hour) Rizatriptan Benzoate (Tablet Immediate- Maximum of 12 tablets per 30 days Release) Rizatriptan Benzoate ODT (Tablet Dispersible) Maximum of 12 tablets per 30 days Rosuvastatin Calcium (Tablet) Maximum of 1 tablet per day Roxicodone (15mg Tablet) Maximum of 8 tablets per day Roxicodone (30mg Tablet) Maximum of 6 tablets per day

Bold type = Brand name drug Plain type = Generic drug 158158 27 27 Last updated October 1, 2018 Drug Name Quantity Limit Roxicodone (5mg Tablet) Maximum of 12 tablets per day Rubraca (Tablet) Maximum of 4 tablets per day Rydapt (Capsule) Maximum of 8 capsules per day Sabril (500mg Packet) Maximum of 6 packets per day Sabril (500mg Tablet) Maximum of 6 tablets per day Saphris (Tablet Sublingual) Maximum of 2 tablets per day Savaysa (Tablet) Maximum of 1 tablet per day Segluromet (2.5mg-1000mg Tablet, Maximum of 2 tablets per day 7.5mg-1000mg Tablet, 7.5mg-500mg Tablet) Segluromet (2.5mg-500mg Tablet) Maximum of 4 tablets per day Selzentry (150mg Tablet, 75mg Tablet) Maximum of 3 tablets per day Selzentry (20mg/ml Oral Solution) Maximum of 92 ml per day Selzentry (25mg Tablet, 300mg Tablet) Maximum of 6 tablets per day Sensipar (30mg Tablet, 60mg Tablet) Maximum of 2 tablets per day Sensipar (90mg Tablet) Maximum of 4 tablets per day Maximum of 1 inhaler (60 inhalations) per 30 Serevent Diskus (Aerosol Powder) days Seroquel (100mg Tablet, 200mg Tablet, Maximum of 3 tablets per day 50mg Tablet) Seroquel (25mg Tablet) Maximum of 4 tablets per day Seroquel (300mg Tablet, 400mg Tablet) Maximum of 2 tablets per day Seroquel XR (150mg Tablet Extended- Release 24 Hour, 200mg Tablet Extended- Maximum of 1 tablet per day Release 24 Hour) Seroquel XR (300mg Tablet Extended- Release 24 Hour, 400mg Tablet Extended- Maximum of 2 tablets per day Release 24 Hour, 50mg Tablet Extended- Release 24 Hour) Simvastatin (Tablet) Maximum of 1 tablet per day Singulair (10mg Tablet) Maximum of 1 tablet per day Singulair (4mg Packet) Maximum of 1 packet per day Singulair (4mg Tablet Chewable, 5mg Tablet Maximum of 1 tablet per day Chewable) Soliqua 100/33 (Injection) Maximum of 18 ml (6 pens) per 30 days Solodyn (Tablet Extended-Release 24 Hour) Maximum of 1 tablet per day Somavert (Injection) Maximum of 1 vial per day Sonata (Capsule) Maximum of 90 days of use per year Sovaldi (Tablet) Maximum of 1 tablet per day

Bold type = Brand name drug Plain type = Generic drug Last159 updated October 1, 2018 28 28 159 Drug Name Quantity Limit Spiriva HandiHaler (Capsule) Maximum of 1 capsule per day Spiriva Respimat (Aerosol Solution) Maximum of 1 inhaler (4 grams) per 30 days Starlix (120mg Tablet) Maximum of 3 tablets per day Starlix (60mg Tablet) Maximum of 6 tablets per day Stavudine (15mg Capsule, 30mg Capsule, Maximum of 3 capsules per day 40mg Capsule) Stavudine (20mg Capsule) Maximum of 2 capsules per day Steglatro (15mg Tablet) Maximum of 1 tablet per day Steglatro (5mg Tablet) Maximum of 2 tablets per day Steglujan (Tablet) Maximum of 1 tablet per day Stivarga (Tablet) Maximum of 4 tablets per day Stribild (Tablet) Maximum of 2 tablets per day Suboxone (12mg-3mg Film, 4mg-1mg Film) Maximum of 2 films per day Suboxone (2mg-0.5mg Film, 8mg-2mg Film) Maximum of 3 films per day Subsys (Liquid) Maximum of 4 sprays per day Sumatriptan (Nasal Solution) Maximum of 12 devices per 30 days Sumatriptan Succinate (100mg Tablet, 25mg Maximum of 12 tablets per 30 days Tablet, 50mg Tablet) Sumatriptan Succinate (4mg/0.5ml Solution Maximum of 12 injections (6 ml) per 30 days Auto injector, 6mg/0.5ml Solution Auto injector) Sumatriptan Succinate (6mg/0.5ml Maximum of 12 injections (6 ml) per 30 days Subcutaneous Solution) Sumatriptan Succinate Refill (Injection) Maximum of 12 injections (6 ml) per 30 days Sumatriptan/Naproxen Sodium (Tablet) Maximum of 9 tablets per 30 days Sustiva (200mg Capsule) Maximum of 3 capsules per day Sustiva (50mg Capsule) Maximum of 9 capsules per day Sustiva (600mg Tablet) Maximum of 2 tablets per day Symbicort (Aerosol) Maximum of 1 inhaler (10.2 grams) per 30 days Symdeko (Tablet Therapy Pack) Maximum of 1 pack (56 tablets) per 28 days Symfi (Tablet) Maximum of 2 tablets per day Symfi Lo (Tablet) Maximum of 2 tablets per day Symproic (Tablet) Maximum of 1 tablet per day Synjardy (Tablet) Maximum of 2 tablets per day Synjardy XR (10mg-1000mg Tablet Extended- Release 24 Hour, 25mg-1000mg Tablet Maximum of 1 tablet per day Extended-Release 24 Hour)

Bold type = Brand name drug Plain type = Generic drug 160160 29 29 Last updated October 1, 2018 Drug Name Quantity Limit Synjardy XR (12.5mg-1000mg Tablet Extended-Release 24 Hour, 5mg-1000mg Maximum of 2 tablets per day Tablet Extended-Release 24 Hour) Syprine (Capsule) Maximum of 8 capsules per day Tagrisso (Tablet) Maximum of 1 tablet per day Tamiflu (30mg Capsule, 45mg Capsule, Maximum of 2 capsules per day 75mg Capsule) Tamiflu (6mg/ml Suspension) Maximum of 26 ml per day Tanzeum (Injection) Maximum of 4 pens per 28 days Tarceva (100mg Tablet, 150mg Tablet) Maximum of 1 tablet per day Tarceva (25mg Tablet) Maximum of 3 tablets per day Tarka (Tablet Extended-Release) Maximum of 1 tablet per day Tasigna (150mg Capsule) Maximum of 5 capsules per day Tasigna (200mg Capsule) Maximum of 4 capsules per day Tasigna (50mg Capsule) Maximum of 14 capsules per day Tasmar (Tablet) Maximum of 6 tablets per day Tavalisse (Tablet) Maximum of 2 tablets per day Tecfidera (Capsule Delayed-Release) Maximum of 2 capsules per day Technivie (Tablet) Maximum of 2 tablets per day Tekturna (Tablet) Maximum of 1 tablet per day Tekturna HCT (Tablet) Maximum of 1 tablet per day Telmisartan (Tablet) Maximum of 1 tablet per day Telmisartan/Amlodipine (Tablet) Maximum of 1 tablet per day Telmisartan/Hydrochlorothiazide (40mg-12.5mg Maximum of 1 tablet per day Tablet, 80mg-25mg Tablet) Telmisartan/Hydrochlorothiazide (80mg-12.5mg Maximum of 2 tablets per day Tablet) Temazepam (22.5mg Capsule) Maximum of 1 capsule per day Tenofovir Disoproxil Fumarate (Tablet) Maximum of 2 tablets per day Thalomid (100mg Capsule, 50mg Capsule) Maximum of 1 capsule per day Thalomid (150mg Capsule, 200mg Capsule) Maximum of 2 capsules per day Tivicay (10mg Tablet, 25mg Tablet) Maximum of 2 tablets per day Tivicay (50mg Tablet) Maximum of 3 tablets per day TOBI (Nebulized Solution) Maximum of 10 ml (2 ampules) per day TOBI Podhaler (Capsule) Maximum of 8 capsules per day Tobramycin (Nebulized Solution) Maximum of 10 ml (2 ampules) per day Tolazamide (250mg Tablet) Maximum of 4 tablets per day Tolazamide (500mg Tablet) Maximum of 2 tablets per day

Bold type = Brand name drug Plain type = Generic drug Last161 updated October 1, 2018 30 30 161 Drug Name Quantity Limit Tolbutamide (Tablet) Maximum of 6 tablets per day Tolcapone (Tablet) Maximum of 6 tablets per day Toviaz (Tablet Extended-Release 24 Hour) Maximum of 1 tablet per day Tracleer (125mg Tablet, 62.5mg Tablet) Maximum of 2 tablets per day Tracleer (32mg Tablet Soluble) Maximum of 4 tablets per day Tradjenta (Tablet) Maximum of 1 tablet per day Tramadol HCl (Tablet Immediate-Release) Maximum of 8 tablets per day Tramadol HCl ER (100mg Capsule Extended- Release 24 Hour, 200mg Capsule Extended- Maximum of 1 capsule per day Release 24 Hour, 300mg Capsule Extended- Release 24 Hour) Tramadol HCl ER (100mg Tablet Extended- Release 24 Hour, 200mg Tablet Extended- Maximum of 1 tablet per day Release 24 Hour, 300mg Tablet Extended- Release 24 Hour) Tramadol HCl/Acetaminophen (Tablet) Maximum of 12 tablets per day Trandolapril (1mg Tablet, 2mg Tablet) Maximum of 1 tablet per day Trandolapril (4mg Tablet) Maximum of 2 tablets per day Trandolapril/Verapamil HCl (Tablet Extended- Maximum of 1 tablet per day Release) Tranxene T (7.5mg Tablet) Maximum of 12 tablets per day Trelegy Ellipta (Aerosol Powder) Maximum of 1 inhaler (60 blisters) per 30 days Treximet (Tablet) Maximum of 9 tablets per 30 days Trezix (Capsule) Maximum of 10 capsules per day Tribenzor (Tablet) Maximum of 1 tablet per day Trientine HCl (Capsule) Maximum of 8 capsules per day Trintellix (Tablet) Maximum of 1 tablet per day Triumeq (Tablet) Maximum of 2 tablets per day Trizivir (Tablet) Maximum of 3 tablets per day Trulicity (Injection) Maximum of 4 pens (2 ml) per 28 days Truvada (Tablet) Maximum of 2 tablets per day Twynsta (Tablet) Maximum of 1 tablet per day Tybost (Tablet) Maximum of 2 tablets per day Tylenol/Codeine #3 (Tablet) Maximum of 13 tablets per day Tylenol/Codeine #4 (Tablet) Maximum of 13 tablets per day Tymlos (Injection) Maximum of 1.56 ml per 30 days Ultracet (Tablet) Maximum of 12 tablets per day Ultram (Tablet) Maximum of 8 tablets per day

Bold type = Brand name drug Plain type = Generic drug 162162 31 31 Last updated October 1, 2018 Drug Name Quantity Limit Uptravi (1000mcg Tablet, 1200mcg Tablet, 1400mcg Tablet, 1600mcg Tablet, 400mcg Maximum of 2 tablets per day Tablet, 600mcg Tablet, 800mcg Tablet) Uptravi (200mcg Tablet) Maximum of 5 tablets per day Valacyclovir HCl (1000mg Tablet) Maximum of 4 tablets per day Valacyclovir HCl (500mg Tablet) Maximum of 2 tablets per day Valcyte (450mg Tablet) Maximum of 4 tablets per day Valcyte (50mg/ml Oral Solution) Maximum of 36 ml per day Valganciclovir (Tablet) Maximum of 4 tablets per day Valganciclovir Hydrochlorde (Oral Solution) Maximum of 36 ml per day Valium (Tablet) Maximum of 4 tablets per day Valsartan (160mg Tablet, 40mg Tablet, 80mg Maximum of 2 tablets per day Tablet) Valsartan (320mg Tablet) Maximum of 1 tablet per day Valsartan/Hydrochlorothiazide (Tablet) Maximum of 1 tablet per day Valtrex (1gm Tablet) Maximum of 4 tablets per day Valtrex (500mg Tablet) Maximum of 2 tablets per day Vaseretic (Tablet) Maximum of 2 tablets per day Vasotec (10mg Tablet, 2.5mg Tablet, 20mg Maximum of 2 tablets per day Tablet, 5mg Tablet) Veltassa (Packet) Maximum of 1 packet per day Vemlidy (Tablet) Maximum of 1 tablet per day Venclexta (100mg Tablet) Maximum of 4 tablets per day Venclexta (10mg Tablet) Maximum of 2 tablets per day Venclexta (50mg Tablet) Maximum of 1 tablet per day Verzenio (Tablet) Maximum of 2 tablets per day Vesicare (Tablet) Maximum of 1 tablet per day Viberzi (Tablet) Maximum of 2 tablets per day Vicodin (Tablet) Maximum of 13 tablets per day Vicodin ES (Tablet) Maximum of 13 tablets per day Vicodin HP (Tablet) Maximum of 13 tablets per day Victoza (Injection) Maximum of 3 pens (9 ml) per 30 days Videx EC (Capsule Delayed-Release) Maximum of 2 capsules per day Videx Pediatric (Oral Solution) Maximum of 30 ml per day Viekira Pak (Tablet Therapy Pack) Maximum of 1 pack (112 tablets) per 28 days Viekira XR (Tablet Extended-Release 24 Maximum of 1 pack (84 tablets) per 28 days Hour) Vigabatrin (Packet) Maximum of 6 packets per day

Bold type = Brand name drug Plain type = Generic drug Last163 updated October 1, 2018 32 32 163 Drug Name Quantity Limit Viibryd (Tablet) Maximum of 1 tablet per day Viibryd Starter Pack (Kit) Maximum of 1 pack (30 tablets) per 30 days Vimpat (100mg Tablet, 150mg Tablet, 200mg Maximum of 2 tablets per day Tablet, 50mg Tablet) Vimpat (10mg/ml Oral Solution) Maximum of 40 ml per day Viracept (250mg Tablet) Maximum of 15 tablets per day Viracept (625mg Tablet) Maximum of 6 tablets per day Viramune (200mg Tablet) Maximum of 3 tablets per day Viramune (50mg/5ml Suspension) Maximum of 60 ml per day Viramune XR (100mg Tablet Extended- Maximum of 3 tablets per day Release 24 Hour) Viramune XR (400mg Tablet Extended- Maximum of 2 tablets per day Release 24 Hour) Viread (150mg Tablet) Maximum of 1 tablet per day Viread (200mg Tablet, 250mg Tablet, 300mg Maximum of 2 tablets per day Tablet) Viread (40mg/gm Powder) Maximum of 6 bottles (360 grams) per 30 days Vivelle-Dot (Patch Twice Weekly) Maximum of 8 patches per 28 days Vivlodex (Capsule) Maximum of 1 capsule per day Vosevi (Tablet) Maximum of 1 tablet per day Votrient (Tablet) Maximum of 4 tablets per day Vraylar (1.5mg Capsule, 3mg Capsule, 4.5mg Maximum of 1 capsule per day Capsule, 6mg Capsule) Vytorin (Tablet) Maximum of 1 tablet per day Xanax (0.25mg Tablet, 0.5mg Tablet, 1mg Maximum of 4 tablets per day Tablet) Xanax (2mg Tablet) Maximum of 5 tablets per day Xanax XR (0.5mg Tablet Extended-Release 24 Hour, 1mg Tablet Extended-Release 24 Maximum of 1 tablet per day Hour) Xanax XR (2mg Tablet Extended-Release 24 Maximum of 5 tablets per day Hour) Xanax XR (3mg Tablet Extended-Release 24 Maximum of 3 tablets per day Hour) Xarelto (10mg Tablet, 20mg Tablet) Maximum of 1 tablet per day Xarelto (15mg Tablet) Maximum of 2 tablets per day Xarelto Starter Pack (Tablet Therapy Pack) Maximum of 1 pack (51 tablets) per 30 days Xeljanz (Tablet) Maximum of 2 tablets per day

Bold type = Brand name drug Plain type = Generic drug 164164 33 33 Last updated October 1, 2018 Drug Name Quantity Limit Xeljanz XR (Tablet Extended-Release 24 Maximum of 1 tablet per day Hour) Xermelo (Tablet) Maximum of 3 tablets per day Xigduo XR (10mg-1000mg Tablet Extended- Release 24 Hour, 10mg-500mg Tablet Maximum of 1 tablet per day Extended-Release 24 Hour, 5mg-500mg Tablet Extended-Release 24 Hour) Xigduo XR (2.5mg-1000mg Tablet Extended- Release 24 Hour, 5mg-1000mg Tablet Maximum of 2 tablets per day Extended-Release 24 Hour) Xiidra (Ophthalmic Solution) Maximum of 2 vials per day Ximino (Capsule Extended-Release 24 Hour) Maximum of 1 capsule per day Xtampza ER (13.5mg Capsule Extended- Release 12 Hour Abuse-Deterrent, 18mg Capsule Extended-Release 12 Hour Abuse- Maximum of 3 capsules per day Deterrent, 9mg Capsule Extended-Release 12 Hour Abuse-Deterrent) Xtampza ER (27mg Capsule Extended- Release 12 Hour Abuse-Deterrent, 36mg Maximum of 6 capsules per day Capsule Extended-Release 12 Hour Abuse- Deterrent) Xultophy 100/3.6 (Injection) Maximum of 5 pens (15 ml) per 30 days Xyrem (Oral Solution) Maximum of 18 ml per day Zaleplon (Capsule) Maximum of 90 days of use per year Zejula (Capsule) Maximum of 3 capsules per day Zelboraf (Tablet) Maximum of 8 tablets per day Zembrace Symtouch (Injection) Maximum of 8 ml (16 syringes) per 30 days Zenzedi (10mg Tablet, 2.5mg Tablet, 5mg Maximum of 6 tablets per day Tablet, 7.5mg Tablet) Zenzedi (15mg Tablet) Maximum of 4 tablets per day Zenzedi (20mg Tablet) Maximum of 3 tablets per day Zenzedi (30mg Tablet) Maximum of 2 tablets per day Zepatier (Tablet) Maximum of 1 tablet per day Zerit (15mg Capsule, 30mg Capsule, 40mg Maximum of 3 capsules per day Capsule) Zerit (1mg/ml Oral Solution) Maximum of 120 ml per day Zerit (20mg Capsule) Maximum of 2 capsules per day Zestoretic (10mg-12.5mg Tablet) Maximum of 1 tablet per day Zestoretic (20mg-12.5mg Tablet) Maximum of 4 tablets per day

Bold type = Brand name drug Plain type = Generic drug Last165 updated October 1, 2018 34 34 165 Drug Name Quantity Limit Zestoretic (20mg-25mg Tablet) Maximum of 2 tablets per day Zestril (Tablet) Maximum of 2 tablets per day Ziac (Tablet) Maximum of 2 tablets per day Ziagen (20mg/ml Oral Solution) Maximum of 48 ml per day Ziagen (300mg Tablet) Maximum of 3 tablets per day Zidovudine (100mg Capsule) Maximum of 8 capsules per day Zidovudine (300mg Tablet) Maximum of 3 tablets per day Zidovudine (50mg/5ml Syrup) Maximum of 96 ml per day Ziprasidone HCl (Capsule) Maximum of 2 capsules per day Zocor (Tablet) Maximum of 1 tablet per day Zohydro ER (Capsule Extended-Release 12 Maximum of 2 capsules per day Hour Abuse-Deterrent) Zolmitriptan (Tablet) Maximum of 12 tablets per 30 days Zolmitriptan ODT (Tablet Dispersible) Maximum of 12 tablets per 30 days Zolpidem Tartrate (10mg Tablet Immediate- Maximum of 90 days of use per year Release, 5mg Tablet Immediate-Release) Zomig Nasal Spray (2.5mg Solution) Maximum of 18 devices per 30 days Zomig (2.5mg Tablet, 5mg Tablet) Maximum of 12 tablets per 30 days Zomig Nasal Spray (5mg Solution) Maximum of 12 devices per 30 days Zomig ZMT (Tablet Dispersible) Maximum of 12 tablets per 30 days Zonalon (Cream) Maximum of 90 grams per 30 days Zubsolv (1.4mg-0.36mg Tablet Sublingual, Maximum of 3 tablets per day 5.7mg-1.4mg Tablet Sublingual) Zubsolv (11.4mg-2.9mg Tablet Sublingual) Maximum of 1 tablet per day Zubsolv (2.9mg-0.71mg Tablet Sublingual) Maximum of 5 tablets per day Zubsolv (8.6mg-2.1mg Tablet Sublingual) Maximum of 2 tablets per day Zydelig (Tablet) Maximum of 2 tablets per day Zypitamag (Tablet) Maximum of 1 tablet per day Zyprexa (10mg Tablet, 15mg Tablet, 2.5mg Tablet, 20mg Tablet, 5mg Tablet, 7.5mg Maximum of 1 tablet per day Tablet) Zyprexa Zydis (10mg Tablet Dispersible, 15mg Tablet Dispersible, 20mg Tablet Maximum of 1 tablet per day Dispersible, 5mg Tablet Dispersible) track

Bold type = Brand name drug Plain type = Generic drug 166166 0 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 1-800-457-8506, TTY 711 8 a.m. - 8 p.m. local time, Monday - Friday

www.UHCRetiree.com

UHEX19PP4282860_003 Last updated October 1, 2018