20191 COMPLETE DRUG LIST (FORMULARY)

Prescription drug list information

AARP® MedicareRx Saver Plus (PDP)

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

Toll-free 1-866-460-8854, TTY 711 8 a.m. - 8 p.m. local time, 7 days a week

www.myAARPMedicare.com

If you are a member of a group sponsored plan (your coverage is provided through a former employer, union group or trust), please call the Customer Service number on the back of your UnitedHealthcare member ID card.

Formulary ID Number 00019082, Version 9 Y0066_180629_123918_v96.03_C 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 What is a compounded drug?...... 4 Drug payment stage and drug tiers...... 5 Getting Extra Help...... 5 Are there any rules or limits on my drug coverage?...... 6 What if my drug is not on this list?...... 8 How can I get an exception?...... 8 Can I get my drug while I wait for an exception?...... 9 Can the drug list change?...... 10 Drugs with dosages other than a 1-month supply...... 11 Covered drugs by name (Drug index)...... 12 Covered drugs by medical condition...... 27 Covered drugs with a quantity limit (QL)...... 80

Questions?

If you have questions, we’re here to help. Call UnitedHealthcare Customer Service at: Toll-free 1-866-460-8854, TTY 711 8 a.m. - 8 p.m. local time, 7 days a week 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 UnitedHealthcare Customer Service. Our contact information is on the cover. This drug list has changed since last year. Please review this document to make sure your prescription drugs are still covered. In most cases, you must use network pharmacies to have your prescriptions covered by the plan. When this drug list refers to “we,” “us,” or “our,” it means UnitedHealthcare. When it refers to “plan,” “our plan,” or “your plan,” it means AARP MedicareRx Saver Plus (PDP) Plans. 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 12–26 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 ...... 27–79 to look for drugs based on your medical conditions. For example, if you have a heart ...... condition, you should look in the category Cardiovascular Agents. This is where you will find ...... drugs that treat heart conditions.

Can’t find your drug? Check the complete drug list by visiting our plan website at www.myAARPMedicare.com. You can use online tools to look up your drugs. This information is updated on a regular basis.

What are generic drugs? Generic drugs have the same active ingredients as brand name drugs. They usually cost less than brand name drugs and are approved by the Food and Drug Administration (FDA). Our plan covers both brand name and generic drugs. Talk with your doctor to see if any of the brand name drugs you take have generic versions. Then review the drug list to make sure you are getting the drug you need for the least amount of money. The drug list shows brand name drugs in bold type (for example, Humalog) and generic drugs in plain type (for example, Simvastatin).

What is a compounded drug? A compounded drug is created by a pharmacist by combining or mixing ingredients to create a prescription customized to the needs of an individual patient. Generally compounded drugs are non-formulary drugs (not covered) by your plan. You may need to ask for and receive an approved coverage determination from us to have your compounded drug covered. Compounded drugs may be Part D eligible. For more information about compounded drugs, please review your Evidence of Coverage. 4 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 5 drug tiers. Each tier has a copay or coinsurance amount. The chart below shows the differences between the tiers. If you need help or have any questions about your drug costs, please review your Evidence of Coverage or call UnitedHealthcare Customer Service. Our contact information is on the cover.

Drug Tier Includes Tier 1: Lower-cost, commonly used generic drugs. Preferred generic Tier 2: Many generic drugs. Generic Tier 3: Many common brand name drugs, called preferred Preferred brand brands and some higher-cost generic drugs. Tier 4: Non-preferred generic and non-preferred brand name Non-preferred drug drugs. Tier 5: Unique and/or very high-cost brand and generic drugs. Specialty tier

Getting Extra Help If you qualify for Extra Help paying for your prescription drugs, your copays and coinsurance may be lower. Members who qualify for Extra Help will receive the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (LIS Rider). Please read it to learn about your costs. You can also call UnitedHealthcare 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 27. The codes and what they mean are shown below and on the next page. You can also get more information about the coverage rules and/or limits applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. If you would like a copy sent to you, please call UnitedHealthcare Customer Service. Our contact information is on the cover. Coverage Rules and Limits

PA - Prior authorization The plan requires you or your doctor to get prior approval for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. If you don’t get approval, the plan may not cover the drug. QL - Quantity limits The plan will cover only a certain amount of this drug for 1 copay or over a certain number of days. These limits may be in place to ensure safe and effective use of the drug. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you or your doctor can ask the plan to cover the additional quantity. ST - Step therapy There may be effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try 1 or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you or your doctor can ask the plan to cover this drug. 6 7 Other Special Coverage Rules

B/D - Medicare Part B or Part D Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it’s correctly covered by Medicare. LA - Limited access Drugs are considered “limited access” if the FDA says the drug can be given out only by certain facilities or doctors. These drugs may require extra handling, provider coordination or patient education that can’t be done at a network pharmacy. MME - Morphine milligram equivalent Additional quantity limits may apply across all drugs in the opioid class used for the treatment of pain. This additional limit is called a cumulative morphine milligram equivalent (MME), and is designed to monitor safe dosing levels of opioids for individuals who may be taking more than 1 opioid drug for pain management. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you or your doctor can ask the plan to cover the additional quantity. 7D - 7-Day limit An opioid drug used for the treatment of acute pain may be limited to a 7-day supply for members with no recent history of opioid use. This limit is intended to minimize long-term opioid use. For members who are new to the plan, and have a recent history of using opioids, the limit may be overridden by having the pharmacy contact the plan. DL - Dispensing limit Dispensing limits apply to this drug. This drug is limited to a 1 month supply per prescription. For Track Refered Purpose

You and your doctor may ask the plan for an exception to the coverage rules and/or limits for your drug. See section “How can I get an exception?" on page 8 or see your Evidence of Coverage to learn more. If you don’t get approval from the plan before you fill a prescription for a drug with coverage rules or limits, you may have to pay the full cost of the drug. 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 UnitedHealthcare Customer Service to ask if it’s covered. Or go to www.myAARPMedicare.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 UnitedHealthcare Customer Service for a list of similar drugs that are covered by the plan. When you get the list, show it to your doctor and ask him or her to prescribe a covered drug. 2. Ask the plan to make an exception and cover your drug. Review the next section for more exception information.

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

· Drug list exception: Ask the plan to cover your drug even if it’s not on the drug list. If approved, this drug will be covered at a pre-determined cost-sharing level. You will not be able to ask us to provide the drug at a lower cost-sharing level. · Utilization exception: Ask the plan to revise the coverage rules or limits on your drug. For example, if your drug has a quantity limit, you can ask the plan to change the limit and cover more. · Tiering exception: Ask the plan to cover your drug on our list at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you pay out-of-pocket for your drug. The plan may approve your request for an exception if the covered alternative drugs wouldn’t be as effective in treating your condition or would cause adverse medical effects. Who can ask for an exception?

You, your authorized representative or your doctor can ask for an exception by calling UnitedHealthcare Customer Service. Your doctor must give us a supporting statement with the reason for the exception. How long does it take to get an exception?

After we get the statement from your doctor supporting your request for an exception, we’ll give you a decision within 72 hours. You can ask for an expedited (fast) decision if you or your doctor believes that your health could be seriously harmed by waiting 72 hours. If your 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 80-98. 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 UnitedHealthcare Customer Service or go to www.myAARPMedicare.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 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 UnitedHealthcare Customer Service toll-free at 1-866-460-8854, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week. Or visit us online at www.myAARPMedicare.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 Alfuzosin HCl ER...... 65 Amphetamine/ Abacavir...... 48 Alinia...... 44 Dextroamphetamine...... 57 Abacavir Sulfate/Lamivudine/ Allopurinol...... 41 Amphotericin B...... 40 Zidovudine...... 48 Alosetron HCl...... 63 Ampicillin...... 33 Abacavir/Lamivudine...... 48 Alprazolam...... 50 Ampicillin Sodium...... 33 Abelcet...... 40 Altavera...... 67 Ampicillin-Sulbactam...... 33 Abilify Maintena...... 46 Alunbrig...... 43 Ampyra...... 58 Acamprosate Calcium DR.....30 Alyacen 1/35...... 67 Anadrol-50...... 67 Acarbose...... 50 Amabelz...... 67 Anagrelide HCl...... 52 Acetaminophen/Codeine...... 28 Amantadine HCl...... 45 Anastrozole...... 43 Acetazolamide...... 55 AmBisome...... 40 Androderm...... 67 Acetazolamide ER...... 55 Amethia...... 67 Anoro Ellipta...... 78 Acetic Acid...... 76 Amethia Lo...... 67 Apokyn...... 45 Acetylcysteine...... 78 Amikacin Sulfate...... 30 Apraclonidine...... 75 Acitretin...... 59 Amiloride HCl...... 56 Aprepitant...... 40 Actemra...... 73 Aminosyn 7%/Electrolytes.... 60 Apri...... 67 ActHIB...... 73 Aminosyn 8.5%/Electrolytes Apriso...... 73 Actimmune...... 73 ...... 60 Aptiom...... 37 Acyclovir...... 48 Aminosyn II...... 60 Aptivus...... 49 Acyclovir Sodium...... 48 Aminosyn II 8.5%/Electrolytes Aralast NP...... 64 Adacel...... 73 ...... 60 Aranelle...... 67 Adapalene...... 59 Aminosyn-HBC...... 60 Aranesp Albumin Free.... 52, 53 Adempas...... 78 Aminosyn-PF...... 60 Arcalyst...... 73 Afinitor...... 43 Aminosyn-RF...... 60 Aripiprazole...... 46 Afinitor Disperz...... 43 Amiodarone HCl...... 54 Aripiprazole ODT...... 46 Ala-Cort...... 65 Amitriptyline HCl...... 39 Aristada...... 46 Albenza...... 44 Amlodipine Besylate...... 54 Ashlyna...... 67 Albuterol Sulfate...... 77 Ammonium Lactate...... 59 Aspirin/Dipyridamole...... 53 Albuterol Sulfate ER...... 77 Amoxapine...... 39 Atazanavir Sulfate...... 49 Alclometasone Dipropionate Amoxicillin...... 33 Atenolol...... 54 ...... 65 Amoxicillin/Clavulanate Atenolol/Chlorthalidone...... 55 Potassium...... 33 Alcohol Prep Pads...... 74 Atomoxetine...... 57 Amoxicillin/Clavulanate Alecensa...... 43 Atorvastatin Calcium...... 56 Potassium ER...... 33 Alendronate Sodium...... 74 Atovaquone...... 44 13Tracked 13 13 Atovaquone/Proguanil HCl....44 Betamethasone Valerate...... 65 Bupropion HCl SR...... 30, 38 Atripla...... 48 Betaxolol HCl...... 75 Bupropion HCl XL...... 38 Atropine Sulfate...... 74 Bethanechol Chloride...... 65 Buspirone HCl...... 50 Atrovent HFA...... 77 Betimol...... 75 Butalbital/Acetaminophen/ Aubra...... 67 Bevespi Aerosphere...... 78 Caffeine...... 27 Augmented Betamethasone Bexarotene...... 44 Butalbital/Aspirin/Caffeine....27 Dipropionate...... 65 Bexsero...... 73 Butorphanol Tartrate...... 28 Auryxia...... 62 Bicalutamide...... 42 Bydureon Bcise...... 50 Austedo...... 58 Bicillin C-R...... 33 Bydureon Pen...... 51 Aviane...... 67 Bicillin L-A...... 33 Bydureon Vial...... 51 Azathioprine...... 72 Biktarvy...... 48 C Azelastine HCl...... 75, 76 Biltricide...... 44 Cabergoline...... 71 Azithromycin...... 34 Binosto...... 74 Cabometyx...... 43 Aztreonam...... 33 Bisoprolol Fumarate...... 54 Calcipotriene...... 59 B BIVIGAM...... 72 Calcitonin-Salmon...... 74 Bacitracin...... 31 Blephamide...... 74 Calcitriol...... 59, 74 Bacitracin/Polymyxin B...... 74 Blephamide S.O.P...... 74 Calcium Acetate...... 62 Baclofen...... 79 Blisovi 24 Fe...... 67 Calquence...... 43 Bactocill in Dextrose...... 33 Blisovi Fe 1.5/30...... 67 Camila...... 70 Bactroban Nasal...... 31 Blisovi Fe 1/20...... 67 Camrese Lo...... 67 Balsalazide Disodium...... 73 Boostrix...... 73 Canasa...... 73 Balziva...... 67 Bosulif...... 43 Caprelsa...... 43 Banzel...... 37 Breo Ellipta...... 78 Carafate...... 64 Baraclude...... 47 Briellyn...... 67 Carbaglu...... 60 BCG Vaccine...... 73 Brilinta...... 53 Carbamazepine...... 37 Belsomra...... 79 Brimonidine Tartrate...... 75 Carbamazepine ER...... 37 Benazepril HCl...... 53 Briviact...... 35 Carbidopa/Levodopa...... 45 Benazepril HCl/ Bromocriptine Mesylate...... 45 Carbidopa/Levodopa ER...... 45 Hydrochlorothiazide...... 55 Budesonide...... 74, 77 Carbidopa/Levodopa ODT....45 Benlysta...... 73 Bumetanide...... 56 Carbidopa/Levodopa/ Benznidazole...... 44 Entacapone...... 45 Buprenorphine HCl...... 30 Benztropine Mesylate...... 45 Carimune Nanofiltered...... 72 Buprenorphine HCl/Naloxone Berinert...... 71 HCl...... 30 Carteolol HCl...... 75 Betamethasone Dipropionate Bupropion HCl...... 38 Cartia XT...... 54 ...... 65 Carvedilol...... 54 14 14Tracked 14 Cayston...... 78 Cholestyramine Light...... 56 Colchicine...... 41 Caziant...... 67 Ciclopirox...... 40 Colestipol HCl...... 56 Cefaclor...... 32 Ciclopirox Nail Lacquer...... 40 Colistimethate Sodium...... 31 Cefadroxil...... 32 Ciclopirox Olamine...... 40 Colocort...... 74 Cefazolin Sodium...... 32 Cilostazol...... 53 Combivent Respimat...... 78 Cefdinir...... 32 Cimduo...... 48 Cometriq...... 43 Cefepime...... 32 Ciprofloxacin...... 34 Complera...... 48 Cefixime...... 32 Ciprofloxacin HCl...... 34 Compro...... 39 Cefotaxime Sodium...... 32 Ciprofloxacin I.V. in D5W...... 34 Constulose...... 63 Cefotetan...... 32 Citalopram HBr...... 38 Corlanor...... 55 Cefoxitin Sodium...... 32 Claravis...... 59 Cosentyx...... 59 Cefpodoxime Proxetil...... 32 Clarithromycin...... 34 Cosentyx Sensoready Pen.....59 Cefprozil...... 32 Clarithromycin ER...... 34 Cosopt PF...... 75 Ceftazidime...... 32 Climara Pro...... 68 Cotellic...... 43 Ceftriaxone Sodium...... 32 Clindamycin HCl...... 31 Coumadin...... 52 Cefuroxime Axetil...... 32 Clindamycin Palmitate HCl....31 Creon...... 64 Cefuroxime Sodium...... 32 Clindamycin Phosphate...31, 59 Crinone...... 70 Celontin...... 36 Clindamycin Phosphate in D5W Crixivan...... 49 Cephalexin...... 32 ...... 31 Cromolyn Sodium...... 63, 75, 78 Cetirizine HCl...... 76 Clindamycin/Benzoyl Peroxide Cryselle-28...... 68 ...... 59 Chantix...... 30 Cuvposa...... 63 Clomipramine HCl...... 39 Chantix Continuing Month Pak Cyclafem...... 68 Clonazepam...... 50 ...... 30 Cyclobenzaprine HCl...... 79 Clonazepam ODT...... 50 Chantix Starting Month Pak...30 Cyclophosphamide...... 42 Clonidine HCl...... 53 Chenodal...... 63 Cyclosporine...... 72 Clonidine HCl ER...... 57 Chlordiazepoxide HCl...... 50 Cyclosporine Modified...... 72 Clopidogrel...... 53 Chlorhexidine Gluconate Oral Cyproheptadine HCl...... 76 Rinse...... 59 Clorazepate Dipotassium...... 50 Cystadane...... 64 Chloroquine Phosphate...... 44 Clotrimazole...... 40 Cystagon...... 64 Chlorothiazide...... 56 Clotrimazole/Betamethasone Cystaran...... 75 Chlorpromazine HCl...... 45 Dipropionate...... 59 D Chlorthalidone...... 56 Clozapine...... 47 Daliresp...... 78 Chlorzoxazone...... 79 Clozapine ODT...... 47 ...... 67 Cholbam...... 64 Coartem...... 44 Dantrolene Sodium...... 79 Cholestyramine...... 56 Codeine Sulfate...... 28 15Tracked 15 15 Dapsone...... 42 Diazepam Intensol...... 50 Doxepin HCl...... 39, 59 Daptacel...... 73 Diclofenac Potassium...... 27 Doxercalciferol...... 74 Daptomycin...... 31 Diclofenac Sodium.... 27, 59, 76 Doxy 100...... 35 DARAPRIM...... 44 Diclofenac Sodium DR...... 27 Doxycycline...... 35 Deblitane...... 70 Diclofenac Sodium ER...... 27 Doxycycline Hyclate...... 35 Delyla...... 68 Dicloxacillin Sodium...... 33 Doxycycline Monohydrate..... 35 Demeclocycline HCl...... 35 Dicyclomine HCl...... 63 Dronabinol...... 40 Depen Titratabs...... 65 Didanosine...... 49 Drospirenone/Ethinyl Depo-Provera...... 70 Dificid...... 34 ...... 68 Descovy...... 48 Digitek...... 55 Droxia...... 42 Desipramine HCl...... 39 Digox...... 55 Duavee...... 68 Desmopressin Acetate...... 67 Digoxin...... 55 Duloxetine HCl...... 58 Desogestrel/Ethinyl Estradiol Dihydroergotamine Mesylate Duramorph...... 28 ...... 68 ...... 41 Durezol...... 76 Desonide...... 65 Dilantin...... 37 E Desoximetasone...... 65 Dilantin INFATABS...... 37 E.E.S. Granules...... 34 Dexamethasone...... 65 Dilt-XR...... 54 Edurant...... 48 Dexamethasone Sodium Diltiazem HCl...... 54 ...... 48 Phosphate...... 76 Diltiazem HCl ER...... 54 Egrifta...... 71 Dexmethylphenidate HCl...... 58 Diphenoxylate/Atropine...... 63 Elestrin...... 68 Dexmethylphenidate HCl ER Diphtheria/Tetanus Toxoids Elidel...... 59 ...... 58 Adsorbed Pediatric...... 73 Eliquis...... 52 Dextrose 10%...... 60 Disulfiram...... 30 Eliquis Starter Pack...... 52 Dextrose 10%/NaCl 0.2%...... 60 Diuril...... 56 Elmiron...... 65 Dextrose 10%/NaCl 0.45%.... 60 Divalproex Sodium...... 50 Embeda...... 27 Dextrose 2.5%/NaCl 0.45%... 60 Divalproex Sodium DR...... 50 Emcyt...... 42 Dextrose 5%...... 60 Divalproex Sodium ER...... 50 Emend...... 40 Dextrose 5%/NaCl 0.2%...... 60 Dofetilide...... 54 Emoquette...... 68 Dextrose 5%/NaCl 0.225%.... 60 Donepezil HCl...... 37 Emsam...... 38 Dextrose 5%/NaCl 0.33%...... 60 Donepezil HCl ODT...... 37 Emtriva...... 49 Dextrose 5%/NaCl 0.45%...... 60 Doripenem...... 33 Enalapril Maleate...... 53 Dextrose 5%/NaCl 0.9%...... 60 Dorzolamide HCl...... 75 Enalapril Maleate/ Diastat AcuDial...... 36 Dorzolamide HCl/Timolol Hydrochlorothiazide...... 55 Diastat Pediatric...... 36 Maleate...... 75 Endocet...... 28 Diazepam...... 50 Doxazosin Mesylate...... 53 Engerix-B...... 73 16 16Tracked 16 Enoxaparin Sodium...... 52 Estradiol/Norethindrone Fluconazole...... 40 Enpresse-28...... 68 Acetate...... 68 Fluconazole in NaCl...... 40 Enskyce...... 68 Estring...... 68 Flucytosine...... 40 Entacapone...... 45 ...... 68 Fludrocortisone Acetate...... 65 Entecavir...... 47 Ethambutol HCl...... 42 Flunisolide...... 77 Entresto...... 55 Ethosuximide...... 36 Fluocinolone Acetonide...65, 76 Enulose...... 63 Ethynodiol Diacetate/Ethinyl Fluocinonide...... 66 Estradiol...... 68 Envarsus XR...... 72 Fluocinonide Emulsified Base Evotaz...... 49 Epclusa...... 47 ...... 66 Exemestane...... 43 Epinastine HCl...... 75 Fluorometholone...... 76 Extavia...... 58 Epinephrine...... 77 Fluorouracil...... 59 Ezetimibe...... 56 Epitol...... 37 Fluphenazine Decanoate...... 45 F Epivir HBV...... 47 Fluphenazine HCl...... 45 Falmina...... 68 Ergotamine Tartrate/Caffeine Flurbiprofen Sodium...... 76 ...... 41 Famciclovir...... 48 Flutamide...... 42 Erivedge...... 43 Fanapt...... 46 Fluticasone Propionate....66, 77 Erleada...... 42 Fanapt Titration Pack...... 46 Fluticasone Propionate/ Errin...... 70 Fareston...... 42 Salmeterol...... 78 Ery...... 59 Farxiga...... 51 Fluvoxamine Maleate...... 38 Ery-Tab...... 34 Farydak...... 43 Fondaparinux Sodium...... 52 EryPed 200...... 34 Felbamate...... 36 Fosamprenavir Calcium...... 49 EryPed 400...... 34 Femynor...... 68 Fosinopril Sodium...... 53 Erythrocin Lactobionate...... 34 Fenofibrate...... 56 FreAmine HBC 6.9%...... 60 Erythromycin...... 34, 59 Fentanyl...... 28 Furosemide...... 56 Erythromycin Base...... 34 Fentanyl Citrate Oral Fuzeon...... 49 Transmucosal...... 28 Erythromycin Ethylsuccinate Fyavolv...... 68 ...... 34 Ferriprox...... 62 Fycompa...... 36 Erythromycin/Benzoyl Peroxide Fetzima...... 38 G ...... 59 Fetzima Titration Pack...... 38 Gabapentin...... 36 Esbriet...... 78 Finacea...... 59 Gammagard S/D IGA Less Escitalopram Oxalate...... 38 Finasteride...... 65 Than 1 mcg/ml...... 72 Estarylla...... 68 Firazyr...... 71 Gammaked...... 72 Estradiol...... 68 Firmagon...... 71 Gammaplex...... 72 ...... 68 Flebogamma DIF...... 72 Gardasil 9...... 73 Flecainide Acetate...... 54 Gattex...... 63 17Tracked 17 17 Gauze...... 74 H Humulin R U-500 Vial...... 52 GaviLyte-C...... 63 Halobetasol Propionate...... 66 Humulin R Vial...... 52 GaviLyte-G...... 63 Haloperidol...... 45 Hydralazine HCl...... 57 GaviLyte-N/Flavor Pack...... 63 Haloperidol Decanoate...... 46 Hydrochlorothiazide...... 56 Gemfibrozil...... 56 Haloperidol Lactate...... 46 Hydrocodone/Acetaminophen Generlac...... 63 Harvoni...... 47 ...... 29 Gengraf...... 72 Havrix...... 73 Hydrocodone/Ibuprofen...... 29 Genotropin...... 67 Heparin Sodium...... 52 Hydrocortisone...... 66, 74 Genotropin Miniquick...... 67 HepatAmine...... 60 Hydrocortisone Butyrate...... 66 Gentak...... 30 Hetlioz...... 79 Hydrocortisone Valerate...... 66 Gentamicin Sulfate...... 30 Hexalen...... 42 Hydrocortisone/Acetic Acid ...... 76 Gentamicin Sulfate/0.9% Hiberix...... 73 Hydromorphone HCl...... 29 Sodium Chloride...... 31 Humalog Cartridge...... 51 Hydroxychloroquine Sulfate Genvoya...... 48 Humalog Junior KwikPen...... 51 ...... 44 Geodon...... 46 Humalog KwikPen...... 51 Hydroxyurea...... 42 Gianvi...... 68 Humalog Mix 50/50 KwikPen Hydroxyzine HCl...... 50 Gilenya...... 58 ...... 51 Hydroxyzine Pamoate...... 39 Gilotrif...... 43 Humalog Mix 50/50 Vial...... 51 Hysingla ER...... 28 Glatiramer Acetate...... 58 Humalog Mix 75/25 KwikPen I Glatopa...... 58 ...... 51 Ibandronate Sodium...... 74 Gleostine...... 42 Humalog Mix 75/25 Vial...... 52 Ibrance...... 43 Glimepiride...... 51 Humalog Vial...... 52 Ibu...... 27 Glipizide...... 51 Humira...... 72 Ibuprofen...... 27 Glipizide ER...... 51 Humira Pediatric Crohns Disease Starter Pack...... 72 Iclusig...... 43 Glipizide/Metformin HCl...... 51 Humira Pen...... 72 Idhifa...... 43 GlucaGen HypoKit...... 51 Humira Pen Crohns Disease Imatinib Mesylate...... 43 Glucagon Emergency Kit...... 51 Starter Pack...... 72 Imbruvica...... 43 Glyxambi...... 51 Humira Pen-Psoriasis Starter Imipenem/Cilastatin...... 33 Granisetron HCl...... 40 ...... 72 Imipramine HCl...... 39 Griseofulvin Microsize...... 40 Humulin 70/30 KwikPen...... 52 Imipramine Pamoate...... 39 Griseofulvin Ultramicrosize....40 Humulin 70/30 Vial...... 52 Imiquimod...... 59 Guanfacine HCl...... 53 Humulin N KwikPen...... 52 Imovax Rabies...... 73 Guanidine HCl...... 41 Humulin N Vial...... 52 Incassia...... 70 Humulin R U-500 KwikPen.....52 Increlex...... 67 18 18Tracked 18 Indapamide...... 56 Itraconazole...... 40 KCl 0.3%/D5W/NaCl 0.45% Indomethacin...... 27 Ivermectin...... 44 ...... 61 Infanrix...... 73 Ixiaro...... 73 KCl 0.3%/D5W/NaCl 0.9%.... 61 Ingrezza...... 58 J Kelnor 1/35...... 68 Inlyta...... 43 Jadenu...... 62 Kelnor 1/50...... 68 Insulin Syringes, Needles...... 74 Jadenu Sprinkle...... 62 Ketoconazole...... 40 Intelence...... 48 Jakafi...... 43 Ketorolac Tromethamine...... 76 Intralipid...... 60 Jantoven...... 52 Kimidess...... 68 Intron A...... 47 Jardiance...... 51 Kinrix...... 73 Introvale...... 68 Jentadueto...... 51 Kionex...... 62 Invanz...... 33 Jentadueto XR...... 51 Kisqali...... 42 Invega Sustenna...... 46 Jinteli...... 68 Kisqali Femara 200 Dose...... 43 Invega Trinza...... 46 Jolivette...... 70 Kisqali Femara 400 Dose...... 43 Invirase...... 49 Jublia...... 40 Kisqali Femara 600 Dose...... 43 Ionosol-MB/Dextrose 5%...... 60 Juleber...... 68 Klor-Con...... 61 IPOL Inactivated IPV...... 73 Juluca...... 48 Klor-Con 10...... 61 Ipratropium Bromide...... 77 Junel 1.5/30...... 68 Klor-Con 8...... 61 Ipratropium Bromide/Albuterol Junel 1/20...... 68 Klor-Con M10...... 61 Sulfate...... 78 Junel Fe 1.5/30...... 68 Klor-Con M15...... 61 Irbesartan...... 53 Junel Fe 1/20...... 68 Klor-Con M20...... 61 Irbesartan/Hydrochlorothiazide Junel Fe 24...... 68 Kombiglyze XR...... 51 ...... 55 Juxtapid...... 56 Korlym...... 67 Iressa...... 43 K Kurvelo...... 68 Isentress...... 48 Kaitlib Fe...... 68 Kuvan...... 64 Isentress HD...... 48 Kaletra...... 49 L Isibloom...... 68 Kalydeco...... 78 Labetalol HCl...... 54 Isolyte-P/Dextrose 5%...... 60 Kariva...... 68 Lacrisert...... 75 Isolyte-S...... 60 KCl 0.075%/D5W/NaCl 0.45% Lactulose...... 63 Isoniazid...... 42 ...... 60 Lamivudine...... 47, 49 Isosorbide Dinitrate...... 57 KCl 0.15%/D5W/NaCl 0.2% Lamivudine/Zidovudine...... 49 Isosorbide Dinitrate ER...... 57 ...... 61 Lamotrigine...... 36 Isosorbide Mononitrate...... 57 KCl 0.15%/D5W/NaCl 0.45% Lanoxin...... 55 ...... 61 Isosorbide Mononitrate ER....57 Lantus SoloStar...... 52 KCl 0.15%/D5W/NaCl 0.9% Isotonic Gentamicin...... 31 Lantus Vial...... 52 ...... 61 Isotretinoin...... 59 19Tracked 19 19 LARIN 1.5/30...... 68 Lidocaine HCl...... 30 Magnesium Sulfate...... 61 LARIN 1/20...... 68 Lidocaine Viscous...... 30 Malathion...... 45 LARIN Fe 1.5/30...... 68 Lidocaine/Prilocaine...... 30 Maprotiline HCl...... 38 LARIN Fe 1/20...... 68 Lindane...... 45 Marlissa...... 69 Larissia...... 68 Linezolid...... 31 Marplan...... 38 Lastacaft...... 75 Linzess...... 63 Matulane...... 42 Latanoprost...... 76 Liothyronine Sodium...... 71 Mavyret...... 47 Latuda...... 46 Lisinopril...... 53 Meclizine HCl...... 39 Layolis Fe...... 68 Lisinopril/Hydrochlorothiazide Medroxyprogesterone Acetate Leena...... 69 ...... 55 ...... 70 Leflunomide...... 73 Lithium...... 50 Mefloquine HCl...... 44 Lenvima...... 43 Lithium Carbonate...... 50 Megestrol Acetate...... 70, 71 Lessina...... 69 Lithium Carbonate ER...... 50 Mekinist...... 44 Letrozole...... 43 Livalo...... 56 Melodetta 24 Fe...... 69 Leucovorin Calcium...... 43 Lonsurf...... 43 Meloxicam...... 27 Leukeran...... 42 Loperamide HCl...... 63 Memantine HCl...... 38 Leuprolide Acetate...... 71 Lopinavir/Ritonavir...... 49 Memantine HCl ER...... 38 Levetiracetam...... 35 Lorcet...... 29 Memantine HCl Titration Pak ...... 38 Levetiracetam ER...... 35 Lorcet HD...... 29 Menactra...... 73 Levobunolol HCl...... 76 Lorcet Plus...... 29 Menest...... 69 Levocarnitine...... 61 Loryna...... 69 Menveo...... 73 Levocetirizine Dihydrochloride Losartan Potassium...... 53 ...... 76 Losartan Potassium/ Mercaptopurine...... 42 Levofloxacin...... 34 Hydrochlorothiazide...... 55 Meropenem...... 33 Levofloxacin in D5W...... 34 Lovastatin...... 56 Mesalamine...... 74 Levonest...... 69 Low-Ogestrel...... 69 Mesnex...... 44 Levonorgestrel and Ethinyl Loxapine Succinate...... 46 Metformin HCl...... 51 Estradiol...... 69 Lupron Depot...... 71 Metformin HCl ER...... 51 Levonorgestrel/Ethinyl Lutera...... 69 Methadone HCl...... 28 Estradiol...... 69 Lynparza...... 43 Methamphetamine HCl...... 57 Levora 0.15/30-28...... 69 Lyrica...... 58 Methazolamide...... 55 Levothyroxine Sodium...... 71 Lysodren...... 71 Methenamine Hippurate...... 31 Levoxyl...... 71 Lyza...... 70 Methimazole...... 71 Lexiva...... 49 M Methotrexate...... 72 Lidocaine...... 30 M-M-R II...... 73 Methotrexate Sodium...... 72 20 20Tracked 20 Methscopolamine Bromide... 63 Mirtazapine ODT...... 38 Neomycin Sulfate...... 31 Methyclothiazide...... 56 Mirvaso...... 59 Neomycin/Bacitracin/ Methyldopa...... 53 Misoprostol...... 64 Polymyxin...... 75 Methylphenidate HCl...... 58 Modafinil...... 79 Neomycin/Polymyxin/ Bacitracin/Hydrocortisone Methylphenidate HCl ER...... 58 Mometasone Furoate...... 66 ...... 75 Methylprednisolone...... 66 MonoNessa...... 69 Neomycin/Polymyxin/ Methylprednisolone Dose Pack Montelukast Sodium...... 77 Dexamethasone...... 75 ...... 66 Morphine Sulfate...... 29 Neomycin/Polymyxin/ Metoclopramide HCl...... 39 Morphine Sulfate ER...... 28 Gramicidin...... 75 Metolazone...... 56 Moxifloxacin HCl/Sodium HCl Neomycin/Polymyxin/ Metoprolol Succinate ER...... 54 ...... 34 Hydrocortisone...... 75, 76 Metoprolol Tartrate...... 54 Moxifloxacin HCl...... 35 Nephramine...... 61 Metoprolol/ Mupirocin...... 31 Nerlynx...... 44 Hydrochlorothiazide...... 55 Myalept...... 63 Neulasta...... 53 Metronidazole...... 31 Mycamine...... 40 Neupro...... 45 Metronidazole in NaCl 0.79% Mycophenolate Mofetil...... 72 Nevirapine...... 48 ...... 31 Mycophenolic Acid DR...... 72 Nevirapine ER...... 48 Metronidazole Vaginal...... 31 Myrbetriq...... 64 Nexavar...... 44 Mexiletine HCl...... 54 N Niacor...... 56 Mibelas 24 Fe...... 69 Nafcillin Sodium...... 33 Nicotrol Inhaler...... 30 Miconazole 3...... 40 Naloxone HCl...... 30 Nikki...... 69 Microgestin 1.5/30...... 69 Naltrexone HCl...... 30 Nilutamide...... 42 Microgestin 1/20...... 69 Namzaric...... 58 Nimodipine...... 54 Microgestin Fe...... 69 Naproxen...... 27 Ninlaro...... 43 Microgestin Fe 1.5/30...... 69 Naproxen DR...... 27 Nitro-Bid...... 57 Midodrine HCl...... 53 Naratriptan HCl...... 41 Nitrofurantoin...... 31 Migergot...... 41 Narcan...... 30 Nitrofurantoin Macrocrystals Miglustat...... 64 ...... 31 Natacyn...... 40 Mili...... 69 Nitrofurantoin Monohydrate Nateglinide...... 51 Mimvey...... 69 ...... 32 Natpara...... 74 Mimvey Lo...... 69 Nitroglycerin...... 57 Nebupent...... 44 Minitran...... 57 Nitroglycerin Lingual...... 57 Necon 0.5/35-28...... 69 Minocycline HCl...... 35 Nitroglycerin Transdermal..... 57 Necon 7/7/7...... 69 Minoxidil...... 57 Nitrostat...... 57 Nefazodone HCl...... 38 Mirtazapine...... 38 Nizatidine...... 63 21Tracked 21 21 Nora-BE...... 71 Octreotide Acetate...... 71 Panretin...... 44 Norethindrone...... 71 Odefsey...... 48 Pantoprazole Sodium...... 64 Norethindrone Acetate...... 71 Odomzo...... 44 Paricalcitol...... 74 Norethindrone Acetate/Ethinyl Ofev...... 78 Paromomycin Sulfate...... 31 Estradiol...... 69 Ofloxacin...... 35 Paroxetine HCl...... 38 Norethindrone Acetate/Ethinyl Ogestrel...... 70 Paser...... 42 Estradiol/Ferrous Fumarate Olanzapine...... 46 Paxil...... 38 ...... 69 Olanzapine ODT...... 46 Pediarix...... 73 Norethindrone/Ethinyl Estradiol/Ferrous Fumarate Olopatadine HCl...... 75 Pedvax HIB...... 73 ...... 69 Omeprazole...... 64 PEG 3350/Electrolytes...... 63 Norgestimate/Ethinyl Estradiol Ondansetron HCl...... 40 PEG-3350/Electrolytes...... 64 ...... 69 Ondansetron ODT...... 40 PEG-3350/NaCl/Na Norlyroc...... 71 Onfi...... 36 Bicarbonate/KCl...... 64 Normosol-M in D5W...... 61 Onglyza...... 51 Peganone...... 37 Normosol-R...... 61 Opsumit...... 78 Pegasys...... 47 Normosol-R in D5W...... 61 Orenitram...... 78 Penicillin G Potassium...... 33 Northera...... 53 Orfadin...... 64 Penicillin G Procaine...... 33 Nortrel 0.5/35...... 69 Orkambi...... 78 Penicillin G Sodium...... 33 Nortrel 1/35...... 69 Orsythia...... 70 Penicillin V Potassium...... 33 Nortrel 7/7/7...... 69 Oseltamivir Phosphate...... 50 Pentam 300...... 44 Nortriptyline HCl...... 39 Osphena...... 71 Pentoxifylline ER...... 55 Norvir...... 49 Oxacillin Sodium...... 33 Perforomist...... 77 Noxafil...... 40 Oxandrolone...... 67 Periogard...... 59 Nucala...... 78 Oxcarbazepine...... 37 Permethrin...... 45 Nuedexta...... 58 Oxybutynin Chloride...... 64 Perphenazine...... 39 Nuplazid...... 46 Oxybutynin Chloride ER...... 65 Phenadoz...... 77 Nutrilipid...... 61 Oxycodone HCl...... 29 Phenelzine Sulfate...... 38 NuvaRing...... 70 Oxycodone/Acetaminophen Phenobarbital...... 36 Nyamyc...... 40 ...... 29 Phenytek...... 37 Nymalize...... 54 Oxycodone/Aspirin...... 29 ...... 37 Nystatin...... 41 Oxycodone/Ibuprofen...... 30 Phenytoin Sodium Extended Nystop...... 41 P ...... 37 O Pacerone...... 54 Phoslyra...... 62 Ocella...... 70 Paliperidone ER...... 46 Phospholine Iodide...... 76 Octagam...... 72 Picato...... 59 22 22Tracked 22 Pilocarpine HCl...... 59, 76 Prednisolone...... 66 Propafenone HCl...... 54 Pimozide...... 46 Prednisolone Sodium Proparacaine HCl...... 75 Pimtrea...... 70 Phosphate...... 66, 76 Propranolol HCl...... 54 Pioglitazone HCl...... 51 Prednisone...... 66 Propranolol HCl ER...... 54 Piperacillin/Tazobactam...... 33 Prednisone Intensol...... 66 Propylthiouracil...... 71 Pirmella 1/35...... 70 Premarin...... 70 ProQuad...... 73 Plasma-Lyte A...... 61 Premasol...... 62 Prosol...... 62 Plasma-Lyte-148...... 61 Premphase...... 70 Protriptyline HCl...... 39 Plenamine...... 61 Prempro...... 70 PRUDOXIN...... 60 Podofilox...... 59 Prevalite...... 56 Pulmicort Flexhaler...... 77 Polyethylene Glycol 3350 Previfem...... 70 Pulmozyme...... 79 Powder...... 64 Prezcobix...... 49 Purixan...... 42 Polymyxin B Sulfate...... 32 Prezista...... 49 Pyrazinamide...... 42 Polymyxin B Sulfate/ Priftin...... 42 Pyridostigmine Bromide...... 41 Trimethoprim Sulfate...... 75 Primaquine Phosphate...... 44 Pyridostigmine Bromide ER Pomalyst...... 42 Primidone...... 36 ...... 42 Portia-28...... 70 Privigen...... 72 Q Potassium Chloride...... 61 Probenecid...... 41 Quadracel...... 73 Potassium Chloride CR...... 61 Probenecid/Colchicine...... 41 Quasense...... 70 Potassium Chloride ER...... 61 Procalamine...... 62 Quetiapine Fumarate...... 46 Potassium Chloride/Dextrose Prochlorperazine...... 39 Quinapril HCl...... 53 ...... 61 Prochlorperazine Maleate...... 40 Quinapril/Hydrochlorothiazide Potassium Chloride/Dextrose/ Procrit...... 53 ...... 55 Lactated Ringers...... 62 Procto-Med HC...... 74 Quinidine Sulfate...... 54 Potassium Chloride/Dextrose/ Quinine Sulfate...... 44 Sodium Chloride...... 62 Procto-Pak...... 74 Potassium Chloride/Sodium Proctosol HC...... 74 R Chloride...... 62 Proctozone-HC...... 74 Rabavert...... 73 Potassium Citrate ER...... 62 Proglycem...... 51 HCl...... 71 Pradaxa...... 52 Prolastin-C...... 64 Ramipril...... 53 Praluent...... 56 Prolensa...... 76 Ranexa...... 55 Pramipexole Dihydrochloride Prolia...... 74 Ranitidine HCl...... 63 ...... 45 Promacta...... 53 Rapamune...... 72 Pravastatin Sodium...... 56 Promethazine HCl...... 77 Rasagiline Mesylate...... 45 Prazosin HCl...... 53 Promethegan...... 77 Ravicti...... 64 Prednicarbate...... 66 Rayaldee...... 74 23Tracked 23 23 Reclipsen...... 70 Roweepra...... 35 Sodium Fluoride...... 62 Recombivax HB...... 73 Roweepra XR...... 36 Sodium Lactate...... 62 Regranex...... 60 Rubraca...... 43 Sodium Phenylbutyrate...... 64 Relenza Diskhaler...... 50 Rydapt...... 44 Sodium Polystyrene Sulfonate Relistor...... 63 Rytary...... 45 ...... 62 Repaglinide...... 51 S Sodium Sulfacetamide...... 35 Repatha...... 56 Sabril...... 36 Soliqua 100/33...... 51 Repatha Pushtronex System Samsca...... 62 Soltamox...... 42 ...... 56 Sandimmune...... 72 Somatuline Depot...... 71 Repatha SureClick...... 56 Santyl...... 60 Somavert...... 71 Rescriptor...... 48 Saphris...... 47 Sotalol HCl...... 54 Restasis...... 75 Savella...... 58 Spiriva HandiHaler...... 77 Revlimid...... 42 Savella Titration Pack...... 58 Spiriva Respimat...... 77 Rexulti...... 46 Scopolamine...... 40 ...... 56 Reyataz...... 50 Selegiline HCl...... 45 Spironolactone/ Hydrochlorothiazide...... 55 Ribasphere...... 47 Selenium Sulfide...... 60 Sporanox...... 41 Ribavirin...... 47 Selzentry...... 49 Sprintec 28...... 70 Rifabutin...... 42 Sensipar...... 74 Spritam...... 36 Rifampin...... 42 Serevent Diskus...... 77 Sprycel...... 44 Rifater...... 42 Sertraline HCl...... 39 SPS...... 62 Riluzole...... 58 Setlakin...... 70 Sronyx...... 70 Rimantadine HCl...... 50 Sevelamer Carbonate...... 62 SSD...... 35 Risperdal Consta...... 46, 47 Sharobel...... 71 Stavudine...... 49 Risperidone...... 47 Shingrix...... 73 Stiolto Respimat...... 79 Risperidone ODT...... 47 Signifor...... 71 Stivarga...... 44 Ritonavir...... 50 Sildenafil...... 78 Streptomycin Sulfate...... 31 Rivastigmine Tartrate...... 37 Silver Sulfadiazine...... 35 Stribild...... 48 Rivastigmine Transdermal Simbrinza...... 76 System...... 37 Suboxone...... 30 Simvastatin...... 56 Rizatriptan Benzoate...... 41 Sucraid...... 64 Sirolimus...... 72 Rizatriptan Benzoate ODT..... 41 Sucralfate...... 64 Sirturo...... 42 Ropinirole HCl...... 45 Sulfacetamide Sodium...... 35 Sodium Chloride...... 62 Rosuvastatin Calcium...... 56 Sulfacetamide Sodium/ Sodium Chloride 0.9%...... 62 Rotarix...... 73 Prednisolone Sodium Sodium Chloride 0.45%...... 62 Phosphate...... 75 RotaTeq...... 73 24 24Tracked 24 Sulfadiazine...... 35 Tazarotene...... 60 Tobramycin Sulfate...... 31 Sulfamethoxazole/ Tazicef...... 33 Tobramycin/Dexamethasone Trimethoprim...... 35 Tazorac...... 60 ...... 75 Sulfamethoxazole/ Tecfidera...... 58 Topiramate...... 37 Trimethoprim DS...... 35 Tecfidera Starter Pack...... 58 Torsemide...... 56 Sulfasalazine...... 74 Telmisartan...... 53 Toujeo Max Solostar...... 52 Sulindac...... 27 Temazepam...... 79 Toujeo SoloStar...... 52 Sumatriptan...... 41 Tenivac...... 73 TPN Electrolytes...... 62 Sumatriptan Succinate...... 41 Tenofovir Disoproxil Fumarate Tradjenta...... 51 Sumatriptan Succinate Refill ...... 49 Tramadol HCl...... 30 ...... 41 Terazosin HCl...... 65 Tramadol HCl ER...... 28 Suprax...... 33 Terbinafine HCl...... 41 Tramadol HCl/Acetaminophen Suprep Bowel Prep Kit...... 64 Terconazole...... 41 ...... 30 Sutent...... 44 ...... 67 Tranexamic Acid...... 53 Syeda...... 70 ...... 67 Tranylcypromine Sulfate...... 38 Sylatron...... 47 ...... 67 Travasol...... 62 Symbicort...... 79 Testosterone Pump...... 67 Trazodone HCl...... 39 Symfi...... 48 Tetanus/Diphtheria Toxoids- Trecator...... 42 Symfi Lo...... 48 Adsorbed Adult...... 73 Trelstar Mixject...... 71 Synarel...... 71 Tetrabenazine...... 58 Tretinoin...... 44, 60 Synjardy...... 51 Tetracycline HCl...... 35 Trexall...... 72 Synjardy XR...... 51 Thalomid...... 42 Trezix...... 30 Synribo...... 43 Theophylline CR...... 78 Tri-Legest Fe...... 70 Synthroid...... 71 Theophylline ER...... 78 Tri-Lo-Estarylla...... 70 T Thioridazine HCl...... 46 Tri-Lo-Sprintec...... 70 Tabloid...... 42 Thiothixene...... 46 Tri-Mili...... 70 Tacrolimus...... 60, 72 Tiagabine HCl...... 36 Tri-Previfem...... 70 Tafinlar...... 44 Tigecycline...... 32 Tri-Sprintec...... 70 Tagrisso...... 44 Timolol Maleate...... 76 Tri-Vylibra...... 70 Citrate...... 42 Tinidazole...... 32 Triamcinolone Acetonide...... 66, Tamsulosin HCl...... 65 Tivicay...... 48 77 Tarceva...... 44 Tizanidine HCl...... 79 Triamcinolone Acetonide Dental Paste...... 59 Targretin...... 44 TOBI Podhaler...... 78 Triamterene/ Tarina Fe 1/20...... 70 Tobradex...... 75 Hydrochlorothiazide...... 55 Tasigna...... 44 Tobramycin...... 78 25Tracked 25 25 Triderm...... 66 Vancomycin HCl...... 32 Vosevi...... 47 Trientine HCl...... 62 Vandazole...... 32 Votrient...... 44 Trifluoperazine HCl...... 46 VAQTA...... 73 VP-PNV-DHA...... 63 Trifluridine...... 48 Varivax...... 73 Vraylar...... 47 Trihexyphenidyl HCl...... 45 Varizig...... 73 Vyfemla...... 70 TriLyte...... 64 Vascepa...... 56 Vylibra...... 70 Trimethoprim...... 32 Velivet...... 70 Vyzulta...... 76 Trimipramine Maleate...... 39 Velphoro...... 63 W Trinessa...... 70 Veltassa...... 62 Warfarin Sodium...... 52 Trintellix...... 39 Vemlidy...... 47 WYMZYA Fe...... 70 Triumeq...... 48 Venclexta...... 44 X Trivora-28...... 70 Venclexta Starting Pack...... 44 Xalkori...... 44 Trophamine...... 62 Venlafaxine HCl...... 39 Xarelto...... 52 Trulicity...... 51 Venlafaxine HCl ER...... 39 Xarelto Starter Pack...... 52 Trumenba...... 73 Ventolin HFA...... 77 Xatmep...... 72 Truvada...... 49 Verapamil HCl...... 54 Xgeva...... 74 Twinrix...... 73 Verapamil HCl ER...... 55 Xigduo XR...... 51 Tybost...... 48 Versacloz...... 47 Xiidra...... 75 Tykerb...... 44 Verzenio...... 43 Xolair...... 73 Tymlos...... 74 Vesicare...... 65 Xtampza ER...... 28 Typhim Vi...... 73 Viberzi...... 63 Xtandi...... 42 U Vibramycin...... 35 Xyrem...... 79 Uloric...... 41 Videx EC...... 49 Y Unithroid...... 71 Videx Pediatric...... 49 YF-Vax...... 73 Ursodiol...... 63 Vienva...... 70 Z V Vigabatrin...... 36 Zafirlukast...... 77 Valacyclovir HCl...... 48 Viibryd...... 39 Zaleplon...... 79 Valchlor...... 42 Viibryd Starter Pack...... 39 Zarah...... 70 Valganciclovir...... 47 Vimpat...... 37 Zarxio...... 53 Valganciclovir Hydrochlorde Viracept...... 50 Zejula...... 43 ...... 47 Viramune...... 48 Zelboraf...... 44 Valproic Acid...... 36 Viread...... 49 Zenchent...... 70 Valsartan...... 53 Vivitrol...... 30 Zenpep...... 64 Valsartan/Hydrochlorothiazide Voriconazole...... 41 Zerbaxa...... 33 ...... 55 26 26Tracked 26 Zerit...... 49 Zolinza...... 43 Zovia 1/35E...... 70 Zidovudine...... 49 Zolpidem Tartrate...... 79 Zydelig...... 44 Zioptan...... 76 Zonisamide...... 36 Zykadia...... 44 Ziprasidone HCl...... 47 Zortress...... 72 Zyprexa Relprevv...... 47 Zirgan...... 47 Zostavax...... 73 Zytiga...... 42 tRACK 27 27 Covered drugs by medical condition 126 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 12-26. 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 80-98. tRACK

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

A1 IbupC1 rofe Analgesics Ibuprofenn (100mg/5ml B1 Suspension, 400mg Analgesics 2

ButalC1 bital/ Tablet, 600mg Tablet, Acet Butalbital/amin ophe n/ Caff eine 800mg Tablet) Acetaminophen/ IndoC1 meth Caffeine 3 QL Indomethacinacin (25mg (50mg-325mg-40mg Capsule, 50mg 2 Tablet) Capsule)

MeloC1 ButalC1 xica bital/ m Aspir Meloxicam (Tablet) 1 Butalbital/Aspirin/in/ Caff eine NaprC1 Caffeine Naproxenoxen (125mg/5ml 3 QL 4 (50mg-325mg-40mg Suspension)

NaprC1 Capsule) Naproxenoxen (Tablet B1 2 Anti-inflammatory Drugs Immediate-Release)

DicloC1 NaprC1 fena oxen c DR DiclofenacPota Potassium Naproxen DR (Tablet ssiu m 2 (Tablet) Delayed-Release) 2

DicloC1 fena c (Generic EC-Naprosyn) DiclofenacSodi Sodium um 3 PA SulinC1 (1% Gel) Sulindacdac (Tablet) 2

DicloC1 B1 fena c DiclofenacSodi Sodium DR Opioid Analgesics, Long-acting um DR EmbC1 (Tablet Delayed- 2 Embedaeda (Capsule 7D, DL, QL, 3 Release) Extended-Release) MME DicloC1 fena c DiclofenacSodi Sodium ER um ER (Tablet Extended- 2 Release 24 Hour)

IbuC1 Ibu (Tablet) 2

Bold type = Brand name drug Plain type = Generic drug 28 tRACK 28 Last updated October 1, 2018 227 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

FentC1 TramC1 anyl adol HCl Fentanyl (100mcg/hr TramadolER HCl ER Patch 72 Hour, (100mg Tablet 12mcg/hr Patch 72 Extended-Release 24 Hour, 25mcg/hr Patch 7D, DL, QL, Hour, 200mg Tablet 7D, DL, QL, 3 3 72 Hour, 50mcg/hr MME Extended-Release 24 MME Patch 72 Hour, Hour, 300mg Tablet 75mcg/hr Patch 72 Extended-Release 24 Hour) Hour)

HysiC1 XtamC1 ngla pza HysinglaER ER (Tablet XtampzaER ER (Capsule Extended-Release 24 7D, DL, QL, Extended-Release 12 7D, DL, QL, 3 3 Hour Abuse- MME Hour Abuse- MME Deterrent) Deterrent)

MethC1 B1 adon e MethadoneHCl HCl (10mg Opioid Analgesics, Short-acting

AcetC1 amin Tablet, 5mg Tablet, ophe Acetaminophen/n/ Cod 7D, DL, QL, eine 10mg/5ml Oral 3 MME Codeine Solution, 5mg/5ml Oral (120mg-12mg/5ml 7D, DL, QL, Solution) Oral Solution, 2

MorC1 phin MME e MorphineSulfa Sulfate ER 300mg-15mg Tablet, te (100mgER Tablet 300mg-30mg Tablet, Extended-Release, 300mg-60mg Tablet)

ButoC1 rpha 15mg Tablet Extended- nol ButorphanolTartr Tartrate 7D, DL, QL, 7D, DL, QL, ate Release, 30mg Tablet 3 3 MME (Nasal Solution) MME

Extended-Release, CodC1 eine Sulfa Codeinete Sulfate 7D, DL, QL, 60mg Tablet Extended- 3 Release) (Generic MS (Tablet) MME DuraC1 mor Contin) Duramorphph (Injection) 4 7D, DL

MorC1 phin e EndC1 Sulfa 7D, DL, QL, Morphine Sulfate ER ocet te ER Endocet (Tablet) 3 (200mg Tablet 7D, DL, QL, MME

4 C1 Fent anyl Extended-Release MME Citra Fentanylte Citrate Oral Oral Tran smu cosa Generic MS Contin) Transmucosall 5 DL, PA, QL (Lozenge on a Handle)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 29 29 328 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

HydrC1 MorC1 ocod phin one/ e Hydrocodone/Acet MorphineSulfa Sulfate amin te ophe n Acetaminophen (100mg/5ml Oral 7D, DL, QL, (10mg-325mg Tablet, Solution, 10mg/5ml 3 2.5mg-325mg Tablet, 7D, DL, QL, Oral Solution, 20mg/ MME 3 5mg-325mg Tablet, MME 5ml Oral Solution)

MorC1 phin 7.5mg-325mg Tablet, e MorphineSulfa Sulfate te 7.5mg-325mg/15ml (10mg/ml Injection, 4 7D, DL Oral Solution) 4mg/ml Injection,

HydrC1 ocod one/ Hydrocodone/Acet 8mg/ml Injection) amin ophe n 7D, DL, QL, MorC1 phin Acetaminophen 3 e MorphineSulfa Sulfate MME te (Tablet) (15mg Tablet HydrC1 ocod 7D, DL, QL, one/ Hydrocodone/Ibup rofe Immediate-Release, n 7D, DL, QL, 3 Ibuprofen 3 MME MME 30mg Tablet (7.5mg-200mg Tablet) Immediate-Release) HydrC1 omo rpho MorC1 Hydromorphonene HCl phin HCl e MorphineSulfa Sulfate te (10mg/ml Injection, 4 7D, DL (2mg/ml Injection, 4 7D, DL 50mg/5ml Injection) 5mg/ml Injection) HydrC1 omo rpho neHydromorphone HCl 7D, DL, QL, OxycC1 HCl odon e 4 OxycodoneHCl HCl (1mg/ml Liquid) MME 7D, DL, QL, (100mg/5ml 4 HydrC1 omo rpho MME Hydromorphonene HCl HCl Concentrate)

OxycC1 (2mg Tablet odon e OxycodoneHCl HCl (10mg Immediate-Release, 7D, DL, QL, 2 Tablet Immediate- 4mg Tablet Immediate- MME Release, 15mg Tablet Release, 8mg Tablet Immediate-Release, Immediate-Release) 20mg Tablet HydrC1 omo 7D, DL, QL, rpho Hydromorphonene HCl HCl Immediate-Release, 3 4 7D, DL MME (2mg/ml Injection) 30mg Tablet

LorcC1 7D, DL, QL, Immediate-Release, etLorcet (Tablet) 3 MME 5mg Tablet Immediate- Release, 5mg/5ml Oral LorcC1 7D, DL, QL, et LorcetHD HD (Tablet) 3 Solution)

MME C1 Oxyc odon e/ Oxycodone/Acet amin ophe LorcC1 7D, DL, QL, n 7D, DL, QL, et LorcetPlus Plus (Tablet) 3 Acetaminophen 3 MME (Tablet) MME

OxycC1 odon e/ Oxycodone/AspirinAspir 7D, DL, QL, in 3 (Tablet) MME

Bold type = Brand name drug Plain type = Generic drug 30 tRACK 30 Last updated October 1, 2018 429 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 OxycC1 Bupr odon enor e/ phin Ibup 7D, DL, QL, Buprenorphinee HCl/ Oxycodone/Ibuprofen HCl/ rofe n Nalo xone 3 HCl (Tablet) MME Naloxone HCl (Tablet 2 QL

TramC1 adol Sublingual) TramadolHCl HCl (Tablet 7D, DL, QL, SubC1 2 oxon Immediate-Release) MME Suboxonee (Film) 4 QL

B1 TramC1 adol HCl/ Opioid Reversal Agents TramadolAcet HCl/ amin ophe n 7D, DL, QL, NaloC1 xone Acetaminophen 2 Naloxone HCl HCl MME 4 (Tablet) (Injection)

NarcC1 an TreziC1 7D, DL, QL, Narcan (Liquid) 3 Trezixx (Capsule) 4 MME SmokingB1 Cessation Agents

A1 BuprC1 opio Anesthetics n BupropionHCl HCl SR SR

B1 Local Anesthetics (150mg Tablet LidoC1 cain Lidocainee (5% Extended-Release 12 2 4 QL Ointment) Hour Smoking-

LidoC1 Deterrent) cain Lidocainee (5% Patch) 4 PA, QL ChaC1 ntix LidoC1 Chantix (Tablet) 3 cain e HClLidocaine HCl (4% ChaC1 ntix 2 Cont Chantixinuin Continuing g External Solution) Mont h Pak 3 LidoC1 cain Month Pak (Tablet) e LidocaineHCl HCl (Gel) 2 ChaC1 ntix Starti LidoC1 ng cain Chantix Starting Mont e h Visc Lidocaine Viscous Pak ous 2 3 (Solution) Month Pak (Tablet) NicoC1 trol LidoC1 Inhal cain Nicotroler Inhaler e/ Lidocaine/PrilocainePrilo cain e 3 4 (Cream) (Inhaler)

A1 Anti-Addiction/SubstanceA1 Abuse Treatment Antibacterials Agents AminoglycosidesB1

C1 B1 Amik acin Sulfa Amikacinte Sulfate Alcohol Deterrents/Anti-craving 4 AcaC1 mpr (Injection) osat Acamprosatee Calcium Calci um GentC1 DR Gentakak (Ophthalmic DR (Tablet Delayed- 4 2 Release) Ointment)

GentC1 DisulC1 amic firam in GentamicinSulfa Sulfate Disulfiram (Tablet) 2 te

NaltrC1 exon (0.1% Cream, 0.1% e NaltrexoneHCl HCl 3 2 (Tablet) Ointment, 0.3%

VivitrC1 Ophthalmic Solution) ol

Vivitrol (Injection) 5 C1 Gent amic in B1 GentamicinSulfa Sulfate te 4 Opioid Dependence Treatments (40mg/ml Injection) BuprC1 enor phin Buprenorphinee HCl HCl 2 QL (Tablet Sublingual)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 31 31 530 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

GentC1 ClindC1 amic amy in cin GentamicinSulfa Sulfate/ ClindamycinPhos te/ phat 0.9% e in Sodi D5W um Chlo 0.9%ride Sodium Chloride 4 Phosphate in D5W 4 (Injection) (Injection)

IsotoC1 ColisC1 nic timet Gent hate Isotonicamic Gentamicin ColistimethateSodi Sodium in 4 um 4 (Injection) (Injection)

NeoC1 DaptC1 myci omy n cin NeomycinSulfa Sulfate Daptomycin (Injection) 5 te 2 LineC1 (Tablet) Linezolidzolid (100mg/5ml ParoC1 5 PA mom ycin ParomomycinSulfa Sulfate Suspension) te 4 LineC1 (Capsule) Linezolidzolid (600mg StreC1 4 PA, QL ptom ycin StreptomycinSulfa Sulfate Tablet) te 4 LineC1 (Injection) Linezolidzolid (600mg/ TobrC1 4 PA amy cin TobramycinSulfa Sulfate 300ml Injection) te MethC1 ena (0.3% Ophthalmic 2 mine Methenamine Hipp urate 4 Solution) Hippurate (Tablet)

TobrC1 amy MetrC1 cin onid TobramycinSulfa Sulfate azol te Metronidazolee (0.75% 3 (10mg/ml Injection, 4 Cream, 0.75% Gel)

MetrC1 80mg/2ml Injection) onid azol Metronidazolee (250mg B1 Antibacterials, Other Tablet Immediate- BacitC1 2 Bacitracinracin (Ophthalmic Release, 500mg Tablet 2 Ointment) Immediate-Release)

BactC1 MetrC1 roba onid n azol BactrobanNasa Nasal Metronidazolee in in NaCl l NaCl 0.79 4 PA % 4 (Ointment) 0.79% (Injection)

C1 C1 Metr Clind onid amy azol cin e HCl Metronidazole Vaginal Clindamycin HCl Vagi nal 3 (Capsule Immediate- 2 (Gel)

MupiC1 Release) Mupirocinrocin (2%

ClindC1 2 amy cin ClindamycinPalm Palmitate Ointment) itate HCl

4 NitroC1 furan HCl (Oral Solution) Nitrofurantointoin

ClindC1 4 amy cin ClindamycinPhos (Suspension) phat e

3 NitroC1 furan toin Phosphate (2% Cream) NitrofurantoinMacr ocry stals ClindC1 amy cin ClindamycinPhos Macrocrystals (100mg phat e Capsule, 50mg 3 Phosphate (300mg/ 2ml Injection, 600mg/ 4 Capsule) (Generic 4ml Injection, 900mg/ Macrodantin) 6ml Injection)

Bold type = Brand name drug Plain type = Generic drug 32 tRACK 32 Last updated October 1, 2018 631 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

NitroC1 CefoC1 furan tetan toin NitrofurantoinMon Cefotetan (Injection) 4 ohyd rate

CefoC1 xitin Monohydrate (100mg Sodi 3 Cefoxitinum Sodium Capsule) (Generic (10gm Injection, 1gm 4 Macrobid) Injection, 2gm

PolyC1 myxi n B PolymyxinSulfa B Sulfate Injection) te 4 CefpC1 odox (Injection) ime CefpodoximeProx Proxetil etil

TigeC1 cycli Tigecyclinene (Injection) 5 (100mg Tablet, 200mg TinidC1 azol Tinidazolee (Tablet) 2 Tablet, 100mg/5ml 4

TrimC1 etho Suspension, 50mg/5ml Trimethoprimprim (Tablet) 2

C1 Suspension) Vanc omy cin VancomycinHCl HCl CefpC1 Cefprozilrozil (125mg/5ml (1000mg Injection, Suspension, 250mg/ 10gm Injection, 500mg 4 5ml Suspension, 3 Injection, 125mg 250mg Tablet, 500mg Capsule, 250mg Tablet) Capsule) CeftC1 azidi me VanC1 dazo Ceftazidime (Injection) 4 Vandazolele (Gel) 3 CeftrC1 iaxo ne B1 CeftriaxoneSodi Sodium Beta-lactam, Cephalosporins um

C1 (10gm Injection, 1gm Cefa Cefaclorclor (250mg Injection, 250mg 4 Capsule Immediate- Injection, 2gm Release, 500mg 2 Injection, 500mg Capsule Immediate- Injection)

Release) CefuC1 roxi me Axeti C1 Cefuroxime Axetil Cefa l droxi l 2 Cefadroxil (250mg/5ml (Tablet)

Suspension, 500mg/ CefuC1 roxi me 2 CefuroximeSodi Sodium 5ml Suspension, um (1.5gm Injection, 500mg Capsule) 4

C1 7.5gm Injection, Cefa zolin Sodi Cefazolinum Sodium 4 750mg Injection) (Injection) CepC1 hale xin

C1 Cephalexin (125mg/ Cefd Cefdinirinir (125mg/5ml 5ml Suspension, Suspension, 250mg/ 3 250mg/5ml 5ml Suspension, Suspension, 250mg 2 300mg Capsule) Capsule, 500mg CefeC1 Cefepimepime (Injection) 4 Capsule, 750mg

CefixC1 Cefiximeime (Suspension) 4 Capsule)

CefoC1 taxi me CefotaximeSodi Sodium um 4 (Injection)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 33 33 732 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

SuprC1 AmoC1 ax xicilli n/ Suprax (100mg Tablet Amoxicillin/Clav ulan ate Pota ssiu m Chewable, 200mg 3 ClavulanateER Potassium 4 Tablet Chewable) ER (Tablet Extended-

SuprC1 Supraxax (400mg Release 12 Hour) AmpC1 Capsule, 500mg/5ml 3 Ampicillinicillin (Capsule) 2

AmpC1 icillin

Suspension) AmpicillinSodi Sodium um

TaziC1 cef (10gm Injection, Tazicef (Injection) 4 4 ZerbC1 Zerbaxaaxa (Injection) 4 PA 125mg Injection, 1gm

B1 Injection)

Beta-lactam, Other AmpC1 icillin - Sulb AztreC1 Ampicillin-Sulbactam acta ona m m 4 Aztreonam (Injection) 4 (Injection) DoriC1 pene m BactC1 Doripenem (Injection) 3 ocill in BactocillDext in Dextrose rose ImipC1 ene 4 m/ Imipenem/CilastatinCilas tatin 4 (Injection) BicillC1 (Injection) in C- BicillinR C-R (Injection) 4 InvaC1 nz BicillC1 Invanz (Injection) 4 in L- BicillinA L-A (Injection) 4 MerC1 open em DicloC1 Meropenem (Injection) 4 xacill in DicloxacillinSodi Sodium um B1 2 Beta-lactam, Penicillins (Capsule)

AmoC1 xicilli NafciC1 n llin Amoxicillin (125mg Sodi Nafcillinum Sodium Tablet Chewable, (10gm Injection, 1gm 4 250mg Tablet Injection)

OxacC1 Chewable, 125mg/5ml illin Sodi Oxacillinum Sodium 4 Suspension, 200mg/ (Injection)

5ml Suspension, C1 Peni cillin G PenicillinPota G Potassium ssiu 250mg/5ml 2 m 4 Suspension, 400mg/ (Injection) PeniC1 cillin G PenicillinProc G Procaine 5ml Suspension, aine 4 250mg Capsule, (Injection)

PeniC1 cillin G 500mg Capsule, PenicillinSodi G Sodium um 4 500mg Tablet, 875mg (Injection)

PeniC1 Tablet) cillin V PenicillinPota V Potassium ssiu AmoC1 m xicilli n/ Amoxicillin/Clav ulan (125mg/5ml Oral ate Pota ssiu Clavulanatem Potassium Solution, 250mg/5ml 2 (Tablet Chewable, 2 Oral Solution, 250mg Suspension, Tablet Tablet, 500mg Tablet)

PipeC1 Immediate-Release) racilli n/ Piperacillin/Tazo bact am 4 (Generic Augmentin) Tazobactam (Injection)

Bold type = Brand name drug Plain type = Generic drug 34 tRACK 34 Last updated October 1, 2018 833 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

B1 ErythC1 romy cin Macrolides ErythromycinBase Base 4 AzithC1 romy Azithromycincin (100mg/ (Tablet)

ErythC1 romy cin 5ml Suspension, ErythromycinEthyl succ 200mg/5ml Ethylsuccinateinate 2 Suspension, 250mg (200mg/5ml 4 Tablet, 500mg Tablet, Suspension, 400mg 600mg Tablet) Tablet)

AzithC1 B1 romy Azithromycincin (500mg Quinolones 4 CiprC1 oflox Injection) Ciprofloxacinacin ClaritC1 4 hro myci Clarithromycinn (Suspension)

CiprC1 oflox (125mg/5ml acin 4 CiprofloxacinHCl HCl Suspension, 250mg/ (0.3% Ophthalmic 5ml Suspension) Solution, 250mg Tablet

ClaritC1 hro myci Clarithromycinn (250mg Immediate-Release, 3 2 Tablet, 500mg Tablet) 500mg Tablet

ClaritC1 hro myci Immediate-Release, Clarithromycinn ER ER (Tablet Extended- 3 750mg Tablet Release 24 Hour) Immediate-Release)

CiprC1 oflox DificiC1 d acin Dificid (Tablet) 5 CiprofloxacinHCl HCl

E.E.C1 S. (0.3% Ophthalmic Gran E.E.S.ules Granules 4 Solution, 250mg Tablet 2 (Suspension) Immediate-Release, EryPC1 ed EryPed200 200 4 750mg Tablet) CiprC1 (Suspension) oflox acin CiprofloxacinI.V. I.V. in in EryPC1 D5W ed 4 EryPed400 400 4 D5W (Injection) LevoC1 floxa (Suspension) Levofloxacincin (0.5%

Ery-C1 Ery-TabTab (Tablet Ophthalmic Solution, 4 3 Delayed-Release) 250mg Tablet, 500mg

ErythC1 rocin Tablet, 750mg Tablet) ErythrocinLact obio nate LevoC1 floxa Lactobionate 4 Levofloxacincin (25mg/ml (Injection) Injection, 25mg/ml 4

ErythC1 romy Erythromycincin (250mg Oral Solution)

LevoC1 floxa cin Capsule Delayed- 4 Levofloxacinin in D5W D5W 4 Release) (Injection)

ErythC1 MoxiC1 romy floxa cin cin Erythromycin (5mg/gm MoxifloxacinHCl/ HCl/ Sodi um 2 HCl 4 Ophthalmic Ointment) Sodium HCl (Injection)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 35 35 934 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

MoxiC1 DoxyC1 floxa cycli cin ne MoxifloxacinHCl HCl DoxycyclineHycl Hyclate 3 ate (Tablet) (100mg Capsule,

OfloC1 xaci Ofloxacinn (0.3% 50mg Capsule, 100mg 2 3 Ophthalmic Solution) Tablet Immediate-

OfloC1 xaci Release, 20mg Tablet Ofloxacinn (0.3% Otic Immediate-Release) Solution, 300mg 3 DoxyC1 cycli ne DoxycyclineMon ohyd Tablet, 400mg Tablet) rate

B1 Monohydrate (100mg Sulfonamides C1 Capsule, 50mg Silve r Sulfa 3 Silverdiazi Sulfadiazine ne 3 Capsule, 100mg (Cream) Tablet, 50mg Tablet, SodiC1 um Sulfa Sodiumceta Sulfacetamide mide 2 75mg Tablet) MinoC1 cycli (Ophthalmic Solution) ne MinocyclineHCl HCl SSDC1 SSD (Cream) 3 (Capsule Immediate- 2

SulfaC1 ceta mide Release) Sulfacetamide Sodium Sodi um 2 TetraC1 cycli ne (Ophthalmic Ointment) TetracyclineHCl HCl

C1 4 Sulfa diazi Sulfadiazinene (Tablet) 4 (Capsule)

VibraC1 SulfaC1 myci meth n oxaz Vibramycin (50mg/ Sulfamethoxazole/ole/ Trim etho prim 4 5ml Syrup) Trimethoprim (200mg-40mg/5ml 2 AnticonvulsantsA1 Suspension, Anticonvulsants,B1 Other

400mg-80mg Tablet) BriviC1 act

SulfaC1 Briviact (100mg meth oxaz Sulfamethoxazole/ole/ Trim etho prim Tablet, 10mg Tablet, TrimethoprimDS DS 2 25mg Tablet, 50mg (Tablet) 5 QL

B1 Tablet, 75mg Tablet, Tetracyclines 10mg/ml Oral DemC1 eclo cycli Demeclocyclinene HCl HCl 4 Solution)

(Tablet) LeveC1 tirac etam DoxyC1 Levetiracetam (Tablet, 100 Doxy 100 (Injection) 4 100mg/ml Oral 3 DoxyC1 cycli Doxycyclinene (25mg/ 4 Solution) LeveC1 5ml Suspension) tirac etam Levetiracetam ER ER (Tablet Extended- 3 Release 24 Hour)

RowC1 eepr Roweepraa (Tablet) 3

Bold type = Brand name drug Plain type = Generic drug 36 tRACK 36 Last updated October 1, 2018 1035 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

RowC1 TiagC1 eepr abin a XR e Roweepra XR (Tablet TiagabineHCl HCl (Tablet) 4 ValprC1 oic Extended-Release 24 3 Acid Valproic Acid (250mg Hour) Capsule, 250mg/5ml 2

SpritC1 Spritamam (Tablet Oral Solution)

VigaC1 batri Disintegrating 4 Vigabatrinn (Packet) 5 PA, QL, LA Soluble) GlutamateB1 Reducing Agents

B1

FelbC1 amat Calcium Channel Modifying Agents Felbamatee (400mg CeloC1 ntin 4 Celontin (Capsule) 4 Tablet, 600mg Tablet)

C1 Etho FelbC1 suxi amat Ethosuximidemide (250mg Felbamatee (600mg/ 5 Capsule, 250mg/5ml 2 5ml Suspension)

FycoC1 Oral Solution) Fycompampa (0.5mg/ml ZoniC1 sami Zonisamidede (Capsule) 2 Suspension, 10mg Gamma-aminobutyricB1 Acid (GABA) Tablet, 12mg Tablet, 4 Augmenting Agents 2mg Tablet, 4mg

DiastC1 at Acu Tablet, 6mg Tablet, DiastatDial AcuDial (Gel) 4

DiastC1 at Pedi 8mg Tablet) Diastatatric Pediatric (Gel) 4

LamC1 otrigi C1 Gab ne apen Gabapentintin (100mg Lamotrigine (100mg Capsule, 300mg Tablet Immediate- Capsule, 400mg Release, 150mg Tablet 2 Immediate-Release, Capsule, 250mg/5ml 2 Oral Solution, 600mg 200mg Tablet Tablet, 800mg Tablet) Immediate-Release,

OnfiC1 25mg Tablet Onfi (10mg Tablet, 4 PA, QL Immediate-Release)

20mg Tablet) LamC1 otrigi ne OnfiC1 Lamotrigine (25mg Onfi (2.5mg/ml 4 PA Tablet Chewable, 5mg 3 Suspension) Tablet Chewable) PheC1 noba Phenobarbitalrbital (100mg Tablet, 15mg Tablet, 16.2mg Tablet, 30mg Tablet, 32.4mg Tablet, 2 60mg Tablet, 64.8mg Tablet, 97.2mg Tablet, 20mg/5ml Elixir)

PrimiC1 Primidonedone (Tablet) 2

SabriC1 Sabrill (500mg Tablet) 5 PA, QL, LA

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 37 37 1136 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

TopirC1 DilanC1 amat tin Topiramatee (100mg Dilantin (Capsule) 3

DilanC1 tin Tablet Immediate- INFA DilantinTAB INFATABS S 3 Release, 200mg Tablet (Tablet Chewable)

EpitoC1 Immediate-Release, l Epitol (Tablet) 2

25mg Tablet C1 Oxca rbaz epin Oxcarbazepinee Immediate-Release, 50mg Tablet 2 (150mg Tablet, 300mg 3 Immediate-Release, Tablet, 600mg Tablet) OxcaC1 rbaz epin 15mg Capsule Oxcarbazepinee Sprinkle Immediate- (300mg/5ml 4 Release, 25mg Suspension)

PegaC1 Capsule Sprinkle Peganonenone (Tablet) 4

PheC1 Immediate-Release) nyte Phenytekk (Capsule) 2 B1

PheC1 Sodium Channel Agents nytoi Phenytoinn (125mg/5ml AptiC1 om 2 Aptiom (Tablet) 4 QL Suspension)

BanzC1 el PheC1 nytoi Banzel (200mg Phenytoinn (50mg 3 Tablet, 400mg Tablet, 4 Tablet Chewable)

PheC1 nytoi 40mg/ml Suspension) n PhenytoinSodi Sodium um Exte CarbC1 nded 2 ama zepi Carbamazepinene Extended (Capsule)

VimpC1 (100mg Tablet Vimpatat (100mg Chewable, 100mg/5ml 2 Tablet, 150mg Tablet, Suspension, 200mg 200mg Tablet, 50mg 4 QL Tablet Immediate- Tablet, 10mg/ml Oral Release)

C1 Solution) Carb ama zepi ne Carbamazepine ER A1 ER (100mg Capsule Antidementia Agents B1 Extended-Release 12 Cholinesterase Inhibitors

DonC1 epez il Hour, 200mg Capsule DonepezilHCl HCl (10mg 2 QL Extended-Release 12 Tablet, 5mg Tablet)

DonC1 epez Hour, 300mg Capsule il DonepezilHCl HCl ODT Extended-Release 12 ODT 2 QL 2 (Tablet Dispersible) Hour, 100mg Tablet RivaC1 stig mine Rivastigmine Tartrate Tartr Extended-Release 12 ate 2 QL (Capsule) Hour, 200mg Tablet RivaC1 stig mine Rivastigmine Tran Extended-Release 12 sder mal Syst Hour, 400mg Tablet Transdermalem System 4 QL, ST Extended-Release 12 (Patch 24 Hour) Hour)

Bold type = Brand name drug Plain type = Generic drug 38 tRACK 38 Last updated October 1, 2018 1237 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

B1 TranC1 ylcyp romi N-methyl-D-aspartate (NMDA) Receptor Tranylcyprominene Sulfa te 4 Antagonist Sulfate (Tablet)

B1 MemC1 antin e MemantineHCl HCl (10mg SSRI/SNRI (Selective Serotonin Reuptake 3 PA, QL Tablet, 5mg Tablet) Inhibitors/Serotonin and Norepinephrine

MemC1 antin e HClMemantine HCl (2mg/ Reuptake Inhibitors)

4 PA, QL CitalC1 opra m ml Oral Solution) HBr Citalopram HBr (10mg MemC1 antin e HClMemantine HCl ER Tablet, 20mg Tablet, 1 ER (Capsule Extended- 3 PA, QL 40mg Tablet)

CitalC1 opra m Release 24 Hour) HBr Citalopram HBr MemC1 antin e HClMemantine HCl (10mg/5ml Oral 2 Titrat ion Pak 3 PA Titration Pak (Tablet) Solution)

EscitC1

A1 alopr am EscitalopramOxal Oxalate Antidepressants ate

B1 (10mg Tablet, 20mg Antidepressants, Other

C1 Tablet, 5mg Tablet, 2 Bupr opio n BupropionHCl HCl (Tablet 2 5mg/5ml Oral Immediate-Release) Solution) BuprC1 opio n FetziC1 BupropionHCl HCl SR ma SR Fetzima (Capsule (100mg Tablet Extended-Release 24 4 QL, ST Extended-Release 12 Hour) Hour, 150mg Tablet C1 Fetzi ma 2 Titrat Fetzimaion Titration Extended-Release 12 Pack Pack (Capsule Hour, 200mg Tablet 4 ST Extended-Release 12 Extended-Release 24 Hour) Hour Therapy Pack)

BuprC1 FluvC1 opio oxa n mine BupropionHCl HCl XL Fluvoxamine Maleate XL Male ate 3 (Tablet Extended- 2 (Tablet)

MapC1 rotili Release 24 Hour) ne MaprotilineHCl HCl MirtaC1 4 zapi Mirtazapinene (Tablet) 2 (Tablet)

MirtaC1 NefaC1 zapi zodo ne ne MirtazapineODT ODT NefazodoneHCl HCl 2 4 (Tablet Dispersible) (Tablet)

B1 ParoC1 xetin e Monoamine Oxidase Inhibitors ParoxetineHCl HCl (Tablet 2 EmsC1 Emsamam (Patch 24 Immediate-Release) 5 QL PaxilC1 Hour) Paxil (10mg/5ml 4 MarC1 Marplanplan (Tablet) 4 Suspension)

PheC1 nelzi ne PhenelzineSulfa Sulfate te 3 (Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 39 39 1338 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

SertrC1 DoxeC1 aline pin Sertraline HCl HCl (100mg DoxepinHCl HCl (100mg Tablet, 25mg Tablet, 1 Capsule, 10mg 50mg Tablet) Capsule, 150mg

SertrC1 aline Sertraline HCl HCl (20mg/ Capsule, 25mg 4 2 ml Concentrate) Capsule, 50mg

TrazC1 odon Capsule, 75mg e TrazodoneHCl HCl (100mg Capsule, 10mg/ml Tablet, 150mg Tablet, 1 Concentrate) 50mg Tablet) ImiprC1 amin e TrintC1 HCl ellix Imipramine HCl Trintellix (Tablet) 4 QL 4

C1 (Tablet) Venl afaxi ne VenlafaxineHCl HCl ImiprC1 amin e ImipraminePam Pamoate (Tablet Immediate- 2 oate 4 (Capsule) Release) NortrC1 iptyli ne VenlC1 HCl afaxi Nortriptyline HCl ne VenlafaxineHCl HCl ER ER (10mg Capsule, 25mg (150mg Capsule Capsule, 50mg Extended-Release 24 2 Capsule, 75mg Hour, 37.5mg Capsule 2 Capsule, 10mg/5ml Extended-Release 24 Oral Solution) Hour, 75mg Capsule ProtrC1 iptyli ne ProtriptylineHCl HCl Extended-Release 24 4 Hour) (Tablet)

TrimiC1 ViibrC1 pram yd ine TrimipramineMale Maleate Viibryd (Tablet) 4 QL ate 4

ViibrC1 yd (Capsule) Start Viibryder Starter Pack Pack 4 QL A1 (Kit) Antiemetics

B1 TricyclicsB1 Antiemetics, Other ComC1 pro AmitC1 riptyl Compro (Suppository) 4 ine AmitriptylineHCl HCl HydrC1 3 oxyzi ne HydroxyzinePam Pamoate (Tablet) oate 3 AmoC1 xapi (Capsule) Amoxapinene (Tablet) 3 MeclC1 izine CloC1 HCl mipr Meclizine HCl (Tablet) 2 amin Clomipraminee HCl HCl MetoC1 4 clopr amid Metoclopramidee HCl (Capsule) HCl

DesiC1 pram (10mg Tablet, 5mg ine DesipramineHCl HCl 3 2 (Tablet) Tablet, 5mg/5ml Oral Solution)

PerpC1 hena Perphenazinezine (Tablet) 4

ProcC1 hlorp erazi Prochlorperazinene 4 (Suppository)

Bold type = Brand name drug Plain type = Generic drug 40 tRACK 40 Last updated October 1, 2018 1439 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

ProcC1 ClotrC1 hlorp imaz erazi ole Prochlorperazinene Clotrimazole (1% Male ate 2 Maleate (Tablet) Cream, 1% External 2 ScoC1 pola Scopolaminemine (Patch 72 Solution, 10mg 4 Hour) Lozenge)

FlucC1

B1 onaz Emetogenic Therapy Adjuncts Fluconazoleole (100mg

ApreC1 pitan Tablet, 150mg Tablet, Aprepitantt (Therapy 4 PA 200mg Tablet, 50mg Pack, Capsule) 2

C1 Tablet, 10mg/ml Dron abin Dronabinolol (Capsule) 4 PA Suspension, 40mg/ml EmeC1 Emendnd (125mg Suspension) 4 PA FlucC1 onaz Suspension) ole Fluconazolein in NaCl NaCl GranC1 4 isetr on GranisetronHCl HCl (Injection)

3 B/D, PA, QL C1 Fluc ytosi (Tablet) Flucytosinene (Capsule) 5

OndC1 anse GrisC1 tron eoful HClOndansetron HCl vin GriseofulvinMicr Microsize osize (24mg Tablet, 4mg 2 B/D, PA (125mg/5ml 4 Tablet, 8mg Tablet) Suspension, 500mg

OndC1 anse tron HClOndansetron HCl Tablet)

GrisC1 eoful (4mg/5ml Oral 4 B/D, PA vin GriseofulvinUltra micr osize 4 Solution) Ultramicrosize (Tablet)

OndC1 anse ItracC1 tron onaz ODTOndansetron ODT ole 2 B/D, PA Itraconazole (Capsule) 4 PA, QL

JubliC1 (Tablet Dispersible) Jubliaa (External A1 4 Antifungals Solution)

B1

KetoC1 cona Antifungals Ketoconazolezole (2% AbelC1 Abelcetcet (Injection) 4 B/D, PA Cream, 2% Shampoo, 2

AmBC1 isom eAmBisome (Injection) 4 B/D, PA 200mg Tablet)

MicoC1 AmpC1 nazo hote le 3 ricin Miconazole 3 BAmphotericin B 4 B/D, PA 3 (Injection) (Suppository)

MycC1 CicloC1 amin piroxCiclopirox (0.77% Gel, Mycaminee (Injection) 4

C1 Nata 0.77% Suspension, 1% 3 Natacyncyn (Suspension) 4

NoxaC1 Shampoo) Noxafilfil (100mg Tablet

CicloC1 pirox 5 PA, QL Nail CiclopiroxLacq Nail uer Delayed-Release)

NoxaC1 Lacquer (External 3 Noxafilfil (40mg/ml Solution) 5 QL Suspension) CicloC1 pirox

Ola NyaC1 Ciclopirox Olamine myc mine 3 Nyamyc (Powder) 2 (Cream)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 41 41 1540 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

NystC1 DihyC1 atin droe rgota Nystatin (Cream, Dihydroergotaminemine

Mes 1 ylate Ointment) Mesylate (Nasal 5

NystC1 Nystatinatin (Powder, Solution) 2 ErgoC1 tami ne Suspension, Tablet) ErgotamineTartr Tartrate/ ate/ Caff eine 3 NystC1 Nystopop (Powder) 2 Caffeine (Tablet)

MigeC1 SporC1 rgot Sporanoxanox (10mg/ml Migergot (Suppository) 4 5 PA B1 Oral Solution) Serotonin (5-HT) 1b/1d Receptor Agonists

NaraC1 TerbiC1 tripta nafin n e HCl TerbinafineHCl HCl Naratriptan HCl 2 3 QL (Tablet) (Tablet)

C1 C1 Rizat Terc ripta onaz n ole RizatriptanBenz Benzoate Terconazole (0.4% oate 2 QL Cream, 0.8% Cream, 3 (Tablet)

RizatC1 ripta n 80mg Suppository) RizatriptanBenz Benzoate oate ODT VoricC1 onaz ole ODT (Tablet 2 QL Voriconazole (200mg Injection, 40mg/ml 5 Dispersible)

SumC1 atript Suspension) Sumatriptanan (Nasal

VoricC1 4 QL onaz Voriconazoleole (200mg Solution)

4 SumC1 atript an Tablet, 50mg Tablet) SumatriptanSucc Succinate inate AntigoutA1 Agents (100mg Tablet, 25mg 2 QL AntigoutB1 Agents Tablet, 50mg Tablet) SumC1 atript AllopC1 an urino SumatriptanSucc Succinate Allopurinoll (Tablet) 1 inate

ColcC1 (4mg/0.5ml Injection, 4 QL hicin Colchicinee (0.6mg 6mg/0.5ml Injection)

Capsule) (Generic 3 QL SumC1 atript an SumatriptanSucc Mitigare) inate

C1 Succinate (6mg/ Colc 4 QL hicin Colchicinee (0.6mg 0.5ml Injection)

Tablet) (Generic 3 QL C1 Sum atript an SumatriptanSucc inate Colcrys) Refill

ProbC1 enec Succinate Refill 4 QL Probenecidid (Tablet) 2

ProbC1 (Injection) enec id/ Colc Probenecid/Colchicine A1 hicin e 2 (Tablet) Antimyasthenic Agents B1

UloriC1 Uloricc (Tablet) 3 ST Parasympathomimetics GuaC1 nidin A1 e GuanidineHCl HCl Antimigraine Agents 3 B1 (Tablet)

Ergot Alkaloids C1 Pyrid ostig mine Pyridostigmine Bro mide Bromide (Tablet 3 Immediate-Release)

Bold type = Brand name drug Plain type = Generic drug 42 tRACK 42 Last updated October 1, 2018 1641 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

PyridC1 HexaC1 ostig len mine Pyridostigmine Hexalen (Capsule) 5 PA Bro mide ER LeukC1 Bromide ER (Tablet 4 Leukeraneran (Tablet) 4

MatuC1 Extended-Release) lane Matulane (Capsule) 5 LA A1

ValcC1 Antimycobacterials hlor Valchlor (Gel) 5 PA, LA B1

Antimycobacterials, Other B1 Antiandrogens DapsC1 one BicalC1 Dapsone (Tablet) 3 utam Bicalutamideide (Tablet) 2 RifaC1 butin

ErleaC1 Rifabutin (Capsule) 4 da Erleada (Tablet) 5 PA, QL B1

FlutaC1 Antituberculars mide Flutamide (Capsule) 3 EthaC1 mbut ol HCl NilutC1 Ethambutol HCl amid 2 Nilutamidee (Tablet) 5

(Tablet) C1 Xtan di IsoniC1 Xtandi (Capsule) 5 PA, QL, LA azid Isoniazid (100mg C1 Zytig 2 a Tablet, 300mg Tablet) Zytiga (Tablet) 4 PA, QL, LA

B1

IsoniC1 Isoniazidazid (50mg/5ml Antiangiogenic Agents PomC1 4 alyst Syrup) Pomalyst (Capsule) 5 PA, QL

RevliC1 PaseC1 Paserr (Packet) 4 Revlimidmid (Capsule) 5 PA, QL, LA

ThalC1 PriftiC1 Priftinn (Tablet) 4 omidThalomid (Capsule) 5 PA, QL

B1 PyraC1 zina Pyrazinamidemide (Tablet) 4 /Modifiers

C1 C1 Emc Rifa mpin Emcytyt (Capsule) 4 Rifampin (150mg FareC1 Capsule, 300mg 2 Farestonston (Tablet) 5

SoltaC1 Capsule) Soltamoxmox (Oral RifaC1 Rifampinmpin (600mg 4 4 Solution)

TamC1 Injection) oxife n TamoxifenCitra Citrate te RifatC1 er 2 Rifater (Tablet) 4 (Tablet)

SirtuC1 ro Sirturo (Tablet) 5 PA, LA AntimetabolitesB1 TrecC1 ator DroxiC1 Trecator (Tablet) 4 Droxiaa (Capsule) 3

A1 HydrC1 oxyu Antineoplastics Hydroxyurearea (Capsule) 2

B1

MercC1 apto Alkylating Agents purin Mercaptopurinee

CyclC1 opho 3 spha Cyclophosphamidemide (Tablet) 4 B/D, PA PurixC1 (Capsule) Purixanan (Suspension) 5 PA

GleoC1 stine TablC1 Gleostine (100mg oid Tabloid (Tablet) 4 PA Capsule, 40mg 4 Antineoplastics,B1 Other

Capsule) KisqC1 ali

C1 Kisqali (Tablet) 5 PA, QL Gleo Gleostinestine (10mg 3 Capsule)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 43 43 1742 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

KisqC1 AlunC1 ali brig Fem Kisqaliara Femara 200 Alunbrig (Tablet 200 Dose Dose (Tablet Therapy 5 PA, QL Therapy Pack, 180mg 5 PA, QL, LA Pack) Tablet, 30mg Tablet,

KisqC1 ali Fem 90mg Tablet) araKisqali Femara 400 400 Dose BosuC1 Dose (Tablet Therapy 5 PA, QL lifBosulif (Tablet) 5 PA, QL

CabC1 omet Pack) Cabometyxyx (Tablet) 5 PA, QL, LA

KisqC1 ali CalqC1 Fem uenc araKisqali Femara 600 e 600 Calquence (Capsule) 5 PA, QL Dose

CaprC1 Dose (Tablet Therapy 5 PA, QL Caprelsaelsa (Tablet) 5 PA, LA

ComC1 Pack) etriqCometriq (Kit) 5 PA, LA LeucC1 ovori n CoteC1 Calci Leucovorin Calcium llic um Cotellic (Tablet) 5 PA, QL, LA

(10mg Tablet, 15mg 3 C1 Erive Tablet, 5mg Tablet) dgeErivedge (Capsule) 5 PA, QL, LA FaryC1 dak LeucC1 ovori Farydak (Capsule) 5 PA n LeucovorinCalci Calcium um GilotC1 4 rif (25mg Tablet) Gilotrif (Tablet) 5 PA, LA

IbranC1 C1 Lons ce Lonsurfurf (Tablet) 5 PA, QL, LA Ibrance (Capsule) 5 PA, QL, LA

IclusiC1 C1 Ninla g Ninlaroro (Capsule) 5 PA, QL Iclusig (Tablet) 5 PA, QL, LA

IdhifC1 C1 Synri a boSynribo (Injection) 5 PA Idhifa (Tablet) 5 PA, QL, LA

ImatiC1 C1 Verz nib enio Mes ylateImatinib Mesylate Verzenio (Tablet) 5 PA, QL, LA 5 PA, QL ZolinC1 Zolinzaza (Capsule) 5 PA (Tablet) ImbrC1 uvic AromataseB1 Inhibitors, 3rd Generation Imbruvicaa (140mg

AnasC1 Capsule, 70mg trozo 5 PA, QL, LA Anastrozolele (Tablet) 2

ExeC1 Capsule) mest ane Exemestane (Tablet) 4 ImbrC1 uvic a LetrC1 Imbruvica (140mg ozol Letrozolee (Tablet) 2 Tablet, 280mg Tablet, B1 5 PA, QL Enzyme Inhibitors 420mg Tablet, 560mg RubrC1 Rubracaaca (Tablet) 5 PA, QL, LA Tablet)

ZejulC1 a InlytC1 Zejula (Capsule) 5 PA, QL, LA Inlytaa (Tablet) 5 PA, QL, LA

B1 IressC1 Molecular Target Inhibitors aIressa (Tablet) 5 PA, QL, LA

AfinitC1 or JakaC1 Afinitor (Tablet) 5 PA fiJakafi (Tablet) 5 PA, QL, LA

AfinitC1 or LenvC1 Disp ima Afinitorerz Disperz Lenvima (Capsule 5 PA 5 PA, LA (Tablet Soluble) Therapy Pack)

AlecC1 ensa LynpC1 Alecensa (Capsule) 5 PA, QL, LA arzaLynparza (100mg Tablet, 150mg Tablet, 5 PA, QL, LA 50mg Capsule)

Bold type = Brand name drug Plain type = Generic drug 44 tRACK 44 Last updated October 1, 2018 1843 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

MekiC1 MesC1 Mekinistnist (Tablet) 5 PA, LA Mesnexnex (400mg

C1 5 Nerly Nerlynxnx (Tablet) 5 PA, QL, LA Tablet)

A1 NexaC1 Nexavarvar (Tablet) 5 PA, LA Antiparasitics

B1 OdoC1 Odomzomzo (Capsule) 5 PA, QL, LA Anthelmintics

AlbeC1 RydaC1 nza Rydaptpt (Capsule) 5 PA, QL Albenza (Tablet) 5 QL

BiltriC1 SpryC1 cide celSprycel (Tablet) 5 PA, QL Biltricide (Tablet) 4

IverC1 StivaC1 mect rgaStivarga (Tablet) 5 PA, QL, LA Ivermectinin (Tablet) 3

B1 SuteC1 Sutentnt (Capsule) 5 PA, QL Antiprotozoals

AliniC1 TafinC1 a lar Alinia (100mg/5ml Tafinlar (Capsule) 5 PA, LA TagriC1 Tagrissosso (Tablet) 5 PA, QL, LA Suspension, 500mg 4

TarcC1 Tarcevaeva (Tablet) 5 PA, QL, LA Tablet) AtovC1 aquo ne TasiC1 gna Atovaquone Tasigna (Capsule) 5 PA, QL 5

C1 (Suspension) Tyke rb

Tykerb (Tablet) 5 PA, LA AtovC1 aquo ne/ Prog C1 Atovaquone/Proguanil Venc uanil Venclextalexta (100mg HCl 4 PA, QL, LA HCl (Tablet) (Generic 3 Tablet, 50mg Tablet) Malarone)

VencC1 lexta BenzC1 nida Venclexta (10mg zole 3 PA, QL, LA Benznidazole (Tablet) 4

ChloC1 Tablet) roqui ne ChloroquinePhos phat VencC1 e lexta 2

VenclextaStarti Starting ng Phosphate (Tablet) Pack

CoarC1 Pack (Tablet Therapy 4 PA, LA Coartemtem (Tablet) 4

DARC1 Pack) APRI DARAPRIMM (Tablet) 4 VotriC1 ent HydrC1 Votrient (Tablet) 5 PA, QL, LA oxyc hloro Hydroxychloroquinequin e XalkC1 Sulfa ori te 2 Xalkori (Capsule) 5 PA, LA Sulfate (Tablet)

ZelbC1 oraf MeflC1 oqui Zelboraf (Tablet) 5 PA, QL, LA ne MefloquineHCl HCl ZydeC1 2 Zydeliglig (Tablet) 5 PA, QL, LA (Tablet)

ZykaC1 NebC1 dia upen Zykadia (Capsule) 5 PA, QL Nebupentt (Inhalation

B1 4 B/D, PA, QL Retinoids Solution)

PentC1 BexaC1 am rote 300 ne Pentam 300 Bexarotene (Capsule) 5 PA 4 PanrC1 Panretinetin (Gel) 5 (Injection) PrimC1 aqui TargC1 ne retin PrimaquinePhos Phosphate phat Targretin (1% Gel) 5 PA e 4 TretiC1 (Tablet) noin Tretinoin (10mg C1 Quin ine 5 Sulfa Quininete Sulfate Capsule) 4 PA B1 (Capsule)

Treatment Adjuncts B1 Pediculicides/Scabicides

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 45 45 1944 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

LindC1 CarbC1 ane idop a/ Lindane (Shampoo) 4 Carbidopa/LevodopaLevo dopa ER MalaC1 Malathionthion (Lotion) 4 ER (Tablet Extended- 2

PerC1 meth Release) Permethrinrin (Cream) 3 CarbC1 idop a/ A1 Carbidopa/LevodopaLevo dopa Antiparkinson Agents ODT

B1 ODT (Tablet 2 Anticholinergics Dispersible) BenzC1 tropi ne CarbC1 Mes idop Benztropine Mesylate a/ ylate Carbidopa/Levodopa/Levo dopa 2 / Enta 4 capo (Tablet) Entacaponene (Tablet) TriheC1 xyph enid RytaC1 Trihexyphenidylyl HCl ry HCl Rytary (Capsule 4 ST (0.4mg/ml Elixir, 2mg 2 Extended-Release)

Tablet, 5mg Tablet) B1

B1 Monoamine Oxidase B (MAO-B) Inhibitors

Antiparkinson Agents, Other RasaC1 gilin e Mes C1 Ama Rasagiline Mesylate ylate ntadi ne HCl 4 Amantadine HCl (Tablet)

(100mg Capsule, 2 SeleC1 gilin e SelegilineHCl HCl (5mg 50mg/5ml Syrup) 3

EntaC1 Capsule, 5mg Tablet) capo ne Entacapone (Tablet) 4 A1

B1 Antipsychotics

Dopamine Agonists B1

ApoC1 1st Generation/Typical kyn

Apokyn (Injection) 5 PA, QL, LA ChloC1 rpro mazi ne C1 Bro Chlorpromazine HCl HCl mocr iptin Bromocriptinee 4 Mes ylate (Tablet)

Mesylate (2.5mg 4 FlupC1 hena zine FluphenazineDec anoa Tablet, 5mg Capsule) te 4

NeuC1 Decanoate (Injection) pro

C1 Neupro (Patch 24 Flup hena zine 4 FluphenazineHCl HCl Hour) C1 (10mg Tablet, 1mg Pra mipe xole 2 PramipexoleDihy droc hlori Tablet, 2.5mg Tablet, Dihydrochloridede 2 5mg Tablet) (Tablet Immediate- FlupC1 hena zine FluphenazineHCl HCl Release)

C1 (2.5mg/5ml Elixir, 4 Ropi nirol e RopiniroleHCl HCl (Tablet 2 2.5mg/ml Injection) Immediate-Release) FlupC1 hena zine HCl B1 Fluphenazine HCl 3 Dopamine Precursors/L-Amino Acid (5mg/ml Concentrate)

HaloC1 Decarboxylase Inhibitors perid Haloperidolol (0.5mg CarbC1 idop a/ Carbidopa/LevodopaLevo dopa Tablet, 10mg Tablet, (Tablet Immediate- 2 1mg Tablet, 20mg 2 Release) Tablet, 2mg Tablet, 5mg Tablet, 2mg/ml Concentrate)

Bold type = Brand name drug Plain type = Generic drug 46 tRACK 46 Last updated October 1, 2018 2045 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

HaloC1 InveC1 perid ga ol Sust HaloperidolDec Decanoate Invegaenna Sustenna anoa te 4 (Injection) (117mg/0.75ml

HaloC1 perid ol HaloperidolLact Lactate Injection, 156mg/ml ate 4 (Injection) Injection, 234mg/ 5

LoxaC1 pine Succ Loxapineinate Succinate 1.5ml Injection, 2 (Capsule) 78mg/0.5ml

PimoC1 Pimozidezide (Tablet) 3 Injection)

InveC1 ThiorC1 ga idazi Sust ne Invegaenna Sustenna ThioridazineHCl HCl 3 (Tablet) (39mg/0.25ml 4

ThiotC1 hixe Thiothixenene (Capsule) 3 Injection)

InveC1 TrifluC1 ga oper Trinz azin Invegaa Trinza Trifluoperazinee HCl HCl 3 5 (Tablet) (Injection)

LatuC1 B1 2nd Generation/Atypical Latudada (Tablet) 5 QL

NuplC1 C1 Abilif azid y Main Abilifytena Maintena Nuplazid (Tablet) 5 PA, QL

5 OlanC1 zapi (Injection) Olanzapinene (10mg

C1 4 Aripi praz Aripiprazoleole (10mg Injection)

OlanC1 zapi Tablet, 15mg Tablet, Olanzapinene (10mg 20mg Tablet, 2mg Tablet, 15mg Tablet, 4 QL Tablet, 30mg Tablet, 2.5mg Tablet, 20mg 2 QL 5mg Tablet, 1mg/ml Tablet, 5mg Tablet, Oral Solution) 7.5mg Tablet)

AripiC1 OlanC1 praz zapi ole ne AripiprazoleODT ODT OlanzapineODT ODT 4 QL 2 QL (Tablet Dispersible) (Tablet Dispersible)

AristC1 PalipC1 ada erido ne Aristada (Injection) 5 PaliperidoneER ER

FanaC1 Fanaptpt (Tablet) 4 QL, ST (Tablet Extended- 4 QL

FanaC1 pt Release 24 Hour) Titrat ionFanapt Titration Pack Pack QuetC1 iapin 4 ST e QuetiapineFum Fumarate (Tablet) arate

GeoC1 (Tablet Immediate- 2 QL Geodondon (20mg 4 Release)

Injection) RexuC1 Rexultilti (Tablet) 5 QL

RispC1 erdal

RisperdalCon Consta sta 4 (12.5mg Injection)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 47 47 2146 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

RispC1 A1 erdal

RisperdalCon Consta Antivirals sta (25mg Injection, B1 5 Anti-cytomegalovirus (CMV) Agents ValgC1 anci 37.5mg Injection, clovi Valganciclovirr (Tablet) 5 QL

ValgC1 50mg Injection) anci clovi Valganciclovirr Hydr RispC1 ochl erido orde Risperidonene (0.25mg Hydrochlorde (Oral 5 QL Tablet, 0.5mg Tablet, Solution)

ZirgaC1 1mg Tablet, 2mg 2 Zirgann (Gel) 4

Tablet, 3mg Tablet, B1 4mg Tablet) Anti-hepatitis B (HBV) Agents BaraC1 clud RispC1 e erido Baraclude (0.05mg/ Risperidonene (1mg/ml 4 4 Oral Solution) ml Oral Solution) EnteC1 cavir RispC1 erido ne Entecavir (Tablet) 4 RisperidoneODT ODT

EpiviC1 4 r (Tablet Dispersible) EpivirHBV HBV (5mg/ml

C1 4 Sap Saphrishris (Tablet Oral Solution)

4 QL LamiC1 vudi Sublingual) Lamivudinene (100mg 3 VraylC1 Vraylarar (1.5mg Tablet)

VemlC1 Capsule, 3mg Vemlidyidy (Tablet) 5 QL Capsule, 4.5mg 4 QL, ST Anti-hepatitisB1 C (HCV) Agents, Other

IntroC1 Capsule, 6mg Intronn A A (Injection) 5 PA, LA

PegaC1 Capsule) sysPegasys (Injection) 5 PA VraylC1 ar RibaC1 Vraylar (Capsule sphe 4 ST Ribaspherere (200mg Therapy Pack) Tablet, 400mg Tablet, 3

ZipraC1 sido ne ZiprasidoneHCl HCl 600mg Tablet) 2 QL RibaC1 (Capsule) Ribavirinvirin (200mg ZyprC1 3 exa Relp Zyprexarevv Relprevv Tablet)

4 C1 Sylat (Injection) Sylatronron (Injection) 5 PA

B1 Treatment-Resistant Anti-hepatitisB1 C (HCV) Direct Acting Agents

ClozC1 apin EpclC1 Clozapinee (100mg Epclusausa (Tablet) 5 PA, QL

HarvC1 Tablet, 25mg Tablet, oni 3 Harvoni (Tablet) 5 PA, QL

50mg Tablet, 200mg MavC1 yret Tablet) Mavyret (Tablet) 5 PA, QL VoseC1 vi ClozC1 apin Vosevi (Tablet) 5 PA, QL e ClozapineODT ODT (Tablet 4 QL B1 Dispersible) Antiherpetic Agents

VersC1 aclo Versaclozz 5 (Suspension)

Bold type = Brand name drug Plain type = Generic drug 48 tRACK 48 Last updated October 1, 2018 2247 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

AcycC1 EfaviC1 lovir renz Acyclovir (200mg Efavirenz (200mg Capsule, 400mg 2 Capsule, 600mg 5 QL Tablet, 800mg Tablet) Tablet)

AcycC1 EfaviC1 Acyclovirlovir (200mg/5ml Efavirenzrenz (50mg 4 4 QL Suspension) Capsule)

AcycC1 IntelC1 lovir ence Sodi Acyclovirum Sodium Intelence (100mg 4 B/D, PA 5 QL (Injection) Tablet, 200mg Tablet)

C1 Fam C1 ciclo Intel virFamciclovir (Tablet) 3 QL Intelenceence (25mg

TrifluC1 4 QL ridin Trifluridinee Tablet)

3 C1 Julu (Ophthalmic Solution) Julucaca (Tablet) 5 QL

ValaC1 cycl NevirC1 ovir apin ValacyclovirHCl HCl e 2 QL Nevirapine (Tablet) 2 QL NevirC1 (Tablet) apin Nevirapinee ER ER (Tablet B1 Anti-HIV Agents, Integrase Inhibitors (INSTI) Extended-Release 24 4 QL

GenC1 Genvoyavoya (Tablet) 5 QL Hour)

C1 IsentC1 Odef Isentressress (100mg Odefseysey (Tablet) 5 QL

RescC1 ripto Packet, 25mg Tablet 3 QL Rescriptorr (Tablet) 4 QL

SymfC1 Chewable) Symfii (Tablet) 5 QL

IsentC1 ress SymfC1 Isentress (100mg Symfii Lo Lo (Tablet) 5 QL

ViraC1 Tablet Chewable, 5 QL mun Viramunee (50mg/5ml 5 QL 400mg Tablet) Suspension) IsentC1 ress IsentressHD HD (Tablet) 5 QL Anti-HIVB1 Agents, Nucleoside and Nucleotide StribiC1 Stribildld (Tablet) 5 QL Reverse Transcriptase Inhibitors (NRTI)

TivicC1 ay AbaC1 Tivicay (10mg Tablet) 4 QL Abacavircavir (20mg/ml

TivicC1 Tivicayay (25mg Tablet, Oral Solution, 300mg 4 QL 5 QL 50mg Tablet) Tablet)

AbaC1 TriuC1 cavir meq

AbacavirSulfa Sulfate/ Triumeq (Tablet) 5 QL te/ Lami vudi ne/ TyboC1 Zido st Lamivudine/vudi 5 QL Tybost (Tablet) 4 QL ne

B1 Zidovudine (Tablet)

Anti-HIV Agents, Non-nucleoside Reverse C1 Aba cavir / Abacavir/LamivudineLami vudi Transcriptase Inhibitors (NNRTI) ne 4 QL

AtripC1 (Tablet) la

Atripla (Tablet) 5 QL BiktaC1 rvy

C1 Biktarvy (Tablet) Com 5 QL plera

Complera (Tablet) 5 QL CimC1 duo

C1 Cimduo (Tablet) Edur 5 QL ant

Edurant (Tablet) 5 QL DescC1 Descovyovy (Tablet) 5 QL

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 49 49 2348 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

DidaC1 SelzC1 nosi entry Didanosinene (Capsule Selzentry (25mg 2 QL 3 QL Delayed-Release) Tablet)

C1 Emtri B1 Emtrivava (10mg/ml Anti-HIV Agents, Protease Inhibitors

AptivC1 Oral Solution, 200mg 4 QL Aptivusus (100mg/ml Capsule) Oral Solution, 250mg 5 QL

LamiC1 vudi Lamivudinene (10mg/ml Capsule)

AtazC1 Oral Solution, 150mg 3 QL anav ir AtazanavirSulfa Sulfate te 5 QL Tablet, 300mg Tablet) (Capsule) LamiC1 vudi ne/ CrixiC1 Lamivudine/Zido van vudi ne 4 QL Crixivan (Capsule) 3 QL

Zidovudine (Tablet) EvotC1 az

C1 Evotaz (Tablet) 5 QL Stav udin e Stavudine (Capsule) 2 QL FosaC1 mpr enav ir C1 Fosamprenavir Teno Calci fovir um Diso 5 QL Tenofovirproxi Disoproxil l Fum Calcium (Tablet) arate 5 QL

Fumarate (Tablet) InvirC1 ase

C1 Invirase (200mg Truv ada Truvada (Tablet) 5 QL Capsule, 500mg 5 QL VideC1 Videxx EC EC (125mg Tablet)

KaletC1 Capsule Delayed- 4 QL Kaletrara (100mg-25mg 4 QL Release) Tablet) VideC1 x Pedi KaletC1 atric Videx Pediatric (Oral Kaletrara (200mg-50mg 4 QL 5 QL Solution) Tablet) VireaC1 d LexivC1 Viread (150mg Tablet, Lexivaa (50mg/ml 200mg Tablet, 250mg 4 QL 5 QL Suspension)

Tablet, 40mg/gm LopiC1 navir / Lopinavir/RitonavirRito Powder) navir 4 QL (Oral Solution) ZeritC1

NorviC1 Zerit (1mg/ml Oral r 4 QL Norvir (100mg Solution) Capsule, 100mg ZidoC1 vudi ne 4 QL Zidovudine (100mg Packet, 80mg/ml Oral Capsule, 300mg 2 QL Solution)

Tablet, 50mg/5ml PrezC1 cobi Syrup) Prezcobixx (Tablet) 5 QL PreziC1 sta Anti-HIVB1 Agents, Other Prezista (100mg/ml

FuzeC1 Suspension, 600mg 5 QL Fuzeonon (Injection) 5 QL

SelzC1 Tablet, 800mg Tablet) entry

Selzentry (150mg PreziC1 Prezistasta (150mg Tablet, 300mg Tablet, 4 QL 5 QL Tablet, 75mg Tablet) 75mg Tablet, 20mg/ ml Oral Solution)

Bold type = Brand name drug Plain type = Generic drug 50 tRACK 50 Last updated October 1, 2018 2449 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

ReyaC1 ClorC1 taz azep ate Reyataz (50mg ClorazepateDipo tassi 5 QL um 3 QL Packet) Dipotassium (Tablet)

C1 C1 Diaz Rito epa Ritonavirnavir (Tablet) 4 QL Diazepamm (10mg

ViracC1 Viraceptept (Tablet) 5 QL Tablet, 2mg Tablet, 2 QL

B1 5mg Tablet)

Anti-influenza Agents C1 Diaz epa m C1 Oselt Diazepam (1mg/ml amivi r OseltamivirPhos Phosphate 2 phat e Oral Solution)

(30mg Capsule, 45mg C1 Diaz epa m DiazepamInten Intensol Capsule, 75mg 3 QL sol 2 QL Capsule, 6mg/ml (5mg/ml Concentrate) Suspension) BipolarA1 Agents

B1 ReleC1 nza Disk Relenzahaler Diskhaler Mood Stabilizers

3 QL DivalC1 proe x (Aerosol Powder) DivalproexSodi Sodium um RimaC1 ntadi ne (Capsule Sprinkle 2 RimantadineHCl HCl 2 (Tablet) Delayed-Release)

DivalC1 A1 proe x DivalproexSodi Sodium DR um Anxiolytics DR Anxiolytics,B1 Other (Tablet Delayed- 2

BusC1 Release) piron e HCl Buspirone HCl (Tablet) 2 DivalC1 proe x Sodi HydrC1 Divalproex Sodium ER um oxyzi ER ne HydroxyzineHCl HCl (Tablet Extended- 2 (10mg Tablet, 25mg 3 Release 24 Hour)

Tablet, 10mg/5ml LithiC1 Lithiumum (Oral Syrup) 3

HydrC1 Solution) oxyzi ne HCl Hydroxyzine HCl C1 Lithi um Carb Lithiumonat Carbonate (10mg Tablet, 25mg e 3 (Capsule Immediate- Tablet, 50mg Tablet, 2 10mg/5ml Syrup) Release,Tablet

B1 Immediate-Release)

Benzodiazepines C1 Lithi um Carb AlprC1 Lithiumonat Carbonate ER azol e ER Alprazolamam (Tablet 2 QL (Tablet Extended- 2 Immediate-Release) Release) ChloC1 rdiaz epox A1 Chlordiazepoxideide HCl HCl 2 Blood Glucose Regulators

(Capsule) B1

ClonC1 Antidiabetic Agents azep am

Clonazepam (Tablet C1 Acar 2 QL bose Immediate-Release) Acarbose (Tablet) 2 QL BydC1 ureo ClonC1 n azep BydureonBcis Bcise (Auto am e ClonazepamODT ODT 4 QL 3 QL (Tablet Dispersible) injector)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 51 51 2550 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

BydC1 RepC1 ureo aglin n ide BydureonPen Pen Repaglinide (Tablet) 2 QL

3 QL C1 Soliq ua (Injection) 100/ Soliqua33 100/33

BydC1 3 QL ureo n BydureonVial Vial (Injection)

3 QL C1 Synj (Injection) Synjardyardy (Tablet) 3 QL

FarxiC1 ga SynjC1 ardy Farxiga (Tablet) 3 QL SynjardyXR XR (Tablet

GlimC1 epiri Glimepiridede (Tablet) 1 QL Extended-Release 24 3 QL

GlipiC1 Glipizidezide (Tablet Hour)

1 QL TradjC1 Immediate-Release) Tradjentaenta (Tablet) 3 QL

C1 Glipi C1 zide Truli GlipizideER ER (Tablet Trulicitycity (Injection) 3 QL

XigdC1 Extended-Release 24 1 QL uo XigduoXR XR (Tablet Hour) Extended-Release 24 3 QL GlipiC1 zide/ Metf Glipizide/Metforminormi n HCl 1 QL Hour) HCl (Tablet) B1 Glycemic Agents GlyxC1 ambi Glyxambi (Tablet) 3 QL GlucC1 aGe n GlucaGenHyp HypoKit JardiC1 oKit ance 4 Jardiance (Tablet) 3 QL (Injection) JentC1 adue to GlucC1 Jentadueto (Tablet) 3 QL agon

GlucagonEme Emergency rgen JentC1 cy adue Kit 3 to JentaduetoXR XR Kit (Injection)

ProgC1 (Tablet Extended- 3 QL lyce Proglycemm 5 Release 24 Hour) (Suspension) KomC1 bigly ze B1 KombiglyzeXR XR Insulins

(Tablet Extended- 3 QL HumC1 alog Cartr Humalogidge Cartridge Release 24 Hour) 3 (Injection) MetfC1 ormi n MetforminHCl HCl (Tablet HumC1 alog Juni 1 QL Humalogor Junior Kwik Immediate-Release) Pen 3

MetfC1 KwikPen (Injection) ormi n HCl Metformin HCl ER HumC1 ER alog Kwik HumalogPen KwikPen (500mg Tablet 3 Extended-Release 24 (Injection) HumC1 alog Mix Humalog50/5 Mix 50/50 Hour, 750mg Tablet 1 QL 0 Kwik Pen 3 Extended-Release 24 KwikPen (Injection)

HumC1 alog Hour) (Generic Mix Humalog50/5 Mix 50/50 0 Vial 3 Glucophage XR) Vial (Injection) NateC1 glini de HumC1 Nateglinide (Tablet) 2 QL alog Mix Humalog75/2 Mix 75/25 5 OnglC1 Kwik yza Pen 3 Onglyza (Tablet) 3 QL KwikPen (Injection)

PioglC1 itazo ne PioglitazoneHCl HCl 1 QL (Tablet)

Bold type = Brand name drug Plain type = Generic drug 52 tRACK 52 Last updated October 1, 2018 2651 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

HumC1 EnoxC1 alog apari Mix n Humalog75/2 Mix 75/25 EnoxaparinSodi Sodium 5 um Vial 3 4 QL Vial (Injection) (Injection)

C1 C1 Fond Hum apari alog nux Vial FondaparinuxSodi Sodium Humalog Vial um 3 4 (Injection) (Injection)

HepC1 HumC1 arin ulin Sodi 70/3 Heparinum Sodium Humulin0 70/30 Kwik Pen 3 KwikPen (Injection) (10000unit/ml

HumC1 Injection, 20000unit/ml 3 ulin 70/3 Humulin0 70/30 Vial Vial 3 Injection, 5000unit/ml (Injection) Injection) HumC1 ulin N HepC1 HumulinKwik N KwikPen arin Pen Sodi Heparinum Sodium 3 3 B/D, PA (Injection) (1000unit/ml Injection) HumC1 ulin N JantC1 HumulinVial N Vial oven 3 Jantoven (Tablet) 1

PradC1 (Injection) axa Pradaxa (Capsule) 4 QL HumC1 ulin R U-50 WarfC1 Humulin R U-500 arin 0 Kwik Sodi Pen Warfarinum Sodium 3 1 KwikPen (Injection) (Tablet) HumC1 ulin R XarelC1 HumulinU-50 R U-500 Vial to 0 Vial Xarelto (Tablet) 3 QL

(Concentrated) 3 XarelC1 to Start Xareltoer Starter Pack (Injection) Pack 3 QL (Tablet Therapy Pack) HumC1 ulin R HumulinVial R Vial B1 3 Blood Formation Modifiers

(Injection) C1 Ana greli de

C1 HCl Lant Anagrelide HCl us Solo LantusStar SoloStar 3 3 (Capsule)

(Injection) AranC1 esp Albu min C1 Aranesp Albumin Lant Free us LantusVial Vial (Injection) 3 Free (100mcg/0.5ml ToujC1 eo Max ToujeoSolo Max Solostar star 3 Injection, 100mcg/ml (Injection) Injection, 150mcg/

ToujC1 eo Solo ToujeoStar SoloStar 3 0.3ml Injection, (Injection) 200mcg/0.4ml BloodA1 Products/Modifiers/Volume Expanders Injection, 200mcg/ml

B1 5 PA Anticoagulants Injection, 300mcg/

CouC1 madi Coumadinn (Tablet) 3 0.6ml Injection,

EliquC1 Eliquisis (Tablet) 3 QL 300mcg/ml Injection,

EliquC1 500mcg/ml Injection, is Start Eliquiser Starter Pack Pack 3 QL 60mcg/0.3ml (Tablet) Injection, 60mcg/ml Injection)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 53 53 2752 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

AranC1 CloniC1 esp dine Albu HCl Aranespmin Albumin Clonidine HCl (0.1mg/ Free Free (10mcg/0.4ml 24hr Patch Weekly, Injection, 25mcg/ 0.2mg/24hr Patch 4 0.42ml Injection, Weekly, 0.3mg/24hr 4 PA 25mcg/ml Injection, Patch Weekly) CloniC1 dine ClonidineHCl HCl (Tablet 40mcg/0.4ml 2 Injection, 40mcg/ml Immediate-Release) GuaC1 nfaci ne GuanfacineHCl HCl (Tablet Injection) 2 QL NeulC1 Neulastaasta (Injection) 5 PA Immediate-Release) MethC1 yldo pa ProcC1 Procritrit (10000unit/ml Methyldopa (Tablet) 3 MidoC1 drine Injection, 2000unit/ Midodrine HCl HCl (Tablet) 3

NortC1 ml Injection, Northerahera (Capsule) 4 PA, QL, LA

4 PA B1 3000unit/ml Alpha-adrenergic Blocking Agents

DoxaC1 zosin Injection, 4000unit/ DoxazosinMes Mesylate ylate 2 ml Injection) (Tablet)

ProcC1 PrazC1 rit osin Procrit (20000unit/ml PrazosinHCl HCl (Capsule) 2 Injection, 40000unit/ 5 PA AngiotensinB1 II Receptor Antagonists

IrbesC1 ml Injection) Irbesartanartan (Tablet) 2 QL ProC1 mact a LosaC1 Promacta (Tablet) 5 PA, QL, LA rtan Pota Losartanssiu Potassium m ZarxiC1 o 1 QL Zarxio (Injection) 5 (Tablet)

B1 TelmC1 isart Hemostasis Agents Telmisartanan (Tablet) 3 QL

TranC1 exa ValsC1 mic artan TranexamicAcid Acid 3 Valsartan (Tablet) 2 QL (Tablet) Angiotensin-convertingB1 Enzyme (ACE)

B1 Platelet Modifying Agents Inhibitors

AspirC1 in/ BenC1 Dipy azep Aspirin/Dipyridamolerida ril mole BenazeprilHCl HCl (Tablet) 1 QL

EnalC1 (Capsule Extended- 4 QL april Male Enalaprilate Maleate 2 QL Release 12 Hour) (Tablet) BrilinC1 ta FosiC1 Brilinta (Tablet) 4 QL nopri l FosinoprilSodi Sodium um CilosC1 tazol 2 QL Cilostazol (Tablet) 2 (Tablet)

ClopiC1 dogr LisinC1 Clopidogrelel (75mg opril 2 QL Lisinopril (Tablet) 1 QL

QuinC1 Tablet) april QuinaprilHCl HCl (Tablet) 2 QL A1

RamiC1 Cardiovascular Agents Ramiprilpril (Capsule) 2 QL B1 Alpha-adrenergic Agonists AntiarrhythmicsB1

Bold type = Brand name drug Plain type = Generic drug 54 tRACK 54 Last updated October 1, 2018 2853 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

AmioC1 PropC1 daro ranol ne ol AmiodaroneHCl HCl PropranololHCl HCl 2 (200mg Tablet) (Tablet Immediate- 2

DofeC1 Dofetilidetilide (Capsule) 4 Release, Oral Solution)

PropC1 FlecC1 ranol ainid ol e PropranololHCl HCl ER FlecainideAcet Acetate ER ate 2 (Tablet) (Capsule Extended- 2

MexiC1 letin Release 24 Hour) e MexiletineHCl HCl 3 B1 (Capsule) Calcium Channel Blocking Agents

AmloC1 PaceC1 dipin rone e AmlodipineBesy Besylate Pacerone (200mg late 2 1 Tablet) (Tablet)

CartiC1 PropC1 a XT afen one Cartia XT (Capsule PropafenoneHCl HCl 2 (Tablet) Extended-Release 24 2

QuinC1 idine Hour)

QuinidineSulfa Sulfate te DiltiaC1 zem 2 DiltiazemHCl HCl (Tablet (Tablet) 2

SotalC1 ol Immediate-Release) SotalolHCl HCl (AF) DiltiaC1 zem 2 HCl (Tablet) DiltiazemER HCl ER

SotalC1 ol (120mg Capsule SotalolHCl HCl (Tablet) 2

B1 Extended-Release 24 Beta-adrenergic Blocking Agents Hour, 180mg Capsule AtenC1 Atenolololol (Tablet) 1 Extended-Release 24 BisoC1 prolo l Hour, 240mg Capsule 2 BisoprololFum Fumarate arate 2 (Tablet) Extended-Release 24

CarvC1 edilo Hour, 300mg Capsule Carvediloll (Tablet) 1

LabeC1 Extended-Release 24 talol LabetalolHCl HCl (Tablet) 2 Hour) (Generic MetoC1 prolo l MetoprololSucc Succinate inate Cardizem CD) ER

Dilt-C1 ER (Tablet Extended- 1 XR Dilt-XR (Capsule Release 24 Hour) Extended-Release 24 2 MetoC1 prolo l MetoprololTartr Tartrate ate Hour)

NimC1 (100mg Tablet odipi Nimodipinene (Capsule) 4

Immediate-Release, NymC1 Nymalizealize (Oral 25mg Tablet 1 5 Immediate-Release, Solution) VeraC1 pami Verapamill HCl HCl (Tablet 50mg Tablet 2 Immediate-Release) Immediate-Release)

PropC1 ranol ol PropranololHCl HCl (Tablet Immediate- 2 Release)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 55 55 2954 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

VeraC1 LosaC1 pami rtan l HCl Pota VerapamilER HCl ER Losartanssiu Potassium/ m/ Hydr ochl orot hiazi (120mg Tablet Hydrochlorothiazidede 1 QL Extended-Release, (Tablet) MetoC1 prolo 180mg Tablet 2 l/ Metoprolol/Hydr ochl orot hiazi Extended-Release, Hydrochlorothiazidede 2 240mg Tablet (Tablet)

PentC1 Extended-Release) oxifyl line PentoxifyllineER ER B1 Cardiovascular Agents, Other (Tablet Extended- 2

AtenC1 olol/ Chlo Atenolol/rthali Release) done 1 QuinC1 april Chlorthalidone (Tablet) / Quinapril/Hydr ochl orot BenC1 hiazi azep de ril BenazeprilHCl/ HCl/ Hydrochlorothiazide 2 QL Hydr ochl orot hiazi Hydrochlorothiazidede 1 QL (Tablet)

RanC1 (Tablet) Ranexaexa (Tablet

CorlC1 Corlanoranor (Tablet) 4 PA, QL Extended-Release 12 3 QL

DigitC1 ekDigitek (Tablet) 2 Hour)

C1 DigoC1 Spir x onol acto Spironolactone/ne/ Digox (Tablet) 2 Hydr ochl orot hiazi C1 Digo de Digoxinxin (0.05mg/ml Hydrochlorothiazide 2 4 Oral Solution) (Tablet) TriaC1 mter DigoC1 ene/ xin Triamterene/Hydr ochl orot Digoxin (125mcg hiazi 2 de Tablet, 250mcg Tablet) Hydrochlorothiazide

C1 Enal (37.5mg-25mg april Male Enalaprilate/ Maleate/ 2 Hydr ochl orot Capsule, 37.5mg-25mg hiazi Hydrochlorothiazidede 2 QL Tablet, 75mg-50mg (Tablet) Tablet) EntrC1 esto ValsC1 Entresto (Tablet) 3 QL artan / Valsartan/Hydr ochl IrbesC1 orot artan hiazi / de Irbesartan/Hydr ochl Hydrochlorothiazide 2 QL orot hiazi Hydrochlorothiazidede 2 QL (Tablet) (Tablet) Diuretics,B1 Carbonic Anhydrase Inhibitors LanoC1 xin AcetC1 Lanoxin (125mcg azol amid Acetazolamidee (Tablet Tablet, 250mcg 3 4 Immediate-Release)

AcetC1 Tablet, 62.5mcg azol amid Acetazolamidee ER ER Tablet) (Capsule Extended- 4 LisinC1 opril / Lisinopril/Hydr ochl Release 12 Hour) orot hiazi de MethC1 Hydrochlorothiazide 1 QL azol amid Methazolamidee 4 (Tablet) (Tablet) Diuretics,B1 Loop

Bold type = Brand name drug Plain type = Generic drug 56 tRACK 56 Last updated October 1, 2018 3055 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

BumC1 B1 etani Bumetanidede (0.25mg/ Dyslipidemics, HMG CoA Reductase 4 ml Injection) Inhibitors

C1 Bum C1 etani Ator de vasta tin Bumetanide (0.5mg AtorvastatinCalci Calcium um 1 QL Tablet, 1mg Tablet, 2 (Tablet)

LivalC1 2mg Tablet) Livaloo (Tablet) 3 QL FuroC1 semi de LovaC1 Furosemide (10mg/ml stati 4 B/D, PA Lovastatinn (Tablet) 2 QL

Injection) PravC1 astat in Sodi C1 Pravastatin Sodium Furo um semi de 1 QL Furosemide (10mg/ml (Tablet)

Oral Solution, 8mg/ml RosC1 uvas tatin RosuvastatinCalci Calcium Oral Solution, 20mg 1 um 2 QL Tablet, 40mg Tablet, (Tablet) SimvC1 astat 80mg Tablet) Simvastatinin (Tablet) 1 QL

B1 TorsC1 emid Torsemidee (Tablet) 2 Dyslipidemics, Other

CholC1 B1 estyr amin Cholestyraminee Diuretics, Potassium-sparing 3 AmilC1 oride (Packet) Amiloride HCl HCl (Tablet) 2 CholC1 estyr amin C1 Spir e onol Cholestyramine Light Light acto Spironolactonene 2 3 (Tablet) (Powder) ColeC1 stipo l HCl B1 Colestipol HCl (1gm Diuretics, Thiazide 3

C1 Tablet) Chlo rothi azid Chlorothiazidee (Tablet) 2 ColeC1 stipo l HCl C1 Colestipol HCl (5gm Chlo rthali done 4 Chlorthalidone (Tablet) 2 Packet) DiurilC1 EzetiC1 Diuril (Suspension) 3 Ezetimibemibe (Tablet) 3 QL HydrC1 ochl orot JuxtC1 Hydrochlorothiazidehiazi apid de Juxtapid (Capsule) 5 PA, LA

C1 (12.5mg Capsule, Niac 1 or 12.5mg Tablet, 25mg Niacor (Tablet) 2 PraluC1 Tablet, 50mg Tablet) Praluentent (Injection) 5 PA, QL, LA

PrevC1 IndaC1 alite pami Indapamidede (Tablet) 2 Prevalite (Packet) 3

RepC1 MethC1 atha yclot hiazi Repatha (Injection) 5 PA, QL Methyclothiazidede 3 RepC1 atha Push (Tablet) Repathatron Pushtronex ex Syst em C1 5 PA, QL Meto lazo Metolazonene (Tablet) 3 System (Injection)

RepC1 B1 atha Sure RepathaClick SureClick Dyslipidemics, Fibric Acid Derivatives 5 PA, QL FenoC1 fibrat Fenofibratee (160mg (Injection) VascC1 2 epa Tablet, 54mg Tablet) Vascepa (Capsule) 4

GemC1 B1 fibro Gemfibrozilzil (Tablet) 2 Vasodilators, Direct-acting Arterial Vasodilators,B1 Direct-acting Arterial/Venous

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 57 57 3156 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

IsosC1 AmpC1 orbid heta e mine IsosorbideDinit Dinitrate Amphetamine// rate Dext roam phet amin (Tablet Immediate- 2 Dextroamphetaminee Release) (10mg Capsule

IsosC1 orbid e Extended-Release 24 IsosorbideDinit Dinitrate ER rate ER (Tablet Extended- 2 Hour, 15mg Capsule Release) Extended-Release 24

IsosC1 orbid Hour, 20mg Capsule e IsosorbideMon Mononitrate onitr ate Extended-Release 24 4 QL (Tablet Immediate- 2 Hour, 25mg Capsule Release)

C1 Extended-Release 24 Isos orbid e IsosorbideMon Mononitrate onitr ate Hour, 30mg Capsule ER ER (Tablet Extended- 2 Extended-Release 24 Release 24 Hour) Hour, 5mg Capsule MinitC1 Minitranran (Patch 24 2 Extended-Release 24 Hour) Hour)

C1 Nitro C1 Amp -Bid heta mine Nitro-Bid (Ointment) 4 Amphetamine// Dext roam phet NitroC1 amin glyc e Nitroglycerinerin (Tablet Dextroamphetamine 3 Sublingual) (10mg Tablet

NitroC1 glyc Immediate-Release, erin NitroglycerinLing Lingual ual 4 (Translingual Solution) 12.5mg Tablet

NitroC1 Immediate-Release, glyc erin NitroglycerinTran sder mal 15mg Tablet Transdermal (Patch 24 2 Immediate-Release, 3 QL Hour) 20mg Tablet NitroC1 Nitrostatstat (Tablet 3 Immediate-Release, Sublingual) 30mg Tablet

HydrC1 alazi ne Immediate-Release, HydralazineHCl HCl 2 (Tablet) 5mg Tablet Immediate-

MinoC1 Minoxidilxidil (Tablet) 2 Release, 7.5mg Tablet

A1 Immediate-Release)

Central Nervous System Agents MethC1 amp heta mine B1 Methamphetamine HCl HCl 4 PA Attention Deficit Hyperactivity Disorder (Tablet)

Agents, Amphetamines B1 Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines

AtoC1 mox Atomoxetineetine (Capsule) 4 QL

CloniC1 dine HCl ClonidineER HCl ER (Tablet Extended- 4 PA Release 12 Hour)

Bold type = Brand name drug Plain type = Generic drug 58 tRACK 58 Last updated October 1, 2018 3257 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

DexC1 DuloC1 meth xetin ylph e Dexmethylphenidateenid DuloxetineHCl HCl (20mg ate HCl (Tablet Immediate- 3 QL Capsule Delayed- Release) Release, 30mg

DexC1 meth ylph Capsule Delayed- 2 QL Dexmethylphenidateenid ate HCl HClER ER (Capsule Release, 60mg 4 Extended-Release 24 Capsule Delayed- Hour) Release)

LyricC1 MethC1 a ylph enid Lyrica (100mg Methylphenidateate HCl HCl (10mg Tablet Capsule, 150mg Immediate-Release, Capsule, 200mg 20mg Tablet Capsule, 225mg 3 QL Immediate-Release, Capsule, 25mg 3 QL 5mg Tablet Immediate- Capsule, 300mg Release) (Generic Capsule, 50mg Ritalin) Capsule, 75mg MethC1 ylph enid Methylphenidateate HCl HCl ER Capsule, 20mg/ml ER (10mg Tablet Oral Solution)

Extended-Release, 4 QL SaveC1 lla 20mg Tablet Extended- Savella (Tablet) 3 SaveC1 lla Titrat Savellaion Titration Pack Release) Pack 3 CentralB1 Nervous System, Other MultipleB1 Sclerosis Agents

AustC1 AmpC1 Austedoedo (Tablet) 5 PA, QL, LA Ampyrayra (Tablet

IngreC1 Ingrezzazza (Capsule) 5 PA, QL Extended-Release 12 5 QL, LA

NamC1 zaricNamzaric (Therapy Hour) ExtaC1 Pack, Capsule viaExtavia (Injection) 5

3 PA, QL GileC1 Extended-Release 24 Gilenyanya (Capsule) 5 QL

GlatiC1 rame r Hour) GlatiramerAcet Acetate ate

C1 Nue dext aNuedexta (Capsule) 4 PA (Solution Prefilled 5

RiluzC1 Riluzoleole (Tablet) 4 Syringe) GlatC1 opa TetraC1 bena Glatopa (Injection) 5 Tetrabenazinezine (Tablet) 5 PA, QL, LA TecfiC1 dera B1 Tecfidera (Capsule Fibromyalgia Agents 5 QL, LA Delayed-Release)

TecfiC1 dera Start erTecfidera Starter Pack 5 LA Pack DentalA1 and Oral Agents

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 59 59 3358 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

B1 ClotrC1 imaz ole/ Dental and Oral Agents Clotrimazole/Beta meth ason e ChloC1 Dipr rhexi opio nate dine Betamethasone ChlorhexidineGluc onat e 2 Oral Rins Gluconatee Oral Rinse 2 Dipropionate (Solution) (1%-0.05% Cream)

ClotrC1 imaz PerioC1 gard ole/ Clotrimazole/Beta meth Periogard (Solution) 2 ason e Dipr opio PilocC1 nate arpin Betamethasone e PilocarpineHCl HCl (5mg 4 4 Dipropionate Tablet, 7.5mg Tablet)

C1 (1%-0.05% Lotion) Tria mcin olon Triamcinolonee CoseC1 Acet ntyx onid e Dent Cosentyx (Injection) 5 PA, LA al AcetonidePast Dental 3 e CoseC1 ntyx Sens oreaCosentyx Sensoready dy Paste (Paste) Pen 5 PA, LA DermatologicalA1 Agents Pen (Injection) DicloC1 fena B1 c SodiDiclofenac Sodium Dermatological Agents um 4 PA

AcitrC1 (3% Gel) etin

Acitretin (Capsule) 4 DoxeC1 pin HCl AdaC1 Doxepin HCl (Cream) 4 PA, QL pale ne Adapalene (0.1% ElideC1 4 l Cream) Elidel (Cream) 4 ST EryC1 AdaC1 pale Ery (2% Pad) 3 Adapalenene (0.1% Gel) 3 ErythC1 romy AmC1 cin moni Erythromycin (2% um AmmoniumLact Lactate ate 2 (12% Cream, 12% 3 External Solution) ErythC1 romy Lotion) Erythromycincin (2% Gel) 4

ErythC1 CalciC1 romy potri cin/ ene Erythromycin/BenzoylBenz Calcipotriene (0.005% oyl Pero xide 4 Cream, 0.005% 4 Peroxide (Gel)

FinaC1 External Solution) Finaceacea (15% Foam,

CalciC1 4 Calcitrioltriol (3mcg/gm 15% Gel)

4 FluorC1 oura Ointment) cil Fluorouracil (2% ClarC1 Claravisavis (Capsule) 4 PA External Solution, 5% 3

ClindC1 amy External Solution) cin ClindamycinPhos phat e FluorC1 oura Fluorouracilcil (5% Phosphate (1% 4 External Solution, 1% 3 Cream)

ImiqC1 uimo Gel, 1% Lotion, 1% Imiquimodd (Cream) 4

IsotrC1 Swab) etino Isotretinoinin (Capsule) 4 PA ClindC1 amy cin/ MirvC1 Clindamycin/BenzoylBenz aso oyl Pero Mirvaso (Gel) 4 xide

Peroxide (1%-5% Gel) 4 PicatC1 Picatoo (Gel) (Generic BenzaClin) 3 PodC1 ofilo Podofiloxx (External 3 Solution)

Bold type = Brand name drug Plain type = Generic drug 60 tRACK 60 Last updated October 1, 2018 3459 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

PRUC1 CarbC1 DOX aglu PRUDOXININ (Cream) 4 PA, QL Carbaglu (Tablet) 5 LA

RegrC1 DextC1 anex rose Regranex (Gel) 5 PA 10%Dextrose 10%

C1 4 Sant Santylyl (Ointment) 4 (Injection)

DextC1 SeleC1 rose nium 10% Dextrose/ 10%/NaCl SeleniumSulfi Sulfide NaCl de 2 0.2% 4 (Lotion) 0.2% (Injection)

C1 TacrC1 Dext olim rose us 10% Dextrose/ 10%/NaCl Tacrolimus (0.03% NaCl 0.45 % 4 Ointment, 0.1% 4 ST 0.45% (Injection)

DextC1 rose Ointment) 2.5% Dextrose/ 2.5%/NaCl NaCl 0.45 TazaC1 % rote 4 Tazarotenene (Cream) 4 PA 0.45% (Injection)

TazoC1 rac DextC1 rose Tazorac (0.05% 5% 4 PA Dextrose 5% (Injection) 4 B/D, PA DextC1 rose Cream) 5%/ DextroseNaCl 5%/NaCl 0.2%

TretiC1 noin 4 Tretinoin (0.01% Gel, 0.2% (Injection)

DextC1 0.025% Gel, 0.025% rose 5%/ DextroseNaCl 5%/NaCl 4 PA 0.22 5% 4 Cream, 0.05% Cream, 0.225% (Injection)

0.1% Cream) C1 Dext rose 5%/ A1 DextroseNaCl 5%/NaCl 0.33 Electrolytes/Minerals/Metals/Vitamins % 4

B1 0.33% (Injection)

Electrolyte/Mineral Replacement DextC1 rose 5%/ NaCl C1 Dextrose 5%/NaCl Amin 0.45 osyn % 7%/ AminosynElect 7%/ 4 rolyt es 0.45% (Injection)

Electrolytes 4 B/D, PA DextC1 rose 5%/ DextroseNaCl 5%/NaCl (Injection) 0.9% 4 B/D, PA

C1 0.9% (Injection) Amin osyn

8.5%Aminosyn 8.5%/ FreAC1 / mine Elect rolyt HBC es FreAmine HBC 6.9% Electrolytes 4 B/D, PA 6.9% 4 B/D, PA (Injection)

(Injection) C1 Hep atA mine AminC1 HepatAmine osyn AminosynII II (10% 4 B/D, PA 4 B/D, PA (Injection)

Injection) C1 Intral ipid AminC1 Intralipid (Injection) 4 B/D, PA osyn II 8.5% Aminosyn II 8.5%/ C1 / Iono Elect sol- rolyt MB/ es Ionosol-MB/DextroseDext rose Electrolytes 4 B/D, PA 5% 4 (Injection) 5% (Injection) IsolytC1 e-P/ Dext AminC1 osyn Isolyte-P/Dextroserose 5% - 5% HBCAminosyn-HBC 4 B/D, PA 4 (Injection) (Injection) IsolytC1 e-S AminC1 osyn Isolyte-S (Injection) 4 -Aminosyn-PFPF KClC1 0.07 4 B/D, PA 5%/ KClD5W 0.075%/D5W/ / (Injection) NaCl 0.45 %

AminC1 osyn NaCl 0.45% 4 -Aminosyn-RFRF 4 B/D, PA (Injection) (Injection)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 61 61 3560 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

KClC1 NorC1 0.15 mos %/ ol-M KClD5W 0.15%/D5W/NaCl Normosol-Min in D5W / D5W NaCl 0.2% 4 4 0.2% (Injection) (Injection)

KClC1 NorC1 0.15 mos %/ ol-R KClD5W 0.15%/D5W/NaCl Normosol-R / NaCl 0.45 % 4 4 0.45% (Injection) (Injection)

KClC1 NorC1 0.15 mos %/ ol-R KClD5W 0.15%/D5W/NaCl Normosol-Rin in D5W / D5W NaCl 0.9% 4 4 0.9% (Injection) (Injection)

KClC1 NutriC1 0.3% lipid / KClD5W 0.3%/D5W/NaCl Nutrilipid (Injection) 4 B/D, PA / NaCl 0.45 % 4 C1 Plas ma- 0.45% (Injection) Lyte Plasma-LyteA A

KClC1 4 0.3% / KClD5W 0.3%/D5W/NaCl (Injection) / NaCl 0.9% 4 C1 Plas ma- 0.9% (Injection) Lyte- Plasma-Lyte-148148

Klor-C1 4 Klor-ConCon (Packet) 3 (Injection)

Klor-C1 PlenC1 Con amin Klor-Con10 10 (Tablet Plenaminee (Injection) 4 B/D, PA

3 C1 Pota ssiu Extended-Release) m PotassiumChlo Chloride ride

Klor-C1 Con Klor-Con8 8 (Tablet (10% Oral Solution, 3 3 Extended-Release) 20% Oral Solution)

Klor-C1 PotaC1 Con ssiu M10 m Klor-Con M10 (Tablet PotassiumChlo Chloride 2 ride Extended-Release) (10meq/100ml

Klor-C1 Con Klor-ConM15 M15 (Tablet Injection, 20meq/ 2 4 B/D, PA Extended-Release) 100ml Injection,

Klor-C1 Con Klor-ConM20 M20 (Tablet 40meq/100ml 2 Extended-Release) Injection)

LevoC1 PotaC1 carni ssiu tine m Levocarnitine (1gm/ PotassiumChlo Chloride 3 ride 4 B/D, PA 10ml Oral Solution) (2meq/ml Injection)

LevoC1 PotaC1 carni ssiu tine m Levocarnitine (330mg PotassiumChlo Chloride CR ride 3 CR Tablet) (Tablet Extended- 2

MagC1 nesi Release) um MagnesiumSulfa Sulfate te PotaC1 ssiu m PotassiumChlo Chloride ER (1gm/2ml-50% ride 4 ER Injection) (10meq Tablet

MagC1 Extended-Release, nesi um MagnesiumSulfa Sulfate te 20meq Tablet 2 (5gm/10ml-50% 4 Extended-Release, Injection) 8meq Tablet Extended- NepC1 hram Nephramineine 4 B/D, PA Release)

PotaC1 (Injection) ssiu m PotassiumChlo Chloride/ ride/ Dext rose 4 B/D, PA Dextrose (Injection)

Bold type = Brand name drug Plain type = Generic drug 62 tRACK 62 Last updated October 1, 2018 3661 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

PotaC1 SodiC1 ssiu um m Fluor PotassiumChlo Chloride/ Sodiumide Fluoride ride/ Dext rose 2 / Lact ated (Tablet) Dextrose/LactatedRing 4 ers

SodiC1 um Lact Ringers (Injection) Sodiumate Lactate

PotaC1 4 ssiu m PotassiumChlo Chloride/ (Injection) ride/ Dext rose C1 / TPN Sodi Elect um rolyt Dextrose/SodiumChlo 4 TPNes Electrolytes ride 4 Chloride (Injection) (Injection)

C1 Pota TravC1 ssiu asol m PotassiumChlo Chloride/ ride/ Travasol (Injection) 4 B/D, PA Sodi um Chlo C1 ride Trop hami Sodium Chloride Trophaminene (10% 4 B/D, PA 4 B/D, PA (20meq/L-0.45% Injection)

Injection) B1

PotaC1 Electrolyte/Mineral/Metal Modifiers ssiu m Chlo Potassium Chloride/ FerriC1 ride/ Sodi prox um Chlo Ferriprox (100mg/ml rideSodium Chloride Oral Solution, 500mg 5 PA (20meq/L-0.9% 4 B/D, PA Tablet) Injection, 40meq/ JadeC1 L-0.9% Injection) Jadenunu (Tablet) 4 PA JadeC1 nu PotaC1 Spri ssiu Jadenunkle Sprinkle m CitraPotassium Citrate ER te ER 4 PA (Tablet Extended- 4 (Packet) KionC1 Release) Kionexex (Suspension) 3

PreC1 SamC1 mas sca Premasolol (Injection) 4 B/D, PA Samsca (Tablet) 5 PA, QL

ProcC1 SodiC1 alam um ine Poly Procalamine Sodiumstyre Polystyrene ne Sulfo 4 B/D, PA nate 3 (Injection) Sulfonate (Powder)

SPSC1 C1 Pros olProsol (Injection) 4 B/D, PA SPS (Suspension) 3

TrienC1 C1 Sodi tine um HCl Chlo rideSodium Chloride Trientine HCl (Capsule) 5 PA, QL 0.9%

VeltaC1 0.9% (Irrigation 3 Veltassassa (Powder) 4 QL Solution) PhosphateB1 Binders

SodiC1 um AuryC1 Chlo xia Sodiumride Chloride (0.9% 4 B/D, PA Auryxia (Tablet) 4 PA CalciC1 Injection) um Acet Calciumate Acetate SodiC1 um Chlo rideSodium Chloride 4 (667mg Capsule, 2 (2.5meq/ml Injection) 667mg Tablet)

SodiC1 PhosC1 um lyra Chlo Sodiumride Chloride (3% Phoslyra (Oral 3 Injection, 5% 4 B/D, PA Solution)

SeveC1 lame Injection) r SevelamerCarb Carbonate onat e SodiC1 um Chlo rideSodium Chloride (0.8gm Packet, 2.4gm 4 0.45 % 4 0.45% (Injection) Packet, 800mg Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 63 63 3762 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

VelpC1 RelisC1 Velphorohoro (Tablet Relistortor (150mg 4 4 PA, QL Chewable) Tablet)

B1 UrsoC1 Vitamins Ursodioldiol (250mg 4 VP-C1 PNV- VP-PNV-DHADHA (Capsule) 2 Tablet, 500mg Tablet)

UrsoC1 diol A1 Ursodiol (300mg Gastrointestinal Agents 3 B1 Capsule) Antispasmodics, Gastrointestinal B1

CuvC1 Cuvposaposa (Oral Histamine2 (H2) Receptor Antagonists NizatC1 4 idine Solution) Nizatidine (150mg

DicyC1 Capsule, 300mg 2 clom ine DicyclomineHCl HCl Capsule)

(10mg Capsule, 10mg/ 2 C1 Rani tidin e RanitidineHCl HCl (150mg 5ml Oral Solution) 2

DicyC1 Tablet, 300mg Tablet) clom ine HCl Dicyclomine HCl B1 2 (Tablet) Irritable Bowel Syndrome Agents AlosC1 etro MethC1 n scop AlosetronHCl HCl (Tablet) 5 PA olam Methscopolamineine Bro mide LinzC1 4 ess Bromide (Tablet) Linzess (Capsule) 3 QL

C1 B1 Vibe Gastrointestinal Agents, Other Viberzirzi (Tablet) 5 PA, QL

B1 CheC1 noda Chenodall (Tablet) 5 Laxatives

ConC1 CroC1 stulo moly se n CromolynSodi Sodium Constulose (Oral um 2 (100mg/5ml 4 Solution)

EnulC1 Concentrate) Enuloseose (Oral Solution) 2

DiphC1 enox GaviC1 ylate Lyte- Diphenoxylate// C Atro GaviLyte-C (Oral pine 2 Atropine Solution)

GaviC1 (2.5mg-0.025mg Lyte- GaviLyte-GG (Oral 3 2 Tablet, Solution)

2.5mg-0.025mg/5ml GaviC1 Lyte- N/ GaviLyte-N/FlavorFlav or Liquid) Pack 2

GattC1 Pack (Oral Solution) ex

Gattex (Injection) 5 PA, LA GenC1 erlac LopeC1 Generlac (Oral rami de LoperamideHCl HCl 2 2 Solution)

(Capsule) LactC1 ulos e MyalC1 Lactulose (Oral ept 2 Myalept (Injection) 5 PA, LA Solution) RelisC1 tor PEGC1 Relistor (12mg/0.6ml 3350 / PEGElect 3350/Electrolytes rolyt es 3 Injection, 8mg/0.4ml 4 PA (Oral Solution) Injection)

Bold type = Brand name drug Plain type = Generic drug 64 tRACK 64 Last updated October 1, 2018 3863 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

PEG-C1 CholC1 3350 bam / PEG-3350/ElectrolytesElect Cholbam (Capsule) 5 PA rolyt es CreoC1 (Oral Solution) 3 Creonn (Capsule 3 (Generic GoLYTELY) Delayed-Release) PEG-C1 3350 / CystC1 PEG-3350/NaCl/NaNaCl adan /Na e Bicar Cystadane (Powder) 5 bona te/ KCl C1 Bicarbonate/KCl (Oral Cyst 3 Cystagonagon (Capsule) Solution) (Generic 4 LA KuvaC1 NuLYTELY) nKuvan (100mg

PolyC1 ethyl Packet, 500mg ene PolyethyleneGlyc Glycol ol 3350 5 LA Pow 3350der Powder (Generic 2 Packet, 100mg Tablet MiraLAX) Soluble)

MiglC1 SuprC1 ustat ep Bow Miglustat (Capsule) 5 PA, LA Suprepel Bowel Prep Prep Kit 3 OrfaC1 Kit (Oral Solution) dinOrfadin (10mg

TriLyC1 TriLytete (Oral Solution) 2 Capsule, 20mg B1 Capsule, 2mg Protectants 5 LA

CaraC1 Carafatefate (1gm/10ml Capsule, 5mg 4 Suspension) Capsule, 4mg/ml

MisoC1 Suspension) prost ol

Misoprostol (Tablet) 3 ProlaC1 stin- C SucrC1 Prolastin-C (Injection) 5 PA, LA alfat e

Sucralfate (Tablet) 2 RaviC1 cti

B1 Ravicti (Liquid) 5 QL, LA

Proton Pump Inhibitors SodiC1 um Phe nylb OmeC1 Sodium Phenylbutyrate utyra praz te ole Omeprazole (10mg (3gm/TSP Powder, 5 Capsule Delayed- 500mg Tablet)

Release, 40mg 2 QL SucrC1 Sucraidaid (Oral Capsule Delayed- 5 LA Release) Solution)

ZenC1 pep OmeC1 praz ole Zenpep (Capsule Omeprazole (20mg 3 Capsule Delayed- 2 Delayed-Release) Release) GenitourinaryA1 Agents

C1 Pant B1 opra zole PantoprazoleSodi Sodium um Antispasmodics, Urinary

MyrbC1 (Tablet Delayed- 2 QL Myrbetriqetriq (Tablet

Release) Extended-Release 24 3 A1 Genetic or Enzyme Disorder: Replacement, Hour)

OxybC1 Modifiers, Treatment utyni n OxybutyninChlo Chloride ride GeneticB1 or Enzyme Disorder: Replacement, (5mg Tablet 2 Modifiers, Treatment Immediate-Release,

AralaC1 st AralastNP NP (Injection) 5 PA, LA 5mg/5ml Syrup)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 65 65 3964 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

OxybC1 AugC1 utyni ment n ed OxybutyninChlo Chloride AugmentedBeta ride meth ER ason e Dipr opio ER (Tablet Extended- 2 QL Betamethasonenate Release 24 Hour) Dipropionate (0.05% 2 VesiC1 Vesicarecare (Tablet) 3 QL Cream, 0.05% Gel,

B1 0.05% Lotion, 0.05% Benign Prostatic Hypertrophy Agents

C1 Ointment) Alfuz osin HCl AlfuzosinER HCl ER BetaC1 meth ason Betamethasonee Dipr opio (Tablet Extended- 2 nate Dipropionate (0.05% Release 24 Hour) 3

C1 Cream, 0.05% Lotion, Fina steri Finasteridede (5mg 0.05% Ointment)

Tablet) (Generic 2 BetaC1 meth ason Betamethasonee Valer Proscar) ate C1 Valerate (0.1% Cream, Tam sulo sin 3 TamsulosinHCl HCl 2 0.1% Lotion, 0.1% (Capsule) Ointment) TeraC1 zosin HCl DesoC1 Terazosin HCl Desonidenide (0.05% 2 4 (Capsule) Ointment)

B1

DesoC1 xime Genitourinary Agents, Other taso Desoximetasonene BethC1 anec hol BethanecholChlo Chloride ride 2 (0.05% Cream, 0.25% 4 (Tablet) Cream)

DepC1 DexaC1 en meth Titrat ason Depenabs Titratabs Dexamethasonee 5 (Tablet) (0.5mg Tablet, 0.75mg

ElmirC1 Elmironon (Capsule) 4 Tablet, 1.5mg Tablet, A1 1mg Tablet, 2mg 2 Hormonal Agents, Stimulant/Replacement/ Tablet, 4mg Tablet, Modifying (Adrenal) 6mg Tablet, 0.5mg/ B1 Hormonal Agents, Stimulant/Replacement/ 5ml Elixir)

FludrC1 Modifying (Adrenal) ocort ison Fludrocortisonee Acet Ala-C1 ate Cort 2 Ala-Cort (Cream) 2 Acetate (Tablet)

C1 Alclo C1 meta Fluo sone cinol one Alclometasone Acet Dipr Fluocinolone opio onid Dipropionatenate (0.05% Acetonidee (0.01% 3 3 Cream, 0.05% Cream, 0.025% Cream, Ointment) 0.025% Ointment)

FluoC1 cinol one FluocinoloneAcet onid e Acetonide (0.01% 4 External Solution)

Bold type = Brand name drug Plain type = Generic drug 66 tRACK 66 Last updated October 1, 2018 4065 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

FluoC1 PredC1 cino nicar Fluocinonidenide (0.05% Prednicarbatebate (0.1% 4 External Solution, Cream, 0.1% Ointment) 3 PredC1 nisol 0.05% Gel, 0.05% Prednisoloneone (15mg/ 2 Ointment) 5ml Oral Solution)

FluoC1 cino PredC1 nide nisol FluocinonideEmul one sifie Sodi d Prednisolone Sodium um Base Phos phat Emulsified Base 3 Phosphatee (25mg/5ml 2 (Cream) Oral Solution, 5mg/5ml

FlutiC1 caso ne FluticasoneProp Propionate Oral Solution) ionat e PredC1 niso (0.005% Ointment, 3 Prednisonene (10mg 0.05% Cream) Tablet Therapy Pack,

HaloC1 beta sol HalobetasolProp 5mg Tablet Therapy ionat Propionatee (0.05% Pack, 10mg Tablet, 4 Cream, 0.05% 1mg Tablet, 2.5mg 2 Ointment) Tablet, 20mg Tablet,

HydrC1 ocort ison 50mg Tablet, 5mg Hydrocortisonee (1% Cream, 2.5% Cream, Tablet, 5mg/5ml Oral 1% Ointment, 2.5% Solution) 2 PredC1 niso ne Ointment, 10mg PrednisoneInten Intensol sol 2 Tablet, 20mg Tablet, (5mg/ml Concentrate)

TriaC1 mcin 5mg Tablet) olon Triamcinolonee Acet onid HydrC1 e ocort ison Hydrocortisonee (2.5% Acetonide (0.025% 3 Lotion) Cream, 0.1% Cream, HydrC1 ocort ison 0.5% Cream, 0.025% 2 Hydrocortisonee Buty rate Butyrate (0.1% 3 Ointment, 0.1% Ointment) Ointment, 0.5%

HydrC1 ocort Ointment) ison Hydrocortisonee Valer C1 ate Tria mcin olon Triamcinolonee Acet Valerate (0.2% Cream, 4 onid e 0.2% Ointment) Acetonide (0.025% 3

MethC1 ylpre Lotion, 0.1% Lotion) dnis Methylprednisoloneolon e TrideC1 2 rm (Tablet) Triderm (Cream) 2

A1

MethC1 ylpre dnis Hormonal Agents, Stimulant/Replacement/ Methylprednisoloneolon e Dose Pack Dose Pack (Tablet 2 Modifying (Pituitary) Therapy Pack) HormonalB1 Agents, Stimulant/Replacement/

MomC1 etas one MometasoneFuro Furoate Modifying (Pituitary) ate (0.1% Cream, 0.1% 3 External Solution, 0.1% Ointment)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 67 67 4166 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

DesC1 OxaC1 mop ndrol ressi one Desmopressinn Acetate Oxandrolone (10mg Acet ate 4 PA, QL (0.01% Nasal Spray 4 Tablet)

OxaC1 ndrol Solution) Oxandroloneone (2.5mg DesC1 3 PA, QL mop ressi Desmopressinn Acetate Tablet) Acet ate TestC1 oster (0.1mg Tablet, 0.2mg 2 one Testosterone (25mg/ Tablet) 2.5gm Gel, 50mg/5gm 3

GenC1 otro Genotropinpin (12mg Gel)

TestC1 oster Injection, 5mg one 5 PA TestosteroneCypi onat e 4 Injection) Cypionate (Injection)

C1 Gen TestC1 otro oster pin one GenotropinMini Miniquick Enan quic Testosterone thate k 4 PA 4 (0.2mg Injection) Enanthate (Injection)

C1 GenC1 Test otro oster pin one Mini TestosteronePum Pump Genotropin Miniquick p quic k 3 (0.4mg Injection, (Gel) 0.6mg Injection, EstrogensB1

AltavC1 0.8mg Injection, Altaveraera (Tablet) 4

AlyaC1 cen 1.2mg Injection, 1/35 5 PA Alyacen 1/35 (Tablet) 4 AmaC1 1.4mg Injection, Amabelzbelz (Tablet) 3

1.6mg Injection, AmeC1 Amethiathia (Tablet) 4 1.8mg Injection, 1mg AmeC1 thia Injection, 2mg AmethiaLo Lo (Tablet) 4 ApriC1 Injection) Apri (Tablet) 4

AranC1 IncreC1 elle Increlexlex (Injection) 5 PA, LA Aranelle (Tablet) 4

AshlC1 yna HormonalA1 Agents, Stimulant/Replacement/ Ashlyna (Tablet) 4

AubrC1 Modifying (Prostaglandins) Aubraa (Tablet) 4

C1 B1 Avia Hormonal Agents, Stimulant/Replacement/ Avianene (Tablet) 4

BalziC1 Modifying (Prostaglandins) Balzivava (Tablet) 4

C1 Korly BlisoC1 m vi 24 Korlym (Tablet) 5 PA, QL, LA BlisoviFe 24 Fe (Tablet) 4

A1 BlisoC1 vi Fe 1.5/ Hormonal Agents, Stimulant/Replacement/ Blisovi30 Fe 1.5/30 4 Modifying (Sex Hormones/Modifiers) (Tablet)

C1 B1 Bliso vi Fe Androgens Blisovi1/20 Fe 1/20 (Tablet) 4

C1 AnaC1 Briell drol- yn Anadrol-5050 (Tablet) 4 PA Briellyn (Tablet) 4

C1 AndrC1 Cam oder rese Androdermm (Patch 24 CamreseLo Lo (Tablet) 4

3 QL CaziC1 Hour) Caziantant (Tablet) 4

DanC1 Danazolazol (Capsule) 4

Bold type = Brand name drug Plain type = Generic drug 68 tRACK 68 Last updated October 1, 2018 4267 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

ClimC1 EstroC1 ara pipat ClimaraPro Pro (Patch Estropipatee (Tablet) 2

4 C1 Ethy nodi Weekly) ol EthynodiolDiac Diacetate/ etate /

C1 Ethin Crys yl elle- Estra Cryselle-2828 (Tablet) 4 Ethinyldiol Estradiol 4

CyclC1 Cyclafemafem (Tablet) 4 (Tablet) FalmC1 ina DelylC1 Delylaa (Tablet) 4 Falmina (Tablet) 4 FemC1 ynor DesoC1 gestr Femynor (Tablet) 4 el/ Desogestrel/EthinylEthin yl Estra FyavC1 diol 4 olv Estradiol (Tablet) Fyavolv (Tablet) 3

C1 C1 Gian Dros vi piren one/ Drospirenone/EthinylEthin Gianvi (Tablet) 4 yl Estra diol 4 IntroC1 Estradiol (Tablet) Introvalevale (Tablet) 4

DuavC1 ee IsiblC1 Duavee (Tablet) 4 Isibloomoom (Tablet) 4

ElestC1 rin JinteC1 Elestrin (Gel) 4 Jintelili (Tablet) 3

EmoC1 quett JuleC1 Emoquettee (Tablet) 4 Juleberber (Tablet) 4

EnprC1 esse- JuneC1 28 l 1.5/ Enpresse-28 (Tablet) 4 Junel30 1.5/30 (Tablet) 4

EnskC1 yce JuneC1 l Enskyce (Tablet) 4 Junel1/20 1/20 (Tablet) 4

EstarC1 ylla JuneC1 l Fe 1.5/ Estarylla (Tablet) 4 Junel30 Fe 1.5/30

EstraC1 4 Estradioldiol (0.025mg/ (Tablet)

JuneC1 l Fe 24hr Patch Weekly, Junel1/20 Fe 1/20 (Tablet) 4

JuneC1 0.05mg/24hr Patch l Fe Junel24 Fe 24 (Tablet) 4

Weekly, 0.06mg/24hr KaitliC1 b Fe Patch Weekly, Kaitlib Fe (Tablet 2 QL 4 0.075mg/24hr Patch Chewable) KarivC1 Weekly, 0.1mg/24hr Karivaa (Tablet) 4

KelnC1 or Patch Weekly, Kelnor1/35 1/35 (Tablet) 4

KelnC1 or 37.5mcg/24hr Patch Kelnor1/50 1/50 (Tablet) 4

Weekly) KimiC1 dess

C1 Kimidess (Tablet) 4 Estra diol Estradiol (0.5mg KurvC1 Kurveloelo (Tablet) 4 Tablet, 1mg Tablet, LARIC1 N 2 1.5/ 2mg Tablet) (Generic LARIN30 1.5/30 (Tablet) 4

LARIC1 N Estrace) LARIN1/20 1/20 (Tablet) 4

EstraC1 LARIC1 diol N Fe Valer 1.5/ Estradiolate Valerate LARIN30 Fe 1.5/30 4 4 (Injection) (Tablet)

EstraC1 LARIC1 diol/ N Fe Nore 1/20 Estradiol/thind LARIN Fe 1/20 (Tablet) 4 rone Acet ate LarisC1 Norethindrone Acetate 3 Larissiasia (Tablet) 4

LayoC1 (Tablet) Layolislis Fe Fe (Tablet EstriC1 ng 4 Estring (Ring) 4 Chewable)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 69 69 4368 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

LeenC1 MiliC1 Leenaa (Tablet) 4 Mili (Tablet) 4

LessiC1 MimC1 Lessinana (Tablet) 4 Mimveyvey (Tablet) 3

LevoC1 MimC1 nest vey Levonest (Tablet) 4 MimveyLo Lo (Tablet) 3

LevoC1 MonC1 norg oNe estre ssa Levonorgestrell and and MonoNessa (Tablet) 4 Ethin yl Estra diol NecC1 on Ethinyl Estradiol 4 0.5/ Necon35-2 0.5/35-28 8 4 (90mcg-20mcg Tablet) (Tablet)

LevoC1 norg NecC1 estre on Levonorgestrel/Ethinyll/ 7/7/ Ethin 7 yl Necon 7/7/7 (Tablet) 4 Estra diol Estradiol NikkiC1 Nikki (Tablet) 4

(0.15mg-0.03mg C1 Nore thind rone NorethindroneAcet ate/ Tablet, 0.1mg-20mcg Ethin yl Estra Acetate/Ethinyldiol Tablet, 0.05mg-30mcg/ 4 Estradiol 3 0.075mg-40mcg/ (2.5mcg-0.5mg Tablet, 0.125mg-30mcg 5mcg-1mg Tablet) NoreC1 thind rone NorethindroneAcet Tablet, ate/ Ethin yl Estra diol/ Acetate/EthinylFerr 0.15mg-0.03mg/ ous Fum Estradiol/Ferrousarate 0.01mg Tablet) 4 LevoC1 ra 0.15 Fumarate Levora/30- 0.15/30-28 28 4 (Tablet) (1mg-20mcg-75mg

LoryC1 Tablet Chewable) na

Loryna (Tablet) 4 C1 Nore thind rone Low-C1 NorethindroneAcet Oge ate/ strel Ethin yl Low-Ogestrel (Tablet) 4 Estra diol/ Acetate/EthinylFerr ous LuteC1 Fum Luterara (Tablet) 4 Estradiol/Ferrousarate MarliC1 4 Marlissassa (Tablet) 4 Fumarate

MeloC1 detta 24 (1mg-20mcg-75mg MelodettaFe 24 Fe 4 (Tablet Chewable) Tablet)

NoreC1 thind MenC1 est rone Norethindrone/Ethinyl/ Ethin Menest (Tablet) 3 yl Estra diol/ Ferr MibeC1 ous las Estradiol/Ferrous Fum 24 arate MibelasFe 24 Fe (Tablet 4 4 Fumarate (Tablet Chewable)

C1 Chewable) Micr oges tin Microgestin1.5/ 1.5/30 NorgC1 30 esti mate 4 Norgestimate/Ethinyl/ Ethin yl (Tablet) Estra 4 diol

C1 Estradiol (Tablet) Micr oges tin Microgestin1/20 1/20 NortrC1 el 0.5/ 4 Nortrel35 0.5/35 (28) (Tablet) 4

C1 (Tablet) Micr oges tin MicrogestinFe Fe (Tablet) 4 NortrC1 el 1/35

C1 Nortrel 1/35 (Tablet) 4 Micr oges tin MicrogestinFe Fe 1.5/30 NortrC1 1.5/ el 30 7/7/ 4 Nortrel7 7/7/7 (Tablet) 4 (Tablet)

Bold type = Brand name drug Plain type = Generic drug 70 tRACK 70 Last updated October 1, 2018 4469 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

NuvaC1 Tri-C1 Ring Vylib NuvaRing (Ring) 4 Tri-Vylibrara (Tablet) 4

OcellC1 VelivC1 Ocellaa (Tablet) 4 Velivetet (Tablet) 4

OgeC1 VienC1 Ogestrelstrel (Tablet) 4 Vienvava (Tablet) 4

OrsyC1 VyfeC1 Orsythiathia (Tablet) 4 Vyfemlamla (Tablet) 4

PimtC1 VylibC1 Pimtrearea (Tablet) 4 Vylibrara (Tablet) 4

PirmC1 WYC1 ella MZY Pirmella1/35 1/35 (Tablet) 4 WYMZYAA Fe Fe (Tablet 4 PortiC1 Portia-28a-28 (Tablet) 4 Chewable)

ZaraC1 PreC1 h mari Premarinn (0.3mg Zarah (Tablet) 4

ZencC1 Tablet, 0.45mg Zenchenthent (Tablet) 4

ZoviC1 a 1/35 Tablet, 0.625mg 4 QL ZoviaE 1/35E (Tablet) 4 Tablet, 0.9mg Tablet, ProgestinsB1

CamiC1 1.25mg Tablet) Camilala (Tablet) 3 PreC1 mari n CrinC1 Premarin (Vaginal one 3 Crinone (Gel) 4 PA Cream) DebliC1 Deblitanetane (Tablet) 3 PreC1 mph ase Premphase (Tablet) DepC1 4 QL o- Prov Depo-Proveraera PreC1 mpr o 4 Prempro (Tablet) 4 QL (Injection) PreviC1 fem ErrinC1 Previfem (Tablet) 4 Errin (Tablet) 3 QuaC1 sens e IncaC1 Quasense (Tablet) 4 Incassiassia (Tablet) 3 RecliC1 psen JolivC1 Reclipsen (Tablet) 4 Jolivetteette (Tablet) 3 SetlaC1 kin LyzaC1 Setlakin (Tablet) 4 Lyza (Tablet) 3 SpriC1 ntec 28 MedC1 Sprintec 28 (Tablet) 4 roxy prog Medroxyprogesteroneester one Acet SronC1 Sronyxyx (Tablet) 4 Acetateate (10mg Tablet,

SyedC1 2 Syedaa (Tablet) 4 2.5mg Tablet, 5mg

TarinC1 a Fe Tablet) Tarina1/20 Fe 1/20 (Tablet) 4 MedC1 roxy Tri-C1 prog Lege Medroxyprogesteroneester st Fe one Acet Tri-Legest Fe (Tablet) 4 ate

C1 Tri- Acetate (150mg/ml Lo- Estar ylla 4 Tri-Lo-Estarylla (Tablet) 4 Injection Prefilled Tri-C1 Lo- Spri Tri-Lo-Sprintecntec (Tablet) 4 Syringe)

Tri-C1 Mili MegC1 estro Tri-Mili (Tablet) 4 l MegestrolAcet Acetate ate

TrineC1 Trinessassa (Tablet) (20mg Tablet, 40mg 4 3 Tri-C1 Previ Tri-Previfemfem (Tablet) 4 Tablet, 40mg/ml

Tri-C1 Suspension) Spri Tri-Sprintecntec (Tablet) 4

TrivoC1 Trivora-28ra-28 (Tablet) 4

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 71 71 4570 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

MegC1 FirmC1 estro agon l MegestrolAcet Acetate Firmagon (120mg ate 5 PA (625mg/5ml 4 Injection)

FirmC1 Suspension) Firmagonagon (80mg NoraC1 -BE 4 PA Nora-BE (Tablet) 3 Injection)

NoreC1 thind LeupC1 rone rolid Norethindrone e LeuprolideAcet Acetate 3 ate 4 PA (0.35mg Tablet) (Injection)

NoreC1 thind LuprC1 rone on NorethindroneAcet Acetate Dep ate Lupronot Depot (1- 2 5 PA (5mg Tablet) Month) (Injection) NorlC1 yroc LuprC1 on Norlyroc (Tablet) 3 Dep Lupronot Depot (3- SharC1 obel 5 PA Sharobel (Tablet) 3 Month) (Injection)

B1 LuprC1 on Dep Selective Receptor Modifying Lupronot Depot (4- 5 PA Agents Month) (Injection)

OspC1 hena LuprC1 on Dep Osphena (Tablet) 3 PA, QL Lupronot Depot (6-

RaloC1 5 PA xifen e HClRaloxifene HCl (Tablet) 2 QL Month) (Injection)

A1 OctrC1 eotid e Hormonal Agents, Stimulant/Replacement/ OctreotideAcet Acetate ate 4 PA Modifying (Thyroid) (Injection)

C1 B1 Signi Hormonal Agents, Stimulant/Replacement/ Signiforfor (Injection) 5 PA, LA

SomC1 atuli ne Modifying (Thyroid) DepSomatuline Depot ot

LevoC1 5 thyro xine LevothyroxineSodi Sodium (Injection) um

1 SomC1 (Tablet) Somavertavert (Injection) 5 PA, QL, LA

LevoC1 xyl SynaC1 Levoxyl (Tablet) 3 relSynarel (Nasal

LiothC1 5 yroni ne LiothyronineSodi Sodium Solution) um 2 TrelsC1 tar (Tablet) Mixj Trelstarect Mixject

SyntC1 hroid 5 PA Synthroid (Tablet) 3 (Injection)

C1 Unit A1 Unithroidhroid (Tablet) 3 Hormonal Agents, Suppressant (Thyroid)

A1 Hormonal Agents, Suppressant (Adrenal) AntithyroidB1 Agents

B1 MethC1 imaz Hormonal Agents, Suppressant (Adrenal) Methimazoleole (Tablet) 2

C1 Lyso C1 Prop dren ylthi oura Lysodren (Tablet) 5 Propylthiouracilcil

A1 2 Hormonal Agents, Suppressant (Pituitary) (Tablet)

A1 HormonalB1 Agents, Suppressant (Pituitary) Immunological Agents

B1 CabC1 ergol Cabergolineine (Tablet) 2 Angioedema Agents

BeriC1 EgrifC1 nert Egriftata (Injection) 5 PA, LA Berinert (Injection) 5 PA, LA

FirazC1 yrFirazyr (Injection) 5 PA, QL, LA

Bold type = Brand name drug Plain type = Generic drug 72 tRACK 72 Last updated October 1, 2018 4671 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

B1 MycC1 ophe nolat Immune Suppressants Mycophenolatee Mofetil Mofe til

AzatC1 hiopr Azathioprineine (Tablet) 2 B/D, PA (250mg Capsule, 3 B/D, PA

CyclC1 ospo 500mg Tablet) rineCyclosporine MycC1 ophe 4 B/D, PA nolic Mycophenolic Acid Acid DR (Capsule) DR

CyclC1 ospo (Tablet Delayed- 4 B/D, PA rine ModiCyclosporine Modified fied Release) (100mg Capsule, RapC1 amu Rapamunene (1mg/ml 25mg Capsule, 50mg 4 B/D, PA 5 B/D, PA Capsule, 100mg/ml Oral Solution)

SanC1 dim mun Oral Solution) Sandimmunee

EnvaC1 rsus XREnvarsus XR (Tablet (100mg/ml Oral 4 B/D, PA Extended-Release 24 4 B/D, PA Solution)

SiroliC1 Hour) Sirolimusmus (Tablet) 4 B/D, PA

C1 Gen C1 graf Tacr olim Gengraf (100mg Tacrolimusus (0.5mg Capsule, 25mg 4 B/D, PA Capsule, 1mg Capsule, 2 B/D, PA Capsule, 100mg/ml 5mg Capsule)

TrexC1 Oral Solution) Trexallall (Tablet) 4 HumC1 ira XatmC1 Humira (Injection) 5 PA Xatmepep (Oral HumC1 ira 4 PA Pedi Humiraatric Pediatric Croh Solution) ns Dise ase Start ZortrC1 er ess CrohnsPack Disease 5 PA Zortress (Tablet) 5 B/D, PA Starter Pack B1 Immunizing Agents, Passive

(Injection) BIVIC1 GAM

HumC1 BIVIGAM (Injection) 4 PA ira Pen Humira Pen CariC1 mun e 5 PA CarimuneNan ofilte (Injection) red

HumC1 Nanofiltered 4 PA ira Pen HumiraCroh Pen Crohns ns Dise ase (Injection) Start er Pack Disease Starter Pack 5 PA FlebC1 oga mma Flebogamma DIF DIF (Injection) 4 PA

HumC1 (Injection) ira Pen- Psori Humira Pen-Psoriasis GamC1 asis Start mag er ard 5 PA GammagardS/D S/D IGA IGA Less Starter (Injection) Than 1 mcg /ml MethC1 Less Than 1 mcg/ml 4 PA otrex Methotrexateate (Tablet) 2 (Injection) MethC1 otrex ate Sodi GamC1 Methotrexate Sodium mak um 4 Gammakeded (Injection) 4 PA

(Injection) C1 Gam mapl ex MycC1 Gammaplex ophe nolat Mycophenolatee Mofetil 4 PA Mofe til (Injection) (200mg/ml 5 B/D, PA OctaC1 Suspension) Octagamgam (Injection) 4 PA

PriviC1 Privigengen (Injection) 4 PA

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 73 73 4772 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

VarizC1 MenC1 Varizigig (Injection) 3 Menveoveo (Injection) 3

B1 M-M-C1 Immunomodulators M-M-RR II II (Injection) 3

ActeC1 PediC1 Actemramra (162mg/ Pediarixarix (Injection) 3

5 PA C1 Pedv ax 0.9ml Injection) PedvaxHIB HIB (Injection) 3

ActiC1 mmu ProQC1 Actimmunene (Injection) 5 LA ProQuaduad (Injection) 3

ArcalC1 yst QuaC1 drac Arcalyst (Injection) 5 PA, LA Quadracelel (Injection) 3

BenlC1 ysta RabC1 Benlysta (Injection) 5 PA Rabavertavert (Injection) 3 B/D, PA

LefluC1 nomi RecC1 de ombi vax Leflunomide (Tablet) 3 RecombivaxHB HB

XolaiC1 3 B/D, PA Xolairr (Injection) 5 PA, LA (Injection)

B1 RotaC1 Vaccines Rotarixrix (Suspension) 3

ActHC1 RotaC1 ActHIBIB (Injection) 3 RotaTeqTeq (Oral

C1 3 Ada Adacelcel (Injection) 3 Solution)

ShinC1 BCGC1 grix Vacc BCGine Vaccine Shingrix (Injection) 4 PA

3 TeniC1 (Injection) Tenivacvac (Injection) 3

BexsC1 TetaC1 ero nus/ Diph Bexsero (Injection) 3 Tetanus/Diphtheriatheri a Toxo ids- Adso BoosC1 trix rbed

Toxoids-AdsorbedAdul 3 Boostrix (Injection) 3 t

DaptC1 Daptacelacel (Injection) 3 Adult (Injection) TruC1 men C1 Diph ba theri a/ Trumenba (Injection) 3 Diphtheria/TetanusTeta nus Toxo TwinC1 ids rix Adso rbed Twinrix (Injection) 3 ToxoidsPedi Adsorbed 3 atric

TyphC1 Pediatric (Injection) Typhimim Vi Vi (Injection) 3

EngeC1 VAQC1 Engerix-Brix-B (Injection) 3 B/D, PA VAQTATA (Injection) 3

GardC1 VarivC1 asilGardasil 9 9 (Injection) 3 Varivaxax (Injection) 3

HavriC1 YF-C1 Havrixx (Injection) 3 YF-VaxVax (Injection) 3

HibeC1 ZostC1 Hiberixrix (Injection) 3 Zostavaxavax (Injection) 4 PA

ImovC1 A1 ax Rabi Imovaxes Rabies Inflammatory Bowel Disease Agents

3 B/D, PA B1 (H.D.C.V.) (Injection) Aminosalicylates

InfanC1 rix AprisC1 Infanrix (Injection) 3 Aprisoo (Capsule

IPOLC1 Inact ivate IPOLd Inactivated IPV Extended-Release 24 3 QL IPV 3 (Injection) Hour)

IxiarC1 BalsC1 o alazi de Ixiaro (Injection) 3 BalsalazideDiso Disodium dium 4 KinriC1 Kinrixx (Injection) 3 (Capsule)

CanC1 asa MenC1 Menactraactra (Injection) 3 Canasa (Suppository) 4

Bold type = Brand name drug Plain type = Generic drug 74 tRACK 74 Last updated October 1, 2018 4873 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

MesC1 CalciC1 alam triol Mesalamineine (Enema) 4 QL Calcitriol (0.25mcg B1 Capsule, 0.5mcg Glucocorticoids 2 B/D, PA

BudC1 eson Capsule, 1mcg/ml Oral Budesonideide (3mg Solution) Capsule Delayed- 4 DoxeC1 rcalc Doxercalciferoliferol Release) 4 B/D, PA, QL ColoC1 cort (Capsule) Colocort (Enema) 3 IbanC1 dron ate HydrC1 Sodi ocort Ibandronate Sodium um ison Hydrocortisonee 3 QL 3 (150mg Tablet) (100mg/60ml Enema) NatpC1 ara

ProcC1 to- Natpara (Injection) 5 PA, LA Med Procto-MedHC HC ParicC1 alcit 2 ol (Cream) Paricalcitol (Capsule) 4 B/D, PA

ProliC1 a ProcC1 to- Procto-PakPak (Cream) 2 Prolia (Injection) 4 QL

RayaC1 ldee ProcC1 tosol HC Rayaldee (Capsule Proctosol HC (Cream) 2 5 QL ProcC1 tozo Extended-Release) ne- Proctozone-HCHC SensC1 2 ipar (Cream) Sensipar (Tablet) 5 B/D, PA, QL

TymlC1 SulfonamidesB1 Tymlosos (Injection) 5 PA, QL

XgevC1 SulfaC1 a salaz Sulfasalazineine (500mg Xgeva (Injection) 5 PA Tablet Delayed- A1 2 Miscellaneous Therapeutic Agents Release, 500mg Tablet MiscellaneousB1 Therapeutic Agents

Immediate-Release) AlcoC1 hol Prep Pads A1 Alcohol Prep Pads 3

Metabolic Bone Disease Agents GauC1 ze B1 Gauze (Non-medicated 3 Metabolic Bone Disease Agents 2X2) AlenC1 dron ate InsulC1 AlendronateSodi Sodium in um Syrin Insulinges, Syringes, Nee dles 3 (10mg Tablet, 35mg Needles

Tablet, 40mg Tablet, 1 QL A1 5mg Tablet, 70mg Ophthalmic Agents B1 Tablet) Ophthalmic Agents, Other

AtroC1 AlenC1 pine dron Sulfa ate Atropinete Sulfate (1% AlendronateSodi Sodium um 3 (70mg/75ml Oral 4 Ophthalmic Solution)

BacitC1 racin / Solution) Bacitracin/PolymyxinPoly B myxi n B BinoC1 2 Binostosto (Tablet (Ophthalmic Ointment)

4 QL BlepC1 hami Effervescent) Blephamidede

C1 4 Calci tonin - Calcitonin-SalmonSalm (Suspension) on

2 QL BlepC1 hami de (Nasal Solution) BlephamideS.O. S.O.P. P. 4 (Ointment)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 75 75 4974 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

CystC1 TobrC1 aran amy cin/ Cystaran (Ophthalmic Tobramycin/Dexa meth ason 5 LA Dexamethasonee Solution) 3 LacriC1 Lacrisertsert (Insert) 4 (Ophthalmic

LastC1 Suspension) acaft Lastacaft (Ophthalmic C1 Xiidr 3 Xiidraa (Ophthalmic Solution) 4 QL

NeoC1 Solution) myci n/ Bacit Neomycin/Bacitracin/ B1 racin / Poly 3 myxi Ophthalmic Anti-allergy Agents Polymyxinn (Ointment) AzelC1 astin NeoC1 e myci AzelastineHCl HCl (0.05% n/ Neomycin/Polymyxin/Poly myxi 2 n/ Bacit racin Ophthalmic Solution) / Bacitracin/Hydr ocort ison CroC1 e 3 moly n CromolynSodi Sodium (4% Hydrocortisone um 2 (Ophthalmic Ointment) Ophthalmic Solution)

C1 C1 Epin Neo astin myci e n/ HCl Neomycin/Polymyxin/Poly Epinastine HCl myxi n/ Dexa 3 meth ason e (Ophthalmic Solution) Dexamethasone (0.1% OlopC1 atadi ne Ophthalmic Ointment, 2 OlopatadineHCl HCl 3 0.1% Ophthalmic (Ophthalmic Solution) Suspension) OphthalmicB1 Antiglaucoma Agents NeoC1 myci n/ ApraC1 Neomycin/Polymyxin/Poly cloni myxi dine n/ Gra Apraclonidine mici din 3 Gramicidin 3 (Ophthalmic Solution)

(Ophthalmic Solution) BetaC1 xolol HCl NeoC1 Betaxolol HCl myci n/ Neomycin/Polymyxin/Poly 3 myxi n/ Hydr (Ophthalmic Solution) ocort ison e C1 Hydrocortisone (1% Beti 4 Betimolmol (Ophthalmic Ophthalmic 4 Suspension) Solution) BrimC1 onidi PolyC1 ne myxi Tartr n B Brimonidine Tartrate ate PolymyxinSulfa B Sulfate/ te/ Trim etho prim Sulfa (0.2% Ophthalmic 2 Trimethoprimte Sulfate 2 (Ophthalmic Solution) Solution) CartC1 eolol PropC1 HCl arac aine Carteolol HCl ProparacaineHCl HCl 2 2 (Ophthalmic Solution) (Ophthalmic Solution) CosC1 opt RestC1 PF asis Cosopt PF Restasis (Emulsion) 3 QL 4

SulfaC1 ceta (Ophthalmic Solution) mide Sulfacetamide Sodi um/ DorzC1 Pred olam nisol ide one DorzolamideHCl HCl Sodium/PrednisoloneSodi um Phos 2 phat 2 Sodiume Phosphate (Ophthalmic Solution)

DorzC1 olam ide (Ophthalmic Solution) DorzolamideHCl/ HCl/ Timo lol Male TobrC1 ate Tobradexadex (0.3%-0.1% Timolol Maleate 2 3 Ophthalmic Ointment) (Ophthalmic Solution)

Bold type = Brand name drug Plain type = Generic drug 76 tRACK 76 Last updated October 1, 2018 5075 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

LevoC1 ProleC1 buno nsa lol LevobunololHCl HCl Prolensa (Ophthalmic 2 4 (Ophthalmic Solution) Solution)

C1 Phos B1 pholi ne PhospholineIodid Iodide e 4 Ophthalmic Prostaglandin and Prostamide (Ophthalmic Solution) Analogs

C1 Piloc C1 arpin Lata e nopr PilocarpineHCl HCl (1% Latanoprostost 1 Ophthalmic Solution, (Ophthalmic Solution) VyzuC1 2% Ophthalmic 3 Vyzultalta (Ophthalmic 4 Solution, 4% Solution)

Ophthalmic Solution) ZioptC1 an

SimbC1 Zioptan (Ophthalmic Simbrinzarinza 4 3 Solution)

(Suspension) A1

TimoC1 Otic Agents lol Male ate Timolol Maleate B1 (0.25% Ophthalmic Otic Agents AcetiC1 c AceticAcid Acid (Otic Solution, 0.5% 2 2 Ophthalmic Solution) Solution)

FluoC1 cinol one (Generic Timoptic) FluocinoloneAcet onid e OphthalmicB1 Anti-inflammatories Acetonide (0.01% Otic 4

DexaC1 meth Oil) ason Dexamethasonee Sodi um HydrC1 Phos ocort phat ison e Hydrocortisone/Acetice/ Sodium Phosphate Aceti c 2 Acid 3 (0.1% Ophthalmic Acid (Otic Solution)

NeoC1 myci n/ Solution) Neomycin/Polymyxin/Poly myxi n/ Hydr DicloC1 ocort fena ison c e DiclofenacSodi Sodium Hydrocortisone (1% um 3 (0.1% Ophthalmic 2 Otic Solution, 1% Otic Solution) Suspension)

A1 DureC1 Durezolzol (Emulsion) 3 Respiratory Tract/Pulmonary Agents

B1 FluorC1 omet holo Fluorometholonene Antihistamines

C1 Azel astin e (Ophthalmic 3 HCl Azelastine HCl (0.1% Suspension) Nasal Solution, 0.15% 3

FlurbC1 iprof en FlurbiprofenSodi Sodium Nasal Solution) um

2 CetirC1 izine (Ophthalmic Solution) CetirizineHCl HCl (Oral

KetoC1 2 rolac

KetorolacTro Solution) meth amin e C1 Cypr ohep tadin Tromethamine 3 Cyproheptadinee HCl HCl 3 (Ophthalmic Solution) (4mg Tablet)

PredC1 C1 nisol Levo one cetiri Sodi zine Prednisolone Sodium Dihy um Levocetirizine Phos droc phat hlori Phosphatee (1% 2 Dihydrochloridede (5mg 3 QL Ophthalmic Solution) Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 77 77 5176 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

PheC1 AtroC1 nado vent Phenadozz AtroventHFA HFA 4 4 (Suppository) (Aerosol Solution)

C1 Pro C1 meth Iprat azin ropiu e m Promethazine HCl Bro HCl Ipratropium Bromide mide (12.5mg Suppository, 4 (0.02% Inhalation 2 B/D, PA 25mg Suppository) Solution)

C1 Pro C1 meth Iprat azin ropiu e m Promethazine HCl Bro HCl Ipratropium Bromide mide (12.5mg Tablet, 25mg 3 (0.03% Nasal Solution, 2 Tablet, 50mg Tablet, 0.06% Nasal Solution)

SpiriC1 6.25mg/5ml Syrup) va Han SpirivadiHal HandiHaler er ProC1 meth 3 QL Prometheganegan (25mg 4 (Capsule) SpiriC1 Suppository) va Res Spirivapima Respimat t B1 3 QL Anti-inflammatories, Inhaled Corticosteroids (Aerosol Solution)

BudC1 eson B1 Budesonideide (0.25mg/ Bronchodilators, Sympathomimetic

2ml Suspension, AlbuC1 terol Sulfa 4 B/D, PA Albuterolte Sulfate 0.5mg/2ml (0.083% Nebulized Suspension) Solution, 0.5% FluniC1 solid eFlunisolide (Nasal 3 Nebulized Solution, 2 B/D, PA Solution) 0.63mg/3ml Nebulized

FlutiC1 caso ne FluticasoneProp Propionate ionat Solution, 1.25mg/3ml e (50mcg/act 2 Nebulized Solution)

AlbuC1 terol Suspension) Sulfa Albuterolte Sulfate (2mg PulmC1 icort Flex Pulmicorthaler Flexhaler Tablet Immediate- 4 3 QL (Aerosol Powder) Release)

C1 TriaC1 Albu mcin terol olon Sulfa e Albuterolte Sulfate ER Triamcinolone ER Acet onid e Acetonide (55mcg/act 4 (Tablet Extended- 4 Aerosol) Release 12 Hour)

C1 B1 Epin ephri Antileukotrienes Epinephrinene (0.15mg/

MontC1 eluk ast 0.3ml Injection, 0.3mg/ MontelukastSodi Sodium um 3 QL (10mg Tablet, 4mg 0.3ml Injection) Packet, 4mg Tablet 2 QL (Generic EpiPen)

PerfC1 oro Chewable, 5mg Tablet Perforomistmist 4 B/D, PA, QL Chewable) (Nebulized Solution)

C1 Zafirl SereC1 ukas vent t Disk Zafirlukast (Tablet) 2 QL Sereventus Diskus

B1 3 QL Bronchodilators, Anticholinergic (Aerosol Powder)

VentC1 olin VentolinHFA HFA (Aerosol 3 Solution)

Bold type = Brand name drug Plain type = Generic drug 78 tRACK 78 Last updated October 1, 2018 5277 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

B1 OrenC1 Cystic Fibrosis Agents Orenitramitram (0.25mg

CaysC1 Caystonton (Inhalation Tablet Extended- 5 PA, LA Solution) Release, 1mg Tablet

KalyC1 deco Extended-Release, Kalydeco (150mg 5 PA, LA Tablet, 50mg Packet, 5 PA, QL, LA 2.5mg Tablet 75mg Packet) Extended-Release,

OrkaC1 Orkambimbi (Tablet) 5 PA, QL, LA 5mg Tablet Extended-

TOBIC1 Release) Pod haler

TOBI Podhaler C1 Silde 5 PA, QL nafil (Capsule) Sildenafil (20mg

C1 Tablet) (Generic 3 PA, QL Tobr amy cinTobramycin (Nebulized 5 B/D, PA, QL Revatio)

Solution) B1

B1 Pulmonary Fibrosis Agents

Mast Cell Stabilizers EsbriC1 et

C1 Esbriet (267mg Cro moly n CromolynSodi Sodium um Capsule, 267mg 5 PA, QL, LA (20mg/2ml Nebulized 3 B/D, PA Tablet, 801mg Tablet) Solution) OfevC1

B1 Ofev (Capsule) 5 PA, QL, LA Phosphodiesterase Inhibitors, Airways B1 Disease Respiratory Tract Agents, Other AcetC1 ylcys DalirC1 teine esp Acetylcysteine Daliresp (Tablet) 4 PA, QL 2 B/D, PA

TheoC1 (Inhalation Solution) phylli ne CR Theophylline CR C1 Anor o Ellipt Anoroa Ellipta (Aerosol (Tablet Extended- 2 3 QL Release 12 Hour) Powder)

BeveC1 spi TheoC1 phylli Aero ne Bevespisphe Aerosphere TheophyllineER ER re 3 QL (300mg Tablet (Aerosol)

BreoC1 Ellipt Extended-Release 12 Breoa Ellipta (Aerosol Hour, 400mg Tablet 3 QL 2 Powder) ComC1 Extended-Release 24 bive nt CombiventRes Respimat pima Hour, 600mg Tablet t 3 (Aerosol Solution) Extended-Release 24 FlutiC1 caso ne FluticasoneProp ionat Hour) e/ Salm etero l B1 Propionate/Salmeterol 3 QL Pulmonary Antihypertensives (Aerosol Powder) AdeC1 mpa s Adempas (Tablet) 5 PA, LA IpratC1 ropiu m IpratropiumBro Bromide/ OpsC1 mide umit / Albu terol Opsumit (Tablet) 5 PA, LA Sulfa Albuterolte Sulfate 2 B/D, PA

OrenC1 Orenitramitram (0.125mg (Inhalation Solution)

NucC1 Tablet Extended- 4 PA, LA Nucalaala (Injection) 5 PA, QL, LA Release)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 79 79 5378 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

PulmC1 TizaC1 ozy nidin me e Pulmozyme TizanidineHCl HCl (2mg 5 B/D, PA, QL 2 (Inhalation Solution) Tablet, 4mg Tablet)

A1 StioltC1 o Res pimaStiolto Respimat Sleep Disorder Agents t

3 QL B1 (Aerosol Solution) GABA Receptor Modulators

C1 Sym TemC1 bicor azep Symbicortt (Aerosol) 3 QL Temazepamam (15mg SkeletalA1 Muscle Relaxants Capsule, 30mg 2 QL SkeletalB1 Muscle Relaxants Capsule) ZaleC1 plon BaclC1 Baclofenofen (10mg Tablet, Zaleplon (Capsule) 3 QL ZolpiC1 dem Tartr 20mg Tablet, 5mg 2 Zolpidemate Tartrate Tablet) (10mg Tablet

ChloC1 rzox Immediate-Release, 2 QL azon Chlorzoxazonee (500mg 3 Tablet) 5mg Tablet Immediate-

CyclC1 Release) oben zapri ne Cyclobenzaprine HCl B1 HCl (10mg Tablet, 5mg 3 Sleep Disorders, Other BelsC1 Tablet) Belsomraomra (Tablet) 3 QL

HetliC1 DantC1 oz rolen e Hetlioz (Capsule) 5 PA, QL, LA DantroleneSodi Sodium um 2 ModC1 (Capsule) afinilModafinil (Tablet) 4 PA, QL

XyreC1 Xyremm (Oral Solution) 5 PA, QL, LA

Bold type = Brand name drug Plain type = Generic drug 80 80 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 UnitedHealthcare Customer Service. Our contact information is on the cover. Drugs are listed in alphabetical order in the chart below. track

Drug Name Quantity Limit Abacavir (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 Acarbose (100mg Tablet) Maximum of 3 tablets per day Acarbose (25mg Tablet) Maximum of 12 tablets per day Acarbose (50mg Tablet) Maximum of 6 tablets per day Acetaminophen/Codeine (120mg-12mg/5ml Maximum of 150 ml per day Oral Solution) Acetaminophen/Codeine (300mg-15mg Tablet, Maximum of 13 tablets per day 300mg-30mg Tablet, 300mg-60mg Tablet) Albenza (Tablet) Maximum of 16 tablets per day Alecensa (Capsule) Maximum of 8 capsules per day Alendronate Sodium (10mg Tablet, 40mg Maximum of 1 tablet per day Tablet, 5mg Tablet) Alendronate Sodium (35mg Tablet) Maximum of 8 tablets per 28 days Alendronate Sodium (70mg Tablet) Maximum of 4 tablets per 28 days Alprazolam (0.25mg Tablet Immediate-Release, Maximum of 4 tablets per day 0.5mg Tablet Immediate-Release) Alprazolam (1mg Tablet Immediate-Release) Maximum of 4 tablets per day Alprazolam (2mg Tablet Immediate-Release) Maximum of 5 tablets 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

Bold type = Brand name drug Plain type = Generic drug Last81 updated October 1, 2018 2 2 81 Drug Name Quantity Limit 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 Androderm (Patch 24 Hour) Maximum of 1 patch per day Anoro Ellipta (Aerosol Powder) Maximum of 1 inhaler (60 blisters) per 30 days Apokyn (Injection) Maximum of 3 ml per day Apriso (Capsule Extended-Release 24 Hour) Maximum of 4 capsules per day Aptiom (200mg Tablet, 400mg Tablet) 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 Aripiprazole (10mg Tablet, 15mg Tablet, 20mg Maximum of 1 tablet per day Tablet, 2mg Tablet, 30mg Tablet, 5mg Tablet) 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 Aspirin/Dipyridamole (Capsule Extended- Maximum of 2 capsules per day Release 12 Hour) Atazanavir Sulfate (150mg Capsule, 300mg Maximum of 2 capsules per day Capsule) Atazanavir Sulfate (200mg Capsule) Maximum of 3 capsules per day Atomoxetine (100mg Capsule, 60mg Capsule, Maximum of 1 capsule per day 80mg Capsule) Atomoxetine (10mg Capsule, 18mg Capsule, Maximum of 2 capsules per day 25mg Capsule, 40mg Capsule) Atorvastatin Calcium (Tablet) Maximum of 1 tablet per day

Bold type = Brand name drug Plain type = Generic drug 82 82 3 3 Last updated October 1, 2018 Drug Name Quantity Limit Atripla (Tablet) Maximum of 2 tablets per day Austedo (Tablet) Maximum of 4 tablets 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 Bevespi Aerosphere (Aerosol) Maximum of 1 inhaler (10.7 grams) per 30 days Biktarvy (Tablet) Maximum of 2 tablets per day Binosto (Tablet Effervescent) Maximum of 4 tablets per 28 days 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, 25mg Maximum of 2 tablets per day Tablet, 50mg Tablet, 75mg Tablet) Briviact (10mg/ml Oral Solution) Maximum of 20 ml per day Buprenorphine HCl (Tablet Sublingual) Maximum of 3 tablets per day Buprenorphine HCl/Naloxone HCl (Tablet Maximum of 3 tablets per day Sublingual) Butalbital/Acetaminophen/Caffeine (Tablet) Maximum of 6 tablets per day Butalbital/Aspirin/Caffeine (Capsule) Maximum of 6 capsules per day Butorphanol Tartrate (10mg/ml Nasal Solution) Maximum of 2 bottles (5 ml) per 30 days Bydureon 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 Cabometyx (20mg Tablet, 60mg Tablet) Maximum of 1 tablet per day Cabometyx (40mg Tablet) Maximum of 2 tablets per day Calcitonin-Salmon (Nasal Solution) Maximum of 1 bottle per 28 days Calquence (Capsule) Maximum of 2 capsules 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

Bold type = Brand name drug Plain type = Generic drug Last83 updated October 1, 2018 4 4 83 Drug Name Quantity Limit Clorazepate Dipotassium (3.75mg Tablet) Maximum of 24 tablets per day Clorazepate Dipotassium (7.5mg Tablet) Maximum of 12 tablets per day Clozapine ODT (100mg Tablet Dispersible) Maximum of 9 tablets per day Clozapine ODT (12.5mg Tablet Dispersible) Maximum of 2 tablets per day Clozapine ODT (150mg Tablet Dispersible) Maximum of 6 tablets per day Clozapine ODT (200mg Tablet Dispersible) Maximum of 4 tablets per day Clozapine ODT (25mg Tablet Dispersible) Maximum of 3 tablets per day Codeine Sulfate (Tablet) Maximum of 6 tablets per day Colchicine (0.6mg Capsule) (Generic Maximum of 4 capsules per day Mitigare) Colchicine (0.6mg Tablet) (Generic Colcrys) Maximum of 4 tablets per day Complera (Tablet) Maximum of 2 tablets per day Corlanor (Tablet) Maximum of 2 tablets per day Cotellic (Tablet) Maximum of 3 tablets per day Crixivan (Capsule) Maximum of 9 capsules per day Daliresp (Tablet) Maximum of 1 tablet 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) Dexmethylphenidate HCl (Tablet Immediate- Maximum of 2 tablets per day Release) 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 Donepezil HCl (10mg Tablet) Maximum of 2 tablets per day Donepezil HCl (5mg Tablet) Maximum of 1 tablet per day Donepezil HCl ODT (10mg Tablet Dispersible) Maximum of 2 tablets per day Donepezil HCl ODT (5mg Tablet Dispersible) Maximum of 1 tablet per day Doxepin HCl (Cream) Maximum of 90 grams per 30 days Doxercalciferol (0.5mcg Capsule) Maximum of 3 capsules per day Doxercalciferol (1mcg Capsule, 2.5mcg Maximum of 4 capsules per day Capsule)

Bold type = Brand name drug Plain type = Generic drug 84 84 5 5 Last updated October 1, 2018 Drug Name Quantity Limit Duloxetine HCl (20mg Capsule Delayed- Release, 30mg Capsule Delayed-Release, 60mg Maximum of 2 capsules per day Capsule Delayed-Release) 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 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) Emsam (Patch 24 Hour) Maximum of 1 patch per day Emtriva (10mg/ml Oral Solution) Maximum of 42.5 ml per day Emtriva (200mg Capsule) Maximum of 2 capsules per day Enalapril Maleate (Tablet) Maximum of 2 tablets per day Enalapril Maleate/Hydrochlorothiazide 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) 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

Bold type = Brand name drug Plain type = Generic drug Last85 updated October 1, 2018 6 6 85 Drug Name Quantity Limit Epclusa (Tablet) Maximum of 1 tablet per day Epinephrine (Injection) (Generic EpiPen) Maximum of 4 pens (2 boxes) per 30 days 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 Estradiol (0.025mg/24hr Patch Weekly, 0.05mg/24hr Patch Weekly, 0.06mg/24hr Patch Weekly, 0.075mg/24hr Patch Weekly, 0.1mg/ Maximum of 4 patches per 28 days 24hr Patch Weekly, 37.5mcg/24hr Patch Weekly) Evotaz (Tablet) Maximum of 2 tablets per day Ezetimibe (Tablet) Maximum of 1 tablet per day Famciclovir (125mg Tablet, 250mg Tablet) Maximum of 2 tablets per day Famciclovir (500mg Tablet) Maximum of 3 tablets per day Fanapt (Tablet) Maximum of 2 tablets per day Farxiga (Tablet) Maximum of 1 tablet per day Fentanyl (100mcg/hr Patch 72 Hour, 12mcg/hr Patch 72 Hour, 25mcg/hr Patch 72 Hour, Maximum of 15 patches per 30 days 50mcg/hr Patch 72 Hour, 75mcg/hr Patch 72 Hour) Fentanyl Citrate Oral Transmucosal (Lozenge Maximum of 4 lozenges per day on a Handle) Fetzima (Capsule Extended-Release 24 Hour) Maximum of 1 capsule per day Firazyr (Injection) Maximum of 9 ml per day Fluticasone Propionate/Salmeterol (Aerosol Maximum of 1 inhaler per 30 days Powder) Fosamprenavir Calcium (Tablet) Maximum of 6 tablets per day Fosinopril Sodium (Tablet) Maximum of 2 tablets per day Fuzeon (Injection) Maximum of 3 vials per day Genvoya (Tablet) Maximum of 2 tablets per day Gilenya (Capsule) Maximum of 1 pack (30 capsules) per 30 days Glimepiride (1mg Tablet) Maximum of 8 tablets per day 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

Bold type = Brand name drug Plain type = Generic drug 86 86 7 7 Last updated October 1, 2018 Drug Name Quantity Limit 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) Glyxambi (Tablet) Maximum of 1 tablet per day Granisetron HCl (Tablet) Maximum of 2 tablets per day Guanfacine HCl (Tablet Immediate-Release) Maximum of 2 tablets per day Harvoni (Tablet) Maximum of 1 tablet per day Hetlioz (Capsule) Maximum of 1 capsule per day Hydrocodone Bitartrate/Acetaminophen Maximum of 12 tablets per day (2.5mg-325mg 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 (7.5mg-200mg 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) Hysingla ER (Tablet Extended-Release 24 Maximum of 1 tablet per day Hour Abuse-Deterrent) Ibandronate Sodium (150mg Tablet) Maximum of 1 tablet per 28 days Ibrance (Capsule) Maximum of 1 capsule per day Iclusig (15mg Tablet) Maximum of 2 tablets per day Iclusig (45mg Tablet) Maximum of 1 tablet per day Idhifa (Tablet) Maximum of 1 tablet per day Imatinib Mesylate (Tablet) Maximum of 3 tablets per day Imbruvica (140mg Capsule) Maximum of 4 capsules per day Imbruvica (140mg Tablet, 280mg Tablet, Maximum of 1 tablet per day 420mg Tablet, 560mg Tablet) Imbruvica (70mg Capsule) Maximum of 1 capsule per day Ingrezza (Capsule) Maximum of 1 capsule per day Inlyta (Tablet) Maximum of 4 tablets per day

Bold type = Brand name drug Plain type = Generic drug Last87 updated October 1, 2018 8 8 87 Drug Name Quantity Limit 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 Invirase (200mg Capsule) Maximum of 15 capsules per day Invirase (500mg Tablet) Maximum of 6 tablets 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 Itraconazole (Capsule) Maximum of 4 capsules per day Jakafi (Tablet) Maximum of 2 tablets per day 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 Kaletra (100mg-25mg Tablet) Maximum of 10 tablets per day Kaletra (200mg-50mg Tablet) Maximum of 6 tablets per day Kalydeco (150mg Tablet) Maximum of 2 tablets per day Kalydeco (50mg Packet, 75mg Packet) Maximum of 2 packets per day Kisqali (Tablet) Maximum of 3 tablets per day Kisqali Femara 200 Dose (Tablet Therapy Maximum of 1 pack (91 tablets) per 28 days Pack) Kisqali Femara 400 Dose (Tablet Therapy Maximum of 1 pack (91 tablets) per 28 days Pack) Kisqali Femara 600 Dose (Tablet Therapy Maximum of 1 pack (91 tablets) per 28 days Pack) Kombiglyze XR (2.5mg-1000mg Tablet Maximum of 2 tablets per day Extended-Release 24 Hour)

Bold type = Brand name drug Plain type = Generic drug 88 88 9 9 Last updated October 1, 2018 Drug Name Quantity Limit Kombiglyze XR (5mg-1000mg Tablet Extended-Release 24 Hour, 5mg-500mg Maximum of 1 tablet per day Tablet Extended-Release 24 Hour) Korlym (Tablet) Maximum of 4 tablets per day Lamivudine (10mg/ml Oral Solution) Maximum of 48 ml per day Lamivudine (150mg Tablet) Maximum of 3 tablets per day Lamivudine (300mg Tablet) Maximum of 2 tablets per day Lamivudine/Zidovudine (Tablet) Maximum of 3 tablets per day Latuda (120mg Tablet, 20mg Tablet, 40mg Maximum of 1 tablet per day Tablet, 60mg Tablet) Latuda (80mg Tablet) Maximum of 2 tablets per day Levocetirizine Dihydrochloride (5mg Tablet) Maximum of 1 tablet per day Lexiva (50mg/ml Suspension) Maximum of 90 ml per day Lidocaine (5% Ointment) Maximum of 150 grams per 30 days Lidocaine (5% Patch) Maximum of 3 patches per day Linezolid (600mg Tablet) Maximum of 2 tablets per day Linzess (Capsule) Maximum of 1 capsule per day Lisinopril (Tablet) Maximum of 2 tablets per day Lisinopril/Hydrochlorothiazide (10mg-12.5mg 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 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 (2mg/ml Concentrate) Maximum of 5 ml per day Lorcet (Tablet) Maximum of 12 tablets per day Lorcet HD (Tablet) Maximum of 12 tablets per day Lorcet Plus (Tablet) Maximum of 12 tablets per day Losartan Potassium (100mg Tablet) Maximum of 1 tablet per day Losartan Potassium (25mg Tablet, 50mg Maximum of 2 tablets per day Tablet)

Bold type = Brand name drug Plain type = Generic drug Last89 updated October 1, 2018 10 10 89 Drug Name Quantity Limit 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) Lovastatin (10mg Tablet, 20mg Tablet) Maximum of 1 tablet per day Lovastatin (40mg Tablet) Maximum of 2 tablets per day Lynparza (100mg Tablet, 150mg Tablet) Maximum of 4 tablets per day Lynparza (50mg Capsule) Maximum of 16 capsules 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 Mavyret (Tablet) Maximum of 3 tablets per day Memantine HCl (10mg Tablet) Maximum of 2 tablets per day Memantine HCl (2mg/ml Oral Solution) Maximum of 10 ml per day Memantine HCl (5mg Tablet) Maximum of 3 tablets per day Memantine HCl ER (Capsule Extended-Release Maximum of 1 capsule per day 24 Hour) Mesalamine (Enema) Maximum of 1 bottle (60 ml) 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 (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 Methylphenidate HCl (10mg Tablet Immediate- Maximum of 3 tablets per day Release) (Generic Ritalin) Methylphenidate HCl (20mg Tablet Immediate- Release, 5mg Tablet Immediate-Release) Maximum of 3 tablets per day (Generic Ritalin)

Bold type = Brand name drug Plain type = Generic drug 90 90 11 11 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 (20mg Tablet Maximum of 3 tablets per day Extended-Release) Modafinil (100mg Tablet) Maximum of 1 tablet per day Modafinil (200mg Tablet) Maximum of 2 tablets per day Montelukast Sodium (10mg Tablet) Maximum of 1 tablet per day Montelukast Sodium (4mg Packet) Maximum of 1 packet per day Montelukast Sodium (4mg Tablet Chewable, 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) Morphine Sulfate ER (100mg Tablet Extended- Release, 15mg Tablet Extended-Release) Maximum of 3 tablets per day (Generic MS Contin) Morphine Sulfate ER (200mg Tablet Extended- Maximum of 2 tablets per day Release) (Generic MS Contin) Morphine Sulfate ER (30mg Tablet Extended- Release, 60mg Tablet Extended-Release) Maximum of 4 tablets per day (Generic MS Contin) 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 Nevirapine (Tablet) 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)

Bold type = Brand name drug Plain type = Generic drug Last91 updated October 1, 2018 12 12 91 Drug Name Quantity Limit Ninlaro (Capsule) Maximum of 3 capsules per 28 days Northera (100mg Capsule) Maximum of 3 capsules per day Northera (200mg Capsule, 300mg Capsule) Maximum of 6 capsules per day Norvir (100mg Capsule) Maximum of 18 capsules per day Norvir (100mg Packet) Maximum of 18 packets 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 Nuplazid (Tablet) Maximum of 2 tablets 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, 15mg Tablet, 2.5mg Maximum of 1 tablet per day Tablet, 20mg Tablet, 5mg Tablet, 7.5mg Tablet) Olanzapine ODT (Tablet Dispersible) 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 Onfi (10mg Tablet, 20mg Tablet) Maximum of 2 tablets per day Onglyza (Tablet) Maximum of 1 tablet per day Orkambi (Tablet) Maximum of 112 tablets per 28 days Oseltamivir Phosphate (30mg Capsule, 45mg Maximum of 2 capsules per day Capsule, 75mg Capsule) Oseltamivir Phosphate (6mg/ml Suspension) Maximum of 26 ml per day Osphena (Tablet) Maximum of 1 tablet per day Oxandrolone (10mg Tablet) Maximum of 2 tablets per day Oxandrolone (2.5mg Tablet) Maximum of 4 tablets per day Oxybutynin Chloride ER (10mg Tablet 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 Oxycodone HCl (10mg Tablet Immediate- Maximum of 12 tablets per day Release) Oxycodone HCl (15mg Tablet Immediate- Maximum of 8 tablets per day Release)

Bold type = Brand name drug Plain type = Generic drug 92 92 13 13 Last updated October 1, 2018 Drug Name Quantity Limit Oxycodone HCl (20mg Tablet Immediate- Maximum of 6 tablets per day Release) Oxycodone HCl (30mg Tablet Immediate- Maximum of 6 tablets per day Release) Oxycodone HCl (5mg Tablet Immediate- Maximum of 12 tablets per day Release, 10mg Tablet Immediate-Release) Oxycodone HCl (5mg/5ml Oral Solution) Maximum of 130 ml per day 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 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) Pantoprazole Sodium (20mg Tablet Delayed- Maximum of 3 tablets per day Release) Pantoprazole Sodium (40mg Tablet Delayed- Maximum of 2 tablets per day Release) Perforomist (Nebulized Solution) Maximum of 2 vials (4 ml) per day Pioglitazone HCl (15mg Tablet) Maximum of 3 tablets per day Pioglitazone HCl (30mg Tablet, 45mg Tablet) Maximum of 1 tablet per day Pomalyst (Capsule) Maximum of 1 capsule per day Pradaxa (Capsule) Maximum of 2 capsules per day Praluent (Injection) Maximum of 2 pens (2 ml) per 28 days Pravastatin Sodium (Tablet) Maximum of 1 tablet per day Premarin (0.3mg Tablet, 0.45mg Tablet, 0.625mg Tablet, 0.9mg Tablet, 1.25mg Maximum of 1 tablet per day Tablet) Premphase (Tablet) Maximum of 1 tablet per day Prempro (Tablet) Maximum of 1 tablet per day Prezcobix (Tablet) Maximum of 2 tablets per day Prezista (100mg/ml Suspension) Maximum of 60 ml per day Prezista (150mg Tablet) Maximum of 6 tablets per day Prezista (600mg Tablet, 800mg Tablet) Maximum of 3 tablets per day Prezista (75mg Tablet) Maximum of 7 tablets per day

Bold type = Brand name drug Plain type = Generic drug Last93 updated October 1, 2018 14 14 93 Drug Name Quantity Limit 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 PRUDOXIN (Cream) Maximum of 90 grams per 30 days Pulmicort Flexhaler (Aerosol Powder) Maximum of 2 inhalers per 30 days Pulmozyme (Inhalation Solution) Maximum of 5 ml (2 ampules) 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) 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) Raloxifene HCl (Tablet) Maximum of 1 tablet per day Ramipril (Capsule) Maximum of 2 capsules per day Ranexa (Tablet Extended-Release 12 Hour) Maximum of 2 tablets per day Ravicti (Liquid) Maximum of 17.5 ml per day Rayaldee (Capsule Extended-Release) Maximum of 2 capsules per day Relenza Diskhaler (Aerosol Powder) Maximum of 3 inhalers (60 blisters) per 30 days Relistor (150mg Tablet) Maximum of 3 tablets per day 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 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 Revlimid (Capsule) Maximum of 1 capsule per day Rexulti (Tablet) Maximum of 1 tablet per day Reyataz (50mg Packet) Maximum of 8 packets per day Ritonavir (Tablet) Maximum of 18 tablets per day Rivastigmine Tartrate (Capsule) Maximum of 2 capsules per day

Bold type = Brand name drug Plain type = Generic drug 94 94 15 15 Last updated October 1, 2018 Drug Name Quantity Limit Rivastigmine Transdermal System (Patch 24 Maximum of 1 patch per day Hour) Rizatriptan Benzoate (Tablet) Maximum of 12 tablets per 30 days Rizatriptan Benzoate ODT (Tablet Dispersible) Maximum of 12 tablets per 30 days Rosuvastatin Calcium (Tablet) Maximum of 1 tablet per day Rubraca (Tablet) Maximum of 4 tablets per day Rydapt (Capsule) Maximum of 8 capsules per day Sabril (500mg Tablet) Maximum of 6 tablets per day Samsca (Tablet) Maximum of 2 tablets per day Saphris (Tablet Sublingual) Maximum of 2 tablets per day Selzentry (150mg Tablet, 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 Sildenafil (20mg Tablet) (Generic Revatio) Maximum of 3 tablets per day Simvastatin (Tablet) Maximum of 1 tablet per day Soliqua 100/33 (Injection) Maximum of 18 ml (6 pens) per 30 days Somavert (Injection) Maximum of 1 vial per day Spiriva HandiHaler (Capsule) Maximum of 1 capsule per day Spiriva Respimat (Aerosol Solution) Maximum of 1 inhaler (4 grams) per 30 days Sprycel (100mg Tablet, 140mg Tablet, 70mg Maximum of 1 tablet per day Tablet) Sprycel (20mg Tablet, 50mg Tablet) Maximum of 3 tablets per day Sprycel (80mg Tablet) Maximum of 2 tablets per day Stavudine (15mg Capsule, 30mg Capsule, Maximum of 3 capsules per day 40mg Capsule) Stavudine (20mg Capsule) Maximum of 2 capsules per day Stiolto Respimat (Aerosol Solution) Maximum of 1 inhaler (4 grams) per 30 days Stivarga (Tablet) Maximum of 4 tablets per day 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 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)

Bold type = Brand name drug Plain type = Generic drug Last95 updated October 1, 2018 16 16 95 Drug Name Quantity Limit 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 Solution Maximum of 12 injections (6 ml) per 30 days 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 Sutent (12.5mg Capsule, 25mg Capsule, Maximum of 1 capsule per day 50mg Capsule) Sutent (37.5mg Capsule) Maximum of 2 capsules per day Symbicort (Aerosol) Maximum of 1 inhaler (10.2 grams) per 30 days Symfi (Tablet) Maximum of 2 tablets per day Symfi Lo (Tablet) Maximum of 2 tablets 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) Synjardy XR (12.5mg-1000mg Tablet Extended-Release 24 Hour, 5mg-1000mg Maximum of 2 tablets per day Tablet Extended-Release 24 Hour) Tagrisso (Tablet) Maximum of 1 tablet per day Tarceva (100mg Tablet, 150mg Tablet) Maximum of 1 tablet per day Tarceva (25mg Tablet) Maximum of 3 tablets per day Tasigna (150mg Capsule) Maximum of 5 capsules per day Tasigna (200mg Capsule) Maximum of 4 capsules per day Tasigna (50mg Capsule) Maximum of 14 capsules per day Tecfidera (Capsule Delayed-Release) Maximum of 2 capsules per day Telmisartan (Tablet) Maximum of 1 tablet per day Temazepam (15mg Capsule, 30mg Capsule) Maximum of 1 capsule per day Tenofovir Disoproxil Fumarate (Tablet) Maximum of 2 tablets per day Tetrabenazine (12.5mg Tablet) Maximum of 3 tablets per day Tetrabenazine (25mg Tablet) Maximum of 4 tablets per day Thalomid (100mg Capsule, 50mg Capsule) Maximum of 1 capsule per day Thalomid (150mg Capsule, 200mg Capsule) Maximum of 2 capsules per day Tivicay (10mg Tablet, 25mg Tablet) Maximum of 2 tablets per day Tivicay (50mg Tablet) Maximum of 3 tablets per day TOBI Podhaler (Capsule) Maximum of 8 capsules per day Tobramycin (Nebulized Solution) Maximum of 10 ml (2 ampules) per day

Bold type = Brand name drug Plain type = Generic drug 96 96 17 17 Last updated October 1, 2018 Drug Name Quantity Limit Tradjenta (Tablet) Maximum of 1 tablet per day Tramadol HCl (Tablet Immediate-Release) Maximum of 8 tablets per day Tramadol HCl ER (Tablet Extended-Release 24 Maximum of 1 tablet per day Hour) Tramadol HCl/Acetaminophen (Tablet) Maximum of 12 tablets per day Trezix (Capsule) Maximum of 10 capsules 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 Trulicity (Injection) Maximum of 4 pens (2 ml) per 28 days Truvada (Tablet) Maximum of 2 tablets per day Tybost (Tablet) Maximum of 2 tablets per day Tymlos (Injection) Maximum of 1.56 ml per 30 days Valacyclovir HCl (1gm Tablet) Maximum of 4 tablets per day Valacyclovir HCl (500mg Tablet) Maximum of 2 tablets per day Valganciclovir (Tablet) Maximum of 4 tablets per day Valganciclovir Hydrochlorde (Oral Solution) Maximum of 36 ml 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 Veltassa (Powder) 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 Videx EC (125mg Capsule Delayed-Release) Maximum of 2 capsules per day Videx Pediatric (Oral Solution) Maximum of 30 ml per day Vigabatrin (Packet) Maximum of 6 packets per day Viibryd (Tablet) Maximum of 1 tablet per day Viibryd Starter Pack (Kit) Maximum of 1 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

Bold type = Brand name drug Plain type = Generic drug Last97 updated October 1, 2018 18 18 97 Drug Name Quantity Limit Viracept (250mg Tablet) Maximum of 15 tablets per day Viracept (625mg Tablet) Maximum of 6 tablets per day Viramune (Suspension) Maximum of 60 ml per day Viread (150mg Tablet) Maximum of 1 tablet per day Viread (200mg Tablet, 250mg Tablet) Maximum of 2 tablets per day Viread (40mg/gm Powder) Maximum of 6 bottles (360 grams) per 30 days 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) 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 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 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) Xtandi (Capsule) Maximum of 4 capsules per day Xyrem (Oral Solution) Maximum of 18 ml per day Zafirlukast (Tablet) Maximum of 2 tablets per day Zaleplon (10mg Capsule) Maximum of 2 capsules per day Zaleplon (5mg Capsule) Maximum of 1 capsule per day Zejula (Capsule) Maximum of 3 capsules per day Zelboraf (Tablet) Maximum of 8 tablets per day Zerit (Oral Solution) Maximum of 120 ml per day Zidovudine (100mg Capsule) Maximum of 8 capsules per day

Bold type = Brand name drug Plain type = Generic drug 98 98 19 19 Last updated October 1, 2018 Drug Name Quantity Limit Zidovudine (300mg Tablet) Maximum of 3 tablets per day Zidovudine (50mg/5ml Syrup) Maximum of 96 ml per day Ziprasidone HCl (Capsule) Maximum of 2 capsules per day Zolpidem Tartrate (10mg Tablet Immediate- Maximum of 1 tablet per day Release, 5mg Tablet Immediate-Release) Zydelig (Tablet) Maximum of 2 tablets per day Zykadia (Capsule) Maximum of 5 capsules per day Zytiga (250mg Tablet) Maximum of 4 tablets per day Zytiga (500mg Tablet) Maximum of 2 tablets per day track

Bold type = Brand name drug Plain type = Generic drug 99 0 99 Required information Benefits, drug list (formulary), pharmacy network and/or copayments/coinsurance may change on January 1 of each year, and from time to time during the plan year. You will receive notice when necessary. ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Please call UnitedHealthcare Customer Service. Our contact information is on the cover. ATENCIÓN: Si habla español, hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame a Servicio al Cliente de UnitedHealthcare. Nuestra información de contacto se encuentra en la portada. This document is available for free in other languages. Please call UnitedHealthcare Customer Service. Our contact information is on the cover. Este documento está disponible sin costo en otros idiomas. Llame a Servicio al Cliente de UnitedHealthcare. Nuestra información de contacto se encuentra en la portada. Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare-approved Part D sponsor. Enrollment in the plan depends on the plan’s contract renewal with Medicare. AARP® MedicareRx Plans carry the AARP name, and UnitedHealthcare Insurance Company pays royalty fees to AARP for the use of its intellectual property. These fees are used for the general purposes of AARP. For more up-to-date information or if you have other questions, please call UnitedHealthcare Customer Service at:

Toll-free 1-866-460-8854, TTY 711 8 a.m. - 8 p.m. local time, 7 days a week

www.myAARPMedicare.com

If you are a member of a group sponsored plan (your coverage is provided through a former employer, union group or trust), please call the Customer Service number on the back of your UnitedHealthcare member ID card.

PDEX19PD4310625_003 Last updated October 1, 2018